2019 Antibiotic Stewardship

Guidebook
On Call Infectious Disease Physician
Beacon Center Phone 303-415-8850
PE ARL S
Person on Call Icon in Citrix
*ID doctors can also be contacted on Voalte for non-urgent issues • Take a daily “antibiotic time out” to assess
the appropriateness of antibiotic therapy.
Pharmacy Phone Extensions: see Voalte
• Document the indications for specific
Main Pharmacy Phone Number: 303-415-7782 antibiotic use in H&P and daily in
progress note.

© 2019 Boulder Community Health

Printed 06/12/2019
2019 Antibiotic Stewardship Guidebook

Table of Contents Page

Empiric Antibiotic Guidelines 1-3
Empiric Antibiotic Therapy for Severe Sepsis & Septic Shock of Unknown Source 4-5
Guidelines for Treatment of UTI 6-7
Testing Algorithm for Clostridium difficile 8
Ambulatory Management of Upper Respiratory Tract Infections in Adults 9
Antimicrobial Dosing Chart 10-12
Prophylactic Antibiotics by Procedure 13-14
Antibiogram 2018 15-18
Antimicrobial Cost Information 19
Vancomycin Nomogram 20-21
Antimicrobial Stewardship Team & Other Contributors 22
Empiric Antimicrobial Guidelines for Hospitalized Adults 2019
Suggested initial therapies based on guidelines 1-9 and local resistance patterns, these guidelines are not a substitution for an ID consult.
Indication Likely Pathogens Empiric Therapy Alternative Therapy Duration Oral Empiric Step Down

Community S. pneumo., H. flu, Mycoplasma, C. Ceftriaxone 1gm IV q24h + β lactam allergy 5-7 days • Amox/Clav + Azithromycin
Acquired pneumoniae, Legionella, S. aureus, Azithromycin 500mg IV q24h Levofloxacin 750mg IV q24h
If abscess or • 3rd gen PO Cephalosporin
Pneumonia1 respiratory viruses OR Levofloxacin 750mg IV q24h
Risk for Prolonged QT empyema is +Azithro
Isolate and rule out influenza at ICU admit + Risks for MDR: consider HAP antibiotic Use Doxycycline 100mg IV/PO present, ID consult
• Levofloxacin
pertinent times of year recs +/- Levofloxacin 750mg IV q24h q12h for atypical coverage recommended
Blood and respiratory cultures
recommended, in cases of severe
pneumonia send legionella urinary
antigen.

HCAP Treat as CAP unless specific risks for MDR Risks: prior IV antibiotic use last 90 days, past
MDR then HAP recommendations cultures demonstrating MDR or MRSA risk factors

HAP/VAP2* Enteric GNR, Pseudomonas, MRSA Cefepime 2gm IV 8h Severe β lactam allergy 7 days Depends on microbiologic data
OR Pip/taz 4.5gm IV q6h Consult ID
+/- Vancomycin IV

Aspiration PNA1,2,8 Streptococcus, H flu, S. Aureus, Community acquired β lactam allergy 7-10 days • Amox/Clav
Enterobacteraciae. Anaerobes Amp/Sulbactam 3gm IV q6h Moxifloxacin 400mg IV/PO q24h
If abscess or • Moxifloxacin
considered less common OR Ceftriaxone 1gm IV daily
empyema is
• PCN + Metronidazole
1) Clear CXR +mild to moderate Hospital acquired present, ID consult
illness consider withholding Low risk: same as community acquired recommended • Clindamycin
antibiotics and monitoring
High risk: antibiotics in last 90 days and/or
2) If no evidence of infection hospitalized 5 days
after 2 days following witnessed Pip/taz 3.375gm to 4.5gm IV q6h
aspiration in the hospital, consider
discontinuation of antibiotics

Community E coli, other enteric GNR, Enteric Ceftriaxone 1gm IV q24h + Severe β lactam allergy 5-7 days with Based on cultures
Acquired streptococci, Bacteroides, Metronidazole 500mg IV q8h Levofloxacin 750mg q24h + source control
Empiric
Intra-abdominal anaerobes Metronidazole 500mg IV q8h
Infection3 • Amox/Clav
22% local E coli resistance to
Levofloxacin • Levofloxacin +
Metronidazole

Severe Sepsis ESBL E coli, Pseudomonas, strep Pip/taz 4.5gm IV q6h β lactam allergy 7-14 days Based on cultures
with Peritonitis or sp, enterococcus, staph, MRSA, +/- Vancomycin IV Meropenem 1gm IV q8h depending on
Empiric
Hospital Acquired yeast (MRSA colonized or failing current therapy) source control
Severe β lactam allergy
Intra-abdominal • Levofloxacin + Metronidazole
Consider yeast coverage Consult ID ID Consult
Infection3
Recommended

*Blood and respiratory cultures recommended, in cases of severe pneumonia send legionella urinary antigen.
NOTE: Antibiotic dosing in this chart does not take into account renal or liver dysfunction.
1
Empiric Antimicrobial Guidelines for Hospitalized Adults 2019
Suggested initial therapies based on guidelines 1-9 and local resistance patterns, these guidelines are not a substitution for an ID consult.
Indication Likely Pathogens Empiric Therapy Alternative Therapy Duration Oral Empiric Step Down

Febrile Enteric gram neg, Pseudomonas, Cefepime 2gm IV q8h Severe β lactam allergy Depends on • Levofloxacin
Neutropenia4 Streptococcus sp, Staphylococcus +/- Vancomycin IV (cath related, SSTI, PNA, unstable) Consult ID clinical response/
• Amox/Clav
+/- Metronidazole IV 500mg q8h (abdominal source/count
symptoms) recovery
OR Meropenem 1gm IV q8hr
+/- Vancomycin IV (cath related, SSTI, PNA, unstable)

Meningitis5 S. pneumo., N. meningitis, Listeria, Ceftriaxone 2gm IV q12h Nosocomial/post-neurosurgical 7-21 days Not applicable
Viral (enterovirus, HSV, VZV) + Vancomycin IV Consult ID depending on
+/- Ampicillin 2gm IV q4h (Listeria, consider if >50y/o, pathogen: consult
Suspect HSV/VZV » consult ID Severe β lactam allergy
preg, immunocompromised) ID
Consult ID
+/- Dexamethasone 0.15 mg/kg IV q6h administered
10–20 min before, or concomitant with, 1st dose of
antibiotics with suspected/proven pneumococcal
meningitis

Skin and Soft Erysipelas, Non-purulent6 Cefazolin 1gm IV q8h β lactam allergy 5-7 days • Dicloxacillin
Tissue Infections Streptococcus Vancomycin IV
• Cephalexin
OR Clindamycin 600mg IV q8h
• Clindamycin
(check antibiogram)

Purulent/abscess6 Vancomycin IV Allergy to Vancomycin IV Variable, if Empiric or MRSA

Staphylococcus sp Consult ID abscess evacuated TMP/SMX or Doxycycline
consider shorter
• Consider Surgical consult for I&D MSSA
5-7 days
Dicloxacillin or Cephalexin
• Obtain culture

Necrotizing Fasciitis6 Vancomycin IV Severe β lactam allergy Variable Not applicable

Type 1 Polymicrobial +Pip/taz 4.5gm IV q6h Consult ID
Type 2 S. pyogenes (GAS) +/- Clindamycin IV 600 IV q8h
(if high concern S. pyogenes)
Immediate Surgical and ID consult
recommended.

NOTE: Antibiotic dosing in this chart does not take into account renal or liver dysfunction.

2
Empiric Antimicrobial Guidelines for Hospitalized Adults 2019
Suggested initial therapies based on guidelines 1-9 and local resistance patterns, these guidelines are not a substitution for an ID consult.
Indication Likely Pathogens Empiric Therapy Alternative Therapy Duration Oral Empiric Step Down

Diabetic Foot Polymicrobial: Staphylococcus, Amp/sulbactam 3gm IV q6h Concern for Pseudomonas Variable Based on cultures
Infection7 Streptococcus predominant OR Ertapenem 1gm IV q24h Pip/taz 4.5gm IV q6h
+/- Vancomycin IV
Consider ESBL GNR, Severe β lactam allergy
Pseudomonas, anaerobes Recommend culture from deep tissue, obtained by Levofloxacin 750mg IV q24h
as well. biopsy or curettage after the wound cleansed and + Clindamycin 600mg IV q8h
debrided. +/-Vancomycin IV

Urinary Tract See pages 5-6

Infection8,9

ID consult available for any ID condition, but strongly recommended for bacteremia, fungemia, meningitis,
necrotizing fasciitis, severe intra-abdominal infection and endocarditis
NOTE: Antibiotic dosing in this chart does not take into account renal or liver dysfunction.

REFERENCES: PE ARL S
1 CID 2007; 44:S27–72
a) Penicillin allergy: Cross reactivity with 3rd and 4th generation
2 CID 2016; 63(5):e61 cephalosporin or carbapenem is low < 10%.
3 CID 2010; 50:133–64 & Surg Infect 2017: 18:1-56
b) 28% of non-urine staphylococcus aureus isolates are MRSA.
4 CID 2011; 52(4):e56–e93
5 CID 2004; 39:1267–84 c) Rate of non-urine ESBL is 6-9% among E coli and Klebsiella
6 CID 2014 Jul 15; 59(2):147-59
7 CID 2012; 54(12):132–173
8 CID 2011; 52(5):e103–e120 & NEJM 2019; 380:651-63
9 CID 2010; 50:625–663

3
BCH Empiric Antibiotic Therapy for Severe Sepsis
and Septic Shock of Unknown Source
Risk factors for Resistant Organisms 1. Refer to specific sections in antibiotic guidelines for
Hospitalized previous 90 days specific sources of infection. Sepsis treatment should be
targeted at the specific source whenever possible.
Long term HD
Immunosuppressed 2. Review prior microbiology data

Broad spectrum antibiotics in last 90 days 3. Blood cultures should be collected PRIOR to antibiotics.

NH or LTC NOTE: Dosing below assumes Normal Renal Function

Known MDR organism
NO YES

Ceftriaxone 2gm IV q24h Pip/Tazo 4.5gm IV q6hrs

(q12hrs for CNS) OR
+/- Meropenem 1gm IV q8h
Vancomycin IV (reserve for h/o ESBL, more resistant GNRs)
(IF suspect MRSA or resistant S. pneumoniae) +/-
Vancomycin IV
OPTIONAL TREATMENT +/-
Atypical CAP coverage: Atypical CAP coverage:
Azithromycin 500mg IV q24h Azithromycin 500mg IV q24h
Anaerobic coverage : Metronidazole
IV 500mg q8h SEVERE BETA LACTAM ALLERGY
Aztreonam 2gm IV q8h
Broad-spectrum empiric therapy used OR
while cultures are pending i.e. first Levofloxacin 750mg IV daily
48-72 hours. Antibiotic regimen should +
be evaluated daily and streamlined Vancomycin IV
based on culture data. +/-
Anaerobic coverage: Metronidazole
IV 500mg q8h
4
SEVERE SEPSIS EMPIRIC TREATMENT WITH NO CLEAR SOURCE
If patient meets ALL 3 of the criteria listed below, the patient has Two sets of blood cultures must be obtained prior to initiating
severe sepsis: antibiotics to help guide therapy.

1. Suspected infection For proper bundle compliance, use the physician Sepsis Order set in
Meditech. This is required as part of the BCH sepsis bundle:
2. ≥2 SIRS Criteria:
• Blood cultures x 2 sets prior to antibiotics
• Temperature greater than 100.4 F (38°C) or less than
96.8 F (36°C) • Lactate
• Heart rate greater than 90 bpm • Broad spectrum antibiotics (see flow sheet on page 4)
• Respiratory rate greater than 20 or PaCO less than
2 • IV Fluids of 30 mL/kg bolus, unless direct contraindication.
32 mmHg or mechanical ventilation
Medicare core measures also require the following within 6 hours of
• WBC greater than 12,000 or less than 4,000 mm3
time of presentation as part of the sepsis bundle:
3. Any one of the following measures of organ dysfunction: • Repeat lactate level if the initial lactate level is elevated
• Systolic BP less than 90 mmHg, MAP <65 • If hypotension persists after IVF administration: Repeat
• Serum lactate ≥2 volume status and tissue perfusion assessment consisting of
• INR >1.5 either a focused physical exam or 2 of 4 of the following: CVP
measurement, central venous oxygen measurement, bedside
• Creatinine >2 ultrasound, additional fluid challenge or passive leg raise
• Platelets <100,000
• Bilirubin >2
• Need for intubation or PPV PE ARL S
• Two beta-lactam agents should not be used concurrently
(e.g. Pip/Tazo/Cefepime/Meropenem).

• Potential sources (e.g. pneumonia, peritonitis, central venous catheters)

must be considered when selecting therapy.

• Broad-spectrum empiric therapy is ONLY appropriate while cultures are

pending i.e. first 48-72 hours. Antibiotic regimen should be evaluated
daily and regimen should be streamlined based on culture data.

5
Guidelines for Management of Urinary Tract Infection
in the Inpatient and Outpatient Setting
GENERAL RULE: Limit development of resistant bacteria by ONLY using antibiotics when ALL three things exist:
1. Symptoms, 2. Abnormal urinalysis, 3. Positive urine culture (>105 CFU/mL of 1 organism in clean catch or 103 CFU/mL in catheterized specimen)
See antibiogram for BCH patterns of resistance. More than half of urinary isolates are E coli. E coli resistance to levofloxacin is 22% in NON-urine isolates, 10% in urinary isolates and Bactrim is 27% in NON-urine
isolates and 19% urine isolates. ESBL rate in urine is 4% outpatient and 12% inpatient combining E. coli, Klebsiella.

Typical Symptoms of an Infection along the Urinary Tract Symptoms NOT Indicative of UTI in the Absence of Typical Symptoms

• Dysuria, frequency, urinary urgency, urinary retention, hematuria Foul smelling urine, dark urine, cloudy urine, sediment in urine
• Pelvic pain, suprapubic pain, flank pain
• Complicated UTI: Localizing urinary symptoms with new onset or worsening fever, rigors, AMS, or lethargy
without other identifiable cause.
• Spinal cord injury: increased spasticity, autonomic dysreflexia

Definition / Comments Organisms Inpatient Treatment Outpatient Treatment

Asymptomatic Bacteriuria 105 bacteria in the urine without symptoms No antibiotic treatment recommended (exceptions: pregnancy, planned urinary
instrumentation, or 1st month following renal transplant)
Pearl: Pyuria does NOT differentiate UTI, PPV for
infection between 30 and 56.

Uncomplicated Cystitis Guidelines suggest that UA/Culture not needed E. coli, Klebsiella, Proteus N/A Listed in order of recommendation:
with uncomplicated UTI in women, but with Nitrofurantoin 100mg PO BID x 5 days*
S. saphrophyticus (women)
increasing resistance rates, may be clinically Fosfomycin 3gm PO x1 dose*
justified. r/o STDs in sexually active individuals Cephalexin 500mg PO BID x 5 days
Bactrim DS 1 PO BID x 3-5 days
Indications for culture: Male, History of MDR
Cipro 250 or 500mg PO BID x 3 days
positive culture, inpatient stay at health care
Men should receive 7 days of therapy
facility, broad spectrum antibiotic use in last 90
except fluoroquinolones 5 days
days, recent travel to areas with high rates of
adequate.
MDR (eg, India, Israel, Spain, Mexico)
GC/Chlamydia: Ceftriaxone 250mg IM x1
PLUS doxycycline 100mg PO BID x 7 d
OR Azithromycin 1gm PO x1 dose

*Not recommended if concern for pyelonephritis. Short term use of Macrobid okay for CrCl >30. One study did show Fosfomycin inferior to Macrobid for cystitis (JAMA. 2018; 319(17):1781-1789).
PPV = positive predictive value, MDRO = multidrug resistant organisms
Renal dose adjustments not included in this chart, see pages 10 to 11.
Severe β lactam allergy: Consult ID

6
 Definition / Comments Organisms Inpatient Treatment Outpatient Treatment

Complicated UTI including Upper or lower tract disease associated with E. coli, Klebsiella, Enterococcus, General admit Specific antibiotic guided by cultures
pyelonephritis factor(s) that increase(s) risk of failing therapy Pseudomonas Ceftriaxone 1gm IV q24h from inpatient. Duration of therapy 5 to 14
and generally requires hospitalization. days depending on rapidity of response
Moderate to severe illness and/or
and antibiotic used to complete therapy.
Pearl: May need to order Urine Culture separately Concern for Pseudomonas
(fluoroquinolones 5-7 days, TMP-SMX
if suspicious of pyelonephritis as pyuria may not Cefepime 1-2gm IV q8h
7-10 days, beta-lactams 10-14 days)
be present. OR Pip/taz 4.5gm IV q6h
+/- Vancomycin IV Outpatient therapy for pyelonephritis
Obtain Urine culture
H/O MDRO:
Levofloxacin 750mg daily x 5-7 days
Ertapenem 1gm IV q24h
Consult ID for Ceftriaxone 1gm IV daily
x 7d

CAUTI Urinary catheter placed during hospitalization: E. coli, Klebsiella, Staphylococcus, Change or discontinue Foley Based on cultures
With fever, limit evaluation of urine with 1) clinical Enterococcus, Pseudomonas
Uncomplicated
signs: suprapubic pain or CVA tenderness, or
Ceftriaxone 1gm IV q24h
2) risk factors such as: kidney transplant, recent
GU surgery, evidence of obstructive uropathy, Antibiotics in last 90 days/
profound immunosuppression or neutropenia. Severe sepsis/ Concern for
Pseudomonas or MDRO
Pearl: Urinary tract infection is rarely a cause of
Cefepime 2gm IV q8h
fever in hospitalized patient.
OR Meropenem 1gm IV q8h
Pearl: PPV of pyuria is low for infection in +/- Vancomycin IV
catheterized patients (15 to 28%)

Acute Prostatitis Symptoms of cystitis PLUS fever, chills, malaise, Gram negative rods Moderate disease Based on cultures, possible empiric
myalgias, pelvic or perineal pain, or obstructive Ceftriaxone 1gm IV q24h therapy:
r/o STDs in sexually active individuals
symptoms. Swollen, tender prostate on exam. Bactrim DS 1 PO BID
ICU admission/Concern for
OR Cipro 500mg PO BID
Pearl: Only instance when urine culture may Pseudomonas
Duration 6 weeks
be repeated after approximately 7 days of Cefepime 2gm IV q8h
antibiotics to assure clearance of bacteriuria. Consider empiric Rx for GC/Chlamydia if
high risk. Ceftriaxone 250mg IM x1 PLUS
Doxycycline 100mg PO BID x 10 days
Consider urology referral

PPV = positive predictive value, MDRO = multidrug resistant organisms

Renal dose adjustments not included in this chart, see pages 10 to 11.
Severe β lactam allergy: Consult ID

REFERENCES:
O’Grady, et al Crit Care Med 2008 (36): 1330; Mody, et al., JAMA 2014 (311):844; Gupta, et al., CID 2011;52(5):e103–e120; Hooton, et al., CID 2010; 50:625–663;
CAUTI Guidelines. http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf . Schaeffer, et al. NEJM 2016; 374: 562-71. Nicolle LE, et al. CID 2019; 68:e83-e110.

7
Testing Algorithm for Clostridium difficile.
Hospitalized patient with clinically-significant diarrhea Observe for 24 hours to assess for persistence of symptoms.
(3 or more loose/liquid stools per day for at least 1-2 days) NO 5 Do not order test for C. diff.

YES p
Has patient received laxatives, tube feedings, or oral contrast Stop medication and gauge clinical response for ≥ 24 hrs PRIOR to
over the past 24-48 hours? YES 5 ordering C. diff testing.

NO p
Does patient meet clinical criteria for C. diff colitis:
Risk factor: recent antibiotic exposure
NO 5 Consider alternate diagnosis for diarrhea.
S/s: fever, dehydration, abdominal distension/pain, ileus,
unexplained white count

YES p
Order test: C. diff PCR 5 C. diff. order will automatically cancel after 24 hours if not collected.

p
C. diff test results positive? NO 5 Consider alternate diagnosis for diarrhea.

YES* p
Start Vancomycin 125mg PO QID. * Patients with a positive C. diff test should be put into
Contact Isolation with Additional Precautions for 30 days.
Do not send test of cure.

8
Ambulatory Management of Upper Respiratory Tract Infections in Adults
Definition / Comments Organisms Non-Antibiotic Treatments Antibiotics

Acute Sinusitis 90-98% of cases are viral Respiratory viruses Acetaminophen/NSAIDs ONLY IF meets criteria for bacterial sinusitis, Rx 5-7 days:
Only consider antibiotics if: Bacterial: Nasal saline Augmentin: 500mg q8h OR 875mg q12h
S. pneumoniae,
• Persistent: >10 days without improvement Nasal steroid Doxycycline: 100mg q12h
H. influenzae,
• Worsening: 3-4 days M. catarrhalis, Decongestants Cefpodoxime: 200mg q12h OR Cefixime: 400mg q24h
• Symptoms: Fever >39 ⁰C, facial/tooth pain S. aureus Risk for resistance or severe beta-lactam allergy:
Respiratory fluoroquinolone*

Pharyngitis Majority viral, 5-10% GAS Respiratory viruses Acetaminophen/NSAIDs Penicillin V: 500mg q12h x10 days
• GAS and viral pharyngitis cannot be distinguished by Group A Lozenges Amoxicillin: 500mg q12h x10 days
clinical symptoms Streptococcus (GAS),
Cephalexin: 500mg q12h x10 days
Fusobacterium
• Send GAS testing: fever, tonsillar exudates, tender
If true allergy or anaphylaxis to Penicillin:
cervical, lymphadenopathy, absence of cough
Clindamycin: 300mg TID x10 days**

Acute Uncomplicated • Mostly viral or non-infectious causes Respiratory viruses Cough suppressants Rarely recommended regardless of cough duration
Bronchitis
• Colored sputum does not indicate bacterial infection Antihistamines
• Consider pneumonia, underlying lung disease, Decongestants
pertussis in Ddx
Beta-agonists

*Risk of fluoroquinolones generally outweighs benefits for sinusitis. Levofloxacin 750 mg q24h or moxifloxacin 400 mg q24h can be used but should be reserved for those who:
1. Cannot tolerate other antibiotic options, 2. Have risks for resistance (e.g. hospitalization last 5 days, antibiotic use in last month, immune compromise), or 3. Have severe disease with systemic toxicity.
**Patients prescribed clindamycin for pharyngitis should have scheduled follow-up to assess resolution due to increasing rates of GAS resistance

9
Antimicrobial Dosing Guidelines for Hospitalized Adults
Suggested initial doses, these guidelines are not a substitution for an ID or Pharmacy consult.

Antibiotic category Antibiotic Route Dose for normal renal function Reduced renal function mL/min Hemodialysis (HD)*

11-29: 250-500mg BID

Amoxicillin/clavulanate PO 500-875mg BID or 500mg TID 500mg q24h, give after HD on HD days
<10: 250-500mg q24h

11-29: 500mg q12h

Amoxicillin PO 500mg TID 500mg q24h, give after HD on HD days
<10: 250-500mg q24h

30-49: 1.5-3gm q6-8h

Ampicillin/sulbactam IV 1.5-3gm q6h 15-29: 1.5-3gm q12h 1.5-3gm q24h, give after HD on HD days
<14: 1.5-3gm q24h

11-49: 2gm q6h

Ampicillin IV 2gm IV q4h 1-2gm q24h, give after HD on HD days
<10: 2gm q12h

Dicloxacillin PO 250-500mg PO q6h No adjustment No adjustment

PENICILLIN
High KCl, cautious use in renal failure
Penicillin G IV 2-4MU q4-6h, max 24 MU/day 11-49: 1-2MU q6-8h 1-2 MU q8-12h after HD
<10: 1-2 MU q8-12h

Penicillin VK PO 250-500mg q6h <10: 250-500mg TID 250-500mg TID after HD

Nafcillin IV 1-2gm q4-6h No adjustment No adjustment

Standard dose 21-39: 2.25gm q6h

2.25gm q12h after HD
3.375gm q6h <20: 2.25gm q8h
Piperacillin/tazobactam IV
Severe Infection or Pseudomonas 21-39: 3.375gm q6h
2.25gm q8h dosed after HD
4.5gm q6h <20: 2.25gm q6h

Ertapenem IV 1gm q24h <30: 0.5gm q24h 0.5gm q24h after HD

CARBAPENEM 1gm q8h 26-50: 1gm q12h

Meropenem IV *higher doses may be needed for severe 10-25: 0.5gm q12h 0.5gm q24h after HD
infection or meningitis, Consult ID <10: 0.5gm q24h

CEPHALOSPORIN

Mild to Moderate Infection 11-49: 1g q12h

1g dosed 3x/week after HD
1gm q8h <10: 1gm q24h
Cefazolin IV
1st Severe Infection 11-49: 2g q12h
2g dosed 3x/week after HD
2gm q8h <10: 2gm q24h

31-49: 250-500mg TID

Cephalexin PO 500mg – 1000mg TID to QID 11-30: 250-500mg BID 250mg BID after HD
<10: 250mg BID

¥ Oral and IV dosing is equivalent.

*Consider Pharmacy consult 10
Antimicrobial Dosing Guidelines for Hospitalized Adults
Antibiotic category Antibiotic Route Dose for normal renal function Reduced renal function mL/min Hemodialysis (HD)*

30-50: 1-2gm q8-12h

Cefoxitin IV 1-2gm q6-8h 10-29: 1-2gm q12-24h 1-2gm q24h after HD
<10: 1gm q24h

2nd 10-20: 0.75 to 1.5gm q12h

IV 0.75gm to 1.5gm q8h 0.75 to 1.5gm after HD
<10: 0.75 to 1.5gm q24h
Cefuroxime
30-10: 250-500mg q24h
PO 250-500mg BID 250-500mg after HD
<10: 250-500mg q48h

Standard dose
1gm q24h

Bacteremia, Endocarditis, Osteomyelitis

Ceftriaxone IV No adjustment No adjustment
2gm q24h **Consult ID
3rd
Meningitis
2gm q12h

Cefdinir PO 300mg PO q12h <30: 300mg q24h 300mg q48h

30-59: 1-2gm q24h

Mild to Moderate Infection, Pneumonia
11-29: 0.5-1gm q24h 1gm dosed 3x weekly after HD
1-2gm q12h
<10: 0.5gm q24h
4th Cefepime IV
Severe Infection (Pseudomonas, Neutropenia) 30-59: 2gm q12h
2gm q8h 11-29: 2gm q24h 2gm dosed 3x weekly after HD
**Consult ID <10: 1gm q24h

Mild to Moderate Infection,

Uncomplicated cystitis
PO 250-500mg BID <30: same dose q24h Same dose as for <30, dose after HD
Severe Infection
750mg BID
Ciprofloxacin
Mild to Moderate Infection
400mg q12h
FLUORO-
QUINOLONES IV Severe Infection (OM, neutropenic fever, <30: same dose q24h Same dose as for <30, dose after HD
nosocomial PNA)
400mg IV q8h

Mild to Moderate Infection 20-49: 500mg load then 250mg q24h

500mg q24h <20: 500mg load then 250mg q48h
Levofloxacin¥ PO/IV Same dose as for <20, dose after HD
CAP, Severe Infection 20-49: 750mg load then 750mg q48h
750mg q24h <20: 750mg load then 500mg q48h

¥ Oral and IV dosing is equivalent.

*Consider Pharmacy consult 11
Antimicrobial Dosing Guidelines for Hospitalized Adults
Antibiotic category Antibiotic Route Dose for normal renal function Reduced renal function mL/min Hemodialysis (HD)*

TETRACYCLINE Doxycycline¥ PO/IV 100mg q12h No adjustment No adjustment

MACROLIDE Azithromycin¥ PO/IV 250-500mg q24h <10: use with caution Consult ID

Vancomycin IV See Nomogram

Vancomycin PO 125mg PO q6h (Only for C. diff) No adjustment, not absorbed No adjustment

IV **Consult ID if using IV
Trimethoprim/
Sulfamethoxazole
1-2 DS tab BID (5-8mg TMP/kg/day total)
MISC (TMP/Sulfa) PO Consult ID
Severe Infection or PJP suspect, **Consult ID

PO 300mg QID or 450mg TID No adjustment No adjustment

Clindamycin
IV 600-900mg q8h No adjustment No adjustment

Metronidazole¥ PO/IV 500mg q8h No adjustment No adjustment

Mild to Moderate Infection

<50: 200-400mg load,
Fluconazole¥ PO/IV 200-400mg q24h Consult ID or pharmacy
then 100-200mg daily
ANTIFUNGAL **Severe infection, Consult ID

Micafungin IV ID restricted

Shingles 10-25: 800mg TID

Acyclovir PO 800mg BID post HD
800mg 5 times daily <10: 800mg BID

25-49: 5mg/kg q12h

HSV skin lesions in immunocompromised/ICU
11-24: 5mg/kg q24h 2.5mg/kg IV q24h, give after HD on HD days
5mg/kg IV q8h
Acyclovir <10: 2.5mg/kg q24h

Dose based in ideal body IV

ANTIVIRAL HSV encephalitis, Primary varicella, or shingles
weight. 25-49: 10mg/kg q12h
>1 dermatome, disseminated
11-24: 10mg/kg q24h 5mg/kg IV q24h, give after HD on HD days
10mg/kg IV q8h
<10: 5mg/kg q24h
**Consult ID

30-49: 1gm BID

Shingles
Valacyclovir PO 10-29: 1gm q24h 500mg q24h post HD
Valacyclovir 1000mg TID x 7 days
<10: 500mg q24h

¥ Oral and IV dosing is equivalent.

*Consider Pharmacy consult

REFERENCES:
Sanford Guide of Antimicrobial Therapy 2018, Micromedex, Ahern, JW. Am J Health Syst Pharm January 1, 2003; 60:178-81; Sowinski, KM. Am J Kidney Dis. 2001; 37:766-76; Heintz, BH Pharmacotherapy.
2009 May;29(5):562-77

12
Recommended Prophylactic Antibiotics by Procedure*
Surgical Procedure Organisms Recommended IV Antibiotics* Dosing Redosing Hours**

<120kg: 2gm IV
Cefazolin 4
>120kg: 3gm IV
Cardiovascular surgery, thoracic, cardiac Staphylococcus &
device insertion, vascular surgery streptococcus
OR Severe β lactam allergy
15mg/kg IV (max 2gm). Start 60 to 120 min prior to procedure. —
Vancomycin

<120kg: 2gm IV
Cefazolin 4
>120kg: 3gm IV
Spinal procedures, hip fracture, internal Staphylococcus &
fixation, total joint replacement streptococcus
OR Severe β lactam allergy
15mg/kg IV (max 2gm). Start 60 to 120 min prior to procedure. —
Vancomycin

Ceftriaxone 1gm IV —
Ceftriaxone + metronidazole
Metronidazole 500mg IV —

Enteric GNR, OR Cefoxitin 2gm IV 2

Appy, Colon Surgery, Biliary,
anaerobes,
Gastroduodenal***
enterococcus Vanco 15mg/kg IV (max 2gm). Start 60 to 120 min prior to procedure. —
OR Severe β lactam allergy
Cipro 400mg IV —
Vancomycin + Cipro + metronidazole
Metronidazole 500mg IV —

<120kg: 2gm IV
Cefazolin 4
>120kg: 3gm IV
Staphylococcus &
Hernia
streptococcus
OR Severe β lactam allergy
15mg/kg IV (max 2gm). Start 60 to 120 min prior to procedure. —
Vancomycin

<120kg: 2gm IV
Cefazolin 4
>120kg: 3gm IV
Enteric GNR,
OR Cefoxitin 2gm IV 2
Hysterectomy anaerobes, GBS,
enterococcus
Vanco 15mg/kg IV (max 2gm). Start 60 to 120 min prior to procedure. —
OR Severe β lactam allergy
Vancomycin + Cipro
Cipro 400mg IV —

<120kg: 2gm IV
Cefazolin 4
>120kg: 3gm IV
Staphylococcus &
C section
streptococcus Vanco 15mg/kg IV (max 2gm). Start 60 to 120 min prior to procedure. —
OR Severe β lactam allergy
Vancomycin + Gentamicin
Gentamicin 5mg/kg IV —

* Additional pre-op antibiotic not needed for patients already on systemic antibiotics which would provide protection against expected surgical pathogens.
** If surgery longer 2 to 4 hours or loss 1500cc blood or more
*** Neomycin PLUS erythromycin base or metronidazole on Pre-Op day for elective colon procedures. ERCP: No antibiotics needed if no obstruction
13
 Surgical Procedure Organisms Recommended IV Antibiotics* Dosing Redosing Hours**

<120kg: 2gm IV
Cefazolin 4
>120kg: 3gm IV

PLUS Metronidazole (for entry into intestine) 500mg IV —

Enteric GNR,
Laparoscopic or Open GU procedures
enterococcus OR Cefoxitin 2gm IV 2

Vanco 15mg/kg IV (max 2gm). Start 60 to 120 min prior to procedure —

OR Severe β lactam allergy
Vancomycin + Cipro^
Cipro 400mg IV —

<120kg: 2gm IV
Cefazolin 4
>120kg: 3gm IV
Cystoscopy with manipulation or Enteric GNR,
upper tract instrumentation^^ enterococcus OR Bactrim DS 160mg TMP/800mg SMX PO/IV —

OR Cipro 400mg IV or 500mg PO —

Enteric GNR, Cipro 400mg IV or 500mg PO 12

enterococcus,
Prostate Biopsy
sometimes skin
OR Bactrim DS 160mg TMP/800mg SMX PO/IV 12
flora

<120kg: 2gm IV
Staphylococcus Cefazolin 4
>120kg: 3gm IV
aureus, S.
epidermidis, PLUS Metronidazole (for contaminated case) 500mg IV —
Head and neck surgery
streptococci.
Sometimes: GNR, OR Ampicillin-sulbactam 3gm IV 2
anaerobes
OR Clindamycin 900mg IV —

<120kg: 2gm IV
Staphylococcus Cefazolin 4
>120kg: 3gm IV
Plastic surgery with risk factors, aureus, S.
breast surgery epidermidis,
OR Severe β lactam allergy
streptococcus 15mg/kg IV (max 2gm). Start 60 to 120 min prior to procedure. —
Vancomycin

* Additional pre-op antibiotic not needed for patients already on systemic antibiotics Recommended documentation of known or suspected infection present
which would provide protection against expected surgical pathogens.
** If surgery longer 2 to 4 hours or loss 1500cc blood or more at time of surgery (PATOS):
^ In rare circumstances of known resistance patterns & severe B lactam allergy, • Document evidence of infection intraoperatively in operative note or report of surgery (appropriate terms
Clindamycin 600mg IV plus gentamicin 5mg/kg may be used include: purulence, abscess, feculent peritonitis, infected appendix that has ruptured).
^^ Urine culture prior to procedure recommended to direct antibiotic therapy.
• The following verbiage ALONE does NOT meet the PATOS definition: colon perforation, necrosis, gangrene, fecal
NOTE: Vancomycin is preferred for over clindamycin for severe B lactam allergy for prevention spillage, nicked bowel, and inflammation or use of term with “itis” such as diverticulitis, peritonitis, appendicitis.
of Group A and B streptococcus due to up to 55% resistance to clindamycin locally.
Vancomycin should also be considered if known history of MRSA. Other risk factors for use of SELECTED REFERENCES:
vancomycin: High risk patient with recent hospital stay, High risk patient from nursing home, Obstet Gynecol May 2009; 113(5): 1180-1189, Am J Health Syst Pharm. 1999;56:1839-1888, Am J Health-Syst Pharm.
Dialysis, Transfer from another hospital in the last three days. 2013; 70:195-283, CID. 2004:38:1706-1715, CID. 1994; 18:422-427, The Sanford Guide to Antimicrobial Therapy 2018.,
N Engl J Med. 2006 Dec 21; 355 (25): 2640-2651, Infect Control Hosp Epidemiol. 1999; 20:247-280, Med Lett
Drugs Ther. 2016; 58: 63-68, Arch Surg. 1993; 128:79-88. 14
Antibiogram 2018
Species with less than 30 isolates, sensitivities should be interpreted with caution. Grey boxes indicate organism has intrinsic resistance to corresponding antimicrobial or resistance testing is not applicable.

Sulfamethoxazole
Total # Isolates

Trimethoprim
Ciprofloxacin

Levofloxacin
Meropenem
Tazobactam

Ceftazidime
Gram Negative NON-URINE

Ceftriaxone

Tobramycin
Gentamicin
Ertapenem
Ampicillin-

Pipercillin-
Sulbactam
Ampicillin

Cefepime
Cefazolin
Isolates Inpatient and
Emergency Department

Organism # Results %S %S %S %S %S %S %S %S %S %S %S %S %S %S

Acinetobacter 4 50% 75% 100% 100% 100% 100% 100% 100% 100%

Citrobacter 8 38% 100% 13% 100% 100% 100% 100% 88% 88% 88% 100% 100%

Enterobacter 19 78% 79% 95% 84% 100% 100% 100% 100% 100% 100%

Escherichia coli 120 49% 54% 93% 77% 93% 93% 100% 100% 77% 78% 73% 94% 94%

Klebsiella 50 70% 98% 82% 96% 96% 100% 100% 100% 100% 92% 100% 100%

Proteus 12 83% 90% 100% 58% 83% 100% 100% 100% 75% 75% 92% 92% 92%

Pseudomonas aeruginosa 31 81% 87% 90% 77% 81% 81% 100% 100%

Serratia 9 78% 78% 100% 100% 100% 100% 100% 100% 100% 100%

Stenotrophomonas 6 83% 100% 100%

Haemophilus influenzae beta-lactamase positive 28%, n=69

Carbapenem Resistant Ps. aeruginosa (CRPA): 1) NON-URINE 23%, 2) URINE 21%

% Susceptible

80% or better

70-79%

<69%

15
Antibiogram 2018
Species with less than 30 isolates, sensitivities should be interpreted with caution. Grey boxes indicate organism has intrinsic resistance to corresponding antimicrobial or resistance testing is not applicable.

Sulfamethoxazole
Amp-sulbactam
Total # Isolates

Trimethoprim-

Nitrofurantoin
Levofloxacin
Ceftazidime

Tetracycline
Meropenem
Ceftriaxone

Ertapenem
Ampicillin

Cefepime
Cefazolin
Gram Negative URINE
Inpatient Isolates

Organism # Results %S %S %S %S %S %S %S %S %S %S %S %S

Acinetobacter 5 60% 100% 60% 100% 100% 80%

Citrobacter 17 65% 88% 94% 100% 100% 82% 88% 82%

Enterobacter 13 77% 92% 69% 100% 100% 100% 62% 100%

Escherichia coli 154 56% 60% 89% 95% 97% 96% 100% 84% 84% 99% 82%

Escherichia coli (ED/Outpatient) 2591 66% 68% 93% 95% 92% 95% 100% 90% 81% 99% 80%

Klebsiella 76 61% 72% 96% 97% 89% 100% 97% 95% 55% 89%

Proteus 30 80% 93% 87% 90% 100% 87% 100% 83% 97%

Pseudomonas aeruginosa 35 91% 100% 79% 76%

Stenotrophomonas 1 0% 0% 100%

ESBL Rate (E.coli and Klebsiella): Inpatient: 1) NON-URINE 6%, 2) URINE 12%; Outpatient: 1) NON-URINE 9%, 2) URINE 4%

% Susceptible

80% or better

70-79%

<69%

16
Antibiogram 2018
Species with less than 30 isolates, sensitivities should be interpreted with caution. Grey boxes indicate organism has intrinsic resistance to corresponding antimicrobial or resistance testing is not applicable.

Sulfamethoxazole
Total # Isolates

Erythromycin
Trimethoprim
Levofloxacin
Clindamycin

Vancomycin

Tetracycline
(meningitis)

(meningitis)

Gentamycin
Gram Positive NON-URINE

Ceftriaxone

Ceftriaxone
Penicillin G

Penicillin G

Oxacillin2

synergy
Sterile Site Isolates Inpatient and
Emergency Department

Organism # Results %S %S %S %S %S %S %S %S %S %S %S %S

Enterococcus faecalis 31 100% 100% 90%

Enterococcus faecium 14 64% 64% 100%

Streptococcus pneumoniae (all locations)1 36 94% 83% 100% 100% 94% 100% 69% 100% 72%

Viridans Strep (includes S.anginosus)3 23 87% 96% 87% 100%

Streptococcus pyogenes (Group A) 22 100% 100% 45% 100% 45%

Streptococcus agalactiae (Group B) 4 100% 100% 75% 100% 75%

Staphylocccus aureus 241 72% 76% 93% 100% 96%

Staphylocccus aureus (Outpatient) 957 84% 78% 97% 100% 93%

Staphylococcus epidermidis 29 44% 60% 80%

Staphylococcus lugdunensis (all locations) 29 100% 79% 100%

1. CLSI requires publication of two breakpoints for all pneumococcal isolates designated: meningitis and non-meningitis.
2. Oxacillin results can be applied to other anti-staph penicillins and β-lactam/β-lactamase inhibitors, cephalosporins and carbapenems.
3. Viridans Strep non-susceptible to penicillin 67% (n=3) were intermediate (MIC 0.25-2.0).

% Susceptible

80% or better

70-79%

<69%

17
Antibiogram 2018
Species with less than 30 isolates, sensitivities should be interpreted with caution. Grey boxes indicate organism has intrinsic resistance to corresponding antimicrobial or resistance testing is not applicable.

Sulfamethoxazole
Total # Isolates

Nitrofurantoin
Trimethoprim

Tetracylcine
Vancomycin
Gram Positive URINE

Penicillin G

Oxacillin2
Isolates Inpatient and
Emergency Department

Organism # Results %S %S %S %S %S %S

Enterococcus faecalis 44 100% 95% 100% 24%

Enterococcus faecium 6 50% 83% 50%

Staphylocccus aureus 33 76% 97% 100% 97%

Staphylocccus aureus (Outpatient) 123 85% 98% 100% 95%

MRSA rate:
1) NON-URINE Inpatient/ED 28% & Outpatient 16%,
2) URINE Inpatient/ED 24% & Outpatient 15%
VRE rate: Inpatient/ED: Inpatient/ED
1) NON-URINE 11%,
2) URINE 4%

PTD = pharmacy to dose

% Susceptible

80% or better

70-79%

<69%

18
BCH Antimicrobial Cost Information
Medication Route Cost per Dose ($) Cost per Day ($) Relative Cost/Day Medication Route Cost per Dose ($) Cost per Day ($) Relative Cost/Day

Acyclovir IV 4.60 13.8 $$$ Fluconazole IV 6.76 6.76 $$

Acyclovir PO 0.36 1.8 $$ Fluconazole PO 2.70 2.70 $$

Amoxicillin PO 0.09 0.258 $ Levofloxacin IV 4.59 4.59 $$

Ampicillin IV 3.72 14.88 $$$ Levofloxacin PO 0.42 0.42 $

Augmentin PO 0.40 0.80 $ Meropenem IV 40.76 122.28 $$$$$

Azithromycin IV 7.07 7.07 $$ Metronidazole IV 1.23 3.69 $$

Azithromycin PO 1.65 1.65 $$ Metronidazole PO 0.60 1.80 $$

Bactrim IV 8.78 17.56 $$$ Micafungin IV 181.05 181.05 $$$$$

Bactrim PO 0.15 0.30 $ Nafcillin IV 13.78 55.12 $$$$

Cefazolin IV 7.16 21.48 $$$ Penicillin G IV 3.00 12.00 $$$

Cefdinir PO 1.53 3.06 $$ Penicillin VK PO 0.15 0.60 $

Cefepime IV 14.99 29.98 $$$$ Unasyn IV 4.70 18.80 $$$

Cefoxitin IV 8.50 25.50 $$$ Valacyclovir PO 2.16 6.48 $$

Ceftriaxone IV 57.37 57.37 $$$$ Vancomycin IV 15.49 15.49 $$$

Cephalexin PO 0.08 0.32 $ Zosyn IV 17.78 71.12 $$$$

Ciprofloxacin IV 2.16 4.32 $$

Ciprofloxacin PO 0.19 0.38 $

Clindamycin IV 13.49 40.47 $$$$

Clindamycin PO 0.16 0.48 $

Dicloxacillin PO 0.35 1.40 $$

Ertapenem IV 70.52 70.52 $$$$

19
BCH Adult Vancomycin Dosing and Monitoring Guidelines.
*Please contact pharmacy or get ID consult if concerns about vancomycin dosing. It is important to consider if other renal toxic agents are
being co-administered when dosing vancomycin.

Goal Trough Vancomycin Loading Doses Vancomycin Maintenance Dosing in Dialysis

Indication
(mcg/mL) (actual body weight)
500-1000mg (5-10mg/kg) after
IHD level < 10-15
10-15 UTI, Cellulitis, Prophylaxis PTD Non-critically ill 15-20mg/kg each session
MRSA Bacteremia, MRSA Osteomyelitis, Complicated infections in seriously ill 25mg/kg PD level < 10-15 500-1000mg Q48-72h
15-20 Endocarditis, Meningitis, Documented Consult ID
Renal Impairment, CRRT, IHD, PD 15-25mg/kg 1000 mg (10-15mg/kg) daily dose may vary
MRSA PNA CRRT level < 1-15
by type of CRRT and rate of filtration
Preoperative antimicrobial prophylaxis 15mg/kg
MRSA Vancomycin MIC greater than or equal to 2: Alternate therapy is
suggested & ID should be consulted Maximum of 2 grams per dose

Vancomycin Maintenance Doses: Goal 10-15mg/L Vancomycin Maintenance Doses:

~15mg/kg per Dose Goal 15-20mg/L
~20mg/kg per Dose
Creatinine Clearance (mL/min)
Notify Infectious Disease for:
20 30 40 50 60 70 80 90 ≥100
• Any indication with a goal trough of 15-20
50 750mg 500mg 750mg 750mg 1000mg 1000mg 500mg 750mg 1000mg
q48h q24h q24h q24h q24h q24h q12h q12h q12h • Any order with a goal trough of 15-20
60 750mg 750mg 750mg 1000mg 1250mg 750mg 750mg 1000mg 1000mg • Any MRSA with an MIC of 2 or greater
q48h q24h q24h q24h q24h q12h q12h q12h q12h • Any patient requiring greater than or equal to 3
70 1000mg 750mg 1000mg 1250mg 1500mg 750mg 750mg 1000mg 1250mg grams vancomycin total per day
q48h q24h q24h q24h q24h q12h q12h q12h q12h If infectious Disease is unavailable, pharmacists
80 1250mg 750mg 1000mg 1250mg 1500mg 750mg 1000mg 1250mg 1250mg may order the first dose of vancomycin to a goal
trough of 15 for listed indications. Infectious
Actual Body Weight (kg)

q48h q24h q24h q24h q24h q12h q12h q12h q12h

Disease will be notified ASAP.
90 1250mg 1000mg 1250mg 1500mg 1750mg 1000mg 1250mg 1250mg CALL
q48h q24h q24h q24h q24h q12h q12h q12h ID
100 1500mg 1000mg 1250mg 1500mg 1000mg 1000mg 1250mg CALL CALL
q48h q24h q24h q24h q12h q12h q12h ID ID
110 1750mg 1000mg 1500mg 1750mg 1000mg 1000mg 1250mg CALL CALL
q48h q24h q24h q24h q12h q12h q12h ID ID
120 1750mg 1250mg 1500mg 1750mg 1000mg 1250mg CALL CALL CALL
q48h q24h q24h q24h q12h q12h ID ID ID
130 2000mg 1250mg 1500mg 1000mg 1000mg 1250mg CALL CALL CALL
q48h q24h q24h q12h q12h q12h ID ID ID
140 2000mg 1500mg 1750mg 1000mg 1250mg CALL CALL CALL CALL
q48h q24h q24h q12h q12h ID ID ID ID
150 1000mg 1500mg 1750mg 1000mg 1250mg CALL CALL CALL CALL
q24h q24h q24h q12h q12h ID ID ID ID
Notify ID if required calculated daily dose equals or exceeds 3 grams
20
BCH Adult Vancomycin Dosing and Monitoring Guidelines.
*Please contact pharmacy or get ID consult if concerns about vancomycin dosing. It is important to consider if other renal toxic agents are
being co-administered when dosing vancomycin.

Timing of First Vancomycin Trough or Level Additional Monitoring

Labs which can be initiated following a PTD order
Dosing Interval Timing
Renal function SCr, BUN, urine output
Q8h
Trough 30 min prior to 4th or 5th dose Response to therapy WBC, Segs/Bands, ANC, TMax
Q12h
Appropriateness of therapy Culture, Sensitivity, Levels
Q24h Trough 30 min prior to 3rd or 4th dose
Toxicity Alb/Tbili, Platelets
Random level w/in 24 hours of first dose
Q48h
Begin maintenance dose if random is <15

Random level prior to re-dose

CrCl <20, ARF, IHD, CRRT
Wait at least 4-6 hours after IHD before drawing level

Frequency of Trough Monitoring General Recommendation for Dose Adjustment Based on Levels

Stable patient following trough at goal At least once weekly Actual Trough Target Trough Recommendation
Following change in dose Trough prior to 3rd or 4th dose ≤5 10-15 Decrease dosing interval AND keep TDD same
Change in renal function 15-20 Decrease dosing interval
Trough prior to next dose
SCr increase ≥ 0.3, decreased urine output
6-9 10-15 Increase dose by 250mg
Change in renal function Hold vancomycin AND trough prior to
15-20 Decrease dosing interval OR increase dose by 500mg
SCr increase ≥ 0.5 OR ≥ 50% from baseline next dose *Contact provider*
10-15 10-15 No change required
Trough every 3 days to avoid risk of supra-
Obese patients (BMI > 30)
therapeutic levels due to accumulation 15-20 Increase dose by 250mg

CrCl < 20, ARF, IHD, CRRT Random level prior to dose 15-20 10-15 Decrease dose by 250mg

Hemodynamically unstable OR rapidly 15-20 No change required

Daily troughs may be warranted
changing renal function
> 20 10-15 Increase dosing interval OR decrease dose by 500mg

15-20 Decrease dose by 250mg

General Calculation Strategy if Interval Remains the Same:

(Current vancomycin dose)/(Vancomycin trough) = (New vancomycin dose)/(Desired trough)

References: see online document on Scoop

21
For more information about the Infectious Disease Team at BCH see:
bch.org/beaconcenter

Antibiotic Stewardship Team

Amie Meditz, MD, Co-Chair
Christopher Zielenski, PharmD, Co-Chair

Members
Mark King, MD Susie Pfister, RN, BSN, ONC
Casey Diekmann, PharmD Kristin Robson, MPH
Katherine Macchi, PharmD Kylie Chilton, MPH, CIC
Joslyn Winterland, PharmD Michelle Johler, BS, HACP
Jaime Mesenbrink, PharmD Kate Norris, BS
Austin Hinkel, PharmD (resident) Caitlyn Hockenbury
Cynthia Littlehorn, SM (ASCP), MB Tracy Nagell, RN, MSN, MHA

22