Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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1. Patients with large volumes of distribution may require higher milligram per kilogram doses andserum concentrations are necessary to adjust doses as the volume of distribution changes. Initialloading doses of 20 to 25 mg/kg are useful to achieve and maintain therapeutic concentrationssooner. Patient conditions that can have larger volumes of distribution are sepsis, recent cardiac or41, 43trauma surgery, burns over 20% of the total body surface area or pregnancy. The usual volumeof distribution varies from 0.4 to 1 liter/kg. 12. In patients with normal renal function the half-life ranges from 6 to 12 hours; as a result it can take upto 60 hours to reach steady state in patients with normal renal function and even longer in patientswith renal compromise. 13. Trough concentrations are recommended for patients with aggressive dosing, targeting serumconcentrations of 15 to 20 mcg/mL, obesity (BMI >30 kg/m 2 ), at high risk for nephrotoxicity, withunstable renal function or on dialysis. 13 Patients with targeted trough levels of 15 mcg/mL or greatershould have trough levels drawn approximately every three days and serum creatinine levelsapproximately every other day. The unit pharmacist may order a serum creatinine without aphysician’s cosignature for the purposes of drug concentration monitoring. Patients with rapidlychanging renal function where vancomycin kinetics may be difficult to predict may be candidates foralternatives to vancomycin.4. All patients receiving vancomycin therapy for prolonged therapy (at least 4 days) should have at leastone steady-state concentration drawn. Concentrations should be drawn weekly on patients withstable hemodynamic and renal function and more frequently on unstable patients. Patients on morethan 4 weeks of therapy can have a decrease in vancomycin clearance, thus it is important to monitorconcentrations at this point in therapy. 44 Infectious Disease guidance should strongly be consideredfor patients requiring more than 4 grams of vancomycin per day, and if the patient is on the InfectiousDisease consult service, the ID attending physician should be consulted.5. Target trough concentrations (within 30 minutes of the next dose):Treatment populationAll patients 1313, 14Endocarditis 10An infection with a MIC ≥ 1 mcg/mL, hospital-acquiredpneumonia, healthcare-associated pneumonia, ventilatorassociatedpneumonia, meningitis with intermittent dosingMeningitis, continuous infusion 65, 13, 1515Desired Concentrations> 10 mcg/mL– 20 mcg/mL– 20 mcg/mL20 – 28 mcg/mL6. If a steady-state concentration is outside the target therapeutic range, then proportionate dosageadjustments should be made in 250-mg increments and/or consider changing the dosing interval.7. High-flux hemodialysis (HD) is now the primary means of HD at UWHC and removes a significantamount of vancomycin. 45 The average amount of vancomycin removed by high flux HD during a 3- to4-hour session is 30 to 38%. 467.1. Most patients will require a vancomycin dose after each dialysis session. One method for dosingpatients on a regular HD schedule (of three times per week) is to give an initial loading dose of15 to 20 mg/kg and then empirically give 500 to 750 mg during the last hour of each HD46, 47session. If greater than three days of treatment is planned, then serum concentrationmonitoring is recommended.7.2. A second method of dosing with HD is to draw a concentration 2 hours after the end of dialysis(to allow for vancomycin redistribution) and then give a supplemental dose to attain the desiredtarget concentration.
7.3. Patients on a regular dialysis schedule will likely require the same dose of vancomycin aftereach dialysis session.8. Continuous renal replacement therapy (CRRT) clears vancomycin more quickly than peritoneal orHD. Usually patients on CRRT require a vancomycin dose (1 g) every 12 to 24 hours and troughserum concentrations are used to ensure adequate dosing. 491. Rybak MJ. The pharmacokinetic and pharmacodynamic properties of vancomycin. Clin Infect Dis.2006;42 Suppl 1:S35-39.2. Schentag JJ. Antimicrobial management strategies for gram-positive bacterial resistance in theintensive care unit. Crit Care Med. 2001;29(Suppl 4):100-107.3. Cruciani M, Gatti G, Lazzarini L, et al. Penetration of vancomycin into human lung tissue. JAntimicrob Chemother. 1996;38:865-869.4. Lamer C, de Beco V, Soler P, et al. Analysis of vancomycin entry into pulmonary lining fluid bybronchoalveolar lavage in critically ill patients. Antimicrob Agents Chemother. 1993;37:281-286.5. American Thoracic Society, Infectious Diseases Society of America. Guidelines for themanagement of adults with hospital-acquired, ventilator-associated, and healthcare-associatedpneumonia. Am J Respir Crit Care Med. 2005;171:388-416.6. Albanese J, Leone M, Bruguerolle B, Ayem ML, Lacarelle B, Martin C. Cerebrospinal fluidpenetration and pharmacokinetics of vancomycin administered by continuous infusion tomechanically ventilated patients in an intensive care unit. Antimicrob Agents Chemother.2000;44:1356-1358.7. LaPlante KL, Rybak MJ. Impact of high-inoculum Staphylococcus aureus on the activities ofnafcillin, vancomycin, linezolid, and daptomycin, alone and in combination with gentamicin, in anin vitro pharmacodynamic model. Antimicrob Agents Chemother. 2004;48:4665-4672.8. Rose WE, Leonard SN, Rossi KL, Kaatz GW, Rybak MJ. Impact of inoculum size andheterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) on vancomycin activityand emergence of VISA in an in vitro pharmacodynamic model. Antimicrob Agents Chemother.2009;53:805-807.9. Cantu TG, Yamanaka-Yuen NA, Lietman PS. Serum Vancomycin Concentrations: Reappraisal ofTheir Clinical Value. Clinical Infectious Diseases. 1994;18:533-543.10. Darko W, Medicis JJ, Smith A, Guharoy R, Lehmann DE. Mississippi mud no more: costeffectivenessof pharmacokinetic dosage adjustment of vancomycin to prevent nephrotoxicity.Pharmacotherapy. 2003;23:643-650.11. Craig WA. Basic pharmacodynamics of antibacterials with clinical applications to the use of betalactams,glycopeptides, and linezolid. Infect Dis Clin North Am. 2003;17:479-501.12. Moise-Broder PA, Forrest A, Birmingham MC, Schentag JJ. Pharmacodynamics of vancomycinand other antimicrobials in patients with Staphylococcus aureus lower respiratory tract infections.Clin Pharmacokinet. 2004;43:925-942.13. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adultpatients: a consensus review of the American Society of Health-System Pharmacists, theInfectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. AmJ Health Syst Pharm. 2009;66:82-98.14. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: diagnosis, antimicrobial therapy,and management of complications: a statement for healthcare professionals from the Committeeon Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease inthe Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery andAnesthesia, American Heart Association: endorsed by the Infectious Diseases Society ofAmerica. Circulation. 2005;111:e394-434.15. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterialmeningitis. Clin Infect Dis. 2004;39:1267-1284.
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PREFACEThe Antimicrobial Use Guidel
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Antimicrobial Cost Table (Cost info
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Summary of Antibiotic Order Form: S
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LUNGS/PULMONARYCommunity-Acquired P
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PART I: BY DRUGABACAVIRFor up-to-da
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constructed systemic-pulmonary shun
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AMPICILLIN/SULBACTAM (Unasyn ® )Us
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ATOVAQUONE/PROGUANIL (Malarone ® )
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CEFAZOLINUsual DoseAdult: Moderate/
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CommentsDose adjustment required fo
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1. Typhoid fever. (NOTE: Third-gene
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-Dutasteride-Eltrombopag-Theophylli
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CLINDAMYCINUsual DoseAdult: 600-900
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DAPTOMYCINInfectious Disease approv
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Concurrent administration with peni
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• Cisapride (contraindicated) •
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• Oral contraceptives/hormones -
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Synergy in infective endocarditis a
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• Colchicine • Indinavir • Ta
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• Donepezil • Pioglitazone• D
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with linezolid should be considered
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4. Life-threatening Gram-negative i
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MOXIFLOXACINLevofloxacin and moxifl
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Indications1. Uncomplicated cystiti
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CommentsDose adjustment required fo
Page 54 and 55: PIPERACILLIN/TAZOBACTAM (Zosyn ® )
Page 56 and 57: PRIMAQUINEUsual DoseAdult: Malaria
Page 58 and 59: RIFABUTINUsual DoseAdult (150 mg ca
Page 60 and 61: • Chloramphenicol • Leflunomide
Page 62 and 63: SULFISOXAZOLENo longer available as
Page 64 and 65: TICARCILLIN/CLAVULANATE (Timentin
Page 66 and 67: 2. Recurrent urinary tract infectio
Page 68 and 69: VANCOMYCINUsual DoseAdult: 1 g Q12H
Page 70 and 71: Careful monitoring of patients usin
Page 72 and 73: APPENDIX B: UWHC SURGICAL ANTIMICRO
Page 74 and 75: GI:Appendectomy 3Anaerobic organism
Page 76 and 77: VascularLIKELYPATHOGENS• ANTIMICR
Page 78 and 79: Cleanorthopedicprocedures(other)Sta
Page 80 and 81: APPENDIX C: THERAPY FOR TUBERCULOSI
Page 82 and 83: p-Aminosalicylic acid(PAS)Granules
Page 84 and 85: Appendix D: UNIVERSITY OF WISCONSIN
Page 86 and 87: Appendix E: UWHC Guidelines for the
Page 88 and 89: B. Antifungal Prophylaxis for BMT a
Page 90 and 91: D. Cost ComparisonDrugAmphotericin
Page 92 and 93: 17. Maertens J, Glasmacher A, Herbr
Page 94 and 95: 47. Courtney R, Wexler D, Radwanski
Page 96 and 97: 2.1.7 Patient is without placement
Page 98 and 99: Medications Approved for Parenteral
Page 100 and 101: APPENDIX G: Serum Drug Concentratio
Page 102 and 103: APPENDIX H: Guidelines for Monitori
Page 106 and 107: 16. Tsuji B, Rybak MJ. The influenc
Page 108 and 109: APPENDIX I: Infectious Diseases App
Page 110 and 111: APPENDIX J: UWHC Guidelines For the
Page 112 and 113: with aztreonam and other beta-lacta
Page 114 and 115: D. Side Chains1.2.5. The prescriber
Page 116 and 117: 14. Pichichiro ME. Use of selected
Page 118 and 119: Appendix KUWHC Guidelines for Cost-
Page 120 and 121: sulfa and can be prescribed topatie
Page 122 and 123: superinfection: amoxicillin 1 g PO
Page 124 and 125: 17. Smucny J, Fahey T, Becker L, Gl
Page 126 and 127: Appendix M: Guidelines for the Prop
Page 128 and 129: D. CategorizationPatients should be
Page 130 and 131: Empiric coverage for Enterococcus i
Page 132 and 133: H. Necrotizing PancreatitisThe publ
Page 134 and 135: Bone or JointEndocarditis 4Streptoc
Page 136 and 137: Candidemia or candidiasis 11Non-neu
Page 138 and 139: 11. Pappas PG, Kauffman CA, Andes D
Page 140 and 141: piperacillin/tazobactam. There were
Page 142 and 143: D. Dose of Antibiotic1. Piperacilli
Page 144 and 145: TNAVasopressinVoriconazoleMeropenem
Page 146 and 147: pretreatment with an H1-histamine b
Page 148 and 149: formal consult is not required, but
Page 150: K. References1.0 Bliziotis IA, Ples
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