Problemas

Arsenal reducido Prdida de sensibilidad Tto emprico Enterococo +++ +++ ++ S. Viridans + Neumococo ++ ++ Meningococo + + ++ Hemofilus ++ ++ M. Catharralis ++ ++ S. Aureus Meti-R ++ ++ S. Coag. negativo ++ ++ B. Fragilis + + +++

Meningococo
Infecc respiratorias altas y bajas (bacteriemia) ITU inferior (uretritis) Sepsis +/- meningitis Meningitis +/- sepsis Cepas insensibles a penicilina Tto previo al ingreso en meningitis y mortalidad (BMJ 2006; 332:1299-1303 metaanalisis) Penicilina, cloranfenicol, cef. 3 generacin Cefotaxima o ceftriaxona (cloranfenicol si alergia) PG > 300.000 U/kg/da (cloranfenicol si alergia)

Ab po: combined risk ratio 0.17 (IC95%: 0.07 to 0.44)

Tto previo al ingreso y mortalidad

doctors are likely to prescribe oral antibiotics only when they do not consider the diagnosis to be meningococcal disease. The latter is more probable in case of milder or slower progressing disease. the observed beneficial effect of oral antibiotics on survival is strongly confounded by severity A higher proportion of patients given parenteral antibiotics before admission was associated with reduced mortality after such treatment and vice versa. This observation could be explained either through confounding by severity or by effect modification. study of Norgard et al,19 antibiotics before admission were recommended only in those cases of suspected meningococcal disease when petechiae or other signs of meningococcal sepsis were present or if the patient showed other signs of severe meningitis and the transport time to the nearest hospital was more than half an hour. parenteral antibiotic treatment before admission is that treatment facilities in primary care may be inadequate to deal with haemodynamic instability that might result from massive release of meningococcal endotoxins during initial phases of the therapy MODIFICACION EFECTO TTO PELIGROSO EN LOS GRAVES (no probado exp). OTROS: anafilaxia, retraso en dco PARECE QUE NO It is unlikely that studies of sufficient quality to give evidence of the effectiveness of antibiotic treatment before admission on survival in meningococcal disease will become available (data on severity of disease, disease evolution, and characteristics of subsequent hospital treatment) Such studies may never be done in view of the anticipated logistical and ethical difficulties. We cannot conclude from this review whether or not antibiotics given before admission have an effect on case fatality. The data are consistent with benefit when a substantial proportion of cases are treated. though the recent research paper published in BMJ on the role of prehospital parenteral penicillin (3) and the systematic review on this subject(4) did not provide conclusive evidence for the role of parenteral penicillin, administration of penicillin by the general practitioner indirectly implies that he/she has strongly considered the possibility of meningococcal disease by carefully looking for its symptoms and signs which in turn will lead on to rapid initiation of appropriate treatment in hospital resulting in reduced mortality.

Enterococo
ITU inferior, prostatitis.
Factores:
Nosocomial Cateter o instrumentacin urinaria.
Endocarditis (valvulopatas, cardiopata congnita, prtesis valvular, antecedentes de endocarditis)

Heridas quirrgicas, lceras de decbito, infecc. pie diabtico. Tratamiento:

Amoxicilina (+/- gentamicina) Gentamicina Nitrofurantoina Co-trimoxazol suele ser ineficaz Prostatitis crnica: refractaria al tto Ampicilina o vancomicina + gentamicina

S. viridans
Infecciones:
Infecc. buco dentales
Endocarditis (valvulopatas, cardiopata congnita, prtesis valvular, antecedentes de endocarditis)

Tratamiento:
Amoxicilina (y otros beta-lactmicos)
Resistencias a penicilina en pac. expuestos previamente

Eritromicina (y otros macrlidos) Clindamicina (Otros)

Profilaxis de endocarditis
Amoxicilina (2 g, po, 1 h antes) Clindamicina (600 mg, po, 1 h antes)

Neumococo
Infecciones: Otitis media aguda (+ H. Influenzae, M. Catharralis) Sinusitis aguda (+ H. Influenzae, anaerobios) Neumona (agentes atpicos y otros, si fact. Riesgo H. Influenzae; Klebsiella, anaerobios-) Meningitis: Neumococos resistentes a penicilina (Meningococo y otros, segn edad) EPOC reagudizada (H. Influenzae, M. Catharralis) Tratamiento: Amoxicilina +/- clavulanico, cefalosporinas Vancomicina, ceftriaxona , co-trimoxazol Clindamicina, macrlidos Levofloxacino, moxifloxacino

Resistencia a penicilina y cefalosporinas; posible papel de otros MO y gravedad de la infeccin.

% de resistencia (Pk/Pd breakpoints)

Antimicrobial Agent S. pneumoniae Amoxicillin-clavulanate Amoxicillin Cefaclor Cefixime Cefpodoxime Cefprozil Cefuroxime Azitromicina Clindamycin TMP-SMX Doxiciclina Levofloxacino 90 90 27 57 63 64 64 67 89 57 76 99,8 (D?) H. influenzae M. catarrhalis 97 61 2 99 99 18 79 0 N/A <10? 75 20 (?) 100 100 14 5 100 100 6 37 N/A >95? N/A <10? 9 96 99

Claritromicina: >90%; 0%, >90%? Ciprofloxacino: >90%; >70%, >90%?

Neumococo et al
Neumococo ms:

Otitis media ag. Sinusitis ag. Neumona Meningitis EPOC reagudizada

H. Influenzae y M. catharralis H. Influenzae, estaf, anaerobios Micoplasma, clamidia, legionella Meningococo y H. Influenzae H. Influenzae y M. catharralis

Amoxicilina + clavulanico, cefuroxima axetil, ceftriaxona, azitromicina, claritromicina Amoxicilina + clavulanico, cefuroxima, ceftriaxona axetilo, levofloxacino, moxifloxacino Macrlido, levofloxacino Ceftriaxona + vancomicina +/- rifampicina Amoxicilina + clavulanico, cefuroxima axetil, levofloxacino

S. aureus
Infecciones cutneas
Impetigo, foliculitis, fornculos, golondrinos, mastitis, infecc. de heridas, celulitis.

Antibiticos
Mupirocina o fusidico tpicos (imptigo) Amoxiciclina+ clavulnico Clindamicina Cloxacilina, cefalosporina de 1 generacin Levofloxacino (moxifloxacino?)

Otros agentes:
S. piognicos, H. influenzae (nio), BG-, anaerobios (mitad inferior cuerpo, DM, escaras, insuf. vascular, mordeduras)

Los SAMR comunitarios conservan susceptibilidad a clindamicina, doxiciclina y co-trimoxazol

(1) infection of the epidermis is represented by impetigo; (2) infection of the superficial dermis by folliculitis; (3) infection of the deep dermis by furuncles, carbuncles, and hidradenitis suppurativa; and (4) infection of subcutaneous cellular tissues by erysipelas, cellulitis, and fasciitis.

S. saprophyticus
20% de las ITU inferior en mujeres sanas de 16 a 35 aos Clnica inespecfica (>90% sintomticas) Resistente a cido nalidxico, R+/- a sulfamidas y norfloxacina R mltiple R intermedia a vancomicina Minociclina Rifampicina + clindamicina Daptomicina, linezolid, quinupristina/dalfopristina

Hemfilus
Meningitis, epiglotitis, celulitis, otitis media, sinusitis, EPOC reagudizada, bronquitis, conjuntivitis purulenta, neumona (anciano, EPOC), orbital cellulitis, endophthalmitis, urinary tract infection Antibiticos activos:
Amoxicilina-clavulanico, cefuroxima-axetil y cefalosporinas de 3 generacin Quinolonas fluoradas Azitromicina y claritromicina Co-trimoxazol

% de resistencia (Pk/Pd breakpoints)

Antimicrobial Agent S. pneumoniae Amoxicillin-clavulanate Amoxicillin Cefaclor Cefixime Cefpodoxime Cefprozil Cefuroxime Azitromicina Clindamycin TMP-SMX Doxiciclina Levofloxacino 90 90 27 57 63 64 64 67 89 57 76 99,8 (D?) H. influenzae M. catarrhalis 97 61 2 99 99 18 79 0 N/A <10? 75 20 (?) 100 100 14 5 100 100 6 37 N/A >95? N/A <10? 9 96 99

Claritromicina: >90%; 0%, >90%? Ciprofloxacino: >90%; >70%, >90%?

Hemfilus et al
Neumococo ms:

Otitis media ag. Sinusitis ag. Neumona Meningitis EPOC reagudizada

H. Influenzae y M. catharralis H. Influenzae, estaf, anaerobios Micoplasma, clamidia, legionella Meningococo y H. Influenzae H. Influenzae y M. catharralis

Amoxicilina + clavulanico, cefuroxima axetil, ceftriaxona, azitromicina, claritromicina Amoxicilina + clavulanico, cefuroxima, ceftriaxona axetilo, levofloxacino, moxifloxacino Macrlido, levofloxacino Ceftriaxona + vancomicina +/- rifampicina Amoxicilina + clavulanico, cefuroxima axetil, levofloxacino

M. Catharralis
14 20 % de otitis medias 30% de reag. de EPOC 3 causa de sinusitis 10% de las neumonas en anciano (diabetes, ICC, EPOC) Antibiticos:
Amoxicilina-clavulanico, cefuroxima-axetil y cefalosporinas de 3 generacin Quinolonas fluoradas Azitromicina y claritromicina

Anaerobios
Gram-negative Gram-positive Bacteroides spp. * Peptostreptococcus spp. Porphyromonas spp. Clostridium spp. Prevotella spp. Actinomyces spp. Fusobacterium spp. *: B. fragilis es el ms frecuente entre ellos colonization resistance, vit K, abs. de lipidos, colesterol

Boca: Prevotella and Porphyromonas species

Colon: Fusobacterium y grupo Bacteroides fragilis Vaginal: Prevotella, Bacteroides, Fusobacterium y Clostridium

Anaerobios
B. fragilis ...most commonly isolated , particularly in infections emanating from the lower intestine Clostridia are commonly isolated from wounds, abscesses, and blood. oral cavity Prevotella and Porphyromonas are pathogenic species. Prevotella bivia and Prevotella disiens colonize the vagina most frequently isolated from infections arising at this site. The fusobacteria are often isolated from necrotizing pneumonia and abscesses.

Anaerobios
B. Fragilis es B. fragilis ...most commonly isolated , particularly in resistente a infections emanating from the lower intestine y a otros penicilina anaerobicidas Clostridia are commonly isolated from wounds, abscesses, and blood. oral cavity Prevotella and Porphyromonas are pathogenic species. Prevotella bivia and Prevotella disiens colonize the vagina most frequently isolated from infections arising at this site. The fusobacteria are often isolated from necrotizing pneumonia and abscesses.

Abdominal Cavity (mixta, B. fragilis) Peritonitis Intra-abdominal abscess Appendicitis Liver abscess Wound infection Biliary tract infections Mouth, Head, and Neck Sinusitis (mixta) Otitis media Periodontitis Root canal infection Periodontal abscess Ocular infections Thoracic Cavity Empyema Lung abscess Aspiration pneumonia

Pelvic Cavity/Vagina (B. fragilis, mixta o no) Pelvic inflammatory disease Vaginal abscess, pelvic abscesses, septic abortion, endometritis, tuboovarian abscess. Skin and Soft Tissue Infections (contamination with fecal or oral flora) Diabetic foot ulcers Cutaneous abscess Gas gangrene Bite wound infections Central Nervous System Brain abscess Subdural empyema Epidural abscess

Bacteriemia: B. fragilis (flebitis (15%) o foco abdominal)

Anaerobios: tratamiento (Ubi pus, ibi evacua)

<2% Resistance Imipenem Meropenem Metronidazole Ticarcillin/clavulanic acid Piperacillin/tazobactam Chloramphenicol Amoxicilina/Clavulnico
Variable Resistance Penicillin Cephalosporins Tetracycline Vancomycin Erythromycin Resistance Aminoglycosides Quinolones (exc. moxifloxacino) Monobactams

<15% Resistance Cefoxitin Clindamycin High-dose antipseudomonal penicillins

Anaerobios: tratamiento (Ubi pus, ibi evacua) Amoxicillin-clavulnico Chloramphenicol Metronidazole Moxifloxacin Clindamycin (ha perdido actividad frente a B fragilis) NO: aminoglycosides, trimethoprimsulfamethoxazole, most third-generation cephalosporins, quinolones and monobactams

Metronidazol
B. fragilis y otros anaerobios No aerobios, asociar:
Enterococo (i. intra abd.): vanco, ampi CG+ (i. dental, pulmon): clindamicina, amoxicilina, quinolona BG- (i. intra abd.): genta, ceftriaxona

No Actinomyces spp ni Propionibacterium spp

Anaerobios
Infecc. dentales Sinusitis crnica Otitis con mastoiditis or colesteatoma Parotiditis (S. aureus y anaerobios) Neumona por aspiracin (boca en mal estado) Infecciones intra-abdominales (B. fragilis) Bacteremia por bacteroides: origen intra-abdominal (fragilis) 50-66%; tracto genital femenino, 8% to 25%; tejidos blandos (u. decbito), 5% to 10% Endocarditis Piel y tejido subcutneo: patologa vascular, heridas con contaminacin fecal o saliva, diabetes, decbitos (B. fragilis), mordeduras, quiste pilonidal infect. fascitis necrotizante: Bacteroides y Prevotella spp. B. fragilis en infecc. cutneas situadas en la mitad inferior del cuerpo. Osteomielitis (fragilis) y artitris

Anaerobios: eleccin del ab

Absceso SNC: metronidazol (cloranfenicol) + ampi o cefalosporina de 3 generacin, segn origen Mordedura humana (Prevotella spp., penic. R+/-, Eikenella corrodens, staf.): clinda + quinolona, amoxi + clavulanico. Infecc. pulmonar por aspiracin (flora anaerobica bucal): clindamicina (+/- cef. 3); amoxicilina + clavulanico (+/- metronidazol); no usar monoterapia con metronidazol (estreptococos). Infecc. intra-abdominales (B. fragilis + otros anaerobios + BG-): Metronidazol+ cef. 3 o quinolona (+/- gentamicina) o Tracto genital femenino (BG- + anaerobios B. fragilis- + estreptococos): como infecc intra-abdominales Piel y tejidos blandos: Amoxicilina+clavulnico o clindamicina + quinolona (asociar metronidazol si B. fragilis)