Therapy empirical

Clinical features SCD carries a high risk for overwhelming sepsis due to functional asplenia and failure to make antibodies against encapsu lated organisms patients should be evaluated for temperature greater than 38.5°C. A low threshold for empiric therapy is recommended. 

Empirical therapy should be based on patient- and antimicrobial-specific factors such as the anatomic location of the infection, the likely pathogens associated with the presentation, the potential for adverse effects, and the antimicrobial spectrum of activity. 

Most initial antimicrobial therapy is empirical because cultures usually have not had sufficient time to identify a pathogen. Empirical therapy should be based on patient- and antimicrobial-specific factors such as the anatomic location of the infection, the likely pathogens associated with the presentation, the potential for adverse effects in a given patient, and the antimicrobial spectrum of activity. Prompt initiation of appropriate therapy is paramount in hospitalized patients who are critically ill. Patients who receive initial antimicrobial therapy that provides coverage against the causative pathogen survive at twice the rate of patients who do not receive adequate therapy initially.8... 

Modifying Empirical Therapy Based on Cultures and Clinical Response... 

Empirical therapy should be directed at the most likely pathogen (s) for a specific patient, taking into account age, risk factors for infection (including underlying disease and immune dysfunction, vaccine history, and recent exposures), CSF Gram stain results, CSF antibiotic penetration, and local antimicrobial resistance patterns. 

TABLE 67-1. Most Likely Pathogens and Recommended Empirical Therapy, by Risk Factor, for Bacterial Meningitis14 24... 

Empirical therapy for postoperative infections in neurosurgical patients (including patients with CSF shunts) should include vancomycin in combination with either cefepime, ceftazidime, or meropenem. Linezolid has been reported to reach adequate CSF concentrations and resolve cases of meningitis refractory to vancomycin.35 However, data with linezolid are limited. The addition of rifampin should be considered for treatment of shunt infections. When culture and sensitivity data are available, pathogen-directed antibiotic therapy should be administered. Removal of infected devices is desirable aggressive antibiotic therapy (including high-dose intravenous antibiotic therapy plus intraventricular vancomycin and/or tobramycin) may be effective for patients in whom hardware removal is not possible.36... 

TABLE 68-4. Empirical Therapy for Late-Onset HAP, HCAP, or VAP... 

Assess the patient s symptoms and/or laboratory results to determine if the empirical therapy is effective. Is the patient s fever resolving Is the patient s WBC decreasing ... 

Appropriate empiric anti-infective therapy decreases 28-day mortality compared to inappropriate empiric therapy (24% versus 39%).22 23,30 Additionally, appropriate therapy administered within 1 hour of sepsis recognition also decreases complications and mortality.22-23,30 Empiric anti-infective therapy should include one, two, or three drugs, depending on the site of infection and causative pathogens (Table 79-3). Anti-infective clinical trials in sepsis and septic shock patients are scarce and have not demonstrated differences among agents therefore, factors that determine selection are ... 

Monotherapy is equivalent to combination therapy once a causative pathogen has been identified. Empiric therapy should include combination regimens to ensure coverage of causative organisms. 

If a patient is non-neutropenic and has never received prior azole therapy, fluconazole 800 mg/day is an appropriate first-line therapy for invasive candidiasis until identification of the Candida isolate. Amphotericin B deoxycholate 0.7 mg/kg per day or caspofungin 70 mg on day 1, then 50 mg/day, voriconazole, or a lipid amphotericin B formulation are recommended as empiric therapy in patients with neutropenic fever. 

Empirical therapy in Fluconazole 6-12 mg/kg/day (low risk) Antifungals with coverage of Aspergillus... 

O The administration of empirical therapy should begin immediately after cultures are taken. Therapy should not be withheld until after culture results are obtained. 

Hydration and analgesics are the mainstays of treatment for vasoocclusive (painful) crisis. Fluid replacement should be 1.5 times the maintenance requirement, can be administered IV or orally, and should be monitored to avoid volume overload. An infectious etiology should be considered if appropriate, empiric therapy should be initiated. 

When evaluating a patient for initial or empiric therapy, the following factors should be considered ... 

Antibiotics are not essential in the treatment of most mild diarrheas, and empirical therapy for acute GI infections may result in unnecessary... 

The selection of a specific agent or combination should be based on culture and susceptibility data for peritonitis that occurs from chronic peritoneal dialysis. If microbiologic data are unavailable, empiric therapy should be initiated. 

Because the causative organisms and their susceptibilities are generally known, a cost-effective approach to management is recommended that includes a urinalysis and initiation of empiric therapy without a urine culture (Fig. 50-1). 

Empiric therapy for febrile neutropenic patients - As monotherapy for empiric treatment of febrile neutropenic patients. In patients at high risk for severe infection (including patients with a history of recent bone marrow transplantation, with hypotension at presentation, with an underlying hematologic malignancy, or with severe or prolonged neutropenia), antimicrobial monotherapy may not be appropriate. Insufficient data exist to support the efficacy of cefepime monotherapy in such patients. 

Pediatric patients (2 months to 16 years of age) - Treatment of uncomplicated and complicated urinary tract infections (including pyelonephritis), uncomplicated skin and skin structure infections, pneumonia, and as empiric therapy for febrile neutropenic patients. 

Empirical therapy in febrile neutropenic severe ciprofloxacin 400 mg IV q 8 h 1200 mg IV 7 to 14 days... 

Febrile neutropenia, empiric (oral solution and injection) For empiric therapy of febrile neutropenic (ETFN) patients with suspected fungal infections. 

For infections frequently encountered outside hospitals, e.g. uncomplicated urinary tract infection in young women, surveillance of resistance data of the most likely pathogens Escherichia coli) allows physicians to prescribe empiric therapy without performing cultures in the individual patient. However, in severely ill hospitalised patients, it is necessary to take samples for culture before starting empiric therapy. Microscopy of the Gram stained smear can help fine-tune empiric therapy at an early stage. Whether the infection is community-acquired or hospital-acquired, and whether the patient has been exposed to previous antimicrobial therapy should also be taken into account when choosing empiric therapy. 

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