Essentials of Clinical Infectious Diseases 2nd Edition 2018: Kindler Edition by William F.DO & MPH Wright

Author:William F.DO & MPH Wright [William F.DO]
Language: eng
Format: epub
Publisher: Persons Medical; 2 edition (April 28, 2018)
Published: 2020-03-08T16:00:00+00:00

232 VIII. APPROACH TO RENAL–URINARY INFECTIONS

duration of antimicrobial therapy has traditionally been 4 to 6weeks. Suggested regimens according to the likely pathogen include:

(a) Staphylococcus aureus:

• Oxacillin or methicillin sensitive. Nafcillin 2 g IV q4–6

• Oxacillin or methicillin resistant. Vancomycin 15 mg/kg IVq12–24 (the vancomycin dose may need adjustments to main-tain a serum trough level between 15 and 20 mcg/mL)

(b) Streptococcus spp. Penicillin G 5 million units IV q6 (if the poly-merase chain reaction [PCN] minimum inhibitory concentration[MIC] data indicate the bacteria is susceptible) or ceftriaxone 2 gIV q24 .

(c) Enterococcus spp:

• Penicillin-sensitive. Penicillin G 5 million units IV q6

• Ampicillin-sensitive. Ampicillin 2 g IV q4–6

• Ampicillin-resistant. Vancomycin 15 mg/kg IV q12–24 (thevancomycin dose may need adjustments to maintain a serumtrough level between 15 and 20 mcg/mL)

The addition of gentamicin at 1 mg/kg IV q8 is also suggested (dos-ing 3 mg/kg IV q24 has been associated with less nephrotoxicity).

(d) Enteric gram-negative rods. Ceftriaxone 2 g IV q24 , or ciproflox-acin 400 mg IV q12 (or 500–750 mg PO q12 ), or ertapenem 1,000mg IV q24 (carbapenem antibiotics are reserved for multidrug-resistant organisms).

(e) Pseudomonas aeruginosa . Ceftazidime or cefepime 2 g IV q8 incombination with an aminoglycoside antibiotic (see gentamicinin the preceding), or piperacillin–tazobactam 3.375 g IV q6 , or meropenem 1,000 mg IV q8 , or doripenem 500 mg IV q8 , or imi-penem–cilastatin 500–1,000 mg IV q6 .

(f) Anaerobes. Metronidazole 500 mg IV or PO q8.

(g) Fungal. Fluconazole 200 mg IV or PO q24 or lipid complex ampho-tericin B 3 to 5 mg/kg IV q24 . ( Do not use micafungin, caspofun-gin, or anidulafungin as these agents do not achieve adequateurinary concentrations.)

ii. Surgical therapy . Abscesses larger than 5 cm may require percu-taneous drainage with the assistance of ultrasound or CT guidance;however, smaller abscesses that have not responded to appropriateantimicrobial therapy may also require drainage.

b. Perinephric abscesses . These abscesses are associated with mortal-ity rates as high as 50%; therefore, a combined medical and surgicalapproach should be considered in all cases. While antimicrobial therapyis the same as for intrarenal abscesses, surgical measures may requireassisted percutaneous drainage, open surgical drainage, or nephrectomy.Diffuse or advanced-stage xanthogranulomatous pyelonephritis almostalways requires nephrectomy.

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