Antibiotic Poilicy

ANTIBIOTIC POLICY
MMI NARAYANA Multi Specialty Hospital

Lalpur, Dhamtari Road, Raipur (C.G.)
India- 492001
© This document is a sole property of Narayana Hrudayalaya Limited. All rights reserved. No
part of this document shall be reproduced or utilized in any form without permission of issuer of
the document. DOWNLOADED AND/OR HARD COPY UNCONTROLLED. Verify that this is
the correct version before use.
Version : 4.0
Antibiotic Policy Date : 1-Nov-17
Page : Page 2 of 52
Document Summary
Document Title Antibiotic Policy
Department Code CLINICAL Department Name Clinical
Classification Internal Storage Location All ICUS, HDU, wards, Microbiology
Current Version 4.0 Date of Release 1--2017
Reference clauses Combination of all Procedures & protocols applicable for ICUs & HDUs
addressed
Author Dr. Pradeep Sharma
Name Dr. Pradeep Sharma
Document Owner
Designation Incharge MICU
Document Id NH-MMI- POLICY- AP
Document Reviewers
Version
Name Department Designation Date
No
1.0 Dr. Sonal Bajpeyee MICU Incharge MICU 01.11.2014
2.0 Dr. Sonal Bajpeyee MICU Incharge MICU 01.11.2015
3.0 Dr. Pradeep Sharma MICU Incharge MICU 01.11.2016
4.0 Dr. Pradeep Sharma MICU Incharge MICU 01.11.2017
Document Approvers
Version No Name Designation Signature Date
1.0 Dr. R Parganiha Chairperson – HIC Committee 01.08.2014
Document Distribution
Sl. No. Name Department Designation
1.0 Dr. Pradeep Sharma MICU Incharge MICU
2.0 Sr. Rupa Das Barman Nursing Nursing Head
3.0 Dr. Neha Jain Microbiology Consultant Microbiology
4.0 Mr. Anand Infection Control Infection Control Nurse
5.0 Nursing All Incharges
6.0
7.0
Revision History
Version No Date of Revision Pages Affected Description of Change
1.0 Draft NA Addition of new SOP
2.0 01.09.2015 NA Review & updations done
Version : 4.0
Page : Page 3 of 52
Table of Contents
1. ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES .......................................................................................................... 4

2. MONITORING TREATMENT ............................................................................................................................................. 5
3. THE IMPORTANCE OF INFECTION CONTROL (IC) TO CONTROL ANTIMICROBIAL RESISTANCE ........................................ 5
4. HYPERSENSITIVITY ........................................................................................................................................................... 5
5. PATIENT RISK STRATIFICATION ........................................................................................................................................ 7
6. HOSPITAL MICROBIOLOGY DATA..................................................................................................................................... 9
7. ANTIBIOGRAM -IPD & ICU ............................................................................................................................................. 11
2. NOTES: ANTIBIOTIC PROTOCOL: ICU ............................................................................................................................. 28
3. NOTES: ANTIBIOTIC PROTOCOL: IPD ............................................................................................................................. 28
4. RECOMMENDATIONS FOR MONITORING PATIENTS RECEIVING LONG-TERM ANTIMICROBIAL THERAPY .................... 29
5. ORAL ANTIMICROBIAL USE IN HOSPITALIZED PATIENTS ............................................................................................... 31
6. BIOAVAILABILITY OF ORAL ANTIMICROBIALS ................................................................................................................ 31
7. ANTIMICROBIAL DOSING IN RENAL INSUFFICIENCY ...................................................................................................... 33
8. SELECTED FORMULARY ANTIMICROBIALS AND RESTRICTION STATUS .......................................................................... 41
9. HOW TO USE THE POCKET GUIDE? ............................................................................................................................... 51
Version : 4.0
Page : Page 4 of 52
1. ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES

 Send for the appropriate investigations in all these infections as recommended. These are the
minimum required for diagnosis, prognosis and follow up of these infections.
 All antibiotic initiations would be done after sending appropriate cultures
 Change in antibiotic would be done after sending fresh cultures
 Follow the Hospital policy when choosing antimicrobial therapy whenever possible. If alternatives
are chosen, document the reason in the case records.
 Check for factors which will affect drug choice & dose, e.g. renal function, interactions, allergy.
 Check that the appropriate dose is prescribed. If uncertain, contact Infectious disease
 physician, Pharmacy, or check in the formulary.
 The need for antimicrobial therapy should be reviewed on a daily basis. For most
o infections 5 - 7 days of antimicrobial therapy is sufficient (simple UTIs can be adequately treated
with 3 days of antibiotic).
 All IV antibiotics may only be given for 48 - 72 hours without review and consideration of oral
alternatives. New microbiological or other information (eg. fever defervescence for at least 24h,
marked clinical improvement; low CRP) should at this stage often permit a switch to oral
antibiotic(s), or switch to an IV narrow spectrum alternative, or cessation of antibiotics (no
infection present).
 Once culture reports are available, the physician shall step down to the narrowest spectrum, most
efficacious and most cost effective option. If there is no step down availed, the reason shall be
documented and is subjected to clinical audit.
 Empiric Therapy -Where delay in initiating therapy to await microbiological results would be life
threatening or risk serious morbidity, antimicrobial therapy based on a clinically defined infection
is justified. Where empiric therapy is used the accuracy of diagnosis should be reviewed regularly
and treatment altered/stopped when microbiological results become available.
 Microbiological samples must always be sent prior to initiating antimicrobial therapy.
o Rapid tests, such as Gram smears, can help determine therapeutic choices when empiric therapy
is required.
 Prescribing antibiotics just in case an infection is present is rarely justified. Where patients are in
hospital close observation is usually a better option.
Version : 4.0
Page : Page 5 of 52
2. MONITORING TREATMENT
The continued need for antimicrobial therapy should be reviewed at least daily. For most types of infection
treatment should continue until the clinical signs and symptoms of infection have resolved - exceptions to this
are indicated in the relevant sections. Parenteral therapy is normally used in seriously ill patients and those
with gastrointestinal upset. Oral therapy can often be substituted as the patient improves.
Where treatment is apparently failing, advice from the microbiologist and ID Physician should normally be
sought rather than blindly changing to an alternative choice of antimicrobial agent.
3. THE IMPORTANCE OF INFECTION CONTROL (IC) TO CONTROL ANTIMICROBIAL

RESISTANCE
The use of antimicrobial agents inevitably leads to the emergence of resistant micro-organisms. It also
destroys the normal flora of the body and renders patients far more susceptible to colonization with micro-
organisms introduced from elsewhere in the hospital through the process of cross infection.
Hospitals may be considered as reservoirs and breeding grounds within the world of antibiotic resistance.
Prevention of cross infection and good quality antimicrobial prescribing contribute to the prevention of
antimicrobial resistance. Infection Control and Clinical Microbiology are linked.
The importance of hand washing in preventing hospital acquired infection and the spread of antibiotic
resistant micro-organisms is clear. High standards of hospital cleanliness may be important in controlling the
spread of resistant organism in the environment e.g. MRSA, Acinetobacter baumanni.
Surveillance is a crucial part of the control of antimicrobial resistance.
4. HYPERSENSITIVITY
All patients should be asked about drug allergies. This is the responsibility of the doctor examining the
patient. If a patient reports a drug allergy clarify whether this is an allergy or drug intolerance. In some cases
there will be an overlap between drug allergy and drug intolerance.
Clinical features suggestive of drug allergy:

One or more symptoms developed during or following drug administration including
:difficulty in breathing, swelling, itching, rash, anaphylaxis, swelling of the lips, loss of consciousness, seizures
or congestion involving mucous membranes of eyes, nose and mouth.
Clinical features suggestive of drug intolerance:

One or more symptoms developed during or following drug administration including gastrointestinal
symptoms eg. nausea, vomiting, diarrhoea, abdominal pain and giddiness.
Version : 4.0
Page : Page 6 of 52
If patients are unable to give an allergy history, the doctor should take reasonable steps to contact someone
who can provide a reliable allergy history.
It is the prime responsibility of the prescribing doctor to ensure that;
i. The allergy box on the patients drug chart is completed when a new prescription chart is written or
transcribed. If no allergy - specify "No known allergy or NKA". The box should be signed and dated. If allergy
history cannot be obtained, then specify "history not available." Under no circumstances should the allergy
box be left blank.
A pharmacist or nurse may complete the allergy box if the allergy status is documented in the clerking in
notes.
ii. The allergy box is completed before prescribing a new drug, except in exceptional circumstances.
If patients have a suspected drug allergy then the drug and suspected reaction should be documented in the
clerking-in notes and the drug chart.
Version : 4.0
Page : Page 7 of 52
5. PATIENT RISK STRATIFICATION

Patient Type 1 Patient Type 2 Patient Type 3 Patient Type 4
No contact with health Contact with health care Hospitalization >5 days Type 3 patient with fever
care system system (e.g. recent and or infections despite
hospital following antibiotic therapy (>5days)
admission, nursing home, invasive procedures with no obvious source /
CAPD) without/minimal after appropriate
invasive procedures source control
No prior antibiotic Antibiotic therapy in last Recent & multiple ± severe sepsis/septic shock
treatment in last 90 90 antibiotic therapies PLUS
days days
Patient young with no Patient old ( > 65years) Has 1 or more than 1 of the
co-morbid conditions with Patient with multiple following factors. (but not
few co-morbidities Co-morbidities eg: limited to) for
cystic invasive fungal infections : T
fibrosis, structural lung P N , Hemodialysis,
disease, advanced AIDS, Immunodeficiency of
neutropenia, other variable origin, Major
severe Abdominal surgery,
immunodeficiency Multi-focal candida
colonization, Diabetes
• Bacterial infections • Risk of Bacterial • High risk of Bacterial • Risk of Bacterial infections
with minimal risk of infections with infections with any of with Pan-drug resistant
Multidrug resistant pathogens like ESBL Multi drug resistant Pseudomonas and
pathogens like ESBL producing pathogens like ESBL Acinetobacter
producing Enterobacteriacae and producing
Enterobacteriacae, MRSA. Enterobacteriacae, • High Risk of Invasive
MRSA or Non MRSA and non- fungal
fermentors like • Minimal risk of fermentors like infections
Pseudomonas and Nonfermentors like Pseudomonas and
Acinetobacter Pseudomonas and Acinetobacter
• Invasive Fungal Acinetobacter • Risk of invasive fungal
Infections are infections in special
unlikely • Minimal risk of Invasive cases like patients
Fungal infections. undergoing Allogenic
BMT, Liver transplant
or chemotherapy
induced
neutropenic patients.
Version : 4.0
Page : Page 8 of 52
• Limited use of broad • ESBL infections to be • Bacterial infections to • Bacterial infections to be

spectrum treated with Non- be treated with broad treated with novel
antibacterials Pseudomonal antibiotics spectrum antibiotics combination of
• No role of like Group 1 Carbapenem like Group 2. antibacterials
Antifungal agents Carbapenem or Anti- suggested for Pan resistant
• BL+BLI's can also be Pseudomonal BL-BLI's bacteria using alternate
preferred for mild ESBL in combination with drug
infections. Fluoroquinolones/ami delivery systems/PK-PD
noglycosides/Glycope parameters.
•Vancomycin/Tiecoplanin ptides.
to be used for MRSA • Prophylaxis for fungal •
infections in select Empiric treatment of fungal
• No role of Antifungal cases as per IDSA infections for both stable
agents guidelines and unstable patients as per
IDSA guidelines.
Version : 4.0
Page : Page 9 of 52
6. HOSPITAL MICROBIOLOGY DATA
RESPIRATORY INFECTIONS (N =230)

MOST COMMON PREVALENCE
S.N PATHOGENS % ANTIBIOTIC SENSITIVITY (%)
Colistin/Polymixin-B/Tigecyclin (100%), Fosfomycin (81%),
1 Acinetobacter n=94 41% Doxycyclin (24), Netillin (19%),
Colistin/Polymixin-B (100%), Netillin/Imipenem (59%),
Gentamycin (57%), Meropenem/Doripenem/Amikacin (56%),
Cefepime-Tz (52%), Tobramycin (51%),
Pseudomonas Aztreonam/Ceftazidime/Cefepime (49%), Cefoparazone-Tz-
2 N=63 27% Slb/Levofloxacin (48%), Ceftriaxone-Tz/Ciprofloxacin (46%), -
Colistin/Polymixin-B/Tigecyclin/Fosfomycin (100%), Amikacin
(51%), Netillin (49%), Tobramycin (46%), Doxycyclin (36%),
Doripenem (33%), Imipenem (31%), Meropenem (26%),
Cefaparazone-Tz-Slb (23%)-
3 Klebsiella N=39 17%
Colistin/Polymixin-B/Tigecyclin/Fosfomycin (100%), Amikacin
(80%), Netillin (75%), Doripenem (70%), Cefepime-
Tz/Tobramycin (60%), Meropenem (55%), Doxicyclin (50%),
Imipenem/Ceftriaxone-Tz/Gentamycin (45%), Cefaparazone-
4 E. coli N=20 9% Tz/Slb (40%)
5. S. aureus n=16 7% Linezolid/Vancomycin/Teicoplanine(100%),
URINARY TRACT INFECTIONS (UTI) (N = 127)

MOST COMMON
S.N PATHOGENS PREVALENCE % ANTIBIOTIC SENSITIVITY (%)

Netillin/Amikacin (69%), Doripenem (60%), Cefepime-Tz
(58%), Toramycin (54%), Imipenem (52%), Ceftriaxone-Tz
E. coli N=48 (48%), Meropenem (46%), Cefoparazone-Tz (42%),
1 38% Nitrofurantoin (40%), Cefoparazone-Slb (36%)
Klebsiella 31 Colistin/Polymixin-B/Tigecyclin (100%), Fosfomycin (90%),
2 spp 24% Doxycyclin (39%), Meropenem, Netillin, Toramycin (29%)
Linezolid (100%), Vancomycin/Teicoplanine(96%),
Fosfomycin (93%), Tetracyclin (93%), Chloramphenicol
(57%), High level Gentamycin (25%)
3 Enterococci 28 22%
Version : 4.0
Page : Page 10 of 52
Colistin/Polymixin B (100%), Netllin (42%), Amikacin

(38%), Gentamycin (33%), Cefaparazone-Slb, Cefepime-
4 Pseudomonas 24 19% Tz, Meropenam, Tobramycin (29%)
BLOOD STREAM INFECTIONS (BSI) (N=71)

MOST COMMON PREVALENCE
S.N PATHOGENS % ANTIBIOTIC SENSITIVITY (%)
Doxycyclin (64%), Cefepime-Tz, Amikacin/Netillin (41%),
Klebsiella 22 Imipenem/Gentamycin (36%), Meropenem (32%)
1 spp 31%
Acinetobacter spp Colistin/Polymixin-B/Tigecyclin (100%), Fosfomycin (84%),
19 Amikacin/Minocyclin (21%), Cefepime-
2 27% Tz/Meropenem/Netillin/Tobramycin (16%)
Colistin/Polymixin-B/Tigecyclin/Fosfomycin (100%), Netllin (88%),
Cefepime-Tz, Ceftriaxone-Tz (81%), Meropenem/Doripenem (75%),
Imipenem (63%), Cefoparazone-Tz/Tobramycin/Amikacin (56%),
3 E. Coli 16 23% Doxycyclin (36%), Piperacillin-Tz (31%)
Fosfomycin/Vancomycin/Teicoplanine/Linezolide/Tetracycline
(>86%), Amoxyclave/Chloramphenicol (43%), Gentamycin/Penicillin
(36%), Ciprofloxacin/Ofloxacin (14%)
4 Enterococcus 14 20%
Vancomycin/Teicoplanine/Linezolide/Tetracycline (>90%), Cefoxitin

(50%), Clindamycin (40%), Gentamycin (30%), , Penicillin (30%),
5. Staph. Aureus 10 14% Amoxyclave (20%), Pipracillin/Tz (10%), Ciprofloxcin (10%)
Colistin/Polymixin-B/Cefepime-Tz/Imipenem (100%),
Aztreonam/Ceftazidime/Cefepime/Cefoparazone-Slb-
Tz/Ceftriaxone-Tz/Meropenem/Doripenem/Gentamycin
/Amikacin/Toramycin/Netillin (89%)/ Ticarcillin-Clv/Cefotaxime
6. Pseudomonas 9 13% /Ceftriaxone/ Ciprofloxacin/Levofloxacin (56%)
Version : 4.0
7. Antibiogram -IPD & ICU

Blood stream infections (n=32)
MOST n= PREVELENCE ANTIBIOTIC SENSITIVITY (%)

COMMON
PATHOGEN
E. coli 16 50% Colistin/Polymixin-B/Tigecyclin/Fosfomycin (100%), Amikacin
(94%), Netillin/Cefepime-Tz (88%), Cefoparazone-Tz/Slb,
Ceftriaxone/Tz, Imipenem, Doripenem (81%), Tobramycin
(75%), Meropenem/Gentamycin (69%), Piperacillin/Tz (56%),
Ampicillin-Slb/Oflxacin/Doxycyclin (44%),
Ciprofloxacin/Levofloxacin/Minocyclin (38%)
Klebshiella 5 16% Colistin/Polymixin-B/Tigecyclin/Fosfomycin (100%),
Doxycyclin (80%), Doripenem (40%)
Psudomonas 5 16% Colistin/Polymixin-B/Cefepime-Tz/Doripenem/Gentamycin
(100%), Cefoparazone-Tz/Slb, Ceftriaxone/Tz, Imipenem,
Netillin/Toramycin/Amikacin/Levofloxacin/Coprofloxacin/
Ceftazidime/Aztreanam (80%)
Enterococci 4 13% Linezolide/Vancomycin/Teicoplanine/Tetracyclin/Fosfomycin
(100%), High level Gentamycin/Amocyclave (75%)
Staphylococci 3 9% Linezolide/Vancomycin/Teicoplanine/Tetracyclin (100%),
Clindamycin/Cefoxitin (67%), Piperacillin/Tz (33%)
UTI: IPD
N=271
MOST n= PREVELENCE ANTIBIOTIC SENSITIVITY (%)

COMMON
PATHOGEN
E. coli 152 56 Colistin/Polymixin-B/Tigecyclin/ (100%), Fosfomycin
(96%), Netillin (74%), Amikacin (73%), Doripenem (72%),
Cefepime/Tz (71%), Imipenem (64%), Tobramycin (62%),
Nitrofurantoin (56%), Cefoparazone-Tz-Slb/ Ceftriaxone-
Tz/ Meropenem (55%), Gentamycin (51%), Piperacillin/Tz
(40%)
Enterococci 56 21 Linozolid (100%),
Vancomycin/Teicoplanine/Tetracycline/Fosfomycin(96%),
Amoxyclave/Penicillin (27%
Kleshiella 49 18% Colistin/Polymixin-B/Tigecyclin/ (100%), Fosfomycin
(88%), Netillin (45%), Tobramycin (43%), Amikacin(41%),
Doripenem (39%), Cefepime-Tz (39%),
Imipenem/Meropenem/Doxycyclin (37%), Nitrofurantoin
(16%)
Version : 4.0
Pseudomonas 40 15% Colistin/Polymixin-B (100%), Imipenem (40%),

Meropenem (38%), Amikacin (35%), Cefepime-Tz (20%
Proteus 11 4% Tegicycline (100%), Cefepime-Tz/ Piperacillin/Tz (91%),
Fosfomycin/Doripenem/Ceftriaxine-Tz/Ticarcillin-
Ca(82%), Ampicillin-Slb(73%), Cefoparazone-Tz-Slb/
Amikacin (64%),
Meropenem/Ertapenem/Cefotaxim/Ciprofloxacin
(55%),
Imipenem/Netillin/Amoxyclave/Ofloxacin/Levoflxacin/
Cefuroxime(45%)
IPD: Respiratory infections
N=36
MOST n= PREVELEN ANTIBIOTIC SENSITIVITY (%)

COMMON CE
PATHOGEN
Kleshiella 14 39% Colistin/Polymixin-B/Tigecyclin (100%), Fosfomycin (93%),
Imipenem (64%), Cefepime-Tz/Doripenem/Meropenem/Amikacin
(57%), Gentamycin/Netillin/Tobramycin (50%)
Pseudomon 11 31% Colistin/Polymixin-B/ (100%), Meropenem(91%),
as Imipenem/Gentamycin (82%), Cefepime-
Tz/Diripenem/Amikacin/Netillin/Tobramycin/Aztreonam (73%),
Ciproflixacin/Levofloxacin/Cefoparazone-Tz-
Slb/Ceftriaxone/Tx(64%)
Acinetobact 9 25% Colistin/Polymixin-B/Tigecyclin/ (100%), Fosfomycin/Netillin (56%),
er Doxyxyclin (64%), Amikacin (44%), Cefoparazone-Tz/Ceftriaxine-Tz
(36%), Cefoparazone-Slb/ Chloramphinecol/ Pipercaillin-Tz/
Ciproflixacin/Levofloxacin/Oflaxacin(21%)
Streptococc 5 14% Linozolid/Vancomycin/Teicoplanine/Tetracycline(100%),
i Gentamycin/Penicillin(60%), Amoxyclave/Clindamycin (40%)
Enterococci 2 6% Linozolid/Vancomycin/Teicoplanine/Tetracycline(100%),
Gentamycin/Penicillin/Amoxyclave/Clindamycin/Chloramphenicol/
Fosfomycin (50%)
IPD Soft Tissue
N=166
MOST COMMON n= PREVELENCE ANTIBIOTIC SENSITIVITY (%)

PATHOGEN
Kleshiella 24 14% Colistin/Polymixin-B/Tigecyclin (100%),
Fosfomycin (79%),
Pseudomonas 39 23% Colistin/Polymixin-B/ (100%),
Version : 4.0
Imipenem(59%), Cefepime-Tz(44%)
Staphylococci 29 17% Linozolid/Vancomycin/Teicoplanine(100%),
Teteracyclin (90%),
Acinetobacter 12 7% Colistin/Polymixin-
B/Tigecyclin(100%),Fosfomycin (92%),
Minocyclin (50%), Doxycyclin (42%)
Enterococci 24 14% Linozolid/Vancomycin/Teicoplanine(100%)
Fosfomycin (81%), Teteracyclin (69%),
E. coli 27 16% Colistin/Polymixin-B/Tigecyclin,Fosfomycin
(100%), Doripenem(67%), Cefepime-
Tz/Netillin/Amikacin (63%),
Imipenem(56%),
Meropenem/Tobramycin(52%),
gentamycin (48%)
Blood Stream Infection (BSls) : Antibiotic Protocol : ICU
Patient risk stratification
Patient type 1 (CAI) Patient type 2 (HCAI)
 Patient Risk  Patient Risk

1. No contact with health care system in last 90 1. Rescent contact with health care system
days. (hospital / nursing home admission, CAPD)
2. No prior antibiotic treatment in last 90 days. without major invasive procedure.
3. Patient young with no or few co- morbid 2. Antibiotic therapy in last 90 days.
conditions. 3. Patient old (>65 yrs.) with few co-morbidities.
 Send Sample for Culture (Presumptive  Send Sample for Culture (Presumptive
Therapy) Therapy)
Ceftriaxone OR Amoxicilin –Clavulanate OR
Ciprofloxin*/ Ofloxin. Ertapenem or Piperacillin – Tazobactam +/- Amikacin
* Avoid Ciprofloxin in patient type 1 since it has Note: Vancomycin / Teicoplanin to be used only in
patient antipseudomonal activity. MRSA suspicion is high.
 After Culture Report  After Culture Report (Continue

(Continue Treatment) Treatment)
If the pathogen is sensitive to the drug used
empirically or culture is negative & patient responds 1. If the pathogen is susceptible to the drug
to clinical treatment. used empirically or culture is negative &
patient responds to clinical treatment.
2. If ESBL +ve Enterobacteriaceae: Continue
treatment with monotherapy as per
sensitivity report (Avoid using broad
spectrum anti-pseudomonal drugs)
Version : 4.0
3. If MRSA / Enterococus: Use Vancomycin or

Teicoplanin Monotherapy.
 Step down “ De-Escalate”  Step down “ De-Escalate”

If Non ESBL enterobacteriacae / MSSA: shift to If Non ESBL Enterobacteriaceae / MSSA: De-Escalate
monotherapy if combination used empirically as per & treat as patient type 1
the sensitivity report.
 Consider Escalation
1. If culture negative & no clinical response
within 48 hours of treatment. 1. If culture negative & no clinical response
2. If culture is ESBL positive, treat as patient within 48 hrs. of treatment.
type 2 2. If culture shows Pseudomonas /
Acinetobacter – Treat as Patient type 3
Blood Stream Infection (BSls): Antibiotic Protocol : ICU
Patient Type 3 (NI) Patient Type 4 (NI)

1. Hospitalization > 5 days = infection following 1. Type 3 patient with fever despite antibiotic
major invasive procedures. therapy (> 5 days) with no obvious source /
2. Recent & multiple antibiotic therapies after appropriate source control
3. Patient old (>65 years) + multiple co- 2. Severe sepsis / septic shock
morbidities (eg. Structural lung disease, 3. Plus >1 of the following (but not limited to)
immunodeficiency) risk factors for invasive fungal infections:
TPN, Hemodialysis, Immunodeficiency of
variable origin. Major abdominal surgery.
Multifocal candida colonization, Diabetes
 Send Samples for culture  Send Samples for culture

(Presumptive Therapy) (Presumptive Therapy)
1. Imipenem/Meropenem + /- Vancomycin 1. Hemodynamically stable and no prior
2. Note: Colistin can be used empirically on exposure to Azoles Fluconzole
physician’s discretion in very sick patients 2. Hemodynamically stable + prior exposure to
Azoles Echinocandins (Caspofungin / Lip
Amp B / Conv. Amp B
(use conv. Amp B intolerance of limited
availability of other antifungals, with proper
administration guidelines / precautions)
3. Hemodynamically Unstable – Echinocandins
(Caspofungin) / Lip Amp B
Version : 4.0
 After Culture Report  After Culture Report

(Continue Treatment) (Continue Treatment)
1. If candida Albicans and patient stable :
1. If the culture is negative & patient responds to Continue Fluconazole
clinical treatment 2. If candida Non – Albicans OR Patient
2. If sensitive Pseudomonas / Acinetobacter unstable : Continue Echinocandin / Lip Amp
Preferably a combination of Antipseudomonal B
beta-lactam + Aminoglycoside /
Antipseudomonal FQ for 3-5 days followed by
beta lactam monotherapy for another 5-7
days
3. If MRSA – shift to Vancomycin / Teicoplanin
monotherapy.

Empirically started on Echinocandin / Lip Amp B
1. If ESBL +ve Enterobacteriaceae – Deescalate and Culture shows Candida albicans plus patient
and treat as patient Type 2 is stable De- escalate to Azoles
2. If non ESBL / MSSA – De- escalate and Treat as
patient Type 1
 Consider Escalation  Consider Escalation

Empirically started on Azole but culture shows
1. MDR Pseudomonas / Klebsilla : Colistin + anti candida species resistant to azoles OR the patient
Pseudomonal Beta lactam (pref. Carbapenem condition deteriorates : Escalate to Echinocandin /
in Extended Infusion) with maximum Lip Amp B / Conv. Amp B ased on C/S report and
sensitivity patient condition
2. MDR Acinetobacter: Colistin + High dose
Sulbactam +/- Carbapenem in Extended
Infusion
3. VRSA / VRE : Escalate to Linezolid or
Daptomycin
Version : 4.0
Blood Stream Infection (BSls): Antibiotic protocol : IPD
Patient type 1 (CAI) Patient type 2 (HCAI) Patient Type 3 (NI)
 Patient Risk  Patient Risk  Patient Risk

1. No contact with health 1. Hospitalization > 5 days =
care system in last 90 days. 1. Resent contact with health infection following major
2. No prior antibiotic care system (hospital / invasive procedures.
treatment in last 90 days. nursing home admission, 2. Recent & multiple
3. Patient young with no or CAPD) without major invasive antibiotic therapies
few co- morbid conditions. procedure. 3. Patient old (>65 years) +
2. Antibiotic therapy in last 90 multiple co-morbidities (eg.
days. Structural lung disease,
3. Patient old (>65 yrs.) with immunodeficiency)
few co-morbidities.
 Send Sample for Culture  Send Sample for Culture  Send Samples for culture
(Presumptive Therapy) (Presumptive Therapy) (Presumptive Therapy)
Oral: Cefotaxime OR Ofloxacin. Ertapenem or Piperacillin – 1. Imipenem / Piperacillin - +

– Amoxicillin OR Clavulanate Tazobactam Tazobactam /
IV/IM: Ceftriaxone OR Note: Vancomycin / Teicoplanin Cefoperazone-Sulbactam +
Amoxicillin OR Clavulanate OR to be used only in MRSA incidence is /- Vancomycin
Ciprofloxine* / Ofloxin high.
* Avoid Ciprofloxin in patient

type 1 since it has patient
antipseudomonal activity.
 After Culture Report  After Culture Report  After Culture Report
(Continue Treatment) (Continue Treatment) (Continue Treatment)
If the pathogen is sensitive to 1. If the pathogen is susceptible 1. If the culture is negative &
the drug used empirically or to the drug used empirically patient responds to clinical
culture is negative & patient or culture is negative & treatment
responds to clinical treatment. patient responds to clinical 2. If sensitive Pseudomonas /
treatment. Acinetobacter Preferably a
2. If ESBL +ve combination of
Enterobacteriaceae: Antipseudomonal beta-
Continue treatment with lactam + Aminoglycoside /
monotherapy as per Antipseudomonal FQ for 3-
sensitivity report (Avoid using 5 days followed by beta
broad spectrum anti- lactam monotherapy for
pseudomonal drugs) another 5-7 days
3. If MRSA / Enterococus: Use 3. If MRSA – shift to
Vancomycin or Teicoplanin Vancomycin / Teicoplanin
Monotherapy. monotherapy.
Version : 4.0

If Non ESBL enterobacteriacae /  Step down “ De-Escalate”
MSSA: shift to monotherapy if If Non ESBL Enterobacteriaceae / 1. If ESBL +ve
combination used empirically as MSSA: De-Escalate & treat as patient Enterobacteriaceae –
per the sensitivity report type 1 Deescalate and treat as
patient Type 2
2. If non ESBL / MSSA – De-
escalate and Treat as
patient Type 1
1. If culture negative & no  Consider Escalation  Consider Escalation
clinical response within 48
hours of treatment. 1. If culture negative & no 1. MDR Pseudomonas /
2. If culture is ESBL positive, clinical response within 48 Klebsilla : Colistin + anti
treat as patient type 2 hrs. of treatment. Pseudomonal Beta lactam
2. If culture shows (pref. Carbapenem in
Pseudomonas / Extended Infusion) with
Acinetobacter – Treat as maximum sensitivity
Patient type 3 2. MDR Acinetobacter:
Colistin + High dose
Sulbactam +/- Carbapenem
in Extended Infusion
3. VRSA / VRE : Escalate to
Linezolid of Dartomycin
Urinary Tract Infections (UTI): Antibiotic protocol : ICU

1. No contact with health care system in last 90
days. 1. Resent contact with health care system
2. No prior antibiotic treatment in last 90 days. (hospital / nursing home admission, CAPD)
3. Patient young with no or few co- morbid without major invasive procedure.
conditions. 2. Antibiotic therapy in last 90 days.
3. Patient old (>65 yrs.) with few co-morbidities.
Therapy) Therapy)
1. Ceftriaxone / Ofloxin OR Amikacin / Ertapenem / Piperacillin – Tazobactam +/-

Version : 4.0
Ertapenem (If community acquired ESBL Amikacin

producing pathogen)
 After Culture Report (Continue  After Culture Report (Continue
Treatment) Treatment)
If the pathogen is sensitive to the drug used 1. If the pathogen is susceptible to the drug
empirically or culture is negative & patient used empirically or culture is negative &
responds to clinical treatment. patient responds to clinical treatment.

1. If culture negative & no clinical response 1. If culture negative & no clinical response
within 48 hours of treatment. within 48 hrs. of treatment.
2. If culture is ESBL positive, treat as patient 2. If culture shows Pseudomonas /
type 2 Acinetobacter – Treat as Patient type 3
Urinary Tract Infections (UTI): Antibiotic protocol : ICU

1. Hospitalization > 5 days = infection following
major invasive procedures. 1. Type 3 patient with fever despite antibiotic
2. Recent & multiple antibiotic therapies therapy (> 5 days) with no obvious source /
3. Patient old (>65 years) + multiple co- after appropriate source control
morbidities (eg. Structural lung disease, 2. Severe sepsis / septic shock
immunodeficiency) 3. Plus >1 of the following (but not limited to)
risk factors for invasive fungal infections: TPN
Hemodialysis Immunodeficiency of variable
origin. Major abdominal surgery. Multifocal
candida colonization Diabetes
Version : 4.0
1. Imipenem / Piperacillin – Tazobactam / 1. Hemodynamically stable and no prior

Cefoperazone – Sulbactam + Amikacin exposure to Azoles Fluconzole
2. Note: Colistin can be used empirically on 2. Hemodynamically stable + prior exposure to
physician’s discretion in very sick patients Azoles Echinocandins (Caspofungin / Lip Amp
B / Conv. Amp B
3. Hemodynamically Unstable – Lip Amp B /
Conv. Amp B Echinocandins ** (Can use
Azoles like Voriconazole as alternative if no
prior exposure to azoles)
** The urine concentration of Echinocandin is
low, therefore they are not preferred therapy for
UTI, use only if UTI leads to Candidemia

1. If candida Albicans and patient stable :
1. If the culture is negative & patient responds Continue Fluconazole
to clinical treatment 2. If candida Non – Albicans OR Patient unstable
2. If sensitive Pseudomonas / Acinetobacter – : Continue Lip Amp B / Amp B OR
Use Antipseudomonal beta-lactam as per Echinocandin**
sensitivity either alone or in combination with (** The urine concentration of Echinocandin is
flouroquinolone of aminoglycoside low, therefore they are not preferred therapy for
UTI, use only if UTI leads to Candidemia)

2. If non ESBL / MSSA – De- escalate and Treat
as patient Type 1
3. If sensitive Enterococcus – A combination of
Ampicillin + Gentamicin (look for synergy
test) OR Vancomycin alone
1. MDR Pseudomonas / Klebsilla : Colistin + anti Empirically started on Azole but culture
Pseudomonal Beta lactam (pref. Carbapenem shows candida species resistant to azoles OR
in Extended Infusion) with maximum the patient condition deteriorates : Escalate
sensitivity to Echinocandin / Lip Amp B / Conv. Amp B
2. MDR Acinetobacter: Colistin + High dose ased on C/S report and patient condition
Sulbactam +/- Carbapenem in Extended
Infusion
Urinary Tract Infections (UTI): Antibiotic protocol : IPD

Version : 4.0
Patient type 2 (HCAI)

Patient type 1 (CAI) Patient Type 3 (NI)

1. No contact with health 1. Hospitalization > 5 days =
care system in last 90 days. 1. Resent contact with health infection following major
2. No prior antibiotic care system (hospital / invasive procedures.
treatment in last 90 days. nursing home admission, 2. Recent & multiple
3. Patient young with no or CAPD) without major antibiotic therapies
few co- morbid conditions. invasive procedure. 3. Patient old (>65 years) +
2. Antibiotic therapy in last multiple co-morbidities
90 days. (eg. Structural lung
3. Patient old (>65 yrs.) with disease,
few co-morbidities. immunodeficiency)
1. Imipenem / Piperacillin –
Oral: Norfloxacin OR Ertapenem / Piperacillin – Tazobactam +/- Amikacin
Cefuroxime / Cefixime. OR Tazobactam 2. Note: Colistin can be used
Amoxicillin - Clavulanate OR empirically on physician’s
Nitrofurantoin (If community discretion in very sick
acquired ESBL Cystitis) patients
IV/IM: Ceftriaxone / Ofloxacin
OR Amikacin / Ertapenem (If
community acquired ESBL UTI)

If the pathogen is sensitive to 1. If the pathogen is 1. If the culture is negative &

the drug used empirically or susceptible to the drug patient responds to clinical
culture is negative & patient used empirically or culture treatment
responds to clinical treatment. is negative & patient 2. If sensitive Pseudomonas /
responds to clinical Acinetobacter – Use
treatment. Antipseudomonal beta-
2. If ESBL +ve lactam as per sensitivity
Enterobacteriaceae: either alone or in
Continue treatment with combination with
monotherapy as per flouroquinolone of
sensitivity report (Avoid aminoglycoside
using broad spectrum anti-
Version : 4.0
pseudomonal drugs)
3. If MRSA / Enterococus:
Use Vancomycin or
 Step down “ De-Escalate”  Step down “ De-Escalate”  Step down “ De-Escalate”

If Non ESBL enterobacteriacae / 1. If Non ESBL
MSSA: shift to monotherapy if Enterobacteriaceae / 1. If ESBL +ve
combination used empirically as MSSA: De-Escalate & treat Enterobacteriaceae –
per the sensitivity report. as patient type 1 Deescalate and treat as
2. If sensitive Enterococcus – patient Type 2
A combination of 2. If non ESBL / MSSA – De-
Ampicillin + Gentamicin escalate and Treat as
(look for synergy test) OR patient Type 1
Vancomycin alone 3. If sensitive Enterococcus –
A combination of
Ampicillin + Gentamicin
(look for synergy test) OR
Vancomycin alone
 Consider Escalation  Consider Escalation  Consider Escalation
1. If culture negative & no 1. If culture negative & no 1. MDR Pseudomonas /

clinical response within 48 clinical response within 48 Klebsilla : Colistin + anti
hours of treatment. hrs. of treatment. Pseudomonal Beta lactam
2. If culture is ESBL positive, 2. If culture shows (pref. Carbapenem in
treat as patient type 2 Pseudomonas / Extended Infusion) with
Acinetobacter – Treat as maximum sensitivity
Patient type 3 2. MDR Acinetobacter:
Sulbactam +/-
Carbapenem in Extended
Infusion
Version : 4.0
Respiratory / Skin Soft Tissue infection: Antibiotic protocol :ICU
Patients stratification

1. No contact with health care system in last 90
days. 1. Resent contact with health care system
2. No prior antibiotic treatment in last 90 days. (hospital / nursing home admission, CAPD)
3. Patient young with no or few co- morbid without major invasive procedure.
conditions. 2. Antibiotic therapy in last 90 days.
3. Patient old (>65 yrs.) with few co-morbidities.
Therapy) Therapy)
SSTI: Cefazolin / Cefuroxime / Cloxacillin / SSTI: Ertapenem / Piperacillin – Tazobactam +

Ciprofloxacin* + Metronidazole OR Clindamycin / Amikacin
Amoxicillin – Clavulanate alone Note: Vancomycin / Teicoplanin to be used only
*Avoid ciprofloxacin in patient type 1 since it has in MRSA incidence is high
patient anti pseudomonal activity RTI: Piperacillin- Tazobactam / Cefoperazone-
Note: Source control is must in SSTIs Sulbactam+/- Ciprofloxacin / Amikacin
RTI: Ceftriaxone / Amoxicillin – Clavulanate alone
+/- Macrolide OR Respiratory Flouroquinolone (eg
Gemifloxacin, Moxifloxacin)
 After Culture Report (Continue  After Culture Report (Continue

Treatment) Treatment)
If the pathogen is sensitive to the drug used 1. If the pathogen is susceptible to the drug
empirically or culture is negative & patient used empirically or culture is negative &
responds to clinical treatment. patient responds to clinical treatment.

Version : 4.0
1. If culture negative & no clinical response 1. If culture negative & no clinical response
within 48 hours of treatment. within 48 hrs. of treatment.
2. If culture is ESBL positive, treat as patient 2. If culture shows Pseudomonas /
type 2 Acinetobacter – Treat as Patient type 3
Respiratory / Skin Soft Tissue infection: Antibiotic protocol :ICU

1. Hospitalization > 5 days = infection following
major invasive procedures. 1. Type 3 patient with fever despite antibiotic
2. Recent & multiple antibiotic therapies therapy (> 5 days) with no obvious source /
3. Patient old (>65 years) + multiple co- after appropriate source control
morbidities (eg. Structural lung disease, 2. Severe sepsis / septic shock
immunodeficiency) 3. Plus >1 of the following (but not limited to)
risk factors for invasive fungal infections: TPN
Hemodialysis Immunodeficiency of variable
origin. Major abdominal surgery. Multifocal
candida colonization Diabetes

SSTI and RTI: Imipenem / Piperacillin – 1. Hemodynamically stable and no prior
Tazobactam / Cefoperazone – Sulbactam + exposure to Azoles Fluconzole
Amikacin / Levofloxacin 2. Hemodynamically stable + prior exposure to
Note: Colistin can be used empirically on Azoles Echinocandins (Caspofungin / Lip Amp
physician’s discretion in very sick patients B / Conv. Amp B
(Use conv Amp B if intolerance or limited
availability of other antifungals, with proper
administration guidelines / precautions)
3. Hemodynamically Unstable – Echinocandins
(Caspofungin) / Lip Amp B

1. If the culture is negative & patient responds 1. If candida Albicans and patient stable :
to clinical treatment Continue Fluconazole
Version : 4.0
2. If sensitive Pseudomonas / Acinetobacter – 2. If candida Non – Albicans OR Patient unstable

Use Antipseudomonal beta-lactam as per : Continue Lip Amp B / Amp B OR
sensitivity either alone or in combination with Echinocandin**
flouroquinolone of aminoglycoside
3. If MRSA-shift to Vancomycin / Teicoplanin
Monotherapy.

2. If non ESBL / MSSA – De- escalate and Treat
as patient Type 1
1. MDR Pseudomonas / Klebsilla : Colistin + anti Empirically started on Azole but culture
Pseudomonal Beta lactam (pref. Carbapenem shows candida species resistant to azoles OR
in Extended Infusion) with maximum the patient condition deteriorates : Escalate
sensitivity to Echinocandin / Lip Amp B / Conv. Amp B
2. MDR Acinetobacter: Colistin + High dose ased on C/S report and patient condition
Sulbactam +/- Carbapenem in Extended 
Infusion OR Tigecycline (Only in SSTI)
3. VRSA / VRE : Escalate to Linezolid /
Daptomycin (only in SSTI)

Version : 4.0
Respiratory / Skin Soft Tissue infection: Antibiotic protocol :IPD
Patient type 1 (CAI) Patient type 2 (HCAI) Patient Type 3 (NI)

1. No contact with health 1. Hospitalization > 5 days
care system in last 90 1. Resent contact with = infection following
days. health care system major invasive
2. No prior antibiotic (hospital / nursing home procedures.
treatment in last 90 admission, CAPD) 2. Recent & multiple
days. without major invasive antibiotic therapies
3. Patient young with no procedure. 3. Patient old (>65 years) +
or few co- morbid 2. Antibiotic therapy in last multiple co-morbidities
conditions. 90 days. (eg. Structural lung
3. Patient old (>65 yrs.) disease,
with few co-morbidities. immunodeficiency)
SSTI and RTI: Imipenem /
SSTI: Oral: Amoxicillin – SSTI and RTI: Ertapenem / Piperacillin – Tazobactam /
Clavulanate OR Piperacillin – Tazobactam + Cefoperazone – Sulbactam +
Cefuroxime / Cephalexin / Amikacin / Ciprofloxacin Vancomycin + /- Amikacin /
Cefadroxyl +/- Note: Vancomycin / Levofloxacin
Metronidazole Teicoplanin to be used only
IV/IM: Cefazolin / in MRSA incidence is very
Cefuroxime / Oxacillin / high
Ciprofloxacin* +/ Macrolide can be added in
Metronidazole OR RTI
Amoxicillin Clavulanate /
Clindamycin
*Avoid ciprofloxacin in
patient type 1 since it has
patient anti pseudomonal
activity
Note: Source control is
must in SSTIs
RTI: ORAL: Amoxicillin –
Clavulanate OR
Ceftriaxone / Cefdinir +/-
Macrolide (Erythromycin /
Azithromycin) OR
Respiratory
Flouroquinolone (eg
Version : 4.0
Gemifloxacin, Moxifloxacin)
IV/IM: Ceftriaxone OR
Amoxicillin- Clavulanate +/-
Macrolide

If the pathogen is sensitive 1. If the pathogen is 1. If the culture is negative

to the drug used susceptible to the drug & patient responds to
empirically or culture is used empirically or clinical treatment
negative & patient culture is negative & 2. If sensitive Pseudomonas
responds to clinical patient responds to / Acinetobacter
treatment. clinical treatment. Preferably a combination
2. If ESBL +ve of Antipseudomonal
Enterobacteriaceae: beta-lactam +
Continue treatment Aminoglycoside /
with monotherapy as Antipseudomonal FQ for
per sensitivity report 3-5 days followed by
(Avoid using broad beta lactam
spectrum anti- monotherapy for
pseudomonal drugs) another 5-7 days
3. If MRSA / Enterococus: 3. If MRSA – shift to
Use Vancomycin or Vancomycin /
Teicoplanin Teicoplanin
Monotherapy. monotherapy.
 Step down “ De-  Step down “ De-Escalate”  Step down “ De-Escalate”

Escalate” If Non ESBL Enterobacteriaceae
If Non ESBL enterobacteriacae / / MSSA: De-Escalate & treat as 1. If ESBL +ve
MSSA: shift to monotherapy if patient type 1 Enterobacteriaceae –
combination used empirically Deescalate and treat as
as per the sensitivity report. patient Type 2
2. If non ESBL / MSSA – De-
escalate and Treat as
patient Type 1
 Consider Escalation  Consider Escalation  Consider Escalation
1. If culture negative & no 1. If culture negative & no 1. MDR Pseudomonas /

clinical response within clinical response within Klebsilla : Colistin + anti
48 hours of treatment. 48 hrs. of treatment. Pseudomonal Beta
2. If culture is ESBL 2. If culture shows lactam (pref.
positive, treat as Pseudomonas / Carbapenem in
patient type 2 Acinetobacter – Treat as Extended Infusion) with
Version : 4.0
Patient type 3 maximum sensitivity

 2. MDR Acinetobacter:
Sulbactam +/-
Carbapenem in Extended
Infusion OR Tigecycline
(Only in SSTI)
3. VRSA / VRE : Escalate to
Linezolid / Daptomycin
(only in SSTI)
Version : 4.0
2. Notes: Antibiotic Protocol: ICU

1. For treating the Indoor patients, the Microbiology data should be considered mainly for patients belonging to
PatientTypes 2, 3 and 4. Patient type 1 refers to the patients reporting with Community acquired infections,
and for them the treatment options are based on the guidelines.
2. Avoid Antipseudomonal Fluoroquinolones (e.g.Ciprofloxacin and Levofloxacin) and Antipseudomonal 3rd
generation Cephalosporins (e.g. Ceftazidime and Cefoperazone) in PatientsType 1 and 2 since they have
potent antipseudomonal activity
3. Treatment of serious infections caused by ESBL +ve pathogens with BL-BLI combinations (eg Piperacillin-
Tazobactam, Cefepime-Tazobactam and Cefoperazone-Sulbactam) should be avoided as there is limited
clinical data and evidence available for the use of these drugs in such infections.
4. In infections with MDR Pseudomonas/ Acinetobacter, Carbapenems should be used as Extended Infusions e.g.
Imipenem (2 -3 hrs infusion), Meropenem (3hrs infusion), Doripenem (4hrs infusion)
5. Linezolid and Daptomycin are reserved drugs for inpatients and should be used only in cases of Vancomycin
Resistant Staph Aureus (VRSA) orVancomycin Resistant Enterococci(VRE)
6. # De-escalation to Fluconazole if: Isolates susceptible to Fluconazoie (eg: Candida Albicans) + Patient clinically
stable. Deescalation to Voriconazole if : C. Krusei or Voriconazole susceptible C.Glabrata + Patient clinically
stable. De-escalation to fluconazole or voriconazole not recommended without confirmation of isolate
susceptibility
3. Notes: Antibiotic Protocol: IPD

1. For treating the Indoor patients, the Microbiology data should be considered mainly for patients belonging to
Patient Types 2
and 3. Patient type 1 refers to the patients reporting with Community acquired infections, and for them the
treatment options are based on the guidelines.
2. Avoid Antipseudomonal Fluoroquinolones (e.g.Ciprofloxacin and Levofloxacin) and Antipseudomonal 3rd
generation Cephalosporins (e.g. Ceftazidime and Cefoperazone) in PatientsType 1 and 2 since they have
potent antipseudomonal activity
3. Treatment of serious infections caused by ESBL +ve pathogens with BL-BLI combinations (eg Piperacillin-
Tazobactam, Cefepime-Tazobactam and Cefoperazone-Sulbactam) should be avoided as there is limited
clinical data and evidence available for the use of these drugs in such infections.
4. In infections with MDR Pseudomonas/ Acinetobacter, Carbapenems should be used as Extended Infusions e.g.
Imipenem (2 -3
hrs infusion), Meropenem (3hrs infusion), Doripenem (4hrs infusion)
5. Linezolid and Daptomycin are reserved drugs for inpatients and should be used only in cases of Vancomycin
Resistant Staph
Aureus (VRSA) orVancomycin Resistant Enterococci(VRE)
Version : 4.0
4. Recommendations for monitoring patients receiving long-term antimicrobial

therapy
 Long term defined ≥ 1 week, except for aminoglycosides and Amphotericin B (see below)
 These monitoring recommendations and monitoring for agents not listed should be individualized,
based on each patients, including general health status, age,
underlying conditions and organ dysfunction, concomitant medications, drug treatment history, type of
infection, and type and dose of antibiotic
Antimicrobial Test Frequency Other

agent(s)
Aminoglycosides CBC Weekly Clinical monitoring and

(Amikacin, patient education for
Gentamicin, BUN, Creatinine Twice weekly hearing/vestibular
Aminoglycoside level - Weekly dysfunction at each visit
Tobramycin,
Streptomycin) trough
(twice weekly, if
increased risk)
Amphotericin B, BUN, Creatinine, K, Mg, Twice weekly

AmBisome® Phosphorus
CBC, AST, ALT

1-2 weeks
β-lactams CBC, BUN, Creatinine Weekly

(Aztreonam,
carbapenems,
cephalosporins,
penicillins)
Oxacillin, Nafcillin,
carbapenems
AST/ALT/bilirubin Weekly
Penicillin G
potassium
Version : 4.0
Micafungin AST/ALT/bilirubin Weekly
Colistin BUN, Creatinine Weekly Clinical monitoring for

neurotoxicity
(twice weekly, if
increased risk) (dizziness, paresthesia,
vertigo,
confusion, visual
disturbances, ataxia)
Daptomycin CBC, BUN, Creatinine , CPK Weekly Clinical monitoring for

myopathy
Linezolid CBC Weekly Clinical monitoring for

peripheral neuropathy
and optic neuritis
Rifampin CBC, AST/ALT/bilirubin Weekly Drug interactions

(monitor start of any
new medications)
Voriconazole CBC, AST/ALT/ bilirubin 1-2 weeks Drug interactions

/Posaconazole (monitor start of any
new medication), visual

changes
Vancomycin Normal renal function: Weekly
CBC, BUN, Creatinine Weekly, unless change

in creatinine
Vancomycin level- trough
( ↑50% from baseline),
then twice weekly
Dialysis:Vancomycin level At each dialysis session
Reference: Practice Guidelines for Outpatient Parenteral Antimicrobial Therapy: Clin Infect Dis 2004;38:1651.
Version : 4.0
5. Oral antimicrobial use in hospitalized patients

When using an agent that is considered to be bioequivalent (no significant difference in rate and extent of
absorption of the therapeutic ingredient) via the parenteral and oral route, the oral formulation is preferred if
the patient does not have the contraindications listed below.
Contraindications to oral therapy
 NPO (including medications)

 Inability to take other oral medications OR not tolerating a liquid diet/tube feeds
 Hemodynamic instability
 Receiving continuous NG suctioning
 Severe nausea, vomiting, diarrhea, GI obstructions the use of oral mucositis
 A malabsorption syndrome
 A concomitant disease state that contraindicates the use of oral medications
NOTE: There are only a limited number of agents that can be used orally for bacteremia or fungemia; these
are noted in the table below.
6. Bioavailability of oral antimicrobials
Antimicrobial % Oral absorption
Should NOT be used orally for bacteremia
Amoxicillin 74-90%
Amoxicillin/Clavulanate (Augmentin®) 74-90%
Azithromycin* 38-83%
Cephalexin 90%
Cefpodoxime* 41-50%
Clindamycin 90%
Doxycycline 90-100%
Version : 4.0
Tetracycline 75-80%
Can be used orally for bacteremia or fungemia
Ciprofloxacin 65-85%
Fluconazole >90%
Linezolid† 100%
Metronidazole 100%
Moxifloxacin 90%
Trimethoprim/sulfamethoxazole† 100%
Voriconazole‡¶ 60-96%
* Oral absorption is enhanced in presence of food
† Should not be used for S. aureus bacteremia
‡ Oral absorption is decreased in presence of food
¶ Inter-patient variability
Do not use with continuous tube feeds (IV preferred), Patients with cyclic tube feeds:
separate oral fluoroquinolone by 2 hours before and 6 hours after tube feeds.
Version : 4.0
7. Antimicrobial dosing in renal insufficiency
Dosing recommendations can vary according to indication and patient specific parameters. All dosage
adjustments are based on creatinine clearance calculated by Cockcroft-Gault equation.
CrCl = (140 – age) (weight in kg) x 0.85 (if female)
72 (serum creatinine*)
†If patient is on hemodialysis (HD) schedule administration so that patient
receives daily dose immediately AFTER dialysis.
Drug Typical dose (may CrCl (mL/min) Dose adjustment for

vary)
renal insufficiency
Acyclovir IV 5-10 mg/kg Q8h >50 5-10 mg/kg Q8H
25-50 5-10 mg/kg Q12H
10-24 5-10 mg/kg Q24H
<10 or HD† 2.5-5 mg/kg Q24H
Acyclovir PO 200 mg 5x daily >10 200 mg 5x daily
(Genital herpes) <10 200 mg Q12H
Acyclovir PO 800 mg 5x daily >25 800 mg 5 x daily
(Herpes Zoster) 10-25 800 mg Q8H
<10 or HD† 800 mg Q12H
Amoxicillin 500-1000 mg Q12H >30 500-1000 mg Q12H
10-30 250-875 mg Q12H
<10 or HD† 250-875 mg Q24H

Version : 4.0
Amoxicillin (pneumonia) 1 g Q8H >30 1 g Q8H
10-30 1 g Q12H
<10 or HD† 1 g Q24H
Amoxicillin / clavulanate 500-1000 mg Q12H >30 500-1000 mg Q12H
10-30 200-500 mg Q12H
<10 or HD† 200-500 mg Q24H
Amphotericin β 0.7-1 mg/kg Q24H - No dosage adjustment
AmBisome® 3-5 mg/kg Q24H - No dosage adjustment
Ampicillin 1-2g Q4-6H >50 1-2 g Q4-6H
10-50 1-2 g Q6-8H
<10 or HD† 1-2 g Q8H
Ampicillin / sulbactam 1.5-3 g Q6H ≥ 30 1.5-3 g Q6H
15-29 1.5-3 g Q12H
≤ 14 or HD† 1.5-3 g Q24H
Ampicillin / sulbactam (for 3 g Q4H ≥50 3 g Q4H

Acinetobacter, E. faecalis)
10-50 3 g Q6H
HD† 3 g Q8H
Azithromycin 250-500 mg Q24H - No dosage adjustment
Aztreonam 1-2 g Q8H ≥ 30 1-2 g Q8H
10-29 1-2 g Q12H
≤ 10 or HD† 1-2 g Q24H
Cefazolin 1-2 g Q8H ≥ 35 1-2 g Q8H
11-34 1 g Q12H
<10 or intermittent 1 g Q24H

Version : 4.0
HD† 2 g Q HD, if HD in 2 days
HD† OR 3g Q HD, if HD in 3
days

vary)
renal insufficiency
Cefdinir 300 mg Q12H ≥ 30 300 mgQ12H
<30 HD† 300 mgQ24H
300 mg QHD
Cefepime 1 g Q8H >60 1 g Q8H
30-60 1 g Q12H
<29 or HD† 1 g Q24H
Cefepime (Central nervous 2 g Q5H >60 2 g Q8H

system infections or
Pseudomonas) 30-60 1 g Q8H
11-29 1 g Q12H
< 11 or HD† 1 g Q24H
Cefotetan 1-2 g Q12H ≥ 30 1 g Q12H
10-29 1 g Q24H
<10 or HD† 500 mg Q24H
Cefpodoxime 100-400 mg Q12H ≥ 30 100-400 mg Q12H
<30 100-400 mg Q24H
HD† 100-400 mg three

times/week
Ceftaroline 600 mg Q12H >50 600 mg Q12H
30-50 400 mg Q12H

Version : 4.0
15-29 300 mg Q12H
<15 or HD† 200 mg Q12H
Ceftaroline for MRSA 600 mg Q8H >50 600 mg Q8H
30-50 400 mg Q8H
15-29 300 mg Q8H
<15 or HD† 400 mg Q12H
Ceftazidime 1-2 g Q8H >50 1-2 g Q8H
For Pseudomonas 30-50 1-2 g Q12H
2 g Q8H 15-29 1-2 g Q24H
<15 or HD† 1 g Q8H
Ceftolozane/Tazobactam 1.5 g Q8H >50 1.5 g Q8H
30-50 750 mg Q8H
15-29 375 mg Q8H
<29 or HD† Load with 750 mg, then
150 mg Q8H
Ceftriaxone 1-2 g Q24H - No dosage adjustment
Ceftriaxone (Central 2 g Q12H - No dosage adjustment

nervous system infections)
Cephalexin 500 mg PO Q6H >50 500 mg Q6H
10-50 500 mg Q8H
<10 or HD† 500 mg Q12H
Cidofovir 5 mg/kg Q week for 2 ≤55 or Cr>1.5 Not recommended

weeks, then every
other week
Ciprofloxacine IV 400 mg Q8-12H ≥30 400 mg Q8-12H

Version : 4.0
<30 or HD† 400 mg Q24H
Ciprofloxacine PO 250-750 mg Q12H ≥30 250-750 mg Q12H
<30 or HD† 250-500 mg Q24H
Claritthromycin 250-500 mg Q12H ≥30 250-750 mg Q12H
<30 250-500 mg Q24H
Clindamycin PO: 300 mg Q8H IV: - No dosage adjustment

600 mg Q8H
Colistin 2.5 mg/kg Q12H ≥50 2.5 mg/kg Q12H

Colistin base 5.0
( Colistimethate) mg/kg weekly 20-50 2.5 mg/kg Q24H
≤20 or HD† 1.25 mg/kg Q24H

vary)
renal insufficiency
Daptomycin for 6-10 mg/kg Q24H ≥30 6-10 mg/kg Q24H

endocarditis/bacteremia
<30 6-10 mg/kg Q48H
HD† 6-10 mg/kg Q48H
Dicloxacillin 250-500 mg Q6H - No dosage adjustment
Doxycycline 100 mg Q12H - No dosage adjustment
Ertapenem 1 g Q24H ≥30 1 g Q24H
<30 or HD† 500 mg Q24H
Ethambutol 15-25 mg/kg Q24H ≥10 Normal dose Q24H
<10 or HD† Normal dose Q48H
Normal dose QHD session
Fluconazole 200-800 mg Q24H ≥50 Normal dose

(e.g.100,400,800 mg)
Version : 4.0
Q24H
Load w/normal dose,

then 50% of normal dose
<50 or HD† Q24H
Flucytosine (5-FC) 12.5-25 mg/kg Q6H >40 12.5-25 mg/kgQ6H
20-40 12.5-25 mg/kgQ12H
10-19 12.5-25 mg/kgQ24H
<10 or HD† 12.5-25 mg/kgQ24-48H
Ganciclovir (Maintenance 5 mg/kg Q24H 5 mg/kg Q24H

dose)
2.5 mg/kg Q24H
1.25 mg/kg Q24H
0.625 mg/kg Q24H
0.625 mg/kg three

times/week, administer
after HD
Gentamicin - - See section on

aminoglycoside dosing
Isoniazid 300 mg Q24H - No dosage adjustment
Linezolid 600 mg Q12H - No dosage adjustment
Meropenem 1 g Q8H >51 1 g Q8H
26-50 1 g Q12H
10-25 500 mg Q12H
<10 or HD† 500 mg Q24H
Meropenem (Meningitis, 2 g Q8H >51 2 g Q8H

CRE infections)
26-50 1 g Q8H
10-25 1 g Q12H
Version : 4.0
<10 or HD† 1 g Q24H
Metronidazole 500 mg Q8H - No dosage adjustment
Micafungin 100-150 mg Q24H - No dosage adjustment
Moxifloxacin 400 mg Q24H - No dosage adjustment
Nitrofurantoin 100 mg Q12H ≥50 100 mg Q12H

(Macrobid®)
<50 Not recommended
Oseltamivir (Treatment) 75 mg Q12H >60 75 mg Q12H
30-60 75 mg Q24H
10-29 30 mg Q24H
<10 or HD† 30 mg QHD session
Oseltamivir (Prophylaxis) 75 mg Q24H >60 30-60 10-29 <10 75 mg Q24H

or HD†
30 mg Q24H
30 mg Q24H
30 mg every other HD
session
Oxacillin 1-2 Q4-6H - No dosage adjustment
Penicillin G 3-4 million units Q4H ≥50 3-4 million units Q4H
10-49 1.5 million units Q4H
<10 or HD† 1.5 million units Q6H

Version : 4.0
Drug Typical dose (may vary) CrCl (mL/min) Dose adjustment for
renal insufficiency
Piperacillin / Tazobactam 3.375-4.5 g Q6H >40 3.375 g Q6H (4.5 g Q6H

for Pseudomonas)
20-40
2.25 g Q6H (3.375 g Q6H
<20 for Pseudomonas)
HD† 2.25 g Q8H (2.25 g Q6H
for Pseudomonas)
2.25 g Q12H (2.25 g Q8H

for Pseudomonas)
Posaconazole See Posaconazole - No dosage adjustment

Guidelinesp.18
Pyrazinamide 15-30 mg/kg Q24H ≥10 15-30 mg/kgQ24H
<10 12-20 mg/kgQ24H
HD† 25-30 mg/kg QHD session
Quinupristin/Dalfopristin 7.5 mg/kg Q8H - No dosage adjustment
Rifampin (TB) 600 mgQ24H - No dosage adjustment
Rifampin 300 mg Q8-12H - No dosage adjustment
Tigecycline 100 mg once, then 50 mg - No dosage adjustment

Q12H
TMP/SMX (UTIs or PO: 1-2 DS tab Q12H ≥30 1-2 DS tab Q12 or
cellulitis)
IV: 160-320 mg Q12H 160-320 mg IV Q12H
(Dosing is based on TMP <30 or HD† 1-2 DS tab Q24H or

component)
160-320 mg IV Q24H
TMP/SMX (PCP or serious 5 mg/kg Q6-8H ≥30 5 mg/kg Q6-8H

systemic infections)
<30 or HD† 2.5 mg/kg Q6-8H
Version : 4.0
2.5 mg/kg Q8H
Valacyclovir (Genital 500-1000 mg Q12H ≥30 500-1000 mg Q12H 500-

herpes) 1000 mg Q12H
10-29
500 mg Q24H
<10 or HD†
Voriconazole See Voriconazole - No dosage adjustment is

guidelines p. 19 necessary for PO IV
should not be
administered to patients
with CrCl ≥50 mL/min
due to accumulation of
the vehicle.
† If patient is on hemodialysis (HD) schedule administration so that patient receives
daily dose immediately AFTER dialysis.
8. Selected formulary antimicrobials and restriction status

The following list applies to ALL adult floors and includes the status of both oral and injectable dosage forms,
unless otherwise noted.
Unrestricted Restricted (requires approval)
Amoxicillin Cefepime
Amoxicillin/clavulanate
Colistin IV
Ampicillin/sulbactam
Daptomycin
Ampicillin IV
Version : 4.0
Azithromycin Imipenem
Cefazolin Fosfomycin
Cefdinir
Linezolid
Cefotetan
Meropenem
Cefpodoxime
Tigecycline
Ceftriaxone
Moxifloxacin Vancomycin
Piperacillin/tazobactam Polymixin B
Ceftazidime
Doripenem
Ciprofloxacin
Cefuroxime IV
Cephalexin
Clarithromycin
Clindamycin
Doxycycline
Ertapenem
Erythromycin
Gentamicin
Metronidazole
Minocycline
Nitrofurantoin
Oxacillin
Penicillin V/G
Ribavirin oral
Version : 4.0
Rifampin
Streptomycin
Tobramycin
Trimethoprim/sulfamethoxazole
Amikacin
Aztreonam
Amphotericin B deoxycholate Liposomal amphotericin B (AmBisome)

Micafungin
Flucytosine
Posaconazole
Itraconazole oral solution
Voriconazole
Cefuroxime
Fluconazole
Colistin (Colistimethate)
Colistin is a polymixin antibiotic. It has in vitro activity against Acinetobacter spp. and Pseudomonas spp.
but does NOT have activity against Proteus, Serratia, Providentia, Burkholderia, Stenotrophomonas, Gram-
negative cocci, Gram-positive organisms, or anaerobes.
Acceptable uses
Management of infections due to multidrug resistant Acinetobacter and Pseudomonas on a case by case
basis.
Unacceptable uses
Monotherpay for empiric treatment of suspected Gram-Negative infections
Dose
 Loading Dose: 5 mg/kg once (30 mg = 1 million unit )

 Maintenance dose: 2.5 mg/kg Q12H; must adjust for worsening renal function and dialysis (refer
for dose adjustment recommendation)
Toxicity
Version : 4.0
 Renal impairment, neuromuscular blockage, neurotoxicity

 Monitoring: BUN, creatinine twice weekly
Daptomycin
Daptomycin is a lipopeptide antibiotic. It has activity against most strains of staphylococci and streptococci
(including MRSA and VRE). It does NOT have activity against Gram-negative organisms.
Acceptable uses (Cases must be discussed with Infectious Diseases and Antimicrobial Stewardship
Program)
 Bacteremia or endocarditis caused by MRSA or Methicillin – resistant coagulase-negative

staphylococci in a patient with serious allergy to Vancomycin
 Bacteremia or endocarditis caused by MRSA in a patient failing Vancomycin therapy as defined by:
o Clinical decompensation after 3-4 days
o Failure to clear blood cultures after 7 days despite Vancomycin therapy
o Therapy for VRE infections other than Pneumonia, on a case by case basis
Unacceptable uses
 Daptomycin should NOT be used for treatment pneumonia due to its inactivation by pulmonary
surfactant.
 Initial therapy for Gram- positive infections
 VRE colonization of the urine, respiratory tract, wounds, or drains
Dose
 Bacteremia; 6-12 mg/kg IV Q 24 H

 Endocarditis: 6-12 mg/kg IV Q 24 H
 Dose adjustment is necessary for CrCI< 30 ml/min refer for dose adjustment recommendation)
Toxicity
 Myopathy (defined as CK≥5 times the upper limit of normal without symptoms or ≥5 times the
upper limit of normal with symptoms)
 Eosinophilic pneumonia
 Monitoring: CK weekly , more frequently during initial therapy
Ertapenem
Version : 4.0
Ertapenem is a carbapenem antibiotic. It has in vitro activity against many Gram-negative organisms
including those that produce extended spectrum beta-lactamases (ESBL), but it does not have activity
against Pseudomonas spp. or Acinetobacter spp. Its anaerobic and Grampositive activity is similar to that of
other carbapenems, except it does not have activity against Enteroccocus spp.
Acceptable uses
 Mild to moderate intraabdominal infections (biliary tract infections diverticulitis, secondary

peritonitis/GI perforation)
 Moderate diabetic foot infections without osteomyelitis
 Moderate surgical – site infections following contaminated procedure
 Pelvic inflammatory disease
 Urinary tract infections caused by ESBL – producing organisms
 Pyelonephritis in a patient who is not severely ill
Unacceptable uses
 Severe infections in which Pseudomonas spp. are suspected.
Dose
 1 g IV or IM Q24H, must adjust for worsening renal function and dialysis (refer dose adjustment
recommendation)
Toxicity
 Diarrhea, nausea, headache, phlebitis/ thrombophlebitis
Fosfomycin
Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in vitro activity against large number
of Gram-negative and Gram-positive organisms including E. coli, Klebsiella spp., Proteus spp.,
Pseudomonas spp., and VRE. It does not have activity against Acinetobacter spp. Fosfomycin is available in
an oral formulation only in the U.S. and its pharmacokinetics allow for one-time dosing.
Acceptable uses
 Management of uncomplicated UTI in patients with multiple antibiotic allergies and/or when no
other oral therapy options are available.
 Uncomplicated UTI due to VRE
 Salvage therapy for UTI due to multidrug resistant Gram-negative organisms (e.g. Pseudomonas
spp.) on case by case basis.
Version : 4.0
NOTE: Susceptibility to Fosfomycin should be confirmed prior to initiation of therapy.
Unacceptable uses
 Fosfomycin should NOT be usedfor management of any infections outside of the urinary tract
because it does not achieve adequate concentrations at other sites.
 Treatment of asymptomic bacteria
Dose
 Uncomplicated UTI : 3 g (1 sachet ) PO once

 Complicated UTI : 3 g (1 sachet ) PO every 1-3 days (up to 21 days of treatment)
 Frequency adjustment may be necessary in patients with CrCI<50 mL/min. Powder should be
mixed with 90-120 mL of cool water , stirred to dissolve and administered immediately.
Toxicity
Diarrhea, nausea, headache, dizziness, asthenia and dyspepsia
Linezolid
Uses:
 Documented Vancomycin intermediate Staphylococcus aureus (VISA) or Vancomycin resistant

Staphylococcus aureus (VRSA) infection
 Documented MRSA or Methicillin- resistant coagulase- negative staphylococcal infection in a
patient with serious allergy to Vancomycin
 Documented MRSA or Methicillin- resistant coagulase- negative staphylococcal infection in a
patient failing Vancomycin therapy (as defined below)
o Bacteremia/ Endocarditis: Failure to clear blood cultures after 7 days despite Vancomycin
troughts of 15-20 mcg/mL. Should be used in combination with another agent
o Pneumonia: Worsening infiltrate or pulmonary status in a patient with documented MRSA
pneumonia after 2 to 3 days or if the MIC of Vancomycin is 2 mcg/mL, or if achieving
appropriate vancomycin trough is unlikely (e.g., obesity)
o Cases should be discussed with infectious Diseases or Antimicrobial stewardship
 High suspicion of CA-MRSA necrotizing pneumonia in a seriously ill patient
 Documented VRE infection
 Gram – positive cocci in chains in blood cultures in an ICU, or oncology transplant patient known to
be colonized with VRE
Unacceptable uses
Version : 4.0
 Prophylaxis
 Initial therapy for staphylococcal infection
 VRE colonization of stool , urine, respiratory tract, wounds, or drains
Dose
 600 mg/IV/PO Q12H

 Skin and skin structure infections: 400 mg IV / PO Q 12H
Toxicity
 Bone marrow suppression (usually occurs within first 2 weeks of therapy)

 Optic neuritis and irreversible sensory motor polyneuropathy (usually occurs with prolonged
therapy > 28 days)
 Case reports of lactic acidosis
 Case reports of serotonin syndrome when co-administered with serotonergic agents (SSRIs, TCAs,
MAOIs, etc.)
 Monitoring : CBC weekly
Tigecycline
Tigecycline is a tetracycline derivative called a glycylcycline. It has in vitro activity against most strains of
staphylococci and streptococci (including MRSA and VRE), anaerobes, and many Gram-negative organisms
with the exception of Proteus spp. and Pseudomonas aeruginosa. It is FDA approved for skin and skin-
structure infections and intra-abdominal infections.
NOTE: Peak serum concentrations of Tigecycline do not exceed 1 mcg/mL which limits its use for treatment
of bacteremia
Acceptable uses
 Management of intra- abdominal infections in patients with contraindications to both beta-lactams

and fluoroquinolones
 Management of infections due to multidrug resistant Gram- Negative organisms including Acinetobacter
spp. on a case by case basis
 Salvage therapy for MRSA/ VRE infections on a case by case basis
Dose
 100 mg IV once, then 50 mg IV Q12H

 100 mg IV once, then 25 mg IV Q12H if severe hepatic impairment (child – Pugh 10-15)
Version : 4.0
Toxicity
 Nausea & Vomiting
Multi-drug resistant Gram-negative rods
Extended spectrum beta-lactamase (ESBL)-producing organisms
 ESBLs are enzymes that confer resistance to all penicillins, cephalosporins and Aztreonam.
 They are most commonly seen in K. pneumoniae and K. oxytoca, E. coli and P. mirabilis,
 Risk factors for infection or colonization: recent hospitalization at an institution with a high rate of
ESBLs, residence in a long-term care facility and prolonged use of broad spectrum antibiotics.
Treatment:
 Meropenem 1 g IV Q8H (2 g IV Q8H for CNS infections) should be used for ALL severe infections if the
organism is susceptible.
 Ertapenem 1 g IV Q24H can be used for uncomplicated UTI or soft tissue infection with adequate
source control if the organism is susceptible.
 Ciproflaxacin or TMP/SMX can be used as altermatives to Ertapenem for uncomplicated UTI or soft
tissue infection with adequate source control if the organism is susceptible. Nitrofurantoin may also
be used for uncomplicated UTI if the organism is susceptible.
Carbapenemase-producing Enterobacteriacae (CRE)
 Carbapenemases are enzymes that confer resistance to all penicillins, cephalosporins, carbapenems
and Aztreonam.
Treatment:
 Meropenem 2 g IV Q8H infused over 3 hours should be included in most regimens based on data from
small, retrospective studies showing benefit even when the isolate is intermediate or resistant.
 At least one additional agent should be added based on susceptibilities (e.g. Amikacin, Tigecycline,
Colistin) except for UTI.
Multi-drug resistant (MDR) gram-negative organisms: defined as organisms susceptible to NO MORE than
ONE of the following antibiotic classes: carbapenems, aminoglycosides, fluorquinolines, penicillins, or
cephalosporins. Note: susceptibility to sulfonamides, tetracyclines, polymixins, and Sulbactam are NOT
considered in this definition
Treatment
MDR Pseudomonas aeruginosa MDR Acinetobacter baumannii
 Anti-pseudomonal β-lactam PLUS  Colistin + Tigecyclin

aminoglycoside if synergy predicted or OR
Version : 4.0
confirmed  Colistin + Sulbactam

OR
 Colistin
*Combination therapy should be considered in severe infections.
Synergy:
 If the organism is intermediate to a beta-lactam and susceptible to aminoglycosides, synergy can be

assumed.
Antibiotic doses for MDR and carbapenemase-producing
infections – normal renal and hepatic function
 Meropenem : 2 g IV Q8H, infuse over 3 hours

 Colistin: 5 mg/kg colistin base once, then 2.5 mg/kg IVQ12h(30mg colistin base = 80 mg colistimethate
sodium = 1 million unit)
 Ampicillin/sulbactam: 3 g Q4H (for MDR A. Baumannii only)
 Tigecycline: 100-150 mg IV Q 12 H
-Interpreting the microbiology report
Interpretation of preliminary microbiology data
Gram-positive cocci Gram-negative cocci
Aerobic Aerobic
In clusters Diplococcus: N. meningiditis, N.gonorrhoeae,

Moraxella catarrhalis
 Coagulase (+): S. Aureus
Coagulase (-): S. epidermidis, Cocco-bacillus: H. flu, Acinetobacter spp.,
S. lugdunensis HACEK organisms
In pairs/chains
-Diplococcus, Quellung positive:S.

pneumoniae
 Alpha-hemolytic: Viridans group

Streptococci, Enterococcus
(faecalis and faecium)
Version : 4.0
 Beta-hemolytic:
Group A strep (S. pyogenes),
Group B strep (S. agalactiae),
Group C, D, G strep
Anaerobic: Peptostretococcus spp.
Gram-positive rods Gram-negative rods
AEROBIC Aerobic
Large: Bacillus spp. Lactose fermenting: Citrobacter spp.,

Enterobacter spp., E. coli, Klebsiella spp., Serratia
Cocco-bacillus: Listeria monocytogenes, spp.
Lactobacillus spp. Non-lactose fermenting
Small, pleomorphic: Corynebacterium spp.  Oxidase(-): Acinetobacter spp.,Burkholderia
spp., Proteus spp., Salmonella spp., Shigella
Branching filaments: Nocardia spp.,
spp., Serratia spp., Stenotrophomonas
Streptomyces spp.
maltophilia
 Oxidase(+): P. aeruginosa, Aeromonas
spp., Vibrio spp., Campylobacter spp.
(curved)
Anaerobic
Anaerobic: Bacteroides spp., Fusobacterium
Large: Clostridium spp. spp., Prevotella spp.
Small, pleomorphic: P. acnes, Actinomyces
spp.
The minimum inhibitory concentration (MIC) value represents the concentration of the antimicrobial agent
required at the site of infection for inhibition of the organism. The MIC of each antibiotic tested against the
organism is reported with one of three interpretations S (susceptible), I (intermediate), or R (resistant). The
highest MIC which is still considered susceptible represents the breakpoint concentration. This is the
highest MIC which is usually associated with clinical efficacy. MICs which are 1 ⁄ 2 - 1 ⁄ 8 the breakpoint
MIC are more frequently utilized to treat infections where antibiotic penetration is variable or poor
(endocarditis, meningitis,
Version : 4.0
osteomyelitis, pneumonia, etc.). Similarly, organisms yielding antibiotic MICs at the breakpoint frequently
possess or have acquired a low-level resistance determinant with the potential for selection of high-level
expression and resistance. This is most notable with cephalosporins and Enterobacter spp., Serratia spp.,
Morganella spp., Providencia spp., Citrobacter spp. and Pseudomonas aeruginosa. These organisms
all possess a chromosomal beta-lactamase which frequently will be over-expressed during therapy despite
initial in vitro susceptibility. The intermediate (I) category includes isolates with MICs that approach
attainable blood and tissue levels, but response rates may be lower than fully susceptible isolates. Clinical
efficacy can potentially be expected in body sites where the drug is concentrated (e.g., aminoglycosides
and beta-lactams in urine) or when a higher dose of the drug can be used (e.g., beta-lactams). The resistant
(R) category indicates the organism will not be inhibited by usually achievable systemic concentrations of
the antibiotic of normal doses.
NOTE: MIC values vary from one drug to another and from one bacterium to another, and thus MIC
values are NOT comparable between antibiotics or between organisms.
9. HOW TO USE THE POCKET GUIDE?

 This pocket guide is divided into 3 sections: the first part contains a drug dose ready
reckoner, the second part has the antibiotic protocols for each infection type and the third part has
footnotes along with space for personal notes.
 To use these protocols follow these steps:
• Identify the type of infection - Respiratory, intra-abdominal, pneumonia, blood stream, urinary tract
and skin and soft tissue.
• Define the location - ICU or ward patient
• Accordingly refer to the respective chart.
Version : 4.0
• Identify the patient type based on described parameters -Type 1, 2, 3, or 4

• Refer to the empiric/presumptive therapy column for that patient type.
• This will give you the protocol drug to start.
• If a column has more than one drug option -
- Choose the drug showing better susceptibility data in the left hand side table OR
- Doctor's discretion advised
• Send respective cultures before starting antibiotic therapy
• Once culture / sensitivity report available:
- Presumptive therapy antibiotic may require to be changed
- Consult Microbiologist / ID physician to decide the choice of antibiotic (based on
narrowest spectrum antibiotic which covers the pathogen isolated)
• In all cases physician's discretion is advised based on patient condition

Antibiotic Poilicy

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Antibiotic Poilicy

Caricato da

Copyright:

Formati disponibili

ANTIBIOTIC POLICY

MMI NARAYANA Multi Specialty Hospital

1. ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES .......................................................................................................... 4

1. ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES

3. THE IMPORTANCE OF INFECTION CONTROL (IC) TO CONTROL ANTIMICROBIAL

Clinical features suggestive of drug allergy:

Clinical features suggestive of drug intolerance:

5. PATIENT RISK STRATIFICATION

• Limited use of broad • ESBL infections to be • Bacterial infections to • Bacterial infections to be

6. HOSPITAL MICROBIOLOGY DATA

RESPIRATORY INFECTIONS (N =230)

5. S. aureus n=16 7% Linezolid/Vancomycin/Teicoplanine(100%),

URINARY TRACT INFECTIONS (UTI) (N = 127)

Colistin/Polymixin-B/Tigecyclin (100%), Fosfomycin (96%),

Colistin/Polymixin B (100%), Netllin (42%), Amikacin

BLOOD STREAM INFECTIONS (BSI) (N=71)

Vancomycin/Teicoplanine/Linezolide/Tetracycline (>90%), Cefoxitin

7. Antibiogram -IPD & ICU

MOST n= PREVELENCE ANTIBIOTIC SENSITIVITY (%)

MOST n= PREVELENCE ANTIBIOTIC SENSITIVITY (%)

Pseudomonas 40 15% Colistin/Polymixin-B (100%), Imipenem (40%),

MOST n= PREVELEN ANTIBIOTIC SENSITIVITY (%)

IPD Soft Tissue

MOST COMMON n= PREVELENCE ANTIBIOTIC SENSITIVITY (%)

Blood Stream Infection (BSls) : Antibiotic Protocol : ICU

Patient risk stratification

Patient type 1 (CAI) Patient type 2 (HCAI)

 Patient Risk  Patient Risk

 After Culture Report  After Culture Report (Continue

3. If MRSA / Enterococus: Use Vancomycin or

 Step down “ De-Escalate”  Step down “ De-Escalate”

Blood Stream Infection (BSls): Antibiotic Protocol : ICU

Patient risk stratification

Patient Type 3 (NI) Patient Type 4 (NI)

 Patient Risk  Patient Risk

 Send Samples for culture  Send Samples for culture

 After Culture Report  After Culture Report

 Step down “ De-Escalate”  Step down “ De-Escalate”

 Consider Escalation  Consider Escalation

Blood Stream Infection (BSls): Antibiotic protocol : IPD

Patient risk stratification

Patient type 1 (CAI) Patient type 2 (HCAI) Patient Type 3 (NI)

 Patient Risk  Patient Risk  Patient Risk

Oral: Cefotaxime OR Ofloxacin. Ertapenem or Piperacillin – 1. Imipenem / Piperacillin - +

* Avoid Ciprofloxin in patient

 Step down “ De-Escalate”  Step down “ De-Escalate”

Urinary Tract Infections (UTI): Antibiotic protocol : ICU

Patient risk stratification

Patient type 1 (CAI) Patient type 2 (HCAI)

 Patient Risk  Patient Risk

1. Ceftriaxone / Ofloxin OR Amikacin / Ertapenem / Piperacillin – Tazobactam +/-

Ertapenem (If community acquired ESBL Amikacin

 Step down “ De-Escalate”  Step down “ De-Escalate”

Urinary Tract Infections (UTI): Antibiotic protocol : ICU

Patient risk stratification

Patient Type 3 (NI) Patient Type 4 (NI)

 Patient Risk  Patient Risk

1. Imipenem / Piperacillin – Tazobactam / 1. Hemodynamically stable and no prior

 After Culture Report  After Culture Report

 Step down “ De-Escalate”  Step down “ De-Escalate”

 Consider Escalation  Consider Escalation

Urinary Tract Infections (UTI): Antibiotic protocol : IPD

Patient risk stratification

Patient type 2 (HCAI)