14 A n t i b i o t i c E s s e n t i a l s

Relative Bradycardia*

Temperature-Pulse Relationships

	Appropriate Pulse Response	If Relative Bradycardia
Temperature	(beats/min)	Pulse (beats/min)
106°F (41..1°C)	150	< 140
105°F (40..6°C)	140	< 130
104°F (40..7°C)	130	< 120
103°F (39..4°C)	120	< 110
102°F (38..9°C)	110	< 100

*Relative bradycardia refers to heart rates that are inappropriately slow relative to body temperature (pulse must be taken simultaneously with temperature elevation). . Applies to adult patients with temperature­ ≥ 102°F; does not apply to patients with second/third-degree heart block, ­pacemaker-induced rhythms, or those taking beta-blockers, diltiazem, or verapamil..

ANTIBIOTIC FAILURE

Table 1.11. Causes of Apparent/Actual Antibiotic Failure

Microbiologic Factors

•In vitro susceptibility but ineffective in vivo

•Antibiotic “tolerance” with gram-positive cocci

•Treating colonization (not infection)

Antibiotic Factors

•Inadequate coverage/spectrum

•Inadequate antibiotic blood tissue levels

•Decreased antibiotic activity in tissue

•Drug-drug interactions (inactivation/antagonism)

Antibiotic Penetration Problems

•Undrained abscess

•Foreign body-related infection

•Protected focus e..g.., cerebrospinal fluid

•Organ hypoperfusion/diminished blood supply

Noninfectious Diseases

•Medical disorders mimicking infection e..g.., SLE

•Drug fever

Antibiotic-unresponsive Infectious Diseases

•Viral or Fungal infections

Chapter 1.  Overview of Antimicrobial Therapy

15

PITFALLS IN ANTIBIOTIC PRESCRIBING

•Do not use antibiotics to “treat” colonization or non-infectious/diseases.

•Overuse of combination therapy.. Monotherapy is preferred over combination therapy unless compelling reasons prevail, such as drug synergy or extended spectrum beyond what can be obtained with a single drug.. Monotherapy reduces the risk of drug interactions and side effects, and is usually less expensive..

•Use of antibiotics for persistent fevers. . For patients with persistent fevers on an antimicrobial regimens that appears to be failing, it is important to reassess the patient rather than add additional antibiotics. . Causes of prolonged fevers include undrained septic foci, noninfectious medical disorders, and drug fevers. . Undiagnosed causes of leukocytosis/lowgrade fevers should not be treated with prolonged courses of antibiotics.

•Inadequate surgical therapy. . Infections involving infected prosthetic materials or fluid collections e. .g. ., abscesses often require surgical therapy for cure. . For infections such as chronic osteomyelitis, surgery is the only way to cure the infection; antibiotics are useful only for suppression or to prevent local infectious complications..

16	A n t i b i o t i c E s s e n t i a l s

REFERENCES AND SUGGESTED READINGS

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Cunha BA.. Oral Antibiotic Therapy of Serious Systemic Infections.. Med Clin N Am 90:1197–1222, 2006..

Cunha BA. . Pseudomonas aeruginosa: Resistance and therapy. . Semin Respir Infect 17:231–9, 2002..

Cunha BA. . Clinical relevance of penicillin-resistant Streptococcus pneumoniae.. Semin Respir Infect 17:204–14, 2002..

Cunha BA.. Effective antibiotic resistance and control strategies.. Lancet 357:1307–1308, 2001..

Cunha BA.. The significance of antibiotic false sensitivity testing with in vitro testing.. J Chemother 9:25–33, 1997..

Cunha BA, Ortega A.. Antibiotic failure.. Medical Clinics of North America 79:663–672, 1995..

Cunha CB, Varughese CA, Mylonakis E. . Antimicrobial Stewardship programs (ASPs).. The devil is in the details.. Virulence 4: 147-149, 2013..

Empey KM, Rapp RP, Evans ME. . The effect of an antimicrobial formulary change on hospital resistance ­patterns.. Pharmacotherapy 22:81–7, 2002..

Endimiani A, Perez F, Bajaksouzian S, et al.. Evaluation of updated interpretive criteria for categorizing Klebsiella pneumoniae with reduced carbapenem susceptibility. . J Clin Microbiol. . 48:4417–4425, 2010..

Hicks LA, Monnet DL, Roberts RM.. Increase in pneumococcus macrolide resistance, USA.. Emerg.. Infect.. Dis.. 16:896–897, 2010..

Johnson DH, Cunha BA.. Drug fever.. Infectious Disease Clinics of North America 10:85–91, 1996..

Jorgensen JH, Ferraro MJ. Antimicrobial susceptibility testing: a review of general principles and contemporary practices.. Clin Infect Dis 49:1749–1755, 2009..

Leekha S, Terrell CL, Edson RS. . General principles of antimicrobial therapy.. Mayo Clin.. Proc.. 86:156–167, 2011..

Patel SM, Saravolatz LD.. Monotherapy versus ­combination therapy.. Med Clin N Am 90:1183–95, 2006..

Schlossberg D.. Clinical approach to antibiotic failure.. Med Clin N Am 90:1265–77, 2006..

Tenover FC, Moellering RC. . The rationale for revising the clinical and laboratory standards institute vancomycin­ minimal inhibitory concentration interpretive ­criteria for Staphylococcus aureus.. Clinical Infect Dis 44:1208–1215, 2007..

Weinstein MP, Klugman KP, Jones RN.. Rationale for revised penicillin susceptibility breakpoints versus Streptococcus pneumoniae: coping with antimicrobial susceptibility in an era of resistance.. Clin Infect Dis 48:1596–1600, 2009..

Yamagishi Y, Terada M, Ohki E, Miura Y, Umemura T, Mikamo H.. Investigation of the clinical breakpoints of piperacillin-tazo- bactam against infections caused by Pseudomonas aeruginosa, J Chemo 18: 127-129, 2012..

TEXTBOOKS

Anaissie EJ, McGinnis MR, Pfaller MA (eds). . Clinical Mycology­. . Churchill Livingstone, New York, 2003..

Baddour L,Gorbach SL (eds).. Therapy of Infectious ­Diseases.. Saunders, Philadelphia, 2003..

Bennett JE, Dolin R, Blaser MJ (eds).. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious­ Diseases (8th Ed).. Philadelphia Elsevier Churchill Livingstone,­ 2015..

Bryskier A (ed). . Antimicrobial Agents. . ASM Press, ­Washington, D..C.., 2005..

Cohen J, Powderly WG, Opal S (eds).. Infectious Diseases (4th Ed).. Philadelphia: Elsevier, 2015..

Finch RG, Greenwood D, Norrby SR, Whitley RJ (eds).. Antibiotic and Chemotherapy (8th Ed).. Churchill Livingstone, Edinburgh, 2003..

Gorbach SL, Bartlett JG, Blacklow NR (eds). . Infectious Diseases (3rd Ed).. Philadelphia, Lippincott, Williams & Wilkins, 2004..

Grayson ML (ed). . Kucers’ The Use of Antibiotics (6th Ed), ASM Press, Washington, DC, Blaser MJ 2010..

O’Grady F, Lambert HP, Finch RG, Greenwood D (eds).. Antibiotic and Chemotherapy (2nd Ed).. Churchill Livingston, New York, 1997..

Ristuccia AM, Cunha BA (eds). . Antimicrobial Therapy. . Raven Press, New York, 1984..

Scholar EM Pratt WB (eds). . The Antimicrobial Drugs (2nd Ed), Oxford University Press, New York, 2000..

Schlossberg D (ed). . Clinical Infectious Disease (2nd Ed), Cambridge ­University Press, Cambridge, 2015..

Yoshikawa TT, Rajagopalan S (eds).. Antibiotic Therapy for Geriatric Patients.. Taylor & Francis, New York, 2006..

Yu V, Edwards G, McKinnon PS, Peloquin C, Morse G (eds). . Antimicrobial Therapy and Vaccines, Volume II: Antimicrobial­ Agents (2nd Ed), Esun ­Technologies, ­Pittsburgh, 2005..