Download Statin Dosing

Pharmacy & Therapeutics Committee News
July 2015
Fluoroquinolone Formulary Change: Levofloxacin to Replace Moxifloxacin – Start Date: 7/21/15
Both levofloxacin and moxifloxacin are respiratory fluoroquinolones. Unlike ciprofloxacin, both agents have excellent
activity against Streptococcus pneumoniae and can be used for the treatment of community acquired pneumonia (CAP).
Another important difference is that levofloxacin has activity against Pseudomonas aeruginosa while moxifloxacin does
not. Due to the fact that levofloxacin is available generically for both the IV and oral preparations, the P&T committee
decided to replace moxifloxacin with levofloxacin on the hospital formulary. This will result in significant cost savings.
Note that ciprofloxacin will remain on formulary for the treatment of Pseudomonas infections, since ciprofloxacin has
slightly better activity against SJH Pseudomonas isolates.
Although the fluoroquinolone class has FDA indications for a variety of infections, this class of antimicrobials is
associated with an increased risk of Clostridium difficile. This includes the NAP1 strain, which can cause severe cases of
colitis requiring colectomies and resulting in an increased risk of mortality. For this reason and the increased risk of
resistance, fluoroquinolones are NOT the first line option for either pneumonia or urinary tract infections.
Approved indications for levofloxacin include:


CAP in patients with documented anaphylaxis to the beta-lactam class of antibiotics
Other indications will be based on the specific organism and the patient’s allergy history
The Antibiotic Stewardship Team reviews every fluoroquinolone order for appropriate use.
Auto-substitution conversion of moxifloxacin IV/PO to levofloxacin IV/PO
If ordered for Pneumonia
Moxifloxacin 400mg IV/PO q 24h
Moxifloxacin 400mg IV/PO q 24h
Moxifloxacin 400mg IV/PO q 24h
And the estimated
creatinine clearance is…
≥ 50 ml/min
20-49 ml/min
10-19 ml/min OR
hemodialysis
Pharmacist will convert to…
Levofloxacin 750mg IV/PO q 24h
Levofloxacin 750mg IV/PO q 48h
Levofloxacin 750mg IV/PO x 1,
then 500mg IV/PO q 48h
Pneumonia Pathway Revisions
The goal of the pneumonia pathway is to ensure patients receive evidence based treatment regimens and appropriate
diagnostic tests to improve overall outcomes. The pathway was reviewed with the Infectious Diseases Physicians and the
following recommendations were made:
Community Acquired Pneumonia: No risk for Pseudomonas
 Levofloxacin IV/PO replaces Moxifloxacin IV/PO for CAP patients with anaphylaxis to beta-lactam antibiotics.
 A comment was added to choose doxycycline for atypical coverage in patients with QTc prolongation. There is
also data that the use of doxycycline may decrease the risk of Clostridium difficile when combined to ceftriaxone.
o
Doernberg SB, Winston LG, Deck DH, Chambers HF. Does doxycycline protect against development of Clostridium difficile Infection. Clin
Infect Dis 2012;55(5):615-20.
 A 5 day stop was added to azithromycin therapy.
Community Acquired Pneumonia: Pseudomonas risk or Health-Care Associated Pneumonia
 For Non-ICU patients: There will no longer be double pseudomonas coverage with ciprofloxacin and
piperacillin-tazobactam or cefepime, since the 2015 antibiogram shows Pseudomonas isolates have a 91%
sensitivity to piperacillin-tazobactam and 97% sensitivity to cefepime.
 Azithromycin or doxycycline was added for atypical coverage.
 For ICU patients: The regimen of Piperacillin-tazobactam + ciprofloxacin + Vancomycin was added which is
consistent with the sepsis pathway.
 When vancomycin IV is ordered for MRSA coverage, a MRSA nasal screen by PCR will automatically be
ordered. This test is rapid and has a 98-99% negative predictive value. If this test is negative, providers should
consider discontinuing vancomycin therapy. Patients will not require isolation while the result is pending.
2015 Antibiogram
The 2015 Inpatient and Outpatient Antibiogram is now available electronically on the Pharmacy Website under Pharmacy
Reference Materials or on the Antibiotic Stewardship Page. For printed copies, please email Lisa Avery, Pharm.D. @
[email protected]
Highlighted Antibiogram Issues
 E.coli sensitivities to Ciprofloxacin or levofloxacin are only 77%. This makes fluoroquinolones inappropriate
empiric therapy for UTIs or intra-abdominal infections.
 MRSA accounts for 44% of all Staphylococcus aureus isolates.
 Only 62% of community-wide Streptococcus pneumoniae isolates are sensitive to azithromycin. This is due to
the overuse of Z-Paks.
New Cephaloporins Added to Restricted Medication List – Restricted to ID
The following antibiotics have a “first dose restriction” and may be ordered by Infectious Disease physicians. Avycaz is
restricted to carbapenamase producing enterobactericiae (CRE) and Zerbaxa is restricted to resistant pseudomonas
isolates.
Brand Name
FDA Indications
Dose
Dose Adjustment
for Clcr
Contraindication
Warnings
Adverse Drug
Reactions
Drug
Interactions
Cost
Ceftolozane-tazobactam
Zerbaxa
Complicated intra-abdominal in combination
with metronidazole
Ceftazidime-avibactam
Avycaz
Complicated intra-abdominal in combination
with metronidazole
Complicated UTI - Pyelonephritis
1.5g IV q 8h
30-50 ml/min
750mg IV q 8h
15-29 ml/min
375mg IV q 8h
ESRD on HD
750mg x 1, then
150mg IV q 8h
Allergy to piperacillin-tazobactam and other
members of the beta-lactam class
Decreased efficacy in patients with a creatinine
clearance 30 to <50 ml/min
Nausea, diarrhea, headache, pyrexia
Complicated UTI - Pyelonephritis
2.5g IV q 8h
31-50 ml/min
1.25g IV q 8h
16-30 ml/min
0.94g IV q 12h
6-15 ml/min
0.94g IV q 24h
≤ 5 ml/min
0.94g IV q 48h
Allergy to ceftazidime/avibactam
None
1.5g = $83
1.5g IV q 8h = $249 per day
Decreased efficacy in Clcr 30-50 ml/min
CNS – seizures (renal impairment)
Vomiting, nausea, constipation, anxiety
Avibactam is a substrate of OAT1 and OAT3
transporters. Do not coadminister probenecid.
2.5g = $267
2.5g IV q 8h = $801 per day
How to request a nonformulary drug for use in one specific patient (aka Fast Track Process)
All requests for nonformulary products will require completion of a fast-track request form located on-line in the forms
catalog (Form # 20207). Please alert your pharmacist as soon as possible when considering these products. All requests
require Pharmacy & Therapeutics Committee Leadership and VPMA approval before an order for the product can be
placed. Retrospective review of all “fast-tracks” will occur at the following P & T meeting.
How to request addition or status change to the Formulary
Formulary additions, deletions and new policy development or revisions may be requested using the Form #18711.
Formulary requests should only be completed by medical or hospital staff; requests from vendors are unacceptable.
Meeting Schedule
The P & T Committee meets monthly (with some exceptions) on the fourth Tuesday morning each month in Room 201B
at 0700. Approvals are forwarded to the next possible Medical Department and Medical Executive Committee meetings.
The July P & T Committee meeting has been cancelled.
For more information on Antimicrobial actions, please email Lisa Avery, Infectious Disease Pharmacist [email protected]
For more information on Pharmacy & Therapeutics Committee actions, please contact Karen Whalen, Drug Information Pharmacist 448-6519.