Antimicrobial Stewardship Guidebook by uri703

Antimicrobial Guide

Empiric Therapy & Treatment Recommendations For Adult Patients

Table of Contents A. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 B. Guidelines for the Treatment of Various Infections in Adults

Central Nervous System (CNS) • Meningitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Clostridium difficile Infection (CDI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Extended Spectrum Beta-Lactamases Infections (ESBL). . . . . . . . . . 6 Febrile Neutropenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Fungal Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Influenza. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Intra-abdominal Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Lyme Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Proton Pump Inhibitor (PPI) Use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Respiratory Tract - Upper and Lower • Acute Bacterial Sinusitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 • Acute Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 • Chronic Obstructive Pulmonary Disease (COPD). . . . . . . . . . . . . . . . . . . . 14 Exacerbation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 • Pneumonia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Sepsis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Sexually Transmitted Infections (STI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Skin and Soft Tissue • Skin and Soft Tissue Infections (SSTI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 • Diabetic Foot Infections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Surgical Decolonization and Prophylaxis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Urinary Tract • Catheter-Associated Urinary Tract Infection (CA-UTI). . . . . . . . . . . . . . 29 • Non-Catheter Associated Urinary Tract Infection/Cystitis . . . . . . . . . . 30 • Prostatitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

C. Immunizations • Pneumococcal Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 D. Antibiogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Table of Contents E. Guidelines for Restricted Antimicrobials Antibiotics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Ceftaroline (Teflaro®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Ceftazidime/avibactam (Avycaz®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Ceftolozane/tazobactam (Zerbaxa®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Dalbavancin (Dalvance®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Daptomycin (Cubicin®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Ertapenem (Invanz®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Fidaxomicin (Dificid®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Fosfomycin (Monurol®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Linezolid (Zyvox®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Oritavancin (Orbactiv®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Polymyxin B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Colistin (Polymyxin E). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Tedizolid (Sivextro®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Tigecycline (Tygacil®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antifungals • Amphotericin B lipid complex (L-AmB)(AmBisome®). . . . . . . . . . . . . . . • Caspofungin (Cancidas ®). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Isavuconazonium sulfate (Cresemba®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • Voriconazole (VFend®) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56

F. Vancomycin Dosing and Monitoring in Adult Patients. . . . . . . . . . . . . 57 G. Aminoglycoside High Dose Once Daily (HDOD) and Monitoring in Adult Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 H. Antimicrobial Dosing for Adult Patients Based on Renal Function

. . . . . . . .

I. Antimicrobial Duration of Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 J. IV to PO Antibiotic Step-Down Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 K. Infection Control • Twelve Steps to Prevent Antimicrobial Resistance . . . . . . . . . . . . . . . . . . 72 • Contact Precautions for Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 L. Pharmacokinetic Equations/Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Introduction â&#x20AC;&#x201A;Introduction Antimicrobial resistance is globally recognized as one of the greatest healthcare threats. Infections associated with multi-drug resistant organisms and limited antimicrobial choices have placed an immense burden upon clinicians. In order to preserve currently available antimicrobials we must use them appropriately; ensuring that each patient is on the right drug, route, dose, and duration. The pathways and tables in this booklet are based on national guidelines and consensus statements, expert opinions from the Infectious Diseases team (pharmacy and medicine) and microbiology data from the microbiology laboratory. DISCLAIMER: The opinions expressed in this publication reflect those of the authors to the best of their ability. However, the authors make no warranty regarding the contents of the publication. The guidelines described herein are general and may not apply to a specific patient. The recommendations given in this guide are meant to serve as treatment guidelines. They should not replace clinical judgment or Infectious Diseases consultation when indicated. The recommendations may not be appropriate at other settings. We have attempted to verify that all information is correct but because of ongoing research, recommendations may change. Please let us know if there are sections that you think could be improved or if there is more information you would like to see included. Our goal is for the Antimicrobial Stewardship Program to be a useful service in optimizing antibiotic use and patient outcomes. We welcome your thoughts and comments. Thank you, Kerry L. LaPlante, PharmD., FCCP Professor of Pharmacy, University of Rhode Island, Kingston, RI Adjunct Professor of Medicine, Brown University, Providence, RI Director of the Rhode Island Infectious Diseases Research Program (RIID) and Infectious Diseases Pharmacotherapy Specialist, Providence Veterans Medical Center, RI Kerry.LaPlante@va.gov or KerryLaPlante@uri.edu. The following people reviewed ALL the treatment guidelines: Melissa Gaitanis, MD (Chief of Infectious Diseases) Kerry L. LaPlante, PharmD, FCCP (Infectious Diseases) Haley Morrill, PharmD (Infectious Diseases) The following people served as section/topic reviewers: Tanya Ali, MD (Infectious Diseases), Patricia Cristofaro, MD (Infectious Diseases), Cheston Cunha, MD (Infectious Diseases), Megan Luther, PharmD, Kevin McConeghy, PharmD, MS, BCPS, Jacob Morton, PharmD, MBA, BCPS, Tristan T. Timbrook, PharmD, MBA, BCPS

A special thank you for assistance with the Antimicrobial Guidebook Kayla Chouinard, Jaclyn Cusumano, Channel DeLeon, Jillian Dougherty, Anthony Harrison, Sarah Harrison, Brittany Julich, Elizabeth Koczera, Amanda Maione, Nicholas Mercuro, Rachel Morgans, Lindsey Williamson Editorial and formatting assistance Jennifer DeAngelis, Graphic Design, Kathie McKinstry, Graphic Design, Diane M. Parente, PharmD (Infectious Diseases) PAGE 1

Central Nervous System: Meningitis Central Nervous System: Meningitis ACUTE BACTERIAL MENINGITIS Clinical Syndrome Age < 50 Most commonly isolated organisms: • S. pneumoniae • N. meningitidis • H . influenzae

Age ≥ 50 Most commonly isolated organisms: • S. pneumoniae • N. meningitidis • H. influenzae

• L. monocytogenes

• Aerobic gram negative bacilli

Preferred Regimen

Alternative Regimen

Ceftriaxone 2 gm IV Q12H AND Vancomycin 15 mg/kg IV AND Dexamethasone 0.15 mg/kg IV Q6H given 10 to 20 minutes before the first dose of antimicrobial therapy and continue for 4 days for pneumococcal meningitis (discontinue for all other microorganisms)

PCN allergy (anaphylaxis): Vancomycin 15 mg/kg IV AND Moxifloxacin 400 mg IV Q24H AND Dexamethasone 0.15 mg/kg IV Q6H given 10 to 20 minutes before the first dose of antimicrobial therapy and continue for 4 days for pneumococcal meningitis (discontinue for all other microorganisms)

Ceftriaxone 2 gm IV Q12H AND Vancomycin 15 mg/kg IV AND Ampicillin 2 gm IV Q4H AND Dexamethasone 0.15 mg/kg IV Q6H given 10 to 20 minutes before the first dose of antimicrobial therapy and continue for 4 days for pneumococcal meningitis (discontinue for all other microorganisms)

PCN allergy (anaphylaxis): Vancomycin IV 15 mg/kg AND Moxifloxacin 400 mg IV Q24H AND SMX/TMP 5 mg/kg IV Q6H AND Dexamethasone 0.15 mg/kg IV Q6H given 10 to 20 minutes before the first dose of antimicrobial therapy and continue for 4 days for pneumococcal meningitis (discontinue for all other microorganisms)

Diagnostics and Clinical Considerations • Consult Infectious Diseases • Obtain lumbar puncture and blood cultures prior to starting therapy • Patients with the following conditions should receive head CT prior to lumbar puncture: - Immunocompromised (HIV) - History of CNS lesion, stroke or focal infection - New onset seizure - Papilledema - Abnormal level of consciousness - Focal neurologic deficit • Typical CSF findings in bacterial meningitis - Cloudy CSF - Glucose < 40 mg/dL OR <50% serum - Protein 100-500 - WBC 1000-5000 - > 90% PMNs • Narrow therapy based on CSF culture results • If CSF culture negative, consult ID • Repeat lumbar puncture if no improvement in 48 hours and consider viral panel

CNS= central nervous system; CSF= cerebral spinal fluid; CT= computed tomography; H= hour(s); HIV= human immunodeficiency virus; ID= infectious diseases; IV= intravenous; PCN= Penicillin; PMNs= poly morphonuclear cells; Q= every; SMX/TMP= Sulfamethoxazole/Trimethoprim; WBC= white blood cell

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Central Nervous System: Meningitis Central Nervous System: Meningitis ASEPTIC / VIRAL /OTHER MENINGITIS AND HERPES SIMPLEX TYPE 2 Central Nervous System: Meningitis Diagnostics ASEPTIC/ VIRAL/OTHER MENINGITIS AND HERPES SIMPLEX TYPE 2and Clinical Clinical Syndrome Preferred Regimen Considerations Diagnostics and Clinical Clinical Syndrome Preferred Supportive care Regimen Aseptic/Viral/Other • ConsultConsiderations Infectious Diseases • Respiratory viruses

• Send CSF and order: • Consult Infectious - Viral culture Diseases HSV PCR • Send CSF and order: - Enteroviral Viral culturePCR - Lyme Antibody (IgG index, HSV PCR simultaneous - requires Enteroviral PCR - serum) Lyme Antibody (IgG index, - VDRL requires simultaneous • Typical CSF findings in viral serum) meningitis - VDRL - Clear • Typical CSF CSF findings in viral - Glucose 30-70 mg/dL meningitis - Protein 30-150 Clear CSF - WBC 100-1000 Acyclovir 10 mg/kg* IV Q8H Herpes Simplex Type 2 Glucose 30-70 mg/dL - <Protein 90% PMNs, Treat for 7 to 10 days 30-150increased - lymphocytes WBC 100-1000 Acyclovir 10 mg/kg* IV Q8H Herpes Simplex Type 2 - < 90% PMNs, increased Treat for 7 to 10 days CSF= cerebral spinal fluid; H= hour(s); HSV= Herpes Simplex Virus; IV= intravenous; LP= lumbar puncture; PCR= Polymerase Chain lymphocytes • Enteroviruses (90%) Aseptic/Viral/Other • • • • • • •

Arboviruses Respiratory viruses West Nile Virus(90%) Enteroviruses Epstein Barr Virus Arboviruses Lyme West Nile Virus Syphilis Epstein Barr Virus Lyme Syphilis

If Lyme Suspected: Supportive care Ceftriaxone 2 gm IV Q24H If Lyme Suspected: Ceftriaxone 2 gm IV Q24H

Reaction; PMNs= poly morphonuclear cells; Q= every; VDRL= Veneral Disease Research Laboratory Test; WBC= white blood cell

CSF= cerebral spinal fluid;based H= hour(s); HSV= Herpes Simplex Virus; IV= intravenous; LP= lumbar puncture; PCR= Polymerase Chain * Acyclovir mg/kg dosing on ideal body weight. Reaction; PMNs= poly morphonuclear cells; Q= every; VDRL= Veneral Disease Research Laboratory Test; WBC= white blood cell NOTE: If dexamethasone or imaging studies (LP or CT) is not immediately available DO NOT delay administration of *antibiotics. Acyclovir mg/kg dosing based on ideal body weight. NOTE: dexamethasone or imaging (LP Refer or CT)to is Table not immediately DOon NOT delay administration of NOTE: IfDosing based on normal renalstudies function. of Contentsavailable for section Vancomycin Dosing and Monitoring antibiotics. in Adult Patients and Antimicrobial Dosing for Adult Patients Based on Renal Function NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients and Antimicrobial Dosing for Adult Patients Based on Renal Function

References: 1. Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. References: PAGE 3 1. Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84.

Clostridium difficile Infection Clostridium difficile Infec2on (CDI) (CDI) •  Stop anIbioIcs that are no longer indicated, especially broad-‐spectrum anIbioIcs (fluoroquinolones, clindamycin, piperacillin-‐tazobactam, cephalosporins) as they increase the risk for CDI •  Stop use of any anI-‐diarrheal/anIperistalIc agents •  Consider disconInuaIon of proton-‐pump inhibitors (PPIs) •  If high clinical suspicion of CDI iniIate anIbioIc therapy before laboratory confirmaIon INITIAL EPISODE Clinical and Therapeu4c Considera4ons

Clinical Classiﬁca4on

Suppor4ve Clinical Data

Ini4al episode Mild or Moderate

•  Diarrhea (passage of ≥ 3 unformed stools in ≤ 24H) AND •  WBC < 15,000 cells/ µL AND •  SCr < 1.5 Imes the premorbid level

Vancomycin* 125 mg PO Q6H for 10-‐14 days

Ensure loose stools are not a result of laxaIve

Severe

•  Diarrhea AND •  WBC ≥ 15,000 cells/ µL OR •  SCr ≥ 1.5 Imes the premorbid level

Vancomycin 125 mg PO Q6H for 10-‐14 days

Complicated Severe

Severe criteria PLUS ≥ 1 of the following: •  Hypotension •  Shock •  Toxic Megacolon •  PerforaIon •  Ileus

If no complete ileus: Oral vancomycin 500 mg PO Q6H OR via NG tube AND if micro perforaIon is suspected metronidazole 500 mg IV Q8H

Consult ID and Surgery Start suppor4ve care as needed: •  IV ﬂuid resuscitaIon •  Electrolyte replacement

Recommended Regimens

If complete ileus: Add vancomycin retenIon enema 500 mg in 500 mL NS Q6H

Treatment duraIon: 14 days CDI= Clostridium diﬃcile InfecIon; H= hour(s); ID= InfecIous Diseases; IV= intravenous; NG= nasogastric; NS= normal saline; PO= by mouth; PPI= proton pump inhibitor; Q= every; SCr= Serum CreaInine; WBC= white blood cell * This recommendaIon is based on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole

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Clostridium diﬃcile Infec2on (CDI) Clostridium diﬃcile Infec2on (CDI) (CDI) Clostridium difficile Infection RECURRENT EPISODES

No. of Recurrences

RECURRENT EPISODES Recommended Regimens

No. of Recurrences 1st Recurrence

Recommended Regimens Vancomycin* 125 mg PO Q6H for 10-‐14 days

1stnd Recurrence 2 Recurrence

Vancomycin* 125 mg PO Q6H for 10-‐14 days Consult ID for tailoring anIbioIc therapy. Oral vancomycin tapered over 6 weeks and/or ulse dosing Consult ID for tpailoring anIbioIc therapy. Oral vancomycin tapered over 6

2nd Recurrence

weeks and/or pulse Rdegimen: osing Vancomycin Taper 125 mg PO QT6H for R1egimen: 4 days Vancomycin aper 125 m mg g P PO O Q Q6H 12H for 7 d days ays 125 for 14 125 m mg g P PO O Q once 7 days 125 12H dfaily or 7f or days 125 m mg g P PO O o every ther day 8 days 125 nce doaily for 7 dfor ays 125 m mg g P PO O eevery very o 3 ther days dfay or f1or 5 d8ays 125 days

125 mg PO every 3 dFidaxomicin ays for 15 d2ays If Severe: Consider 00 mg PO Q12H (ID Restricted)

≥ 3 recurrences ≥ 3 recurrences

If Severe: Consult ID Ctonsider eam Fidaxomicin 200 mg PO Q12H (ID Restricted) 2 •  Possible referral Consult ID team for fecal microbiota replacement therapy 200 2m Consider rreferral estarIng taper replacement OR Fidaxomicin • •  Possible for vfancomycin ecal microbiota therapy g PO Q12H 3,4 Restricted) •  (ID Consider restarIng vancomycin taper OR Fidaxomicin 200 mg PO Q12H (ID Restricted)3,4 RISK FACTORS FOR CDI

RISK FACTORS FOR CDI •  ≥ 64 years of age •  Exposure to CDI (household family member with CDI) Exposure in previous 90 Long-‐term care or nursing hm ome resident • •  ≥ 64 years to of aanIbioIcs ge • •  Exposure to CDI f(acility household family ember with CDI) Gastric acid reducing agent (proton-‐pump inhibitors) •  days Exposure to anIbioIcs in previous 90 • •  Long-‐term care facility or nursing home resident •  days HospitalizaIon in previous 30 days Tube feedings • •  Gastric acid reducing agent (proton-‐pump inhibitors) Recent GI surgery • •  HospitalizaIon in previous 30 days •  Tube feedings •  Recent GI surgery INFECTION CONTROL INFECTION CONTROL RouIne screening for C. diﬃcile in hospitalized paIents without diarrhea is not recommended AsymptomaIc carriers not treated paIents without diarrhea is not recommended RouIne screening for Cs. hould diﬃcile in bhe ospitalized PaIents should cbarriers e placed in a p oom or with other paIents who have CDI AsymptomaIc should nrivate ot be trreated IniIate csontact aIents posiIve with CDI u 48 hwours rom CrDI esoluIon of PaIents hould pbrecauIons e placed in faor pp rivate room or with other pnIl aIents ho hfave •  symptoms IniIate contact precauIons for paIents posiIve with CDI unIl 48 hours from resoluIon of •  Place contact precauIons plus sign on paIent’s door symptoms Hand chontact ygiene parecauIons nd barrier pprecauIons and gowns) • •  Place lus sign on (pgloves aIent’s door Place h dygiene edicated stethoscope in paIent’s room and gowns) • •  Hand and barrier precauIons (gloves •  When aIent ddedicated ischarged or symptoms •  pPlace stethoscope in presolve, aIent’s rroom oom should be terminally cleaned •  • •  • •  • •

•  When paIent discharged or symptoms resolve, room should be terminally cleaned MISCELLANEOUS

MISCELLANEOUS •  Repeat CDI PCR tesIng not recommended due to the likelihood of false posiIves. Toxin A, B, and TC m ay r emain p osiIve f or a s l ong a s 3 0 d ays in to paIent with symptom •  Repeat CDI PCR tesIng not recommended due the likelihood of false resoluIon. posiIves. Toxin A, B, and

may remain piosiIve long as 30 dHays in paIent with symptom esoluIon. CDI= TC Clostridium diﬃcile nfecIon; for GI= ags astrointesInal; = hour(s); ID= InfecIous Diseases; PrCR= Polymerase Chain ReacIon; PO= by mouth; Q= every; TC= Toxigenic Culture CDI= Clostridium diﬃcile infecIon; GI= gastrointesInal; H= hour(s); ID= InfecIous Diseases; PCR= Polymerase Chain ReacIon; PO= by mouth; Q= every; Toxigenic Culture Use EvaluaIon which showed a higher rate of recurrence with metronidazole * This recommendaIon is TbC= ased on a MedicaIon * This recommendaIon is based on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole

References: 1.  Cohen, SH, et al. SHEA-‐IDSA Clinical PracIce Guidelines for Clostridium difficile InfecIon in adults. ICHE. 2010 May; 31(5): References: 431-‐55. 1.  SH, et eat l. aSl. HEA-‐IDSA Clinical PracIce G uidelines for Clostridium difficile InfecIon diifficile n adults. ICHE. 2010 2.  Cohen, Surawicz CM, Guidelines for Diagnosis, Treatment, and PrevenIon of Clostridium InfecIons. Am M J ay; 31(5): 431-‐55. Gastroenterol 2013; 108:478–98. 2.  Surawicz CM, et al. Guidelines for Diagnosis, Treatment, and PrevenIon of Clostridium difficile InfecIons. Am J 3.  Kim PK, et al. Intracolonic Vancomycin for severe clostridium difficile coliIs. Surg Infect (Larchmt). 2013 Dec; 14(6):532-‐9. 013; 108:478–98. 4.  Gastroenterol Louie T, et al. F2idaxomicin versus Vancomycin for Clostridium difficile InfecIon. N Engl J Med. 2011 Feb 3;364(5):422-‐31. 3.  PK, eOt A, al. eIt ntracolonic Vancomycin for severe cflostridium difficile oliIs. Surg Infect i(n Larchmt). 013 Dec; 14(6):532-‐9. 5.  Kim Cornely al. Fidaxomicin versus vancomycin or infecIon with Cclostridium difficile Europe, C2anada, and the USA: a 4.  Louie T , e t a l. F idaxomicin v ersus Vancomycin for Clostridium difficile InfecIon. N 1E2: ngl 2J81–9. Med. 2011 Feb 3;364(5):422-‐31. double-‐blind, non-‐inferiority, randomised controlled trial. Lancet Infect Dis 2012; 5.  Cornely OA, et al. Fidaxomicin versus vancomycin for infecIon with Clostridium difficile in Europe, Canada, and the USA: a double-‐blind, non-‐inferiority, randomised controlled trial. Lancet Infect Dis 2012; 12: 281–9. PAGE 5

Extended Spectrum Beta-Lactamase (ESBL)

Extended Extended Spectrum Beta-Lactamase Beta-Lactamase (ESBL) (ESBL) Infection Infection Infection Spectrum

CLINICAL SYNDROME CLINICAL SYNDROME Extended Spectrum Extended Spectrum Beta-Lactamase (ESBL) Beta-Lactamase (ESBL) Infection Infection Carbapenem-resistant Carbapenem-resistant Enterobacteriaceae Enterobacteriaceae (CRE) (CRE)

PREFERRED REGIMEN PREFERRED REGIMEN Meropenem 2 gm IV Meropenem 2 gm IV Q8H Q8H (Use maximum doses) (Use maximum doses) Consult ID Consult ID

ALTERNATIVE REGIMEN ALTERNATIVE REGIMEN Consult ID Consult ID Consult ID Consult ID

CLINICAL CONSIDERATIONS CLINICAL CONSIDERATIONS Please DO NOT treat Please DO NOT treat colonization, or a “dirty colonization, or a “dirty urine” sample urine” sample

Febrile FebrileNeutropenia Neutropenia Febrile Neutropenia CLINICAL SYNDROME CLINICAL SYNDROME Febrile Neutropenia Febrile Neutropenia High risk: anticipated High risk: anticipated prolonged prolonged (>7 days duration) (>7 days duration) AND AND profound neutropenia profound neutropenia (ANC ≤100 cells/mm33 (ANC ≤100 cells/mm following cytotoxic following cytotoxic chemotherapy) +/chemotherapy) +/significant co-morbid significant co-morbid conditions: conditions: hypotension, hypotension, pneumonia, new-onset pneumonia, new-onset abdominal pain, or abdominal pain, or neurologic changes neurologic changes

PREFERRED REGIMEN PREFERRED REGIMEN Cefepime 2gm IV Q8H Cefepime 2gm IV Q8H OR OR Piperacillin/tazobactam Piperacillin/tazobactam 3.375gm IV Q4H 3.375gm IV Q4H (18gm/day) (18gm/day)

ALTERNATIVE REGIMEN ALTERNATIVE REGIMEN Meropenem 1 gm IV Meropenem 1 gm IV Q8H Q8H

CLINICAL CONSIDERATIONS CLINICAL CONSIDERATIONS If patient has indwelling If patient has indwelling catheter, is persistently catheter, is persistently febrile febrile OR OR previously colonized previously colonized with MRSA: with MRSA: ADD vancomycin ADD vancomycin Consult ID for Consult ID for Anti-fungal therapy; Anti-fungal therapy; Consider when fever Consider when fever fails to respond after fails to respond after 3-7 days of therapy 3-7 days of therapy

ANC= Absolute neutrophil count; CRE= Extended Spectrum Beta-Lactamase; ESBL= Extended Spectrum Beta-Lactamase; ANC= Absolute count; CRE= Spectrum ESBL=S.Extended Spectrum H= hour(s); ID= neutrophil Infectious Diseases; IV= Extended intravenous; MRSA=Beta-Lactamase; Methicillin-Resistant aureus; Q= every Beta-Lactamase; H= hour(s); ID= Infectious Diseases; IV= intravenous; MRSA= Methicillin-Resistant S. aureus; Q= every NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult NOTE: Dosing on normal renal function. Refer to Table of Contents for section Antimicrobial Dosing for Adult Patients Basedbased on Renal Function, Aminoglycoside High Dose Once Daily (HDOD) and on Monitoring in Adult Patients, and Patients Based on Renal Function, Aminoglycoside High Dose Once Daily (HDOD) and Monitoring in Adult Patients, and Vancomycin Dosing and Monitoring in Adult Patients. Vancomycin Dosing and Monitoring in Adult Patients.

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Fungal Infections Fungal Infections Fungal Infections CONDITION CONDITION Candidemia Candidemia Non-neutropenic Non-neutropenic

Candidemia Candidemia Neutropenic Neutropenic

Urinary Urinary Candidiasis Candidiasis Symptomatic Symptomatic Cystitis Cystitis Urinary Urinary Candidiasis Candidiasis Pyelonephritis Pyelonephritis

PRIMARY THERAPY PRIMARY THERAPY Caspofungin IV Caspofungin LD: 70 mg IV LD: 70 MD: 50mg mg Q24H MD: 50 mg Q24H OR OR Fluconazole IV Fluconazole LD: 800 mg IV LD: 800 mg (12mg/kg) (12mg/kg) MD: 400 mg MD: 400 mg 6 mg/kg) Q24H 6 mg/kg) Q24H

ALTERNATIVE THERAPY ALTERNATIVE THERAPY L-AmB 3–5 mg/kg IV L-AmB Q24H 3–5 mg/kg IV Q24H OR OR Voriconazole IV/PO Voriconazole IV/PO 400 mg 400 mg Q12H for (6 mg/kg) (6 mg/kg) Q12H 2 doses then 200for mg 2 doses then 200 mg (3 mg/kg) Q12H (3 mg/kg) Q12H

DURATION DURATION 14 days after 14 days after first negative first negative culture result culture result AND AND resolution of resolution of signs/symptoms signs/symptoms

COMMENTS COMMENTS Remove all IV Remove allifIV catheters, catheters, if possible possible Consult ID Consult ID Consider eye Consider eye exam exam Transition to Transition fluconazoletois fluconazole is for recommended recommended clinically stable for clinically stable patients with patients with fluconazole fluconazole susceptible susceptible isolates AND isolates negativeAND repeat negative repeat blood cultures blood cultures Caspofungin IV Fluconazole IV 14 days after Fluconazole is Caspofungin Fluconazole IV mg/kg) 14 after Fluconazole LD: 70 mg IV LD: 800 mg (12 firstdays negative preferred in is LD: LD: mg/kg) first negative preferred in MD:70 50mg mg Q24H MD:800 400mg mg(12 (6 mg/kg) culture result patients without MD: MD: patients without OR 50 mg Q24H Q24H400 mg (6 mg/kg) culture AND result recent azole OR Q24H AND recent azole L-AmB OR resolution of exposure AND L-AmB OR resolution of exposure AND 3–5 mg/kg IV Q24H Voriconazole IV/PO signs/symptoms who are NOT 3–5 mg/kg IV Q24H Voriconazole IV/PO signs/symptoms are NOT 400 mg (6 mg/kg) and neutropenia who critically ill. 400 mgfor(62mg/kg) Q12H doses then and neutropenia critically ill. Remove IV Q12H doses then 200 mgfor(32mg/kg) Remove IVif catheters, 200 mg (3 mg/kg) Q12H catheters, if possible Q12H possible Consult ID Consult ID Consider eye Consider eye exam exam Fluconazole Conventional Fluconazole: Alternative Fluconazole Conventional B Fluconazole: Alternativeis 200 mg (3 mg/kg) Amphotericin 14 days treatment 200 mg (3 mg/kg) Amphotericin days is for PO Q24H 0.3–0.6 mg/kgBIV Q24H 14 Amphotericin B: treatment recommended PO Q24H 0.3–0.6 mg/kg IV Q24H Amphotericin B: recommended for 1-7 days fluconazole 1-7 days fluconazole resistant resistant organisms organisms Fluconazole Conventional Fluconazole: Alternative Fluconazole Conventional Fluconazole: Alternative 200–400 mg (3–6 Amphotericin B 14 days treatment is 200–400 mg (3–6 Amphotericin days is for mg/kg) PO Q24H 0.5–0.7 mg/kgBIV Q24H 14 Amphotericin B: treatment recommended mg/kg) PO Q24H 0.5–0.7 mg/kg IV Q24H 14 Amphotericin B: fluconazole recommended for days 14 days fluconazole resistant resistant organisms organisms

H= hour(s); ID= Infectious Diseases; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance H= hour(s); ID= Infectious Diseases; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose; PO= by mouth; Q= every dose; PO= by mouth; Q= every NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents NOTE: Some will require ID consult/approval for section onagents Guidelines for Restricted Antibiotics (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents for section on Guidelines for Restricted Antibiotics

References: 1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. References: Clin Infect 2016; 62(4):e1-e50. 1. Pappas PG,Dis. et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016; 62(4):e1-e50.

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Fungal Infections Fungal CONDITION Infections PRIMARY THERAPY ALTERNATIVE THERAPY Fungal Infections Nongenital CONDITION Oropharyngeal (Oral Thrush) Nongenital Oropharyngeal (Oral Thrush)

Esophageal Candidiasis Esophageal Candidiasis

Clotrimazole 10 mg PRIMARY THERAPY troche 5 times daily OR Clotrimazole 10 mg Nystatin5 suspension troche times daily PO OR four times a day OR Nystatin suspension Fluconazole PO four times a day 100–200 mg OR PO once daily Fluconazole Fluconazole 100–200 mg 200–400 mg PO once daily (3–6 mg/kg) Fluconazole PO Q24H mg 200–400 (3–6 mg/kg) PO Q24H

Itraconazole oral ALTERNATIVE THERAPY solution 200 mg PO once Itraconazole oral daily OR solution Voriconazole 200daily mg 200 mg PO once PO OR Q12H Voriconazole 200 mg PO Q12H

Caspofungin IV LD: 70 mg MD: 50 mg Q24H Caspofungin IV OR LD: 70 mg Conventional MD: 50 mg Q24H Amphotericin B OR 0.3–0.7 mg/kg IV Conventional Q24H Amphotericin B 0.3–0.7 mg/kg IV General Susceptibility Patterns of Candida spp. Q24H

General Susceptibility Patterns ofItraconazole Candida spp. Fluconazole Candida albicans Candida C. tropicalis albicans C. C. tropicalis parapsilosis C. C. glabrata parapsilosis C. krusei C. glabrata C. lusitaniae C. krusei

Amphotericin B Amphotericin S B

DURATION Uncomplicated DURATION disease 7 to 14 days Uncomplicated disease 7 to 14 days

14–21 days 14–21 days

COMMENTS Refractory COMMENTS disease: Voriconazole Refractory 200 mg PO Q12H disease: OR Voriconazole L-AmB 200 mg PO Q12H suspension 1 mL OR of 100 mg/mL L-AmB four times a1day suspension mL Patients unable of 100 mg/mL to tolerate oral four times aanday agent, PatientsIVunable fluconazole ororal to tolerate an alternative agent, IV agent listed may be fluconazole or used. alternative agent listed may be used.

Caspofungin

Voriconazole

S Caspofungin

S Voriconazole

S Fluconazole

S Itraconazole

S S

S S-DD

S S-DD to R

S S-I

S S

S S-DD to R

R S-DD S R

S-DD to R S-DD to R S S-DD to R

S-I S-I S to R S-I

S S S S

S S-DD to R S S

H= hour(s); I= Intermediate; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose;

C. lusitaniae S S-DD= Susceptibility S to Ris dose dependent; Sspp= species PO= by mouth; Q= every; R=SResistant; S= susceptible;

H= hour(s); Intermediate; IV= intravenous; L-AmB= (amphotericin Liposomal Amphotericin B; LD=voriconazole). loading dose; MD= dose; NOTE: SomeI=agents will require ID consult/approval B, caspofungin, Refermaintenance to Table of Contents PO= by mouth; Q= every; R= susceptible; S-DD= Susceptibility is dose dependent; spp= species for section on Guidelines forResistant; RestrictedS=Antibiotics NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents for section on Guidelines for Restricted Antibiotics

References: 1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016; 62(4):e1-e50. References: 1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases SocietyPAGE of America. Clin Infect Dis. 2016; 62(4):e1-e50.

Influenza A and B (Flu) Influenza A and (Flu)B (Flu) Influenza A Band CLINICAL AND THERAPEUTIC ALGORITHM CLINICAL AND THERAPEUTIC ALGORITHM

CLINICAL SEVERITY CLINICAL SEVERITY

RECOMMENDED REGIMENS RECOMMENDED REGIMENS

Diagnosis is based on the clinical presentation Diagnosis is based on the of clinical presentation of the patient and results RT-PCR. of the patient and results of RT-PCR. Decision to initiate treatment should NOT wait Decision to initiate for confirmation of treatment laboratory should results.NOT wait for confirmation of laboratory results. Continue the full course of treatment Continue the full course of treatment if first RT-PCR is negative and if signs and if first RT-PCR is negative anddue if signs and symptoms indicate influenza to possibility symptoms indicate influenza due to possibility of false negative. of false negative. History of influenza vaccination does not History influenzawhen vaccination does not precludeofinfluenza signs and symptoms preclude influenza signs and symptoms are compatible withwhen the clinical syndrome. are compatible with the clinical syndrome. Zanamivir use is not recommended in people Zanamivir use is respiratory not recommended with underlying disease in people with underlying respiratory disease (e.g. asthma, COPD.) (e.g. asthma, COPD.) Treatment Population: Treatment Population: High risk adults (any of the following): riskyears adults (any of the following): •High≥65 • ≥65 years Chronic health conditions* Chronic health conditions* • Immunosuppression, including caused by • medication Immunosuppression, including caused by or HIV infection medication HIV infection • Pregnant oror postpartum (within 2 weeks of • Pregnant or postpartum (within 2 weeks of delivery) women delivery) women • American Indian/Alaska Natives American • Body massIndian/Alaska index ≥40 Natives Body massofindex ≥40homes and other • Residents nursing • Residents of nursing chronic-care facilitieshomes and other chronic-care facilities Previously healthy, symptomatic outpatient Previously symptomatic outpatient NOT at highhealthy, risk NOT at 48 high risk of symptom onset) (within hours (within 48 hours of symptom onset) Hospitalized patients CDC Flu health advisory 2 Treatment Hospitalized patients CDC Flu health advisory February 2016: may also be February 2016: Treatment may also be after beneficial when2 started up to 4 to 5 days beneficial onset when in started up to 4patients. to 5 days after symptom hospitalized symptom onset in hospitalized patients.

Outpatient High Risk Outpatient High Risk (see left panel) (see left panel) Previously Healthy Previously Healthy

Select ONE of the Select ONE of the following: following: • Oseltamivir 75 mg PO • Q12H Oseltamivir 75 mg PO Q12H • Zanamivir 10 mg • (two Zanamivir 10 mg 5 mg inhalations) (two Q12H5 mg inhalations) Q12H Treat for 5 days ONLY if Treat for 5 can daysbeONLY if treatment treatment can be initiated within 48 hours initiated of illness within onset. 48 hours of illness onset. • Oseltamivir 75 mg PO • or Oseltamivir enterally- 75 mg PO or enterally- Q12H administered administered Q12H Treat for 5 days. If illness Treat for or 5 days. If illness is severe prolonged, is severe or prolonged, may extend duration may extend duration based on clinical based on clinical judgment. judgment. • Oseltamivir 75 mg PO • or Oseltamivir enterally- 75 mg PO or enterally- Q12H administered administered Q12H Treat for 5 days. Treat for 5 days. Select ONE of the Select ONE of the following: following: • Oseltamivir 75 mg PO • Oseltamivir once daily 75 mg PO once daily 10 mg (two • Zanamivir • 5 Zanamivir 10 mg (two mg inhalations) once 5 mg inhalations) once daily daily Treat for 10 days** Treat for 10 days**

Inpatient High Risk Inpatient High Risk (see left panel) (see left panel)

Inpatient Inpatient

Post-Exposure Post-Exposure Chemoprophylaxis Chemoprophylaxis • High risk • (see Highleft riskpanel) (see left panel)

CDC= Centers for Disease Control and Prevention; COPD= chronic obstructive pulmonary disease; H= Hour(s); HIV= human immunodeficiency virus; PO= by mouth; Q= every;COPD= RT-PCR= reverse transcriptase polymerase chain CDC= Centers for Disease Control and Prevention; chronic obstructive pulmonary disease; H=reaction Hour(s); HIV= human immunodeficiency virus; PO= by mouth; Q= every; RT-PCR= reverse transcriptase polymerase chain reaction *Chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including sickle cellpulmonary disease), metabolic diabetes mellitus), neurologic conditions (disorders of the brain, (including spinal cord, *Chronic (includingdisorders asthma),(including cardiovascular (except hypertension alone), renal, hepatic, hematological nerve, muscle, epilepsy, stroke, or intellectual disability) sickle cell disease), metabolic disorders (including diabetes mellitus), neurologic conditions (disorders of the brain, spinal cord, nerve, muscle, epilepsy, stroke, or intellectual disability) **After most recent known exposure to a close contact known to have influenza. **After most recent known exposure to a close contact known to have influenza. NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based Renalbased Function NOTE: on Dosing on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function References: 1. Centers for Disease Control and Prevention. CMV home. Cytomegalovirus (CMV) and Congenital CMV infection Web site. References: http://www.cdc.gov/cmv/clinical/features.html. Published 6 Dec 2016. Updated 2010. 6 March 2016. Web site. 1. Centers for Disease Control and Prevention. CMV home. Cytomegalovirus (CMV) andAccessed Congenital CMV infection 2. Department of Health and Human Services. FluPublished season begins: influenza2010. illness reported. Centers for Disease Control http://www.cdc.gov/cmv/clinical/features.html. 6 Dec Severe 2016. Updated Accessed 6 March 2016. and Prevention:ofEmergency and Flu Response site.Severe http://emergency.cdc.gov/han/han00387.asp. Published 1 2. Department Health andPreparedness Human Services. season Web begins: influenza illness reported. Centers for Disease Control Feb 2016. Updated 2016. Accessed 12 March 2016 . and Prevention: Emergency Preparedness and Response Web site. http://emergency.cdc.gov/han/han00387.asp. Published 1 Feb 2016. Updated 2016. Accessed 12 March 2016.

PAGE 9

Intra-abdominal Infections Intra-abdominal Infections CLINICAL SYNDROME Intra-abdominal Infections Community acquired OR Hospital acquired

PREFERRED REGIMEN

ALTERNATIVE REGIMEN

CLINICAL CONSIDERATIONS

Piperacillin/tazobactam 3.375 gm IV Q6H

Ciprofloxacin 400 mg IV Q12H +/- Metronidazole 500 mg IV Q8H

Piperacillin/tazobactam provides excellent anaerobic coverage, addition of clindamycin OR metronidazole is NOT indicated or necessary

Meropenem 1gm Q8H

Lyme Disease Lyme Disease CLINICAL SYNDROME Lyme Disease Early disease

Late disease with central OR peripheral nervous system disease

PREFERRED REGIMEN Doxycycline 100 mg PO Q12H* OR Amoxicillin 500 mg PO Q8H* OR Cefuroxime 500 mg PO Q12H*

ALTERNATIVE REGIMEN Consult ID

Consult ID

CLINICAL CONSIDERATIONS Relapse may occur with any regimen; patients with objective signs/symptoms may need a second course Duration of Treatment: Doxycycline 10-21 days Amoxicillin/Cefuroxime 14-21 days Lyme antibody testing can be negative in first 6 weeks Consider co-infection with anaplasma or babesia

H= hour(s); ID= Infectious Diseases; IV= intravenous; PO= By Mouth; Q= every *Doxycycline also has activity against Ehrlichia and Anaplasma. Amoxicillin and cefuroxime do not. NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function, Aminoglycoside High Dose Once Daily (HDOD) and Monitoring in Adult Patients, and Vancomycin Dosing and Monitoring in Adult Patients.

PAGE 10

Proton-Pump Inhibitor (PPI) Use

Proton-Pump Inhibitor Proton-Pump Inhibitor (PPI) Use(PPI) Use The FDA has issued multiple warnings on the long-term use of PPIs. These include: increased risk

1, hypomagnesemia2, and fractures of the hip, wrist, and spine3. Therefore, of C.FDA difficile infection The has issued multiple warnings on the long-term use of PPIs. These include: increased risk prudent prescribing of is warranted. The FDA recommends use of the and lowest dose and 1 2, and 3. Therefore, of C. difficile infection ,PPIs hypomagnesemia fractures of the hip, wrist, spine 1-3. Patient shortest prescribing duration of of PPIPPIs therapy appropriate condition being treated prudent is warranted. Thefor FDAthe recommends use of the lowest dose and compliance, time of (prior to meals), dietary indiscretions alcohol or shortest duration of administration PPI therapy appropriate for the and condition being treated1-3(i.e. . Patient irritating foods) be assessed (prior prior to of PPI doses. compliance, timeshould of administration to titration meals), and dietary indiscretions (i.e. alcohol or irritating foods) should be assessed prior to titration of PPI doses.

Indication

Indication Gastroesophageal reflux disease 6 (GERD) Gastroesophageal reflux disease 6 (GERD) Symptomatic relief

Symptomatic Acute healingrelief of erosive or ulcerative esophagitis Acute healing of erosive or ulcerative esophagitis Maintenance healing of erosive or ulcerative esophagitis Maintenance healing of erosive or

ulcerative esophagitis Stress ulcer prophylaxis should be used for critically ill patients withbe Stress ulcer prophylaxis should 4,5: increased risk of bleeding including used for critically ill patients with - Coagulopathy (plateletincluding count 4,5: increased risk of bleeding <50,000 mm3, (platelet INR >1.5,count or aPTT - Coagulopathy >2x control) <50,000 mm3, INR >1.5, or aPTT - >2x Mechanical control)ventilation for >48 hours - Mechanical ventilation for >48 - hours Traumatic, severe thermal or spinal cord severe injury thermal or - Traumatic, - spinal Historycord of GIinjury ulceration or bleedingofwithin past year - History GI ulceration or Twobleeding or morewithin minorpast risk factors: year - Sepsis, ICUminor stay ≥1 occult GI Two or more riskweek, factors: bleeding ≥6stay days, - Sepsis, ICU ≥1glucocorticoid week, occult GI therapy (>250 mgglucocorticoid hydrocortisone bleeding ≥6 days, equivalent) therapy (>250 mg hydrocortisone

Treatment

Duration

Treatment

Duration Initial 8 week course for symptom relief or esophagitis Initial 8 week course for symptom

Omeprazole 20 mg PO once daily 20 mg PO Omeprazole OR daily once Pantoprazole 40mg PO OR once daily 40mg PO Pantoprazole once daily

relief or esophagitis Maintenance therapy determined by response severity of Maintenanceand therapy determined disease by response and severity of disease Consider dose titration, or intermittent Consider dosetherapy titration, or

intermittent therapy Transition to PO when possible Transition to PO when possible Continue until resolution of underlyinguntil riskresolution factors and/or Continue of critical illness underlying risk factors and/or

Omeprazole 10-20 mg IV/PO once Omeprazole daily mg IV/PO once 10-20 OR daily Pantoprazole 40mg OR IV/PO once daily Pantoprazole 40mg IV/PO once daily

critical illness

equivalent) aPTT= activated partial thromboplastin time; GERD= Gastroesophageal reflux disease; GI= Gastrointestinal; ICU= intensive care unit; INR= International normalized ratio; IV= intravenous; PO= by mouth; PPI= proton pump inhibitor aPTT= activated partial thromboplastin time; GERD= Gastroesophageal reflux disease; GI= Gastrointestinal; ICU= intensive care unit; INR= International normalized ratio; IV= intravenous; PO= by mouth; PPI= proton pump inhibitor

References 1. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be References associated with stomach acid drugs known as proton pump inhibitors (PPIs) [internet]. Updated May 2012 [cited 1. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be 11/21/12]. Available from: http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm associated withDrug stomach acid drugs(FDA). knownFDA as proton pumpCommunication: inhibitors (PPIs) Low [internet]. Updated May 2012 [cited 2. U.S. Food and Administration Drug Safety magnesium levels can be associated with 11/21/12]. Available from: http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm long-term use of Proton Pump Inhibitor drugs (PPIs) [internet]. Updated February 2012 [cited 11/21/12]. Available from: 2. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Low magnesium levels can be associated with http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm. use of Proton Pump Inhibitor drugs [internet]. Updated February 2012 [cited 11/21/12]. Available from: 3. long-term U.S. Food and Drug Administration (FDA). FDA (PPIs) Drug Safety Communication: Possible increased risk of fractures of the hip, http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm. wrist, and spine with the use of proton pump inhibitors [internet]. Updated March 2011 [cited 11/21/12]. Available from: 3. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Possible increased risk of fractures of the hip, http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm and spine with the use of inhibitors [internet]. Updated March 2011 [citedand 11/21/12]. from: 4. wrist, ASHP Therapeutic Guidelines onproton Stress pump Ulcer Prophylaxis. ASHP Commission on Therapeutics approvedAvailable by the ASHP http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm Board of Directors on November 14, 1998. Am J Health Syst Pharm 1999; 56:347. 4. ASHP Therapeutic Guidelines on Stress Ulcer Prophylaxis. ASHP Commission on Therapeutics and approved by the ASHP 5. Spirt MJ, Stanley S. Update on stress ulcer prophylaxis in critically ill patients. Crit Care Nurse 2006; 26:18. of Gerson Directors November 14, 1998. Syst Pharm 1999; 56:347. 6. Board Katz PO, LB,onVela MF. Guidelines forAm theJ Health diagnosis and management of gastroesophageal reflux disease. Am J 5. Spirt MJ, Stanley S. Update on stress ulcer prophylaxis in critically ill patients. Crit Care Nurse 2006; 26:18. Gastroenterol 2013;108:308-28. 6. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013;108:308-28.

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Respiratory Tract: Acute Bacterial Sinusitis

Respiratory Respiratory Tract: Acute Bacterial Sinusitis Tract: Acute Bacterial Sinusitis C T LINICAL AND HERAPEUTIC

RISK FACTORS ALGORITHM CLINICAL AND THERAPEUTIC RISK FACTORS 1a. Antibiotics are indicated if the Presence of Risk ALGORITHM patient has ANY of the Factors for 1a. following: Antibiotics are indicated if the Presence Antibioticof Risk patient has ANY of the≥ 10 Factors for • Symptoms lasting Resistance: following: Antibiotic days without clinical • Age > 65 • Symptoms lasting ≥ 10 Resistance: improvement • Antibiotics • Age > 65 ORdays without clinical within last 30 • Antibiotics • improvement Severe symptoms at onset days OR lasting last 30 • within Hospitalization • Severe symptoms onset days within last 5 ≥ 3 days [Fever (≥ at 102 °F), lasting facial pain, or • Hospitalization severe days last 5 ≥ 3 days discharge] [Fever (≥ 102 °F), purulent • within Immunosevere facial pain, or days OR compromised discharge] •ORImmuno• purulent New onset fever, severe OR headache, or increase • compromised Fever > 102°F • New fever,after severe ORwith signs of nasalonset discharge 5-6 headache, or increase • Fever > 102°F days following initial systemic illness nasal discharge after 5-6 with signs of improvement None of the illness above days following initial systemic 1b. If the patient does not meet risk factors for improvement None of the above this criteria likely viral and antibiotic 1b. self-limiting. If the patientMay doesprovide not meet risk factors for resistance this criteria likely viral and antibiotic symptom relief. AND Maysymptoms: provide resistance •self-limiting. Reduce nasal symptom relief. topical or nasal No fever or signs of AND • Reduce nasal symptoms: decongestants, intranasal systemic illness topical or nasal intranasal No fever or signs of corticosteroids, decongestants, intranasal systemic illness saline corticosteroids, intranasal 2. If nosaline improvement after 3 to 5 days of antibiotic therapy 2. switch If no improvement afteragent 3 to 5 to an alternative days of antibiotic therapy from a different antibiotic class switch to an alternative agent CrCl= creatinine clearance; H= hour(s); PO= by mouth; Q= every from a different antibiotic class

RECOMMENDED REGIMENS

RECOMMENDED REGIMENS Initial Empiric Antibiotic Therapy: Amoxicillin/clavulanate Initial Empiric AntibioticPO: Therapy: ‡ CrCl > 30 ml/min: 2000/125 Amoxicillin/clavulanate PO: mg Q12H ‡ CrCl 2000/125 mgmg CrCl >1030– ml/min: 29 ml/min: 875/125 Q12H Q12H CrCl – 29 ml/min: 875/125 mg ‡ mg CrCl 10 < 10 ml/min: 2000/125 Q12H Q24H CrCl < 10 ml/min: 2000/125‡ mg Alternatives*: Q24H Moxifloxacin 400 mg PO Q24H Alternatives*: Treat for 7 to400 10 days Moxifloxacin mg PO Q24H

Treat for 7 to 10 days

No risk for Antibiotic Resistance: Amoxicillin/clavulanate PO: No risk for Antibiotic Resistance: CrCl > 30 ml/min: 875/125 Amoxicillin/clavulanate PO: mg Q12H CrCl 10–29 ml/min: 500/125 mg CrCl Q12H> 30 ml/min: 875/125 mg Q12H CrCl ml/min: 500/125 CrCl 10–29 < 10 ml/min: 875/125 mgmg Q24H Q12H Alternatives*: CrCl < 10 ml/min: 875/125 mg Q24H Doxycycline 100 mg PO Q12H Alternatives*: OR Doxycycline Moxifloxacin100 400mg mgPO POQ12H Q24H OR Treat for 5 to400 7 days Moxifloxacin mg PO Q24H Treat for 5 to 7 days

‡ Pharmacy does not carry amoxicillin/clavulanate 2000/125 mg tablets. Order 875/125 mg tablets of amoxicillin/clavulanate CrCl= creatinine clearance; H= hour(s); PO= by mouth; Q= every AND 1000 mg tablets of amoxicillin amoxicillin/clavulanate = 1,875/125 mg per dose). ‡(total Pharmacy does not carry amoxicillin/clavulanate 2000/125 mg tablets. Order 875/125 mg tablets of amoxicillin/clavulanate AND 1000 mg tablets of amoxicillin *Macrolides, trimethoprim-sulfamethoxazole, anddose). 2nd or 3rd generation cephalosporins are not recommended due to (total amoxicillin/clavulanate = 1,875/125 mg per increasing rates of antimicrobial resistance. *Macrolides, trimethoprim-sulfamethoxazole, and 2nd or 3rd generation cephalosporins are not recommended due to increasing rates of antimicrobial resistance.

References: 1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012; 54:e72. References: 1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and PAGE 12 adults. Clin Infect Dis. 2012; 54:e72.

Respiratory Tract: Acute Pharyngitis Respiratory Tract: Acute Pharyngitis Respiratory Tract: Acute Pharyngitis

QUICK FACTS1-2: •QUICK OnlyFACTS 5-15%1-2of: adult cases of acute pharyngitis are caused by Group A β-hemolytic (GAS). • streptococci Only 5-15% of adult cases of acute pharyngitis are caused by Group A β-hemolytic • It is estimated that 3,000 to 4,000 patients with GAS must be treated for every 1 streptococci (GAS). of acute rheumatic prevented. • case It is estimated that 3,000fever to 4,000 patients with GAS must be treated for every 1 • Antibiotic therapy of GASfever hastens resolution by 1-2 days if initiated within 2-3 days case of acute rheumatic prevented. symptom onset.of GAS hastens resolution by 1-2 days if initiated within 2-3 days • of Antibiotic therapy of symptom onset. CLINICAL CLASSIFICATION

CLINICAL PRESENTATION

RECOMMENDED REGIMENS

CLASSIFICATION Group A β-hemolytic Group A streptococcus β-hemolytic (GAS) streptococcus (GAS)

CLINICAL PRESENTATION ≥ 2 of the following: • Fever (≥ 100.4°) ≥ 2 of the following: • Tonsillar exudates • Fever (≥ 100.4°) • No cough • Tonsillar exudates • Tender anterior • No cough cervical • Tender anterior lymphadenopathy cervical (lymphadenitis) lymphadenopathy • Scarlatiniform rash (lymphadenitis) • Scarlatiniform rash

RECOMMENDED REGIMENS Amoxicillin 500 mg PO Q12H Amoxicillin 500 mg PO OR Q12H Penicillin VK 250 mg Q6H OR OR Penicillin VK 250 mg Q6H 500 mg PO Q12H OR 500 10 mgdays PO Q12H For

Viral Pharyngitis

• • • • • • • • • • • • •

For 10 days Penicillin Allergy Non-anaphylactic allergy: Penicillin Allergy Cephalexin 500 mg PO Non-anaphylactic allergy: Q12H x 10 days Cephalexin 500 mg PO OR Q12H x 10 days Clindamycin 300 mg PO OR Q6H for 10 days Clindamycin 300 mg PO OR Q6H for 10 days Azithromycin 500 mg PO x OR 1 day, then 250 mg PO Azithromycin 500 mg PO x Q24H x 4 days 1 day, then 250 mg PO Q24H x 4 days Supportive treatment (antipyretic OR analgesic) Supportive treatment (antipyretic OR analgesic)

CONSIDERATIONS CLINICAL CONSIDERATIONS Clinical suspicion

for GAS: Clinical suspicion Obtain throat swab for GAS: OR order GAS rapid Obtain throat swab antigen detection OR order GAS rapid test (RADT)* antigen detection test (RADT)* If culture is negative: If culture is No antibiotics AND negative: consider supportive No antibiotics AND treatment consider supportive (antipyretic OR treatment analgesic) (antipyretic OR analgesic)

Conjunctivitis Coryza Conjunctivitis Cough Coryza Diarrhea Cough Hoarseness Diarrhea Discrete ulcerative Hoarseness stomatitis Discrete ulcerative Viral exanthema stomatitis GAS= Group A β-hemolytic Streptococci; H= hour(s); PO= by mouth; Q= every; RADT= Rapid antigen detection test • Viral exanthema Viral Pharyngitis

GAS= Group β-hemolytic Streptococci; hour(s); PO= by70-90%, mouth; specificity Q= every; 95% RADT= Rapid antigen detection test *Throat swabAculture sensitivity: 90-95%;H= RADT: sensitivity *Throat swab culture sensitivity: 90-95%; RADT: sensitivity 70-90%, specificity 95%

References: 1. Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A References: Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society America. Clin Infect Dis. 2012 Nov 15;55(10):12791. 82. Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update byantibiotic the Infectious Society America. ClinBackground. Infect Dis. 2012 Novof15;55(10):12792. Cooper RJ et al. Principles of appropriate use forDiseases acute pharyngitis in adults: Annals Internal 82. Medicine. 2001;134(6):509-17. 2. Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal Medicine. 2001;134(6):509-17. PAGE 13

Respiratory Tract: ChronicObstructive Obstructive Pulmonary Respiratory Tract: Chronic Pulmonary Disease (COPD) Exacerbation Disease (COPD) Exacerbation CLINICAL AND THERAPEUTIC ALGORITHM

CLINICAL SEVERITY

RECOMMENDED REGIMENS

Respiratory Tract: Chronic Obstructive Pulmonary Diagnosis: Based on the clinical Outpatient Select ONE of the following: Disease of(COPD) presentation the patient,Exacerbation including Uncomplicated • Doxycycline 100 mg PO Q12H complaints of an acute change of cardinal CLINICAL AND THERAPEUTIC ALGORITHM symptoms as follows: Diagnosis: Based on the clinical sputum Does patient have: increased presentation of the patient,dyspnea includingOR purulence AND increased complaintssputum of an acute change of cardinal increased

CLINICAL SEVERITY Outpatient Uncomplicated

symptoms as follows:

1. Initiate therapy with: Does patient have: increased sputum • Short-acting bronchodilators purulence AND increased dyspnea OR (i.e. sputum albuterol) increased to 6 to 8 increased puffs Q1-2H in severe exacerbations 1. Initiate therapy with: • +/- Short-acting anticholinergics • Short-acting bronchodilators (i.e. albuterol) ipratropium bromide) (i.e. increased to 6increased to 8 to 6 to 8 puffs Q3-4Hexacerbations in severe puffs Q1-2H in severe exacerbations given via • +/- Short-acting anticholinergics nebulizer/inhaler (i.e. ipratropium bromide) increased to 6 to 8 puffs Q3-4H in severe PLUS exacerbations given via • Corticosteroids (prednisone or nebulizer/inhaler equivalent PO 40 mg/day for 5 days) PLUS if admitted OR have significant • Corticosteroids (prednisone or shortness of breath equivalent PO 40 mg/day for 5 days) Methylprednisolone IV Q6-12H if admitted OR have significant may be used initially shortness of breath Methylprednisolone IV Q6-12H

2. Consider obtaining sputum culture may be used initially AND treat with an antimicrobial 2. Consider sputum culture based onobtaining clinical severity treat with antimicrobial •AND If patient hasan only an acute increase based on clinical severity in 1 cardinal symptom no antibiotic • If patient has only an acute increase therapy is recommended in 1 cardinal symptom no antibiotic

• Amoxicillin 500 mg PO Q8H RECOMMENDED REGIMENS • Azithromycin 500 mg once, then 250 mg PO Q24H Select ONE of the following: • SMX/TMP DSPO tablet • Doxycycline 100 1mg Q12HPO Q12H • •

Amoxicillin PO Q8H Treat for 500 3 tomg 5 days Azithromycin 500 mg once, then 250 mg PO Q24H Primary Recommendation: SMX/TMP 1 DS tablet PO Q12H

Outpatient • Complicated* • Amoxicillin/clavulanate 875 mg Treat forPO 3 toQ12H 5 days OR Failure of Penicillin Allergy or Treatment Outpatient Primary Recommendation: Previous Failure with Primary Regimen: Complicated* • Amoxicillin/clavulanate 875 mg • Q12H Moxifloxacin 400 mg PO Q24H** OR Antimicrobial PO Therapy Failure of Penicillin or5Treatment TreatAllergy for 3 to days Previous Antimicrobial Inpatient Therapy

Failure with Primary Regimen: • Moxifloxacin 400 mg PO Q24H** Primary Recommendation:

Inpatient

Primary OR Recommendation: • Amoxicillin/clavulanate 875 mg • Doxycycline 100 mg PO Q12H PO Q12H OR Penicillin Allergy or Treatment Failure with Regimen: • Doxycycline 100Primary mg PO Q12H • Moxifloxacin 400 mg PO Q24H** Penicillin Allergy or Treatment Failure with Primary Regimen: Treat for 5 days • Moxifloxacin 400 mg PO Q24H**

875 mg Treat• forAmoxicillin/clavulanate 3 to 5 days

PO Q12H

Treat for 5 days

therapy is recommended 3. Manage risk factors: Assessrisk if patient 3. •Manage factors: is due for influenza • Assess vaccineif patient is due for influenza • vaccine Smoking cessation counseling •

Smoking cessation counseling

4. Inpatient: If worsening clinical status 4. Inpatient: If worsening clinical status OR inadequate response in 72H: OR inadequate response in 72H: re-evaluate AND obtain sputum re-evaluate AND obtain sputum culture ANDgram gramstain stain culture AND

DS= strength;H= H=hour(s); hour(s); intravenous; by mouth; Q= every; SMX/TMP= sulfamethoxazole/trimethoprim DS= double double strength; IV=IV= intravenous; PO=PO= by mouth; Q= every; SMX/TMP= sulfamethoxazole/trimethoprim *In withfrequent frequentexacerbations, exacerbations, in previous 12 months) severe airflow limitation, exacerbations *In patient patient with (> 4(>in4previous 12 months) severe airflow limitation, and/orand/or exacerbations requiringrequiring mechanical ventilation, and/or cardiovascular disease mechanical ventilation,FEV1 FEV1< <50%, 50%, and/or cardiovascular disease ** Previously Previously failed azithromycin, doxycycline, and and a betalactam OR received treatment with thewith aforementioned ** failedtherapy therapywith with azithromycin, doxycycline, a betalactam OR received treatment the aforementioned antibiotics within days OROR patient hashas other comorbidities (i.e. chronic heart, heart, liver, orliver, renalordisease, diabetes,diabetes, antibiotics withinthe theprevious previous9090 days patient other comorbidities (i.e. chronic renal disease, alcoholism, malignancy, asplenia, immunocompromised or on immunosuppressing drugs. An FDA advisory committee determined that alcoholism, malignancy, asplenia, immunocompromised or on immunosuppressing drugs. An FDA advisory committee determined that the risks of fluoroquinolone use in COPD exacerbation outweighed any potential benefit, and should not be a first-line agent. the risks of fluoroquinolone use in COPD exacerbation outweighed any potential benefit, and should not be a first-line agent. NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based

NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function on Renal Function References:

1. Vollenweider DJ, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec References: 12;12:CD010257. 1. Vollenweider DJ, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 2. Vestbo J, et al. Global strategy for the diagnosis, manageent, and prevention of chronic obstructive pulmonary disease: GOLD executive 12;12:CD010257. summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65. 2. Vestbo J, et al. Global strategy formeeting the diagnosis, manageent, Drugs and prevention of chronicand obstructive pulmonary GOLD executive 3. Food and Drug Administration. Joint of the Antimicrobial Advisory Committee the Drug Safety & Risk disease: Management summary. Am J Respir Crit Care Med. Recording. 2013 Feb 15;187(4):347-65. Advisory Committee (DSaRM)-Webcast 2015. 3. Food and Drug Administration. Joint meeting of the Antimicrobial Drugs Advisory Committee and the Drug Safety & Risk Management Advisory Committee (DSaRM)-Webcast Recording. 2015.

PAGE 14

Respiratory Pneumonia Respiratory Tract:Tract: Pneumonia START HERE Does the patient presenting with pneumonia have any risk factors for multidrug resistant organisms (MDROs): • •

Hospitalized for ≥ 2 days within previous 90 days Resides in a nursing home OR long-term care facility, OR skilled nursing facility

• • •

Received recent antibiotic therapy (previous 90 days), chemotherapy, OR wound care within previous 30 days Chronic hemodialysis Have immunosuppressive disease OR receiving immunosuppressing medications

CLINICAL CONSIDERATIONS • • • •

Infiltrate on chest x-ray required for pneumonia diagnosis Collect BAL OR PSB AND blood cultures prior to starting antimicrobial therapy Re-assess antibiotic therapy on day 2 or 3 when cultures return from microbiology lab Specific isolated pathogens should prompt clinicians to de-escalate treatment based on the pathogen's susceptibility pattern NO RISK FACTORS FOR MDROS

RISK FACTORS FOR MDROS

INPATIENT NON-ICU

INPATIENT

Ceftriaxone 1 gm IV Q24H AND Azithromycin 500 mg PO/IV for 1 day, then 250 mg PO/IV Q24H for 4 days OR Moxifloxacin 400 mg IV/PO Q24H

Beta-lactam/beta-lactamase inhibitor: Piperacillin-tazobactam 3.375 gm IV Q4H† OR Piperacillin-tazobactam 4.5 gm IV Q6H OR Antipseudomonal carbapenem: Imipenem 500 mg IV Q8H

INPATIENT ICU Ceftriaxone 2 gm IV Q24H AND Moxifloxacin 400 mg IV Q24H OR Ampicillin/sulbactam 3 gm IV Q6H AND Moxifloxacin 400 mg IV Q24H OR Penicillin-allergic patients: Aztreonam 2 gm IV Q8–12H AND Moxifloxacin 400 mg IV Q24H

PLUS Aminoglycoside‡ (Preferred) Gentamicin 5-6 mg/kg (IBW) once daily Tobramycin 5-6 mg/kg (IBW) once daily OR Antipseudomonal fluoroquinolone: Levofloxacin 750 mg IV Q24H Ciprofloxacin 400 mg IV Q8H PLUS If at risk for MRSA: Vancomycin 15 mg/kg IV‡ OR Linezolid 600 mg IV/PO Q12H (See Criteria for Use)

BAL= Bronchoalveolar Lavage; BP= blood pressure; bpm= beats or breaths per minute; CrCl= Creatinine Clearance; H= hour(s); IBW= ideal body weight; ICU= Intensive Care Unit; IV= intravenous; MDRO= multi-drug resistant organism; MRSA= MethicillinResistant S. aureus; PO= by mouth; PSB= Protected Specimen Brush; Q= every †Suspect P. aeruginosa: CrCl >50 ml/min = 3.375 gm q4h; CrCl 50-10 ml/min = 3.375 gm IV Q6H; CrCl < 10 ml/min = 3.375 gm Q8H ‡Refer to

Table of Contents for section on vancomycin and aminoglycoside dosing and monitoring

Note: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function.

PAGE 15

Respiratory Tract: Pneumonia Respiratory Tract: Pneumonia Respiratory Tract: Pneumonia NO RISK FACTORS FOR MDRO S RISK FACTORS FOR MDROS OUTPATIENT NO RISK FACTORS FOR MDROS Previously healthy AND no antibiotic use in previous 90 days: OUTPATIENT Previously healthy AND no antibiotic use in Doxycycline 100 mg PO Q12H for 5 days previous 90 days: OR Azithromycin 500mg mgPO POQ12H for 1 for dose, then Doxycycline 100 5 days 250 OR mg PO Q24H for 4 days Azithromycin 500 mg PO for 1 dose, then OUTPATIENT 250 mg PO Q24H for 4 days

OUTPATIENT RISK FACTORS FOR MDROS Treat accordingly based on risk factors and microbiologic OUTPATIENT history Treat accordingly based on risk factors and Consider paging Infectious Diseases microbiologic history Consider paging Infectious Diseases

Presence of ≥ 1 co-morbidities* OR antibiotic OUTPATIENT use in previous 30 days: Presence of ≥ 1 co-morbidities* OR antibiotic Moxifloxacin 400 mg PO Q24H for 5 to 7 days use in previous 30 days: OR Amoxicillin 1 gm for 5 to Moxifloxacin 400PO mgQ8H PO Q24H for7 5days to 7 days OR OR Amoxicillin/clavulanate 875 PO7 Q12H Amoxicillin 1 gm PO Q8H formg 5 to days for OR 5 to 7 days AND Amoxicillin/clavulanate 875 mg PO Q12H Azithromycin for 5 to 7 days500 mg PO for 1 dose, then 250 ANDmg PO Q24H for 4 days Azithromycin 500 mg PO for 1 dose, then THERAPY CONSIDERATIONS 250 mg PO Q24H for 4 days • Cough and chest X-ray may take 4 to T6HERAPY weeksCto improve/change ONSIDERATIONS • Duration of therapy • and Community-acquired pneumonia: 5–7 to days • Cough chest X-ray may take 4 to 6 weeks improve/change • Healthcare-associated pneumonia, hospital-acquired pneumonia, ventilator-associated • Duration of therapy 7–8 days;pneumonia: provided that the targeted pathogen is identified based on • pneumonia: Community-acquired 5–7 days and the etiologic pathogen is not P. aeruginosa, andventilator-associated that the patient is: • bronchoscopy Healthcare-associated pneumonia, hospital-acquired pneumonia, afebrile for 487–8 to days; 72 hours pneumonia: provided that the targeted pathogen is identified based on AND ≤ 1 of theand following: bronchoscopy the etiologic pathogen is not P. aeruginosa, and that the patient is: HR >100 for bpm, >24hours bpm, BP < 90 mmHg (systolic), O2 sat <90%, altered mental status afebrile 48 RR to 72 AND ≤ 1 of the following: BP= blood pressure; bpm= beats or breaths per minute; H= hour(s); HR= heart rate; IV= intravenous; MDRO= multi-drug HR >100 bpm, RR >24 bpm, BP < 90 mmHg (systolic), O2 sat <90%, altered mental status resistant organism; PO= by mouth; Q= every; RR= respiratory rate

BP= blood of pressure; bpm= beats or breaths per minute; hour(s); HR=diabetes; heart rate; IV= intravenous; MDRO=asplenia; multi-drug *Presence comorbidities: chronic heart, lung, liver or H= renal disease; alcoholism; malignancies; resistant organism; PO= by mouth; Q= every; RR= respiratory rate immunosuppressing conditions or medications *Presence of based comorbidities: chronic heart, lung, livertoorTable renalof disease; diabetes; alcoholism; malignancies; asplenia; Note: Dosing on normal renal function. Refer Contents for section on Antimicrobial Dosing for Adult immunosuppressing conditions or medications Patients Based on Renal Function. Note: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function.

References: 1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72 References: 2. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, 1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Thoracic Society consensus guidelines on the ventilator-associated, and healthcare-associated pneumonia. Am JSociety Respir of CritAmerica/American Care Med. 2005 Feb 15;171(4):388-416. management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72 2. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, PAGE 16 ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416.

Sepsis Sepsis IV Antibiotics:

• If the patient is pregnant, contact pharmacy or Infectious Diseases for assistance regarding safety and dosage • Penicillin allergic or optional antibiotic choices are listed second and italicized • Antibiotics should be adjusted for weight and renal function in ALL patients - Consult pharmacy or Infectious Diseases if needed for assistance in monitoring therapeutic drug level Administer antibiotics within FIRST HOUR of recognition of sepsis

• Antibiotics should be ordered AFTER a review of previous microbiology data present in patient’s electronic medical record • Risk Factors for MRSA,VRE, and ESBL include: - Hospitalization within the past year - Patient receives hemodialysis - Oozing or open wound - Past history of documented MRSA, VRE, or ESBL - Patient is a nursing home resident - Patient has a catheter or line present

SUSPECTED Clostridium difficile INFECTION Vancomycin 500 mg PO/NGT x1 NOW PLUS Metronidazole 500 mg IV x1 NOW

SUSPECTED RESPIRATORY SOURCE

SUSPECTED URINARY SOURCE

SUSPECTED INTRA-ABDOMINAL SOURCE

Azithromycin 500 mg IV x1 NOW PLUS Ceftriaxone 2 gm IV x1 NOW OR Piperacillin/tazobactam 3.375 gm IV x1 NOW OR If risk factors for MDR GNR or ESBL Meropenem 2 gm x1 NOW

Piperacillin/tazobactam 3.375 gm IV x1 NOW OR If risk factors for MDR GNR or ESBL Meropenem 2 gm x1 NOW

Piperacillin/tazobactam 3.375 gm IV x1 NOW OR If risk factors for MDR GNR or ESBL Meropenem 2 gm IV x1 NOW

If risk factors for MRSA Vancomycin 25-30 mg/kg ABW* IV LD x1 NOW

If risk factors for VRE If risk factors for MRSA Daptomycin 8-10mg/kg (ABW) x1 Vancomycin 25-30 mg/kg ABW* NOW & Consult ID IV LD x1 NOW If penicillin allergy, may consider consulting ID or substituting meropenem 2gm x1 NOW for other beta lactams (monitor; ≤5% cross-reactivity with penicillins). ABW= Actual Body Weight; ESBL= Extended Spectrum Beta-Lactamase; ID= Infectious Diseases; IV= intravenous; LD= loading dose; MDR GNR= Multi-Drug Resistant Gram-Negative Rods; MRSA= Methicillin-Resistant S. aureus; NGT= Nasogastric tube; PO= By Mouth; VRE= Vancomycin –Resistant Enterococcus *Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients

PAGE 17

Symptomatic SymptomaticSexually SexuallyTransmitted TransmittedInfection InfectionScreening Screening SYMPTOMATIC Symptoms Female

Recommended Diagnostic Testing

• Vaginal itching

Vaginal examination:

Clinical and Therapeutic Considerations Promptly begin empiric

• Vaginal Sexually discharge 1. Observe vaginal anatomyScreening treatment of Chlamydia and Symptomatic Transmitted Infection • Painful urination 2. Gram stain for bacterial Gonorrhea before lab results

Female

• Increased urinary urgency • Pelvic pain • PainSymptoms with sexual intercourse • Vaginal itching •• Vaginal bleeding Vaginal discharge •• Genital warts Painful urination Increasedlesion/ulcer urinary •• Genital urgency • Pharyngitis • Pelvic pain • Pain with sexual intercourse • Vaginal bleeding • Genital warts • Genital lesion/ulcer • Pharyngitis

Male

• • • • • ••

• •• •

• • • ••

vaginosis return SYMPTOMATIC 3. Vaginal swabs for PCR assay: • Gonorrhea exam will allow Clinical Vaginal and Therapeutic Recommended Diagnostic Testing • Chlamydia visualization of vaginal Considerations 4. Vaginal swabs for Affirm DNA anatomy Vaginal examination: Promptly begin empiric • Trichomoniasis 1. Observe vaginal anatomy treatment of Chlamydia and orresults cervical swab may 5. HIV 2. Gram staintest for bacterial Gonorrhea Vaginal before lab vaginosis 6. Syphilis (RPR screen/ titer) return be necessary for specific test 3. Vaginal swabs for PCR assay: kits 7. Urinalysis Gonorrhea Test Vaginal exam will allow 8. • Pregnancy • Chlamydia visualization of vaginal 9. Oropharyngeal (OP) Cultureanatomy 4. Vaginal swabs for Affirm DNA for GC when indicated • swab Trichomoniasis 5. 6. 7. 8. 9.

Penile discharge Painful urination Increased urgency Pelvic pain Penile discharge Swollen/tender Painful urination testicles Increased urgency Pelvicwith pain sexual Pain Swollen/tender intercourse testicles Genital warts Pain with sexual Genital lesion/ulcer intercourse Pharyngitis Genital warts

HIV test Unable(RPR to perform vaginal Syphilis screen/ titer) examination: Urinalysis 1. Urinalysis Pregnancy Test Oropharyngeal 2. Urine for(OP) PCRCulture assay: swab for GC when indicated • Gonorrhea

Vaginal or cervical swab may Promptly be necessary for specificbegin test empiric treatment of Chlamydia and kits

Gonorrhea before lab results return

• Chlamydia Unable to perform vaginal examination: 3. HIV test 1. Urinalysis 4. Syphilis (RPR screen/titer) 2. Urine for PCR assay: 5. Pregnancy Test • Gonorrhea 6. • OP Culture for GC when Chlamydia indicated 3. HIV test 4. Syphilis (RPR screen/titer) 1. Urinalysis 5. Pregnancy Test 2. Culture Urinefor forGC PCR assay: 6. OP when indicated• Gonorrhea

Promptly begin empiric treatment of Chlamydia and Gonorrhea before lab results return

1. Urinalysis 3. HIV testassay: 2. Urine for PCR 4. • Syphilis (RPR screen/ titer) Gonorrhea Chlamydia 5. • OP Culture Swab or Rectal 3. HIV test culture swab for GC when 4. Syphilis (RPR screen/ titer) indicated 5. OP Culture Swab or Rectal culture swab for GC when indicated

Promptly begin empiric treatment of Chlamydia and Gonorrhea before lab results return

• Chlamydia

Promptly begin empiric treatment of Chlamydia and Gonorrhea before lab results return

• Genital lesion/ulcer • Pharyngitis TREATMENT (DISCUSS TREATMENT OF PREGNANT WOMEN WITH ID AND OB/GYN)

Gonorrhea Chlamydia Gonorrhea

TREATMENTCeftriaxone (DISCUSS TREATMENT WOMEN WITH ID AND OB/GYN) 250 OF mgPREGNANT IM AND Azithromycin 1 gm PO x 1 dose

Chlamydia

HIV or Syphilis

Bacterial vaginosis Bacterial vaginosis

OR doxycycline 100 mg PO Q12H for 7 days

Ceftriaxone 250 mg IM AND Azithromycin 1 gm PO x 1 dose OR doxycycline 100 mg PO Q12H for 7 days

Penicillin Allergy (anaphylaxis): Consult ID

Consult Infectious Diseases

Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at

Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at bedtime 5 days bedtime for 5for days

Metronidazole mg PO OR clindamycin 300 mg PO Q12H Alternatives: Alternatives: Metronidazole 500 mg 500 PO Q12H OR Q12H clindamycin 300 mg PO Q12H forfor 7 days 7 days Trichomonas vaginalis Trichomonas vaginalis

Metronidazole 2 gm PO x 1 dose OR metronidazole 500 mg PO Q12H for 7 days

DNA= deoxyribonucleic acid; GC= gonococcus; H= hours; HIV= human immunodeficiency virus; ID= infectious diseases; IM= intramuscular; DNA= deoxyribonucleic acid; GC= gonococcus; H=PCR= hours; HIV= human immunodeficiency virus; ID= infectious IM= intramuscular; OB/GYN= obstetrics/gynecology; OP= Oropharyngeal; Polymerase chain reaction; PO= by mouth; Q= every; RPR= rapiddiseases; plasma reagin; STI= sexually transmitted infection. OP= Oropharyngeal; PCR= Polymerase chain reaction; PO= by mouth; Q= every; RPR= rapid plasma reagin; OB/GYN= obstetrics/gynecology;

STI= sexually transmitted infection.

PAGE 18

Asymptomatic AsymptomaticSexually SexuallyTransmitted TransmittedInfection InfectionScreening Screening ASYMPTOMATIC Population Female

Age ≤ 25

Screening Recommendations

Frequency

Urine PCR for Chlamydia

Annually

Urine PCR for Gonorrhea

Annually

HIV test

At least once No later than age 21

Cervical Screening

Age > 25

No routine screening for STIs Screen according to risk

Pregnant

Urine PCR for Chlamydia

First trimester

Urine PCR for Gonorrhea

First trimester

HIV test

First trimester

Hepatitis B S Ag, S Ab, C Ab

First trimester

Hepatitis C Ab

First trimester

Syphilis RPR/titer

First trimester

Urine PCR for Chlamydia

Annually

Urine PCR for Gonorrhea*

Annually

Syphilis RPR/titer

Annually

Trichomoniasis

Annually

Hepatitis B S Ag, S Ab, C Ab

Baseline

Hepatitis C Ab

Yearly if high

HIV-positive

Clinical and Therapeutic Considerations Cervical screening should be performed 3 years after initiating sexual activity or no later than age 21

Consider minimum of annual screening if high risk* patient Repeat Screening (all pathogens) in 3rd trimester and at birth if patient is high risk*

*Consider rectal and pharyngeal culture swabs for GC if exposed May repeat screening every 3-6 months, as indicated by risk

risk* EPT= expedited partner treatment; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Antibody; HIV= human immunodeficiency virus; MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma reagin; STI= sexually transmitted infection Test of Cure/ Retest Post Diagnosis and Treatment of Gonorrhea or Chlamydia Retest all patients after 3 months for reinfection (if 3 months not possible, within 1 year). Retest all pregnant patients a minimum of >/=3 weeks after completion of therapy. If suspect treatment failure, reinfection , or failure due to alternative regimen then repeat testing at a minimum of >/= 3weeks after completion of therapy. For pharyngeal gonorrhea– get test of cure on all patients after 14 days. Culture and susceptibilities preferred. Note: Gonnorrhea/Chlamydial PCR <3 weeks from completion of therapy are not recommended due to presence of non-viable organisms and false-positive results. STIs: Partner Treatment -Any recent sexual partner who has had contact with the infected patient within 60 days of their diagnosis should be considered for treatment. -Discuss treatment of partners or questions regarding Expedited Partner Treatment (EPT) with the Infectious Disease Service. -EPT should not be employed with MSMs (these patients should be referred for comprehensive STI testing first). *Definition of High Risk Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

PAGE 19

Asymptomatic Sexually Transmitted Infection Screening

Asymptomatic AsymptomaticSexually SexuallyTransmitted Transmitted Infection Screening Screening ASYMPTOMATICInfection Population

Screening ASYMPTOMATIC Frequency Clinical and Therapeutic Recommendations Considerations Screening Clinical and Therapeutic No routine screening Frequency for STIs. Screen according to *risk. Recommendations Considerations Note: All ‘Babyboomers’ (Patients born from 1945 through 1965) should be

Male

Heterosexual Population men

Male

Heterosexual men who have Men sex with men (MSM) Men who have OR sex with men *high (MSM)risk heterosexual men OR

screened for HCV No routine screening for STIs. Screen according to *risk. Note: All ‘Babyboomers’ (Patients born from 1945 through 1965)culture, should be Consider GC/Chl Urine PCR for Chlamydia Annually screened for HCVrectal and pharyngeal swabs Urine PCR for Gonorrhea Annually Consider GC/Chl culture, Urine PCR for Chlamydia Annually High as: swabs HIV test Annually rectalrisk anddefined pharyngeal Urine PCR for Gonorrhea Annually - New or multiple sex Hepatitis B S Ag, S Ab, C Ab Baseline Highpartners risk defined as: HIV test Annually Hepatitis C Ab Annually -- Inconsistent condom New or multiple sex use Hepatitis B S Ag, S Ab, C Ab Baseline Commercial sex work Syphilis (RPR screen/ titer) Annually partners -- Drug use Hepatitis C Ab Annually Inconsistent condom use Commercial sex work Syphilis (RPR screen/ titer) Annually May repeat screening every - Drug use 3-6 months, as indicated by risk May repeat screening every

HIV-positive men

Urine PCR for Chlamydia

Annually

Urine PCR for Gonorrhea Urine PCR for Chlamydia Syphilis (RPR screen/ titer) Urine PCR for Gonorrhea Hepatitis B S Ag, S Ab, C Ab Syphilis (RPR screen/ titer) Hepatitis C Ab Hepatitis B S Ag, S Ab, C Ab

Annually Annually Annually Annually Baseline Annually Annually Baseline

*high risk heterosexual men

HIV-positive men

3-6 months, as indicated Consider GC/Chl culture, by risk and pharyngeal swabs rectal

Consider GC/Chl culture, May screening every rectalrepeat and pharyngeal swabs 3-6 months, as indicated by risk May repeat screening every 3-6 months, as indicated by risk

GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Hepatitis C Ab Annually Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Core Antibody; HIV= human immunodeficiency virus; MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection. GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Core Antibody; HIV= human immunodeficiency virus; *Definition of High Riskwith men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection. MSM= Men who have sex

Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, *Definition of Highoutside Risk the US. recent sex contact Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

References: 1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf. References: 2. "Primary, Secondary, and Early Latent Syphilis Surveillance 2007-2011." Division of Infectious Disease & Epidemiology. Rhode Island Department 1. of "Sexually Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human Health,Transmitted 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf. Services, 17Sexually Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf. 3. “California Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL: 2. http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf "Primary, Secondary, and Early Latent Syphilis Surveillance 2007-2011." Division of Infectious Disease & Epidemiology. Rhode Island Department of Health, 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf. 3. “California Sexually Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL: PAGE 20 http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf

Asymptomatic Sexually Transmitted Infection Screening Infection Screening Asymptomatic AsymptomaticSexually SexuallyTransmitted Transmitted HIV testing Infection Screening Population

Frequency

HIV testing

Special Considerations

Consider frequent testing if high Special Considerations risk* Consider frequent testing if high All women age 13-64 Baseline Consider PREP if HIV+ partner risk* All women who seek STI screening At time of STI (Consult ID) Consider PREP if HIV+ partner All women who seek STI screening At time of STI Third trimester and at birth if high (Consult ID) All pregnant women First Trimester risk Third trimester and at birth if high All pregnant women First Trimester Consider frequent testing if high risk All men age 13-64 Baseline risk* Consider frequent testing if high All men age 13-64 Baseline Q3-6 months if higher risk activity risk* MSM Annually (minimum) (Consider PREP and consult ID) Q3-6 months if higher risk activity MSM Annually (minimum) Consider PREP HIV+ partner (Consider PREPifand consult ID) All men who seek STI screening At time of STI (consult ID) Consider PREP if HIV+ partner All men who seek STI screening At time of STI HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP= pre-exposure prophylaxis; Q= every; (consult ID) Population All women age 13-64

Frequency Baseline

RPR= rapid plasma regain; STI= sexually transmitted infection.

HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP= pre-exposure prophylaxis; Q= every;

*Definition of High RiskSTI= sexually transmitted infection. RPR= rapid plasma regain; Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , *Definition High Risk inconsistentof condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, Those have a new sex the partner, recentwho sex contact outside US. >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

References: 1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf. References: 2. "Sexually "Primary, Transmitted Secondary, and Early Latent Syphilis Surveillance 2007-2011." Infectious & Epidemiology. Island 1. Diseases Treatment Guidelines, 2015." Centers forDivision DiseaseofControl andDisease Prevention. Department Rhode of Health andDepartment Human of Health,17 2011. Services, Dec.URL: 2010.http://www.health.ri.gov/data/diseases/Syphilis.pdf. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf. 3. "Primary, “CaliforniaSecondary, Sexually Transmitted Disease (STD) Surveillance Screening Recommendations 2010”. California Disease Department Of Public Health, 2011. URL: 2. and Early Latent Syphilis 2007-2011." Division of Infectious & Epidemiology. RhodeJune. Island Department http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf of Health, 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf. 3. “California Sexually Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL: http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf PAGE 21

Skin and Soft Tissue Infections (SSTI)

Skin and Infections (SSTI) Skin and SoftSoft TissueTissue Infections (SSTI) NONPURULENT Necrotizing Infection/Cellulitis/Erysipelas NONPURULENT [Usually Streptococcus pyogenes (Group A Strep)] Necrotizing Infection/Cellulitis/Erysipelas [Usually Streptococcus pyogenes (Group A Strep)]

Mild: No systemic Mild: signs infection* Noofsystemic signs

Moderate: Systemic signs of Moderate: infection* Systemic signs of

Oral Antibiotic OralTherapy Antibiotic Therapy

Intravenous Antibiotic Therapy Intravenous

Select ONE: Penicillin VK Select ONE: 250-500 mg PO Q6H Penicillin VK Cephalexin 250-500 mg PO Q6H 500 mg PO Q6H Cephalexin Dicloxacillin 500 mg PO Q6H 250 mg PO Q6H Dicloxacillin Clindamycin 250 mg PO Q6H 300-450 mg PO Q6H Clindamycin 300-450 mg PO Q6H

Select ONE: Penicillin Select ONE: 2-4 million units IV Penicillin Q4-6H 2-4 million units IV Ceftriaxone Q4-6H 1 gm IV Q24H Ceftriaxone Cefazolin 1 gm IV Q24H 1 gm IV Q8H Cefazolin Clindamycin 1 gm IV Q8H 600-900 mg IV Q6H Clindamycin 600-900 mg IV Q6H

of infection*

infection*

Antibiotic Therapy

Severe:

(any of Severe: the following): Systemic signs of infection*, (any of the following): failed antibiotic treatment, Systemic signs of infection*, immunocompromise, failed antibiotic treatment, hemodynamic instability, or immunocompromise, deep infection hemodynamic instability, or deep infection Intravenous Antibiotic Therapy Intravenous Antibiotic Therapy Emergent Surgical Inspection/Debridement Emergent Surgical • Rule out necrotizing Inspection/Debridement process • Rule out necrotizing Culture & Sensitivity process Empiric Treatment Culture & Sensitivity • Vancomycin 15 mg/kg Empiric Treatment IV** PLUS • Vancomycin 15 mg/kg • Piperacillin/tazobactam IV** PLUS 3.375 gm IV Q6H • Piperacillin/tazobactam +/3.375 gm IV Q6H • Clindamycin 900 mg IV +/Q8H*** • Clindamycin 900 mg IV Q8H***

Defined Treatment (Necrotizing Infections) Monomicrobial Defined Treatment (Necrotizing Infections) Streptococcus pyogenes Monomicrobial • Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H Streptococcus pyogenes Vibrio vulnificus • Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H • Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H Vibrio vulnificus Aeromonas hydrophila • Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H • Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H Aeromonas hydrophila Polymicrobial • Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H • Vancomycin 15 mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H Polymicrobial • Vancomycin 15every mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H H= hours; IV= intravenous; PO= oral; Q=

*Systemic of infection include, not limited to, temperature >38°C, tachycardia (heart rate >90 beats per minute), H= hours;signs IV= intravenous; PO= oral;but Q=are every tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL). *Systemic of on infection include, but are limited to,intemperature >38°C, tachycardia (heart rate >90 beats per minute), **Refer to signs section Vancomycin Dosing andnot Monitoring Adult Patients. tachypnea (respiratory rate breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL). ***Consider this addition for>24 necrotizing fasciitis. **Refer to section on Vancomycin Dosing and Monitoring in Adult Patients. Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in ***Consider addition for necrotizing fasciitis. patients withthis renal impairment. Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in patients with renal impairment. References: 1. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2): e10-52. References: 2. Markwell S, Chambers Peter J, Barenkamp S. Randomized, trialSL,ofetantibiotics in guidelines the management community-acquired skinof skin 1. Duong StevensM,DL, Bisno AL, HF, Dellinger EP, Goldsteincontrolled EJ, Gorbach al. Practice for the of diagnosis and management abscesses in theinfections: pediatric patient. Ann Emerg 2010; Diseases 55:401–7.Society of America. Clin Infect Dis. 2014; 59(2): e10-52. and soft tissue 2014 update by the Med Infectious 3. J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br Jmanagement Surg 1977; 64:264–6. 2. Macfie Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the of community-acquired skin 4. Llera JL, Levy RC. pediatric Treatment of cutaneous abscess: double-blind clinical study. Ann Emerg Med 1985; 14:15–9. abscesses in the patient. Ann Emerg Meda2010; 55:401–7. 5. WH, Hart D,treatment Calderwood Merrett JD. Antibiotics treatment septic Lancet 1970; 1:1077–80. 3. Rutherford Macfie J, Harvey J. The of JW, acute superficial abscesses:ina surgical prospective clinicaloftrial. Br Jlesions. Surg 1977; 64:264–6. 6. D, Pitotti of R, cutaneous et al. Randomized trial of trimethoprim-sulfamethoxazole for14:15–9. uncomplicated skin abscesses in 4. Schmitz Llera JL, GR, LevyBruner RC. Treatment abscess:controlled a double-blind clinical study. Ann Emerg Med 1985; patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7. 5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970; 1:1077–80. 6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7.

PAGE 22

Skin and Infections (SSTI) Skin and SoftSoft TissueTissue Infections (SSTI) PURULENT Skin and Soft Tissue Infections (SSTI)

Furuncle/Carbuncle/Abscess (Usually Staphylococcus aureus) PURULENT

Furuncle/Carbuncle/Abscess Moderate: aureus) (Usually Staphylococcus

Mild: No systemic signs Mild: of infection*

Systemic signs of Moderate: infection*

Systemic signs of infection*

No systemic signs of infection* No Antibiotic No Therapy

Incision and Drainage and C&S

Antibiotic Therapy

Incision and Drainage Incision and Drainage

Incision and Drainage and C&S Oral Antibiotic Oral Therapy Antibiotic

instability, or deep infection

Incision and Drainage

andDrainage C&S Incision and and C&S

Therapy

Empiric Therapy (select ONE):

Severe:

(any of the following): Severe: Failed I&D and oral (anyantibiotics, of the following): systemic Failed I&D oral signs ofand infection*, antibiotics, systemic immunocompromise, signs hemodynamic of infection*, immunocompromise, instability, or deep hemodynamic infection

• TMP/SMX 1-2 DS tablets Empiric Therapy (select ONE): PO Q12H Doxycycline mg POPO Q12H •• TMP/SMX 1-2100 DS tablets Q12H Therapy •Defined Doxycycline 100 mg PO Q12H MRSA Therapy Defined MRSA • TMP/SMX (see empiric dose) •MSSA TMP/SMX empiric dose) (select(see ONE): MSSA (select ONE): • Dicloxacillin 500 mg PO Q6H •• Dicloxacillin Cephalexin 500 500mg mgPO POQ6H Q6H • Cephalexin 500 mg PO Q6H

Intravenous

Antibiotic Intravenous Therapy Antibiotic Therapy

Empiric Therapy (select ONE):

Empiric Therapy (select ONE): • Vancomycin 15 mg/kg IV** • Vancomycin 15 mg/kg IV** • Daptomycin 6 mg/kg IV Q24H • Daptomycin 6 mg/kg IV Q24H • Linezolid 600 mg IV Q12H • Linezolid 600 mg IV Q12H Ceftaroline mgQ12H IV Q12H • •Ceftaroline 600600 mg IV Defined Therapy Defined Therapy MRSA MRSA empiric therapy above • •SeeSee empiric therapy above MSSA (select ONE): MSSA (select ONE): Nafcillin IV Q4H • •Nafcillin 1-2 1-2 gm gm IV Q4H • •Cefazolin 1 gm IV Q8H Cefazolin 1 gm IV Q8H • •Clindamycin 600600 mg IV Clindamycin mgQ8H IV Q8H C&S= cultureand andsensitivity; sensitivity; DS= DS= double-strength; double-strength; H= incision andand drainage; IV= intravenous; MRSA= methicillinC&S= culture H=Hours; Hours;I&D= I&D= incision drainage; IV= intravenous; MRSA= methicillinresistantStaphylococcus Staphylococcusaureus; aureus; MSSA= MSSA= methicillin-susceptible Staphylococcus aureus; PO=PO= by mouth; Q= every; resistant methicillin-susceptible Staphylococcus aureus; by mouth; Q= every; Rx= treatment; TMP/SMX= trimethoprim-sulfamethoxazole Rx= treatment; TMP/SMX= trimethoprim-sulfamethoxazole *Systemic signs of infection, but are not limited to, include temperature >38°C, tachycardia (heart rate >90 beats per minute),

*Systemic signs of infection, but are not limited to, include temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL). tachypnea rate >24 breaths or abnormal white blood cell count (>12 000 or <4000 cells/µL). **Refer to(respiratory section on Vancomycin Dosingper andminute) Monitoring in Adult Patients . **Refer to section on Vancomycin Dosing and Monitoring in Adult Patients. References:

References: 1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the DL, Infectious Diseases Society ofet America. Clin Infect Dis. 2014; 59(2): e10-52. and management of skin and soft tissue infections: 2014 update 1. Stevens Bisno AL, Chambers HF, al. Practice guidelines for the diagnosis 2.byDuong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled of e10-52. antibiotics in the management of community-acquired skin the Infectious Diseases Society of America. Clin Infect Dis. 2014; trial 59(2): abscesses in the pediatric Ann Emerg Med 2010; 55:401–7. 2. Duong M, Markwell S, Peterpatient. J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin 3.abscesses Macfie J,inHarvey J. The treatment acute superficial abscesses: a prospective clinical trial. Br J Surg 1977; 64:264–6. the pediatric patient. of Ann Emerg Med 2010; 55:401–7. Llera JL, Levy RC.J. Treatment of cutaneous a double-blind study. Ann Emergtrial. MedBr1985; 14:15–9. 3. 4.Macfie J, Harvey The treatment of acuteabscess: superficial abscesses:clinical a prospective clinical J Surg 1977; 64:264–6. Rutherford Hart D, Calderwood JW, Merrett JD.aAntibiotics in surgical of Emerg septic lesions. Lancet 1970; 1:1077–80. 4. 5.Llera JL, Levy WH, RC. Treatment of cutaneous abscess: double-blind clinicaltreatment study. Ann Med 1985; 14:15–9. 6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in 5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970; 1:1077–80. patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7. 6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7.

PAGE 23

Skin Skinand andSoft SoftTissue: Tissue: Diabetic Foot Infections Diabetic Foot Infections SEVERITY OF INFECTION Mild • Only skin and subcutaneous tissue involvement AND • Erythema > 0.5 cm and ≤ 2 cm around ulcer • Perform incision and drainage as necessary

Moderate** • Deeper tissue involvement OR • Erythema > 2.0 cm around ulcer AND • No systemic signs of infection • Perform incision and drainage as necessary

SUSPECTED ORGANISMS

RECOMMENDED EMPIRICAL TREATMENT

DURATION

MSSA Streptococcus spp.

Oral Amoxicillin/clavulanate 875 mg PO Q12H OR Cephalexin 500 mg PO Q6H OR Dicloxacillin 250 – 500 mg PO Q6H

MRSA

Doxycycline 100 mg PO Q12H OR SMX/TMP 2 DS tablets PO Q12H (Does not cover Group A Strep) Oral OR Initially Parenteral 1–3 weeks Ampicillin-sulbactam 1.5–3 gm IV Q6H OR Ceftriaxone 1 gm IV Q24H

MSSA Streptococcus spp. Enterobacteriaceae Obligate anaerobes

1–2 weeks

Penicillin Allergy:

MRSA

Pseudomonas aeruginosa

Ciprofloxacin 500 mg PO Q12H AND Clindamycin 300 mg PO Q6H OR Ceftriaxone 1 gm IV Q24H Linezolid 600 mg IV/PO Q12H† (Requires ID Consult) OR Daptomycin 6 mg/kg IV Q24H† (Requires ID Consult) OR Vancomycin 15 mg/kg IV* Piperacillin-tazobactam 3.375 gm IV Q4H

DS= Double Strength; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin sensitive S. aureus; PO= by mouth; Q= every; SMX-TMP= sulfamethoxazole/trimethoprim; spp= species † Restricted Antibiotic – refer to Table of Contents for Guidelines for Restricted Antimicrobials * Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients ** Consult Infectious Diseases and Podiatry NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function

PAGE 24

Skin and Soft Tissue: Diabetic Foot Infections

Skin Skinand andSoft SoftTissue: Tissue: Diabetic Foot Infections Diabetic Foot Infections R E SEVERITY OF INFECTION

SUSPECTED ORGANISMS

ECOMMENDED MPIRICAL

DURATION TREATMENT RECOMMENDED EMPIRICAL SUSPECTED ORGANISMS Initially Parenteral DURATION MSSA/MRSA TREATMENT P. aeruginosa Vancomycin 15 mg/kg IV* MSSA/MRSA Initially Parenteral Streptococcus spp. AND** P. aeruginosa 2–4 weeks Enterobacteriaceae Vancomycin 15 IV mg/kg Cefepime 2 gm Q8HIV* + Streptococcus spp. Obligate anaerobes AND** metronidazole 500 mg IV Q6H 2–4 weeks Enterobacteriaceae Cefepime 2 gm IV Q8H + OR Obligate anaerobes metronidazole 500 mg IV Q6H Piperacillin-tazobactam OR 3.375 gm IV Q4H Piperacillin-tazobactam 3.375 gm IV Q4H Bone OR Joint Involvement‡

SevereS**EVERITY OF INFECTION • Same as moderate ** Severe AND •• Same as moderate Systemic signs of infection AND present • Systemic signs of infection Systemic Inflammatory presentSyndrome (SIRS) Response Systemic Criteria ≥2Inflammatory of the following: Response Syndrome (SIRS) • Temperature Criteria ≥2 of the <96.8°F following: OR >100.4°F •• Temperature P > 90 BPM <96.8°F SourceOR removed: 2-5 days ‡ Joint Involvement Bone • OR RR >>100.4°F 20 BPM •• PPaCO > 90 BPM < 32 mmHg Source removed but 2 removed: 2-5 residual days tissue infection: •• RR > 20 BPM cells/mm³ WBC < 4000 1-3 weeks • PaCO Source removed but residual tissue infection: 2 < 32 mmHg OR >12,000 cells/mm³ Source removed but residual bone infection: •• WBC 4000 cells/mm³ 1-3 weeks ≥ 10%< immature (band) 4-6 weeks >12,000 cells/mm³ OR forms Source removed but residual bone infection: •• ≥Perform 10% immature (band) incision and Source not removed: ≥3 months 4-6 weeks forms drainage as necessary • Perform incision and Source not removed: ≥3 months BPM= beats or breaths per minute; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin drainage as necessary sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic Inflammatory Syndrome; spp= species; white blood cellmethicillin resistant S. aureus; MSSA= methicillin BPM= beats orResponse breaths per minute; H= hour(s); IV=WBC= intravenous; MRSA= sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic † Restricted Antibiotic – refer to Table of Contents for Guidelines for Restricted Antimicrobials Inflammatory Response Syndrome; spp= species; WBC= white blood cell * Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients Consult Infectious and Podiatry †**Restricted AntibioticDiseases – refer to Table of Contents for Guidelines for Restricted Antimicrobials Discuss Infectious Podiatry, and Vascular *‡ Refer toplan Tablewith of Contents forDiseases, section on Vancomycin Dosing and Monitoring in Adult Patients ** Consult Infectious Diseases and Podiatry NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult ‡ Discuss plan with Infectious Diseases, Podiatry, and Vascular Patients Based on Renal Function NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function

References: 1. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73. References: 2. insert]. York, 2015.EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the 1. Flagyl Lipsky[package BA, Berendt AR, New Cornia PB, NY: Pile Pfizer; JC, Peters Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73. 2. Flagyl [package insert]. New York, NY: Pfizer; 2015. PAGE 25

Surgical Decolonization and Prophylaxis

Surgical Decolonization and Prophylaxis Surgical Decolonization and Prophylaxis DECOLONIZATION Nasal Screening Result Nasal Screening Result MRSA Negative MSSA MRSA Negative Negative MSSA Negative MSSA Positive MSSA Positive MRSA Positive MRSA Positive

• •

DECOLONIZATION Recommended Intervention Recommended Intervention • No decolonization required • No decolonization required • Intranasal mupirocin twice daily x 5 days • Intranasal mupirocin twice daily x 5 days • Intranasal mupirocin twice daily x 5 days, AND • Intranasal mupirocin twice daily x 5 days, •AND Chlorhexidine bathing one day prior to surgery • Chlorhexidine bathing one day prior to surgery ANTIMICROBIAL PROPHYLAXIS

ANTIMICROBIAL PROPHYLAXIS CLINICAL CONSIDERATIONS Preoperative dose-timing CLINICAL CONSIDERATIONS Within 60 minutes of surgical incision Preoperative dose-timing Exceptions: vancomycin and fluoroquinolones within 120 minutes of surgical Within 60 minutes of surgical incision incision Exceptions: vancomycin and fluoroquinolones within 120 minutes of surgical Weight-based dosing incision Cefazolin: 2 gm for patients <120 kg, and 3 gm for patients ≥120 kg Weight-based dosing Vancomycin: usefor ABW Cefazolin: 2 gm patients <120 kg, and 3 gm for patients ≥120 kg Gentamicin: Vancomycin:use useABW ABWunless ABW is >120% of their IBW, in which case use AdjBW (see below for equation) Gentamicin: use ABW unless ABW is >120% of their IBW, in which case use Duration prophylaxis AdjBW of (see below for equation) A singleof dose, or continuation for <24 hours is recommended Duration prophylaxis A single dose, or continuationINTRA for <24 hours isREDOSING recommended -OPERATIVE

INTRA-OPERATIVE REDOSING Required if the duration of procedure exceeds two half-lives of the drug or if there is extensive blood loss during the procedure (>1500 mL) Ŧ of the drug or if there Required if the duration of procedure exceeds two half-lives Ŧ Recommendation: use during the same dose and mL) measure the redosing interval is extensive blood loss theantibiotic procedure (>1500 from the time of administration of the preoperative dose, not the the redosing time of incision Recommendation: use the same antibiotic dose and measure interval from administration of the preoperative not the time of incision ABW= actualthe bodytime weight;of AdjBW= adjusted body weight; IBW= ideal body weight;dose, MRSA= Methicillin-resistant Staphylococcus • • • •

aureus; MSSA= Methicillin-susceptible Staphylococcus aureus ABW= actual body weight; AdjBW= adjusted body weight; IBW= ideal body weight; MRSA= Methicillin-resistant Staphylococcus MSSA= Staphylococcus Ŧaureus; Redosing may Methicillin-susceptible not be necessary for patients with pooraureus renal function (CrCl <30mL/min) Ŧ Redosing may not be necessary for patients with poor renal function (CrCl <30mL/min)

IBW Calculation: Male = 50 kg + [2.3 kg for each inch over 5 feet] IBW Calculation: Female = 45 kg + [2.3 kg for each inch over 5 feet] Male = 50 kg + [2.3 kg for each inch over 5 feet] Female = 45 kg + [2.3 kg for each inch over 5 feet]

AdjBW Calculation: AdjBW = 0.4 (ABW-IBW) + IBW AdjBW Calculation: AdjBW = 0.4 (ABW-IBW) + IBW

References: 1. Schweuzer ML, Chiang H, Septimus E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections Among Patients Undergoing Cardiac, Hip, or Knee Surgery (STOP SSI – Study to Optimally Prevent SSI in Select Cardiac and Orthopedic References: Procedures). JAMA 2015; 1. Schweuzer ML, Chiang H, 313(21): Septimus2162-2171. E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections 2. Chen AF,Patients Wessel Undergoing CB, Rao N. Staphylococcus Screening andSSI Decolonization in Orthopaedic and Reduction of Orthopedic Surgical Site Among Cardiac, Hip, oraureus Knee Surgery (STOP – Study to Optimally PreventSurgery SSI in Select Cardiac and Infections. ClinJAMA Orthop Relat Res 2013; 471: 2383-2399. Procedures). 2015; 313(21): 2162-2171. 3. Bratzler Dellinger EP,N. Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines 2. Chen AF,DW, Wessel CB, Rao Staphylococcus aureus Screening and Decolonization in Orthopaedic Surgeryfor andantimicrobial Reduction ofprophylaxis Surgical Sitein surgery. AmClin J Health Syst Pharm Infections. Orthop Relat Res 2013; 70:195-283. 471: 2383-2399. 3. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283.

PAGE 26

Antimicrobial Surgical Prophylaxis

â&#x20AC;&#x201A;Antimicrobial Surgical Prophylaxis Antimicrobial Surgical R Prophylaxis R EDOSING

ECOMMENDATIONS

REDOSING ECOMMENDATIONS Half-life R (hours)

Antibiotic

Redosing Interval (hours)

Ampicillin/sulbactam Antibiotic

0.8-1.3

Cefazolin Ampicillin/sulbactam

1.2-2.2 0.8-1.3

Cefoxitin Cefazolin

0.7-1.1 1.2-2.2

Ciprofloxacin Cefoxitin

3-7 0.7-1.1

Not 2 necessary

Clindamycin Ciprofloxacin

2-4 3-7

6Not necessary

Gentamicin Clindamycin

2-3 2-4

Not 6 necessary

Metronidazole Gentamicin

6-8 2-3

Not Not necessary necessary

Vancomycin Metronidazole SURGICAL Vancomycin PROCEDURE SURGICAL Laparoscopic, PROCEDURE

4-8 6-8

low-risk Laparoscopic, Laparoscopic, low-risk high-risk Laparoscopic, high-risk Small intestine, nonobstructed Small intestine, nonobstructed Small intestine, obstructed Small intestine, obstructed Hernia repair Hernia repair Colorectal Colorectal

Head and neck,

Half-life (hours)

RECOMMENDED AGENTS 4-8

NoneRECOMMENDED AGENTS None Cefazolin, cefoxitin, cefotetan, ceftriaxone, Cefazolin, cefoxitin, ampicillin/sulbactam cefotetan, ceftriaxone, Cefazolin ampicillin/sulbactam Cefazolin Cefazolin + metronidazole, cefoxitin, cefotetan Cefazolin + metronidazole, cefoxitin, cefotetan Cefazolin Cefazolin + metronidazole, Cefazolin cefoxitin, cefotetan, Cefazolin + metronidazole, ampicillin/sulbactam, cefoxitin, cefotetan, ceftriaxone + ampicillin/sulbactam, metronidazole, ertapenem ceftriaxone + None metronidazole, ertapenem

clean Jen - this page is too Head and neck, None long. Youâ&#x20AC;&#x2122;ll to Cefazolin, cefuroxime Head and neck, clean have of shortenplacement it somehow. Head and neck, Cefazolin, cefuroxime prosthetic placement of prosthetic Cleancontaminated Clean- surgery cancer contaminated cancer surgery

Cefazolin + metronidazole, cefuroxime + Cefazolin + metronidazole, metronidazole, cefuroxime + ampicillin/sulbactam metronidazole, ampicillin/sulbactam

Redosing Interval (hours)

Not Not necessary necessary

ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM Not necessary ALLERGY

ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM None ALLERGY

None Clindamycin or vancomycin + aminoglycoside or aztreonam or fluoroquinolone Clindamycin or vancomycin + aminoglycoside or aztreonam or fluoroquinolone Clindamycin + aminoglycoside or aztreonam or fluroquinolone Clindamycin + aminoglycoside or aztreonam or fluroquinolone Metronidazole + aminoglycoside or fluoroquinolone Metronidazole + aminoglycoside or fluoroquinolone Clindamycin, vancomycin Clindamycin,+vancomycin Clindamycin aminoglycoside or aztreonam or fluroquinolone; Clindamycin + aminoglycoside or or Metronidazole + aminoglycoside aztreonam or fluroquinolone; fluoroquinolone Metronidazole + aminoglycoside or fluoroquinolone None None Clindamycin

Clindamycin Clindamycin Clindamycin

References: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. References: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. PAGE 27

Antimicrobial Surgical Prophylaxis Antimicrobial Surgical Prophylaxis Antimicrobial Surgical Prophylaxis ALTERNATIVES FOR PATIENTS WITH SURGICAL PROCEDURE

RECOMMENDED AGENTS

SURGICAL PROCEDURE

RECOMMENDED AGENTS

Ortho: clean hand, knee, or foot not Ortho: clean hand, involving implantation knee, or foot not of foreign materials involving implantation Ortho: implantation of foreign materials of foreign material and/or Ortho: implantation of total joints foreign material and/or Urologic with risk total joints factors for infection Urologic with risk Urologic, without factors forclean infection entry into urinary tract Urologic, clean without Urologic entry intoinvolving urinary tract implanted prosthesis Urologic involving implanted prosthesis

None

BETA-LACTAM ALLERGY ALTERNATIVES FOR PATIENTS WITH None BETA-LACTAM ALLERGY

None

Cefazolin

Clindamycin, vancomycin

Cefazolin

Clindamycin, vancomycin

Fluoroquinolone, TMP/SMX, cefazolin Fluoroquinolone, Cefazolin* TMP/SMX, cefazolin

Aminoglycoside +/- clindamycin

Cefazolin* Cefazolin ± aminoglycoside, Cefazolin ± cefazolin ± aztreonam, aminoglycoside, ampicillin/sulbactam cefazolin ± aztreonam, Cefazolin* ampicillin/sulbactam

Clindamycin, vancomycin Clindamycin ± aminoglycoside or aztreonam, vancomycin ± Clindamycin ± aminoglycoside or aminoglycoside or aztreonam aztreonam, vancomycin ± aminoglycoside or aztreonam Fluoroquinolone, aminoglycoside ± clindamycin Fluoroquinolone, aminoglycoside ± Fluoroquinolone, aminoglycoside + clindamycin metronidazole or clindamycin Fluoroquinolone, aminoglycoside + metronidazole or clindamycin

Urologic, clean with entry into urinary tract Urologic, clean with Cefazolin* Urologic, Cefazolin + entry intocleanurinary tract contaminated metronidazole, cefoxitin Urologic, cleanCefazolin + contaminated metronidazole, cefoxitin TMP/SMX= trimethoprim/sulfamethoxazole

Aminoglycoside +/- clindamycin Clindamycin, vancomycin

*Addition a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile TMP/SMX=oftrimethoprim/sulfamethoxazole prosthesis) *Addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile prosthesis)

Tract:Catheter-Associated Catheter-Associated Urinary Tract Urinary Urinary Tract: Urinary Tract Infection Infection CLASSIFICATION Asymptomatic Bacteriuria

CLINICAL FINDINGS • Positive urine culture (≥ 100,000 cfu/mL of ≥ 1 bacterial species in a single catheter urine specimen) AND • No sign or symptoms

Remove catheter

No antibiotics unless the patient is: • Scheduled for urologic procedure • Pregnant Scheduled Urologic Procedure: SMX/TMP 1 DS tablet PO Q12H OR Ciprofloxacin 500 mg PO OR Ciprofloxacin 400 mg IV Q12H Initiate within 24 hours prior to procedure and until foley removed Pregnant: Amoxicillin 500 mg PO Q12H for 3 to 7 days OR Cephalexin 500 mg PO Q12H for 3 to 7 days OR Nitrofurantoin (MacroBID)‡ 100 mg PO Q12H for 5 days

Symptomatic AND ≥ 1 of the following: • Male • Pyelonephritis • Antibiotic use in previous 90 days • History of infection with MDRO • Immunocompromised • Functional or anatomic urologic abnormality • Severe sepsis

• Positive urine culture (≥ 1,000 cfu/mL of ≥ 1 bacterial species in a single catheter urine specimen) AND • Presence of signs/symptoms Catheter still in place: - Malaise/lethargy - Fever (≥100.4°F)/rigors - Altered mental status - Flank pain - Pelvic discomfort - Acute hematuria Catheter removed within past 48 h: - Dysuria - Urgency - Frequency - Suprapubic pain/tenderness

CLINICAL CONSIDERATIONS

RECOMMENDED EMPIRIC REGIMENS

Outpatient: SMX/TMP DS tablet PO Q12H OR Nitrofurantoin (MacroBID)‡ 100 mg PO Q12H OR Ciprofloxacin 250 - 500 mg PO Q12H Inpatient: Cefazolin 2 gm IV Q8H OR Cefepime 1 gm IV Q12H OR Ampicillin/sulbactam 1.5 gm IV Q6H Known or suspected ESBL bacteria: Meropenem 1 gm IV Q8H OR Ertapenem 1 gm IV Q24H

•

• •

•

Obtaining routine cultures in asymptomatic patients is NOT recommended In the presence of a catheter, pyuria (>5-10 WBC) in an asymptomatic patient is NOT an indication for antibiotic treatment Presence or absence of odorous or cloudy urine alone is NOT an indication for antibiotic treatment Antibiotics do NOT decrease asymptomatic bacteriuria or prevent subsequent UTI

Remove catheter whenever possible Narrow antibiotic therapy when organism and susceptibilities are known Follow-up urine cultures or urinalysis are only warranted for ongoing symptoms. They should NOT be obtained routinely to monitor response to therapy

Duration of Treatment: Prompt resolution: 7 days Delay response: 10-14 days

cfu= colony forming units; DS= double strength; ESBL= extended spectrum beta-lactamase; H= hour(s); IV= intravenous; MDRO= multi-drug resistant organism; PO= by mouth; Q= every; SMX/TMP= sulfamethoxazole/trimethoprim; UTI= Urinary Tract Infection; WBC= white blood cell ‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis

PAGE 29

Urinary Tract: Urinary Tract UrinaryTract: Tract:Non-Catheter-Associated Non-CatheterAssociated Associated Urinary Tract Urinary Non-Catheter Urinary Tract Infection / Cystitis Infection/Cystitis Infection/Cystitis LASSIFICATION CCLASSIFICATION

Asymptomatic Asymptomatic Bacteriuria Bacteriuria

LINICALFFINDINGS INDINGS CCLINICAL

Pyuria • • Pyuria (urinalysis>>5-5-10 10 (urinalysis WBC) WBC) OR OR Positiveurine urine • • Positive culture culture 100,000cfu/mL) cfu/mL)† † (≥(≥100,000 AND AND Nosign signororsymptoms symptoms • • No (seebelow) below) (see

ECOMMENDEDEEMPIRIC MPIRIC RRECOMMENDED EGIMENS RREGIMENS

LINICAL CCLINICAL ONSIDERATIONS CCONSIDERATIONS

Noantibiotics antibioticsunless unlessthe thepatient patient No is: is: Scheduledfor forurologic urologic • • Scheduled procedure procedure Pregnant • • Pregnant

Obtainingroutine routine • • Obtaining culturesinin cultures asymptomatic asymptomatic patientsisisNOT NOT patients recommended recommended Antibioticsdo doNOT NOT • • Antibiotics decrease decrease asymptomatic asymptomatic bacteriuriaoror bacteriuria prevent prevent subsequentUTI UTI subsequent

ScheduledUrologic UrologicProcedure: Procedure: Scheduled SMX/TMP11DS DStablet tabletPO POQ12H Q12H SMX/TMP OR OR Ciprofloxacin500 500mg mgPO PO Ciprofloxacin OR OR Ciprofloxacin400 400mg mgIVIVQ12H Q12H Ciprofloxacin

Initiatewithin within24 24hours hoursprior priortoto Initiate procedureand anduntil untilfoley foley procedure removed removed Pregnant: Pregnant: Amoxicillin500 500mg mgPO POQ12H Q12Hfor for Amoxicillin days 33toto77days OR OR Cephalexin500 500mg mgPO POQ12H Q12Hfor for Cephalexin days 33toto77days OR OR Nitrofurantoin(MacroBID) (MacroBID)‡ ‡ Nitrofurantoin 100mg mgPO POQ12H Q12Hfor for55days days 100 Symptomatic: Symptomatic: Complicated Complicated thefollowing: following: ≥≥11ofofthe Male • • Male Pyelonephritis • • Pyelonephritis Antibioticuse useinin • • Antibiotic previous90 90days days previous Historyofof • • History infectionwith with infection MDRO MDRO Immuno• • Immunocompromised compromised Functionaloror • • Functional anatomic anatomic urologic urologic abnormality abnormality Severesepsis sepsis • • Severe

Pyuria • • Pyuria (Urinalysis≥≥55WBC) WBC) (Urinalysis AND AND Positiveurine urine • • Positive culture culture 100,000cfu/mL) cfu/mL)† † (≥(≥100,000 AND AND Presenceofof • • Presence symptoms: symptoms: Dysuria - - Dysuria Urgency - - Urgency Frequency - - Frequency Suprapubicpain pain - - Suprapubic AND/OR AND/OR Presenceofofsigns: signs: • • Presence Fever - - Fever 100.4°F) (≥(≥100.4°F) Alteredmental mental - - Altered status status Leukocytosis - - Leukocytosis

Outpatient: Outpatient: SMX/TMP11DS DStablet tabletPO POQ12H Q12H SMX/TMP OR OR Nitrofurantoin(MacroBID) (MacroBID)‡ ‡ Nitrofurantoin 100mg mgPO POQ12H Q12H 100 OR OR Ciprofloxacin250 250- -500 500mg mgPO PO Ciprofloxacin Q12H Q12H Inpatient: Inpatient: Cefazolin22gm gmIVIVQ8H Q8H Cefazolin OR OR Cefepime11gm gmIVIVQ12H Q12H Cefepime OR OR Ampicillin/sulbactam1.5 1.5gm gmIVIV Ampicillin/sulbactam Q6H Q6H

Narrowantibiotic antibiotic • • Narrow therapywhen when therapy organismand and organism susceptibilitiesare are susceptibilities known known Follow-upurine urine • • Follow-up culturesoror cultures urinalysisare areonly only urinalysis warrantedfor forononwarranted goingsymptoms. symptoms. going Theyshould shouldNOT NOT They beobtained obtained be routinelytoto routinely monitorresponse response monitor therapy tototherapy

Knownororsuspected suspectedESBL ESBL Known bacteria: bacteria: Meropenem11gm gmIVIVQ8H Q8H Meropenem OR OR Ertapenem11gm gmIVIVQ24H Q24H Ertapenem DurationofofTreatment: Treatment: Duration 14days days 77toto14

cfu=colony colonyforming formingunits; units;ESBL= ESBL=extended extendedspectrum spectrumbeta-lactamase; beta-lactamase;H= H=hour(s); hour(s);IV= IV=intravenous; intravenous;MDRO= MDRO=multi-drug multi-drugresistant resistant cfu= organism;PO= PO=by bymouth; mouth;Q= Q=every; every;SMX/TMP= SMX/TMP=sulfamethoxazole/trimethoprim; sulfamethoxazole/trimethoprim;UTI= UTI=Urinary UrinaryTract TractInfection; Infection;WBC= WBC=white white organism; bloodcell cellcount count blood †Positiveurine urineculture: culture: †Positive ForWomen: Women:22consecutive consecutivevoided voidedurine urinespecimens specimenswith withisolation isolationofof>10 >105 5cfu/mL cfu/mLofofthe thesame samebacterial bacterialstrain strain For ForMen: Men:AAsingle, single,clean-catch, clean-catch,voided voidedurine urinespecimen specimenwith withisolation isolationofof>10 >105 5cfu/mL cfu/mLfrom from11bacterial bacterialspecies species For ‡Nitrofurantoin:Contraindicated ContraindicatedififCrCl< CrCl<60 60mL/min mL/minAND ANDonly onlyindicated indicatedininacute acutecystitis cystitis ‡Nitrofurantoin: NOTE:Dosing Dosingbased basedon onnormal normalrenal renalfunction. function.Refer RefertotoTable TableofofContents Contentsfor forsection sectionon onAntimicrobial AntimicrobialDosing Dosingfor forAdult Adult NOTE: PAGE 30 PatientsBased Basedon onRenal RenalFunction Function Patients

Urinary Tract: Non-Catheter Associated Urinary Tract Infection/Cystitis Urinary Tract: Non-Catheter Non-Catheter-Associated Urinary Tract: AssociatedUrinary UrinaryTract Tract CLINICAL Urinary Tract: Non-Catheter Associated Urinary Infection / Cystitis C LASSIFICATION C LINICAL FINDINGS R ECOMMENDED EMPIRIC R EGIMENS Tract Infection/Cystitis CONSIDERATIONS Infection/Cystitis CLINICAL CLASSIFICATION Symptomatic Uncomplicated/ CLASSIFICATION Cystitis Symptomatic • Female Uncomplicated/ Symptomatic AND Cystitis Uncomplicated/ • Female No criteria for •Cystitis complicated AND • Female (seecriteria previous •AND No for page) • complicated No criteria for (see previous complicated page) (see previous page)

LINICAL FINDINGS • CPyuria ≥5 C(Urinalysis: LINICAL FINDINGS WBC) • Pyuria (Urinalysis: ≥5 •AND Pyuria • WBC) Positive urine (Urinalysis: ≥5 culture (≥ 100,000 AND WBC) † cfu/mL) urine •AND Positive AND 100,000 • culture Positive(≥urine • cfu/mL) Presence culture †(≥of 100,000 symptoms: AND cfu/mL)† - Dysuria •AND Presence of - Urgency • symptoms: Presence of Frequency -- Dysuria symptoms: Suprapubic --- Urgency Dysuria pain -- Frequency Urgency -- Suprapubic Frequency - pain Suprapubic pain

RECOMMENDED EMPIRIC R‡EGIMENS Nitrofurantoin (MacroBID) 100 mg PO Q12H for 5 daysREGIMENS RECOMMENDED EMPIRIC OR Nitrofurantoin (MacroBID)‡ SMX/TMP DS(MacroBID) tablet Q12H for ‡ 100 mg PO 1Q12H for 5 PO days Nitrofurantoin 3 days OR 100 mg PO Q12H for 5 days SMX/TMP DS tablet PO Q12H for OR Alternative1 agents should be avoided 3SMX/TMP 1 DStotablet PO of Q12H for ifdays possible due the risk C. difficile 3 daysantibiotic resistance. IF patient AND Alternative agents should be avoided an allergy/contraindication to the ifhas possible due to the risk ofbeC.avoided difficile Alternative agents should above antibiotics alternatives include: AND antibiotic resistance. if possible due to the risk ofIFC.patient difficile Ciprofloxacin 250 mg PO Q12H for 3 has allergy/contraindication to the ANDanantibiotic resistance. IF patient days OR Cephalexin 500 mg PO Q12H above antibiotics alternatives include: has an allergy/contraindication to the for 3 days Ciprofloxacin 250 mg PO Q12Hinclude: for 3 above antibiotics alternatives days OR Cephalexin 500 PO Q12H Ciprofloxacin 250 mg POmg Q12H for 3 for 3 days days OR Cephalexin 500 mg PO Q12H for 3 days

Urinary Tract: Prostatitis Urinary Prostatitis CLASSIFICATIONTract: PREFERRED REGIMEN Urinary Tract: Prostatitis Urinary Tract: Prostatitis Outpatient CLASSIFICATION

Urine culture

CLINICAL CONSIDERATIONS should be Cperformed ONSIDERATIONS ONLY IF:

• Urine culture - History be of • should Urine culture multiple UTIs IF: performed should be ONLY OR MDRO - History of performed ONLY IF: infection(s) UTIs - multiple History of • Narrow antibiotic OR MDRO multiple UTIs therapy when infection(s) OR MDRO organism and • Narrow antibiotic infection(s) susceptibilities are • therapy Narrow when antibiotic known organism and therapy when • susceptibilities Follow-up urineare organism and cultures or UA are known susceptibilities are only warranted • Follow-up urine for known on-going or urine UA are • cultures Follow-up symptoms. They only warranted for cultures or UA are should NOT be for on-going only warranted obtained routinely symptoms. on-going They to monitor should NOT They be symptoms. response to be obtained routinely should NOT therapy to monitorroutinely obtained response to to monitor therapy response to therapy

CLINICAL CONSIDERATIONS CLINICAL Beta-lactams DO NOT CLINICAL ONSIDERATIONS haveCadequate C ONSIDERATIONS penetration into prostate Beta-lactams DO NOT

SMX/TMP 1 DS tabletRPO Q12H ALTERNATIVE EGIMENS OR ALTERNATIVE REGIMENS Levofloxacin mg PO SMX/TMP 1 DS500 tablet PO once Q12Hdaily Outpatient (Requires ID Consult) OR have adequateDO NOT SMX/TMP 1 DS tablet PO Q12H Beta-lactams Outpatient Levofloxacin 500 mg PO 28 once daily penetration into prostate OR have adequate Duration of Treatment: days (Requires ID Consult) Levofloxacin 500 mg PO once daily penetration into prostate cfu= colony forming units; DS= double strength; H= hour(s); MDRO= multi-drug resistant organism; PO= by mouth; Q= every; (Requires ID Consult) Duration ofUrinary Treatment: 28 days WBC= white blood cell count SMX/TMP= sulfamethoxazole/trimethoprim; UA= urinalysis; UTI= Tract Infection; Duration of Treatment: 28 days cfu= colony forming units; DS= double strength; H= hour(s); MDRO= multi-drug resistant organism; PO= by mouth; Q= every;

CLASSIFICATION

Ciprofloxacin mg PO PREFERRED500 REGIMEN Q12H PREFERRED REGIMEN Ciprofloxacin 500 mg PO Q12H Ciprofloxacin 500 mg PO Q12H

ALTERNATIVE REGIMENS

•

†Positive urine culture: SMX/TMP= sulfamethoxazole/trimethoprim; UA=H= urinalysis; UTI= Urinary Tract Infection; WBC= white blood cell count cfu= colony units; DS= doublevoided strength; hour(s); MDRO= multi-drug resistant organism; PO= by mouth; Q= every; 5 cfu/mL Forforming Women: 2 consecutive urine specimens with isolation of >10 of the same bacterial strain SMX/TMP= UA=urine urinalysis; UTI=with Urinary TractofInfection; WBC= white blood cell count Forsulfamethoxazole/trimethoprim; Men: A single, clean-catch, voided specimen isolation >105 cfu/mL from 1 bacterial species †Positive urine culture: Women: 2 consecutive voided urine specimens with isolation of >105 cfu/mL of the same bacterial strain †PositiveFor urine culture: ‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis 5 cfu/mL from 1 bacterial species 5 cfu/mL For A single, clean-catch, voided urine specimen with isolation ForMen: Women: 2 consecutive voided urine specimens with isolation of of >10>10 of the same bacterial strain For Men: single, clean-catch, voidedRefer urineto specimen isolation of >105 on cfu/mL from 1 bacterial NOTE: Dosing basedA on normal renal function. Table ofwith Contents for section Antimicrobial Dosingspecies for Adult ‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis Patients Based on Renal Function ‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Basedbased on Renal Function NOTE: Dosing on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function

References: 1. Hooton TM, Bradley SF, Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Disease Society of America. CID 2010;50:625-63. References: 2. Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin 1. Hooton TM,2005 Bradley Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 Infect Dis. Mar SF, 1;40(5):643-54. References: clinical practice guidelines the Infectious Disease Society America. CID 2010;50:625-63. 3. Gupta et al. International clinical guidelines for the treatment of of acute cystitisurinary and pyelonephritis in in women: 2010 1. international HootonK,TM, Bradley SF, Cardena DD,practice et from al. Diagnosis, prevention, and treatment ofuncomplicated catheter-associated tract infection adults:A2009 2. Nicolle LE, Infectious Diseases Society America guidelines forSociety the diagnosis and treatment of asymptomatic bacteriuria adults. update by et theal. Infectious Diseases Society ofofAmerica and European for Microbiology and Infectious Diseases. Clin InfectinDis. 2011Clin Mar international clinical practice guidelines from the Infectious Disease Society of America. CID 2010;50:625-63. Infect Dis. 2005 Mar 1;40(5):643-54. 1;52(5):e103-20. 2. Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin 3. Gupta et2005 al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 Infect K, Dis. Mar 1;40(5):643-54. byetthe Diseases Society of America and Societyoffor Microbiology and Infectious Diseases. Clin Infect Dis. 2011 3. update Gupta K, al.Infectious International clinical practice guidelines forEuropean the treatment acute uncomplicated cystitis and pyelonephritis in women: A Mar 2010 PAGE 31 1;52(5):e103-20. update by the Infectious Diseases Society of America and European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20.

At Age ≥ 65

AtAge Age≥≥65 GIVE: PPSV23† † V23 At 65 † after †PPSV23 GIVE: PPSV23 ≥ 8≥65 weeks* At Age GIVE: GIVE: PPSV23† † V23 † GIVE: and PPSV23 ≥ after 8 after weeks* after≥5 years after ≥ 5years years †PPSV23 PCV13 ≥5 GIVE: PPSV23 ≥5 years after ≥PPSV23 5years years after PCV13 and ≥ 5 after PPSV23 PPSV23 PPSV23 PPSV23

Pneumococcal Vaccine

At Age ≥ 65

At Age 65 † ≥≥ GIVE: PPSV23 8 weeks* after † GIVE: PPSV23 ≥ 8 weeks* after PCV13 and ≥ 5 years after PPSV2 PCV13 and ≥ 5 years after PPSV2

Pneumococcal Vaccination Pneumococcal Vaccination Pneumococcal Vaccination Recommendations Recommendations Recommendations

DE EI SI S L

E H ALT H EA LT H

RRH

LT H

TT DDEEPPAARR

D N D N

LA A n of EPCV13 and PPSV23 OOD is 8 weeks in immunocompromised patients. D ISLA nOof PCV13Please and PPSV23 8 weeks ull months. refer to is page 4. in immunocompromised patients. recommends only 14.dose of PPSV23 at age ≥65. Revaccination is not necessary. ullPractices) months. Please refer to page not necessary. COLLEGE OF 1-4 COLLEGE OF Adults ≥19 1-4 Years PHARMACY Adults ≥19 Years only 1 isdose of PPSV23 at age not necessary. PHARMACY lPractices) fluid leak, recommends or cochlear implant not required. ≥65. Revaccination is not necessary. COLLEGE OF DRUG INFORMATION 1-4 M DRUG INFORMATION M E® F is not required. Adults ≥19 Years (Including updated recommendations the use of PCV13 in Adults) SERVICES PHARMACY leak,(Pneumovax or cochlear N23) FO E Nimplant (Including updated recommendations for the usefor of PCV13 in Adults) el fluid Vaccine SERVICES T TO DRUG INFORMATION 401-874-9188 401-874-9188 M ® 2014 Island Board of Education for the use of PCV13 in Adults) © SERVICES 2014 Rhode Island Board of E E (Prevnar recommendations ene Vaccine 23)Rhodeupdated 13®) © (Including N T O F (Pneumovax 401-874-9188 Healthy © 2014 Rhode Island Board of E ne (Prevnar 13®) © 2014 Rhode Island Board of Education Healthy AdultsAdults ≥ 65 ≥ 65

Healthy Adults ≥ 65vaccinated with Pneumococcal Vaccination Previously Previously Pneumococcal Vaccination Previously vaccinated with Previously vaccinated withvaccinated with Naive or Unknown History PPSV23 at age ≥65 PPSV23 before age 65 Naive or Unknown History PPSV23 atwith age ≥65 PPSV23vaccinated before age 65with Pneumococcal Vaccination Previously vaccinated Previously Naive or Unknown History PPSV23 at age ≥65 PPSV23 before ≥ 1age year65 after PPSV23 ≥ 1 year after PPSV23

GIVE: PCV13 GIVE: PCV13

GIVE: PCV13 Wait ≥ 1 year*

Wait ≥ 1 year* Wait ≥ 1 year*

≥ 1 year after PPSV23 ≥ 1 year after PPSV23

GIVE: PCV13 if not previously given ≥ 1 year after PPSV23 GIVE: PCV13 if not previously given

Wait ≥ 1 year* GIVE: PCV13 if1not previously given Wait ≥(and year* ≥ 5 years after PPSV23) (and ≥ 5 years after PPSV23) Wait ≥ 1 year*GIVE: PPSV23† GIVE: PCV13 if not previously given † (and ≥ 5 years after PPSV23) GIVE: PPSV23 GIVE: PCV13 if not previously given

≥ 1 year after PPSV23

GIVE: PPSV23† GIVE: PPSV23†

ADULTS ≥ 19GIVE: withPCV13 UNDERLYING MEDICAL CONDITIONS chart on back) GIVE:(see PPSV23 if not MEDICAL previously givenCONDITIONS (see chart ADULTS ≥ 19 with UNDERLYING on back) † OR who SMOKE or live in a NURSING HOME OR who SMOKE or live in a NURSING HOME ADULTS ≥Pneumococcal 19 with UNDERLYING CONDITIONS chart on back) Vaccination MEDICAL Previously vaccinated(see with one Pneumococcal Vaccination with HOME one Naive or Unknown History or Previously dose PPSV23 OR who SMOKE live in avaccinated NURSING Vaccination is NOT Naive or Unknown History dose PPSV23 Vaccination is NOTfor healthy persons indicated Pneumococcal Vaccination Previously vaccinated with one indicated for healthy 19 persons - 64 years of age GIVE: PPSV23 Naive or Unknown History dose PPSV23 Vaccination 19 - 64 yearsisofNOT age GIVE: PPSV23 indicated for healthy persons While PCV13 is FDA-approved for While PCV13 is FDA-approved persons > for 50 years, the Advisory 19 - 64 years of age GIVE: PPSV23 At Age ≥65 At Age ≥65 persons > 50 years,Committee the Advisoryon Immune Practices GIVE: PCV13 ≥ 1 ≥65 year after PPSV23 GIVE: PCV13 At Age At Age ≥65≥ 1year after PPSV23Committee on Immune doesPractices not provide guidance for use GIVE: PPSV23†

THEN: PPSV23 ≥ 1 year* after GIVE: PCV13 ≥ 1 year†after PPSV23 † ≥ 1 year* PCV13 ≥ 5 years after PPSV23 THEN: and PPSV23 after

At Age ≥65 PCV13 and ≥ 5 years after PPSV23

While PCV13 is FDA-approved for † ≥ 1 year* after THEN: PPSV23 GIVE: PCV13 ≥ 1year after PPSV23 this population. does not provide guidance forinuse persons > 50 years, the Advisory †≥1 PCV13 and ≥ year* 5 years THEN: PPSV23 afterafter PPSV23 in this population.

AtPCV13 Age and ≥65 ≥ 5 years after PPSV23

Committee on Immune Practices

VE: PCV13 ≥ 1 year after PPSV23 GIVE: PCV13 ≥ 1year after PPSV23 does not provide guidance for use † ≥ 1 year* after ADULTS IMMUNE COMPROMISING CONDITIONS (see chart on back), OR ASPLEN after ≥ 19 withTHEN: THEN: PPSV23† ≥ 1 year* PPSV23 in this population. CV13 and ≥ 5 years after PPSV23 PCV13 and ≥ 5 years after PPSV23 ADULTS ≥ 19sickle with IMMUNE COMPROMISING CONDITIONSFLUID (see chart on back), OR ASPLENIA (including cell anemia), CEREBROSPINAL LEAK, or COCHLEAR IMPLANT

(including sickle cell anemia), CEREBROSPINAL FLUID LEAK, or COCHLEAR IMPLANT Pneumococcal Vaccination Previously vaccinated with Previously vaccinated with one ADULTS ≥ 19 with IMMUNE COMPROMISING CONDITIONS (see chart on back),two ORdoses ASPLENIA Naive or Unknown History Pneumococcal Vaccination Previously vaccinated with of PPSV23 dose PPSV23 Previously vaccinated with one (including sickle cell CEREBROSPINAL IMPLANT Naive or anemia), Unknown History two doses of PPSV23 doseFLUID PPSV23LEAK, or COCHLEAR GIVE: PCV13

≥ 1 year after PPSV23

Pneumococcal Vaccination Previously vaccinated with vaccinated withPPSV23 one ≥ 1 year after GIVE: PCV13 Previously ≥8 weeks* later GIVE: PCV13 if not previously given ≥ 1 year after PPSV23 Naive or Unknown History two doses of PPSV23 dose PPSV23

≥8 weeks* laterIf ≥65 GIVE: PCV13 if not previously given ≥ 1 year after PPSV23 ≥8 weeks* later If ≥65 ≥ 1 year after PPSV23 ≥8 weeks* later GIVE: PCV13 if not previously given If ≥65 GIVE: PPSV23 If < 65 and ≥8 weeks* later GIVE: PCV13 if not≥previously given 5 years after ≥ GIVE: 1 year afterif not PPSV23 PCV13 previously given If ≥65 If < 65 and If < 65 and PPSV23 ≥ after ≥ 5 years after If5 years ≥65 If < 65 GIVE: second If PPSV23 < 65 and ≥8 weeks* later PPSV23 VE: PPSV23 ≥ 5 years after PPSV23 § GIVE: second GIVE: second PPSV23 GIVE: PCV13 if not previously given If < 65 and PPSV23 § If ≥65 PPSV23 § GIVE: second ≥ 5 years after < 65 and PPSV23 § PPSV23 ≥ 5 years after GIVE: second At Age ≥ 65 At Age ≥65 At Age ≥65 PPSV23 GIVE: PPSV23† GIVE:PPSV23 PPSV23†§ GIVE: PPSV23† ≥ 8 weeks* after † GIVE: PPSV23 GIVE: PPSV23† VE: second ≥5 years after At Age ≥ 65 At ≥Age 5 years≥65 after At Age ≥65 ≥ 5 years afterGIVE: PPSV23† PCV13 and ≥ 5 years after PPSV23 GIVE: PPSV23† PPSV23GIVE: PPSV23 PPSV23 § † ≥ 8 weeks* after † PPSV23 PPSV23 GIVE: PPSV23† GIVE: PPSV23 ≥5 years after ≥ 5 years after ≥ 5 years after PCV13 and ≥ 5 years after PPSV23 PPSV23 PPSV23 PPSV23 interval between sequential administration of PCV13 and PPSV23 is 8 weeks in immunocompromised patients. GIVE: PPSV23 At Age ≥ 65 Age ≥65 * Minimum At Age ≥65 † interval must be 11 full months. Please referGIVE: For Medicare reimbursement to page 4.PPSV23† GIVE: PPSV23 GIVE: PPSV23† ≥ 8 weeks* after † E: PPSV23† † The GIVE: PPSV23 ACIPinterval (Advisory Committee on Immunization Practices) recommends 1 dose after of PPSV23 at age ≥65. Revaccination is not necessary. Minimum between sequential of PCV13 and PPSV23 years is 8 weeks≥5 inonly immunocompromised patients. GIVE: PPSV23 administration * ≥ 5 years after ≥ 5 yearsfluid after § A second PPSV23 for patients with cerebrospinal PCV13 and ≥ 5 years after PPSV23 leak, is not required. For Medicare reimbursement interval must be 11 full months. Please referortocochlear page 4. implant PPSV23 ®23) PPSV23 PPSV23 † The ACIP (Advisory Committee PPSV23=23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax on Immunization Practices) recommends only 1 dose of PPSV23 at age ≥65. Revaccination is not necessary.

If < 65

GIVE: GIVE: PCV13 If <PPSV23 65

®) is not required. § A second PPSV23 for PCV13=13-Valent Pneumococcal Conjugate fluid Vaccine patients with cerebrospinal leak, (Prevnar or cochlear13 implant PPSV23=23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax®23) ® m interval between sequential administration of PCV13 and PPSV23 8 weeks PCV13=13-Valent Pneumococcal Conjugate Vaccine is (Prevnar 13 in ) immunocompromised patients. GIVE: PPSV23 dicare reimbursement interval must be 11 full months. Please refer to page 4. IP (Advisory Committee on Immunization Practices) recommends only 1 dose of PPSV23 at age ≥65. Revaccination is not necessary. nd PPSV23 for patients with cerebrospinal fluid leak, or cochlear implant is not required. =23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax®23) 13-Valent Pneumococcal Conjugate Vaccine (Prevnar 13®)

At Age ≥ 65

AtAge Age≥≥65 GIVE: PPSV23† † V23 At 65 † after †PPSV23 GIVE: PPSV23 ≥ 8≥65 weeks* At Age GIVE: GIVE: PPSV23 † ≥5 years after † V23 † GIVE: PPSV23 ≥ 8 weeks* after ≥ 5years years after PCV13 and ≥5 after†PPSV23 GIVE: PPSV23 ≥5PPSV23 years after ≥PPSV23 5years years after PCV13 and ≥ 5 after PPSV23 PPSV23 PPSV23

Pneumococcal Vaccine

At Age ≥ 65

At Age 65 † ≥≥ GIVE: PPSV23 8 weeks* after † ≥ 8 after GIVE: and PPSV23 weeks* after PCV13 ≥ 5 years PPSV2 PCV13 and ≥ 5 years after PPSV2

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TT DDEEPPAARR

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COLLEGE OF PHARMACY

Adults ≥19 Years ≥65. Revaccination is not necessary. COLLEGE OF 1-4 M na>on Informa>on Sh cina>on Informa>on S M E® ®23) Adults ≥19 Years (Including updated recommendations for the use of PCV13 in Adults) PHARMACY leak,(Pneumovax or cochlear OF F is not required. E implant e fluid Vaccine ®23) NN23) cina>on Informa>on TT O (Including updated recommendations for the use of PCV13 in Adults) PSV23 (Pneumovax® 23) 23 (Pneumovax® 23) M ® DRUG INFORMATION DRUG INFORMATION SERVICES SERVICES 401-874-9188 401-874-9188 DRUG INFORMATION © SERVICES 2014 Rhode Island Board of 401-874-9188

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Healthy Adults ≥ 65vaccinated with ®23) Pneumococcal Vaccination Previously

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®23)

Ho GIVE: PCV13 Persons with normal Cigarette smoker GIVE: PCV13 if not previously given PPSV23 ≥ 1 year after PPSV23 ≥ 1✓year after Pr immune function (1 Wait ≥ 1 year* GIVE: PCV13 Chronic heart disease† ✓ Wait ≥ 1 year* GIVE: PCV13 if not previously given ≥ 1 year after PPSV23 (and ≥ 5 years after PPSV23) e St Chronic lung disease§ ✓ e Wait ≥ 1 year* Re Wait ≥ 1 year*GIVE: PPSV23† e † GIVE: PPSV23 GIVE: PCV13 if not previously given ✓ Diabetes mellitus St (and ≥ 5 years after PPSV23) PSV23 (Pneumovax® 23)

cina>on Informa>on cina>on Informa>on cina>on Informa>on

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HealthCare www.unitedhea

persons > 50 years, the Advisory (PleasePCV13 refer to reference and 3≥for5 years after PPSV23 PCV13 and ≥ 5 years after PPSV23 Department of Health State www.bcbsri.com/providers RI www.bcbsri.com/provid HIV infection Insurance Carrie ✓ ✓ on Immune Practices ✓ At Agespecific ≥65 At Age ≥65 guidance.) Committee Department of Health State ®23) RI www.bcbsri.com/provid e Department of Health State E: PCV13 ≥ 1 year afterwww.health.ri.gov/reso PPSV23 GIVE: PCV13 ≥ 1year after PPSV23 does not provide guidance for use cina>on Informa>on

e Medicare www.medicaren renal failure ✓ (see chart on✓back), OR ASPLEN HealthCare www.unitedheal althCare www.unitedhealth www.health.ri.gov/reso † ≥ 1 year* after ✓ CONDITIONS ADULTS withTHEN: IMMUNE COMPROMISING e PPSV23† ≥ 1 year* after ≥ 19 Chronic THEN: PPSV23 in this population. www.health.ri.gov/reso PSV23 (Pneumovax® 23) are Part B reimburses for both the c HealthCare www.unitedhea V13 and ≥ 5 years after PPSV23 Contraindica>ons PCV13 and ≥ 5 years after PPSV23 (including sickle cell anemia), CEREBROSPINAL FLUID LEAK, or COCHLEAR IMPLANT Nephrotic syndrome ✓ ✓ ✓

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For Department of Health State neumococcal Vaccination Previously vaccinated with V13 to pa@ents who have a h PCV13 to pa@ents who have a Previously vaccinated with one Insurance Carrie y a dose of PPSV23 at least 8 d PCV13 simultaneously. For Insurance Carrie ≥8 weeks* later malignancy e GIVE: PCV13 if not previously given PCV13 to pa@ents who have Generalized ✓ ✓ ✓ after PPSV23 y a dose of PPSV23 at least 8 ≥ 1 year Naive or Medicare www.medicaren Unknown History two doses of PPSV23 13, PPSV, or one of their com PPSV, or one of their compo www.health.ri.gov/reso dose PPSV23 SV23. y a dose of PPSV23 at least 8 Medicare www.medicaren 13, PPSV, or one of their com If ≥65 SV23. If < 65 Medicare www.medicaren are Part B reimburses for both the c latrogenic immunosuppression** ≥8 weeks* SV23. are Part B reimburses for both the c ✓ later ✓ ✓ ≥ 1 year after PPSV23 d PCV13 simultaneously. For CV13 simultaneously. For pa@ GIVE: PPSV23 Contraindica>ons GIVE: PCV13 both inac@vated vaccines. Yo are Part B reimburses for both the c (Both high and low level immunosuppression) d PCV13 simultaneously. For Insurance Carrie both inac@vated vaccines. Yo GIVE: PCV13 if not previously given y a dose of PPSV23 at least 8 dose of PPSV23 at least 8 we If ≥65 If < 65 and f the person is a candidate fo RI www.bcbsri.com/provid both inac@vated vaccines. Yo ≥8 weeks* later e PCV13 to pa@ents who have GIVE: PCV13 if not≥previously given ✓ 5 years after RI www.bcbsri.com/provid y a dose of PPSV23 at least 8 Solid organ transplant ✓ ≥ 1✓year after PPSV23 f the person is a candidate fo 23. SV23. RI www.bcbsri.com/provid weeks and then give MCV4-‐D If < 65 and Medicare www.medicaren f the person is a candidate fo PPSV23 13, PPSV, or one of their com ≥ after SV23. If5 years ≥65 weeks and then give MCV4-‐D HealthCare www.unitedhea If < 65 Multiple myeloma ✓ ✓ ✓ GIVE: second annot give PCV13 and PPSV2 are Part B reimburses for both the c HealthCare www.unitedhea ≥8 weeks* later weeks and then give MCV4-‐D PPSV23 th inac@vated vaccines. You c both inac@vated vaccines. Yo HealthCare www.unitedhea E: PPSV23 PPSV23 § annot give PCV13 and PPSV2 GIVE: second d PCV13 simultaneously. For Insurance Carrie both inac@vated vaccines. Yo Hematopoietic stem cell transplant Please refer to reference 3 for specific guidance annot give PCV13 and PPSV2 Department of Health State he person is a candidate for M f the person is a candidate fo GIVE: PCV13 if not previously given Side Eff If ≥65 e If < 65 and PPSV23 § Department of Health State RI www.bcbsri.com/provid y a dose of PPSV23 at least 8 Department of Health State f the person is a candidate fo ≥ 5 years after Side Eff † Including congestive heart failure and cardiomyopathies, excluding hypertension. eeks and then give MCV4-‐D. I weeks and then give MCV4-‐D www.health.ri.gov/reso Medicare www.medicaren < 65 and Side Eff £ If feasible, www.health.ri.gov/reso SV23. administer PCV13 and PPSV23 ≥ 2 weeks before planned cochlear implant surgery at appropriate intervals as described in the algorithm on the front page. PPSV23 weeks and then give MCV4-‐D ects from either PPSV23 or PC www.health.ri.gov/reso 5 years after are Part B reimburses for both the c not give PCV13 and PPSV23 s annot give PCV13 and PPSV2 HealthCare www.unitedhea ∞ For PPSV23 naive patients planning splenectomy: Givesecond PCV13; wait at least 8 weeks then give PPSV23. Do not give PPSV23 within 2 weeks of planned splenectomy. GIVE: At Age ≥ 65 ects from either PPSV23 or PC At Age ≥65 pulmonary At Age ≥65 Contraindica>ons PPSV23 annot give PCV13 and PPSV2 § Including chronic obstructive disease,PPSV23 emphysema, and GIVE: PPSV23† †§ asthma. GIVE: Insurance Carrie ects from either PPSV23 or PC † ≥ 8 weeks* after PPSV23 both inac@vated vaccines. Yo GIVE: PPSV23 † Contraindica>ons † GIVE: PPSV23 ¶ Includes B(humoral) or T-lymphocyte deficiency, complement deficiencies (particularly C1, C2, C3, and C4 deficiencies), and phagocytic disorders (excluding chronic granulomatous disease). GIVE: PPSV23 VE: second Contraindica>ons ≥5 years after Side Effe Side Eff Department of Health State ≥ 5 yearstreatment after ≥ 5 years after RI www.bcbsri.com/provid ** Those requiring with immunosuppressive drugs, including long-term systemic corticosteroids and radiation. PCV13 and ≥ 5 years after PPSV23 § f the person is a candidate fo PCV13 to pa@ents who have PPSV23 PPSV23 Side Eff ma>on Services 401-‐874-‐918 Medicare www.medicaren PPSV23 PPSV23 PCV13 to pa@ents who have REFERENCES: www.health.ri.gov/reso PCV13 to pa@ents who have ma>on Services 401-‐874-‐918 weeks and then give MCV4-‐D 13, PPSV, or one of their com ects from either PPSV23 or PC s from either PPSV23 or PCV1 1. Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC. Advisory Committee on Immunization Practices (ACIP) are Part B reimburses for both the c HealthCare www.unitedhea 13, PPSV, or one of their com ma>on Services 401-‐874-‐918 c@on Coali@on (www.immunize.org) in coll Recommended Immunization Schedules for Persons Aged 0 Through 18 years and Adults Aged 19 Years and Older - United States, 2013. 13, PPSV, or one of their com ects from either PPSV23 or PC annot give PCV13 and PPSV2 September 4, 2013. MMWR 2012; 61(40):8 c@on Coali@on (www.immunize.org) in coll Insurance Carrie Minimum interval between sequential administration of PCV13 and MMWR Morb Mortal Wkly Rep. 2013;62(Suppl):9-19. PPSV23 is 8 weeks in immunocompromised patients. Contraindica>ons GIVE: PPSV23 At Age ≥65 * At Age ≥ 65 Age ≥65 d PCV13 simultaneously. For c@on Coali@on (www.immunize.org) in coll † GIVE: PPSV23 September 4, 2013. MMWR 2012; 61(40):8 2. For CDC. Use ofPPSV23 13-valent pneumococcal conjugate vaccine 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: † interval Department of Health State Medicare reimbursement must be 11 fulland months. Please refer to page 4. GIVE: RI www.bcbsri.com/provid d PCV13 simultaneously. For † ≥ 8 weeks* after GIVE: PPSV23necessary. † (ACIP). MMWR September 4, 2013. MMWR 2012; 61(40):8 E: PPSV23† † The GIVE: PPSV23 d PCV13 simultaneously. For recommendations of theCommittee Advisory Committee on Immunization Practices Morb Mortal Rep. 2012;61(40):816-819. ACIP (Advisory on Immunization Practices) recommends only 1 dose of Wkly PPSV23 at age ≥65. Revaccination is not ≥5 years after y a dose of PPSV23 at least 8 Side Eff ma>on Services 401-‐874-‐918 >on Services 401-‐874-‐9188 PCV13 to pa@ents who have 5 years after Medicare www.medicaren ≥vaccine 5 yearsand after § y a dose of PPSV23 at least 8 www.health.ri.gov/reso PCV13 and ≥ 5 years after PPSV23 3. ACDC. Use PPSV23 of 13-valentforpneumococcal conjugate 23-valent polysaccharide vaccine among adults aged ≥ 19 years: Recommendations of the Advisory second patients with cerebrospinal fluid leak, orpneumococcal cochlear implant is not required. PPSV23 ma>on Services 401-‐874-‐918 y a dose of PPSV23 at least 8 are Part B reimburses for both the c SV23. ®23) Committee on Immunization Practices (ACIP). MMWR Morb Mortal (Pneumovax Wkly Rep. 2014;63(37):822-825. HealthCare www.unitedhea PPSV23 PPSV23 PPSV23=23-Valent Pneumococcal Polysaccharide Vaccine 13, PPSV, or one of their com n Coali@on (www.immunize.org) in collabor c@on Coali@on (www.immunize.org) in coll SV23. 4. Kobayashi M, Bennett NM, Gierke R,Conjugate et al. Intervals between(Prevnar PCV13 and PPSV23 vaccines: Recommendations of the Advisory Committee in Immunization Practice (ACIP) © 2014 Rhode Island Board of Educat ects from either PPSV23 or PC SV23. PCV13=13-Valent Pneumococcal Vaccine 13® ) tember 4, 2013. MMWR 2012; 61(40):816-‐8 September 4, 2013. MMWR 2012; 61(40):8 c@on Coali@on (www.immunize.org) in coll MMWR Morb Mortal Wkly Rep.Contraindica>ons 2015; 64(34): 944-947. both inac@vated vaccines. Yo September 4, 2013. MMWR 2012; 61(40):8 Department of Health State d PCV13 simultaneously. For 5. Rubinadministration LG, Levin MJ, Davies EG, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58:e44-e100. doi: 10.1093/cid/cit684. both inac@vated vaccines. Yo m RI www.bcbsri.com/provid interval between sequential of PCV13 and PPSV23 is 8 weeks in immunocompromised patients. GIVE: PPSV23 both inac@vated vaccines. Yo f the person is a candidate fo PCV13 to pa@ents who have y a dose of PPSV23 at least 8 icare reimbursement interval mustwww.health.ri.gov/reso be 11 full months. Please refer to page 4. f the person is a candidate fo ma>on Services 401-‐874-‐918 f the person is a candidate fo P (Advisory Committee on Immunization Practices) recommends only 1 dose of PPSV23 at age ≥65. Revaccination is not necessary. HealthCare www.unitedhea PAGE 33 weeks and then give MCV4-‐D 13, PPSV, or one of their com SV23. weeks and then give MCV4-‐D d PPSV23 for patients with cerebrospinal fluid leak, or cochlear implant is not required. weeks and then give MCV4-‐D Contraindica>ons c@on Coali@on (www.immunize.org) in coll annot give PCV13 and PPSV2 23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax®23) annot give PCV13 and PPSV2 Department of Health State September 4, 2013. MMWR 2012; 61(40):8 d PCV13 simultaneously. For © 2014 Rhode Island Board of Education both inac@vated vaccines. Yo annot give PCV13 and PPSV2 3-Valent Pneumococcal Conjugate Vaccine (Prevnar 13®) PCV13 to pa@ents who have y a dose of PPSV23 at least 8 www.health.ri.gov/reso Side Eff f the person is a candidate fo Side Eff 13, PPSV, or one of their com Side Eff

Pneumococcal Vaccine Pneumococcal Vaccination Information Sheet PCV13 (Prevnar 13®) and PPSV23 (Pneumovax® 23)

COLLEGE OF PHARMACY

Facts About Pneumococcal Disease: • Streptococcus pneumoniae bacteria (i.e., pneumococci) are usually found in the upper respiratory tract of most people. • Pneumococcal disease most commonly presents as a serious infection in the lungs (pneumonia), blood (bacteremia), or brain (meningitis). The annual U.S. case estimate for invasive pneumococcal disease (bacteremia and/or meningitis) is 40,000 and 4,250 deaths. • Pneumococcal disease most often occurs in older people as well as in people with a predisposing condition (e.g., immunosuppression, pulmonary disease, heart disease, diabetes). The disease rates for adults in these groups can be more than 20 times those for adults without high-risk medical conditions. • PPSV23 is 60–70% effective in preventing serious pneumococcal disease; it does not provide substantial protection against all types of pneumonia (viral and bacterial). It is not a “pneumonia” vaccine.

Frequently Asked Questions: Question: Can I get the influenza and pneumococcal vaccines at the same time? Yes. These vaccines can be given at the same time. If giving two IM vaccinations, separate by one inch in the body muscle to reduce likelihood of local reactions overlapping. Question: If patients who are in a recommended risk group for PPSV23 or PCV13 aren’t sure if they have previously received these vaccines, should healthcare providers vaccinate them? Yes. If patients do not have a documented vaccination history for these two vaccines and their records are not readily obtainable, you should administer the recommended doses. Extra doses will not cause harm to the patient. Question: Is an egg allergy a contraindication for PCV13 or PPSV23? No. Both vaccinations are safe for persons with egg allergies. Question: If my state has a registry, do I still need to give patients vaccine record cards? Yes. Patient-held cards are an extremely important part of a person’s medical history. The person may move to an area without a registry, and a personal record may be the only vaccination record available. In addition, even within a state, all healthcare providers may not participate in the registry, and the personal record card would be needed. Question: My patient has had laboratory-confirmed pneumococcal pneumonia. Does he/she still need to be vaccinated with PPSV23? Yes. There are more than 90 known serotypes of pneumococcus (23 serotypes are in the current vaccine). Infection with one serotype does not necessarily produce immunity to other serotypes. As a result, if the person is a candidate for vaccination, he/she should receive it even after one or more episodes of invasive pneumococcal disease. Question: Why is pneumococcal vaccination recommended for smokers and asthmatics? In 2008, the Advisory Committee on Immunization Practices (ACIP) reviewed new information that suggests that asthma is an independent risk factor for pneumococcal disease among adults. ACIP also reviewed new information that demonstrates an increased risk of pneumococcal disease among smokers. Consequently, ACIP recommends to include both asthma and cigarette smoking as risk factors for pneumococcal disease among adults age 19 through 64 years and as indications for PPSV23. Acquired from www.immunize.org on September 4, 2013. We thank the Immunization Action Coalition. MMWR Morb Mortal Wkly Rep 2012; 61(40):816-819.

PAGE 34

Pneumococcal Vaccine Pneumococcal Vaccination Information Sheet PCV13 (Prevnar 13®) and PPSV23 (Pneumovax® 23)

PPSV23

(Pneumovax®23)

COLLEGE OF PHARMACY

PCV13

Manufacturer: Merck www.merckvaccines.com/Products/Pneumovax/Pages/home

How Supplied:

(Prevnar13®)

Manufacturer: Pfizer http://www.pfizerpro.com/hcp/prevnar13

How Supplied:

0.5mL Single Dose Vial Multi-Dose (5 dose Vial)

Prefilled Syringe (10 per Package)

Storage and Handling:

Refrigerate on Arrival Store at 2◦C to 8◦C DO NOT FREEZE Discard after the expiration date

Special instructions:

None

Shake well to obtain a homogeneous white suspension

Route of Administration:

0.5mL IM or SQ

0.5mL IM ONLY

Insurance Carrier Information: Medicare www.medicarenhic.com 1-866-801-5304* BCBS of RI www.bcbsri.com/providers 401-274-4848 1-800-230-9050 UnitedHealthCare www.unitedhealthcareonline.com 1-877-842-3210 RI Department of Health State Supplied Vaccination Program www.health.ri.gov/resources/immunization/

Contraindications and Precautions: • Do not give PPSV23 or PCV13 to patients who have a history of a serious reaction (e.g., anaphylaxis) after a previous dose of PCV13, PPSV23, or one of their components. • Do not give PPSV23 and PCV13 simultaneously. For vaccine naive patients, give PCV13 first, followed by a dose of PPSV23 ≥ 1 year† (unless patient in a population specified by ACIP to require shorter interval, see page 1). For patients who have already received PPSV23, give PCV13 12 months after the most recent dose of PPSV23. • Vaccine Co-administration: (1) all vaccines used for routine vaccination in the United States can be given on the same day; (2) an inactivated vaccine can be administered either on the same day as or at any time before or after another inactivated or a live vaccine; and (3) any 2 LIVE vaccines that are not given on the same day must be spaced at least 4 weeks apart. Zoster vaccine is a live, attenuated vaccine; injectable influenza vaccine and pneumococcal polysaccharide vaccine are inactivated vaccines. So these 3 vaccines can be given on the same day or at any time before or after each other. They should be given as separate injections, not combined in the same syringe.

Side Effects: • Most common side effects from either PPSV23 or PCV13 are soreness and redness at the injection site, lasting 1-2 days. Drug Information Services 401-874-9188

Monday-Friday 8:30 am - 4:00 pm EST

initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second * An pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered). Please note that the “interval” between the two different pneumococcal vaccines must be at least 11 full months or greater for Medicare reimbursement, not the shorter “interval” recommended for specific populations identified by ACIP. Acquired from www.immunize.org on September 4, 2013. We thank the Immunization Action Coalition.

† Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines: Recommendations of the Advisory Committee in Immunization Practice (ACIP) MMWR Morb Mortal Wkly Rep. 2015; 64(34): 944-947.

PAGE 35

Individual Isolates Cefotaxime

Streptococcus pneumoniae 75

52 100

7 86

100

Moxifloxacin 98

100

10 0 100

*If < 30 isolates use caution extrapolating results; data may be inconclusive for therapeutic efficacy and selection of empiric treatment.

Staphylococcus epidermidis

100

Chloramphenicol

111

Clindamycin 72

100

Oxacillin

100

Penicillin G

124

Erythromycin

Sulfamethoxazole /Trimethoprim

Staphylococcus aureus (MSSA) Staphylococcus aureus, Methicillin-resistant (MRSA)

Ampicillin

Ciprofloxacin

Enterococcus faecium

Gentamicin 73

Nitrofurantoin

Tetracycline

Streptomycin

126

Vancomycin

Enterococcus fecalis

Inpatient/Outpatient Isolates 2015

Gram Positive Organisms:

Percent Susceptible (2015 Isolates)

â&#x20AC;&#x201A;Antibiogram

PAGE 36

Amikacin

Individual Isolates 71

100

109

Proteus mirabilis Pseudomonas aeruginosa Serratia marcescens

Stenotrophomonas maltophilia

100 100

100

100 37

100 97

100 26

100 100 83

100 93

100 100

100

*If < 30 isolates use caution extrapolating results; data may be inconclusive for therapeutic efficacy and selection of empiric treatment.

100

28*

Klebsiella oxytoca

100

Haemophilus influenzae 25*

100

Morganella morganii 7

14*

Klebsiella pneumoniae 78

246 100

100

Escherichia coli

Enterobacter cloacae 10

Ampicillin

Cefazolin 0

Ceftriaxone

100

Aztreonam 78

Cefuroxime

Enterobacter aerogenes 12* 100

Ampicillin /Sulbactam 33

Nitrofurantoin

100

Piperacillin/ tazobactam

100

Cefepime

Cefotaxime

Citrobacter freundii

Ceftazidime 83

Ciprofloxacin

Gentamicin

Imipenem

Tetracycline

100

Sulfamethoxazole /Trimethoprim

14*

100

Tobramycin

Acinetobacter baumanni

Inpatient/Outpatient Isolates 2015

Gram Negative Organisms:

Percent Susceptible (2015 Isolates)

â&#x20AC;&#x201A;Antibiogram

PAGE 37

Guidelines for for Restricted Antimicrobials Guidelines Restricted Antimicrobials I.            

  II.

The use of the following formulary antimicrobial agents are restricted Antibiotics Ceftaroline (Teflaro®) Ceftazidime/avibactam (Avycaz®) Ceftolozane/tazobactam (Zerbaxa®) Colistin (Polymyxin E) Dalbavancin (Dalvance®) Daptomycin (Cubicin®) Ertapenem (Invanz®) Fidaxomicin (Dificid®) Fosfomycin (Monurol®) Linezolid (Zyvox®) Oritavancin (Orbactiv®) Polymyxins Polymyxin B Colistin (Polymyxin E) Tedizolid (Sivextro®) Tigecycline (Tygacil®)

   

Antifungals Amphotericin B lipid complex (AmBisome®) Caspofungin (Cancidas ®) Isavuconazonium sulfate (Cresemba®) Voriconazole (V-Fend®)

To ensure the rational use of formulary, restricted, or non-formulary antimicrobial agents, the following policies and procedures are to be used:

When a prescriber wishes to prescribe a restricted or non-formulary antimicrobial agent, he/she shall indicate the “approved” reason (see following pages) in the comments section of the order form. If the use is outside of an approved indication, the physician MUST obtain approval of use. This approval must be obtained from the Infectious Diseases consult team, by directly contacting the on-call Infectious Diseases physician/fellow or by calling the Department of Medicine who will contact the on-call Infectious Diseases physician/fellow.

When pharmacy receives an order for a restricted antimicrobial agent, the pharmacist will verify the “approved” reason for use and if applicable, fill the order. If the pharmacy receives an order for a restricted or non-formulary antimicrobial agent and the ordering box does not indicate an approved reason for use, the pharmacist will immediately contact the prescriber to obtain “criteria for use of a restricted agent.”

If the prescriber cannot be reached, the pharmacist will dispense a maximum 24 hour supply of the drug. The pharmacist MUST notify the prescriber that the further drug will be dispensed only when the completed order form or ID approval is received. It is up to the prescriber to obtain authorization from the Infectious Diseases fellow or Infectious Diseases consult team.

PAGE 38

Ceftaroline (Teflaro®) Ceftaroline (Teflaro®) IV Only

Use requires formal ID Consult

Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus pneumoniae, most gram-negatives, and some gram-positive anaerobic bacteria NOT ACTIVE against Pseudomonas spp., Acinetobacter spp., or Enterococcus spp. Criteria for Use:  Acute bacterial skin and skin structure infection (ABSSSI) caused by MRSA +/bacteremia or community-acquired bacterial pneumonia (CABP)  Unable to use vancomycin (VAN; due to intolerance, MIC ≥ 2 mg/mL, or infection unresponsive to VAN despite therapeutic concentrations)  Unable to use other agents (refer to empiric therapy for ABSSSI/CABP) Unacceptable Uses:  Treatment of P. aeruginosa, Enterococcus spp., or Acinetobacter spp. Infections (limited to no activity)  Treatment of ESBL producing organisms, such as E. coli or Klebsiella spp. (inactivated by AmpC and ESBL beta-lactamases)  Known serious hypersensitivity to ceftaroline or other members of the cephalosporin class. Cross-reactivity may occur in patients with a history of other beta-lactam allergies Dosing in Adults:  Standard dose: 600 mg IV Q12H For MSSA/MRSA bacteremia consider: 600 mg IV Q8H  Renal dose adjustment: CrCl 30-50 mL/min: 400 mg IV Q12H CrCl 15-30 mL/min: 300 mg IV Q12H CrCl <15 mL/min: 200 mg IV Q12H Hemodialysis: 200 mg IV Q12H  All infusions should be over 1 hour  No hepatic dose adjustment Monitoring:  Monitor CBC for drug-induced hemolytic anemia (none observed in studies, but seroconversion from negative to positive Direct Coombs’ Test is observed in 10.8% on ceftaroline vs 4.4% on comparator) ABSSSI= Acute bacterial skin and skin structure infection; CABP= community-acquired bacterial pneumonia; CBC= Complete blood count; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= infectious diseases; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; Q= every; spp= Species; VAN= vancomycin

PAGE 39

Ceftazidime/avibactam Ceftazidime/avibactam (Avycaz®)(Avycaz®) IV Only

Use requires formal ID Consult

Use reserved for patients who have limited or no alternative treatment options since it was approved based upon limited clinical safety and efficacy data Activity: Coverage against many resistant gram-negatives such as Enterobacteriaceae and Pseudomonas aeruginosa, including some ESBL producers (e.g. CTX-M), carbapenemases (e.g. KPC, some OXA ), and AmpCs NOT ACTIVE against MBLs or gram-negatives that overexpress efflux pumps or have porin mutations, and most anaerobic bacteria Criteria for Use:  Treatment of cIAI (in combination with metronidazole) or cUTI, including pyelonephritis, caused by MDR gram-negative organisms Unacceptable Uses:  Empiric use without confirmed susceptibility  Treatment of cIAI and cUTI with other available treatment options  Known serious hypersensitivity to the components of ceftazidime/avibactam, avibactam-containing products, or other members of the cephalosporin class. Cross-reactivity may occur in patients with a history of penicillin allergy Dosing in Adults:  Standard dose: 2.5gm IV Q8H For cIAI must use in combination with metronidazole  Renal dose adjustment: CrCl 31 - 50 mL/min: 1.25gm IV Q8H CrCl 16-30 mL/min: 0.94gm IVQ12H CrCl 6-15 mL/min: 0.94gm IV Q24H CrCl <5 mL/min: 0.94gm IV Q48H Administer after hemodialysis  No hepatic dose adjustment anticipated Monitoring:  Scr/BUN at baseline and daily; adjust dose accordingly. CBC with differential. Monitor for signs of anaphylaxis with first dose Considerations for Use:  Decreased efficacy in patients with = CrCl 30-50 mL/min in clinical trials  CNS reactions have been reported in patients treated with ceftazidime, particularly in the setting of renal impairment BUN= blood urea nitrogen; CBC= Complete blood count; cIAI= Complicated intraabdominal infections; CNS= Central nervous system; CrCl= Creatinine clearance; cUTI= complicated urinary tract infections; ESBL= extended-spectrum beta-lactamases; H= hour(s); ID= infectious diseases; IV= Intravenous; KPC= Klebsiella pneumoniae carbapenemases; MBL= metallo-betalactamases; MDR= multi-drug resistant; Q= every; Scr= Serum creatinine

PAGE 40

Ceftolozane/tazobactam (Zerbaxa®) Ceftolozane/tazobactam (Zerbaxa®) IV Only

Use requires formal ID Consult

Activity: Coverage against many MDR gram-negatives such as Enterobacteriaceae and Pseudomonas aeruginosa. Potent in vitro activity against most P. aeruginosa isolates, including some MDR and carbapenem-resistant strains. Inhibits many Enterobacteriaceae, including some ESBL producers (e.g. CTX-M) and some AmpCs NOT ACTIVE against serine carbapenemases (e.g. KPCs or MBLs) Criteria for Use:  Treatment of cIAI (in combination with metronidazole) or cUTI, including pyelonephritis, caused by MDR gram-negative organisms Unacceptable Uses:  Empiric use without confirmed susceptibility  Treatment of cIAI and cUTI with other available treatment options  Known serious hypersensitivity to ceftolozane/tazobactam, piperacillin/tazobactam, or other members of the beta-lactam class Dosing in Adults:  Standard dose: 1500 mg IV Q8H For cIAI must use in combination with metronidazole  Renal dose adjustment: CrCl 30-50 mL/min: 750 mg IV Q8H CrCl 15-29 mL/min: 375 mg IV Q8H Hemodialysis: 750mg IV ONCE (load), then 150mg IV Q8H after dialysis  No hepatic dose adjustment anticipated Monitoring:  Scr/BUN, CBC with differential at baseline and daily Considerations for Use:  Package insert states decreased efficacy seen in patients with a baseline CrCl <50mL/min or patients >65 years of age, in the cIAI trial  May have a role in the treatment of other infections caused by multidrug resistant gram-negatives, however alternate dosing may be recommended depending on site of infection. ID team must be consulted for all potential on and off label use BUN= blood urea nitrogen; CBC= Complete blood count; cIAI= Complicated intraabdominal infections; CrCl= Creatinine clearance; cUTI= complicated urinary tract infections; ESBL= extended-spectrum beta-lactamases; ID= infectious disease; IV= Intravenous; KPC= Klebsiella pneumoniae carbapenemases; MBL= metallo-beta-lactamases; MDR= multi-drug resistant; Q= every; H= hour(s); Scr= Serum creatinine

PAGE 41

Dalbavancin (Dalvance®) Dalbavancin (Dalvance®) IV Only

Use requires formal ID Consult

Activity: Coverage against Staphylococcus aureus (including MSSA and MRSA), Streptococcus pyogenes, Streptococcus agalactiae (Group B Strep.) and Streptococcus anginosus group (including S. anginosus, S. intermedius, S. constellatus) No clinical data, but activity in vitro vs. Enterococcus faecalis (vancomycin-susceptible strains only), Enterococcus faecium (vancomycin-susceptible strains only), vancomycin-intermediate S. aureus (not vancomycin-resistant strains) Criteria for Use:  Treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible gram-positive isolates  Unable to use vancomycin (due to intolerance, MIC >2mg/L, or infection unresponsive to vancomycin despite therapeutic concentrations)  Unable to use other agents (refer to empiric therapy for ABSSSI) Unacceptable Uses:  Infections due to vancomycin-resistant enterococci  Contraindicated in patients with known hypersensitivity to dalbavancin. Due to the possibility of cross-reactivity to glycopeptide, avoid in patients with previous glycopeptide hypersensitivity due to long half-life Dosing in Adults:  Standard dose: Administration should be over 30 minutes 1 Dose Regimen: 1500mg IV once 2 Dose Regimen: 1000mg IV once, then 500mg IV on day 8  Renal dose adjustment: 1 Dose Regimen CrCl <30 mL/min 1125 mg IV 2 Dose Regimen CrCl <30 mL/min: 750mg IV once, then 325mg IV day 8 If receiving regularly scheduled hemodialysis: No dosage adjustment  No hepatic dose adjustment anticipated Monitoring:  Baseline BUN/Scr, AST/ALT/bili, CBC w/ diff, infusion-related reactions Considerations for Use:  In clinical trials, 6 (0.9%) patients in the dalbavancin arm had ALT elevations greater than 5x ULN including 3 with ALT >10x ULN. No subjects in the comparator arm had this degree of ALT elevations ABSSSI= acute bacterial skin and skin structure infections; ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; bili= Bilirubin; BUN= Blood urea nitrogen; CBC= Complete Blood Count; CrCl= Creatinine clearance; ID= infectious diseases; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; SCr= Serum creatinine; ULN= Upper Limit of Normal

PAGE 42

Daptomycin (Cubicin®) Daptomycin (Cubicin®) IV Only

Use requires formal ID Consult

Activity: Coverage against most gram-positive bacteria (including MRSA and VRE) NOT ACTIVE against gram-negative bacteria Criteria for Use:  MRSA bacteremia and/or endocarditis and unable to use vancomycin (due to intolerance, MIC ≥ 2 mg/L, or infection unresponsive to vancomycin despite therapeutic concentrations)  MRSA skin and skin structure infections in patients with true, serious allergic reaction to vancomycin or linezolid  Patients receiving vancomycin for > 72 h for resistant staphylococcal skin and skin structure infection without clinical improvement  VRE confirmed bacteremia (see dosing below, use high doses) Formal ID consult for use in osteomyelitis or complicated skin and soft tissue infection and all indications that are not listed above Unacceptable Uses:  Empiric therapy  Pneumonia (lung surfactant inactivates daptomycin) or any lower respiratory tract infection Dosing in Adults:  Standard dose: 6-10 mg/kg IV Q24H of actual body weight (ABW) May be dosed 8-10 mg/kg for Enterococcus (safety data for healthy volunteers up to 12 mg/kg/day)  Renal dose adjustment: CrCl < 30 mL/min: 8 mg/kg IV Q48H Hemodialysis: 8 mg/kg IV Q48H  No hepatic dose adjustment

Monitoring:  Obtain CPK at baseline and weekly. Monitor for muscle pain or weakness, and for signs/symptoms of eosinophilic pneumonia Considerations for Use:  Consider discontinuation of concurrent statin therapy while on daptomycin due to additive muscle toxicity ABW= Actual Body Weight; CPK= Creatine phosphokinase; CrCl= Creatinine clearance; H= hour(s); ID= Infectious Disease; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; VRE= Vancomycin-resistant enterococci

PAGE 43

Ertapenem (Invanz®) Ertapenem (Invanz®) IV and IM Only

Use requires formal ID Consult

Activity: Coverage against many gram-negatives (including those that produce ESBL), gram-positives, and anaerobes NOT ACTIVE against Pseudomonas spp., Acinetobacter spp., MRSA, or Enterococcus spp. Criteria for Use:  Outpatient treatment of community acquired infections; outpatient settings Unacceptable Uses:  Caution use of ertapenem in organisms producing AmpC beta-lactamase without testing the organisms specifically against ertapenem susceptibility  Contraindicated in patients with documented hypersensitivity to beta-lactams  Treatment of P. aeruginosa, Acinetobacter spp., MRSA, or Enterococcus spp. Infections Dosing in Adults:  Standard dose: 1 gm IV or IM Q24H  Renal dose adjustment: CrCl < 30 mL/min: 500 mg IV or IM Q24H Hemodialysis: 500 mg IV or IM Q24H; supplemental dose of 150 mg after dialysis if last 500 mg dose given within 6 hours prior to dialysis, no supplemental dose necessary if last 500 mg dose given at least 6 hours prior to dialysis  No hepatic dose adjustment Monitoring:  Fever, CBC, hepatic function, pulmonary function (in pneumonia) CBC= Complete blood count; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= Infectious Disease; IM= Intramuscular; IV= Intravenous; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; Spp= Species

PAGE 44

Fidaxomicin (Dificid®) Fidaxomicin (Dificid®) PO Only

Use requires formal ID Consult

Patients with multiple Clostridium difficile infection (CDI) recurrences (i.e. severe or mild-moderate CDI with greater than 2 and 3 recurrences, respectively) or severe, complicated CDI should obtain ID and/or GI consult for optimal therapy Criteria for Use:  Patient with severe CDI with a 2nd recurrence (previously received appropriate therapy [i.e., vancomycin 125 mg PO Q6H for initial and 1st recurrence]). Alternatively, a provider has the option to prescribe a vancomycin taper for a 2nd recurrence OR  Patients with mild-moderate CDI with a 3rd recurrence (previously received appropriate therapy i.e., vancomycin 125 mg PO Q6H for initial and 1st recurrence and then a vancomycin taper for the 2nd recurrence) Unacceptable Uses:  Treatment of systemic infections  Treatment of severe, complicated CDI (i.e., life-threatening or fulminant CDI or toxic megacolon)  Use in combination with PO vancomycin or PO metronidazole Dosing in Adults:  Standard dose: 200 mg PO Q12H for 10 days  No renal or hepatic dose adjustment  May be given with or without food; systemic absorption is minimal Considerations for Use:  Fidaxomicin was only studied in patients with an initial episode or 1st recurrence (defined as within 3 months of initial episode). Recurrence rates in both phase III studies were significantly lower in patients treated with fidaxomicin. However, in a subgroup analysis, recurrence rates were NOT significantly lower in fidaxomicin-treated patients who had the hypervirulent BI/NAP1/027 strain  The Society for Healthcare Epidemiology in America (SHEA) and Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for CDI recommend to discontinue therapy with the inciting antimicrobial as soon as possible, as this may influence the risk of CDI recurrence CDI= Clostridium difficile infection; FDA= Food and Drug Administration; GI= gastrointestinal; H= hour(s); ID= infectious diseases; IDSA= Infectious Diseases Society of America; PO= Oral; Q= every; SHEA= Society for Healthcare Epidemiology in America

PAGE 45

Fosfomycin (Monurol®) Fosfomycin (Monurol®) PO Only

Use requires formal ID Consult

Activity: Coverage against many gram-negatives (including ESBL-producing and carbapenem-resistant Enterobacteriaceae [such as E. coli, Klebsiella spp.]) and grampositives (including MRSA and VRE) NOT ACTIVE against Acinetobacter spp. In the United States only the oral formulation is available. Criteria for Use:  Management of uncomplicated UTI in patients with multiple antibiotic allergies and/or when no other oral therapy options are available  Uncomplicated UTI due to VRE  Salvage therapy for UTI due to multi-drug resistant organisms (e.g. ESBL, VRE, +/- Pseudomonas; confirm fosfomycin susceptibility prior to initiation of therapy) Unacceptable Uses:  Management of any infections outside of the urinary tract. Oral fosfomycin does not achieve adequate concentrations at other sites  Treatment of asymptomatic bacteriuria Dosing in Adults:  Standard dose: Uncomplicated UTI: 3 gm (1 sachet) PO once Complicated UTI: 3 gm (1 sachet) PO every 2 to 3 days (up to 21 days of treatment) Powder should be mixed with 90-120 mL of cool water, stirred to dissolve and administered immediately. May be administered with or without food  Renal dose adjustment: CrCl < 50 mL/min: Frequency adjustment may be necessary; contact antimicrobial stewardship team  No hepatic dose adjustment Monitoring:  Signs and symptoms of urinary tract infection CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; ID= Infectious Disease; MRSA= Methicillin-resistant Staphylococcus aureus; PO= Oral; Spp= Species; UTI= Urinary Tract Infection; VRE= Vancomycin-resistant enterococci

PAGE 46

Linezolid (Zyvox®) Linezolid (Zyvox®) IV and PO Only

Use requires formal ID Consult

Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus pneumoniae, VRE Criteria for Use:  Vancomycin (VAN) MIC ≥ 2 mg/L in MRSA pneumonia  Patient with allergy to beta-lactams/vancomycin and organism resistant to other antimicrobials  Significant VRE infections (i.e. isolated from a sterile site: blood, abscess)  Infections due to MRSA in patient with well documented intolerance to VAN (NOTE: Red man syndrome is not a serious intolerance to VAN) Formal ID consult for use in osteomyelitis or complicated skin and soft tissue infection and all indications that are not listed above Unacceptable Uses:  Empiric use when VRE has not been cultured or documented  Uncomplicated urinary tract infection  Positive respiratory culture for VRE  VRE colonization Dosing in Adults:  Standard dose: 600 mg PO or IV Q12H In patients tolerating PO medications, should be given orally Oral formulation is completely absorbed and has 100% availability  No renal or hepatic dose adjustment Monitoring:  CBC at baseline and weekly (MONITOR platelets at baseline and weekly) Considerations for Use:  Caution in patients with thrombocytopenia. 3 percent of patients were noted to have a platelet decrease <75% of baseline or lower limit of normal in controlled trials (therapy <28 days, most < 21 days. Thrombocytopenia is reversible upon discontinuation and is correlated with duration  Linezolid is a weak MAOI. Use in caution with decongestants (i.e. pseudoephedrine) and serotonergic agents (i.e. SSRIs [fluoxetine, escitalopram, sertraline, paroxetine, citalopram]) Warn patients to avoid large quantities of tyramine containing foods CBC= Complete blood count; H= hour(s); ID= infectious disease; IV= Intravenous; MAOI= Monoamine oxidase inhibitors; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; PO= Oral; Q= every; SSRI= serotonin-specific reuptake inhibitors; VAN= Vancomycin; VRE= Vancomycinresistant enterococci

PAGE 47

Oritavancin (Orbactiv®) Oritavancin (Orbactiv®) IV Only

Use requires formal ID Consult

Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae, Streptococcus anginosus group and vancomycin-susceptible Enterococcus faecalis No clinical data, but activity in vitro vs. vancomycin-resistant enterococci and vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus Criteria for Use:  Treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible gram-positive isolates  Unable to use vancomycin (due to intolerance, MIC >2, or infection unresponsive to vancomycin despite therapeutic concentrations)  Unable to use other agents (refer to empiric therapy for ABSSSI) Unacceptable Uses:  Patients with suspected osteomyelitis. If OM is suspected, alternative antibacterial therapy should be initiated  Contraindicated in patients with known hypersensitivity to oritavancin. Due to the possibility of cross-reactivity to glycopeptide, avoid in patients with previous glycopeptide hypersensitivity due to long half-life. Dosing in Adults:  Standard dose: 1200mg dose IV over 3 hours x1  No renal or hepatic dose adjustment Monitoring:  SCr/BUN, AST, ALT, bilirubin, infusion-related reactions (pruritus, urticaria, flushing), hypersensitivity reactions, signs/symptoms of OM Considerations for Use:  The use of unfractionated heparin is contraindicated for 48 hours after oritavancin administration due to artificial prolongation of aPTT  Co-administration of oritavancin and warfarin may result in higher exposure of warfarin, which may increase the risk of bleeding  Oritavancin can artificially prolong aPTT for up to 120 Hr, and may prolong PT and INR for up to 12 Hr and ACT for up to 24 Hrs ABSSSI= acute bacterial skin and skin structure infections; ACT= Activated clotting time; ALT= Alanine aminotransferase; aPTT= Activated partial thromboplastin time; AST= Aspartate aminotransferase; BUN= Blood urea nitrogen; ID= Infectious Disease; INR= International normalized ratio; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillinresistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; OM= osteomyelitis; PT= Prothrombin time; SCr= Serum creatinine

PAGE 48

Polymyxin Polymyxin B B IV Only

Use requires formal ID Consult

Polymyxin B and Colistin (also known as Polymyxin E or Colistimethate) are the two polymyxin antibiotics. Their spectrum of activity is similar. However, their pharmacology is very different. Polymyxin B is administered as the active drug and is not cleared renally. Colistin is a prodrug (Colistimethate sodium) and is cleared renally.

The product vials may be labeled as International Units (IU) or mg. To avoid major dosing errors, carefully read vial labels. Recommend that all doses be converted to mg. Conversion: 10,000 International Units = 1 mg Activity: Coverage against most gram-negatives, including many multi-drug resistant (MDR) Enterobacteriaceae (such as E. coli, Klebsiella spp.; including ESBL-producing and carbapenem-resistant Enterobacteriaceae), Pseudomonas spp., and Acinetobacter spp. NOT ACTIVE against Proteus, Serratia, Providencia, Burkholderia, Stenotrophomonas, gram-negative cocci, gram-positive organisms, or anaerobes Criteria for Use:  Treatment of infections due to MDR Enterobacteriaceae, Pseudomonas spp., and Acinetobacter spp. with no other treatment options Unacceptable Uses:  Empiric treatment of suspected gram-negative infections  Monotherapy for serious infections due to rapid resistance development  Treatment of UTIs. Colistin preferred over polymyxin B for UTIs Dosing in Adults: Optimal dosing regimens are not well established  Standard dose: 2.5 mg/kg IV as a 2 hr infusion ONCE (load), then 12 hours later start 1.5 mg/kg IV as a 1 hr IV infusion. Repeat Q12H  No renal or hepatic dose adjustment  Use actual body weight for dosing  Caution in use > maximum product recommended daily dose (300mg) Monitoring:  BUN/ SCr at baseline and at least twice weekly Considerations for Use:  The most important side effect of IV polymyxin B is nephrotoxicity (20-40% of patients); less frequently reported concerns include neurotoxicity and neuromuscular blockade  Recent literature suggests that nephrotoxicity rates may be lower with polymyxin B as compared to colistin BUN= Blood urea nitrogen; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= Infectious Diseases; IU= international Units; IV= Intravenous; MDR= multi-drug resistant; Q= every; SCr= Serum creatinine; spp= Species; UTI= Urinary tract infection

PAGE 49

Colistin (Polymyxin E or Colistimethate) Colistin (Polymyxin E or Colistimethate) IV Only

Use requires formal ID Consult

Colistin (also known as Polymyxin E or Colistimethate) and Polymyxin B are the two different polymyxin antibiotics. Colistin is a prodrug (Colistimethate sodium). The product vials may be labeled as International Units (IU) of prodrug, or mg of the active product: colistin base activity (CBA). To avoid major dosing errors, carefully read vial labels. Recommend that all doses be converted to mg of CBA. Conversion: 1,000,000 units of Colistimethate (prodrug) = 80 mg of Colistimethate (prodrug) = 30 mg of colistin base activity (CBA) Activity: Coverage against most gram-negatives, including many multi-drug resistant (MDR) Enterobacteriaceae (such as E. coli, Klebsiella spp.; including ESBL-producing and carbapenem-resistant Enterobacteriaceae), Pseudomonas spp., and Acinetobacter spp. NOT ACTIVE against Proteus spp., Serratia spp., Providencia spp, Burkholderia spp, Stenotrophomonas spp, gram-negative cocci, gram-positive organisms, or anaerobes Criteria for Use:  Treatment of infections due to MDR Enterobacteriaceae, Pseudomonas spp., and Acinetobacter spp. with no other treatment options  Treatment of UTI. Colistin preferred over polymyxin B for UTIs Unacceptable Uses:  Empiric treatment of suspected gram-negative infections  Use as monotherapy due to rapid resistance development Dosing in Adults: Optimal dosing regimens are not well established  Standard dose: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q12H  Renal dose adjustment: CrCl 20-50 mL/min: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q24H CrCl < 20 mL/min: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q48H Hemodialysis: 5 mg CBA/kg ONCE (load), then 30 mg CBA IV Q12H, AD  No hepatic dose adjustment  Use ideal body weight in obese patients for dosing  Caution in use > max product recommended daily dose (300 mg CBA) Monitoring:  BUN/ SCr at baseline and at least twice weekly Considerations for Use:  The most important side effect of IV colistin is nephrotoxicity (rates 50-60% of patients); less frequently reported concerns include neurotoxicity and neuromuscular blockade AD= After dialysis; BUN= Blood urea nitrogen; CBA= Colistin base activity; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= infectious diseases; IU= international units; IV= Intravenous; MDR= multi-drug resistant; Q= every; SCr= Serum creatinine; spp= species; UTI= Urinary tract infection

PAGE 50

Tedizolid (Sivextro®) Tedizolid (Sivextro®) IV and PO Only

Use requires formal ID Consult

Activity: Coverage includes Staphylococcus aureus (MSSA and MRSA), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus anginosus group, and Enterococcus faecalis Criteria for Use:  Treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible gram-positive isolates  Unable to use vancomycin (due to intolerance, MIC >2, or infection unresponsive to vancomycin despite therapeutic concentrations)  Unable to use other agents (refer to empiric therapy for ABSSSI) Unacceptable Uses:  Infections for other indications not listed above  Patients with neutropenia. Safety and efficacy in patients with neutrophil counts <1000 cells/mm3 have not been assessed. Decreased activity in the absence of granulocytes in animal models Dosing in Adults:  Standard dose: 200 mg IV/PO once daily for 6 days  No renal or hepatic dose adjustment  No dose adjustment is necessary when changing from IV to PO Monitoring:  CBC with differential

Considerations for Use:  Tedizolid has been shown to be a reversible inhibitor of monoamine oxidase (MAO) in vitro, but no restrictions exist for concomitant use of drugs with serotonergic and adrenergic activity or tyramine containing foods. Of note, patients taking such medications were excluded from clinical trials. In vitro, in vivo, and clinical studies indicate weak MAO inhibition and a low potential for serotonergic adverse consequences  In phase 3 trials, reduction in hemoglobin, reduction in platelet count, and reduction in absolute neutrophil count were similar between tedizolid and linezolid  In phase 3 trials, adverse effects associated with neurologic and optic nerve disorders did not differ between tedizolid and linezolid ABSSSI= acute bacterial skin and skin structure infections; CBC= Complete Blood Count; ID= Infectious Disease; IV= Intravenous; MAO= monoamine oxidase; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; PO= By Mouth

PAGE 51

Tigecycline (Tygacil®) Tigecycline (Tygacil®) IV Only

Use requires formal ID Consult

Activity: Coverage against MRSA, VRE, most gram-negatives, and anaerobes NOT active against Pseudomonas aeruginosa or Proteus spp. Criteria for Use:  Alternative therapy in patients with mixed aerobic-anaerobic infections and severe allergy to beta-lactam agents, if VRE or MRSA are involved  Alternative therapy for patients with systemic infections due to ESBL-producing organisms (Klebsiella spp., E. coli) with severe allergies to first-line therapy (imipenem/cilastatin or meropenem)  Alternative therapy for selected isolates of Acinetobacter, Stenotrophomonas, and VRE  Treatment of documented VRE infections in patients unable to take linezolid

Unacceptable Uses:  Treatment of P. aeruginosa or Proteus spp. infections  Urinary tract infections (low urinary concentrations)  Peak serum concentrations do not exceed 1 mcg/mL, which limits its use for treatment of bacteremia Dosing in Adults:  Standard dose: 100 mg IV load x1, then 50 mg IV Q12H (use higher doses for infections due to Acinetobacter and other MDR organisms) Infuse each dose over 30 to 60 minutes  No renal dose adjustment Supplemental dosing is not necessary following hemodialysis  Hepatic dose adjustment: Severe hepatic disease (Child Pugh C): 100mg IV load x1, then 25 mg IV Q12H Important Side Effects:  Nausea and vomiting (most common in first 1-2 days of therapy)  To minimize GI side effects avoid fasting state administration  Prolonging the infusion time (>1 hour) may make GI side effects worse  Shortening infusion time (<30 minutes) may increase the incidence of infusion related reactions (inflammation, pain, phlebitis, other) Management of tigecycline-induced nausea and vomiting:  Ondansetron (Zofran®): Single dose of 8-12 mg IV or 8-24 mg PO ESBL= Extended spectrum beta-lactamase; GI= Gastrointestinal; H= hour(s); ID= infectious diseases; IV= Intravenous; MDR= multidrug resistant; MRSA= Methicillin-resistant Staphylococcus aureus; PO= by mouth; Q= every; spp= species; VRE= Vancomycinresistant enterococci

PAGE 52

Liposomal Amphotericin Amphotericin BB (L-AmB)(AmBisome®) (L-AMB)(AmBisome®) Liposomal IV Only

Use requires formal ID Consult

Activity: Broad-spectrum antifungal activity with in vitro activity against Candida, Cryptococcosis, Aspergillus, Zygomycosis, and Fusarium Dosing of AmBisome and Amphotericin B deoxycholate is significantly different and not interchangeable. Do not use AmBisome doses when ordering Amphotericin B deoxycholate and vice versa Criteria for Use:  Pre-existing renal insufficiency defined as SCr of ≥ 2 mg/dL or calculated CrCl of ≤ 25 mL/min, or SCr doubled from baseline  Patient refractory to or cannot tolerate conventional amphotericin B deoxycholate  SCr > 1.5 mg/dL and receiving concomitant cyclosporine or tacrolimus  Patients with irreversible ESRD on chronic HD or PD should receive amphotericin B deoxycholate

Dosing in Adults:  Standard dose: Febrile neutropenia: 3 mg/kg/day, may consider 5 mg/kg/day in patients with neutropenia > 10 days, evidence of fungal infection, or clinically unstable Documented yeast (Candida spp., others) infection: 3-5 mg/kg/day Documented mold (Aspergillus spp., others) infection: 3-5 mg/kg/day Endopthalmitis: 5 mg/kg/day ± Flucytosine 25 mg/kg PO Q6H Endocarditis: 5 mg/kg/day Cryptococcal meningitis: 4 mg/kg/day ± Flucytosine 25 mg/kg PO Q6H  No renal/ hepatic dose adjustment Monitoring:  BUN/SCr, K, Mg, Phos at baseline and daily in hospitalized patients; AST/ALT at baseline and every 1-2 weeks ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; BUN= Blood urea nitrogen; CrCl= Creatinine clearance; ESRD= End-stage renal disease; H= hour(s); HD= Hemodialysis; ID= infectious diseases; IV= Intravenous; K= Potassium; Mg= Magnesium; PD= Peritoneal dialysis; Phos= Phosphorus; PO= by mouth; Q= every; SCr= Serum creatinine; spp= species

PAGE 53

Caspofungin (Cancidas®) Caspofungin (Cancidas®) IV Only

Use Requires Formal ID Consult

Criteria for Use:

Invasive Aspergillosis:  Patients refractory to or who cannot tolerate conventional amphotericin B, liposomal amphotericin B, or voriconazole  In combination with voriconazole or amphotericin B in patients with documented invasive aspergillosis Systemic Candida infections:  Systemic Candida infections secondary to C. glabrata or C. kruseii and other non-Candida albicans (pending fluconazole susceptibility testing)  Patients unable to tolerate conventional amphotericin B or patients with concomitant renal insufficiency as per liposomal amphotericin B guidelines  Patients unable to tolerate fluconazole as defined by a serious rash, tripling of baseline LFTs, or other adverse reaction  Empiric use until non-albicans is confirmed Dosing in Adults:  Standard dose: 70 mg IV x1, then 50 mg IV Q24H  No renal dose adjustment  Hepatic dose adjustment: Moderate hepatic impairment: 70 mg IV x1, then 35 mg IV Q24H  Patients receiving rifampin or phenytoin: Consider 70 mg IV Q24H (due to enzyme induction effect) Monitoring:  Aspartate aminotransferase (AST)/ Alanine aminotransferase (ALT) at baseline and weekly ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; H= hour(s); ID= infectious diseases; IV= Intravenous; LFTs= Liver Function Tests; PO= by mouth; Q= every

PAGE 54

Isavuconazonium sulfate (Cresemba®) Isavuconazonium sulfate (Cresemba®) IV and PO Only

Use requires formal ID Consult

Activity: Coverage against most strains of the following microorganisms, both in vitro and in clinical infections: Aspergillus flavus, Aspergillus fumigatus, Aspergillus niger, and Mucorales such as Rhizopus oryzae and Mucormycetes species Criteria for Use:  Treatment of invasive aspergillosis  Treatment of invasive mucormycosis Unacceptable Uses:  Treatment for other fungal infections (Blastomyces, Histoplasma, etc.)  Contraindicated with known hypersensitivity to isavuconazole. Caution in use in patients with hypersensitivity to other azoles  Contraindicated in patients with familial short QT syndrome (shortens the QTc interval in a concentration-related manner) Dosing in Adults:  Standard dose: 372 mg IV/PO Q8H x 6 doses (48 hours; load), then 372 mg Q24H starting 12-24 hours after last loading dose  No renal or hepatic dose adjustment  IV must be administered via an infusion set with in-line filter (pore size 0.2-1.2 micron) and should be infused over a minimum of 1 hour  No dose adjustment is necessary when changing from IV to PO Monitoring:  AST/ALT/bilirubin at baseline and every 1-2 weeks after Considerations for Use:  Elevated LFTs have been reported in clinical trials. Elevations generally reversible and do not require discontinuation  May cause fetal harm when administered to a pregnant woman

Important note regarding drug interactions:  Isavuconazole is a substrate/inhibitor of CYP3A4 and has multiple drug interactions that may affect its levels and/or those of co-administered drugs. Dose adjustment may be necessary  Some drugs with interactions of major significance include: − Carbamazepine − Cyclosporine − Rifampin/rifabutin − Warfarin − Ritonavir − Tacrolimus − Sirolimus − Phenytoin ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; H= hour(s); ID= infectious diseases; IV= Intravenous; LFT’s= Liver Function Tests; PO= by mouth; Q= every

PAGE 55

Voriconazole (V-Fend®) Voriconazole (V-Fend®) IV and PO Only

Use requires formal ID Consult

Activity: Does not cover zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.). Criteria for Use:  Treatment of documented invasive aspergillosis  Used in combination with caspofungin in microbiologically or radiographically confirmed Aspergillus  Serious mycosis infections due to Fusarium spp., Scedosporium apiospermum Dosing in Adults:  Standard dose: PO: 400 mg PO x2 doses (load), then 200 mg PO Q12H (oral formulation may be used without dose adjustment) IV: 6 mg/kg IV x2 doses (load), then 4 mg/kg IV Q12H In patients tolerating PO medications, should be given orally Voriconazole oral formulation is >95% bioavailable  Renal dose adjustment: IV voriconazole should be avoided in patients with CrCl < 50 mL/min due to visual disturbances and accumulation of cyclodextran vehicle (excipient)  Hepatic dose adjustment: Moderate hepatic impairment: ½ maintenance dose (PO: 100mg PO q12H; IV: 2 mg/kg IV Q12H) Monitoring:  Aspartate aminotransferase (AST)/ Alanine aminotransferase (ALT)/ bilirubin at baseline and every 1-2 weeks after Important note regarding drug interactions:  Voriconazole has multiple drug interactions that may affect its levels and/or those of co-administered drugs. Dose adjustment may be necessary



Some drugs with interactions of major significance include: − Carbamazepine − Tacrolimus − Rifampin/rifabutin − Cyclosporine − Ritonavir − Warfarin − Sirolimus − Phenytoin

ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; CrCl= Creatinine Clearance; H= hour(s); ID= infectious diseases; IV= Intravenous; PO= by mouth; Q= every; spp= species

PAGE 56

Guidelines for Vancomycin Dosing and Determination of Trough Levels in Guidelines Vancomycin Dosing and Determination Adult Patients Guidelines for for Vancomycin Dosing and Determination of Trough Levels in Refer of Trough Adult PatientsLevels in Adult Patients to Vancomycin Dosing Nomogram OR calculate dose as described below: Refer Dosing Nomogram I. HowtotoVancomycin calculate a vancomycin dose: OR calculate dose as described below: I. Howa)toObtain calculate a vancomycin dose: actual body weight (ABW) a) Obtain actual body weight (ABW)on lean body weight; if morbidly obese use NOTE: do not calculate dose based ABW for initial loading dose and monitor or consult ID. NOTE: do not calculate based on leantrough body weight; if morbidly obese use ABW for initial loading dose and monitor trough or consult ID. endocarditis, b) Loading Dose (LD): For more severe infections (i.e., Meningitis, pneumonia, a loading dose of 25-30 ABW endocarditis, b) Loading Doseetc.) (LD):consider For more severe infections (i.e.,mg/kg Meningitis, pneumonia, etc.) consider a loading dose of 25-30 mg/kg ABW LD = 25-30 mg/kg (Use ACTUAL body weight) LD = 25-30 mg/kg body weight) c) Maintenance dose (Use (MD):ACTUAL Calculate each maintenance dose: c) Maintenance dose (MD): Calculate each maintenance dose: MD = 15 mg/kg (Use ACTUAL body weight) MD = 15Populations: mg/kg (Use ACTUAL body weight) d.) Special

MorbidPopulations: obesity ( 130% of IBW) use 30 mg/kg/day divided Q8H as obese d.) Special 1,2,3 Obese patients often require more frequent intervalsdivided (i.e., Q8H) Morbid obesity ( 130% of IBW) use dosing 30 mg/kg/day Q8H as obese 1,2,3 Obese patients rarely need doses excess ofdosing 3.5 gmintervals per day.(i.e., Suggest at 1 often require moreinfrequent Q8H)starting to 1.25 gm Q8Hneed and doses adjustin upward patients rarely excessifofnecessary. 3.5 gm per day. Suggest starting at 1 to 1.25 gm Q8Hdose: and adjust upwardbe if necessary. Round calculated doses should rounded to the nearest 250 mg

increment (i.e., 500 mg, doses 750 mg, 1000be mg, 1250 mg, 1500 mg, etc.) Round calculated dose: should rounded to the nearest 250 mg increment (i.e., 500 mg, 750 mg, 1000 mg, 1250 mg, 1500 mg, etc.) II. Estimate patient’s creatinine clearance (CrCl)

Use the Cockcroft-Gault equation. (See Pharmacokinetic Section for equation) II. Estimate patient’s creatinine clearance (CrCl) Use the Cockcroft-Gault equation. (See Pharmacokinetic Section for equation) III. Select dosing interval based on CrCl III. Select dosing interval based on CrCl Estimated CrCl (mL/min) Estimated≥100 CrCl (mL/min)

Dosing interval to consider Dosing interval Q8Hto consider

≥100 80-99 80-99 50-79

Q8HQ8H or Q12H Q8HQ12H or Q12H

50-79 25-49 <2525-49 mL/min

Q18HQ12H or Q24H Q18H Q36H or or Q24H Q48H

<25 mL/min Q36H or Q48H Hemodialysis Give an initial loading dose of (checkHemodialysis pre-dialysis level) 15-20loading mg/kg dose of Give an initial (check pre-dialysis level) Peritoneal dialysis Re-dose patient15-20 with 15 mg/kg when serum mg/kg (IV administration) levelwith ≤ 2015mcg/mL Peritoneal dialysis Re-dose patient mg/kg when serum (IV administration) level ≤ 20 mcg/mL If the estimated renal function (CrCl) is near the border of two dosing intervals, it may be reasonable to begin the more aggressive interval; dosedosing can then be modified If the estimated renalwith function (CrCl) is near the borderthe of two intervals, it may ifbe necessary to serum levels. reasonableaccording to begin with the more aggressive interval; the dose can then be modified if ABW= Actual body weight; CrCl= Creatinine clearance; H= hour(s); IBW= ideal body weight; ID= infectious diseases; LD= loading necessary according to serum levels. dose; MD= maintenance dose; Q= every ABW= Actual body weight; CrCl= Creatinine clearance; H= hour(s); IBW= ideal body weight; ID= infectious diseases; LD= loading dose; MD= maintenance dose; Q= every

References: 1. Bauer LA, Black DJ, Lill JS. Vancomycin dosing in morbidly obese patients. Eur J Clin Pharmacol. 1998 Oct;54(8):621-5. References: 2. Vance-Bryan K, Guay DR, Gilliland SS, et al. Effect of obesity on vancomycin pharmacokinetic parameters as determined by using a Bayesian 1. Bauer LA,technique. Black DJ, Lill JS. Vancomycin in morbidly obese patients. Eur J Clin Pharmacol. 1998 Oct;54(8):621-5. forecasting Antimicrob Agentsdosing Chemother. 1993 Mar;37(3):436-40. 2. Vance-Bryan K, Guay DR, Gilliland et al. Effect of obesity on vancomycin pharmacokinetic parameters as determined by usingChemother. a Bayesian 3. Blouin RA, Bauer LA, Miller DD, et SS, al. Vancomycin pharmacokinetics in normal and morbidly obese subjects. Antimicrob Agents forecasting technique. Antimicrob Agents Chemother. 1993 Mar;37(3):436-40. 1982 Apr;21(4):575-80. 3. Blouin RA, Bauer LA, Miller DD, et al. Vancomycin pharmacokinetics in normal and morbidly obese subjects. Antimicrob Agents Chemother. 1982 Apr;21(4):575-80. PAGE 57

Guidelines Guidelines for Vancomycin Dosing and Determination for Vancomycin Dosing and Determination of Trough Levels in Adult of Trough Patients Levels in Adult Patients IV. Vancomycin Levels Vancomycin levels are NOT needed in patients with stable renal function who are on standard doses of vancomycin AND are on therapy for less than 5 days. Vancomycin peak levels are rarely, if ever, indicated. NOTE: Vancomycin demonstrates concentration-independent killing; therefore, peak concentrations are NOT useful or correlated to clinical outcomes. Measure Trough Concentrations Only if:  Patient is receiving vancomycin therapy > 5 days  Patient has unstable renal function  Patient is on an unusual/aggressive dosing regimen  Patient is morbidly obese (> 130% of IBW)  Patient has severe or life threatening infection and is receiving concomitant nephrotoxic drugs (i.e., cyclosporine, amphotericin B, aminoglycosides) V. Implications for NURSING Vancomycin needs to accumulate (steady state concentration) in order to obtain an accurate concentration. Please DO NOT order a plasma level unless 3 doses have been administered on a given schedule (i.e., order trough prior to the 4th dose) Exception: Dosing interval of 24 hours or longer Trough level should be drawn within 30 minutes of the next dose • Check what time the previous vancomycin dose (prior to the trough) was administered • Calculate how many hours are between the dose and level • Interpret the level in the context of recent vancomycin doses

Example: If the patient is on 1gm Q12H and received a dose at 11pm, then a level taken at 6am is 7 hours post-dose and is NOT a trough level. • Be careful NOT to adjust OR hold vancomycin doses based on incorrectly drawn levels • Do NOT hold the next dose while waiting for trough results (sub-therapeutic levels <15mcg/mL are not effective and can lead to resistant pathogens) H= hour(s); IBW= Ideal body weight; Q= every

PAGE 58

Guidelines for Vancomycin Dosing and Determination of Trough Levels in Adult Patients

VI. Target Trough Vancomycin Level Type of Infection

Target Trough Vancomycin Level

MRSA pneumonia, CNS infection (meningitis), bacteremia, endocarditis, osteomyelitis

15-20 mcg/mL

Endovascular Infection

15-20 mcg/mL

Hemodialysis Serious infection and renal dysfunction (CrCl < 25mL/min)

Maintain 15-20 mcg/mL Check pre-dialysis level, re-dose when ≤ 20 mcg/mL Often recommend to load with 15 – 20 mg/kg and re-dose If ≥ 24H dosing check trough at 24 hours Maintain 15-20 mcg/mL

VII. Adjusting a vancomycin dose (Recommendations) Trough is too low- change the interval, keep the dose • If the level is < 5 mcg/mL, the dosing INTERVAL should be shortened Example: Trough level after 5 days of treatment reported as 3 mcg/mL on a regimen of 1000 mg Q12H, the interval should be shortened to 1000 mg Q8H Trough is too high- decrease the dose, keep the interval • If the trough level is >25 mcg/mL, the DOSE should be decreased 50% Example: Trough level after 5 days of treatment is reported as 29 mcg/mL on a regimen of 1000 mg Q12H; the dose should be decreased to 500 mg Q12H VIII. Monitoring (Inpatient) • Baseline weight, BUN, serum creatinine, WBC, temperature, cultures, and sensitivities should be taken every other day in stable patients • Daily urinary IN’s and OUT’s, CBC, and temperature should be monitored; should be performed in patients admitted to the ICU BUN= Blood urea nitrogen; CBC= Complete Blood Count; CNS= Central nervous system; CrCl= Creatinine clearance; H= hour(s); ICU= Intensive Care Unit; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; WBC= White blood cells

PAGE 59

1.5g q24h

1.25g q24h

1.5g q24h

≥100

1.25g q24h

1g q24h

1g q8h

1.25g q12h

1g q12h

750mg q12h

500mg q12h

Contact Antimicrobial Stewardship Team

1.25g q24h

1g q24h

1.25g q24h

1g q24h

750mg q24h

500mg q24h

1g q24h

500mg q24h 500mg q24h 500mg q24h 750mg q24h 750mg q24h

CrCl (mL/min) Weight (kg)

Vancomycin Dosing Nomogram

1g q8h

1.25g q12h

1g q12h

750mg q12h

500mg q12h

1.5g q8h

1.25g q8/12h

1g q8/12h

500mg q8/12h 500mg q8/12h 500mg q8/12h 750mg q8/12h 750mg q8/12h 750mg q8/12h

1.5g q8h

1.25g q8h

1.25g q8/12h

1g q8/12h

500mg q8/12h 500mg q8/12h 500mg q8/12h 750mg q8/12h 750mg q8/12h 750mg q8/12h

≥100

1.5g q8h

1.25g q8h

1g q8h

750mg q8h

500mg q8h

If Patient is obese: 30mg/kg/day in divided doses q8h

1.25g q12h

1g q12h

750mg q12h

500mg q12h

Cr Cl in mL/min

Vancomycin Dosing Nomogram

weight in kg

PAGE 60

Guidelines Administration of High Dose Once Daily Guidelines for for Administration of High Dose Once Daily Aminoglycosides (HDOD) Aminoglycosides (HDOD) High Dose Once Daily Aminoglycosides (HDOD) are considered safe and effective in patients with stable renal function Exclusion Criteria for HDOD: If patients fall into the following categories, use traditional/conventional dosing since there is limited data using HDOD in the following patient populations Acute renal failure OR CrCl < 20 mL/min Half-life (t1/2) ≥ 4 hours Dialysis

Age < 18 OR > 90 Severe burns Ascites

To use Traditional Dosing Methods, see www.globalrph.com “medical calculator”

II.

For AMG dosing, contact the Antimicrobial Stewardship team or follow the steps below: Calculate the patient’s Ideal Body Weight (IBW) Male: 50 kg + [2.3 kg for each inch over 5 feet] Female: 45 kg + [2.3 kg for each inch over 5 feet] Determine the dose based on the table below (round dose to the nearest 20 mg) Aminoglycoside

Maintenance Dose

Tobramycin

5 mg/kg (IBW)

Gentamicin

5 mg/kg (IBW)

• Dose is based on IBW except in obese patients OR those under their IBW • Use ABW if patient weight is less than IBW • Use AdjBW in patients who are obese (≥ 130% of IBW) Adjusted Body Weight (AdjBW) Calculation AdjBW = 0.4 (ABW – IBW) + IBW III.

Estimate the patient’s creatinine clearance (CrCl) using the Cockcroft and Gault equation (refer to Pharmacokinetic Section)

IV.

Select dosing interval based on calculated CrCl from the tables below: CrCl (mL/min)

Estimated Dosing Interval

≥ 60

Every 24 hours

40–59

Every 36 hours

20–39

Every 48 hours

≤ 20

Use traditional dosing method, see www. Globalrph.com “medical calculator”

ABW= Actual Body Weight; AdjBW= Adjusted Body Weight; AMG= aminoglycosides (i.e., gentamicin and tobramycin); CrCl= Creatinine clearance; HDOD= High Dose Once Daily Aminoglycosides; IBW= Ideal Body Weight (in kg); t1/2= half life

PAGE 61

Guidelines Guidelines for Administration of Once HighDaily Dose Once Daily for Administration of High Dose Aminoglycosides Aminoglycosides (HDOD)(HDOD) V.

Commonly Targeted Peak and Trough Concentrations in HDOD

Disease State

Gentamicin/Tobramycin

Amikacin

Recommended Peak (mcg/mL)

Estimated mg/kg (IBW)

Recommended Peak (mcg/mL)

Estimated mg/kg (IBW)

6–8

2–3

30-40

10–15

6–8

2–3

30–40

10–15

12–14

3–4

60–70

16–20

5–6

60–80

20–25

Sepsis

10–12

3–4

60–70

Intra-abd/SSTI

12–16

4–5

60–70

Cystitis Gram-Positive Synergy Pyelonephritis Pneumonia

Clinical Considerations

VI.

Trough should not exceed 0.3 mcg/mL

Trough should not exceed 1 mcg/mL

Monitoring of serum levels and dosage adjustments a. First-dose levels are NOT routinely needed  First-dose levels may be indicated in patients with variable volume of distribution or unstable renal function (sepsis or post-operatively) to assess clearance b. Serum levels should be performed routinely by day 3 of therapy only once it has been determined that aminoglycoside therapy is to continue  Example: empiric therapy for sepsis from a UTI awaiting culture results does not require peak/trough levels c. Peak and trough serum levels: 1–2 hours post-end of infusion (peak) and immediately prior to the next dose  Document actual time medication was hung  Obtain peak level 1-2 hour post infusion (very important for distribution phase); 2 hr preferred if dose > 400 mg  Use pharmacokinetic formulas (or www.globalrph.com “medical calculator”), to extrapolate peaks and troughs  Extrapolated trough concentrations should not exceed 0.30 mg/mL  Dosage or interval adjustments should be made at this time d. Once stabilized, if therapy is to continue > 1 week, obtain the following laboratory values:  SCr and BUN levels to monitor renal function (every other day)  Peak and trough levels (efficacy and no toxicity), twice per week e. If there is a suggested change in renal function OR other nephrotoxic agents (e.g., cisplatin, amphotericin B, pentamidine, vancomycin) are being used concurrently, more frequent levels of BUN, SCr, and monitoring may be necessary

BUN= Blood urea nitrogen; HDOD= high dose once daily; IBW= ideal body weight; SCr= Serum creatinine; SSTI= skin and soft tissue infection; UTI= Urinary tract infection

PAGE 62

Dosing Guidelines for Adult Patients Antimicrobial Antimicrobial Dosing Guidelines for Adult Patients Function Based Basedon on Renal Renal Function CRCL (ML/MIN) ACYCLOVIR IV >50 30-50 10-29 <10

STANDARD DOSE 5 mg/kg Q8H 5 mg/kg Q12H 5 mg/kg Q24H 2.5 mg/kg Q24H

MAXIMAL DOSE

10 mg/kg Q8H* 10 mg/kg Q12H* 10 mg/kg Q24H* 5 mg/kg Q24H*

Dose using ideal body weight *Use maximum dose for meningitis/encephalitis and varicella in immunocompromised host

AMOXICILLIN PO > 30 10-29 <10 AMOXICILLIN/CLAVULANATE PO > 30 10-29 <10

250 mg Q8H 250 mg Q12H 500 mg Q24H

500 mg Q8H 500 mg Q12H 500 mg Q24H

500 mg Q8-12H* 500 mg Q12H 500 mg Q24H

875 mg Q12H 875 mg Q12H 875 mg Q24H

*Use 500 mg Q8H for osteomyelitis for CrCl ≥ 30 mL/min

AMPICILLIN IV >50 30-50 10-29 <10

1 gm Q4-6H 1 gm Q8H 1 gm Q12H 1 gm Q24H

2 gm Q4-6H* 2 gm Q6-8H 2 gm Q8-12H 2 gm Q24H

AMPICILLIN/SULBACTAM IV >50 30-50 10-29 <10

1.5 gm Q6H 1.5 gm Q8H 1.5 gm Q12H 1.5 gm Q24H

3 gm Q6H* 3 gm Q8H* 3 gm Q12H* 3 gm Q24H*

*Use 2 gm Q4H for meningitis

*Use 3 gm if penetration is an issue (abscess/diabetic foot /vascular insufficiency/ osteomyelitis/intra-abdominal)

AZTREONAM IV >50 30-50 10-29 <10 CEFAZOLIN IV >50 30-50 10-29 <10

1 gm Q8H 1 gm Q12H 1 gm Q24H 500 mg Q24H

2 gm Q6H 1 gm Q8H 1 gm Q12 1 gm Q24H

1 gm Q8H 1 gm Q8H 1 gm Q12H 1 gm Q24H (2gm

2 gm Q8H 2 gm Q8H 2 gm Q12H 2 gm Q24H

Q48H)

PAGE 63

Dosing Guidelines for Adult Patients Antimicrobial Antimicrobial Dosing Guidelines for Adult Patients RenalFunction Function Based Based on on Renal CRCL (ML/MIN) CEFEPIME IV >50 30-50 10-29 <10

STANDARD DOSE 1 gm Q12H 1 gm Q24H 1 gm Q24H 0.5-1 gm Q24H

MAXIMAL DOSE 2 gm Q12H 2 gm Q24H 1 gm Q24H 1 gm Q24H

HD D

Pseudomonal Coverage or Febrile Neutropenia: >50: 2gm Q8H; 30-50: 2gm Q12H; 10-29: 1gm Q12H; < 10: 1gm Q24H

CEFPODOXIME PO 30 <30 HD CEFUROXIME PO 20 < 20 CEFTRIAXONE IV >50 <50-5 (INCLUDING HD)

100 – 200 mg Q12H 100 – 200 mg Q24H 100 – 200 mg 3 times per week

400 mg Q12H 400 mg Q24H 400 mg 3 times per week

250 mg Q12H 250 mg Q24H

500 mg Q12H 500 mg Q24H

1 gm Q24H No Change

2 gm Q24H* No Change

*All indications are dosed at 1gm Q24H with the exception of meningitis (2 gm Q12H) and osteomyelitis (2 gm Q24H)

CEPHALEXIN PO >30 10-29 <10 CIPROFLOXACIN IV >30 10-29 <10

250 mg Q6H 250 mg Q8H 250 mg Q12H

500 mg Q6H 500 mg Q8H 500 mg Q12H

400 mg Q12H* 400 mg Q24H 400 mg Q24H

400 mg Q8H* 400 mg Q12H 400 mg Q24H

500 mg Q12H 500 mg Q24H 250 mg Q24H

750 mg Q8H 750 mg Q12H 500 mg Q24H

600 mg Q8H No Change

900 mg Q8H No Change

300 – 450 mg Q8H No Change

450 mg Q6H No Change

*Use Q8H dosing only for Pseudomonas aeruginosa

CIPROFLOXACIN PO >30 10-29 <10 CLINDAMYCIN IV >50 <50 CLINDAMYCIN PO >50 <50

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Dosing Guidelines for Adult Patients Antimicrobial DosingGuidelines Guidelines Adult Patients Antimicrobial Antimicrobial Dosing for for Adult Patients Function Based Basedon on Renal Renal Function Based on Renal Function C CRRC CLL ((M ML/ L/MIN MIN))

D DICLOXACILLIN ICLOXACILLIN PO PO >50 >50 <50 <50 D DOXYCYCLINE OXYCYCLINE PO PO >50 >50 <50 <50 FFLUCONAZOLE LUCONAZOLE IV/PO* IV/PO* >30 >30 10-29 10-29 <10 <10

SSTANDARD TANDARD D DOSE OSE

M MAXIMAL AXIMAL D DOSE OSE

250 250 –– 500 500 mg mg Q6H Q6H No Change No Change

100 100 mg mg Q12H Q12H No Change No Change

200 200 mg mg Q24H Q24H 100 100 mg mg Q24H Q24H 100 100 mg mg Q48H Q48H

400 400 mg mg Q24H** Q24H** 200 200 mg mg Q24H Q24H 200 200 mg mg Q48H Q48H

2.5-5*mg/kg Q24H 2.5-5*mg/kg Q24H 1.25 mg/kg Q24H 1.25 mg/kg Q24H 0.625 0.625 mg/kg mg/kg Q24H Q24H 0.625 mg/kg mg/kg Q48H Q48H 0.625

5 5 mg/kg mg/kg Q12H Q12H 2.5 2.5 mg/kg mg/kg Q24H Q24H 1.25 1.25 mg/kg mg/kg Q24H Q24H 1.25 mg/kg mg/kg Q48H Q48H 1.25

HD HD ND ND

ND ND

MD MD

*RECOMMENDATIONS *RECOMMENDATIONS FOR FOR SYSTEMIC SYSTEMIC INFECTION INFECTION ONLY, ONLY, NOT NOT FUNGURIA. FUNGURIA. Give Give PO PO if if patient patient has has functioning functioning GI GI tract tract **May **May require require dosages dosages up up to to 800 800 mg/d mg/d depending depending on on Candida Candida species/sensitivities species/sensitivities

G GANCICLOVIR ANCICLOVIR IV IV >50 >50 30-50 30-50 10-29 10-29 <10 <10

D D

*5 *5 mg/kg mg/kg for for CrCl CrCl ≥70 ≥70 mL/min, mL/min, 2.5 2.5 mg/kg mg/kg for for CrCl CrCl 50-69 50-69 mL/min mL/min

G GANCICLOVIR ANCICLOVIR PO PO >50 >50 30-50 30-50 10-29 10-29 <10 <10 IIMIPENEM MIPENEM/C /CILASTATIN ILASTATIN >50 >50 30-50 30-50 10-29 10-29 <10 <10

1 1 gm gm Q8H Q8H 1-1.5 gm Q24H Q24H 1-1.5 gm 500 mg Q24H 500 mg Q24H 500 500 mg mg Q48H Q48H

D D

500 500 mg mg Q6H Q6H 500 500 mg mg Q8H Q8H 500 500 mg mg Q12H Q12H 250 250 mg mg Q12H Q12H

1 1 gm gm Q6H* Q6H* 500 500 mg mg Q6H* Q6H* 500 500 mg mg Q8H* Q8H* 500 500 mg mg Q12H* Q12H*

M MEROPENEM EROPENEM IV IV 50 >> 50 26 26 –– 50 50 10 10 –– 25 25 <10 <10 OR OR HD* HD*

1 1 gm gm Q8H Q8H 1 1 gm gm Q12H Q12H 500 500 mg mg Q12H Q12H 500 500 mg mg Q24H Q24H

2 2 gm gm Q8H Q8H 1 1 gm gm Q8H Q8H 1 1 gm gm Q12H Q12H 1 1 gm gm Q24H Q24H

M METRONIDAZOLE ETRONIDAZOLE IV/PO* IV/PO* >10 >10 <10 <10

500 500 mg mg Q8H Q8H 500 500 mg mg Q12H Q12H

MD MD

For For suspected suspected pseudomonas pseudomonas or or ESBL ESBL infection infection use use max max doses doses

MD MD

*If *If patient patient on on HD HD schedule schedule daily daily dose dose to to be be administered administered immediately immediately after after dialysis. dialysis.

*No *No indication indication for for Q6H Q6H dosing dosing

MD MD

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Antimicrobial DosingGuidelines Guidelines Adult Patients Antimicrobial Dosing forfor Adult Patients BasedononRenal Renal Function Based Function CRCL (ML/MIN) MOXIFLOXACIN IV/PO >50 <50 NAFCILLIN/OXACILLIN >50 <50-5 (Including HD) NITROFURANTOIN* >50 <50

STANDARD DOSE

MAXIMAL DOSE

400 mg Q24H No Change

1 gm Q4H No Change

2 gm Q4H No Change

100 mg Q12H Not Recommended

N/A

*Do not use in systemic infections. Drug is ineffective with CrCl < 40mL/min due to inadequate urinary concentrations.

OSELTAMIVIR PO > 60 >30-60 >10-30 PIPERACILLIN/TAZOBACTAM* >50 30-50 10-29 <10

75 mg Q12H 30 mg Q12H 30 mg Q24H

3.375 gm Q6H 3.375 gm Q6H 3.375 gm Q8H 3.375 gm Q12H

3.375 gm Q4H 3.375 gm Q6H 3.375 gm Q6H 3.375 gm Q8H

10 mg/kg Q24H 10 mg/kg Q24H

10 mg/kg Q12H 10 mg/kg Q24H

Non-PCP 2.5 mg/kg Q12H 2.5 mg/kg Q12H 2.5 mg/kg Q12H 2.5 mg/kg Q24H

PCP 5 mg/kg Q6H 5 mg/kg Q6H 5 mg/kg Q12H 5 mg/kg Q24H*

N/A

*Use for maximal dose for empiric therapy or treatment of Pseudomonas aeruginosa. If polymicrobial infection without P. aeruginosa is suspected, consider using ampicillin/sulbactam

RIFAMPIN PO >10 <10 SULFAMETHOXAZOLE/ TRIMETHOPRIM IV >50 30-50 10-29 <10

N/A

Dosing based on trimethoprim (TMP) component. *Avoid if possible, not recommended by manufacturer for CrCl <15 mL/min due to nephrolithiasis.

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DosingGuidelines Guidelines Adult Patients Antimicrobial Antimicrobial Dosing for for Adult Patients Based Basedon on Renal Renal Function Function CRCL (ML/MIN) SULFAMETHOXAZOLE/ TRIMETHOPRIM PO >50 30-50 10-29* <10*

STANDARD DOSE

MAXIMAL DOSE

(Equal to IV Dose)

1-2 DS Q8-12H 1-2 DS Q12H 1-2 DS Q12H* 1-2 DS Q24H*

5 mg/kg Q6H 5 mg/kg Q6H 5 mg/kg Q12H* 5 mg/kg Q24H*

Dosing based on trimethoprim (TMP) component. Round to the nearest 160 mg of TMP component. *Not recommended by manufacturer for CrCl <15 mL/min due to nephrolithiasis

VANCOMYCIN PO ** >50 <50

125 mg Q6H No Change

**For C. difficile only in patients with sdevere disease or failed metronidazole therapy *For IV dosing see vancomycin dosing guidelines

Dosing based on Cockcroft and Gault Equation

D= Dialyzed 50 – 100%; HD= Hemodialysis; MD= Moderately dialyzed 20-49%; N/A= No information available; ND= Not dialyzed 0-5%

PAGE 67

Antimicrobial Duration of Therapy Antimicrobial Duration of Therapy INFECTIOUS DISEASE

Clostridium difficile Mild-moderate (initial episode) Severe, uncomplicated (initial episode) First recurrence (based on severity)

RECOMMENDED DURATION OF THERAPY

STRENGTH OF RECOMMENDATION

10 – 14 days (vancomycin) 10 – 14 days (vancomycin)

A-I B-I

10 – 14 days

A-II (C-III)

5 days (may require additional therapy depending on patient’s response)

7-14 days (based on patient’s response)

7 days if prompt resolution of symptoms OR 10-14 days for delayed clinical response

A-III

5 days if using levofloxacin in a patient who is not seriously ill

B-III

3 days in a female ≤ 65 years old without upper urinary tract symptoms after catheter has been removed

B-II

Asymptomatic bacteriuria in a pregnant female

3 -7 days

A-III

Acute uncomplicated cystitis in an adult female

Nitrofurantoin: 5 days Trimethoprim-sulfamethoxazole: 3 days Fosfomycin: 1 dose

A-I A-I

4-7 days

A-III

Acute stomach and proximal jejunal perforations where source control is achieved within 24 hours, in the absence of acid-reducing therapy or malignancy

24 hours of therapy

B-II

Acute appendicitis without evidence of perforation, abscess, or local peritonitis

≤24 hours

A-I

Bowel injuries attributable to penetrating, blunt, or iatrogenic trauma that are repaired within 12h and any other intraoperative contamination of the operative field by enteric contents

≤24 hours

A-I

Skin and Skin Structure Uncomplicated cellulitis Complicated MRSA (deeper soft tissue infections, surgical/traumatic wound infection, major abscesses, cellulitis, and infected ulcers and burns) Genitourinary Catheter-associated urinary tract infection

Intra-abdominal Established intra-abdominal infection where source control is achieved

A-I

MRSA= Methicillin-Resistant S. aureus; NA= not applicable

PAGE 68

Antimicrobial of Antimicrobial Duration of Therapy Antimicrobial Duration Duration of Therapy Therapy IINFECTIOUS DISEASE NFECTIOUS DISEASE

Pneumonia Pneumonia Community-acquired Community-acquired pneumonia pneumonia

Hospital-acquired, Hospital-acquired, ventilatorventilatorassociated, associated, and and healthcarehealthcareassociated associated pneumonia pneumonia

Diabetic Diabetic Foot Foot General General recommendation recommendation

Specific Specific situations: situations: Mild Mild DFI DFI Moderate Moderate to to severe severe DFI DFI (without (without osteomyelitis) osteomyelitis) Diabetic Diabetic Foot Foot Infection Infection with with Osteomyelitis Osteomyelitis Catheter-related Catheter-related Bloodstream Bloodstream Infections Infections (CRBSI) (CRBSI) Uncomplicated Uncomplicated CRBSI CRBSI due due to to coagulase coagulase negative negative staphylococci staphylococci other than S. lugdunensis other than S. lugdunensis (catheter (catheter removed) removed) CRBSI CRBSI with with persistent persistent bacteremia bacteremia and and fungemia fungemia >> 72H 72H following following catheter catheter removal, removal, associated associated endocarditis, endocarditis, or or supportive supportive thrombophlebitis thrombophlebitis CRBSI CRBSI with with associated associated osteomyelitis osteomyelitis Catheter-associated Catheter-associated exit exit site site or or tunnel tunnel infection infection without without associated associated bacteremia bacteremia or or fungemia fungemia

RRECOMMENDED DURATION OF THERAPY ECOMMENDED DURATION OF THERAPY

SSTRENGTH OF TRENGTH OF RRECOMMENDATION ECOMMENDATION

Minimum Minimum of of 55 days days

B-I/II B-I/II

14 14 to to 21 21 days days

Level Level II

-- Should Should be be afebrile afebrile for for 48–72 48–72 H H AND have ≤ 1 associated sign of of AND have ≤ 1 associated sign clinical clinical instability instability before before discontinuation of therapy discontinuation of therapy -- As As short short as as 77 days, days, provided provided that that the the targeted targeted pathogen pathogen is is identified identified based on bronchoscopy and the based on bronchoscopy and the etiologic etiologic pathogen pathogen is is not not P. P. aeruginosa, aeruginosa, and and that that the the patient patient has has aa good good clinical clinical response response with with resolution resolution of of clinical clinical features features of of infection infection

Continue Continue antibiotic antibiotic therapy therapy until until there there is is evidence evidence that that the the infection infection has has resolved resolved but but not not necessarily necessarily until until aa wound wound has has healed healed 1-2 1-2 weeks weeks (though (though some some require require an an additional additional 1-2 1-2 weeks) weeks) 2-4 2-4 weeks weeks

A-II A-II

4-6 4-6 weeks weeks

B-II B-II

5-7 5-7 days days OR OR observation observation alone alone (if (if no no

B-III B-III C-III C-III

4-6 4-6 weeks weeks from from first first negative negative blood blood culture culture following following catheter catheter removal removal

A-II A-II for for S. S. aureus; aureus; C-III C-III for for other other pathogens pathogens

6-8 6-8 weeks weeks from from first first negative negative blood blood culture culture following following catheter catheter removal removal

A-II A-II

-- shorter shorter ifif entire entire infected infected bone bone is is removed removed and and probably probably longer longer ifif bone remains bone remains

intravascular intravascular or or orthopedic orthopedic hardware hardware is is present present and and additional additional blood blood cultures cultures are obtained after catheter withdrawal are obtained after catheter withdrawal to to confirm confirm the the absence absence of of bacteremia) bacteremia)

7-10 7-10 days days following following catheter catheter removal removal and and incision incision and and drainage drainage (if (if indicated) indicated)

A-II A-II

CRBSI= Catheter-related Bloodstream Infections; DFI= Diabetic foot infections; H= hour(s) CRBSI= Catheter-related Bloodstream Infections; DFI= Diabetic foot infections; H= hour(s)

PAGE 69

Antimicrobial Duration of Therapy â&#x20AC;&#x201A;Antimicrobial Duration of Therapy This guidance is adopted from the National Antimicrobial Stewardship Taskforce References: 1. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-63. 2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54. 3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103-e120. 4. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50:133-64. 5. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2): S27-S72. 6. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416. 7. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004;39:885910. 8. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1-45. 9. Jenkins TC, Knepper BC, Sabel AL, et al. Decreased Antibiotic Utilization After Implementation of a Guideline for Inpatient Cellulitis and Cutaneous Abscess. Arch Intern Med. 2011;171(12):1072-79. 10. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31(5):431-55. 11. Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis 2011;52:1-38. 12. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52.

PAGE 70

IVIVtotoPOPOAntibiotic Antibiotic Step-Down Guidelines Step-Down Guidelines Candidates for Antimicrobial Step-Down therapy:     

Patient is able to tolerate PO medication AND has a functioning GI tract The infection is treatable with oral antimicrobial therapy AND the indications and spectrum of activity are identical or similar between alternative drugs No evidence of malabsorption, dysphagia, or gastrointestinal bleed Patient is hemodynamically stable with improving body temperature and WBC High risk patients who MAY NOT be candidates for PO step-down may be identified by: − Pulse >125bpm − RR >30bpm − Systolic BP < 90 mmHg − T < 35oC OR >40oC, altered mental status

Contraindications to Antimicrobial Step-Down therapy:  Serious infections concomitant with chemotherapy induced severe neutropenia  Infections caused by resistant organisms (i.e. MRSA, VRE) unresponsive to >1 course of antimicrobials  Situations where oral antimicrobials may not achieve adequate drug concentrations at the site of infection (i.e. meningitis, endocarditis)  Oral antimicrobial therapy may be used in neutropenic patients with negative blood cultures, temperatures < 38oC, and no indication of clinical sepsis Table 1. IV to PO Antimicrobial Step-Down Options IV Antimicrobial

PO Antimicrobial

Ampicillin/sulbactam

Amoxicillin/clavulanate

Azithromycin

Cefazolin/Ceftazidime

Cephalexin/Cephadrine

Ciprofloxacin

Ciprofloxacin*

Ceftriaxone

Cefpodoxime

Cefuroxime

Cefuroxime axetil

Clindamycin

Clindamycin*

Doxycycline

Fluconazole

Fluconazole*

Moxifloxacin

Moxifloxacin *

Metronidazole

Metronidazole*

Nafcillin

Dicloxacillin

Trimethoprim/sulfamethoxazole

Trimethoprim/sulfamethoxazole*

*Oral drugs which achieve serum levels similar to the parenteral dose form BP= blood pressure; bpm= beats/breaths per minute; GI= Gastrointestinal; IV= intravenous; MRSA= Methicillin-resistant Staphylococcus aureus; PO= by mouth; RR= Respiratory rate; T= temperature; VRE= Vancomycin-resistant enterococci; WBC= White blood cells

PAGE 71

Twelve TwelveSteps Steps Prevent Antimicrobial Resistance to to Prevent Antimicrobial Resistance Twelve Steps to Prevent Antimicrobial Resistance 1. Wash your hands! 1. Wash your hands! 2. Vaccinate 2. Vaccinate 3. Get the catheters out 3. Get the catheters out 4. Obtain cultures 4. Obtain cultures 5. Target the pathogen 5. Target the pathogen 6. Seek expert input 6. Seek expert input 7. Know the local sensitivity patterns 7. Know the local sensitivity patterns

8. Know when to say “NO” to broad spectrum 8. Know when to say “NO” to broad spectrum agents agents 9. Treat infection - not colonization 9. Treat infection - not colonization 10. Treat infection - not contamination 10. Treat infection - not contamination 11. Stop treatment when infection is cured 11. Stop treatment when infection is cured or unlikely or unlikely 12. Prevent transmission 12. Prevent transmission

Adopted from the Centers for Disease Control Campaign for Clinicians Adopted from the Centers for Disease Control Campaign for Clinicians

Contact ContactPrecautions Precautions Contact Precautions

TYPES OF CONTACT PRECAUTIONS FOR INFECTION CONTROL TYPES OF CONTACT PRECAUTIONS FOR INFECTION CONTROL

Gloves Masks Hands Conditions Gloves Hands Conditions For contacts If Masks WASH upon ALL patients For If WASH upon withcontacts mucous aerosolization entering and ALL patients with mucous aerosolization entering and membranes, or splattering leaving room membranes, splattering leaving room non-intact skin or of body fluids non-intact skin of and ALL body or body bloodfluids is and or blood is fluidsALL body likely fluids Use Transmission likelyBased Precautions below in addition to Standard Use Standard Precautions on all patients.

Precaution Precaution Standard Standard

Gowns Gowns If splattering If ofsplattering body fluids of or body bloodfluids is or blood is likely likely

Use Standard Precautions on all patients. Use Transmission PrecautionsBased Precautions below in addition to Standard Precautions CATEGORY SPECIFIC ISOLATION PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS CATEGORY SPECIFIC ISOLATION PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS Approved, Tuberculosis or rule Approved, prefitted Tuberculosis or rule WASH upon out tuberculosis. prefitted respirator WASH upon out tuberculosis. Not necessary Not necessary entering and Respiratory phase of Airborne respirator protection and Not necessary Not necessary entering and Respiratory of Airborne leaving room measles andphase chicken protection and required N-95 leaving room measles and chicken pox required N-95 mask pox mask Infected or colonized Infected colonized patients, or whether Upon entering patients, bedriddenwhether or Upon entering room and for all bedridden For suctioning, if WASH upon ambulatory,orwith Contact room andwith for all contacts Upon entering For suctioning, WASH upon ambulatory, with organism is in if entering and wounds or diarrhea: Contact contacts with patient and Upon patiententering room organism entering and wounds or diarrhea: sputum is in leaving room multi-resistant patient surfacesand or patient room sputum leaving room multi-resistant organisms, MRSA, VRE, surfaces or in equipment organisms, MRSA, VRE, C. difficile diarrhea or equipment in room C. difficile diarrhea or ESBL room ESBL MRSA in sputum,

Droplet Droplet Protective Protective Environment Environment

MRSA in sputum, Neisseria meningitidis, Neisseria meningitidis, drug resistant drug resistant pneumococci, pneumococci, diptheria, pertussis, diptheria, influenza pertussis, influenza WASH upon Neutropenia (< 1000 WASH upon Not necessary Not necessary Not necessary entering and Neutropenia (< 1000 neutrophils), ANC <100 Not necessary Not necessary Not necessary entering and leaving room neutrophils), ANC <100 leaving room Refer to Policy MCM 111-P26 Standard and Transmission Based Precautions Refer Policy MCM 111-P26and Standard Based Precautions CalltoInfection Prevention Controland forTransmission further guidance at ext 2654 Call Infection Prevention and Control for further guidance at ext 2654 Not necessary Not necessary

To handle To handle respiratory respiratory secretions or secretions suctioning or suctioning

Within three feet Within three feet of the patient of the patient (regular masks) (regular masks)

WASH upon WASH upon entering and entering and leaving room leaving room

PAGE 72

Pharmacokinetic Calculations Pharmacokinetic Calculations Pharmacokinetic Calculations

Ideal Body Weight (IBW) Calculation: Male: 50 kg + [2.3 kg for each inch over 5 feet] Ideal Body Weight (IBW) Calculation: Female: 45 kg + [2.3 kg for each inch over 5 feet] Male: 50 Female: 45 kg + [2.3 kg for each inch over 5 feet] Creatinine Clearance (CrCl) using Cockcroft-Gault Equation:

Creatinine expressed in mL/min using Cockcroft-Gault Equation: Creatinine is Clearance (CrCl) Creatinine is expressed in mL/min CrCl (mL/min) =(140 – age) (IBW in kg)* ‡ * mg/dL) CrCl (mL/min) =(14072– (SCr age)in (IBW in kg) 72 (SCr in mg/dL)‡ NOTE: For Females multiply by 0.85 NOTE: For Females multiply by 0.85 CrCl for elderly patients or when no height is available: CrCl for elderly patients=(114 or when no *age)) height is available: CrCl (mL/min) – (0.8 ‡ CrCl (mL/min) =(114 *age)) SCr–in(0.8 mg/dL ‡ SCr in mg/dL NOTE: For females multiply by 0.9

NOTE: For females multiply by 0.9 patients actual body weight is less than IBW, use actual body weight to calculate *CrCl If patients actual body weight is less than IBW, use actual body weight to calculate CrCl ‡If patient is underweight/cachectic, may consider rounding SCr up to 1 mg/dL.1,2 *If

‡Do not round to 1 mg/dL for all patients 60 yearsrounding of age.3-5SCr If patient is underweight/cachectic, may >consider

age.3-5

up to 1 mg/dL.1,2

Do not round 1 mg/dL for all patients dosing) > 60 years of Adjusted BodytoWeight (aminoglycoside Use adjusted body weight (AdjBW) whendosing) actual body weight (ABW) is ≥ 30% of ideal Adjusted Body Weight (aminoglycoside body weight (IBW) Use adjusted body weight (AdjBW) when actual body weight (ABW) is ≥ 30% of ideal AdjBW = 0.4 (ABW - IBW) + IBW body weight (IBW) AdjBW = 0.4 (ABW - IBW) + IBW IBW= Ideal Body Weight (in kg); AdjBW= Adjusted Body Weight; ABW= Actual Body Weight; CrCl= Creatinine clearance; SCr= serum creatinine IBW= Ideal Body Weight (in kg); AdjBW= Adjusted Body Weight; ABW= Actual Body Weight; CrCl= Creatinine clearance; SCr= serum creatinine

References: 1. Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med. References: 1993;21(10):1487-1495. 1. Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med. 2. Khuu T, Bagdasarian G, Leung J, et al. Estimating aminoglycoside clearance and creatinine clearance in underweight patients. Am J Health1993;21(10):1487-1495. Sys Pharm. 2010;67(4):274-279. 2. Khuu T, Bagdasarian G, Leung J, et al. Estimating aminoglycoside clearance and creatinine clearance in underweight patients. Am J Health3. Bertino JS. Measured versus estimated creatinine clearance in patients with low serum creatinine values. Ann Pharmacother. Sys Pharm. 2010;67(4):274-279. 1993;27(12):1439-1442. 3. Bertino JS. Measured versus estimated creatinine clearance in patients with low serum creatinine values. Ann Pharmacother. 4. Smythe M, Hoffman J, Kizy K, Dmuchowski C. Estimating creatinine clearance in elderly patients with low serum creatinine concentrations. 1993;27(12):1439-1442. Am J Hosp Pharm. 1994;51(2):198-204. 4. Smythe M, Hoffman J, Kizy K, Dmuchowski C. Estimating creatinine clearance in elderly patients with low serum creatinine concentrations. 5. Dowling TC, Wang E-S, Ferrucci L, Sorkin JD. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals Am J Hosp Pharm. 1994;51(2):198-204. Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy. 2013;33(9):912-921. 5. Dowling TC, Wang E-S, Ferrucci L, Sorkin JD. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy. 2013;33(9):912-921.

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COLLEGE OF PHARMACY