Prisma 

Health
Adult
Antimicrobial
Guidebook
2021
Antimicrobial stewardship in 2021
The current pandemic brought additional challenges to
antimicrobial stewardship teams. Seasonal variations in
antibiotic use and resistance are well-described phenomena.
Antibiotic use usually picks up in the winter months during the
peak of acute respiratory tract infections and starts declining as
temperature warms up. The COVID‑19 pandemic has created
unusual circumstances of steady number of acute respiratory
infections throughout the spring and into the summer months.
The pain from this pandemic has been felt at every level in
the community and healthcare systems. Even in the most
robust settings, antimicrobial stewardship continues to face
unprecedented challenges. During these trying times, we ask all
our colleagues to help us minimize unnecessary and excessive
antibiotic use.
The Antimicrobial Guidebook features multiple institutional
guidelines for management of infections, including
community‑onset and hospital-onset pneumonia. These
guidelines are derived from the clinical and microbiological
data of our local population. Building on previous success
of utilizing precision medicine in the selection of antibiotic
therapy, a new clinical tool for prediction of antimicrobial
resistance has been added. We will continue to work hard and
collaborate with our colleagues in every discipline to optimize
antimicrobial therapy and patient care throughout and after the
end of this pandemic.
Prisma Health Antimicrobial Stewardship
Table of contents
Guidelines................................................................................................2
Gram-negative bloodstream infections......................................................... 2
Bloodstream infection de-escalation guide................................................. 6
Staphylococcus aureus bloodstream infections....................................... 14
Intra-abdominal infections...............................................................................17
Skin and soft tissue infections.........................................................................22
Diabetic foot infections.....................................................................................26
Clostridioides difficile testing algorithm UPDATED.................................30
Clostridioides difficile infection management UPDATED.....................32
Acute cystitis and pyelonephritis: Inpatient................................................34
Acute cystitis and pyelonephritis: Outpatient............................................40
Community-onset bacterial pneumonia.....................................................48
Hospital-acquired, ventilator-associated bacterial pneumonia...........50
Community-onset pneumonia in the ED/Ambulatory setting.............58
Pneumonia de-escalation guide....................................................................66
Neutropenic fever...............................................................................................70
Neutropenic fever de-escalation guide.......................................................72
Ambulatory acute sinusitis................................................................................76
Patient-specific antibiograms.......................................................... 80
Pseudomonas aeruginosa prediction score..............................................80
Risk of β-lactam resistant Pseudomonas aeruginosa.............................81
ESBL prediction score........................................................................................84
Fluoroquinolone resistance score.................................................................86
Trimethoprim/Sulfamethoxazole resistance tool NEW..........................87
Prisma Health antibiogram for 2021.............................................. 88
Gram-negative ALL sources.............................................................................89
Gram-positive ALL sources..............................................................................90
Gram-negative ICU ALL sources....................................................................91
Gram-positive ICU ALL sources......................................................................92
Gram-positive/Gram-negative Systemic – Tuomey................................93
Gram-positive/Gram-negative Urine – Tuomey.......................................94
Antibiotic costs.................................................................................... 95
Prisma Health Antimicrobial Stewardship.....................................97
 Gram-negative bloodstream infections
Definitions:
Guidelines • Hospital-acquired bloodstream infection (BSI): occurring ≥
48 hours after hospital admission
Prisma Health guidelines for the • Healthcare-associated BSI: prior hospitalization for ≥ 2 days
in the past 90 days, residence in nursing home or extended
management of gram‑negative bloodstream care facility, home infusion therapy (chemotherapy,
infections in adults intravenous antibiotics, etc.), chronic dialysis, or home
wound care within 30 days
Empiric antimicrobial therapy • Critically ill: intensive care unit admissions, high acute
Suspected or confirmed gram‑negative severity of illness score (Pitt bacteremia score ≥ 4) or
bloodstream infection (BSI) relatively high predicted mortality (BSI risk score ≥ 5)

Source of infection:
• Identification of primary source of infection is essential.
Hospital-acquired or Optimal management of BSI includes appropriate
Community-acquired
healthcare‑associated antimicrobial therapy as well as adequate source control
Cefepime 2g IV q8-12h* OR (relief of urinary or biliary obstruction; removal of infected
Piperacillin/tazobactam central venous catheters; drainage of intra-abdominal, pelvic
3.375–4.5gm IV q6h* or deep tissue abscesses, etc.).
• In patients with suspected intra-abdominal source of
infection, metronidazole should be added to ceftriaxone or
Critically ill cefepime for anaerobic coverage. Piperacillin-tazobactam
Non-critically ill
Cefepime 2gm IV q8–12h* OR provides adequate coverage for obligate anaerobes.
Ceftriaxone 2gm IV q24h
Piperacillin/tazobactam
3.375–4.5gm IV q6h* Penicillin allergy:
• Patients with penicillin allergy should not receive
piperacillin‑tazobactam.
Revise antimicrobial regimen based on identification of
microorganism, if needed. • In patients with minor penicillin allergies (nonspecific rashes,
intolerance, etc.), cross‑reactivity with 3rd and 4th generation
Streamline definitive therapy based on antimicrobial cephalosporins is low (< 3%). The benefit from beta‑lactam
susceptibility testing results. antibiotics outweighs the potential risk in these patients.5
*Higher doses of cefepime or piperacillin/tazobactam
may be used for patient‑specific factors, such as site of
infection (pulmonary, central nervous system, etc.) and/or
microorganism MIC.
Nimmich E, et al. Hosp Pharm 2017; 52: 691–697

2 3
 • Treatment options in patients with serious reactions Severity of illness scores
(anaphylaxis, angioedema, breathing problems and
hives) include aztreonam, aminoglycosides (tobramycin, Pitt bacteremia score criterion* Points
gentamicin) or ciprofloxacin in the absence of prior exposure Fever
to the respective class of antibiotics in the past 90 days. ≤ 35 C (95 F) or ≥40 C (104 F) 2
35.1–36.0 C (95.1–96.9 F) or 39.0–39.9 C (102.1–103.9 F) 1
Consider consultation with an infectious diseases specialist
36.1–38.9 C (97–102 F) 0
for optimal empirical therapy.
Hypotension (defined by at least 1 of the following) 2
Acute hypotensive event with drop in SBP > 30 mmHg
Risk factors for antimicrobial resistance: and DBP > 20 mmHg
Extended-spectrum beta-lactamase producing Requirement for intravenous vasopressors
SBP < 90 mmHg
organisms (ESBL)
• Meropenem is preferred in patients with high risk of BSI due Mechanical ventilation 2
to ESBLs, including: Cardiac arrest 4
- Documentation of prior infections or colonization with Mental status
ESBL‑producing organisms in the past 12 months. Alert 0
Disoriented 1
- Receipt of multiple courses of beta-lactam and Stuporous 2
fluoroquinolone antibiotics in the past 90 days. Comatose 4
Carbapenem-resistant Enterobacteriaceae (CRE) or *All criteria are graded within 48 hours before or on the day of first
multi‑drug resistant (MDR) Pseudomonas aeruginosa positive culture. The highest point scored during that time is recorded.

• Combination therapy is preferred in patients at high risk of Modified from Paterson DL, et al. Ann Intern Med 2004;140:26-32
BSI due to CRE or MDR P. aeruginosa, including:
- Documentation of prior infections or colonization with
CRE or MDR P. aeruginosa in the past 12 months.
Bloodstream infection mortality risk score
- Receipt of ≥ 7 days of carbapenems in the past 90 days.
• Please consult Antimicrobial Stewardship and Support Team Risk factor Points
(ASST) during business hours or an infectious diseases Malignancy 3
specialist for optimal empirical antimicrobial therapy.
Liver cirrhosis 4
High inoculum infection* 4
Pitt bacteremia score
0–1 0
2–3 2
≥4 5
*High inoculums infection represents source of bloodstream infection
other than urinary tract or central venous catheter infection.
Al-Hasan MN, et al. Clin Microbial Infect 2013; 19: 948-954.

4 5
 Bloodstream infection de-escalation guide
Enterobacteriaceae (Escherichia coli, Klebsiella species and

(for transitions of care)

SMZ-TMP (primarily for

Proteus mirabilis)
In vitro susceptibility
testing • E. coli, Klebsiella spp. and P. mirabilis represent >75% of

urinary source)
gram‑negative bloodstream isolates.

Ciprofloxacin

Ciprofloxacin

Ciprofloxacin
Levofloxacin

Levofloxacin

Piperacillin/tazobactam Levofloxacin
de‑escalation options • Patients with an ESBL prediction score <1 (no known
Susceptibility-based

colonization with ESBL‑producing Enterobacteriaceae and

PO no prior use of beta‑lactams or fluoroquinolones within
past 3 months) have a predicted probability of BSI due to
Prisma Health bloodstream infection de‑escalation guide

ESBL‑producing Enterobacteriaceae <1%. De‑escalation

inoculum infections)
to ceftriaxone is recommended in these patients based on
(narrowest‑spectrum

Ampicillin/sulbactam

Ampicillin/sulbactam
MALDI-TOF

Ceftriaxone (for low

microscan

identification of bloodstream isolate as E. coli, Klebsiella spp.

susceptible agent)

or P. mirabilis.
• Ertapenem is the preferred agent in patients with high
Ceftriaxone

Ceftriaxone
Ceftriaxone (refer to ESBL Ampicillin

Ampicillin
Cefepime

Cefepime
Cefazolin

suspicion (ESBL prediction score ≥3) or confirmed BSI due to

ESBL‑producing Enterobacteriaceae.
IV

Chromosomally mediated AmpC‑producing

Film array BCID

Enterobacteriaceae (CAE):
de‑escalation options

Piperacillin/tazobactam • De‑escalation from IV cefepime to IV ceftriaxone is an

prediction score)

option in patients with CAE BSI secondary to low inoculum

infections such as urinary source or central venous catheter
BCID-based

Ceftriaxone infection s/p removal.

Cefepime

Cefepime

• However, IV therapy with cefepime is preferred in

patients with deep‑seated infections. Transition to oral
fluoroquinolones may be pursued in certain cases (if
Gram stain

susceptible) pending appropriate source control and clinical

chromosomal AmpC production)

improvement of the patient.

Other Enterobacteriaceae (with

• Non‑fermenting gram‑negative bacilli:

Pseudomonas aeruginosa
Acinetobacter baumannii

Haemophilus influenzae

• Please refer to Patient‑specific antibiogram (risk of

Non-Enterobacteriaceae
Klebsiella pneumoniae

Neisseria meningitidis
Gram‑negative bacteria

Enterobacter cloacae
Serratia marcescens
Enterobacteriaceae

beta‑lactam resistant Pseudomonas aeruginosa) for

Klebsiella oxytoca

optimal empirical antimicrobial therapy in critically ill

Proteus mirabilis
Escherichia coli
Blood Cx drawn

(non‑fermenters)

patients with BSI due to P. aeruginosa or A. baumannii

Miscellaneous

(page 81).

6 7
8
(page 12).
infections (BSI):

susceptible isolates.

treatment failure rates.

available upon special request.

source of Enterobacteriaceae BSI.

adherence and low treatment failure rates.

• Duration: Please refer to Customized antimicrobial

• Ampicillin‑sulbactam may be an option for definitive

A. baumannii susceptibility to ampicillin‑sulbactam is

suboptimal serum and kidney concentrations and high

• Use of oral cephalosporins is highly discouraged due to
• Levofloxacin 750mg PO is the preferred oral regimen for

• In patients with Enterobacteriaceae bloodstream isolates

that are resistant to both fluoroquinolones and TMP/SMX,
1 tab PO BID is an option primarily in patients with urinary
Enterobacteriaceae given its high bioavailability, favorable
Oral antimicrobial options for gram‑negative bloodstream
therapy of susceptible A. baumannii bloodstream isolates.

amoxicillin/clavulanate 500 mg TID may be considered for

treatment duration for uncomplicated gram‑negative BSI

definitive therapy of BSI due to fluoroquinolone‑susceptible

• Trimethoprim‑sulfamethoxazole (TMP/SMX) DS 800/160mg

MALDI-TOF In vitro susceptibility

Blood Cx drawn Gram stain Film array BCID
microscan testing

Susceptibility‑based
Gram‑positive bacteria BCID‑based de‑escalation options de‑escalation options
Staphylococcus aureus
MSSA (MecA not detected) Cefazolin or nafcillin Cefazolin or nafcillin
MRSA (MecA detected) Vancomycin Vancomycin
Staphylococcus species (S. aureus not Clinical correlation is required to differentiate skin contamination from
detected), coagulase‑negative staphylococci bloodstream infection*
Beta‑hemolytic streptococci
Streptococcus pyogenes (group A) Penicillin G Penicillin G
Streptococcus agalactiae (group B) Cefazolin (for penicillin allergy)+ Cefazolin (for penicillin allergy)
Streptococcus pneumoniae Ceftriaxone Penicillin G
Ampicillin
Ceftriaxone
Enterococcus species
Non‑VRE (VanA/B not detected) Ampicillin Ampicillin
Vancomycin (for penicillin allergy) Vancomycin (for penicillin allergy)
VRE (VanA/B detected) Daptomycin Daptomycin
Linezolid
*Growth of coagulase‑negative staphylococci (CONS) in 1 out of 2 sets of blood cultures usually represents skin contamination;
however, growth in 2 of 2 sets in the presence of symptoms and signs of bloodstream infection (e.g., fever, hypotension) in the
appropriate clinical setting (suspicion of central line or surgical site infection) likely represents a bloodstream infection and warrants
antimicrobial therapy similar to S. aureus as above. S.lugdunensis should not be disregarded as a contaminant and should be
treated similar to S.aureus. Note: CONS deemed a contaminant may be either methicillin‑susceptible (MEC A Not‑ Detected) or
Methicillin‑resistant (MEC A Detected).
+Penicillin Allergy Skin Testing may be considered. Please consult Prisma Health Antimicrobial Stewardship and Support Team for patient
qualification and testing.
9
 Oral antimicrobial options for gram‑positive
bloodstream infections (BSI):
• Oral antimicrobial agents are not recommended in patients
with S. aureus BSI. Please see guidelines for management
of staphylococcus aureus bloodstream infections in adults.
(page 14).
• Oral levofloxacin is a reasonable option for definitive therapy
of BSI due to S. pneumoniae.
• High‑quality data on effectiveness of oral antimicrobials
for definitive therapy of BSI due to other gram‑positive
cocci are lacking. Infectious Diseases consultation is
highly recommended in these settings.
4. Foster RA, Troficanto C, Kohn J, et al. Utility of combination
antimicrobial therapy for bloodstream infections due to
Enterobacteriaceae and non‑fermenting gram‑negative bacilli.
Antibiotics 2019; 8: e15.
5. Kutob LF, Justo JA, Bookstaver PB, et al. Effectiveness of oral
antibiotics for definitive therapy of gram‑negative bloodstream
infections. Int J Antimicrob Agents 2016; 48: 498‑503.
6. Nelson AN, Justo JA, Bookstaver PB, et al. Optimal duration of
antimicrobial therapy for uncomplicated gram‑negative bloodstream
infections. Infection 2017; 45: 613‑20.
7. Watson CM, Al‑Hasan MN. Bloodstream infections and central
line‑associated bloodstream infections. Sur Clin N Am 2014; 94:
1233‑1244.

Treatment duration of gram‑positive BSI:

• Please refer to Guidelines for management of
staphylococcus aureus bloodstream infections in adults
(page 14) for further information on work‑up, source
control and optimal treatment duration of S. aureus BSI.
• An echocardiogram and/or Infectious Diseases consultation
are valuable to determine treatment duration in patients
with continuous BSI due to viridans group streptococci or
community‑onset BSI due to Enterococcus species.
References:
1. Augustine MR, Testerman TL, Justo JA, et al. Clinical risk score
for prediction of extended‑spectrum beta‑lactamase producing
Enterobacteriaceae in bloodstream isolates. Infect Control
Hosp Epidemiol 2017; 38: 266‑272.
2. Bookstaver PB, Nimmich EB, Smith TJ 3rd, et al. Cumulative effect
of an antimicrobial stewardship and rapid diagnostic testing bundle
on early streamlining of antimicrobial therapy in gram‑negative
bloodstream infections. Antimicrob Agents Chemother 2017; 16:
e00189‑17.
3. Derrick C, Bookstaver PB, Lu ZK, et al. Multicenter observational
cohort study evaluating third‑generation cephalosporin therapy
for bloodstream infections secondary to Enterobacter, Serratia, and
Citrobacter species. Antibiotics 2020; 9: e254.

10 11
 Customized antimicrobial treatment durations Early clinical failure criteria
for uncomplicated gram‑negative bloodstream These criteria are evaluated after 72–96 hours of gram‑negative
infections BSI. Presence of ≥2 criteria predict poor outcomes of patients
with gram‑negative BSI such as high mortality or prolonged
A “one‑size‑fits‑all” treatment duration for gram‑negative
hospitalization.
bloodstream infections (BSI) does not fit our high standards
of antimicrobial therapy in the era of precision medicine. Early clinical failure criteria within Point
These customized treatment durations are derived from 72–96 hours of BSI allocation
a recent clinical trial results and re‑analysis of our local
Systolic blood pressure <100 mmHg or vasopressor use 1
data after stratification based on clinical response to
antimicrobial therapy within the first 4 days of BSI. Heart rate >100 beats/minute 1
Respiratory rate ≥22 breaths/minute or mechanical 1
ventilation
Short duration Moderate duration Long duration
(7–8 days) (9–11 days) (12–14 days) Altered mental status from baseline 1
Patients meeting all of Patients not meeting Patients meeting any Peripheral white blood cell count >12,000/mm 3
1
the following criteria: all criteria for short of the following
• Women with urinary duration or any criteria:
criteria for long Rac H, et al. Clin Microbiol Infect 2020; 26: 73‑7.
source of BSI • Men with urinary
duration of therapy source of BSI
• Early clinical failure
criteria <2 • Early clinical failure References:
• Optimal source criteria ≥2 1. Yahav D, et al. Seven versus fourteen days of antibiotic therapy
control* • Suboptimal source for uncomplicated gram‑negative bacteremia: A non‑inferiority
• First episode of BSI control* randomized controlled trial. Clin Infect Dis 2019; 69: 1091‑8
• No major risk • Recurrent episodes 2. Nelson AN, et al. Optimal duration of antimicrobial therapy
factors for recurrent of BSI for uncomplicated gram‑negative bloodstream infections.
infections+ • Major risk factors for Infection 2017; 45: 613‑20.
• Antimicrobial recurrent infections+ 3. Al‑Hasan MN, et al. Reply to comments: Duration of antimicrobial
therapy with first‑line • Antimicrobial therapy therapy for gram‑negative bacteremia secondary to urinary source
agents# with second‑line of infection. Infection 2018; 46: 283‑4.
agents# 4. Rac H, et al. Evaluation of early clinical failure criteria for
gram‑negative bloodstream infections. Clin Microbiol Infect 2020;
*Optimal source control implies either no opportunities for source 26: 73‑7.
control (e.g., acute pyelonephritis in the absence of ureteric stones)
or complete source control (e.g., removal of gall bladder or central
venous catheter, etc.).
+Major risk factors for recurrent infections include liver cirrhosis,
end-stage renal diseases and immune compromising conditions
(neutropenia, transplant recipients, recent high dose steroids, etc.).
#First-line therapy includes susceptible intravenous antimicrobial
agents or oral fluoroquinolones (e.g., levofloxacin 750 mg daily).
Second-line therapy includes oral agents other than fluoroquinolones
(e.g., trimethoprim/sulfamethoxazole or amoxicillin/clavulanate).

12 13
 Staphylococcus aureus bloodstream
Prisma Health
infections guidelines for the
management of Staphylococcus aureus
bloodstream infections in adults
The following evidence‑based interventions have been
demonstrated to improve the quality of care and patient
outcomes with this condition:
1. ID consultation
Can help identify complications, optimize source control,
define type of indicated echocardiography, determine
duration of antimicrobial therapy and manage outpatient
antibiotics.
2. Document microbiological clearance of bloodstream
Follow‑up blood cultures drawn 48–96 h after starting
appropriate antimicrobial therapy.
Note: If a central venous catheter (CVC) is required, ideally
await documentation of microbiological clearance of the
bloodstream prior to placing a new CVC.
3. Early source control within 72 h of presentation, such
as removal of vascular catheters, drainage of abscesses,
debridement of infected wounds or ulcers, etc.
4. Echocardiography, i.e., TTE and/or TEE based on
patient‑specific risk for infective endocarditis.
5. For MSSA isolates, early use of IV anti‑staphylococcal
beta‑lactams (e.g., nafcillin, cefazolin) (Staphylococcus
aureus DETECTED, but Mec A NOT DETECTED by BCID)
14
Highly recommended regimens:
• Cefazolin 2g IV q8h (For hemodialysis: 2gm/2gm/3gm IV
3X weekly)
• Nafcillin 2g IV q4h OR continuous infusion of 12g over
24 hours OR
MRSA isolates, Mec A DETECTED by BCID, OR severe
Beta‑lactam allergy
• Vancomycin dosed to optimize drug exposure: 20mg/kg IV
loading dose
• Recommend Pharmacy consult for vancomycin dosing to
achieve goal trough concentrations: 12–18 mg/L (surrogate
for target AUC/MIC >400).
6. A
 ppropriate duration of antimicrobial therapy
(ID consultation is highly recommended to determine
optimal duration of therapy)
Uncomplicated bacteremia (such as nosocomial S. aureus
bacteremia secondary to CVC infection s/p early removal, rapid
clinical response to therapy, clearance of bloodstream within
72 h, and no vegetations on echocardiography):
• At least 14 days of adequate IV antimicrobial therapy.
Complicated bacteremia (such as endocarditis, septic joints,
osteomyelitis, etc.) or risk factors for complicated bacteremia,
defined by presence of any of the below criteria:
• >2 weeks of adequate IV antimicrobial therapy depending
on ID consult recommendations and clinical response to
therapy.
15
 Intra-abdominal infections
Risk factors for complicated bacteremia: Prisma Health guidelines for
• Persistent bacteremia > 72 h management of intra-abdominal
• Persistent fever > 72 h
infections (IAI) in hospitalized adults:
• Janeway lesions, Osler nodes or other cutaneous/mucosal
lesions suggestive of acute systemic infection Empiricantimicrobial therapy
• Permanent cardiac and orthopedic prosthetic devices
• Device‑related infections where device could not be Suspected or confirmed
removed within 72 h intra-abdominal infection (IAI)
• Chronic hemodialysis

Community-onset Hospital-acquired, re-opening

Ceftriaxone 2 G IV Q24h + abdominal surgery, severely
Metronidazole 500 mg IV/PO Q8h Immunocompromised, or
critically ill*
Piperacillin-tazobactam
3.375–4.5 G IV Q6h ±
OR
Cefepime 2 G IV Q8h–Q12h +
Metronidazole 500 mg IV Q8h

• Obtain 2 sets of blood cultures in all hospitalized adults with

References:
1. López‑Cortés LE, Del Toro MD, Gálvez‑Acebal J, et al. Clin Infect Dis
2013; 57: 1225‑33.
2. Fowler VG Jr, Olsen MK, Corey GR, et al. Arch Intern Med 2003; 163:
2066‑72.
3. Bai AD, Showler A, Burry L, et al. Clin Infect Dis 2015; 60: 1451‑61.
4. Holland TL, Arnold C, Fowler VG Jr. JAMA 2014; 312: 1330‑41.
5. Palraj BR, Baddour LM, Hess EP, et al. Clin Infect Dis 2015; 61: 18‑28.
IAI prior to starting antibiotics. Also obtain fluid or tissue
cultures from the primary site of infection, as applicable.
• Daily assessment of antimicrobial regimen is strongly
encouraged: 1) Revision of empirical antimicrobial therapy
based on identification of microorganism, 2) Further
streamlining to definitive therapy based on antimicrobial
susceptibility testing results.
• All dosages provided assume normal renal and hepatic
function.
• Duration of therapy is 4 to 7 days after source control in
localized IAI.1‑3 Consider a longer course in patients with
bloodstream infections.4 Please refer to Customized
antimicrobial treatment durations for uncomplicated
gram‑negative BSI (page 12).

16 17
 • Please refer to Guidelines for management of
gram‑negative bloodstream infections in adults for further
guidance (page 2).
• The non‑stratified use of fluoroquinolones for empirical
therapy of hospitalized adults with IAI is not recommended
due to increasing rates of antimicrobial resistance
among E. coli and other gram‑negative isolates.5
(See fluoroquinolone resistance score.)
*Critically ill and previous MRSA infections: Consider adding
vancomycin# 15 mg/kg IV Q8h–Q12h (consider Pharmacy consult
for dosing).
#If adding vancomycin, consider using cefepime + metronidazole
regimen. Concomitant use of vancomycin and piperacillin/tazobactam
is associated with an increased risk of nephrotoxicity.6‑8
Definitions:
• Hospital‑acquired infection: symptom onset >5 days after
hospital admission.
• Critically ill: persistent hypotension, unexplained metabolic
acidosis, ICU admission, qSOFA score ≥2, or Pitt bacteremia
score ≥4.9
• Severely immunocompromised host: Chemotherapy,
neutropenia, transplant recipient, treatment with high dose
steroids (>20 mg of prednisone equivalents daily for >2
weeks) or other immunosuppressive medications within
one month.
Source control:
• Optimal management of IAI includes appropriate
antimicrobial therapy as well as adequate source control
(relief of biliary obstruction, drainage of intra‑abdominal or
pelvic abscesses, etc.).
18
Alternative antimicrobial regimens:
Beta‑lactam allergy
• Patients with penicillin allergy should not receive
piperacillin‑tazobactam.
• In patients with minor penicillin allergies (nonspecific
rashes, intolerance, etc.), cross‑reactivity with 2nd, 3rd and
4th generation cephalosporins is low (< 3%).10 The benefit
from beta‑lactam antibiotics outweighs the potential risk in
these patients.11
• In patients with serious reactions to β‑lactams (anaphylaxis,
angioedema, breathing problems and hives), levofloxacin
750 mg PO/IV Q24h + metronidazole 500 mg PO/IV Q8h is
preferred in the absence of nursing home residence or prior
exposure to a fluoroquinolone in the past six months (i.e.,
fluoroquinolone resistance score <2).12
Hyperbilirubinemia (total bilirubin >4 mg/dL) precluding
ceftriaxone use or metronidazole intolerance
• Cefoxitin 2g IV Q8h may be used in mild IAI in the absence
of prior exposure to beta‑lactam antibiotics within the past
one month.1,13,14
References:
1. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and
management of complicated intra‑abdominal infection in adults
and children: guidelines by the Surgical Infection Society and the
Infectious Diseases Society of America. Clin Infect Dis 2010; 50:
133‑64.
2. Gomi H, Solomkin JS, Takada T, et al; Tokyo Guideline Revision
Committee. TG13 antimicrobial therapy for acute cholangitis and
cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20: 60‑70.
3. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short‑course
antimicrobial therapy for intra‑abdominal infection. N Engl J Med
2015; 372:1996‑2005.
4. Nelson A, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al‑Hasan MN.
Optimal duration of antimicrobial therapy for bloodstream infections
due to gram‑negative bacilli. Infection 2017; 45: 613‑20.
19
 5. Al‑Hasan MN, Lahr BD, Eckel‑Passow JE, Baddour LM. Antimicrobial
resistance trends of Escherichia coli bloodstream isolates: a
population‑based study, 1998‑2007. J Antimicrob Chemother 2009;
64: 169‑74.
6. Justo JA, Dickert EL, Kohn J, Bookstaver PB. Comparative
risk of acute kidney injury in patients receiving vancomycin
monotherapy or vancomycin and beta‑lactam combination
therapy. 54th Interscience Conference on Antimicrobial Agents
and Chemotherapy, Washington DC, 5‑9 September 2014. Abstract
#2544.
7. Gomes DM, Smotherman C, Birch A, et al. Comparison of acute
kidney injury during treatment with vancomycin in combination with
piperacillin‑tazobactam or cefepime. Pharmacotherapy 2014; 34:
662‑9.
8. Burgess LD, Drew RH. Comparison of the incidence of
vancomycin‑induced nephrotoxicity in hospitalized patients with
and without concomitant piperacillin‑tazobactam. Pharmacotherapy
2014; 34: 670‑6.
9. Singer M, Deutschman CS, Seymour CW, et al. The third international
consensus definitions for sepsis and septic shock (Sepsis‑3). JAMA
2016; 315: 801‑10.
10. Pichichero ME. Cephalosporins can be prescribed safely for
penicillin‑allergic patients. J Fam Pract 2006; 55: 106‑12.
11. Jeffres MN, Narayanan PP, Shuster JE, Schramm GE. Consequences
of avoiding β‑lactams in patients with β‑lactam allergies. J Allergy
Clin Immunol 2016; 137: 1148‑53.
12. Dan S, Shah A, Justo JA, et al. Prediction of fluoroquinolone
resistance in gram‑negative bacteria causing bloodstream
infections. Antimicrob Agents Chemother 2016; 60: 2265‑72.
13. Hammer KL, Stoessel A, Justo JA, et al. Association between chronic
hemodialysis and bloodstream infections due to chromosomally
mediated AmpC‑producing Enterobacteriaceae. Am J Infect Control
2016; 44: 1611‑6.
14. Augustine MR, Testerman TL, Justo JA, et al. Clinical risk score
for prediction of extended‑spectrum beta‑lactamase‑producing
Enterobacteriaceae in bloodstream isolates. Infect Control Hosp
Epidemiol 2017; 38: 266‑72.

20 21
 Skin and soft tissue infections
Footnotes:

million units IV Q4h

streptococci (grp A,
PLUS clindamycin 5

to beta‑hemolytic
Necrotizing

PLUS clindamycin
to penicillin G7 4
non‑necrotizing

(as above) if due

600–900mg IV

De-escalation
fasciitis
1. Use 2G of weight >80kg

Critically ill/Severely immunocompromised

infections
Same as

B, etc.)
2. Please send deep tissue cultures at the time of surgical debridement.
Prisma Health guidelines for the management of skin and soft tissue
infection (SSTI) in hospitalized adults: Empiric antimicrobial therapy

Q8h
3. Vancomycin loading dose of 20mg/kg once is recommended; Q8h
dosing of vancomycin is preferred in young adults.
4. Alternative regimens include those for patients with severe penicillin

Urgent surgical
consultation 2
allergy (i.e., anaphylaxis, angioedema, hives).
5. Limit clindamycin duration to 5 days for suppression of toxin

blood or tissue culture results.

Piperacillin/tazobactam 4.5 IV

Ciprofloxacin 400mg IV Q8h

PLUS Vancomycin (as above)
PLUS vancomycin (as above)

on rapid diagnostics and/or

spectrum antibiotics based
production.

Cefepime 2G iV Q8–12h

De-escalate to narrower
15mg/kg IV Q8–12h
6. De-escalation to an oral antibiotic should occur when fever

PLUS Vancomycin3
subsides, and signs and symptoms of skin infection improve. The

Alternative4:
total duration of therapy for uncomplicated cellulitis is 7 days. Longer
Q6H
Non-necrotizing

OR
duration may be required in complicated cases (deep abscesses or
necrotizing infections) and depending on clinical response.
infection

7. Alternately, ceftriaxone 2G IV Q24

Recommendations are modified from the Infectious Disease

Society of America (IDSA) 2014 SSTI Management Guidelines1 .
De-escalate to PO antibiotics6:

Doxy/Minocycline 100mg PO All dosages assume normal renal and hepatic renal function.

Clindamycin 300–450mg
SSTI

1–2 DS tabs PO Q12h

Blood cultures should be collected to assist in identification of

a causative pathogen.
TMP-SMZ

Q6–8h
Q12h
15mg/kg Q8–12h
Purulent cellulitis

OR

OR
600–900mg IV

Supportive measures such as limb elevation are important for

Vancomycin3

Clindamycin
Alternative4:

rapid resolution of swelling.

Q8h

Streamline definitive therapy based on antimicrobial

susceptibility testing results.
Non-critically ill/Immunocompetent

Definitions:
Clindamycin 300–450mg PO Q6-8h
Clindamycin 600–900mg IV Q8h
indicated2

De-escalate to PO antibiotics :

• Critically ill: persistent hypotension, unexplained metabolic

6

Dicloxacillin 500mg PO Q6h

Cephalexin 500mg PO Q6h

I&D if

Ceftriaxone1 1–2G IV Q24h

Cefazolin1 1–2G IV Q8h

acidosis, ICU admission or qSOFA score ≥2.

Nafcillin1 1–2G IV Q4h

• Purulent cellulitis: cellulitis surrounding current or prior

Alternative4:

Alternative:

furuncle, carbuncle or abscess.

OR

OR

OR

• Severely immunocompromised host: recent chemotherapy,

Non-purulent

neutropenia, transplant recipient, treatment with high dose

cellulitis

steroids or other immunosuppressive medications.

22 23
 Penicillin allergy:
• Patients with penicillin allergy should not receive nafcillin
or piperacillin/tazobactam. In patients with minor
penicillin allergies (non-specific rashes, intolerances, etc.),
cross‑reactivity with 3rd and 4th generation cephalosporins
is low (<3%). 2 In critically ill patients, the benefit from beta-
lactam antibiotics may outweigh the potential risk.

24 25
 Diabetic foot infections
Prisma Health guidelines for the management of diabetic foot infections Footnotes:

De-escalate based on deep tissue cultures

1. Please send deep tissue cultures upon debridement, preferably

PLUS metronidazole 500mg IV Q8h

Piperacillin/tazobactam 4.5 IV Q6H
prior to starting antibiotics in the clinically stable patient. Superficial

PLUS metronidazole (as above)

PLUS vancomycin3-4 (as above)

PLUS vancomycin3-4 (as above)

swab cultures have poor correlation with deep tissue cultures except

Ciprofloxacin 400mg IV Q8h

Cefepime 2G iV Q8–12h
Staphylococcus aureus.

PLUS vancomycin3-4
15mg/kg IV Q8–12h
Limb-threatening
2. Use 2G if weight >80kg

Alternative 5:
3. If methicillin-resistant Staphylococcus aureus (MRSA) is suspected

OR
(known colonization, prior MRSA infections, etc.)
4. Vancomycin loading dose of 20mg/kg once is recommended; Q8h
dosing of vancomycin is preferred in young adults.
(DFI) in hospitalized adults empiric antimicrobial therapy

debridement 1
5. Alternative regimen for patients with severe penicillin allergy (i.e.,
Urgent

anaphylaxis, angioedema, hives, etc.)

Levofloxacin and metronidazole may be given orally in

hemodynamically stable patients who can otherwise tolerate oral
medications.
PLUS Metronidazole 500mg IV Q8h

Recommendations are modified form Infectious Disease Society

(all with or without vancomycin3-4)
Levofloxacin 750mg IV/PO Q24h
PLUS Metronidazole 500mg IV/
of America (IDSA) 2012 DFI Management Guidelines3.
Cefoxitin 2 1–2G IV q6–8h

De‑escalation based on
Ceftriaxone 2G IV Q24h

deep tissue cultures

All dosages provided assume normal renal and hepatic function.
DFI

Alternative 5-6:

PO Q8h

Definitive antimicrobial therapy should be based on deep tissue

Deep

OR

culture results.

Definitions:
• Superficial: Limited in size and depth, erythema >0.5cm to
Debridement
if indicated1

≤2cm around the ulcer.

• Deep: Involving structures deeper than skin and subcutaneous
tissues (e.g., abscess, osteomyelitis, septic arthritis, fasciitis).
Clindamycin3 300–450mg PO Q6–8h
Non-limb-threatening

Clindamycin 600–900mg IV Q8h

De-escalation to PO antibiotics:
Vancomycin3-4 15mg/kg IV Q8H

• Limb-threatening: Systemic toxicity (i.e., hypotension), critical

Doxycycline3 100mg PO Q12h
SMZ-TMP3 1–2 DS tabs Q12h
Cephalexin 500mg PO Q6h
Cefazolin 2 1–2G IV Q8h

ischemia (i.e., wet gangrene), ICU admission or qSOFA

score ≥2.
Alternatives5:
Alternative 5:
OR

OR

OR
Superficial

26 27
 Management of special situations
Scenario Treatment
Human/Animal bites • Irrigation, debridement, and updating
Cat bites are more likely tetanus toxoids, if indicated
to cause deep infections • Ampicillin/sulbactam 3G IV Q6h OR
including osteomyelitis/ • Cefoxitin 2G IV Q6–8h
septic joints
• De‑escalation to oral antibiotics based
on tissue cultures:
‑ Amoxicillin‑clavulanate 875mg PO
Q12h, if cultures show no growth
Suspicion for water • Ceftriaxone 2G IV q24h OR
pathogens • Levofloxacin 750mg IV/PO Q24h
(Aeromonas hydrophilia, • ID consult
Vibrio Vulnificus)
Cellulitis surrounding sacral • Ceftriaxone 2G IV Q24h PLUS
decubitus metronidazole 500mg IV/PO Q8h1 OR
Ulcers • Levofloxacin PLUS metronidazole1
(as above) OR
‑ Cefoxitin (as above)
1. Levofloxacin and metronidazole may be given orally in
hemodynamically stable patients who can otherwise tolerate oral
medications.

References:
1. Stevens DL, Bisno AL, Chambers HF, et al. Practice Guidelines for the
Diagnosis and Management of Skin and Soft Tissue Infections: 2014
Update by the Infectious Diseases Society of America. Clin Infect Dis
2014; 59: e10‑52.
2. Pichichero ME. Cephalosporins can be prescribed safely for
penicillin‑allergic patients. J Fam Pract 2006; 55: 106‑112.
3. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases
Society of America Clinical Practice Guideline for the Diagnosis
and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012; 54:
132–173.

28 29
30
Clostridiodes difficile infection (CDI) testing algorithm

Signs/Symptoms: Confounding factors: Risk factors:

• ≥ 3 loose, watery stools in 24 hours • Laxative use within 48 hours of diarrhea onset • Age > 65 years
UPDATED

(required)a • Tube feeds: starting or change of rate • Recent antibiotic use

• Lower abdominal pain/cramping • Recent chemotherapy
• Low-grade fever • Recent hospitalization
• Elevated WBC • Recent PPI use
• Radiologic evidence Consider stopping laxatives or modifying tub • Previous history of C.difficile
feeds prior to testing.

Should a test be
ordered?

C.difficile classificationb: Place order in EMR YES NO Consider alternative

diagnosis
Community-onset
C.difficile Infection:
Infection that has been Specimen collected?
diagnosed within 3 days
of admission.
Auto-cancellation:
Hospital-onset C.difficile Order automatically canceled if:
Clostridioides difficile testing algorithm

Infection: Infection that • Specimen not received in lab within 24 hours

has been diagnosed after • Specimen fails to take the shape of the container (i.e., it is a formed, non-liquid stool)
hospital; day 3

Reorder if patient has

unformed, liquid stools and NO YES
CDI is still suspected

Treatment c: Positive Test Result? Negative

• Treat per Prisma Health Antimicrobial Guidebook
• Contact precautions until complete resolution
of diarrhea for 48 hours.
Hard stop on reordering
C.difficile testing within 7 days
following negative test
Hard stop on reordering C.difficile testing within
14 days following positive test
Level of clinical suspicion?

Retesting
Test of cure is not recommended
Consider ID HIGH LOW
Consult

(a) Patients with severe CDI with ileus and/or toxic megacolon may not experience diarrhea. Consider ID consult for
such cases.
(b) F or additional information, please see www.cdc.gov/hai/
(c) See Complete treatment guidelines in Prisma Health Antimicrobial Guidebook at phformulary.net under
Antimicrobial Stewardship-Adults.

Approved 14 January 2020

31
32
Prisma Health guidelines for the management of Clostridioides difficile
infection (CDI) in adults

Clostridioides difficile Infection (CDI) disease severity

UPDATED

Fulminant/Critically ill
Mild-severe CDI Severe disease + hypotension or shock; ileus; megacolon;
Mild-moderate/Non-severe: WBC≤ 15 cells/mm3; OR admission to the ICU secondary to CDI
SCr <1.5 mg/dl
Severe: WBC >15 cells/mm3; SC >1.5 mg/dl (or 1.5 X
baseline); endoscopic or radiographic evidence of Vancomycin 125–500 mg PO Q6hb,d
Pseudomembranous colitis +
Metronidazole 500mg IV q8h for
10–14 days

Initial episode?a

Second or subsequent recurrencee,f

YES NO Vancomycin taper/Pulse dosing
suggested regimen
125mg PO q6h X 21 days
125mg PO q12h X 7 days
Vancomycin 125mg PO First recurrence 125mg PO daily X 7 days
4XD for 10 days Vancomycin 125mg PO 4XD for 10 daysb,c 125mg PO 3 X weekly X 7 days
OR 125mg PO 2X weekly X 7 days
May consider vancomycin taper 125mg PO once weekly X 7 days
Clostridioides difficile infection management

If clinical decline after 72 hours, consider Infectious Diseases consult.

Contact floor clinical pharmacist for transitions of care.
Concierge should be considered for patients who are to be discharged prior to completion of therapy.

Additional orders/Recommendations:
• C onsider discontinuation of concomitant systemic antimicrobial therapy. If the patient must remain on antibiotics, de‑escalate/
change to an antibiotic that is low‑risk for CDI such as aminoglycosides, tetracyclines, macrolides, sulfonamides (SMZ‑TMP).
• Discontinue bowel regimens including stool softeners, laxatives, antiperistaltic agents (e.g., docusate, sennosides, loperamide,
metoclopramide, polyethylene glycol)
• Consider discontinuation of ALL acid‑suppressing agents (PPI risk > H2 antagonist)
• Concurrent cholestyramine and oral vancomycin are not recommended due to extensive binding and inactivation of vancomycin.
• Combo therapy strongly discouraged for non‑critically ill patients. Data does not support increased effectiveness but increased
adverse events. When combination therapy used in fulminant disease, consider discontinuation of metronidazole following
discharge from ICU.

a
Recurrence/relapse is limited to 90 days from initial episode. Onset beyond this threshold should be treated as initial episode.
b
Extended courses of oral vancomycin may be considered if multi‑recurrent CDI or when concomitant broad‑spectrum antibiotics are
necessary (e.g. >10days)
c
Fidaxomicin requires Antimicrobial Stewardship and Support Team (PHASST/ID/GI) approval. Patients at high risk for recurrence:
Active cancer, s/p transplant on immunosuppression, HIV/AIDS, h/o recurrence, receiving broad spectrum antibiotics and unable to
de‑escalate/discontinue.
d
Intracolonic delivery of vancomycin 500mg in 100ml saline every 6–12 hours via retention enema may be considered in critically ill
patients without oral access or those with blind rectal pouch.
e
500mg oral vancomycin doses may be considered in critically ill patients with suspected or identified bowel obstruction. Doses can be
decreased (e.g., 125mg) once GI motility established.
f
Openbiome® (i.e., fecal microbiota transplant) recommended for patients with at least 3 CDI (≥2 recurrences) who have failed
antibiotic treatment.

Please contact the Prisma Health Antimicrobial Stewardship and Support Team (PHASST) for assistance.
33
34
Prisma Health guidelines for acute cystitis and pyelonephritis: Inpatient
management in adults

Do NOT treat asymptomatic patients Urinary symptoms

with positive urine cultures*

Acute cystitis Acute pyelonephritis

Defined as lower urinary symptoms/
signs (e.g., dysuria, new or increased
frequency or urgency, suprapubic
tenderness), pyuria on urinalysis and
temperature <38 C
Defined as fever >38 C, unilateral back
or flank pain, costovertebral angle
tenderness ± radiologic evidence of
kidney involvement

Uncomplicated Complicated cystitis No risk factors Risk factors for Risk factors for
cystitis Defined as: for drug-resistant P.aeruginosa ESBL‑producing
Defined as: • >2 UTIs in past bacteria (Any of the following) bacteria
• Female of 12 months • Severely immune (Any of the following)
childbearing • Urologic compromised • Colonization with
potential abnormalities • Currently ESBLs in past
• No urologic • (e.g., stones) hospitalized >5 12 months
abnormalities • Males days • ≥2 courses of
• Indwelling • Beta-lactam use beta‑lactams or
catheters within past 90 days fluoroquinolones
• Colonization with in past 90 days
P.aeruginosa in
past 12 months
Acute cystitis and pyelonephritis: Inpatient

Nitrofurantoin Oral options: Ceftriaxone Cefepime Contact PHASST

(Macrobid)1 Nitrofurantoin 1–2g IV Q24h 2g IV Q8–12h OR
100mg PO Q12h X (Macrobid)1 Ertapenem
5 days ONLY if CrCl 100mg PO Q12h X 1g IV Q24h
≥30 ml/min 7 days ONLY if CrCl
OR ≥30 ml/min
Fosfomycin2 OR
3G PO X 1 dose SMZ‑TMP3
Total treatment duration: 7–14 days**
OR 1 DS PO Q12h X 7
days IV de-escalation options:
SMZ‑TMP3
De-escalate to narrowest spectrum IV antibiotic based on susceptibility
1 DS PO Q12h X
**Avoid SMZ‑TMP if results (ampicillin, ampicillin-sulbactam, cefazolin, ceftriaxone, etc.)
3 days
SMZ‑TMP use or prior Oral de-escalation options:
**Avoid SMZ‑TMP if urinary culture with Levofloxacin4 750mg PO Q24h OR
SMZ‑TMP use or prior SMZ‑TMP‑resistant Ciprofloxacin 5 500mg PO Q12h OR
urinary culture with bacteria within SMZ-TMP3 1 DS PO Q12h
SMZ‑TMP‑resistant 12 months
bacteria within
12 months If IV antibiotics
are indicated, use
same options as for
pyelonephritis.

1
Nitrofurantoin should be avoided in patients with CrCl <30 ml/min.
2
Fosfomycin is not recommended as a first‑line therapy in patients with complicated disease. If used for complicated disease, should
repeat Q72h for 2–3 doses.
3
SMZ‑TMP can be used in patients with decreased renal function. If CrCl <30 ml/min, reduce dose to 1 SS PO Q12h. SMZ‑TMP should be
used with caution in pregnancy.
4
If CrCl <20‑49ml/min, give 750mg Q48h, and if <20 ml/min, give 750mg followed by 500mg Q48h.
5
If CrCl <30 ml/min, give 250mg Q12h.
35
 Definitions:
• Severely immune compromised host: chemotherapy,
neutropenia, transplant recipient, treatment with high dose
steroids (20mg of prednisone equivalents daily for >2 weeks)
or other immunosuppressive medications within one month.
• A prior course of antibiotics should be at least 24h or longer;
short‑term perioperative antibiotics do not qualify as a course.
• >2 courses of β‑lactams or fluoroquinolones have to be at least
3 days apart; concurrent or sequential therapy is considered
one course.
Diagnosis:
• Urinalysis and urine culture should be obtained prior to
initiating antibiotics in patients with recurrent infections,
urologic abnormalities, pregnancy and in males.
• Urinalysis, urine culture and blood cultures should be obtained
prior to initiating antibiotics in all patients in the emergency
room or hospital with acute pyelonephritis.
• For patients with indwelling catheters in place for >2 weeks
from onset of symptoms, catheter should be replaced prior
to obtaining urinalysis and urine culture. If possible, catheter
should be discontinued, and a culture of a voided midstream
urine specimen should be obtained.
• Consider imaging in males and patients with recurrent urinary
infections.
• Presence of pyuria on urinalysis without symptoms does not
indicate a urinary tract infection. Absence of pyuria is indicative
that a urinary tract infection is not present with the exception of
acute pyelonephritis with complete uretic obstruction.
• Patients with non‑specific symptoms:
‑ Change in urine color, odor or turbidity are typically due to
dehydration and not indicators for urinalysis or urine culture.
‑ Behavioral changes including worsening mental or functional
status do not on their own indicate a urinary tract infection.
These patients should be monitored and encouraged to have
increased fluid intake, if possible. Other causes of mental
status change should be assessed including constipation,
36
dehydration, electrolyte abnormalities, medications
(e.g., narcotics, etc.), liver failure, renal failure, blood sugar
issues, sleep deprivation, stroke and other infections.
• Urine cultures should not be done after treatment of cystitis or
pyelonephritis to document cure.
Treatment:
• Asymptomatic bacteriuria
*Treatment of asymptomatic bacteriuria is strongly
discouraged because antibiotics may lead to harmful effects
to patient (e.g., Clostridium difficile infection, induction
of antimicrobial resistance) that cannot be justified based
on lack of any treatment benefits. The only exceptions are
pregnant women and before transurethral resection of the
prostate or other urologic procedures for which mucosal
bleeding is anticipated.
• Acute cystitis
‑ Fluoroquinolone (ciprofloxacin, levofloxacin) use is
strongly discouraged for the treatment of acute cystitis
because the risk of harmful adverse effects (e.g., C.difficile
infection; tendonitis; neurotoxicity; QTc prolongation;
induction of antimicrobial resistance) exceeds
potential benefit.
‑ Similarly, oral 3rd generation cephalosporins (e.g., cefdinir,
cefpodoxime) should be AVOIDED due to low urinary
concentrations and high risk of adverse events, including
induction of antimicrobial resistance.
‑ If IV antibiotics are continued, transition to a less broad
agent (ampicillin, cefazolin, etc.) based on culture and
susceptibility data is appropriate. If IV antibiotics are used
for uncomplicated cystitis, limit duration to 3 days.
Alternative oral regimens for cystitis:
• Contraindications to first‑line therapy
‑ In patients with contraindications to all first‑line therapies
(e.g., complicated cystitis AND CrCl <30 mL/min AND
SMZ‑TMP allergy), cephalexin 500 mg PO Q8h or
37
 amoxicillin/clavulanic acid 500 mg/125 mg PO Q12h for
7–10 days may be used.
‑ Fluoroquinolones are considered only as last resort
options in patients with cystitis in the absence of
risk factors for fluoroquinolone resistance. May use
ciprofloxacin 250 mg PO Q12h x 3 days.
• Extended‑spectrum β–lactamase (ESBL)‑producing
Enterobacteriaceae
‑ Non‑β‑lactam antibiotics (nitrofurantoin, fosfomycin and
SMZ‑TMP) often retain activity against ESBL‑producing
Enterobacteriaceae if not previously used and may be
considered therapeutic options for suspected cystitis
due to ESBL‑producing Enterobacteriaceae. Fosfomycin
should be given 3 G PO Q72h x 3 doses.
• Vancomycin‑resistant Enterococcus (VRE)
‑ Growth of VRE in a urine culture often indicates urinary
colonization due to recent use of antibiotics, rather than
a urinary infection. However, when treatment is indicated
in symptomatic patients, fosfomycin retains good activity
and may be considered a therapeutic option for suspected
cystitis due to VRE. Fosfomycin should be given 3 G PO
Q72h x 2 doses.
• Acute pyelonephritis
‑ In critically ill patients with acute pyelonephritis
(qSOFA ≥2), please refer to Guidelines for management
of gram‑negative bloodstream infections for
recommendations on empirical antimicrobial therapy
(page 2).
‑ **In patients with concurrent gram‑negative bloodstream
infection, levofloxacin 750 mg daily is the preferred oral
agent for definitive therapy in susceptible bloodstream
isolates. Please refer to Customized antimicrobial
treatment duration for uncomplicated gram‑negative BSI
(page 12).
‑ **For acute pyelonephritis without bloodstream infection,
7 days of therapy is typically appropriate for females, if
38
fluoroquinolones are used. For males, on fluoroquinolones
or all patients on SMZ‑TMP, 14 days of therapy is preferred.
‑ If IV antibiotics are continued in the hospital, transition to a
narrower spectrum agent (ampicillin, ampicillin‑sulbactam,
cefazolin, etc.) based on final culture and in vitro
antimicrobial susceptibility data as appropriate.
‑ Transition to oral therapy such as fluoroquinolones
or SMZ‑TMP is appropriate based on culture and
susceptibility data.
‑ Use of oral 3rd generation cephalosporins (e.g., cefdinir,
cefpodoxime) is highly discouraged due to low urinary
concentrations and higher risk of treatment failure in
comparison to fluoroquinolones and SMZ‑TMP.
‑ Nitrofurantoin and fosfomycin should be AVOIDED in
patients with suspected documented pyelonephritis.
These antibiotics do not concentrate outside the urine,
including the interstitial cells of the kidney.
β‑lactam allergy with pyelonephritis:
- 
• In patients with minor penicillin allergies (e.g., itching,
nonspecific rash), cross‑reactivity with 3rd and
4th generation cephalosporins is low (<3%). The benefit
of β‑lactam antibiotics outweighs the potential risk.
• In patients with severe β‑lactam allergies (e.g.,
anaphylaxis) and low risk of fluoroquinolone resistance
(no prior fluoroquinolone use within past 12 months,
non‑residents of a nursing home or skilled nursing
facility, etc.), ciprofloxacin 400 mg IV Q8‑12h is
recommended.
• In patients who have severe β‑lactam allergies and risk
factors for fluoroquinolone resistance, please contact
Prisma Health‑Midlands Antimicrobial Stewardship
and Support Team (PHASST) during business hours or
an infectious diseases specialist for optimal empirical
antimicrobial therapy or penicillin skin testing (PHR
pager 803‑352‑1322).
39
40
Acute cystitis and pyelonephritis: Outpatient
Prisma Health guidelines for acute cystitis and pyelonephritis:
Outpatient management in adults
Do NOT treat asymptomatic patients NO Urinary symptoms YES
with positive urine cultures*

Acute cystitis Acute pyelonephritis

Defined as lower urinary symptoms/signs (e.g., Defined as fever >38 C, unilateral back or flank pain,
dysuria, new or increased frequency or urgency, costovertebral angle tenderness ± radiologic evidence of
suprapubic tenderness), pyuria on urinalysis, and kidney involvement
temperature <38 C

Uncomplicated Complicated cystitis Risk factors for fluoroquinolone resistance

cystitis Defined as: Any of the following:
Defined as: • >2 UTIs in past • Use of fluoroquinolones in the past 12 months
• Female of 12 months • Outpatient gastrointestinal or genitourinary procedure in
childbearing • Urologic the past 30 days.
potential abnormalities • Resident of a nursing home/skilled nursing facility
• No urologic • (e.g., stones)
abnormalities • Males
• Indwelling
catheters NO YES

Nitrofurantoin Oral options: Levofloxacin4 Ceftriaxone

(Macrobid)1 Nitrofurantoin 750mg PO Q24h X 5 days 1g IV/IM X1
100mg PO Q12h X (Macrobid)1 or 14 days PLUS
5 days ONLY if CrCl 100mg PO Q12h X OR OR
≥30 ml/min 7 days ONLY if CrCl Ciprofloxacin5 SMZ-TMP3
OR ≥30 ml/min 500mg PO Q12h X 7 days 1 DS PO Q12h X 14 days
Fosfomycin2 OR
3G PO X 1 dose SMZ‑TMP3 Avoid SMZ‑TMP if SMZ‑TMP
OR 1 DS PO Q12h X 7 days use or prior urinary culture
SMZ‑TMP3 with SMZ‑TMP‑resistant
Avoid SMZ‑TMP if
1 DS PO Q12h X bacteria within 12 months
SMZ‑TMP use or prior
3 days urinary culture with
SMZ‑TMP‑resistant
**Avoid SMZ‑TMP if bacteria within
SMZ‑TMP use or prior 12 months
urinary culture with
SMZ‑TMP‑resistant If IV antibiotics
bacteria within are indicated, use
12 months same options as for
pyelonephritis.

1
Nitrofurantoin should be avoided in patients with CrCl <30 ml/min.
2
Fosfomycin is not recommended as a first-line therapy in patients with complicated disease. If used for complicated disease, should
repeat Q72h for 2–3 doses.
3
SMZ-TMP can be used in patients with decreased renal function. If CrCl <30 ml/min, reduce dose to 1 SS PO Q12h. SMZ-TMP should be
used with caution in pregnancy.
4
If CrCl <20–49ml/min, give 750mg Q48h, and if <20 ml/min, give 750mg followed by 500mg Q48h.
5
If CrCl <30 ml/min, give 250mg Q12h.
41
 Diagnosis:
• Urinalysis and urine culture should be obtained prior to
initiating antibiotics in patients with recurrent infections,
urologic abnormalities, pregnancy and in males.
• Urinalysis, urine culture and blood cultures should be
obtained prior to initiating antibiotics in patients with acute
pyelonephritis, when feasible.
• For patients with indwelling catheters in place for > 2 weeks
from onset of symptoms, catheter should be replaced prior
to obtaining urinalysis and urine culture. If possible, catheter
should be discontinued, and a culture of a voided midstream
urine specimen should be obtained.
• Consider imaging in males and patients with recurrent
urinary infections.
• Presence of pyuria on urinalysis without symptoms does
not indicate a urinary tract infection. Absence of pyuria
is indicative that a urinary tract infection is not present
with the exception of acute pyelonephritis with complete
uretic obstruction.
• Patients with non‑specific symptoms:
‑ Change in urine color, odor or turbidity are typically
due to dehydration and not indicators for urinalysis or
urine culture.
‑ Behavioral changes including worsening mental or
functional status do not on their own indicate a urinary
tract infection. These patients should be monitored and
encouraged to have increased fluid intake, if possible.
Other causes of mental status change should be
assessed including constipation, dehydration, electrolyte
abnormalities, medications (e.g., narcotics, etc.), liver
failure, renal failure, blood sugar issues, sleep deprivation,
stroke, and other infections.
• Urine cultures should not be done after treatment of cystitis
or pyelonephritis to document cure.
42
Treatment:
• Asymptomatic bacteriuria
*Treatment of asymptomatic bacteriuria is strongly
discouraged because antibiotics may lead to harmful effects
to patient (e.g., Clostridium difficile infection, induction of
antimicrobial resistance, etc.) that cannot be justified based
on lack of any treatment benefits. The only exceptions are
pregnant women and before transurethral resection of the
prostate or other urologic procedures for which mucosal
bleeding is anticipated.
• Acute cystitis
‑ Fluoroquinolone (ciprofloxacin, levofloxacin) use is
strongly discouraged for the treatment of acute cystitis
because the risk of harmful adverse effects (e.g., C. difficile
infection; tendonitis; neurotoxicity; QTc prolongation;
induction of antimicrobial resistance) exceeds
potential benefit.
‑ Similarly, oral 3rd generation cephalosporins (e.g., cefdinir,
cefpodoxime) should be AVOIDED due to low urinary
concentrations and high risk of adverse events, including
induction of antimicrobial resistance.
‑ Alternative oral regimens for cystitis:
• Contraindications to first‑line therapy
- In patients with contraindications to all first‑line
therapies (e.g., complicated cystitis AND CrCl
<30 mL/min AND SMZ‑TMP allergy), cephalexin
500 mg PO Q8h or amoxicillin/clavulanic acid 500
mg/125 mg PO Q12h for 7–10 days may be used.
‑ Fluoroquinolones are considered only as last resort
options in patients with cystitis in the absence of
risk factors for fluoroquinolone resistance. May use
ciprofloxacin 250 mg PO Q12h x 3 days.
43
 Extended‑spectrum β–lactamase (ESBL)‑producing
• 
bacteria
‑ 
Non‑β‑lactam antibiotics (nitrofurantoin, fosfomycin
and SMZ‑TMP) often retain activity against
ESBL‑producing Enterobacteriaceae if not previously
used and may be considered therapeutic options
for suspected cystitis due to ESBL‑producing
Enterobacteriaceae. Fosfomycin should be given 3 G
PO Q72h x 3 doses.
• Vancomycin‑resistant Enterococcus (VRE)
‑ Growth of VRE in a urine culture often indicates
urinary colonization due to recent use of antibiotics,
rather than a urinary infection. However, when
treatment is indicated in symptomatic patients,
fosfomycin retains good activity and may be
considered a therapeutic option for suspected cystitis
due to VRE. Fosfomycin should be given 3 G PO Q72h
x 2 doses.
• Acute pyelonephritis
‑ Nitrofurantoin and fosfomycin should be AVOIDED in
patients with suspected of documented pyelonephritis.
These antibiotics do not concentrate outside the urine,
including the interstitial cells of the kidney.
‑ Use of oral 3rd generation cephalosporins (e.g., cefdinir,
cefpodoxime) is highly discouraged due to low urinary
concentrations and higher risk of treatment failure in
comparison to fluoroquinolones and SMZ‑TMP.
‑ If a patient meets any of the criteria for fluoroquinolone
resistance, but SMZ‑TMP cannot be used due to allergy or
high risk of resistance:
• Consider oral ciprofloxacin or levofloxacin following
ceftriaxone 1g IV/IM dose as long as patient has only
one risk factor for fluoroquinolone resistance and prior
fluoroquinolone use was within the past 3–12 months.
44
Estimated probability of fluoroquinolone resistance is
20–40%. Urine culture would need follow‑up.
• Patients with fluoroquinolones use within the past
3 months or multiple risk factors for resistance
have >50% probability of pyelonephritis due to
fluoroquinolone‑resistant bacteria. Fluoroquinolone
empirical therapy is discouraged in this group. There
are currently insufficient data to recommend alternative
oral antibiotics for acute pyelonephritis in these
patients. Observation/admission may be considered
while receiving IV ceftriaxone, awaiting blood and urine
culture results.
References:
1. Gupta K, Hooton TM, Naber KG, et al. International clinical practice
guidelines for the treatment of acute uncomplicated cystitis and
pyelonephritis in women: A 2010 update by the Infectious Diseases
Society of America and the European Society for Microbiology and
Infectious Diseases. Clin Infect Dis 2011; 52: e103‑20.
2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of
America guidelines for the diagnosis and treatment of asymptomatic
bacteriuria in adults. Clin Infect Dis 2006; 40: 643‑54.
3. FDA updates warnings for fluoroquinolone antibiotics. U.S. Food
& Drug Administration. Released 26 July 2016. Available at: http://
www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/
ucm513183.htm
4. Dan S, Shah A, Justo JA, et al. Prediction of fluoroquinolone
resistance in gram‑negative bacteria causing bloodstream
infections. Antimicrob Agents Chemother 2016; 60: 2265‑72.
5. Shah A, Justo JA, Bookstaver PB, et al. Application of
fluoroquinolone resistance score in management of complicated
urinary tract infections. Antimicrob Agents Chemother 2017; 61:
e02313‑16.
6. Falagas ME, Kastoris AC, Kapaskelis AM, Karageorgopoulos DE.
Fosfomycin for the treatment of multidrug‑resistant, including
extended‑spectrum beta‑lactamase producing, Enterobacteriaceae
infections: a systematic review. Lancet Infect Dis 2010; 10: 43‑50.
7. Veve MP, Wagner JL, Kenny RM, et al. Comparison of fosfomycin
to ertapenem for outpatient or step‑down therapy of
extended‑spectrum beta‑lactamase urinary tract infection. Int J
Antimicrob Agents 2016; 48: 56‑60.
45
 8. Hayes JE, O’Quinn B, Lu K, et al. Fosfomycin resistance among
vancomycin‑resistant enterococcal isolates at a tertiary care medical
center. Presented at American College of Clinical Pharmacy 2016;
Abstract #176.
9. Hammer KL, Justo J, Bookstaver PB, et al. Differential effect of prior
β‑lactams and fluoroquinolones on risk of bloodstream infections
secondary to Pseudomonas aeruginosa. Diagn Microbiol Infect Dis
2017; 87: 87‑91.
10. Augustine M, Testerman TL, Justo J, et al. Clinical risk score for
prediction of extended‑spectrum beta‑lactamase‑producing
Enterobacteriaceae in bloodstream isolates. Infect Control Hosp
Epidemiol 2017; 38: 266‑272.
11. Pichichero ME. Cephalosporins can be prescribed safely for
penicillin‑allergic patients. J Fam Pract 2006; 55: 106‑12.
12. Jeffres MN, Narayanan PP, Shuster JE, Schramm GE. Consequences
of avoiding β‑lactams in patients with β‑lactam allergies. J Allergy
Clin Immunol 2016; 137: 1148‑53.
13. Hoang P, Salbu RL. Updated nitrofurantoin recommendations in the
elderly: a closer look at the evidence. Consult Pharm 2016; 31: 381‑4.
14. Nelson AN, Justo JA, Bookstaver PB, et al. Optimal duration of
antimicrobial therapy for uncomplicated gram‑negative bloodstream
infections. Infection 2017; 45: 613‑20.
15. Kutob LF, Justo JA, Bookstaver PB, et al. Effectiveness of oral
antibiotics for definitive therapy of gram‑negative bloodstream
infections. Int J Antimicrob Agents 2016; 48: 498‑503.
16. Falagas ME, et al. Fosfomycin for the treatment of
multidrug‑resistant, including extended‑spectrum beta‑lactamase
producing Enterobacteriaceae infections: a systematic review.
Lancet Infect Dis 2010; 10: 43‑50.
17. Veve MP, et al. Comparison of fosfomycin to ertapenem for
outpatient or step‑down therapy of extended‑spectrum
beta‑lactamase urinary tract infection. Int J Antimicrob Agents 2016;
48: 56‑60.
18. Sanasi‑Bhola K, et al. Fosfomycin in vitro activity against extended
spectrum beta‑lactamase positive and carbapenem resistant
Enterobacteriaceae urine isolates. Presented at IDWeek 2014.
Abstract #40851.
19. Nieuwkoop C, van der Starre WE, Stalenhoef JE, et al. Treatment
duration of febrile urinary tract infection: a pragmatic randomized,
double‑blind, placebo‑controlled non‑inferiority trial in men and
women. BMC Medicine 2017; 15: 70.
20. Johnson JR, Russo TA. Acute pyelonephritis in adults. N Engl J Med
2018; 378: 48‑59.

46 47
48
Prisma Health inpatient management of community‑onset bacterial
pneumonia in adults
Suspected or confirmed pneumonia
• Radiographic infiltrate AND
• 2 of 3 clinical features: fever (>38 C or >100.4 F), leukocytosis or leukopenia, purulent sputum

Type of pneumonia
• CAP: Symptom onset occurring in the community setting or <48hrs after hospital admission
• HCAP: Use of this term is no longer recommended due to poor predictive performance for drug resistance.

Diagnostics to consider:
CXR, Vitals, ABG/O2sat, CBC, respiratory Gram stain and culture, blood culture from 2 sites, Streptococcus
pneumoniae and Legionella urinary antigens, MRSA nasal swab for PCR, Influenza A & B PCR

Any risk factors for Pseudomonas aeruginosa

No risk factors Risk factors for Antipseudomonal (APBL)‑susceptible
Pseudomonas aeruginosa
• Interstitial lung disease (e.g., severe pulmonary fibrosis, but
excluding COPD or asthma)
• Prior use of non-APBL 2 within last 3–30 days (e.g., AMC, CRO)
Risk factors for
APBL‑resistant Pseudomonas aeruginosa
• Cystic fibrosis or bronchiectasis3
• Prior APBL 2 use for ≥ 48hrs within
3–30 days (e.g., TZP, FEP, CAZ)
Community-onset bacterial pneumonia

• Prior airway colonization with P. aeruginosa susceptible • Prior airway colonization with
to APBL (e.g., TZP, FEP, CAZ) within the last 12 months P. aeruginosa resistant to APBL (e.g.,
• Severe immune compromise (neutropenia, steroids, etc.) TZP, FEP, CAZ) within the last 12 months

Standard coverage4 APBL-Susceptible pseudomonal coverage7 APBL‑Resistant pseudomonal coverage10

Ceftriaxone 2 G IV Q24h
± Atypical coverage
Azithromycin 500mg IV/PO X 1 5
(Continue if Legionella urinary
antigen positive or if clinical
suspicion high)
Potential PO Transition6:
Amoxicillin/Clavulanate
500mg/125mg PO Q8h
± Atypical coverage (if still
needed)
Azithromycin 500mg PO Q24h 5
Total duration: 7 days
Cefepime 2G IV Q8h
OR
Piperacillin-tazobactam 4.5 G IV Q6h7
± Atypical coverage:
Azithromycin 500mg IVPO x1 5
(Continue if Legionella urinary antigen
positive or if clinical suspicion high)
Potential PO transition6:
Levofloxacin 750mg PO Q24h
Total duration: 7 days9
Cefepime 2G IV Q8h 8,11
OR
Piperacillin‑tazobactam 4.5 G IV Q6h11
+ Double gram‑negative coverage:
Tobramycin 5–7.5 mg/kg IV Q24h
(Consider pharmacy consult to dose)
± Atypical coverage:
Azithromycin 500mg IV/PO x1 5 (Continue
if Legionella urinary antigen positive or if
clinical suspicion high)
Potential PO transition:
Limited options, consult ID/ASST
Total duration: 7 Days9

If critically ill, also ADD:

Vancomycin 25 mg/kg IV X1 as loading dose, then maintenance dose per Prisma Health Guidelines (consider pharmacy consult to
dose). Discontinue vancomycin if MRSA nasal swab PCR is negative.

Abbreviations:
APBL: Antipseudomonal beta-lactam
AMC: Amoxicillin-clavulanate
FEP: Cefepime
CRO: Ceftriaxone
CAZ: Ceftazidime
TZP: Piperacillin-tazobactam
49
50
Prisma Health inpatient management of hospital‑acquired,
ventilator‑associated bacterial pneumonia in adults
Suspected or confirmed pneumonia
• Radiographic infiltrate AND
• 2 of 3 clinical features: fever (>38 C or >100.4 F), leukocytosis or leukopenia, purulent sputum

Type of pneumonia
• HAP: Symptom onset occurring ≥48hrs after hospital admission
• VAP: Symptom onset occurring ≥48hrs after endotracheal intubation
bacterial pneumonia

Diagnostics to consider:
CXR, Vitals, ABG/O2sat, CBC, respiratory Gram stain and culture, blood culture from 2 sites, Streptococcus
pneumoniae and Legionella urinary antigens, MRSA nasal swab for PCR, Influenza A & B PCR

Any risk factors for Pseudomonas aeruginosa

No risk factors Risk factors for antipseudomonal (APBL)‑susceptible Risk factors for APBL‑resistant
AND Pseudomonas aeruginosa Pseudomonas aeruginosa
hospitalization • Interstitial lung disease (e.g., severe pulmonary fibrosis, but • Cystic fibrosis or bronchiectasis3
≤5 days excluding COPD or asthma) • Prior APBL 2 use for ≥ 48hrs within 3–30
• Prior use of non‑APBL2 within last 3–30 days (e.g., AMC, CRO) days (e.g., TZP, FEP, CAZ)
• Prior airway colonization with P. aeruginosa susceptible to • Prior airway colonization with
Hospital-acquired, ventilator-associated

APBL (e.g., TZP, FEP, CAZ) within the last 12 months P. aeruginosa resistant to APBL (e.g.,
• Severe immune compromise TZP, FEP, CAZ) within the last 12 months
• Prolonged hospitalization of >5 days at symptom onset

Standard coverage4 APBL-susceptible pseudomonal & APBL-resistant pseudomonal &

Ceftriaxone 2 G IV Q24h
+ Cefepime 2G IV Q8h 8
Vancomycin 15mg/kg IV q8–12h
(Consider pharmacy consult
to dose, & discontinue if MRSA
nasal swab PCR is negative)
± Atypical coverage:
Azithromycin 500mg IVPO x1 5
(Continue if Legionella urinary
antigen positive or if clinical
suspicion high)
Potential PO transition6:
Amoxicillin/clavulanate
500mg/125mg PO Q8h
MRSA coverage7
OR
Piperacillin-tazobactam 4.5 G IV Q6h
+ Double gram-negative coverage:
Vancomycin 15mg/kg IV q8–12h (Consider
pharmacy consult to dose, & discontinue if
MRSA nasal swab PCR is negative)
± Atypical coverage:
Azithromycin 500mg IV/PO x1 5
(Continue if Legionella urinary antigen positive
or if clinical suspicion high)
9
Total duration: 7 days
MRSA coverage10
Cefepime 2G IV Q8h 8,11
OR Piperacillin-tazobactam 4.5 G IV Q6h11
+
Tobramycin 5–7.5 mg/kg IV Q24h
(Consider pharmacy consult to dose)
+
Vancomycin 15mg/kg IV q8–12h (Consider
pharmacy consult to dose, & discontinue if
MRSA nasal swab PCR is negative)
± Atypical coverage:
Azithromycin 500mg IVPO x1 5 (Continue
if Legionella urinary antigen positive or if
clinical suspicion high)

± Atypical coverage Total duration: 7 days9

(if still needed)
Azithromycin 500mg PO Q24h 5

Total duration: 7 days9

Abbreviations:
APBL: Antipseudomonal beta-lactam
AMC: Amoxicillin-clavulanate
FEP: Cefepime
CRO: Ceftriaxone
CAZ: Ceftazidime
TZP: Piperacillin-tazobactam
51
 Footnotes:
1. Use of clinical judgment is encouraged when selecting empiric
therapy for a patient, including consideration of severity of
illness, prior microbiology and prior antimicrobial history. Revise
antimicrobial regimen based on microorganism identification (e.g.,
culture, PCR) and antimicrobial susceptibility testing results.
2. Prior antibiotics defined as a duration ≥48 hours (excludes one‑time
doses and/or most surgical prophylaxis).
3. Patients with cystic fibrosis or bronchiectasis may have extensive
histories of multidrug‑resistant organisms and may require
customized therapy. Strongly consider consulting with infectious
diseases, the Prisma Health Antimicrobial Stewardship and
Support Team (PHASST), and/or pulmonology for assistance with
antimicrobial selection.
4. Standard coverage for early onset (≤5 days) pathogens:
Streptococcus pneumoniae, Haemophilus influenzae, MSSA,
Enterobacteriaceae (e.g., E. coli, Klebsiella spp.)
5. Add if atypical pneumonia (e.g., Legionella spp., Mycoplasma
spp., Chlamydia spp.) is suspected. If azithromycin cannot be
used, consider doxycycline 100 mg PO Q12h as an alternative
(or levofloxacin 750 mg PO Q24h for documented Legionella
pneumonia).
6. Consider transition to oral therapy once clinically improved/stable.
Depending on causative pathogen, oral options may be even
narrower spectrum than those presented herein. Narrowest effective
therapy is generally preferred to minimize adverse effects and
emergence of resistance.
7. Provides coverage for late onset (>5 days) pathogens: Early onset
organisms PLUS P. aeruginosa, resistant Enterobacteriaceae,
Acinetobacter spp., etc.
8. Cefepime generally preferred to minimize risk of acute kidney injury
with concomitant vancomycin and piperacillin/tazobactam
9. Duration of therapy may be extended (e.g., total 10–14 days) for
patients who fail to respond clinically and/or are definitely diagnosed
with pneumonia due to non‑lactose fermenting gram‑negative
bacteria (e.g., P. aeruginosa) or Legionella spp.
10. Provides coverage for multidrug‑resistant (MDR) gram‑negative
pathogens: MDR P. aeruginosa, MDR Acinetobacter spp., etc.
11. Avoid using same APBL the patient was recently exposed to or
that recent organism was resistant to (e.g., if recent TZP exposure,
select FEP); antipseudomonal carbapenems (e.g., meropenem) may
also be considered as the APBL component for patients eligible for
APBL‑resistant pseudomonal coverage.
12. All dosages provided assume normal renal and hepatic function.
52
Definitions:
• Severe immune compromise: neutropenia
(ANC <500 cells/mm3), HIV/AIDS (CD4 < 200 cells/
mm3), or immunocompromising medications within the
last 30 days (e.g., high‑dose corticosteroids of ≥ 20 mg
daily prednisone‑equivalents ≥2 weeks, chemotherapy,
calcineurin inhibitors)
• Critical illness: Intensive care unit admission, need for
mechanical ventilation or vasopressors, or other severe
complications of pneumonia (e.g., empyema)
Local risk factors vs. historical
healthcare‑associated pneumonia (HCAP)
risk factors
• These guidelines are based on local studies and national
clinical guidelines for pneumonia.1‑3
• Historical risk factors for healthcare‑associated pneumonia
(HCAP) were published in a previous version of ATS/IDSA
HAP/VAP/HCAP Guidelines from 2005.4
‑ HCAP risk factors: residence in a nursing home or
extended care facility; hospitalization for ≥2 days in the
preceding 90 days; home infusion therapy, home wound
care or chronic dialysis within 30 days; or family member
with a multidrug‑resistant (MDR) organism.
• Subsequent research demonstrated HCAP risk factors had
a limited ability to predict for MDR organisms and, due to
their low specificity, favored unnecessary overutilization of
broad‑spectrum antibiotics.3,5,6
‑ Thus, the HCAP designation was omitted from the
current 2016 IDSA/ATS HAP/VAP Guidelines, and the panel
stated further recommendations for community‑onset
pneumonia will likely be based on validated risk factors
for MDR organisms.3 These recommendations are
expected in a pending update to the 2007 IDSA/ATS
Community‑acquired Pneumonia Guidelines.2
53
 • Current national guidelines strongly encourage
customization of local guidelines based on local
epidemiology and antimicrobial resistance data.3 In 2018,
a local study was published evaluating pneumonia in adult
hospitalized patients at Palmetto Health.1 It identified local
risk factors to predict for both susceptible and resistant
Pseudomonas aeruginosa, respectively, compared to other
respiratory bacterial pathogens. These local guidelines
reflect the risk factors identified in this study combined with
other local data on predicting antimicrobial resistance.7,11,12
Beta‑lactam allergy:
• Minor penicillin allergies (nonspecific or maculopapular
rashes, intolerance, etc.): Consider a cephalosporin, such
as ceftriaxone (or cefepime if antipseudomonal coverage
is needed). Cross‑reactivity with 3rd and 4th generation
cephalosporins is low (<3%) in patients with minor penicillin
allergies, and the benefit from beta‑lactam antibiotics
outweighs the potential risk in these patients.
• Serious penicillin allergies (anaphylaxis, angioedema,
breathing problems and hives): Consider a respiratory
fluoroquinolone, such as levofloxacin 750 mg IV Q24h, in the
absence of prior exposure to fluoroquinolones in the past
12 months. Ciprofloxacin 400 mg IV Q8h can be considered
if antipseudomonal coverage is needed, but does not provide
adequate gram‑positive coverage (e.g., Streptococcus
pneumoniae, MRSA) and may need to be coupled with
vancomycin. Consider consultation with an infectious
diseases specialist or PHASST for optimal empirical therapy
or penicillin skin testing.
54
Empiric levofloxacin use:
• Given the importance of fluoroquinolones in the
management of serious infections and their relative
toxicity (e.g., dysglycemias, CNS side effects, muscle
injury, tendonitis) compared to alternative agents, it is
recommended to reserve fluoroquinolones for select
patient cases where benefit outweighs the risk (e.g., severe
beta‑lactam allergy, oral antipseudomonal coverage).
• Avoid levofloxacin for gram‑negative bacterial coverage
if patient had prior fluoroquinolone use, particularly
within the past 3 months (risk of infections due to
fluoroquinolone‑resistant bacteria may persist for up to
12 months from fluoroquinolone use).
Aspiration pneumonia:
• Add metronidazole to either cephalosporins or levofloxacin
to include coverage for obligate anaerobic bacteria. The use
of clindamycin is discouraged due to added risk of C. difficile
infection when combined with other broad‑spectrum
agents. Piperacillin‑tazobactam and carbapenems provide
adequate anaerobic coverage if selected for empirical
therapy of P. aeruginosa or MDR gram‑negative bacteria,
respectively.
Renal impairment:
• If tobramycin is recommended above, consider replacing
this agent with an antipseudomonal fluoroquinolone (i.e.,
ciprofloxacin or levofloxacin) in the absence of recent
fluoroquinolone use within the past 3 months. Inhaled
tobramycin may be considered in patients with renal
impairment who received fluoroquinolones recently.
55
 De‑escalation tips: influenza A or B virus, supportive care for rhinovirus) or atypical
Atypical coverage: bacterial pneumonia management (e.g., azithromycin).
• If diagnostics for atypical bacteria are negative (e.g., atypical
bacteria on the respiratory viral PCR panel, Legionella urinary Additional risk factors for antimicrobial
antigen), consider discontinuing atypical coverage altogether. resistance:
• If Legionella is highly suspected (recent outbreak or classic • Extended‑spectrum beta‑lactamase (ESBL)‑producing
clinical and laboratory manifestations for Legionella organisms
pneumonia, e.g., high fever, severe hypoxia, hyponatremia, ‑ Carbapenems are preferred in patients with high risk of
elevated liver enzymes), consider levofloxacin or pneumonia due to ESBL‑producing bacteria, including:
azithromycin over doxycycline as atypical coverage. • Documentation of prior infections or colonization with
• The recommended duration of azithromycin therapy varies ESBL‑producing bacteria in the past 12 months.
based on dosage and is often shorter than a concomitant • Receipt of multiple courses of broad‑spectrum
beta‑lactam antibiotic agent. Two acceptable regimens antibiotics (piperacillin‑tazobactam, cefepime, etc.) in
include either: the past 90 days.12
‑ Azithromycin 500mg IV/PO Q24h x total 3 days • Consult PHASST during business hours or an infectious
OR diseases specialist for assistance determining optimal
‑ Azithromycin 500mg IV/PO x 1 day, then 250 mg IV/PO empirical antimicrobial therapy.
Q24h x 4 days (x total 5 days)
‑ For Legionella pneumonia: Duration of azithromycin
therapy may be extended to total 10–14 days,
particularly for cases of severe illness and/or slow clinical
improvement
MRSA nasal swab PCR:
This test typically demonstrates a negative predictive value
of >95% for ruling out MRSA as a causative pathogen for
pneumonia.8‑10 This is a useful diagnostic in patients at
increased risk of MRSA pneumonia at baseline (e.g., residence
in a long‑term care facility, wound care in the last 30 days, prior
MRSA infection/colonization within 90 days).

Respiratory viral PCR panel:

This test, which is designed for upper respiratory tract
infections, includes both viral and atypical bacterial targets
for community‑acquired pneumonia. If the patient is unlikely
to have polymicrobial pneumonia, consider streamlining to
appropriate viral pneumonia management (e.g., oseltamivir for

56 57
58
Prisma Health guidelines for community-onset pneumonia in adults in
the ED/Ambulatory setting
Suspected or confirmed pneumonia
• Radiographic infiltrate AND
• 2 of 3 clinical features: fever (>38 C or >100.4 F), leukocytosis or leukopenia, purulent sputum

Type of pneumonia
• CAP: Symptom onset occurring in the community setting or <48hrs after hospital admission
Ambulatory setting

• HCAP: Use of this term is no longer recommended by clinical guidelines due to poor predictive
performance for drug resistance.

Diagnostics to consider:
CXR, Vitals, ABG/O2sat, CBC, respiratory Gram stain and culture, blood culture from 2 sites, Streptococcus
pneumoniae and Legionella urinary antigens, MRSA nasal swab for PCR, Influenza A & B PCR

Severity of illness (CURB-65 score)

Low: CURB-65 < 2 Moderate: CURB-65 = 2 Severe: CURB-65 >2

Community-onset pneumonia in the ED/

Consider outpatient management Consider observation/admission to floor Consider admission (possibly to ICU)

Any risk factors for Pseudomonas aeruginosa?1

• Interstitial lung disease (e.g., severe pulmonary fibrosis, • Prior airway colonization with P. aeruginosa within the
but excluding COPD or asthma) last 12 months
YES • Cystic fibrosis or bronchiectasis2 • Severe immune compromise (e.g., neutropenia, high
• Prior use of beta-lactams within 30 days dose corticosteroids)

NO

Pseudomonal coverage Standard coverage: Low severity Standard coverage: Moderate severity
Levofloxacin Amoxicillin-clavulanate Ceftiaxone 2G IV Q24h
750mg IV/PO Q24h 500mg/125mg Q8h
± Atypical coverage:
(Low CURB‑65 use PO,
Mod. CURB‑65 use IV) ± Atypical coverage: Azithromycin 500mg IV/PO Q24h
OR
Azithromycin 500mg PO X1, Doxycycline 100mg IV/PO Q12h
Total duration: 7 days Then 250mg PO Q24h
OR Potential PO transition
Doxycyline 100mg PO Q12h Amoxicillin-clavulanate 500mg/125mg Q8h
± Atypical coverage:
Total duration: 5–7 days Azithromycin 500mg PO X1, Then 250mg PO Q24h
OR
Doxycyline 100mg PO Q12h
Common pathogens Total duration: 5-7 days
Typical bacteria Atypical bacteria
S.pneumoniae Legionella spp.
H.influenzae Mycoplasma spp.
M.catarrhalis Chlamydia spp. See Guidelines for inpatient community-onset bacterial pneumonia in adults (page 48).
59
 Footnotes: Definitions:
1. Use of clinical judgment is encouraged when selecting empiric • Severe immune compromise: neutropenia (ANC
therapy for a patient, including consideration of severity of
illness, prior microbiology and prior antimicrobial history. Revise <500 cells/mm3), HIV/AIDS (CD4 <200 cells/mm3), or
antimicrobial regimen based on microorganism identification (e.g., immunocompromising medications within the last 30
culture, PCR) and antimicrobial susceptibility testing results. days (e.g., high‑dose corticosteroids of ≥20 mg daily
2. Patients with cystic fibrosis or bronchiectasis may have extensive prednisone‑equivalents ≥2 weeks, chemotherapy,
histories of multidrug‑resistant organisms and may require calcineurin inhibitors)
alternative therapy aside from levofloxacin monotherapy. Strongly
consider consulting with infectious diseases, the Prisma Health
Antimicrobial Stewardship and Support Team (PHASST), and/or
pulmonology for assistance with antimicrobial selection. CURB‑65 score: Sum of each of the following characteristics
3. All dosages provided assume normal renal and hepatic function.
Characteristic Points
Confusion (defined by one of the following): 1
Abbreviated Mental Test Score <8
New disorientation in person, place or time
Uremia (BUN >19 mg/dL) 1
Respiratory rate ≥30 breaths/min 1
Blood pressure (SBP <90 mmHg or DBP ≤60 mmHg) 1
Age ≥65 years 1

CURB-65 score 30-day mortality risk

<2 <2%
2 9%
>2 >19%

Local‑risk factors vs. historical

healthcare‑associated pneumonia (HCAP)
risk factors
• These guidelines are based on local studies and national
clinical guidelines for pneumonia.1‑3
• Historical risk factors for healthcare‑associated pneumonia
(HCAP) were published in a previous version of ATS/IDSA
HAP/VAP/HCAP Guidelines from 2005.4

60 61
 - HCAP risk factors: residence in a nursing home or
extended care facility; hospitalization for ≥2 days in the
preceding 90 days; home infusion therapy, home wound
care or chronic dialysis within 30 days; or family member
with a multidrug‑resistant (MDR) organism.
• Subsequent research demonstrated HCAP risk factors had
a limited ability to predict for MDR organisms and, due to
their low specificity, favored unnecessary overutilization of
broad‑spectrum antibiotics.3,5,6
- Thus, the HCAP designation was omitted from the current
2016 IDSA/ATS HAP/VAP Guidelines, and the panel
stated further recommendations for community‑onset
pneumonia will likely be based on validated risk factors
for MDR organisms.3 These recommendations are
expected in a pending update to the 2007 IDSA/ATS
Community‑acquired Pneumonia Guidelines.2
• Current national guidelines strongly encourage
customization of local guidelines based on local
epidemiology and antimicrobial resistance data.3 In 2018,
a local study was published evaluating pneumonia in adult
hospitalized patients at Prisma Health in the Midlands.1 It
identified local risk factors to predict for both susceptible
and resistant Pseudomonas aeruginosa, respectively,
compared to other respiratory bacterial pathogens. These
local guidelines reflect the risk factors identified in this study
combined with other local data on predicting antimicrobial
resistance.7,11,12
Beta‑lactam allergy:
• Minor penicillin allergies (nonspecific or maculopapular
rashes, intolerance, etc.): Consider a cephalosporin, such as
cefuroxime 500 mg PO Q12h or cefdinir 300 mg PO Q12h.
Cross‑reactivity with these higher generation cephalosporins
is low (<3%) in patients with minor penicillin allergies and the
benefit from beta‑lactam antibiotics outweighs the potential
risk in these patients.
62
• Serious penicillin allergies (anaphylaxis, angioedema,
breathing problems and hives): Consider a respiratory
fluoroquinolone, such as levofloxacin 750 mg PO Q24h, in
the absence of prior exposure to fluoroquinolones in the
past 12 months. Consider consultation with an infectious
diseases specialist or PHASST for optimal empirical therapy
or penicillin skin testing.
Empiric levofloxacin use:
• Given the importance of fluoroquinolones in the
management of serious infections and their relative
toxicity (e.g., dysglycemias, CNS side effects, muscle
injury, tendonitis) compared to alternative agents, it is
recommended to reserve fluoroquinolones for select patient
cases where the benefit outweighs the risk (e.g., severe
beta‑lactam allergy, oral antipseudomonal coverage).
• Avoid levofloxacin for gram‑negative bacterial coverage
if patient had prior fluoroquinolone use, particularly
within the past 3 months (risk of infections due to
fluoroquinolone‑resistant bacteria may persist for up to 12
months from fluoroquinolone use).
• If antipseudomonal or other gram‑negative bacterial
coverage is warranted and an oral fluoroquinolone is not
reliable empiric coverage, the patient may require hospital
admission for further work‑up and consultation with an
infectious diseases specialist or PHASST to determine
optimal empirical therapy.
De‑escalation tips:
Atypical coverage:
• If diagnostics for atypical bacteria are negative (e.g., atypical
bacteria on the respiratory viral PCR panel, Legionella urinary
antigen), consider discontinuing atypical coverage altogether
- While Legionella urinary antigen only evaluates for
L. pneumophila group 1, this represents ~70–80% of
Legionnaires’ disease in the community.
63
 • If Legionella is highly suspected (recent outbreak or classic
clinical and laboratory manifestations for Legionella
pneumonia, e.g., high fever, severe hypoxia, hyponatremia,
elevated liver enzymes), consider azithromycin or
levofloxacin over doxycycline as atypical coverage.
• The recommended duration of azithromycin therapy varies
based on dosage and is often shorter than a concomitant
beta‑lactam antibiotic agent. Two acceptable regimens
include either:
- Azithromycin 500mg IV/PO Q24h x total 3 days
OR
- Azithromycin 500mg IV/PO x 1 day, then 250 mg IV/PO
Q24h x 4 days (x total 5 days)
- For Legionella pneumonia: Duration of azithromycin
therapy may be extended to total 10–14 days,
particularly for cases of severe illness and/or slow clinical
improvement
MRSA nasal swab PCR:
• This test typically demonstrates a negative predictive value
of >95% for ruling out MRSA as a causative pathogen for
pneumonia.8‑10 This is a useful diagnostic in patients at
increased risk of MRSA pneumonia at baseline (e.g., residence
in a long‑term care facility, wound care in the last 30 days,
prior MRSA infection/colonization within 90 days).
Respiratory viral PCR panel:
• This test, which is designed for upper respiratory tract
infections, includes both viral and atypical bacterial targets
for community‑acquired pneumonia. If the patient is
unlikely to have a secondary bacterial pneumonia, consider
streamlining to appropriate viral pneumonia management
(e.g., oseltamivir for influenza A or B virus, supportive care
for rhinovirus) or atypical bacterial pneumonia management
(e.g., azithromycin).

64 65
 Pneumonia de-escalation guide
Pneumonia de‑escalation guide De‑escalation options De‑escalation options
based on rapid based on susceptibility
Organism diagnostic testing testing
De‑escalation options De‑escalation options
based on rapid based on susceptibility Other Enterobacteriaceae (with potential chromosomal AmpC production)
Organism diagnostic testing testing
Enterobacter cloacae Cefepime -- Cefepime Levofloxacin
IV PO IV PO Klebsiella (formerly
Enterobacter)
Typical gram‑positive bacteria aerogenes
Serratia marcescens
Streptococcus Ampicillin- Amoxicillin- Penicillin G Amoxicillin
pneumoniae sulbactam clavulanate Ampicillin Amoxicillin- Non-lactose-fermenting gram-negative bacteria
Ceftriaxone Ampicillin- clavulanate
sulbactam Pseudomonas Cefepime -- Cefepime Ciprofloxacin
Ceftriaxone aeruginosa Piperacillin- Piperacillin- Levofloxacin
Acinetobacter tazobactam tazobactam
Typical gram‑negative bacteria baumannii

Haemophilus Ampicillin- Amoxicillin- Ampicillin Amoxicillin

influenzae sulbactam clavulanate Ampicillin- Amoxicillin-
Moraxella catarrhalis Ceftriaxone sulbactam clavulanate
Ceftriaxone References:
Atypical bacteria 1. Al‑Jaghbeer MJ, Justo JA, Owens W, Kohn J, Bookstaver PB,
Hucks J, Al‑Hasan MN. Risk factors for pneumonia due to
Legionella spp. Levofloxacin Levofloxacin Levofloxacin Levofloxacin beta‑lactam‑susceptible and beta‑lactam‑resistant Pseudomonas
Azithromycin Azithromycin Azithromycin Azithromycin
aeruginosa: a case‑case‑control study. Infection. 2018; 46: 487‑94.
Chlamydia Azithromycin Azithromycin Azithromycin Azithromycin 2. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases
(Chlamydophila) Doxycycline Doxycycline Doxycycline Doxycycline Society of America/American Thoracic Society consensus guidelines
pneumoniae
on the management of community‑acquired pneumonia in adults.
Mycoplasma
pneumoniae Clin Infect Dis 2007; 44 Suppl 2: S27‑72.
3. Kalil AC, Metersky ML, Klompas M, et al. Management of adults
Staphylococcus aureus with hospital‑acquired and ventilator‑associated pneumonia: 2016
MSSA Nafcillin Dicloxacillin Nafcillin Dicloxacillin clinical practice guidelines by the Infectious Diseases Society of
Cefazolin Cephalexin Cefazolin Cephalexin America and the American Thoracic Society. Clin Infect Dis 2016; 63:
e61‑e111.
MRSA Vancomycin Linezolid Vancomycin Doxycycline
Linezolid Linezolid SMZ-TMP 4. American Thoracic Society, Infectious Diseases Society of America.
Clindamycin Guidelines for the management of adults with hospital‑acquired,
Linezolid ventilator‑associated, and healthcare‑associated pneumonia. Am J
Respir Crit Care Med 2005; 171: 388‑416.
Enterobacteriaceae
5. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare‑associated
Escherichia coli Ceftriaxone -- Ampicillin Amoxicillin pneumonia does not accurately identify potentially resistant
Klebsiella pneumoniae Ampicillin- Amoxicillin- pathogens: a systematic review and meta‑analysis. Clin Infect Dis
Klebsiella oxytoca sulbactam clavulanate 2014; 58: 330‑339.
Proteus mirabilis Cefazolin Cephalexin
Ceftriaxone Levofloxacin 6. Webb BJ, Dascomb K, Stenehjem E, et al. Derivation and multicenter
validation of the drug resistance in pneumonia clinical prediction
score. Antimicrob Agents Chemother 2016; 60: 2652‑63.

66 67
 7. Hammer KL, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al‑Hasan
MN. Differential effect of prior β‑lactams and fluoroquinolones
on risk of bloodstream infections secondary to Pseudomonas
aeruginosa. Diagn Microbiol Infect Dis 2017; 87: 87‑91.
8. Langsjoen J, Brady C, Obenauf E, Kellie S. Nasal screening is
useful in excluding methicillin‑resistant Staphylococcus aureus in
ventilator‑associated pneumonia. Am J Infect Control 2014; 42:
1014‑5.
9. Hiett J, Patel RK, Tate V, Smulian G, Kelly A. Using active
methicillin‑resistant Staphylococcus aureus surveillance nasal swabs
to predict clinical respiratory culture results. Am J Health Syst Pharm
2015; 72 (Suppl 1): S20‑4.
10. Smith MN, Brotherton AL, Lusardi K, Tan CA, Hammond DA.
Systematic review of the clinical utility of Methicillin‑Resistant
Staphylococcus aureus (MRSA) nasal screening for MRSA
pneumonia. Ann Pharmacother 2019; 53: 627‑638.
11. Dan S, Shah A, Justo JA, Bookstaver PB, Kohn J, Albrecht H,
Al‑Hasan MN. Prediction of fluoroquinolone resistance in
gram‑negative bacteria causing bloodstream infections. Antimicrob
Agents Chemother 2016; 60: 2265‑72.
12. Augustine MR, Testerman TL, Justo JA, Bookstaver PB, Kohn J,
Albrecht H, Al‑Hasan MN. Clinical risk score for prediction of
extended‑spectrum beta‑lactamase producing Enterobacteriaceae
in bloodstream isolates. Infect Control Hosp Epidemiol 2017; 38:
266‑72.

68 69
70
Prisma Health neutropenic fevera empiric treatment guideline

Diagnostics to consider: procalcitonin, CBC, BMP, blood cultures X 2 sites, MRSA nasal swab for PCR

NO Risk factors for ESBLsb YES

Neutropenic fever

Cefepime 2 G IV Q8H Meropenem 1 G IV Q8H

OR piperacillin/tazobactam 4.5 G IV Q6H c

NO Clinical indication for gram-positive coveraged YES

Continue with gram-negative coverage Vancomycin 25mg/kg IV X1 as loading dose,

then maintenance dosing per PH Guidelines.

Concern for fungal infections e

NO YES

Continue empiric antibiotics NO Concern for aspergillosisf YES

Refer to de-escalation algorithm Anidulafungin 200mg IV X 1 dose Voriconazole 6mg/kg IV Q12H X 2 doses,
then 100mg IV Q24H then 4 mg/kg IV/PO Q12H

Refer to de-escalation algorithm Refer to de-escalation algorithm

71
 Neutropenic fever de-escalation guide
Footnotes:

regimen if indicated based on risk factors.j,k

Most recent repeat procalcitonin
If not previously
on prophylactic
antibiotics, see
a) Febrile neutropenia defined as single oral temperature of ≥101 F

DC empiric therapy and resume previous

(38.3 C) or a temperature ≥100.4 F (38.0 C) sustained over a 1‑hour

footnote g.

OR consider initiation or prophylactic

period, with ANC <500 cells/mm3 or an ANC that is expected to
decrease to <500 cells/mm3 during the next 48 hours

YES
YES
b) Clinical indications for coverage of ESBL‑producing bacteria:
• Documentation of prior infections or colonization with

<0.25ng/mL i
ESBL‑producing organisms in past 12 months OR

Above criteria AND completed minimum 5 days therapy

prophylaxis regimen
Clinical improvement indicated by afebrile ≥48 hours
• Receipt of ≥2 courses of beta‑lactam/fluoroquinolone antibiotics
(pip‑tazo, cefepime, levofloxacin, etc.) in past 90 days
• Receipt of fluoroquinolone prophylaxis or as a single course is not
an indicator for ESBL risk.

days until <0.25 ng/mL OR

c) For penicillin allergy

until ANC recovery >500

Trend procalcitonin Q 2
NO
Negative finalized culture(s) AND no

• Patients with penicillin allergy should not receive

Patient on empiric treatment for neutropenic fever

conclusive evidence of infection.

piperacillin‑tazobactam.
• In patients with minor penicillin allergies (nonspecific rashes,
intolerance, etc.), cross‑reactivity with 3rd and 4th generation
cephalosporins is low (<3%). The benefit from beta‑lactam
Neutropenic fever de‑escalation algorithm

antibiotics outweighs the potential risk in these patients.

• Treatment options in patients with serious reactions (anaphylaxis,
angioedema, breathing problems and hives) include aztreonam,
aminoglycosides (tobramycin, gentamicin), or ciprofloxacin in the
Continue empiric therapy;

absence of prior exposure to the respective class of antibiotics in

re‑evaluate for possible

the past 90 days.

sources of infection.h

• Consider consultation with PHASST or an infectious diseases

specialist for optimal empirical therapy.
• Consider penicillin allergy skin test consult.
NO

d) Clinical indications for additional gram‑positive coverage:

• Suspected catheter‑related infection OR
• Probable skin and soft tissue infection OR
Positive culture, deemed true pathogen

narrowest definitive therapy based on

• Hemodynamic instability OR
De‑escalate to most effective and

• Preliminary culture positive for gram‑positive cocci

indicated based on risk factors.j,k

e) Clinical indications or fungal coverage:

previous prophylaxis regimen

• Unexplained fever >96 hours despite broad‑spectrum antibiotics

definitive therapy, resume
organism and infection.h

Following completion of

OR consider initiation of

OR
prophylactic regimen if

• Sinus CT suggestive of fungal infection OR

• Recovery of fungus from any site

72 73
 f) Clinical indications for aspergillosis coverage:

culture negative patients.

• Criteria under footnote (e) met AND

Draw PCT Q48 hours for

If culture negative

Day 5 and beyond

Discontinue antibiotics
• Chest or sinus CT with macronodules with or without halo sign OR

≥80% decrease from

PCT level 0.25ng/mL
continue:
• History of invasive aspergillosis OR

Afebrile ≥48 hours

AND
• Patients undergoing intensive chemotherapy for AML/MDS OR

OR
• HSCT recipients with anticipated prolonged neutropenic periods
of at least 14 days

baseline
g) If cultures are negative, patient afebrile ≥ 48 hours, and their

when:
reason for hospital admission was not febrile neutropenia,
consider de‑escalation to fluoroquinolone prior to completion
of 5 days of empiric therapy if patient was not previously on
fluoroquinolone prophylaxis.

Draw PCT at 48–72 hours

h) For treatment‑related questions, contact PHASST.

Procalcitonin laboratory draw timeline recommendations

i) Procalcitonin laboratory draw timeline recommendations at end

Days 2–3
of document. Discontinuation of therapy recommended for PCT
<0.25 ng/mL OR a decrease of ≥80% from baseline.
j) In patients deemed at intermediate or high risk, the NCCN Guidelines
Panel advises that fluoroquinolone prophylaxis (levofloxacin is

All patients presenting with febrile neutropenia:

preferred) be considered in patients with an expected duration of
neutropenia (absolute neutrophil count [ANC] <1000 neutrophils/
mcL) for more than 7 days.
k) In patients at low risk of overall infection, neutropenia expected to
last less than 7 days, and who are not receiving immunosuppressive
regimens like systemic steroids, the NCCN panel suggests no
antibiotic prophylaxis.

Draw PCT at 24 hours

Day 1
Abbreviations:
ASST: antibiotic stewardship and support team
ESBL: extended-spectrum beta-lactamase
MRSA: methicillin resistant Staphylococcus aureus
NCCN: National Comprehensive Cancer Network
PCT: procalcitonin

Draw baseline PCT prior

Day 0

to antibiotics

74 75
 Ambulatory acute sinusitis
Prisma Health guidelines for management Diagnosis:
of ambulatory acute sinusitis in adults • The majority of patients with minor symptoms (clear nasal
drainage, cough, etc.) have self‑limiting viral rhinosinusitis.
• The diagnosis of allergic rhinosinusitis should be considered
Symptoms/signs consistent with acute bacterial sinusitis in patients with prolonged minor symptoms and pale nasal
• Severe symptoms for >3–4 days: fever ≥102 F or facial
pain/pressure/tenderness plus purulent (e.g., green, mucosa on physical examination, particularly in patients with
NO yellow) nasal drainage history of chronic perennial rhinosinusitis or during pollen
OR
•  Persistent symptoms >10 days without improvement:
activity in patients with seasonal allergies.
Nasal drainage and daytime cough • Secondary bacterial sinusitis is suggested in patients with
double sickening, that is acute worsening of symptoms
(fever ≥102 F or facial pain/pressure or tenderness in
Viral rhinosinusitis YES
(≥98% of acute sinusitis addition to purulent nasal drainage for >3–4 days) after initial
cases are caused by viruses) improvement from viral upper respiratory tract infection.
Precise estimation of symptom onset • Physical examination is essential to confirm the diagnosis
verified to meet >3–4 days duration if
severe of >10 days if persistent of acute bacterial sinusitis, rule out more serious infections
Symptomatic treatment: such as pneumonia or meningitis, and determine the need
Saline nasal irrigation, for imaging in patients with high risk for complications such
analgesics, intranasal
steroids, antihistamines, etc. as intracranial abscesses, sagittal sinus thrombosis, etc.
NO YES
Symptomatic treatment:
• Nasal saline irrigation may provide relief with low risk of
adverse effects.
Symptomatic treatment (as above) Symptomatic treatment (as above)
• Analgesics/antipyretics (e.g., acetaminophen, NSAIDs) may
PLUS watchful waiting PLUS antibiotics improve symptoms of pain and fever.
• Follow-up visit for clinical • Amoxicillin/clavulanate • Intranasal steroids (e.g., fluticasone) may improve symptoms
evaluation in few days (preferred) 875mg/125mg PO BID X 7 days of facial pain and nasal congestion.
OR OR • Oral antihistamines (e.g., diphenhydramine, cetirizine) may
improve symptoms of excessive secretions and sneezing.
• Communicate plan for antibiotic • Doxycycline 100mg PO BID X
prescription if patient calls back 7 days (if penicillin allergy or recent • Oral decongestants (e.g., pseudoephedrine) may improve
without improvement (preferred) amoxicillin use) nasal congestion – should be used for <5 days and in
OR the absence of co‑morbidities such as uncontrolled
hypertension or anxiety.
• Antibiotic prescription with
instructions: ”Do not fill until • Topical decongestants (e.g., oxymetazoline,
[specified future date]” tetrahydrazoline) may improve nasal congestion – use should
not exceed 3–5 days to prevent rebound congestion.

76 77
 Antibiotic comments: References:
1. Chow AW, et al. IDSA clinical practice guideline for acute bacterial
• The risks of antibiotics (Clostridium difficile infection, etc.)
rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:
exceed any potential benefits in patients with likely acute e72‑e112.
viral sinusitis based on symptoms and signs as previously 2. Rosenfeld RM, et al. Clinical practice guideline (update): adult
described. sinusitis. Otolaryngol Head Neck Surg 2015; 152: S1‑S39.
• Prescribing antibiotics on the phone without an initial patient 3. Lemiengre MB, et al. Antibiotics for clinically diagnosed acute
rhinosinusitis in adults. Cochrane Database Syst Rev 2012;
encounter and physical examination to confirm the diagnosis
10:CD006089.
and rule out complications as previously described is highly
4. Young J, et al. Antibiotics for adults with clinically diagnosed acute
discouraged. rhinosinusitis: a meta‑analysis of individual patient data. Lancet
• Counseling points: 2008; 371: 908‑914.
5. Falagas ME, et al. Comparison of antibiotics with placebo for
‑ Amoxicillin/clavulanic acid is better tolerated when taken
treatment of acute sinusitis: a meta‑analysis of randomized
with food. controlled trials. Lancet 2008; 8: 543‑552.
‑ Advise patients to drink enough fluids when taking 6. FDA updates warnings for fluoroquinolone antibiotics. U.S. Food and
Drug Administration. Released 26 July 2016.
doxycycline and avoid taking the evening dose within
Available at: http://www.fda.gov/NewsEvents/Newsroom/
2 hours of going to bed to reduce the risk of pill‑induced PressAnnouncements/ucm513183.htm.
esophagitis.
• Macrolides (e.g., azithromycin): Use discouraged due
to increasing antimicrobial resistance rates among
Streptococcus pneumoniae, the most common bacterial
etiology of acute sinusitis. Macrolide therapy should be
limited to patients with no prior macrolide use within the
past 3 months and allergy/intolerance or prior use of both
amoxicillin and doxycycline.
• Fluoroquinolones (e.g., levofloxacin, moxifloxacin): According
to recent FDA warning, fluoroquinolones should not be
used in patients with upper respiratory tract infections,
including acute bacterial sinusitis, due to high risk of adverse
events. Their use should be reserved for severely immune
compromised patients (neutropenia, etc.) or those who have
failed first‑line therapy.
• Second‑ and third‑generation cephalosporins (e.g.,
cefuroxime, cefdinir): Similarly, cephalosporin use is not
recommended due to high risk of adverse events and
induction of antimicrobial resistance. Their use should be
limited to patients who have failed first‑line options.

78 79
 Pseudomonas aeruginosa prediction score Risk of β-lactam resistant Pseudomonas
aeruginosa
Risk of beta‑lactam‑resistant Pseudomonas
Patient-specific antibiograms aeruginosa
Pseudomonas aeruginosa risk score (PARS) This model predicts the risk of resistance to antipseudomonal
beta‑lactams among respiratory and bloodstream isolates
This score predicts the probability of Pseudomonas aeruginosa of Pseudomonas aeruginosa and other non‑fermenting
bloodstream isolates in patients with suspected or confirmed gram‑negative bacilli (NFGN) such as Acinetobacter baumanii,
gram-negative bloodstream infections (BSI). It may be utilized etc. It is particularly useful in critically ill patients with risk of
in hospitalized patients with complicated urinary tract or infections due to P. aeruginosa or NFGN in the respiratory tract
intra-abdominal infections. Pseudomonas aeruginosa risk (ventilator‑associated pneumonia) or bloodstream (prolonged
score is calculated by adding the number of risk factors in each hospitalization or severely immune compromised hosts with
individual patient. qSOFA score ≥2).
Point Risk factors for beta-lactam-resistant Pseudomonas aeruginosa
Risk factors for P. aeruginosa BSI Allocation
• Bronchiectasis/cystic fibrosis
Severely immune compromised host 1
• Prior infections or colonization with beta-lactam resistant
Hospital-acquired BSI after >5 days of 1 P. aeruginosa within past 12 months
hospitalization
• Prior use of antipseudomonal beta-lactams for >48 hours within
Prior use of beta-lactam antibiotics within 1 3–30 days of index infection
3–90 days of BSI
Severely immune compromised hosts include those with neutropenia, Antipseudomonal beta‑lactams include piperacillin‑tazobactam,
recent chemotherapy, high dose steroids, etc. Beta‑lactam antibiotics
include penicillins, cephalosporins, carbapenems, monobactams and ceftazidime, cefepime, meropenem and imipenem. Resistance
beta‑lactam/beta‑lactamase inhibitors. to any of these agents confers beta‑lactam‑resistant
P. aeruginosa.
100%
Probability of P. aeruginosa

80%
60% 45%
40%
BSI

21%
20% 8%
1%
0%
0 1 2 3
Pseudomonas aeruginosa Risk Score

Area under receiver operating characteristic curve (AUROC) after

adjustment for source of BSI=0.79; negative predictive value (NPV)
=99% for score ≥1 to indicate high risk.

Hammer KL, et al. Diagn Microbiol Infect Dis 2017; 87: 87-91.

80 81
 Antimicrobial susceptibility of respiratory and bloodstream Antimicrobial susceptibility of respiratory and bloodstream
isolates of Pseudomonas aeruginosa and NFGN in the isolates of Pseudomonas aeruginosa and NFGN to
presence or absence of risk factors for beta‑lactam resistance beta‑lactam monotherapy and combination regimens in the
presence of risk factors for beta‑lactam resistance

Pip-tazo 78
92 Pip-tazo+FQ 78 91

Ceftazidime 78
91 Cefepime+FQ 83 90

Cefepime 83
95 Meropenem +FQ 77 92

77 Pip-tazo+AGS 78 96
Meropenem
94

0 10 20 30 40 50 60 70 80 90 100 Cefepime+AGS 83 98
Susceptibility (%)
n ≥1 risk factor n No risk factors Meropenem +AGS 77 97

NFGN: non‑fermenting gram‑negative bacilli 0 10 20 30 40 50 60 70 80 90 100

Pip‑tazo: piperacillin‑tazobactam Susceptibility (%)
n Monotherapy n Combination
NFGN: non‑fermenting gram‑negative bacilli; Pip‑tazo:
piperacillin‑tazobactam; AGS: aminoglycosides; FQ: fluoroquinolones.
Monotherapy refers to empirical use of an antipseudomonal
beta‑lactam. Combination therapy is defined as the use of an
antipseudomonal beta‑lactam plus either an aminoglycoside
(tobramycin or gentamicin) or a fluoroquinolone (ciprofloxacin or
levofloxacin) within the first 48 hours of index infection.
Please streamline antimicrobial therapy based on bacterial identification
(BCID for bloodstream or MALDI‑TOF for respiratory isolates) and
in vitro antimicrobial susceptibility testing results.
The use of empirical combination therapy has limited utility for
Entertobacteriaceae (E. coli, Klebsiella species, Proteus mirabilis, etc.)
and is highly discouraged since the risks of adverse events exceed
potential benefits, if any at all.

Foster RA, et al. Antibiotics 2019; 8: e15.

Al‑Jaghbeer MJ, et al. Infection 2018; 46: 487‑494.

82 83
 ESBL prediction score
ESBL prediction score (ESBL‑PS) Algorithm for application of ESBL prediction score in
management of patients with suspected or confirmed
This score predicts probability of extended‑spectrum gram‑negative BSI
beta‑lactamase (ESBL)‑producing Enterobacteriaceae
bloodstream isolates in patients with suspected or confirmed Risk of BSI due to ESBLE
gram‑negative bloodstream infections (BSI). The ESBL
prediction score is calculated by adding allocated points for
each risk factor if present in a particular patient.
Low: <1% Moderate: 5–10% High: ≥20%
Point
Risk factors for BSI due to ESBLs Allocation ESBL-PS: 0 ESBL-PS: 1-2 ESBL-PS: ≥3
(74% of cohort) (20% of cohort) (6% of cohort)
Outpatient GI/GU procedure within past 30 days 1
Number of beta-lactam/fluoroquinolone courses
within 3–90 days of BSI
No need for Start
0 0
carbapenems carbapenems
1 1
≥2 3
Documented colonization or infections with
ESBLs within past 12 months 4 Non-critically ill: Critically ill:
GI: gastrointestinal, GU: genitourinary; BSI: bloodstream infection. Pitt score <4 Pitt score ≥4
Short‑term perioperative antibiotics do not qualify as a course of (16% of cohort) (4% of cohort)
antibiotics. Multiple courses of antibiotics have to be at least 3 days
apart; concurrent or sequential therapy is considered one course.
Defer Consider
carbapenems carbapenems
Probability of BSI due to ESBLs

100% 93%
84%

80% BSI: bloodstream infection; ESBLE: extended‑spectrum

66% beta‑lactamase‑producing Enterobacteriaceae; ESBL‑PS: ESBL
prediction score.
60%
44% Please refer to the Guidelines for management of gram‑negative
bloodstream infections in adults (page 2) for assistance in selection
40% of empirical antimicrobial therapy when carbapenems are not indicated.
24%
Please streamline definitive antimicrobial therapy based on in vitro
20% 11% antimicrobial susceptibility testing results of bloodstream isolates.
5%
0.7% Augustine MR, et al. Infect Control Hosp Epidemiol 2017; 38: 266‑272
0%
0 1 2 3 4 5 6 ≥7
ESBL Prediction Score

AUROC = 0.86; NPV = 97–99% if used according to proposed algorithm.

84 85

Fluoroquinolone resistance score
Fluoroquinolone resistance score (FQRS)
The score predicts probability of fluoroquinolone‑resistant
gram‑negative bacilli in patients with bloodstream infections
(BSI) and complicated urinary tract infections (cUTI). It is
particularly useful in patients with gram‑negative BSI who have
severe β‑lactam allergy and in patients with acute pyelonephritis
who do not otherwise require hospitalization. Fluoroquinolones
are not recommended for acute cystitis. The FQRS is calculated
by adding allocated points for each risk factor if present.
Risk factors for fluoroquinolone resistance
Male sex
Diabetes mellitus
Residence in a skilled nursing facility
Outpatient procedure within past 30 days
Prior fluoroquinolone use within 12 months
None
Within 3 months
Within 3–12 months
GI: gastrointestinal, GU: genitourinary.
Fluoroquinolones include ciprofloxacin, levofloxacin and moxifloxacin.
Probability of fluoroquinolone-
Trimethoprim/Sulfamethoxazole resistance
tool NEW
Trimethoprim/sulfamethoxazole (SMX/TMP)
resistance tool
This simple clinical tool predicts probability of SMX/TMP
resistance among gram‑negative urinary isolates in patients
with acute cystitis and pyelonephritis. This tool is particularly
useful in patients with acute cystitis who may not be candidates
for first‑line therapy with nitrofurantoin. It is also helpful in
ambulatory management of acute pyelonephritis in patients
whom empirical treatment with fluoroquinolones is not ideal
Point allocation due to allergies, potential drug‑drug interactions or high
1 predicted risk of fluoroquinolone resistance. See Outpatient
1 management guidelines for acute cystitis and pyelonephritis
2 (page 40).
3
Risk factors for SMX/TMP resistance
0 • Prior SMX/TMP use within past 12 months
5 • Prior urinary infections/colonization with SMX/
TMP‑resistant (SMX/TMP‑R) bacteria within past 12 months
3
Predicted risk of SMX/TMP resistance based on risk factors:

95% 100%
100% 89%
84%
74%
resistant bacteria

80% 80% 68%

Resistance %
60%
60% 60%
45%

40% 40% 35%

31%
19%
20% 20% 13%
10%
6%
0% 0%
0 1 2 3 4 5 6 7 ≥8 No risk factors Prior Prior Prior SMX/
SMX/TMP use colonization TMP use
Fluoroquinolone resistance score with SMX/ colonization
TMP‑R bacteria with SMX/
AUROC =0.73 in derivation (BSI) and 0.80 in validation (cUTI) cohorts.
TMP‑R bacteria
NPV =91% for score ≥2 to indicate high risk of resistance.
Dan S, et al. Antimicrob Agents Chemother 2016; 60: 2265-72. DeMarsh M, et al. J Glob Antimicrob Resist 2019; 21: 218-222
Shah A, et al. Antimicrob Agents Chemother 2017; 61: e2313-16.

86 87
 Gram-negative ALL sources

Rate of Klebsiella ESBL = 18%

100

86

91 90 90 94
91 84 35 82
93

76 97 75

18
Doxycylineb

0
Prisma Health antibiogram

Rate of Proteus ESBL = 4%

Rate of E.coli ESBL = 15%
Nitrofurantoin

for 2021

100

99 100
88
94

98

64 96
62
65

86 87
90 81
SMZ-TMP

100
100
60

99
95

76
71
Levofloxacin

Important notes: Adult patients only

100
98

99

89
58

85
85
82
95
70

97
91
Ciprofloxacin

Gray spaces = intrinsic resistance and/or not recommended for use;

100

90
98
98

98

98
96

94
99
95
92

97
Tobramycin

Blank spaces = insufficient data available

100

100
80
96

94

96

96
99

95
93
97
91
Gentamicin

Following recommendations from the Clinical and Laboratory

100
100

100
100

100

100
100

100
98

89 64 98
99

99
Amikacin
Standards Institute (CLSI), only the first isolate of a given species per
patient was used to compile the data.
Aztreonama

100
100

100

100
100
Reported results are based on available susceptibility data.

96 96
99
99

99
97
75
Meropenem

Clinical judgment should be used when interpreting susceptibility

100
100

100
100
98

99

99
93

97
Ertapenem
information on a low number of isolates. (<30 isolates per CLSI

72 75 100

92 92 100
230 89 97 100 93 94 99 99 100
1346 48 78 96 83 87 89 89 96
70 71 99

96 99 99
58 58

98 98 95

71 73 95

89 92
87 91 83 91 86 85 93
Guidelines M39).

90 91 59 97 88 91 97
Cefepime

Gray shading indicates intrinsic resistance and/or not recommended for use.
Numbers reported in each cell represents the percentage of

98 98

27
Ceftazidime

susceptible isolates. This antibiogram represents isolates tested Ceftriaxone

from January–December 2020.
Cefoxitin
Revised breakpoints (CLSI M100‑S21) for Enterobacteriaceae
(Citrobacter spp., Enterobacter spp., Escherichia coli, Klebsiella spp.,
Cefazolin

Proteus, Serratia) have been utilized for this report.

60

98
96
69
73
75

91
Piperacillin/tazobactam

Revised breakpoints (CLSI M100‑S22) for Pseudomonas aeruginosa

45 60 89
Amoxicillin/clavulanate
have been utilized for this report.

Includes Acinetobacter baumannii complex

SMZ-TMP: trimethoprim-sulfamethoxazole
Ampicillin
Susceptibility breakpoints for Streptococcus pneumoniae in

407
Enterobacter cloacae complex 132

573
40

48

Stenotrophomonas maltophilia 45
58
43
83
47

72
Number of Isolates
patients with meningitis is ≤0.5 mcg/ml for ceftriaxone and ≤0.6
mcg/ml for penicillin (IV).
Susceptibility breakpoints for Streptococcus pneumoniae

organisms — ALL sources
Prisma Health (Midlands)

Acinetobacter baumanniic

Pseudomonas aeruginosa

Deduced from tracycline

Haemophilus influenzae
Enterobacter aerogenes
in patients with nonmeningitis infections is ≤1 mcg/ml for

Klebsiella pneumoniae
Morganella morganii

Serratia marcescens
Citrobacter freundii
ceftriaxone and ≤2 mcg/ml for penicillin (IV) or ≤0.06 mcg/ml for

Few isolates tested

Klebsiella oxytoca
Citrobacter koseri

Proteus mirabilis
penicillin (oral).

Escherichia coli
Gram‑negative

Gentamicin and rifampin should not be used as monotherapy for

gram‑positive organisms, but may be in combination for synergy.
2020

Nitrofurantoin should be used for cystitis only.

b
c
a
88 89
90
Gram‑positive organisms — ALL sources

Number of Isolates
Ampicillin
Oxacillin
Penicillin
Cefazolina
Ceftriaxone
Gentamicin (synergy)
Erythromycin
Clindamycin
Linezolid
Levofloxacin
SMZ-TMP
Nitrofurantoin
Rifampin (synergy)
Doxycyclineb
Vancomycin

Prisma Health (Midlands) 2020

Staphylococcus aureusc 715 57 57 99 77 100 91 99 99 95 100
MR-Staphylococcus aureus 303 99 72 100 41 90 99 90 100
Staphylococcus lugdunensis 45 66 66 100 59 100 95 99 100 89 100
Enterococcus faecalis 384 100 100 80 99 23 100
Enterococcus faecium 70 24 84 25 29 47 37
Streptococcus pneumoniae (meningitis) 32 56 91 100
Streptococcus pneumoniae 32 94 97 50 73 97 57 67 100
Gram-positive ALL sources

Gray shading indicates intrinsic resistance and/or not recommended for use.
a
Deduced frm oxacillin
b
Deduced from tetracycline
c
Rate of Methicillin-resistant Staphylococcus aureus (MRSA) = 42%
SMZ-TMP: trimethoprim-sulfamethoxazole

Gram‑negative organisms —
ALL sources Prisma Health
Number of Isolates
Ampicillin
Amoxicillin/clavulanate
Piperacillin/tazobactam
Cefazolin
Cefoxitin
Ceftriaxone
Ceftazidime
Cefepime
Ertapenem
Meropenem
Aztreonama
Amikacin
Gentamicin
Tobramycin
Ciprofloxacin
Levofloxacin
SMZ-TMP
Nitrofurantoin
Doxycylineb

(Midlands) ICU 2020
Acinetobacter baumanniic 5 60 40 40 80 100 60 100 60 60 60
Citrobacter freundii 8 38 38 38 100 100 100 100 100 100 100 100 100
Citrobacter koseri 6 100 100 100 100 100 100 100 100 100 100 100 100 100
Enterobacter aerogenes 10 90 90 90 100 100 100 100 100 100 100 100 100 100
Enterobacter cloacae complex 29 55 52 52 66 83 97 100 86 72 62 92 71 79
Escherichia coli 155 37 61 90 76 84 81 81 88 98 98 99 91 90 61 57 70 99 75
Haemophilus influenzae 16 69 88 100 100 56
Klebsiella oxytoca 3 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
Klebsiella pneumoniae 93 71 89 71 98 73 73 86 100 100 100 82 78 70 70 74 19 73
Morganella morganii 9 100 89 100 100 100 100 100 100 100 67 67 89 0
Gram-negative ICU ALL sources

Proteus mirabilis 40 90 98 100 90 98 100 100 100 100 100 100 98 98 78 78 90

Pseudomonas aeruginosa 138 82 83 85 85 64 94 86 99 78 67
Serratia marcescens 18 89 100 100 100 100 100 94 89 94 89 100 19
Stenotrophomonas maltophilia 31 23 90 90

Gray shading indicates intrinsic resistance and/or not recommended for use.
a
Few isolates tested
b
Deduced from tracycline Rate of E.coli ESBL = 18%
c
Includes Acinetobacter baumannii complex Rate of Klebsiella ESBL = 26%
SMZ-TMP: trimethoprim-sulfamethoxazole Rate of Proteus ESBL = 0%
91
92
Gram‑positive organisms — ALL sources

Number of Isolates
Ampicillin
Oxacillin
Penicillin
Cefazolina
Ceftriaxone
Gentamicin (synergy)
Erythromycin
Clindamycin
Linezolid
Levofloxacin
SMZ-TMP
Nitrofurantoin
Rifampin (synergy)
Doxycyclineb
Vancomycin

Prisma Health (Midlands) ICU 2020

Staphylococcus aureusc 171 55 55 99 74 100 70 81 94 93 100
MR-Staphylococcus aureus 77 100 68 100 44 83 97 88 100
Staphylococcus lugdunensis 10 56 56 100 50 100 89 90 100 100 100
Enterococcus faecalis 60 100 100 81 97 20 100
Enterococcus faecium 13 21 100 0 57 71 36
Streptococcus pneumoniae (meningitis) 7 71 86 100
Streptococcus pneumoniae 7 86 86 75 75 100 50 75 100

Gray shading indicates intrinsic resistance and/or not recommended for use.
a
Deduced frm oxacillin
b
Deduced from tetracycline
c
Gram-positive ICU ALL sources

Rate of Methicillin-resistant Staphylococcus aureus (MRSA) = 45%

SMZ-TMP: trimethoprim-sulfamethoxazole

ANTIBIOGRAM – Systemic
Percent Susceptible (January – December 2020)
Antibiotic Tested

Organism
(# Isolates)
Meropenem
Nafcillin / Oxacillin
Penicillin
Piperacillin /
tazobactam
Tetracycline
Tobramycin
TMP/SMX
Vancomycin

Amoxicillin /
clavulanate
Ampicillin
Ampicillin /
sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefepime
Ceftriaxone
Cefuroxime
Ciprofloxacin
Clindamycin
Ertapenem
Erythromycin
Gentamicin
Levofloxacin
Linezolid

Amikacin
Ceftazidime
Tuomey

Gram Negative
Acinetobacter baumannii/hemolyticus (33) 97 91 82 85 48 91 94 97 97 91 85 85
Citrobacter freundii (13) 100 0 0 0 69 0 100 77 69 100 100 92 100 100 92 92 85 85
Enterobacter aerogenes (18) 100 0 0 0 83 0 94 78 72 89 100 94 94 100 83 94 100 89
Enterobacter cloacae (62) 100 0 0 0 89 0 95 92 87 100 95 98 100 100 94 ## 94 92
Escherichia coli (190) 98 87 42 53 82 59 84 83 83 74 100 89 74 100 97 89 64 64
Haemophilus influenzae (2) 100 100 100 50
Klebsiella oxytoca (30) 100 93 9 63 83 3 83 83 83 92 100 100 97 100 97 87 ## 97
Klebsiella pneumoniae (108) 98 94 0 79 82 82 84 84 84 86 99 98 87 100 96 82 94 81
Morganella morganii (47) 100 0 0 11 83 0 98 77 81 79 100 89 89 100 98 51 94 77
Proteus mirabilis (110) 100 98 85 96 92 76 95 95 95 84 100 97 88 100 100 0 96 93
Ps. fluor / putida (9) 100 44 100 100 100 100 100 89 100 89
Pseudomonas aeruginosa (144) 97 81 89 90 86 88 83 94 92 99
Salmonella sp. (5) 100 100 100 100 100 100 100 100 100 100 100 100 100 100
Serratia marcescens (52) 100 0 0 0 67 0 96 67 71 96 98 100 96 98 73 2 87 100
Stenotrophomonas (Xanthomonas)
maltophilia (29) 45 90 100
Gram Positive
Amikacin
Amoxicillin /
clavulanate
Ampicillin
Ampicillin /
sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefepime
Ceftazidime
Ceftriaxone
Cefuroxime
Ciprofloxacin
Clindamycin
Ertapenem
Erythromycin
Gentamicin
Levofloxacin
Linezolid
Meropenem
Nafcillin / Oxacillin
Penicillin
Piperacillin /
tazobactam
Tetracycline
Tobramycin
TMP/SMX
Vancomycin

Enterococcus faecalis (199) 100 12 80* 83 100 100 20 100

Enterococcus faecium (15) 13 7 100* 13 100 13 7 27
(MRSA) Methicillin-Resistant Staphylococcus
aureus (194) [44.5%] 0 0 0 0 0 77 18 99* 32 99 0 0 0 92 95 99
Staphylococcus aureus (242) [55.5%] 100 0 100 100 100 76 58 99* 89 100 100 100 18 92 100 100
Staphylococcus epidermidis (114) 32 0 32 32 32 62 32 54 100 32 32 9 82 59 100
Gram-positive/Gram-negative Systemic –

Streptococcus pyogenes (2) 100 100 100 100 100 ## 100 100 100 100
Streptococcus pneumoniae (13) 100 50 92 83 67 50 100 83 50 67 67 100
> 10 % Decrease in susceptibility > 10% Increase in susceptibility
* Gentamicin is only for synergy dosing in gram-positive organisms – it should NOT be used as monotherapy.
93
94
ANTIBIOGRAM – Urine
Percent S usceptible (January – December 2020)
Antibiotic Tested

Organism
(# Isolates)

Amikacin
Amoxicillin /
clavulanate
Ampicillin
Ampicillin /
sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefepime
Ceftazidime
Ceftriaxone
Cefuroxime
Ciprofloxacin
Ertapenem
Erythromycin
Gentamicin
Levofloxacin
Linezolid
Meropenem
Nafcillin / Oxacillin
Nitrofurantoin
Penicillin
Piperacillin /
tazobactam
Tetracycline
Tobramycin
TMP/SMX
Vancomycin
Tuomey

Gram Negative
Acinetobacter baumannii/hemolyticus (13) 100 85 69 85 69 92 69 85 69 92
Citrobacter freundii (11) 100 0 0 0 91 0 100 100 91 91 100 100 91 100 100 100 82 91 82
Citrobacter koseri (11) 100 96 0 100 96 96 100 100 100 100 100 100 100 100 61 100 91 100 100
Enterobacter aerogenes (24) 100 0 0 0 92 0 96 88 88 96 96 100 96 100 8 92 92 100 96
Enterobacter cloacae (35) 100 0 0 0 66 0 83 66 60 80 69 91 89 100 20 71 71 89 77
Escherichia coli (894) 99 88 47 54 91 66 93 91 91 78 99 90 78 100 98 98 78 91 76
Klebsiella oxytoca (15) 100 87 7 47 87 13 100 100 93 87 100 93 100 100 93 93 100 93 87
Klebsiella pneumoniae (314) 99 92 0 79 89 82 89 89 89 90 99 94 94 99 39 97 81 93 86
Morganella morganii (22) 100 0 0 9 86 0 100 82 86 59 100 82 73 100 0 100 45 95 64
P. stuartii (11) 100 0 0 0 82 0 100 82 82 36 100 0 45 100 0 91 0 0 91
Proteus mirabilis (121) 99 99 88 97 90 77 95 95 95 77 100 97 82 100 0 98 0 93 87
Pseudomonas aeruginosa (99) 95 75 84 87 76 79 72 96 95 97
Serratia marcescens (13) 100 0 0 0 69 0 100 69 69 100 100 100 100 100 0 85 0 85 100
Gram Positive
Nitrofurantoin

Cefuroxime
Ciprofloxacin

Amikacin
Ampicillin /
sulbactam
Azithromycin
Cefepime
Ceftazidime
Ceftriaxone
Erythromycin
Gentamicin
Levofloxacin
Linezolid
Meropenem
Nafcillin / Oxacillin
Penicillin
Piperacillin /
tazobactam
Tetracycline
Tobramycin
TMP/SMX

Amoxicillin /
clavulanate
Ampicillin
Aztreonam
Cefazolin
Vancomycin

Ertapenem

Enterococcus faecalis (194) 100 72* 69 100 99 100 20 99

Enterococcus faecium (34) 15 97* 6 94 50 15 12 41
(MRSA) Methicillin-Resistant Staphylococcus
aureus (15) [48.4%] 0 0 0 0 0 20 100* 20 100 0 100 0 100 87 100
Staphylococcus aureus (242) [55.5%] 100 0 100 100 100 100* 94 100 100 100 25 88 100 100
Gram-positive/Gram-negative Urine –

Susceptibility key (change from previous year) – May not be statistically significant if <30 isolates
> 10 % Decrease in susceptibility > 10% Increase in susceptibility
* Gentamicin is only for synergy dosing in gram-positive organisms – it should NOT be used as monotherapy.

500mg
Ampicillin/

Nafcillin 2g
Cefoxtin 2g

Cefazolin 2g
Cefepime 2g
Levofloxacin

Ampicillin 2g
Ceftolozane/

sulbactam 3g
IV antibiotic

Ertapenem 1g
Penicillin 5MU
Ceftriaxone 2g
750mg/500mg

Meropenem 1g
tazobactam 1.5g
Ceftaroline 600mg

Imipenem/cilastatin
Ciprofloxacin 400mg
Antibiotic costs

$
$
$
$

$$
$$
$$
$$
$$
cost

$$$
$$$
$$$
$$$
Daily

$$$$
$$$$$$
500mg

Amoxicillin/
Levofloxacin
750mg/500mg
PO antibiotic

Penicillin 500mg
Cefuroxime axetil

Amoxicillin 500mg

clavulanate 875mg
Cephalexin 500mg
Ciprofloxacin 500mg

$
$

¢
¢
¢
¢
¢
cost
Daily

95
 Daily Daily
IV antibiotic cost PO antibiotic cost Prisma Health Antimicrobial
Piperacillin/
tazobactam 4.5g
$$$
Stewardship

Vancomycin 1g $$$ Midlands

Linezolid 600mg $$$$$ Linezolid 600mg $$ Majdi Al‑Hasan, MBBS
Medical Director, Adult Antimicrobial Stewardship and Support
Daptomycin 500mg $$$$$
Professor and Academic Vice Chair of Research
Eravacycline 50mg $$$$$ Fosfomycin 3g $$$ Department of Internal Medicine
Clindamycin $$$ Clindamycin 150mg $$ University of South Carolina School of Medicine
900mg/600mg Email: majdi.alhasan@uscmed.sc.edu
Doxycycline 100mg $$ Doxycycline 100mg ¢
Prisma Health Richland Hospital:
TMP-SMZ 320mg $$$ SMZ-TMP DS ¢ 803‑250‑9430 (cell) 352‑1322 (pager) M–F 8a–5p
Azithromycin 500mg IV $ Azithromycin 250mg $ Joseph Kohn, PharmD, BCPS
Aztreonam 2g $$$$$ Nitrofurantoin $ Antimicrobial Stewardship and Support
Prisma Health Richland Hospital
Tobramycin/ $
Gentamicin 80mg Columbia, South Carolina

Amikacin 500mg $ Julie Ann Justo, PharmD, MS, FIDSA, BCPS, AQ‑ID
Clinical Associate Professor
Department of Clinical Pharmacy and Outcome Sciences
Cost indicator USC College of Pharmacy

Daily cost P. Brandon Bookstaver, PharmD, FCCP, FIDSA, BCPS, AAHIVP

$$$$$$ >$200 Professor
Department of Clinical Pharmacy and Outcome Sciences
$$$$$ $100–$199 USC College of Pharmacy
$$$$ $60–$99
$$$ $30–$59
$$ $15–$29
$ $1–$14
¢ < $1

96 97
 Prisma Health Baptist Hospital:
803‑250‑9380 (cell) 352‑0697 (pager) M–F 8a–5p
Emily Youngue, PharmD, BCPS
Casey Troficanto, PharmD, BCPS
Antimicrobial Stewardship and Support
Critical Care
Prisma Health Baptist Hospital
Columbia, South Carolina
Prisma Health Baptist Parkridge Hospital:
803‑315‑4305 (cell) 352‑1596 (pager) M–F 8a–5p
Krishnan Brown, PharmD
Infectious Diseases/Antimicrobial Stewardship and Support
Prisma Health Baptist Parkridge Hospital
Prisma Health Tuomey Hospital:
803‑774‑9054 M–Sn 8a–5p
Chad Jolly, PharmD, BCCCP, BCIDP
Yorika Hammett, PharmD
Prisma Health Tuomey Hospital
Sumter, South Carolina
98
Ambulatory Antimicrobial Stewardship
Hana Winders, PharmD, BCIDP
Ambulatory Antimicrobial Stewardship Pharmacist
803‑434‑3592
Upstate
John Schrank, MD
Medical Director, Antimicrobial Stewardship
Assistant Professor, Medicine
University of South Carolina School of Medicine Greenville
Carmen M Faulkner‑Fennell, PharmD, BCPS, BCIDP
Clinical Pharmacy Specialist, Antimicrobial Stewardship
Program
Clinical Assistant Professor
University of South Carolina School of Medicine Greenville
864‑455‑3738
Sarah Withers, PharmD, MS, BCPS
Clinical Pharmacy Specialist, Infectious Diseases
Greenville Campus Coordinator, Affiliate Assistant Professor
University of South Carolina College of Pharmacy
University of South Carolina School of Medicine Greenville
864‑455‑6651
99
 © 2021 Prisma Health.
21-1260 | 07/21 | Reorders available on DigiPath.

100