Orders preceded with a: must be checked to be initiated. will be initiated unless a line is drawn through them.

Bulleted items indicate reminders 1026 A Avenue NE Cedar Rapids, Iowa 52406

Antimicrobial Treatment for Sepsis

Patient data

Information needed for pharmacy to dose antibiotics: Weigh patient as soon as possible. Actual weight ________kg

If unable to weigh now: Estimate weight _________kg Height ________ ft _________in or __________cm

Unknown Sources

(Choose one): Piperacillin/Tazobactam (Zosyn) 3.375 grams intravenously NOW and every 6 hours AND Levofloxacin (Levaquin) 750mg intravenously NOW and every 24s AND Vancomycin 20mg/kg = _____________ mg IV NOW then per pharmacy protocol If Penicillin/Cephalosporin Allergy: Levofloxacin (Levaquin) 750 mg intravenously NOW and every 24 hours AND Aztreonam (Azactam) 2 grams intravenously NOW and every 8 hours AND Vancomycin 20mg/kg = _____________mg IV NOW then per pharmacy protocol. (Choose one): Cefotetan (Cefotan) 1gram intravenously NOW and every 12 hours If Penicillin/Cephalosporin Allergy: Levofloxacin (Levaquin) 500mg intravenously NOW and every 24 hours AND Metronidazole 500mg intravenously NOW and every 8 hours (Choose one): MSSA SSTI (Methicillin-susceptible Staph aureus): Nafcillin 1gram intravenously NOW and every 4 hours Cefazolin (Ancef) 1 gram or (2 grams if weight is greater than 80 kilograms) intravenously NOW and every 8 hours PCN/Cephalosporin Allergy: Clindamycin (Cleocin) 600 mg intravenously every 8 hours MRSA SSTI (Methicillin-resistant Staph aureus): Vancomycin 20mg/kg = __________ mg intravenously NOW and per pharmacy protocol

Intraabdominal Infection

Skin and Soft Tissue Infection (SSTI)

Date: ____________ Time: _______ Physician Signature: _______________________________

VORB

Date: ____________ Time: _______ Nurse Signature: _____________________________________ Date: ____________ Time: _______ Sent to Pharmacy by: _____________________ Initials__________

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Patient Label

Antimicrobial Treatment for Sepsis

Order Set

Urinary Tract Infection

(Choose one): Ceftriaxone (Rocephin) 1 gram intravenously NOW and every 24 hours Piperacillin/Tazobactam (Zosyn) 3.375 grams intravenously NOW and every 6 hours Levofloxacin (Levaquin) 750mg intravenously NOW and every 24 hours Ampicillin 2 grams intravenously NOW and every 6 hours AND Tobramycin 5mg/kg intravenously NOW (if creatinine clearance greater than 20 ml/minutes) and then per pharmacy protocol (Choose one): Monotherapy: Imipenem/Cilastatin (Primaxin) 500 mg intravenously NOW and every 6 hours Combination therapy: Imipinem/Cilastatin (Primaxin) 500mg intravenously NOW and every 6 hours AND Tobramycin 7mg/kg intravenously NOW (if creatinine clearance greater than 20 ml/minutes) and then per pharmacy protocol Cefepime (Maxipime) 2 grams intravenously NOW and every 8 hours AND Tobramycin 7mg/kg intravenously NOW (if creatinine clearance greater than 20 ml/minutes) and then per pharmacy protocol If risk factors for MRSA are present, ADD the following in addition to the selections above, Vancomycin 20mg/kg = ________mg intravenously NOW and per pharmacy protocol (Choose one): Ceftriaxone (Rocephin) 2 grams intravenously NOW and every 12 hours Ceftriaxone (Rocephin) 2 grams intravenously NOW and every 12 hours AND Vancomycin 20 mg/kg = ______ mg intravenously NOW and per pharmacy protocol If patient is over 50 years old OR immunocompromised ADD the following in addition to the selections above: Ampicillin 2 grams intravenously NOW and every 4 hours

Febrile Neutropenia

Meningitis

Date: ____________ Time: _______ Physician Signature: _______________________________

VORB

Date: ____________ Time: _______ Nurse Signature: _____________________________________ Date: ____________ Time: _______ Sent to Pharmacy by: _____________________ Initials__________

Page 2 of 2
Version: 1 Release Date:

Original-Chart

Copy-Pharmacy

Patient Label

Antimicrobial Treatment for Sepsis

Order Set