UK Antimicrobial Manual

8/8/2019 UK Antimicrobial Manual

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University of KentuckyGuide to Empiric Antimicrobial Therapy

2004

The University of Kentucky Chandler Medical Center800 Rose Street

Lexington, KY 40536

Edited by:

Craig Martin, Pharm.D.Pharmacy Services

Antimicrobial Management ServiceUniversity of Kentucky Medical Center

and

Ardis Hoven, M.D.Department of Medicine, Division of Infectious Diseases

Antimicrobial Management ServiceUniversity of Kentucky Medical Center

1st Edition edited by Ighovwhera Ofotokun, M.D.


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TABLE OF CONTENTS

I. INTRODUCTIONIntroductory Comments. 3

Antimicrobial Subcommittee .... 3Restricted Antimicrobial Policy. 4Restricted Antimicrobial Policy Flowchart 5Antimicrobial Management Team (AMT) Daily Follow-Up 6Restricted Antimicrobial Order Form.... 7

II. GUIDELINES FOR EMPIRIC ANTIMICROBIAL THERAPY FOR ADULTSCommunity Acquired Pneumonia Point Scoring System............................... 8Community Acquired Pneumonia ...... 9Hospital Acquired Pneumonia......... 10Management of Neutropenic Fever .... 11Acute Bacterial Meningitis. ... 12Duke Criteria for Diagnosis of Infective Endocarditis .. 13Bacterial Endocarditis.. .. 14Urinary Tract Infections.. .. 15

Osteomyelitis .. 16Septic Arthritis ... 17Intravascular Catheter-Related Infections 18Preoperative Antibiotic Prophylaxis.... 19

III. ANTIMICROBIAL DOSAGE FOR NORMAL AND IMPAIRED RENALFUNCTION.. 21

IV. COMPARATIVE COST TABLE. 22V. REFERENCES...... 23VI. CONTACT INFORMATION ... 24VII. ANTIBIOGRAM 25


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INTRODUCTION TO UKCMC GUIDE TO EMPIRIC

ANTIMICROBIAL THERAPY

2004

This book is designed to assist practitioners in selecting the most effective antibiotics with thefewest adverse reactions that are most cost-effective for overall care delivery. The first sectionprovides guidelines for empiric antibiotic use according to disease state. In this section,recommendations for empiric antibiotics are based upon the organisms most likely to cause theinfection; thus, susceptibility patterns of the organisms at this institution were taken intoconsideration in the selection of antibiotics of choice. Recommendations on the final antibioticselection and duration of therapy should be based on microbiologic results, the patients clinicalcourse, and the results of published clinical literature. The recommendations in this manual aremeant for the management of adult patients.

Additional sections provide information on dosing guidelines for antibiotics in patients withnormal and impaired renal function, University of Kentucky Chandler Medical Center(UKCMC) antimicrobial cost data, and antibiotic susceptibility patterns in our institution.

This booklet is intended to serve as an adjunct to obtaining infectious disease consultation ratherthan as a replacement for appropriately indicated consultations.

ANTIMICROBIAL SUBCOMMITTEE CHARGE

The Antimicrobial Subcommittee was appointed by the Pharmacy and Therapeutics Committeeto review existing antimicrobial formulary agents and to develop and implement effectiverestricted policies for selected antimicrobial agents in the effort to prevent the development ofresistant nosocomial pathogens, minimize inappropriate antimicrobial use, and containexpenditures.

Committee Members

Ardis Hoven, MD, Chair Paul Kearney, MDCraig Martin, PharmD, Secretary Susanne Liewer, PharmDJohn Armitstead, MS, RPh Malkanthie McCormick, MD


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RESTRICTED ANTIMICROBIAL POLICY

I. The use of the following formulary antimicrobial agents is restricted at UKCMC:Amphotericin B lipid complex (Abelcet)

Caspofungin (Cancidas)Daptomycin (Cubicin)

IV Itraconazole (Sporanox

)Meropenem (Merrem)

Quinupristin/dalfopristin (Synercid)

Linezolid (Zyvox)

Valganciclovir (Valcyte)Vancomycin

Voriconazole (VFend)

II. To ensure the rational use of restricted formulary antimicrobial agents, the followingpolicies and procedures are to be used at UKCMC.

a) When a physician wishes to prescribe a restricted antimicrobial agent, he/she shallindicate on the Restricted Antimicrobial Order form (RAOF) the approvedreason for use. If the use is outside of an approved indication, the physician mustobtain approval for use from the Antimicrobial Management Team (AMT) bypaging 3737 between 0800 & 1700 Monday to Friday. Having received approvalfor use, the physician shall order the drug using the RAOF.(RAOF may be completed and sent to Pharmacy without prior approval to obtaina restricted agent between 1701 & 0759 M-F and weekends).

b) Upon receipt of an incomplete RAOF or an order for a restricted antimicrobialagent written on a standard physicians order form, the pharmacist will dispense a24 hour supply of drug. The pharmacist must notify the prescribing physician that

further drug will be dispensed only when a completed RAOF is received.


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RESTRICTED ANTIMICROBIAL POLICY FLOWCHART

Physician determines that a patient requires a restricted formulary antimicrobial agent

Reason for use within approved indications Reason for use outside approved indications

The physician completes a RestrictedAntimicrobial Order form (RAOF)

and sends it to Pharmacy

Physician pages beeper #4309 between 0800 & 1700 for

approval. (From 1701 to 0759 M-F & weekends, RAOF may

be completed and sent to Pharmacy without prior approval to

obtain a restricted agent)

Restricted antimicrobial agentdispensed by Pharmacy

Approval made either via a

discussion with AMT personnel or

full ID consult

Not approved and restricted

agent D/Cd by AMT

personnel

RAOF reviewed by Antimicrobial

Management Team (AMT) andfeedback provided to prescribing

physician if needed

ID Consult may be obtained

if continuation of restricted

agent is desired

5


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ANTIMICROBIAL MANAGEMENT TEAM (AMT) DAILY

FOLLOW-UP

AMT pharmacist reviews all RAOF and cultures

and identifies need for intervention

AMT pharmacist reviews problem

cases with AMT physician

AMT contacts prescribing

physician and then D/C

inappropriate therapy

No culture growth after 48 hrs

Prescribing physician notified by

AMT pharmacist of D/C of restricted

agent. Thereafter, continuation of

restricted agent, if still desired, will

be by the approval of ID physician

Pathogens identified

from culture report6

Physicians Dept. Chair or

Division Chief may be

notified of non-compliance

with policy

Pathogen susceptible to unrestricted agent, and

no CI to the use of unrestricted agent. AMT

pharmacist notifies prescribing physician of

D/C of restricted agent and recommends an

alternative unrestricted agent.

Pathogen susceptible only

to restricted agents, therapy is

continued

Contraindication


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RESTRICTED ANTIMICROBIAL ORDER FORM

DATE: _________ TIME: __________ Name:

PROCESSED BY: _______ Medical Record #:

Allergies ________________________________ Date of Birth:

Wt _________ kg Sex: M F

Serum Creatinine______mg/dL

VANCOMYCIN CONTINUATION

Vancomycin (IV/PO/PR)Automatic discontinuation after 72 hrs if patientfails to meet any of the listed criteria unlessapproved by Antimicrobial Management Team(AMT, pager 3737) or ID Consult Service. Pts

will be reevaluated every 2 weeks by AMT forcontinuation of vancomycin therapy.For documented infections, please include:Site (s) ______________________________Pathogen(s)__________________________

*In patients with neutropenic fever, vancomycinmay be used beyond 72h in patients who havebeen afebrile within first 3 days of vancomycintreatment, have no identified etiology, and are

at high risk for complications as defined by theInfectious Diseases Society of America fromClin Infect Dis1997-25:551-73

Serious infection due to -lactam resistant gram-positivemicroorganism documented by culture-per HICPAC of the CDC

Serious infection due to gram-positive microorganism in patients with

serious allergy to -lactam agents when other agents are not

adequate-per HICPAC of the CDC Antibiotic-associated colitis (AAC) failing to respond to metronidazole

or if AAC is severe and potentially life-threatening (or for AAC inpediatric patients who cannot tolerate oral metronidazole)-perHICPAC of the CDC

Unexplained fever (single oral temp >101F or 100.4F over 1hr) inneutropenic patients who have severe mucositis, previous quinoloneprophylaxis, known MRSA colonization or penicillin/cephalosporinresistant S. pneumoniae, clinically obvious catheter-related infection,or hypotension.

None of the above criteria met, vancomycin continuation approved byInfectious Diseases Consult ServiceAntimicrobial Management Team (AMT)

FOR THE FOLLOWING AGENTS: NO PRIOR APPROVAL NECESSARY WHEN USED FOR AN APPROVEDINDICATION. FOR USE OUTSIDE THE APPROVED INDICATIONS,

ANTIMICROBIAL MANAGEMENT APPROVAL IS REQUIRED (PAGER 3737) M-F 0800-1700.

DRUG APPROVED INDICATIONS FOR USE

Caspofungin (Cancidas) Invasive aspergillosis in pts. refractory/intolerant to Amphotericin B

IV Itraconazole (Sporanox) Invasive fungal infection in pts. refractory/intolerant to Amphotericin B

Valganciclovir (Valcyte) AIDS patient with cytomegalovirus retinitis admitted for inductiontherapySolid organ or bone marrow transplant patient

Meropenem (Merrem)For documented infections, please include:Site (s) ______________________________

Pathogen(s)__________________________

Pathogen resistant to other antimicrobial agents Documented Extended Spectrum Beta-Lactamase producingorganism

Quinupristin/Dalfopristin (Synercid)Patients should have central line/PICC line

and/or dilute drug in250ml D5W

Pathogen resistant to other antimicrobials, including vancomycin

Allergy to -Lactams/vancomycin and resistant to other antimicrobials

Linezolid (Zyvox) (IV/PO)Caution in patients with thrombocytopenia

Pathogen resistant to other antimicrobials including vancomycin

Allergy to -Lactams/vancomycin and resistant to other antimicrobials

Voriconazole (VFend ) (IV/PO) Broad spectrum antifungal therapy needed and one of the following:


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PREDICTIVE RULES POINT SCORING SYSTEM FOR

COMMUNITY ACQUIRED PNEUMONIA

Class I Age< 50 y; no comorbidities, no abnormal physical exam (PE) findings

Class II 70 pointsClass III 71-90 pointsClass IV 91-130 pointsClass V >130 points

SCORING SYSTEM

Patient Characteristics Points Assigned

Demographic FactorsMale Age (in yrs)Female Age (in yrs) 10Nursing home resident +10

ComorbiditiesNeoplastic disease +30Liver disease +20Congestive heart failure +10Cerebrovascular disease +10Renal disease +10

PE findings

Altered mental status +20Respiratory rate 30 breaths/min +20Systolic blood pressure < 90 mm Hg +20

Temperature < 35C (95F) or 40C (104F) +15

Pulse rate 125 beats/min +10

Lab findingspH < 7.35 +30

BUN >30 mg/dL +20Sodium < 130 mEq/L +20Glucose > 250 mg/dL +10Hematocrit < 30% +10PO2 < 60 mm Hg +10Pleural effusion +10


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COMMUNITY ACQUIRED PNEUMONIA

PNEUMOCOCCAL VACCINE INDICATE

1. All patients ages 65 years

2. Patients ages 2-64 years with

-Chronic obstructive pulmonary disease

-Diabetes mellitus

-Alcoholism

-Cardiovascular disease

-Liver disease

-CSF leak

-Asplenia

-Immunocompromised

Clinical features: fever, cough, pleuritic chest pain, dyspnea,

purulent sputum, leukocytosis, hypoxia, CXR infiltrate

Lab tests: CXR, sputum GS & culture, blood culture x 2 sets,

consider urinaryLegionella antigen, O2Sat/ABG

EVALUATE FOR HOSPITALIZATION USING CLINICALPREDICTIVE RULES

CLASS I & II

Manage as outpatient

CLASS III & IV

Hospitalize patient

CLASS V

Hospitalize patient

9

EMPIRIC THERAPY

doxycycline or

levofloxacin or

high dose amoxicillin +

azithromycin

GENERAL MEDICAL FLOOR INTENSIVE CARE UNIT

PATHOGEN DEFINED

No pathogen defined or

test pendingNo pathogen defined or

test pending

EMPIRIC THERAPY

ceftriaxone + azithromycin or

levofloxacin or

ampicillin/sulbactam + azithromycin

Pathogen-specific

therapy EMPIRIC THERAPY

piperacillin/tazobactam + levofloxacin or

cefepime + levofloxacin

Likely pathogens include Pneumococcus, Mycoplasma, Legionella, Chlamydia pneumoniae, H. influenzae, viruses. No organism isolated in 40-60% of cases.

Compromised patients, e.g. HIV, transplant, recipients of steroids (15mg of prednisone qd) or other immunosuppressants may have pneumonia due to CMV,

Aspergillus, Nocardia, etc. See clinical predictive rules on page 6. In patient with -lactam allergy, use aminoglycoside + levofloxacin.

HOSPITAL ACQUIRED PNEUMONIA (HAP)


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HOSPITAL ACQUIRED PNEUMONIA (HAP)

Pneumonia occurring later than 48 hrs after hospitalization

Clinical features: fever, cough, purulent sputum,

Dyspnea, CXR infiltrate, leukocytosis, hypoxia

LABS: CXR, ABG/O2Sat, Blood culture x 2,

sputum/ET secretions/BAL/bronchoscopy brush if

available for GS and cultures

NO PATHOGEN DEFINEDOR CULTURE PENDING

PATHOGEN IDENTIFIED1Initiate pathogen-specific therapy

Non-ICU2

Hospital days 4 daysMildly ill

Non-ICU

Severely ill ICU Vent

10

piperacillin/tazobactam or

ceftriaxone piperacillin/tazobactam + aminoglycoside orcefepime + aminoglycoside For ICU pts, aminoglycoside mbe replaced by levofloxacin

RENAL FAILURE OR RISK OF RENAL FAILURE

For patients on other nephrotoxic drugs, in patients with

pre-existing renal failure, s/p kidney transplant, MOF5,

consider replacing aminoglycoside with levofloxacin

ADD VANCO IF MRSA SUSPECTED

Previous MRSA pneumonia

Gram stain with GPC in clusters

No response to above antibiotics

PCN ALLERGY (anaphylax

levofloxacin + aminoglycoside

aztreonam + aminoglycoside

1Organisms to ignore in most cases: Candida, Enterococci, coag. neg. Staph, all gram positive rods other thanB. anthracis. Compromised pts, e.g. HIV, transplant, patients on steroids (15mg

prednisone qd) and other immunosuppressants may have pneumonia due to CMV,Aspergillus, Nocardia, etc.2Early onset 4 days, Pathogens include Pseudomonas, MRSA, resistant gram negative bacilli, Acinetobacter.4Add azithromycin or levofloxacin if atypical pneumonia (Legionella, Mycoplasma, Chlamydia pneumoniae) suspected. 5Multiple organ failure.

NEUTROPENIC FEVER


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NEUTROPENIC FEVER

Single oral temp > 38.3C (101F), OR > 38.0C (100.4F) over 1 hour and

ANC < 500/mm3 or < 1000/mm3 with predicted decline to < 500/mm3

Common pathogens: Staphylococcus sp,

Enterococcus sp, Pseudomonas and other gramnegative bacteria, virus (CMV and adenovirus),

Candida and other invasive fungi

Lab tests: Blood cultures from all indwelling catheter ports and 1

peripheral culture, urinalysis and urine culture, sputum culture (ifavailable), chest x-ray (per symptoms), stool culture (if diarrhea

present), electrolytes, and CBC with differential

Empiric Therapy

Tobramycin + Piperacillin/tazobactam 3.375 g IV q6h

Check random tobramycin levels 4 and 12 hours after 1st dose

Patients with a non-anaphylactic penicillin

allergy should receive cefepime in place of

piperacillin/tazobactam

Patients with an anaphylactic penicillin

allergy should receive levofloxacin in place

of piperacillin/tazobactam

Add vancomycin IF the patient has any of the following:

Severe mucositis

Colonization history with MRSA

Previous documented MRSA or Methicillin Resistant

Staph. epidermidis (MRSE) infection

Obvious catheter infection

Hypotension

Reassess after three

days of therapy

Fever resolves Fever persist

11

s

Etiology not identified Etiology identified Etiology not identified

Continue antibiotics until

ANC > 500/mm3 or x 5-7

days after last documented

fever (consider switching tolevofloxacin)

Adjust antibiotic agent

and duration of

therapy for

documented infection

Progressive disease (clinically unstable): Review empiric

antibiotics & consider Infectious Disease team consult

Clinically stable: Add vancomycin

*Page Pharm.D. for antibiotic dosing in patients with decreased renal function

Reassess five days after empiric therapy

initiated. If fever persists, add amphotericin B

or voriconazole

ACUTE BACTERIAL MENINGITIS


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ACUTE BACTERIAL MENINGITIS

Clinical features: fever, headache, neck pain/stiffness, mental status changes

Obtain blood cultures ASAP (within 5 min of arrival) and GIVE 1st ANTIBIOTIC DOSE AS

SOON AS POSSIBLE, AT LEAST WITHIN 30 MINUTES OF ARRIVAL

CSF STUDIES*

Opening pressure, cell count, protein, glucose, gram stain & routine bacterial

cultures, latex agglutination test. In appropriate clinical scenarios, consider PCR

for HSV, cryptococcal antigen, VDRL, AFB/fungal smears & cultures

Community acquiredElderly or

Compromised ptPost-neurosurgery

Post-traumatic

EMPIRIC THERAPY

Dexamethasone 10mg IV q6h(1stdose prior to antibiotics)

vancomycin + ceftriaxone 2g IV q12h

EMPIRIC THERAPY

Dexamethasone 10mg IV q6h(1stdose prior to antibiotics)

vancomycin +ceftriaxone 2g IV q12h + ampicillin

EMPIRIC ANTIBIOTICS

vancomycin + cefepime or


12

ADJUST ANTIBIOTICS BASED ON FINAL CULTURE RESULTS

ID CONSULT HIGHLY RECOMMENDED

*Consider head CT in patients with altered mental status, focal neurologic deficit or papilledemaCommonly isolated pathogens includepneumococcus, meningococcus, H. influenzae

Commonly isolated pathogens includepneumococcus, meningococcus, H. influenza; Listeria is also a concern

Commonly isolated pathogens include S. aureus, coag. neg. Staph, gram negative bacilli (Pseudomonas, E.coli, Klebsiella, Serratia, Enterobacter)


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DUKE CRITERIA FOR DIAGNOSIS OF INFECTIVE ENDOCARDITIS (IE)

MAJOR CRITERIA

1. BLOOD CULTURES:a. At least two separate blood cultures positive for typical organisms for IE in the

absence of a primary focusb. Persistently positive blood cultures (i.e. all 3 or a majority of 4 or more sets; with

the first and last drawn at least 1 hr apart)

2. CARDIAC INVOLVEMENT:a. Oscillating intra-cardiac massb. Intra-cardiac abscessc. New partial dehiscence of prosthetic valved. New regurgitant murmur

MINOR CRITERIA

1. Predisposing heart condition or intravenous drug use

2. Fever: 38C (100.4F)3. Vascular phenomenon: septic emboli, mycotic aneurysm, Janeway lesions,

subconjunctival hemorrhages4. Immunologic phenomena: glomerulonephritis, Oslers nodes, Roth spots, rheumatoid

factor5. Positive blood cultures not meeting major criteria above6. Echocardiogram findings not meeting major criteria above

DEFINITIVE ENDOCARDITIS DIAGNOSIS requires the presence of:Two (2) major criteria ORFive (5) minor criteria OROne (1) major and three (3) minor criteria.

POSSIBLE ENDOCARDITIS DIAGNOSIS requires the presence of:

Three (3) minor criteria OROne (1) major and one (1) minor criteria

ENDOCARDITIS DIAGNOSIS IS EXCLUDED if:Resolution of manifestations of endocarditis, with antibiotic therapy for 4 days or less,OR firm alternate diagnosis for manifestations of endocarditis Does not meet criteria for


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BACTERIAL ENDOCARDITIS

Clinical features: fever, night sweats, weight loss, cardiac murmur

Establish diagnosis based on Duke criteria

LABS: 3 sets of blood cultures drawn 1 hr apart

CBC with differential, CMP, ESR/CRP, UA + micro

Echocardiogram: Transthoracic/transesophageal as indicated

Native valve2 IV drug user3 Prosthetic valve4

EMPIRIC ANTIBIOTICS

nafcillin5 gentamicin6EMPIRIC ANTIBIOTICS

vancomycin + gentamicin6


ID CONSULT HIGHLY RECOMMENDED

See Duke diagnostic criteria on page 11

Pathogens of concern include S. aureus, pneumococcus, Enterococci species, HACEKgroup

Pathogens of concern include S. aureus, Pseudomonas and other gram negative bacilli, Candida species Pathogens of concern include coag. neg. Staph, S. aureus, Enterococci species, Candida Use VANCOMYCIN ifMRSA/Enterococcus suspected or pt has severe penicillin allergy Synergistic dose of gentamicin recommended

EMPIRIC ANTIBIOTICS

vancomycin + gentamicin6

rifampin

14

URINARY TRACT INFECTION


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URINARY TRACT INFECTION

LABS: Urinalysis, urine micro, gram stain & culture, blood cultures in patients

with systemic symptoms. Consider renal ultrasound/CT in patients not responding

to appropriate treatment or with recurrent UTIs.

Clinical features: Urinary frequency/urgency/dysuria, suprapubic

discomfort, (fever, hematuria, CVA tenderness, WBC)

Asymptomatic

bacteriuria

UncomplicatedUTI

Acutepyelonephritis

ComplicatedUTI

If catheter-associated,

replace or

D/C catheter

Treatmentindicated

in pregnant

women

Obstruction, reflux,

azotemia, transplant,Foley catheter-related

TMP/SMX or

cephalexin

Rx for 3 days

ampicillin/sulbactam or

amoxicillin/clavulanate or

ampicillin + gentamicin or

levofloxacin

Rx for 10-14 days


Enterococcus and Candida are common colonizers of the urinary tract in hospitalized patients. No Rx required in asymptomatic immunocompetent patients

Likely pathogens: enteric gram negative bacilli (E.coli, Klebsiella, Proteus, Enterobacter, Citrobacter), S. saprophyticus

Likely pathogens: enteric gram negative bacilli listed above, Pseudomonas, Enterococcus


ceftriaxone or

levofloxacin

Rx for 2-3 wks

Work-up structural abnormalities

amoxicillin or

cephalexin

Rx for 3 days

Screen for recurrence

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OSTEOMYELITIS

(Requiring urgent antibiotic treatment; e.g. associated with fever, WBC, limb threateninLABS: Bone biopsy for gram stain and culture and pathology if possible. Gram stain and

culture of pus (wound swab usually not helpful), CBC with differential, ESR/CRP, blood

culture in acute cases. Bone imaging: Plain XR/MRI/bone scan as indicated

Osteo: HematogenousCommunity acquired1

Post-op osteo2

following ORIF3

,sternostomy, etc.

Osteo with acute symptoms complicatingvascular insufficiency or DM foot ulcers4

16

EMPIRIC ANTIBIOTICS

nafcillin or

cefazolin or

clindamycin

EMPIRIC ANTIBIOTICS

vancomycin tobramycin or


EMPIRIC ANTIBIOTICS


clindamycin + gentamicin

ADJUST ANTIBIOTICS TO FINAL CULTURES & SENSITIVITIES

SURGICAL DEBRIDEMENT AND HARDWARE REMOVAL SHOULD BE CONSIDERED

1Likely pathogens: S. aureus, Streptococci species, Salmonella in sickle cell pts, Pseudomonas following nail puncture injury2Likely pathogens: Staph (MSSA, MSSE, MRSA, MRSE), gram negative bacilli including Pseudomonas3Open reduction and internal fixation4

Likely pathogens: Usually polymicrobial including Staph species, gram negative bacilli, anaerobes, Streptococci species

SEPTIC ARTHRITIS


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SEPTIC ARTHRITIS

LABS: CBC with differential, blood cultures, arthrocentesis, ESR/CRP

Joint imaging: Plain XR or CT/MRI as indicated

SEND JOINT FLUID FOR: Gram stain, routine bacterialcultures, crystals, CBC with diff, glucose

If indicated, AFB/fungal smears and cultures

NATIVE JOINT PROSTHETIC JOINT

EMPIRIC ANTIBIOTICS

cefazolin + gentamicin

EMPIRIC ANTIBIOTICS

vancomycin + gentamicin

JOINT FLUID GRAM STAIN AVAILABLE1

7

GRAM POSITIVE COCCI

nafcillin or

vancomycin

GRAM NEGATIVE BACILLI

ceftriaxone + gentamicin

ESTABLISH ADEQUATE JOINT DRAINAGE.

FOR PROSTHETIC JOINT, CONSIDER SURGICALCONSULT

GRAM NEGATIVE COCCI

ceftriaxone

ADJUST ANTIBIOTICS TO FINAL CULTURE AND SENSITIVITIES

ID CONSULT RECOMMENDED

Likely pathogens: S. aureus, Streptococci species, gram negative bacilli andN. gonorrhoeae in sexually active pts.

Likely pathogens: Staph species (MSSA, MSSE, MSSA, MRSA), gram negative bacilli, rarely anaerobes

Use vancomycin in pts with prosthetic joints,MRSA/MRSEcolonization, previousMRSA/MRSEinfections


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INTRAVASCULAR CATHETER-ASSOCIATED INFECTIONS

Remove catheter and send for

semiquantitative culture

If uncomplicated (No pocket

infection or port abscess), may

initially retain catheter.

If no erythema, purulence,

or sepsis, may initially

retain catheter.

If blood cultures become positive

Complicated (Pocket infection

or port abscess)

Unstable pt, begin

vancom cin theraStable pt, considervancomycin therapy

Blood/CVC Culture Results

Blood cx (-), CVC not initially

removed: If fever persists,remove and culture CVC

Blood cx (-), CVC cx (-):

Look for other source of fever

Blood Cx (-), CVC >15 cfu:

Monitor for signs of sepsis andrepeat blood cx as necessary

Blood cx (+), CVC >15 cfu:

Initiate appropriate

antimicrobial therapy

Nontunneled CVCs*

Obtain 2 sets of blood cultures (one percutaneous) before antimicrobial therapy

Peripheral venous catheter Tunneled CVCs and Implantable Devices

Erythema or purulence overexit site or signs of sepsis

If blood cultures become

positive

* CVC-central venous catheter

Note: Neutropenic patients should also receive antimicrobial coverage for nosocomial gram-negative bacteria aspursuant to the UK Guidelines for Neutropenic Fever Therapy.

18


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ADULT Perioperative Antimicrobial Prophylaxis GuidelinesAntimicrobial Selection and Dosing

Surgical Category Antimicrobial Agent and Adult Dose(See opposite side for pediatric doses)

Notes

Cardiac/Vascular/

Non-Cardiac Thoracic

Cefazolin 1g IV x1 Should be continued for nolonger than 24 hours.

GastrointestinalBiliary Tract,

Gastroduodenal,

Appendectomy (non-perf),

Colorectal

Ampicillin/Sulbactam 3g IV x1 For penicillin-allergic patients:Clindamycin 900mg IV x1 +Gentamicin 5mg/kg IV x1(max 400mg)

OrthopedicWith prosthetic material Cefazolin 1g IV x1 Most clean procedures without

prosthetic material do notrequire prophylaxis.

Head and NeckWith prosthetic material Cefazolin 1g IV x1 Most clean procedures without


Clean-contaminated(oral or pharyngeal mucosa is

compromised)

Cefazolin 1g IV x1 +metronidazole 500mg IV infusion x1

For cephalosporin or severelypenicillin-allergic patients:Clindamycin 900mg IV x1 +Gentamicin 5mg/kg IV x1(max 400mg)

Neurosurgical Cefazolin 1g IV x1

OB/GYN

Cesarean delivery with active labor

or premature rupture of membranes

Cefazolin 1g IV x1 Prophylaxis should be givenimmediately after the umbilical

cord is clamped.

Hysterectomy Cefazolin 1g IV x1

Urologic

(for patients with known bacteriuria

only)

Sulfamethoxazole/Trimethoprim 160mg(TMP component) IV infusion over 60minutes x1

Alternative agents may benecessary based on results ofprior urine cultures.Doxycycline 100mg IV infusionover 60 minutes x1 may begiven for patients with a sulfaallergy.

Notes:-For patients with known colonization with MRSA or previous MRSA infection, vancomycin 1gm IV x1 may be used for prophylaxis.

Vancomycin must be given over 60 minutes to minimize the likelihood of Red Mans Syndrome.

-Sulfamethoxazole/Trimethoprim and Doxycycline should be administered as an infusion over 60 minutes.


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PEDIATRIC Perioperative Antimicrobial Prophylaxis GuidelinesAntimicrobial Selection and Dosing

Surgical Category Antimicrobial Agent and Pediatric Dose

(See opposite side for pediatric doses)

Notes

Cardiac/Vascular/

Non-Cardiac Thoracic

Cefazolin 30mg/kg IV Should be continued for nolonger than 24 hours.

Gastrointestinal

Biliary Tract,

Gastroduodenal,

Appendectomy (non-perf),

Colorectal

0-2yrs: Ampicillin 50mg/kg IV +Gentamicin 3mg/kg IV +Clindamycin 15mg/kg IV

>2 yrs: Ampicillin/Sulbactam 50mg/kg

(ampicillin component)

For penicillin-allergic patients:Clindamycin 15mg/kg x1 +Gentamicin 3mg/kg x1

OrthopedicWith prosthetic material Cefazolin 30mg/kg IV x1 Most clean procedures without


Head and NeckWith prosthetic material Cefazolin 30mg/kg IV x1 Most clean procedures without


Clean-contaminated

(oral or pharyngeal mucosa is

compromised)

Cefazolin 30mg/kg IV x1 +Clindamycin 15mg/kg IV x1

For penicillin-allergic patients:Clindamycin 15mg/kg IV x1 +Gentamicin 3mg/kg IV x1

Neurosurgical Cefazolin 30mg/kg IV x1

Urologic

(for patients with known bacteriuria

only)

0-2 yrs: Gentamicin 3mg/kg IV x1>2 yrs: Sulfamethoxazole/Trimethoprim5mg/kg (trimethoprim component) IVinfusion over 60 minutes x1

Alternative agents may benecessary based on results ofprior urine cultures.

Notes:-For patients with known colonization with MRSA or previous MRSA infection, vancomycin 15mg/kg IVPB x1 may be used for

prophylaxis. Vancomycin must be given over 60 minutes to minimize the likelihood of Red Mans Syndrome.

-For all procedures in which cefazolin is administered, a repeat dose should be given if the procedure lasts >4 hours.

-For individuals with prosthetic heart valves, native valve abnormalities, or other conditions requiring endocarditis prophylaxis, consultthe American Heart Association Guidelines, available at JAMA 1997;277:1794-1801 OR The Sanford Guide to AntimicrobialTherapy.

References:

Medical Letter. Antimicrobial Prophylaxis in Surgery. Med Lett Drugs Ther. October 29, 2001;43(1116-1117):92-7.


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ANTIMICROBIAL DOSING RECOMMENDATIONS FOR ADULT PATIENTS

Drug Clcr

>50 ml/min

Clcr

30-50 ml/min

Clcr

10-29 ml/min

Clcr


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ANTIMICROBIAL COST DATA FOR UNIVERSITY OF KENTUCKY

MEDICAL CENTER

Drug Standard Adult Dosing

(Clcr >50 ml/min)

Relative Cost

PenicillinsAmpicillinAmoxicillinPenicillin GPenicillin VNafcillin

Dicloxacillin

Ampicillin/sulbactam (Unasyn)

Amoxicillin/clavulanate (Augmentin)

Piperacillin/tazobactam (Zosyn)

1 g IV q6h500 mg po q8h1-4 MU IV q4h500 mg po q6h1 g IV q4h

500 mg po q6h1.5-3 g IV q6h875 mg IV q12h3.375 g IV q6h

$$$$$

$$$$$$$$$

CephalosporinsCefazolinCephalexinCefdinir

Ceftriaxone (Rocephin)

Cefepime (Maxipime)

1 g IV q8h500 mg po q6h600 mg po q24h1 g IV q24h1-2 g IV q12h

$$$$$$$$$$

AminoglycosidesGentamicinTobramycinAmikacin

7 mg/kg IV q24h7 mg/kg IV q24h15 mg/kg IV q24h

$$$$$

MiscellaneousClindamycin IVClindamycin PODaptomycin IVDoxycycline IV

Doxycycline POErythromycin IVErythromycin POAzithromycin IVAzithromycin POMetronidazole IVMetronidazole POTMP/SMX (non-PCP dose)TMP/SMX POVancomycinMeropenem

AztreonamLevofloxacin IVLevofloxacin POQuinupristin/Dalfopristin

Linezolid IV (Zyvox)

Linezolid PO (Zyrox)

600 mg IV q8h300 mg po q6h4 mg/kg IV q24h100 mg IV q12h

100 mg po q12h500 mg IV q6h500 mg po q6h500 mg IV q24500 mg po q24h500 mg IV q8h500 mg po q8h2.5-5 mg/kg TMP IV q12h160 mg TMP po bid15 mg/kg IV q12-24h

1 g IV q8h1 g IV q8h

500 mg IV q24h500 mg po q24h

7.5 mg/kg IV q8-12h600 mg IV q12h600 mg po q12h

$$$$$$$$$

$$$$$$$$$$$$$

$$$$$$$

$$$$$

$$$$$$$$$$$$$$$

Antifungal Agents


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REFERENCES

Community acquired pneumonia.1. Mandell L, Bartlett J, Dowell S, et al. Update of Practice Guidelines for the Management of Community-

Acquired Pneumonia in Immunocompetent Adults.Clin Infect Dis 2003; 37:1405-33.2. Fine MJ, Smith MA, Carson CA, et al. Prognosis and outcomes of patients with community-acquired

pneumonia. JAMA 1996; 275:134-41.3. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-

acquired pneumonia. N Engl J Med 1997; 336:243-50.Hospital acquired pneumonia.

1. American Thoracic Society: Hospital-acquired pneumonia in adults: assessment of severity, initialantimicrobial therapy and preventive strategies. Am Rev Resp Crit Care Med 1995; 153:1711.

2. McEachern R, Campbell GD Jr. Hospital-acquired pneumonia: epidemiology, etiology and treatment.Infect Dis Clin North Am 1998; 12:761-79.

Management of neutropenic fever in adult patients1. Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use of antimicrobial agents in

neutropenic patients with cancer. Clin Infect Dis 2002; 34:730-51.2. Pappas P, Rex J, Sobel J, et al. Guidelines for the Treatment of Candidiasis. Clin Infect Dis 2004; 38:161-

89.Acute bacterial meningitis in adults.

1. Segreti J, Harris AA. Acute bacterial meningitis. Infect Dis Clin N Am 1996; 10:797-809.2.

Quagliarello VJ, Scheld WM, Treatment of bacterial meningitis. N Engl J Med1997; 336(10):708-16.

3. de Gans J, van de Beek D, et al. Dexamethasone in Adults with Bacterial Meningitis. N Engl J Med 2002;20:1549-56.

Bacterial endocarditis in adults.1. Wilson WR, Karchmer AW, et al. Antibiotic treatment of adults with infective endocarditis due to

Streptococci, Enterococci, Staphylococci, and HACEK organism. JAMA 1995; 274(21):1706-13.2. Alsip SG, Blackstone EH, et al. Indication for cardiac surgery in patients with active infective endocarditis.

Am J Med 1985; 78(suupl 68) 138-148.Urinary tract infection in adults

1. Stamm WE, Norrby SR. Urinary tract infection: disease panaroma and challenge. J Infect Dis 2001;183(suppl 1):S1-4.

2. Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of complicated acutebacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 1999; 29:745-58.

3. Kahn JG, Walker CK, Washington AE, et al. Diagnosing pelvic inflammatory disease: A comprehensiveanalysis and considerations for developing a new model. JAMA1991;266:2594-8.

Osteomyelitis.1. Lew DP, Waldvogel FA. Osteomyelitis. N Eng J Med 1997; 333:999.2. Haas DW, McAndrew MP. Bacterial osteomyelitis in adults: Evolving consideration in diagnosis and

treatment. Am J Med 1996; 101:550-61.Septic arthritis.

1. Smith JW, Piercy EA. Infectious arthritis. Clin Infect Dis 1995; 20:225.2. Goldenberg DL. Septic arthritis. Lancet 1998; 351:197-202.

Intravascular Catheter-Related Infections1. Mermel L, Farr B, Sherertz R, et al. Guidelines for the Management of Intravascular Catheter-Related

Infections Clin Infect Dis 2001;32:1249 72


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CONTACT INFORMATION

Antimicrobial Management Team (AMT) Pager #3737Pharm.D. On-Call Pager #1875

Microbiology Lab 3-5411TDM Lab 3-6393Pharmacy 3-5641Pharmacokinetics Service Pager #1740

7-3378

NOTES


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