Restricted Antimicrobial Pager
2013-2014
Restricted Antimicrobials
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Amikacin*
Amphotericin, liposomal
Amphotericin (Inhaled)
Artemether/lumefantrine
Atovaquone
Aztreonam
Cefotaxime
Ceftaroline
Ceftazidime
Cidofovir*
Colistin (IV)*
Daptomycin
Entecavir
Ertapenem
Fidaxomicin
Foscarnet*
Ganciclovir
Imipenem
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Itraconazole
Ivermectin
Linezolid
Maraviroc
Meropenem
Micafungin
Moxifloxacin
Nitazoxanide
Pentamidine
Posaconazole*
Quinine
Quinupristin/dalfopristin
Ribavirin (Inhaled)*
Rimantadine
Ticarcillin/Clavulanate
Tigecycline
Tobramycin (Inhaled)
Voriconazole
Most Commonly
Requested
Antimicrobials
• Approximately 5-6 pages per day
• 8AM-8PM
Updated: Selected Antimicrobials
That Should Not be Approved by
Pager Service
• Agents are marked with asterisk in policy document
• Agents chosen due to toxicity or cost
Amikacin
Cidofovir
Colistin (IV)
Foscarnet
Posaconazole
Ribavirin (Inhaled)
Approval Log
• Located in MGH ASP (antimicrobial
stewardship) folder
– Daily (if possible) upload or email to Christy
• Purpose:
– To keep an accurate log of approvals/indications
– Stewardship team insight (since lack of formal note
providing indication/purpose)
– Follow up on empiric approvals (either you or Christy)
Approval Log
Approval Log (VPN View)
Network Places or Computer 
MGH_ASP 
Approval Pager
Approval Log
Approval Log
• Empty form = spreadsheet for you to fill out
• Master List = all previous requests (updated by Christy)
• Upload your file with your name & date as seen below
Approval Log
• Can’t find the ASP folder?  Email your
approval log to Christy
– Q 24h-48hrs preferred
• Feel free to email Christy requests to
follow up
– i.e. did team D/C my antibiotic as I requested?
– i.e. did team narrow therapy when cultures
finalized?
Stewardship Strategies
• Bring forward questions or unusual
practices so we can work on unifying
approval process
– Ex. In previous year, rising number of requests for linezolid
based on VRE rectal swab
• Give durations of 72 hrs with empiric approvals
with request to follow up with you or ID consult
Common Requests and
Clinical Pearls
Linezolid
• VRE UTI (30% of requests)
– Clarify if true infection
– If susceptible, amoxicillin, doxycycline and
fosfomycin are less expensive alternatives
• Positive VRE rectal swab
– Low PPV 25%, high NPV 98%
– If approving, limit to 72hr approval only
Linezolid
• HCAP
– No mortality benefit in linezolid vs vancomycin
for nosocomial PNA
• Vanco allergy and wound
infection/cellulitis
– Recommend ceftaroline if possible ($80 vs
$200)
Wunderlink et al. Clin Infect Dis. 2012 Mar 1;54(5):621-9
Linezolid
• Recommend PO if patient has no GI
absorption issues (highly bioavailable)
– If sepsis, consider IV for first dose, and PO for
remaining
• IV to PO ratio is 1:1, goal is 1:4
Carbapenems
• Necrotizing pancreatitis
– No evidence carbapenem is clinically superior (OK to
use in culture documented/history of ESBL)
– Agents with best penetration: fluoroquinolones,
imipenem, ceftazidime, cefepime, metronidazole,
clindamycin, chloramphenicol, doxycycline, and
fluconazole
• PCN or cephalosporin allergy
– Run through PCN & Ceph Hypersensitivity Pathway
Powell JJ et al. Br J Surg. 1998;85:582-587.
Buchler M, et al. Gastroenterology. 1992;103:1902-1908.
Gloor B et al. 2003;26:117-121.
Shrikhande S et al. Antimicrob Agents Chemother. 2000;44:2569-2571.
Bassi C et al. Antimicrob Agents Chemother. 1994;38:830-836.
Aztreonam
• PCN or cephalosporin allergy
– Run through PCN & Ceph Hypersensitivity Pathway
• PSA:
– 76% susceptible to aztreonam
– 89% susceptible to cefepime
– 91% susceptible to ceftazidime
Micafungin
• QT prolongation fear with azoles
– Usually due to drug interactions and multiple
QT prolonging drugs with underlying pt risk
factors
– Azoles unlikely to prolong QT on their own
• Resistant Candida in urine
– Does NOT penetrate into urine
– May be okay in upper UTIs
Ceftazidime
• Globe rupture – approve
• CNS – approve
• HD dosing
– Renal service likes ceftaz 2g q HD
– Note: can also give cefepime 2g q HD
Perez, K. Am J Kidney Dis. 2012;59(5):738-742
Voriconazole
• Resistant UTIs
– Does NOT reach urine
– May be okay for upper UTIs
Moxifloxacin
• Restricted to Tuberculosis
• More costly than other quinolones
• “Anaerobic coverage”
– Poor; recommend levofloxacin/ciprofloxacin
plus metronidazole/clindamycin
Other Tips
• Curbsides: defer to ID consult pager
• Ask if attending of record has ID privileges
– i.e. SICU, MICU, cystic fibrosis, lung
transplant
– Refer to restricted antimicrobial policy for list
of ID approvers
• Posaconazole is restricted to transplant ID only