Antibiotic Treatment Guideline

Antibiotic Treatment Guideline

Name: ___________________________________

Month/Year: _____________________________

Hospital: ________________________________

Department: _____________________________

October 2019

THE GLOBAL HEALTH INITIATIVETHE GLOBAL HEALTH INITIATIVE


Suggested Empiric Antibiotic Therapy

Diagnosis Suspected Pathogens Empiric Therapy Duration of

Therapy

Abdominal infection, community-acquired(e.g. cholecystitis, cholangitis, diverticulitis, abscess)

NOTE:Add gentamicin if MDRO suspected or identified

Enterobacteriaceae Bacteroides sp. EnterococciStreptococci

Preferred:• Ceftriaxone IV 1g q24h +

Metronidazole IV or PO 500mg q8h +/- Gentamicin IV 5mg/kg q24hr

Alternative: • Piperacillin/tazobactam

IV 4.5g q6h• Cefepime IV 2g q12h +

Metronidazole IV or PO 500mg q8h + Gentamicin IV 5mg/kg q24hr

• Imipenem IV 1g q8h

Oral options for outpatient therapy:• Ofloxacin PO 400mg q12h +

Metronidazole PO 500mg q12h• Moxifloxacin PO 400mg q24h

4 days with adequate source

control

NOTE: Pancreatitis

does not require antibiotics if

no necrosis or abscess

COPD Exacerbation (inpatient)Increased sputum volume and/or purulence OR Acute respiratory failure requiring ICU admission

H. influenzaeS. pneumoniaeM. catarrhalis

Preferred: • Azithromycin PO 500mg q24h• Doxycycline PO 100mg q24h

5-7 days

Enteric fever Salmonella typhiSalmonella paratyphi

Preferred: • Ceftriaxone IV 2g q12h• Azithromycin IV or PO 1g q24h

5-10 days

Gastroenteritis

NOTE: Salmonella and campylobacter treat if protracted or comorbidities

Shigella treat

Salmonella sppShigella sppCampylobacter spp

Preferred:• Ciprofloxacin PO 500mg q12h or

IV 400q12• Ofloxacin 400mg q24h• Trimethoprim/

Sulfamethoxazole PO 160/800mg q12h

Alternative:• Azithromycin PO 500mg q24h

3-5 days


Therapy

Meningitis, community-acquired

Risk factors for Listeria spp.: EtOH abuse, age >50, pregnancy

S. pneumoniaeN. meningitidesListeria monocytogenes

• Ceftriaxone IV 2g q12h + Vancomycin 1g q12h (or Linezolid IV 600mg q12h) +/- Ampicillin 2g q4-6h (if risk factors for Listeria spp. present)

TB Meningitis:Anti-tuberculosis medicine (non-IV therapy)

N.meningitis: 7 days

H. influenza: 7 days

S. pneumoniae: 10-14 days

Listeria/neonate:21 days

TB:10 days

Osteomyelitis StaphylococciStreptococciAnaerobesGram-negative bacteria

IV:• Cefazolin IV 2g q8h +/-

Metronidazole IV or PO 500mg q8h• Ceftriaxone IV 1g q24h +

Vancomycin IV 1g q12hOral options:• Ciprofloxacin PO 750mg q12h +/-

Doxycycline PO 100mg q12h OR Clindamycin 450mg q8h

• Trimethoprim/ Sulfamethoxazole PO 320/1600mg q12h

4-6 weeks

Pelvic inflammatory disease

Chlamydia N.gonorrhoeae EnterobacteriaceGroup B Streptococci

Preferred:• Ceftriaxone IM 250mg +

Doxycycline 100mg q12h + Metronidazole 500mg q8h

Alternative:• Cefixime 400mg q24h +

Azithromycin 500mg q24h + Metronidazole 400mg q8h

Single dose ceftriaxone

14 days doxycycline and metronidazole

Pneumonia, community-acquiredInpatient therapy

S. pneumoniaeH. influenzaMycoplasma sp.Chlamydophila sp.Legionella sp.

• Ceftriaxone IV 1g q24h + Azithromycin IV or PO 500mg q24h OR Doxycycline PO 100mg q8h

• Amoxiclav PO 625mg q8h• Moxifloxacin PO 400 q24h

5 days

Pneumonia, community-acquiredOutpatient therapy

S. pneumoniaeH. influenzaMycoplasma sp.Chlamydophila sp.Legionella sp.

• Azithromycin PO 500mg q24hFor patients with comorbidities:• Moxifloxacin PO 400mg q24h,

Ofloxacin 400mg q24h, or Levofloxacin PO 500mg q24h

• Amoxicillin 500mg q8h + Azithromycin PO 500mg q24h

• Amoxiclav PO 625mg q8h

5 days


Therapy

Pneumonia, with risk factors for multidrug resistant bacteria* (healthcare or ventilator associated)

EnterobacteriaceaeP. aeruginosa,A. baumannii

(Add azithromycin OR doxycycline for patients presenting from the community who are at risk for atypical infection)

Patients with risk factors for multi-drug resistant bacteria:• Cefepime IV 2g q12h +/-

Vancomycin 1g q12h OR Linezolid 600mg IV or PO q12h

• Piperacillin/tazobactam V 4.5g q6hr + Gentamicin 5mg/kg q24hr +/- Vancomycin 1g q12h OR Linezolid IV or PO 600mg q12h

• Imipenem/Cilastatin IV 1g q8h or Meropenem IV 0.5-1g q8h +/- Gentamicin 5mg/kg q24hr +/- Vancomycin IV 1g q12h OR Linezolid IV or PO 600mg q12h

When Acinetobacter sp. is suspected:Colistin +/- Tigecycline

7 days

NOTE: Add gentamicin or

amikacin in patients with severe sepsis

or septic shock. Stop after 3

days if a beta-lactam resistant organism is not

isolated or if cultures were not

obtained.

Sepsis of unknown source and bacteremia

Enterobacteriaciae Staphylococci, Streptococci

NOTE: Add gentamicin or amikacin for patients with severe sepsis or septic shock. Stop after 3 days if a beta-lactam resistant organism is not isolated or if cultures were not obtained.

Preferred:• Piperacillin/tazobactam IV 4.5g

q6h + Gentamicin IV 5mg/kg q24hr OR Amikacin IV 15mg/kg q24h +/- Vancomycin 1g q12h OR Linezolid IV or PO 600mg q12h

• Cefepime IV 2g q12h + Gentamicin OR Amikacin +/- Vancomycin 1g q12h OR Linezolid 600mg q12h

Alternative:• Ceftriaxone IV 1g q24h +

Gentamicin IV 5mg/kg q24hr

Critically ill or neutropenic patients: • Imipenem/Cilastatin 1g q8h +/-

Gentamicin IV 5mg/kg q24hr +/- Vancomycin 1g q12h OR Linezolid

• Colistin for CRE

10 days for gram-negative

organisms

14 days for S. aureus


Therapy

Skin and skin structure infections cellulitis

Staphylococci, Streptococci

Cellulitis, oral therapy:Preferred:• Cloxacillin 500mg q8h or

Flucloxacillin PO 500mg q6• Cephalexin 500mg q6h or

Cefadroxil PO 1g q24hCellulitis, no history of MRSA, intravenous therapy:• Cefazolin IV 1g q8h• Cloxacillin 500mg q8h or

FlucloxacillinPurulent cellulitis OR After failure of IV beta-lactam therapy OR MRSA:Vancomycin IV 1g q12h OR Linezolid IV or PO 600mg q12h

5-7 days

Skin and skin structure infections abscess

Staphylococci, Streptococci

Surgical consultation for drainage• Cefazolin IV 1g q8h• Amoxiclav PO 625mg q8h• Flucloxacillin PO 500mg q6h

If failure of IV beta-lactam therapy OR MRSA:• Vancomycin IV 1g q12h OR

Linezolid IV or PO 600mg q12h

5 days (with adequate drainage)

Skin and skin structure infections necrotizing fasciitis

Streptococci Surgical consultation for source control• Clindamycin IV 600mg q8h +

Penicillin IV 5million units q6h• Piperacillin/tazobactam IV 4.5g

q6h + Clindamycin IV 600mg q8h

7-10 days (with adequate source

control)


Therapy

Skin and skin-structure infectionsPolymicrobial, burn victims, Pseudomonas sp. suspected (e.g. open wounds with vascular insufficiency, pressure sore or severe diabetic foot ulcer)

Staphylococcus aureusStreptococciEnterobacteriaceaeAnaerobes

Preferred:• Piperacillin/tazobactam IV 4.5g

q6h +/- Gentamicin IV IV 5mg/kg q24h +/- Vancomycin IV 1g q12h OR Linezolid IV or PO 600mg q12h

• Cefepime 2g q12h + Metronidazole IV or PO 500mg q8h +/- Gentamicin IV 5mg/kg q24hr +/- Vancomycin 1g q12h OR Linezolid

If MDR Acinetobacter sp. confirmed:• Colistin OR Tigecycline

5-7 days

NOTE: Add gentamicin or

amikacin in patients with severe sepsis

or septic shock. Stop after 3

days if a beta-lactam resistant organism is not

isolated or if cultures were not

obtained.

Skin and skin-structure infections, cat/dog/human bite

Pasteurella multocida, StaphylococciStreptococciAnaerobes

• Amoxicillin/clavulanate PO 625mg q8h

• Ofloxacin PO 400mg q12h• Moxifloxacin PO 400mg q24h • Doxycycline PO 100mg q24h

5-7 days

Urinary tract infection uncomplicated cystitis

Enterobacteriaceae

• Preferred: Nitrofurantoin (ONLY for CrCl > 40 to 60 mL/min or age < 65 years) 100mg q6h

• Ofloxacin 400mg q12h• Pregnant women ONLY: Cefixime

400mg q24h

5 days

Urinary tract infectionPyelonephritis

Enterobacteriaceae IV Preferred:• Piperacillin/tazobactam IV 4.5g

q6hr• Ofloxacin 200mg q24h• Imipenem/cilastatin 1g q8h• Cefepime IV 2g q12h

Alternate Oral options:• Ofloxacin 400mg q12h• Cefixime (pregnant women ONLY)

x 14 days 400mg q24h

NOTE: Add gentamicin or amikacin in patients with suspected Pseudomonas spp. and severe sepsis or septic shock. Stop after 3 days if beta-lactam resistant organism is not isolated or if cultures were not obtained.

7 days

Antibiotics on reserve:This group of antibiotics was created by WHO in 2017. They are recommended to be used as “last resort” options when alternative options have failed. The aim is to preserve the effectiveness of these antibiotics.

Reserve group antibiotics: Aztreonam Fosfomycin (IV)

Cefepime Linezolid

Daptomycin Tigecycline

Polymixins (polymyxin B, colistin)

Useful Stewardship Tips• Always attempt to get bacterial cultures!• Stay up to date with your hospital’s antibiogram• Avoid empiric quinolone for most infections due to high resistance rates• Avoid using duplicate antibiotics that cover the same organism unnecessarily (e.g.

carbapenems with metronidazole, which both retain anaerobic bacteria coverage)• Always de-escalate to the narrowest antibiotic therapy possible when susceptibility

results are available• Continue to assess if the patient is truly infected, and treat only for the minimum

duration necessary to cure the patient from infection• Utilize oral agents whenever possible to prevent catheter-associated infections

• Avoid treating asymptomatic bacteriuria

Suggested Definitive Antibiotic Therapy (Check susceptibilities before prescribing therapy)

OrganismPreferred Therapy

(Confirm with susceptibilities)

Alternative Therapy(Depending on allergies

and susceptibility)

Acinetobacter spp Imipenem/cilastatin Meropenem, colistin, tigecycline, trimethoprim/sulfamethoxazole, gentamicin, amikacin

Consider combination therapy for extensively drug resistant Acinetobacter

Citrobacter species(AmpC producing organism)

Cefepime, gentamicin Ciprofloxacin, meropenem, moxifloxacin, ofloxacin, piperacillin/tazobactam trimethoprim/sulfamethoxazole

Oral therapy options: trimethoprim/ sulfamethoxazole preferred, ciprofloxacin, ofloxacin

Enterobacter spp(AmpC producing organism)

Cefepime Ciprofloxacin, gentamicin, meropenem, ofloxacin, piperacillin/tazobactam, trimethoprim/ sulfamethoxazole

Oral therapy options: trimethoprim/sulfamethoxazole preferred, ciprofloxacin, ofloxacin




and susceptibility)

Enterococcus faecalis or faecium

Ampicillin gentamicin sensitive

Ampicillin resistant, vancomycin, gentamicin sensitive

Vancomycin resistant, ampicillin, gentamicin susceptible

Vancomycin resistant,ampicillin, gentamicin resistant

Amoxicillin, penicillin

Vancomycin

Ampicillin ± gentamicin (for endocarditis)

Linezolid

For cystitis only: ofloxacin or nitrofurantoin

Linezolid

Escherichia coli

Extended spectrum beta-lactamase producer

Ampicillin, trimethoprim/sulfametho-xazole or ciprofloxacin preferred for oral therapy

Imipenem/cilastatin, piperacillin/tazobactam (if urine source ONLY)

Ceftriaxone, cefepime, gentamicin, ciprofloxacin, piperacillin/tazobactam

Oral therapy options: amoxicillin/clavulanic acid, ciprofloxacin, ofloxacin, nitrofurantoin (cystitis ONLY)

Meropenem, tigecycline, colistin

Haemophilus influenzaeBeta-lactamase negative

Beta-lactamase positive

Ampicillin, amoxicillin

Amoxicillin/clavulanic acid, trim/sulbactam

Moxifloxacin, azithromycin, doxycycline, trimethoprim/ sulfamethoxazole




and susceptibility)

H. pylori(susceptibilities not necessary)

Amoxicillin 1 gram PO BID + clarithromycin 500 mg PO BID + proton pump inhibitor (PPI) standard dose BID 14 days(Eradication rate 70-85%)

Metronidazole 400 mg PO BID + clarithromycin 500 mg PO BID + PPI standard dose BID (70-85% eradication)

Metronidazole 400 mg PO three times daily + tetracycline 500 mg PO four times daily + bismuth subsalicylate 524 mg (30 mL) PO four times daily + PPI standard dose BID (70-90% eradication)

Clarithromycin

Klebsiella spp

Extended spectrum beta-lactamase producer

Trimethoprim/ sulfamethoxazole preferred for oral therapy

Imipenem/cilastatin, piperacillin/tazobactam (if urine source ONLY)

Gentamicin, ceftriaxone, cefoperazone/sulbactam, cefepime, piperacillin/ tazobactam, ciprofloxacin

Oral therapy options: sulbactam trimethoprim/sulfamethoxazole, ciprofloxacin, ofloxacin

Meropenem, tigecycline, colistin

Moraxella catarrhalisBeta-lactamase negative

Beta-lactamase positive

Amoxicillin

Amoxicillin/clavulanic acid, ceftriaxone

Moxifloxacin, azithromycin, doxycycline, trimethoprim/ sulfamethoxazole




and susceptibility)

Morganella morganii(AmpC producing organism)

Cefepime, Imipenem/cilastatin

Piperacillin/tazobactam, trimethoprim/ sulfamethoxazole, ciprofloxacin, gentamicin

Neiserria gonorrheae Ceftriaxone Cefixime

Neiserria menigitidis Penicillin, ceftriaxone Ampicillin

Proteus mirabilis

Ampicillin, cefazolintrimethoprim/sulfamethoxazole preferred for oral therapy

Amoxicilin, ciprofloxacin, ceftriaxone, gentamicin, trimethoprim/sulfamethoxazole

Proteus vulgaris Ampicillin

Amoxicilin, cefexime, ceftriaxone, gentamicin, trimethoprim/sulfamethoxazole

Providencia spp(AmpC producing organism)

Cefepime, Imipenem/cilastatin

Ciprofloxacin, gentamicin, trimethoprim/sulfamethoxazole, piperacillin/tazobactam

Pseudomonas aeruginosa

Piperacillin/ tazobactam, cefepime (consider double coverage with a beta-lactam plus an aminoglycoside in patients with septic shock until susceptibilities available to ensure adequate coverage)

Imipenem/cilastatin, meropenem, ceftazidime, ciprofloxacin, levofloxacin

Salmonella Typhi

Ceftriaxone, Azithromycin

Gastroenteritis is self limited, treatment not indicated unless patient is immunocompromised or has disseminated infection

Amoxicillin/clavulanic acid




and susceptibility)

Salmonella sp., non typhi

Ceftriaxone, Azithromycin

Gastroenteritis is self-limited, treatment not indicated unless patient is immunocompromised or has disseminated infection

Trimethoprim/sulfamethoxazole

Serratia spp(AmpC producing organism)

Cefepime

Gentamicin, imipenem/cilastatin, meropenem, piperacillin/tazobactam, trimethoprim/sulfamethoxazole, ciprofloxacin

Staphylococcus aureusMSSA

MRSAFlucoxacillin

Vancomycin

VancomycinOral options: cephalexin (not for bacteremia)

Linezolid (pneumonia in ICU patients only), teicoplanin• Oral options: trimethoprim/

sulfamethoxazole, clindamycin, doxycycline (not for bacteremia)

Coagulase negative staphylococcimethicillin susceptible

methicillin resistant

Flucoxacillin

Vancomycin Linezolid

Stenotrophomonas maltophilia

Trimethoprim/ sulfamethoxazole

Ciprofloxacin, levofloxacin, moxifloxacin

Streptococcus pneumoniae (non-CSF) penicillin MIC < 2 penicillin MIC ≥ 2

Penicillin G, amoxicillinMoxifloxacin, ceftriaxone

Ceftriaxone, azithromycin, doxycycline, clindamycin, moxifloxacin

Vancomycin, linezolid




and susceptibility)

Streptococcus pneumoniae (CSF) penicillin MIC < 0.1

penicillin MIC = 0.1-1

penicillin MIC ≥ 2

Penicillin G, ampicillin

Ceftriaxone

Vancomycin + ceftriaxone

Ceftriaxone, vancomycin

Cefepime, vancomycin

Streptococcus, group A, B, C or G

PenicillinAmpicillin, amoxicillin cefazolin, ceftriaxone, clindamycin, vancomycin

Streptococcus viridans group

Penicillin, amoxicillinAmpicillin, ceftriaxone, vancomycin

Suggested Duration of Antimicrobial Therapy Based on Indication

DiagnosisDuration of Antimicrobial Therapy

Key References

Asymptomatic bacteriuria (ASB) 0 days

• ASB treatment is harmful for most patients

• Treatment is only routinely indicated in patients who are pregnant or undergoing a urologic procedure

Infectious Diseases Society of America Guidelines: http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/Asymptomatic%20Bacteriuria.pdf

Candidemia If no ocular involvement or other metastatic complications: • Non-neutropenic: 14 days

from first negative blood culture

• Neutropenic: minimum of 14 days from first negative blood culture and resolution of neutropenia and symptoms

If ocular involvement:• 4 to 6 weeks

Infectious Diseases Society of America Guidelines: http://cid.oxfordjournals.org/content/62/4/e1.full.pdf

COPD exacerbation 5 to 7 days

According to the GOLD guidelines, antibiotics are indicated for patients with increased sputum purulence PLUS increased dyspnea and/or sputum volume. Antibiotics are also indicated if COPD exacerbation requires mechanical ventilation.

GOLD Guidelines http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdfOther resources:http://thorax.bmj.com/content/63/5/415.full.pdf


Key References

Complicated intra-abdominal Infection, community-acquired (appendicitis, cholecystitis, diverticulitis)

4 to 7 days after adequate source control

Infectious Diseases Society of America Guidelines: http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Intra-abdominal%20Infectin.pdf

Other resources: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411162

Meningitis, community-acquired N. meningitidis: • 7 days H. influenzae: • 7 days S. pneumoniae: • 10 to 14 days L. monocytogenes:• ≥ 21 days

Infectious Diseases Society of America Guidelines: http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/Bacterial%20Meningitis(1).pdf


Key References

Pneumonia, community acquired Prompt clinical response• 5 days

Delayed clinical response• 7 to 10 days

Patients should be afebrile for at least 48-72 hours and have no more than one CAP associated sign of clinical instability before discontinuing antibiotics.

Infectious Diseases Society of America Guidelines:http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/CAP%20in%20Adults.pdf

Other resources:https://www.ncbi.nlm.nih.gov/pubmed/10052544http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2536189

Pneumonia, hospital-acquired, ventilator-associated

If empiric therapy was active and prompt clinical response:• 7 days

Infectious Diseases Society of America/ American Thoracic Society Guidelines: http://cid.oxfordjournals.org/content/early/2016/07/06/cid.ciw353.full.pdf

Skin and skin structure, cellulitis If prompt clinical response:• 5 days

If delayed clinical response or during a neutropenic fever episode• 7 to 14 days

Infectious Diseases Society of America Guidelines: http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full.pdf


Key References

Urinary tract infection, uncomplicated cystitis

(Uncomplicated: young, female patients with normal genitourinary anatomy)

3 days:• Sulfamethoxazole/

trimethoprim or urinary quinolone

• Nitrofurantoin7 days:• Beta-lactams

Infectious Diseases Society of America Guidelines: https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciq257

Urinary tract infection, pyelonephritis or complicated infection (including bacteremic pyelonephritis)

7 days: • Urinary quinolone• Ceftriaxone 14 days• Other beta-lactams

Infectious Diseases Society of America Guidelines: https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciq257

Intravenous to Oral Conversion

For an intravenous to oral conversion, the following criteria must be met:

Inclusion Criteria• Patient is admitted to a non-intensive care unit (ICU)/general practice unit (GPU)• Patient has received and is tolerating at least 1 dose of a medication administered enterally

or is tolerating an enteral diet• Patient has received the medication to be converted intravenously for at least 24 hours

Exclusion Criteria• Patient is admitted to an intensive care unit (ICU) (including ICU step-down or mixed ICU unit)• Nonfunctioning gastrointestinal tract

o Gastric obstruction or ileus• Persistent nausea and vomiting• Strict NPO (for a procedure or other medical reason)• Patients receiving treatment for an active GI bleed

Additional criteria:

Inclusion Criteria – Anti-Infectives• Afebrile (T < 38°C, 100.4°F) for at least 24 hours• Resolving/normalizing WBC (unless on oral or injectable steroids)

Exclusion Criteria – Anti-infectives• Neutropenia (ANC <1000)• Endocarditis• Meningitis or brain abscess• MRSA bacteremia• Feeding tubes with intestinal access only (applies to fluoroquinolones only)

o Ex. J-port, J-tube, PEJ (percutaneous endoscopic jejunostomy) tube or any feeding tube accessing the small bowel

Patients not meeting the above criteria, including patients admitted to an intensive care unit, may still be eligible for intravenous (IV) to oral (PO) conversion pursuant to an order by an authorized provider.

Other ConsiderationsWhen an oral antibiotic is available in both solid and liquid dosage forms:• Order the solid form if patient is receiving other solid oral medications• Order the liquid formulation if patient is receiving oral medications in liquid formulation only

Intravenous to Oral Conversion Dosing/Frequency Chart

Anti-Infectives

IV Drug Order Bioavailability Oral ConversionAzithromycin250-500 mg IV daily

< 50% Azithromycin 250-500 mg PO dailyConvert to identical dose orally

Clindamycin600 mg IV q8h

~90% Clindamycin 300 mg PO q6h

Clindamycin900 mg IV q8h

~90% Clindamycin 450 mg PO q6h

Ciprofloxacin 400 mg IV

60 – 80% Ciprofloxacin 500-750 mg PO- Use 750 mg for administration via gastric-access feeding tube-Order standard/maximum dose renal function and infection severity

Levofloxacin750 mg IV

~99% Levofloxacin 750 mg POConvert to identical dose orally

Ofloxacin 400 mg IV

~98% Ofloxacin 400 mg POConvert to identical dose orally

Doxycycline100 – 200 mg IV

~100% Doxycycline 100 – 200 mg POConvert to identical dose orally

Linezolid 600 mg IV q12h

~100% Linezolid 600 mg PO q12h

Metronidazole500 mg IV q8-12h

~100% Metronidazole 500 mg PO q8-12Convert to identical dose orally

Trimethoprim/sulfa-methoxazole5-20 mg/kg

~100% Trimethoprim/sulfamethoxazole 5 to 20 mg/kg PO in divided dosesConvert to identical dose orally

Other considerations for the same class of medication with similar spectrum of activity:• Penicillin G IV step-down to Penicillin VK PO• Cefazolin IV to cephalexin PO

Antibiotic Prophylaxis Guidelines

Condition Empiric Regimen Duration of Therapy

Chronic wound treatment None None

Burn treatment None None

Pre-operation treatment (if infection suspected)

Ceftriaxone (or other third-gen cephalosporin)

1-3 doses

Post-operation treatment (if infection suspected)

Ceftriaxone (or other third-gen cephalosporin)

1-3 doses

Renal Dosing Guidelines for Antimicrobials

Cockroft-Gault Creatinine Clearance EquationCrCL = ((140– Age) x weight) (72 x SCr) x 0.85 (if female)

Alphabetical Index of Antimicrobials (by Generic Name)

AAmoxicillin PO

Creatinine Clearance (mL/minute)

Standard Regimen

Community-acquired pneumonia

(in combination with a macrolide)

> 30 500 mg PO every 8 hoursOR

875 mg PO every 12 hours


10 to 30 500 mg PO every 12 hours 1000 mg PO every 12 hours

< 10 500 mg PO every 24 hours 500 mg PO every 24 hours

Hemodialysis 500 mg PO every 24 hours, schedule after HD on HD days

500 mg PO every 24 hours, schedule after HD on HD days

Amoxicillin/clavulanate PO


Standard Dose Community-acquired pneumonia

> 30 Amoxicillin 500 mg/ clavulanate 125 mg PO every

8 hoursOR

Amoxicillin 875 mg/ clavulanate 125 mg PO every

12 hours

2 grams PO every 12 hours


Standard Dose Community-acquired pneumonia

10 to 29 Amoxicillin 500 mg/ clavulanate 125 mg PO every

12 hours

Not suggested, use standard dose

< 10 Amoxicillin 500 mg/ clavulanate 125 mg PO every

24 hours

Hemodialysis (HD) Amoxicillin 500 mg/ clavulanate 125 mg PO every 24 hours, schedule after HD

on HD days

Azithromycin IV/PO


COPD exacerbation or lower respiratory

infection

MAC prophylaxis

Chlamydia trachomatis

Any 500 mg dailyOR

500 mg x 1, then 250 mg daily x 4 days

1200 mg weekly

1000 mg x 1 dose

No renal dose adjustment

Cefoperazone IV


Standard Dose Maximum Dose

Any 1 to 2 grams IV every 12 hours 2 to 4 grams IV every 8 to 12 hours


Cefoperazone/Sulbactam IV


Standard Dose

> 30 2 to 4 grams IV every 12 hours

29 -15 1 gram IV every 12 hours

< 15 500 mg IV every 12 hours

Hemodialysis (HD) 500 mg IV every 12 hours, schedule after HD on HD days

Cefepime IV



> 60 1 gram IV every 8 hoursOR

2 grams IV every 12 hours

2 grams IV every 8 hoursOR

1 gram IV every 6 hours

30 to 60 1 gram IV every 12 hours 2 grams IV every 12 hoursOR


10 to 29 1 gram IV every 12 hours 1 gram V every 12 hours

≤ 10 1 gram IV every 24 hours 1 gram IV every 24 hours

Hemodialysis (HD) 1 gm IV every 24 hours, sched-ule after HD on HD days

OR 2 gm IV three times per week

after HD

1 gm IV every 24 hours, schedule after HD on HD days

OR 2 gm IV three times per week

after HD

Dose adjustment required in obesity.

Cefpodoxime PO

Creatinine Clearance (mL/minute) Respiratory Infection≥ 30 200 mg PO every 12 hours

< 30 200 mg PO every 24 hours

Hemodialysis (HD) 200 mg PO three times per week after HD

Ceftazidime

Creatinine Clear-ance (mL/minute)


≥ 50 1 gm IV every 8 hours 2 gm IV every 8 hours

31 to 49 1 gm IV every 12 hours 2 gm IV every 12 hours

≤ 30 1 gm IV every 24 hours 1 gm IV every 24 hours

Hemodialysis (HD) 1 gm IV every 24 hours, schedule after HD on HD days

1 gm IV every 24 hours, schedule after

HD on HD days

Ceftriaxone IV


Standard Dose Endocarditis Meningitis

Any 1 gm IV every 24 hours 2 gm IV every 24 hours

2 gm IV every 12 hours


Cephalexin PO

Creatinine Clearance (mL/minute) Standard Dose≥ 60 500 mg PO every 6 hours

30 to 59 500 mg PO every 8 hours



Hemodialysis (HD) 500 mg PO every 24 hours, schedule after HD on HD days

Ciprofloxacin IV



> 60 400 mg IV every 12 hours 400 mg IV every 8 hours

31 to 60 400 mg IV every 12 hours 400 mg IV every 12 hours

≤ 30 400 mg IV every 24 hours 400 mg IV every 24 hours


400 mg IV every 24 hours, schedule after HD on HD days

Ciprofloxacin PO


SBP Prophylaxis


> 60 750 mg PO every 7 days


500 mg PO every 8 hoursOR



500 mg PO every 8 hoursOR


≤ 30 500 mg PO every 24 hours

500 - 750 mg PO every 24 hours

H e m o d i a l y s i s (HD)

500 mg PO every 24 hours, schedule

after HD on HD days

500 mg PO every 24 hours, schedule after HD on HD days

Cloxacillin IV


Standard Dose

Any 2 gm IV every 4 to 6 hours


Colistin IV (doses are in terms of colistin base)


Standard Dose

≥ 50 5 mg/kg (max 300 mg) x 1, then 2.5 mg/kg IV every 12 hours

30 to 49 5 mg/kg (max 300 mg) x 1, then 1.75 mg/kg IV every 12 hours

10 to 29 5 mg/kg (max 300 mg) x 1, then 1.25 mg/kg IV every 12 hours

< 10 5 mg/kg (max 300 mg) x 1, then 1.5 mg/kg IV every 24 hours

Hemodialysis (HD) 5 mg/kg (max 300 mg) x 1, then 1.5 mg/kg IV every 24 hours, schedule after HD on HD days

Dose colistin mg/kg on ideal body weight for all patients (including obese patients). Round all doses to the nearest 50 mg increment.

DDicloxacillin PO

Creatinine Clearance (mL/minute) Standard DoseAny 500 mg PO every 6 hours


Doxycycline IV/PO

Creatinine Clearance (mL/minute) Standard DoseAny 200 mg x 1, then 100 mg every 12 hours


IImipenem/cilastatin IV



> 60 500 mg IV every 6 hours 1000 mg IV every 6 to 8 hours

31 to 60 500 mg IV every 8 hours 750 mg IV every 8 hours

≤ 30 500 mg IV every 12 hours 500 mg IV every 12 hours

Hemodialysis (HD) 500 mg IV every 12 hours, with the second dose after HD on HD days

500 mg IV every 12 hours, with the second dose after HD on HD days

LLevofloxacin IV/PO



> 50 250 – 500 mg every 24 hours 750 mg every 24 hours

20 to 49 500 mg x 1, then 250 mg every 24 hours

750 mg every 48 hours

≤ 30 500 mg x 1, then 250 mg every 48 hours

750 mg x 1, then 500 mg every 48 hours

Hemodialysis (HD) 500 mg x 1, then 250 mg every 48 hours

750 mg x 1, then 500 mg every 48 hours

Linezolid IV/PO

Creatinine Clearance (mL/minute) Standard DoseAny 600 mg every 12 hours


MMeropenem IV



> 50 1 gram IV every 8 hours

OR

500 mg IV every 6 hours


26 to 50 1 gram IV every 12 hours

OR



10 to 25 500 mg IV every 12 hours 1 gram IV every 12 hours

< 10 500 mg IV every 24 hours 1 gram IV every 24 hours


1 gram IV every 24 hours, sched-ule after HD on HD days

Metronidazole IV/PO

Creatinine Clearance (mL/minute) Standard Dose TrichomonasAny 500 mg every 6-12 hours 2000 mg x 1 dose


Moxifloxacin IV/PO

Creatinine Clearance (mL/minute) Standard DoseAny 400 mg every 12 hours


NNafcillin IV

Creatinine Clearance (mL/minute) Standard DoseAny 2 grams IV every 4 hours


Nitrofurantoin PO (MacroBID)


< 40 Avoid in patients with CrCl less than 40 due to inad-equate urinary concentrations and increased risk of

adverse effects

Norfloxacin PO



Hemodialysis 400 mg PO every 24 hours, schedule after HD on HD days

OOfloxacin PO/IV

Creatinine Clearance (mL/minute) Standard Dose> 50 200 - 400 mg every 12 hours

< 50 200 – 400 mg every 24 hours

Hemodialysis 200 – 400 mg every 24 hours. Ofloxacin is not removed efficiently by HD and no manufacturer

recommendations are available.

PPenicillin G IV

Creatinine Clearance (mL/minute) Standard dose Maximum dose> 50 2 million units IV every

4 hours4 million units IV every 4

hours

10 to 50 2 million units IV every 6 hours

4 million units IV every 6 hours

< 10 2 million units IV every 8 hours

4 million units IV every 8 hours

Hemodialysis (HD) 2 million units IV every 8 hours,

schedule so that a dose is administered as soon

as possible after HD

4 million units IV every 8 hours,

schedule so that a dose is administered as soon as

possible after HD

Penicillin V PO



Hemodialysis (HD) 500 mg PO every 8 hours

Piperacillin-tazobactam IV

Creatinine Clearance (mL/minute) Standard Dose> 40 4.5 grams IV every 6 hours

20 to 39 4.5 grams IV every 8 hours

< 20 4.5 grams IV every 12 hours

Hemodialysis (HD) 4.5 grams IV every 12 hours, schedule so that one of the every 12 hour doses is administered after HD

Polymyxin B

Creatinine Clearance (mL/minute) Treatment

ANY 1.25 mg/kg to 1.5 mg/kg IV every 12 hours

No renal dose adjustmentPolymyxin B sulfate 10,000 units = 1 mg. Dose based on actual body weight. Round doses to the near-est 50 mg vial.

TTrimethoprim/sulfamethoxazole IV

Creatinine Clearance (mL/minute) UTI, SSTI Other Infections> 30 2.5 mg/kg IV every 12

hours5 mg/kg IV every 8 to 12

hours

10 to 30 2.5 mg/kg IV every 12 hours

5 mg/kg IV every 12 to 24 hours

< 10 2.5 mg/kg IV every 24 hours

5 mg/kg IV every 24 hours

Hemodialysis (HD) 5 mg/kg IV three times per week after HD

7 to 10 mg/kg IV three times per week after HD

Trimethoprim/sulfamethoxazole is dosed off by mg/kg of trimethoprim component.

Trimethoprim/sulfamethoxazole PO


UTI, SSTI Other Infections

> 30 1 DS tablet PO every 12 hours 2 DS tablets PO every 12 hours

10 to 30 1 DS tablet PO every 12 hours 1 to 2 DS tablets PO every 12 hours

< 10 1 DS tablet PO every 24 hours 1 to 2 DS tablets PO every 24 hours

Hemodialysis (HD) 1 DS tablet PO every 24 hours OR

2 DS tablets PO three times per week after HD

2 DS tablets PO every 24 hours OR

7 to 10 mg/kg PO three times per week after HD

DS = double strength. Trimethoprim/sulfamethoxazole is dosed off of mg/kg by trimethoprim compo-nent.

Tigecycline IV

Creatinine Clearance (mL/minute) Standard DoseANY 100 mg IV x 1, then


No renal dose adjustment necessary. Reduce dose to 100 mg x 1, then 25 mg IV every 12 hours for Child-

Pugh class C liver dysfunction.


Name: ___________________________________

Month/Year: _____________________________

Hospital: ________________________________

Department: _____________________________

October 2019

THE GLOBAL HEALTH INITIATIVETHE GLOBAL HEALTH INITIATIVE

Documents

Antibiotic Treatment Guideline