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Managing poster microbiologia antibioticos
1.
A SYSTEMS APPROACH
TO ANTIMICROBIAL SELECTION MANAGING MICROBES DOSES RECOMMENDED FOR DRUGS LISTED IN CHART Some drugs listed below are not approved for dogs or cats, or may have doses and indications that are extra-label. For extra-label use, safety and efficacy may not be established. These dosing guidelines are based on Dr. Mark Papich’s clinical judgment and product-specific information. A reliable reference should be consulted before administering these drugs. Selection of drug should ideally be based on a test of antimicrobial susceptibility using standards provided by CLSI (www.clsi.org). Drug Administration Route Dose(s) Dose Interval Other Considerations Amikacin IV, IM, SC Dog: 15–30 mg/kg Cat: 10–14 mg/kg Use cautiously in dehydrated patients or those with kidney disease. q24h Amoxicillin PO 22 mg/kg For urinary tract infections, some isolates of the Enterobacteriaceae may be susceptible if urine breakpoint is used. Consult microbiology laboratory for test interpretation. q12h Amoxicillin– clavulanic acid PO Dog: 12.5–25 mg/kg Cat: 62.5 mg/cat Dose listed is based on combined ingredients (amoxicillin plus clavulanic acid). For urinary tract infections, some isolates of the Enterobacteriaceae may be susceptible if urine breakpoint is used. Consult microbiology laboratory for test interpretation. q12h Amphotericin B — — Refer to the Drug Handbook reference listed at the bottom of the table for dosing information. — Ampicillin IM, SC, IV PO 10–20 mg/kg 20–40 mg/kg For oral treatment, amoxicillin, or amoxicillin-clavulanate is preferred. q8h Ampicillin– sulbactam IV, IM 10–20 mg/kg Dose listed is based on combined ingredients (ampicillin plus sulbactam). q8h Azithromycin PO Dog: 3–5 mg/kg Cat: 5–10 mg/kg Start with 10 mg/kg once per day, for 5-7 days, then decrease to every other day. q24–48h Cefadroxil PO Dog: 22–30 mg/kg Cat: 22 mg/kg For urinary tract infections, isolates of the Enterobacteriaceae may be susceptible if urine breakpoint is used. Consult microbiology laboratory for test interpretation. Check cefadroxil availability. Not available in all areas. If the organism is susceptible, cephalexin can be used instead. Dog: q12h Cat: q24h Cefazolin IV, IM 25 mg/kg q6h Cefotaxime IV, IM 30 mg/kg q8–12h Cefotetan IV, IM, SC 30 mg/kg q8h Cefovecin SC 8 mg/kg q14d Cefoxitin IV, IM 30 mg/kg q6–8h Cefpodoxime proxetil PO Dog: 5–10 mg/kg Cat: Dose not established Dog: q24h Ceftazidime IV, IM, SC 25 mg/kg Use a 6 hour interval for treatment of Pseudomonas aeruginosa, but a 8 hour interval for other isolates. q6 or 8h Ceftiofur SC Dog: 4.4 mg/kg Cat: Not recommended Use for treating lower urinary tract infections only. Dog: q24h Cephalexin PO 25 mg/kg For urinary tract infections, isolates of the Enterobacteriaceae may be susceptible if urine breakpoint is used. Consult microbiology laboratory for test interpretation. q12h Chloramphenicol PO Dog: 40–50 mg/kg Cat: 12.5–20 mg/kg This drug can be toxic to humans; wear gloves when administering and avoid human contact with the drug. Dog: q8h Cat: q12h Ciprofloxacin PO 25-30 mg/kg Human-labeled fluoroquinolone; whenever possible, consider a veterinary labeled fluoroquinolone first. Oral absorption is inconsistent in dogs and low in cats (not recommended for cats). It may not be effective in dogs unless the MIC of the isolate is less than 0.12 mcg/mL. q24h Clarithromycin PO 7.5 mg/kg q12h Clindamycin PO Dog: 11–22 mg/kg Cat: 11–33 mg/kg Dog: 11 mg/kg q12h or 22 mg/kg q24h Cat: q24h Doxycycline PO 5 mg/kg If doxycycline is not available, minocycline can be used instead. q12h Enrofloxacin PO, IM Dog: 5–20 mg/kg Cat: 5 mg/kg Avoid administering a high dose to cats, and avoid use in young dogs. q24h Erythromycin PO 10–20 mg/kg Not frequently used because of lack of availability and high incidence of vomiting. Consider azithromycin as a substitute. q8–12h Fluconazole PO Dog: 10–12 mg/kg Cat: 50 mg/cat For Malassezia, lower doses can be used (consult reference). q24h Gentamicin IV, IM, SC Dog: 9–14 mg/kg Cat: 5–8 mg/kg Use cautiously in dehydrated patients or those with renal disease. q24h Imipenem– cilastatin IM, IV 5 mg/kg Imipenem is unstable after reconstitution. Consult label information for stability data. q6–8h Itraconazole PO 10 mg/kg For Malassezia and dermatophytes, lower doses can be used. For cats, the oral solution can be used at a dose of 5 mg/kg per day, on alternating weeks. q12h Levofloxacin Oral Dogs: 25 mg/kg Not approved for animals. Use in dogs is extralabel. 24h Lincomycin PO 10 mg/kg Lincomycin is rarely available for dogs and cats. Clindamycin may be used as a substitute. q12h Linezolid PO 10 mg/kg q12h Marbofloxacin PO 2.2–5.75 mg/kg Avoid use in young dogs. Linezolid is a human-label antibiotic that should be used in animals only when susceptibility test results indicated that it is the only reasonable option q24h 10 mg/kg 30 mg/kg q8h q8h Meropenem IV, IM, SC Dosage for Enterobacteriaceae (E. coli, K.pneumoniae). Dosage for Pseudomonas aeruginosa. Meropenem is a human-label antibiotic that should be used in animals only when susceptibility test results indicated that it is the only reasonable option. After reconstitution it is stable for 3 days. Metronidazole PO Dogs 12 mg/kg Dogs 15 mg/kg Cats 10-15 mg/kg Avoid high doses or there is a risk of neurotoxicity. q8h q12h q24h Minocycline PO Dogs 5 mg/kg Cats 8.8 mg/kg q24 q24h Neomycin PO 10–20 mg/kg Not recommended as an oral treatment for diarrhea. q12h Orbifloxacin PO 2.5–7.5 mg/kg 7.5 mg/kg 2.5 - 7.5 mg/kg Dosage for tablets (dog or cat, avoid in young dogs) Dosage for oral suspension (cats) Oral suspension (dogs, avoid in young dogs ) q24h q24h q24h Ormetoprim– sulfadimethoxine PO Dog: 13.5 mg/kg Cat dose is not established. Dog: q24h Piperacillin- Tazobactam IV 50 mg/kg Alternative dose: 4 mg/kg bolus, followed by 3.2 mg/kg per hour. q6h Posaconazole PO Dog: 5 mg/kg Cat: See comment section for dosing Dosage for sustained-release tablets, dogs only Dosage for oral suspension: 30 mg/kg, loading dose followed by 15 mg/kg q48h, cats only q48h or q72h Pradofloxacin PO Cats, oral suspension: 5-7.5 mg/kg Only oral suspension for cats is available in U.S. Approved in Canada and Europe for dogs; not approved for dogs in U.S. q24h, not to exceed 7 days Rifampin PO 5 mg/kg Rifampin can cause liver injury in dogs. Monitor liver enzymes and bilirubin regularly, starting 7 days after initiating treatment. q12h Ronidazole PO Cat: 30–60 mg/kg Not registered in the U.S. (must be compounded). Dog dose not established. Cat: q24h Tetracycline/ tetracycline hydrochloride PO 15–20 mg/kg Tetracycline formulations are usually not available for dogs and cats. Doxycycline or minocycline can be substituted for oral treatment. q8h Tylosin PO 7–15 mg/kg Not approved in the U.S. for small animals (it is a large-animal product); can be added to a dog’s food for controlling diarrhea. q12–24h Vancomycina IV Dog: 15 mg/kg Cat: 12 mg/kg Administer by slow infusion; use cautiously in dehydrated patients or those with kidney disease. Vancomycin is a human-label antibiotic that should be used in animals only when susceptibility test results indicated that it is the only reasonable option. q8h Voriconazole a Use only as a last resort and only when a susceptibility test indicates that this is the only oral drug with activity. Note: From Papich MG. Saunders Handbook of Veterinary Drugs. 4th Edition, St. Louis: Saunders Elsevier; 2020. PO Dog: 5-6 mg/kg Cat: See comment section for dosing Cat dosage - 25 mg per cat as an initial dose, followed by 12.5 mg every other day. Use cautiously because neurologic disease and ocular problems have been associated with treatment. q12h Ketoconazole PO Dog: 10–15 mg/kg Cat: 5–10 mg/kg For Malassezia, lower doses can be used (consult reference). q12h Aural Gastrointestinal/ Hepatobiliary Lower Respiratory Oral Orthopedic Skin/Soft Tissue Upper Respiratory Urinary Tract Bloodborne Infections Acute suppurative otitis Chronic purulent otitis Bacterial enteritis/colitis Cholecystitis Helicobacter spp gastritis Suppurative cholangiohepatitis Bronchitis Pneumonia Pyothorax Endodontic disease (periapical infections) Gingivitis Periodontitis Stomatitis Diskospondylitis Open fractures Osteomyelitis Abscess Deep pyoderma Folliculitis Soft-tissue infection Superficial pyoderma Wounds Infectious tracheobronchitis Rhinitis Secondary bacterial infection Bladder stones (secondary to infection) Cystitis Nephroliths Prostatitis Pyelonephritis Babesiosis (Babesia canis) Azithromycin + atovaquone Clarithromycin + atovaquone Imidocarb Bartonellosis (Bartonella henselae) Azithromycin or clarithromycin with or without doxycycline, or rifampin. Borreliosis (Borrelia burgdorferi) Amoxicillin Azithromycin Clarithromycin Doxycycline or minocycline. Ehrlichiosis (Ehrlichia spp.) Doxycycline or minocycline Rocky Mountain Spotted Fever (Rickettsia rickettsii) Chloramphenicol Fluoroquinolones1 Doxycycline or minocycline Haemoplasmosis (cats) (Mycoplasma haemofelis) Doxycycline: 10 mg/kg, PO, q24hr, or 5 mg/kg q12h x 7-28 days Alternative: • Enrofloxacin, 5 mg/kg, PO, q24hr for 7-28 days • Marbofloxacin, 2.5 mg/kg, PO, q24hr for 7-28 days • Orbifloxacin, 2.5 mg/kg, PO, q24hr for 7-28 days • Pradofloxacin, 5 or 10 mg/kg, q24h • Imidocarb, 5 mg/kg, IM, 2-4 doses q14 days ORAL Amoxicillin Amoxicillin–clavulanic acid Cefpodoxime proxetil Cephalexin Ormetoprim–sulfadimethoxine Trimethoprim–sulfonamide INJECTABLE Ampicillin–sulbactam Cefazolin Cefovecin Ceftiofur ORAL Amoxicillin Amoxicillin–clavulanic acid Cephalexin Ormetoprim–sulfadimethoxine Trimethoprim–sulfonamide Tetracycline (doxycycline, minocycline) ORAL Amoxicillin–clavulanic acid Cefpodoxime proxetil Cephalexin Clindamycin Ormetoprim–sulfadimethoxine Trimethoprim–sulfonamide INJECTABLE Cefovecin TOPICAL THERAPY Chlorhexidine (2-4%) antiseptic shampoos, sprays, mousses and wipes; applied daily when used as the sole treatment ORAL Amoxicillin–clavulanic acid Cefpodoxime proxetil Chloramphenicol Clindamycin Cephalexin INJECTABLE Cefazolin Cefovecin3 ORAL Amoxicillin–clavulanic acid Clindamycin Metronidazole (anaerobes only) Pradofloxacin (cats only) TOPICAL THERAPY Doxycycline gel ORAL Amoxicillin–clavulanic acid Cefpodoxime proxetil Clindamycin Tetracyclines (doxycycline, monocycline) First-generation cephalosporins (cephalexin) Fluoroquinolones1 Ormetoprim–sulfadimethoxine Trimethoprim–sulfonamide Pradofloxacin (cats only) Macrolides (azithromycin, clarithomycin) INJECTABLE Ampicillin–sulbactam Cefazolin ORAL Biliary disease Chloramphenicol Fluoroquinolones1 Cefpodoxime Enteritis Amoxicillin–clavulanic acid Ampicillin Chloramphenicol First-generation cephalosporins (cephalexin) Fluoroquinolones1 Metronidazole Ormetoprim–sulfadimethoxine Tetracycline (doxycycline, minocycline) Trimethoprim–sulfonamide Colitis Metronidazole Tylosin Ulcerative colitis: Fluoroquinolones1 Chloramphenicol Note: Diarrhea and other GI infections are often self-limiting and antibiotics are usually not necessary. TOPICAL ANTIMICROBIALS Use topical medications whenever possible vs. systemic treatment. Approved products for otitis contain a combination of antibiotics, antifungals, and/or anti-inflammatory medications Use according to the label. TOPICAL ANTIBIOTICS Enrofloxacin Gentamicin Neomycin Polymyxin B Florfenicol TOPICAL ANTIFUNGALS see below OTHER TOPICAL THERAPY Ear cleaners EDTA-Tris micronized silver ORAL Chloramphenicol INJECTABLE Aminoglycosides (amikacin, gentamicin) Carbapenems (imipenem, meropenem) Second-generation cephalosporins (cefoxitin) Third-generation cephalosporins (ceftazidime) Penicillin-Beta-Lactamase Inhibitor (piperacillin-tazobactam) ORAL Metronidazole plus Amoxicillin–clavulanic acid or Fluoroquinolone1 Clindamycin plus Amoxicillin–clavulanic acid or Fluoroquinolone1 BASED ON CULTURE AND SENSITIVITY Methicillin-resistant Staphylococcus spp. Treatment should be guided by culture and susceptibility testing. Options can include: Chloramphenicol Fluoroquinolones1 Rifampin Tetracyclines (doxycycline or minocycline) Linezolid TOPICAL TREATMENT Mupirocin Also consider topical options listed above. Resistant infections in sinuses (rhinitis) can be caused by Pseudomonas aeruginosa. Susceptibility tests are needed to guide treatment. Choices may include: ORAL Fluoroquinolones1 INJECTABLES Carbapenems (eg, meropenem) Ceftazidime ORAL Fluoroquinolones1 INJECTABLE Aminoglycosides (amikacin, gentamicin) Carbapenems (imipenem, meropenem) Third-generation cephalosporins (ceftazidime) Note: When evaluating antimicrobial susceptibility test results for lower urinary tract infections, the susceptibility testing breakpoint is higher for some agents to account for high urine concentrations. These agents include: Cephalexin Cefazolin Amoxicilin Amoxicillin-clavulanate Cefovecin. Check with laboratory for test interpretation. Note: If ESBL-producing strains are identified treatment may be limited to carbapenems, amikacin, ceftazidime or cefepime (if susceptible). ORAL Fluoroquinolones1 INJECTABLE Aminoglycosides (amikacin, gentamicin) Carbapenems (imipenem, meropenem) Third-generation cephalosporins (ceftazidime) Methicillin-resistant Staphylococcus spp. Treatment should be guided by culture and susceptibility testing. Options can include: Chloramphenicol Rifampin Trimethoprim-sulfonamides Tetracyclines (doxycycline, minocycline) Linezolid Vancomycin (injection) can be considered when there are no other options. ORAL Amoxicillin–clavulanic acid Cefpodoxime proxetil Chloramphenicol Fluoroquinolones1 Ormetoprim–sulfadimethoxine Trimethoprim–sulfonamide TOPICAL ANTIMICROBIALS For resistant Pseudomonas aeruginosa or methicillin-resistant Staphylococcus spp., highly concenterated compounded preparations are sometimes needed for topical use. Use cautiously because neurological disease and ocular problems have been associated with treatment. For additional recommendations to treat methicilln-resistant Staphylococcus spp. see the skin infections section. Fungal Infection Systemic Therapy Itraconazole Ketoconazole Posaconazole Mycoplasma Infection Tetracycline (doxycycline, minocycline) Fluoroquinolones1 Macrolides (azithromycin, clarithromycin) Note: Many lower respiratory infections can be a mixed-population and broad coverage for gram-positive, and gram-negative bacteria may be needed. Results from a transtracheal wash may not be representative of all bacteria present. Viral Infection (eg, FIV, FHV), especially in cats Note: Culture of oral infections may not be rewarding because there may be a mixed population of bacteria. Anaerobic bacteria and Pasteurella multocida may be the predominant cause. Therefore select antibiotics for these bacteria for initial treatment (eg, amoxicillin-clavulanate, pradofloxacin cats only, or clindamycin), in addition to other dental procedures that may be necessary. Deep Penetrating Wounds (Consider anaerobic coverage) Malassezia Infection Topical Therapy Lime sulfur Miconazole Climbazole Terbinafine Selenium sulfide Systemic Therapy Fluconazole Itraconazole Ketoconazole Terbinafine Parasites (mites and fleas) Treat appropriately with approved products. Allergy Treat appropriately with approved products. Chlamydia Infection Tetracycline (doxycycline, minocycline) Azithromycin Fluoroquinolone1 Fungal Nasal Aspergillus Topical Antifungal Clotrimazole Enilconazole Systemic Therapy Itraconazole Posaconazole Mycoplasma Infection Systemic Therapy Tetracyclines (doxycyline, minocylcine) Fluoroquinolones1 Macrolides (azithromycin, clarithromycin) Note: Feline upper respiratory infections may have a viral component, which may not require antibacterial therapy. Antiviral treatment may be required for severe infection. Candida (Fungal) Infection Fluconazole Leptospirosis (Leptospira spp.) Amoxicillin Amoxicillin–clavulanic acid Doxycycline Mycoplasma Infection Fluoroquinolones1 Macrolides (azithromycin, clarithromycin) Prostate Fluoroquinolones1 Ormetoprim–sulfadimethoxine Trimethoprim–sulfonamide Borreliosis (joint infection); see Bloodborne Infections Fungal Osteomyelitis (blastomycosis, coccidioidomycosis) Systemic Therapy Amphotericin B Itraconazole Ketoconazole Other considerations: Diskospondylitis is often difficult to culture, unless with an invasive procedure. Most are caused by Staphylococcus spp. therefore, agents active against Staphylococcus should be a initial consideration (eg, oral cephalosporin, amoxicillin-clavulanate, clindamycin). Malassezia Topical Antifungal Clotrimazole Miconazole Terbinafine Otodectes Topical Therapy Miticide Selamectin Systemic Therapy (consult susceptibility test first, before using a systemic drug for treatment.) INJECTABLE Carbapenems (imipenem, meropenem) Ceftazidime Systemic Therapy (as an adjunct to topical therapy; e.g., middle ear involvement) Hypersensitivity and Allergy Giardia Albendazole Fenbendazole Metronidazole Tritrichomonas foetus (cats) Ronidazole2 Coccidiosis Sulfonamides or trimethoprim-sulfonamide, or ormetoprim-sulfadimethoxine Campylobacter Fluoroquinolones1 Azithromycin Clindamycin (Warn owners that this can be zoonotic) Salmonella Fluoroquinolones1 , amoxicillin-clavulanate, trimethoprim-sulfonamide, or a 3rd-generation cephalosporin Clostridium Metronidazole, amoxicillin, a macrolide, or clindamycin Most Common Diagnoses Commonly Associated Pathogens Empirical Antimicrobial First Choice Resistant/ Severe Infections Antibiotic Selection Should Be Based on Culture and Sensitivity Testing Other Considerations AEROBES ANAEROBES GRAM + GRAM - Staphylococcus Streptococcus E. coli Proteus Pseudomonas AEROBES ANAEROBES GRAM + GRAM - Enterococcus Staphylococcus Streptococcus Campylobacter E. coli Enterobacter Klebsiella Salmonella Clostridium Peptostreptococcus Actinomyces Bacteroides, Prevotella, Porphyromonas. AEROBES ANAEROBES GRAM + GRAM - Enterococcus Staphylococcus Streptococcus B. bronchiseptica E. coli Klebsiella Pasteurella Pseudomonas Actinomyces Clostridium Nocardia Peptostreptococcus Bacteroides Fusobacterium Prevotella AEROBES ANAEROBES GRAM + GRAM - Staphylococcus Streptococcus Enterobacteriaceae, Pasteurella Peptostreptococcus Bacteroides Porphyromonas Prevotella AEROBES ANAEROBES GRAM + GRAM - Staphylococcus Streptococcus Brucella E. coli Enterococcus Pasteurella Actinomyces Clostridium Peptostreptococcus Bacteroides Fusobacterium AEROBES ANAEROBES GRAM + GRAM - Staphylococcus Streptococcus E. coli Pasteurella Proteus Pseudomonas Actinomyces Clostridium Bacteroides AEROBES ANAEROBES GRAM + GRAM - Staphylococcus Streptococcus B. bronchiseptica Pasteurella, Pseudomonas aeruginosa. AEROBES ANAEROBES GRAM + GRAM - Enterococcus Staphylococcus Streptococcus E. coli Enterobacter Klebsiella Proteus Pseudomonas Provided as an educational resource. Sponsored by Zoetis Petcare. Authored by Mark G. Papich, DVM, MS, DACVCP, North Carolina State University, College of Veterinary Medicine. All trademarks are the property of Zoetis Services LLC or a related company or a licensor unless otherwise noted. © 2020 Zoetis Services LLC. All rights reserved. AIF-00612 1 Fluoroquinolones include:enrofloxacin, marbofloxacin, orbifloxacin, and pradofloxacin. Ciprofloxacin and levofloxacin are human-labeled fluoroquinolones that are appropriate in some situations. Consult other references before considering these human-approved agents. Pradofloxacin is approved for dogs and cats in Canada, and European countries. In the U.S. it is approved only for cats. 2 Not available in the United States except on a limited experimental basis. 3 Cefovecin: check susceptibility test results to be sure the isolate is susceptible. For cats susceptible isolates will have MIC values < 0.12 mcg/mL or < 0.5 mcg/mL for dogs. TM
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