1. No category

GNR Lactose Fermenting: only E. Coli, Klebsiella, Citrobacter, Enterobacter.
Non-Lactose Fermenting: Pseudomonas, Acinetobacter, Stenotrophomonas, Proteus, Serratia, and
all others.
Empiric nec fasc coverage: Penicillin 4mU IV Q4hrs, Vancomycin 15mg/kg IV Q12, Clindamycin
900mg IV Q6hrs, Gentamicin 7mg/kg IV daily AND discuss level with pharm
May use empirically if recent azole exposure or hx of non-albicans Candida infection
100mg IV Q24 H for invasive candidiasis proven to be fluconazole resistant
(K) Loading dose: 6mg/kg IV/PO Q12hrs x 2 doses. Then 4mg kg Q12hrs
Prophylaxis dose is 200mg PO Qday
For fungemia, give 800mg PO/IV load, then 400mg Qday. Has excellent CSF penetration.
Consider if true PCN allergy
10mg/kg PO/IV Q8hrs for HSV meningitis, otherwise 5mg/kg Q8H
Aztreonam
• If no MRSA positive cultures in 72 hours, please discontinue or change Abx.
• For severe C.diff infection, PO Vanco 125mg Q6hrs is first line therapy. IV will not help.
• 1st line: suspected MRSA infection
• Dose by actual weight. Do not blindly use
“1g IV Q12”
• Has broad GPC coverage, but is not as
bactericidal as the beta-lactams. Switch to
• Trough 15-20 for complicated infxn (e.g MRSA
Nafcillin/Cefazolin if Cx positive for MSSA.
bacteremia, meningitis, HAP, osteomyleitis.)
• Otherwise, trough 10-15. Check before 4th dose.
• Toxicity: DRESS (very rare). “Red man Sx” is NOT
! an allergy.
Vancomycin
(K)
!
1.5-3g IV Q6hrs
!"#$!%&'()!!<&#$(=&:>!#-#.(/$&0%(!?'$(=@[email protected]#!
!
!
Some oral anaerobes
1st line: SSTI (1 tab DS BID), UTI
If pyogenic SSTI, consider giving Trim/Sulfa
and Amoxicillin together.
(K) 15-20mg/kg/day IV
Never use as monotherapy.
Many drug interactions, affects anticoagulation, etc.
Ampicillin
(K)
!
!!
"#$!%&'()!!*+,!#-#.(/$&0%(!!"#$%&'()%*+&!*,1!
!
"2!*3!456!7!8!9:;#!
Some oral anaerobic coverage
Also treats Group A strep pharyngitis
Amoxicillin
Indic: severe osteomyelitis, hardware infxn
Should consult ID/Pharm if using
1-2g IV Q4-6hrs
(K)
250-500mg PO Q8hrs
300mg PO BID, or 600mg QD
Antimicrobial Pearls
K!M!=(':%%;!.%(:=(9!
<!M!J(/:$&.!(%&B&':$&@'!
Prepared by Richard Kim, R3
UWMC Antimicrobial Sterwardship ([email protected])
Last updated March 12, 2009
1-2g Q8hrs
GNR
Enteroc.
Strep
MSSA
MRSA
Anaerobes
Atypicals
P.aeurg
GNR
Enteroc.
Strep
MSSA
1
MRSA
Antimicrobial Pearls
Prepared by Richard Kim, R3
(K)
!
!/-)>'.(>+-$L!!MN"@O!PNH!
!
!
!
! low seizure threshold, or GFR < 50.
Should not use unless pt is resistant to imipenem, has
Do add metronidazole for anaerobic coverage.
!!!!
!
Metronidazole (K) 500mg PO/IV Q6-8hrs
Use in pt with suspected or mild-moderate C.diff
If pt has severe C.diff, use PO Vancomycin
Moxifloxacin
400mg PO/IV QD
!/-)>'.(>+-$L!!Q4)>00O!(=>'<+,+-.$O!6>.=)>.O!
!H-(.,+&B.!<>$(+;G(>'.O!B&;+AC(<&C)>.%<=.6,!
.-.&=+B&$!26++)!R40=.6>;>$!'+I&=.6&9!
!
!
!/-)>'.(>+-L!!PNH!B.'(&=&,>.!28,6\W6!7[3<=$9!
!!!/0!-+-CB.'(&=&,>.O!)+$&!.(!3,6\W6!7[3!:!
If severe staph aureus infection not due to MRSA,
switch from Vanc to Nafcillin.
!S$(!;>-&L!!"&I&=&!M""@!>-0&'(>+-!!
!!!2&464!&-)+'.=)>(>$9!
!
Nitrofurantoin
!
!
!/-)>'L!!!E-'+,%;>'.(&)!)>.B&(>'!0++(!>-0&'(>+-!!!
!
!
GNR holes: Neisseria, Stenotrophomonas!
F+B=.,G'>-!<.$!B&((&=!*4!.&=#6!.'(>I>(G!
!
!
!S$(!;>-&L!!!-&'=+(>Y>-6!%.-'=&.(>(>$!
]-;G!<+;&$L!!"(&-+(=+%<O!^&6>+-&;;.4!
(K)
4
250-750mg IV/PO Q24hrs
Use 750mg Q24hrs for severe infxn.
Resistance emerging in Pseudomonas
Has only partial MRSA coverage. Watch QTc
Meropenem
!
!S$(!;>-&L!!%G&;+O!Q@*!2'+-$>)&=!,+1>!0>=$(9!
!!U+!-+(!#$&!>0!%+$$>B;&!#-)>.6-+$&)!FR!>-01-!!
Anaerobes
Same spectrum as Amox/Clav (Augmentin)
Amp/Sulbactam
Levofloxacin
600mg PO/IV Q12hrs
Key toxicities: Thrombocytopenia,
Serotonin syndrome (if used with SSRI)
!S$(!;>-&L!!F<&!%=&0&==&)!T7!0+=!Q@*!
!!!E-=&;>.B;&!0+=!EF/!(=&.(,&-(!
!!!U&'&-(!+=.;!.-.&=+B>'!'+I&=.6&!
!
No need to add metronidazole unless treating
for C.diff
Linezolid
Atypicals
!
!"#$!%&'()!!A'.@B/%&.:$(9!.@BB-'&$;!:.C-&=(9!
:09@B&':%!&'D(.$&@'#>!#&'-#&$&#!
!!!E,F!.@G(=:2()!!B&##(#!H(==:$&:>!*I!:(=-2!
(K)
*** Consult your pharmacist or ID service for specific recommendations***
P.aeurg
!"#$!%&'()!!!+1*>!+J%:B;9&:!
Azithro (PO/IV) 500mg load, then 250mg Q24h x 4d
500mg IV Q6
(L)
!
In CAP, if no pathogen isolated, give Azithro
500mg PO QD x 7 days
Peak: 6-10 mcg/mL
Trough: 1-2 mcg/mL
Toxicity: Nephro, oto (auditory or vestibular)
Must consult ID if using
Imipenem/Cilastatin
For PCP treatment, dose IV
For PCP prophy, 1 DS (800/160) tab QD
Toxicities: anemia (in G6PD), rash
(K) 15mg/kg IV Q12hrs
(K) 1-2g IV load; 1-2g IV Q6-8h
dosing varies, discuss w/ pharm
Rifampin
!!
E=(:$!E,F!.@G(=:2(!
!
!
(K) 1-2g IV Q6-8hrs
(K)
Trim/Sulfa
Cefazolin (Ancef)
(K)
Gentamicin
1g IV or IM Qday
!
Acyclovir (K)
Fluconazole
Ertapenem
3
If possibility of undiagnosed TB, do NOT use for
CAP, as it reduces diagnostic yield for TB.
Watch for QTc prolongation in susceptible pts
Nafcillin 1-2g IV Q4-6hrs
!S$(!;>-&L!!N>'W&(($>.O!@(G%>'.;!*?@!
!
!!!
Do not use in pregnancy or children < 8 yo
•
•
(L)
Voriconazole
!
!E,F!.@G(=:2()!!?I!+@%&>!*=@$(-#>!K%(0#&(%%:!
No ESBL coverage
!
Cefepime (K) 1-2g IV Q8-12hrs
!"#$!%&'()!!!H-#/(.$(9!@=!.@'D&=B(9!*I!:(=-2!
For Pseudomonas or neut. fever, give 2g IV q8hrs
&'D7'!
. Less AmpC induction in GNR infection
(K)
ID consult required if using this
Inactivated by lung surfactant
Doxycycline
100mg PO/IV Q12hrs
(L)
use only for concern of invasive mould fungal infection (e.g. invasive Aspergillosis)
switch to PO when possible due to accumulation of IV vehicle SBECD
Please consult ID service for advice on serum monitoring guidelines
Daptomycin (Cubicin)
•
•
•
!/-)>'L!!]$(&+O!=&(=+%<.=G-6!.B$'&$$O!!
!!!.-.&=+B>'!%#;,!>-01-O!R.B&$>+$>$O!F+1+%;.$4!
M+$(!0=&D#&-(!'.#$&!+0!Q4)>00!
!
!/-)>'.(>+-L!$&I&=&!)=#6C=&$>$(.-(!X?N!>-01-!
Divide into 2-4 doses daily
Mechanism: disrupts cell wall
Should only use with ID’s recommendation
Severe toxicities: nephro, neuro (paresthesias, neuromuscular
blockade).
!
•
!
Metronidazole used for below-the-diaphragm
due to better B.fragilis coverage.
.
Colistin 2.5-5mg/kg/day (K)
MRSA
!S$(!;>-&L!!EF/!2.0(&=!F=>,\"#;0.9!
!!!U+!?]F!#$&!0+=!Q@*!
!
MSSA
!
Strep
(K)
May need higher doses for Pseudomonas
Can use in ESBL in mild infxns, if sensitive
Watch QTc prolongation in suscept pts
Clindamycin 600-900mg IV Q8hrs
Enteroc.
200-400mg IV Q12
!!
!
/-)>'.(>+-L!!$(=&%(+'+''.;!""F/!
!
GNR
Ciprofloxacin
500mg PO Q6hrs (K)
P.aeurg
Cephalexin (Keflex)
Atypicals
Anaerobes
Antimicrobial Pearls
_!`!=&-.;;G!';&.=&)!
^!`!<&%.(>'!';&.=.-'&!
Micafungin
Ceftazidime (K)
2g IV Q8hrs
!
Weak strep pneumo, viridians strep coverage
!"#$!%&'()!!,(-$=@/('&.!D(G(=!
!!!!!!!!!!!!!#-#/(.$(9!*I!:(=-2!&'D7'!
.
!
Ceftriaxone 1-2g IV q12-24hrs
!
!"#$!%&'()!!L('&'2&$&#>!(B/&=&.!+1*!
CAP: 1g IV Q24hrs
Meningitis: 2g IV Q12hrs
!!
!
***These guidelines and antimicrobrial spectra are generalizations,
based on published literature and
!
clinical experience. For more specific recommendations, please consult your clinical pharmacist or
!
consulting ID service.
MRSA
MSSA
Strep
Enteroc.
GNR
P.aeurg
Atypicals
Anaerobes
2
(K)
100mg PO Q12hrs
!
Don’t use in pyelo, complicated UTI, or CrCl < 50.
Above dosing with sustained release
Penicillin G (K) 2-4 million Units Q4-6hrs
!/-)>'.(>+-L!!PNH!'G$(>(>$!
!
True PCN allergy: urticarial rash, airway swelling,
anaphylaxis. Occurs in 1-10%
!!!S$(!;>-&L!!-&#=+$G%<>;;>$!
!!!!N&.$+-.B;&!+=.;!.-.&=+B>'!'+I&=.6&4!
!
!
@%%=+%=>.(&!V+$G-!E$&!.0(&=!Q1!).(.!W-+A-L!
• !"#$'&%(>B;&!X?N!=&$>$(.-(!(+!'&0(=>.1+-&!
• !"#$'&%(>B;&!"#!$%&'()*+,$!!>-01-O!.;(<+#6<!
)=#6!+0!'<+>'&!$<+#;)!B&!Q&0(.Y.)>,&4!
• !*+;G,>'=+B=>.;!>-01-!A>(<!=&$>$(.-(!X?NO!
.-.&=+B&$O!.-)!&-(&=+'+''>4!
Pip/Tazo
(K) 3.375-4.5g IV Q6hrs
Appropriate Empiric Use of Zosyn:
• !"#$%&'(&)!*$&#)+,+-.$!/-01-!2)+$&!3456!789!
• !:&.;(<!'.=&!.$$+'>.(&)!*?@!
• !*?@!A>(<!'<=+->'!B=+-'<>&'(.$>$!!
• !:+$%>(.;C.'D#>=&)!EF/!+-;G!>0!*$&#)+,+-.$!+=!
!!!!!H-(&=+'+''#$!$#$%&'(&)!
• !"&I&=&!)>.B&(>'!0++(!>-01-!A>(<!.-(>B>+(>'$!+=!
!!!$#=6>'.;!'.=&!A>(<>-!;.$(!JK!).G$!
• !"#$%&'(&)!<+$%4!.'D#>=&)!>-(=.C.B)+,>-.;!>-01-!
!
/-.%%=+%=>.(&!E$&$!+0!V+$G-L!
• !"&%$>$!+0!#-W-+A-!&(>+;+6G!.'D#>=&)!Z![!
).G$!>-!<+$%>(.;4!
• !Q@*!+=!Q@CEF/!!