1.

Acyclovir* (Zovirax®)

200 mg po 5 times qd

$0.70

• Therapy of acute genital herpes simplex

• Does not prevent post-herpetic neuralgia, but may decrease length of acute episode

800 mg po 5 times qd

$1.70

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

• Prophylaxis for BMT/lung/heart transplant

• (Most benefit if started within 72h of onset of symptoms)

400 mg po bid

$0.56

• Suppression of chronic genital herpes

• May use for up to one year, then re-evaluate

5 mg/kg IV q8h

$16.29

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

• Severe first episodes of genital herpes in immunocompetent patients unable to take po

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

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

• Infuse IV doses >500 mg over 120 min to prevent crystal precipitation in renal tubules and subsequent renal dysfunction

10 mg/kg IV q8h

$32.58

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

• HSV encephalitis

100 mg po qd or bid

$0.13 (qd)
$0.26 (bid)

• Treatment of influenza A

• Prophylaxis 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

• Best results are seen if treatment is begun within 48 hours of onset of infection

• Serious aerobic gram-negative bacilli infections

• 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

• Once daily dosing–see Appendix A

Amikacin* (generic)
500 mg qd

$5.43

• Amikacin is 20X should be reserved for gram-negative infections resistant to gentamicin and tobramycin

Gentamicin* (generic)
200 mg qd

$1.05

• Gentamicin activity is comparable to tobramycin against Serratia marcescens

• 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

• For use in the treatment of VRE if strain is sensitive to aminoglycosides

Tobramycin* (generic)
200 mg qd

$7.77

• Tobramycin has better activity against Pseudomonas aeruginosa

250-500 mg po q8h

$0.21-$0.33

• Treatment of acute otitis media, sinusitis and acute bronchitis

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

• Susceptible enterococcal, E. coli, or Proteus UTI

• Caution: Some H. flu and most Moraxella catarrhalis produce beta-lactamase (therefore resistant to amoxicillin)

250 mg po q8h

500 mg po q8h

875 mg po q12h

$4.65

$7.41

$6.98

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

• Human and animal bite wounds, closed fist trauma; higher doses for severe infections

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

• Logical choice for oral therapy after ampicillin/sulbactam parenteral therapy

0.5-1.5 mg/kg IV q24h

$5.48-$16.44

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

• See Section 8, Appendix C for Amphotericin B Lipid Complex indications

• 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

• Monitor serum Na+, K+, Mg+, HCO3-, and SCr; amphotericin B may cause hypokalemia, hypomagnesemia, RTA and azotemia

• 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%

• Efficacy of bladder irrigation is unclear (dose range is
5-50 mg/L of H2O)

Amphotericin B, oral solution
100 mg po qid

$6.00

Oral, pharyngeal or esophageal Candidiasis

Amphotericin B, liposomal
3 mg/kg/d IV

$250

1-2 g IV q4-6h

$7.44-$8.80 (q6h)

$11.16-$13.20 (q4h)

• Susceptible Enterococcus, E. coli, or Proteus UTI

• Listeria infections including meningitis

• H. flu (non-beta-lactamase-producing) infections

• Listeria meningitis requires 2 g IV q4h

• 1 g IV q6h for other infections

1.5-3 g IV q6-8h

$21.51-$36.66 (q8h)

$28.68-$48.88 (q6h)

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

• IV drug of choice for empiric treatment of animal bites

• 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

• Sulbactam does not improve enterococcal activity of ampicillin (use either ampicillin or vancomycin with gentamicin for serious enterococcal infection)

750 mg po q8h
(3 x 250 mg tabs/dose)

$34.17

• Treatment of mild to moderate Pneumocystis carinii pneumonia in AIDS patients who are intolerant of trimethoprim/sulfamethoxazole and able to take po medication

• Take with food

• Clinical failures have been associated with decreased bioavailability particularly in patients with diarrhea

750 mg/mL bid

$4.80

• PCP prophylaxis

500 mg po qd then
250 mg po X 4 d

$10.06
$5.03

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

• Treatment of mild to moderate skin and soft tissue infection due to Staph and Strep

1 g po x 1 single dose

$20.12

• Alternative to doxycycline for Chlamydia urethritis

500 mg IV qd

$19.19

• 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

• When switching from IV to po dose, follow-up doses are 500 mg qd x 5 d

1200 mg po 1X/wk

$24.14/wk

• MAC prophylaxis for AIDS pts.

• Pregnancy category B

Azithromycin oral soln
200 mg/5 mL

$7.10

1-2 g IV q8h

$4.02-$8.04

• 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

• UTI's - with susceptible organisms (E. coli, (Klebsiella pneumonia, Proteus mirabilis)

• Does not cross the blood brain barrier

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

• For cephalosporinase-producing organisms, cefuroxime is agent of choice

1-2 g IV q12h

$23.03-$42.78

• 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

• Ceftazidime is equally active against 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)

• Cefepime may also be more active than either ceftriaxone or ceftazidime against gram-negative bacteria with inducible §-lactamases (Enterobacter, Citrobacter, Serratia, Acinetobacter), although additional data are necessary

2 g IV q8h

$64.17

• Empiric therapy for febrile neutropenia

• Neutropenia: <500 neutrophils

• IM injection available

1 g IV q12h to
2 g IV q8h

$16.52-$46.59

• 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

• Lyme disease, especially with rheumatologic, neurologic, or cardiac involvement

• 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)

• For Lyme disease, especially with rheumatologic, neurologic, or cardiac involvement, dose is 2 g IV q8h

1-2 g IV q12h

$19.60-$34.49

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

• Treatment of mild-moderate mixed anaerobic infections (i.e., PID, mild diverticulitis)

• Interchangeable with cefoxitin

• Disulfuram-like reactions possible. Patients should be advised to avoid alcohol for 72h after last dose. Vitamin K dependent increases in PT and bleeding possible with chronic therapy in malnourished/debilitated patients

100 mg-200 mg po q12h

$2.54-$5.08

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

• UTI

• Skin & soft tissue infections

• Take with food for absorption

• 400 mg bid for skin & soft tissue infections

1-2 g IV q8h

$23.30-$45.09

• 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

• Empiric treatment of febrile neutropenic patients

• 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

• Not recommended for serious Enterobacter infection, regardless of sensitivity

1-2 g IV 12h

1-2 g IV q8h

$15.04-$27.16

$22.56-$40.74

• Mild to moderate mixed aerobic/anaerobic infections

• Not indicated for life-threatening infections

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

• More severe infections require q8h dosing

1-2 g IV q24h

$23.11-$44.13

• 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)

• Lyme disease, especially with rheumatologic, neurologic or cardiac involvement

• 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

• 2 g dose for meningitis

0.75-1.50 g IV q8h

$23.91-$32.40

• Lower respiratory tract infections where beta-lactamase producing organisms are suspected (H. flu, Moraxella cat.)

• Use 1.5 g IV q8h for Klebsiella

• Use of 750 mg IV q8h for Strep pneumo., Moraxella, H. flu is adequate

250-500 mg po bid

$5.20-$10.4

• Intermediate Strep infection

• Switch to po as soon as possible

1.5 g IV q12h

$21.60

• Cardiothoracic surgery prophylaxis

250-500 mg po qid

$0.96-$1.28

• Treatment of mild to moderate community acquired infections of the skin or urinary tract (susceptible organisms)

• First-generation cephalosporin with good in vitro activity against Staph and non-enterococcal Strep

1 g IV q6h

$15.00

• Treatment of bacterial meningitis in penicillin and cephalosporin allergic patients

• Option for treatment of Salmonella typhi (typhoid fever)

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

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

• Multiple drug interactions (Appendix H)

10 mg troche
5 times qd

$3.50

• Oropharyngeal and mild esophageal candidiasis

• Severe esophagitis should be treated with oral ketoconazole, fluconazole, or amphotericin B oral suspension

250 mg po bid

500 mg po bid

$4.92

$5.60

• 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

• Selected soft tissue or respiratory tract infections with susceptible gram-negative organisms

• 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

• Ciprofloxacin should not be used in pregnant women and patients <17 y/o

• 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)

• Higher IV dose may be needed for critically ill patient because of larger volume of distribution

750 mg po q12h

$5.16-$9.14

• Gram-negative osteomyelitis

200-400 mg IV q12h

$16.94-$33.88

• For UTI, dose dependent on severity:
200 mg q12h for mild-moderate infection;
400 mg q12 for severe-complicated (pyelonephritis)

400 mg IV q12h

$33.88-$42.90

• For LRTI, skin and skin structure or bone and joint infection with susceptible gram-negative organisms

500 mg-1 g po bid

$5.44-$10.88

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

• For MAI as part of combination therapy for active infection and prophylaxis

• Drug interactions include: cyclosporine, theophylline (monitor blood concentration of each)

• Gram-positive anaerobic bacteria
(e.g., Peptococcus)

600-900 mg IV q8h
or 1200 mg IV q12h

300-450 mg po tid
or 300 mg po qid

$17.82-$22.89
or 23.76

$7.80-$11.70
or $10.40

• 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

• For therapy of PCP combined with primaquine if intolerant or allergic to trimethoprim-sulfamethoxazole

• Adjust dosage interval in severe renal or hepatic failure

• Relatively high incidence of pseudomembranous colitis

• Not drug of choice for clostridial sepsis due to possible resistance

50-100 mg/d po qd

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

1 mg/kg/d to max 100 mg/d
Adults: 100 mg/d
in combination with TMX 20 mg/kg/d for 21 d

$0.30/100 mg

• Leprosy and dermatitis herpetiforms (infections caused by Mycobacterium leprae

• Prophylaxis & treatment for Pneumocystis carinii pneumonia

• 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

• Check G6PD deficiency

250-500 mg po qid

$0.44-$0.88

• Known or suspected infection caused by penicillin-resistant, methicillin-susceptible Staphylococci

• 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

• Take on empty stomach

100 mg po bid

$0.16

• Non-gonococcal or post gonococcal urethritis, cervicitis

• Chlamydia

• Trichomonas

• Less costly alternative to azithromycin

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

• Do not use in pregnant women or in children <8 yo

500 mg-1 g IV q6h

base:

250-500 mg po q6h

$7.16-$10.32

$0.20-$0.40

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

May also be used for:
• Strep pharyngitis in penicillin allergic
patients
• Mild skin and soft tissue infections
• Preop orally (as base), with neomycin
prior to colorectal surgery

• 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

• High incidence of GI symptoms

$5.56-$9.10

• Oropharyngeal candidiasis in dose of 200 mg IV or po x 1, then 100 mg q24h when topical antifungal (nystatin, clotrimazole) or oral ketoconazole is ineffective

• Oral drug serum concentration and IV are similar

• Reserve IV therapy for patients who cannot absorb oral drug

400 mg x 1, then
200 mg q24h po or IV

$98.30 (IV)
$67.26(IV)

• Candida esophagitis 200 mg/d
(400 mg x 1 load)

• Fluconazole may inhibit drug metabolism because of inhibition of the P-450 isoenzyme (e.g., cyclosporine)

200-400 mg po q24h

$9.10-$18.20

• Coccidioides immitis meningitis (400/d)

• Chronic use may result in colonization with resistant species

100 mg po M, W, F, daily

$16.68/wk

• Chronic suppressive therapy of cryptococcal meningitis in patients with HIV

• Prophylaxis in short term neutropenia (BMT, chemotherapy reaction)

• Fluconazole may not be active against Torulopsis glabrata or Candida krusei

400 mg po or IV q24h

$18.20 (po)
$96.02 (IV)

• Disseminated non-life-threatening Candida albicans (400 mg/d)

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

• Fluconazole should replace ketoconazole if (1) absorption is a problem (ileus, achlorhydria), (2) pt. is taking H2 blockers which cannot be discontinued, (3) Candidal UTI is present, (4) pt. has AIDS and requires indefinite suppressive therapy for Cryptococcus neoformans

60 mg/kg q8h IV x 14 d

90-120 mg/kg IV q24h (maintenance)

$119.75

$59.90-$79.90

• CMV retinitis

• Acyclovir resistant HSV 1 and 2

• CMV pneumonitis, enterocolitis or esophagitis when ganciclovir cannot be used, or resistance suspected

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

• HHV-6 therapy (BMT patients)

• Monitor SCr, serum calcium, phosphorus, potassium, & magnesium

Ganciclovir* (Cytovene® DHPG)

5 mg/kg IV q12h x 2-3 wk

5 mg/kg IV q24h (maintenance)

(See Section 8, Appendix F for po dosing)

$60.52

$30.26

$3.28/250 mg capsule
$6.56/500 mg capsule

• CMV retinitis, pneumonitis, enterocolitis, or esophagitis

• Prophylaxis for CMV in seronegative transplant recipients of graft from a seropositive donor

• 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

• Do not use if patient is allergic to acyclovir

400 mg IV or po qd

$4.86 (po)

$20.00 (IV)

• 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)

• Penicillin-resistant Pneumococcus

• May be used for acute bronchitis exacerbation or acute sinusitis

• 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

500 mg-750 mg IV q6-8h

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

$85.48-$125.28 (500-750 mg q6h)

• Hospital acquired infection

• Mixed intra-abdominal infection

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

• Hospital acquired infections after previous exposure to broad spectrum agents

• 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

• Usual recommended daily dose is 25 mg/kg in divided doses (see Section 7 for dosage adjustment in renal failure)

1 g IV q8h

$128.22

• 1 g q8h reserved for moderately sensitive organisms

300 mg po qd

$0.05

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

• Atypical mycobacteria, when sensitive

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

• Peripheral neuropathy (B6 deficiency- more common in malnourished). Give B6 (pyridoxine) 10-50 mg qd

200 mg capsules po bid x 3d then

200 mg po daily

$80.08 days 1,2,3, then

$10.40/day

$11.68/day oral soln

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

• Histoplasmosis; including chronic cavitary pulmonary disease and disseminated (non-meningeal, non-life threatening)

• For serious infections, start with 200 mg capsules po bid. CNS penetration is unreliable. Food increases absorption of itraconazole capsules but H2 blockers and antacids decrease absorption. Monitor therapy for other significant drug-drug interactions (see ketoconazole)

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

• May increase cyclosporine serum concentrations; combine cautiously!

100-200 mg oral solution swish & swallow 1X daily

$87.64/
1500 mg bottle

• Oropharyngeal Candidiasis

• Esophageal Candidiasis

• Aspergillosis

• 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

• Itraconazole remains secondary/refractory therapy in patients with Aspergillus infection if they cannot tolerate Amphotericin B due to poor renal function

200-400 mg po qd

$2.64-$5.28

• Mucocutaneous or oropharyngeal candidiasis

• Antacids, H2 receptor antagonists interfere with absorption

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

• Do not use when meningitis suspected due to poor CNS penetration

500 mg IV q8h

or 750 mg IV q12h

500-750 mg po tid

250 mg po qid (colitis)

$3.72

$3.72

$0.12-$0.18

$0.08

• 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)

• Amoebic dysentery and other Entamoeba histolytica infections (esp. liver abscesses - may require increased dose)

• 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)

• Metronidazole has limited activity against gram-positive anaerobes and no activity against gram-positive anaerobic cocci involving respiratory tract

• Prophylaxis for colorectal surgery

• Helicobacter pylori gastritis/ulcers in combination with bismuth subsalicylate and amoxicillin or tetracycline with or without ranitidine (Section 8, Appendix E)

2 g po X 1

$0.16

• Trichomoniasis vaginitis

1-2 g IV q4-6h

$11.04
(1 g q6h)

$22.56
(2 g q4h)

• Penicillin-resistant Staphylococcus aureus infection (methicillin sensitive)

• Also has activity against pneumococci and Streptococcus pyogenes

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

• Anaerobic Strep coverage is marginal

• Drug of choice for serious methicillin-sensitive Staph. aureus infection

50-100 mg bid

$0.42-$0.84

• Prophylaxis or treatment of UTI caused by enteric gram-negative bacteria or Enterococcus

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

• Chronic use associated with pulmonary fibrosis

• Use may cause hemolysis in pts. with G6PD deficiency

500,000 units/5 mL qid
swish & swallow

$0.44

• Mild oropharyngeal and esophageal candidiasis

• Severe refractory esophagitis requires treatment with ketoconazole, fluconazole, or amphotericin

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

Pen VK (generic)
250-500 mg po qid

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

$0.32-$0.40

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

• Actinomycosis

• Pasteurella multocida

• Syphilis

• Drug carries 1.7 mEq K+/MU drug. Potassium salt is commonly used, sodium salt may be used upon request (2 MU q4h PenGK provides over 20 mEq K+/day)

• Pneumococcal resistance may require alternate therapy, especially for CNS infection

300 mg-aerosolized once a month

4 mg/kg/d IV (usually 300 mg dose)

$2.64

$2.64

• Prophylaxis for Pneumocystis carinii

• Treatment of 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

• Sudden death can occur with rapid infusion

3.375 g IV q6h

$56.00

• 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

• Against Pseudomonas, combination therapy with an aminoglycoside is recommended

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

• When compared with clavulanic acid and sulbactam, tazobactam is apparently less likely to induce (derepress) production of type I §-lactamases by bacteria such as Pseudomonas, Enterobacter, Citrobacter, and Serratia which may lead to failure of therapy. However, if these §-lactamases are already present, tazobactam is no more active in inhibiting these enzymes than sulbactam or clavulanic acid

600-900 mg qd for MTB

300 mg bid-tid for S. aureus infection

$1.04-$1.56 (po)

$62.20-$93.30 (IV)

• 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

• Not to be used for endocarditis

• Discolors tears, urine, saliva (body fluids)

• Potent hepatic enzyme inducer (may increase drug metabolism)

• Infrequently causes cholestatic hepatitis

525 mg IV q8h

$266.40

• 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.

• Treatment of severe gram-positive infections in patients who are unable to tolerate therapy with active beta-lactams, cephalosporins, glycopeptides, or quinolones.

• 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

• Infuse over 30 min

3.1 g IV q4-6h

$48.72-$73.08

• 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

• For serious community-acquired pneumonia when aspiration is suspected

• Ticarcillin/Clavulanate provides broad spectrum coverage for Staph, Strep, anaerobes, and gram-negatives when used with aminoglycosides

• 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

• Provides 5.2 mEq/g Na+ (can add up to 80-100 mEq Na/day)

• Based on FMLH guidelines, ticarcillin/clavulanate is indicated for Bactrim-resistant Stenotrophomonas maltophilia and must be special-ordered

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

1 DS Tab po bid

$5.88-$17.64 (IV)

$0.12 (po)

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

• UTI's

• Bacterial bronchitis, otitis media, sinusitis

• Enteric bowel infections including shigellosis, typhoid fever, E. coli, Salmonella

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

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

• May cause photosensitivity

• Side effects:
Nausea, vomiting, hepatitis, leukopenia, thrombocytopenia, renal failure, hyperkalemia

1 SS Tab po q24-48h

$0.05-$0.10

• Prophylaxis for recurrent UTI’s in patients with normal urinary tract

2 DS Tabs po qid

$0.48

• PCP therapy

1 DS Tab po qd 3x/wk

$0.18/wk

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

• Pneumocystis carinii prophylaxis

1 g po tid x 7 d

500 mg po bid

500-1000 mg po qd

$12.78

$4.26

$2.13-$4.26

• Primary treatment for Herpes 1 and 2

• Herpes zoster

• Episodic genital Herpes

• Prophylaxis for genital Herpes

• 500 mg qd for chronic suppression

• See Section 8, Appendix F

• Same levels as IV acyclovir

• Switch to po as soon as possible

500 mg-1 g IV q12h

$5.39-$10.74

• Agent of choice for MRSA and MRSE

• Treatment of Enterococcus for penicillin-allergic patients

• Alternative agent for gram-positive infections/prophylaxis in patients with life-threatening beta-lactam allergy

• 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

• Combined with aminoglycoside for life threatening enterococcal infection (endocarditis, sepsis)

Vancomycin* oral solution

125 mg po q6h

$2.69

• C. difficile resistant to metronidazole

Disease

Likely Microbiology

Therapy (IV unless noted otherwise)

Comments

1.

Pneumonia

A.

Community acquired

Mycoplasma or Chlamydia

OR

Quinolone

Macrolide = Erythromycin, Clarithromycin, or Azithromycin

Quinolone = Gatifloxacin or Trovafloxacin

OR

Beta-lactam/Beta-lactamase inhibitor + (Macrolide or quinolone)

OR

Beta-lactam/Beta-lactamase inhibitor

B.

Hospital acquired (including aspiration)

Gram-negatives: E. coli, Enterobacter, Pseudomonas, Klebsiella

Piperacillin/tazobactam + tobramycin 

OR

Clindamycin + ciprofloxacin or
Ceftazidime or Imipenem +/- aminoglycoside

60% of nosocomial pneumonias are gram-negative in origin, 15% staph

Staphylococcus aureus

Nafcillin

If MRSA suspected, treat with vancomycin

Blastomycosis

Itraconazole (non-life threatening, non-meningeal)

Amphotericin B

Itraconazole requires acid pH for absorption. Avoid antacids, H2 blockers

Amphotericin should be reserved for life threatening or CNS disease

Histoplasmosis

Itraconazole (non-life-threatening, non-meningeal)

Amphotericin B

Amphotericin B is indicated for meningeal infections

Cryptococcus

Amphotericin B ± 5-Flucytosine

Amphotericin is the agent of choice for rapidly progressing life-threatening disease

Fluconazole is used for chronic suppression in HIV related disease

Candida albicans
superficial/mucosal

Fluconazole (po)

5-Flucytosine

Miconazole (topical)

Clotrimazole (topical)

Ketoconazole (topical or IV)

For Candida esophagitis, fluconazole is preferred agent

Flucytosine should not be used alone to treat Candida infections

Candida albicans
Deep seated, disseminated

Amphotericin B

Fluconazole

Amphotericin is the agent of choice for rapidly progressing life-threatening disease

Prophylaxis with fluconazole in high risk populations is experimental, and should be limited to short courses

Deep seated, disseminated non-albicans candidiasis, (Torulopsis glabrata, Candida krusei)

Amphotericin B

Fluconazole has relatively poor activity against these species

Candida lusetaniae

Fluconazole

Resistant to Amphotericin

3.

Gastrointestinal

A.

Cholecystitis

Coliforms and enterococci

Cefotetan

Piperacillin/tazobactam (or ampicillin/sulbactam) + Gentamicin

Cefotetan should be reserved for mild to moderate infections

B.

Cholangitis

Enterics

Enterococci

Anaerobes

Piperacillin/tazobactam (or ampicillin/sulbactam) + Gentamicin

C.

Diverticulitis

Enterics

Anaerobes

Cefotetan

Ceftazidime

Clindamycin + Ciprofloxacin

Piperacillin/tazobactam (or ampicillin/sulbactam) + Gentamicin

Cefotetan should be reserved for mild to moderate infections

D.

Intra-abdominal peritonitis or abscess

Enterics

Anaerobes

Enterococci

Piperacillin/tazobactam (or ampicillin/sulbactam) + Gentamicin

Ceftazidime

Ceftizoxime

Imipenem

Clindamycin + Ciprofloxacin

The gram-negative activity of ampicillin/sulbactam and gentamicin may be less than that of the other combinations listed

Cefotetan should be reserved for mild to moderate infections

4.

Genitourinary

A.

Cystitis

E. coli

Staphylococcus saprophyticus

TMP/SMX

Cephalexin

Nitrofurantoin

Three day course; may resolve spontaneously without therapy.

B.

Pyelonephritis

Oral therapy for mild disease is appropriate

E. coli, Proteus

TMP/SMX

Aminoglycosides

Ceftriaxone

Ciprofloxacin (oral)

Enterococcus is an uncommon pathogen and can be identified on gram stain

Other gram-negatives including

E. coli

Pseudomonas

Enterococcus

Ampicillin + gentamicin or tobramycin

Piperacillin/tazobactam + tobramycin

Ciprofloxacin ± ampicillin

These drug combinations are for empiric coverage for Pseudomonas and Enterococcus

Patients who are septic require double gram-negative coverage

C.

Prostatitis

a.

Neisseria gonorrhoeae

Chlamydia

Ceftriaxone 125 mg IM in a single dose
OR
Ciprofloxacin 500 mg po in a single dose
plus
Doxycycline 100 mg po bid X 7 days

Enterobacteraciae

TMP/SMX or ciprofloxacin

b.

Enterobacteraciae

Enterococcus

TMP/SMX X 3 mos or
ciprofloxacin X 4 wks

If treatment failure, rule out prostatic calculi

5.

Skin/Soft tissue

A.

Cellulitis (non-diabetic)

Streptococcus

Staphylococcus

Nafcillin (oral dicloxacillin)

Clindamycin or cefazolin in non-anaphylactic penicillin allergy

For known Streptococcal infection, penicillin G is drug of choice

B.

Decubitus ulcer / Diabetic ulcer

Staphylococcus

Streptococcus

Gram-negatives

Anaerobes

Amoxicillin/clavulanate (po) or ampicillin/sulbactam (IV)

Clindamycin + ciprofloxacin (or ceftazidime)

Ceftizoxime

Piperacillin/tazobactam ± tobramycin

Amoxicillin/clavulanate or ampicillin/sulbactam does not cover Pseudomonas

Surgical consultation should be part of routine management

C.

Necrotizing fasciitis

Streptococcus

Staphylococcus

Gram-negative aerobes

Anaerobes

Penicillin + clindamycin + aminoglycoside (or ciprofloxacin)

Ampicillin/sulbactam + aminoglycoside (or ciprofloxacin)

Imipenem

Necrotizing fasciitis may be due to mixed flora, including anaerobes (Clostridia perfringens). Broad spectrum coverage may be required. Primary emphasis is on surgical treatment

D.

Human/animal bites

Pasteurella multocida

Streptococcus

Staphylococcus

Ampicillin/sulbactam IV or amoxicillin/clavulanate po

Spectrum includes Pasteurella multocida, especially in cat bites

Do not use oral first-generation cephalosporins for Pasteurella

6.

Bone & Joint

A.

Osteomyelitis

a.

Staphylococcus aureus

Gram-negatives (less frequent)

Nafcillin + rifampin

Nafcillin ± aminoglycoside

Establish bacteriology with appropriate cultures whenever possible

Gram-negative osteomyelitis may occur in the setting of underlying gastrointestinal or genito-urinary tract infection

Ceftriaxone therapy may allow outpatient parenteral therapy

Cefazolin or clindamycin may be options for penicillin allergic patients

b.

Gram-negatives

Gram-positives

Anaerobes

Piperacillin/tazobactam or
Ampicillin/sulbactam + aminoglycoside

Establish bacteriology with appropriate deep cultures (not superficial swabs) whenever possible

Adequate surgical debridement is critical to overall success

c.

See comments

Establishing microbiology is primary

B.

Septic Arthritis

a.

Neisseria gonorrhoeae

Gonococcus

Ceftriaxone 1 gm IV q24h (single dose)
OR
Ciprofloxacin 500 mg IV q12h (single doses)
plus
Doxycycline 100 mg po bid X 7 days

Continue IV therapy for 24 h after improvement
Change to ciprofloxacin 400 mg po bid
plus
doxycycline 100 mg po bid X 7 d

b.

Staphylococcus aureus

Group A Streptococcus

Gram-negative aerobes

Nafcillin + gentamicin or
Nafcillin + po ciprofloxacin

Microbiology needed

Orthopedic consultation required

c.

Staphylococcus epidermidis

Staphylococcus aureus

Gram-negatives

Vancomycin + 3rd generation cephalosporin
(+ rifampin if S. aureus)

Orthopedic consultation required

7.

CNS Infections

A.

3rd generation cephalosporins are empiric drug of choice due to concerns of moderately nonsusceptible Pneumococcus

(Penicillin may be used if organism is penicillin-susceptible)

a.

Streptococcus pneumoniae

N. meningitis

Haemophilus influenza (1-3%)

Ceftriaxone

Antimicrobial therapy should be initiated within
30-60 min of presentation

Penicillin-allergic patients should receive chloramphenicol

b.

Gram-negative aerobes

Strep. pneumoniae

Listeria

Ampicillin + ceftriaxone

c.

Staphylococcus epidermidis

MRSA

Gram-negative aerobes

Vancomycin & ceftazidime

Infection related to catheters may require removal

d.

Community acquired pathogens

Listeria monocytogenes

Fungal

Mycobacterial

Ampicillin + ceftriaxone

Initial gram stain may provide clues for likely microbiology

Need to rule out Cryptococcus or other opportunistic infections

B.

Encephalitis

Herpes simplex

Enteroviruses

Coxsackie

Acyclovir

No therapy

No therapy

Early initiation of acyclovir is important for all patients suspected to have viral encephalitis

Bacterial cerebritis expected if contiguous focus, i.e., mastoiditis, sinusitis, otitis media

Legionella or mycoplasma may present with encephalopathy

Herpes simplex

Enteroviruses

Coxsackie

Cryptococcus

Toxoplasmosis

Listeria

Acyclovir

No therapy

No therapy

Amphotericin B

Pyrimethamine + sulfadiazine

Ampicillin

Need to make specific diagnosis to rule out Cryptococcus or toxoplasmosis before empiric therapy

C.

Brain Abscess

a.


b.

Strep. species

Anaerobes

Enterobacteraciae

Ceftriaxone & metronidazole +/– Penicillin G

If endocarditis suspected, nafcillin should be added instead of Pen G for Staph. aureus

8.

Head and Neck

A.

Sinusitis

Strep. pneumoniae

H. influenzae

Moraxella catarrhalis

TMP/SMX po

Cefuroxime po

Amoxicillin/clavulanate po

Need to consider fungal etiology in neutropenic, transplant, or IDDM patients

Above plus anaerobes plus staph

Amoxicillin/clavulanate po

Chronic sinusitis requires surgical drainage

Gram-negative aerobes

Staph. aureus

Anaerobes

See pneumonia treatment

Nasotracheal intubation and nasogastric tubes may increase risk of hospital-acquired sinusitis

B.

Pharyngitis

Group A Strep.

Penicillin po

Mononucleosis may present with exudative pharyngitis

Coxsackie
Herpes simplex virus

Acyclovir (herpes simplex only)

Mononucleosis

Diphtheria

No treatment

Erythromycin

Endotracheal intubation for maintenance of airway

Steroids for impending airway obstruction

C.

Epiglottitis

Group A Strep. or H. flu

Cefuroxime or ceftriaxone

Early elective endotracheal intubation

D.

Periorbital/Orbital Cellulitis

Streptococcus species

Staphylococcus

Haemophilus influenza (adults)

Anaerobes (if related to dental procedures)

Cefuroxime

Ampicillin/sulbactam

R/O dental or sinus focus

If immunosuppressed, fungal etiology must be considered

E.

Otitis media

See acute sinusitis

See acute sinusitis

Consider ENT pathology in adults with recurrent otitis media

F.

Mastoiditis

Strep. pneumoniae

Strep. pyrogenes

Staph. aureus

Dicloxacillin

Cefuroxime

Surgery for abscess or osteomyelitis

Polymicrobial, including Pseudomonas

Staph. aureus and anaerobes

Tobramycin + Piperacillin/tazobactam

Surgery is required

9.

Sexually Transmitted Diseases (STD )

A.

Urethritis

Cervicitis

Prostatitis

N. gonorrhoeae

Chlamydia

Ceftriaxone 125 mg IM in a single dose

OR
Ciprofloxacin 500 mg po in a single dose
plus
Doxycycline 100 mg po bid X 7 days

OR (another alternative is)
Ciprofloxacin 500 mg po in a single dose
plus
Azithromycin 1 g po in a single dose

Disseminated N. gonorrhoeae

Ceftriaxone 1 gm route X 24-48h then switch to ciprofloxacin dose freq route for 7 days

B.

PID

N. gonorrhoeae

Chlamydia

Bacteroides

Enteric gram-negatives

Outpatient - Ceftriaxone 250 mg IM + doxycycline dose po bid X 14 days

Inpatient - Cefotetan 2 gm IV q12h + doxycycline dose po bid X 14 days

Candidates for outpatient–temp <38ˇC, WBC <11,000, no indication of peritonitis

C.

Genital lesions

a.

HSV

Acyclovir, Valacyclovir

b.

Haemophilus ducreyi

Ceftriaxone 250 mg IM single dose
or
Erythromycin 500 mg po qd X 7 days
or
Azithromycin 1 gm po X 1 single dose

c.

Chlamydia

Doxycycline 100 mg po bid X 21 days

Rare disease in USA

d.

HIV patients and pregnant patients with syphilis should have infectious disease consult

Benzathine PCN 2.4 mu IM single dose

Benzathine PCN 2.4 mu IM X 3 doses

Penicillin G - 12 mu-24 mu IM qd X 10-14 days (2-4 mu q4 hr)