Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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Candidemia or candidiasis 11Non-neutropenicNeutropeniaw/out metastaticcomplicationsw/out metastaticcomplicationsChronic Disseminated CandidiasisOsteomyelitisSeptic ArthritisCNS CandidiasisAspergillosis 12Last Guideline: 2009 / Projected Update: Unknown2 weeks after documented clearance from the bloodstream and resolution ofsymptoms attributable to candidemia PLUS catheter removal stronglyrecommended2 weeks after documented clearance from the bloodstream, resolution ofsymptoms attributable to candidemia, and resolution of neutropenia PLUScatheter removaluntil lesions have resolved (usually months) and should continue throughperiods of immunosuppression6-12 months: fluconazole6 weeks: fluconazoleUntil all signs and symptoms, CSF abnormalities have resolvedLast Guideline: 2008 / Projected Update: UnknownDuration of therapy considerations1. Duration of therapy for most aspergillosis conditions has not been optimally defined. Duration is dependent on: site ofinfection, extent of disease, level of immune suppression & ability to reverse immune suppression2. Should be determined by resolution of clinical & radiological findings with or without normalization of galactomannanantigenemia6 - ≥12 weeks: Therapy should be continued throughout the period ofInvasive Pulmonary Aspergillosisimmunosuppression and until lesion resolutionOsteomyelitis &Septic ArthritisBlastomycosis 13ImmunocompetentImmunocompromised> 6-8 weeksLong-term suppressive therapy or treatment throughout immunosuppressionLast Guideline: 2008 / Projected Update: UnknownPulmonaryBlastomycosisDisseminatedExtrapulmonaryBlastomycosisCNS BlastomycosisModerately severeto severe diseaseMild to moderatediseaseModerately severeto severe diseaseMild to moderatediseaseOsteoarticularBlastomycosis in ImmunosuppressedPatientsCryptococcal Disease 14CryptococcalMeningoencepalitisHIV-Infected1-2 weeks (or until improvement): Lipid amphotericin 3-5mg/kg/day orAmB deoxycholate @ 0.7-1 mg/kg/day then3 days: Itraconazole 200mg PO TID then6-12 months: Itraconazole 200mg PO BID3 days: Itraconazole 200mg PO TID then6-12 months: Itraconazole 200mg PO BID1-2 weeks (or until improvement): Lipid amphotericin 3-5mg/kg/day orAmB deoxycholate @ 0.7-1 mg/kg/day then3 days: Itraconazole 200mg PO TID then6-12 months: Itraconazole 200mg PO BID3 days: Itraconazole 200mg PO TID then6-12 months: Itraconazole 200mg PO BID> 12 months of antifungal therapyLipid AmB @ 5mg/kg/day for 4-6 weeks thenOral azole therapy with either fluconazole, itraconazole, or voriconazole1-2 weeks (or until improvement): Lipid amphotericin 3-5mg/kg/day orAmB deoxycholate @ 0.7-1 mg/kg/day then3 days: Itraconazole 200mg PO TID then≥12 months: Itraconazole 200mg PO BIDConsider lifelong suppressive therapy for oral itraconazole 200mg per day ifimmunosuppression cannot be reversed & in patients with relapses despiteadequate treatmentLast Guideline: 2010 / Projected Update: UnknownInduction:AmB deoxycholate or lipid AmB plus flucytosine for 2 weeks orAmB deoxycholate or lipid AmB (for flucytosine-intolerant patients) for 4-6weeksConsolidation:Fluconazole for 8 weeksMaintenance:Fluconazole (preferred-superior) or itraconazole or AmB deoxycholate for >1year
PulmonaryCryptococcalOrgan TransplantRecipientsNon-HIV and NontransplantMild-to-ModerateInfection(absence of diffusepulmonaryinfiltrates, absenceof severeimmunosuppression,& lack ofdissemination)Severe InfectionCryptococcemiaNon CNS disease, no fungemia, singlesite of infection, & no immunosuppressiverisk factorsInduction:Lipid AmB plus flucytosine for 2 weeks orAmB deoxycholate or lipid AmB (without flucytosine) for 4-6 weeksConsolidation:Fluconazole for 8 weeksMaintenance:Fluconazole for 6 months-12 monthsInduction:AmB deoxycholate plus flucytosine for 2->4 weeks or• 2 weeks for low risk patients (early diagnosis, no uncontrolled underlyingcondition or sever immunocompromised state) with excellent clinicalresponse to therapy• 4 weeks for patients with meningitis who have no neurologicalcomplications, no significant underlying disease or immunosuppression, andfor whom CSF culture @ 2 weeks of txtment does not yield yeast• > 4 all other patients not included in 2-4 week categoriesAmB deoxycholate (for fluctyosine-intolerant patients) for >6 weeks orLipid AmB (for AmB deoxycholate-intolerant patients) with flucytosine for >4weeksConsolidation:Fluconazole for 8 weeksMaintenance:Fluconazole for 6-12 monthsFluconazole for 6-12 monthsSame as CNS Disease aboveSame as CNS Disease aboveFluconazole for 6-12 monthsReferences:1. Mermel LA, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-relatedinfections. Clin Infect Dis. 2009;49:1-45.2. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults:2010 update by the Society for <strong>Health</strong>care Epidemiology of America (SHEA) and the Infectious Diseases Societyof America (IDSA). Infect Control Hosp Epidemiol 2010;31:000-000.3. Lipsky BA, Berendt AR, Deery HG, Embil JM et al. Diagnosis and treatment of diabetic foot infections. Clin InfectDis. 2004;39:885-910.4. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis: Diagnosis, antimicrobial therapy, andmanagement of complications. Circulation 2005;111:e394-e433.5. Solomin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infectionin adults and children. Clin Infect Dis 2010;50:133-164.6. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice guidelines for the management of bacterial meningitis. ClinInfect Dis. 2004;39:1267-84.7. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Societyconsensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis.2007;44:S27-72.8. American Thoracic Society. <strong>Guidelines</strong> for the management of adults with hospital-acquired, ventilatorassociated,and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388-416.9. Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: International guidelines for management ofsevere sepsis and septic shock: 2008. Crit Care Med. 2008; 26: 296-327.10. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin andsoft-tissue infections. Clin Infect Dis. 2005;41:1373-406
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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
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PIPERACILLIN/TAZOBACTAM (Zosyn ® )
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PRIMAQUINEUsual DoseAdult: Malaria
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RIFABUTINUsual DoseAdult (150 mg ca
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• 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
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 104 and 105: 1. Patients with large volumes of d
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 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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