WORKUP	Section 5 of 10
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Lab Studies:

• Culture B cepacia from body fluids.

• Although B cepacia-positive cultures from nonsterile sites (eg, respiratory secretions, urine in the setting of Foley catheters) nearly always represent colonization, presence in sterile body fluids such as blood mandates consultation with an infectious disease specialist.

	TREATMENT	Section 6 of 10
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Medical Care:

• The patient-to-patient spread of B cepacia may be minimized and/or prevented by effective infection control measures.

• Use Foley catheters only as long as necessary. If possible, avoid their use in compromised hosts predisposed to urinary tract infections (eg, patients with diabetes, SLE, multiple myeloma).

• Preventing colonization of respiratory secretions in intubated patients who are in ICUs and on broad-spectrum antibiotics is difficult.

Consultations:

• Consultation with an infectious disease specialist helps to differentiate colonization from infection.

	MEDICATION	Section 7 of 10
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Because B cepacia is almost always a colonizer, antimicrobial treatment is unnecessary and may be harmful.

B cepacia, as a nonaeruginosa pseudomonad, is usually resistant to aminoglycosides, antipseudomonal penicillins, and antipseudomonal third-generation cephalosporins.

B cepacia is often susceptible to trimethoprim plus sulfamethoxazole, cefepime, meropenem, minocycline, and tigecycline and has varying susceptibility to fluoroquinolones.

Drug Category: Antibiotics -- Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Drug Name	Trimethoprim and sulfamethoxazole (TMP-SMX) (Bactrim DS, Septra DS) -- Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity includes common urinary tract pathogens, except P aeruginosa.
Adult Dose	160 mg TMP/800 mg SMX PO/IV q12h for 10-14 d
Pediatric Dose	<2 months: Do not administer >2 months: 15-20 mg TMP/kg/d PO tid/qid for 14 d
Contraindications	Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Interactions	May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly individuals; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBCs frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, administer 5-15 mg/d leucovorin); caution in folate deficiency (eg, individuals with chronic alcoholism, elderly individuals, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in individuals with G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); administer fluids to prevent crystalluria and stone formation

Drug Name	Cefepime (Maxipime) -- Fourth-generation cephalosporin with good gram-negative coverage; similar to ceftazidime, but with better gram-positive coverage.
Adult Dose	2 g IV q12h
Pediatric Dose	50 mg/kg IV q8h
Contraindications	Documented hypersensitivity
Interactions	Probenecid at high doses may increase effects of cefepime; aminoglycosides increase the nephrotoxic potential of cefepime
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in patients with severe renal insufficiency (high doses may cause CNS toxicity); prolonged use may predispose patients to superinfection

Drug Name	Tigecycline (Tygacil) -- A glycylcycline antibiotic that is structurally similar to tetracycline antibiotics. Inhibits bacterial protein translation by binding to 30S ribosomal subunit and blocks entry of amino-acyl tRNA molecules in ribosome A site. Indicated for complicated skin and skin structure infections caused by E coli, E faecalis (vancomycin-susceptible isolates only), S aureus (methicillin-susceptible and -resistant isolates), S agalactiae, S anginosus grp (includes S anginosus, S intermedius, S constellatus), S pyogenes, and B fragilis.
Adult Dose	Infuse each dose over 30-60 min 100 mg IV once, then 50 mg IV q12h Severe hepatic impairment (ie, Child Pugh class C): 100 mg IV once, then 25 mg IV q12h
Pediatric Dose	<18 years: Not established >18 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration decreases warfarin clearance and increases warfarin Cmax and AUC (monitor aPTT and INR); coadministration of antibiotics with oral contraceptives may decrease contraceptive effect
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in severe hepatic impairment (reduce dose); may adversely effect tooth development; may permit clostridia overgrowth, resulting in antibiotic-associated colitis; may have adverse effects similar to tetracyclines (eg, photosensitivity, pseudotumor cerebri, pancreatitis, antianabolic action)

Drug Name	Meropenem (Merrem IV) -- Semisynthetic carbapenem antibiotic that inhibits bacterial cell wall synthesis. Effective against most gram-positive and gram-negative bacteria. Has slightly increased activity against gram-negative bacteria and slightly decreased activity against staphylococci and streptococci compared to imipenem.
Adult Dose	1 g IV q8h
Pediatric Dose	<10 years: Not established >10 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication; adjust dose in patients with renal impairment

Drug Name	Cefixime (Suprax) -- Third-generation oral cephalosporin with broad activity against gram-negative bacteria. By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult Dose	400 mg/d PO qd or 200 mg q12h
Pediatric Dose	<12 years: 8 mg/kg/d suspension PO qd or 4 mg/kg bid >50 kg or >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects of cefixime
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of non-susceptible organisms may occur with prolonged use or repeated therapy

Drug Name	Minocycline (Dynacin, Minocin) -- Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma. Was found to be effective in some non-tuberculotic mycobacterial infections.
Adult Dose	100 mg PO bid for 5-7 d
Pediatric Dose	<8 years: Not recommended >8 years: 4 mg/kg PO initially, followed with 2 mg/kg q12h
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Pregnancy	D - Unsafe in pregnancy
Precautions	Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; hepatitis or lupuslike syndromes may occur

	FOLLOW-UP	Section 8 of 10
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Deterrence/Prevention:

• Effective infection control measures can minimize or limit the spread of this and other organisms in the ICU.

• Recovered B cepacia should be considered a nonpathogen unless proven otherwise.

• If B cepacia is recovered from several patients in the same area, then sections of an ICU or ward can become the focus for further colonization within the hospital setting.

• Appropriate isolation procedures rather than antimicrobial therapy should be used to control the spread of B cepacia colonization among patients.

Complications:

• No complications are expected.

	MISCELLANEOUS	Section 9 of 10
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Medical/Legal Pitfalls:

• B cepacia bacteriuria ordinarily should not be treated. In a patient with an indwelling Foley catheter, B cepacia may be accompanied by pyuria, which represents colonization rather than infection unless recent antecedent urological instrumentation has occurred.

• The most common clinical error with B cepacia involves the treatment of patients on respirators in ICUs with B cepacia recovered from respiratory secretions.

• Because B cepacia does not generally cause pneumonia, it typically should not be treated in ventilated patients even if they have fever, pulmonary infiltrates, and leukocytosis. Other causes of the process should be sought.

• The needless and inappropriate treatment of B cepacia with antibiotics (eg, TMP-SMX) may predispose patients to adverse drug effects (eg, drug rash and/or fever secondary to sulfisoxazole component of TMP-SMX).

	BIBLIOGRAPHY	Section 10 of 10
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

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