Guidelines for                      Antimicrobial Usage                            2009-2010CVR(AMUG-10).indd 1           ...
Guidelines for                 Antimicrobial Usage                       2009-2010AMUG-10.indd 1                         9...
Copyright 2009                                                          Cleveland Clinic                                  ...
Committee                                           Susan J. Rehm, MD                                       Department of ...
Introduction            T   he majority of hospitalized patients receive antibiotics for therapy or prophylaxis during the...
TABLE 1                Guidelines1 for Interpretation of Gram Stain Results            Gram-Positive Cocci (GPC)          ...
TABLE 2              Key Characteristics of Selected Organisms            Gram-Positive Cocci (GPC)                       ...
TABLE 2                  Key Characteristics of Selected Organisms (continued)            Gram-Negative Bacilli (GNB)     ...
TABLE 3               Usual Acid-Fast Bacillus Characteristics            Mycobacterium sp                      Time to Is...
TABLE 4             Laboratory Requests and Specimen Types            1. Blood cultures:               a. Blood cultures a...
TABLE 5              Mechanism of Action of Common                                 Antibacterial Agents            Aminogl...
TABLE 5             Mechanism of Action of Common                                Antibacterial Agents (continued)         ...
TABLE 6                  Guidelines for Treatment of Pneumonia in Adults            Source/              Empiric          ...
TABLE 7                Guidelines for Treatment of Infective                                   Endocarditis in Adults     ...
TABLE 7                Guidelines for Treatment of Infective                                   Endocarditis in Adults (con...
TABLE 8                  Guidelines for Treatment of Bone                                      and Joint Infections in Adu...
TABLE 9                   Guidelines for Treatment of Urinary                                      Tract Infections in Adu...
TABLE 10 Guidelines for Treatment of                     Sexually Transmitted Diseases            Disease                 ...
TABLE 10 Guidelines for Treatment of                     Sexually Transmitted Diseases (continued)            Disease     ...
TABLE 10 Guidelines for Treatment of                     Sexually Transmitted Diseases (continued)            Disease     ...
TABLE 11 Guidelines for Treatment of                     Bacterial Meningitis in Adults            Clinical               ...
TABLE 12 Guidelines for Treatment of Miscellaneous                     Nosocomial Infections in Adults            Hospital...
TABLE 12 Guidelines for Treatment of Miscellaneous                     Nosocomial Infections in Adults (continued)        ...
TABLE 13 Guidelines for Treatment of Febrile Neutropenia1             Clinically Stable             Zosyn 3.375 g IV q6h2 ...
TABLE 14 Guidelines for Management of Clostridium difficile                     Toxin-Positive Diarrhea                   S...
TABLE 15 Guidelines1 for Urgent Empiric Treatment of                     Community-Acquired Bacterial Sepsis in Adults    ...
TABLE 15 Guidelines1 for Urgent Empiric Treatment of                     Community-Acquired Bacterial Sepsis in Adults (co...
TABLE 16 Guidelines for Antimicrobial Dosing in Adults                                                                    ...
TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued)                                                        ...
TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued)                                                        ...
TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued)                                                        ...
TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued)                                                        ...
TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued)                                                        ...
TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued)                                                        ...
TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued)            1     Assure that full daily dosing occurs a...
TABLE 17 Formulary-Approved Indications and Dosing                     of Restricted Antimicrobial Agents in Adults       ...
TABLE 17 Formulary-Approved Indications and Dosing                     of Restricted Antimicrobial Agents in Adults (conti...
TABLE 17 Formulary-Approved Indications and Dosing                     of Restricted Antimicrobial Agents in Adults (conti...
TABLE 17 Formulary-Approved Indications and Dosing                     of Restricted Antimicrobial Agents in Adults (conti...
Antimicrobial 2010
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Antimicrobial 2010

  1. 1. Guidelines for Antimicrobial Usage 2009-2010CVR(AMUG-10).indd 1 9/30/2009 5:15:46 PM
  2. 2. Guidelines for Antimicrobial Usage 2009-2010AMUG-10.indd 1 9/30/2009 5:20:24 PM
  3. 3. Copyright 2009 Cleveland Clinic Published by: Professional Communications, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any other information storage and retrieval system, without the prior agreement and written permission of the publisher. Marketing Office: Editorial Office: 400 Center Bay Drive For orders only, please call: PO Box 10 West Islip, NY 11795 Caddo, OK 74729-0010 (t) 631/661-2852 1-800-337-9838 (t) 580/367-9838 (f) 631/661-2167 (f) 580/367-9989 ISBN: 978-1-932610-59-8 Printed in the United States of America DISCLAIMER The opinions expressed in this publication reflect those of the authors. However, the authors make no warranty regarding the contents of the publication. The protocols described herein are general and may not apply to a specific patient. Any product mentioned in this publication should be taken in accordance with the prescribing information provided by the manufacturer. This text is printed on recycled paper.AMUG-10.indd 2 9/30/2009 5:20:43 PM
  4. 4. Committee Susan J. Rehm, MD Department of Infectious Disease Jennifer K. Sekeres, PharmD Elizabeth Neuner, PharmD Department of Pharmacy Department of Infectious Disease Department of Clinical Pathology J. Walton Tomford, MD Gerri S. Hall, PhD Carlos M. Isada, MD Belinda Yen-Lieberman, PhD Robin K. Avery, MD Gary Procop, MD Steven M. Gordon, MD Division of Pediatrics Steven K. Schmitt, MD Steven D. Mawhorter, MD Johanna Goldfarb, MD Sherif B. Mossad, MD Camille Sabella, MD Alan J. Taege, MD Lara Danzinger-Isakov, MD Kristin Englund, MD Charles Foster, MD Thomas G. Fraser, MD Department of Pharmacy Alice I. Kim, MD Marisa Tungsiripat, MD Morton P. Goldman, PharmD Lucileia Johnson, MD Rebecca Corey, PharmD David van Duin, MD Marc Earl, PharmD Cyndee Miranda, MD Jodie M. Fink, PharmD Ume Abbas, MDAMUG-10.indd 3 9/30/2009 5:20:43 PM
  5. 5. Introduction T he majority of hospitalized patients receive antibiotics for therapy or prophylaxis during their inpatient stay. It has been estimated that at least fifty percent of patients receive antibiotics needlessly. Reasons include inappropriate prescribing for antibiotic prophylaxis, continuation of empiric therapy despite negative cultures in a stable patient, and a lack of awareness of susceptibility patterns of common pathogens. Over prescribing not only increases the costs of health care, but may result in superinfection due to antibiotic-resistant bacteria, as well as opportunistic fungi, and may increase the likelihood of an adverse drug reaction. On the other hand, not prescribing (when there is an urgent need at the bedside) may also lead to serious consequences. The materials in this booklet constitute guidelines only and are subject to change pursuant to medical judgement relative to individual patient needs. Our antimicrobial formulary decisions are made annually after thorough deliberations and consensus building with members of the Infectious Disease Department, the Department of Pharmacy, and the Section of Microbiology. In vitro susceptibility data of the previous year are shared and emerging resistance patterns reviewed. Usage and cost data are discussed. The mission of our program is to provide the most cost-effective antimicrobial agents to our patients. This booklet does not contain specific guidelines for treatment of human immunodefi- ciency virus (HIV) infection. Nor is prophylaxis against opportunistic microorganisms included, since such issues are usually handled in our outpatient clinics. Similarly, treatment of infectious diseases commonly seen in the outpatient setting, such as otitis media and pharyngitis, are not included in this booklet.AMUG-10.indd 4 9/30/2009 5:20:43 PM
  6. 6. TABLE 1 Guidelines1 for Interpretation of Gram Stain Results Gram-Positive Cocci (GPC) Gram-Negative Cocci (GNC) • Pairs, chains, clusters: • Diplococci – Staphylococcus sp – Pairs: • Pairs, chains: › Neisseria meningitidis – Streptococcus sp › Neisseria gonorrhoeae – Enterococcus sp › Moraxella catarrhalis • Pairs, lancet-shaped: • Other: – Streptococcus pneumoniae – Acinetobacter sp • Pairs: Gram-Negative Bacilli (GNB) – Enterococcus sp • Enterobacteriaceae: Gram-Positive Bacilli (GPB) – Escherichia coli • Diphtheroids: – Serratia sp – Small, pleomorphic: – Klebsiella sp › Corynebacterium sp – Enterobacter sp › Propionibacterium (anaerobe) – Citrobacter sp • Large, with spores: • Nonfermentative: – Clostridium sp – Pseudomonas aeruginosa – Bacillus sp – Stenotrophomonas (Xanthomonas) maltophilia • Branching, beaded, rods: – Many others – Nocardia sp • Haemophilus influenzae – Actinomyces sp (anaerobe) • Bacteroides fragilis group (anaerobe) • Other: • Fusiform (long, pointed): – Listeria sp (blood/cerebrospinal fluid) – Fusobacterium sp (anaerobe) – Lactobacillus sp (vaginal/blood) – Capnocytophaga sp 1 These guidelines are not definitive but presumptive for the identification of organisms on gram stain. Treatment will depend on the quality of the specimen and appropriate clinical evaluation. 5AMUG-10.indd 5 9/30/2009 5:20:43 PM
  7. 7. TABLE 2 Key Characteristics of Selected Organisms Gram-Positive Cocci (GPC) Gram-Negative Cocci (GNC) • Catalase-positive: • Neisseria meningitidis – Staphylococcus sp • Neisseria gonorrhoeae • Catalase-negative: • Moraxella (Branhamella) catarrhalis – Enterococcus sp • Acinetobacter sp1 – Streptococcus sp (chains) – Micrococcus sp (usually insignificant) Gram-Negative Bacilli (GNB) • Coagulase-positive: • Lactose-positive: – Staphylococcus aureus – Escherichia coli • Coagulase-negative: – Klebsiella pneumoniae (mucoid) – Coagulase-negative staphylococci (CNS): – Enterobacter sp2 › Blood: Staphylococcus epidermidis or CNS – Citrobacter sp2 › Urine: Staphylococcus saprophyticus • Lactose-negative/oxidase-negative: › Staphylococcus lugdunensis4 – Proteus mirabilis: indole-negative – Proteus vulgaris: indole-positive Gram-Positive Bacilli (GPB) – Providencia sp • Diphtheroids: – Morganella morganii – May be Corynebacterium sp: often blood culture – Serratia sp3 contaminants – Salmonella sp – Corynebacterium jeikeium: resistant to many – Shigella sp agents except vancomycin – Acinetobacter sp1 • Anaerobic diphtheroids: Propionibacterium acnes – Stenotrophomonas (Xanthomonas) maltophilia • Bacillus sp: Bacillus anthracis: non-motile and non-- (nonfermenter) hemolytic; Bacillus cereus; Bacillus subtilis, ie, large, • Lactose-negative/oxidase-positive: “box car” rods with spores – Pseudomonas aeruginosa (green; “grape odor”) • Listeria monocytogenes: cerebrospinal fluid, blood – Aeromonas hydrophila (may be lactose-positive) • Lactobacillus sp: vaginal flora, rarely in blood – Rare: • Nocardia sp: Branching, beaded; partial acid–fast- › Other Pseudomonas sp positive › Moraxella sp1 • Rapidly growing mycobacteria: › Alcaligenes sp – Mycobacterium fortuitum › Burkholderia sp – Mycobacterium chelonae/abscessus (Table continued on following page) 6AMUG-10.indd 6 9/30/2009 5:20:44 PM
  8. 8. TABLE 2 Key Characteristics of Selected Organisms (continued) Gram-Negative Bacilli (GNB) – Thermally dimorphic (yeast in tissue, mold in lab): • Other: › Histoplasma capsulatum (slow growing) – Haemophilus influenzae (coccobacillary); requires › Blastomyces dermatitidis supplements/special media (chocolate agar plate) › Coccidioides immitis Fungi • Yeast: • Molds: – Candida sp; Candida albicans if germ tube-positive – Aseptate hyphae: – Cryptococcus sp (no pseudohyphae); › Zygomycetes, such as: Cryptococcus neoformans if latex- or CAD-positive – Rhizopus sp – Candida glabrata – Mucor – Trichosporon sp – Septate hyphae: – Rhodotorula, Saccharomyces sp › Brown pigment (phaeohyphomycetes), such as: – Bipolaris sp Anaerobes – Exserohilum sp • GNB: – Alternaria sp – Bacteroides sp (Bacteroides fragilis) – Curvularia sp – Fusobacterium sp – Sporothrix schenckii (“rose-gardeners”) • GNC: › Non-brown pigmented (hyalohyphomycetes, – Veillonella sp most common), such as: • GPC: – Aspergillus sp (Aspergillus fumigatus, – Peptostreptococcus sp Aspergillus flavus) • GPB: – Fusarium sp – Propionibacterium acnes – Penicillium sp – Clostridium sp (spores) – Paecilomyces sp – Actinomyces sp (branching, filamentous) – Dermatophytes – Lactobacillus sp – Eubacterium sp 1 May be either bacillary or coccoid. – Bifidobacterium sp 2 May be lactose negative. 3 May produce red pigment and appear lactose-positive initially. 4 Clinically can act as Staphylococcus aureus; laboratory results will reflect this by using MIC interpretation for Staphylococcus aureus. 7AMUG-10.indd 7 9/30/2009 5:20:44 PM
  9. 9. TABLE 3 Usual Acid-Fast Bacillus Characteristics Mycobacterium sp Time to Isolation Pigment Usual Clinical Diseases1 Mycobacterium tuberculosis 10-12 d None Pulmonary, extra-pulmonary Mycobacterium avium complex 5-7 d None Pulmonary, extra-pulmonary Mycobacterium gordonae >10 d Yellow Non-pathogenic Mycobacterium kansasii 10-12 d Yellow (in light) Pulmonary, skin and soft tissue Mycobacterium marinum 10-12 d Yellow Skin and soft tissue Rapid Growers: Mycobacterium abscessus <7 d None Skin and soft tissue Mycobacterium chelonae <7 d None Skin and soft tissue Mycobacterium fortuitum <7 d None Skin and soft tissue Partial Acid-Fast Organisms: Nocardia sp Branching, beaded Pulmonary, central nervous bacilli system, skin and soft tissue Rhodococcus and Coccoid, branching, Skin and soft tissue, pulmonary Tsukamurella sp and/or bacillary 1 Note: Any acid-fast bacillus may disseminate in immunocomprised hosts. 8AMUG-10.indd 8 9/30/2009 5:20:44 PM
  10. 10. TABLE 4 Laboratory Requests and Specimen Types 1. Blood cultures: a. Blood cultures are most likely to be positive when an ample volume of blood is collected prior to administration of antibiotics. b. Two sets of 20 mL each should be drawn 1 hour apart, preferably from a peripheral site rather than through a central vascular catheter. c. Ten mL from each blood draw is inoculated into an aerobic bottle and 10 mL into an anaerobic bottle. Cultures are held 4 days before being reported as negative. d. A single positive blood culture of these organisms suggests contamination: Bacillus sp, coagulase-negative staphylococci, diphtheroids, Propionibacterium acnes, viridans streptococci. e. An isolator tube of 10 mL of blood should be drawn if any of the following are suspected: Bartonella, Bordetella, Francisella, Histoplasma capsulatum, Legionella, Mycobacterium sp. These will be incubated for longer than 4 days before being considered negative. 2. Stools for Clostridium difficile: a. Stools are processed for the presence of toxin A and B in an enzyme immunoassay (EIA), and results are available within <24 hours. b. The sensitivity of the assay is 75% to 80%. c. Less than or equal to 2 diarrheal samples are sufficient per week. d. Negative results do not rule out the presence of Clostridium difficile toxin. 3. Stools for enteric pathogens and ova and parasites: a. Stools sent for bacterial pathogens and parasites should be from outpatients or patients who have been in the hospital <3 days. b. Stools are examined for the presence of Salmonella sp, Shigella sp, and Campylobacter jejuni routinely if submitted for enterics; if for parasites, routine testing for Giardia sp and Cryptosporidium sp is performed via EIA unless a microscopic examination is specifically ordered. c. Other pathogens require a special request. 4. Antimicrobial susceptibility testing: a. Testing is performed routinely on clinically relevant aerobic bacteria for which there are guidelines as set forth by the Clinical Laboratory Standards Institute (CLSI). b. Requests for susceptibility testing of fungi, non-tuberculosis Mycobacterium, and anaerobic bacteria are required. 9AMUG-10.indd 9 9/30/2009 5:20:44 PM
  11. 11. TABLE 5 Mechanism of Action of Common Antibacterial Agents Aminoglycosides interfere with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits. • Gentamicin • Tobramycin • Amikacin Beta Lactams: Penicillins and cephalosporins inhibit bacterial cell-wall synthesis by binding to one or more penicillin-binding proteins which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell-wall biosynthesis. Bacteria eventually lyse due to ongoing activity of organism autolytic enzymes (autolysins and murein hydrolases) while cell-wall assembly is arrested. Penicillins Cephalosporins Others • Amoxicillin • Cefazolin • Imipenem • Ampicillin • Cefprozil • Aztreonam • Dicloxacillin • Ceftazidime • Oxacillin • Ceftizoxime • Piperacillin • Ceftriaxone • Piperacillin/tazobactam • Cefuroxime • Cephalexin Ciprofloxacin inhibits DNA-gyrase which does not allow the uncoiling of supercoiled DNA and promotes breakdown of double-strand DNA. Clindamycin binds to the 50S ribosomal subunit (reversibly), preventing peptid-bond formation and inhibiting protein synthesis. (Table continued on following page) 10AMUG-10.indd 10 9/30/2009 5:20:44 PM
  12. 12. TABLE 5 Mechanism of Action of Common Antibacterial Agents (continued) Daptomycin acts at the cytoplasmic membrane and is hypothesized to rapidly depolarize the cell membrane via an efflux of potassium and possibly other ions. Cell death occurs as a result of multiple failures in biosystems, including DNA, RNA, and protein synthesis. Linezolid binds to a site on the 23S ribosomal RNA of the 50S subunit, blocking formation of the 70S initiation complex thus inhibiting translation. Macrolides inhibit protein synthesis at the chain elongation step and binds to the 50S ribosomal subunit. • Erythromycin • Azithromycin • Clarithromycin Metronidazole interacts with DNA causing a loss of helical DNA structure and strand breakage, resulting in inhibition of protein synthesis. Tetracyclines inhibit protein synthesis by binding to the 30S and possibly the 50S ribosomal subunits. • Doxycycline • Tetracycline Tigecycline binds at the same site on the ribosome as tetracyclines, however binds 5-fold more tightly. Also able to overcome the ribosomal protection mechanism of tetracycline resistance. Trimethoprim/sulfamethoxazole: Trimethoprim inhibits dihydrofolic acid reduction to tetrahydrofolate, resulting in sequential inhibition of the folic acid pathway. Sulfamethoxazole interferes with bacterial folic acid synthesis and growth via inhibition of dihydrofolic acid formation from PABA. Vancomycin inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding to the D-alanyl-D-alanine portion of the cell wall precursor. 11AMUG-10.indd 11 9/30/2009 5:20:44 PM
  13. 13. TABLE 6 Guidelines for Treatment of Pneumonia in Adults Source/ Empiric Likely Directed Usual Setting Therapy Pathogens Therapy Duration Community1 Ceftriaxone + Pneumococcus Penicillin 7-14 d2 azithromycin Legionella Azithromycin Mycoplasma Doxycycline Haemophilus influenzae Cefuroxime Chlamydia pneumoniae Doxycycline Moraxella catarrhalis Cefuroxime Aspiration Ampicillin/sulbactam Mouth flora Ampicillin/sulbactam 14 d3 or clindamycin or clindamycin Hospital Piperacillin/tazobactam Pseudomonas aeruginosa Piperacillin/tazobactam 8-14 d6 ± vancomycin ± + gentamicin5 gentamicin4 Enterobacter sp Piperacillin/tazobactam7 ± gentamicin Serratia marcescens Piperacillin/tazobactam Klebsiella sp Piperacillin/tazobactam Acinetobacter sp Imipenem8 Staphylococcus aureus Oxacillin9 1 In immunocompromised hosts, consider adding TMP/SMX for Pneumocystis jirovecii (carinii) coverage. For penicillin-allergic patients, please see Table 15. 2 Duration of therapy to be determined by presence of co-existing illnesses, bacteremia, severity of illness at onset, and hospital course. 3 Anaerobic pleuropulmonary infections may require 6 weeks of therapy. 4 Amikacin should be considered in intensive care units where gentamicin/tobramycin susceptibilities are lower. 5 Substitute tobramycin if resistant to gentamicin. 6 If no improvement or slow response, may require further treatment. 7 For piperacillin/tazobactam-resistant isolates, TMP/SMX or imipenem may be appropriate alternative agents. 8 Carbapenem-resistance Acinetobacter have been detected. Consider ampicillin/sulbactam or ID consult for alternative therapies. 9 Note that 50% of S aureus are resistant to oxacillin (or methicillin) and cefazolin. Vancomycin is appropriate in such patients. 12AMUG-10.indd 12 9/30/2009 5:20:44 PM
  14. 14. TABLE 7 Guidelines for Treatment of Infective Endocarditis in Adults Clinical Empiric Likely Directed Usual Setting Therapy Pathogens Therapy Duration Subacute: Normal host Penicillin + Viridans streptococci Penicillin G1,2 4 wk gentamicin Streptococcus bovis Penicillin G1 Enterococcus Ampicillin + gentamicin3 HACEK group Ceftriaxone Acute: Normal host Vancomycin + Staphylococcus aureus (MSSA) Oxacillin4 6 wk gentamicin3 Pneumococcus (rare) Penicillin Injection drug Vancomycin + Staphylococcus aureus5 Oxacillin4 + gentamicin3 2-6 wk6 abuser gentamicin Pseudomonas aeruginosa Piperacillin/tazobactam + gentamicin7 Other GNB Ceftriaxone ± gentamicin PVE: Early (60 days) Vancomycin + Staphylococcus epidermidis Vancomycin8 + 6 wk gentamicin gentamicin3,9 + rifampin Staphylococcus aureus Oxacillin4 + gentamicin3,9 + rifampin Candida albicans Amphotericin B (Table continued on following page) 13AMUG-10.indd 13 9/30/2009 5:20:44 PM
  15. 15. TABLE 7 Guidelines for Treatment of Infective Endocarditis in Adults (continued) Clinical Empiric Likely Directed Usual Setting Therapy Pathogens Therapy Duration Late onset PVE Vancomycin + Viridans streptococci Penicillin G + 6 wk (>60 days) gentamicin gentamicin3,9 Staphylococcus epidermidis Vancomycin8 + 6 wk gentamicin3,9 + rifampin Enterococcus Ampicillin + 6 wk gentamicin3 1 May use penicillin G + gentamicin for 2 weeks. 2 For organisms with penicillin MIC of 0.1 mcg/mL to 0.5 mcg/mL, treat with penicillin + gentamicin; organisms with MIC >0.5 mcg/mL should be treated according to enterococci recommendations. 3 Low-dose gentamicin may be used (i.e., 1 mg/kg q8h; interval adjusted for renal function; it is of no value for enterococci with high-level, in vitro resistance to gentamicin.) 4 Substitute vancomycin if oxacillin-resistant. 5 In IV drug abusers, Staphylococcus aureus is often oxacillin-resistant. 6 May treat uncomplicated right-sided endocarditis for 2 weeks. 7 Substitute tobramycin if resistant to gentamicin. 8 Substitute oxacillin if susceptible. 9 Gentamicin for the first 2 weeks of therapy. 14AMUG-10.indd 14 9/30/2009 5:20:45 PM
  16. 16. TABLE 8 Guidelines for Treatment of Bone and Joint Infections in Adults Clinical Empiric Likely Directed Usual Setting Therapy Pathogens Therapy Duration1 Osteomyelitis: Healthy adult Vancomycin Staphylococcus aureus Oxacillin or cefazolin2 4-6 wk Posttraumatic Vancomycin + Staphylococcus aureus Oxacillin or cefazolin2 4-6 wk ceftriaxone Streptococcus Penicillin G or ampicillin Gram-negative bacilli Ceftriaxone Diabetic foot Ampicillin/ Usually polymicrobial Ampicillin/ 4-6 wk sulbactam sulbactam followed by PO Septic arthritis Vancomycin Staphylococcus aureus Oxacillin or cefazolin2 4 wk Gonococcus3 Ceftriaxone 2 wk4 Total joint replacement Vancomycin Staphylococcus aureus Oxacillin or cefazolin2 4 wk Staphylococcus epidermidis Vancomycin5 Streptococcus Penicillin G or ampicillin 1 May require prolonged therapy, depending on clinical situation. 2 Substitute vancomycin if oxacillin-resistant. 3 Young adults. 4 May switch to oral therapy when clinically indicated. 5 Substitute oxacillin or cefazolin if susceptible. 15AMUG-10.indd 15 9/30/2009 5:20:45 PM
  17. 17. TABLE 9 Guidelines for Treatment of Urinary Tract Infections in Adults Clinical Empiric Likely Directed Usual Setting Therapy Pathogens Therapy Duration Cystitis TMP/SMX Escherichia coli TMP/SMX1 3-7 d Proteus mirabilis Staphylococcus saprophyticus Upper tract Ampicillin + Escherichia coli Ampicillin + 2 wk4 gentamicin2 Proteus mirabilis gentamicin2,3 or TMP/SMX or TMP/SMX1 Perinephric abscess Cefazolin Escherichia coli TMP/SMX1 4 wk Staphylococcus aureus Cefazolin5 Prostatitis TMP/SMX or Escherichia coli TMP/SMX1 4-6 wk ciprofloxacin Other GNB TMP/SMX1 Epididymitis: 35 years old Doxycycline Chlamydia Doxycycline 2 wk Gonococcus Ceftriaxone >35 years old TMP/SMX GNB TMP/SMX1 Catheter-associated Piperacillin/tazobactam Escherichia coli Ampicillin3 2-4 wk4 urosepsis + gentamicin2 Enterococci Ampicillin + gentamicin2 Other GNB Piperacillin/tazobactam Yeast Amphotericin B6 1 May substitute ciprofloxacin if TMP/SMX-resistant. 2 Stop gentamicin when patient becomes clinically stable. 3 Substitute cefazolin if ampicillin-resistant. 4 May switch to oral therapy when appropriate. 5 Substitute vancomycin if oxacillin-resistant. 6 Switch to oral fluconazole when appropriate. 16AMUG-10.indd 16 9/30/2009 5:20:45 PM
  18. 18. TABLE 10 Guidelines for Treatment of Sexually Transmitted Diseases Disease Recommended Treatment Pathogens Primary Alternates Comments Chancroid: Haemophilus ducreyi Erythromycin 500 mg PO Ceftriaxone 250 mg IM Azithromycin is most tid × 7 d × 1 or azithromycin expensive alternative 1 g PO × 1 Disseminated gonorrhea: Neisseria gonorrhoeae Ceftriaxone 1 g IV q24h Change to penicillin G × 1-2 d or until improved, 2 million units IV q4h or followed by cefixime1 amoxicillin 500 mg PO bid 500 mg PO bid to complete if susceptible total therapy of 7-10 d Epididymitis (sexually acquired): Chlamydia trachomatis Ceftriaxone 250 mg IM Ciprofloxacin 500 mg If nonsexually acquired Neisseria gonorrhoeae × 1 + doxycycline × 1 + doxycycline epididymitis, treat as UTI 100 mg PO bid × 10 d 100 mg PO bid × 7 d for at least 10 d Genital herpes: Herpes simplex virus First episode genital: Recurrent: Acyclovir 400 mg PO tid × 7-10 d Acyclovir 400 mg PO tid or First episode proctitis: 800 mg PO bid × 5 d Acyclovir 400 mg PO 5×/d × 7-10 d Severe herpes infection: Prevention of recurrence: Acyclovir 5 mg/kg IV q8h × 5-7 d Acyclovir 400 mg PO bid (Table continued on following page) 17AMUG-10.indd 17 9/30/2009 5:20:45 PM
  19. 19. TABLE 10 Guidelines for Treatment of Sexually Transmitted Diseases (continued) Disease Recommended Treatment Pathogens Primary Alternates Comments Pelvic inflammatory disease (PID): Chlamydia trachomatis Inpatient: Ceftriaxone 2 g Clindamycin 900 mg IV Refer to Table 20 for gentami- Neisseria gonorrhoeae IV q24h + doxycycline q8h + gentamicin, cin dosing. Evaluate and treat Mycoplasma hominis 100 mg IV q12h ± metro- followed by doxycycline sexual partners. Test for Streptococci nidazole 500 mg IV q12h 100 mg PO bid to com- syphilis and HIV. Erythro- Enterobacteriaceae until improved, then doxy- plete total therapy of mycin stearate 500 mg PO Anaerobes cycline 100 mg PO bid 14 d qid instead of doxycycline if × 14 d pregnant. For PID unrelated Outpatient: Ceftriaxone 250 to sexual activity, treat as mg IM × 1 + doxycycline for intra-abdominal sepsis 100 mg PO bid ± metronidazole 500 mg PO bid × 14 d Syphilis: Treponema pallidum Primary, secondary or latent <1 year: All stages of syphilis require Penicillin G benzathine Doxycycline 100 mg follow-up for possible 2.4 million units IM × 1 PO bid × 14 d relapse. Evaluate and treat sexual partners. Test for Late latent >1 year: HIV. Pregnant women aller- Penicillin G benzathine Doxycycline 100 mg gic to penicillin should be 2.4 million units IM q wk PO bid × 28 d desensitized × 3 wk Neurosyphilis: Procaine penicillin Patient allergic to penicillin Penicillin G 3-4 million 2.4 million units IM q24h should be desensitized units IV q4h × 10-14 d + Probenecid 500 mg PO qid × 10-14 d (Table continued on following page) 18AMUG-10.indd 18 9/30/2009 5:20:45 PM
  20. 20. TABLE 10 Guidelines for Treatment of Sexually Transmitted Diseases (continued) Disease Recommended Treatment Pathogens Primary Alternates Comments Urethritis or cervicitis: Chlamydia trachomatis Ceftriaxone 125 mg IM Ciprofloxacin 500 mg Quinolones do not eradicate Ureaplasma urealyticum × 1 + doxycycline × 1 + doxycycline2 incubating syphilis. Evalu- Neisseria gonorrhoeae 100 mg PO bid × 7 d 100 mg PO bid × 7 d ate and treat sexual part- OR OR ners. Test for syphilis and Azithromycin 2 g PO × 1 Ciprofloxacin 500 mg HIV. Due to increased prev- × 1 + erythromycin2 alence of fluoroquinolone- 500 mg PO qid × 7 d resistant Neisseria gonor- rhoeae the CDC no longer recommends fluoroquino- lones for the treatment of gonorrhea in men who have sex with men 1 Ciprofloxacin may be used if susceptibility documented. 2 Pregnant women allergic to penicillin: Chlamydia trachomatis – erythromycin stearate 500 mg PO qid. Neisseria gonorrhoeae – spectinomycin 2 g IM × 1. 19AMUG-10.indd 19 9/30/2009 5:20:45 PM
  21. 21. TABLE 11 Guidelines for Treatment of Bacterial Meningitis in Adults Clinical Empiric Likely Directed Usual Setting Therapy Pathogens Therapy Duration Community1 Vancomycin + Pneumococcus Penicillin G2 2 wk ceftriaxone Meningococcus Penicillin G 1-2 wk Haemophilus influenzae Ceftriaxone3 1-2 wk Postneurosurgical/ Vancomycin + Staphylococcus epidermidis Vancomycin4 2-4 wk posttraumatic ceftazidime Staphylococcus aureus Oxacillin5 GNB (Pseudomonas aeruginosa) Ceftazidime + gentamicin6 Pneumococcus Penicillin G2 Immunocompromised Ceftriaxone + Listeria sp Ampicillin + gentamicin 2-3 wk7 vancomycin + GNB (Pseudomonas aeruginosa) Ceftazidime + gentamicin6 ampicillin Pneumococcus Penicillin G2 1 If elderly or immunocompromised, consider Listeria and add ampicillin. 2 Substitute ceftriaxone or vancomycin if isolate is resistant to penicillin. 3 If isolate is –lactamase-negative, ampicillin may be substituted. 4 Substitute oxacillin if susceptible. 5 Substitute vancomycin if oxacillin-resistant. 6 Substitute tobramycin if resistant to gentamicin. 7 Three weeks recommended for GNB. 20AMUG-10.indd 20 9/30/2009 5:20:45 PM
  22. 22. TABLE 12 Guidelines for Treatment of Miscellaneous Nosocomial Infections in Adults Hospital Setting Empiric Therapy Likely Pathogens Directed Therapy Usual Duration “ICU sepsis” Vancomycin + Staphylococcus aureus Oxacillin or cefazolin2 2-4 wk piperacillin/ Escherichia coli Ampicillin 3 tazobactam ± Pseudomonas aeruginosa Piperacillin/tazobactam + gentamicin4 gentamicin1 Enterococcus sp Ampicillin + gentamicin5 Candida albicans Fluconazole Anaerobes Metronidazole or clindamycin Candida glabrata Amphotericin B6 Postsurgical wound Vancomycin + Staphylococcus aureus Oxacillin or cefazolin2 1-4 wk8 infection7 piperacillin/tazobactam Staphylococcus epidermidis Vancomycin 9 Enterococcus sp Ampicillin + gentamicin5 Enterobacter sp Piperacillin/tazobactam10 ± gentamicin Pseudomonas aeruginosa Piperacillin/tazobactam + gentamicin4 Candida albicans Fluconazole Anaerobes Metronidazole or clindamycin Candida glabrata Amphotericin B6 (Table continued on following page) 21AMUG-10.indd 21 9/30/2009 5:20:45 PM
  23. 23. TABLE 12 Guidelines for Treatment of Miscellaneous Nosocomial Infections in Adults (continued) Hospital Setting Empiric Therapy Likely Pathogens Directed Therapy Usual Duration Vascular catheter Vancomycin + Staphylococcus aureus Oxacillin or cefazolin2,11 2-4 wk gentamicin1 Staphylococcus epidermidis Vancomycin 9 Enterococcus sp Ampicillin + gentamicin5 Pseudomonas aeruginosa Piperacillin/tazobactam + gentamicin4 Candida albicans Fluconazole Candida glabrata Amphotericin B6 1 Amikacin should be considered in intensive care units where gentamicin/tobramycin susceptibilities are lower. 2 Substitute vancomycin if oxacillin-resistant. 3 Substitute cefazolin if ampicillin-resistant. 4 Substitute tobramycin if resistant to gentamicin. 5 Low dose gentamicin (ie, 1 mg/kg q8h; interval adjusted for renal function). 6 Consider high-dose fluconazole for susceptible dose-dependent isolates. 7 Often mixed infection. 8 Superficial wounds 2 weeks of therapy. 9 Substitute oxacillin if susceptible. 10 If isolate is resistant to piperacillin/tazobactam, trimethoprim/sulfamethoxazole or imipenem may be appropriate alternate agents. 11 Risk of endocarditis; follow closely if treating less than 4 weeks. 22AMUG-10.indd 22 9/30/2009 5:20:45 PM
  24. 24. TABLE 13 Guidelines for Treatment of Febrile Neutropenia1 Clinically Stable Zosyn 3.375 g IV q6h2 Vancomycin3 should be added only if patient meets one of the following criteria: • Severe mucositis • Suspected catheter-related infection • History of bacterial prophylaxis (quinolone or cotrimoxazole) • Suspected skin or skin structure infection • Gram-positive organism in blood culture Clinically Unstable (based on BP, HR, RR, and mental status) Zosyn 3.375 g IV q6h2 AND gentamicin4 AND vancomycin3 Penicillin-Allergic Patients History of rash to penicillin: Ceftazidime 2 g IV q8h2 (add vancomycin and/or gentamicin as indicated above) History of anaphylaxis to a penicillin: Aztreonam 2 g IV q6h2 AND gentamicin4 (or ciprofloxacin 400 mg IV q12h2) AND vancomycin3 1 Neutropenia ANC <500. 2 Renal dose adjustments necessary. 3 See Table 21 for dosing recommendations. 4 See Table 19 and Table 20 for dosing recommendations; extended interval dosing preferred if patient meets criteria. 23AMUG-10.indd 23 9/30/2009 5:20:46 PM
  25. 25. TABLE 14 Guidelines for Management of Clostridium difficile Toxin-Positive Diarrhea Suspected Send one stool Test positive Place patient in contact precautions: Clostridium difficile– specimen to 1. Private room preferred associated diarrhea laboratory 2. Gloves before entering room (CDAD) 3. Gowns for patient contact 4. Hand hygiene with soap and water after removing gown/gloves 5. Alcohol wipes for stethoscope after use CDAD with illeus or CDAD critical illness1 • Surgical and Infectious Disease Treatment Preferred Regimen: Consult Metronidazole 500 mg PO tid • Vancomycin 500 mg PO or NG q6h × 10 days AND Alternative Regimen2: Metronidazole 500 mg IV q6h Vancomycin 125 or 250 mg PO qid AND × 10 days Vancomycin 500 mg PR q6h Follow-Up: 1. No need for further stool specimens (note: diarrhea may take 3-4 days to respond to treatment) 1 Critical illness definition: ICU stay or shock. 2 Consider vancomycin if metronidazole intolerant, failing to respond to metronidazole (ie, failure to improve after 3 to 4 days of therapy), or in moderate to severe disease (ie, WBC >20,000, acute renal failure, abdominal distension, hemodynamic instability). 24AMUG-10.indd 24 9/30/2009 5:20:46 PM
  26. 26. TABLE 15 Guidelines1 for Urgent Empiric Treatment of Community-Acquired Bacterial Sepsis in Adults Suspected Likely Recommended Alternate Alternate Source Pathogens Initial Therapy Cost2 Therapy Cost2 Therapy Cost2 Abdominal Aerobic GNBs Ampicillin/ 40.00 Ciprofloxacin + 30.00 Clindamycin + 15.00 sepsis Anaerobes sulbactam3 + metronidazole4 gentamicin gentamicin Cellulitis Staphylococcus aureus5 Vancomycin + 8.00 Oxacillin or 20.00 Clindamycin4 12.00 Group A streptococci clindamycin cefazolin Diabetic foot Staphylococcus aureus Ampicillin/ 40.00 Cefazolin + 12.00 Ciprofloxacin + 25.00 Group A streptococci sulbactam metronidazole clindamycin4 Aerobic GNBs Anaerobes Endocarditis Staphylococcus aureus Vancomycin + 12.00 — — — — (native, acute) gentamicin Meningitis Streptococcus pneumoniae Ceftriaxone + 15.00 Chloramphenicol + 24.00 — — Neisseria meningitidis vancomycin vancomycin4 (Haemophilus influenzae) Pneumonia Streptococcus pneumoniae Ceftriaxone + 20.00 Moxifloxacin4 12.00 Vancomycin + 20.00 Haemophilus influenzae azithromycin ciprofloxacin Legionella sp Mycoplasma (Table continued on following page) 25AMUG-10.indd 25 9/30/2009 5:20:46 PM
  27. 27. TABLE 15 Guidelines1 for Urgent Empiric Treatment of Community-Acquired Bacterial Sepsis in Adults (continued) Suspected Likely Recommended Alternate Alternate Source Pathogens Initial Therapy Cost2 Therapy Cost2 Therapy Cost2 Pyelonephritis Escherichia coli Ampicillin + 12.00 Trimethoprim/ 5.00 Ciprofloxacin4 12.00 Proteus sp gentamicin sulfamethoxazole Enterococcus sp Septic arthritis Staphylococcus aureus5 Cefazolin6 8.00 Oxacillin6 20.00 Clindamycin4 12.00 (native) 1 These recommendations are guidelines only, based on the Cleveland Clinic formulary choices of antimicrobial agents. They are intended for patients with suspected bacteremias from the suspected source in the left column. 2 Costs include medication and piggy-back only. Pharmacy preparation and nursing administration times are not included. 3 Consider piperacillin/tazobactam for nosocomial acquired infections since 40% of hospital-acquired Escherichia coli isolates are resistant to ampicillin/sulbactam. 4 Regimen of choice in patients who are penicillin-allergic. 5 Community-acquired methicillin-resistant Staphylococcus aureus infections are occurring more frequently. 6 Substitute vancomycin if oxacillin-resistant. 26AMUG-10.indd 26 9/30/2009 5:20:46 PM
  28. 28. TABLE 16 Guidelines for Antimicrobial Dosing in Adults Supplement Admin CrCl Suggested for Dialysis Drug Route (mL/min) Dosage Regimen H/D1 P/D Acyclovir IV/PO >50 5-10 mg/kg q8h Yes — 25-50 5-10 mg/kg q12h 10-25 5-10 mg/kg q24h 0-10 2.5-5 mg/kg q24h Amantadine PO >80 100 mg bid No No 60-80 200 mg/100 mg, alternating q24h 40-60 100 mg q24h 30-40 200 mg 2×/wk 20-30 100 mg 3×/wk 10-20 200 mg/100 mg, alternating weekly Amikacin IV/IM Individualize regimen with serum concentrations (see Table 19) Amoxicillin PO >50 250-500 mg q8h Yes No 10-50 250-500 mg q8-12h <10 250-500 mg q12h Amoxicillin/ PO >30 875 mg q12h OR Yes No clavulanate 250-500 mg q8h 10-30 250-500 mg q12h <10 250-500 mg q24h Amphotericin B IV No renal dosage adjustment necessary 0.5-1mg/kg q24h (max dose 100 mg) No No Amphotericin B IV See Table 17 for appropriate usage guidelines Lipid Complex ABELCET® Ampicillin IV >50 1-2 g q4-6h Yes No 10-50 1-2 g q6-12h <10 1-2 g q8-12h (Table continued on following page) 27AMUG-10.indd 27 9/30/2009 5:20:46 PM
  29. 29. TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued) Supplement Admin CrCl Suggested for Dialysis Drug Route (mL/min) Dosage Regimen H/D1 P/D Ampicillin/ IV >30 1.5-3 g q6-8h Yes — sulbactam 15-30 1.5-3 g q12h <15 1.5-3 g q24h Atovaquone PO No renal dose adjustment necessary 750 mg bid — — Atovaquone/ PO No renal dose adjustment necessary 1 g/400 mg q24h — — proguanil2 Azithromycin IV No renal dose adjustment necessary 500 mg q24h No No PO No renal dose adjustment necessary 250-500 mg q24h No No Aztreonam IV See Table 17 for appropriate usage guidelines Cefazolin3 IV >55 1 g q8h Yes No 35-54 1 g q8-12h 11-34 500 mg-1 g q12h <10 500 mg-1 g q24h Cefdinir PO >30 300 mg q12h or 600 mg q24h Yes — <30 300 mg q24h Cefixime4 PO >60 400 mg q24h Yes — 21-59 300 mg q24h <20 200 mg q24h Cefpodoxime PO >30 100-400 mg q12h No — 10-29 100-400 mg q24h <10 100-400 mg 3×/wk Cefprozil PO >30 500 mg q12-24h Yes — <30 250 mg q12h (Table continued on following page) 28AMUG-10.indd 28 9/30/2009 5:20:46 PM
  30. 30. TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued) Supplement Admin CrCl Suggested for Dialysis Drug Route (mL/min) Dosage Regimen H/D1 P/D Ceftazidime IV See Table 17 for appropriate usage guidelines Ceftriaxone IV See Table 17 for appropriate usage guidelines Cefuroxime IV >20 750 mg-1.5 g q8-12h Yes No 10-20 750 mg q12h <10 750 mg q24h Cephalexin PO >40 250-500 mg q6h Yes Yes 10-40 250-500 mg q8-12h <10 250 mg q12-24h Chloramphenicol IV No renal dose adjustment necessary 0.5-1 g q6h No No Cidofovir IV See Table 17 for appropriate usage guidelines Ciprofloxacin IV See Table 17 for appropriate usage guidelines PO >30 250, 500 or 750 mg q12h No — <30 500 or 750 mg q24h Clarithromycin PO >30 250-500 mg q12h — — <30 250-500 mg q24h Clindamycin IV No renal dose adjustment necessary 600-900 mg q8h No No PO No renal dose adjustment necessary 150-450 mg q6h No No Clofazimine PO No renal dose adjustment necessary 100 mg q24h — — Colistimethate Inhaled See Table 17 for appropriate usage guidelines IV Cytomegalovirus IV See Table 17 for appropriate usage guidelines immune globulin (Table continued on following page) 29AMUG-10.indd 29 9/30/2009 5:20:46 PM
  31. 31. TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued) Supplement Admin CrCl Suggested for Dialysis Drug Route (mL/min) Dosage Regimen H/D1 P/D Dapsone PO No renal dose adjustment necessary 100 mg q24h — — Daptomycin IV See Table 17 for appropriate usage guidelines Dicloxacillin PO No renal dose adjustment necessary 500 mg q6h No — Doxycycline IV/PO >10 100 mg q12h No — <10 100 mg q24h Erythromycin IV >10 0.5-1 g q6h No No <10 250-500 mg q6h PO No renal dose adjustment necessary 250-500 mg q6h No No Ethambutol PO >50 15-25 mg/kg q24h Yes Yes 10-50 15 mg/kg q24-36h <10 15 mg/kg q48h Maximum daily dose: 2.5 g Fluconazole IV/PO >50 100-400 mg q24h Yes — 10-50 50% of recommended dose Flucytosine PO >40 12.5-37.5 mg/kg q6h Yes — 20-40 12.5-37.5 mg/kg q12h 10-20 12.5-37.5 mg/kg q24h <10 12.5-37.5 mg/kg q24-48h Foscarnet IV See footnote 5 for dosing Fosfomycin PO No renal dose adjustment necessary 3 g × 1 dose (may be repeated if needed) (Table continued on following page) 30AMUG-10.indd 30 9/30/2009 5:20:46 PM
  32. 32. TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued) Supplement Admin CrCl Suggested for Dialysis Drug Route (mL/min) Dosage Regimen H/D1 P/D Ganciclovir IV >80 5 mg/kg q12h Yes — 50-79 2.5 mg/kg q12h 25-49 2.5 mg/kg q24h <25 1.25 mg/kg q24h Gentamicin IM/IV Individualize regimen with serum concentrations (see Table 19) Imipenem/ IV See Table 17 for appropriate usage guidelines cilastatin Isoniazid IV/PO No renal dose adjustment necessary 300 mg q24h Yes Yes Itraconazole PO No renal dose adjustment necessary 200 mg q12-24h No No Ketoconazole PO No renal dose adjustment necessary 200 mg q24h No No Linezolid IV/PO See Table 17 for appropriate usage guidelines Metronidazole PO/IV >10 500 mg q6-8h Yes — <10 500 mg q8-12h Micafungin IV See Table 17 for appropriate usage guidelines Nitrofurantoin PO >50 50-100 mg q6h — — <50 Avoid use Norfloxacin PO >30 400 mg q12h No — <30 400 mg q24h Oseltamivir PO See Table 17 for appropriate usage guidelines Oxacillin IV No renal dose adjustment necessary 1-2 g q4-6h No — (Table continued on following page) 31AMUG-10.indd 31 9/30/2009 5:20:47 PM
  33. 33. TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued) Supplement Admin CrCl Suggested for Dialysis Drug Route (mL/min) Dosage Regimen H/D1 P/D Penicillin G IV >50 2-4 million units q2-4h Yes — 10-50 1-2 million units q4-6h <10 1-2 million units q8-12h OR 0.5-1 million units q4-6h Penicillin VK PO >10 250-500 mg q6h Yes — <10 250 mg q6h Pentamidine IV >50 4 mg/kg q24h — — 10-50 4 mg/kg q24-36h <10 4 mg/kg q48h Piperacillin/ IV >40 3.375 g q6h Yes — tazobactam 20-40 3.375 g q8h <20 3.375 g q12h Posaconazole PO See Table 17 for appropriate usage guidelines Pyrazinamide PO No renal dose adjustment necessary 15-30 mg/kg q24h — — Maximum dose: 2 g Pyrimethamine PO6 No renal dose adjustment necessary 100 mg q24h — — Rifabutin PO No renal dose adjustment necessary 300 mg q24h — — Rifampin IV/PO No renal dose adjustment necessary 600 mg q24h No — Rimantadine PO >10 100 mg bid — — <10 100 mg q24h Streptomycin7 IV/IM >50 7.5 mg/kg q12h Yes Yes 10-50 7.5 mg/kg q24-72h <10 7.5 mg/kg q72-96h (Table continued on following page) 32AMUG-10.indd 32 9/30/2009 5:20:47 PM
  34. 34. TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued) Supplement Admin CrCl Suggested for Dialysis Drug Route (mL/min) Dosage Regimen H/D1 P/D Sulfisoxazole PO >50 1-2 g q6h Yes No 10-50 1 g q8-12h <10 1 g q12-24h Sulfadiazine PO No renal dose adjustment necessary 1-2 g q6h — — Tetracycline PO >50 250-500 mg q6-12h No No 10-50 250-500 mg q12-24h <10 250-500 mg q24h Tigecycline IV See Table 17 for appropriate usage guidelines Tobramycin IV/IM Individualize dosing with serum concentrations (see Table 19) Trimethoprim/ IV >30 5 mg/kg q6-8h Yes No sulfamethoxazole 15-30 2.5-5 mg/kg q12h <15 2.5-5 mg/kg q24h (All doses based on trimethoprim) PO8 >30 1 DS q12h Yes No <30 1 DS q24h 1 DS = 160 mg of trimethoprim Trimethoprim PO >50 100-200 mg q6h Yes — 10-50 100 mg q12-24h <10 50-100 mg q24h Valganciclovir PO See Table 17 for appropriate usage guidelines Vancomycin IV See Table 21 for individualized dosing PO See Table 17 for appropriate usage guidelines Voriconazole IV/PO See Table 17 for appropriate usage guidelines (Table continued on following page) 33AMUG-10.indd 33 9/30/2009 5:20:47 PM
  35. 35. TABLE 16 Guidelines for Antimicrobial Dosing in Adults (continued) 1 Assure that full daily dosing occurs after dialysis as an alternative to supplemental dosing. 2 For malaria prophylaxis, the recommended dose is 250/100 mg q24h. 3 Dose may be doubled in severe infection. 4 Only available in a 100 mg/5 mL oral suspension. 5 Foscarnet dosing in renal insufficiency: Induction for HSV Induction for CMV Maintenance Dosage for CMV (dose in mg/kg) (dose in mg/kg) (dose in mg/kg) Creatinine Clearance Equivalent to Equivalent to Equivalent to mL/min/kg 40 mg/kg q12h 90 mg/kg q12h 90 mg/kg q24h >1.4 40 q12h 90 q12h 90 q24h >1-1.4 30 q12h 70 q12h 70 q24h >0.8-1 20 q12h 50 q12h 50 q24h >0.6-0.8 35 q24h 80 q24h 80 q48h >0.5-0.6 25 q24h 60 q24h 60 q48h 0.4-0.5 20 q24h 50 q24h 50 q48h <0.4 Not recommended Not recommended Not recommended 6 Plus folinic acid, 10 mg, with each dose of pyrimethamine. 7 Recommended dosing for synergy in the treatment of enterococcal infections. Serum levels should be monitored. 8 Higher doses may be warranted for serious infections; up to 3 DS q8h or 2 DS q6h. 34AMUG-10.indd 34 9/30/2009 5:20:47 PM
  36. 36. TABLE 17 Formulary-Approved Indications and Dosing of Restricted Antimicrobial Agents in Adults Suggested Supplement Drug/ Admin Usual CrCl Dosage for Dialysis Indication Route Regimen ~Cost/d ~Cost/wk (mL/min) Regimen H/D P/D Amphotericin B Lipid Complex ABELCET® IV Prophylaxis: $150 $1050 — No renal dose adjustment necessary • Infectious Diseases 3 mg/kg q24h Service only Treatment: • Serum creatinine >21 5 mg/kg q24h $260 $1820 or 50% decrease in baseline renal function • Amphotericin B failure Aztreonam IV 1-2 g q6-8h $90-250 $630-1750 >30 1-2 g q6-8h Yes Yes • Infections due to 10-30 1-500 mg q6-8h resistant organisms <10 250-500 mg q6-8h • Allergy to -lactam antibiotics Ceftazidime IV 1-2 g q8h $20-45 $140-315 >50 1-2 g q8h Yes Yes • Penicillin-allergic patients 31-50 1-2 g q12h who can tolerate cephalosporins 16-30 1-2 g q24h • Organisms resistant to piperacillin/tazobactam <15 500 mg-1g q24h • Failed empiric piperacillin/tazobactam therapy • Neurosurgical patients • Gram-negative monotherapy in febrile neutropenic patients Ceftriaxone IM/IV 1 g q24h $10 $70 — No renal dose adjustment necessary • Dose limited to 1 g q24h unless endocarditis or meningitis (Table continued on following page) 35AMUG-10.indd 35 9/30/2009 5:20:47 PM
  37. 37. TABLE 17 Formulary-Approved Indications and Dosing of Restricted Antimicrobial Agents in Adults (continued) Suggested Supplement Drug/ Admin Usual CrCl Dosage for Dialysis Indication Route Regimen ~Cost/d ~Cost/wk (mL/min) Regimen H/D P/D Cidofovir2 IV 5 mg/kg N/A $297 <55 Avoid use — — • Infectious Diseases every other week Service only (+ probenecid and hydration) Ciprofloxacin IV 400 mg q12h $12 $84 >30 400 mg q12h No — • Infection due to <30 400 mg q24h resistant organisms • Allergy to -lactam antibiotics • Patients who can not take oral medications Colistimethate Inhaled 75 mg q12h Inhaled: $15 Inhaled: $105 • Infectious Diseases Service only • Serum IV IV: $50 IV: $350 creatinine: 0.7-1.2 mg/dL 100-125 mg q6-12h No data on dialysis clearance 1.3-1.5 mg/dL 75-115 mg q12h 1.6-2.5 mg/dL 66-150 mg q24h 2.6-4 mg/dL 100-150 mg q48h Cytomegalovirus IV Initial dose: 150 mg/kg — No renal dose adjustment necessary immune globulin Week 2, 4, 6, 8: 100 mg/kg • Infectious Diseases Week 12, 16: 50 mg/kg and Transplant Services Cost/course: ~$12,000 (Table continued on following page) 36AMUG-10.indd 36 9/30/2009 5:20:47 PM
  38. 38. TABLE 17 Formulary-Approved Indications and Dosing of Restricted Antimicrobial Agents in Adults (continued) Suggested Supplement Drug/ Admin Usual CrCl Dosage for Dialysis Indication Route Regimen ~Cost/d ~Cost/wk (mL/min) Regimen H/D P/D Daptomycin IV 6 mg/kg q24h $200 $1400 30 q24h — — • Infectious Diseases (500 mg q24h) <30 q48h Service only • Not indicated for pneumonia • Higher mg/kg doses may be warranted for certain infections Imipenem IV 500 mg q6h $85 $600 >70 500 mg q6h Yes — • Infections due to 30-70 500 mg q8h resistant organisms or 20-30 500 mg q12h mixed infection <20 250 mg q12h Linezolid IV/PO 600 mg q12h IV: $180 $1260 — No renal dose adjustment necessary • Infectious Diseases PO: $140 $980 Service only Micafungin IV 100 mg q24h $80 $560 — No renal dose adjustment necessary • Infectious Diseases 150 mg q24h $120 $840 Service only • 100-mg dose recommended for candidemia, disseminated candidiasis, candida peritonitis, and abscesses • 150-mg dose recommended for candida endocarditis, osteomyelitis, or meningitis and mould infections (Table continued on following page) 37AMUG-10.indd 37 9/30/2009 5:20:47 PM
  39. 39. TABLE 17 Formulary-Approved Indications and Dosing of Restricted Antimicrobial Agents in Adults (continued) Suggested Supplement Drug/ Admin Usual CrCl Dosage for Dialysis Indication Route Regimen ~Cost/d ~Cost/wk (mL/min) Regimen H/D P/D Moxifloxacin IV/PO 400 mg q24h IV: $12 IV: $84 — No renal dose adjustment necessary • Penicillin-allergic PO: $9 PO: $63 patients with community- acquired pneumonia Oseltamivir PO 75 mg bid $6 $42 >30 75 mg bid — — • Use between Nov-March in 10-30 75 mg q24h patients who present within <10 No data available 36-48 h of symptoms • Patients with documented influenza B or prophylaxis of documented influenza B exposure Posaconazole PO 200 mg q8h $65 $455 — No renal dose adjustment necessary • Infectious Diseases 200 mg q6h $85 $595 Service • BMT Service Tigecycline IV Loading dose: $115 — No renal dose adjustment necessary • Infectious Diseases 100 mg × 1 Service only Maintenance $115 $805 • Treatment of MDR dose: 50 mg q12h Gram-negative infections (Table continued on following page) 38AMUG-10.indd 38 9/30/2009 5:20:47 PM
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