Antibiotic Recommendations

Published on 10/02/2015 by admin

Filed under Emergency Medicine

Last modified 10/02/2015

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185 Antibiotic Recommendations

The proper selection of antibiotic therapy in the setting of the emergency department (ED) is often complicated. The offending pathogen is rarely known with certainty, and emergency physicians must contend with diseases caused by emerging microbes, such as human immunodeficiency virus and the coronavirus that causes sudden acute respiratory syndrome. Many common bacterial pathogens have developed novel antimicrobial resistance patterns, such as drug-resistant Streptococcus pneumoniae and Escherichia coli, and some well-known bacteria have developed new strains, such as community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Complicating this challenge is a perpetually growing list of new antimicrobial agents, and emergency physicians clearly must remain diligent to keep current with the ever-changing arena of infectious diseases that are frequently encountered in the ED.

Fortunately, many helpful resources are available, such as local hospital antibiograms and hospital-specific protocols. National guidelines such as the Surviving Sepsis Campaign and the Centers for Disease Control and Prevention (CDC) guidelines for sexually transmitted diseases provide helpful references. The annually updated Sanford Guide to Antimicrobial Therapy remains an invaluable up-to-date tool literally found within one’s pocket.

In general, antibiotic therapy is empiric, based on epidemiologic data of the most likely encountered pathogen. Critically ill patients benefit from early and appropriate antibiotic therapy and therefore initially require broad-spectrum therapy, unless a specific pathogen has been identified. Whenever possible, the safest, least expensive, and easiest to administer antibiotic should be prescribed. Oral therapy is preferable over parenteral, and single-dose regimens eliminate concerns regarding compliance when compared with multidose regimens.

Recommendations for antibiotic therapy in the ED for selected infectious diseases are outlined in the sections that follow.

Acute Bacterial Meningitis

The treatment of acute bacterial meningitis is guided by epidemiologic risk factors; likely pathogens are determined primarily by the age of the patient and by exposure following trauma or surgical intervention. The goal of treatment is to administer antibiotics within 30 minutes of the patient’s arrival to the ED.

A Cochrane Review of more than 4000 patients with acute bacterial meningitis concluded that the use of adjunctive steroids decreases neurologic sequelae including hearing loss. Dexamethasone should be given intravenously 15 minutes before or concomitantly with the first dose of antibiotics and continued for 4 days (adults: 10 mg every 6 hours; children: 0.15 mg/kg every 6 hours).