Infectious Diseases in Critical Care Medicine

metronidazole, polymyxin B, vancomycin, quinupristin/dalfopristin, linezolid, daptomycin,
quinolones, monobactams, and as previously mentioned, carbapenems. In thirty years of
clinical experience in infectious disease, the author has never had to resort to penicillin
desensitization to treat a patient. There is always an alternative, nonb-lactam antibiotic, which
is suitable for virtually every conceivable clinical situation. Although penicillin sensitivity
testing/desensitization is a potential consideration in the non-critical ambulatory patient, in
the critical care setting there is no time or need for penicillin testing/desensitization. If there is
any question about a penicillin allergy in a non-communicative patient in the CCU, then
monotherapy or combination therapy with one of the nonb-lactam antibiotics mentioned
above is appropriate and safe. The nonb-lactam antibiotics most useful in the critical care
setting for the most common infectious disease syndromes encountered are presented here in
tabular form (Tables 2 and 3) (22,26).

Table 1 Antimicrobials Safe to Use in Penicillin-Allergic Patients in the CCU

Antibacterials Antivirals
Carbapenems Amantadine
Meropenem Rimantadine
Imipenema Acyclovir
Ertapenemb Gancyclovir
Monobactams Valganciclovir
Aztreonam Aminoglycosides
Quinolones Gentamicin
Ciprofloxacin Tobramycin
Levofloxacin Amikacin
Moxifloxacin Tetracyclines
Antifungals Doxycycline
Amphotericin B/Lipid preparations Minocycline
Minocycline
Flucytosine Other
Fluconazole Clindamycin
Itraconazole Chloramphenicol
Caspofungin TMP-SMX
Voriconazole Rifampin
Voriconazole Colistin
Micafungin Polymyxin B
Vancomycin
Quinupristin/dalfopristin
Linezolid
Daptomycin
Tigecycline

aAllergic reactions very uncommon.
bNo data.

Table 2 Clinical Approach tob-Lactam Use in Those with Known or Unknown Reactions to Penicillin

Nature of reported penicillin allergy b-Lactams safe to use

Non-anaphylactic
reactions

Drug fever 1st, 2nd, 3rd, and 4th generation cephalosporins
Drug rash
E. multiforme Avoid penicillins or cephalosporins
Steven–Johnson Syndrome
Anaphylactic
reactions

Hypotension Meropenema

Laryngospasm

Bronchospasm Imipenemb

Generalized hives Ertapenemc

aNo/minimal potential for allergic cross reactions.
bVery low, but definite potential for allergic cross reactions.
cNo data.

538 Cunha