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Affix patient label within this box 

GNCH Emergency Medicine: Uncomplicated Skin and Soft Tissue Infection ceFAZolin and probenecid Order Form. (For Outpatient Adult Use Only)

1. Allergies: Check Caution Record before ordering. 2. All co-signatures must be timed and dated within 24 hours. 3. Orders may be deleted by stroking the order out and initialing the

entry or by leaving prompts blank (boxes). 4. All orders must be completed and signed by the prescriber.

Date:_________________________________ Time: _________________________________________ Ht:(cm)_______________________________ Wt:(kg)_________________________________________ Criteria for use:

1. No documented ceFAZolin or probenecid allergy or intolerance 2. Normal renal function (creatinine clearance greater than 50 mL/min) 3. No significant drug interactions between current medications and probenecid: see list on reverse 4. No evidence or suspicion of acute gout attack or history of uric acid renal calculi 5. No evidence or suspicion of:

osteomyelitis, septic arthritis or deep space infection complicated polymicrobial infection such as diabetic foot, bite wounds, decubitus ulcer or

trauma sepsis or septic shock (hypotensive, tachycardic, evidence of end-organ dysfunction) Gram negative infections e.g. P. aeruginosa folliculitis related to hot tub use

6. Does not have a skin and soft tissue infection such as folliculitis or furunculosis that is self-limiting and does not require IV antibiotics

7. Note: if known to be colonized with MRSA or at high risk for MRSA colonization, see reverse

Emergency Department Orders:

1. Lab work: CBC and differential serum creatinine

Blood cultures 2 sets, 2 sites (check if desired) 2. Medications:

probenecid 2 g PO now ceFAZolin 2 g IV given 30 minutes after probenecid

3. Refer to GNCH IV Clinic to see:

Nurse Practitioner

General Internal Medicine

Infectious Diseases (requires phone consultation) 4. Fax these orders to GNCH IV Clinic

GNCH IV Clinic Orders (start the day after Emergency Orders):

1. Medications: probenecid 2 g PO daily. Give on arrival to GNCH IV Clinic (if not tolerated, see reverse)

ceFAZolin 2 g IV daily given 30 minutes after probenecid

2. Send patient to Emergency Department for assessment by physician if there are concerns regarding patient safety or hemodynamic instability

Prescriber’s Signature: _________________________________________________

Prescriber’s Printed Name: _______________________________________________________

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If probenecid 2 g PO daily is not tolerated, contact prescriber for alternate regimen. Alternate regimens include:

ceFAZolin 2 g IV BID and probenecid 1 g PO BID 30 minutes before each ceFAZolin dose ceFAZolin 2 g IV daily and probenecid 1 g PO daily 30 minutes before each ceFAZolin dose ceFAZolin 2 g IV TID (no probenecid)

Simple cellulitis and erysipelas (superficial skin and soft tissue infections) are typically caused by Staphylococcus aureus and Streptococci (Lancefield Groups A, B, C and G). Probenecid is a uricosuric drug that has been shown to increase the half life of ceFAZolin which allows for extending the dosing interval in the treatment of skin and soft tissue infections. Its utility in the treatment of deep space infections (osteomyelitis, septic arthritis, tenosynovitis) with ceFAZolin has not been established.

Risk factors for MRSA colonization (CID 2005:41:159)

Known positive MRSA Living in close quarters with known positive MRSA History of incarceration Multiple contacts with the health care system

Injection drug use History of recurrent boils/skin

infections Street-involved Recent antibiotic use

If known to be colonized with MRSA, consider adding MRSA coverage in addition to ceFAZolin: trimethoprim-sulfamethoxazole 2 DS tablets PO BID OR doxycycline 100 mg PO BID OR vancomycin 15 mg/kg IV Q12H

Potential drug interactions with probenecid. Note: this list may not be complete. Lexicomp® Risk Class C: monitor therapy; D: consider therapy modification; X: avoid combination.

high dose salicylates (ASA 81 mg PO daily is safe) (C) ketorolac (X) lorazepam (D)

oseltamivir (D) methotrexate (D) mycophenolate (MMF) (D)

Side effects of probenecid: Nausea/vomiting/gastrointestinal intolerance (take with food to minimize) Dizziness, headache Hemolytic anemia in patients with G6PD deficiency (rare)