Immunocompromised antibiotics

Overview

The antibiotics listed are for common diseases in immunocompromised hosts

CMV Retinitis

Severe Vision Threatening

• Ganciclovir intraocular implant for 8 months AND
  • Valganciclovir 900mg PO q12hrs x 14 days FOLLOWED BY 900mg PO q24hrs x 7 days

Peripheral lesions

• Valganciclovir 900mg PO q12hrs x 21 days FOLLOWED BY 900mg PO q24hrs x 7 days

CMV esophagitis

• Ganciclovir 5mg/kg IV q12hrs daily x 21 days (or until symptom resolution)
• Foscarnet 90mg/kg IV q12 hrs daily x 21 days (or until symptom resolution)

CMV colitis

• Ganciclovir 5mg/kg IV q12hrs x 21 days (or until resolution of symptoms)
• Foscarnet 90mg/kg IV q12hrs daily x 21 days (or until resolution of symptoms)

CMV neurologic disease

• Ganciclovir 5mg/kg IV q12hrs daily x 21 days FOLLOWED BY 5mg/kg IV q24hrs +
  • Foscarnet 90mg/kg IV q12hrs x 21 days THEN 90-120mg/kg IV q24hrs

CMV pneumonia

• Ganciclovir 5mg/kg IV q12hrs x 3 weeks

Cryptococcosis

Pulmonary (not AIDs associated)

• Fluconazole 400mg PO IV q24hrs x 6-12 months
• Itraconazole 200mg PO q12hrs daily x 6-12 months
• Voriconazole 200mg PO q12hrs x 6-12 months

Pulmonary (with AIDS)

• Fluconazole 400mg PO q24hrs x 6-12 months

Meningitis (not AIDs associated)

• Amphotericin B 0.7-1mg/kg IV q24hrs + Flucytosine 25mg/kg PO q6hrs x 4 weeks
  • Followed by Fluconazole 400mg PO q24hrs x 8 weeks

Meningitis (with AIDS)

• Amphotericine B 0.7=1mg/kg IV q24hrs + Flycytosine 25mg/kg PO q6hrs x 2 weeks
  • Followed by Fluconazole 400mg PO q24hrs x 8 weeks

Neutropenic Fever

Therapy is aimed at treating multiple flora that include Gram Negatives, Gram Positive Bacteria, Pseudomonas and if there is an indwelling catheter or high risk, then MRSA.

Inpatient

• Monotherapy appears to be as good as dual-drug therapy
  • Cefepime 2g IV q8hr or Ceftazidime 2g IV q8hr OR
  • Imipenem/Cilastin 1gm IV q8hr or Meropenem 1gm IV q8hr OR
  • Piperacillin/Tazobactam 4.5gm IV q 6hr
• Consider adding Vancomycin to above regimen for:
  • Severe mucositis
  • Signs of catheter site infection
  • Fluoroquinolone prophylaxis was recently used against gram-negative bacteremia
  • Hypotension is present
  • Institutions with hospital-associated MRSA
  • Patient has known colonization with resistant gram-positive organisms

Outpatient

• Ciprofloxacin 750mg PO q12hrs AND Amoxicillin/Clavulanate 875mg PO q12hrs x7d OR
• Ciprofloxacin 750mg PO q12hrs AND Clindamycin 450mg PO q8hrs

Pneumocystis Pneumonia (PCP)

Mild Disease

• TMP/SMX 2 DS tablets PO q8hrs daily OR
  • High incidence of allergy in HIV
• Dapsone 100mg PO once daily + TMP 5mg/kg PO q8hrs OR
  • caution: dapsone can cause methemoglobinemia
• Atavaquone 750mg PO q12hrs OR
• Primaquine 30mg PO q24hrs + Clindamycin 450mg PO q8hrs

Severe Disease

• TMP/SMX 5mg/kg IV q8hrs daily x 21 days OR
• Pentamidine 4mg/kg IV daily infused over 60 minutes OR
  • Watch for side effects of hypoglycemia and hypotension
• Primaquine 30mg PO once daily + Clindamycin 900mg IV q8hrs daily

Prophylaxis

• TMP/SMX 1 double strength tablet daily, but one single strength tablet daily or one double-strength three times weekly is acceptable.

Toxoplasmosis

Immunocompetent

Antibiotics only needed if patient has severe symptoms

• Pyrimethamine 200mg PO one dose (for loading) THEN 50mg PO q24hrs x4wks AND
  • Leucovorin 10mg PO q24hrs AND
  • Sulfadiazine 1g PO q6hrs

Immunosprepressed

• TMP/SMX 5mg/kg IV q12hrs OR
• Pyrimethamine 200mg PO one dose (for loading) THEN 75mg PO q24hrs x4-8wks AND Leucovorin 25mg PO q24hrs PLUS
  • Sulfadiazine 1500mg PO q6hrs OR
  • Clindamycin 600mg PO or IV q6hrs OR
  • Azithromycin 12000mg PO q24hrs OR
  • Atovaquone 1500mg PO q12hrs

Pregnant

• Spiramycin 1 g orally every 8 hours
  • If amniotic fluid is positive treat with 3 weeks of pyrimethamine (50 mg/day orally) + sulfadiazine (3 g/day orally in 2-3 divided doses)
  • Alternate with a 3-week course of Spiramycin 1 g 3 times daily OR
• Pyrimethamine (25 mg/day orally) and sulfadiazine (4 g/day orally) divided 2 or 4 times daily until delivery AND
  • Leucovorin 10-25 mg/day orally to prevent bone marrow suppression

See Also

Antibiotics by diagnosis

• Bone and joint antibiotics
• Cardiovascular antibiotics
• ENT antibiotics
• Eye antibiotics
• GI antibiotics
• GU antibiotics
• Neuro antibiotics
• OB/GYN antibiotics
• Pulmonary antibiotics
• Skin and soft tissue antibiotics
• Bioterrorism antibiotics
• Environmental exposure antibiotics
• Immunocompromised antibiotics
• Post exposure prophylaxis antibiotics
• Pediatric antibiotics
• Sepsis antibiotics
• Arthropod and parasitic antibiotics

For antibiotics by organism see Microbiology (Main)

References

Authors

Ross Donaldson, Yos Yachivev, Daniel Ostermayer