Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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• Oral contraceptives/hormones – levels may increase or decrease• Phenytoin – levels increased• Tretinoin – levels increasedFLUCYTOSINEUsual DoseAdult: 50-100 mg/kg per day PO in 4 divided doses (UWHC cost/day $278.18-556.36).Pediatrics:** 50-100 mg/kg/day PO in divided doses Q6H.Indications1. Uncomplicated cystitis due to Candida (including C glabrata) (NOTE: Fluconazole is safer and may be more effectivefor Candida.)2. Cryptococcal infections – in combination with amphotericin B.3. Selected life-threatening Candida infections – in combination with amphotericin B.CommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect.Some Candida species are resistant to flucytosine and repeat culture or susceptibility testing should be done if treatmentwith this agent is considered outside the urinary tract. Other than for the treatment of urinary tract infections, flucytosineshould not be used alone for the treatment of Candida infections. To avoid toxicity in patients with impaired renal function,the peak level should be monitored and maintained at
• Astemizole (contraindicated)• Chloral hydrate• Cisapride (contraindicated)• Fluconazole• Terfenadine (contraindicated)• TMP/SMZ• Tricyclic antidepressantsConcurrent administration of foscarnet with other nephrotoxic drugs increases the risk of development of renalimpairment.FOSFOMYCIN (Monurol ® )Usual DoseAdult women: Single 3 g dose mixed in 3 to 4 ounces of water (UWHC cost/day $37.90)Indications1. Uncomplicated urinary tract infections in women due to E. coli and E. faecalis2. Fosfomycin may have utility in UTIs caused by ESBL-producing organisms and VRE.CommentsLab is capable of providing susceptibilities for E. coli and Enterococcus faecialisorganisms only.GANCICLOVIR (Also see valganciclovir)Usual DoseAdult: Treatment 5 mg/kg Q12H IV (UWHC cost/day $87.93).Maintenance 5 mg/kg Q24H IV (UWHC cost/day $43.97)Pediatrics:** Induction 5 mg/kg Q12H IV.Maintenance 5 mg/kg Q24H IV.Indications1. Cytomegalovirus (CMV) retinitis, pneumonitis or enterocolitis, esophagitis or bloodstream infections.2. CMV prophylaxis - oral formulation is now valganciclovir3. Congenital CMV infectionsCommentsDose adjustment required for renal impairment. See renal dosing guideline on uconnect. Dosing in excess of thatrecommended by the renal dosing guideline may occasionally be necessary depending on the clinical scenario.Ganciclovir has a high incidence of complicating neutropenia (30-40%) and thrombocytopenia (20%). Dosage reductionsshould be considered if patients develop neutropenia, anemia or thrombocytopenia. Do not administer to patients withsevere neutropenia. Patients have received longer courses of ganciclovir when the neutropenia has been controlled withcolony-stimulating factors. If colony-stimulating factors are given to maintain ANC >1000, the cost is less than foscarnettherapy. The alkaline pH of ganciclovir causes pain and phlebitis at the injection site. The manufacturer recommends thatganciclovir be handled similarly to chemotherapeutic drugs during preparation and administration – discard waste in blackmedication bins. Ganciclovir has activity against herpes simplex virus and varicella-zoster virus. Concomitant use ofganciclovir and acyclovir is unnecessary, and increases costs and toxicity.Drug InteractionsGanciclovir increases the hematotoxicity of zidovudine.Ganciclovir increases the bioavailablity of didanosine, thus increasing the toxicity of didanosine.Ganciclovir increases drug exposure to tenofovir (and vice-versa) due to competition for drug secretion, potentiallyincreasing toxicity.Concurrent administration with tacrolimus increases the risk of nephrotoxicity.GENTAMICINUsual DoseAdult: Systemic infections 5 mg/kg daily or 2.5 mg/kg Q12H or 1.5 mg/kg Q8H IV (UWHC cost/day $2.48-4.31).Urinary tract infections 1-3 mg/kg daily IV/IM (UWHC cost/day $0.83-2.48).
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 30 and 31: DAPTOMYCINInfectious Disease approv
Page 32 and 33: Concurrent administration with peni
Page 34 and 35: • Cisapride (contraindicated) •
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
Page 80 and 81: APPENDIX C: THERAPY FOR TUBERCULOSI
Page 82 and 83: p-Aminosalicylic acid(PAS)Granules
Page 84 and 85: 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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Antimicrobial Use Guidelines (AMUG) version 21 - UW Health

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