1. No category

GRAM-NEGATIVE BACTERIA
Enterobacter cloacae
Escherichia coli
Klebsiella pneumoniae
Proteus mirabilis
Pseudomonas aeruginosa
ADDITIONAL INFORMATION
NO renal adjustment needed
Usual adult daily dose (IV,
Nitrofurantoin PO only)
Estimated hospital cost/day
100
100
100
100
99
15 mg/kg
Q24h
$
42
59
1 gm
Q6h
$
52
81
73
3 gm
Q6h
$$$
84
92
92

500 mg
Q24h
$
1 gm
Q8h
$
98
89
93
94
93
83
88
93
94
93
1 gm
Q12h
$$
1 gm
Q8h
$$
100
100
100

49
100
98
87
96
84
91

98
100
100
91
63
94
68
97
67
73
91
35

85
95
95
99
91
Vancomycin
Tobramycin
Tetracycline
Sulfa/trimethoprim
(Bactrim, Septra)
97
Piperacillin/tazobactam
(Zosyn)
Penicillin
Nafcillin/oxacillin
Levofloxacin
(Levaquin)
Imipenem/cilastatin
(Primaxin)
49
98
100
99
94
97
34
100
65
85
100
92
61
87
59
100
57
100
1 gm 600 mg 100 mg 1 gm 5 mg/kg 500 mg 500 mg 2 gm 100 mg 2.5 MU 3.375gm 160 mg 500mg
Q24h
Q8h
Q12h Q24h Q24h
Q6h
Q24h
Q4h
bid
Q6h
Q6h TMP Q6h Q6h
$
$$$
$$$ $$$$
$
$$$
$$
$$$$
$
$
$$$
$$
$
Note: Only antibiotic susceptibility >30% included ; tested on bioMerieux Vitek 2
*Meningitis isolates
S
VRE rate: 16% of all Enterococcus are resistant to vancomycin
For synergy use only
MRSA rate: 54% of all S. aureus isolates are MRSA
Extended-spectrum beta-lactamase (ESBL) rate: 11% of E. coli and 4% Klebsiella pneumoniae are ESBLs
Green = significant improvement over last year
Yellow = significant decline over last year
64
100
82
89
93
94

Gentamicin
Ertapenem
(Invanz)
Doxycycline
Clindamycin
Ceftriaxone
Ceftazidime
Cefepime
Cefazolin
Azithromycin
Ampicillin/sulbactam
(Unasyn)
83
100/93
*
40
125
3487
727
207
444
52S
92S
96
98
Nitrofurantoin
(Macrobid®) (urine only)
409
108
1614
Ampicillin
Amikacin
ORGANISM
GRAM-POSITIVE BACTERIA
Enterococcus faecalis
Enterococcus faecium
Staphylococcus aureus
Streptococcus pneumoniae
# Isolates
PERCENT SUSCEPTIBLITY- COMMONLY ISOLATED BACTERIA AT YRMC (FROM INPATIENT AND OUTPATIENT ISOLATES COLLECTED 10/2012 TO 9/2013)
99
86
96
84
98
5 mg/kg
Q24h
$
Key: $=<$10; $$= $10-19; $$$= $20-50; $$$$= >$50
1 gm
Q12h
$$
Antibiogram
2014
Pharmacy Department
Inpatient Pharmacy
Outpatient Pharmacy
Clinical Pharmacist
ICU Pharmacist
336-3381
336-7814
373-7398
276-6154
All antibiotics are automatically given a 10-day stop
date unless duration specified by physician.
Created 3/2014
Contents:
1. Antibiogram data 2014
2. Antimicrobial Stewardship
3. Antibiotic Restricted Formulary
4. CAP dosing guidelines
5. Levaquin dosing guidelines
6. TREATMENT OF COMMUNITY-ACQUIRED PNEUMONIA IN ADULTS
7. TYPICAL DURATION OF THERAPY-BACTERIAL INFECTIONS
8. VANCOMYCIN MONITORING- ADULT PATIENTS
Antimicrobial Stewardship
Definition:
A system of informatics, data collection, personnel, and policy/procedures which promotes the optimal
selection, use and duration of therapy for antimicrobial agents throughout the course of their use.
Purpose:
• Limit excessive and inappropriate use
• Improve and optimize therapy and clinical outcomes for the individual infected patient
6 Goals of an Antibiotic Stewardship Program
1.
2.
3.
4.
5.
6.
Reduce antibiotic consumption and inappropriate use
Reduce clostridium difficile infections
Improve patient outcomes
Increase adherence/utilization of treatment outcomes
Reduce adverse drug events
Decrease or limit antibiotic resistance
Principles of Antibiotic Therapy
Empiric Therapy (85%)
• Infection not well defined (“best guess”)
• Broad spectrum
• Multiple drugs
• More adverse reactions
• More expensive
Directed Therapy (15%)
• Infection well defined
• Narrow spectrum
• One, seldom two drugs
• Less adverse reactions
• Less expensive
5 Tenets of Appropriate Antibiotic Use
1. Treat bacterial infection, not colonization
• Many patient become colonized with potentially pathogenic bacteria but are not infected
• Asymptomatic bacteriuria or foley catheter colonization
• Tracheostomy colonization in chronic respiratory failure
• Chronic wounds and decubiti
• Lower extremity stasis ulcers
• Chronic bronchitis
• Can be difficult to differentiate
• Presence of WBCs not always indicative of infection
• Fever may be due to another reason, not the positive culture
2. Do Not Treat Sterile Inflammation or Abnormal Imaging Without Infection
• Examples:
• Atelectasis
• Malignancy
• Hemorrhage
• Pulmonary edema
• Do not treat abnormal X-ray with antibiotics if the patient does not have systemic evidence of
inflammation (fever, WBC, sputum production, etc.)
3. Do Not Treat Viral Infections With Antibiotics
• Common Colds
• Acute sinusitis <7 days old
4. Limit Duration of Antibiotic Therapy to Appropriate Length
• Ventilator associated pneumonia: 8 days
• Most community acquired pneumonia: 5 days
• Cystitis: 3 days
• Pyelonephritis: 7 days
• Cellulitis: 5-10 days
5. Other Tenets of Antibiotic Stewardship
• Re-evaluate, de-escalate or stop antibiotic therapy at 48-72 hours based on diagnosis and microbiologic
results
• Do not give antibiotics with overlapping activity (i.e., PCN + Ceph)
• Practice good hand hygiene
CAP dosing guidelines
Hospitalized on Med Floor
Hospitalized in ICU
(must be duel therapy)
Ceftriaxone 1 gm IV Q24H
Ceftriaxone 1gm IV Q24H
and
and
Azithromycin 500gm IV Q24H Azithromycin 500gm IV Q24H
OR
OR
Levaquin 750mg IV Q24H
Ceftriaxone 1gm IV Q24H
and
Levaquin 750mg IV Q24H
At Risk for Pseudomonas
Zosyn 4.5 gm IV Q6h
and
Levaquin 750mg IV Q24h
OR
Zosyn 4.5 gm IV Q6h
and
an aminoglycoside
ICU Antibiotic Restricted Formulary*
Category A Restricted Agents (Authorization needed for use)
Amikacin
Caspofungin (Cancidas)
Ceftaroline (Teflaro)
Chloramphenicol
Colistimethate (Coly-Mycin M)
Daptomycin (Cubicin)
Ertapenem (Invanz)
Fidaxomicin (Dificid)
Foscarnet (Foscavir)
Ganciclovir (Cytovene)
Kanamycin
Linezolid (Zyvox)
Micafungin (Mycamine)
Moxifloxacin (Avelox)
Rifaximin (Xifaxan)
Streptomycin
Tigecycline (Tigacil)
Valganciclovir (Valcyte)
Voriconazole (Vfend)
1. I.D. authorization required before pharmacy dispensing
2. Intensivist may authorize or deny if I.D. physician unavailable
3. Maximum 10 day therapy unless order is renewed
Category B Restricted Agents (limited to 48 hours unless approved)
Ceftazidime (Fortaz / Tazicef)
Imipenem / cilastatin (Primaxin)
Vancomycin
1.
a.
b.
c.
Initial order discontinued after 48 hours unless:
Authorized by I.D. specialist or
Documentation of appropriate indication and supportive findings by treating physician
Maximum of 10 day therapy unless order is renewed
Category C Restricted Agents
All other formulary antibiotics are unrestricted
* Restricted formulary approved by Medical Executive Committee 11/2005
Levaquin dosing guidelines
Creatinine Clearance
Dose (mg)
>50 mL / min
20-49 mL / min
10-19 mL / min
500 Daily
500, then 250 Daily
500, then 250 QOD
Hemodialysis / CAPD
500, then 250 Q48H
CAP Dose (5 days
only)
750 Daily
750 day 1,3,5
750 then 500 on day 3,
5
750 then 500 Q48H
TREATMENT OF COMMUNITY-ACQUIRED
PNEUMONIA IN ADULTS
Hospitalized Patients
Ceftriaxone + azithromycin
Non-ICU Patient
OR
Levofloxacin
Ceftriaxone + azithromycin
ICU Patient
OR
Ceftriaxone + levofloxacin
Pseudomonas risk
Piperacillin/tazobactam (Zosyn®) OR cefepime
(Structural lung disease or repeated
severe COPD exacerbations requiring
PLUS
frequent steroid and/or antibiotic use)
Levofloxacin OR [tobramycin + azithromycin]
Community-acquired MRSA
Vancomycin
Reference- IDSA/ATS Consensus Guidelines for the Treatment of Community-Acquired
Pneumonia in Adults, 2007
TYPICAL DURATION OF THERAPY:
BACTERIAL INFECTIONS
Site
Bone
Clinical Diagnosis
Osteomyelitis
Short-term CVC or AC
Uncomplicated
S. aureus
Complicated
Catheter-related,
Bloodstream
(CVC= central venous
catheter, AC= arterial
catheter)
Long-term CVC or port
Uncomplicated
S. aureus
Complicated
Tunnel infection,
port abscess
Duration
4-6 weeks
7-14 days
≥ 14 days
4-6 weeks
7-14 days
4-6 weeks
4-6 weeks
7-10 days
Consider catheter removal
Meningitis
Neisseria meningitidis
Haemophilus influenzae
Streptococcus pneumoniae
Group B streptococcus
Aerobic gram-negative bacilli
Listeria monocytogenes
CNS
Heart
Endocarditis
Urinary tract infection
Uncomplicated
Complicated
(male, catheter)
Kidney
Pyelonephritis
Pneumonia
Lung
Skin/soft tissue
Community-acquired
Nosocomial (if appropriate initial therapy;
Except Pseudomonas)
CellulitisUncomplicated diabetic foot infection
7 days
7 days
10-14 days
14-21 days
21 days
≥ 21 days
4-6 weeks
3 days
14-21 days
7-14 days
5-7 days
7-8 days
5 days
2-4 weeks
VANCOMYCIN MONITORING:
ADULT PATIENTS
Clinical Indication
Mild-moderate infections
Complicated infections
(endocarditis, meningitis, hospital-acquired pneumonia, osteomyelitis)




Targeted Trough
10-15 µg/mL
15-20 µg/mL
Dose 15-20 mg/kg (actual body weight) Q8-12H for most patients with normal renal function
Troughs should be obtained approximately before the 5th dose
Troughs should be drawn only if patient will be on longer therapy (>3-5 days)
Failure rates in MRSA have been associated with vancomycin MIC=2, although reported
susceptible
Reference- Consensus review from ASHP, IDSA, & SIDP, 2009