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
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
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
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
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.
