SUGGESTED
DrugUsual Dose (CrCl > 80)
Beta-Lactams
Ampicillin
2gm q 4-6h
Nafcillin
2gm q 4-6h
Unasyn
1.5-3gm q 6h
Zosyn
3.375gm q 8h (x 4hr infusion)
Cefazolin
1-2gm q 8h
Ceftriaxone
1-2gm q 24h
Cefepime
2gm q 12h
Aztreonam
2gm q 8h
Ertapenem
1gm q 24h
Meropenem
500mg q 6h
Flouroquinolones
Levaquin
Levaquin
750mg q 24h
500mg q 24h
Miscellaneous
Azithromycin
Doxycycline
Tigecycline
Clindamycin Flagyl
TMP/SMX Vancomycin
Fluconazole
500mg IV q 24h
100mg q 12h
100mg x 1, then 50mg q 12h 600mg q 8h
500mg q 8-12h
1-2 DS tabs BID
18mg/kg load then per Pharmacy 200-400mg q 24h
Aminoglycosides
Gentamicin
Tobramycin
5-7mg/kg (ODA)
5-7mg/kg (ODA)
NOTES
FORMULARY
50-80
usual
usual
q 6-8h
usual
usual
usual
2gm q 24h
usual
usual
usual
Adjustments Based on CrCl•
10-50
<10
q 6-12h
q 8-12h
usual
usual
q 8-12h
q 24h
<20 = 3.375 q12h (x 4hr infusion)
q 8-12h
q 24
usual
usual
2gm q 48h
500mg q 24h
1gm q 8h
500mg q 8h
≤30 = 500mg q 24h
q 8-12h
q 24h
usual
usual
750mg q 48h
250mg q 24h
500mg q 48h
250mg q 48h
usual
usual
usual
usual usual
usual
per Pharmacy
usual
usual
usual
usual
usual
usual
q 18h
per Pharmacy
50% of dose
usual
usual
usual
usual
usual
q 24h
per Pharmacy
25% of dose
*
CrCl = [(140-age)(Wt in kg)] [0.85 if female]
72 x serum Cr
1.
Use of Cephalosporins in Patients With Penicillin
Allergy: After taking a careful history, cephalosporins
may be given safely to any patient without a history of
a Type I (immediate hypersensitivity: i.e., anaphylaxis,
hives, angioedema) reaction to penicillin. (Pediatrics
2005;115:1048). Potential alternatives to penicillins and/
or cephalosporins include combinations of [Levaquin
or Aztreonam] PLUS, [(Clindamycin PLUS Flagyl) or
(Vancomycin PLUS Flagyl)].
2.
At AWH in 2011, the % of E. coli susceptible to Levaquin,
Bactrim, and Unasyn was 83%, 83%, and 76% respectively.
3.Ertapenem (UTI) or Meropenem (all other infections) are
the drugs of choice for infections due to ESBL-producing
gram-negative rods (i.e. E-coli).
4.Nafcillin and cefazolin are superior to vancomycin for
treatment of infections due to MSSA.
Suggested Empiric
Antimicrobial
Agents of Choice
(9th Edition)
Aspirus Wausau Hospital
5.Most proven MRSA infections, especially bacteremias,
warrant an ID consultation. Bacteremia due to MSSA also
may warrant an ID consultation.
2012 - 2014
6.Zyvox should NOT be prescribed when VRE is cultured only
from the stool (i.e., colonization).
Infectious Disease Section
7.
Bioavailability: Levaquin, Bactrim, Clindamycin,
Azithromycin, Fluconazole, and Flagyl are highly bioavailable
(90-100% GI absorption). After the initial IV dose(s), they
should generally be given PO if the GI tract is functional.
8.
Once Daily Aminoglycosides (ODA): Gentamicin or
Tobramcycin: 5mg/kg (age >50) or 7mg/kg (age <50).
Order a level for 12 hours after initial dose, and “Pharmacy
to dose.”
IC-002 mps 06/12
&
Pharmacy and Therapeutics Committee
©WAB/06/12
I. ANTIBIOTIC STEWARDSHIP
• (1) Before initiating empiric antibiotic therapy;
or, making a change in therapy due to lack of
response to initial therapy, make certain that
all relevant cultures have been obtained or
repeated.
• (2) Always change (“de-escalate”) to a narrower
spectrum antibiotic(s) based on culture results.
• (3) Whenever possible, consider stopping
Vancomycin if: cultures are negative for MRSA,
MRSE, or pencillin-resistant Enterococcus; and,
no Hx of MRSA colonization; and, MRSA infection
unlikely; and, no Type I allergy to penicillins.
• (4) Combination therapy with Levaquin PLUS
[Zosyn or Cefepime] is not beneficial beyond 48
hr (except for proven nonurinary Pseudomonas
infections) - one or the other should be
discontinued based on culture data.
• (5) Switch Therapy: convert IV to PO, and change
to narrower - spectrum agent(s) (“de-escalate”)
based on microbiology results.
II. “SEPSIS” OF UNKNOWN ETIOLOGY
• Community-Acquired/Normal Host: [Levaquin
750mg or Gentamicin (5-7mg/kg)], PLUS
Ceftriaxone 2gm q 24h, PLUS Vancomycin
18mg/kg (then per Pharmacy protocol).
• Health Care-Associated/Compromised Host:
[Levaquin 750mg or Tobramycin (5-7mg/kg)],
PLUS [Zosyn 3.375gm q 8h (x 4hr) or Cefepime
2gm q 12h], PLUS Vancomycin 18mg/kg, (then per
Pharmacy protocol).
III. COMMUNITY-ACQUIRED PNEUMONIA (CAP)
[CID 2007;44(Suppl 2):S27]
• First doses within 6 hours of presentation.
• Non-ICU: OPTION 1 - Ceftriaxone 2gm q 24h,
PLUS [Azithromycin 500mg q 24h or Doxycycline
100mg q 12h].
OPTION 2 - Levaquin 750mg q 24h (x 5 days).
• ICU: Ceftriaxone 2gm q 24h, PLUS Levaquin
750mg q 24h (x 5 days).
IV.HEALTH CARE ASSOCIATED PNEUMONIA (HCAP)
[Am J Respir Crit Care Med 2005;171:388]
• [Cefepime 1gm q6h or Zosyn 3.375gm q 8h
(x 4hr)], PLUS Levaquin 750mg q 24h, PLUS
[Vancomycin 18mg/kg or Zyvox 600mg q 12h].
Zyvox ONLY if gram (+) cocci in clusters on sputum
gram-stain, or Hx of MRSA colonization - Zyvox MUST
be discontinued at 48hr if no MRSA in culture.
• For proven MRSA HCAP, Zyvox is superior to
Vancomycin (CID 2012;54;621).
• For respiratory infections due to Pseudomonas with
a Cefepime MIC ≥ 4, 1gm q 6h is superior to 2gm q
12h.
• Duration of Rx for HCAP = 8 days (14 days if proven
Pseudomonas).
V.ASPIRATION PNEUMONIA
[Ceftriaxone 2gm q 24h (CAP) or Cefepime 1gm
q 6h (HCAP)], PLUS Flagyl 500mg q 8h. OR
Zosyn 3.375gm q 8h (x 4hr). Both options PLUS
Vancomycin 18mg/kg or Zyvox (as above).
VI.COMPLICATED INTRA-ABDOMINAL, or BILIARY
TRACT INFECTIONS, and PANCREATITIS
[CID 2010;50:133-164]
• A. Community-Acquired/Normal Host/Mild-Moderate
Severity: Preferred: Ceftriaxone 2gm q 24h, PLUS
Flagyl 500mg IV q 8h. First alternate: Ertapenem
1gm q 24h. 2nd Alternate: Tigecycline 100mg x 1,
then 50mg q 12h.
. • B. Community-Acquired/Compromised Host/High
Severity: Zosyn 3.375gm q 8h (x 4h). OR Cefepime
2gm q 12h, PLUS Flagyl 500mg q 8h.
• C. Health Care Associated: Same as “B” PLUS
Vancomycin 18mg/kg, PLUS Fluconazole 400mg q
24h (if yeast on gram-stain).
• D. “Bonafide” Type I Penicillin Allergy: Tigecycline
100 mg x 1, then 50mg q 12h, PLUS Levaquin
750mg q 24h (if “B” or “C”), PLUS Fluconazole
400mg q 24h (if “C” above) .
• E. Duration of ATBs: 7 days after adequate “source
control” is generally sufficient.
• F. Pancreatitis: Routine “prophylactic”
Meropenem on admission is not recommended
(Ann Surg 2007;245:674. Am J Gastroenterol.
2006;101:2379. UpToDate. Crit Care Med.
2004:32;2524). Antibiotics indicated only if
admission CT, or repeat CT (with contrast) at 48hr
after admission shows ≥ 30% pancreatic necrosis.
Ideally, CT-directed FNA for culture to guide Rx.
VII. PYLEONEPHRITIS, or SEPSIS DUE to UTI
[CID 2010;50:133-164]
• A. Community-Acquired/Normal Host: Gentamicin
5mg/kg x 1, PLUS [Ceftriaxone 2gm q 24h or
Levaquin 500mg q 24h], PLUS Ampicillin 2 gm q 6h.
• B. Health Care Associated: Tobramycin 5mg/
kg x 1, PLUS [Cefepime 2gm q 12h or Levaquin
500mg q 24h], PLUS Ampicillin 2 gm q 6h.
VIII.COMPLICATED SKIN AND SOFT TISSUE INFECTIONS
[CID 2005;41:1373-1406]
• A. Cellulitis: Strep: Penicillin G 4 million units q
6h, PLUS Clindamycin 600mg q 8h. Unknown or
Staph: Nafcillin 2 gm 6h or Cefazolin 1gm q 8h.
• B. Wound Infection or Abscess: [Nafcillin 2gm
q 6h or Cefazolin 1gm q 8h], PLUS Levaquin
750mg q 24h. Add Vancomycin 18mg/kg x
1 dose pending culture results. Discontinue
Levaquin if no gram-negative rod in culture.
• C. Diabetic or Ischemic Foot Infection (AFTER
deep tissue, ulcer curettage, or bone biopsy
culture): Levaquin 750mg q 24h, PLUS
Clindamycin 600mg q 8h. OR, Ceftriaxone 2gm
q 24h, PLUS Flagyl 500mg q 8h. OR, Ertapenem
1gm q 24h. Each option: Vancomycin 18mg/kg x
1 dose pending culture results.
IX. OPTIONS FOR MRSA INFECTIONS:
[CID 2011;52:285-292]
• Older, Inexpensive Agents: Bactrim DS 2 tabs PO
q 12h, Minocycline 100mg PO q 12h; Clindamycin
450-600mg PO/IV q 8; or Vancomycin IV.
• Newer/Expensive Agents: Linezolid 600mg IV/PO
q 12h; Tigecycline 100mg, then 50mg IV q 12h;
or Daptomycin 4-6mg/kg IV q 24h.
(Note: ID consultation will occur when newer,
expensive agents are continued ≥ 48h.)
Remember: Antibiotic Stewardship!