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Table 2. Recommended Empiric Regimens to Reduce Fluoroquinolone

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Table 2. Recommended Empiric Regimens to Reduce Fluoroquinolone Table 2. Recommended empiric regimens to reduce fluoroquinolone exposure – B4/6 Diagnosis Previous Therapy Comments Proposed Empiric Therapy Step Down Therapy* Base on final culture results Cystitis/Urinary tract Nitrofurantoin Ciprofloxacin OR Nitrofurantoin infection (non-renal Fosfomycin Levofloxacin Fosfomycin transplant) Cefpodoxime Cefpodoxime No concern for MDRO Ceftriaxone Base on final culture results Ciprofloxacin Concern for extended spectrum Cefepime OR Piperacillin/tazobactam Positive urine culture in GNRs Ceftriaxone susceptibility predicts the deceased renal ADD Vancomycin IF activity for cefpodoxime. transplant donor concern for Gram For patients with immediate IgE- Tobramycin positive organisms mediated or severe allergy Aztreonam** If no oral options, page 3333 for fluoroquinolone approval Base on final culture results No empiric antibiotics. Await final Ceftriaxone susceptibility predicts ASYMPTOMATIC <3 months post culture results to start therapy. activity for cefpodoxime. RENAL transplant Provide 5-7 day therapy course. If no oral options, page 3333 for fluoroquinolone approval Cystitis in renal transplant Ciprofloxacin ASYMPTOMATIC >3 months post No treatment, unless associated rise patient N/A RENAL transplant in creatinine Nonsystemic therapies Continuation of empiric, non-systemic -nitrofurantoin if GFR >40 mL/min SYMPTOMS PRESENT therapies (left) or based on final -fosfomycin if GFR <40 mL/min or culture results concern for drug resistant isolates No concern for MDRO Ceftriaxone Base on final culture results Ciprofloxacin Concern for extended spectrum Ceftriaxone susceptibility predicts Pyelonephritis in renal Cefepime OR Piperacillin/tazobactam ADD Vancomycin IF GNRs activity for cefpodoxime. transplant patient concern for Gram - Tobramycin while awaiting positive organisms For patients with immediate IgE- If no oral options, page 3333 for organism identification mediated or severe allergy fluoroquinolone approval - Aztreonam** Reference: Prevention, Diagnosis, and Treatment of Clostridium difficile Infection – Adult/Pediatric – Inpatient/Ambulatory Guideline Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: [email protected] Vermeulen, [email protected] Last Revised: 06/2016 Diagnosis Previous Therapy Comments Proposed Empiric Therapy Step Down Therapy* Piperacillin/tazobactam OR Cefepime Cefpodoxime OR Cefuroxime Cholangitis in the Ciprofloxacin PLUS PLUS Metronidazole PLUS Amoxicillin (Enterococcus) historical liver transplant Amoxicillin OR For patients with immediate IgE- Vancomycin (10-20) PLUS If no oral options, page 3333 for recipient Moxifloxacin mediated or severe allergy Tobramycin OR Aztreonam** fluoroquinolone approval Ciprofloxacin AND Base on final culture results, some No risk factors for MDRO Ceftriaxone AND metronidazole metronidazole examples of potential oral options Vancomycin (15-20) PLUS -Cefpodoxime OR Cefuroxime Intraabdominal Piperacillin/tazobactam With risk factors for MDRO PLUS Metronidazole infection – Other Vancomycin (15-20) PLUS Vancomycin PLUS -Amoxicillin/clavulanic acid community or Piperacillin/tazobac Meropenem healthcare associated tam AND If final culture results require FQ Ciprofloxacin For patients with immediate IgE- Vancomycin (15-20) PLUS step down (Pseudomonas, etc) mediated or severe allergy Aztreonam PLUS Metronidazole single oral dose prior to discharge is acceptable Ceftriaxone PLUS Azithromycin Cefpodoxime OR Cefuroxime No risk factors for MDRO Community-acquired Moxifloxacin OR Ceftriaxone PLUS Doxycycline PLUS Azithromycin OR Doxycycline Pneumonia Levofloxacin For patients with immediate IgE- Vancomycin PLUS aztreonam** If no oral options, page 3333 for mediated or severe allergy fluoroquinolone approval Double coverage for Pseudomonas Vancomycin (15-20) PLUS With risk factors for MDRO is not required in clinically stable, Cefepime general ward patient Vancomycin PLUS Healthcare associated Pending transfer to higher care Cefepime AND If patient in septic shock ADD Tobramycin Pneumonia level Ciprofloxacin For patients with immediate IgE- Vancomycin (15-20) PLUS If no oral options, page 3333 for mediated or severe allergy Aztreonam** fluoroquinolone approval If concern for atypical bacteria ADD Azithromycin * Base step down therapy on culture results, if no oral step down therapy except fluoroquinolones exist, please page 3333 for approval or other options ** Empiric aztreonam use is allowed without ID approval for 72 hours. Further therapy with aztreonam will require approval via 3333 pager or ID consult If severe or immediate IgE-mediated beta-lactam allergy, please page 3333 for alternative options Reference: Prevention, Diagnosis, and Treatment of Clostridium difficile Infection – Adult/Pediatric – Inpatient/Ambulatory Guideline Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: [email protected] Vermeulen, [email protected] Last Revised: 06/2016 Recommended Empiric Regimens to Reduce Fluoroquinolone Exposure – Adult – Inpatient –Table Collateral Document/Guideline: Prevention, Diagnosis, and Treatment of Clostridium difficile Infection – Pediatric/Adult – Inpatient/Ambulatory Clinical Practice Guideline Contact Information: Name: Lucas Schulz, PharmD, BCPS AQ-ID - Pharmacy Phone Number: (608) 890-8617 Email Address: [email protected] Authors: Lucas Schulz, PharmD, BCPS AQ-ID – Pharmacy Barry Fox, MD – Infectious Disease Coordinating Team Members: Alex Lepak, MD – Infectious Disease Nasia Safdar, MD – Infectious Disease Dave Andes, MD – Infectious Diseases Didier Mandelbrot, MD – Nephrology Dixon Kaufman, MD – Transplant Surgery Ann O’Rourke, MD – Surgical Critical Care Pierre Kory, MD – Critical Care Medicine Chris Green, MD – Administration Philip Trapskin, PharmD – Drug Policy Program Mei Jorgenson, PharmD – Transplant Pharmacy Jeff Fish, PharmD – Critical Care Pharmacy Joshua Vanderloo, PharmD – Drug Policy Program Review Individuals/Bodies: Clostridium difficile Infection Reduction Workgroup Antimicrobial Use Subcommittee, June 2016 Committee Approvals/Dates: Pharmacy &Therapeutics Committee, June 2016 Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: [email protected] Vermeulen, [email protected] Last Revised: 06/2016.
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