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stewardship program
1/1/2014
Antimicrobial Guideline
Dr.Tarif Al-Aama
We are proud to introduce the first edition of the
antimicrobial guideline it has been our aim to provide staff
with reliable, up-to-date drug information. In the daily
management of patients, clinicians are often faced with the
need to access drug information quickly in order to make
swift therapeutic decisions. It is hoped that this guideline
may be a readily accessible source of clinically important
information for antibiotics usage. Additionally, it is meant to
provide a quick and reliable source of information for
nursing staff. At a time when worldwide attention is being.
Reviewers
Guideline Purpose:
To improve antimicrobial use for hospitalized adults.
Minimizing the emergence and spread of antimicrobial resistance.
Core strategies:
Prospective audit with intervention and feedback:
It is a method that allows the antimicrobial stewardship program (an infectious diseases physician or a clinical
pharmacist) to interact directly with prescribers in order to modify specific antibiotic therapy for each patient.
These strategies are employed after the initial prescribing and dispensing of the antibiotic.
Education: education alone, without incorporation of active intervention, is only marginally effective in changing
antimicrobial prescribing practices and has not demonstrated a sustained impact
Antimicrobial dosing:
All the following should be considered during antibiotics prescribing:
Dose optimization (pharmacokinetics/pharmacodynamics) is essential to optimize the treatment of organisms with
reduced susceptibility
Dosing Monitoring for vancomycin and aminoglycoside (Appendix: D)
Dose adjustments in cases of renal dysfunction (Appendix: J)
The antibiotic policy shall depend heavily on surveillance of antimicrobial resistance ((Appendix: F (antibiogram)
and antibiotic consumption ((Appendix: G (antibiotics consumption)) in any setting. Hence, it is mandatory to
establish an efficient surveillance system.
The surveillance for antimicrobial resistance/antibiotic consumption and preparation of an “enhanced” or
cumulative antibiogram at the local level helps in clinical decision-making, design infection control interventions,
and antimicrobial-resistance containment strategies.
The clinical microbiology laboratory plays a critical role in antimicrobial stewardship by providing patient-specific
culture and susceptibility data
The pharmacy department responsible for antibiotics consumption at all hospital setting
(ICU, non-ICU, Outpatient …etc)
Determining the impact of antimicrobial stewardship on antimicrobial use and resistance patterns by two
steps:
Process measures (did the intervention result in the desired change in antimicrobial use?)
Outcome measures (did the process implemented reduce or prevent resistance or other unintended
consequences of antimicrobial use?)
Antimicrobial committee
PURPOSE:
To provide a standard method/ guidelines in prescribing medication (antimicrobials) for health care providers
at MOH.
EQUIPMENTS/ MATERIALS:
Patient Medical record.
Antibiotic order form
POLICY STATEMENT:
This guideline only for adult
Antibiotics order form is controlled and a guided method to all health care providers (physician, pharmacist,
clinical pharmacist and nurse) during prescribing the antibiotics
The guideline is formatted as physician order
The use of this order form is only for community acquired infection.
The management of nosocomial infection depend on the hospital antibiogram results
Referral to the original guideline is very important for a pharmacist/clinical pharmacist for more detail or any
update.
The antimicrobial order should be renew every 7 days ( automatic stop order)
PROCEDURE:
The treating physician write the patient information
The treating physician must write the symptom, diagnose and culture result ( if available)
Choosing the therapy dosage( antibiotics, dose, interval and duration) depending on patient age group and
micro-organism
Either using E- prescription or hand writing prescription depend on hospital system
Send the copy of order form to pharmacy and keep the original in patient’s file
and the third copy will send to the Drug Use Evaluation department
Finally the pharmacist/clinical pharmacist must follow up the patient and write down his commen
RESPONSIBILIT
The hospital antibiotics approval team shall routinely reports the renewal of these forms to region antibiotic
committee and then submits it to pharmaceutical care administration of antibiotic Advisory Committee to
review it.
The antibiogram should be quarterly reported to regional antibiotic committee and then submitted it to central
antibiotic Committee to review it and create the guideline of nosocomial infection according to this result.
_________Hospital FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
CONSULTANT IN CHARGE:_______________________
Department within 24 hrs)
Diagnosis: ………………………………………………………………………………………………………………………………..
Culture: Pending ( + ) Culture ( - ) Culture Not sending .
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Shulman, ST; Bisno, AL; Clegg, HW; Gerber, MA; Kaplan, EL; Lee, G; Martin, JM; Van Beneden, C (Sep 9, 2012). "Clinical Practice
Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society
of America.". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 55 (10): e86–102
__________________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Diagnosis:……………………………………………………………………………………………………………………..
Culture: Pending ( + ) Culture ( - ) Culture Not
IDSA recommends that any of the 3 following clinical presentations be used to identify patients with acute bacterial vs.
viral rhinosinusitis:
Symptoms or signs persistent & not improving for ≥10 days
Severe symptoms or signs for at least 3–4 days
Worsening symptoms or signs OR "double sickening" for lasted 5–6 days and were initially improving).
Empiric Therapy for Acute Bacterial Rhinosinusitis (for renal failure patient appendix)
First line therapy
Initial empirical therapy 1 Amox-Clav (extended release tabs) 1000/62.5 mg 2 tablets PO q12hr 5-7 days
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Chow, AW; Benninger, MS; Brook, I; Brozek,. "IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and
adults". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America March 20, 2012 ;54 (8): e72–
e112
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Diagnosis:……………………………………………………………………………………………………………………..
Culture: Pending ( + ) Culture ( - ) Culture Not sending
CURB-65 Mortality Prediction Tool for Patients with Community-Acquired Pneumonia
Confusion Points(Assign 1 point for each
Blood urea nitrogen level > 20 mg per dL (7.14 mmol per L) variable)
Respiratory rate ≥ 30 breaths per minute
Blood pressure (systolic < 90 mm Hg or diastolic ≤ 60 mm Hg)
Age ≥ 65 years
Inpatient vs Outpatient
0 or 1 point Treat as outpatient
2 points Treat as inpatient
≥3 points Treat in intensive care unit
Empiric Therapy for Community-Acquired Pneumonia (for renal failure patient appendix)
Patient group Therapy (dosing interval in hours) patient with normal renal function
Previously healthy outpatients; no 1 Azithromycin 500 mg PO on day 1 followed by 250 mg q24hr on days 2-5
antibiotic use in past 3months 2 Clarithromycin 250 mg PO q12h x 7 days
3 Doxycycline 100 mg PO q12hr 7-10 days
Outpatients with comorbidities or 1 Cefuroxime 500 mg PO q12 hr + Clarithromycin 500 mg PO q12h
antibiotic use in past three months 2 Amoxicillin 1 g PO q8h + Clarithromycin 500 mg PO q12h
3 Amoxicillin-clavulanate 2 g PO q12h + Clarithromycin 500 mg PO q12h
4 Levofloxacin 750 mg PO q24h
Inpatients, non-ICU 1 Ceftriaxone 2 gm IV q24h + Clarithromycin 500 mg PO q12h
2 Amoxicillin-clavulanate 1 g IV q12h + Clarithromycin 500 mg POq12h
Inpatients, ICU (admission ) 1 Ceftriaxone 1-2g IV q24h+ Clarithromycin 500 mg PO q12h
+Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr ( the regemin
should de-escalated depending on culture result)
2 Ceftriaxone 1-2g IV q24h+ Azithromycin 500 mg POq24hr +Vancomycin
IV loading dose of 25-30 mg/kg then 1g q8hr Ceftriaxone 1-2g IV q24h +
3 Levofloxacin 750 mg IV q24h
Vancomycin, target trough serum concentration of 15-20 μg/mL
for penicillin-allergic patients 1 Levofloxacin 750 mg IV q24h
Risk factors for Pseudomonas 1 Piperacillin/tazobactam 4.5g IV q6h + Gentamycin IV 1 mg/kg q8h +
species Clarithromycin 500 mg PO q12h
2 Piperacillin/tazobactam 4.5g IV q6h + Gentamycin IV 1 mg/kg q8h +
Azithromycin 500mg PO q12hr
Gentamycin calculated dose:……………. ( trough levels of <1 mcg/mL)
If CA-MRSA is a consideration 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr Linezolid IV
600 mg q12h
2 Vancomycin calculated dose:………………….. Vancomycin, target
trough serum concentration of 15-20 μg/mL
Influenza virus 1 Oseltamivir (Tamiflu) 75mg q12hr for 5 days
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Diagnosis:…………………………………………………………………………………………………………………….
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Allan R. Tunkel,1 Barry J. Hartman,Practice Guidelines for the Management of Bacterial Meningitis" Infectious Diseases ; 2004 ; 39 : 1267 -
Sanford guide Antimicrobial Therapy, web edition, Inc. 2014
_________Hospital FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Diagnosis:……………………………………………………………………………………………………………………
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Empiric Therapy for brain abscesses (for renal failure patient appendix)
Empiric(Origin of Therapy (dosing interval in hours) Duration
abscess)
Oral source or 1 Ceftriaxone IV 2 g q12hr +Metronidazole 500 mg IV q8hr Duration of
otogenic, or sinus Penicillin G 3-4 million units IV q4h + Metronidazole 500 mg IV q8hr treatment is
source 2 unclear. Treat
until
Hematogenous 1 Flucloxacillin IV 2g oral q4-6hr
response by
spread Suspect MSSA 2 Cloxacillin IV 2 g oral q4-6hr
neuroimaging
Staph. Aureus
MRSA Vancomycin IV loading dose of 25-30 mg/kg then 1 g q8hr ± (CT/MRI).
Metronidazole IV 500 mg q8hr
(Vancomycin target trough serum concentration of 15-20 μg/mL)
Postoperative 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
neurosurgical patients meropenem IV2 g q8hr
2 Vancomycin IV loading dose of 25-30 mg/kg 1g q8hr + Ceftazidime
IV 2 g q8hr
(vancomycin target trough serum concentration of 15-20 μg/mL)
Penetrating trauma 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr +
OR unknowing source Ceftriaxone IV 2 g q12hr
(Vancomycin target trough serum concentration of 15-20 μg/mL)
If the paranasal sinuses are involved, add metronidazole 500 mg IV
q8hr
NOTES_________________________________________________________________________________________________________________________________
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Diagnosis: ………………………………………………………………………………………………………………….
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Microbiology:
-Three to five blood cultures of at least 10 mL each should be drawn during the first 24–48 hours.
Therapy for Infective Endocarditis (for renal failure patient appendix)
Native Valve
Patient group Therapy (dosing interval in hours) (weeks)
Empiric therapy 1 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Ceftriaxone IV/IM 2g
(If patient is not 24h
acutely ill and not in 2 Vancomycin IV loading dose of 25-30 mg/kg then 1g q8hr + Gentamicin 1 mg/kg IV
heart failure, the q8h
preference is to wait (Vancomycin target trough concentration of 15-20 μg/mL)
for blood culture Gentamicin calculated dose: …………………(trough levels should be < 1 μg/mL)
results)
Streptococcus viridans 1 Penicillin- G : IV 3-4 million Unit q4 h (4wks)
( Penicillin MIC ≤ 2 Penicillin- G: IV 3-4 million Unit q4 h + Gentamicin 1 mg/kg IV q8h (2wks)
0.12) Ceftriaxone IV/IM 2g q24 hr (4wks)
3 Ceftriaxone IV/IM 2 g q24hr + gentamicin 1 mg/kg IV q8h (2wks)
4 Gentamicin calculated dose: …………………..(trough levels should be < 1 μg/mL)
Streptococcus viridans 1 Penicillin –G: IV 3-4 million Unit q4 h+ gentamicin 1 mg/kg q8 h IV/IM (4wks)
( penicillin MIC > Ceftriaxone IV/IM 2 g q24 h in 1 dose +gentamicin 1 mg/kg q8 h IV/IM (4wks)
0.12) 2 Gentamicin calculated dose: …………..(trough levels should be < 1 μg/mL)
Prosthetic valve
Routine dental cleaning or routine anesthetic injections through non-infected tissue does
not require antibiotic prophylaxis.
The risk of IE is highest for the following dental procedures hence prophylaxis is
indicated:
Those involving manipulation of gingival tissue or
The peri-apical region of the teeth or
Perforation of the oral mucosa, such as tooth extractions or
Drainage of a dental abscess
Prosthetic heart valves, including bioprosthetic and homograft valves
1 Amoxicillin 2 g PO one hour before procedure
2 Ampicillin 2 g IM/IV 30 min before procedure
Penicillin allergy:
1 Cefazolin 1g IV/IM 30 min before procedure
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Physician/Clinical Pharmacist Name: ________________________________ pager:_____________
Physician/Clinical Pharmacist signature: ___________
Nurse name:____________ Nurse signature:____________
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis. Guidelines from the American Heart Association.
Circulation 2007;115:1656–8.
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Diagnosis:…………………………………………………………………………………………………………………
Culture: Pending ( + ) Culture ( - ) Culture Not sending
NOTES______________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
- 1, Thomas M. Hooton. Guidelines for Antimicrobial Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women". 2011 ; 52 : e103 -e120
-Thomas M. Hooton,1 Suzanne F. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical
Practice Guidelines from the Infectious Diseases Society of America". 2010 ; 50 : 625 -66
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Diagnosis: …………………………………………………………………………………………………………………….
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Patients with Debride overlying ulcer and submit bone for histology and culture.
vascular
insufficiency Select antibiotic based on culture results and treat for 6 weeks.
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Diagnosis:………………………………………………………………………………………………………….
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Therapy for Diabetic foot infection (for renal failure patient appendix)
Suspected Antibiotic Therapy Duration
pathogen
Oral agents for empiric Streptococci and 1 Amoxicillin-clavulanate ER PO 1000 7-10 days
treatment of mild to Staphylococci 2 mg q12h
moderate early diabetic (MSSA) 3 Clindamycin PO 300-450 mg q8hr
foot infections 4 Cloxacillin 500mg PO q6hr
( Outpatient ) Flucloxacillin PO 250-500 mg q6h
Streptococci and 1 Amoxicillin 1g IV q12hr + Trimethoprim- 7-10 days
MRSA (preview sulfamethoxazole PO160/800 mg [DS]
MRSA infected q12hr
or colonized|) 2 Clindamycin PO 300-450 mg q8hr +
Trimethoprim-sulfamethoxazole PO
160/800 mg [DS] q12hr
3 Linezolid PO 600 mg q12hr
Parenteral agents for 1 Piperacillin-tazobactam IV 4.5g q6-8hr 10-14 days
empiric treatment of + vancomycin IV 1g q8hr And expand
moderate to severe 2 Piperacillin-tazobactam IV 4.5g q6-8hr the duration
diabetic foot infections + Linezolid IV 600 mg q12hr depend on
3 Imipenem-cilastatin IV 500mg q6hr clinical
+Linezolid IV 600 mg q12hr symptom
4 Imipenem-cilastatin IV 500mg q6hr + progress
Vancomycin IV 1g q8hr
Vancomycin trough level 15-20 μg/mL
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Benjamin A. Lipsky,1 Anthony R. Diagnosis and Treatment of Diabetic Foot infection 2012 ; 54 : e132 -e173
Uptodate 2014
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Diagnosis:…………………………………………………………………………………………………………………….
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Therapy for Cellulitis, Erysipelas: Extremities, Non-Diabetic (for renal failure patient appendix)
Micro-organism Therapy (dosing interval ) Duration
Empiric therapy Inpatient 1 Cefazoline IV 1-2 g q8hr
parenteral 2 Clindamycin PO 600-900mg q6-8hr
Streptococcus therapy 3 Flucloxacillin 1–2 gm IV q6h
pyogenes 4 Cloxacillin IV 1g q6h
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it DIAGNOSIS:__________________________________
WARD:________________BED__________________
on patient profile, and forward the copy to the
CONSULTANT IN CHARGE:_______________________
Pharmacy Department within 24 hrs)
Dennis L. Stevens,1,3 Alan L. Bisno. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:41
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Dennis L. Stevens,1,3 Alan L. Bisno. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID 2005:
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Antibiotics order(peritonitis)
Primary peritonitis: Spontaneous bacterial peritonitis (SBP), Primary infection
Diagnosis:………………………………………………………………………………………………………………….
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Primary peritonitis therapy (for renal failure patient appendix)
Therapy (dosing interval ) Duration
For treatment 1 Ceftriaxone IV 2 gm q24h
2 Aztreonam 1-2 g IV/IM q8-12hr
3 Pip-Tazo IV 3.375 gm q6h ( if suspected pseudomonas )
Prevention in patients Antibiotic prophylaxis indication/ prevention of SBP:
with chronic ascites 1- Patients with cirrhosis and gastrointestinal bleeding. 5-7 days
2- Patients who have had one or more episodes of SBP.
1 TMP-SMX-DS 1 tab PO 5 days/week
2 Ciprofloxacin 750 mg PO once/week
resistant E. coli, 1 Imipenem IV 500 mg q6h
Klebsiella species (e.g., 2 Meropenem IV 1g q8h
ESBL):
Peritonitis, Secondary, bowel perforation, ruptured appendix, ruptured diverticula
Therapy ( Source Control is Mandatory)
Therapy (dosing interval ) Duration
Mild/Moderate Peritonitis; 1 Piperacillin- Tazobactam IV 4.5 gm q8h ±
inpatient; requires parenteral 2 Gentamycin IV/IM 1mg/kg q8hr (3-5days) 10-14days
therapy: Hemodynemically 3 Ceftazidem IV 2 gm q12h + Metronidazole IV 1 gm
stable q12hr
4 Tigecyline 100mg IV infusion then 50mg IV infusion
q12hr
Severe Disease: Patient is in 1 Imipenem 500 mg -1 gm IV q6h 14 days
ICU; requires parenteral 2 Meropenem IV 1g q8hr
3 Tigecyline 100mg IV infusion then 50mg IV infusion
q12hr
-Solomkin JS,et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Clin Infect Dis. 2010 Jun
15;50(12):1695
-Runyon BA,et al. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009 Jun;49(6):2087-107
-Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
-Solomkin JS,et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Clin Infect Dis. 2010 Jun
15;50(12):1695
-Antimicrobial Therapy, WEBEDITION/Sanfordguide 2014
_________Hospital FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Diagnosis: …………………………………………………………………………………………………………………..
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Therapy for Sexually transmitted disease (for renal failure patient appendix)
Type or Stage Therapy
Chlamydial Infection Urethritis 1 Doxycycline 100 mg PO q12hr x 7days
and Related Clinical Cervicitis 2 Azithromycin 1 g PO q24hr single dose
Syndromes Conjunctivitis 3 Levofloxacin PO500mg q24hr x 7days
proctitis (except
lymphogranuloma venereum)
Brucellosis
Diagnosis: …………………………………………………………………………………………………………………..
Culture: Pending ( + ) Culture ( - ) Culture Not sending
Active TB diagnosis:
Smear (+) culture PCR Histopathology
Therapy for Active TB (for renal failure patient appendix)
1) First-line for Treatment of Active TB
Condition Drugs Adult Dosage Alternative Duration
Daily Intermittent
Empiric initial treatment Isoniazid 5 mg/kg 15 mg/kg 1-3x/wk Initial
should include 4 drugs: Rifampin(RIF) 10 mg/kg 10 mg/kg 2-3x/wk Rifabutin (RPT phase
5 mg/kg
2 months
pyrazinamide 40-55 kg: 40-55 kg: 2000 mg
1000 mg 56-75 kg: 3000 mg
56-75 kg: 76-90 kg: 4000 mg
1500 mg 2x/wk
76-90 kg:
2000 mg
ethambutol 40-55 kg: 40-55 kg: 2000 mg
800 mg 56-75 kg: 2800 mg
56-75 kg: 76-90 kg: 4000 mg
1200 mg
76-90 kg:
1600 mg
When susceptibility to Isoniazid(INH) 5 mg/kg 15 mg/kg 1-3x/wk
isoniazid, rifampin and Rifampin 10 mg/kg 10 mg/kg 2-3x/wk Rifabutin 5 mg/kg
pyrazinamide
Pyrazinamide 40-55 kg: 40-55 kg: 2000 mg
800 mg 56-75 kg: 2800 mg
56-75 kg: 76-90 kg: 4000 mg
1200 mg
76-90 kg:
1600 mg
Patients who cannot take Isoniazid The same The same dose Rifabutin 5 mg/kg
pyrazinamide, such as Rifampin dose
those with severe liver ethambutol
disease or gout
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Drugs for Tuberculosis. Treatment Guidelines from The Medical Letter. April 2012;10 (116) 29-35
Abbreviations:
Rifampicin (RIF)
Rifabutin (RPT) Isoniazid (INH)
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
NOTES________________________________________________________________________________________________________________________________
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______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Antiviral Drugs. Treatment Guidelines from The Medical Letter. March 2013;11 (127) 19-29
_________Hospital FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region
(Antibiotics Program)
Protozoa
Infection Therapy (drug interval )
Amebiasis Asymptomatic 1 Diloxanide furoate 500 mg PO tid x 10 d
(Entamoeba Mild to moderate 1 Metronidazole 500 to 750 mg PO tid x 7 to 10 d
histolytica) intestinal disease
Severe intestinal and 1 Metronidazole 750 mg PO tid x 7 to 10 d
extraintestinal disease
Amebic Naegleria fowleri 1 Amphotericin B 1.5 mg/kg/d IV in 2 doses x 3 d, then 1
meningoencephalitis mg/kg/d x 6 d plus 1.5 mg/d intrathecally x 2 d, then 1
, primary and mg/d every other day x 8 d
granulomatous
ASCARIASIS 1 Albendazole 400 mg PO once
(Ascaris lumbricoides, roundworm) 2 Mebendazole 100 mg bid PO x 3d or 500 mg once
GIARDIASIS
(Giardia duodenalis) 1 Metronidazole 250 mg PO tid x 5-7d
2 Tinidazole 2 g PO once
GNATHOSTOMIASIS
(Gnathostoma spinigerum) 1 Albendazole 400 mg PO bid x 21d
GONGYLONEMIASIS
(Gongylonema sp.) 1 Surgical removal
2 OR Albendazole 400 mg/d PO x 3d
HOOKWORM infection
(Ancylostoma duodenale, Necator 1 Albendazole 400 mg PO once
americanus) 2 Mebendazole 100 mg PO bid x 3d or 500 mg once
3 Pyrantel pamoate 11 mg/kg (max. 1g) PO x 3d
ISOSPORIASIS
(Isospora belli) 1 Trimethoprim- sulfamethoxazole TMP 160 mg/SMX 800
mg (1 DS tab) PO bid /10 days
LEISHMANIA
Visceral 1 Liposomal amphotericin B 3 mg/kg/d IV d 1-5, 14 and 21
2 Sodium stibo gluconate 20 mg Sb/kg/d IV or IM x 28d
3 Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28d
Cutaneous 1 Sodium stibo gluconate 20 mg Sb/kg/d IV
2 Meglumine antimonite 20 mg Sb/kg/d IV or IM x 20d
3 Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28 days
Mucosal 1 Sodium stibo gluconate 20 mg Sb/kg/d IV or IM x 28d
2 Meglumine antimonite 20 mg Sb/kg/d IV or IM
3 Amphotericin B 0.5-1 mg/kg IV daily or every second
day for up to 8wks
4 Miltefosine 2.5 mg/kg/d PO (max 150 mg/d) x 28d
LICE infestation
(Pediculus humanus, P. capitis, Phthirus pubis) 1 0.5% Malathion Topically
2 1% Permethrin Topically
3 Ivermectin 200 mcg/kg PO
MALARIA, Treatment of (Plasmodium falciparum, P. vivax, P. ovale, and P. malariae)
ORAL
P. falciparum Drug of choice:
or unidentified species acquired in areas of 1 Single administration of Sulfadoxine (25 mg/kg) /
chloroquine-resistant P. falciparum Pyramethamine (1.25 mg/kg) on day 1 + Artesunate 4
mg/kg/day on day 1 , 2, and 3
2 Artemether/lumefantrine 6 doses over 3d (4 tabs/dose 0,
8, 24, 36, 48 and 60 hours)
Alternatives:
1 Atovaquone/ proguanil 2 adult tabs bid or 4 adult tabs
once/d x 3d
2 Mefloquine 750 mg followed 12 hrs later by 500mg
Quinine sulfate 650 mg q8h x 3 or 7d
Plus doxycycline 100 mg bid x 7d
3 or plus tetracycline 250 mg qid x 7d
4 or plus clindamycin 20 mg/kg/d in 3 doses x 7d
P. vivax Drug of choice:
acquired in areas of chloroquine-resistant P. vivax 1 Mefloquine 750 mg PO followed 12 hrs later by 500mg
Atovaquone/ proguanil 2 adult tabs bid or 4 adult tabs
once/d x 3d
either followed by
Primaquine phosphate 30 mg base/d PO x 14d
Alternatives:
1 Chloroquine phosphate 25 mg base/kg PO in 3 doses over
48 hrs
2 Quinine sulfate 650 mg PO q8h x 3-7d
Plus Doxycycline 100mg PO bid x 7d
either followed by
3 Primaquine phosphate 30 mg base/d PO x 14d
All Plasmodium species 1 Chloroquine phosphate 1g (600mg base) PO, then
except chloroquine-resistant P. falciparum and 500mg (300mg base) 6hrs later, then 500mg (300mg
chloroquine-resistant P. vivax base) at 24 and 48 hrs
PARENTRAL
All Plasmodium species 1 Artesunate 2.4 mg/kg/dose IV x 3d at 0, 12, 24 and 48 hrs
2 Artemether 3.2 mg/kg i.m., then 1.6 mg/kg I.m. daily up
(Chloroquine-sensitive and resistant) to day 6
PNEUMOCYSTIS JIROVECI
(formerly carinii) pneumonia (PCP) Drug of choice:
1 Trimethoprim/sulfamethoxazole TMP 15mg/SMX
75mg/kg/d, PO or IV in 3 or 4 dose x 21d
Alternatives:
1 Primaquine 30 mg base PO daily x 21 d
plus clindamycin 600mg IV q6h x 21d, or 300-450 mg
PO q6h x21d
2 Trimethoprim 5mg/kg PO tid x 21d
plus dapsone 100mg daily x 21 d
3 Pentamidine 3-4 mg/kg IV daily x 21d
4 Atovaquone 750 mg PO bid x 21d
Primary and secondary prophylaxis 1 Trimethoprim/sulfamethoxazole 1 tab (single or double
strength) daily or 1 DS tab PO 3d/wk
2 Dapsone 50 mg PO daily or 200 mg PO each wk
SCABIES
(Sarcoptes scabiei) 1 5% Permethrin Topically once
2 Ivermectin 200 mcg/kg PO once
3 10% Crotamiton Topically once/d x 2
SCHISTOSOMIASIS (Bilharziasis)
S. haematobium, S. japonicum, S. mansoni, S. 1 Praziquantel 40 mg/kg/d PO in 2 doses x 1d
mekongi
Tapeworm infection
Diphyllobothrium latum (fish), Taenia saginata 1 Praziquantel 5 to 10 mg/kg PO once
(beef),Taenia solium (pork), Dipylidium 2 Niclosamide 2 g PO once
caninum (dog)
Hymenolepis nana (dwarf tapeworm) 1 Praziquantel 25 mg/kg PO once
2 Niclosamide 2 g PO daily x 7 d
Echinococcus granulosus (hydatid cyst) 1 Albendazole 400 mg PO bid x 1 to 6 months
Taenia solium (Cysticercosis) 1 Albendazole 400 mg PO bid x 8 to 30 d; can be repeated
as necessary
2 Praziquantel 100 mg/kg/d PO in 3 doses x 1 day then 50
mg/kg/d in 3 doses x 29 days
Trichinellosis (Trichinella spiralis) 1 Albendazole 400 mg PO bid x 8 to 14 d
Trichostrongylus infection 1 Albendazole 400 mg PO once
Trichuriasis (Trichuris trichiura, whipworm) 1 Albendazole 400 mg PO x 3 d
2 Ivermectin 200 mcg/kg/d PO x 3 d
Visceral larva migrans[40] (Toxocariasis) 1 Albendazole 400 mg PO bid x 5 d
TOXOPLASMOSIS
Toxoplasma gondii 1 Pyrimethamine 25-100 mg/d PO x 3-4wks
plus sulfadiazine 1-1.5 g PO qid x 3-4wks
TRICHOMONIASIS
Trichomonas vaginalis 1 Metronidazole 2 g PO once or 500 mg bid x 7d
2 Tinidazole 2 g PO once
TRICHURIASIS
Trichuris trichiura, whipworm 1 Mebendazole 100 mg PO bid x 3d or 500 mg once
2 Albendazole 400 mg PO x 3d
NOTES________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
NOTES_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Uptodate 2010
Peter G. Pappas, Carol A. Kauffman. Clinical Practice Guidelines for the Management of Candidiasis: 2009 Update by the Infectious Diseases Society of America.
Clinical Infectious Diseases 2009; 48:503–35
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Orders that are checked will be implemented. Additions, Deletions or Modifications (including strike through) or
orders (line items) must be individually initiated.
Select appropriate antibiotic as determined by procedure and initiate 30-60 minutes prior to incision.
Vancomycin, Ciprofloxacin and Metronidazole should be initiated within 60-120 minutes prior to incision.
Ordered
Given
Not ordered or given for the following reason:
• Medical (eg, not indicated, contraindicated, other medical reason)
___________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Cephalosporins allergic:
Cefazolin or Cephradine 2 gm (40mg/kg if
Thoracic (None Cardiac)
child) IV for one dose ( for obese pateint 3g) Vancomycin 1 gm (15 mg/kg if child) IV for 1
dose
Other Surgery
For procedures lasting greater than 4 hours, or greater than 1000mL blood loss, repeat pre-op dose of Cefazolin OR Clindamycin every 4
hours intraoperatively.
Repeat Dosing of Antibiotic: Drug Name: _________________ Dose: _________ Interval: _______________
NOTE:
If post-op prophylaxis antibiotic given, duration: less than 24 hours 24 hours more than 24 hours
Routine blood cultures should be performed on any patient in whom there is a suspicion of bacteremia or candidemia.
II. TIMING
Blood cultures should be drawn prior to the institution of antibiotics whenever possible. If empiric treatment is an
emergency, blood cultures should still be drawn as soon as possible after institution of antibiotics. There are no data to
suggest that the timing of culture in relation to the appearance of fever or chills will maximize the yield.
There is a direct relationship between the volume of blood obtained and the yield of a blood culture set. Forty to 60 ml of
blood should be obtained per episode (in other words, 2-3 sets with 20 ml per set, and 10 ml per bottle) According to the
age.
Single sets should not be used to evaluate any patient with suspected bacteremia or candidemia. The optimal yield is
obtained with two or three sets of blood cultures. No more than three blood cultures should be obtained for any given 24
hour period.
Blood should be obtained from peripheral venous or arterial sites. Obtaining blood cultures from central venous catheters,
arterial lines and inguinal vessels increases the likelihood of obtaining a false positive blood culture.
For suspected catheter-related bloodstream infection (CR-BSI) draw one set through device and one set from a separate
venipuncture..
VI. LABELING
Labeling the site of each set of blood cultures, particularly regarding whether a set was drawn from a catheter, the groin,
or not, is of ulmost importance in helping to distinguish pathogens from contaminants in those cases in which no
peripheral access can be found.
The use of a 2% chlorhexidine-based preparation for cutaneous antisepsis is classified as a Category 1A recommendation
If not available then alcohol can be used
After the vessel site is selected, a 5 cm area of skin should be disinfected by swabbing concentrically with 70% alcohol,
from the venipuncture site outward. vigorous friction back and forth
2. The site should be cleansed once again, this time with 10% povidone-iodine or 2% tincture of iodine again in a circular
motion.
3. Allow the iodine to dry completely before performing venipuncture. This should take 1 - 2 minutes.
4. While waiting for the site to dry, the plastic cap covering each blood culture bottle should be removed, and the rubber
stopper should be decontaminated with 70% alcohol. (Iodine solutions will disintegrate the rubber and should not be
used.)
6. Do not change needles between venipuncture and inoculation of the bottles, or between bottles. The risk of needlestick
is increased, while the chance of contamination is not significantly lessened.
7. Remove the iodine solution from the skin with alcohol. This will minimize the possibility of hypersensitivity.
Appendix B: Guidelines for Infection Control
ISOLATION SYSTEMS
Standard Precautions are designed to reduce the risk of transmission of microorganisms from recognized and
unrecognized sources of infection.
Use Standard Precautions for care of ALL patients, regardless of their diagnosis.
Blood
All body fluids, secretions, and excretions except sweat regardless of whether they contain visible blood
Non-intact skin
Mucous membranes
Gloves will be worn whenever contact with these fluids is anticipated. Gloves will be changed between patients, between
tasks, or when torn.
Hand washing between patients and after contact with blood/body fluids is essential.
If aerosolization or splattering of blood/body fluids is likely, additional barriers must be worn (gowns, splash shields,
goggles, masks).
To reduce the risk of airborne transmission of infectious agents. Use Airborne Precautions for patients known or
suspected to have infections transmitted by tiny droplet nuclei (particles 5 microns or smaller in size). 2Illnesses include:
Patients must be placed in a room with negative air pressure ventilation to prevent transmission of droplet nuclei. Without
negative pressure ventilation, infectious droplet nuclei can remain suspended in air for long periods of time.
Doors and windows in negative pressure isolation rooms must be kept closed at all times.
Hospital personnel and visitors entering an Airborne isolation room must wear the N95 TB respirator.
For patients isolated with chickenpox or measles - persons immune to chickenpox/measles may enter an Airborne
isolation room without a mask.
Patients in Airborne isolation must remain in their room. Patients should leave their room only for essential studies.
Patients must wear a paper surgical mask when leaving their room.
To reduce the risk of droplet transmission of infectious agents. Involves contact of the conjunctivae, or mucous
membranes of the nose or mouth of a susceptible person with large droplets (greater than 5 microns in size) containing
microorganisms from a person who has clinical disease or is a carrier of the microorganism.
1Illnesses include:
Diphtheria
Influenza
Rubella
Pertussis
Mumps
Droplets are generated during sneezing, coughing, talking, and during certain procedures such as suctioning or
bronchoscopy.
Close contact (usually 3 feet or less= 1 meter) to the infectious person is required for transmission of the disease. Large
droplets travel only short distances and do not remain suspended in the air.
Hospital personnel and visitors entering a Droplet isolation room must wear a paper surgical mask.
To reduce the transmission of epidemiologically important infectious agents spread by direct or indirect contact.
Indirect Contact - contact with a contaminated intermediate object from the patient's environment.
2Contact precautions apply to patients who are actively infected or colonized with epidemiologically important
organisms, including :
Enteric infections with a low infective dose or prolonged survival in the environment (C. difficile, etc.). Skin infections
that are highly contagious (scabies, major abscesses, impetigo, Herpes Simplex, active Zoster, etc.)
Hospital personnel and visitors entering a contact isolation room must wear gloves and gowns.
Disinfection of non-disposable, reusable patient equipment must be performed before leaving the contact isolation room
and before reuse with another patient. When possible, dedicate equipment to the contact isolation room.
HAND HYGIENE:
Hand washing is the single most important step you can perform to reduce the transmission of infectious agents from
person to person or from one site to another.
Wearing gloves does not replace the need to wash your hands!!!
Culturing observation check list
Medication (emergency kit) and resuscitation equipment must be readily available as per Anaphylaxis Protocol.
procedure:
Prick/puncture. A diluted allergen is applied with a prick or a puncture on the surface of the skin. (With
positive (histamine) and negative control( normal saline) )
Results of Prick Test Dose:
Erythema and Weal Response 5x5mm (>25mm) positive, no further testing indicated.
o Erythema and Weal Response <5x5mm (25mm) proceed to intradermal test dose
Intradermal test dose: Using a 26-27-guage (very thin) needle, a diluted allergen is injected immediately below the
skin surface.
Results of Intradermal (ID) Test Dose:
o Erythema and Weal at Injection Site 5x5mm (>25mm) positive allergy to antibiotic tested.
o Erythema and Weal at Injection Site >3x3mm (>9mm) but <5x5mm
o (<25mm) borderline positive
o If intradermal skin test negative oral challenge indicated
Skin test reagent Route Drug test conc. Skin test volume
Penicillin G prick/puncture (10,000 units/mL) droplets
Intradermal (10,000 units/mL) 0.02 - 0.05 mL
histamine dichloride prick/puncture (10 mg/mL) droplets
Intradermal (0.001 mg/mL) 0.02 - 0.05 mL
Normal saline prick/puncture 0.9 % NACL droplets
Intradermal 0.9 % NACL 0.02 - 0.05 mL
Note:--------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------------------
--------------------------------------
Physician name: signature:
http://www.uptodate.com/contents/overview-of-skin-testing-for-allergic-disease?source=see_link&anchor=H27#H27
http://www.acaai.org/allergist/allergies/Treatment/diagnosing-allergies/Pages/allergy-skin-tests.aspx
Roland solensky, and david a. khan. drug allergy: an updated practice parameter. annals of allergy, asthma & immunology, volume 105, october, 2010: 273.e1-e78
Anaphylaxis Algorithm
Anaphylactic reaction
Diagnosis:
Acute onset of illness
Life threatening Airway and/or Breathing and/or circulation problem
Usual skin changes
Adrenaline
Emergency treatment of anaphylactic reactions Guidelines for healthcare providers, Resuscitation Council (UK)January 2008
Vancomycin Monitoring:
Peak serum concentration is not necessary because it does not correlate well with vancomycin
toxicity (e.g., nephrotoxicity or ototoxicity).
Only the trough concentration monitoring is needed in order to assess efficacy.
For patients with normal renal function, it takes approximately 4 doses for vancomycin to
reach steady state. As such, trough concentrations should be drawn before the 4th dose.
Trough concentrations may be drawn earlier in critically ill patients, patients with unstable
renal function, and patients on vancomycin dosing interval ≥ 24 hours.
However, these trough concentrations must be interpreted with caution since additional doses
will continue to accumulate until steady state is reached.
Trough concentrations should be drawn right before the next dose (within 2 hours prior to
administration).
Vancomycin is being dosed by level (patients with creatinine clearance < 25 mL/min,
hemodialysis, or CRRT), it should be re-dosed if the level is < 20 mg/L.
Aminoglycosides fight against bacteria by interfering with bacterial protein synthesis, which is
achieved through irreversible binding to 30S ribosomal subunit.
Aminoglycosides have bactericidal activity against aerobic Gram-negative infections and
demonstrates concentration-dependent killing with a prolonged PAE (~4-6 hours).
The best pharmacodynamics parameter to determine the ideal dosing regimen is peak/MIC
ratio
Dosing weight: ideal body weight (IBW) unless 20% over IBW (use adjusted body weight
instead)
Initial dosing: dependent on traditional versus extended interval dosing
Extended interval dosing in all patients* except patients with altered pharmacokinetics using
Traditional dosing:
Burns > 20%
Morbidly obese
Pregnancy
Ascites or significant third spacing
Hemodynamic instability
Unstable renal function and cystic fibrosis
*Rationale: maximize concentration-dependent killing and minimize toxicity (i.e., nephrotoxicity and ototoxicity), ease of
administration and monitoring, reductions in administration and monitoring-related costs.
Aminoglycoside Monitoring:
Traditional Dosing:
Obtain serum peak and trough concentrations after 3rd dose following initiation of
therapy and any dosing adjustments in therapy.
Draw trough concentration just prior to next dose.
Draw peak concentration 30-45 minutes after the end of an intravenous infusion.
Once achieved, monitor periodically (e.g., 2-3 times weekly) throughout therapy
with changes in renal function.
If stable renal function, monitor at least once weekly.
World Health Organization (WHO) reports that the irrational use of medicines is a major
problem worldwide. The overuse of injections, when oral formulations would be more
appropriate, is one of the key factors for the irrational use of medicines. Hence IV to oral
switch over within an appropriate time is one of the major aspects to improve the rational use
of injections. Moreover, once the culture and sensitivity reports are available, IV to oral switch
over enables one to select a cheaper or older antibiotic, which is as effective as the IV
antibiotic.
Early switch over from IV to oral therapy has the following major advantages:
-Patient is able to eat their regular or modified diet or -Patients with unreliable response to oral medications
receiving enteral nutrition by oral, gastric or other (severe nausea or vomiting)
appropriate enteral route Patient receives other
scheduled oral medications -Unable to swallow or unconscious Strict (nothing per
oral) for a procedure
-For patients who receive antibiotics, signs and
symptoms of infection resolved or improving (WBC -GI obstruction, malabsorption, active GI bleeding,
decreasing toward normal range, improving chest X-ray paralytic ileus or severe diarrhea
findings, temperature less than 100°F for at least 24-48
hours and respiratory rate<20 breaths/min.) -Unresponsive to previous oral therapy Patients with
grade 3 or 4 mucocytosis
-Patient has functional gastrointestinal tract (tolerating
at least 1 liter/day of oral fluids or 40 ml/hour of -Patients whose disease state that does not support
enteral nutrition)
oral therapy (meningitis, infective endocarditis,
-An appropriate oral dosage form of prescribed drug is infection of a prosthetic device, osteomyelitis, sepsis,
available Absorption and bioavailability of oral severe cellulitis, bronchiectasis, pneumonia with AIDS)
counterpart is almost comparable to that of parenteral
form -Documented pseudomonal infection and/or on IV
antibiotic for <24 hours Candidemia treated less than
7 days
*Absorption of flouroquinolones is reduced by concurrent administration of products containing divalent and trivalent cations such as calcium,
magnesium or aluminum, for example, antacids, multivitamin products containing minerals, iron, or zinc salts. Hence an interval of at least 4 hours
should elapse between their oral administration
Drugs with excellent bioavailability (60-90%) eligible for IV to oral switch over
Drugs IV to PO conversion
IV dose PO dose
References:
Kuper KM. Intravenous to oral therapy conversion. Text Book of CompetenceAssessmentToolsforHealth ‑SystemPharmacies,4th ed.ASHP 2008.p.347‑60.
Jissa Maria Cyriac, Emmanuel James. Switch over from intravenous to oral therapy: A concise overview, Journal of Pharmacology and Pharmacotherapeutics | April-June
2014 | Vol 5 | Issue 2
_________Hospital
FILE NO.
Pharmaceutical Care Department NAME:_________________________________________
___________Region AGE: SEX: M F
(Antibiotics Program) NATIONALITY:__________________________________
WEIGHT (ACTUAL/ESTIMATED)_________________KG
Physician Order Form HIGHT:______________________________CM
ALLEGRY:___________________________________
(Please fill all applicable information and stick it on DIAGNOSIS:__________________________________
patient profile, and forward the copy to the Pharmacy WARD:________________BED__________________
Department within 24 hrs) CONSULTANT IN CHARGE:_______________________
Date/Time:
Pharmacy recommends:
D/C ( ) Start ( )
The period:
Clarithromycin
Trimeth/Sulfa
Azithromycin
Erythromycin
Streptomycin
Levofloxacin
Clindamycin
Vancomycin
Tetracycline
Gentamycin
Cefuroxime
Antibiotic
Ceftriaxone
Ampicillin
Isolates
Cefazolin
Penicillin
Linezolid
Rifampin
Susceptibility
Enterococcus faecium
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pneumoniae
MRSA
Pipracilli/Tazo
Moxifluxaci
Ciprofluxacin
Levofloxacin
Antibiotic
Ceftazidime
Gentamycin
Meropenem
Cefuroxime
Ceftriaxone
Tigecycline
Augmentin
Isolates
Imipenem
Amikacin
Colistin
Cefepime
Susceptibility
Klepsiella P.
E. Coli
Pseudomona A.
Acinetobacter
Proteuos
Serratia M
Enterobacter
Citrobacter
Clarithromycin
Trimeth/Sulfa
Azithromycin
Erythromycin
Streptomycin
Levofloxacin
Clindamycin
Vancomycin
Tetracycline
Gentamycin
Cefuroxime
Antibiotic
Ceftriaxone
Ampicillin
Isolates
Cefazolin
Penicillin
Linezolid
Rifampin
Susceptibility
Enterococcus faecium
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pneumoniae
MRSA
Pipracilli/Tazo
Moxifluxaci
Ciprofluxacin
Levofloxacin
Antibiotic
Ceftazidime
Gentamycin
Meropenem
Cefuroxime
Ceftriaxone
Tigecycline
Augmentin
Isolates
Imipenem
Amikacin
Colistin
Cefepime
Susceptibility
Klepsiella P.
E. Coli
Pseudomona A.
Acinetobacter
Proteuos
Serratia M
Enterobacter
Citrobacter
Clarithromycin
Trimeth/Sulfa
Azithromycin
Erythromycin
Streptomycin
Levofloxacin
Clindamycin
Vancomycin
Tetracycline
Gentamycin
Antibiotic
Cefuroxime
Ceftriaxone
Ampicillin
Isolates
Cefazolin
Penicillin
Linezolid
Rifampin
Susceptibility
Enterococcus faecium
Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pneumoniae
MRSA
Pipracilli/Tazo
Moxifluxaci
Ciprofluxacin
Levofloxacin
Antibiotic
Ceftazidime
Gentamycin
Meropenem
Cefuroxime
Ceftriaxone
Tigecycline
Augmentin
Isolates
Imipenem
Amikacin
Colistin
Cefepime
Susceptibility
Klepsiella P.
E. Coli
Pseudomona A.
Acinetobacter
Proteuos M.
Serratia M
Enterobacter
Citrobacter
Anidulafungin
Amphotericin
Voriconazole
Antifungal
Caspofungin
Fluconazole
Fluconazole
Isolates
Susceptibility
No.
B
Candida Percentage of Isolates that are Susceptible Susceptible
Candida albicans
Candida glabrata
Candida parapsilosis
Candida krusei
Cryptococcus
Asperglosis
Ward: ICU
Secretion
Orophar
Antifungal
yngyal
Isolates
Other
Blood
Urine
Resp.
Susceptibility
No.
Candida glabrata
Candida parapsilosis
Candida krusei
Cryptococcus
Asperglosis
100
90
80
70
60
50
40
30
20
10
0
Jan. Feb. March April May June July August Sept. Oct. Nov. Dec.
Acinetobacter P. Pseudomonas A. MRSA
100
90
80
70
60
50
40
30
20
10
0
Jan. Feb. March April May June July August Sept. Oct. Nov. Dec.
Appendix I:
_________Hospital
Pharmaceutical Care Department
___________Region
(Antibiotics Program)
Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this
form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.
Drug Procedure:
Ceftazidime Ciprofloxacin Oral
Controlled Antibiotics Amikacin
Fluconazol Oral Fluconazol IV
Ciprofloxacin IV Cefepime
Piperacillin/Tazobactam Meropenem
Moxifloxacin Oral Vancomycin PO
Imipenem Linzolid IV
Colistin (fill special form) Caspofungin
Restricted Antibiotics Voriconazole IV Ethionamide.
Linezolid Oral Cyclovir
Kanamycin
Voriconazole PO Para amino acid.
Tigecycline (fill special form)
.
Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this
form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.
Indication Commenst:
Complicated Skin and Skin Structure Infections and the
Tigecycline
micoorganism is sensitive only to Tigecycline
Complicated Intra-abdominal Infections and the
micoorganism isonly sensitive to Tigecycline
Treatment of infection due to sensitive strain of certain
gram-negative bacilli which are resistant to other
antibacterials including Colistin or in patients allergic to all
other antibacterial agents.
Physician Signature:
Must be used for ALL antibiotic orders including: admit, dose changes, route changes, transfer orders, post-operative orders etc.
When choosing therapy, please select one of the available diagnoses if applicable. If the desired indication does not appear on this
form, WRITE the indication and all applicable culture data in the blank spaces provided at the bottom of the form.
For renal dosing Adjustment contact Drug & Poisoning Information Center (DPIC), DPIC will adjust the dose according to the Protocol.
DPIC will continue to follow and adjust antibiotics throughout the duration of hospital stay.
Indication Comments:
Treatment of infections due to sensitive strains of certain
Colistin gram-negative bacilli which are resistant to other antibacterials
or in patients’ allergic to all other antibacterials.
Physician Signature:
IV: intravenous
IM: intramuscular
PO: oral
Min: minute
hr: hour
d: day
mo: month
mcg: microgram
mg: milligram
kg: kilogram
Appendix G: Dose adjustment for renal impairment
Clarithromycin GFR <30ml/min: Give 50% of normal dose Administer after HD session Administer after HD session is Administer after HD session
iv/po/ng every 12 hours is completed completed is completed
(amoxicillin+ CrCl <30 mL/minute: Do not use 875 mg tablet 250-500 mg every 24 hours; Continuous arteriovenous or Peritoneal dialysis:
Clavulanic acid) administer dose during and venovenous hemofiltration Moderately dialyzable (20%
CrCl 10-30 mL/minute: 250-500 mg every 12 hours after dialysis. Do not use effects: to 50%)
extended release tablets. Amoxicillin: ~50 mg of Amoxicillin: Administer 250
CrCl <10 mL/minute: 250-500 mg every 24 hours amoxicillin/L of filtrate is mg every 12 hours
removed Clavulanic acid: Dose for
Clavulanic acid: Dose for CrCl CrCl <10 mL/minute
<10 mL/minute
Co-trimoxazole CrCl 15-30 mL/min: Administer 50% of 2.5-10 mg/kg trimethoprim 2.5-7.5 mg/kg of TMP every 12 Use CrCl <15 mL/minute
recommended dose every 24 hours or 5-20 hours dosing recommendations.
CrCl <15 mL/min: Use is not recommended mg/kg trimethoprim 3 Not significantly removed
times weekly after IHD by PD
Colistimethate CrCl 50-79 mL/min: 2.5-3.8 mg/kg/day in 2 1.5 mg/kg every 24-48 hours 2.5 mg/kg every 24-48 hours Give 50% of normal dose
(colistin) divided doses iv every 18-24 hours(2)
IM, IV CrCl 30-49 mL/min: 2.5 mg/kg/day once daily or
in 2 divided doses
CrCl 10-29 mL/min: 1.5 mg/kg every 36 hours
Erythromycin GFR <10ml/min: Give 50-75% of normal total No dosage adjustment No dosage adjustment No dosage adjustment
daily dose;max 1.5g in 24 hours (2) required required required
Flucloxacillin(2) GFR <10ml/min: Give normal dose iv q 8 hours Give normal dose IV q 8 hr Give normal dose IV q 8 hr Give normal dose IV q 8 hr
Fluconazole CrCl ≤50 mL/minute (no dialysis): Administer 50% of 200-400 mg every 48-72 Loading dose of 400-800 mg
recommended dose daily hours or 100-200 mg every followed by 200-400 mg every
24 hours have been 24 hours
recommended
renal impairment: HD CVVH PD
Ganciclovir IV (Induction): IV: Induction: 1.25 mg/kg every IV: Induction: 2.5 mg/kg every Dose as for CrCl <10
CrCl 50-69 mL/min: Administer 2.5 mg/kg/dose 48-72 hours; 24 hours mL/minute
every 12 hours.
CrCl 25-49 mL/min: Administer 2.5 mg/kg/dose
every 24 hours.
CrCl 10-24 mL/min: Administer 1.25 mg/kg/dose
every 24 hours.
CrCl <10 mL/min: Administer 1.25 mg/kg/dose 3
times/week following hemodialysis
IV (Maintenance): IV: Maintenance: 0.625 mg/kg Maintenance: 1.25 mg/kg every Dose as for CrCl <10
CrCl 50-69 mL/minute: Administer 2.5 every 48-72 hours 24 hours mL/minute
mg/kg/dose every 24 hours.
CrCl 25-49 mL/minute: Administer 1.25
mg/kg/dose every 24 hours.
CrCl 10-24 mL/minute: Administer 0.625
mg/kg/dose every 24 hours
CrCl <10 mL/minute: Administer 0.625
mg/kg/dose 3 times/week following hemodialysis.
Gentamicin Conventional dosing: Loading dose of 2-3 mg/kg Give 2mg/kg iv, take trough Administration via PD fluid:
CrCl 40-60 mL/minute: Administer every 12 hours loading dose followed by: level after 24 hours, and hold -Gram-positive infection (eg,
CrCl 20-40 mL/minute: Administer every 24 hours A)Mild UTI or synergy: 1 mg/kg next dose until trough level is synergy): 3-4 mg/L (3-4
CrCl <20 mL/minute: Loading dose, then monitor every 48-72 hours; consider available. Adjust dosage
redosing for pre-HD or post-HD mcg/mL) of PD fluid
levels interval according to serum -Gram-negative infection: 4-
concentrations <1 mg/L
Take trough level after 24hours, and hold next B)Moderate-to-severe UTI: 1- Levels – aim to keep trough 8 mg/L (4-8 mcg/mL) of PD
dose until trough level is available. 1.5 mg/kg every 48-72 hours; <1mg/L and peak 5-10mg/L fluid
Adjust dosage interval according to serum levels consider redosing for pre-HD -Administration via IV, IM
aim to keep trough <1mg/L and peak 5-10mg/L. concentrations <1.5-2 mg/L or route during PD: Dose as for
post-HD concentrations <1
mg/L CrCl <10 mL/minute and
C)Systemic gram-negative rod follow levels
infection: 1.5-2 mg/kg every
48-72 hours; consider redosing
for pre-HD concentrations <3-5
mg/L or post-HD
concentrations <2 mg/L
Imipenem + GFR 31-70ml/min: 500 mg every 6-8 hours Use the dosing Give 50% of the normal dose Loading dose of 1 g followed
cilastatin GFR 21-30ml/min: 500 mg every 8-12 hours recommendation for patients every 24 hours by either 250 mg every 6
GFR <20ml/min: 250 mg every 12 hours with a CrCl 6-20 mL/minute; hours or 500 mg every 8
GFR <5ml/min: Do not start imipenem/cilastatin administer dose after dialysis hours
session and every 12 hours
unless haemodialysis or haemofiltration is to be
thereafter or 250-500 mg every
started within 48 hours 12 hours
Meropenem CrCl 26-50 mL/min: Administer recommended 500 mg every 24 hours CVVH: Loading dose of 1 g
dose based on indication every 12 hours followed by either 500 mg every
CrCl 10-25 mL/min: 8 hours or 1000 mg every 12
Renal impairment HD Administer one-half PD CVVH
recommended dosenormal
based on indication hours
Teicoplanin(2) GFR 40-60ml/min: Give normal regimen for Give regimen for q12hGive normal regimen for Give normal regimen for
CrClon
the first three days, then reduce dose <10
Day mL/min: Administer
the first one-half
three days, then the first three days, then the first three days, then
4 to 50% of the dose once daily or give 100% reduce dose on Day 4 to q24reduce
recommended dose based on indication h dose on Day 4 to reduce dose on Day 4 to
of the dose every Oseltamivir
second day GFR 10-30ml/min: Treatment:
one third 75 mgonce
of the dose oneforthirdTreatment:
once daily of the doseLow-flux
once one third of Treatment: 30 mg once daily
the dose once
5 days
GFR <40ml/min: Give normal regimen for the daily or give 100% of the hemodialysis:
daily or give 100% of the30 mg daily
after or give
for100%
5 daysoforthe
75 mg every 48
Prophylaxis: 75 mg every other
first three days, then reduce dose on Day 4 to dose every third day day or 30 mgdose every each dialysis session for 5 hours
dose every third dayto provide a 5-day
once daily
one third of the dose once daily or give 100% third day days. duration
of the dose every third day.2 High-flux hemodialysis: 75 Prophylaxis: no data
mg after each dialysis
Vancomycin : Vancomycin levels should be monitored in Following loading dose of Administration via PD Give 10mg/kg3 iv as
patients with any renal impairment: 15 to 25 mg/kg, give either fluid: 15 sessionto 30 mg/Lfor 5 days
(15 to determined by serum
Prophylaxis:
500 to 1,000 mg or 5 to 10 30 mcg/mL) of PD fluid Low-flux levels.3 Hold dose until the
CrCl >50 mL/minute: Start with 15 to 20 mg/kg after each dialysis hemodialysis: 30 mg serum after level is between 5-
mg/kg/dose (usual: 750 to 1,500 mg) every 8 session alternate dialysis
Systemic: Loading dose of 10mg/L sessions
to 12 hours 1,000 mg, until outbreak
followed by is
500over
High-flux hemodialysis:
to 1,000 mg every 48 to 72 No
data.
Piperacillin + CrCl 20-40 mL/min: Administer 2.25 g q 6 hr 2.25 g every 12 hours 2.25-3.375 g every 6-8 hours
tazobactam (3.375 g every 6 hours for nosocomial
pneumonia)
CrCl <20 mL/min: Administer 2.25 g q 8 hr (2.25
g every 6 hours for nosocomial pneumonia)
CrCl 20 to 49 mL/minute: Start with 15 to 20 hours with close
mg/kg/dose (usual: 750 to 1,500 mg) every 24 monitoring of levels.
hours
1. uptodate, 2014
2.Rachelle Booth (PICU Senior Specialist Pharmacist), Sue Patey (Quen Mok (Consultant Paediatric Intensivist). Drug Dosage Adjustments in Renal Impairment & CVVH
Gt Ormond St Hospital for Children NHS Trust. Nov 2013
3..McEvoy GK et al. American Hospital Formulary Service (AHFS) Drug Information, 2009. American Society of Health-System Pharmacists, Bethesda, 2009. Accessed online 16/12/10.
4. Aronoff GR, Bennett WM, Berns JS et al. Drug Prescribing in Renal Failure, Dosing Guidelines for Adults and Children, 5th edn. American College of Physicians, US, 2007
5.Ashley C, Currie A. The Renal Drug Handbook. 3rd edn. Radcliffe Medical Press Ltd, Oxon UK, 2009