SUPPLEMENT TO JAPI december VOL. 58 51 Antibiotic Usage Guidelines in Hospital Camilla Rodrigues * Use of surveillance data information of Hospital antibiotic policy guidelines from Hinduja Hospital. The data presented includes only the top few isolated from the respective cultures at Hinduja Hospital and intends to represent at least 80 of the responsible for a given infection. The antibiotic susceptibilities are obtained as per available microbiology records, from Hinduja Hospital. Antibiotic with at least 80 cover for most common should be selected as empenic choice. Drug susceptibility is mentioned as based on data collected from January to August 2009, at Hinduja Hospital. Steps to Follow the Protocols Identify the type of infection bloodstream, respiratory, intra-abdominal or urinary tract, o Define the location ICU or floor patient o Accordingly refer the respective chart Identify the patient type based on described parameters Type 1, Type 2 or Type 3. Refer to the empiric column for that patient type. This will give you the protocol drug to start If a column has more than one drug option Choose the drug showing better susceptibility data in the left hand side table OR Doctor s discretion advised Send respective cultures before starting antibiotic Once culture / sensitivity report available: Presumptive antibiotic may require to be changed Consult Microbiology / ID physician to decide the choice of antibiotic (based on narrowest spectrum antibiotic which covers the pathogen isolated) In all cases physician s discretion is advised based on patient condition * Consultant Microbiologist, PD Hinduja Hospital, Mahim, Mumbai 400 016 Hospital surveillance data (January-09 to August 09) Most common (n=124) 1 Klebsiella (n=44) 2 Escherichia coli (n=31) Blood Stream Infections - ICU Validity of these data: August- 35 Colistin (100) (96) (92) Amikacin (82) Pip-Taz/Cef- Sulb (75) 25 Colistin (100) Imipenem/ (91) /Amikacin (84 ) Pip - Taz /Cef- Sulb (71) 3 Pseudomonas 21 Colistin (100) aeruginosa (n=26) Imipenem (23) /Pip - Taz / Cef- Sulb / Amikacin (19) 4 Acinetobacter 11 Colistin (100) baumanii (n=14) Imipenem (43) Amikacin (36) 5 Enterobacter (n=9) 7 Colistin (100) / Pip-Taz / / Cef-Sulb /Amikacin (89) contact with health Contact with health Long hospitalization (e.g. last last with multiple within last exposure to group 2 carbapenems: Colistin - until culture report Consult Microbiology /ID Physician to decide on choice of
52 SUPPLEMENT TO JAPI december VOL. 58 Urinary Tract Infections - ICU (January- 09 - August 09) (n=115) (n=47) (n=28) 3 Pseudomonas aeruginosa (n=27) Validity of these data: August- 41 Colistin / (96) Amikacin (91) Pip - Taz (87) Netilmicin (85) Cef-Sulb(83) 24 Colistin (96) Amikacin / (78) 23 Colistin (100) Imipenem (47) Pip- Taz / Cef- Sulb / (41) 4 Enterococcus (n=7) 6 Vancomycin / linezolid (100) Co-amoxiclav (57) contact with health Contact with health Long hospitalization (e.g. last last within last exposure to group 2 carbapenems: Colistin - until culture report Consult Microbiology / ID Physician to decide on choice of Respiratory Tract Infections - ICU (January-09 to October 09) (n=224) 1 Pseudomonas aeruginosa (n=90) (n=64) 3 Acinetobacter baumanii (n=20) 40 Colistin (100) Cef- Sulb (49) Amikacin (44) 29 Colistin (97) Tigecycline (92) Imipenem (92) (92) Amikacin (83) 9 Colistin (100) Tigecycline (55) Imipenem (25) (15) 4 Enterobacter (n=ll) 5 Colistin / Tigecycline (100) /Amikacin (73) contact with health Contact with health Long hospitalization (e.g. last last within last / Coamoxiclav + Macrolide + Macrolide + Newer Colistin + Newer Consult Microbiology /ID Physician to decide on choice of
SUPPLEMENT TO JAPI december VOL. 58 53 Intra - Abdominal Infections - ICU (January-09 - October 09) (n=29) (n=10) 2 Enterococcus (n=6) 3 Klebsiella (n=5) 4 Enterobacter (n=4) 34 / Colistin / Tigecycline (100) (97) Amikacin / Cef- sulb (80) 21 Vancomycin / linezolid (100) Chloramphenicol (83) 17 Colistin (100) (83) Tigecycline / (80) 14 / Pip -Taz / / Cef- Sulb / Amikacin / Ciprofloxacin / Cotrimoxazole / Colistin (100) Tigecycline / Gentamicin (75) 5 Pseudomonas 10 Colistin (100) aeruginosa (n=3) Pip-Taz / Cef- sulb (33) contact with health Contact with health Long hospitalization (e.g. last last within last Cefuroxime + Tigecycline Sulbactam Colistin + Co-amoxiclav Consult Microbiology / ID Physician to decide on choice of (January-09 to August 09) (n=52) (n=29) (n=15) Blood Stream Infections - Floor Validity of these data: August- 56 / Colistin / Amikacin (97) (90) Pip -Taz / Cef - Sulb (86) 29 / Colistin / (100) Amikacin (93) Pip -Taz / Cef- Sulb (73) contact with health Contact with health Long hospitalization (e.g. last last within last Cefoperazone - / - Tazobactam ± Amikacin Consult Microbiology / ID Physician to decide on choice of
54 SUPPLEMENT TO JAPI december VOL. 58 Urinary Tract Infections - Floor (January-09 - August 09) (n=369) 1 Escherichia coii (n=231) Validity of these data: August- 63 (96) Amikacin (91) Pip-Taz/cefsulb(92) 2 Pseudomonas 15 Colistin (100) aeruginosa (n=56) Imipenem (39) (37) 3 Klebsiella (n=47) 13 Colistin (96) Imipenem/ (91) Amikacin (80) 4 Enterobacter (n=9) 2 Colistin (100) (78) Pip-Taz/Cef- Sulb (67) 5 Enterococcus (n=9) 2 Vancomycin / linezolid (100) contact with health Contact with health Long hospitalization (e.g. last last within last imm unodeficiency. Cefoperazone exposure to group 2 carbapenems: Colistin - until culture report Consult Microbiology / ID Physician to decide on choice of Respiratory Tract Infections - Floor (January-09 to October 09) (n=104) 1 Pseudomonas aeruginosa (n=37) (n=35) 3 Enterobacter (n=8) 4 Streptococcus (n=6) 5 Escherichia coli (n=5) 36 Colistin (94) Imipenem (78) Amikacin/Cef - sulb (73) Pip-Taz / / Ciprofloxacin (70) 34 Colistin (100 ) (96) Tigecycline (92) Amikacin (86) 8 / Pip-Taz /Cef - sulb Amikacin (100) Gentamicin /Tigecycline (88) 6 Ampicillin/ / Erythromycin (100) 5 / Pip-Taz / Cef- sulb Amikacin /Tigecycline / Colistin / (100) Gentamicin (80) contact with health Contact with health Long hospitalization (e.g. last last within last imm unodeficiency. / Coamoxiclav + Macrolide + Macrolide + Newer Colistin + Newer Consult Microbiology /ID Physician to decide on choice of
SUPPLEMENT TO JAPI december VOL. 58 55 Intra - Abdominal Infections - Floor (January-09 to October 09) (n=66) (n=34) 2 Enterococcus (n=12) 3 Klebsiella (n=9) 4 Pseudomonas aeruginosa (n=4) 5 Enterobacter (n=3) 52 / Colistin (100) / Amikacin / Tigecycline (97) 18 Vancomycin (100) 14 Colistin (100) Amikacin (88) (77) (75), Tigecycline (55) 6 Pip-Taz /Gentamicin / Colistin (100) / Cef-sulb /Netilmicin /Amikacin (75) 5 / Pip -Taz / Cef - Sulb / / Ciprofloxacin / Tigecycline / Colistin (100) contact with health Contact with health Long hospitalization (e.g. last last within last Cefuroxime + Tigecycline Sulbactam Colistin + Co-amoxiclav Consult Microbiology /ID Physician to decide on choice of Antibiotic Prophylaxis for Surgery * Procedure Antibiotic Clean surgeries (example: elective hernia repair, breast surgeries) Orthopedic surgery Cardiovascular / vascular surgery Neurosurgery Ophthalmic surgery Topical quinolone. Immediate pre operative betadine, Systemic Head, neck and ENT surgery Gastroduodenal Cefuroxime / Cefazolin Appendicular / Colorectal surgery Biliary Abdominal / Vaginal hysterectomy / Caesarian section Urologic surgery Cefuroxime / Cefazolin and Cefuroxime / Cefazolin Cefuroxime (or as guided by urine culture) Antibiotic Dosing Drug Standard dose Weight based dose Cefazolin < 80 kg: 1 gm > 80 kg: 2 gm 20-30 mg/kg/ dose Duration for bolus injection (infusion) 3-5 mins (20-60 mins) Cefuroxime 1.5 gm 50 mg/kg 3-5 mins (20-60 mins) 0.5-1 gm 15 mg/kg initial dose (7.5 mg/kg subsequent doses) (30-60 mins) * As per existing Infection Control Book - Hinduja Hospital
56 SUPPLEMENT TO JAPI december VOL. 58 Standard Dosages of Commonly Used Drugs * Antibiotic Colistin Imipenem/cilastatin Piperacilin Tazobactam Ampicillin - Sulbactam Doses <60 Kg : 50,000-75,000 Units/Kg daily in 3 divided doses >60 Kg : 1-2 million units every 8hrs 1-2 gm daily (in 3-4 divided doses) Less sensitive organism: upto 50 mg/ kg daily (max 4 gm daily) in 3-4 divided doses. 500 mg every 8 hrs, dose doubled to 1 gm every 8 hours in hospital-acquired pneumonia, peritonitis, septicemia and infections in neutropenic patients 1 gm once daily 12 g piperacillin /1.5 g tazobactam given in divided doses every 6 or 8 hours. Doses as high as 18g piperacillin /2.25 g tazobactam per day in divided doses can be used in infections. 1.5 g (1 g ampicillin as the sodium salt plus 0.5 g sulbactam as the sodium salt) to 3 g (2 g ampicillin as the sodium salt plus 1 g sulbactam as the sodium salt) every six hours Sulbactam Cefoperazone Sulbactam(l:l) ( available as 1+1 gm OR 2+2 gm forms) - 2gm to 4gm per day IM or IV, in equally divided doses every 12h. Cefoperazone Sulbactam(2:l) ie. 3 gm : 1.5 gm 12 h Co Amoxiclav 500 mg every 12 hours or 250 mg every 8 hours 1 gm every 8 hrs to 1 gm every 6hrs in more serious infection Tigecycline >18 yrs : initially loomg, then 50mg every 12 hrs for 5-14 days lgm daily OR 2-4gm daily in infections Cefuroxime Ofloxacin Oral (cefuroxime axetil): 250-500 mg twice daily for 10 days 1.5 gm every 6-8 hrs in infection 200 to 400 mg every 12 hours 200mg over at least 30 mins once to twice daily Antibiotic Ciprofloxacin Moxifloxacin Levofloxacin rfloxacin Linezolid Vancomycin Teicoplanin Amikacin Erythromycin Clarithromycin Azithromycin Nitrofurantoin Doses 250 to 500 mg twice daily 200 mg over 30-60 mins OR 400mg over 60 mins - twice daily Oral / 400 mg (orally or as an intravenous infusion) once every 24 hours 250, 500 or 750 mg every 24 hours 500 mg once or twice daily - over at least 60 mins 400 mg twice daily Oral / intravenous: 600 mg every 12hrs (if i.v - infusion over 30-120 mins) 2 gm given as 500 mg 6 hourly or 1 gm every 12 hrs; elderly over 65 yrs, 500 mg every 12 hrs or 1 gm once daily Severe infection lomg/kg/day every 12 hours for first 3 doses, then lomg/kg/day iv once daily 15 mg/kg over 1 hour loading dose and 7.5 mg/kg 3 to 4 tomes a day maintainance dose 15 mg/kg daily in 2 divided doses; increased to 22.5 mg/kg daily in 3 divided doses in infection; maximum 1.5 gm daily for upto 10 days (max cumulative dose 15 gm) 500 mg four times a day Severe infection, 50 mg/kg daily by continuous infusion or in divided doses every 6 hrs; mild infection (if oral not possible) : 25 mg/kg daily 250 to 500 mg twelve hourly Intravenous / 500 mg once daily for 3 days or 500 mg on first day then 250 mg once daily for 4 days 50 mg every 6 hrs with food; chronic recurrent infection : 100 mg every 6 hrs with food * All dosages mentioned are from British National Formulary 2008 / respective product monographs, and are for healthy adult. Necessary adjustments to be for hepatic / renal insufficiency, pediatric patients and as per clinician s discretion. Please refer product literature for dosages of drugs not listed here.