8/3/2019 Antimicrobial Treatment of Sepsis (2)

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Date: ____________ Time: _______ Physician Signature: _______________________________ VORB

Date: ____________ Time: _______ Nurse Signature: _____________________________________

Date: ____________ Time: _______ Sent to Pharmacy by: _____________________ Initials__________

Page 1 of 2 Original-Chart Copy-Pharmacy Patient Label

Version: 1 Antimicrobial Treatment for Sepsis

Release Date: Order Set

Orders preceded with a:

must be checked to be initiated.

will be initiated unless a line is drawn through them.

Bulleted items indicate reminders 1026 A Avenue NE

Antimicrobial Treatment for Sepsis Cedar Rapids, Iowa 52406

Patient data

Information needed for pharmacy to dose antibiotics:Weigh patient as soon as possible. Actual weight ________kgIf unable to weigh now: Estimate weight _________kgHeight ________ ft _________in or __________cm

UnknownSources

(Choose one):Piperacillin/Tazobactam (Zosyn) 3.375 grams intravenously NOW and every 6 hoursAND

Levofloxacin (Levaquin) 750mg intravenously NOW and every 24s ANDVancomycin 20mg/kg = _____________ mg IV NOW then per pharmacy protocol

If Penicillin/Cephalosporin Allergy:Levofloxacin (Levaquin) 750 mg intravenously NOW and every 24 hours AND

Aztreonam (Azactam) 2 grams intravenously NOW and every 8 hours AND

Vancomycin 20mg/kg = _____________mg IV NOW then per pharmacy protocol.

Intra-abdominalInfection

(Choose one):Cefotetan (Cefotan) 1gram intravenously NOW and every 12 hours

If Penicillin/Cephalosporin Allergy:Levofloxacin (Levaquin) 500mg intravenously NOW and every 24 hours AND

Metronidazole 500mg intravenously NOW and every 8 hours

Skin and SoftTissue

Infection(SSTI)

(Choose one):MSSA SSTI (Methicillin-susceptible Staph aureus):Nafcillin 1gram intravenously NOW and every 4 hoursCefazolin (Ancef) 1 gram or (2 grams if weight is greater than 80 kilograms)intravenously

NOW and every 8 hours

PCN/Cephalosporin Allergy:Clindamycin (Cleocin) 600 mg intravenously every 8 hours

MRSA SSTI (Methicillin-resistant Staph aureus):Vancomycin 20mg/kg = __________ mg intravenously NOW and per pharmacy protocol

8/3/2019 Antimicrobial Treatment of Sepsis (2)

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Date: ____________ Time: _______ Physician Signature: _______________________________ VORB

Date: ____________ Time: _______ Nurse Signature: _____________________________________

Date: ____________ Time: _______ Sent to Pharmacy by: _____________________ Initials__________

Page 2 of 2 Original-Chart Copy-Pharmacy Patient Label

Version: 1 Antimicrobial Treatment for Sepsis

Release Date: Order Set

Urinary TractInfection

(Choose one):Ceftriaxone (Rocephin) 1 gram intravenously NOW and every 24 hoursPiperacillin/Tazobactam (Zosyn) 3.375 grams intravenously NOW and every 6 hoursLevofloxacin (Levaquin) 750mg intravenously NOW and every 24 hoursAmpicillin 2 grams intravenously NOW and every 6 hours AND Tobramycin 5mg/kg

intravenously NOW (if creatinine clearance greater than 20 ml/minutes) and then perpharmacy protocol

FebrileNeutropenia

(Choose one):Monotherapy:Imipenem/Cilastatin (Primaxin) 500 mg intravenously NOW and every 6 hours

Combination therapy:Imipinem/Cilastatin (Primaxin) 500mg intravenously NOW and every 6 hours AND

Tobramycin 7mg/kg intravenously NOW (if creatinine clearance greater than 20ml/minutes)

and then per pharmacy protocolCefepime (Maxipime) 2 grams intravenously NOW and every 8 hours AND

Tobramycin 7mg/kg intravenously NOW (if creatinine clearance greater than 20ml/minutes)

and then per pharmacy protocol

If risk factors for MRSA are present, ADD the following in addition to the selections above,Vancomycin 20mg/kg = ________mg intravenously NOW and per pharmacy protocol

Meningitis

(Choose one):Ceftriaxone (Rocephin) 2 grams intravenously NOW and every 12 hoursCeftriaxone (Rocephin) 2 grams intravenously NOW and every 12 hours AND

Vancomycin 20 mg/kg = ______ mg intravenously NOW and per pharmacy protocol

If patient is over 50 years old OR immunocompromised ADD the following in addition tothe selections above:Ampicillin 2 grams intravenously NOW and every 4 hours