Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect.Cefpodoxime proxetil 100 mg BID PO is equivalent to cefuroxime axetil 250 mg BID PO (for upper respiratory tractinfections and bronchitis).CEFTAZIDIMEUse of ceftazidime is limited to endophtalmitis per order sets and in antibiotic lock solutionsUsual DoseAdult: 2.25 mg in 0.1 mg for intravitreous administration for treating endophthalmitis; systemic dosing is 0.5-2 g Q8Hdepending on indication (UWHC cost/day $5.41-21.66 for systemic dosing)CEFTRIAXONECefotaxime, ceftriaxone and ceftizoxime are therapeutically interchangeable at the UWHC. Ceftriaxone is the currentformulary choice. Cefotaxime may be used in children 1 month of age or younger or in infants with hyperbilirubinemia.Usual DoseAdult: Moderate infections 1 g Q24H IV/ IM (UWHC cost/day $1.21). The 1 gram dose should be used for communityacquired pneumonia, and should be efficacious in most infections.Severe infections: 2 g Q24H IV/IM (UWHC cost/day $2.89).Pediatrics:** 50 - 100 mg/kg/day IV/IM in divided doses Q12 – 24H.Meningitis 100 mg/kg/day IM/IV in divided doses Q12H, to a maximum dose of 2 g IV Q12H in adults.Indications1. Community-acquired pneumonia in patients >60 years old or with comorbidity, given with a macrolide or doxycycline.The usual dose in the CAP UW pathway is 1 gram/24 hours.2. Bacterial meningitis, including infection with enteric Gram-negative bacilli, S pneumoniae or Haemophilus influenzae,pending susceptibility or test results.3. H influenzae or pneumococcal life-threatening infections (e.g., bacteremias, epiglottitis).4. Uncomplicated gonorrhea (125 mg IM as a single dose).5. Serious Gram-negative bacillus infections, other than Pseudomonas, especially if the patient is at high risk foraminoglycoside toxicity (CAUTION: Many nosocomial Gram-negative bacillus infections, especially those due toEnterobacter spp. and Pseudomonas aeruginosa, are resistant to ceftriaxone).6. Pneumonia caused by Gram-negative bacilli, other than P aeruginosa.7. Acute otitis mediaa. One-time dose in patients unable to take oral medications.b. Single daily dose times 3 days in patients with clinical treatment failure with oral antibiotics.8. Community-acquired pneumonia, urosepsis, skin and soft tissue infection or sepsis of unknown etiology.9. Endocarditis due to slow-growing fastidious Gram-negative organisms, usually in combination with an aminoglycoside.10. Alternative to ampicillin plus gentamicin. Also alternative therapy in endocarditis caused by Streptococcus viridans.11. Lyme Disease, especially with rheumatologic, neurologic or cardiac involvement (2 g IV daily).12. Presumptive bacteremia/sepsis in febrile children > 2 months old.13. Meningococcal prophylaxis, in ambulatory clinics. (Pregnant women 250 mg IM single dose, children 125 mg IM singledose).CommentsDo not use as empiric therapy for nosocomial infections where resistant Gram-negative rods such as Pseudomonas maybe present. Ceftriaxone is not active against Listeria monocytogenes, an organism of increasing importance inimmunosuppressed or transplant patients. Ceftriaxone can cause biliary sludging, especially in high doses in adults (2 gQ12H) and children. Ceftriaxone displaces bilirubin from plasma protein binding sites, which may be important if aneonate is already hyperbilirubinemic. For IM use, 1% lidocaine (without epinephrine) can be used as the diluent todecrease local pain. NOTE: Ceftriaxone 1 g/day is equal to cefotaxime 1 g Q8H and ceftriaxone 2 g/day is equal tocefotaxime 2 g Q8H. Monotherapy is usually possible for community-acquired Gram-negative bacillus septicemia,pneumonia, osteomyelitis and sepsis of unknown cause (unless in ICU, where double coverage is recommended forCAP). Ceftriaxone in combination with vancomycin is now considered the initial regimen of choice for suspectedpenicillin-resistant pneumococcal meningitis given the increase and spread of pneumococcal strains highlyresistant to penicillin, including southern Wisconsin and northern Illinois (up to 5%). Most pulmonary infections
can still be successfully treated with ceftriaxone even if the breakpoint MIC is intermediate or resistant topenicillin. Breakthrough infections with coagulase-negative staphylococci, enterococci and Candida are occurring withincreasing frequency with cephalosporin use.Do not administer ceftriaxone with calcium-containing IV solutions in the same IV line, including continuouscalcium-containing infusions such as parenteral nutrition via a Y-site concurrently. In patients other thanneonates, ceftriaxone may be administered sequentially with calcium-containing solutions with thoroughflushing of lines with compatible fluid between administrations.CEFUROXIMEUsual DoseAdult: 750 mg-1.5 g Q8H IV (UWHC cost/day $4.20-8.40).Surgical prophylaxis 1.5 g IV (UWHC cost/day $2.80), then 750 mg – 1.5 g Q8H or q 12 h. if subsequent doses are given.There are no comparative prophylaxis efficacy studies comparing q12h vs. q8h prophylaxis.Pediatrics:** 100-150 mg/kg/day IV/IM in divided doses Q8H.Pediatric surgical prophylaxis: 30 mg/kg/dose IV Q8HIndications1. Cardiovascular surgery prophylaxis (see Appendix B).2. Orthopedic surgery prophylaxis (see Appendix B).3. Community-acquired pneumonia, with age >60 or comorbidity, given with a macrolide or doxycycline. (But not severeinfection requiring ICU care).4. Periorbital cellulitis, buccal cellulitis in children.CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect.Cefuroxime may have similar oral anaerobic activity to penicillin G (Acta Clin Belg 1989;44:228-36) with greatest activityagainst Gram-positive strict anaerobes (Pathol Biol (Paris) 1990;38:343-6). Safety and effectiveness have not beenestablished in children below the age of 3 months. Should not be used to treat meningitis in children as treatment failureshave been reported. Oral cefuroxime and cefpodoxime are therapeutically interchangeable at UWHC. The currentformulary choice is cefpodoxime.CEPHALEXINCephalexin and cephradine are therapeutically interchangeable at the UWHC. Cephalexin is the current formulary choice.Step-down therapy from cefazolin.Usual DoseAdult: 250-500 mg PO Q6H (UWHC cost/day $0.25-0.50).Pediatrics:** 25-50 mg/kg/day PO in divided doses Q6H.Indications1. Skin and skin structure infections caused by susceptible staphylococci or streptococci in patients unable to toleratedicloxacillin (the drug of choice).2. Bacterial endocarditis prophylaxis (see Appendix A).CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect.CHLORAMPHENICOLUsual DoseAdult: 12.5-18.75 mg/kg Q6H IV (up to 4 g daily) (UWHC cost/day $61.62-70.42).Pediatric:** 50-100 mg/kg/day IV in divided doses Q6H.Indications
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 12 and 13: PART I: BY DRUGABACAVIRFor up-to-da
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 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
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
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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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