Antibiotic Treatment Guideline
Transcript of Antibiotic Treatment Guideline
Antibiotic Treatment Guideline
Name: ___________________________________
Month/Year: _____________________________
Hospital: ________________________________
Department: _____________________________
October 2019
THE GLOBAL HEALTH INITIATIVETHE GLOBAL HEALTH INITIATIVE
Antibiotic Treatment Guideline
Suggested Empiric Antibiotic Therapy
Diagnosis Suspected Pathogens Empiric Therapy Duration of
Therapy
Abdominal infection, community-acquired(e.g. cholecystitis, cholangitis, diverticulitis, abscess)
NOTE:Add gentamicin if MDRO suspected or identified
Enterobacteriaceae Bacteroides sp. EnterococciStreptococci
Preferred:• Ceftriaxone IV 1g q24h +
Metronidazole IV or PO 500mg q8h +/- Gentamicin IV 5mg/kg q24hr
Alternative: • Piperacillin/tazobactam
IV 4.5g q6h• Cefepime IV 2g q12h +
Metronidazole IV or PO 500mg q8h + Gentamicin IV 5mg/kg q24hr
• Imipenem IV 1g q8h
Oral options for outpatient therapy:• Ofloxacin PO 400mg q12h +
Metronidazole PO 500mg q12h• Moxifloxacin PO 400mg q24h
4 days with adequate source
control
NOTE: Pancreatitis
does not require antibiotics if
no necrosis or abscess
COPD Exacerbation (inpatient)Increased sputum volume and/or purulence OR Acute respiratory failure requiring ICU admission
H. influenzaeS. pneumoniaeM. catarrhalis
Preferred: • Azithromycin PO 500mg q24h• Doxycycline PO 100mg q24h
5-7 days
Enteric fever Salmonella typhiSalmonella paratyphi
Preferred: • Ceftriaxone IV 2g q12h• Azithromycin IV or PO 1g q24h
5-10 days
Gastroenteritis
NOTE: Salmonella and campylobacter treat if protracted or comorbidities
Shigella treat
Salmonella sppShigella sppCampylobacter spp
Preferred:• Ciprofloxacin PO 500mg q12h or
IV 400q12• Ofloxacin 400mg q24h• Trimethoprim/
Sulfamethoxazole PO 160/800mg q12h
Alternative:• Azithromycin PO 500mg q24h
3-5 days
Diagnosis Suspected Pathogens Empiric Therapy Duration of
Therapy
Meningitis, community-acquired
Risk factors for Listeria spp.: EtOH abuse, age >50, pregnancy
S. pneumoniaeN. meningitidesListeria monocytogenes
• Ceftriaxone IV 2g q12h + Vancomycin 1g q12h (or Linezolid IV 600mg q12h) +/- Ampicillin 2g q4-6h (if risk factors for Listeria spp. present)
TB Meningitis:Anti-tuberculosis medicine (non-IV therapy)
N.meningitis: 7 days
H. influenza: 7 days
S. pneumoniae: 10-14 days
Listeria/neonate:21 days
TB:10 days
Osteomyelitis StaphylococciStreptococciAnaerobesGram-negative bacteria
IV:• Cefazolin IV 2g q8h +/-
Metronidazole IV or PO 500mg q8h• Ceftriaxone IV 1g q24h +
Vancomycin IV 1g q12hOral options:• Ciprofloxacin PO 750mg q12h +/-
Doxycycline PO 100mg q12h OR Clindamycin 450mg q8h
• Trimethoprim/ Sulfamethoxazole PO 320/1600mg q12h
4-6 weeks
Pelvic inflammatory disease
Chlamydia N.gonorrhoeae EnterobacteriaceGroup B Streptococci
Preferred:• Ceftriaxone IM 250mg +
Doxycycline 100mg q12h + Metronidazole 500mg q8h
Alternative:• Cefixime 400mg q24h +
Azithromycin 500mg q24h + Metronidazole 400mg q8h
Single dose ceftriaxone
14 days doxycycline and metronidazole
Pneumonia, community-acquiredInpatient therapy
S. pneumoniaeH. influenzaMycoplasma sp.Chlamydophila sp.Legionella sp.
• Ceftriaxone IV 1g q24h + Azithromycin IV or PO 500mg q24h OR Doxycycline PO 100mg q8h
• Amoxiclav PO 625mg q8h• Moxifloxacin PO 400 q24h
5 days
Pneumonia, community-acquiredOutpatient therapy
S. pneumoniaeH. influenzaMycoplasma sp.Chlamydophila sp.Legionella sp.
• Azithromycin PO 500mg q24hFor patients with comorbidities:• Moxifloxacin PO 400mg q24h,
Ofloxacin 400mg q24h, or Levofloxacin PO 500mg q24h
• Amoxicillin 500mg q8h + Azithromycin PO 500mg q24h
• Amoxiclav PO 625mg q8h
5 days
Diagnosis Suspected Pathogens Empiric Therapy Duration of
Therapy
Pneumonia, with risk factors for multidrug resistant bacteria* (healthcare or ventilator associated)
EnterobacteriaceaeP. aeruginosa,A. baumannii
(Add azithromycin OR doxycycline for patients presenting from the community who are at risk for atypical infection)
Patients with risk factors for multi-drug resistant bacteria:• Cefepime IV 2g q12h +/-
Vancomycin 1g q12h OR Linezolid 600mg IV or PO q12h
• Piperacillin/tazobactam V 4.5g q6hr + Gentamicin 5mg/kg q24hr +/- Vancomycin 1g q12h OR Linezolid IV or PO 600mg q12h
• Imipenem/Cilastatin IV 1g q8h or Meropenem IV 0.5-1g q8h +/- Gentamicin 5mg/kg q24hr +/- Vancomycin IV 1g q12h OR Linezolid IV or PO 600mg q12h
When Acinetobacter sp. is suspected:Colistin +/- Tigecycline
7 days
NOTE: Add gentamicin or
amikacin in patients with severe sepsis
or septic shock. Stop after 3
days if a beta-lactam resistant organism is not
isolated or if cultures were not
obtained.
Sepsis of unknown source and bacteremia
Enterobacteriaciae Staphylococci, Streptococci
NOTE: Add gentamicin or amikacin for patients with severe sepsis or septic shock. Stop after 3 days if a beta-lactam resistant organism is not isolated or if cultures were not obtained.
Preferred:• Piperacillin/tazobactam IV 4.5g
q6h + Gentamicin IV 5mg/kg q24hr OR Amikacin IV 15mg/kg q24h +/- Vancomycin 1g q12h OR Linezolid IV or PO 600mg q12h
• Cefepime IV 2g q12h + Gentamicin OR Amikacin +/- Vancomycin 1g q12h OR Linezolid 600mg q12h
Alternative:• Ceftriaxone IV 1g q24h +
Gentamicin IV 5mg/kg q24hr
Critically ill or neutropenic patients: • Imipenem/Cilastatin 1g q8h +/-
Gentamicin IV 5mg/kg q24hr +/- Vancomycin 1g q12h OR Linezolid
• Colistin for CRE
10 days for gram-negative
organisms
14 days for S. aureus
Diagnosis Suspected Pathogens Empiric Therapy Duration of
Therapy
Skin and skin structure infections cellulitis
Staphylococci, Streptococci
Cellulitis, oral therapy:Preferred:• Cloxacillin 500mg q8h or
Flucloxacillin PO 500mg q6• Cephalexin 500mg q6h or
Cefadroxil PO 1g q24hCellulitis, no history of MRSA, intravenous therapy:• Cefazolin IV 1g q8h• Cloxacillin 500mg q8h or
FlucloxacillinPurulent cellulitis OR After failure of IV beta-lactam therapy OR MRSA:Vancomycin IV 1g q12h OR Linezolid IV or PO 600mg q12h
5-7 days
Skin and skin structure infections abscess
Staphylococci, Streptococci
Surgical consultation for drainage• Cefazolin IV 1g q8h• Amoxiclav PO 625mg q8h• Flucloxacillin PO 500mg q6h
If failure of IV beta-lactam therapy OR MRSA:• Vancomycin IV 1g q12h OR
Linezolid IV or PO 600mg q12h
5 days (with adequate drainage)
Skin and skin structure infections necrotizing fasciitis
Streptococci Surgical consultation for source control• Clindamycin IV 600mg q8h +
Penicillin IV 5million units q6h• Piperacillin/tazobactam IV 4.5g
q6h + Clindamycin IV 600mg q8h
7-10 days (with adequate source
control)
Diagnosis Suspected Pathogens Empiric Therapy Duration of
Therapy
Skin and skin-structure infectionsPolymicrobial, burn victims, Pseudomonas sp. suspected (e.g. open wounds with vascular insufficiency, pressure sore or severe diabetic foot ulcer)
Staphylococcus aureusStreptococciEnterobacteriaceaeAnaerobes
Preferred:• Piperacillin/tazobactam IV 4.5g
q6h +/- Gentamicin IV IV 5mg/kg q24h +/- Vancomycin IV 1g q12h OR Linezolid IV or PO 600mg q12h
• Cefepime 2g q12h + Metronidazole IV or PO 500mg q8h +/- Gentamicin IV 5mg/kg q24hr +/- Vancomycin 1g q12h OR Linezolid
If MDR Acinetobacter sp. confirmed:• Colistin OR Tigecycline
5-7 days
NOTE: Add gentamicin or
amikacin in patients with severe sepsis
or septic shock. Stop after 3
days if a beta-lactam resistant organism is not
isolated or if cultures were not
obtained.
Skin and skin-structure infections, cat/dog/human bite
Pasteurella multocida, StaphylococciStreptococciAnaerobes
• Amoxicillin/clavulanate PO 625mg q8h
• Ofloxacin PO 400mg q12h• Moxifloxacin PO 400mg q24h • Doxycycline PO 100mg q24h
5-7 days
Urinary tract infection uncomplicated cystitis
Enterobacteriaceae
• Preferred: Nitrofurantoin (ONLY for CrCl > 40 to 60 mL/min or age < 65 years) 100mg q6h
• Ofloxacin 400mg q12h• Pregnant women ONLY: Cefixime
400mg q24h
5 days
Urinary tract infectionPyelonephritis
Enterobacteriaceae IV Preferred:• Piperacillin/tazobactam IV 4.5g
q6hr• Ofloxacin 200mg q24h• Imipenem/cilastatin 1g q8h• Cefepime IV 2g q12h
Alternate Oral options:• Ofloxacin 400mg q12h• Cefixime (pregnant women ONLY)
x 14 days 400mg q24h
NOTE: Add gentamicin or amikacin in patients with suspected Pseudomonas spp. and severe sepsis or septic shock. Stop after 3 days if beta-lactam resistant organism is not isolated or if cultures were not obtained.
7 days
Antibiotics on reserve:This group of antibiotics was created by WHO in 2017. They are recommended to be used as “last resort” options when alternative options have failed. The aim is to preserve the effectiveness of these antibiotics.
Reserve group antibiotics: Aztreonam Fosfomycin (IV)
Cefepime Linezolid
Daptomycin Tigecycline
Polymixins (polymyxin B, colistin)
Useful Stewardship Tips• Always attempt to get bacterial cultures!• Stay up to date with your hospital’s antibiogram• Avoid empiric quinolone for most infections due to high resistance rates• Avoid using duplicate antibiotics that cover the same organism unnecessarily (e.g.
carbapenems with metronidazole, which both retain anaerobic bacteria coverage)• Always de-escalate to the narrowest antibiotic therapy possible when susceptibility
results are available• Continue to assess if the patient is truly infected, and treat only for the minimum
duration necessary to cure the patient from infection• Utilize oral agents whenever possible to prevent catheter-associated infections
• Avoid treating asymptomatic bacteriuria
Suggested Definitive Antibiotic Therapy (Check susceptibilities before prescribing therapy)
OrganismPreferred Therapy
(Confirm with susceptibilities)
Alternative Therapy(Depending on allergies
and susceptibility)
Acinetobacter spp Imipenem/cilastatin Meropenem, colistin, tigecycline, trimethoprim/sulfamethoxazole, gentamicin, amikacin
Consider combination therapy for extensively drug resistant Acinetobacter
Citrobacter species(AmpC producing organism)
Cefepime, gentamicin Ciprofloxacin, meropenem, moxifloxacin, ofloxacin, piperacillin/tazobactam trimethoprim/sulfamethoxazole
Oral therapy options: trimethoprim/ sulfamethoxazole preferred, ciprofloxacin, ofloxacin
Enterobacter spp(AmpC producing organism)
Cefepime Ciprofloxacin, gentamicin, meropenem, ofloxacin, piperacillin/tazobactam, trimethoprim/ sulfamethoxazole
Oral therapy options: trimethoprim/sulfamethoxazole preferred, ciprofloxacin, ofloxacin
OrganismPreferred Therapy
(Confirm with susceptibilities)
Alternative Therapy(Depending on allergies
and susceptibility)
Enterococcus faecalis or faecium
Ampicillin gentamicin sensitive
Ampicillin resistant, vancomycin, gentamicin sensitive
Vancomycin resistant, ampicillin, gentamicin susceptible
Vancomycin resistant,ampicillin, gentamicin resistant
Amoxicillin, penicillin
Vancomycin
Ampicillin ± gentamicin (for endocarditis)
Linezolid
For cystitis only: ofloxacin or nitrofurantoin
Linezolid
Escherichia coli
Extended spectrum beta-lactamase producer
Ampicillin, trimethoprim/sulfametho-xazole or ciprofloxacin preferred for oral therapy
Imipenem/cilastatin, piperacillin/tazobactam (if urine source ONLY)
Ceftriaxone, cefepime, gentamicin, ciprofloxacin, piperacillin/tazobactam
Oral therapy options: amoxicillin/clavulanic acid, ciprofloxacin, ofloxacin, nitrofurantoin (cystitis ONLY)
Meropenem, tigecycline, colistin
Haemophilus influenzaeBeta-lactamase negative
Beta-lactamase positive
Ampicillin, amoxicillin
Amoxicillin/clavulanic acid, trim/sulbactam
Moxifloxacin, azithromycin, doxycycline, trimethoprim/ sulfamethoxazole
OrganismPreferred Therapy
(Confirm with susceptibilities)
Alternative Therapy(Depending on allergies
and susceptibility)
H. pylori(susceptibilities not necessary)
Amoxicillin 1 gram PO BID + clarithromycin 500 mg PO BID + proton pump inhibitor (PPI) standard dose BID 14 days(Eradication rate 70-85%)
Metronidazole 400 mg PO BID + clarithromycin 500 mg PO BID + PPI standard dose BID (70-85% eradication)
Metronidazole 400 mg PO three times daily + tetracycline 500 mg PO four times daily + bismuth subsalicylate 524 mg (30 mL) PO four times daily + PPI standard dose BID (70-90% eradication)
Clarithromycin
Klebsiella spp
Extended spectrum beta-lactamase producer
Trimethoprim/ sulfamethoxazole preferred for oral therapy
Imipenem/cilastatin, piperacillin/tazobactam (if urine source ONLY)
Gentamicin, ceftriaxone, cefoperazone/sulbactam, cefepime, piperacillin/ tazobactam, ciprofloxacin
Oral therapy options: sulbactam trimethoprim/sulfamethoxazole, ciprofloxacin, ofloxacin
Meropenem, tigecycline, colistin
Moraxella catarrhalisBeta-lactamase negative
Beta-lactamase positive
Amoxicillin
Amoxicillin/clavulanic acid, ceftriaxone
Moxifloxacin, azithromycin, doxycycline, trimethoprim/ sulfamethoxazole
OrganismPreferred Therapy
(Confirm with susceptibilities)
Alternative Therapy(Depending on allergies
and susceptibility)
Morganella morganii(AmpC producing organism)
Cefepime, Imipenem/cilastatin
Piperacillin/tazobactam, trimethoprim/ sulfamethoxazole, ciprofloxacin, gentamicin
Neiserria gonorrheae Ceftriaxone Cefixime
Neiserria menigitidis Penicillin, ceftriaxone Ampicillin
Proteus mirabilis
Ampicillin, cefazolintrimethoprim/sulfamethoxazole preferred for oral therapy
Amoxicilin, ciprofloxacin, ceftriaxone, gentamicin, trimethoprim/sulfamethoxazole
Proteus vulgaris Ampicillin
Amoxicilin, cefexime, ceftriaxone, gentamicin, trimethoprim/sulfamethoxazole
Providencia spp(AmpC producing organism)
Cefepime, Imipenem/cilastatin
Ciprofloxacin, gentamicin, trimethoprim/sulfamethoxazole, piperacillin/tazobactam
Pseudomonas aeruginosa
Piperacillin/ tazobactam, cefepime (consider double coverage with a beta-lactam plus an aminoglycoside in patients with septic shock until susceptibilities available to ensure adequate coverage)
Imipenem/cilastatin, meropenem, ceftazidime, ciprofloxacin, levofloxacin
Salmonella Typhi
Ceftriaxone, Azithromycin
Gastroenteritis is self limited, treatment not indicated unless patient is immunocompromised or has disseminated infection
Amoxicillin/clavulanic acid
OrganismPreferred Therapy
(Confirm with susceptibilities)
Alternative Therapy(Depending on allergies
and susceptibility)
Salmonella sp., non typhi
Ceftriaxone, Azithromycin
Gastroenteritis is self-limited, treatment not indicated unless patient is immunocompromised or has disseminated infection
Trimethoprim/sulfamethoxazole
Serratia spp(AmpC producing organism)
Cefepime
Gentamicin, imipenem/cilastatin, meropenem, piperacillin/tazobactam, trimethoprim/sulfamethoxazole, ciprofloxacin
Staphylococcus aureusMSSA
MRSAFlucoxacillin
Vancomycin
VancomycinOral options: cephalexin (not for bacteremia)
Linezolid (pneumonia in ICU patients only), teicoplanin• Oral options: trimethoprim/
sulfamethoxazole, clindamycin, doxycycline (not for bacteremia)
Coagulase negative staphylococcimethicillin susceptible
methicillin resistant
Flucoxacillin
Vancomycin Linezolid
Stenotrophomonas maltophilia
Trimethoprim/ sulfamethoxazole
Ciprofloxacin, levofloxacin, moxifloxacin
Streptococcus pneumoniae (non-CSF) penicillin MIC < 2 penicillin MIC ≥ 2
Penicillin G, amoxicillinMoxifloxacin, ceftriaxone
Ceftriaxone, azithromycin, doxycycline, clindamycin, moxifloxacin
Vancomycin, linezolid
OrganismPreferred Therapy
(Confirm with susceptibilities)
Alternative Therapy(Depending on allergies
and susceptibility)
Streptococcus pneumoniae (CSF) penicillin MIC < 0.1
penicillin MIC = 0.1-1
penicillin MIC ≥ 2
Penicillin G, ampicillin
Ceftriaxone
Vancomycin + ceftriaxone
Ceftriaxone, vancomycin
Cefepime, vancomycin
Streptococcus, group A, B, C or G
PenicillinAmpicillin, amoxicillin cefazolin, ceftriaxone, clindamycin, vancomycin
Streptococcus viridans group
Penicillin, amoxicillinAmpicillin, ceftriaxone, vancomycin
Suggested Duration of Antimicrobial Therapy Based on Indication
DiagnosisDuration of Antimicrobial Therapy
Key References
Asymptomatic bacteriuria (ASB) 0 days
• ASB treatment is harmful for most patients
• Treatment is only routinely indicated in patients who are pregnant or undergoing a urologic procedure
Infectious Diseases Society of America Guidelines: http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/Asymptomatic%20Bacteriuria.pdf
Candidemia If no ocular involvement or other metastatic complications: • Non-neutropenic: 14 days
from first negative blood culture
• Neutropenic: minimum of 14 days from first negative blood culture and resolution of neutropenia and symptoms
If ocular involvement:• 4 to 6 weeks
Infectious Diseases Society of America Guidelines: http://cid.oxfordjournals.org/content/62/4/e1.full.pdf
COPD exacerbation 5 to 7 days
According to the GOLD guidelines, antibiotics are indicated for patients with increased sputum purulence PLUS increased dyspnea and/or sputum volume. Antibiotics are also indicated if COPD exacerbation requires mechanical ventilation.
GOLD Guidelines http://www.goldcopd.org/uploads/users/files/GOLD_Report_2013_Feb20.pdfOther resources:http://thorax.bmj.com/content/63/5/415.full.pdf
DiagnosisDuration of Antimicrobial Therapy
Key References
Complicated intra-abdominal Infection, community-acquired (appendicitis, cholecystitis, diverticulitis)
4 to 7 days after adequate source control
Infectious Diseases Society of America Guidelines: http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Intra-abdominal%20Infectin.pdf
Other resources: http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411162
Meningitis, community-acquired N. meningitidis: • 7 days H. influenzae: • 7 days S. pneumoniae: • 10 to 14 days L. monocytogenes:• ≥ 21 days
Infectious Diseases Society of America Guidelines: http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/Bacterial%20Meningitis(1).pdf
DiagnosisDuration of Antimicrobial Therapy
Key References
Pneumonia, community acquired Prompt clinical response• 5 days
Delayed clinical response• 7 to 10 days
Patients should be afebrile for at least 48-72 hours and have no more than one CAP associated sign of clinical instability before discontinuing antibiotics.
Infectious Diseases Society of America Guidelines:http://www.idsociety.org/uploadedFiles/IDSA/GuidelinesPatient_Care/PDF_Library/CAP%20in%20Adults.pdf
Other resources:https://www.ncbi.nlm.nih.gov/pubmed/10052544http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2536189
Pneumonia, hospital-acquired, ventilator-associated
If empiric therapy was active and prompt clinical response:• 7 days
Infectious Diseases Society of America/ American Thoracic Society Guidelines: http://cid.oxfordjournals.org/content/early/2016/07/06/cid.ciw353.full.pdf
Skin and skin structure, cellulitis If prompt clinical response:• 5 days
If delayed clinical response or during a neutropenic fever episode• 7 to 14 days
Infectious Diseases Society of America Guidelines: http://cid.oxfordjournals.org/content/early/2014/06/14/cid.ciu296.full.pdf
DiagnosisDuration of Antimicrobial Therapy
Key References
Urinary tract infection, uncomplicated cystitis
(Uncomplicated: young, female patients with normal genitourinary anatomy)
3 days:• Sulfamethoxazole/
trimethoprim or urinary quinolone
• Nitrofurantoin7 days:• Beta-lactams
Infectious Diseases Society of America Guidelines: https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciq257
Urinary tract infection, pyelonephritis or complicated infection (including bacteremic pyelonephritis)
7 days: • Urinary quinolone• Ceftriaxone 14 days• Other beta-lactams
Infectious Diseases Society of America Guidelines: https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/ciq257
Intravenous to Oral Conversion
For an intravenous to oral conversion, the following criteria must be met:
Inclusion Criteria• Patient is admitted to a non-intensive care unit (ICU)/general practice unit (GPU)• Patient has received and is tolerating at least 1 dose of a medication administered enterally
or is tolerating an enteral diet• Patient has received the medication to be converted intravenously for at least 24 hours
Exclusion Criteria• Patient is admitted to an intensive care unit (ICU) (including ICU step-down or mixed ICU unit)• Nonfunctioning gastrointestinal tract
o Gastric obstruction or ileus• Persistent nausea and vomiting• Strict NPO (for a procedure or other medical reason)• Patients receiving treatment for an active GI bleed
Additional criteria:
Inclusion Criteria – Anti-Infectives• Afebrile (T < 38°C, 100.4°F) for at least 24 hours• Resolving/normalizing WBC (unless on oral or injectable steroids)
Exclusion Criteria – Anti-infectives• Neutropenia (ANC <1000)• Endocarditis• Meningitis or brain abscess• MRSA bacteremia• Feeding tubes with intestinal access only (applies to fluoroquinolones only)
o Ex. J-port, J-tube, PEJ (percutaneous endoscopic jejunostomy) tube or any feeding tube accessing the small bowel
Patients not meeting the above criteria, including patients admitted to an intensive care unit, may still be eligible for intravenous (IV) to oral (PO) conversion pursuant to an order by an authorized provider.
Other ConsiderationsWhen an oral antibiotic is available in both solid and liquid dosage forms:• Order the solid form if patient is receiving other solid oral medications• Order the liquid formulation if patient is receiving oral medications in liquid formulation only
Intravenous to Oral Conversion Dosing/Frequency Chart
Anti-Infectives
IV Drug Order Bioavailability Oral ConversionAzithromycin250-500 mg IV daily
< 50% Azithromycin 250-500 mg PO dailyConvert to identical dose orally
Clindamycin600 mg IV q8h
~90% Clindamycin 300 mg PO q6h
Clindamycin900 mg IV q8h
~90% Clindamycin 450 mg PO q6h
Ciprofloxacin 400 mg IV
60 – 80% Ciprofloxacin 500-750 mg PO- Use 750 mg for administration via gastric-access feeding tube-Order standard/maximum dose renal function and infection severity
Levofloxacin750 mg IV
~99% Levofloxacin 750 mg POConvert to identical dose orally
Ofloxacin 400 mg IV
~98% Ofloxacin 400 mg POConvert to identical dose orally
Doxycycline100 – 200 mg IV
~100% Doxycycline 100 – 200 mg POConvert to identical dose orally
Linezolid 600 mg IV q12h
~100% Linezolid 600 mg PO q12h
Metronidazole500 mg IV q8-12h
~100% Metronidazole 500 mg PO q8-12Convert to identical dose orally
Trimethoprim/sulfa-methoxazole5-20 mg/kg
~100% Trimethoprim/sulfamethoxazole 5 to 20 mg/kg PO in divided dosesConvert to identical dose orally
Other considerations for the same class of medication with similar spectrum of activity:• Penicillin G IV step-down to Penicillin VK PO• Cefazolin IV to cephalexin PO
Antibiotic Prophylaxis Guidelines
Condition Empiric Regimen Duration of Therapy
Chronic wound treatment None None
Burn treatment None None
Pre-operation treatment (if infection suspected)
Ceftriaxone (or other third-gen cephalosporin)
1-3 doses
Post-operation treatment (if infection suspected)
Ceftriaxone (or other third-gen cephalosporin)
1-3 doses
Renal Dosing Guidelines for Antimicrobials
Cockroft-Gault Creatinine Clearance EquationCrCL = ((140– Age) x weight) (72 x SCr) x 0.85 (if female)
Alphabetical Index of Antimicrobials (by Generic Name)
AAmoxicillin PO
Creatinine Clearance (mL/minute)
Standard Regimen
Community-acquired pneumonia
(in combination with a macrolide)
> 30 500 mg PO every 8 hoursOR
875 mg PO every 12 hours
1000 mg PO every 8 hours
10 to 30 500 mg PO every 12 hours 1000 mg PO every 12 hours
< 10 500 mg PO every 24 hours 500 mg PO every 24 hours
Hemodialysis 500 mg PO every 24 hours, schedule after HD on HD days
500 mg PO every 24 hours, schedule after HD on HD days
Amoxicillin/clavulanate PO
Creatinine Clearance (mL/minute)
Standard Dose Community-acquired pneumonia
> 30 Amoxicillin 500 mg/ clavulanate 125 mg PO every
8 hoursOR
Amoxicillin 875 mg/ clavulanate 125 mg PO every
12 hours
2 grams PO every 12 hours
Creatinine Clearance (mL/minute)
Standard Dose Community-acquired pneumonia
10 to 29 Amoxicillin 500 mg/ clavulanate 125 mg PO every
12 hours
Not suggested, use standard dose
< 10 Amoxicillin 500 mg/ clavulanate 125 mg PO every
24 hours
Hemodialysis (HD) Amoxicillin 500 mg/ clavulanate 125 mg PO every 24 hours, schedule after HD
on HD days
Azithromycin IV/PO
Creatinine Clearance (mL/minute)
COPD exacerbation or lower respiratory
infection
MAC prophylaxis
Chlamydia trachomatis
Any 500 mg dailyOR
500 mg x 1, then 250 mg daily x 4 days
1200 mg weekly
1000 mg x 1 dose
No renal dose adjustment
Cefoperazone IV
Creatinine Clearance (mL/minute)
Standard Dose Maximum Dose
Any 1 to 2 grams IV every 12 hours 2 to 4 grams IV every 8 to 12 hours
No renal dose adjustment
Cefoperazone/Sulbactam IV
Creatinine Clearance (mL/minute)
Standard Dose
> 30 2 to 4 grams IV every 12 hours
29 -15 1 gram IV every 12 hours
< 15 500 mg IV every 12 hours
Hemodialysis (HD) 500 mg IV every 12 hours, schedule after HD on HD days
Cefepime IV
Creatinine Clearance (mL/minute)
Standard Dose Maximum Dose
> 60 1 gram IV every 8 hoursOR
2 grams IV every 12 hours
2 grams IV every 8 hoursOR
1 gram IV every 6 hours
30 to 60 1 gram IV every 12 hours 2 grams IV every 12 hoursOR
1 gram IV every 8 hours
10 to 29 1 gram IV every 12 hours 1 gram V every 12 hours
≤ 10 1 gram IV every 24 hours 1 gram IV every 24 hours
Hemodialysis (HD) 1 gm IV every 24 hours, sched-ule after HD on HD days
OR 2 gm IV three times per week
after HD
1 gm IV every 24 hours, schedule after HD on HD days
OR 2 gm IV three times per week
after HD
Dose adjustment required in obesity.
Cefpodoxime PO
Creatinine Clearance (mL/minute) Respiratory Infection≥ 30 200 mg PO every 12 hours
< 30 200 mg PO every 24 hours
Hemodialysis (HD) 200 mg PO three times per week after HD
Ceftazidime
Creatinine Clear-ance (mL/minute)
Standard Dose Maximum Dose
≥ 50 1 gm IV every 8 hours 2 gm IV every 8 hours
31 to 49 1 gm IV every 12 hours 2 gm IV every 12 hours
≤ 30 1 gm IV every 24 hours 1 gm IV every 24 hours
Hemodialysis (HD) 1 gm IV every 24 hours, schedule after HD on HD days
1 gm IV every 24 hours, schedule after
HD on HD days
Ceftriaxone IV
Creatinine Clearance (mL/minute)
Standard Dose Endocarditis Meningitis
Any 1 gm IV every 24 hours 2 gm IV every 24 hours
2 gm IV every 12 hours
No renal dose adjustment
Cephalexin PO
Creatinine Clearance (mL/minute) Standard Dose≥ 60 500 mg PO every 6 hours
30 to 59 500 mg PO every 8 hours
15 to 29 500 mg PO every 12 hours
< 15 500 mg PO every 24 hours
Hemodialysis (HD) 500 mg PO every 24 hours, schedule after HD on HD days
Ciprofloxacin IV
Creatinine Clearance (mL/minute)
Standard Dose Maximum Dose
> 60 400 mg IV every 12 hours 400 mg IV every 8 hours
31 to 60 400 mg IV every 12 hours 400 mg IV every 12 hours
≤ 30 400 mg IV every 24 hours 400 mg IV every 24 hours
Hemodialysis (HD) 400 mg IV every 24 hours, schedule after HD on HD days
400 mg IV every 24 hours, schedule after HD on HD days
Ciprofloxacin PO
Creatinine Clearance (mL/minute)
SBP Prophylaxis
Standard Dose Maximum Dose
> 60 750 mg PO every 7 days
500 mg PO every 12 hours
500 mg PO every 8 hoursOR
750 mg PO every 12 hours
31 to 60 500 mg PO every 12 hours
500 mg PO every 8 hoursOR
750 mg PO every 12 hours
≤ 30 500 mg PO every 24 hours
500 - 750 mg PO every 24 hours
H e m o d i a l y s i s (HD)
500 mg PO every 24 hours, schedule
after HD on HD days
500 mg PO every 24 hours, schedule after HD on HD days
Cloxacillin IV
Creatinine Clearance (mL/minute)
Standard Dose
Any 2 gm IV every 4 to 6 hours
No renal dose adjustment
Colistin IV (doses are in terms of colistin base)
Creatinine Clearance (mL/minute)
Standard Dose
≥ 50 5 mg/kg (max 300 mg) x 1, then 2.5 mg/kg IV every 12 hours
30 to 49 5 mg/kg (max 300 mg) x 1, then 1.75 mg/kg IV every 12 hours
10 to 29 5 mg/kg (max 300 mg) x 1, then 1.25 mg/kg IV every 12 hours
< 10 5 mg/kg (max 300 mg) x 1, then 1.5 mg/kg IV every 24 hours
Hemodialysis (HD) 5 mg/kg (max 300 mg) x 1, then 1.5 mg/kg IV every 24 hours, schedule after HD on HD days
Dose colistin mg/kg on ideal body weight for all patients (including obese patients). Round all doses to the nearest 50 mg increment.
DDicloxacillin PO
Creatinine Clearance (mL/minute) Standard DoseAny 500 mg PO every 6 hours
No renal dose adjustment
Doxycycline IV/PO
Creatinine Clearance (mL/minute) Standard DoseAny 200 mg x 1, then 100 mg every 12 hours
No renal dose adjustment
IImipenem/cilastatin IV
Creatinine Clearance (mL/minute)
Standard Dose Maximum Dose
> 60 500 mg IV every 6 hours 1000 mg IV every 6 to 8 hours
31 to 60 500 mg IV every 8 hours 750 mg IV every 8 hours
≤ 30 500 mg IV every 12 hours 500 mg IV every 12 hours
Hemodialysis (HD) 500 mg IV every 12 hours, with the second dose after HD on HD days
500 mg IV every 12 hours, with the second dose after HD on HD days
LLevofloxacin IV/PO
Creatinine Clearance (mL/minute)
Standard Dose Maximum Dose
> 50 250 – 500 mg every 24 hours 750 mg every 24 hours
20 to 49 500 mg x 1, then 250 mg every 24 hours
750 mg every 48 hours
≤ 30 500 mg x 1, then 250 mg every 48 hours
750 mg x 1, then 500 mg every 48 hours
Hemodialysis (HD) 500 mg x 1, then 250 mg every 48 hours
750 mg x 1, then 500 mg every 48 hours
Linezolid IV/PO
Creatinine Clearance (mL/minute) Standard DoseAny 600 mg every 12 hours
No renal dose adjustment
MMeropenem IV
Creatinine Clearance (mL/minute)
Standard Dose Maximum Dose
> 50 1 gram IV every 8 hours
OR
500 mg IV every 6 hours
2 gram IV every 8 hours
26 to 50 1 gram IV every 12 hours
OR
500 mg IV every 8 hours
2 gram IV every 12 hours
10 to 25 500 mg IV every 12 hours 1 gram IV every 12 hours
< 10 500 mg IV every 24 hours 1 gram IV every 24 hours
Hemodialysis (HD) 500 mg IV every 24 hours, schedule after HD on HD days
1 gram IV every 24 hours, sched-ule after HD on HD days
Metronidazole IV/PO
Creatinine Clearance (mL/minute) Standard Dose TrichomonasAny 500 mg every 6-12 hours 2000 mg x 1 dose
No renal dose adjustment
Moxifloxacin IV/PO
Creatinine Clearance (mL/minute) Standard DoseAny 400 mg every 12 hours
No renal dose adjustment
NNafcillin IV
Creatinine Clearance (mL/minute) Standard DoseAny 2 grams IV every 4 hours
No renal dose adjustment
Nitrofurantoin PO (MacroBID)
Creatinine Clearance (mL/minute) Standard Dose≥ 40 100 mg PO every 12 hours
< 40 Avoid in patients with CrCl less than 40 due to inad-equate urinary concentrations and increased risk of
adverse effects
Norfloxacin PO
Creatinine Clearance (mL/minute) Standard Dose≥ 30 400 mg PO every 12 hours
< 30 400 mg PO every 24 hours
Hemodialysis 400 mg PO every 24 hours, schedule after HD on HD days
OOfloxacin PO/IV
Creatinine Clearance (mL/minute) Standard Dose> 50 200 - 400 mg every 12 hours
< 50 200 – 400 mg every 24 hours
Hemodialysis 200 – 400 mg every 24 hours. Ofloxacin is not removed efficiently by HD and no manufacturer
recommendations are available.
PPenicillin G IV
Creatinine Clearance (mL/minute) Standard dose Maximum dose> 50 2 million units IV every
4 hours4 million units IV every 4
hours
10 to 50 2 million units IV every 6 hours
4 million units IV every 6 hours
< 10 2 million units IV every 8 hours
4 million units IV every 8 hours
Hemodialysis (HD) 2 million units IV every 8 hours,
schedule so that a dose is administered as soon
as possible after HD
4 million units IV every 8 hours,
schedule so that a dose is administered as soon as
possible after HD
Penicillin V PO
Creatinine Clearance (mL/minute) Standard Dose≥ 10 500 mg PO every 6 hours
< 10 500 mg PO every 8 hours
Hemodialysis (HD) 500 mg PO every 8 hours
Piperacillin-tazobactam IV
Creatinine Clearance (mL/minute) Standard Dose> 40 4.5 grams IV every 6 hours
20 to 39 4.5 grams IV every 8 hours
< 20 4.5 grams IV every 12 hours
Hemodialysis (HD) 4.5 grams IV every 12 hours, schedule so that one of the every 12 hour doses is administered after HD
Polymyxin B
Creatinine Clearance (mL/minute) Treatment
ANY 1.25 mg/kg to 1.5 mg/kg IV every 12 hours
No renal dose adjustmentPolymyxin B sulfate 10,000 units = 1 mg. Dose based on actual body weight. Round doses to the near-est 50 mg vial.
TTrimethoprim/sulfamethoxazole IV
Creatinine Clearance (mL/minute) UTI, SSTI Other Infections> 30 2.5 mg/kg IV every 12
hours5 mg/kg IV every 8 to 12
hours
10 to 30 2.5 mg/kg IV every 12 hours
5 mg/kg IV every 12 to 24 hours
< 10 2.5 mg/kg IV every 24 hours
5 mg/kg IV every 24 hours
Hemodialysis (HD) 5 mg/kg IV three times per week after HD
7 to 10 mg/kg IV three times per week after HD
Trimethoprim/sulfamethoxazole is dosed off by mg/kg of trimethoprim component.
Trimethoprim/sulfamethoxazole PO
Creatinine Clearance (mL/minute)
UTI, SSTI Other Infections
> 30 1 DS tablet PO every 12 hours 2 DS tablets PO every 12 hours
10 to 30 1 DS tablet PO every 12 hours 1 to 2 DS tablets PO every 12 hours
< 10 1 DS tablet PO every 24 hours 1 to 2 DS tablets PO every 24 hours
Hemodialysis (HD) 1 DS tablet PO every 24 hours OR
2 DS tablets PO three times per week after HD
2 DS tablets PO every 24 hours OR
7 to 10 mg/kg PO three times per week after HD
DS = double strength. Trimethoprim/sulfamethoxazole is dosed off of mg/kg by trimethoprim compo-nent.
Tigecycline IV
Creatinine Clearance (mL/minute) Standard DoseANY 100 mg IV x 1, then
50 mg IV every 12 hours
No renal dose adjustment necessary. Reduce dose to 100 mg x 1, then 25 mg IV every 12 hours for Child-
Pugh class C liver dysfunction.
Antibiotic Treatment Guideline
Name: ___________________________________
Month/Year: _____________________________
Hospital: ________________________________
Department: _____________________________
October 2019
THE GLOBAL HEALTH INITIATIVETHE GLOBAL HEALTH INITIATIVE