% Susceptible Atlanta VAMC January - December 2018
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Acinetobacter baumanii * 2017 and 2018 49 98 77 61 74 94 80 79 100 100 85
Citrobacter freundii * 2017 and 2018 46 89 91 89 100 98 98 98 98 98 100 96 98
Citrobacter koseri 59 100 98 100 100 100 98 98 98 98 100 97 98
Enterobacter aerogenes 44 84 80 80 100 73 95 95 95 95 100 98
Enterobacter cloacae 79 85 75 82 94 96 87 87 96 95 80
Escherichia coli 1128 49 55 97 90 91 95 99 100 73 73 90 91 100 94 78
Klebsiella oxytoca 67 64 88 88 96 99 100 90 90 91 91 100 82 91
Klebsiella pneumoniae 424 82 95 84 92 91 98 100 91 91 93 93 100 43 89
Morganella morganii 54 98 87 83 100 76 78 89 94 74
Proteus mirabilis 217 78 87 100 97 98 100 100 73 74 88 89 99 76
Pseudomonas aeruginosa 185 92 87 89 90 81 91 98 97
Serratia marcescens 49 99 99 100 99 97 99 89 100 100
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Staph. aureus (MSSA) 242 100 66 82 93 100 100 98 100 98
Staph. aureus (MRSA) 164 0 18 66 92 99 95 99 100 85
Staphylococcus, coagulase negative 276 57 45 68 83 99 96 99 100 69
Strep. pneumoniae 8 88 25 50 100 88 100 100 88
Enterococcus faecalis 607 100 29 89 99 99
Enterococcus faecium 20 30 30 25 50 42
1=respresentative of moxifloxacin
2=representative of nafcillin,dicloxacillin,cefazolin,cephalexin
3=representative of minocycline, doxycycline # = synergistic with B-lactam or vancomycin4=representative of cephalexin,
5=active in urine only
Clostridium difficile Infection10
1. Severe: pseudomembraneous colitis or ≥ 2 of the following (WBC ≥ 15,000 cells/µL, SCr ≥ 1.5 times baseline, ICU admit, age > 60yr, albumin < 2.5 mg/dL, temp > 38.3oC) 2. Severe/complicated: above criteria + hypotension, shock, ileus, and/or megacolon
Discontinue inciting antimicrobial agent(s) & opiates as soon as possible – may increase relapse risk
Initial episode, mild, moderate or severe: Vancomycin 125mg PO q6h
Initial episode, severe/complicated: Vancomycin 500mg PO/NG q6h + Metronidazole 500mg IV q8h (may add Vancomycin enema for ileus) -Vancomycin 500mg/100ml NS Per Rectally q6h
Recurrence: 1st recurrence: Vancomycin PO if metronidazole used initially OR Vancomycin PO with taper if vancomycin PO used initially
2nd recurrence: Consider ID consult
Vancomycin oral taper: 125mg po q6h for 10-14 days then 125 mg po q12h for 7 days then 125mg po q24h for 7 days then 125mg po q48h for 2-8 weeks
Consider ID consult for with complicating factors
10 days May consider extending treatment for CDI in patients who are continued on antibiotics for other infections.
ID consult strongly recommended for: S. aureus bacteremia, fungemia, meningitis in immunosuppressed, necrotizing fasciitis, and endocarditis. Consult Pharmacy to dose and monitor vancomycin and aminoglycosides
Duration of therapy recommendations are based on uncomplicated course with control/removal of infected sources, longer courses may be necessary depending on complicating factors
Penicillin allergy = non-anaphylactic reaction; 3rd and 4th gen cephalosporins and carbapenems have 1% cross reactivity rate
Severe B-lactam allergy= Type I reaction (anaphylaxis); avoid all β-lactams
Indication Likely pathogens Empiric Therapy
*Dosing based on normal renal function Alternative Therapy
*Dosing based on normal renal function Duration
Oral Empiric Step Down
Community Acquired Pneumonia1(CAP)
S. pneumo, H. influenzae Atypicals Enteric gram negs
Ceftriaxone 2g IV q24h +Azithromycin 500mg IV q24h
Penicillin allergy Levofloxacin 750mg IV/PO q24h
5 days Amox/clav + Azithromycin
HAP/VAP/HCAP 2,11 (nosocomial)
HCAP 1. Hospitalized pre 3mths 2. NH or LTC pt 3. Long term HD pt 4. Immunosuppressed
Enteric gram neg, Pseudomonas, Acinetobacter, Enterobacter, MRSA or MSSA
Cefepime 2g IV q8h OR Pip/tazo 4.5g IV q6h + Vancomycin IV
Optional expanded gram negative double coverage: Gentamicin 7mg/kg IV q24h
OR Levofloxacin 750 IV mg q24h
Penicillin allergy (non IgE mediated) Cefepime 2g IV q8h + Vancomycin IV Severe β –lactam allergy (IgE mediated) Aztreonam 2g IV q8h + Levofloxacin 750mg IV q24h + Vancomycin IV
7 days
Levofloxacin
Aspiration Pneumonia
Gram + anaerobes, respiratory flora
Amp/sul 3g IV q6h if CAP (+ azithromycin) OR Pip/tazo 4.5g IV q6h if HAP/HCAP (+vancomycin)
Severe β –lactam allergy Moxifloxacin 400mg IV/PO q24h
7-10 days Amox/clav , Moxi or Clinda
Community Acquired Intraabdominal3
E. coli, Bacteroides, other enteric gram negs
Ceftriaxone 2g IV q24h + Metronidazole 500mg IV q8h
Severe β –lactam allergy Cipro 400mg IV q12h +Metronidazole 500mg IVq8h
4-7 days w/ adequate drainage
Cefpoxidime or Ciprofloxacin +Metronidazole
Complicated or Hospital Acquired
Intraabdominal3
E. coli, Bacteroides, Enterococcus other enteric gram negs, yeast
Cefepime 2g IV q8h + Metronidazole 500mg IV q8h OR Pip/tazo 4.5g IV q6h +/- Vancomycin IV
Severe β –lactam allergy Cipro 400mg IVq12h + Metronidazole 500mg IV q8h +/- Vancomycin IV
4-7 days w/ adequate source
control
Ciprofloxacin +Metronidazole
Febrile Neutropenia4 Enteric gram neg, Pseudomonas, Strep sp. Staph sp, MRSA
Cefepime 2g IV q8h +/- Vancomycin IV (catheter in place, SSTI, PNA, or unstable)
Severe β –lactam allergy Aztreonam 2g IV q8h + Gentamicin 7mg/kg IV q24h + Vancomycin IV
Depends on source/count
recovery
Levofloxacin
Meningitis5
S. pneumo N. meningitides Listeria Viral (HSV)
Ceftriaxone 2g IV q12h +Ampicillin 2g IV q4h (if pt >50 y/o, pregnant or immunosuppressed) +Vancomycin IV
+/- Acyclovir 10mg/kg IV q8h if HSV suspected
If nosocomial risks or post neuro surgical Cefepime 2g IV q8h + Vancomycin Severe β –lactam allergy- (Obtain ID Consult) Vancomycin IV + Moxifloxacin 400mg IV q24h +/- Trimeth/Sulfa IV
7-21 days Pathogen dependent
*Consult ID*
Not appropriate
Skin and Soft Tissue Infections (SSTI) 6,7
Non-purulent/cellulitis β-hemolytic Streptococcus sp
Mild See oral empiric step down section
Moderate/Severe Cefazolin 2g IV q8h
Severe/Sepsis, bites, open wound, foreign body, or immunosuppressed Pip/tazo 4.5g IV q6h + Vancomycin IV
Mild- Severe β-lactam allergy Clindamycin 300mg PO q6h
Moderate/Severe Severe β-lactam allergy Vancomycin IV OR Clindamycin 900mg IV q8h
Severe/Sepsis etc Severe β-lactam allergy Cipro 400mg IVq12hr + Metronidazole 500mg IV q8h + Vancomycin IV
7-10 days Cephalexin, Clindamycin or Amox/clav
Purulent/abscess Staphylococcus sp MRSA vs MSSA
Mild – if no systemic symptoms, I&D may be all that is needed See oral empiric step down
Moderate/Severe MRSA- Vancomycin IV MSSA - Cefazolin 2g IV q8hrs OR Nafcillin 2g IV q4hrs
Mild Severe β-lactam allergy Trimeth/Sulfa 2 DS BID OR Doxycycline 100mg BID
Moderate/Severe Severe β-lactam allergy Vancomycin IV
7-10 days MRSA- Trimeth/Sulfa or Doxycycline MSSA – Cephalexin or Amox/clav
Necrotizing Fasciitis Surgical Debridement Necessary Type I- Polymicrobial Type II- Group A Strep
Initial empiric or polymicrobial coverage Pip/tazo 4.5g IV q6h + Clindamycin 900mg IV q8h +Vancomycin IV
If Streptococcus sp or Clostridia sp Penicillin 24 MU IV continuous over 24h + Clindamycin 900mg IV q8h
Initial empiric - Severe β –lactam allergy Aztreonam 2g IV q8h + Clindamycin 900mg IV q8h + Vancomycin IV
Variable Depends on
response and surgical
debridement
Diabetic Foot Infection 8
Polymicrobial Staph sp, Strep sp, Pseudomonas, anaerobes
If no evidence of clinical instability/sepsis-get bone/wound cx first Mild- see SSTI section
Moderate Ampicillin/Sulbactam 3g IV q6h + Vancomycin IV
Severe limb/life threatening Pip/tazo 4.5g IV q6h + Vancomycin IV
Mild- see SSTI section Moderate/Severe – Severe β-lactam allergy Cipro 400mg q12h IV + Metronidazole 500mg IV q8hr + Vancomycin IV
Variable Depends on severity +/-
osteomyelitis
Based on cultures or initial empiric treatment
Atlanta VA Medical Center Antimicrobial Empiric Treatment Guidelines
Only obtain UA & Urine Culture in patients with signs and symptoms of UTI* [fever (>38.0°C) in a pt = 65 yrs, suprapubic tenderness, costovertebral angle tenderness, urinary urgency, frequency, or dysuria]
Asymptomatic bacteriuria (ASB) - positive urine culture w/o symptoms - Should be considered colonization, NOT infection. - Treatment of ASB is NOT recommended * *Exception: pregnant women and pts undergoing invasive urologic procedure with risk of mucosal bleeding
Key Points on ASB in the Elderly - In elderly, UA SHOULD NOT be done as a matter of routine - UA often contaminated in the elderly and many have ASB - Pyuria is common in pts with ASB— as high as 100% in pts with long-term catheters - Use caution in testing in pts with weakness, delirium, and mental status change - Seek other causes, remember the high prevalence of ASB, and individualize care
Setting Definition Organisms Inpatient Treatment 1,3 Outpatient/Oral1,3 Other
Uncomplicated
Women without kidney involvement, obstruction, or recent instrumentation (foley)
S. saprophyticus, E. coli, Klebsiella, Proteus
Inpatient IV preferred Ceftriaxone 1g IV q24h x 7 days If severe penicillin allergy Ciprofloxacin IV 400mg BID x 5 days
Oral options preferred Nitrofurantion 100mg po BID2 x 5 days Cephalexin 500mg po q8h x 7 days Trimeth/Sulfa 1 DS po BID x 3 days
If resistant or allergy to preferred Ciprofloxacin 500mg BID x 5 days Fosfomycin 3g sachet x1
Ciprofloxacin and Trimeth/Sulfa should be avoided in pregnancy
Men without kidney or prostate involvement, obstruction, or recent instrumentation (foley)
E. coli, Klebsiella, Proteus
Same as women above Oral options preferred Trimeth/Sulfa 1 DS po BID x 7 days Cephalexin 500mg po q8h x 7 days
If resistant or allergy to preferred Ciprofloxacin 500mg BID x 5 days Fosfomycin 3g sachet x1
Caution use or avoid nitrofurantoin and trimeth/sulfa in adults > 75 yo
Complicated
Obstruction, recent instrumentation (foley), stone, neurologic deficit, congenital abnormalities
E. coli, Enterococcus, Pseudomonas, Other GNRs
Change Foley
Inpatient IV preferred Ceftriaxone 2g IV q24h x 7-10days
Risk of pseudomonas Cefepime1g IV q8h x 7-10days
If severe penicillin allergy Ciprofloxacin 400mg IV BID x 7 days
Oral options preferred Cefpodoxime 400mg BID x 7-10 days Trimeth/Sulfa 1 DS po BID x 7-10 days
If resistant or allergy to preferred Ciprofloxacin 500mg BID x 7 days
IV recommended until patient is afebrile for 24hrs
Do NOT use nitrofurantion, cephalexin, or fosfomycin
UA does not reflex to a urine culture. Please order urine culture separately
R/O prostatitis. B-lactams will penetrate in acute prostatitis but quinolones/Bactrim recommended in chronic prostatitis (see below)
Pyelonephritis Upper GU tract infection
E. coli, Enterococcus, Pseudomonas, Other GNRs
Same as complicated Give 1x dose of long acting agent before starting oral Ceftriaxone 1g x 1 Gentamicin 5mg/kg x1
Oral options preferred Cefpodoxime 400mg BID x 14 days Trimeth/Sulfa 1 DS po BID x 14 days
If resistant or allergy to preferred Ciprofloxacin 500mg BID x 7 days
Prostatitis
<35y/o gonorrhoea & chlamydia
Ceftriaxone 250mg IM x1 then Doxycycline 100mg po BID x 7 days OR Azithromycin 1g po x1
Same ID consult Quinolones no longer recommended for GC Test of cure for non-1st line
>35y/o GNRs Bactrim DS po BID x 4-6 weeks Ciprofloxacin 500mg po BID x 4-6 weeks
Same Same β-lactams do not penetrate the prostate very well
Notice: Due to >30% resistance to amoxicillin, and amox/clavu to E.coli, these agents are no longer recommended for empiric treatment of UTIs at ATL. ***Please obtain UA AND culture then adjust therapy appropriately***
Empiric Urinary Tract Infection Guidelines9
1Adjust therapy based on culture and or s/s of improvement 2 Not recommended in men with complicated UTI or prostate involvement, pyelonephritis, or CrCl <40; it is considered a urinary antiseptic and does not penetrate systemically 3 Based on normal renal function
References
1.CID. 2007; 44:S27-S72 2.Am J Respir Crit Care Med 2005;171:388-416 3.CID. 2010;501:133-164 4.CID. 2011;52:e56-e93 5.CID. 2004;39:1267-1284 6.CID. 2005;41:1373-1406 7.CID. 2011;52:1-38 8.CID. 2004;39:885-910
9.CID. 2011; 52: e103-e120 and CID. 2005; 40: 643-54 and CID. 2010; 50: 625-63 10.Infect Control Hosp Epidemiol, 2010; 31(5): 431-55 11.CID. 2016; Jul 14 Epub
CPRS order menu: Orders —> Inpatient Medications —> Empiric Antimicrobial Order Menu (left column) Questions? - Tiffany Goolsby, ID PharmD 203453
Atlanta VA Medical Center Antimicrobial Dosing Guideline January 2019
Antimicrobial Normal Dose Renal dose Adjustment Based on CrCl - ml/min
Hemodialysis (HD)* Comments
Amikacin PKS pharmacy consult
See PK dosing card# Level is sent out
Amphotericin B lipid complex
Restricted to ID
Abelcet ® 3-5mg/kg IV (TBW) q24h
No change No change IVF bolus w/ q dose & Mx K/Mg daily. Use ABW if obese.
Acyclovir
IV: 5-10mg/kg (TBW) q8h Use 10mg/kg in CNS and Zoster
25-49: 5-10mg/kg q12h 11-24: 5-10mg/kg q24h ≤ 10: 2.5-5mg/kg q24h
2.5-5mg/kg q24h post HD
Use IBW if obese
Oral: Zoster, ophthalmic HSV 400mg (HSV)-800mg (Zoster) 5Xday
10-25: 400-800mg q8h <10: 400-800mg q12h
400-800mg q12h
Oral: HSV genital/oral Treatment - 400mg q8h Suppression - 400mg q12h
< 10: 400mg q12h <10: 200mg q12h
400mg q12h 200mg q12h
Amoxicillin 500-1000mg PO q8h
11-29: 500-1000mg q12h ≤ 10: 250-500mg q24h
250-500mg q24h
Amoxicillin/ Clavulanate
875/125mg PO q12h OR 500/125mg PO q8h
11-29: 500/125mg q12h ≤ 10: 500/125mg q24h
500/125mg q24h Only use 875mg in CrCl >30
Ampicillin 1-2g IV q4-6h Use 2g IV q4h in meningitis and endocarditis
30-49: 1-2g q6-8h 11-29: 1-2g q8-12h ≤ 10: 1-2g q12h
1-2g q12h –give 2nd dose post HD on HD days
Ampicillin/ Sulbactam
3g IV q6h
30-49: 3g q8h 15-29: 3g q12h ≤ 14: 3g q24h
3g q12h –give 2nd dose post HD on HD days
Azithromycin 250-500mg PO/IV q24h No change No change Do not use with QTC >500
Aztreonam 1-2g IV q8h Use 2g in Pseudomonas, Sepsis, Pneumonia, Obese, Febrile Neutropenia
11-29: 1-2g q12h ≤ 10: 1-2g q24h
1-2g q24h
Cefazolin 1-2g IV q8h Use 2g in >80kg, Endocarditis, Bacteremia, Pneumonia, Osteomyelitis
11-49: 1-2g q12h ≤ 10: 1-2g q24h
2g M,W & 3g F post HD (or 2g T,Th and 3g Sat)
Cefepime 1-2g IV q8h Use 2g in Pseudomonas, Sepsis, Pneumonia, Meningitis, Febrile neutropenia
30-59:1- 2g q12h 11-29: 1-2g q24h ≤ 10: 2g load x1, 1g q24h
2g 3x week post HD
Cefpodoxime 200-400mg PO q12h ≤30: 200-400mg q24h 200-400mg 3x week post
HD
Ceftazidime 1-2g IV q8h Use 2g in Pseudomonas, Sepsis, Pneumonia, Meningitis, Febrile neutropenia
31-49: 1-2g q12h 10-30: 1-2g q24h <10: 1-2g x1, 500mg - 1g q24h
1-2g 3x week post HD
Ceftriaxone 1-2g IV q24h Use 2g in >80kg, endocarditis, osteomyelitis 2g q12h in meningitis
No change
No change
Cephalexin 500mg PO q6h Use q8h dosing in cystitis only
31-49: 500mg q8h 11-30: 500mg q12h ≤ 10: 250mg q12h
250mg q12h Do not use in bacteremia or pyelonephritis
Ciprofloxacin
Oral: 500-750mg q12h Use 750mg in Osteo,Nosocomial pneumonia, Pseudomonas
<30: 500 - 750mg q24h
500- 750mg q24h
SBP ppx: 500mg q24h (preferred) or 750mg qweek Do not use with QTC >500
IV: 400mg IV q8-12h Use q8h in Sepsis, Osteo,Nosocomial Pneumonia, Pseudomonas, Febrile Neutropenia
<30: 400mg q12-24h 400mg q24h
Clarithromycin 500mg PO q12h <30: 500mg q24h 500mg q24h Monitor QTC
Clindamycin IV dose: 600-900mg IV q8h Oral dose: 300-450mg PO q6-8h
No change No Change
Daptomycin Restricted to ID
4-6mg/kg IV q24h Use 4mg/kg q24h UTI and SSTIs 8-10mg/kg may be used in severe infxns
< 30: 4-6mg/kg q48h
4-6mg/kg q48h OR 4-6mg/kg MW & 6-9mg/kg F post HD
Do not use in pneumonia. Follow CPK weekly.
Doxycycline 100mg IV/PO q12h No change No change
Ertapenem Nonformulary
1g IV q24h < 30: 500mg q24h 500mg q24h
Fluconazole
Severe Infections- Candidemia:
800mg (12mg/kg)x1, then 400mg IV (6mg/kg) q24h Other: 200-400mg IV/PO q24h
< 50: 50% dose q24h 100% 3x week post HD OR 50% dose q24h
Monitor QTC
Gentamicin PKS pharmacy consult
See PK dosing card#
Level is done in house
Levofloxacin
Mild-Moderate Infections 500mg IV/PO q24h
21-49: 500mg x1, 250mg q24h ≤ 20: 500mg x1, 250mg q48h
500mg x1, 250mg q48h
Do not use with QTC >500
Severe Infections - Sepsis, Osteo,
Nosocomial pneumonia, Pseudomonas, cSSTI 750mg IV/PO q24h
21-49: 750mg q48h ≤ 20: 750mg x1, 500mg q48h
750mg x1, 500mg q48h
Atlanta VA Medical Center Antimicrobial Dosing Guideline January 2019
TBW- Total Body weight IBW- Ideal Body weight ABW- Adjusted Body Weight = IBW+[0.4 x(ABW-IBW)] Obese - >120% of IBW MU- Million Units CI – Continuous infusion
Contact: Tiffany Goolsby, ID PharmD ext 203453
SSTI- Skin and soft tissue infection cSSTI- Complicated skin and soft tissue infection PJP- Pneumocystis jiroveci pneumonia PKS- Pharmacokinetic Service
*No supplement after dialysis needed unless specified for the individual
medication; give all q24h or q48h doses after HD on HD days
#More info available on CPRS Tools Antimicrobial Stewardship References
Linezolid Restricted to ID
600mg IV/PO q12h No change No change Do not use in bacteremia. Follow platelets.
Meropenem Restricted to ID
1-2g IV q8h Use 2g in meningitis
26-50: 1-2g q12h 10-25: 1-2g x1, 0.5-1g q12h <10: 1-2g x1, 0.5-1g q24h
1-2g x1, 0.5-1g q24h
Metronidazole 500mg IV/PO q8h <10: 500mg q12h No change
Micafungin 100mg IV q24h 150mg IV q24h in Esophageal candidiasis
No change No change
Moxifloxacin 400mg IV/PO qday No change No change Do not use in UTI. Do not use with QTC > 500
Nafcillin 2g IV q4h or 12g CI over 24 hours No change No change
Nitrofurantoin (Macrobid)
100mg PO q12h for uncomplicated UTI Limit to short courses of 5-7 days
<30: Avoid use; ↑ risk of toxic serum levels and lack of efficacy
Avoid use
Do not use for pyelonephritis
Oseltamivir
Treatment 75mg PO q12h x 5 -10 days
30-59: 30mg q12h 10-29: 30mg q24h
30mg 3x week post HD
Prophylaxis 75mg PO q24h x 7-10 day
30-59: 30mg q24h 10-29: 30mg q48h
30mg alternating every other HD session
Penicillin G
2- 4MU IV q4h
11-49: 2-3MU q4h ≤ 10: 1-2MU q4-6h
1-2MU q4-6h Avoid K in renal dx. Use higher dose in neurosyphilis, endocarditis, or serious infections.
12-24MU IV CI over 24h 11-49: 8-16MU CI q24h ≤ 10: 6-12MU CI q 24h
Use above dose
Penicillin VK 250-500mg PO q6h < 10: 250-500mg q8h 250-500mg q8h
Posaconazole Nonformulary
300mg IV/PO BID x1 day, then qday (IV or Delayed Release (DR) tabs dosing only) No change No change
Suspension dosing differs. DR tabs preferred
Piperacillin/ tazobactam
Mild to Moderate Infections 3.375g IV q6h
21-39: 2.25g q6h ≤ 20: 2.25g q8h
2.25g q8h
HD: Give next scheduled dose right after HD on HD days to avoid need for supplement dose
Severe or Nosocomial Infections / Sepsis 4.5g IV q6h
21-39: 3.375g q6h ≤ 20: 2.25g q6h
2.25g q6h
Trimethoprim/Sulfameth
Mild to Moderate - SSTI or UTI 5mg/kg/day IV/PO divided q12h OR 1 DS tab q12h
10-29: 2.5 mg/kg/day OR 1 DS tab q24h <10: 1 SS tab q24-48h
5mg/kg 3x week post HD OR 1 SS tab q24h
Dosed by Trimethoprim (TMP) component Single strength (SS)=80mg TMP Double Strength (DS)=160mg TMP Follow K and SrCr
Moderate to Severe- cSSTI 8-15mg/kg/day IV/PO divided q6-12h 1-2 DS tab q12h
<30: 8-15mg/kg/day divided q6-12h for 48h, then 4-7 mg/kg/day divided q12h OR 1 SS tab q12h <10: 1 SS tab q24h
8-15mg/kg 3x week after HD OR 1 SS tab q24h
Severe Infection or PJP 15-20mg/kg/day IV/PO divided q6-8h
10-29: 7-10mg/kg/day divided q8-12h <10: 5mg/kg q24h
5mg/kg q24h
PJP Prophylaxis 1DS tab q24h or 3x week
10-29: 1SS tab q24h or 3x wk <10: 1SS tab 3x week
1SS tab 3x week after HD
Tobramycin PKS pharmacy consult
See PK dosing card#
Level is sent out
Vancomycin
PKS pharmacy consult Load: 20-25mg/kg IV (TBW) x1 Maintenance: 15mg/kg IV (TBW) q12h Use q8h if ≤35 y/o and crcl >90
40-59: q24h 20-39: q48h <20: 15mg/kg x1, Consult PKS
15mg/kg x1, Consult PKS Adjust based on levels
Max 1st dose: 2000mg
See PK dosing card#
Valacyclovir
Herpes Zoster (Shingles) 1g PO q8h
30-49: 1g q12h 10-29: 1g q24h
<10/HD:1g x1, 500mg q24h
Herpes labialis (cold sore) 2g PO q12h x 2 doses
30-49: 1g q12h x 2 doses 10-29: 500mg q12h x 2 doses
<10/HD: 500mg x 1 dose
HSV genital, Initial 1g PO q12h x 7days
10-29: 1g q24h <10/HD: 500mg q24h
HSV genital, Recurrent 500mg PO q12h x3 days
<30: 500mg q24h 500mg q24h
HSV genital Suppression, ≤9 episodes/year 500mg PO q24h
<30: 500mg q48h 500mg 3x week post HD
HSV genital Suppression , ≥10 episodes/year 1g PO q24h (500mg q12h for HIV + pts)
<30: 500mg q24h 500mg q24h
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