Adult Inpatient Antibiogram

Antimicrobial Susceptibilities of Frequently Recovered Clinical Isolates

January to December 2016

Department of Pathology

Camille Hamula, PhD Director, Clinical Microbiology Laboratory

Department of Medicine, Division of Infectious Diseases

Judith Aberg, MD Chief, Infectious Diseases

Gopi Patel, MD MS Director, Antimicrobial Stewardship Program

Hospital Epidemiologist

Meena Rana, MD Associate Director, Antimicrobial Stewardship Program

Department of Pharmacy

Joanne Meyer, MS PharmD Chief Pharmacy Officer, Mount Sinai Health System

Patricia L. Saunders-Hao, PharmD Gargi Patel, PharmD

Polina Lerner, PharmD ID Clinical Pharmacists, Antibiotic Stewardship Program

Contact Information:

Microbiology – Ext. 88168

Infection Prevention – Ext. 89450

Antibiotic Approval – Pager 9407

Agent (avg. cost/day)

Dosing Recommendations Based on Renal Function

Estimated CrCl (ml/min) Supplement for HD/CAPD/CVVH/CAVH

>50 30-50 10-30 <10

Ampicillin/ sulbactam

($14)

1.5 – 3g IV q6h

1.5 – 3g IV q8h

1.5 – 3g IV q12h

1.5 – 3g IV q24h

HEMO: Dose for CrCl <10, Dose AD1

CAPD: 3g IV q24h CVVH/CAVH: 3g IV q8-12h

Aztreonam ($198)

1 – 2g IV q8h

1 – 2g IV q8h

1 – 2g IV q12h

1 - 2g IV q24h

HEMO: Dose for CrCl <10, Extra 0.5g AD1

CAPD: Dose for CrCl <10 CVVH/CAVH: 1 – 2g IV q12h

Cefazolin

($9) 1 – 2g IV

q8h 1 – 2g IV

q8h 1 - 2g IV

q12h

1g q24h IV or 2g IV

q48h

HEMO: Dose for CrCl <10, Dose AD1

CAPD: 500mg IV q12h CVVH/CAVH: 1 - 2g IV q12h

Cefepime

($21) 1 – 2g IV q8-12h

1 – 2g IV q12h

1 – 2g IV q24h

0.5g - 1g IV q24h

HEMO: Dose for CrCl <10, Dose AD1

CAPD: 1-2 g IV q48h CVVH/CAVH: 1 - 2g q12h

Colistin2

($18)

5 mg/kg/day IV divided

in 2-3 doses

2

2.5 – 3.8 mg/kg/day IV divided

in 2 doses

2

1.5 mg/kg/day IV divided

in 2 doses

2

1.5 mg/kg IV q36h

2

HEMO: 2.5 mg/kg AD1

CVVH: 2.5 mg/kg/day divided in 2 doses

Daptomycin3

($260)

4 – 6 mg/kg IV

q24h

4 – 6 mg/kg IVq24h

4 – 6 mg/kg IV

q48h

4 – 6 mg/kg IV

q48h

HEMO (MWF or TThSa): 6 mg/kg post HD for 2 sessions; 9mg/kg post HD for 3

rd session

HEMO (PRN): 6mg/kg post HD CAPD: 4 – 6 mg/kg q48h CVVH: 4 – 6 mg/kg q48h

Ertapenem

($90) 1g IV q24h

1 g IV q24h

0.5g IV q24h

0.5g IV q24h

HEMO: Dose for CrCl <10; if dosed <6 hrs prior to HD, give 150 mg supplement AD*

Fluconazole4

($3 IV/

$ 3 PO)

200 – 400 mg IV/PO

q24h

50% IV/PO q24h

50% IV/PO q24h

50% IV/PO q24h

HEMO: 100% of dose AD1

CAPD: 100 – 200 mg q24h CVVH: 200 – 400 mg q24h

Imipenem/

cilastatin

($40)

500 mg IV q6h

500 mg IV q8h

500 mg IV q12h

250 mg IV q12h

HEMO: 500 mg IV q12h CAPD: 250 mg IV q12h CVVH/CAVH: 500mg IV q8h

Levofloxacin

($3 IV/

$0.37 PO)

500 – 750 mg IV/PO

q24h

500 - 750 mg q48h

750 mg x1, then 500 mg

q48h (CrCl <

20)

750 mg x1, then 250-500 mg q48h

HEMO: Dose for CrCl <10 CAPD: Dose for CrCl <10 CVVH/CAVH: 500 - 750 mg q48h

Meropenem

($30) 1-2g IV

q8h 1-2g IV q12h

0.5 – 1g IV q12h

0.5 - 1g IV q24h

HEMO: Dose for CrCl <10 CAPD: Dose for CrCl <10 CVVH/CAVH: 1g q12h

Piperacillin/

tazobactam

($40)

3.375-4.5 g IV q6h

2.25g IV q6h

2.25g IV q6h

2.25g IV q8h

HEMO: Dose for CrCl <10 CAPD: Dose for CrCl <10 CVVH/CAVH: 2.25 – 3.375g IV q6h

1AD= after dialysis; Antibiotics should be dosed after dialysis on HD days. If dose is given right before HD, then a

supplemental dose may be required. 2Always consider using loading dose on day one: 5 x IBW (max of 300mg); wait 24hrs before giving next dose

3Dosing (6-12mg/kg) depends on severity and pathogen – consult ID

4Consider loading dose (12mg/kg max) for treatment of invasive candidiasis infections

FORMULARY ANTIMICROBIAL AGENTS REQUIRING APPROVAL AT ALL TIMES (24/7)

Acyclovir IV (pediatrics only) Foscarnet Voriconazole

Amphotericin B Isavuconazole

Caspofungin Linezolid Antimalaria medications:

Ceftaroline Pentamidine inhaled - Atovaquone/proguanil

Cidofovir Polymyxin B - Primaquine

Colistin Posaconazole - Quinidine IV (if for malaria)

Cytomegalovirus IVIG Tigecycline - Quinine

Daptomycin Varicella Zoster IVIG

VANCOMYCIN DOSING

VANCOMYCIN MONITORING

CrCl (mL/min) Vancomycin Dosing

> 70 mL/min 15 mg/kg every 8-12 hours

40 – 69 mL/min 15 mg/kg every 12-24 hours

20 – 39 mL/min 15 mg/kg every 24-48 hours

<20 mL/min 15 mg/kg x 1, then re-dose by level

HD/CAPD 15 mg/kg x 1, then re-dose by level

CVVH 1 g IV every 24 hours

Doses are based on actual body weight Doses should be rounded to the nearest 250 mg (maximum 2 g per dose) Consultation with an Infectious Disease specialist is strongly

recommended for Staphylococcus aureus bacteremia (irrespective of source and susceptibilities)

Am J Health-Syst Pharm. 2009; 66:82-98

Trough serum concentrations are the most accurate and practical method

for monitoring efficacy and avoiding adverse effects

Troughs should be obtained just prior to the next dose when patient at steady-state (usually before 4

th or 5

th dose)

o Minimum serum trough levels should always be maintained > 10 mg/L

o Minimum serum trough levels of 15-20 mg/L are recommended for complicated infections (endocarditis, osteomyelitis, meningitis, and staphylococcal pneumonia)

ADULT AMINOGLYCOSIDE DOSING

Once daily dosing of aminoglycosides is recommended for the treatment of Gram-negative

infections. An Infectious Diseases (ID) or ID Pharmacist consultation is recommended.

Exclusions to Once Daily Dosing

Avoid aminoglycosides in neuromuscular disease

Traditional dosing is preferred for: o CrCl < 20ml/min or HD o Burns (involving >20% BSA) o Pregnancy o Significant ascites or patients with significant third spacing

Calculating Dose

Dosing is based on Ideal Body Weight (IBW)

In obese patients (>120% IBW) use Adjusted Body Weight (ABW)

o ABW= IBW + 0.4(actual body weight – IBW)

If actual body weight is under IBW, use actual body weight

CrCl

(mL/min)

Aminoglycoside Once Daily Initial Dose

Gentamicin OR

Tobramycin Amikacin

> 60 7 mg/kg every 24 hours 15 mg/kg every 24 hours

40 to 59 7 mg/kg every 36 hours 15 mg/kg every 36 hours

20 - 39 7 mg/kg every 48 hours 15 mg/kg every 48 hours

<20 or HD Use “traditional AG dosing” protocol

ONCE DAILY AMINOGLYCOSIDE MONITORING Order a random level 8-10 hours after the beginning of the infusion. Please communicate with the

nursing staff. Plot the level on the nomogram below based on when it was drawn.

Nomogram† for Gentamicin & Tobramycin at 7mg/kg**:

†Adopted from Hartford Hospital

**Amikacin: Divide amikacin level by “2” and plot above TIPS ON EVALUATING LEVELS AND REPEAT MONITORING:

If the level falls on a line, the longer dosage interval should be selected.

If the level falls above the Q 48H line: The drug should be held. o Serial random levels should be followed until <1mcg/mL

If initial level falls below the nomogram, consider going to traditional dosing

Repeat serum AG levels as necessary, with significant changes in CrCl or when therapy continues beyond 96 hours after previous level and every 96 hours to minimize toxicity.

Patients on concurrent nephrotoxic agents (diuretics, vancomycin, contrast, etc) o Recommend monitor level twice a week and monitor BUN and Cr daily

**For Gram-positive endocarditis, use 1mg/kg

CrCl

(mL/min)

Traditional Aminoglycoside Dosing Monitoring – Traditional Dosing

Gentamicin**/

Tobramycin Amikacin

Gentamicin/

Tobramycin Amikacin

> 60 1-2mg/kg every 8 hours 5mg/kg every 8hours Target Peaks/Troughs:

Sepsis/Pneumonia:

7-10/ <2

OB-GYN: 5-7/ <2

**Synergy for Enterococcal or Streptococcal Endocarditis (Gent 1mg/kg): 2-4/ <1

Target Peaks/Troughs:

Sepsis/Pneumonia:

20-30/ <10

UTI/Cystitis:

10-15/ <7

5/ <7

40-60 1-2mg/kg every 12

hours

5mg/kg every

12hours

20-40 1-2mg/kg every 24

hours

5mg/kg every

24hours

<20 1-2mg/kg every 48

hours

5mg/kg loading dose,

then monitor levels

<10 1-2mg/kg after HD 5mg/kg after HD

If the point is near the line, the longer interval is chosen to avoid drug

accumulation and provide sufficient drug-free period.

If the random level is off (i.e., above) the nomogram between the 6- and 14-

hr time points, the scheduled therapy is discontinued and the drug

concentration is monitored to determine appropriate time of the next dose

(i.e ,concentration of <1 µg/ml)

If level falls in area designated q24h, the

dosing interval is q24h (the same applies for

the areas q36h and q48h)