2021 Antibiotic Stewardship Guidebook - On Call Infectious Disease Physician Pharmacy Phone Extensions: See Voalte
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2021 Antibiotic Stewardship Guidebook On Call Infectious Disease Physician Beacon Center Phone 303-415-8850 Person on Call Icon in Citrix Pharmacy Phone Extensions: See Voalte © 2021 Boulder Community Health. Printed 07/13/2021
2021 Antibiotic Stewardship Guidebook Table of Contents Page 2020 Antibiogram 1-5 Empiric Antibiotic Guidelines 6-8 Empiric Antibiotic Therapy for Severe Sepsis and Septic Shock of Unknown Source 9 Guidelines for Treatment of UTI 10-11 Ambulatory Management of Upper Respiratory Tract Infections in Adults 12-13 Antimicrobial Dosing Chart 14-16 Prophylactic Antibiotics by Procedure 17-19 Antibiotic Allergy Tip Sheet and Cross Reactivity Chart between Penicillins and Cephalosporins 20-21 Testing Algorithm for Clostridium difficile 22 GI Pathogen PCR Testing Algorithm 23 Recommended Interpretation and Management of GI PCR 24-25 Antimicrobial Cost Information 26 Vancomycin Nomogram 27-28 Antimicrobial Stewardship Team and Other Contributors 29
Antibiogram 2020
Species with less than 30 isolates, susceptibilities should be interpreted with caution. Grey boxes indicate organism has intrinsic resistance or
susceptibilities are not published to corresponding antimicrobial.
Sulfamethoxazole
Total # Isolates
Trimethoprim
Levofloxacin
Meropenem
Tazobactam
Ceftazidime
Gram Negative NON-URINE
Ceftriaxone
Tobramycin
Gentamicin
Ertapenem
Ampicillin-
Pipercillin-
Sulbactam
Ampicillin
Cefepime
Cefazolin
Isolates Inpatient and
Emergency Department
Organism # Results % Susceptibility
Acinetobacter spp. 3 50% 67% 100% 100% 100% 100% 100% 100%
Citrobacter spp.1 10 30% 90% 20% 90% 100% 100% 100% 100% 100% 100% 100%
Enterobacter spp.1 27 70% 67% 89% 70%2 100% 100% 100% 100% 100%
Escherichia coli 105 65% 69% 98% 85% 92% 93% 100% 100% 83% 78% 94% 96%
Klebsiella spp. 47 64% 91% 74% 94% 96% 100% 100% 100% 98% 98% 98%
Klebsiella spp excluding K. aerogenes 41 73% 93% 85% 95% 98% 100% 100% 100% 100% 98% 98%
K. aerogenes 6 0% 83% 83% 83% 100% 100% 100% 100% 100% 100%
Proteus1
P. vulgaris group 2 100% 100% 100% 100% 100% 100% 100% 100%
P. mirabilis 13 75% 92% 92% 92% 100% 100% 100% 77% 85% 77% 77%
Pseudomonas aeruginosa 37 92% 92% 97% 95% 97% 97% 97%
Serratia spp.1 6 83% 83% 100% 100% 100% 100% 100% 100% 100%
Stenotrophomonas maltophilia (all locations) 9 100% 78% 100%
1. Citrobacter freundii, Enterobacter, Proteus vulgaris, Klebsiella aerogenes, & Serratia have the potential to induce AmpC beta-lactamase production and
become resistant to 3rd generation cephlosporins, aztreonam, piperacillin-tazobactam on therapy. Use those agents with caution. Failure rates appear
highest with Enterobacter » Citrobacter » Serratia. Cefepime and carbapenems appear to be stable. % Susceptible
2. Among Enterobacter resistant to ertapenem, none were identified as true CRE at CDPHE.
80% or better
Haemophilus influenzae beta-lactamase positive 25%, n=32
70-79%
Carbapenem Resistant Ps. aeruginosa (CRPA): 1) NON-URINE 5%, 2) URINE 11%
ESBL Rate (E.coli and Klebsiella): Inpatient: 1) NON-URINE 5%, 2) URINE 4%; Outpatient: 1) NON-URINE 5%, 2) URINE 4%Antibiogram 2020
Species with less than 30 isolates, susceptibilities should be interpreted with caution. Grey boxes indicate organism has intrinsic resistance or
susceptibilities are not published to corresponding antimicrobial.
Sulfamethoxazole
Total # Isolates
Erythromycin
Trimethoprim
Levofloxacin
Clindamycin
Vancomycin
Tetracycline
(meningitis)
(meningitis)
Gentamycin
Gram Positive NON-URINE
Ceftriaxone
Ceftriaxone
Penicillin G
Penicillin G
Oxacillin3
synergy
Isolates Inpatient and
Emergency Department
Organism # Results % Susceptibility
Enterococcus spp. 1
43 91% 93% 91%
E. faecalis 33 97% 97% 88%
E. faecium 10 70% 80% 100%
Streptococcus pneumoniae (all locations)2 21 100% 71% 100% 100% 90% 100% 81% 100% 76%
Viridans streptococcus (includes S.anginosus)4 29 97% 100% X X 100%
Streptococcus pyogenes (Group A) 11 100% 100% 73% 100% 73%
Streptococcus agalactiae (Group B) 7 100% 100% 57% 100% 43%
Staphlococcus aureus all locations 859 79% 82% 98% 100% 95%
Inpatient/ED 255 66% 83% 97% 100% 95%
Outpatient only 614 85% 82% 98% 100% 94%
Staphylococcus epidermidis 26 56% 73% 92%
Staphylococcus lugdunensis (all locations) 44 98% 98% 98%
1. Enterococci susceptible to penicillin are predictably susceptible to ampicillin, amoxicillin, ampicillin-sulbactam, amoxicillin-clavulanate and pip/tazo
2. CLSI requires publication of two breakpoints for all pneumococcal isolates designated: meningitis and non-meningitis. There were 7 blood & 14 Respiratory/Wound isolates.
3. Oxacillin results can be applied to other anti-staph penicillins and β-lactam/β-lactamase inhibitors, cephalosporins and carbapenems.
4. Isolate of Viridans streptococcus non-susceptible to penicillin (n=1) was intermediate (MIC 0.25-2.0).
% Susceptible
X=Not recommended
80% or better
70-79%Antibiogram 2020 Species with less than 30 isolates, susceptibilities should be interpreted with caution. Grey boxes indicate
organism has intrinsic resistance or susceptibilities are not published to corresponding antimicrobial.
Sulfamethoxazole
Total # Isolates
Nitrofurantoin
Trimethoprim
Levofloxacin
Ceftazidime
Vancomycin
Tetracycline
Meropenem
Ceftriaxone
Penicillin G
Ertapenem
Sulbactam
Ampicillin
Ampicillin
Cefepime
Cefazolin
Oxacillin
URINE Isolates Inpatient and
Emergency Department
Organism # Results % Susceptibility
Acinetobacter species 1 100% 100% 100% 100% 100%
Citrobacter spp. 17 76% 100% 92% 100% 94% 94% 71% 88%
Enterobacter spp. 13 85% 100% 91% 100% 100% 100% 46% 100%
E. coli 304 63% 67% 93% 94% 94% 100% 100% 88% 80% 98% 77%
Klebsiella spp.
Klebsiella excluding K. aerogenes 74 81% 91% 95% 95% 100% 100% 97% 93% 63% 86%
K. aerogenes 10 0% 0% 80% 100% 100% 100% 100% 100% 50% 100%
Proteus spp.
P. mirabilis 20 90% 90% 100% 100% 100% 100% 65% 95%
P. vulgaris group 1 100% 100% 100% 100% 100%
Ps. aeruginosa 37 89% 95% 86% 81%
Serratia marcescens 2 0% 100% 50% 100% 100%
Stenotrophomonas (all locations)1 5 80% 80% 100%
Enterococcus spp. Total2 45 91% 91% 98% 100% 27%
E. faecalis 39 100% 100% 100% 100% 23%
E. faecium 6 33% 33% 83% * 50%
Staphylocccus aureus 42 76% 88% 100% 100% 83%
Staph species not aureus 17 29% * 100% 100% 88%
*In house testing not available % Susceptible
1. No Stenotrophomonas isolated from urine collected in 2020, data from 2019
80% or better
2. Enterococci susceptible to penicillin are predictably susceptible to ampicillin, amoxicillin, ampicillin-sulbactam, amoxicillin-clavulanate and pip/tazo
70-79%Antibiogram 2020 Species with less than 30 isolates, susceptibilities should be interpreted with caution. Grey boxes indicate
organism has intrinsic resistance or susceptibilities are not published to corresponding antimicrobial.
Sulfamethoxazole
Total # Isolates
Nitrofurantoin
Trimethoprim
Levofloxacin
Ceftazidime
Vancomycin
Tetracycline
Meropenem
Ceftriaxone
Penicillin G
Ertapenem
Sulbactam
Ampicillin
Ampicillin
Cefepime
Cefazolin
Oxacillin
URINE Isolates Outpatient
Organism # Results % Susceptibility
Acinetobacter baumanii 1 100% 100% 100% 100% 100% 100% 100%
Citrobacter spp. 78 53% 44% 94% 100% 92% 83% 73% 87%
Enterobacter spp. 50 82% 98% 98% 92% 54% 84%
E. coli 1716 67% 71% 93% 95% 100% 91% 82% 99% 79%
Klebsiella spp.
Klebsiella excluding K. aerogenes 209 81% 92% 96% 100% 99% 94% 63% 92%
K. aerogenes 32 0% 0% 84% 100% 100% 100% 41% 97%
Proteus spp.
P. mirabilis 64 86% 92% 89% 100% 94% 91%
P. vulgaris group 7 0% 14% 100% 100%
Ps. aeruginosa 37 100% 100% 89% 81%
Serratia marcesens 9 100% 100% 100% *
Enterococcus spp. 125 98% 98% 99% 100% 26%
E. faecalis 120 100% 100% 100% 100% 24%
E. faecium 5 20% 20% 80% * 40%
Staphylocccus aureus 117 87% 97% 100% 100% 96%
Staph species not aureus 56 64% 100% 100% 93%
*In house testing not available. % Susceptible
Cefepime and Ertapenem not reported for outpatient urines Enterobacteriaceae group 80% or better
70-79%
Carbapenem Resistant Ps. aeruginosa (CRPA): 1) NON-URINE 5%, 2) URINE 11%
ESBL Rate (E.coli and Klebsiella): Inpatient: 1) NON-URINE 5%, 2) URINE 4%; Outpatient: 1) NON-URINE 5%, 2) URINE 4%Antibiogram 2020
Species with less than 30 isolates, susceptibilities should be interpreted with caution.
Total # Isolates
Voriconazole
Fluconazole
Micafungin
Yeast All locations1
Organism # Results % Susceptibility
Candida albicans 10 100% 100% 100%
Candida glabrata 10 80% 100% 100%
Candida krusei2 3 0% 100% 100%
Candida tropicalis 2 100% 100% 50%
Candida parapsilosis 2 100% 100% 100%
Overall 27 89% 100% 96%
1. Testing performed at Mayo Laboratories % Susceptible
2. Intrinsically resistant to Fluconazole
80% or better
70-79%
Isolate sources:
Peritoneal n=11; Blood n=4;Empiric Antimicrobial Guidelines for Hospitalized Adults 2021
Suggested initial therapies based on guidelines1-9 and local resistance patterns, these guidelines are not a substitution for an ID consult.
Indication Likely Pathogens Empiric Therapy Alternative Therapy Duration Oral Empiric Step Down
Community S. pneumo., H. flu, Mycoplasma, C. Ceftriaxone 1-2g IV q24h + Severe β lactam allergy 5-7 days • Amox/Clav + Azithromycin
Acquired pneumoniae, Legionella, S. aureus, Azithromycin 500mg IV q24h Levofloxacin 750mg IV q24h
If abscess or • 3rd gen PO Cephalosporin
Pneumonia1 respiratory viruses
Risk for Prolonged QT empyema is +Azithro
OR Levofloxacin 750mg IV q24h
Important to consider respiratory Use Doxycycline 100mg IV/PO present, ID consult
• Levofloxacin
viruses and isolate if appropriate. ICU admit + Risks for MDRO: consider HAP antibiotic q12h for atypical coverage recommended
recs +/- Levofloxacin 750mg IV q24h
Blood and respiratory cultures
recommended, in cases of severe
pneumonia send Legionella
urinary antigen.
HCAP Treat as CAP unless specific risks for MDRO Risks: prior IV antibiotic use last 90 days, past
MDRO then HAP recommendations cultures demonstrating MDRO or MRSA risk factors
HAP/VAP2 Enteric GNR, Pseudomonas, MRSA Cefepime 2g IV 8h Severe β lactam allergy 7 days Depends on microbiologic data
OR Pip/taz 4.5g IV q6h Consult ID
Blood and respiratory cultures
+/- Vancomycin IV
recommended, in cases of severe
pneumonia, send Legionella urinary
antigen.
Aspiration PNA1,2,8 Streptococcus, H flu, S. Aureus, Community acquired Severe β lactam allergy 5-7 days • Amox/Clav
Enterobacteraciae. Anaerobes Amp/Sulbactam 3g IV q6h Moxifloxacin 400mg IV/PO q24h
If abscess or • Moxifloxacin
considered less common
empyema is
OR Ceftriaxone 1g IV daily • PCN + Metronidazole
1) Clear CXR + mild to moderate present, ID consult
illness consider withholding Hospital acquired recommended • Clindamycin
antibiotics and monitoring Low risk: same as community acquired
2) If no evidence of infection High risk: antibiotics in last 90 days and/or
after 2 days following witnessed hospitalized ≥ 5 days
aspiration in the hospital, consider Pip/taz 3.375g to 4.5g IV q6h
discontinuation of antibiotics
Community E coli, other enteric GNR, Enteric Ceftriaxone 1g IV q24h + Severe β lactam allergy 5-7 days with Based on cultures
Acquired streptococci, Bacteroides, Metronidazole 500mg IV q8h Levofloxacin 750mg q24h + source control
Empiric
Intra-abdominal anaerobes Metronidazole 500mg IV q8h
Infection3 • Amox/Clav
17% local non-urine E coli
resistance to Levofloxacin • Levofloxacin +
Metronidazole
NOTE: Antibiotic dosing in this chart does not take into account renal or liver dysfunction.
6Empiric Antimicrobial Guidelines for Hospitalized Adults 2021
Suggested initial therapies based on guidelines1-9 and local resistance patterns, these guidelines are not a substitution for an ID consult.
Indication Likely Pathogens Empiric Therapy Alternative Therapy Duration Oral Empiric Step Down
Severe Sepsis ESBL E coli, Pseudomonas, strep Pip/taz 4.5g IV q6h β lactam allergy 5-14 days Based on cultures
with Peritonitis or sp, enterococcus, staph, MRSA, +/- Vancomycin IV Meropenem 1g IV q8h depending on
Empiric
Hospital Acquired yeast (MRSA colonized or failing current therapy) source control
Severe β lactam allergy
Intra-abdominal • Levofloxacin + Metronidazole
Consider yeast coverage Consult ID ID Consult
Infection3
Recommended
Febrile Enteric gram neg, Pseudomonas, Cefepime 2g IV q8h Severe β lactam allergy Depends on • Levofloxacin
Neutropenia4 Streptococcus sp, Staphylococcus +/- Vancomycin IV (cath related, SSTI, PNA, unstable) Consult ID clinical response/
• Amox/Clav
+/- Metronidazole IV 500mg IV q8h (abdominal source/count
symptoms) recovery
OR Pip/taz 4.5g IV q6h
+/- Vancomycin IV (cath related, SSTI, PNA, unstable)
Meningitis5 S. pneumo., N. meningitis, Listeria, Ceftriaxone 2g IV q12h Nosocomial/post-neurosurgical 7-21 days Not applicable
Viral (enterovirus, HSV, VZV) + Vancomycin IV Consult ID depending on
+/- Ampicillin 2g IV q4h (Listeria, consider if >50y/o, pathogen: consult
Suspect HSV/VZV » consult ID Severe β lactam allergy
preg, immunocompromised) ID
Consult ID
+/- Dexamethasone 0.15mg/kg IV q6h administered
10–20 min before, or concomitant with, 1st dose of
antibiotics with suspected/proven pneumococcal
meningitis
Skin and Soft Erysipelas, Non-purulent6 Cefazolin 1-2g IV q8h Severe β lactam allergy 5-7 days • Dicloxacillin
Tissue Infections Streptococcus Vancomycin IV
• Cephalexin
OR Clindamycin 600mg IV q8h
• Clindamycin
(check antibiogram)
Purulent/abscess6 Vancomycin IV Allergy to Vancomycin IV Variable, if Empiric or MRSA
Staphylococcus sp Consult ID abscess evacuated TMP/SMX or Doxycycline
consider shorter
• Consider Surgical consult for I&D MSSA
5-7 days
Dicloxacillin or Cephalexin
• Obtain culture
Necrotizing Fasciitis6 Vancomycin IV Severe β lactam allergy Variable Not applicable
Type 1 Polymicrobial +Pip/taz 4.5g IV q6h Consult ID
Type 2 S. pyogenes (GAS) +/- Clindamycin IV 600mg IV q8h
(if high concern S. pyogenes)
Immediate Surgical and ID consult
recommended.
NOTE: Antibiotic dosing in this chart does not take into account renal or liver dysfunction.
7Empiric Antimicrobial Guidelines for Hospitalized Adults 2021
Suggested initial therapies based on guidelines1-9 and local resistance patterns, these guidelines are not a substitution for an ID consult.
Indication Likely Pathogens Empiric Therapy Alternative Therapy Duration Oral Empiric Step Down
Diabetic Foot Polymicrobial: Staphylococcus, Amp/sulbactam 3g IV q6h Concern for Pseudomonas Variable Based on cultures
Infection7 Streptococcus predominant Pip/taz 4.5g IV q6h
OR ceftriaxone 2g IV q24h + Metronidazole 500mg
Consider ESBL GNR, Severe β lactam allergy
PO/IV q8h
Pseudomonas, anaerobes Levofloxacin 750mg IV q24h
+/- Vancomycin IV
as well. + Clindamycin 600mg IV q8h
Recommend culture from deep tissue, obtained by +/-Vancomycin IV
biopsy or curettage after the wound cleansed and
debrided.
Urinary Tract See pages 10-11
Infection8,9
ID consult available for any ID condition, but strongly recommended for bacteremia, fungemia, meningitis,
necrotizing fasciitis, severe intra-abdominal infection and endocarditis
NOTE: Antibiotic dosing in this chart does not take into account renal or liver dysfunction.
REFERENCES:
1 CID 2007; 44:S27–72
2 CID 2016; 63(5):e61 PEARLS:
3 CID 2010; 50:133–64 & Surg Infect 2017: 18:1-56
• Penicillin allergy: Recommend review of Antibiotic Allergy Tip Sheet
4 CID 2011; 52(4):e56–e93
and Chart on Cross Reactivity between Penicillins and Cephalosporins,
5 CID 2004; 39:1267–84
page 20-21.
6 CID 2014 Jul 15; 59(2):147-59
• 34% of non-urine staphylococcus aureus isolates are MRSA.
7 CID 2012; 54(12):132–173
8 CID 2011; 52(5):e103–e120 & NEJM 2019; 380:651-63 • Rate of non-urine ESBL is 5% among E coli, Klebsiella and Proteus.
9 CID 2010; 50:625–663
8BCH Empiric Antibiotic Therapy for Sepsis and Septic Shock
of Unknown Source
Risk
Risk Factors
factors for
for Resistant
Resistant Organisms
Organisms 1. R
efer to specific sections in antibiotic guidelines for
Hospitalized previous 90 days specific sources of infection. Sepsis treatment should be
Long term HD targeted at the specific source whenever possible.
Immunosuppressed
2. Review prior microbiology data.
Broad spectrum antibiotics in last 90 days
NH or LTC 3. Blood cultures should be collected PRIOR to antibiotics.
Known MDRO organism 4. Consider viral etiologies.
Concern for Pseudomonas
NO YES
Ceftriaxone 2g IV q24h Zosyn 4.5g IV q6hrs
(q12hrs for CNS) OR
+/- Meropenem 1g IV q8h NOTE: If Septic Shock: initial use of
Vancomycin IV +/- broader spectrum antibiotics may be
(IF suspect MRSA or resistant S. pneumoniae) Vancomycin IV appropriate, even in the absence of risk
+/- factors for resistant organisms, and is
OPTIONAL TREATMENT Atypical CAP coverage: left to clinical judgment.
Atypical CAP coverage: Azithromycin 500mg IV q24h
Azithromycin 500mg IV q24h
Anaerobic coverage : Metronidazole
SEVERE BETA LACTAM ALLERGY
Aztreonam 2g IV q8h
Broad-spectrum empiric therapy used OR
while cultures are pending i.e. first Levofloxacin 750mg IV daily
48-72 hours. Antibiotic regimen should +
be evaluated daily and streamlined Vancomycin IV
based on culture data. +/-
Anaerobic coverage: Metronidazole IV
9Guidelines for Management of Urinary Tract Infection
in the Inpatient and Outpatient Setting
GENERAL RULE: Limit development of resistant bacteria by ONLY using antibiotics when ALL three things exist:
1. New or Different Symptoms, 2. Abnormal urinalysis, 3. Positive urine culture (>105 CFU/mL of 1 organism in clean catch or 103 CFU/mL in
catheterized specimen)
*See 2020 antibiogram for BCH patterns of resistance, now separated by inpatient and outpatient urine.
Typical Symptoms of an Infection along the Urinary Tract Symptoms NOT Indicative of UTI in the Absence of Typical Symptoms
• Dysuria, frequency, urinary urgency, urinary retention, hematuria Foul smelling urine, dark urine, cloudy urine, sediment in urine
• Pelvic pain, suprapubic pain, flank pain
• Complicated UTI: Localizing urinary symptoms with new onset or worsening fever, rigors, AMS, or lethargy
without other identifiable cause.
• Spinal cord injury: increased spasticity, autonomic dysreflexia
Definition / Comments Organisms Inpatient Treatment Outpatient Treatment
Asymptomatic Bacteriuria 105 bacteria in the urine without symptoms No antibiotic treatment recommended (exceptions: pregnancy, planned urinary
instrumentation, or 1st month following renal transplant)
PEARL: Pyuria does NOT differentiate UTI, PPV
for infection between 30 and 56.
Uncomplicated Cystitis Guidelines suggest that UA/Culture not E. coli, Klebsiella, Proteus N/A Listed in order of recommendation:
needed with uncomplicated UTI in women, Nitrofurantoin 100mg PO BID x 5 days1
S. saprophyticus (women)
but with increasing resistance rates, may be Fosfomycin 3g PO x1 dose2
clinically justified. r/o STDs in sexually active individuals Cephalexin 500mg PO BID x 5 days
Bactrim DS 1 PO BID x 3-5 days
Indications for culture: Male, History of MDRO Cipro 250 or 500mg PO BID x 3 days
positive culture, inpatient stay at health care Men should receive 7 days of therapy
facility, broad spectrum antibiotic use in last 90 except fluoroquinolones 5 days adequate.
days, recent travel to areas with high rates of
MDRO (e.g., India, Israel, Spain, Mexico) GC/Chlamydia:3 Ceftriaxone 500mg IM x1
PLUS doxycycline 100mg PO BID x 7 d
PPV = positive predictive value, MDRO = multi-drug resistant organisms
Renal dose adjustments not included in this chart, see pages 14 to 16.
10Definition / Comments Organisms Inpatient Treatment Outpatient Treatment
Complicated UTI including Upper or lower tract disease associated with E. coli, Klebsiella, Enterococcus, General admit Specific antibiotic guided by cultures
pyelonephritis factor(s) that increase(s) risk of failing therapy Pseudomonas Ceftriaxone 1g IV q24h from inpatient. Duration of therapy 5 to 14
and generally requires hospitalization. days depending on rapidity of response
Moderate to severe illness and/or
and antibiotic used to complete therapy.
PEARL: May need to order Urine Culture Concern for Pseudomonas
(fluoroquinolones 5-7 days, TMP-SMX
separately if suspicious of pyelonephritis as Cefepime 1-2g IV q8h
7-10 days, beta-lactams 10-14 days)
pyuria may not be present. OR Pip/taz 4.5g IV q6h
+/- Vancomycin IV Outpatient therapy for pyelonephritis
Obtain Urine culture
H/O MDRO:
Levofloxacin 750mg daily x 5-7 days
Ertapenem 1g IV q24h
Consult ID for Ceftriaxone 1g IV daily x 7d
CAUTI Urinary catheter placed during hospitalization: E. coli, Klebsiella, Staphylococcus, Change or discontinue Foley Based on cultures
If fever do not evaluate unless additional factors: Enterococcus, Pseudomonas
Uncomplicated
1) clinical signs: suprapubic pain or CVA
Ceftriaxone 1g IV q24h
tenderness, or 2) risk factors such as:
kidney transplant, recent GU surgery, Antibiotics in last 90 days/
evidence of obstructive uropathy, profound Severe sepsis/ Concern for
immunosuppression or neutropenia. Pseudomonas or MDRO
Cefepime 2g IV q8h
PEARL: Urinary tract infection is rarely a cause of
OR Meropenem 1g IV q8h
fever in hospitalized patient.
+/- Vancomycin IV
PEARL: PPV of pyuria is low for infection in
catheterized patients (15 to 28%)
Acute Prostatitis Symptoms of cystitis PLUS fever, chills, malaise, Gram negative rods Moderate disease Based on cultures, possible empiric
myalgias, pelvic or perineal pain, or obstructive Ceftriaxone 1g IV q24h therapy:
r/o STDs in sexually active individuals
symptoms. Swollen, tender prostate on exam. Bactrim DS 1 PO BID
ICU admission/Concern for
OR Cipro 500mg PO BID
PEARL: Only instance when urine culture Pseudomonas
Duration 14 days to 6 weeks
appropriate to repeat after ~7 days of antibiotics Cefepime 2g IV q8h
to assure clearance of bacteriuria. Consider empiric Rx for GC/Chlamydia3 if
high risk. Ceftriaxone 500mg IM x1 PLUS
Doxycycline 100mg PO BID x 7 days
Consider urology referral
PPV = positive predictive value, MDRO = multi-drug resistant organisms
Renal dose adjustments not included in this chart, see pages 14 to 16.
1. Not recommended if concern for pyelonephritis. Short term use of Macrobid okay for CrCl >30.
2. One study showed Fosfomycin inferior to Macrobid for cystitis (JAMA. 2018; 319(17):1781-1789).
3. Ceftriaxone 1000mg IM if greater than 150kg. Azithromycin no longer recommended. If serious β lactam allergy call ID.
Severe β lactam allergy: Consult ID and/or review Recommend review of Antibiotic Allergy Tip Sheet and Chart on Cross Reactivity between Penicillins and Cephalosporins, page 20-21
REFERENCES:
O’Grady, et al Crit Care Med 2008 (36): 1330; Mody, et al., JAMA 2014 (311):844; Gupta, et al., CID 2011;52(5):e103–e120; Hooton, et al., CID 2010; 50:625–663;
CAUTI Guidelines. https://www.cdc.gov/infectioncontrol/guidelines/cauti/index.html/CAUTIguideline2009final.pdf. Schaeffer, et al. NEJM 2016; 374: 562-71. Nicolle LE, et al. CID 2019; 68:e83-e110.
11Ambulatory Management of Upper Respiratory Tract Infections
in Adults 2021
Due to COVID-19 pandemic, testing for SARS-CoV-2 remains an important part of standard practice when evaluating upper respiratory
infection including sinusitis, pharyngitis, and acute bronchitis. It remains necessary to test for COVID-19 in individuals with symptoms, even if fully
vaccinated, because identifying and isolating individuals with SARS-CoV-2 is an important part of containing the pandemic and testing may identify
individuals who may be candidates for specific therapies for COVID-19.
Definition / Comments Organisms Non-Antibiotic Treatments Antibiotics1
Acute Sinusitis 90-98% of cases are viral Respiratory viruses Acetaminophen/NSAIDs ONLY IF meets criteria for bacterial sinusitis, Rx 5-7 days:
Criteria to consider antibiotics: Nasal saline Augmentin: 500mg q8h OR 875mg q12h
Less Common:
• Persistent: >10 days without improvement S. pneumoniae, Nasal steroid Doxycycline: 100mg q12h
• Worsening: 3-4 days H. influenzae, Decongestants Cefpodoxime: 200mg q12h
M. catarrhalis,
• Symptoms: Fever >38°C, facial/tooth pain S. aureus Respiratory fluoroquinolone could be considered in rare
instances (see footnote 2).
Pharyngitis Respiratory viruses are the most common cause of SARS-CoV-2, adenovirus, Acetaminophen/NSAIDs Penicillin V: 500mg q12h x10 days
acute pharyngitis. rhinovirus, and other
Lozenges Amoxicillin: 500mg q12h x10 days
Signs and symptoms more suggestive of viral etiology: coronaviruses.
fatigue, nasal congestion, cough, conjunctivitis, Cephalexin: 500mg q12h x10 days
sneezing, hoarseness, ear pain, sinus discomfort, oral Less Common: Anaphylaxis to penicillin or cephalosporin can consider
ulcers. Low grade fever also typical, but may be higher GAS, Clindamycin 300mg PO TID x 10 days. Scheduled follow
if COVID-19 is etiology. Fusobacterium up to assess resolution is important due to high rates of
PEARL: SARS-CoV-2 can cause an isolated sore throat. GAS resistance to clindamycin.
Group A Streptococcus (GAS) is cause: 5-15% PEARL: Macrolides are NOT recommended to treat GAS
Signs and symptoms more suggestive of GAS: fever, due to high levels of resistance.
tonsillar exudates, tender cervical, lymphadenopathy,
absence of additional symptoms listed for viral
infection above.
PEARL: Known exposure to individual with GAS makes
diagnosis of GAS more likely.
12Definition / Comments Organisms Non-Antibiotic Treatments Antibiotics1
Acute Uncomplicated Cough is the cardinal symptom, lasting 1-3 weeks. Influenza A & B, Parainfluenza, Cough suppressants Rarely recommended regardless of cough duration
Bronchitis Coronaviruses, SARS-CoV-2,
PEARL: cough caused by COVID-19 may persist for Antihistamines
Rhinovirus, RSV, Human
longer duration.
metapneumovirus Decongestants
Mostly viral or non-infectious cause
Less Common: Beta-agonists
• Colored sputum does not indicate bacterial infection
M. pneumoniae
• Consider further work up if concern for pneumonia,
B. pertussis
underlying lung disease, or if pertussis in Ddx
C. pneumoniae
Case series suggest bacteria is cause : 6%
PEARL: no convincing
In addition to testing for COVID-19, testing for
evidence that pneumococcus,
influenza should also be considered
staph, H. flu or Moraxella cause
acute bronchitis in the absence
of instrumentation or COPD
1. If your patient describes penicillin or cephalosporin allergy and meets criteria for antibiotic therapy, recommend reviewing Antibiotic Allergy Tip Sheet and Chart on Cross Reactivity between Penicillins and
Cephalosporins, page 20-21.
2. Risk of fluoroquinolones generally outweighs benefits for sinusitis. Levofloxacin 750mg q24h or moxifloxacin 400mg q24h can be used but should be reserved for those who: (a) cannot tolerate other
antibiotic options, (b) have risks for resistance (e.g. hospitalization last 5 days, antibiotic use in last month, immune compromise), or (c) have severe disease with systemic toxicity.
13Antimicrobial Dosing Guidelines for Hospitalized Adults
Suggested initial doses, these guidelines are not a substitution for an ID or Pharmacy consult.
Antibiotic category Antibiotic Route Dose for normal renal function Reduced renal function mL/min Hemodialysis (HD)
11-29: 250-500mg BID
Amoxicillin/clavulanate PO 500-875mg BID or 500mg TID 500mg q24h, give after HD on HD daysAntimicrobial Dosing Guidelines for Hospitalized Adults
Antibiotic category Antibiotic Route Dose for normal renal function Reduced renal function mL/min Hemodialysis (HD)
30-50: 1-2g q8-12h
Cefoxitin IV 1-2g q6-8h 10-29: 1-2g q12-24h 1-2g q24h after HDAntimicrobial Dosing Guidelines for Hospitalized Adults
Antibiotic category Antibiotic Route Dose for normal renal function Reduced renal function mL/min Hemodialysis (HD)
TETRACYCLINE Doxycycline ¥
PO/IV 100mg q12h No adjustment No adjustment
MACROLIDE Azithromycin¥ PO/IV 250-500mg q24h2021 Recommended Prophylactic Antibiotics by Procedure
Surgical Procedure Organisms Recommended IV Antibiotics1 Dosing Redosing Hours2
Plastic
120kg: 3g IV
Plastic surgery with risk factors, aureus, S.
breast surgery epidermidis,
OR Severe β lactam allergy
streptococcus 15mg/kg IV (max 2g). Start 60 to 120 min prior to procedure. —
Vancomycin
Cardiovascular
120kg: 3g IV
Cardiovascular, thoracic, cardiac Staphylococcus &
device insertion streptococcus
OR Severe β lactam allergy
15mg/kg IV (max 2g). Start 60 to 120 min prior to procedure. —
Vancomycin
Gastroduodenal, Biliary3, Colorectal4 and Other General Surgery
Ceftriaxone 1g IV —
Ceftriaxone + metronidazole
Metronidazole 500mg IV —
OR Cefoxitin 2g IV 2
Enteric GNR,
Appy, biliary3, colon4, gastroduodenal anaerobes,
Vanco 15mg/kg IV (max 2g). Start 60 to 120 min prior to
enterococcus —
procedure.
OR Severe β lactam allergy
Vancomycin + Cipro + metronidazole Cipro 400mg IV —
Metronidazole 500mg IV —
120kg: 3g IV
Staphylococcus &
Hernia
streptococcus
OR Severe β lactam allergy
15mg/kg IV (max 2g). Start 60 to 120 min prior to procedure. —
Vancomycin
Head and Neck
120kg: 3g IV
aureus, S.
PLUS Metronidazole (for contaminated case) 500mg IV —
epidermidis,
Head and neck surgery
streptococci.
OR Ampicillin-sulbactam (for contaminated case) 3g IV 2
Sometimes: GNR,
anaerobes OR Severe β lactam allergy
900mg IV 6
Clindamycin
17Surgical Procedure Organisms Recommended IV Antibiotics1 Dosing Redosing Hours2
Neurosurgery and Orthopedic
120kg: 3g IV
Spinal, hip fracture, internal fixation, Staphylococcus &
total joint replacement streptococcus
OR Severe β lactam allergy
15mg/kg IV (max 2g). Start 60 to 120 min prior to procedure. —
Vancomycin
Ob-Gyn
120kg: 3g IV
PLUS Azithromycin (for conversion to C-section) 500mg IV —
Staphylococcus &
C section without suspected infection
streptococcus
Vancomycin 15mg/kg IV (max 2g).
—
OR Severe β lactam allergy Start 60 to 120 min prior to procedure.
Vancomycin + Gentamicin5
Gentamicin 5mg/kg IV (use IBW) —
Ampicillin 2g q6h
Ampicillin + Gentamicin5 Typically patient
Gentamicin 5mg/kg IV q24h (use IBW) receives 1
Staphylococcus, additional dose of
streptococcus, OR Ampicillin/sulbactam 3gm IV q 6h antibiotic unless
C-section with intraamniotic infection genital mycoplasma, has bacteremia or
suspected gardnerella, Vancomycin 15mg/kg IV (max 2g). persistent fever,
bacteroides, Enteric OR Severe β lactam allergy Start 60 to 120 min prior to procedure then antibiotics
GNRs Vancomycin + Gentamicin 5 may be continued.
Gentamicin 5mg/kg IV q24h (use IBW)
PLUS Azithromycin for mycoplasma coverage 500mg IV q24h —
120kg: 3g IV
Enteric GNR, OR Cefoxitin 2g IV 2
Hysterectomy anaerobes, GBS,
enterococcus Vancomycin 15mg/kg IV (max 2g). Start 60 to 120 min prior
—
OR Severe β lactam allergy to procedure.
Vancomycin + Cipro
Cipro 400mg IV —
100mg PO/IV 60 min prior to procedure, then 200mg
Vaginal flora and post-procedure
Uterine evacuation (suction D&C/D&E) Doxycycline —
Chlamydia
OR Doxycycline 200mg PO/IV 60 min prior to procedure.
18Surgical Procedure Organisms Recommended IV Antibiotics1 Dosing Redosing Hours2
Urologic 6
120kg: 3g IV
Cystoscopy with manipulation or Enteric GNR,
upper tract instrumentation enterococcus OR Cipro 400mg IV or 500mg PO —
OR Bactrim DS 160mg TMP/800mg SMX PO/IV —
120kg: 3g IV
PLUS Metronidazole (for entry into intestine) 500mg IV —
Enteric GNR,
Laparoscopic or Open GU OR Cefoxitin 2g IV 2
enterococcus
Vancomycin 15mg/kg IV (max 2g). Start 60 to 120 min prior
—
OR Severe β lactam allergy to procedure
Vancomycin + Cipro
Cipro 400mg IV —
Enteric GNR, Cipro 400mg IV or 500mg PO 12
enterococcus
Prostate Biopsy
Sometimes skin OR Bactrim DS 160mg TMP/800mg SMX PO 60 min prior to procedure 12
flora
1. Additional pre-op antibiotic not needed for patients already on systemic antibiotics which would provide protection against expected surgical pathogens.
2. Indicates timing of re-dosing antibiotics based on length of surgery and half-life of antibiotic. Re-dosing also recommended if loss 1500cc blood or more
3. ERCP: No antibiotics needed if no obstruction
4. Neomycin PLUS erythromycin base or metronidazole on Pre-Op day for elective colon procedures.
5. Gentamicin should be dosed using ideal body weight (IBW).
6. Treat patients with UTI prior to procedure using an antimicrobial active against bacteria isolated in urine culture.
Vancomycin is preferred over clindamycin for severe β lactam allergy for prevention of Group A and B streptococcus due to higher resistance to clindamycin locally. Vancomycin should also be considered if
known history of MRSA. Other risk factors for use of vancomycin: High risk patient with recent hospital stay, high risk patient from nursing home, dialysis, transfer from another hospital in the last three days.
SELECTED REFERENCES:
Obstet Gynecol May 2009; 113(5): 1180-1189, Am J Health Syst Pharm. 1999;56:1839-1888, Am J Health-Syst Pharm. 2013; 70:195-283, CID. 2004:38:1706-1715, CID. 1994; 18:422-427, The Sanford Guide to
Antimicrobial Therapy 2021., N Engl J Med. 2006 Dec 21; 355 (25): 2640-2651, Infect Control Hosp Epidemiol. 1999; 20:247-280, Med Lett Drugs Ther. 2016; 58: 63-68, Arch Surg. 1993; 128:79-88. Intrapartum
management of intraamniotic infection. Committee Opinion No. 712. ACOG. Obstet Gynecol 2017; 130 e95-101.
19Antibiotic Allergy Tip Sheet Don’t accept penicillin or other
Examples of Reactions to Antibiotics & What to Do antibiotic allergy without getting more
information. Use these questions to
Azithromycin/ Azithromycin/ obtain history to document accurate
Penicillins/β-Lactams Vancomycin allergy label with details in EPIC.
Sulfa Levofloxacin
Childhood Do you have allergies to medications?
reactions,
family history, Anaphylaxis:
Flushing Maculopapular What was your reaction?
intolerance throat tightness, Arrhythmias
during infusion rash without
(GI symptoms, SOB severe and other
(Vanco flushing systemic
fatigue, rash required cardiac issues
syndrome) symptoms How long ago did the reaction take
headache, treatment
place? (age, onset of reaction)
limited rash,
isolated itching)
Did you require medical treatment,
hospitalization or medications for
Delayed T-cell the reaction?
Type 1
mediated Significant
hypersensitivity/
Not allergy Pseudoallergy reaction without adverse
anaphylaxis
systemic reaction Why was the medication being used?
incidence isHow to Give a Different β-Lactam Antibiotics with an Existing
β-Lactam Allergy
Cross reactivity between penicillins and cephalosporins is not a class effect, but an allergic reaction to an antibiotic with a similar side chain.
This chart shows which β-lactams are safe to administer based on a patient’s allergy history and β-lactam side chains. This does not need to
be considered in the setting of symptoms that likely do not reflect true allergy (e.g. isolated mild rashes, GI symptoms, etc.). Call Pharmacy or
Infectious Diseases providers for questions.
Penicillins 1 2 3 4 Key
High cross reactivity, do not give
Carbapenems
Ceftazidime
Ceftriaxone
Cefuroxime
Cefotaxime
Amoxicillin
Piperacillin
Cephalexin
Ampicillin
Cefepime
Cefazolin
Antibiotic class
Cefoxitin
Penicillin
Low cross reactivity, can give
Same medication
Amoxicillin X X X X What is a side chain? AVOID ALL β-lactams if
Penicillins
Ampicillin X X X X
Chemical group attached to the main administration of any
Penicillin X X X X molecular structure β-lactam caused:
Piperacillin X X X X • ICU admission related to allergy
Cefazolin • Interstitial nephritis
1
Cephalexin X X X • Severe hepatitis
Cefoxitin X X • Hemolytic anemia
2
Cefuroxime X X X X X • Steven-Johnson Syndrome
Cefotaxime X X X X • Toxic Epidermal Necrolysis
Ceftazidime X X X X • Acute Generalized
3
Ceftriaxone X X X X Exanthematous Pustulosis
Cefepime X X X X • DRESS
4
Carbapenems
SELECTED REFERENCES:
https://asp.nm.org/uploads/9/0/7/8/90789983/cross_rxn__graded_challenge__final_1.23.19.pdf; http://vhpharmsci.com/Newsletters/2018-NEWS/P%20&%20T%20%20Newsletter%20Aug%202018.pdf ;
Zagursky R, Pichichero ME. Cross-reactivity in beta-lactam allergy. J Allergy Clin Immunol: In Practice. 2018 Jan; 6(1): 72-81.e1; Adler NR, Aung AK, Ergen EN, Trubiano JA. Recent advances in the understanding of
severe cutaneous adverse reactions. Brit J Derm. 2017 Mar; 177(5). doi:10*111/bjd.15423.
21Testing Algorithm for Clostridium difficile.
Hospitalized patient with clinically-significant diarrhea Observe for 24 hours to assess for persistence of symptoms.
(3 or more loose/liquid stools per day for at least 1-2 days) NO 5 Do not order test for C. diff.
YES p
Has patient received laxatives, tube feedings, or oral contrast Stop medication and gauge clinical response for ≥ 24 hrs PRIOR to
over the past 24-48 hours? YES 5 ordering C. diff testing.
NO p
Does patient meet clinical criteria for C. diff colitis:
• Risk factor: recent antibiotic exposure
NO 5 Consider alternate diagnosis for diarrhea.
• Symptoms & Signs: fever, dehydration, abdominal
distension/pain, ileus, unexplained white count
YES p
Order test: C. diff PCR 5 C. diff. order will automatically cancel after 24 hours if not collected.
p
C. diff test results positive? NO 5 Consider alternate diagnosis for diarrhea.
YES* p * Patients with a positive C. diff test should be put into
Contact Isolation with Additional Precautions for 30 days.
Start Vancomycin 125mg PO QID.
Questions about isolation precautions or discontinuation of
Do not send test of cure. isolation can be directed to Infection Prevention or Infectious
Disease Physicians.
22GI Pathogen Panel PCR (GIP) Testing Algorithm
Specimen: ONE unformed stool submitted in:
(1) Orange ParaPak C&S transport OR (2) Raw stool received within 2 hrs. of collection
Outpatient with persistent diarrhea >7 days
OR Health-care associated diarrhea
Outpatient with diarrhea 7 days tested q 7 days
1. Only if clinically indicated; GI illness often self-limited.
2. IF GIP negative in patient with persistent diarrhea >2 weeks consider: Ova and Parasite Exam in traveler, Microsporidium and Cystoisospora belli for immunocompromised patient, non-infectious cause,
and/or GI or Infectious Diseases Consult.
3. Repeat GIP is not performed less than 14 days from previous sample tested. If you think it is indicated, please call ID on call for approval (Person on Call App or 303-415-8850). Approval request will only be
taken during regular business hours 7 am to 7 pm.
GI pathogen panel should NOT be used for test of cure.
4.
23Recommended Interpretation and Management of GI Pathogen Panel PCR (GIP) Results At BCH, total number of GIPs run in 2020 (n=1,404) was 38% lower than in 2019 (n=2,272). Total percentage of GIPs that were positive for an organism in 2020 was 28% compared to 38% in 2019 (p
BCH Prevalance
Pathogen/Result Clinical Significance 2020 – Avg % of Treatment and Clinical Guidance
positive panels
Yersinia enterocolitica Uncooked pork, contaminated 1% Typically self-limiting.
food; associated with cecitis,
Severe infection or severely immunocompromised:
pseudoappendicitis
Bactrim DS, 1 tab PO BID, doxycycline 100mg PO BID OR
ciprofloxacin 500mg PO BID x 5 days
Enteropathogenic E. coli (EPEC) Common cause of gastroenteritis; 11% Usually supportive care only for mild disease. Bismuth or loperamide can be given.
ETEC associated with traveler’s
Moderate: azithromycin 1g PO x 1 dose
Enteroaggregative E. coli (EAEC) diarrhea
Bacteria
Severe: azithromycin 500mg to 1g PO daily x 3 days
Enterotoxigenic E. coli (ETEC),
Alternate: Cipro 750mg PO q24h OR 500mg PO BID x 1-3 days
Shiga-like toxin producing E. coli (STEC) and Contaminated meat, dairy, produce,BCH Antimicrobial Cost Information
Medication Route Relative Cost/Day Medication Route Relative Cost/Day Medication Route Relative Cost/Day
Acyclovir IV $$ Ciprofloxacin IV $$ Nafcillin IV $$$$
Acyclovir PO $ Ciprofloxacin PO $ Penicillin G IV $$$
Amoxicillin PO $ Clindamycin Penicillin VK PO $
IV $$
600mg
Ampicillin IV $$$ Unasyn IV $$
Clindamycin
Augmentin PO $ IV $$ Valacyclovir PO $
900mg
Azithromycin IV $$ Clindamycin PO $ Vancomycin IV $$
Azithromycin PO $ Dicloxacillin PO $ Vancomycin
PO $$
125mg
Bactrim IV $$ Ertapenem IV $$$$
Zosyn 2.25mg IV $$$
Bactrim PO $ Fluconazole IV $
Zosyn 3.375mg IV $$$
Cefazolin 2g IV $$ Fluconazole PO $
Zosyn 4.5mg IV $$$
Cefazolin 1g IV $$ Levofloxacin IV $
Cefdinir PO $ Levofloxacin PO $
Daily Cost Relative Cost Key
Cefepime IV $$ Meropenem IV $$$
$50 $$$$
26BCH Adult Vancomycin Dosing and Monitoring Guidelines.
*Please contact pharmacy or get ID consult if concerns about vancomycin dosing. It is important to consider if other renal toxic agents are
being co-administered when dosing vancomycin.
Goal Trough Vancomycin Loading Doses Vancomycin Maintenance Dosing in Dialysis
Indication
(mcg/mL) (actual body weight)
500-1000mg (5-10mg/kg) after
IHD level < 10-15
10-15 UTI, Cellulitis, Prophylaxis PTD Non-critically ill 15-20mg/kg each session
MRSA Bacteremia, MRSA Osteomyelitis, Complicated infections in seriously ill 25mg/kg PD level < 10-15 500-1000mg Q48-72h
15-20 Endocarditis, Meningitis, Documented Consult ID
Renal Impairment, CRRT, IHD, PD 15-25mg/kg 1000mg (10-15mg/kg) daily dose may vary
MRSA PNA CRRT level < 1-15
by type of CRRT and rate of filtration
Preoperative antimicrobial prophylaxis 15mg/kg
MRSA Vancomycin MIC greater than or equal to 2: Alternate therapy is
suggested & ID should be consulted Maximum of 2 grams per dose
Vancomycin Maintenance Doses: Goal 10-15mg/L Vancomycin Maintenance Doses:
~15mg/kg per Dose Goal 15-20mg/L
~20mg/kg per Dose
Creatinine Clearance (mL/min)
Infectious Diseases Team will be notified for:
20 30 40 50 60 70 80 90 ≥100
• Any indication with a goal trough of 15-20
50 750mg 500mg 750mg 750mg 1000mg 1000mg 500mg 750mg 1000mg
q48h q24h q24h q24h q24h q24h q12h q12h q12h • Any order with a goal trough of 15-20
60 750mg 750mg 750mg 1000mg 1250mg 750mg 750mg 1000mg 1000mg • Any MRSA with an MIC of 2 or greater
q48h q24h q24h q24h q24h q12h q12h q12h q12h • Any patient requiring greater than or equal to
70 1000mg 750mg 1000mg 1250mg 1500mg 750mg 750mg 1000mg 1250mg 3 grams vancomycin total per day
q48h q24h q24h q24h q24h q12h q12h q12h q12h Pharmacists may order the first dose(s) of
80 1250mg 750mg 1000mg 1250mg 1500mg 750mg 1000mg 1250mg 1250mg vancomycin to goal trough of 15 to 20 for
listed indications.
Actual Body Weight (kg)
q48h q24h q24h q24h q24h q12h q12h q12h q12h
90 1250mg 1000mg 1250mg 1500mg 1750mg 1000mg 1250mg 1250mg CALL
q48h q24h q24h q24h q24h q12h q12h q12h ID
100 1500mg 1000mg 1250mg 1500mg 1000mg 1000mg 1250mg CALL CALL
q48h q24h q24h q24h q12h q12h q12h ID ID
110 1750mg 1000mg 1500mg 1750mg 1000mg 1000mg 1250mg CALL CALL
q48h q24h q24h q24h q12h q12h q12h ID ID
120 1750mg 1250mg 1500mg 1750mg 1000mg 1250mg CALL CALL CALL
q48h q24h q24h q24h q12h q12h ID ID ID
130 2000mg 1250mg 1500mg 1000mg 1000mg 1250mg CALL CALL CALL
q48h q24h q24h q12h q12h q12h ID ID ID
140 2000mg 1500mg 1750mg 1000mg 1250mg CALL CALL CALL CALL
q48h q24h q24h q12h q12h ID ID ID ID
150 1000mg 1500mg 1750mg 1000mg 1250mg CALL CALL CALL CALL
q24h q24h q24h q12h q12h ID ID ID ID
Notify ID if required calculated daily dose equals or exceeds 3 grams
27BCH Adult Vancomycin Dosing and Monitoring Guidelines.
*Please contact pharmacy or get ID consult if concerns about vancomycin dosing. It is important to consider if other renal toxic agents are
being co-administered when dosing vancomycin.
Timing of First Vancomycin Trough or Level Additional Monitoring
Labs which can be initiated following a PTD order
Dosing Interval Timing
Renal function SCr, BUN, urine output
Q8h
Trough 30 min prior to 4th or 5th dose Response to therapy WBC, Segs/Bands, ANC, TMax
Q12h
Appropriateness of therapy Culture, Sensitivity, Levels
Q24h Trough 30 min prior to 3rd or 4th dose
Toxicity Alb/Tbili, Platelets
Random level w/in 24 hours of first dose
Q48h
Begin maintenance dose if random is 20 10-15 Increase dosing interval OR decrease dose by 500mg
15-20 Decrease dose by 250mg
General Calculation Strategy if Interval Remains the Same:
(Current vancomycin dose)/(Vancomycin trough) = (New vancomycin dose)/(Desired trough)
References: see online document on Scoop
28For more information about the Infectious Diseases Team at BCH see:
bch.org/beaconcenter
Antibiotic Stewardship Team
Amie Meditz, MD, Co-Chair*
Christopher Zielenski, PharmD, BCPS, BCCCP, Co-Chair*
Members
Mark King, MD* Susie Pfister, RN, BSN, ONC
Cynthia Littlehorn, SM (ASCP), MB* Kristie Robson, MPH*
Casey Diekmann, PharmD Kylie Chilton, MPH, CIC
Katherine Macchi, PharmD BCPS Charlie Mathis, BSN, RN
Joslyn Winterland, PharmD* Caitlyn Hockenbury
Jaime Mesenbrink PharmD, Tracy Nagell, RN, MSN, MHA
BCPS, BCCCP* Austin Hinkel, PharmD, BCPS*
Kelley Nguyen, PharmD
(Pharmacy Resident)*
*Contributors to Antibiotic Stewardship Guidebook
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