• Therapy of Herpes zoster (varicella) or primary varicella (chicken pox) or CMV prophylaxis in renal transplant patients

• Prophylaxis or treatment of mucosal or cutaneous HSV 1 & 2 in immunocompromised patients who are unable to take po drug

• May require dosage adjustment if CrCl<50 mL/min

• Infuse IV dose 500 mg or less slowly over 60 min

• Disseminated Herpes zoster or severe localized HZ infection, especially facial lesions near the eye in patients unable
to take po

• Treatment of influenza A

• Decrease dose to once a day in elderly

• Prophylaxis should be considered for patients who cannot be immunized or for 7-10 days after recent immunization

• Aminoglycosides should not be used alone to treat gram-negative pneumonia

• No effective CNS penetration

• Nephro/ototoxic, especially associated with prolonged therapy

• Suggest pharmacokinetics for initial and follow up individualization of dosage regimen

• Gentamicin or tobramycin via HHN in cystic fibrosis patients

• When synergy for gram-positive coverage (Staph, S. viridans, and Enterococcus) is desired, gentamicin is aminoglycoside of choice at 1 mg/kg q8h (assuming CrCl >50), max of 80 mg q8h

• Treatment of acute otitis media, sinusitis and acute bronchitis

• Bacterial endocarditis prophylaxis in patients undergoing dental, oral or upper respiratory tract procedures

500 mg po q8h

$4.65

$7.41

• Respiratory tract infections where beta-lactamase producing organisms and/or anaerobes are suspected; higher doses for lower respiratory tract infections

• Incidence of diarrhea with oral drug may be decreased if drug is taken with food

• Life threatening Candida, Histoplasma capsulatum, Blastomyces dermatitidis, Coccidioides immitis, Aspergillus, Mucormycosis and Cryptococcus infections

• Full dose may be given in first 24 h of therapy; give first 1 mg slowly, watching for anaphylaxis

• Premedication (acetaminophen and diphenhydramine) may limit infusion-related side effects such as fevers, chills, and nausea

• Dilute 1 mg to 10 mL D5W (not saline) for peripheral lines

• Infuse over 1-4 h

• Saline loading with 0.9% NaCl reduces azotemia (500 mL)

• Does not cover Pseudallescheria boydii (Scedosoprium apiospermum)

• Although the drug is not renally excreted, the incidence of nephrotoxicity is about 80%

$7.44-$8.80 (q6h)

• Susceptible Enterococcus, E. coli, or Proteus UTI

• Listeria infections including meningitis

• Listeria meningitis requires 2 g IV q4h

$21.51-$36.66 (q8h)

• Mixed gram-positive and anaerobic infections such as community acquired aspiration pneumonia, diabetic foot infections, decubitus infections or mild/moderate intra-abdominal infections

• Sulbactam is a beta-lactamase inhibitor that enhances ampicillin's spectrum to include penicillinase producing Staphylococcus aureus, (MSSA), ampicillin resistant H. flu, Moraxella catarrhalis, ampicillin resistant anaerobes. NOTE: Amp/sulbactam does not cover hospital acquired gram-negative aerobes or MRSA

• Anaerobic activity is similar to metronidazole, imipenem/cilastatin and clindamycin

• Take with food

• Mild to moderate upper and lower respiratory tract infections due to mycoplasma, S. pneumoniae, Moraxella catarrhalis, H. influenza or Chlamydia

• Should only be used as an alternative to erythromycin when patients do not tolerate erythromycin

• To be used in fluid restricted patients who need macrolide therapy

• When macrolide monotherapy is needed to have active coverage against H. flu

• Perioperative surgical prophylaxis, agent of choice for most elective operations with the exception of colorectal and gynecological

• Intraperitoneally for CAPD patients with peritonitis

• Skin and soft tissue infections, osteomyelitis

• Does not cross the blood brain barrier

• Nafcillin is agent of choice for life-threatening Staphylococcal infection

• Treatment of severe community- or hospital-acquired infections that are documented or suspected to involve resistant aerobic gram-negative bacteria, including Enterobacteriaceae (Serratia, Enterobacter, Citrobacter, Morganella), and Pseudomonas

• Cefepime exhibits good activity in vitro against Pseudomonas (as does ceftazidime) as well as against gram-positive bacteria such as streptococci (as for ceftriaxone)

• Neutropenia: <500 neutrophils

• Empiric therapy of community acquired pneumonia, urosepsis, meningitis, or intraabdominal infection with aerobic organisms

• Uncomplicated gonorrhea as 1 g IM single dose

• Osteomyelitis or skin and soft tissue infection with susceptible organisms

• Nonformulary; can be used as third-generation cephalosporin for nonpseudomonal infections

• Cefotaxime 1 g q8h is equal to ceftriaxone 1 g/d and cefotaxime 2 g q8h is equal to ceftriaxone 2 g/day

• For meningitis, 200 mg/kg/day q6h (not to exceed 12 g/d)

• Surgical prophylaxis where anaerobic coverage needed (colorectal, gynecologic )

• Interchangeable with cefoxitin

• Upper and lower RTI due to Strep, H. flu, or Moraxella catarrhalis

• UTI

• Take with food for absorption

• Known or suspected nosocomial aerobic gram-negative bacilli infection (including meningitis), with concurrent aminoglycoside if Pseudomonas is suspected

• If aspiration has occurred, clindamycin may be added for gram-positive and anaerobic activity

• Most active antipseudomonal third-generation cephalosporin

• Inappropriate for community acquired infections

• Poor Staph / Strep and anaerobic coverage

• Recent antibiogram patterns show decreasing activity against Enterobacter and Citrobacter species

1-2 g IV 12h

$15.04-$27.16

• Not indicated for life-threatening infections

• Spectrum of activity similar to other third generation cephalosporins (no Pseudomonas activity)

• Empiric therapy of community acquired pneumonia, urosepsis, meningitis, or intraabdominal infection with anaerobic agent

• Gonorrhea, dose 125 mg IM x 1 for urogenital, rectal or pharyngeal infections

• Dose 1 g IV q24 hours (for 7-10 days) for disseminated gonorrhea

• Osteomyelitis or skin and soft tissue infection with susceptible organisms (often given as IV therapy at home)

• Considered the primary non-pseudomonal third generation cephalosporin

• Empiric drug of choice for community acquired meningitis in an immunocompetent host

• Not active against Listeria monocytogenes, Pseudomonas aeruginosa, Enterococcus or MRSA

• May administer q12h for meningitis, otherwise use q24h interval

• Once-a-day dosing is advantageous for outpatient use for susceptible osteomyelitis or skin and soft tissue infections

• Use 1.5 g IV q8h for Klebsiella

• Treatment of bacterial meningitis in penicillin and cephalosporin allergic patients

• Toxicities include dose-related bone marrow suppression when drug levels >25 mcg/mL

• Idiosyncratic aplastic anemia 1 in 20,000 to 40,000

250 mg po bid

$4.92

• Cystitis caused by susceptible organisms

• Therapy of bacterial gastrointestinal infection (including Shigella, Salmonella, enterotoxigenic E. coli and Enterobacter)

• Pyelonephritis, prostatitis or serious UTI, esp. when organisms are known or suspected to be resistant to TMP/SMX

• Poor gram-positive drug, no anaerobic coverage

• Consider amoxicillin, TMP/SMX for UTI

• May be combined with other agents (clindamycin) for infections that may include gram-positive organisms or anaerobes

• Ciprofloxacin should not be used for: methicillin-resistant Staph aureus or epidermidis; urinary tract infections unless due to multiresistant gram-negatives, CNS infections, serious Pseudomonas infection unless known sensitive, respiratory infections

• Decreased po absorption with antacids, sucralfate, didanosine tablets, iron

• IV Cipro should be used only when absorption from the oral route is questionable or impossible

• Decreases metabolism of theophylline, caffeine, cyclosporine, warfarin

• 400 mg IV = 500 mg po (oral is about 80% bioavailable)

• Legionella, Strep pneumonia, H. influenza, or upper/lower RTI, if intolerant of erythromycin

600-900 mg IV q8h
or 1200 mg IV q12h

$17.82-$22.89
or 23.76

• Community acquired aspiration pneumonia and lung abscess

• Recurrent group A beta-streptococcal pharyngitis

• Toxoplasmosis in patients allergic to sulfonamides (combined with pyrimethamine)

• May be drug of choice for life-threatening group A Strep infections

• Adjust dosage interval in severe renal or hepatic failure

• Relatively high incidence of pseudomembranous colitis

50-100 mg/d po qd

Initial 50 mg/d
Increase to max 300 mg/d

• Leprosy and dermatitis herpetiforms (infections caused by Mycobacterium leprae

• Monitor pts. for signs of jaundice and hemolysis

• CBC weekly for first month; monthly for 6 months

• Use with caution in pts. allergic to sulfonamides

• Should not be used for initial treatment of severe, life-threatening infections, but can be used as follow-up to parenteral therapy, e.g., in chronic osteomyelitis

• High dose (500 mg qid) may cause diarrhea

• Non-gonococcal or post gonococcal urethritis, cervicitis

• Chlamydia

• Less costly alternative to azithromycin

• Can be used in patients with renal failure without dosage adjustments

500 mg-1 g IV q6h

base:

$7.16-$10.32

Drug of choice for:
• Legionella pneumonia
• Mycoplasma pneumonia
• Campylobacter jejuni enteritis
• H. ducreyi (chancroid)

• For patients <50 kg use 500 mg IV dose q6h as maximum

• High doses (4 g/day), diminished CrCl's and hepatic dysfunction puts patients at increased risk for ototoxicity

• Peripheral IV administration requires substantial dilution to avoid phlebitis/pain

• Significant drug interaction may occur with concurrent use of astemizole antihistamines, theophylline

• Oral drug serum concentration and IV are similar

• Chronic suppressive therapy of cryptococcal meningitis in patients with HIV

• Treatment of urinary colonization may not be effective (need removal of Foley catheter, avoidance of antibiotics, treatment of diabetes, etc.)

60 mg/kg q8h IV x 14 d

$119.75

• CMV retinitis

• Acyclovir resistant HSV 1 and 2

• May cause nephrotoxicity; prehydration with NS may decrease insult to kidneys (500-1000 mL)

• HHV-6 therapy (BMT patients)

5 mg/kg IV q12h x 2-3 wk

5 mg/kg IV q24h (maintenance)

$60.52

$30.26

• CMV retinitis, pneumonitis, enterocolitis, or esophagitis

• High incidence of complicating neutropenia (30-40%) and thrombocytopenia (20%)

• Concomitant use of other bone marrow suppressive agents (zidovudine) may need to be discontinued while on ganciclovir

• Neutropenia may be treated with G or GM-CSF

• Consult Section 7 to adjust dose for patients with CrCl < 80 mL/min

$4.86 (po)

• May be used as an alternative to macrolides in the treatment of documented or suspected community-acquired pneumonia (CAP)

• May be considered as alternative to cephalosporins and/or macrolides for patients requiring empiric therapy

• Has in vitro activity against typical respiratory pathogens (S. pneumoniae, H. influenzae, S. aureus, Moraxella catarrhalis) and atypical pathogens (C. pneumoniae, M. pneumoniae, L. pneumoniae)

• IV gatifloxacin should be used only when absorption from oral route is questionable or impossible

• Iron, zinc, and magnesium should be taken 4 h before or after gatifloxacin administration

• May prolong QT interval

• The manufacturer recommends careful serum monitoring of digoxin levels

• Careful blood glucose monitoring is recommended in diabetic patients receiving oral hypoglycemics or insulin

$64.11-$93.96 (500-750 mg q8h)

• Hospital acquired infection

• Mixed intra-abdominal infection

• Resistant nosocomial gram-negatives, e.g., Enterobacter

• Resistance seen when used alone for Pseudomonas aeruginosa

• Seizures have been reported in patients on imipenem/cilastatin therapy, esp. in patients with renal insufficiency, elderly patients, those with CNS abnormalities and/or patients receiving high doses

• Treatment of infections due to Mycobacterium tuberculosis, either as a single agent (prophylaxis) or in combination with other antitubercular agents

• Hepatotoxicity more common in elderly and patients with underlying liver disease

200 mg capsules po bid x 3d then

$80.08 days 1,2,3, then

$10.40/day

• Blastomycosis, pulmonary and extrapulmonary (non-meningeal, non-life threatening)

• Studies on use for prophylactic or therapeutic treatment of Aspergillosis is limited

• Oropharyngeal Candidiasis

• Esophageal Candidiasis

• Dose oropharyngeal Candidiasis 200 mg swish & swallow daily for 1-2 weeks

• Dose esophageal Candidiasis 100 mg swish & swallow daily for a minimum of 3 weeks. Treatment should continue for 2 weeks following resolution of symptoms

• Bioavailability of oral solution increases in the fasting patient

• Doses may be increased to 200 mg oral solution based on medical judgment & patient’s response to therapy

• Antacids, H2 receptor antagonists interfere with absorption

• For long term use, monitor LFT's (may cause hepatitis)

500 mg IV q8h

or 750 mg IV q12h

500-750 mg po tid

$3.72

$3.72

$0.12-$0.18

• Anaerobic infections where Bacteroides fragilis is a likely pathogen

• Brain abscess (if anaerobes suspected)

• Bacterial vaginosis (Gardnerella vaginalis)

• Giardiasis

• Drug of choice for Clostridium difficile colitis (oral or IV)

• Disulfuram-like reactions have been reported. Counsel patients regarding abstinence from alcohol while on metronidazole therapy and for 72 hours after last dose of drug

• Take po drug with food

• Due to long half-life of drug, dosage regimen may be every 12 h (increased dose)

• Prophylaxis for colorectal surgery

$11.04
(1 g q6h)

• Penicillin-resistant Staphylococcus aureus infection (methicillin sensitive)

• CAUTION: Not effective against enterococci, MRSA, gram-negative bacilli or Bacteroides fragilis

• Anaerobic Strep coverage is marginal

• Do not use if CrCl <40 (unable to achieve adequate tubular levels)

• Chronic use associated with pulmonary fibrosis

(Na or K salt)
600,000 units q6h to
2-4 MU q3-4h

$10.50-$28.90 (Pen GK)
$0.75-$1.50 (PenGNa)

• All Strep infections (Groups A, B, C, Dviridans , Pneumococcus, and Enterococcus)

• Actinomycosis

• Pasteurella multocida

300 mg-aerosolized once a month

$2.64

• Prophylaxis for Pneumocystis carinii

• Usually 300 mg dose

• TMP/SMX is initial drug of choice for PCP

• TMP/SMX or dapsone are preferred for prophylaxis

• Side effects include pancreatitis, hypoglycemia, renal insufficiency

• Treatment of moderate to severe community- or hospital-acquired infections involving mixed bacteria (respiratory, skin/soft tissue, intraabdominal bacteremia) such as staphylococci, streptococci, anaerobic bacteria including Bacteroides

• Zosyn will not be any more active against Pseudomonas than piperacillin because §-lactamases of Pseudomonas are not inhibited by tazobactam

$1.04-$1.56 (po)

• Part of multi-drug regimen for MTB

• Part of multi-drug regimen for atypical mycobacterium

• Part of multi-drug regimen for Staph infection of joints, osteomyelitis

• Serious MRSA infections with vancomycin

• Prophylaxis of Neisseria meningitidis exposure

• Discolors tears, urine, saliva (body fluids)

• Potent hepatic enzyme inducer (may increase drug metabolism)

• Treatment of vancomycin-resistant (MIC>16 mcg/mL) Enterococcus faecium

• Treatment of MRSA or MRSE infections that have failed to respond to vancomycin or for patients intolerant of vancomycin

• Treatment of multi-drug-resistant Streptococcus pneumoniae infections for which PCN, erythromycin, or a fluoroquinolone have been determined ineffective or intolerable.

• Poor activity against Enterococcus faecalis - should not be used to treat vancomycin-resistant E. faecalis infections

• Should not be used to treat infections due to gram-negative or anaerobic pathogens

• Dose should be reduced to 7.5 mg/kg q12h in patients with markedly decreased liver function

• Synercid is a strong inhibitor of the cytochrome P450 3A4 enzyme – carefully monitor cyclosporine and tacrolimus

• For peripheral administration, administer the drug in a minimum of 250 mL D5W to avoid irritation

• Volume of 100 mL may be used if infused via central line only

• Synercid can cause elevations of liver enzymes (usually reversible); liver enzymes and bilirubin should be checked at least twice during the first week of therapy and once per week thereafter

• Therapy for polymicrobial infection (includes anaerobes) such as intra-abdominal sepsis

• Polymicrobial skin and soft tissue infection (diabetic foot)

• Polymicrobial coverage with an aminoglycoside for nosocomial pneumonia

• Activity against E. coli and Klebsiella may be variable

• Good anaerobic activity for intra-abdominal infections

• May produce platelet dysfunction

• 3.1 g Timentin = 3 g Ticarcillin + 100 mg Clavulanate

10-20 mg TMP/kg/d IV or
po in 2-3 doses

$5.88-$17.64 (IV)

• Pneumocystis carinii pneumonia (15-20 mg/kg/day)

• UTI's

• Bacterial bronchitis, otitis media, sinusitis

• Double Strength (DS): 160 mg TMP/800 mg SMX

• Single Strength (SS): 80 mg TMP/400 mg SMX

• May cause photosensitivity

• Sensitive infections with Stenotrophomonas and Pseudomonas cepacia, and non TB mycobacterial sp.

1 g po tid x 7 d

500 mg po bid

$12.78

$4.26

• Primary treatment for Herpes 1 and 2

• Herpes zoster

• Episodic genital Herpes

• 500 mg qd for chronic suppression

• See Section 8, Appendix F

• Same levels as IV acyclovir

• Agent of choice for MRSA and MRSE

• Treatment of Enterococcus for penicillin-allergic patients

• See Vancomycin Guidelines (Appendix B, Section A)

• Vancomycin is the only reliable antibiotic for MRSA or methicillin-resistant coagulase-negative Staph

• Vancomycin is not absorbed orally

• Monitor blood levels so trough <10 mg/mL (IV drug) to reduce nephrotoxicity

• Nephrotoxicity increased when used in combination with aminoglycoside, cyclosporine, Amphotericin B