OLIVE VIEW-UCLA MEDICAL CENTER Medicine Ward / ICU Empiric Antibiotic Recommendations 2013 These are the agents generally preferred for first-line empiric therapy at Olive View-UCLA. Circumstances of individual cases may dictate different antibiotic choices. SITE INFECTION/DIAGNOSIS LIKELY PATHOGEN INITIAL TREATMENT Abdomen Spontaneous Bacterial Peritonitis E.coli, other Enterobacteriaceae, Streptococci Ceftriaxone 2g q24h Paracentesis fluid WBC > 250 PMNs Intra-abdominal Infection (Appendicitis, diverticulitis, secondary peritonitis, intraabdominal abscess) E. coli, other Enterobacteriaceae, Strep.viridans, Enterococci, anaerobes (B.fragilis) Ceftriaxone 2g q24h + Metronidazole Source control most important Biliary Infection (Cholecystitis, cholangitis) E. coli, other Enterobacteriaceae, S.viridans, Enterococci Ceftriaxone 2g q24h Abdominal Sepsis (Shock, healthcare-associated, immunocompromised) E. coli, other Enterobacteriaceae, S.viridans, Enterococci Piperacillin/tazobactam C. difficile colitis C. difficile Metronidazole PO (for mild to mod cases) Vanco PO if metronidazole fails or severe / ICU level / megacolon Bone Osteomyelitis (NOT diabetic foot) S. aureus Vancomycin See Skin-diabetic foot below for osteomyelitis in diabetics CNS Meningitis S. pneumoniae, N. meningitidis, H.flu, Listeria in infants, elderly, pregnant, immunosuppressed Ceftriaxone 2g q12h. Consider Dexamethasone 0.4mg/kg IV q6h prior to abx if bacterial meningitis is confirmed or strongly suspected Streptococci, Bacteroides, other oral anaerobes, Enterobacteriaceae Ceftriaxone 2g q24h + Metronidazole Brain Abscess COMMENTS Or Cefoxitin 1-2g IV q6h Add metronidazole if biliary-enteric anastomosis, severe ileus - Add Amikacin if septic shock -Add ampicillin 2g IV q4h if elderly, pregnant, immunosuppressed -Consider Vanco if bacterial meningitis confirmed by LP or GS: GPC pairs/chains Vanco only necessary for full-PCN resistant S.pneumoniae Need neurosurgery for drainage if size >2.5 cm Endocarditis Native valve S. aureus, Strep.viridans, Enterococci Ceftriaxone 2 g q24h + Vancomycin Need TEE Endocarditis Prosthetic valve S. epidermidis, S aureus, Strep.viridans Vancomycin + Gentamicin 1mg/kg IV q8h + Rifampin 300mg PO TID Need TEE Sinusitis/otitis media/mastoiditis S. pneumoniae, H.flu, Moraxella Ceftriaxone Odontogenic infection Strep.viridans, oral anaerobes Ampicillin/Sulbactam Malignant otitis externa Pseudomonas aeruginosa Cefepime 2g IV q8h ENT consultation Pelvic Inflammatory Disease Chlamydia, N gonorrhoeae, E. coli, streptococci , anaerobes Cefoxitin + Doxycycline PO Complete STD public health report form. Pyelonephritis Uncomplicated Enterobacteriaceae, (E. coli, Klebsiella, Proteus), Enterococcus Ceftriaxone Pyelonephritis Complicated (Foley, instrumentation, underlying disease, etc.) Enterobacteriaceae (E. coli, Klebsiella, Proteus), Pseudomonas, Enterococci, Staph spp Piperacillin/tazobactam Remove/change foley/nephrostomy tube Joint Septic Arthritis S. aureus, -hemolytic streptococci, N. gonorrhea Ceftriaxone + Vancomycin Consider urethral, pharyngeal, rectal cultures if GC suspected. Lung Community-Acquired Pneumonia (CAP) S. pneumoniae, H. flu, Chlamydophila pneumoniae, Mycoplasma pneumoniae, Legionella Ceftriaxone + Azithromycin PO or Doxycycline PO Follow clinical pathway guidelines. Consider fungi (Cocci, Crypto), mycobacterial (TB), viral (influenza), or non-infectious causes of pneumonia if fail empiric therapy Severe CommunityAcquired Pneumonia (ICU) S. pneumoniae, S. aureus (incl CAMRSA), Klebsiella, Legionella Ceftriaxone + Azithromycin + Vancomycin Severe CAP RR > 30/min, severe resp. failure, shock, vasopressors Healthcare-Associated Pneumonia S. aureus, Pseudomonas, Enterobacteriaceae, Acinetobacter Piperacillin/tazobactam + Vancomycin Add amikacin if severe sepsis. Aspiration/Anaerobic Strep viridans, Ceftriaxone True aspiration pneumonia is subacute CV ENT GU Skin Pneumonia oral anaerobes + Metronidazole PO necrotizing pna, often with cavitation, abscess, and empyema formation AIDS Pneumonia PCP, S. pneumoniae, H. flu, fungi (Crytpcococcus, Cocci, Histoplasma), Mycobacteria (TB, MAC) Ceftriaxone + Azithromycin PO + Bactrim 15-20mg/kg/day Isolate, r/o TB. If no etiology by sputum studies, need bronchoscopy. Acute Exacerbation of Chronic Bronchiectasis /Cystic Fibrosis S. pneumoniae, H. flu, P. aeruginosa Cefepime 2g IV q8h Antibiotics not indicated for acute bronchitis. Cellulitis (No pus) -hemolytic strep (GAS), S. aureus Cefazolin 1-2g IV q8h Follow clinical pathway guidelines Cellulitis with abscess or purulent drainage S. aureus, including MRSA Vancomycin Outpatient treatment depends on bacteria susceptibilities from wound culture. Bite infections Pasteurella (cat, dog) Eikenella (human) streptococci, S. aureus, oral anaerobes Ampicillin/sulbactam Necrotizing fasciitis Type 2: Group A strep Piperacillin/tazobactam + Vancomycin + Clindamycin 900mg IV q8h Type 1: Strep, GNB, anaerobes 3rd Type: S. aureus (CAMRSA) Fournier’s Gangrene Streptococci, GNB, anaerobes Early surgical consultation If GAS: use PCN G + Clindamycin Omit clindamycin in Type 1 (ie mixed synergistic necrotizing fasciitis) 3rd type involving CA-MRSA is uncommon and has more sub-acute course Piperacillin/tazobactam Urology consult for debridement - Add Vancomycin if sepsis Diabetic foot infection – Cellulitis Streptococci (esp Group B strep), S.aureus Cefazolin 2g IV q8h If significant osteomyelitis by MRI and no amputation, need longer IV therapy (6-8 weeks) Diabetic Foot infection – Acute ulcer (< 7 days) Streptococci (esp Group B strep), S.aureus Cefazolin 2g IV q8h See above comment for osteomyelitis Diabetic foot infectionChronic ulcer Streptococci (esp Group B strep), S.aureus, GNB Ceftriaxone 2g + Metronidazole PO If osteomyelitis, anaerobic coverage (with metronidazole) not necessary for entire duration Diabetic foot infection Severe (ICU), limb/lifethreatening, wet gangrenous/fetid foot Systemic Neutropenic Fever Sepsis - Immunocompetent No obvious source S. aureus, streptococci, GNB, anaerobes Piperacillin/tazobactam + Vancomycin See above comments for osteomyelitis E. coli, Pseudomonas, Klebsiella, Streptococci, Candida Cefepime 2g IV q8h Add anaerobic coverage (metronidazole) if suspect abdominal source (diarrhea, abdominal pain, typhlitis) Strep. pneumoniae, E. coli, S. aureus Ceftriaxone + Vancomycin + /- Metronidazole - Add Amikacin if sepsis (ICU) and Vancomycin if central line, soft tissue source, severe pneumonia, and/or sepsis (ICU) Evaluate the abdomen (eg CT abd) for sepsis without obvious source. -If nosocomial, use Pip/tazo instead of ceftriaxone/metronidazole Line-related infection S. aureus, coag-negative Staphylococci Vancomycin - Consider Cefepime if sepsis Removal of line is important for all bacteria (except possibly coag-neg Staph) (01/2013) Antibiotic Dosing and Cost INJECTABLE Cost range per day: $=<20, $$=20-45, $$$=45-70, $$$=70-120, $$$$$=>120 ORAL Cost range per day: $=<2, $$=2-4, $$$=4-6, $$$$=6-10, $$$$$=>10 ANTIBIOTIC (Generic/Brand) USUAL ADULT DOSE COMMENTS COST per DAY Amoxicillin PO: 250 - 500 mg q8h Replaces ampicillin PO on formulary PO: $ Amoxicillin/Clavulanate (Augmentin®) PO: 500 - 875/125mg BID Extends amoxicillin activity to include ß -lactamase producing strains, enteric gram (-) bacilli, and anaerobes. PO: $ Ampicillin IV/IM:1-2 g q4-6h PO: not on formulary Active against Gm (+) cocci, some Shigella, Salmonella, P. mirabilis & E. coli. IV:$-$$ Ampicillin/Sulbactam (Unasyn®) IV/IM: 1.5 - 3 g q6h Extends spectrum of ampicillin to include b-lactamase producing strains of H. influenzae, M. catarrhalis, S. aureus, Neisseria & Bacteroides sp. Not usually active vs. Ps. aeruginosa, Serratia or Enterobacter. IV:$$ Dicloxacillin (Dynapen®) PO: 250- 500 mg q6h Penicillinase-resistant penicillin, Oral anti-staphylococcal agent PO:$ Oxacillin IV: 1-2 g q4-6h Penicillinase-resistant penicillin. Good anti-staphylococcal activity IV:$$$$ Penicillin PO (pen VK): 250-500 mg q6h IV: 2- 4 million units q4-6h CNS (seizures) reactions can occur with high doses (>20 MU/day) and renal failure. IV:$ PO:$ Piperacillin/Tazobactam (Zosyn®) IV: 3.375g q8h extended infusion over 4h Antipseudomonal, broad spectrum. Restricted to I.D. IV:$$ Cefazolin (Ancef®, Kefzol®) IV/IM: 1-2 g q8h Active against Gm(+) cocci, E. Coli, S. pneumoniae, Proteus mirabilis. (Not effective against enterococci or MRSA) IV:$ Cephalexin (Keflex®) PO: 250 - 500 mg q6h Activity similar to cefazolin PO:$ Cefotetan (Cefotan®) IV/IM: 1-2 g q12h Improved Gm (-) coverage over 1st gen. & good anaerobic activity. IV:$ -$$ 2nd 3rd Gen Cephalosporins 1st Gen Penicillins CLASS ® Cefoxitin (Mefoxin ) IV/IM: 1-2 g q6-8h Ceftriaxone (Rocephin®) IV/IM: 1 g q24h 2gm q24h for abdominal infections 2gm q12h for meningitis Good Gm (-) & H. influenzae, N. gonorrhea coverage. (Cefotaxime on formulary Restricted to Pediatrics or ID) IV:$ Ceftazidime (Fortaz®, Tazidime®) IV/IM: 1- 2 g q8h Antipseudomonal cephalosporin. Good Gm (-), poor Gm (+), poor anaerobic activity. Restricted to ID or Oncology IV:$ Cefixime (Suprax®) PO: 400 mg q24 hours. (Reserve for patients that cannot tolerate ceftriaxone IM in treatment of gonorrhea) PO:$$ Cefdinir (Omnicef®) PO: 300mg q12h PO:$$ Antipseudomonal cephalosporin. Good Gm (-) and Gm (+) coverage. Restricted to ID except for neutropenic fever IV: $ Carbapenemems Ertapenem (Invanz®) IV: 1gm q24h Similar to meropenem, but no pseudomonas activity. Restricted to ID IV: $$$ Meropenem (Merrem®) IV: 500mg -1gm q8h, (2gm IV q8h for meningitis) Broad spectrum antibiotic. Restricted to ID IV: $$ Ciprofloxacin (Cipro®) PO: 250mg-750mg BID IV: 400mg q12h Ciprofloxacin preferred over levofloxacin for UTI IV: $ PO: $ Levofloxacin (Levaquin®) PO: 250-750mg daily IV: 250-750mg daily Activity vs. S. pneumoniae and other respiratory pathogens. Use 750mg dose for pneumonia. IV: $ PO: $ Amikacin IV/IM: 15mg/kg q24h IV:$ Gentamicin IV/IM: 5-7 mg/kg q24h Gm (+) synergy: 1mg/kg q8h Tobramycin IV/IM: 5-7mg/kg q24h Check baseline Scr to evaluate renal function. For once daily dosing, check a single level 8 to12 hours after the start of infusion. For traditional and synergy dosing, check peak and trough level around the fourth dose. Call pharmacy for guidelines. Azithromycin (Zithromax®) IV/PO: 500mg daily Macrolide antibiotic, better activity vs. H. influenzae compared to erythromycin, with better GI tolerance. IV:$ PO:$ Clindamycin (Cleocin®) IV: 600-900 mg q8h PO: 150-450 mg q8-6h Good gm (+) cocci & anaerobic coverage. Can cause severe diarrhea and pseudomembranous colitis. IV:$-$$ PO:$ Daptomycin (Cubicin®) IV: 4mg/kg q24h for skin infections; 6mg/kg q24h for bacteremia Covers gm (+) including MRSA. Not to be used for pneumonia. Restricted to ID IV: $$$$ Doxycycline IV/PO: 100mg q12h Tetracycline antibiotic IV:$ PO:$ PO: 3gm q48h x3 doses Oral powder, mix in 3 oz of water. Restricted to ID PO:$$$$$ Linezolid (Zyvox ) IV/PO: 600 mg q12h Used only for gram-positive infections resistant to other agents. Restricted to ID. IV: $$$$$ PO:$$$$$ Metronidazole (Flagyl®) IV: 500mg q6-8h PO: 500mg TID (750mg q8h for amebic disease) Very good anaerobic coverage. Agent of choice for pseudomembranous enterocolitis caused by Clostridium difficile (po form). IV:$ PO:$ Nitrofurantoin (Macrobid®) PO: 100 mg po bid (macrocrystals) Not recommended with significant renal dysfunction. (Crcl <60ml/min) PO:$ Sulfamethoxazole/Trimethoprim (Bactrim®, Septra®) PO: 1 DS tab BID PO/IV: Pneumocystis 15-20 mg/kg/day of TMP in 3-4 div doses Double strength tab contains 800mg SMX and 160mg TMP. Standard 5ml vial (1 amp) contains 400mg SMX and 80mg TMP IV:$ PO:$ Vancomycin (Vancocin®) IV: 1 gm q12h Drug of choice for infections caused by methicillin-resistant IV:$ Miscellaneous Antibiotics AMG 4th IV: 1-2 g q8-12 h Fluoroquinolone Cefepime (Maxipime®) ® Fosfomycin (Monurol ) ® S.aureus/epidermidis. PO form not for systemic infections. PO: 125-500 mg q6h PO:$$$$$ Antiretroviral Agents CLASS Antiretroviral USUAL ADULT DOSE AVAILABLE FORMS FOOD RESTRICTION COMMENTS 600mg qday or 300mg bid Tablet, Oral Sol -- Check HLA-B*5701 Didanosine (Videx ) ddI 400mg qday (Wt<60kg: 250mg qday) Capsule Oral powd for susp On empty stomach; 1h before 2h after meal Peripheral neuropathy, pancreatitis Emtricitabine (Emtriva®) FTC 200mg qday Capsule, Oral soln -- Lamivudine (Epivir ) 3TC 300mg qday or 150mg bid Tablet , Oral soln -- Tenofovir (Viread®) TDF 300mg qday Tablet, Oral powder -- Monitor renal function Zidovudine (Retrovir ) AZT, ZDV 300mg bid or 200mg tid Perinatal transmission ppx: 2mg/kg IV x1, 1mg/kg/hr IV until umbilical cord clamping Capsule, Tablet, Syrup, IV -- Monitor H/H. (Infant prophylaxis usual dose: 2mg/kg PO q6h - refer to form OV2147) Efavirenz (Sustiva®) EFV 600mg qday Capsule, Tablet On empty stomach; preferably at bedtime Avoid in 1st trimester of pregnancy or in women trying to conceive Etravirine (Intelence®) ETV 200mg bid Tablet (may be dispersed in water) Take after a meal; avoid on empty stomach Check for significant drug interactions Abacavir (Ziagen®) ABC Inhibitors - NNRTI Reverse Transcriptase Protease Inhbitors - PI Non-nucleoside Nucleoside/Nucleotide Analogues - NRTI ® ® ® Nevirapine (Viramune®) NVP XR: 400mg qday IR: 200mg bid Tablet, Oral susp -- Monitor LFTs Rilpivirine (Edurant®) RPV 25mg qday Tablet Take with a fatty meal Contraindicated with PPI Atazanavir (Reyataz®) ATV 300mg qday (+RTV) or 400mg qday Capsule Take with food Avoid if >20mg of omeprazole per day required. Expect ↑ indirect bili d/t ↑ conjugation Darunavir (Prezista®) DRV 800mg qday (+ RTV) or 600mg bid (+ RTV bid) Tablet Must be taken with food Fosamprenavir (Lexiva®) FPV 700mg bid (+RTV bid) or 1400mg qday (+ RTV) Tablet Oral susp -- Lopinavir/ritonavir (Kaletra®) 400/100mg (2 tabs) bid or 800/200mg (4 tabs) qday Tab (200/50mg), Oral soln (contains 42% ethanol) Tab: no restriction Oral soln: take with food Once daily dosing is not recommended in pregnant women Nelfinavir (Viracept®) NFV 1250mg bid or 750mg tid Tablet Must take with meal Ritonavir (Norvir ) RTV Used primarily as boosting agent in low doses (100mg) Tablets, capsules, Oral soln -- Saquinavir (Invirase®) SQV 1000mg bid (+ RTV bid) Hard gel caps, tablets With or after a meal 500mg bid (+ RTV 200mg bid) Capsules, oral soln With food 400mg bid Tablets, chewable tab -- 300mg bid Tablet -- 90mg (1ml) SQ bid Powder for injection -- ® ® ® Tipranavir (Aptivus ) TPV Baseline ECG Integrase Inhibitor Raltegravir (Isentress®) RAL Chemokine Coreptor Antagonist Maraviroc (Selzentry®) MVC Check for sig drug interactions Fusion Inhibitor Dual Enfuvirtide (Fuzeon®) ENF Emtricitabine/Tenofovir (Truvada ) 1 tab (200/300mg) daily Tablet -- Abacavir/Lamivudine (Epzicom®) 1 tab (600/300mg) daily Tablet -- Lamivudine/Zidovudine (Combivir ) 1 tab (150/300mg) bid Tablet -- Efavirenz/Emtricitabine/Tenofovir (Atripla®) 1 tab (600/200/300mg) qhs Tablet On empty stomach; preferably qhs Abacavir/Lamivudine/Zidovudine (Trizivir®) 1 tab (300/150/300mg) bid Tablet -- Emtricitabine/Rilpivirine/Tenofovir (Complera®) 1 tab (200/25/300mg) daily Tablet With food Elvitegravir/cobicistat/tenofovir/emtr icitabine (Stribild®) 1 tab (150/150/300/200mg) daily Tablet With food Triple Quad Combinations ® Avoid initiation in Crcl <70 ml/min & discontinue if Crcl <50 ml/min Expect mild ↑ Scr (01/2013)