Victoria General Hospital - Diagnostic Services Manitoba
Transcription
Victoria General Hospital - Diagnostic Services Manitoba
Table 8. Adult parenteral antimicrobial dosage guidelinesa Antibiotic Table 9. Parenteral to oral conversion suggestions Usual Dosagesb Parenteral Drug ANTIBACTERIAL AGENTS Penicillins Amoxicillin Cloxacillin 2 g q4-6h Cloxacillin Cloxacillin, Cephalexin Penicillin G 1-2 million units q4-6h Penicillin G Penicillin V Piperacillin-Tazobactam Amoxicillin-Clavulanate Co-trimoxazole (TMP-SMX) +/- Metronidazole Ciprofloxacin +/- Metronidazole 3.375 g q6h Meropenem 500 mg q6h Cephalosporins Cefoxitin 1-2 g q6-8h Cefuroxime 0.75-1.5 g q8h Ceftriaxone 1-2 g q24h Ceftazidime 1-2 g q8h Ciprofloxacin 400 mg q12h Levofloxacin 500-750 mg q24h Moxifloxacin 400 mg q24h 500 mg q24h Aminoglycosides Gentamicin 80 mg q8h Tobramycin 80 mg q8h Co-trimoxazole (TMP-SMX) Metronidazole Vancomycin Cefoxitin Cefuroxime Co-trimoxazole (TMP-SMX) Amoxicillin-Clavulanate Azithromycin, Clarithromycin Ciprofloxacin Levofloxacin Levofloxacin Azithromycin Clindamycin 600 mg q8h Fluconazole 1 g q12h Fluconazole 100-400 mg q24h Micafungin 100 mg q24h ANTIVIRAL AGENTS 5-10 mg/kg q8h 5 mg/kg q12h Reviewed by the WRHA Antimicrobial Pharmacotherapy Subcommittee November 2013. b Based on normal renal function in a 70 kg patient. Acyclovir a b > 40 (q6h) 20-40 (q8h) < 20 (q12h) > 50 (q8h) 10-50 (q12h) < 10 (q24h) > 30 (q6-8h) 10-30 (q12-24h) < 10 (q24h) > 50 (q8h) 30-50 (q12h) 10-30 (q24h) Cefuroxime > 20 (q8h) 10-20 (q12h) < 10 (q24h) > 50 (q8h) 25-50 (q12h) 10-25 (q24h) Acyclovir Aminoglycosides > 30 (q12h) < 30 (q24h) > 50 (q24h) 20-50 (50% q24h) < 20 (25% q24h) 50-70 2.5 mg/kg q12h > 50 (q24h) > 50 (q6h) 25-50 2.5 mg/kg q24h 20-49 (500 mg load, then 50% q24h) 30-49 (q8h) 10-25 1.25 mg/kg q24h 10-19 (500 mg load, then 50% q48h) 10-29 (q12h) TMP-SMX > 25 (q6-8h) 15-25 (50% q6-8h) Vancomycind > 70 (q12h) 50-70 (q24h) Fluconazole Ganciclovir (induction doses) Levofloxacin (e.g. CAP) Cloxacillin +/- Metronidazole Cephalexin +/- Metronidazole Clindamycin Meropenem NO CHANGE NECESSARY Metronidazole Fluconazole Reviewed by the WRHA Antimicrobial Pharmacotherapy Subcommittee November 2013. Selection of oral therapy should be based on cultures and sensitivities. In absence of useful cultures, oral therapy may be selected based on potential pathogens, community- versus hospital-acquired infection, pharmacokinetics, spectrum of activity, and cost of each oral agent. Oral agents listed above represent those currently on the WRHA Formulary and does not represent all commercially available oral agents. < 10 (50% q24h) NO CHANGE NECESSARY Clindamycin Azithromycin Acyclovir < 10 (50% q24-48h) Contact the Pharmacist at your facility for dosing assistance d Azithromycin ANTIVIRAL AGENTS 0.5-1 mg/kg q24h < 10 (20-50%)b Victoria General Hospital Antibiogram for 2015 (Based on data from 2014) Miscellaneous ANTIFUNGAL AGENTS 500 mg q8h 10-50 (q6-8h) Ceftazidime Ciprofloxacin Ciprofloxacin 10-20 mg/kg/day trimethoprim in divided doses q6-8h Amphotericin B Ganciclovir Amoxicillin-Clavulanate Cephalexin Ciprofloxacin, Levofloxacin Others ANTIFUNGAL AGENTS Acyclovir Ceftriaxone Ciprofloxacin > 50 (q4-6h) NO CHANGE NECESSARY Macrolides Others Clindamycin Cefazolin Ceftriaxone Ceftazidime < 10 (q12h) Cephalosporins Fluoroquinolones Macrolides Azithromycin Piperacillin (± Tazobactam) Cephalexin, Cloxacillin Cephalexin + Metronidazole Co-trimoxazole (TMP-SMX) + Metronidazole Amoxicillin-Clavulanate 10-30 (q6-12h) NO CHANGE NECESSARY Penicillin Cefazolin Cefoxitin > 30 (q6h) Cloxacillin Cephalosporins 1-2 g q8h Fluoroquinolones a Ampicillin Ampicillin Piperacillin-Tazobactam Creatinine Clearance (CrCl) in mL/minc (suggested dosage adjustment based on normal dose) Penicillins 1-2 g q6h Cefazolin Drug ANTIBACTERIAL AGENTS Penicillins Ampicillin Table 10. Adult dosing recommendations in renal impairmenta, b Oral Therapy Optionsa, b For further information contact: < 10 1.25 mg/kg 3x/wk < 10 (q24h) NO CHANGE NECESSARY < 15 (2.5-5 mg/kg, generally not recommended)b 10-49 (q24-72h) < 10 (q5-7days) Reviewed by the WRHA Antimicrobial Pharmacotherapy Subcommittee November 2013. b Suggested dosages – for individualized dosage modifications or more information contact the Pharmacy Department at your facility. c To estimate creatinine clearance (CLCR) (mL/min) use the following calculation normalized for a 72 kilogram person. CLCR male = (140-age) x 88.4 CLCR female = 0.85 x CLCR male SCR (μmoles/L) d Monitor serum concentrations. a Provided by: Diagnostic Services Manitoba, Clinical Microbiology Discipline Andrew Walkty, MD, FRCPC Medical Microbiologist, Health Sciences Centre/Diagnostic Services Manitoba or Daryl J. Hoban, PhD, D(ABMM), FCCM Clinical Microbiologist, Health Sciences Centre/Diagnostic Services Manitoba or Philippe Lagacé-Wiens, MD, FRCPC Medical Microbiologist, St. Boniface Hospital/Diagnostic Services Manitoba Reviewed by the WRHA Antimicrobial Pharmacotherapy Subcommittee November 2013 62 100 TrimethoprimSulfamethoxazole 100 100 100 80 80 78 86 98 60 100 Methicillin Resistant Staphylococcus aureus (53) 0 100 96 84 87 97 98 23 72 100 100 Isolates tested and reported are from all sources (surveillance isolates excluded), Jan to Dec, 2014; data compiled according to the recommendations of the Clinical and Laboratory Standards Institute (CLSI) in their document M39-A4 (2014). b Oxacillin accurately predicts the activity of all semi-synthetic penicillins, including cloxacillin, beta-lactam/ beta‑lactamase inhibitor combinations, cephalosporins, and carbapenems for Staphylococcus aureus. Table 5. In vitro activity of selected anti-infective agents tested against anaerobic isolates collected at the Health Sciences Centre, Winnipega Percent Susceptible Organism (number tested) =Not tested, not routinely reported, or not recommended Bacteroides fragilis group (70) (includes Bacteroides fragilis) a 81 100 56 49 100 100 Isolates tested and reported are from all sources. Data were extracted from the CANAEROBES study (Zhanel et al.). 100 97 Antibiotic ANTIBACTERIAL AGENTS Penicillins Amoxicillin Amoxicillin-Clavulanate Cloxacillin Penicillin V Cephalosporins Cephalexin Macrolides Azithromycin Clarithromycin Erythromycin Fluoroquinolones Ciprofloxacin Levofloxacin Moxifloxacin Others Clindamycin Co-trimoxazole (TMP-SMX) Doxycycline Nitrofurantoin Trimethoprim Metronidazole ANTIFUNGAL AGENTS Fluconazole Itraconazole ANTIVIRAL AGENTS Acyclovir Valacyclovir a b 100 n.d. Table 7. Adult oral antimicrobial dosage guidelinesa Linezolid Tetracycline Methicillin Susceptible Staphylococcus aureus (168) 97 100 Data obtained by testing a random sample of C. albicans and C. glabrata isolates from Health Sciences Centre and St. Boniface Hospital, collected between Jan 2010 and Dec 2012. Susceptibility interpretations are based on updated CLSI breakpoints (M27-S4). Isolates tested and reported are from blood only. b For fluconazole, there is only a susceptible-dose dependent (SDD) breakpoint for C. glabrata. The percentage of C. glabrata isolates that tested SDD to fluconazole was 100%. Susceptibility of SDD isolates to fluconazole is dependent on achieving the maximum blood level possible (i.e., should use the maximum dosage regimen). Consultation with infectious diseases is recommended for further guidance. n.d. = breakpoints have not been defined for voriconazole versus C. glabrata Percent Susceptible =Not tested, not routinely reported, or not recommended Candida albicans (30) Candida glabrata (30) a Table 4. In vitro activity of selected anti-infective agents tested against Methicillin Susceptible and Methicillin Resistant Staphylococcus aureus isolates Organism (number tested) Micafungin Clindamycin 100 Voriconazole Clarithromycin 70 Organism (number tested) Fluconazoleb Levofloxacin 92 92 Clindamycin 92 98 100 100 92 Erythromycin Nitrofurantoin 98 Isolates tested and reported are from all sources (surveillance isolates excluded), Jan to Dec, 2014; data compiled according to the recommendations of the Clinical and Laboratory Standards Institute (CLSI) in their document M39-A4 (2014). Oxacillin accurately predicts the activity of all semi-synthetic penicillins, including cloxacillin, beta-lactam/ beta-lactamase inhibitor combinations, cephalosporins, and carbapenems for Staphylococcus aureus and Coagulase-negative Staphylococci. c Susceptibility to high-level gentamicin or high-level streptomycin indicates that these agents can be used in combination with a cell wall active agent (e.g. ampicillin or vancomycin) for synergy. Gentamicin and streptomycin should never be used alone as treatment for Enterococcus spp. d Erythromycin activity predicts the activity of azithromycin and clarithromycin for staphylococci and streptococci. e Rifampin should NOT be used alone as treatment for infection. f Nitrofurantoin is indicated for acute cystitis only. g n.a. = not applicable – Susceptibility testing of Streptococcus pyogenes is not routinely performed as 100% are susceptible to penicillin. If treating infection in a penicillin allergic patient, contact the lab for testing of second line agents. h Streptococcus agalactiae isolates were obtained from vaginal/rectal swabs submitted for Group B Streptococcus detection to the Health Sciences Centre, St. Boniface Hospital, and Westman Laboratory in 2012. a 73 Data were obtained by testing a random sample of 59 bloodstream isolates and 54 respiratory isolates obtained from patients at the Health Sciences Centre (HSC) and St. Boniface Hospital (SBH) between January and December, 2014. b For Streptococcus pneumoniae, different susceptibility breakpoints for penicillin and ceftriaxone exist depending on whether meningitis or a non-meningitis infection is being treated [CLSI, M100-S25]. For penicillin, when treating a non-meningitis infection different breakpoints exist for oral and intravenous dosing. For non‑meningitis infections, susceptibility to oral penicillin predicts susceptibility to amoxicillin. Oral agents are not appropriate for the treatment of bacterial meningitis. f Tetracycline 91 100 100 100 100 98 Metronidazole 64 100 100 Imipenem 55 98 100 a Linezolid 96 Rifampine 83 d 69 88 100 Clindamycin 100 79 88 Cefoxitin 45 84 TrimethoprimSulfamethoxazole 100 100 High-Level Gentamicinc High-Level Streptomycinc 78 Clindamycin 94 Erythromycin Enterococcus spp. (192) Staphylococcus aureus (217) Coagulase-negative Staphylococci (42) Streptococcus pyogenes (n.a.)g (Group A Streptococcus) Streptococcus agalactiae (162)h (Group B Streptococcus) Vancomycin =Not tested, not routinely reported, or not recommended Vancomycin 28 Percent Susceptible Organism (number tested): January through December 2014 Ceftriaxone 93 TrimethoprimSulfamethoxazole 96 97 85 Bloodstream Isolates Meningitis (59) Non-Meningitis infection (59) Respiratory Isolates Non-Meningitis infection (54) PiperacillinTazobactam 98 94 98 Penicillin (intravenous) 99 94 92 25 Vancomycin Ciprofloxacin 97 98 100 100 100 100 100 100 91 91 100 85 67 70 80 93 85 AmoxicillinClavulanate Tobramycin 90 64 72 Penicillin (oral) Gentamicin 94 84 88 Oxacillinb Amikacin 96 88 88 Nitrofurantoinc Meropenem 98 100 100 100 100 100 TrimethoprimSulfamethoxazole Ceftazidime Cefuroxime Cefazolin AmoxicillinClavulanate PiperacillinTazobactam 81 88 95 =Not tested, not routinely reported, or not recommended Penicillin • If anti-infective agent susceptibilities are known, anti-infective therapy should be tailored based on available data. 88 64 95 77 86 92 Table 6. In vitro activity of selected anti-fungal agents tested against Candida species collected from hospitals in Winnipega Percent Susceptible Infection Type (number tested) Table 2. In vitro activity of selected anti-infective agents tested against Gram-positive coccia • Clinical improvement of infectious signs and symptoms (e.g., temperature defervescence, decreased white blood cell count). • For rapid step-down, choose agents with high bioavailability (e.g., clindamycin, co‑trimoxazole (TMP-SMX), fluoroquinolones). 47 63 Isolates tested and reported are from all sources combined, with the exception of Escherichia coli (subdivided into systemic isolates and urine isolates); isolates were collected from Jan 1 to Dec 31, 2014 with the exception of Enterobacter cloacae complex (collected from Jan 2013 to Dec 2014); data compiled according to the recommendations of the Clinical and Laboratory Standards Institute (CLSI) in their document M39-A4 (2014). b New breakpoints for cefazolin, ceftriaxone, and ceftazidime were implemented in 2013. This change accounts for the apparent reduction in cefazolin susceptibility for members of the family Enterobacteriaceae. c Nitrofurantoin is indicated for acute cystitis only. d H. influenzae data obtained from isolates tested at St. Boniface Hospital and Health Sciences Centre, Jan 1 to Dec 31, 2014. Seventy-one isolates were tested for Trimethoprim-Sulfamethoxazole. n.d. = no data – absence of data for certain drug-organism combinations reflects limitations of the testing method currently used by DSM Clinical Microbiology laboratories. SUGGESTED CRITERIA FOR IV TO ORAL ANTIBIOTIC CONVERSION IN ADULTS • Patient can tolerate oral feeding and medications (bowel sounds, no diarrhea/nausea/ vomiting). 82 90 75 97 80 97 n.d. 96 99 n.d. 100 88 Table 3. In vitro activity of selected anti-infective agents tested against Streptococcus pneumoniaea, b Percent Susceptible a • Consideration should be given to equally efficacious but less expensive anti-infective agents for empiric therapy or when streamlining of therapy is desired, if the situation permits. • Patient is clinically stable (excludes patients in the intensive care unit, patients with febrile neutropenia, or patients with life threatening infections). 52 56 75 Ceftriaxone Enterobacter cloacae complex (48) Escherichia coli (64) systemic Escherichia coli (436) urine Haemophilus influenzae (74)d Klebsiella pneumoniae (94) Proteus mirabilis (33) Pseudomonas aeruginosa (67) Ampicillin =Not tested, not routinely reported, or not recommended Oxacillin • Initial broad-spectrum empiric therapy should be focused to the most appropriate narrow‑spectrum agent(s) based on the laboratory identification of pathogen(s) and known susceptibility patterns/results, if the situation permits. Organism (number tested): January through December 2014 b • The information presented in the antibiogram is intended only to guide initial empiric anti‑infective agent therapy at the Victoria General Hospital. Percent Susceptible Ampicillin HOW TO USE THE ANTIBIOGRAM PORTION OF THE GUIDE (Tables 1-6) Table 1. In vitro activity of selected anti-infective agents tested against Gram-negative bacillia, b Penicillin DISCLAIMERS This guide is provided as an educational resource for physicians and other healthcare professionals caring for patients at the Victoria General Hospital. The authors of the guide have made every effort to ensure that the information contained in it was accurate at the time of publication. Users of the guide are encouraged to consult other references to confirm the information presented in it. The authors are not responsible for errors, omissions, inaccuracies, or the continued completeness of the information contained in the guide. The information in the guide should not be used or relied upon to replace the skill and professional judgment required to determine appropriate patient care and treatment. Also, the guide is not intended to replace or to be used as a substitute for the complete prescribing information prepared by each pharmaceutical manufacturer for their anti-infective agents. Because of possible changes in anti-infective indications, changes in dosage information, differences in patients’ responses to therapy, newly described toxicities, drug-drug interactions, and other items of importance, reference to complete prescribing information is recommended before any of the anti-infective agents described in the guide are used. a b Usual Dosages Cost ($) per dayb 250 – 500 mg tid 250 – 500 mg tid 250 – 500 mg qid 300 mg qid 0.60 – 1.10 2.10 – 3.10 0.80 – 1.50 0.30 250 – 500 mg qid 0.90 – 1.80 250 – 500 mg daily 250 – 500 mg bid 250 – 500 mg qid 3.10 – 6.20 2.20 – 4.50 0.80 – 1.60 250 – 750 mg bid 500 - 750 mg daily 400 mg daily 2.80 – 6.00 3.50 – 7.00 5.00 300 – 450 mg tid 1 DS (double strength) tab bid 100 mg bid 50 – 100 mg qid 100 mg bid 500 mg tid 3.30 – 5.00 0.30 1.30 0.70 –1.50 0.75 0.35 100 – 400 mg daily 200 – 400 mg daily 6.10 – 25.00 8.00 – 16.00 200 – 800 mg 5x/day 500 mg – 1 g tid 5.00 – 16.00 8.00 – 16.00 Reviewed by the WRHA Antimicrobial Pharmacotherapy Subcommittee November 2013. Approximate cost per inpatient day excluding dispensing costs as of February 2010 based on the Manitoba Drug Interchangibility Formulary and Manufacturer’s List Prices. Prices have been rounded.