Title:
Restricted Antimicrobial Policy
Designated Clinical Areas:
All Inpatient Care areas
ED and ED observation/short stay
Level of Personnel:
MD, PA, NP, RPh
Applicable Policy Statement:
1)
In collaboration with the Antimicrobial Stewardship Program (ASP) and the
Infectious Disease Division, MESAC approves and maintains a list of restricted
antibiotics and authorized prescribers (Refer to: Table 1 and Appendix).
2)
Restricted antibiotics require approval from an authorized prescriber [member of
the Infectious Disease Division or an affiliated member of ASP with approval
privileges (Refer to: appendix). These restricted antibiotics will be prescribed and
dispensed according to the guidelines and procedures outlined below.
Procedure:
Prescribing Guidelines
General:
1. Empiric antimicrobial use should be limited to no more than 72hrs of
therapy and subsequently guided by microbiological data.
2. Between 0800-2000, the ordering provider must obtain approval (verbal or
written) from an authorized prescriber prior to ordering a restricted antimicrobial;
the use of an authorized prescriber’s name in the ordering of a restricted
antimicrobial without obtaining verbal or written approval constitutes a violation of
hospital policy. Note: Approval cannot be transferred or obtained from previously
approved antibiotic courses or when level of care changes.
3. Restricted antimicrobial approval can be obtained through:
a. Restricted antimicrobial pager (p21884)
i. The restricted antimicrobial pager service is active from 08:0020:00, 7 days a week
ii. The restricted antimicrobial pager service shall not approve
selected antimicrobials marked by an asterisk (see list below)
b. Infectious Disease Consultation (p16136)
c. Discussion with an authorized prescriber resulting in their specific
approval (see Appendix)
4. Between the hours of 20:00 and 08:00, ID approval is not required:
a. The pharmacist will dispense enough drug to cover all scheduled doses
through 08:00. Note: doses after 08:00 will require ID approval as
described above.
b. A notice of this temporary approval and requirement for follow up approval
will be provided to the overnight prescriber as an alert in POE when
entering the order. The overnight prescriber must provide pass-off to
the daytime prescriber to obtain approval to reorder the antimicrobial
if the plan is to continue the antimicrobial.
5. Restricted antimicrobials included in approved ordering pathways do not require
ID approval.
6. The restricted antimicrobial approval process applies to all inpatient floors,
including the emergency room.
Guidelines for selected restricted antimicrobials:
1. Moxifloxacin approval is restricted to treatment of tuberculosis
2. Posaconazole is restricted to approval by the transplant ID service.
3. Cystic fibrosis patients requiring ceftazidime or inhaled tobramycin can receive
these agents through the cystic fibrosis pathway in POE.
4. Cefotaxime is restricted to ID approval in adults only; cefotaxime does not require
approval in pediatrics.
5. Linezolid and voriconazole are highly bioavailable and oral formulations should
be used as indicated by the IV:PO protocol.
a. Linezolid oral suspension is restricted to pediatrics; oral tablets can be
crushed for adults
Dispensing Procedure
1. Between the hours of 0800 and 2000, all restricted antibiotics (below) require
approval from an authorized prescriber.
a. The name of the approving provider must appear in the “approval field” in
each POE order (see appendix).
2. Between the hours of 20:00 and 08:00, ID approval is not required:
a. The pharmacist will dispense enough drug to cover all scheduled doses
through 08:00. Note: doses after 08:00 will require ID approval as
described above.
b. A notice of this temporary approval and requirement for follow up approval
will be provided to the overnight prescriber as an alert in POE when
entering the order. The overnight prescriber must provide pass-off to the
daytime prescriber to obtain approval to reorder the antimicrobial if the
plan is to continue the antimicrobial.
c. Additionally, after 08:00, the designated floor/region pharmacist will
identify temporary approval orders that were entered overnight through
Sentri7 “Restricted Antimicrobial” rule and page the responding clinician
prior to 10:00 to remind the prescriber to reorder the antimicrobial.
i. The pharmacist will page the responding clinician with the following
information: “Temporary doses for (name of restricted antimicrobial)
have expired; please reorder with ID approval or will result in
missed dose at (time of next dose).”
ii. If the responding clinician does not change the antimicrobial order
or fails to communicate the plan with the pharmacist within 1 hour
after the page is sent, the pharmacist will page the attending
physician with the same page above.
iii. If a responding clinician fails to communicate the plan and does not
reorder the antimicrobial, a safety report is strongly encouraged.
Table 1: The following antimicrobials require verbal or written approval from an
authorized prescriber (Refer to: Appendix).
Amikacin*
Amphotericin, liposomal
Amphotericin (Inhaled)
Artemether/lumefantrine
Aztreonam
Cefotaxime
Ceftaroline
Ceftazidime
Cidofovir*
Colistin (IV)*
Daptomycin
Ertapenem
Fidaxomicin
Foscarnet*
Ganciclovir
Imipenem
Itraconazole
Linezolid
Maraviroc
Meropenem
Micafungin
Moxifloxacin
Nitazoxanide
Posaconazole**
Quinine
Quinupristin/dalfopristin
Ribavirin (Inhaled)*
Rimantadine
Sofosbuvir
Ticarcillin/clavulanate
Tigecycline
Tobramycin (Inhaled)
Voriconazole
Unless specified, restriction applies to all routes of administration
*Antimicrobials marked with a * shall not be approved by the restricted antimicrobial pager; due
to cost or toxicity concerns; an Infectious Disease Consult is recommended
**Approval privileges restricted to Transplant Infectious Disease Service
Appendix: MEMBERS OF THE ANTIMICROBIAL STEWARDSHIP PROGRAMJULY 2014- JULY 2015
INFECTIOUS DISEASE DIVISION FACULTY/AFFILIATED FACULTY
Kevin L. Ard
Michael Aronoff
Miriam Barshak
Nesli O. Basgoz
Ingrid V. Bassett
Allyson Bloom
Stephen B. Calderwood
Michael Callahan
Richelle C. Charles
Andrea Ciaranello
Benjamin T. Davis
Marlene L. Durand
Joseph El-Khoury
Chadi El Saleeby (PEDI)
Donna Felsenstein
Jay A. Fishman
Kenneth A. Freedberg
Dahlene Fusco
Rajesh T. Gandhi
Jeffrey A. Gelfand
Marcia B. Goldberg
Jason Harris (PEDI)
Howard M. Heller
Elizabeth L. Hohmann
David C. Hooper
Rocio Hurtado
Arthur Kim
Dennis Kim
Camille N. Kotton
Douglas S. Kwon
Regina C. LaRocque
Cammie F. Lesser
Alyssa Letourneau
Lynn Luginbuhl (PEDI)
Vandana Madhavan (PEDI)
Lynn T. Matthews
Sandra B. Nelson
Bisola O. Ojikutu
Mark S. Pasternack
Virginia Pierce
Mark Poznansky
Gregory K. Robbins
Eric S. Rosenberg
Edward T. Ryan
Erica S. Shenoy
Mark J. Siedner
Virginia Triant
Athe Tsibris
Jatin M. Vyas
Rochelle P. Walensky
Bruce D. Walker
H. Shaw Warren
Kimon C. Zachary
AFFILIATED MEMBERS OF ASP WITH APPROVAL PRIVILEGES*
Todd Astor (TRANS)
Walter O’Donnell (MICU)
Christy Varughese
Marc DeMoya (SICU)
Ulrich Schmidt (SICU)
(Pharmacy)
Samuel Moskowitz (CF)
*The ASP Leadership determines minimum requirements for affiliates with approval privileges. These
requirements include, but are not limited to, attendance and active participation in at least one of the
biannual ASP/Pharmacy/Clinical Microbiology Meetings. Failure to meet stated requirements will result in
termination of privileges.
Aima A. Ahonkhai
Amy K. Barczak
Roby P.
Bhattacharyya
Laura K. Certain
Brian T. Chan
JUNIOR FACULTY
Paul K. Drain
Emily P. Hyle
Anne G. Kasmar
Mathias D. Lichterfeld
Michael A. Lobritz
Tariro Makadzange
Tara M. Babu
Kelly E. R. Bachta
Lisa M. Bebell
Taison Bell
Daniel L. Bourque
Daniel A. Caroff
Justin J. Chan
Jacqueline T. Chu
CLINICAL & RESEARCH FELLOWS
Boris D. Juelg
Sanjat Kanjilal
Philip A. Lederer
Lenette L. Lu
Anne Neilan
Damaris D. Nou
Ann L. Piantadosi
Jonathan A. Robbins
Michael K. Mansour
Read Pukkila-Worley
Jennifer L. Reedy
Eileen P. Scully
Pritha Sen
Thomas F. Rogers
Daniel A. Solomon
Gustavo E.
Velasquez
Ana A. Weil
Anne E. Woolley
Cynthia R. Young
Brian C. Zanoni
Revision Detail
SUBJECT :
TITLE:
APPROVED BY AND DATE:
GENERAL POLICY AND PROCEDURE
RESTRICTED ANTIMICROBIAL POLICY
MESAC 3/2011, 10/2013
MESAC EXEC 5/2011, 9/2011
PENDING 6/2014