Narrow spectrum (β-lactamase susceptible)

• Penicillin G (IV)
  
• Benzathine penicillin G (IM)
  
• Procaine penicillin G (IM)
  
• Penicillin V (PO)

• Streptococcus Group A, B, viridans
  
• Most Streptococcus pneumoniae
  
• Treponema pallidum
  
• Neisseria meningitidis
  
• Actinomyces spp.
  
• Pasteurella multocida
  
• Some anaerobes

• Anaphylaxis
  
• Rash
  
• Drug fever
  
• Bone marrow suppression
  
• Hemolytic anemia
  
• Interstitial nephritis
  
• Renal impairment

• Penicillin V is acid stable in the stomach
  
• Resistance caused by degradation of antibiotic by bacterial penicillinases

Aminopenicillins

• Ampicillin (IV, IM, PO)
  
• Amoxicillin (PO)

• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Enterococcus spp.
  
• Listeria monocytogenes
  
• Haemophilus influenzae if β-lactamase negative
  
• Kingella kingae
  
• Some gram- negative organisms: Escherichia coli, Salmonella spp., Shigella spp., Proteus spp.

• GI disturbance
  
• Elevated LFTs
  
• Bone marrow suppression
  
• Hemolytic anemia
  
• Allergic reaction
  
• Renal impairment

• Better PO with amoxicillin than ampicillin

β-Lactamase resistant (antistaphylococcal penicillins)

• Nafcillin (IV)
  
• Oxacillin (IV)
  
• Dicloxacillin (PO)

• S. aureus (MSSA)
  
• Streptococcus Group A, B, viridans
  
• S. pneumoniae

• Interstitial nephritis
  
• Renal impairment
  
• Hepatic toxicity
  
• Bone marrow suppression
  
• Allergic reaction

• No activity against gram-negative organisms
  
• Nafcillin causes more phlebitis than oxacillin (decreased with slow infusion, large-gauge IV)

Antipseudomonal penicillins

• Piperacillin (IV)
  
• Ticarcillin (IV)
  
• Carbenicillin (PO)

• Pseudomonas aeruginosa
  
• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Enterococcus spp.
  
• Some gram-negative → Escherichia coli, Enterobacter spp., Salmonella spp., Shigella spp., Proteus spp., Citrobacter spp., Haemophilus spp.
  
• Neisseria spp.

• Platelet dysfunction
  
• High Na load
  
• Hypokalemia
  
• Serum sickness
  
• Bone marrow suppression
  
• Renal impairment

• S. viridans and Enterococci are only 30%-60% susceptible

Penicillin + β-lactamase inhibitor

• Amoxicillin + clavulanate (PO)
  
• Ticarcillin + clavulanate (IV)
  
• Ampicillin + sulbactam (IV)
  
• Piperacillin + tazobactam (IV)

• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Enterococcus spp.
  
• S. aureus (MSSA)
  
• Gram-negative organisms: E. coli, Klebsiella spp., Salmonella spp., Shigella spp., Proteus spp., Aeromonas spp., Pasteurella multocida
  
• P. aeruginosa (piperacillin/tazobactam and ticarcillin/ clavulanate)
  
• Anaerobes

• GI disturbance
  
• Diarrhea (especially amoxicillin/clavulanate)
  
• Rash
  
• Renal impairment

• S. viridans and Enterococci are only 30%–60% susceptible to ticarcillin/clavulanate and piperacillin/tazobactam

First generation

• Cefazolin (IV)
  
• Cephradine (IV, PO)
  
• Cephalexin (PO)
  
• Cefadroxil (PO)
  
• Cephapirin (IV)

• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• S. aureus (MSSA)
  
• Some gramnegative organisms: M. catarrhalis, H. influenzae, E. coli, Klebsiella spp., Proteus spp.

• Anaphylaxis
  
• Rash
  
• Delayed rash
  
• Drug fever
  
• Bone marrow suppression
  
• Renal impairment

• Minimal CSF penetration
  
• Renal excretion
  
• Cephalosporins have no activity against Enterococcus spp.

Second Generation

• Cefamandole (IV, IM)
  
• Cefuroxime (IV, PO)
  
• Cefonicid (IV)
  
• Cefaclor (PO)
  
• Cefprozil (PO)
  
• Cefotetan (IV)
  
• Cefoxitin (IV, IM)

• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• S. aureus (MSSA)
  
• Some gram-negative organisms: M. catarrhalis, H. influenzae, E. coli, Klebsiella spp., Proteus spp.
  
• Some anaerobes (cefotetan, cefoxitin)

• Allergic reaction
  
• Coagulation disturbance
  
• Bone marrow suppression
  
• Renal impairment

• Minimal CSF penetration
  
• Renal excretion
  
• Decreased gram-positive activity compared with first generation but improved gram-negative activity

Third generation

• Cefotaxime (IV, IM)
  
• Ceftizoxime (IV, IM)
  
• Ceftriaxone (IV, IM)
  
• Ceftazidime (IV, IM)
  
• Cefixime (PO)
  
• Cefpodoxime (PO)
  
• Cefdinir (PO)
  
• Ceftibutin (PO)

• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Decreased anti-staphylococcal activity
  
• Neisseria spp.
  
• Gram-negative organisms: M. catarrhalis, H. influenzae, E. coli, Klebsiella spp., Enterobacter spp., Salmonella spp., Shigella spp., Proteus spp., Citrobacter spp., Aeromonas spp.
  
• P. aeruginosa (ceftazidime only)

• Biliary sludging (ceftriaxone)
  
• Allergic reaction
  
• Bone marrow suppression
  
• Renal impairment

• Good CSF penetration for cefotaxime, ceftriaxone, and ceftazidime
  
• Renal excretion
  
• Better gram-negative activity, less gram-positive activity compared with first- and second- generation cephalosporins except for S. pneumoniae
  
• Ceftriaxone is a strong bilirubin displacer from albumin, limiting its use in neonates

Fourth generation

• Cefepime (IV, IM)

• Pseudomonas aeruginosa
  
• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Neisseria spp.
  
• Gram-negative organisms: M. catarrhalis, H. influenzae, E. coli, Klebsiella spp., Enterobacter spp., Salmonella spp., Shigella spp., Proteus spp., Citrobacter spp., Aeromonas spp.

• Allergic reaction
  
• Bone marrow suppression
  
• Renal impairment

• Good gram-positive activity except (S. aureus and Enterococcus spp.) and gram-negative activity, including Pseudomonas spp.

• Aztreonam (IV, IM)

• Gram-negative organisms only: Neisseria spp., M. catarrhalis, H. influenzae, E. coli, Klebsiella spp., Serratia spp., Salmonella spp., Shigella spp., Proteus spp., Citrobacter spp., Aeromonas spp., Pseudomonas spp.

• GI disturbance
  
• Rash

• Good CSF penetration
  
• Renal excretion
  
• No activity against gram-positive organisms or anaerobes

Bactericidal: Inhibit cell wall biosynthesis

Examples

Antimicrobial Spectrum

Adverse Effects

Miscellaneous

• Meropenem (IV, IM)
  
• Imipenem (IV, IM)

• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• S. aureus (MSSA)
  
• Anaerobes
  
• Gram-negative organisms: Neisseria spp., M. catarrhalis, H. influenzae, E. coli, Klebsiella spp., Serratia spp., Salmonella spp., Shigella spp., Proteus spp., Citrobacter spp., Aeromonas spp., Pseudomonas spp.

• GI disturbance
  
• Allergic reaction
  
• Seizures with imipenem in children with meningitis

• Renal excretion
  
• No activity against Enterococcus spp., Burkholderia cepacia, Stenotrophomonas maltophilia

• Vancomycin (IV, PO)

• S. aureus (MSSA & MRSA)
  
• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Enterococcus spp.
  
• CONS
  
• Bacillus spp.
  
• Gram-positive anaerobes: Actinomyces spp., Clostridium spp., Peptostreptococcus spp.
  
• Use in high doses as an alternative for treatment of Listeria in a penicillin allergic patient

• Red man syndrome
  
• Ototoxicity
  
• Renal toxicity, particularly in combination with other nephrotoxic drugs

• Renal excretion
  
• Activity against most gram-positive organisms
  
• No activity against gram-negative organisms except Flavobacterium meningosepticum
  
• PO for C. difficile infections ONLY

• Azithromycin (IV, PO)
  
• Erythromycin (IV, PO, ophthalmic ointment)
  
• Clarithromycin (PO)

• Atypical organisms→ Legionella spp., Mycoplasma spp., Chlamydia spp.
  
• Bordetella pertussis
  
• Streptococcus spp.
  
• Mycobacterium avium
  
• Gram-negative organisms: Neisseria spp., M. catarrhalis, H. influenzae, B. henselae

• GI disturbance
  
• Rare cholestatic jaundice
  
• Prolonged QT syndrome
  
• Erythromycin ethylsuccinate use has been associated with pyloric stenosis in neonates

• Metabolized by cytochrome P450; thus, multiple drug interactions
  
• Can use azithromycin or clarithromycin as empiric therapy for cat scratch disease

• Clindamycin (IV, IM, PO)

• S. aureus (MSSA & MRSA)
  
• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Anaerobes
  
• Toxoplasma gondii
  
• Plasmodium falciparum and vivax

• Pseudomembranous colitis
  
• Hepatotoxicity
  
• GI disturbance
  
• Bone marrow suppression
  
• Rash

• Bile and urine excretion
  
• No activity against gram-negative organisms
  
• No activity against Enterococci
  
• Minimal CSF penetration

• Linezolid (IV, PO)

• S. aureus (MSSA & MRSA)
  
• CONS
  
• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Enterococcus spp. (including VRE)
  
• Nocardia spp.

• GI disturbance
  
• Bone marrow suppression
  
• Lactic acidosis
  
• Peripheral neuropathy
  
• Serotonin syndrome
  
• Optic neuritis

• Metabolized partially in liver
  
• Excreted in urine
  
• Expensive
  
• Side effects associated with longer use (>4 wk)
  
• 100% oral bioavailability
  
• Active against some atypical mycobacteria

• Tetracycline (PO)
  
• Doxycycline (IV, PO)
  
• Minocycline (PO)

• Rickettsia spp.
  
• Chlamydia spp.
  
• Mycoplasma spp.
  
• Entamoeba histolytica
  
• Ehrlichia spp.
  
• Anaerobes
  
• Streptococcus Group A, B, viridans
  
• S. aureus (MSSA & MRSA)
  
• Gram-negative organisms: M. catarrhalis, H. influenzae, E. coli, Legionella spp., Brucella spp.
  
• Propionibacterium acnes

• GI disturbance
  
• Phototoxic dermatitis
  
• Renal toxicity
  
• Hepatic toxicity
  
• Staining of permanent teeth
  
• Fanconi syndrome
  
• Teratogenic

• Absorption is impaired by food, milk, Ca, Mg
  
• Avoid use in children <8 yr if alternate antibiotic is available except for treatment of Rocky Mountain spotted fever

• Amikacin (IV, IM)
  
• Gentamicin (IV, IM)
  
• Streptomycin (IV, IM)
  
• Tobramycin (IV, IM, inhaled)

• Gram-negative enteric organisms
  
• P. aeruginosa
  
• Tularemia spp.
  
• Yersinia pestis
  
• Brucella spp. (plus TMP/SMX or azithromycin)
  
• Mycobacterium tuberculosis and other atypical mycobacteria
  
• Gram-positive synergy (GBS, E. faecalis, α strep)

• Ototoxicity
  
• Renal toxicity
  
• Competitive neuromuscular blockade

• Renal excretion
  
• CNS penetration minimal even when meninges inflamed

First generation quinolone

• Nalidixic acid (PO)

• Not currently available in the United States

Second generation quinolone

• Ciprofloxacin (IV, PO)
  
• Ofloxacin (PO, ophthalmic, otic)
  
• Levofloxacin (IV, PO, ophthalmic)

• Gram-negative organisms
  
• P. aeruginosa
  
• Legionella spp., Brucella spp.
  
• Atypical mycobacterium
  
• S. aureus (MSSA)
  
• S. pneumoniae for levofloxacin

• Damage to cartilage in animals
  
• GI disturbance
  
• CNS symptoms
  
• Tendonitis
  
• Clostridium difficile colitis
  
• Prolonged QT interval
  
• Hepatic dysfunction
  
• Rash
  
• Drug interactions common, check prior to prescribing

• Use of fluoroquinolones should be avoided in children <18 yr; ciprofloxacin is FDA approved in children <18 yr for postexposure treatment of inhalation anthrax and complicated UTI
  
• Resistance develops by point mutations of DNA gyrase enzyme

Third generation quinolone

• Gatifloxacin (PO, ophthalmic)

• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Enterococcus spp. UTI
  
• S. aureus (MSSA & MRSA)
  
• Listeria spp.
  
• Gram-negative organisms
  
• Pseudomonas aeruginosa

• Damage to cartilage in animals
  
• GI disturbance
  
• CNS symptoms
  
• Hyper- and hypoglycemia
  
• C. difficile colitis
  
• Drug interactions common, checked prior to prescribing

• Resistance develops by point mutations of DNA gyrase enzyme

Fourth generation quinolone

• Moxifloxacin (IV, PO, ophthalmic)

• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Enterococcus spp. UTI
  
• S. aureus (MSSA & MRSA)
  
• Listeria spp.
  
• Gram-negative organisms
  
• P. aeruginosa
  
• Anaerobes

• Damage to cartilage in animals
  
• GI disturbance
  
• CNS symptom
  
• C. difficile colitis
  
• Drug interactions common, check prior to prescribing

• Treatment of choice for open globe injuries
  
• Resistance develops by point mutations of DNA gyrase enzyme

• Trimethoprim/ sulfamethoxazole (IV, PO)

• Gram-negative enterics
  
• S. pneumoniae
  
• S. aureus (MSSA & MRSA)
  
• Pneumocystis jiroveci
  
• Chlamydia spp.
  
• Toxoplasma spp.
  
• Nocardia spp.
  
• Legionella spp.
  
• Brucella spp.
  
• Stenotrophomonas maltophilia

• Allergic reaction
  
• Rash
  
• GI disturbance
  
• Bone marrow suppression
  
• Stevens-Johnson syndrome

• Metabolized in liver
  
• Renal excretion
  
• No Group A Strep activity
  
• No Enterococcus activity
  
• Contraindicated <3 months of age due to risk of hyperbilirubinemia

• Metronidazole (IV, PO)

• Anaerobes
  
• Clostridium spp.
  
• Trichomonas
  
• Entamoeba histolytica
  
• No aerobic activity

• Neutropenia
  
• Metallic taste
  
• Reversible peripheral neuropathy
  
• Antabuse effect when consumed with alcohol

• Good CSF penetration

• Daptomycin (IV)

• S. aureus (MSSA and MRSA)
  
• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• Enterococcus spp.

• GI disturbance
  
• Rash
  
• Headache
  
• Insomnia
  
• Myopathy (elevates CK)

• Renal excretion
  
• Low lung penetration and decreased activity by pulmonary surfactant; should not be used to treat pneumonia

• Rifampin (IV, PO)

• S. aureus (MSSA and MRSA)
  
• Streptococcus Group A, B, viridans
  
• S. pneumoniae
  
• CoNS
  
• Listeria spp.
  
• Neisseria spp.
  
• M. catarrhalis,
  
• H. influenzae
  
• Brucella spp.
  
• M. tuberculosis

• Asymptomatic jaundice
  
• Hepatotoxicity
  
• Reddish/orange discoloration of urine, sweat, tears

• Penetrates into all fluids and tissues
  
• Excreted via liver
  
• Rapid development of resistance when used alone
  
• Synergistic applications (CONS and S. aureus)
  
• Useful in treating device-related infections
  
• Should not be used alone to treat infection
  
• Many drug interactions

Acyclovir (IV, PO)

• Guanosine analogue
  
• Inhibits DNA polymerase

• HSV1 and 2
  
• VZV
  
• CMV prophylaxis after BMT

• Nephrotoxic
  
• Neurotoxic
  
• GI disturbance with PO
  
• Phlebitis (pH, 9–11)

• Ensure adequate hydration
  
• Not as effective against CMV or EBV

Valacyclovir (PO)

• Prodrug of acyclovir

• Herpes zoster
  
• Primary and recurrent HSV
  
• CMV prophylaxis after BMT

• GI disturbance
  
• Headache
  
• Dizziness
  
• Bone marrow suppression (prolonged administration)

• Enhanced PO absorption

Famciclovir (PO)

• Prodrug of penciclovir (a DNA polymerase inhibitor)

• Recurrent VZV
  
• Recurrent HSV

• GI disturbance
  
• Headache
  
• Dizziness, confusion

• Enhanced PO absorption

Ganciclovir (IV)

• Inhibits DNA polymerase

• CMV
  
• HSV1 and 2
  
• VZV

• Neutropenia
  
• Thrombocytopenia
  
• CNS
  
• Phlebitis (pH, 11)

• Discontinue if ANC <500

Valganciclovir (PO)

• Prodrug of ganciclovir

• CMV
  
• HSV1 and 2
  
• VZV

• Same as ganciclovir
  
• Diarrhea

• Liquid pediatric formulation not available
  
• Requires fewer pills than PO ganciclovir

• Cidofovir (IV)

• Cytosine analogue
  
• Inhibits DNA polymerase

• CMV
  
• HSV (especially acyclovir resistant)
  
• EBV
  
• Adenovirus
  
• HPV
  
• BK virus

• Nephrotoxic (50%) causing Fanconi syndrome
  
• Neutropenia
  
• Ocular toxicity

• Perform frequent urinalysis
  
• Document ophthalmologic evaluation
  
• A nephrotoxic sparing protocol for administration is widely utilized

Foscarnet (IV)

• Pyrophosphate analogue
  
• Inhibits viral DNA polymerase and reverse transcriptase

• CMV
  
• HSV (especially acyclovir resistant)
  
• VZV (especially acyclovir resistant)

• Anemia
  
• CNS toxicity
  
• Reversible nephrotoxicity (30%)
  
• Electrolyte abnormalities (chelates bivalent ions)

• Ensure adequate hydration

• Inhibits uncoating of influenza A

• Influenza A prophylaxis and treatment

• CNS effects
  
• Anticholinergic
  
• Teratogenic

• Renal excretion
  
• Not effective against influenza B

Rimantadine (PO)

Oseltamivir (PO)

• Neuraminidase inhibitor

• Influenza A and B prophylaxis and treatment

• Dizziness
  
• Headache
  
• Fatigue
  
• Insomnia
  
• Vertigo

• Must be started within 2 d of onset of flu symptoms
  
• Resistance may develop

• Epistaxis

• Do not use in patients with COPD or asthma

Ribavirin (PO, INH, IV)

• Guanosine analogue
  
• Inhibits DNA polymerase

• RSV
  
• Lassa fever
  
• Hantavirus
  
• Hepatitis C
  
• Influenza

• Hemolysis with IV form
  
• Topical irritation
  
• Teratogenic in small mammals

• Very expensive
  
• Broad antimicrobial activity
  
• Intermittent, high-dose nebulizations preferred to continuous therapy

Interferon alpha 2b (IV, IM, SC)

• Induces host cell production of proteins with antiviral activity

• Chronic hepatitis C
  
• Chronic hepatitis B
  
• Condyloma acuminatum from HPV

• Influenza-like syndrome
  
• Bone marrow suppression
  
• Neuropsychiatric problems

• When interferon is discontinued, >50% of patients will have a relapse

Trifluridine (ophthalmic)

• Nucleoside analogue
  
• Inhibits DNA polymerase

• HSV keratitis

• Only to be used topically

Aspergillosis (Aspergillus spp.)

• Ubiquitous

• ENT:
  
  
  
  • Otomycosis (external ear canal)
    
  • Allergic sinusitis (nasal polyps, history of sinusitis, sinus surgery—chronic sinusitis, dark plugs of nasal discharge)
  
  
• Lung:
  
  
  
  • Noninvasive pulmonary aspergillosis
    
  • Aspergilloma in patients with underlying lung disease, such as CF or TB hemoptysis, cough, fever.
    
  • ABPA results from host hypersensitivity—wheezing, brown mucus plugs, fever, eosinophilia, pulmonary infiltrates (asthma/CF)
    
  • Invasive pulmonary aspergillosis in neutropenic patients: Necrotizing or granulomatous pneumonia that can disseminate; invasive (immunocompromised—pulmonary, sinus, cerebral, cutaneous)

• Invasive: Voriconazole or amphotericin B 1-1.5mg/kg/day (non-liposomal) or echinocandin for invasive disease; Aspergilloma surgical excision
  
• Otomycosis: topical irrigation ± PO antifungals
  
• Sinusitis: steroids, surgery
  
• ABPA: corticosteroids + itraconazole (CID 2008;46:327)

Blastomycosis (Blastomyces dermatitidis)

• Southeastern, central, Great Lakes area in US
  
• Canada, Africa, India
  
• Exposure: Soil, wooded areas

• Asymptomatic (50%)
  
• Pulmonary (children)
  
• Cutaneous (ulcerative > nodular > verrucous)
  
• Disseminated disease: ≤80% commonly affects bones, skin, CNS, abdominal viscera, GU tract

• Amphotericin B until improvement (usually 2 wk) followed by PO itraconazole for at least 6–12 mo (CID 2008;46:1801)

Candidiasis (Candida spp.)

• Ubiquitous

• Oropharyngeal (thrush)
  
• Esophageal
  
• Vaginal
  
• Cutaneous: Intertriginous, paronychia, onychia
  
• Immunocompromised: Systemic, respiratory, CNS, chronic mucocutaneous candidiasis
  
• Endocarditis
  
• Neonatal: See chapter 31

• Immunocompetent oropharyngeal or esophageal: PO nystatin or clotrimazole troches
  
• Immunocompromised: Fluconazole or itraconazole (14–21 days for esophagitis)
  
• Cutaneous: Topical nystatin or azoles
  
• Vulvovaginal: Topical (OTC) or PO azoles
  
• Candidemia or invasive candidiasis: Fluconazole, liposomal amphotericin B, or echinocandins
  
• Chronic mucocutaneous: Fluconazole/itraconazole/low-dose amphotericin B for severe cases (0.3 mg/kg/day) (CID 2009;48(5):503)

Coccidioidomycosis (Coccidioides immitis)

• Southwestern US: CA, AZ, NM, TX, UT
  
• Northern Mexico
  
• Central and South America

• Acquired by inhalation
  
• Asymptomatic or self-limited (60%)
  
• Malaise, fever, cough, myalgia, headache, chest pain; rash (early: diffuse erythematous or maculopapular; late: erythema multiforme, erythema nodosum)
  
• Disseminated: <1%; skin, bones, joints, lungs, CNS

• Primary uncomplicated disease: usually self-limited, no treatment needed
  
• Severe or progressive disease: Amphotericin B for 1–12 mo; itraconazole or fluconazole may be used for less severe cases
  
• CNS involvement: Consultation with specialist (CID 2005;41:1217)

Cryptococcosis (Cryptococcus neoformans)

• Worldwide; present in aged pigeon droppings

• Acquired by inhalation
  
• Pulmonary nodules or infiltrates
  
• Disseminated in immunocompromised patients; meningoencephalitis is most common

• For CNS disease: amphotericin B with PO flucytosine for 2 wk followed by fluconazole for 10 wk or amphotericin B and flucytosine for 6–10 wk; monitor CSF during therapy
  
• Lifelong prophylaxis for immunocompromised patients (CID 2000;30:710)

Histoplasmosis (Histoplasma capsulatum)

• Eastern, central US, Mississippi, Ohio, and Missouri River valleys
  
• Exposure: caves, wooded or demolition areas.

• Acquired by inhalation
  
• Pulmonary (flu like symptoms, infiltrates)
  
• Cutaneous lesions
  
• Progressive disseminated histoplasmosis may occur in children <2 yr

• Uncomplicated, immunocompetent host: no treatment
  
• Disseminated and CNS disease: Amphotericin B for 4–6 wk followed by itraconazole for 3–6 mo

Paracoccidioidomycosis (Paracoccidioides brasiliensis)

• Latin America from Mexico to Argentina (usually in adults)

• Constitutional symptoms
  
• Lymphadenopathy, HSM

• Amphotericin B followed by itraconazole or itraconazole alone for 6 mo

Sporotrichosis (Sporothrix schenckii)

• Tropical or subtropical climates: North, Central, and /South America

• Fixed cutaneous (single violaceous nodule)
  
• Lymphocutaneous (multiple nodules along lymphatic)
  
• Pulmonary and disseminated disease rare in children

• Lymphocutaneous or fixed cutaneous: Super-saturated potassium iodide (40–50 drops PO TID; itraconazole × 3–6 mo)
  
• Extracutaneous: Amphotericin B or itraconazole for 3–6 mo; Disseminated: amphotericin B; surgery may be required for cavitary pulmonary disease (CID 2007;45:1255)

Amebiasis (Entamoeba histolytica)

• Worldwide

• Fecal–oral (ingestion of amebic cysts)
  
• Sexually

• Diarrhea
  
• Dysentery
  
• Tenesmus
  
• Liver Abscess
  
• Peritonitis
  
• Ameboma

• Trophozoites or cysts visualized on wet mount exam of stool
  
• Biopsy
  
• IHA for serum Ab

• Asymptomatic: Iodoquinol, paromomycin, diloxanide
  
• Liver abscess or other extraintestinal infections: metronidazole or tinidazole

Giardiasis (Giardia spp.)

• Worldwide; many animal reservoirs; daycare; camping; swimming

• Acute
  
• Watery diarrhea
  
• Abdominal Pain
  
• Foul-Smelling Stools
  
• Malabsorption
  
• Anemia

• Stool antigen testing
  
• 3 stool exams for cysts evaluation of duodenal aspirate (rare)

• Metronidazole × 5–7 days; tinidazole × 1 dose; nitazoxanide × 3 days

Ascaris lumbricoides

• Tropical areas

• Ingestion of eggs from contaminated soil

• Often asymptomatic
  
• Malnutrition, GI symptoms
  
• Löffler Syndrom‡
  
• Obstruction

• Ova on microscopic exam of stool

• Single-dose albendazole or ivermectin
  
• Metronidazole for 3 days
  
• Conservative management of obstruction (NG suction, IVF)
  
• Surgery may be required

Balantidium coli

• Reservoir: Pigs

• Fecal–oral (ingestion of cysts in contaminated water or food)

• Often asymptomatic
  
• N/V
  
• Abdominal discomfort
  
• Diarrhea

• Serial O&P (fresh stool)
  
• Endoscopy, exam of scrapings, bx

• Tetracycline 40 mg/kg/day × 10 days
  
• Alternatives: metronidazole, iodoquinol

Cryptosporidiosis (Cryptosporidium species)

• Summer and early fall
  
• Multiple animal reservoirs
  
• Water-borne outbreaks (eg, swimming)

• Fecal–oral (ingestion of cysts in contaminated water or food)

• Nonbloody
  
• Profuse watery diarrhea

Note: Cystoisospora may cause eosinophilia

• Antigen testing (eg, IFA, EIA)
  
• Serial micro exam of stool (≥3; sucrose flotation + Kinyoun stain)
  
• Intestinal bx

• Usually no treatment required in immunocompetent hosts
  
• Nitazoxanide × 3 days
  
• Immunocompromised: PO human IVIG or bovine colostrum

Cyclosporiasis (Cyclospora cayetanensis)

• Tropical/ subtropical areas: particularly Nepal, Peru, Haiti, Guatemala, Indonesia

• Serial stool micro exam (modified acid-fast stain)

• TMP/SMX × 7–10 days

Cystoisosporiasis (Cystoisospora belli)

• Tropical or subtropical areas

• Serial stool micro exam (modified acid-fast stain)
  
• Duodenal aspirate, small intestine bx
  
• String test

• TMP/SMX × 10 days
  
• Pyrimethamine

Microsporidiosis (Microsporidia spp.)

• Worldwide opportunistic infection in immunocompromised hosts

• Fecal–oral (ingestion of spores in contaminated water or food)

• Varies according to causal species
  
• Afebrile
  
• Watery
  
• Nonbloody diarrhea most commonly

• Micro exam of stained fecal samples
  
• EM (gold standard)
  
• Antigen testing
  
• PCR

• Restoration of immune function
  
• Albendazole
  
• Metronidazole
  
• Atovaquone
  
• Nitazoxanide
  
• Fumagillin

Strongyloidiasis (Strongyloides stercoralis)

• Tropics
  
• Subtropics
  
• Southeastern US
  
• Multiple animal reservoirs

• Skin penetration of larvae from contaminated soil

• Asymptomatic
  
• Rash at entry site
  
• Abdominal pain
  
• Malabsorption
  
• Vomiting/diarrhea
  
• Eosinophilia
  
• Löffler syndrome‡

• Serial micro exam of fresh
  
• Concentrated stool for larvae
  
• Duodenal aspirate or string test

• Ivermectin
  
• Alternative: Albendazole

Tapeworm (Taenia spp.)

• Latin America
  
• Asia
  
• E. Africa
  
• Central Europe
  
• Reservoirs: cattle
  
• Pigs

• Fecal–oral (ingestion of undercooked beef or pork)

• Nausea
  
• Diarrhea
  
• Abdominal pain
  
• Neurocysticercosis

• Exam of perianal area
  
• Proglottids or ova in stool
  
• Consider neuroimaging

• Taenia: praziquantel
  
• Neurocysticercosis: See Clin Microbiol Rev 2002;15:747

Malaria (Plasmodium spp.)

• Tropics

• Injection of sporozoites by Anopheles mosquito bite

• Fever
  
• Rigors
  
• Sweats
  
• Headache
  
• Hemolysis

• Thick and thin blood films Q12–24 h

• ICU care for >5% parasitemia
  
• Exchange transfusion for >10%
  
• rx depends on strain, where contracted, clinical status

African sleeping sickness (Trypanosoma spp.)

• Africa

• Injection of trypomastigotes by tsetse fly (Glossina species) bite

• Cutaneous nodule
  
• Chancre
  
• Fever
  
• Posterior cervical LAD
  
• Chronic meningoencephalitis

• Exam of blood
  
• CSF
  
• Chancre fluid
  
• LAD
  
• Giemsa stain of buffy coat

• Pentamidine (W. African disease)
  
• Suramin (E. African disease)

Chagas disease (Trypanosoma cruzi)

• Mexico
  
• Central America
  
• South America

• Inoculation with trypomastigotes in feces of reduviid bug after bite

• Red nodule
  
• Fever
  
• Generalized LAD
  
• Malaise
  
• HSM
  
• Romaña’s sign (unilateral palpebral or periocular swelling)

• Giemsa staining concentrated blood, wet mount or buffy coat prep
  
• Serologic testing

• Benznidazole
  
• Nifurtimox (CDC)

Cutaneous larva migrans (Ancylostoma spp.)

• Southeastern US

• Skin penetration of larvae from contaminated soil

• Pruritic, reddish papules at site of entry (creeping eruption)
  
• Löffler syndrome‡

• See clinical presentation
  
• Biopsy (rare)

• Usually self-limited
  
• Albendazole
  
• Ivermectin
  
• Topical thiabendazole

Hookworm infection (Ancylostoma duodenale, Necator americanus)

• Worldwide

• Skin penetration of larvae from contaminated soil
  
• Rarely by ingestion

• Hypochromic, microcytic anemia from chronic GI bleeding
  
• Growth delay
  
• Cognitive deficits

• Eggs seen on micro exam of stool with saline or potassium iodide

• Albendazole
  
• Mebendazole
  
• Pyrantel pamoate

Naegleria fowleri

• Worldwide (uncommon)
  
• Warm fresh water, moist soil
  
• Usually occurs in the summer in the US

• Invasion of the brain from the nose along the olfactory nerves by trophozoites

• Fever
  
• Headache
  
• Disturbances of smell or taste, meningoencephalitis, seizures

• Microscopic evaluation of wet mount of spun CSF
  
• Culture
  
• Giemsa stain of CSF smear

• Amphotericin B ± miconazole/ rifampin

Pediculosis (Pediculus humanus capitis—head lice)

(Pediculus humanus corporis—body lice)

• Worldwide

• Direct contact with hair of infested people or with personal belongings

• Itching
  
• Asymptomatic

• Identification of eggs (nits), nymphs, or lice

• 1% or 5% permethrin (consider retreatment in 7–10 days)
  
• Pyrethrin and piperonyl butoxide (2 doses 7–10 days apart)
  
• Malathion (contraindicated in children <2 yr) Ivermectin for treatment failures
  
• Evaluate and treat household contacts

• Worldwide

• Poor hygiene
  
• Contact with infested clothing/fomites

• Itching, particularly at night

• Improve hygiene; clean clothes and bedding

Pinworm infection (Enterobius vermicularis)

• Worldwide

• Fecal–oral (ingestion of eggs from contaminated hands and fomites)

• Anal or vulvovaginal itching, irritability

• Examine anus (preferably 2–3 h after asleep) to check for eggs
  
• Scotch tape test§

• Mebendazole
  
• Pyrantel Pamoate
  
• Albendazole
  
• Repeat in 2 wk
  
• Morning baths
  
• Change linens frequently
  
• Treat entire household

Toxocariasis (Toxocara canis or cati)

• Hot, humid, underserved urban areas
  
• Reservoirs: dogs, cats

• Ingestion of eggs from contaminated soil

• Fever
  
• Leukocytosis
  
• Eosinophilia
  
• Hepatomegaly
  
• Wheezing

• Elevated Ig
  
• Isohemagglutinin
  
• EIA (CDC)

• Albendazole
  
• Alternatively: mebendazole
  
• Steroids if severe

Toxoplasmosis (Toxoplasma gondii)

• Worldwide
  
• Reservoir: cats

• Ingestion of cysts in raw or undercooked meat, soil, contaminated food or water

• Fever
  
• Sore throat
  
• Myalgia
  
• LAD

• Serology
  
• IgG and IgM
  
• IgG avidity test
  
• IgA, IgE

• Pyrimethamine + sulfadiazine or clindamycin + leucovorin
  
• Consult infectious disease specialist if host is pregnant or congenitally infected

Babesiosis (Babesia microti in the US; other Babesia spp.)

Vector: Ixodes scapularis

Reservoir: White-footed mouse

• Northeast, Midwestern, Western U.S
  
• Late spring, summer, and autumn
  
• Frequent co-infection with Lyme’s parasite

• Often asymptomatic
  
• Malaise
  
• Anorexia
  
• Nausea or vomiting
  
• Fatigue
  
• High fever
  
• Minimal physical findings: HSM.
  
• Hemolytic anemia

Note: Transmissible through blood transfusion

• Thick or thin blood smear stained with Giemsa or Wright stain (Morphologically similar to Plasmodium spp., and disease can be indistinguishable from malaria)
  
• Serology and PCR available from CDC

• Clindamycin + PO quinine for 7–10 days
  
• Atovaquone + azithromycin for 7–10 days
  
• Consider exchange transfusion if ≥10% parasitemia or severe disease

Lyme disease (Borrelia burgdorferi)

Vectors: Ixodes scapularis, Ixodes pacificus

• Southern New England, eastern mid-Atlantic, upper Midwest, West Coast
  
• Mostly April–October with peak from June–July

• Early localized: erythema migrans, flulike illness
  
• Disseminated:
  
  
  
  • Early (∼ 3–5 wk after the tick bite) Systemic symptoms, cranial nerve palsies, meningitis, carditis
    
  • Late: arthritis, encephalitis, polyneuropathy

• Clinical
  
• Serology (screen with EIA or IFA, if +, do Western blot; IgG and IgM if early; only IgG if late)
  
• Intrathecal antibody for CNS (NEJM 2001;345:115)

• Early localized: ≥8 yr: doxycycline†; <8 yr: amoxicillin or cefuroxime for 2–3 wk
  
• Disseminated or late: Treat 3–4 wk
  
  
  
  • Arthritis: Ceftriaxone or PCN × 2–3 wk
    
  • Facial palsy: Same as early localized but × 3–4 wk
  
  
• Watch for Jarisch-Herxheimer reaction‡

Relapsing fever (Borrelia spp., usually B. hermsii in US)

Vector: Ornithodoros ticks

• Western mountains, Texas in US
  
• Sporadic cases

• Sudden high fever
  
• Chills
  
• Sweats
  
• Headache
  
• Myalgia, arthralgia
  
• Nausea
  
• Macular rash
  
• Petechiae (skin, mucous membranes)

• Dark-field microscopy: Thin or dehemoglobinized thick blood smears stained with Wright, Giemsa, or acridine orange; buffy coat preparation
  
• Obtain when patient is febrile

• Doxycycline† × 5–10 days
  
• Penicillin or erythromycin for children <8 yr or pregnant women
  
• Jarisch-Herxheimer reaction‡ common

Human granulocytotropic anaplasmosis (Anaplasma phagocytophilum)

Vectors: Ixodes scapularis and Ixodes pacificus in the US

• New England, North Central and Pacific states
  
• Usually occurs April–September

• Fever
  
• Headache
  
• Malaise
  
• Myalgia
  
• Leukopenia
  
• Lymphopenia
  
• Hyponatremia
  
• ↑ ALT

• Specific antibody titer ≥1:64 or a fourfold increase using IFA
  
• Specific PCR in reference labs

• Doxycycline† 4 mg/kg/ day (max dose: 100 mg/dose) for a minimum of 7 days or until 3 days after defervescence

Human monocytotropic ehrlichiosis (Ehrlichia chaffeensis)

Vectors: Amblyomma americanum (Lone Star tick), Dermacentor variabilis (dog tick) are the major tick vectors

• South and mid-Atlantic, North and South Central US, isolated areas in New England
  
• Usually occurs April– September

Rocky Mountain spotted fever (Rickettsia rickettsii)

Vectors: Dermacentor variabilis (dog tick), Dermacentor andersoni (Rocky Mountain wood tick)

• Widespread throughout US, especially south Atlantic, southeastern and south central states; Canada, Mexico, Central and South America
  
• Usually occurs
  
• April– September

• Systemic small vessel vasculitis
  
• Fever, myalgia, headache
  
• Nausea or vomiting
  
• Anorexia
  
• Petechial rash starting on wrists or ankles→ trunk
  
• Including palms or soles
  
• All three, fever, rash, headache, present in only 60% of patients

• Specific antibody titer ≥1:64: Probable diagnosis if clinically compatible or fourfold increase using IFA, enzyme immunoassay, CF, latex agglutination, IHA, or microagglutination
  
• PCR

• Doxycycline† × 7–10 days

Immediate TST or IGRA indicated for:

Children who have one of following:

• Contact with person with confirmed or suspected infectious TB or with persons in jail or prison in the past 5 years
  
• CXR or clinical findings suggestive of TB
  
• Immigration from endemic countries (Asia, Middle East, Africa, Latin America), international adoptees
  
• Travel history to endemic countries or significant contact with indigenous persons from TB endemic countries

Annual TST or IGRA indicated for:

Children with HIV or incarcerated adolescents

Testing every 2–3 years

Children exposed to the previously mentioned high-risk individuals

Indications for testing 4–6 yo and 11–16 yo children

Children whose parents or other household contacts immigrated from endemic areas or who frequently travel to endemic areas

• Close contact with known or contagious TB case
  
• Children suspected to have TB:
  
  
  
  • Abnormal chest X-ray consistent with TB (prior or active)
    
  • Clinical evidence of tuberculosis
  
  
• HIV-infected and other immunosuppressed patients

• Known risk factors
  
• Infants and children <4 yr
  
• Foreign-born people from high-prevalence countries
  
• Children in close contact with high-risk adults
  
• Residents of prisons, nursing homes, and institutions
  
• Health care workers in high-risk settings
  
• Some low-income populations
  
• IV drug users
  
• Locally identified high-risk populations

Children >4 yr with no risk factors

Latent TB infection (LTBI)

Isoniazid* for 9 mo

TB disease†

Isoniazid + rifampin + pyrazinamide + ethambutol ‡ × 2 mo → isoniazid + rifampin × 4 mo OR

Isoniazide + rifampin + ethambutol‡ × 2 mo → isoniazid + rifampin × 7 mo

Isoniazid*

15–20 mg/kg/day (not to exceed 300 mg/day); use 10 mg/kg/day if rifampin is given simultaneously

Alternate regimen: 20–30 mg/kg/dose PO twice weekly × 9 mo

900 mg/day

Rifampin

10–20 mg/kg/day

600 mg/day

Pyrazinamide

15–30 mg/kg/day

2000 mg/day

Ethambutol†

15–20 mg/kg/day or 50 mg/kg twice weekly

1000 mg max daily dose or 2500 mg max biweekly dose