Antimicrobial regimens for the treatment of Streptococcus anginosus group infections

Antimicrobial regimens for the treatment of Streptococcus anginosus group infections

	Adult dosing	Pediatric dosing
Initial antimicrobial regimen*
Preferred regimens	Ceftriaxone 2 g IV every 24 hours, or Penicillin G 2 to 4 million units IV every 4 to 6 hours PLUS Metronidazole 500 mg orally or IV every 8 hours	Ceftriaxone 50 to 100 mg/kg/dose IV every 24 hours (maximum: 1000 mg/dose), or Penicillin G 100,000 to 300,000 units/kg/day IV divided every 4 to 6 hours (maximum dose: 24 million units/day) PLUS Metronidazole 30 to 40 mg/kg/day orally or IV in 3 divided doses (maximum: 500 mg/dose)
Preferred regimens	Ampicillin-sulbactam^¶ 3 g IV every 6 hours	Ampicillin-sulbactam^¶ 100 to 200 mg ampicillin/kg/day IV divided every 6 hours (maximum: 2000 mg ampicillin/dose)
Alternative regimens (for patients who cannot tolerate or have contraindications to preferred regimens)	For patients who require anti-anaerobic therapy: Ertapenem 1 g IV every 24 hours	For patients who require anti-anaerobic therapy: Ertapenem Children ≥3 months to <13 years: 15 mg/kg/dose IV every 12 hours (maximum: 500 mg/dose) Children ≥13 years: 1 g IV every 24 hours
	For patients with endovascular infections without associated abscess: Vancomycin IV^Δ or Linezolid 600 mg orally or IV every 12 hours	For patients with endovascular infections without associated abscess: Vancomycin IV^◊ or Linezolid Children <12 years: 10 mg/kg/dose orally or IV every 8 hours (maximum: 600 mg/dose) Children ≥12 years: 600 mg orally or IV every 12 hours
Oral step-down regimens for select cases^§
Preferred regimens	Amoxicillin-clavulanate 875 mg/125 mg orally 2 to 3 times daily	Amoxicillin-clavulanate^¥ 45 mg amoxicillin/kg/day orally in 2 divided doses (maximum: 1750 mg/day)
Preferred regimens	Cefuroxime 500 mg orally twice daily PLUS Metronidazole 500 mg orally 3 times daily, or Clindamycin 300 mg orally 4 times daily or 300 to 450 mg orally 3 times daily	Cefuroxime 20 to 30 mg/kg/day orally in 2 divided doses (mild to moderate infection, maximum: 500 mg/dose) PLUS Metronidazole 30 to 40 mg/kg/day orally in 3 divided doses (maximum: 500 mg/dose), or Clindamycin 10 to 25 mg/kg/day orally in 3 divided doses (maximum: 1800 mg/day)
Alternative regimens (for patients who cannot tolerate or have contraindications to preferred regimens)	Linezolid 600 mg orally twice daily PLUS Ciprofloxacin 500 mg orally twice daily PLUS Metronidazole 500 mg orally every 8 hours, or Clindamycin 300 mg orally 4 times daily or 300 to 450 mg orally 3 times daily	Linezolid Children <12 years: 10 mg/kg/dose orally every 8 hours (maximum: 600 mg/dose) Children ≥12 years: 600 mg orally twice daily PLUS Ciprofloxacin 10 to 15 mg/kg/dose orally twice daily (maximum: 500 mg/dose)^‡ PLUS Metronidazole 30 to 40 mg/kg/day orally in 3 divided doses (maximum: 500 mg/dose), or Clindamycin 10 to 25 mg/kg/day orally in 3 divided doses (maximum: 1800 mg/day)

Selected antimicrobial regimens are listed here. Other regimens with the same spectrum of activity are also appropriate. The doses recommended in this table are intended for patients with normal kidney and liver function. Pediatric dosing is intended for patients >28 days of age, unless otherwise noted. Refer to Lexicomp drug monographs and the UpToDate clinical topic review of S. anginosus group infections for additional information.

IV: intravenously.

* Dosing of certain antimicrobials (eg, ceftriaxone, penicillin G, ampicillin, clindamycin) for treatment of severe infections (eg, central nervous system infections, endocarditis) differs from the doses listed in this table. Refer to Lexicomp drug monographs.

¶ Ampicillin-sulbactam is a combination product formulated in a 2:1 ratio (eg, each vial contains 2 g of ampicillin and 1 g of sulbactam). Adult dosing is provided as total grams of ampicillin and sulbactam. Pediatric dosing is expressed as mg of ampicillin component.

Δ For severely ill patients, a vancomycin loading dose (20 to 35 mg/kg) is appropriate; within this range, we use a higher dose for critically ill patients. The loading dose is based on actual body weight, rounded to the nearest 250 mg increment and not exceeding 3000 mg. The initial maintenance dose and interval are determined by nomogram (typically 15 to 20 mg/kg every 8 to 12 hours for most patients with normal kidney function). Subsequent dose and interval adjustments are based on area under the curve (AUC)-guided or trough-guided serum concentration monitoring. Refer to the UpToDate topic on vancomycin dosing for sample nomogram and discussion of vancomycin monitoring.

◊ The approach to pediatric vancomycin dosing is generally determined at the institutional level. A typical dose is 15 mg/kg/dose IV every 6 to 8 hours (use every 6-hour interval for serious infections; maximum dose: 4 g/day), however other dosing strategies (eg, AUC-guided approach) may be used. Refer to UpToDate content on invasive staphylococcal infections in children for details of trough-guided and AUC-guided vancomycin dosing.

§ Oral step-down therapy is appropriate for certain clinical syndromes (eg, abscess in the absence of bacteremia). However, we favor continuing initial intravenous therapy for endovascular infections (eg, bacteremia, endocarditis) as well as other severe or difficult to treat syndromes.

¥ Dosing is based on the amoxicillin component for the amoxicillin:clavulanate 7:1 formulations (eg, amoxicillin-clavulanate 200 mg/28.5 mg, 400 mg/57 mg, or 875 mg/125 mg). Not all products are interchangeable; using a product with the incorrect amoxicillin:clavulanate ratio could result in subtherapeutic clavulanic acid concentrations or adverse effects (eg, severe diarrhea). For dosing for other amoxicillin-clavulanate formulations, refer to the Lexicomp drug monograph.

‡ Although ciprofloxacin is not routinely used in children, it is a reasonable alternative when no other oral options are available.

Graphic 139420 Version 2.0

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Antimicrobial regimens for the treatment of Streptococcus anginosus group infections