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2016-2017

Antimicrobial
Guide

Empiric Therapy & Treatment


Recommendations For Adult
Patients
Table of Contents
A. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

B. Guidelines for the Treatment of Various Infections in Adults

Central Nervous System (CNS)


Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Clostridium difficile Infection (CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Extended Spectrum Beta-Lactamases Infections (ESBL). . . . . . . . . . 6
Febrile Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Intra-abdominal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Lyme Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Proton Pump Inhibitor (PPI) Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Respiratory Tract - Upper and Lower
Acute Bacterial Sinusitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Acute Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Chronic Obstructive Pulmonary Disease (COPD). . . . . . . . . . . . . . . . . . . . 14
Exacerbation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Sepsis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Sexually Transmitted Infections (STI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Skin and Soft Tissue
Skin and Soft Tissue Infections (SSTI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Diabetic Foot Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Surgical Decolonization and Prophylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Urinary Tract
Catheter-Associated Urinary Tract Infection (CA-UTI). . . . . . . . . . . . . . 29
Non-Catheter Associated Urinary Tract Infection/Cystitis . . . . . . . . . . 30
Prostatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

C. Immunizations
Pneumococcal Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

D. Antibiogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Table of Contents
E. Guidelines for Restricted Antimicrobials
Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Ceftaroline (Teflaro). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Ceftazidime/avibactam (Avycaz) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Ceftolozane/tazobactam (Zerbaxa). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Dalbavancin (Dalvance) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Daptomycin (Cubicin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Ertapenem (Invanz). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Fidaxomicin (Dificid). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Fosfomycin (Monurol). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Linezolid (Zyvox) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Oritavancin (Orbactiv). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Polymyxin B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Colistin (Polymyxin E). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Tedizolid (Sivextro). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Tigecycline (Tygacil). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Antifungals
Amphotericin B lipid complex (L-AmB)(AmBisome). . . . . . . . . . . . . . . 53
Caspofungin (Cancidas ). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Isavuconazonium sulfate (Cresemba) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Voriconazole (VFend) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

F. Vancomycin Dosing and Monitoring in Adult Patients. . . . . . . . . . . . . 57

G. Aminoglycoside High Dose Once Daily (HDOD) and


Monitoring in Adult Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

H. Antimicrobial Dosing for Adult Patients Based on Renal . . . . . . . . 63


Function

I. Antimicrobial Duration of Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

J. IV to PO Antibiotic Step-Down Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

K. Infection Control
Twelve Steps to Prevent Antimicrobial Resistance . . . . . . . . . . . . . . . . . . 72
Contact Precautions for Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

L. Pharmacokinetic Equations/Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Introduction
Introduction
Antimicrobial resistance is globally recognized as one of the greatest healthcare threats.
Infections associated with multi-drug resistant organisms and limited antimicrobial choices
have placed an immense burden upon clinicians. In order to preserve currently available
antimicrobials we must use them appropriately; ensuring that each patient is on the right
drug, route, dose, and duration.
The pathways and tables in this booklet are based on national guidelines and consensus
statements, expert opinions from the Infectious Diseases team (pharmacy and medicine) and
microbiology data from the microbiology laboratory.
DISCLAIMER: The opinions expressed in this publication reflect those of the authors to the
best of their ability. However, the authors make no warranty regarding the contents of the
publication. The guidelines described herein are general and may not apply to a specific
patient.
The recommendations given in this guide are meant to serve as treatment guidelines. They
should not replace clinical judgment or Infectious Diseases consultation when indicated. The
recommendations may not be appropriate at other settings. We have attempted to verify
that all information is correct but because of ongoing research, recommendations may
change.
Please let us know if there are sections that you think could be improved or if there is more
information you would like to see included. Our goal is for the Antimicrobial Stewardship
Program to be a useful service in optimizing antibiotic use and patient outcomes.
We welcome your thoughts and comments.
Thank you,
Kerry L. LaPlante, PharmD., FCCP
Professor of Pharmacy, University of Rhode Island, Kingston, RI
Adjunct Professor of Medicine, Brown University, Providence, RI
Director of the Rhode Island Infectious Diseases Research Program (RIID) and Infectious
Diseases Pharmacotherapy Specialist, Providence Veterans Medical Center, RI
Kerry.LaPlante@va.gov or KerryLaPlante@uri.edu.

The following people reviewed ALL the treatment guidelines:


Melissa Gaitanis, MD (Chief of Infectious Diseases)
Kerry L. LaPlante, PharmD, FCCP (Infectious Diseases)
Haley Morrill, PharmD (Infectious Diseases)
The following people served as section/topic reviewers:
Tanya Ali, MD (Infectious Diseases), Patricia Cristofaro, MD (Infectious Diseases),
Cheston Cunha, MD (Infectious Diseases), Megan Luther, PharmD,
Kevin McConeghy, PharmD, MS, BCPS, Jacob Morton, PharmD, MBA, BCPS,
Tristan T. Timbrook, PharmD, MBA, BCPS
A special thank you for assistance with the Antimicrobial Guidebook
Kayla Chouinard, Jaclyn Cusumano, Channel DeLeon, Jillian Dougherty,
Anthony Harrison, Sarah Harrison, Brittany Julich, Elizabeth Koczera, Amanda Maione,
Nicholas Mercuro, Rachel Morgans, Lindsey Williamson
Editorial and formatting assistance
Jennifer DeAngelis, Graphic Design, Kathie McKinstry, Graphic Design,
Diane M. Parente, PharmD (Infectious Diseases)

PAGE 1
Central Nervous
Central Nervous System:
System: Meningitis
Meningitis
ACUTE BACTERIAL MENINGITIS
Clinical Diagnostics and
Preferred Regimen Alternative Regimen
Syndrome Clinical Considerations
Age < 50 Ceftriaxone 2 gm IV PCN allergy Consult Infectious
Q12H (anaphylaxis): Diseases
Most commonly AND Vancomycin 15 mg/kg IV Obtain lumbar
isolated Vancomycin 15 mg/kg IV AND puncture and blood
organisms: AND Moxifloxacin 400 mg IV cultures prior to
S. pneumoniae Dexamethasone Q24H starting therapy
N. meningitidis 0.15 mg/kg IV AND Patients with the
H . influenzae Q6H given 10 to 20 Dexamethasone following conditions
minutes before the first 0.15 mg/kg IV should receive head
dose of antimicrobial Q6H given 10 to 20 CT prior to lumbar
therapy and continue minutes before the first puncture:
for 4 days for dose of antimicrobial - Immuno-
pneumococcal therapy and continue compromised (HIV)
meningitis for 4 days for - History of CNS
(discontinue for all other pneumococcal lesion, stroke or
microorganisms) meningitis focal infection
(discontinue for all other - New onset seizure
microorganisms) - Papilledema
- Abnormal level of
Age 50 Ceftriaxone 2 gm IV PCN allergy consciousness
Q12H (anaphylaxis): - Focal neurologic
Most commonly AND Vancomycin IV 15 mg/kg deficit
isolated Vancomycin 15 mg/kg IV AND Typical CSF findings in
organisms: AND Moxifloxacin 400 mg IV bacterial meningitis
Ampicillin 2 gm IV Q4H Q24H - Cloudy CSF
S. pneumoniae
AND AND - Glucose < 40 mg/dL
N. meningitidis
H. influenzae Dexamethasone 0.15 SMX/TMP 5 mg/kg IV OR <50% serum
L. monocytogenes mg/kg IV Q6H - Protein 100-500
Aerobic gram Q6H given 10 to 20 AND - WBC 1000-5000
negative bacilli minutes before the first Dexamethasone 0.15 - > 90% PMNs
dose of antimicrobial mg/kg IV Narrow therapy
therapy and continue Q6H given 10 to 20 based on CSF culture
for 4 days for minutes before the first results
pneumococcal dose of antimicrobial If CSF culture
meningitis therapy and continue negative, consult ID
(discontinue for all other for 4 days for Repeat lumbar
microorganisms) pneumococcal puncture if no
meningitis improvement in 48
(discontinue for all other hours and consider
microorganisms) viral panel

CNS= central nervous system; CSF= cerebral spinal fluid; CT= computed tomography; H= hour(s); HIV= human
immunodeficiency virus; ID= infectious diseases; IV= intravenous; PCN= Penicillin; PMNs= poly morphonuclear cells; Q= every;
SMX/TMP= Sulfamethoxazole/Trimethoprim; WBC= white blood cell

PAGE 2
Central Nervous System: Meningitis
Central Nervous
Central Nervous
ASEPTIC System:
/ VIRAL System:
/OTHER Meningitis
MENINGITIS Meningitis
AND HERPES SIMPLEX TYPE 2

ASEPTIC/ VIRAL/OTHER MENINGITIS Diagnostics


AND HERPES SIMPLEX TYPE 2and Clinical
Clinical Syndrome Preferred Regimen
Considerations
Diagnostics and Clinical
Clinical Syndrome
Aseptic/Viral/Other Preferred
Supportive care Regimen ConsultConsiderations
Infectious Diseases
Respiratory viruses
Send CSF and order:
Enteroviruses (90%)
Aseptic/Viral/Other If Lyme Suspected: Consult Infectious
Supportive care - Viral culture Diseases
Arboviruses
Respiratory viruses Ceftriaxone 2 gm IV Q24H
- HSV PCR
Send CSF and order:
West Nile Virus(90%)
Enteroviruses If Lyme Suspected: - Enteroviral
Viral culturePCR
Epstein Barr Virus
Arboviruses Ceftriaxone 2 gm IV Q24H - Lyme
HSV PCRAntibody (IgG index,
Lyme
West Nile Virus
- requires
Enteroviralsimultaneous
PCR
Syphilis
Epstein Barr Virus
- serum)
Lyme Antibody (IgG index,
Lyme - VDRL
requires simultaneous
Syphilis Typical CSF findings in viral
serum)
meningitis
- VDRL
- Clear
Typical CSF CSF
findings in viral
- Glucose 30-70 mg/dL
meningitis
- Protein
Clear CSF 30-150
Herpes Simplex Type 2 Acyclovir 10 mg/kg* IV Q8H - WBC 100-1000
Glucose 30-70 mg/dL
Treat for 7 to 10 days - <Protein
90% PMNs,
30-150increased
Herpes Simplex Type 2 Acyclovir 10 mg/kg* IV Q8H - lymphocytes
WBC 100-1000
Treat for 7 to 10 days - < 90% PMNs, increased
lymphocytes
CSF= cerebral spinal fluid; H= hour(s); HSV= Herpes Simplex Virus; IV= intravenous; LP= lumbar puncture; PCR= Polymerase Chain
Reaction; PMNs= poly morphonuclear cells; Q= every; VDRL= Veneral Disease Research Laboratory Test; WBC= white blood cell
CSF= cerebral
* Acyclovir spinal
mg/kg fluid;based
dosing H= hour(s); HSV=
on ideal Herpes
body Simplex Virus; IV= intravenous; LP= lumbar puncture; PCR= Polymerase Chain
weight.
Reaction; PMNs= poly morphonuclear cells; Q= every; VDRL= Veneral Disease Research Laboratory Test; WBC= white blood cell
NOTE: If dexamethasone or imaging studies (LP or CT) is not immediately available DO NOT delay administration of
*antibiotics.
Acyclovir mg/kg dosing based on ideal body weight.

NOTE:
NOTE: IfDosing
dexamethasone or imaging
based on normal renalstudies (LP Refer
function. or CT)to
is Table
not immediately
of Contentsavailable DOon
for section NOT delay administration
Vancomycin of
Dosing and Monitoring
antibiotics.
in Adult Patients and Antimicrobial Dosing for Adult Patients Based on Renal Function
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Vancomycin Dosing and Monitoring
in Adult Patients and Antimicrobial Dosing for Adult Patients Based on Renal Function

References:
1. Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84.
References:
PAGE 3
1. Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84.
Clostridium difficile
Clostridium dicile Infection
Infec2on (CDI) (CDI)
Stop anIbioIcs that are no longer indicated, especially broad-spectrum anIbioIcs
(uoroquinolones, clindamycin, piperacillin-tazobactam, cephalosporins) as they increase the
risk for CDI
Stop use of any anI-diarrheal/anIperistalIc agents
Consider disconInuaIon of proton-pump inhibitors (PPIs)
If high clinical suspicion of CDI iniIate anIbioIc therapy before laboratory conrmaIon

INITIAL EPISODE

Clinical and
Clinical Suppor4ve Clinical
Recommended Regimens Therapeu4c
Classica4on Data
Considera4ons

Ini4al episode Diarrhea (passage Vancomycin* 125 mg PO Q6H Ensure loose stools
Mild or of 3 unformed for 10-14 days are not a result of
Moderate stools in 24H) laxaIve
AND
WBC < 15,000 cells/
L
AND
SCr < 1.5 Imes the
premorbid level
Severe Diarrhea Vancomycin 125 mg PO Q6H for Consult ID and
AND 10-14 days Surgery
WBC 15,000 cells/
L Start suppor4ve
OR care as needed:
SCr 1.5 Imes the IV uid
premorbid level resuscitaIon
Severe criteria PLUS 1 Electrolyte
Complicated If no complete ileus: replacement
Severe of the following: Oral vancomycin 500 mg PO Q6H
Hypotension OR via NG tube
Shock AND
Toxic Megacolon if micro perforaIon is suspected
PerforaIon metronidazole 500 mg IV Q8H
Ileus

If complete ileus:
Add vancomycin retenIon
enema 500 mg in 500 mL NS
Q6H

Treatment duraIon: 14 days


CDI= Clostridium dicile InfecIon; H= hour(s); ID= InfecIous Diseases; IV= intravenous; NG= nasogastric; NS= normal saline;
PO= by mouth; PPI= proton pump inhibitor; Q= every; SCr= Serum CreaInine; WBC= white blood cell

* This recommendaIon is based on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole

PAGE 4
Clostridium dicile Infec2on (CDI)
Clostridium
Clostridium difficile
dicile Infection
Infec2on (CDI) (CDI)
RECURRENT EPISODES
RECURRENT EPISODES
No. of Recurrences Recommended Regimens
No. of Recurrences Recommended Regimens
1st Recurrence Vancomycin* 125 mg PO Q6H for 10-14 days
1stnd Recurrence Vancomycin* 125 mg PO Q6H for 10-14 days
2 Recurrence Consult ID for tailoring anIbioIc therapy. Oral vancomycin tapered over 6
2nd Recurrence weeks and/or
Consult ID for tpailoring
ulse dosing
anIbioIc therapy. Oral vancomycin tapered over 6
weeks and/or
Vancomycin pulse Rdegimen:
Taper osing
125 mg PO QT6H
Vancomycin for R1egimen:
aper 4 days
125 m
125 mg
g PPO
O QQ6H
12H for
for 7 d
14 days
ays
125 m
125 mg
g PPO
O Qonce
12H dfaily
or 7f or 7 days
days
125 m
125 mg
g PPO
O oevery
nce doaily
ther day
for 7 dfor
ays 8 days
125 m
125 mg
g PPO
O eevery
very o3 ther
days dfay
or f1or
5 d8ays
days

125 mg PO
If Severe: every 3 dFidaxomicin
Consider ays for 15 d2ays
00 mg PO Q12H (ID Restricted)

3 recurrences If Severe:
Consult ID Ctonsider
eam Fidaxomicin 200 mg PO Q12H (ID Restricted)
3 recurrences Possible referral
Consult ID team for fecal microbiota replacement therapy
2

Possible
Consider rreferral
estarIng for vfancomycin OR Fidaxomicin
taper replacement
ecal microbiota therapy200 2m
g PO Q12H
(ID Restricted) 3,4
Consider restarIng vancomycin taper OR Fidaxomicin 200 mg PO Q12H
(ID Restricted)3,4
RISK FACTORS FOR CDI
RISK FACTORS FOR CDI
64 years of age Exposure to CDI (household family member with CDI)

Exposure
64 years to
of aanIbioIcs
ge in previous 90 Exposure
Long-term care
to CDI f(acility or nursing
household hm
family ome resident
ember with CDI)
days
Exposure to anIbioIcs in previous 90 Long-term
Gastric acid reducing
care agent
facility (proton-pump
or nursing inhibitors)
home resident
days
HospitalizaIon in previous 30 days Gastric
Tube feedings
acid reducing agent (proton-pump inhibitors)
HospitalizaIon
Recent GI surgery in previous 30 days Tube feedings
Recent GI surgery INFECTION CONTROL
INFECTION CONTROL
RouIne screening for C. dicile in hospitalized paIents without diarrhea is not recommended

AsymptomaIc
RouIne carriers
screening for Cs. hould
dicile not
in bhe treated paIents without diarrhea is not recommended
ospitalized

PaIents should cbarriers
AsymptomaIc e placed in a p
should nrivate
ot be trreated
oom or with other paIents who have CDI

IniIate csontact
PaIents hould pbrecauIons
e placed in faor
pp aIents
rivate posiIve
room with
or with CDI u
other pnIl 48 hwours
aIents ho hfave
rom CrDI
esoluIon of
symptoms
IniIate contact precauIons for paIents posiIve with CDI unIl 48 hours from resoluIon of
Place contact precauIons plus sign on paIents door
symptoms
Place
Hand chontact
ygiene parecauIons
nd barrier pprecauIons
lus sign on (pgloves and
aIents gowns)
door
Hand
Place h
dygiene
edicated stethoscope
and in paIents
barrier precauIons room and gowns)
(gloves
When
pPlace
aIent ddedicated
ischarged or symptoms
stethoscope in presolve,
aIents rroom
oom should be terminally cleaned
When paIent discharged or symptoms resolve, room should
MISCELLANEOUS be terminally cleaned
MISCELLANEOUS
Repeat CDI PCR tesIng not recommended due to the likelihood of false posiIves. Toxin A, B, and
TC m ay r emain p osiIve f or a s l ong
Repeat CDI PCR tesIng not recommended due a s 3 0 d ays in to
paIent with symptom
the likelihood of false resoluIon.
posiIves. Toxin A, B, and
CDI= TC may remain
Clostridium piosiIve
dicile nfecIon; for
GI= ags long as 30 dHays
astrointesInal; in paIent
= hour(s); with symptom
ID= InfecIous Diseases; PrCR=
esoluIon.
Polymerase Chain ReacIon;
PO= by mouth; Q= every; TC= Toxigenic Culture
CDI=
Clostridium dicile infecIon; GI= gastrointesInal; H= hour(s); ID= InfecIous Diseases; PCR= Polymerase Chain ReacIon;
PO= by
* This mouth; Q= every;
recommendaIon is TbC= Toxigenic
ased Culture Use EvaluaIon which showed a higher rate of recurrence with metronidazole
on a MedicaIon

* This recommendaIon is based on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole

References:
1. Cohen, SH, et al. SHEA-IDSA Clinical PracIce Guidelines for Clostridium dicile InfecIon in adults. ICHE. 2010 May; 31(5):
References:
431-55.
1.
2. Cohen,
Surawicz SH,
CM, et eat
l. aSl.
HEA-IDSA Clinical
Guidelines PracIce G
for Diagnosis, uidelines for
Treatment, Clostridium
and PrevenIon dicile InfecIon diicile
of Clostridium n adults. ICHE. 2010
InfecIons. Am MJ ay; 31(5):
431-55.
Gastroenterol 2013; 108:47898.
2. Surawicz CM, et al. Guidelines for Diagnosis, Treatment, and PrevenIon of Clostridium dicile InfecIons. Am J
3. Kim PK, et al. Intracolonic Vancomycin for severe clostridium dicile coliIs. Surg Infect (Larchmt). 2013 Dec; 14(6):532-9.
4. Gastroenterol
Louie T, et al. F2idaxomicin
013; 108:47898.
versus Vancomycin for Clostridium dicile InfecIon. N Engl J Med. 2011 Feb 3;364(5):422-31.
3.
5. Kim PK, eOt A,
Cornely al. eIt ntracolonic Vancomycin
al. Fidaxomicin for severe cflostridium
versus vancomycin dicile
or infecIon oliIs. Surg
with Cclostridium Infect i(n
dicile Larchmt).
Europe, C2anada,
013 Dec; 14(6):532-9.
and the USA: a
4. Louie T , e t a l. F idaxomicin
double-blind, non-inferiority, v ersus Vancomycin
randomised for Clostridium
controlled dicile
trial. Lancet InfecIon.
Infect N 1E2:
Dis 2012; ngl 2J819.
Med. 2011 Feb 3;364(5):422-31.
5. Cornely OA, et al. Fidaxomicin versus vancomycin for infecIon with Clostridium dicile in Europe, Canada, and the USA: a
double-blind, non-inferiority, randomised controlled trial. Lancet Infect Dis 2012; 12: 2819. PAGE 5
Extended Spectrum Beta-Lactamase (ESBL)
Extended
Infection Spectrum
Extended Spectrum Beta-Lactamase
Beta-Lactamase (ESBL)
(ESBL) Infection
Infection
CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS
CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS
Extended Spectrum Meropenem 2 gm IV Consult ID Please DO NOT treat
Extended Spectrum Meropenem 2 gm IV Consult ID Please DO NOT treat
Beta-Lactamase (ESBL) Q8H colonization, or a dirty
Beta-Lactamase (ESBL) Q8H colonization, or a dirty
Infection (Use maximum doses) urine sample
Infection (Use maximum doses) Consult ID urine sample
Consult ID
Carbapenem-resistant Consult ID
Carbapenem-resistant Consult ID
Enterobacteriaceae
Enterobacteriaceae
(CRE)
(CRE)

Febrile
FebrileNeutropenia
Febrile Neutropenia
Neutropenia
CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS
CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS
Febrile Neutropenia Cefepime 2gm IV Q8H Meropenem 1 gm IV If patient has indwelling
Febrile Neutropenia Cefepime 2gm IV Q8H Meropenem 1 gm IV If patient has indwelling
OR Q8H catheter, is persistently
High risk: anticipated OR Q8H catheter, is persistently
High risk: anticipated Piperacillin/tazobactam febrile
prolonged Piperacillin/tazobactam febrile
prolonged 3.375gm IV Q4H OR
(>7 days duration) 3.375gm IV Q4H OR
(>7 days duration) (18gm/day) previously colonized
AND (18gm/day) previously colonized
AND with MRSA:
profound neutropenia with MRSA:
profound neutropenia ADD vancomycin
(ANC 100 cells/mm33 ADD vancomycin
(ANC 100 cells/mm
following cytotoxic Consult ID for
following cytotoxic Consult ID for
chemotherapy) +/- Anti-fungal therapy;
chemotherapy) +/- Anti-fungal therapy;
significant co-morbid Consider when fever
significant co-morbid Consider when fever
conditions: fails to respond after
conditions: fails to respond after
hypotension, 3-7 days of therapy
hypotension, 3-7 days of therapy
pneumonia, new-onset
pneumonia, new-onset
abdominal pain, or
abdominal pain, or
neurologic changes
neurologic changes
ANC= Absolute neutrophil count; CRE= Extended Spectrum Beta-Lactamase; ESBL= Extended Spectrum Beta-Lactamase;
ANC= Absolute
H= hour(s); ID= neutrophil count; CRE=
Infectious Diseases; IV= Extended Spectrum
intravenous; MRSA=Beta-Lactamase; ESBL=S.Extended
Methicillin-Resistant Spectrum
aureus; Q= every Beta-Lactamase;
H= hour(s); ID= Infectious Diseases; IV= intravenous; MRSA= Methicillin-Resistant S. aureus; Q= every
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
NOTE: Dosing
Patients Basedbased on normal
on Renal renal
Function, function. Refer
Aminoglycoside to Table
High of Contents
Dose Once for section
Daily (HDOD) and on Antimicrobial
Monitoring Dosing
in Adult for Adult
Patients, and
Patients Based
Vancomycin on Renal
Dosing Function, Aminoglycoside
and Monitoring High Dose Once Daily (HDOD) and Monitoring in Adult Patients, and
in Adult Patients.
Vancomycin Dosing and Monitoring in Adult Patients.

PAGE 6
Fungal Infections
Fungal Infections
Fungal Infections
CONDITION PRIMARY THERAPY ALTERNATIVE THERAPY DURATION
COMMENTS
CONDITION PRIMARY THERAPY ALTERNATIVE THERAPY DURATION
COMMENTS
Candidemia Caspofungin IV L-AmB 35 mg/kg IV 14 days after
Remove all IV
Candidemia
Non-neutropenic Caspofungin
LD: 70 mg IV L-AmB
Q24H 35 mg/kg IV 14
Remove days after
allifIV
first negative
catheters,
Non-neutropenic LD: 70
MD: 50mg
mg Q24H Q24H
OR first negative
catheters, if
culture
possible result
MD: 50 mg Q24H
OR OR
Voriconazole IV/PO culture result
possible
AND
OR Voriconazole IV/PO Consult ID
AND
Fluconazole IV 400 mg resolution of
Consult ID
Fluconazole
LD: 800 mg IV 400 mg Q12H for
(6 mg/kg) resolution
Consider eye of
signs/symptoms
LD: 800 mg
(12mg/kg) (6 mg/kg)
2 doses Q12H
then 200for
mg Consider
exam eye
signs/symptoms
(12mg/kg)
MD: 400 mg 2 doses
(3 then
mg/kg) 200 mg
Q12H exam
Transition to
MD:
6 400 mg
mg/kg) Q24H (3 mg/kg) Q12H Transition
fluconazoletois
6 mg/kg) Q24H fluconazole is for
recommended
recommended
clinically stable for
clinically stable
patients with
patients
fluconazolewith
fluconazole
susceptible
susceptible
isolates AND
negativeAND
isolates repeat
negative repeat
blood cultures
blood cultures
Candidemia Caspofungin IV Fluconazole IV 14 days after Fluconazole is
Candidemia
Neutropenic Caspofungin
LD: 70 mg IV Fluconazole
LD: 800 mg (12IV mg/kg) 14
firstdays after
negative Fluconazole
preferred in is
Neutropenic LD:
MD:7050mg
mg Q24H LD:
MD:800
400mg mg(12 mg/kg) first
(6 mg/kg) negative
culture result preferred in
patients without
MD:
OR 50 mg Q24H MD:
Q24H400 mg (6 mg/kg) culture
AND result patients without
recent azole
OR
L-AmB Q24H
OR AND
resolution of recent azole
exposure AND
L-AmB
35 OR
mg/kg IV Q24H Voriconazole IV/PO resolution of
signs/symptoms exposure
who are NOTAND
35 mg/kg IV Q24H Voriconazole
400 mg (6 mg/kg)IV/PO signs/symptoms
and neutropenia who are NOT
critically ill.
400
Q12Hmgfor(62mg/kg)
doses then and neutropenia critically ill.
Q12H Remove IV
200 mgfor(32mg/kg)
doses then
Remove IVif
200 mg (3 mg/kg) catheters,
Q12H catheters, if
Q12H possible
possible
Consult ID
Consult ID
Consider eye
Consider
exam eye
Urinary Fluconazole Conventional Fluconazole: exam
Alternative
Urinary
Candidiasis Fluconazole
200 mg (3 mg/kg) Conventional B
Amphotericin Fluconazole:
14 days Alternativeis
treatment
Candidiasis
Symptomatic 200 mg (3 mg/kg)
PO Q24H Amphotericin
0.30.6 mg/kgBIV Q24H 14 days
Amphotericin B: treatment
recommended is for
Symptomatic
Cystitis PO Q24H 0.30.6 mg/kg IV Q24H Amphotericin
1-7 days B: recommended
fluconazole for
Cystitis 1-7 days fluconazole
resistant
resistant
organisms
organisms
Urinary Fluconazole Conventional Fluconazole: Alternative
Urinary
Candidiasis Fluconazole
200400 mg (36 Conventional
Amphotericin B Fluconazole:
14 days Alternative
treatment is
Candidiasis
Pyelonephritis 200400
mg/kg) POmg (36
Q24H Amphotericin
0.50.7 mg/kgBIV Q24H 14 days
Amphotericin B: treatment
recommended is for
Pyelonephritis mg/kg) PO Q24H 0.50.7 mg/kg IV Q24H 14 Amphotericin
days B: fluconazole
recommended for
14 days fluconazole
resistant
resistant
organisms
organisms
H= hour(s); ID= Infectious Diseases; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance
H= hour(s);
dose; PO= byID= Infectious
mouth; Diseases; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance
Q= every
dose; PO= by mouth; Q= every
NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents
NOTE:
for Some
section onagents will require
Guidelines ID consult/approval
for Restricted Antibiotics (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents
for section on Guidelines for Restricted Antibiotics

References:
1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America.
References:
1. Clin Infect
Pappas PG,Dis. 2016;
et al. 62(4):e1-e50.
Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America.
Clin Infect Dis. 2016; 62(4):e1-e50.
PAGE 7
Fungal Infections
Fungal
Fungal Infections
CONDITION Infections
PRIMARY THERAPY ALTERNATIVE THERAPY DURATION COMMENTS
Nongenital Clotrimazole 10 mg Itraconazole oral Uncomplicated Refractory
CONDITION
Oropharyngeal PRIMARY
troche THERAPY
5 times daily ALTERNATIVE THERAPY
solution DURATION
disease 7 to 14 COMMENTS
disease:
(Oral Thrush)
Nongenital OR
Clotrimazole 10 mg 200 mg PO once
Itraconazole oral daily days
Uncomplicated Voriconazole
Refractory
Oropharyngeal Nystatin5 suspension
troche times daily OR
solution disease 7 to 14 200 mg PO Q12H
disease:
(Oral Thrush) PO
OR four times a day Voriconazole 200daily
200 mg PO once mg days OR
Voriconazole
OR
Nystatin suspension PO
OR Q12H L-AmB
200 mg PO Q12H
Fluconazole
PO four times a day Voriconazole 200 mg suspension
OR 1 mL
100200
OR mg PO Q12H of 100 mg/mL
L-AmB
PO once daily
Fluconazole four times a1day
suspension mL
Esophageal Fluconazole
100200 mg Caspofungin IV 1421 days Patients unable
of 100 mg/mL
Candidiasis 200400 mg
PO once daily LD: 70 mg to
fourtolerate
times aanday
oral
Esophageal (36 mg/kg)
Fluconazole MD: 50 mg Q24H
Caspofungin IV 1421 days agent,
PatientsIVunable
Candidiasis PO Q24H mg
200400 OR
LD: 70 mg fluconazole
to tolerate anororal
(36 mg/kg) Conventional
MD: 50 mg Q24H alternative
agent, IV agent
PO Q24H Amphotericin
OR B listed may be
fluconazole or
0.30.7 mg/kg IV
Conventional used.
alternative agent
Q24H
Amphotericin B listed may be
0.30.7 mg/kg IV used.
General Susceptibility Patterns of Candida spp.
Q24H
Amphotericin
General Susceptibility Patterns ofItraconazole
Fluconazole Candida spp. Caspofungin Voriconazole
B
Amphotericin
Candida S
Fluconazole S
Itraconazole S S
Caspofungin S
Voriconazole
B
albicans
Candida S S S S S
C. tropicalis S S S S S
albicans
C. S S S S S
C. tropicalis S S S S S
parapsilosis
C. S S S S S
C. glabrata S-DD S-DD to R S-I S S-DD to R
parapsilosis
C. krusei R S-DD to R S-I S S
C. glabrata S-DD S-DD to R S-I S S-DD to R
C. lusitaniae S S S to R S S
C. krusei R S-DD to R S-I S S
H= hour(s); I= Intermediate; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose;
C.
PO=lusitaniae
by mouth; Q= every; R=SResistant; S= susceptible;
S S-DD= Susceptibility
S to Ris dose dependent; Sspp= species S
H= hour(s);
NOTE: SomeI=agents
Intermediate; IV= intravenous;
will require L-AmB= (amphotericin
ID consult/approval Liposomal Amphotericin B; LD=voriconazole).
B, caspofungin, loading dose; MD=
Refermaintenance dose;
to Table of Contents
PO= by mouth;
for section Q= every; R=
on Guidelines forResistant;
RestrictedS=Antibiotics
susceptible; S-DD= Susceptibility is dose dependent; spp= species

NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents
for section on Guidelines for Restricted Antibiotics

References:
1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of
America. Clin Infect Dis. 2016; 62(4):e1-e50.
References:
1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases SocietyPAGE
of 8
America. Clin Infect Dis. 2016; 62(4):e1-e50.
Influenza A and B (Flu)
Influenza A Band
Influenza A and (Flu)B (Flu)
CLINICAL AND THERAPEUTIC ALGORITHM CLINICAL SEVERITY RECOMMENDED REGIMENS
CLINICAL AND THERAPEUTIC ALGORITHM CLINICAL SEVERITY RECOMMENDED REGIMENS
Diagnosis is based on the clinical presentation Outpatient High Risk Select ONE of the
Diagnosis
of is based
the patient on the of
and results clinical
RT-PCR.presentation Outpatient
(see High Risk
left panel) Select ONE of the
following:
of the patient and results of RT-PCR. (see left panel) following:
Oseltamivir 75 mg PO
Decision to initiate treatment should NOT wait Previously Healthy Q12H
Oseltamivir 75 mg PO
Decision
for to initiate
confirmation of treatment results.NOT wait
laboratory should Previously Healthy Q12H
for confirmation of laboratory results. Zanamivir 10 mg
Continue the full course of treatment (two
Zanamivir 10 mg
Continue the full course of treatment 5 mg inhalations)
if first RT-PCR is negative and if signs and (two
if first RT-PCR is negative anddueif signs and Q12H5 mg inhalations)
symptoms indicate influenza to possibility Q12H
symptoms
of indicate influenza due to possibility
false negative. Treat for 5 days ONLY if
of false negative. daysbeONLY if
Treat for 5 can
treatment
History of influenza vaccination does not treatment can be
History initiated within 48 hours
precludeofinfluenza
influenzawhen vaccination
signs anddoes not
symptoms initiated
preclude influenza of illness within
onset. 48 hours
are compatible withwhen signs and
the clinical symptoms
syndrome. of illness onset.
are compatible with the clinical syndrome. Inpatient High Risk Oseltamivir 75 mg PO
Zanamivir use is not recommended in people
Zanamivir use is respiratory
not recommended Inpatient
(see High Risk
left panel) orOseltamivir
enterally- 75 mg PO
with underlying disease in people
with underlying respiratory disease (see left panel) or enterally- Q12H
administered
(e.g. asthma, COPD.)
(e.g. asthma, COPD.) administered Q12H
Treatment Population: Treat for 5 days. If illness
Treatment Population: Treat
is for or
severe 5 days. If illness
prolonged,
High risk adults (any of the following):
is
maysevere or prolonged,
extend duration
High65
riskyears
adults (any of the following):
65 years may extend
based duration
on clinical
Chronic health conditions*
Chronic health conditions* based on clinical
judgment.
Immunosuppression, including caused by
medication
Immunosuppression, including caused by judgment.
or HIV infection Inpatient Oseltamivir 75 mg PO
medication
Pregnant oror HIV infection
postpartum (within 2 weeks of Inpatient orOseltamivir
enterally- 75 mg PO
Pregnant or postpartum (within 2 weeks of
delivery) women or enterally- Q12H
administered
delivery) women
American Indian/Alaska Natives administered Q12H
American
Body massIndian/Alaska
index 40 Natives Treat for 5 days.
Body massofindex
Residents 40homes and other
nursing Treat for 5 days.
Residents
chronic-care of nursing
facilitieshomes and other Post-Exposure Select ONE of the
chronic-care facilities Post-Exposure
Chemoprophylaxis Select ONE of the
following:
Previously healthy, symptomatic outpatient Chemoprophylaxis
High risk following:
Oseltamivir 75 mg PO
Previously
NOT at highhealthy,
risk symptomatic outpatient (see
Highleft
riskpanel) Oseltamivir
once daily 75 mg PO
NOT at 48
(within high risk of symptom onset)
hours (see left panel) once daily 10 mg (two
Zanamivir
(within 48 hours of symptom onset) 5 Zanamivir 10 mg (two
Hospitalized patients CDC Flu health advisory mg inhalations) once
Hospitalized
February 2016: patients CDC Flu
2 Treatment may health advisory
also be 5 mg inhalations) once
daily
February 2016:
beneficial Treatment
when2 started up tomay4 toalso be after
5 days daily
beneficial onset
symptom when in started up to 4patients.
hospitalized to 5 days after Treat for 10 days**
symptom onset in hospitalized patients. Treat for 10 days**
CDC= Centers for Disease Control and Prevention; COPD= chronic obstructive pulmonary disease; H= Hour(s); HIV= human
immunodeficiency virus; PO=
CDC= Centers for Disease by mouth;
Control Q= every;COPD=
and Prevention; RT-PCR= reverse
chronic transcriptase
obstructive polymerase
pulmonary chain
disease; H=reaction
Hour(s); HIV= human
immunodeficiency virus; PO= by mouth; Q= every; RT-PCR= reverse transcriptase polymerase chain reaction
*Chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including
sickle cellpulmonary
*Chronic disease), metabolic
(includingdisorders
asthma),(including diabetes
cardiovascular mellitus),
(except neurologic
hypertension conditions
alone), (disorders
renal, hepatic, of the brain, (including
hematological spinal cord,
nerve, muscle,
sickle cell epilepsy,
disease), stroke,
metabolic or intellectual
disorders disability)
(including diabetes mellitus), neurologic conditions (disorders of the brain, spinal cord,
nerve, muscle, epilepsy, stroke, or intellectual disability)
**After most recent known exposure to a close contact known to have influenza.
**After most recent known exposure to a close contact known to have influenza.
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients
Based
NOTE: on Renalbased
Dosing Function
on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients
Based on Renal Function

References:
1. Centers for Disease Control and Prevention. CMV home. Cytomegalovirus (CMV) and Congenital CMV infection Web site.
References:
http://www.cdc.gov/cmv/clinical/features.html. Published
1. Centers for Disease Control and Prevention. CMV 6 Dec 2016. Updated
home. Cytomegalovirus 2010.
(CMV) andAccessed 6 March
Congenital 2016. Web site.
CMV infection
2. Department of Health and Human Services. FluPublished
http://www.cdc.gov/cmv/clinical/features.html. season begins:
6 Dec Severe influenza2010.
2016. Updated illness reported.
Accessed Centers
6 March for Disease Control
2016.
and Prevention:ofEmergency
2. Department Health andPreparedness and Flu
Human Services. Response
season Web site.Severe
begins: http://emergency.cdc.gov/han/han00387.asp. Published
influenza illness reported. Centers for Disease 1
Control
Feb 2016. Updated 2016. Accessed 12 March 2016
and Prevention: Emergency Preparedness and Response Web site. http://emergency.cdc.gov/han/han00387.asp. Published 1
.
Feb 2016. Updated 2016. Accessed 12 March 2016.
PAGE 9
Intra-abdominal Infections
Intra-abdominal Infections
CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS
Intra-abdominal Piperacillin/tazobactam Ciprofloxacin 400 mg IV Piperacillin/tazobactam
Infections 3.375 gm IV Q6H Q12H provides excellent
Community acquired +/- Metronidazole anaerobic coverage,
OR 500 mg IV Q8H addition of clindamycin
Hospital acquired OR metronidazole is
Meropenem 1gm Q8H
NOT indicated or
necessary

Lyme Disease
Lyme Disease
CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS
Lyme Disease Doxycycline 100 mg PO Consult ID Relapse may occur with
Early disease Q12H* any regimen; patients
OR with objective
Amoxicillin 500 mg PO signs/symptoms may
Q8H* need a second course
OR
Duration of Treatment:
Cefuroxime 500 mg PO
Doxycycline 10-21 days
Q12H*
Amoxicillin/Cefuroxime
14-21 days
Late disease with
central OR peripheral Lyme antibody testing
nervous system disease Consult ID can be negative in first
6 weeks
Consider co-infection
with anaplasma or
babesia

H= hour(s); ID= Infectious Diseases; IV= intravenous; PO= By Mouth; Q= every

*Doxycycline also has activity against Ehrlichia and Anaplasma. Amoxicillin and cefuroxime do not.

NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function, Aminoglycoside High Dose Once Daily (HDOD) and Monitoring in Adult Patients, and
Vancomycin Dosing and Monitoring in Adult Patients.

PAGE 10
Proton-Pump Inhibitor (PPI) Use
Proton-Pump
Proton-Pump Inhibitor Inhibitor
(PPI) Use(PPI) Use
The FDA has issued multiple warnings on the long-term use of PPIs. These include: increased risk
of C.FDA
The difficile infection
has issued
1, hypomagnesemia2, and fractures of the hip, wrist, and spine3. Therefore,
multiple warnings on the long-term use of PPIs. These include: increased risk
of C. difficile infection ,PPIs
prudent prescribing of
1 is warranted. The
hypomagnesemia 2, andFDA recommends
fractures use of
of the hip, the and
wrist, lowest dose
spine and
3. Therefore,
shortest prescribing
prudent duration of ofPPIPPIs
therapy appropriate
is warranted. TheforFDAthe condition being
recommends treated
use of
1-3. Patient
the lowest dose and
compliance,
shortest time of
duration of administration (prior to meals),
PPI therapy appropriate for the and dietary
condition indiscretions
being treated1-3(i.e. alcohol or
. Patient
irritating foods)
compliance, timeshould be assessed (prior
of administration prior to
to titration of PPI
meals), and doses.
dietary indiscretions (i.e. alcohol or
irritating foods) should be assessed prior to titration of PPI doses.
Indication Treatment Duration
Indication Treatment Duration
Gastroesophageal reflux disease Initial 8 week course for symptom
(GERD) 6
Gastroesophageal reflux disease relief or esophagitis
Initial 8 week course for symptom
(GERD) 6 Omeprazole 20 mg PO relief or esophagitis
Symptomatic relief Maintenance therapy determined
once daily 20 mg PO
Omeprazole
Symptomatic
Acute healingrelief
of erosive or ulcerative OR daily Maintenanceand
by response severity
therapy of
determined
once disease
esophagitis Pantoprazole 40mg PO by response and severity of
Acute healing of erosive or ulcerative OR
once daily 40mg PO disease
Consider dose titration, or
esophagitis
Maintenance healing of erosive or Pantoprazole
once daily intermittent
Consider dosetherapy
titration, or
ulcerative esophagitis
Maintenance healing of erosive or
intermittent therapy
ulcerative esophagitis
Stress ulcer prophylaxis should be Transition to PO when possible
used for critically ill patients
Stress ulcer prophylaxis withbe
should Transition to PO when possible
Continue until resolution of
increased
used risk of bleeding
for critically including
ill patients with
4,5:
underlyinguntil
Continue riskresolution
factors and/or
of
- Coagulopathy
increased (plateletincluding
risk of bleeding count 4,5:
critical illness
underlying risk factors and/or
<50,000 mm3, (platelet
- Coagulopathy INR >1.5,count
or aPTT
>2x control) Omeprazole critical illness
<50,000 mm3, INR >1.5, or aPTT
- >2x
Mechanical
control)ventilation for >48 10-20 mg IV/PO once
Omeprazole
hours
- Mechanical ventilation for >48 daily mg IV/PO once
10-20
- hours
Traumatic, severe thermal or OR
daily
spinal cord severe
- Traumatic, injury thermal or Pantoprazole 40mg
OR
- spinal
Historycord
of GIinjury
ulceration or IV/PO once daily
Pantoprazole 40mg
bleedingofwithin
- History past year
GI ulceration or IV/PO once daily
Twobleeding
or morewithin
minorpastrisk factors:
year
- Sepsis,
Two or more ICUminor
stay 1 riskweek, occult GI
factors:
bleeding
- Sepsis, 6stay
ICU days,1glucocorticoid
week, occult GI
therapy (>250
bleeding 6 days,mgglucocorticoid
hydrocortisone
equivalent)
therapy (>250 mg hydrocortisone
equivalent)
aPTT= activated partial thromboplastin time; GERD= Gastroesophageal reflux disease; GI= Gastrointestinal; ICU= intensive care
unit; INR= International normalized ratio; IV= intravenous; PO= by mouth; PPI= proton pump inhibitor
aPTT= activated partial thromboplastin time; GERD= Gastroesophageal reflux disease; GI= Gastrointestinal; ICU= intensive care
unit; INR= International normalized ratio; IV= intravenous; PO= by mouth; PPI= proton pump inhibitor

References
1. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be
References
associated with stomach acid drugs known as proton pump inhibitors (PPIs) [internet]. Updated May 2012 [cited
1. U.S. Food and
11/21/12]. Drug Administration
Available (FDA). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be
from: http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm
associated
2. U.S. Food and withDrug
stomach acid drugs(FDA).
Administration knownFDA
as proton pumpCommunication:
Drug Safety inhibitors (PPIs) Low
[internet]. Updated
magnesium May
levels can2012 [cited
be associated with
11/21/12]. Available
long-term use from:
of Proton http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm
Pump Inhibitor drugs (PPIs) [internet]. Updated February 2012 [cited 11/21/12]. Available from:
2. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Low magnesium levels can be associated with
http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm.
3. long-term use of
U.S. Food and Proton
Drug Pump Inhibitor
Administration drugs
(FDA). FDA (PPIs) [internet].
Drug Safety Updated February
Communication: 2012
Possible [cited 11/21/12].
increased Available
risk of fractures from:
of the hip,
http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm.
wrist, and spine with the use of proton pump inhibitors [internet]. Updated March 2011 [cited 11/21/12]. Available from:
3. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Possible increased
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm risk of fractures of the hip,
4. wrist, and spine with
ASHP Therapeutic the use of
Guidelines onproton
Stress pump inhibitors [internet].
Ulcer Prophylaxis. Updated March
ASHP Commission 2011 [citedand
on Therapeutics 11/21/12].
approvedAvailable from:
by the ASHP
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm
Board of Directors on November 14, 1998. Am J Health Syst Pharm 1999; 56:347.
4. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved
5. Spirt MJ, Stanley S. Update on stress ulcer prophylaxis in critically ill patients. Crit Care Nurse 2006; 26:18. by the ASHP
6. Board of Gerson
Katz PO, Directors
LB,onVela
November forAm
14, 1998.
MF. Guidelines theJ Health Syst
diagnosis Pharm
and 1999; 56:347.
management of gastroesophageal reflux disease. Am J
5. Spirt MJ, Stanley
Gastroenterol S. Update on stress ulcer prophylaxis in critically ill patients. Crit Care Nurse 2006; 26:18.
2013;108:308-28.
6. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J
Gastroenterol 2013;108:308-28.
PAGE 11
Respiratory Tract: Acute Bacterial Sinusitis
Respiratory
Respiratory
C T
Tract:
Tract: Acute
Acute Bacterial
Bacterial
LINICAL AND HERAPEUTIC
Sinusitis
Sinusitis
RISK FACTORS RECOMMENDED REGIMENS
ALGORITHM
CLINICAL AND THERAPEUTIC
RISK FACTORS RECOMMENDED REGIMENS
1a. Antibiotics are indicated if the Presence of Risk
ALGORITHM Initial Empiric Antibiotic Therapy:
patient has ANY of the Factors for
1a. following:
Antibiotics are indicated if the Presence Amoxicillin/clavulanate
Initial Empiric AntibioticPO:
Therapy:
Antibioticof Risk
patient has ANY of the 10 Factors for CrCl > 30 ml/min: 2000/125
Symptoms PO: mg

lasting Resistance: Amoxicillin/clavulanate
following:
days without clinical Antibiotic
Age > 65 Q12H
Symptoms
improvement lasting 10 Resistance:
Antibiotics CrCl
CrCl >1030 ml/min: 2000/125
29 ml/min: mgmg
875/125

ORdays without clinical Age


within> 65
last 30 Q12H
Q12H
improvement
Severe symptoms at onset Antibiotics
days CrCl
CrCl 10
< 10 29 ml/min:
ml/min: 875/125
2000/125 mg
mg
OR lasting within last 30
Hospitalization Q12H
Q24H
Severe
3 days symptoms
[Fever ( at102onset
F), days
within last 5 CrCl < 10 ml/min: 2000/125 mg
Alternatives*:
lasting facial pain, or
severe Hospitalization
days Q24H
Moxifloxacin 400 mg PO Q24H
[Fever ( 102 F),
3 days discharge]
purulent within
Immuno- last 5 Alternatives*:
severe facial pain, or days Treat for 7 to400
Moxifloxacin 10 days
mg PO Q24H
OR compromised
purulent
New onset discharge]
fever, severe ORImmuno-
Treat for 7 to 10 days
OR headache, or increase compromised
Fever > 102F
Newnasalonset fever,after
discharge severe
5-6 ORwith signs of
headache,
days following or increase
initial Fever
systemic> 102F
illness
nasal discharge after 5-6
improvement with signs of
days following initial None of the illness
systemic above No risk for Antibiotic Resistance:
1b. If the patient does not meet
improvement risk factors for
None of the above Amoxicillin/clavulanate
No PO:
risk for Antibiotic Resistance:
this criteria likely viral and antibiotic
1b. self-limiting.
If the patientMay doesprovide
not meet risk factors for CrCl > 30 ml/min: 875/125
resistance Amoxicillin/clavulanate PO: mg Q12H
this criteria
symptom likely viral and
relief. antibiotic CrCl 1029 ml/min: 500/125 mg
AND
self-limiting.
Reduce nasal Maysymptoms:
provide resistance CrCl
Q12H> 30 ml/min: 875/125 mg Q12H
symptom relief.
topical or nasal No fever or signs of CrCl
CrCl 1029 ml/min:
< 10 ml/min: 500/125
875/125 mgmg
Q24H
AND
Reduce nasal symptoms:
decongestants, intranasal systemic illness Q12H
Alternatives*:
topical or nasal intranasal
corticosteroids, No fever or signs of CrCl < 10 ml/min:
Doxycycline 875/125
100 mg mg Q24H
PO Q12H
decongestants,
saline intranasal systemic illness Alternatives*:
OR
corticosteroids, intranasal Doxycycline
Moxifloxacin100
400mg
mgPOPOQ12H
Q24H
2. If nosaline
improvement after 3 to 5 OR
days of antibiotic therapy Treat for 5 to400
Moxifloxacin 7 days
mg PO Q24H
2. switch
If no improvement
to an alternativeafteragent
3 to 5
days of antibiotic therapy
from a different antibiotic class Treat for 5 to 7 days
switch to an alternative agent
CrCl= creatinine clearance; H= hour(s); PO= by mouth; Q= every
from a different antibiotic class
Pharmacy does not carry amoxicillin/clavulanate 2000/125 mg tablets. Order 875/125 mg tablets of amoxicillin/clavulanate
CrCl= creatinine clearance; H= hour(s); PO= by mouth; Q= every
AND 1000 mg tablets of amoxicillin
(total amoxicillin/clavulanate
Pharmacy = 1,875/125 mg per dose).
does not carry amoxicillin/clavulanate 2000/125 mg tablets. Order 875/125 mg tablets of amoxicillin/clavulanate
AND 1000 mg tablets of amoxicillin
*Macrolides,
(total trimethoprim-sulfamethoxazole,
amoxicillin/clavulanate anddose).
= 1,875/125 mg per 2nd or 3rd generation cephalosporins are not recommended due to
increasing rates of antimicrobial resistance.
*Macrolides, trimethoprim-sulfamethoxazole, and 2nd or 3rd generation cephalosporins are not recommended due to
increasing rates of antimicrobial resistance.

References:
1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and
adults. Clin Infect Dis. 2012; 54:e72.
References:
1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and
adults. Clin Infect Dis. 2012; 54:e72. PAGE 12
Respiratory Tract: Acute Pharyngitis
Respiratory Tract:
Respiratory Tract:
QUICK FACTS1-2:
Acute
Acute Pharyngitis
Pharyngitis
QUICK
OnlyFACTS
5-15%1-2of: adult cases of acute pharyngitis are caused by Group A -hemolytic
streptococci
Only 5-15% of (GAS).
adult cases of acute pharyngitis are caused by Group A -hemolytic
It is estimated
streptococci that 3,000 to 4,000 patients with GAS must be treated for every 1
(GAS).
case of acute rheumatic
It is estimated that 3,000fever prevented.
to 4,000 patients with GAS must be treated for every 1
Antibiotic therapy
case of acute of GASfever
rheumatic hastens resolution by 1-2 days if initiated within 2-3 days
prevented.
of symptom
Antibiotic onset.of GAS hastens resolution by 1-2 days if initiated within 2-3 days
therapy
of symptom onset. CLINICAL
CLASSIFICATION CLINICAL PRESENTATION RECOMMENDED REGIMENS
CONSIDERATIONS
CLINICAL
CLASSIFICATION CLINICAL PRESENTATION RECOMMENDED REGIMENS
Group A 2 of the following: Amoxicillin 500 mg PO CONSIDERATIONS
Clinical suspicion
-hemolytic Fever ( 100.4) Q12H for GAS:
Group A 2 of the following: Amoxicillin 500 mg PO Clinical suspicion
streptococcus Tonsillar exudates OR Obtain throat swab
-hemolytic Fever ( 100.4) Q12H for GAS:
(GAS) No cough Penicillin VK 250 mg Q6H OR order GAS rapid
streptococcus Tonsillar exudates OR Obtain throat swab
Tender anterior OR antigen detection
(GAS) No cough Penicillin VK 250 mg Q6H OR order GAS rapid
cervical 500 mg PO Q12H test (RADT)*
Tender anterior OR antigen detection
lymphadenopathy
cervical 500 10
For mgdays
PO Q12H test
If (RADT)*
culture is
(lymphadenitis)
lymphadenopathy negative:
Scarlatiniform rash Penicillin
For 10 daysAllergy If culture is
(lymphadenitis) No antibiotics AND
Non-anaphylactic allergy: negative:
Scarlatiniform rash Penicillin Allergy consider supportive
Cephalexin 500 mg PO No antibiotics AND
Non-anaphylactic allergy: treatment
Q12H x 10 days consider supportive
Cephalexin 500 mg PO (antipyretic OR
OR treatment
Q12H x 10 days analgesic)
Clindamycin 300 mg PO (antipyretic OR
OR
Q6H for 10 days analgesic)
Clindamycin 300 mg PO
OR
Q6H for 10 days
Azithromycin 500 mg PO x
OR
1 day, then 250 mg PO
Azithromycin 500 mg PO x
Q24H x 4 days
1 day, then 250 mg PO
Viral Pharyngitis Conjunctivitis Q24H x 4 days
Supportive treatment
Coryza (antipyretic OR analgesic)
Viral Pharyngitis Conjunctivitis Supportive treatment
Cough
Coryza (antipyretic OR analgesic)
Diarrhea
Cough
Hoarseness
Diarrhea
Discrete ulcerative
Hoarseness
stomatitis
Discrete ulcerative
Viral exanthema
stomatitis
GAS= Group A -hemolytic Streptococci; H= hour(s); PO= by mouth; Q= every; RADT= Rapid antigen detection test
Viral exanthema
GAS= Group
*Throat swabAculture
-hemolytic Streptococci;
sensitivity: 90-95%;H= hour(s);
RADT: PO= by70-90%,
sensitivity mouth; specificity
Q= every; 95%
RADT= Rapid antigen detection test

*Throat swab culture sensitivity: 90-95%; RADT: sensitivity 70-90%, specificity 95%

References:
1. Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A
References:
Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society America. Clin Infect Dis. 2012 Nov 15;55(10):1279-
1. 82.
Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A
Streptococcal
2. Cooper Pharyngitis:
RJ et al. 2012
Principles of Update byantibiotic
appropriate the Infectious
use forDiseases Society America.
acute pharyngitis ClinBackground.
in adults: Infect Dis. 2012 Novof15;55(10):1279-
Annals Internal
82.
Medicine. 2001;134(6):509-17.
2. Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal
Medicine. 2001;134(6):509-17. PAGE 13
Respiratory Tract:
Respiratory ChronicObstructive
Tract: Chronic Obstructive Pulmonary
Pulmonary
Disease (COPD) Exacerbation
Disease (COPD) Exacerbation
CLINICAL
CLINICAL AND THERAPEUTIC ALGORITHM RECOMMENDED REGIMENS
SEVERITY
Respiratory Tract: Chronic Obstructive Pulmonary
Diagnosis: Based on the clinical Outpatient Select ONE of the following:
Disease of(COPD)
presentation the patient,Exacerbation
including Uncomplicated Doxycycline 100 mg PO Q12H
complaints of an acute change of cardinal CLINICAL Amoxicillin 500 mg PO Q8H
CLINICAL AND THERAPEUTIC ALGORITHM RECOMMENDED REGIMENS
symptoms as follows: SEVERITY Azithromycin 500 mg once, then
250 mg PO Q24H
Does patient
Diagnosis: have:
Based increased
on the clinical sputum Outpatient Select ONE of the following:
presentation of the patient,dyspnea
includingOR Uncomplicated SMX/TMP
Doxycycline 100 1mgDSPO
tablet
Q12HPO Q12H
purulence AND increased
complaintssputum
increased of an acute change of cardinal Amoxicillin
Treat for 500
3 tomg PO Q8H
5 days
symptoms as follows: Azithromycin 500 mg once, then
1. Initiate therapy with: 250 mg PO Q24H
Does patient have: increased sputum Outpatient Primary Recommendation:
Short-acting bronchodilators SMX/TMP 1 DS tablet PO Q12H
purulence AND increased dyspnea OR Complicated* Amoxicillin/clavulanate 875 mg
(i.e. sputum
increased albuterol) increased to 6 to 8 Treat forPO3 toQ12H
5 days
OR
puffs Q1-2H in severe exacerbations
1. Initiate therapy with: Failure of Penicillin Allergy or Treatment
+/- Short-acting anticholinergics Outpatient Primary Recommendation:
Short-acting bronchodilators Previous
Complicated*
Failure with Primary Regimen:
Amoxicillin/clavulanate 875 mg
(i.e. albuterol)
ipratropium bromide)to 6increased
(i.e. increased to 8
OR Antimicrobial Q12H
PO Moxifloxacin 400 mg PO Q24H**
to 6 to
puffs 8 puffs
Q1-2H Q3-4Hexacerbations
in severe in severe
Therapy
Failure of Penicillin
exacerbations given via
+/- Short-acting anticholinergics TreatAllergy or5Treatment
for 3 to days
Previous Failure with Primary Regimen:
nebulizer/inhaler
(i.e. ipratropium bromide) increased
Antimicrobial
Inpatient Moxifloxacin 400 mg PO Q24H**
Primary Recommendation:
PLUS
to 6 to 8 puffs Q3-4H in severe
Therapy
exacerbations given
Corticosteroids via
(prednisone or Treat forAmoxicillin/clavulanate
3 to 5 days 875 mg
nebulizer/inhaler PO Q12H
equivalent PO 40 mg/day for 5 days) Inpatient Primary
PLUS OR Recommendation:
if admitted OR have significant Amoxicillin/clavulanate 875 mg
Corticosteroids (prednisone or Doxycycline 100 mg PO Q12H
shortness of breath
equivalent PO 40 mg/day for 5 days)
PO Q12H
Methylprednisolone IV Q6-12H OR Penicillin Allergy or Treatment
if admitted OR have significant Failure with
may be used initially Doxycycline 100Primary Regimen:
mg PO Q12H
shortness of breath Moxifloxacin 400 mg PO Q24H**
Penicillin Allergy or Treatment
Methylprednisolone IV Q6-12H
2. Consider obtaining sputum culture Failure with Primary Regimen:
may be used initially Treat for 5 days
Moxifloxacin 400 mg PO Q24H**
AND treat with an antimicrobial
2. Consider
based onobtaining sputum culture
clinical severity Treat for 5 days
AND treat with
If patient hasan antimicrobial
only an acute increase
based on clinical severity
in 1 cardinal symptom no antibiotic
If patient has only an acute increase
therapy
in is recommended
1 cardinal symptom no antibiotic
therapy
3. Manage is recommended
risk factors:
3. Manage
Assessrisk
if patient
factors: is due for influenza
vaccineif patient is due for influenza
Assess
vaccine
Smoking cessation counseling
Smoking cessation counseling
4. Inpatient: If worsening clinical status
4. Inpatient: If worsening clinical status
OR inadequate response in 72H:
OR inadequate response in 72H:
re-evaluate AND obtain sputum
re-evaluate AND obtain sputum
culture ANDgram
culture AND gramstain
stain
DS=
DS= double strength;H=
double strength; H=hour(s);
hour(s);IV=IV= intravenous;
intravenous; PO=PO= by mouth;
by mouth; Q= every;
Q= every; SMX/TMP=
SMX/TMP= sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim
*In
*In patient withfrequent
patient with frequentexacerbations,
exacerbations,(> 4(>in4previous
in previous 12 months)
12 months) severe
severe airflow
airflow limitation,
limitation, and/orand/or exacerbations
exacerbations requiringrequiring
mechanical ventilation,FEV1
mechanical ventilation, FEV1< <50%,
50%, and/or
and/or cardiovascular
cardiovascular disease
disease
** Previously
** Previously failed
failedtherapy
therapywith azithromycin,
with doxycycline,
azithromycin, and and
doxycycline, a beta- lactam
a beta- OR received
lactam treatment
OR received with thewith
treatment aforementioned
the aforementioned
antibiotics within
antibiotics withinthe
theprevious
previous9090
days OROR
days patient hashas
patient other comorbidities
other (i.e. chronic
comorbidities heart, heart,
(i.e. chronic liver, orliver,
renalordisease, diabetes,diabetes,
renal disease,
alcoholism, malignancy, asplenia, immunocompromised or on immunosuppressing drugs. An FDA advisory committee determined that
alcoholism, malignancy, asplenia, immunocompromised or on immunosuppressing drugs. An FDA advisory committee determined that
the risks of fluoroquinolone use in COPD exacerbation outweighed any potential benefit, and should not be a first-line agent.
the risks of fluoroquinolone use in COPD exacerbation outweighed any potential benefit, and should not be a first-line agent.
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based
NOTE: Dosing
on Renal based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based
Function
on Renal Function
References:
1. Vollenweider DJ, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec
References:
1. 12;12:CD010257.
Vollenweider DJ, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec
2. Vestbo J, et al. Global strategy for the diagnosis, manageent, and prevention of chronic obstructive pulmonary disease: GOLD executive
12;12:CD010257.
summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65.
2.
3. Vestbo J, et al. Global strategy
Food and Drug Administration. formeeting
Joint the diagnosis, manageent, Drugs
of the Antimicrobial and prevention of chronicand
Advisory Committee obstructive pulmonary
the Drug Safety & Risk disease: GOLD executive
Management
summary. Am J Respir
Advisory Committee Crit Care Med. Recording.
(DSaRM)-Webcast 2013 Feb 15;187(4):347-65.
2015.
3. Food and Drug Administration. Joint meeting of the Antimicrobial Drugs Advisory Committee and the Drug Safety & Risk Management
Advisory Committee (DSaRM)-Webcast Recording. 2015.
PAGE 14
Respiratory
Respiratory Tract:Tract: Pneumonia
Pneumonia
START HERE Does the patient presenting with
pneumonia have any risk factors for multidrug Received recent antibiotic therapy (previous 90
resistant organisms (MDROs): days), chemotherapy, OR wound care within
previous 30 days
Hospitalized for 2 days within previous 90 days
Chronic hemodialysis
Resides in a nursing home OR long-term care
Have immunosuppressive disease OR receiving
facility, OR skilled nursing facility
immunosuppressing medications

CLINICAL CONSIDERATIONS

Infiltrate on chest x-ray required for pneumonia diagnosis


Collect BAL OR PSB AND blood cultures prior to starting antimicrobial therapy
Re-assess antibiotic therapy on day 2 or 3 when cultures return from microbiology lab
Specific isolated pathogens should prompt clinicians to de-escalate treatment based on the
pathogen's susceptibility pattern
NO RISK FACTORS FOR MDROS RISK FACTORS FOR MDROS

INPATIENT NON-ICU INPATIENT


Ceftriaxone 1 gm IV Q24H Beta-lactam/beta-lactamase inhibitor:
AND Piperacillin-tazobactam 3.375 gm IV Q4H
Azithromycin 500 mg PO/IV for 1 day, then OR
250 mg PO/IV Q24H for 4 days Piperacillin-tazobactam 4.5 gm IV Q6H
OR OR
Moxifloxacin 400 mg IV/PO Q24H Antipseudomonal carbapenem:
Imipenem 500 mg IV Q8H
INPATIENT ICU
PLUS
Ceftriaxone 2 gm IV Q24H
AND Aminoglycoside (Preferred)
Moxifloxacin 400 mg IV Q24H Gentamicin 5-6 mg/kg (IBW) once daily
OR Tobramycin 5-6 mg/kg (IBW) once daily
Ampicillin/sulbactam 3 gm IV Q6H OR
AND Antipseudomonal fluoroquinolone:
Moxifloxacin 400 mg IV Q24H Levofloxacin 750 mg IV Q24H
OR Ciprofloxacin 400 mg IV Q8H
Penicillin-allergic patients: PLUS
Aztreonam 2 gm IV Q812H If at risk for MRSA:
AND
Moxifloxacin 400 mg IV Q24H Vancomycin 15 mg/kg IV
OR
Linezolid 600 mg IV/PO Q12H
(See Criteria for Use)

BAL= Bronchoalveolar Lavage; BP= blood pressure; bpm= beats or breaths per minute; CrCl= Creatinine Clearance; H= hour(s);
IBW= ideal body weight; ICU= Intensive Care Unit; IV= intravenous; MDRO= multi-drug resistant organism; MRSA= Methicillin-
Resistant S. aureus; PO= by mouth; PSB= Protected Specimen Brush; Q= every
Suspect P. aeruginosa: CrCl >50 ml/min = 3.375 gm q4h; CrCl 50-10 ml/min = 3.375 gm IV Q6H; CrCl < 10 ml/min = 3.375 gm

Q8H
Refer to Table of Contents for section on vancomycin and aminoglycoside dosing and monitoring
Note: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function.

PAGE 15
Respiratory Tract: Pneumonia
Respiratory
Respiratory Tract:
NO RISK FACTORS Tract: Pneumonia
Pneumonia
FOR MDRO S RISK FACTORS FOR MDROS

OUTPATIENTNO RISK FACTORS FOR MDROS OUTPATIENT RISK FACTORS FOR MDROS
Previously healthy AND no antibiotic use in Treat accordingly based on risk factors and
previous 90 days:
OUTPATIENT microbiologic
OUTPATIENT history
Previously healthy AND no antibiotic use in Treat accordingly based on risk factors and
Doxycycline 100 mg PO Q12H for 5 days Consider paging Infectious Diseases
previous 90 days: microbiologic history
OR
Azithromycin 500mg
Doxycycline 100 mgPO
POQ12H
for 1 for
dose, then
5 days Consider paging Infectious Diseases
250
OR mg PO Q24H for 4 days
Azithromycin 500 mg PO for 1 dose, then
OUTPATIENT
250 mg PO Q24H for 4 days
Presence of 1 co-morbidities* OR antibiotic
OUTPATIENT
use in previous 30 days:
Presence of 1 co-morbidities* OR antibiotic
Moxifloxacin 400 mg PO Q24H for 5 to 7 days
use in previous 30 days:
OR
Amoxicillin
Moxifloxacin 1 gm
400PO mgQ8H for 5 to
PO Q24H for7 5days
to 7 days
OR
OR
Amoxicillin/clavulanate
Amoxicillin 1 gm PO Q8H 875
formg
5 toPO7 Q12H
days
for
OR 5 to 7 days
AND
Amoxicillin/clavulanate 875 mg PO Q12H
Azithromycin
for 5 to 7 days500 mg PO for 1 dose, then
250
ANDmg PO Q24H for 4 days
Azithromycin 500 mg PO for 1 dose, then
250 mg PO Q24H for 4 days THERAPY CONSIDERATIONS
Cough and chest X-ray may take 4 to T6HERAPY weeksCto improve/change
ONSIDERATIONS
Duration of therapy
Cough and
Community-acquired
chest X-ray may take pneumonia: 57 to
4 to 6 weeks daysimprove/change
Healthcare-associated
Duration of therapy pneumonia, hospital-acquired pneumonia, ventilator-associated
pneumonia: 78 days;pneumonia:
Community-acquired provided that the
57 targeted pathogen is identified based on
days
bronchoscopy and the etiologic
Healthcare-associated pneumonia,pathogen is not P. aeruginosa,
hospital-acquired pneumonia, andventilator-associated
that the patient is:
afebrile
pneumonia:for 4878
to days;
72 hoursprovided that the targeted pathogen is identified based on
AND 1 of theand
bronchoscopy the etiologic pathogen is not P. aeruginosa, and that the patient is:
following:
HR >100 for
afebrile bpm,48 RR >24hours
to 72 bpm, BP < 90 mmHg (systolic), O2 sat <90%, altered mental status
AND 1 of the following:
BP= blood pressure; bpm= beats or breaths per minute; H= hour(s); HR= heart rate; IV= intravenous; MDRO= multi-drug
HR >100 bpm, RR >24 bpm, BP < 90 mmHg (systolic), O2 sat <90%, altered mental status
resistant organism; PO= by mouth; Q= every; RR= respiratory rate
BP= blood of
*Presence pressure; bpm= beats
comorbidities: or breaths
chronic per minute;
heart, lung, liver or H= hour(s);
renal HR=diabetes;
disease; heart rate; IV= intravenous;
alcoholism; MDRO=asplenia;
malignancies; multi-drug
resistant organism; PO=
immunosuppressing by mouth;
conditions Q= every; RR= respiratory rate
or medications
*Presence
Note: of based
Dosing comorbidities:
on normalchronic heart, lung,
renal function. livertoorTable
Refer renalof
disease; diabetes;
Contents alcoholism;
for section malignancies;
on Antimicrobial asplenia;
Dosing for Adult
immunosuppressing
Patients conditions
Based on Renal or medications
Function.
Note: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function.

References:
1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the
management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72
References:
2. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired,
1. Mandell LA, Wunderink
ventilator-associated, RG,
and Anzueto A, et al. Infectious
healthcare-associated Diseases
pneumonia. Am JSociety
Respir of
CritAmerica/American Thoracic
Care Med. 2005 Feb Society consensus guidelines on the
15;171(4):388-416.
management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72
2. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired,
ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. PAGE 16
Sepsis
Sepsis
IV Antibiotics:
If the patient is pregnant, contact pharmacy or
Infectious Diseases for assistance regarding Antibiotics should be ordered AFTER a review
safety and dosage of previous microbiology data present in
Penicillin allergic or optional antibiotic choices patients electronic medical record
are listed second and italicized Risk Factors for MRSA,VRE, and ESBL include:
Antibiotics should be adjusted for weight and - Hospitalization within the past year
renal function in ALL patients - Patient receives hemodialysis
- Consult pharmacy or Infectious Diseases if - Oozing or open wound
needed for assistance in monitoring - Past history of documented MRSA, VRE, or
therapeutic drug level ESBL
- Patient is a nursing home resident
Administer antibiotics within FIRST HOUR of - Patient has a catheter or line present
recognition of sepsis

SUSPECTED Clostridium difficile INFECTION

Vancomycin 500 mg PO/NGT x1 NOW PLUS Metronidazole 500 mg IV x1 NOW

SUSPECTED RESPIRATORY SOURCE SUSPECTED URINARY SOURCE SUSPECTED INTRA-ABDOMINAL SOURCE

Azithromycin 500 mg IV x1 NOW Piperacillin/tazobactam 3.375 gm Piperacillin/tazobactam 3.375 gm


PLUS IV x1 NOW IV x1 NOW
Ceftriaxone 2 gm IV x1 NOW OR OR
OR If risk factors for MDR GNR or If risk factors for MDR GNR or
Piperacillin/tazobactam 3.375 gm ESBL ESBL
IV x1 NOW Meropenem 2 gm x1 NOW Meropenem 2 gm IV x1 NOW
OR
If risk factors for MRSA
If risk factors for MDR GNR or
Vancomycin 25-30 mg/kg ABW*
ESBL
IV LD x1 NOW
Meropenem 2 gm x1 NOW
If risk factors for VRE
If risk factors for MRSA
Daptomycin 8-10mg/kg (ABW) x1
Vancomycin 25-30 mg/kg ABW*
NOW & Consult ID
IV LD x1 NOW
If penicillin allergy, may consider consulting ID or substituting meropenem 2gm x1 NOW for other beta
lactams (monitor; 5% cross-reactivity with penicillins).
ABW= Actual Body Weight; ESBL= Extended Spectrum Beta-Lactamase; ID= Infectious Diseases; IV= intravenous; LD= loading
dose; MDR GNR= Multi-Drug Resistant Gram-Negative Rods; MRSA= Methicillin-Resistant S. aureus; NGT= Nasogastric tube;
PO= By Mouth; VRE= Vancomycin Resistant Enterococcus

*Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients

PAGE 17
Symptomatic
SymptomaticSexually
SexuallyTransmitted
TransmittedInfection
InfectionScreening
Screening
SYMPTOMATIC

Clinical and Therapeutic


Symptoms Recommended Diagnostic Testing
Considerations

Female Vaginal itching Vaginal examination: Promptly begin empiric


Vaginal Sexually
Symptomatic discharge Transmitted Infection
1. Observe vaginal anatomyScreening
treatment of Chlamydia and
Painful urination 2. Gram stain for bacterial Gonorrhea before lab results
Increased urinary vaginosis return
SYMPTOMATIC
urgency 3. Vaginal swabs for PCR assay:
Pelvic pain Gonorrhea Clinical Vaginal exam will allow
and Therapeutic
PainSymptoms
with sexual Recommended Diagnostic Testing
Chlamydia visualization of vaginal
Considerations
intercourse 4. Vaginal swabs for Affirm DNA anatomy
Female Vaginal itching Vaginal examination: Promptly begin empiric
Vaginal bleeding
Vaginal discharge Trichomoniasis
1. Observe vaginal anatomy treatment of Chlamydia and
Genital warts
Painful urination 5. HIV
2. Gram staintest
for bacterial Gonorrhea Vaginal orresults
before lab cervical swab may
Genital
Increasedlesion/ulcer
urinary 6. Syphilis (RPR screen/ titer) return
vaginosis be necessary for specific test
Pharyngitis
urgency 3. Vaginal swabs
7. Urinalysis for PCR assay: kits
Pelvic pain 8. Pregnancy
Gonorrhea Test Vaginal exam will allow
Pain with sexual Chlamydia visualization of vaginal
intercourse
9. Oropharyngeal (OP) Cultureanatomy
4. Vaginal swabs for Affirm DNA
Vaginal bleeding swab for GC when indicated
Trichomoniasis
Genital warts 5. HIV test Vaginal or cervical swab may
Genital lesion/ulcer 6. Unable(RPR
Syphilis to perform vaginal
screen/ titer) be necessaryPromptly
for specificbegin
test empiric
Pharyngitis 7. examination:
Urinalysis kits treatment of Chlamydia and
8. 1. Urinalysis
Pregnancy Test Gonorrhea before lab results
9. Oropharyngeal
2. Urine for(OP)PCRCulture
assay: return
swab for GC when indicated
Gonorrhea
Chlamydia
Unable to perform vaginal Promptly begin empiric
3. HIV test
examination: treatment of Chlamydia and
1. Urinalysis
4. Syphilis (RPR screen/titer) Gonorrhea before lab results
2. Urine for PCR assay:
5. Pregnancy Test return
Gonorrhea
6. OP Culture for GC when
Chlamydia
indicated
3. HIV test
4. Syphilis (RPR screen/titer)
Male Penile discharge 1. Urinalysis
5. Pregnancy Test Promptly begin empiric
Painful urination 2. Culture
6. OP Urinefor
forGC
PCR assay:
when treatment of Chlamydia and
Increased urgency indicated Gonorrhea Gonorrhea before lab results
Pelvic pain Chlamydia return
Male Penile discharge 1. Urinalysis Promptly begin empiric
Swollen/tender
Painful urination 3. HIV
2. Urine testassay:
for PCR treatment of Chlamydia and
testicles
Increased urgency 4. Syphilis (RPR screen/ titer)
Gonorrhea Gonorrhea before lab results
Pain
Pelvicwith
pain sexual 5. OP Culture Swab or Rectal
Chlamydia return
Swollen/tender
intercourse 3. HIV test
culture swab for GC when
testicles
Genital warts 4. Syphilis (RPR screen/ titer)
indicated
Pain with sexual 5. OP Culture Swab or Rectal
Genital lesion/ulcer
intercourse culture swab for GC when
Pharyngitis
Genital warts indicated
Genital lesion/ulcer
TREATMENT (DISCUSS TREATMENT OF PREGNANT WOMEN WITH ID AND OB/GYN)
Pharyngitis

Gonorrhea TREATMENTCeftriaxone 250 OF


(DISCUSS TREATMENT IM AND
mgPREGNANT Azithromycin
WOMEN 1 gm PO x 1 dose
WITH ID AND OB/GYN)

Chlamydia
Gonorrhea
OR doxycycline 100 mg PO Q12H for 7 days
Ceftriaxone 250 mg IM AND Azithromycin 1 gm PO x 1 dose
Chlamydia OR doxycycline 100 mg PO Q12H for 7 days
Penicillin Allergy (anaphylaxis): Consult ID
Penicillin Allergy (anaphylaxis): Consult ID
HIV or Syphilis Consult Infectious Diseases
HIV or Syphilis Consult Infectious Diseases
Bacterial vaginosis Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at
Bacterial vaginosis Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at
bedtime
bedtime for 5for 5 days
days

Alternatives:
Alternatives: Metronidazole
Metronidazole 500 mg 500 mg PO
PO Q12H OR Q12H OR clindamycin
clindamycin 300 mg PO Q12H
300 mg PO Q12H
forfor
7 days
7 days
Trichomonas vaginalis Metronidazole 2 gm PO x 1 dose OR metronidazole 500 mg PO Q12H for 7 days
Trichomonas vaginalis Metronidazole 2 gm PO x 1 dose OR metronidazole 500 mg PO Q12H for 7 days
DNA= deoxyribonucleic acid; GC= gonococcus; H= hours; HIV= human immunodeficiency virus; ID= infectious diseases; IM= intramuscular;
DNA= deoxyribonucleic
OB/GYN= acid; GC=
obstetrics/gynecology; OP=gonococcus; H=PCR=
Oropharyngeal; hours; HIV= human
Polymerase immunodeficiency
chain reaction; virus;
PO= by mouth; ID= infectious
Q= every; RPR= rapiddiseases; IM= intramuscular;
plasma reagin;
STI= sexually
OB/GYN= transmitted infection. OP= Oropharyngeal; PCR= Polymerase chain reaction; PO= by mouth; Q= every; RPR= rapid plasma reagin;
obstetrics/gynecology;
STI= sexually transmitted infection.
PAGE 18
Asymptomatic
AsymptomaticSexually
SexuallyTransmitted
TransmittedInfection
InfectionScreening
Screening
ASYMPTOMATIC
Screening Clinical and Therapeutic
Population Frequency
Recommendations Considerations
Female Age 25 Urine PCR for Chlamydia Annually Cervical screening should be
performed 3 years after
Urine PCR for Gonorrhea Annually initiating sexual activity or no
HIV test At least once later than age 21
Cervical Screening No later than
age 21

Age > 25 No routine screening for Consider minimum of annual


STIs screening if high risk* patient
Screen according to risk

Pregnant Urine PCR for Chlamydia First trimester Repeat Screening


(all pathogens) in 3rd trimester
Urine PCR for Gonorrhea First trimester and at birth if patient is high
HIV test First trimester risk*
Hepatitis B S Ag, S Ab, C Ab First trimester
Hepatitis C Ab First trimester
Syphilis RPR/titer First trimester

HIV-positive Urine PCR for Chlamydia Annually *Consider rectal and


pharyngeal culture swabs for
Urine PCR for Gonorrhea* Annually GC if exposed
Syphilis RPR/titer Annually
May repeat screening every
Trichomoniasis Annually
3-6 months, as indicated by
Hepatitis B S Ag, S Ab, C Ab Baseline risk
Hepatitis C Ab Yearly if high
risk*

EPT= expedited partner treatment; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody;
Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Antibody; HIV= human immunodeficiency virus;
MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma reagin; STI= sexually transmitted
infection
Test of Cure/ Retest Post Diagnosis and Treatment of Gonorrhea or Chlamydia
- Retest all patients after 3 months for reinfection (if 3 months not possible, within 1 year).
- Retest all pregnant patients a minimum of >/=3 weeks after completion of therapy.
- If suspect treatment failure, reinfection , or failure due to alternative regimen then repeat testing at a minimum of
>/= 3weeks after completion of therapy.
- For pharyngeal gonorrhea get test of cure on all patients after 14 days. Culture and susceptibilities preferred.

Note: Gonnorrhea/Chlamydial PCR <3 weeks from completion of therapy are not recommended due to presence of non-viable
organisms and false-positive results.

STIs: Partner Treatment


-Any recent sexual partner who has had contact with the infected patient within 60 days of their diagnosis should be considered
for treatment.
-Discuss treatment of partners or questions regarding Expedited Partner Treatment (EPT) with the Infectious Disease Service.
-EPT should not be employed with MSMs (these patients should be referred for comprehensive STI testing first).

*Definition of High Risk


Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
recent sex contact outside the US.

PAGE 19
Asymptomatic Sexually Transmitted Infection Screening
Asymptomatic
AsymptomaticSexually
SexuallyTransmitted
Transmitted Infection Screening
ASYMPTOMATICInfection Screening
Screening
ASYMPTOMATIC Frequency Clinical and Therapeutic
Population
Recommendations Considerations
Screening Clinical and Therapeutic
Male Population
Heterosexual No routine screening Frequency
for STIs. Screen according to *risk.
men Recommendations
Note: Considerations
All Babyboomers (Patients born from 1945 through 1965) should be
screened for HCV
Male Heterosexual No routine screening for STIs. Screen according to *risk.
men who have
Men Note: All Babyboomers (Patients born from 1945 through
Consider 1965)culture,
GC/Chl should be
Urine PCR for Chlamydia Annually
screened for HCVrectal and pharyngeal swabs
sex with men
(MSM) Urine PCR for Gonorrhea Annually
Men who have Urine PCR for Chlamydia Annually Consider GC/Chl culture,
OR
sex with men HIV test Annually High
rectalriskanddefined as: swabs
pharyngeal
*high
(MSM)risk Urine PCR for Gonorrhea Annually - New or multiple sex
Hepatitis B S Ag, S Ab, C Ab Baseline
heterosexual
OR men HIV test Annually Highpartners
risk defined as:
Hepatitis C Ab Annually -- Inconsistent condom
*high risk New or multiple sex use
Hepatitis B S Ag, S Ab, C Ab Baseline - Commercial sex work
heterosexual men Syphilis (RPR screen/ titer) Annually partners
Hepatitis C Ab Annually -- Drug use
Inconsistent condom use
Syphilis (RPR screen/ titer) Annually - Commercial sex work
May repeat
- Drug use screening every
3-6 months, as indicated by
risk
May repeat screening every
HIV-positive men 3-6 months,
Consider as indicated
GC/Chl culture, by
Urine PCR for Chlamydia Annually risk and pharyngeal swabs
rectal
Urine PCR for Gonorrhea Annually
HIV-positive men Urine PCR for Chlamydia Annually Consider GC/Chl culture,
Syphilis (RPR screen/ titer) Annually May
rectalrepeat screening every
and pharyngeal swabs
Urine PCR for Gonorrhea Annually 3-6 months, as indicated by
Hepatitis B S Ag, S Ab, C Ab Baseline
Syphilis (RPR screen/ titer) Annually risk
May repeat screening every
Hepatitis C Ab Annually
3-6 months, as indicated by
Hepatitis B S Ag, S Ab, C Ab Baseline
risk
GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface
Hepatitis C Ab Annually
Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Core Antibody; HIV= human immunodeficiency virus;
MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection.
GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface
Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Core Antibody; HIV= human immunodeficiency virus;
*Definition
MSM= Men whoof High Riskwith men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection.
have sex
Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
*Definition
recent of Highoutside
sex contact Risk the US.
Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
recent sex contact outside the US.

References:
1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human
Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
References:
2. "Primary, Secondary, and Early Latent Syphilis Surveillance 2007-2011." Division of Infectious Disease & Epidemiology. Rhode Island Department
1. of
"Sexually
Health,Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human
2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf.
Services, 17Sexually
3. California Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
Transmitted Disease (STD) Screening Recommendations 2010. California Department Of Public Health, June. 2011. URL:
2. http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf
"Primary, Secondary, and Early Latent Syphilis Surveillance 2007-2011." Division of Infectious Disease & Epidemiology. Rhode Island Department
of Health, 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf.
3. California Sexually Transmitted Disease (STD) Screening Recommendations 2010. California Department Of Public Health, June. 2011. URL:
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf PAGE 20
Asymptomatic Sexually Transmitted Infection Screening
Asymptomatic
AsymptomaticSexually
SexuallyTransmitted
Transmitted Infection Screening
HIV testing Infection Screening
Population Frequency Special Considerations
HIV testing
Population Frequency Consider
Special frequent testing if high
Considerations
All women age 13-64 Baseline
risk*
Consider frequent testing if high
All women age 13-64 Baseline
Consider PREP if HIV+ partner
risk*
All women who seek STI screening At time of STI
(Consult ID)
Consider PREP if HIV+ partner
All women who seek STI screening At time of STI
Third trimester
(Consult ID) and at birth if high
All pregnant women First Trimester
risk
Third trimester and at birth if high
All pregnant women First Trimester
Consider frequent testing if high
risk
All men age 13-64 Baseline
risk*
Consider frequent testing if high
All men age 13-64 Baseline
Q3-6 months if higher risk activity
risk*
MSM Annually (minimum)
(Consider PREP and consult ID)
Q3-6 months if higher risk activity
MSM Annually (minimum)
Consider PREP
(Consider PREPifand
HIV+ partner
consult ID)
All men who seek STI screening At time of STI
(consult ID)
Consider PREP if HIV+ partner
All men who seek STI screening At time of STI
HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP= pre-exposure prophylaxis; Q= every;
(consult ID)
RPR= rapid plasma regain; STI= sexually transmitted infection.
HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP= pre-exposure prophylaxis; Q= every;
*Definition of High
RPR= rapid plasma RiskSTI= sexually transmitted infection.
regain;
Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
*Definition
inconsistentof High Risk
condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
Those
recentwho have a new
sex contact sex the
outside partner,
US. >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI ,
inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs,
recent sex contact outside the US.

References:
1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human
Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
References:
2. "Sexually
1. "Primary, Transmitted
Secondary, and Early Latent
Diseases Syphilis
Treatment Surveillance
Guidelines, 2007-2011."
2015." Centers forDivision
DiseaseofControl
Infectious
andDisease & Epidemiology.
Prevention. Department Rhode Island
of Health andDepartment
Human
of Health,17
Services, 2011.
Dec.URL:
2010.http://www.health.ri.gov/data/diseases/Syphilis.pdf.
URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf.
3. "Primary,
2. CaliforniaSecondary,
Sexually Transmitted Disease
and Early Latent (STD) Surveillance
Syphilis Screening Recommendations 2010.
2007-2011." Division California Disease
of Infectious Department Of Public Health,
& Epidemiology. RhodeJune. 2011.
Island URL:
Department
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf
of Health, 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf.
3. California Sexually Transmitted Disease (STD) Screening Recommendations 2010. California Department Of Public Health, June. 2011. URL:
http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf PAGE 21
Skin and Soft Tissue Infections (SSTI)
Skin and
Skin and SoftSoft
TissueTissue Infections
Infections (SSTI)
NONPURULENT
(SSTI)
Necrotizing Infection/Cellulitis/Erysipelas
NONPURULENT
[Usually Streptococcus
Necrotizing pyogenes (Group A Strep)]
Infection/Cellulitis/Erysipelas
[Usually Streptococcus pyogenes (Group A Strep)]
Mild: Moderate: Severe:
No systemic (any of Severe:
the following):
Mild: signs Systemic signs of
Moderate: Systemic signs of infection*,
Noofsystemic
infection*
signs infection*
Systemic signs of (any of the following):
failed antibiotic treatment,
of infection* infection* Systemic signs of infection*,
immunocompromise,
failed antibiotic treatment,
Intravenous hemodynamic instability, or
Oral immunocompromise,
deep infection
Antibiotic Antibiotic Therapy
Intravenous hemodynamic instability, or
OralTherapy deep infection
Antibiotic Therapy Antibiotic Therapy
Intravenous Antibiotic Therapy
Select ONE: Select ONE: Intravenous Antibiotic Therapy
Penicillin VK Penicillin
Select ONE: Select ONE: Emergent Surgical
250-500 mg PO Q6H 2-4 million units IV
Penicillin VK Penicillin Inspection/Debridement
Cephalexin Q4-6H Emergent Surgical
250-500 mg PO Q6H 2-4 million units IV Rule out necrotizing
500 mg PO Q6H Ceftriaxone Inspection/Debridement
Cephalexin Q4-6H process
Dicloxacillin 1 gm IV Q24H Rule out necrotizing
500 mg PO Q6H Ceftriaxone Culture & Sensitivity
250 mg PO Q6H Cefazolin process
Dicloxacillin 1 gm IV Q24H Empiric Treatment
Clindamycin 1 gm IV Q8H Culture & Sensitivity
250 mg PO Q6H Cefazolin Vancomycin 15 mg/kg
300-450 mg PO Q6H Clindamycin Empiric Treatment
Clindamycin 1 gm IV Q8H IV** PLUS
600-900 mg IV Q6H Vancomycin 15 mg/kg
300-450 mg PO Q6H Clindamycin Piperacillin/tazobactam
IV** PLUS
600-900 mg IV Q6H 3.375 gm IV Q6H
Piperacillin/tazobactam
+/-
3.375 gm IV Q6H
Clindamycin 900 mg IV
+/-
Q8H***
Clindamycin 900 mg IV
Q8H***
Defined Treatment (Necrotizing Infections)
Monomicrobial
Defined Treatment (Necrotizing Infections)
Streptococcus pyogenes
Monomicrobial
Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H
Streptococcus pyogenes
Vibrio vulnificus
Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H
Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H
Vibrio vulnificus
Aeromonas hydrophila
Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H
Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H
Aeromonas hydrophila
Polymicrobial
Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H
Vancomycin 15 mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H
Polymicrobial
Vancomycin
H= hours; IV= intravenous; mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H
15every
PO= oral; Q=

*Systemic
H= hours;signs of infection include,
IV= intravenous; PO= oral;but
Q=are not limited to, temperature >38C, tachycardia (heart rate >90 beats per minute),
every
tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/L).
*Systemic
**Refer to signs
sectionof on
infection include,
Vancomycin but are
Dosing andnot limited to,intemperature
Monitoring >38C, tachycardia (heart rate >90 beats per minute),
Adult Patients.
tachypnea (respiratory
***Consider rate
this addition for>24 breaths per
necrotizing minute) or abnormal white blood cell count (>12 000 or <4000 cells/L).
fasciitis.
**Refer to section on Vancomycin Dosing and Monitoring in Adult Patients.
Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in
***Consider
patients withthis addition
renal for necrotizing fasciitis.
impairment.
Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in
patients with renal impairment.
References:
1. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin
and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2): e10-52.
References:
2.
1. Duong
StevensM,DL,Markwell
Bisno AL, S, Chambers
Peter J, Barenkamp S. Randomized,
HF, Dellinger EP, Goldsteincontrolled
EJ, GorbachtrialSL,ofetantibiotics
al. Practicein guidelines
the management
for the of community-acquired
diagnosis skinof skin
and management
abscesses in theinfections:
and soft tissue pediatric patient.
2014 updateAnn Emerg
by the Med
Infectious 55:4017.Society of America. Clin Infect Dis. 2014; 59(2): e10-52.
2010; Diseases
3.
2. Macfie
Duong M,J, Harvey
MarkwellJ. The treatment
S, Peter of acute superficial
J, Barenkamp abscesses:
S. Randomized, a prospective
controlled clinical trial.
trial of antibiotics Br Jmanagement
in the Surg 1977; 64:2646.
of community-acquired skin
4. Llera JL, Levy
abscesses RC. pediatric
in the Treatment Ann Emerg
of cutaneous
patient. Meda2010;
abscess: double-blind
55:4017.clinical study. Ann Emerg Med 1985; 14:159.
5.
3. Rutherford WH, Hart
Macfie J, Harvey J. TheD,treatment
Calderwood of JW, Merrett
acute JD. Antibiotics
superficial abscesses:ina surgical
prospective treatment
clinicaloftrial. Br Jlesions.
septic Lancet
Surg 1977; 1970; 1:107780.
64:2646.
6.
4. Schmitz
Llera JL, GR,
LevyBruner D, Pitotti of
RC. Treatment R, cutaneous
et al. Randomized
abscess:controlled trial of
a double-blind clinical study. Ann Emerg Med 1985;
trimethoprim-sulfamethoxazole for14:159.
uncomplicated skin abscesses in
5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970;
patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:2837.
1:107780.
6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in
patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:2837.
PAGE 22
Skin and
Skin and SoftSoft
TissueTissue Infections
Infections (SSTI) (SSTI)
Skin and Soft Tissue Infections (SSTI)
PURULENT
Furuncle/Carbuncle/Abscess
(Usually Staphylococcus
PURULENT aureus)
Furuncle/Carbuncle/Abscess
Mild: Moderate: aureus)
(Usually Staphylococcus Severe:
No systemic signs Systemic signs of (any of the following):
Mild:
of infection* Moderate:
infection* Severe:
Failed I&D and oral
No systemic signs Systemic signs of (anyantibiotics,
of the following):
systemic
of infection*
No infection* Failed I&D
signs ofand oral
infection*,
Antibiotic
Incision and Drainage antibiotics, systemic
immunocompromise,
No
Therapy and C&S signs hemodynamic
of infection*,
Antibiotic
Incision and Drainage immunocompromise,
and C&S instability, or deep
Therapy hemodynamic
Oral infection
instability, or deep
Antibiotic infection
Incision and Drainage Oral
Therapy
Antibiotic Incision and Drainage
Incision and Drainage Therapy andDrainage
C&S
Incision and
and C&S
Empiric Therapy (select ONE):
TMP/SMX
Empiric Therapy 1-2 DS tablets
(select ONE): PO Q12H Intravenous
TMP/SMX
Doxycycline1-2100 mg POPO
DS tablets Q12H
Q12H Antibiotic
Intravenous
Defined Therapy
Doxycycline 100 mg PO Q12H Therapy
Antibiotic
MRSA Therapy
Defined Therapy
TMP/SMX (see empiric dose)
MRSA
MSSA
TMP/SMX
(select(see empiric dose)
ONE):
MSSA (select ONE):
Dicloxacillin 500 mg PO Q6H
Dicloxacillin
Cephalexin 500
500mgmgPOPOQ6H
Q6H
Cephalexin 500 mg PO Q6H

Empiric Therapy (select ONE):


Empiric Therapy (select ONE):
Vancomycin 15 mg/kg IV**
Vancomycin 15 mg/kg IV**
Daptomycin 6 mg/kg IV Q24H
Daptomycin 6 mg/kg IV Q24H
Linezolid 600 mg IV Q12H
Linezolid 600 mg IV Q12H
Ceftaroline
Ceftaroline
600600 mgQ12H
mg IV IV Q12H
Defined
Defined Therapy
Therapy
MRSA
MRSA
SeeSee empiric
empiric therapy
therapy above
above
MSSA
MSSA (select
(select ONE):ONE):
Nafcillin
Nafcillin
1-2 1-2
gm gm IV Q4H
IV Q4H
Cefazolin
Cefazolin
1 gm1 gm IV Q8H
IV Q8H
Clindamycin
Clindamycin 600600
mg IV
mgQ8H
IV Q8H

C&S=
C&S= cultureand
culture andsensitivity;
sensitivity; DS=
DS= double-strength;
double-strength; H=
H=Hours;
Hours;I&D=
I&D=incision andand
incision drainage; IV= intravenous;
drainage; MRSA=
IV= intravenous; methicillin-
MRSA= methicillin-
resistantStaphylococcus
resistant Staphylococcusaureus;
aureus; MSSA=
MSSA= methicillin-susceptible
methicillin-susceptible Staphylococcus
Staphylococcusaureus; PO=PO=
aureus; by mouth; Q= every;
by mouth; Q= every;
Rx= treatment; TMP/SMX= trimethoprim-sulfamethoxazole
Rx= treatment; TMP/SMX= trimethoprim-sulfamethoxazole
*Systemic signs of infection, but are not limited to, include temperature >38C, tachycardia (heart rate >90 beats per minute),
*Systemic signs of infection, but are not limited to, include temperature >38C, tachycardia (heart rate >90 beats per minute),
tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/L).
tachypnea
**Refer to(respiratory rate >24 breaths
section on Vancomycin Dosingper
andminute) or abnormal
Monitoring white blood
in Adult Patients.
cell count (>12 000 or <4000 cells/L).
**Refer to section on Vancomycin Dosing and Monitoring in Adult Patients.
References:
References:
1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update
1. Stevens
by the DL, Bisno AL,
Infectious Chambers
Diseases SocietyHF,
ofet
America. Clin Infect
al. Practice Dis. 2014;
guidelines for the diagnosis
59(2): e10-52. and management of skin and soft tissue infections: 2014 update
2.byDuong M, Markwell
the Infectious S, Peter
Diseases J, Barenkamp
Society S. Randomized,
of America. controlled
Clin Infect Dis. 2014; trial
59(2):of e10-52.
antibiotics in the management of community-acquired skin
2. Duongabscesses in the pediatric
M, Markwell S, Peterpatient. Ann Emerg
J, Barenkamp Med 2010; 55:4017.
S. Randomized, controlled trial of antibiotics in the management of community-acquired skin
3.abscesses
Macfie J,inHarvey J. The treatment
the pediatric patient. of
Annacute superficial
Emerg Med 2010;abscesses: a prospective clinical trial. Br J Surg 1977; 64:2646.
55:4017.
3. 4.Macfie
Llera JL, Levy RC.J. Treatment
J, Harvey of cutaneous
The treatment of acuteabscess: a double-blind
superficial abscesses:clinical study. Ann
a prospective Emergtrial.
clinical MedBr1985; 14:159.
J Surg 1977; 64:2646.
4. 5.Llera
Rutherford
JL, Levy WH, Hart D, Calderwood
RC. Treatment JW, Merrett
of cutaneous abscess: JD.aAntibiotics in surgical
double-blind clinicaltreatment
study. Ann of Emerg
septic lesions. Lancet
Med 1985; 1970; 1:107780.
14:159.
6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in
5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970; 1:107780.
patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:2837.
6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in
patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:2837.
PAGE 23
Skin
Skinand
andSoft
SoftTissue:
Tissue: Diabetic
Diabetic Foot
Foot Infections
Infections
RECOMMENDED EMPIRICAL
SEVERITY OF INFECTION SUSPECTED ORGANISMS DURATION
TREATMENT
Mild MSSA Oral 12 weeks
Only skin and Streptococcus spp. Amoxicillin/clavulanate 875 mg
subcutaneous tissue PO Q12H
involvement OR
AND Cephalexin 500 mg PO Q6H
Erythema > 0.5 cm and OR
2 cm around ulcer Dicloxacillin 250 500 mg PO
Perform incision and Q6H
drainage as necessary
MRSA Doxycycline 100 mg PO Q12H
OR
SMX/TMP 2 DS tablets PO Q12H
(Does not cover Group A Strep)
Moderate** MSSA Oral OR Initially Parenteral 13 weeks
Deeper tissue Streptococcus spp. Ampicillin-sulbactam 1.53 gm IV
involvement Enterobacteriaceae Q6H
OR Obligate anaerobes OR
Erythema > 2.0 cm Ceftriaxone 1 gm IV Q24H
around ulcer
Penicillin Allergy:
AND
No systemic signs of Ciprofloxacin 500 mg PO Q12H
infection AND
Perform incision and Clindamycin 300 mg PO Q6H
drainage as necessary OR
Ceftriaxone 1 gm IV Q24H
MRSA Linezolid 600 mg IV/PO Q12H
(Requires ID Consult)
OR
Daptomycin 6 mg/kg IV Q24H
(Requires ID Consult)
OR
Vancomycin 15 mg/kg IV*
Pseudomonas Piperacillin-tazobactam
aeruginosa 3.375 gm IV Q4H

DS= Double Strength; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin sensitive S. aureus;
PO= by mouth; Q= every; SMX-TMP= sulfamethoxazole/trimethoprim; spp= species

Restricted Antibiotic refer to Table of Contents for Guidelines for Restricted Antimicrobials
* Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
** Consult Infectious Diseases and Podiatry

NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function

PAGE 24
Skin and Soft Tissue: Diabetic Foot Infections
Skin
Skinand
andSoft
SoftTissue:
Tissue: Diabetic
Diabetic Foot
Foot
R
Infections
Infections
E ECOMMENDED MPIRICAL
SEVERITY OF INFECTION SUSPECTED ORGANISMS DURATION
TREATMENT
RECOMMENDED EMPIRICAL
SevereS**EVERITY OF INFECTION SUSPECTED ORGANISMS Initially Parenteral
MSSA/MRSA TREATMENT
DURATION
Same as moderate P. aeruginosa
Severe ** MSSA/MRSA Vancomycin 15 mg/kg
Initially Parenteral IV*
AND Streptococcus spp.
Same as moderate P. aeruginosa AND** 24 weeks
Systemic signs of infection Enterobacteriaceae Vancomycin 15 IV
mg/kg
AND Streptococcus spp. Cefepime 2 gm Q8HIV*
+
present Obligate anaerobes AND**
Systemic signs of infection Enterobacteriaceae metronidazole 500 mg IV Q6H 24 weeks
Systemic Inflammatory Cefepime 2 gm IV Q8H +
presentSyndrome (SIRS) Obligate anaerobes OR
Response metronidazole 500 mg IV Q6H
Systemic Piperacillin-tazobactam
Criteria 2Inflammatory
of the following: OR
Response Syndrome (SIRS) 3.375 gm IV Q4H
Temperature Piperacillin-tazobactam
Criteria 2 of the <96.8F
following:
OR >100.4F 3.375 gm IV Q4H
Bone OR Joint Involvement
Temperature
P > 90 BPM <96.8F
OR
RR >>100.4F
20 BPM SourceOR
Bone removed: 2-5 days
Joint Involvement
PPaCO
> 90 BPM
< 32 mmHg
2 Source removed: 2-5 residual
removed but days tissue infection:
RR
WBC> 20 BPM cells/mm
< 4000 1-3 weeks
PaCO 2 < 32 mmHg
OR >12,000 cells/mm Source removed but residual tissue infection:
WBC
10%< immature
4000 cells/mm
(band) Source
1-3 weeksremoved but residual bone infection:
OR
forms>12,000 cells/mm 4-6 weeks
Perform
10% immature (band) Source removed but residual bone infection:
incision and Source
4-6 weeksnot removed: 3 months
forms
drainage as necessary
Perform incision and Source not removed: 3 months
BPM= beats or breaths per minute; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin
drainage as necessary
sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic
Inflammatory
BPM= beats orResponse Syndrome;
breaths per minute; H=spp= species;
hour(s); IV=WBC= white blood
intravenous; MRSA=cellmethicillin resistant S. aureus; MSSA= methicillin
sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic
Restricted Antibiotic refer to Table of Contents for Guidelines
Inflammatory Response Syndrome; spp= species; WBC= white blood cell for Restricted Antimicrobials
* Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
**Restricted
Consult Infectious
AntibioticDiseases and
refer to Podiatry
Table of Contents for Guidelines for Restricted Antimicrobials
* Refer
Discuss
toplan
Tablewith Infectious
of Contents forDiseases, Podiatry,
section on and Vascular
Vancomycin Dosing and Monitoring in Adult Patients
** Consult Infectious Diseases and Podiatry
NOTE: Dosing based on normal renal function. Refer to
Discuss plan with Infectious Diseases, Podiatry, and Vascular Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function

References:
1. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73.
References:
1. Flagyl
2. Lipsky[package insert].
BA, Berendt AR, New York,
Cornia PB, NY:
Pile Pfizer; 2015.EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
JC, Peters
Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73.
2. Flagyl [package insert]. New York, NY: Pfizer; 2015. PAGE 25
Surgical Decolonization and Prophylaxis
Surgical Decolonization
Surgical Decolonization and Prophylaxis
and Prophylaxis
DECOLONIZATION
DECOLONIZATION
Nasal Screening Result Recommended Intervention
Nasal Screening Result Recommended Intervention
MRSA Negative No decolonization required
MSSA
MRSA Negative
Negative No decolonization required
MSSA Negative
MSSA Positive Intranasal mupirocin twice daily x 5 days
MSSA Positive Intranasal mupirocin twice daily x 5 days
MRSA Positive Intranasal mupirocin twice daily x 5 days,
MRSA Positive AND
Intranasal mupirocin twice daily x 5 days,
AND
Chlorhexidine bathing one day prior to surgery
Chlorhexidine
ANTIMICROBIAL bathing one day prior to surgery
PROPHYLAXIS
ANTIMICROBIAL PROPHYLAXIS
CLINICAL CONSIDERATIONS
Preoperative dose-timing CLINICAL CONSIDERATIONS
Within 60 minutes
Preoperative of surgical incision
dose-timing
Exceptions:
Within vancomycin
60 minutes and fluoroquinolones
of surgical incision within 120 minutes of surgical
incision
Exceptions: vancomycin and fluoroquinolones within 120 minutes of surgical
Weight-based
incision dosing
Cefazolin: 2 gm
Weight-based for patients <120 kg, and 3 gm for patients 120 kg
dosing
Vancomycin: usefor
Cefazolin: 2 gm ABWpatients <120 kg, and 3 gm for patients 120 kg
Gentamicin:
Vancomycin:use useABW
ABWunless ABW is >120% of their IBW, in which case use
AdjBW (see below
Gentamicin: use ABWfor equation)
unless ABW is >120% of their IBW, in which case use
Duration
AdjBW of prophylaxis
(see below for equation)
A singleof
Duration dose, or continuation for <24 hours is recommended
prophylaxis
A single dose, or continuationINTRA
for <24 hours isREDOSING
-OPERATIVE recommended

Required if the duration of procedure INTRA-OPERATIVE


exceeds two REDOSING
half-lives of the drug or if there
is extensive
Required blood
if the loss during
duration the procedure
of procedure exceeds (>1500 mL) of the drug or if there
two half-lives
Recommendation:
is extensive blood loss use during
the same theantibiotic
procedure dose and mL)
(>1500 measure
the redosing interval
from the time of administration of the preoperative
Recommendation: use the same antibiotic dose and measure dose, not the
the redosing
time of incision
interval
from
ABW= actualthe
bodytime
weight;of administration
AdjBW= of the
adjusted body weight; preoperative
IBW= ideal body weight;dose, not the time of
MRSA= Methicillin-resistant incision
Staphylococcus
aureus; MSSA= Methicillin-susceptible Staphylococcus aureus
ABW= actual body weight; AdjBW= adjusted body weight; IBW= ideal body weight; MRSA= Methicillin-resistant Staphylococcus
aureus; MSSA=
Redosing may Methicillin-susceptible Staphylococcus
not be necessary for patients with pooraureus
renal function (CrCl <30mL/min)

Redosing may not be necessary for patients with poor renal function (CrCl <30mL/min)
IBW Calculation: AdjBW Calculation:
Male = 50 kg + [2.3 kg for each inch over 5 feet] AdjBW = 0.4 (ABW-IBW) + IBW
IBW Calculation: AdjBW Calculation:
Female = 45 kg + [2.3 kg for each inch over 5 feet]
Male = 50 kg + [2.3 kg for each inch over 5 feet] AdjBW = 0.4 (ABW-IBW) + IBW
Female = 45 kg + [2.3 kg for each inch over 5 feet]

References:
1. Schweuzer ML, Chiang H, Septimus E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections
Among Patients Undergoing Cardiac, Hip, or Knee Surgery (STOP SSI Study to Optimally Prevent SSI in Select Cardiac and Orthopedic
References:
1. Procedures).
Schweuzer ML, JAMA 2015;
Chiang H, 313(21):
Septimus2162-2171.
E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections
2. Chen
Among AF,Patients
Wessel Undergoing
CB, Rao N. Staphylococcus
Cardiac, Hip, oraureus Screening
Knee Surgery andSSI
(STOP Decolonization in Orthopaedic
Study to Optimally PreventSurgery and Reduction
SSI in Select of Orthopedic
Cardiac and Surgical Site
Infections.
Procedures).ClinJAMA
Orthop Relat
2015; Res 2013;
313(21): 471: 2383-2399.
2162-2171.
3.
2. Bratzler
Chen AF,DW, Dellinger
Wessel EP,N.
CB, Rao Olsen KM, Perl TM,
Staphylococcus Auwaerter
aureus PG, Bolon
Screening MK, et al. Clinical
and Decolonization practice guidelines
in Orthopaedic Surgeryfor
andantimicrobial
Reduction ofprophylaxis
Surgical Sitein
surgery. AmClin
Infections. J Health
OrthopSyst Pharm
Relat Res 2013; 70:195-283.
471: 2383-2399.
3. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283.
PAGE 26
Antimicrobial Surgical Prophylaxis
Antimicrobial Surgical
Antimicrobial Surgical Prophylaxis
R Prophylaxis
R EDOSING ECOMMENDATIONS

Antibiotic REDOSING
Half-life R ECOMMENDATIONS
(hours) Redosing Interval (hours)

Ampicillin/sulbactam
Antibiotic 0.8-1.3 Half-life (hours) 2 Redosing Interval (hours)
Cefazolin
Ampicillin/sulbactam 1.2-2.2
0.8-1.3 42

Cefoxitin
Cefazolin 0.7-1.1
1.2-2.2 24
Ciprofloxacin
Cefoxitin 3-7
0.7-1.1 Not
2 necessary
Clindamycin
Ciprofloxacin 2-4
3-7 6Not necessary
Gentamicin
Clindamycin 2-3
2-4 Not
6 necessary
Metronidazole
Gentamicin 6-8
2-3 Not
Not necessary
necessary
Vancomycin
Metronidazole 4-8
6-8 Not
Not necessary
necessary
SURGICAL ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM
Vancomycin RECOMMENDED
4-8 AGENTS Not necessary
PROCEDURE ALLERGY
SURGICAL ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM
Laparoscopic, NoneRECOMMENDED AGENTS None
PROCEDURE ALLERGY
low-risk
Laparoscopic,
Laparoscopic, None
Cefazolin, cefoxitin, None
Clindamycin or vancomycin + aminoglycoside
low-risk
high-risk cefotetan, ceftriaxone, or aztreonam or fluoroquinolone
Laparoscopic, Cefazolin, cefoxitin,
ampicillin/sulbactam Clindamycin or vancomycin + aminoglycoside
high-risk cefotetan, ceftriaxone, or aztreonam or fluoroquinolone
Small intestine, Cefazolin
ampicillin/sulbactam Clindamycin + aminoglycoside or
nonobstructed aztreonam or fluroquinolone
Small intestine, Cefazolin Clindamycin + aminoglycoside or
nonobstructed
Small intestine, Cefazolin + metronidazole, aztreonam or fluroquinolone
Metronidazole + aminoglycoside or
obstructed cefoxitin, cefotetan fluoroquinolone
Small intestine, Cefazolin + metronidazole, Metronidazole + aminoglycoside or
obstructed
Hernia repair cefoxitin, cefotetan
Cefazolin fluoroquinolone
Clindamycin, vancomycin
Hernia repair
Colorectal Cefazolin + metronidazole,
Cefazolin Clindamycin,+vancomycin
Clindamycin aminoglycoside or
cefoxitin, cefotetan, aztreonam or fluroquinolone;
Colorectal Cefazolin + metronidazole,
ampicillin/sulbactam, Clindamycin + aminoglycoside
Metronidazole or or
+ aminoglycoside
cefoxitin, cefotetan,
ceftriaxone + aztreonam or fluroquinolone;
fluoroquinolone
ampicillin/sulbactam,
metronidazole, ertapenem Metronidazole + aminoglycoside or
ceftriaxone + fluoroquinolone
Head and neck, None
metronidazole, ertapenem None
Jen - this page is too
clean
Head and neck, None None
long. Youll
clean have
Head to Cefazolin, cefuroxime
and neck, Clindamycin
shortenplacement
it somehow.
of
Head and neck, Cefazolin, cefuroxime Clindamycin
prosthetic
placement of
prosthetic
Clean- Cefazolin + metronidazole, Clindamycin
contaminated cefuroxime +
Clean- surgery
cancer Cefazolin + metronidazole,
metronidazole, Clindamycin
contaminated cefuroxime +
ampicillin/sulbactam
cancer surgery metronidazole,
ampicillin/sulbactam

References:
1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283.
References:
1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283. PAGE 27
Antimicrobial Surgical Prophylaxis
Antimicrobial Surgical
Antimicrobial Surgical Prophylaxis
Prophylaxis ALTERNATIVES FOR PATIENTS WITH
SURGICAL PROCEDURE RECOMMENDED AGENTS
BETA-LACTAM ALLERGY
ALTERNATIVES FOR PATIENTS WITH
SURGICAL PROCEDURE RECOMMENDED AGENTS
Ortho: clean hand, None None BETA-LACTAM ALLERGY
knee, or foot not
Ortho: clean hand, None None
involving implantation
knee, or foot not
of foreign materials
involving implantation
Ortho: implantation
of foreign materials of Cefazolin Clindamycin, vancomycin
foreign material and/or
Ortho: implantation of Cefazolin Clindamycin, vancomycin
total joints
foreign material and/or
Urologic with risk
total joints Fluoroquinolone, Aminoglycoside +/- clindamycin
factors for infection TMP/SMX, cefazolin
Urologic with risk Fluoroquinolone, Aminoglycoside +/- clindamycin
Urologic,
factors forclean without
infection Cefazolin*
TMP/SMX, cefazolin Clindamycin, vancomycin
entry into urinary tract
Urologic, clean without Cefazolin* Clindamycin, vancomycin
Urologic
entry intoinvolving
urinary tract Cefazolin Clindamycin aminoglycoside or
implanted prosthesis aminoglycoside, aztreonam, vancomycin
Urologic involving Cefazolin Clindamycin aminoglycoside or
cefazolin aztreonam, aminoglycoside or aztreonam
implanted prosthesis aminoglycoside, aztreonam, vancomycin
ampicillin/sulbactam
cefazolin aztreonam, aminoglycoside or aztreonam
Urologic, clean with Cefazolin*
ampicillin/sulbactam Fluoroquinolone, aminoglycoside
entry into urinary tract clindamycin
Urologic, clean with Cefazolin* Fluoroquinolone, aminoglycoside
Urologic,
entry intoclean-
urinary tract Cefazolin + Fluoroquinolone,
clindamycin aminoglycoside +
contaminated metronidazole, cefoxitin metronidazole or clindamycin
Urologic, clean- Cefazolin + Fluoroquinolone, aminoglycoside +
contaminated metronidazole, cefoxitin
TMP/SMX= trimethoprim/sulfamethoxazole metronidazole or clindamycin

*Addition
TMP/SMX=oftrimethoprim/sulfamethoxazole
a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile
prosthesis)
*Addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile
prosthesis)

References:
1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283.
References:
1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195-283. PAGE 28
Urinary Tract:Catheter-Associated
Urinary Tract: Catheter-Associated Urinary
Urinary Tract
Tract Infection
Infection
CLINICAL
CLASSIFICATION CLINICAL FINDINGS RECOMMENDED EMPIRIC REGIMENS
CONSIDERATIONS
Asymptomatic Positive urine culture Remove catheter Obtaining routine
Bacteriuria ( 100,000 cfu/mL of cultures in
No antibiotics unless the patient
1 bacterial species asymptomatic
is:
in a single catheter patients is NOT
Scheduled for urologic
urine specimen) recommended
procedure
AND In the presence of a
Pregnant
No sign or symptoms catheter, pyuria
Scheduled Urologic Procedure: (>5-10 WBC) in an
SMX/TMP 1 DS tablet PO Q12H asymptomatic
OR patient is NOT an
Ciprofloxacin 500 mg PO indication for
OR antibiotic
Ciprofloxacin 400 mg IV Q12H treatment
Presence or
Initiate within 24 hours prior to absence of odorous
procedure and until foley removed or cloudy urine
Pregnant: alone is NOT an
Amoxicillin 500 mg PO Q12H for indication for
3 to 7 days antibiotic
OR treatment
Cephalexin 500 mg PO Q12H for Antibiotics do NOT
3 to 7 days decrease
OR asymptomatic
Nitrofurantoin (MacroBID) bacteriuria or
100 mg PO Q12H for 5 days prevent
subsequent UTI

Symptomatic Positive urine culture Outpatient: Remove catheter


AND ( 1,000 cfu/mL of 1 SMX/TMP DS tablet PO Q12H whenever possible
1 of the bacterial species in a OR Narrow antibiotic
following: single catheter urine Nitrofurantoin (MacroBID) therapy when
Male specimen) 100 mg PO Q12H organism and
Pyelonephritis AND OR susceptibilities are
Antibiotic use Presence of Ciprofloxacin 250 - 500 mg PO known
in previous 90 signs/symptoms Q12H Follow-up urine
days cultures or
Catheter still in place: Inpatient:
History of urinalysis are only
- Malaise/lethargy Cefazolin 2 gm IV Q8H
infection with warranted for on-
- Fever OR
MDRO going symptoms.
(100.4F)/rigors Cefepime 1 gm IV Q12H
Immuno- They should NOT
- Altered mental OR
compromised be obtained
status Ampicillin/sulbactam 1.5 gm IV
Functional or routinely to
- Flank pain Q6H
anatomic monitor response
- Pelvic discomfort
urologic Known or suspected ESBL to therapy
- Acute hematuria
abnormality bacteria:
Severe sepsis Catheter removed Meropenem 1 gm IV Q8H
within past 48 h: OR
- Dysuria Ertapenem 1 gm IV Q24H
- Urgency
Duration of Treatment:
- Frequency
Prompt resolution: 7 days
- Suprapubic
Delay response: 10-14 days
pain/tenderness
cfu= colony forming units; DS= double strength; ESBL= extended spectrum beta-lactamase; H= hour(s); IV= intravenous;
MDRO= multi-drug resistant organism; PO= by mouth; Q= every; SMX/TMP= sulfamethoxazole/trimethoprim; UTI= Urinary Tract
Infection; WBC= white blood cell

Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis

PAGE 29
Urinary
Urinary Tract:
Tract:Non-Catheter-Associated
UrinaryTract: Non-CatheterAssociated
Non-Catheter AssociatedUrinary Tract
Urinary
Urinary Tract
Tract
Infection / Cystitis
Infection/Cystitis
Infection/Cystitis
RRECOMMENDED
ECOMMENDEDEEMPIRIC
MPIRIC CCLINICAL
LINICAL
CCLASSIFICATION
LASSIFICATION CCLINICAL
LINICALFFINDINGS
INDINGS
RREGIMENS
EGIMENS CCONSIDERATIONS
ONSIDERATIONS

Asymptomatic
Asymptomatic Pyuria
Pyuria NoNoantibiotics
antibioticsunless
unlessthe
thepatient
patient Obtaining
Obtainingroutine
routine
Bacteriuria
Bacteriuria (urinalysis>>5-5-10
(urinalysis 10 is:
is: culturesinin
cultures
WBC)
WBC) Scheduled
Scheduledforforurologic
urologic asymptomatic
asymptomatic
OROR procedure
procedure NOT
patientsisisNOT
patients
Positive
Positiveurine
urine Pregnant
Pregnant recommended
recommended
culture
culture Antibiotics
Antibioticsdo NOT
doNOT
ScheduledUrologic
Scheduled UrologicProcedure:
Procedure:
((100,000
100,000cfu/mL)
cfu/mL) decrease
decrease
SMX/TMP11DS
SMX/TMP DStablet
tabletPO
POQ12H
Q12H
AND
AND asymptomatic
asymptomatic
OR
OR
No
Nosign
signororsymptoms
symptoms bacteriuriaoror
bacteriuria
Ciprofloxacin500
Ciprofloxacin 500mg
mgPOPO
(seebelow)
(see below) prevent
prevent
OR
OR subsequentUTI
subsequent UTI
Ciprofloxacin400
Ciprofloxacin 400mg
mgIVIVQ12H
Q12H
Initiatewithin
Initiate within24
24hours
hoursprior
priortoto
procedureand
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untilfoley
foley
removed
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Pregnant:
Pregnant:
Amoxicillin500
Amoxicillin 500mg
mgPO
POQ12H
Q12Hfor
for
33toto77days
days
OR
OR
Cephalexin500
Cephalexin 500mg
mgPOPOQ12H
Q12Hfor
for
33toto77days
days
OR
OR
Nitrofurantoin(MacroBID)
Nitrofurantoin (MacroBID)
100mg
100 mgPO
POQ12H
Q12Hfor
for55days
days

Symptomatic:
Symptomatic: Pyuria
Pyuria Outpatient:
Outpatient: Narrow
Narrowantibiotic
antibiotic
Complicated
Complicated (Urinalysis55WBC)
(Urinalysis WBC) SMX/TMP11DS
SMX/TMP DStablet
tabletPO
POQ12H
Q12H therapywhen
therapy when
AND
AND OR
OR organismand
organism and
11ofofthe
thefollowing:
following:
Positive
Positiveurineurine Nitrofurantoin(MacroBID)
Nitrofurantoin (MacroBID) susceptibilitiesare
susceptibilities are
Male
Male
culture 100mg
mgPOPOQ12H
Q12H known
culture 100 known
Pyelonephritis
Pyelonephritis ((100,000
100,000cfu/mL)
cfu/mL) OR
OR Follow-up
Follow-upurine
urine
Antibiotic
Antibioticuse
useinin AND
AND Ciprofloxacin250
Ciprofloxacin 250- -500
500mg
mgPOPO culturesoror
cultures
previous90
previous 90days
days Presence
Presenceofof Q12H
Q12H urinalysisare
urinalysis areonly
only
History
Historyofof symptoms:
symptoms: warrantedfor
warranted foron-
on-
Inpatient:
Inpatient:
infectionwith
infection with - - Dysuria
Dysuria goingsymptoms.
going symptoms.
Cefazolin22gm
Cefazolin gmIVIVQ8H
Q8H
MDRO
MDRO - - Urgency
Urgency Theyshould
They shouldNOTNOT
OR
OR
Immuno-
Immuno- - - Frequency
Frequency bebeobtained
obtained
Cefepime11gm
Cefepime gmIVIVQ12H
Q12H
compromised
compromised - - Suprapubic
Suprapubicpain
pain routinelytoto
routinely
OR
OR
AND/OR
AND/OR monitorresponse
monitor response
Functional
Functionaloror Ampicillin/sulbactam1.5
Ampicillin/sulbactam 1.5gm
gmIVIV
Presence
Presenceofofsigns:
signs: tototherapy
therapy
anatomic
anatomic Q6H
Q6H
- - Fever
Fever
urologic
urologic
((100.4F)
100.4F) Knownororsuspected
Known suspectedESBL
ESBL
abnormality
abnormality
- - Altered
Alteredmental
mental bacteria:
bacteria:
Severe
Severesepsis
sepsis status
status Meropenem11gm gmIVIVQ8H
Q8H
Meropenem
- - Leukocytosis
Leukocytosis OR
OR
Ertapenem11gm
Ertapenem gmIVIVQ24H
Q24H
DurationofofTreatment:
Duration Treatment:
77toto14
14days
days
cfu=colony
cfu= colonyforming
formingunits;
units;ESBL=
ESBL=extended
extendedspectrum
spectrumbeta-lactamase;
beta-lactamase;H=
H=hour(s);
hour(s);IV=
IV=intravenous;
intravenous;MDRO=
MDRO=multi-drug
multi-drugresistant
resistant
organism;PO=
organism; PO=bybymouth;
mouth;Q=Q=every;
every;SMX/TMP=
SMX/TMP=sulfamethoxazole/trimethoprim;
sulfamethoxazole/trimethoprim;UTI=
UTI=Urinary
UrinaryTract
TractInfection;
Infection;WBC=
WBC=white
white
bloodcell
blood cellcount
count

Positiveurine
Positive urineculture:
culture:
ForWomen:
For Women:22consecutive
consecutivevoided
voidedurine
urinespecimens
specimenswith
withisolation
isolationofof>10
>105 5cfu/mL
cfu/mLofofthe
thesame
samebacterial
bacterialstrain
strain
ForMen:
For Men:AAsingle,
single,clean-catch,
clean-catch,voided
voidedurine
urinespecimen
specimenwith
withisolation
isolationofof>10
>105 5cfu/mL
cfu/mLfrom
from11bacterial
bacterialspecies
species

Nitrofurantoin:Contraindicated
Nitrofurantoin: ContraindicatedififCrCl<
CrCl<60
60mL/min ANDonly
mL/minAND onlyindicated
indicatedininacute
acutecystitis
cystitis

NOTE:Dosing
NOTE: Dosingbased
basedon
onnormal
normalrenal
renalfunction.
function.Refer
RefertotoTable
TableofofContents
Contentsfor
forsection
sectionon
onAntimicrobial
AntimicrobialDosing
Dosingfor
forAdult
Adult
PAGE 30
PatientsBased
Patients Basedon
onRenal
RenalFunction
Function
Urinary Tract: Non-Catheter Associated Urinary Tract
Urinary Tract: Non-Catheter
Infection/Cystitis
Urinary Tract: Non-Catheter-Associated
AssociatedUrinaryUrinaryTract Tract
Urinary
Infection Tract:
/
Infection/Cystitis
C LASSIFICATION CNon-Catheter
Cystitis
LINICAL FINDINGS RAssociated Urinary
ECOMMENDED EMPIRIC R EGIMENS Tract
CLINICAL
CONSIDERATIONS
Infection/Cystitis CLINICAL
CLASSIFICATION
Symptomatic CPyuria
LINICAL FINDINGS RECOMMENDED
Nitrofurantoin EMPIRIC REGIMENS
(MacroBID) Urine culture
CLINICAL
CONSIDERATIONS
CLASSIFICATION
Uncomplicated/ C(Urinalysis:
LINICAL FINDINGS
5 100RECOMMENDED
mg PO Q12H for EMPIRIC
5 daysREGIMENS should be
Cystitis WBC) OR Cperformed
ONSIDERATIONS
ONLY IF:
Symptomatic Pyuria Nitrofurantoin (MacroBID) Urine culture
Female
Uncomplicated/
Symptomatic AND(Urinalysis:
Pyuria 5 SMX/TMP
100 mg PO 1Q12H
Nitrofurantoin DS(MacroBID)
tablet
for 5 PO Q12H
days for - History
should
Urine be of
culture
AND
Cystitis
Uncomplicated/ WBC)
Positive urine
(Urinalysis: 5 3 days
OR
100 mg PO Q12H for 5 days multiple
performed
should be ONLYUTIs IF:
Female
No criteria for
Cystitis AND culture ( 100,000 SMX/TMP OR MDRO
- History
WBC) Alternative1 agents
OR DS tablet PO Q12H
should for
be avoided performed of
ONLY IF:
AND complicated AND cfu/mL) urine
Positive

3SMX/TMP infection(s)
Female ifdays 1 DStotablet
possible due PO of
the risk Q12H for
C. difficile - multiple
History ofUTIs
AND (seecriteria
No previous
for AND
culture
Positive(urine
100,000 3 daysantibiotic resistance. IF patient Narrow
OR antibiotic
MDRO
multiple UTIs
AND
Alternative agents should be avoided
page)
complicated
No criteria for cfu/mL)
Presence
culture (of100,000 therapy when
infection(s)
OR MDRO
symptoms: ifhas an allergy/contraindication
possible
Alternative due to the
agents should to the
risk ofbeC.avoided
difficile organism and
(see previous
complicated AND cfu/mL) above antibiotics alternatives include: Narrow antibiotic
infection(s)
- Dysuria AND antibiotic
if possible resistance.
due to the risk ofIFC.patient
difficile susceptibilities are
page)
(see previous AND Presence of Ciprofloxacin 250 mg PO Q12H for 3 therapy
Narrow when
antibiotic
- Urgency has
ANDanantibiotic
allergy/contraindication
resistance. to the
IF patient known
page) symptoms:
Presence of days OR Cephalexin 500 mg PO Q12H organism
therapy whenand
above
has an antibiotics alternatives
allergy/contraindication include:
to the
-- Dysuria
Frequency
symptoms: for 3 days
susceptibilities
Follow-up
organism and urineare
Ciprofloxacin
above 250 mg
antibiotics PO Q12Hinclude:
alternatives for 3
--- Urgency
Suprapubic
Dysuria cultures
known or UA are
susceptibilities are
pain days OR Cephalexin
Ciprofloxacin 250 mg 500POmgQ12H PO Q12H
for 3 only warranted
-- Frequency
Urgency Follow-up
known urine for
for
days3 days
OR Cephalexin 500 mg PO Q12H on-going
-- Suprapubic
Frequency cultures
Follow-up or urine
UA are
for 3 days symptoms. They
- pain
Suprapubic only warranted
cultures or UA for
are
pain should
on-going NOT
only warranted be for
obtained
symptoms. routinely
on-going They
to monitor
should
symptoms.NOT They
be
response
obtained
should NOT to be
routinely
therapy
to monitorroutinely
obtained
response
to monitor to
Urinary Tract: Prostatitis therapy
response to
therapy
Urinary
CLASSIFICATIONTract:
Urinary Tract: Prostatitis
Prostatitis CLINICAL
Urinary Tract: Prostatitis
PREFERRED REGIMEN ALTERNATIVE REGIMENS
CONSIDERATIONS
Outpatient
CLASSIFICATION Ciprofloxacin
PREFERRED500 mg PO
REGIMEN SMX/TMP 1 DS tabletRPO
ALTERNATIVE Q12H
EGIMENS
CLINICAL
Beta-lactams DO NOT
Q12H OR CLINICAL
haveCadequate
ONSIDERATIONS
CLASSIFICATION PREFERRED REGIMEN ALTERNATIVE REGIMENS
Outpatient Ciprofloxacin 500 mg PO Levofloxacin
SMX/TMP 1 DS500 mg PO
tablet PO once
Q12Hdaily C
penetration into
Beta-lactams prostate
ONSIDERATIONS
DO NOT
Outpatient Q12H
Ciprofloxacin 500 mg PO (Requires ID
OR
SMX/TMP Consult)
1 DS tablet PO Q12H have adequateDO NOT
Beta-lactams
Q12H Levofloxacin
OR 500 mg PO 28
Duration of Treatment: once daily
days penetration into prostate
have adequate
(Requires ID Consult)
Levofloxacin 500 mg PO once daily penetration into prostate
cfu= colony forming units; DS= double strength; H= hour(s); MDRO=
(Requires multi-drug resistant organism; PO= by mouth; Q= every;
ID Consult)
Duration
SMX/TMP= sulfamethoxazole/trimethoprim; UA= urinalysis; ofUrinary
UTI= Treatment: 28 days WBC= white blood cell count
Tract Infection;
Duration of Treatment: 28 days
cfu= colony forming units; DS= double strength; H= hour(s); MDRO= multi-drug resistant organism; PO= by mouth; Q= every;
Positive urine culture:
SMX/TMP=
cfu= colony sulfamethoxazole/trimethoprim; UA=H=
urinalysis; UTI= Urinary Tract Infection; WBC= white blood cell count
Forforming
Women: units; DS= doublevoided
2 consecutive strength;
urine hour(s); MDRO=
specimens multi-drug
with isolation resistant
of >10 5 cfu/mLorganism; PO=
of the same by mouth;
bacterial Q= every;
strain
SMX/TMP= Forsulfamethoxazole/trimethoprim;
Men: A single, clean-catch, voidedUA=urine
urinalysis;
specimenUTI=with
Urinary TractofInfection;
isolation WBC=
>105 cfu/mL white
from blood cell
1 bacterial count
species
Positive urine culture:
PositiveFor Women:
urine
Nitrofurantoin: culture:2 consecutive voided urine specimens with isolation of >105 cfu/mL of the same bacterial strain
Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis
For
ForMen:
Women:A single, clean-catch,
2 consecutive voided
voided urine
urine specimen
specimens with
with isolation
isolation of of
>10>10
5 cfu/mL from 1 bacterial species
5 cfu/mL of the same bacterial strain
For Men:
NOTE: Dosing basedA on
single, clean-catch,
normal voidedRefer
renal function. urineto
specimen
Table ofwith isolation
Contents of >105 on
for section cfu/mL from 1 bacterial
Antimicrobial Dosingspecies
for Adult
Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis
Patients Based on Renal Function
Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Basedbased
NOTE: Dosing on Renal Function
on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function

References:
1. Hooton TM, Bradley SF, Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009
international clinical practice guidelines from the Infectious Disease Society of America. CID 2010;50:625-63.
References:
2. Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin
1. Hooton TM,2005
Infect Dis.
References: Bradley
Mar SF, Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009
1;40(5):643-54.
1. international
3. Gupta
HootonK,TM,
et al.clinical
Bradley practice
International guidelines
clinical
SF, Cardena et from
DD,practice the Infectious
guidelines
al. Diagnosis, Disease
for the Society
treatment
prevention, and of of America.
acute
treatment CID 2010;50:625-63.
ofuncomplicated cystitisurinary
catheter-associated and pyelonephritis
tract infectionin in
women:
adults:A2009
2010
2. Nicolle
update LE,
by et
internationaltheal. Infectious
Infectious
clinical Diseases
Diseases
practice Society
Society
guidelines ofofAmerica
from America
the guidelines
and European
Infectious forSociety
Disease the diagnosis
Society for and treatment
Microbiology
of America. of asymptomatic
and Infectious
CID 2010;50:625-63. bacteriuria
Diseases. Clin InfectinDis. 2011Clin
adults. Mar
Infect Dis. 2005
1;52(5):e103-20. Mar 1;40(5):643-54.
2. Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin
3. Gupta
Infect K, et2005
Dis. al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010
Mar 1;40(5):643-54.
3. update byetthe
al.Infectious Diseases Society of America andforEuropean Societyoffor Microbiology and Infectious Diseases. Clin Infect Dis. 2011A Mar
Gupta K,
1;52(5):e103-20.
International clinical practice guidelines the treatment acute uncomplicated cystitis and pyelonephritis PAGE
in women: 31
2010
update by the Infectious Diseases Society of America and European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar
1;52(5):e103-20.
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patients. Revaccination is not necessary.
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For Medicare reimbursement interval must be 11 full months. Please referortocochlear
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PPSV23 PCV13 and 5 years after PPSV23
PPSV23 The ACIP (Advisory Committee
PPSV23=23-Valent Pneumococcal
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A second PPSV23 for
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patients with cerebrospinal Vaccine
leak, (Prevnar
or cochlear13 ) is not required.
implant 2014 Rhode Island Board of Educa

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m interval between sequential administration of PCV13 and PPSV23
Vaccine is 8 weeks
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GIVE: PPSV23 PCV13=13-Valent Pneumococcal Conjugate (Prevnar 2014 Rhode Island Board of Education
dicare reimbursement interval must be 11 full months. Please refer to page 4.
IP (Advisory Committee on Immunization Practices) recommends only 1 dose of PPSV23 at age 65. Revaccination is not necessary.
nd PPSV23 for patients with cerebrospinal fluid leak, or cochlear implant is not required. PAGE 32
=23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax23)
13-Valent Pneumococcal Conjugate Vaccine (Prevnar 13) 2014 Rhode Island Board of Education
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MMWR Morb Mortal Wkly Rep.Contraindica>ons
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Pneumococcal Vaccine
Pneumococcal Vaccination Information Sheet
PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) COLLEGE OF PHARMACY

Facts About Pneumococcal Disease:


Streptococcus pneumoniae bacteria (i.e., pneumococci) are usually found in the upper respiratory tract of
most people.

Pneumococcal disease most commonly presents as a serious infection in the lungs (pneumonia), blood
(bacteremia), or brain (meningitis). The annual U.S. case estimate for invasive pneumococcal disease
(bacteremia and/or meningitis) is 40,000 and 4,250 deaths.

Pneumococcal disease most often occurs in older people as well as in people with a predisposing condition
(e.g., immunosuppression, pulmonary disease, heart disease, diabetes). The disease rates for adults in
these groups can be more than 20 times those for adults without high-risk medical conditions.

PPSV23 is 6070% effective in preventing serious pneumococcal disease; it does not provide substantial
protection against all types of pneumonia (viral and bacterial). It is not a pneumonia vaccine.

Frequently Asked Questions:


Question: Can I get the influenza and pneumococcal vaccines at the same time?
Yes. These vaccines can be given at the same time. If giving two IM vaccinations, separate by one inch in the
body muscle to reduce likelihood of local reactions overlapping.

Question: If patients who are in a recommended risk group for PPSV23 or PCV13 arent sure if they
have previously received these vaccines, should healthcare providers vaccinate them?
Yes. If patients do not have a documented vaccination history for these two vaccines and their records are not
readily obtainable, you should administer the recommended doses. Extra doses will not cause harm to the
patient.

Question: Is an egg allergy a contraindication for PCV13 or PPSV23?


No. Both vaccinations are safe for persons with egg allergies.

Question: If my state has a registry, do I still need to give patients vaccine record cards?
Yes. Patient-held cards are an extremely important part of a persons medical history. The person may move
to an area without a registry, and a personal record may be the only vaccination record available. In addition,
even within a state, all healthcare providers may not participate in the registry, and the personal record card
would be needed.

Question: My patient has had laboratory-confirmed pneumococcal pneumonia. Does he/she still need
to be vaccinated with PPSV23?
Yes. There are more than 90 known serotypes of pneumococcus (23 serotypes are in the current vaccine).
Infection with one serotype does not necessarily produce immunity to other serotypes. As a result, if the
person is a candidate for vaccination, he/she should receive it even after one or more episodes of invasive
pneumococcal disease.

Question: Why is pneumococcal vaccination recommended for smokers and asthmatics?


In 2008, the Advisory Committee on Immunization Practices (ACIP) reviewed new information that suggests
that asthma is an independent risk factor for pneumococcal disease among adults. ACIP also reviewed new
information that demonstrates an increased risk of pneumococcal disease among smokers. Consequently,
ACIP recommends to include both asthma and cigarette smoking as risk factors for pneumococcal disease
among adults age 19 through 64 years and as indications for PPSV23.

Acquired from www.immunize.org on September 4, 2013. We thank the Immunization Action Coalition.
MMWR Morb Mortal Wkly Rep 2012; 61(40):816-819.

PAGE 34
Pneumococcal Vaccine
Pneumococcal Vaccination Information Sheet
PCV13 (Prevnar 13) and PPSV23 (Pneumovax 23) COLLEGE OF PHARMACY

PPSV23 (Pneumovax23) PCV13 (Prevnar13)


Manufacturer: Manufacturer:
Merck Pfizer
www.merckvaccines.com/Products/Pneumovax/Pages/home http://www.pfizerpro.com/hcp/prevnar13

How Supplied: How Supplied:


0.5mL Single Dose Vial Prefilled Syringe
Multi-Dose (5 dose Vial) (10 per Package)

Storage and Handling: Storage and Handling:


Refrigerate on Arrival Refrigerate on Arrival
Store at 2C to 8C Store at 2C to 8C
DO NOT FREEZE DO NOT FREEZE
Discard after the expiration date Discard after the expiration date

Special instructions: Special instructions:


None Shake well to obtain a homogeneous white suspension

Route of Administration: Route of Administration:


0.5mL IM or SQ 0.5mL IM ONLY

Insurance Carrier Information:


Medicare www.medicarenhic.com 1-866-801-5304*
BCBS of RI www.bcbsri.com/providers 401-274-4848 1-800-230-9050
UnitedHealthCare www.unitedhealthcareonline.com 1-877-842-3210
RI Department of Health State Supplied Vaccination Program www.health.ri.gov/resources/immunization/

Contraindications and Precautions:


Do not give PPSV23 or PCV13 to patients who have a history of a serious reaction (e.g., anaphylaxis) after
a previous dose of PCV13, PPSV23, or one of their components.

Do not give PPSV23 and PCV13 simultaneously. For vaccine naive patients, give PCV13 first, followed by a
dose of PPSV23 1 year (unless patient in a population specified by ACIP to require shorter interval, see
page 1). For patients who have already received PPSV23, give PCV13 12 months after the most recent
dose of PPSV23.

Vaccine Co-administration: (1) all vaccines used for routine vaccination in the United States can be given on
the same day; (2) an inactivated vaccine can be administered either on the same day as or at any time
before or after another inactivated or a live vaccine; and (3) any 2 LIVE vaccines that are not given on the
same day must be spaced at least 4 weeks apart. Zoster vaccine is a live, attenuated vaccine; injectable
influenza vaccine and pneumococcal polysaccharide vaccine are inactivated vaccines. So these 3 vaccines
can be given on the same day or at any time before or after each other. They should be given as separate
injections, not combined in the same syringe.

Side Effects:
Most common side effects from either PPSV23 or PCV13 are soreness and redness at the injection site,
lasting 1-2 days.

Drug Information Services 401-874-9188 Monday-Friday 8:30 am - 4:00 pm EST


* An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second
pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine
was administered). Please note that the interval between the two different pneumococcal vaccines must be at least 11 full months or greater for Medicare reimbursement, not the
shorter interval recommended for specific populations identified by ACIP.
Acquired from www.immunize.org on September 4, 2013. We thank the Immunization Action Coalition.
Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines: Recommendations of the Advisory Committee in Immunization Practice (ACIP)
MMWR Morb Mortal Wkly Rep. 2015; 64(34): 944-947.

PAGE 35
Percent Susceptible (2015 Isolates)

Gram Positive
Organisms:
Inpatient/Outpatient

Oxacillin

Ampicillin
Antibiogram

Cefotaxime
Gentamicin
Penicillin G
Isolates 2015
Tetracycline
Vancomycin

Clindamycin
Moxifloxacin

Ciprofloxacin
Streptomycin

Erythromycin
Nitrofurantoin
/Trimethoprim

Chloramphenicol
Sulfamethoxazole

Individual Isolates
Enterococcus fecalis 126 99 64 73 99 29 86 95

10
Enterococcus faecium 4* 25 0 100 100 0 100 75
0
Staphylococcus aureus
124 79 72 99 100 100 28 98 100 100
(MSSA)
Staphylococcus aureus,
111 63 7 97 95 0 0 98 98 100
Methicillin-resistant (MRSA)
Staphylococcus epidermidis 74 52 30 86 98 47 10 86 66 100

Streptococcus pneumoniae 7* 100 75 100 100 100 38 89 100

*If < 30 isolates use caution extrapolating results; data may be inconclusive for therapeutic efficacy and
selection of empiric treatment.

PAGE 36
Percent Susceptible (2015 Isolates)

Gram Negative
Organisms:
Inpatient/Outpatient

Cefazolin

Amikacin
Cefepime
Imipenem

Ampicillin
Ampicillin
Aztreonam

/Sulbactam
Cefotaxime
Gentamicin

Cefuroxime

Ceftriaxone
tazobactam

Ceftazidime
Piperacillin/
Tobramycin

Tetracycline

Ciprofloxacin
Isolates 2015

Nitrofurantoin
/Trimethoprim
Sulfamethoxazole

Individual Isolates
Acinetobacter
14* 100 79 55 83 83 100 86 64 79 100
Antibiogram

baumanni
Citrobacter freundii 9* 100 11 33 78 0 89 67 67 33 78 89 100 93 100 67 0

Enterobacter aerogenes 12* 100 8 50 100 0 100 100 100 83 100 100 100 0 100 100

Enterobacter cloacae 49 100 10 36 82 6 90 82 84 36 94 96 100 26 73 78 0

Escherichia coli 246 100 52 58 92 85 92 92 92 85 75 88 100 97 94 72 23

Klebsiella pneumoniae 79 99 0 78 91 89 95 94 94 81 91 96 100 37 97 91 0

Morganella morganii 14* 100 7 7 86 7 86 86 86 7 86 71 100 0 100 57 75

Proteus mirabilis 49 100 71 88 86 82 94 94 94 92 65 92 96 0 100 76 50


Pseudomonas
109 93 70 93 89 78 77 95 94 98
aeruginosa
Serratia marcescens 23 100 0 0 71 0 96 52 79 0 91 92 100 0 52 100 0

Haemophilus influenzae 25* 72

Klebsiella oxytoca 28* 100 0 61 82 36 89 86 68 93 100 100 83 96 93


Stenotrophomonas
8* 100
maltophilia
*If < 30 isolates use caution extrapolating results; data may be inconclusive for therapeutic efficacy and

PAGE 37
selection of empiric treatment.
Guidelines
Guidelines for for Restricted
Restricted Antimicrobials
Antimicrobials
I. The use of the following formulary antimicrobial agents are restricted

Antibiotics Antifungals
Ceftaroline (Teflaro) Amphotericin B lipid complex
Ceftazidime/avibactam (Avycaz) (AmBisome)
Ceftolozane/tazobactam (Zerbaxa) Caspofungin (Cancidas )
Colistin (Polymyxin E) Isavuconazonium sulfate (Cresemba)
Dalbavancin (Dalvance) Voriconazole (V-Fend)
Daptomycin (Cubicin)
Ertapenem (Invanz)
Fidaxomicin (Dificid)
Fosfomycin (Monurol)
Linezolid (Zyvox)
Oritavancin (Orbactiv)
Polymyxins
Polymyxin B
Colistin (Polymyxin E)
Tedizolid (Sivextro)
Tigecycline (Tygacil)

II. To ensure the rational use of formulary, restricted, or non-formulary antimicrobial


agents, the following policies and procedures are to be used:

1. When a prescriber wishes to prescribe a restricted or non-formulary antimicrobial


agent, he/she shall indicate the approved reason (see following pages) in the
comments section of the order form. If the use is outside of an approved indication, the
physician MUST obtain approval of use. This approval must be obtained from the
Infectious Diseases consult team, by directly contacting the on-call Infectious Diseases
physician/fellow or by calling the Department of Medicine who will contact the on-call
Infectious Diseases physician/fellow.

2. When pharmacy receives an order for a restricted antimicrobial agent, the pharmacist
will verify the approved reason for use and if applicable, fill the order. If the
pharmacy receives an order for a restricted or non-formulary antimicrobial agent and
the ordering box does not indicate an approved reason for use, the pharmacist will
immediately contact the prescriber to obtain criteria for use of a restricted agent.

3. If the prescriber cannot be reached, the pharmacist will dispense a maximum 24 hour
supply of the drug. The pharmacist MUST notify the prescriber that the further drug
will be dispensed only when the completed order form or ID approval is received. It is
up to the prescriber to obtain authorization from the Infectious Diseases fellow or
Infectious Diseases consult team.

PAGE 38
Ceftaroline (Teflaro)
Ceftaroline (Teflaro)
IV Only Use requires formal ID Consult
Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus
pneumoniae, most gram-negatives, and some gram-positive anaerobic bacteria
NOT ACTIVE against Pseudomonas spp., Acinetobacter spp., or Enterococcus spp.
Criteria for Use:
Acute bacterial skin and skin structure infection (ABSSSI) caused by MRSA +/-
bacteremia or community-acquired bacterial pneumonia (CABP)
Unable to use vancomycin (VAN; due to intolerance, MIC 2 mg/mL, or
infection unresponsive to VAN despite therapeutic concentrations)
Unable to use other agents (refer to empiric therapy for ABSSSI/CABP)
Unacceptable Uses:
Treatment of P. aeruginosa, Enterococcus spp., or Acinetobacter spp. Infections
(limited to no activity)
Treatment of ESBL producing organisms, such as E. coli or Klebsiella spp.
(inactivated by AmpC and ESBL beta-lactamases)
Known serious hypersensitivity to ceftaroline or other members of the
cephalosporin class. Cross-reactivity may occur in patients with a history of
other beta-lactam allergies
Dosing in Adults:
Standard dose: 600 mg IV Q12H
For MSSA/MRSA bacteremia consider: 600 mg IV Q8H
Renal dose adjustment:
CrCl 30-50 mL/min: 400 mg IV Q12H
CrCl 15-30 mL/min: 300 mg IV Q12H
CrCl <15 mL/min: 200 mg IV Q12H
Hemodialysis: 200 mg IV Q12H
All infusions should be over 1 hour
No hepatic dose adjustment
Monitoring:
Monitor CBC for drug-induced hemolytic anemia (none observed in studies, but
seroconversion from negative to positive Direct Coombs Test is observed in
10.8% on ceftaroline vs 4.4% on comparator)
ABSSSI= Acute bacterial skin and skin structure infection; CABP= community-acquired bacterial pneumonia; CBC= Complete
blood count; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= infectious diseases;
IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus;
MSSA= Methicillin-susceptible Staphylococcus aureus; Q= every; spp= Species; VAN= vancomycin

PAGE 39
Ceftazidime/avibactam
Ceftazidime/avibactam (Avycaz)(Avycaz)
IV Only Use requires formal ID Consult
Use reserved for patients who have limited or no alternative treatment options
since it was approved based upon limited clinical safety and efficacy data
Activity: Coverage against many resistant gram-negatives such as Enterobacteriaceae
and Pseudomonas aeruginosa, including some ESBL producers (e.g. CTX-M),
carbapenemases (e.g. KPC, some OXA ), and AmpCs
NOT ACTIVE against MBLs or gram-negatives that overexpress efflux pumps or have
porin mutations, and most anaerobic bacteria
Criteria for Use:
Treatment of cIAI (in combination with metronidazole) or cUTI, including
pyelonephritis, caused by MDR gram-negative organisms
Unacceptable Uses:
Empiric use without confirmed susceptibility
Treatment of cIAI and cUTI with other available treatment options
Known serious hypersensitivity to the components of ceftazidime/avibactam,
avibactam-containing products, or other members of the cephalosporin class.
Cross-reactivity may occur in patients with a history of penicillin allergy

Dosing in Adults:
Standard dose: 2.5gm IV Q8H
For cIAI must use in combination with metronidazole
Renal dose adjustment:
CrCl 31 - 50 mL/min: 1.25gm IV Q8H
CrCl 16-30 mL/min: 0.94gm IVQ12H
CrCl 6-15 mL/min: 0.94gm IV Q24H
CrCl <5 mL/min: 0.94gm IV Q48H
Administer after hemodialysis
No hepatic dose adjustment anticipated

Monitoring:
Scr/BUN at baseline and daily; adjust dose accordingly. CBC with differential.
Monitor for signs of anaphylaxis with first dose
Considerations for Use:
Decreased efficacy in patients with = CrCl 30-50 mL/min in clinical trials
CNS reactions have been reported in patients treated with ceftazidime,
particularly in the setting of renal impairment
BUN= blood urea nitrogen; CBC= Complete blood count; cIAI= Complicated intraabdominal infections; CNS= Central nervous
system; CrCl= Creatinine clearance; cUTI= complicated urinary tract infections; ESBL= extended-spectrum beta-lactamases;
H= hour(s); ID= infectious diseases; IV= Intravenous; KPC= Klebsiella pneumoniae carbapenemases; MBL= metallo-beta-
lactamases; MDR= multi-drug resistant; Q= every; Scr= Serum creatinine

PAGE 40
Ceftolozane/tazobactam (Zerbaxa)
Ceftolozane/tazobactam (Zerbaxa)
IV Only Use requires formal ID Consult
Activity: Coverage against many MDR gram-negatives such as Enterobacteriaceae and
Pseudomonas aeruginosa. Potent in vitro activity against most P. aeruginosa isolates,
including some MDR and carbapenem-resistant strains. Inhibits many
Enterobacteriaceae, including some ESBL producers (e.g. CTX-M) and some AmpCs
NOT ACTIVE against serine carbapenemases (e.g. KPCs or MBLs)
Criteria for Use:
Treatment of cIAI (in combination with metronidazole) or cUTI, including
pyelonephritis, caused by MDR gram-negative organisms
Unacceptable Uses:
Empiric use without confirmed susceptibility
Treatment of cIAI and cUTI with other available treatment options
Known serious hypersensitivity to ceftolozane/tazobactam,
piperacillin/tazobactam, or other members of the beta-lactam class

Dosing in Adults:
Standard dose: 1500 mg IV Q8H
For cIAI must use in combination with metronidazole
Renal dose adjustment:
CrCl 30-50 mL/min: 750 mg IV Q8H
CrCl 15-29 mL/min: 375 mg IV Q8H
Hemodialysis: 750mg IV ONCE (load), then 150mg IV Q8H after dialysis
No hepatic dose adjustment anticipated

Monitoring:
Scr/BUN, CBC with differential at baseline and daily
Considerations for Use:
Package insert states decreased efficacy seen in patients with a baseline CrCl
<50mL/min or patients >65 years of age, in the cIAI trial
May have a role in the treatment of other infections caused by multidrug
resistant gram-negatives, however alternate dosing may be recommended
depending on site of infection. ID team must be consulted for all potential on
and off label use
BUN= blood urea nitrogen; CBC= Complete blood count; cIAI= Complicated intraabdominal infections; CrCl= Creatinine
clearance; cUTI= complicated urinary tract infections; ESBL= extended-spectrum beta-lactamases; ID= infectious disease;
IV= Intravenous; KPC= Klebsiella pneumoniae carbapenemases; MBL= metallo-beta-lactamases; MDR= multi-drug resistant;
Q= every; H= hour(s); Scr= Serum creatinine

PAGE 41
Dalbavancin (Dalvance)
Dalbavancin (Dalvance)
IV Only Use requires formal ID Consult
Activity: Coverage against Staphylococcus aureus (including MSSA and MRSA),
Streptococcus pyogenes, Streptococcus agalactiae (Group B Strep.) and Streptococcus
anginosus group (including S. anginosus, S. intermedius, S. constellatus)
No clinical data, but activity in vitro vs. Enterococcus faecalis (vancomycin-susceptible
strains only), Enterococcus faecium (vancomycin-susceptible strains only),
vancomycin-intermediate S. aureus
(not vancomycin-resistant strains)
Criteria for Use:
Treatment of adult patients with acute bacterial skin and skin structure
infections (ABSSSI) caused by susceptible gram-positive isolates
Unable to use vancomycin (due to intolerance, MIC >2mg/L, or infection
unresponsive to vancomycin despite therapeutic concentrations)
Unable to use other agents (refer to empiric therapy for ABSSSI)
Unacceptable Uses:
Infections due to vancomycin-resistant enterococci
Contraindicated in patients with known hypersensitivity to dalbavancin. Due to
the possibility of cross-reactivity to glycopeptide, avoid in patients with previous
glycopeptide hypersensitivity due to long half-life
Dosing in Adults:
Standard dose: Administration should be over 30 minutes
1 Dose Regimen: 1500mg IV once
2 Dose Regimen: 1000mg IV once, then 500mg IV on day 8
Renal dose adjustment:
1 Dose Regimen CrCl <30 mL/min 1125 mg IV
2 Dose Regimen CrCl <30 mL/min: 750mg IV once, then 325mg IV day 8
If receiving regularly scheduled hemodialysis: No dosage adjustment
No hepatic dose adjustment anticipated

Monitoring:
Baseline BUN/Scr, AST/ALT/bili, CBC w/ diff, infusion-related reactions
Considerations for Use:
In clinical trials, 6 (0.9%) patients in the dalbavancin arm had ALT elevations
greater than 5x ULN including 3 with ALT >10x ULN. No subjects in the
comparator arm had this degree of ALT elevations
ABSSSI= acute bacterial skin and skin structure infections; ALT= Alanine aminotransferase; AST= Aspartate aminotransferase;
bili= Bilirubin; BUN= Blood urea nitrogen; CBC= Complete Blood Count; CrCl= Creatinine clearance; ID= infectious diseases;
IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus;
MSSA= Methicillin-susceptible Staphylococcus aureus; SCr= Serum creatinine; ULN= Upper Limit of Normal

PAGE 42
Daptomycin (Cubicin)
Daptomycin (Cubicin)
IV Only Use requires formal ID Consult
Activity: Coverage against most gram-positive bacteria (including MRSA and VRE)
NOT ACTIVE against gram-negative bacteria
Criteria for Use:
MRSA bacteremia and/or endocarditis and unable to use vancomycin (due to
intolerance, MIC 2 mg/L, or infection unresponsive to vancomycin despite
therapeutic concentrations)
MRSA skin and skin structure infections in patients with true, serious allergic
reaction to vancomycin or linezolid
Patients receiving vancomycin for > 72 h for resistant staphylococcal skin and
skin structure infection without clinical improvement
VRE confirmed bacteremia (see dosing below, use high doses)
Formal ID consult for use in osteomyelitis or complicated skin and soft tissue infection
and all indications that are not listed above
Unacceptable Uses:
Empiric therapy
Pneumonia (lung surfactant inactivates daptomycin) or any lower respiratory
tract infection
Dosing in Adults:
Standard dose: 6-10 mg/kg IV Q24H of actual body weight (ABW)
May be dosed 8-10 mg/kg for Enterococcus (safety data for healthy volunteers
up to 12 mg/kg/day)
Renal dose adjustment:
CrCl < 30 mL/min: 8 mg/kg IV Q48H
Hemodialysis: 8 mg/kg IV Q48H
No hepatic dose adjustment
Monitoring:
Obtain CPK at baseline and weekly. Monitor for muscle pain or weakness, and
for signs/symptoms of eosinophilic pneumonia
Considerations for Use:
Consider discontinuation of concurrent statin therapy while on daptomycin due
to additive muscle toxicity
ABW= Actual Body Weight; CPK= Creatine phosphokinase; CrCl= Creatinine clearance; H= hour(s); ID= Infectious Disease;
IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every;
VRE= Vancomycin-resistant enterococci

PAGE 43
Ertapenem (Invanz)
Ertapenem (Invanz)
IV and IM Only Use requires formal ID Consult
Activity: Coverage against many gram-negatives (including those that produce ESBL),
gram-positives, and anaerobes
NOT ACTIVE against Pseudomonas spp., Acinetobacter spp., MRSA, or Enterococcus
spp.
Criteria for Use:
Outpatient treatment of community acquired infections; outpatient settings
Unacceptable Uses:
Caution use of ertapenem in organisms producing AmpC beta-lactamase
without testing the organisms specifically against ertapenem susceptibility
Contraindicated in patients with documented hypersensitivity to beta-lactams
Treatment of P. aeruginosa, Acinetobacter spp., MRSA, or Enterococcus spp.
Infections

Dosing in Adults:
Standard dose: 1 gm IV or IM Q24H
Renal dose adjustment:
CrCl < 30 mL/min: 500 mg IV or IM Q24H
Hemodialysis: 500 mg IV or IM Q24H; supplemental dose of 150 mg after
dialysis if last 500 mg dose given within 6 hours prior to dialysis, no
supplemental dose necessary if last 500 mg dose given at least 6 hours prior
to dialysis
No hepatic dose adjustment
Monitoring:
Fever, CBC, hepatic function, pulmonary function (in pneumonia)
CBC= Complete blood count; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= Infectious
Disease; IM= Intramuscular; IV= Intravenous; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; Spp= Species

PAGE 44
Fidaxomicin (Dificid)
Fidaxomicin (Dificid)
PO Only Use requires formal ID Consult
Patients with multiple Clostridium difficile infection (CDI) recurrences (i.e. severe or
mild-moderate CDI with greater than 2 and 3 recurrences, respectively) or severe,
complicated CDI should obtain ID and/or GI consult for optimal therapy
Criteria for Use:
Patient with severe CDI with a 2nd recurrence (previously received appropriate
therapy [i.e., vancomycin 125 mg PO Q6H for initial and 1st recurrence]).
Alternatively, a provider has the option to prescribe a vancomycin taper for a
2nd recurrence
OR
Patients with mild-moderate CDI with a 3rd recurrence (previously received
appropriate therapy i.e., vancomycin 125 mg PO Q6H for initial and 1st
recurrence and then a vancomycin taper for the 2nd recurrence)
Unacceptable Uses:
Treatment of systemic infections
Treatment of severe, complicated CDI (i.e., life-threatening or fulminant CDI or
toxic megacolon)
Use in combination with PO vancomycin or PO metronidazole

Dosing in Adults:
Standard dose: 200 mg PO Q12H for 10 days
No renal or hepatic dose adjustment
May be given with or without food; systemic absorption is minimal

Considerations for Use:


Fidaxomicin was only studied in patients with an initial episode or 1st
recurrence (defined as within 3 months of initial episode). Recurrence rates in
both phase III studies were significantly lower in patients treated with
fidaxomicin. However, in a subgroup analysis, recurrence rates were NOT
significantly lower in fidaxomicin-treated patients who had the hypervirulent
BI/NAP1/027 strain
The Society for Healthcare Epidemiology in America (SHEA) and Infectious
Diseases Society of America (IDSA) Clinical Practice Guidelines for CDI
recommend to discontinue therapy with the inciting antimicrobial as soon as
possible, as this may influence the risk of CDI recurrence
CDI= Clostridium difficile infection; FDA= Food and Drug Administration; GI= gastrointestinal; H= hour(s); ID= infectious diseases;
IDSA= Infectious Diseases Society of America; PO= Oral; Q= every; SHEA= Society for Healthcare Epidemiology in America

PAGE 45
Fosfomycin (Monurol)
Fosfomycin (Monurol)
PO Only Use requires formal ID Consult
Activity: Coverage against many gram-negatives (including ESBL-producing and
carbapenem-resistant Enterobacteriaceae [such as E. coli, Klebsiella spp.]) and gram-
positives (including MRSA and VRE)
NOT ACTIVE against Acinetobacter spp.
In the United States only the oral formulation is available.
Criteria for Use:
Management of uncomplicated UTI in patients with multiple antibiotic allergies
and/or when no other oral therapy options are available
Uncomplicated UTI due to VRE
Salvage therapy for UTI due to multi-drug resistant organisms (e.g. ESBL, VRE,
+/- Pseudomonas; confirm fosfomycin susceptibility prior to initiation of
therapy)
Unacceptable Uses:
Management of any infections outside of the urinary tract. Oral fosfomycin
does not achieve adequate concentrations at other sites
Treatment of asymptomatic bacteriuria

Dosing in Adults:
Standard dose:
Uncomplicated UTI: 3 gm (1 sachet) PO once
Complicated UTI: 3 gm (1 sachet) PO every 2 to 3 days
(up to 21 days of treatment)
Powder should be mixed with 90-120 mL of cool water, stirred to dissolve
and administered immediately. May be administered with or without food
Renal dose adjustment:
CrCl < 50 mL/min: Frequency adjustment may be necessary; contact
antimicrobial stewardship team
No hepatic dose adjustment
Monitoring:
Signs and symptoms of urinary tract infection
CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; ID= Infectious Disease; MRSA= Methicillin-resistant
Staphylococcus aureus; PO= Oral; Spp= Species; UTI= Urinary Tract Infection; VRE= Vancomycin-resistant enterococci

PAGE 46
Linezolid (Zyvox)
Linezolid (Zyvox)
IV and PO Only Use requires formal ID Consult
Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus
pneumoniae, VRE
Criteria for Use:
Vancomycin (VAN) MIC 2 mg/L in MRSA pneumonia
Patient with allergy to beta-lactams/vancomycin and organism resistant to other
antimicrobials
Significant VRE infections (i.e. isolated from a sterile site: blood, abscess)
Infections due to MRSA in patient with well documented intolerance to VAN
(NOTE: Red man syndrome is not a serious intolerance to VAN)
Formal ID consult for use in osteomyelitis or complicated skin and soft tissue
infection and all indications that are not listed above
Unacceptable Uses:
Empiric use when VRE has not been cultured or documented
Uncomplicated urinary tract infection
Positive respiratory culture for VRE
VRE colonization
Dosing in Adults:
Standard dose: 600 mg PO or IV Q12H
In patients tolerating PO medications, should be given orally
Oral formulation is completely absorbed and has 100% availability
No renal or hepatic dose adjustment
Monitoring:
CBC at baseline and weekly (MONITOR platelets at baseline and weekly)
Considerations for Use:
Caution in patients with thrombocytopenia. 3 percent of patients were noted to
have a platelet decrease <75% of baseline or lower limit of normal in controlled
trials (therapy <28 days, most < 21 days. Thrombocytopenia is reversible upon
discontinuation and is correlated with duration
Linezolid is a weak MAOI. Use in caution with decongestants
(i.e. pseudoephedrine) and serotonergic agents
(i.e. SSRIs [fluoxetine, escitalopram, sertraline, paroxetine, citalopram])
Warn patients to avoid large quantities of tyramine containing foods
CBC= Complete blood count; H= hour(s); ID= infectious disease; IV= Intravenous; MAOI= Monoamine oxidase inhibitors;
MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible
Staphylococcus aureus; PO= Oral; Q= every; SSRI= serotonin-specific reuptake inhibitors; VAN= Vancomycin; VRE= Vancomycin-
resistant enterococci

PAGE 47
Oritavancin (Orbactiv)
Oritavancin (Orbactiv)
IV Only Use requires formal ID Consult
Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus
pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae, Streptococcus
anginosus group and vancomycin-susceptible Enterococcus faecalis
No clinical data, but activity in vitro vs. vancomycin-resistant enterococci and
vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus
Criteria for Use:
Treatment of adult patients with acute bacterial skin and skin structure
infections (ABSSSI) caused by susceptible gram-positive isolates
Unable to use vancomycin (due to intolerance, MIC >2, or infection
unresponsive to vancomycin despite therapeutic concentrations)
Unable to use other agents (refer to empiric therapy for ABSSSI)
Unacceptable Uses:
Patients with suspected osteomyelitis. If OM is suspected, alternative
antibacterial therapy should be initiated
Contraindicated in patients with known hypersensitivity to oritavancin. Due to
the possibility of cross-reactivity to glycopeptide, avoid in patients with
previous glycopeptide hypersensitivity due to long half-life.
Dosing in Adults:
Standard dose: 1200mg dose IV over 3 hours x1
No renal or hepatic dose adjustment

Monitoring:
SCr/BUN, AST, ALT, bilirubin, infusion-related reactions (pruritus, urticaria,
flushing), hypersensitivity reactions, signs/symptoms of OM
Considerations for Use:
The use of unfractionated heparin is contraindicated for 48 hours after
oritavancin administration due to artificial prolongation of aPTT
Co-administration of oritavancin and warfarin may result in higher exposure of
warfarin, which may increase the risk of bleeding
Oritavancin can artificially prolong aPTT for up to 120 Hr, and may prolong PT
and INR for up to 12 Hr and ACT for up to 24 Hrs
ABSSSI= acute bacterial skin and skin structure infections; ACT= Activated clotting time; ALT= Alanine aminotransferase;
aPTT= Activated partial thromboplastin time; AST= Aspartate aminotransferase; BUN= Blood urea nitrogen; ID= Infectious
Disease; INR= International normalized ratio; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-
resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; OM= osteomyelitis; PT= Prothrombin
time; SCr= Serum creatinine

PAGE 48
Polymyxin
Polymyxin B B
IV Only Use requires formal ID Consult
Polymyxin B and Colistin (also known as Polymyxin E or Colistimethate) are the two
polymyxin antibiotics. Their spectrum of activity is similar. However, their
pharmacology is very different. Polymyxin B is administered as the active drug and is
not cleared renally. Colistin is a prodrug (Colistimethate sodium) and is cleared
renally.
The product vials may be labeled as International Units (IU) or mg.
To avoid major dosing errors, carefully read vial labels. Recommend that all doses
be converted to mg.
Conversion: 10,000 International Units = 1 mg

Activity: Coverage against most gram-negatives, including many multi-drug resistant


(MDR) Enterobacteriaceae (such as E. coli, Klebsiella spp.; including ESBL-producing
and carbapenem-resistant Enterobacteriaceae), Pseudomonas spp., and Acinetobacter
spp.
NOT ACTIVE against Proteus, Serratia, Providencia, Burkholderia, Stenotrophomonas,
gram-negative cocci, gram-positive organisms, or anaerobes
Criteria for Use:
Treatment of infections due to MDR Enterobacteriaceae, Pseudomonas spp., and
Acinetobacter spp. with no other treatment options
Unacceptable Uses:
Empiric treatment of suspected gram-negative infections
Monotherapy for serious infections due to rapid resistance development
Treatment of UTIs. Colistin preferred over polymyxin B for UTIs
Dosing in Adults: Optimal dosing regimens are not well established
Standard dose: 2.5 mg/kg IV as a 2 hr infusion ONCE (load), then 12 hours later
start 1.5 mg/kg IV as a 1 hr IV infusion. Repeat Q12H
No renal or hepatic dose adjustment
Use actual body weight for dosing
Caution in use > maximum product recommended daily dose (300mg)
Monitoring:
BUN/ SCr at baseline and at least twice weekly
Considerations for Use:
The most important side effect of IV polymyxin B is nephrotoxicity (20-40% of
patients); less frequently reported concerns include neurotoxicity and
neuromuscular blockade
Recent literature suggests that nephrotoxicity rates may be lower with
polymyxin B as compared to colistin
BUN= Blood urea nitrogen; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= Infectious Diseases; IU= international
Units; IV= Intravenous; MDR= multi-drug resistant; Q= every; SCr= Serum creatinine; spp= Species; UTI= Urinary tract infection

PAGE 49
Colistin (Polymyxin
Colistin (Polymyxin E or Colistimethate)
E or Colistimethate)
IV Only Use requires formal ID Consult
Colistin (also known as Polymyxin E or Colistimethate) and Polymyxin B are the two
different polymyxin antibiotics. Colistin is a prodrug (Colistimethate sodium).
The product vials may be labeled as International Units (IU) of prodrug, or mg of the
active product: colistin base activity (CBA).
To avoid major dosing errors, carefully read vial labels.
Recommend that all doses be converted to mg of CBA.
Conversion: 1,000,000 units of Colistimethate (prodrug) = 80 mg of Colistimethate
(prodrug) = 30 mg of colistin base activity (CBA)
Activity: Coverage against most gram-negatives, including many multi-drug resistant
(MDR) Enterobacteriaceae (such as E. coli, Klebsiella spp.; including ESBL-producing
and carbapenem-resistant Enterobacteriaceae), Pseudomonas spp., and Acinetobacter
spp.
NOT ACTIVE against Proteus spp., Serratia spp., Providencia spp, Burkholderia spp,
Stenotrophomonas spp, gram-negative cocci, gram-positive organisms, or anaerobes
Criteria for Use:
Treatment of infections due to MDR Enterobacteriaceae, Pseudomonas spp., and
Acinetobacter spp. with no other treatment options
Treatment of UTI. Colistin preferred over polymyxin B for UTIs
Unacceptable Uses:
Empiric treatment of suspected gram-negative infections
Use as monotherapy due to rapid resistance development
Dosing in Adults: Optimal dosing regimens are not well established
Standard dose: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q12H
Renal dose adjustment:
CrCl 20-50 mL/min: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q24H
CrCl < 20 mL/min: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q48H
Hemodialysis: 5 mg CBA/kg ONCE (load), then 30 mg CBA IV Q12H, AD
No hepatic dose adjustment
Use ideal body weight in obese patients for dosing
Caution in use > max product recommended daily dose (300 mg CBA)
Monitoring:
BUN/ SCr at baseline and at least twice weekly
Considerations for Use:
The most important side effect of IV colistin is nephrotoxicity
(rates 50-60% of patients); less frequently reported concerns include
neurotoxicity and neuromuscular blockade
AD= After dialysis; BUN= Blood urea nitrogen; CBA= Colistin base activity; CrCl= Creatinine clearance; ESBL= Extended spectrum
beta-lactamase; H= hour(s); ID= infectious diseases; IU= international units; IV= Intravenous; MDR= multi-drug resistant;
Q= every; SCr= Serum creatinine; spp= species; UTI= Urinary tract infection

PAGE 50
Tedizolid (Sivextro)
Tedizolid (Sivextro)
IV and PO Only Use requires formal ID Consult
Activity: Coverage includes Staphylococcus aureus (MSSA and MRSA), Streptococcus
pyogenes, Streptococcus agalactiae, Streptococcus anginosus group, and
Enterococcus faecalis
Criteria for Use:
Treatment of adult patients with acute bacterial skin and skin structure
infections (ABSSSI) caused by susceptible gram-positive isolates
Unable to use vancomycin (due to intolerance, MIC >2, or infection
unresponsive to vancomycin despite therapeutic concentrations)
Unable to use other agents (refer to empiric therapy for ABSSSI)
Unacceptable Uses:
Infections for other indications not listed above
Patients with neutropenia. Safety and efficacy in patients with neutrophil
counts <1000 cells/mm3 have not been assessed. Decreased activity in the
absence of granulocytes in animal models
Dosing in Adults:
Standard dose: 200 mg IV/PO once daily for 6 days
No renal or hepatic dose adjustment
No dose adjustment is necessary when changing from IV to PO

Monitoring:
CBC with differential
Considerations for Use:
Tedizolid has been shown to be a reversible inhibitor of monoamine oxidase
(MAO) in vitro, but no restrictions exist for concomitant use of drugs with
serotonergic and adrenergic activity or tyramine containing foods. Of note,
patients taking such medications were excluded from clinical trials. In vitro, in
vivo, and clinical studies indicate weak MAO inhibition and a low potential for
serotonergic adverse consequences
In phase 3 trials, reduction in hemoglobin, reduction in platelet count, and
reduction in absolute neutrophil count were similar between tedizolid and
linezolid
In phase 3 trials, adverse effects associated with neurologic and optic nerve
disorders did not differ between tedizolid and linezolid
ABSSSI= acute bacterial skin and skin structure infections; CBC= Complete Blood Count; ID= Infectious Disease; IV= Intravenous;
MAO= monoamine oxidase; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus;
MSSA= Methicillin-susceptible Staphylococcus aureus; PO= By Mouth

PAGE 51
Tigecycline (Tygacil)
Tigecycline (Tygacil)
IV Only Use requires formal ID Consult
Activity: Coverage against MRSA, VRE, most gram-negatives, and anaerobes
NOT active against Pseudomonas aeruginosa or Proteus spp.
Criteria for Use:
Alternative therapy in patients with mixed aerobic-anaerobic infections and
severe allergy to beta-lactam agents, if VRE or MRSA are involved
Alternative therapy for patients with systemic infections due to ESBL-producing
organisms (Klebsiella spp., E. coli) with severe allergies to first-line therapy
(imipenem/cilastatin or meropenem)
Alternative therapy for selected isolates of Acinetobacter, Stenotrophomonas,
and VRE
Treatment of documented VRE infections in patients unable to take linezolid
Unacceptable Uses:
Treatment of P. aeruginosa or Proteus spp. infections
Urinary tract infections (low urinary concentrations)
Peak serum concentrations do not exceed 1 mcg/mL, which limits its use for
treatment of bacteremia
Dosing in Adults:
Standard dose: 100 mg IV load x1, then 50 mg IV Q12H (use higher doses for
infections due to Acinetobacter and other MDR organisms)
Infuse each dose over 30 to 60 minutes
No renal dose adjustment
Supplemental dosing is not necessary following hemodialysis
Hepatic dose adjustment:
Severe hepatic disease (Child Pugh C): 100mg IV load x1, then 25 mg IV Q12H
Important Side Effects:
Nausea and vomiting (most common in first 1-2 days of therapy)
To minimize GI side effects avoid fasting state administration
Prolonging the infusion time (>1 hour) may make GI side effects worse
Shortening infusion time (<30 minutes) may increase the incidence of infusion
related reactions (inflammation, pain, phlebitis, other)
Management of tigecycline-induced nausea and vomiting:
Ondansetron (Zofran): Single dose of 8-12 mg IV or 8-24 mg PO
ESBL= Extended spectrum beta-lactamase; GI= Gastrointestinal; H= hour(s); ID= infectious diseases; IV= Intravenous; MDR= multi-
drug resistant; MRSA= Methicillin-resistant Staphylococcus aureus; PO= by mouth; Q= every; spp= species; VRE= Vancomycin-
resistant enterococci

PAGE 52
Liposomal Amphotericin
Liposomal Amphotericin BB (L-AmB)(AmBisome)
(L-AMB)(AmBisome)
IV Only Use requires formal ID Consult
Activity: Broad-spectrum antifungal activity with in vitro activity against Candida,
Cryptococcosis, Aspergillus, Zygomycosis, and Fusarium
Dosing of AmBisome and Amphotericin B deoxycholate is significantly different and
not interchangeable. Do not use AmBisome doses when ordering Amphotericin B
deoxycholate and vice versa
Criteria for Use:
Pre-existing renal insufficiency defined as SCr of 2 mg/dL or calculated CrCl of
25 mL/min, or SCr doubled from baseline
Patient refractory to or cannot tolerate conventional amphotericin B
deoxycholate
SCr > 1.5 mg/dL and receiving concomitant cyclosporine or tacrolimus
Patients with irreversible ESRD on chronic HD or PD should receive amphotericin
B deoxycholate
Dosing in Adults:
Standard dose:
Febrile neutropenia: 3 mg/kg/day, may consider 5 mg/kg/day in patients with
neutropenia > 10 days, evidence of fungal infection, or clinically unstable
Documented yeast (Candida spp., others) infection: 3-5 mg/kg/day
Documented mold (Aspergillus spp., others) infection: 3-5 mg/kg/day
Endopthalmitis: 5 mg/kg/day Flucytosine 25 mg/kg PO Q6H
Endocarditis: 5 mg/kg/day
Cryptococcal meningitis: 4 mg/kg/day Flucytosine 25 mg/kg PO Q6H
No renal/ hepatic dose adjustment
Monitoring:
BUN/SCr, K, Mg, Phos at baseline and daily in hospitalized patients; AST/ALT at
baseline and every 1-2 weeks
ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; BUN= Blood urea nitrogen; CrCl= Creatinine clearance;
ESRD= End-stage renal disease; H= hour(s); HD= Hemodialysis; ID= infectious diseases; IV= Intravenous; K= Potassium;
Mg= Magnesium; PD= Peritoneal dialysis; Phos= Phosphorus; PO= by mouth; Q= every; SCr= Serum creatinine; spp= species

PAGE 53
Caspofungin
Caspofungin (Cancidas)
(Cancidas)
IV Only Use Requires Formal ID Consult
Criteria for Use:
Invasive Aspergillosis:
Patients refractory to or who cannot tolerate conventional amphotericin B,
liposomal amphotericin B, or voriconazole
In combination with voriconazole or amphotericin B in patients with
documented invasive aspergillosis
Systemic Candida infections:
Systemic Candida infections secondary to C. glabrata or C. kruseii and other
non-Candida albicans (pending fluconazole susceptibility testing)
Patients unable to tolerate conventional amphotericin B or patients with
concomitant renal insufficiency as per liposomal amphotericin B guidelines
Patients unable to tolerate fluconazole as defined by a serious rash, tripling of
baseline LFTs, or other adverse reaction
Empiric use until non-albicans is confirmed

Dosing in Adults:
Standard dose: 70 mg IV x1, then 50 mg IV Q24H
No renal dose adjustment
Hepatic dose adjustment:
Moderate hepatic impairment: 70 mg IV x1, then 35 mg IV Q24H
Patients receiving rifampin or phenytoin:
Consider 70 mg IV Q24H (due to enzyme induction effect)

Monitoring:
Aspartate aminotransferase (AST)/ Alanine aminotransferase (ALT) at baseline
and weekly
ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; H= hour(s); ID= infectious diseases; IV= Intravenous;
LFTs= Liver Function Tests; PO= by mouth; Q= every

PAGE 54
Isavuconazonium sulfate
Isavuconazonium sulfate (Cresemba)
(Cresemba)
IV and PO Only Use requires formal ID Consult
Activity: Coverage against most strains of the following microorganisms, both in vitro
and in clinical infections: Aspergillus flavus, Aspergillus fumigatus, Aspergillus niger,
and Mucorales such as Rhizopus oryzae and Mucormycetes species
Criteria for Use:
Treatment of invasive aspergillosis
Treatment of invasive mucormycosis
Unacceptable Uses:
Treatment for other fungal infections (Blastomyces, Histoplasma, etc.)
Contraindicated with known hypersensitivity to isavuconazole. Caution in use in
patients with hypersensitivity to other azoles
Contraindicated in patients with familial short QT syndrome
(shortens the QTc interval in a concentration-related manner)
Dosing in Adults:
Standard dose: 372 mg IV/PO Q8H x 6 doses (48 hours; load), then 372 mg
Q24H starting 12-24 hours after last loading dose
No renal or hepatic dose adjustment
IV must be administered via an infusion set with in-line filter (pore size 0.2-1.2
micron) and should be infused over a minimum of 1 hour
No dose adjustment is necessary when changing from IV to PO

Monitoring:
AST/ALT/bilirubin at baseline and every 1-2 weeks after
Considerations for Use:
Elevated LFTs have been reported in clinical trials. Elevations generally reversible
and do not require discontinuation
May cause fetal harm when administered to a pregnant woman
Important note regarding drug interactions:
Isavuconazole is a substrate/inhibitor of CYP3A4 and has multiple drug
interactions that may affect its levels and/or those of co-administered drugs.
Dose adjustment may be necessary
Some drugs with interactions of major significance include:
Carbamazepine Cyclosporine
Rifampin/rifabutin Warfarin
Ritonavir Tacrolimus
Sirolimus Phenytoin
ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; H= hour(s); ID= infectious diseases; IV= Intravenous;
LFTs= Liver Function Tests; PO= by mouth; Q= every

PAGE 55
Voriconazole (V-Fend)
Voriconazole (V-Fend)
IV and PO Only Use requires formal ID Consult
Activity: Does not cover zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
Criteria for Use:
Treatment of documented invasive aspergillosis
Used in combination with caspofungin in microbiologically or radiographically
confirmed Aspergillus
Serious mycosis infections due to Fusarium spp., Scedosporium apiospermum

Dosing in Adults:
Standard dose:
PO: 400 mg PO x2 doses (load), then 200 mg PO Q12H (oral formulation may
be used without dose adjustment)
IV: 6 mg/kg IV x2 doses (load), then 4 mg/kg IV Q12H
In patients tolerating PO medications, should be given orally
Voriconazole oral formulation is >95% bioavailable
Renal dose adjustment:
IV voriconazole should be avoided in patients with CrCl < 50 mL/min due to
visual disturbances and accumulation of cyclodextran vehicle (excipient)
Hepatic dose adjustment:
Moderate hepatic impairment: maintenance dose (PO: 100mg PO q12H;
IV: 2 mg/kg IV Q12H)
Monitoring:
Aspartate aminotransferase (AST)/ Alanine aminotransferase (ALT)/ bilirubin at
baseline and every 1-2 weeks after
Important note regarding drug interactions:
Voriconazole has multiple drug interactions that may affect its levels and/or
those of co-administered drugs. Dose adjustment may be necessary
Some drugs with interactions of major significance include:
Carbamazepine Tacrolimus
Rifampin/rifabutin Cyclosporine
Ritonavir Warfarin
Sirolimus Phenytoin

ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; CrCl= Creatinine Clearance; H= hour(s); ID= infectious
diseases; IV= Intravenous; PO= by mouth; Q= every; spp= species

PAGE 56
Guidelines
Guidelines for Vancomycin Dosing and Determination of Trough Levels in
Adult for for
Patients
Guidelines Vancomycin
Vancomycin Dosing
Dosing and and Determination
Determination of Trough Levels in
Refer
of Trough
Adult PatientsLevels in Adult Patients
to Vancomycin Dosing Nomogram OR calculate dose as described below:
Refer
I. HowtotoVancomycin Dosing Nomogram
calculate a vancomycin dose: OR calculate dose as described below:
I. Howa)toObtain
calculate a vancomycin
actual dose:
body weight (ABW)
a) Obtain
NOTE: actual
do not body weight
calculate (ABW)on lean body weight; if morbidly obese use
dose based
ABW for initial loading
NOTE: do not calculate dose and monitor
based on leantrough or consult
body weight; ID.
if morbidly obese use
ABW for initial loading dose and monitor trough or consult ID. endocarditis,
b) Loading Dose (LD): For more severe infections (i.e., Meningitis,
pneumonia,
b) Loading Doseetc.)
(LD):consider a loading
For more dose of 25-30
severe infections (i.e.,mg/kg ABW endocarditis,
Meningitis,
pneumonia, etc.) consider a loading dose
LD = 25-30 mg/kg (Use ACTUAL body weight) of 25-30 mg/kg ABW
LD = 25-30 mg/kg
c) Maintenance dose (Use
(MD):ACTUAL body
Calculate weight)
each maintenance dose:
c) Maintenance dose (MD): Calculate each
MD = 15 mg/kg (Use ACTUAL body weight) maintenance dose:
MD = 15Populations:
d.) Special mg/kg (Use ACTUAL body weight)
MorbidPopulations:
d.) Special obesity ( 130% of IBW) use 30 mg/kg/day divided Q8H as obese
patients often require
Morbid obesity more
( 130% frequent
of IBW) use dosing intervalsdivided
30 mg/kg/day (i.e., Q8H)
Q8H1,2,3 Obese
as obese
patients rarely need doses
often require moreinfrequent
excess ofdosing
3.5 gmintervals
per day.(i.e.,
Suggest
Q8H)starting at 1
1,2,3 Obese

to 1.25 gm
patients Q8Hneed
rarely and doses
adjustin
upward
excessifofnecessary.
3.5 gm per day. Suggest starting at 1
to 1.25
Round gm Q8Hdose:
calculated and adjust upwardbe
doses should if necessary.
rounded to the nearest 250 mg
increment (i.e., 500
Round calculated mg, doses
dose: 750 mg, 1000be
should mg, 1250 mg,
rounded 1500
to the mg, etc.)
nearest 250 mg
increment (i.e., 500 mg, 750 mg, 1000 mg,
II. Estimate patients creatinine clearance (CrCl) 1250 mg, 1500 mg, etc.)
Use the
II. Estimate Cockcroft-Gault
patients equation.
creatinine (See
clearance Pharmacokinetic Section for equation)
(CrCl)
Use the Cockcroft-Gault equation.
III. Select dosing interval based on CrCl (See Pharmacokinetic Section for equation)
III. Select dosing interval based on CrCl
Estimated CrCl (mL/min) Dosing interval to consider
Estimated100
CrCl (mL/min) Dosing interval
Q8Hto consider
100
80-99 Q8HQ8H
or Q12H
80-99
50-79 Q8HQ12H
or Q12H
50-79
25-49 Q18HQ12H
or Q24H
<2525-49
mL/min Q18H
Q36H or
or Q24H
Q48H
<25 mL/min
Hemodialysis Q36H or Q48H
(checkHemodialysis
pre-dialysis level) Give an initial loading dose of
15-20loading
Give an initial mg/kg dose of
(check pre-dialysis level)
Peritoneal dialysis Re-dose patient15-20 with 15 mg/kg when serum
mg/kg
(IV administration)
Peritoneal dialysis Re-dose patient levelwith
2015mcg/mL
mg/kg when serum
(IV administration) level 20 mcg/mL
If the estimated renal function (CrCl) is near the border of two dosing intervals, it may be
reasonable to begin
If the estimated renalwith the more
function (CrCl)aggressive
is near theinterval;
borderthe dosedosing
of two can then be modified
intervals, it may ifbe
necessary
reasonableaccording to serum
to begin with levels.
the more aggressive interval; the dose can then be modified if
necessary according
ABW= Actual body to serum
weight; CrCl= levels.
Creatinine clearance; H= hour(s); IBW= ideal body weight; ID= infectious diseases; LD= loading
dose; MD= maintenance dose; Q= every
ABW= Actual body weight; CrCl= Creatinine clearance; H= hour(s); IBW= ideal body weight; ID= infectious diseases; LD= loading
dose; MD= maintenance dose; Q= every
References:
1. Bauer LA, Black DJ, Lill JS. Vancomycin dosing in morbidly obese patients. Eur J Clin Pharmacol. 1998 Oct;54(8):621-5.
References:
2. Vance-Bryan K, Guay DR, Gilliland SS, et al. Effect of obesity on vancomycin pharmacokinetic parameters as determined by using a Bayesian
1. Bauer LA,technique.
forecasting Black DJ, Lill JS. Vancomycin
Antimicrob Agentsdosing in morbidly
Chemother. obese patients. Eur J Clin Pharmacol. 1998 Oct;54(8):621-5.
1993 Mar;37(3):436-40.
2. Vance-Bryan
3. K, Guay
Blouin RA, Bauer DR, Gilliland
LA, Miller DD, et SS, et al. Effect of
al. Vancomycin obesity on vancomycin
pharmacokinetics pharmacokinetic
in normal parameters
and morbidly obese as determined
subjects. by usingChemother.
Antimicrob Agents a Bayesian
forecasting
1982 technique. Antimicrob Agents Chemother. 1993 Mar;37(3):436-40.
Apr;21(4):575-80.
3. Blouin RA, Bauer LA, Miller DD, et al. Vancomycin pharmacokinetics in normal and morbidly obese subjects. Antimicrob Agents Chemother.
1982 Apr;21(4):575-80. PAGE 57
Guidelines
Guidelines for Vancomycin
for Vancomycin Dosing
Dosing and and Determination
Determination of Trough Levels in
Adult
of Trough
Patients Levels in Adult Patients
IV. Vancomycin Levels
Vancomycin levels are NOT needed in patients with stable renal function who are
on standard doses of vancomycin AND are on therapy for less than 5 days.
Vancomycin peak levels are rarely, if ever, indicated.
NOTE: Vancomycin demonstrates concentration-independent killing; therefore,
peak concentrations are NOT useful or correlated to clinical outcomes.
Measure Trough Concentrations Only if:
Patient is receiving vancomycin therapy > 5 days
Patient has unstable renal function
Patient is on an unusual/aggressive dosing regimen
Patient is morbidly obese (> 130% of IBW)
Patient has severe or life threatening infection and is receiving concomitant
nephrotoxic drugs (i.e., cyclosporine, amphotericin B, aminoglycosides)
V. Implications for NURSING
Vancomycin needs to accumulate (steady state concentration) in order to
obtain an accurate concentration. Please DO NOT order a plasma level unless
3 doses have been administered on a given schedule (i.e., order trough prior to
the 4th dose) Exception: Dosing interval of 24 hours or longer
Trough level should be drawn within 30 minutes of the next dose
Check what time the previous vancomycin dose (prior to the trough) was
administered
Calculate how many hours are between the dose and level
Interpret the level in the context of recent vancomycin doses
Example: If the patient is on 1gm Q12H and received a dose at 11pm, then a
level taken at 6am is 7 hours post-dose and is NOT a trough level.
Be careful NOT to adjust OR hold vancomycin doses based on incorrectly
drawn levels
Do NOT hold the next dose while waiting for trough results
(sub-therapeutic levels <15mcg/mL are not effective and can lead to
resistant pathogens)
H= hour(s); IBW= Ideal body weight; Q= every

PAGE 58
Guidelines for Vancomycin Dosing and Determination
of Trough Levels in Adult Patients
Guidelines for Vancomycin Dosing and Determination of Trough Levels in
Adult Patients
VI. Target Trough Vancomycin Level

Type of Infection Target Trough Vancomycin Level

MRSA pneumonia, CNS infection


(meningitis), bacteremia, endocarditis, 15-20 mcg/mL
osteomyelitis
Endovascular Infection 15-20 mcg/mL
Maintain 15-20 mcg/mL
Check pre-dialysis level, re-dose when
Hemodialysis 20 mcg/mL
Often recommend to load with
15 20 mg/kg and re-dose
Serious infection and renal dysfunction If 24H dosing check trough at 24 hours
(CrCl < 25mL/min) Maintain 15-20 mcg/mL
VII. Adjusting a vancomycin dose (Recommendations)
Trough is too low- change the interval, keep the dose
If the level is < 5 mcg/mL, the dosing INTERVAL should be shortened
Example: Trough level after 5 days of treatment reported as 3 mcg/mL on a
regimen of 1000 mg Q12H, the interval should be shortened to 1000 mg Q8H
Trough is too high- decrease the dose, keep the interval
If the trough level is >25 mcg/mL, the DOSE should be decreased 50%
Example: Trough level after 5 days of treatment is reported as 29 mcg/mL on a
regimen of 1000 mg Q12H; the dose should be decreased to 500 mg Q12H
VIII. Monitoring (Inpatient)
Baseline weight, BUN, serum creatinine, WBC, temperature, cultures, and
sensitivities should be taken every other day in stable patients
Daily urinary INs and OUTs, CBC, and temperature should be monitored;
should be performed in patients admitted to the ICU
BUN= Blood urea nitrogen; CBC= Complete Blood Count; CNS= Central nervous system; CrCl= Creatinine clearance; H= hour(s);
ICU= Intensive Care Unit; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; WBC= White blood cells

PAGE 59
Vancomycin Dosing Nomogram

CrCl
(mL/min) Cr Cl in mL/min
Weight (kg) 30 40 50 60 70 80 90 100
500mg 500mg 500mg
30 500mg q24h 500mg q12h 500mg q12h 500mg q12h 500mg q8h
q24h q8/12h q8/12h
500mg 500mg 500mg
35 500mg q24h 500mg q12h 500mg q12h 500mg q12h 500mg q8h
q24h q8/12h q8/12h
500mg 500mg 500mg
40 500mg q24h 500mg q12h 500mg q12h 500mg q12h 500mg q8h
q24h q8/12h q8/12h
750mg 750mg 750mg
45 750mg q24h 750mg q12h 750mg q12h 750mg q12h 750mg q8h
q24h q8/12h q8/12h
750mg 750mg 750mg
50 750mg q24h 750mg q12h 750mg q12h 750mg q12h 750mg q8h
q24h q8/12h q8/12h
750mg 750mg
55 1g q24h 1g q24h 1g q12h 1g q12h 1g q12h 750mg q8h
q8/12h q8/12h
60 1g q24h 1g q24h 1g q12h 1g q12h 1g q12h 1g q8/12h 1g q8/12h 1g q8h
65 1g q24h 1g q24h 1g q12h 1g q12h 1g q12h 1g q8/12h 1g q8/12h 1g q8h
70 1g q24h 1g q24h 1g q12h 1g q12h 1g q12h 1g q8/12h 1g q8/12h 1g q8h
75 1.25g q24h 1.25g q24h 1.25g q12h 1.25g q12h 1.25g q12h 1.25g q8/12h 1.25g q8/12h 1.25g q8h

weight in kg
80 1.25g q24h 1.25g q24h 1.25g q12h 1.25g q12h 1.25g q12h 1.25g q8/12h 1.25g q8h 1.25g q8h

85 1.25g q24h 1.25g q24h 1.25g q12h 1.25g q12h 1.25g q12h 1.25g q8/12h 1.25g q8h 1.25g q8h
Vancomycin Dosing Nomogram

90 1.25g q24h 1.25g q24h 1.25g q12h 1.25g q12h 1.25g q12h 1.25g q8/12h 1.25g q8h 1.25g q8h
95 1.5g q24h 1.5g q24h 1g q8h 1g q8h 1g q8h 1.5g q8h 1.5g q8h 1.5g q8h
100 Contact Antimicrobial Stewardship Team If Patient is obese: 30mg/kg/day in divided doses q8h

PAGE 60
Guidelines
Guidelines for for Administration
Administration of High
of High Dose Dose Once Daily
Once Daily
Aminoglycosides
Aminoglycosides (HDOD)(HDOD)
High Dose Once Daily Aminoglycosides (HDOD) are considered safe and effective in
patients with stable renal function
Exclusion Criteria for HDOD:
If patients fall into the following categories, use traditional/conventional dosing since
there is limited data using HDOD in the following patient populations

Acute renal failure OR CrCl < 20 mL/min Age < 18 OR > 90


Half-life (t1/2) 4 hours Severe burns
Dialysis Ascites
To use Traditional Dosing Methods, see
www.globalrph.com medical calculator
For AMG dosing, contact the Antimicrobial Stewardship team
or follow the steps below:
I. Calculate the patients Ideal Body Weight (IBW)
Male: 50 kg + [2.3 kg for each inch over 5 feet]
Female: 45 kg + [2.3 kg for each inch over 5 feet]
II. Determine the dose based on the table below (round dose to the nearest
20 mg)
Aminoglycoside Maintenance Dose
Tobramycin 5 mg/kg (IBW)
Gentamicin 5 mg/kg (IBW)

Dose is based on IBW except in obese patients OR those under their IBW
Use ABW if patient weight is less than IBW
Use AdjBW in patients who are obese ( 130% of IBW)
Adjusted Body Weight (AdjBW) Calculation
AdjBW = 0.4 (ABW IBW) + IBW
III. Estimate the patients creatinine clearance (CrCl) using the Cockcroft and Gault
equation
(refer to Pharmacokinetic Section)
IV. Select dosing interval based on calculated CrCl from the tables below:
CrCl (mL/min) Estimated Dosing Interval
60 Every 24 hours
4059 Every 36 hours
2039 Every 48 hours
20 Use traditional dosing method, see www.
Globalrph.com medical calculator
ABW= Actual Body Weight; AdjBW= Adjusted Body Weight; AMG= aminoglycosides (i.e., gentamicin and tobramycin);
CrCl= Creatinine clearance; HDOD= High Dose Once Daily Aminoglycosides; IBW= Ideal Body Weight (in kg); t1/2= half life

PAGE 61
Guidelines
Guidelines for Administration
for Administration of Once
of High Dose HighDaily
Dose Once Daily
Aminoglycosides
Aminoglycosides (HDOD)(HDOD)
V. Commonly Targeted Peak and Trough Concentrations in HDOD
Disease State Gentamicin/Tobramycin Amikacin

Recommended Estimated mg/kg Recommended Estimated mg/kg


Peak (mcg/mL) (IBW) Peak (mcg/mL) (IBW)
Cystitis
68 23 30-40 1015
Gram-Positive
68 23 3040 1015
Synergy
Pyelonephritis
1214 34 6070 20
Pneumonia
1620 56 6080 2025
Sepsis 1012 34 6070 20
Intra-abd/SSTI 1216 45 6070 20
Clinical
Considerations Trough should not exceed 0.3 mcg/mL Trough should not exceed 1 mcg/mL

VI. Monitoring of serum levels and dosage adjustments


a. First-dose levels are NOT routinely needed
First-dose levels may be indicated in patients with variable volume of
distribution or unstable renal function (sepsis or post-operatively) to assess
clearance
b. Serum levels should be performed routinely by day 3 of therapy only once it has
been determined that aminoglycoside therapy is to continue
Example: empiric therapy for sepsis from a UTI awaiting culture results does
not require peak/trough levels
c. Peak and trough serum levels: 12 hours post-end of infusion (peak) and
immediately prior to the next dose
Document actual time medication was hung
Obtain peak level 1-2 hour post infusion (very important for distribution
phase); 2 hr preferred if dose > 400 mg
Use pharmacokinetic formulas (or www.globalrph.com medical calculator),
to extrapolate peaks and troughs
Extrapolated trough concentrations should not exceed 0.30 mg/mL
Dosage or interval adjustments should be made at this time
d. Once stabilized, if therapy is to continue > 1 week, obtain the following laboratory
values:
SCr and BUN levels to monitor renal function (every other day)
Peak and trough levels (efficacy and no toxicity), twice per week
e. If there is a suggested change in renal function OR other nephrotoxic agents (e.g.,
cisplatin, amphotericin B, pentamidine, vancomycin) are being used concurrently,
more frequent levels of BUN, SCr, and monitoring may be necessary
BUN= Blood urea nitrogen; HDOD= high dose once daily; IBW= ideal body weight; SCr= Serum creatinine; SSTI= skin and soft
tissue infection; UTI= Urinary tract infection

PAGE 62
Antimicrobial Dosing Guidelines for Adult Patients
Antimicrobial Dosing Guidelines for Adult Patients
Based
Basedon
on Renal Function
Renal Function
CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD
ACYCLOVIR IV
>50 5 mg/kg Q8H 10 mg/kg Q8H*
30-50 5 mg/kg Q12H 10 mg/kg Q12H* D
10-29 5 mg/kg Q24H 10 mg/kg Q24H*
<10 2.5 mg/kg Q24H 5 mg/kg Q24H*
Dose using ideal body weight
*Use maximum dose for meningitis/encephalitis and varicella in immunocompromised
host
AMOXICILLIN PO
> 30 250 mg Q8H 500 mg Q8H
MD
10-29 250 mg Q12H 500 mg Q12H
<10 500 mg Q24H 500 mg Q24H
AMOXICILLIN/CLAVULANATE
PO
> 30 500 mg Q8-12H* 875 mg Q12H MD
10-29 500 mg Q12H 875 mg Q12H
<10 500 mg Q24H 875 mg Q24H
*Use 500 mg Q8H for osteomyelitis for CrCl 30 mL/min
AMPICILLIN IV
>50 1 gm Q4-6H 2 gm Q4-6H*
30-50 1 gm Q8H 2 gm Q6-8H MD
10-29 1 gm Q12H 2 gm Q8-12H
<10 1 gm Q24H 2 gm Q24H
*Use 2 gm Q4H for meningitis
AMPICILLIN/SULBACTAM IV
>50 1.5 gm Q6H 3 gm Q6H*
30-50 1.5 gm Q8H 3 gm Q8H* MD
10-29 1.5 gm Q12H 3 gm Q12H*
<10 1.5 gm Q24H 3 gm Q24H*
*Use 3 gm if penetration is an issue (abscess/diabetic foot /vascular insufficiency/
osteomyelitis/intra-abdominal)
AZTREONAM IV
>50 1 gm Q8H 2 gm Q6H
30-50 1 gm Q12H 1 gm Q8H MD
10-29 1 gm Q24H 1 gm Q12
<10 500 mg Q24H 1 gm Q24H
CEFAZOLIN IV
>50 1 gm Q8H 2 gm Q8H
30-50 1 gm Q8H 2 gm Q8H
MD
10-29 1 gm Q12H 2 gm Q12H
<10 1 gm Q24H (2gm 2 gm Q24H
Q48H)
PAGE 63
Antimicrobial Dosing Guidelines for Adult Patients
Antimicrobial Dosing Guidelines for Adult Patients
Based
Based on RenalFunction
on Renal Function
CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD
CEFEPIME IV
>50 1 gm Q12H 2 gm Q12H
30-50 1 gm Q24H 2 gm Q24H D
10-29 1 gm Q24H 1 gm Q24H
<10 0.5-1 gm Q24H 1 gm Q24H
Pseudomonal Coverage or Febrile Neutropenia: >50: 2gm Q8H; 30-50: 2gm Q12H; 10-29:
1gm Q12H; < 10: 1gm Q24H
CEFPODOXIME PO
30 100 200 mg Q12H 400 mg Q12H
<30 100 200 mg Q24H 400 mg Q24H MD
HD 100 200 mg 3 times 400 mg 3 times per
per week week
CEFUROXIME PO
20 250 mg Q12H 500 mg Q12H MD
< 20 250 mg Q24H 500 mg Q24H
CEFTRIAXONE IV
>50 1 gm Q24H 2 gm Q24H* SD
<50-5 (INCLUDING HD) No Change No Change
*All indications are dosed at 1gm Q24H with the exception of meningitis (2 gm Q12H)
and osteomyelitis (2 gm Q24H)
CEPHALEXIN PO
>30 250 mg Q6H 500 mg Q6H
MD
10-29 250 mg Q8H 500 mg Q8H
<10 250 mg Q12H 500 mg Q12H
CIPROFLOXACIN IV
>30 400 mg Q12H* 400 mg Q8H*
SD
10-29 400 mg Q24H 400 mg Q12H
<10 400 mg Q24H 400 mg Q24H
*Use Q8H dosing only for Pseudomonas aeruginosa
CIPROFLOXACIN PO
>30 500 mg Q12H 750 mg Q8H
SD
10-29 500 mg Q24H 750 mg Q12H
<10 250 mg Q24H 500 mg Q24H
CLINDAMYCIN IV
>50 600 mg Q8H 900 mg Q8H ND
<50 No Change No Change
CLINDAMYCIN PO
>50 300 450 mg Q8H 450 mg Q6H ND
<50 No Change No Change

PAGE 64
Antimicrobial
Antimicrobial Dosing
Antimicrobial Dosing
Guidelines
DosingGuidelines
Guidelines for Adult
for for Adult
Adult
Patients
Patients
Patients
Based
Basedon
Based on Renal
on Renal Function
Function
Renal Function
C
CRRC
CLL ((M
ML/ MIN))
L/MIN SSTANDARD
TANDARD D
DOSE
OSE MAXIMAL D
MAXIMAL DOSE
OSE HD
HD
D ICLOXACILLIN PO
DICLOXACILLIN PO ND
ND
>50
>50 250
250 500
500 mg
mg Q6H
Q6H 250
250 500
500 mg
mg Q6H
Q6H
<50
<50 No Change
No Change No Change
No Change
D OXYCYCLINE PO
DOXYCYCLINE PO
>50
>50 100
100 mg
mg Q12H
Q12H 100
100 mg
mg Q12H
Q12H ND
ND
<50
<50 No Change
No Change No Change
No Change
FFLUCONAZOLE
LUCONAZOLE IV/PO*
IV/PO*
>30
>30 200
200 mg
mg Q24H
Q24H 400
400 mg
mg Q24H**
Q24H** MD
MD
10-29
10-29 100
100 mg
mg Q24H
Q24H 200
200 mg
mg Q24H
Q24H
<10
<10 100
100 mg
mg Q48H
Q48H 200
200 mg
mg Q48H
Q48H
*RECOMMENDATIONS
*RECOMMENDATIONS FOR FOR SYSTEMIC
SYSTEMIC INFECTION
INFECTION ONLY,
ONLY, NOT
NOT FUNGURIA.
FUNGURIA.
Give
Give PO
PO if
if patient
patient has
has functioning
functioning GI
GI tract
tract
**May
**May require
require dosages
dosages up
up to
to 800
800 mg/d
mg/d depending on Candida
depending on Candida species/sensitivities
species/sensitivities
G ANCICLOVIR IV
GANCICLOVIR IV
>50
>50 2.5-5*mg/kg Q24H
2.5-5*mg/kg Q24H 5
5 mg/kg
mg/kg Q12H
Q12H
30-50
30-50 1.25 mg/kg Q24H
1.25 mg/kg Q24H 2.5
2.5 mg/kg
mg/kg Q24H
Q24H D
D
10-29
10-29 0.625
0.625 mg/kg
mg/kg Q24H
Q24H 1.25
1.25 mg/kg
mg/kg Q24H
Q24H
<10
<10 0.625 mg/kg
0.625 mg/kg Q48H
Q48H 1.25 mg/kg
1.25 mg/kg Q48H
Q48H
*5
*5 mg/kg
mg/kg for
for CrCl
CrCl 70
70 mL/min,
mL/min, 2.5
2.5 mg/kg
mg/kg for
for CrCl
CrCl 50-69
50-69 mL/min
mL/min
G ANCICLOVIR PO
GANCICLOVIR PO
>50
>50 1
1 gm
gm Q8H
Q8H
30-50
30-50 1-1.5 gm Q24H
1-1.5 gm Q24H D
D
10-29
10-29 500 mg Q24H
500 mg Q24H
<10
<10 500
500 mg
mg Q48H
Q48H
IIMIPENEM
MIPENEM/C
/CILASTATIN
ILASTATIN
>50
>50 500
500 mg
mg Q6H
Q6H 1
1 gm
gm Q6H*
Q6H*
30-50
30-50 500
500 mg
mg Q8H
Q8H 500
500 mg
mg Q6H*
Q6H* MD
MD
10-29
10-29 500
500 mg
mg Q12H
Q12H 500
500 mg
mg Q8H*
Q8H*
<10
<10 250
250 mg
mg Q12H
Q12H 500
500 mg
mg Q12H*
Q12H*
For
For suspected
suspected pseudomonas
pseudomonas or
or ESBL
ESBL infection
infection use
use max
max doses
doses
M EROPENEM IV
MEROPENEM IV
>> 50
50 1
1 gm
gm Q8H
Q8H 2
2 gm
gm Q8H
Q8H
26
26 50
50 1
1 gm
gm Q12H
Q12H 1
1 gm
gm Q8H
Q8H MD
MD
10
10 25
25 500
500 mg
mg Q12H
Q12H 1
1 gm
gm Q12H
Q12H
<10 OR HD*
<10 OR HD* 500
500 mg
mg Q24H
Q24H 1
1 gm
gm Q24H
Q24H
*If
*If patient
patient on
on HD
HD schedule
schedule daily
daily dose
dose to
to be
be administered
administered immediately
immediately after
after dialysis.
dialysis.
M ETRONIDAZOLE IV/PO*
METRONIDAZOLE IV/PO*
>10
>10 500
500 mg
mg Q8H
Q8H 500
500 mg
mg Q8H
Q8H MD
MD
<10
<10 500
500 mg
mg Q12H
Q12H 500
500 mg
mg Q12H
Q12H
*No
*No indication
indication for
for Q6H
Q6H dosing
dosing

PAGE 65
Antimicrobial DosingGuidelines
Antimicrobial Dosing Guidelines
forfor Adult
Adult Patients
Patients
BasedononRenal
Based Function
Renal Function
CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD
MOXIFLOXACIN IV/PO
>50 400 mg Q24H 400 mg Q24H ND
<50 No Change No Change
NAFCILLIN/OXACILLIN
>50 1 gm Q4H 2 gm Q4H ND
<50-5 (Including HD) No Change No Change
NITROFURANTOIN*
>50 100 mg Q12H N/A
<50 Not Recommended
*Do not use in systemic infections. Drug is ineffective with CrCl < 40mL/min due to
inadequate urinary concentrations.
OSELTAMIVIR PO
> 60 75 mg Q12H 75 mg Q12H
>30-60 30 mg Q12H 30 mg Q12H N/A
>10-30 30 mg Q24H 30 mg Q24H
PIPERACILLIN/TAZOBACTAM*
>50 3.375 gm Q6H 3.375 gm Q4H
30-50 3.375 gm Q6H 3.375 gm Q6H MD
10-29 3.375 gm Q8H 3.375 gm Q6H
<10 3.375 gm Q12H 3.375 gm Q8H
*Use for maximal dose for empiric therapy or treatment of Pseudomonas aeruginosa. If
polymicrobial infection without P. aeruginosa is suspected, consider using
ampicillin/sulbactam
RIFAMPIN PO
>10 10 mg/kg Q24H 10 mg/kg Q12H N/A
<10 10 mg/kg Q24H 10 mg/kg Q24H
SULFAMETHOXAZOLE/
TRIMETHOPRIM IV Non-PCP PCP
>50 2.5 mg/kg Q12H 5 mg/kg Q6H
MD
30-50 2.5 mg/kg Q12H 5 mg/kg Q6H
10-29 2.5 mg/kg Q12H 5 mg/kg Q12H
<10 2.5 mg/kg Q24H 5 mg/kg Q24H*
Dosing based on trimethoprim (TMP) component. *Avoid if possible, not recommended
by manufacturer for CrCl <15 mL/min due to nephrolithiasis.

PAGE 66
Antimicrobial DosingGuidelines
Antimicrobial Dosing Guidelines
for for Adult
Adult Patients
Patients
Based
Basedon
on Renal Function
Renal Function
CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD
SULFAMETHOXAZOLE/
TRIMETHOPRIM PO (Equal to IV Dose)
>50 1-2 DS Q8-12H 5 mg/kg Q6H
5 mg/kg Q6H MD
30-50 1-2 DS Q12H
10-29* 1-2 DS Q12H* 5 mg/kg Q12H*
<10* 1-2 DS Q24H* 5 mg/kg Q24H*
Dosing based on trimethoprim (TMP) component. Round to the nearest 160 mg of TMP
component. *Not recommended by manufacturer for CrCl <15 mL/min due to
nephrolithiasis
VANCOMYCIN PO **
>50 125 mg Q6H ND
<50 No Change
**For C. difficile only in patients with sdevere disease or failed metronidazole therapy
*For IV dosing see vancomycin dosing guidelines
Dosing based on Cockcroft and Gault Equation
D= Dialyzed 50 100%; HD= Hemodialysis; MD= Moderately dialyzed 20-49%; N/A= No information available;
ND= Not dialyzed 0-5%

PAGE 67
Antimicrobial Duration
Antimicrobial Duration of Therapy
of Therapy
STRENGTH OF
INFECTIOUS DISEASE RECOMMENDED DURATION OF THERAPY
RECOMMENDATION

Clostridium difficile
Mild-moderate (initial episode) 10 14 days (vancomycin) A-I
Severe, uncomplicated 10 14 days (vancomycin) B-I
(initial episode)
First recurrence (based on severity) 10 14 days A-II (C-III)
Skin and Skin Structure
5 days (may require additional therapy NA
Uncomplicated cellulitis
depending on patients response)
Complicated MRSA (deeper soft
7-14 days (based on patients NA
tissue infections, surgical/traumatic
response)
wound infection, major abscesses,
cellulitis, and infected ulcers and
burns)
Genitourinary
Catheter-associated urinary tract 7 days if prompt resolution of A-III
infection symptoms OR 10-14 days for delayed
clinical response
5 days if using levofloxacin in a patient B-III
who is not seriously ill
3 days in a female 65 years old B-II
without upper urinary tract symptoms
after catheter has been removed
Asymptomatic bacteriuria in a 3 -7 days A-III
pregnant female

Acute uncomplicated cystitis in an Nitrofurantoin: 5 days A-I


adult female Trimethoprim-sulfamethoxazole: A-I
3 days
Fosfomycin: 1 dose A-I
Intra-abdominal
Established intra-abdominal 4-7 days A-III
infection where source control is
achieved
Acute stomach and proximal jejunal 24 hours of therapy B-II
perforations where source control is
achieved within 24 hours, in the
absence of acid-reducing therapy or
malignancy
Acute appendicitis without evidence 24 hours A-I
of perforation, abscess, or local
peritonitis
Bowel injuries attributable to 24 hours A-I
penetrating, blunt, or iatrogenic
trauma that are repaired within 12h
and any other intraoperative
contamination of the operative field
by enteric contents
MRSA= Methicillin-Resistant S. aureus; NA= not applicable

PAGE 68
Antimicrobial
Antimicrobial Duration
Antimicrobial Duration
Duration of of Therapy
of Therapy
Therapy
SSTRENGTH OF
IINFECTIOUS DISEASE
NFECTIOUS DISEASE
RRECOMMENDED DURATION OF THERAPY
ECOMMENDED DURATION OF THERAPY
TRENGTH OF
RRECOMMENDATION
ECOMMENDATION

Pneumonia
Pneumonia
Community-acquired
Community-acquired pneumonia
pneumonia Minimum
Minimum of
of 55 days
days B-I/II
B-I/II
-- Should
Should be be afebrile
afebrile for
for 4872
4872 H
H
AND
AND have 1 associated sign
have 1 associated sign of
of
clinical
clinical instability
instability before
before
discontinuation of therapy
discontinuation of therapy
Hospital-acquired,
Hospital-acquired, ventilator- 14
associated,
ventilator- 14 to
to 21
21 days
days Level
Level II
associated, and
and healthcare-
healthcare- -- As
As short
short as
as 77 days,
days, provided
provided that
that
associated
associated pneumonia the
pneumonia the targeted
targeted pathogen
pathogen is is identified
identified
based on bronchoscopy
based on bronchoscopy and theand the
etiologic
etiologic pathogen
pathogen is not P.
is not P.
aeruginosa,
aeruginosa, and
and that
that the
the patient
patient
has
has aa good
good clinical
clinical response
response with
with
resolution
resolution ofof clinical
clinical features
features of
of
infection
infection
Diabetic
Diabetic Foot
Foot
General
General recommendation
recommendation Continue
Continue antibiotic
antibiotic therapy
therapy until
until
there
there is
is evidence
evidence that
that the
the infection
infection
has
has resolved
resolved but
but not
not necessarily
necessarily until
until
aa wound
wound has
has healed
healed
Specific
Specific situations:
situations:
Mild
Mild DFI
DFI 1-2
1-2 weeks
weeks (though
(though some
some require
require an
an A-II
A-II
additional
additional 1-2
1-2 weeks)
weeks)
Moderate
Moderate toto severe
severe DFI
DFI 2-4
2-4 weeks
weeks A-II
A-II
(without
(without osteomyelitis)
osteomyelitis)
Diabetic
Diabetic Foot
Foot Infection
Infection with
with 4-6
4-6 weeks
weeks B-II
B-II
Osteomyelitis
Osteomyelitis -- shorter
shorter ifif entire
entire infected
infected bone
bone is is
removed
removed and and probably
probably longer
longer ifif
bone remains
bone remains
Catheter-related
Catheter-related Bloodstream
Bloodstream
Infections
Infections (CRBSI)
(CRBSI)
Uncomplicated
Uncomplicated CRBSI
CRBSI due
due to
to 5-7 days OR
5-7 days OR observation
observation alone
alone (if
(if no
no B-III
B-III
coagulase
coagulase negative
negative staphylococci
staphylococci intravascular
intravascular or
or orthopedic
orthopedic hardware
hardware isis C-III
C-III
other than S. lugdunensis
other than S. lugdunensis
present
present and
and additional
additional blood
blood cultures
cultures
(catheter are obtained after catheter withdrawal
(catheter removed)
removed) are obtained after catheter withdrawal
to
to confirm
confirm the
the absence
absence of
of bacteremia)
bacteremia)
CRBSI 4-6
4-6 weeks
weeks from
from first
first negative
negative blood
CRBSI with
with persistent
persistent bacteremia
bacteremia blood A-II
A-II for
for
culture
culture following
following catheter
catheter removal S.
and
and fungemia
fungemia >> 72H
72H following
following removal S. aureus;
aureus;
catheter
catheter removal,
removal, associated
associated C-III
C-III for
for other
other
endocarditis,
endocarditis, or
or supportive
supportive pathogens
pathogens
thrombophlebitis
thrombophlebitis
CRBSI 6-8
6-8 weeks
weeks from
from first
first negative
negative blood A-II
CRBSI with
with associated
associated blood A-II
osteomyelitis culture
culture following
following catheter
catheter removal
removal
osteomyelitis
7-10 A-II
A-II
Catheter-associated
Catheter-associated exit
exit site
site or
or 7-10 days
days following
following catheter
catheter removal
removal
tunnel and
and incision
incision and
and drainage
drainage (if
tunnel infection
infection without
without (if
associated indicated)
associated bacteremia
bacteremia or
or indicated)
fungemia
fungemia
CRBSI= Catheter-related Bloodstream Infections; DFI= Diabetic foot infections; H= hour(s)
CRBSI= Catheter-related Bloodstream Infections; DFI= Diabetic foot infections; H= hour(s)
PAGE 69
Antimicrobial Duration
Antimicrobial Duration of Therapy
of Therapy
This guidance is adopted from the National Antimicrobial Stewardship Taskforce

References:
1. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract
infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin
Infect Dis 2010;50:625-63.
2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of
asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54.
3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated
cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European
Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103-e120.
4. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults
and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis
2010;50:133-64.
5. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2): S27-S72.
6. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-
acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416.
7. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004;39:885-
910.
8. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular
catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1-45.
9. Jenkins TC, Knepper BC, Sabel AL, et al. Decreased Antibiotic Utilization After Implementation of a Guideline for Inpatient
Cellulitis and Cutaneous Abscess. Arch Intern Med. 2011;171(12):1072-79.
10. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update
by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect
Control Hosp Epidemiol 2010;31(5):431-55.
11. Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis 2011;52:1-38.
12. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue
infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52.

PAGE 70
IVIVtotoPOPOAntibiotic
Antibiotic Step-Down
Step-Down Guidelines
Guidelines
Candidates for Antimicrobial Step-Down therapy:
Patient is able to tolerate PO medication AND has a functioning GI tract
The infection is treatable with oral antimicrobial therapy AND the indications
and spectrum of activity are identical or similar between alternative drugs
No evidence of malabsorption, dysphagia, or gastrointestinal bleed
Patient is hemodynamically stable with improving body temperature and WBC
High risk patients who MAY NOT be candidates for PO step-down may be
identified by:
Pulse >125bpm
RR >30bpm
Systolic BP < 90 mmHg
T < 35oC OR >40oC, altered mental status
Contraindications to Antimicrobial Step-Down therapy:
Serious infections concomitant with chemotherapy induced severe neutropenia
Infections caused by resistant organisms (i.e. MRSA, VRE) unresponsive to >1
course of antimicrobials
Situations where oral antimicrobials may not achieve adequate drug
concentrations at the site of infection (i.e. meningitis, endocarditis)
Oral antimicrobial therapy may be used in neutropenic patients with negative
blood cultures, temperatures < 38oC, and no indication of clinical sepsis
Table 1. IV to PO Antimicrobial Step-Down Options
IV Antimicrobial PO Antimicrobial
Ampicillin/sulbactam Amoxicillin/clavulanate
Azithromycin Azithromycin
Cefazolin/Ceftazidime Cephalexin/Cephadrine
Ciprofloxacin Ciprofloxacin*
Ceftriaxone Cefpodoxime
Cefuroxime Cefuroxime axetil
Clindamycin Clindamycin*
Doxycycline Doxycycline
Fluconazole Fluconazole*
Moxifloxacin Moxifloxacin *
Metronidazole Metronidazole*
Nafcillin Dicloxacillin
Trimethoprim/sulfamethoxazole Trimethoprim/sulfamethoxazole*
*Oral drugs which achieve serum levels similar to the parenteral dose form
BP= blood pressure; bpm= beats/breaths per minute; GI= Gastrointestinal; IV= intravenous; MRSA= Methicillin-resistant
Staphylococcus aureus; PO= by mouth; RR= Respiratory rate; T= temperature; VRE= Vancomycin-resistant enterococci;
WBC= White blood cells

PAGE 71
Twelve
TwelveSteps
Steps
to to Prevent
Prevent Antimicrobial
Antimicrobial Resistance
Resistance
Twelve Steps to Prevent Antimicrobial Resistance
1. Wash your hands! 8. Know when to say NO to broad spectrum
1. Wash your hands! 8. Know when to say NO to broad spectrum
2. Vaccinate agents
2. Vaccinate agents
3. Get the catheters out 9. Treat infection - not colonization
3. Get the catheters out 9. Treat infection - not colonization
4. Obtain cultures 10. Treat infection - not contamination
4. Obtain cultures 10. Treat infection - not contamination
5. Target the pathogen 11. Stop treatment when infection is cured
5. Target the pathogen 11. Stop treatment when infection is cured
6. Seek expert input or unlikely
6. Seek expert input or unlikely
7. Know the local sensitivity patterns 12. Prevent transmission
7. Know the local sensitivity patterns 12. Prevent transmission
Adopted from the Centers for Disease Control Campaign for Clinicians
Adopted from the Centers for Disease Control Campaign for Clinicians

Contact
ContactPrecautions
Contact Precautions
Precautions
TYPES OF CONTACT PRECAUTIONS FOR INFECTION CONTROL
TYPES OF CONTACT PRECAUTIONS FOR INFECTION CONTROL
Precaution Gowns Gloves Masks Hands Conditions
Precaution
Standard Gowns
If splattering Gloves
For contacts If Masks WASHHands Conditions
upon ALL patients
Standard If
ofsplattering
body fluids For
withcontacts
mucous If
aerosolization WASH
enteringupon
and ALL patients
of
or body
bloodfluids
is with mucous
membranes, aerosolization
or splattering entering and
leaving room
or blood is
likely membranes,
non-intact skin or splattering
of body fluids leaving room
likely non-intact
and ALL bodyskin of
or body
bloodfluids
is
and
fluidsALL body or blood is
likely
fluids Use Transmission
Use Standard Precautions on all patients. likelyBased Precautions below in addition to Standard
Use Standard Precautions on all patients. Use Transmission
PrecautionsBased Precautions below in addition to Standard
Precautions
CATEGORY SPECIFIC ISOLATION PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS
CATEGORY SPECIFIC ISOLATION PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS
Approved,
Approved, Tuberculosis or rule
prefitted
WASH upon Tuberculosis or rule
out tuberculosis.
prefitted
respirator
Airborne Not necessary Not necessary WASH upon
entering and out tuberculosis.
Respiratory phase of
respirator
protection and
Airborne Not necessary Not necessary entering and
leaving room Respiratory
measles andphase of
chicken
protection
required N-95and
leaving room measles
pox and chicken
required
mask N-95
pox
mask Infected or colonized
Infected
patients, or colonized
whether
Upon entering patients,
bedriddenwhether
or
Upon entering
room and for all
Contact For suctioning, if WASH upon bedridden
ambulatory,orwith
Upon entering room andwith
contacts for all
Contact For suctioning,
organism is in if WASH upon
entering and ambulatory, with
wounds or diarrhea:
Upon
patiententering
room contacts with
patient and organism
sputum is in entering and
leaving room wounds or diarrhea:
multi-resistant
patient room patient
surfacesand
or sputum leaving room multi-resistant
organisms, MRSA, VRE,
surfaces
equipment or in
organisms, MRSA, VRE,
C. difficile diarrhea or
equipment
room in
C. difficile diarrhea or
ESBL
room
ESBL
MRSA in sputum,
To handle MRSA in sputum,
Neisseria meningitidis,
Within three feet WASH upon
To handle
respiratory Neisseria meningitidis,
drug resistant
Droplet Not necessary
respiratory
secretions or
Within three feet
of the patient WASH upon
entering and
drug resistant
pneumococci,
Droplet Not necessary
secretions
of the patient
(regular masks) entering and
leaving room
suctioning or pneumococci,
diptheria, pertussis,
(regular masks) leaving room
suctioning diptheria,
influenza pertussis,
WASH upon influenza
Protective Neutropenia (< 1000
Not necessary Not necessary Not necessary WASH
enteringupon
and
Protective
Environment Neutropenia (< 1000
neutrophils), ANC <100
Not necessary Not necessary Not necessary entering and
leaving room
Environment leaving room
neutrophils), ANC <100
Refer to Policy MCM 111-P26 Standard and Transmission Based Precautions
Refer
CalltoInfection
Policy MCM 111-P26and
Prevention Standard
Controland
forTransmission Based
further guidance Precautions
at ext 2654
Call Infection Prevention and Control for further guidance at ext 2654

PAGE 72
Pharmacokinetic Calculations
Pharmacokinetic Calculations
Pharmacokinetic Calculations
Ideal Body Weight (IBW) Calculation:
Ideal Body Weight (IBW) Calculation:
Male: 50 kg + [2.3 kg for each inch over 5 feet]
Female:
Male: 45 kg + [2.3 kg for each inch over 5 feet]
50
Female: 45 kg + [2.3
Creatinine Clearance (CrCl) using kg for each inch
Cockcroft-Gault over 5 feet]
Equation:
Creatinine is
Creatinine Clearance
expressed (CrCl) using Cockcroft-Gault Equation:
in mL/min
Creatinine is expressed in mL/min
CrCl (mL/min) =(140 age) (IBW in kg)*
CrCl (mL/min) =(14072 (SCr
age)in mg/dL)
(IBW *
in kg)
72 (SCr in mg/dL)
NOTE: For Females multiply by 0.85
NOTE: For Females multiply by 0.85
CrCl for elderly patients or when no height is available:
CrCl for elderly patients=(114
CrCl (mL/min) or when no *age))
(0.8 height is available:
CrCl (mL/min) =(114
SCrin(0.8 *age))
mg/dL

SCr in mg/dL
NOTE: For females multiply by 0.9
NOTE: For females multiply by 0.9
*If patients actual body weight is less than IBW, use actual body weight to calculate
*CrCl
If patients actual body weight is less than IBW, use actual body weight to calculate
CrCl
If patient is underweight/cachectic, may consider rounding SCr up to 1 mg/dL.1,2
Do not round
If patient to 1 mg/dL for all patients
is underweight/cachectic, may >consider
60 yearsrounding
of age.3-5SCr up to 1 mg/dL.1,2
Do not round
Adjusted BodytoWeight
1 mg/dL for all patients dosing)
(aminoglycoside > 60 years of age.3-5
Adjusted
Use Body
adjusted Weight
body (aminoglycoside
weight (AdjBW) whendosing)
actual body weight (ABW) is 30% of ideal
body weight (IBW)
Use adjusted body weight (AdjBW) when actual body weight (ABW) is 30% of ideal
body weight (IBW) AdjBW = 0.4 (ABW - IBW) + IBW
AdjBW = 0.4 (ABW - IBW) + IBW
IBW= Ideal Body Weight (in kg); AdjBW= Adjusted Body Weight; ABW= Actual Body Weight; CrCl= Creatinine clearance;
SCr= serum creatinine
IBW= Ideal Body Weight (in kg); AdjBW= Adjusted Body Weight; ABW= Actual Body Weight; CrCl= Creatinine clearance;
SCr= serum creatinine

References:
1. Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med.
References:
1993;21(10):1487-1495.
1. Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med.
2. Khuu T, Bagdasarian G, Leung J, et al. Estimating aminoglycoside clearance and creatinine clearance in underweight patients. Am J Health-
1993;21(10):1487-1495.
Sys Pharm. 2010;67(4):274-279.
2. Khuu T, Bagdasarian G, Leung J, et al. Estimating aminoglycoside clearance and creatinine clearance in underweight patients. Am J Health-
3. Bertino JS. Measured versus estimated creatinine clearance in patients with low serum creatinine values. Ann Pharmacother.
Sys Pharm. 2010;67(4):274-279.
1993;27(12):1439-1442.
3. Bertino JS. Measured versus estimated creatinine clearance in patients with low serum creatinine values. Ann Pharmacother.
4. Smythe M, Hoffman J, Kizy K, Dmuchowski C. Estimating creatinine clearance in elderly patients with low serum creatinine concentrations.
1993;27(12):1439-1442.
Am J Hosp Pharm. 1994;51(2):198-204.
4. Smythe M, Hoffman J, Kizy K, Dmuchowski C. Estimating creatinine clearance in elderly patients with low serum creatinine concentrations.
5. Dowling TC, Wang E-S, Ferrucci L, Sorkin JD. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals
Am J Hosp Pharm. 1994;51(2):198-204.
Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy. 2013;33(9):912-921.
5. Dowling TC, Wang E-S, Ferrucci L, Sorkin JD. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals
Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy. 2013;33(9):912-921.
PAGE 73
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