Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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PIPERACILLIN/TAZOBACTAM (Zosyn ® )Usual DoseAdult: 2.25 to 3.375 Q4-6H or 4.5g Q6-8H IV (<strong>UW</strong>HC cost/day $26.60-53.24).Pediatric:** 150-400 mg of piperacillin component/kg/day IV in divided doses Q4-8HIndications1. Multiply-resistant Gram-negative infections at various sites.2. Multiply-resistant, mixed polymicrobial infections that include anaerobes.3. Enterococcal infections when ampicillin will not suffice.4. Polymicrobial infections with P aeruginosa and S aureus, (e.g., in cystic fibrosis patients).5. Neutropenic fever.6. Empiric therapy of patients with suspected drug-resistant bacterial infections, including hospital-acquired pneumonia.CommentsAll doses except the first dose are given as prolonged infusion. The first dose is given over 30 minutes to rapidly achievetherapeutic concentrations. Excusion criteria: patients receiving CVVH and patients treated for meningitis. Cystic fibrosispatients may receive prolonged infusion, but are not limited to lower doses specified in the prolonged infusion guideline.Dose adjustment required for renal impairment. See renal dosing guideline on uconnect.NOTE: Other combination antibiotics base their dose either on one component (e.g. Primaxin ® ) or both components (e.g.trimethoprim/sulfamethoxazole). Zosyn ® labeling states the dose (3.375 g) by adding the two components of piperacillin(3 g) plus tazobactam (375 mg). Zosyn ® should be used with an aminoglycoside or ciprofloxacin for the treatment of Paeruginosa infections. For documented serious Pseudomonas infections, 3.375 g Q4H or 4.5 g Q6H IV is recommended.For intra-abdominal infections, 3.375 g IV Q6H is equivalent to 4.5 g Q8H. Zosyn ® contains 2.35 mEq (54 mg) of sodiumper gram of piperacillin. Given as extended-infusion therapy in some ICUs. Tazobactam is important for enhancedanaerobic activity, but piperacillin/tazobactam should not be relied upon for serious oxacillin-sensitive S. aureusinfections.Drug Interactions• Aminoglycosides – inactivated by penicillins in admixtures when penicillin:AG ratio is 50:1 or higher• Vecuronium – piperacillin has caused cases of enhanced neuromuscular blockade• Live typhoid vaccine – decreased efficacy; wait 24 hours after end of therapy to give vaccinePOSACONAZOLEInfectious Disease approval required for all use of posaconazole outside HEM/BMT standard procedures (SeeAppendix I)Usual DoseAdult: 200 mg Q8H-Q6H PO (<strong>UW</strong>HC cost/day $82.28-$109.20)Prophylaxis 200 mg PO TID; Therapeutic 200mg PO Q6HPediatric: Safety and efficacy not established in children under age 13Indications1. Candidiasis prophylaxis in prolonged neutropenia2. Treatment of invasive fungal infections caused by resistant pathogens
CommentsFood and/or acid is required for the absorption of posaconazole; 15 grams of fat are necessary for maximal absorption ofa dose. A meal, nutritional supplement shake or serving of ice cream should be provided with each dose. Ideally, PPIacid suppressants should be avoided, or another class, i.e., histamine H 2 -blockers, substituted to maximize absorption.Jacqueline Sullivan, RD, kindly provided the following list of fat content in Room Service foods and supplements:• 2 cartons whole milk = 16 g• 1 serving French fries = 19 g• 2 – 1 oz slices cheese = 15 g• 1 serving cheeseburger = >15 g• 2 packets (2 Tbsp.) peanut butter = 15 g• 1 serving hot dog = > 15 g• 1 Tbsp. cooking oil or olive oil = 14 g• 1 serving fried chicken breast sandwich = > 15g• 4 pats butter = 16 g• 1 serving Ensure Plus (240 mL) = 11 g• 1 croissant = 19 g• 1 serving Magic Cup = 11 g• 1 serving brownie = 22 g• 1 serving Scandishake (240 mL) = 31 g• 1 serving cherry pie = 14 g• 1 serving Ensure High Protein (240 mL) = 6 g• 1 serving apple cinnamon coffee cake = 23 g• 1 serving Enlive = 0 g• 1 package brown sugar Pop-Tart = 14 g• 1 chocolate chip cookie = 10 gDrug InteractionsPosaconazole is an inhibitor of CYP3A4; concomitant administration of other CYP3A4 substrates may result in increasedplasma levels of those drugs, leading to adverse reactions. The following list of drugs are CYP3A4 substrates that maycause QT interval prolongation and potentially torsades de pointes when serum levels are increased, thus concomitantadministration with posaconazole is contraindicated:• astemizole• cisapride• halofantrine• pimozide• quinidine• terfenadineThe following drugs may have their levels increased by CYP3A4 inhibition with posaconazole; there is the potential forincreased toxicity so caution and increased vigilance are indicated:• Amlodipine • Felodipine • Rifabutin• Atazanavir • Lercanidipine • Ritonavir• Cyclosporine • Midazolam • Sirolimus• Diltiazem • Nifedipine • Tacrolimus• Ergot alkaloids • Nisoldipine • Verapamil• Etravirine • Nitrendipine • Vinca alkaloids• Everolimus • PhenytoinThe following drugs decrease serum levels of posaconazole when administered concurrently:• Efavirenz – induces glucuronidation elimination pathway• Metoclopramide – due to decreased GI motility• Phenytoin – induces metabolism• Rifabutin – induces metabolismMiscellaneous drug interactions with posaconazole are as follows:• Digoxin – increased digoxin serum levels with concurrent administration• Topiramate – increased topiramate serum levels with concurrent administration
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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 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 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
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1. Patients with large volumes of d
Page 106 and 107:
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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