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1. Treatment Recommendations
For Adult Inpatients
Also available online at
insidehopkinsmedicine.0rg/amp
Antibiotic Guidelines
2015-2016

3. 1. Introduction ............................................................................................ 3
2. Johns Hopkins Hospital formulary and restriction status.................... 6
2.1 Obtaining ID approval........................................................................6
2.2 Formulary.........................................................................................7
3. Agent-specific guidelines ...................................................................... 8
3.1 Antibiotics ........................................................................................8
Ceftaroline......................................................................................8
Ceftolozane/tazobactam.................................................................8
Colistin...........................................................................................9
Daptomycin ................................................................................. 10
Ertapenem................................................................................... 11
Fosfomycin.................................................................................. 11
Linezolid...................................................................................... 12
Tigecycline .................................................................................. 13
Trimethoprim/sulfamethoxazole ................................................... 14
3.2 Antifungals..................................................................................... 16
AmBisome®................................................................................ 16
Micafungin................................................................................... 17
Posaconazole.............................................................................. 18
Voriconazole................................................................................ 19
Azole drug interactions................................................................. 20
3.3 Vaccines ....................................................................................... 23
Pneumococcal vaccines............................................................... 23
4. Organism-specific guidelines..............................................................24
4.1 Anaerobes..................................................................................... 24
4.2 Propionibacterium acnes................................................................ 25
4.3 Streptococci.................................................................................. 27
4.4 Multi-drug resistant Gram-negative rods .......................................... 28
5. Microbiology information ....................................................................31
5.1 Interpreting the microbiology report................................................ 31
5.2 Spectrum of antibiotic activity......................................................... 32
5.3 Interpretation of rapid diagnostic tests............................................ 34
5.4 Johns Hopkins Hospital antibiogram ............................................... 36
6. Guidelines for the treatment of various infections...........................39
6.1 Abdominal infections.............................................................39
Biliary tract infections................................................................... 39
Diverticulitis ................................................................................. 40
Pancreatitis ................................................................................. 41
Peritonitis (including SBP, GI perforation and peritonitis
related to peritoneal dialysis) ........................................................ 42
6.2 Clostridium difficile infection (CDI) ............................................47
6.3 Infectious diarrhea .....................................................................51
6.4 H. pylori infection .......................................................................54
6.5 Gynecologic and sexually transmitted infections.....................56
Pelvic inflamatory disease ............................................................ 56
Endomyometritis.......................................................................... 56
Bacterial vaginosis....................................................................... 57
Trichomoniasis ............................................................................ 57
Uncomplicated gonococcal urethritis, cervicitis, proctitis............... 57
Syphilis........................................................................................ 58
6.6 Catheter-related bloodstream infections..................................60
1
Table
of
contents
(continued on next page)

4. 6.7 Endocarditis................................................................................65
6.8 Pacemaker/ICD infections.........................................................71
6.9 Central nervous system (CNS) infections .................................73
Meningitis.................................................................................... 73
Encephalitis ................................................................................. 75
Brain abscess.............................................................................. 76
CNS shunt infection...................................................................... 76
Antimicrobial doses for CNS infections.......................................... 77
6.10 Acute bacterial rhinosinusitis (ABRS).....................................78
6.11 Orbital cellulitis.....................................................................80
6.12 Pulmonary infections..................................................................82
COPD exacerbations.................................................................... 82
Community-acquired pneumonia ................................................... 83
Healthcare-acquired pneumonia.................................................... 87
Ventilator-associated pneumonia................................................... 88
Cystic fibrosis.............................................................................. 91
6.13 Respiratory virus diagnosis and management.........................93
6.14 Tuberculosis (TB)........................................................................95
6.15 Sepsis with no clear source.......................................................99
6.16 Skin, soft-tissue, and bone infections......................................100
Cellulitis..................................................................................... 100
Cutaneous abscess.................................................................... 101
Management of recurrent MRSA infections.................................. 102
Diabetic foot infections............................................................... 103
Surgical-site infections................................................................ 105
Serious, deep soft-tissue infections (necrotizing fasciitis).............. 107
Vertebral osteomyelitis, diskitis, epidural abscess ....................... 108
6.17 Urinary tract infections (UTI)....................................................110
Bacterial UTI (including pyelonephritis and urosepsis)................... 110
6.18 Candidiasis in the non-neutropenic patient ............................115
6.19 Guidelines for the use of prophylactic antimicrobials.................121
Pre-operative and pre-procedure antibiotic prophylaxis................. 121
Prophylaxis against bacterial endocarditis .................................. 125
Prophylactic antimicrobials for patients with
solid organ transplants............................................................... 126
6.20 Guidelines for the use of antimicrobials in
neutropenic hosts.....................................................................129
Treatment of neutropenic fever................................................... 129
Prophylactic antimicrobials for patients with
expected prolonged neutropenia ................................................ 131
Use of antifungal agents in hematologic
malignancy patients ............................................................. 133
7. Informational guidelines .................................................................137
7.1 Approach to the patient with a history of penicillin allergy................ 137
8. Infection control ..............................................................................139
8.1 Hospital Epidemiology & Infection Control.................................... 139
8.2 Infection control precautions ....................................................... 141
8.3 Disease-specific infection control recommendations..................... 142
10. Appendix:
A. Aminoglycoside dosing and therapeutic monitoring ........................ 145
B. Vancomycin dosing and therapeutic monitoring.............................. 150
C. Antimicrobial therapy monitoring ................................................... 153
D. Oral antimicrobial use ................................................................... 154
E. Antimicrobial dosing in renal insufficiency....................................... 155
F. Cost of select antimicrobial agents ................................................ 159
2
Table
of
contents

5. Introduction
Antibiotic resistance is now a major issue confronting healthcare
providers and their patients. Changing antibiotic resistance patterns,
rising antibiotic costs and the introduction of new antibiotics have
made selecting optimal antibiotic regimens more difficult now than
ever before. Furthermore, history has taught us that if we do not
use antibiotics carefully, they will lose their efficacy. As a response
to these challenges, the Johns Hopkins Antimicrobial Stewardship
Program was created in July 2001. Headed by an Infectious Disease
physician (Sara Cosgrove, M.D., M.S.) and an Infectious Disease
pharmacist (Edina Avdic, Pharm.D., M.B.A), the mission of the
program is to ensure that every patient at Hopkins on antibiotics
gets optimal therapy. These guidelines are a step in that direction.
The guidelines were initially developed by Arjun Srinivasan, M.D., and
Alpa Patel, Pharm.D., in 2002 and have been revised and expanded
annually.
These guidelines are based on current literature reviews, including
national guidelines and consensus statements, current microbiologic
data from the Hopkins lab, and Hopkins’ faculty expert opinion.
Faculty from various departments have reviewed and approved these
guidelines. As you will see, in addition to antibiotic recommendations,
the guidelines also contain information about diagnosis and other
useful management tips.
As the name implies, these are only guidelines, and we anticipate
that occasionally, departures from them will be necessary. When these
cases arise, we will be interested in knowing why the departure is
necessary. We want to learn about new approaches and new data as
they become available so that we may update the guidelines as needed.
You should also document the reasons for the departure in the patient’s
chart.
Sara E. Cosgrove, M.D., M.S.
Director, Antimicrobial Stewardship Program
Edina Avdic, Pharm.D., M.B.A
ID Pharmacist
Associate Director, Antimicrobial Stewardship Program
Kate Dzintars, Pharm.D.
ID Pharmacist
Janessa Smith, Pharm.D.
ID Pharmacist
3
1.
Introduction

6. 4
1.
Introduction
The following people served as section/topic reviewers
N. Franklin Adkinson, M.D. (Allergy/Immunology)
Paul Auwaerter, M.D. (Infectious Diseases)
Robin Avery, M.D. (Infectious Diseases)
John Bartlett, M.D. (Infectious Diseases)
Dina Benani, Pharm. D. (Pharmacy)
Michael Boyle, M.D. (Pulmonary)
Roy Brower, M.D. (Critical Care and Pulmonary)
Karen Carroll, M.D. (Pathology/Infectious Diseases)
Michael Choi, M.D. (Nephrology)
John Clarke, M.D. (Gastroenterology)
Todd Dorman, M.D. (Critical Care)
Christine Durand, M.D. (Infectious Diseases)
Khalil Ghanem, M.D. (Infectious Diseases)
James Hamilton, M.D. (Gastroenterology)
Carolyn Kramer, M.D. (Medicine)
Pam Lipsett, M.D. (Surgery and Critical Care)
Colin Massey, M.D. (Medicine)
Lisa Maragakis, M.D. (Infectious Diseases)
Kieren Marr, M.D. (Infectious Diseases)
Robin McKenzie, M.D. (Infectious Diseases)
Michael Melia, M.D. (Infectious Diseases)
George Nelson, M.D. (Infectious Diseases)
Eric Nuermberger, M.D. (Infectious Diseases)
Trish Perl, M.D., M.Sc. (Infectious Diseases)
Stuart Ray, M.D. (Infectious Diseases)
Anne Rompalo, M.D. (Infectious Diseases)
Annette Rowden, Pharm.D. (Pharmacy)
Paul Scheel, M.D. (Nephrology)
Cynthia Sears, M.D. (Infectious Diseases)
Maunank Shah, M.D. (Infectious Diseases)
Tiffeny Smith, Pharm.D. (Pharmacy)
Jennifer Townsend, M.D. (Infectious Diseases)
Robert Wise, M.D. (Pulmonary)
Frank Witter, M.D. (OB-GYN)
How to use this guide
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dose of antibiotics for the particular infection.
UÊALL DOSES IN THE TEXT ARE FOR ADULTS WITH NORMAL
RENAL AND HEPATIC FUNCTION.
UÊÊ
vÊÞœÕÀʫ̈i˜ÌÊ`œiÃÊ /Ê…ÛiʘœÀ“ÊÀi˜ÊœÀÊ…i«ÌˆVÊvÕ˜V̈œ˜]Ê
please refer to the sections on antibiotic dosing to determine the
correct dose.
UÊÊ
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some important treatment notes that explain a bit about WHY the
particular antibiotics were chosen and that provide some important
tips on diagnosis and management. PLEASE glance at these notes

7. 1.
Introduction
5
when you are treating infections, as we think the information will prove
helpful. All references are on file in the office of the Antimicrobial
Stewardship Program (7-4570).
Contacting us
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they are part of an approved order.
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A word from our lawyers
The recommendations given in this guide are meant to serve as
treatment guidelines. They should NOT supplant clinical judgment or
Infectious Diseases consultation when indicated. The recommendations
were developed for use at The Johns Hopkins Hospital and thus may
not be appropriate for other settings. We have attempted to verify
that all information is correct but because of ongoing research, things
may change. If there is any doubt, please verify the information in the
}Õˆ`iÊLÞÊVˆ˜}ÊÌ…iʘ̈LˆœÌˆVÃÊ«}iÀÊÕȘ}Ê* Ê­ÃiÀV…ʺ˜ÌˆLˆœÌˆV»®ÊœÀÊ
Infectious Diseases.
Also, please note that these guidelines contain cost information
that is confidential. Copies of the book should not be distributed
outside of the institution without permission.

9. Obtaining ID approval
The use of restricted and non-formulary antimicrobials requires pre-
approval from Infectious Diseases. This approval can be obtained by any
of the following methods.
Approval method Notes
* ʺ˜ÌˆLˆœÌˆV»Ê Ê
/…iÊ«}iÀʈÃʘÃÜiÀi`ÊLiÌÜii˜ÊnÊ°“°Ê
and 10 p.m. PING the ID consult pager
if you fail to get a response from the ID
approval pager within 10 minutes.
Overnight Approval Restricted antibiotics ordered between
10 p.m. and 8 a.m. must be approved
by noon the following morning.
Ê UÊÊ
*iÃiÊÀi“i“LiÀÊÌœÊÈ}˜ÊœÕÌÊÌ…iʘii`Ê
for approval if you go off shift before
8 a.m.
Ordersets (e.g. neutropenic These forms are PT-approved for
fever, etc.) specific agents and specific indications.
2.1
Obtaining
ID
approval
6

10. 7
2.2
Antimicrobial
formulary
and
restriction
status
Selected formulary antimicrobials
and restriction status
The following list applies to ALL adult floors and includes the status of
both oral and injectable dosage forms, unless otherwise noted.
Unrestricted
Amoxicillin
Amoxicillin/clavulanate
Ampicillin/sulbactam
(Unasyn®
)
Ampicillin IV
Azithromycin
Cefazolin
Cefdinir
Cefotetan
Cefpodoxime
Ceftriaxone
Cefuroxime IV
Cephalexin
Clarithromycin
Clindamycin
Dicloxacillin
Doxycycline
Ertapenem
Erythromycin
Gentamicin
Metronidazole
Minocycline
Nitrofurantoin
Oxacillin
Penicillin V/G
Ribavirin oral
Rifampin
Streptomycin
Tobramycin
Trimethoprim/
sulfamethoxazole
Amphotericin B
deoxycholate
(Fungizone®
)
Flucytosine
Itraconazole oral solution
Restricted (requires ID
approval)
Amikacin
Aztreonam
Cefepime
Ceftaroline1
Ceftazidime
Ceftolozane/tazobactam1
Ciprofloxacin
Colistin IV
Cytomegalovirus Immune
Globulin (Cytogam®
)2
Daptomycin1
Fosfomycin3
Linezolid
Meropenem
Moxifloxacin
Nitazoxanide4
Palivizumab (Synagis®
)5
Piperacillin/tazobactam
­œÃÞ˜®
)
Quinupristin/
dalfopristin (Synercid®
)
Ribavirin inhaled5
Telavancin1
Tigecycline
Vancomycin
Liposomal amphotericin B
(AmBisome®
)
Micafungin
Fluconazole6
Posaconazole
Voriconazole
1Approval must be obtained from Antimicrobial Stewardship Program 24h/7 days a week
2Approval required, except for solid organ transplant patients
3Approval must be obtained 24h/7 days a week
4Approval must be obtained from Polk Service or ID Consult
5Approval must be obtained from ID attending physician 24h/7 days a week
6Oral Fluconazole, when used as a single-dose treatment for vulvovaginal candidiasis or when
used in compliance with the SICU/WICU protocol, does not require ID approval
Restricted antimicrobials that are ordered as part of a PT-approved critical pathway or order
set do NOT require ID approval.
REMINDER: the use of non-formulary antimicrobials is strongly discouraged. ID
approval MUST be obtained for ALL non-formulary antimicrobials.
NOTE: Formulary antivirals (e.g. Acyclovir, Ganciclovir) do NOT require ID approval.

11. Antibiotics
Ceftaroline
Ceftaroline is a cephalosporin with in vitro activity against staphylococci
(including MRSA), most streptococci, and many Gram-negative bacteria.
It does NOT have activity against Pseudomonas spp. or Acinetobacter
spp. or Gram negative anaerobes.
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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Gram negative coverage is also needed
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Unacceptable uses
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*®ÊœÀÊÃŽˆ˜Ê
and soft tissue infections (SSTI) where other more established and
less expensive options are available
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Dose
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serious infections
UÊMust adjust for worsening renal function and dialysis (see p. 155 for
dose adjustment recommendation).
Laboratory interactions
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hemolytic anemia. However, if drug-induced hemolytic anemia is
suspected, discontinue Ceftaroline.
Ceftolozane/tazobactam
Ceftolozane/tazobactam is a novel cephalosporin and β-lactamase-
inhibitor combination. It has activity against Gram-negative organisms
and some strains of multi-resistant Pseudomonas spp. It does NOT have
activity against carbapenemase-producing Enterobacteriaceae. It also
has in vitro activity against some streptococci and some Gram-negative
anaerobes, but it does not have reliable Staphylococcus spp. activity.
8
3.1
Agent-specific
guidelines:
Antibiotics

12. Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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spp. infections on a case by case basis
Unacceptable uses
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or complicated urinary tract infections (cUTI) as current standard
regimens are sufficient for coverage of the typical pathogens involved
in these infections and less expensive options are available
Dose
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metronidazole for cIAI
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for dose adjustment recommendation).
Colistin (Colistimethate)
Colistin is a polymixin antibiotic. It has in vitro activity against
Acinetobacter spp. and Pseudomonas spp. but does NOT have activity
against Proteus, Serratia, Providentia, Burkholderia, Stenotrophomonas,
Gram-negative cocci, Gram-positive organisms, or anaerobes.
Acceptable uses
UÊÊ
˜}i“i˜ÌÊœvʈ˜viV̈œ˜ÃÊ`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃ̘ÌÊAcinetobacter
and Pseudomonas on a case by case basis.
Unacceptable uses
UÊÊ
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Dose
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renal function and dialysis (see p. 155 for dose adjustment
recommendation).
Toxicity
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3.1
Agent-specific
guidelines:
Antibiotics
9

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Daptomycin
Daptomycin is a lipopeptide antibiotic. It has activity against most strains
of staphylococci and streptococci (including MRSA and VRE). It does
NOT have activity against Gram-negative organisms.
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
UÊÊ
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coagulase-negative staphylococci in a patient with serious allergy to
Vancomycin
UÊÊ
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ˆÕÀiÊÌœÊViÀÊLœœ`ÊVՏÌÕÀiÃÊvÌiÀÊÇÊ`ÞÃÊ`iëˆÌiÊ6˜Vœ“ÞVˆ˜Ê
ÌÀœÕ}…ÃÊœvÊ£xqÓäÊ“V}É“Ê­…ˆ}…ÊÀˆÃŽÊœvÊ

15. «Ìœ“ÞVˆ˜ÊÀiÈÃ̘ViÆÊ
check Daptomycin MIC and obtain follow up blood cultures)
UÊÊ
ÊœvÊ6˜Vœ“ÞVˆ˜ÊˆÃÊÓÊ“V}É“
UÊÊ
/…iÀ«ÞÊvœÀÊ6,
ʈ˜viV̈œ˜Ãʜ̅iÀÊÌ…˜Ê«˜iÕ“œ˜ˆ]Êœ˜ÊÊVÃiÊLÞÊVÃiÊLÈÃ
Unacceptable uses
UÊÊ

16. «Ìœ“ÞVˆ˜ÊÃ…œÕ`Ê /ÊLiÊÕÃi`ÊvœÀÊÌÀiÌ“i˜ÌÊœvÊ«˜iÕ“œ˜ˆÊ`ÕiÊÌœÊ
its inactivation by pulmonary surfactant.
UÊÊ
˜ˆÌˆÊÌ…iÀ«ÞÊvœÀÊÀ“‡«œÃˆÌˆÛiʈ˜viV̈œ˜ÃÊ
UÊÊ
6,
ÊVœœ˜ˆâ̈œ˜ÊœvÊÌ…iÊÕÀˆ˜i]ÊÀiëˆÀÌœÀÞÊÌÀVÌ]Êܜ՘`Ã]ÊœÀÊ`Àˆ˜ÃÊ
Dose
UÊÊ
VÌiÀi“ˆÊÈq£ÓÊ“}ÉŽ}Ê6Ê+ÊÓ{
UÊÊ
˜`œVÀ`ˆÌˆÃÊÈq£ÓÊ“}ÉŽ}Ê6Ê+ÊÓ{
UÊÊ

17. œÃiÊ`ÕÃÌ“i˜ÌʈÃʘiViÃÃÀÞÊvœÀÊ
À
Ê 30 ml/min (see p. 155 for
dose adjustment recommendation).
3.1
Agent-specific
guidelines:
Antibiotics
10
Hidden Content
- JHH Internal use only

18. 11
3.1
Agent-specific
guidelines:
Antibiotics
Toxicity
UÊÊ
Þœ«Ì…ÞÊ­`iw˜i`ÊÃÊ
Ê 10 times the upper limit of normal without
symptoms or 5 times the upper limit of normal with symptoms).
UÊÊ
œÃˆ˜œ«…ˆˆVÊ«˜iÕ“œ˜ˆ
UÊÊ
œ˜ˆÌœÀˆ˜}Ê
ÊÜiiŽÞ]Ê“œÀiÊvÀiµÕi˜ÌÞÊ`ÕÀˆ˜}ʈ˜ˆÌˆÊÌ…iÀ«Þ°Ê
,iviÀi˜ViÊ
Daptomycin in S. aureusÊLVÌiÀi“ˆÊ˜`ʈ˜viV̈ÛiÊi˜`œVÀ`ˆÌˆÃÊ Ê
˜}ÊÊi`ÊÓääÈÆÊ
ÎxxÊÈxÎqÈx°
Ertapenem
Ertapenem is a carbapenem antibiotic. It has in vitro activity against
many Gram-negative organisms including those that produce extended
spectrum beta-lactamases (ESBL), but it does not have activity against
Pseudomonas spp. or Acinetobacter spp. Its anaerobic and Gram-
positive activity is similar to that of other carbapenems, except it does
not have activity against Enteroccocus spp.
Acceptable uses
UÊÊ
ˆ`Ê̜ʓœ`iÀÌiʈ˜ÌÀ‡L`œ“ˆ˜Êˆ˜viV̈œ˜ÃÊ­LˆˆÀÞÊÌÀVÌʈ˜viV̈œ˜Ã]Ê
diverticulitis, secondary peritonitis/GI perforation)
UÊÊ
œ`iÀÌiÊ`ˆLïVÊvœœÌʈ˜viV̈œ˜ÃÊ܈̅œÕÌÊœÃÌiœ“ÞiˆÌˆÃ
UÊÊ
œ`iÀÌiÊÃÕÀ}ˆV‡ÃˆÌiʈ˜viV̈œ˜ÃÊvœœÜˆ˜}ÊVœ˜Ì“ˆ˜Ìi`Ê«ÀœVi`ÕÀi
UÊ*iÛˆVʈ˜y““ÌœÀÞÊ`ˆÃiÃi
UÊÊ
1Àˆ˜ÀÞÊÌÀVÌʈ˜viV̈œ˜ÃÊVÕÃi`ÊLÞÊ
- ‡«Àœ`ÕVˆ˜}ÊœÀ}˜ˆÃ“ÃÊ
UÊÊ
*Þiœ˜i«…ÀˆÌˆÃʈ˜Êʫ̈i˜ÌÊÜ…œÊˆÃʘœÌÊÃiÛiÀiÞʈ
Unacceptable uses
UÊÊ
-iÛiÀiʈ˜viV̈œ˜Ãʈ˜ÊÜ…ˆV… Pseudomonas spp. are suspected.
Dose
UÊÊ
£Ê}Ê6ÊœÀÊÊ+Ó{]Ê“ÕÃÌÊ`ÕÃÌÊvœÀÊÜœÀÃi˜ˆ˜}ÊÀi˜ÊvÕ˜V̈œ˜Ê˜`Ê
dialysis (see p. 155 for dose adjustment recommendation)
Toxicity
UÊÊ

19. ˆÀÀ…i]ʘÕÃi]Ê…i`V…i]Ê«…iLˆÌˆÃÉÌ…Àœ“Lœ«…iLˆÌˆÃ
Fosfomycin
Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in
vitro activity against large number of Gram-negative and Gram-positive
organisms including E. coli, Klebsiella spp., Proteus spp., Pseudomonas
spp., and VRE. It does not have activity against Acinetobacter spp.
Fosfomycin is available in an oral formulation only in the U.S. and its
pharmacokinetics allow for one-time dosing.
Acceptable uses
UÊÊ
˜}i“i˜ÌÊœvÊÕ˜Vœ“«ˆVÌi`Ê1/ʈ˜Ê«Ìˆi˜ÌÃÊ܈̅ʓՏ̈«iʘ̈LˆœÌˆVÊ
allergies and/or when no other oral therapy options are available.

20. UÊÊ
1˜Vœ“«ˆVÌi`Ê1/Ê`ÕiÊÌœÊ6,
UÊÊ
Ê
-Û}iÊÌ…iÀ«ÞÊvœÀÊ1/Ê`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃ̘ÌÊÀ“‡˜i}̈ÛiÊ
organisms (e.g. Pseudomonas spp.) on case by case basis.
NOTE: Susceptibility to Fosfomycin should be confirmed prior to
initiation of therapy.
Unacceptable uses
UÊÊ
œÃvœ“ÞVˆ˜ÊÃ…œÕ`Ê /ÊLiÊÕÃi`ÊvœÀÊ“˜}i“i˜ÌÊœvʘÞʈ˜viV̈œ˜ÃÊ
outside of the urinary tract because it does not achieve adequate
concentrations at other sites.
UÊÊ
/ÀiÌ“i˜ÌÊœvÊÃÞ“«Ìœ“ˆVÊLVÌiÀˆÕÀˆÊ­ÃiiÊ«°Ê££ä®
Dose
UÊÊ
1˜Vœ“«ˆVÌi`Ê1/ÊÎÊ}Ê­£ÊÃV…iÌ®Ê*Êœ˜Vi°Ê
UÊÊ
œ“«ˆVÌi`Ê1/ÊÎÊ}Ê­£ÊÃV…iÌ®Ê*ÊiÛiÀÞÊ£‡ÎÊ`ÞÃÊ­Õ«ÊÌœÊÓ£Ê`ÞÃÊœvÊ
treatment)
UÊÊ
ÀiµÕi˜VÞÊ`ÕÃÌ“i˜ÌÊ“ÞÊLiʘiViÃÃÀÞʈ˜Ê«Ìˆi˜ÌÃÊ܈̅Ê
À
Ê 50
mL/min. Contact the ID Pharmacist for dosing recommendations.
UÊÊ
*œÜ`iÀÊÃ…œÕ`ÊLiÊ“ˆÝi`Ê܈̅ʙäq£ÓäÊ“ÊœvÊVœœÊÜÌiÀ]ÊÃ̈ÀÀi`ÊÌœÊ
dissolve and administered immediately.
Toxicity
UÊÊ

21. ˆÀÀ…i]ʘÕÃi]Ê…i`V…i]Ê`ˆâ∘iÃÃ]ÊÃÌ…i˜ˆÊ˜`Ê`Þëi«Ãˆ
Linezolid
Acceptable uses
UÊÊ

22. œVÕ“i˜Ìi`Ê6˜Vœ“ÞVˆ˜Êˆ˜ÌiÀ“i`ˆÌiÊStaphylococcus aureus (VISA)
or Vancomycin resistant Staphylococcus aureus (VRSA) infection
UÊÊ

23. œVÕ“i˜Ìi`Ê,-ÊœÀÊiÌ…ˆVˆˆ˜‡ÀiÈÃ̘ÌÊVœ}ՏÃi‡˜i}̈ÛiÊ
staphylococcal infection in a patient with serious allergy to Vancomycin
UÊÊ

24. œVÕ“i˜Ìi`Ê,-ÊœÀÊiÌ…ˆVˆˆ˜‡ÀiÈÃ̘ÌÊVœ}ՏÃi‡˜i}̈ÛiÊ
staphylococcal infection in a patient failing Vancomycin therapy (as
`iw˜i`ÊLiœÜ®Ê
UÊÊ
VÌiÀi“ˆÉi˜`œVÀ`ˆÌˆÃÊvˆÕÀiÊÌœÊViÀÊLœœ`ÊVՏÌÕÀiÃÊvÌiÀÊ
ÇÊ`ÞÃÊ`iëˆÌiÊ6˜Vœ“ÞVˆ˜ÊÌÀœÕ}…ÃÊœvÊ£xqÓäÊ“V}É“°Ê-…œÕ`ÊLiÊ
used in combination with another agent
UÊÊ
*˜iÕ“œ˜ˆÊÜœÀÃi˜ˆ˜}ʈ˜wÌÀÌiÊœÀʫՏ“œ˜ÀÞÊÃÌÌÕÃʈ˜Êʫ̈i˜ÌÊ
with documented MRSA pneumonia after 2 to 3 days or if the
MIC of Vancomycin is 2 mcg/mL, or if achieving appropriate
vancomycin trough is unlikely (e.g., obesity)
UÊÊ
ÃiÃÊÃ…œÕ`ÊLiÊ`ˆÃVÕÃÃi`Ê܈̅ʘviV̈œÕÃÊ

25. ˆÃiÃiÃÊœÀÊ
Antimicrobial stewardship
UÊHigh suspicion of CA-MRSA necrotizing pneumonia in a seriously
ill patient
3.1
Agent-specific
guidelines:
Antibiotics
12

26. 13
3.1
Agent-specific
guidelines:
Antibiotics
Ê
UÊÊ

27. œVÕ“i˜Ìi`Ê6,
ʈ˜viV̈œ˜Ê
UÊÊ
À“‡«œÃˆÌˆÛiÊVœVVˆÊˆ˜ÊV…ˆ˜Ãʈ˜ÊLœœ`ÊVՏÌÕÀiÃʈ˜Ê˜Ê
1]ÊœÀÊœ˜Vœœ}ÞÊ
transplant patient known to be colonized with VRE
Unacceptable uses
UÊÊ
*Àœ«…ޏ݈Ã
UÊÊ
˜ˆÌˆÊÌ…iÀ«ÞÊvœÀÊÃÌ«…ޏœVœVVÊˆ˜viV̈œ˜
UÊÊ
6,
ÊVœœ˜ˆâ̈œ˜ÊœvÊÌ…iÊÃÌœœ]ÊÕÀˆ˜i]ÊÀiëˆÀÌœÀÞÊÌÀVÌ]Êܜ՘`Ã]ÊœÀÊ`Àˆ˜Ã
Dose
UÊÊ
ÈääÊ“}Ê6É*Ê+£Ó
UÊÊ
-Žˆ˜Ê˜`ÊÃŽˆ˜‡ÃÌÀÕVÌÕÀiʈ˜viV̈œ˜ÃÊ{ääÊ“}Ê6É*Ê+£Ó
Toxicity
UÊÊ
œ˜iÊ“ÀÀœÜÊÃÕ««ÀiÃÈœ˜Ê­ÕÃՏÞÊœVVÕÀÃÊ܈̅ˆ˜ÊwÀÃÌÊÓÊÜiiŽÃÊœvÊÌ…iÀ«Þ®
UÊÊ
«ÌˆVʘiÕÀˆÌˆÃʘ`ʈÀÀiÛiÀÈLiÊÃi˜ÃœÀÞÊ“œÌœÀÊ«œÞ˜iÕÀœ«Ì…ÞÊ­ÕÃՏÞÊ
occurs with prolonged therapy 28 days)
UÊÊ
ÃiÊÀi«œÀÌÃÊœvʏV̈VÊVˆ`œÃˆÃ
UÊÊ
ÃiÊÀi«œÀÌÃÊœvÊÃiÀœÌœ˜ˆ˜ÊÃÞ˜`Àœ“iÊÜ…i˜ÊVœ‡`“ˆ˜ˆÃÌiÀi`Ê܈̅Ê
serotonergic agents (SSRIs, TCAs, MAOIs, etc.)
UÊÊ
œ˜ˆÌœÀˆ˜}Ê
ÊÜiiŽÞ
Tigecycline
Tigecycline is a tetracycline derivative called a glycylcycline. It has in
vitro activity against most strains of staphylococci and streptococci
(including MRSA and VRE), anaerobes, and many Gram-negative
organisms with the exception of Proteus spp. and Pseudomonas
aeruginosa. It is FDA approved for skin and skin-structure infections and
intra-abdominal infections.
NOTE: Peak serum concentrations of Tigecycline do not exceed
1 mcg/mL which limits its use for treatment of bacteremia
Acceptable uses
UÊÊ
˜}i“i˜ÌÊœvʈ˜ÌÀ‡L`œ“ˆ˜Êˆ˜viV̈œ˜Ãʈ˜Ê«Ìˆi˜ÌÃÊ܈̅Ê
contraindications to both beta-lactams and fluoroquinolones
UÊÊ
˜}i“i˜ÌÊœvʈ˜viV̈œ˜ÃÊ`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃ̘ÌÊÀ“‡˜i}̈ÛiÊ
organisms including Acinetobacter spp. and Stenotrophomonas
maltophilia on a case by case basis
UÊÊ
-Û}iÊÌ…iÀ«ÞÊvœÀÊ,-É6,
ʈ˜viV̈œ˜ÃÊœ˜ÊÊVÃiÊLÞÊVÃiÊLÈÃ
Dose
UÊÊ
£ääÊ“}Ê6Êœ˜Vi]ÊÌ…i˜ÊxäÊ“}Ê6Ê+£Ó
UÊÊ
£ääÊ“}Ê6Êœ˜Vi]ÊÌ…i˜ÊÓxÊ“}Ê6Ê+£ÓʈvÊÃiÛiÀiÊ…i«ÌˆVʈ“«ˆÀ“i˜ÌÊ
­
…ˆ`ʇÊ*Õ}…Ê£äq£x®
Toxicity
UÊÊ ÕÃiʘ`ÊÛœ“ˆÌˆ˜}Ê

28. 14
3.1
Agent-specific
guidelines:
Antibiotics
Trimethoprim/sulfamethoxazole
(Bactrim®, TMP/SMX)
Trimethoprim/sulfamethoxazole is a sulfonamide antibiotic. It has in vitro
activity against Enterobacteriaceae spp., B. cepacia, S. maltophilia,
Acinetobacter spp., Achromobacter spp., Nocardia spp., Listeria,
Pneumocystis jirovecii (PCP), staphylococci (including S. aureus and
Coagulase-negative staph), but does NOT cover Pseudomonas spp.
It has variable activity against streptococci and no activity against
anaerobes.
Acceptable uses
UÊ1Àˆ˜ÀÞÊÌÀVÌʈ˜viV̈œ˜ÃÊ­1/®
UÊS. aureus skin and soft-tissue infections (SSTI)
UÊPneumocystis jirovecii pneumonia (PCP) treatment and prophylaxis
UÊS. maltophilia infections
UÊ œVÀ`ˆÊˆ˜viV̈œ˜ÃÊ
UÊÀ“‡˜i}̈ÛiÊLVÌiÀi“ˆÊÜ…i˜ÊœÀ}˜ˆÃ“ʈÃÊÃÕÃVi«ÌˆLiÊ
UÊÊ
-Û}iÊÌ…iÀ«ÞÊvœÀÊ,-ÊLVÌiÀi“ˆÊˆ˜ÊVœ“Lˆ˜Ìˆœ˜Ê܈̅ʘœÌ…iÀÊ
agent
UÊÊ
“«ˆÀˆVÊVœÛiÀ}iÊœvÊListeria meningitis in patients with penicillin
allergies
UÊÊ
-Õ««ÀiÃÈÛiÊÌ…iÀ«Þʘ`ʈ˜ÊÃœ“iÊVÃiÃÊÌÀiÌ“i˜ÌÊvœÀÊLœ˜iʘ`ʍœˆ˜ÌÊ
infections
Unacceptable uses
UÊœ˜œÌ…iÀ«ÞÊvœÀÊS. aureus bacteremia
Dose
UÊTrimethoprim/sulfamethoxazole dosing is based on trimethoprim
component
UÊ/*É-8Ê…ÃÊiÝVii˜ÌÊLˆœÛˆLˆˆÌÞ]ÊÌ…ÕÃÊVœ˜ÛiÀÈœ˜ÊvÀœ“Ê6ÊÌœÊ*Ê
ˆÃÊ££Ê­näÉ{ääÊ“}Ê6ÊrÊ£Ê--ÊÌLÆÊ£ÈäÉnääÊ“}Ê6ÊrÊ£Ê

29. -ÊÌL®Ê
UÊ1ÃiÊ`ÕÃÌi`Ê 7rÊQ 7ʳÊä°{Ê­ 7Ê‡Ê 7®Rʈ˜ÊœLiÃiʫ̈i˜ÌÃÊ­€Îä¯Ê
over IBW)
Treatment
UÊ1/Ê£Ê

30. -ÊÌLÊ+£ÓÊ
UÊ--/Ê£‡ÓÊ

31. -ÊÌLÊ+£Ó
UÊ*
*£x‡ÓäÊ“}ÉŽ}É`ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®
UÊ,-ÊLVÌiÀi“ˆ£ä‡£xÊ“}ÉŽ}É`ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®
UÊS. maltophiliaʈ˜viV̈œ˜Ã£xÊ“}ÉŽ}É`ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®Ê

32. 15
3.1
Agent-specific
guidelines:
Antibiotics
UÊ œVÀ`ˆÊˆ˜viV̈œ˜ÃÊ£xÊ“}ÉŽ}É`ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®ÆʏœÜiÀÊ
doses (5-10 mg/kg/day) can be used after several weeks of therapy
or cutaneous infections
UÊi˜ˆ˜}ˆÌˆÃÊÓäÊ“}ÉŽ}É`ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+È®
UÊÌ…iÀʈ˜viV̈œ˜ÃÊn‡£äÊ“}ÉŽ}É`ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ£Ó®
UÊÕÃÌÊ`ÕÃÌÊ`œÃiÊvœÀÊÜœÀÃi˜ˆ˜}ÊÀi˜ÊvÕ˜V̈œ˜Ê˜`Ê`ˆÞÈÃÊ­ÃiiÊ«°£xxÊ
for dose adjustment recommendation).
Prophylaxis
UÊ*
*Ê£Ê--Ê`ˆÞÊœÀÊ£Ê

33. -ÊÎÊ̈“iÃÉÜiiŽÊ
UÊ/œÝœ«Ã“œÃˆÃÊ£Ê

34. -Ê`ˆÞÊ
Toxicity
UÊ
œ““œ˜Ê…Þ«iÀÃi˜ÃˆÌˆÛˆÌÞÊ­£°È‡n¯®]ʇիÃiÌ]Ê«ÃiÕ`œÊiiÛ̈œ˜Êˆ˜Ê
VÀ˜iÊ­£n¯®Ê
UÊ
œ““œ˜Ê܈̅ʅˆ}…iÀÊ`œÃiÃÊ…Þ«iÀŽi“ˆ]Ê“ÞiœÃÕ««ÀiÃÈœ˜
UÊVVÈœ˜Ê˜i«…ÀœÌœÝˆVˆÌÞ]Ê«…œÌœÃi˜ÃˆÌˆÛˆÌÞ]Ê“iÌ…i“œ}œLˆ˜i“ˆÊ­ÜˆÌ…Ê
severe G6PD deficiency)
UÊ,ÀiÊÃi«ÌˆVÊ“i˜ˆ˜}ˆÌˆÃ]Ê…i«ÌœÌœÝˆVˆÌÞ]Ê̜݈VÊi«ˆ`iÀ“Ê˜iVÀœÞÈÃÊ
(TEN), SJS, Sweet’s syndrome
Drug Interaction
UÊ7ÀvÀˆ˜]Ê“iÌ…œÌÀiÝÌi]Ê«…i˜ÞÌœˆ˜]Ê`ˆ}œÝˆ˜]ÊÃՏvœ˜ÞÕÀiÃ]Ê
procainamide, oral contraceptives

35. 3.2
Agent-specific
guidelines:
Antifungals
16
Antifungals
Liposomal Amphotericin B (AmBisome®)
NOTES:
UÊÊ

36. œÃˆ˜}ÊœvÊ“ ˆÃœ“iʘ`Ê“«…œÌiÀˆVˆ˜Ê Ê`iœÝÞV…œÌiʈÃÊ
significantly different. Do not use AmBisome doses when
ordering Amphotericin B deoxycholate and vice versa.
UÊÊ
“«…œÌiÀˆVˆ˜Ê Ê`iœÝÞV…œÌiʈÃÊ«ÀiviÀÀi`ʈ˜Ê«Ìˆi˜ÌÃÊ܈̅Êi˜`‡
stage renal disease on dialysis who are anuric.
AmBisome, like all Amphotericin B products, has broad spectrum
antifungal activity with in vitro activity against Candida, Aspergillus,
Zygomycosis and Fusarium.
Acceptable uses
UÊ
˜`ˆ`Êi˜`œ«Ì…“ˆÌˆÃ]Êi˜`œVÀ`ˆÌˆÃ]Ê
-ʈ˜viV̈œ˜qwÀÃÌʏˆ˜iÊÌ…iÀ«Þ
UÊ
ÀÞ«ÌœVœVVÕÃÊ“i˜ˆ˜}ˆÌˆÃ‡wÀÃÌʏˆ˜iÊÌ…iÀ«ÞÊÊ
UÊÞ}œ“ÞVœÃiÃÊ­Mucor, Rhizopus, Cunninghamella®qwÀÃÌʏˆ˜iÊÌ…iÀ«ÞÊ
UÊÊ iÕÌÀœ«i˜ˆVÊviÛiÀʈvÊÀiViˆÛˆ˜}Ê6œÀˆVœ˜âœiÊœÀÊ*œÃVœ˜âœiÊ
prophylaxis
UʏÌiÀ˜ÌˆÛiÊÌÀiÌ“i˜ÌÊœvʈ˜ÛÈÛiÊëiÀ}ˆœÃˆÃ
UÊÊ
ÌiÀ˜ÌˆÛiÊÌÀiÌ“i˜ÌÊœvÊV˜`ˆ`i“ˆ]ÊV˜`ˆ`Ê«iÀˆÌœ˜ˆÌˆÃÊ
Dose
UÊÊ
˜`ˆ`i“ˆ]Ê…ˆÃÌœ«Ã“œÃˆÃ]ʜ̅iÀʘœ˜‡ˆ˜ÛÈÛiÊV˜`ˆ`ʈ˜viV̈œ˜ÃÊ
3 mg/kg/day
UÊÊ
˜`ˆ`Êi˜`œ«Ì…“ˆÌˆÃ]Êi˜`œVÀ`ˆÌˆÃ]Ê
-ʈ˜viV̈œ˜]ÊC. krusei
V˜`ˆ`i“ˆÊxÊ“}ÉŽ}É`Þ
UʘÛÈÛiÊw“i˜ÌœÕÃÊvÕ˜}ˆÊxÊ“}ÉŽ}É`Þ
UÊ iÕÌÀœ«i˜ˆVÊviÛiÀ]ÊV˜`ˆ`i“ˆÊˆ˜Ê˜iÕÌÀœ«i˜ˆVʫ̈i˜ÌÊÎqxÊ“}ÉŽ}É`Þ
UÊ
ÀÞ«ÌœVœVVÊ“i˜ˆ˜}ˆÌˆÃÊÎq{Ê“}ÉŽ}É`Þ
Toxicity
UʘvÕÈœ˜‡ÀiÌi`ÊÀiV̈œ˜ÃÊviÛiÀ]ÊV…ˆÃ]ÊÀˆ}œÀÃ]Ê…Þ«œÌi˜Ãˆœ˜
UÊÊ
,i˜Êˆ“«ˆÀ“i˜ÌÊ­i˜…˜Vi`ʈ˜Ê«Ìˆi˜ÌÃÊ܈̅ÊVœ˜Vœ“ˆÌ˜Ìʘi«…ÀœÌœÝˆVÊ
drugs)
UÊ
iVÌÀœÞÌiʈ“L˜ViÃ
UÊÊ
*Տ“œ˜ÀÞÊ̜݈VˆÌÞÊ­V…iÃÌÊ«ˆ˜]Ê…Þ«œÝˆ]Ê`Þë˜i®]ʘi“ˆ]ÊiiÛ̈œ˜Êˆ˜Ê
hepatic enzymes-rare
UÊÊ
œ˜ˆÌœÀˆ˜}Ê 1 ÉVÀ˜i]Ê]Ê}]Ê*…œÃÊÌÊLÃiˆ˜iʘ`Ê`ˆÞʈ˜Ê
…œÃ«ˆÌˆâi`ʫ̈i˜ÌÃÆÊ-/É/ÊÌÊLÃiˆ˜iʘ`ÊiÛiÀÞÊ£‡ÓÊÜiiŽÃÊ

37. Micafungin
NOTE: Micafungin does not have activity against Cryptococcus.
Aspergillosis
UÊVVi«ÌLiÊÕÃiÃ
UÊÊ
˜ÊVœ“Lˆ˜Ìˆœ˜Ê܈̅Ê6œÀˆVœ˜âœiÊvœÀÊVœ˜wÀ“i`ʈ˜ÛÈÛiÊ
aspergillosis (see p. 133)
UÊÊ
,ivÀVÌœÀÞÊ`ˆÃiÃi‡ÊvœÀÊÕÃiʈ˜ÊVœ“Lˆ˜Ìˆœ˜Ê܈̅Ê6œÀˆVœ˜âœi]Ê
Posaconazole or AmBisome® for confirmed invasive aspergillosis.
UÊ1˜VVi«ÌLiÊÕÃiÃ
UÊÊ
ˆVvÕ˜}ˆ˜Êœ˜iÊœÀʈ˜ÊVœ“Lˆ˜Ìˆœ˜Ê܈̅ʜ̅iÀʘ̈vÕ˜}Ê}i˜ÌÃʈÃÊ
not recommended for empiric therapy in patients with CT findings
suggestive of aspergillosis (e.g., possible aspergillosis) without
plans for diagnostic studies.
UÊÊ
ˆVvÕ˜}ˆ˜Ê`œiÃʘœÌÊ…ÛiÊ}œœ`Êin vitro activity against
zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
Candidiasis
UÊVVi«ÌLiÊÕÃiÃ
UÊ/ÀiÌ“i˜ÌÊœvʈ˜ÛÈÛiÊV˜`ˆ`ˆÃˆÃÊ`ÕiÊÌœÊC. glabrata or C. krusei.
UÊÊ
/ÀiÌ“i˜ÌÊœvʈ˜ÛÈÛiÊV˜`ˆ`ˆÃˆÃʈ˜Ê«Ìˆi˜ÌÃÊÜ…œÊÀiÊ /ÊVˆ˜ˆVÞÊ
stable due to candidemia or have received prior long-term azole
therapy.
UʏÌiÀ˜ÌˆÛiÊÌÀiÌ“i˜ÌÊœvÊÀiVÕÀÀi˜ÌÊiÃœ«…}iÊV˜`ˆ`ˆÃˆÃ°
UʏÌiÀ˜ÌˆÛiÊÌÀiÌ“i˜ÌÊœvÊi˜`œVÀ`ˆÌˆÃ°
UÊ1˜VVi«ÌLiÊÕÃiÃ
UÊÊ
ˆVvÕ˜}ˆ˜Ê…ÃÊ«œœÀÊ«i˜iÌÀ̈œ˜Êˆ˜ÌœÊÌ…iÊ
-ʘ`ÊÕÀˆ˜ÀÞÊÌÀVÌ°ÊÌÊ
should be avoided for infections involving those sites.
Neutropenic fever
UÊÊ
ˆVvÕ˜}ˆ˜ÊV˜ÊLiÊÕÃi`ÊvœÀʘiÕÌÀœ«i˜ˆVÊviÛiÀʈ˜Ê«Ìˆi˜ÌÃÊÜ…œÊÀiʘœÌÊ
suspected to have aspergillosis or zygomycosis.
Dose
UÊÊ
˜`ˆ`i“ˆ]ʈ˜ÛÈÛiÊV˜`ˆ`ˆÃˆÃ]ʘiÕÌÀœ«i˜ˆVÊviÛiÀÊ£ääÊ“}Ê6Ê
Q24H
UÊ
˜`ˆ`Êi˜`œVÀ`ˆÌˆÃÊ£xäÊ“}Ê6Ê+Ó{
UÊ,iVÕÀÀi˜ÌÊiÃœ«…}iÊV˜`ˆ`ˆÃˆÃÊ£xäÊ“}Ê6Ê+Ó{
UʘÛÈÛiÊëiÀ}ˆœÃˆÃÊ£ääq£xäÊ“}Ê6Ê+Ó{
UÊLiÃiʫ̈i˜ÌÃ
UÊÊ
£ääq£xäÊŽ}Ê£xäÊ“}Ê6Ê+Ó{
UÊÊ
£xäÊŽ}Ê
œ˜ÃՏÌÊ

38. Ê*…À“VˆÃÌ
Drug Interactions
UÊÊ
œÃiÊ“œ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊÜ…i˜ÊˆVvÕ˜}ˆ˜ÊˆÃÊÕÃi`Ê܈̅ÊÌ…iÊ
vœœÜˆ˜}Ê}i˜ÌÃÊVœ˜Vœ“ˆÌ˜ÌÞ
17
3.2
Agent-specific
guidelines:
Antifungals

39. 3.2
Agent-specific
guidelines:
Antifungals
18
UÊÊ
-ˆÀœˆ“ÕÃÊqʏiÛiÃÊœvÊ-ˆÀœˆ“ÕÃÊ“ÞÊLiʈ˜VÀiÃi`]Ê“œ˜ˆÌœÀÊvœÀÊ
Sirolimus toxicity
UÊÊ ˆvi`ˆ«ˆ˜iÊqʏiÛiÃÊœvÊ ˆvi`ˆ«ˆ˜iÊ“ÞÊLiʈ˜VÀiÃi`]Ê“œ˜ˆÌœÀÊvœÀÊ
Nifedipine toxicity
UÊÊ
ÌÀVœ˜âœiÊqʏiÛiÃÊœvÊÌÀVœ˜âœiÊ“ÞÊLiʈ˜VÀiÃi`]Ê“œ˜ˆÌœÀÊvœÀÊ
Itraconazole toxicity
Toxicity
UÊÊ
˜vÕÈœ˜‡ÀiÌi`ÊÀiV̈œ˜ÃÊ­ÀÃ…]Ê«ÀÕÀˆÌˆÃ®]Ê«…iLˆÌˆÃ]Ê…i`V…i]ʘÕÃiÊ
and vomiting, and elevations in hepatic enzymes.
UÊœ˜ˆÌœÀˆ˜}Ê-/É/ÉLˆˆÀÕLˆ˜ÊÌÊLÃiˆ˜iʘ`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊvÌiÀ°
Posaconazole
Posaconazole is a broad spectrum azole anti-fungal agent. It has in vitro
activity against Candida, Aspergillus, Zygomycosis and Fusarium spp.
Acceptable uses
UÊ/ÀiÌ“i˜ÌÊœvʈ˜ÛÈÛiÊâÞ}œ“ÞVœÃˆÃʈ˜ÊVœ“Lˆ˜Ìˆœ˜Ê܈̅ʓ«…œÌiÀˆVˆ˜Ê
UÊÊ
œ˜œÌ…iÀ«ÞÊvœÀÊâÞ}œ“ÞVœÃˆÃÊvÌiÀÊÇÊ`ÞÃÊœvÊVœ“Lˆ˜Ìˆœ˜ÊÌ…iÀ«ÞÊ
with Amphotericin B
UÊ*Àœ«…ޏ݈Ãʈ˜Ê«Ìˆi˜ÌÃÊ܈̅ʅi“Ìœœ}ˆVÊ“ˆ}˜˜VÞ
UÊ/ÀiÌ“i˜ÌÊœvÊëiÀ}ˆœÃˆÃʈ˜Ê«Ìˆi˜ÌÃÊ܈̅Ê6œÀˆVœ˜âœiʈ˜ÌœiÀ˜Vi
Unacceptable uses
UÊ
˜`ˆ`ˆÃˆÃÉ iÕÌÀœ«i˜ˆVÊviÛiÀ
UʈÀÃ̇ˆ˜iÊÌÀiÌ“i˜ÌÊœvÊëiÀ}ˆœÃˆÃ
Dose
/
-Ê
UÊÊ
V…Ê`œÃiÊœvÊÃÕëi˜Ãˆœ˜ÊÃ…œÕ`ÊLiÊ}ˆÛi˜Ê܈̅ÊÊvՏÊ“iÊœÀÊ܈̅ʏˆµÕˆ`Ê
nutritional supplements if patients cannot tolerate full meals. Can also
be given with an acidic beverage (e.g. ginger ale).
UÊÊ

40. iÞi`ÊÀiiÃiÊÌLiÌÃʘ`ÊœÀÊÃÕëi˜Ãˆœ˜ÊV˜˜œÌÊLiÊÕÃi`Ê
interchangeably due to differences in the dosing of each formulation.
Prophylaxis
UÊÀÊ-Õëi˜Ãˆœ˜ÊÓääÊ“}Ê*Ê+n
UÊ
ÝÌi˜`i`Ê,iiÃiÊ/LiÌÊÎääÊ“}Ê*Ê`ˆÞ
Treatment
UÊÊ
ÀÊ-Õëi˜Ãˆœ˜ÊÓääÊ“}Ê*Ê+ÈÊvœÀÊÇÊ`ÞÃ]ÊÌ…i˜Ê{ääÊ“}Ê*Ê
Q8-Q12H
UÊÊ
ÝÌi˜`i`Ê,iiÃiÊ/LiÌÊÎääÊ“}Ê*Ê+£ÓÊvœÀÊ£Ê`Þ]ÊÌ…i˜ÊÎääÊ“}Ê
PO daily

41. Therapeutic monitoring:
UÊ*œÃVœ˜âœiÊÌÀœÕ}…ʏiÛiÃÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«Ìˆi˜ÌÃÊÜ…œÊÀi
UÊ œÌÊÀi뜘`ˆ˜}ÊÌœÊÌ…iÀ«ÞÊvœÀÊÌʏiÃÌÊÇÊ`ÞÃ
UÊ iˆ˜}ÊÌÀiÌi`ÊvœÀÊÕ˜Vœ““œ˜ÊœÀʏiÃÃÊÃÕÃVi«ÌˆLiÊœÀ}˜ˆÃ“Ã
UÊ
Ý«iÀˆi˜Vˆ˜}Ê“ÕVœÃˆÌˆÃÊœÀÊ“LÃœÀ«Ìˆœ˜ÊÃÞ˜`Àœ“i
UÊ1˜LiÊÌœÊVœ˜ÃÕ“iÊ…ˆ}…ÊvÌÊ“iÃÊ­ˆvÊÀiViˆÛˆ˜}ÊÌ…iÊÃÕëi˜Ãˆœ˜®
Drug Interactions: See Table on p. 21
Toxicity
UÊÊ
ÊÕ«ÃiÌÊ­H{䯮]Ê…i`V…iÃ]ÊiiÛ̈œ˜Êˆ˜Ê…i«ÌˆVÊi˜âÞ“iðÊ,ÀiÊLÕÌÊ
serious effects include QTc prolongation.
UÊÊ
œ˜ˆÌœÀˆ˜}Ê-/É/ÉLˆˆÀÕLˆ˜ÊÌÊLÃiˆ˜iʘ`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊvÌiÀ
,iviÀi˜ViÃ
ˆ˜ˆVÊivwVVÞÊœvʘiÜʘ̈vÕ˜}Ê}i˜ÌÃÊ
ÕÀÀÊ«ˆ˜ÊˆVÀœLˆœ°ÊÓääÈÆ™{n·nn°
*œÃVœ˜âœiÊÊLÀœ`ÊëiVÌÀÕ“ÊÌÀˆâœiʘ̈vÕ˜}Ê˜ViÌʘviVÌÊ

42. ˆÃ°ÊÓääxÆÊxÇÇx‡nx°
Voriconazole
NOTE: Voriconazole does not cover zygomycoses (Mucor,
Rhizopus, Cunninghamella, etc.).
Acceptable uses
UÊAspergillosis
UÊScedosporium apiospermum
UÊProphylaxis in patients with hematologic malignancy
Unacceptable uses
UÊÊ
Candidiasis / Neutropenic fever
Voriconazole should not be used as first-line therapy for the treatment
of candidiasis or for empiric therapy in patients with neutropenic fever.
Dose
UÊÊ
œ`ˆ˜}Ê`œÃiÊÈÊ“}ÉŽ}Ê6É*Ê+£ÓÊÝÊÓÊ`œÃiÃ
Uʈ˜Ìi˜˜ViÊ`œÃiÊ{Ê“}ÉŽ}Ê6É*Ê+£Ó
UÊÊ

43. œÃiÊ`ÕÃÌ“i˜ÌʈÃʘiViÃÃÀÞÊvœÀÊ…i«ÌˆVʈ˜ÃÕvwVˆi˜VÞ
UÊ
…ˆ`ʇÊ*Õ}…Ê­ÊœÀÊ ®Ê↓ “ˆ˜Ìi˜˜ViÊ`œÃiÊLÞÊxä¯
UÊÊ
…ˆ`ʇÊ*Õ}…Ê­
®Ê1ÃiÊœ˜ÞʈvÊLi˜iwÌÃÊœÕÌÜiˆ}…ÊÀˆÃŽÃ°Ê
œ˜ÃՏÌÊ
ID pharmacist for dose adjustment recommendations.
UÊÊ

44. œÃiÊiÃVÌˆœ˜Ê“ÞÊLiʘiViÃÃÀÞÊvœÀÊÃœ“iʫ̈i˜ÌÃÊ`ÕiÊÌœÊ
subtherapeutic levels.
UÊÊ

45. œÃiÊLÃi`Êœ˜ÊVÌՏÊLœ`ÞÊÜiˆ}…ÌÊÕ˜iÃÃʫ̈i˜ÌÊ€Îä¯ÊœÛiÀÊ 7ÆÊ
then use adjusted body weight. (Adj. BW).
`°Ê 7ÊrÊQ 7ʳÊä°{Ê­ 7Ê‡Ê 7®R
IBW - Ideal Body Weight
ABW - Actual Body Weight
19
3.2
Agent-specific
guidelines:
Antifungals

46. 3.2
Agent-specific
guidelines:
Antifungals
20
Therapeutic monitoring
UÊÊ
6œÀˆVœ˜âœiÊÌÀœÕ}…ʏiÛiÃÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«Ìˆi˜ÌÃÊÜ…œÊÀi
UÊÊ œÌÊÀi뜘`ˆ˜}ÊÌœÊÌ…iÀ«ÞÊvÌiÀÊÌʏiÃÌÊxÊ`ÞÃÊœvÊÌ…iÀ«ÞÊÕȘ}ÊÊ
mg/kg dosing strategy
UÊÊ
,iViˆÛˆ˜}ÊVœ˜Vœ“ˆÌ˜ÌÊ`ÀÕ}ÃÊÌ…ÌÊ“Þʈ˜VÀiÃiÊœÀÊ`iVÀiÃiÊ
Voriconazole levels
UÊÊ
Ý«iÀˆi˜Vˆ˜}Ê`ÛiÀÃiÊiÛi˜ÌÃÊ`ÕiÊÌœÊ6œÀˆVœ˜âœi
UÊÊ
Ý«iÀˆi˜Vˆ˜}ÊÊ`ÞÃvÕ˜V̈œ˜
UÊÊ
6œÀˆVœ˜âœiÊÌÀœÕ}…ʏiÛiÃÊÃ…œÕ`ÊLiÊœL̈˜i`ÊxqÇÊ`ÞÃÊvÌiÀÊÃÌÀÌÊœvÊ
Ì…iÀ«ÞÊ­«iÀvœÀ“i`Êq®°
UÊÊ
œÊÌÀœÕ}…ÊÓqx°xÊ“V}É“°ÊiÛiÃʐʣʓV}É“Ê…ÛiÊLii˜Ê
associated with clinical failures and levels 5.5 mcg/mL with toxicity.
Drug Interactions: See Table on p. 21
Toxicity
UÊÊ
6ˆÃՏÊ`ˆÃÌÕÀL˜ViÃÊ­HÎ䯮ÊÕÃՏÞÊÃiv‡ˆ“ˆÌi`]ÊÀÃ…]ÊviÛiÀ]ÊiiÛ̈œ˜ÃÊ
in hepatic enzymes.
UÊÊ
œ˜ˆÌœÀˆ˜}Ê-/É/ÉLˆˆÀÕLˆ˜ÊÌÊLÃiˆ˜iʘ`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊvÌiÀ
,iviÀi˜ViÃ
6œÀˆVœ˜âœiÊ
ˆ˜Ê˜viVÌÊ

47. ˆÃÊÓääÎÆÊÎÈÈÎä°
6œÀˆVœ˜âœiʈ˜Ê˜iÕÌÀœ«i˜ˆVÊviÛiÀÊ Ê
˜}ÊÊi`ÊÓääÓÆÎ{È­{®ÓÓx°Ê
6œÀˆVœ˜âœiÊ/

48. Ê
ˆ˜Ê˜viVÌÊ

49. ˆÃÊÓäänÆÊ{ÈÓ䣰
Azole drug interactions
The following list contains major drug interactions involving drug
metabolism and absorption. This list is not comprehensive and is
intended as a guide only. You must check for other drug interactions
when initiating azole therapy or starting new medication in patients
already receiving azole therapy.
Drug metabolism:
ÞÌœV…Àœ“iÊ­
9*®Ê*{xäʈ˜…ˆLˆÌœÀÃÊ`iVÀiÃiÊÌ…iÊ“iÌLœˆÃ“ÊœvÊViÀ̈˜Ê
drugs (CYP450 substrates) resulting in increased drug concentrations in
the body (occurs immediately)
ÞÌœV…Àœ“iÊ­
9*®Ê*{xäʈ˜`ÕViÀÃʈ˜VÀiÃiÊÌ…iÊ“iÌLœˆÃ“ÊœvÊViÀ̈˜Ê
drugs (CYP450 substrates) resulting in decreased drug concentrations
in the body (may take up to 2 weeks for upregulation of enzymes to
occur)
Drug absorption/penetration:
*‡}ÞVœ«ÀœÌiˆ˜Ê­*‡}«®Êˆ˜…ˆLˆÌœÀÊ`iVÀiÃiÊÌ…iÊvÕ˜V̈œ˜ÊœvÊÌ…iÊivyÕÝÊ«Õ“«]Ê
resulting in increased absorption/penetration of P-gp substrates
*‡}ÞVœ«ÀœÌiˆ˜Êˆ˜`ÕViÀʈ˜VÀiÃiÊÌ…iÊvÕ˜V̈œ˜ÊœvÊÌ…iÊivyÕÝÊ«Õ“«]Ê
resulting in decreased absorption/penetration of P-gp substrates
PotencyÊœvÊ
ÞÌœV…Àœ“iÊ*{xäʈ˜…ˆLˆÌˆœ˜Ê6œÀˆVœ˜âœiÊ€ÊÌÀVœ˜âœiÊ€Ê
Posaconazole Fluconazole

50. 21
3.2
Agent-specific
guidelines:
Antifungals
POSACONAZOLE
(substrate
and
inhibitor
for
P-gp
efflux,
inhibitor
of
CYP3A4)
Drug
Recommendations
Contraindicated
œ““œ˜ÞÊ«ÀiÃVÀˆLi`
sirolimus
Do
not
use
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`
cisapride,
ergot
alkaloids,
pimozide,
quinidine,
triazolam
Warning/precaution
Cyclosporine
↓
cyclosporine
dose
to
3
⁄
4
and
monitor
levels
Metoclopramide,
proton
pump
inhibitors
May
↓
posaconazole
concentrations
when
using
suspension
Midazolam
Consider
dose
reducing
Tacrolimus
↓
tacrolimus
dose
to
1
⁄
3
and
monitor
levels
Cimetidine,
efavirenz,
phenytoin,
rifabutin,
rifampin
Avoid
concomitant
use
unless
benefit
outweighs
risk
If
used
together,
monitor
effects
of
drugs
and
consider
decreasing
dose
when
posaconazole
is
added
Amiodarone,
atazanavir,
digoxin,
erythromycin,
all
calcium
channel
blockers,
Monitor
effect
of
drugs
and
consider
decreasing
dose
when
ritonavir,
statins
(avoid
lovastatin
and
simvastatin),
vinca
alkaloids
posaconazole
is
added
ITRACONAZOLE
and
major
metabolite
hydroxyitraconazole
(substrate
and
inhibitor
of
CYP3A4
and
P-gp
efflux)
Drug
Recommendations
Contraindicated
œ““œ˜ÞÊ«ÀiÃVÀˆLi`
statins
(lovastatin,
simvastatin)
Do
not
use
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`
cisapride,
dofetilide,
ergot
alkaloids,
nisoldipine,
oral
midazolam,
pimozide,
quinidine,
triazolam
Warning/precaution
œ““œ˜ÞÊ«ÀiÃVÀˆLi`
atorvastatin,
benzodiazepines,
chemotherapy
plasma
concentration
of
the
interacting
drug,
monitor
levels
when
(busulfan,
docetaxel,
vinca
alkaloids),
cyclosporine,
digoxin,
efavirenz,
possible,
monitor
for
drug
toxicity
and
consider
dose
reduction
eletriptan,
fentanyl,
oral
hypoglycemics,
indinavir,
IV
midazolam,
nifedipine,
ritonavir,
saquinavir,
sirolimus,
tacrolimus,
verapamil,
steroids
(budesonide,
dexamethasone,
fluticasone,
methylprednisolone),
warfarin
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`
alfentanil,
buspirone,
cilostazol,
disopyramide,
felodipine,
trimetrexate
œ““œ˜ÞÊ«ÀiÃVÀˆLi`
carbamazepine,
efavirenz,
isoniazid,
nevirapine,
↓
plasma
concentration
of
itraconazole,
if
possible
avoid
concomitant
phenobarbital,
phenytoin,
rifabutin,
rifampin,
antacids,
H2
receptor
use
or
monitor
itraconazole
levels
antagonists,
proton
pump
inhibitors
Clarithromycin,
erythromycin,
fosamprenavir,
indinavir,
ritonavir,
saquinavir
plasma
concentration
of
itraconazole,
monitor
itraconazole
levels
and
monitor
for
toxicity
↓
↓

51. 3.2
Agent-specific
guidelines:
Antifungals
22
VORICONAZOLE
(substrate
and
inhibitor
of
CYP2C19,
CYP2C9,
and
CYP3A4)
Drug
Recommendations
Contraindicated
œ““œ˜ÞÊ«ÀiÃVÀˆLi`
carbamazepine,
rifabutin,
rifampin,
Do
not
use
ritonavir
400
mg
Q12H
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`
long-acting
barbiturates,
cisapride,
ergot
alkaloids,
pimozide,
quinidine,
St.
John’s
Wort
Warning/precaution
Cyclosporine
↓
cyclosporine
dose
to
1
⁄
2
and
monitor
levels
Efavirenz
↓
voriconazole
dose
to
5
mg/kg
IV/PO
Q12H
and
↓
efavirenz
to
300
mg
PO
daily
Tacrolimus
↓
tacrolimus
dose
to
1
⁄
3
and
monitor
levels
Sirolimus
↓ÊÈÀœˆ“ÕÃÊ`œÃiÊLÞÊÇx¯Ê˜`Ê“œ˜ˆÌœÀʏiÛiÃ
Omeprazole
↓
omeprazole
dose
to
1
⁄
2
Maraviroc
↓
maraviroc
dose
to
150
mg
twice
daily
Methadone
Monitor
effect
of
the
interacting
drug
and
consider
decreasing
dose
Phenytoin
↓
voriconazole
to
5
mg/kg
IV/PO
Q12H
and
monitor
levels
Ritonavir
low
dose
(100
mg
Q12H)
Avoid
this
combination
unless
benefits
outweigh
risks
Warfarin
Monitor
INR
levels
œ““œ˜ÞÊ«ÀiÃVÀˆLi`
all
benzodiazepines
(avoid
midazolam
and
triazolam),
Monitor
effect
of
drugs
and
consider
decreasing
dose
when
voriconazole
all
calcium
channel
blockers,
fentanyl,
oxycodone
other
long
acting
opioids,
is
added
NSAIDs,
oral
contraceptives,
statins
(avoid
lovastatin
and
simvastatin),
sulfonylureas,
vinca
alkaloids,
pomalidomide,
simeprevir,
boceprevir,
telaprevir
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`
alfentanil
FLUCONAZOLE
(substrate
of
CYP3A4
and
inhibitor
of
CYP3A4,
CYP2C9,
and
CYP2C19,
interactions
are
often
dose
dependent)
Drug
Recommendations
Contraindicated
Cisapride
Do
not
use
Warning/precaution
œ““œ˜ÞÊ«ÀiÃVÀˆLi`
cyclosporine,
glipizide,
glyburide,
phenytoin,
↓
plasma
concentration
of
the
interacting
drug,
monitor
levels
when
rifabutin,
tacrolimus,
warfarin
possible,
monitor
for
drug
toxicity
and
consider
dose
reduction
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`
oral
midazolam,
theophylline,
tolbutamide
Rifampin
↓
plasma
concentration
of
fluconazole,
consider
increasing
fluconazole
dose

52. 23
3.3
Agent-specific
guidelines:
Vaccines
Pneumococcal vaccination
There are two types of pneumococcal vaccines that are recommended
LÞÊ
*Ê}Õˆ`iˆ˜iÃÊvœÀÊ`ՏÌʫ̈i˜ÌÃÊ*˜iÕ“œVœVVÊ«œÞÃVV…Àˆ`iÊ
(Pneumovax 23®, PPV23) and Pneumococcal conjugate vaccine (Prevnar
13®, PCV13). Most patients should receive both vaccines in sequential
order, but NEVER together. See table below for indications for each vaccine.
Indications for pneumococcal vaccines for adults ≥ 19 years of age
Risk group Prevnar 13® Pneumovax 23®
All adults ≥ 65 years of age Yes Yes
CSF leak or cochlear implants Yes Yes
Functional or anatomic asplenia Yes Yes, revaccinate 5
years after first dose
Immunocompetent persons with certain
chronic medical conditions (e.g. heart
disease*, lung disease†, liver disease,
DM), alcoholism, cigarette smoking
No Yes
““Õ˜œVœ“«Àœ“ˆÃi`Ê…œÃÌÊVœ˜}i˜ˆÌÉ
acquired immunodeficiencies, HIV,
chronic renal failure, nephrotic
syndrome, hematologic malignancies,
organ transplant, long-term
immunosuppressive therapy (e.g.
steroids, active chemotherapy, radiation)
Yes Yes, revaccinate 5
years after first dose
I˜VÕ`ˆ˜}Ê
]ÊVÀ`ˆœ“Þœ«Ì…ˆiÃ]ÊiÝVÕ`ˆ˜}Ê…Þ«iÀÌi˜Ãˆœ˜ÆÊa˜VÕ`ˆ˜}Ê
*

53. ]Êi“«…ÞÃi“]Ê
asthma
Timing and sequential administration of pneumococcal vaccines
UÊ œÊ…ˆÃÌœÀÞÊœÀÊÕ˜Ž˜œÜ˜Ê…ˆÃÌœÀÞÊœvÊ«˜iÕ“œVœVVÊÛVVˆ˜Ìˆœ˜Ê˜`ÊLœÌ…Ê
vaccines are indicated, patient should receive Prevnar 13® first followed
by Pneumovax 23® at a minimum of 8 weeks later (ideally 6-12 months)
UÊvʫ̈i˜ÌÊ…ÃÊÀiViˆÛi`Ê*˜iÕ“œÛÝÊÓή and both vaccines are indicated,
the patient should receive Prevnar 13® (minimum 1 year separation)
UÊvʫ̈i˜ÌÊ…ÃÊÀiViˆÛi`Ê*ÀiÛ˜Àʣή ≥ 8 weeks ago, and both vaccines
are indicated, the patient should receive Pneumovax 23® (minimum 8
weeks separation)
UÊvʫ̈i˜ÌÊ…ÃÊÀiViˆÛi`ÊLœÌ…ÊÛVVˆ˜iÃÊ≥ 5 years ago and revaccination
is needed with Pneumovax 23®, a second dose should be administered
(minimum 5 years apart)
UÊ*̈i˜ÌÃÊÜ…œÊÀiÊÃiÛiÀiÞʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê­i°}°Ê /]ÊÃœˆ`ÊœÀ}˜Ê
transplant) should follow institutional policy when available or consult ID
for optimal timing of vaccine administration
,iviÀi˜ViÊ
*Ê,iVœ““i˜`̈œ˜ÃÊ7,ÊÓä£{ÆÈέÎÇ®ÆnÓÓ‡nÓxʘ`Ê7,ÊÓä£ÓÆÈ£­{ä®Æn£È‡n£™°Ê

54. 4.1
Organism-specific
guidelines:
Anaerobes
24
Organism-specific guidelines
Anaerobes
Although anaerobic bacteria dominate the human intestinal microbiome
only a few species seem to play an important role in human infections.
Infections caused by anaerobes are often polymicrobial.
UÊÊ
À“‡˜i}̈ÛiÊLVˆˆÊ‡ÊBacteroides spp., Prevotella spp.,
Porphyromonas spp., Fusobacterium spp.
UÊÊ
À“‡˜i}̈ÛiÊVœVVˆÊ‡ÊVeillonella spp.
UÊÊ
À“‡«œÃˆÌˆÛiÊLVˆˆÊ‡ÊPropionibacterium spp., Lactobacillus spp.,
Actinomyces spp., Clostridium spp.
UÊÊ
À“‡«œÃˆÌˆÛiÊVœVVˆÊ‡ÊPeptostreptococcus spp. and related genera
Clinical diagnosis of anaerobic infections should be suspected in the
presence of foul smelling discharge, infection in proximity to a mucosal
surface, gas in tissues or negative aerobic cultures. Proper specimen
VœiV̈œ˜ÊˆÃÊVÀˆÌˆVÆÊÀiviÀÊÌœÊëiVˆ“i˜ÊVœiV̈œ˜Ê}Õˆ`iˆ˜iÃÊÌÊ…ÌÌ«ÉÉ
www.hopkinsmedicine.org/microbiology/specimen/index.html
Treatment Notes
.
UÊÊ
-ÕÀ}ˆVÊ`iLÀˆ`i“i˜ÌÊœvʘiÀœLˆVʈ˜viV̈œ˜ÃʈÃʈ“«œÀ̘ÌÊLiVÕÃiÊ
anaerobic organisms can cause severe tissue damage.
UÊÊ
“«ˆVˆˆ˜ÉÃՏLV̓ʘ`Ê
ˆ˜`“ÞVˆ˜ÊÀiÊVœ˜Ãˆ`iÀi`ÊÌœÊLiÊivviV̈ÛiÊ
empiric therapy against Gram-positive anaerobes seen in infections
Metronidazole
Clindamycin
Ertapenem
Cefotetan
Pip/Tazo
Amox/Clav
Penicillin
#
Patients
Hidden Content
- JHH Internal use only

55. 25
4.1
Organism-specific
guidelines:
Anaerobes
above the diaphragm. Metronidazole is not active against
microaerophilic streptococci (e.g. S. anginosus group) and should not
be used for these infections.
UÊÊ
6˜Vœ“ÞVˆ˜ÊˆÃʏÜÊV̈ÛiÊ}ˆ˜ÃÌÊ“˜ÞÊÀ“‡«œÃˆÌˆÛiʘiÀœLiÃÊ­i°}°Ê
Clostridium spp., Peptostreptococcus spp., P. acnes).
UÊÊ
“«ˆÀˆVÊ`œÕLiÊVœÛiÀ}iÊ܈̅ÊiÌÀœ˜ˆ`✏iÊ

56. ÊVÀL«i˜i“ÃÊ
(Meropenem, Ertapenem) or beta-lactam/beta-lactamase inhibitors
(Ampicillin/Sulbactam, Piperacillin/Tazobactam, Amoxicillin/Clavulanic
acid) is NOT recommended given the excellent anaerobic activity of
these agents.
UÊÊ
B. fragilis group resistance to Clindamycin, Cefotetan, Cefoxitin, and
Moxifloxacin has increased and these agents should not be used
empirically for treatment of severe infections where B. fragilis is
suspected (e.g. intra-abdominal infections).
UÊÊ
œÃÌÊÀiÈÃ̘Viʈ˜ÊÌ…iÊB. fragilis group is caused by beta-lactamase
production, which is screened for by the JHH micro lab.
UÊÊ
Bacteroides thetaiotaomicron is less likely to be susceptible to
*ˆ«iÀVˆˆ˜É/âœLVÌ“ÆÊÌ…iÀivœÀi]ÊÜ…i˜ÊÌ…ˆÃÊœÀ}˜ˆÃ“ʈÃʈ܏Ìi`Ê
or strongly suspected (e.g. Gram negative rods in anaerobic blood
cultures in a patient on Piperacillin/tazobactam) alternative agents
with anaerobic coverage should be used until susceptibilities are
confirmed.
UÊÊ
/ˆ}iVÞVˆ˜iʈÃÊV̈ÛiÊ}ˆ˜ÃÌÊÊ܈`iÊëiVÌÀÕ“ÊœvÊ}À“‡«œÃˆÌˆÛiʘ`Ê
gram-negative anaerobic bacteria in vitro but clinical experience with
this agent is limited.
Propionibacterium acnes
Indications for consideration of testing for P. acnes:
UÊ
-ÊÃ…Õ˜Ìʈ˜viV̈œ˜Ã
UÊ*ÀœÃÌ…ïVÊÃ…œÕ`iÀʍœˆ˜Ìʈ˜viV̈œ˜ÃÊ
UÊÌ…iÀʈ“«˜ÌLiÊ`iÛˆViʈ˜viV̈œ˜Ã
Diagnosis
UÊÊ
ՏÌÕÀiÃÊÃ…œÕ`ÊLiÊ…i`ÊvœÀʣ䇣{Ê`ÞÃʈvÊ…ˆ}…ÊÃÕëˆVˆœ˜ÊvœÀÊP. acnes
as growth is slow
UÊÊ
œiV̈œ˜ÊœvÊ̈ÃÃÕiʘ`ÊyÕˆ`ÊëiVˆ“i˜ÃÊvœÀÊVՏÌÕÀiʈÃÊ«ÀiviÀÀi`°Ê

57. œÊ˜œÌÊ
send swabs for culture
UÊÊ
Տ̈«iÊÀi«ÀiÃi˜Ì̈ÛiÊëiVˆ“i˜ÃÊ­«ÀiviÀLÞÊήÊÃ…œÕ`ÊLiÊÃi˜ÌÊ
for shoulder joint infections to assist in distinguishing contaminants
from pathogenic isolates — these could include synovial fluid, any
inflammatory tissue, and synovium
U Tissue specimens should also be sent for histopathology

58. 26
4.2
Organism-specific
guidelines:
P.
acnes
Treatment
UÊÊ
*i˜ˆVˆˆ˜ÊÊÓ‡ÎÊ“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{Ê­«ÀiviÀÀi`®
OR
UÊ*
ʏiÀ}ÞÊÊ6˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
NOTES
UÊÊ

59. ÊVœ˜ÃՏÌÊÀiVœ““i˜`i`ÊvœÀÊÃÈÃ̘ViÊ܈̅ÊV…œˆViʘ`Ê
duration of antibiotic therapy
UÊÊ
P. acnes is usually a contaminant in blood culture specimens. Draw
repeat cultures and consider clinical context before treatment
UÊÊ
,ÀiÊÀi«œÀÌÃÊœvÊ눘Êˆ˜viV̈œ˜ÃÊ…ÛiÊLii˜Ê˜œÌi`ÊvœÀÊP. acnes
UÊÊ
ÊP. acnes isolutes at JHH are susceptible to Penicillin (see anaerobic
antibiogram p. 24)
UÊÊ
iÌÀœ˜ˆ`✏iÊ`œiÃʘœÌÊ…ÛiÊV̈ۈÌÞÊ}ˆ˜ÃÌÊP. acnes. Tetracyclines
are not routinely tested and resistance rates are variable.
UÊÊ
Àœ`iÀÊëiVÌÀÕ“Ê}i˜ÌÃÊÃÕV…ÊÃÊiÀœ«i˜i“ʘ`Ê*ˆ«iÀVˆˆ˜É
tazobactam would be expected to be active for Penicillin susceptible
isolates, but these are not first-line therapy
UÊÊ
-ÕÃVi«ÌˆLˆˆÌÞÊ`ÌÊÃ…œÕ`ÊLiÊÕÃi`Ê̜ʅi«Ê}Õˆ`iÊÌ…iÀ«iṎVÊ`iVˆÃˆœ˜Ã
U Consider removal of associated hardware

60. Streptococci
Viridans group Streptococci (alpha-hemolytic streptococci)
œÀ“Ê“ˆVÀœLˆœÌÊœvÊÌ…iÊœÀÊVÛˆÌÞʘ`ÊÊÌÀVÌÆÊȘ}iÊLœœ`ÊVՏÌÕÀiÃÊ
growing these organisms often represent contamination or transient
bacteremia
Five groups
UÊÊ
S. anginosus group (contains S. intermedius, anginosus, and
constellatus®ÊÊVœ““œ˜ÞÊVÕÃiÊLÃViÃÃiÃÆÊ“œÀˆÌÞÊÀiÊ*i˜ˆVˆˆ˜Ê
susceptible
UÊÊ
S. bovisÊ}ÀœÕ«ÊQVœ˜Ìˆ˜ÃÊS. gallolyticus subspecies gallolyticus
(associated with colon cancer—colonoscopy mandatory, endocarditis
ÃœÊ«ÀiÃi˜Ìʈ˜Ê€Êxä¯ÊœvÊVÃiîʘ`ÊÃÕLëiVˆiÃÊpasteurinus
­ÃÃœVˆÌi`Ê܈̅ʅi«ÌœLˆˆÀÞÊ`ˆÃiÃi]Êi˜`œVÀ`ˆÌˆÃʏiÃÃÊVœ““œ˜®RÆÊ
majority are Penicillin susceptible
UÊS. mitis group (contains S. mitis, oralis, gordonii, and sanguinous®Ê
Vœ““œ˜ÞÊVÕÃiÊLVÌiÀi“ˆÊˆ˜Ê˜iÕÌÀœ«i˜ˆVʫ̈i˜ÌÃʘ`Êi˜`œVÀ`ˆÌˆÃÆÊ
many have Penicillin resistance
UÊÊ
S. salivariusÊ}ÀœÕ«ÊiÃÃÊVœ““œ˜ÊVÕÃiÊœvÊi˜`œVÀ`ˆÌˆÃÆÊ“œÀˆÌÞÊÀiÊ
Penicillin susceptible
UÊÊ
S. mutansÊ}ÀœÕ«ÊVœ““œ˜ÊVÕÃiÊœvÊ`i˜ÌÊVÀˆiÃÆÊÕ˜Vœ““œ˜ÊVÕÃiÊ
œvÊi˜`œVÀ`ˆÌˆÃÆÊ“œÀˆÌÞÊÀiÊ*i˜ˆVˆˆ˜ÊÃÕÃVi«ÌˆLi
Beta-hemolytic Streptococci
All are susceptible to Penicillin
6ÀˆLiÊÀÌiÃÊœvÊÀiÈÃ̘ViÊÌœÊ
ˆ˜`“ÞVˆ˜ÆÊÃŽÊÌ…iÊ“ˆVÀœLˆœœ}ÞÊ
laboratory to perform susceptibility testing if you plan to use
Clindamycin or macrolides for moderate to severe infections.
While anti-staphylococcal penicillins (Oxacillin and Nafcillin) are the
agents of first choice for susceptible S. aureus infections, their activity
against streptococci is sub-optimal
ˆ}…ÊÀÌiÃÊœvÊÀiÈÃ̘ViÊÌœÊÌiÌÀVÞVˆ˜iÃʘ`Ê/*É-8Ê«ÀiVÕ`iÊÌ…iˆÀÊ
empiric use for infections suspected to be caused by beta-hemolytic
streptococci
UÊÊ
S. pyogenesÊ­}ÀœÕ«ÊÊÃÌÀi«®Ê«…ÀÞ˜}ˆÌˆÃ]ÊÃŽˆ˜Ê˜`ÊÃœvÌÊ̈ÃÃÕiÊ
ˆ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ÊiÀÞÈ«iÃ]ÊViÕˆÌˆÃ]ʘiVÀœÌˆâˆ˜}ÊvÃVˆˆÌˆÃÆÊ
ˆ˜`“ÞVˆ˜ÊÀiÈÃ̘Viʈ˜Ê£°x‡x°Ó¯ÆÊ“VÀœˆ`iÊÀiÈÃ̘Viʈ˜Ê{‡Ç¯°Ê
UÊÊ
S. agalactiaeÊ­}ÀœÕ«Ê ÊÃÌÀi«®Ê˜iœ˜ÌÊˆ˜viV̈œ˜Ã]ʈ˜viV̈œ˜ÃÊœvÊÌ…iÊ
vi“iÊ}i˜ˆÌÊÌÀVÌ]ÊÃŽˆ˜Ê˜`ÊÃœvÌÊ̈ÃÃÕiʈ˜viV̈œ˜Ã]ÊLVÌiÀi“ˆÆÊ
ˆ˜`“ÞVˆ˜ÊÀiÈÃ̘Viʈ˜Ê£È‡ÓȯÆÊ“VÀœˆ`iÊÀiÈÃ̘Viʈ˜ÊLJÎÓ¯°Ê
4.3
Organism-specific
guidelines:
Streptococci
27

61. 28
4.3
Organism
specific
guidelines:
Multi-drug
resistant
Gram-negative
rods
Antibiotic Susceptible Intermediate Resistant
Penicillin (oral) ≤ 0.06 0.12-1 ≥ 2
Penicillin (parenteral)
Non-CNS ≤ 2 4 ≥ 8
CNS ≤ 0.06 ≥ 0.12
Ceftriaxone
Non-CNS ≤ 1 2 ≥ 4
CNS ≤ 0.5 1 ≥ 2
UÊÊ
``ˆÌˆœ˜ÊœvÊ6˜Vœ“ÞVˆ˜ÊÌœÊ
ivÌÀˆÝœ˜iʈÃʘœÌʈ˜`ˆVÌi`ʈ˜ÊÌ…iÊi“«ˆÀˆVÊ
treatment of non-CNS infections caused by S. pneumoniae due to low
rates of resistance
Multi-drug resistant Gram-negative rods
Patients with infection or colonization with the resistant
organisms listed below should be placed on CONTACT
precautions (see isolation chart on p. 141)
Extended spectrum beta-lactamase (ESBL)-producing organisms
UÊÊ
- ÃÊÀiÊi˜âÞ“iÃÊÌ…ÌÊVœ˜viÀÊÀiÈÃ̘ViÊ̜ʏÊ«i˜ˆVˆˆ˜Ã]Ê
cephalosporins, and Aztreonam.
UÊÊ
/…iÞÊÀiÊ“œÃÌÊVœ““œ˜ÞÊÃii˜Êˆ˜ÊK. pneumoniae and K. oxytoca,
E. coli, and P. mirabilis, and these organisms are automatically
screened by the JHH microbiology lab for the presence of ESBLs.
UÊÊ
ÀœÕ«Ê
ʘ`ÊÊÃÌÀi«ÌœVœVVˆÊˆ˜viV̈œ˜ÃÊÈ“ˆÀÊÌœÊS. pyogenes and
S. agalactiaeÆÊÃÃœVˆÌi`Ê܈̅ÊÕ˜`iÀÞˆ˜}Ê`ˆÃiÃiÃÊ­i°}°Ê`ˆLiÌiÃ]Ê
“ˆ}˜˜VÞ]ÊVÀ`ˆœÛÃVՏÀÊ`ˆÃiÃi®ÆÊ
ˆ˜`“ÞVˆ˜ÊÀiÈÃ̘Viʈ˜ÊH£È¯Ê
œvÊ}ÀœÕ«Ê
ʘ`ÊHÎίʜvÊ}ÀœÕ«Êʈ܏ÌiÃÆÊ“VÀœˆ`iÊÀiÈÃ̘Viʈ˜Ê
HÓx¯ÊœvÊ}ÀœÕ«Ê
ʘ`ÊHÓn¯ÊœvÊ}ÀœÕ«Êʈ܏ÌiðÊ
Streptococcus pneumoniae
UÊÊ
œ““œ˜ÊVÕÃiÊœvÊÀiëˆÀÌœÀÞÊÌÀVÌʈ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ʜ̈̈ÃÊ“i`ˆ]Ê
ȘÕÈ̈Ã]Ê«˜iÕ“œ˜ˆÊۈʏœVÊëÀi`ÊvÀœ“ÊÌ…iʘÜ«…ÀÞ˜ÝÆʈ˜viV̈œ˜ÃÊ
involving the CNS, bones/joints and endocarditis via hematogenous
spread
UÊÊ
i˜ïVÞ]ÊS. pneumoniae is in the S. mitis group of viridans group
ÃÌÀi«ÌœVœVVˆÆÊVœ˜ÃiµÕi˜ÌÞ]ÊÀ«ˆ`Ê“œiVՏÀÊÌiÃÌÃÊ“ÞʘœÌÊLiÊLiÊÌœÊ
distinguish S. pneumoniae and streptococci in the S. mitis group.
UÊÊ
*i˜ˆVˆˆ˜ÊˆÃÊÌ…iÊ}i˜ÌÊœvÊwÀÃÌÊV…œˆViÊvœÀÊÃiÀˆœÕÃÊS. pneumoniae
infections when it is susceptible
UÊÊ
*i˜ˆVˆˆ˜Ê˜`Ê
ivÌÀˆÝœ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊLÀiŽ«œˆ˜ÌÃÊÀiÊ`ˆvviÀi˜ÌÊvœÀÊ
CNS and non-CNS sites
MIC breakpoints for Penicillin and Ceftriaxone against
S. pneumoniae

62. UÊÊ
,ˆÃŽÊvVÌœÀÃÊvœÀʈ˜viV̈œ˜ÊœÀÊVœœ˜ˆâ̈œ˜ÊÀiVi˜ÌÊ…œÃ«ˆÌˆâ̈œ˜ÊÌʘÊ
institution with a high rate of ESBLs, residence in a long-term care
facility and prolonged use of broad spectrum antibiotics.
/ÀiÌ“i˜Ì
UÊÊ
iÀœ«i˜i“Ê£Ê}Ê6Ê+nÊ­ÓÊ}Ê6Ê+nÊvœÀÊ
-ʈ˜viV̈œ˜Ã®ÊÃ…œÕ`ÊLiÊ
used for ALL severe infections if the organism is susceptible.
UÊÊ
ÀÌ«i˜i“Ê£Ê}Ê6Ê+Ó{ÊV˜ÊLiÊÕÃi`ÊvœÀÊÕ˜Vœ“«ˆVÌi`Ê1/ÊœÀÊÃœvÌÊ̈ÃÃÕiÊ
infection with adequate source control if the organism is susceptible.
UÊÊ
ˆ«ÀœyœÝVˆ˜ÊœÀÊ/*É-8ÊV˜ÊLiÊÕÃi`ÊÃʏÌiÀ˜ÌˆÛiÃÊÌœÊ
ÀÌ«i˜i“Ê
for uncomplicated UTI or soft tissue infection with adequate source
control if the organism is susceptible. Nitrofurantoin may also be used
for uncomplicated UTI if the organism is susceptible.
Carbapenemase-producing Enterobacteriacae (CRE)
UÊ
ÀL«i˜i“ÃiÃÊÀiÊi˜âÞ“iÃÊÌ…ÌÊVœ˜viÀÊÀiÈÃ̘ViÊ̜ʏÊ«i˜ˆVˆˆ˜Ã]Ê
cephalosporins, carbapenems and Aztreonam.
UÊÊ“ˆVÀœLˆœœ}ÞʏLʈÃʘœÊœ˜}iÀÊ«iÀvœÀ“ˆ˜}ÊÌ…iÊ“œ`ˆwi`Êœ`}iÊÌiÃÌ
UÊvÊVÀL«i˜i“ʈÃÊÀiÈÃ̘ÌÊÊ“ˆVÀœLˆœœ}ÞʏLÊ܈ÊÀi«œÀÌÊœÀ}˜ˆÃ“Ê
ÃʺVÀL«i˜i“ÊÀiÈÃ̘̻ÆÊ…œÜiÛiÀ]ÊÌ…iÊiÝVÌÊ“iV…˜ˆÃ“ÊœvÊ
resistance is not tested for at this time.
/ÀiÌ“i˜ÌÊ
UÊiÀœ«i˜i“ÊÓÊ}Ê6Ê+nʈ˜vÕÃi`ÊœÛiÀÊÎÊ…œÕÀÃÊÃ…œÕ`ÊLiʈ˜VÕ`i`Ê
in most regimens based on data from small, retrospective studies
showing benefit even when the isolate is intermediate or resistant.
UÊÌʏiÃÌÊœ˜iÊ``ˆÌˆœ˜Ê}i˜ÌÊÃ…œÕ`ÊLiÊ``i`ÊLÃi`Êœ˜ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ
(e.g. Amikacin, Tigecycline, Colistin) except for UTI.
Multi-drug resistant (MDR) gram-negative organisms: defined as
organisms susceptible to NO MORE than ONE of the following antibiotic
VÃÃiÃÊVÀL«i˜i“Ã]Ê“ˆ˜œ}ÞVœÃˆ`iÃ]ÊyÕœÀœµÕˆ˜œœ˜iÃ]Ê«i˜ˆVˆˆ˜Ã]Ê
or cephalosporins. Note: susceptibility to sulfonamides, tetracyclines,
polymixins, and Sulbactam are NOT considered in this definition
Treatment
MDR Pseudomonas aeruginosa MDR Acinetobacter baumannii/calcoaceticus
complex
UÊÊ
ivÌœœâ˜iÉÌâœLVÌ“ÊÊ UÊ-lactam PLUS aminoglycoside if synergy expected
(if susceptible) OR
ORÊ UÊÊ
œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê
UÊÊ
˜Ìˆ‡«ÃiÕ`œ“œ˜Ê-lactam PLUS OR
ÊÊÊ“ˆ˜œ}ÞVœÃˆ`iʈvÊÃÞ˜iÀ}ÞÊ«Ài`ˆVÌi`ÊÊ UÊÊ
“«ˆVˆˆ˜ÉÃՏLVÌ“Ê­ˆvÊÃÕÃVi«ÌˆLi®ÊPLUS
or confirmed aminoglycoside (Sulbactam component has in vitro
OR activity against Acinetobacter spp.)
UÊÊ
œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê ÊÊÊOR
Ê UÊÊ
/ˆ}iVÞVˆ˜iÊ­ˆvÊÃÕÃVi«ÌˆLiÆÊvœÀʈ˜viV̈œ˜Ãʜ̅iÀÊÌ…˜Ê
bacteremia)
*Combination therapy should be considered in severe infections.
4.4
Organism
specific
guidelines:
Multi-drug
resistant
Gram-negative
rods
29

63. 30
4.4
Organism
specific
guidelines:
Multi-drug
resistant
Gram-negative
rods
Synergy:
UÊvÊÌ…iÊœÀ}˜ˆÃ“ʈÃʈ˜ÌiÀ“i`ˆÌiÊÌœÊÊLi̇V̓ʘ`ÊÃÕÃVi«ÌˆLiÊÌœÊ
aminoglycosides, synergy can be assumed.
UÊ/…iÊ“ˆVÀœLˆœœ}ÞʏLÊ`œiÃʘœÌÊ«iÀvœÀ“ÊÃÞ˜iÀ}ÞÊÌiÃ̈˜}°Ê
Antibiotic doses for MDR and carbapenemase-producing
infections – normal renal and hepatic function
UÊiÀœ«i˜i“ÊÓÊ}Ê6Ê+n]ʈ˜vÕÃiÊœÛiÀÊÎÊ…œÕÀÃÊ
UÊ
ivi«ˆ“iÊÓÊ}Ê6Ê+n]ʈ˜vÕÃiÊœÛiÀÊÎÊ…œÕÀÃ
UÊ
ivÌâˆ`ˆ“iÉ
ivi«ˆ“iÊÓÊ}Ê6ÊLœÕÃʏœ`ˆ˜}Ê`œÃiÊœÛiÀÊÎäÊ“ˆ˜ÕÌiÃ]Ê
then 6 g IV as continuous infusion over 24 hours
UÊ*ˆ«iÀVˆˆ˜ÉÌâœLVÌ“ÊΰÎÇxÊ}Ê6ÊLœÕÃʏœ`ˆ˜}Ê`œÃiÊœÛiÀÊÎäÊ
minutes, then continuous infusion 3.375 g IV Q4H infused over 4
hours OR 4.5 g IV Q6H, infuse over 4 hours
UÊ
œˆÃ̈˜ÊxÊ“}ÉŽ}Êœ˜Vi]ÊÌ…i˜ÊÓ°xÊ“}ÉŽ}Ê6Ê+£ÓÊ­vœÀÊ``ˆÌˆœ˜Ê
information, see p. 9)
UÊ“«ˆVˆˆ˜ÉÃՏLVÌ“ÊÎÊ}Ê6Ê+{Ê­vœÀÊ

64. ,ÊA. baumannii only)
UÊ“ˆ˜œ}ÞVœÃˆ`iÃÊ­vœÀÊ`œÃˆ˜}]ÊÃiiÊ«°Ê£{È®
UÊ/ˆ}iVÞVˆ˜iÊ£ä䇣xäÊ“}Ê6Ê+£ÓÊ
UÊ
ivÌœœâ˜iÉÌâœLVÌ“Ê£°x‡ÎÊ}Ê6Ê+n
,iviÀi˜ViÃÊ
- Ãʘ`ÊVˆ˜ˆVÊœÕÌVœ“iðÊ
ˆ˜Ê˜viVÌÊ

65. ˆÃÊÓä£xÊÈä­™®Ê£Î£™Óx°
Current therapies for P. aeruginosa°Ê
ÀˆÌÊ
ÀiÊ
ˆ˜ÊÓäänÆÓ{ÓÈ£°Ê
œ“Lˆ˜Ìˆœ˜ÊÌ…iÀ«ÞÊvœÀÊ
,
°Ê
ˆ˜ÊˆVÀœLˆœÊ˜viVÊÓä£{ÆÓäÊnÈÓ‡ÇÓ°

66. Interpreting the microbiology report
Interpretation of preliminary microbiology data
Gram-positive cocci Gram-negative cocci
Aerobic
In clusters
UÊ
œ}ՏÃiÊ­³®ÊS. aureus
UÊÊ
œ}ՏÃiÊ­q®ÊS. epidermidis,
S. lugdunensis
In pairs/chains
UÊÊ

67. ˆ«œVœVVÕÃ]Ê+ÕiÕ˜}Ê«œÃˆÌˆÛiÊ
S. pneumoniae
UÊÊ
«…‡…i“œÞ̈VÊ6ˆÀˆ`˜ÃÊ}ÀœÕ«ÊÊ
Streptococci, Enterococcus
(faecalis and faecium)
UÊÊ
i̇…i“œÞ̈VÊ
Group A strep (S. pyogenes),
Group B strep (S. agalactiae),
Group C, D, G strep
Anaerobic: Peptostreptococcus spp. Anaerobic: Veillonella spp.
Gram-positive rods Gram-negative rods
Aerobic
À}i Bacillus spp.
œVVœ‡LVˆÕÃÊListeria monocytogenes,
Lactobacillus spp.
-“]Ê«iœ“œÀ«…ˆV Corynebacterium spp.
À˜V…ˆ˜}Êw“i˜Ìà Nocardia spp.,
Streptomyces spp.
Anaerobic
À}iÊClostridium spp.
Small, pleomorphic: P. acnes, Actinomyces
spp.
* Serratia spp. can appear initially as non-lactose fermenting due to slow fermentation.
The Johns Hopkins microbiology laboratory utilizes standard reference
methods for determining susceptibility. The majority of isolates are
tested by the automated system.
The minimum inhibitory concentration (MIC) value represents the
concentration of the antimicrobial agent required at the site of infection
for inhibition of the organism.
The MIC of each antibiotic tested against the organism is reported
with one of three interpretations S (susceptible), I (intermediate), or
R (resistant). The highest MIC which is still considered susceptible
represents the breakpoint concentration. This is the highest MIC which
is usually associated with clinical efficacy. MICs which are 1
⁄2q1
⁄8 the
Aerobic

68. ˆ«œVœVVÕÃÊN. meningiditis, N.
gonorrhoeae, Moraxella catarrhalis
œVVœ‡LVˆÕà H. flu, Acinetobacter spp.,
HACEK organisms
Aerobic
Lactose fermenting: Citrobacter spp.,
Enterobacter spp., E. coli, Klebsiella
spp., Serratia spp.*
Non-lactose fermenting
UÊÊ
݈`ÃiÊ­q®: Acinetobacter spp.,
Burkholderia spp., E. coli (rare), Proteus
spp., Salmonella spp., Shigella spp.,
Serratia spp.*, Stenotrophomonas
maltophilia
UÊÊ
݈`ÃiÊ ­³®Ê P. aeruginosa, Aeromonas
spp., Vibrio spp., Campylobacter spp.
(curved)
Anaerobic: Bacteroides spp.,
Fusobacterium spp., Prevotella spp.
5.1
Interpreting
the
microbiology
report
31

69. 5.1
Interpreting
the
microbiology
report
32
breakpoint MIC are more frequently utilized to treat infections where
antibiotic penetration is variable or poor (endocarditis, meningitis,
osteomyelitis, pneumonia, etc.). Similarly, organisms yielding antibiotic
MICs at the breakpoint frequently possess or have acquired a low-level
resistance determinant with the potential for selection of high-level
expression and resistance. This is most notable with cephalosporins
and Enterobacter spp., Serratia spp., Morganella spp., Providencia
spp., Citrobacter spp. and Pseudomonas aeruginosa. These organisms
all possess a chromosomal beta-lactamase which frequently will be
over-expressed during therapy despite initial in vitro susceptibility. The
intermediate (I) category includes isolates with MICs that approach
attainable blood and tissue levels, but response rates may be lower than
fully susceptible isolates. Clinical efficacy can potentially be expected in
body sites where the drug is concentrated (e.g., aminoglycosides and
beta-lactams in urine) or when a higher dose of the drug can be used
(e.g., beta-lactams). The resistant (R) category indicates the organism
will not be inhibited by usually achievable systemic concentrations of the
antibiotic of normal doses.
NOTE: MIC values vary from one drug to another and from one
bacterium to another, and thus MIC values are NOT comparable
between antibiotics or between organisms.
Spectrum of antibiotic activity
The spectrum of activity table is an approximate guide of the activity of
commonly used antibiotics against frequently isolated bacteria. It takes
into consideration JHH specific resistance rates, in vitro susceptibilities
and expert opinion on clinically appropriate use of agents. For antibiotic
recommendations for specific infections refer to relevant sections of the
JHH Antibiotic Guidelines.

70. 33
5.2
Spectrum
of
antibiotic
activity
Penicillin
G
Ampicillin
Ampicillin/sulbactam
Oxacillin/Nafcillin
Piperacillin/tazobactam
Cefazolin
Cefotetan
Ceftriaxone
Cefepime
Aztreonam
Ertapenem
Meropenem
Moxifloxacin
Ciprofloxacin
Azithromycin
Gent/Tobra/Amikacin
Vancomycin
Linezolid
Daptomycin
Ê
/*É-8
Clindamycin
Doxycycline
Colistin
Metronidazole
GRAM-POSITIVE
GRAM-NEGATIVE
Not
active
Less
active
or
potential
resistance
Active
Atypicals
Abdominal anaerobes
Oral anaerobes
Pseudomonas spp.
Enterobacter spp.
Serratia spp.
Proteus spp.
Kebsiella spp.
E. coli
H. influenzae
Viridans strep.
S. pneumoniae
-hemolytic strep.
Coag. neg. staph
MSSA
MRSA
E. faecalis
VRE

71. 5.3
Interpretation
of
rapid
diagnostic
tests
34
Interpretation of rapid diagnostic tests
The JHH microbiology lab performs rapid nucleic acid microarray testing
on blood cultures growing Gram-positive organisms and peptide nucleic
acid fluorescence in situ hybridization (PNA-FISH) testing on blood
cultures growing yeast.
Nucleic acid microarray testing (Verigine®) for Gram-positive
cocci in blood cultures
UÊÊ

72. iÌiVÌÃʘ`ʈ`i˜ÌˆwiÃÊÌ…iʘÕViˆVÊVˆ`ÃÊœvÊ£ÓÊÀ“‡«œÃˆÌˆÛiÊLVÌiÀˆÊ
genera/species and 3 resistance markers.
UÊÊ
VÌiÀˆÊëiVˆiÃÊS. aureus, Coagulase-negative staphylococci, S.
lugdunensis, Staphylococcus spp. E. faecalis, E. faecium, S. pyogenes
(group A streptococci), S. agalactiae (group B streptococci), S.
pneumoniae, S. anginosus, Streptococcus spp. (e.g.,group C and G
streptococci, viridans group streptococci, etc.), Listeria spp.
UÊ,iÈÃ̘ViÊ“ÀŽiÀÃÊ“iV]ÊÛ˜]ÊÛ˜
Ê UÊÊ
vÊS. aureus is mecA positive the organism is resistant to Methicillin
and is reported as MRSA
Ê UÊÊ
vÊS. aureus is mecA negative the organism is susceptible to
Methicillin and is reported as MSSA
Ê UÊÊ
vÊ
°Êfaecalis/faecium is vanA/B positive the organism is resistant
ÌœÊ6˜Vœ“ÞVˆ˜Êʘ`ʈÃÊÀi«œÀÌi`ÊÃÊ6,
ÆʘœÌiÊÌ…ÌʏÊ6˜Vœ“ÞVˆ˜‡
resistant E. faecalis are susceptible to Ampicillin at JHH
UÊÊ
,iÃՏÌÃÊœvÊÌ…iÊÌiÃÌÊÀiÊÀi«œÀÌi`Ê܈̅ˆ˜Ê·{Ê…œÕÀÃÊvÌiÀÊÌ…iÊLœœ`Ê
cultures turn positive
UÊ/iÃ̈˜}ʈÃÊ«iÀvœÀ“i`Êœ˜ÞÊœ˜ÊÌ…iÊwÀÃÌÊ«œÃˆÌˆÛiÊLœœ`ÊVՏÌÕÀiÊ
UÊÊ
/iÃ̈˜}ʈÃÊ /Ê«iÀvœÀ“i`Êœ˜ÊLœœ`ÊVՏÌÕÀiÃÊ}ÀœÜˆ˜}Ê“œÀiÊÌ…˜Êœ˜iÊ
Gram positive organism but is performed on blood cultures growing
both Gram positive and negative organisms
UÊÊ
vÊÌ…iÊÌiÃÌʈÃʘi}̈ÛiʈÌÊ܈ÊLiÊÀi«œÀÌi`ÊÃʘi}̈ÛiÊvœÀÊÌ…iÊvœœÜˆ˜}Ê
œÀ}˜ˆÃ“ÃÊ-Ì«…ޏœVœVVÕÃÊë«]ÊStreptococcus spp., E. faecalis, E.
faecium, Listeria spp.

73. 35
5.3
Interpretation
of
rapid
diagnostic
tests
Organism Preferred empiric therapy Alternative empiric therapy
(% susceptible in blood at JHH) if PCN allergic
MSSA Ê ÝVˆˆ˜Ê­£ää¯®Ê œ˜‡ÃiÛiÀiÊ*
ʏiÀ}ÞÊ
iv✏ˆ˜Ê
Ê Ê -iÛiÀiÊ*
ʏiÀ}ÞÊ6˜Vœ“ÞVˆ˜1
MRSAÊ 6˜Vœ“ÞVˆ˜Ê­£ä䯮Ê

74. «Ìœ“ÞVˆ˜
Ê -ˆ˜}iÊ«œÃˆÌˆÛiÊVՏÌÕÀiÃÊÀiÊœvÌi˜ÊÊVœ˜Ì“ˆ˜˜ÌÆʘœÊÌÀiÌ“i˜ÌÊ
Coagulase-negative recommended. See p. 60 of the JHH Antibiotic Guidelines for
staphylococci information and indications for treatment. Call the microbiology lab for
more information and further work up if infection suspected (5-6510).
S. lugdunensisÊ 6˜Vœ“ÞVˆ˜Ê­£ä䯮2Ê ÝVˆˆ˜Ê­™È¯®ÊœÀÊ

75. «Ìœ“ÞVˆ˜Ê
E. faecalisÊ “«ˆVˆˆ˜Ê­™n¯®Ê 6˜Vœ“ÞVˆ˜Ê­™x¯®1
E. faecium (VRE)Ê ˆ˜i✏ˆ`Ê­nǯ®3Ê

76. «Ìœ“ÞVˆ˜Ê­™Ç¯®
E. faecium (not VRE)Ê6˜Vœ“ÞVˆ˜Ê­£ä䯮3 Linezolid
Streptococcus spp.Ê œ˜‡œ˜Vœœ}Þʫ̈i˜ÌÊ
ivÌÀˆÝœ˜i4 -iÛiÀiÊ*
ʏiÀ}ÞÊ6˜Vœ“ÞVˆ˜1
Ê ˜Vœœ}Þʫ̈i˜ÌÊ6˜Vœ“ÞVˆ˜4
S. anginosus Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ*
ʏiÀ}ÞÊ
ivÌÀˆÝœ˜i
Ê Ê -iÛiÀiÊ*
ʏiÀ}ÞÊ6˜Vœ“ÞVˆ˜1
S. pyogenes Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ*
ʏiÀ}ÞÊ
iv✏ˆ˜
(group A strep) -iÛiÀiÊ*
ʏiÀ}ÞÊ6˜Vœ“ÞVˆ˜1
S. agalactiae Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ*
ʏiÀ}ÞÊ
iv✏ˆ˜
(group B strep) Ê -iÛiÀiÊ*
ʏiÀ}ÞÊ6˜Vœ“ÞVˆ˜1
S. pneumoniae Ê
ivÌÀˆÝœ˜iÊ­£ä䯮4Ê -iÛiÀiÊ*
ʏiÀ}ÞÊ6˜Vœ“ÞVˆ˜1
(not meningitis)
S. pneumoniae Ê
ivÌÀˆÝœ˜iʳÊ6˜Vœ“ÞVˆ˜ÊÊ -iÛiÀiÊ*
ʏiÀ}ÞÊ
(meningitis)
…œÀ“«…i˜ˆVœÊ³Ê6˜Vœ“ÞVˆ˜1
Listeria spp. Ê “«ˆVˆˆ˜Ê­£ää¯®Ê /Àˆ“iÌ…œ«Àˆ“ÉÃՏv“iÌ…œÝ✏i
1Consult allergy for skin testing /desensitization
2Narrow to Oxacillin if found to be susceptible
3Narrow to Ampicillin if found to be susceptible
4Narrow to Penicillin G if found to be susceptible
PNA-FISH for yeast
UÊÊ
vÊ* ‡-ÊÃ…œÜÃÊC. albicans, most non-oncology patients without
prior azole exposure can be treated with fluconazole. For more
information see p. 117 and 134.
UÊÊ
vÊ* ‡-ÊÃ…œÜÃÊC. glabrata, treat with Micafungin until
susceptibilities available. For more information see p. 117 and 134.
UÊÊ
vÊ* ‡-ʘi}̈ÛiÊvœÀÊC. albicans or C. glabrata, most cases can be
treated as unspeciated candidemia, unless cryptococcus is suspected
(send serum cryptococcal antigen). For more information see p. 117
and 134.

77. Biliary tract infections – cholecystitis and
cholangitis
EMPIRIC TREATMENT
Community-acquired infections in patients without previous
biliary procedures AND who are not severely ill
UÊ
ivÌÀˆÝœ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊÊ
ÀÌ«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ
-iÛiÀiÊ*
ʏiÀ}ÞÊ
ˆ«ÀœyœÝVˆ˜Ê{ääÊ“}Ê6Ê+£Ó
Hospital-acquired infections OR patients with multiple therapeutic
biliary manipulations (e.g. stent placement/exchange, bilio-enteric
anastamosis of any severity) OR patients who are severely ill
UÊÊ
*ˆ«iÀVˆˆ˜ÉÌâœLVÌ“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ*
ʏiÀ}ÞÊ
ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ
-iÛiÀiÊ*
ʏiÀ}ÞÊâÌÀiœ˜“Ê£Ê}Ê6Ê+nÊPLUS Metronidazole 500
mg IV Q8H Vancomycin (see dosing section, p. 150)
In severely ill patients with cholangitis and complicated cholecystitis,
adequate biliary drainage is crucial as antibiotics will not enter bile in
the presence of obstruction.
Duration
UÊÊ
Uncomplicated cholecystitisÊÌÀiÌÊœ˜ÞÊ՘̈ÊœLÃÌÀÕV̈œ˜ÊˆÃÊÀiˆiÛi`°Ê
NO post-procedure antibiotics are necessary if the obstruction is
successfully relieved.
UÊÊ
œ“«ˆVÌi`ÊV…œiVÞÃ̈̈ÃÊ{Ê`ÞÃ]ÊÕ˜iÃÃÊ`iµÕÌiÊÃœÕÀViÊVœ˜ÌÀœÊˆÃÊ
not achieved.
U Ê
ˆˆÀÞÊÃi«ÃˆÃÊ{‡ÇÊ`ÞÃ]ÊÕ˜iÃÃÊ`iµÕÌiÊÃœÕÀViÊVœ˜ÌÀœÊˆÃʘœÌÊ
achieved.
TREATMENT NOTES
Microbiology
UÊÊ
À“‡˜i}̈ÛiÊÀœ`ÃÊqÊE. coli, Klebsiella spp., Proteus spp.,
P. aeruginosa (mainly in patients already on broad-spectrum antibiotics
or those who have undergone prior procedures)
UÊÊ
˜iÀœLiÃÊqÊBacteroides spp., generally in more serious infections, or
ˆ˜Ê«Ìˆi˜ÌÃÊ܈̅ÊÊ…ˆÃÌœÀÞÊœvÊLˆˆÀÞÊ“˜ˆ«ÕÌˆœ˜ÃÆÊÀÀiʈ˜ÊÕ˜Vœ“«ˆVÌi`Ê
and community-acquired infections
UÊÊ
Enterococcus spp°ÊqÊÌÀiÌ“i˜ÌʘœÌʏÜÞÃʈ˜`ˆVÌi`ÆÊÕÃiÊVˆ˜ˆVÊÕ`}“i˜Ì
UÊÊ
9iÃÌÊqÊÀÀi
39
6.1
Abdominal
infections

78. 6.1
Abdominal
infections
40
Management
UÊÊ
˜ÊVÃiÃÊœvÊÕ˜Vœ“«ˆVÌi`ÊVÕÌiÊV…œiVÞÃ̈̈Ã]ʘ̈LˆœÌˆVÃÊÃ…œÕ`ÊLiÊ
given until the biliary obstruction is relieved (either by surgery, ERCP,
or percutaneous drain).
UÊÊ
/ÀiÌ“i˜ÌÊœvÊi˜ÌiÀœVœVVˆÊˆÃÊÕÃՏÞʘœÌʘii`i`ʈ˜Ê“ˆ`É“œ`iÀÌiÊ
disease.
UÊÊ
9iÃÌÊ}i˜iÀÞÊÃ…œÕ`ÊLiÊÌÀiÌi`Êœ˜ÞʈvÊÌ…iÞÊÀiÊÀiVœÛiÀi`ÊvÀœ“Ê
biliary cultures, not empirically.
,iviÀi˜ViÃ
ˆˆÀÞÊÌÀVÌʈ˜viV̈œ˜ÃÊ

79. ÀÕ}ÃÊ£™™™ÆxÇ­£®n£‡™£°

80. -ÊÕˆ`iˆ˜iÃÊvœÀʘÌÀ‡L`œ“ˆ˜Ê˜viV̈œ˜ÃÊ
ˆ˜Ê˜viVÌÊ

81. ˆÃÊÓä£äÆxä£ÎÎq£È{°
-…œÀÌÊVœÕÀÃiÊÌ…iÀ«ÞÊvœÀÊÊ Ê
˜}ÊÊi`ÊÓä£xÆÎÇÓ£™™ÈqÓääx°
Diverticulitis
EMPIRIC TREATMENT
NOTE: Patients with uncomplicated diverticulitis (defined as CT
Vœ˜wÀ“i`ʏiv̇È`i`Ê`ˆÃiÃiÊ܈̅œÕÌÊLÃViÃÃÆÊvÀiiʈÀÊœÀÊwÃÌՏʱ fever
and elevated inflammatory markers), can be treated conservatively
without antibiotics based on a RCT.
Mild/moderate infections – can be oral if patient can take PO
UÊÊ
“œÝˆVˆˆ˜ÉVÛՏ˜ÌiÊnÇxÊ“}Ê*Ê+£Ó
OR
UÊÊ
ivÌÀˆÝœ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Metronidazole 500 mg IV/PO Q8H
OR
UÊÊ
ÀÌ«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ
-iÛiÀiÊ*
ʏiÀ}ÞÊQ
ˆ«ÀœyœÝVˆ˜Ê{ääÊ“}Ê6Ê+£ÓÊ,Ê
ˆ«ÀœyœÝVˆ˜Ê
xääÊ“}Ê*Ê+£ÓRÊPLUS Metronidazole 500 mg IV/PO Q8H
Severe infections
UÊÊ
*ˆ«iÀVˆˆ˜ÉÌâœLVÌ“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ*
ʏiÀ}ÞÊ
ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ
-iÛiÀiÊ*
ʏiÀ}ÞÊQ
ˆ«ÀœyœÝVˆ˜Ê{ääÊ“}Ê6Ê+£ÓÊ,ÊâÌÀiœ˜“Ê
£Ê}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV Q8H
Duration
UÊ{Ê`ÞÃ]ÊÕ˜iÃÃÊ`iµÕÌiÊÃœÕÀViÊVœ˜ÌÀœÊˆÃʘœÌÊV…ˆiÛi`°

82. TREATMENT NOTES
Microbiology
UÊÊ
“œÃÌʏÊˆ˜viV̈œ˜ÃÊÀiÊ«œÞ“ˆVÀœLˆ
UÊÊ
œÃÌÊVœ““œ˜Þʈ܏Ìi`ÊiÀœLˆVÊœÀ}˜ˆÃ“ÃÊqÊE. coli, K. pneumoniae,
Enterobacter spp., Proteus spp., Enterococcus spp.
UÊÊ
œÃÌÊVœ““œ˜Þʈ܏Ìi`ʘiÀœLˆVÊœÀ}˜ˆÃ“ÃÊqÊB. fragilis, Prevotella,
Peptostreptococci
Other considerations
UÊÊ
˜Ìˆ“ˆVÀœLˆÊÌÀiÌ“i˜ÌÊvœÀÊVÕÌiÊÕ˜Vœ“«ˆVÌi`Ê`ˆÛiÀ̈VՏˆÌˆÃÊ“ÞʘœÌÊ
accelerate recovery or prevent complications/recurrence.
UÊÊ
/ÊÃV˜ÊˆÃʈ“«œÀ̘Ìʈ˜ÊÃÃiÃȘ}ʘii`ÊvœÀÊ`Àˆ˜}iʈ˜ÊÃiÛiÀiÊ`ˆÃiÃi°ÊÊ
,iviÀi˜Vi

83. -ÊÕˆ`iˆ˜iÃÊvœÀʘÌÀ‡L`œ“ˆ˜Ê˜viV̈œ˜ÃÊ
ˆ˜Ê˜viVÌÊ

84. ˆÃÊÓä£äÆxä£ÎÎq£È{°
˜ÌˆLˆœÌˆVÃʈ˜ÊVÕÌiÊÕ˜Vœ“«ˆVÌi`Ê`ˆÛiÀ̈VՏˆÌˆÃ°Ê ÀÊÊ-ÕÀ}ÊÓä£ÓÆ™™xÎÓqxΙ°
-…œÀÌÊVœÕÀÃiÊÌ…iÀ«ÞÊvœÀÊÊ Ê
˜}ÊÊi`ÊÓä£xÆÎÇÓ£™™ÈqÓääx°
Pancreatitis
TREATMENT
UÊÊ
˜ÌˆLˆœÌˆVÊ«Àœ«…ޏ݈ÃʈÃÊ /ʈ˜`ˆVÌi`ʈ˜Ê«Ìˆi˜ÌÃÊ܈̅ÊÃiÛiÀiÊVÕÌiÊ
pancreatitis (SAP), including those with sterile pancreatic necrosis.
Uʘ̈“ˆVÀœLˆÊÌ…iÀ«ÞÊ…ÃʘœÊivviVÌÊœ˜Ê“œÀLˆ`ˆÌÞʘ`Ê“œÀ̏ˆÌÞ]ʘ`Ê
prophylactic antibiotics have been associated with a change in the
spectrum of pancreatic isolates from enteric Gram-negatives to
Gram-positive organisms and fungi.
UÊÊ
˜viVÌi`Ê«˜VÀïVʘiVÀœÃˆÃʈÃÊ`iw˜i`ÊLÞÊ
/ÊÃV˜Ê܈̅Ê}Ãʈ˜ÊÌ…iÊ
pancreas and/or percutaneous or surgical specimen with organisms
evident on gram stain or culture. Therapy should be directed based on
culture results.
UÊÊ
˜Ê«Ìˆi˜ÌÃÊ«ÀiÃi˜Ìˆ˜}Ê܈̅ÊÃÕëiVÌi`ÊL`œ“ˆ˜ÊÃi«ÃˆÃ]ÊVœ˜Ãˆ`iÀÊ
i“«ˆÀˆVÊÌ…iÀ«Þ
UÊÊ
*ˆ«iÀVˆˆ˜‡ÌâœLVÌ“Ê{°xÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ*
ʏiÀ}ÞÊ
ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ
-iÛiÀiÊ*
ʏiÀ}ÞÊ
ˆ«ÀœyœÝVˆ˜Ê{ääÊ“}Ê6Ê+£ÓÊPLUS
Metronidazole 500 mg IV Q8H
41
6.1
Abdominal
infections

85. 6.1
Abdominal
infections
42
Pancreatic penetration of selected antibiotics
Good (40%; MIC exceeded for most relevant organisms):
fluoroquinolones, carbapenems, Ceftazidime, Cefepime, Metronidazole,
Piperacillin-tazobactam
Poor (40%): aminoglycosides, first-generation cephalosporins,
Ampicillin
Duration
For infected pancreatic necrosis, continue antibiotics for 14 days after
source control is obtained. Continuation of antibiotics beyond this time
places the patient at risk for colonization or infection with resistant
organisms and drug toxicity.
TREATMENT NOTES
UÊÊ
˜viV̈œ˜Ê`iÛiœ«Ãʈ˜ÊÎäqxä¯Êœvʫ̈i˜ÌÃÊ܈̅ʘiVÀœÃˆÃÊ`œVÕ“i˜Ìi`ÊLÞÊ
CT scan or at the time of surgery.
UÊÊ
*iŽÊˆ˜Vˆ`i˜ViÊœvʈ˜viV̈œ˜ÊœVVÕÀÃʈ˜ÊÌ…iÊÎÀ`ÊÜiiŽÊœvÊ`ˆÃiÃi
UÊÊ
/…iÀiʈÃʈ˜ÃÕvwVˆi˜ÌÊiÛˆ`i˜ViÊÌœÊÀiVœ““i˜`ÊÃiiV̈ÛiÊ}ÕÌÊ
decontamination in management of pancreatitis.
,iviÀi˜ViÃ
VŽÊœvÊṎˆÌÞÊœvÊ«Àœ«…ޏV̈Vʘ̈LˆœÌˆVÃʘ˜Ê-ÕÀ}ÊÓääÇÆÓ{xÈÇ{°
Õˆ`iˆ˜iÃÊvœÀÊ“˜}i“i˜ÌÊœvÊ-*Ê
ÀˆÌÊ
ÀiÊi`ÊÓää{ÆÎÓÓxÓ{°
Peritonitis
DEFINITIONS
Primary peritonitis is spontaneous infection of the peritoneal cavity,
ÕÃՏÞÊÃÃœVˆÌi`Ê܈̅ʏˆÛiÀÊ`ˆÃiÃiʘ`ÊÃVˆÌiÃÊQ뜘̘iœÕÃÊLVÌiÀˆÊ
«iÀˆÌœ˜ˆÌˆÃÊ­- *®R°Ê
Secondary peritonitis is infection of the peritoneal cavity due to
spillage of organisms into the peritoneum, usually associated with GI
perforation.
Tertiary peritonitis is a recurrent infection of the peritoneal cavity
following an episode of secondary peritonitis.
Primary peritonitis/Spontaneous bacterial
peritonitis (SBP)
EMPIRIC TREATMENT
UÊÊ
ivÌÀˆÝœ˜iÊ£Ê}Ê6Ê+£Ó
OR
UÊÊ
-iÛiÀiÊ*
ʏiÀ}Þʜ݈yœÝVˆ˜Ê{ääÊ“}Ê6É*Ê+Ó{Ê­VÊ

86. ÊœÀÊ
Antimicrobial Stewardship to discuss regimens for patients who have
been taking fluoroquinolones for SBP prophylaxis).

87. UÊÊ
*̈i˜ÌÃÊ܈̅ÊÃiÀÕ“ÊVÀ˜iÊ€£Ê“}É`]Ê 1 Ê€ÎäÊ“}É`ÊœÀÊ̜̏Ê
LˆˆÀÕLˆ˜Ê€{Ê“}É`ÊÃ…œÕ`ʏÜÊÀiViˆÛiʏLÕ“ˆ˜Ê­Óx¯®Ê£°xÊ}ÉŽ}Êœ˜Ê
day 1 and 1 g/kg on day 3 (round to the nearest 12.5 g).
Duration
UÊÊ
/ÀiÌÊvœÀÊ5 days
PROPHYLAXIS
Cirrhotic patients with gastrointestinal hemorrhage
UÊÊ
ˆ«ÀœyœÝVˆ˜ÊxääÊ“}Ê*Ê

88. ÊvœÀÊÇÊ`ÞÃÊ
UÊÊ
ivÌÀˆÝœ˜iÊ£Ê}Ê6Ê+Ó{ÊV˜ÊLiÊÕÃi`Êœ˜Þʈvʫ̈i˜ÌʈÃÊ *]ÊÌ…i˜Ê
switch to Ciprofloxacin 500 mg PO BID once bleeding is controlled
Non-bleeding cirrhotic patients with ascites
UÊÊ
/*É-8Ê£Ê

89. -Ê*Êœ˜ViÊ`ˆÞ
OR
UÊÊ
vÊÃՏvʏiÀ}ˆV]Ê
ˆ«ÀœyœÝVˆ˜ÊxääÊ“}Ê*Ê`ˆÞÊ
TREATMENT NOTES
Microbiology
UÊÊ
À“‡˜i}̈ÛiÊÀœ`ÃÊ­
˜ÌiÀœLVÌiÀˆVii]Êië°ÊE. coli and K.
pneumoniae), S. pneumoniae, enterococci, and other streptococci.
UÊÊ
*œÞ“ˆVÀœLˆÊˆ˜viV̈œ˜ÊÃ…œÕ`Ê«Àœ“«ÌÊÃÕëˆVˆœ˜ÊœvÊÊ«iÀvœÀ̈œ˜°
Diagnostic criteria
UÊÊ
ÓxäÊ* Ê«iÀÊ““3
of ascitic fluid.
UÊÊ
*œÃˆÌˆÛiÊVՏÌÕÀiÊ܈̅ʐÊÓxäÊ* ÊÃ…œÕ`Ê«Àœ“«ÌÊÀi«iÌÊÌ«°ÊvÊ* Ê€Ê
250 OR culture remains positive, patient should be treated.
Follow-up
UÊÊ
œ˜Ãˆ`iÀÊÀi«iÌÊ«ÀVi˜ÌiÈÃÊvÌiÀÊ{nÊ…œÕÀÃÊœvÊÌ…iÀ«Þ°
UÊÊ
œ˜Ãˆ`iÀÊV…˜}ˆ˜}ʘ̈LˆœÌˆVÃʈvÊÃVˆÌiÃÊyÕˆ`Ê* Ê…ÃʘœÌÊ`Àœ««i`ÊLÞÊ
Óx¯ÊvÌiÀÊ{nÊ…œÕÀÃʘ`ÉœÀʫ̈i˜ÌʈÃʘœÌÊVˆ˜ˆVÞÊÀi뜘`ˆ˜}°
Notes on prophylaxis against SBP
UÊÊ
Ê«Ìˆi˜ÌÃÊ܈̅ÊVˆÀÀ…œÃˆÃʘ`ÊÕ««iÀÊÊLii`ÊÃ…œÕ`ÊÀiViˆÛiÊ
«Àœ«…ޏ݈ÃÊvœÀÊÇÊ`ÞÃÊ­xä¯Ê`iÛiœ«Ê- *ÊvÌiÀÊLii`®°
UÊÊ
*̈i˜ÌÃÊÜ…œÊ}iÌÊ- *ÊÃ…œÕ`Ê}iÌʏˆviœ˜}Ê«Àœ«…ޏ݈ÃÊ̜ʫÀiÛi˜ÌÊvÕÌÕÀiÊ
i«ˆÃœ`iÃÊ­{äqÇä¯ÊÀˆÃŽÊœvÊÀiVÕÀÀi˜Viʈ˜Ê£ÊÞiÀ®°
UÊÊ
*Àœ«…ޏ݈ÃÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊvœÀÊÌ…œÃiÊ܈̅ʏœÜÊ«ÀœÌiˆ˜Ê
Vœ˜Vi˜ÌÀ̈œ˜Ãʈ˜ÊÃVˆÌiÃÊ­Ê£äÊ}ɮʜÀʈ““Õ˜œÃÕ««ÀiÃÈœ˜ÊÜ…ˆiÊ
patient is in hospital.
,iviÀi˜ViÃ

90. ˆ}˜œÃˆÃ]ÊÌÀiÌ“i˜Ìʘ`Ê«Àœ«…ޏ݈ÃÊœvÊ- *ÊÊi«ÌœÊÓäääÆÎÓ£{Ó°
˜}i“i˜ÌÊœvÊÛÀˆViÊ…i“œÀÀ…}iʈ˜ÊVˆÀÀ…œÃˆÃÊi«Ìœœ}ÞÊÓääÇÆ{È™ÓÓqÎn°
43
6.1
Abdominal
infections

91. 6.1
Abdominal
infections
44
Secondary peritonitis/GI perforation
EMPIRIC TREATMENT
Perforation of esophagus, stomach, small bowel, colon, or
appendix
Patient mild to moderately ill
UÊÊ
ÀÌ«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ
-iÛiÀiÊ*
ʏiÀ}ÞÊ
ˆ«ÀœyœÝVˆ˜Ê{ääÊ“}Ê6Ê+£ÓÊPLUS
Metronidazole 500 mg IV Q8H
Patient severely ill or immunosuppressed
UÊÊ
*ˆ«iÀVˆˆ˜ÉÌâœLVÌ“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ*
ʏiÀ}ÞÊ
ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ
-iÛiÀiÊ*
ʏiÀ}ÞÊ6˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
QâÌÀiœ˜“Ê£Ê}Ê6Ê+nÊORÊ
ˆ«ÀœyœÝVˆ˜Ê{ääÊ“}Ê6Ê+nRÊPLUS
Metronidazole 500 mg IV Q8H
Empiric antifungal therapy is generally not indicated for GI
perforation unless patient has one of the following risk factors:
Esophageal perforation, immunosuppression, prolonged antacid or
antibiotic therapy, prolonged hospitalization, persistent GI leak.
Recommendations for patients who are clinically stable and have not
ÀiViˆÛi`Ê«ÀˆœÀʏœ˜}‡ÌiÀ“Ê✏iÊÌ…iÀ«Þ
UÊÊ
ÕVœ˜âœiÊ{ää‡nääÊ“}Ê6É*Ê+Ó{
Recommendations for patients who are NOT clinically stable or have
ÀiViˆÛi`Ê«ÀˆœÀʏœ˜}‡ÌiÀ“Ê✏iÊÌ…iÀ«Þ
UÊÊ
ˆVvÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{Ê
Duration of therapy for secondary peritonitis/GI perforation
Stomach Small Bowel Colon Appendix
Uncomplicated
Definition Operated on Operated on Operated on Non-necrotic or
within within within gangrenous
24 hours 12 hours 12 hours appendix

92. ÕÀ̈œ˜Ê Ó{q{nÊ…œÕÀÃÊ Ó{q{nÊ…œÕÀÃÊ Ó{q{nÊ…œÕÀÃÊ Ó{Ê…œÕÀÃ
Complicated