Nebraska Methodist Hospital

2013 Guide to Antimicrobial Therapy

2012 Microbial Susceptibility (# of isolates tested) Gram-Positive Gram-Negative
) 1) 5) plex ) (43 (50 ) 36 6) 70 a ( ii com 96 cus niae (93 119) ( s 6 ) ( s o ( ) ) o 4) us oc 5) (78 ugin man 73 niae (97 gene cae 312) ure loc eum (77 r u ( i (4 dii o 40 s a aphy s pn sp. li ( eum toca aero cloa bilis 60) oser reun s ae r ba u o y r s e c c t ia a pn la ox cter acte mira sp. ( ter k ter F ona bact oc g. S occu ccu h c l s ba ob om to ric co ac ylo ne ac iel iel oc tia ph ag- ept ntero sche lebs lebs ntero nter roteu erra itrob itrob seud cine A E E S K P P K E Sta Co Str C E C ) (22

Antimicrobial Agent
Beta-lactams ampicillin amoxicillin/clavulanate ampicillin/sulbactam meropenem oxacillin (nafcillin) penicillin G piperacillin/tazobactam

% Susceptible
91 91 52 7 44 7 59 78

Relative Acquisition Cost/Day

Parenteral Antimicrobials
Regimen Adult Dose & Interval Amikin amikacin 500 mg q12h Ampen ampicillin 1g to 2g q4-6h ampicillin + sulbactam Unasyn 1.5g-3.0g q6h Ancef cafezolin 1g q8h Maxipime cefepime 1g-2g q12h Claforan cefotaxime 1g-2g q8h Rocephin ceftriaxone 1g q24h Zinacef cefuroxime 750mg q8h Chloromycetin 12.5mg-25mg/kg q6h chloramphenicol Cleocin clindamycin 600mg-900mg q8h Garamycin gentamicin 80mg q8h Levaquin levooxacin 250-750 q24h Zyvox linezolid 600mg q12h Merrem meropenem 1g q8h Flagyl metronidazole 500mg q8h Nafcil nafcillin 1g-2g q4-6h 1-4 million units q4-6h Pzerpen penicillin G piperacillin + tazobactam Zosyn 3.375g-4.5g q6-8h Rifadin rifampin 300mg q12h Nebcin tobramycin 80mg q8h Bactrim trimethoprim+ 160-800mg q8h Septra sulfamethoxazole Vancocin vancomycin 1g q12h Generic Name Brand Name

Antimicrobial

70 92 70 89 100 100 100 100 100

Daily Cost of Therapy $ $ $ $ $ $ $ $ $$$$ $ $ $ $$$$$ $$ $ $$$$ $$ $$$$ $ $ $

93

58

90 91 67 92 98

95

Cephalosporins cefazolin 52 44 92 98 cefoxitin 90 cefpodoxime ceftriaxone 96 98 96 cefepime cefuroxime cephalexin Ceftriaxone also predicts the sensitivity to cefotaxime. Aminoglycosides amikacin gentamicin tobramycin Quinolones levooxacin Miscellaneous clarithromycin clindamycin erythromycin nitrofurantoin* tetracycline* trimethoprim/ sulfamethoxazole Vancomycin 100 93 99 93 99 56 43 100 65 82 97

91

96 78 100 98

98

98 100 82 91 64

98 100 99 98 100 97 91 100 94

88 100 100 94 91 100 100 94 67 93 96 97

95 80 90 66

73

Cost Code based on daily average cost of therapy in dollars $ = <20; $$ = 21 - 40; $$$ = 41 - 60; $$$$ = >61; $$$$$ = most expensive

64

Oral Antimicrobials
Antimicrobial

73 71 36 99 93 99 57 37 98 87 59 77 76 90 23 92 80 23 94 45 3 15 0 72 0 98 47 96 85 84

Generic Name

Brand Name

Amoxil amoxicillin amoxicillin + clavulanate Augmentin Polycillin ampicillin azithromycin Zithromax Duricef Omnicef Ceftin Keex Biaxin Cleocin Dynapen E-mycin Levaquin Zyvox Flagyl Macrobid Pen Vee K Rifadin Bactrim Septra

93 100 85

100 99 100 94

Denotes Urinary Isolates Only

(empty box) Agent NOT Tested

When reviewing the patients culture susceptibilities in Cerner, if there is an asterisk (*) beside the antibiotic listed, double clicking on the asterisk (*) beside the antibiotic will provide additional susceptibility and treatment information.

MD care sets in Cerner

__ Cellulits __ Clostridium difclie infection __ OB-Group B strep prophylaxis __ Pneumonia, community acquired __ Pneumonia, Health Care acquired __ Severe sepsis/Septic shock bundle

cefadroxil cefdinir cefuroxime axetil cephalexin clarithromycin clindamycin dicloxacillin erythromycin base levooxacin Linezolid metronidazole nitrofurantoin penicillin VK rifampin trimethoprim + sulfamethoxazole

Regimen Daily Cost of Adult Therapy Dose & Interval 250mg-500 mg tid $ 500mg-875mg bid $$ 500mg qid $ 500mgx1; 250mg x 4d $$ 500mg qd $$ 500mg-1gm qd-bid $$ bid $$ 300mg 125mg-500mg bid $$ 250mg-500mg qid $ 250mg-500mg bid $$$ 150mg-300mg qid $ 250mg-1000mg qid $$ 250mg-500mg qid $$$ 750mg qd $$ 600mg bid $$$$ 250mg-500mg qid $ 50mg-100mg qid $$$ 250mg-500mg qid $ 300mg bid $$ 1 double strength bid $

Cost Code based on daily average cost of therapy in dollars $ = <1.00; $$ = 1.01 - 5.25; $$$ = 5.30 - 9.00; $$$$ = >9.01; $$$$$ = most expensive

Do NOT Remove This Table From the Patients Chart

Orders & Progress Notes

NMH Preferred Antimicrobial Therapy For Specic Pathogens

Gram-Positive Infections
Organism Syndrome Preferred
Dicloxacillin PO

Gram-Negative Infections
Alternative
Cefadroxil PO or Cephalexin PO or Amoxicillinclavulanate PO Cefazonlin IV Clindamycin IV Doxycycline PO or TMP-SMX PO *Consider IDConsult

Organism
Escherichia coli

Syndrome
UTI(Cystitis)

Preferred
Levooxacin PO or TMP-SMXPO Ceftriaxone IV

Alternative
Nitrofurantoin PO (if CrCI60mL/min) Cefazolin IV or Cefoxitin IVor Levooxacin or Piperacillin / tazobactam IV Levooxacin

Staphylococcus Skin infection aureus Methicillinsusceptible

Serious infection*

Serious infection*

Nafcillin IV Vancomycin IV Vancomycin IV

Staphylococcus Skin infection aureus MethicillinSerious infection* resistant (MRSA Coagulase negative staphylococcus Streptococcus (group A) pyogenes
Serious infection*

Klebsiella pneumoniae

UTI(Cystitis)

TMP-SMXPO

Vancomycin IV

*Consider IDConsult

Serious infection*

Ceftriaxone IV or Levooxacin Amoxicillin PO

Cefazolin IV

Pharyngitis

Penicillin V PO

Amoxicillin POor Azithromycin PO or Clindamycin PO Cefazolin IV or Clindamycin IV Cefazolin IV or Clindamycin IV

Proteus mirabilis

UTI(Cystitis)

TMP-SMX PO or Levooxacin PO

Serious infection*

Penicillin GIV

Serratia marcesscens or Enterobacter species or Citrobacter freundii

UTI(Cystitis)

TMP-SMXPO or Levooxacin Ceftriaxone IV or Meropenem IV

Ceftriaxone IV

Streptococcus (group B) algalactia

Serious infection*

Penicillin G IV or Ampicillin IV

Serious infection*

Levooxacin

OB-GYN: See Group B Strep Order Set in Cerner

Streptococcus pneumoniae Entercoccus species

Serious infection*

Ceftriaxone IV or Vancomycin IV Amoxicillin PO

Levooxacin IV or Clindamycin IV Nitrofurantoin PO (if CrCI60mL/min) *Consider IDConsult

Pseudomonas aeruginosa

UTI(Cystitis)

Levooxacin PO

*Consider IDConsult

Urinary Tract (Cystitis) Endocarditis*

Serious infection*

Piperacillin / tazobactam IV

Meropenem IV or Levoloxacin IV or cefepime *Consider IDConsult

Ampicillin IV + Gentamicin IV

Acinetobacter baumanni complex

*Consider IDConsult

MeropenemIV

*serious infection = e.g. bacteremia, pneumonia, meningitis. Consider ID consult for serious infection.

Anaerobic Infections
Organism
Clostridium difcile

Syndrome
Mild/Moderate Serious infection*

Preferred
Metronidazole PO Vancomycin PO Metronidazole IV

Alternative

Resources: The Medical Letter Therapeutic Guidelines; 2007. Sanford Guide to Antimicrobial Therapy; 2010. John Hopkins ABXGuide: http://hopkins-abxguide.org/

(See CDIPhysician Order Set in Cerner)

Bacteroides fragilis

Ampicllinsulbactam IV or Ertapenem IV or Piperacillintazobactam IV or Cefoxitin IV

This therapy card should be used as an aid in making decisions and is NOT meant to be a comprehensive reference. Susceptibility tests should be used along with clinical judgement for choosing optimal antimicrobial therapy.

Karre, Penn, Kotula, Gholami, Jones, Neff; 2013