% Susceptible Atlanta VAMC January - December 2018

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1 # tested Penicillin (non-meningeal) Penicillin (meningeal) Erythromycin Clindamycin Rifampin Vancomycin Trimeth-Sulfa # tested Amp / Sulbactam Piperacillin/Tazo Cefazolin (Urine ONLY) 4 Ceftriaxone Ceftazidime Cefepime Imipenem Gentamicin Tobramycin Amikacin Trimeth-Sulfa % Susceptible Atlanta VAMC January - December 2018 Gram Negative Aerobe Acinetobacter baumanii * 2017 and Citrobacter freundii * 2017 and Citrobacter koseri Enterobacter aerogenes Enterobacter cloacae Escherichia coli Klebsiella oxytoca Klebsiella pneumoniae Morganella morganii Proteus mirabilis Pseudomonas aeruginosa Serratia marcescens Levofloxacin 1 Nitrofurantoin 5 Methicillin 2 Gram Positive Aerobe Staph. aureus (MSSA) Staph. aureus (MRSA) Staphylococcus, coagulase negative Strep. pneumoniae Enterococcus faecalis Enterococcus faecium Ceftriaxone (non-meningeal) Ceftriaxone (meningeal) Tetracycline 3 Levofloxacin 1 Gentamicin # Nitrofurantoin 5 1=respresentative of moxifloxacin 2=representative of nafcillin,dicloxacillin,cefazolin,cephalexin 3=representative of minocycline, doxycycline # = synergistic with B-lactam or vancomycin 4=representative of cephalexin, 5=active in urine only

2 Indication Community Acquired Pneumonia 1 (CAP) HAP/VAP/HCAP 2,11 (nosocomial) HCAP 1. Hospitalized pre 3mths 2. NH or LTC pt 3. Long term HD pt 4. Immunosuppressed Aspiration Pneumonia Community Acquired Intraabdominal 3 Complicated or Hospital Acquired Intraabdominal 3 Likely pathogens S. pneumo, H. influenzae Atypicals Enteric gram negs Enteric gram neg, Acinetobacter, Enterobacter, MRSA or MSSA Gram + anaerobes, respiratory flora Bacteroides, other enteric gram negs Bacteroides, Enterococcus other enteric gram negs, yeast Atlanta VA Medical Center Antimicrobial Empiric Treatment Guidelines Empiric Therapy *Dosing based on normal renal function Ceftriaxone 2g IV q24h +Azithromycin 500mg IV q24h Cefepime 2g IV q8h OR Pip/tazo 4.5g IV q6h + Vancomycin IV Optional expanded gram negative double coverage: Gentamicin 7mg/kg IV q24h OR Levofloxacin 750 IV mg q24h Amp/sul 3g IV q6h if CAP (+ azithromycin) OR Pip/tazo 4.5g IV q6h if HAP/HCAP (+vancomycin) Ceftriaxone 2g IV q24h + Metronidazole 500mg IV q8h Cefepime 2g IV q8h + Metronidazole 500mg IV q8h OR Pip/tazo 4.5g IV q6h +/- Vancomycin IV Alternative Therapy *Dosing based on normal renal function Penicillin allergy Levofloxacin 750mg IV/PO q24h Penicillin allergy (non IgE mediated) Cefepime 2g IV q8h + Vancomycin IV (IgE mediated) Aztreonam 2g IV q8h + Levofloxacin 750mg IV q24h + Vancomycin IV Moxifloxacin 400mg IV/PO q24h Cipro 400mg IV q12h +Metronidazole 500mg IVq8h Cipro 400mg IVq12h + Metronidazole 500mg IV q8h +/- Vancomycin IV Duration Oral Empiric Step Down 5 days Amox/clav + Azithromycin 7 days Levofloxacin 7-10 days Amox/clav, Moxi or Clinda 4-7 days w/ adequate drainage 4-7 days w/ adequate source control Cefpoxidime or +Metronidazole +Metronidazole Febrile Neutropenia 4 Meningitis 5 Enteric gram neg, Strep sp. Staph sp, MRSA S. pneumo N. meningitides Listeria Viral (HSV) Non-purulent/cellulitis β-hemolytic Streptococcus sp Cefepime 2g IV q8h +/- Vancomycin IV (catheter in place, SSTI, PNA, or unstable) Ceftriaxone 2g IV q12h + 2g IV q4h (if pt >50 y/o, pregnant or immunosuppressed) +Vancomycin IV +/- Acyclovir 10mg/kg IV q8h if HSV suspected Mild See oral empiric step down section Moderate/Severe Cefazolin 2g IV q8h Aztreonam 2g IV q8h + Gentamicin 7mg/kg IV q24h + Vancomycin IV If nosocomial risks or post neuro surgical Cefepime 2g IV q8h + Vancomycin - (Obtain ID Consult) Vancomycin IV + Moxifloxacin 400mg IV q24h +/- Trimeth/Sulfa IV Mild- Severe β-lactam allergy Clindamycin 300mg PO q6h Moderate/Severe Severe β-lactam allergy Vancomycin IV OR Clindamycin 900mg IV q8h source/count recovery 7-21 days Pathogen dependent *Consult ID* Levofloxacin Not appropriate 7-10 days Cephalexin, Clindamycin or Amox/clav Skin and Soft Tissue Infections (SSTI) 6,7 Diabetic Foot Infection 8 Purulent/abscess Staphylococcus sp MRSA vs MSSA Necrotizing Fasciitis Surgical Debridement Necessary Type I- Polymicrobial Type II- Group A Strep Polymicrobial Staph sp, Strep sp, anaerobes Severe/Sepsis, bites, open wound, foreign body, or immunosuppressed Pip/tazo 4.5g IV q6h + Vancomycin IV Mild if no systemic symptoms, I&D may be all that is needed See oral empiric step down Moderate/Severe MRSA- Vancomycin IV MSSA - Cefazolin 2g IV q8hrs OR Nafcillin 2g IV q4hrs Initial empiric or polymicrobial coverage Pip/tazo 4.5g IV q6h + Clindamycin 900mg IV q8h +Vancomycin IV If Streptococcus sp or Clostridia sp Penicillin 24 MU IV continuous over 24h + Clindamycin 900mg IV q8h If no evidence of clinical instability/sepsis-get bone/wound cx first Mild- see SSTI section Moderate /Sulbactam 3g IV q6h + Vancomycin IV Severe/Sepsis etc Severe β-lactam allergy Cipro 400mg IVq12hr + Metronidazole 500mg IV q8h + Vancomycin IV Mild Severe β-lactam allergy Trimeth/Sulfa 2 DS BID OR Doxycycline 100mg BID Moderate/Severe Severe β-lactam allergy Vancomycin IV Initial empiric - Aztreonam 2g IV q8h + Clindamycin 900mg IV q8h + Vancomycin IV Mild- see SSTI section Moderate/Severe Severe β-lactam allergy Cipro 400mg q12h IV + Metronidazole 500mg IV q8hr + Vancomycin IV 7-10 days MRSA- Trimeth/Sulfa or Doxycycline MSSA Cephalexin or Amox/clav Variable response and surgical debridement Variable severity +/- osteomyelitis Based on cultures or initial empiric treatment Clostridium difficile Infection Severe: pseudomembraneous colitis or 2 of the following (WBC 15,000 cells/µl, SCr 1.5 times baseline, ICU admit, age > 60yr, albumin < 2.5 mg/dl, temp > 38.3oC) 2. Severe/complicated: above criteria + hypotension, shock, ileus, and/or megacolon Severe limb/life threatening Pip/tazo 4.5g IV q6h + Vancomycin IV Discontinue inciting antimicrobial agent(s) & opiates as soon as possible may increase relapse risk Initial episode, mild, moderate or severe: Vancomycin 125mg PO q6h Initial episode, severe/complicated: Vancomycin 500mg PO/NG q6h + Metronidazole 500mg IV q8h (may add Vancomycin enema for ileus) -Vancomycin 500mg/100ml NS Per Rectally q6h Recurrence: 1st recurrence: Vancomycin PO if metronidazole used initially OR Vancomycin PO with taper if vancomycin PO used initially 2nd recurrence: Consider ID consult Vancomycin oral taper: 125mg po q6h for days then 125 mg po q12h for 7 days then 125mg po q24h for 7 days then 125mg po q48h for 2-8 weeks 10 days May consider extending treatment for CDI in patients who are continued on antibiotics for other infections. Consider ID consult for with complicating factors ID consult strongly recommended for: S. aureus bacteremia, fungemia, meningitis in immunosuppressed, necrotizing fasciitis, and endocarditis. Consult Pharmacy to dose and monitor vancomycin and aminoglycosides Duration of therapy recommendations are based on uncomplicated course with control/removal of infected sources, longer courses may be necessary depending on complicating factors Penicillin allergy = non-anaphylactic reaction; 3 rd and 4 th gen cephalosporins and carbapenems have 1% cross reactivity rate Severe B-lactam allergy= Type I reaction (anaphylaxis); avoid all β-lactams

3 Only obtain UA & Urine Culture in patients with signs and symptoms of UTI* [fever (>38.0 C) in a pt = 65 yrs, suprapubic tenderness, costovertebral angle tenderness, urinary urgency, frequency, or dysuria] Asymptomatic bacteriuria (ASB) - positive urine culture w/o symptoms - Should be considered colonization, NOT infection. - Treatment of ASB is NOT recommended * *Exception: pregnant women and pts undergoing invasive urologic procedure with risk of mucosal bleeding Key Points on ASB in the Elderly - In elderly, UA SHOULD NOT be done as a matter of routine - UA often contaminated in the elderly and many have ASB - Pyuria is common in pts with ASB as high as 100% in pts with long-term catheters - Use caution in testing in pts with weakness, delirium, and mental status change - Seek other causes, remember the high prevalence of ASB, and individualize care Setting Definition Organisms Inpatient Treatment 1,3 Outpatient/Oral 1,3 Other Uncomplicated Complicated Pyelonephritis Prostatitis Women without kidney involvement, obstruction, or recent (foley) Men without kidney or prostate involvement, obstruction, or recent (foley) Obstruction, recent (foley), stone, neurologic deficit, congenital abnormalities Upper GU tract infection S. saprophyticus, Klebsiella, Proteus Klebsiella, Proteus Enterococcus, Other GNRs Enterococcus, Other GNRs <35y/o gonorrhoea & chlamydia >35y/o GNRs Inpatient IV preferred Ceftriaxone 1g IV q24h x 7 days If severe penicillin allergy IV 400mg BID x 5 days Same as women above Change Foley Inpatient IV preferred Ceftriaxone 2g IV q24h x 7-10days Risk of pseudomonas Cefepime1g IV q8h x 7-10days Empiric Urinary Tract Infection Guidelines 9 Notice: Due to >30% resistance to amoxicillin, and amox/clavu to E.coli, these agents are no longer recommended for empiric treatment of UTIs at ATL. ***Please obtain UA AND culture then adjust therapy appropriately*** If severe penicillin allergy 400mg IV BID x 7 days Same as complicated Ceftriaxone 250mg IM x1 then Doxycycline 100mg po BID x 7 days OR Azithromycin 1g po x1 Bactrim DS po BID x 4-6 weeks 500mg po BID x 4-6 weeks Nitrofurantion 100mg po BID 2 x 5 days Cephalexin 500mg po q8h x 7 days Trimeth/Sulfa 1 DS po BID x 3 days Trimeth/Sulfa 1 DS po BID x 7 days Cephalexin 500mg po q8h x 7 days Cefpodoxime 400mg BID x 7-10 days Trimeth/Sulfa 1 DS po BID x 7-10 days Give 1x dose of long acting agent before starting oral Ceftriaxone 1g x 1 Gentamicin 5mg/kg x1 Cefpodoxime 400mg BID x 14 days Trimeth/Sulfa 1 DS po BID x 14 days 500mg BID x 5 days Fosfomycin 3g sachet x1 500mg BID x 5 days Fosfomycin 3g sachet x1 500mg BID x 7 days 500mg BID x 7 days and Trimeth/Sulfa should be avoided in pregnancy Caution use or avoid nitrofurantoin and trimeth/sulfa in adults > 75 yo IV recommended until patient is afebrile for 24hrs Do NOT use nitrofurantion, cephalexin, or fosfomycin UA does not reflex to a urine culture. Please order urine culture separately R/O prostatitis. B-lactams will penetrate in acute prostatitis but quinolones/bactrim recommended in chronic prostatitis (see below) Same ID consult Quinolones no longer recommended for GC Test of cure for non-1 st line Same Same β-lactams do not penetrate the prostate very well 1 Adjust therapy based on culture and or s/s of improvement 2 Not recommended in men with complicated UTI or prostate involvement, pyelonephritis, or CrCl <40; it is considered a urinary antiseptic and does not penetrate systemically 3 Based on normal renal function CPRS order menu: Orders > Inpatient Medications > Empiric Antimicrobial Order Menu (left column) Questions? - Tiffany Goolsby, ID PharmD References 1.CID. 2007; 44:S27-S72 2.Am J Respir Crit Care Med 2005;171: CID. 2010;501: CID. 2011;52:e56-e93 5.CID. 2004;39: CID. 2005;41: CID. 2011;52: CID. 2004;39: CID. 2011; 52: e103-e120 and CID. 2005; 40: and CID. 2010; 50: Infect Control Hosp Epidemiol, 2010; 31(5): CID. 2016; Jul 14 Epub

4 Antimicrobial Amikacin Amphotericin B lipid complex Acyclovir Amoxicillin Amoxicillin/ Clavulanate / Sulbactam Azithromycin Aztreonam Cefazolin Cefepime Cefpodoxime Ceftazidime Ceftriaxone Cephalexin Atlanta VA Medical Center Antimicrobial Dosing Guideline January 2019 Normal Dose Abelcet 3-5mg/kg IV (TBW) q24h IV: 5-10mg/kg (TBW) q8h Use 10mg/kg in CNS and Zoster Oral: Zoster, ophthalmic HSV 400mg (HSV)-800mg (Zoster) 5Xday Oral: HSV genital/oral Treatment - 400mg q8h Suppression - 400mg q12h mg PO q8h Renal dose Adjustment Based on CrCl - ml/min Hemodialysis (HD)* Comments Level is sent out IVF bolus w/ q dose & Mx K/Mg daily. Use ABW if obese : 5-10mg/kg q12h 11-24: 5-10mg/kg q24h 10: 2.5-5mg/kg q24h 10-25: mg q8h <10: mg q12h 2.5-5mg/kg q24h post HD mg q12h Use IBW if obese < 10: 400mg q12h <10: 200mg q12h 400mg q12h 200mg q12h 11-29: mg q12h mg q24h 10: mg q24h 875/125mg PO q12h OR 11-29: 500/125mg q12h 500/125mg q24h Only use 875mg in 500/125mg PO q8h 10: 500/125mg q24h CrCl >30 1-2g IV q4-6h 30-49: 1-2g q6-8h 1-2g q12h give 2nd Use 2g IV q4h in meningitis and endocarditis 11-29: 1-2g q8-12h dose post HD on HD days 10: 1-2g q12h 3g IV q6h 30-49: 3g q8h 3g q12h give 2nd dose 15-29: 3g q12h post HD on HD days 14: 3g q24h mg PO/IV q24h Do not use with 1-2g q24h Use 2g in Sepsis, Pneumonia, Obese, Febrile Neutropenia Use 2g in >80kg, Endocarditis, Bacteremia, Pneumonia, Osteomyelitis Use 2g in Sepsis, Pneumonia, Meningitis, Febrile neutropenia 11-29: 1-2g q12h 10: 1-2g q24h 11-49: 1-2g q12h 10: 1-2g q24h 30-59:1-2g q12h 11-29: 1-2g q24h 10: 2g load x1, 1g q24h 2g M,W & 3g F post HD (or 2g T,Th and 3g Sat) 2g 3x week post HD mg PO q12h 30: mg q24h mg 3x week post HD 31-49: 1-2g q12h 1-2g 3x week post HD Use 2g in Sepsis, Pneumonia, 10-30: 1-2g q24h Meningitis, Febrile neutropenia <10: 1-2g x1, 500mg - 1g q24h 1-2g IV q24h Use 2g in >80kg, endocarditis, osteomyelitis 2g q12h in meningitis 500mg PO q6h Use q8h dosing in cystitis only Oral: mg q12h Use 750mg in Osteo,Nosocomial pneumonia, Pseudomonas IV: 400mg IV q8-12h Use q8h in Sepsis, Osteo,Nosocomial Pneumonia, Febrile Neutropenia 31-49: 500mg q8h 11-30: 500mg q12h 250mg q12h Do not use in bacteremia or 10: 250mg q12h pyelonephritis <30: mg q24h mg q24h SBP ppx: 500mg q24h (preferred) or 750mg qweek <30: 400mg q12-24h 400mg q24h Do not use with Clarithromycin 500mg PO q12h <30: 500mg q24h 500mg q24h Monitor QTC IV dose: mg IV q8h No Change Clindamycin Oral dose: mg PO q6-8h 4-6mg/kg IV q24h < 30: 4-6mg/kg q48h 4-6mg/kg q48h OR Do not use in Daptomycin Use 4mg/kg q24h UTI and SSTIs 4-6mg/kg MW & 6- pneumonia. 8-10mg/kg may be used in severe infxns 9mg/kg F post HD Follow CPK weekly. Doxycycline 100mg IV/PO q12h Ertapenem Nonformulary 1g IV q24h < 30: 500mg q24h 500mg q24h Severe Infections- Candidemia: < 50: 50% dose q24h 100% 3x week post HD Fluconazole 800mg (12mg/kg)x1, then 400mg IV OR 50% dose q24h (6mg/kg) q24h Other: mg IV/PO q24h Gentamicin Levofloxacin Mild-Moderate Infections 500mg IV/PO q24h Severe Infections - Sepsis, Osteo, Nosocomial pneumonia, cssti 750mg IV/PO q24h 21-49: 500mg x1, 250mg q24h 20: 500mg x1, 250mg q48h 21-49: 750mg q48h 20: 750mg x1, 500mg q48h Monitor QTC Level is done in house 500mg x1, 250mg q48h Do not use with 750mg x1, 500mg q48h

5 Atlanta VA Medical Center Antimicrobial Dosing Guideline January 2019 Linezolid Meropenem 600mg IV/PO q12h Do not use in bacteremia. Follow platelets. Use 2g in meningitis 26-50: 1-2g q12h 10-25: 1-2g x1, 0.5-1g q12h <10: 1-2g x1, 0.5-1g q24h 1-2g x1, 0.5-1g q24h Metronidazole 500mg IV/PO q8h <10: 500mg q12h Micafungin 100mg IV q24h 150mg IV q24h in Esophageal candidiasis Moxifloxacin 400mg IV/PO qday Nafcillin 2g IV q4h or 12g CI over 24 hours Nitrofurantoin (Macrobid) 100mg PO q12h for uncomplicated UTI Limit to short courses of 5-7 days <30: Avoid use; risk of toxic serum levels and lack of efficacy Avoid use Treatment 30-59: 30mg q12h 30mg 3x week post HD 75mg PO q12h x 5-10 days 10-29: 30mg q24h Oseltamivir Prophylaxis 30-59: 30mg q24h 30mg alternating every 75mg PO q24h x 7-10 day 10-29: 30mg q48h other HD session 2-4MU IV q4h 11-49: 2-3MU q4h 1-2MU q4-6h 10: 1-2MU q4-6h Penicillin G 12-24MU IV CI over 24h 11-49: 8-16MU CI q24h Use above dose 10: 6-12MU CI q 24h Penicillin VK mg PO q6h < 10: mg q8h mg q8h Posaconazole 300mg IV/PO BID x1 day, then qday (IV or Delayed Release (DR) tabs dosing only) Nonformulary Piperacillin/ tazobactam Trimethoprim /Sulfameth Tobramycin Vancomycin Valacyclovir Mild to Moderate Infections 3.375g IV q6h Severe or Nosocomial Infections / Sepsis 4.5g IV q6h Mild to Moderate - SSTI or UTI 5mg/kg/day IV/PO divided q12h OR 1 DS tab q12h Moderate to Severe- cssti 8-15mg/kg/day IV/PO divided q6-12h 1-2 DS tab q12h Severe Infection or PJP 15-20mg/kg/day IV/PO divided q6-8h PJP Prophylaxis 1DS tab q24h or 3x week Load: 20-25mg/kg IV (TBW) x1 Maintenance: 15mg/kg IV (TBW) q12h Use q8h if 35 y/o and crcl >90 Herpes Zoster (Shingles) 1g PO q8h Herpes labialis (cold sore) 2g PO q12h x 2 doses HSV genital, Initial 1g PO q12h x 7days HSV genital, Recurrent 500mg PO q12h x3 days HSV genital Suppression, 9 episodes/year 500mg PO q24h HSV genital Suppression, 10 episodes/year 1g PO q24h (500mg q12h for HIV + pts) 21-39: 2.25g q6h 20: 2.25g q8h 21-39: 3.375g q6h 20: 2.25g q6h 10-29: 2.5 mg/kg/day OR 1 DS tab q24h <10: 1 SS tab q24-48h <30: 8-15mg/kg/day divided q6-12h for 48h, then 4-7 mg/kg/day divided q12h OR 1 SS tab q12h <10: 1 SS tab q24h 10-29: 7-10mg/kg/day divided q8-12h <10: 5mg/kg q24h 10-29: 1SS tab q24h or 3x wk <10: 1SS tab 3x week 40-59: q24h 20-39: q48h <20: 15mg/kg x1, Consult PKS Do not use in UTI. Do not use with QTC > 500 Do not use for pyelonephritis Avoid K in renal dx. Use higher dose in neurosyphilis, endocarditis, or serious infections. Suspension dosing differs. DR tabs preferred 2.25g q8h HD: Give next scheduled dose right after HD on HD days 2.25g q6h to avoid need for supplement dose 5mg/kg 3x week post HD OR 1 SS tab q24h 8-15mg/kg 3x week after HD OR 1 SS tab q24h 5mg/kg q24h 1SS tab 3x week after HD Dosed by Trimethoprim (TMP) component Single strength (SS)=80mg TMP Double Strength (DS)=160mg TMP Follow K and SrCr Level is sent out 15mg/kg x1, Consult PKS Adjust based on levels 30-49: 1g q12h <10/HD:1g x1, 500mg 10-29: 1g q24h q24h 30-49: 1g q12h x 2 doses <10/HD: 500mg x 1 dose 10-29: 500mg q12h x 2 doses 10-29: 1g q24h <10/HD: 500mg q24h <30: 500mg q24h 500mg q24h <30: 500mg q48h 500mg 3x week post HD <30: 500mg q24h 500mg q24h Max 1 st dose: 2000mg TBW- Total Body weight IBW- Ideal Body weight ABW- Adjusted Body Weight = IBW+[0.4 x(abw-ibw)] Obese - >120% of IBW MU- Million Units CI Continuous infusion Contact: Tiffany Goolsby, ID PharmD ext SSTI- Skin and soft tissue infection cssti- Complicated skin and soft tissue infection PJP- Pneumocystis jiroveci pneumonia PKS- Pharmacokinetic Service *No supplement after dialysis needed unless specified for the individual medication; give all q24h or q48h doses after HD on HD days # More info available on CPRS Tools Antimicrobial Stewardship References