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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