Professional Documents
Culture Documents
Antimicrobial 2013
Antimicrobial 2013
Antimicrobial Usage
2012-2013
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Guidelines for
Antimicrobial Usage
2012-2013
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Copyright 2012
Cleveland Clinic
Published by:
1-800-337-9838
PO Box 10
Caddo, OK 74729-0010
(t) 580/367-9838
(f) 580/367-9989
ISBN: 978-1-932610-85-7
Printed in Mexico
DISCLAIMER
The opinions expressed in this publication reflect those of the authors. However, the authors make no
warranty regarding the contents of the publication. The protocols described herein are general and may not
apply to a specific patient. Any product mentioned in this publication should be taken in accordance with the
prescribing information provided by the manufacturer.
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Committee
Susan J. Rehm, MD
Department of Infectious Disease
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Introduction
he majority of hospitalized patients receive antimicrobials for therapy or prophylaxis during their
inpatient stay. It has been estimated that at least fty percent of patients receive antimicrobials
needlessly. Reasons include inappropriate prescribing for antimicrobial prophylaxis, continuation of
empiric therapy despite negative cultures in a stable patient, and a lack of awareness of susceptibility
patterns of common pathogens. Over prescribing not only increases the costs of health care, but may
result in superinfection due to antimicrobial-resistant bacteria, as well as opportunistic fungi, and
may increase the likelihood of an adverse drug reaction. On the other hand, not prescribing (when
there is an urgent need at the bedside) may also lead to serious consequences.
The materials in this booklet constitute guidelines only and are subject to change pursuant
to medical judgement relative to individual patient needs. Our antimicrobial formulary decisions
are made annually after thorough deliberations and consensus building with members of the
Infectious Disease Department, the Department of Pharmacy, and the Section of Microbiology. In
vitro susceptibility data of the previous year are shared and emerging resistance patterns reviewed.
Usage and cost data are discussed. The mission of our program is to provide the most cost-effective
antimicrobial agents to our patients.
This booklet does not contain specic guidelines for treatment of human immunodeciency virus (HIV) infection. Nor is prophylaxis against opportunistic microorganisms included, since
such issues are usually handled in our outpatient clinics. Similarly, treatment of infectious diseases
commonly seen in the outpatient setting, such as otitis media and pharyngitis, are not included in
this booklet.
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TABLE 1
1 These organisms represent a subset of possible identications correlating with gram stain morphology observed on direct
specimen preparations. Correlation with culture, specimen quality, and clinical ndings is required.
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TABLE 2
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TABLE 2
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TABLE 3
Mycobacterium sp
Mycobacterium tuberculosis
Mycobacterium avium complex
Mycobacterium gordonae
Mycobacterium kansasii
Mycobacterium marinum
Time to Isolation
10-12 d
5-7 d
>10 d
10-12 d
10-12 d
Pigment
None
None
Yellow
Yellow (in light)
Yellow
Rapid Growers:
Mycobacterium abscessus
Mycobacterium chelonae
Mycobacterium fortuitum
<7 d
<7 d
<7 d
None
None
None
Beaded bacilli
Coccoid and/or
bacillary
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TABLE 4
1. Blood cultures:
a. Blood cultures are most likely to be positive when an ample volume of blood is collected prior to
administration of antimicrobials.
b. Two initial sets of 20 mL each should be drawn by separate phlebotomy procedures. Venipuncture is
preferred (less prone to contamination) rather than collection through an intravascular catheter.
c. Ten mL from each blood draw is inoculated into an aerobic bottle and 10 mL into an anaerobic bottle.
Cultures are held 5 days before being reported as negative.
d. A single positive blood culture of these organisms (ie, other blood cultures collected within 48 h
are negative) suggests contamination: Bacillus sp, coagulase-negative staphylococci, diphtheroids,
Propionibacterium acnes, viridans streptococci.
e. An isolator tube of 10 mL of blood should be drawn if any of the following are suspected: Bordetella,
Francisella, Histoplasma capsulatum, Legionella, Mycobacterium sp. These will be incubated for longer
than 5 days before being considered negative.
2. Stools for Clostridium difficile:
a. Liquid stools are tested for the presence of Clostridium difficile toxin by PCR.
b. The sensitivity of the assay is >90%.
c. Due to the sensitivity of the assay, only one sample per week is necessary.
d. Since C difficile colonization rather than infection may exist, only unformed stool specimens from patients
with signs and symptoms of C difficile infection should be tested. Once a patient is diagnosed with
C difficile infection, therapeutic response should be based on clinical signs and symptoms; a test of cure
should not be done since patients may remain colonized with toxin-producing strains following recovery.
3. Stools for enteric pathogens and ova and parasites:
a. Stools sent for bacterial pathogens and parasites should be from outpatients or patients who have been in
the hospital <3 days.
b. Stools are examined for the presence of Salmonella sp, Shigella sp, Campylobacter jejuni, Escherichia coli
0157:H7 and shiga toxinproducing E coli routinely if submitted for enterics; if for parasites, routine testing
for Giardia sp and Cryptosporidium sp is performed via EIA unless a microscopic examination is specifically
ordered.
c. Other pathogens require a special request.
(Table continued on following page)
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TABLE 4
10
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TABLE 5
Aminoglycosides interfere with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
Gentamicin
Tobramycin
Amikacin
Beta-Lactams: Penicillins and cephalosporins inhibit bacterial cell-wall synthesis by binding to one or more
penicillin-binding proteins which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in
bacterial cell walls, thus inhibiting cell-wall biosynthesis. Bacteria eventually lyse due to ongoing activity of
organism autolytic enzymes (autolysins and murein hydrolases) while cell-wall assembly is arrested.
Penicillins
Cephalosporins
Others
Amoxicillin
Cefazolin
Meropenem
Ampicillin
Cefprozil
Aztreonam
Dicloxacillin
Cefepime
Oxacillin
Ceftriaxone
Piperacillin
Cefuroxime
Piperacillin/tazobactam
Cephalexin
Ciprofloxacin inhibits DNA-gyrase which does not allow the uncoiling of supercoiled DNA and promotes
breakdown of double-strand DNA.
Clindamycin binds to the 50S ribosomal subunit (reversibly), preventing peptid-bond formation and inhibiting
protein synthesis.
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TABLE 5
Daptomycin acts at the cytoplasmic membrane and is hypothesized to rapidly depolarize the cell membrane via
an efflux of potassium and possibly other ions. Cell death occurs as a result of multiple failures in biosystems,
including DNA, RNA, and protein synthesis.
Linezolid binds to a site on the 23S ribosomal RNA of the 50S subunit, blocking formation of the 70S initiation
complex thus inhibiting translation.
Macrolides inhibit protein synthesis at the chain elongation step and binds to the 50S ribosomal subunit.
Erythromycin
Azithromycin
Clarithromycin
Metronidazole interacts with DNA causing a loss of helical DNA structure and strand breakage, resulting in
inhibition of protein synthesis.
Tetracyclines inhibit protein synthesis by binding to the 30S and possibly the 50S ribosomal subunits.
Doxycycline
Tetracycline
Tigecycline binds at the same site on the ribosome as tetracyclines, however binds 5-fold more tightly. Also able
to overcome the ribosomal protection mechanism of tetracycline resistance.
Trimethoprim/sulfamethoxazole: Trimethoprim inhibits dihydrofolic acid reduction to tetrahydrofolate, resulting in
sequential inhibition of the folic acid pathway. Sulfamethoxazole interferes with bacterial folic acid synthesis and
growth via inhibition of dihydrofolic acid formation from PABA.
Vancomycin inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding to the
D-alanyl-D-alanine portion of the cell wall precursor.
12
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TABLE 6
Source/
Setting
Empiric
Therapy
Empiric Therapy
Likely
1
Severe Penicillin Allergy Pathogens
Directed
Therapy
Usual
Duration
Community2 Ceftriaxone +
azithromycin
Levofloxacin
Pneumococcus
Legionella
Mycoplasma
Haemophilus influenzae
Chlamydia pneumoniae
Moraxella catarrhalis
Penicillin G
Azithromycin
Doxycycline
Cefuroxime
Doxycycline
Cefuroxime
7-14 d
Communityaspiration
Amp/Sulb
Clindamycin
Mouth flora
Amp/Sulb or
clindamycin
14 d
Hospital or
hospitalaspiration
or VAP
Pip/Tazo
vancomycin
gentamicin3
Ciprofloxacin +
vancomycin
Pseudomonas
aeruginosa
Enterobacter sp
Pip/Tazo +
gentamicin4
Pip/Tazo6
gentamicin
Pip/Tazo
Pip/Tazo
Meropenem7
Oxacillin8
8 d5
Serratia marcescens
Klebsiella sp
Acinetobacter sp
Staphylococcus aureus
1 For severe pencillin allergy (ie, anaphylaxis). For delayed hypersensitivity reactions (eg, rash to a penicillin), a third/fourthgeneration cephalosporin (ie, ceftriaxone for CAP/cefepime for HAP) or carbapenem may be considered.
2 In immunocompromised hosts, consider adding TMP/SMX for Pneumocystis jirovecii (carinii) coverage.
3 Amikacin should be considered in intensive care units where gentamicin/tobramycin susceptibilities are lower.
4 Substitute tobramycin if resistant to gentamicin.
5 Consider a longer 14-day duration for Pseudomonas and Acinetobacter HAP.
6 For piperacillin/tazobactam-resistant isolates, TMP/SMX or meropenem may be appropriate alternative agents.
7 Carbapenem-resistant Acinetobacter have been detected. Consider ampicillin/sulbactam or ID consult for alternative therapies.
8 Note that 50% of S aureus are resistant to oxacillin (or methicillin) and cefazolin. Vancomycin is appropriate in such patients.
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TABLE 7
Alternate Empiric
Therapy
Native valve
Penicillin G +
gentamicin
OR
ceftriaxone
Vancomycin
PVE
Vancomycin + Same
gentamicin +
rifampin
IE Setting
Likely Pathogens
Directed Therapy
Viridans streptococci
Streptococcus bovis
Enterococcus
HACEK group
Staphylococcus aureus
Penicillin G2 or ceftriaxone3
Penicillin G2 or ceftriaxone3
Ampicillin4 + gentamicin5
Ceftriaxone3
Oxacillin gentamicin5,6
Staphylococcus aureus
Oxacillin + gentamicin +
rifampin5,6
Oxacillin + gentamicin +
rifampin5,6
Penicillin G7 or ceftriaxone3
gentamicin5
Ampicillin4 + gentamicin5
Coagulase-negative
staphylococci
Viridans streptococci
Enterococcus
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TABLE 8
Clinical
Setting
Empiric
Therapy
Likely
Pathogens
Directed
Therapy
Usual
Duration1
Osteomyelitis:
Healthy adult
Vancomycin
Staphylococcus aureus
Oxacillin or cefazolin2
4-6 wk
Posttraumatic
Piperacillin/
tazobactam
+ vancomycin
Staphylococcus aureus
Streptococcus
Gram-negative bacilli
Pseudomonas aeruginosa
Oxacillin or cefazolin2
Penicillin G or ampicillin
Ceftriaxone
Piperacillin/tazobactam
4-6 wk
Diabetic foot
Ampicillin/
sulbactam
Usually polymicrobial
Ampicillin/sulbactam
4-6 wk
followed
by PO
Septic arthritis
Vancomycin
Staphylococcus aureus
Gonococcus3
Oxacillin or cefazolin2
Ceftriaxone
4 wk
2 wk4
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus
Oxacillin or cefazolin2
Vancomycin5
Penicillin G or ampicillin
4 wk
1
2
3
4
5
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TABLE 9
Clinical
Setting
Likely
Pathogens
Empiric Therapy
Alternatives
Usual
Duration
Acute uncomplicated
cystitis
TMP/SMX2
Ciprofloxacin2
3d
Mild-moderate
pyelonephritis3
TMP/SMX2
Ciprofloxacin2
10-14 d
Severe pyelonephritis4
Piperacillin/tazobactam5,6
Ciprofloxacin5,6
10-14 d
1
2
3
4
5
6
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Recommended Treatment
Primary
Erythromycin 500 mg PO
tid 7 d
Uncomplicated Gonorrhea
Neisseria gonorrhoeae Ceftriaxone 250 mg IM
1 dose
Alternates
Comments
Ceftriaxone 250 mg IM
1 or azithromycin
1 g PO 1
Azithromycin 1 g
1 dose
Disseminated gonorrhea:
Neisseria gonorrhoeae Ceftriaxone 1 g IV q24h
1-2 d or until improved,
followed by cefixime1
400 mg PO bid to complete
total therapy of 7-10 d
Epididymitis (sexually acquired):
Chlamydia trachomatis Ceftriaxone 250 mg IM
Neisseria gonorrhoeae 1 + doxycycline
100 mg PO bid 10 d
Levofloxacin 500 mg
PO 10 d
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Recommended Treatment
Primary
Alternates
Comments
Recurrent:
Acyclovir 400 mg PO tid or
800 mg PO bid 5 d or
800 mg PO tid 2 d
Prevention of recurrence:
Acyclovir 400 mg PO bid
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Recommended Treatment
Primary
Alternates
Doxycycline 100 mg
PO bid 28 d
Comments
All stages of syphilis require
follow-up for possible
relapse. Evaluate and treat
sexual partners. Test for
HIV. Pregnant women allergic to penicillin should be
desensitized
Procaine penicillin
Patient allergic to penicillin
2.4 million units IM q24h should be desensitized
+ Probenecid 500 mg
PO qid 10-14 d
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Recommended Treatment
Primary
Urethritis or cervicitis:
Chlamydia trachomatis Ceftriaxone 250 mg IM
Ureaplasma urealyticum 1 + doxycycline
Neisseria gonorrhoeae
100 mg PO bid 7 d
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Alternates
Comments
Azithromycin 2 g PO
1
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Empiric
Therapy
Likely
Pathogens
Directed
Therapy
Usual
Duration
Community1
Vancomycin +
ceftriaxone2
Pneumococcus
Meningococcus
Haemophilus influenzae
Penicillin G3
Penicillin G
Ceftriaxone2,4
2 wk
1-2 wk
1-2 wk
Immunocompromised
or age >50 years
Ceftriaxone2 +
vancomycin +
ampicillin
Listeria sp
GNB (Pseudomonas aeruginosa)
Pneumococcus
Ampicillin + gentamicin
Cefepime6 + gentamicin7
Penicillin G3
2-3 wk5
Postneurosurgical/
posttraumatic
Vancomycin +
cefepime6
Staphylococcus epidermidis
Staphylococcus aureus
GNB (Pseudomonas aeruginosa)
Pneumococcus
Vancomycin8
Oxacillin9
Cefepime6 + gentamicin7
Penicillin G3
2-4 wk
1
2
3
4
5
6
7
8
9
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Cefepime 2 g IV q8h2
Aztreonam 2 g IV q6h2 + vancomycin3 + gentamicin4
Severe mucositis or
Suspected catheter-related infection or
Suspected skin or skin structure infection or
Gram-positive oganism in blood cultures
1
2
3
4
5
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Test positive
Treatment
Preferred Regimen:
Metronidazole 500 mg PO tid
10-14 days
Alternative Regimen2:
Vancomycin 125 PO qid
10-14 days
Follow-Up:
1. No need for further stool specimens (note: diarrhea may take
3-4 days to respond to treatment)
1 Severe, complicated illness dened as hypotension, shock, or illeus.
2 Consider vancomycin if metronidazole intolerant, failing to respond to metronidazole (ie, failure to improve after 3 to 4 days of
therapy), or severe disease dened as WBC 15,000 or serum creatinine >1.5 baseline.
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Likely Pathogens
Empiric Therapy
Alternatives
Usual Duration
Uncomplicated cellulitus2
S aureus
Streptococci
Oxacillin or cefazolin3
Vancomycin3,4
7 days
Diabetic foot
S aureus
Streptococci
Aerobic GNBs
Anaerobes
Ampicillin/sulbactam
Ciprofloxacin +
clindamycin
Guided by patient
response to
treatments
Necrotizing fasciitis
Group A streptococci
Polymicrobial
Guided by patient
response to
treatments
1 If abscess present, incision and drainage (I&D) is imperative for cure. I&D may be sufcient if isolated abscess <5 cm.
2 Complicating risk factors: chronic ulcer; including diabetic, vascular insufciency; including chronic venous stasis and peripheral
arterial disease, surgical wound, residence in health care facility within 90 days, recurrent cellulitis > twice in the preceding year,
animal or human bite, indwelling medical device, perirectal infection, periorbital infection, salt or fresh water exposure, and immunocompromised state.
3 If culture negative or unavailable, change to oral doxycycline 100 mg PO bid, TMP/SMX DS 1-2 tabs PO bid, or clindamycin 300450 mg PO tid when able.
4 Use rst-line empiric if MRSA risk factors present. Risk factors include: injection drug use, diabetes mellitus, end-stage renal
disease, human immunodeciency virus infection, contact sports, prisoners, soldiers, men who have sex with men, Native
Americans, recent antimicrobial exposure, known colonization with MRSA, contact with person diagnosed with MRSA infection,
and report of spider bite.
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Admin
Route
CrCl
(mL/min)
Suggested
Dosage Regimen
Supplement
for Dialysis
H/D1
P/D
Acyclovir
IV
>50
25-50
10-25
0-10
Yes
Amantadine
PO
>80
60-80
40-60
30-40
20-30
10-20
100 mg bid
200 mg/100 mg, alternating q24h
100 mg q24h
200 mg 2/wk
100 mg 3/wk
200 mg/100 mg, alternating weekly
No
No
Amikacin
IV/IM
Amoxicillin
PO
>50
10-50
<10
250-500 mg q8h
250-500 mg q8-12h
250-500 mg q12h
Yes
No
Amoxicillin/
clavulanate
PO
>30
Yes
No
10-30
<10
875 mg q12h OR
250-500 mg q8h
250-500 mg q12h
250-500 mg q24h
No
No
Yes
No
Amphotericin B IV
Amphotericin B IV
See Table 16 for appropriate usage guidelines
Lipid Complex ABELCET
Ampicillin
IV
>50
10-50
<10
1-2 g q4-6h
1-2 g q6-12h
1-2 g q8-12h
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Admin
Route
CrCl
(mL/min)
Suggested
Dosage Regimen
Supplement
for Dialysis
H/D1
P/D
Ampicillin/
sulbactam
IV
>30
15-30
<15
1.5-3 g q6-8h
1.5-3 g q12h
1.5-3 g q24h
Yes
Atovaquone
PO
750 mg bid
Atovaquone/
proguanil2
PO
1 g/400 mg q24h
Azithromycin
IV
PO
500 mg q24h
250-500 mg q24h
No
No
No
No
Aztreonam
IV
Cefazolin3
IV
>55
35-54
11-34
<10
Yes
No
Cefdinir
PO
>30
300 mg q12h or 600 mg q24h
<30
300 mg q24h
See Table 16 for appropriate usage guidelines
Yes
Cefepime
IV
1 g q8h
1 g q8-12h
500 mg-1 g q12h
500 mg-1 g q24h
Cefixime
PO
>60
21-59
<20
400 mg q24h
300 mg q24h
200 mg q24h
Yes
Cefpodoxime
PO
>30
10-29
<10
100-400 mg q12h
100-400 mg q24h
100-400 mg 3/wk
No
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Admin
Route
CrCl
(mL/min)
Suggested
Dosage Regimen
Cefprozil
PO
>30
<30
500 mg q12-24h
250 mg q12h
Supplement
for Dialysis
H/D1
P/D
Yes
Ceftriaxone
IV
Cefuroxime
IV
>20
10-20
<10
Yes
No
Cephalexin
PO
>40
10-40
<10
250-500 mg q6h
250-500 mg q8-12h
250 mg q12-24h
Yes
Yes
Chloramphenicol IV
0.5-1 g q6h
No
No
Cidofovir
IV
Ciprofloxacin
IV
>30
<30
>30
<30
400 mg q12h
400 mg q24h
250, 500 or 750 mg q12h
500 or 750 mg q24h
No
PO
Clarithromycin
PO
>30
<30
250-500 mg q12h
250-500 mg q24h
Clindamycin
IV
PO
600-900 mg q8h
150-450 mg q6h
No
No
No
No
Clofazimine
PO
100 mg q24h
Colistimethate Inhaled
IV
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Admin
Route
CrCl
(mL/min)
Suggested
Dosage Regimen
Cytomegalovirus IV
immune globulin
Dapsone
PO
Daptomycin
IV
Dicloxacillin
PO
Doxycycline
IV/PO
Erythromycin
IV
PO
Supplement
for Dialysis
H/D1
P/D
100 mg q24h
500 mg q6h
No
100 mg q12h
No
>10
<10
No renal dose adjustment necessary
0.5-1 g q6h
250-500 mg q6h
250-500 mg q6h
No
No
No
No
Ethambutol
PO
>50
10-50
<10
Yes
Yes
Fluconazole
IV/PO
>50
10-50
100-400 mg q24h
50% of recommended dose
Yes
Flucytosine
PO
>40
20-40
10-20
<10
Yes
Foscarnet
IV
Fosfomycin
PO
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Admin
Route
Supplement
for Dialysis
H/D1
P/D
CrCl
(mL/min)
Suggested
Dosage Regimen
>70
50-69
25-49
10-24
<10
5 mg/kg q12h
Yes
2.5 mg/kg q12h
2.5 mg/kg q24h
1.25 mg/kg q24h
1.25 mg/kg 3/wk, following hemodialysis
Ganciclovir
IV
Gentamicin
IM/IV
Isoniazid
IV/PO
300 mg q24h
Yes
Yes
Itraconazole
PO
200 mg q12-24h
No
No
Ketoconazole
PO
200 mg q24h
No
No
Levofloxacin
IV/PO
Linezolid
IV/PO
IV
Meropenem
500 mg q6-8h
500 mg q8-12h
Metronidazole PO/IV
>10
<10
Micafungin
IV
Nitrofurantoin
PO
>50
<50
50-100 mg q6h
Avoid use
Norfloxacin
PO
>30
<30
400 mg q12h
400 mg q24h
No
Oxacillin
IV
1-2 g q4-6h
No
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Drug
Admin
Route
CrCl
(mL/min)
Suggested
Dosage Regimen
Oseltamivir
PO
>30
10-30
<10
75 mg bid
75 mg q24h
30 mg, following hemodialysis
Penicillin G
IV
>50
10-50
<10
Yes
Penicillin VK
PO
>10
<10
250-500 mg q6h
250 mg q6h
Yes
Pentamidine
IV
>50
10-50
<10
4 mg/kg q24h
4 mg/kg q24-36h
4 mg/kg q48h
Piperacillin/
tazobactam
IV
>40
20-40
<20
3.375 g q6h
3.375 g q8h
3.375 g q12h
Yes
Posaconazole
PO
Pyrazinamide
PO
>30
<30
Pyrimethamine PO5
100 mg q24h
Quinupristin/
dalfopristin
IV
Rifabutin
PO
300 mg q24h
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Drug
Admin
Route
CrCl
(mL/min)
Suggested
Dosage Regimen
Rifampin
IV/PO
600 mg q24h
No
>10
<10
100 mg bid
100 mg q24h
Streptomycin6 IV/IM
>50
10-50
<10
Yes
Yes
Sulfisoxazole
PO
>50
10-50
<10
1-2 g q6h
1 g q8-12h
1 g q12-24h
Yes
No
Sulfadiazine
PO
1-2 g q6h
Tetracycline
PO
>50
10-50
<10
250-500 mg q6-12h
250-500 mg q12-24h
250-500 mg q24h
No
No
Tigecycline
IV
Tobramycin
IV/IM
Yes
No
Yes
No
Rimantadine
PO
Trimethoprim/ IV
sulfamethoxazole
PO7
5 mg/kg q6-8h
2.5-5 mg/kg q12h
2.5-5 mg/kg q24h
(All doses based on trimethoprim)
1 DS q12h
1 DS q24h
1 DS = 160 mg of trimethoprim
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Admin
Route
CrCl
(mL/min)
Trimethoprim
PO
Valganciclovir
PO
>50
100-200 mg q6h
10-50
100 mg q12-24h
<10
50-100 mg q24h
See Table 16 for appropriate usage guidelines
Vancomycin
IV
PO
Voriconazole IV/PO
1
2
3
4
Suggested
Dosage Regimen
125 mg q6h
Supplement
for Dialysis
H/D1
P/D
Yes
No
No
Assure that full daily dosing occurs after dialysis as an alternative to supplemental dosing.
For malaria prophylaxis, the recommended dose is 250/100 mg q24h.
Dose may be doubled in severe infection.
Foscarnet dosing in renal insufciency:
Induction for HSV
Induction for CMV
Maintenance Dosage for CMV
(dose in mg/kg)
(dose in mg/kg)
(dose in mg/kg)
Creatinine Clearance
Equivalent to
Equivalent to
Equivalent to
mL/min/kg
40 mg/kg q12h
90 mg/kg q12h
90 mg/kg q24h
>1.4
>1-1.4
>0.8-1
>0.6-0.8
>0.5-0.6
t0.4-0.5
<0.4
40 q12h
30 q12h
20 q12h
35 q24h
25 q24h
20 q24h
Not recommended
90 q12h
70 q12h
50 q12h
80 q24h
60 q24h
50 q24h
Not recommended
90 q24h
70 q24h
50 q24h
80 q48h
60 q48h
50 q48h
Not recommended
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CrCl
~Cost/wk (mL/min)
Suggested
Dosage
Regimen
$160
$1120
$265
$1860
$100-200
$700-1400
>30
10-30
<10
1-2 g q6-8h
Yes
1-500 mg q6-8h
250-500 mg q6-8h
Yes
Cefepime
IV
2 g q8h
$25
Penicillin-allergic patients
who can tolerate cephalosporins
Organisms resistant to piperacillin/tazobactam
CNS infections
$175
>60
30-60
11-29
<11
2 g q8h
2 g q12h
2 g q24h
1 g q24h
Yes
Ceftriaxone
IM/IV
Dose limited to 1 g q24h
unless endocarditis or
meningitis
$40
Drug/
Indication
Admin
Route
Usual
Regimen
1 g q24h
$5
Supplement
for Dialysis
H/D P/D
Yes
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Admin
Route
Usual
Regimen
~Cost/d
5 mg/kg3
N/A
$297
every other week
(+ probenecid and hydration)
Colistimethate
Inhaled
Infectious
Diseases
Service only
75 mg q12h
$60
Cytomegalovirus
IV
immune globulin
Infectious Diseases
and Transplant Services
$420
Daptomycin
IV
6 mg/kg q24h
Infectious Diseases
Service only
Not indicated for pneumonia
Higher mg/kg doses may be warranted
for certain infections
Supplement
for Dialysis
H/D P/D
<55
Avoid use
t30
10-30
<10 or
dialysis
No
No
t30
<30
q24h
q48h
CrCl
~Cost/wk (mL/min)
Cidofovir2
IV
Infectious Diseases
Service only
Infectious
IV
Diseases
Services only
Dose based on
ideal body weight
Optional 3 mg/kg
loading dose
Suggested
Dosage
Regimen
$275
$1920
(500 mg q24h)
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Admin
Route
Suggested
Dosage
Regimen
Supplement
for Dialysis
H/D P/D
Usual
Regimen
~Cost/d
CrCl
~Cost/wk (mL/min)
Ertapenem
IV
Infectioius Diseases
Service
Single dose prior
to discharge for
CoPAT
1 g q24h
$65
$460
t30
<30
1 g q24h
500 mg q24h
Levofloxacin
IV/PO
Penicillinallergic patients
with CAP
750 mg q24h
IV: $20
PO: $1
$140
$7
t50
20-49
19
750 mg q24h
750 mg q48h
750 mg x 1 then
500 mg q48h
Linezolid
IV/PO
Infectious Diseases
Service only
600 mg q12h
IV: $285
PO: $180
$1580
$1260
Meropenem
IV
Infections due to
Pip/Tazo-resistant
organisms or Pip/Tazo
clinical failures
Dose may be increased
for CNS infection
500 mg q6h
$25
$188
50
500 mg q6h or
1 g q8h
500 mg q8h or
1 g q12h
500 mg q12h
500 mg q24h
26-49
10-25
<10
Yes
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Admin
Route
Usual
Regimen
Suggested
Dosage
Regimen
Supplement
for Dialysis
H/D P/D
~Cost/d
CrCl
~Cost/wk (mL/min)
Micafungin
IV
100 mg q24h
Infectious Diseases
150 mg q24h
Service only
100-mg dose recommended for
candidemia, disseminated candidiasis,
candida peritonitis, and abscesses
150-mg dose recommended for
candida endocarditis, osteomyelitis,
or meningitis and mould infections
$80
$120
$560
$840
Posaconazole
PO
Infectious Diseases
Service
BMT Service
200 mg q8h
200 mg q6h
$120
$160
$840
$1120
Quinupristin/
IV
dalfopristin
Infectious Diseases
Services only
7.5 mg/kg
q8-12h
$515
$3600
(500 mg q8h)
Tigecycline
IV
Infectious Diseases
Service only
Treatment of MDR
Gram-negative infections
Loading dose:
$145
100 mg 1
Maintenance
$145
dose: 50 mg q12h
$1020
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Admin
Route
Valganciclovir
PO
Infectious Diseases
Service
Transplantation services:
Voriconazole
IV/PO
Infectious Diseases
Service
Hematology/Oncology
Service
Usual
Regimen
900 mg bid
~Cost/d
CrCl
~Cost/wk (mL/min)
Suggested
Dosage
Regimen
$200
$1400
Yes
(See table
below)
CrCl (mL/min)
Induction
Maintenance
t60
40-59
25-39
10-24
<10
900 mg q12h
450 mg q12h
450 mg q24h
450 mg q48h
Not recommended
900 mg q24h
450 mg q24h
450 mg q48h
450 mg q2/wk
Not recommended
Loading dose:
400 mg q12h
IV: $360
2 doses
PO: $120
(>100 kg; 600 mg q12h 2 doses)
Maintenance dose:
200 mg q12h IV: $180
IV: $1260
PO: $60
PO: $420
Supplement
for Dialysis
H/D P/D
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TABLE 17 Antiretrovirals1
(Guidelines subject to change; check www.aidsinfo.nih.gov for updates.)
Generic: Chemical
(Trade) Drug Names
Manufacturer
Dosage Forms
Selected
Adverse Reactions
300 mg bid
150 mg bid when given with
PIs other than tipranavir
600 mg bid when given with
efavirenz, rifampin, or
etravirine
Entry Inhibitor
Maraviroc (Selzentry)
Pfizer
Integrase Inhibitor
Raltegravir (Isentress)
Merck
Tab: 400 mg
400 mg bid
Tab: 300 mg
Oral Sol: 20 mg/mL,
240 mL/bottle
300 mg bid
600 mg daily
Child-Pugh:
5-6: 200 mg bid
>6: contraindicated
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Dosage Forms
Emtricitabine: FTC3
(Emtriva) Gilead
Cap: 200 mg
Selected
Adverse Reactions
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Dosage Forms
Selected
Adverse Reactions
60 kg: 40 mg bid
CrCl (mL/min):
26-50: 20 mg bid
10-25: 20 mg q24h
<60 kg: 30 mg bid
CrCl (mL/min):
26-50: 15 mg bid
10-25: 15 mg q24h
Zidovudine: AZT
(Retrovir)3
GlaxoSmithKline
Tab: 300 mg
Cap: 100 mg
Syrup: 50 mg/5 mL,
240 mL/bottle
Inj: 10 mg/mL, 20 mL/vial
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Dosage Forms
Selected
Adverse Reactions
CrCl (mL/min):
Asthenia, headache, diarrhea, nausea,
50: 300 mg q24h
Fanconi syndrome, osteomalacia
with food
30-49: 300 mg q48h with food
10-29: 300 mg twice weekly with food
Dialysis: 300 mg weekly
600 mg q24h on empty
stomach at bedtime
Tab: 25 mg
Oral Susp: 10 mg/mL,
240 mL/bottle
Tab (XR): 400 mg
200 mg q24h 14 d,
then 200 mg bid or
400 mg (XR) q24h
Rilpivirine (Edurant)
Tibotec
Tab: 25 mg
25 mg q24h
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Dosage Forms
Protease Inhibitors4
Atazanavir ATV (Reyataz) Cap: 100, 150, 200, 300 mg
Bristol-Myers Squibb
Selected
Adverse Reactions
ARV-nave:
Rash, serum transaminase elevations,
300/100 mg7 q24h or
hyperlipidemia, hyperbilirubenemia,
400 mg q24h
decreased absorption in patients
With TDF or AFV-experienced:
receiving antacids, H2 blockers, or
300/100 mg q24h7
proton pump inhibitors
With EFV in ARV-nave:
400/100 mg7 q24h
With Maraviroc:
300/100 mg q24h
Do not use with ETR or NVP
or in ARV-experienced
patients on EFV
Child-Pugh:
7-9: 300 mg q24h
>9: Not recommended
Not recommended for patients
on hemodialysis
600/100 mg bid7
800/100 mg q24h5,7
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Dosage Forms
Protease Inhibitors4
Fosamprenavir FPV
Tab: 700 mg
(Lexiva) GlaxoSmithKline
Lopinavir/ritonavir LPV/r
(Kaletra) Abbott
Selected
Adverse Reactions
1400 mg bid6
Rash, nausea, vomiting, diarrhea. Avoid
700/100 mg bid7
boosted dose in persons with hepatic
6,7
1400/100 q24h
insufficiency
1400/200 mg q24h6,7
Child-Pugh:
5-6: 700 mg bid6
700 mg bid +
RTV 100 mg daily
7-9: 700 mg bid6
450 mg bid +
RTV 100 mg daily
10-12: 350 mg bid6 or
300 mg bid +
RTV 100 mg q24h
Hyperbilirubinemia, nephrolithiasis,
800 mg q8h with water8
(hepatic insufficiency:
abdominal pain, nausea, diarrhea, taste
600 mg tid)
perversion
800/100 mg bid7
800/200 mg bid7
Diarrhea, nausea, vomiting, abdominal
400/100 mg bid6,7
6,7,9
800/200 mg q24h
pain, asthenia, headache. See ritonavir
500/125 mg q24h10
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Dosage Forms
Protease Inhibitors4
Nelfinavir NFV (Viracept)
Agouron (Pfizer)
Cap: 250 mg
Oral Sol: 100 mg/mL
Fusion Inhibitors
Enfuvirtide: T-20 (Fuzeon) Vials for injection:
Roche
90 mg/1 mL
Selected
Adverse Reactions
Diarrhea, nausea
90 mg SC q12h
1 tablet daily
Combination Products
Abacavir/lamivudine
(Epzicom)
GlaxoSmithKline
Tab: 600/300 mg
44
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Dosage Forms
Combination Products
Abacavir/lamivudine/
Tab: 300/150/300 mg
zidovudine (Trizivir)
GlaxoSmithKline
Efavirenz/emtricitabine/
Tab: 600/200/300 mg
tenofovir (Atripla)
Bristol-Myers Squibb/Gilead
Emtricitabine/tenofovir
Tab: 200/300 mg
(Truvada) Gilead
Selected
Adverse Reactions
1 tablet bid
1 tablet daily
CrCl (mL/min):
30-49: 1 tablet q48h
1 tablet bid
Lamivudine/zidovudine:
Tab: 150 mg/300 mg
Avoid in patients with CrCl <50 mL/min
3TC/AZT (Combivir)
and hepatic impairment
GlaxoSmithKline
Rilpivirine/emtricitabine/ Tab: 25 /200/300 mg
1 tablet daily with food
Avoid in patients with CrCl<50 mL/min
tenofovir (Complera) Gilead
1 These agents, especially protease inhibitors and non-nucleoside reverse transcriptase inhibitors, have numerous drug interactions.
Please be aware of potential drug interactions when initiating or discontinuing any medication.
2 Therapy with these agents has been reported to cause lactic acidosis.
3 Available in combination product. See Combination Products section.
4 These agents have been associated with hyperglycemia, hypertriglyceridemia, fat redistribution, and possible increased bleeding
episodes in patients with hemophilia.
5 Dose for ARV-nave or -experienced patient with no darunavir mutations.
6 Only for treatment-nave patients.
7 All boosted regimens utilize ritonavir. Boosted doses are listed as original protease inhibitor dose/ritonavir dose.
8 A minimum of 1.5 liters (48 ounces) of liquids per day is recommended.
9 Not for 3 LPV mutations, pregnant females, patients receiving EFV, NVP, FPV, NFV, carbamazepine, phenobarbital, or phenytoin.
10 Dose when given with EFV, NFV, or NVP.
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0.8
1.0
30
40
50
60
70
80
90
q8h
q8h
q12h
q12h
q24h
q24h
q24h
q8h
q12h
q12h
q12h
q24h
q24h
q24h
Serum Creatinine
1.2
q8h
q12h
q12h
q12h
q24h
q24h
q24h
1.5
2.0
>2.0
q12h
q24h
q24h
q24h
one dose
one dose
one dose
q24h
q24h
q24h
one dose
one dose
one dose
one dose
one dose
one dose
one dose
one dose
one dose
one dose
one dose
Dose (mg/kg)
Dosing Interval
Tobramycin/Gentamicin
Amikacin
q8h
q12h
q24h
One dose
1.5
2
2.5
3
5
7
9
11
Levels
Peak and trough with third dose
Peak and trough with third dose
Peak and trough with third dose
Peak and 24-hour random level; redose when
random level is <2 mcg/mL (tobramycin/
gentamicin) or <8 mcg/mL (amikacin)
Use actual body weight. If obese, use adjusted body weight (ABW):
Ideal weight: Male: 50 kg + [2.3 (inches >5 feet)] Female: 45 kg + [2.3 (inches >5 feet)]
ABW (25% over ideal weight): [0.4 (actual weight ideal weight)] + ideal weight
Round dose to nearest 20 mg.
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Amikacin
Streptomycin
8-10 mcg/mL
7-10 mcg/mL
6-8 mcg/mL
4 mcg/mL
28-35 mcg/mL
25-35 mcg/mL
22-28 mcg/mL
15-20 mcg/mL
20-30 mcg/mL
Peaks
Pneumonia
Sepsis
Intra-abdominal
Endocarditis1/UTI
Note: For synergistic effect against gram-positive organisms, peaks of 3 to 4 are sufficient (ie, gentamicin 1 mg/kg
q8h; interval adjusted for renal function).
Troughs
Tobramycin/Gentamicin
Amikacin
Streptomycin
<2 mcg/mL
<8 mcg/mL
<5 mcg/mL
1 Gram-positive endocarditis.
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Gentamicin/
Tobramycin Dose1
Amikacin Dose2
Interval
t60
30-59
5 mg/kg
5 mg/kg
15-18 mg/kg
15-18 mg/kg
q24h
q48h
Dosing adjustments:
Gentamicin/Tobramycin
Trough Concentration3
Amikacin Trough
Concentration3
Dosing Recommendation
<1 mcg/mL
1-3 mcg/mL
>3 mcg/mL
<4 mcg/mL
4-8 mcg/mL
>8 mcg/mL
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CrCl Female:
CrCl (mL/min)
>50
30-50
<30
Hemodialysis
Dosing Interval
q12h2
q24h
One dose, then check a random vancomycin level in 24-48 hours, redose when level is <15-20 mcg/mL
500-750 mg after each hemodialysis session
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Dosage Adjustment
Half the dosage interval to next frequency AND consider increase in dose by 250-500 mg
Half the dosage interval to next frequency OR increase dose by 250-500 mg
No change if goal trough 10-20 mcg/mL. If goal trough is 15-25 mcg/mL, increase dose by 250-500 mg
No change
No change if goal trough 15-25 mcg/mL. If goal trough is 10-20 mcg/mL, decrease dose by 250-500 mg
OR double the dosage interval to next frequency
Double the dosage interval to next frequency AND/OR decrease the dosage
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Cyclo/Tacro
Siro1
Decrease Effect
Cyclo/Tacro
Siro1
Additive Toxicity
Cyclo/Tacro
XX Nephrotoxicity
XX Nephrotoxicity
XX
X
XX
XXX
X
XX
XX
X
XX
XXX
X
XX
XX
X
X
X
XX
?
XX
XXX
XXX
X
XX
X
XXX
X
XX
X Nephrotoxicity
See footnote 3
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Increase
Warfarin Effect
XX
XX
XX
X
XX
XX
X
XX
XX
XXX
XX
XX
XX
Decrease
Warfarin Effect
XX
?
XXX
XXX
X
XXX
XX
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Pregnancy
Category
Antimicrobial
Name (Generic)
Pregnancy
Category
Antimicrobial
Name (Generic)
Pregnancy
Category
Antimicrobial
Pregnancy
Name (Generic) Category
Ganciclovir
C
Clarithromycin
C
Pyrimethamine
C
Abacavir
C
Gentamicin
C
Clavulanate
B
Quinupristin/dalfopristin B
Acyclovir
B
Indinavir
C
Clindamycin
B
Raltegravir
C
Amantadine
C
Isoniazid
C
Clofazimine
C
Rifabutin
B
Amikacin
D
Itraconazole
C
Colistimethate
C
Rifampin
C
Amoxicillin
B
Ketoconazole
C
Cytomegalovirus
C
Rimantadine
C
Amphotericin B
B
Lamivudine
C
immune globulin
Ritonavir
B
Ampicillin
B
Levofloxacin
C
Dapsone
C
Saquinavir
B
Ampicillin/sulbactam
B
Linezolid
C
Daptomycin
C
Stavudine
C
Atazanavir
B
Lopinavir/ritonavir
C
Darunavir
B
Streptomycin
D
Atovaquone
C
Maraviroc
B
Delavirdine
C
Sulfadiazine2
Atovaquone/proguanil C
B
Meropenem
B
Dicloxacillin
B
Azithromycin
B
Sulfisoxazole2
C
Metronidazole1
Didanosine
B
Aztreonam
B
B
Tenofovir
B
Doxycycline
D
Cefazolin
B
Micafungin
C
Tetracycline
D
Efavirenz
D
Cefdinir
B
Nelfinavir
B
Tigecycline
D
Emtricitabine
B
Cefepime
B
Nevirapine
B
Tipranavir
C
Enfuvirtide
B
Cefixime
B
Nitrofurantoin
B
Tobramycin
D
Erythromycin
B
Cefpodoxime
B
Norfloxacin
C
Trimethoprim
C
Ethambutol
B
Cefprozil
B
Oxacillin
B
TMP/SMX2
C
Etravirine
B
Ceftriaxone
B
Oseltamivir
C
Vaccines
See note
Fluconazole
C
Cefuroxime
B
Penicillin G
B
Valganciclovir
C
Flucytosine
C
Cephalexin
B
Pentamidine
C
Vancomycin
C
Foscarnet
C
Chloramphenicol
C
Piperacillin/tazobactam B
Voriconazole
D
Fosamprenavir
C
Cidofovir
C
Posaconazole
C
Zidovudine
C
Fosfomycin
B
Ciprofloxacin
C
Pyrazinamide
C
1 Metronidazole is contraindicated in the rst trimester.
2 Avoid near term.
Note: Vaccines in pregnancyPregnant women should receive the influenza vaccine. In addition, pregnant women should receive
tetanus-diphtheria (Tdap) if not already immune. Live virus vaccines such as measles-mumps-rubella (MMR) and varicella are
contraindicated in pregnancy with the exception of yellow fever vaccine. For a listing of vaccines recommended during pregnancy,
refer to Table 26 (Adult Immunization).
(Table continued on following page)
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54
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Notes
Chloramphenicol
Ciprofloxacin, norfloxacin
(quinolones)
Clofazimine
Clofazimine is excreted into breast milk and may result in skin pigmentation
of the nursing infant
Furazolidone
Avoid in infants less than 1 month old due to potential risk of hemolytic anemia
Metronidazole
Vaccines
Vaccines are compatible with lactation, including live vaccines such as measlesmumps-rubella (MMR) and oral polio vaccine (OPV). There has been transfer of live
vaccines to nursing infants with no ill effects noted
55
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56
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57
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19-49
t65
50-64
Human papillomavirus
1 or 2 doses
1 dose
Varicella
Influenza
1 dose annually
Pneumococcal (polysaccharide)
Hepatitis A
1-2 doses
2 doses (0, 6-12 months or 0, 6-18 months)
Hepatitis B
Meningococcal
1 or more doses
1 dose1
Zoster
For all persons in this category who meet the
age requirements and who lack evidence of
immunity (eg, lack documentation of vaccination or have no evidence of prior infection)
1 Recommended beginning at age 60. (Note: FDA approved to begin at age 50.)
AMUG13.indd 58
1 dose
58
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Vaccine
Pregnancy
Td/Tdap
Diabetes,
kidney failure, Health
ESRD, receipt care
of hemodialysis personnel
HPV (female)
HPV (male)
MMR
Contraindicated
1 or 2 doses
Varicella
Contraindicated
Influenza (annually)
1 dose TIV
PPV
TIV/LAIV
1-2 doses
HepA
HepB
Meningococcal
Zoster
1 or more doses
Contraindicated
For all persons in this category who meet the age requirements
and who lack evidence of immunity (eg, lack documentation of
vaccination or have no evidence of prior infection)
1 dose
Recommended if some other risk factor
is present (eg, on the basis of medical,
occupational, lifestyle, or other indications)
Adapted from: Recommended Adult Immunization Schedule. Centers for Disease Control and Prevention Web site. http://www.cdc
.gov/vaccines/recs/schedules/downloads/adult/07-08/adult-schedule.pdf. Accessed August 15, 2012.
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Contact (#101)
Organism/
disease
Disseminated herpes
zoster (shingles)1
RSV when receiving
aerosolized ribavarin
therapy
Varicella/chickenpox1
Smallpox
Tuberculosis
Same as Standard
Same as Standard
Signage
None
Contact Precautions5
Droplet Precautions
Airborne Precautions5
Gloves
Same as Standard
Same as Standard
Droplet (#102)
Airborne (#103)
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Contact (#101)
Droplet (#102)
Airborne (#103)
Gown
To protect clothing
when splash and/
or spray likely
Same as Standard
Mask/eye
protection
Surgical mask
Respirator7
Patient placement
No restrictions
Patient-care
equipiment
Same as Standard
Patient
transport
No restrictions
Cover wheelchair/cart;
Surgical mask on
have patient clean hands patient8
and don clean gown
before ambulation8
Surgical mask on
patient8
1
2
3
4
5
6
7
8
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Antimicrobial3 Program
Cardiothoracic
Routine prophylaxis:
Cefuroxime 1.5 g q12h
MRSA colonized patients:
Cefuroxime 1.5 g q12h PLUS
vancomycin 1 g q12h
Penicillin-Allergic Patient
Colorectal
Ampicillin/sulbactam 3 g
General surgery
Cefazolin 1 g
Vancomycin 1 g OR
clindamycin 900 mg
Neurosurgical
Cefazolin 1 g
Vancomycin 1 g
Orthopedics
Cefazolin 1 g4
Vancomycin 1 g OR
clindamycin 900 mg
Vascular Surgery
Cefazolin 1 g4 OR
cefuroxime 1.5 g
Vancomycin 1 g OR
clindamycin 900 mg
1
2
3
4
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Agent
Amoxicillin
Cephalexin1 or
Clindamycin or
Azithromycin
Ampicillin or
Cefazolin or ceftriaxone1
Cefazolin or ceftriaxone1
Clindamycin
1 Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or
ampicillin.
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Heart
PCP
Fungal
Preferred Regimen
Alternatives
Liver
PCP
Fungal
Lung
PCP
Fungal
65
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Fungal
1 Guidelines subject to change; please check website version for most current recommendations.
2 Trough level >250 mcg/mL; usually achieved around day 10 to 14.
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Regimen
Heart
D-/RD-/R+2
D+/R+2
D+/R-2
Lung4
D-/R-5
D-/R+5
D+/R+5
D+/R-5
Ganciclovir3 5 mg/k IV q12h until able to take oral, then acyclovir3 400 mg PO tid 180 days
Ganciclovir3 5 mg/kg IV q12h until able to take oral, then valganciclovir3 900 mg PO q24h 1 year
Same as D-/R+
Same as D-/R+
Kidney
D-/RD-/R+
D+/R+
D+/R-
1 Guidelines subject to change; please check website for most current recommendations.
2 Patients unable to tolerate oral medications by day 7, ganciclovir4 5 mg/kg IV q12h 2 wk then 6 mg/kg IV q24h 2 wk; change
to valganciclovir when able to tolerate oral medications.
3 Renal dosage adjustment necessary.
4 CMV DNA checked at least every 2 weeks for rst year.
5 If patients unable to tolerate oral medications by day 14, decrease to ganciclovir 2.5 mg/kg IV q12h.
(Table continued on following page)
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(continued)
Regimen
Liver
D-/RD-/R+
D+/R+
D+/RSmall Bowel
Ganciclovir2 5 mg/kg IV q12h until able to take oral, then valganciclovir2 450 mg PO bid 6 months
Same as D-/RSame as D-/RSame as D-/R- PLUS CMV immune globulin 50 mg/kg once monthly 6 months
D-/RD-/R+
D+/R+
D+/RValganciclovir4
1
2
3
4
5
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Ganciclovir IV
Acyclovir
CrCl
(mL/min)
Induction3
Maintenance5
CrCl
(mL/min)
Dose
t60
40-59
25-39
10-24
900 mg bid
450 mg bid
450 mg q24h
450 mg q2d
900 mg q24h
450 mg q24h
450 mg q2d
450 mg twice weekly
>80
50-79
25-49
<25
5 mg/kg q12h
2.5 mg/kg q12h
2.5 mg/kg q24h
1.25 mg/kg q24h
CrCl
(mL/min)
Dose
>50
25-50
<25
q6-8h
q8-12h
q12h
Guidelines subject to change; please check website for most current recommendations.
Renal dosage adjustment necessary.
Heart and liver transplants use 2 wk of induction followed by maintenance dosing or a change to acyclovir.
Monitor CBC; valganciclovir may cause bone marrow suppression.
Lung and kidney transplants ONLY use maintenance dosing.
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Regimen
Viral
Fungal:
Pre-engraftment
Post-engraftment
Viral:
Patients will have weekly CMV PCR for the first 3 months after transplant, then every 2 weeks for 3 months if tests are negative.
Monitoring should continue for patients treated with immunosuppressive therapy for GVHD due to the risk of CMV reactivation.
Asymptomatic patient with viral load >1,000 copies/mL: valganciclovir1 900 mg PO bid
Symptomatic patient or viral load >10,000 copies/mL: ganciclovir1 5 mg/kg IV q12h
Cord Blood Stem-Cell Transplants
Bacterial (see Allogeneic Stem-Cell Transplant)
Fungal (see Allogeneic Stem-Cell Transplant)
Viral:
CMV recipient:
Negative
Positive
1
2
3
4
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Dose
Doses/d
Cost/d1
Cost/wk2
Acyclovir
Amikacin
Amphotericin B
Amphotericin B Lipid
Complex
Ampicillin
Ampicillin/sulbactam
Azithromycin
Azithromycin (PO)
Aztreonam
Cefazolin
Cefepime
Ceftriaxone
Ceftriaxone
Cefuroxime
Cefuroxime
Cidofovir
Ciprofloxacin
Ciprofloxacin (PO)
Clindamycin
Daptomycin
Ertapenem
Erythromycin
Fluconazole
Fluconazole
Fluconazole (PO)
Foscarnet
Fosfomycin (PO)
500 mg q8h
500 mg q12h
50 mg q24h
3 mg/kg q24h
3
2
1
1
$25
$5
$5
$160
$180
$35
$40
$1120
1 g q6h
3 g q8h
500 mg q24h
500 mg q24h
2 g q8h
1 g q8h
2 g q8h
1 g q24h
2 g q24h
750 mg q8h
1.5 g q8h
5 mg/kg OW2 wk
400 mg q12h
750 mg bid
600 mg q8h
500 mg q24h
1 g q24h
1 g q6h
200 mg q24h
400 mg q24h
200 mg q24h
6.3 g q12h
3 g single dose
4
3
1
1
3
3
3
1
1
3
3
N/A
2
2
3
1
1
4
1
1
1
2
1
$10
$30
$10
$5
$155
$10
$25
$5
$10
$15
$30
N/A
$5
$0.25
$10
$275
$65
$10
$5
$10
$0.40
$105
$45
$60
$220
$70
$30
$1080
$80
$175
$40
$80
$120
$200
$700
$35
$2.00
$80
$1920
$460
$80
$40
$70
$3
$720
Not applicable
(Table continued on following page)
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Dose
Doses/d
Cost/d1
Cost/wk2
Ganciclovir
Gentamicin
Linezolid (IV)
Linezolid (PO)
Meropenem (IV)
Metronidazole
Micafungin
Oxacillin
Piperacillin/tazobactam
Posaconazole (PO)
Tigecycline (IV)
Tobramycin
TMP/SMX
TMP/SMX (PO)
Valganciclovir (PO)
Vancomycin
Vancomycin (PO)
Voriconazole (IV)
Voriconazole (PO)
350 mg q12h
80 mg q8h
600 mg q12h
600 mg q12h
500 mg q6h
500 mg q6h
150 mg q24h
2 g q4h
3.375 mg q6h
200 mg q8h
50 mg q12h
80 mg q8h
320 mg q6h3
160 mg q12h
900 mg q12h
1 g q12h
125 mg q6h
200 mg q12h
200 mg q12h
2
3
2
2
4
4
1
6
4
3
2
3
4
2
2
2
4
2
2
$90
$5
$190
$150
$40
$10
$120
$50
$60
$90
$120
$10
$10
$5
$200
$10
$5
$180
$60
$640
$20
$1340
$1050
$280
$60
$840
$360
$420
$620
$840
$80
$80
$20
$1400
$70
$40
$1260
$420
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Acyclovir
Amikacin
Ampicillin
Ampicillin/sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefepime
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Ceftriaxone
Ciprofloxacin
Clindamycin
Colistin
Daptomycin
Doxycycline
Fluconazole
Ganciclovir
Gentamicin
Linezolid
Meropenem
Metronidazole
Micafungin
Moxifloxacin
Oxacillin
Penicillin G
Piperacillin/tazobactam
Tigecycline
Tobramycin
TMP/SMX
Vancomycin
Voriconazole
73
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Gent
Amp
Amp/Sulb
Cefazolin
Cftx
Pip/Tazo
Acinetobacter baumanii
Citrobacter freundii
Citrobacter koseri
Enterobacter aerogenes
Enterobacter cloacae
Escherichia coli
Klebsiella pneumoniae
Proteus mirabilis
32
95
100
100
94
90
89
90
0
0
0
0
0
46
0
75
37
0
0
0
56
72
88
0
0
0
0
84
86
93
0
72
97
84
77
94
84
99
13
87
97
84
80
96
85
99
TMP/SMX Cipro
24
75
94
95
83
74
81
76
Mero
19
78
100
95
90
69
84
74
23
100
100
100
98
99
85
100
Antimicrobial
Organism
Pseudomonas aeruginosa
Stenotrophomonas (Xanthomonas)
maltophilia
Gent
Tobra
Amik
Cefep
57
85
93
79
Pip/Tazo TMP/SMX
86
0
83
Cipro
Mero
68
76
0
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Pcn
Cftx
Amp
Vanc
Clinda
TMP/SMX
Tetracycline
Erythro
Lin
Dapto
20
0
100
100
89
59
100
97
95
94
63
0
N/A3
100
N/A3
100
N/A
N/A
100
N/A
67
84
43
N/A
N/A
86
0
N/A
0
91
0
100
0
N/A
N/A
N/A
N/A
21
10
N/A
N/A
N/A
99
N/A
100
83
93
100
75
60
N/A
37
N/A
N/A
1 Results are from species represented by at least 10 isolates tested between 1/1/11 and 12/31/11 from Cleveland Clinic
inpatients.
2 Oxacillin-susceptible staphylococci are also susceptible to cefazolin, ampicillin/sulbactam, and piperacillin/tazobactam.
MRSA makes up 49% of the total S aureus isolates.
3 N/A = data not applicable to that isolate or not available.
4 High-level aminoglycoside resistance in vancomycin-resistant enterococcus (VRE) = 23% for gentamicin and 53% for streptomycin; for vancomycin-susceptible enterococcus (VSE), 27% for gentamicin and 28% for streptomycin.
5 VRE makes up 44% of total inpatient Enterococcal isolates of total Enterococcus isolates.
6 83% of S pneumoniae were fully susceptible to penicillin.
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Glossary of Abbreviations/Acronyms
AIDS acquired immune
deficiency syndrome
Amp ampicillin
Amp/Sulb ampicillin/sulbactam
ANC absolute neutrophil count
ARDS acute respiratory distress
syndrome
ARV antiretroviral
bid twice a day
BMT bone marrow transplant
BP blood pressure
CAD cryptococcal antigen
detection
Cap capsule
CAP community-acquired
pneumonia
CBC complete blood cell count
CDAD Clostridium difficile
associated diarrhea
CDC Centers for Disease Control
and Prevention
Cefep cefepime
Cftx ceftizoxime
Chloramph chloramphenicol
Cipro cirpofloxacin
CLD chronic liver disease
Clinda clindamycin
CMV cytomegalovirus
CNS central nervous system
CNS coagulase-negative
staphylococci
CoPAT community-based
parenteral antimicrobial
therapy
AMUG13.indd 76
GPC
GVHD
h
H/D
HACEK
[group]
HAP
HBIG
heme-onc
HepA
HepB
Hib
HIV
HPV
HR
HSV
ICU
ID
IE
IgE
IgG
IHD
IM
Inj
IP
IPV
IV
IVIG
kg
gram-positive cocci
graft-vs-host disease
hour(s)
hemodialysis
Hemophilus, Actinobacillus,
Cardiobacterium, Eikinella,
Kingella
hospital-acquired
pneumonia
hepatitis B immune globulin
hematology-oncology
hepatitis A vaccine
hepatitis B vaccine
Haemophilus influenzae
type B [vaccine]
human immunodeficiency
virus
human papilloma virus
heart rate
herpes simplex virus
intensive-care unit
infectious disease
infective endocarditis
immunoglobulin E
immunoglobulin G
intermittent hemodialysis
intramuscular
injection
intraperitoneal
inactivated poliomyelitis
vaccine
intravenous
intravenous immunoglobulin
kilogram
76
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NVP
OD
OPV
OW
PABA
PaO2
PAPR
Pcn
PCP
PCR
P/D
PI
PICC
PID
Pip
Pip/Tazo
PO
Powd
PPV
PR
PVE
q
qid
R
R+/
RIG
RR
RSV
RTV
nevirapine
once a day
oral polio vaccine
once weekly
para-aminobenzoic acid
partial pressure of oxygen
in arterial blood
powered air purifying
respirator
penicillin
Pneumocystis carinii
pneumonia
polymerase chain reaction
peritoneal dialysis
protease inhibitor
peripherally inserted central
catheters
pelvic inflammatory disease
piperacillin
piperacillin/tazobactam
oral
powder
pneumococcal
polysaccharide vaccine
by way of the rectum
prosthetic valve
endocarditis
every
four times a day
recipient
seropositive/seronegative R
rabies immune globulin
respiratory rate
respiratory synctial virus
ritonavir
77
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NOTES
78
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NOTES
79
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Table of Contents
Introduction ...............................................................................................................................................................................................................4
TABLE 1
Typical Gram Stain Morphology of Selected Organisms.............................................................................................................5
TABLE 2 Key Characteristics of Selected Organisms ....................................................................................................................................6
TABLE 3
Usual Acid-Fast Bacillus Characteristics ........................................................................................................................................8
TABLE 4
Laboratory Requests and Specimen Types ....................................................................................................................................9
TABLE 5
Mechanism of Action of Common Antibacterial Agents ...........................................................................................................11
TABLE 6 Guidelines for Treatment of Pneumonia in Adults ....................................................................................................................13
TABLE 7 Guidelines for Treatment of Infective Endocarditis in Adults ..................................................................................................14
TABLE 8 Guidelines for Treatment of Bone and Joint Infections in Adults ............................................................................................15
TABLE 9 Guidelines for Treatment of Urinary Tract Infections in Adults ..............................................................................................16
TABLE 10 Guidelines for Treatment of Sexually Transmitted Infections ..................................................................................................17
TABLE 11 Guidelines for Treatment of Bacterial Meningitis in Adults .....................................................................................................21
TABLE 12
Guidelines for Treatment of Febrile Neutropenia.......................................................................................................................22
TABLE 13 Guidelines for Management of Clostridium difcile Toxin-Positive Diarrhea ..........................................................................23
TABLE 14 Treatment of Skin and Skin Structure Infections.........................................................................................................................24
TABLE 15
Guidelines for Antimicrobial Dosing in Adults ..........................................................................................................................25
TABLE 16 Formulary-Approved Indications and Dosing of Restricted Antimicrobial Agents in Adults............................................33
TABLE 17 Antiretrovirals ..................................................................................................................................................................................38
TABLE 18 Traditional Aminoglycoside Dosing .............................................................................................................................................46
TABLE 19 Extended Interval Aminoglycoside Dosing .................................................................................................................................48
TABLE 20 Vancomycin Dosing Guidelines for Adults .................................................................................................................................49
TABLE 21 Antimicrobial Interactions With Cyclosporine, Tacrolimus, and Sirolimus ...........................................................................51
TABLE 22 Antimicrobial Interactions With Warfarin ...................................................................................................................................52
TABLE 23 Antimicrobials in Pregnancy ..........................................................................................................................................................53
TABLE 24 Antimicrobials in Lactation ............................................................................................................................................................55
TABLE 25 Community-Based Parenteral Antimicrobial Therapy (CoPAT) Guidelines..........................................................................56
TABLE 26 Recommended Adult Immunization Schedule ...........................................................................................................................58
TABLE 27
Isolation Precaution Quick Guide .................................................................................................................................................60
TABLE 28 Guidelines for Antimicrobial Prophylaxis for Clean and Clean-Contaminated Surgical Wounds ....................................62
TABLE 29 Guidelines for Prophylaxis of Infective Endocarditis ................................................................................................................63
TABLE 30 Solid-Organ Transplant: Antimicrobial Prophylaxis ..................................................................................................................65
TABLE 31
Solid-Organ Transplant: CMV Prophylaxis .................................................................................................................................67
TABLE 32 Bone Marrow Transplant: Antimicrobial and CMV Prophylaxis .............................................................................................69
TABLE 33
Antimicrobial Cost Data for the Cleveland Clinic ......................................................................................................................70
TABLE 34
Guidelines for Selective Antimicrobial Dosing in Adults Receiving Continuous Venovenous Hemodialysis .................72
TABLE 35
Percentage of Bacteria Susceptible to Various Antimicrobial Agents at the Cleveland Clinic ............................................74
Glossary of Abbreviations/Acronyms ................................................................................................................................................................ 76
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