Health care providers are regularly faced with having to decide how best to manage infections in a fast-paced primary care setting. Many common infections may be routinely and safely managed with outpatient oral antibiotics. However, several situations may warrant parenteral antibiotic therapy and/or inpatient admission. Key decision points are often reached for such common disease states as community-acquired pneumonia (CAP), skin and soft-tissue infections (SSTIs) in diabetics, and pelvic inflammatory diseases (PID).
>WHAT DO THE EXPERTS SAY?
CAP Safe management of CAP can be achieved with appropriate outpatient oral antibiotics, provided key parameters are considered. The CRB-65 score is a quick method for assessing risk and requires no laboratory studies or imaging. One point is awarded for the presence of each of the following: Confusion, Respiratory rate greater than or equal to 30 breaths per minute, BP of less than 90 mm Hg systolic OR 60 mm Hg diastolic, age 65 years or older. A score of 0 indicates low-risk/outpatient therapy; a 1 or 2 represents increased risk, with consideration of a short hospitalization; and a 3 or 4 warrants immediate admission.1 Appropriate outpatient empiric antibiotics for low-risk adults should include agents with coverage of Streptococcus pneumoniae and atypical pathogens, such as Mycoplasma pneumoniae and Chlamydia pneumoniae. Therapy should continue for at least 5 days and until the patient is afebrile for 48 to 72 hours.2 Patients with no other comorbidities who present in regions with low rates of S pneumoniae resistance may be treated with a macrolide, such as azithromycin, clarithromycin, or erythromycin. However, patients with other common comorbidities, such as diabetes; those with chronic cardiac, pulmonary, renal, or hepatic disease; or even otherwise healthy patients presenting in regions with increased rates of macrolide-resistant S pneumoniae (>25%) should receive therapy with a respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily) or a macrolide plus a beta-lactam. Preferred beta-lactams include high-dose amoxicillin (1 g three times daily) or amoxicillinclavulanate (2 g twice daily).2
SSTIs As a general rule, the etiology of SSTIs in reasonably well-controlled diabetic patients closely mimics that of nondiabetic patients, and treatment is the same. The chief exception is treatment of diabetic foot infections.3 Outpatient coverage for mild SSTIs should include antibiotics active against gram-positive cocci, such as Streptococcus pyogenes and Staphylococcus aureus. Nonpurulent cellulitis (ie, without abscess) is generally thought to be caused by S pyogenes in contrast to cellulitis with adjacent abscess, which is frequently linked to methicillin-resistant S aureus (MRSA).4 Mild cases without abscess may be treated with dicloxacillin or cephalexin (clindamycin, if the patient is allergic to beta-lactam agents). Draining a local abscess and providing outpatient antibiotic coverage is a reasonable approach for community-acquired MRSA as well as the usual streptococcal suspects, such as S pyogenes. Appropriate antibiotics include trimethoprim-sulfamethoxazole (TMP-SMX), doxycycline, or clindamycin. However, TMP-SMX and doxycycline may have suboptimal coverage of S pyogenes, and combination with a typical beta-lactam should be considered.5 Erythema may increase during the first 24 hours of treatment as bacteria are lysed by antibiotics. Reassessment should occur in 48 to 72 hours. Clinical worsening or appearance of systemic symptoms warrants prompt reevaluation and possible admission for parenteral antibiotic therapy.
PID Avoiding serious complications and long-term fertility implications in women is key. Bottom line upfront: Refer and admit cases involving pregnancy; surgical emergencies, such as appendicitis; possible ectopic pregnancy or abscess; nausea/vomiting that prevents adequate oral therapy; worsening symptoms after 48 to 72 hours of appropriate oral antibiotics; or lack of confidence that follow-up will occur in 72 hours. If none of the above applies, a reasonable outpatient regimen may include ceftriaxone 250 mg IM once plus doxycycline 100 mg and metronidazole 500 mg by mouth twice daily for 14 days.6 Don't forget to treat the sexual partner(s) for chlamydial and gonococcal infection.
1. Bauer TT, Ewig S, Marre R, et al. CRB-65 predicts death from community-acquired pneumonia. J Intern Med. 2006; 260(1):93-101.
2. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72.
3. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-e173.
4. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-e55.
5. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007;357(4):380-390.
6. Vergidis PI, Falagas ME. Pelvic inflammatory disease. In: Falagas ME, Mylonakis E, eds. Gorbach's 5-Minute Infectious Diseases Consult. 2nd ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2012:304-305.