Download Antimicrobial stewardship program

Antimicrobial
stewardship program
1/1/2014
Antimicrobial Guideline
This 1st Edition of the antimicrobial guideline of Ministry of
Health truly substantiates our commitment to the general
pharmaceutical care administration Mission and Vision,
dedicated to humanity as inspired by Allah. This story of
success speaks a lot about the integrity of the pharmacy
profession. As the world of pharmacy is not excused to the
constant occurrence of changes, our pursuit to give top
priority to patient care and safety prevails. Congratulations
on the success of the Task Force to initiate, Review, And
Update the antimicrobial guideline comprised of
Pharmaceutical Care Services in the different regions.
Deputy Minister of Health for Curative Service
Dr.Tarif Al-Aama
We are proud to introduce the first edition of the
antimicrobial guideline it has been our aim to provide staff
with reliable, up-to-date drug information. In the daily
management of patients, clinicians are often faced with the
need to access drug information quickly in order to make
swift therapeutic decisions. It is hoped that this guideline
may be a readily accessible source of clinically important
information for antibiotics usage. Additionally, it is meant to
provide a quick and reliable source of information for
nursing staff. At a time when worldwide attention is being.
Assistant Deputy Minister for Supportive Medical Services
DR. Munira Hemdan Al-esseimi
I would like to thank the working committee for their tireless
efforts in developing the first edition of the ‘infectious
disease guideline’. Due to the rapidly expanding using of
antibiotics nationwide, it is very timely and essential that the
Pharmaceutical Services Division, Ministry of Health
develops and publishes this guideline
The contents of this guideline will be able to serve as a
standard reference for all hospital pharmacists in handling
and managing antibiotics. I am confident that this guideline
will also provide useful information on ensuring quality,
safety and efficacy of products.
Director of General Administration of
Pharmaceutical care at Ministry of Health
Dr. Yousef ahamed alomi
Editors
Dr. Yousef Al-omi
Clinical Ph. Alaa Mutlaq
Reviewers
Ph. Abeer Al-Masoody
Ph. Ahmad Al-yamani
Dr. Ameenah Ghandeel
Ph. Abeer Muhssen
Dr. Abdullah Al-mohaizeie
Dr. Abdulrazaq Ghareeb
Ph. Abdullah Al-Methhan
Dr. Batool Mohammad Suliman
Dr. Deema Al Okaili
Dr. Faten Saif
Dr. Hail Al-Abdali
Ph. Hind Almuteri
Dr. Hala Rushdi
Dr. Hanan Hanafi
Dr. Musheera Anani
Dr. Maha Alawy
Dr. Mustafa Alkalaf
Clinical Ph. Mohammad Al- Zaid
Ph. Muna Fuleflan
Dr. Mohammad Shaik Ahmad
Dr. Samira Fallatah
Clinical Ph. Sultan Al- Mubarky
Dr. Sara Shalhoub
Table of content:
Guideline for Establish Antimicrobial Stewardship at MOH hospitals
Section I: Policy and procedure
Section II: National antimicrobial guideline:
Group A streptococcal Pharyngitis
Acute Bacterial Rhinosinusitis
Community Acquired Pneumonia
Bacterial Meningitis
Brain Abscess
Infective endocarditis
Urinary Tract Infection
Osteomyelitis
Diabetic Foot Infection
Skin and Soft Tissue Infection
Peritonitis
Sexually Transmitted Disease
Pelvic Inflammatory Disease
Intra-abdominal Infection
Brucellosis
Tuberculosis
Antiviral Infection
Antifungal Infection
Parasitic Infection
Surgical Prophylaxis
Appendix A: Guideline for blood culture collection
Appendix B: Infection Control
Appendix C: Skin test kits, Anaphylactic kits , Skin test procedure and anaphylaxis algorithm
Appendix D: Antibiotics dosing monitoring
Appendix E: Practical Approaches for Conversion IV antibiotics to Oral therapy
Appendix F: Antibiogram
Appendix G: Antimicrobial Consumption
Appendix H: Formulary/ Pre-Authorization Restricted Forms
Appendix I: Abbreviation
Appendix J: Dose Adjustment for Renal Impairment
Guidelines for Developing an Antimicrobial Stewardship
in MOH hospitals:
NOTE: These guidelines focus on the development of effective hospital-based stewardship programs and do not include specific
outpatient recommendations.
Guideline Purpose:
To improve antimicrobial use for hospitalized adults.
Minimizing the emergence and spread of antimicrobial resistance.
The antimicrobial stewardship team and administrative support
Core members of antimicrobial stewardship:
Infectious diseases physician ( Leader )
Clinical pharmacist with infectious diseases training (Coordinator)
Clinical microbiologist
An information system specialist
An infection control professional
hospital epidemiologist
Administrative support:
Hospital administration (necessary infrastructure)
Medical staff leadership
local providers ( e.g: nurses)
Collaborated providers:
Hospital infection control
Pharmacy and therapeutics committees
Core strategies:
Prospective audit with intervention and feedback:
It is a method that allows the antimicrobial stewardship program (an infectious diseases physician or a clinical
pharmacist) to interact directly with prescribers in order to modify specific antibiotic therapy for each patient.
These strategies are employed after the initial prescribing and dispensing of the antibiotic.
Formulary restriction and preauthorization:
It is a method that allows the antimicrobial stewardship program (an infectious diseases physician or a clinical
pharmacist) to interact directly with prescribers for approval (Appendix: H)
Supplemental Antimicrobial Stewardship Strategies:
Education: education alone, without incorporation of active intervention, is only marginally effective in changing
antimicrobial prescribing practices and has not demonstrated a sustained impact
Guidelines and clinical pathways: (Section II: National Guideline of Antimicrobial)
This guideline covers the community acquired pneumonia only because the creation of nosocomial infection
guideline depends mainly on the local microbiology and resistance patterns.
It is an order forms to enhance the adherence of this guideline
Guideline implementation can be facilitated through provider education and feedback on antimicrobial use and
patient outcomes
Antimicrobial order forms:
Use of antimicrobial order forms with automatic discontinuation according to the guideline with optimal timing and
duration of antibiotics resulted in a decrease in the misuse of antimicrobial
Combination empirical therapy and de-escalation antimicrobial:
The guideline recommended the combination antimicrobial therapy includes broad-spectrum empirical therapy for
serious infections to improved clinical outcomes, and the prevention of resistance but the de-escalation depend on
the culture result is essential to decreased antimicrobial exposure and substantial cost savings
Conversion from parenteral to oral therapy
A systematic plan for parenteral to oral conversion of antimicrobials with excellent bioavailability, when the
patient’s condition allows, can decrease length of hospital stay and health care costs
Development of clinical criteria and guidelines allowing conversion to use of oral agents can facilitate
implementation at the institutional level (Appendix: E)
Antimicrobial dosing:
All the following should be considered during antibiotics prescribing:
Dose optimization (pharmacokinetics/pharmacodynamics) is essential to optimize the treatment of organisms with
reduced susceptibility
Dosing Monitoring for vancomycin and aminoglycoside (Appendix: D)
Dose adjustments in cases of renal dysfunction (Appendix: J)
Surveillance of antimicrobial resistance:
The antibiotic policy shall depend heavily on surveillance of antimicrobial resistance ((Appendix: F (antibiogram)
and antibiotic consumption ((Appendix: G (antibiotics consumption)) in any setting. Hence, it is mandatory to
establish an efficient surveillance system.
The surveillance for antimicrobial resistance/antibiotic consumption and preparation of an “enhanced” or
cumulative antibiogram at the local level helps in clinical decision-making, design infection control interventions,
and antimicrobial-resistance containment strategies.
The clinical microbiology laboratory plays a critical role in antimicrobial stewardship by providing patient-specific
culture and susceptibility data
The pharmacy department responsible for antibiotics consumption at all hospital setting
(ICU, non-ICU, Outpatient …etc)
Computer Surveillance and Decision Support
(Note: the antimicrobial order form should be electronic unless the electronic prescription system does not exist in the hospital
setting)
Health care information technology in the form of electronic medical records , CPOE , and clinical decision support
can improve antimicrobial decisions through the incorporation of data on patient-specific microbiology cultures
and susceptibilities, hepatic and renal function, drug-drug interactions, allergies, and cost
Computer-based surveillance can facilitate good stewardship by more efficient targeting of antimicrobial
interventions, tracking of antimicrobial resistance patterns, and identification of nosocomial infections and adverse
drug events
Monitoring of Process and Outcome Measurements
Determining the impact of antimicrobial stewardship on antimicrobial use and resistance patterns by two
steps:
Process measures (did the intervention result in the desired change in antimicrobial use?)
Outcome measures (did the process implemented reduce or prevent resistance or other unintended
consequences of antimicrobial use?)
Please fill the following surveys:
Antimicrobial Stewardship Process Measure:
Antimicrobial Stewardship Outcome Measure:
Step-wise implementation of an antimicrobial stewardship program initially with passive strategies, such
as education and order forms, followed by an active strategy with prospective audit and intervention
Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Infectious Diseases (January 2007 vol. 44 no. 2 159-177
Checklist for Core Elements of Hospital Antibiotic Stewardship Programs. CDC March 3, 2014
General Administration
‫ﺍﻹﺩﺍﺭﺓ ﺍﻟﻌﺎﻣﺔ ﻟﻠﺮﻋﺎﻳﺔ ﺍﻟﺼﻴﺪﻟﻴﺔ‬
Of Pharmaceutical care
‫ﳉﻨﺔ ﺍﳌﻀﺎﺩﺍﺕ ﺍﳊﻴﻮﻳﺔ‬
Antimicrobial committee
Administrative Policies and Procedures
  for MOH hospitals /PHC Centers
‫اﻟﺴﯿﺎﺳﺎت واﻹﺟﺮاءات اﻹدارﯾﺔ‬
‫ﺑﻤﺴﺘﺸﻔﯿﺎت وﻣﺮاﻛﺰ وزارة اﻟﺼﺤﺔ‬
TITLE : Antimicrobial Guideline
NO. of Pages: 2
ORIGINAL DATE: 1/1/2015
REVISION DATE : every 6 months
PURPOSE:
To provide a standard method/ guidelines in prescribing medication (antimicrobials) for health care providers
at MOH.
EQUIPMENTS/ MATERIALS:
Patient Medical record.
Antibiotic order form
POLICY STATEMENT:
This guideline only for adult
Antibiotics order form is controlled and a guided method to all health care providers (physician, pharmacist,
clinical pharmacist and nurse) during prescribing the antibiotics
The guideline is formatted as physician order
The use of this order form is only for community acquired infection.
The management of nosocomial infection depend on the hospital antibiogram results
Referral to the original guideline is very important for a pharmacist/clinical pharmacist for more detail or any
update.
The antimicrobial order should be renew every 7 days ( automatic stop order)
PROCEDURE:
The treating physician write the patient information
The treating physician must write the symptom, diagnose and culture result ( if available)
Choosing the therapy dosage( antibiotics, dose, interval and duration) depending on patient age group and
micro-organism
Either using E- prescription or hand writing prescription depend on hospital system
Send the copy of order form to pharmacy and keep the original in patient’s file
and the third copy will send to the Drug Use Evaluation department
Finally the pharmacist/clinical pharmacist must follow up the patient and write down his commen
RESPONSIBILIT
The hospital antibiotics approval team shall routinely reports the renewal of these forms to region antibiotic
committee and then submits it to pharmaceutical care administration of antibiotic Advisory Committee to
review it.
The antibiogram should be quarterly reported to regional antibiotic committee and then submitted it to central
antibiotic Committee to review it and create the guideline of nosocomial infection according to this result.
     
_________Hospital
Pharmaceutical Care Department
___________Region
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
(Antibiotics Program)
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
Antibiotics order (Group A Streptococcal Pharyngitis)
Diagnosis: ………………………………………………………………………………………………………………………………..
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
.
The modified Centor criteria
Absence of a cough, rhinorrhea, hoarseness and oral ulcer
Swollen and tender cervical lymph nodes
Temperature >38.0 °C (100.4 °F)
Tonsillar exudate or swelling
One point is given for each of the
criteria
Age less than 15years (a point is subtracted if age >44 years)
0 or 1 point
2-3 points
>3 points
No antibiotic or culture needed
Antibiotic based on culture or RADT*
Empiric antibiotics
* Negative rapid antigen detection test (RADT) tests should be backed up by a throat culture (strong, high). Positive RADTs do not necessitate a back-up culture
because they are highly specific (strong, high)
* Routine use of back-up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances, because of the low incidence of GAS
pharyngitis in adults
Empiric Therapy for (GAS) Pharyngitis (for renal failure patient appendix)
Patient group
Therapy (dosing interval in hours)- Duration
For individuals
without
penicillin allergy
1
2
3
Penicillin V, PO 500 mg q12hr- 10 days
Amoxicillin, PO 500 mg q12hr 10days
penicillin G Benzathine, intramuscular 1.2 million units single dose
For individuals
with
penicillin allergy
1
Cephalexin PO 500 mg q12hr -10 days
(avoid for immediate-type hypersensitivity to penicillin)
Clindamycin PO 300 mg q8hr for 10 days
Clarithromycin PO 250 mg q12hr for 10 days
Azithromycin PO 500mg q24hr for 5 days
2
3
4
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
Shulman, ST; Bisno, AL; Clegg, HW; Gerber, MA; Kaplan, EL; Lee, G; Martin, JM; Van Beneden, C (Sep 9, 2012). "Clinical Practice
Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society
of America.". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 55 (10): e86–102
__________________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (Acute Bacterial Rhinosinusitis)
Diagnosis:……………………………………………………………………………………………………………………..
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not
IDSA recommends that any of the 3 following clinical presentations be used to identify patients with acute bacterial vs.
viral rhinosinusitis:
Symptoms or signs persistent & not improving for ≥10 days
Severe symptoms or signs for at least 3–4 days
Worsening symptoms or signs OR "double sickening" for lasted 5–6 days and were initially improving).
Empiric Therapy for Acute Bacterial Rhinosinusitis (for renal failure patient appendix)
First line therapy
Initial empirical therapy
1 Amox-Clav (extended release tabs) 1000/62.5 mg 2 tablets PO q12hr 5-7 days
Penicillin
allergy
anaphylaxis
1
Doxycycline 100 mg PO q12hr for 5-7 days
Skin rash
1
Cefuroxime axetil 500 mg PO q12 hr 5-7 days
1
2
Amox-Clav IV 1.5g q12 hr for 5-7 days
Ceftriaxone 1–2 g IV q24 hr for 5-7 days
If penicillin allergy:
Clindamycin IV ( off –lable )
Severe infection requiring
hospitalization
3
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
Chow, AW; Benninger, MS; Brook, I; Brozek,. "IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and
adults". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America March 20, 2012 ;54 (8): e72–
e112
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (community acquired pneumonia)
Diagnosis:……………………………………………………………………………………………………………………..
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
CURB-65 Mortality Prediction Tool for Patients with Community-Acquired Pneumonia
Confusion
Points(Assign 1 point for each
Blood urea nitrogen level > 20 mg per dL (7.14 mmol per L)
variable)
Respiratory rate ≥ 30 breaths per minute
Blood pressure (systolic < 90 mm Hg or diastolic ≤ 60 mm Hg)
Age ≥ 65 years
Inpatient vs Outpatient
0 or 1 point
Treat as outpatient
2 points
Treat as inpatient
≥3 points
Treat in intensive care unit
Empiric Therapy for Community-Acquired Pneumonia (for renal failure patient appendix)
Patient group
Therapy (dosing interval in hours) patient with normal renal function
Previously healthy outpatients; no 1 Azithromycin 500 mg PO on day 1 followed by 250 mg q24hr on days 2-5
antibiotic use in past 3months
2 Clarithromycin 250 mg PO q12h x 7 days
3 Doxycycline 100 mg PO q12hr 7-10 days
Outpatients with comorbidities or 1 Cefuroxime 500 mg PO q12 hr + Clarithromycin 500 mg PO q12h
antibiotic use in past three months 2 Amoxicillin 1 g PO q8h + Clarithromycin 500 mg PO q12h
3 Amoxicillin-clavulanate 2 g PO q12h + Clarithromycin 500 mg PO q12h
4 Levofloxacin 750 mg PO q24h
Inpatients, non-ICU
1 Ceftriaxone 2 gm IV q24h + Clarithromycin 500 mg PO q12h
2 Amoxicillin-clavulanate 1 g IV q12h + Clarithromycin 500 mg POq12h
Inpatients, ICU (admission )
1 Ceftriaxone 1-2g IV q24h+ Clarithromycin 500 mg PO q12h
+Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr ( the regemin
should de-escalated depending on culture result)
2 Ceftriaxone 1-2g IV q24h+ Azithromycin 500 mg POq24hr +Vancomycin
IV loading dose of 25-30 mg/kg then 1g q8hr Ceftriaxone 1-2g IV q24h +
3 Levofloxacin 750 mg IV q24h
Vancomycin, target trough serum concentration of 15-20 μg/mL
for penicillin-allergic patients
1 Levofloxacin 750 mg IV q24h
Risk factors for Pseudomonas
1 Piperacillin/tazobactam 4.5g IV q6h + Gentamycin IV 1 mg/kg q8h +
species
Clarithromycin 500 mg PO q12h
2 Piperacillin/tazobactam 4.5g IV q6h + Gentamycin IV 1 mg/kg q8h +
Azithromycin 500mg PO q12hr
Gentamycin calculated dose:……………. ( trough levels of <1 mcg/mL)
If CA-MRSA is a consideration
1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr Linezolid IV
600 mg q12h
2 Vancomycin calculated dose:………………….. Vancomycin, target
trough serum concentration of 15-20 μg/mL
Influenza virus
1 Oseltamivir (Tamiflu) 75mg q12hr for 5 days
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
Mandell LA, Wunderink RG, Anzueto A, et al. (March 2007). "Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults". Clinical Infectious Diseases 44 (Suppl 2): S27–72.
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics Order (Bacterial Meningitis)
Diagnosis:…………………………………………………………………………………………………………………….
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Therapy for Bacterial Meningitis (for renal failure patient appendix)
Patient group
Therapy (dosing interval in hours) pt. with normal renal function
Empiric
< 50 years
1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
Therapy
Cefotaxime IV 2g q4–6h
2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
Ceftriaxone IV 2g q12hr
Vancomycin, target trough serum concentration of 15-20
μg/mL
> 50 years
1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
ampicillin IV 2g q4hr+ Ceftriaxone IV 2g q12hr
Vancomycin, target trough serum concentration of 15-20
μg/mL
head trauma:
1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
Basilar skull
Ceftriaxone IV 2g q12hr
fracture
Vancomycin, target trough serum concentration of 15-20
μg/mL
Penetrating, post- 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
neurosurgery
Meropenem IV 2 g q8hr
2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
Ceftazidime IV 2 g q8 hr
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Immunocompromised 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
state
ampicillin IV 2g q4hr + Meropenem 2 g q8hr
2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
ampicillin IV 2g q4hr + Cefepime IV 2g q 8hr
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Encephalitis
1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
(confusion, agitation,
ampicillin IV 2g q4hr + Meropenem 2 g q8hr + Acyclovir 10
or seizure)
mg/kg/dose IV q8hr for 10 days
2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
ampicillin IV 2g q4hr + Cefepime IV 2g q 8hr + Acyclovir 10
mg/kg/dose IV q8hr for 10 days
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Streptococcus
Penicillin MIC
1 Penicillin_ G: 4 million Unit q4hr
pneumonia
< 0.1 mg/mL
2 Ampicillin IV 2 g q4hr
Penicillin MIC
1 Ceftriaxone IV 2 gm q12hr
0.1–1.0 mg/mL
Penicillin MIC
1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
≥ 1.0 mg/mL
Ceftriaxone IV 2 g q12hr
Vancomycin, target trough serum concentration of 15-20
μg/Ml
1 Ceftriaxone IV 2 g q12hr
Neisseria meningitids
Listeria monocytogenes
1
2
Ampicillin IV 2 gm q4h ± (Gentamicin 2 mg/kg loading dose
then 1.7 mg/kg q8h
Trimethoprim-sulfamethoxazole IV (5 mg/kg [based on the
Duration
10-14
days
10-14
Days
10-14
days
7 days
21
days
Haemophilus influenzae
Staphylococcus
aureus
Methicillin
susceptible
Methicillin
resistance
Staphylococcus epidermidis
3
1
1
2
1
2
1
2
Enterococcus species
trimethoprim component] q6-12 hr
Calculated dose: ……………….
MeropenemIV 2 g q 8hr
Ceftriaxone IV 2 gm q12h
Flucloxacillin IV 2g oral q4-6hr
Cloxacillin IV 2 g oral q4-6hr
Vancomycin IV loading dose of 25-30 mg/kg then 1 g q8hr ±
Rifampin PO 600 mg q24hr
Linezolid IV 600 mg q12h
Vancomycin, target trough serum concentration of 15-20
μg/Ml
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr
Vancomycin, target trough serum concentration of 15-20
μg/mL
linezolid IV 600 mg q12h
Ampicillin
susceptible
Ampicillin
resistant
1
Ampicillin
and
vancomycin
resistant
1
Ampicillin IV 2 g q4h ± gentamicin IV 1 mg/kg q8h
Gentamicin dose: ……………….( trough levels of <1 mcg/mL)
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr ±
gentamicin IV 1 mg/kg q8h
Gentamicin Calculated dose:…………………………………..
( trough levels of <1 mcg/mL)
Linezolid IV 600 mg q 12hr
1
2
3
Only indicated for "close contact" who have had prolonged (>8
hours) contact while in close proximity (<1 meter) to the
patient or who have been directly exposed to the patient's oral
secretions during the 7 days before the onset of the patient's
symptoms and until 24 hours after initiation of appropriate
antibiotic therapy.
Ciprofloxacin 500 mg PO one dose
Ceftriaxone 125-250 mg IM one dose
Rifampin 600mg PO q12hr for 4 doses
1
Meningitis prophylaxis
N.influenzae
7 days
14days
14days
14-21
days
28
days
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
Allan R. Tunkel,1 Barry J. Hartman,Practice Guidelines for the Management of Bacterial Meningitis" Infectious Diseases ; 2004 ; 39 : 1267 Sanford guide Antimicrobial Therapy, web edition, Inc. 2014
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (Brain Abscess)
Diagnosis:……………………………………………………………………………………………………………………
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Empiric Therapy for brain abscesses (for renal failure patient appendix)
Empiric(Origin of
Therapy (dosing interval in hours)
Duration
abscess)
Oral source or
1 Ceftriaxone IV 2 g q12hr +Metronidazole 500 mg IV q8hr
Duration of
otogenic, or sinus
Penicillin G 3-4 million units IV q4h + Metronidazole 500 mg IV q8hr treatment is
source
2
unclear. Treat
until
Hematogenous
1 Flucloxacillin IV 2g oral q4-6hr
response by
spread Suspect MSSA 2 Cloxacillin IV 2 g oral q4-6hr
neuroimaging
Staph. Aureus
(CT/MRI).
MRSA
Vancomycin IV loading dose of 25-30 mg/kg then 1 g q8hr ±
Metronidazole IV 500 mg q8hr
(Vancomycin target trough serum concentration of 15-20 μg/mL)
Postoperative
1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
neurosurgical patients
meropenem IV2 g q8hr
2 Vancomycin IV loading dose of 25-30 mg/kg 1g q8hr + Ceftazidime
IV 2 g q8hr
(vancomycin target trough serum concentration of 15-20 μg/mL)
Penetrating trauma
1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
OR unknowing source
Ceftriaxone IV 2 g q12hr
(Vancomycin target trough serum concentration of 15-20 μg/mL)
If the paranasal sinuses are involved, add metronidazole 500 mg IV
q8hr
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Sanford guide antimicrobial web edition 2014
Up-to-date 2014
pager:_____________
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (infective endocarditis)
Diagnosis: ………………………………………………………………………………………………………………….
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Microbiology:
-Three to five blood cultures of at least 10 mL each should be drawn during the first 24–48 hours.
Therapy for Infective Endocarditis (for renal failure patient appendix)
 Native Valve
Patient group
Empiric therapy
(If patient is not
acutely ill and not in
heart failure, the
preference is to wait
for blood culture
results)
Streptococcus viridans
( Penicillin MIC ≤
0.12)
1
2
1
2
3
4
Therapy (dosing interval in hours) (weeks)
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Ceftriaxone IV/IM 2g
24h
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg IV
q8h
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: …………………(trough levels should be < 1 μg/mL)
Penicillin- G : IV 3-4 million Unit q4 h (4wks)
Penicillin- G: IV 3-4 million Unit q4 h + Gentamicin 1 mg/kg IV q8h (2wks)
Ceftriaxone IV/IM 2g q24 hr (4wks)
Ceftriaxone IV/IM 2 g q24hr + gentamicin 1 mg/kg IV q8h (2wks)
Gentamicin calculated dose: …………………..(trough levels should be < 1 μg/mL)
Streptococcus viridans
( penicillin MIC >
0.12)
1
Staphylococcus
methicillin sensitive
1
2
3
1
Cloxacillin IV 2 g q4hr (6wks)
Flucloxacillin IV 2g q4-6hr (6wks)
Cefazolin IV 2 mg q8hr (6wks)
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr (6wks)
(Vancomycin Target trough of 15-20 µg/mL)
1
2
Penicillin _G: IV 3-4 million Unit q4 h (4-6 wks)
Ampicillin IV 2g q4 h (4-6 wks)
If patient penicillin allergy:
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg q8hr
IV/IM (6 wks)
(target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: ………………………(trough levels should be < 1 μg/mL)
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg q8hr
IV (6 wks)
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: ………….. ………(trough levels should be < 1 μg/mL)
Streptomycin (MIC < 2000 µg/mL):
Ampicillin IV 2g q4hr + Streptomycin 15 mg/kg IV/IM q12hr (6 weeks)
Penicillin-G: IV 3-4 million unit q4h (4-6 weeks) + Streptomycin IV/IM 15 mg/kg
q12hr (6 weeks)
Streptomycin Calculated dose: ……………………….. Peak: 20-30 mcg/mL; Trough:
Staphylococcus
methicillin resistant
Enterococcus
Penicillin sensitive
2
3
Enterococcus—
penicillin resistant
gentamicin resistance
(MIC > 500 μg/mL):
(Penicillin sensitive )
1
1
2
Penicillin –G: IV 3-4 million Unit q4 h+ gentamicin 1 mg/kg q8 h IV/IM (4wks)
Ceftriaxone IV/IM 2 g q24 h in 1 dose +gentamicin 1 mg/kg q8 h IV/IM (4wks)
Gentamicin calculated dose: …………..(trough levels should be < 1 μg/mL)
<5 mcg/mL
E. faecium penicillin,
aminoglycoside, and
vancomycin resistant
1
2
Linezolid IV 600 mg q12hr (≥8wks)
Daptomycin 6 mg/kg q24hr ( 2-6wks)
Daptomycin calculated dose :……………………………….
E. faecalis penicillin,
aminoglycoside, and
vancomycin resistant
1
2
3
HACEK group
1
2
3
4
Imipenem/cilastatin IV 500 mg q6hr + ampicillin IV 2 g q4h ( ≥ 8wks)
Ceftriaxone 2g IV/IM q12hr + ampicillin IV 2 g q4 h ( ≥ 8wks)
Daptomycin 6 mg/kg q24hr ( 2-6wks)
Daptomycin calculated dose:…………………………
Ceftriaxone IV/IM 2 g q24 h (4wks)
Ciprofloxacin IV 400 mg q12h(4 wks)
Piperacillin/tazobactam IV 3.375g q6h (4wks)
Ceftriaxone IV 2 gm q12hr (4 weeks)
 Prosthetic valve
Patient group
Empiric therapy
1
Streptococcus
viridans
(pen. MIC ≤ 0.12)
Streptococcus
viridans
(pen. MIC > 0.12)
Staphylococcu
methicillin
sensitive
1
2
1
2
1
2
3
Staphylococcus—
methicillin
resistant
Enterococcus
1
1
2
3
Enterococcus—
penicillin resistant
1
E. faecium
penicillin,
aminoglycoside, &
vancomycin
resistant
E. faecalis—
penicillin,
aminoglycoside, &
vancomycin
resistant
HACEK group
1
2
Endocarditis
prevention
Therapy (dosing interval in hours) (weeks)
patient with normal renal function
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg q8hr
IV + Rifampin 300 mg PO/IV q12h (6wk)
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: ……………………….. ( trough levels should be < 1 μg/mL)
Penicillin_G: IV 3-4 million Unit q4 h + Gentamicin IV/IM 1mg/kg q8hr (6wk)
Ceftriaxone 2 g q24 h IV/IM + Gentamicin IV/IM 3 mg/kg q8hr (6wk)
Gentamicin calculated dose: ……………………….. ( trough levels should be < 1 μg/mL)
Penicillin_G: IV 3-4 million Unit q4h + Gentamicin IV/IM 1 mg/kg q8 h (6wk)
Ceftriaxone IV/IM 2 g q24 h + Gentamicin IV/IM 1 mg/kg q8h (6wks )
Gentamicin calculated dose: ……………….. …( trough levels should be < 1 μg/mL)
Cloxacillin IV 2g q4hr(6wks) ± Gentamicin IV/IM 1 mg/kg q8h for 3–5 days + Rifampin
IV/PO 300 mg q12 h ( ≥6wks )
Flucloxacillin IV 2g q4-6hr (6wks) ± Gentamicin IV/IM 1 mg/kg q8 h for 3–5 days +
Rifampin IV/PO 300mg q12hr ( ≥6wks )
Cefazolin IV 2mg q8hr ± Gentamicin 1 mg/kg q8hr IV/IM for 3–5 days (6wks) +
Rifampin IV/PO 300 mg q12hr ( ≥6wks )
Gentamicin calculated dose: ………………… ………trough levels should be < 1 μg/mL)
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr (≥6wks) + Rifampin IV/PO
300mg q12hr ( ≥6wks )
(Vancomycin target trough concentration of 15-20 μg/mL)
Penicillin_G: IV 3-4 million Unit q4 h + gentamicin IV/IM 1 mg/kg q8h (6wks)
Ampicillin IV 2g q4 h + gentamicin IV/IM 1 mg/kg q8h (6wks)
If patient penicillin allergy:
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + gentamicin IV/IM 1 mg/kg
q8hr (6wks)
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: ……………………….. (trough levels should be < 1 μg/mL)
Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin IV/IM 1 mg/kg
q8hr (6wks)
(Vancomycin target trough concentration of 15-20 μg/mL)
Gentamicin calculated dose: …………………………(trough levels should be < 1 μg/mL)
Linezolid 600mg IV q12hr (≥8wks)
Daptomycin 6 mg/kg q24hr ( 2-6wks)
Daptomycin calculated dose:…………………………
1
2
3
Imipenem/cilastatin IV 500 mg q6hr + ampicillin IV 2 g q4 h ( ≥ 8wks)
Ceftriaxone IV 2g q12hr + ampicillin IV 2 g q4 h ( ≥ 8wks)
Daptomycin 6 mg/kg q24hr ( 2-6wks)
Daptomycin calculated dose:…………………………
1
2
3
4
Ceftriaxone IV/IM 2 g q24 h (6wks)
Ciprofloxacin IV 400 mg q12h (6wks)
Piperacillin/tazobactam IV 3.375g q6h (6wks)
Ceftriaxone IV 2 gm q24h X 4 weeks + gentamicin IV 1 mg/kg q8 h (6wks)
Gentamicin calculated dose: ……………………….(trough levels should be < 1 μg/mL)
a. I.E prophylaxis is indicated only for high-risk cardiac conditions such as:
- Prosthetic material used for cardiac valve repair
- A prior history of IE
- Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
- Completely repaired congenital heart defects with prosthetic material or device during
the first six months after the procedure (whether placed by surgery or by catheter
intervention).
- Repaired congenital heart disease with residual defects at the site or adjacent to site of
the prosthetic device
- Cardiac "valvulopathy" in a transplanted heart. Valvulopathy is defined as
documentation of substantial leaflet pathology and regurgitation
Routine dental cleaning or routine anesthetic injections through non-infected tissue does
not require antibiotic prophylaxis.
The risk of IE is highest for the following dental procedures hence prophylaxis is
indicated:
Those involving manipulation of gingival tissue or
The peri-apical region of the teeth or
Perforation of the oral mucosa, such as tooth extractions or
Drainage of a dental abscess
Prosthetic heart valves, including bioprosthetic and homograft valves
1
2
1
Amoxicillin 2 g PO one hour before procedure
Ampicillin 2 g IM/IV 30 min before procedure
Penicillin allergy:
Cefazolin 1g IV/IM 30 min before procedure
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
pager:_____________
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis. Guidelines from the American Heart Association.
Circulation 2007;115:1656–8.
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (UTI)
Diagnosis:…………………………………………………………………………………………………………………
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Asymptomatic(+) culture should not be treated with antibiotics
Therapy for UTI (for renal failure patient appendix)
Patient Group
Therapy (Days) patient with normal renal function
Empirically therapy of Acute
Cystitis
1
2
Empirically
therapy of
Uncomplicated
Pyelonephritis
Inpatient
therapy
3
4
1
2
Outpatient
therapy
1
2
3
Complicated UTIs
( Catheter-Related,
Inpatient
therapy
Functional or
Structurally
abnormalities , UTI
in men )
Pregnancy
Symptomatic
or
asymptomatic
Cystitis
1
2
3
1
2
Nitrofurantoin is contraindicated in pregnant
patients at term (38-42 weeks gestation
3
4
Recurrent cystitis
Asymptomatic
( +) culture of
recurrent
bacteriuria
should not be
treated with
antibiotics
Trimethoprim-sulfamethoxazole PO (160/800
mg [DS] q 12hr (3 days)
Nitrofurantoin monohydrate/macrocrystals
PO100 mg q12hr (5days)
Amoxicillin-clavulanate 1g PO q12hr (5-7days)
Cefuroxime 125-250mg PO q12hr (7-10 days)
Ceftriaxone 1-2 gm IV q24h ± Gentamycin
1mg/kg IV/IM q8hr (10-14 days )
Ampicillin 2 gm IV q6h ± Gentamicin IV/IM 1
mg/kg q8hr (14 days)
Gentamycin calculated dose:…………………
(trough levels should be < 1 μg/mL)
Ceftriaxone 1-2 gm IM q24h(10-14 days)
Trimethoprim-sulfamethoxazole PO
160/800 mg [DS] q12hr (14 days )
Amox-Clav 875/125 mg PO q12h or 500/125
mg PO q8hr or 2000/125 mg PO q12hr (14
days)
Amox-Clav dose:…………
Pipracillin- tazobactam 3.375 gm IV q6h
Imipenem 0.5 gm IV q6h (max 4 gm/day)
Ceftazidime 2 gm IV q8h ± Gentamicin IV/IM
1 mg/kg q8hr
Gentamycin calculated dose:…………………
(trough levels should be < 1 μg/mL)
Seven-days treatment regimen
Amoxicillin/clavulanate PO 1g q12hr
Nitrofurantoin100 mg PO q12hr
Cefuroxime 125-250 mg PO q12hr
Trimethoprim-sulfamethoxazole 160/800 mg
[DS] PO q12hr
Ceftriaxone IV 1-2mg q24hr (10-14 days )
-choice between
these
agents should be
based on
local resistance
data(antibiogram)
2 weeks
TMP/SMZ (used
frequently
but avoidance
recommended,
especially during
the late
third trimester)
Pyelonephritis
1
Relapse
( referral to
the ID
Consultant is
mandatory)
Reinfection
( referral to
the ID
Consultant is
Relapse is a new episode of bacteriuria with microorganism that is
same from the original one
-Assess for pharmacologic reason for treatment failure.
-Longer treatment (for 2–6 weeks, depending on length of initial course)
Reinfection is a new episode of bacteriuria with microorganism that is
different from the original one
i.If patient has two or fewer UTIs in 1 year, use patient-initiated therapy for
symptomatic episodes (3-day treatment regimens).
mandatory)
ii. If patient has three or more UTIs in 1 year and they are temporally
related to sexual activity, use post-intercourse prophylaxis with TMP/SMZ
SS, cephalexin 250 mg, or nitrofurantoin 50–100 mg.
iii. If patient has three or more UTIs in 1 year that are not related to sexual
activity, use daily or 3 times/week prophylaxis with trimethoprim 100 mg,
TMP/SMZ SS, cephalexin 250 mg, norfloxacin 200 mg, or nitrofurantoin
50–100 mg.
NOTES______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
- 1, Thomas M. Hooton. Guidelines for Antimicrobial Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women". 2011 ; 52 : e103 -e120
-Thomas M. Hooton,1 Suzanne F. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical
Practice Guidelines from the Infectious Diseases Society of America". 2010 ; 50 : 625 -66
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (Osteomyelitis)
Diagnosis: …………………………………………………………………………………………………………………….
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Therapy for Osteomyelitis (for renal failure patient appendix)
Patient Subtype
Likely Infecting
Antibiotic
Organism
Adults
S. aureus
MSSA
MRSA
1
2
3
1
2
Intravenous drug
abusers
Pseudomonas
1
Postoperative or
post-trauma
patients
Gram-positive
and gramnegative
organisms
1
2
3
4
Patients with
vascular
insufficiency
Duration
Cloxacillin IV 2 mg q6hr
Flucloxacillin sodium IV 2g q6hr
Cefazoline IV 2 g q8 hr
Vancomycin 15-30 mg/kg IV q8-12h ±
Rifampin 300-450 mg IV/PO q12hr
Linezolid 600 mg IV/PO q12h
4 to 6 weeks
If signs or
symptoms are still
present at 6 weeks,
therapy should be
extended
Ceftazidime 2 gm IV q12h + Gentamycin
IV/IM 1mg/kg q8hr x 2 weeks followed by
Ciprofloxacin 750 mg PO q12hr x 10 weeks
Gentamycin calculated dose:……………….
(trough levels should be < 1 μg/mL)
Pipracillin-tazobactam 4.45g IV q6hr
Clindamycin IV 300-450mg q8hr +
Ceftazidime 2 g IV q8 hr
Cloxacillin 2g IV q6hr + Ceftazidime 2 g IV
q8 hr
Flucloxacillin sodium 2g IV q6hr +
Ceftazidime 2 g IV q 8 hr
Debride overlying ulcer and submit bone for histology and culture.
Select antibiotic based on culture results and treat for 6 weeks.
No empiric therapy recommended unless patient is acutely ill.
For acute illness, treat as Diabetic Foot.
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004;364:369–79.
pager:_____________
_________Hospital
Pharmaceutical Care Department
___________Region
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
(Antibiotics Program)
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
Antibiotics order (Diabetic foot infection)
Diagnosis:………………………………………………………………………………………………………….
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Therapy for Diabetic foot infection (for renal failure patient appendix)
Suspected
Antibiotic Therapy
pathogen
Oral agents for empiric
Streptococci and
1 Amoxicillin-clavulanate ER PO 1000
treatment of mild to
Staphylococci
2 mg q12h
moderate early diabetic
(MSSA)
3 Clindamycin PO 300-450 mg q8hr
foot infections
4 Cloxacillin 500mg PO q6hr
( Outpatient )
Flucloxacillin PO 250-500 mg q6h
Streptococci and
1 Amoxicillin 1g IV q12hr + Trimethoprimsulfamethoxazole PO160/800 mg [DS]
MRSA (preview
q12hr
MRSA infected
or colonized|)
2 Clindamycin PO 300-450 mg q8hr +
Duration
7-10 days
7-10 days
Trimethoprim-sulfamethoxazole PO
160/800 mg [DS] q12hr
Linezolid PO 600 mg q12hr
Parenteral agents for
empiric treatment of
moderate to severe
diabetic foot infections
3
1 Piperacillin-tazobactam IV 4.5g q6-8hr
+ vancomycin IV 1g q8hr
2 Piperacillin-tazobactam IV 4.5g q6-8hr
+ Linezolid IV 600 mg q12hr
3 Imipenem-cilastatin IV 500mg q6hr
+Linezolid IV 600 mg q12hr
4 Imipenem-cilastatin IV 500mg q6hr +
Vancomycin IV 1g q8hr
Vancomycin trough level 15-20 μg/mL
10-14 days
And expand
the duration
depend on
clinical
symptom
progress
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Benjamin A. Lipsky,1 Anthony R. Diagnosis and Treatment of Diabetic Foot infection 2012 ; 54 : e132 -e173
pager:_____________
Uptodate 2014
_________Hospital
Pharmaceutical Care Department
___________Region
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
(Antibiotics Program)
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
Antibiotics order (Skin and Soft tissue Infection)
Diagnosis:…………………………………………………………………………………………………………………….
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Therapy for Cellulitis, Erysipelas: Extremities, Non-Diabetic (for renal failure patient appendix)
Micro-organism
Therapy (dosing interval )
Duration
1 Cefazoline IV 1-2 g q8hr
Empiric therapy
Inpatient
parenteral 2 Clindamycin PO 600-900mg q6-8hr
3 Flucloxacillin 1–2 gm IV q6h
therapy
Streptococcus
4 Cloxacillin IV 1g q6h
pyogenes
Staphylococcus
aureus (rare)
outpatient
therapy:
MSSA
outpatient
MRSA
1 Flucloxacillin PO 250-500 mg q6h
2 Cephalexin PO 500 mg q6hr
If penicillin or cephalosporin allergic
1 Clindamycin PO 300- 450 mg q6-8hr
1 Cloxacillin PO 500 mg q6h
2 Flucloxacillin PO 250-500 mg q6h
3 Amox-clav PO 1g q12hr
4 Clindamycin IV 300-450mg q8hr
5
Trimethoprim-sulfamethoxazole PO160/800 mg [DS] q12hr
inpatient
1
2
outpatient
1
Flucloxacillin IV 1–2 gm q4-6h
Cloxacillin IV 1-2 g q6h
Cephazoline IV 1-2 g q8hr
Trimethoprim-sulfamethoxazole [160/80 double
strength] PO q12h
Linzoild PO 600mg q12hr
Clindamycin IV 300-450mg q8hr
Vancomycin IV1g q8h
Linezolid IV 600mg q12hr
Vancomycin target trough level 15-20 μg/mL
2
3
inpatient
1
2
Therapy for Erysipelas: Facial(for renal failure patient appendix)
Therapy (dosing interval )
1 Penicillin V: PO 500 mg q6hr
Outpatient
2 Amoxicillin PO 500 mg q8hr
3 Clindamycin PO 300- 450 mg q6-8hr
1 Ceftriaxone 1 g intravenously every 24 hours
Inpatient
2 Cefazoline IV 1-2 g q8hr
3 Clindamycin IV 450mg q8hr
7–10
days
7-10days
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
Dennis L. Stevens,1,3 Alan L. Bisno. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41
UPT
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it
on patient profile, and forward the copy to the
Pharmacy Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (Skin and Soft tissue Infection)
Self-initiated therapy of recurrent cellulitis and lymphedema (for renal failure patient appendix)
Therapy (dosing interval )
Micro-organism
Streptococcus sp. (Group A, B, C, G)
1 Amoxicillin 500mg PO q12hr
Start antibiotics and
2 Penicillin V 250 mg PO q12 h
report back to the
3 Clindamycin 300-450mg PO q8-12hr
physician ASAP
Necrotizing fasciitis
Diagnosis:………………………………………………………………………………………………………………….
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Necrotizing fasciitis Therapy (for renal failure patient appendix)
Need early surgical intervention
Patient group
Necrotizing Mixed infection
fasciitis
Streptococcus infection
If group A strep. The IVIG
should be added
Therapy (dosing interval )
1
2
3
4
1
2
piperacillin-tazobactam 3.375 g IV q 6–8 h
Imipenem/cilastatin 1 g IV q 6–8 h
Ceftriaxone 2 g IV q24 h + metronidazole
500 mg IV q 6 h
Vancomycin 1 g q8hr
Penicillin G: 4 million Unit IV q4 h +
Cindamycin 600–900 mg IV q8 h
Ceftriaxone 2 gm IV q24h + Clindamycin
600-900 mg IV q8h
14 days and
expand depend
on the clinical
symptom
progressing
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
Dennis L. Stevens,1,3 Alan L. Bisno. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (Skin and Soft tissue Infection)
Animal bite & Human bite
Patient Groups
Animal bite
Human bite
Therapy (dosing interval)
1
Amoxicillin-clavulanic acid 875 mg/125 mg PO q12 h
2
Doxycycline 100–200 mg PO q 12 h
3
Cefuroxime axetil 500 mg PO q12 h + metronidazole 250–500 mg
PO q8h
1
Amoxicillin-clavulanic acid 875 mg/125 mg q12 h
2
Doxycycline 100–200 mg q12 h
3
Cefuroxime axetil 500 mg q12 h+ metronidazole 250–500 mg q8h
Duration
7 days
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
Dennis L. Stevens,1,3 Alan L. Bisno. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order(peritonitis)
Primary peritonitis: Spontaneous bacterial peritonitis (SBP), Primary infection
Diagnosis:………………………………………………………………………………………………………………….
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Primary peritonitis therapy (for renal failure patient appendix)
Therapy (dosing interval )
Duration
For treatment
1 Ceftriaxone IV 2 gm q24h
2 Aztreonam 1-2 g IV/IM q8-12hr
3 Pip-Tazo IV 3.375 gm q6h ( if suspected pseudomonas )
Prevention in patients
Antibiotic prophylaxis indication/ prevention of SBP:
5-7 days
with chronic ascites
1- Patients with cirrhosis and gastrointestinal bleeding.
1
2
1
resistant E. coli,
Klebsiella species (e.g., 2
ESBL):
2- Patients who have had one or more episodes of SBP.
TMP-SMX-DS 1 tab PO 5 days/week
Ciprofloxacin 750 mg PO once/week
Imipenem IV 500 mg q6h
Meropenem IV 1g q8h
Peritonitis, Secondary, bowel perforation, ruptured appendix, ruptured diverticula
Therapy ( Source Control is Mandatory)
Therapy (dosing interval )
1
Piperacillin- Tazobactam IV 4.5 gm q8h ±
Mild/Moderate Peritonitis;
2
Gentamycin
IV/IM 1mg/kg q8hr (3-5days)
inpatient; requires parenteral
3
Ceftazidem
IV
2 gm q12h + Metronidazole IV 1 gm
therapy: Hemodynemically
q12hr
stable
4 Tigecyline 100mg IV infusion then 50mg IV infusion
q12hr
1 Imipenem 500 mg -1 gm IV q6h
Severe Disease: Patient is in
2 Meropenem IV 1g q8hr
ICU; requires parenteral
3 Tigecyline 100mg IV infusion then 50mg IV infusion
q12hr
Duration
10-14days
14 days
Peritonitis, Dialysis (CAPD) Associated:
Diagnosis:………………………………………………………………………………………………………………….
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Peritonitis, Dialysis (CAPD) Associated Therapy: (for renal failure patient appendix)
Empiric therapy
Empiric therapy:
1 Vancomycin IV 1g q8hr + Piperacillin- Tazobactam IV 4.5 gm q8h (14 days )
Vancomycin, cephalosporins, and aminoglycosides can be mixed in the same
dialysis bag without loss of bioactivity.
Transfer the patient to the (CAPD) center to treat the patient depend on the protocol
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
-Solomkin JS,et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Clin Infect Dis. 2010 Jun
15;50(12):1695
-Runyon BA,et al. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009 Jun;49(6):2087-107
-Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotic order (intra-abdominal infection)
Therapy: (for renal failure patient appendix):
Empirical therapy
Therapy (dosing interval )
Hepatic Abscess
1 Ceftriaxone IV 1-2 gm q24h + Metronidazole PO 500 mg q6-8h
2 Piperacillin- Tazobactam IV 4.5 gm q8h + Metronidazole PO 500 mg q6-8h
Gallbladder
mild-to-moderate
Infections(Gallbladder
1 Cefuroxime IV 1.5 g q8 h
infections, cholecystitis,
Sever infection:
cholangitis, biliary sepsis, 1 Piperacillin-Tazobactam IV 4.5 gm q8h
common duct obstruction 2 Ceftriaxone 1-2 gm IV q24h ± Gentamycin IV/IM 1mg/kg q8hr
If life-threatening infection: Imipenem IV 500mg q6h + Gentamycin single dose
3
Acute
without evidence of tissue necrosis
Alcoholic
No indication for an antimicrobial agent
pancreatitis
Necrotizing
1 Piperacillin-Tazobactam IV 4.5gm q6h
pancreatitis
2 Imipenem IV 500 mg q6h
infected
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
-Solomkin JS,et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Clin Infect Dis. 2010 Jun
15;50(12):1695
-Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (Sexually transmitted disease)
Diagnosis: …………………………………………………………………………………………………………………..
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Therapy for Sexually transmitted disease (for renal failure patient appendix)
Type or Stage
Chlamydial Infection
and Related Clinical
Syndromes
Gonorrhea
Epididymitis
Bacterial Vaginosis
Trichomoniasis
Urethritis
Cervicitis
Conjunctivitis
proctitis (except
lymphogranuloma venereum)
Therapy
1 Doxycycline 100 mg PO q12hr x 7days
2 Azithromycin 1 g PO q24hr single dose
3 Levofloxacin PO500mg q24hr x 7days
Infection in Pregnancy
1
Azithromycin 1 g PO single dose
Lymphogranuloma venereum
1
2
1
Doxycycline 100 mg PO q6hr x 21days
Azithromycin 1 g PO once weekly for 3 weeks
Ceftriaxone IM 250 mg once + Azithromycin 1 g PO
single dose
Ceftriaxone 250 mg IM once followed
by doxycycline PO 100 mg q12hr x 10 days
Levofloxacin 500 mg PO q24hr x 10d
Metronidazole 500 mg PO q12hr for 7days
Clindamycin 300 mg PO q12hr for 7 days
Metronidazole 500 PO q12hr for 7 days
Tinidazole PO 2g single dose
Urethritis, Cervicitis,
Proctitis
1
2
1
2
1
2
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
_______________________________________________________________________________________________________________________
Drugs for Sexually Transmitted Infections. Treatment Guidelines from The Medical Letter. July 2010; 8 (95) 53-59
Uptodate 2014
Sanford guide webedition 2014
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotic order (Pelvic Inflammatory Disease)
Diagnosis: …………………………………………………………………………………………………………………..
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Therapy for PID (for renal failure patient appendix):
Empiric therapy
Outpatient:
Inpatient:
Therapy (dosing interval )
1 Ceftriaxone 250 mg IM x 1 dose followed by Azithromycin 1 gm PO weekly x 2 weeks
2 Cefoxitin 2 gm IM with Probenecid PO 1 gm both as single dose + Doxycycline 100
mg PO q12hr with Metronidazole 500 mg q12hr both x 14 days
1 Ceftraixone IV 2 g q24 h + Doxycycline IV/PO 100 mg q12h
2 Clindamycin 900 mg IV q8h + Gentamicin 1mg/kg IV/IM q8hr , then Doxycycline 100
mg PO q12hr x 14 days
Gentamicin Calculated dose: ………………………………. Target trough <1
μg/mL
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014
pager:_____________
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Brucellosis
Diagnosis: …………………………………………………………………………………………………………………..
Culture:  Pending
 ( + ) Culture
 ( - ) Culture
 Not sending
Therapy of brucellosis (dosing of renal failure appendix )
Infection or patient
Therapy (dosing interval )
condition
Non-localizing
disease
Spondylitis/
sacroileitis/
arthritis
Inpatient
Outpatient
1 Doxycycline 100 mg PO q12hr x 6 weeks +
Streptomycin 1 gm IM/IV q24hr x 14-21 days
2 Doxycycline 100 mg PO q12hr x 6 weeks + rifampicin
600mg q24hr
3 Doxycycline 100 mg PO q12hr x 6 weeks +
TMP-SMX 5 mg/kg of TMP component POq12hr x 6 weeks
1 Doxycycline 100 mg PO q12hr + Gentamycin 1mg/kg q8hr
2 Doxycycline 100 mg PO q12hr + rifampicin IV/PO 600mg
3 q24hr
Doxycycline 100 mg PO q12hr +TMP-SMX 5 mg/kg of
4 TMP component IV q12hr
Ciprofloxacin 500 mg PO q12hr + rifampicin 600mg q24hr
Gentamycin dose:…………...Target trough <1 μg/mL
1 Doxycycline 100 mg PO q12hr + Streptomycin IV/IM 15
12 weeks
mg/kg q12hr
Streptomycin Calculated dose: ……………………….. Peak: 2030 mcg/mL; Trough: <5 mcg/mL
Brucella during
Pregnancy
1 TMP-SMX 5 mg/kg of TMP component PO q12hr +
Rifampicin 900mg q24hr x 6 weeks
If ≥ 38 weeks
2 Rifampicin 900mg q24hr x 6 weeks
TMP-SMX
may cause
kernicterus if
given in last
week of
pregnancy
Neurobrucellosis
1 Doxycycline 100 mg IV/PO q12hr + Ceftriaxone 2 gm IV
q12h.(4wk)
1 Doxycycline 100 mg IV/PO q12hr + gentamycin 1mg/kg
IV/IM q8hr
Gentamyci n calculated dose:…………………….trough
level < 1 μg/mL
Continue until
CSF is normal
3-6 months
Endocarditis
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
-Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014
pager:_____________
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (tuberculosis)
Treatment of Latent TB recommended for:
patients at increased risk for developing active
close contacts of patients with
disease, such as those co-infected with HIV or
recent pulmonary TB
receiving immunosuppressive therapy, children
<5 years old, those with diabetes or chronic
renal failure on hemodialysis
Therapy for Latent TB (for renal failure patient appendix)
those who have converted from (-) to a
(+) tuberculin skin test PPD
or interferon-gamma release assay
(IGRA) within the mprevious 2 years)
Isoniazid 5 mg/kg/day (max 300 mg/day) or 15 mg/kg 2x/wk (max 900 mg/dose)x 9 months
Isoniazid 15 mg/kg (max 900 mg/dose) + rifapentine 300-900 mg weeklyx 12 weeks
Rifampin 10 mg/kg/day (max 600 mg/day) or 10 mg/kg 2x/wk (max 600 mg/dose) x 4 months
Active TB diagnosis:
Smear
(+) culture
PCR
Therapy for Active TB (for renal failure patient appendix)
1) First-line for Treatment of Active TB
Condition
Drugs
Adult Dosage
Daily
Intermittent
Empiric initial treatment
Isoniazid
5 mg/kg
15 mg/kg 1-3x/wk
should include 4 drugs:
10 mg/kg
10 mg/kg 2-3x/wk
Rifampin(RIF)
pyrazinamide
ethambutol
When susceptibility to
isoniazid, rifampin and
pyrazinamide
Isoniazid(INH)
Rifampin
Pyrazinamide
Patients who cannot take
pyrazinamide, such as
those with severe liver
disease or gout
Isoniazid
Rifampin
ethambutol
40-55 kg:
1000 mg
56-75 kg:
1500 mg
76-90 kg:
2000 mg
40-55 kg:
800 mg
56-75 kg:
1200 mg
76-90 kg:
1600 mg
5 mg/kg
10 mg/kg
40-55 kg:
800 mg
56-75 kg:
1200 mg
76-90 kg:
1600 mg
The same
dose
Histopathology
Alternative
Rifabutin (RPT
5 mg/kg
40-55 kg: 2000 mg
56-75 kg: 3000 mg
76-90 kg: 4000 mg
2x/wk
40-55 kg: 2000 mg
56-75 kg: 2800 mg
76-90 kg: 4000 mg
15 mg/kg 1-3x/wk
10 mg/kg 2-3x/wk
Rifabutin 5 mg/kg
40-55 kg: 2000 mg
56-75 kg: 2800 mg
76-90 kg: 4000 mg
The same dose
Rifabutin 5 mg/kg
Duration
Initial
phase
2 months
_________Hospital
Pharmaceutical Care Department
___________Region
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antibiotics order (tuberculosis)
2) Duration of Continuation Therapy (For treatment of drug-susceptible disease after two months of initial
therapy):
Cavity on Chest (x-ray)
Sputum Culture (Taken at 2
Drugs
Duration (
Months)
months)
Negative
INH/RIF
4
No
4
Positive
INH/RIF
7
No
Yes
Yes
Patients who could not take
pyrazinamide as part of the
initial regimen.
Negative
Positive
INH/RIF
INH/RIF
INH/RIF
4
7
7
Some Second-Line Drugs for Active Tuberculosis
Streptomycin
Capreomycin (Capastat)
Kanamycin (Kantrex,
Amikacin
Cycloserine (Seromycin)
Ethionamide (Trecator)
15 mg/kg IM or IV (max 1 g)
15 mg/kg IM or IV (max 1 g)
15 mg/kg IM or IV (max 1 g)
15 mg/kg IM or IV (max 1 g)
10-15 mg/kg PO
15-20 mg/kg in 1 or 2 divided doses PO (max 500 mg
q12hr )
Levofloxacin
500-1000 mg PO/ IV …..
Moxifloxacin
400 mg PO or IV……..
Para-aminosalicylic acid
8-12 g in 2-3 doses PO
-At least 12 months of treatment with isoniazid, ethambutol and
Resistance to Rifamycins –
a fluoroquinolone (levofloxacin or moxifloxacin) can be used.
-Pyrazinamide, with or without an injectable drug, should also
be used during the initial 2 months of therapy.
Multidrug Resistance Isolates with resistance to at least Refer to the specialized physician
isoniazid and rifampin
Extensively drug-resistant TB (XDRTB)
Isolates with resistance not only to isoniazid and
rifampin, but also to any fluoroquinolone and at least one
of three injectable second-line drugs [i.e., amikacin,
kanamycin or capreomycin]) are based on limited data.
Refer to the specialized physician
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Drugs for Tuberculosis. Treatment Guidelines from The Medical Letter. April 2012;10 (116) 29-35
Abbreviations:
Rifampicin (RIF)
Rifabutin (RPT)
Isoniazid (INH)
pager:_____________
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antiviral order (VIRAL infections)
Antiviral Drugs (for renal failure patient appendix):
Viral infection
Varicella-Zoster Virus
Infections
Type or condition
Varicella
Herpes Zoster
Herpes Simplex Virus
Infections
Varicella or Zoster in
Immunocompromised Patients
Acyclovir-resistant Zoster
First episode
Orolabial
Recurrences
Suppression
Genital
First episode
Recurrences
Suppression
Mucocutaneous in
Immunocompromised Patients
Acyclovir-resistant Mucocutaneous
Severe infection,
immunocompromised
Encephalitis
Other Severe or Disseminated
Keratitis
1
1
2
1
1
2
1
2
1
2
1
2
1
2
1
1
2
1
1
Influenza
Chronic Hepatitis
B
Chronic Hepatitis C
Therapy
1 Acyclovir 800 mg PO q6hr x 5d
2 Valacyclovir 1 g PO q8hr x 5d
1 Valacyclovir 1 g PO q8hr x 7d
2 Acyclovir 800 mg PO q6hr x 7d
1 Acyclovir 10 mg/kg IV q8hr x7d
Foscarnet 40-60 mg/kg IV q8hr x 14-21d
Acyclovir 400 mg PO q8hr x 7-10d
Valacyclovir 1 g PO q12hr x 7-10d
Acyclovir 400 mg PO q6hr 5d
Acyclovir 400 mg PO q12hr
Valacyclovir 500 mg-1 g PO once/d
Acyclovir 400 mg PO q8hr x 7-10d
Valacyclovir 1 g PO q12hr x 7-10d
Acyclovir 800 mg PO q8hr x 5d
Valacyclovir 500 mg PO q12hr x 3d
Acyclovir 400 mg PO q12hr for 12 months
Valacyclovir 500 mg-1 g PO once/d for 12 months
Acyclovir 5 mg/kg IV q8h x 7-14d or 400 mg PO 5x/d x
7-10d
Valacyclovir 500 mg-1 g PO bid x 7-10d
Foscarnet 40 mg/kg IV q8h x 14-21d or until healed
Acyclovir 10-15 mg/kg IV q8h x 14-21d
Acyclovir 5-10 mg/kg IV q8h x 14-21d
Acyclovir 3% ophthalmic ointment
for 1week
Oseltamivir 75 mg PO once/d prophylaxis
75 mg PO q12hr x 5d treatment
Refer to hepatologiest
Refer to hepatologiest
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Antiviral Drugs. Treatment Guidelines from The Medical Letter. March 2013;11 (127) 19-29
pager:_____________
_________Hospital
Pharmaceutical Care Department
___________Region
FILE NO.
     
NAME:_________________________________________
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the
Pharmacy Department within 24 hrs)
AGE:
 
SEX:
 M
 F
NATIONALITY:__________________________________
Drugs for parasitic infections
Protozoa
Infection
Amebiasis
(Entamoeba
histolytica)
Asymptomatic
Mild to moderate
intestinal disease
Severe intestinal and
extraintestinal disease
Naegleria fowleri
Therapy (drug interval )
1 Diloxanide furoate 500 mg PO tid x 10 d
1 Metronidazole 500 to 750 mg PO tid x 7 to 10 d
1
Metronidazole 750 mg PO tid x 7 to 10 d
Amebic
meningoencephalitis
, primary and
granulomatous
ASCARIASIS
(Ascaris lumbricoides, roundworm)
1
Amphotericin B 1.5 mg/kg/d IV in 2 doses x 3 d, then 1
mg/kg/d x 6 d plus 1.5 mg/d intrathecally x 2 d, then 1
mg/d every other day x 8 d
1
2
Albendazole 400 mg PO once
Mebendazole 100 mg bid PO x 3d or 500 mg once
BABESIOSIS
(Babesia microti)
1
Clindamycin1.2 g bid IV or 600 mg tid PO x 7-10 days
plus quinine 650 mg PO tid x 7-10d
Atovaquone 750 mg PO bid x 7-10d
plus azithromycin 500 mg PO daily x 7-10d
2
Balantidiasis (Balantidium coli)
CAPILLARIASIS
(Capillaria philippinensis)
Cryptosporidiosis (Cryptosporidium)
Cyclosporiasis (Cyclospora cayetanensis)
Cystoisosporiasis (Cystoisospora belli, formerly
known as Isospora)
Microsporidiosis Ocular (Encephalitozoon
hellem, E. cuniculi,
Vittaforma [Nosema]
corneae)
Intestinal (E. intestinalis)
E. bieneusi
Disseminated (E. hellem, E.
cuniculi, E. intestinalis,
Pleistophora sp.,
Trachipleistophora sp. and
Anncaliia [Brachiola]
vesicularum
Helminths
Infection
Ancylostoma caninum (Eosinophilic
enterocolitis)
Ascariasis (Ascaris lumbricoides,
roundworm)
Capillariasis (Capillaria philippinensis
Enterobius vermicularis (pinworm) infection
1
2
1
2
1
1
2
1
Tetracycline 500 mg PO qid x 10 d
Metronidazole 750 mg PO tid x 5d
Mebendazole7 200 mg PO bid x 20d
Albendazole7,12 400 mg PO daily x 10d
Nitazoxanide 500 mg PO bid x 3 d
TMP/SMX160 mg/ 800 mg (1 DS tab) PO bid x 7 to 10 d
Ciprofloxacin500 mg PO bid x 7 d
TMP/SMX160 mg/ 800 mg (1 DS tab) PO bid x 7 to 10 d
1
Albendazole 400 mg PO bid
1
Albendazole 400 mg PO bid
1
Albendazole 400 mg PO bid
1
Therapy
Albendazole 400 mg PO once
1
Albendazole 400 mg PO once
1
1
Albendazole 400 mg PO once
Albendazole 400 mg PO once
Fluke, hermaphroditic, infection
Clonorchis sinensis (Chinese liver fluke)
Fasciolopsis buski, Heterophyes
heterophyes, Metagonimus yokogawai
(intestinal flukes)
Metorchis conjunctus (North American liver
fluke)
Nanophyetus salmincola
Opisthorchis viverrini (Southeast Asian liver
fluke)[
Paragonimiasis (P. westermani, P. miyazaki,
P. skrjabini, P. hueitungensis, P.
heterotrema, P. utcerobilaterus, P. Africanus,
P. Mexicanus, P. Kellicotti) (lung fluke)
Schistosomiasis (Bilharziasis)
Strongyloidiasis (Strongyloides stercoralis)
GIARDIASIS
(Giardia duodenalis)
GNATHOSTOMIASIS
(Gnathostoma spinigerum)
GONGYLONEMIASIS
(Gongylonema sp.)
HOOKWORM infection
(Ancylostoma duodenale, Necator
americanus)
ISOSPORIASIS
(Isospora belli)
LEISHMANIA
Visceral
Cutaneous
Mucosal
LICE infestation
(Pediculus humanus, P. capitis, Phthirus pubis)
1
2
1
Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
Albendazole 10 mg/kg/d PO x 7 d
Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
1
Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
1
1
Praziquantel 60 mg/kg/d PO in 3 doses x 1 d
Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
1
Praziquantel 75 mg/kg/d PO in 3 doses x 2 d
1
1
2
Praziquantel 40 mg/kg/d PO in 1 or 2 doses x 1 d
Ivermectin 200 mcg/kg/d PO x 2 d
Albendazole 400 mg PO bid x 7 d
1
2
Metronidazole 250 mg PO tid x 5-7d
Tinidazole 2 g PO once
1
Albendazole 400 mg PO bid x 21d
1
2
Surgical removal
OR Albendazole 400 mg/d PO x 3d
1
2
3
Albendazole 400 mg PO once
Mebendazole 100 mg PO bid x 3d or 500 mg once
Pyrantel pamoate 11 mg/kg (max. 1g) PO x 3d
1
Trimethoprim- sulfamethoxazole TMP 160 mg/SMX 800
mg (1 DS tab) PO bid /10 days
1
2
3
1
2
3
1
2
3
4
Liposomal amphotericin B 3 mg/kg/d IV d 1-5, 14 and 21
Sodium stibo gluconate 20 mg Sb/kg/d IV or IM x 28d
Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28d
Sodium stibo gluconate 20 mg Sb/kg/d IV
Meglumine antimonite 20 mg Sb/kg/d IV or IM x 20d
Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28 days
Sodium stibo gluconate 20 mg Sb/kg/d IV or IM x 28d
Meglumine antimonite 20 mg Sb/kg/d IV or IM
Amphotericin B 0.5-1 mg/kg IV daily or every second
day for up to 8wks
Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28d
1
2
3
0.5% Malathion Topically
1% Permethrin Topically
Ivermectin 200 mcg/kg PO
MALARIA, Treatment of (Plasmodium falciparum, P. vivax, P. ovale, and P. malariae)
ORAL
P. falciparum
Drug of choice:
or unidentified species acquired in areas of
1 Single administration of Sulfadoxine (25 mg/kg) /
Pyramethamine (1.25 mg/kg) on day 1 + Artesunate 4
chloroquine-resistant P. falciparum
mg/kg/day on day 1 , 2, and 3
2 Artemether/lumefantrine 6 doses over 3d (4 tabs/dose 0,
8, 24, 36, 48 and 60 hours)
Alternatives:
1 Atovaquone/ proguanil 2 adult tabs bid or 4 adult tabs
once/d x 3d
2 Mefloquine 750 mg followed 12 hrs later by 500mg
Quinine sulfate 650 mg q8h x 3 or 7d
Plus doxycycline 100 mg bid x 7d
3 or plus tetracycline 250 mg qid x 7d
4 or plus clindamycin 20 mg/kg/d in 3 doses x 7d
P. vivax
acquired in areas of chloroquine-resistant P. vivax
1
1
2
All Plasmodium species
except chloroquine-resistant P. falciparum and
chloroquine-resistant P. vivax
PARENTRAL
All Plasmodium species
(Chloroquine-sensitive and resistant)
Severe malaria
3
1
1
2
3
PNEUMOCYSTIS JIROVECI
(formerly carinii) pneumonia (PCP)
1
1
2
3
4
Drug of choice:
Mefloquine 750 mg PO followed 12 hrs later by 500mg
Atovaquone/ proguanil 2 adult tabs bid or 4 adult tabs
once/d x 3d
either followed by
Primaquine phosphate 30 mg base/d PO x 14d
Alternatives:
Chloroquine phosphate 25 mg base/kg PO in 3 doses over
48 hrs
Quinine sulfate 650 mg PO q8h x 3-7d
Plus Doxycycline 100mg PO bid x 7d
either followed by
Primaquine phosphate 30 mg base/d PO x 14d
Chloroquine phosphate 1g (600mg base) PO, then
500mg (300mg base) 6hrs later, then 500mg (300mg
base) at 24 and 48 hrs
Artesunate 2.4 mg/kg/dose IV x 3d at 0, 12, 24 and 48 hrs
Artemether 3.2 mg/kg i.m., then 1.6 mg/kg I.m. daily up
to day 6
Quinine dihydrochloride 20 mg/kg IV loading dose in
5% dextrose over 4 hrs, followed by 10 mg/kg over 2-4
hrs q8h (max. 1800 mg/d) until PO therapy can be started
Drug of choice:
Trimethoprim/sulfamethoxazole TMP 15mg/SMX
75mg/kg/d, PO or IV in 3 or 4 dose x 21d
Alternatives:
Primaquine 30 mg base PO daily x 21 d
plus clindamycin 600mg IV q6h x 21d, or 300-450 mg
PO q6h x21d
Trimethoprim 5mg/kg PO tid x 21d
plus dapsone 100mg daily x 21 d
Pentamidine 3-4 mg/kg IV daily x 21d
Atovaquone 750 mg PO bid x 21d
Primary and secondary prophylaxis
SCABIES
(Sarcoptes scabiei)
SCHISTOSOMIASIS (Bilharziasis)
S. haematobium, S. japonicum, S. mansoni, S.
mekongi
Tapeworm infection
Diphyllobothrium latum (fish), Taenia saginata
(beef),Taenia solium (pork), Dipylidium
caninum (dog)
Hymenolepis nana (dwarf tapeworm)
Echinococcus granulosus (hydatid cyst)
Taenia solium (Cysticercosis)
1
2
Trimethoprim/sulfamethoxazole 1 tab (single or double
strength) daily or 1 DS tab PO 3d/wk
Dapsone 50 mg PO daily or 200 mg PO each wk
1
2
3
5% Permethrin Topically once
Ivermectin 200 mcg/kg PO once
10% Crotamiton Topically once/d x 2
1
Praziquantel 40 mg/kg/d PO in 2 doses x 1d
1
2
Praziquantel 5 to 10 mg/kg PO once
Niclosamide 2 g PO once
1
2
1
1
Praziquantel 25 mg/kg PO once
Niclosamide 2 g PO daily x 7 d
Albendazole 400 mg PO bid x 1 to 6 months
Albendazole 400 mg PO bid x 8 to 30 d; can be repeated
as necessary
Praziquantel 100 mg/kg/d PO in 3 doses x 1 day then 50
mg/kg/d in 3 doses x 29 days
Albendazole 400 mg PO bid x 8 to 14 d
Albendazole 400 mg PO once
Albendazole 400 mg PO x 3 d
Ivermectin 200 mcg/kg/d PO x 3 d
Albendazole 400 mg PO bid x 5 d
2
Trichinellosis (Trichinella spiralis)
Trichostrongylus infection
Trichuriasis (Trichuris trichiura, whipworm)
Visceral larva migrans[40] (Toxocariasis)
TOXOPLASMOSIS
Toxoplasma gondii
TRICHOMONIASIS
Trichomonas vaginalis
TRICHURIASIS
Trichuris trichiura, whipworm
1
1
1
2
1
1
Pyrimethamine 25-100 mg/d PO x 3-4wks
plus sulfadiazine 1-1.5 g PO qid x 3-4wks
1
2
Metronidazole 2 g PO once or 500 mg bid x 7d
Tinidazole 2 g PO once
1
2
Mebendazole 100 mg PO bid x 3d or 500 mg once
Albendazole 400 mg PO x 3d
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
Drugs for Parasitic Infections.
UPTODATE 2014
The Medical Letter, Inc.3rd (2013)
pager:_____________
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Antifungal order (fungal infection)
Antifungal infection: (for renal failure patient appendix)
Condition
Treatment group
Therapy
Duration
Candidemia
Non-neutropenic
1 Fluconazole IV/PO 800-mg(12-mg/kg) loading
14 days after
adults
dose, then 400 mg(6 mg/kg) daily
first negative
for moderately severe to severe illness and
blood culture
for patients with recent azole exposure
2 Anidulafungin, I.V. 200-mg loading dose, then and
resolution of
I.V.100 mg/day
signs/
3 Caspofungin, 70-mg I.V. loading dose, then
symptoms
I.V. 50 mg/day (35mg for moderate hepatic
insufficiency)
4 Lipid base Ampho B I.V 3–5 mg/kg daily
5 AmphoB 0.5–1 mg/kg I.V daily
Calculated Dose: ……………………………..
Neutropenic
1 Anidulafungin, I.V.200-mg loading dose, then
patients
I.V. 100 mg/day
2 Caspofungin, I.V. 70-mg loading dose, then
I.V. 50 mg/day (35mg for moderate hepatic
insufficiency)
3 Lipid base Ampho B I.V 3–5 mg/kg daily
4 Fluconazole 800-mg (12-mg/kg) loading dose,
then 400 mg (6 mg/kg) daily I.V. or P.O
Suspected candidiasis
Non-neutropenic
1 Fluconazole 800-mg (12-mg/kg) loading dose,
(Treated with empiric
patients
then 400 mg (6 mg/kg) daily I.V. or P.O
antifungal therapy)
for moderately severe to severe illness and for
patients with recent azole exposure
2 Anidulafungin, IV 200-mg loading dose, then
I.V. 100 mg/day
3 Caspofungin IV 70-mg loading dose, then I.V.
50 mg/day (35mg for moderate hepatic
insufficiency)
4 Lipid base Ampho B IV 3–5 mg/kg daily
Neutropenic
1 Lipid base Ampho B IV 3–5 mg/kg daily
patients
2 Caspofungin 70-mg loading dose, then 50 mg
Daily (35mg for moderate hepatic
insufficiency)
3 Voriconazole IV 400 mg (6 mg/kg) Q12hrs for
2 doses then 200 mg (3 mg/kg) I.V. Q12hrs
4 Fluconazole IV/PO 800-mg (12-mg/kg) loading
dose, then 400 mg (6 mg/kg) daily
Urinary tract infection
Asymptomatic
Therapy not usually indicated, unless
cystitis
patients are at high risk (e.g., neonates
and neutropenic adults
Symptomatic
1 Fluconazole 200 mg (3 mg/kg) daily IV/PO for
cystitis
2 weeks
2 Ampho B I.V. 0.3–0.6 mg/kg for 7 - 10 days
3 Flucytosine 25 mg/kg q6hr for 7–10 days
Pyelonephritis
1
2
3
Fluconazole 200–400 mg (3–6 mg/kg) once
daily orally for 2 weeks
AmphoB I.V. 0.5–0.7 mg/kg daily ± 5-FC 25
mg/kg P.O Q6hrs
5-FC alone for 2 weeks
Urinary fungus
balls
1
2
Vulvovaginal
candidiasis
Chronic disseminated
Candidiasis (Refer patient
to the specialized
physician)
1
1
2
3
4
5
Candida osteoarticular
Infection
(Refer patient to the
specialized physician)
Osteomyelitis
1
2
Septic arthritis
1
2
CNS candidiasis
(Refer patient to the
specialized physician)
1
2
Candida Endophthalmitis
(Refer patient to the
specialized physician)
1
2
Candida infection of the
cardiovascular
System
(Refer patient to the
specialized physician)
Endocarditis
1
2
3
4
Pericarditis or
myocarditis
1
2
3
4
Suppurative
1
2
Surgical removal strongly recommended (BIII)
fluconazole 200–400 mg (3–6 mg/kg) daily
AmphoB I.V. 0.5–0.7 mg/kg daily± 5-FC 25
mg/kg P.O Q6hrs
Topical agents or fluconazole 150 mg single
dose for uncomplicated vaginitis
Fluconazole 400 mg (6 mg/kg) daily I.V. or PO
Anidulafungin I.V. 200-mg loading dose, then
I.V. 100 mg/day
caspofungin, 70-mg loading dose, then 50
mg/day (35mg for moderate hepatic
insufficiency)
Lipid base Ampho B I.V 3–5 mg/kg daily
AmphoB I.V. 0.5–0.7 mg/kg daily
after patient is stable change to fluconazole
Fluconazole 400 mg (6 mg/kg) daily I.V. or
Orally for 6–12 months
Lipid base Ampho B I.V 3–5 mg/kg daily for
several weeks, then fluconazole for 6–12
months
Fluconazole 400 mg (6 mg/kg) daily I.V. or
Orally for at least 6 weeks
Lipid base Ampho B I.V 3–5 mg/kg daily for
several weeks, then fluconazole to completion
Lipid base Ampho B I.V 3–5 mg/kg ± 5- FC 25
mg/kg P.O Q 6hrs for several weeks, followed
by fluconazole 400–800 mg (6–12 mg/kg) daily
I.V. or P.O
Fluconazole 400–800 mg (6–12 mg/ kg) daily
for patients unable to tolerate Lipid base
Ampho B
Ampho B I.V 0.7–1 mg/kg with 5-FC 25 mg/
kg orally Q6hrs
Fluconazole 6–12 mg/kg daily
Duration of therapy : 4-6 weeks or longer,
based on resolution determined by repeated
examinations.
Lipid base Ampho B 3–5 mg/kg ± 5-FC 25
mg/kg P.O Q6hrs
AmphoB I.V 0.6–1 mg/kg daily ± 5-FC 25
mg/kg P.O Q6hrs
Anidulafungin, I.V 200-mg loading dose, then
I.V 100 mg/day
caspofungin, I.V 70-mg loading dose, then I.V
50 mg/day(35mg for moderate hepatic
insufficiency)
Lipid base Ampho B I.V 3–5 mg/kg daily
Fluconazole 400–800 mg (6–12 mg/kg) daily
I.V or P.O
Anidulafungin, I.V 200-mg loading dose, then
I.V 100 mg/day
Caspofungin, I.V 70-mg loading dose, then I.V
50 mg/day (35mg for moderate hepatic
insufficiency)
LFAmB 3–5 mg/kg daily
Fluconazole 400–800 mg (6–12 mg/kg) daily
An
echinocandi
n for several
weeks
followed by
fluconazole
surgical
intervention
for patients
with severe
endophthalm
itis or
vitreitis
Step-down
therapy to
fluconazole
400–800 mg
(6–12
mg/kg) daily
for
susceptible
organism in
stable patient
with
negative
blood culture
results
After stable,
step-down
therapy to
fluconazole
400–800 mg
(6–12
mg/kg)
daily
thrombophlebitis
3
4
Infected
pacemaker, ICD,
or VAD
1
2
3
4
Candida isolated from
respiratory secretions
Nongenital
mucocutaneous
candidiasis
Therapy not recommended
Oropharyngeal
1
2
3
Clotrimazole troches 10 mg 5 times Daily
Nystatin suspension pastilles Q6hrs
Fluconazole 100–200 mg daily
Esophageal
1
2
Fluconazole 200–400 mg (3–6 mg/kg) daily
Anidulafungin, I.V 200-mg loading dose, then
I.V 100 mg/day
Caspofungin, I.V 70-mg loading dose, then I.V
50 mg/day
LFAmB 3–5 mg/kg ± 5- FC 25 mg/kg q6h
AmphoB I.V 0.3–0.7 mg/kg daily
Voriconazole 6 mg/kg IV q12h x 1d then 4
mg/kg IV q12h or 200-300 mg PO bid
Caspofungin, I.V 70-mg loading dose, then I.V
50 mg/day
LFAmB 3–5 mg/kg ± 5- FC 25 mg/kg q6h
Amphotericin B 1-1.5 mg/kg/d IV
LFAmB 3–5 mg/kg ± 5- FC 25 mg/kg q6h
Posaconazole 200 mg PO q6-8hr
Amphotericin B 1-1.5 mg/kg/d IV x 6-10 wks
3
Aspergillosis
4
5
1
2
Mucormycosis
Anidulafungin, 200-mg loading dose, then 100
mg/day
Caspofungin, 70-mg loading dose, then 50
mg/day;
LFAmB 3–5 mg/kg ± 5- FC 25 mg/kg q6h
AmB-d 0.6–1 mg/kg daily ± 5-FC 25 mg/kg
q6h
Anidulafungin, 200-mg loading dose, then 100
mg/day
Caspofungin, 70-mg loading dose, then 50
mg/day;
3
4
1
2
3
Duration
≥10 weeks
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Date: ___/___/____ Time:________ am/Pm
pager:_____________
Uptodate 2010
Peter G. Pappas, Carol A. Kauffman. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America.
Clinical Infectious Diseases 2009; 48:503–35
_________Hospital
Pharmaceutical Care Department
___________Region
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
(Antibiotics Program)
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
ANTIBIOTIC SURGICAL PROPHYLAXIS FOLLOW-UP SHEET
Pre-Operative Antibiotics for Surgical Prophylaxis
No antibiotics given at the wards ( it should be given at inta-operative room)
Date:
Time of Antibiotic Administration:
Time of Incision:
Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.
Review patient allergies prior to prescribing/administering medications.
Select appropriate antibiotic as determined by procedure and initiate 30-60 minutes prior to incision.
Vancomycin, Ciprofloxacin and Metronidazole should be initiated within 60-120 minutes prior to incision.
Prophylactic Antibiotic Within Timeframe
Yes
No
Ordered


Given




Not ordered or given for the following reason:
• Medical (eg, not indicated, contraindicated, other medical reason)
Document reason here and in medical chart.
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Type of Surgery:
 Clean
 Clean Contaminated
 Contaminated
 Dirty
Procedure
Drug of Choice
*Alternative choice
Colorectal
 Cefazolin or Cephradine 2 gm (40mg/kg if
child) IV + Metronidazole (7.5mg/kg if child) IV
x dose
 Oral Neomycin 1 gm (20mg/kg if child) and
Erythromycin base 1 gm (10mg/kg if child)
19, 18, and 9 hours before surgery
Cardiac
 Cefazolin or Cephradine 2 gm (40mg/kg if
child) IV one dose before and q 8 hr for up to 24
hr after surgery ( for obese pateint 3g)
 Cephalosporins allergic or MRSA colonized:
Vancomycin 1 gm (15 mg/kg if child) IV
 Cephalosporins allergic:
Thoracic (None Cardiac)
 Cefazolin or Cephradine 2 gm (40mg/kg if
child) IV for one dose ( for obese pateint 3g)
Vancomycin 1 gm (15 mg/kg if child) IV for 1
dose
 Cefazolin or Cephradine 2 gm IV for one dose
Obstetric / Gynecologic
( for obese pateint 3g)
Head / Neck
 Clean cut procedures: none incision through
oral or pharygeal mucosa:
Clindamycin 600mg (10mg/kg if child)
 Clindamycin 600mg IV + Gentamycin
1.5mg/kg
(Max. 120mg) IV for one dose
 - Cefazolin or Cephradine 2 gm (40mg/kg if
child) one dose before and q 8 hr for 24 hr
 Cephalosporin allergic or MRSA colonized:
Neurosurgery
 Cefazolin or Cephradine 2 gm (40mg/kg if
child) IV for one dose ( for obese pateint 3g)
Vancomycin 1 gm (15mg/kg if child) IV for 1
dose
Orthopedic
Vascular
Other Surgery
 Cefazolin or Cephradine 2 gm (40mg/kg if child)
IV for one dose ( for obese pateint 3g)
 Cefazolin or Cephradine 2 gm (40mg/kg if
child) IV for one dose ( for obese pateint 3g)

 Cephalosporins allergic or MRSA colonized:
Vancomycin 1 gm (15 mg/kg if child) IV
 Cephalosporins allergic or MRSA colonized:
Vancomycin 1 gm (15 mg/kg if child) IV

For procedures lasting greater than 4 hours, or greater than 1000mL blood loss, repeat pre-op dose of Cefazolin OR Clindamycin every 4
hours intraoperatively.
Duration of Surgury:_____________ Hours.
Repeat Dosing of Antibiotic: Drug Name: _________________ Dose: _________ Interval: _______________
NOTE:
If post-op prophylaxis antibiotic given, duration:  less than 24 hours  24 hours  more than 24 hours
Physician / Nurse Signature:
Clinical Pharmacist Comment:
Appendix A: Guidelines for Blood Culture Collection
INDICATIONS
Routine blood cultures should be performed on any patient in whom there is a suspicion of bacteremia or candidemia.
II. TIMING
Blood cultures should be drawn prior to the institution of antibiotics whenever possible. If empiric treatment is an
emergency, blood cultures should still be drawn as soon as possible after institution of antibiotics. There are no data to
suggest that the timing of culture in relation to the appearance of fever or chills will maximize the yield.
III. VOLUME OF BLOOD PER SET
There is a direct relationship between the volume of blood obtained and the yield of a blood culture set. Forty to 60 ml of
blood should be obtained per episode (in other words, 2-3 sets with 20 ml per set, and 10 ml per bottle) According to the
age.
IV. NUMBER OF SETS OF BLOOD CULTURES
Single sets should not be used to evaluate any patient with suspected bacteremia or candidemia. The optimal yield is
obtained with two or three sets of blood cultures. No more than three blood cultures should be obtained for any given 24
hour period.
V. SITE OF BLOOD CULTURE
Blood should be obtained from peripheral venous or arterial sites. Obtaining blood cultures from central venous catheters,
arterial lines and inguinal vessels increases the likelihood of obtaining a false positive blood culture.
For suspected catheter-related bloodstream infection (CR-BSI) draw one set through device and one set from a separate
venipuncture..
VI. LABELING
Labeling the site of each set of blood cultures, particularly regarding whether a set was drawn from a catheter, the groin,
or not, is of ulmost importance in helping to distinguish pathogens from contaminants in those cases in which no
peripheral access can be found.
VII. PREPARATION OF THE SITE FOR CULTURE
The use of a 2% chlorhexidine-based preparation for cutaneous antisepsis is classified as a Category 1A recommendation
If not available then alcohol can be used
After the vessel site is selected, a 5 cm area of skin should be disinfected by swabbing concentrically with 70% alcohol,
from the venipuncture site outward. vigorous friction back and forth
2. The site should be cleansed once again, this time with 10% povidone-iodine or 2% tincture of iodine again in a circular
motion.
3. Allow the iodine to dry completely before performing venipuncture. This should take 1 - 2 minutes.
4. While waiting for the site to dry, the plastic cap covering each blood culture bottle should be removed, and the rubber
stopper should be decontaminated with 70% alcohol. (Iodine solutions will disintegrate the rubber and should not be
used.)
5. 20 ml of blood should be withdrawn from the puncture site.
6. Do not change needles between venipuncture and inoculation of the bottles, or between bottles. The risk of needlestick
is increased, while the chance of contamination is not significantly lessened.
7. Remove the iodine solution from the skin with alcohol. This will minimize the possibility of hypersensitivity.
Appendix B: Guidelines for Infection Control
ISOLATION SYSTEMS
I. STANDARD PRECAUTIONS (formerly known as Universal Precautions)
Standard Precautions are designed to reduce the risk of transmission of microorganisms from recognized and
unrecognized sources of infection.
Use Standard Precautions for care of ALL patients, regardless of their diagnosis.
1Standard Precautions applies to:
Blood
All body fluids, secretions, and excretions except sweat regardless of whether they contain visible blood
Non-intact skin
Mucous membranes
Gloves will be worn whenever contact with these fluids is anticipated. Gloves will be changed between patients, between
tasks, or when torn.
Hand washing between patients and after contact with blood/body fluids is essential.
Wash hands after removing gloves.
If aerosolization or splattering of blood/body fluids is likely, additional barriers must be worn (gowns, splash shields,
goggles, masks).
II. AIRBORNE PRECAUTIONS
To reduce the risk of airborne transmission of infectious agents. Use Airborne Precautions for patients known or
suspected to have infections transmitted by tiny droplet nuclei (particles 5 microns or smaller in size). 2Illnesses include:
Tuberculosis , Measles and Varicella (chickenpox), including disseminated Zoster
Patients must be placed in a room with negative air pressure ventilation to prevent transmission of droplet nuclei. Without
negative pressure ventilation, infectious droplet nuclei can remain suspended in air for long periods of time.
Doors and windows in negative pressure isolation rooms must be kept closed at all times.
Hospital personnel and visitors entering an Airborne isolation room must wear the N95 TB respirator.
For patients isolated with chickenpox or measles - persons immune to chickenpox/measles may enter an Airborne
isolation room without a mask.
Patients in Airborne isolation must remain in their room. Patients should leave their room only for essential studies.
Patients must wear a paper surgical mask when leaving their room.
III. DROPLET PRECAUTIONS
To reduce the risk of droplet transmission of infectious agents. Involves contact of the conjunctivae, or mucous
membranes of the nose or mouth of a susceptible person with large droplets (greater than 5 microns in size) containing
microorganisms from a person who has clinical disease or is a carrier of the microorganism.
1Illnesses include:
Diphtheria
Influenza
Rubella
Pertussis
Mumps
Invasive N. meningitidis disease
Invasive H. influenzae disease, etc..
Droplets are generated during sneezing, coughing, talking, and during certain procedures such as suctioning or
bronchoscopy.
Close contact (usually 3 feet or less= 1 meter) to the infectious person is required for transmission of the disease. Large
droplets travel only short distances and do not remain suspended in the air.
Hospital personnel and visitors entering a Droplet isolation room must wear a paper surgical mask.
IV. CONTACT PRECAUTIONS
To reduce the transmission of epidemiologically important infectious agents spread by direct or indirect contact.
Direct Contact - skin to skin contact, the physical transfer of microorganisms.
Indirect Contact - contact with a contaminated intermediate object from the patient's environment.
2Contact precautions apply to patients who are actively infected or colonized with epidemiologically important
organisms, including :
Multi-Drug Resistant Bacteria (MRSA, VRE, etc.)
Enteric infections with a low infective dose or prolonged survival in the environment (C. difficile, etc.). Skin infections
that are highly contagious (scabies, major abscesses, impetigo, Herpes Simplex, active Zoster, etc.)
Hospital personnel and visitors entering a contact isolation room must wear gloves and gowns.
Disinfection of non-disposable, reusable patient equipment must be performed before leaving the contact isolation room
and before reuse with another patient. When possible, dedicate equipment to the contact isolation room.
HAND HYGIENE:
Hand washing is the single most important step you can perform to reduce the transmission of infectious agents from
person to person or from one site to another.
Wearing gloves does not replace the need to wash your hands!!!
Culturing observation check list
CARE ELEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
Prepare the materials needed (i.e., specimen bottles, syringes, skin prep
products, etc.)
Hands washed with soap and water or alcohol gel applied prior to set up for the
procedure.
Visibly soiled skin cleaned with soap and water (patient)
Disinfect blood culture specimen tops with 2% chlorhexidine or 70% alcohol
wipe.
Hands washed with soap and water or alcohol gel was applied prior to
procedure.
Standard precautions followed (i.e., gloves worn)
Patient’s skin disinfected with 2% Chlorhexidine solution for 30 seconds and
then allowed to dry for another 30 seconds OR disinfected with 70% alcohol
and/or 10% povidone-iodine or 2% tincture of iodine. Allow to dry completely
before performing venipuncture (1-2 minutes)
Disposable tourniquet used.
Venipuncture site not touched again following disinfection of the skin.
Venipuncture site:.............................................
Blood culture bottles inoculated before tubes for haematology/chemistry.
Discard first 10 mL in separate syringe if venipuncture site other than forearm or
via new cannula
Inoculate anaerobic bottle first. (Aerobic if using winged method-see over)
Sharps disposed in sharp container/bin.
Hands washed following the procedure
Sample taken by:
Name: ……………………………………… job title: …………………………………
Signature: ……………………………
Observed by:
Name: ……………………………………… job title: …………………………………
Signature: ……………………………
YES
NO
Appendix C: Skin Test and anaphylactic
Skin test only performed for patient with history of penicillin allergy
Skin test and anaphylactic kits bag
Skin test kits:
1ml
syringe
(3)
3ml
syringe
(3)
5ml
syringe
(3)
Gloves (2)
prick
lancetter
bifurcated
vaccination
needle
Histamine Base: 6mg/mL
(1ml)
(+) control
Scarifier
26 -27
gauge
needle
(Histamine
Dihydrochloride:
10mg/mL (1ml)
(+) control
Filter
needle
Alcohol
swab
Normal Saline for
injection 5ml (-)
control
Anaphylactic shock kits:
1ml
syringe
(3)
3ml
syringe
(3)
5ml
syringe
(3)
Epinephrine 1mg/ml (1:1000)
injection (3)
Gloves (3)
18 gauge 5/8
needle (3)
Normal saline
500ml (2)
Albuterol (Salbutamol)
5mg/2.5 ml Nebulizer
solution (1)
Diphenydramin
50mglml injection
(1)
Ranitidine
50mg/2ml injection
(1)
Methylprednisolone Na Glucoagon 1mg (1
Succinate 500mg
unit ) syringe (2)
injection (1)
Attached: skin test procedure and anaphylactic shock treatment protocol (adult, paediatric)
ANTIBIOTIC SKIN TEST
Patient name:
age:
sex:
ward:
file no.:
Patient medical history:
Pre-procedure precautions include:
If possible to stop, OR to do it before starting the medications that interfere with skin test, (wheal/flare suppression)
for 3-5 days:
H1 antihistamines, Antihistamine nasal sprays, H2 receptor antagonists, topical glucocorticoids for longer than one week,
omalizumab, Tricyclic antidepressants and Higher doses of methotrexate
Medication (emergency kit) and resuscitation equipment must be readily available as per Anaphylaxis Protocol.
procedure:
Prick/puncture. A diluted allergen is applied with a prick or a puncture on the surface of the skin. (With
positive (histamine) and negative control( normal saline) )
Results of Prick Test Dose:
Erythema and Weal Response 5x5mm (>25mm) positive, no further testing indicated.
o Erythema and Weal Response <5x5mm (25mm) proceed to intradermal test dose
Intradermal test dose: Using a 26-27-guage (very thin) needle, a diluted allergen is injected immediately below the
skin surface.
Results of Intradermal (ID) Test Dose:
o Erythema and Weal at Injection Site 5x5mm (>25mm) positive allergy to antibiotic tested.
o Erythema and Weal at Injection Site >3x3mm (>9mm) but <5x5mm
o (<25mm) borderline positive
o If intradermal skin test negative oral challenge indicated
Skin test reagent
Route
Drug test conc.
Skin test volume
Penicillin G
prick/puncture
Intradermal
prick/puncture
Intradermal
prick/puncture
Intradermal
(10,000 units/mL)
(10,000 units/mL)
(10 mg/mL)
(0.001 mg/mL)
0.9 % NACL
0.9 % NACL
droplets
0.02 - 0.05 mL
droplets
0.02 - 0.05 mL
droplets
0.02 - 0.05 mL
histamine dichloride
Normal saline
Note:----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Physician name:
signature:
http://www.uptodate.com/contents/overview-of-skin-testing-for-allergic-disease?source=see_link&anchor=H27#H27
http://www.acaai.org/allergist/allergies/Treatment/diagnosing-allergies/Pages/allergy-skin-tests.aspx
Roland solensky, and david a. khan. drug allergy: an updated practice parameter. annals of allergy, asthma & immunology, volume 105, october, 2010: 273.e1-e78
Anaphylaxis Algorithm
Anaphylactic reaction
Airway, Breathing, Circulation, Disability, Exposure
Diagnosis:
 Acute onset of illness
 Life threatening Airway and/or Breathing and/or circulation problem
 Usual skin changes



Call for help
Lie patient flat
Rise patient legs
Adrenaline
When skills and equipment available:
Establish airway
monitor:
High flow oxygen
Pulses oximetry
IV fluid challenge
ECG
Chlorophenamine
Blood Pressure
Hydrocortisone
Life threatening problem:
Airway: swelling, hoarseness, stridor
Breathing: rapid breathing, wheezing, fatigue, cyanosis, SpO2 < 92%, Confusion
Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma
Adrenaline (give IM unless experienced with IV adrenaline)
IM doses of 1:1000 adrenaline (repeat after 5 min if no
better)
Adult: 500 micrograms IM (0.5 ML)
Adrenalin IV to be given only by experienced specialists
Titrate: adult 50 micrograms
IV fluid challenge:
Adult: 500-1000 ml
Stop IV colloid if this might be the
cause of anaphylaxis
Chlorphenamine (IM or slow IV):10MG
Hydrocortisone (IM or slow IV): 200MG
Emergency treatment of anaphylactic reactions Guidelines for healthcare providers, Resuscitation Council (UK)January 2008
Appendix D: antibiotics dosing monitoring
Vancomycin:
Vancomycin is a tricyclic glycopeptide that inhibits bacterial cell wall synthesis.
It is considered to be bactericidal against most Gram-positive organisms, except Enterococcus
species.
Vancomycin has bot time-dependent killing and moderate persistent effects that is dependent
on concentration (i.e., peak).
Persistent effects include the Post-Antibiotic Effect (PAE), which is the persistent suppression
of bacterial growth following antibiotic exposure.
The ideal dosing regimen is to maximize the amount of drug received. Thus, the appropriate
pharmacodynamics parameter that correlates with efficacy is the 24H- Area Under the Curve
(AUC)/MIC ratio.
Dosing weight: actual body weight unless morbidly obese (use adjusted body weight instead)
Loading dose (if appropriate): 25-30 mg/kg (one-time dose)
Use: seriously ill patients (e.g., requiring intensive care) and patients with complicated
infections (e.g., bacteremia or pneumonia).
Initial or maintenance dose4: 15-20 mg/kg
Dosing interval: Determine creatinine clearance (based on Cockroft-Gault equation)
Vancomycin Monitoring:
Peak serum concentration is not necessary because it does not correlate well with vancomycin
toxicity (e.g., nephrotoxicity or ototoxicity).
Only the trough concentration monitoring is needed in order to assess efficacy.
For patients with normal renal function, it takes approximately 4 doses for vancomycin to
reach steady state. As such, trough concentrations should be drawn before the 4th dose.
Trough concentrations may be drawn earlier in critically ill patients, patients with unstable
renal function, and patients on vancomycin dosing interval ≥ 24 hours.
However, these trough concentrations must be interpreted with caution since additional doses
will continue to accumulate until steady state is reached.
Trough concentrations should be drawn right before the next dose (within 2 hours prior to
administration).
Vancomycin is being dosed by level (patients with creatinine clearance < 25 mL/min,
hemodialysis, or CRRT), it should be re-dosed if the level is < 20 mg/L.
The target trough concentration is dependent on the type of infection as reported
Aminoglycosides
Aminoglycosides fight against bacteria by interfering with bacterial protein synthesis, which is
achieved through irreversible binding to 30S ribosomal subunit.
Aminoglycosides have bactericidal activity against aerobic Gram-negative infections and
demonstrates concentration-dependent killing with a prolonged PAE (~4-6 hours).
The best pharmacodynamics parameter to determine the ideal dosing regimen is peak/MIC
ratio
Dosing weight: ideal body weight (IBW) unless 20% over IBW (use adjusted body weight
instead)
Initial dosing: dependent on traditional versus extended interval dosing
Extended interval dosing in all patients* except patients with altered pharmacokinetics using
Traditional dosing:
Burns > 20%
Morbidly obese
Pregnancy
Ascites or significant third spacing
Hemodynamic instability
Unstable renal function and cystic fibrosis
*Rationale: maximize concentration-dependent killing and minimize toxicity (i.e., nephrotoxicity and ototoxicity), ease of
administration and monitoring, reductions in administration and monitoring-related costs.
Aminoglycoside Monitoring:
Traditional Dosing:
Obtain serum peak and trough concentrations after 3rd dose following initiation of
therapy and any dosing adjustments in therapy.
Draw trough concentration just prior to next dose.
Draw peak concentration 30-45 minutes after the end of an intravenous infusion.
Once achieved, monitor periodically (e.g., 2-3 times weekly) throughout therapy
with changes in renal function.
If stable renal function, monitor at least once weekly.
Extended Interval Dosing:
Random serum concentration monitoring approximately 6-12 hours after 1st dose.
Interpret by using an established nomogram or based on MIC data. For amikacin
therapy, divide serum concentration by 2 before using nomogram.
Monitor periodically if unstable renal function or prolonged therapy (> 7-10 days).
Appendix E: Switching IV antimicrobial to oral
The ideal route of administration of any medication is the one that achieves serum
concentrations sufficient to produce the desired effect without producing any untoward
effects.
World Health Organization (WHO) reports that the irrational use of medicines is a major
problem worldwide. The overuse of injections, when oral formulations would be more
appropriate, is one of the key factors for the irrational use of medicines. Hence IV to oral
switch over within an appropriate time is one of the major aspects to improve the rational use
of injections. Moreover, once the culture and sensitivity reports are available, IV to oral switch
over enables one to select a cheaper or older antibiotic, which is as effective as the IV
antibiotic.
Advantages of oral over IV route
Early switch over from IV to oral therapy has the following major advantages:
Reduced risk of cannula‑related infections: For the administration of IV
medications, one is required to insert a cannula, which remains in place for some
days and eventually can result in secondary infections caused by bacteria and fungi.
This may ultimately lead to the need for additional antibiotics and subsequently
financial burden to the patient
Risk of thrombophlebitis: No risk of thrombophlebitis in case of oral administration
Less expensive than IV therapy: Most of the oral medications available at the market
are less expensive as the parenteral medications must be sterile and isotonic,
consequently leading to cost savings by the patient
Reduction in the hidden costs: Hidden costs mainly refer to cost of diluents,
equipment for administration, needles, syringes, and nursing time. Needles, syringes,
diluents, and other equipment are the unavoidable requisites for the parenteral
administration.
Earlier discharge: Injections are usually administered in a hospital setting as it
requires an experienced professional to administer the medication, especially IV
infusions. Hence the patient stay at the hospital is prolonged. Early switch over to
oral medications can help to overcome this barrier and may result in early discharge
of the patient
Practical approaches for conversion of a patient from IV to oral therapy
First, a clinical pharmacist should identify patients who receive IV medications and also
recognize the need for IV medication in those patients and check for the indication
Second, regular follow up is needed to check whether the patient’s clinical status (WBC [white
blood cells], vitals, culture report, patient’s physical and mental condition, etc.) is improving or
not. If the patient is eligible for conversion , check whether the conversion was done
Inform the physician about the patients who are eligible for conversion but not converted
within the appropriate time
Make suitable recommendations for the selection of an oral medication for conversion
Review the feedback of the physicians
Monitor the patient’s clinical progress after the switch over and convert the
patient back to parenteral medication, if required
It is always advisable to verify the knowledge and beliefs of physicians regarding
the guideline for switch over from IV to oral therapy. A data collection tool like
questionnaires can be used for the same
Patient selection criteria for IV to oral switch over therapy
Inclusion criteria
Exclusion criteria
-Patient is able to eat their regular or modified diet or
receiving enteral nutrition by oral, gastric or other
appropriate enteral route Patient receives other
scheduled oral medications
-Patients with unreliable response to oral medications
(severe nausea or vomiting)
-For patients who receive antibiotics, signs and
symptoms of infection resolved or improving (WBC
decreasing toward normal range, improving chest X-ray
findings, temperature less than 100°F for at least 24-48
hours and respiratory rate<20 breaths/min.)
-Patient has functional gastrointestinal tract (tolerating
at least 1 liter/day of oral fluids or 40 ml/hour of
enteral nutrition)
-An appropriate oral dosage form of prescribed drug is
available Absorption and bioavailability of oral
counterpart is almost comparable to that of parenteral
form
-Unable to swallow or unconscious Strict (nothing per
oral) for a procedure
-GI obstruction, malabsorption, active GI bleeding,
paralytic ileus or severe diarrhea
-Unresponsive to previous oral therapy Patients with
grade 3 or 4 mucocytosis
-Patients whose disease state that does not support
oral therapy (meningitis, infective endocarditis,
infection of a prosthetic device, osteomyelitis, sepsis,
severe cellulitis, bronchiectasis, pneumonia with AIDS)
-Documented pseudomonal infection and/or on IV
antibiotic for <24 hours Candidemia treated less than
7 days
-Seizure and risk of aspiration Hypotension or shock
-Patient refuses oral medication as mentioned in
charts Immunocompromized patients (febrile
neutropenia, on cancer chemotherapy,
posttransplant, functional asplenia)
Bioavailability of medications included in IV to oral conversion
Drugs with excellent bioavailability (>90%) eligible for IV to oral switch over
Drugs
IV to PO conversion
IV dose
PO dose
Ciprofloxacin*
200 mg q12h (every 12 hours)
500 mg q12h
Doxycycline
100-200 mg q12h
100-200 mg q12h
Levofloxacin*
500 mg q24h
500 mg q24h
Linezolid
600 mg q12h
600 mg q12h
Metronidazole
500 mg q12h
500 mg q12h
Minocycline
200 mg q12h
200 mg q12h
Moxifloxacin*
400 mg q24h
400 mg q24h
Rifampicin
600 mg q24h
600 mg q24h
Voriconazole
200 mg q24h
200 mg q24h
*Absorption of flouroquinolones is reduced by concurrent administration of products containing divalent and trivalent cations such as calcium,
magnesium or aluminum, for example, antacids, multivitamin products containing minerals, iron, or zinc salts. Hence an interval of at least 4 hours
should elapse between their oral administration
Drugs with excellent bioavailability (60-90%) eligible for IV to oral switch over
Drugs
IV to PO conversion
IV dose
PO dose
Ampicillin
1gm q6h
250-500 mg q6h
Azithromycin
500 mg q24h
250-500 mg q24h
Cefazolin
1 gm q8h
Table t. cephalexin 500 mg q6h
Cefotaxime
1 gm q12h
Ceftazidime
1-2 g q8h
Tablet .ciprofloxacin 500-750 mg
q12h
Tablet .ciprofloxacin 500-750 mg q12h
Cefuroxime
500-750 gm q8h
Clindamycin
300-600 mg q8h
Tab. cefuroxime axetil 250-500 mg
q12h
300-450 mg q6h
Erythromycin
500-1000 mg q6h
500 mg q6h
References:
Kuper KM. Intravenous to oral therapy conversion. Text Book of CompetenceAssessmentToolsforHealth ‑SystemPharmacies,4th ed.ASHP 2008.p.347‑60.
Jissa Maria Cyriac, Emmanuel James. Switch over from intravenous to oral therapy: A concise overview, Journal of Pharmacology and Pharmacotherapeutics | April-June
2014 | Vol 5 | Issue 2
_________Hospital
Pharmaceutical Care Department
___________Region
     
FILE NO.
NAME:_________________________________________
AGE:
 
SEX:  M
 F
NATIONALITY:__________________________________
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
WEIGHT (ACTUAL/ESTIMATED)_________________KG
HIGHT:______________________________CM
ALLEGRY:___________________________________
DIAGNOSIS:__________________________________
WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
IV to PO Conversion Order Form/Worksheet
Criteria for Conversion to PO:
_ Tolerating other drugs by oral route
_ Being fed enterally (at minimum a clear liquid diet),
i.e. a functioning GIT
_ Patient does NOT have persistent N/V, ileus, gastric outlet obstruction, active GI bleed, loss of
consciousness, NPO orders that applies to all meds
_ Resolution of fever for 24 hours
_ CBC improving, preferably < 15K in absence of steroids
_ Patient does NOT have meningitis, endocarditis, septicemia, neutropenia, osteomyelitis, or MRSA
_ hemodynamically stable
Date/Time:
Pharmacy recommends:
D/C (
This change will take place on
) Start (
at
)
Appendix F: Antibiogram
Percentage of Isolates that are Susceptible
Gram Positive
Enterococcus spp.
Enterococcus faecalis
Enterococcus faecium
Staphylococcus aureus
Staphylococcus epidermidis
Staphylococcus coag. neg.
Streptococcus pneumoniae
Gram Negative
H. influenza
Klepsiella P.
E. Coli
Pseudomona A.
Acinetobacter
Proteuos
Serratia M
Enterobacter
Citrobacter
Klebsiella pneumoniae carbapenemas
(KPC)
Percentage of Isolates that are Susceptible
Augmentin
Meropenem
Tigecycline
Colistin
Moxifluxaci
Levofloxacin
Ciprofluxacin
Imipenem
Gentamycin
Amikacin
Pipracilli/Tazo
Cefepime
Ceftriaxone
Isolates
Cefuroxime
Antibiotic
Susceptibility
Ceftazidime
MRSA
Vancomycin
Trimeth/Sulfa
Tetracycline
Streptomycin
Rifampin
Levofloxacin
Linezolid
Gentamycin
Azithromycin
Clarithromycin
Erythromycin
Clindamycin
Cefazolin
Ceftriaxone
Cefuroxime
Isolates
Penicillin
Antibiotic
Susceptibility
Ampicillin
The period:
Ward: (outpatient, ICU, Medical, Surgical)
Percentage of Isolates that are Susceptible
Gram Positive
Enterococcus spp.
Enterococcus faecalis
Enterococcus faecium
Staphylococcus aureus
Staphylococcus epidermidis
Staphylococcus coag. neg.
Streptococcus pneumoniae
Gram Negative
H. influenza
Klepsiella P.
E. Coli
Pseudomona A.
Acinetobacter
Proteuos
Serratia M
Enterobacter
Citrobacter
Klebsiella pneumoniae carbapenemas
(KPC)
Percentage of Isolates that are Susceptible
Augmentin
Meropenem
Tigecycline
Colistin
Moxifluxaci
Levofloxacin
Ciprofluxacin
Imipenem
Gentamycin
Amikacin
Pipracilli/Tazo
Cefepime
Ceftriaxone
Isolates
Cefuroxime
Antibiotic
Susceptibility
Ceftazidime
MRSA
Vancomycin
Trimeth/Sulfa
Tetracycline
Streptomycin
Rifampin
Levofloxacin
Linezolid
Gentamycin
Azithromycin
Clarithromycin
Erythromycin
Clindamycin
Cefazolin
Ceftriaxone
Cefuroxime
Isolates
Penicillin
Antibiotic
Susceptibility
Ampicillin
The period:
ANTIBIOGRAM
The period
Ward: ICU
Percentage of Isolates that are Susceptible
Gram Positive
Enterococcus spp.
Enterococcus faecalis
Enterococcus faecium
Staphylococcus aureus
Staphylococcus epidermidis
Staphylococcus coag. neg.
Streptococcus pneumoniae
Gram Negative
H. influenza
Klepsiella P.
E. Coli
Pseudomona A.
Acinetobacter
Proteuos M.
Serratia M
Enterobacter
Citrobacter
Klebsiella pneumoniae carbapenemas
(KPC)
Percentage of Isolates that are Susceptible
Augmentin
Meropenem
Tigecycline
Colistin
Moxifluxaci
Levofloxacin
Ciprofluxacin
Imipenem
Gentamycin
Amikacin
Pipracilli/Tazo
Cefepime
Ceftriaxone
Isolates
Cefuroxime
Antibiotic
Susceptibility
Ceftazidime
MRSA
Vancomycin
Trimeth/Sulfa
Tetracycline
Streptomycin
Rifampin
Levofloxacin
Linezolid
Gentamycin
Azithromycin
Clarithromycin
Erythromycin
Clindamycin
Cefazolin
Ceftriaxone
Cefuroxime
Isolates
Penicillin
Antibiotic
Susceptibility
Ampicillin
System: Blood/Respiratory Tract/Urinary Tract/ Wound
Fluconazole
Voriconazole
Fluconazole
Anidulafungin
Isolates
No.
Caspofungin
Antifungal
Susceptibility
Amphotericin
B
Fungal infection
Percentage of Isolates that are Susceptible Susceptible
Candida
Candida albicans
Candida glabrata
Candida parapsilosis
Candida krusei
Cryptococcus
Asperglosis
Other
Urine
Orophar
yngyal
Isolates
No.
Blood
Antifungal
Susceptibility
Resp.
Secretion
Ward: ICU
Percentage of Isolates that are Susceptible
Candida
Candida albicans
Candida glabrata
Candida parapsilosis
Candida krusei
Cryptococcus
Asperglosis
Sensitivity Line chart example
Acinetobacter P.
Pseudomonas A.
MRSA
100
90
80
70
60
50
40
30
20
10
0
Jan.
Feb.
March
April
May
June
July
August
Sept.
Oct.
Nov.
Dec.
Acinetobacter P.
Pseudomonas A.
MRSA
100
90
80
70
60
50
40
30
20
10
0
Jan.
Feb.
March
April
May
June
July
August
Sept.
Oct.
Nov.
Dec.
Appendix I:
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Physician Order Form
(Please fill all applicable information and stick it on
patient profile, and forward the copy to the Pharmacy
Department within 24 hrs)
ANTIBIOTIC RESTRICTED AND CONTROLED ORDER FORM
 Male  Female
Patient’s Name
Patient’s No
Age
Wt:
Ht:
Gender
Write down and Read Back for all Verbal Orders
ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY
Antibiotics Order Form
Date:
Time of Antibiotic order :
Time of Administration:
Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.
Review patient allergies prior to prescribing/administering medications.
Select appropriate antibiotic as determined by Antibiotic Guidelines, after requesting gram stain and C/S for
speciment(s)
Document reason here and in medical chart.
___________________________________________________________________________________________________________________________________
 Diagnosis _______________________________________________________________________________________________________
Site of Infection � Blood
� CNS
� Skin/Soft Tissue
� Heart
� Respiratory Tract
� Intra-abdominal/GI
� Bone/Joint � Other______________
Type of Infection  Community associated
 C/S
� Urinary Tract
 Health care associated (HCA)
 Organism 1 _______________________ Organism 2 ________________________ Organism 3 _____________________
Sensitivity: Resistant to_______________________________________________________________________________________________________
Type of Therapy:


 Empircal
 Specific
Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this


form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.
Drug
Controlled Antibiotics
Restricted Antibiotics
Procedure:
 Ceftazidime
 Ciprofloxacin Oral
 Amikacin
 Fluconazol Oral
 Fluconazol IV
 Ciprofloxacin IV
 Cefepime
 Piperacillin/Tazobactam  Meropenem
 Moxifloxacin Oral
 Vancomycin PO
 Imipenem
 Linzolid IV
 Colistin (fill special form)  Caspofungin
 Voriconazole IV
 Ethionamide.
 Linezolid Oral
 Cyclovir
Kanamycin
 Voriconazole PO
Para amino acid.
 Tigecycline (fill special form)
.
Antibiotic_______________ _____dose______________ route________ frequency_____duration_____________
□ New Order
□ Renew Order
Physician Signature:
Clinical Pharmacist Follow up and Comment:
TIGECYCLINE ORDER FORM
 Male  Female
Patient’s Name
Patient’s No
Age
Wt:
Ht:
Gender
Write down and Read Back for all Verbal Orders
ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY
Antibiotics Order Form
Date:
Time of Antibiotic order :
Time of Administration:
Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.
Review patient allergies prior to prescribing/administering medications.
Select appropriate antibiotic as determined Antibiotic Guidelines, after collecting specimen for Gram stain and C/S
Document reason here and in medical chart.
___________________________________________________________________________________________________________________________________
 Diagnosis _______________________________________________________________________________________________________
Site of Infection � Blood
� CNS
� Skin/Soft Tissue
� Heart
� Respiratory Tract
� Intra-abdominal/GI
� Bone/Joint � Other______________
Type of Infection  Community Associated
 C/S
� Urinary Tract
 Health care Associated
 Organism 1 _______________________ Organism 2 ________________________ Organism 3 _____________________
Sensitivity: Resistant to_______________________________________________________________________________________________________
Type of Therapy:




 Empircal
 Specific
Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this
form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.
Indication
Tigecycline
 Complicated Skin and Skin Structure Infections and the
micoorganism is sensitive only to Tigecycline

Complicated Intra-abdominal Infections and the

Treatment of infection due to sensitive strain of certain
gram-negative bacilli which are resistant to other
micoorganism isonly sensitive to Tigecycline
Commenst:
antibacterials including Colistin or in patients allergic to all
other antibacterial agents.

Antibiotic_______________ _____dose______________ route________ frequency_____duration_____________
□ New Order
□ Renew Order
Physician Signature:
Clinical Pharmacist Follow up and Comment:
COLISTIN ORDER FORM
 Male  Female
Patient’s Name
Patient’s No
Age
Wt:
Ht:
Gender
Write down and Read Back for all Verbal Orders
ANOTHER MEDICATION SIMILAR IN FORM AND ACTION MAY BE DISPENSED PER MEDICAL STAFF POLICY
Antibiotics Order Form
Date:
Time of Antibiotic order :
Time of Administration:
Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.
Review patient allergies prior to prescribing/administering medications.
Select appropriate antibiotic as determined Antibiotic Guidelines, after collecting specimen for Gram stain and C/S
Document reason here and in medical chart.
___________________________________________________________________________________________________________________________________
 Diagnosis _______________________________________________________________________________________________________
Site of Infection � Blood
� CNS
� Skin/Soft Tissue
� Heart
� Respiratory Tract
� Intra-abdominal/GI
� Bone/Joint � Other______________
Type of Infection  Community Associated
 C/S
� Urinary Tract
 Hospital care Associated
 Organism 1 _______________________ Organism 2 ________________________ Organism 3 _____________________
Sensitivity: Resistant to_______________________________________________________________________________________________________
Type of Therapy:




 Emperical
 Specific
Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this
form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.
Indication
Treatment of infections due to sensitive strains of certain
gram-negative bacilli which are resistant to other antibacterials
or in patients’ allergic to all other antibacterials.

Colistin
Comments:


Antibiotic_______________ _____dose______________ route________ frequency__________duration_____________
□ New Order
□ Renew Order
Physician Signature:
Clinical Pharmacist Follow up and Comment:
Appendix G: Antibiotics Consumption
Hospital: …………………………………………….. from : /
/
to:
Anti-infectious drugs
/
Inpatient
Forms
Adult
Cloxacillin sodium IV 250mg
/
Vial or amp.
Flucloxacillin sodium IV 250mg
Vial or amp.
Piperacillin + Tazobactam IV 2.25 g
Vial
Piperacillin + Tazobactam IV 4.5 g
Vial
Ceftazidime IV 1g
Vial
Ceftriaxone IV 1g
Vial
Cefepime IV 1g
Vial
Cefepime IV 2g
Vial
Imipenem + Cilastatin IV
500mg+500mg
Meropenem IV 500mg
Vial
Meropenem IV 1g
Vial
Tigecycline IV 50mg
Vial
Amikacin IV 100mg
Vial or amp.
Amikacin IV 500mg
Vial or amp.
Vial
Gentamicin IV 20mg
Vial or amp.
Gentamicin IV 80mg
Vial or amp.
Azithromycin PO 250mg
Tablet
Azithromycin PO 200mg/15ml
Suspension
Clindamycin IV 300mg
Ampoule
Vancomycin IV 500mg
Vial
Linezolid PO 600mg
Tablet
Linezolid IV 600mg
Linezolid PO 100mg
Premixed
bag
Suspension
Rifabutine PO 150mg
Tablet
Ciprofloxacin IV 200mg
Bottle
Moxifloxacin IV 400mg
Vial
Moxifloxacin PO 400mg
Tablet
Levofloxacin IV 500mg
Premixed
bag
ICU
Ped.
Neo.
Wards
Adult Ped.
Outpatient
Neo.
Adult
Ped.
ER
Neo.
Adult
Ped.
Neo.
Total
Hospital: …………………………………………….. from : /
/
to:
Anti-infectious drugs
Adult
Amphotericin B liposomal 50mg
Vial
Amphotericin B 50mg
Vial
Voriconazole IV 200mg
Vial
Voriconazole PO 200mg
Tablet
Caspofungin IV 50mg
Vial
Micafungin IV 50 mg
Vial
Acyclovir IV 250mg
Vial
Valaciclovir PO 500mg
Tablet
Artemisinin PO 250mg
Capsule
Artesunate PO 50mg
Tablet
Artesunate IV 60mg
Ampoule
Proguanil PO 100mg
Tablet
Artemether +Lumefantrine PO
20/120mg
Artmether IV 20mg
Tablet
Neo: Neonate
/
Inpatient
Forms
Ped. : Pediatric
/
Ampoule
ICU
Ped.
Neo.
Wards
Adult Ped.
Outpatient
Neo.
Adult
Ped.
ER
Neo.
Adult
Ped.
Neo.
Total
Abbreviation
IV: intravenous
IM: intramuscular
SC, SQ: subcutaneous
PO: oral
Min: minute
hr: hour
d: day
mo: month
q24hr: every 24 hours
q12hr: every 12 hours
q8hr: every 8 hours
q6hr: every 6 hours
q4hr: every 4 hours
mcg: microgram
mg: milligram
kg: kilogram
Dose adjustment for renal impairment
Appendix G:
Aciclovir
renal impairment:
GFR 25-50ml/min: Administer recommended dose
every 12 hours IV
HD
CVVH
IV: 2.5-5 mg/kg every 24
hours
5-10 mg/kg every 24 hours
5-7.5 mg/kg every 48-72
hours. Follow levels. Redose
when pre-HD concentration
<10 mg/L; redose when postHD concentration <6-8 mg/L
IV: 1-2 g every 12-24 hours
Loading dose of 10 mg/kg
followed by maintenance dose
of 7.5 mg/kg every 24-48 hours
Dose as CrCl <20
mL/minute: Follow levels
Loading dose of 2 g followed by
1-2 g every 8-12 hours
250 mg every 12 hours
Administer a normal dose
followed by either 25% to
50% of normal dose every 46 hours or 50% to 100% of
normal dose every 8-12
hours
Administer 1 to 2 g every 24
hours.
Loading dose of 4 million units,
followed by 2 million units every
4-6 hours
Give normal dose every 8
-12 hours
1 to 2 g every 8 to 12 hours
1 g every 24 hours
500 mg to 1 g every 24 hours
or 1 to 2 g every 48 to 72
hours
Loading dose of 2 g followed by
1 to 2 g every 12 hours
Loading dose of 1 g,
followed by 500 mg every 24
hours
GFR 10-25ml/min: Administer recommended dose
PD
Give half the normal dose
iv every 24 hours
every 24 hours IV
GFR <10ml/min: Administer 50% of recommended
Amikacin
Ampicillin
Benzylpenicillin
Cefotaxime
Ceftazidime
dose every 24 hours IV
CrCl ≥60 mL/min: Administer every 8 hours
CrCl 40-60 mL/min: Administer every 12 hours
CrCl 20-40 mL/min: Administer every 24 hours
CrCl <20 mL/min: Loading dose, then monitor level
CrCl >50 mL/minute: Administer every 6 hours
CrCl 10-50 mL/minute: Administer every 6-12 hours
CrCl <10 mL/minute: Administer every 12-24 hours
FR >50 mL/min:No dosage adjustments are necessary
FR 10-50 mL/min: Administer 75% of the normal dose
GFR <10 mL/min: Administer 20% to 50% of the
normal dose
GFR >50 mL/minute: Administer every 6 hours
GFR10-50 mL/minute: Administer every 6 to 12 hours
GFR <10 mL/minute: Administer every 24 hours or
decrease the dose by 50%
CrCl 31 to 50 mL/minute: 1 g every 12 hours
CrCl 16 to 30 mL/minute: 1 g every 24 hours
CrCl 6 to 15 mL/minute: 500 mg every 24 hours
CrCl <5 mL/minute: 500 mg every 48 hours
Ceftriaxone
No dosage adjustment is generally necessary in renal
impairment; Note: Concurrent renal and hepatic
dysfunction: Maximum dose: ≤2 g daily
Ciprofloxacin
Oral
Ciprofloxacin
IV
renal impairment:
HD
CVVH
PD
Oral, immediate release
CrCl 30-50 mL/minute: 250-500 mg every 12 hours
CrCl 5-29 mL/minute: 250-500 mg every 18 hours
Oral, extended release:
CrCl <30 mL/minute: 500 mg every 24 hour
Oral, immediate release
250-500 mg every 24 hours
Oral, extended release:
500 mg every 24 hours
250-500 mg every 24 hours
Oral, immediate release
250-500 mg every 24 hours
Oral, extended release:
500 mg every 24 hours
IV: 200-400 mg every 24
hours
200-400 mg every 12-24 hours
IV: 200-400 mg every 24
hours
Administer after HD session
is completed
250-500 mg every 24 hours;
administer dose during and
after dialysis. Do not use
extended release tablets.
Administer after HD session is
completed
Continuous arteriovenous or
venovenous hemofiltration
effects:
Amoxicillin: ~50 mg of
amoxicillin/L of filtrate is
removed
Clavulanic acid: Dose for CrCl
<10 mL/minute
2.5-7.5 mg/kg of TMP every 12
hours
Administer after HD session
is completed
Peritoneal dialysis:
Moderately dialyzable (20%
to 50%)
Amoxicillin: Administer 250
mg every 12 hours
Clavulanic acid: Dose for
CrCl <10 mL/minute
CrCl 5-29 mL/minute: 200-400 mg every 18-24 hours
Clarithromycin
GFR <30ml/min: Give 50% of normal dose
iv/po/ng every 12 hours
(amoxicillin+
Clavulanic acid)
CrCl <30 mL/minute: Do not use 875 mg tablet
CrCl 10-30 mL/minute: 250-500 mg every 12 hours
CrCl <10 mL/minute: 250-500 mg every 24 hours
Co-trimoxazole CrCl 15-30 mL/min: Administer 50% of
2.5-10 mg/kg trimethoprim
every 24 hours or 5-20
mg/kg trimethoprim 3
times weekly after IHD
CrCl 50-79 mL/min: 2.5-3.8 mg/kg/day in 2
divided doses
CrCl 30-49 mL/min: 2.5 mg/kg/day once daily or
IM, IV
in 2 divided doses
CrCl 10-29 mL/min: 1.5 mg/kg every 36 hours
GFR <10ml/min: Give 50-75% of normal total
Erythromycin
daily dose;max 1.5g in 24 hours (2)
Flucloxacillin(2) GFR <10ml/min: Give normal dose iv q 8 hours
1.5 mg/kg every 24-48 hours
2.5 mg/kg every 24-48 hours
No dosage adjustment
required
Give normal dose IV q 8 hr
No dosage adjustment
required
Give normal dose IV q 8 hr
Fluconazole
200-400 mg every 48-72
hours or 100-200 mg every
24 hours have been
recommended
Loading dose of 400-800 mg
followed by 200-400 mg every
24 hours
recommended dose
CrCl <15 mL/min: Use is not recommended
Colistimethate
(colistin)
CrCl ≤50 mL/minute (no dialysis): Administer 50% of
recommended dose daily
Use CrCl <15 mL/minute
dosing recommendations.
Not significantly removed
by PD
Give 50% of normal dose
iv every 18-24 hours(2)
No dosage adjustment
required
Give normal dose IV q 8 hr
Ganciclovir
Gentamicin
Imipenem +
cilastatin
renal impairment:
IV (Induction):
CrCl 50-69 mL/min: Administer 2.5 mg/kg/dose
every 12 hours.
CrCl 25-49 mL/min: Administer 2.5 mg/kg/dose
every 24 hours.
CrCl 10-24 mL/min: Administer 1.25 mg/kg/dose
every 24 hours.
CrCl <10 mL/min: Administer 1.25 mg/kg/dose 3
times/week following hemodialysis
IV (Maintenance):
CrCl 50-69 mL/minute: Administer 2.5
mg/kg/dose every 24 hours.
CrCl 25-49 mL/minute: Administer 1.25
mg/kg/dose every 24 hours.
CrCl 10-24 mL/minute: Administer 0.625
mg/kg/dose every 24 hours
CrCl <10 mL/minute: Administer 0.625
mg/kg/dose 3 times/week following hemodialysis.
Conventional dosing:
CrCl 40-60 mL/minute: Administer every 12 hours
CrCl 20-40 mL/minute: Administer every 24 hours
CrCl <20 mL/minute: Loading dose, then monitor
levels
Take trough level after 24hours, and hold next
dose until trough level is available.
Adjust dosage interval according to serum levels
aim to keep trough <1mg/L and peak 5-10mg/L.
GFR 31-70ml/min: 500 mg every 6-8 hours
GFR 21-30ml/min: 500 mg every 8-12 hours
GFR <20ml/min: 250 mg every 12 hours
GFR <5ml/min: Do not start imipenem/cilastatin
unless haemodialysis or haemofiltration is to be
started within 48 hours
HD
CVVH
PD
IV: Induction: 1.25 mg/kg every
48-72 hours;
IV: Induction: 2.5 mg/kg every
24 hours
Dose as for CrCl <10
mL/minute
IV: Maintenance: 0.625 mg/kg
every 48-72 hours
Maintenance: 1.25 mg/kg every
24 hours
Dose as for CrCl <10
mL/minute
Loading dose of 2-3 mg/kg
loading dose followed by:
A)Mild UTI or synergy: 1 mg/kg
every 48-72 hours; consider
redosing for pre-HD or post-HD
concentrations <1 mg/L
B)Moderate-to-severe UTI: 11.5 mg/kg every 48-72 hours;
consider redosing for pre-HD
concentrations <1.5-2 mg/L or
post-HD concentrations <1
mg/L
C)Systemic gram-negative rod
infection: 1.5-2 mg/kg every
48-72 hours; consider redosing
for pre-HD concentrations <3-5
mg/L or post-HD
concentrations <2 mg/L
Use the dosing
recommendation for patients
with a CrCl 6-20 mL/minute;
administer dose after dialysis
session and every 12 hours
thereafter or 250-500 mg every
12 hours
Give 2mg/kg iv, take trough
level after 24 hours, and hold
next dose until trough level is
available. Adjust dosage
interval according to serum
Levels – aim to keep trough
<1mg/L and peak 5-10mg/L
Administration via PD fluid:
-Gram-positive infection (eg,
synergy): 3-4 mg/L (3-4
mcg/mL) of PD fluid
-Gram-negative infection: 48 mg/L (4-8 mcg/mL) of PD
fluid
-Administration via IV, IM
route during PD: Dose as for
CrCl <10 mL/minute and
follow levels
Give 50% of the normal dose
every 24 hours
Loading dose of 1 g followed
by either 250 mg every 6
hours or 500 mg every 8
hours
CVVH: Loading dose of 1 g
CrCl 26-50 mL/min: Administer recommended
500 mg every 24 hours
followed by either 500 mg every
dose based on indication every 12 hours
8 hours or 1000 mg every 12
CrCl 10-25 mL/min:
Renal impairment
HD Administer one-half PD
CVVH
hours
recommended
dosenormal
based on
indication
GFR 40-60ml/min: Give normal regimen
for
Give
regimen
for q12h
Give normal regimen for
Give normal regimen for
CrClon
<10
mL/min:
Administer
one-half
the first three days, then reduce dose
Day
the first
three days,
then
the first three days, then
the first three days, then
recommended
dose
based
on
indication
h
4 to 50% of the dose once daily or give 100% reduce dose on Day 4 to q24reduce
dose on Day 4 to
reduce dose on Day 4 to
GFR 10-30ml/min:
Treatment:
75 mgonce
once daily
Treatment:
30 mg once daily
Oseltamivir
of the dose every
second day
one third
of the dose
oneforthirdTreatment:
of the doseLow-flux
once one third of
the dose once
5
days
hemodialysis:
30 mg daily
after or give
for100%
5 daysoforthe
75 mg every 48
GFR <40ml/min: Give normal regimen for the daily or give 100% of the
daily or give
100% of the
Prophylaxis:
75
mg
every
other
day
or
30
mg
each
dialysis
session
for
5
hours
to
provide
a 5-day
first three days, then reduce dose on Day 4 to dose every third day
dose every
dose every third day
once
daily
days.
duration
one third of the dose once daily or give 100%
third day
High-flux hemodialysis: 75
Prophylaxis: no data
of the dose every third day.2
mg
after
each
dialysis
: Vancomycin levels should be monitored in
Following loading dose of
Administration via PD
Give 10mg/kg3 iv as
for 5
days
patients with any renal impairment:
15 to 25 mg/kg, give either fluid: 15 session
to 30 mg/L
(15
to
determined by serum
Prophylaxis:
Low-flux
500 to 1,000 mg or 5 to 10 30 mcg/mL) of PD fluid
levels.3 Hold dose until the
hemodialysis: 30 mg serum
after level is between 5CrCl >50 mL/minute: Start with 15 to 20
mg/kg after each dialysis
alternate
dialysis
sessions
mg/kg/dose (usual: 750 to 1,500 mg) every 8
session
Systemic: Loading dose of 10mg/L
until
outbreak
over
to 12 hours
1,000 mg,
followed
by is
500
High-flux
hemodialysis:
No
to 1,000 mg every 48 to 72
data.
2.25 g every 12 hours
2.25-3.375 g every 6-8 hours
Piperacillin + CrCl 20-40 mL/min: Administer 2.25 g q 6 hr
(3.375 g every 6 hours for nosocomial
tazobactam
pneumonia)
CrCl <20 mL/min: Administer 2.25 g q 8 hr (2.25
g every 6 hours for nosocomial pneumonia)
Meropenem
Teicoplanin(2)
Vancomycin
CrCl 20 to 49 mL/minute: Start with 15 to 20
mg/kg/dose (usual: 750 to 1,500 mg) every 24
hours
hours with close
monitoring of levels.
CrCl <20 mL/minute: Will need longer
intervals; determine by serum concentration
monitoring
1. uptodate, 2014
2.Rachelle Booth (PICU Senior Specialist Pharmacist), Sue Patey (Quen Mok (Consultant Paediatric Intensivist). Drug Dosage Adjustments in Renal Impairment & CVVH
Gt Ormond St Hospital for Children NHS Trust. Nov 2013
3..McEvoy GK et al. American Hospital Formulary Service (AHFS) Drug Information, 2009. American Society of Health-System Pharmacists, Bethesda, 2009. Accessed online 16/12/10.
4. Aronoff GR, Bennett WM, Berns JS et al. Drug Prescribing in Renal Failure, Dosing Guidelines for Adults and Children, 5th edn. American College of Physicians, US, 2007
5.Ashley C, Currie A. The Renal Drug Handbook. 3rd edn. Radcliffe Medical Press Ltd, Oxon UK, 2009