Antibiotic selection guide

SINAI ANTIBIOTIC SELECTION GUIDE
DISCLAIMER: Clinical recommendations in this guide are offered as general empiric therapy based on nationally accepted guidelines and adjusted according to Sinai antibiogram. Clinical judgement and cultures results / susceptibilities should always guide the physician in the selection, dosing, and duration of antimicrobial therapy individual patients. All antimicrobial dosing is for patients with normal renal and hepatic function. Please use the Sinai nomogram for vancomycin dosing. All aminoglycosides will be dosed by the TDM consult service. EMPIRIC ANTIBIOTICS
DURATION OF
PATHOGENS
Bacterial
Meningitis
If age >50 / alcoholism / immunocompromised, ADD: Chloramphenicol 12.5mg/kg IV Q6h (max 4g/day) PLUS Bactrim Neutropenic
Zosyn® 3.375gm IV Q4h PLUS Aminoglycoside (gentamicin / ** Vancomycin (consider adding if mucositis, skin / catheter site infection, history of MRSA colonization OR clinical deterioration / persistent fever despite empiric antibiotics after 1-2 days) ** If persistent fever after 5 days, add Caspofungin 70mg IV x 1, then 50mg IV Qday Ceftriaxone 1gm IV Q24h PLUS Azithromycin 500mg Q24h or Unasyn® 3gm IV Q6h PLUS Azithromycin 500mg Q24h Ceftriaxone 2gm IV Q24h or Unasyn® 3gm IV Q6h PLUS Moxifloxacin 400mg Q24h or Azithromycin 500mg Q24h PCN allergy – Moxifloxacin PLUS Aztreonam 2gm IV Q8h Zosyn® 3.375gm IV Q4h or Cefepime 2gm IV Q12h PLUS Aminoglycoside (gentamicin / tobramycin) PLUS Moxifloxacin 400mg Q24h PCN allergy – substitute Aztreonam 2gm IV Q8h for Zosyn® or Cefepime If suspecting community-acquired MRSA necrotizing pneumonia: Consider Clindamycin 900mg IV Q8h or Linezolid 600mg Q12h Early onset (<48 hours) / No known risk factors for MDRP: Moxifloxacin 400mg Q24h or Ceftriaxone 2gm IV Q24h or Unasyn® Acinetobacter spp. Late onset (>48 hours) / Risk factors for MDRP: Zosyn® 3.375gm IV Q4h or Cefepime 2gm Q8h or Imipenem 1gm GPC = gram-positive cocci; GNC = gram-negative cocci; GPB = gram-positive bacilli; GNB = gram-negative bacilli; ESBL = Extended-Spectrum -Lactamases; MDRP = Multi-drug Resistant Pathogens Cellulitis
Cefazolin 1gm IV Q8h or Nafcillin 1gm IV Q4h Oral therapy – Cephalexin 500mg QID or Dicloxacillin 500mg QID PCN allergy / suspecting community-acquired MRSA: Clindamycin 600mg IV Q8h or 300mg PO QID Bactrim 2.5mg/kg IV Q8h or DS 2 tabs PO BID + Rifampin 300mg If facial cellulitis or signs / sx of sepsis present: Diabetic Foot
**No antibiotics for clinically uninfected ulcerations** Infections
Unasyn® 3gm IV Q6h / Augmentin® 875mg PO TID PLUS Bactrim 2.5mg/kg IV Q8h / Bactrim DS 2 PO BID Clindamycin 600mg IV Q8h / Clindamycin 300mg PO QID PLUS Ciprofloxacin 400mg IV Q8h / 750mg PO BID Zosyn® 3.375gm IV Q6h PLUS vancomycin PCN allergy – aztreonam 1-2gm IV Q8h PLUS Metronidazole 500mg Q8h PLUS vancomycin Abdominal
Cefazolin 1-2gm IV Q8h + Metronidazole 500mg Q8h Ciprofloxacin 400mg IV Q12h + Metronidazole 500mg Q8h Zosyn® 3.375gm IV Q6h Aminoglycoside + Metronidazole 500mg Q8h Aztreonam 1-2gm Q8h + Metronidazole 500mg Q8h Clostridium
difficile –
Mild – moderate disease: metronidazole 500mg IV/PO Q8h Associated
Diarrhea
First relapse: Repeat treatment as in initial episode above Second relapse: Tapering and pulsed oral vancomycin: Vancomycin 125mg PO QID x 14 days, followed by rifaximin 400mg PO BID x 14 days Cefazolin 1gm IV Q8h or cephalexin 500mg PO QID ** If GPC in pairs/chains seen on gram stain, consider adding ampicillin GPC = gram-positive cocci; GNC = gram-negative cocci; GPB = gram-positive bacilli; GNB = gram-negative bacilli; ESBL = Extended-Spectrum -Lactamases; MDRP = Multi-drug Resistant Pathogens

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