Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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PART I: BY DRUGABACAVIRFor up-to-date information on the use of antiretrovirals, consult an HIV expert or www.aidsinfo.nih.gov/ABACAVIR/LAMIVUDINE (Epzicom ® ) – non-formulary at UWHCFor up-to-date information on the use of antiretrovirals, consult an HIV expert or www.aidsinfo.nih.gov/ABACAVIR/LAMIVUDINE/ZIDOVUDINE (Trizivir®) – non-formulary at UWHCFor up-to-date information on the use of antiretrovirals, consult an HIV expert or www.aidsinfo.nih.gov/ACYCLOVIRUsual DoseAdult: 200 mg Q4H PO five doses per day, 400 mg PO TID or 800 mg five times daily PO (UWHC cost/day $0.46-1.15)OR 5-12 mg/kg Q8H IV (UWHC cost/day $7.31-17.54)Pediatric: 20 mg/kg/day (maximum 800 mg/dose) PO/IV in divided doses four times daily or 25-50 mg/kg/day IV in divideddoses Q8HIndications1. Herpes simplex encephalitis (10-12 mg/kg Q8H IV x 21 days). In children 3 months to 12 years old, the dose is 20mg/kg every 8 hours for 10 days.2. Herpes simplex (severe mucosal or cutaneous)a. Immunocompromised or burn patients (5 mg/kg Q8H IV x 7-14 days).b. In select immunocompetent patients, such as for eczema herpeticum, proctitis, severe primary oral or periorbitalherpes or other severe mucosal or cutaneous disease (20 mg/kg/dose, up to 800 mg, four times daily PO x 5 days OR5 mg/kg/dose Q8H IV).3. Herpes simplex (genital herpes)a. Immunocompetenti. Initial acute, mild/moderate (200 mg 5 times daily PO x 10 days OR 400 mg TID PO x 10 days). Initial acute,severe (5 mg/kg Q8H IV x 5 days).ii. Chronic recurrent, prophylaxis (400 mg BID PO for up to 6 months, then reassess need).iii. Episodic (200 mg Q4H PO 5 times daily x 5 days OR 400 mg TID PO x 5 days).b. Immunocompromisedi. Acute, severe (5 mg/kg Q8H IV x 7 days).4. Varicella (chicken pox)a. Immunocompromised children (500 mg/m 2 Q8H IV over 1 hour x 7-10 days).b. In selected immunocompetent pediatric or adult patients (20 mg/kg/dose, up to 800 mg, five times daily PO x 7 days– begin within the first 24 hours of onset of rash).c. Varicella (chicken pox) pneumonia, immunocompetent (10 mg/kg Q8H IV x 7 days).5. Herpes zoster (shingles)a. Immunocompetent (800 mg 5 times daily PO x 7-10 days); must be started within 72 hours of onset.b. Immunocompromised (10-12 mg/kg Q8H IV x 7 days).c. Immunocompromised - disseminated, severe localized (but >1 dermatome), or involving ophthalmic division of thetrigeminal nerve (10 mg/kg Q8H IV x 7 days).6. Cytomegalovirus prophylaxis in transplant patients (800 mg four times daily PO x 3 months).7. Herpes simplex prophylaxis for bone marrow transplant recipients (400 mg four times daily PO).8. Neonatal herpes (20 mg/kg/dose Q8H IV x 14-21 days).CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect.With high dose (>10 mg/kg) IV therapy, administer over 60 minutes and maintain hydration to prevent urine crystallization.For obese patients the 10 mg/kg IV dose is based on ideal body weight. Maximum dose is 500 mg/m 2 . Concomitant useof ganciclovir and acyclovir is unnecessary, and increases costs and toxicity. In general, it is not considered necessary totreat uncomplicated, single dermatome (unless trigeminal) herpes zoster in immunocompetent children or adolescents orpregnant women.
ADEFOVIR – nonformulary at UWHCUsual DoseAdult: 10 mg PO once daily (UWHC cost/day $28.25)Indications:1. Chronic hepatitis B infectionComments:Adefovir may be taken without regard to food. Dosing interval should be increased in patients with renal insufficiency. Nodose adjustment necessary in hepatic failure. Discontinuation of therapy may be followed by a severe exacerbation ofhepatitis.AMIKACINUsual DoseAdult, Pediatric: 7.5 mg/kg IV Q12H or 15 mg/kg daily IV (UWHC cost/day $8.48)Note: Dose using IBW. For obese patients (BMI>30 kg/m 2 ) use a dosing weight (DW) = 0.4 (ABW-IBW) + IBW.(IBW=Ideal Body Weight ABW=Actual Body Weight)Indications1. Serious infections with aerobic Gram-negative bacilli with documented resistance to gentamicin and tobramycin, orwhere resistance is suspected based on history.2. Resistant tuberculosis, adjunctive therapy (750 mg/day for patients 100 kg, 7.5 mg/kg/day).3. Mycobacterium avium complex, adjunctive therapy (7.5 mg/kg/day).CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect. Amikacin is comparable intoxicity to gentamicin. Contact the unit pharmacist for assistance in pharmacokinetic dosing. For extended-interval (Q24H)dosing draw midpoint level 8-12 H after the start of infusion. Peak: 30 minutes after the end of a 30- to 60-minute infusion.Trough: 15-30 minutes prior to next dose (peak and trough used with Q12H dosing only)AMOXICILLINUsual DoseAdult: 250-500 mg Q8H or 500-1000 mg Q12H PO (UWHC cost/day: $0.15-0.21) Note: Q12H dose is for outpatientsetting only.Pediatric:** 40 mg/kg/day PO in divided doses Q8H; 80-90 mg/kg/day, divided, for suspected resistant S. pneumoniaeinfectionsIndications1. Acute otitis media - First-line therapy.2. Acute sinusitis - First-line therapy.3. Streptococcal pharyngitis in children – First-line therapy.4. Enterococcal cystitis – Drug of choice for oral therapy.5. Early Lyme disease in children < 8 years (40 mg/kg/day x 30 days) and pregnant women (500 mg Q8H x 2-4 weeks).6. Bacterial endocarditis prophylaxis (see Appendix A).7. H pylori infection as part of combination regimen.8. Group A streptococcal pharyngitis in adults (500 mg PO BID).CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect.Moraxella catarrhalis is almost always (85-100%) resistant due to beta-lactamases. Haemophilus influenzae is alsofrequently (30%) resistant due to beta-lactamases and Streptococcus pneumoniae is increasingly showing penicillinresistance by altered penicillin-binding proteins. Ampicillin IV plus gentamicin or vancomycin plus gentamicin may bepreferred for prophylaxis in patients with prosthetic heart valves, a previous history of endocarditis or surgically
Page 2 and 3: PREFACEThe Antimicrobial Use Guidel
Page 4 and 5: Antimicrobial Cost Table (Cost info
Page 6 and 7: Summary of Antibiotic Order Form: S
Page 8: LUNGS/PULMONARYCommunity-Acquired P
Page 14 and 15: constructed systemic-pulmonary shun
Page 16 and 17: AMPICILLIN/SULBACTAM (Unasyn ® )Us
Page 18 and 19: ATOVAQUONE/PROGUANIL (Malarone ® )
Page 20 and 21: CEFAZOLINUsual DoseAdult: Moderate/
Page 22 and 23: CommentsDose adjustment required fo
Page 24 and 25: 1. Typhoid fever. (NOTE: Third-gene
Page 26 and 27: -Dutasteride-Eltrombopag-Theophylli
Page 28 and 29: CLINDAMYCINUsual DoseAdult: 600-900
Page 30 and 31: DAPTOMYCINInfectious Disease approv
Page 32 and 33: Concurrent administration with peni
Page 34 and 35: • Cisapride (contraindicated) •
Page 36 and 37: • Oral contraceptives/hormones -
Page 38 and 39: Synergy in infective endocarditis a
Page 40 and 41: • Colchicine • Indinavir • Ta
Page 42 and 43: • Donepezil • Pioglitazone• D
Page 44 and 45: with linezolid should be considered
Page 46 and 47: 4. Life-threatening Gram-negative i
Page 48 and 49: MOXIFLOXACINLevofloxacin and moxifl
Page 50 and 51: Indications1. Uncomplicated cystiti
Page 52 and 53: 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
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SULFISOXAZOLENo longer available as
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TICARCILLIN/CLAVULANATE (Timentin
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2. Recurrent urinary tract infectio
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VANCOMYCINUsual DoseAdult: 1 g Q12H
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Careful monitoring of patients usin
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APPENDIX B: UWHC SURGICAL ANTIMICRO
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GI:Appendectomy 3Anaerobic organism
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VascularLIKELYPATHOGENS• ANTIMICR
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Cleanorthopedicprocedures(other)Sta
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APPENDIX C: THERAPY FOR TUBERCULOSI
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p-Aminosalicylic acid(PAS)Granules
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Appendix D: UNIVERSITY OF WISCONSIN
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Appendix E: UWHC Guidelines for the
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B. Antifungal Prophylaxis for BMT a
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D. Cost ComparisonDrugAmphotericin
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17. Maertens J, Glasmacher A, Herbr
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47. Courtney R, Wexler D, Radwanski
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2.1.7 Patient is without placement
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Medications Approved for Parenteral
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APPENDIX G: Serum Drug Concentratio
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APPENDIX H: Guidelines for Monitori
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1. Patients with large volumes of d
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16. Tsuji B, Rybak MJ. The influenc
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APPENDIX I: Infectious Diseases App
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APPENDIX J: UWHC Guidelines For the
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with aztreonam and other beta-lacta
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D. Side Chains1.2.5. The prescriber
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14. Pichichiro ME. Use of selected
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Appendix KUWHC Guidelines for Cost-
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sulfa and can be prescribed topatie
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superinfection: amoxicillin 1 g PO
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17. Smucny J, Fahey T, Becker L, Gl
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Appendix M: Guidelines for the Prop
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D. CategorizationPatients should be
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Empiric coverage for Enterococcus i
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H. Necrotizing PancreatitisThe publ
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Bone or JointEndocarditis 4Streptoc
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Candidemia or candidiasis 11Non-neu
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11. Pappas PG, Kauffman CA, Andes D
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piperacillin/tazobactam. There were
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D. Dose of Antibiotic1. Piperacilli
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TNAVasopressinVoriconazoleMeropenem
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pretreatment with an H1-histamine b
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formal consult is not required, but
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K. References1.0 Bliziotis IA, Ples
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