GLN-003 Antimicrobial Stewardship Guidelines

Guideline N0
GLN-003
Function Medication Management and Use Issue Date Effective Date

01 Dec 2019 01 JAN 2020
Guideline name: Antimicrobial Stewardship Next Review Guideline Version
Guidelines 01 Jan 2022 2
Applies to All clinical staff including physicians, pharmacists, nurses, technicians and others
involved in patient care.
1. Introduction
Goals of antibiotic stewardship:

1. Optimize antimicrobial use
2. Improve patient mortality and morbidity
3. Reduce cost
4. Reduce resistance
Risks of antibiotics misuse or overuse:

Risk for serious adverse effects with no clinical benefit
 Direct drug-related toxicity
 Development of super-infections Clostridium difficile infection
 Patient-specific development of resistance
Development of global resistance
Reduced number of antimicrobial agents approved in the past 25 years
Antibiotic Stewardship Program Core Elements

• Leadership Commitment: Dedicating necessary human, financial and IT resources
• Accountability: Appointing a single leader responsible for program outcomes.
• Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic
use.
• Action: Implementing at least one recommended action
• Tracking: Monitoring antibiotic prescribing and resistance patterns
• Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and
relevant staff
• Education
GLN-003 Antimicrobial Stewardship Program Page 1 of 95

2. Table of Content
Topics
I- Introduction 5
IV to Oral Switch Protocol 6
II- Antibiotic Stewardship Metrics 8
III- Suggested Duration for some Bacterial Infections 11
IV- Dose Adjustment of Antibiotics

1- Dose adjustment of antibiotics in obesity 13
2- Dose adjustment in renal impairment 14
3- Doses of antimicrobials in pediatrics 18
4- Doses of antimicrobials in neonates 20
V- Pregnancy Risk and Lactation Safety 22
VI- Vancomycin Dosing Protocol 24
VII- Colistin Dosing Protocol 27
VIII- Prolonged Infusion of Beta Lactams Protocol 28
IX- Aminoglycosides Dosing Protocol 33
X- Aerosolized Antibiotic Therapy in ICU 38
XI- Antimicrobial Guidelines for Community-Acquired Infections
Antibiotic order: Acute bacterial meningitis 43
Antibiotic order: Acute Bacterial Sinusitis 46
Antibiotic order: Animal Bites/ Human Bites/ Acne/ Paronychia 47

Antibiotic order: Brain Abscess 49
Antibiotic order: Brucellosis/ Bone Mycobacterium Tuberculosis 50
Antibiotic order: Community-Acquired Intra-Abdominal Infections 51
Antibiotic order: Community- Acquired Pneumonia 52
Antibiotic order: COPD Exacerbation 54
Antibiotic order: Diabetic Foot Infections 56
Antibiotic order: Group A Streptococcal Pharyngitis 57
Antibiotic order: Infective Endocarditis 58
Antibiotic order: Osteomyelitis 61
Antibiotic order: Pancreatitis 63
Antibiotic order: Peritonitis 64
Antibiotic order: Skin and Soft Tissues Infections 66
Antibiotic order: Urinary Tract Infections 67

XII- Antimicrobial Guidelines for Hospital-Acquired Infections
Antibiotic order: Sepsis and Septic Shock 70
Antibiotic order: Aspiration Pneumonia 72
Antibiotic order: Ventilator-Associated Pneumonia 73
Antibiotic order: Hospital- Acquired Pneumonia 75
Antibiotic order: Catheter-Related Blood Stream Infections 77

Antibiotic order: Central-Line Associated Blood Stream Infections 80
Antibiotic order: Hospital-Acquired Intra-abdominal Infections 81
Antibiotic order: Clostridium-Difficile Infections 82
Antibiotic order: Post-Operative Wound Infections 84
Antibiotic order: Potentially Infected Wounds Orthopedics 85
XIII- Surgical Antibiotic Prophylaxis Guidelines 86
3. References 92
4. Approvals 95

I- Introduction
Antibiotic stewardship program and ICU:

1-Which is the best core antibiotic
stewardship strategy?
The majority of the reports have evaluated

the prospective audit and feedback strategy.
Antibiotic decisions are reviewed with the
prescriber by the
stewardship team 2–3 days after initiation
with recommendations for optimization of
treatment.
2-Start Smart: Empirical Antibiotic

Guidelines
Inadequate empirical antibiotic
therapy, accounts for an estimated 39-
51% of excess mortality in ICU 72
patients hrs
Guidelines:
 Syndrome specific guidelines
for empirical antibiotic
therapy (intra-abdominal
infections, HAP or VAP)
 Based on local antibiograms
and drug availability

3-De-escalation of empirical antibiotics
 Discontinuation of duplicative or unnecessary therapy
 Always continually assess patient response to therapy (i.e., monitor resolution of subjective
symptoms and objective data such as WBC and temperature, hemodynamic stability, CRP)
 Continued dose optimization based on organ function
4- IV to Oral Switch Protocol
Definitions:
1. Sequential therapy: changing to the oral version of the same compound .
Example: Levofloxacin 500mg IV Q24H to levofloxacin 500mg PO Q24H.
2. Switch therapy: changing to an oral drug that is a different compound and has the same potency.
Example: Levofloxacin 500mg IV Q24H to ciprofloxacin 500mg PO Q12H.
3. Step-down therapy: changing to an oral drug that is a different compound and has different
frequency, dose, or spectrum of activity.
Example: Ampicillin-sulbactam 1.5gm IV Q6H to amoxicillin-clavulanic acid 875mg/125mg PO
Q12H.
Potential advantages of changing from IV to PO antibiotics
1. Removal of intravenous catheter
2. Reduce length of stay
3. Reduce volume of fluid administered to patient
4. Increase patient satisfaction and comfort
5. Decreased possibility for phlebitis
6. Decreased costs
Criteria for IV to Oral Switch
 Functioning GI tract
 Receiving other oral medications
 Tolerating diet
 No nausea, vomiting, or profuse diarrhea
 Patient is clinically stable
 Absence of life-threatening infection (e.g., bacteremia, endocarditis, febrile neutropenia, meningitis,
osteomyelitis, sepsis, or septic shock)
 Patient has received IV therapy for at least 48 hours
 Afebrile for >24 hours
 Normalizing WBC
Conditions in which SWITCH TO ORAL THERAPY should be considered:
 Pneumonia
 Skin and soft tissue infections
 Urinary tract infections
 Uncomplicated gram negative bacteremia
 Intra-abdominal infections without deep seated collections.

IV to Oral Switch Review Worksheet

II- Antibiotic Stewardship Metrics
1- Antimicrobial Consumption Metrics

Point of Defined Daily Doses Days of Therapy (DOT) Length of Therapy (LOT)
comparison (DDD)
Advantages  Widely recognized  Minimizes impact of  Focuses on duration
metric; allows for drugs requiring dose of therapy rather
between-hospital adjustment with renal than quantity of
comparisons impairment; antimicrobials;
 Recommended by appropriate for useful in pediatric
WHO pediatric patients; populations
 Unlike DDD, no
“standard” comparator,
allowing for better
reporting assessment
Disadvantages  Overestimates or  Assumes that dosing  Not useful for
underestimates was appropriate during comparing specific
antimicrobial treatment; may not antimicrobial use
consumption when adequately account for between units or
“standard” dose not drugs with long half- hospitals
used; lives or prolonged
 Unreliable in dosing intervals (e.g.,
pediatrics; Does vancomycin in patients
not account for receiving hemodialysis)
dosing adjustments  Difficult to report
with renal without IT support
impairment; and/or third-party
 WHO defined vendors
DDD may change  Do not always account
over time, making for appropriate de-
it difficult to escalation strategies
compare drugs (e.g., a shift from 3
longitudinally drugs to a single agent
other than 1 of the
originally prescribed
agents)
Antibiotic Standard WHO DDD Unit Note

Piperacillin and tazobactam 14 Gm Refers to piperacillin
only
Ceftriaxone 2 Gm
Meropenem 3 Gm
Imipenem and cilastatin 4 Gm Refers to imipenem only
Linezolid 1.2 Gm
Tigecycline 0.1 Gm
Teicoplanin 0.4 Gm
Vancomycin 2 Gm
Colistin 9 Million units
Cefepime 4 Gm
Cefazolin 3 Gm
Cefuroxime 3 Gm
Cefotaxime 4 Gm
Ceftobiprole 1.5 Gm

Amoxicillin-beta lactamase 3 Gm Refers to amoxicillin
inhibitor component
2- Antimicrobial Resistance:
 Antimicrobial resistance is reported as the percentage of isolates resistant to a single agent and as a
resistance rate (the number of resistant isolates, divided by the total number tested, per 1,000 patient-
days).
 Antimicrobial resistance is often tracked through the development of an antibiogram in collaboration
with a microbiology laboratory.
 Resistance attribution to a facility can occur regardless of ASP activity as when a patient infected with
drug-resistant organisms is transferred among facilities.
3- Antimicrobial Expenditures
 Antimicrobial costs can be based on purchased or administered over certain period of time.
 Antibiotic cost per patient day
 When evaluating costs, it is important to recognize that appropriate ASP interventions may actually
increase costs in cases where higher-cost agents are considered optimal.
4- C.difficile rates:
 Number of patients with documented C.difficile infection divided by the number of patients admitted to the
ward over certain period of time.
 It can be used as a measurable Adverse Drug Reaction for antibiotic associated C.difficile nosocomial
(confirmed) or antibiotic associated diarrhea (unconfirmed).
5- Interventions:
 Tally of the number and type of interventions made and accepted

III- Suggested Duration for Selected Bacterial Infections
Site Diagnosis Duration of therapy

Bacteremia Bacteremia with removable focus 10-14 days
Bone Osteomyelitis, adult, acute 42 days
Osteomyelitis, adult, chronic Until ESR normal (often > 3 months)
In patients with vertebral osteomyelitis, 6
weeks as effective as 12 weeks.
Child, acute staphylococcal and 21 days: may be able to shorten to 7 days if
Enterobacteriaceae resolution of signs and symptoms and
concomitant normalization of biomarkers
Ear Otitis media with effusion Age< 2 years: 10 days
Age ≥ 2 years: 5-7 days
Gastrointestinal Bacillary dysentery (shigellosis) or 1 dose, but up to 3 days if no response.
traveler’s diarrhea
Typhoid fever Azithromycin 5-7 days
(child/adolescent)
Ceftriaxone 7-14 days
Fluoroquinolone 7-14 days
Chloramphenicol 14 days
H. pylori 14 days
C. difficile 10 days
Genital Non-gonococcal urethritis or 7 days of doxycycline OR
mucopurulent cervicitis Azithromycin 1 dose
Pelvic inflammatory disease 14 days
Heart Endocarditis Viridians strep: 14 or 28 days
Infective, native valve Enterococci: 28 or 42 days
Staph. Aureus: 14 days
(right-sided only) or 28 days
Pericarditis (purulent) 28 days or until resolution of signs and
symptoms and normalization of biomarkers
Joint Arthritis, disseminated, gonorrhea 7 days
Kidney Cystitis, acute 3 days or one dose of ciprofloxacin extended
release
Lung Pneumonia, pneumococcal 5 days (minimum) and until afebrile for 3-5
days
Can customize the Pneumonia-community acquired 5 days (minimum) and until afebrile for 2-3
duration of days
therapy by Pneumonia 21 days often up to 42 days
trending serum Enterobacteriaceae, pseudomonas
procalcitonin Pneumonia staphylococcal 21-28 days
levels, treat until Pneumonia Doxycycline 7-10 days
80% decrease Legionella, Fluoroquinolone 5 days
from peak level or Mycoplasma,
when it reaches Chlamydia
0.25 ng/ml Lung abscess 28-42 days
After patient is afebrile for 4-5 days, switch
to oral therapy
Muscle Gas gangrene, 10 days but variable depending on severity

Clostridial
Peritoneum Peritonitis from bowel flora Mild and moderate peritonitis and source
control 4 days is recommended
Pharynx Strep pharyngitis group A, B or G If group A: 10 days with penicillin
5 days for azithromycin, oral cephalosporines
If group C or G strept.:5 days of an oral
cephalosporin is acceptable
Diphtheria (membranous) 14 days (pen G, erythro)
If carrier 1 dose (Pen G)
7-10 days erythromycin
Prostate Prostatitis, chronic Fluoroquinolone: 28-42 days
Sinusitis Acute bacterial sinusitis 5 days
For severe cases using beta lactams:
10-14 days
For mild and moderate cases using
fluoroquinolones: 5-7 days
TMP-SMX and azithromycin: 3 days
Skin Cellulitis 3 days after acute inflammation disappears.
Systemic Brucellosis 42 days, duration varies with specific sites of
infection.
Rocky Mountain Spotted Fever Until afebrile
Tularemia 7-21 days depending on severity.

IV- Dose Adjustment of Antibiotics
1- Dose Adjustment in Obesity

Drug Dose adjustment
Aminoglycosides Use adjusted body weight
Cefazolin No dose adjustment required
Cefepime Moderate dose increase: 2 gm IV Q8H instead of Q12H
Ciprofloxacin In critically ill, septic patients on CRRT with organisms with MIC >0.5 mg/L
>90 kg: 400 mg IV Q8H
Clindamycin Use actual body weight
IV: 600 mg Q9H or 900 mg Q8H
PO: 450-600 mg Q6H or 600-900 mg Q8H
Colistin Use IBW
Levofloxacin No dose adjustment required
Ex: 750 mg PO/IV Q24H
Piperacillin- 6.75 gm IV over 4 hours and dosed Q8H
tazobactam
Sulphamethoxazole Skin and soft tissue infections or severe complicated UTI: up to 320 mg PO BID
/trimethoprim or 8-10 mg/kg ABW/day in divided doses
Vancomycin Use actual body weight
Ex: loading dose 25-30 mg/kg IV actual body weight
Maintenance dose: 15-20 mg/kg IV actual body weightQ8-12H
NO SINGLE DOSE ABOVE 2 GM

2- Dose Adjustment of Antibiotics in Renal Impairment:
Drug CrCl > 50 mL/min CrCl 10 – 50 mL/min CrCl < 10 mL/min Intermittent CRRT
Hemodialysis
(IHD)
Amikacin 5 – 7.5 mg/kg 10mg/k

post HD only g load,
then 7.5
mg/kg
q24–
48h
Amoxicillin Usual dose: 250 – 500 mg CrCl 10–30: 250 – 500 mg 250 – 500 mg q24h 250 – 500 mg No data
(PO) q8h or 875 mg q12h q12h q24h;
H pylori: 1,000 mg q12h administer
additional dose
at the end of
dialysis
Amoxicillin Usual dose: CrCl 10 – 30: 250 – 500 mg q24h 250-500 mg No data
/clavulanate 250-500mg q8h 250 – 500 mg q12h q24h;
(PO) or 875 mg q12h administer
CAP: 2,000 mg ER q12h additional dose
at the end of
dialysis
Ampicillin Mild/uncomplicated: Mild/uncomplicated: 1 g Mild/uncomplicated Mild/ CVVH:
(IV) 1 – 2 g q6h q6–8h : uncomplicated: 2 g q8–
Meningitis/endovascular: 2 g Meningitis/endovascular: 2 1 g q12h 1 g q12h 12H
q4h g q6–12h Meningitis CVVH
Meningitis/ /endovascular: DF: 2 g
endovascular: 2 g 2 g q12–24h q6–8h
q12–24h; or 1 g q8h Mening
itis
2 g q6h
Ampicillin 1.5 – 3 g q6h CrCl < 30: 1.5 – 3 g q12h CrCl < 15: 1.5 – 3 g 1.5 – 3 g q12– 3 g q6–
/sulbactam q24h 24h Dose daily, 8ha
but after HD on
HD days
Azithromycin 500 mg Q24H No change No change No change No

change
Cefazolin CrCl ≥ 35: CrCl 10 –34: 1 g q24h 1 g q24h 2 g

Mild/moderate: 1 g q8h Mild/moderate: 0.5 g q12h Dose daily, but q12h
Severe: 2 g q8h Severe: 1 g q12h after HD on HD
days
alt: 2g/2g/3g
post-HD only
Cefepime General: 0.5 g q24h 0.5 – 1 g q24h 2 g
CNS: 1 g q24h Dose daily, but load,
after HD on HD then 1 g
days q8h – or
– 2 g
alt: 2 g post-HD q12h
GLN-003 Antimicrobial Stewardship Program Page 14 of 95 only
Ceftazidime Usual dose: 1 – 2 g q8h CrCl 30 – 50: 1 – 2 g q12h CrCl < 5: 0.5 g 0.5-1g q24h
Severe: 2 g q8h CrCl 16 – 30: 1 – 2 g q24h q24h Dose daily, but
CrCl 6 – 15: 0.5 – 1 g after HD on HD
q24h days
alt: 1 – 2 g q48–
72h or post-HD
only
Ceftriaxone 1 – 2 g q24h No change No change No
Endovascular/osteomyelitis: 2 g q24h change
Meningitis, E. faecalis endocarditis: 2 g q12h
Cephalexin 250 – 1000 mg q6h CrCl 15 – 29: 250 mg q8–12h 500mg q24h No data
Uncomplicated cystitis: CrCl 5 – 14: 250 mg q24h Dose daily, but
500 mg q12h after HD on HD
Cellulitis/SSTI: 500 mg q6h days
Ciprofloxacin 200 – 400 mg 400 mg
(IV/PO) IV q24h IV q12–
24h
250 – 500 mg 500 mg
PO q24h PO
Dose daily, but q12–
after HD on HD 24h
days Septic
pt > 90
kg
Clindamycin 600 – 900 mg IV q8h 150 No change No change No change No

– 450 mg PO q6h change
Colistin Loading Dose: 4 Loading

x IBW (kg) Dose: 4
(max dose: 300 x IBW
mg) (kg)
Maintenance
Preferred dosing in critically ill patients Dose: (max
65 mg q12h; dose:
then supplement 300
an additional 40 mg)
mg (for a 3-hr Mainten
IHD session) or ance
50 mg (for a 4- Dose:
hr IHD session)
post-dialysis 220 mg
q12h
alt: 1.5 mg/kg
q24h alt: 2.5
mg/kg
q24h
Doxycycline 100 mg q12h No change No change No change No

(IV/PO) change

Gentamicin
Levofloxacin Same as 750 mg

(IV/PO) CrcL<20 load then
ml/min
250-750
mg Q24H
Linezolid 600 mg q12h No change No change No change No

(IV/PO) change
Meropenem 500 mg 1 g q8–

q24h 12h
CNS: 1 g – or –
q24h 500 mg
Dose daily, q6–8h
but after CNS: 2 g
HD on HD q12h
days
Moxifloxacin 400 mg IV/PO q24h No change No change No change No
(IV/PO) change
Penicillin G 2 – 4 mu q4h 2 – 3 mu q4h 1 – 2 mu q6h Mild: 0.5 – 4 mu q4–

(IV) 1 mu q4– 6h
Dose range: 12 – 24 6h; or 1 –
million units/day 2 mu q8–
continuous infusion or in 12h
divided doses every 4 to
6 hours Severe: 2
mu q4–6h;
or 4 mu
q8–12h
Piperacillin General: 3.375 g

2.25 g q6h
tazobactam q12h
Extended
Severe infusion:
infections:
3.375 g 3.375 –
q12h over 4.5 g q8h
4-hr over 4-hr
alt: 2.25 g
q8h
TMP/SMX Usual Dose Range: CrCl 15 – 30: Administer CrCl < 15: Use is not 2.5 – 5 5 – 10
(PO) 50% of recommended dose recommended, but if needed mg/kg mg/kg/da
PO: 1 – 2 DS tabs q12– PCP/Stenotrophomonas: for PCP/Stenotrophomonas: y TMP
24h 7.5 – 10 mg/kg/day TMP 5 – 10 mg/kg TMP q24h TMP q24h divided
UTI: 1 DS tab PO BID divided q8–12h PCP/ q12h
SSTI: 1 – 2 DS tab PO Stenotroph PCP: 15

BID PCp: (pneumocystis omonas: 5 mg/kg/da

jiroveci pneumonia); – 10 mg/kg y TMP
/Stenotrophomonas: 15 – TMP q24h divided
20 mg/kg/day TMP q8–12h
divided q6–8h Dose daily,
(approximately 2 DS tab but after
q8h) HD on HD
days alt: 5
– 20 mg/kg
TMP post-
HD only
Vancomycin 15 – 20 15 – 20
(IV) mg/kg x 1, mg/kg x
then re- 1, then 10
dose per – 15
algorithm mg/kg
q24h

3- Antimicrobials Doses for Pediatrics:
Drug Dose (age>28 days) Max/day
Aminoglycosides
Amikacin 15-20 mg/kg q24h; 5-7.5 mg/kg q8h
Gentamycin 5-7 mg/kg q24h; 2.5 mg/kg q8h
Tobramycin 5-7 mg/kg q24h; 2.5 mg/kg q8h
Carbapenems
Imipenem 60-100 mg/kg/day (divided q6-8h) 2-4 gm
Meropenem 60 mg/kg/day (divided q8h)
Meningitis: 120 mg/kg/day (divided q8h)
Cephalosporines (PO)
Cefaclor 20-40 mg/kg/day (divided q8-12h) 1 gm
Cefadroxil 30 mg/kg/day (divided q12h) 2 gm
Cefdinir 14 mg/kg/day (divided q12-24h)
Cefixime 8 mg/kg/day (divided q12-24h)
Cefpodoxime 10 mg/kg/day (divided q12h) 400 mg
Cefprozil 15-30 mg/kg/day (divided q12h)
Use 30 mg for AOM
Cephalosporines (IV)
Cefazolin 50-150 mg/kg/day (divided q6-8h) 6 gm
Cefepime Non-pseudomonal: 100 mg/kg/day (divided q8h)
Pseudomonal: 150 mg/kg/day (divided q8h)
Cefotaxime Usual: 150-200 mg/kg/day (divided q6-8h)
Meningitis: 300 mg/kg/day (divided q6h)
Ceftazidime Usual: 150-200 mg/kg/day (divided q8h)
Cystic fibrosis: 300 mg/kg/day (divided q8h)
Ceftriaxone Usual: 50-100 mg/kg q24h
Meningitis: 50 mg/kg q12h
Cefuroxime Usual: 150 mg/kg/day (divided q8h)
Meningitis: 80 mg/kg q8h
Penicillins
Amoxicillin 25-50 mg/kg/day (divided q8h)
Amoxicillin (AOM, 80-100 mg/kg/day (divided q8h-12h; q12h for AOM)
pneumonia)
Amoxicillin-clavulanate 7:1 45 mg/kg/day (divided q12h)
formula
Amoxicillin-clavulanate 14:1 90 mg/kg/day (divided q12h) for weight < 40 kg
formula (AOM)
Ampicillin IV Usual: 200 mg/kg/day (divided q6h)
Meningitis: 300-400 mg/kg/day (divided q6h)
Ampicillin/ sulbactam 100-300 mg/kg/day (divided q6h)
Penicillin G 150,000-300,000 units/kg/day (divided q4-6h) 12-20 million
units
Piperacillin-tazobactam 300 mg/kg/day (divided q6h)
Fluroquinolones
Ciprofloxacin (IV) 20-30 mg/kg/day (divided q12h) 1.2 gm
Levofloxacin (IV/PO) 16-20 mg/kg (divided q12h) 750 mg
Lincosamides
Clindamycin IV 20-40 mg/kg/day (divided q6-8h)
Macrolides
Azithromycin PO 5-12 mg/kg/day (once daily)

Azithromycin IV 10 mg/kg/day (once daily)
Clarithromycin 15 mg/kg/day (divided q12h) 1 gm
Other
Colistin Usual: 2.5-5 mg/kg/day (divided q6-12h)
CF: 3-8 mg/kg/day (divided q8h)
Linezolid Age up to 12 years: 30 mg/kg/day IV/PO (divided q8h)
Metronidazole PO 30-40 mg/kg/day (divided q6h) 2.25 gm
Giardiasis: 15 mg/kg/day (divided q8h) * 7-10 days (max 250
mg/ dose)
Acute amebic dysentery: 35-50 mg/kg/day (divided q8h) * 10
days
Amebic liver abscess: 50 mg/kg/day (divided q8h) * 7 days
Metronidazole IV 22.5-40 mg/kg/day (divided q6h) 2.25 gm
Teicoplanin Age: 0-≤2 mon: 16 mg/kg IV * 1 dose, then 8 mg/kg IV q24h
Age 2 mon-12 years: 10 mg/kg IV q12h * 3 doses, then 6-10
mg/kg IV q24h
Tigecycline Avoid, but if necessary:
Age 8-11 years: 1.2 mg/kg (max 50 mg) q12h
Age 12-17 years: 50 mg q12h
TMP-SMX UTI& other: 8-12 mg TMP/kg/day (divided q12h)
Pneumocystis: 15-20 mg TMP/kg/day (divided q12h)
Vancomycin IV 40-60 mg/kg/day (divided q6-8h)
Vancomycin PO C.difficile: 40 mg/kg/day (divided q6h)
Antifungals
Anidulafungin 1.5-3 mg/kg load, then 0.75-1.5 mg/kg/day once daily
Caspofungin 70 mg/m² load, then 50 mg/m² (once daily) 70 mg
Micafungin Candidiasis, age> 4 mon: 2 mg/kg q24h (max 100 mg)
Esophageal candidiasis:
Wt.<30 kg: 3 mg/kg q24h
Wt.> 30kg: 2.5 mg/kg (max 150 mg)
Antivirals
Acyclovir IV Herpes simplex, neonate: 60 mg/kg/day (divided q8h)
Herpes simplex virus encephalitis, age> 3 mon: 30-45
mg/kg/day (divided q8h)
Acyclovir IV Varicella, age<1 year: 30 mg/kg/day (divided q8h)
immunocompromised Varicella, age> 1 year: 30 mg/kg/day or 1500 mg/m²/day
(divided q8h)
HSV: 30 mg/kg/day (divided q8h)
Oseltamivir Age < 1year: 6 mg/kg/day (divided q12h)
Age ≥ 1 year:
Body weight Dose
< 15 kg 30 mg bid
>15 -23 kg 45 mg bid
>23- 40 kg 60 mg bid
>40 kg 75 mg bid

4- Antimicrobial Doses for Neonates
Chronologic Age ≤ 28 daysDosages (mg/kg/day)
Antimicrobial Route Body Weight ≤2,000 g Body Weight >2,000 g
0–7 days old 8–28 days old 0–7 days old 8–28 days
old
Acyclovir (treatment of IV 40 div q12h 60 div q8h 60 div q8h 60 div q8h
acute disease)
Acyclovir (suppression PO ------ 900/m2/day ------ 900/m2/day
followingtreatment for divq8h divq8h
acute disease)
Amoxicillin-clavulanate PO 30 div q12h 30 div q12h
25- or 50-mg/mL
formulation.
Ampicillin IV, IM 100 div q12h 150 div q12h 150 div q8h 150 div q8h
300 mg/kg/day for GBS meningitis div q8h for all neonates ≤ 7 days of age andq6h >7 days of age.
Anidulafungin IV 1.5 q24h 1.5 q24h 1.5 q24h 1.5 q24h
Loading dose 3 mg/kg followed 24 h later by maintenance dose listed.
Azithromycin PO 10 q24h 10 q24h 10 q24h 10 q24h
Caspofungin IV 25/m² q24h 25/m² q24h 25/m² q24h 25/m² q24h
Higher dosage of 50 mg/m2 may be needed for Aspergillus.
Cefazolin IV/IM 50 div q12h 75 div q8h 100 div q12h 150 div q8h
Cefepime IV/IM 60 div q12h 60 div q12h 100 div q12h 100 div q12h
Cefotaxime IV/IM 100 div q12h 150 div q8h 100 div q12h 150 div q6h
Ceftazidime IV/IM 100 div q12h 150 div q8h 100 div q12h 150 div q8h
Ceftriaxone IV/IM ------ ------ 50 q24h 50 q24h
Usually avoided in neonates. Can be considered for transitioning to outpatienttreatment of GBS
bacteremia in well-appearing neonates at low risk for hyperbilirubinemia.Contraindicated if
concomitant IV calcium.
Cefuroxime IV/IM 100 div q12h 150 div q8h 100 div q12h 150 div q8h
Clindamycin IV/IM/PO 15 div q8h 15 div q8h 21 div q8h 27 div q8h
Erythromycin PO 40 div q6h 40 div q6h 40 div q6h 40 div q6h
Fluconazole
Treatment IV 12 q24h 12 q24h 12 q24h 12 q24h
Loading dose 25 mg/kg followed 24 h later by maintenance dose listed.
Prophylaxis IV 6mg/kg/dose 6mg/kg/dose 6mg/kg/dose 6mg/kg/dose
twice weekly twice weekly twice weekly twice weekly
Linezolid IV/PO 20 div q12h 30 div q8h 30 div q8h 30 div q8h
Meropenem
Sepsis IV 40 div q12h 60 div q8h 60 div q8h 90 div q8h
Meningitis IV 80 div q12h 120 div q8h 120 div q8h 120 div q8h
Metronidazole IV/PO 15 div q12h 15 div q12h 22.5 div q8h 30 div q8h
Loading dose 15 mg/kg.
Micafungin IV 10 q24h 10 q24h 10 q24h 10 q24h
Penicillin G benzathine IM 50,000 U 50,000 U 50,000 U 50,000 U
Piperacillin/tazobactam IV 300 div q8h 320 div q6h 320 div q6h 320 div q6h
Aminoglycosides
Empiric Dosage (mg/kg/dose) by Gestational and Postnatal Age

Medication Route <30 wk 30-34 wk ≥ 34 wk
0–14 days >14 days 0–10 days >10 days 0–7 days >7 days
Amikacin IV/IM 15 q48h 15 q24h 15 q24h 15 q24h 15 q24h 17.5 q24h
Desired serum concentrations: 20–35 mg/L or >10 * MIC (peak), <7 mg/L (trough).
Gentamicin IV/IM 5 q48h 5 q36h 5 q36h 5 q36h 4 q24h 5 q24h
Desired serum concentrations: 6–12 mg/L or 10 * MIC (peak), <2 mg/L (trough).
Tobramycin IV/IM 5 q48h 5 q36h 5 q36h 5 q36h 4 q24h 5 q24h
Vancomycin
Empiric Dosage (mg/kg/dose) by Gestational Age and Serum Creatinine
(Begin with a 20 mg/kg loading dose)
Serum creatinine Dose Frequency Serum Dose Frequency
creatinine
≤ 28 wk > 28 wk
<0.5 15 q12h < 0.7 15 q12h
0.5–0.7 20 q24h 0.7–0.9 20 q24h
0.8–1.0 15 q24h 1.0–1.2 15 q24h
1.1–1.4 10 q24h 1.3–1.6 10 q24h
>1.4 15 q48h >1.6 15 q48h

V- Pregnancy Risk and Lactation Safety
 FDA categorized pregnancy risk in 5 categories:
A Adequate studies in pregnant women, no risk
B Animal reproduction studies, no fetal risk, no controlled studies in pregnant women
C Animal reproduction studies demonstrate fetal abnormalities; no controlled studies in
human; potential benefit may warrant use despite potential risk.
D Evidence of human fetal risk; potential benefit may warrant use despite potential risk
X Animal and human studies demonstrate fetal abnormalities; risk in pregnant women clearly
exceed potential benefits.
Drug Pregnancy risk FDA risk Use during lactation

category (old) category
(new)
Amikacin D Probably safe, monitor the baby for GI toxicity
Azithromycin B Safe, monitor infant for GI toxicity
Cephalosporines B Safe, monitor infant for GI toxicity
Ciprofloxacin C Avoid breastfeeding for 3-4 hours after a dose,
monitor infant for GI toxicity.
Clarithromycin C Safe, monitor for GI toxicity
Clindamycin B Avoid use if possible, otherwise monitor infant
for GI toxicity
Colistin (polymyxin C Probably safe with monitoring, but data limited
E)
Doxycycline D Short-term use safe, monitor infant for GI toxicity
Erythromycin B Safe, monitor infant for GI toxicity
Gemifloxacin C Short-term use safe, monitor infant for GI toxicity
Gentamicin D Probably safe, monitor infant for GI toxicity
Imipenem C Safe, monitor infant for GI toxicity
Levofloxacin C Avoid breastfeeding for 4-6 hours after a dose,
monitor infant for GI toxicity
Linezolid C Probably safe with monitoring, systemic exposure
is low.
Meropenem B Probably safe with monitoring, but no data
available
Metronidazole B Data and options conflict; best to avoid
Moxifloxacin C Short term use safe, monitor infant for GI
toxicity; avoid if possible
Nitrofurantoin B Avoid if infant< 8 days of age, or if G6PD-
deficent (any age)
Penicillins B Safe, monitor infant for GI toxicity.
Tetracycline D Short-term use safe, monitor infant for GI
toxicity.
Tigecycline D Safety not established, avoid use
TMP-SMX C Risk of kernicterus in premature infants; avoid if
infant G6PD-deficent.
Vancomycin C Safe with monitoring
Antifungals
Amphotericin B (all B Probably safe but no data available

products)
Anidulafungin B Safety not established, avoid use.
Caspofungin C Probably safe with monitoring, but no data
available; avoid if possible.
Fluconazole (single C Safe with monitoring
dose)
Fluconazole (other D Safe with monitoring
regimens)
Itraconazole C Little data available, avoid if possible
Ketoconazole C Little data available, avoid if possible
Micafungin C Safety not established, avoid use
Antimycobacterials
Dapsone C Safe but avoid if infant G6PD-deficent
Ethambutol Safe Probably safe monitor infant for toxicity
Ethionamide C Probably safe with monitoring, but data limited;
avoid if possible
Isoniazid C Safe but mother and infant should receive
pyridoxine
Pyrazinamide C Probably safe monitor infant for toxicity
Rifampin C Probably safe monitor infant for toxicity

VI- Vancomycin Dosing Guide
A. Initial Dosing Considerations
Calculate CrCl using the Cockcroft-Gault equation
a) Use ideal body weight (IBW) for non-obese patients
b) Use adjusted body weight (ABW) for obese patients [total body weight (TBW) >20% of IBW or BMI
>30 kg/m2]
c) Use total body weight (TBW) if TBW < IBW
Adverse Effects
i. Red Man Syndrome is characterized by hypotension and/or a maculopapular rash appearing on the face,
neck, trunk, and/or upper extremities.
ii. If this occurs, slow the infusion rate (e.g. to 90-120 mins per 1 gm.) ± increase the dilution volume ±
recommend diphenhydramine 25-50mg premedication.
B. Loading Dose
1. Targeted populations:
▪ Preferred in seriously ill (e.g. severe sepsis or septic shock requiring coverage for S. aureus, meningitis,
pneumonia, osteomyelitis, endocarditis, and bacteremia)
2. Standard load for patients with normal renal function: 25-30mg/kg TBW
Patient Weight Standard Loading Modified Loading Dose

Dose ~25 mg/kg TBW 15-20mg/kg TBW
Obese (BMI ≥ 30), CrCL< 30, AKI, IHD,
CRRT, unavailable Scr in emergent situations
(e.g sepsis or ED)
36 – 45 kg 1,000 mg x 1 750 mg x 1
46 – 55 kg 1,250 mg x 1 1,000 mg x 1
56 – 65 kg 1,500 mg x 1 1,250 mg x 1
66 – 75 kg 1,750 mg x1 1,500 mg x 1
76 – 120 kg 2,000 mg x 1 1,750 mg x1
> 120 kg 2,000 mg x 1 2,000 mg x 1
Use total body weight (TBW); Round doses to nearest 250mg. Infuse each 1000mg over 60 minutes.
C. Maintenance Dosing
 MD= 15-20 mg/kg (ABW)
 Round doses to nearest 250mg
 Maximum dose: 2gm per dose and 4.5g per 24h initially (including load)

D. Dosing interval
Estimated CrCl Dosing Interval
≥100 Q8H
80-99 Q8H or Q12H
50-79 Q12H
25-49 Q18H or Q24H
<25 Q36H or Q48H
E. Dosing in Renal Replacement Therapy

1- CRRT  Loading dose: 15 – 20 mg/kg x 1 (max 2gm)
 Maintenance: 10 – 15 mg/kg Q24H
 Monitoring: Trough 30 min before 3rd or 4th dose
2- Peritoneal  Dose: 10 – 15 mg/kg IV x1, then dose by level
Dialysis  Monitoring: Check level 24h after initial dose
3- Intermittent  Initial dose: 15 – 20 mg/kg x 1 (max 2gm)
Hemodialysis:  Maintenance dose: see the algorithm
 Monitoring:
 Single pre-dialysis level (preferred)
 Alternative: single level 4 hours after completion of dialysis session
F. Therapeutic Drug Monitoring:

 Trough level
 Peak concentrations are NOT recommended.
 Trough level should be obtained 30 minutes before the next dose.
 Do not order plasma level until 3 doses have been administered (to reach steady state) except in
dosing interval of 24 hours or longer
 Measure trough concentration only in case of:
 Receiving aggressive dosing: >1500 mg Q12H.
 Serious infections: meningitis, endocarditis, osteomyelitis and MRSA pneumonia.
 Unstable renal function (change in renal function of 0.5 mg/dl or 50% from baseline) or
dialysis.
 Receiving other nephrotoxic drugs, Therapy for more than 5 days

Target trough vancomycin level
Pneumonia, endocarditis, bacteremia, osteomyelitis: 15-20 mcg/ml
CNS infection: 20 mcg/ml
Neutropenic fever, skin and skin-structure infections 10-15 mcg/ml
Minimum serum trough concentration must be maintained> 10 mcg/ml to avoid development of resistance

G- Adjusting a vancomycin dose (Recommendations)
 Trough is too low- change the interval, keep the dose
 If the level is < 5 mcg/mL, the dosing INTERVAL should be shortened
 Trough is too high- decrease the dose, keep the interval
VII-Colistin Dosing Protocol

Conversions 33 mg CBA=1000000 IU CMS
Loading dose First administer colistin loading dose then begin daily maintenance dose 12 hours
later.
Dose= 4* body weight in kg
Use lower ideal weight or actual weight
Maintenance CrCl PK study group div BID FDA IBW
dose
≥ 90 ml/min 360 mg/day 2.5-5 mg/kg/day div
80 to < 90 340 mg/day 2-4 doses
70 to <80 300 mg/day 2.5-3.8 mg/kg/day
60 to <70 275 mg/day div 2 doses
50 to<60 245 mg/day
40 to<50 220 mg/day 2.5 mg/kg once daily
30 to<40 195 mg/day or div 2 doses
20 to<30 175 mg/day 1.5 mg/kg q36h
10 to<20 160 mg/day
5 to< 10 145 mg/day Not recommended
<5 130 mg/day
Inhalation 1. 50-75 mg CBA in 3-4 ml saline 2-3 times/day: concentration in lung

therapy epithelial lining is 100-1000 times greater with inhaled dosing versus IV
dosing alone
2. Pre-medicate with salbutamol
3. Use inhalation solution promptly after reconstitution
4. Do not use after 24 hours.
CSF 1. Intrathecal: 150,000-300,000 q24h
sterilization 2. Intraventricular: 60,000-300,000 units q24h
3. Dose should be diluted in 1-2 ml NS, remove equal volume of CSF, the give
colistin either Intrathecally via lumbar puncture OR intra-ventriculary via an
external ventricular drain (EVD), clamp for 1 hour and release.
CRRT IV loading dose: 300 mg CBA followed by 220 mg CBA every 12 hours

VIII- Prolonged Infusion of Beta-Lactams Protocol
Pharmacodynamics of antibacterial agents:
Drugs Bacterial killing Therapy Goal PK/PD Measurement
/persistent effect
Aminoglycosides Concentration dependent High peak serum AUC24/ MIC
Daptomycin killing, concentration
Fluoroquinolones Prolonged persistent
Metronidazole effect
Penicillin Time dependent killing, Long duration of T> MIC (time above
Cephalosporines no persistent effect exposure MIC)
Carbapenems
Monobactams
Clindamycin Time dependent killing, Enhanced amount of AUC24/MIC
Macrolides moderate to long drug
Linezolid persistent effect
Tigecycline
Vancomycin
Tetracyclines

Prolonged infusion of beta lactam antibiotics:
 Beta lactams display concentration independent
killing of bacteria. That means that once a critical
concentration is obtained, no further speed or extent
of killing is observed with increasing the
concentration.
 The best predictor of bacterial killing by beta lactam
is the TIME DURING THE DOSAGE
INTERVAL THAT THE FREE DRUG
CONCENTRATION EXCEEDS THE MIC OF
THE TARGET ORGANISMS (%fT>MIC).
Rationale:
 Patients with altered pharmacokinetics: Critical illness can also lead to variable
pharmacokinetics, such as augmented drug clearance, altered volume of distribution, abnormal fluid
balance, and/or changes in protein binding. Achieving adequate serum levels of antibiotics in these
populations can thus be extremely challenging.
 Reduced selection for drug resistance: Rapid bacterial killing, reduced organism burden, and
reduced time in the presence of sub-MIC antibiotic concentrations may result in reduced
opportunities for pathogens to acquire new genetic elements or de-repress chromosomal resistance
gen
 Maximizing the duration of exposure can be accomplished in three possible ways: increasing the
dose, shortening the dosing interval, or prolonging the infusion time

Effect on fT> MIC of (a) doubling the antibiotic dose, (b) shortening the dosing interval, (c) prolonging the
infusion time from 0.5 h to 3 h and (d) a combination of increasing the dose and prolonging the infusion
time.
Supporting Literature for extended infusion and

alternative dosing:
1- Monte Carlo simulations using 67% fT>MIC as

the pharmacodynamic target, cefepime 1g IV Q6H
as a 30-minute infusion similar probability of target
attainment profile as maximal cefepime dosing (2g
IV Q8H as a 30-minute infusion)
2- A Monte Carlo analysis evaluated cefepime

exposures in patients infected with Pseudomonas
aeruginosa to identify the pharmacodynamic
relationship of microbiologic response.
Microbiological failure was associated with fT>
MIC of <60% (77.8% failed cefepime therapy when
fT> MIC was <60%, whereas 36.2% failed cefepime
therapy when fT> MIC was>60%; P = 0.013).
Cefepime doses of at least 2 g every 8 h are required to
achieve this target against CLSI-defined susceptible P. aeruginosa organisms in patients with normal renal
function.
Potential indications:
●Structural lung disease (including cystic fibrosis)
●Frequent healthcare exposures
●Prior repeated antibiotic exposures
●Critical illness with severe infection (including central nervous system infections, necrotizing
fasciitis, neutropenic fever, burns)
●Infections due to pathogens with high intrinsic resistance and predilection for developing acquired
resistance during therapy (eg, P. aeruginosa, Burkholderiacepacia, Acinetobacter baumannii)
Goal target attainments by beta-lactam class:
Pathogen Carbapenems Cephalosporins Penicillins

Gram-positive 20-30% fT>MIC 40-50% fT>MIC 30-40% fT>MIC
Gram-negative 40-50% fT>MIC 60-70% fT>MIC

Dosing for prolonged infusions of beta-lactams:
Antibiotic Comment Creatinine Dose Minimum stability

Clearance
Piperacillin- Initial dose: 4.5 gm >20 mL/minute 3.375 or 4.5 g @ 37 C: 24 hrs.
tazobactam* over 30 minutes then over 4 hours q8h @25 C: 24 hrs.
4 hours later start ≤20 mL/minute or 3.375 or 4.5 g
the infusion intermittent HD or over 4 hours
according to PD q12h
creatinine clearance CRRT 3.375 or 4.5 g
over 4 hours q8h
Cefepime Δ Initial dose: 15 ≥50 mL/minute 2 gm over 3 or 4
mg/kg over 30 min, hours q8h @37 C: 8 hrs.
then immediately 30 to 49 2 gm over 3 or 4 @25 C: 24 hrs.
begin the infusion mL/minute hours q12h @4 C: ≥ 24 hrs.
according to 15 to 29 ml/min 1 gm over 3 or 4
creatinine clearance hours q12h
< 15ml/min or 1 gm over 3 or 4
IHD hours q24h
CRRT 2 gm over 3 or 4
hours q12h
Imipenem Imipenem is dosed >70 500 mg or 1 g @25 C: 4 hrs.
by both weight and over 3 hours q6h @4 C: 24 hrs.
renal function. 41-70 500 mg or 750 mg
Dosing is based on over 3 hours q8h
patient weight >70 21 to 40 250 or 500 mg
kg. over 3 hours q6h
6 to 20 or 250 or 500 mg
intermittent HD or over 3 hours q
PD 12h
CRRT¶ 500 mg over 3
hours q6h
Meropenem§ ≥50 mL/minute 1 or 2 g over 3 @37 C: <4 hrs.
hours q8h @25 C: 4 hrs.
25 to 49 1 or 2 g over 3 @4 C: 24 hrs.
mL/minute hours q12h
10 to 24 500 mg or 1 g
mL/minute over 3 hours q12h
< 10 ml/min or 500 mg or 1 gm
IHD q24h, over 3
hours given after
IHD
CRRT 1 or 2 gm q12h
over 3 hours
Ceftazidime Initial dose: 15 CrCl> 50 6 gm over 24 hrs. @37 C: 8 hrs.
mg/kg over 30 min, OD @25 C: 24 hrs.

then immediately CrCl 31-50 4 gm over 24 hrs. @4 C: ≥24 hrs.
begin the infusion OD
according to CrCl 10-30 2 gm over 24 hrs.
creatinine clearence OD
Ampicillin/ Recommended dose 12 gm (8 gm ampicillin+4 gm @37 C: stability in NS
sulbactam is for ventilator sulbactam) IV over 4 hours divided q8h at 24 hr is ampicillin
associated 77%, sulbactam 93%.
pneumonia due to @25 C: 8 hrs. in NS at
Acinetobacter. a concentration of ≤
Recommended dose 30mg/15 mg
is for adults with ampicillin/sulbactam
normal renal per 15 ml
function
The higher dose of piperacillin-tazobactam (4.5 g) is used case of critical illness, cystic fibrosis or in cases
of infections with pathogens that have high, but still susceptible, MICs to piperacillin-tazobactam when
alternative agents are not appropriate.
Δ Some studies have also used a 3-hour infusion time for cefepime.
◊§ The higher dose of meropenem is used in patients with infections of the central nervous system or other
life-threatening infections such as necrotizing fasciitis.

IX- Aminoglycosides Dosing Protocol
Appendix A: High Dose Extended Interval Regimen (gram-negative infections)
RATIONALE:
1- Optimize concentration-dependent bacterial

killing by achieving a high peak (>10x MIC):
The bactericidal action of aminoglycosides is
concentration dependent. The conventional dosing
regimenresults in relatively low peak/MIC ratios (<5),
while once daily dosing results in much higher ratios
(>10).
2- Utilize the post-antibiotic effect (PAE):

Aminoglycosides exhibit a significant PAE against aerobic gram- negative bacteria. The duration of this
effect (2 - 8 hours). The PAE phenomenon suggests that the aminoglycoside serum level may be allowed to
fall below the MIC of the pathogen without compromising antimicrobial efficacy. Factors affecting PAE
are:height of the preceding AMG peak, shortened by neutropenia, and extended in the presence of beta-
lactams
3- Minimize nephrotoxicity
By administering larger, less frequent doses
and potentially decreasing renal cortical
aminoglycoside concentrations. Uptake of the
aminoglycosides into the tubular epithelium
is receptor-mediated ➜ saturable
4- Allow the reversal of adaptive
resistance:
Continuous exposure of susceptible Gram-
negative bacilli to aminoglycosides causes an
apparent increase in the MIC. A longer dosing interval can be achieved with once-daily dosing, which
allows
for a drug-free period in which the bacteria are not exposed to an aminoglycoside and therefore preserve
antibacterial activity.
To minimize adaptive resistance, the goal should be complete clearance of drug before subsequent
dose.
5- Decrease emergence of resistant subpopulation:

Bacterial regrowth following an animal dose of aminoglycoside was prevented by regimens in which the
peak drug concentration was at least eight folders higher than the MIC.
Exclusion Criteria:

 Renal insufficiency (CrCl<30 mL/min or rapidly declining renal function)
 Pregnancy
 Synergy for gram-positive infections
 Ascites
 Burns (>20%)
Appendix A1: Hartford Nomogram

Initial Dose:

 7 mg/kg using actual body weight
 If obese, use adjusted body weight
 IBW + (0.4 [TBW – IBW])
 IBW Male: 50 kg + [2.3 kg for each inch over 5 feet]
 IBW Female: 45 kg + [2.3 kg for each inch over 5 feet]
 The dose of 7mg/kg is expected to achieve a Cmax level of ~20 mg/L
CrCl Gentamycin/ tobramycin Amikacin
≥ 60 ml/min 7 mg/kg/Q24H 15mg/kgQ24H
40-59 ml/min 7 mg/kg/Q36H 15mg/kgQ36H
Monitoring:
Initial Monitoring
 Single level drawn 8-12 hours after first dose (from
the start of infusion)
 Use nomogram to confirm/modify dosage interval
 Only applicable for 7 mg/kg
 Gentamicin/tobramycin (7 mg/kg/dose): Plot level
on graph
 Amikacin (15 mg/kg/dose): Divide level in half,
then plot on graph
Follow up trough level testing

 Trough monitoring (30-60 minutes prior to dose)
should be considered in patients demonstrating
acute changes in renal function or suspicion of
extended interval failure
 Maintenance random levels should be monitored at least once weekly
 If duration of therapy is anticipated to be > 2 weeks, audiometry should be considered
Appendix A2: Urban & Craig Nomogram
Initial dosing:
Gentamicin/Tobramycin 5 mg/kg IV Q24H based on actual body weight

≥ 60 ml/min 5 mg/kg/Q24H 15mg/kgQ24H

Monitoring:
Initial Monitoring
 Single level drawn 8-12 hours after the first
dose.
 Use nomogram to confirm/modify dosage
interval.
 Only applicable for 5 mg/kg
Follow up monitoring:
 Trough monitoring (30-60 minutes prior to
dose) should be considered in patients
demonstrating acute changes in renal function
or suspicion of extended interval failure
 Maintenance random levels should be
monitored at least once weekly
 If duration of therapy is anticipated to be > 2
weeks, audiometry should be considered
Appendix A3: Cystic Fibrosis Dosing

≥ 60 ml/min 10 mg/kg/Q24H 20 mg/kgQ24H
40-59 ml/min 10 mg/kg/Q36H 20 mg/kgQ36H
30-39 ml/min 10 mg/kg/Q48H 20 mg/kgQ48H
Monitoring:
Timing of Levels
Peaks Troughs
Initial levels 30 minutes after second dose 30-60 minutes before second
dose
Maintenance levels  Weekly peaks/troughs for prolonged duration of therapy
 Acute renal changes
 Changes in dosing regimen
Goal levels
Antibiotic Target Peak Target Trough
Gentamicin/Tobramycin 20 – 30 mcg/mL < 1 – 2 mcg/mL
Amikacin 40 – 60 mcg/mL < 4 – 8 mcg/mL

Appendix B: Conventional / Traditional Dosing (Gram-negative infections)
Appendix C: Gram-positive Synergy Dosing

X- Aerosolized Antibiotic Therapy in ICU
1. Rationale:
 For patients receiving mechanical ventilation, aerosolized antibiotics delivered via an efficient
system may achieve airway-drug concentrations 100–300-fold higher than the MIC of most bacteria,
including MDR pathogens, with reduced systemic toxicity and reduced pressure for selection of
resistant organisms. It can be used also when IV antibiotics may cause deleterious side effects.
 There are 4 proposed clinical settings for inhaled antibiotics, including prevention, monotherapy,
adjunct therapy with IV antibiotics, and treatment of extensively drug-resistant and even pan drug-
resistant pathogens.
 2016 IDSA Guideline on VAP suggests augmenting parenteral therapy with inhaled antibiotics,
especially for highly resistant bacteria.
 All patients receiving aerosolized antibiotics should be pretreated with aerosolized
albuterol 2.5mg prior to each dose.
 Aerosolized antibiotics are reserved mainly for adjunctive therapy in these patients with multidrug-
resistant (MDR) pathogens.
Intravenous infusion leads to high Nebulized delivery results in higher

extrapulmonary concentrations and pulmonary concentrations that are
potential toxicities. Diffusion to the above the resistance emergence
lung is limited and resulting prevention threshold, thus reducing
concentrations that may not exceed the likelihood of resistant strain
MIC can lead to treatment failure in selection. These concentrations are
challenging host–pathogen well above the MIC, thus resulting
combinations. in improved efficacy of
concentration-dependent antibiotics;
systemic side effects may be reduced

2. Key good practices for optimal antibiotic nebulization during mechanical ventilation
Nebulizer  Use nebulizers with a small residual volume

 Do not operate jet nebulizers with gas external to the ventilator
Medication  Use solutions for inhalation
solution
Nebulizer position  Position the nebulizer (continuous delivery) upstream in the inspiratory
limb at 15–40 cm of the Y-piece
Humidification  Remove the heat and moisture exchanger during nebulization; if using a
heated humidifier, consider switching it off or use of a dry circuit
Ventilator settings  Volume-controlled constant flow ventilation. Use low respiratory rate, low
inspiratory flow and a long inspiratory time
Safety  Place a new filter between the expiratory limb and the ventilator for each
nebulization
 Monitor patients closely during the nebulization, particularly in regard to
airway pressure, arterial pressure and oxygen saturation
 Check for resumption of humidification at the end of the nebulization
3. Literature Review:
1- Retrospective cohort study of patients with microbiologically documented VAP who received i.v. colistin
with or without inhaled colistin. Seventy-eight patients with VAP received i.v. plus inhaled colistin, whereas
43 patients received i.v. colistin alone. The use of inhaled colistin was independently associated with the
cure of VAP in a multivariable analysis (OR 2.53, 95% CI 1.11-5.76). Independent predictors of mortality
were a higher APACHE II score (OR 1.12, 95% CI 1.04-1.20), presence of malignancy (OR 4.11, 95% CI
1.18-14.23) and lower daily dosage of i.v. colistin (OR 0.81, 95% CI 0.68-0.96). The outcome of VAP was
better in patients who received inhaled colistin with i.v. colistin than those who received i.v. colistin alone.
There was no difference in all-cause in-hospital and ICU mortality between the two groups. Randomized
controlled trials are needed to evaluate further the role of inhaled colistin in VAP. (Clin Microbiol Infect.
2010 Aug;16(8):1230-6. doi: 10.1111/j.1469-0691.2009.03040.x. Epub 2009 Sep 2.)
2- A randomized nonblinded controlled trial was performed on ninety patients with VAP. Patients were
randomized into three equal groups: Group I received IV amikacin 20 mg/kg/24 h and meropenem 2 g over
30 min/8 h. Group II received the same as Group I in addition to nebulized amikacin 25 mg/kg/day every 8
h. Group III received IV amikacin 20 mg/kg/24 h, nebulized amikacin 25 mg/kg/day every 8 h, and
meropenem 2 g diluted in 240 ml normal saline over 3 h/8 h. The primary outcome was the clinical outcome
of VAP. Secondary outcomes were microbiological outcome, VAP-related mortality, duration of MV, ICU
stay, and nephrotoxicity.
Results: Group II and Group III compared to Group I showed higher incidence of clinical cure (53.33% in
Group II and 66.67% in Group III vs. 26.67% in Group I, P = 0.007). Group II compared to Group I showed
significant reduction in ventilator days (5.32 ± 1.86 vs. 7.3 ± 2.1 days, respectively, P < 0.001) and reduction
in ICU days (11.87 ± 2.6 vs. 15.3 ± 3.1 days, respectively, P < 0.001). Group III compared to Group II
showed significant reduction in ventilator days (4.22 ± 1.32 vs. 5.32 ± 1.86, respectively, P = 0.011) and
highly significant reduction in ICU days (9.21 ± 1.17 vs. 11.87 ± 2.6, respectively, P < 0.001). All groups
were comparable as regards nephrotoxicity or mortality.
Conclusions: Adding nebulized amikacin to systemic antibiotics in patients with VAP caused by
Gram-negative MDRO may offer efficacy benefits, and the use of extended infusions of meropenem

could improve the clinical outcomes in critically ill populations. (Ammar MA, Abdalla W. Effect of
extended infusion of meropenem and nebulized amikacin on Gram-negative multidrug-resistant
ventilator-associated pneumonia. Saudi J Anaesth 2018;12:89-94)
3- In a double-blind placebo-controlled study, critically ill intubated patients were randomized if they
exhibited signs of respiratory infection (purulent secretions and Clinical Pulmonary Infection Score ≥6).
Using a well-characterized aerosol delivery system, AA or saline placebo was given for 14 days or until
extubation. The responsible clinician determined administration of systemic antibiotics for ventilator-
associated pneumonia and any other infection.
Measurements and main results: AA eradicated 26 of 27 organisms present at randomization compared with
2 of 23 organisms with placebo (P < 0.0001). AA eradicated the original resistant organism on culture and
Gram stain at end of treatment in 14 out of 16 patients compared with 1 of 11 for placebo (P < 0.001). New
drug resistance to AA was not seen. Compared with AA, resistance to systemic antibiotics significantly
increased in placebo patients (P = 0.03). Compared with placebo, AA significantly reduced Clinical
Pulmonary Infection Score (mean ± SEM, 9.3 ± 2.7 to 5.3 ± 2.6 vs. 8.0 ± 23 to 8.6 ± 2.10; P = 0.0008).
Conclusions: In chronically intubated critically ill patients, AA successfully eradicated existing
MDRO organisms and reduced the pressure from systemic agents for new respiratory resistance.
Clinical trial registered with www.clinicaltrials.gov (NCT 01878643). (Am J Respir Crit Care Med
. 2014 May 15;189(10):1225-33. doi: 10.1164/rccm.201312-2161OC.
4. Adverse events:
Airway irritation that may lead to bronchospasm. Pretreatment with albuterol may prevent this effect.
5. Pharmacokinetics of antibiotics:
Antibiotics with concentration-dependent effects (ie, greater area under the curve/minimum inhibitory
concentration ratio) are typically chosen for aerosolization, as it is possible to achieve high concentrations in
the airway to maximize bacterial killing. Different from time-dependent antibiotics (time over minimum
inhibitory concentration of 90%), concentration-dependent antibiotics do not need to be present in the target
tissue for a long period of time, usually requiring frequent administration.
6. Indications and dosing:

Colistin
1- HAP or VAP due  Via ventilator circuit: 150 mg CBA every 8 hours delivered over 60
to multi-drug minutes for 14 days or until successful wean from mechanical ventilation
resistant gram- (7-19 days). May consider use as an adjunct in patients receiving IV
negative bacilli: colistin.
 50- 75 mg CBA in 3-4 ml saline via vibrating mesh nebulizer 2-3 times
per day: concentration in lung epithelial lining is 100-1000* greater with
inhaled dosing verses IV dosing alone.
Levofloxacin
Delivery system  eFlow vibrating mesh nebulizer.
Dose  240 mg BID for 28 days in cystic fibrosis patients.
Amikacin
Dose  Patients less than 30kg: Not routinely used in children less than 30kg in
weight.
 Weight 30-50kg: 250mg twice daily

 Weight ≥ 50kg: 500mg twice daily or 15 mg/kg once daily
Precautions  As systemic absorption of amikacin following nebulization is low, dose
adjustment is not routinely required. However, caution should be taken if
inhaled amikacin is used in patients with renal impairment or failure.
Administration  To prepare a 250mg dose:
Using the 500mg/2mL formulation, draw up 1mL of the solution and
dilute to 4mL with sodium chloride 0.9%
 To prepare a 500mg dose:
Using the 500mg/2mL formulation, draw up 2mL of the solution and
dilute to 4mL with sodium chloride 0.9%
 Part vials of amikacin may be stored in the refrigerator for up to 24 hours
and used for the subsequent dose.
Monitoring  Measure lung function before and after the initial dose of amikacin and
monitor for bronchospasm.
Adverse effects  Minimal adverse effects were seen in clinical trials of inhaled amikacin;
however, some systemic absorption may occur.
 Rare: Nephrotoxicity, vestibular and cochlear toxicity, anaphylaxis,
bronchospasm, oliguria, peripheral neuropathy, neuromuscular blockade.

Reproduced from Athanassia et al. and Rouby et al.

XI- Antimicrobial Guidelines for Community-Acquired
Infections
Addressograph
PIN:
NAME: Antibiotic order: Acute Bacterial Meningitis
AGE:
GENDER:
Antibiotics should be started as soon as the possibility of bacterial meningitis becomes

evident IDEALLY WITHIN 30 MINUTES.
Get blood cultures and start therapy.
Clinical Syndrome Preferred Regimen Alternative Regimen
Age < 50 Cefotaxime 2gm Q4-6H OR Vancomycin 500-750 mg
Most commonly isolated Ceftriaxone 2 gm IV Q12H IV Q6H
organisms: AND AND
 S. pneumoniae Vancomycin 45-60 Meropenem 2 gm IV Q8H
 N. meningitides mg/kg/day divided into Q6-8H AND
 H . influenzae IV Dexamethasone
AND
Dexamethasone 0.15 mg/kg
IV Q6h for2-4 days given 10
to 20 minutes before
antibiotic.
If listeria is consideration
add:
Ampicillin 2 gm IV q4h
Age ≥ 50 Cefotaxime 2gm Q6H OR PCN allergy (anaphylaxis):
Most commonly isolated Ceftriaxone 2 gm IV Q12H Vancomycin IV 15 mg/kg
organisms: AND AND
 S. pneumoniae Ampicillin 2 gm IV q4h Moxifloxacin 400 mg IV
 N. meningitides AND Q24H OR
 H. influenzae Vancomycin 15-20
 L. monocytogenes mg/kg/day divided into Q8- Ciprofloxacin 400 mgIV Q24H
Aerobic gram-negative bacilli 12H IV AND
AND SMX/TMP 5 mg/kg IV Q6H
Dexamethasone 0.15 mg/kg
IV Q6h for2-4 days given 10
to 20 minutes before
antibiotic.
Infected shunt Vancomycin 15-20 Vancomycin 15-20 mg/kg/day
mg/kg/day divided into Q8- divided into Q8-12H IV
12H IV Meropenem 2 gm IV Q8H
AND Serious beta lactam allergy:
Cefepime 2g IV Q8H OR Substitute meropenem for ciprofloxacin
Ceftazidime 2 gm IV Q8H 400 mg IV Q8H

Post neurosurgery or Cefepime 2g IV Q8H OR Vancomycin 15-20 mg/kg/day
penetrating head trauma Ceftazidime 2 gm IV Q8H divided into Q8-12H IV
PLUS PLUS
Metronidazole 500 mg IV Meropenem 2 gm IV Q8H
q8h Serious beta lactam allergy:
PLUS Substitute meropenem for ciprofloxacin
Unasyn 1.5 gm q6h 400 mg IV Q8H
Post- basilar skull fracture Ceftriaxone 2g IV Q12H Vancomycin 15-20 mg/kg/day
OR divided into Q8-12H IV
Cefotaxime 2 gm IV Q4-6H PLUS
PLUS Meropenem 2 gm IV Q8H
Metronidazole 500 mg IV
q8h
PLUS
Unasyn 1.5 gm q6h
Recommendations for antimicrobial therapy of bacterial meningitis in adults with presumptive
pathogen identification by positive Gram stain
Microorganism Recommended therapy Alternative therapies

Streptococcus pneumoniae Vancomycin 500-750 mg IV q6h  Meropenem 2 gm IV q8h
PLUS Moxifloxacin 400 mg IV q24h
Ceftriaxone 2 gm IV q12h OR
Cefotaxime 2 gm IV q4-6h
Neisseria meningitidis Ceftriaxone 2 gm IV q12h OR Ampicillin 2 gm IV q4h
Cefotaxime 2 gm IV q4-6h Moxifloxacin 400 mg IV q24h
Listeria monocytogenes Ampicillin 2 gm IV q4h ±  Meropenem 2 gm IV q8h
gentamicin LD: 2 mg/kg then 1.7
Haemophilus influenzae Ceftriaxone 2 gm IV q12h OR  Meropenem 2 gm IV q8h
Cefotaxime 2 gm IV q4-6h
Duration of Therapy
Microorganism Duration
Neisseria meningitidis 7
Haemophilus influenzae 7
Streptococcus pneumoniae 10-14
Streptococcus agalactiae 14-21
Aerobic gram-negative bacilli 21
Listeria monocytogenes ≥21
Viral Meningitis Herpes Simplex Type 2
Acyclovir 10 mg/kg (based on ideal body weight) IV Q8H. Treat for 7 to 10 days
Meningitis Prophylaxis

Haemophilus influenza (Type B) Rifampicin 600mg PO q24hr for 4 days
Close contact group: persons who reside with the patient or
non-resident who has spent ≥ 4 hours with the index patient
for at least 5 of 7 days preceding the day of hospitalization of
the patient.
N. meningitides Ciprofloxacin 500 mg PO one dose OR
Ceftriaxone 125-250 mg IM one dose OR
1- "Close contact" who have had prolonged (>8 hours)
Rifampicin 600mg PO q12hr for 4 doses
contact while in close proximity (<1 meter) to the
2- Direct exposure to the patient's oral secretions during the 7
days before the onset of the patient's symptoms and less
than24 hours of initiation of appropriate antibiotic therapy.
Physician name: Physician signature
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Addressograph
PIN:
NAME: Antibiotic order: Acute Bacterial Sinusitis
AGE:
GENDER:
Primary regimen Alternative regimen

Amoxicillin- clavulanate 1000 mg Type 1 allergy (ex: Anaphylaxis)
BID PO Levofloxacin 750 mg PO OD OR
Moxifloxacin 400 mg PO OD* 5-7 days OR
Doxycycline 100 mg PO BID
Type 2 allergy (ex: skin rash)
Cefdinir 600 mg OD OR
Cefpodoxime 200 mg PO BID *5-7 days OR
Cefuroxime 500 mg PO BID *5-7 days
Antibiotic therapy is indicated only in case of:
1- If at initial evaluation: fever 39, intense facial pain and purulent nasal discharge, syndrome justifies
treatment as bacterial sinusitis.
2- If despite withholding treatment patient is still symptomatic after 10 days.
3- If treated as bacterial sinusitis but patient fails therapy
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Addressograph
PIN: Antibiotic order: Animal/human bites, Acne,
NAME:
AGE: Paronychia
GENDER:
Animal bite Oral Therapy

Amoxicillin-clavulanic acid 1000 mg q12h (PREFERRED) OR
Cefuroxime 500mg q12h PLUS clindamycin 300 mg q8h OR
metronidazole 250-500 mg q8h OR
Levofloxacin 500 mg OD or ciprofloxacin 500 mg q12h PLUS clindamycin
300 mg q8h or metronidazole 500 mg q8h OR
Moxifloxacin 400 mg PO q24h.
Parenteral therapy:
Ampicillin-sulbactam 1.5-3 gm q6-8h OR
Ceftriaxone 1gm OD plus metronidazole 500 mg PO q8h or clindamycin
300 mg PO q8h.
Human bite Oral Therapy
Levofloxacin 500 mg q24h or ciprofloxacin 500 mg q12h PLUS
clindamycin 300 mg PO q8h or metronidazole 500 mg PO q8h
Moxifloxacin 400 mg q24h
Amoxicillin-clavulanic acid 1000 mg q12h (PREFERRED)
Parenteral therapy:
Ampicillin-sulbactam 1.5-3 gm q6-8h OR
Carbapenem
Wound and TDAP vaccine
Propionibacterium Primary regimen Alternative regimen

acne
Ceftriaxone 2 gm IV q24h Vancomycin 15 mg/kg q12h
Paronychia
Bacterial Incision and drainage and culture of abscess
TMP-SMX DS 1-2-tab PO q12h OR
Cephalexin 500 mg q8h
Fungal Ketoconazole 400 mg PO q24h* 14 days

Viral Acyclovir 400 mg PO q8h*10 days
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Addressograph
PIN:
NAME: Antibiotic order: Brain Abscess
AGE:
GENDER:
Origin of Abscess Empiric Regimen

Oral source; Otogenic; or Ceftriaxone IV 2 g q12hr PLUS
sinus source Metronidazole 500 mg IV q8hr
OR
Penicillin G 3-4 million units IV q4h PLUS
Metronidazole 500 mg IV q8hr
Hematogenous MSSA Ceftriaxone 2 gm IV OD
spread Suspect
MRSA Vancomycin IV loading dose of 25 mg/kg then 1 g q8hr ±
Staph. aureus
Metronidazole IV 500 mg q8hr (Vancomycin target trough serum
concentration of 15-20 μg/mL)
Postoperative Vancomycin IV loading dose of 25 mg/kg then 1g q8hr PLUS
neurosurgical patients Meropenem IV2 g q8hr OR
Vancomycin IV loading dose of 25 mg/kg 1g q8hr PLUS
Ceftazidime IV 2 g q8hr (vancomycin target trough serum concentration
of 15-20
Penetrating trauma OR Vancomycin IV loading dose of 25 mg/kg then 1g q8hr PLUS
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
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Addressograph
PIN: Antibiotic order: Brucellosis, Bone
NAME:
AGE: Mycobacterium tuberculosis
GENDER:
Adult and children > 8 years Doxycycline 100 mg PO BID+ Gentamicin 5 mg/kg IV OD * 7 days
with non-localizing disease OR
Doxycycline 100 mg PO BID+ Rifampin 600-900 mg PO OD *6
weeks
Adult and children > 8 years Doxycycline 100 mg PO BID+ Rifampin 600-900 mg PO OD both *3
with months
spondylitis/arthritis/sacroileitis PLUS, gentamicin IV 5 mg/kg OD for first 7 days
Ciprofloxacin 750 mg PO BID + Rifampicin 600-900 mg PO OD*3

months
Brucella during pregnancy < TMP-SMX 5 mg/kg BID+ Rifampicin 600-900 mg PO Q24h
36 weeks If ≥36 weeks add rifampicin monotherapy
Neurobrucellosis Doxycycline 100 mg PO BID+ Rifampin 600-900 mg PO OD +
ceftriaxone 2 gm IV BID, continue until CSF is normal.
Endocarditis: (Doxycycline 100 mg PO BID+ Rifampin 600 mg PO OD+ TMP-

SMX) *6 weeks-6 months + Gentamicin 5 mg/kg IV OD *2-4 weeks.
Bone Mycobacterium Isoniazid 300 mg PO OD +Rifampicin 600 mg OD +Pyrazinamide 25
tuberculosis mg /kg PO OD+ Ethambutol 15 mg/kg OD *2 MONTHS THEN
Isoniazid 300 mg PO OD +Rifampicin 600 mg OD* 4 months
Plus, pyridoxine 25-50 mg PO OD
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Addressograph
PIN: Antibiotic order: Community-acquired Intra-
NAME:
AGE: Abdominal Infections
GENDER:
Risk factors that warrant broad empiric antimicrobial coverage for intra-abdominal infections
Factors associated with mortality
 Age >70 years, medical comorbidity
 Immunocompromising condition, high severity of illness (ie, sepsis)
 Extensive peritoneal involvement or diffuse peritonitis
 Delay in initial intervention (source control) >24 hours
 Inability to achieve adequate debridement or drainage control
Infection Regimen
Low risk Single agent regimen
community-acquired Ertapenem 1g IV once daily OR
intra-abdominal Piperacillin-tazobactam 3.375g IV every 6 hours
infections Combination regimen with metronidazole
Cefazolin 1 to 2 g IV every 8 hours OR
Cefuroxime 1.5g IV every 8 hours OR
Ceftriaxone 2g IV once daily OR
Cefotaxime 2g IV every 8 hours OR
Ciprofloxacin 400mg IV every 12 hours or 500mg PO q12h OR
Levofloxacin 750mg IV or PO once daily
PLUS:
Metronidazole 500 mg IV or PO every 8 hours
High-risk Single agent regimen:

community-acquired Imipenem-cilastatin 500mg IV Q6H OR
intra-abdominal Meropenem 1g IV Q8H OR
infections Piperacillin-tazobactam 4.5 g IV Q6H
Combination regimen with metronidazole:
Cefepime2g IV Q8H OR
Ceftazidime 2g IV Q8H
PLUS
Metronidazole500 mg IV or PO Q8H
Physician notes:
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Addressograph
PIN: Antibiotic order: Community-Acquired
NAME:
AGE: Pneumonia
GENDER:
CURB-65 SCORE  C: Confusion

 U: Urea blood nitrogen>18
 R: Respiratory rate≥ 30 breath/min.
 B: Blood pressure< 90/60
 65: Age 65 years
Major criteria for ICU admission:
Septic shock requiring use of vasopressors
Mechanical ventilation
OUTPATIENT
0-1 Without comorbidities Amoxicillin 1 gm PO tid OR
 Azithromycin 500 mg on first day then 250 mg daily
With comorbidities Levofloxacin 750 mg OD OR
Chronic lung, heart, Moxifloxacin 400 mg OD OR
renal or liver disease Gemifloxacin 320 mg OD OR
Diabetus mellitus OR
Alcoholism One of the following:
Malignancy or Amoxicillin/clavulanate: 1 gm q12h OR
asplenia Cefuroxime 500 mg BID
Risk factors for MDR: PLUS, one of the following:
Antibiotics in the last Azithromycin 500 mg on first day then 250 mg daily OR
90 days Clarithromycin 500 mg BID
INPATIENT
2 Standard regimen Levofloxacin 750 mg IV/PO q24h OR
No risk factors for Moxifloxacin 400 mg IV/PO q24h
MRSA or
Pseudomonas OR Beta-lactam
Ampicillin/sulbactam 1.5-3 gm q6h OR
Cefotaxime 1-2 gm q8h OR
Ceftriaxone 1-2 gm daily
PLUS
Azithromycin 500 mg daily OR
Clarithromycin 500 mg Q12h
Prior respiratory Vancomycin 15 mg/kg/12hr OR
isolation of MRSA  Linezolid 600mg oral or iv /12hr
ADD And obtain cultures/nasal PCR
Recent hospitalization and parenteral antibiotic and risk factors for
MRSA:
Don't start MRSA coverage until positive culture results
Prior respiratory Piperacillin/tazobactam 4.5g/6h OR
isolation of Cefepime 1-2g iv/8-12h OR
Pseudomonas Imipenem/ cilastatin 500mg iv q/6hr OR

aeruginosa Meropenem 1 gm IV/q8hr
Recent hospitalization and parenteral antibiotics and risk factors for
Pseudomonas aeruginosa:
Don't start Pseudomonas coverage until positive culture results
ICU Standard regimen Beta Lactam
Ceftriaxone 1-2 gm IV q24h OR
Cefotaxime (1-2 gm IV q8h) OR
Ampicillin-sulbactam (1.5-3gm q6h)
Physician name: PLUS Physician signature
Levofloxacin 750 mg IV/PO q24h OR
Moxifloxacin 400 mg IV/PO q24h OR
Azithromycin 500 mg Q24h OR
Clarithromycin 500 mg Q12h
Prior respiratory Vancomycin 15 mg/kg/12hr OR
isolation of MRSA  Linezolid 600mg oral or iv /12hr
ADD Recent hospitalization, parenteral antibiotic and risk factors for
MRSA:
Add MRSA coverage and obtain nasal PCR and cultures
Prior respiratory Piperacillin/tazobactam 4.5g/6h OR
isolation of Cefepime 1-2g iv/8-12h OR
Pseudomonas Imipenem/cilastin 500mg iv /6hr OR
aeruginosa Meropenem 1 gm iv/8hr
Recent hospitalization and parenteral antibiotics and risk factors for
Pseudomonas aeruginosa:
Add coverage for pseudomonas and obtain cultures
Risk factors for pseudomonas 4 or more courses of antibiotics in the last year
Hospitalization for 2 or more days in the last 90 days
Mechanical ventilation
History of COPD
Malignancies.
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Addressograph
PIN:
NAME: Antibiotic order: COPD Exacerbation
AGE:
GENDER:
COPD Exacerbation outpatient

Mild exacerbation No antibiotics
Only 1 of 3 cardinal symptoms Increase bronchodilators
 Increased sputum volume Symptomatic therapy
 Increased sputum purulence
 Increased dyspnea
Moderate and severe exacerbation Un complicated COPD

At least 2 of 3 cardinal symptoms  Age<65 years
 <2 exacerbation/year
 FEV1>50% expected
 No cardiac disease
Azithromycin or Clarithromycin OR
Cefuroxime or Cefpodoxime
Complicated COPD
 Age> 65 years
 ≥2 exacerbation/year
 FEV1< 50% expected
 Cardiac disease
 Moxifloxacin 400 mg PO OD OR
 Levofloxacin 500 mg PO OD OR
 Amoxicillin/ clavulanate 1 gm BID
COPD exacerbation in inpatient
Moderate and severe exacerbation Risk factors for pseudomonas:
At least 2 of 3 cardinal symptoms Levofloxacin 750 mg OD PO or IV OR
AND Cefepime 2 gm IV q8h OR
 Age> 65 years Ceftazidime 2 gm IV q8h OR
 ≥2 exacerbation/year Piperacillin/tazobactam 4.5 gm q6h
 FEV1< 50% expected
 cardiac disease No risk factors for pseudomonas:
Pseudomonas risk factors : Levofloxacin 750 mg IV OD OR
 Advanced COPD Moxifloxacin 400 mg PO OD OR
 Previous isolation of Pseudomonas Ceftriaxone 2 GM IV OD OR
from sputum Cefotaxime 2 gm IV q8h
 Concomitant bronchiectasis
 Frequent administration of antibiotics
 Frequent hospital admissions

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Addressograph
PIN:
NAME: Antibiotic order: Diabetic Foot Infection
AGE:
GENDER:
Severity of infection Recommended empiric therapy

PEDIS GRADE 1 No recommended antibiotic therapy
IDSA: uninfected
Ulcer but no inflammation
PEDIS GRADE 2 MRSA
IDSA: mild Trimethoprim-sulfamethoxazole PO 160/800mg [DS] q12h OR
Local infection involving Doxycycline PO 100mg q12h
the skin and the MSSA
Cephalexin 500mg PO q6h (non-severe hypersensitivity reaction to
subcutaneous tissues
penicillin) OR
Erythema: >0.5 - ≤ 2 cm
Amoxicillin-clavulanate PO 1000mg q12h OR
Duration: 1-2 weeks
Clindamycin
Levofloxacin 750 mg PO OD
PEDIS GRADE 3 Moxifloxacin 400 mg PO
IDSA: moderate Unasyn 1.5 gm q6h
Erythema: > 2 cm Ciprofloxacin OR levofloxacin PLUS clindamycin
No SIRS RISK FACTORS FOR MRSA:
Duration: 1-3 weeks Infection is severe, patient has previous history of MRSA,
prevalence of MRSA is high
Vancomycin 15 mg/kg BID
Linezolid 600 mg BID IV
RISK FACTORS FOR PSEUDO:
Infection is severe, warm climate, exposure of feet to water, high
prevalence of pseudomonas
Piperacillin-tazobactam 4.5 gm IV q6h
PEDIS GRADE 4 Vancomycin IV 15mg/kg q12hr
IDSA: severe PLUS
≥ 2 SIRS One of the following
1. Temp> 38 or < 36 Piperacillin-tazobactam IV 4.5g q6-8hr OR
2. Heart rate> 90 Imipenem-cilastatin IV 500mg q6hr OR
3. Respiratory rate>20 Meropenem IV 1000mg q8hr
4. WBC>12000 OR < 4000 Cefepime 1-2 gm IV q8h
Duration: 2-4 weeks Ceftazidime 1 gm q8h
Physician notes:
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Addressograph
PIN: Antibiotic order: Group A Streptococcal
NAME:
AGE: Pharyngitis
GENDER:
Modified Centor score ≥ 2 points

Fever, temperature > 38 degrees (1 point)
Tonsillar or pharyngeal exudates (1 point)
Tender / swollen anterior cervical lymphnodes (1 point)
Age 3-14 years (1 point)
Absence of cough (1 point)
M-CENTOR < 1 Low likelihood of Strep pharyngitis
 No RADT test, culture or antibiotic required
M-CENTOR 2-3 Moderate likelihood of strep pharyngitis
 RADT test± culture
 Antibiotic therapy based on culture or test results
M-CENTOR> 4 High likelihood of strep pharyngitis
 RADT test +empirical antibiotics
Patient group Empiric regimen
No penicillin allergy Penicillin V, PO 500 mg q12hr for 10 days OR
Amoxicillin, PO 500 mg q12hr for 10 days OR
Penicillin G Benzathine, IM 1.2 million units single dose
Penicillin allergy Cephalexin PO 500 mg q12hr for 10 days (only for non-immediate-type and
non-severe hypersensitivity reactions to penicillin) OR
Clindamycin PO 300 mg q8hr for 10 days OR
Azithromycin PO 500 mg PO first day then 250 mg PO OD for 4 days OR
Clarithromycin PO 250 mg q12hr for 10 days
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Addressograph
PIN:
NAME: Antibiotic order: Infective Endocarditis
AGE:
GENDER:
Therapy of Native Valve Caused by Highly Penicillin-Susceptible VGS and Streptococcus gallolyticus
(bovis)
Empiric regimen No of Comment
weeks
Aqueous crystalline penicillin G sodium 12–18 4 Preferred in most patients >65 y or patients
million U/24 h IV either continuously or in 4 or 6 with impairment of eighth cranial nerve
equally divided doses. function or renal function. Ampicillin 2 g
IV every 4 h is a reasonable alternative to
penicillin if a penicillin shortage exists.
Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose 4
Aqueous crystalline penicillin G sodium 12–18 2 2-wk regimen not intended for patients with
million U/24 h IV either continuously or in 4 or 6 known cardiac or extracardiac abscess or
equally divided doses. OR for those with creatinine clearance of < 20
Ceftriaxone sodium 2 g/24 h IV/IM ml/min, impaired eighth cranial nerve
PLUS function.
Gentamicin sulfate 3 mg/kg per 24 h IV or IM in
1 dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV 4 Vancomycin therapy is reasonable only
in 2 equally divided doses for patients unable to tolerate penicillin or
ceftriaxone.
Therapy of NVE Caused by Strains of VGS and Streptococcus gallolyticus (bovis) Relatively Resistant
to Penicillin
Penicillin G sodium 24 million U/24 h IV either 4 For penicillin-resistant (MIC ≥0.5
continuously or in 4–6 equally divided doses μg/mL) VGS strains with a combination of
PLUS ampicillin or penicillin plus gentamicin.
Ampicillin 2 g IV every 4 h is a
Gentamicin sulfate 3 mg/kg per 24 h IV or IM in reasonable alternative to penicillin
1 dose 2 Ceftriaxone may be a reasonable
alternative treatment option for VGS
isolates that are susceptible to ceftriaxone
Vancomycin hydrochloride 30 mg/kg per 24 h IV 4 Vancomycin therapy is reasonable only
in 2 equally divided doses for patients unable to tolerate penicillin or
ceftriaxone therapy.
Therapy for NVE Caused by Staphylococci
Oxacillin-susceptible strains 6 For penicillin-allergic (non-anaphylactoid
Nafcillin or oxacillin 12 g/24 h IV in 4–6 equally type) patients
divided doses Cefazolin 6 g/24 h IV in 3 equally
divided doses
Oxacillin-resistant strains 6

Vancomycin 30 mg/kg per 24 h IV in 2 equally
divided doses
Therapy for Endocarditis Involving a Prosthetic Valve or Other Prosthetic Material Caused by
viridans group streptococci and Streptococcus gallolyticus (bovis)
Penicillin-susceptible strain (≤0.12 μg/mL) 6
Aqueous crystalline penicillin G sodium 24
million U/24 h IV either continuously or in 4–6
equally divided doses
Ceftriaxone 2 g/24 h IV or IM in 1 dose 6
With or without Gentamicin sulfate 3 mg/kg per 24
h IV or IM in 1 dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV 6 Vancomycin is reasonable only for
in 2 equally divided doses patients unable to tolerate penicillin or
ceftriaxone.
Penicillin relatively or fully resistant strain Ampicillin 2 g IV every 4 h is a
(MIC >0.12 μg/mL) reasonable alternative to penicillin if a
Aqueous crystalline penicillin sodium 24 million 6 penicillin shortage exists.
U/24 h IV either continuously or in 4–6 equally
divided doses
Or
Ceftriaxone 2 g/24 h IV/IM in 1 dose 6
PLUS
Gentamicin sulfate 3 mg/kg per 24 h IV/IM in 1 2
dose
Vancomycin hydrochloride 30 mg/kg per 24 h IV 6 Vancomycin is reasonable only for
in 2 equally divided doses patients unable to tolerate penicillin or
ceftriaxone.
Therapy for Endocarditis Involving a Prosthetic Valve or Other Prosthetic Material Caused by
Staphylococci
Oxacillin-susceptible strains Vancomycin should be used in patients
Nafcillin or oxacillin 12 g/24 h IV in 6 equally with immediate-type hypersensitivity
≥6
divided doses reactions to β-lactam antibiotics cefazolin
Plus may be substituted for nafcillin or oxacillin
Rifampin 900 mg per 24 h IV or orally in 3 in patients with non–immediate-type
equally divided doses ≥6 ≥6 hypersensitivity reactions to penicillins.
Plus
Gentamicin 3 mg/kg per 24 h IV or IM in 2 or 3
equally divided doses 2
Oxacillin-resistant strains
Vancomycin 30 mg/kg 24 h in 2 equally divided ≥6
doses
Plus
Rifampin 900 mg/24 h IV/PO in 3 equally ≥6
divided doses ≥6 Plus
Gentamicin 3 mg/kg per 24 h IV/IM in 2 or 3
equally divided doses

2
Therapy for Endocarditis Involving a Native or Prosthetic Valve or Other Prosthetic Material
Resulting from Enterococcus Species Caused by Strains Susceptible to Penicillin and Gentamicin in
Patients Who Can Tolerate β-Lactam Therapy
Ampicillin sodium 2 g IV every 4 h OR 4-6 Native valve: 4-wk therapy recommended
for patients with symptoms of < 3 mo, 6-wk
Aqueous penicillin G sodium 18–30 million U/24 4-6
therapy recommended for native valve
h IV either continuously or in 6 equally divided
symptoms >3 mo and for patients with
doses
prosthetic valve or prosthetic material.
PLUS
Gentamicin sulfate 3 mg/kg ideal body weight in Recommended for patients with creatinine
2–3 equally divided doses 4-6 clearance >50 mL/min.
OR Recommended for patients with initial
Ampicillin 2 g IV every 4 h creatinine clearance < 50 ml/min
PLUS 6
Ceftriaxone 2 gm IV q12h 6
Vancomycin-Containing Regimens for Vancomycin- and Aminoglycoside-Susceptible Penicillin-
Resistant Enterococcus Species for Native or Prosthetic Valve (or Other Prosthetic Material) IE in
Patients Unable to Tolerate β-Lactam
Unable to tolerate β-lactams, Penicillin resistance;
intrinsic or β-lactamase producer
Vancomycin 30 mg/kg per 24 h IV in 2 equally
divided doses 6
Plus
Gentamicin 3 mg/kg per 24 h IV or IM in 3
equally divided doses 6
Therapy for Endocarditis Involving a Native or Prosthetic Valve or Other Prosthetic Material
Resulting from Enterococcus Species Caused by Strains Resistant to Penicillin, Aminoglycosides, and
Vancomycin
Linezolid 600 mg IV or orally every 12 h Cardiac valve replacement may be necessary for cure
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Addressograph
PIN:
NAME:
AGE:
Antibiotic order: Osteomyelitis
GENDER:
Clinical setting Empiric regimen Alternative regimen

Hematogenous One of the following If severe allergy
osteomyelitis Ceftriaxone 2 gm q24h OR One of the following:
Ceftazidime 1-2 gm q8-12h OR Ciprofloxacin 400 mg BID OR
Cefipime 1-2 gm q8-12h OR Levofloxacin 500 mg OD IV
Cefotaxime 2 gm q8h PLUS
PLUS Linezolid 600 mg BID OR
Vancomycin 15-20 mg/kg BID Clindamycin 600-900 mg q8-12h
Vertebral One of the following Piperacillin/tazobactam 4.5 gm q6h
ostemyelitis Ceftriaxone 2 gm q24h OR PLUS
Cefipime 2 gm q8h OR Linezolid 600 mg IV BID
Ciprofloxacin 400 mg BID OR
Levofloxacin 500 mg OD IV
PLUS
Vancomycin 15-20 mg/kg q8-12h
Candida Fluconazole 400 mg IV/PO OD OR Amphotercin B 3-5 mg/kg daily for
Caspofungin 70 mg loading dose then 50 at least 2 weeks
mg daily for 2 weeks followed by followed by
Fluconazole 400 mg IV/PO OD Fluconazole 400 mg IV/PO OD
Duration: 6-12 months
Surgical debridment is necessary, hardware should be removed
Prosthetic joint Empirical therapy is not recommended before obtaining culture results
infection
Osteomyelitis with One of the following One of the following
contiguous focus of Ceftazidime 1-2 gm q8-12h OR Ceftazidime 1-2 gm q8-12h OR
infection Cefipime 2 gm q12h Cefipime 2 gm q12h
PLUS PLUS
Vancomycin 15-20 mg/kg BID Linezolid 600 mg PO/IV BID
Chronic If acute exacerbation, treat as acute hematogenous Osteomyelitis
osteomyelitis Surgical debridement is critical
Oral and parenteral therapy are equally effective.
Optimum duration is unknown
Consider intermittent therapy or chronic suppressive therapy for relapses, if
surgical debridement is not successful
Sternal Vancomycin 15-20 mg/kg BID Linezolid 600 mg PO/IV BID OR
Cefazolin 2 gm IV q8h (confirmed
MSSA)
Spinal implant Empiric therapy is not recommended, cultures must be obtained first
associated
osteomyelitis

Early onset: within 30 days of hardware implantation
MSSA/MSSE Cefazolin 2 gm IV q8h PLUS
Rifampicin 300 mg PO BID
for 2 weeks followed by:
Ciprofloxacin 750 mg PO BID OR
Levofloxacin 750 mg po od
PLUS
Rifampin 300 mg PO BID * 10 weeks
MRSA/MRSE Vancomycin 15-20 mg/kg q8-12h PLUS
Rifampicin 300 mg PO BID
Levofloxacin 750 mg PO OD PLUS
Rifampin 300 mg PO BID * 10 weeks
Streptococci Ceftriaxone 2 gm IV q24h *2 weeks followed by:
Ampicillin 2 gm PO BID* 10 weeks
Enterococcus Ampicillin 2 gm IV q4h
Followed by
Amoxicillin 2 gm PO BID*10 weeks
Pseudomonas Cefipime 2 gm IV q12h OR
aeruginosa Meropenem 1 gm IV q8h
PLUS
Tobramycin 5.1 mg/kg OD IV
Levofloxacin 750 mg po od
Late onset, debrided and hardware removed: same regimens as above for a total duration of 6-8
weeks
Late onset, hardware retained: same regimens except continue oral suppressive therapy until there is
bony fusion and hardware can be removed.
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Addressograph
PIN:
NAME: Antibiotic order: Pancreatitis
AGE:
GENDER:
Clinical condition Primary regimen Alternative regimen

Acute alcoholic No antibiotics required
pancreatitis without
evidence of tissue
necrosis
Infected pancreatic Imipenem/cilastatin 0.5-1 gm IV One of the following
necrosis Q6H OR Ciprofloxacin 400 mg IV q12h OR
Meropenem 1 gm IV Q8H OR Levofloxacin 750 mh IV OD
Moxifloxacin 400 mg IV Q24H PLUS
Metronidazole
Post necrotizing Piperacillin/tazobactam 3.375 gm IV Q6H OR
pancreatitis infected Moxifloxacin 400 mg IV Q24H
pseudocyst or
pancreatic abscess
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Addressograph
PIN:
NAME: Antibiotic order: Peritonitis
AGE:
GENDER:
Spontaneous Bacterial Peritonitis" Primary"

Treatment of Cefotaxime 2gm Q8H (Q4H if life threatening)
Community-acquired Piperacillin/tazobactam 3.375 gm IV Q6H (or 4-hour infusion of 3.375 gm
with low-risk of MDR Q8H)
GNB and or Ceftriaxone 2 gm IV Q24H
vancomycin resistant Beta lactam allergy:
enterococci: Ciprofloxacin 400 mg IV Q12H
IV albumin: 1.5 gm/kg at diagnosis and 1 gm/kg on day 3 to decrease
frequency of renal impairment
Prophylaxis or Indications of antibiotic prophylaxis:
secondary prevention
1- Patients with cirrhosis and gastrointestinal bleeding.
in chronic ascites
2- Patients who have had one or more episodes of SBP.
Norfloxacin 400 mg PO OD OR
Ciprofloxacin 500 mg PO OD
Nosocomial with Meropenem 1 gm Q8H
associated high risk of PLUS
infection due to MDR Daptomycin 6mg/kg Q24H (If VRE 8-12 mg/kg Q24H)
GNBs or vancomycin IV albumin: 1.5 gm/kg at diagnosis and 1 gm/kg on day 3 to decrease frequency
resistant enterococci of renal impairment
Secondary Peritonitis: rupture, perforation, abscess
Mild/moderate Primary Regimen Secondary Regimen
Peritonitis Piperacillin/tazobactam 3.375 gm IV Ciprofloxacin 400 mg IV q12h OR
Q6H (or 4-hour infusion of 3.375 gm Levofloxacin 750 mg IV q24h
Q8H) PLUS
Metronidazole 1 gm IV q12h
Severe disease (diffuse Meropenem 1 gm Q8H OR Ciprofloxacin 400 mg IV q8h OR
peritonitis or septic Imipenem 500 mg q6h Levofloxacin 750 mg IV q24h
shock), patient in ICU PLUS
Metronidazole 1 gm IV q12h
CAPD associated Peritonitis
 Initiate antibiotics after collection of peritoneal fluid and blood for culture.
 Can treat by IP route or systemic IV therapy, but guidelines favor IP therapy.
 Intraperitoneal therapy, can be either continuous (drugs in each exchange) or intermittent (once
daily)
 Start with continuous therapy (drug in all dialysis bags) until culture results available.
 If specific therapy with beta lactam: continuous therapy, if with aminoglycoide: intermittent
therapy.
 If intermittent, need antibiotic containing dialysis fluid to dwell for minimum 6 hours.
 Vancomycin, cephalosporines and aminoglycosides can be combines in the same bag, penicillins

and aminoglycosides cannot be combined.
Possible gram-positive Cefazolin

infection Vancomycin
Possible gram-negative Cefepime
infections Ceftazidime
Gentamicin
Drug Intermittent (one exchange) Continuous (all exchanges)
Amikacin 2 mg/kg daily LD: 25 mg/l
MD:12 mg/l
Gentamicin 0.6 mg/kg daily LD: 8 mg/l
MD: 4 mg/l
Cefazolin 15-20 mg/kg daily LD: 500 mg/l
MD: 125 mg/l
Ceftazidime 1 to 1.5 grams in one exchange per day LD: 500 mg/L dialysate
MD:125 mg/L dialysate
Cefipime 1 gm daily LD: 250-500 mg/l
MD: 100-125 mg/l
Vancomycin 15-30 mg/kg every 5-7 days LD: 30 mg/kg
Supplemental doses may be needed for MD: 1.5 mg/kg/bag
automated peritoneal dialysis patients.
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Addressograph
PIN:
NAME: Antibiotic order: Skin and soft tissues infection
AGE:
GENDER:
Therapy for Non-Purulent Skin and Soft Tissue Infections

(Cellulitis/Erysipelas)
Mild Cephalexin 500mg PO q6h (if non-immediate-type or non-
No systemic signs of infections severe hypersensitivity reaction to penicillin) OR
Clindamycin PO 300-450 mg q6hr (if immediate-type or
severe hypersensitivity reaction to beta-lactam
Moderate Penicillin G 2-4 million units IV q4-6h OR
SIRS
Cefazolin 1g IV q8h (if non-immediate-type or non-severe
1-Temperature >38°C,
hypersensitivity reaction to penicillin) OR
2-Heart rate >90 beats per minute
3-Respiratory rate >24 breaths/min Clindamycin 600mg IV q8h (if immediate-type or severe
4-WBC> 12000 or< 4000 hypersensitivity reaction to beta-lactam)
Ceftriaxone 1-2 gm q24h
Severe Vancomycin IV 15mg/kg q12hr PLUS
 Skin sloughing or hypotension
Piperacillin-tazobactam IV 4.5g q6-8hr OR
 Failed antibiotic therapy
 Immunocompromise Imipenem-cilastatin IV 500mg q6hr OR
 Hemodynamic instability or deep Meropenem IV 1000 mg q8hr
infection
 SIRS
 Signs of organ dysfunction
Patient must undergo immediate
evaluation to exclude necrotizing
fascitis
Necrotizing fasciitis
Distinguishing between necrotizing fasciitis and cellulitis may be difficult but the following
symptoms suggest deep tissue involvement:
1- Severe pain 2- Wooden hard feel of subcutaneous tissues 3- Crepitus 4- Bullous lesions
5- Skin necrosis or ecchymosis 6- Dis-orientation, fever and lethargy
Management
1- Immediate surgical excision, perform culture on the tissue extracted from the surgery
2- Blood culture
3- Start empiric antibiotics same as in severe cellulitis
4-If the culture shows streptococcus pyogenes add penicillin and clindamycin.
Therapy for Purulent Skin and Soft Tissue Infections (Furuncle/Carbuncle/Abscess)
Mild Incision and drainage only
No signs of systemic infections
Moderate Incision and drainage with:

Trimethoprim-sulfamethoxazole PO160/800 mg [DS] q12h
Doxycycline PO 100mg q12h
Severe (any one of the following) Send cultures
1-Failed incision and drainage and oral Vancomycin IV 15mg/kg q12h OR
antibiotics Linezoild PO 600mg q12hr
2-Systemic signs of infection
3-Immunocompromise
4-Hemodynamic instability or deep
infection
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Addressograph
PIN:
NAME: Antibiotic order: Urinary Tract Infections
AGE:
GENDER:
I- Non-catheter associated UTI

Asymptomatic Bacteriuria
Clinical findings Empiric regimen
 Positive urine Remove catheter
culture (≥ 100,000 No antibiotics unless the patient is:
cfu/mL) AND no 1-Scheduled for urologic procedure
sign or symptoms SMX/TMP 1 DS tablet PO Q12H OR
 Obtaining routine Ciprofloxacin 500 mg PO BID OR
cultures in Levofloxacin 750 mg q24h
asymptomatic 2-Pregnant
patients is NOT Amoxicillin 500 mg PO Q12H for 3 to 7 days OR
recommended Cephalexin 500 mg PO Q12H for 3 to 7 days OR
Nitrofurantoin 100 mg PO Q12H for 5 days “ avoid from 38 weeks”
Acute cystitis in adult female without signs or symptoms of upper urinary tract
infections
Urine culture should be Primary regimen Alternative regimen
performed
TMP/SMX double strength 1 tab BID In case of allergy or
ONLY IF: -
for 3 days OR contraindications:
 History of multiple
Nitrofurantoin 100 mg orally BID for 5 Ciprofloxacin 250 mg PO
UTIs OR MDRO
days (Not in patients with CrCl <50 Q12H for 3 days OR
infection(s)
ml/min) Cephalexin 500 mg PO Q12H
for 3 days
Amoxicillin/clavulanate PO 1
gm BID
Acute cystitis in adult male
Primary regimen Alternative regimen
TMP/SMX double strength 1-tab BID Amoxicillin/clavulanate PO 1
for 7 days OR gm BID OR
Ciprofloxacin 750 mg PO Q12H for 7 Cefdinir 300 mg BID for 7
days OR days
Levofloxacin 750 mg PO q24h for 7
days OR
Nitrofurantoin 100 mg orally BID for 7
days
Acute pyelonephritis Primary regimen Alternative regimen
Women age 18-40 years, Patients at LOW-RISK for resistant Patients at LOW-RISK for
Temp> 102 F, definite bacteria: resistant bacteria:
costovertebral tenderness
Ciprofloxacin 500 mg PO Q12H for 5- Gentamicin 5 mg/kg q24h
Obtain urine and blood
7 days or 400 mg IV BID

cultures Levofloxacin 750 mg PO or IV q24h Patients at HIGH-RISK for
for 5-7 days resistant bacteria:
Ceftriaxone 1 gm IV OD for 10 days. Piperacillin-tazobactam 3.375
Patients at HIGH-RISK for resistant gm IV q6h
bacteria: Cefipime 2 gm IV q12h
Ertapenem 1 gm IV q24h
Patients at HIGH-RISK for resistant
bacteria and critical illness:
Ciprofloxacin 400 mg BID
PLUS
Ceftriaoxne 2 gm IV OD
II- Complicated or Catheter-associated UTI
Complicated: Primary regimen Alternative regimen
obstruction, reflux, Ciprofloxacin 500 mg PO Q12H for 7 TMP/SMX double strength 1-
azotemia, transplant days or 400 mg IV BID OR tab BID OR
Levofloxacin 750 mg PO or IV q24h Nitrofurantoin 100 mg orally
for 7 days BID
If high risk for multidrug
resistant organisms
Cefepime 2 gm IV q12h OR
Piperacillin-tazobactam 3.375
gm IV Q6H
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XII- Antimicrobial Guidelines for Hospital-Acquired Infections
Addressograph
PIN:
NAME: Antibiotic order: Sepsis
AGE:
GENDER:
Treatment duration from 7-10 days

qSofa score Respiratory rate ≥22/min
used in non-ICU Altered mentation
setting Systolic blood pressure ≤100 mm Hg
At least 2 points indicates sepsis
SOFA score Lung: Respiration Cardiovascular: Blood pressure Liver: Bilirubin
Sequential Organ PaO2/FIO2> Hypotension absent (0 point) <1.2 (0 points)
failure Assessment 400 (0 points) Mean arterial pressure <70 (1 1.2-1.9 (1 point)
severity PaO2/FIO2: point) 2-5.9 (2 points)
Sepsis: An acute 301-400 (1 point) On dopamine≤5 or dobutamine at 6-11.9 (3 points)
increase of ≥ 2 SOFA PaO2/FIO2 any dose administered for at least 1 >12 (4 points)
≤300 (2 points) hour (2 points) Kidney: renal
PaO2/FIO2:  On dopamine>5, or function
101-200 (3 points) Norepinephrine ≤ 0.1 (3 points) Creatinine <1.2
PaO2/FIO2≤100 On dopamine > 15 or (0 points)
(4 points) Norepinephrine> 0.1 (4 points) 1.2-1.9 (1 point)
Coagulation: Glascow Coma Scale: 2-3.4 (2 points)
Platelets 15 (o point) 3.5-4.9 (3 points)
> 150 (0 point) 13-14 (1 point) >5 (4 points)
101-150 (1 10-12 (2 points)
point) 6-9 (3 points)
51-100 (2 <6 (4 points)
points)
21-50 (3 points)
≤20 (4 points)
Empiric antibiotic Imipenem 0.5 gm q6h IV+ Vancomycin 1 gm q12h OR
therapy when source Meropenem 1 gm q8h IV+ Vancomycin 1 gm q12h
is not clear
If low prevalence of ESBL and/ or carbapenemase producing aerobic
gram-negative bacteria:
Piperacillin/tazobactam 4.5 gm q6h IV+ Vancomycin 1 gm q12h
Suspect biliary source Piperacillin/tazobactam 4.5 gm IV loading dose over 20 minutes and then
starting 4 hours later 4-hr infusion of 3.375 gm q8h OR
Ceftriaxone 2 gm IV q12h+ metronidazole 1 gm LD then 0.5 gm q6h
Suspect community Levofloxacin 750 mg IV q24h or moxifloxacin 400 mg IV q24h+
acquired pneumonia Piperacillin/tazobactam 4.5 gm IV loading dose over 20 minutes and then
source: starting 4 hours later 4-hr infusion of 3.375 gm q8h+ vancomycin 1 gm IV q12h

Septic shock
Meets sepsis definition plus need for vasopressor therapy to maintain MAP at >65 mm Hg, lactate > 18
mg/dl
Suspected MRSA Vancomycin 25 mg/kg loading dose then 15-20 mg/kg q8-12h IV
Suspected ESBL Meropenem 2 gm IV q8h or
producing GNB Imipenem 500 mg q6h
Suspected Carbapenem Colistin for urinary tract source: loading dose 300 mg CBA followed by 150
resistant GNB mg CBA BID
Suspected Ceftazidime 2 gm q8h IV OR
Pseudomonas Meropenem 2 gm q8h IV OR
aureginosa Piperacillin/tazobactam 4.5 gm q6h IV
Polymicrobial Aerobic- Ceftriaxone 2 gm IV q24h+ metronidazole 500 mg IV q8h OR
anerobic infection Meropenem 2 gm IV q8h
Unknown source Vancomycin+ piperacillin-tazobactam (<15%MDR prevalence) OR
Vancomycin+ meropenem (>15%MDR prevalence)
Physician notes:
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Addressograph
PIN:
NAME: Antibiotic order: Aspiration Pneumonia
AGE:
GENDER:
Primary regimens Parenteral regimens:

Ceftriaxone 1 gm q24h+Metronidazole 500 mg IV q6h
Clindamycin 300-450 mg TID
Moxifloxacin 400 mg OD
Piperacillin-tazobactam 4.5 gm q6h
Oral regimens:
Amoxicillin-clavulanate 1 gm BID
Moxifloxacin 400 mg q24h
 Can switch to oral therapy once patient has responded clinically

 Duration of therapy: 7-10 days in patients without empyema or lung
abscess
 4-6 weeks for empyema or lung abscess until resolution of the abscess as
shown in X- ray
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Addressograph
PIN: Antibiotic order: Ventilator-associated
NAME:
AGE: Pneumonia
GENDER:
No MDR risk factors Piperacillin- tazobactam 4.5gm IV /8 hours OR

Cefepime 2gm IV /8 hours OR
Levofloxacin 750mg IV / 24 hours OR
 Imipenem 500 mg IV /6 hours OR
 Meropenem 1 gm IV /8 hours
Risk factors for MRSA only Piperacillin- tazobactam 4.5gm IV /8 hours OR
VAP MRSA prevalence > 10-20
 Ceftazidime 2 gm IV /8 hours OR
% or unknown
PLUS
Vancomycin 15 mg/ kg IV / 8 to 12 hours OR
Linezolid 600 mg IV /12 hours
Risk factors for MDR pathogens One of the following:
Piperacillin- tazobactam 4.5gm IV /8 hour OR
IV antibiotic use within the
previous 90 days
Septic shock at the time of VAP
ARDS preceding VAP
≥5 days of hospitalization prior
PLUS one of the following:
to the occurrence of VAP
Amikacin 15 to 20 mg/kg IV daily OR
Acute renal replacement therapy
 Gentamycin 5 to 7 mg /kg IV daily OR
prior to VAP onset
Ciprofloxacin 400 mg IV 8 hours
PLUS one of the following:
Vancomycin 15 mg/ kg IV / 8 to 12 hours OR
 Linezolid 600 mg IV /12 hours
Risk factors for gram negative One of the following:
bacilli Piperacillin- tazobactam 4.5gm IV /8 hours OR
Pseudomonas resistance> 10% to
an agent considered monotherapy
Bronchiectasis or cystic fibrosis
Sputum culture with numerous PLUS One of the following:
and predominant gram-negative Amikacin 15to 20 mg/kg IV daily OR
bacilli  Gentamycin 5 to 7 mg /kg IV daily OR
VAP prevention 1- Improve use of sedation and reduce the length of
mechanical ventilation as daily interruption of sedation
and spontaneous breathing trials
2- Minimize pooling of secretions above endotracheal tube

cuff.
3- Elevate head of bed 30-45 degrees
4- Maintain ventilator circuit
Physician notes:
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Addressograph
PIN:
NAME: Antibiotic order: Hospital-Acquired Pneumonia
AGE:
GENDER:
No MDR risk factors or One of the following:

increased mortality Piperacillin- tazobactam 4.5gm IV /8 hours
Cefepime 2gm IV /8 hours
Levofloxacin 750mg IV / 24 hours
Risk factors for MDR gram- One of the following:
negative bacilli only Piperacillin- tazobactam 4.5gm IV /8 hours
Bronchiectasis or cystic fibrosis
 Ceftazidime 2 gm IV /8 hours
Sputum culture with numerous  Imipenem 500 mg IV /6 hours
and predominant gram-negative  Meropenem 1 gm IV /8 hours
bacilli PLUS One of the following:
Amikacin 15to 20 mg/kg IV daily
Pseudomonas resistance> 10%  Gentamycin 5 to 7 mg /kg IV daily
to an agent considered Levofloxacin 750mg IV / 24 hours
monotherapy or unknown Ciprofloxacin 400 mg IV 8 hours
Risk factors for MRSA: One of the following:
Piperacillin- tazobactam 4.5gm IV /8 hours
HAP MRSA prevelance> 20 %
or unknown
 Imipenem 500 mg IV /6 hours
PLUS One of the following:
Vancomycin 15 mg/ kg IV / 8 to 12 hours
Linezolid 600 mg IV /12 hours
Risk factors for MDR gram- One of the following:
negative bacilli and MRSA or Piperacillin- tazobactam 4.5gm IV /8 hour
for increased mortality Cefepime 2gm IV /8 hours
Ventilatory support for HAP
Septic shock
IV antibiotics within the past 90
days
Amikacin 15 to 20 mg/kg IV daily
 Gentamycin 5 to 7 mg /kg IV daily
Levofloxacin 750mg IV / 24 hours
Vancomycin 15 mg/ kg IV / 8 to 12 hours
 Linezolid 600 mg IV /12 hours

Physician notes:
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Addressograph
PIN: Antibiotic order: Catheter Related Blood Stream
NAME:
AGE: Infection
GENDER:
CRBSI due to gram- Vancomycin 15-20 mg/kg q8-12h

positive organisms Linezolid is not appropriate agent
CRBSI due to gram- In patients with neutropenia or severe burns
negative bacilli Piperacillin- tazobactam 4.5gm IV /8 hours
In patients with hemodynamic instability and in areas with high resistance
pattern add aminoglycoside or ciprofloxacin
In absence of neutropenia, severe burns or hemodynamic instability:
Ceftriaxone 2 gm IV OD
Catheter management Catheter removal is warranted in the following conditions:
strategy
Sepsis
Hemodynamic instability
Endocarditis or evidence of metastatic infection
Suppurative thrombophlebitis
Propagating clot
Bacteremia after 72 hours of appropriate antimicrobial therapy
Subcutaneously tunneled central venous catheter tunnel tract infection
Infection with: staph.aureus, P.aeruginosa, drug-resistant gram-negative
bacilli, candida
Catheter salvage:
Antibiotic lock therapy+ systemic antimicrobials:
Instillation of concentrated antibiotic solution in the catheter lumen
Criteria for use in patients who:
Have a long-term intravascular device (>14 days), including tunneled
catheters and implanted ports
Are clinically and hemodynamically stable
Have infections caused by coagulase-negative staphylococci, gram-negative
rods, or vancomycin-sensitive enterococci

Antimicrobial Pathogen Preferred antibiotic Alternative antibiotic
treatment of
intravascular Staphylococci
catheter-related
Methicillin susceptible Cefazolin 2 gm IV Vancomycin 1gm IV
bloodstream infection
q8h. q 12h
(CRBSI) according to
the pathogen isolated Methicillin resistant Vancomycin 1gm IV Daptomycin 6 mg/kg
q 12h IV q24h
Enterococci
Ampicillin susceptible Ampicillin 2 gm IV Vancomycin
q4h
Ampicillin resistant, Vancomycin 1gm IV Daptomycin 6 mg/kg
vancomycin susceptible q 12h IV q24h
Ampicillin resistant, Daptomycin Linezolid 600 mg

vancomycin resistant BID
Enterobacteriaceae (examples include E. coli, Klebsiella spp, Enterobacter

spp)
ESBL negative Ceftriaxone Ciprofloxacin
ESBL positive Carbapenem Ciprofloxacin
Pseudomonas species Ceftazidime Carbapenem
Combination therapy is Cefepime Ciprofloxacin
warranted for patients Piperacillin-
with sepsis, tazobactam
neutropenia, or severe
burns. In such cases, an
aminoglycoside may be
also administered.

Patient requiring Long Caspofungin 70 mg
term alimentation, or IV on day 1, then 50 mg
high risk for Candida q24h
sp. Infection (Remove
Catheter)
Physician notes:
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Addressograph
PIN: Antibiotic order: Central Line Associated Blood
NAME:
AGE: Stream Infection (CLABSI)
GENDER:
IV Line Infection, Non-Tunneled Catheters

Clinical setting Primary regimens
Staph aureus MSSA or MRSA
Evidence of infected IV
line with: Remove catheter
Peripheral capped Vancomycin 15-20 mg/kg q8-12 h
needle with heparin lock. Minimum duration is 2 weeks
Midline catheter. Staph epidermidis
Internal jugular or Save the catheter
subclavian catheter Vancomycin 15-20 mg/kg q8-12 h *10-14 days with catheter lock technique.
Femoral vein catheter
Peripherally inserted If IV line with multiple lumens, it is recommended that blood cultures be
central catheter obtained through each channel
IV Line Infection, Tunneled Catheters

Empiric therapy Non-neutropenic and not a burn patient
Vancomycin 15-20 mg/kg q8-12 h
Neutropenic or burn patient
Vancomycin 15-20 mg/kg q8-12 h PLUS
Piperacillin- tazobactam 4.5gm IV /8 hours
Specific therapy Staph aureus in blood or subcutaneous tunnel is infected, remove the line.
Positive blood and/or Staph aureus or staph epidermidis
catheter culture Vancomycin 15-20 mg/kg q8-12 h
Lactobacillus use:
Penicillin G, Ampicillin or Clindamycin
Physician notes:
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Addressograph
PIN: Antibiotic order: Hospital Acquired Intra-
NAME:
AGE: abdominal infections
GENDER:
Risk factors that warrant broad empiric antimicrobial coverage for intra-abdominal infections
Factors associated with mortality
 Age >70 years
 Medical comorbidity
 Immunocompromising condition
 High severity of illness (ie, sepsis)
 Extensive peritoneal involvement or diffuse peritonitis
 Delay in initial intervention (source control) >24 hours
 Inability to achieve adequate debridement or drainage control
Factors associated with infection with antibiotic-resistant bacteria
 Healthcare-acquired infection
 Travel to areas with higher rates of antibiotic-resistant organisms* within the few weeks prior to
infection onset or if antibiotics were received during travel
 Known colonization with antibiotic-resistant organisms
Single Agent Regimen
Piperacillin- tazobactam 4.5gm IV /8 hour
Combination regimen
 Cefepime 2 gm IV q8h
 Ceftazidime 2gm IV q8h
PLUS:
 Metronidazole 500mg IV or PO q8h
PLUS (to provide enterococcal coverage, particularly in those with
postoperative infection, immunocompromising condition, valvular heart
disease, or prosthetic intravascular materials)
Ampicillin 2 g IV q4h
Vancomycin 15 to 20 mg/kg IV every q8-12h
Physician notes:
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Addressograph
PIN:
NAME: Antibiotic order: Clostridium-difficile Infections
AGE:
GENDER:
• Stop antibiotics that are no longer indicated, especially broad-‐spectrum antibiotics (fluoroquinolones,
clindamycin, piperacillin-‐tazobactam, cephalosporins) as they increase the risk for CDI
• Stop use of any anti‐diarrheal/ant peristaltic agents
• Consider discontinuation of proton pump inhibitors (PPIs)
• If high clinical suspicion of CDI: initiate antibiotic therapy before laboratory confirmation
RISK FACTORS FOR CDI
 ≥ 65 years of age
 Exposure to antibiotics in previous 90 days
 Hospitalization in previous 30 days
 Recent GI surgery
Antimicrobial agents that may induce Clostridioides
Frequently associated Occasionally associated Rarely associated
Fluroquinolone Macrolides Aminoglycosides
Clindamycin Trimethoprim/sulphamethoxazole Metronidazole
Cephalosporine (broad spectrum) Vancomycin
Penicillin (broad spectrum) Tetracycline
Clinical definition Treatment
Initial infection
Non severe disease  Vancomycin 125 mg orally 4 times daily for 10 days, OR
WBC<15,000 cells/mL  Metronidazole 500 mg orally 3 times daily for 10 days¶
Serum creatinine <1.5

mg/dL
Severe disease Vancomycin 125 mg orally 4 times daily for 10 days
WBC ≥15,000 cells/mL
Serum creatinine ≥1.5
mg/dl
Fulminant disease Vancomycin 500 mg orally or via nasogastric tube 4 times daily, AND
Hypotension or shock, Metronidazole 500 mg intravenously every 8 hours
Ileus,
Toxic megacolon If ileus is present,
ICU admission Rectal vancomycin may be administered as a retention enema (500 mg in
WBC> 35000 OR <2000 100 mL normal saline per rectum; retained for as long as possible and
readministered every 6 hours)

Recurrent infection
First recurrence (non- If vancomycin was used for the initial episode:
severe and severe
Vancomycin pulsed-tapered regimen:
disease)
o 125 mg orally 4 times daily for 10 to 14 days, then
o 125 mg orally 3 times daily for 7 days, then
o 125 mg orally twice daily for 7 days then
o 125 mg orally once daily for 7 days then
o 125 mg orally every 2 or 3 days for 7 days
If metronidazole was used for the initial episode:
Vancomycin 125 mg orally 4 times daily for 10 days
Second or subsequent Vancomycin pulsed-tapered regimen (outlined above)
recurrence (non-severe
Vancomycin followed by rifaximin:
and severe disease)
 Vancomycin 125 mg orally 4 times per day for 10 days, then
 Rifaximin 400 mg 3 times daily for 20 days
Physician notes:
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Addressograph
PIN: Antibiotic order: Post-operative wound
NAME:
AGE: infections
GENDER:
Management
 Fever in the first 48 hours and up to 4 days, unlikely to represent wound infection.
No systemic illness Systemic illness
No wound infection, observe. Wound drainage or marked local signs of inflammation
Yes No
Gram stain to rule out streptococci and Seek other sources of
clostridia fever
None Either found
Seek other Open wound, debride,
sources of start penicillin and
fever clindamycin
 Fever > 4 days after operation.

Erythema and/or induration open wound
1- Erythema > 5 cm from incision with induration 1- Erythema < 5 cm from the edge of the wound
or any necrosis 2- Temp< 38.5°
2- Temp> 38.5° 3- WBC< 12000 cells/mm³
3- WBC> 12000 cells/mm³
4- Heart rate> 110 beats/minute
Start antibiotics and dressing changes. Dressing changes, no antibiotics
 Suture removal plus incision and drainage

Causative organisms: During the first 48 hours Strept. Pyogenes or clostridium
species.
Clean operations: (head, neck, trunk and extremities)
Causative organism: Staph. Aureus is the Cefazolin 1 gm IV Q8H
most common cause. Risk factors for MRSA:
Risk factors for MRSA: 1. Vancomycin 15-20 mg/kg/dose IV
MRSA colonization, prior MRSA infection, 2. Linezolid 600 mg BID
recent hospitalization, recent antibiotics.
Surgery in axilla, gastrointestinal tract, perineum or female genital tract
Causative organism: 1- Fluroquinolone with metronidazole
Gm negative bacteria or anaerobes 2- Cephalosporine with metronidazole
3- Carbapenem

Addressograph
PIN: Antibiotic order: Potentially infected wounds
NAME:
AGE: Orthopedics
GENDER:
Type Antibiotic Duration

Open fracture: Cefazolin or cefuroxime 24 hours
G type 1
Open fracture: Cefazolin OR 24 hours after wound closure
G type 2 Piperacillin/Tazobactam
PLUS,
Tobramycin
Open fractures: Cefazolin OR 3 days after wound closure
G type 3 Piperacillin/Tazobactam PLUS
Tobramycin
Risk for anaerobes (ex: farm Add penicillin OR clindamycin OR metronidazole
injuries, severe tissue necrosis)
Tetanus toxoid or tetanus immunoglobulin should be considered according to immunization history of
the patient.
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XIII- Surgical Antibiotics Prophylaxis Guidelines
 Pre-operative antibiotics should be infused within 60 minutes prior to first incision (except vancomycin
and fluoroquinolones should be infused within 120 minutes prior to first incision to prevent RED
MAN Syndrome in vancomycin).
 Patients undergoing Cardiothoracic and spinal surgery should be screened for MRSA nasal carriage
preoperatively, if positive use nasal mupirocin ointment at the evening before, day of surgery and bid
x 5 days post-op, with (2 or 4%) chlorhexidine body wash the night before the surgery and daily
after for 5 days.
 The use of antimicrobial agents for dirty procedure or established infection is classified as treatment of
presumed infection, not prophylaxis. It is excluded from this guideline.
 New recommendations for a shortened post-operative course of antimicrobials involving either a
single dose or continuation for less than 24 hours from surgery end time regardless of the presence
of indwelling catheters, drains or prothesis.
CDC Classification of Surgical site Infections (SSIs)
1. Clean: An uninfected operative wound in which no inflammation is encountered and the respiratory,
alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily
closed and, if necessary, drained with closed drainage. Operative incisional wounds that follow non
penetrating (blunt) trauma should be included in this category if they meet the criteria.
2. Clean-Contaminated: Operative wounds in which the respiratory, alimentary, genital, or urinary tracts
are entered under controlled conditions and without unusual contamination. Specifically, operations
involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no
evidence of infection or major break in technique is encountered.
3. Contaminated: Open, fresh, accidental wounds. In addition, operations with major breaks in sterile
technique (e.g., open cardiac massage) or gross spillage from the gastrointestinal tract, and incisions in
which acute, no purulent inflammation is encountered including necrotic tissue without evidence of
purulent drainage (e.g., dry gangrene) are included in this category
Surgical Site Prevention Bundle
1. The appropriate prophylactic antibiotic was administered within 60 minutes before the operation and
discontinued after surgery.
 Re-dosing of antibiotics may be required during:
 Prolonged surgery (more than two half-lives of the antibiotic used)
 Procedures in which there is significant blood loss (more than 1.5 L) to maintain therapeutic levels
preoperatively.
Antimicrobial Recommended re-dosing interval Antimicrobial Recommended re-dosing interval
from initiation of pre-operative from initiation of pre-operative
dose dose
Cefazolin 4 hours Clindamycin 6 hours
Cefuroxime 4 hours Levofloxacin NA
Ciprofloxacin NA Metronidazole NA
Vancomycin NA Gentamicin NA
2. 2% chlorhexidine gluconate in 70% isopropyl alcohol solution was used for skin preparation. Povidone
iodine was used for skin preparation (povidone iodine was used if patient sensitive or for head and neck
surgeries)
3. The patient’s temperature was maintained above 36°C in the preoperative period (excludes cardiac
surgery)
4. The known diabetic patient’s glucose level was kept < 11 mmol/l throughout the operation.

Surgical Antibiotics Prophylaxis Guideline
Type of Surgery Preferred regimen Alternative
Orthopedic
1. Clean operations 1- Cefazolin 1. Vancomycin 1 g IV stat
involving head, knee or  2 g IV stat (weight<120 kg)  Children dose:15 mg/kg IV
foot and not involving  3 g IV stat for weight > 120kg) 2. Clindamycin: 900 mg
implantation of foreign  Repeat dose 4 hours after the  Children clindamycin dose:
materials first dose if still in surgery. 10 mg/kg
2. Spinal procedures with  Children dose: Cefazolin
and without 30mg/kg) IV single dose
instrumentation 2- Cefuroxime 1.5 gm
3. Joint replacement &  Children dose: 50 mg/kg
limb amputation. 3- Cefazolin/cefuroxime plus
4. Total joint replacement vancomycin in MRSA colonization
General Surgery
1. Colorectal 1- Cefazolin 1- Metronidazole 500mg IV
Appendectomy  2 g IV stat (weight<120 kg)  Children dose:15mg/kg,
(uncomplicated)  3 g IV stat for weight > 120kg) IV single dose
 Repeat dose 4 hours after the PLUS
first dose if still in surgery. Gentamicin 4.5 mg/kg IV.
 Children dose: Cefazolin  Children dose 2.5mg/kg
30mg/kg) IV single dose
IV
PLUS
Metronidazole 500mg IV stat
 Children Metronidazole
dose:15mg/kg IV.
2- Cefuroxime
 1.5 gm
 Children dose: 50 mg/kg
For colorectal surgery:
In addition to systemic antibiotics and
mechanical bowel preparation (if no
contraindication), the following oral
antibiotic regimen is administered:
 Neomycin 1 g of PO PLUS
 Erythromycin base 1 g at 1 PM,
2 PM, and 11 PM,
OR
 Neomycin 2 g PO PLUS
 Metronidazole 2 g PO at 7 PM
and 11 PM the day before an 8
AM operation.

Hernia repair 1- Cefazolin 1- Vancomycin IV
 2 g IV stat (weight<120 kg)  15-20 mg/kg q8h (target
Laproscopic (elective, high  3 g IV stat for weight > 120kg) trough 15-20mg/ml) single
risk or cholecystectomy  Repeat dose 4 hours after the dose completely infused
bariatric surgery first dose if still in surgery. within 120 minutes before
 Children dose: Cefazolin incision
Whipple procedure
OR
PLUS
2- Clindamycin
Metronidazole
 500mg  900mg
 children dose:15mg/kg  Children dose: 10 mg/kg IV
 7.5mg/kg if body weight <1.2kg PLUS
IV single dose Ciprofloxacin
2- Cefuroxime 1.5 gm  400mg IV
 Children dose: 50 mg/kg  Children dose: 10 mg/kg
PLUS single dose completely
Metronidazole infused within 120 minutes
prior to first incision
Bariatric surgery
Gastroduodonal 1- Cefazolin 1- Clindamycin
 2 g IV stat (weight<120 kg)  900 mg
 3 g IV stat for weight > 120kg)  Children dose: 10mg/kg IV
 Repeat dose 4 hours after the PLUS
first dose if still in surgery.
Levofloxacin
 Children dose: Cefazolin
30mg/kg) IV single dose  500 mg IV
2- Cefuroxime 1.5 gm  Children dose: 10 mg/kg IV
Illeal involvement 1- Cefazolin 1- Metronidazole
 2 g IV stat (weight<120 kg)  500mg
 3 g IV stat for weight > 120kg)  children dose:15mg/kg
 Repeat dose 4 hours after the  7.5mg/kg if body weight
first dose if still in surgery. <1.2kg IV single dose
 Children dose: Cefazolin PLUS
30mg/kg) IV single dose Levofloxacin
PLUS  500 mg IV
Metronidazole  Children dose: 10 mg/kg IV
 500mg
 children dose:15mg/kg
 7.5mg/kg if body weight <1.2kg
IV single dose
2- Cefuroxime 1.5 gm
Children dose: 50 mg/kg
Cardiothoracic
1- Cefazolin 1- Vancomycin IV
 2 g IV stat (weight<120 kg)  15-20 mg/kg
 3 g IV stat for weight > 120kg)

 Repeat dose 4 hours after the target trough 15-20 mg/ml)
Ob/Gyn
1. Cesarean delivery 1- Cefazolin 1- Clindamycin
2. Vaginal or abdominal  2 g IV stat (weight<120 kg)  900mg IV
3. hysterectomy/other  3 g IV stat for weight > 120kg) PLUS
4. Obstetric procedure  Repeat dose 4 hours after the  Gentamicin 4.5 mg/kg
Children dose: 50 mg/kg
5. Abortion, surgical 1- Doxycycline 1- Vancomycin 1 g IV single dose
 100 mg orally one hour before completely infused 120 minutes
procedure and 200 mg orally prior to incision
after procedure 2- Metronidazole 500 mg orally
twice daily for five days.
Head / Neck
1- Cefazolin 1- Clindamycin
 2 g IV stat (weight<120 kg)  900mg IV stat
 3 g IV stat for weight > 120kg)  Children Clindamycin
 Repeat dose 4 hours after the dose:10mg/kg IV single
first dose if still in surgery. dose
 Children dose: Cefazolin PLUS
Gentamicin 4.5 mg/kg
 Children Gentamicin dose:
PLUS
2.5mg/kg.
Metronidazole 500 mg IV as a single
dose for clean-contaminated surgery
Neurosurgery
Elective craniotomy and 1-Cefazolin 1- Clindamycin 900mg IV stat
cerebrospinal fluid-shunting  2 g IV stat (weight<120 kg)  Children dose:10mg/kg IV
Procedures, Implantation of  3 g IV stat for weight > 120kg) single dose
intrathecal pumps  Repeat dose 4 hours after the 2- If MRSA colonization is
first dose if still in surgery. present:
 Children dose: Cefazolin  Vancomycin 1 g IV stat
 Children dose:15mg/kg IV
single dose completely
infused 120 minutes prior to
incision
Vascular
1-Cefazolin 1- Vancomycin
 2 g IV stat (weight<120 kg)  1 g IV stat
 3 g IV stat for weight > 120kg)  Children Vancomycin

 Repeat dose 4 hours after the dose:15 mg/kg IV single
first dose if still in surgery. dose completely infused
 Children dose: Cefazolin within 120 minutes prior to
30mg/kg) IV single dose incision
Genitourinary
Open or laparoscopic 1-Cefazolin 1-Ciprofloxacin
including percutaneous renal  2 g IV stat (weight<120 kg)
 3 g IV stat for weight > 120kg)  400mg
surgery
 Repeat dose 4 hours after the  Children dose:10mg/kg IV
first dose if still in surgery. single dose completely
 Children dose: Cefazolin infused 120 minutes prior to
30mg/kg) IV single dose OR incision
Cystoscopy with manipulation 1- Ciprofloxacin 1- Trimethoprim-
or upper tract instrumentation  500 mg orally sulfamethoxazole Once 160/800
 400 mg IV mg (double strength, DS) tablet
or Cystoscopy alone but with
orally
positive urine cultures or
preoperative catheter,
transrectal prostatic biopsy, or
placement of prosthetic
material
Plastic
Clean with risk factors or clean- 1- Clindamycin 900mg IV stat
contaminated
 Children dose:10mg/kg IV
1-Cefazolin single dose OR
 2 g IV stat (weight<120 kg)
 3 g IV stat for weight > 120kg) 2- Vancomycin 1 g IV stat
 Repeat dose 4 hours after the  Children dose: 15 mg/kg IV
30mg/kg) IV single dose OR
Ophthalmic
 Topical Moxifloxacin 1 drop  Cefazolin 1–2.5 mg
every 5–15 min for 5 doses at Intracameral
the end of procedure
 Cefazolin 100 mg by
subconjunctival injection

Dental management of patients with bacterial endocarditis
High risk patients: 1- Amoxicillin Penicillin allergic patients:
1. Prosthetic heart valves  2 gm PO 1 hour before 1- Clindamycin:
2. Any history of bacterial procedure  600 mg PO 1 hour before
endocarditis  Children dose: 50 mg/kg PO 1 procedure
3. Complex cyanotic hr before procedure  Children dose: 20 mg/kg
congenital heart disease within 30 minutes before
and surgically procedure
constructed systemic
2- Cephalexin
pulmonary shunts
3- Cephadroxil:
Moderate risk patients:
 2 gm PO 1 hour before
Congenital cardiac
procedure
malformations
1. Acquired valvular heart 4- Azithromycin
disease 5- Clarithromycin:
2. Mitral valve relapse with  500 mg PO 1 hour before
regurgitation procedure
3. Hypertrophic Patients unable to take oral
cardiomyopathy medications:
Negligible risk: 1- Ampicillin (skin test required):
1. Isolated ostium  2 gm IV/IM 30 min before
secundum ASD and procedure
surgically repaired ASD,  Children dose: 50 mg/kg IV
VSD and PDA or IM within 30 minutes
2. Mitral valve prolapse before procedure
without mitral
Patients unable to take oral
regurgitation and without
medications and are penicillin
thickened leaflets
3. Innocent or physiologic allergic:
murmurs 1- Clindamycin
4. Cardiac pacemakers and  600 mg IV 30 minutes
defibrillators before procedure
5. History of isolated  Children dose: 20 mg/kg IV
bypass surgery, history OR
of Kawasaki disease 2- Cefazolin
without valvular  1 gm 30 minutes before
dysfunction and history procedure
of rheumatic fever  Children dose: 25 mg/kg IM
without valvular or IV within 30 minutes
dysfunction
before procedure

3. References
3.1 Metlay, Joshua P., et al. "Diagnosis and treatment of adults with community-acquired pneumonia. An
official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of
America." American journal of respiratory and critical care medicine 200.7 (2019): e45-e67.
3.2 IDSA guidelines for ABRS. Clin Infect Dis 2012; 54(8): e72-e112
3.3 Surgical Infection Society (SIS): Revised guidelines on the management of intra-abdominal infection
(2017)
3.4 Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American
Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults.
Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72
3.5 Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-
associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and
the American Thoracic Society. Clin Infect Dis 2016; 63: e61. AXZZAwwa
3.6 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice
guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the
Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2): e10-52.
3.7 Hooton TM, Bradley SF, Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated
urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Disease
Society of America. CID 2010;50:625-63.
3.8 Fernandez-Hidalgo N, Almirante B, Gavalda J, et al. Ampicillin plus ceftriaxone is as effective as
ampicillin plus gentamicin for treating Enterococcus faecalis infective endocarditis. Clin Infect Dis 2013;
56:1261.
3.9 Clin Infect Dis.2014 Jul15:59(2): 147-59. Doi: 10.1093/cid/ciu296.Epub 2014 Jun 18.
3.10 Sanford guide to antimicrobial therapy 2019
3.11 Sarah M. Wieczorkiewicz, Carrie A. Sincak, (2016). The Pharmacist’s Guide to Antimicrobial Therapy
and Stewardship: American Society of Health-System Pharmacists (ASHP)
3.12 Kerry L. LaPlante, Melissa Gaitanis, Kerry L. LaPlante, Haley Morrill. 2016-2017 antimicrobial guide
3.13 Clin Gastroenteral Hepatol. 2013 Feb;11(2):123-30.e1.doi: 10. 1016/j.cgh.202.11.007.Epub 2012 NOV
22.
3.14 J Hepatol. 2014 Jun;60(6): 1310-24.doi:10.1016/j.jhep.2014.01.024.Epub 2014 Feb 12.
3.15 Bennett, N., Schulz, L., Boyd, S. and Newland, J.G., 2018. Understanding inpatient antimicrobial
stewardship metrics. The Bulletin of the American Society of Hospital Pharmacists, 75(4), pp.230-238.
3.16 Morris AM. Antimicrobial stewardship programs: appropriate measures and metrics to study their
impact. Current treatment options in infectious diseases. 2014 Jun 1;6(2):101-12.
3.17 https://asap.nebraskamed.com/wp-content/uploads/sites/3/2018/06/Antibiotic-Stewardship-Metrics-
How-Do-you-Measure-Up_Kuper.pdf.
3.18 https://www.whocc.no/atc_ddd_index/

3.19 National Antimicrobial Therapy Guidelines for Community and Hospital Acquired Infections in
Adults 2018
3.20 John S. Bradley, MD, John D. Nelson, MD. American Academy of Pediatrics. Nelson’s pediatric
antimicrobial therapy 2019
3.21 David N. Gilbert, M.D. Henry F. Chambers, M.D. George M. Eliopoulos, M.D. Michael S. Saag, M.D.
Andrew T. Pavia, M.D.Sanford Guide To Antimicrobial Therapy 2019
3.22 Sarah M. Wieczorkiewicz, Carrie A. Sincak, (2016). The Pharmacist’s Guide
to Antimicrobial Therapy and Stewardship: American Society of Health-System Pharmacists (ASHP)
3.23 Kerry L. LaPlante, Melissa Gaitanis, Kerry L. LaPlante, Haley Morrill. 2016-2017 antimicrobial guide
3.24 Sara E. Cosgrove, Edina Avdic, Kate Dzintars, Janessa Smith, Antibiotic Guidelines 2015-2016: Johns
Hopkins
3.25 Larry K. Golightly, Isaac Teitelbaum Tyree H. Kiser, Dimitriy A. Levin Gerard R. Barber, Michael A.
Jones, Nancy M. Stolpman, Katherine S. Lundin (2015). Renal Pharmacotherapy Dosage Adjustment of
Medications Eliminated by the Kidneys: Springer Science Business Media New York
3.26 Alexander A. Vinks, Hartmut Derendorf and Johan W.Mouton: Fundamentals of Antimicrobial
Pharmacokinetics and Pharmacodynamics (2014)
3.27 Extended infusion cefepime protocol 12/2018. Stanford Hospitals and clinics.
3.28 Emily mui: Stanford healthcare dosing guidelines 2017
3.29 Kerry L. LaPlante: Antimicrobial Guide 2016-2017.
3.30 Alexander A. Vinks, Hartmut Derendorf and Johan W.Mouton: Fundamentals of Antimicrobial
Pharmacokinetics and Pharmacodynamics (2014)
3.31 Moran, Gregory J., et al. "Acute bacterial skin infections: developments since the 2005 Infectious
Diseases Society of America (IDSA) guidelines." The Journal of emergency medicine 44.6 (2013): e397-
e412.
3.32 Lipsky, Benjamin A., et al. "Executive summary: 2012 Infectious Diseases Society of America clinical
practice guideline for the diagnosis and treatment of diabetic foot infections." Clinical Infectious Diseases
54.12 (2012): 1679-1684.
3.33 Respiratory Care August 2019, 64 (8) 962-979; DOI: https://doi.org/10.4187/respcare.07024
3.34 Vincent, JL., Bassetti, M., François, B. et al. Advances in antibiotic therapy in the critically ill. Crit
Care 20, 133 (2016). https://doi.org/10.1186/s13054-016-1285-6
3.35 Ammar MA, Abdalla W. Effect of extended infusion of meropenem and nebulized amikacin on Gram-
negative multidrug-resistant ventilator-associated pneumonia. Saudi J Anaesth 2018;12:89-94

3.36 Clin Microbiol Infect. 2010 Aug;16(8):1230-6. doi: 10.1111/j.1469-0691.2009.03040.x. Epub 2009
Sep 2.
3.37https://pch.health.wa.gov.au/~/media/Files/Hospitals/PCH/General%20documents/Health%20professio
nals/ChAMP%20Monographs/Amikacin%20Inhaled.pdf
3.38 Yagi, K., Ishii, M., Namkoong, H. et al. The efficacy, safety, and feasibility of inhaled amikacin for the
treatment of difficult-to-treat non-tuberculous mycobacterial lung diseases. BMC Infect Dis 17, 558 (2017).
https://doi.org/10.1186/s12879-017-2665-5
3.39 Ehrmann S, Chastre J, Diot P, Lu Q. Nebulized antibiotics in mechanically ventilated patients: a
challenge for translational research from technology to clinical care. Ann Intensive Care. 2017;7(1):78.
doi:10.1186/s13613-017-0301-6
3.4 Restrepo, Marcos I., Holly Keyt, and Luis F. Reyes. "Aerosolized antibiotics." Respiratory Care 60.6
(2015): 762-773.
3.41 Rouby, J. J., C. Sole-Lleonart, and J. Rello. "Ventilator-associated pneumonia caused by multidrug-
resistant Gram-negative bacteria: understanding nebulization of aminoglycosides and colistin." Intensive
Care Medicine (2020): 1-5.
3.42 Saudi Central Board of Accreditation for Healthcare Institutions CBAHI, National Hospital Standards,
Third Edition 2016.
3.43 https://bestpractice.bmj.com/topics/en-us/220


GLN-003 Antimicrobial Stewardship Guidelines

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Guideline N0

Function Medication Management and Use Issue Date Effective Date

Goals of antibiotic stewardship:

Risks of antibiotics misuse or overuse:

Antibiotic Stewardship Program Core Elements

GLN-003 Antimicrobial Stewardship Program Page 1 of 95

IV to Oral Switch Protocol 6

II- Antibiotic Stewardship Metrics 8

III- Suggested Duration for some Bacterial Infections 11

IV- Dose Adjustment of Antibiotics

VI- Vancomycin Dosing Protocol 24

VII- Colistin Dosing Protocol 27

VIII- Prolonged Infusion of Beta Lactams Protocol 28

IX- Aminoglycosides Dosing Protocol 33

X- Aerosolized Antibiotic Therapy in ICU 38

XI- Antimicrobial Guidelines for Community-Acquired Infections

Antibiotic order: Acute bacterial meningitis 43

Antibiotic order: Acute Bacterial Sinusitis 46

Antibiotic order: Animal Bites/ Human Bites/ Acne/ Paronychia 47

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Antibiotic order: Brucellosis/ Bone Mycobacterium Tuberculosis 50

Antibiotic order: Community-Acquired Intra-Abdominal Infections 51

Antibiotic order: Community- Acquired Pneumonia 52

Antibiotic order: COPD Exacerbation 54

Antibiotic order: Diabetic Foot Infections 56

Antibiotic order: Group A Streptococcal Pharyngitis 57

Antibiotic order: Infective Endocarditis 58

Antibiotic order: Osteomyelitis 61

Antibiotic order: Pancreatitis 63

Antibiotic order: Peritonitis 64

Antibiotic order: Skin and Soft Tissues Infections 66

Antibiotic order: Urinary Tract Infections 67

Antibiotic order: Sepsis and Septic Shock 70

Antibiotic order: Aspiration Pneumonia 72

Antibiotic order: Ventilator-Associated Pneumonia 73

Antibiotic order: Hospital- Acquired Pneumonia 75

Antibiotic order: Catheter-Related Blood Stream Infections 77

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Antibiotic order: Hospital-Acquired Intra-abdominal Infections 81

Antibiotic order: Clostridium-Difficile Infections 82

Antibiotic order: Post-Operative Wound Infections 84

Antibiotic order: Potentially Infected Wounds Orthopedics 85

XIII- Surgical Antibiotic Prophylaxis Guidelines 86

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Antibiotic stewardship program and ICU:

The majority of the reports have evaluated

2-Start Smart: Empirical Antibiotic

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4- IV to Oral Switch Protocol

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1- Antimicrobial Consumption Metrics

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Antibiotic Standard WHO DDD Unit Note

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Site Diagnosis Duration of therapy

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1- Dose Adjustment in Obesity

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Amikacin 5 – 7.5 mg/kg 10mg/k

Azithromycin 500 mg Q24H No change No change No change No

Cefazolin CrCl ≥ 35: CrCl 10 –34: 1 g q24h 1 g q24h 2 g