Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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PREFACEThe Antimicrobial Use Guidelines represent the expert opinion and advice of attending physicians of the University ofWisconsin Hospital and Clinics, particularly, the Infectious Diseases Section of the Department of Medicine andDepartment of Pediatrics. Originally conceived in 1988 as a selection guide to the more expensive antimicrobials intendedto maximize optimal patient care, the document now has guidelines for use on all UWHC formulary antimicrobials. Theseguidelines serve not only the function of rational antimicrobial selection from a powerful array of choices, but also asguidelines for cost-effective use. The guidelines also function as the Drug Use Evaluation criteria for antimicrobial audits.Although general guidelines can be written, not every patient will fit these guidelines. When faced with atherapeutic dilemma, the Infectious Diseases Section provides timely consults. If pharmacokinetic monitoring is desired,the unit pharmacist schedules levels and calculates a new regimen. The unit pharmacist also provides information ondoses, routes of administration and other facts as they relate to drug use.Care has been taken to make this publication error-free and as up-to-date as possible at the time of publication. However,no responsibility is assumed by UWHC, the Pharmacy and Therapeutics Committee or the UWHC Department ofPharmacy for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, orfrom any use or operation of any methods, products, instructions, doses or ideas contained in this material. Because ofthe rapid advances in the medical sciences, the publisher recommends that drug doses and susceptibilities beindependently verified.Often empiric broad-spectrum coverage is appropriate before culture and susceptibilities are known. However, onceculture and susceptibilities are known, therapy should be reviewed to change the patient's antimicrobials to thenarrowest spectrum possible (de-escalation) or have doses adjusted based on pharmacokinetic andpharmacodynamic principles. This will decrease needless broad-spectrum antibiotic pressure, a factor in theemergence of resistant strains. This will also decrease unnecessary drug costs and potential adverse effects.Costs reflect current prices as of April 2011The Pharmacy and Therapeutics Committee wishes to specially thank the members of the Antimicrobial UseSubcommittee for their time and input into the writing of these guidelines: David Andes MD, James Conway MD, BarryFox MD, Carol Spiegel PhD, and Andrew Urban MD. Also, special thanks to the following people who wrote or updatedsections of the guidelines including Jennifer Schauer PharmD, MaryAnn Steiner PharmD, Michael Madalon RPh, RickKittell PharmD, Lucas Schultz, PharmD and Jeff Fish PharmD. The revision of this twenty-first edition was coordinated bySara Shull, PharmD, MBA.*Each drug entry includes: drug name, adult (70 kg) and pediatric doses, UWHC and managed care cost per day.**Pediatric dose should not exceed adult dose.A version of this guideline is also available online on uconnect in the Drug Use Guidelines SectionEvidence based articles are available online on Workspaces athttp://workspaces.uconnect.wisc.edu/display/AST/Home
Useful Web Sites and ResourcesInformation on HIV/AIDS Treatment, Prevention and Research http://aidsinfo.nih.gov/Johns Hopkins AIDS Service http://www.hopkins-aids.edu/UCSF Center for HIV Information http://hivinsite.ucsf.edu/Johns Hopkins Antibiotic Guide http://hopkins-abxguide.orgCenters for Disease Control and Prevention http://www.cdc.gov/University of California-San Francisco National HIV/AIDS Clinical Consultation Center http://www.nccc.ucsf.edu/International AIDS Society – USA http://www.iasusa.org/National HIV Telephone Consultation Service “Warmline” 1-800-933-3413 (Open Monday through Friday)National Clinicians' Post-Exposure Prophylaxis Hotline (“PEPline”) 1-888-448-4911 (Open 24 hours/7 days a week)Guidelines at the CDC website: http://cdc.gov/DiseasesConditions/• Guidelines for Preventing Opportunistic Infections among Hematopoietic Stem Cell Transplant Recipients• Sexually Transmitted Diseases Treatment Guidelines• Prevention and Control of Influenza• U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIVand Recommendations for Postexposure Prophylaxis• Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure toHIV in the United StatesSurbhi L, Terrell CL, Edson RS. General principles of antimicrobial therapy. Mayo Clin Proc. 2011;86(2):156-167.Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guidelines for the use of antimicrobial agents in neutropenicpatients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52(4):427-431.UWHC Medication Shortages List: http://rx.uwhealth.wisc.edu/OrdeRx/Docs/DrugShortages.xls
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 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
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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
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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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