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Antimicrobial

stewardship program

1/1/2014
Antimicrobial Guideline

This 1st Edition of the antimicrobial guideline of Ministry of


Health truly substantiates our commitment to the general
pharmaceutical care administration Mission and Vision,
dedicated to humanity as inspired by Allah. This story of
success speaks a lot about the integrity of the pharmacy
profession. As the world of pharmacy is not excused to the
constant occurrence of changes, our pursuit to give top
priority to patient care and safety prevails. Congratulations
on the success of the Task Force to initiate, Review, And
Update the antimicrobial guideline comprised of
Pharmaceutical Care Services in the different regions.

Deputy Minister of Health for Curative Service

Dr.Tarif Al-Aama
We are proud to introduce the first edition of the
antimicrobial guideline it has been our aim to provide staff
with reliable, up-to-date drug information. In the daily
management of patients, clinicians are often faced with the
need to access drug information quickly in order to make
swift therapeutic decisions. It is hoped that this guideline
may be a readily accessible source of clinically important
information for antibiotics usage. Additionally, it is meant to
provide a quick and reliable source of information for
nursing staff. At a time when worldwide attention is being.

Assistant Deputy Minister for Supportive Medical Services

DR. Munira Hemdan Al-esseimi


I would like to thank the working committee for their tireless
efforts in developing the first edition of the ‘infectious
disease guideline’. Due to the rapidly expanding using of
antibiotics nationwide, it is very timely and essential that the
Pharmaceutical Services Division, Ministry of Health
develops and publishes this guideline
The contents of this guideline will be able to serve as a
standard reference for all hospital pharmacists in handling
and managing antibiotics. I am confident that this guideline
will also provide useful information on ensuring quality,
safety and efficacy of products.

Director of General Administration of

Pharmaceutical care at Ministry of Health

Dr. Yousef ahamed alomi


Editors

Dr. Yousef Al-omi

Clinical Ph. Alaa Mutlaq

Reviewers

Ph. Abeer Al-Masoody


Ph. Ahmad Al-yamani
Dr. Ameenah Ghandeel
Ph. Abeer Muhssen
Dr. Abdullah Al-mohaizeie
Dr. Abdulrazaq Ghareeb
Ph. Abdullah Al-Methhan
Dr. Batool Mohammad Suliman
Dr. Deema Al Okaili
Dr. Faten Saif
Dr. Hail Al-Abdali
Ph. Hind Almuteri
Dr. Hala Rushdi
Dr. Hanan Hanafi
Dr. Musheera Anani
Dr. Maha Alawy
Dr. Mustafa Alkalaf
Clinical Ph. Mohammad Al- Zaid
Ph. Muna Fuleflan
Dr. Mohammad Shaik Ahmad
Dr. Samira Fallatah
Clinical Ph. Sultan Al- Mubarky
Dr. Sara Shalhoub
Table of content:

Guideline for Establish Antimicrobial Stewardship at MOH hospitals


Section I: Policy and procedure
Section II: National antimicrobial guideline:

Group A streptococcal Pharyngitis


Acute Bacterial Rhinosinusitis
Community Acquired Pneumonia
Bacterial Meningitis
Brain Abscess
Infective endocarditis
Urinary Tract Infection
Osteomyelitis
Diabetic Foot Infection
Skin and Soft Tissue Infection
Peritonitis
Sexually Transmitted Disease
Pelvic Inflammatory Disease
Intra-abdominal Infection
Brucellosis
Tuberculosis
Antiviral Infection
Antifungal Infection
Parasitic Infection
Surgical Prophylaxis

Appendix A: Guideline for blood culture collection


Appendix B: Infection Control
Appendix C: Skin test kits, Anaphylactic kits , Skin test procedure and anaphylaxis algorithm
Appendix D: Antibiotics dosing monitoring
Appendix E: Practical Approaches for Conversion IV antibiotics to Oral therapy
Appendix F: Antibiogram
Appendix G: Antimicrobial Consumption
Appendix H: Formulary/ Pre-Authorization Restricted Forms
Appendix I: Abbreviation
Appendix J: Dose Adjustment for Renal Impairment
Guidelines for Developing an Antimicrobial Stewardship
in MOH hospitals:
NOTE: These guidelines focus on the development of effective hospital-based stewardship programs and do not include specific
outpatient recommendations.

Guideline Purpose:
To improve antimicrobial use for hospitalized adults.
Minimizing the emergence and spread of antimicrobial resistance.

The antimicrobial stewardship team and administrative support

Core members of antimicrobial stewardship:


Infectious diseases physician ( Leader )
Clinical pharmacist with infectious diseases training (Coordinator)
Clinical microbiologist
An information system specialist
An infection control professional
hospital epidemiologist
Administrative support:
Hospital administration (necessary infrastructure)
Medical staff leadership
local providers ( e.g: nurses)
Collaborated providers:
Hospital infection control
Pharmacy and therapeutics committees

Core strategies:
Prospective audit with intervention and feedback:
It is a method that allows the antimicrobial stewardship program (an infectious diseases physician or a clinical
pharmacist) to interact directly with prescribers in order to modify specific antibiotic therapy for each patient.
These strategies are employed after the initial prescribing and dispensing of the antibiotic.

Formulary restriction and preauthorization:


It is a method that allows the antimicrobial stewardship program (an infectious diseases physician or a clinical
pharmacist) to interact directly with prescribers for approval (Appendix: H)

Supplemental Antimicrobial Stewardship Strategies:

Education: education alone, without incorporation of active intervention, is only marginally effective in changing
antimicrobial prescribing practices and has not demonstrated a sustained impact

Guidelines and clinical pathways: (Section II: National Guideline of Antimicrobial)


This guideline covers the community acquired pneumonia only because the creation of nosocomial infection
guideline depends mainly on the local microbiology and resistance patterns.
It is an order forms to enhance the adherence of this guideline
Guideline implementation can be facilitated through provider education and feedback on antimicrobial use and
patient outcomes

Antimicrobial order forms:


Use of antimicrobial order forms with automatic discontinuation according to the guideline with optimal timing and
duration of antibiotics resulted in a decrease in the misuse of antimicrobial
Combination empirical therapy and de-escalation antimicrobial:
The guideline recommended the combination antimicrobial therapy includes broad-spectrum empirical therapy for
serious infections to improved clinical outcomes, and the prevention of resistance but the de-escalation depend on
the culture result is essential to decreased antimicrobial exposure and substantial cost savings

Conversion from parenteral to oral therapy


A systematic plan for parenteral to oral conversion of antimicrobials with excellent bioavailability, when the
patient’s condition allows, can decrease length of hospital stay and health care costs
Development of clinical criteria and guidelines allowing conversion to use of oral agents can facilitate
implementation at the institutional level (Appendix: E)

Antimicrobial dosing:
All the following should be considered during antibiotics prescribing:
Dose optimization (pharmacokinetics/pharmacodynamics) is essential to optimize the treatment of organisms with
reduced susceptibility
Dosing Monitoring for vancomycin and aminoglycoside (Appendix: D)
Dose adjustments in cases of renal dysfunction (Appendix: J)

Surveillance of antimicrobial resistance:

The antibiotic policy shall depend heavily on surveillance of antimicrobial resistance ((Appendix: F (antibiogram)
and antibiotic consumption ((Appendix: G (antibiotics consumption)) in any setting. Hence, it is mandatory to
establish an efficient surveillance system.
The surveillance for antimicrobial resistance/antibiotic consumption and preparation of an “enhanced” or
cumulative antibiogram at the local level helps in clinical decision-making, design infection control interventions,
and antimicrobial-resistance containment strategies.
The clinical microbiology laboratory plays a critical role in antimicrobial stewardship by providing patient-specific
culture and susceptibility data
The pharmacy department responsible for antibiotics consumption at all hospital setting
(ICU, non-ICU, Outpatient …etc)

Computer Surveillance and Decision Support


(Note: the antimicrobial order form should be electronic unless the electronic prescription system does not exist in the hospital
setting)
Health care information technology in the form of electronic medical records , CPOE , and clinical decision support
can improve antimicrobial decisions through the incorporation of data on patient-specific microbiology cultures
and susceptibilities, hepatic and renal function, drug-drug interactions, allergies, and cost
Computer-based surveillance can facilitate good stewardship by more efficient targeting of antimicrobial
interventions, tracking of antimicrobial resistance patterns, and identification of nosocomial infections and adverse
drug events

Monitoring of Process and Outcome Measurements

Determining the impact of antimicrobial stewardship on antimicrobial use and resistance patterns by two
steps:
Process measures (did the intervention result in the desired change in antimicrobial use?)
Outcome measures (did the process implemented reduce or prevent resistance or other unintended
consequences of antimicrobial use?)

Please fill the following surveys:


Antimicrobial Stewardship Process Measure:
Antimicrobial Stewardship Outcome Measure:
Step-wise implementation of an antimicrobial stewardship program initially with passive strategies, such
as education and order forms, followed by an active strategy with prospective audit and intervention
Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Infectious Diseases (January 2007 vol. 44 no. 2 159-177
Checklist for Core Elements of Hospital Antibiotic Stewardship Programs. CDC March 3, 2014
General Administration ‫ﺍﻹﺩﺍﺭﺓ ﺍﻟﻌﺎﻣﺔ ﻟﻠﺮﻋﺎﻳﺔ ﺍﻟﺼﻴﺪﻟﻴﺔ‬

Of Pharmaceutical care ‫ﳉﻨﺔ ﺍﳌﻀﺎﺩﺍﺕ ﺍﳊﻴﻮﻳﺔ‬

Antimicrobial committee

Administrative Policies and Procedures


‫اﻟﺴﯿﺎﺳﺎت واﻹﺟﺮاءات اﻹدارﯾﺔ‬
  for MOH hospitals /PHC Centers
‫ﺑﻤﺴﺘﺸﻔﯿﺎت وﻣﺮاﻛﺰ وزارة اﻟﺼﺤﺔ‬
TITLE : Antimicrobial Guideline
NO. of Pages: 2
ORIGINAL DATE: 1/1/2015
REVISION DATE : every 6 months

PURPOSE:
To provide a standard method/ guidelines in prescribing medication (antimicrobials) for health care providers
at MOH.
EQUIPMENTS/ MATERIALS:
Patient Medical record.
Antibiotic order form
POLICY STATEMENT:
This guideline only for adult
Antibiotics order form is controlled and a guided method to all health care providers (physician, pharmacist,
clinical pharmacist and nurse) during prescribing the antibiotics
The guideline is formatted as physician order
The use of this order form is only for community acquired infection.
The management of nosocomial infection depend on the hospital antibiogram results
Referral to the original guideline is very important for a pharmacist/clinical pharmacist for more detail or any
update.
The antimicrobial order should be renew every 7 days ( automatic stop order)
PROCEDURE:
The treating physician write the patient information
The treating physician must write the symptom, diagnose and culture result ( if available)
Choosing the therapy dosage( antibiotics, dose, interval and duration) depending on patient age group and
micro-organism
Either using E- prescription or hand writing prescription depend on hospital system
Send the copy of order form to pharmacy and keep the original in patient’s file
and the third copy will send to the Drug Use Evaluation department
Finally the pharmacist/clinical pharmacist must follow up the patient and write down his commen
RESPONSIBILIT
The hospital antibiotics approval team shall routinely reports the renewal of these forms to region antibiotic
committee and then submits it to pharmaceutical care administration of antibiotic Advisory Committee to
review it.
The antibiogram should be quarterly reported to regional antibiotic committee and then submitted it to central
antibiotic Committee to review it and create the guideline of nosocomial infection according to this result.
_________Hospital FILE NO.      
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Department within 24 hrs)

Antibiotics order (Group A Streptococcal Pharyngitis)

Diagnosis: ………………………………………………………………………………………………………………………………..
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending .

The modified Centor criteria


Absence of a cough, rhinorrhea, hoarseness and oral ulcer One point is given for each of the
Swollen and tender cervical lymph nodes criteria
Temperature >38.0 °C (100.4 °F)
Tonsillar exudate or swelling
Age less than 15years (a point is subtracted if age >44 years)

0 or 1 point No antibiotic or culture needed


2-3 points Antibiotic based on culture or RADT*
>3 points Empiric antibiotics
* Negative rapid antigen detection test (RADT) tests should be backed up by a throat culture (strong, high). Positive RADTs do not necessitate a back-up culture
because they are highly specific (strong, high)
* Routine use of back-up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances, because of the low incidence of GAS
pharyngitis in adults
Empiric Therapy for (GAS) Pharyngitis (for renal failure patient appendix)

Patient group Therapy (dosing interval in hours)- Duration

For individuals 1 Penicillin V, PO 500 mg q12hr- 10 days


without 2 Amoxicillin, PO 500 mg q12hr 10days
penicillin allergy 3 penicillin G Benzathine, intramuscular 1.2 million units single dose

For individuals 1 Cephalexin PO 500 mg q12hr -10 days


with (avoid for immediate-type hypersensitivity to penicillin)
penicillin allergy 2 Clindamycin PO 300 mg q8hr for 10 days
3 Clarithromycin PO 250 mg q12hr for 10 days
4 Azithromycin PO 500mg q24hr for 5 days

NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Shulman, ST; Bisno, AL; Clegg, HW; Gerber, MA; Kaplan, EL; Lee, G; Martin, JM; Van Beneden, C (Sep 9, 2012). "Clinical Practice
Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society
of America.". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 55 (10): e86–102
__________________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (Acute Bacterial Rhinosinusitis)

Diagnosis:……………………………………………………………………………………………………………………..
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not

IDSA recommends that any of the 3 following clinical presentations be used to identify patients with acute bacterial vs.
viral rhinosinusitis:
Symptoms or signs persistent & not improving for ≥10 days
Severe symptoms or signs for at least 3–4 days
Worsening symptoms or signs OR "double sickening" for lasted 5–6 days and were initially improving).
Empiric Therapy for Acute Bacterial Rhinosinusitis (for renal failure patient appendix)
First line therapy
Initial empirical therapy 1 Amox-Clav (extended release tabs) 1000/62.5 mg 2 tablets PO q12hr 5-7 days

Penicillin anaphylaxis 1 Doxycycline 100 mg PO q12hr for 5-7 days


allergy
Skin rash 1 Cefuroxime axetil 500 mg PO q12 hr 5-7 days
Severe infection requiring 1 Amox-Clav IV 1.5g q12 hr for 5-7 days
hospitalization 2 Ceftriaxone 1–2 g IV q24 hr for 5-7 days
If penicillin allergy:
3 Clindamycin IV ( off –lable )

NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Chow, AW; Benninger, MS; Brook, I; Brozek,. "IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and
adults". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America March 20, 2012 ;54 (8): e72–
e112
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (community acquired pneumonia)

Diagnosis:……………………………………………………………………………………………………………………..
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending
CURB-65 Mortality Prediction Tool for Patients with Community-Acquired Pneumonia
Confusion Points(Assign 1 point for each
Blood urea nitrogen level > 20 mg per dL (7.14 mmol per L) variable)
Respiratory rate ≥ 30 breaths per minute
Blood pressure (systolic < 90 mm Hg or diastolic ≤ 60 mm Hg)
Age ≥ 65 years
Inpatient vs Outpatient
0 or 1 point Treat as outpatient
2 points Treat as inpatient
≥3 points Treat in intensive care unit
Empiric Therapy for Community-Acquired Pneumonia (for renal failure patient appendix)
Patient group Therapy (dosing interval in hours) patient with normal renal function
Previously healthy outpatients; no 1 Azithromycin 500 mg PO on day 1 followed by 250 mg q24hr on days 2-5
antibiotic use in past 3months 2 Clarithromycin 250 mg PO q12h x 7 days
3 Doxycycline 100 mg PO q12hr 7-10 days
Outpatients with comorbidities or 1 Cefuroxime 500 mg PO q12 hr + Clarithromycin 500 mg PO q12h
antibiotic use in past three months 2 Amoxicillin 1 g PO q8h + Clarithromycin 500 mg PO q12h
3 Amoxicillin-clavulanate 2 g PO q12h + Clarithromycin 500 mg PO q12h
4 Levofloxacin 750 mg PO q24h
Inpatients, non-ICU 1 Ceftriaxone 2 gm IV q24h + Clarithromycin 500 mg PO q12h
2 Amoxicillin-clavulanate 1 g IV q12h + Clarithromycin 500 mg POq12h
Inpatients, ICU (admission ) 1 Ceftriaxone 1-2g IV q24h+ Clarithromycin 500 mg PO q12h
+Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr ( the regemin
should de-escalated depending on culture result)
2 Ceftriaxone 1-2g IV q24h+ Azithromycin 500 mg POq24hr +Vancomycin
IV loading dose of 25-30 mg/kg then 1g q8hr Ceftriaxone 1-2g IV q24h +
3 Levofloxacin 750 mg IV q24h
Vancomycin, target trough serum concentration of 15-20 μg/mL
for penicillin-allergic patients 1 Levofloxacin 750 mg IV q24h
Risk factors for Pseudomonas 1 Piperacillin/tazobactam 4.5g IV q6h + Gentamycin IV 1 mg/kg q8h +
species Clarithromycin 500 mg PO q12h
2 Piperacillin/tazobactam 4.5g IV q6h + Gentamycin IV 1 mg/kg q8h +
Azithromycin 500mg PO q12hr
Gentamycin calculated dose:……………. ( trough levels of <1 mcg/mL)
If CA-MRSA is a consideration 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr Linezolid IV
600 mg q12h
2 Vancomycin calculated dose:………………….. Vancomycin, target
trough serum concentration of 15-20 μg/mL
Influenza virus 1 Oseltamivir (Tamiflu) 75mg q12hr for 5 days
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Mandell LA, Wunderink RG, Anzueto A, et al. (March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults". Clinical Infectious Diseases 44 (Suppl 2): S27–72.
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics Order (Bacterial Meningitis)

Diagnosis:…………………………………………………………………………………………………………………….
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending

Therapy for Bacterial Meningitis (for renal failure patient appendix)


Patient group Therapy (dosing interval in hours) pt. with normal renal function Duration
Empiric < 50 years 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + 10-14
Therapy Cefotaxime IV 2g q4–6h days
2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
Ceftriaxone IV 2g q12hr
Vancomycin, target trough serum concentration of 15-20
μg/mL
> 50 years 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + 10-14
ampicillin IV 2g q4hr+ Ceftriaxone IV 2g q12hr Days
Vancomycin, target trough serum concentration of 15-20
μg/mL
head trauma: 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
Basilar skull Ceftriaxone IV 2g q12hr
fracture Vancomycin, target trough serum concentration of 15-20
μg/mL
Penetrating, post- 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
neurosurgery Meropenem IV 2 g q8hr
2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
Ceftazidime IV 2 g q8 hr
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Immunocompromised 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
state ampicillin IV 2g q4hr + Meropenem 2 g q8hr
2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
ampicillin IV 2g q4hr + Cefepime IV 2g q 8hr
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Encephalitis 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
(confusion, agitation, ampicillin IV 2g q4hr + Meropenem 2 g q8hr + Acyclovir 10
or seizure) mg/kg/dose IV q8hr for 10 days
2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
ampicillin IV 2g q4hr + Cefepime IV 2g q 8hr + Acyclovir 10
mg/kg/dose IV q8hr for 10 days
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Streptococcus Penicillin MIC 1 Penicillin_ G: 4 million Unit q4hr 10-14
pneumonia < 0.1 mg/mL 2 Ampicillin IV 2 g q4hr days
Penicillin MIC 1 Ceftriaxone IV 2 gm q12hr
0.1–1.0 mg/mL
Penicillin MIC 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
≥ 1.0 mg/mL Ceftriaxone IV 2 g q12hr
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Neisseria meningitids 1 Ceftriaxone IV 2 g q12hr 7 days
Listeria monocytogenes 1 Ampicillin IV 2 gm q4h ± (Gentamicin 2 mg/kg loading dose 21
then 1.7 mg/kg q8h days
2 Trimethoprim-sulfamethoxazole IV (5 mg/kg [based on the
trimethoprim component] q6-12 hr
Calculated dose: ……………….
3 MeropenemIV 2 g q 8hr
Haemophilus influenzae 1 Ceftriaxone IV 2 gm q12h 7 days
Staphylococcus Methicillin 1 Flucloxacillin IV 2g oral q4-6hr 14days
aureus susceptible 2 Cloxacillin IV 2 g oral q4-6hr

Methicillin 1 Vancomycin IV loading dose of 25-30 mg/kg then 1 g q8hr ±


resistance Rifampin PO 600 mg q24hr
2 Linezolid IV 600 mg q12h
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Staphylococcus epidermidis 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr 14days
Vancomycin, target trough serum concentration of 15-20
μg/mL
2 linezolid IV 600 mg q12h

Enterococcus species Ampicillin 1 Ampicillin IV 2 g q4h ± gentamicin IV 1 mg/kg q8h 14-21


susceptible Gentamicin dose: ……………….( trough levels of <1 mcg/mL) days
Ampicillin 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr ±
resistant gentamicin IV 1 mg/kg q8h
Gentamicin Calculated dose:…………………………………..
( trough levels of <1 mcg/mL)
Ampicillin 1 Linezolid IV 600 mg q 12hr 28
and days
vancomycin
resistant
Meningitis prophylaxis Only indicated for "close contact" who have had prolonged (>8
hours) contact while in close proximity (<1 meter) to the
N.influenzae patient or who have been directly exposed to the patient's oral
secretions during the 7 days before the onset of the patient's
symptoms and until 24 hours after initiation of appropriate
antibiotic therapy.
1 Ciprofloxacin 500 mg PO one dose
2 Ceftriaxone 125-250 mg IM one dose
3 Rifampin 600mg PO q12hr for 4 doses
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Allan R. Tunkel,1 Barry J. Hartman,Practice Guidelines for the Management of Bacterial Meningitis" Infectious Diseases ; 2004 ; 39 : 1267 -
Sanford guide Antimicrobial Therapy, web edition, Inc. 2014
_________Hospital FILE NO.      
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (Brain Abscess)

Diagnosis:……………………………………………………………………………………………………………………
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending
Empiric Therapy for brain abscesses (for renal failure patient appendix)
Empiric(Origin of Therapy (dosing interval in hours) Duration
abscess)
Oral source or 1 Ceftriaxone IV 2 g q12hr +Metronidazole 500 mg IV q8hr Duration of
otogenic, or sinus Penicillin G 3-4 million units IV q4h + Metronidazole 500 mg IV q8hr treatment is
source 2 unclear. Treat
until
Hematogenous 1 Flucloxacillin IV 2g oral q4-6hr
response by
spread Suspect MSSA 2 Cloxacillin IV 2 g oral q4-6hr
neuroimaging
Staph. Aureus
MRSA Vancomycin IV loading dose of 25-30 mg/kg then 1 g q8hr ± (CT/MRI).
Metronidazole IV 500 mg q8hr
(Vancomycin target trough serum concentration of 15-20 μg/mL)
Postoperative 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
neurosurgical patients meropenem IV2 g q8hr
2 Vancomycin IV loading dose of 25-30 mg/kg 1g q8hr + Ceftazidime
IV 2 g q8hr
(vancomycin target trough serum concentration of 15-20 μg/mL)
Penetrating trauma 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
OR unknowing source Ceftriaxone IV 2 g q12hr
(Vancomycin target trough serum concentration of 15-20 μg/mL)
If the paranasal sinuses are involved, add metronidazole 500 mg IV
q8hr

NOTES_________________________________________________________________________________________________________________________________
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Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Sanford guide antimicrobial web edition 2014


Up-to-date 2014
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (infective endocarditis)

Diagnosis: ………………………………………………………………………………………………………………….
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending
Microbiology:
-Three to five blood cultures of at least 10 mL each should be drawn during the first 24–48 hours.
Therapy for Infective Endocarditis (for renal failure patient appendix)
 Native Valve
Patient group Therapy (dosing interval in hours) (weeks)
Empiric therapy 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Ceftriaxone IV/IM 2g
(If patient is not 24h
acutely ill and not in 2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg IV
heart failure, the q8h
preference is to wait (Vancomycin target trough concentration of 15-20 μg/mL)
for blood culture Gentamicin calculated dose: …………………(trough levels should be < 1 μg/mL)
results)
Streptococcus viridans 1 Penicillin- G : IV 3-4 million Unit q4 h (4wks)
( Penicillin MIC ≤ 2 Penicillin- G: IV 3-4 million Unit q4 h + Gentamicin 1 mg/kg IV q8h (2wks)
0.12) Ceftriaxone IV/IM 2g q24 hr (4wks)
3 Ceftriaxone IV/IM 2 g q24hr + gentamicin 1 mg/kg IV q8h (2wks)
4 Gentamicin calculated dose: …………………..(trough levels should be < 1 μg/mL)

Streptococcus viridans 1 Penicillin –G: IV 3-4 million Unit q4 h+ gentamicin 1 mg/kg q8 h IV/IM (4wks)
( penicillin MIC > Ceftriaxone IV/IM 2 g q24 h in 1 dose +gentamicin 1 mg/kg q8 h IV/IM (4wks)
0.12) 2 Gentamicin calculated dose: …………..(trough levels should be < 1 μg/mL)

Staphylococcus 1 Cloxacillin IV 2 g q4hr (6wks)


methicillin sensitive 2 Flucloxacillin IV 2g q4-6hr (6wks)
3 Cefazolin IV 2 mg q8hr (6wks)
Staphylococcus 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr (6wks)
methicillin resistant (Vancomycin Target trough of 15-20 µg/mL)

Enterococcus 1 Penicillin _G: IV 3-4 million Unit q4 h (4-6 wks)


Penicillin sensitive 2 Ampicillin IV 2g q4 h (4-6 wks)
If patient penicillin allergy:
3 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg q8hr
IV/IM (6 wks)
(target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: ………………………(trough levels should be < 1 μg/mL)
Enterococcus— 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg q8hr
penicillin resistant IV (6 wks)
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: ………….. ………(trough levels should be < 1 μg/mL)
gentamicin resistance Streptomycin (MIC < 2000 µg/mL):
(MIC > 500 μg/mL): 1 Ampicillin IV 2g q4hr + Streptomycin 15 mg/kg IV/IM q12hr (6 weeks)
(Penicillin sensitive ) Penicillin-G: IV 3-4 million unit q4h (4-6 weeks) + Streptomycin IV/IM 15 mg/kg
2 q12hr (6 weeks)
Streptomycin Calculated dose: ……………………….. Peak: 20-30 mcg/mL; Trough:
<5 mcg/mL
E. faecium penicillin, 1 Linezolid IV 600 mg q12hr (≥8wks)
aminoglycoside, and 2 Daptomycin 6 mg/kg q24hr ( 2-6wks)
vancomycin resistant Daptomycin calculated dose :……………………………….
E. faecalis penicillin, 1 Imipenem/cilastatin IV 500 mg q6hr + ampicillin IV 2 g q4h ( ≥ 8wks)
aminoglycoside, and 2 Ceftriaxone 2g IV/IM q12hr + ampicillin IV 2 g q4 h ( ≥ 8wks)
vancomycin resistant 3 Daptomycin 6 mg/kg q24hr ( 2-6wks)
Daptomycin calculated dose:…………………………
HACEK group 1 Ceftriaxone IV/IM 2 g q24 h (4wks)
2 Ciprofloxacin IV 400 mg q12h(4 wks)
3 Piperacillin/tazobactam IV 3.375g q6h (4wks)
4 Ceftriaxone IV 2 gm q12hr (4 weeks)

 Prosthetic valve

Patient group Therapy (dosing interval in hours) (weeks)


patient with normal renal function
Empiric therapy 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg q8hr
IV + Rifampin 300 mg PO/IV q12h (6wk)
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: ……………………….. ( trough levels should be < 1 μg/mL)
Streptococcus 1 Penicillin_G: IV 3-4 million Unit q4 h + Gentamicin IV/IM 1mg/kg q8hr (6wk)
viridans 2 Ceftriaxone 2 g q24 h IV/IM + Gentamicin IV/IM 3 mg/kg q8hr (6wk)
(pen. MIC ≤ 0.12) Gentamicin calculated dose: ……………………….. ( trough levels should be < 1 μg/mL)
Streptococcus 1 Penicillin_G: IV 3-4 million Unit q4h + Gentamicin IV/IM 1 mg/kg q8 h (6wk)
viridans Ceftriaxone IV/IM 2 g q24 h + Gentamicin IV/IM 1 mg/kg q8h (6wks )
(pen. MIC > 0.12) 2 Gentamicin calculated dose: ……………….. …( trough levels should be < 1 μg/mL)
Staphylococcu 1 Cloxacillin IV 2g q4hr(6wks) ± Gentamicin IV/IM 1 mg/kg q8h for 3–5 days + Rifampin
methicillin IV/PO 300 mg q12 h ( ≥6wks )
sensitive 2 Flucloxacillin IV 2g q4-6hr (6wks) ± Gentamicin IV/IM 1 mg/kg q8 h for 3–5 days +
Rifampin IV/PO 300mg q12hr ( ≥6wks )
3 Cefazolin IV 2mg q8hr ± Gentamicin 1 mg/kg q8hr IV/IM for 3–5 days (6wks) +
Rifampin IV/PO 300 mg q12hr ( ≥6wks )
Gentamicin calculated dose: ………………… ………trough levels should be < 1 μg/mL)
Staphylococcus— 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr (≥6wks) + Rifampin IV/PO
methicillin 300mg q12hr ( ≥6wks )
resistant (Vancomycin target trough concentration of 15-20 μg/mL)
Enterococcus 1 Penicillin_G: IV 3-4 million Unit q4 h + gentamicin IV/IM 1 mg/kg q8h (6wks)
2 Ampicillin IV 2g q4 h + gentamicin IV/IM 1 mg/kg q8h (6wks)
If patient penicillin allergy:
3 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + gentamicin IV/IM 1 mg/kg
q8hr (6wks)
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: ……………………….. (trough levels should be < 1 μg/mL)
Enterococcus— 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin IV/IM 1 mg/kg
penicillin resistant q8hr (6wks)
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: …………………………(trough levels should be < 1 μg/mL)
E. faecium 1 Linezolid 600mg IV q12hr (≥8wks)
penicillin, 2 Daptomycin 6 mg/kg q24hr ( 2-6wks)
aminoglycoside, & Daptomycin calculated dose:…………………………
vancomycin
resistant
E. faecalis— 1 Imipenem/cilastatin IV 500 mg q6hr + ampicillin IV 2 g q4 h ( ≥ 8wks)
penicillin, 2 Ceftriaxone IV 2g q12hr + ampicillin IV 2 g q4 h ( ≥ 8wks)
aminoglycoside, & 3 Daptomycin 6 mg/kg q24hr ( 2-6wks)
vancomycin Daptomycin calculated dose:…………………………
resistant
HACEK group 1 Ceftriaxone IV/IM 2 g q24 h (6wks)
2 Ciprofloxacin IV 400 mg q12h (6wks)
3 Piperacillin/tazobactam IV 3.375g q6h (6wks)
4 Ceftriaxone IV 2 gm q24h X 4 weeks + gentamicin IV 1 mg/kg q8 h (6wks)
Gentamicin calculated dose: ……………………….(trough levels should be < 1 μg/mL)
Endocarditis a. I.E prophylaxis is indicated only for high-risk cardiac conditions such as:
prevention - Prosthetic material used for cardiac valve repair
- A prior history of IE
- Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
- Completely repaired congenital heart defects with prosthetic material or device during
the first six months after the procedure (whether placed by surgery or by catheter
intervention).
- Repaired congenital heart disease with residual defects at the site or adjacent to site of
the prosthetic device
- Cardiac "valvulopathy" in a transplanted heart. Valvulopathy is defined as
documentation of substantial leaflet pathology and regurgitation

Routine dental cleaning or routine anesthetic injections through non-infected tissue does
not require antibiotic prophylaxis.
The risk of IE is highest for the following dental procedures hence prophylaxis is
indicated:
Those involving manipulation of gingival tissue or
The peri-apical region of the teeth or
Perforation of the oral mucosa, such as tooth extractions or
Drainage of a dental abscess
Prosthetic heart valves, including bioprosthetic and homograft valves
1 Amoxicillin 2 g PO one hour before procedure
2 Ampicillin 2 g IM/IV 30 min before procedure
Penicillin allergy:
1 Cefazolin 1g IV/IM 30 min before procedure

NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________ pager:_____________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________

Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis. Guidelines from the American Heart Association.
Circulation 2007;115:1656–8.
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (UTI)

Diagnosis:…………………………………………………………………………………………………………………
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending

Asymptomatic(+) culture should not be treated with antibiotics

Therapy for UTI (for renal failure patient appendix)


Patient Group Therapy (Days) patient with normal renal function

Empirically therapy of Acute 1 Trimethoprim-sulfamethoxazole PO (160/800 -choice between


Cystitis mg [DS] q 12hr (3 days) these
2 Nitrofurantoin monohydrate/macrocrystals agents should be
PO100 mg q12hr (5days) based on
3 Amoxicillin-clavulanate 1g PO q12hr (5-7days) local resistance
4 Cefuroxime 125-250mg PO q12hr (7-10 days) data(antibiogram)
Empirically Inpatient 1 Ceftriaxone 1-2 gm IV q24h ± Gentamycin
therapy of therapy 1mg/kg IV/IM q8hr (10-14 days )
Uncomplicated 2 Ampicillin 2 gm IV q6h ± Gentamicin IV/IM 1
Pyelonephritis mg/kg q8hr (14 days)
Gentamycin calculated dose:…………………
(trough levels should be < 1 μg/mL)
Outpatient 1 Ceftriaxone 1-2 gm IM q24h(10-14 days)
therapy 2 Trimethoprim-sulfamethoxazole PO
160/800 mg [DS] q12hr (14 days )
3 Amox-Clav 875/125 mg PO q12h or 500/125
mg PO q8hr or 2000/125 mg PO q12hr (14
days)
Amox-Clav dose:…………
Complicated UTIs Inpatient 1 Pipracillin- tazobactam 3.375 gm IV q6h 2 weeks
( Catheter-Related, therapy 2 Imipenem 0.5 gm IV q6h (max 4 gm/day)
Functional or 3 Ceftazidime 2 gm IV q8h ± Gentamicin IV/IM
Structurally 1 mg/kg q8hr
abnormalities , UTI Gentamycin calculated dose:…………………
in men ) (trough levels should be < 1 μg/mL)
Pregnancy Symptomatic Seven-days treatment regimen TMP/SMZ (used
or 1 Amoxicillin/clavulanate PO 1g q12hr frequently
asymptomatic 2 Nitrofurantoin100 mg PO q12hr but avoidance
Cystitis Nitrofurantoin is contraindicated in pregnant recommended,
patients at term (38-42 weeks gestation especially during
3 Cefuroxime 125-250 mg PO q12hr the late
4 Trimethoprim-sulfamethoxazole 160/800 mg third trimester)
[DS] PO q12hr
Pyelonephritis 1 Ceftriaxone IV 1-2mg q24hr (10-14 days )
Recurrent cystitis Relapse Relapse is a new episode of bacteriuria with microorganism that is
( referral to same from the original one
Asymptomatic the ID -Assess for pharmacologic reason for treatment failure.
( +) culture of Consultant is -Longer treatment (for 2–6 weeks, depending on length of initial course)
recurrent mandatory)
bacteriuria Reinfection Reinfection is a new episode of bacteriuria with microorganism that is
should not be ( referral to different from the original one
treated with the ID i.If patient has two or fewer UTIs in 1 year, use patient-initiated therapy for
antibiotics Consultant is symptomatic episodes (3-day treatment regimens).
mandatory) ii. If patient has three or more UTIs in 1 year and they are temporally
related to sexual activity, use post-intercourse prophylaxis with TMP/SMZ
SS, cephalexin 250 mg, or nitrofurantoin 50–100 mg.
iii. If patient has three or more UTIs in 1 year that are not related to sexual
activity, use daily or 3 times/week prophylaxis with trimethoprim 100 mg,
TMP/SMZ SS, cephalexin 250 mg, norfloxacin 200 mg, or nitrofurantoin
50–100 mg.

NOTES______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

- 1, Thomas M. Hooton. Guidelines for Antimicrobial Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women". 2011 ; 52 : e103 -e120
-Thomas M. Hooton,1 Suzanne F. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical
Practice Guidelines from the Infectious Diseases Society of America". 2010 ; 50 : 625 -66
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (Osteomyelitis)

Diagnosis: …………………………………………………………………………………………………………………….
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending

Therapy for Osteomyelitis (for renal failure patient appendix)


Patient Subtype Likely Infecting Antibiotic Duration
Organism
Adults MSSA 1 Cloxacillin IV 2 mg q6hr 4 to 6 weeks
S. aureus 2 Flucloxacillin sodium IV 2g q6hr If signs or
3 Cefazoline IV 2 g q8 hr symptoms are still
MRSA 1 Vancomycin 15-30 mg/kg IV q8-12h ± present at 6 weeks,
Rifampin 300-450 mg IV/PO q12hr therapy should be
2 Linezolid 600 mg IV/PO q12h extended

Intravenous drug Pseudomonas 1 Ceftazidime 2 gm IV q12h + Gentamycin


abusers IV/IM 1mg/kg q8hr x 2 weeks followed by
Ciprofloxacin 750 mg PO q12hr x 10 weeks
Gentamycin calculated dose:……………….
(trough levels should be < 1 μg/mL)
Postoperative or Gram-positive 1 Pipracillin-tazobactam 4.45g IV q6hr
post-trauma and gram- 2 Clindamycin IV 300-450mg q8hr +
patients negative Ceftazidime 2 g IV q8 hr
organisms 3 Cloxacillin 2g IV q6hr + Ceftazidime 2 g IV
q8 hr
4 Flucloxacillin sodium 2g IV q6hr +
Ceftazidime 2 g IV q 8 hr

Patients with Debride overlying ulcer and submit bone for histology and culture.
vascular
insufficiency Select antibiotic based on culture results and treat for 6 weeks.

No empiric therapy recommended unless patient is acutely ill.

For acute illness, treat as Diabetic Foot.

NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004;364:369–79.


_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (Diabetic foot infection)

Diagnosis:………………………………………………………………………………………………………….
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending

Therapy for Diabetic foot infection (for renal failure patient appendix)
Suspected Antibiotic Therapy Duration
pathogen
Oral agents for empiric Streptococci and 1 Amoxicillin-clavulanate ER PO 1000 7-10 days
treatment of mild to Staphylococci 2 mg q12h
moderate early diabetic (MSSA) 3 Clindamycin PO 300-450 mg q8hr
foot infections 4 Cloxacillin 500mg PO q6hr
( Outpatient ) Flucloxacillin PO 250-500 mg q6h
Streptococci and 1 Amoxicillin 1g IV q12hr + Trimethoprim- 7-10 days
MRSA (preview sulfamethoxazole PO160/800 mg [DS]
MRSA infected q12hr
or colonized|) 2 Clindamycin PO 300-450 mg q8hr +
Trimethoprim-sulfamethoxazole PO
160/800 mg [DS] q12hr
3 Linezolid PO 600 mg q12hr
Parenteral agents for 1 Piperacillin-tazobactam IV 4.5g q6-8hr 10-14 days
empiric treatment of + vancomycin IV 1g q8hr And expand
moderate to severe 2 Piperacillin-tazobactam IV 4.5g q6-8hr the duration
diabetic foot infections + Linezolid IV 600 mg q12hr depend on
3 Imipenem-cilastatin IV 500mg q6hr clinical
+Linezolid IV 600 mg q12hr symptom
4 Imipenem-cilastatin IV 500mg q6hr + progress
Vancomycin IV 1g q8hr
Vancomycin trough level 15-20 μg/mL

NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Benjamin A. Lipsky,1 Anthony R. Diagnosis and Treatment of Diabetic Foot infection 2012 ; 54 : e132 -e173
Uptodate 2014

_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (Skin and Soft tissue Infection)

Diagnosis:…………………………………………………………………………………………………………………….
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending
Therapy for Cellulitis, Erysipelas: Extremities, Non-Diabetic (for renal failure patient appendix)
Micro-organism Therapy (dosing interval ) Duration
Empiric therapy Inpatient 1 Cefazoline IV 1-2 g q8hr
parenteral 2 Clindamycin PO 600-900mg q6-8hr
Streptococcus therapy 3 Flucloxacillin 1–2 gm IV q6h
pyogenes 4 Cloxacillin IV 1g q6h

Staphylococcus outpatient 1 Flucloxacillin PO 250-500 mg q6h


aureus (rare) therapy: 2 Cephalexin PO 500 mg q6hr
If penicillin or cephalosporin allergic
1 Clindamycin PO 300- 450 mg q6-8hr 7–10
MSSA outpatient 1 Cloxacillin PO 500 mg q6h days
2 Flucloxacillin PO 250-500 mg q6h
3 Amox-clav PO 1g q12hr
4 Clindamycin IV 300-450mg q8hr
5 Trimethoprim-sulfamethoxazole PO160/800 mg [DS] q12hr
inpatient 1 Flucloxacillin IV 1–2 gm q4-6h
2 Cloxacillin IV 1-2 g q6h
Cephazoline IV 1-2 g q8hr
MRSA outpatient 1 Trimethoprim-sulfamethoxazole [160/80 double
strength] PO q12h
2 Linzoild PO 600mg q12hr
3 Clindamycin IV 300-450mg q8hr
inpatient 1 Vancomycin IV1g q8h
2 Linezolid IV 600mg q12hr
Vancomycin target trough level 15-20 μg/mL
Therapy for Erysipelas: Facial(for renal failure patient appendix)
Therapy (dosing interval )
Outpatient 1 Penicillin V: PO 500 mg q6hr 7-10days
2 Amoxicillin PO 500 mg q8hr
3 Clindamycin PO 300- 450 mg q6-8hr
Inpatient 1 Ceftriaxone 1 g intravenously every 24 hours
2 Cefazoline IV 1-2 g q8hr
3 Clindamycin IV 450mg q8hr

NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Dennis L. Stevens,1,3 Alan L. Bisno. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41
UPT

_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it DIAGNOSIS:__________________________________
WARD:________________BED__________________
on patient profile, and forward the copy to the
CONSULTANT IN CHARGE:_______________________
Pharmacy Department within 24 hrs)

Antibiotics order (Skin and Soft tissue Infection)


Self-initiated therapy of recurrent cellulitis and lymphedema (for renal failure patient appendix)
Micro-organism Therapy (dosing interval )
Streptococcus sp. (Group A, B, C, G) 1 Amoxicillin 500mg PO q12hr Start antibiotics and
2 Penicillin V 250 mg PO q12 h report back to the
3 Clindamycin 300-450mg PO q8-12hr physician ASAP
Necrotizing fasciitis
Diagnosis:………………………………………………………………………………………………………………….
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending
Necrotizing fasciitis Therapy (for renal failure patient appendix)

Need early surgical intervention


Patient group Therapy (dosing interval )
Necrotizing Mixed infection 1 piperacillin-tazobactam 3.375 g IV q 6–8 h
fasciitis 2 Imipenem/cilastatin 1 g IV q 6–8 h
3 Ceftriaxone 2 g IV q24 h + metronidazole
4 500 mg IV q 6 h 14 days and
Vancomycin 1 g q8hr expand depend
Streptococcus infection 1 Penicillin G: 4 million Unit IV q4 h + on the clinical
If group A strep. The IVIG Cindamycin 600–900 mg IV q8 h symptom
should be added 2 Ceftriaxone 2 gm IV q24h + Clindamycin progressing
600-900 mg IV q8h
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Dennis L. Stevens,1,3 Alan L. Bisno. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (Skin and Soft tissue Infection)

Animal bite & Human bite


Patient Groups Therapy (dosing interval) Duration
Animal bite 1 Amoxicillin-clavulanic acid 875 mg/125 mg PO q12 h
2 Doxycycline 100–200 mg PO q 12 h
3 Cefuroxime axetil 500 mg PO q12 h + metronidazole 250–500 mg
PO q8h
Human bite 1 Amoxicillin-clavulanic acid 875 mg/125 mg q12 h
2 Doxycycline 100–200 mg q12 h 7 days
3 Cefuroxime axetil 500 mg q12 h+ metronidazole 250–500 mg q8h

NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Dennis L. Stevens,1,3 Alan L. Bisno. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order(peritonitis)
Primary peritonitis: Spontaneous bacterial peritonitis (SBP), Primary infection
Diagnosis:………………………………………………………………………………………………………………….
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending
Primary peritonitis therapy (for renal failure patient appendix)
Therapy (dosing interval ) Duration
For treatment 1 Ceftriaxone IV 2 gm q24h
2 Aztreonam 1-2 g IV/IM q8-12hr
3 Pip-Tazo IV 3.375 gm q6h ( if suspected pseudomonas )
Prevention in patients Antibiotic prophylaxis indication/ prevention of SBP:
with chronic ascites 1- Patients with cirrhosis and gastrointestinal bleeding. 5-7 days
2- Patients who have had one or more episodes of SBP.
1 TMP-SMX-DS 1 tab PO 5 days/week
2 Ciprofloxacin 750 mg PO once/week
resistant E. coli, 1 Imipenem IV 500 mg q6h
Klebsiella species (e.g., 2 Meropenem IV 1g q8h
ESBL):
Peritonitis, Secondary, bowel perforation, ruptured appendix, ruptured diverticula
Therapy ( Source Control is Mandatory)
Therapy (dosing interval ) Duration
Mild/Moderate Peritonitis; 1 Piperacillin- Tazobactam IV 4.5 gm q8h ±
inpatient; requires parenteral 2 Gentamycin IV/IM 1mg/kg q8hr (3-5days) 10-14days
therapy: Hemodynemically 3 Ceftazidem IV 2 gm q12h + Metronidazole IV 1 gm
stable q12hr
4 Tigecyline 100mg IV infusion then 50mg IV infusion
q12hr
Severe Disease: Patient is in 1 Imipenem 500 mg -1 gm IV q6h 14 days
ICU; requires parenteral 2 Meropenem IV 1g q8hr
3 Tigecyline 100mg IV infusion then 50mg IV infusion
q12hr

Peritonitis, Dialysis (CAPD) Associated:


Diagnosis:………………………………………………………………………………………………………………….
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending
Peritonitis, Dialysis (CAPD) Associated Therapy: (for renal failure patient appendix)
Empiric therapy
Empiric therapy:
1 Vancomycin IV 1g q8hr + Piperacillin- Tazobactam IV 4.5 gm q8h (14 days )
Vancomycin, cephalosporins, and aminoglycosides can be mixed in the same
dialysis bag without loss of bioactivity.
Transfer the patient to the (CAPD) center to treat the patient depend on the protocol
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________ pager:_____________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

-Solomkin JS,et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Clin Infect Dis. 2010 Jun
15;50(12):1695
-Runyon BA,et al. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009 Jun;49(6):2087-107
-Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotic order (intra-abdominal infection)


Therapy: (for renal failure patient appendix):
Empirical therapy Therapy (dosing interval )
Hepatic Abscess 1 Ceftriaxone IV 1-2 gm q24h + Metronidazole PO 500 mg q6-8h
2 Piperacillin- Tazobactam IV 4.5 gm q8h + Metronidazole PO 500 mg q6-8h
Gallbladder mild-to-moderate
Infections(Gallbladder 1 Cefuroxime IV 1.5 g q8 h
infections, cholecystitis, Sever infection:
cholangitis, biliary sepsis, 1 Piperacillin-Tazobactam IV 4.5 gm q8h
common duct obstruction 2 Ceftriaxone 1-2 gm IV q24h ± Gentamycin IV/IM 1mg/kg q8hr
If life-threatening infection: Imipenem IV 500mg q6h + Gentamycin single dose
3
Acute without evidence of tissue necrosis
Alcoholic No indication for an antimicrobial agent
pancreatitis
Necrotizing 1 Piperacillin-Tazobactam IV 4.5gm q6h
pancreatitis 2 Imipenem IV 500 mg q6h
infected
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

-Solomkin JS,et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Clin Infect Dis. 2010 Jun
15;50(12):1695
-Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014
_________Hospital FILE NO.     
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (Sexually transmitted disease)

Diagnosis: …………………………………………………………………………………………………………………..
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending

Therapy for Sexually transmitted disease (for renal failure patient appendix)
Type or Stage Therapy
Chlamydial Infection Urethritis 1 Doxycycline 100 mg PO q12hr x 7days
and Related Clinical Cervicitis 2 Azithromycin 1 g PO q24hr single dose
Syndromes Conjunctivitis 3 Levofloxacin PO500mg q24hr x 7days
proctitis (except
lymphogranuloma venereum)

Infection in Pregnancy 1 Azithromycin 1 g PO single dose

Lymphogranuloma venereum 1 Doxycycline 100 mg PO q6hr x 21days


2 Azithromycin 1 g PO once weekly for 3 weeks
Gonorrhea Urethritis, Cervicitis, 1 Ceftriaxone IM 250 mg once + Azithromycin 1 g PO
Proctitis single dose
Epididymitis 1 Ceftriaxone 250 mg IM once followed
by doxycycline PO 100 mg q12hr x 10 days
2 Levofloxacin 500 mg PO q24hr x 10d
Bacterial Vaginosis 1 Metronidazole 500 mg PO q12hr for 7days
2 Clindamycin 300 mg PO q12hr for 7 days
Trichomoniasis 1 Metronidazole 500 PO q12hr for 7 days
2 Tinidazole PO 2g single dose
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________ pager:_____________
_______________________________________________________________________________________________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Drugs for Sexually Transmitted Infections. Treatment Guidelines from The Medical Letter. July 2010; 8 (95) 53-59
Uptodate 2014
Sanford guide webedition 2014
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotic order (Pelvic Inflammatory Disease)


Diagnosis: …………………………………………………………………………………………………………………..
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending

Therapy for PID (for renal failure patient appendix):


Empiric therapy Therapy (dosing interval )
Outpatient: 1 Ceftriaxone 250 mg IM x 1 dose followed by Azithromycin 1 gm PO weekly x 2 weeks
2 Cefoxitin 2 gm IM with Probenecid PO 1 gm both as single dose + Doxycycline 100
mg PO q12hr with Metronidazole 500 mg q12hr both x 14 days
Inpatient: 1 Ceftraixone IV 2 g q24 h + Doxycycline IV/PO 100 mg q12h
2 Clindamycin 900 mg IV q8h + Gentamicin 1mg/kg IV/IM q8hr , then Doxycycline 100
mg PO q12hr x 14 days
Gentamicin Calculated dose: ………………………………. Target trough <1
μg/mL
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014


_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Brucellosis

Diagnosis: …………………………………………………………………………………………………………………..
Culture:  Pending  ( + ) Culture  ( - ) Culture  Not sending

Therapy of brucellosis (dosing of renal failure appendix )


Infection or patient Therapy (dosing interval )
condition
Non-localizing 1 Doxycycline 100 mg PO q12hr x 6 weeks +
disease Streptomycin 1 gm IM/IV q24hr x 14-21 days
2 Doxycycline 100 mg PO q12hr x 6 weeks + rifampicin
600mg q24hr
3 Doxycycline 100 mg PO q12hr x 6 weeks +
TMP-SMX 5 mg/kg of TMP component POq12hr x 6 weeks
Spondylitis/ Inpatient 1 Doxycycline 100 mg PO q12hr + Gentamycin 1mg/kg q8hr
sacroileitis/
arthritis
2 Doxycycline 100 mg PO q12hr + rifampicin IV/PO 600mg
3 q24hr
Doxycycline 100 mg PO q12hr +TMP-SMX 5 mg/kg of
4 TMP component IV q12hr
Ciprofloxacin 500 mg PO q12hr + rifampicin 600mg q24hr 12 weeks
Gentamycin dose:…………...Target trough <1 μg/mL
Outpatient 1 Doxycycline 100 mg PO q12hr + Streptomycin IV/IM 15
mg/kg q12hr
Streptomycin Calculated dose: ……………………….. Peak: 20-
30 mcg/mL; Trough: <5 mcg/mL
Brucella during 1 TMP-SMX 5 mg/kg of TMP component PO q12hr + TMP-SMX
Pregnancy Rifampicin 900mg q24hr x 6 weeks may cause
If ≥ 38 weeks kernicterus if
2 Rifampicin 900mg q24hr x 6 weeks given in last
week of
pregnancy

Neurobrucellosis 1 Doxycycline 100 mg IV/PO q12hr + Ceftriaxone 2 gm IV Continue until


q12h.(4wk) CSF is normal
Endocarditis 1 Doxycycline 100 mg IV/PO q12hr + gentamycin 1mg/kg 3-6 months
IV/IM q8hr
Gentamyci n calculated dose:…………………….trough
level < 1 μg/mL
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

-Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014


_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (tuberculosis)


Treatment of Latent TB recommended for:
patients at increased risk for developing active close contacts of patients with those who have converted from (-) to a
disease, such as those co-infected with HIV or recent pulmonary TB (+) tuberculin skin test PPD
receiving immunosuppressive therapy, children or interferon-gamma release assay
<5 years old, those with diabetes or chronic (IGRA) within the mprevious 2 years)
renal failure on hemodialysis
Therapy for Latent TB (for renal failure patient appendix)
Isoniazid 5 mg/kg/day (max 300 mg/day) or 15 mg/kg 2x/wk (max 900 mg/dose)x 9 months
Isoniazid 15 mg/kg (max 900 mg/dose) + rifapentine 300-900 mg weeklyx 12 weeks
Rifampin 10 mg/kg/day (max 600 mg/day) or 10 mg/kg 2x/wk (max 600 mg/dose) x 4 months

Active TB diagnosis:
Smear (+) culture PCR Histopathology
Therapy for Active TB (for renal failure patient appendix)
1) First-line for Treatment of Active TB
Condition Drugs Adult Dosage Alternative Duration
Daily Intermittent
Empiric initial treatment Isoniazid 5 mg/kg 15 mg/kg 1-3x/wk Initial
should include 4 drugs: Rifampin(RIF) 10 mg/kg 10 mg/kg 2-3x/wk Rifabutin (RPT phase
5 mg/kg
2 months
pyrazinamide 40-55 kg: 40-55 kg: 2000 mg
1000 mg 56-75 kg: 3000 mg
56-75 kg: 76-90 kg: 4000 mg
1500 mg 2x/wk
76-90 kg:
2000 mg
ethambutol 40-55 kg: 40-55 kg: 2000 mg
800 mg 56-75 kg: 2800 mg
56-75 kg: 76-90 kg: 4000 mg
1200 mg
76-90 kg:
1600 mg
When susceptibility to Isoniazid(INH) 5 mg/kg 15 mg/kg 1-3x/wk
isoniazid, rifampin and Rifampin 10 mg/kg 10 mg/kg 2-3x/wk Rifabutin 5 mg/kg
pyrazinamide
Pyrazinamide 40-55 kg: 40-55 kg: 2000 mg
800 mg 56-75 kg: 2800 mg
56-75 kg: 76-90 kg: 4000 mg
1200 mg
76-90 kg:
1600 mg
Patients who cannot take Isoniazid The same The same dose Rifabutin 5 mg/kg
pyrazinamide, such as Rifampin dose
those with severe liver ethambutol
disease or gout
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antibiotics order (tuberculosis)


2) Duration of Continuation Therapy (For treatment of drug-susceptible disease after two months of initial
therapy):
Cavity on Chest (x-ray) Sputum Culture (Taken at 2 Drugs Duration (
Months) months)
No Negative INH/RIF 4
4
No Positive INH/RIF 7

Yes Negative INH/RIF 4


Yes Positive INH/RIF 7
Patients who could not take INH/RIF 7
pyrazinamide as part of the
initial regimen.
Some Second-Line Drugs for Active Tuberculosis

Streptomycin 15 mg/kg IM or IV (max 1 g)


Capreomycin (Capastat) 15 mg/kg IM or IV (max 1 g)
Kanamycin (Kantrex, 15 mg/kg IM or IV (max 1 g)
Amikacin 15 mg/kg IM or IV (max 1 g)
Cycloserine (Seromycin) 10-15 mg/kg PO
Ethionamide (Trecator) 15-20 mg/kg in 1 or 2 divided doses PO (max 500 mg
q12hr )
Levofloxacin 500-1000 mg PO/ IV …..
Moxifloxacin 400 mg PO or IV……..
Para-aminosalicylic acid 8-12 g in 2-3 doses PO
Resistance to Rifamycins – -At least 12 months of treatment with isoniazid, ethambutol and
a fluoroquinolone (levofloxacin or moxifloxacin) can be used.
-Pyrazinamide, with or without an injectable drug, should also
be used during the initial 2 months of therapy.
Multidrug Resistance Isolates with resistance to at least Refer to the specialized physician
isoniazid and rifampin

Extensively drug-resistant TB (XDRTB) Refer to the specialized physician


Isolates with resistance not only to isoniazid and
rifampin, but also to any fluoroquinolone and at least one
of three injectable second-line drugs [i.e., amikacin,
kanamycin or capreomycin]) are based on limited data.
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Drugs for Tuberculosis. Treatment Guidelines from The Medical Letter. April 2012;10 (116) 29-35
Abbreviations:
Rifampicin (RIF)
Rifabutin (RPT) Isoniazid (INH)
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antiviral order (VIRAL infections)

Antiviral Drugs (for renal failure patient appendix):


Viral infection Type or condition Therapy
Varicella-Zoster Virus Varicella 1 Acyclovir 800 mg PO q6hr x 5d
Infections 2 Valacyclovir 1 g PO q8hr x 5d
Herpes Zoster 1 Valacyclovir 1 g PO q8hr x 7d
2 Acyclovir 800 mg PO q6hr x 7d
Varicella or Zoster in 1 Acyclovir 10 mg/kg IV q8hr x7d
Immunocompromised Patients
Acyclovir-resistant Zoster 1 Foscarnet 40-60 mg/kg IV q8hr x 14-21d
Herpes Simplex Virus Orolabial First episode 1 Acyclovir 400 mg PO q8hr x 7-10d
Infections 2 Valacyclovir 1 g PO q12hr x 7-10d
Recurrences 1 Acyclovir 400 mg PO q6hr 5d
Suppression 1 Acyclovir 400 mg PO q12hr
2 Valacyclovir 500 mg-1 g PO once/d
Genital First episode 1 Acyclovir 400 mg PO q8hr x 7-10d
2 Valacyclovir 1 g PO q12hr x 7-10d
Recurrences 1 Acyclovir 800 mg PO q8hr x 5d
2 Valacyclovir 500 mg PO q12hr x 3d
Suppression 1 Acyclovir 400 mg PO q12hr for 12 months
2 Valacyclovir 500 mg-1 g PO once/d for 12 months
Mucocutaneous in 1 Acyclovir 5 mg/kg IV q8h x 7-14d or 400 mg PO 5x/d x
Immunocompromised Patients 7-10d
2 Valacyclovir 500 mg-1 g PO bid x 7-10d
Acyclovir-resistant Mucocutaneous 1 Foscarnet 40 mg/kg IV q8h x 14-21d or until healed
Severe infection,
immunocompromised
Encephalitis 1 Acyclovir 10-15 mg/kg IV q8h x 14-21d
Other Severe or Disseminated 2 Acyclovir 5-10 mg/kg IV q8h x 14-21d
Keratitis 1 Acyclovir 3% ophthalmic ointment
for 1week
Influenza 1 Oseltamivir 75 mg PO once/d prophylaxis
75 mg PO q12hr x 5d treatment
Chronic Hepatitis Refer to hepatologiest
B
Chronic Hepatitis C Refer to hepatologiest

NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Antiviral Drugs. Treatment Guidelines from The Medical Letter. March 2013;11 (127) 19-29
_________Hospital FILE NO.      
Pharmaceutical Care Department NAME:_________________________________________
___________Region
(Antibiotics Program)

Physician Order Form AGE:   SEX:  M  F

(Please fill all applicable information and stick it on NATIONALITY:__________________________________


patient profile, and forward the copy to the
Pharmacy Department within 24 hrs)

Drugs for parasitic infections

Protozoa
Infection Therapy (drug interval )
Amebiasis Asymptomatic 1 Diloxanide furoate 500 mg PO tid x 10 d
(Entamoeba Mild to moderate 1 Metronidazole 500 to 750 mg PO tid x 7 to 10 d
histolytica) intestinal disease
Severe intestinal and 1 Metronidazole 750 mg PO tid x 7 to 10 d
extraintestinal disease
Amebic Naegleria fowleri 1 Amphotericin B 1.5 mg/kg/d IV in 2 doses x 3 d, then 1
meningoencephalitis mg/kg/d x 6 d plus 1.5 mg/d intrathecally x 2 d, then 1
, primary and mg/d every other day x 8 d
granulomatous
ASCARIASIS 1 Albendazole 400 mg PO once
(Ascaris lumbricoides, roundworm) 2 Mebendazole 100 mg bid PO x 3d or 500 mg once

BABESIOSIS 1 Clindamycin1.2 g bid IV or 600 mg tid PO x 7-10 days


(Babesia microti) plus quinine 650 mg PO tid x 7-10d
2 Atovaquone 750 mg PO bid x 7-10d
plus azithromycin 500 mg PO daily x 7-10d

Balantidiasis (Balantidium coli) 1 Tetracycline 500 mg PO qid x 10 d


2 Metronidazole 750 mg PO tid x 5d
CAPILLARIASIS 1 Mebendazole7 200 mg PO bid x 20d
(Capillaria philippinensis) 2 Albendazole7,12 400 mg PO daily x 10d
Cryptosporidiosis (Cryptosporidium) 1 Nitazoxanide 500 mg PO bid x 3 d
Cyclosporiasis (Cyclospora cayetanensis) 1 TMP/SMX160 mg/ 800 mg (1 DS tab) PO bid x 7 to 10 d
2 Ciprofloxacin500 mg PO bid x 7 d
Cystoisosporiasis (Cystoisospora belli, formerly 1 TMP/SMX160 mg/ 800 mg (1 DS tab) PO bid x 7 to 10 d
known as Isospora)
Microsporidiosis Ocular (Encephalitozoon 1 Albendazole 400 mg PO bid
hellem, E. cuniculi,
Vittaforma [Nosema]
corneae)
Intestinal (E. intestinalis) 1 Albendazole 400 mg PO bid
E. bieneusi
Disseminated (E. hellem, E. 1 Albendazole 400 mg PO bid
cuniculi, E. intestinalis,
Pleistophora sp.,
Trachipleistophora sp. and
Anncaliia [Brachiola]
vesicularum
Helminths
Infection Therapy
Ancylostoma caninum (Eosinophilic 1 Albendazole 400 mg PO once
enterocolitis)
Ascariasis (Ascaris lumbricoides, 1 Albendazole 400 mg PO once
roundworm)
Capillariasis (Capillaria philippinensis 1 Albendazole 400 mg PO once
Enterobius vermicularis (pinworm) infection 1 Albendazole 400 mg PO once
Fluke, hermaphroditic, infection
Clonorchis sinensis (Chinese liver fluke) 1 Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
2 Albendazole 10 mg/kg/d PO x 7 d
Fasciolopsis buski, Heterophyes 1 Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
heterophyes, Metagonimus yokogawai
(intestinal flukes)
Metorchis conjunctus (North American liver 1 Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
fluke)
Nanophyetus salmincola 1 Praziquantel 60 mg/kg/d PO in 3 doses x 1 d
Opisthorchis viverrini (Southeast Asian liver 1 Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
fluke)[
Paragonimiasis (P. westermani, P. miyazaki, 1 Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
P. skrjabini, P. hueitungensis, P.
heterotrema, P. utcerobilaterus, P. Africanus,
P. Mexicanus, P. Kellicotti) (lung fluke)
Schistosomiasis (Bilharziasis) 1 Praziquantel 40 mg/kg/d PO in 1 or 2 doses x 1 d
Strongyloidiasis (Strongyloides stercoralis) 1 Ivermectin 200 mcg/kg/d PO x 2 d
2 Albendazole 400 mg PO bid x 7 d

GIARDIASIS
(Giardia duodenalis) 1 Metronidazole 250 mg PO tid x 5-7d
2 Tinidazole 2 g PO once

GNATHOSTOMIASIS
(Gnathostoma spinigerum) 1 Albendazole 400 mg PO bid x 21d

GONGYLONEMIASIS
(Gongylonema sp.) 1 Surgical removal
2 OR Albendazole 400 mg/d PO x 3d

HOOKWORM infection
(Ancylostoma duodenale, Necator 1 Albendazole 400 mg PO once
americanus) 2 Mebendazole 100 mg PO bid x 3d or 500 mg once
3 Pyrantel pamoate 11 mg/kg (max. 1g) PO x 3d

ISOSPORIASIS
(Isospora belli) 1 Trimethoprim- sulfamethoxazole TMP 160 mg/SMX 800
mg (1 DS tab) PO bid /10 days

LEISHMANIA
Visceral 1 Liposomal amphotericin B 3 mg/kg/d IV d 1-5, 14 and 21
2 Sodium stibo gluconate 20 mg Sb/kg/d IV or IM x 28d
3 Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28d
Cutaneous 1 Sodium stibo gluconate 20 mg Sb/kg/d IV
2 Meglumine antimonite 20 mg Sb/kg/d IV or IM x 20d
3 Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28 days
Mucosal 1 Sodium stibo gluconate 20 mg Sb/kg/d IV or IM x 28d
2 Meglumine antimonite 20 mg Sb/kg/d IV or IM
3 Amphotericin B 0.5-1 mg/kg IV daily or every second
day for up to 8wks
4 Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28d

LICE infestation
(Pediculus humanus, P. capitis, Phthirus pubis) 1 0.5% Malathion Topically
2 1% Permethrin Topically
3 Ivermectin 200 mcg/kg PO
MALARIA, Treatment of (Plasmodium falciparum, P. vivax, P. ovale, and P. malariae)
ORAL
P. falciparum Drug of choice:
or unidentified species acquired in areas of 1 Single administration of Sulfadoxine (25 mg/kg) /
chloroquine-resistant P. falciparum Pyramethamine (1.25 mg/kg) on day 1 + Artesunate 4
mg/kg/day on day 1 , 2, and 3
2 Artemether/lumefantrine 6 doses over 3d (4 tabs/dose 0,
8, 24, 36, 48 and 60 hours)
Alternatives:
1 Atovaquone/ proguanil 2 adult tabs bid or 4 adult tabs
once/d x 3d
2 Mefloquine 750 mg followed 12 hrs later by 500mg
Quinine sulfate 650 mg q8h x 3 or 7d
Plus doxycycline 100 mg bid x 7d
3 or plus tetracycline 250 mg qid x 7d
4 or plus clindamycin 20 mg/kg/d in 3 doses x 7d
P. vivax Drug of choice:
acquired in areas of chloroquine-resistant P. vivax 1 Mefloquine 750 mg PO followed 12 hrs later by 500mg
Atovaquone/ proguanil 2 adult tabs bid or 4 adult tabs
once/d x 3d
either followed by
Primaquine phosphate 30 mg base/d PO x 14d
Alternatives:
1 Chloroquine phosphate 25 mg base/kg PO in 3 doses over
48 hrs
2 Quinine sulfate 650 mg PO q8h x 3-7d
Plus Doxycycline 100mg PO bid x 7d
either followed by
3 Primaquine phosphate 30 mg base/d PO x 14d
All Plasmodium species 1 Chloroquine phosphate 1g (600mg base) PO, then
except chloroquine-resistant P. falciparum and 500mg (300mg base) 6hrs later, then 500mg (300mg
chloroquine-resistant P. vivax base) at 24 and 48 hrs
PARENTRAL
All Plasmodium species 1 Artesunate 2.4 mg/kg/dose IV x 3d at 0, 12, 24 and 48 hrs
2 Artemether 3.2 mg/kg i.m., then 1.6 mg/kg I.m. daily up
(Chloroquine-sensitive and resistant) to day 6

Quinine dihydrochloride 20 mg/kg IV loading dose in


3 5% dextrose over 4 hrs, followed by 10 mg/kg over 2-4
Severe malaria
hrs q8h (max. 1800 mg/d) until PO therapy can be started

PNEUMOCYSTIS JIROVECI
(formerly carinii) pneumonia (PCP) Drug of choice:
1 Trimethoprim/sulfamethoxazole TMP 15mg/SMX
75mg/kg/d, PO or IV in 3 or 4 dose x 21d
Alternatives:
1 Primaquine 30 mg base PO daily x 21 d
plus clindamycin 600mg IV q6h x 21d, or 300-450 mg
PO q6h x21d
2 Trimethoprim 5mg/kg PO tid x 21d
plus dapsone 100mg daily x 21 d
3 Pentamidine 3-4 mg/kg IV daily x 21d
4 Atovaquone 750 mg PO bid x 21d
Primary and secondary prophylaxis 1 Trimethoprim/sulfamethoxazole 1 tab (single or double
strength) daily or 1 DS tab PO 3d/wk
2 Dapsone 50 mg PO daily or 200 mg PO each wk
SCABIES
(Sarcoptes scabiei) 1 5% Permethrin Topically once
2 Ivermectin 200 mcg/kg PO once
3 10% Crotamiton Topically once/d x 2
SCHISTOSOMIASIS (Bilharziasis)
S. haematobium, S. japonicum, S. mansoni, S. 1 Praziquantel 40 mg/kg/d PO in 2 doses x 1d
mekongi

Tapeworm infection
Diphyllobothrium latum (fish), Taenia saginata 1 Praziquantel 5 to 10 mg/kg PO once
(beef),Taenia solium (pork), Dipylidium 2 Niclosamide 2 g PO once
caninum (dog)
Hymenolepis nana (dwarf tapeworm) 1 Praziquantel 25 mg/kg PO once
2 Niclosamide 2 g PO daily x 7 d
Echinococcus granulosus (hydatid cyst) 1 Albendazole 400 mg PO bid x 1 to 6 months
Taenia solium (Cysticercosis) 1 Albendazole 400 mg PO bid x 8 to 30 d; can be repeated
as necessary
2 Praziquantel 100 mg/kg/d PO in 3 doses x 1 day then 50
mg/kg/d in 3 doses x 29 days
Trichinellosis (Trichinella spiralis) 1 Albendazole 400 mg PO bid x 8 to 14 d
Trichostrongylus infection 1 Albendazole 400 mg PO once
Trichuriasis (Trichuris trichiura, whipworm) 1 Albendazole 400 mg PO x 3 d
2 Ivermectin 200 mcg/kg/d PO x 3 d
Visceral larva migrans[40] (Toxocariasis) 1 Albendazole 400 mg PO bid x 5 d

TOXOPLASMOSIS
Toxoplasma gondii 1 Pyrimethamine 25-100 mg/d PO x 3-4wks
plus sulfadiazine 1-1.5 g PO qid x 3-4wks

TRICHOMONIASIS
Trichomonas vaginalis 1 Metronidazole 2 g PO once or 500 mg bid x 7d
2 Tinidazole 2 g PO once

TRICHURIASIS
Trichuris trichiura, whipworm 1 Mebendazole 100 mg PO bid x 3d or 500 mg once
2 Albendazole 400 mg PO x 3d

NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Drugs for Parasitic Infections. The Medical Letter, Inc.3rd (2013)


UPTODATE 2014
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

Antifungal order (fungal infection)


Antifungal infection: (for renal failure patient appendix)
Condition Treatment group Therapy Duration
Candidemia Non-neutropenic 1 Fluconazole IV/PO 800-mg(12-mg/kg) loading
adults dose, then 400 mg(6 mg/kg) daily 14 days after
for moderately severe to severe illness and first negative
for patients with recent azole exposure blood culture
2 Anidulafungin, I.V. 200-mg loading dose, then and
resolution of
I.V.100 mg/day signs/
3 Caspofungin, 70-mg I.V. loading dose, then symptoms
I.V. 50 mg/day (35mg for moderate hepatic
insufficiency)
4 Lipid base Ampho B I.V 3–5 mg/kg daily
5 AmphoB 0.5–1 mg/kg I.V daily
Calculated Dose: ……………………………..
Neutropenic 1 Anidulafungin, I.V.200-mg loading dose, then
patients I.V. 100 mg/day
2 Caspofungin, I.V. 70-mg loading dose, then
I.V. 50 mg/day (35mg for moderate hepatic
insufficiency)
3 Lipid base Ampho B I.V 3–5 mg/kg daily
4 Fluconazole 800-mg (12-mg/kg) loading dose,
then 400 mg (6 mg/kg) daily I.V. or P.O
Suspected candidiasis Non-neutropenic 1 Fluconazole 800-mg (12-mg/kg) loading dose,
(Treated with empiric patients then 400 mg (6 mg/kg) daily I.V. or P.O
antifungal therapy) for moderately severe to severe illness and for
patients with recent azole exposure
2 Anidulafungin, IV 200-mg loading dose, then
I.V. 100 mg/day
3 Caspofungin IV 70-mg loading dose, then I.V.
50 mg/day (35mg for moderate hepatic
insufficiency)
4 Lipid base Ampho B IV 3–5 mg/kg daily
Neutropenic 1 Lipid base Ampho B IV 3–5 mg/kg daily
patients 2 Caspofungin 70-mg loading dose, then 50 mg
Daily (35mg for moderate hepatic
insufficiency)
3 Voriconazole IV 400 mg (6 mg/kg) Q12hrs for
2 doses then 200 mg (3 mg/kg) I.V. Q12hrs
4 Fluconazole IV/PO 800-mg (12-mg/kg) loading
dose, then 400 mg (6 mg/kg) daily
Urinary tract infection Asymptomatic Therapy not usually indicated, unless
cystitis patients are at high risk (e.g., neonates
and neutropenic adults
Symptomatic 1 Fluconazole 200 mg (3 mg/kg) daily IV/PO for
cystitis 2 weeks
2 Ampho B I.V. 0.3–0.6 mg/kg for 7 - 10 days
3 Flucytosine 25 mg/kg q6hr for 7–10 days

Pyelonephritis 1 Fluconazole 200–400 mg (3–6 mg/kg) once


daily orally for 2 weeks
2 AmphoB I.V. 0.5–0.7 mg/kg daily ± 5-FC 25
mg/kg P.O Q6hrs
3 5-FC alone for 2 weeks
Urinary fungus Surgical removal strongly recommended (B-
balls III)
1 fluconazole 200–400 mg (3–6 mg/kg) daily
2 AmphoB I.V. 0.5–0.7 mg/kg daily± 5-FC 25
mg/kg P.O Q6hrs
Vulvovaginal 1 Topical agents or fluconazole 150 mg single
candidiasis dose for uncomplicated vaginitis
Chronic disseminated 1 Fluconazole 400 mg (6 mg/kg) daily I.V. or PO An
Candidiasis (Refer patient 2 Anidulafungin I.V. 200-mg loading dose, then echinocandi
to the specialized I.V. 100 mg/day n for several
physician) 3 caspofungin, 70-mg loading dose, then 50 weeks
mg/day (35mg for moderate hepatic followed by
insufficiency) fluconazole
4 Lipid base Ampho B I.V 3–5 mg/kg daily
5 AmphoB I.V. 0.5–0.7 mg/kg daily
after patient is stable change to fluconazole
Candida osteoarticular Osteomyelitis 1 Fluconazole 400 mg (6 mg/kg) daily I.V. or
Infection Orally for 6–12 months
(Refer patient to the 2 Lipid base Ampho B I.V 3–5 mg/kg daily for
specialized physician) several weeks, then fluconazole for 6–12
months
Septic arthritis 1 Fluconazole 400 mg (6 mg/kg) daily I.V. or
Orally for at least 6 weeks
2 Lipid base Ampho B I.V 3–5 mg/kg daily for
several weeks, then fluconazole to completion
CNS candidiasis 1 Lipid base Ampho B I.V 3–5 mg/kg ± 5- FC 25
(Refer patient to the mg/kg P.O Q 6hrs for several weeks, followed
specialized physician) by fluconazole 400–800 mg (6–12 mg/kg) daily
I.V. or P.O
2 Fluconazole 400–800 mg (6–12 mg/ kg) daily
for patients unable to tolerate Lipid base
Ampho B
Candida Endophthalmitis 1 Ampho B I.V 0.7–1 mg/kg with 5-FC 25 mg/ surgical
(Refer patient to the kg orally Q6hrs intervention
specialized physician) for patients
2 Fluconazole 6–12 mg/kg daily with severe
Duration of therapy : 4-6 weeks or longer, endophthalm
based on resolution determined by repeated itis or
examinations. vitreitis
Candida infection of the Endocarditis 1 Lipid base Ampho B 3–5 mg/kg ± 5-FC 25 Step-down
cardiovascular mg/kg P.O Q6hrs therapy to
System 2 AmphoB I.V 0.6–1 mg/kg daily ± 5-FC 25 fluconazole
(Refer patient to the mg/kg P.O Q6hrs 400–800 mg
specialized physician) 3 Anidulafungin, I.V 200-mg loading dose, then (6–12
I.V 100 mg/day mg/kg) daily
4 caspofungin, I.V 70-mg loading dose, then I.V for
50 mg/day(35mg for moderate hepatic susceptible
insufficiency) organism in
stable patient
with
negative
blood culture
results
Pericarditis or 1 Lipid base Ampho B I.V 3–5 mg/kg daily After stable,
myocarditis 2 Fluconazole 400–800 mg (6–12 mg/kg) daily step-down
I.V or P.O therapy to
3 Anidulafungin, I.V 200-mg loading dose, then fluconazole
I.V 100 mg/day 400–800 mg
4 Caspofungin, I.V 70-mg loading dose, then I.V (6–12
50 mg/day (35mg for moderate hepatic mg/kg)
insufficiency) daily
Suppurative 1 LFAmB 3–5 mg/kg daily
2 Fluconazole 400–800 mg (6–12 mg/kg) daily
thrombophlebitis 3 Anidulafungin, 200-mg loading dose, then 100
mg/day
4 Caspofungin, 70-mg loading dose, then 50
mg/day;
Infected 1 LFAmB 3–5 mg/kg ± 5- FC 25 mg/kg q6h
pacemaker, ICD, 2 AmB-d 0.6–1 mg/kg daily ± 5-FC 25 mg/kg
or VAD q6h
3 Anidulafungin, 200-mg loading dose, then 100
mg/day
4 Caspofungin, 70-mg loading dose, then 50
mg/day;
Candida isolated from
respiratory secretions Therapy not recommended

Nongenital Oropharyngeal 1 Clotrimazole troches 10 mg 5 times Daily


mucocutaneous 2 Nystatin suspension pastilles Q6hrs
candidiasis 3 Fluconazole 100–200 mg daily

Esophageal 1 Fluconazole 200–400 mg (3–6 mg/kg) daily


2 Anidulafungin, I.V 200-mg loading dose, then
I.V 100 mg/day
3 Caspofungin, I.V 70-mg loading dose, then I.V
50 mg/day
4 LFAmB 3–5 mg/kg ± 5- FC 25 mg/kg q6h
5 AmphoB I.V 0.3–0.7 mg/kg daily
Aspergillosis 1 Voriconazole 6 mg/kg IV q12h x 1d then 4 Duration
mg/kg IV q12h or 200-300 mg PO bid ≥10 weeks
2 Caspofungin, I.V 70-mg loading dose, then I.V
50 mg/day
3 LFAmB 3–5 mg/kg ± 5- FC 25 mg/kg q6h
4 Amphotericin B 1-1.5 mg/kg/d IV
Mucormycosis 1 LFAmB 3–5 mg/kg ± 5- FC 25 mg/kg q6h
2 Posaconazole 200 mg PO q6-8hr
3 Amphotericin B 1-1.5 mg/kg/d IV x 6-10 wks

NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________

Physician/Clinical Pharmacist Name: ________________________________ pager:_____________


Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm

Uptodate 2010
Peter G. Pappas, Carol A. Kauffman. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America.
Clinical Infectious Diseases 2009; 48:503–35
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

ANTIBIOTIC SURGICAL PROPHYLAXIS FOLLOW-UP SHEET

Pre-Operative Antibiotics for Surgical Prophylaxis

No antibiotics given at the wards ( it should be given at inta-operative room)

Date: Time of Antibiotic Administration: Time of Incision:

Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.

Review patient allergies prior to prescribing/administering medications.

Select appropriate antibiotic as determined by procedure and initiate 30-60 minutes prior to incision.

Vancomycin, Ciprofloxacin and Metronidazole should be initiated within 60-120 minutes prior to incision.

Prophylactic Antibiotic Within Timeframe Yes No

Ordered  

Given  
Not ordered or given for the following reason:
 
• Medical (eg, not indicated, contraindicated, other medical reason)

Document reason here and in medical chart.

___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________

Type of Surgery:  Clean  Clean Contaminated  Contaminated  Dirty

Procedure Drug of Choice *Alternative choice

 Cefazolin or Cephradine 2 gm (40mg/kg if


 Oral Neomycin 1 gm (20mg/kg if child) and
child) IV + Metronidazole (7.5mg/kg if child) IV
Erythromycin base 1 gm (10mg/kg if child)
Colorectal x dose
19, 18, and 9 hours before surgery

 Cefazolin or Cephradine 2 gm (40mg/kg if  Cephalosporins allergic or MRSA colonized:


Cardiac child) IV one dose before and q 8 hr for up to 24
hr after surgery ( for obese pateint 3g) Vancomycin 1 gm (15 mg/kg if child) IV

 Cephalosporins allergic:
 Cefazolin or Cephradine 2 gm (40mg/kg if
Thoracic (None Cardiac)
child) IV for one dose ( for obese pateint 3g) Vancomycin 1 gm (15 mg/kg if child) IV for 1
dose

 Clindamycin 600mg IV + Gentamycin


 Cefazolin or Cephradine 2 gm IV for one dose
1.5mg/kg
Obstetric / Gynecologic
( for obese pateint 3g)
(Max. 120mg) IV for one dose

 Clean cut procedures: none incision through


oral or pharygeal mucosa:  - Cefazolin or Cephradine 2 gm (40mg/kg if
Head / Neck
child) one dose before and q 8 hr for 24 hr
Clindamycin 600mg (10mg/kg if child)
 Cephalosporin allergic or MRSA colonized:
 Cefazolin or Cephradine 2 gm (40mg/kg if
Neurosurgery
child) IV for one dose ( for obese pateint 3g) Vancomycin 1 gm (15mg/kg if child) IV for 1
dose

 Cephalosporins allergic or MRSA colonized:


 Cefazolin or Cephradine 2 gm (40mg/kg if child)
Orthopedic
IV for one dose ( for obese pateint 3g)
Vancomycin 1 gm (15 mg/kg if child) IV

 Cephalosporins allergic or MRSA colonized:


 Cefazolin or Cephradine 2 gm (40mg/kg if
Vascular
child) IV for one dose ( for obese pateint 3g)
Vancomycin 1 gm (15 mg/kg if child) IV

Other Surgery  

For procedures lasting greater than 4 hours, or greater than 1000mL blood loss, repeat pre-op dose of Cefazolin OR Clindamycin every 4
hours intraoperatively.

Duration of Surgury:_____________ Hours.

Repeat Dosing of Antibiotic: Drug Name: _________________ Dose: _________ Interval: _______________

NOTE:

If post-op prophylaxis antibiotic given, duration:  less than 24 hours  24 hours  more than 24 hours

Physician / Nurse Signature:

Clinical Pharmacist Comment:


Appendix A: Guidelines for Blood Culture Collection
INDICATIONS

Routine blood cultures should be performed on any patient in whom there is a suspicion of bacteremia or candidemia.

II. TIMING

Blood cultures should be drawn prior to the institution of antibiotics whenever possible. If empiric treatment is an
emergency, blood cultures should still be drawn as soon as possible after institution of antibiotics. There are no data to
suggest that the timing of culture in relation to the appearance of fever or chills will maximize the yield.

III. VOLUME OF BLOOD PER SET

There is a direct relationship between the volume of blood obtained and the yield of a blood culture set. Forty to 60 ml of
blood should be obtained per episode (in other words, 2-3 sets with 20 ml per set, and 10 ml per bottle) According to the
age.

IV. NUMBER OF SETS OF BLOOD CULTURES

Single sets should not be used to evaluate any patient with suspected bacteremia or candidemia. The optimal yield is
obtained with two or three sets of blood cultures. No more than three blood cultures should be obtained for any given 24
hour period.

V. SITE OF BLOOD CULTURE

Blood should be obtained from peripheral venous or arterial sites. Obtaining blood cultures from central venous catheters,
arterial lines and inguinal vessels increases the likelihood of obtaining a false positive blood culture.

For suspected catheter-related bloodstream infection (CR-BSI) draw one set through device and one set from a separate
venipuncture..

VI. LABELING

Labeling the site of each set of blood cultures, particularly regarding whether a set was drawn from a catheter, the groin,
or not, is of ulmost importance in helping to distinguish pathogens from contaminants in those cases in which no
peripheral access can be found.

VII. PREPARATION OF THE SITE FOR CULTURE

The use of a 2% chlorhexidine-based preparation for cutaneous antisepsis is classified as a Category 1A recommendation
If not available then alcohol can be used

After the vessel site is selected, a 5 cm area of skin should be disinfected by swabbing concentrically with 70% alcohol,
from the venipuncture site outward. vigorous friction back and forth

2. The site should be cleansed once again, this time with 10% povidone-iodine or 2% tincture of iodine again in a circular
motion.

3. Allow the iodine to dry completely before performing venipuncture. This should take 1 - 2 minutes.

4. While waiting for the site to dry, the plastic cap covering each blood culture bottle should be removed, and the rubber
stopper should be decontaminated with 70% alcohol. (Iodine solutions will disintegrate the rubber and should not be
used.)

5. 20 ml of blood should be withdrawn from the puncture site.

6. Do not change needles between venipuncture and inoculation of the bottles, or between bottles. The risk of needlestick
is increased, while the chance of contamination is not significantly lessened.

7. Remove the iodine solution from the skin with alcohol. This will minimize the possibility of hypersensitivity.
Appendix B: Guidelines for Infection Control
ISOLATION SYSTEMS

I. STANDARD PRECAUTIONS (formerly known as Universal Precautions)

Standard Precautions are designed to reduce the risk of transmission of microorganisms from recognized and
unrecognized sources of infection.

Use Standard Precautions for care of ALL patients, regardless of their diagnosis.

1Standard Precautions applies to:

Blood

All body fluids, secretions, and excretions except sweat regardless of whether they contain visible blood

Non-intact skin

Mucous membranes

Gloves will be worn whenever contact with these fluids is anticipated. Gloves will be changed between patients, between
tasks, or when torn.

Hand washing between patients and after contact with blood/body fluids is essential.

Wash hands after removing gloves.

If aerosolization or splattering of blood/body fluids is likely, additional barriers must be worn (gowns, splash shields,
goggles, masks).

II. AIRBORNE PRECAUTIONS

To reduce the risk of airborne transmission of infectious agents. Use Airborne Precautions for patients known or
suspected to have infections transmitted by tiny droplet nuclei (particles 5 microns or smaller in size). 2Illnesses include:

Tuberculosis , Measles and Varicella (chickenpox), including disseminated Zoster

Patients must be placed in a room with negative air pressure ventilation to prevent transmission of droplet nuclei. Without
negative pressure ventilation, infectious droplet nuclei can remain suspended in air for long periods of time.

Doors and windows in negative pressure isolation rooms must be kept closed at all times.

Hospital personnel and visitors entering an Airborne isolation room must wear the N95 TB respirator.

For patients isolated with chickenpox or measles - persons immune to chickenpox/measles may enter an Airborne
isolation room without a mask.

Patients in Airborne isolation must remain in their room. Patients should leave their room only for essential studies.
Patients must wear a paper surgical mask when leaving their room.

III. DROPLET PRECAUTIONS

To reduce the risk of droplet transmission of infectious agents. Involves contact of the conjunctivae, or mucous
membranes of the nose or mouth of a susceptible person with large droplets (greater than 5 microns in size) containing
microorganisms from a person who has clinical disease or is a carrier of the microorganism.

1Illnesses include:

Diphtheria

Influenza
Rubella

Pertussis

Mumps

Invasive N. meningitidis disease

Invasive H. influenzae disease, etc..

Droplets are generated during sneezing, coughing, talking, and during certain procedures such as suctioning or
bronchoscopy.

Close contact (usually 3 feet or less= 1 meter) to the infectious person is required for transmission of the disease. Large
droplets travel only short distances and do not remain suspended in the air.

Hospital personnel and visitors entering a Droplet isolation room must wear a paper surgical mask.

IV. CONTACT PRECAUTIONS

To reduce the transmission of epidemiologically important infectious agents spread by direct or indirect contact.

Direct Contact - skin to skin contact, the physical transfer of microorganisms.

Indirect Contact - contact with a contaminated intermediate object from the patient's environment.

2Contact precautions apply to patients who are actively infected or colonized with epidemiologically important
organisms, including :

Multi-Drug Resistant Bacteria (MRSA, VRE, etc.)

Enteric infections with a low infective dose or prolonged survival in the environment (C. difficile, etc.). Skin infections
that are highly contagious (scabies, major abscesses, impetigo, Herpes Simplex, active Zoster, etc.)

Hospital personnel and visitors entering a contact isolation room must wear gloves and gowns.

Disinfection of non-disposable, reusable patient equipment must be performed before leaving the contact isolation room
and before reuse with another patient. When possible, dedicate equipment to the contact isolation room.

HAND HYGIENE:

Hand washing is the single most important step you can perform to reduce the transmission of infectious agents from
person to person or from one site to another.

Wearing gloves does not replace the need to wash your hands!!!
Culturing observation check list

CARE ELEMENT YES NO


Prepare the materials needed (i.e., specimen bottles, syringes, skin prep
1
products, etc.)
Hands washed with soap and water or alcohol gel applied prior to set up for the
2
procedure.
3 Visibly soiled skin cleaned with soap and water (patient)
Disinfect blood culture specimen tops with 2% chlorhexidine or 70% alcohol
4
wipe.
Hands washed with soap and water or alcohol gel was applied prior to
5
procedure.
6 Standard precautions followed (i.e., gloves worn)
Patient’s skin disinfected with 2% Chlorhexidine solution for 30 seconds and
then allowed to dry for another 30 seconds OR disinfected with 70% alcohol
7
and/or 10% povidone-iodine or 2% tincture of iodine. Allow to dry completely
before performing venipuncture (1-2 minutes)
8 Disposable tourniquet used.
Venipuncture site not touched again following disinfection of the skin.
9
Venipuncture site:.............................................
Blood culture bottles inoculated before tubes for haematology/chemistry.
10 Discard first 10 mL in separate syringe if venipuncture site other than forearm or
via new cannula
11 Inoculate anaerobic bottle first. (Aerobic if using winged method-see over)
12 Sharps disposed in sharp container/bin.
13 Hands washed following the procedure

Sample taken by:


Name: ……………………………………… job title: …………………………………
Signature: ……………………………
Observed by:
Name: ……………………………………… job title: …………………………………
Signature: ……………………………
Appendix C: Skin Test and anaphylactic
Skin test only performed for patient with history of penicillin allergy

Skin test and anaphylactic kits bag

Skin test kits:

1ml 3ml 5ml prick bifurcated Scarifier 26 -27 Filter Alcohol


syringe syringe syringe lancetter vaccination gauge needle swab
(3) (3) (3) needle needle

Gloves (2) Histamine Base: 6mg/mL (Histamine Normal Saline for


(1ml) Dihydrochloride: injection 5ml (-)
(+) control 10mg/mL (1ml) control
(+) control

Anaphylactic shock kits:

1ml 3ml 5ml Gloves (3) 18 gauge 5/8 Normal saline


syringe syringe syringe needle (3) 500ml (2)
(3) (3) (3)

Epinephrine 1mg/ml (1:1000) Albuterol (Salbutamol) Diphenydramin Ranitidine


injection (3) 5mg/2.5 ml Nebulizer 50mglml injection 50mg/2ml injection
solution (1) (1) (1)

Methylprednisolone Na Glucoagon 1mg (1


Succinate 500mg unit ) syringe (2)
injection (1)
Attached: skin test procedure and anaphylactic shock treatment protocol (adult, paediatric)
ANTIBIOTIC SKIN TEST

Patient name: age: sex: ward: file no.:

Patient medical history:

Pre-procedure precautions include:


If possible to stop, OR to do it before starting the medications that interfere with skin test, (wheal/flare suppression)
for 3-5 days:
H1 antihistamines, Antihistamine nasal sprays, H2 receptor antagonists, topical glucocorticoids for longer than one week,
omalizumab, Tricyclic antidepressants and Higher doses of methotrexate

Medication (emergency kit) and resuscitation equipment must be readily available as per Anaphylaxis Protocol.
procedure:
Prick/puncture. A diluted allergen is applied with a prick or a puncture on the surface of the skin. (With
positive (histamine) and negative control( normal saline) )
Results of Prick Test Dose:
Erythema and Weal Response 5x5mm (>25mm) positive, no further testing indicated.
o Erythema and Weal Response <5x5mm (25mm) proceed to intradermal test dose

Intradermal test dose: Using a 26-27-guage (very thin) needle, a diluted allergen is injected immediately below the
skin surface.
Results of Intradermal (ID) Test Dose:
o Erythema and Weal at Injection Site 5x5mm (>25mm) positive allergy to antibiotic tested.
o Erythema and Weal at Injection Site >3x3mm (>9mm) but <5x5mm
o (<25mm) borderline positive
o If intradermal skin test negative oral challenge indicated

Skin test reagent Route Drug test conc. Skin test volume
Penicillin G prick/puncture (10,000 units/mL) droplets
Intradermal (10,000 units/mL) 0.02 - 0.05 mL
histamine dichloride prick/puncture (10 mg/mL) droplets
Intradermal (0.001 mg/mL) 0.02 - 0.05 mL
Normal saline prick/puncture 0.9 % NACL droplets
Intradermal 0.9 % NACL 0.02 - 0.05 mL

Note:--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------
Physician name: signature:

http://www.uptodate.com/contents/overview-of-skin-testing-for-allergic-disease?source=see_link&anchor=H27#H27
http://www.acaai.org/allergist/allergies/Treatment/diagnosing-allergies/Pages/allergy-skin-tests.aspx
Roland solensky, and david a. khan. drug allergy: an updated practice parameter. annals of allergy, asthma & immunology, volume 105, october, 2010: 273.e1-e78
Anaphylaxis Algorithm
Anaphylactic reaction

Airway, Breathing, Circulation, Disability, Exposure

Diagnosis:
 Acute onset of illness
 Life threatening Airway and/or Breathing and/or circulation problem
 Usual skin changes

 Call for help


 Lie patient flat
 Rise patient legs

Adrenaline

When skills and equipment available:


Establish airway monitor:
High flow oxygen Pulses oximetry
IV fluid challenge ECG
Chlorophenamine Blood Pressure
Hydrocortisone

Life threatening problem:


Airway: swelling, hoarseness, stridor
Breathing: rapid breathing, wheezing, fatigue, cyanosis, SpO2 < 92%, Confusion
Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma

Adrenaline (give IM unless experienced with IV adrenaline)


IV fluid challenge:
IM doses of 1:1000 adrenaline (repeat after 5 min if no
Adult: 500-1000 ml
better)
Adult: 500 micrograms IM (0.5 ML)
Stop IV colloid if this might be the
Adrenalin IV to be given only by experienced specialists
cause of anaphylaxis
Titrate: adult 50 micrograms

Chlorphenamine (IM or slow IV):10MG

Hydrocortisone (IM or slow IV): 200MG

Emergency treatment of anaphylactic reactions Guidelines for healthcare providers, Resuscitation Council (UK)January 2008

Appendix D: antibiotics dosing monitoring


Vancomycin:

Vancomycin is a tricyclic glycopeptide that inhibits bacterial cell wall synthesis.


It is considered to be bactericidal against most Gram-positive organisms, except Enterococcus
species.
Vancomycin has bot time-dependent killing and moderate persistent effects that is dependent
on concentration (i.e., peak).
Persistent effects include the Post-Antibiotic Effect (PAE), which is the persistent suppression
of bacterial growth following antibiotic exposure.
The ideal dosing regimen is to maximize the amount of drug received. Thus, the appropriate
pharmacodynamics parameter that correlates with efficacy is the 24H- Area Under the Curve
(AUC)/MIC ratio.
Dosing weight: actual body weight unless morbidly obese (use adjusted body weight instead)
Loading dose (if appropriate): 25-30 mg/kg (one-time dose)
Use: seriously ill patients (e.g., requiring intensive care) and patients with complicated
infections (e.g., bacteremia or pneumonia).
Initial or maintenance dose4: 15-20 mg/kg
Dosing interval: Determine creatinine clearance (based on Cockroft-Gault equation)

Vancomycin Monitoring:
Peak serum concentration is not necessary because it does not correlate well with vancomycin
toxicity (e.g., nephrotoxicity or ototoxicity).
Only the trough concentration monitoring is needed in order to assess efficacy.
For patients with normal renal function, it takes approximately 4 doses for vancomycin to
reach steady state. As such, trough concentrations should be drawn before the 4th dose.
Trough concentrations may be drawn earlier in critically ill patients, patients with unstable
renal function, and patients on vancomycin dosing interval ≥ 24 hours.
However, these trough concentrations must be interpreted with caution since additional doses
will continue to accumulate until steady state is reached.
Trough concentrations should be drawn right before the next dose (within 2 hours prior to
administration).
Vancomycin is being dosed by level (patients with creatinine clearance < 25 mL/min,
hemodialysis, or CRRT), it should be re-dosed if the level is < 20 mg/L.

The target trough concentration is dependent on the type of infection as reported


Aminoglycosides

Aminoglycosides fight against bacteria by interfering with bacterial protein synthesis, which is
achieved through irreversible binding to 30S ribosomal subunit.
Aminoglycosides have bactericidal activity against aerobic Gram-negative infections and
demonstrates concentration-dependent killing with a prolonged PAE (~4-6 hours).
The best pharmacodynamics parameter to determine the ideal dosing regimen is peak/MIC
ratio

Dosing weight: ideal body weight (IBW) unless 20% over IBW (use adjusted body weight
instead)
Initial dosing: dependent on traditional versus extended interval dosing
Extended interval dosing in all patients* except patients with altered pharmacokinetics using
Traditional dosing:
Burns > 20%
Morbidly obese
Pregnancy
Ascites or significant third spacing
Hemodynamic instability
Unstable renal function and cystic fibrosis
*Rationale: maximize concentration-dependent killing and minimize toxicity (i.e., nephrotoxicity and ototoxicity), ease of
administration and monitoring, reductions in administration and monitoring-related costs.
Aminoglycoside Monitoring:
Traditional Dosing:
Obtain serum peak and trough concentrations after 3rd dose following initiation of
therapy and any dosing adjustments in therapy.
Draw trough concentration just prior to next dose.
Draw peak concentration 30-45 minutes after the end of an intravenous infusion.
Once achieved, monitor periodically (e.g., 2-3 times weekly) throughout therapy
with changes in renal function.
If stable renal function, monitor at least once weekly.

Extended Interval Dosing:


Random serum concentration monitoring approximately 6-12 hours after 1st dose.
Interpret by using an established nomogram or based on MIC data. For amikacin
therapy, divide serum concentration by 2 before using nomogram.
Monitor periodically if unstable renal function or prolonged therapy (> 7-10 days).
Appendix E: Switching IV antimicrobial to oral
The ideal route of administration of any medication is the one that achieves serum
concentrations sufficient to produce the desired effect without producing any untoward
effects.

World Health Organization (WHO) reports that the irrational use of medicines is a major
problem worldwide. The overuse of injections, when oral formulations would be more
appropriate, is one of the key factors for the irrational use of medicines. Hence IV to oral
switch over within an appropriate time is one of the major aspects to improve the rational use
of injections. Moreover, once the culture and sensitivity reports are available, IV to oral switch
over enables one to select a cheaper or older antibiotic, which is as effective as the IV
antibiotic.

Advantages of oral over IV route

Early switch over from IV to oral therapy has the following major advantages:

Reduced risk of cannula‑related infections: For the administration of IV


medications, one is required to insert a cannula, which remains in place for some
days and eventually can result in secondary infections caused by bacteria and fungi.
This may ultimately lead to the need for additional antibiotics and subsequently
financial burden to the patient
Risk of thrombophlebitis: No risk of thrombophlebitis in case of oral administration
Less expensive than IV therapy: Most of the oral medications available at the market
are less expensive as the parenteral medications must be sterile and isotonic,
consequently leading to cost savings by the patient
Reduction in the hidden costs: Hidden costs mainly refer to cost of diluents,
equipment for administration, needles, syringes, and nursing time. Needles, syringes,
diluents, and other equipment are the unavoidable requisites for the parenteral
administration.
Earlier discharge: Injections are usually administered in a hospital setting as it
requires an experienced professional to administer the medication, especially IV
infusions. Hence the patient stay at the hospital is prolonged. Early switch over to
oral medications can help to overcome this barrier and may result in early discharge
of the patient

Practical approaches for conversion of a patient from IV to oral therapy


First, a clinical pharmacist should identify patients who receive IV medications and also
recognize the need for IV medication in those patients and check for the indication
Second, regular follow up is needed to check whether the patient’s clinical status (WBC [white
blood cells], vitals, culture report, patient’s physical and mental condition, etc.) is improving or
not. If the patient is eligible for conversion , check whether the conversion was done
Inform the physician about the patients who are eligible for conversion but not converted
within the appropriate time
Make suitable recommendations for the selection of an oral medication for conversion
Review the feedback of the physicians
Monitor the patient’s clinical progress after the switch over and convert the
patient back to parenteral medication, if required
It is always advisable to verify the knowledge and beliefs of physicians regarding
the guideline for switch over from IV to oral therapy. A data collection tool like
questionnaires can be used for the same

Patient selection criteria for IV to oral switch over therapy


Inclusion criteria Exclusion criteria

-Patient is able to eat their regular or modified diet or -Patients with unreliable response to oral medications
receiving enteral nutrition by oral, gastric or other (severe nausea or vomiting)
appropriate enteral route Patient receives other
scheduled oral medications -Unable to swallow or unconscious Strict (nothing per
oral) for a procedure
-For patients who receive antibiotics, signs and
symptoms of infection resolved or improving (WBC -GI obstruction, malabsorption, active GI bleeding,
decreasing toward normal range, improving chest X-ray paralytic ileus or severe diarrhea
findings, temperature less than 100°F for at least 24-48
hours and respiratory rate<20 breaths/min.) -Unresponsive to previous oral therapy Patients with
grade 3 or 4 mucocytosis
-Patient has functional gastrointestinal tract (tolerating
at least 1 liter/day of oral fluids or 40 ml/hour of -Patients whose disease state that does not support
enteral nutrition)
oral therapy (meningitis, infective endocarditis,
-An appropriate oral dosage form of prescribed drug is infection of a prosthetic device, osteomyelitis, sepsis,
available Absorption and bioavailability of oral severe cellulitis, bronchiectasis, pneumonia with AIDS)
counterpart is almost comparable to that of parenteral
form -Documented pseudomonal infection and/or on IV
antibiotic for <24 hours Candidemia treated less than
7 days

-Seizure and risk of aspiration Hypotension or shock

-Patient refuses oral medication as mentioned in


charts Immunocompromized patients (febrile
neutropenia, on cancer chemotherapy,
posttransplant, functional asplenia)
Bioavailability of medications included in IV to oral conversion
Drugs with excellent bioavailability (>90%) eligible for IV to oral switch over
Drugs IV to PO conversion
IV dose PO dose

Ciprofloxacin* 200 mg q12h (every 12 hours) 500 mg q12h

Doxycycline 100-200 mg q12h 100-200 mg q12h

Levofloxacin* 500 mg q24h 500 mg q24h

Linezolid 600 mg q12h 600 mg q12h

Metronidazole 500 mg q12h 500 mg q12h

Minocycline 200 mg q12h 200 mg q12h

Moxifloxacin* 400 mg q24h 400 mg q24h

Rifampicin 600 mg q24h 600 mg q24h

Voriconazole 200 mg q24h 200 mg q24h

*Absorption of flouroquinolones is reduced by concurrent administration of products containing divalent and trivalent cations such as calcium,
magnesium or aluminum, for example, antacids, multivitamin products containing minerals, iron, or zinc salts. Hence an interval of at least 4 hours
should elapse between their oral administration

Drugs with excellent bioavailability (60-90%) eligible for IV to oral switch over
Drugs IV to PO conversion
IV dose PO dose

Ampicillin 1gm q6h 250-500 mg q6h

Azithromycin 500 mg q24h 250-500 mg q24h

Cefazolin 1 gm q8h Table t. cephalexin 500 mg q6h

Cefotaxime 1 gm q12h Tablet .ciprofloxacin 500-750 mg


q12h
Ceftazidime 1-2 g q8h Tablet .ciprofloxacin 500-750 mg q12h

Cefuroxime 500-750 gm q8h Tab. cefuroxime axetil 250-500 mg


q12h
Clindamycin 300-600 mg q8h 300-450 mg q6h

Erythromycin 500-1000 mg q6h 500 mg q6h

References:
Kuper KM. Intravenous to oral therapy conversion. Text Book of CompetenceAssessmentToolsforHealth ‑SystemPharmacies,4th ed.ASHP 2008.p.347‑60.
Jissa Maria Cyriac, Emmanuel James. Switch over from intravenous to oral therapy: A concise overview, Journal of Pharmacology and Pharmacotherapeutics | April-June
2014 | Vol 5 | Issue 2
_________Hospital      
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE:   SEX:  M  F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________

IV to PO Conversion Order Form/Worksheet

Criteria for Conversion to PO:

_ Tolerating other drugs by oral route


_ Being fed enterally (at minimum a clear liquid diet),
i.e. a functioning GIT
_ Patient does NOT have persistent N/V, ileus, gastric outlet obstruction, active GI bleed, loss of
consciousness, NPO orders that applies to all meds
_ Resolution of fever for 24 hours
_ CBC improving, preferably < 15K in absence of steroids
_ Patient does NOT have meningitis, endocarditis, septicemia, neutropenia, osteomyelitis, or MRSA
_ hemodynamically stable

Date/Time:

Pharmacy recommends:

D/C ( ) Start ( )

This change will take place on at


Appendix F: Antibiogram

The period:

Clarithromycin

Trimeth/Sulfa
Azithromycin
Erythromycin

Streptomycin
Levofloxacin
Clindamycin

Vancomycin
Tetracycline
Gentamycin
Cefuroxime
Antibiotic

Ceftriaxone
Ampicillin
Isolates

Cefazolin
Penicillin

Linezolid

Rifampin
Susceptibility

Gram Positive Percentage of Isolates that are Susceptible


Enterococcus spp.
Enterococcus faecalis

Enterococcus faecium

Staphylococcus aureus

Staphylococcus epidermidis

Staphylococcus coag. neg.

Streptococcus pneumoniae

MRSA
Pipracilli/Tazo

Moxifluxaci
Ciprofluxacin

Levofloxacin

Antibiotic
Ceftazidime

Gentamycin

Meropenem
Cefuroxime

Ceftriaxone

Tigecycline

Augmentin
Isolates
Imipenem
Amikacin

Colistin
Cefepime

Susceptibility

Percentage of Isolates that are Susceptible


Gram Negative
H. influenza

Klepsiella P.

E. Coli

Pseudomona A.

Acinetobacter

Proteuos
Serratia M

Enterobacter

Citrobacter

Klebsiella pneumoniae carbapenemas


(KPC)
Ward: (outpatient, ICU, Medical, Surgical)
The period:

Clarithromycin

Trimeth/Sulfa
Azithromycin
Erythromycin

Streptomycin
Levofloxacin
Clindamycin

Vancomycin
Tetracycline
Gentamycin
Cefuroxime
Antibiotic

Ceftriaxone
Ampicillin
Isolates

Cefazolin
Penicillin

Linezolid

Rifampin
Susceptibility

Gram Positive Percentage of Isolates that are Susceptible


Enterococcus spp.
Enterococcus faecalis

Enterococcus faecium

Staphylococcus aureus

Staphylococcus epidermidis

Staphylococcus coag. neg.

Streptococcus pneumoniae

MRSA
Pipracilli/Tazo

Moxifluxaci
Ciprofluxacin

Levofloxacin
Antibiotic
Ceftazidime

Gentamycin

Meropenem
Cefuroxime

Ceftriaxone

Tigecycline

Augmentin
Isolates
Imipenem
Amikacin

Colistin
Cefepime

Susceptibility

Percentage of Isolates that are Susceptible


Gram Negative
H. influenza

Klepsiella P.

E. Coli

Pseudomona A.

Acinetobacter

Proteuos
Serratia M

Enterobacter

Citrobacter

Klebsiella pneumoniae carbapenemas


(KPC)
ANTIBIOGRAM
The period
Ward: ICU
System: Blood/Respiratory Tract/Urinary Tract/ Wound

Clarithromycin

Trimeth/Sulfa
Azithromycin
Erythromycin

Streptomycin
Levofloxacin
Clindamycin

Vancomycin
Tetracycline
Gentamycin
Antibiotic

Cefuroxime

Ceftriaxone
Ampicillin
Isolates

Cefazolin
Penicillin

Linezolid

Rifampin
Susceptibility

Gram Positive Percentage of Isolates that are Susceptible


Enterococcus spp.
Enterococcus faecalis

Enterococcus faecium

Staphylococcus aureus

Staphylococcus epidermidis

Staphylococcus coag. neg.

Streptococcus pneumoniae

MRSA
Pipracilli/Tazo

Moxifluxaci
Ciprofluxacin

Levofloxacin

Antibiotic
Ceftazidime

Gentamycin

Meropenem
Cefuroxime

Ceftriaxone

Tigecycline

Augmentin
Isolates
Imipenem
Amikacin

Colistin
Cefepime

Susceptibility

Percentage of Isolates that are Susceptible


Gram Negative
H. influenza

Klepsiella P.

E. Coli

Pseudomona A.

Acinetobacter

Proteuos M.
Serratia M

Enterobacter

Citrobacter

Klebsiella pneumoniae carbapenemas


(KPC)
Fungal infection

Anidulafungin
Amphotericin

Voriconazole
Antifungal

Caspofungin

Fluconazole

Fluconazole
Isolates
Susceptibility
No.

B
Candida Percentage of Isolates that are Susceptible Susceptible

Candida albicans

Candida glabrata

Candida parapsilosis

Candida krusei

Cryptococcus
Asperglosis

Ward: ICU
Secretion

Orophar
Antifungal
yngyal
Isolates

Other
Blood

Urine
Resp.

Susceptibility
No.

Candida Percentage of Isolates that are Susceptible


Candida albicans

Candida glabrata

Candida parapsilosis

Candida krusei

Cryptococcus

Asperglosis

Sensitivity Line chart example

Acinetobacter P. Pseudomonas A. MRSA

100

90

80

70

60

50

40

30

20

10

0
Jan. Feb. March April May June July August Sept. Oct. Nov. Dec.
Acinetobacter P. Pseudomonas A. MRSA

100

90

80

70

60

50

40

30

20

10

0
Jan. Feb. March April May June July August Sept. Oct. Nov. Dec.

Appendix I:

_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)

Physician Order Form

(Please fill all applicable information and stick it on


patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)

ANTIBIOTIC RESTRICTED AND CONTROLED ORDER FORM

 Male  Female Wt: Ht:


Patient’s Name Patient’s No Age Gender

Write down and Read Back for all Verbal Orders


ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY

Antibiotics Order Form


Date: Time of Antibiotic order : Time of Administration:
Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.
Review patient allergies prior to prescribing/administering medications.
Select appropriate antibiotic as determined by Antibiotic Guidelines, after requesting gram stain and C/S for
speciment(s)
Document reason here and in medical chart.
___________________________________________________________________________________________________________________________________
 Diagnosis _______________________________________________________________________________________________________
Site of Infection � Blood � CNS � Heart � Respiratory Tract � Intra-abdominal/GI � Urinary Tract
� Skin/Soft Tissue � Bone/Joint � Other______________

Type of Infection  Community associated  Health care associated (HCA)

 C/S  Organism 1 _______________________ Organism 2 ________________________ Organism 3 _____________________


Sensitivity: Resistant to_______________________________________________________________________________________________________
Type of Therapy:  Empircal  Specific

 Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
 When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this
form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
 For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
 DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.
Drug Procedure:
 Ceftazidime  Ciprofloxacin Oral
Controlled Antibiotics  Amikacin
 Fluconazol Oral  Fluconazol IV
 Ciprofloxacin IV  Cefepime
 Piperacillin/Tazobactam  Meropenem
 Moxifloxacin Oral  Vancomycin PO
 Imipenem  Linzolid IV
 Colistin (fill special form)  Caspofungin
Restricted Antibiotics  Voriconazole IV  Ethionamide.
 Linezolid Oral  Cyclovir
Kanamycin
 Voriconazole PO Para amino acid.
 Tigecycline (fill special form)
.

Antibiotic_______________ _____dose______________ route________ frequency_____duration_____________

□ New Order □ Renew Order


Physician Signature:
Clinical Pharmacist Follow up and Comment:

TIGECYCLINE ORDER FORM

 Male  Female Wt: Ht:


Patient’s Name Patient’s No Age Gender

Write down and Read Back for all Verbal Orders


ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY

Antibiotics Order Form


Date: Time of Antibiotic order : Time of Administration:
Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.
Review patient allergies prior to prescribing/administering medications.
Select appropriate antibiotic as determined Antibiotic Guidelines, after collecting specimen for Gram stain and C/S
Document reason here and in medical chart.
___________________________________________________________________________________________________________________________________
 Diagnosis _______________________________________________________________________________________________________
Site of Infection � Blood � CNS � Heart � Respiratory Tract � Intra-abdominal/GI � Urinary Tract
� Skin/Soft Tissue � Bone/Joint � Other______________

Type of Infection  Community Associated  Health care Associated

 C/S  Organism 1 _______________________ Organism 2 ________________________ Organism 3 _____________________


Sensitivity: Resistant to_______________________________________________________________________________________________________
Type of Therapy:  Empircal  Specific

 Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
 When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this
form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
 For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
 DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.

Indication Commenst:
 Complicated Skin and Skin Structure Infections and the
Tigecycline
micoorganism is sensitive only to Tigecycline
 Complicated Intra-abdominal Infections and the
micoorganism isonly sensitive to Tigecycline
 Treatment of infection due to sensitive strain of certain
gram-negative bacilli which are resistant to other
antibacterials including Colistin or in patients allergic to all
other antibacterial agents.

Antibiotic_______________ _____dose______________ route________ frequency_____duration_____________

□ New Order □ Renew Order

Physician Signature:

Clinical Pharmacist Follow up and Comment:

COLISTIN ORDER FORM

 Male  Female Wt: Ht:


Patient’s Name Patient’s No Age Gender

Write down and Read Back for all Verbal Orders


ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY

Antibiotics Order Form


Date: Time of Antibiotic order : Time of Administration:
Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.
Review patient allergies prior to prescribing/administering medications.
Select appropriate antibiotic as determined Antibiotic Guidelines, after collecting specimen for Gram stain and C/S
Document reason here and in medical chart.
___________________________________________________________________________________________________________________________________
 Diagnosis _______________________________________________________________________________________________________
Site of Infection � Blood � CNS � Heart � Respiratory Tract � Intra-abdominal/GI � Urinary Tract
� Skin/Soft Tissue � Bone/Joint � Other______________

Type of Infection  Community Associated  Hospital care Associated

 C/S  Organism 1 _______________________ Organism 2 ________________________ Organism 3 _____________________


Sensitivity: Resistant to_______________________________________________________________________________________________________
Type of Therapy:  Emperical  Specific

 Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
 When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this
form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
 For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
 DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.

Indication Comments:
 Treatment of infections due to sensitive strains of certain
Colistin gram-negative bacilli which are resistant to other antibacterials
or in patients’ allergic to all other antibacterials.

Antibiotic_______________ _____dose______________ route________ frequency__________duration_____________

□ New Order □ Renew Order

Physician Signature:

Clinical Pharmacist Follow up and Comment:


Appendix G: Antibiotics Consumption

Hospital: …………………………………………….. from : / / to: / /

Anti-infectious drugs Inpatient Outpatient ER


Forms ICU Wards
Adult Ped. Neo. Adult Ped. Neo. Adult Ped. Neo. Adult Ped. Neo. Total

Cloxacillin sodium IV 250mg Vial or amp.


Flucloxacillin sodium IV 250mg Vial or amp.
Piperacillin + Tazobactam IV 2.25 g Vial
Piperacillin + Tazobactam IV 4.5 g Vial
Ceftazidime IV 1g Vial
Ceftriaxone IV 1g Vial
Cefepime IV 1g Vial
Cefepime IV 2g Vial
Imipenem + Cilastatin IV Vial
500mg+500mg
Meropenem IV 500mg Vial
Meropenem IV 1g Vial
Tigecycline IV 50mg Vial
Amikacin IV 100mg Vial or amp.
Amikacin IV 500mg Vial or amp.
Gentamicin IV 20mg Vial or amp.
Gentamicin IV 80mg Vial or amp.
Azithromycin PO 250mg Tablet
Azithromycin PO 200mg/15ml Suspension
Clindamycin IV 300mg Ampoule
Vancomycin IV 500mg Vial
Linezolid PO 600mg Tablet
Linezolid IV 600mg Premixed
bag
Linezolid PO 100mg Suspension
Rifabutine PO 150mg Tablet
Ciprofloxacin IV 200mg Bottle
Moxifloxacin IV 400mg Vial
Moxifloxacin PO 400mg Tablet
Levofloxacin IV 500mg Premixed
bag
Hospital: …………………………………………….. from : / / to: / /

Anti-infectious drugs Inpatient Outpatient ER


Forms ICU Wards
Adult Ped. Neo. Adult Ped. Neo. Adult Ped. Neo. Adult Ped. Neo. Total

Amphotericin B liposomal 50mg Vial


Amphotericin B 50mg Vial
Voriconazole IV 200mg Vial
Voriconazole PO 200mg Tablet
Caspofungin IV 50mg Vial
Micafungin IV 50 mg Vial
Acyclovir IV 250mg Vial
Valaciclovir PO 500mg Tablet
Artemisinin PO 250mg Capsule
Artesunate PO 50mg Tablet
Artesunate IV 60mg Ampoule
Proguanil PO 100mg Tablet
Artemether +Lumefantrine PO Tablet
20/120mg
Artmether IV 20mg Ampoule

Ped. : Pediatric Neo: Neonate


Abbreviation

IV: intravenous

IM: intramuscular

SC, SQ: subcutaneous

PO: oral

Min: minute

hr: hour

d: day

mo: month

q24hr: every 24 hours

q12hr: every 12 hours

q8hr: every 8 hours

q6hr: every 6 hours

q4hr: every 4 hours

mcg: microgram

mg: milligram

kg: kilogram
Appendix G: Dose adjustment for renal impairment

renal impairment: HD CVVH PD


Aciclovir GFR 25-50ml/min: Administer recommended dose IV: 2.5-5 mg/kg every 24 5-10 mg/kg every 24 hours Give half the normal dose
every 12 hours IV hours iv every 24 hours
GFR 10-25ml/min: Administer recommended dose
every 24 hours IV
GFR <10ml/min: Administer 50% of recommended
dose every 24 hours IV
Amikacin CrCl ≥60 mL/min: Administer every 8 hours 5-7.5 mg/kg every 48-72 Loading dose of 10 mg/kg Dose as CrCl <20
CrCl 40-60 mL/min: Administer every 12 hours hours. Follow levels. Redose followed by maintenance dose mL/minute: Follow levels
CrCl 20-40 mL/min: Administer every 24 hours when pre-HD concentration of 7.5 mg/kg every 24-48 hours
CrCl <20 mL/min: Loading dose, then monitor level <10 mg/L; redose when post-
HD concentration <6-8 mg/L
Ampicillin CrCl >50 mL/minute: Administer every 6 hours IV: 1-2 g every 12-24 hours Loading dose of 2 g followed by 250 mg every 12 hours
CrCl 10-50 mL/minute: Administer every 6-12 hours 1-2 g every 8-12 hours
CrCl <10 mL/minute: Administer every 12-24 hours
Benzylpenicillin FR >50 mL/min:No dosage adjustments are necessary Administer a normal dose Loading dose of 4 million units, Give normal dose every 8
FR 10-50 mL/min: Administer 75% of the normal dose followed by either 25% to followed by 2 million units every -12 hours
GFR <10 mL/min: Administer 20% to 50% of the 50% of normal dose every 4- 4-6 hours
normal dose 6 hours or 50% to 100% of
normal dose every 8-12
hours
Cefotaxime GFR >50 mL/minute: Administer every 6 hours Administer 1 to 2 g every 24 1 to 2 g every 8 to 12 hours 1 g every 24 hours
GFR10-50 mL/minute: Administer every 6 to 12 hours hours.
GFR <10 mL/minute: Administer every 24 hours or
decrease the dose by 50%
Ceftazidime CrCl 31 to 50 mL/minute: 1 g every 12 hours 500 mg to 1 g every 24 hours Loading dose of 2 g followed by Loading dose of 1 g,
CrCl 16 to 30 mL/minute: 1 g every 24 hours or 1 to 2 g every 48 to 72 1 to 2 g every 12 hours followed by 500 mg every 24
hours hours
CrCl 6 to 15 mL/minute: 500 mg every 24 hours
CrCl <5 mL/minute: 500 mg every 48 hours
Ceftriaxone No dosage adjustment is generally necessary in renal
impairment; Note: Concurrent renal and hepatic
dysfunction: Maximum dose: ≤2 g daily
renal impairment: HD CVVH PD
Ciprofloxacin Oral, immediate release Oral, immediate release 250-500 mg every 24 hours Oral, immediate release
Oral CrCl 30-50 mL/minute: 250-500 mg every 12 hours 250-500 mg every 24 hours 250-500 mg every 24 hours
CrCl 5-29 mL/minute: 250-500 mg every 18 hours Oral, extended release: Oral, extended release:
Oral, extended release: 500 mg every 24 hours 500 mg every 24 hours
CrCl <30 mL/minute: 500 mg every 24 hour
Ciprofloxacin CrCl 5-29 mL/minute: 200-400 mg every 18-24 hours
IV: 200-400 mg every 24 200-400 mg every 12-24 hours IV: 200-400 mg every 24
IV hours hours

Clarithromycin GFR <30ml/min: Give 50% of normal dose Administer after HD session Administer after HD session is Administer after HD session
iv/po/ng every 12 hours is completed completed is completed
(amoxicillin+ CrCl <30 mL/minute: Do not use 875 mg tablet 250-500 mg every 24 hours; Continuous arteriovenous or Peritoneal dialysis:
Clavulanic acid) administer dose during and venovenous hemofiltration Moderately dialyzable (20%
CrCl 10-30 mL/minute: 250-500 mg every 12 hours after dialysis. Do not use effects: to 50%)
extended release tablets. Amoxicillin: ~50 mg of Amoxicillin: Administer 250
CrCl <10 mL/minute: 250-500 mg every 24 hours amoxicillin/L of filtrate is mg every 12 hours
removed Clavulanic acid: Dose for
Clavulanic acid: Dose for CrCl CrCl <10 mL/minute
<10 mL/minute
Co-trimoxazole CrCl 15-30 mL/min: Administer 50% of 2.5-10 mg/kg trimethoprim 2.5-7.5 mg/kg of TMP every 12 Use CrCl <15 mL/minute
recommended dose every 24 hours or 5-20 hours dosing recommendations.
CrCl <15 mL/min: Use is not recommended mg/kg trimethoprim 3 Not significantly removed
times weekly after IHD by PD
Colistimethate CrCl 50-79 mL/min: 2.5-3.8 mg/kg/day in 2 1.5 mg/kg every 24-48 hours 2.5 mg/kg every 24-48 hours Give 50% of normal dose
(colistin) divided doses iv every 18-24 hours(2)
IM, IV CrCl 30-49 mL/min: 2.5 mg/kg/day once daily or
in 2 divided doses
CrCl 10-29 mL/min: 1.5 mg/kg every 36 hours
Erythromycin GFR <10ml/min: Give 50-75% of normal total No dosage adjustment No dosage adjustment No dosage adjustment
daily dose;max 1.5g in 24 hours (2) required required required
Flucloxacillin(2) GFR <10ml/min: Give normal dose iv q 8 hours Give normal dose IV q 8 hr Give normal dose IV q 8 hr Give normal dose IV q 8 hr
Fluconazole CrCl ≤50 mL/minute (no dialysis): Administer 50% of 200-400 mg every 48-72 Loading dose of 400-800 mg
recommended dose daily hours or 100-200 mg every followed by 200-400 mg every
24 hours have been 24 hours
recommended
renal impairment: HD CVVH PD
Ganciclovir IV (Induction): IV: Induction: 1.25 mg/kg every IV: Induction: 2.5 mg/kg every Dose as for CrCl <10
CrCl 50-69 mL/min: Administer 2.5 mg/kg/dose 48-72 hours; 24 hours mL/minute
every 12 hours.
CrCl 25-49 mL/min: Administer 2.5 mg/kg/dose
every 24 hours.
CrCl 10-24 mL/min: Administer 1.25 mg/kg/dose
every 24 hours.
CrCl <10 mL/min: Administer 1.25 mg/kg/dose 3
times/week following hemodialysis
IV (Maintenance): IV: Maintenance: 0.625 mg/kg Maintenance: 1.25 mg/kg every Dose as for CrCl <10
CrCl 50-69 mL/minute: Administer 2.5 every 48-72 hours 24 hours mL/minute
mg/kg/dose every 24 hours.
CrCl 25-49 mL/minute: Administer 1.25
mg/kg/dose every 24 hours.
CrCl 10-24 mL/minute: Administer 0.625
mg/kg/dose every 24 hours
CrCl <10 mL/minute: Administer 0.625
mg/kg/dose 3 times/week following hemodialysis.
Gentamicin Conventional dosing: Loading dose of 2-3 mg/kg Give 2mg/kg iv, take trough Administration via PD fluid:
CrCl 40-60 mL/minute: Administer every 12 hours loading dose followed by: level after 24 hours, and hold -Gram-positive infection (eg,
CrCl 20-40 mL/minute: Administer every 24 hours A)Mild UTI or synergy: 1 mg/kg next dose until trough level is synergy): 3-4 mg/L (3-4
CrCl <20 mL/minute: Loading dose, then monitor every 48-72 hours; consider available. Adjust dosage
redosing for pre-HD or post-HD mcg/mL) of PD fluid
levels interval according to serum -Gram-negative infection: 4-
concentrations <1 mg/L
Take trough level after 24hours, and hold next B)Moderate-to-severe UTI: 1- Levels – aim to keep trough 8 mg/L (4-8 mcg/mL) of PD
dose until trough level is available. 1.5 mg/kg every 48-72 hours; <1mg/L and peak 5-10mg/L fluid
Adjust dosage interval according to serum levels consider redosing for pre-HD -Administration via IV, IM
aim to keep trough <1mg/L and peak 5-10mg/L. concentrations <1.5-2 mg/L or route during PD: Dose as for
post-HD concentrations <1
mg/L CrCl <10 mL/minute and
C)Systemic gram-negative rod follow levels
infection: 1.5-2 mg/kg every
48-72 hours; consider redosing
for pre-HD concentrations <3-5
mg/L or post-HD
concentrations <2 mg/L
Imipenem + GFR 31-70ml/min: 500 mg every 6-8 hours Use the dosing Give 50% of the normal dose Loading dose of 1 g followed
cilastatin GFR 21-30ml/min: 500 mg every 8-12 hours recommendation for patients every 24 hours by either 250 mg every 6
GFR <20ml/min: 250 mg every 12 hours with a CrCl 6-20 mL/minute; hours or 500 mg every 8
GFR <5ml/min: Do not start imipenem/cilastatin administer dose after dialysis hours
session and every 12 hours
unless haemodialysis or haemofiltration is to be
thereafter or 250-500 mg every
started within 48 hours 12 hours
Meropenem CrCl 26-50 mL/min: Administer recommended 500 mg every 24 hours CVVH: Loading dose of 1 g
dose based on indication every 12 hours followed by either 500 mg every
CrCl 10-25 mL/min: 8 hours or 1000 mg every 12
Renal impairment HD Administer one-half PD CVVH
recommended dosenormal
based on indication hours
Teicoplanin(2) GFR 40-60ml/min: Give normal regimen for Give regimen for q12hGive normal regimen for Give normal regimen for
CrClon
the first three days, then reduce dose <10
Day mL/min: Administer
the first one-half
three days, then the first three days, then the first three days, then
4 to 50% of the dose once daily or give 100% reduce dose on Day 4 to q24reduce
recommended dose based on indication h dose on Day 4 to reduce dose on Day 4 to
of the dose every Oseltamivir
second day GFR 10-30ml/min: Treatment:
one third 75 mgonce
of the dose oneforthirdTreatment:
once daily of the doseLow-flux
once one third of Treatment: 30 mg once daily
the dose once
5 days
GFR <40ml/min: Give normal regimen for the daily or give 100% of the hemodialysis:
daily or give 100% of the30 mg daily
after or give
for100%
5 daysoforthe
75 mg every 48
Prophylaxis: 75 mg every other
first three days, then reduce dose on Day 4 to dose every third day day or 30 mgdose every each dialysis session for 5 hours
dose every third dayto provide a 5-day
once daily
one third of the dose once daily or give 100% third day days. duration
of the dose every third day.2 High-flux hemodialysis: 75 Prophylaxis: no data
mg after each dialysis
Vancomycin : Vancomycin levels should be monitored in Following loading dose of Administration via PD Give 10mg/kg3 iv as
patients with any renal impairment: 15 to 25 mg/kg, give either fluid: 15 sessionto 30 mg/Lfor 5 days
(15 to determined by serum
Prophylaxis:
500 to 1,000 mg or 5 to 10 30 mcg/mL) of PD fluid Low-flux levels.3 Hold dose until the
CrCl >50 mL/minute: Start with 15 to 20 mg/kg after each dialysis hemodialysis: 30 mg serum after level is between 5-
mg/kg/dose (usual: 750 to 1,500 mg) every 8 session alternate dialysis
Systemic: Loading dose of 10mg/L sessions
to 12 hours 1,000 mg, until outbreak
followed by is
500over
High-flux hemodialysis:
to 1,000 mg every 48 to 72 No
data.
Piperacillin + CrCl 20-40 mL/min: Administer 2.25 g q 6 hr 2.25 g every 12 hours 2.25-3.375 g every 6-8 hours
tazobactam (3.375 g every 6 hours for nosocomial
pneumonia)
CrCl <20 mL/min: Administer 2.25 g q 8 hr (2.25
g every 6 hours for nosocomial pneumonia)
CrCl 20 to 49 mL/minute: Start with 15 to 20 hours with close
mg/kg/dose (usual: 750 to 1,500 mg) every 24 monitoring of levels.
hours

CrCl <20 mL/minute: Will need longer


intervals; determine by serum concentration
monitoring

1. uptodate, 2014
2.Rachelle Booth (PICU Senior Specialist Pharmacist), Sue Patey (Quen Mok (Consultant Paediatric Intensivist). Drug Dosage Adjustments in Renal Impairment & CVVH
Gt Ormond St Hospital for Children NHS Trust. Nov 2013
3..McEvoy GK et al. American Hospital Formulary Service (AHFS) Drug Information, 2009. American Society of Health-System Pharmacists, Bethesda, 2009. Accessed online 16/12/10.
4. Aronoff GR, Bennett WM, Berns JS et al. Drug Prescribing in Renal Failure, Dosing Guidelines for Adults and Children, 5th edn. American College of Physicians, US, 2007
5.Ashley C, Currie A. The Renal Drug Handbook. 3rd edn. Radcliffe Medical Press Ltd, Oxon UK, 2009