What is the recommended antibiotic regimen based on the local antibiogram in Fort Worth, Texas?

Recommended Antibiotic Regimen Based on Local Antibiogram in Fort Worth, Texas

Empiric antibiotic therapy in Fort Worth, Texas should be guided by the local institutional antibiogram, which should be regularly updated to reflect current resistance patterns and inform appropriate treatment decisions. 1

Importance of Local Antibiogram Data

• The Infectious Diseases Society of America (IDSA) and American Thoracic Society strongly recommend that empiric treatment regimens be informed by the local distribution of pathogens and their antimicrobial susceptibilities 1
• Each healthcare facility in Fort Worth should maintain and regularly update their antibiogram to guide empiric therapy
• The frequency of updates should be determined by the institution based on:
  • Rate of change in resistance patterns
  • Available resources
  • Amount of data available for analysis

Empiric Therapy Recommendations

For Community-Acquired Infections:

• Respiratory infections:

  • First-line: Amoxicillin-clavulanate 875/125 mg PO every 12 hours or 500/125 mg PO every 8 hours for 7-14 days 2
  • Alternative: Doxycycline for respiratory tract infections 2

• Urinary tract infections:

  • Consider local resistance patterns when selecting therapy
  • Avoid TMP-SMX and ciprofloxacin if local resistance exceeds 20% 3
  • First-line alternatives: Nitrofurantoin or fosfomycin (shown to have low resistance rates in similar settings) 3

• Skin and soft tissue infections:

  • First-line: Amoxicillin-clavulanate for 7-10 days 2
  • If MRSA suspected: Consider clindamycin or TMP-SMX based on local susceptibility patterns 2

For Hospital-Acquired Infections:

• Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP):

  • Early VAP (≤7 days): Coverage should be based on local antibiogram data 4
  • Late VAP (>7 days): Broader coverage needed due to increased risk of resistant organisms 4

• For patients with risk factors for multidrug-resistant (MDR) pathogens:

  • Prior IV antibiotic use within 90 days
  • Septic shock at time of VAP
  • ARDS preceding VAP
  • Five or more days of hospitalization prior to VAP
  • Acute renal replacement therapy prior to VAP onset 1

• When MRSA coverage and double antipseudomonal/gram-negative coverage are appropriate:

  • Select one agent from each category:
    1. Gram-positive coverage: Vancomycin 15 mg/kg IV q8-12h or Linezolid 600 mg IV q12h
    2. Gram-negative β-lactam: Piperacillin-tazobactam 4.5 g IV q6h, Cefepime 2 g IV q8h, or Meropenem 1 g IV q8h
    3. Second gram-negative agent: Ciprofloxacin 400 mg IV q8h or an aminoglycoside 1

Special Considerations

• Monitoring resistance trends:

  • Continuous antibiogram monitoring is essential as pathogen distribution can change over time 4
  • Recent studies show increasing rates of resistant gram-negative organisms in early VAP and Stenotrophomonas and Acinetobacter in late VAP 4

• Decision support tools:

  • Digital antibiogram platforms can improve clinician confidence in antibiotic selection 5
  • Consider implementing web-based tools accessible via EHR to support antimicrobial stewardship

• Factors affecting resistance:

  • Prior antibiotic exposure significantly increases the risk of resistant infections
  • For patients with previous resistant infections, consider their prior culture results when selecting empiric therapy 3

Pitfalls to Avoid

• Relying on outdated antibiogram data:

  • Resistance patterns change over time; using outdated information may lead to inappropriate empiric therapy 4

• Ignoring patient-specific risk factors:

  • Consider individual risk factors for resistant organisms when selecting therapy 1

• Overuse of broad-spectrum antibiotics:

  • Balance providing adequate coverage with avoiding unnecessary broad-spectrum therapy that may lead to increased resistance, C. difficile infections, and adverse effects 1

• Failure to de-escalate:

  • Once culture results are available, narrow therapy based on susceptibility results to reduce selective pressure for resistance

Remember that the local antibiogram from each specific healthcare facility in Fort Worth should be the primary guide for empiric antibiotic selection, as resistance patterns can vary significantly between institutions even within the same city.