Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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DAPTOMYCINInfectious Disease approval is required for all use of daptomycin (See Appendix I).Usual DoseAdult: 4 or 6 mg/kg once daily IV based on IBW (UWHC cost/day $136.04-203.28).Indications1. Complicated skin and skin-structure infections caused by resistant Gram-positive pathogens, including penicillinresistantStreptococcus pneumoniae, methicillin-resistant Staphylococcus aureus with vancomycin MIC greaterthan 1.5, and vancomycin-resistant enterococci.2. Gram-positive right-sided Endocarditis and complicated Staphylococcal bacteremias. Dose is 6 mg/kg/day.3. Empiric therapy for known Staph aureus bacteremia for 24-48 hours until the vancomycin MIC for MRSA is knownto be less than 1.5.CommentsIncreased dosing interval to every 48 hours recommended in renal insufficiency with creatinine clearance less than 30mL/min. Not indicated in pneumonia. Dosing in HD patients should occur after the dialysis session for inpatients. Therecommended dosing strategy for outpatient dialysis is the 2 minute infusion immediately following the HD session. Thismethod does not require a supplemental dosage increase.DARUNAVIRFor up-to-date information on the use of antiretrovirals, consult an HIV expert or www.aidsinfo.nih.gov/DELAVIRIDINE non-formulary at UWHCFor up-to-date information on the use of antiretrovirals, consult an HIV expert or www.aidsinfo.nih.gov/DICLOXACILLINUsual DoseAdult: 250-500 mg four times daily PO (UWHC cost/day $0.82-1.45).Pediatrics:** 12 – 25 mg/kg/day PO in divided doses Q6H (no suspension available – use nearest capsule size).Indications1. Infections caused by or suspected of being caused by methicillin-susceptible staphylococci. Dicloxacillin is the drug ofchoice for outpatient therapy of susceptible S aureus infections.2. Skin and soft tissue infections.CommentsDicloxacillin should not be used for initial treatment of severe, life-threatening infections but can be used as follow-up toparenteral therapy in osteomyelitis or septic arthritis. GI intolerance may require switch to alternate antimicrobial.Drug InteractionDicloxacillin decreases the anticoagulant effect of warfarin.DIDANOSINEFor up-to-date information on the use of antiretrovirals, consult an HIV expert or www.aidsinfo.nih.gov/DORIPENEM – non-formulary at UWHC. Therapeutically interchangeable with meropenem and imipenem at UW.Usual DoseAdult: 500 mg Q8H IV (UWHC cost/day $111.09)Pediatric: safety and efficacy not established in childrenComments
For use in patients with reported penicillin allergies, see Appendix J: UWHC Guidelines For the Use of Beta-LactamAntibiotics in Patients with Reported Allergies to Penicillin.DOXYCYCLINEUsual DoseAdult: Load 200 mg, then 100 mg Q12H IV/PO; Maintenance 100-200 mg daily or 100 mg BID IV/PO (PO UWHC cost/day$0.14-0.28; IV UWHC cost/day $14.79-29.58).Pediatrics:** 2-4 mg/kg/day PO Q12H on day 1, then half dose Q24H (not for children < 8 years).Indications1. Pneumonia caused by Mycoplasma pneumoniae, Chlamydia or Legionella -- alternative treatment to macrolides.2. Uncomplicated Chlamydia trachomatis and non-gonococcal urethritis infections in adults.3. Brucellosis and bartonellosis in combination with rifampin.4. Rickettsial infections (e.g. Rocky Mountain Spotted Fever, Q fever).5. Acute exacerbations of chronic bronchitis.6. Lyme disease in adults and children 8 years or older.7. Malaria chemoprophylaxis in areas where chloroquine-resistant Plasmodium falciparum is prevalent (100 mg daily PO,start 1-2 days before travel and continue for 4 weeks after leaving malarious area). Alternative to mefloquine.8. Treatment of chloroquine-resistant Plasmodium falciparum in combination with quinine.9. Traveler’s diarrhea – third-line agent (after quinolones and trimethoprim/sulfamethoxazole) for treatment or prophylaxisin persons traveling to high risk areas.10. Plague and tularemia - alternative to streptomycin for treatment. May be used for prophylaxis in selected patients.11. Inflammatory acne - alternative to oral erythromycin or tetracycline.12. Ehrlichiosis.13. Primary or secondary syphilis in patients with an anaphylactoid-type reaction to penicillin.14. CAP treatment: alternative for outpatient treatment and for non-ICU inpatient15. Susceptible community-acquired MRSA infections.16. Susceptible VRE in the urine.CommentsDoxycycline can cause discoloration of permanent teeth and should not be used during the last half of pregnancy nor inchildren < 8 years old. Doxycycline may cause photosensitivity reactions. Patients should be counseled to avoid directsunlight and to apply sunscreens. The IV load may be given as one or two infusions. Close follow-up is mandatory inpatients with syphilis who receive tetracyclines due to reduced cure rates compared to penicillin. Tetracyclines appear tobe superior to penicillin for treatment of early Lyme disease.Drug InteractionsDoxycycline is contraindicated with acitretin because the combination may increase ICP.Concurrent administration with isotretinoin may cause pseudotumor cerebri.Divalent cations such as calcium, iron, aluminum or zinc will chelate doxycycline, preventing its absorption.Medications containing these ions should be given 2 hours before or 6 hours after doxycycline.Concurrent administration with methotrexate increases methotrexate toxicity due to displacement from plasma proteins.Concurrent administration with many neuromuscular blockers increases the activity of the NMB.Concurrent administration with warfarin increases the risk of bleeding.Concurrent administration with porfimer increases intracellular damage due to increased photosensitivity.Concurrent administration with oral contraceptives may cause a failure of the contraceptive.Rifampin decreases the efficacy of doxycycline via increased clearance.Phenytoin and fosphenytoin decrease the efficacy of doxycycline due to induction of metabolism.Phenobarbital decreases the efficacy of doxycycline due to the induction of metabolism.Concurrent administration with chronic carbamazepine administration reduces the efficacy of doxycycline due toincreased metabolism.
Page 2 and 3: PREFACEThe Antimicrobial Use Guidel
Page 4 and 5: Antimicrobial Cost Table (Cost info
Page 6 and 7: Summary of Antibiotic Order Form: S
Page 8: LUNGS/PULMONARYCommunity-Acquired P
Page 12 and 13: PART I: BY DRUGABACAVIRFor up-to-da
Page 14 and 15: constructed systemic-pulmonary shun
Page 16 and 17: AMPICILLIN/SULBACTAM (Unasyn ® )Us
Page 18 and 19: ATOVAQUONE/PROGUANIL (Malarone ® )
Page 20 and 21: CEFAZOLINUsual DoseAdult: Moderate/
Page 22 and 23: CommentsDose adjustment required fo
Page 24 and 25: 1. Typhoid fever. (NOTE: Third-gene
Page 26 and 27: -Dutasteride-Eltrombopag-Theophylli
Page 28 and 29: CLINDAMYCINUsual DoseAdult: 600-900
Page 32 and 33: Concurrent administration with peni
Page 34 and 35: • Cisapride (contraindicated) •
Page 36 and 37: • Oral contraceptives/hormones -
Page 38 and 39: Synergy in infective endocarditis a
Page 40 and 41: • Colchicine • Indinavir • Ta
Page 42 and 43: • Donepezil • Pioglitazone• D
Page 44 and 45: with linezolid should be considered
Page 46 and 47: 4. Life-threatening Gram-negative i
Page 48 and 49: MOXIFLOXACINLevofloxacin and moxifl
Page 50 and 51: Indications1. Uncomplicated cystiti
Page 52 and 53: CommentsDose adjustment required fo
Page 54 and 55: PIPERACILLIN/TAZOBACTAM (Zosyn ® )
Page 56 and 57: PRIMAQUINEUsual DoseAdult: Malaria
Page 58 and 59: RIFABUTINUsual DoseAdult (150 mg ca
Page 60 and 61: • Chloramphenicol • Leflunomide
Page 62 and 63: SULFISOXAZOLENo longer available as
Page 64 and 65: TICARCILLIN/CLAVULANATE (Timentin
Page 66 and 67: 2. Recurrent urinary tract infectio
Page 68 and 69: VANCOMYCINUsual DoseAdult: 1 g Q12H
Page 70 and 71: Careful monitoring of patients usin
Page 72 and 73: APPENDIX B: UWHC SURGICAL ANTIMICRO
Page 74 and 75: GI:Appendectomy 3Anaerobic organism
Page 76 and 77: VascularLIKELYPATHOGENS• ANTIMICR
Page 78 and 79: Cleanorthopedicprocedures(other)Sta
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APPENDIX C: THERAPY FOR TUBERCULOSI
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p-Aminosalicylic acid(PAS)Granules
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Appendix D: UNIVERSITY OF WISCONSIN
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Appendix E: UWHC Guidelines for the
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B. Antifungal Prophylaxis for BMT a
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D. Cost ComparisonDrugAmphotericin
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17. Maertens J, Glasmacher A, Herbr
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47. Courtney R, Wexler D, Radwanski
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2.1.7 Patient is without placement
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Medications Approved for Parenteral
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APPENDIX G: Serum Drug Concentratio
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APPENDIX H: Guidelines for Monitori
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1. Patients with large volumes of d
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16. Tsuji B, Rybak MJ. The influenc
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APPENDIX I: Infectious Diseases App
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APPENDIX J: UWHC Guidelines For the
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with aztreonam and other beta-lacta
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D. Side Chains1.2.5. The prescriber
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14. Pichichiro ME. Use of selected
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Appendix KUWHC Guidelines for Cost-
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sulfa and can be prescribed topatie
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superinfection: amoxicillin 1 g PO
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17. Smucny J, Fahey T, Becker L, Gl
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Appendix M: Guidelines for the Prop
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D. CategorizationPatients should be
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Empiric coverage for Enterococcus i
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H. Necrotizing PancreatitisThe publ
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Bone or JointEndocarditis 4Streptoc
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Candidemia or candidiasis 11Non-neu
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11. Pappas PG, Kauffman CA, Andes D
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piperacillin/tazobactam. There were
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D. Dose of Antibiotic1. Piperacilli
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TNAVasopressinVoriconazoleMeropenem
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pretreatment with an H1-histamine b
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formal consult is not required, but
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K. References1.0 Bliziotis IA, Ples
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