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CKHS EMPIRIC ANTIBIOTIC GUIDANCE FOR ADULT PNEUMONIA

(CDAD-SPARING)
TREATMENT INITIATION IN ED:
Recommend microbiologic culture for pathogen identification
Urine Antigen Assays for: S. Pneumoniae and Legionella pathogens
Administer antibiotic within 6 hours as it is shown to improve survival in PNA and sepsis
Administer first dose in the ED if admitting diagnosis of PNA suspected or made
Use of quinolones and cephalosporins are associated with higher incidence of CDAD

OUTPATIENT SEVERITY OF ILLNESS ANTIBIOTIC AGENTS TOTAL DURATION/NOTES


MILD Azithromycin 500 mg PO x 1, then 250 mg PO daily
(CURB-65=1 & NO RISK FACTORS, OR 5 days with evidence of clinical
PREVIOUSLY HEALTHY) Doxycycline 100 mg PO q12h stability of:
Stable BP
MILD PREFERRED: Afebrile for 48-72h
(CURB-65=1 & PRESENCE OF Amoxicillin 1 gram PO q8h* AND Adequate PO intake
COMORBIDITIES: Azithromycin 500 mg PO x 1, then 250mg PO daily Room air O2sat > 90%
COPD OR
Heart disease Amoxicillin/clavulanate 875 mg PO q12h* AND CKHS patients under
Liver disease Azithromycin 500 mg PO x 1, then 250mg PO daily Observation status should
Renal disease follow the antibiotic agents for
DM ALTERNATIVES: OUTPATIENT SEVERITY OF
Alcoholism Cefuroxime 500 mg PO q12h* AND ILLNESS
Malignancies Azithromycin 500 mg PO x 1, then 250mg PO daily
Use of antibiotics within previous 3 OR
months (antibiotic from a different class Cefpodoxime 200 mg PO q12h* AND
should be selected) Azithromycin 500 mg PO x 1, then 250mg PO daily
Immunosuppressing conditions or use OR
of such drugs Cefdinir 300 mg PO q12h* AND
Azithromycin 500 mg PO x 1, then 250mg PO daily

SEVERE IgE MEDIATED PCN ALLERGY:


Levofloxacin 750 mg PO daily*

IN-PATIENTSEVERITY OF ILLNESS ANTIBIOTIC AGENTS TOTAL DURATION/NOTES


MODERATE Ampicillin/sulbactam 3 gms IV q6h* AND 5 days with evidence of clinical
(CURB-65 >1 & <3, NON-ICU) Azithromycin 500 mg IV/PO daily stability of:
Stable BP
SEVERE IgE MEDIATED PCN ALLERGY: Afebrile for 48-72h
Levofloxacin 750 mg IV/PO daily* Adequate PO intake
Room air O2sat > 90%
SEVERE Piperacillin/tazobactam 4.5 gms IV over 30min 7 days with shorter or longer
(CURB-653, ICU, Pseudomonas Risks**: x 1, then 3.375 gms IV over 4h q8h*(?) AND duration based on
structural lung disease such as: Azithromycin 500 mg IV daily AND improvement of:
bronchiectasis, CF, Tobramycin 7 mg/kg (IBW/CBW) IV daily* clinical
frequent COPD exacerbations on steroid radiologic
and/or antibiotic use ESBL MDROs KNOWN COLONIZATION ONLY: lab parameters
chronic trach Imipenem/cilastatin 500 mg IV q6h* AND
febrile neutropenia Azithromycin 500 mg IV daily AND IBW=Ideal Body Wt.
asplenia Tobramycin 7mg/kg (IBW/CBW) IV daily* CBW=Corrected Body Wt.
underlying malignancy
organ failure, hypoxia and/or SEVERE IgE MEDIATED PCN ALLERGY: ESBL=Extended Spectrum Beta
hypotension Levofloxacin 750 mg IV daily* AND Lactamase
prior antibiotic use within 90days Aztreonam 2 gm IV q8h* AND MDROs=Multi Drug Resistant
Tobramycin 7 mg/kg (IBW/CBW) IV daily* Organisms
PATHOGEN-SUSPECTED THERAPY ADD ON ANTIBIOTIC AGENTS TOTAL DURATION/NOTES
CA-MRSA Linezolid 600 mg IV/PO q12h OR 7 days with shorter or longer
(in-patient, non-ICU or ICU) with MRSA risks: duration based on
ESRD Vancomycin 25 mg/kg (ABW) IV x 1, then improvement of:
IVDA 15 mg/kg (IBW/CBW)IV q8-12h* clinical
prior MRSA infection radiologic
post-influenza A &B lab parameters
recent antibiotic use
empyema Use MRSA antibiotic choices as
presence of cavitary disease monotherapy or in
combination with regimens
listed in the IN-PATIENT
SEVERITY OF ILLNESS section

ABW=Actual Body Wt.

INFLUENZA A&B Oseltamivir 75 mg PO q12h* 5 days treatment duration for


(in-patient, non-ICU or ICU) Oseltamivir

ALTERNATIVE REGIMEN: Peramivir reserved for the


Peramivir 600 mg IV x 1* following patients:
Unable to tolerate/absorb
PO oseltamivir
Suspected or known
gastric stasis,
malabsorption or GI bleed
Must be approved by ID prior
to dispensing
HSV Acyclovir 10 mg/kg (IBW) IV q8h* 5-7 days per PI or 2-7 days of
(in-patient, non-ICU or ICU) IV treatment; followed by PO
for total of 10 days per CDC
2015

- CKHS Antimicrobial Restriction Policy Applies


*CKHS Renal Dosing Guidelines Applies (please note table below for additional agents requiring Renal Dosing Adj. not listed
in CKHS Renal Dosing Guidelines)
**see Appendix A (Risk Factors for Drug Resistant S. PneumoniaDRSP) and Appendix B (Risk Factors for Identifying MDROs)
- CKHS IV to PO applies
- Refer to CKHS Antibiogram when applicable
- Consider Allergy/Immunology evaluation for patients with PCN allergy

Disclaimer: The contents of this document are to be used as a guide only and health-care professionals should use sound
clinical judgment and individualize therapy to each specific patient care situation. This guide is not meant to be a replacement
for training, expertise, experience or studying the latest drug prescribing literature. This guide is intended to be a quick and
convenient reminder of information you have learned elsewhere.

Draft prepared by: Ozana Lipka, Pharm.D. on 10/5/2016 Reviewed by: S. Nelson, MD 10/7/16
*RENAL DOSING ADJUSMENT BASED ON PATIENT CREATININE CLEARANCE (CrCl)
FOR ANTIBIOTICS NOT INCLUDED IN CKHS RENAL DOSING GUIDELINES

ANTIBIOTIC AGENT CrCl DOSE FREQUENCY

AMOXICILLIN 30ml/min 1 gm PO q8h


10-30ml/min 1 gm PO q12h
10ml/min 1 gm PO daily
IHD 1 gm PO daily post-IHD

AMOXICILLIN/CLAVULANATE 30ml/min 875 mg PO q12h


10-30m//min 500 mg PO q12h D0 NOT USE 875mg
10ml/min 500 mg PO daily- DO NOT USE 875mg
IHD 500 mg PO daily post-IHD DO NOT USE 875mg

CEFUROXIME 30ml/min 500 mg PO q12h


10-30ml/min 500 mg PO daily
10ml/min 500 mg PO q48h
IHD 500 mg PO daily post-IHD

CEFPODOXIME 30ml/min 200 mg PO q12h


<30ml/min 200 mg PO daily
IHD 200 mg PO post-IHD on IHD days

CEFDINIR 30ml/min 300 mg PO q12h


<30ml/min 300 mg PO daily
IHD 300 mg PO post-IHD on IHD days

OSELTAMIVIR >60ml/min 75 mg PO q12h


>30-60ml/min 30 mg PO q12h
>10-30ml/min 30 mg PO daily
IHD 30 mg PO times1, then 30 mg PO post-IHD on IHD
days

PERAMIVIR 50ml/min 600 mg IV times 1


30-49ml/min 200 mg IV times 1
10-29ml/min 100 mg IV times 1
IHD 100 mg IV times 1 post-IHD

ACYCLOVIR 50ml/min 10 mg/kg IV q8h


25-50ml/min 10 mg/kg IV q12h
10-25ml/min 10 mg/kg IV daily
<10ml/min 5 mg/kg IV daily
IHD 5 mg/kg IV daily