2016-2017
Antimicrobial
Guide
Empiric Therapy & Treatment
Recommendations For Adult
Patients
Table of Contents
A. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
B. Guidelines for the Treatment of Various Infections in Adults
Central Nervous System (CNS)
• Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Clostridium difficile Infection (CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Extended Spectrum Beta-Lactamases Infections (ESBL). . . . . . . . . . 6
Febrile Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Intra-abdominal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Lyme Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Proton Pump Inhibitor (PPI) Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Respiratory Tract - Upper and Lower
• Acute Bacterial Sinusitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
• Acute Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
• Chronic Obstructive Pulmonary Disease (COPD). . . . . . . . . . . . . . . . . . . . 14
Exacerbation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
• Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Sepsis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Sexually Transmitted Infections (STI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Skin and Soft Tissue
• Skin and Soft Tissue Infections (SSTI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
• Diabetic Foot Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Surgical Decolonization and Prophylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Urinary Tract
• Catheter-Associated Urinary Tract Infection (CA-UTI). . . . . . . . . . . . . . 29
• Non-Catheter Associated Urinary Tract Infection/Cystitis . . . . . . . . . . 30
• Prostatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
C. Immunizations
• Pneumococcal Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
D. Antibiogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Table of Contents
E. Guidelines for Restricted Antimicrobials
Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Ceftaroline (Teflaro®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Ceftazidime/avibactam (Avycaz®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Ceftolozane/tazobactam (Zerbaxa®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Dalbavancin (Dalvance®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Daptomycin (Cubicin®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Ertapenem (Invanz®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Fidaxomicin (Dificid®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Fosfomycin (Monurol®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Linezolid (Zyvox®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Oritavancin (Orbactiv®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Polymyxin B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Colistin (Polymyxin E). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Tedizolid (Sivextro®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Tigecycline (Tygacil®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antifungals
• Amphotericin B lipid complex (L-AmB)(AmBisome®). . . . . . . . . . . . . . .
• Caspofungin (Cancidas ®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Isavuconazonium sulfate (Cresemba®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Voriconazole (VFend®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
F. Vancomycin Dosing and Monitoring in Adult Patients. . . . . . . . . . . . . 57
G. Aminoglycoside High Dose Once Daily (HDOD) and
Monitoring in Adult Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
H. Antimicrobial Dosing for Adult Patients Based on Renal
Function
I.
. . . . . . . .
63
Antimicrobial Duration of Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
J. IV to PO Antibiotic Step-Down Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
K. Infection Control
• Twelve Steps to Prevent Antimicrobial Resistance . . . . . . . . . . . . . . . . . . 72
• Contact Precautions for Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
L. Pharmacokinetic Equations/Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Introduction
Introduction
Antimicrobial resistance is globally recognized as one of the greatest healthcare threats.
Infections associated with multi-drug resistant organisms and limited antimicrobial choices
have placed an immense burden upon clinicians. In order to preserve currently available
antimicrobials we must use them appropriately; ensuring that each patient is on the right
drug, route, dose, and duration.
The pathways and tables in this booklet are based on national guidelines and consensus
statements, expert opinions from the Infectious Diseases team (pharmacy and medicine) and
microbiology data from the microbiology laboratory.
DISCLAIMER: The opinions expressed in this publication reflect those of the authors to the
best of their ability. However, the authors make no warranty regarding the contents of the
publication. The guidelines described herein are general and may not apply to a specific
patient.
The recommendations given in this guide are meant to serve as treatment guidelines. They
should not replace clinical judgment or Infectious Diseases consultation when indicated. The
recommendations may not be appropriate at other settings. We have attempted to verify
that all information is correct but because of ongoing research, recommendations may
change.
Please let us know if there are sections that you think could be improved or if there is more
information you would like to see included. Our goal is for the Antimicrobial Stewardship
Program to be a useful service in optimizing antibiotic use and patient outcomes.
We welcome your thoughts and comments.
Thank you,
Kerry L. LaPlante, PharmD., FCCP
Professor of Pharmacy, University of Rhode Island, Kingston, RI
Adjunct Professor of Medicine, Brown University, Providence, RI
Director of the Rhode Island Infectious Diseases Research Program (RIID) and Infectious
Diseases Pharmacotherapy Specialist, Providence Veterans Medical Center, RI
Kerry.LaPlante@va.gov or KerryLaPlante@uri.edu.
The following people reviewed ALL the treatment guidelines:
Melissa Gaitanis, MD (Chief of Infectious Diseases)
Kerry L. LaPlante, PharmD, FCCP (Infectious Diseases)
Haley Morrill, PharmD (Infectious Diseases)
The following people served as section/topic reviewers:
Tanya Ali, MD (Infectious Diseases), Patricia Cristofaro, MD (Infectious Diseases),
Cheston Cunha, MD (Infectious Diseases), Megan Luther, PharmD,
Kevin McConeghy, PharmD, MS, BCPS, Jacob Morton, PharmD, MBA, BCPS,
Tristan T. Timbrook, PharmD, MBA, BCPS
A special thank you for assistance with the Antimicrobial Guidebook
Kayla Chouinard, Jaclyn Cusumano, Channel DeLeon, Jillian Dougherty,
Anthony Harrison, Sarah Harrison, Brittany Julich, Elizabeth Koczera, Amanda Maione,
Nicholas Mercuro, Rachel Morgans, Lindsey Williamson
Editorial and formatting assistance
Jennifer DeAngelis, Graphic Design, Kathie McKinstry, Graphic Design,
Diane M. Parente, PharmD (Infectious Diseases)
PAGE 1
Central
Nervous
System:
Meningitis
Central
Nervous
System:
Meningitis
ACUTE BACTERIAL MENINGITIS
Clinical
Syndrome
Age < 50
Most commonly
isolated
organisms:
• S. pneumoniae
• N. meningitidis
• H . influenzae
Age ≥ 50
Most commonly
isolated
organisms:
• S. pneumoniae
• N. meningitidis
• H. influenzae
• L. monocytogenes
• Aerobic gram
negative bacilli
Preferred Regimen
Alternative Regimen
Ceftriaxone 2 gm IV
Q12H
AND
Vancomycin 15 mg/kg IV
AND
Dexamethasone
0.15 mg/kg IV
Q6H given 10 to 20
minutes before the first
dose of antimicrobial
therapy and continue
for 4 days for
pneumococcal
meningitis
(discontinue for all other
microorganisms)
PCN allergy
(anaphylaxis):
Vancomycin 15 mg/kg IV
AND
Moxifloxacin 400 mg IV
Q24H
AND
Dexamethasone
0.15 mg/kg IV
Q6H given 10 to 20
minutes before the first
dose of antimicrobial
therapy and continue
for 4 days for
pneumococcal
meningitis
(discontinue for all other
microorganisms)
Ceftriaxone 2 gm IV
Q12H
AND
Vancomycin 15 mg/kg IV
AND
Ampicillin 2 gm IV Q4H
AND
Dexamethasone 0.15
mg/kg IV
Q6H given 10 to 20
minutes before the first
dose of antimicrobial
therapy and continue
for 4 days for
pneumococcal
meningitis
(discontinue for all other
microorganisms)
PCN allergy
(anaphylaxis):
Vancomycin IV 15 mg/kg
AND
Moxifloxacin 400 mg IV
Q24H
AND
SMX/TMP 5 mg/kg IV
Q6H
AND
Dexamethasone 0.15
mg/kg IV
Q6H given 10 to 20
minutes before the first
dose of antimicrobial
therapy and continue
for 4 days for
pneumococcal
meningitis
(discontinue for all other
microorganisms)
Diagnostics and
Clinical Considerations
• Consult Infectious
Diseases
• Obtain lumbar
puncture and blood
cultures prior to
starting therapy
• Patients with the
following conditions
should receive head
CT prior to lumbar
puncture:
- Immunocompromised (HIV)
- History of CNS
lesion, stroke or
focal infection
- New onset seizure
- Papilledema
- Abnormal level of
consciousness
- Focal neurologic
deficit
• Typical CSF findings in
bacterial meningitis
- Cloudy CSF
- Glucose < 40 mg/dL
OR <50% serum
- Protein 100-500
- WBC 1000-5000
- > 90% PMNs
• Narrow therapy
based on CSF culture
results
• If CSF culture
negative, consult ID
• Repeat lumbar
puncture if no
improvement in 48
hours and consider
viral panel
CNS= central nervous system; CSF= cerebral spinal fluid; CT= computed tomography; H= hour(s); HIV= human
immunodeficiency virus; ID= infectious diseases; IV= intravenous; PCN= Penicillin; PMNs= poly morphonuclear cells; Q= every;
SMX/TMP= Sulfamethoxazole/Trimethoprim; WBC= white blood cell
PAGE 2
Central Nervous System: Meningitis
Central
Nervous
System:
Meningitis
ASEPTIC
/ VIRAL
/OTHER
MENINGITIS
AND HERPES SIMPLEX TYPE 2
Central
Nervous
System:
Meningitis
Diagnostics
ASEPTIC/ VIRAL/OTHER
MENINGITIS
AND HERPES SIMPLEX
TYPE 2and Clinical
Clinical Syndrome
Preferred
Regimen
Considerations
Diagnostics and Clinical
Clinical Syndrome
Preferred
Supportive
care Regimen
Aseptic/Viral/Other
• ConsultConsiderations
Infectious Diseases
• Respiratory viruses
• Send CSF and order:
• Consult
Infectious
- Viral
culture Diseases
HSV
PCR
• Send CSF and order:
- Enteroviral
Viral culturePCR
- Lyme
Antibody (IgG index,
HSV PCR
simultaneous
- requires
Enteroviral
PCR
- serum)
Lyme Antibody (IgG index,
- VDRL
requires simultaneous
• Typical
CSF findings in viral
serum)
meningitis
- VDRL
- Clear
• Typical
CSF CSF
findings in viral
- Glucose 30-70 mg/dL
meningitis
- Protein
30-150
Clear CSF
- WBC
100-1000
Acyclovir 10 mg/kg* IV Q8H
Herpes Simplex Type 2
Glucose
30-70 mg/dL
- <Protein
90% PMNs,
Treat for 7 to 10 days
30-150increased
- lymphocytes
WBC 100-1000
Acyclovir 10 mg/kg* IV Q8H
Herpes Simplex Type 2
- < 90% PMNs, increased
Treat for 7 to 10 days
CSF= cerebral spinal fluid; H= hour(s); HSV= Herpes Simplex Virus; IV= intravenous; LP= lumbar puncture;
PCR= Polymerase Chain
lymphocytes
• Enteroviruses (90%)
Aseptic/Viral/Other
•
•
•
•
•
•
•
Arboviruses
Respiratory viruses
West
Nile Virus(90%)
Enteroviruses
Epstein
Barr Virus
Arboviruses
Lyme
West Nile Virus
Syphilis
Epstein Barr Virus
Lyme
Syphilis
If
Lyme Suspected:
Supportive
care
Ceftriaxone 2 gm IV Q24H
If Lyme Suspected:
Ceftriaxone 2 gm IV Q24H
Reaction; PMNs= poly morphonuclear cells; Q= every; VDRL= Veneral Disease Research Laboratory Test; WBC= white blood cell
CSF=
cerebral
spinal
fluid;based
H= hour(s);
HSV=
Herpes
Simplex Virus; IV= intravenous; LP= lumbar puncture; PCR= Polymerase Chain
* Acyclovir
mg/kg
dosing
on ideal
body
weight.
Reaction; PMNs= poly morphonuclear cells; Q= every; VDRL= Veneral Disease Research Laboratory Test; WBC= white blood cell
NOTE: If dexamethasone or imaging studies (LP or CT) is not immediately available DO NOT delay administration of
*antibiotics.
Acyclovir mg/kg dosing based on ideal body weight.
NOTE:
dexamethasone
or imaging
(LP Refer
or CT)to
is Table
not immediately
DOon
NOT
delay administration
of
NOTE: IfDosing
based on normal
renalstudies
function.
of Contentsavailable
for section
Vancomycin
Dosing and Monitoring
antibiotics.
in
Adult Patients and Antimicrobial Dosing for Adult Patients Based on Renal Function
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Vancomycin Dosing and Monitoring
in Adult Patients and Antimicrobial Dosing for Adult Patients Based on Renal Function
References:
1. Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84.
References:
PAGE 3
1. Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84.
Clostridium
difficile
Infection
Clostridium difficile Infec2on (CDI) (CDI)
• Stop anIbioIcs that are no longer indicated, especially broad-­‐spectrum anIbioIcs (fluoroquinolones, clindamycin, piperacillin-­‐tazobactam, cephalosporins) as they increase the risk for CDI • Stop use of any anI-­‐diarrheal/anIperistalIc agents • Consider disconInuaIon of proton-­‐pump inhibitors (PPIs) • If high clinical suspicion of CDI iniIate anIbioIc therapy before laboratory confirmaIon INITIAL EPISODE Clinical Classifica4on Suppor4ve Clinical Data Recommended Regimens Clinical and Therapeu4c Considera4ons Ini4al episode Mild or Moderate •
Diarrhea (passage of ≥ 3 unformed stools in ≤ 24H) AND • WBC < 15,000 cells/
µL AND • SCr < 1.5 Imes the premorbid level Vancomycin* 125 mg PO Q6H for 10-­‐14 days Ensure loose stools are not a result of laxaIve Severe • Diarrhea AND • WBC ≥ 15,000 cells/
µL OR • SCr ≥ 1.5 Imes the premorbid level Vancomycin 125 mg PO Q6H for 10-­‐14 days Complicated Severe Severe criteria PLUS ≥ 1 of the following: • Hypotension • Shock • Toxic Megacolon • PerforaIon • Ileus If no complete ileus: Oral vancomycin 500 mg PO Q6H OR via NG tube AND if micro perforaIon is suspected metronidazole 500 mg IV Q8H Consult ID and Surgery Start suppor4ve care as needed: • IV fluid resuscitaIon • Electrolyte replacement If complete ileus: Add vancomycin retenIon enema 500 mg in 500 mL NS Q6H Treatment duraIon: 14 days CDI= Clostridium difficile InfecIon; H= hour(s); ID= InfecIous Diseases; IV= intravenous; NG= nasogastric; NS= normal saline; PO= by mouth; PPI= proton pump inhibitor; Q= every; SCr= Serum CreaInine; WBC= white blood cell * This recommendaIon is based on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole PAGE 4
Clostridium difficile Infec2on (CDI) Clostridium difficile Infec2on (CDI) (CDI)
Clostridium
difficile
Infection
RECURRENT EPISODES No. of Recurrences RECURRENT EPISODES Recommended Regimens No. of Recurrences 1st Recurrence Recommended Regimens Vancomycin* 125 mg PO Q6H for 10-­‐14 days 1stnd Recurrence 2 Recurrence Vancomycin* 125 mg PO Q6H for 10-­‐14 days Consult ID for tailoring anIbioIc therapy. Oral vancomycin tapered over 6 weeks and/or ulse dosing Consult ID for tpailoring anIbioIc therapy. Oral vancomycin tapered over 6 2nd Recurrence weeks and/or pulse Rdegimen: osing Vancomycin Taper 125 mg PO QT6H for R1egimen: 4 days Vancomycin aper 125 m
mg g P
PO O Q
Q6H 12H for 7 d
days ays 125 for 14 125 m
mg g P
PO O Q
once 7 days 125 12H dfaily or 7f or days 125 m
mg g P
PO O o
every ther day 8 days 125 nce doaily for 7 dfor ays 125 m
mg g P
PO O eevery very o
3 ther days dfay or f1or 5 d8ays 125 days 125 mg PO every 3 dFidaxomicin ays for 15 d2ays If Severe: Consider 00 mg PO Q12H (ID Restricted) ≥ 3 recurrences ≥ 3 recurrences If Severe: Consult ID Ctonsider eam Fidaxomicin 200 mg PO Q12H (ID Restricted) 2
•Consult Possible referral ID team for fecal microbiota replacement therapy 200 2m
Consider rreferral estarIng taper replacement OR Fidaxomicin •• Possible for vfancomycin ecal microbiota therapy
g PO Q12H 3,4 Restricted)
• (ID Consider restarIng vancomycin taper OR Fidaxomicin 200 mg PO Q12H (ID Restricted)3,4 RISK FACTORS FOR CDI RISK FACTORS FOR CDI • ≥ 64 years of age • Exposure to CDI (household family member with CDI) Exposure in previous 90 Long-­‐term care or nursing hm
ome resident •• ≥ 64 years to of aanIbioIcs ge •• Exposure to CDI f(acility household family ember with CDI) Gastric acid reducing agent (proton-­‐pump inhibitors) • days Exposure to anIbioIcs in previous 90 •• Long-­‐term care facility or nursing home resident • days HospitalizaIon in previous 30 days Tube feedings •• Gastric acid reducing agent (proton-­‐pump inhibitors) Recent GI surgery •• HospitalizaIon in previous 30 days • Tube feedings • Recent GI surgery INFECTION CONTROL INFECTION CONTROL RouIne screening for C. difficile in hospitalized paIents without diarrhea is not recommended AsymptomaIc carriers not treated paIents without diarrhea is not recommended RouIne screening for Cs. hould difficile in bhe ospitalized PaIents should cbarriers e placed in a p
oom or with other paIents who have CDI AsymptomaIc should nrivate ot be trreated IniIate csontact aIents posiIve with CDI u
48 hwours rom CrDI esoluIon of PaIents hould pbrecauIons e placed in faor pp
rivate room or with other pnIl aIents ho hfave • symptoms IniIate contact precauIons for paIents posiIve with CDI unIl 48 hours from resoluIon of • Place contact precauIons plus sign on paIent’s door symptoms Hand chontact ygiene parecauIons nd barrier pprecauIons and gowns) •• Place lus sign on (pgloves aIent’s door Place h
dygiene edicated stethoscope in paIent’s room and gowns) •• Hand and barrier precauIons (gloves • When aIent ddedicated ischarged or symptoms • pPlace stethoscope in presolve, aIent’s rroom oom should be terminally cleaned •
••
••
••
• When paIent discharged or symptoms resolve, room should be terminally cleaned MISCELLANEOUS
MISCELLANEOUS • Repeat CDI PCR tesIng not recommended due to the likelihood of false posiIves. Toxin A, B, and TC m
ay r
emain p
osiIve f
or a
s l
ong a
s 3
0 d
ays in to paIent with symptom • Repeat CDI PCR tesIng not recommended due the likelihood of false resoluIon. posiIves. Toxin A, B, and may remain piosiIve long as 30 dHays in paIent with symptom esoluIon. CDI= TC Clostridium difficile nfecIon; for GI= ags astrointesInal; = hour(s); ID= InfecIous Diseases; PrCR= Polymerase Chain ReacIon; PO= by mouth; Q= every; TC= Toxigenic Culture CDI= Clostridium difficile infecIon; GI= gastrointesInal; H= hour(s); ID= InfecIous Diseases; PCR= Polymerase Chain ReacIon; PO= by mouth; Q= every; Toxigenic Culture Use EvaluaIon which showed a higher rate of recurrence with metronidazole * This recommendaIon is TbC= ased on a MedicaIon * This recommendaIon is based on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole References: 1. Cohen, SH, et al. SHEA-­‐IDSA Clinical PracIce Guidelines for Clostridium difficile InfecIon in adults. ICHE. 2010 May; 31(5): References: 431-­‐55. 1.
SH, et eat l. aSl. HEA-­‐IDSA Clinical PracIce G
uidelines for Clostridium difficile InfecIon diifficile n adults. ICHE. 2010 2. Cohen, Surawicz CM, Guidelines for Diagnosis, Treatment, and PrevenIon of Clostridium InfecIons. Am M
J ay; 31(5): 431-­‐55. Gastroenterol 2013; 108:478–98. 2. Surawicz CM, et al. Guidelines for Diagnosis, Treatment, and PrevenIon of Clostridium difficile InfecIons. Am J 3. Kim PK, et al. Intracolonic Vancomycin for severe clostridium difficile coliIs. Surg Infect (Larchmt). 2013 Dec; 14(6):532-­‐9. 013; 108:478–98. 4. Gastroenterol Louie T, et al. F2idaxomicin versus Vancomycin for Clostridium difficile InfecIon. N Engl J Med. 2011 Feb 3;364(5):422-­‐31. 3.
PK, eOt A, al. eIt ntracolonic Vancomycin for severe cflostridium difficile oliIs. Surg Infect i(n Larchmt). 013 Dec; 14(6):532-­‐9. 5. Kim Cornely al. Fidaxomicin versus vancomycin or infecIon with Cclostridium difficile Europe, C2anada, and the USA: a 4. Louie T
, e
t a
l. F
idaxomicin v
ersus Vancomycin for Clostridium difficile InfecIon. N 1E2: ngl 2J81–9. Med. 2011 Feb 3;364(5):422-­‐31. double-­‐blind, non-­‐inferiority, randomised controlled trial. Lancet Infect Dis 2012; 5. Cornely OA, et al. Fidaxomicin versus vancomycin for infecIon with Clostridium difficile in Europe, Canada, and the USA: a double-­‐blind, non-­‐inferiority, randomised controlled trial. Lancet Infect Dis 2012; 12: 281–9. PAGE 5
Extended SpectrumBeta-Lactamase
Beta-Lactamase (ESBL)Infection
Extended
Extended
Spectrum Beta-Lactamase (ESBL)
(ESBL) Infection
Infection Spectrum
CLINICAL SYNDROME
CLINICAL SYNDROME
Extended Spectrum
Extended Spectrum
Beta-Lactamase (ESBL)
Beta-Lactamase (ESBL)
Infection
Infection
Carbapenem-resistant
Carbapenem-resistant
Enterobacteriaceae
Enterobacteriaceae
(CRE)
(CRE)
PREFERRED REGIMEN
PREFERRED REGIMEN
Meropenem 2 gm IV
Meropenem 2 gm IV
Q8H
Q8H
(Use maximum doses)
(Use maximum doses)
Consult ID
Consult ID
ALTERNATIVE REGIMEN
ALTERNATIVE REGIMEN
Consult ID
Consult ID
Consult ID
Consult ID
CLINICAL CONSIDERATIONS
CLINICAL CONSIDERATIONS
Please DO NOT treat
Please DO NOT treat
colonization, or a “dirty
colonization, or a “dirty
urine” sample
urine” sample
Febrile
FebrileNeutropenia
Neutropenia
Febrile
Neutropenia
CLINICAL SYNDROME
CLINICAL SYNDROME
Febrile Neutropenia
Febrile Neutropenia
High risk: anticipated
High risk: anticipated
prolonged
prolonged
(>7 days duration)
(>7 days duration)
AND
AND
profound neutropenia
profound neutropenia
(ANC ≤100 cells/mm33
(ANC ≤100 cells/mm
following cytotoxic
following cytotoxic
chemotherapy) +/chemotherapy) +/significant co-morbid
significant co-morbid
conditions:
conditions:
hypotension,
hypotension,
pneumonia, new-onset
pneumonia, new-onset
abdominal pain, or
abdominal pain, or
neurologic changes
neurologic changes
PREFERRED REGIMEN
PREFERRED REGIMEN
Cefepime 2gm IV Q8H
Cefepime 2gm IV Q8H
OR
OR
Piperacillin/tazobactam
Piperacillin/tazobactam
3.375gm IV Q4H
3.375gm IV Q4H
(18gm/day)
(18gm/day)
ALTERNATIVE REGIMEN
ALTERNATIVE REGIMEN
Meropenem 1 gm IV
Meropenem 1 gm IV
Q8H
Q8H
CLINICAL CONSIDERATIONS
CLINICAL CONSIDERATIONS
If patient has indwelling
If patient has indwelling
catheter, is persistently
catheter, is persistently
febrile
febrile
OR
OR
previously colonized
previously colonized
with MRSA:
with MRSA:
ADD vancomycin
ADD vancomycin
Consult ID for
Consult ID for
Anti-fungal therapy;
Anti-fungal therapy;
Consider when fever
Consider when fever
fails to respond after
fails to respond after
3-7 days of therapy
3-7 days of therapy
ANC= Absolute neutrophil count; CRE= Extended Spectrum Beta-Lactamase; ESBL= Extended Spectrum Beta-Lactamase;
ANC=
Absolute
count; CRE=
Spectrum
ESBL=S.Extended
Spectrum
H= hour(s);
ID= neutrophil
Infectious Diseases;
IV= Extended
intravenous;
MRSA=Beta-Lactamase;
Methicillin-Resistant
aureus; Q=
every Beta-Lactamase;
H= hour(s); ID= Infectious Diseases; IV= intravenous; MRSA= Methicillin-Resistant S. aureus; Q= every
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
NOTE:
Dosing
on normal
renal
function. Refer
to Table
of Contents
for section
Antimicrobial
Dosing
for Adult
Patients
Basedbased
on Renal
Function,
Aminoglycoside
High
Dose Once
Daily (HDOD)
and on
Monitoring
in Adult
Patients,
and
Patients
Based
on Renal
Function, Aminoglycoside
High Dose Once Daily (HDOD) and Monitoring in Adult Patients, and
Vancomycin
Dosing
and Monitoring
in Adult Patients.
Vancomycin Dosing and Monitoring in Adult Patients.
PAGE 6
Fungal
Infections
Fungal
Infections
Fungal
Infections
CONDITION
CONDITION
Candidemia
Candidemia
Non-neutropenic
Non-neutropenic
Candidemia
Candidemia
Neutropenic
Neutropenic
Urinary
Urinary
Candidiasis
Candidiasis
Symptomatic
Symptomatic
Cystitis
Cystitis
Urinary
Urinary
Candidiasis
Candidiasis
Pyelonephritis
Pyelonephritis
PRIMARY THERAPY
PRIMARY THERAPY
Caspofungin IV
Caspofungin
LD: 70 mg IV
LD: 70
MD:
50mg
mg Q24H
MD: 50 mg Q24H
OR
OR
Fluconazole IV
Fluconazole
LD: 800 mg IV
LD:
800 mg
(12mg/kg)
(12mg/kg)
MD:
400 mg
MD:
400 mg
6
mg/kg)
Q24H
6 mg/kg) Q24H
ALTERNATIVE THERAPY
ALTERNATIVE THERAPY
L-AmB 3–5 mg/kg IV
L-AmB
Q24H 3–5 mg/kg IV
Q24H
OR
OR
Voriconazole
IV/PO
Voriconazole
IV/PO
400 mg
400
mg Q12H for
(6 mg/kg)
(6
mg/kg)
Q12H
2 doses
then
200for
mg
2 doses
then
200 mg
(3
mg/kg)
Q12H
(3 mg/kg) Q12H
DURATION
DURATION
14 days after
14
days
after
first negative
first negative
culture
result
culture result
AND
AND
resolution of
resolution
of
signs/symptoms
signs/symptoms
COMMENTS
COMMENTS
Remove all IV
Remove
allifIV
catheters,
catheters, if
possible
possible
Consult ID
Consult ID
Consider eye
Consider
eye
exam
exam
Transition to
Transition
fluconazoletois
fluconazole is for
recommended
recommended
clinically
stable for
clinically
stable
patients with
patients
with
fluconazole
fluconazole
susceptible
susceptible
isolates
AND
isolates
negativeAND
repeat
negative
repeat
blood cultures
blood cultures
Caspofungin IV
Fluconazole IV
14 days after
Fluconazole is
Caspofungin
Fluconazole
IV mg/kg) 14
after
Fluconazole
LD: 70 mg IV
LD: 800 mg (12
firstdays
negative
preferred in is
LD:
LD:
mg/kg) first
negative
preferred
in
MD:70
50mg
mg Q24H
MD:800
400mg
mg(12
(6 mg/kg)
culture
result
patients without
MD:
MD:
patients
without
OR 50 mg Q24H
Q24H400 mg (6 mg/kg) culture
AND result
recent azole
OR
Q24H
AND
recent azole
L-AmB
OR
resolution
of
exposure
AND
L-AmB
OR
resolution of
exposure
AND
3–5
mg/kg IV Q24H Voriconazole
IV/PO
signs/symptoms
who
are NOT
3–5 mg/kg IV Q24H Voriconazole
IV/PO
signs/symptoms
are NOT
400 mg (6 mg/kg)
and neutropenia who
critically
ill.
400
mgfor(62mg/kg)
Q12H
doses then and neutropenia critically ill.
Remove IV
Q12H
doses then
200
mgfor(32mg/kg)
Remove IVif
catheters,
200 mg (3 mg/kg)
Q12H
catheters, if
possible
Q12H
possible
Consult ID
Consult ID
Consider eye
Consider
eye
exam
exam
Fluconazole
Conventional
Fluconazole:
Alternative
Fluconazole
Conventional B
Fluconazole:
Alternativeis
200
mg (3 mg/kg)
Amphotericin
14
days
treatment
200
mg (3 mg/kg)
Amphotericin
days
is for
PO Q24H
0.3–0.6 mg/kgBIV Q24H 14
Amphotericin
B: treatment
recommended
PO Q24H
0.3–0.6 mg/kg IV Q24H Amphotericin
B: recommended
for
1-7 days
fluconazole
1-7 days
fluconazole
resistant
resistant
organisms
organisms
Fluconazole
Conventional
Fluconazole:
Alternative
Fluconazole
Conventional
Fluconazole:
Alternative
200–400 mg (3–6
Amphotericin B
14 days
treatment is
200–400
mg
(3–6
Amphotericin
days
is for
mg/kg) PO
Q24H
0.5–0.7 mg/kgBIV Q24H 14
Amphotericin
B: treatment
recommended
mg/kg) PO Q24H
0.5–0.7 mg/kg IV Q24H 14
Amphotericin
B: fluconazole
recommended for
days
14 days
fluconazole
resistant
resistant
organisms
organisms
H= hour(s); ID= Infectious Diseases; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance
H= hour(s);
ID=
Infectious
Diseases; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance
dose;
PO= by
mouth;
Q= every
dose; PO= by mouth; Q= every
NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents
NOTE:
Some
will require
ID consult/approval
for
section
onagents
Guidelines
for Restricted
Antibiotics (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents
for section on Guidelines for Restricted Antibiotics
References:
1.
Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America.
References:
Clin
Infect
2016;
62(4):e1-e50.
1.
Pappas
PG,Dis.
et al.
Clinical
Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America.
Clin Infect Dis. 2016; 62(4):e1-e50.
PAGE 7
Fungal Infections
Fungal
CONDITION Infections
PRIMARY THERAPY
ALTERNATIVE THERAPY
Fungal
Infections
Nongenital
CONDITION
Oropharyngeal
(Oral
Thrush)
Nongenital
Oropharyngeal
(Oral Thrush)
Esophageal
Candidiasis
Esophageal
Candidiasis
Clotrimazole 10 mg
PRIMARY
THERAPY
troche
5 times
daily
OR
Clotrimazole
10 mg
Nystatin5 suspension
troche
times daily
PO
OR four times a day
OR
Nystatin suspension
Fluconazole
PO four times a day
100–200
mg
OR
PO
once daily
Fluconazole
Fluconazole
100–200 mg
200–400
mg
PO once daily
(3–6
mg/kg)
Fluconazole
PO
Q24H mg
200–400
(3–6 mg/kg)
PO Q24H
Itraconazole oral
ALTERNATIVE THERAPY
solution
200
mg PO once
Itraconazole
oral daily
OR
solution
Voriconazole
200daily
mg
200 mg PO once
PO
OR Q12H
Voriconazole 200 mg
PO Q12H
Caspofungin IV
LD: 70 mg
MD:
50 mg Q24H
Caspofungin
IV
OR
LD: 70 mg
Conventional
MD: 50 mg Q24H
Amphotericin
B
OR
0.3–0.7
mg/kg IV
Conventional
Q24H
Amphotericin B
0.3–0.7 mg/kg IV
General Susceptibility Patterns of Candida
spp.
Q24H
General Susceptibility
Patterns ofItraconazole
Candida spp.
Fluconazole
Candida
albicans
Candida
C. tropicalis
albicans
C.
C. tropicalis
parapsilosis
C.
C. glabrata
parapsilosis
C. krusei
C. glabrata
C. lusitaniae
C. krusei
Amphotericin
B
Amphotericin
S
B
DURATION
Uncomplicated
DURATION
disease
7 to 14
days
Uncomplicated
disease 7 to 14
days
14–21 days
14–21 days
COMMENTS
Refractory
COMMENTS
disease:
Voriconazole
Refractory
200
mg PO Q12H
disease:
OR
Voriconazole
L-AmB
200 mg PO Q12H
suspension
1 mL
OR
of
100 mg/mL
L-AmB
four
times a1day
suspension
mL
Patients
unable
of 100 mg/mL
to
tolerate
oral
four
times aanday
agent,
PatientsIVunable
fluconazole
ororal
to tolerate an
alternative
agent, IV agent
listed
may be
fluconazole
or
used.
alternative agent
listed may be
used.
Caspofungin
Voriconazole
S
Caspofungin
S
Voriconazole
S
Fluconazole
S
Itraconazole
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S
S-DD
S
S-DD to R
S
S-I
S
S
S
S-DD to R
R
S-DD
S
R
S-DD to R
S-DD to R
S
S-DD to R
S-I
S-I
S to R
S-I
S
S
S
S
S
S-DD to R
S
S
H= hour(s); I= Intermediate; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose;
C.
lusitaniae
S S-DD= Susceptibility
S to Ris dose dependent; Sspp= species
PO=
by mouth; Q= every; R=SResistant; S= susceptible;
S
H=
hour(s);
Intermediate;
IV= intravenous;
L-AmB= (amphotericin
Liposomal Amphotericin
B; LD=voriconazole).
loading dose; MD=
dose;
NOTE:
SomeI=agents
will require
ID consult/approval
B, caspofungin,
Refermaintenance
to Table of Contents
PO=
by mouth;
Q= every; R=
susceptible; S-DD= Susceptibility is dose dependent; spp= species
for section
on Guidelines
forResistant;
RestrictedS=Antibiotics
NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents
for section on Guidelines for Restricted Antibiotics
References:
1.
Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of
America. Clin Infect Dis. 2016; 62(4):e1-e50.
References:
1.
Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases SocietyPAGE
of
America. Clin Infect Dis. 2016; 62(4):e1-e50.
8
Influenza A and B (Flu)
Influenza
A and
(Flu)B
Influenza
A Band
(Flu)
CLINICAL AND THERAPEUTIC ALGORITHM
CLINICAL AND THERAPEUTIC ALGORITHM
CLINICAL SEVERITY
CLINICAL SEVERITY
RECOMMENDED REGIMENS
RECOMMENDED REGIMENS
Diagnosis is based on the clinical presentation
Diagnosis
is based
on the of
clinical
presentation
of
the patient
and results
RT-PCR.
of the patient and results of RT-PCR.
Decision to initiate treatment should NOT wait
Decision
to initiate
for
confirmation
of treatment
laboratory should
results.NOT wait
for confirmation of laboratory results.
Continue the full course of treatment
Continue
the full
course of
treatment
if
first RT-PCR
is negative
and
if signs and
if
first RT-PCR
is negative
anddue
if signs
and
symptoms
indicate
influenza
to possibility
symptoms
indicate influenza due to possibility
of
false negative.
of false negative.
History of influenza vaccination does not
History
influenzawhen
vaccination
does
not
precludeofinfluenza
signs and
symptoms
preclude
influenza
signs and
symptoms
are compatible
withwhen
the clinical
syndrome.
are compatible with the clinical syndrome.
Zanamivir use is not recommended in people
Zanamivir
use is respiratory
not recommended
with
underlying
disease in people
with
underlying
respiratory disease
(e.g. asthma,
COPD.)
(e.g. asthma, COPD.)
Treatment Population:
Treatment Population:
High risk adults (any of the following):
riskyears
adults (any of the following):
•High≥65
• ≥65
years
Chronic
health conditions*
Chronic health conditions*
• Immunosuppression,
including caused by
• medication
Immunosuppression,
including caused by
or HIV infection
medication
HIV infection
• Pregnant
oror
postpartum
(within 2 weeks of
• Pregnant
or postpartum (within 2 weeks of
delivery) women
delivery) women
• American
Indian/Alaska Natives
American
• Body
massIndian/Alaska
index ≥40 Natives
Body massofindex
≥40homes and other
• Residents
nursing
• Residents
of nursing
chronic-care
facilitieshomes and other
chronic-care facilities
Previously healthy, symptomatic outpatient
Previously
symptomatic outpatient
NOT
at highhealthy,
risk
NOT at 48
high
risk of symptom onset)
(within
hours
(within 48 hours of symptom onset)
Hospitalized patients CDC Flu health advisory
2 Treatment
Hospitalized
patients
CDC Flu
health
advisory
February
2016:
may
also be
February 2016:
Treatment
may
also
be after
beneficial
when2 started
up to
4 to
5 days
beneficial onset
when in
started
up to 4patients.
to 5 days after
symptom
hospitalized
symptom onset in hospitalized patients.
Outpatient High Risk
Outpatient
High Risk
(see
left panel)
(see left panel)
Previously Healthy
Previously Healthy
Select ONE of the
Select ONE of the
following:
following:
• Oseltamivir 75 mg PO
• Q12H
Oseltamivir 75 mg PO
Q12H
• Zanamivir 10 mg
• (two
Zanamivir
10 mg
5 mg inhalations)
(two
Q12H5 mg inhalations)
Q12H
Treat for 5 days ONLY if
Treat for 5 can
daysbeONLY if
treatment
treatment
can be
initiated
within
48 hours
initiated
of illness within
onset. 48 hours
of illness onset.
• Oseltamivir 75 mg PO
• or
Oseltamivir
enterally- 75 mg PO
or
enterally- Q12H
administered
administered Q12H
Treat for 5 days. If illness
Treat
for or
5 days.
If illness
is
severe
prolonged,
is
severe
or prolonged,
may
extend
duration
may extend
duration
based
on clinical
based on clinical
judgment.
judgment.
• Oseltamivir 75 mg PO
• or
Oseltamivir
enterally- 75 mg PO
or enterally- Q12H
administered
administered Q12H
Treat for 5 days.
Treat for 5 days.
Select ONE of the
Select ONE of the
following:
following:
• Oseltamivir 75 mg PO
• Oseltamivir
once daily 75 mg PO
once daily 10 mg (two
• Zanamivir
• 5
Zanamivir
10 mg (two
mg inhalations)
once
5 mg inhalations) once
daily
daily
Treat for 10 days**
Treat for 10 days**
Inpatient High Risk
Inpatient
High Risk
(see
left panel)
(see left panel)
Inpatient
Inpatient
Post-Exposure
Post-Exposure
Chemoprophylaxis
Chemoprophylaxis
• High risk
• (see
Highleft
riskpanel)
(see left panel)
CDC= Centers for Disease Control and Prevention; COPD= chronic obstructive pulmonary disease; H= Hour(s); HIV= human
immunodeficiency
virus; PO=
by mouth;
Q= every;COPD=
RT-PCR=
reverse
transcriptase
polymerase
chain
CDC= Centers for Disease
Control
and Prevention;
chronic
obstructive
pulmonary
disease;
H=reaction
Hour(s); HIV= human
immunodeficiency virus; PO= by mouth; Q= every; RT-PCR= reverse transcriptase polymerase chain reaction
*Chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including
sickle
cellpulmonary
disease), metabolic
diabetes
mellitus),
neurologic
conditions
(disorders
of the brain, (including
spinal cord,
*Chronic
(includingdisorders
asthma),(including
cardiovascular
(except
hypertension
alone),
renal, hepatic,
hematological
nerve,
muscle,
epilepsy,
stroke,
or intellectual
disability)
sickle cell
disease),
metabolic
disorders
(including
diabetes mellitus), neurologic conditions (disorders of the brain, spinal cord,
nerve, muscle, epilepsy, stroke, or intellectual disability)
**After most recent known exposure to a close contact known to have influenza.
**After most recent known exposure to a close contact known to have influenza.
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients
Based
Renalbased
Function
NOTE: on
Dosing
on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients
Based on Renal Function
References:
1.
Centers for Disease Control and Prevention. CMV home. Cytomegalovirus (CMV) and Congenital CMV infection Web site.
References:
http://www.cdc.gov/cmv/clinical/features.html.
Published
6 Dec 2016. Updated
2010.
6 March
2016. Web site.
1. Centers for Disease Control and Prevention. CMV
home. Cytomegalovirus
(CMV)
andAccessed
Congenital
CMV infection
2.
Department of Health and Human Services. FluPublished
season begins:
influenza2010.
illness
reported.
Centers
for Disease Control
http://www.cdc.gov/cmv/clinical/features.html.
6 Dec Severe
2016. Updated
Accessed
6 March
2016.
and
Prevention:ofEmergency
and Flu
Response
site.Severe
http://emergency.cdc.gov/han/han00387.asp.
Published
1
2. Department
Health andPreparedness
Human Services.
season Web
begins:
influenza illness reported. Centers for Disease
Control
Feb
2016.
Updated
2016.
Accessed
12
March
2016
.
and Prevention: Emergency Preparedness and Response Web site. http://emergency.cdc.gov/han/han00387.asp. Published 1
Feb 2016. Updated 2016. Accessed 12 March 2016.
PAGE 9
Intra-abdominal
Infections
Intra-abdominal
Infections
CLINICAL SYNDROME
Intra-abdominal
Infections
Community acquired
OR
Hospital acquired
PREFERRED REGIMEN
ALTERNATIVE REGIMEN
CLINICAL CONSIDERATIONS
Piperacillin/tazobactam
3.375 gm IV Q6H
Ciprofloxacin 400 mg IV
Q12H
+/- Metronidazole
500 mg IV Q8H
Piperacillin/tazobactam
provides excellent
anaerobic coverage,
addition of clindamycin
OR metronidazole is
NOT indicated or
necessary
Meropenem 1gm Q8H
Lyme
Disease
Lyme
Disease
CLINICAL SYNDROME
Lyme Disease
Early disease
Late disease with
central OR peripheral
nervous system disease
PREFERRED REGIMEN
Doxycycline 100 mg PO
Q12H*
OR
Amoxicillin 500 mg PO
Q8H*
OR
Cefuroxime 500 mg PO
Q12H*
ALTERNATIVE REGIMEN
Consult ID
Consult ID
CLINICAL CONSIDERATIONS
Relapse may occur with
any regimen; patients
with objective
signs/symptoms may
need a second course
Duration of Treatment:
Doxycycline 10-21 days
Amoxicillin/Cefuroxime
14-21 days
Lyme antibody testing
can be negative in first
6 weeks
Consider co-infection
with anaplasma or
babesia
H= hour(s); ID= Infectious Diseases; IV= intravenous; PO= By Mouth; Q= every
*Doxycycline also has activity against Ehrlichia and Anaplasma. Amoxicillin and cefuroxime do not.
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function, Aminoglycoside High Dose Once Daily (HDOD) and Monitoring in Adult Patients, and
Vancomycin Dosing and Monitoring in Adult Patients.
PAGE 10
Proton-Pump Inhibitor (PPI) Use
Proton-Pump
Inhibitor
Proton-Pump
Inhibitor
(PPI) Use(PPI)
Use
The FDA has issued multiple warnings on the long-term use of PPIs. These include: increased risk
1, hypomagnesemia2, and fractures of the hip, wrist, and spine3. Therefore,
of C.FDA
difficile
infection
The
has issued
multiple
warnings on the long-term use of PPIs. These include: increased risk
prudent
prescribing
of
is warranted. The
FDA
recommends
use of
the and
lowest
dose
and
1
2, and
3. Therefore,
of C. difficile infection ,PPIs
hypomagnesemia
fractures
of the hip,
wrist,
spine
1-3. Patient
shortest prescribing
duration of of
PPIPPIs
therapy
appropriate
condition being
treated
prudent
is warranted.
Thefor
FDAthe
recommends
use of
the lowest
dose and
compliance,
time of
(prior to meals),
dietary
indiscretions
alcohol or
shortest
duration
of administration
PPI therapy appropriate
for the and
condition
being
treated1-3(i.e.
. Patient
irritating foods)
be assessed (prior
prior to
of PPI
doses.
compliance,
timeshould
of administration
to titration
meals), and
dietary
indiscretions (i.e. alcohol or
irritating foods) should be assessed prior to titration of PPI doses.
Indication
Indication
Gastroesophageal reflux disease
6
(GERD)
Gastroesophageal reflux disease
6
(GERD)
Symptomatic relief
Symptomatic
Acute healingrelief
of erosive or ulcerative
esophagitis
Acute
healing of erosive or ulcerative
esophagitis
Maintenance healing of erosive or
ulcerative esophagitis
Maintenance
healing of erosive or
ulcerative
esophagitis
Stress ulcer
prophylaxis should be
used
for
critically
ill patients
withbe
Stress ulcer prophylaxis
should
4,5:
increased
risk of bleeding
including
used
for critically
ill patients
with
- Coagulopathy
(plateletincluding
count 4,5:
increased
risk of bleeding
<50,000 mm3, (platelet
INR >1.5,count
or aPTT
- Coagulopathy
>2x control)
<50,000
mm3, INR >1.5, or aPTT
- >2x
Mechanical
control)ventilation for >48
hours
- Mechanical
ventilation for >48
- hours
Traumatic, severe thermal or
spinal cord severe
injury thermal or
- Traumatic,
- spinal
Historycord
of GIinjury
ulceration or
bleedingofwithin
past year
- History
GI ulceration
or
Twobleeding
or morewithin
minorpast
risk factors:
year
- Sepsis,
ICUminor
stay ≥1
occult GI
Two
or more
riskweek,
factors:
bleeding
≥6stay
days,
- Sepsis,
ICU
≥1glucocorticoid
week, occult GI
therapy (>250
mgglucocorticoid
hydrocortisone
bleeding
≥6 days,
equivalent)
therapy
(>250 mg hydrocortisone
Treatment
Duration
Treatment
Duration
Initial 8 week course for symptom
relief
or
esophagitis
Initial 8 week course for symptom
Omeprazole 20 mg PO
once daily 20 mg PO
Omeprazole
OR daily
once
Pantoprazole 40mg PO
OR
once daily 40mg PO
Pantoprazole
once daily
relief
or esophagitis
Maintenance
therapy determined
by
response
severity
of
Maintenanceand
therapy
determined
disease
by
response and severity of
disease
Consider dose titration, or
intermittent
Consider
dosetherapy
titration, or
intermittent therapy
Transition to PO when possible
Transition
to PO
when possible
Continue until
resolution
of
underlyinguntil
riskresolution
factors and/or
Continue
of
critical illness
underlying
risk factors and/or
Omeprazole
10-20 mg IV/PO once
Omeprazole
daily mg IV/PO once
10-20
OR
daily
Pantoprazole 40mg
OR
IV/PO once daily
Pantoprazole
40mg
IV/PO once daily
critical illness
equivalent)
aPTT=
activated partial thromboplastin time; GERD= Gastroesophageal reflux disease; GI= Gastrointestinal; ICU= intensive care
unit; INR= International normalized ratio; IV= intravenous; PO= by mouth; PPI= proton pump inhibitor
aPTT= activated partial thromboplastin time; GERD= Gastroesophageal reflux disease; GI= Gastrointestinal; ICU= intensive care
unit; INR= International normalized ratio; IV= intravenous; PO= by mouth; PPI= proton pump inhibitor
References
1. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be
References
associated with stomach acid drugs known as proton pump inhibitors (PPIs) [internet]. Updated May 2012 [cited
1. U.S.
Food and
Drug Administration
(FDA). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be
11/21/12].
Available
from: http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm
associated
withDrug
stomach
acid drugs(FDA).
knownFDA
as proton
pumpCommunication:
inhibitors (PPIs) Low
[internet].
Updated
May
2012
[cited
2. U.S. Food and
Administration
Drug Safety
magnesium
levels
can
be associated
with
11/21/12].
Available
from:
http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm
long-term use
of Proton
Pump
Inhibitor drugs (PPIs) [internet]. Updated February 2012 [cited 11/21/12]. Available from:
2. U.S.
Food and Drug Administration (FDA). FDA Drug Safety Communication: Low magnesium levels can be associated with
http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm.
use of
Proton
Pump Inhibitor
drugs
[internet].
Updated February
2012
[cited 11/21/12].
Available
from:
3. long-term
U.S. Food and
Drug
Administration
(FDA).
FDA (PPIs)
Drug Safety
Communication:
Possible
increased
risk of fractures
of the
hip,
http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm.
wrist, and spine with the use of proton pump inhibitors [internet]. Updated March 2011 [cited 11/21/12]. Available from:
3. U.S.
Food
and
Drug
Administration
(FDA).
FDA
Drug
Safety
Communication:
Possible
increased
risk
of
fractures
of
the
hip,
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm
and spine with
the use of
inhibitors [internet].
Updated March
2011 [citedand
11/21/12].
from:
4. wrist,
ASHP Therapeutic
Guidelines
onproton
Stress pump
Ulcer Prophylaxis.
ASHP Commission
on Therapeutics
approvedAvailable
by the ASHP
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm
Board of Directors on November 14, 1998. Am J Health Syst Pharm 1999; 56:347.
4.
ASHP
Therapeutic
Guidelines
on
Stress
Ulcer
Prophylaxis.
ASHP
Commission
on
Therapeutics
and
approved
by
the
ASHP
5. Spirt MJ, Stanley S. Update on stress ulcer prophylaxis in critically ill patients. Crit Care Nurse 2006; 26:18.
of Gerson
Directors
November
14, 1998.
Syst
Pharm
1999; 56:347.
6. Board
Katz PO,
LB,onVela
MF. Guidelines
forAm
theJ Health
diagnosis
and
management
of gastroesophageal reflux disease. Am J
5. Spirt
MJ, Stanley
S. Update on stress ulcer prophylaxis in critically ill patients. Crit Care Nurse 2006; 26:18.
Gastroenterol
2013;108:308-28.
6. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J
Gastroenterol 2013;108:308-28.
PAGE 11
Respiratory Tract: Acute Bacterial Sinusitis
Respiratory
Tract:
Acute
Bacterial
Sinusitis
Respiratory
Tract:
Acute
Bacterial
Sinusitis
CLINICAL AND THERAPEUTIC
RISK FACTORS
ALGORITHM
CLINICAL AND THERAPEUTIC
RISK FACTORS
1a. Antibiotics
are indicated if the Presence of Risk
ALGORITHM
patient has ANY of the
Factors for
1a. following:
Antibiotics are indicated if the Presence
Antibioticof Risk
patient
has ANY
of the≥ 10
Factors
for
• Symptoms
lasting
Resistance:
following:
Antibiotic
days without clinical
• Age > 65
• Symptoms
lasting ≥ 10
Resistance:
improvement
• Antibiotics
• Age
> 65
ORdays without clinical
within
last 30
• Antibiotics
• improvement
Severe symptoms at onset
days
OR lasting
last 30
• within
Hospitalization
• Severe
symptoms
onset
days
within last 5
≥ 3 days
[Fever (≥ at
102
°F),
lasting facial pain, or
• Hospitalization
severe
days
last 5
≥ 3 days discharge]
[Fever (≥ 102 °F),
purulent
• within
Immunosevere
facial
pain,
or
days
OR
compromised
discharge]
•ORImmuno• purulent
New onset
fever, severe
OR headache, or increase
• compromised
Fever > 102°F
• New
fever,after
severe
ORwith signs of
nasalonset
discharge
5-6
headache,
or increase
• Fever
> 102°F
days following
initial
systemic
illness
nasal
discharge after 5-6
with signs of
improvement
None
of the illness
above
days following initial
systemic
1b. If the
patient does not meet
risk factors for
improvement
None
of the above
this criteria likely viral and
antibiotic
1b. self-limiting.
If the patientMay
doesprovide
not meet
risk
factors for
resistance
this
criteria
likely viral and
antibiotic
symptom
relief.
AND
Maysymptoms:
provide
resistance
•self-limiting.
Reduce nasal
symptom
relief.
topical or nasal
No fever or signs of
AND
• Reduce
nasal symptoms:
decongestants,
intranasal
systemic illness
topical
or nasal intranasal
No fever or signs of
corticosteroids,
decongestants,
intranasal
systemic illness
saline
corticosteroids, intranasal
2. If nosaline
improvement after 3 to 5
days of antibiotic therapy
2. switch
If no improvement
afteragent
3 to 5
to an alternative
days
of
antibiotic
therapy
from a different antibiotic class
switch to an alternative agent
CrCl= creatinine clearance; H= hour(s); PO= by mouth; Q= every
from a different antibiotic class
RECOMMENDED REGIMENS
RECOMMENDED REGIMENS
Initial Empiric Antibiotic Therapy:
Amoxicillin/clavulanate
Initial
Empiric AntibioticPO:
Therapy:
‡
CrCl > 30 ml/min: 2000/125
Amoxicillin/clavulanate
PO: mg
Q12H
‡
CrCl
2000/125
mgmg
CrCl >1030– ml/min:
29 ml/min:
875/125
Q12H
Q12H
CrCl
– 29
ml/min:
875/125
mg
‡ mg
CrCl 10
< 10
ml/min:
2000/125
Q12H
Q24H
CrCl
< 10 ml/min: 2000/125‡ mg
Alternatives*:
Q24H
Moxifloxacin 400 mg PO Q24H
Alternatives*:
Treat for 7 to400
10 days
Moxifloxacin
mg PO Q24H
Treat for 7 to 10 days
No risk for Antibiotic Resistance:
Amoxicillin/clavulanate
PO:
No
risk for Antibiotic Resistance:
CrCl > 30 ml/min: 875/125
Amoxicillin/clavulanate
PO: mg Q12H
CrCl 10–29 ml/min: 500/125 mg
CrCl
Q12H> 30 ml/min: 875/125 mg Q12H
CrCl
ml/min:
500/125
CrCl 10–29
< 10 ml/min:
875/125
mgmg
Q24H
Q12H
Alternatives*:
CrCl
< 10 ml/min:
875/125
mg Q24H
Doxycycline
100 mg
PO Q12H
Alternatives*:
OR
Doxycycline
Moxifloxacin100
400mg
mgPO
POQ12H
Q24H
OR
Treat for 5 to400
7 days
Moxifloxacin
mg PO Q24H
Treat for 5 to 7 days
‡ Pharmacy does not carry amoxicillin/clavulanate 2000/125 mg tablets. Order 875/125 mg tablets of amoxicillin/clavulanate
CrCl= creatinine clearance; H= hour(s); PO= by mouth; Q= every
AND 1000 mg tablets of amoxicillin
amoxicillin/clavulanate
= 1,875/125 mg per dose).
‡(total
Pharmacy
does not carry amoxicillin/clavulanate
2000/125 mg tablets. Order 875/125 mg tablets of amoxicillin/clavulanate
AND 1000 mg tablets of amoxicillin
*Macrolides,
trimethoprim-sulfamethoxazole,
anddose).
2nd or 3rd generation cephalosporins are not recommended due to
(total
amoxicillin/clavulanate
= 1,875/125 mg per
increasing rates of antimicrobial resistance.
*Macrolides, trimethoprim-sulfamethoxazole, and 2nd or 3rd generation cephalosporins are not recommended due to
increasing rates of antimicrobial resistance.
References:
1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and
adults. Clin Infect Dis. 2012; 54:e72.
References:
1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and
PAGE 12
adults. Clin Infect Dis. 2012; 54:e72.
Respiratory Tract: Acute Pharyngitis
Respiratory
Tract:
Acute
Pharyngitis
Respiratory
Tract:
Acute
Pharyngitis
QUICK FACTS1-2:
•QUICK
OnlyFACTS
5-15%1-2of: adult cases of acute pharyngitis are caused by Group A β-hemolytic
(GAS).
• streptococci
Only 5-15% of
adult cases of acute pharyngitis are caused by Group A β-hemolytic
• It
is estimated
that 3,000 to 4,000 patients with GAS must be treated for every 1
streptococci
(GAS).
of acute rheumatic
prevented.
• case
It is estimated
that 3,000fever
to 4,000
patients with GAS must be treated for every 1
• Antibiotic
therapy
of GASfever
hastens
resolution by 1-2 days if initiated within 2-3 days
case of acute
rheumatic
prevented.
symptom
onset.of GAS hastens resolution by 1-2 days if initiated within 2-3 days
• of
Antibiotic
therapy
of symptom onset.
CLINICAL
CLASSIFICATION
CLINICAL PRESENTATION
RECOMMENDED REGIMENS
CLASSIFICATION
Group A
β-hemolytic
Group A
streptococcus
β-hemolytic
(GAS)
streptococcus
(GAS)
CLINICAL PRESENTATION
≥ 2 of the following:
• Fever (≥ 100.4°)
≥ 2 of the following:
• Tonsillar exudates
• Fever (≥ 100.4°)
• No cough
• Tonsillar exudates
• Tender anterior
• No cough
cervical
• Tender anterior
lymphadenopathy
cervical
(lymphadenitis)
lymphadenopathy
• Scarlatiniform rash
(lymphadenitis)
• Scarlatiniform rash
RECOMMENDED REGIMENS
Amoxicillin 500 mg PO
Q12H
Amoxicillin 500 mg PO
OR
Q12H
Penicillin VK 250 mg Q6H
OR
OR
Penicillin VK 250 mg Q6H
500 mg PO Q12H
OR
500 10
mgdays
PO Q12H
For
Viral Pharyngitis
•
•
•
•
•
•
•
•
•
•
•
•
•
For 10 days
Penicillin
Allergy
Non-anaphylactic allergy:
Penicillin Allergy
Cephalexin 500 mg PO
Non-anaphylactic allergy:
Q12H x 10 days
Cephalexin 500 mg PO
OR
Q12H x 10 days
Clindamycin 300 mg PO
OR
Q6H for 10 days
Clindamycin 300 mg PO
OR
Q6H for 10 days
Azithromycin 500 mg PO x
OR
1 day, then 250 mg PO
Azithromycin 500 mg PO x
Q24H x 4 days
1 day, then 250 mg PO
Q24H x 4 days
Supportive
treatment
(antipyretic OR analgesic)
Supportive treatment
(antipyretic OR analgesic)
CONSIDERATIONS
CLINICAL
CONSIDERATIONS
Clinical
suspicion
for GAS:
Clinical suspicion
Obtain throat swab
for GAS:
OR order GAS rapid
Obtain throat swab
antigen detection
OR order GAS rapid
test (RADT)*
antigen detection
test
(RADT)*
If
culture
is
negative:
If culture is
No antibiotics AND
negative:
consider supportive
No antibiotics AND
treatment
consider supportive
(antipyretic OR
treatment
analgesic)
(antipyretic OR
analgesic)
Conjunctivitis
Coryza
Conjunctivitis
Cough
Coryza
Diarrhea
Cough
Hoarseness
Diarrhea
Discrete ulcerative
Hoarseness
stomatitis
Discrete ulcerative
Viral exanthema
stomatitis
GAS= Group A β-hemolytic Streptococci;
H= hour(s); PO= by mouth; Q= every; RADT= Rapid antigen detection test
• Viral exanthema
Viral Pharyngitis
GAS= Group
β-hemolytic
Streptococci;
hour(s);
PO= by70-90%,
mouth; specificity
Q= every; 95%
RADT= Rapid antigen detection test
*Throat
swabAculture
sensitivity:
90-95%;H=
RADT:
sensitivity
*Throat swab culture sensitivity: 90-95%; RADT: sensitivity 70-90%, specificity 95%
References:
1. Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A
References:
Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society America. Clin Infect Dis. 2012 Nov 15;55(10):12791. 82.
Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A
Streptococcal
Pharyngitis:
2012
Update byantibiotic
the Infectious
Society America.
ClinBackground.
Infect Dis. 2012
Novof15;55(10):12792. Cooper
RJ et al.
Principles of
appropriate
use forDiseases
acute pharyngitis
in adults:
Annals
Internal
82.
Medicine. 2001;134(6):509-17.
2. Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal
Medicine. 2001;134(6):509-17.
PAGE 13
Respiratory
ChronicObstructive
Obstructive
Pulmonary
Respiratory Tract:
Tract: Chronic
Pulmonary
Disease
(COPD)
Exacerbation
Disease (COPD) Exacerbation
CLINICAL AND THERAPEUTIC ALGORITHM
CLINICAL
SEVERITY
RECOMMENDED REGIMENS
Respiratory Tract: Chronic Obstructive Pulmonary
Diagnosis: Based on the clinical
Outpatient
Select ONE of the following:
Disease of(COPD)
presentation
the patient,Exacerbation
including
Uncomplicated • Doxycycline 100 mg PO Q12H
complaints of an acute change of cardinal
CLINICAL AND THERAPEUTIC ALGORITHM
symptoms as follows:
Diagnosis:
Based
on the
clinical sputum
Does
patient
have:
increased
presentation
of the
patient,dyspnea
includingOR
purulence
AND
increased
complaintssputum
of an acute change of cardinal
increased
CLINICAL
SEVERITY
Outpatient
Uncomplicated
symptoms as follows:
1. Initiate therapy with:
Does patient have: increased sputum
• Short-acting
bronchodilators
purulence
AND increased
dyspnea OR
(i.e. sputum
albuterol) increased to 6 to 8
increased
puffs Q1-2H in severe exacerbations
1. Initiate therapy with:
• +/- Short-acting anticholinergics
• Short-acting bronchodilators
(i.e. albuterol)
ipratropium
bromide)
(i.e.
increased
to 6increased
to 8
to 6 to
8 puffs
Q3-4Hexacerbations
in severe
puffs
Q1-2H
in severe
exacerbations
given
via
• +/- Short-acting anticholinergics
nebulizer/inhaler
(i.e.
ipratropium bromide) increased
to
6 to 8 puffs Q3-4H in severe
PLUS
exacerbations given
via
• Corticosteroids
(prednisone
or
nebulizer/inhaler
equivalent
PO 40 mg/day for 5 days)
PLUS
if
admitted OR have significant
• Corticosteroids (prednisone or
shortness
of breath
equivalent PO 40 mg/day for 5 days)
Methylprednisolone
IV Q6-12H
if
admitted OR have significant
may be used
initially
shortness
of breath
Methylprednisolone IV Q6-12H
2. Consider obtaining sputum culture
may be used initially
AND treat with an antimicrobial
2. Consider
sputum culture
based onobtaining
clinical severity
treat with
antimicrobial
•AND
If patient
hasan
only
an acute increase
based on clinical severity
in 1 cardinal symptom no antibiotic
• If patient has only an acute increase
therapy
is recommended
in
1 cardinal
symptom no antibiotic
• Amoxicillin 500 mg PO Q8H
RECOMMENDED REGIMENS
• Azithromycin 500 mg once, then
250 mg PO Q24H
Select ONE of the following:
• SMX/TMP
DSPO
tablet
• Doxycycline
100 1mg
Q12HPO Q12H
•
•
Amoxicillin
PO Q8H
Treat for 500
3 tomg
5 days
Azithromycin 500 mg once, then
250 mg PO Q24H
Primary Recommendation:
SMX/TMP 1 DS tablet PO Q12H
Outpatient
•
Complicated*
• Amoxicillin/clavulanate 875 mg
Treat forPO
3 toQ12H
5 days
OR
Failure of
Penicillin Allergy or Treatment
Outpatient
Primary Recommendation:
Previous
Failure with Primary Regimen:
Complicated*
• Amoxicillin/clavulanate 875 mg
• Q12H
Moxifloxacin 400 mg PO Q24H**
OR Antimicrobial
PO
Therapy
Failure
of
Penicillin
or5Treatment
TreatAllergy
for 3 to
days
Previous
Antimicrobial
Inpatient
Therapy
Failure with Primary Regimen:
• Moxifloxacin
400 mg PO Q24H**
Primary Recommendation:
Inpatient
Primary
OR Recommendation:
• Amoxicillin/clavulanate 875 mg
• Doxycycline 100 mg PO Q12H
PO Q12H
OR Penicillin Allergy or Treatment
Failure with
Regimen:
• Doxycycline
100Primary
mg PO Q12H
• Moxifloxacin
400 mg PO Q24H**
Penicillin
Allergy or Treatment
Failure with Primary Regimen:
Treat for 5 days
• Moxifloxacin 400 mg PO Q24H**
875 mg
Treat• forAmoxicillin/clavulanate
3 to 5 days
PO Q12H
Treat for 5 days
therapy
is recommended
3. Manage
risk
factors:
Assessrisk
if patient
3. •Manage
factors: is due for influenza
• Assess
vaccineif patient is due for influenza
• vaccine
Smoking cessation counseling
•
Smoking cessation counseling
4. Inpatient: If worsening clinical status
4. Inpatient: If worsening clinical status
OR inadequate response in 72H:
OR inadequate response in 72H:
re-evaluate
AND obtain sputum
re-evaluate AND obtain sputum
culture
ANDgram
gramstain
stain
culture AND
DS=
strength;H=
H=hour(s);
hour(s);
intravenous;
by mouth;
Q= every;
SMX/TMP=
sulfamethoxazole/trimethoprim
DS= double
double strength;
IV=IV=
intravenous;
PO=PO=
by mouth;
Q= every;
SMX/TMP=
sulfamethoxazole/trimethoprim
*In
withfrequent
frequentexacerbations,
exacerbations,
in previous
12 months)
severe
airflow
limitation,
exacerbations
*In patient
patient with
(> 4(>in4previous
12 months)
severe
airflow
limitation,
and/orand/or
exacerbations
requiringrequiring
mechanical ventilation,
and/or
cardiovascular
disease
mechanical
ventilation,FEV1
FEV1< <50%,
50%,
and/or
cardiovascular
disease
** Previously
Previously failed
azithromycin,
doxycycline,
and and
a betalactam
OR received
treatment
with thewith
aforementioned
**
failedtherapy
therapywith
with
azithromycin,
doxycycline,
a betalactam
OR received
treatment
the aforementioned
antibiotics within
days
OROR
patient
hashas
other
comorbidities
(i.e. chronic
heart, heart,
liver, orliver,
renalordisease,
diabetes,diabetes,
antibiotics
withinthe
theprevious
previous9090
days
patient
other
comorbidities
(i.e. chronic
renal disease,
alcoholism, malignancy, asplenia, immunocompromised or on immunosuppressing drugs. An FDA advisory committee determined that
alcoholism, malignancy, asplenia, immunocompromised or on immunosuppressing drugs. An FDA advisory committee determined that
the risks of fluoroquinolone use in COPD exacerbation outweighed any potential benefit, and should not be a first-line agent.
the risks of fluoroquinolone use in COPD exacerbation outweighed any potential benefit, and should not be a first-line agent.
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based
NOTE:
Dosing
based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based
on Renal
Function
on Renal Function
References:
1.
Vollenweider DJ, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec
References:
12;12:CD010257.
1.
Vollenweider
DJ, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec
2.
Vestbo J, et al. Global strategy for the diagnosis, manageent, and prevention of chronic obstructive pulmonary disease: GOLD executive
12;12:CD010257.
summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65.
2.
Vestbo
J,
et
al.
Global strategy
formeeting
the diagnosis,
manageent, Drugs
and prevention
of chronicand
obstructive
pulmonary
GOLD executive
3.
Food and Drug Administration.
Joint
of the Antimicrobial
Advisory Committee
the Drug Safety
& Risk disease:
Management
summary.
Am J Respir
Crit Care Med. Recording.
2013 Feb 15;187(4):347-65.
Advisory Committee
(DSaRM)-Webcast
2015.
3.
Food and Drug Administration. Joint meeting of the Antimicrobial Drugs Advisory Committee and the Drug Safety & Risk Management
Advisory Committee (DSaRM)-Webcast Recording. 2015.
PAGE 14
Respiratory
Pneumonia
Respiratory
Tract:Tract:
Pneumonia
START HERE Does the patient presenting with
pneumonia have any risk factors for multidrug
resistant organisms (MDROs):
•
•
Hospitalized for ≥ 2 days within previous 90 days
Resides in a nursing home OR long-term care
facility, OR skilled nursing facility
•
•
•
Received recent antibiotic therapy (previous 90
days), chemotherapy, OR wound care within
previous 30 days
Chronic hemodialysis
Have immunosuppressive disease OR receiving
immunosuppressing medications
CLINICAL CONSIDERATIONS
•
•
•
•
Infiltrate on chest x-ray required for pneumonia diagnosis
Collect BAL OR PSB AND blood cultures prior to starting antimicrobial therapy
Re-assess antibiotic therapy on day 2 or 3 when cultures return from microbiology lab
Specific isolated pathogens should prompt clinicians to de-escalate treatment based on the
pathogen's susceptibility pattern
NO RISK FACTORS FOR MDROS
RISK FACTORS FOR MDROS
INPATIENT NON-ICU
INPATIENT
Ceftriaxone 1 gm IV Q24H
AND
Azithromycin 500 mg PO/IV for 1 day, then
250 mg PO/IV Q24H for 4 days
OR
Moxifloxacin 400 mg IV/PO Q24H
Beta-lactam/beta-lactamase inhibitor:
Piperacillin-tazobactam 3.375 gm IV Q4H†
OR
Piperacillin-tazobactam 4.5 gm IV Q6H
OR
Antipseudomonal carbapenem:
Imipenem 500 mg IV Q8H
INPATIENT ICU
Ceftriaxone 2 gm IV Q24H
AND
Moxifloxacin 400 mg IV Q24H
OR
Ampicillin/sulbactam 3 gm IV Q6H
AND
Moxifloxacin 400 mg IV Q24H
OR
Penicillin-allergic patients:
Aztreonam 2 gm IV Q8–12H
AND
Moxifloxacin 400 mg IV Q24H
PLUS
Aminoglycoside‡ (Preferred)
Gentamicin 5-6 mg/kg (IBW) once daily
Tobramycin 5-6 mg/kg (IBW) once daily
OR
Antipseudomonal fluoroquinolone:
Levofloxacin 750 mg IV Q24H
Ciprofloxacin 400 mg IV Q8H
PLUS
If at risk for MRSA:
Vancomycin 15 mg/kg IV‡
OR
Linezolid 600 mg IV/PO Q12H
(See Criteria for Use)
BAL= Bronchoalveolar Lavage; BP= blood pressure; bpm= beats or breaths per minute; CrCl= Creatinine Clearance; H= hour(s);
IBW= ideal body weight; ICU= Intensive Care Unit; IV= intravenous; MDRO= multi-drug resistant organism; MRSA= MethicillinResistant S. aureus; PO= by mouth; PSB= Protected Specimen Brush; Q= every
†Suspect P. aeruginosa: CrCl >50 ml/min = 3.375 gm q4h; CrCl 50-10 ml/min = 3.375 gm IV Q6H; CrCl < 10 ml/min = 3.375 gm
Q8H
‡Refer to
Table of Contents for section on vancomycin and aminoglycoside dosing and monitoring
Note: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function.
PAGE 15
Respiratory Tract: Pneumonia
Respiratory
Tract:
Pneumonia
Respiratory
Tract:
Pneumonia
NO RISK FACTORS
FOR MDRO
S
RISK FACTORS FOR MDROS
OUTPATIENT
NO RISK FACTORS FOR MDROS
Previously healthy AND no antibiotic use in
previous
90 days:
OUTPATIENT
Previously healthy AND no antibiotic use in
Doxycycline 100 mg PO Q12H for 5 days
previous 90 days:
OR
Azithromycin
500mg
mgPO
POQ12H
for 1 for
dose,
then
Doxycycline 100
5 days
250
OR mg PO Q24H for 4 days
Azithromycin 500 mg PO for 1 dose, then
OUTPATIENT
250 mg PO Q24H for 4 days
OUTPATIENT RISK FACTORS FOR MDROS
Treat accordingly based on risk factors and
microbiologic
OUTPATIENT history
Treat accordingly based on risk factors and
Consider paging Infectious Diseases
microbiologic history
Consider paging Infectious Diseases
Presence of ≥ 1 co-morbidities* OR antibiotic
OUTPATIENT
use in previous 30 days:
Presence of ≥ 1 co-morbidities* OR antibiotic
Moxifloxacin 400 mg PO Q24H for 5 to 7 days
use in previous 30 days:
OR
Amoxicillin
1 gm
for 5 to
Moxifloxacin
400PO
mgQ8H
PO Q24H
for7 5days
to 7 days
OR
OR
Amoxicillin/clavulanate
875
PO7 Q12H
Amoxicillin 1 gm PO Q8H
formg
5 to
days
for
OR 5 to 7 days
AND
Amoxicillin/clavulanate 875 mg PO Q12H
Azithromycin
for 5 to 7 days500 mg PO for 1 dose, then
250
ANDmg PO Q24H for 4 days
Azithromycin 500 mg PO for 1 dose, then
THERAPY CONSIDERATIONS
250 mg PO Q24H for 4 days
• Cough and chest X-ray may take 4 to T6HERAPY
weeksCto
improve/change
ONSIDERATIONS
• Duration of therapy
• and
Community-acquired
pneumonia:
5–7 to
days
• Cough
chest X-ray may take
4 to 6 weeks
improve/change
• Healthcare-associated
pneumonia, hospital-acquired pneumonia, ventilator-associated
• Duration
of therapy
7–8 days;pneumonia:
provided that
the
targeted pathogen is identified based on
• pneumonia:
Community-acquired
5–7
days
and the etiologic
pathogen
is not P. aeruginosa,
andventilator-associated
that the patient is:
• bronchoscopy
Healthcare-associated
pneumonia,
hospital-acquired
pneumonia,
afebrile
for 487–8
to days;
72 hours
pneumonia:
provided that the targeted pathogen is identified based on
AND
≤ 1 of theand
following:
bronchoscopy
the etiologic pathogen is not P. aeruginosa, and that the patient is:
HR
>100 for
bpm,
>24hours
bpm, BP < 90 mmHg (systolic), O2 sat <90%, altered mental status
afebrile
48 RR
to 72
AND ≤ 1 of the following:
BP= blood pressure; bpm= beats or breaths per minute; H= hour(s); HR= heart rate; IV= intravenous; MDRO= multi-drug
HR >100 bpm, RR >24 bpm, BP < 90 mmHg (systolic), O2 sat <90%, altered mental status
resistant organism; PO= by mouth; Q= every; RR= respiratory rate
BP= blood of
pressure;
bpm= beats
or breaths
per minute;
hour(s);
HR=diabetes;
heart rate;
IV= intravenous;
MDRO=asplenia;
multi-drug
*Presence
comorbidities:
chronic
heart, lung,
liver or H=
renal
disease;
alcoholism;
malignancies;
resistant organism; PO=
by mouth;
Q= every; RR= respiratory rate
immunosuppressing
conditions
or medications
*Presence
of based
comorbidities:
chronic
heart, lung,
livertoorTable
renalof
disease;
diabetes;
alcoholism;
malignancies;
asplenia;
Note:
Dosing
on normal
renal function.
Refer
Contents
for section
on Antimicrobial
Dosing
for Adult
immunosuppressing
conditions
or medications
Patients
Based on Renal
Function.
Note: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function.
References:
1.
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the
management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72
References:
2.
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired,
1.
Mandell LA, Wunderink
RG,
Anzueto A, et al. Infectious
Diseases
Thoracic
Society consensus guidelines on the
ventilator-associated,
and
healthcare-associated
pneumonia.
Am JSociety
Respir of
CritAmerica/American
Care Med. 2005 Feb
15;171(4):388-416.
management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72
2.
American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired,
PAGE 16
ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416.
Sepsis
Sepsis
IV Antibiotics:
• If the patient is pregnant, contact pharmacy or
Infectious Diseases for assistance regarding
safety and dosage
• Penicillin allergic or optional antibiotic choices
are listed second and italicized
• Antibiotics should be adjusted for weight and
renal function in ALL patients
- Consult pharmacy or Infectious Diseases if
needed for assistance in monitoring
therapeutic drug level
Administer antibiotics within FIRST HOUR of
recognition of sepsis
• Antibiotics should be ordered AFTER a review
of previous microbiology data present in
patient’s electronic medical record
• Risk Factors for MRSA,VRE, and ESBL include:
- Hospitalization within the past year
- Patient receives hemodialysis
- Oozing or open wound
- Past history of documented MRSA, VRE, or
ESBL
- Patient is a nursing home resident
- Patient has a catheter or line present
SUSPECTED Clostridium difficile INFECTION
Vancomycin 500 mg PO/NGT x1 NOW PLUS Metronidazole 500 mg IV x1 NOW
SUSPECTED RESPIRATORY SOURCE
SUSPECTED URINARY SOURCE
SUSPECTED INTRA-ABDOMINAL SOURCE
Azithromycin 500 mg IV x1 NOW
PLUS
Ceftriaxone 2 gm IV x1 NOW
OR
Piperacillin/tazobactam 3.375 gm
IV x1 NOW
OR
If risk factors for MDR GNR or
ESBL
Meropenem 2 gm x1 NOW
Piperacillin/tazobactam 3.375 gm
IV x1 NOW
OR
If risk factors for MDR GNR or
ESBL
Meropenem 2 gm x1 NOW
Piperacillin/tazobactam 3.375 gm
IV x1 NOW
OR
If risk factors for MDR GNR or
ESBL
Meropenem 2 gm IV x1 NOW
If risk factors for MRSA
Vancomycin 25-30 mg/kg ABW*
IV LD x1 NOW
If risk factors for VRE
If risk factors for MRSA
Daptomycin 8-10mg/kg (ABW) x1
Vancomycin 25-30 mg/kg ABW*
NOW & Consult ID
IV LD x1 NOW
If penicillin allergy, may consider consulting ID or substituting meropenem 2gm x1 NOW for other beta
lactams (monitor; ≤5% cross-reactivity with penicillins).
ABW= Actual Body Weight; ESBL= Extended Spectrum Beta-Lactamase; ID= Infectious Diseases; IV= intravenous; LD= loading
dose; MDR GNR= Multi-Drug Resistant Gram-Negative Rods; MRSA= Methicillin-Resistant S. aureus; NGT= Nasogastric tube;
PO= By Mouth; VRE= Vancomycin –Resistant Enterococcus
*Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
PAGE 17
Symptomatic
SymptomaticSexually
SexuallyTransmitted
TransmittedInfection
InfectionScreening
Screening
SYMPTOMATIC
Symptoms
Female
Recommended Diagnostic Testing
• Vaginal itching
Vaginal examination:
Clinical and Therapeutic
Considerations
Promptly begin empiric
• Vaginal Sexually
discharge
1. Observe vaginal
anatomyScreening
treatment of Chlamydia and
Symptomatic
Transmitted
Infection
• Painful urination
2. Gram stain for bacterial
Gonorrhea before lab results
Female
• Increased urinary
urgency
• Pelvic pain
• PainSymptoms
with sexual
intercourse
• Vaginal itching
•• Vaginal
bleeding
Vaginal discharge
•• Genital
warts
Painful urination
Increasedlesion/ulcer
urinary
•• Genital
urgency
• Pharyngitis
• Pelvic pain
• Pain with sexual
intercourse
• Vaginal bleeding
• Genital warts
• Genital lesion/ulcer
• Pharyngitis
Male
Male
•
•
•
•
•
••
•
••
•
•
•
•
••
vaginosis
return
SYMPTOMATIC
3. Vaginal swabs for PCR assay:
• Gonorrhea
exam will allow
Clinical Vaginal
and Therapeutic
Recommended Diagnostic Testing
• Chlamydia
visualization of vaginal
Considerations
4. Vaginal swabs for Affirm DNA
anatomy
Vaginal examination:
Promptly begin empiric
• Trichomoniasis
1. Observe vaginal
anatomy
treatment of Chlamydia and
orresults
cervical swab may
5. HIV
2. Gram
staintest
for bacterial
Gonorrhea Vaginal
before lab
vaginosis
6. Syphilis (RPR screen/ titer) return
be necessary for specific test
3. Vaginal
swabs
for
PCR
assay:
kits
7. Urinalysis
Gonorrhea Test
Vaginal exam will allow
8. • Pregnancy
• Chlamydia
visualization of vaginal
9. Oropharyngeal (OP) Cultureanatomy
4. Vaginal swabs for Affirm DNA
for GC when indicated
• swab
Trichomoniasis
5.
6.
7.
8.
9.
Penile discharge
Painful urination
Increased urgency
Pelvic pain
Penile discharge
Swollen/tender
Painful urination
testicles
Increased urgency
Pelvicwith
pain sexual
Pain
Swollen/tender
intercourse
testicles
Genital warts
Pain with sexual
Genital
lesion/ulcer
intercourse
Pharyngitis
Genital warts
HIV test
Unable(RPR
to perform
vaginal
Syphilis
screen/ titer)
examination:
Urinalysis
1. Urinalysis
Pregnancy
Test
Oropharyngeal
2. Urine for(OP)
PCRCulture
assay:
swab for GC
when indicated
• Gonorrhea
Vaginal or cervical swab may
Promptly
be necessary
for specificbegin
test empiric
treatment of Chlamydia and
kits
Gonorrhea before lab results
return
• Chlamydia
Unable to perform
vaginal
examination:
3. HIV test
1. Urinalysis
4. Syphilis (RPR screen/titer)
2. Urine
for PCR assay:
5. Pregnancy
Test
• Gonorrhea
6. • OP
Culture for GC when
Chlamydia
indicated
3. HIV test
4. Syphilis (RPR screen/titer)
1. Urinalysis
5. Pregnancy
Test
2. Culture
Urinefor
forGC
PCR
assay:
6. OP
when
indicated• Gonorrhea
Promptly begin empiric
treatment of Chlamydia and
Gonorrhea before lab results
return
1. Urinalysis
3. HIV
testassay:
2. Urine
for PCR
4. • Syphilis
(RPR screen/ titer)
Gonorrhea
Chlamydia
5. • OP
Culture Swab or Rectal
3. HIV test
culture swab for GC when
4. Syphilis
(RPR screen/ titer)
indicated
5. OP Culture Swab or Rectal
culture swab for GC when
indicated
Promptly begin empiric
treatment of Chlamydia and
Gonorrhea before lab results
return
• Chlamydia
Promptly begin empiric
treatment of Chlamydia and
Gonorrhea before lab results
return
• Genital lesion/ulcer
• Pharyngitis
TREATMENT (DISCUSS TREATMENT OF PREGNANT WOMEN WITH ID AND OB/GYN)
Gonorrhea
Chlamydia
Gonorrhea
TREATMENTCeftriaxone
(DISCUSS TREATMENT
WOMEN
WITH ID AND OB/GYN)
250 OF
mgPREGNANT
IM AND
Azithromycin
1 gm PO x 1 dose
Chlamydia
HIV or Syphilis
HIV or Syphilis
Bacterial vaginosis
Bacterial vaginosis
OR doxycycline 100 mg PO Q12H for 7 days
Ceftriaxone 250 mg IM AND Azithromycin 1 gm PO x 1 dose
OR doxycycline 100 mg PO Q12H for 7 days
Penicillin Allergy (anaphylaxis): Consult ID
Penicillin Allergy (anaphylaxis): Consult ID
Consult Infectious Diseases
Consult Infectious Diseases
Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at
Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at
bedtime
5 days
bedtime
for 5for
days
Metronidazole
mg PO
OR clindamycin
300 mg PO Q12H
Alternatives:
Alternatives:
Metronidazole
500 mg 500
PO Q12H
OR Q12H
clindamycin
300 mg PO Q12H
forfor
7 days
7 days
Trichomonas vaginalis
Trichomonas
vaginalis
Metronidazole 2 gm PO x 1 dose OR metronidazole 500 mg PO Q12H for 7 days
Metronidazole 2 gm PO x 1 dose OR metronidazole 500 mg PO Q12H for 7 days
DNA= deoxyribonucleic acid; GC= gonococcus; H= hours; HIV= human immunodeficiency virus; ID= infectious diseases; IM= intramuscular;
DNA=
deoxyribonucleic
acid; GC=
gonococcus;
H=PCR=
hours;
HIV= human
immunodeficiency
virus;
ID= infectious
IM= intramuscular;
OB/GYN=
obstetrics/gynecology;
OP=
Oropharyngeal;
Polymerase
chain reaction;
PO= by mouth;
Q= every;
RPR= rapiddiseases;
plasma reagin;
STI= sexually
transmitted infection. OP= Oropharyngeal; PCR= Polymerase chain reaction; PO= by mouth; Q= every; RPR= rapid plasma reagin;
OB/GYN=
obstetrics/gynecology;
STI= sexually transmitted infection.
PAGE 18
AsymptomaticSexually
SexuallyTransmitted
TransmittedInfection
InfectionScreening
Screening
Asymptomatic
ASYMPTOMATIC
Population
Female
Age ≤ 25
Screening
Recommendations
Frequency
Urine PCR for Chlamydia
Annually
Urine PCR for Gonorrhea
Annually
HIV test
At least once
No later than
age 21
Cervical Screening
Age > 25
No routine screening for
STIs
Screen according to risk
Pregnant
Urine PCR for Chlamydia
First trimester
Urine PCR for Gonorrhea
First trimester
HIV test
First trimester
Hepatitis B S Ag, S Ab, C Ab
First trimester
Hepatitis C Ab
First trimester
Syphilis RPR/titer
First trimester
Urine PCR for Chlamydia
Annually
Urine PCR for Gonorrhea*
Annually
Syphilis RPR/titer
Annually
Trichomoniasis
Annually
Hepatitis B S Ag, S Ab, C Ab
Baseline
Hepatitis C Ab
Yearly if high
HIV-positive
Clinical and Therapeutic
Considerations
Cervical screening should be
performed 3 years after
initiating sexual activity or no
later than age 21
Consider minimum of annual
screening if high risk* patient
Repeat Screening
(all pathogens) in 3rd trimester
and at birth if patient is high
risk*
*Consider rectal and
pharyngeal culture swabs for
GC if exposed
May repeat screening every
3-6 months, as indicated by
risk
risk*
EPT= expedited partner treatment; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody;
Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Antibody; HIV= human immunodeficiency virus;
MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma reagin; STI= sexually transmitted
infection
Test of Cure/ Retest Post Diagnosis and Treatment of Gonorrhea or Chlamydia
Retest all patients after 3 months for reinfection (if 3 months not possible, within 1 year).
Retest all pregnant patients a minimum of >/=3 weeks after completion of therapy.
If suspect treatment failure, reinfection , or failure due to alternative regimen then repeat testing at a minimum of
>/= 3weeks after completion of therapy.
For pharyngeal gonorrhea– get test of cure on all patients after 14 days. Culture and susceptibilities preferred.
Note: Gonnorrhea/Chlamydial PCR <3 weeks from completion of therapy are not recommended due to presence of non-viable
organisms and false-positive results.
STIs: Partner Treatment
-Any recent sexual partner who has had contact with the infected patient within 60 days of their diagnosis should be considered
for treatment.
-Discuss treatment of partners or questions regarding Expedited Partner Treatment (EPT) with the Infectious Disease Service.
-EPT should not be employed with MSMs (these patients should be referred for comprehensive STI testing first).
*Definition of High Risk
Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
recent sex contact outside the US.
PAGE 19
Asymptomatic Sexually Transmitted Infection Screening
AsymptomaticSexually
SexuallyTransmitted
Transmitted
Infection Screening
Screening
ASYMPTOMATICInfection
Asymptomatic
Population
Screening
ASYMPTOMATIC Frequency Clinical and Therapeutic
Recommendations
Considerations
Screening
Clinical and Therapeutic
No routine screening Frequency
for STIs. Screen according to *risk.
Recommendations
Considerations
Note:
All ‘Babyboomers’ (Patients born from 1945 through
1965) should be
Male
Heterosexual
Population
men
Male
Heterosexual
men who have
Men
sex with men
(MSM)
Men who have
OR
sex with men
*high
(MSM)risk
heterosexual
men
OR
screened
for HCV
No routine screening for
STIs. Screen
according to *risk.
Note: All ‘Babyboomers’ (Patients born from 1945
through
1965)culture,
should be
Consider
GC/Chl
Urine PCR for Chlamydia
Annually
screened for HCVrectal and pharyngeal swabs
Urine PCR for Gonorrhea
Annually
Consider GC/Chl culture,
Urine PCR for Chlamydia
Annually
High
as: swabs
HIV test
Annually
rectalrisk
anddefined
pharyngeal
Urine PCR for Gonorrhea
Annually
- New or multiple sex
Hepatitis B S Ag, S Ab, C Ab
Baseline
Highpartners
risk defined as:
HIV test
Annually
Hepatitis C Ab
Annually
-- Inconsistent
condom
New or multiple
sex use
Hepatitis B S Ag, S Ab, C Ab
Baseline
Commercial
sex work
Syphilis (RPR screen/ titer)
Annually
partners
-- Drug
use
Hepatitis C Ab
Annually
Inconsistent
condom use
Commercial
sex work
Syphilis (RPR screen/ titer)
Annually
May
repeat
screening
every
- Drug use
3-6 months, as indicated by
risk
May repeat screening every
HIV-positive men
Urine PCR for Chlamydia
Annually
Urine PCR for Gonorrhea
Urine PCR for Chlamydia
Syphilis (RPR screen/ titer)
Urine PCR for Gonorrhea
Hepatitis B S Ag, S Ab, C Ab
Syphilis (RPR screen/ titer)
Hepatitis C Ab
Hepatitis B S Ag, S Ab, C Ab
Annually
Annually
Annually
Annually
Baseline
Annually
Annually
Baseline
*high risk
heterosexual men
HIV-positive men
3-6 months,
as indicated
Consider
GC/Chl
culture, by
risk and pharyngeal swabs
rectal
Consider GC/Chl culture,
May
screening every
rectalrepeat
and pharyngeal
swabs
3-6 months, as indicated by
risk
May repeat screening every
3-6 months, as indicated by
risk
GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface
Hepatitis C Ab
Annually
Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Core Antibody; HIV= human immunodeficiency virus;
MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection.
GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface
Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Core Antibody; HIV= human immunodeficiency virus;
*Definition
of High
Riskwith men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection.
MSM=
Men who
have sex
Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
*Definition
of Highoutside
Risk the US.
recent
sex contact
Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
recent sex contact outside the US.
References:
1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human
Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
References:
2.
"Primary, Secondary, and Early Latent Syphilis Surveillance 2007-2011." Division of Infectious Disease & Epidemiology. Rhode Island Department
1. of
"Sexually
Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human
Health,Transmitted
2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf.
Services, 17Sexually
Dec. 2010.
URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
3. “California
Transmitted
Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL:
2. http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf
"Primary, Secondary, and Early Latent Syphilis Surveillance 2007-2011." Division of Infectious Disease & Epidemiology. Rhode Island Department
of Health, 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf.
3. “California Sexually Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL:
PAGE 20
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf
Asymptomatic Sexually Transmitted Infection Screening
Asymptomatic
Infection Screening
AsymptomaticSexually
SexuallyTransmitted
Transmitted
HIV testing Infection Screening
Population
Frequency
HIV testing
Special Considerations
Consider
frequent testing if high
Special
Considerations
risk*
Consider frequent testing if high
All women age 13-64
Baseline
Consider PREP if HIV+ partner
risk*
All women who seek STI screening
At time of STI
(Consult ID)
Consider PREP if HIV+ partner
All women who seek STI screening
At time of STI
Third trimester
and at birth if high
(Consult
ID)
All pregnant women
First Trimester
risk
Third trimester and at birth if high
All pregnant women
First Trimester
Consider frequent testing if high
risk
All men age 13-64
Baseline
risk*
Consider frequent testing if high
All men age 13-64
Baseline
Q3-6 months if higher risk activity
risk*
MSM
Annually (minimum)
(Consider PREP and consult ID)
Q3-6 months if higher risk activity
MSM
Annually (minimum)
Consider PREP
HIV+
partner
(Consider
PREPifand
consult
ID)
All men who seek STI screening
At time of STI
(consult ID)
Consider PREP if HIV+ partner
All
men who seek STI screening
At time of STI
HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP=
pre-exposure
prophylaxis; Q= every;
(consult
ID)
Population
All women age 13-64
Frequency
Baseline
RPR= rapid plasma regain; STI= sexually transmitted infection.
HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP= pre-exposure prophylaxis; Q= every;
*Definition
of High
RiskSTI= sexually transmitted infection.
RPR= rapid plasma
regain;
Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
*Definition
High Risk
inconsistentof
condom
use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
Those
have a new
sex the
partner,
recentwho
sex contact
outside
US. >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
recent sex contact outside the US.
References:
1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human
Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
References:
2. "Sexually
"Primary, Transmitted
Secondary, and
Early Latent
Syphilis
Surveillance
2007-2011."
Infectious
& Epidemiology.
Island
1.
Diseases
Treatment
Guidelines,
2015."
Centers forDivision
DiseaseofControl
andDisease
Prevention.
Department Rhode
of Health
andDepartment
Human
of
Health,17
2011.
Services,
Dec.URL:
2010.http://www.health.ri.gov/data/diseases/Syphilis.pdf.
URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
3. "Primary,
“CaliforniaSecondary,
Sexually Transmitted
Disease
(STD) Surveillance
Screening Recommendations
2010”.
California Disease
Department
Of Public Health,
2011.
URL:
2.
and Early Latent
Syphilis
2007-2011." Division
of Infectious
& Epidemiology.
RhodeJune.
Island
Department
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf
of
Health, 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf.
3. “California Sexually Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL:
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf
PAGE 21
Skin and Soft Tissue Infections (SSTI)
Skinandand
Infections
Skin
SoftSoft
TissueTissue
Infections
(SSTI)
NONPURULENT
(SSTI)
Necrotizing Infection/Cellulitis/Erysipelas
NONPURULENT
[Usually
Streptococcus
pyogenes (Group A Strep)]
Necrotizing
Infection/Cellulitis/Erysipelas
[Usually Streptococcus pyogenes (Group A Strep)]
Mild:
No systemic
Mild: signs
infection*
Noofsystemic
signs
Moderate:
Systemic
signs of
Moderate:
infection*
Systemic
signs of
Oral
Antibiotic
OralTherapy
Antibiotic Therapy
Intravenous
Antibiotic
Therapy
Intravenous
Select ONE:
Penicillin VK
Select ONE:
250-500 mg PO Q6H
Penicillin VK
Cephalexin
250-500 mg PO Q6H
500 mg PO Q6H
Cephalexin
Dicloxacillin
500 mg PO Q6H
250 mg PO Q6H
Dicloxacillin
Clindamycin
250 mg PO Q6H
300-450 mg PO Q6H
Clindamycin
300-450 mg PO Q6H
Select ONE:
Penicillin
Select ONE:
2-4 million units IV
Penicillin
Q4-6H
2-4 million units IV
Ceftriaxone
Q4-6H
1 gm IV Q24H
Ceftriaxone
Cefazolin
1 gm IV Q24H
1 gm IV Q8H
Cefazolin
Clindamycin
1 gm IV Q8H
600-900 mg IV Q6H
Clindamycin
600-900 mg IV Q6H
of infection*
infection*
Antibiotic Therapy
Severe:
(any of Severe:
the following):
Systemic signs of infection*,
(any of the following):
failed antibiotic treatment,
Systemic signs of infection*,
immunocompromise,
failed antibiotic treatment,
hemodynamic instability, or
immunocompromise,
deep infection
hemodynamic instability, or
deep infection
Intravenous Antibiotic Therapy
Intravenous Antibiotic Therapy
Emergent Surgical
Inspection/Debridement
Emergent Surgical
• Rule out necrotizing
Inspection/Debridement
process
• Rule out necrotizing
Culture & Sensitivity
process
Empiric Treatment
Culture & Sensitivity
• Vancomycin 15 mg/kg
Empiric Treatment
IV** PLUS
• Vancomycin 15 mg/kg
• Piperacillin/tazobactam
IV** PLUS
3.375 gm IV Q6H
• Piperacillin/tazobactam
+/3.375 gm IV Q6H
• Clindamycin 900 mg IV
+/Q8H***
• Clindamycin 900 mg IV
Q8H***
Defined Treatment (Necrotizing Infections)
Monomicrobial
Defined Treatment (Necrotizing Infections)
Streptococcus pyogenes
Monomicrobial
• Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H
Streptococcus pyogenes
Vibrio vulnificus
• Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H
• Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H
Vibrio vulnificus
Aeromonas hydrophila
• Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H
• Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H
Aeromonas hydrophila
Polymicrobial
• Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H
• Vancomycin 15 mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H
Polymicrobial
• Vancomycin
15every
mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H
H= hours; IV= intravenous;
PO= oral; Q=
*Systemic
of infection include,
not limited to, temperature >38°C, tachycardia (heart rate >90 beats per minute),
H= hours;signs
IV= intravenous;
PO= oral;but
Q=are
every
tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL).
*Systemic
of on
infection
include,
but are
limited to,intemperature
>38°C, tachycardia (heart rate >90 beats per minute),
**Refer
to signs
section
Vancomycin
Dosing
andnot
Monitoring
Adult Patients.
tachypnea (respiratory
rate
breaths per
minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL).
***Consider
this addition
for>24
necrotizing
fasciitis.
**Refer
to
section
on
Vancomycin
Dosing
and
Monitoring
in
Adult
Patients.
Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in
***Consider
addition
for necrotizing fasciitis.
patients
withthis
renal
impairment.
Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in
patients with renal impairment.
References:
1. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin
and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2): e10-52.
References:
2.
Markwell
S, Chambers
Peter J, Barenkamp
S. Randomized,
trialSL,ofetantibiotics
in guidelines
the management
community-acquired
skinof skin
1. Duong
StevensM,DL,
Bisno AL,
HF, Dellinger
EP, Goldsteincontrolled
EJ, Gorbach
al. Practice
for the of
diagnosis
and management
abscesses
in theinfections:
pediatric patient.
Ann Emerg
2010; Diseases
55:401–7.Society of America. Clin Infect Dis. 2014; 59(2): e10-52.
and soft tissue
2014 update
by the Med
Infectious
3.
J, Harvey
J. The
treatment
of acute superficial
abscesses:
a prospective
clinical trial.
Br Jmanagement
Surg 1977; 64:264–6.
2. Macfie
Duong M,
Markwell
S, Peter
J, Barenkamp
S. Randomized,
controlled
trial of antibiotics
in the
of community-acquired skin
4. Llera
JL, Levy
RC. pediatric
Treatment
of cutaneous
abscess:
double-blind
clinical study. Ann Emerg Med 1985; 14:15–9.
abscesses
in the
patient.
Ann Emerg
Meda2010;
55:401–7.
5.
WH, Hart
D,treatment
Calderwood
Merrett
JD. Antibiotics
treatment
septic
Lancet
1970; 1:1077–80.
3. Rutherford
Macfie J, Harvey
J. The
of JW,
acute
superficial
abscesses:ina surgical
prospective
clinicaloftrial.
Br Jlesions.
Surg 1977;
64:264–6.
6.
D, Pitotti of
R, cutaneous
et al. Randomized
trial of
trimethoprim-sulfamethoxazole
for14:15–9.
uncomplicated skin abscesses in
4. Schmitz
Llera JL, GR,
LevyBruner
RC. Treatment
abscess:controlled
a double-blind
clinical
study. Ann Emerg Med 1985;
patients
at
risk
for
community-associated
methicillin-resistant
Staphylococcus
aureus
infection.
Ann
Emerg
Med
2010;
56:283–7.
5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970;
1:1077–80.
6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in
patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7.
PAGE 22
Skinandand
Infections
Skin
SoftSoft
TissueTissue
Infections
(SSTI)
(SSTI)
PURULENT
Skin and Soft Tissue Infections
(SSTI)
Furuncle/Carbuncle/Abscess
(Usually Staphylococcus
aureus)
PURULENT
Furuncle/Carbuncle/Abscess
Moderate: aureus)
(Usually Staphylococcus
Mild:
No systemic signs
Mild:
of infection*
Systemic signs of
Moderate:
infection*
Systemic signs of
infection*
No systemic signs
of infection*
No
Antibiotic
No
Therapy
Incision and Drainage
and C&S
Antibiotic
Therapy
Incision and Drainage
Incision and Drainage
Incision and Drainage
and C&S
Oral
Antibiotic
Oral
Therapy
Antibiotic
instability, or deep
infection
Incision and Drainage
andDrainage
C&S
Incision and
and C&S
Therapy
Empiric Therapy (select ONE):
Severe:
(any of the following):
Severe:
Failed
I&D and oral
(anyantibiotics,
of the following):
systemic
Failed
I&D
oral
signs
ofand
infection*,
antibiotics,
systemic
immunocompromise,
signs hemodynamic
of infection*,
immunocompromise,
instability, or deep
hemodynamic
infection
• TMP/SMX
1-2
DS tablets
Empiric
Therapy
(select
ONE): PO Q12H
Doxycycline
mg POPO
Q12H
•• TMP/SMX
1-2100
DS tablets
Q12H
Therapy
•Defined
Doxycycline
100 mg PO Q12H
MRSA Therapy
Defined
MRSA
• TMP/SMX (see empiric dose)
•MSSA
TMP/SMX
empiric dose)
(select(see
ONE):
MSSA
(select ONE):
• Dicloxacillin
500 mg PO Q6H
•• Dicloxacillin
Cephalexin 500
500mg
mgPO
POQ6H
Q6H
• Cephalexin 500 mg PO Q6H
Intravenous
Antibiotic
Intravenous
Therapy
Antibiotic
Therapy
Empiric Therapy (select ONE):
Empiric Therapy (select ONE):
• Vancomycin 15 mg/kg IV**
• Vancomycin 15 mg/kg IV**
• Daptomycin 6 mg/kg IV Q24H
• Daptomycin 6 mg/kg IV Q24H
• Linezolid 600 mg IV Q12H
• Linezolid 600 mg IV Q12H
Ceftaroline
mgQ12H
IV Q12H
• •Ceftaroline
600600
mg IV
Defined
Therapy
Defined
Therapy
MRSA
MRSA
empiric
therapy
above
• •SeeSee
empiric
therapy
above
MSSA
(select
ONE):
MSSA
(select
ONE):
Nafcillin
IV Q4H
• •Nafcillin
1-2 1-2
gm gm
IV Q4H
• •Cefazolin
1 gm
IV Q8H
Cefazolin
1 gm
IV Q8H
• •Clindamycin
600600
mg IV
Clindamycin
mgQ8H
IV Q8H
C&S=
cultureand
andsensitivity;
sensitivity; DS=
DS= double-strength;
double-strength; H=
incision
andand
drainage;
IV= intravenous;
MRSA=
methicillinC&S=
culture
H=Hours;
Hours;I&D=
I&D=
incision
drainage;
IV= intravenous;
MRSA=
methicillinresistantStaphylococcus
Staphylococcusaureus;
aureus; MSSA=
MSSA= methicillin-susceptible
Staphylococcus
aureus;
PO=PO=
by mouth;
Q= every;
resistant
methicillin-susceptible
Staphylococcus
aureus;
by mouth;
Q= every;
Rx= treatment; TMP/SMX= trimethoprim-sulfamethoxazole
Rx= treatment; TMP/SMX= trimethoprim-sulfamethoxazole
*Systemic signs of infection, but are not limited to, include temperature >38°C, tachycardia (heart rate >90 beats per minute),
*Systemic
signs of infection, but are not limited to, include temperature >38°C, tachycardia (heart rate >90 beats per minute),
tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL).
tachypnea
rate >24 breaths
or abnormal
white blood
cell count (>12 000 or <4000 cells/µL).
**Refer to(respiratory
section on Vancomycin
Dosingper
andminute)
Monitoring
in Adult Patients
.
**Refer to section on Vancomycin Dosing and Monitoring in Adult Patients.
References:
References:
1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update
by the DL,
Infectious
Diseases
Society
ofet
America.
Clin Infect
Dis. 2014;
59(2):
e10-52. and management of skin and soft tissue infections: 2014 update
1. Stevens
Bisno AL,
Chambers
HF,
al. Practice
guidelines
for the
diagnosis
2.byDuong
M, Markwell
S, Peter
J, Barenkamp
S. Randomized,
controlled
of e10-52.
antibiotics in the management of community-acquired skin
the Infectious
Diseases
Society
of America.
Clin Infect Dis.
2014; trial
59(2):
abscesses
in the pediatric
Ann Emerg
Med 2010; 55:401–7.
2. Duong
M, Markwell
S, Peterpatient.
J, Barenkamp
S. Randomized,
controlled trial of antibiotics in the management of community-acquired skin
3.abscesses
Macfie J,inHarvey
J. The treatment
acute
superficial
abscesses:
a prospective clinical trial. Br J Surg 1977; 64:264–6.
the pediatric
patient. of
Ann
Emerg
Med 2010;
55:401–7.
Llera JL,
Levy RC.J. Treatment
of cutaneous
a double-blind
study. Ann
Emergtrial.
MedBr1985;
14:15–9.
3. 4.Macfie
J, Harvey
The treatment
of acuteabscess:
superficial
abscesses:clinical
a prospective
clinical
J Surg
1977; 64:264–6.
Rutherford
Hart D, Calderwood
JW, Merrett
JD.aAntibiotics
in surgical
of Emerg
septic lesions.
Lancet
1970; 1:1077–80.
4. 5.Llera
JL, Levy WH,
RC. Treatment
of cutaneous
abscess:
double-blind
clinicaltreatment
study. Ann
Med 1985;
14:15–9.
6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in
5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970; 1:1077–80.
patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7.
6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in
patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7.
PAGE 23
Skinand
andSoft
SoftTissue:
Tissue:
Diabetic
Foot
Infections
Skin
Diabetic
Foot
Infections
SEVERITY OF INFECTION
Mild
• Only skin and
subcutaneous tissue
involvement
AND
• Erythema > 0.5 cm and
≤ 2 cm around ulcer
• Perform incision and
drainage as necessary
Moderate**
• Deeper tissue
involvement
OR
• Erythema > 2.0 cm
around ulcer
AND
• No systemic signs of
infection
• Perform incision and
drainage as necessary
SUSPECTED ORGANISMS
RECOMMENDED EMPIRICAL
TREATMENT
DURATION
MSSA
Streptococcus spp.
Oral
Amoxicillin/clavulanate 875 mg
PO Q12H
OR
Cephalexin 500 mg PO Q6H
OR
Dicloxacillin 250 – 500 mg PO
Q6H
MRSA
Doxycycline 100 mg PO Q12H
OR
SMX/TMP 2 DS tablets PO Q12H
(Does not cover Group A Strep)
Oral OR Initially Parenteral
1–3 weeks
Ampicillin-sulbactam 1.5–3 gm IV
Q6H
OR
Ceftriaxone 1 gm IV Q24H
MSSA
Streptococcus spp.
Enterobacteriaceae
Obligate anaerobes
1–2 weeks
Penicillin Allergy:
MRSA
Pseudomonas
aeruginosa
Ciprofloxacin 500 mg PO Q12H
AND
Clindamycin 300 mg PO Q6H
OR
Ceftriaxone 1 gm IV Q24H
Linezolid 600 mg IV/PO Q12H†
(Requires ID Consult)
OR
Daptomycin 6 mg/kg IV Q24H†
(Requires ID Consult)
OR
Vancomycin 15 mg/kg IV*
Piperacillin-tazobactam
3.375 gm IV Q4H
DS= Double Strength; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin sensitive S. aureus;
PO= by mouth; Q= every; SMX-TMP= sulfamethoxazole/trimethoprim; spp= species
† Restricted Antibiotic – refer to Table of Contents for Guidelines for Restricted Antimicrobials
* Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
** Consult Infectious Diseases and Podiatry
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function
PAGE 24
Skin and Soft Tissue: Diabetic Foot Infections
Skinand
andSoft
SoftTissue:
Tissue:
Diabetic
Foot
Infections
Skin
Diabetic
Foot
Infections
RECOMMENDED EMPIRICAL
SEVERITY OF INFECTION
SevereS**EVERITY OF INFECTION
SUSPECTED ORGANISMS
DURATION
TREATMENT
RECOMMENDED EMPIRICAL
SUSPECTED ORGANISMS Initially Parenteral
DURATION
MSSA/MRSA
TREATMENT
P. aeruginosa
Vancomycin
15
mg/kg
IV*
MSSA/MRSA
Initially Parenteral
Streptococcus spp.
AND**
P.
aeruginosa
2–4 weeks
Enterobacteriaceae
Vancomycin
15 IV
mg/kg
Cefepime 2 gm
Q8HIV*
+
Streptococcus
spp.
Obligate anaerobes
AND**
metronidazole 500 mg IV Q6H 2–4 weeks
Enterobacteriaceae
Cefepime
2 gm IV Q8H +
OR
Obligate anaerobes
metronidazole
500 mg IV Q6H
Piperacillin-tazobactam
OR
3.375 gm IV Q4H
Piperacillin-tazobactam
3.375 gm IV Q4H
Bone OR Joint Involvement‡
• Same
as moderate
**
Severe
AND
•• Same
as moderate
Systemic
signs of infection
AND
present
•
Systemic
signs
of infection
Systemic Inflammatory
presentSyndrome (SIRS)
Response
Systemic
Criteria ≥2Inflammatory
of the following:
Response Syndrome (SIRS)
• Temperature
Criteria
≥2 of the <96.8°F
following:
OR >100.4°F
•• Temperature
P > 90 BPM <96.8°F
SourceOR
removed:
2-5 days ‡
Joint Involvement
Bone
• OR
RR >>100.4°F
20 BPM
•• PPaCO
> 90 BPM
<
32
mmHg
Source
removed
but
2
removed: 2-5 residual
days tissue infection:
•• RR
> 20
BPM cells/mm³
WBC
< 4000
1-3 weeks
• PaCO
Source removed but residual tissue infection:
2 < 32 mmHg
OR >12,000
cells/mm³
Source
removed but residual bone infection:
•• WBC
4000 cells/mm³
1-3
weeks
≥ 10%< immature
(band)
4-6 weeks
>12,000 cells/mm³
OR
forms
Source removed but residual bone infection:
•• ≥Perform
10% immature
(band)
incision and
Source
not removed: ≥3 months
4-6
weeks
forms
drainage as necessary
• Perform incision and
Source not removed: ≥3 months
BPM= beats or breaths per minute; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin
drainage as necessary
sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic
Inflammatory
Syndrome;
spp=
species;
white blood
cellmethicillin resistant S. aureus; MSSA= methicillin
BPM=
beats orResponse
breaths per
minute; H=
hour(s);
IV=WBC=
intravenous;
MRSA=
sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic
†
Restricted
Antibiotic
–
refer
to
Table
of
Contents
for
Guidelines
for
Restricted Antimicrobials
Inflammatory Response Syndrome; spp= species; WBC= white blood cell
* Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
Consult Infectious
and
Podiatry
†**Restricted
AntibioticDiseases
– refer to
Table
of Contents for Guidelines for Restricted Antimicrobials
Discuss
Infectious
Podiatry,
and Vascular
*‡ Refer
toplan
Tablewith
of Contents
forDiseases,
section on
Vancomycin
Dosing and Monitoring in Adult Patients
** Consult Infectious Diseases and Podiatry
NOTE:
Dosing
based
on
normal
renal
function.
Refer
to
Table of Contents for section on Antimicrobial Dosing for Adult
‡ Discuss plan with Infectious Diseases, Podiatry, and Vascular
Patients Based on Renal Function
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function
References:
1. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73.
References:
2.
insert].
York,
2015.EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
1. Flagyl
Lipsky[package
BA, Berendt
AR, New
Cornia
PB, NY:
Pile Pfizer;
JC, Peters
Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73.
2. Flagyl [package insert]. New York, NY: Pfizer; 2015.
PAGE 25
Surgical Decolonization and Prophylaxis
Surgical
Decolonization
and Prophylaxis
Surgical
Decolonization
and Prophylaxis
Nasal Screening Result
Nasal Screening Result
MRSA Negative
MSSA
MRSA Negative
Negative
MSSA
Negative
MSSA Positive
MSSA Positive
MRSA Positive
MRSA Positive
•
•
•
•
•
•
DECOLONIZATION
DECOLONIZATION
Recommended Intervention
Recommended Intervention
• No decolonization required
• No decolonization required
• Intranasal mupirocin twice daily x 5 days
• Intranasal mupirocin twice daily x 5 days
• Intranasal mupirocin twice daily x 5 days,
AND
• Intranasal mupirocin twice daily x 5 days,
•AND
Chlorhexidine bathing one day prior to surgery
•
Chlorhexidine
bathing one day prior to surgery
ANTIMICROBIAL
PROPHYLAXIS
ANTIMICROBIAL PROPHYLAXIS
CLINICAL CONSIDERATIONS
Preoperative dose-timing CLINICAL CONSIDERATIONS
Within 60 minutes
of surgical incision
Preoperative
dose-timing
Exceptions:
vancomycin
and fluoroquinolones
within 120 minutes of surgical
Within
60 minutes
of surgical
incision
incision
Exceptions: vancomycin and fluoroquinolones within 120 minutes of surgical
Weight-based
dosing
incision
Cefazolin: 2 gm
for patients <120 kg, and 3 gm for patients ≥120 kg
Weight-based
dosing
Vancomycin:
usefor
ABW
Cefazolin: 2 gm
patients <120 kg, and 3 gm for patients ≥120 kg
Gentamicin:
Vancomycin:use
useABW
ABWunless ABW is >120% of their IBW, in which case use
AdjBW
(see below
for equation)
Gentamicin:
use ABW
unless ABW is >120% of their IBW, in which case use
Duration
prophylaxis
AdjBW of
(see
below for equation)
A singleof
dose,
or continuation for <24 hours is recommended
Duration
prophylaxis
A single dose, or continuationINTRA
for <24
hours isREDOSING
recommended
-OPERATIVE
INTRA-OPERATIVE
REDOSING
Required if the duration of procedure
exceeds two
half-lives of the drug or if there
is
extensive
blood
loss during
the procedure
(>1500
mL) Ŧ of the drug or if there
Required
if the
duration
of procedure
exceeds
two half-lives
Ŧ
Recommendation:
use during
the same
dose
and mL)
measure
the redosing interval
is extensive blood loss
theantibiotic
procedure
(>1500
from
the
time
of
administration
of
the
preoperative
dose,
not the
the redosing
time of incision
Recommendation: use the same antibiotic dose and measure
interval
from
administration
of the
preoperative
not the time of
incision
ABW=
actualthe
bodytime
weight;of
AdjBW=
adjusted body weight;
IBW=
ideal body weight;dose,
MRSA= Methicillin-resistant
Staphylococcus
•
•
•
•
aureus; MSSA= Methicillin-susceptible Staphylococcus aureus
ABW= actual body weight; AdjBW= adjusted body weight; IBW= ideal body weight; MRSA= Methicillin-resistant Staphylococcus
MSSA=
Staphylococcus
Ŧaureus;
Redosing
may Methicillin-susceptible
not be necessary for patients
with pooraureus
renal function (CrCl <30mL/min)
Ŧ Redosing may not be necessary for patients with poor renal function (CrCl <30mL/min)
IBW Calculation:
Male = 50 kg + [2.3 kg for each inch over 5 feet]
IBW Calculation:
Female = 45 kg + [2.3 kg for each inch over 5 feet]
Male = 50 kg + [2.3 kg for each inch over 5 feet]
Female = 45 kg + [2.3 kg for each inch over 5 feet]
AdjBW Calculation:
AdjBW = 0.4 (ABW-IBW) + IBW
AdjBW Calculation:
AdjBW = 0.4 (ABW-IBW) + IBW
References:
1.
Schweuzer ML, Chiang H, Septimus E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections
Among Patients Undergoing Cardiac, Hip, or Knee Surgery (STOP SSI – Study to Optimally Prevent SSI in Select Cardiac and Orthopedic
References:
Procedures).
JAMA
2015;
1.
Schweuzer ML,
Chiang
H, 313(21):
Septimus2162-2171.
E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections
2.
Chen
AF,Patients
Wessel Undergoing
CB, Rao N. Staphylococcus
Screening
andSSI
Decolonization
in Orthopaedic
and Reduction
of Orthopedic
Surgical Site
Among
Cardiac, Hip, oraureus
Knee Surgery
(STOP
– Study to Optimally
PreventSurgery
SSI in Select
Cardiac and
Infections.
ClinJAMA
Orthop
Relat
Res 2013;
471: 2383-2399.
Procedures).
2015;
313(21):
2162-2171.
3.
Bratzler
Dellinger
EP,N.
Olsen
KM, Perl TM,
Auwaerter
PG, Bolon
MK, et al. Clinical
practice guidelines
2.
Chen AF,DW,
Wessel
CB, Rao
Staphylococcus
aureus
Screening
and Decolonization
in Orthopaedic
Surgeryfor
andantimicrobial
Reduction ofprophylaxis
Surgical Sitein
surgery.
AmClin
J Health
Syst
Pharm
Infections.
Orthop
Relat
Res 2013; 70:195-283.
471: 2383-2399.
3.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283.
PAGE 26
Antimicrobial Surgical Prophylaxis
Antimicrobial
Surgical
Prophylaxis
Antimicrobial
Surgical
Prophylaxis
REDOSING
RECOMMENDATIONS
REDOSING
ECOMMENDATIONS
Half-life R
(hours)
Antibiotic
Redosing Interval (hours)
Ampicillin/sulbactam
Antibiotic
0.8-1.3
Cefazolin
Ampicillin/sulbactam
1.2-2.2
0.8-1.3
42
Cefoxitin
Cefazolin
0.7-1.1
1.2-2.2
24
Ciprofloxacin
Cefoxitin
3-7
0.7-1.1
Not
2 necessary
Clindamycin
Ciprofloxacin
2-4
3-7
6Not necessary
Gentamicin
Clindamycin
2-3
2-4
Not
6 necessary
Metronidazole
Gentamicin
6-8
2-3
Not
Not necessary
necessary
Vancomycin
Metronidazole
SURGICAL
Vancomycin
PROCEDURE
SURGICAL
Laparoscopic,
PROCEDURE
4-8
6-8
low-risk
Laparoscopic,
Laparoscopic,
low-risk
high-risk
Laparoscopic,
high-risk
Small intestine,
nonobstructed
Small intestine,
nonobstructed
Small
intestine,
obstructed
Small intestine,
obstructed
Hernia
repair
Hernia repair
Colorectal
Colorectal
Head and neck,
Half-life (hours)
RECOMMENDED
AGENTS
4-8
NoneRECOMMENDED AGENTS
None
Cefazolin,
cefoxitin,
cefotetan, ceftriaxone,
Cefazolin, cefoxitin,
ampicillin/sulbactam
cefotetan, ceftriaxone,
Cefazolin
ampicillin/sulbactam
Cefazolin
Cefazolin + metronidazole,
cefoxitin, cefotetan
Cefazolin + metronidazole,
cefoxitin, cefotetan
Cefazolin
Cefazolin + metronidazole,
Cefazolin
cefoxitin, cefotetan,
Cefazolin + metronidazole,
ampicillin/sulbactam,
cefoxitin, cefotetan,
ceftriaxone
+
ampicillin/sulbactam,
metronidazole,
ertapenem
ceftriaxone +
None
metronidazole, ertapenem
clean
Jen - this
page is too
Head and neck, None
long. You’ll
to Cefazolin, cefuroxime
Head
and neck,
clean have
of
shortenplacement
it
somehow.
Head and neck, Cefazolin, cefuroxime
prosthetic
placement of
prosthetic
Cleancontaminated
Clean- surgery
cancer
contaminated
cancer surgery
Cefazolin + metronidazole,
cefuroxime +
Cefazolin + metronidazole,
metronidazole,
cefuroxime +
ampicillin/sulbactam
metronidazole,
ampicillin/sulbactam
2
Redosing Interval (hours)
Not
Not necessary
necessary
ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM
Not necessary
ALLERGY
ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM
None
ALLERGY
None
Clindamycin
or vancomycin + aminoglycoside
or aztreonam or fluoroquinolone
Clindamycin or vancomycin + aminoglycoside
or aztreonam or fluoroquinolone
Clindamycin + aminoglycoside or
aztreonam or fluroquinolone
Clindamycin + aminoglycoside or
aztreonam or fluroquinolone
Metronidazole
+ aminoglycoside or
fluoroquinolone
Metronidazole + aminoglycoside or
fluoroquinolone
Clindamycin,
vancomycin
Clindamycin,+vancomycin
Clindamycin
aminoglycoside or
aztreonam or fluroquinolone;
Clindamycin + aminoglycoside
or or
Metronidazole
+ aminoglycoside
aztreonam or fluroquinolone;
fluoroquinolone
Metronidazole + aminoglycoside or
fluoroquinolone
None
None
Clindamycin
Clindamycin
Clindamycin
Clindamycin
References:
1.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283.
References:
1.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283.
PAGE 27
Antimicrobial Surgical Prophylaxis
Antimicrobial
Surgical
Prophylaxis
Antimicrobial
Surgical
Prophylaxis
ALTERNATIVES FOR PATIENTS WITH
SURGICAL PROCEDURE
RECOMMENDED AGENTS
SURGICAL PROCEDURE
RECOMMENDED AGENTS
Ortho: clean hand,
knee, or foot not
Ortho: clean hand,
involving implantation
knee, or foot not
of foreign materials
involving implantation
Ortho:
implantation
of foreign
materials of
foreign material and/or
Ortho: implantation of
total joints
foreign material and/or
Urologic
with risk
total joints
factors for infection
Urologic with risk
Urologic,
without
factors forclean
infection
entry into urinary tract
Urologic, clean without
Urologic
entry intoinvolving
urinary tract
implanted prosthesis
Urologic involving
implanted prosthesis
None
BETA-LACTAM ALLERGY
ALTERNATIVES FOR PATIENTS WITH
None BETA-LACTAM ALLERGY
None
None
Cefazolin
Clindamycin, vancomycin
Cefazolin
Clindamycin, vancomycin
Fluoroquinolone,
TMP/SMX, cefazolin
Fluoroquinolone,
Cefazolin*
TMP/SMX, cefazolin
Aminoglycoside +/- clindamycin
Cefazolin*
Cefazolin ±
aminoglycoside,
Cefazolin ±
cefazolin ± aztreonam,
aminoglycoside,
ampicillin/sulbactam
cefazolin ± aztreonam,
Cefazolin*
ampicillin/sulbactam
Clindamycin, vancomycin
Clindamycin ± aminoglycoside or
aztreonam, vancomycin ±
Clindamycin ± aminoglycoside or
aminoglycoside or aztreonam
aztreonam, vancomycin ±
aminoglycoside or aztreonam
Fluoroquinolone, aminoglycoside ±
clindamycin
Fluoroquinolone, aminoglycoside ±
Fluoroquinolone,
aminoglycoside +
clindamycin
metronidazole or clindamycin
Fluoroquinolone, aminoglycoside +
metronidazole or clindamycin
Urologic, clean with
entry into urinary tract
Urologic, clean with
Cefazolin*
Urologic,
Cefazolin +
entry intocleanurinary tract
contaminated
metronidazole, cefoxitin
Urologic, cleanCefazolin +
contaminated
metronidazole, cefoxitin
TMP/SMX= trimethoprim/sulfamethoxazole
Aminoglycoside +/- clindamycin
Clindamycin, vancomycin
*Addition
a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile
TMP/SMX=oftrimethoprim/sulfamethoxazole
prosthesis)
*Addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile
prosthesis)
References:
1.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283.
References:
1.
Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283.
PAGE 28
Urinary
Tract:Catheter-Associated
Catheter-Associated
Urinary
Tract
Urinary Tract:
Urinary
Tract Infection
Infection
CLASSIFICATION
Asymptomatic
Bacteriuria
CLINICAL FINDINGS
• Positive urine culture
(≥ 100,000 cfu/mL of
≥ 1 bacterial species
in a single catheter
urine specimen)
AND
• No sign or symptoms
Remove catheter
No antibiotics unless the patient
is:
• Scheduled for urologic
procedure
• Pregnant
Scheduled Urologic Procedure:
SMX/TMP 1 DS tablet PO Q12H
OR
Ciprofloxacin 500 mg PO
OR
Ciprofloxacin 400 mg IV Q12H
Initiate within 24 hours prior to
procedure and until foley removed
Pregnant:
Amoxicillin 500 mg PO Q12H for
3 to 7 days
OR
Cephalexin 500 mg PO Q12H for
3 to 7 days
OR
Nitrofurantoin (MacroBID)‡
100 mg PO Q12H for 5 days
Symptomatic
AND
≥ 1 of the
following:
• Male
• Pyelonephritis
• Antibiotic use
in previous 90
days
• History of
infection with
MDRO
• Immunocompromised
• Functional or
anatomic
urologic
abnormality
• Severe sepsis
• Positive urine culture
(≥ 1,000 cfu/mL of ≥ 1
bacterial species in a
single catheter urine
specimen)
AND
• Presence of
signs/symptoms
Catheter still in place:
- Malaise/lethargy
- Fever
(≥100.4°F)/rigors
- Altered mental
status
- Flank pain
- Pelvic discomfort
- Acute hematuria
Catheter removed
within past 48 h:
- Dysuria
- Urgency
- Frequency
- Suprapubic
pain/tenderness
CLINICAL
CONSIDERATIONS
RECOMMENDED EMPIRIC REGIMENS
Outpatient:
SMX/TMP DS tablet PO Q12H
OR
Nitrofurantoin (MacroBID)‡
100 mg PO Q12H
OR
Ciprofloxacin 250 - 500 mg PO
Q12H
Inpatient:
Cefazolin 2 gm IV Q8H
OR
Cefepime 1 gm IV Q12H
OR
Ampicillin/sulbactam 1.5 gm IV
Q6H
Known or suspected ESBL
bacteria:
Meropenem 1 gm IV Q8H
OR
Ertapenem 1 gm IV Q24H
•
•
•
•
•
•
•
Obtaining routine
cultures in
asymptomatic
patients is NOT
recommended
In the presence of a
catheter, pyuria
(>5-10 WBC) in an
asymptomatic
patient is NOT an
indication for
antibiotic
treatment
Presence or
absence of odorous
or cloudy urine
alone is NOT an
indication for
antibiotic
treatment
Antibiotics do NOT
decrease
asymptomatic
bacteriuria or
prevent
subsequent UTI
Remove catheter
whenever possible
Narrow antibiotic
therapy when
organism and
susceptibilities are
known
Follow-up urine
cultures or
urinalysis are only
warranted for ongoing symptoms.
They should NOT
be obtained
routinely to
monitor response
to therapy
Duration of Treatment:
Prompt resolution: 7 days
Delay response: 10-14 days
cfu= colony forming units; DS= double strength; ESBL= extended spectrum beta-lactamase; H= hour(s); IV= intravenous;
MDRO= multi-drug resistant organism; PO= by mouth; Q= every; SMX/TMP= sulfamethoxazole/trimethoprim; UTI= Urinary Tract
Infection; WBC= white blood cell
‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis
PAGE 29
Urinary Tract:
Tract:
Urinary
Tract
Urinary
Tract:Non-Catheter-Associated
Non-CatheterAssociated
Associated
Urinary
Tract
Urinary
Non-Catheter
Urinary
Tract
Infection
/
Cystitis
Infection/Cystitis
Infection/Cystitis
LASSIFICATION
CCLASSIFICATION
Asymptomatic
Asymptomatic
Bacteriuria
Bacteriuria
LINICALFFINDINGS
INDINGS
CCLINICAL
Pyuria
• • Pyuria
(urinalysis>>5-5-10
10
(urinalysis
WBC)
WBC)
OR
OR
Positiveurine
urine
• • Positive
culture
culture
100,000cfu/mL)
cfu/mL)† †
(≥(≥100,000
AND
AND
Nosign
signororsymptoms
symptoms
• • No
(seebelow)
below)
(see
ECOMMENDEDEEMPIRIC
MPIRIC
RRECOMMENDED
EGIMENS
RREGIMENS
LINICAL
CCLINICAL
ONSIDERATIONS
CCONSIDERATIONS
Noantibiotics
antibioticsunless
unlessthe
thepatient
patient
No
is:
is:
Scheduledfor
forurologic
urologic
• • Scheduled
procedure
procedure
Pregnant
• • Pregnant
Obtainingroutine
routine
• • Obtaining
culturesinin
cultures
asymptomatic
asymptomatic
patientsisisNOT
NOT
patients
recommended
recommended
Antibioticsdo
doNOT
NOT
• • Antibiotics
decrease
decrease
asymptomatic
asymptomatic
bacteriuriaoror
bacteriuria
prevent
prevent
subsequentUTI
UTI
subsequent
ScheduledUrologic
UrologicProcedure:
Procedure:
Scheduled
SMX/TMP11DS
DStablet
tabletPO
POQ12H
Q12H
SMX/TMP
OR
OR
Ciprofloxacin500
500mg
mgPO
PO
Ciprofloxacin
OR
OR
Ciprofloxacin400
400mg
mgIVIVQ12H
Q12H
Ciprofloxacin
Initiatewithin
within24
24hours
hoursprior
priortoto
Initiate
procedureand
anduntil
untilfoley
foley
procedure
removed
removed
Pregnant:
Pregnant:
Amoxicillin500
500mg
mgPO
POQ12H
Q12Hfor
for
Amoxicillin
days
33toto77days
OR
OR
Cephalexin500
500mg
mgPO
POQ12H
Q12Hfor
for
Cephalexin
days
33toto77days
OR
OR
Nitrofurantoin(MacroBID)
(MacroBID)‡ ‡
Nitrofurantoin
100mg
mgPO
POQ12H
Q12Hfor
for55days
days
100
Symptomatic:
Symptomatic:
Complicated
Complicated
thefollowing:
following:
≥≥11ofofthe
Male
• • Male
Pyelonephritis
• • Pyelonephritis
Antibioticuse
useinin
• • Antibiotic
previous90
90days
days
previous
Historyofof
• • History
infectionwith
with
infection
MDRO
MDRO
Immuno• • Immunocompromised
compromised
Functionaloror
• • Functional
anatomic
anatomic
urologic
urologic
abnormality
abnormality
Severesepsis
sepsis
• • Severe
Pyuria
• • Pyuria
(Urinalysis≥≥55WBC)
WBC)
(Urinalysis
AND
AND
Positiveurine
urine
• • Positive
culture
culture
100,000cfu/mL)
cfu/mL)† †
(≥(≥100,000
AND
AND
Presenceofof
• • Presence
symptoms:
symptoms:
Dysuria
- - Dysuria
Urgency
- - Urgency
Frequency
- - Frequency
Suprapubicpain
pain
- - Suprapubic
AND/OR
AND/OR
Presenceofofsigns:
signs:
• • Presence
Fever
- - Fever
100.4°F)
(≥(≥100.4°F)
Alteredmental
mental
- - Altered
status
status
Leukocytosis
- - Leukocytosis
Outpatient:
Outpatient:
SMX/TMP11DS
DStablet
tabletPO
POQ12H
Q12H
SMX/TMP
OR
OR
Nitrofurantoin(MacroBID)
(MacroBID)‡ ‡
Nitrofurantoin
100mg
mgPO
POQ12H
Q12H
100
OR
OR
Ciprofloxacin250
250- -500
500mg
mgPO
PO
Ciprofloxacin
Q12H
Q12H
Inpatient:
Inpatient:
Cefazolin22gm
gmIVIVQ8H
Q8H
Cefazolin
OR
OR
Cefepime11gm
gmIVIVQ12H
Q12H
Cefepime
OR
OR
Ampicillin/sulbactam1.5
1.5gm
gmIVIV
Ampicillin/sulbactam
Q6H
Q6H
Narrowantibiotic
antibiotic
• • Narrow
therapywhen
when
therapy
organismand
and
organism
susceptibilitiesare
are
susceptibilities
known
known
Follow-upurine
urine
• • Follow-up
culturesoror
cultures
urinalysisare
areonly
only
urinalysis
warrantedfor
forononwarranted
goingsymptoms.
symptoms.
going
Theyshould
shouldNOT
NOT
They
beobtained
obtained
be
routinelytoto
routinely
monitorresponse
response
monitor
therapy
tototherapy
Knownororsuspected
suspectedESBL
ESBL
Known
bacteria:
bacteria:
Meropenem11gm
gmIVIVQ8H
Q8H
Meropenem
OR
OR
Ertapenem11gm
gmIVIVQ24H
Q24H
Ertapenem
DurationofofTreatment:
Treatment:
Duration
14days
days
77toto14
cfu=colony
colonyforming
formingunits;
units;ESBL=
ESBL=extended
extendedspectrum
spectrumbeta-lactamase;
beta-lactamase;H=
H=hour(s);
hour(s);IV=
IV=intravenous;
intravenous;MDRO=
MDRO=multi-drug
multi-drugresistant
resistant
cfu=
organism;PO=
PO=by
bymouth;
mouth;Q=
Q=every;
every;SMX/TMP=
SMX/TMP=sulfamethoxazole/trimethoprim;
sulfamethoxazole/trimethoprim;UTI=
UTI=Urinary
UrinaryTract
TractInfection;
Infection;WBC=
WBC=white
white
organism;
bloodcell
cellcount
count
blood
†Positiveurine
urineculture:
culture:
†Positive
ForWomen:
Women:22consecutive
consecutivevoided
voidedurine
urinespecimens
specimenswith
withisolation
isolationofof>10
>105 5cfu/mL
cfu/mLofofthe
thesame
samebacterial
bacterialstrain
strain
For
ForMen:
Men:AAsingle,
single,clean-catch,
clean-catch,voided
voidedurine
urinespecimen
specimenwith
withisolation
isolationofof>10
>105 5cfu/mL
cfu/mLfrom
from11bacterial
bacterialspecies
species
For
‡Nitrofurantoin:Contraindicated
ContraindicatedififCrCl<
CrCl<60
60mL/min
mL/minAND
ANDonly
onlyindicated
indicatedininacute
acutecystitis
cystitis
‡Nitrofurantoin:
NOTE:Dosing
Dosingbased
basedon
onnormal
normalrenal
renalfunction.
function.Refer
RefertotoTable
TableofofContents
Contentsfor
forsection
sectionon
onAntimicrobial
AntimicrobialDosing
Dosingfor
forAdult
Adult
NOTE:
PAGE 30
PatientsBased
Basedon
onRenal
RenalFunction
Function
Patients
Urinary Tract: Non-Catheter Associated Urinary Tract
Infection/Cystitis
UrinaryTract:
Tract: Non-Catheter
Non-Catheter-Associated
Urinary
AssociatedUrinary
UrinaryTract
Tract
CLINICAL
Urinary
Tract:
Non-Catheter
Associated
Urinary
Infection
/
Cystitis
C
LASSIFICATION
C
LINICAL FINDINGS
R
ECOMMENDED EMPIRIC
R
EGIMENS Tract
Infection/Cystitis
CONSIDERATIONS
Infection/Cystitis
CLINICAL
CLASSIFICATION
Symptomatic
Uncomplicated/
CLASSIFICATION
Cystitis
Symptomatic
• Female
Uncomplicated/
Symptomatic
AND
Cystitis
Uncomplicated/
• Female
No criteria for
•Cystitis
complicated
AND
• Female
(seecriteria
previous
•AND
No
for
page)
• complicated
No criteria for
(see
previous
complicated
page)
(see previous
page)
LINICAL FINDINGS
• CPyuria
≥5
C(Urinalysis:
LINICAL FINDINGS
WBC)
• Pyuria
(Urinalysis:
≥5
•AND
Pyuria
• WBC)
Positive urine
(Urinalysis:
≥5
culture (≥ 100,000
AND
WBC)
†
cfu/mL) urine
•AND
Positive
AND
100,000
• culture
Positive(≥urine
• cfu/mL)
Presence
culture †(≥of
100,000
symptoms:
AND
cfu/mL)†
- Dysuria
•AND
Presence
of
- Urgency
• symptoms:
Presence
of
Frequency
-- Dysuria
symptoms:
Suprapubic
--- Urgency
Dysuria
pain
-- Frequency
Urgency
-- Suprapubic
Frequency
- pain
Suprapubic
pain
RECOMMENDED
EMPIRIC R‡EGIMENS
Nitrofurantoin
(MacroBID)
100
mg PO Q12H for
5 daysREGIMENS
RECOMMENDED
EMPIRIC
OR
Nitrofurantoin
(MacroBID)‡
SMX/TMP
DS(MacroBID)
tablet
Q12H
for
‡
100
mg PO 1Q12H
for 5 PO
days
Nitrofurantoin
3 days
OR
100
mg PO Q12H for 5 days
SMX/TMP
DS tablet
PO Q12H
for
OR
Alternative1 agents
should
be avoided
3SMX/TMP
1 DStotablet
PO of
Q12H
for
ifdays
possible due
the risk
C. difficile
3
daysantibiotic resistance. IF patient
AND
Alternative
agents should be avoided
an allergy/contraindication
to the
ifhas
possible
due
to the
risk ofbeC.avoided
difficile
Alternative
agents
should
above
antibiotics
alternatives
include:
AND
antibiotic
resistance.
if possible
due to
the
risk ofIFC.patient
difficile
Ciprofloxacin
250
mg PO Q12H
for
3
has
allergy/contraindication
to the
ANDanantibiotic
resistance.
IF patient
days
OR
Cephalexin
500 mg PO
Q12H
above
antibiotics
alternatives
include:
has an
allergy/contraindication
to the
for
3 days
Ciprofloxacin
250 mg
PO Q12Hinclude:
for 3
above
antibiotics
alternatives
days
OR Cephalexin
500
PO Q12H
Ciprofloxacin
250 mg
POmg
Q12H
for 3
for
3 days
days
OR Cephalexin 500 mg PO Q12H
for 3 days
Urinary Tract: Prostatitis
Urinary
Prostatitis
CLASSIFICATIONTract:
PREFERRED
REGIMEN
Urinary
Tract:
Prostatitis
Urinary
Tract:
Prostatitis
Urine culture
CLINICAL
CONSIDERATIONS
should be
Cperformed
ONSIDERATIONS
ONLY IF:
• Urine culture
- History
be of
• should
Urine
culture
multiple
UTIs IF:
performed
should
be ONLY
OR MDRO
- History
of
performed
ONLY IF:
infection(s)
UTIs
- multiple
History of
• Narrow
antibiotic
OR
MDRO
multiple
UTIs
therapy
when
infection(s)
OR MDRO
organism
and
• Narrow
antibiotic
infection(s)
susceptibilities
are
• therapy
Narrow when
antibiotic
known
organism
and
therapy when
• susceptibilities
Follow-up
urineare
organism and
cultures
or UA are
known
susceptibilities
are
only
warranted
• Follow-up
urine for
known
on-going
or urine
UA are
• cultures
Follow-up
symptoms.
They
only
warranted
for
cultures
or UA
are
should
NOT
be for
on-going
only warranted
obtained
routinely
symptoms.
on-going They
to
monitor
should
NOT They
be
symptoms.
response
to be
obtained
routinely
should NOT
therapy
to
monitorroutinely
obtained
response
to
to monitor
therapy
response to
therapy
CLINICAL
CONSIDERATIONS
CLINICAL
Beta-lactams
DO NOT
CLINICAL
ONSIDERATIONS
haveCadequate
C
ONSIDERATIONS
penetration into
prostate
Beta-lactams
DO NOT
SMX/TMP
1 DS tabletRPO
Q12H
ALTERNATIVE
EGIMENS
OR
ALTERNATIVE REGIMENS
Levofloxacin
mg PO
SMX/TMP
1 DS500
tablet
PO once
Q12Hdaily
Outpatient
(Requires ID
Consult)
OR
have
adequateDO NOT
SMX/TMP
1 DS
tablet PO Q12H
Beta-lactams
Outpatient
Levofloxacin
500 mg PO 28
once
daily
penetration
into prostate
OR
have adequate
Duration of Treatment:
days
(Requires
ID Consult)
Levofloxacin
500 mg PO once daily
penetration into prostate
cfu= colony forming units; DS= double strength; H= hour(s);
MDRO=
multi-drug resistant organism; PO= by mouth; Q= every;
(Requires
ID Consult)
Duration
ofUrinary
Treatment:
28 days WBC= white blood cell count
SMX/TMP= sulfamethoxazole/trimethoprim; UA= urinalysis;
UTI=
Tract Infection;
Duration
of
Treatment:
28 days
cfu= colony forming units; DS= double strength; H= hour(s); MDRO= multi-drug resistant organism; PO= by mouth; Q= every;
Outpatient
CLASSIFICATION
CLASSIFICATION
Ciprofloxacin
mg PO
PREFERRED500
REGIMEN
Q12H
PREFERRED REGIMEN
Ciprofloxacin 500 mg PO
Q12H
Ciprofloxacin 500 mg PO
Q12H
ALTERNATIVE REGIMENS
•
†Positive urine culture:
SMX/TMP=
sulfamethoxazole/trimethoprim;
UA=H=
urinalysis;
UTI= Urinary
Tract Infection;
WBC= white
blood
cell count
cfu= colony
units;
DS= doublevoided
strength;
hour(s); MDRO=
multi-drug
resistant
organism;
PO=
by mouth;
Q= every;
5 cfu/mL
Forforming
Women:
2 consecutive
urine
specimens
with isolation
of >10
of the same
bacterial
strain
SMX/TMP=
UA=urine
urinalysis;
UTI=with
Urinary
TractofInfection;
WBC=
white
blood cell
count
Forsulfamethoxazole/trimethoprim;
Men: A single, clean-catch, voided
specimen
isolation
>105 cfu/mL
from
1 bacterial
species
†Positive urine culture:
Women:
2 consecutive voided urine specimens with isolation of >105 cfu/mL of the same bacterial strain
†PositiveFor
urine
culture:
‡Nitrofurantoin:
Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis
5 cfu/mL from 1 bacterial species
5 cfu/mL
For
A single,
clean-catch,
voided
urine
specimen
with
isolation
ForMen:
Women:
2 consecutive
voided
urine
specimens
with
isolation
of of
>10>10
of the same bacterial strain
For Men:
single,
clean-catch,
voidedRefer
urineto
specimen
isolation
of >105 on
cfu/mL
from 1 bacterial
NOTE: Dosing
basedA on
normal
renal function.
Table ofwith
Contents
for section
Antimicrobial
Dosingspecies
for Adult
‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis
Patients Based on Renal Function
‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients
Basedbased
on Renal
Function
NOTE: Dosing
on normal
renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function
References:
1. Hooton TM, Bradley SF, Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009
international clinical practice guidelines from the Infectious Disease Society of America. CID 2010;50:625-63.
References:
2. Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin
1.
Hooton
TM,2005
Bradley
Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009
Infect Dis.
Mar SF,
1;40(5):643-54.
References:
clinical
practice
guidelines
the Infectious
Disease
Society
America.
CID 2010;50:625-63.
3.
Gupta
et al.
International
clinical
guidelines
for the
treatment
of of
acute
cystitisurinary
and pyelonephritis
in in
women:
2010
1. international
HootonK,TM,
Bradley
SF, Cardena
DD,practice
et from
al. Diagnosis,
prevention,
and
treatment
ofuncomplicated
catheter-associated
tract infection
adults:A2009
2. Nicolle
LE,
Infectious
Diseases
Society
America
guidelines
forSociety
the diagnosis
and treatment
of asymptomatic
bacteriuria
adults.
update
by et
theal.
Infectious
Diseases
Society
ofofAmerica
and
European
for
Microbiology
and Infectious
Diseases.
Clin InfectinDis.
2011Clin
Mar
international
clinical
practice
guidelines
from
the
Infectious
Disease
Society
of America.
CID 2010;50:625-63.
Infect
Dis.
2005
Mar
1;40(5):643-54.
1;52(5):e103-20.
2. Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin
3. Gupta
et2005
al. International
clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010
Infect K,
Dis.
Mar 1;40(5):643-54.
byetthe
Diseases
Society
of America
and
Societyoffor
Microbiology
and Infectious
Diseases.
Clin Infect
Dis. 2011
3. update
Gupta K,
al.Infectious
International
clinical
practice
guidelines
forEuropean
the treatment
acute
uncomplicated
cystitis and
pyelonephritis
in women:
A Mar
2010
PAGE
31
1;52(5):e103-20.
update by the Infectious Diseases Society of America and European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar
1;52(5):e103-20.
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PAGE 32
© 2014 Rhode Island Board of Education
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are Part B reimburses for both the c
HealthCare www.unitedhea
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ma>on Services 401-­‐874-­‐918
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Recommended Immunization Schedules for Persons Aged 0 Through 18 years and Adults Aged 19 Years and Older - United States, 2013.
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PPSV23
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ects from either PPSV23 or PC
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MMWR Morb Mortal Wkly Rep.Contraindica>ons 2015; 64(34): 944-947.
both inac@vated vaccines. Yo
September 4, 2013. MMWR 2012; 61(40):8
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LG, Levin MJ, Davies
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2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58:e44-e100. doi: 10.1093/cid/cit684.
both inac@vated vaccines. Yo
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PAGE 33
weeks and then give MCV4-­‐D
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Side Eff
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Pneumococcal Vaccine
Pneumococcal Vaccination Information Sheet
PCV13 (Prevnar 13®) and PPSV23 (Pneumovax® 23)
COLLEGE OF PHARMACY
Facts About Pneumococcal Disease:
• Streptococcus pneumoniae bacteria (i.e., pneumococci) are usually found in the upper respiratory tract of
most people.
• Pneumococcal disease most commonly presents as a serious infection in the lungs (pneumonia), blood
(bacteremia), or brain (meningitis). The annual U.S. case estimate for invasive pneumococcal disease
(bacteremia and/or meningitis) is 40,000 and 4,250 deaths.
• Pneumococcal disease most often occurs in older people as well as in people with a predisposing condition
(e.g., immunosuppression, pulmonary disease, heart disease, diabetes). The disease rates for adults in
these groups can be more than 20 times those for adults without high-risk medical conditions.
• PPSV23 is 60–70% effective in preventing serious pneumococcal disease; it does not provide substantial
protection against all types of pneumonia (viral and bacterial). It is not a “pneumonia” vaccine.
Frequently Asked Questions:
Question: Can I get the influenza and pneumococcal vaccines at the same time?
Yes. These vaccines can be given at the same time. If giving two IM vaccinations, separate by one inch in the
body muscle to reduce likelihood of local reactions overlapping.
Question: If patients who are in a recommended risk group for PPSV23 or PCV13 aren’t sure if they
have previously received these vaccines, should healthcare providers vaccinate them?
Yes. If patients do not have a documented vaccination history for these two vaccines and their records are not
readily obtainable, you should administer the recommended doses. Extra doses will not cause harm to the
patient.
Question: Is an egg allergy a contraindication for PCV13 or PPSV23?
No. Both vaccinations are safe for persons with egg allergies.
Question: If my state has a registry, do I still need to give patients vaccine record cards?
Yes. Patient-held cards are an extremely important part of a person’s medical history. The person may move
to an area without a registry, and a personal record may be the only vaccination record available. In addition,
even within a state, all healthcare providers may not participate in the registry, and the personal record card
would be needed.
Question: My patient has had laboratory-confirmed pneumococcal pneumonia. Does he/she still need
to be vaccinated with PPSV23?
Yes. There are more than 90 known serotypes of pneumococcus (23 serotypes are in the current vaccine).
Infection with one serotype does not necessarily produce immunity to other serotypes. As a result, if the
person is a candidate for vaccination, he/she should receive it even after one or more episodes of invasive
pneumococcal disease.
Question: Why is pneumococcal vaccination recommended for smokers and asthmatics?
In 2008, the Advisory Committee on Immunization Practices (ACIP) reviewed new information that suggests
that asthma is an independent risk factor for pneumococcal disease among adults. ACIP also reviewed new
information that demonstrates an increased risk of pneumococcal disease among smokers. Consequently,
ACIP recommends to include both asthma and cigarette smoking as risk factors for pneumococcal disease
among adults age 19 through 64 years and as indications for PPSV23.
Acquired from www.immunize.org on September 4, 2013. We thank the Immunization Action Coalition.
MMWR Morb Mortal Wkly Rep 2012; 61(40):816-819.
PAGE 34
Pneumococcal Vaccine
Pneumococcal Vaccination Information Sheet
PCV13 (Prevnar 13®) and PPSV23 (Pneumovax® 23)
PPSV23
(Pneumovax®23)
COLLEGE OF PHARMACY
PCV13
Manufacturer:
Merck
www.merckvaccines.com/Products/Pneumovax/Pages/home
How Supplied:
(Prevnar13®)
Manufacturer:
Pfizer
http://www.pfizerpro.com/hcp/prevnar13
How Supplied:
0.5mL Single Dose Vial
Multi-Dose (5 dose Vial)
Prefilled Syringe
(10 per Package)
Storage and Handling:
Storage and Handling:
Refrigerate on Arrival
Store at 2◦C to 8◦C
DO NOT FREEZE
Discard after the expiration date
Refrigerate on Arrival
Store at 2◦C to 8◦C
DO NOT FREEZE
Discard after the expiration date
Special instructions:
Special instructions:
None
Shake well to obtain a homogeneous white suspension
Route of Administration:
Route of Administration:
0.5mL IM or SQ
0.5mL IM ONLY
Insurance Carrier Information:
Medicare www.medicarenhic.com 1-866-801-5304*
BCBS of RI www.bcbsri.com/providers 401-274-4848 1-800-230-9050
UnitedHealthCare www.unitedhealthcareonline.com 1-877-842-3210
RI Department of Health State Supplied Vaccination Program www.health.ri.gov/resources/immunization/
Contraindications and Precautions:
• Do not give PPSV23 or PCV13 to patients who have a history of a serious reaction (e.g., anaphylaxis) after
a previous dose of PCV13, PPSV23, or one of their components.
• Do not give PPSV23 and PCV13 simultaneously. For vaccine naive patients, give PCV13 first, followed by a
dose of PPSV23 ≥ 1 year† (unless patient in a population specified by ACIP to require shorter interval, see
page 1). For patients who have already received PPSV23, give PCV13 12 months after the most recent
dose of PPSV23.
• Vaccine Co-administration: (1) all vaccines used for routine vaccination in the United States can be given on
the same day; (2) an inactivated vaccine can be administered either on the same day as or at any time
before or after another inactivated or a live vaccine; and (3) any 2 LIVE vaccines that are not given on the
same day must be spaced at least 4 weeks apart. Zoster vaccine is a live, attenuated vaccine; injectable
influenza vaccine and pneumococcal polysaccharide vaccine are inactivated vaccines. So these 3 vaccines
can be given on the same day or at any time before or after each other. They should be given as separate
injections, not combined in the same syringe.
Side Effects:
• Most common side effects from either PPSV23 or PCV13 are soreness and redness at the injection site,
lasting 1-2 days.
Drug Information Services 401-874-9188
Monday-Friday 8:30 am - 4:00 pm EST
initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second
* An
pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine
was administered). Please note that the “interval” between the two different pneumococcal vaccines must be at least 11 full months or greater for Medicare reimbursement, not the
shorter “interval” recommended for specific populations identified by ACIP.
Acquired from www.immunize.org on September 4, 2013. We thank the Immunization Action Coalition.
† Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines: Recommendations of the Advisory Committee in Immunization Practice (ACIP)
MMWR Morb Mortal Wkly Rep. 2015; 64(34): 944-947.
PAGE 35
Individual Isolates
Cefotaxime
7*
Streptococcus pneumoniae
75
52
100
30
7
86
97
99
100
Moxifloxacin
98
95
100
0
47
0
100
100
10
0
28
38
86
98
98
100
29
89
66
98
100
100
100
100
75
10
0
100
95
86
*If < 30 isolates use caution extrapolating results; data may be inconclusive for therapeutic efficacy and
selection of empiric treatment.
74
Staphylococcus epidermidis
63
100
Chloramphenicol
111
Clindamycin
72
100
Oxacillin
79
100
Penicillin G
124
0
Erythromycin
25
99
Sulfamethoxazole
/Trimethoprim
Staphylococcus aureus
(MSSA)
Staphylococcus aureus,
Methicillin-resistant (MRSA)
Ampicillin
4*
Ciprofloxacin
Enterococcus faecium
Gentamicin
73
Nitrofurantoin
64
Tetracycline
99
Streptomycin
126
Vancomycin
Enterococcus fecalis
Inpatient/Outpatient
Isolates 2015
Gram Positive
Organisms:
Percent Susceptible (2015 Isolates)
Antibiogram
PAGE 36
Amikacin
Individual Isolates
71
93
100
109
Proteus mirabilis
Pseudomonas
aeruginosa
Serratia marcescens
8*
Stenotrophomonas
maltophilia
61
0
88
7
82
86
86
91
36
0
82
7
89
85
6
0
67
89
96
93
94
86
95
92
90
52
94
86
94
92
82
100 100
89
89
86
79
94
86
94
92
84
100
67
68
0
92
7
81
85
36
83
33
93
91
78
65
86
91
75
94
100
78
100
95
96
100
0
0
0
100 37
100 97
100 26
100 100 83
92
77
92
71
96
88
96
0
100 93
100 100
89
96
52
94
100
100
97
94
73
100
100
64
*If < 30 isolates use caution extrapolating results; data may be inconclusive for therapeutic efficacy and
selection of empiric treatment.
0
100
28*
Klebsiella oxytoca
0
71
72
100
Haemophilus influenzae 25*
23
70
100
49
Morganella morganii
7
14*
Klebsiella pneumoniae
78
92
0
58
52
79
99
246 100
82
100
Escherichia coli
36
50
Enterobacter cloacae
10
8
Ampicillin
49
Cefazolin
0
Ceftriaxone
100
Aztreonam
78
Cefuroxime
Enterobacter aerogenes 12* 100
Ampicillin
/Sulbactam
33
86
Nitrofurantoin
11
100
Piperacillin/
tazobactam
100
Cefepime
9*
Cefotaxime
Citrobacter freundii
Ceftazidime
83
Ciprofloxacin
83
Gentamicin
55
Imipenem
79
Tetracycline
100
100
93
100
76
57
91
72
78
100
67
79
Sulfamethoxazole
/Trimethoprim
14*
0
98
50
75
0
23
0
0
100
Tobramycin
Acinetobacter
baumanni
Inpatient/Outpatient
Isolates 2015
Gram Negative
Organisms:
Percent Susceptible (2015 Isolates)
Antibiogram
PAGE 37
Guidelines
for for
Restricted
Antimicrobials
Guidelines
Restricted
Antimicrobials
I.














II.
The use of the following formulary antimicrobial agents are restricted
Antibiotics
Ceftaroline (Teflaro®)
Ceftazidime/avibactam (Avycaz®)
Ceftolozane/tazobactam (Zerbaxa®)
Colistin (Polymyxin E)
Dalbavancin (Dalvance®)
Daptomycin (Cubicin®)
Ertapenem (Invanz®)
Fidaxomicin (Dificid®)
Fosfomycin (Monurol®)
Linezolid (Zyvox®)
Oritavancin (Orbactiv®)
Polymyxins
Polymyxin B
Colistin (Polymyxin E)
Tedizolid (Sivextro®)
Tigecycline (Tygacil®)




Antifungals
Amphotericin B lipid complex
(AmBisome®)
Caspofungin (Cancidas ®)
Isavuconazonium sulfate (Cresemba®)
Voriconazole (V-Fend®)
To ensure the rational use of formulary, restricted, or non-formulary antimicrobial
agents, the following policies and procedures are to be used:
1.
When a prescriber wishes to prescribe a restricted or non-formulary antimicrobial
agent, he/she shall indicate the “approved” reason (see following pages) in the
comments section of the order form. If the use is outside of an approved indication, the
physician MUST obtain approval of use. This approval must be obtained from the
Infectious Diseases consult team, by directly contacting the on-call Infectious Diseases
physician/fellow or by calling the Department of Medicine who will contact the on-call
Infectious Diseases physician/fellow.
2.
When pharmacy receives an order for a restricted antimicrobial agent, the pharmacist
will verify the “approved” reason for use and if applicable, fill the order. If the
pharmacy receives an order for a restricted or non-formulary antimicrobial agent and
the ordering box does not indicate an approved reason for use, the pharmacist will
immediately contact the prescriber to obtain “criteria for use of a restricted agent.”
3.
If the prescriber cannot be reached, the pharmacist will dispense a maximum 24 hour
supply of the drug. The pharmacist MUST notify the prescriber that the further drug
will be dispensed only when the completed order form or ID approval is received. It is
up to the prescriber to obtain authorization from the Infectious Diseases fellow or
Infectious Diseases consult team.
PAGE 38
Ceftaroline
(Teflaro®)
Ceftaroline
(Teflaro®)
IV Only
Use requires formal ID Consult
Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus
pneumoniae, most gram-negatives, and some gram-positive anaerobic bacteria
NOT ACTIVE against Pseudomonas spp., Acinetobacter spp., or Enterococcus spp.
Criteria for Use:

Acute bacterial skin and skin structure infection (ABSSSI) caused by MRSA +/bacteremia or community-acquired bacterial pneumonia (CABP)

Unable to use vancomycin (VAN; due to intolerance, MIC ≥ 2 mg/mL, or
infection unresponsive to VAN despite therapeutic concentrations)

Unable to use other agents (refer to empiric therapy for ABSSSI/CABP)
Unacceptable Uses:

Treatment of P. aeruginosa, Enterococcus spp., or Acinetobacter spp. Infections
(limited to no activity)

Treatment of ESBL producing organisms, such as E. coli or Klebsiella spp.
(inactivated by AmpC and ESBL beta-lactamases)

Known serious hypersensitivity to ceftaroline or other members of the
cephalosporin class. Cross-reactivity may occur in patients with a history of
other beta-lactam allergies
Dosing in Adults:

Standard dose: 600 mg IV Q12H
For MSSA/MRSA bacteremia consider: 600 mg IV Q8H

Renal dose adjustment:
CrCl 30-50 mL/min: 400 mg IV Q12H
CrCl 15-30 mL/min: 300 mg IV Q12H
CrCl <15 mL/min: 200 mg IV Q12H
Hemodialysis: 200 mg IV Q12H

All infusions should be over 1 hour

No hepatic dose adjustment
Monitoring:

Monitor CBC for drug-induced hemolytic anemia (none observed in studies, but
seroconversion from negative to positive Direct Coombs’ Test is observed in
10.8% on ceftaroline vs 4.4% on comparator)
ABSSSI= Acute bacterial skin and skin structure infection; CABP= community-acquired bacterial pneumonia; CBC= Complete
blood count; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= infectious diseases;
IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus;
MSSA= Methicillin-susceptible Staphylococcus aureus; Q= every; spp= Species; VAN= vancomycin
PAGE 39
Ceftazidime/avibactam
Ceftazidime/avibactam
(Avycaz®)(Avycaz®)
IV Only
Use requires formal ID Consult
Use reserved for patients who have limited or no alternative treatment options
since it was approved based upon limited clinical safety and efficacy data
Activity: Coverage against many resistant gram-negatives such as Enterobacteriaceae
and Pseudomonas aeruginosa, including some ESBL producers (e.g. CTX-M),
carbapenemases (e.g. KPC, some OXA ), and AmpCs
NOT ACTIVE against MBLs or gram-negatives that overexpress efflux pumps or have
porin mutations, and most anaerobic bacteria
Criteria for Use:

Treatment of cIAI (in combination with metronidazole) or cUTI, including
pyelonephritis, caused by MDR gram-negative organisms
Unacceptable Uses:

Empiric use without confirmed susceptibility

Treatment of cIAI and cUTI with other available treatment options

Known serious hypersensitivity to the components of ceftazidime/avibactam,
avibactam-containing products, or other members of the cephalosporin class.
Cross-reactivity may occur in patients with a history of penicillin allergy
Dosing in Adults:

Standard dose: 2.5gm IV Q8H
For cIAI must use in combination with metronidazole

Renal dose adjustment:
CrCl 31 - 50 mL/min: 1.25gm IV Q8H
CrCl 16-30 mL/min: 0.94gm IVQ12H
CrCl 6-15 mL/min: 0.94gm IV Q24H
CrCl <5 mL/min: 0.94gm IV Q48H
Administer after hemodialysis

No hepatic dose adjustment anticipated
Monitoring:

Scr/BUN at baseline and daily; adjust dose accordingly. CBC with differential.
Monitor for signs of anaphylaxis with first dose
Considerations for Use:

Decreased efficacy in patients with = CrCl 30-50 mL/min in clinical trials

CNS reactions have been reported in patients treated with ceftazidime,
particularly in the setting of renal impairment
BUN= blood urea nitrogen; CBC= Complete blood count; cIAI= Complicated intraabdominal infections; CNS= Central nervous
system; CrCl= Creatinine clearance; cUTI= complicated urinary tract infections; ESBL= extended-spectrum beta-lactamases;
H= hour(s); ID= infectious diseases; IV= Intravenous; KPC= Klebsiella pneumoniae carbapenemases; MBL= metallo-betalactamases; MDR= multi-drug resistant; Q= every; Scr= Serum creatinine
PAGE 40
Ceftolozane/tazobactam
(Zerbaxa®)
Ceftolozane/tazobactam
(Zerbaxa®)
IV Only
Use requires formal ID Consult
Activity: Coverage against many MDR gram-negatives such as Enterobacteriaceae and
Pseudomonas aeruginosa. Potent in vitro activity against most P. aeruginosa isolates,
including some MDR and carbapenem-resistant strains. Inhibits many
Enterobacteriaceae, including some ESBL producers (e.g. CTX-M) and some AmpCs
NOT ACTIVE against serine carbapenemases (e.g. KPCs or MBLs)
Criteria for Use:

Treatment of cIAI (in combination with metronidazole) or cUTI, including
pyelonephritis, caused by MDR gram-negative organisms
Unacceptable Uses:

Empiric use without confirmed susceptibility

Treatment of cIAI and cUTI with other available treatment options

Known serious hypersensitivity to ceftolozane/tazobactam,
piperacillin/tazobactam, or other members of the beta-lactam class
Dosing in Adults:

Standard dose: 1500 mg IV Q8H
For cIAI must use in combination with metronidazole

Renal dose adjustment:
CrCl 30-50 mL/min: 750 mg IV Q8H
CrCl 15-29 mL/min: 375 mg IV Q8H
Hemodialysis: 750mg IV ONCE (load), then 150mg IV Q8H after dialysis

No hepatic dose adjustment anticipated
Monitoring:

Scr/BUN, CBC with differential at baseline and daily
Considerations for Use:

Package insert states decreased efficacy seen in patients with a baseline CrCl
<50mL/min or patients >65 years of age, in the cIAI trial

May have a role in the treatment of other infections caused by multidrug
resistant gram-negatives, however alternate dosing may be recommended
depending on site of infection. ID team must be consulted for all potential on
and off label use
BUN= blood urea nitrogen; CBC= Complete blood count; cIAI= Complicated intraabdominal infections; CrCl= Creatinine
clearance; cUTI= complicated urinary tract infections; ESBL= extended-spectrum beta-lactamases; ID= infectious disease;
IV= Intravenous; KPC= Klebsiella pneumoniae carbapenemases; MBL= metallo-beta-lactamases; MDR= multi-drug resistant;
Q= every; H= hour(s); Scr= Serum creatinine
PAGE 41
Dalbavancin
(Dalvance®)
Dalbavancin
(Dalvance®)
IV Only
Use requires formal ID Consult
Activity: Coverage against Staphylococcus aureus (including MSSA and MRSA),
Streptococcus pyogenes, Streptococcus agalactiae (Group B Strep.) and Streptococcus
anginosus group (including S. anginosus, S. intermedius, S. constellatus)
No clinical data, but activity in vitro vs. Enterococcus faecalis (vancomycin-susceptible
strains only), Enterococcus faecium (vancomycin-susceptible strains only),
vancomycin-intermediate S. aureus
(not vancomycin-resistant strains)
Criteria for Use:

Treatment of adult patients with acute bacterial skin and skin structure
infections (ABSSSI) caused by susceptible gram-positive isolates

Unable to use vancomycin (due to intolerance, MIC >2mg/L, or infection
unresponsive to vancomycin despite therapeutic concentrations)

Unable to use other agents (refer to empiric therapy for ABSSSI)
Unacceptable Uses:

Infections due to vancomycin-resistant enterococci

Contraindicated in patients with known hypersensitivity to dalbavancin. Due to
the possibility of cross-reactivity to glycopeptide, avoid in patients with previous
glycopeptide hypersensitivity due to long half-life
Dosing in Adults:

Standard dose: Administration should be over 30 minutes
1 Dose Regimen: 1500mg IV once
2 Dose Regimen: 1000mg IV once, then 500mg IV on day 8

Renal dose adjustment:
1 Dose Regimen CrCl <30 mL/min 1125 mg IV
2 Dose Regimen CrCl <30 mL/min: 750mg IV once, then 325mg IV day 8
If receiving regularly scheduled hemodialysis: No dosage adjustment

No hepatic dose adjustment anticipated
Monitoring:

Baseline BUN/Scr, AST/ALT/bili, CBC w/ diff, infusion-related reactions
Considerations for Use:

In clinical trials, 6 (0.9%) patients in the dalbavancin arm had ALT elevations
greater than 5x ULN including 3 with ALT >10x ULN. No subjects in the
comparator arm had this degree of ALT elevations
ABSSSI= acute bacterial skin and skin structure infections; ALT= Alanine aminotransferase; AST= Aspartate aminotransferase;
bili= Bilirubin; BUN= Blood urea nitrogen; CBC= Complete Blood Count; CrCl= Creatinine clearance; ID= infectious diseases;
IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus;
MSSA= Methicillin-susceptible Staphylococcus aureus; SCr= Serum creatinine; ULN= Upper Limit of Normal
PAGE 42
Daptomycin
(Cubicin®)
Daptomycin
(Cubicin®)
IV Only
Use requires formal ID Consult
Activity: Coverage against most gram-positive bacteria (including MRSA and VRE)
NOT ACTIVE against gram-negative bacteria
Criteria for Use:

MRSA bacteremia and/or endocarditis and unable to use vancomycin (due to
intolerance, MIC ≥ 2 mg/L, or infection unresponsive to vancomycin despite
therapeutic concentrations)

MRSA skin and skin structure infections in patients with true, serious allergic
reaction to vancomycin or linezolid

Patients receiving vancomycin for > 72 h for resistant staphylococcal skin and
skin structure infection without clinical improvement

VRE confirmed bacteremia (see dosing below, use high doses)
Formal ID consult for use in osteomyelitis or complicated skin and soft tissue infection
and all indications that are not listed above
Unacceptable Uses:

Empiric therapy

Pneumonia (lung surfactant inactivates daptomycin) or any lower respiratory
tract infection
Dosing in Adults:

Standard dose: 6-10 mg/kg IV Q24H of actual body weight (ABW)
May be dosed 8-10 mg/kg for Enterococcus (safety data for healthy volunteers
up to 12 mg/kg/day)

Renal dose adjustment:
CrCl < 30 mL/min: 8 mg/kg IV Q48H
Hemodialysis: 8 mg/kg IV Q48H

No hepatic dose adjustment
Monitoring:

Obtain CPK at baseline and weekly. Monitor for muscle pain or weakness, and
for signs/symptoms of eosinophilic pneumonia
Considerations for Use:

Consider discontinuation of concurrent statin therapy while on daptomycin due
to additive muscle toxicity
ABW= Actual Body Weight; CPK= Creatine phosphokinase; CrCl= Creatinine clearance; H= hour(s); ID= Infectious Disease;
IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every;
VRE= Vancomycin-resistant enterococci
PAGE 43
Ertapenem
(Invanz®)
Ertapenem
(Invanz®)
IV and IM Only
Use requires formal ID Consult
Activity: Coverage against many gram-negatives (including those that produce ESBL),
gram-positives, and anaerobes
NOT ACTIVE against Pseudomonas spp., Acinetobacter spp., MRSA, or Enterococcus
spp.
Criteria for Use:

Outpatient treatment of community acquired infections; outpatient settings
Unacceptable Uses:

Caution use of ertapenem in organisms producing AmpC beta-lactamase
without testing the organisms specifically against ertapenem susceptibility

Contraindicated in patients with documented hypersensitivity to beta-lactams

Treatment of P. aeruginosa, Acinetobacter spp., MRSA, or Enterococcus spp.
Infections
Dosing in Adults:

Standard dose: 1 gm IV or IM Q24H

Renal dose adjustment:
CrCl < 30 mL/min: 500 mg IV or IM Q24H
Hemodialysis: 500 mg IV or IM Q24H; supplemental dose of 150 mg after
dialysis if last 500 mg dose given within 6 hours prior to dialysis, no
supplemental dose necessary if last 500 mg dose given at least 6 hours prior
to dialysis

No hepatic dose adjustment
Monitoring:

Fever, CBC, hepatic function, pulmonary function (in pneumonia)
CBC= Complete blood count; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= Infectious
Disease; IM= Intramuscular; IV= Intravenous; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; Spp= Species
PAGE 44
Fidaxomicin
(Dificid®)
Fidaxomicin
(Dificid®)
PO Only
Use requires formal ID Consult
Patients with multiple Clostridium difficile infection (CDI) recurrences (i.e. severe or
mild-moderate CDI with greater than 2 and 3 recurrences, respectively) or severe,
complicated CDI should obtain ID and/or GI consult for optimal therapy
Criteria for Use:

Patient with severe CDI with a 2nd recurrence (previously received appropriate
therapy [i.e., vancomycin 125 mg PO Q6H for initial and 1st recurrence]).
Alternatively, a provider has the option to prescribe a vancomycin taper for a
2nd recurrence
OR

Patients with mild-moderate CDI with a 3rd recurrence (previously received
appropriate therapy i.e., vancomycin 125 mg PO Q6H for initial and 1st
recurrence and then a vancomycin taper for the 2nd recurrence)
Unacceptable Uses:

Treatment of systemic infections

Treatment of severe, complicated CDI (i.e., life-threatening or fulminant CDI or
toxic megacolon)

Use in combination with PO vancomycin or PO metronidazole
Dosing in Adults:

Standard dose: 200 mg PO Q12H for 10 days

No renal or hepatic dose adjustment

May be given with or without food; systemic absorption is minimal
Considerations for Use:

Fidaxomicin was only studied in patients with an initial episode or 1st
recurrence (defined as within 3 months of initial episode). Recurrence rates in
both phase III studies were significantly lower in patients treated with
fidaxomicin. However, in a subgroup analysis, recurrence rates were NOT
significantly lower in fidaxomicin-treated patients who had the hypervirulent
BI/NAP1/027 strain

The Society for Healthcare Epidemiology in America (SHEA) and Infectious
Diseases Society of America (IDSA) Clinical Practice Guidelines for CDI
recommend to discontinue therapy with the inciting antimicrobial as soon as
possible, as this may influence the risk of CDI recurrence
CDI= Clostridium difficile infection; FDA= Food and Drug Administration; GI= gastrointestinal; H= hour(s); ID= infectious diseases;
IDSA= Infectious Diseases Society of America; PO= Oral; Q= every; SHEA= Society for Healthcare Epidemiology in America
PAGE 45
Fosfomycin
(Monurol®)
Fosfomycin
(Monurol®)
PO Only
Use requires formal ID Consult
Activity: Coverage against many gram-negatives (including ESBL-producing and
carbapenem-resistant Enterobacteriaceae [such as E. coli, Klebsiella spp.]) and grampositives (including MRSA and VRE)
NOT ACTIVE against Acinetobacter spp.
In the United States only the oral formulation is available.
Criteria for Use:

Management of uncomplicated UTI in patients with multiple antibiotic allergies
and/or when no other oral therapy options are available

Uncomplicated UTI due to VRE

Salvage therapy for UTI due to multi-drug resistant organisms (e.g. ESBL, VRE,
+/- Pseudomonas; confirm fosfomycin susceptibility prior to initiation of
therapy)
Unacceptable Uses:

Management of any infections outside of the urinary tract. Oral fosfomycin
does not achieve adequate concentrations at other sites

Treatment of asymptomatic bacteriuria
Dosing in Adults:

Standard dose:
Uncomplicated UTI: 3 gm (1 sachet) PO once
Complicated UTI: 3 gm (1 sachet) PO every 2 to 3 days
(up to 21 days of treatment)
Powder should be mixed with 90-120 mL of cool water, stirred to dissolve
and administered immediately. May be administered with or without food

Renal dose adjustment:
CrCl < 50 mL/min: Frequency adjustment may be necessary; contact
antimicrobial stewardship team

No hepatic dose adjustment
Monitoring:

Signs and symptoms of urinary tract infection
CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; ID= Infectious Disease; MRSA= Methicillin-resistant
Staphylococcus aureus; PO= Oral; Spp= Species; UTI= Urinary Tract Infection; VRE= Vancomycin-resistant enterococci
PAGE 46
Linezolid
(Zyvox®)
Linezolid
(Zyvox®)
IV and PO Only
Use requires formal ID Consult
Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus
pneumoniae, VRE
Criteria for Use:

Vancomycin (VAN) MIC ≥ 2 mg/L in MRSA pneumonia

Patient with allergy to beta-lactams/vancomycin and organism resistant to other
antimicrobials

Significant VRE infections (i.e. isolated from a sterile site: blood, abscess)

Infections due to MRSA in patient with well documented intolerance to VAN
(NOTE: Red man syndrome is not a serious intolerance to VAN)
Formal ID consult for use in osteomyelitis or complicated skin and soft tissue
infection and all indications that are not listed above
Unacceptable Uses:

Empiric use when VRE has not been cultured or documented

Uncomplicated urinary tract infection

Positive respiratory culture for VRE

VRE colonization
Dosing in Adults:

Standard dose: 600 mg PO or IV Q12H
In patients tolerating PO medications, should be given orally
Oral formulation is completely absorbed and has 100% availability

No renal or hepatic dose adjustment
Monitoring:

CBC at baseline and weekly (MONITOR platelets at baseline and weekly)
Considerations for Use:

Caution in patients with thrombocytopenia. 3 percent of patients were noted to
have a platelet decrease <75% of baseline or lower limit of normal in controlled
trials (therapy <28 days, most < 21 days. Thrombocytopenia is reversible upon
discontinuation and is correlated with duration

Linezolid is a weak MAOI. Use in caution with decongestants
(i.e. pseudoephedrine) and serotonergic agents
(i.e. SSRIs [fluoxetine, escitalopram, sertraline, paroxetine, citalopram])
Warn patients to avoid large quantities of tyramine containing foods
CBC= Complete blood count; H= hour(s); ID= infectious disease; IV= Intravenous; MAOI= Monoamine oxidase inhibitors;
MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible
Staphylococcus aureus; PO= Oral; Q= every; SSRI= serotonin-specific reuptake inhibitors; VAN= Vancomycin; VRE= Vancomycinresistant enterococci
PAGE 47
Oritavancin
(Orbactiv®)
Oritavancin
(Orbactiv®)
IV Only
Use requires formal ID Consult
Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus
pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae, Streptococcus
anginosus group and vancomycin-susceptible Enterococcus faecalis
No clinical data, but activity in vitro vs. vancomycin-resistant enterococci and
vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus
Criteria for Use:

Treatment of adult patients with acute bacterial skin and skin structure
infections (ABSSSI) caused by susceptible gram-positive isolates

Unable to use vancomycin (due to intolerance, MIC >2, or infection
unresponsive to vancomycin despite therapeutic concentrations)

Unable to use other agents (refer to empiric therapy for ABSSSI)
Unacceptable Uses:

Patients with suspected osteomyelitis. If OM is suspected, alternative
antibacterial therapy should be initiated

Contraindicated in patients with known hypersensitivity to oritavancin. Due to
the possibility of cross-reactivity to glycopeptide, avoid in patients with
previous glycopeptide hypersensitivity due to long half-life.
Dosing in Adults:

Standard dose: 1200mg dose IV over 3 hours x1

No renal or hepatic dose adjustment
Monitoring:

SCr/BUN, AST, ALT, bilirubin, infusion-related reactions (pruritus, urticaria,
flushing), hypersensitivity reactions, signs/symptoms of OM
Considerations for Use:

The use of unfractionated heparin is contraindicated for 48 hours after
oritavancin administration due to artificial prolongation of aPTT

Co-administration of oritavancin and warfarin may result in higher exposure of
warfarin, which may increase the risk of bleeding

Oritavancin can artificially prolong aPTT for up to 120 Hr, and may prolong PT
and INR for up to 12 Hr and ACT for up to 24 Hrs
ABSSSI= acute bacterial skin and skin structure infections; ACT= Activated clotting time; ALT= Alanine aminotransferase;
aPTT= Activated partial thromboplastin time; AST= Aspartate aminotransferase; BUN= Blood urea nitrogen; ID= Infectious
Disease; INR= International normalized ratio; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillinresistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; OM= osteomyelitis; PT= Prothrombin
time; SCr= Serum creatinine
PAGE 48
Polymyxin
Polymyxin
B
B
IV Only
Use requires formal ID Consult
Polymyxin B and Colistin (also known as Polymyxin E or Colistimethate) are the two
polymyxin antibiotics. Their spectrum of activity is similar. However, their
pharmacology is very different. Polymyxin B is administered as the active drug and is
not cleared renally. Colistin is a prodrug (Colistimethate sodium) and is cleared
renally.
The product vials may be labeled as International Units (IU) or mg.
To avoid major dosing errors, carefully read vial labels. Recommend that all doses
be converted to mg.
Conversion: 10,000 International Units = 1 mg
Activity: Coverage against most gram-negatives, including many multi-drug resistant
(MDR) Enterobacteriaceae (such as E. coli, Klebsiella spp.; including ESBL-producing
and carbapenem-resistant Enterobacteriaceae), Pseudomonas spp., and Acinetobacter
spp.
NOT ACTIVE against Proteus, Serratia, Providencia, Burkholderia, Stenotrophomonas,
gram-negative cocci, gram-positive organisms, or anaerobes
Criteria for Use:

Treatment of infections due to MDR Enterobacteriaceae, Pseudomonas spp., and
Acinetobacter spp. with no other treatment options
Unacceptable Uses:

Empiric treatment of suspected gram-negative infections

Monotherapy for serious infections due to rapid resistance development

Treatment of UTIs. Colistin preferred over polymyxin B for UTIs
Dosing in Adults: Optimal dosing regimens are not well established

Standard dose: 2.5 mg/kg IV as a 2 hr infusion ONCE (load), then 12 hours later
start 1.5 mg/kg IV as a 1 hr IV infusion. Repeat Q12H

No renal or hepatic dose adjustment

Use actual body weight for dosing

Caution in use > maximum product recommended daily dose (300mg)
Monitoring:

BUN/ SCr at baseline and at least twice weekly
Considerations for Use:

The most important side effect of IV polymyxin B is nephrotoxicity (20-40% of
patients); less frequently reported concerns include neurotoxicity and
neuromuscular blockade

Recent literature suggests that nephrotoxicity rates may be lower with
polymyxin B as compared to colistin
BUN= Blood urea nitrogen; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= Infectious Diseases; IU= international
Units; IV= Intravenous; MDR= multi-drug resistant; Q= every; SCr= Serum creatinine; spp= Species; UTI= Urinary tract infection
PAGE 49
Colistin
(Polymyxin
E or Colistimethate)
Colistin
(Polymyxin
E or Colistimethate)
IV Only
Use requires formal ID Consult
Colistin (also known as Polymyxin E or Colistimethate) and Polymyxin B are the two
different polymyxin antibiotics. Colistin is a prodrug (Colistimethate sodium).
The product vials may be labeled as International Units (IU) of prodrug, or mg of the
active product: colistin base activity (CBA).
To avoid major dosing errors, carefully read vial labels.
Recommend that all doses be converted to mg of CBA.
Conversion: 1,000,000 units of Colistimethate (prodrug) = 80 mg of Colistimethate
(prodrug) = 30 mg of colistin base activity (CBA)
Activity: Coverage against most gram-negatives, including many multi-drug resistant
(MDR) Enterobacteriaceae (such as E. coli, Klebsiella spp.; including ESBL-producing
and carbapenem-resistant Enterobacteriaceae), Pseudomonas spp., and Acinetobacter
spp.
NOT ACTIVE against Proteus spp., Serratia spp., Providencia spp, Burkholderia spp,
Stenotrophomonas spp, gram-negative cocci, gram-positive organisms, or anaerobes
Criteria for Use:

Treatment of infections due to MDR Enterobacteriaceae, Pseudomonas spp., and
Acinetobacter spp. with no other treatment options

Treatment of UTI. Colistin preferred over polymyxin B for UTIs
Unacceptable Uses:

Empiric treatment of suspected gram-negative infections

Use as monotherapy due to rapid resistance development
Dosing in Adults: Optimal dosing regimens are not well established

Standard dose: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q12H

Renal dose adjustment:
CrCl 20-50 mL/min: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q24H
CrCl < 20 mL/min: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q48H
Hemodialysis: 5 mg CBA/kg ONCE (load), then 30 mg CBA IV Q12H, AD

No hepatic dose adjustment

Use ideal body weight in obese patients for dosing

Caution in use > max product recommended daily dose (300 mg CBA)
Monitoring:

BUN/ SCr at baseline and at least twice weekly
Considerations for Use:

The most important side effect of IV colistin is nephrotoxicity
(rates 50-60% of patients); less frequently reported concerns include
neurotoxicity and neuromuscular blockade
AD= After dialysis; BUN= Blood urea nitrogen; CBA= Colistin base activity; CrCl= Creatinine clearance; ESBL= Extended spectrum
beta-lactamase; H= hour(s); ID= infectious diseases; IU= international units; IV= Intravenous; MDR= multi-drug resistant;
Q= every; SCr= Serum creatinine; spp= species; UTI= Urinary tract infection
PAGE 50
Tedizolid
(Sivextro®)
Tedizolid
(Sivextro®)
IV and PO Only
Use requires formal ID Consult
Activity: Coverage includes Staphylococcus aureus (MSSA and MRSA), Streptococcus
pyogenes, Streptococcus agalactiae, Streptococcus anginosus group, and
Enterococcus faecalis
Criteria for Use:

Treatment of adult patients with acute bacterial skin and skin structure
infections (ABSSSI) caused by susceptible gram-positive isolates

Unable to use vancomycin (due to intolerance, MIC >2, or infection
unresponsive to vancomycin despite therapeutic concentrations)

Unable to use other agents (refer to empiric therapy for ABSSSI)
Unacceptable Uses:

Infections for other indications not listed above

Patients with neutropenia. Safety and efficacy in patients with neutrophil
counts <1000 cells/mm3 have not been assessed. Decreased activity in the
absence of granulocytes in animal models
Dosing in Adults:

Standard dose: 200 mg IV/PO once daily for 6 days

No renal or hepatic dose adjustment

No dose adjustment is necessary when changing from IV to PO
Monitoring:

CBC with differential
Considerations for Use:

Tedizolid has been shown to be a reversible inhibitor of monoamine oxidase
(MAO) in vitro, but no restrictions exist for concomitant use of drugs with
serotonergic and adrenergic activity or tyramine containing foods. Of note,
patients taking such medications were excluded from clinical trials. In vitro, in
vivo, and clinical studies indicate weak MAO inhibition and a low potential for
serotonergic adverse consequences

In phase 3 trials, reduction in hemoglobin, reduction in platelet count, and
reduction in absolute neutrophil count were similar between tedizolid and
linezolid

In phase 3 trials, adverse effects associated with neurologic and optic nerve
disorders did not differ between tedizolid and linezolid
ABSSSI= acute bacterial skin and skin structure infections; CBC= Complete Blood Count; ID= Infectious Disease; IV= Intravenous;
MAO= monoamine oxidase; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus;
MSSA= Methicillin-susceptible Staphylococcus aureus; PO= By Mouth
PAGE 51
Tigecycline
(Tygacil®)
Tigecycline
(Tygacil®)
IV Only
Use requires formal ID Consult
Activity: Coverage against MRSA, VRE, most gram-negatives, and anaerobes
NOT active against Pseudomonas aeruginosa or Proteus spp.
Criteria for Use:

Alternative therapy in patients with mixed aerobic-anaerobic infections and
severe allergy to beta-lactam agents, if VRE or MRSA are involved

Alternative therapy for patients with systemic infections due to ESBL-producing
organisms (Klebsiella spp., E. coli) with severe allergies to first-line therapy
(imipenem/cilastatin or meropenem)

Alternative therapy for selected isolates of Acinetobacter, Stenotrophomonas,
and VRE

Treatment of documented VRE infections in patients unable to take linezolid
Unacceptable Uses:

Treatment of P. aeruginosa or Proteus spp. infections

Urinary tract infections (low urinary concentrations)

Peak serum concentrations do not exceed 1 mcg/mL, which limits its use for
treatment of bacteremia
Dosing in Adults:

Standard dose: 100 mg IV load x1, then 50 mg IV Q12H (use higher doses for
infections due to Acinetobacter and other MDR organisms)
Infuse each dose over 30 to 60 minutes

No renal dose adjustment
Supplemental dosing is not necessary following hemodialysis

Hepatic dose adjustment:
Severe hepatic disease (Child Pugh C): 100mg IV load x1, then 25 mg IV Q12H
Important Side Effects:

Nausea and vomiting (most common in first 1-2 days of therapy)

To minimize GI side effects avoid fasting state administration

Prolonging the infusion time (>1 hour) may make GI side effects worse

Shortening infusion time (<30 minutes) may increase the incidence of infusion
related reactions (inflammation, pain, phlebitis, other)
Management of tigecycline-induced nausea and vomiting:

Ondansetron (Zofran®): Single dose of 8-12 mg IV or 8-24 mg PO
ESBL= Extended spectrum beta-lactamase; GI= Gastrointestinal; H= hour(s); ID= infectious diseases; IV= Intravenous; MDR= multidrug resistant; MRSA= Methicillin-resistant Staphylococcus aureus; PO= by mouth; Q= every; spp= species; VRE= Vancomycinresistant enterococci
PAGE 52
Liposomal Amphotericin
Amphotericin BB (L-AmB)(AmBisome®)
(L-AMB)(AmBisome®)
Liposomal
IV Only
Use requires formal ID Consult
Activity: Broad-spectrum antifungal activity with in vitro activity against Candida,
Cryptococcosis, Aspergillus, Zygomycosis, and Fusarium
Dosing of AmBisome and Amphotericin B deoxycholate is significantly different and
not interchangeable. Do not use AmBisome doses when ordering Amphotericin B
deoxycholate and vice versa
Criteria for Use:

Pre-existing renal insufficiency defined as SCr of ≥ 2 mg/dL or calculated CrCl of
≤ 25 mL/min, or SCr doubled from baseline

Patient refractory to or cannot tolerate conventional amphotericin B
deoxycholate

SCr > 1.5 mg/dL and receiving concomitant cyclosporine or tacrolimus

Patients with irreversible ESRD on chronic HD or PD should receive amphotericin
B deoxycholate
Dosing in Adults:

Standard dose:
Febrile neutropenia: 3 mg/kg/day, may consider 5 mg/kg/day in patients with
neutropenia > 10 days, evidence of fungal infection, or clinically unstable
Documented yeast (Candida spp., others) infection: 3-5 mg/kg/day
Documented mold (Aspergillus spp., others) infection: 3-5 mg/kg/day
Endopthalmitis: 5 mg/kg/day ± Flucytosine 25 mg/kg PO Q6H
Endocarditis: 5 mg/kg/day
Cryptococcal meningitis: 4 mg/kg/day ± Flucytosine 25 mg/kg PO Q6H

No renal/ hepatic dose adjustment
Monitoring:

BUN/SCr, K, Mg, Phos at baseline and daily in hospitalized patients; AST/ALT at
baseline and every 1-2 weeks
ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; BUN= Blood urea nitrogen; CrCl= Creatinine clearance;
ESRD= End-stage renal disease; H= hour(s); HD= Hemodialysis; ID= infectious diseases; IV= Intravenous; K= Potassium;
Mg= Magnesium; PD= Peritoneal dialysis; Phos= Phosphorus; PO= by mouth; Q= every; SCr= Serum creatinine; spp= species
PAGE 53
Caspofungin
(Cancidas®)
Caspofungin
(Cancidas®)
IV Only
Use Requires Formal ID Consult
Criteria for Use:
Invasive Aspergillosis:

Patients refractory to or who cannot tolerate conventional amphotericin B,
liposomal amphotericin B, or voriconazole

In combination with voriconazole or amphotericin B in patients with
documented invasive aspergillosis
Systemic Candida infections:

Systemic Candida infections secondary to C. glabrata or C. kruseii and other
non-Candida albicans (pending fluconazole susceptibility testing)

Patients unable to tolerate conventional amphotericin B or patients with
concomitant renal insufficiency as per liposomal amphotericin B guidelines

Patients unable to tolerate fluconazole as defined by a serious rash, tripling of
baseline LFTs, or other adverse reaction

Empiric use until non-albicans is confirmed
Dosing in Adults:

Standard dose: 70 mg IV x1, then 50 mg IV Q24H

No renal dose adjustment

Hepatic dose adjustment:
Moderate hepatic impairment: 70 mg IV x1, then 35 mg IV Q24H

Patients receiving rifampin or phenytoin:
Consider 70 mg IV Q24H (due to enzyme induction effect)
Monitoring:

Aspartate aminotransferase (AST)/ Alanine aminotransferase (ALT) at baseline
and weekly
ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; H= hour(s); ID= infectious diseases; IV= Intravenous;
LFTs= Liver Function Tests; PO= by mouth; Q= every
PAGE 54
Isavuconazonium
sulfate
(Cresemba®)
Isavuconazonium
sulfate
(Cresemba®)
IV and PO Only
Use requires formal ID Consult
Activity: Coverage against most strains of the following microorganisms, both in vitro
and in clinical infections: Aspergillus flavus, Aspergillus fumigatus, Aspergillus niger,
and Mucorales such as Rhizopus oryzae and Mucormycetes species
Criteria for Use:

Treatment of invasive aspergillosis

Treatment of invasive mucormycosis
Unacceptable Uses:

Treatment for other fungal infections (Blastomyces, Histoplasma, etc.)

Contraindicated with known hypersensitivity to isavuconazole. Caution in use in
patients with hypersensitivity to other azoles

Contraindicated in patients with familial short QT syndrome
(shortens the QTc interval in a concentration-related manner)
Dosing in Adults:

Standard dose: 372 mg IV/PO Q8H x 6 doses (48 hours; load), then 372 mg
Q24H starting 12-24 hours after last loading dose

No renal or hepatic dose adjustment

IV must be administered via an infusion set with in-line filter (pore size 0.2-1.2
micron) and should be infused over a minimum of 1 hour

No dose adjustment is necessary when changing from IV to PO
Monitoring:

AST/ALT/bilirubin at baseline and every 1-2 weeks after
Considerations for Use:

Elevated LFTs have been reported in clinical trials. Elevations generally reversible
and do not require discontinuation

May cause fetal harm when administered to a pregnant woman
Important note regarding drug interactions:

Isavuconazole is a substrate/inhibitor of CYP3A4 and has multiple drug
interactions that may affect its levels and/or those of co-administered drugs.
Dose adjustment may be necessary

Some drugs with interactions of major significance include:
− Carbamazepine
− Cyclosporine
− Rifampin/rifabutin
− Warfarin
− Ritonavir
− Tacrolimus
− Sirolimus
− Phenytoin
ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; H= hour(s); ID= infectious diseases; IV= Intravenous;
LFT’s= Liver Function Tests; PO= by mouth; Q= every
PAGE 55
Voriconazole
(V-Fend®)
Voriconazole
(V-Fend®)
IV and PO Only
Use requires formal ID Consult
Activity: Does not cover zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
Criteria for Use:

Treatment of documented invasive aspergillosis

Used in combination with caspofungin in microbiologically or radiographically
confirmed Aspergillus

Serious mycosis infections due to Fusarium spp., Scedosporium apiospermum
Dosing in Adults:

Standard dose:
PO: 400 mg PO x2 doses (load), then 200 mg PO Q12H (oral formulation may
be used without dose adjustment)
IV: 6 mg/kg IV x2 doses (load), then 4 mg/kg IV Q12H
In patients tolerating PO medications, should be given orally
Voriconazole oral formulation is >95% bioavailable

Renal dose adjustment:
IV voriconazole should be avoided in patients with CrCl < 50 mL/min due to
visual disturbances and accumulation of cyclodextran vehicle (excipient)

Hepatic dose adjustment:
Moderate hepatic impairment: ½ maintenance dose (PO: 100mg PO q12H;
IV: 2 mg/kg IV Q12H)
Monitoring:

Aspartate aminotransferase (AST)/ Alanine aminotransferase (ALT)/ bilirubin at
baseline and every 1-2 weeks after
Important note regarding drug interactions:

Voriconazole has multiple drug interactions that may affect its levels and/or
those of co-administered drugs. Dose adjustment may be necessary

Some drugs with interactions of major significance include:
− Carbamazepine
− Tacrolimus
− Rifampin/rifabutin
− Cyclosporine
− Ritonavir
− Warfarin
− Sirolimus
− Phenytoin
ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; CrCl= Creatinine Clearance; H= hour(s); ID= infectious
diseases; IV= Intravenous; PO= by mouth; Q= every; spp= species
PAGE 56
Guidelines for Vancomycin Dosing and Determination of Trough Levels in
Guidelines
Vancomycin
Dosing
and Determination
Adult
Patients
Guidelines
for for
Vancomycin
Dosing and
Determination
of Trough Levels in
of
Trough
Adult
PatientsLevels in Adult Patients
Refer to Vancomycin Dosing Nomogram OR calculate dose as described below:
Refer
Dosing Nomogram
I. HowtotoVancomycin
calculate a vancomycin
dose: OR calculate dose as described below:
I. Howa)toObtain
calculate
a vancomycin
dose:
actual
body weight
(ABW)
a)
Obtain
actual
body weight
(ABW)on lean body weight; if morbidly obese use
NOTE:
do not
calculate
dose based
ABW
for
initial
loading
dose
and
monitor
or consult
ID.
NOTE: do not calculate
based
on leantrough
body weight;
if morbidly
obese use
ABW
for
initial
loading
dose
and
monitor
trough
or
consult
ID. endocarditis,
b) Loading Dose (LD): For more severe infections (i.e., Meningitis,
pneumonia,
a loading
dose of 25-30
ABW endocarditis,
b) Loading
Doseetc.)
(LD):consider
For more
severe infections
(i.e.,mg/kg
Meningitis,
pneumonia,
etc.)
consider
a
loading
dose
of
25-30
mg/kg
ABW
LD = 25-30 mg/kg (Use ACTUAL body weight)
LD = 25-30 mg/kg
body
weight)
c) Maintenance
dose (Use
(MD):ACTUAL
Calculate
each
maintenance dose:
c) Maintenance
dose
(MD):
Calculate
each
maintenance dose:
MD = 15 mg/kg (Use ACTUAL body weight)
MD = 15Populations:
mg/kg (Use ACTUAL body weight)
d.) Special
MorbidPopulations:
obesity ( 130% of IBW) use 30 mg/kg/day divided Q8H as obese
d.) Special
1,2,3 Obese
patients
often require
more
frequent
intervalsdivided
(i.e., Q8H)
Morbid obesity
( 130%
of IBW)
use dosing
30 mg/kg/day
Q8H
as obese
1,2,3 Obese
patients rarely
need doses
excess ofdosing
3.5 gmintervals
per day.(i.e.,
Suggest
at 1
often require
moreinfrequent
Q8H)starting
to
1.25 gm
Q8Hneed
and doses
adjustin
upward
patients
rarely
excessifofnecessary.
3.5 gm per day. Suggest starting at 1
to 1.25
gm Q8Hdose:
and adjust
upwardbe
if necessary.
Round
calculated
doses should
rounded to the nearest 250 mg
increment
(i.e., 500
mg, doses
750 mg,
1000be
mg,
1250 mg,
1500
mg, etc.)
Round calculated
dose:
should
rounded
to the
nearest
250 mg
increment
(i.e.,
500
mg,
750
mg,
1000
mg,
1250
mg,
1500
mg, etc.)
II. Estimate patient’s creatinine clearance (CrCl)
Use the
Cockcroft-Gault
equation.
(See
Pharmacokinetic Section for equation)
II. Estimate
patient’s
creatinine
clearance
(CrCl)
Use
the
Cockcroft-Gault
equation.
(See
Pharmacokinetic Section for equation)
III. Select dosing interval based on CrCl
III. Select dosing interval based on CrCl
Estimated CrCl (mL/min)
Estimated≥100
CrCl (mL/min)
Dosing interval to consider
Dosing interval
Q8Hto consider
≥100
80-99
80-99
50-79
Q8HQ8H
or Q12H
Q8HQ12H
or Q12H
50-79
25-49
<2525-49
mL/min
Q18HQ12H
or Q24H
Q18H
Q36H or
or Q24H
Q48H
<25 mL/min
Q36H or Q48H
Hemodialysis
Give an initial loading dose of
(checkHemodialysis
pre-dialysis level)
15-20loading
mg/kg dose of
Give an initial
(check pre-dialysis level)
Peritoneal dialysis
Re-dose patient15-20
with 15
mg/kg when serum
mg/kg
(IV
administration)
levelwith
≤ 2015mcg/mL
Peritoneal
dialysis
Re-dose patient
mg/kg when serum
(IV administration)
level ≤ 20 mcg/mL
If the estimated renal function (CrCl) is near the border of two dosing intervals, it may be
reasonable
to begin
the more
aggressive
interval;
dosedosing
can then
be modified
If the estimated
renalwith
function
(CrCl)
is near the
borderthe
of two
intervals,
it may ifbe
necessary
to serum
levels.
reasonableaccording
to begin with
the more
aggressive interval; the dose can then be modified if
ABW= Actual body
weight; CrCl=
Creatinine
clearance; H= hour(s); IBW= ideal body weight; ID= infectious diseases; LD= loading
necessary
according
to serum
levels.
dose; MD= maintenance dose; Q= every
ABW= Actual body weight; CrCl= Creatinine clearance; H= hour(s); IBW= ideal body weight; ID= infectious diseases; LD= loading
dose; MD= maintenance dose; Q= every
References:
1. Bauer LA, Black DJ, Lill JS. Vancomycin dosing in morbidly obese patients. Eur J Clin Pharmacol. 1998 Oct;54(8):621-5.
References:
2. Vance-Bryan K, Guay DR, Gilliland SS, et al. Effect of obesity on vancomycin pharmacokinetic parameters as determined by using a Bayesian
1. Bauer LA,technique.
Black DJ, Lill
JS. Vancomycin
in morbidly
obese patients. Eur J Clin Pharmacol. 1998 Oct;54(8):621-5.
forecasting
Antimicrob
Agentsdosing
Chemother.
1993 Mar;37(3):436-40.
2. Vance-Bryan
K, Guay
DR, Gilliland
et al. Effect of
obesity on vancomycin
pharmacokinetic
parameters
as determined
by usingChemother.
a Bayesian
3.
Blouin RA, Bauer
LA, Miller
DD, et SS,
al. Vancomycin
pharmacokinetics
in normal
and morbidly obese
subjects.
Antimicrob Agents
forecasting
technique. Antimicrob Agents Chemother. 1993 Mar;37(3):436-40.
1982
Apr;21(4):575-80.
3. Blouin RA, Bauer LA, Miller DD, et al. Vancomycin pharmacokinetics in normal and morbidly obese subjects. Antimicrob Agents Chemother.
1982 Apr;21(4):575-80.
PAGE 57
Guidelines
for Vancomycin
Dosing
and Determination
Guidelines
for Vancomycin
Dosing and
Determination
of Trough Levels in
of Trough
Adult
Patients Levels in Adult Patients
IV. Vancomycin Levels
Vancomycin levels are NOT needed in patients with stable renal function who are
on standard doses of vancomycin AND are on therapy for less than 5 days.
Vancomycin peak levels are rarely, if ever, indicated.
NOTE: Vancomycin demonstrates concentration-independent killing; therefore,
peak concentrations are NOT useful or correlated to clinical outcomes.
Measure Trough Concentrations Only if:
 Patient is receiving vancomycin therapy > 5 days
 Patient has unstable renal function
 Patient is on an unusual/aggressive dosing regimen
 Patient is morbidly obese (> 130% of IBW)
 Patient has severe or life threatening infection and is receiving concomitant
nephrotoxic drugs (i.e., cyclosporine, amphotericin B, aminoglycosides)
V. Implications for NURSING
Vancomycin needs to accumulate (steady state concentration) in order to
obtain an accurate concentration. Please DO NOT order a plasma level unless
3 doses have been administered on a given schedule (i.e., order trough prior to
the 4th dose) Exception: Dosing interval of 24 hours or longer
Trough level should be drawn within 30 minutes of the next dose
• Check what time the previous vancomycin dose (prior to the trough) was
administered
• Calculate how many hours are between the dose and level
• Interpret the level in the context of recent vancomycin doses
Example: If the patient is on 1gm Q12H and received a dose at 11pm, then a
level taken at 6am is 7 hours post-dose and is NOT a trough level.
• Be careful NOT to adjust OR hold vancomycin doses based on incorrectly
drawn levels
• Do NOT hold the next dose while waiting for trough results
(sub-therapeutic levels <15mcg/mL are not effective and can lead to
resistant pathogens)
H= hour(s); IBW= Ideal body weight; Q= every
PAGE 58
Guidelines for Vancomycin Dosing and Determination
of Trough Levels in Adult Patients
Guidelines for Vancomycin Dosing and Determination of Trough Levels in
Adult Patients
VI. Target Trough Vancomycin Level
Type of Infection
Target Trough Vancomycin Level
MRSA pneumonia, CNS infection
(meningitis), bacteremia, endocarditis,
osteomyelitis
15-20 mcg/mL
Endovascular Infection
15-20 mcg/mL
Hemodialysis
Serious infection and renal dysfunction
(CrCl < 25mL/min)
Maintain 15-20 mcg/mL
Check pre-dialysis level, re-dose when
≤ 20 mcg/mL
Often recommend to load with
15 – 20 mg/kg and re-dose
If ≥ 24H dosing check trough at 24 hours
Maintain 15-20 mcg/mL
VII. Adjusting a vancomycin dose (Recommendations)
Trough is too low- change the interval, keep the dose
• If the level is < 5 mcg/mL, the dosing INTERVAL should be shortened
Example: Trough level after 5 days of treatment reported as 3 mcg/mL on a
regimen of 1000 mg Q12H, the interval should be shortened to 1000 mg Q8H
Trough is too high- decrease the dose, keep the interval
• If the trough level is >25 mcg/mL, the DOSE should be decreased 50%
Example: Trough level after 5 days of treatment is reported as 29 mcg/mL on a
regimen of 1000 mg Q12H; the dose should be decreased to 500 mg Q12H
VIII. Monitoring (Inpatient)
• Baseline weight, BUN, serum creatinine, WBC, temperature, cultures, and
sensitivities should be taken every other day in stable patients
• Daily urinary IN’s and OUT’s, CBC, and temperature should be monitored;
should be performed in patients admitted to the ICU
BUN= Blood urea nitrogen; CBC= Complete Blood Count; CNS= Central nervous system; CrCl= Creatinine clearance; H= hour(s);
ICU= Intensive Care Unit; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; WBC= White blood cells
PAGE 59
1.5g q24h
1.25g q24h
1.25g q24h
1.5g q24h
85
90
95
≥100
1.25g q24h
1.25g q24h
80
1g q24h
1g q8h
1.25g q12h
1.25g q12h
1.25g q12h
1.25g q12h
1g q12h
1g q12h
1g q12h
1g q12h
750mg q12h
750mg q12h
500mg q12h
500mg q12h
500mg q12h
50
Contact Antimicrobial Stewardship Team
1.25g q24h
1.25g q24h
1.25g q24h
1g q24h
1g q24h
1.25g q24h
1g q24h
65
1g q24h
75
1g q24h
60
1g q24h
750mg q24h
750mg q24h
500mg q24h
500mg q24h
500mg q24h
40
70
1g q24h
500mg
q24h
500mg
q24h
500mg
q24h
750mg
q24h
750mg
q24h
30
55
50
45
40
35
30
CrCl
(mL/min)
Weight (kg)
Vancomycin Dosing Nomogram
1g q8h
1g q8h
1.25g q12h
1.25g q12h
1.25g q12h
1.25g q12h
1g q12h
1g q12h
1g q12h
1g q12h
750mg q12h
750mg q12h
500mg q12h
500mg q12h
500mg q12h
70
80
1.5g q8h
1.25g q8/12h
1.25g q8/12h
1.25g q8/12h
1.25g q8/12h
1g q8/12h
1g q8/12h
1g q8/12h
500mg
q8/12h
500mg
q8/12h
500mg
q8/12h
750mg
q8/12h
750mg
q8/12h
750mg
q8/12h
90
1.5g q8h
1.25g q8h
1.25g q8h
1.25g q8h
1.25g q8/12h
1g q8/12h
1g q8/12h
1g q8/12h
500mg
q8/12h
500mg
q8/12h
500mg
q8/12h
750mg
q8/12h
750mg
q8/12h
750mg
q8/12h
≥100
1.5g q8h
1.25g q8h
1.25g q8h
1.25g q8h
1.25g q8h
1g q8h
1g q8h
1g q8h
750mg q8h
750mg q8h
750mg q8h
500mg q8h
500mg q8h
500mg q8h
If Patient is obese: 30mg/kg/day in divided doses q8h
1.25g q12h
1.25g q12h
1.25g q12h
1.25g q12h
1g q12h
1g q12h
1g q12h
1g q12h
750mg q12h
750mg q12h
500mg q12h
500mg q12h
500mg q12h
60
Cr Cl in mL/min
Vancomycin Dosing Nomogram
weight in kg
PAGE 60
Guidelines
Administration
of High
Dose Once Daily
Guidelines for for
Administration
of High Dose
Once Daily
Aminoglycosides
(HDOD)
Aminoglycosides (HDOD)
High Dose Once Daily Aminoglycosides (HDOD) are considered safe and effective in
patients with stable renal function
Exclusion Criteria for HDOD:
If patients fall into the following categories, use traditional/conventional dosing since
there is limited data using HDOD in the following patient populations
Acute renal failure OR CrCl < 20 mL/min
Half-life (t1/2) ≥ 4 hours
Dialysis
Age < 18 OR > 90
Severe burns
Ascites
To use Traditional Dosing Methods, see
www.globalrph.com “medical calculator”
I.
II.
For AMG dosing, contact the Antimicrobial Stewardship team
or follow the steps below:
Calculate the patient’s Ideal Body Weight (IBW)
Male:
50 kg + [2.3 kg for each inch over 5 feet]
Female:
45 kg + [2.3 kg for each inch over 5 feet]
Determine the dose based on the table below (round dose to the nearest
20 mg)
Aminoglycoside
Maintenance Dose
Tobramycin
5 mg/kg (IBW)
Gentamicin
5 mg/kg (IBW)
• Dose is based on IBW except in obese patients OR those under their IBW
• Use ABW if patient weight is less than IBW
• Use AdjBW in patients who are obese (≥ 130% of IBW)
Adjusted Body Weight (AdjBW) Calculation
AdjBW = 0.4 (ABW – IBW) + IBW
III.
Estimate the patient’s creatinine clearance (CrCl) using the Cockcroft and Gault
equation
(refer to Pharmacokinetic Section)
IV.
Select dosing interval based on calculated CrCl from the tables below:
CrCl (mL/min)
Estimated Dosing Interval
≥ 60
Every 24 hours
40–59
Every 36 hours
20–39
Every 48 hours
≤ 20
Use traditional dosing method, see www.
Globalrph.com “medical calculator”
ABW= Actual Body Weight; AdjBW= Adjusted Body Weight; AMG= aminoglycosides (i.e., gentamicin and tobramycin);
CrCl= Creatinine clearance; HDOD= High Dose Once Daily Aminoglycosides; IBW= Ideal Body Weight (in kg); t1/2= half life
PAGE 61
Guidelines
for Administration
of Once
HighDaily
Dose Once Daily
Guidelines
for Administration
of High Dose
Aminoglycosides
Aminoglycosides
(HDOD)(HDOD)
V.
Commonly Targeted Peak and Trough Concentrations in HDOD
Disease State
Gentamicin/Tobramycin
Amikacin
Recommended
Peak (mcg/mL)
Estimated mg/kg
(IBW)
Recommended
Peak (mcg/mL)
Estimated mg/kg
(IBW)
6–8
2–3
30-40
10–15
6–8
2–3
30–40
10–15
12–14
3–4
60–70
20
16–20
5–6
60–80
20–25
Sepsis
10–12
3–4
60–70
20
Intra-abd/SSTI
12–16
4–5
60–70
20
Cystitis
Gram-Positive
Synergy
Pyelonephritis
Pneumonia
Clinical
Considerations
VI.
Trough should not exceed 0.3 mcg/mL
Trough should not exceed 1 mcg/mL
Monitoring of serum levels and dosage adjustments
a. First-dose levels are NOT routinely needed
 First-dose levels may be indicated in patients with variable volume of
distribution or unstable renal function (sepsis or post-operatively) to assess
clearance
b. Serum levels should be performed routinely by day 3 of therapy only once it has
been determined that aminoglycoside therapy is to continue
 Example: empiric therapy for sepsis from a UTI awaiting culture results does
not require peak/trough levels
c. Peak and trough serum levels: 1–2 hours post-end of infusion (peak) and
immediately prior to the next dose
 Document actual time medication was hung
 Obtain peak level 1-2 hour post infusion (very important for distribution
phase); 2 hr preferred if dose > 400 mg

Use pharmacokinetic formulas (or www.globalrph.com “medical calculator”),
to extrapolate peaks and troughs
 Extrapolated trough concentrations should not exceed 0.30 mg/mL
 Dosage or interval adjustments should be made at this time
d. Once stabilized, if therapy is to continue > 1 week, obtain the following laboratory
values:
 SCr and BUN levels to monitor renal function (every other day)
 Peak and trough levels (efficacy and no toxicity), twice per week
e. If there is a suggested change in renal function OR other nephrotoxic agents (e.g.,
cisplatin, amphotericin B, pentamidine, vancomycin) are being used concurrently,
more frequent levels of BUN, SCr, and monitoring may be necessary
BUN= Blood urea nitrogen; HDOD= high dose once daily; IBW= ideal body weight; SCr= Serum creatinine; SSTI= skin and soft
tissue infection; UTI= Urinary tract infection
PAGE 62
Antimicrobial
Dosing Guidelines for Adult Patients
Antimicrobial Dosing Guidelines for Adult Patients
Based
Function
Basedon
on Renal
Renal Function
CRCL (ML/MIN)
ACYCLOVIR IV
>50
30-50
10-29
<10
STANDARD DOSE
5 mg/kg Q8H
5 mg/kg Q12H
5 mg/kg Q24H
2.5 mg/kg Q24H
MAXIMAL DOSE
HD
10 mg/kg Q8H*
10 mg/kg Q12H*
10 mg/kg Q24H*
5 mg/kg Q24H*
D
Dose using ideal body weight
*Use maximum dose for meningitis/encephalitis and varicella in immunocompromised
host
AMOXICILLIN PO
> 30
10-29
<10
AMOXICILLIN/CLAVULANATE
PO
> 30
10-29
<10
250 mg Q8H
250 mg Q12H
500 mg Q24H
500 mg Q8H
500 mg Q12H
500 mg Q24H
500 mg Q8-12H*
500 mg Q12H
500 mg Q24H
875 mg Q12H
875 mg Q12H
875 mg Q24H
MD
MD
*Use 500 mg Q8H for osteomyelitis for CrCl ≥ 30 mL/min
AMPICILLIN IV
>50
30-50
10-29
<10
1 gm Q4-6H
1 gm Q8H
1 gm Q12H
1 gm Q24H
2 gm Q4-6H*
2 gm Q6-8H
2 gm Q8-12H
2 gm Q24H
AMPICILLIN/SULBACTAM IV
>50
30-50
10-29
<10
1.5 gm Q6H
1.5 gm Q8H
1.5 gm Q12H
1.5 gm Q24H
3 gm Q6H*
3 gm Q8H*
3 gm Q12H*
3 gm Q24H*
*Use 2 gm Q4H for meningitis
MD
MD
*Use 3 gm if penetration is an issue (abscess/diabetic foot /vascular insufficiency/
osteomyelitis/intra-abdominal)
AZTREONAM IV
>50
30-50
10-29
<10
CEFAZOLIN IV
>50
30-50
10-29
<10
1 gm Q8H
1 gm Q12H
1 gm Q24H
500 mg Q24H
2 gm Q6H
1 gm Q8H
1 gm Q12
1 gm Q24H
1 gm Q8H
1 gm Q8H
1 gm Q12H
1 gm Q24H (2gm
2 gm Q8H
2 gm Q8H
2 gm Q12H
2 gm Q24H
Q48H)
MD
MD
PAGE 63
Antimicrobial
Dosing Guidelines for Adult Patients
Antimicrobial Dosing Guidelines for Adult Patients
Based
RenalFunction
Function
Based on
on Renal
CRCL (ML/MIN)
CEFEPIME IV
>50
30-50
10-29
<10
STANDARD DOSE
1 gm Q12H
1 gm Q24H
1 gm Q24H
0.5-1 gm Q24H
MAXIMAL DOSE
2 gm Q12H
2 gm Q24H
1 gm Q24H
1 gm Q24H
HD
D
Pseudomonal Coverage or Febrile Neutropenia: >50: 2gm Q8H; 30-50: 2gm Q12H; 10-29:
1gm Q12H; < 10: 1gm Q24H
CEFPODOXIME PO
30
<30
HD
CEFUROXIME PO
20
< 20
CEFTRIAXONE IV
>50
<50-5 (INCLUDING HD)
100 – 200 mg Q12H
100 – 200 mg Q24H
100 – 200 mg 3 times
per week
400 mg Q12H
400 mg Q24H
400 mg 3 times per
week
250 mg Q12H
250 mg Q24H
500 mg Q12H
500 mg Q24H
MD
1 gm Q24H
No Change
2 gm Q24H*
No Change
SD
MD
*All indications are dosed at 1gm Q24H with the exception of meningitis (2 gm Q12H)
and osteomyelitis (2 gm Q24H)
CEPHALEXIN PO
>30
10-29
<10
CIPROFLOXACIN IV
>30
10-29
<10
250 mg Q6H
250 mg Q8H
250 mg Q12H
500 mg Q6H
500 mg Q8H
500 mg Q12H
400 mg Q12H*
400 mg Q24H
400 mg Q24H
400 mg Q8H*
400 mg Q12H
400 mg Q24H
500 mg Q12H
500 mg Q24H
250 mg Q24H
750 mg Q8H
750 mg Q12H
500 mg Q24H
600 mg Q8H
No Change
900 mg Q8H
No Change
ND
300 – 450 mg Q8H
No Change
450 mg Q6H
No Change
ND
*Use Q8H dosing only for Pseudomonas aeruginosa
CIPROFLOXACIN PO
>30
10-29
<10
CLINDAMYCIN IV
>50
<50
CLINDAMYCIN PO
>50
<50
MD
SD
SD
PAGE 64
Antimicrobial
Dosing
Guidelines
for Adult
Patients
Antimicrobial
DosingGuidelines
Guidelines
Adult
Patients
Antimicrobial Dosing
for for
Adult
Patients
Based
Function
Basedon
on Renal
Renal Function
Based
on
Renal
Function
C
CRRC
CLL ((M
ML/
L/MIN
MIN))
D
DICLOXACILLIN
ICLOXACILLIN PO
PO
>50
>50
<50
<50
D
DOXYCYCLINE
OXYCYCLINE PO
PO
>50
>50
<50
<50
FFLUCONAZOLE
LUCONAZOLE IV/PO*
IV/PO*
>30
>30
10-29
10-29
<10
<10
SSTANDARD
TANDARD D
DOSE
OSE
M
MAXIMAL
AXIMAL D
DOSE
OSE
250
250 –– 500
500 mg
mg Q6H
Q6H
No
Change
No Change
250
250 –– 500
500 mg
mg Q6H
Q6H
No
Change
No Change
100
100 mg
mg Q12H
Q12H
No
Change
No Change
100
100 mg
mg Q12H
Q12H
No
Change
No Change
200
200 mg
mg Q24H
Q24H
100
100 mg
mg Q24H
Q24H
100
100 mg
mg Q48H
Q48H
400
400 mg
mg Q24H**
Q24H**
200
200 mg
mg Q24H
Q24H
200
200 mg
mg Q48H
Q48H
2.5-5*mg/kg
Q24H
2.5-5*mg/kg Q24H
1.25
mg/kg
Q24H
1.25 mg/kg Q24H
0.625
0.625 mg/kg
mg/kg Q24H
Q24H
0.625 mg/kg
mg/kg Q48H
Q48H
0.625
5
5 mg/kg
mg/kg Q12H
Q12H
2.5
2.5 mg/kg
mg/kg Q24H
Q24H
1.25
1.25 mg/kg
mg/kg Q24H
Q24H
1.25 mg/kg
mg/kg Q48H
Q48H
1.25
HD
HD
ND
ND
ND
ND
MD
MD
*RECOMMENDATIONS
*RECOMMENDATIONS FOR
FOR SYSTEMIC
SYSTEMIC INFECTION
INFECTION ONLY,
ONLY, NOT
NOT FUNGURIA.
FUNGURIA.
Give
Give PO
PO if
if patient
patient has
has functioning
functioning GI
GI tract
tract
**May
**May require
require dosages
dosages up
up to
to 800
800 mg/d
mg/d depending
depending on
on Candida
Candida species/sensitivities
species/sensitivities
G
GANCICLOVIR
ANCICLOVIR IV
IV
>50
>50
30-50
30-50
10-29
10-29
<10
<10
D
D
*5
*5 mg/kg
mg/kg for
for CrCl
CrCl ≥70
≥70 mL/min,
mL/min, 2.5
2.5 mg/kg
mg/kg for
for CrCl
CrCl 50-69
50-69 mL/min
mL/min
G
GANCICLOVIR
ANCICLOVIR PO
PO
>50
>50
30-50
30-50
10-29
10-29
<10
<10
IIMIPENEM
MIPENEM/C
/CILASTATIN
ILASTATIN
>50
>50
30-50
30-50
10-29
10-29
<10
<10
1
1 gm
gm Q8H
Q8H
1-1.5
gm Q24H
Q24H
1-1.5 gm
500
mg
Q24H
500 mg Q24H
500
500 mg
mg Q48H
Q48H
D
D
500
500 mg
mg Q6H
Q6H
500
500 mg
mg Q8H
Q8H
500
500 mg
mg Q12H
Q12H
250
250 mg
mg Q12H
Q12H
1
1 gm
gm Q6H*
Q6H*
500
500 mg
mg Q6H*
Q6H*
500
500 mg
mg Q8H*
Q8H*
500
500 mg
mg Q12H*
Q12H*
M
MEROPENEM
EROPENEM IV
IV
50
>> 50
26
26 –– 50
50
10
10 –– 25
25
<10
<10 OR
OR HD*
HD*
1
1 gm
gm Q8H
Q8H
1
1 gm
gm Q12H
Q12H
500
500 mg
mg Q12H
Q12H
500
500 mg
mg Q24H
Q24H
2
2 gm
gm Q8H
Q8H
1
1 gm
gm Q8H
Q8H
1
1 gm
gm Q12H
Q12H
1
1 gm
gm Q24H
Q24H
M
METRONIDAZOLE
ETRONIDAZOLE IV/PO*
IV/PO*
>10
>10
<10
<10
500
500 mg
mg Q8H
Q8H
500
500 mg
mg Q12H
Q12H
500
500 mg
mg Q8H
Q8H
500
500 mg
mg Q12H
Q12H
MD
MD
For
For suspected
suspected pseudomonas
pseudomonas or
or ESBL
ESBL infection
infection use
use max
max doses
doses
MD
MD
*If
*If patient
patient on
on HD
HD schedule
schedule daily
daily dose
dose to
to be
be administered
administered immediately
immediately after
after dialysis.
dialysis.
*No
*No indication
indication for
for Q6H
Q6H dosing
dosing
MD
MD
PAGE 65
Antimicrobial
DosingGuidelines
Guidelines
Adult
Patients
Antimicrobial Dosing
forfor
Adult
Patients
Basedon
onRenal
Renal Function
Based
Function
CRCL (ML/MIN)
MOXIFLOXACIN IV/PO
>50
<50
NAFCILLIN/OXACILLIN
>50
<50-5 (Including HD)
NITROFURANTOIN*
>50
<50
STANDARD DOSE
MAXIMAL DOSE
HD
400 mg Q24H
No Change
400 mg Q24H
No Change
ND
1 gm Q4H
No Change
2 gm Q4H
No Change
ND
100 mg Q12H
Not Recommended
N/A
*Do not use in systemic infections. Drug is ineffective with CrCl < 40mL/min due to
inadequate urinary concentrations.
OSELTAMIVIR PO
> 60
>30-60
>10-30
PIPERACILLIN/TAZOBACTAM*
>50
30-50
10-29
<10
75 mg Q12H
30 mg Q12H
30 mg Q24H
75 mg Q12H
30 mg Q12H
30 mg Q24H
3.375 gm Q6H
3.375 gm Q6H
3.375 gm Q8H
3.375 gm Q12H
3.375 gm Q4H
3.375 gm Q6H
3.375 gm Q6H
3.375 gm Q8H
10 mg/kg Q24H
10 mg/kg Q24H
10 mg/kg Q12H
10 mg/kg Q24H
Non-PCP
2.5 mg/kg Q12H
2.5 mg/kg Q12H
2.5 mg/kg Q12H
2.5 mg/kg Q24H
PCP
5 mg/kg Q6H
5 mg/kg Q6H
5 mg/kg Q12H
5 mg/kg Q24H*
N/A
MD
*Use for maximal dose for empiric therapy or treatment of Pseudomonas aeruginosa. If
polymicrobial infection without P. aeruginosa is suspected, consider using
ampicillin/sulbactam
RIFAMPIN PO
>10
<10
SULFAMETHOXAZOLE/
TRIMETHOPRIM IV
>50
30-50
10-29
<10
N/A
MD
Dosing based on trimethoprim (TMP) component. *Avoid if possible, not recommended
by manufacturer for CrCl <15 mL/min due to nephrolithiasis.
PAGE 66
Antimicrobial
DosingGuidelines
Guidelines
Adult
Patients
Antimicrobial Dosing
for for
Adult
Patients
Basedon
on Renal
Renal Function
Based
Function
CRCL (ML/MIN)
SULFAMETHOXAZOLE/
TRIMETHOPRIM PO
>50
30-50
10-29*
<10*
STANDARD DOSE
MAXIMAL DOSE
HD
(Equal to IV Dose)
1-2 DS Q8-12H
1-2 DS Q12H
1-2 DS Q12H*
1-2 DS Q24H*
5 mg/kg Q6H
5 mg/kg Q6H
5 mg/kg Q12H*
5 mg/kg Q24H*
MD
Dosing based on trimethoprim (TMP) component. Round to the nearest 160 mg of TMP
component. *Not recommended by manufacturer for CrCl <15 mL/min due to
nephrolithiasis
VANCOMYCIN PO **
>50
<50
125 mg Q6H
No Change
ND
**For C. difficile only in patients with sdevere disease or failed metronidazole therapy
*For IV dosing see vancomycin dosing guidelines
Dosing based on Cockcroft and Gault Equation
D= Dialyzed 50 – 100%; HD= Hemodialysis; MD= Moderately dialyzed 20-49%; N/A= No information available;
ND= Not dialyzed 0-5%
PAGE 67
Antimicrobial
Duration
of
Antimicrobial
Duration
of Therapy
INFECTIOUS DISEASE
Clostridium difficile
Mild-moderate (initial episode)
Severe, uncomplicated
(initial episode)
First recurrence (based on severity)
Therapy
RECOMMENDED DURATION OF THERAPY
STRENGTH OF
RECOMMENDATION
10 – 14 days (vancomycin)
10 – 14 days (vancomycin)
A-I
B-I
10 – 14 days
A-II (C-III)
5 days (may require additional therapy
depending on patient’s response)
NA
7-14 days (based on patient’s
response)
NA
7 days if prompt resolution of
symptoms OR 10-14 days for delayed
clinical response
A-III
5 days if using levofloxacin in a patient
who is not seriously ill
B-III
3 days in a female ≤ 65 years old
without upper urinary tract symptoms
after catheter has been removed
B-II
Asymptomatic bacteriuria in a
pregnant female
3 -7 days
A-III
Acute uncomplicated cystitis in an
adult female
Nitrofurantoin: 5 days
Trimethoprim-sulfamethoxazole:
3 days
Fosfomycin: 1 dose
A-I
A-I
4-7 days
A-III
Acute stomach and proximal jejunal
perforations where source control is
achieved within 24 hours, in the
absence of acid-reducing therapy or
malignancy
24 hours of therapy
B-II
Acute appendicitis without evidence
of perforation, abscess, or local
peritonitis
≤24 hours
A-I
Bowel injuries attributable to
penetrating, blunt, or iatrogenic
trauma that are repaired within 12h
and any other intraoperative
contamination of the operative field
by enteric contents
≤24 hours
A-I
Skin and Skin Structure
Uncomplicated cellulitis
Complicated MRSA (deeper soft
tissue infections, surgical/traumatic
wound infection, major abscesses,
cellulitis, and infected ulcers and
burns)
Genitourinary
Catheter-associated urinary tract
infection
Intra-abdominal
Established intra-abdominal
infection where source control is
achieved
A-I
MRSA= Methicillin-Resistant S. aureus; NA= not applicable
PAGE 68
Antimicrobial
Duration
of
Antimicrobial
Duration
of
Antimicrobial
Duration
of Therapy
Therapy
IINFECTIOUS
DISEASE
NFECTIOUS DISEASE
Pneumonia
Pneumonia
Community-acquired
Community-acquired pneumonia
pneumonia
Hospital-acquired,
Hospital-acquired, ventilatorventilatorassociated,
associated, and
and healthcarehealthcareassociated
associated pneumonia
pneumonia
Diabetic
Diabetic Foot
Foot
General
General recommendation
recommendation
Specific
Specific situations:
situations:
Mild
Mild DFI
DFI
Moderate
Moderate to
to severe
severe DFI
DFI
(without
(without osteomyelitis)
osteomyelitis)
Diabetic
Diabetic Foot
Foot Infection
Infection with
with
Osteomyelitis
Osteomyelitis
Catheter-related
Catheter-related Bloodstream
Bloodstream
Infections
Infections (CRBSI)
(CRBSI)
Uncomplicated
Uncomplicated CRBSI
CRBSI due
due to
to
coagulase
coagulase negative
negative staphylococci
staphylococci
other
than
S.
lugdunensis
other than S. lugdunensis
(catheter
(catheter removed)
removed)
CRBSI
CRBSI with
with persistent
persistent bacteremia
bacteremia
and
and fungemia
fungemia >> 72H
72H following
following
catheter
catheter removal,
removal, associated
associated
endocarditis,
endocarditis, or
or supportive
supportive
thrombophlebitis
thrombophlebitis
CRBSI
CRBSI with
with associated
associated
osteomyelitis
osteomyelitis
Catheter-associated
Catheter-associated exit
exit site
site or
or
tunnel
tunnel infection
infection without
without
associated
associated bacteremia
bacteremia or
or
fungemia
fungemia
Therapy
RRECOMMENDED
DURATION OF THERAPY
ECOMMENDED DURATION OF THERAPY
SSTRENGTH
OF
TRENGTH OF
RRECOMMENDATION
ECOMMENDATION
Minimum
Minimum of
of 55 days
days
B-I/II
B-I/II
14
14 to
to 21
21 days
days
Level
Level II
-- Should
Should be
be afebrile
afebrile for
for 48–72
48–72 H
H
AND
have
≤
1
associated
sign of
of
AND have ≤ 1 associated sign
clinical
clinical instability
instability before
before
discontinuation
of
therapy
discontinuation of therapy
-- As
As short
short as
as 77 days,
days, provided
provided that
that
the
the targeted
targeted pathogen
pathogen is
is identified
identified
based
on
bronchoscopy
and
the
based on bronchoscopy and the
etiologic
etiologic pathogen
pathogen is
is not
not P.
P.
aeruginosa,
aeruginosa, and
and that
that the
the patient
patient
has
has aa good
good clinical
clinical response
response with
with
resolution
resolution of
of clinical
clinical features
features of
of
infection
infection
Continue
Continue antibiotic
antibiotic therapy
therapy until
until
there
there is
is evidence
evidence that
that the
the infection
infection
has
has resolved
resolved but
but not
not necessarily
necessarily until
until
aa wound
wound has
has healed
healed
1-2
1-2 weeks
weeks (though
(though some
some require
require an
an
additional
additional 1-2
1-2 weeks)
weeks)
2-4
2-4 weeks
weeks
A-II
A-II
4-6
4-6 weeks
weeks
B-II
B-II
5-7
5-7 days
days OR
OR observation
observation alone
alone (if
(if no
no
B-III
B-III
C-III
C-III
4-6
4-6 weeks
weeks from
from first
first negative
negative blood
blood
culture
culture following
following catheter
catheter removal
removal
A-II
A-II for
for
S.
S. aureus;
aureus;
C-III
C-III for
for other
other
pathogens
pathogens
6-8
6-8 weeks
weeks from
from first
first negative
negative blood
blood
culture
culture following
following catheter
catheter removal
removal
A-II
A-II
-- shorter
shorter ifif entire
entire infected
infected bone
bone is
is
removed
removed and
and probably
probably longer
longer ifif
bone
remains
bone remains
intravascular
intravascular or
or orthopedic
orthopedic hardware
hardware is
is
present
present and
and additional
additional blood
blood cultures
cultures
are
obtained
after
catheter
withdrawal
are obtained after catheter withdrawal
to
to confirm
confirm the
the absence
absence of
of bacteremia)
bacteremia)
7-10
7-10 days
days following
following catheter
catheter removal
removal
and
and incision
incision and
and drainage
drainage (if
(if
indicated)
indicated)
A-II
A-II
A-II
A-II
CRBSI= Catheter-related Bloodstream Infections; DFI= Diabetic foot infections; H= hour(s)
CRBSI= Catheter-related Bloodstream Infections; DFI= Diabetic foot infections; H= hour(s)
PAGE 69
Antimicrobial
Duration
of Therapy
Antimicrobial
Duration
of
Therapy
This guidance is adopted from the National Antimicrobial Stewardship Taskforce
References:
1. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract
infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin
Infect Dis 2010;50:625-63.
2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of
asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated
cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European
Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103-e120.
4. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults
and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis
2010;50:133-64.
5. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2): S27-S72.
6. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.
7. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004;39:885910.
8. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular
catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1-45.
9. Jenkins TC, Knepper BC, Sabel AL, et al. Decreased Antibiotic Utilization After Implementation of a Guideline for Inpatient
Cellulitis and Cutaneous Abscess. Arch Intern Med. 2011;171(12):1072-79.
10. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update
by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect
Control Hosp Epidemiol 2010;31(5):431-55.
11. Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis 2011;52:1-38.
12. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue
infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52.
PAGE 70
IVtotoPOPO
Antibiotic
Step-Down
Guidelines
IV
Antibiotic
Step-Down
Guidelines
Candidates for Antimicrobial Step-Down therapy:





Patient is able to tolerate PO medication AND has a functioning GI tract
The infection is treatable with oral antimicrobial therapy AND the indications
and spectrum of activity are identical or similar between alternative drugs
No evidence of malabsorption, dysphagia, or gastrointestinal bleed
Patient is hemodynamically stable with improving body temperature and WBC
High risk patients who MAY NOT be candidates for PO step-down may be
identified by:
− Pulse >125bpm
− RR >30bpm
− Systolic BP < 90 mmHg
− T < 35oC OR >40oC, altered mental status
Contraindications to Antimicrobial Step-Down therapy:

Serious infections concomitant with chemotherapy induced severe neutropenia

Infections caused by resistant organisms (i.e. MRSA, VRE) unresponsive to >1
course of antimicrobials

Situations where oral antimicrobials may not achieve adequate drug
concentrations at the site of infection (i.e. meningitis, endocarditis)

Oral antimicrobial therapy may be used in neutropenic patients with negative
blood cultures, temperatures < 38oC, and no indication of clinical sepsis
Table 1. IV to PO Antimicrobial Step-Down Options
IV Antimicrobial
PO Antimicrobial
Ampicillin/sulbactam
Amoxicillin/clavulanate
Azithromycin
Azithromycin
Cefazolin/Ceftazidime
Cephalexin/Cephadrine
Ciprofloxacin
Ciprofloxacin*
Ceftriaxone
Cefpodoxime
Cefuroxime
Cefuroxime axetil
Clindamycin
Clindamycin*
Doxycycline
Doxycycline
Fluconazole
Fluconazole*
Moxifloxacin
Moxifloxacin *
Metronidazole
Metronidazole*
Nafcillin
Dicloxacillin
Trimethoprim/sulfamethoxazole
Trimethoprim/sulfamethoxazole*
*Oral drugs which achieve serum levels similar to the parenteral dose form
BP= blood pressure; bpm= beats/breaths per minute; GI= Gastrointestinal; IV= intravenous; MRSA= Methicillin-resistant
Staphylococcus aureus; PO= by mouth; RR= Respiratory rate; T= temperature; VRE= Vancomycin-resistant enterococci;
WBC= White blood cells
PAGE 71
TwelveSteps
Steps
Prevent
Antimicrobial
Resistance
Twelve
to to
Prevent
Antimicrobial
Resistance
Twelve Steps to Prevent Antimicrobial Resistance
1. Wash your hands!
1. Wash your hands!
2. Vaccinate
2. Vaccinate
3. Get the catheters out
3. Get the catheters out
4. Obtain cultures
4. Obtain cultures
5. Target the pathogen
5. Target the pathogen
6. Seek expert input
6. Seek expert input
7. Know the local sensitivity patterns
7. Know the local sensitivity patterns
8. Know when to say “NO” to broad spectrum
8. Know when to say “NO” to broad spectrum
agents
agents
9. Treat infection - not colonization
9. Treat infection - not colonization
10. Treat infection - not contamination
10. Treat infection - not contamination
11. Stop treatment when infection is cured
11. Stop treatment when infection is cured
or unlikely
or unlikely
12. Prevent transmission
12. Prevent transmission
Adopted from the Centers for Disease Control Campaign for Clinicians
Adopted from the Centers for Disease Control Campaign for Clinicians
Contact
ContactPrecautions
Precautions
Contact
Precautions
TYPES OF CONTACT PRECAUTIONS FOR INFECTION CONTROL
TYPES OF CONTACT PRECAUTIONS FOR INFECTION CONTROL
Gloves
Masks
Hands
Conditions
Gloves
Hands
Conditions
For contacts
If Masks
WASH
upon ALL patients
For
If
WASH
upon
withcontacts
mucous
aerosolization
entering
and ALL patients
with
mucous
aerosolization
entering
and
membranes,
or splattering
leaving room
membranes,
splattering
leaving room
non-intact skin or
of body
fluids
non-intact
skin of
and ALL body
or body
bloodfluids
is
and
or
blood is
fluidsALL body
likely
fluids Use Transmission
likelyBased Precautions below in addition to Standard
Use Standard Precautions on all patients.
Precaution
Precaution
Standard
Standard
Gowns
Gowns
If splattering
If
ofsplattering
body fluids
of
or body
bloodfluids
is
or
blood is
likely
likely
Use Standard Precautions on all patients. Use Transmission
PrecautionsBased Precautions below in addition to Standard
Precautions
CATEGORY SPECIFIC ISOLATION PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS
CATEGORY SPECIFIC ISOLATION PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS
Approved,
Tuberculosis or rule
Approved,
prefitted
Tuberculosis
or rule
WASH upon
out tuberculosis.
prefitted
respirator
WASH
upon
out
tuberculosis.
Not necessary
Not necessary
entering
and
Respiratory
phase of
Airborne
respirator
protection and
Not necessary
Not necessary
entering
and
Respiratory
of
Airborne
leaving room
measles andphase
chicken
protection
and
required N-95
leaving room
measles
and chicken
pox
required
N-95
mask
pox
mask
Infected or colonized
Infected
colonized
patients, or
whether
Upon entering
patients,
bedriddenwhether
or
Upon
entering
room and
for all
bedridden
For suctioning, if
WASH upon
ambulatory,orwith
Contact
room
andwith
for all
contacts
Upon entering
For
suctioning,
WASH
upon
ambulatory,
with
organism
is in if
entering
and
wounds or diarrhea:
Contact
contacts
with
patient and
Upon
patiententering
room
organism
entering
and
wounds
or diarrhea:
sputum is in
leaving room
multi-resistant
patient
surfacesand
or
patient room
sputum
leaving room
multi-resistant
organisms, MRSA, VRE,
surfaces
or in
equipment
organisms,
MRSA, VRE,
C. difficile diarrhea
or
equipment
in
room
C.
difficile diarrhea or
ESBL
room
ESBL
MRSA in sputum,
Droplet
Droplet
Protective
Protective
Environment
Environment
MRSA
in sputum,
Neisseria
meningitidis,
Neisseria
meningitidis,
drug resistant
drug
resistant
pneumococci,
pneumococci,
diptheria, pertussis,
diptheria,
influenza pertussis,
influenza
WASH upon
Neutropenia (< 1000
WASH
upon
Not necessary
Not necessary
Not necessary
entering
and
Neutropenia
(< 1000
neutrophils), ANC
<100
Not necessary
Not necessary
Not necessary
entering
and
leaving room
neutrophils), ANC <100
leaving
room
Refer to Policy MCM 111-P26 Standard and Transmission Based Precautions
Refer
Policy MCM
111-P26and
Standard
Based
Precautions
CalltoInfection
Prevention
Controland
forTransmission
further guidance
at ext
2654
Call Infection Prevention and Control for further guidance at ext 2654
Not necessary
Not necessary
To handle
To
handle
respiratory
respiratory
secretions or
secretions
suctioning or
suctioning
Within three feet
Within
three feet
of the patient
of
the patient
(regular
masks)
(regular masks)
WASH upon
WASH
upon
entering
and
entering
and
leaving room
leaving room
PAGE 72
Pharmacokinetic Calculations
Pharmacokinetic
Calculations
Pharmacokinetic
Calculations
Ideal Body Weight (IBW) Calculation:
Male:
50 kg + [2.3 kg for each inch over 5 feet]
Ideal Body Weight (IBW) Calculation:
Female:
45 kg + [2.3 kg for each inch over 5 feet]
Male:
50
Female:
45
kg + [2.3
kg for each inch
over 5 feet]
Creatinine Clearance (CrCl) using
Cockcroft-Gault
Equation:
Creatinine
expressed
in mL/min
using Cockcroft-Gault Equation:
Creatinine is
Clearance
(CrCl)
Creatinine is expressed in mL/min
CrCl (mL/min) =(140 – age) (IBW in kg)*
‡ *
mg/dL)
CrCl (mL/min) =(14072– (SCr
age)in
(IBW
in kg)
72 (SCr in mg/dL)‡
NOTE: For Females multiply by 0.85
NOTE: For Females multiply by 0.85
CrCl for elderly patients or when no height is available:
CrCl for elderly
patients=(114
or when
no *age))
height is available:
CrCl (mL/min)
– (0.8
‡
CrCl (mL/min) =(114
*age))
SCr–in(0.8
mg/dL
‡
SCr
in
mg/dL
NOTE: For females multiply by 0.9
NOTE: For females multiply by 0.9
patients actual body weight is less than IBW, use actual body weight to calculate
*CrCl
If patients actual body weight is less than IBW, use actual body weight to calculate
CrCl
‡If patient is underweight/cachectic, may consider rounding SCr up to 1 mg/dL.1,2
*If
‡Do
not round
to 1 mg/dL for all patients
60 yearsrounding
of age.3-5SCr
If patient
is underweight/cachectic,
may >consider
age.3-5
up to 1 mg/dL.1,2
Do not round
1 mg/dL
for all patients dosing)
> 60 years of
Adjusted
BodytoWeight
(aminoglycoside
Use
adjusted
body
weight
(AdjBW) whendosing)
actual body weight (ABW) is ≥ 30% of ideal
Adjusted
Body
Weight
(aminoglycoside
body
weight (IBW)
Use adjusted
body weight (AdjBW) when actual body weight (ABW) is ≥ 30% of ideal
AdjBW = 0.4 (ABW - IBW) + IBW
body weight (IBW)
AdjBW = 0.4 (ABW - IBW) + IBW
IBW= Ideal Body Weight (in kg); AdjBW= Adjusted Body Weight; ABW= Actual Body Weight; CrCl= Creatinine clearance;
SCr= serum creatinine
IBW= Ideal Body Weight (in kg); AdjBW= Adjusted Body Weight; ABW= Actual Body Weight; CrCl= Creatinine clearance;
SCr= serum creatinine
References:
1.
Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med.
References:
1993;21(10):1487-1495.
1.
Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med.
2.
Khuu T, Bagdasarian G, Leung J, et al. Estimating aminoglycoside clearance and creatinine clearance in underweight patients. Am J Health1993;21(10):1487-1495.
Sys Pharm. 2010;67(4):274-279.
2.
Khuu T, Bagdasarian G, Leung J, et al. Estimating aminoglycoside clearance and creatinine clearance in underweight patients. Am J Health3.
Bertino JS. Measured versus estimated creatinine clearance in patients with low serum creatinine values. Ann Pharmacother.
Sys Pharm. 2010;67(4):274-279.
1993;27(12):1439-1442.
3.
Bertino JS. Measured versus estimated creatinine clearance in patients with low serum creatinine values. Ann Pharmacother.
4.
Smythe M, Hoffman J, Kizy K, Dmuchowski C. Estimating creatinine clearance in elderly patients with low serum creatinine concentrations.
1993;27(12):1439-1442.
Am J Hosp Pharm. 1994;51(2):198-204.
4.
Smythe M, Hoffman J, Kizy K, Dmuchowski C. Estimating creatinine clearance in elderly patients with low serum creatinine concentrations.
5.
Dowling TC, Wang E-S, Ferrucci L, Sorkin JD. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals
Am J Hosp Pharm. 1994;51(2):198-204.
Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy. 2013;33(9):912-921.
5.
Dowling TC, Wang E-S, Ferrucci L, Sorkin JD. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals
Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy. 2013;33(9):912-921.
PAGE 73
COLLEGE OF
PHARMACY