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*PHYSORDER*
ADULT Diabetic Foot Infection
Medication Orders
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Page 1 of 4
Form Origination Date: 01/2013
Version: 1
from the note.
Patient Name
MRN
PATIENT IDENTIFICATION LABEL
ALLERGIES/DRUG SENSITIVITY:
1.
2.
3.
4.
Weight: ________ kg
Height: ________ cm
Height: ________ in
Ideal body weight (IBW): 50 kg + 2.3 kg for each in > 5 feet (male); 45.5 kg + 2.3 kg for each in > 5 feet (female)
Adjusted body weight: IBW + 0.4 (actual weight - IBW)
Diagnostic orders: see algorithm (link)
Foot X-ray
Culture if expressible exudate present (for moderate, severe or limb-threatening infections):
Diabetic foot culture
Document Pseudomonas risk (mark all that apply):
Recent (within 90 days) ICU admission
Immunosuppressive state / medications (see algorithm for examples)
Document MRSA risk (mark all that apply):
Resident of long-term care facility
History of MRSA colonization
ESRD / dialysis
Hospitalized / institutionalized /
Wound care in past 30 days
Immunosuppressive state / medications
IV drug abuse
Home infusion therapy
Recent antibiotics
incarcerated 2 days out of past
90 days
MILD (may treat as outpatient) - see algorithm (link): Choose from I or II
I. No MRSA risk factors: Choose 1 of the following
Cephalexin 500 mg PO Q ___ H
Amoxicillin-clavulanate 875 mg PO Q ___ H
II. MRSA risk factors: Choose 1 of the following
A. No sulfa allergy:
Sulfamethoxazole-trimethoprim DS ___ tab PO Q ___ H
B. Sulfa allergy:
Doxycycline 100 mg PO Q 12 H
MODERATE - see algorithm (link): Diagnostic orders
Consult General Surgery (if need for further debridement)
Consult Wound Care
Consult Infectious Diseases (if osteomyelitis present)
Bone biopsy for culture
CRP, low sensitivity
ESR
MRI of foot (consider if elevated CRP or ESR)
MODERATE: NO Pseudomonal AND NO MRSA risk factors present: Choose 1 of the following
A. Preferred regimen:
Ampicillin-sulbactam ___ gram IV Q ___ H
B. Penicillin allergy not anaphylaxis:
Ertapenem ___ gram IV Q 24 H
C. Penicillin allergy anaphylaxis:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Metronidazole 500 mg IV/PO Q 8 H (if gangrene present)
Physician Signature
Pager ID
Date
Time
AM/PM
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*PHYSORDER*
ADULT Diabetic Foot Infection
Medication Orders
Page 2 of 4
Form Origination Date: 01/2013
Version: 1
For HIPAA Compliance reasons, this form
IS NOT TO BE SAVED with patient information.
Selecting the PRINT button will clear all information
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Patient Name
MRN
PATIENT IDENTIFICATION LABEL
MODERATE: NO Pseudomonal AND NO MRSA risk factors present (CONT): Choose 1 of the following
D. ESBL-producing organism isolated or history of:
Meropenem ___ gram IV Q ___ H
MODERATE: Pseudomonal risk factors but NO MRSA risk factors present: Choose 1 of the following
A. Preferred regimen, including penicillin allergy not anaphylaxis:
Cefepime ___ gram IV Q ___ H
AND
Metronidazole 500 mg IV/PO Q 8 H (if gangrene present)
B. Penicillin allergy anaphylaxis:
Aztreonam ___ gram IV Q ___ H
AND
Clindamycin 300 mg IV or
PO Q 8 H
C. ESBL-producing organism isolated or history of:
Meropenem ___ gram IV Q ___ H
MODERATE: NO Pseudomonal risk factors BUT MRSA risk factors present: Choose 1 of the following
A. Preferred:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Ampicillin-sulbactam ___ gram IV Q ___ H
B. Penicillin allergy not anaphylasis:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Ertapenem ___ gram IV Q 24 H
C. Penicillin allergy anaphylaxis:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Aztreonam ___ gram IV Q ___ H
AND
Metronidazole 500 mg IV/PO Q 8 H (if gangrene present)
D. ESBL-producing organism present or history of:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Meropenem ___ gram IV Q ___ H
Physician Signature __________________________________________ Pager ID _________ Date ______ Time _____ AM/PM
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*PHYSORDER*
ADULT Diabetic Foot Infection
Medication Orders
Page 3 of 4
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Form Origination Date: 01/2013
Version: 1
from the note.
Patient Name
MRN
PATIENT IDENTIFICATION LABEL
MODERATE: BOTH Pseudomonal AND MRSA risk factors present: Choose 1 of the following
A. Preferred regimen, including penicillin allergy not anaphylaxis:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Cefepime ___ gram IV Q ___ H
AND
Metronidazole 500 mg IV/PO Q 8 H (if gangrene present)
B. Penicillin allergy anaphylaxis:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Aztreonam ___ gram IV Q ___ H
AND
Metronidazole 500 mg IV/PO Q 8 H (if gangrene present)
C. ESBL-producing organism isolated or history of:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Meropenem ___ gram IV Q ___ H
SEVERE OR LIMB-THREATENING: see algorithm (link)
Diagnostic orders:
Consult General Surgery (if need for further debridement)
Consult Wound Care
Consult Infectious Diseases
Bone biopsy for culture
CRP, low sensitivity
ESR
MRI of foot (consider if suspected soft tissue abscess or diagnosis of osteomyelitis uncertain)
SEVERE OR LIMB-THREATENING ANTIBIOTIC ORDERS: Choose 1 of the following
A. Preferred regimen, including penicillin allergy not anaphylaxis:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Cefepime ___ gram IV Q ___ H
AND
Metronidazole 500 mg IV/PO Q 8 H (if gangrene present)
Physician Signature __________________________________________ Pager ID _________ Date ______ Time _____ AM/PM
This form may be completed on line. Tab or move
cursor to text field and type in text.
*PHYSORDER*
ADULT Diabetic Foot Infection
Medication Orders
For HIPAA Compliance reasons, this form
IS NOT TO BE SAVED with patient information.
Selecting the PRINT button will clear all information
Page 4 of 4
Form Origination Date: 01/2013
Version: 1
from the note.
Patient Name
MRN
PATIENT IDENTIFICATION LABEL
SEVERE OR LIMB-THREATENING ANTIBIOTIC ORDERS (CONT)
B. Penicillin allergy anaphylaxis:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Aztreonam ___ gram IV Q ___ H
AND
Tobramycin (once-daily dosing) 7 mg/kg ___ mg (round to nearest 10 mg; use adjusted body weight) IV over at least 30 minutes (larger
doses may need to be infused over 1 hour) 2 x 1 (consult pharmacy for additional dosing)
AND
Metronidazole 500 mg IV/PO Q 8 H (if gangrene present)
C. ESBL-producing organism isolated or history of:
Vancomycin ___ mg (25 mg/kg) IV x 11 then ___ mg (15 mg/kg) IV Q __ H (consult pharmacy for additional dosing)
AND
Meropenem ___ gram IV Q ___ H
For loading doses > 2 g, consult with pharmacy. If the patient has a history of vancomycin MIC  2 for S. aureus, consult Infectious Diseases or
Antimicrobial Stewardship Team for alternatives.
2
Once-daily dosing should not be used in the setting of endocarditis, pregnancy, CrCl <50 ml/min, or in patients with significant burns. In these situations,
traditional dosing should be utilized (consult pharmacy for dosing recommendations).
1
Antibiotic dosing based on renal function (see also http://kdpnet.louisville.edu/renalbook/adult/):
> 50
≥ 30 to ≤ 50
≥ 10 to ≤ 30
≤ 10 or HD
CVVH
Amoxicillinclavulanate
875 mg PO Q12H
875 mg PO Q12H
500 mg PO Q12H
500 mg PO Q24H
No data
Ampicillin-sulbactam
3 grams IV Q 6H
3 grams IV Q8H
3 grams IV Q12H
3 grams IV Q24H
3 grams IV Q8H
Aztreonam
2 grams IV Q6H
2 grams IV Q8H
2 grams IV Q12H
1 gram IV Q24H (after HD)
2 grams IV Q12H
CrCl (mL/min)
Cefepime
2 grams IV Q8H
2 grams IV Q12H
2 grams IV Q24H
1 gram IV Q24H (after HD)
2 grams IV Q12H
Cephalexin
500 mg PO Q6H
500 mg PO Q12H
500 mg PO Q12H
500 mg PO Q12H
500 mg PO Q12H
Clindamycin
300 mg PO/IV Q8H
300 mg PO/IV Q8H
300 mg PO/IV Q8H
300 mg PO/IV Q8H
300 mg PO/IV Q8H
Doxycycline
100 mg PO Q12H
100 mg PO Q12H
100 mg PO Q12H
100 mg PO Q12H
100 mg PO Q12H
Ertapenem
1000 mg IV Q24H
1000 mg IV Q24H
500 mg IV Q24H
500 mg IV Q24H
No data
Meropenem
1000 mg IV Q8H
1000 mg IV Q12H
1000 mg IV Q12H
1000 mg IV Q24H
1000 mg IV Q12H
1 DS PO Q12-24H
No data
Sulfamethoxazoletrimethoprim
Tetracycline
1 DS 1-2 TAB
PO Q12H
1 DS 1-2 TAB
PO Q12H
1 DS PO Q12-24H
1 DS PO Q24H if on
hemodialysis
Not recommended if not on
dialysis
250 mg PO Q6H
250 mg PO Q12H
250 mg PO Q24H
250 mg PO Q24H
15 mg/kg IV
≤ 10: dose based on levels
Vancomycin+
15 mg/kg IV Q8-12H
15 mg/kg IV Q12-24H
Q24-48H
HD: 15 mg/kg after each HD
+
Adjust dosing based on trough levels (goal 10-15 mcg/mL for empiric use, 15-20 mcg/mL for confirmed MRSA)
15 mg/kg Q24H
Physician Signature __________________________________________ Pager ID _________ Date ______ Time _____ AM/PM