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Guidelines for antimicrobial usage - 2012 - 2013

CVR(AMUG13).indd 1 8/15/2012 1:48:57 PM Guidelines for
2012-2013 8/15/2012 2:53:48 PM Published by: All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording or any other information storage and retrieval system, without the prior agreement and written permission of the publisher. 400 Center Bay Drive West Islip, NY 11795 For orders only, please call: Caddo, OK 74729-0010 (t) 631/661-2852 (f) 631/661-2167 ISBN: 978-1-932610-85-7 Printed in Mexico DISCLAIMER
The opinions expressed in this publication refl ect those of the authors. However, the authors make no
warranty regarding the contents of the publication. The protocols described herein are general and may not
apply to a specifi c patient. Any product mentioned in this publication should be taken in accordance with the
prescribing information provided by the manufacturer.
This text is printed on recycled paper. 8/15/2012 2:54:01 PM Susan J. Rehm, MD Jennifer K. Sekeres, PharmD Department of Infectious Disease Elizabeth Neuner, PharmD Department of Pharmacy Department of Infectious Disease
Department of Clinical Pathology
J. Walton Tomford, MD Gerri S. Hall, PhD Carlos M. Isada, MD Belinda Yen-Lieberman, PhD Steven M. Gordon, MD Susan Harrington, PhD Steven K. Schmitt, MD Sandra Richter, MD Steven D. Mawhorter, MD Sherif B. Mossad, MD Department of Pediatrics
Alan J. Taege, MD Kristin Englund, MD Johanna Goldfarb, MD Thomas G. Fraser, MD Camille Sabella, MD Marisa Tungsiripat, MD Lara Danzinger-Isakov, MD Lucileia Johnson, MD Charles Foster, MD David van Duin, MD Department of Pharmacy
Cyndee Miranda, MD Marc Earl, PharmD Jodie M. Fink, PharmD Adarsh Bhimraj, MD Dalia El-Bejjani, MD Christine Koval, MD 8/15/2012 2:54:01 PM The majority of hospitalized patients receive antimicrobials for therapy or prophylaxis during their inpatient stay. It has been estimated that at least ſ fty percent of patients receive antimicrobials needlessly. Reasons include inappropriate prescribing for antimicrobial prophylaxis, continuation of empiric therapy despite negative cultures in a stable patient, and a lack of awareness of susceptibility patterns of common pathogens. Over prescribing not only increases the costs of health care, but may result in superinfection due to antimicrobial-resistant bacteria, as well as opportunistic fungi, and may increase the likelihood of an adverse drug reaction. On the other hand, not prescribing (when there is an urgent need at the bedside) may also lead to serious consequences.
The materials in this booklet constitute guidelines only and are subject to change pursuant to medical judgement relative to individual patient needs. Our antimicrobial formulary decisions are made annually after thorough deliberations and consensus building with members of the Infectious Disease Department, the Department of Pharmacy, and the Section of Microbiology. In vitro susceptibility data of the previous year are shared and emerging resistance patterns reviewed. Usage and cost data are discussed. The mission of our program is to provide the most cost-effective antimicrobial agents to our patients.
This booklet does not contain speciſ c guidelines for treatment of human immunodeſ - ciency virus (HIV) infection. Nor is prophylaxis against opportunistic microorganisms included, since such issues are usually handled in our outpatient clinics. Similarly, treatment of infectious diseases commonly seen in the outpatient setting, such as otitis media and pharyngitis, are not included in this booklet.
8/15/2012 2:54:01 PM TABLE 1 Typical Gram Stain Morphology of
Selected
Gram-Positive Cocci (GPC)
Gram-Negative Cocci (GNC)
Staphylococcus sp • Pairs, chains: › Neisseria meningitidis Streptococcus sp › Neisseria gonorrhoeae Enterococcus sp › Moraxella catarrhalis Peptostreptococcus sp (anaerobe) Acinetobacter sp (coccobacilli) Gram-Positive Bacilli (GPB)
Gram-Negative Bacilli (GNB)
• Enterobacteriaceae: › Corynebacterium Escherichia coli › Propionibacterium sp (anaerobe) Serratia sp • Large, with spores: Klebsiella sp Clostridium sp (anaerobe) Enterobacter sp Bacillus sp Citrobacter sp • Branching, beaded, rods: • Nonfermentative: Actinomyces sp (anaerobe) Stenotrophomonas maltophilia Listeria monocytogenes (blood/cerebrospinal fluid) • Haemophilus influenzae (coccobacilli) Lactobacillus sp (vaginal/blood) • Bacteroides fragilis group (anaerobe)• Fusiform (long, pointed): – Fusobacterium sp (anaerobe) Capnocytophaga sp 1 These organisms represent a subset of possible identifi cations correlating with gram stain morphology observed on direct specimen preparations. Correlation with culture, specimen quality, and clinical fi ndings is required. 8/15/2012 2:54:01 PM TABLE 2 Key Characteristics of Selected Organisms
Gram-Positive Cocci (GPC)
Gram-Negative Cocci (GNC)
• Catalase-positive:
• Neisseria meningitidis Staphylococcus sp • Neisseria gonorrhoeae • Catalase-negative: • Moraxella catarrhalis Enterococcus sp • Acinetobacter sp1 Streptococcus sp (chains) • Coagulase-positive: Gram-Negative Bacilli (GNB)
Staphylococcus aureus • Lactose-positive: • Coagulase-negative: Escherichia coli – Coagulase-negative staphylococci (CNS): Klebsiella pneumoniae (mucoid) › Blood: Staphylococcus epidermidis or CNS Enterobacter sp2 › Urine: Staphylococcus saprophyticus Citrobacter sp2 › Staphylococcus lugdunensis4 • Lactose-negative/oxidase-negative: – Proteus mirabilis: indole-negative Gram-Positive Bacilli (GPB)
Proteus vulgaris: indole-positive Providencia sp – May be Corynebacterium sp: can be blood culture Serratia sp3 – Corynebacterium jeikeium, Corynebacterium Salmonella sp striatum, Corynebacterium amycolatum: resistant Shigella sp to many agents except vancomycin Acinetobacter sp1 • Anaerobic diphtheroids: Propionibacterium acnes Stenotrophomonas (Xanthomonas) maltophilia usually susceptible to beta-lactams and vancomycin • Bacillus sp: Bacillus anthracis: non-motile and non-E- hemolytic; Bacillus cereus; Bacillus subtilis, ie, large, Pseudomonas aeruginosa (green; "grape odor") "box car" rods with spores Aeromonas hydrophila (may be lactose-positive) • Listeria monocytogenes: cerebrospinal fluid, blood • Lactobacillus sp: vaginal flora, rarely in blood › Other Pseudomonas sp • Nocardia sp: Branching, beaded; partial acid–fast- › Moraxella sp1 › Alcaligenes sp • Rapidly growing mycobacteria: › Burkholderia sp Mycobacterium chelonae/abscessus, Mycobacterium mycogenicum (Table continued on following page) 8/15/2012 2:54:01 PM TABLE 2 Key Characteristics of Selected Organisms (continued)
Gram-Negative Bacilli (GNB)
– Thermally dimorphic (yeast in tissue, mold in lab): › Histoplasma capsulatum (slow growing) Haemophilus influenzae (coccobacillary); requires › Blastomyces dermatitidis supplements/special media (chocolate agar plate) › Coccidioides immitis Candida sp; Candida albicans if germ tube-positive Aseptate hyphae: Cryptococcus sp (no pseudohyphae); › Zygomycetes, such as: Cryptococcus neoformans if latex- or CAD-positive Rhizopus sp Candida glabrata Trichosporon sp Rhodotorula, Saccharomyces sp › Brown pigment (phaeohyphomycetes), such as: – Bipolaris sp Exserohilum sp Alternaria sp Bacteroides sp (Bacteroides fragilis) Curvularia sp Fusobacterium sp Sporothrix schenckii ("rose-gardeners") › Non-brown pigmented (hyalohyphomycetes, Veillonella sp most common), such as: Aspergillus sp (Aspergillus fumigatus, Aspergillus flavus) Fusarium sp Penicillium sp Clostridium sp (spores) Paecilomyces sp Actinomyces sp (branching, filamentous) Lactobacillus sp Eubacterium sp 1 May be either bacillary or coccoid.
2 May be lactose negative.
3 May produce red pigment and appear lactose-positive initially.
4 Clinically can act as Staphylococcus aureus.
8/15/2012 2:54:01 PM TABLE 3 Usual Acid-Fast Bacillus Characteristics
Mycobacterium sp
Time to Isolation
Usual Clinical Diseases1
Mycobacterium tuberculosis Mycobacterium avium complex 5-7 d Mycobacterium gordonae
Mycobacterium kansasii Yellow (in light) Pulmonary, skin and soft tissue Mycobacterium marinum Skin and soft tissue Rapid Growers:
Mycobacterium abscessus
Skin and soft tissue, pulmonary Mycobacterium chelonae Skin and soft tissue Mycobacterium fortuitum Skin and soft tissue Partial Acid-Fast Organisms:
Nocardia sp
Pulmonary, central nervous system, skin and soft tissue Rhodococcus and Catheter-related bloodstream, Tsukamurella sp 1 Note: Any acid-fast bacillus may disseminate in immunocomprised hosts.
8/15/2012 2:54:01 PM TABLE 4 Laboratory Requests and Specimen Types
1. Blood cultures:
a. Blood cultures are most likely to be positive when an ample volume of blood is collected prior to
administration of antimicrobials.
b. Two initial sets of 20 mL each should be drawn by separate phlebotomy procedures. Venipuncture is preferred (less prone to contamination) rather than collection through an intravascular catheter.
c. Ten mL from each blood draw is inoculated into an aerobic bottle and 10 mL into an anaerobic bottle. Cultures are held 5 days before being reported as negative.
d. A single positive blood culture of these organisms (ie, other blood cultures collected within 48 h are negative) suggests contamination: Bacillus sp, coagulase-negative staphylococci, diphtheroids, Propionibacterium acnes, viridans streptococci.
e. An isolator tube of 10 mL of blood should be drawn if any of the following are suspected: Bordetella, Francisella, Histoplasma capsulatum, Legionella, Mycobacterium sp. These will be incubated for longer than 5 days before being considered negative.
2. Stools for Clostridium difficile:
a. Liquid stools are tested for the presence of Clostridium difficile toxin by PCR.
b. The sensitivity of the assay is >90%.
c. Due to the sensitivity of the assay, only one sample per week is necessary.
d. Since C difficile colonization rather than infection may exist, only unformed stool specimens from patients
with signs and symptoms of C difficile infection should be tested. Once a patient is diagnosed with C difficile infection, therapeutic response should be based on clinical signs and symptoms; a "test of cure" should not be done since patients may remain colonized with toxin-producing strains following recovery.
3. Stools for enteric pathogens and ova and parasites: a. Stools sent for bacterial pathogens and parasites should be from outpatients or patients who have been in the hospital <3 days.
b. Stools are examined for the presence of Salmonella sp, Shigella sp, Campylobacter jejuni, Escherichia coli 0157:H7 and shiga toxin–producing E coli routinely if submitted for enterics; if for parasites, routine testing for Giardia sp and Cryptosporidium sp is performed via EIA unless a microscopic examination is specifically ordered.
c. Other pathogens require a special request.
(Table continued on following page) 8/15/2012 2:54:01 PM TABLE 4 Laboratory Requests and Specimen Types (continued)
4. Antimicrobial susceptibility testing: a. Testing is performed routinely on clinically relevant aerobic bacteria for which there are guidelines as set forth by the Clinical Laboratory Standards Institute (CLSI).
b. Requests for susceptibility testing of fungi, non-tuberculosis Mycobacterium, and anaerobic bacteria are 8/15/2012 2:54:01 PM TABLE 5 Mechanism of Action of Common
Antibacterial
Aminoglycosides interfere with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
•
Beta-Lactams: Penicillins and cephalosporins inhibit bacterial cell-wall synthesis by binding to one or more
penicillin-binding proteins which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in
bacterial cell walls, thus inhibiting cell-wall biosynthesis. Bacteria eventually lyse due to ongoing activity of
organism autolytic enzymes (autolysins and murein hydrolases) while cell-wall assembly is arrested.
Penicillins
• Dicloxacillin • Piperacillin • Piperacillin/tazobactam Ciprofloxacin inhibits DNA-gyrase which does not allow the uncoiling of supercoiled DNA and promotes
breakdown of double-strand DNA.
Clindamycin binds to the 50S ribosomal subunit (reversibly), preventing peptid-bond formation and inhibiting
protein synthesis.
(Table continued on following page) 8/15/2012 2:54:01 PM TABLE 5 Mechanism of Action of Common
Antibacterial
Daptomycin acts at the cytoplasmic membrane and is hypothesized to rapidly depolarize the cell membrane via
an efflux of potassium and possibly other ions. Cell death occurs as a result of multiple failures in biosystems,
including DNA, RNA, and protein synthesis.
Linezolid binds to a site on the 23S ribosomal RNA of the 50S subunit, blocking formation of the 70S initiation
complex thus inhibiting translation.
Macrolides inhibit protein synthesis at the chain elongation step and binds to the 50S ribosomal subunit.
• Erythromycin • Azithromycin • Clarithromycin Metronidazole interacts with DNA causing a loss of helical DNA structure and strand breakage, resulting in
inhibition of protein synthesis.
Tetracyclines inhibit protein synthesis by binding to the 30S and possibly the 50S ribosomal subunits.
• Doxycycline • Tetracycline Tigecycline binds at the same site on the ribosome as tetracyclines, however binds 5-fold more tightly. Also able
to overcome the ribosomal protection mechanism of tetracycline resistance.
Trimethoprim/sulfamethoxazole: Trimethoprim inhibits dihydrofolic acid reduction to tetrahydrofolate, resulting in
sequential inhibition of the folic acid pathway. Sulfamethoxazole interferes with bacterial folic acid synthesis and
growth via inhibition of dihydrofolic acid formation from PABA.
Vancomycin inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding to the
D-alanyl-D-alanine portion of the cell wall precursor.
8/15/2012 2:54:01 PM TABLE 6 Guidelines for Treatment of Pneumonia in Adults
Source/ Empiric
Therapy— Likely
Severe Penicillin Allergy1 Pathogens
Community2 Ceftriaxone + Haemophilus influenzae Cefuroxime Chlamydia pneumoniae Doxycycline Moraxella catarrhalis Cefuroxime Community- Amp/Sulb Pseudomonas vancomycin ± vancomycin aeruginosa Enterobacter sp Serratia marcescens Pip/Tazo Klebsiella sp Acinetobacter sp Staphylococcus aureus Oxacillin8 1 For severe pencillin allergy (ie, anaphylaxis). For delayed hypersensitivity reactions (eg, rash to a penicillin), a third/fourth- generation cephalosporin (ie, ceftriaxone for CAP/cefepime for HAP) or carbapenem may be considered.
2 In immunocompromised hosts, consider adding TMP/SMX for Pneumocystis jirovecii (carinii) coverage.
3 Amikacin should be considered in intensive care units where gentamicin/tobramycin susceptibilities are lower.
4 Substitute tobramycin if resistant to gentamicin.
5 Consider a longer 14-day duration for Pseudomonas and Acinetobacter HAP.
6 For piperacillin/tazobactam-resistant isolates, TMP/SMX or meropenem may be appropriate alternative agents.
7 Carbapenem-resistant Acinetobacter have been detected. Consider ampicillin/sulbactam or ID consult for alternative therapies. 8 Note that 50% of S aureus are resistant to oxacillin (or methicillin) and cefazolin. Vancomycin is appropriate in such patients.
8/15/2012 2:54:01 PM TABLE 7 Guidelines for Treatment of Infective
Endocarditis in Adults
Alternate
IE Setting
Therapy1
Likely Pathogens
Viridans streptococci Penicillin G2 or ceftriaxone3 Streptococcus bovis Penicillin G2 or ceftriaxone3 Enterococcus Ampicillin4 + gentamicin5 Staphylococcus aureus Oxacillin ± gentamicin5,6 Staphylococcus aureus Oxacillin + gentamicin + Coagulase-negative Oxacillin + gentamicin + Viridans streptococci Penicillin G7 or ceftriaxone3 Ampicillin4 + gentamicin5 1 Antimicrobial therapy should be initiated AFTER blood cultures are drawn.
2 Penicillin MIC <0.12 mcg/mL = penicillin 12-18 million units/day in 4 or 6 divided doses (renal dose adjustment necessary).
Penicillin MIC >0.12 mcg/mL and <0.5 mcg/mL = penicillin 24 million units/day in 4 or 6 divided doses (renal dose adjustment necessary).
Penicillin MIC >0.5 mcg/mL should be treated with enterococci regimen.
3 Ceftriaxone 2 g IV q24h.
4 Ampicillin 12 g/day in 6 divided doses (renal dose adjustment necessary). Vancomycin should be substituted for ampicillin- resistant isolates.
5 Low-dose gentamicin; 1 mg/kg IV q8h with interval adjusted for renal insuffi ciency.
6 Oxacillin 2 g IV q4h. Vancomycin should be substituted if the isolate is oxacillin-resistant.
7 Penicillin 24 million units/day in 4 or 6 divided doses (renal dose adjustment necessary).
8/15/2012 2:54:01 PM TABLE 8 Guidelines for Treatment of Bone
and Joint Infections in Adults
Clinical Empiric
Setting Therapy
Pathogens Therapy Duration1
Staphylococcus aureus Oxacillin or cefazolin2 4-6 Posttraumatic Piperacillin/ Staphylococcus aureus Oxacillin or cefazolin2 4-6 Penicillin G or ampicillin Gram-negative bacilli Pseudomonas aeruginosa Piperacillin/tazobactam Usually polymicrobial Ampicillin/sulbactam Septic arthritis Vancomycin
Staphylococcus aureus Oxacillin or cefazolin2 4 Gonococcus3 Ceftriaxone Total joint replacement Vancomycin
Staphylococcus aureus Oxacillin or cefazolin2 4 Staphylococcus epidermidis Vancomycin5 Penicillin G or ampicillin 1 May require prolonged therapy, depending on clinical situation.
2 Substitute vancomycin if oxacillin-resistant.
3 Young adults.
4 May switch to oral therapy when clinically indicated.
5 Substitute oxacillin or cefazolin if susceptible.
8/15/2012 2:54:02 PM TABLE 9 Guidelines for Treatment of Urinary
Infections1 in Adults
Clinical Likely
Setting Pathogens
Acute uncomplicated Escherichia coli, other TMP/SMX2 Ciprofloxacin2 3 Enterobacteriace Escherichia coli, other TMP/SMX2 Ciprofloxacin2 10-14 pyelonephritis3 Enterobacteriaceae Severe pyelonephritis4 Escherichia coli, other Piperacillin/tazobactam5,6 Ciprofloxacin5,6 10-14 Enterobacteriace 1 UTI defi ned as symptoms plus pyuria (ie, >10 WBC).
2 Oral therapy preferred.
3 Limited nausea and vomiting; able to tolerate oral medication.
4 Nausea and vomiting; NPO.
5 May switch to oral therapy when appropriate.
6 Narrow therapy when culture and susceptibility results are available.
8/15/2012 2:54:02 PM TABLE 10 Guidelines for Treatment of
Sexually Transmitted Infections
Disease Recommended
Pathogens Primary
Chancroid:
Haemophilus ducreyi
Erythromycin 500 mg PO Ceftriaxone 250 mg IM × 1 or azithromycin Uncomplicated Gonorrhea
Neisseria gonorrhoeae Ceftriaxone 250 mg IM
Azithromycin 1 g Disseminated gonorrhea:
Neisseria gonorrhoeae Ceftriaxone 1 g IV q24h
× 1-2 d or until improved, followed by cefixime1 400 mg PO bid to complete total therapy of 7-10 d Epididymitis (sexually acquired):
Chlamydia trachomatis Ceftriaxone 250 mg IM
Levofloxacin 500 mg Levofloxacin should only be Neisseria gonorrhoeae × 1 + doxycycline used if nonsexually acquired epididymitis, due to FQ- resistant N gonorrhoeae (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 10 Guidelines for Treatment of
Sexually Transmitted Infections (continued)
Disease Recommended
Pathogens Primary
Genital herpes:
Herpes simplex virus
First episode genital: Acyclovir 400 mg PO tid × 7-10 d Acyclovir 400 mg PO tid or First episode proctitis: Acyclovir 400 mg PO 5×/d × 7-10 d Severe herpes infection: Prevention of recurrence: Acyclovir 5 mg/kg IV q8h × 5-7 d Acyclovir 400 mg PO bid Pelvic inflammatory disease (PID):
Chlamydia trachomatis Inpatient: Ceftriaxone 2 g
Clindamycin 900 mg IV Refer to Table 18 for gentami- Neisseria gonorrhoeae IV q24h + doxycycline q8h + gentamicin, cin dosing. Evaluate and treat Mycoplasma hominis 100 mg IV q12h ± metro- followed by doxycycline sexual partners. Test for nidazole 500 mg IV q12h 100 mg PO bid to com- syphilis and HIV. Erythro- Enterobacteriaceae until improved, then doxy- plete total therapy of mycin stearate 500 mg PO cycline 100 mg PO bid qid instead of doxycycline if pregnant. For PID unrelated Outpatient: Ceftriaxone 250 to sexual activity, treat as mg IM × 1 + doxycycline for intra-abdominal sepsis 100 mg PO bid ± metronidazole (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 10 Guidelines for Treatment of
Sexually Transmitted Infections (continued)
Disease Recommended
Pathogens Primary
Syphilis:
Treponema pallidum
Primary, secondary or latent <1 year: All stages of syphilis require Penicillin G benzathine Doxycycline 100 mg follow-up for possible 2.4 million units IM × 1 relapse. Evaluate and treat sexual partners. Test for Late latent >1 year: HIV. Pregnant women aller- Penicillin G benzathine Doxycycline 100 mg gic to penicillin should be 2.4 million units IM q wk Procaine penicillin Patient allergic to penicillin Penicillin G 3-4 million 2.4 million units IM q24h should be desensitized units IV q4h × 10-14 d + Probenecid 500 mg PO qid × 10-14 d (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 10 Guidelines for Treatment of
Sexually Transmitted Infections (continued)
Pathogens Primary
Urethritis or cervicitis:
Chlamydia trachomatis Ceftriaxone 250 mg IM
Azithromycin 2 g PO Quinolones do not eradicate Ureaplasma urealyticum × 1 + doxycycline incubating syphilis. Evalu- Neisseria gonorrhoeae 100 mg PO bid × 7 d ate and treat sexual part- ners. Test for syphilis and HIV. Due to increased prev- alence of fluoroquinolone- resistant Neisseria gonor- rhoeae the CDC no longer recommends fluoroquino- lones for the treatment of 1 Ciprofl oxacin may be used if susceptibility documented.
8/15/2012 2:54:02 PM TABLE 11 Guidelines for Treatment of
Bacterial Meningitis in Adults
Clinical Empiric
Directed
Setting Therapy
Pathogens
Haemophilus influenzae Ceftriaxone2,4 1-2 Immunocompromised Ceftriaxone2 + Listeria sp Ampicillin + gentamicin or age >50 years GNB (Pseudomonas aeruginosa) Cefepime6 + gentamicin7 Postneurosurgical/ Vancomycin Staphylococcus epidermidis Vancomycin8 2-4 Staphylococcus aureus Oxacillin9 (Pseudomonas aeruginosa) Cefepime6 + gentamicin7 1 If age >50 years or immunocompromised, consider Listeria and add ampicillin.
2 Ceftriaxone 2 g IV q12h.
3 Substitute ceftriaxone or vancomycin if isolate is resistant to penicillin.
4 If isolate is E–lactamase-negative, ampicillin may be substituted.
5 Three weeks recommended for GNB. 6 Cefepime 2 g IV q8h (renal dose adjustment necessary).
7 Substitute tobramycin if resistant to gentamicin. 8 Substitute oxacillin if susceptible.
9 Substitute vancomycin if oxacillin-resistant.
8/15/2012 2:54:02 PM TABLE 12 Guidelines for Treatment of Febrile Neutropenia1
Clinically stable
Piperacillin/tazobactam 3.375 g IV q6h2 Pencillin allergy with history of: Rash Cefepime 2 g IV q8h2 Aztreonam 2 g IV q6h2 + vancomycin3 + gentamicin4 Severe mucositis or Add vancomycin3,5 to regimen Suspected catheter-related infection orSuspected skin or skin structure infection orGram-positive oganism in blood cultures Clinically unstable (based on BP, HR, RR, and Add gentamicin4 and vancomycin3,5 to regimen Fever •72 hours on broad-spectrum antimicrobials Consider adding voriconazole Fever >72 hours and hemodynamic instability Consider change in antibacterial regimen (eg, change to and/or respiratory distress 1 Neutropenia ANC <500. 2 Renal dose adjustment necessary.
3 See Table 20 for dosing recommendations.
4 See Table 18 and Table 19 for dosing recommendations; extended interval dosing preferred if patient meets criteria.
5 Consider discontinuing vancomycin if cultures negative for MRSA at 48 hours.
8/15/2012 2:54:02 PM TABLE 13 Guidelines for Management of Clostridium difſ cile
Toxin-Positive
Send one stool
Place patient in contact precautions: 1. Private room preferred associated diarrhea 2. Gloves before entering room 3. Gowns for patient contact
4. Hand hygiene with soap and water after
removing gown/gloves 5. Alcohol wipes for stethoscope after use CDAD with illeus or severe, complicated illness1 • Surgical and Infectious Disease Metronidazole 500 mg PO tid • Vancomycin 500 mg PO or NG q6h Metronidazole 500 mg IV q8h Vancomycin 125 PO qid Vancomycin 500 mg/100 mL PR q6h Follow-Up:
1. No need for further stool specimens (note: diarrhea may take
3-4 days to respond to treatment) 1 Severe, complicated illness defi ned as hypotension, shock, or illeus.
2 Consider vancomycin if metronidazole intolerant, failing to respond to metronidazole (ie, failure to improve after 3 to 4 days of therapy), or severe disease defi ned as WBC •15,000 or serum creatinine >1.5 × baseline.
8/15/2012 2:54:02 PM TABLE 14 Treatment of Skin and Skin Structure Infections1
Clinical Setting
Likely Pathogens
Empiric Therapy
Uncomplicated cellulitus2 Oxacillin or cefazolin3 Vancomycin3,4 7 Ampicillin/sulbactam Guided by patient Necrotizing fasciitis Group A streptococci STAT Surgery Consult Guided by patient Vancomycin + clindamycin 1 If abscess present, incision and drainage (I&D) is imperative for cure. I&D may be suffi cient if isolated abscess <5 cm.
2 Complicating risk factors: chronic ulcer; including diabetic, vascular insuffi ciency; including chronic venous stasis and peripheral arterial disease, surgical wound, residence in health care facility within 90 days, recurrent cellulitis > twice in the preceding year, animal or human bite, indwelling medical device, perirectal infection, periorbital infection, salt or fresh water exposure, and immu-nocompromised state.
3 If culture negative or unavailable, change to oral doxycycline 100 mg PO bid, TMP/SMX DS 1-2 tabs PO bid, or clindamycin 300- 450 mg PO tid when able.
4 Use fi rst-line empiric if MRSA risk factors present. Risk factors include: injection drug use, diabetes mellitus, end-stage renal disease, human immunodefi ciency virus infection, contact sports, prisoners, soldiers, men who have sex with men, Native Americans, recent antimicrobial exposure, known colonization with MRSA, contact with person diagnosed with MRSA infection, and report of spider bite.
8/15/2012 2:54:02 PM TABLE 15 Guidelines for Antimicrobial Dosing in Adults

Suggested
for Dialysis
Drug Route
(mL/min)
200 mg/100 mg, alternating q24h 200 mg/100 mg, alternating weekly Individualize regimen with serum concentrations (see Table 18) 250-500 mg q8-12h Amphotericin B IV No renal dosage adjustment necessary 0.5-1mg/kg q24h (max dose 100 mg) Amphotericin B IV See Table 16 for appropriate usage guidelines Lipid Complex ABELCET® (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 15 Guidelines for Antimicrobial Dosing in Adults (continued)

Suggested
for Dialysis
Drug Route
(mL/min)
No renal dose adjustment necessary No renal dose adjustment necessary No renal dose adjustment necessary No renal dose adjustment necessary See Table 16 for appropriate usage guidelines 300 mg q12h or 600 mg q24h See Table 16 for appropriate usage guidelines 100-400 mg 3×/wk (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 15 Guidelines for Antimicrobial Dosing in Adults (continued)

Admin CrCl
Suggested
for Dialysis
Drug Route
(mL/min)
See Table 16 for appropriate usage guidelines 750 mg-1.5 g q8-12h 250-500 mg q8-12h Chloramphenicol IV No renal dose adjustment necessary See Table 16 for appropriate usage guidelines 250, 500 or 750 mg q12h 500 or 750 mg q24h Clarithromycin PO No renal dose adjustment necessary No renal dose adjustment necessary No renal dose adjustment necessary Colistimethate Inhaled See Table 16 for appropriate usage guidelines (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 15 Guidelines for Antimicrobial Dosing in Adults (continued)

Admin CrCl
Suggested
for Dialysis
Drug Route
(mL/min)
Cytomegalovirus IV See Table 16 for appropriate usage guidelines immune globulin No renal dose adjustment necessary See Table 16 for appropriate usage guidelines No renal dose adjustment necessary No renal dose adjustment necessary No renal dose adjustment necessary 15-25 mg/kg q24h Maximum daily dose: 2.5 g 50% of recommended dose 12.5-37.5 mg/kg q6h 12.5-37.5 mg/kg q12h 12.5-37.5 mg/kg q24h 12.5-37.5 mg/kg q24-48h See footnote 4 for dosing No renal dose adjustment necessary 3 g × 1 dose (may be repeated if needed) (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 15 Guidelines for Antimicrobial Dosing in Adults (continued)

Admin CrCl
Suggested
for Dialysis
Drug Route
(mL/min)
1.25 mg/kg 3×/wk, following hemodialysis Individualize regimen with serum concentrations (see Table 18) No renal dose adjustment necessary No renal dose adjustment necessary No renal dose adjustment necessary Levofloxacin IV/PO See Table 16 for appropriate usage guidelines See Table 16 for appropriate usage guidelines See Table 16 for appropriate usage guidelines Metronidazole PO/IV See Table 16 for appropriate usage guidelines Nitrofurantoin PO No renal dose adjustment necessary (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 15 Guidelines for Antimicrobial Dosing in Adults (continued)

Admin CrCl
Suggested
for Dialysis
Drug Route
(mL/min)
30 mg, following hemodialysis 2-4 million units q2-4h 1-2 million units q4-6h 1-2 million units q8-12h OR 0.5-1 million units q4-6h See Table 16 for appropriate usage guidelines 15-30 mg/kg q24h 15-30 mg/kg 3×/wk Maximum dose: 2 g Pyrimethamine PO5 No renal dose adjustment necessary See Table 16 for appropriate usage guidelines No renal dose adjustment necessary (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 15 Guidelines for Antimicrobial Dosing in Adults (continued)

Admin CrCl
Suggested
for Dialysis
Drug Route
(mL/min)
No renal dose adjustment necessary Streptomycin6 IV/IM 7.5 mg/kg q24-72h 7.5 mg/kg q72-96h Sulfisoxazole PO No renal dose adjustment necessary 250-500 mg q6-12h 250-500 mg q12-24h See Table 16 for appropriate usage guidelines Tobramycin IV/IM Individualize dosing with serum concentrations (see Table 18) Trimethoprim/ IV sulfamethoxazole (All doses based on trimethoprim) 1 DS = 160 mg of trimethoprim (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 15 Guidelines for Antimicrobial Dosing in Adults (continued)

Admin CrCl
Suggested
for Dialysis
Drug Route
(mL/min)
Valganciclovir PO See Table 16 for appropriate usage guidelines See Table 20 for individualized dosing No renal dose adjustment necessary Voriconazole IV/PO See Table 16 for appropriate usage guidelines 1 Assure that full daily dosing occurs after dialysis as an alternative to supplemental dosing.
2 For malaria prophylaxis, the recommended dose is 250/100 mg q24h.
3 Dose may be doubled in severe infection.
4 Foscarnet dosing in renal insuffi ciency: Induction for HSV
Induction for CMV
Maintenance Dosage for CMV
(dose in mg/kg) (dose in mg/kg) (dose in mg/kg)
Creatinine Clearance
Equivalent to
Equivalent to
mL/min/kg 40
mg/kg q12h
90 mg/kg q12h
90 mg/kg q24h
5 Plus folinic acid, 10 mg, with each dose of pyrimethamine. 6 Recommended dosing for synergy in the treatment of enterococcal infections. Serum levels should be monitored.
7 Higher doses may be warranted for serious infections; up to 3 DS q8h or 2 DS q6h.
8/15/2012 2:54:02 PM TABLE 16 Formulary-Approved Indications and Dosing
of Restricted Antimicrobial Agents in Adults
Suggested
Drug/ Admin
CrCl Dosage for
Dialysis
Indication Route Regimen Cost/d
(mL/min) Regimen
Amphotericin B Lipid Complex ABELCET® No renal dose adjustment necessary • Infectious Diseases • Serum creatinine >21 or 50% decrease in baseline renal function • Amphotericin B failure • Infections due to resistant organisms 250-500 mg q6-8h • Allergy to E-lactam antimicrobials • Penicillin-allergic patients who can tolerate cephalosporins • Organisms resistant to piperacillin/tazobactam • CNS infections No renal dose adjustment necessary • Dose limited to 1 g q24h unless endocarditis or meningitis (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 16 Formulary-Approved Indications and Dosing
of Restricted Antimicrobial Agents in Adults (continued)
Suggested
Drug/ Admin
CrCl Dosage for
Dialysis
Indication Route Regimen Cost/d
(mL/min) Regimen
5 mg/kg3 N/A $297 <55 • Infectious Diseases every other week (+ probenecid and hydration) Inhaled: $15 Inhaled: $105 Diseases Service only • Dose based on ideal body weight • Optional 3 mg/kg loading dose Initial dose: 150 mg/kg No renal dose adjustment necessary immune globulin Week 2, 4, 6, 8: 100 mg/kg • Infectious Diseases Week 12, 16: 50 mg/kg and Transplant Services Cost/course: $20,000 • Infectious Diseases Service only • Not indicated for pneumonia • Higher mg/kg doses may be warranted for certain infections (Table continued on following page) 8/15/2012 2:54:02 PM TABLE 16 Formulary-Approved Indications and Dosing
of Restricted Antimicrobial Agents in Adults (continued)
Suggested
Drug/ Admin
CrCl Dosage for
Dialysis
Indication Route Regimen Cost/d
(mL/min) Regimen
• Infectioius Diseases Service • Single dose prior to discharge for CoPAT • Penicillin- allergic patients No renal dose adjustment necessary • Infectious Diseases • Infections due to Pip/Tazo-resistant organisms or Pip/Tazo clinical failures • Dose may be increased for CNS infection (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 16 Formulary-Approved Indications and Dosing
of Restricted Antimicrobial Agents in Adults (continued)
Suggested
Drug/ Admin
CrCl Dosage for
Dialysis
Indication Route Regimen Cost/d
(mL/min) Regimen
No renal dose adjustment necessary • Infectious Diseases Service only • 100-mg dose recommended for candidemia, disseminated candidiasis, candida peritonitis, and abscesses • 150-mg dose recommended for candida endocarditis, osteomyelitis, or meningitis and mould infections No renal dose adjustment necessary • Infectious Diseases Service • BMT Service No renal dose adjustment necessary • Infectious Diseases Services only No renal dose adjustment necessary • Infectious Diseases • Treatment of MDR dose: 50 mg q12h Gram-negative infections (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 16 Formulary-Approved Indications and Dosing
of Restricted Antimicrobial Agents in Adults (continued)
Suggested
Drug/ Admin
CrCl Dosage for
Dialysis
Indication Route Regimen Cost/d
(mL/min) Regimen
• Infectious Diseases Service • Transplantation services: No renal dosage adjustment • Infectious Diseases necessary; IV not recommended in patients with a CrCl <50 mL/min • Hematology/Oncology (>100 kg; 600 mg q12h × 2 doses) Maintenance dose: 200 mg q12h IV: $180 1 Not for chronic renal failure.
2 Administer with probenecid; 2 g orally 3 hours prior to each infusion and 1 g at 2 and 8 hours after completion of infusion (total 4 g). Hydrate with 1 L of 0.9% NS IV prior to infusion. A second liter may be given over 1 to 3 hour period immediately following infusion, if tolerated.
3 BK virus dosing is 1 mg/kg; no probenecid or hydration necessary.
8/15/2012 2:54:03 PM TABLE 17 Antiretrovirals1
(Guidelines subject to change; check www.aidsinfo.nih.gov for updates.) Generic: Chemical
(Trade) Drug Names
Recommended Dose & Selected
Manufacturer
Dosage Forms
Dosage Adjustments
Adverse Reactions
Maraviroc (Selzentry) Tab: 150, 300 mg Hepatotoxicity, rash, upper respiratory 150 mg bid when given with infection, postural hypotension PIs other than tipranavir Avoid use with CrCl <30 mL/min if used 600 mg bid when given with with strong inhibitor or inducer efavirenz, rifampin, or Tropism tesing required prior to use Integrase Inhibitor
Raltegravir (Isentress)
GI upset, headache, fatigue, hyperglyce- mia, creatine kinase elevations Nucleoside Reverse Transcriptase Inhibitors2
Abacavir ABC (Ziagen)3 Hypersensitivity syndrome (fever, fatigue, GlaxoSmithKline Oral Sol: 20 mg/mL, GI symptoms, ± rash). DO NOT RESTART: screen for HLAB*5701 prior to use >6: contraindicated (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 17 Antiretrovirals1 (continued)
Generic: Chemical
(Trade) Drug Names
Recommended Dose & Selected
Manufacturer
Dosage Forms
Dosage Adjustments
Adverse Reactions
Nucleoside Reverse Transcriptase Inhibitors2
Didanosine Delayed-
Cap: 125, 200, 250, •60 kg: 400 mg q24h Pancreatitis, peripheral neuropathy, nausea, Release ddI (Videx EC) <60 kg: 250 mg q24h potential association with noncirrhotic Bristol-Myers Squibb Ped Powder: 2, 4 g Adjust for CrCl <60 mL/min portal hypertension, presenting with Dosing for persons on esophageal varices lactic acidosis with concomitant tenofovir: 60 kg: 250 mg daily on Insulin resistance/diabetes <60 kg: 200 mg daily on Emtricitabine: FTC3 Nausea, diarrhea, headache, rash, (Emtriva) Gilead hyperpigmentation/skin discoloration 30-49: 200 mg q48h 15-29: 200 mg q72h <15: 200 mg q96h Oral Sol: 10 mg/mL, 30-49: 120 mg q24h 15-29: 80 mg q24h <15: 60 mg q24h (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 17 Antiretrovirals1 (continued)
Generic: Chemical
(Trade) Drug Names
Recommended Dose & Selected
Manufacturer
Dosage Forms
Dosage Adjustments
Nucleoside Reverse Transcriptase Inhibitors2
Lamivudine: 3TC (Epivir)3 Tab: 150, 300 mg
•50 kg: 150 mg bid; Minimal toxicity, pancreatitis in children GlaxoSmithKline Oral Sol: 10 mg/mL, <50 kg: 2 mg/kg bid 30-49: 150 mg q24h 15-29: 150 mg × 1, then 100 mg q24h 5-14: 150 mg × 1, then 50 mg q24h <5: 50 mg × 1, then 25 mg q24h Stavudine: d4T (Zerit) Cap: 15, 20, 30, 40 mg Peripheral neuropathy, headache, Bristol-Myers Squibb Oral Sol: 1 mg/mL, abdominal or back pain, asthenia, 26-50: 20 mg bid nausea, diarrhea, myalgia, pancreatitis, 10-25: 20 mg q24h mitochondrial toxicities <60 kg: 30 mg bid 26-50: 15 mg bid 10-25: 15 mg q24h 200 mg tid or 300 mg bid Anemia, neutropenia, thrombocytopenia, on empty stomach headache, nausea, vomiting, myopathy, GlaxoSmithKline Syrup: 50 mg/5 mL, hepatitis, hyperpigmentation of nails <15: 100 mg tid or Inj: 10 mg/mL, 20 mL/vial (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 17 Antiretrovirals1 (continued)
Generic: Chemical
(Trade) Drug Names
Recommended Dose & Selected
Manufacturer
Dosage Forms
Dosage Adjustments
Nucleotide Reverse Transcriptase Inhibitors2
Tenofovir TDF (Viread)3
Asthenia, headache, diarrhea, nausea, •50: 300 mg q24h Fanconi syndrome, osteomalacia 30-49: 300 mg q48h with food 10-29: 300 mg twice weekly with food Dialysis: 300 mg weekly Non-nucleoside Reverse Transcriptase Inhibitors
Efavirenz EFV (Sustiva)3
600 mg q24h on empty Dizziness, confusion, hallucinations, rash, Bristol-Myers Squibb stomach at bedtime psychiatric symptoms, vivid dreams, hyperlipidemia teratogenic (pregnancy Etravirine ETV (Intelence) Tab: 200 mg 200 mg bid after a meal Rash, nausea, hypersensitivity reactions Nevirapine NVP (Vira- 200 mg q24h × 14 d, Rash, abnormal liver function tests, mune, Viramune XR) Oral Susp: 10 mg/mL, hepatotoxicity. Use with caution in men 400 mg (XR) q24h with CD4 >400 and women >250 due Tab (XR): 400 mg to increased risk of hepatotoxicity Rilpivirine (Edurant) Depression, rash, serum transaminase elevations, hyperlipidemia, hyperbili- rubenemia, headache, nausea, diarrhea (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 17 Antiretrovirals1 (continued)
Generic: Chemical
(Trade) Drug Names
Recommended Dose & Selected
Manufacturer
Dosage Forms
Dosage Adjustments
Protease Inhibitors4
Atazanavir ATV (Reyataz) Cap: 100, 150, 200, 300 mg
Rash, serum transaminase elevations, Bristol-Myers Squibb 300/100 mg7 q24h or hyperlipidemia, hyperbilirubenemia, decreased absorption in patients With TDF or AFV-experienced: receiving antacids, H blockers, or 300/100 mg q24h7 proton pump inhibitors With EFV in ARV-naïve: 400/100 mg7 q24h Do not use with ETR or NVP or in ARV-experienced >9: Not recommended Not recommended for patients Darunavir DRV (Prezista) Tab: 75, 150, 400, 600 mg Use with caution in patients with 800/100 mg q24h5,7 sulfonamide allergies, may cause (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 17 Antiretrovirals1 (continued)
Generic: Chemical
(Trade) Drug Names
Recommended Dose & Selected
Manufacturer
Dosage Forms
Dosage Adjustments
Protease Inhibitors4
Fosamprenavir FPV
Rash, nausea, vomiting, diarrhea. Avoid (Lexiva) GlaxoSmithKline boosted dose in persons with hepatic 1400/100 q24h6,7 1400/200 mg q24h6,7 Oral Sol: 50 mg/mL RTV 100 mg daily RTV 100 mg daily 10-12: 350 mg bid6 or Indinavir IDV (Crixivan) Cap: 100, 200, 400 mg 800 mg q8h with water8 Hyperbilirubinemia, nephrolithiasis, (hepatic insufficiency: abdominal pain, nausea, diarrhea, taste Lopinavir/ritonavir LPV/r Tab: 100/25, 200/50 mg 400/100 mg bid6,7 Diarrhea, nausea, vomiting, abdominal (Kaletra) Abbott 800/200 mg q24h6,7,9 pain, asthenia, headache. See ritonavir Oral Sol: 80/20 mg/mL, 500/125 mg q24h10 (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 17 Antiretrovirals1 (continued)
Generic: Chemical
(Trade) Drug Names
Recommended Dose & Selected
Manufacturer
Dosage Forms
Dosage Adjustments
Protease Inhibitors4
Nelfinavir NFV (Viracept)
Tab: 250, 625 mg 750 mg tid with food or Agouron (Pfizer) Oral Powder: 50 mg/g, 1250 mg bid with food Ritonavir RTV (Norvir) 100-400 mg q12-24h with Asthenia, nausea, diarrhea, vomiting, other protease inhibitor abdominal pain, circumoral and Oral Sol: 80 mg/mL, peripheral paresthesias, taste perversion Saquinavir SQV (Invirase) Cap: 200 mg 1000/100 mg bid 2 hours Diarrhea, abdominal discomfort, nausea, headache, PR and QT prolongation, torsades de pointes Tipranavir TPV (Aptivus) 500/200 mg7 bid with food Nausea, vomiting, diarrhea, rash, Boehringer Ingleheim Oral Sol: 100 mg/mL hepatotoxicity, intracranial hemorrhage Use caution in those with chronic hepatitis B or C, sulfa allergies, and in those with moderate hepatic insufficiency Fusion Inhibitors
Enfuvirtide: T-20 (Fuzeon) Vials for injection:
Injection site reactions, pneumonia Avoid in patients with hepatic impairment or CrCl <50 mL/min GlaxoSmithKline 8/15/2012 2:54:03 PM TABLE 17 Antiretrovirals1 (continued)
Generic: Chemical
(Trade) Drug Names
Recommended Dose & Selected
Manufacturer
Dosage Forms
Dosage Adjustments
Tab: 300/150/300 mg Avoid in patients with CrCl <50 mL/min zidovudine (Trizivir) and hepatic impairment GlaxoSmithKline Tab: 600/200/300 mg 1 tablet daily on empty Avoid in patients with CrCl <50 mL/min tenofovir (Atripla) and patients with mild-moderate hepatic Bristol-Myers Squibb/Gilead impairment (ie, Child-Pugh class B/C) Emtricitabine/tenofovir Avoid in patients with CrCl <30 mL/min (Truvada) Gilead 30-49: 1 tablet q48h Lamivudine/zidovudine: Tab: 150 mg/300 mg Avoid in patients with CrCl <50 mL/min 3TC/AZT (Combivir) and hepatic impairment Tab: 25 /200/300 mg 1 tablet daily with food Avoid in patients with CrCl<50 mL/min tenofovir (Complera) Gilead 1 These agents, especially protease inhibitors and non-nucleoside reverse transcriptase inhibitors, have numerous drug interactions. Please be aware of potential drug interactions when initiating or discontinuing any medication.
2 Therapy with these agents has been reported to cause lactic acidosis.
3 Available in combination product. See Combination Products section.
4 These agents have been associated with hyperglycemia, hypertriglyceridemia, fat redistribution, and possible increased bleeding episodes in patients with hemophilia.
5 Dose for ARV-naïve or -experienced patient with no darunavir mutations.
6 Only for treatment-naïve patients.
7 All boosted regimens utilize ritonavir. Boosted doses are listed as original protease inhibitor dose/ritonavir dose. 8 A minimum of 1.5 liters (48 ounces) of liquids per day is recommended.
9 Not for •3 LPV mutations, pregnant females, patients receiving EFV, NVP, FPV, NFV, carbamazepine, phenobarbital, or phenytoin.
10 Dose when given with EFV, NFV, or NVP.
8/15/2012 2:54:03 PM TABLE 18 Traditional Aminoglycoside Dosing
1.0 1.2 1.5 2.0 >2.0
30 q8h q8h q8h q12h 40 q8h q12h q12h q24h q24h 50 q12h q12h q12h q24h q24h 60 q12h q12h q12h q24h Dose (mg/kg)
Dosing Interval
Amikacin
Peak and trough with third dose Peak and trough with third dose Peak and trough with third dose Peak and 24-hour random level; redose when random level is <2 mcg/mL (tobramycin/ gentamicin) or <8 mcg/mL (amikacin) Use actual body weight. If obese, use adjusted body weight (ABW): • Ideal weight: Male: 50 kg + [2.3 × (inches >5 feet)] Female: 45 kg + [2.3 × (inches >5 feet)] • ABW (25% over ideal weight): [0.4 × (actual weight – ideal weight)] + ideal weight• Round dose to nearest 20 mg.
(Table continued on following page) 8/15/2012 2:54:03 PM TABLE 18 Traditional Aminoglycoside Dosing (continued)
Serum Concentration Monitoring
• Peak serum concentrations should be drawn 30 minutes after the completion of a 30-minute infusion.
Trough serum concentrations should be drawn within 30 minutes prior to the administered dose.
• Serum concentrations should be drawn around the third dose.
Desired measured serum concentrations: Intra-abdominal Endocarditis1/UTI Note: For synergistic effect against gram-positive organisms, peaks of 3 to 4 are sufficient (ie, gentamicin 1 mg/kg q8h; interval adjusted for renal function).
For patients receiving hemodialysis:• Administer the same loading dose.
• Redose after each dialysis if level <2 mcg/mL (tobramycin/gentamicin) or <8 mcg/mL (amikacin).
• Watch for ototoxicity from accumulation of drug.
1 Gram-positive endocarditis.
8/15/2012 2:54:03 PM TABLE 19 Extended Interval Aminoglycoside Dosing
• Exclusion criteria for extended interval aminoglycoside dosing:
– Age <18 years
– Serum creatinine >1.5 or creatinine clearance <30 mL/min
– Synergistic dosing for gram-positive infections (eg, endocarditis)
– History of ototoxicity
–
– Cystic fibrosis patients • Dosing regimens: dose based on actual, or if patient obese, then adjusted body weight.
Gentamicin/
(mL/min)
Tobramycin Dose1 Amikacin
• Dosing adjustments: Gentamicin/Tobramycin Amikacin
Continue current dosing Extend interval to 48 hours Use traditional dosing 1 Max dose of gentamicin/tobramycin 500 mg. 2 Max dose of amikacin 2000 mg.
3 Serum levels should be obtained around the second dose.
8/15/2012 2:54:03 PM TABLE 20 Vancomycin Dosing Guidelines for Adults
1. The dose should be calculated based on patient's actual body weight:
Weight (in kg)1
Dose (in mg)
2. The dosing interval should be based on creatinine clearance (CrCl): CrCl Male: (140 – age)(body weight) 72 × serum creatinine Male CrCl Value × 0.85 CrCl (mL/min)
One dose, then check a random vancomycin level in 24-48 hours, redose when level is <15-20 mcg/mL 500-750 mg after each hemodialysis session 3. Vancomycin trough (pre-dose) levels should be checked: A. On the fifth day of therapy and weekly thereafter for most patients B. Prior to the fourth dose for patients with: i. Morbid obesity (BMI >40) or severe malnutrition (weight <45 kg) ii. Acute renal failure (change in serum creatinine by more than 0.5 mg/dL) iii. Central nervous system infections v. Persistent gram-positive bacteremia (Table continued on following page) 8/15/2012 2:54:03 PM TABLE 20 Vancomycin Dosing Guidelines for Adults (continued)
4. Dose modifications based on the trough (pre-dose) level: Measured Trough
Level (mcg/mL)3
Half the dosage interval to next frequency AND consider increase in dose by 250-500 mg Half the dosage interval to next frequency OR increase dose by 250-500 mg No change if goal trough 10-20 mcg/mL. If goal trough is 15-25 mcg/mL, increase dose by 250-500 mg No change if goal trough 15-25 mcg/mL. If goal trough is 10-20 mcg/mL, decrease dose by 250-500 mg OR double the dosage interval to next frequency Double the dosage interval to next frequency AND/OR decrease the dosage 1 Morbidly obese patients may require doses >1500 mg.
2 For patients >75 years of age, it is recommended to start at a q24h interval regardless of calculated CrCl.
3 Higher trough levels (15-25) may be desirable for serious Staphylococcus aureus infections, such as endocarditis, device infec- tions, high-grade bacteremia, HAP/VAP, and CNS infections.
8/15/2012 2:54:03 PM TABLE 21 Antimicrobial Interactions With Cyclosporine,
Tacrolimus, and Sirolimus

Increase Effect
Decrease Effect
Antimicrobial Agent
Cyclo/Tacro Siro1 Cyclo/Tacro
Aminoglycosides XX Nephrotoxicity
Amphotericin
XX Nephrotoxicity
Ciprofloxacin XClarithromycin XX Quinupristin/dalfopristin XX XXRifabutin ? Protease Inhibitors2
XXX Major interaction.
XX Moderate interaction: Signifi cant interactions have been reported, however the incidence is either low or unknown.
X Minor 1 Limited drug interaction studies have been conducted; most data based on theoretical inhibition/induction of cyctochrome 3A4.
2 Atazanavir, fosamprenavir, indinavir, nelfi navir, ritonavir, saquinavir, lopinavir/ritonavir, tipranavir/ritonavir. 3 Voriconazole and posaconazole are contraindicated with sirolimus.
8/15/2012 2:54:03 PM TABLE 22 Antimicrobial Interactions With Warfarin
Increase
Antimicrobial Agent
Warfarin Effect
Efavirenz
Isoniazid XItraconazole Miconazole (including topical) Penicillins (dicloxacillin) Rifampin
Protease Inhibitors1,2
XXX Major interaction.
XX Moderate interaction: Signifi cant interactions have been reported, however, the incidence is either low or unknown.
X Minor 1 Atazanavir, fosamprenavir, indinavir, nelfi navir, ritonavir, saquinavir, lopinavir/ritonavir, tipranavir/ritonavir. 2 Ritonavir may decrease warfarin effect.
8/15/2012 2:54:03 PM TABLE 23 Antimicrobials in Pregnancy
Antimicrobial Pregnancy
Antimicrobial Pregnancy
Antimicrobial Pregnancy
Name (Generic) Category Name
(Generic) Category Name
(Generic) Category Name
Cytomegalovirus C immune globulin Ampicillin/sulbactam B Lopinavir/ritonavir C Atovaquone/proguanil C Chloramphenicol C 1 Metronidazole is contraindicated in the fi rst trimester.
2 Avoid near term.
Note: Vaccines in pregnancy—Pregnant women should receive the influenza vaccine. In addition, pregnant women should receive
tetanus-diphtheria (Tdap) if not already immune. Live virus vaccines such as measles-mumps-rubella (MMR) and varicella are
contraindicated in pregnancy with the exception of yellow fever vaccine. For a listing of vaccines recommended during pregnancy,
refer to Table 26 (Adult Immunization).
(Table continued on following page) 8/15/2012 2:54:03 PM TABLE 23 Antimicrobials in Pregnancy
Deſ nitions of Pregnancy Category (continued)
Category A: Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester, and there is no evidence of a risk in later trimesters. The possibility of fetal harm appears remote.
Category B: Either animal-reproduction studies have not demonstrated a fetal risk, but there are no controlled studies in pregnant women; or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters).
Category C: Either studies in animals have revealed adverse effects on the fetus (embryogenic, teratogenic, or other), and there are no controlled studies in women; or studies in women and animals are not available. Drugs should be given only if the potential benefit justifies the potential risk to the fetus.
Category D: There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (eg, the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).
Category X: Studies in animals or human beings have demonstrated fetal abnormalities, there is evidence of fetal risk based on human experience, or both; and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant.
8/15/2012 2:54:04 PM TABLE 24 Antimicrobials in Lactation
Most antimicrobials are compatible with lactation and are safe to the nursing infant with a few exceptions that are
listed in the following table. It is, however, prudent to minimize maternal exposure to all medications.
Antimicrobials Contraindicated in Lactation

Antimicrobial Name (Generic)
Chloramphenicol Potential for idiosyncratic bone marrow suppression Ciprofloxacin, norfloxacin Ciprofloxacin is not currently approved for children. Cartilage lesions and arthropathies were seen in immature animals Clofazimine is excreted into breast milk and may result in skin pigmentation of the nursing infant Avoid in infants less than 1 month old due to potential risk of hemolytic anemia Risk of mutagenicity and carcinogenicity. American Academy of Pediatrics recommends discontinuing breast feeding for 12 to 24 hours to allow drug
Vaccines Vaccines
compatible with lactation, including live vaccines such as measles-
mumps-rubella (MMR) and oral polio vaccine (OPV). There has been transfer of live vaccines to nursing infants with no ill effects noted 8/15/2012 2:54:04 PM TABLE 25 Community-Based Parenteral Antimicrobial Therapy
Patients who require long-term parenteral antimicrobials may be candidates for completion of therapy at home, a subacute care unit, an extended care facility, a rehab unit or a dialysis center. All patients who may need CoPAT must be first seen and evaluated by an ID Consultation Service.
1. A potential need for prolonged IV antimicrobial therapy is recognized by the patient's Primary Service.
2. The Primary Service places an Infectious Disease consult (via EPIC consult request) for CoPAT and a Case Manager Consult at least 48 hours prior to the planned discharge.
3. The Infectious Disease Consultant, after evaluating the patient, confirms a need for CoPAT or suggests 4. The Case Manager assesses the patient and caregiver's ability and willingness to participate in CoPAT, provides information on the availability and limitations of Home Health Care, and discusses the potential impact of home-bound status.
5. The PICC team is consulted through an order in EPIC. The PICC team is available Mon-Fri from 8 AM to 6 PM and Sat/Sun from 7 AM to 7 PM (except for Cleveland Clinic holidays) extension 45252 or pager 23520. 6. If a PICC is placed at the bedside, a standard upright chest x-ray (high-resolution technique) must be taken to verify that the tip is in the superior vena cava.
7. The Primary Service must confirm PICC tip verification, and approve use of the PICC prior to discharge.
Vascular Access Devices 1. Peripherally inserted central catheters (PICCs) are flexible long line catheters used for antimicrobial infusions when therapy is planned for 2-8 weeks.
2. Midline catheters (20 cm long) are deep peripheral catheters used for short-term therapy. They are contraindicated for infusates with pH <5 or >9, such as: • Erythromycin • Amphotericin-B products • Quinupristin/dalfopristin (Synercid) (Table continued on following page) 8/15/2012 2:54:04 PM TABLE 25 Community-Based Parenteral Antimicrobial Therapy
Guidelines
Vascular Access Devices (continued)3. Contraindications to placing PICCs or midline catheters include: SAME SIDE flaccid upper extremity, mastectomy, infection, DVT, A/V fistula, permanent pacemaker or implanted cardioverter device.
4. For patients who may require hemodialysis, a Hohn catheter is preferred over a PICC or midline.
5. Other tunneled venous access devices such as a Hickman catheter or subcutaneous ports may also be used 6. Central venous lines that are not tunneled (ie: internal jugular, subclavian or femoral central IV catheters) are not suitable for long-term antimicrobial therapy in the home setting.
CoPAT Consultation Guidelines1. The ID resident should approach the patient like any new consult; that is, the consult should be performed "from scratch," with a careful review of the patient's history, hospital course, laboratory findings, radiographic studies etc.; and a complete physical examination. 2. One should not assume the patient will require CoPAT. The ID Consultant may not agree with the diagnosis, selection of antimicrobial, route of administration, length of therapy, etc.
3. If the patient needs CoPAT, vascular access must be established prior to discharge. 4. A final electronic CoPAT script must be completed by the ID Consultant prior to discharge. If the patient's discharge is delayed more than 72 hours the script must be updated.
5. The CoPAT script provides orders for laboratory monitoring tests, lists the ID Staff physician who will be responsible for overseeing CoPAT, and specifies the date and time for an ID follow-up appointment.
8/15/2012 2:54:04 PM TABLE 26 Recommended Adult Immunization Schedule
Vaccine  Age Group (years)  19-49 50-64 t65
Tetanus, diphtheria, pertussis Substitute 1 dose of Tdap for Td then 1 dose Td booster every 10 years Human papillomavirus 3 doses (0, 2, 6 months): females aged 19-26 Measles, mumps, rubella 2 doses (0, 4-8 weeks) Pneumococcal (polysaccharide) 2 doses (0, 6-12 months or 0, 6-18 months) 3 doses (0, 1-2, 4-6 months) For all persons in this category who meet the Recommended if some other risk factor age requirements and who lack evidence of is present (eg, on the basis of medical, immunity (eg, lack documentation of vaccina- occupational, lifestyle, or other indications) tion or have no evidence of prior infection) 1 Recommended beginning at age 60. (Note: FDA approved to begin at age 50.) (Table continued on following page) 8/15/2012 2:54:04 PM TABLE 26 Recommended Adult Immunization Schedule (continued)

Indication 
comprom- T lymphocyte disease, ising condi- count nent deficien- ESRD, hemodialysis personnel 1 dose Td booster every 10 years Substitute 1 dose of Tdap for Td 3 doses through age 26 years 3 doses through age 26 y 3 doses through age 21 years 2 doses (0, 4-8 weeks) Influenza (annually) 2 doses (0, 6-12 months or 0, 6-18 months) 3 doses (0, 1-2, 4-6 months) Contraindicated 1 For all persons in this category who meet the age requirements Recommended if some other risk factor and who lack evidence of immunity (eg, lack documentation of is present (eg, on the basis of medical, vaccination or have no evidence of prior infection) occupational, lifestyle, or other indications) Adapted from: Recommended Adult Immunization Schedule. Centers for Disease Control and Prevention Web site. http://www.cdc 8/15/2012 2:54:04 PM TABLE 27 Isolation Precaution Quick Guide
Precautions  Standard (#100)
Contact (#101)
Droplet (#102)
(Infection Control Policy #)
all patients • Burkholderia sp in cys- • Infectious bacterial
• Disseminated herpes tic fibrosis patient: call meningitis (Haemo- zoster IC pager #21740 philus influenzae or • RSV when receiving • crAb in all ICUs, H63, Neisseria meningi- • Clostridium difficile • • Disseminated herpes zoster1 (shingles) • Parainfluenza4 Hand hygiene Soap and water or Same as Standard; also Same as Standard Same C difficile: use soap Droplet Precautions Airborne Precautions5 For contact with Gloves to enter room; Same as Standard Same blood and/or any discard upon leaving (Table continued on following page) 8/15/2012 2:54:04 PM TABLE 27 Isolation Precaution Quick Guide (continued)
Precautions  Standard (#100)
Contact (#101)
Droplet (#102)
(Infection Control Policy #)
To protect clothing Gown to enter room; Same as Standard TB: Same as Standard when splash and/ discard upon leaving or spray likely zoster; gown and Wear to protect eyes, Same as Standard6 Surgical nose, and mouth when splash and/or spray likely Patient place- No restrictions Private room; may co- Same as Contact; plus Private NEGATIVE AIR keep door closed Clean and disinfect Use designated equip- Same as Standard Same equipment after ment whenever pos- use; limit patient sible (ie, dedicated supplies in rooms BP cuff and stethoscope) Cover wheelchair/cart; Surgical mask on Surgical mask on have patient clean hands patient8 and don clean gown before ambulation8 1 Chickenpox and disseminated zoster: use Contact AND Airborne Precautions.
2 History of or positive culture in any site.
3 For BMT/heme-onc/solid organ transplant only. Use contact and airborne precautions.
4 For BMT/heme-onc/solid organ transplant only. 5 EXCEPTION: Use chickenpox sign for varicella and disseminated herpes zoster.
6 RSV: NEGATIVE AIR with N-95 or PAPR only if receiving ribavarin.
7 EXCEPTION: Respirator not needed for varicella or disseminated herpes zoster (ONLY IMMUNE EMPLOYEES TO ENTER).
8 Include in Hand Off communication.
8/15/2012 2:54:04 PM TABLE 28 Guidelines for Antimicrobial Prophylaxis for Clean
All Preoperative Doses Must Be Given Within 1 Hour1 Prior to Surgical Incision2
Nature of Operation
Antimicrobial3 Program
Routine prophylaxis: Cefuroxime 1.5 g q12h MRSA colonized patients: With or without MRSA colonization, Cefuroxime 1.5 g q12h PLUS aortic graph material installed, LVAD: vancomycin 1 g q12h Vancomycin 1 g q12h PLUS ciprofloxacin 400 mg q12h Ampicillin/sulbactam 3 g Ciprofloxacin 400 mg AND metronidazole 500 mg Ciprofloxacin 400 mg AND clindamycin 900 mg Vancomycin 1 g OR clindamycin 900 mg Vancomycin 1 g OR clindamycin 900 mg Vascular Surgery Cefazolin 1 g4 OR Vancomycin 1 g OR cefuroxime 1.5 g clindamycin 900 mg 1 Vancomycin should be given within 2 hours prior to surgical incision.
2 If duration of surgical procedure is >4 hours, patient should receive a second prophylactic dose intraoperatively. 3 Total duration must be 24 hours for noncardiothoracic surgery and 48 hours for cardiothoracic surgery.
4 Consider 2 g in patients >100 kg.
8/15/2012 2:54:04 PM TABLE 29 Guidelines for Prophylaxis of Infective Endocarditis
Highest Risk Patients for Adverse Outcomes From Endocarditis
• Prosthetic cardiac valve disease
• Previous infective endocarditis
• Congential heart disease (CHD):
– Unrepaired cyanotic
– Completely repaired with prosthetic materials for 6 months after procedure, allowing for endothelial formation
– Incompletely repaired with residual defects at prosthetic patches or devices
• Cardiac transplantation with valvular defects
Invasive Procedures for Prophylaxis in High-Risk Patients
• Any procedure that involves the gingival tissues or periapical region of a tooth and for those procedures that perforate the oral mucosa • Cystocopy or other genitourinary tract manipulation when the urinary tract is infected with Enterococcus species • Drainage of established infections, such as empyema, abscesses, or phlegmons where Staphylococcus aureus, streptococci, or enterococci are likely or proven pathogens (Table continued on following page) 8/15/2012 2:54:04 PM TABLE 29 Guidelines for Prophylaxis of
Infective
Antimicrobials for Infective Endocarditis Prophylaxis (AHA 2007)
Invasive Procedures for Prophylaxis in High-Risk Patients
Situation Agent
(30-60 minutes before procedure)
Oral Amoxicillin 2 Penicillin-allergic Unable to take oral Cefazolin or ceftriaxone1 Penicillin-allergic Cefazolin or ceftriaxone1 1 Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or 8/15/2012 2:54:04 PM TABLE 30 Solid-Organ Transplant:
Antimicrobial
Infection Preferred
Kidney/Pancreas
PCP and UTI
TMP/SMX SS (80/400) PO q24h Aerosolized Pentamidine 300 mg once for life of allograft monthly × 1 year Clotrimazole troche 10 mg PO tid × 1 month. If ureteral stent, then fluconazole 100 mg PO q24h until stent removed (usually 6 to 8 wk) TMP/SMX DS (160/800) PO MWF × 1 year Aerosolized Pentamidine 300 mg once monthly × 1 year; Dapsone 100 mg PO q24h × 1 year Clotrimazole troche 10 mg PO qid × 1 month, OR Nystatin 5 mL (500,000 units) PO qid swish and swallow × 1 month TMP/SMX DS (160/800) PO MWF for life Aerosolized Pentamidine 300 mg once monthly or dapsone 100 mg PO q24h Clotrimazole troche 10 mg qid ×1 month Nystatin 5 mL PO swish and swallow qid × 1 month TMP/SMX DS (160/800) PO MWF for life Dapsone 100 mg PO MWF, OR aerosolized Pentamidine 300 mg once monthly if G6PD deficient Amphotericin B 10 mg inhaled q12h until therapeutic itraconazole level2 then Itraconazole 200 mg PO q24h × 18 months (Table continued on following page) 8/15/2012 2:54:04 PM TABLE 30 Solid-Organ Transplant:
Antimicrobial
Small Bowel
PCP
TMP/SMX 160 mg IV PO MWF; when Aerosolized pentamidine 300 mg once monthly for life taking PO change to TMP/SMX DS (160/800) MWF for life Micafungin 100 mg IV q24h × 1 month 1 Guidelines subject to change; please check website version for most current recommendations.
2 Trough level >250 mcg/mL; usually achieved around day 10 to 14.
8/15/2012 2:54:04 PM TABLE 31 Solid-Organ Transplant: CMV Prophylaxis1
CMV Status
Acyclovir3 200 mg PO TID × 1 month D-/R+2 Valganciclovir3 900 mg PO q12h × 2 wk, then valganciclovir3 900 mg PO q24h × 2 wk, then acyclovir3 800 mg PO qid for months 2 and 3 D-/R-5 Ganciclovir3 5 mg/k IV q12h until able to take oral, then acyclovir3 400 mg PO tid × 180 days D-/R+5 Ganciclovir3 5 mg/kg IV q12h until able to take oral, then valganciclovir3 900 mg PO q24h × 1 year D+/R+5 Acyclovir3 200 mg PO tid × 3 months Valganciclovir3 900 mg PO q24h × 3 months Valganciclovir3 900 mg PO q24h × 3 months Valganciclovir3 900 mg PO q24h × 6 months 1 Guidelines subject to change; please check website for most current recommendations.
2 Patients unable to tolerate oral medications by day 7, ganciclovir4 5 mg/kg IV q12h × 2 wk then 6 mg/kg IV q24h × 2 wk; change to valganciclovir when able to tolerate oral medications.
3 Renal dosage adjustment necessary.
4 CMV DNA checked at least every 2 weeks for fi rst year.
5 If patients unable to tolerate oral medications by day 14, decrease to ganciclovir 2.5 mg/kg IV q12h.
(Table continued on following page) 8/15/2012 2:54:04 PM TABLE 31 Solid-Organ Transplant: CMV Prophylaxis1 (continued)
CMV Status
Acyclovir 400 mg PO bid × 3 months Ganciclovir2 5 mg/kg IV q12h × 14 d (may change to valganciclovir2 900 mg PO bid if patient discharged within 14 days of transplant) then acyclovir 400 mg PO bid × 3 months Small Bowel
Ganciclovir2 5 mg/kg IV q12h until able to take oral, then valganciclovir2 450 mg PO bid × 6 months Same as D-/R- PLUS CMV immune globulin 50 mg/kg once monthly × 6 months Ganciclovir IV
Acyclovir
(mL/min) Induction3 Maintenance5
(mL/min) Dose
(mL/min)
450 mg twice weekly 1 Guidelines subject to change; please check website for most current recommendations.
2 Renal dosage adjustment necessary.
3 Heart and liver transplants use 2 wk of induction followed by maintenance dosing or a change to acyclovir.
4 Monitor CBC; valganciclovir may cause bone marrow suppression.
5 Lung and kidney transplants ONLY use maintenance dosing.
8/15/2012 2:54:04 PM TABLE 32 Bone Marrow Transplant:
Antimicrobial and CMV Prophylaxis
Autologous Stem-Cell Transplants
Bacterial
Ciprofloxacin1 500 mg PO bid starting at admission2 Acyclovir 250 mg IV q12h or 400 mg PO bid
Allogeneic Stem-Cell Transplants
Bacterial
TMP/SMX DS q12h starting at admission2 Fungal: Pre-engraftment Fluconazole 400 mg PO q24h starting day +1 Post-engraftment Itraconazole solution 200 mg PO q24h4 Viral: Patients will have weekly CMV PCR for the first 3 months after transplant, then every 2 weeks for 3 months if tests are negative. Monitoring should continue for patients treated with immunosuppressive therapy for GVHD due to the risk of CMV reactivation.
Asymptomatic patient with viral load >1,000 copies/mL: valganciclovir1 900 mg PO bid Symptomatic patient or viral load >10,000 copies/mL: ganciclovir1 5 mg/kg IV q12h Cord Blood Stem-Cell Transplants
Bacterial (see Allogeneic Stem-Cell Transplant)
Fungal (see Allogeneic Stem-Cell Transplant) CMV recipient: Negative Acyclovir 400 mg PO q bid Pre-cell infusion: Ganciclovir 5 mg/kg IV q24h Post-cell infusion to day +100 : Valacyclovir 2 g PO TID 1 Renal dose adjustment necessary.
2 If fever develops, discontinue and begin broad spectrum antimicrobials (see Table 12).
3 Change to voriconazole if concern for infection.
4 For patients unable to tolerate itraconazole, posaconazole suspension 200 mg PO tid with high-fat meal or nutritional supplement.
8/15/2012 2:54:04 PM TABLE 33 Antimicrobial Cost Data for the Cleveland Clinic
Drug Dose
Amphotericin B Lipid ComplexAmpicillin Ampicillin/sulbactam Azithromycin (PO) 5 mg/kg OW×2 wk Ciprofloxacin (PO) Fluconazole (PO) (Table continued on following page) 8/15/2012 2:54:04 PM TABLE 33 Antimicrobial Cost Data for the Cleveland Clinic (continued)
Drug Dose
Piperacillin/tazobactam Posaconazole (PO) Tigecycline (IV) Valganciclovir (PO) Voriconazole (IV) Voriconazole (PO) 1 Rounded to nearest $5.00.
2 Rounded to nearest $20.00.
3 Based on trimethoprim.
Note: All agents are IV unless otherwise specifi ed. All costs include the piggy-back containers. Nursing administration and
pharmacy preparation time are not included.
8/15/2012 2:54:04 PM TABLE 34 Guidelines for Selected Antimicrobial Dosing in
Adults Receiving Continuous Venovenous
Hemodialysis
• Many factors affect drug clearance during continuous venovenous hemodialysis (CVVHD), including:
– Drug molecular weight
–
– Protein binding and volume of distribution – Dialysis filter porosity and surface area – Blood flow rate through dialysis filter – • Doses listed are based on clinical studies of CVVHD drug clearance when available. Otherwise, dosage recommendations are based on the drug's: – Estimated GFR provided by CVVHD – Extent of removal by IHD, if known.
• Factors that should also be considered when selecting antimicrobial doses include: – Site and severity of infection – Recommended CVVHD Dose
5-10 mg/kg q12-24h 15-20 mg/kg × 1 (adjust based on goal peak and troughs) Ampicillin/sulbactam (Table continued on following page) 8/15/2012 2:54:04 PM TABLE 34 Guidelines for Selected Antimicrobial Dosing in
Adults Receiving CVVHD (continued)
Recommended CVVHD Dose
1 g q24h (2 g q12h for meningitis, 2 g q24h for endocarditis) 3 mg/kg × 1; then 1.5 mg/kg q8h Induction: 2.5 mg/kg q12h; Maintenance: 2.5 mg/kg q24h 5-6 mg/kg × 1 (adjust based on goal peak and troughs) 500 mg q8h or 1 g q12h 2-4 million units q4-6h Piperacillin/tazobactam 100 mg × 1, 50 mg q12h 5-6 mg/kg × 1 (adjust based on goal peak and troughs) 5 mg/kg TMP component q12h 15 mg/kg q24h (adjust based on troughs) 400 mg q12h × 2, 200 mg q12h 8/15/2012 2:54:04 PM TABLE 35 Percentage of Bacteria Susceptible to Various
Antimicrobial Agents at the Cleveland Clinic
Organism Gent
Amp/Sulb Cefazolin Cftx Pip/Tazo TMP/SMX Cipro Mero
Acinetobacter baumanii 32 Citrobacter freundii 95 Citrobacter koseri 100 Enterobacter aerogenes 100 Enterobacter cloacae 94 Escherichia coli Klebsiella pneumoniae Proteus mirabilis Organism Gent
Pip/Tazo
Pseudomonas aeruginosa Stenotrophomonas (Xanthomonas) — — — — — 83 — 0 maltophilia (Table continued on following page) 8/15/2012 2:54:04 PM TABLE 35 Percentage of Bacteria Susceptible to Various
Antimicrobial Agents at the Cleveland Clinic1 (continued)
Organism Pcn
TMP/SMX Tetracycline Erythro Lin Dapto
Staphylococcus aureus2 MSSA Coagulase-negative 9 staphylococci Enterococcus4 VSE Streptococcus pneumoniae6 1 Results are from species represented by at least 10 isolates tested between 1/1/11 and 12/31/11 from Cleveland Clinic
2 Oxacillin-susceptible staphylococci are also susceptible to cefazolin, ampicillin/sulbactam, and piperacillin/tazobactam. MRSA makes up 49% of the total S aureus isolates.
3 N/A = data not applicable to that isolate or not available.
4 High-level aminoglycoside resistance in vancomycin-resistant enterococcus (VRE) = 23% for gentamicin and 53% for streptomy- cin; for vancomycin-susceptible enterococcus (VSE), 27% for gentamicin and 28% for streptomycin.
5 VRE makes up 44% of total inpatient Enterococcal isolates of total Enterococcus isolates. 6 83% of S pneumoniae were fully susceptible to penicillin.
8/15/2012 2:54:05 PM CPIS clinical pulmonary infection GPC deficiency syndrome carbapenem-resistant h ANC absolute neutrophil count Hemophilus, Actinobacillus, ARDS acute respiratory distress venovenous [group] Cardiobacterium, Eikinella, hospital-acquired BMT bone marrow transplant HBIG hepatitis B immune globulin D heme-onc hematology-oncology HepA hepatitis A vaccine HepB hepatitis B vaccine community-acquired DT diphtheria-tetanus immunodeficiency CBC complete blood cell count aminoglycoside dosing HPV human papilloma virus associated diarrhea CDC Centers for Disease Control ESRD end-stage renal disease HSV herpes simplex virus FiO2 fractional concentration of IE Chloramph chloramphenicol oxygen in inspired gas CLD chronic liver disease GFR glomerular filtration rate CNS central nervous system coagulase-negative GNC glucose-6-phosphate IV parenteral antimicrobial 8/15/2012 2:54:05 PM Glossary of Abbreviations/Acronyms (continued)
carbapenem-resistant SARS severe acute respiratory OPV oral polio vaccine para-aminobenzoic PaO2 partial pressure of oxygen STAT LVAD left ventricular assist device in arterial blood MBAL mini brochial alveolar PAPR powered air purifying tetanus-diphtheria Pneumocystis carinii PCR polymerase chain reaction tid three times a day PICC peripherally inserted central TIV influenza virus vaccine measles-mumps-rubella PID pelvic inflammatory disease TMP/SMX methicillin-resistant UTI urinary tract infection MSM men who have sex with ventilator-associated methicillin-sensitive polysaccharide vaccine vacomycin-intermediate PR by way of the rectum methicillin-sensitive PVE vancomycin-resistant Staphylococcus vacomycin-resistant MVP mitral valve prolapse qid four times a day Monday-Wednesday-Friday R vancomycin-susceptible RIG rabies immune globulin varicella-zoster WBC white blood cell [count] NPO nothing by mouth RSV respiratory synctial virus 8/15/2012 2:54:05 PM 8/15/2012 2:54:05 PM 8/15/2012 2:54:05 PM Order Form
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Typical Gram Stain Morphology of Selected Organisms .5 TABLE 2 Key Characteristics of Selected Organisms .6 Usual Acid-Fast Bacillus Characteristics .8 Laboratory Requests and Specimen Types .9 Mechanism of Action of Common Antibacterial Agents .11 TABLE 6 Guidelines for Treatment of Pneumonia in Adults .13 TABLE 7 Guidelines for Treatment of Infective Endocarditis in Adults .14 TABLE 8 Guidelines for Treatment of Bone and Joint Infections in Adults .15 TABLE 9 Guidelines for Treatment of Urinary Tract Infections in Adults .16 TABLE 10 Guidelines for Treatment of Sexually Transmitted Infections .17 TABLE 11 Guidelines for Treatment of Bacterial Meningitis in Adults .21 Guidelines for Treatment of Febrile Neutropenia .22 TABLE 13 Guidelines for Management of Clostridium difſ cile Toxin-Positive Diarrhea .23 Treatment of Skin and Skin Structure Infections.24 Guidelines for Antimicrobial Dosing in Adults .25 TABLE 16 Formulary-Approved Indications and Dosing of Restricted Antimicrobial Agents in Adults .33 TABLE 17 Antiretrovirals .38 TABLE 18 Traditional Aminoglycoside Dosing .46 TABLE 19 Extended Interval Aminoglycoside Dosing .48 TABLE 20 Vancomycin Dosing Guidelines for Adults .49 TABLE 21 Antimicrobial Interactions With Cyclosporine, Tacrolimus, and Sirolimus .51 TABLE 22 Antimicrobial Interactions With Warfarin .52 TABLE 23 Antimicrobials in Pregnancy .53 TABLE 24 Antimicrobials in Lactation .55 TABLE 25 Community-Based Parenteral Antimicrobial Therapy (CoPAT) Guidelines.56 TABLE 26 Recommended Adult Immunization Schedule .58 Isolation Precaution Quick Guide .60 TABLE 28 Guidelines for Antimicrobial Prophylaxis for Clean and Clean-Contaminated Surgical Wounds .62 TABLE 29 Guidelines for Prophylaxis of Infective Endocarditis .63 TABLE 30 Solid-Organ Transplant: Antimicrobial Prophylaxis .65 Solid-Organ Transplant: CMV Prophylaxis .67 Bone Marrow Transplant: Antimicrobial and CMV Prophylaxis .69 Antimicrobial Cost Data for the Cleveland Clinic .70 Guidelines for Selective Antimicrobial Dosing in Adults Receiving Continuous Venovenous Hemodialysis .72 Percentage of Bacteria Susceptible to Various Antimicrobial Agents at the Cleveland Clinic .74 Glossary of Abbreviations/Acronyms . 76 CVR(AMUG13).indd 2 8/15/2012 1:49:15 PM

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