Bacteremia Medication

  • Author: Nicholas John Bennett, MB, BCh, PhD; Chief Editor: Russell W Steele, MD   more...
 
Updated: May 3, 2012
 

Medication Summary

See Medical Care.

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Antibiotic Agents

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

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Amoxicillin (Amoxil, Biomox, Trimox)

 

Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria.

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Ampicillin (Marcillin, Omnipen, Polycillin, Principen, Totacillin)

 

Bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication PO. Until recently, the HACEK bacteria were uniformly susceptible to ampicillin. Recently, however, beta-lactamase–producing strains of HACEK have been identified.

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Ceftriaxone (Rocephin)

 

Third-generation cephalosporin with broad-spectrum gram-negative activity, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

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Cefotaxime (Claforan)

 

For septicemia and treatment of gynecologic infections caused by susceptible organisms. Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.

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Gentamicin (Garamycin, I-Gent, Jenamicin)

 

Aminoglycoside antibiotic used for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Consider if penicillins or other less-toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be administered IV/IM.

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Vancomycin (Vancocin, Vancoled, Lyphocin)

 

Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or who have not responded to penicillins and cephalosporins or who have infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes.

To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients diagnosed with renal impairment.

Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.

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Nafcillin (Unipen, Nafcil, Nallpen)

 

Initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections.

Initially use parenteral therapy in severe infections. Change to PO therapy as condition warrants.

Because of thrombophlebitis, particularly in children or elderly patients, administer parenterally only for short term (1-2 d); change to PO route as clinically indicated.

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Meropenem (Merrem)

 

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci compared to imipenem.

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Imipenem and cilastatin (Primaxin)

 

For treatment of multiple organism infections in which other agents do not have wide spectrum coverage or are contraindicated because of potential for toxicity.

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Cefepime (Maxipime)

 

Fourth-generation cephalosporin with good gram-negative coverage. Similar to third-generation cephalosporins but has better gram-positive coverage.

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Antipyretic Agents

Class Summary

Inhibits central synthesis and release of prostaglandins that mediate the effect of endogenous pyrogens in the hypothalamus; thus, promotes the return of the set-point temperature to normal.

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Ibuprofen (Advil, Excedrin IB, Ibuprin, Motrin)

 

One of the few NSAIDs indicated for reduction of fever.

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Acetaminophen (Aspirin Free Anacin, Feverall, Tempra, Tylenol)

 

Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.

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Contributor Information and Disclosures
Author

Nicholas John Bennett, MB, BCh, PhD,  Assistant Professor in Pediatrics, Division of Infectious Diseases, Connecticut Children's Medical Center

Nicholas John Bennett, MB, BCh, PhD, is a member of the following medical societies: Alpha Omega Alpha and American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Domachowske, MD  Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Brian J Holland, MD  Assistant Professor of Pediatrics, Pediatric Cardiology, University of Louisville School of Medicine

Brian J Holland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, and American College of Cardiology

Disclosure: Nothing to disclose.

Specialty Editor Board

Itzhak Brook, MD, MSc  Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Mark R Schleiss, MD  American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School

Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

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Application of low-risk criteria and approach for the febrile infant: A reasonable approach for treating febrile infants younger than 3 months who have a temperature of greater than 38°C.
Application of algorithms for children aged 3-36 months: A reasonable approach for treating infants and young children aged 3-36 months who have a temperature of at least 39.5°C.
Table 1. Age, Fever, and Bacterial Infection[36]
AgeTemperature, Degrees CelsiusRate of Bacterial Infection, %
Neonates < 1 mo38-38.95
39-39.97.5
≥ 4018
Infants aged 1-2 mo38-38.93
39-39.95
≥ 4026
Table 2. Children Aged 3-36 Months - Fever and Occult Bacteremia[2, 4, 6, 9, 37]
Temperature, Degrees CelsiusOccult Pneumococcal Bacteremia, %Positive Blood Culture, %Positive Blood Culture, %Occult Pneumococcal Bacteremia, %
≤ 39Very low1.61…
39-39.41.21.65…
39.5-39.72.52.85…
39.8-39.92.52.85…
40-40.23.23.7510-10.4
40.3-40.53.23.7510-10.4
40.5-40.94.43.81210-10.4
≥ 419.39.21210-10.4
Table 3. Causes of Occult Bacteremia in Neonates and Infants with a Temperature of 38°C or Higher[15, 16, 12, 13, 14]
AgeOrganism*Positive Blood Cultures, %
Neonates < 1 moGroup B Streptococcus73
Escherichia coli8
S pneumoniae3
Staphylococcus aureus3
Enterococcus species3
Enterobacter cloacae3
Infants aged 1-2 moGroup B Streptococcus31
E coli20
Salmonella species16
S pneumoniae10
H influenzae type b6
S aureus4
E cloacae4
* Also, less frequently (< 1%), Listeria species, Klebsiella species, group A Streptococcus, Staphylococcus epidermis, Streptococcus viridans, and N meningitidis
Table 4. Causes of Occult Bacteremia and Changes Over Time in Children Aged 3-36 Months with FWS[4, 2, 8, 11, 17, 27, 20]
Organism*1975-1993, %1993, %1993-1996, %1990 to present, %
S pneumoniae83-86939289
H influenzae type b5-13200
N meningitidis1-3………
Salmonella species1-7………
* Also, less frequently (< 1%), E coli, S aureus, Streptococcus pyogenes, group B Streptococcus, Moraxella species, Kingella species, Yersinia species, and Enterobacter species
Table 5. Studies Evaluating the Established WBC More Than 15 per HPF Screen for Occult Bacteremia in FWS
StudyCutoffNPV, %PPV, %
Kuppermann, 1999[2] WBC >15996
Lee, 2001[21] WBC >15995
Strait, 1999[31] WBC >15986
Table 6. Recent Studies Reevaluating WBC Count as a Screen in FWS
StudyScreening GoalCutoff, per HPFNPV, %PPV, %
Fernandez Lopez, 2003[47] Invasive bacterial infection*WBC >176969
Pulliam, 2001[48] Serious bacterial infection†WBC >158930
Lacour, 2001[49] Serious bacterial infection‡WBC >158946
Isaacman, 2002[50] Occult bacterial infection§WBC >179530
* Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; dimercaptosuccinic acid (DMSA)–positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months



† Culture-positive bacteremia/meningitis/septic arthritis/urinary tract infection (UTI); focal infiltrate on chest radiograph



‡ Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia



§ Culture-positive bacteremia/UTI; lobar pneumonia



Table 7. ANC as a Screen for Occult Bacteremia[2, 31]
ANCSensitivity, %Specificity, %PPV, %NPV, %
10,0007678899.2
>7,20082747.599.4
Table 8. Studies Reevaluating CRP level as a Screen in FWS
StudyScreening GoalCutoffNPV, %PPV, %
Lopez, 2003[47] Invasive bacterial infection*2.88169
Pulliam, 2001[48] Serious bacterial infection†598Not reported
Lacour, 2001[49] Serious bacterial infection‡49651
Gendrel, 1999[52] Invasive bacterial infection§49734
Isaacman, 2002[50] Occult bacterial infectionll4.49430
* Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months



† Culture-positive bacteremia/meningitis/septic arthritis/UTI; focal infiltrate on chest radiography



‡ Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia



§ Culture-positive bacteremia/sepsis/meningitis



ll Culture-positive bacteremia/UTI; lobar pneumonia



Table 9. Recent Studies Evaluating PCT level as a Screen in FWS
StudyScreening GoalCutoffNPV, %PPV, %
Lopez, 2003[47] Invasive bacterial infection*0.69091
Lacour, 2001[49] Serious bacterial infection†19755
Gendrel, 1999[52] Invasive bacterial infection‡29952
* Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months



† Culture-positive bacteremia/meningitis/osteomyelitis; DMSA-positive pyelonephritis; lobar pneumonia



‡ Culture-positive bacteremia/sepsis/meningitis



Table 10. Effect of Illness Duration - PCT level as a Screen in FWS[47]
Illness DurationScreening GoalOptimal CutoffNPV, %PPV, %
Any (< 12 h and >12 h)Invasive bacterial infection*0.69091
< 12 hInvasive bacterial infection*0.79097
*Culture-positive bacteremia/meningitis/sepsis/bone/joint infection; DMSA-positive pyelonephritis; lobar pneumonia; bacterial enteritis in infants younger than 3 months
Table 11. Low-Risk Criteria for Infants Younger than 3 Months[65, 66, 67, 8]
CriterionPhiladelphiaBostonRochesterAAP 1993
Age1-2 mo1-2 mo0-3 mo1-3 mo
Temperature38.2°C≥38°C≥38°C≥38°C
AppearanceAIOS* < 15WellAnyWell
HistoryImmuneNo antibiotics in the last 24 h;



No immunizations in the last 48 h



Previously healthyPreviously healthy
ExaminationNonfocalNonfocalNonfocalNonfocal
WBC count< 15,000/μL; band-to-neutrophil ratio



< 0.2



< 20,000/μL5-15,000/μL;



ABC < 1,000



5-15,000/μL;



ABC < 1,000



Urine assessment< 10 WBCs per HPF;



Negative for bacteria



< 10 WBCs per HPF;



Leukocyte esterase negative



< 10 WBCs per HPF< 5 WBCs per HPF
CSF assessment< 8 WBCs per HPF;



Negative for bacteria



< 10 WBCs per HPF< 10-20 WBCs per HPF…
Chest radiographyNo infiltrateWithin reference range, if obtainedWithin reference range, if obtained…
Stool culture< 5 WBCs per HPF…< 5 WBCs per HPF…
* Acute illness observation score
Table 12. Occult Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications[8, 10, 27, 11, 68]
ComplicationNo Antibiotic Therapy, %Oral Antibiotic Therapy, %Intramuscular/Intravenous Antibiotic Therapy, %
Persistent bacteremia18-213.8-50-5
New focal infection135-6.65-7.7
Meningitis9-104.5-8.20.3-1
Table 13. Pneumococcal Bacteremia - Relationship Between Outpatient Antibiotic Use and Complications[2, 8, 10, 18, 21, 29, 37, 69, 9]
ComplicationNo Antibiotic Therapy, %Any Antibiotic Therapy, %Oral Antibiotic Therapy, %Intramuscular/Intravenous Antibiotic Therapy, %
Persistent bacteremia7-171-1.52.5…
Focal infection/SBI9.7-103.3-4……
Meningitis2.7-60.4-10.4-1.50.4-1
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