Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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VANCOMYCINUsual DoseAdult: 1 g Q12H IV (15 mg/kg) OR 125 mg Q6H PO (UWHC cost/day IV $8.12; PO $3.09)At UW, the IV formulation is being used for in hospital oral use.The UWHC cost for a comparable PO dose given as capsules is $73.38.Pediatric:** 40 mg/kg/day IV in divided doses Q6H OR 10-50 mg/kg/day PO in divided doses Q6H.Meningitis 60 mg/kg/day in divided doses Q6H.ICU Dosing: Loading dose of 15-25 mg/kg; Maintenance dose of 10 mg/kg Q8HNote: 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. Major Gram-positive infections, especially bacteremia or endocarditis, in patients with serious penicillin allergy. Empirictherapy with vancomycin should be promptly discontinued in patients whose cultures are negative for beta-lactamaseproducingGram-positive organisms.2. Methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant coagulase-negative Staphylococcus orampicillin-resistant enterococci infections only. Not for colonization.3. Drug for Clostridium difficile colitis. Vancomycin is only effective orally for C difficile colitis. Metronidazole is thedrug of first choice unless the patient is moderately ill (but can take oral medications), has not responded to metronidazoleor is allergic to metronidazole.4. Bacteremia or endocarditis with beta-lactam resistant Corynebacterium species (especially C jeikeium).5. Surgical prophylaxis in patients who are allergic to penicillin, are colonized with methicillin-resistant S aureus or inpatients requiring repeat surgical interventions, especially through the previous incision. Ideally dosed as a singlepreoperative dose and NOT continued for more than 24 hours following surgery.6. Cardiovascular or orthopedic prophylaxis when prosthetic material is being implanted. Ideally dosed as a singlepreoperative dose and NOT continued for more than 24 hours following surgery.7. Bacterial endocarditis prophylaxis (see Appendix A).8. Serious infections with Streptococcus pneumonia including meningitis when given in combination with ceftriaxone untilpenicillin susceptibility documented.9. Treatment of intraventricular shunt infections in combination with rifampin and/or removal of shunt material.CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect.Vancomycin is still a reliable antibiotic for many MRSA infections, or for methicillin-resistant coagulase-negativeStaphylococcus. Vancomycin is not absorbed orally. To avoid histamine-like reactions, which are not true allergicreactions, administer the drug no faster than over 60 minutes. Pre-operative doses may begin 2 hours before the plannedincision time in the OR. Vancomycin infusions should not be administered during patient transport. Trough concentrationsare required only for pharmacokinetic dosing in renal failure, burn and obese patients; suspected toxicity; or suspectedinefficacy. The unit pharmacist will assist with pharmacokinetic dosing (See Serum Drug Concentration MonitoringProtocol [Appendix G] or on uconnect) Consider dosing at 15 mg/kg/day in obese patients or see Appendix H.See Vancomycin Serum Concentration Monitoring [Appendix H] or on uconnect.Trough: 15 minutes to 30 minutes prior to next dose. Monitor long-term therapy by following the serum creatinineconcentrations.Vancomycin use topically or for irrigations is discouraged. Excess use of vancomycin can promote spread of vancomycinresistantenterococci. Organisms with intermediate vancomycin susceptibility have been reported, most commonly inpatients on long-term vancomycin therapy.
VORICONAZOLEInfectious Disease approval is required for all use of voriconazole (See Appendix I).Usual DoseAdult: 6 mg/kg Q12H IV for 2 doses, then 4 mg/kg Q12H. If a patient is unable to tolerate 4 mg/kg, reduce maintenancedose to 3 mg/kg. Oral therapy: For patients weighing >40 kg, 200 mg PO BID. If response is inadequate, may increasedose to 300 mg PO BID. For patients weighing
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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
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
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 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
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
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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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