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Antimicrobial Guide

Antimicrobial Guide

Empiric Therapy & Treatment Recommendations For Adult Patients Table of Contents

A. Introduction...... 1

B. Guidelines for the Treatment of Various in Adults

Central Nervous System (CNS) • Meningitis...... 2 Clostridium difficile (CDI) ...... 4 Extended Spectrum Beta-Lactamases Infections (ESBL)...... 6 Febrile Neutropenia ...... 6 Fungal Infections...... 7 Influenza...... 9 Intra-abdominal Infections ...... 10 Lyme Disease...... 10 Proton Pump Inhibitor (PPI) Use...... 11 Respiratory Tract - Upper and Lower • Acute Bacterial Sinusitis...... 12 • Acute Pharyngitis...... 13 • Chronic Obstructive Pulmonary Disease (COPD)...... 14 Exacerbation...... 14 • Pneumonia...... 15 Sepsis...... 17 Sexually Transmitted Infections (STI)...... 18 Skin and Soft Tissue • Skin and Soft Tissue Infections (SSTI)...... 22 • Diabetic Foot Infections...... 24 Surgical Decolonization and Prophylaxis ...... 26 Urinary Tract • Catheter-Associated (CA-UTI)...... 29 • Non-Catheter Associated Urinary Tract Infection/Cystitis...... 30 • Prostatitis...... 31

C. Immunizations • Pneumococcal Vaccine ...... 32

D. Antibiogram...... 36 Table of Contents

E. Guidelines for Restricted Antimicrobials ...... 38 • Ceftaroline (Teflaro®)...... 39 • / (Avycaz®) ...... 40 • Ceftolozane/ (Zerbaxa®)...... 41 • (Dalvance®) ...... 42 • (Cubicin®) ...... 43 • (Invanz®)...... 44 • Fidaxomicin (Dificid®)...... 45 • (Monurol®)...... 46 • (Zyvox®) ...... 47 • (Orbactiv®)...... 48 • B...... 49 • (Polymyxin E)...... 50 • Tedizolid (Sivextro®)...... 51 • Tigecycline (Tygacil®)...... 52 Antifungals • lipid complex (L-AmB)(AmBisome®)...... 53 • Caspofungin (Cancidas ®)...... 54 • Isavuconazonium sulfate (Cresemba®) ...... 55 • Voriconazole (VFend®)...... 56

F. Dosing and Monitoring in Adult Patients...... 57

G. Aminoglycoside High Dose Once Daily (HDOD) and Monitoring in Adult Patients...... 61

H. Antimicrobial Dosing for Adult Patients Based on Renal ...... 63 Function

I. Antimicrobial Duration of Therapy...... 68

J. IV to PO Step-Down Guidelines...... 71

K. Infection Control • Twelve Steps to Prevent ...... 72 • Contact Precautions for Infection Control...... 72

L. Pharmacokinetic Equations/Calculations ...... 73 IntroductionIntroduction Antimicrobial resistance is globally recognized as one of the greatest healthcare threats. Infections associated with multi-drug resistant organisms and limited antimicrobial choices have placed an immense burden upon clinicians. In order to preserve currently available antimicrobials we must use them appropriately; ensuring that each patient is on the right drug, route, dose, and duration. The pathways and tables in this booklet are based on national guidelines and consensus statements, expert opinions from the Infectious Diseases team (pharmacy and medicine) and microbiology data from the microbiology laboratory. DISCLAIMER: The opinions expressed in this publication reflect those of the authors to the best of their ability. However, the authors make no warranty regarding the contents of the publication. The guidelines described herein are general and may not apply to a specific patient. The recommendations given in this guide are meant to serve as treatment guidelines. They should not replace clinical judgment or Infectious Diseases consultation when indicated. The recommendations may not be appropriate at other settings. We have attempted to verify that all information is correct but because of ongoing research, recommendations may change. Please let us know if there are sections that you think could be improved or if there is more information you would like to see included. Our goal is for the Antimicrobial Stewardship Program to be a useful service in optimizing antibiotic use and patient outcomes. We welcome your thoughts and comments. Thank you, Kerry L. LaPlante, PharmD., FCCP Professor of Pharmacy, University of Rhode Island, Kingston, RI Adjunct Professor of Medicine, Brown University, Providence, RI Director of the Rhode Island Infectious Diseases Research Program (RIID) and Infectious Diseases Pharmacotherapy Specialist, Providence Veterans Medical Center, RI [email protected] or [email protected].

The following people reviewed ALL the treatment guidelines: Melissa Gaitanis, MD (Chief of Infectious Diseases) Kerry L. LaPlante, PharmD, FCCP (Infectious Diseases) Haley Morrill, PharmD (Infectious Diseases) The following people served as section/topic reviewers: Tanya Ali, MD (Infectious Diseases), Patricia Cristofaro, MD (Infectious Diseases), Cheston Cunha, MD (Infectious Diseases), Megan Luther, PharmD, Kevin McConeghy, PharmD, MS, BCPS, Jacob Morton, PharmD, MBA, BCPS, Tristan T. Timbrook, PharmD, MBA, BCPS A special thank you for assistance with the Antimicrobial Guidebook Kayla Chouinard, Jaclyn Cusumano, Channel DeLeon, Jillian Dougherty, Anthony Harrison, Sarah Harrison, Brittany Julich, Elizabeth Koczera, Amanda Maione, Nicholas Mercuro, Rachel Morgans, Lindsey Williamson Editorial and formatting assistance Jennifer DeAngelis, Graphic Design, Kathie McKinstry, Graphic Design, Diane M. Parente, PharmD (Infectious Diseases)

PAGE 1 CentralCentral Nervous Nervous System: System: Meningitis Meningitis

ACUTE BACTERIAL MENINGITIS Clinical Diagnostics and Preferred Regimen Alternative Regimen Syndrome Clinical Considerations Age < 50 Ceftriaxone 2 gm IV PCN allergy • Consult Infectious Q12H (anaphylaxis): Diseases Most commonly AND Vancomycin 15 mg/kg IV • Obtain lumbar isolated Vancomycin 15 mg/kg IV AND puncture and blood organisms: AND 400 mg IV cultures prior to • S. pneumoniae Dexamethasone Q24H starting therapy • N. meningitidis 0.15 mg/kg IV AND • Patients with the • H . influenzae Q6H given 10 to 20 Dexamethasone following conditions minutes before the first 0.15 mg/kg IV should receive head dose of antimicrobial Q6H given 10 to 20 CT prior to lumbar therapy and continue minutes before the first puncture: for 4 days for dose of antimicrobial - Immuno- pneumococcal therapy and continue compromised (HIV) meningitis for 4 days for - History of CNS (discontinue for all other pneumococcal lesion, stroke or microorganisms) meningitis focal infection (discontinue for all other - New onset seizure microorganisms) - Papilledema - Abnormal level of PCN allergy Age ≥ 50 2 gm IV consciousness (anaphylaxis): Q12H - Focal neurologic Most commonly AND Vancomycin IV 15 mg/kg deficit Vancomycin 15 mg/kg IV AND isolated • Typical CSF findings in organisms: AND Moxifloxacin 400 mg IV bacterial meningitis 2 gm IV Q4H Q24H S. pneumoniae - Cloudy CSF • AND AND • N. meningitidis - Glucose < 40 mg/dL Dexamethasone 0.15 SMX/TMP 5 mg/kg IV • H. influenzae OR <50% serum • L. monocytogenes mg/kg IV Q6H - Protein 100-500 • Aerobic gram Q6H given 10 to 20 AND - WBC 1000-5000 before negative bacilli minutes the first Dexamethasone 0.15 - > 90% PMNs dose of antimicrobial mg/kg IV • Narrow therapy therapy and continue Q6H given 10 to 20 based on CSF culture before for 4 days for minutes the first results pneumococcal dose of antimicrobial • If CSF culture meningitis therapy and continue negative, consult ID (discontinue for all other for 4 days for • Repeat lumbar microorganisms) pneumococcal puncture if no meningitis improvement in 48 (discontinue for all other hours and consider microorganisms) viral panel

CNS= central nervous system; CSF= cerebral spinal fluid; CT= computed tomography; H= hour(s); HIV= human immunodeficiency virus; ID= infectious diseases; IV= intravenous; PCN= ; PMNs= poly morphonuclear cells; Q= every; SMX/TMP= /; WBC= white blood cell

PAGE 2 Central Nervous System: Meningitis CentralCentral NervousA SEPTICNervous/ VIRAL System:/OTHER System:M ENINGITISMeningitisAND MeningitisHERPES SIMPLEX TYPE 2 Diagnostics and Clinical Clinical SyndromeASEPTIC/ VIRAL/OTHERPreferredMENINGITISRegimenAND HERPES SIMPLEX TYPE 2 Considerations Diagnostics and Clinical Clinical Syndrome Preferred Regimen Aseptic/Viral/Other Supportive care • ConsultConsiderations Infectious Diseases • Respiratory viruses • Send CSF and order: Enteroviruses (90%) If Lyme Suspected: Aseptic• /Viral/Other Supportive care • Consult- Viral Infectious culture Diseases • RespiratoryArboviruses viruses Ceftriaxone 2 gm IV Q24H • Send- CSFHSV andPCR order: • EnterovirusesWest Nile Virus(90%) If Lyme Suspected: • - ViralEnteroviral culturePCR • ArbovirusesEpstein Barr Virus Ceftriaxone 2 gm IV Q24H • - HSVLyme PCR Antibody (IgG index, • WestLyme Nile Virus • - Enteroviralrequires simultaneousPCR • EpsteinSyphilis Barr Virus • - Lymeserum) Antibody (IgG index, Lyme • - requiresVDRL simultaneous Syphilis • • Typicalserum) CSF findings in viral meningitis- VDRL • Typical- Clear CSF CSFfindings in viral meningitis- Glucose 30-70 mg/dL - ClearProtein CSF 30-150 Herpes Simplex Type 2 Acyclovir 10 mg/kg* IV Q8H - GlucoseWBC 100 30-1000-70 mg/dL Treat for 7 to 10 days - Protein< 90% PMNs, 30-150 increased Herpes Simplex Type 2 Acyclovir 10 mg/kg* IV Q8H - WBClymphocytes 100-1000 Treat for 7 to 10 days - < 90% PMNs, increased CSF= cerebral spinal fluid; H= hour(s); HSV= Herpes Simplex Virus; IV= intravenous; LP= lumbar puncture;lymphocytes PCR= Polymerase Chain Reaction; PMNs= poly morphonuclear cells; Q= every; VDRL= Veneral Disease Research Laboratory Test; WBC= white blood cell

*CSF= Acyclovir cerebral mg/kg spinal dosing fluid; based H= hour(s); on ideal HSV= body Herpes weight. Simplex Virus; IV= intravenous; LP= lumbar puncture; PCR= Polymerase Chain Reaction; PMNs= poly morphonuclear cells; Q= every; VDRL= Veneral Disease Research Laboratory Test; WBC= white blood cell NOTE: If dexamethasone or imaging studies (LP or CT) is not immediately available DO NOT delay administration of antibiotics.* Acyclovir mg/kg dosing based on ideal body weight.

NOTE: IfDosing dexamethasone based on normal or imaging renal studies function. (LP Referor CT) to is Tablenot immediately of Contents available for section DO on NOT Vancomycin delay administrationDosing and Monitoringof inantibiotics. Adult Patients and Antimicrobial Dosing for Adult Patients Based on Renal Function NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients and Antimicrobial Dosing for Adult Patients Based on Renal Function

References: 1. Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267-84. References: 1. Tunkel AR, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004 Nov 1;39(9):1267PAGE-84. 3 ClostridiumClostridium difficile difficile Infec2on Infection (CDI) (CDI)

• Stop anIbioIcs that are no longer indicated, especially broad-­‐spectrum anIbioIcs (fluoroquinolones, clindamycin, -­‐tazobactam, ) as they increase the risk for CDI • Stop use of any anI-­‐diarrheal/anIperistalIc agents • Consider disconInuaIon of proton-­‐pump inhibitors (PPIs) • If high clinical suspicion of CDI iniIate anIbioIc therapy before laboratory confirmaIon

INITIAL PISODE E

Clinical and Clinical Suppor4ve Clinical Recommended Regimens Therapeu4c Classifica4on Data Considera4ons

Ini4al episode • Diarrhea (passage Vancomycin* 125 mg PO Q6H Ensure loose stools Mild or of ≥ 3 unformed for 10-­‐14 days are not a result of Moderate stools in ≤ 24H) laxaIve AND • WBC < 15,000 cells/ µL AND • SCr < 1.5 Imes the premorbid level

Severe • Diarrhea Vancomycin 125 mg PO Q6H for Consult ID and AND 10-­‐14 days Surgery • WBC ≥ 15,000 cells/ µL Start suppor4ve OR care as needed: • SCr ≥ 1.5 Imes the • IV fluid premorbid level resuscitaIon Severe criteria PLUS ≥ 1 • Electrolyte Complicated If no complete ileus: replacement Severe of the following: Oral vancomycin 500 mg PO Q6H • Hypotension OR via NG tube • Shock AND • Toxic Megacolon if micro perforaIon is suspected • PerforaIon 500 mg IV Q8H • Ileus If complete ileus: Add vancomycin retenIon enema 500 mg in 500 mL NS Q6H

Treatment duraIon: 14 days

CDI= Clostridium difficile InfecIon; H= hour(s); ID= InfecIous Diseases; IV= intravenous; NG= nasogastric; NS= normal saline; PO= by mouth; PPI= proton pump inhibitor; Q= every; SCr= Serum CreaInine; WBC= white blood cell

* This recommendaIon is based on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole

PAGE 4 Clostridium difficile Infec2on (CDI) Clostridium difficile Infec2on (CDI) Clostridium difficileRECURRENT Infection PISODES E (CDI) RECURRENT PISODES E No. of Recurrences Recommended Regimens No. of Recurrences Recommended Regimens 1st Recurrence Vancomycin* 125 mg PO Q6H for 10-­‐14 days 1st Recurrence Vancomycin* 125 mg PO Q6H for 10-­‐14 days 2nd Recurrence Consult ID for tailoring anIbioIc therapy. Oral vancomycin tapered over 6 2nd Recurrence Consult weeks and/or ID for pulse tailoring dosing anIbioIc therapy. Oral vancomycin tapered over 6 weeks Vancomycin and/or Taper pulse Regimen: dosing Vancomycin 125 mg PO Taper Q6H Regimen: for 14 days 125 mg PO Q6H Q12H for 14 days for 7 125 mg PO PO once Q12H daily for 7 days for 7 days 125 mg PO every once daily other for 7 days day for 8 days 125 mg PO every 3 days for 15 days 125 mg PO every other day for 8 days 125 If Severe mg : Consider PO every Fidaxomicin 3 days 200 for 15 days mg PO Q12H (ID Restricted)

≥ 3 recurrences If Consult Severe : ID Consider team Fidaxomicin 200 mg PO Q12H (ID Restricted) 2 ≥ 3 recurrences Consult • Possible ID referral team for fecal microbiota replacement therapy • Possible Consider referral restarIng for vancomycin fecal microbiota taper OR Fidaxomicin replacement 200 therapy2 mg PO Q12H 3,4 • (ID Consider Restricted) restarIng vancomycin taper OR Fidaxomicin 200 mg PO Q12H (ID Restricted)3,4 RISK FACTORS FOR CDI RISK FACTORS FOR CDI • ≥ 64 years of age • Exposure to CDI (household family member with CDI) • ≥ Exposure 64 years to of age anIbioIcs in previous 90 • Exposure Long-­‐term to care CDI facility (household or nursing family home resident member with CDI) • days Exposure to anIbioIcs in previous 90 • Long-­‐term Gastric acid care reducing facility agent or nursing (proton-­‐pump home resident inhibitors) • days HospitalizaIon in previous 30 days • Gastric Tube feedings acid reducing agent (proton-­‐pump inhibitors) • HospitalizaIon Recent GI surgery in previous 30 days • Tube feedings • Recent GI surgery INFECTION CONTROL INFECTION CONTROL • RouIne screening for C. difficile in hospitalized paIents without diarrhea is not recommended • RouIne AsymptomaIc screening carriers for C. difficile should in not hospitalized be treated paIents without diarrhea is not recommended • AsymptomaIc PaIents should carriers be placed should in not a be treated private room or with other paIents who have CDI • PaIents IniIate contact should be precauIons placed in for a paIents private posiIve room with CDI unIl 48 or hours with from other paIents who have CDI resoluIon of • symptoms IniIate contact precauIons for paIents posiIve with CDI unIl 48 hours from resoluIon of symptoms • Place contact precauIons plus sign on paIent’s door • Place Hand contact hygiene precauIons and barrier plus precauIons sign on (gloves paIent’s door and gowns) • Hand Place hygiene dedicated and stethoscope barrier in precauIons paIent’s room (gloves and gowns) • When • Place paIent dedicated discharged stethoscope or symptoms in paIent’s resolve, room room should be terminally cleaned • When paIent discharged or symptoms MISCELLANEOUS resolve, room should be terminally cleaned MISCELLANEOUS • Repeat CDI PCR tesIng not recommended due to the likelihood of false posiIves. Toxin A, B, and • TC Repeat may CDI remain PCR posiIve tesIng for not as recommended long as due 30 days in paIent with symptom to the likelihood of false resoluIon. posiIves. Toxin A, B, and CDI= TC Clostridium may difficile remain infecIon; posiIve GI= gastrointesInal; for as long H= hour(s); as 30 ID= days in paIent with symptom InfecIous Diseases; PCR= resoluIon. Polymerase Chain ReacIon; PO= by mouth; Q= every; TC= Toxigenic Culture CDI= Clostridium difficile infecIon; GI= gastrointesInal; H= hour(s); ID= InfecIous Diseases; PCR= Polymerase Chain ReacIon; PO= * This by recommendaIon mouth; Q= every; is based TC= Toxigenic Culture on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole

* This recommendaIon is based on a MedicaIon Use EvaluaIon which showed a higher rate of recurrence with metronidazole

References: 1. Cohen, SH, et al. SHEA-­‐IDSA Clinical PracIce Guidelines for Clostridium difficile InfecIon in adults. ICHE. 2010 May; 31(5): References:431-­‐55. 1. Cohen, SH, et al. SHEA-­‐IDSA Clinical PracIce Guidelines for Clostridium difficile InfecIon in adults. ICHE. 2010 May; 31(5): 2. Surawicz CM, et al. Guidelines for Diagnosis, Treatment, Clostridium and PrevenIon of difficile InfecIons. Am J 431-­‐55. Gastroenterol 2013; 108:478–98. 2. Surawicz CM, et al. Guidelines for Diagnosis, Treatment, and PrevenIon of Clostridium difficile InfecIons. Am J 3. Kim PK, et al. Intracolonic Vancomycin for severe clostridium difficile coliIs. Surg Infect (Larchmt). 2013 Dec; 14(6):532-­‐9. Gastroenterol 2013; 108:478–98. 4. Louie T, et al. Fidaxomicin versus Vancomycin for Clostridium difficile InfecIon. N Engl . J Med 2011 Feb 3;364(5):422-­‐31. Surg Infect (Larchmt). 3.5. Kim Cornely PK, OA, et al. Intracolonic et al. Vancomycin Fidaxomicin for versus severe vancomycin clostridium for difficile infecIon coliIs. with Clostridium 2013 Dec; difficile 14(6):532-­‐9. in Europe, Canada, and the USA: a Clostridium difficile N Engl J Med 4. Louie double-­‐blind, T, et al. non-­‐inferiority, Fidaxomicin randomised versus Vancomycin for controlled trial. Lancet Infect InfecIon. Dis 2012; 12: . 281–9. 2011 Feb 3;364(5):422-­‐31. 5. Cornely OA, et al. Fidaxomicin versus vancomycin for infecIon with Clostridium difficile in Europe, Canada, and the USA: a double-­‐blind, non-­‐inferiority, randomised controlled trial. Lancet Infect Dis 2012; 12: 281–9. PAGE 5 Extended Spectrum Beta-Lactamase (ESBL) ExtendedInfection Spectrum Beta-Lactamase (ESBL) Infection

CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS Extended Spectrum 2 gm IV Consult ID Please DO NOT treat Extended Spectrum Meropenem 2 gm IV Consult ID Please DO NOT treat Beta-Lactamase (ESBL) Q8H colonization, or a “dirty Beta-Lactamase (ESBL) Q8H colonization, or a “dirty Infection (Use maximum doses) urine” sample Infection (Use maximum doses) Consult ID urine” sample Consult ID -resistant Consult ID Carbapenem-resistant Consult ID Enterobacteriaceae Enterobacteriaceae (CRE) (CRE) FebrileFebrile NeutropeniaNeutropenia

CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS Febrile Neutropenia 2gm IV Q8H Meropenem 1 gm IV If patient has indwelling Febrile Neutropenia Cefepime 2gm IV Q8H Meropenem 1 gm IV If patient has indwelling Q8H catheter, is persistently High risk: anticipated OR Q8H catheter, is persistently High risk: anticipated OR febrile prolonged Piperacillin/tazobactam febrile prolonged Piperacillin/tazobactam OR (>7 days duration) 3.375gm IV Q4H OR (>7 days duration) 3.375gm IV Q4H previously colonized AND (18gm/day) previously colonized AND (18gm/day) with MRSA: profound neutropenia with MRSA: profound neutropenia ADD vancomycin (ANC ≤100 cells/mm3 ADD vancomycin (ANC ≤100 cells/mm3 following cytotoxic Consult ID for following cytotoxic Consult ID for chemotherapy) +/- Anti-fungal therapy; chemotherapy) +/- Anti-fungal therapy; significant co-morbid Consider when fever significant co-morbid Consider when fever conditions: fails to respond after conditions: fails to respond after hypotension, 3-7 days of therapy hypotension, 3-7 days of therapy pneumonia, new-onset pneumonia, new-onset abdominal pain, or abdominal pain, or neurologic changes neurologic changes ANC= Absolute neutrophil count; CRE= Extended Spectrum Beta-Lactamase; ESBL= Extended Spectrum Beta-Lactamase; H=ANC hour(s);= Absolute ID= neutrophilInfectious Diseases;count; CRE IV== Extendedintravenous; Spectrum MRSA= Beta -Lactamase;-Resistant ESBL =S. Extended aureus; Q= Spectrum every Beta-Lactamase; H= hour(s); ID= Infectious Diseases; IV= intravenous; MRSA= Methicillin-Resistant S. aureus; Q= every NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult PatientsNOTE: Dosing Based based on Renal on normal Function, renal Aminoglycoside function. Refer High to TDoseable Onceof Contents Daily (HDOD) for section and onMonitoring Antimicrobial in Adult Dosing Patients, for Adult and VancomycinPatients BasedDosing on Renal and MonitoringFunction, Aminoglycoside in Adult Patients High. Dose Once Daily (HDOD) and Monitoring in Adult Patients, and Vancomycin Dosing and Monitoring in Adult Patients.

PAGE 6 Fungal Infections FungalFungal Infections Infections CONDITION PRIMARY THERAPY ALTERNATIVE THERAPY DURATION COMMENTS CONDITION PRIMARY THERAPY ALTERNATIVE THERAPY DURATION COMMENTS Candidemia Caspofungin IV L-AmB 3–5 mg/kg IV 14 days after Remove all IV NonCandidemia-neutropenic LD:Caspofungin70 mg IV Q24HL-AmB 3–5 mg/kg IV first14 days negative after catheters,Remove all ifIV Non-neutropenic MD:LD: 7050mg mg Q24H ORQ24H culturefirst negative result possiblecatheters, if ORMD: 50 mg Q24H VoriconazoleOR IV/PO ANDculture result possible OR Voriconazole IV/PO AND Consult ID Fluconazole IV 400 mg resolution of Consult ID LD:Fluconazole 800 mg IV (6400 mg mg/kg) Q12H for signs/symptomsresolution of Consider eye (12mg/kgLD: 800 mg) 2(6 doses mg/kg) then Q12H 200for mg signs/symptoms examConsider eye (12mg/kg) 2 doses then 200 mg exam MD: 400 mg (3 mg/kg) Q12H Transition to MD: 400 mg (3 mg/kg) Q12H 6 mg/kg) Q24H fluconazoleTransition to is 6 mg/kg) Q24H recommendedfluconazole is for clinicallyrecommendedstable for patientsclinically withstable fluconazolepatients with susceptiblefluconazole isolatessusceptible AND negativeisolates ANDrepeat bloodnegative culturesrepeat blood cultures Candidemia Caspofungin IV Fluconazole IV 14 days after Fluconazole is NCandidemiaeutropenic LD:Caspofungin70 mg IV LDFluconazole: 800 mg (12IV mg/kg) first14 days negative after preferredFluconazole in is Neutropenic MD:LD: 7050mg mg Q24H MDLD: :800 400 mg mg (12 (6 mg/kg)mg/kg) culturefirst negativeresult patientspreferred without in ORMD: 50 mg Q24H Q24HMD: 400 mg (6 mg/kg) ANDculture result recentpatients azole without LOR-AmB ORQ24H resolutionAND of exposurerecent azole AND 3L-–AmB5 mg/kg IV Q24H VoriconazoleOR IV/PO signs/symptomsresolution of whoexposure are NOT AND 3–5 mg/kg IV Q24H 400Voriconazole mg (6 mg/kg)IV/PO andsigns/symptoms neutropenia criticallywho are NOTill. Q12H400 mgfor (6 2 mg/kg) doses then and neutropenia critically ill. Q12H for 2 doses then Remove IV 200 mg (3 mg/kg) Remove IV 200 mg (3 mg/kg) catheters, if Q12H catheters, if Q12H possible possible Consult ID Consult ID Consider eye examConsider eye Urinary Fluconazole Conventional Fluconazole: Alternativeexam CandidiasisUrinary 200Fluconazole mg (3 mg/kg) AmphotericinConventional B 14Fluconazole: days treatmentAlternative is SymptomaticCandidiasis PO200 Q24H mg (3 mg/kg) 0.3Amphotericin–0.6 mg/kg B IV Q24H Amphotericin14 days B: recommendedtreatment is for CystitisSymptomatic PO Q24H 0.3–0.6 mg/kg IV Q24H 1Amphotericin-7 days B: fluconazolerecommended for Cystitis 1-7 days resistantfluconazole organismsresistant organisms Urinary Fluconazole Conventional Fluconazole: Alternative CandidiasisUrinary 200Fluconazole–400 mg (3–6 AmphotericinConventional B 14Fluconazole: days treatmentAlternative is PyelonephritisCandidiasis mg/kg)200–400 PO mg Q24H (3–6 0.5Amphotericin–0.7 mg/kg B IV Q24H Amphotericin14 days B: recommendedtreatment is for Pyelonephritis mg/kg) PO Q24H 0.5–0.7 mg/kg IV Q24H 14Amphotericin days B: fluconazolerecommended for 14 days resistantfluconazole organismsresistant organisms H= hour(s); ID= Infectious Diseases; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose;H= hour(s); PO= by ID= mouth; Infectious Q= every Diseases; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose; PO= by mouth; Q= every NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents forNOTE section: Some on agents Guidelines will require for Restricted ID consult/approval Antibiotics (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents for section on Guidelines for Restricted Antibiotics

References: References:1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. 1. PappasClin Infect PG, Dis et. al.2016; Clinical 62(4):e1 Practice-e50 .Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016; 62(4):e1-e50. PAGE 7 Fungal Infections

FungalFungalCONDITION Infections InfectionsPRIMARY THERAPY ALTERNATIVE THERAPY DURATION COMMENTS Nongenital Clotrimazole 10 mg Itraconazole oral Uncomplicated Refractory OropharyngealCONDITION trochePRIMARY 5 timesTHERAPY daily solutionALTERNATIVE THERAPY diseaseDURATION 7 to 14 disease:COMMENTS Nongenital(Oral Thrush) ClotrimazoleOR 10 mg 200Itraconazole mg PO onceoral daily Uncomplicateddays VRefractoryoriconazole Oropharyngeal trocheNystatin 5 suspensiontimes daily ORsolution disease 7 to 14 200disease: mg PO Q12H (Oral Thrush) POOR four times a day Voriconazole200 mg PO once200 daily mg days ORVoriconazole NystatinOR suspension POOR Q12H L200-AmB mg PO Q12H POFluconazole four times a day Voriconazole 200 mg ORsuspension 1 mL OR100–200 mg PO Q12H Lof-AmB 100 mg/mL FluconazolePO once daily suspensionfour times a1 day mL Esophageal 100Fluconazole–200 mg Caspofungin IV 14–21 days ofPatients 100 mg/mLunable Candidiasis PO200once–400 dailymg LD: 70 mg fourto toleratetimes aan day oral Esophageal (3Fluconazole–6 mg/kg) MDCaspofungin: 50 mg Q24HIV 14–21 days agent,Patients IVunable Candidiasis PO200 Q24H–400 mg ORLD: 70 mg fluconazoleto tolerate an or oral (3–6 mg/kg) ConventionalMD: 50 mg Q24H alternativeagent, IV agent PO Q24H AmphotericinOR B listedfluconazole may be or Conventional0.3–0.7 mg/kg IV used.alternative agent AmphotericinQ24H B listed may be 0.3–0.7 mg/kg IV used. General Susceptibility Patterns of CandidaQ24H spp . Amphotericin General SusceptibilityFluconazole Patterns ofItraconazole Candida spp. Caspofungin Voriconazole B Amphotericin Candida FluconazoleS ItraconazoleS S CaspofunginS VoriconazoleS B albicans Candida S S S S S C. tropicalis S S S S S albicans C. S S S S S C. tropicalis S S S S S parapsilosis C. S S S S S C. glabrata S-DD S-DD to R S-I S S-DD to R parapsilosis C. krusei R S-DD to R S-I S S C. glabrata S-DD S-DD to R S-I S S-DD to R C. lusitaniae S S S to R S S C. krusei R S-DD to R S-I S S H= hour(s); I= Intermediate; IV= intravenous; L-AmB= Liposomal Amphotericin B; LD= loading dose; MD= maintenance dose; C.PO= lusitaniae by mouth; Q= every; R=S Resistant; S= susceptible;S S-DD= SusceptibilityS to R is dose dependent; Sspp= species S

NOTEH= hour(s);: Some I= agents Intermediate; will require IV= intravenous; ID consult/approval L-AmB= (amphotericinLiposomal Amphotericin B, caspofungin B; LD=, voriconazole loading dose;). MD=Refer maintenance to Table of Contents dose; PO=for section by mouth; on Guidelines Q= every; R=for Resistant; Restricted S= Antibiotics susceptible; S-DD= Susceptibility is dose dependent; spp= species

NOTE: Some agents will require ID consult/approval (amphotericin B, caspofungin, voriconazole). Refer to Table of Contents for section on Guidelines for Restricted Antibiotics

References: 1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2016; 62(4):e1-e50. References: 1. Pappas PG, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases SocietyPAGE of 8 America. Clin Infect Dis. 2016; 62(4):e1-e50. Influenza A and B (Flu) InfluenzaInfluenza A and AB (Flu)and B (Flu) CLINICAL AND THERAPEUTIC ALGORITHM CLINICAL SEVERITY RECOMMENDED REGIMENS CLINICAL AND THERAPEUTIC ALGORITHM CLINICAL SEVERITY RECOMMENDED REGIMENS Diagnosis is based on the clinical presentation Outpatient High Risk Select ONE of the ofDiagnosis the patientis basedand resultson the ofclinical RT-PCR. presentation (seeOutpatient left panel) High Risk following:Select ONE of the of the patient and results of RT-PCR. (see left panel) •following:Oseltamivir 75 mg PO Decision to initiate treatment should NOT wait Previously Healthy • Oseltamivir 75 mg PO Decision to initiate treatment should NOT wait Q12H for confirmation of laboratory results. Previously Healthy Q12H for confirmation of laboratory results. • Zanamivir 10 mg Continue the full course of treatment • Zanamivir 10 mg Continue the full course of treatment (two 5 mg inhalations) if first RT-PCR is negative and if signs and (two 5 mg inhalations) if first RT-PCR is negative and if signs and Q12H symptoms indicate influenza due to possibility Q12H ofsymptoms false negative. indicate influenza due to possibility Treat for 5 days ONLY if of false negative. treatmentTreat for 5 candays be ONLY if History of influenza vaccination does not treatment can be History of influenza vaccination does not initiated within 48 hours preclude influenza when signs and symptoms initiated within 48 hours preclude influenza when signs and symptoms of illness onset. are compatible with the clinical syndrome. of illness onset. are compatible with the clinical syndrome. Zanamivir use is not recommended in people Inpatient High Risk • Oseltamivir 75 mg PO Inpatient High Risk • Oseltamivir 75 mg PO withZanamivir underlyinguse is respiratorynot recommended disease in people (see left panel) or enterally- (see left panel) or enterally- (e.g.with asthma,underlying COPD.) respiratory disease administered Q12H (e.g. asthma, COPD.) administered Q12H Treatment Population: Treat for 5 days. If illness Treatment Population: Treat for 5 days. If illness High risk adults (any of the following): is severe or prolonged, is severe or prolonged, •High≥65 risk years adults (any of the following): may extend duration may extend duration • Chronic≥65 years health conditions* based on clinical based on clinical • Immunosuppression,Chronic health conditions* including caused by judgment. judgment. • medicationImmunosuppression, or HIV infection including caused by Inpatient • Oseltamivir 75 mg PO • Pregnantmedication or or postpartum HIV infection (within 2 weeks of Inpatient • orOseltamivir enterally- 75 mg PO • delivery)Pregnant womenor postpartum (within 2 weeks of administeredor enterally- Q12H • Americandelivery) women Indian/Alaska Natives administered Q12H • BodyAmerican mass Indian/Alaska index ≥40 Natives Treat for 5 days. • ResidentsBody mass of index nursing ≥40 homes and other Treat for 5 days. • chronicResidents-care of nursingfacilities homes and other Post-Exposure Select ONE of the chronic-care facilities ChemoprophylaxisPost-Exposure following:Select ONE of the Previously healthy, symptomatic outpatient •ChemoprophylaxisHigh risk •following:Oseltamivir 75 mg PO Previously healthy, symptomatic outpatient NOT at high risk • (seeHigh left risk panel) • onceOseltamivir daily 75 mg PO NOT at high risk (within 48 hours of symptom onset) (see left panel) • Zanamivironce daily 10 mg (two (within 48 hours of symptom onset) Hospitalized patients CDC Flu health advisory • 5Zanamivir mg inhalations)10 mg (twoonce FebruaryHospitalized 2016: patients2 TreatmentCDC Flu may health also beadvisory daily5 mg inhalations) once beneficialFebruary 2016: when2 startedTreatment up tomay 4 to also 5 days be after daily symptombeneficial onsetwhen instarted hospitalized up to 4 patients. to 5 days after Treat for 10 days** symptom onset in hospitalized patients. Treat for 10 days** CDC= Centers for Disease Control and Prevention; COPD= chronic obstructive pulmonary disease; H= Hour(s); HIV= human CDC=immunodeficiency Centers for Disease virus; PO Control= by mouth; and Prevention; Q= every; COPDRT-PCR= chronic= reverse obstructive transcriptase pulmonary polymerase disease; chain H =reaction Hour(s); HIV= human immunodeficiency virus; PO= by mouth; Q= every; RT-PCR= reverse transcriptase polymerase chain reaction *Chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic, hematological (including *Chronicsickle cell pulmonarydisease), metabolic (including disorders asthma), (including cardiovascular diabetes (except mellitus), hypertension neurologic alone), conditions renal, hepatic,(disorders hematological of the brain, (includingspinal cord, sicklenerve, cell muscle, disease), epilepsy, metabolic stroke, disorders or intellectual (including disability) diabetes mellitus), neurologic conditions (disorders of the brain, spinal cord, nerve, muscle, epilepsy, stroke, or intellectual disability) **After most recent known exposure to a close contact known to have influenza. **After most recent known exposure to a close contact known to have influenza. NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients NOTE:Based onDosing Renal based Function on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function

References: References:1. Centers for Disease Control and Prevention. CMV home. Cytomegalovirus (CMV) and Congenital CMV infection Web site. 1.http:// Centerswww.cdc.gov for Disease/cmv/clinical/ Control and features.htmlPrevention. CMV. Published home. Cytomegalovirus6 Dec 2016. Updated (CMV) 2010. and Accessed Congenital 6 MarchCMV infection 2016. Web site. http://2. Departmentwww.cdc.gov of Health/cmv/clinical/ and Humanfeatures.html Services. Flu. Published season begins: 6 Dec Severe2016. Updated influenza 2010. illness Accessed reported. 6 MarchCenters 2016. for Disease Control 2.and Department Prevention: of Emergency Health and Preparedness Human Services. and FluResponse season Webbegins: site. Severe http:// influenzaemergency.cdc.gov illness reported./han/han00387.asp. Centers for Disease Published Control 1 andFeb 2016.Prevention: Updated Emergency 2016. Accessed Preparedness 12 March and 2016 Response. Web site. http://emergency.cdc.gov/han/han00387.asp. Published 1 Feb 2016. Updated 2016. Accessed 12 March 2016. PAGE 9 Intra-abdominalIntra-abdominal Infections Infections

CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS Intra-abdominal Piperacillin/tazobactam 400 mg IV Piperacillin/tazobactam Infections 3.375 gm IV Q6H Q12H provides excellent Community acquired +/- Metronidazole anaerobic coverage, OR 500 mg IV Q8H addition of clindamycin Hospital acquired OR metronidazole is Meropenem 1gm Q8H NOT indicated or necessary LymeLyme Disease Disease

CLINICAL SYNDROME PREFERRED REGIMEN ALTERNATIVE REGIMEN CLINICAL CONSIDERATIONS Lyme Disease Doxycycline 100 mg PO Consult ID Relapse may occur with Early disease Q12H* any regimen; patients OR with objective 500 mg PO signs/symptoms may Q8H* need a second course OR Duration of Treatment: 500 mg PO Doxycycline 10-21 days Q12H* Amoxicillin/Cefuroxime 14-21 days Late disease with central OR peripheral Lyme antibody testing nervous system disease Consult ID can be negative in first 6 weeks Consider co-infection with anaplasma or babesia

H= hour(s); ID= Infectious Diseases; IV= intravenous; PO= By Mouth; Q= every

*Doxycycline also has activity against Ehrlichia and Anaplasma. Amoxicillin and cefuroxime do not.

NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function, Aminoglycoside High Dose Once Daily (HDOD) and Monitoring in Adult Patients, and Vancomycin Dosing and Monitoring in Adult Patients.

PAGE 10 Proton-Pump Inhibitor (PPI) Use Proton-PumpProton-Pump Inhibitor Inhibitor (PPI) Use (PPI) Use The FDA has issued multiple warnings on the long-term use of PPIs. These include: increased risk 1 2 3 Theof C. FDA difficile has issuedinfection multiple, hypomagnesemia warnings on the, and long fractures-term use of ofthe PPIs. hip, Thesewrist, include:and spine increased. Therefore risk, ofprudent C. difficile prescribinginfection of1 ,PPIs hypomagnesemia is warranted. The2, and FDA fractures recommends of the hip,use ofwrist, the andlowest spine dose3. Therefore and , 1-3 prudentshortest prescribingduration of ofPPI PPIs therapy is warranted. appropriate The forFDA the recommends condition being use of treated the lowest. Patient dose and shortestcompliance, duration time of administrationPPI therapy appropriate (prior to meals),for the andcondition dietary being indiscretions treated1- 3(.i.e. Patient alcohol or compliance,irritating foods) time should of administration be assessed (priorprior toto titrationmeals), and of PPI dietary doses. indiscretions (i.e. alcohol or irritating foods) should be assessed prior to titration of PPI doses. Indication Treatment Duration Indication Treatment Duration Gastroesophageal reflux disease Initial 8 week course for symptom 6 Gastroesophageal(GERD) reflux disease Initialrelief or8 week esophagitis course for symptom Omeprazole 20 mg PO (GERD)Symptomatic6 relief reliefMaintenance or esophagitis therapy determined Omeprazoleonce daily 20 mg PO Symptomatic relief Maintenanceby response and therapy severity determined of Acute healing of erosive or ulcerative onceOR daily bydisease response and severity of Acuteesophagitis healing of erosive or ulcerative ORPantoprazole 40mg PO once daily diseaseConsider dose titration, or esophagitisMaintenance healing of erosive or Pantoprazole 40mg PO once daily Considerintermittent dose therapy titration, or Maintenanceulcerative esophagitis healing of erosive or intermittent therapy ulcerativeStress ulcer esophagitisprophylaxis should be Transition to PO when possible Stressused for ulcer criticallyprophylaxis ill patients should with be Transition to PO when possible 4,5 Continue until resolution of usedincreased for critically risk of bleeding ill patients including with : Continueunderlying untilriskresolution factors and/or of increased- Coagulopathy risk of bleeding (platelet including count 4,5: 3 underlyingcritical illnessrisk factors and/or - Coagulopathy<50,000 mm , (plateletINR >1.5, count or aPTT critical illness <50,000>2x control) mm3, INR >1.5, or aPTT Omeprazole - >2xMechanical control) ventilation for >48 Omeprazole10-20 mg IV/PO once - Mechanicalhours ventilation for >48 10daily-20 mg IV/PO once - hoursTraumatic, severe thermal or dailyOR - Traumatic,spinal cord severeinjury thermal or ORPantoprazole 40mg - spinalHistory cord of GI injury ulceration or PantoprazoleIV/PO once daily40mg - Historybleeding of within GI ulceration past year or IV/PO once daily Twobleeding or more within minor past risk factors:year Two- Sepsis, or more ICU minor stay ≥1risk week, factors: occult GI - Sepsis,bleeding ICU ≥6 stay days, ≥1 glucocorticoid week, occult GI bleedingtherapy (> ≥6250 days, mg glucocorticoidhydrocortisone therapyequivalent) (>250 mg hydrocortisone aPTTequivalent)= activated partial thromboplastin time; GERD= Gastroesophageal reflux disease; GI= Gastrointestinal; ICU= intensive care unit; INR= International normalized ratio; IV= intravenous; PO= by mouth; PPI= proton pump inhibitor aPTT= activated partial thromboplastin time; GERD= Gastroesophageal reflux disease; GI= Gastrointestinal; ICU= intensive care unit; INR= International normalized ratio; IV= intravenous; PO= by mouth; PPI= proton pump inhibitor

References 1. U.S. Food and Drug Administration (FDA). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be Referencesassociated with stomach acid drugs known as proton pump inhibitors (PPIs) [internet]. Updated May 2012 [cited 1. U.S.11/21/12]. Food and Available Drug Administration from: http://www.fda.gov/Drugs/DrugSafety/ucm290510.htm (FDA). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be 2. associatedU.S. Food and with Drug stomach Administration acid drugs (FDA). known FDA as proton Drug Safety pump Communication: inhibitors (PPIs) Low[internet]. magnesium Updated levels May can 2012 be associated [cited with 11/21/12].long-term use Available of Proton from: Pump http:// Inhibitorwww.fda.gov/Drugs/DrugSafety/ucm290510.htm drugs (PPIs) [internet]. Updated February 2012 [cited 11/21/12]. Available from: 2. U.S.http ://www.fda.gov/Drugs/DrugSafety/ucm245011.htm.Food and Drug Administration (FDA). FDA Drug Safety Communication: Low magnesium levels can be associated with 3. longU.S. -Foodterm anduse ofDrug Proton Administration Pump Inhibitor (FDA). drugs FDA (PPIs)Drug Safety[internet]. Communication: Updated February Possible 2012 increased [cited 11/21/12]. risk of fractures Available of the from: hip, httpwrist,://www.fda.gov/Drugs/DrugSafety/ucm245011.htm. and spine with the use of proton pump inhibitors [internet]. Updated March 2011 [cited 11/21/12]. Available from: 3. U.S.http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htm Food and Drug Administration (FDA). FDA Drug Safety Communication: Possible increased risk of fractures of the hip, 4. wrist,ASHP Therapeuticand spine with Guidelines the use ofon proton Stress pumpUlcer Prophylaxis. inhibitors [internet]. ASHP Commission Updated March on Therapeutics 2011 [cited and 11/21/12]. approved Available by the ASHP from: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm213206.htmBoard of Directors on November 14, 1998. Am J Health Syst Pharm 1999; 56:347. 4.5. ASHPSpirt MJ, Therapeutic Stanley S. Guidelines Update on on stress Stress ulcer Ulcer prophylaxis Prophylaxis. in critically ASHP Commission ill patients. on Crit TherapeuticsCare Nurse and2006; approved 26:18. by the ASHP 6. BoardKatz PO, of GersonDirectors LB, on Vela November MF. Guidelines 14, 1998. for Am the J Healthdiagnosis Syst andPharm management 1999; 56:347. of gastroesophageal reflux disease. Am J 5. SpirtGastroenterol MJ, Stanley2013;108:308 S. Update on-28. stress ulcer prophylaxis in critically ill patients. Crit Care Nurse 2006; 26:18. 6. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013;108:308-28. PAGE 11 Respiratory Tract: Acute Bacterial Sinusitis

RespiratoryRespiratoryCLINICAL AND THERAPEUTIC Tract: Tract: Acute Acute Bacterial Bacterial Sinusitis Sinusitis RISK FACTORS RECOMMENDED REGIMENS ALGORITHM CLINICAL AND THERAPEUTIC RISK FACTORS RECOMMENDED REGIMENS 1a. AntibioticsALGORITHM are indicated if the Presence of Risk Initial Empiric Antibiotic Therapy: patient has ANY of the Factors for Amoxicillin/clavulanate PO: 1a.following:Antibiotics are indicated if the PresenceAntibiotic of Risk Initial Empiric Antibiotic Therapy: patient has ANY of the Factors for ‡ • Symptoms lasting ≥ 10 Resistance: Amoxicillin/CrCl > 30 ml/min:clavulanate 2000/125PO: mg following:days without clinical Antibiotic• Age > 65 Q12H ‡ • Symptomsimprovement lasting ≥ 10 Resistance• Antibiotics: CrCl >10 30 – ml/min:29 ml/min: 2000/125 875/125mg mg ORdays without clinical • Agewithin > 65 last 30 Q12H • improvementSevere symptoms at onset • Antibioticsdays CrCl 10< 10 – 29ml/min: ml/min: 2000/125 875/125‡ mg mg ORlasting • withinHospitalization last 30 Q12HQ24H ‡ • Severe≥ 3 days symptoms [Fever (≥ at102 onset °F), dayswithin last 5 CrClAlternatives < 10 ml/min:*: 2000/125 mg severelasting facial pain, or • Hospitalizationdays Q24HMoxifloxacin 400 mg PO Q24H purulent≥ 3 days discharge][Fever (≥ 102 °F), withinImmuno last- 5 Alternatives*: • Treat for 7 to 10 days ORsevere facial pain, or dayscompromised Moxifloxacin 400 mg PO Q24H purulent discharge] Immuno- • New onset fever, severe •OR Treat for 7 to 10 days ORheadache, or increase • compromisedFever > 102°F • Newnasal onset discharge fever, after severe 5-6 ORwith signs of headache,days following or increase initial • Feversystemic > 102 illness°F nasalimprovement discharge after 5-6 with signs of days following initial Nonesystemic of the illnessabove No risk for Antibiotic Resistance: 1b. If the patient does not meet risk factors for improvement Amoxicillin/clavulanatePO: this criteria likely viral and Noneantibiotic of the above No risk for Antibiotic Resistance: 1b. If the patient does not meet risk factors for self-limiting. May provide resistance Amoxicillin/CrCl > 30 ml/min:clavulanate 875/125PO: mg Q12H thissymptom criteria relief. likely viral and antibiotic CrCl 10–29 ml/min: 500/125 mg AND •selfReduce-limiting. nasal May symptoms: provide resistance CrClQ12H > 30 ml/min: 875/125 mg Q12H symptom relief. CrCl 10–29 ml/min: 500/125 mg topical or nasal ANDNo fever or signs of CrCl < 10 ml/min: 875/125 mg Q24H • Reducedecongestants, nasal symptoms: intranasal systemic illness Q12HAlternatives*: topicalcorticosteroids, or nasal intranasal No fever or signs of CrClDoxycycline < 10 ml/min: 100 mg 875/125 PO Q12H mg Q24H decongestants,saline intranasal systemic illness Alternatives*:OR , intranasal DoxycyclineMoxifloxacin 100 400 mg mg PO PO Q12H Q24H 2. If nosaline improvement after 3 to 5 OR days of antibiotic therapy MoxifloxacinTreat for 5 to 4007 days mg PO Q24H 2. switchIf no improvement to an alternative after agent 3 to 5 daysfrom ofa differentantibiotic antibiotic therapy class Treat for 5 to 7 days switch to an alternative agent CrCl= creatinine clearance; H= hour(s); PO= by mouth; Q= every from a different antibiotic class ‡ Pharmacy does not carry amoxicillin/clavulanate 2000/125 mg tablets. Order 875/125 mg tablets of amoxicillin/clavulanate CrCl= creatinine clearance; H= hour(s); PO= by mouth; Q= every AND 1000 mg tablets of amoxicillin ‡(total Pharmacy amoxicillin/clavulanate does not carry amoxicillin/clavulanate = 1,875/125 mg per dose). 2000/125 mg tablets. Order 875/125 mg tablets of amoxicillin/clavulanate AND 1000 mg tablets of amoxicillin (total*, amoxicillin/clavulanate trimethoprim-sulfamethoxazole = 1,875/125 mg ,per and dose). 2nd or 3rd generation cephalosporins are not recommended due to increasing rates of antimicrobial resistance. *Macrolides, trimethoprim-sulfamethoxazole, and 2nd or 3rd generation cephalosporins are not recommended due to increasing rates of antimicrobial resistance.

References: 1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and References:adults. Clin Infect Dis. 2012; 54:e72. 1. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012; 54:e72. PAGE 12 Respiratory Tract: Acute Pharyngitis RespiratoryRespiratory Tract: Tract: Acute Acute Pharyngitis Pharyngitis QUICK FACTS1-2: QUICK• Only FACTS5-15%1 -of2: adult cases of acute pharyngitis are caused by Group A β-hemolytic • Onlystreptococci 5-15% of(GAS). adult cases of acute pharyngitis are caused by Group A β-hemolytic • streptococciIt is estimated(GAS). that 3,000 to 4,000 patients with GAS must be treated for every 1 • Itcase is estimated of acute rheumatic that 3,000 fever to 4,000 prevented. patients with GAS must be treated for every 1 • caseAntibiotic of acute therapy rheumatic of GAS fever hastens prevented. resolution by 1-2 days if initiated within 2-3 days • Antibioticof symptom therapy onset .of GAS hastens resolution by 1-2 days if initiated within 2-3 days of symptom onset. CLINICAL CLASSIFICATION CLINICAL PRESENTATION RECOMMENDED REGIMENS CONSIDERATIONS CLINICAL CLASSIFICATION CLINICAL PRESENTATION RECOMMENDED REGIMENS Group A ≥ 2 of the following: Amoxicillin 500 mg PO ClinicalCONSIDERATIONS suspicion β-hemolytic • Fever (≥ 100.4°) Q12H for GAS: Group A ≥ 2 of the following: Amoxicillin 500 mg PO Clinical suspicion • Tonsillar exudates OR Obtain throat swab β-hemolytic • Fever (≥ 100.4°) Q12H for GAS: (GAS) • No cough Penicillin VK 250 mg Q6H OR order GAS rapid streptococcus • Tonsillar exudates OR Obtain throat swab • Tender anterior OR antigen detection (GAS) • No cough Penicillin VK 250 mg Q6H OR order GAS rapid cervical 500 mg PO Q12H test (RADT)* • Tender anterior OR antigen detection lymphadenopathy cervical For500 10mg days PO Q12H Iftest culture (RADT)*is (lymphadenitis) lymphadenopathy negative: • Scarlatiniform rash ForPenicillin 10 days Allergy If culture is (lymphadenitis) No antibiotics AND Non-anaphylactic allergy: negative: • Scarlatiniform rash Penicillin Allergy consider supportive Cephalexin 500 mg PO No antibiotics AND Non-anaphylactic allergy: treatment Q12H x 10 days consider supportive Cephalexin 500 mg PO (antipyretic OR OR treatment Q12H x 10 days analgesic) Clindamycin 300 mg PO (antipyretic OR OR Q6H for 10 days analgesic) Clindamycin 300 mg PO OR Q6H for 10 days Azithromycin 500 mg PO x OR 1 day, then 250 mg PO Azithromycin 500 mg PO x Q24H x 4 days 1 day, then 250 mg PO Viral Pharyngitis • Conjunctivitis SupportiveQ24H x 4 days treatment • Coryza (antipyretic OR analgesic) Viral Pharyngitis • Conjunctivitis Supportive treatment • Cough • Coryza (antipyretic OR analgesic) • Diarrhea • Cough • Hoarseness • Diarrhea • Discrete ulcerative • Hoarseness stomatitis • Discrete ulcerative • Viral exanthema stomatitis GAS= Group A β-hemolytic Streptococci;• Viral exanthema H= hour(s); PO= by mouth; Q= every; RADT= Rapid antigen detection test *ThroatGAS= Group swab A cultureβ-hemolytic sensitivity: Streptococci; 90-95%; H RADT:= hour(s); sensitivity PO= by 70 mouth;-90%, specificityQ= every; 95%RADT= Rapid antigen detection test

*Throat swab culture sensitivity: 90-95%; RADT: sensitivity 70-90%, specificity 95%

References: 1. Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A References:Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society America. Clin Infect Dis. 2012 Nov 15;55(10):1279- 1. 82.Shulman ST, Bisno AL, Clegg HW, et al. Clinical Practice Guidelines for the Diagnosis and Management of Group A 2. CooperStreptococcal RJ et al. Pharyngitis: Principles of2012 appropriate Update by antibiotic the Infectious use for Diseases acute pharyngitis Society America. in adults: Clin Background. Infect Dis. 2012 Annals Nov of 15;55(10):1279 Internal - Medicine.82. 2001;134(6):509-17. 2. Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal Medicine. 2001;134(6):509-17. PAGE 13 RespiratoryRespiratory Tract:Tract: ChronicChronic Obstructive Obstructive Pulmonary Pulmonary DiseaseDisease (COPD) (COPD) ExacerbationExacerbation CLINICAL CLINICAL AND THERAPEUTIC ALGORITHM RECOMMENDED REGIMENS Respiratory Tract: Chronic ObstructiveSEVERITY Pulmonary Diagnosis: Based on the clinical Outpatient Select ONE of the following: presentationDisease of(COPD) the patient, Exacerbation including Uncomplicated • Doxycycline 100 mg PO Q12H complaints of an acute change of cardinal CLINICAL • Amoxicillin 500 mg PO Q8H CLINICAL AND THERAPEUTIC ALGORITHM RECOMMENDED REGIMENS symptoms as follows: SEVERITY • Azithromycin 500 mg once, then 250 mg PO Q24H DoesDiagnosis: patientBased have: on theincreased clinical sputum Outpatient Select ONE of the following: • SMX/TMP 1 DS tablet PO Q12H purulencepresentation AND of theincreased patient, dyspneaincluding OR Uncomplicated • Doxycycline 100 mg PO Q12H increasedcomplaints sputum of an acute change of cardinal • AmoxicillinTreat for 5003 to mg5 days PO Q8H symptoms as follows: • Azithromycin 500 mg once, then 1. Initiate therapy with: 250 mg PO Q24H Does patient have: increased sputum Outpatient Primary Recommendation: • Short-acting bronchodilators • SMX/TMP 1 DS tablet PO Q12H purulence AND increased dyspnea OR Complicated* • Amoxicillin/clavulanate 875 mg (i.e. albuterol) increased to 6 to 8 increased sputum OR Treat forPO 3 to Q12H 5 days puffs Q1-2H in severe exacerbations 1. Initiate therapy with: Failure of Penicillin Allergy or Treatment • +/- Short-acting anticholinergics Outpatient Primary Recommendation: • Short-acting bronchodilators Previous Failure with Primary Regimen: Complicated* • Amoxicillin/clavulanate 875 mg (i.e. albuterol)ipratropium increased bromide) to 6 increased to 8 ORAntimicrobial PO• Q12HMoxifloxacin 400 mg PO Q24H** puffsto 6 to Q1 8- 2puffsH in severe Q3-4H exacerbations in severe FailureTherapy of Penicillin Allergy or Treatment • exacerbations+/- Short-acting given anticholinergics via Treat for 3 to 5 days Previous Failure with Primary Regimen: (i.e.nebulizer/ ipratropiuminhaler bromide) increased AntimicrobialInpatient • MoxifloxacinPrimary Recommendation:400 mg PO Q24H** toPLUS 6 to 8 puffs Q3-4H in severe Therapy • Amoxicillin/clavulanate 875 mg • Corticosteroidsexacerbations given ( via or Treat for 3 to 5 days nebulizer/inhaler PO Q12H equivalent PO 40 mg/day for 5 days) Inpatient Primary Recommendation: PLUS OR if admitted OR have significant • Amoxicillin/clavulanate 875 mg • Corticosteroids (prednisone or • Doxycycline 100 mg PO Q12H PO Q12H equivalentshortness ofPO breath 40 mg/day for 5 days) OR Penicillin Allergy or Treatment ifMethylprednisolone admitted OR have significant IV Q6-12H • DoxycyclineFailure with 100 Primary mg PO Q12HRegimen: shortnessmay be used of breath initially Penicillin• MoxifloxacinAllergy or Treatment400 mg PO Q24H** Methylprednisolone IV Q6-12H 2. Consider obtaining sputum culture Failure with Primary Regimen: may be used initially Treat for 5 days AND treat with an antimicrobial • Moxifloxacin 400 mg PO Q24H** 2. Consider obtaining sputum culture based on clinical severity Treat for 5 days •ANDIf patienttreat with has an only antimicrobial an acute increase basedin 1 oncardinal clinical symptom severity no antibiotic • If patient has only an acute increase intherapy 1 cardinal is recommended symptom no antibiotic 3. Managetherapy risk is recommendedfactors: 3.•ManageAssess risk if patientfactors: is due for influenza • Assessvaccine if patient is due for influenza • vaccineSmoking cessation counseling • Smoking cessation counseling 4. Inpatient: If worsening clinical status 4. Inpatient:OR inadequateIf worsening response clinical in 72H:status OR inadequate response in 72H: re-evaluate AND ANDobtainobtain sputum sputum cultureANDANDgramgram stain stain DS=DS= double strength;strength; H= H= hour(s); hour(s); IV =IV intravenous;= intravenous; PO= PO= by mouth; by mouth; Q= every; Q= every; SMX/TMP= SMX/TMP= sulfamethoxazole sulfamethoxazole/trimethoprim/trimethoprim **InIn patientpatient withwith frequent frequent exacerbations, exacerbations, (> 4(> in 4 previous in previous 12 months) 12 months) severe severe airflow airflow limitation, limitation, and/or and/orexacerbations exacerbations requiring requiring mechanicalmechanical ventilation, FEV1 FEV1 < <50%, 50%, and/or and/or cardiovascular cardiovascular disease disease **** PreviouslyPreviously failedfailed therapy therapy with with azithromycin, azithromycin, doxycycline, doxycycline, and anda beta a -betalactam- lactam OR received OR received treatment treatment with the with aforementioned the aforementioned antibioticsantibiotics withinwithin the the previous previous 90 90 days days OR ORpatientpatient has hasother other comorbidities comorbidities (i.e. chronic (i.e. chronic heart, heart,liver, or liver, renal or disease, renal disease, diabetes, diabetes, alcoholism, malignancy, asplenia, immunocompromised or on immunosuppressing drugs. An FDA advisory committee determined that alcoholism, malignancy, asplenia, immunocompromised or on immunosuppressing drugs. An FDA advisory committee determined that the risks of fluoroquinolone use in COPD exacerbation outweighed any potential benefit, and should not be a first-line agent. the risks of fluoroquinolone use in COPD exacerbation outweighed any potential benefit, and should not be a first-line agent. NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based NOTEon Renal: Dosing Function based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function References: References1. Vollenweider: DJ, et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 1. Vollenweider12;12:CD010257DJ,. et al. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Dec 2. 12;12:CD010257Vestbo J, et al. Global. strategy for the diagnosis, manageent, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2013 Feb 15;187(4):347-65. 2.3. FoodVestbo andJ, Drug et al. Administration. Global strategy Joint for meeting the diagnosis, of the Antimicrobial manageent, Drugsand prevention Advisory Committee of chronic and obstructive the Drug Safety pulmonary & Risk disease:Manageme GOLDnt executive summary.Advisory Committee Am J Respir (DSaRMCrit Care)-Webcast Med. Recording.2013 Feb 15;187(4):3472015. -65. 3. Food and Drug Administration. Joint meeting of the Antimicrobial Drugs Advisory Committee and the Drug Safety & Risk Management Advisory Committee (DSaRM)-Webcast Recording. 2015. PAGE 14 RespiratoryRespiratory Tract: Tract: Pneumonia Pneumonia

START HERE Does the patient presenting with pneumonia have any risk factors for multidrug • Received recent antibiotic therapy (previous 90 resistant organisms (MDROs): days), chemotherapy, OR wound care within previous 30 days • Hospitalized for ≥ 2 days within previous 90 days • Chronic hemodialysis • Resides in a nursing home OR long-term care • Have immunosuppressive disease OR receiving facility, OR skilled nursing facility immunosuppressing medications

CLINICAL CONSIDERATIONS

• Infiltrate on chest x-ray required for pneumonia diagnosis • Collect BAL OR PSB AND blood cultures prior to starting antimicrobial therapy • Re-assess antibiotic therapy on day 2 or 3 when cultures return from microbiology lab • Specific isolated pathogens should prompt clinicians to de-escalate treatment based on the pathogen's susceptibility pattern

NO RISK FACTORS FOR MDROS RISK FACTORS FOR MDROS

INPATIENT NON-ICU INPATIENT Ceftriaxone 1 gm IV Q24H Beta-lactam/beta-lactamase inhibitor: AND Piperacillin-tazobactam 3.375 gm IV Q4H† Azithromycin 500 mg PO/IV for 1 day, then OR 250 mg PO/IV Q24H for 4 days Piperacillin-tazobactam 4.5 gm IV Q6H OR OR Moxifloxacin 400 mg IV/PO Q24H Antipseudomonal carbapenem: 500 mg IV Q8H INPATIENT ICU PLUS Ceftriaxone 2 gm IV Q24H AND Aminoglycoside‡ (Preferred) Moxifloxacin 400 mg IV Q24H Gentamicin 5-6 mg/kg (IBW) once daily OR Tobramycin 5-6 mg/kg (IBW) once daily Ampicillin/ 3 gm IV Q6H OR AND Antipseudomonal fluoroquinolone: Moxifloxacin 400 mg IV Q24H 750 mg IV Q24H OR Ciprofloxacin 400 mg IV Q8H Penicillin-allergic patients: PLUS 2 gm IV Q8–12H If at risk for MRSA: AND Moxifloxacin 400 mg IV Q24H Vancomycin 15 mg/kg IV‡ OR Linezolid 600 mg IV/PO Q12H (See Criteria for Use)

BAL= Bronchoalveolar Lavage; BP= blood pressure; bpm= beats or breaths per minute; CrCl= Creatinine Clearance; H= hour(s); IBW= ideal body weight; ICU= Intensive Care Unit; IV= intravenous; MDRO= multi-drug resistant organism; MRSA= Methicillin- Resistant S. aureus; PO= by mouth; PSB= Protected Specimen Brush; Q= every †Suspect P. aeruginosa: CrCl >50 ml/min = 3.375 gm q4h; CrCl 50-10 ml/min = 3.375 gm IV Q6H; CrCl < 10 ml/min = 3.375 gm Q8H ‡Refer to Table of Contents for section on vancomycin and aminoglycoside dosing and monitoring Note: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function.

PAGE 15 Respiratory Tract: Pneumonia

RespiratoryRespiratoryNO RISK FACTORS Tract:FOR MDROTract: PneumoniaS PneumoniaRISK FACTORS FOR MDROS

OUTPATIENTNO RISK FACTORS FOR MDROS OUTPATIENTRISK FACTORS FOR MDROS Previously healthy AND no antibiotic use in Treat accordingly based on risk factors and previousOUTPATIENT 90 days: microbiologicOUTPATIENT history Previously healthy AND no antibiotic use in Treat accordingly based on risk factors and Doxycycline 100 mg PO Q12H for 5 days Consider paging Infectious Diseases previous 90 days: microbiologic history OR AzithromycinDoxycycline 100 500 mg mg PO PO Q12H for 1 fordose, 5 days then Consider paging Infectious Diseases 250OR mg PO Q24H for 4 days Azithromycin 500 mg PO for 1 dose, then OUTPATIENT250 mg PO Q24H for 4 days Presence of ≥ 1 co-morbidities* OR antibiotic OUTPATIENT use in previous 30 days: Presence of ≥ 1 co-morbidities* OR antibiotic Moxifloxacin 400 mg PO Q24H for 5 to 7 days use in previous 30 days: OR AmoxicillinMoxifloxacin 1 gm400PO mgQ8H PO Q24Hfor 5 tofor 7 5daysto 7 days OROR Amoxicillin/Amoxicillin 1clavulanate gm PO Q8H875 for mg 5 to PO 7 Q12Hdays forOR 5 to 7 days ANDAmoxicillin/clavulanate 875 mg PO Q12H Azithromycinfor 5 to 7 days 500 mg PO for 1 dose, then 250AND mg PO Q24H for 4 days Azithromycin 500 mg PO for 1 dose, then 250 mg PO Q24H for 4 days THERAPY CONSIDERATIONS • Cough and chest X-ray may take 4 to 6 weeks to improve/change THERAPY CONSIDERATIONS • Duration of therapy • Cough• andCommunity chest X--rayacquired may take pneumonia: 4 to 6 weeks 5–7 todays improve/change • Duration• Healthcare of therapy-associated pneumonia, hospital-acquired pneumonia, ventilator-associated • pneumonia:Community- 7acquired–8 days; pneumonia: provided that 5–the7 days targeted pathogen is identified based on • bronchoscopyHealthcare-associated and the etiologicpneumonia, pathogen hospital is -notacquired P. aeruginosa pneumonia,, and ventilator that the patient-associated is: afebrilepneumonia: for 48 7 –to8 days;72 hours provided that the targeted pathogen is identified based on ANDbronchoscopy≤ 1 of the andfollowing:the etiologic pathogen is not P. aeruginosa, and that the patient is: HRafebrile >100 forbpm, 48 RRto 72>24 hours bpm, BP < 90 mmHg (systolic), O2 sat <90%, altered mental status AND ≤ 1 of the following: BP= blood pressure;HR >100 bpm= bpm, beats RRor breaths >24 bpm, per minute; BP < 90 H= mmHghour(s); HR=(systolic heart ),rate; O IV=sat intravenous; <90%, altered MDRO= mental multi-drug status resistant organism; PO= by mouth; Q= every; RR= respiratory rate 2 *PresenceBP= blood ofpressure; comorbidities: bpm= beats chronic or breaths heart, lung, per minute; liver or H=renal hour(s); disease; HR= diabetes; heart rate; alcoholism; IV= intravenous; malignancies; MDRO= asplenia multi-drug; immunosuppressingresistant organism; PO= conditions by mouth; or medications Q= every; RR= respiratory rate Note:*PresenceDosing of basedcomorbidities: on normal chronic renal function.heart, lung, Refer liver to or Table renal of disease; Contents diabetes; for section alcoholism; on Antimicrobial malignancies; Dosing asplenia for Adult; Patientsimmunosuppressing Based on Renal conditions Function or. medications Note: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function.

References: 1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72 2.References:American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, 1. ventilatorMandell LA,-associated, Wunderink andRG, healthcare Anzueto -A,associated et al. Infectious pneumonia Diseases. Am JSociety Respir ofCrit America/AmericanCare Med. 2005 Feb Thoracic 15;171(4):388 Society -consensus416. guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72 2. American Thoracic Society; Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005 Feb 15;171(4):388-416. PAGE 16 SepsisSepsis

IV Antibiotics: • If the patient is pregnant, contact pharmacy or Infectious Diseases for assistance regarding • Antibiotics should be ordered AFTER a review safety and dosage of previous microbiology data present in • Penicillin allergic or optional antibiotic choices patient’s electronic medical record are listed second and italicized • Risk Factors for MRSA,VRE, and ESBL include: • Antibiotics should be adjusted for weight and - Hospitalization within the past year renal function in ALL patients - Patient receives hemodialysis - Consult pharmacy or Infectious Diseases if - Oozing or open wound needed for assistance in monitoring - Past history of documented MRSA, VRE, or therapeutic drug level ESBL - Patient is a nursing home resident Administer antibiotics within FIRST HOUR of - Patient has a catheter or line present recognition of sepsis

SUSPECTED Clostridium difficile INFECTION

Vancomycin 500 mg PO/NGT x1 NOW PLUS Metronidazole 500 mg IV x1 NOW

SUSPECTED RESPIRATORY SOURCE SUSPECTED URINARY SOURCE SUSPECTED INTRA-ABDOMINAL SOURCE

Azithromycin 500 mg IV x1 NOW Piperacillin/tazobactam 3.375 gm Piperacillin/tazobactam 3.375 gm PLUS IV x1 NOW IV x1 NOW Ceftriaxone 2 gm IV x1 NOW OR OR OR If risk factors for MDR GNR or If risk factors for MDR GNR or Piperacillin/tazobactam 3.375 gm ESBL ESBL IV x1 NOW Meropenem 2 gm x1 NOW Meropenem 2 gm IV x1 NOW OR If risk factors for MRSA If risk factors for MDR GNR or Vancomycin 25-30 mg/kg ABW* ESBL IV LD x1 NOW Meropenem 2 gm x1 NOW If risk factors for VRE If risk factors for MRSA Daptomycin 8-10mg/kg (ABW) x1 Vancomycin 25-30 mg/kg ABW* NOW & Consult ID IV LD x1 NOW If penicillin allergy, may consider consulting ID or substituting meropenem 2gm x1 NOW for other beta lactams (monitor; ≤5% cross-reactivity with ). ABW= Actual Body Weight; ESBL= Extended Spectrum Beta-Lactamase; ID= Infectious Diseases; IV= intravenous; LD= loading dose; MDR GNR= Multi-Drug Resistant Gram-Negative Rods; MRSA= Methicillin-Resistant S. aureus; NGT= Nasogastric tube; PO= By Mouth; VRE= Vancomycin –Resistant

*Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients

PAGE 17 SymptomaticSymptomatic Sexually Sexually Transmitted Transmitted Infection Infection Screening Screening

SYMPTOMATIC

Clinical and Therapeutic Symptoms Recommended Diagnostic Testing Considerations

Female • Vaginal itching Vaginal examination: Promptly begin empiric Symptomatic• Vaginal Sexuallydischarge Transmitted1. Observe vaginal Infection anatomy Screeningtreatment of Chlamydia and • Painful urination 2. Gram stain for bacterial Gonorrhea before lab results • Increased urinary vaginosis return SYMPTOMATIC urgency 3. Vaginal swabs for PCR assay: • Pelvic pain • Gonorrhea Clinical Vaginaland Therapeutic exam will allow Symptoms Recommended Diagnostic Testing • Pain with sexual • Chlamydia Considerationsvisualization of vaginal intercourse 4. Vaginal swabs for Affirm DNA anatomy Female • Vaginal itching Vaginal examination: Promptly begin empiric •• Vaginal discharge bleeding 1. Observe vaginal• Trichomoniasis anatomy treatment of Chlamydia and •• GenitalPainful urination warts 2. Gram5. HIV stain test for bacterial Gonorrhea Vaginalbefore lab or results cervical swab may •• GenitalIncreased lesion/ulcer urinary vaginosis6. Syphilis (RPR screen/ titer) return be necessary for specific test • Pharyngitisurgency 3. Vaginal7. Urinalysis swabs for PCR assay: kits • Pelvic pain 8. • PregnancyGonorrhea Test Vaginal exam will allow Pain with sexual Chlamydia visualization of vaginal • 9. • Oropharyngeal (OP) Culture intercourse 4. Vaginal swabs for Affirm DNA anatomy • Vaginal bleeding • swabTrichomoniasis for GC when indicated • Genital warts 5. HIV test Vaginal or cervical swab may • Genital lesion/ulcer 6. SyphilisUnable (RPR to perform screen/ titer) vaginal be necessaryPromptly for specific begin test empiric • Pharyngitis 7. Urinalysisexamination: kits treatment of Chlamydia and 8. Pregnancy1. Urinalysis Test Gonorrhea before lab results 9. Oropharyngeal2. Urine for (OP)PCR Cultureassay: return swab for GC• Gonorrheawhen indicated Unable to perform• Chlamydia vaginal Promptly begin empiric examination:3. HIV test treatment of Chlamydia and 1. Urinalysis4. Syphilis (RPR screen/titer) Gonorrhea before lab results 2. Urine5. Pregnancy for PCR assay: Test return • Gonorrhea 6. OP Culture for GC when • Chlamydia 3. HIV testindicated 4. Syphilis (RPR screen/titer) Male • Penile discharge 5. Pregnancy1. Urinalysis Test Promptly begin empiric • Painful urination 6. OP2. CultureUrine for for GC PCR whenassay: treatment of Chlamydia and • Increased urgency indicated• Gonorrhea Gonorrhea before lab results • Pelvic pain • Chlamydia return Male • Penile discharge 1. Urinalysis Promptly begin empiric •• Swollen/tenderPainful urination 2. Urine3. HIV for PCRtestassay: treatment of Chlamydia and • testiclesIncreased urgency 4. • SyphilisGonorrhea (RPR screen/ titer) Gonorrhea before lab results •• PainPelvic withpain sexual 5. • OPChlamydia Culture Swab or Rectal return • intercourseSwollen/tender 3. HIV testculture swab for GC when • Genitaltesticles warts 4. Syphilisindicated (RPR screen/ titer) • Pain with sexual 5. OP Culture Swab or Rectal • Genitalintercourse lesion/ulcer culture swab for GC when •• PharyngitisGenital warts indicated • Genital lesion/ulcer • PharyngitisTREATMENT (DISCUSS TREATMENT OF PREGNANT WOMEN WITH ID AND OB/GYN)

Gonorrhea TREATMENTCeftriaxone(DISCUSS TREATMENT 250 OFmgPREGNANT IM ANDWOMENAzithromycinWITH ID AND OB/GYN) 1 gm PO x 1 dose Chlamydia OR doxycycline 100 mg PO Q12H for 7 days Gonorrhea Ceftriaxone 250 mg IM AND Azithromycin 1 gm PO x 1 dose Chlamydia OR doxycycline 100 mg PO Q12H for 7 days Penicillin Allergy (anaphylaxis): Consult ID Penicillin Allergy (anaphylaxis): Consult ID HIV or Syphilis Consult Infectious Diseases HIV or Syphilis Consult Infectious Diseases Bacterial vaginosis Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at Bacterial vaginosis Metronidazole gel 0.75%, one full applicator (5gm) intravaginally once daily at bedtimebedtime for 5 for days 5 days

Alternatives:Alternatives: Metronidazole Metronidazole 500 mg 500PO Q12H mg POOR Q12HclindamycinOR clindamycin 300 mg PO Q12H 300 mg PO Q12H forfor 7 days 7 days

TrichomonasTrichomonasvaginalisvaginalis MetronidazoleMetronidazole 2 gm 2PO gm x 1 PO dose x 1OR dosemetronidazole OR metronidazole500 mg PO Q12H500 mg for PO7 days Q12H for 7 days DNA= deoxyribonucleic acid; GC= gonococcus; H= hours; HIV= human immunodeficiency virus; ID= infectious diseases; IM= intramuscular; DNAOB/GYN== deoxyribonucleic obstetrics/gynecology; acid; GC= OP= gonococcus Oropharyngeal;; H= PCR=hours; Polymerase HIV= human chain reaction;immunodeficiency PO= by mouth virus; Q=; every; ID= infectious RPR= rapid diseases;plasma reagin IM=; intramuscular; OB/GYN=STI= sexually obstetrics/gynecology; transmitted infection. OP= Oropharyngeal; PCR= Polymerase chain reaction; PO= by mouth; Q= every; RPR= rapid plasma reagin; STI= sexually transmitted infection. PAGE 18 AsymptomaticAsymptomatic Sexually Sexually Transmitted Transmitted Infection Infection Screening Screening

ASYMPTOMATIC Screening Clinical and Therapeutic Population Frequency Recommendations Considerations

Female Age ≤ 25 Urine PCR for Chlamydia Annually Cervical screening should be performed 3 years after Urine PCR for Gonorrhea Annually initiating sexual activity or no HIV test At least once later than age 21 Cervical Screening No later than age 21 Age > 25 No routine screening for Consider minimum of annual STIs screening if high risk* patient Screen according to risk

Pregnant Urine PCR for Chlamydia First trimester Repeat Screening (all pathogens) in 3rd trimester Urine PCR for Gonorrhea First trimester and at birth if patient is high HIV test First trimester risk* Hepatitis B S Ag, S Ab, C Ab First trimester Hepatitis C Ab First trimester Syphilis RPR/titer First trimester

HIV-positive Urine PCR for Chlamydia Annually *Consider rectal and pharyngeal culture swabs for Urine PCR for Gonorrhea* Annually GC if exposed Syphilis RPR/titer Annually May repeat screening every Trichomoniasis Annually 3-6 months, as indicated by Hepatitis B S Ag, S Ab, C Ab Baseline risk Hepatitis C Ab Yearly if high risk*

EPT= expedited partner treatment; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Antibody; HIV= human immunodeficiency virus; MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma reagin; STI= sexually transmitted infection Test of Cure/ Retest Post Diagnosis and Treatment of Gonorrhea or Chlamydia - Retest all patients after 3 months for reinfection (if 3 months not possible, within 1 year). - Retest all pregnant patients a minimum of >/=3 weeks after completion of therapy. - If suspect treatment failure, reinfection , or failure due to alternative regimen then repeat testing at a minimum of >/= 3weeks after completion of therapy. - For pharyngeal gonorrhea– get test of cure on all patients after 14 days. Culture and susceptibilities preferred.

Note: Gonnorrhea/Chlamydial PCR <3 weeks from completion of therapy are not recommended due to presence of non-viable organisms and false-positive results.

STIs: Partner Treatment -Any recent sexual partner who has had contact with the infected patient within 60 days of their diagnosis should be considered for treatment. -Discuss treatment of partners or questions regarding Expedited Partner Treatment (EPT) with the Infectious Disease Service. -EPT should not be employed with MSMs (these patients should be referred for comprehensive STI testing first).

*Definition of High Risk Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

PAGE 19 Asymptomatic Sexually Transmitted Infection Screening

AsymptomaticAsymptomatic Sexually Sexually Transmitted TransmittedASYMPTOMATIC Infection Infection Screening Screening Screening Clinical and Therapeutic Population ASYMPTOMATIC Frequency Recommendations Considerations Screening Clinical and Therapeutic Male HeterosexualPopulation No routine screening Frequencyfor STIs. Screen according to *risk. men Note:Recommendations All ‘Babyboomers’ (Patients born from 1945 throughConsiderations 1965) should be Male Heterosexual No routine screening forscreened STIs. Screen for HCVaccording to *risk. men Note: All ‘Babyboomers’ (Patients born from 1945 through 1965) should be Men who have Urine PCR for Chlamydia Annually Consider GC/Chl culture, sex with men screened for HCVrectal and pharyngeal swabs (MSM) Urine PCR for Gonorrhea Annually Men who have Urine PCR for Chlamydia Annually Consider GC/Chl culture, ORsex with men HIV test Annually Highrectal risk and defined pharyngeal as: swabs *high risk Urine PCR for Gonorrhea Annually - New or multiple sex (MSM) Hepatitis B S Ag, S Ab, C Ab Baseline heterosexualOR men HIV test Annually Highpartners risk defined as: Hepatitis C Ab Annually *high risk - InconsistentNew or multiple condom sex use Hepatitis B S Ag, S Ab, C Ab Baseline heterosexual men Syphilis (RPR screen/ titer) Annually - Commercialpartners sex work Hepatitis C Ab Annually - DrugInconsistent use condom use Syphilis (RPR screen/ titer) Annually - Commercial sex work May- Drug repeat usescreening every 3-6 months, as indicated by riskMay repeat screening every 3-6 months, as indicated by HIV-positive men Urine PCR for Chlamydia Annually Consider GC/Chl culture, rectalrisk and pharyngeal swabs Urine PCR for Gonorrhea Annually HIV-positive men Urine PCR for Chlamydia Annually Consider GC/Chl culture, Syphilis (RPR screen/ titer) Annually Mayrectal repeat and pharyngealscreening everyswabs Urine PCR for Gonorrhea Annually 3-6 months, as indicated by Hepatitis B S Ag, S Ab, C Ab Baseline Syphilis (RPR screen/ titer) Annually riskMay repeat screening every Hepatitis C Ab Annually 3-6 months, as indicated by Hepatitis B S Ag, S Ab, C Ab Baseline risk GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody; Hepatitis B S Ag= Hepatitis B SurfaceHepatitis Antigen; Hepatitis C Ab C Ab= Hepatitis C CoreAnnually Antibody; HIV= human immunodeficiency virus; MSM= Men who have sex with men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection. GC/Chl= gonorrhea/chlamydia; HCV= Hepatitis C virus; Hepatitis B C Ab= Hepatitis B Core Antibody; Hepatitis B S Ab= Hepatitis B Surface Antibody; Hepatitis B S Ag= Hepatitis B Surface Antigen; Hepatitis C Ab= Hepatitis C Core Antibody; HIV= human immunodeficiency virus; MSM=*Definition Men who of Highhave sexRisk with men; PCR= polymerase chain reaction; RPR= rapid plasma regain; STI = sexually transmitted infection. Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent*Definition sex contact of High outside Risk the US. Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

References: 1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf. 2.References:"Primary, Secondary, and Early Latent Syphilis Surveillance 2007-2011." Division of Infectious Disease & Epidemiology. Rhode Island Department 1. of"Sexually Health, Transmitted 2011. URL: httpDiseases://www.health.ri.gov/data/diseases/Syphilis.pdf Treatment Guidelines, 2015." Centers for Disease. Control and Prevention. Department of Health and Human 3. “CaliforniaServices, 17 Sexually Dec. 2010. Transmitted URL: http Disease://www.cdc.gov/std/treatment/2010/STD (STD) Screening Recommendations-Treatment 2010”. California-2010-RR5912.pdf Department. Of Public Health, June. 2011. URL: 2. http"Primary,://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA Secondary, and Early Latent Syphilis Surveillance 2007--STD2011."-Screening Division-Recommendations.pdf of Infectious Disease & Epidemiology. Rhode Island Department of Health, 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf. 3. “California Sexually Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL: http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf PAGE 20 Asymptomatic Sexually Transmitted Infection Screening Asymptomatic Sexually Transmitted Infection Screening Asymptomatic Sexually TransmittedHIV testing Infection Screening Population Frequency HIV testing Special Considerations Consider frequent testing if high PopulationAll women age 13-64 FrequencyBaseline Special Considerations risk* Consider frequent testing if high All women age 13-64 Baseline risk*Consider PREP if HIV+ partner All women who seek STI screening At time of STI (Consult ID) Consider PREP if HIV+ partner All women who seek STI screening At time of STI (ConsultThird trimester ID) and at birth if high All pregnant women First Trimester risk Third trimester and at birth if high All pregnant women First Trimester riskConsider frequent testing if high All men age 13-64 Baseline risk* Consider frequent testing if high All men age 13-64 Baseline risk*Q3-6 months if higher risk activity MSM Annually (minimum) (Consider PREP and consult ID) Q3-6 months if higher risk activity MSM Annually (minimum) (ConsiderConsider PREP PREP if and HIV+ consult partner ID) All men who seek STI screening At time of STI (consult ID) Consider PREP if HIV+ partner All men who seek STI screening At time of STI HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP=(consult pre-exposure ID) prophylaxis; Q= every; RPR= rapid plasma regain; STI= sexually transmitted infection. HIV= human immunodeficiency virus; ID= infectious diseases; MSM= Men who have sex with men; PREP= pre-exposure prophylaxis; Q= every; *RPR=Definition rapid plasma of High regain; Risk STI= sexually transmitted infection. Those who have a new sex partner, >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , *inconsistentDefinition of condom High Risk use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, Thoserecent whosex contact have a newoutside sex thepartner, US. >1 sex partner, a sex partner with concurrent partners, a sex partner who has a STI , inconsistent condom use in persons not in mutually monogamous relationships, illicit drug use, exchange of sex with drugs, recent sex contact outside the US.

References: 1. "Sexually Transmitted Diseases Treatment Guidelines, 2015." Centers for Disease Control and Prevention. Department of Health and Human References:Services, 17 Dec. 2010. URL: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf. 1.2. "Sexually"Primary, TransmittedSecondary, andDiseases Early LatentTreatment Syphilis Guidelines, Surveillance 2015." 2007 Centers-2011." for Division Disease of Control Infectious and DiseasePrevention. & Epidemiology. Department Rhodeof Health Isla andnd Department Human Services,of Health, 17 2011. Dec. URL: 2010. http URL::// www.health.ri.gov/data/diseases/Syphilis.pdfhttp://www.cdc.gov/std/treatment/2010/STD.-Treatment-2010-RR5912.pdf. 2.3. "“CaliforniaPrimary, Secondary, Sexually Transmitted and Early Latent Disease Syphilis (STD) SurveillanceScreening Recommendations 2007-2011." Division 2010”. of Infectious California DiseaseDepartment & Epidemiology. Of Public Health, Rhode June. Island20 Department11. URL: ofhttp Health,://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA 2011. URL: http://www.health.ri.gov/data/diseases/Syphilis.pdf-STD-Screening. -Recommendations.pdf 3. “California Sexually Transmitted Disease (STD) Screening Recommendations 2010”. California Department Of Public Health, June. 2011. URL: http://www.cdph.ca.gov/pubsforms/Guidelines/Documents/CA-STD-Screening-Recommendations.pdf PAGE 21 Skin and Soft Tissue Infections (SSTI) SkinSkin and and Soft Soft Tissue InfectionsTissue Infections (SSTI) (SSTI) NONPURULENT Necrotizing Infection/Cellulitis/ErysipelasNONPURULENT [UsuallyNecrotizing Streptococcus Infection/Cellulitis/ pyogenes (Group A Strep)] [Usually (Group A Strep)] Mild: Moderate: Severe: No systemic signs Systemic signs of (any of Severe:the following): Mild: Moderate: Systemic signs of infection*, of infection* infection* (any of the following): No systemic signs Systemic signs of failed antibiotic treatment, Systemic signs of infection*, of infection* infection* immunocompromise, failed antibiotic treatment, hemodynamic instability, or Intravenous immunocompromise, Oral deep infection Antibiotic Therapy AntibioticIntravenous Therapy hemodynamic instability, or Oral deep infection Antibiotic Therapy Antibiotic Therapy Intravenous Antibiotic Therapy Select ONE: Select ONE: Intravenous Antibiotic Therapy Penicillin VK Select ONE: Penicillin Emergent Surgical 250-500 mg PO Q6H Select ONE: Penicillin VK 2-4 million units IV Inspection/Debridement Cephalexin Penicillin Emergent Surgical 250-500 mg PO Q6H Q4-6H • Rule out necrotizing 500 mg PO Q6H 2-4 million units IV Inspection/Debridement Cephalexin Ceftriaxone process Q4-6H • Rule out necrotizing 500 mg PO Q6H 1 gm IV Q24H Culture & Sensitivity 250 mg PO Q6H Ceftriaxone process Dicloxacillin Empiric Treatment Clindamycin 1 gm IV Q24H Culture & Sensitivity 250 mg PO Q6H 1 gm IV Q8H • Vancomycin 15 mg/kg 300-450 mg PO Q6H Cefazolin Empiric Treatment Clindamycin Clindamycin IV** PLUS 1 gm IV Q8H • Vancomycin 15 mg/kg 300-450 mg PO Q6H 600-900 mg IV Q6H Piperacillin/tazobactam Clindamycin • IV** PLUS 3.375 gm IV Q6H 600-900 mg IV Q6H • Piperacillin/tazobactam +/- 3.375 gm IV Q6H Clindamycin 900 mg IV • +/- Q8H*** • Clindamycin 900 mg IV Q8H*** Defined Treatment (Necrotizing Infections) Monomicrobial Defined Treatment (Necrotizing Infections) Streptococcus pyogenes Monomicrobial •StreptococcusPenicillin 2- pyogenes4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H Vibrio vulnificus • Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H •VibrioDoxycycline vulnificus100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H Aeromonas hydrophila • Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H •AeromonasDoxycyclinehydrophila 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H Polymicrobial • Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H Vancomycin 15 mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H •Polymicrobial H= hours; IV= intravenous;• Vancomycin PO= oral; Q=15 every mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H

*SystemicH= hours; signs IV= intravenous; of infection include,PO= oral; but Q= are every not limited to, temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL). **Refer*Systemic to signssection of oninfection Vancomycin include,Dosing but are and not Monitoring limited to, in temperature Adult Patients >38. °C, tachycardia (heart rate >90 beats per minute), ***Considertachypnea (respiratory this addition rate for >24 necrotizing breaths perfasciitis. minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL). Note:**Refer Refer to section to Table on of Vancomycin Contents forDosing section and on Monitoring Antimicrobial in Adult Dosing Patients for Adult. Patients Based on Renal Function for dosing in patients***Consider with this renal addition impairment for necrotizing. fasciitis. Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in patients with renal impairment.

References: 1. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin References:and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2): e10-52. 2.1. DuongStevens M, DL, Markwell Bisno AL, S, ChambersPeter J, Barenkamp HF, DellingerS. Randomized, EP, Goldstein controlled EJ, Gorbach trialSL, of et antibiotics al. Practice in guidelinesthe management for the ofdiagnosis community and -managementacquired skin of skin abscessesand soft tissue in the infections: pediatric patient.2014 update Ann Emergby the MedInfectious 2010; Diseases55:401–7 Society. of America. Clin Infect Dis. 2014; 59(2): e10-52. 3.2. MacfieDuong M,J, Harvey Markwell J. The S, Petertreatment J, Barenkamp of acute superficialS. Randomized, abscesses: controlled a prospective trial of antibiotics . in theBr Jmanagement Surg 1977; 64:264 of community–6. -acquired skin 4. LleraabscessesJL, Levy in theRC. pediatricTreatment patient. of cutaneous Ann Emerg abscess:Med a 2010; double 55:401-blind– 7clinical. study. Ann Emerg Med 1985; 14:15–9. 5.3. RutherfordMacfie J, Harvey WH, Hart J. The D, treatmentCalderwood of JW,acute Merrett superficial JD. Antibiotics abscesses: in a surgicalprospective treatment clinical of trial. septicBr Jlesions. Surg 1977; Lancet 64:2641970;–6 1:1077. –80. 6.4. SchmitzLlera JL, GR,Levy Bruner RC. Treatment D, Pitotti ofR, cutaneouset al. Randomized abscess: controlled a double- blindtrial ofclinical trimethoprim study. Ann-sulfamethoxazole Emerg Med 1985; for 14:15 uncomplicated–9. skin abscesses in 5. patientsRutherford at riskWH, for Hart community D, Calderwood-associated JW, Merrettmethicillin JD.- resistantAntibiotics Staphylococcus in surgical treatment aureus infection.of septic lesions. Ann Emerg LancetMed1970; 2010; 1:1077 56:283–80–7.. 6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant infection. Ann Emerg Med 2010; 56:283–7. PAGE 22 SkinSkin and and Soft Soft Tissue InfectionsTissue Infections (SSTI) (SSTI) Skin and Soft Tissue InfectionsPURULENT (SSTI) Furuncle/Carbuncle/Abscess (Usually StaphylococcusPURULENT aureus) Furuncle/Carbuncle/Abscess Mild: (Usually StaphylococcusModerate: aureus) Severe: No systemic signs Systemic signs of (any of the following): of infectionMild: * Moderate:infection* FailedSevere: I&D and oral No systemic signs Systemic signs of (anyantibiotics, of the following): systemic of infectionNo * infection* Failedsigns I&D of and infection*,oral Antibiotic Incision and Drainage antibiotics,immunocompromise systemic , No and C&S signs of infection*, Therapy Incision and Drainage hemodynamic Antibiotic immunocompromiseinstability, or deep, and C&S hemodynamic Therapy Oral infection instability, or deep Antibiotic Incision and Drainage Oral infection AntibioticTherapy Incision and Drainage Incision and Drainage Therapy Incision andand DrainageC&S and C&S Empiric Therapy (select ONE): Empiric• TMP/SMX Therapy 1- (2s electDS tablets ONE): PO Q12H Intravenous • TMP/SMXDoxycycline 1-2 100 DS tabletsmg PO PO Q12H Q12H IntravenousAntibiotic •DefinedDoxycycline Therapy 100 mg PO Q12H AntibioticTherapy DefinedMRSA Therapy Therapy MRSA• TMP/SMX (see empiric dose) •MSSATMP/ (selectSMX (see ONE empiric): dose) MSSA• Dicloxacillin (select ONE500): mg PO Q6H • DicloxacillinCephalexin 500500 mg mg PO PO Q6H Q6H • Cephalexin 500 mg PO Q6H Empiric Therapy (select ONE): Empiric• Vancomycin Therapy (select15 mg/kg ONE): IV** • Vancomycin 15 mg/kg IV** • Daptomycin 6 mg/kg IV Q24H • Daptomycin 6 mg/kg IV Q24H Linezolid 600 mg IV Q12H • •Linezolid 600 mg IV Q12H • •CeftarolineCeftaroline600600 mg IVmg Q12H IV Q12H DefinedDefined Therapy Therapy MRSAMRSA • •SeeSee empiric empiric therapy therapy above above MSSAMSSA (select (select ONE ONE): ): • •NafcillinNafcillin1-2 1gm-2 gmIV Q4HIV Q4H • •CefazolinCefazolin1 gm1 gmIV Q8HIV Q8H • •ClindamycinClindamycin 600 600 mg IVmg Q8H IV Q8H

C&S=C&S= culture culture and and sensitivity; sensitivity; DS= double--strength;strength; H= H= Hours; Hours; I&D= I&D= incision incision and and drainage; drainage; IV= intravenous;IV= intravenous; MRSA= MRSA= methicillin methicillin- - resistantresistant Staphylococcus Staphylococcus aureusaureus; MSSA= methicillinmethicillin-susceptible-susceptible Staphylococcus Staphylococcus aureus aureus; PO=; PO= by mouth; by mouth; Q= every; Q= every; Rx=Rx= treatment; treatment; TMP/SMX= TMP/SMX= trimethoprimtrimethoprim--sulfamethoxazolesulfamethoxazole *Systemic signs of infection, but are not limited to, include temperature >38°C, tachycardia (heart rate >90 beats per minute), *Systemic signs of infection, but are not limited to, include temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL). tachypnea**Refer to (respiratory section on Vancomycinrate >24 breathsDosing per and minute) Monitoring or abnormal in Adult Patients white blood. cell count (>12 000 or <4000 cells/µL). **Refer to section on Vancomycin Dosing and Monitoring in Adult Patients.

References: References:1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update 1. Stevensby the DL,Infectious Bisno AL,Diseases Chambers Society HF, of et America al. Practice. Clin Infect guidelines Dis. 2014; for the 59(2): diagnosis e10-52. and management of skin and soft tissue infections: 2014 update 2.byDuong the Infectious M, Markwell Diseases S, Peter Society J, Barenkamp of AmericaS. Randomized,. Clin Infect Dis.controlled 2014; trial59(2): of e10antibiotics-52. in the management of community-acquired skin 2. Duongabscesses M, Markwell in the pediatric S, Peter patient. J, Barenkamp Ann EmergS. Randomized,Med 2010; 55:401 controlled–7. trial of antibiotics in the management of community-acquired skin 3.abscessesMacfie J, in Harvey the pediatric J. The treatment patient. ofAnn acute Emerg superficialMed 2010; abscesses: 55:401 a –prospective7. clinical trial. Br J Surg 1977; 64:264–6. 3. 4.MacfieLlera JL,J, Harvey Levy RC. J. TreatmentThe treatment of cutaneous of acute abscess: superficial a double abscesses:-blind clinical a prospective study. Ann clinical Emerg trial.Med Br 1985; J Surg 14:151977;–9. 64:264–6. 4. 5.LleraRutherfordJL, Levy WH,RC. TreatmentHart D, Calderwood of cutaneous JW, Merrett abscess: JD. a Antibiotics double-blind in surgical clinical treatment study. Ann of Emergseptic lesionsMed 1985;. Lancet 14:15 1970–9; .1:1077–80. 5. 6.RutherfordSchmitz GR, WH, Bruner Hart D, D, Pitotti CalderwoodR, et al. JW,Randomized Merrett controlledJD. Antibiotics trial ofin trimethoprimsurgical treatment-sulfamethoxazole of septic lesionsfor uncomplicated. Lancet 1970 skin; 1:1077 abscesses–80. in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7. 6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7. PAGE 23 SSkinkin and and Soft Soft Tissue: Tissue: Diabetic Diabetic Foot InfectionsFoot Infections

RECOMMENDED EMPIRICAL SEVERITY OF INFECTION SUSPECTED ORGANISMS DURATION TREATMENT Mild MSSA Oral 1–2 weeks • Only skin and Streptococcus spp. Amoxicillin/clavulanate 875 mg subcutaneous tissue PO Q12H involvement OR AND Cephalexin 500 mg PO Q6H • Erythema > 0.5 cm and OR ≤ 2 cm around ulcer Dicloxacillin 250 – 500 mg PO • Perform incision and Q6H drainage as necessary MRSA Doxycycline 100 mg PO Q12H OR SMX/TMP 2 DS tablets PO Q12H (Does not cover Group A Strep) Moderate** MSSA Oral OR Initially Parenteral 1–3 weeks • Deeper tissue Streptococcus spp. Ampicillin-sulbactam 1.5–3 gm IV involvement Enterobacteriaceae Q6H OR Obligate anaerobes OR • Erythema > 2.0 cm Ceftriaxone 1 gm IV Q24H around ulcer Penicillin Allergy: AND • No systemic signs of Ciprofloxacin 500 mg PO Q12H infection AND • Perform incision and Clindamycin 300 mg PO Q6H drainage as necessary OR Ceftriaxone 1 gm IV Q24H MRSA Linezolid 600 mg IV/PO Q12H† (Requires ID Consult) OR Daptomycin 6 mg/kg IV Q24H† (Requires ID Consult) OR Vancomycin 15 mg/kg IV* Pseudomonas Piperacillin-tazobactam aeruginosa 3.375 gm IV Q4H

DS= Double Strength; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin sensitive S. aureus; PO= by mouth; Q= every; SMX-TMP= sulfamethoxazole/trimethoprim; spp= species

† Restricted Antibiotic – refer to Table of Contents for Guidelines for Restricted Antimicrobials * Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients ** Consult Infectious Diseases and Podiatry

NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function

PAGE 24 Skin and Soft Tissue: Diabetic Foot Infections

SkinSkin and and Soft Soft Tissue: Tissue: Diabetic Diabetic FootR ECOMMENDED InfectionsFoot InfectionsEMPIRICAL SEVERITY OF INFECTION SUSPECTED ORGANISMS DURATION TREATMENT RECOMMENDED EMPIRICAL S**EVERITY OF INFECTION SUSPECTED ORGANISMS DURATION Severe MSSA/MRSA Initially ParenteralTREATMENT • Same as moderate P. aeruginosa ** Vancomycin 15 mg/kg IV* SevereAND MSSA/MRSAStreptococcus spp. Initially Parenteral • Same as moderate P. aeruginosa AND** • Systemic signs of infection Enterobacteriaceae Vancomycin 15 mg/kg IV* 2–4 weeks AND Streptococcus spp. Cefepime 2 gm IV Q8H + present Obligate anaerobes AND** • Systemic signs of infection Enterobacteriaceae metronidazole 500 mg IV Q6H 2–4 weeks Systemic Inflammatory Cefepime 2 gm IV Q8H + present Obligate anaerobes OR Response Syndrome (SIRS) metronidazole 500 mg IV Q6H Systemic Inflammatory Piperacillin-tazobactam Criteria ≥2 of the following: OR Response Syndrome (SIRS) 3.375 gm IV Q4H Piperacillin-tazobactam Criteria• Temperature ≥2 of the <96.8following:°F 3.375 gm IV Q4H OR >100.4°F Bone OR Joint Involvement‡ • TemperatureP > 90 BPM <96.8°F • ORRR >>100.4 20 BPM°F BoneSourceOR removed:Joint Involvement2-5 days ‡ • P > 90 BPM • PaCO2 < 32 mmHg Source removed but residual tissue infection: • RR > 20 BPM Source removed: 2-5 days • WBC < 4000 cells/mm³ 1-3 weeks • PaCOOR >12,0002 < 32 mmHg cells/mm³ Source removed but residual tissue infection: • WBC≥ 10% < immature4000 cells/mm³ (band) 1Source-3 weeksremoved but residual bone infection: ORforms>12,000 cells/mm³ 4-6 weeks • ≥ 10% immature (band) Source removed but residual bone infection: • Perform incision and 4Source-6 weeks not removed: ≥3 months formsdrainage as necessary • Perform incision and Source not removed: ≥3 months BPM=drainage beats or as breaths necessary per minute; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic BPM=Inflammatory beats or Response breaths per Syndrome; minute; H=spp hour(s);= species; IV= WBC= intravenous; white blood MRSA= cell methicillin resistant S. aureus; MSSA= methicillin sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic Inflammatory† Restricted Antibiotic Response – Syndrome;refer to Table spp =of species; Contents WBC= for Guidelines white blood for cell Restricted Antimicrobials * Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients †** Restricted Consult Infectious Antibiotic Diseases – refer to and Table Podiatry of Contents for Guidelines for Restricted Antimicrobials *‡ ReferDiscuss to plan Table with of Contents Infectious for Diseases, section onPodiatry, Vancomycin and VascularDosing and Monitoring in Adult Patients ** Consult Infectious Diseases and Podiatry ‡NOTE: DiscussDosing plan basedwith Infectious on normal Diseases, renal function. Podiatry, Refer and toVascular Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function

References: 1. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the References:Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73. 1.2. FlagylLipsky[packageBA, Berendt insert].AR, NewCornia York,PB, NY:Pile ;JC, Peters 2015. EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73. 2. Flagyl [package insert]. New York, NY: Pfizer; 2015. PAGE 25 Surgical Decolonization and Prophylaxis SurgicalSurgical Decolonization Decolonization and Prophylaxis and Prophylaxis DECOLONIZATION DECOLONIZATION Nasal Screening Result Recommended Intervention Nasal Screening Result Recommended Intervention MRSA Negative • No decolonization required MSSAMRSA NegativeNegative • No decolonization required MSSA PositiveNegative • Intranasal mupirocin twice daily x 5 days MSSA Positive • Intranasal mupirocin twice daily x 5 days MRSA Positive • Intranasal mupirocin twice daily x 5 days, MRSA Positive AND• Intranasal mupirocin twice daily x 5 days, •ANDChlorhexidine bathing one day prior to surgery

ANTIMICROBIAL• ChlorhexidinePROPHYLAXISbathing one day prior to surgery ANTIMICROBIAL PROPHYLAXIS CLINICAL CONSIDERATIONS • Preoperative dose-timing CLINICAL CONSIDERATIONS • PreoperativeWithin 60 minutesdose-timing of surgical incision WithinExceptions: 60 minutes vancomycin of surgicaland fluoroquinolones incision within 120 minutes of surgical incisionExceptions: vancomycin and fluoroquinolones within 120 minutes of surgical • Weightincision-based dosing • WeightCefazolin-based: 2 gm dosingfor patients <120 kg, and 3 gm for patients ≥120 kg Vancomycin:Cefazolin: 2 gm usefor ABW patients <120 kg, and 3 gm for patients ≥120 kg Gentamicin:Vancomycin: use use ABW ABW unless ABW is >120% of their IBW, in which case use AdjBWGentamicin:(see below use ABW for equation)unless ABW is >120% of their IBW, in which case use • DurationAdjBW of(see prophylaxis below for equation) • DurationA single of dose, prophylaxis or continuation for <24 hours is recommended A single dose, or continuationI NTRAfor <24-OPERATIVE hours isREDOSING recommended • Required if the duration of procedureINTRA-OPERATIVE exceeds twoREDOSING half-lives of the drug or if there • isRequired extensive if theblood duration loss during of procedure the procedure exceeds (>1500 two half mL)-livesŦ of the drug or if there • Recommendation:is extensive blood lossuse duringthe same the antibiotic procedure dose (>1500 and mL)measureŦ the redosing interval • fromRecommendation: the time of administration use the same of antibiotic the preoperative dose and dose, measure not the redosingtime of incision interval ABW=from actual the body timeweight; of AdjBW administration= adjusted body weight; of the IBW preoperative= ideal body weight; dose, MRSA= Methicillinnot the- resistanttime of Staphylococcus incision aureus; MSSA= Methicillin-susceptible Staphylococcus aureus ABW= actual body weight; AdjBW= adjusted body weight; IBW= ideal body weight; MRSA= Methicillin-resistant Staphylococcus Ŧaureus Redosing; MSSA may= Methicillinnot be necessary-susceptible for patients Staphylococcus with poor aureus renal function (CrCl <30mL/min)

Ŧ Redosing may not be necessary for patients with poor renal function (CrCl <30mL/min) IBW Calculation: AdjBW Calculation: Male = 50 kg + [2.3 kg for each inch over 5 feet] AdjBW = 0.4 (ABW-IBW) + IBW IBW Calculation: AdjBW Calculation: Female = 45 kg + [2.3 kg for each inch over 5 feet] Male = 50 kg + [2.3 kg for each inch over 5 feet] AdjBW = 0.4 (ABW-IBW) + IBW Female = 45 kg + [2.3 kg for each inch over 5 feet]

References: 1. Schweuzer ML, Chiang H, Septimus E, Moody J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections References:Among Patients Undergoing Cardiac, Hip, or Knee Surgery (STOP SSI – Study to Optimally Prevent SSI in Select Cardiac and Orthopedic 1. Procedures).Schweuzer ML, JAMA Chiang2015; H, 313(21):Septimus 2162E, Moody-2171. J, Braun B, Hafner J, et al. Association of a Bundled Intervention with Surgical Site Infections 2. ChenAmong AF, Patients Wessel UndergoingCB, Rao N. Staphylococcus Cardiac, Hip, or aureus Knee SurgeryScreening (STOP and SSI Decolonization – Study to Optimally in Orthopaedic PreventSurgery SSI in Select and Reduction Cardiac and of OrthopeSurgical dicSite Infections.Procedures). Clin JAMAOrthop2015;Relat 313(21):Res 2013; 2162 471:-2171. 2383-2399. 3.2. BratzlerChen AF,DW, Wessel Dellinger CB, Rao EP,N. Olsen Staphylococcus KM, Perl TM, aureus AuwaerterScreeningPG, Bolonand DecolonizationMK, et al. Clinical in Orthopaedic practice guidelinesSurgery forand antimicrobial Reduction of prophylaxis Surgical Site in surgery.Infections. Am Clin J HealthOrthop SystRelatPharmRes 2013; 70:195471: 2383-283.-2399. 3. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. PAGE 26 Antimicrobial Surgical Prophylaxis

AntimicrobialAntimicrobial Surgical REDOSINGSurgical ProphylaxisRECOMMENDATIONS Prophylaxis

Antibiotic REDOSINGHalf-life R(hours)ECOMMENDATIONS Redosing Interval (hours)

Ampicillin/sulbactamAntibiotic 0.8-1.3 Half-life (hours) 2 Redosing Interval (hours)

CefazolinAmpicillin/sulbactam 1.20.8-2.21.3 42

CefoxitinCefazolin 0.71.2-1.12.2 24 CiprofloxacinCefoxitin 30.7-7-1.1 Not2 necessary ClindamycinCiprofloxacin 23-47 6Not necessary GentamicinClindamycin 2-34 Not6 necessary MetronidazoleGentamicin 62-83 Not necessary VancomycinMetronidazole 46-8 Not necessary SURGICAL ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM Vancomycin RECOMMENDED4-8 AGENTS Not necessary PROCEDURE ALLERGY SURGICAL ALTERNATIVES FOR PATIENTS WITH BETA-LACTAM Laparoscopic, NoneRECOMMENDED AGENTS None PROCEDURE ALLERGY low-risk Laparoscopic, CefazolinNone , , ClindamycinNone or vancomycin + aminoglycoside highlow--riskrisk , ceftriaxone, or aztreonam or fluoroquinolone Laparoscopic, ampicillin/Cefazolin, cefoxitinsulbactam, Clindamycin or vancomycin + aminoglycoside high-risk cefotetan, ceftriaxone, or aztreonam or fluoroquinolone Small intestine, ampicillin/Cefazolin sulbactam Clindamycin + aminoglycoside or nonobstructed aztreonam or fluroquinolone Small intestine, Cefazolin Clindamycin + aminoglycoside or Smallnonobstructed intestine, Cefazolin + metronidazole, Metronidazoleaztreonam or fluroquinolone+ aminoglycoside or obstructed cefoxitin, cefotetan fluoroquinolone Small intestine, Cefazolin + metronidazole, Metronidazole + aminoglycoside or Herniaobstructed repair Cefazolincefoxitin, cefotetan Clindamycinfluoroquinolone, vancomycin

ColorectalHernia repair Cefazolin + metronidazole, Clindamycin,+ vancomycin aminoglycoside or cefoxitin, cefotetan, aztreonam or fluroquinolone; Colorectal ampicillin/sulbactamCefazolin + metronidazole, , MetronidazoleClindamycin + aminoglycoside+ aminoglycoside or or ceftriaxonecefoxitin, cefotetan+ , fluoroquinoloneaztreonam or fluroquinolone; metronidazoleampicillin/sulbactam, ertapenem, Metronidazole + aminoglycoside or ceftriaxone + fluoroquinolone Head and neck, Nonemetronidazole, ertapenem None Jen - thisclean page is too Head and neck, None None long. You’llHeadclean haveand neck, to Cefazolin, cefuroxime Clindamycin shorten placementit somehow. of prostheticHead and neck, Cefazolin, cefuroxime Clindamycin placement of Cleanprosthetic- Cefazolin + metronidazole, Clindamycin contaminated cefuroxime + cancerClean- surgery metronidazoleCefazolin + metronidazole, , Clindamycin contaminated ampicillin/sulbactamcefuroxime + cancer surgery metronidazole, ampicillin/sulbactam

References: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. References: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. PAGE 27 Antimicrobial Surgical Prophylaxis

AntimicrobialAntimicrobial Surgical Surgical Prophylaxis Prophylaxis ALTERNATIVES FOR PATIENTS WITH SURGICAL PROCEDURE RECOMMENDED AGENTS BETA-LACTAM ALLERGY ALTERNATIVES FOR PATIENTS WITH SURGICAL PROCEDURE RECOMMENDED AGENTS Ortho: clean hand, None None BETA-LACTAM ALLERGY knee, or foot not Ortho: clean hand, None None involving implantation knee, or foot not of foreign materials involving implantation ofOrtho: foreign implantation materials of Cefazolin Clindamycin, vancomycin foreign material and/or Ortho: implantation of Cefazolin Clindamycin, vancomycin total joints foreign material and/or totalUrologic jointswith risk Fluoroquinolone, Aminoglycoside +/- clindamycin factors for infection TMP/SMX, cefazolin Urologic with risk Fluoroquinolone, Aminoglycoside +/- clindamycin factorsUrologic, for clean infection without TMP/SMXCefazolin*, cefazolin Clindamycin, vancomycin entry into urinary tract Urologic, clean without Cefazolin* Clindamycin, vancomycin entryUrologic into involving urinary tract Cefazolin ± Clindamycin ± aminoglycoside or implanted prosthesis aminoglycoside, aztreonam, vancomycin ± Urologic involving Cefazolin ± Clindamycin ± aminoglycoside or cefazolin ± aztreonam, aminoglycoside or aztreonam implanted prosthesis aminoglycoside, aztreonam, vancomycin ± ampicillin/sulbactam cefazolin ± aztreonam, aminoglycoside or aztreonam Urologic, clean with ampicillin/sulbactamCefazolin* Fluoroquinolone, aminoglycoside ± entry into urinary tract clindamycin Urologic, clean with Cefazolin* Fluoroquinolone, aminoglycoside ± entryUrologic, into clean urinary- tract Cefazolin + clindamycinFluoroquinolone, aminoglycoside + contaminated metronidazole, cefoxitin metronidazole or clindamycin Urologic, clean- Cefazolin + Fluoroquinolone, aminoglycoside + TMP/SMX=contaminated trimethoprim/sulfamethoxazolemetronidazole, cefoxitin metronidazole or clindamycin

TMP/SMX=*Addition of trimethoprim/ a single dose sulfamethoxazoleof an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile prosthesis) *Addition of a single dose of an aminoglycoside may be recommended for placement of prosthetic material (e.g. penile prosthesis)

References: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. References: 1. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195-283. PAGE 28 UrinaryUrinary Tract: Tract: Catheter-Associated Catheter-Associated Urinary Urinary Tract Infection Tract Infection CLINICAL CLASSIFICATION CLINICAL FINDINGS RECOMMENDED EMPIRIC REGIMENS CONSIDERATIONS

Asymptomatic • Positive urine culture Remove catheter • Obtaining routine Bacteriuria (≥ 100,000 cfu/mL of cultures in No antibiotics unless the patient ≥ 1 bacterial species asymptomatic is: in a single catheter patients is NOT • Scheduled for urologic urine specimen) recommended procedure AND • In the presence of a • Pregnant • No sign or symptoms catheter, pyuria Scheduled Urologic Procedure: (>5-10 WBC) in an SMX/TMP 1 DS tablet PO Q12H asymptomatic OR patient is NOT an Ciprofloxacin 500 mg PO indication for OR antibiotic Ciprofloxacin 400 mg IV Q12H treatment • Presence or Initiate within 24 hours prior to absence of odorous procedure and until foley removed or cloudy urine Pregnant: alone is NOT an Amoxicillin 500 mg PO Q12H for indication for 3 to 7 days antibiotic OR treatment Cephalexin 500 mg PO Q12H for • Antibiotics do NOT 3 to 7 days decrease OR asymptomatic (MacroBID)‡ bacteriuria or 100 mg PO Q12H for 5 days prevent subsequent UTI

Symptomatic • Positive urine culture Outpatient: • Remove catheter AND (≥ 1,000 cfu/mL of ≥ 1 SMX/TMP DS tablet PO Q12H whenever possible ≥ 1 of the bacterial species in a OR • Narrow antibiotic ‡ following: single catheter urine Nitrofurantoin (MacroBID) therapy when • Male specimen) 100 mg PO Q12H organism and • Pyelonephritis AND OR susceptibilities are • Antibiotic use • Presence of Ciprofloxacin 250 - 500 mg PO known in previous 90 signs/symptoms Q12H • Follow-up urine cultures or days Catheter still in place: Inpatient: urinalysis are only • History of - Malaise/lethargy Cefazolin 2 gm IV Q8H warranted for on- infection with - Fever OR going symptoms. MDRO (≥100.4°F)/rigors Cefepime 1 gm IV Q12H They should NOT • Immuno- - Altered mental OR be obtained compromised status Ampicillin/sulbactam 1.5 gm IV routinely to • Functional or - Flank pain Q6H monitor response anatomic - Pelvic discomfort Known or suspected ESBL to therapy urologic - Acute hematuria abnormality : • Severe sepsis Catheter removed Meropenem 1 gm IV Q8H within past 48 h: OR - Dysuria Ertapenem 1 gm IV Q24H - Urgency Duration of Treatment: - Frequency Prompt resolution: 7 days - Suprapubic Delay response: 10-14 days pain/tenderness

cfu= colony forming units; DS= double strength; ESBL= extended spectrum beta-lactamase; H= hour(s); IV= intravenous; MDRO= multi-drug resistant organism; PO= by mouth; Q= every; SMX/TMP= sulfamethoxazole/trimethoprim; UTI= Urinary Tract Infection; WBC= white blood cell

‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis

PAGE 29 UrinaryUrinaryUrinary Tract:Tract:Tract: Non-Catheter-Associated NonNon--CatheterCatheter AssociatedAssociated Urinary UrinaryUrinary Tract TractTract Infection/CystitisInfection/CystitisInfection / Cystitis RRECOMMENDEDECOMMENDEDEEMPIRICMPIRIC CCLINICALLINICAL CCLASSIFICATIONLASSIFICATION CCLINICALLINICALFFINDINGSINDINGS RREGIMENSEGIMENS CCONSIDERATIONSONSIDERATIONS

AsymptomaticAsymptomatic •• PyuriaPyuria NoNoantibioticsantibiotics unless unless the the patient patient •• ObtainingObtainingroutineroutine BacteriuriaBacteriuria (urinalysis(urinalysis > > 5 5--1010 is:is: culturescultures in in WBC)WBC) •• ScheduledScheduled for for urologic urologic asymptomaticasymptomatic OROR procedureprocedure patientspatients is is NOT NOT •• PositivePositiveurineurine •• PregnantPregnant recommendedrecommended cultureculture •• AntibioticsAntibioticsdodo NOT NOT ScheduledScheduled Urologic Urologic Procedure: Procedure: (≥(≥ 100,000 100,000 cfu cfu/mL)/mL)†† decreasedecrease SMX/TMPSMX/TMP 1 1 DS DS tablet tablet PO PO Q12H Q12H ANDAND asymptomaticasymptomatic OROR •• NoNo sign signoror symptoms symptoms bacteriuriabacteriuria or or CiprofloxacinCiprofloxacin 500 500 mg mg PO PO (see(see below) below) preventprevent OROR subsequentsubsequent UTI UTI CiprofloxacinCiprofloxacin 400 400 mg mg IV IV Q12H Q12H InitiateInitiate within within 24 24 hours hours prior prior to to procedureprocedure and and until until foley foley removedremoved Pregnant:Pregnant: AmoxicillinAmoxicillin 500 500 mg mg PO PO Q12H Q12H for for 33 to to 7 7 days days OROR CephalexinCephalexin 500 500 mg mg PO PO Q12H Q12H for for 33 to to 7 7 days days OROR NitrofurantoinNitrofurantoin(MacroBID(MacroBID)‡)‡ 100100 mg mg PO PO Q12H Q12H for for 5 5 days days

Symptomatic:Symptomatic: •• PyuriaPyuria Outpatient:Outpatient: •• NarrowNarrowantibioticantibiotic ComplicatedComplicated (Urinalysis(Urinalysis≥≥ 5 5 WBC) WBC) SMX/TMPSMX/TMP 1 1 DS DS tablet tablet PO PO Q12H Q12H therapytherapy when when ANDAND OROR organismorganism and and ≥≥ 1 1 of of the the following: following: •• PositivePositiveurineurine NitrofurantoinNitrofurantoin(MacroBID(MacroBID)‡)‡ susceptibilitiessusceptibilities are are •• MaleMale cultureculture 100100 mg mg PO PO Q12H Q12H knownknown •• PyelonephritisPyelonephritis (≥(≥ 100,000 100,000 cfu cfu/mL)/mL)†† OROR •• FollowFollow-up-upurineurine •• AntibioticAntibioticuseuse in in ANDAND CiprofloxacinCiprofloxacin 250 250 - -500500 mg mg PO PO culturescultures or or previousprevious 90 90 days days •• PresencePresenceofof Q12HQ12H urinalysisurinalysis are are only only •• HistoryHistory of of symptoms:symptoms: warrantedwarranted for for on on-- Inpatient:Inpatient: infectioninfection with with -- DysuriaDysuria goinggoing symptoms. symptoms. CefazolinCefazolin22 gm gm IV IV Q8H Q8H MDROMDRO -- UrgencyUrgency TheyThey should should NOT NOT OROR -- FrequencyFrequency bebe obtained obtained •• ImmunoImmuno-- CefepimeCefepime 1 1 gm gm IV IV Q12H Q12H -- SuprapubicSuprapubicpainpain routinelyroutinely to to compromisedcompromised OROR AND/ORAND/OR monitormonitor response response •• FunctionalFunctional or or Ampicillin/Ampicillin/sulbactamsulbactam1.51.5 gm gm IV IV •• PresencePresence of of signs: signs: toto therapy therapy anatomicanatomic Q6HQ6H -- FeverFever urologicurologic (≥(≥100.4100.4°F)°F) abnormalityabnormality KnownKnown or or suspected suspected ESBL ESBL -- AlteredAltered mental mental bacteria:bacteria: •• SevereSevere sepsis sepsis statusstatus MeropenemMeropenem11 gm gm IV IV Q8H Q8H -- LeukocytosisLeukocytosis OROR ErtapenemErtapenem11 gm gm IV IV Q24H Q24H DurationDuration of of Treatment: Treatment: 77 to to 14 14 days days

cfucfu== colony colony forming forming units; units; ESBL= ESBL= extended extended spectrum spectrum beta beta-lactamase;-lactamase; H= H= hour(s hour(s);); IV= IV= intravenous; intravenous; MDRO= MDRO= multi multi-drug-drug resistant resistant organism;organism; PO= PO= by by mouth; mouth; Q= Q= every; every; SMX/TMP= SMX/TMP= sulfamethoxazole sulfamethoxazole/trimethoprim;/trimethoprim; UTI= UTI= Urinary Urinary Tract Tract Infection; Infection; WBC= WBC= white white bloodblood cell cell count count

†Positive†Positive urine urine culture: culture: ForFor Women: Women:22 consecutive consecutive voided voided urine urine specimens specimens with with isolation isolation of of >10 >105 5cfucfu/mL/mL of of the the same same bacterial bacterial strain strain ForFor Men: Men:AA single, single, clean clean-catch,-catch, voided voided urine urine specimen specimen with with isolation isolation of of >10 >105 5cfucfu/mL/mL from from 1 1 bacterial bacterial species species

‡Nitrofurantoin:‡Nitrofurantoin: Contraindicated Contraindicated if if CrCl< CrCl< 60 60 mL/min mL/min AND ANDonlyonly indicated indicated in in acute acute cystitis cystitis

NOTE:NOTE: Dosing Dosing based based on on normal normal renal renal function. function. R Referefer to to T Tableable of of C Contentsontents for for section section on on Antimicrobial Antimicrobial Dosing Dosing for for Adult AdultPAGE 30 PatientsPatients Based Based on on Renal Renal Function Function Urinary Tract: Non-Catheter Associated Urinary Tract UrinaryInfection/CystitisUrinary Tract: Tract: NonNon-Catheter-Associated -Catheter Associated Urinary Urinary Tract Tract CLINICAL UrinaryInfectionCLASSIFICATION Tract: / Cystitis CNonLINICAL-FCatheterINDINGS RAssociatedECOMMENDED EMPIRIC UrinaryREGIMENS Tract Infection/Cystitis CONSIDERATIONS Infection/Cystitis CLINICAL SymptomaticCLASSIFICATION •CPyuriaLINICAL FINDINGS NitrofurantoinRECOMMENDED(MacroBIDEMPIRIC )R‡EGIMENS • Urine culture CONSIDERATIONSCLINICAL Uncomplicated/CLASSIFICATION C(Urinalysis:LINICAL FINDINGS ≥ 5 100RECOMMENDED mg PO Q12H forEMPIRIC 5 daysREGIMENS should be CONSIDERATIONS SymptomaticCystitis • PyuriaWBC) NitrofurantoinOR (MacroBID)‡ • Urineperformed culture ONLY IF: Uncomplicated/Symptomatic• Female •AND(Urinalysis:Pyuria ≥ 5 100NitrofurantoinSMX/TMP mg PO 1Q12H DS (tabletMacroBID for 5 POdays Q12H)‡ for • shouldUrine- History culture be of CystitisUncomplicated/AND • WBC)(Urinalysis:Positive urine ≥ 5 OR1003 days mg PO Q12H for 5 days performedshouldmultiple be ONLY UTIs IF: • No criteria for culture (≥ 100,000 OR MDRO •CystitisFemale ANDWBC) SMX/TMPAlternativeOR 1 agentsDS tablet should PO Q12H be avoided for performed- History ofONLY IF: complicated cfu/mL)† infection(s) AND• Female •ANDPositive urine 3ifSMX/TMP dayspossible due1 DS to tablet the risk PO ofQ12H C. difficile for - multipleHistory of UTIs •ANDNo(see criteria previous for •ANDculturePositive (≥urine 100,000 3 days • NarrowORmultiple MDROantibiotic UTIs AlternativeAND antibiotic agents resistance. should be IF avoidedpatient • complicatedpage)No criteria for • cfuculturePresence/mL) †(≥ of100,000 therapyinfection(s)OR MDRO when ifAlternativehas possible an allergy/contraindication due agents to the should risk of be C. avoided difficile to the (seecomplicated previous ANDcfusymptoms:/mL)† • Narroworganisminfection(s)antibiotic and ANDifabove possibleantibiotic antibiotics due toresistance. thealternatives risk of IF C.patient include:difficile page)(see previous •ANDPresence- Dysuriaof • therapyNarrowsusceptibilities whenantibiotic are hasANDCiprofloxacin anantibiotic allergy/contraindication 250 resistance. mg PO Q12H IF patient forto the 3 page) • symptoms:Presence- Urgencyof organismtherapyknown when and abovehasdays an OR antibiotics allergy/contraindicationCephalexin alternatives 500 mg PO include: Q12Hto the symptoms:-- DysuriaFrequency • susceptibilitiesorganismFollow-up andurine are Ciprofloxacinabovefor 3 days antibiotics 250 mgalternatives PO Q12H include: for 3 -- UrgencyDysuriaSuprapubic knownsusceptibilitiescultures or UA areare daysCiprofloxacin OR Cephalexin 250 mg 500 PO mg Q12H PO Q12Hfor 3 -- FrequencyUrgencypain • Followknownonly warranted-up urine for fordays 3 daysOR Cephalexin 500 mg PO Q12H -- SuprapubicFrequency • culturesFollowon-going-up or urineUA are for 3 days - painSuprapubic onlyculturessymptoms. warranted or UAThey are for pain ononlyshould-going warranted NOT be for symptoms.onobtained-going routinely They shouldsymptoms.to monitor NOT Theybe obtainedshouldresponse NOT routinelyto be toobtainedtherapy monitor routinely responseto monitor to Urinary Tract: Prostatitis therapyresponse to therapy CLINICAL UrinaryCLASSIFICATION Tract:PREFERRED ProstatitisREGIMEN ALTERNATIVE REGIMENS UrinaryUrinary Tract: Tract: Prostatitis Prostatitis CONSIDERATIONS CLINICAL OutpatientCLASSIFICATION CiprofloxacinPREFERRED 500REGIMEN mg PO SMX/TMPALTERNATIVE 1 DS tabletR POEGIMENS Q12H Beta-lactams DO NOT Q12H OR haveC adequateONSIDERATIONSCLINICAL CLASSIFICATION PREFERRED REGIMEN ALTERNATIVE REGIMENS Outpatient Ciprofloxacin 500 mg PO SMX/TMPLevofloxacin 1 DS 500 tablet mg PO onceQ12H daily Betapenetration-ClactamsONSIDERATIONS into DO NOTprostate Outpatient Q12HCiprofloxacin 500 mg PO ORSMX/TMP(Requires ID1 DSConsult) tablet PO Q12H haveBeta -adequatelactams DO NOT Q12H LevofloxacinDurationOR of Treatment:500 mg PO 28once days daily penetrationhave adequate into prostate (LevofloxacinRequires ID Consult) 500 mg PO once daily penetration into prostate cfu= colony forming units; DS= double strength; H= hour(s);(Requires MDRO= ID Consult) multi-drug resistant organism; PO= by mouth; Q= every; SMX/TMP= sulfamethoxazole/trimethoprim; UA= urinalysis;Duration UTI=of Urinary Treatment: Tract Infection; 28 days WBC= white blood cell count cfu= colony forming units; DS= double strength; H= hour(s);Duration MDRO=of Treatment: multi-drug resistant 28 days organism; PO= by mouth; Q= every; †Positive urine culture: SMX/TMP= sulfamethoxazole/trimethoprim; UA= urinalysis; UTI= Urinary Tract Infection; WBC= white blood cell count cfu= colonyFor forming Women: units;2 consecutive DS= double voided strength; urine H= specimens hour(s); MDRO= with isolation multi-drug of >10 resistant5 cfu/mL organism; of the same PO= bacterial by mouth; strain Q= every; SMX/TMP=For sulfamethoxazole Men: A single, clean/trimethoprim;-catch, voided UA= urine urinalysis; specimen UTI= with Urinary isolation Tract of Infection; >105 cfu /mLWBC= from white 1 bacterial blood cell species count †Positive urine culture: For Women: 2 consecutive voided urine specimens with isolation of >105 cfu/mL of the same bacterial strain ‡Nitrofurantoin:†Positive urine culture: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis ForFor Men:Women:A single,2 consecutive clean-catch, voided voided urine urine specimens specimen with with isolation isolation of of>10 >105 cfu5 cfu/mL/mL of fromthe same 1 bacterial bacterial species strain 5 NOTE: DosingFor Men: basedA onsingle, normal clean renal-catch, function. voided R urineefer tospecimen Table of with Contents isolation for sectionof >10 oncfu Antimicrobial/mL from 1 bacterial Dosing species for Adult ‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis Patients Based on Renal Function ‡Nitrofurantoin: Contraindicated if CrCl< 60 mL/min AND only indicated in acute cystitis NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult PatientsNOTE: Dosing Based based on Renal on normalFunction renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function

References: 1. Hooton TM, Bradley SF, Cardena DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Disease Society of America. CID 2010;50:625-63. References:2. Nicolle LE, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin 1.References:HootonInfect Dis. TM,2005 Bradley Mar SF,1;40(5):643 Cardena-DD,54. et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 1.3. internationalHootonGupta K, TM, et al. Bradleyclinical International practiceSF, Cardena clinical guidelinesDD, practice et fromal. Diagnosis, guidelines the Infectious prevention, for the Disease treatment and Society treatment of ofacute America. of uncomplicated catheter CID 2010;50:625-associated cystitis urinary- and63. pyelonephrit tract infectionis in inwomen: adults: A 2009 2010 2. Nicolleinternationalupdate LE, by etthe al.clinical Infectious Infectious practice Diseases Diseases guidelines Society Society from of of America theAmerica Infectious and guidelines European Disease for SocietySociety the diagnosis forof America.Microbiology and treatment CID 2010;50:625and Infectiousof asymptomatic-63 Diseases.. bacteriu Clin Infectria in Dis. adults.2011 Clin Mar 2. InfectNicolle1;52(5):e103 Dis. LE,2005 et- 20.al. Mar Infectious 1;40(5):643 Diseases-54. Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin 3. GuptaInfect K,Dis. et2005 al. International Mar 1;40(5):643 clinical-54. practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 Clin Infect Dis. 3. updateGupta K,by et the al. Infectious International Diseases clinical Society practice of Americaguidelines and for European the treatment Society of for acute Microbiology uncomplicated and Infectious cystitis and Diseases. pyelonephrit is in women:PAGE2011 A Mar2010 31 1;52(5):e103update by the-20. Infectious Diseases Society of America and European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20. I D E S L A D E I S L A O I S N O N H D E L PneumococcalH E I SVaccinationL Pneumococcal Vaccination A D D A D

R O N R O N

D H PneumococcalD Vaccination

D H Pneumococcal Vaccination D

R H

R H

D

E E D

H T T RecommendationsH Recommendations

P P E E

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A RecommendationsT A Recommendations P 1-4 COLLEGE OF 1-4 COLLEGE OF P

A L A R R L A AdultsA ≥19 Years1-4 AdultsCOLLEGEPHARMACY ≥19 OF Years PHARMACY E E 1-4 COLLEGE OF T A T R AdultsR ≥19 YearsA PHARMACY M H E M H AdultsDRUG INFORMATION ≥19 Years DRUGPHARMACY INFORMATION T T E E F H (Including updated recommendationsE for Fthe use of PCV13(Including in Adults) updated recommendationsDRUG SERVICESINFORMATION for the use of PCV13 in Adults) SERVICES M N T O M N T O H DRUG INFORMATION E F (Including updated recommendations for Fthe use of PCV13 in Adults) 401-874-9188 401-874-9188 N T O E N T O (Including updated recommendationsSERVICES for the use of PCV13 in Adults) SERVICES 401-874-9188 401-874-9188 Healthy Adults ≥ 65 Healthy Adults ≥ 65 Healthy Adults ≥ 65 Healthy Adults ≥ 65 Pneumococcal Vaccination PreviouslyPneumococcal vaccinated with Vaccination PreviouslyPreviously vaccinated vaccinated with with Previously vaccinated with Pneumococcal Vaccination Previously vaccinated with Previously vaccinated with Naive or Unknown History PPSV23PneumococcalNaive at orage Unknown ≥65 Vaccination History PPSV23Previously beforePPSV23 age vaccinated 65at age ≥65 with PreviouslyPPSV23 vaccinatedbefore age 65with Naive or Unknown History PPSV23Naive at orage Unknown ≥65 History PPSV23 beforePPSV23 age 65at age ≥65 PPSV23 before age 65 ≥ 1 year after PPSV23 ≥ 1 year after PPSV23 ≥ 1 year after PPSV23 ≥ 1 year after PPSV23 GIVE: PCV13 GIVE: PCV13 GIVE: PCV13 ≥ 1 year after PPSV23GIVE: PCV13 GIVE: PCV13≥ if not1 yearpreviously after given PPSV23 GIVE: PCV13 if not previously given ≥ 1 year after PPSV23 GIVE: PCV13≥ if not1 yearpreviously after given PPSV23 GIVE: PCV13 if not previously given Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* (and ≥ 5Wait years ≥ 1after year* PPSV23) (and ≥ 5Wait years ≥ 1after year* PPSV23) (and ≥ 5 years after PPSV23) (and ≥ 5 years after PPSV23)

GIVE: PPSV23† GIVE: PCV13 if notGIVE: previously PPSV23 given † GIVE:GIVE PPSV23: PCV13† if not previously given GIVE: PPSV23† GIVE: PPSV23† GIVE: PCV13 if notGIVE: previously PPSV23 given † GIVE:GIVE PPSV23: PCV13† if not previously given GIVE: PPSV23† ADULTS ≥ 19 with UNDERLYING MEDICAL ADULTS CONDITIONS ≥ 19 with (see UNDERLYING chart on back) MEDICAL CONDITIONS (see chart on back) ADULTS ≥ 19 with UNDERLYING MEDICAL ADULTS CONDITIONS ≥ 19 with (see UNDERLYING chart on back) MEDICAL CONDITIONS (see chart on back) OR who SMOKE or live in a NURSING HOMEOR who SMOKE or live in a NURSING HOME OR who SMOKE or live in a NURSING HOMEOR who SMOKE or live in a NURSING HOME Pneumococcal Vaccination Previously Pneumococcalvaccinated with Vaccination one Previously vaccinated with one Pneumococcal Vaccination Previously Pneumococcalvaccinated with Vaccination one Previously vaccinated with one Naive or Unknown History doseNaive PPSV23 or Unknown History Vaccination isdose NOT PPSV23 Vaccination is NOT Naive or Unknown History doseNaive PPSV23 or Unknown History Vaccination isdose NOT PPSV23 indicated for healthy persons indicatedVaccination for healthy is NOT persons indicated for healthy persons 19 - 64 years of age indicated19 - 64 for years healthy of age persons GIVE: PPSV23 GIVE: PPSV23 19 - 64 years of age GIVE: PPSV23 GIVE: PPSV23 19 - 64 years of age While PCV13 is FDA-approved for While PCV13 is FDA-approved for Whilepersons PCV13 > 50 isyears, FDA-approved the Advisory for Whilepersons PCV13 > 50 isyears, FDA-approved the Advisory for At Age ≥65 At Age ≥65At Age ≥65 persons > 50 years, theAt Advisory Age ≥65 persons > 50 years, the Advisory At Age ≥65 At Age ≥65At Age ≥65 Committee on ImmuneAt Practices Age ≥65 Committee on Immune Practices GIVE: PCV13 ≥ 1 year after PPSV23 GIVE: PCV13GIVE: ≥ 1yearPCV13 after ≥ 1PPSV23 year after PPSV23 doesCommittee not GIVE:provide on Immune guidancePCV13 Practices for≥ 1yearuse after PPSV23 doesCommittee not provide on Immune guidance Practices for use GIVE: PCV13 ≥ 1 year after PPSV23 GIVE: PCV13GIVE: ≥ 1yearPCV13 after ≥ 1PPSV23 year after PPSV23 GIVE: PCV13 ≥ 1year after PPSV23 THEN: PPSV23† ≥ 1 year* after THEN: PPSV23THEN:† ≥PPSV23 1 year* after† ≥ 1 year* after does notin provide thisTHEN: population. guidance PPSV23 for use† ≥ 1 year* after does notin provide this population. guidance for use PCV13THEN: and PPSV23 ≥ 5 years† ≥ after1 year* PPSV23 after PCV13THEN: and PPSV23PCV13 ≥THEN: 5 years †and ≥PPSV23 after1 ≥year* 5 yearsPPSV23 after† ≥ after1 year* PPSV23 after inPCV13 thisTHEN: population. and PPSV23 ≥ 5 years† ≥ after1 year* PPSV23 after in this population. PCV13 and ≥ 5 years after PPSV23 PCV13 andPCV13 ≥ 5 years and after ≥ 5 yearsPPSV23 after PPSV23 PCV13 and ≥ 5 years after PPSV23

ADULTS ≥ 19 with IMMUNE COMPROMISING ADULTS CONDITIONS ≥ 19 with (see IMMUNE chart COMPROMISING on back), OR ASPLENIA CONDITIONS (see chart on back), OR ASPLENIA ADULTS ≥ 19 with IMMUNE COMPROMISING ADULTS CONDITIONS ≥ 19 with (see IMMUNE chart COMPROMISING on back), OR ASPLENIA CONDITIONS (see chart on back), OR ASPLENIA (including sickle cell anemia), CEREBROSPINAL(including FLUID sickle LEAK, cell anemia),or COCHLEAR CEREBROSPINAL IMPLANT FLUID LEAK, or COCHLEAR IMPLANT (including sickle cell anemia), CEREBROSPINAL(including FLUID sickle LEAK, cell anemia),or COCHLEAR CEREBROSPINAL IMPLANT FLUID LEAK, or COCHLEAR IMPLANT Pneumococcal Vaccination Previously Pneumococcalvaccinated with Vaccination one PreviouslyPreviously vaccinated vaccinated with with one Previously vaccinated with Pneumococcal Vaccination Previously Pneumococcalvaccinated with Vaccination one Previously vaccinated with Previously vaccinated with Naive or Unknown History doseNaive PPSV23 or Unknown History two dosesPreviously of PPSV23dose vaccinated PPSV23 with one two doses of PPSV23 Naive or Unknown History doseNaive PPSV23 or Unknown History two doses of PPSV23dose PPSV23 two doses of PPSV23 GIVE: PCV13 ≥ 1 year after PPSV23GIVE: PCV13 ≥ 1 year after PPSV23 GIVE: PCV13 ≥ 1 year after PPSV23GIVE: PCV13 ≥ 1 year after PPSV23 ≥8 weeks* later GIVE: PCV13 if not previously≥8 weeks* given later GIVE: PCV13 if not previously given ≥8 weeks* later ≥8 weeks* later ≥ 1 year after PPSV23 ≥ 1 year after PPSV23 GIVE: PCV13 if not previously given ≥ 1 year GIVE:after PPSV23 PCV13 if not previously given If < 65 If ≥65 If < 65 If ≥65 ≥ 1 year after PPSV23 If < 65 If ≥65 ≥8 weeks*If < 65 later If ≥65 ≥8 weeks* later GIVE: PPSV23 ≥8GIVE: weeks* PPSV23 later ≥8 weeks* later GIVE: PPSV23 GIVE: PPSV23 GIVE: PCV13 if not previously given GIVE: PCV13 if not previously given If < 65 and If ≥65 If < 65 and If ≥65 ≥ 5 years after If ≥65 GIVE: PCV13≥ 5 years if notafter previously given GIVE: PCV13 if not previously given If < 65 and If < 65 and If ≥65 If < 65 and ≥PPSV23 5 years after If < 65 and ≥PPSV23 5 years after If≥ 5< years 65 after and ≥ 5 years afterand GIVE:PPSV23 secondIf < 65 PPSV23 ≥PPSV23 5 years after ≥PPSV23 5 years after GIVE: second GIVE:PPSV23 second§ GIVE: second§ GIVE:PPSV23 second GIVE:PPSV23 second PPSV23 PPSV23 § PPSV23 § GIVE:PPSV23 second§ GIVE:PPSV23 second§ PPSV23 § PPSV23 §

At Age ≥65 At Age ≥65At Age ≥65 AtAt Age Age ≥ ≥65 65 At Age ≥ 65 GIVE: PPSV23† GIVE: PPSV23† † GIVE: PPSV23† At Age ≥65 At Age ≥65 GIVE: PPSV23GIVE: PPSV23At Age† ≥ ≥ 8 weeks*65 after At Age† ≥ 65 GIVE: PPSV23† GIVE: PPSV23† GIVE: PPSV23GIVE:At Age† PPSV23 ≥65GIVE:† PPSV23† GIVE:At Age PPSV23 ≥65† GIVE: PPSV23† GIVE: PPSV23 ≥ 8 weeks* after ≥5 years GIVE:after PPSV23GIVE:† PPSV23† ≥ 8 weeks* after≥5 years after GIVE:≥ 5 years PPSV23 after † GIVE:≥ 5 years PPSV23 afterGIVE: ≥ 5† years PPSV23 after≥5 years† after PCV13 andGIVE: ≥ 5≥ 5years years PPSV23 after after † PPSV23 ≥5 years after PCV13GIVE: andPPSV23 ≥ 5 years† ≥ 8 afterweeks* PPSV23 after ≥ 5 years after ≥ 5 years after ≥ 5 years after PPSV23 PCV13 and ≥ 5≥ 5years years after after PPSV23 PPSV23 PPSV23 PPSV23 PPSV23 PPSV23 PPSV23 PPSV23 PCV13 and ≥ 5 years after PPSV23 PPSV23 PPSV23 PPSV23 PneumococcalPPSV23 Vaccine

DEE I SI S L A OD L A N Minimum interval between sequential administration of PCV13 and Minimum interval between sequential administration of PCV13 and HO N Pneumococcal Vaccination PPSV23 is 8 weeks in immunocompromised patients. I S PPSV23H is 8 weeksD in immunocompromisedPneumococcal patients. Vaccination

* GIVE: PPSV23 GIVE: PPSV23 D E L R D

* A D R O N D

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L † TheFor Medicare ACIP (Advisory reimbursement Committee interval on Immunization must be 11 full Practices) months. Please recommends refer to pageonly† 14. dose of PPSV23 at age H The ACIP (Advisory Committee on Immunization Practices) recommendsA only 1 dose of PPSV23 at age

For Medicare reimbursement≥65. interval Revaccination must be 11 isE fullnot months. necessary. Please refer to page 4.L ≥65. Revaccination is not necessary.1-4 COLLEGE OF A A 1-4 COLLEGE OF T R Recommendations P A Adults ≥19 Years PHARMACY §† The ACIP (Advisory Committee on Immunization Practices) recommends only§† 1 dose of PPSV23 at age R E Adults ≥19 Years PHARMACY A second PPSV23 for patients with cerebrospinal fluid leak, or cochlear implant AThe issecond ACIPnot required. PPSV23(Advisory for Committee patients≥65. Revaccinationwith on Immunizationcerebrospinal is not Practices)fluid necessary. leak, recommends orL cochlearT implant only E1 isdose not ofrequired. PPSV23 at age ≥65. Revaccination is not necessary. A T M H 1-4 COLLEGE OF DRUG INFORMATION A H DRUG INFORMATION § R M E F Adults(Including updated≥19 Years recommendations for the use of PCV13 in Adults)PHARMACY SERVICES PPSV23 A second PPSV23 for patients with cerebrospinal fluid leak, or cochlear® implant§ A issecond not required. PPSV23 for patients with cerebrospinal fluid leak, E or cochlearE® NimplantT FO is not required.(Including updated recommendations for the use of PCV13 in Adults) SERVICES =23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax 23) PPSV23=23-Valent Pneumococcal PolysaccharideT Vaccine (Pneumovax N 23)T O 401-874-9188 M H DRUG401-874-9188 INFORMATION PPSV23 ® ® F ® ® PCV13=13-Valent=23-Valent Pneumococcal Pneumococcal Conjugate Polysaccharide Vaccine Vaccine (Prevnar (Pneumovax 13 ) 23) PCV13PPSV23=13-Valent=23-Valent Pneumococcal Pneumococcal Conjugate Polysaccharide Vaccine VaccineE (PrevnarN T O (Pneumovax 13 ) © (Including201423) Rhode updated Island Boardrecommendations of Education for the use of PCV13 in Adults) © SERVICES2014 Rhode Island Board of Education 401-874-9188 PCV13=13-Valent Pneumococcal Conjugate Vaccine (Prevnar 13®) PCV13=13-Valent Pneumococcal Conjugate Vaccine (Prevnar 13®) © 2014 Rhode Island Board of EducationHealthyHealthy Adults Adults ≥ 65 ≥ 65 © 2014 Rhode Island Board of Education Healthy Adults ≥ 65 Pneumococcal Vaccination Vaccination PreviouslyPreviously vaccinated vaccinated with withPreviously vaccinatedPreviously with vaccinated with Naive or Unknown History PPSV23 at age ≥65 PPSV23 before age 65 Pneumococcal VaccinationNaive or Unknown HistoryPreviously vaccinatedPPSV23 at with age ≥65 PreviouslyPPSV23 vaccinated before age 65 with Naive or Unknown History PPSV23 at age ≥65 PPSV23 before≥ 1age year 65 after PPSV23 ≥ 1 year after PPSV23 GIVE: PCV13 GIVE: PCV13 ≥ 1 year after PPSV23 ≥ 1 year afterGIVE PPSV23: PCV13 if not previously given ≥ 1 year after PPSV23 GIVE: PCV13 if not previously given GIVE: PCV13 Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* GIVE: PCV13 if not previously given ≥ 1 year after PPSV23 Wait ≥(and 1 year* ≥ 5 years after PPSV23) (and ≥ 5 years after PPSV23) Wait ≥ 1 year* Wait ≥ 1 year* GIVE: PPSV23† GIVE: PCV13 if not previously given GIVE: PPSV23† GIVE: PPSV23† GIVE: PCV13 if not previously given (and ≥ 5 yearsGIVE: PPSV23 after PPSV23)† ADULTS ≥ 19 with UNDERLYING MEDICAL CONDITIONS (see chart on back) GIVE: PPSV23† ADULTS ≥ 19 withGIVE UNDERLYING: PCV13 if not MEDICALpreviously given CONDITIONS (see chartGIVE: on PPSV23 back) † OR who SMOKE or live in a NURSING HOME OR who SMOKE or live in a NURSING HOME ADULTS ≥Pneumococcal 19 with UNDERLYING Vaccination MEDICALPreviously CONDITIONS vaccinated (see with onechart on back) PneumococcalNaive orOR Unknown who Vaccination SMOKE History or Previouslylive in a vaccinated NURSINGdose PPSV23with HOMEone Vaccination is NOT Naive or Unknown History dose PPSV23 Vaccination indicated is NOT for healthy persons Pneumococcal Vaccination Previously vaccinated with one indicated for healthy19 persons- 64 years of age Naive or Unknown HistoryGIVE: PPSV23 dose PPSV23 Vaccination is NOT GIVE: PPSV23 19 - 64 years of age indicated for healthyWhile PCV13 persons is FDA-approved for While PCV13 is FDA-approvedpersons > for50 years, the Advisory GIVE: PPSV23 19 - 64 years of age At Age ≥65 At Age ≥65 persons > 50 years,Committee the Advisory on Immune Practices GIVE: PCV13At Age ≥ 1 ≥65year after PPSV23 GIVE:At Age PCV13 ≥65 ≥ 1year after PPSV23Committee on Immunedoes Practices not provide guidance for use While PCV13 is FDA-approved for GIVE:THEN: PCV13 PPSV23 ≥ 1 year† after ≥ 1 year*PPSV23 after GIVE: PCV13THEN: ≥ 1year PPSV23 after PPSV23† ≥ 1 year* after does not provide guidance forin use this population. persons > 50 years, the Advisory PCV13THEN: andPPSV23 ≥ 5 years† ≥ 1 year* after after PPSV23 THEN:PCV13 PPSV23 and† ≥ 1≥ year*5 years after after PPSV23 in this population. At Age ≥65PCV13 and ≥ 5 years after PPSV23 AtPCV13 Age and≥65 ≥ 5 years after PPSV23 Committee on Immune Practices GIVE: PCV13 ≥ 1 year after PPSV23 GIVE: PCV13 ≥ 1year after PPSV23 does not provide guidance for use THEN: PPSV23 † ≥ 1 year*ADULTS after ≥ 19 withTHEN: IMMUNE PPSV23 COMPROMISING† ≥ 1 year* after CONDITIONS (seein this population.chart on back), OR ASPLENIA PCV13 and ≥ 5 years after ADULTS(including PPSV23 ≥ 19 sickle with IMMUNEPCV13 cell anemia), and COMPROMISING ≥ 5 years CEREBROSPINAL after PPSV23 CONDITIONS FLUID (see chart LEAK, on back),or COCHLEAR OR ASPLENIA IMPLANT (including sickle cell anemia), CEREBROSPINAL FLUID LEAK, or COCHLEAR IMPLANT Pneumococcal Vaccination Previously vaccinated with one Previously vaccinated with ADULTS ≥ 19 with IMMUNE COMPROMISING CONDITIONS (see chart on back), OR ASPLENIA PneumococcalNaive or Unknown Vaccination History Previously vaccinateddose PPSV23with one Previously vaccinatedtwo doses with of PPSV23 (including sickleNaive cell or anemia),Unknown History CEREBROSPINALdose FLUID PPSV23 LEAK, or COCHLEARtwo doses ofIMPLANT PPSV23 GIVE: PCV13 ≥ 1 year after PPSV23 Pneumococcal Vaccination Previously vaccinated≥ 1 year after with PPSV23 one Previously vaccinated with GIVE: ≥8 weeks* PCV13 later Naive or Unknown History dose PPSV23GIVE: PCV13 if not previously giventwo doses of PPSV23≥ 1 year after PPSV23 ≥8 weeks* later If < 65 If ≥65 GIVE: PCV13 if not previously given ≥ 1 year after PPSV23 ≥8 weeks* later GIVE: PCV13GIVE:If < PPSV23 65 If ≥65 ≥ 1 year after PPSV23 ≥8 weeks* later GIVE: PPSV23 If < 65 and If ≥65 GIVE: PCV13 if not previously given ≥8 weeks* later GIVE: PCV13 if not≥ previously 5 years after given ≥ 1 year after PPSV23 If < 65 and If < 65 andPPSV23 If ≥65 GIVE: PCV13 if not previously given ≥ 5 years after ≥ 5 years after If < 65 If ≥65 GIVE: second If PPSV23< 65 and ≥8 weeks*PPSV23 later GIVE: PPSV23 ≥ 5 years after PPSV23 § GIVE: second GIVE: second PPSV23 if not previously given PPSV23 § If < 65 and § If ≥65 GIVE: PCV13 GIVE: second PPSV23 ≥ 5 years after If < 65 and PPSV23 § PPSV23 ≥ 5 years after At Age ≥65 GIVE: second At Age ≥65 At Age ≥ 65 PPSV23 † GIVE: PPSV23† GIVE: PPSV23PPSV23 § † GIVE: second GIVE: PPSV23† GIVE: PPSV23† ≥5 years after GIVE: PPSV23 ≥ 8 weeks* after At ≥Age 5 years ≥65 after At Age ≥65≥ 5 years after At AgePCV13 ≥ 65 and ≥ 5 years after PPSV23 PPSV23 § GIVE: PPSV23† GIVE: PPSV23PPSV23† GIVE:PPSV23 PPSV23† GIVE: PPSV23PPSV23† ≥5 years after GIVE: PPSV23† ≥ 8 weeks* after ≥ 5 years after ≥ 5 years after PPSV23 PCV13 and ≥ 5 years after PPSV23 PPSV23 PPSV23 At Age ≥65 * Minimum intervalGIVE: between PPSV23 sequential administrationAt Age of ≥65PCV13 and PPSV23 is 8 weeks in immunocompromised patients. At Age ≥ 65 ForGIVE: Medicare PPSV23 reimbursement† interval must be 11 full months. Please referGIVE: to page 4. PPSV23† GIVE: PPSV23† GIVE: PPSV23† GIVE: PPSV23† ≥ 8 weeks* after † TheMinimum ACIP interval (AdvisoryGIVE: between PPSV23Committee sequential administrationon Immunization of PCV13 Practices) and PPSV23 recommends is 8 weeks≥5 in only immunocompromised years 1 dose afterof PPSV23 patients. at age ≥65. Revaccination is not necessary. ≥ 5 years after §* ≥ 5 years after PCV13 and ≥ 5 years after PPSV23 A For second Medicare PPSV23 reimbursement for patients interval with must cerebrospinalbe 11 full months. fluid Please leak, refer orto pagecochlear 4. implantPPSV23 is not required. ® PPSV23 PPSV23 † The ACIP=23-Valent (Advisory CommitteePneumococcal on Immunization PolysaccharidePPSV23 Practices) Vaccine recommends (Pneumovax only 1 dose23) of PPSV23 at age ≥65. Revaccination is not necessary. ® PCV13 § A second=13-Valent PPSV23 forPneumococcal patients with cerebrospinal Conjugate fluidVaccine leak, (Prevnar or cochlear 13 implant) is not required. © 2014 Rhode Island Board of Education PPSV23=23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax®23) * Minimum intervalGIVE: between PPSV23 sequential PCV13 administration=13-Valent Pneumococcal of PCV13 Conjugate and PPSV23 Vaccine is(Prevnar 8 weeks 13® in) immunocompromised patients. © 2014 Rhode Island Board of Education For Medicare reimbursement interval must be 11 full months. Please refer to page 4. † The ACIP (Advisory Committee on Immunization Practices) recommends only 1 dose of PPSV23 at age ≥65. Revaccination is not necessary. § A second PPSV23 for patients with cerebrospinal fluid leak, or cochlear implant is not required. PAGE 32 PPSV23=23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax®23) PCV13=13-Valent Pneumococcal Conjugate Vaccine (Prevnar 13®) © 2014 Rhode Island Board of Education I D E S L A D E I S L A O I S N O N H D E L PneumococcalH E I SVaccinationL Pneumococcal Vaccination A D D A D

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A L A R R L A AdultsA ≥19 Years1-4 AdultsCOLLEGEPHARMACY ≥19 OF Years PHARMACY E E 1-4 COLLEGE OF T A T R AdultsR ≥19 YearsA PHARMACY M H E M H AdultsDRUG INFORMATION ≥19 Years DRUGPHARMACY INFORMATION T T E E F H (Including updated recommendationsE for Fthe use of PCV13(Including in Adults) updated recommendationsDRUG SERVICESINFORMATION for the use of PCV13 in Adults) SERVICES M N T O M N T O H DRUG INFORMATION E F (Including updated recommendations for Fthe use of PCV13 in Adults) 401-874-9188 401-874-9188 N T O E N T O (Including updated recommendationsSERVICES for the use of PCV13 in Adults) SERVICES 401-874-9188 401-874-9188 Healthy Adults ≥ 65 Healthy Adults ≥ 65 Healthy Adults ≥ 65 Healthy Adults ≥ 65 Pneumococcal Vaccination PreviouslyPneumococcal vaccinated with Vaccination PreviouslyPreviously vaccinated vaccinated with with Previously vaccinated with Pneumococcal Vaccination Previously vaccinated with Previously vaccinated with Naive or Unknown History PPSV23PneumococcalNaive at orage Unknown ≥65 Vaccination History PPSV23Previously beforePPSV23 age vaccinated 65at age ≥65 with PreviouslyPPSV23 vaccinatedbefore age 65with Naive or Unknown History PPSV23Naive at orage Unknown ≥65 History PPSV23 beforePPSV23 age 65at age ≥65 PPSV23 before age 65 ≥ 1 year after PPSV23 ≥ 1 year after PPSV23 ≥ 1 year after PPSV23 ≥ 1 year after PPSV23 GIVE: PCV13 GIVE: PCV13 GIVE: PCV13 ≥ 1 year after PPSV23GIVE: PCV13 GIVE: PCV13≥ if not1 yearpreviously after given PPSV23 GIVE: PCV13 if not previously given ≥ 1 year after PPSV23 GIVE: PCV13≥ if not1 yearpreviously after given PPSV23 GIVE: PCV13 if not previously given Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* Wait ≥ 1 year* (and ≥ 5Wait years ≥ 1after year* PPSV23) (and ≥ 5Wait years ≥ 1after year* PPSV23) (and ≥ 5 years after PPSV23) (and ≥ 5 years after PPSV23)

GIVE: PPSV23† GIVE: PCV13 if notGIVE: previously PPSV23 given † GIVE:GIVE PPSV23: PCV13† if not previously given GIVE: PPSV23† GIVE: PPSV23† GIVE: PCV13 if notGIVE: previously PPSV23 given † GIVE:GIVE PPSV23: PCV13† if not previously given GIVE: PPSV23† ADULTS ≥ 19 with UNDERLYING MEDICAL ADULTS CONDITIONS ≥ 19 with (see UNDERLYING chart on back) MEDICAL CONDITIONS (see chart on back) ADULTS ≥ 19 with UNDERLYING MEDICAL ADULTS CONDITIONS ≥ 19 with (see UNDERLYING chart on back) MEDICAL CONDITIONS (see chart on back) OR who SMOKE or live in a NURSING HOMEOR who SMOKE or live in a NURSING HOME OR who SMOKE or live in a NURSING HOMEOR who SMOKE or live in a NURSING HOME Pneumococcal Vaccination Previously Pneumococcalvaccinated with Vaccination one Previously vaccinated with one Pneumococcal Vaccination Previously Pneumococcalvaccinated with Vaccination one Previously vaccinated with one Naive or Unknown History doseNaive PPSV23 or Unknown History Vaccination isdose NOT PPSV23 Vaccination is NOT Naive or Unknown History doseNaive PPSV23 or Unknown History Vaccination isdose NOT PPSV23 indicated for healthy persons indicatedVaccination for healthy is NOT persons indicated for healthy persons 19 - 64 years of age indicated19 - 64 for years healthy of age persons GIVE: PPSV23 GIVE: PPSV23 19 - 64 years of age GIVE: PPSV23 GIVE: PPSV23 19 - 64 years of age While PCV13 is FDA-approved for While PCV13 is FDA-approved for Whilepersons PCV13 > 50 isyears, FDA-approved the Advisory for Whilepersons PCV13 > 50 isyears, FDA-approved the Advisory for At Age ≥65 At Age ≥65At Age ≥65 persons > 50 years, theAt Advisory Age ≥65 persons > 50 years, the Advisory At Age ≥65 At Age ≥65At Age ≥65 Committee on ImmuneAt Practices Age ≥65 Committee on Immune Practices GIVE: PCV13 ≥ 1 year after PPSV23 GIVE: PCV13GIVE: ≥ 1yearPCV13 after ≥ 1PPSV23 year after PPSV23 doesCommittee not GIVE:provide on Immune guidancePCV13 Practices for≥ 1yearuse after PPSV23 doesCommittee not provide on Immune guidance Practices for use GIVE: PCV13 ≥ 1 year after PPSV23 GIVE: PCV13GIVE: ≥ 1yearPCV13 after ≥ 1PPSV23 year after PPSV23 GIVE: PCV13 ≥ 1year after PPSV23 THEN: PPSV23† ≥ 1 year* after THEN: PPSV23THEN:† ≥PPSV23 1 year* after† ≥ 1 year* after does notin provide thisTHEN: population. guidance PPSV23 for use† ≥ 1 year* after does notin provide this population. guidance for use PCV13THEN: and PPSV23 ≥ 5 years† ≥ after1 year* PPSV23 after PCV13THEN: and PPSV23PCV13 ≥THEN: 5 years †and ≥PPSV23 after1 ≥year* 5 yearsPPSV23 after† ≥ after1 year* PPSV23 after inPCV13 thisTHEN: population. and PPSV23 ≥ 5 years† ≥ after1 year* PPSV23 after in this population. PCV13 and ≥ 5 years after PPSV23 PCV13 andPCV13 ≥ 5 years and after ≥ 5 yearsPPSV23 after PPSV23 PCV13 and ≥ 5 years after PPSV23

ADULTS ≥ 19 with IMMUNE COMPROMISING ADULTS CONDITIONS ≥ 19 with (see IMMUNE chart COMPROMISING on back), OR ASPLENIA CONDITIONS (see chart on back), OR ASPLENIA ADULTS ≥ 19 with IMMUNE COMPROMISING ADULTS CONDITIONS ≥ 19 with (see IMMUNE chart COMPROMISING on back), OR ASPLENIA CONDITIONS (see chart on back), OR ASPLENIA (including sickle cell anemia), CEREBROSPINAL(including FLUID sickle LEAK, cell anemia),or COCHLEAR CEREBROSPINAL IMPLANT FLUID LEAK, or COCHLEAR IMPLANT (including sickle cell anemia), CEREBROSPINAL(including FLUID sickle LEAK, cell anemia),or COCHLEAR CEREBROSPINAL IMPLANT FLUID LEAK, or COCHLEAR IMPLANT Pneumococcal Vaccination Previously Pneumococcalvaccinated with Vaccination one PreviouslyPreviously vaccinated vaccinated with with one Previously vaccinated with Pneumococcal Vaccination Previously Pneumococcalvaccinated with Vaccination one Previously vaccinated with Previously vaccinated with Naive or Unknown History doseNaive PPSV23 or Unknown History two dosesPreviously of PPSV23dose vaccinated PPSV23 with one two doses of PPSV23 Naive or Unknown History doseNaive PPSV23 or Unknown History two doses of PPSV23dose PPSV23 two doses of PPSV23 GIVE: PCV13 ≥ 1 year after PPSV23GIVE: PCV13 ≥ 1 year after PPSV23 GIVE: PCV13 ≥ 1 year after PPSV23GIVE: PCV13 ≥ 1 year after PPSV23 ≥8 weeks* later GIVE: PCV13 if not previously≥8 weeks* given later GIVE: PCV13 if not previously given ≥8 weeks* later ≥8 weeks* later ≥ 1 year after PPSV23 ≥ 1 year after PPSV23 GIVE: PCV13 if not previously given ≥ 1 year GIVE:after PPSV23 PCV13 if not previously given If < 65 If ≥65 If < 65 If ≥65 ≥ 1 year after PPSV23 If < 65 If ≥65 ≥8 weeks*If < 65 later If ≥65 ≥8 weeks* later GIVE: PPSV23 ≥8GIVE: weeks* PPSV23 later ≥8 weeks* later GIVE: PPSV23 GIVE: PPSV23 GIVE: PCV13 if not previously given GIVE: PCV13 if not previously given If < 65 and If ≥65 If < 65 and If ≥65 ≥ 5 years after If ≥65 GIVE: PCV13≥ 5 years if notafter previously given GIVE: PCV13 if not previously given If < 65 and If < 65 and If ≥65 If < 65 and ≥PPSV23 5 years after If < 65 and ≥PPSV23 5 years after If≥ 5< years 65 after and ≥ 5 years afterand GIVE:PPSV23 secondIf < 65 PPSV23 ≥PPSV23 5 years after ≥PPSV23 5 years after GIVE: second GIVE:PPSV23 second§ GIVE: second§ GIVE:PPSV23 second GIVE:PPSV23 second PPSV23 PPSV23 § PPSV23 § GIVE:PPSV23 second§ GIVE:PPSV23 second§ PPSV23 § PPSV23 §

At Age ≥65 At Age ≥65At Age ≥65 AtAt Age Age ≥ ≥65 65 At Age ≥ 65 GIVE: PPSV23† GIVE: PPSV23† † GIVE: PPSV23† At Age ≥65 At Age ≥65 GIVE: PPSV23GIVE: PPSV23At Age† ≥ ≥ 8 weeks*65 after At Age† ≥ 65 GIVE: PPSV23† GIVE: PPSV23† GIVE: PPSV23GIVE:At Age† PPSV23 ≥65GIVE:† PPSV23† GIVE:At Age PPSV23 ≥65† GIVE: PPSV23† GIVE: PPSV23 ≥ 8 weeks* after ≥5 years GIVE:after PPSV23GIVE:† PPSV23† ≥ 8 weeks* after≥5 years after GIVE:≥ 5 years PPSV23 after † GIVE:≥ 5 years PPSV23 afterGIVE: ≥ 5† years PPSV23 after≥5 years† after PCV13 andGIVE: ≥ 5≥ 5years years PPSV23 after after † PPSV23 ≥5 years after PCV13GIVE: andPPSV23 ≥ 5 years† ≥ 8 afterweeks* PPSV23 after ≥ 5 years after ≥ 5 years after ≥ 5 years after PPSV23 PCV13 and ≥ 5≥ 5years years after after PPSV23 PPSV23 PPSV23 PPSV23 PPSV23 PPSV23 PPSV23 PPSV23 PCV13 and ≥ 5 years after PPSV23 PPSV23 PPSV23 PPSV23 PneumococcalPPSV23 Vaccine

E I SI S L ODDE L A A Minimum interval between sequential administration of PCV13 and O N N Pneumococcal Vaccination Pneumococcal PPSV23 is 8 weeks Minimum in immunocompromised interval between sequential patients. administration Vaccina>on of PCV13 I S and PPSV23H is 8 weeksD in immunocompromisedPneumococcal patients. Vaccination Informa>on Sheet

* GIVE: PPSV23 GIVE: PPSV23 D E L R D * A D R

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D For MedicarePCV13 GIVE: reimbursement PPSV23 interval must be 11 full (Prevnar months. Please refer to page For4. Medicare reimbursement 13®) interval must be 11 full months. Please and PPSV23 referE to ispage 8 weeks 4.H in immunocompromised PPSV23 patients. (Pneumovax® 23)

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L † TheFor Medicare ACIP (Advisory reimbursement Committee interval on Immunization must be 11 full Practices) months. Please recommends refer to pageonly† 14. dose of PPSV23 at age H The ACIP (Advisory Committee on Immunization Practices) recommendsA only 1 dose of PPSV23 at age L For Medicare reimbursement≥65. interval Revaccination must be 11 isE fullnot months. necessary. Please refer to page 4. ≥65. Revaccination is not necessary.1-4 COLLEGE OF PCV13 (Prevnar 13®) and A PPSV23 1-5 (Pneumovax® COLLEGE 23) OF A T R Recommendations P A Adults ≥19 Years PHARMACY §† The ACIP (Advisory Committee on Immunization Practices) recommends only§† 1 dose of PPSV23 at age R E PHARMACY PCV13 (Prevnar13®) A second PPSV23 PPSV23 for patients with cerebrospinal fluid leak, or cochlear (Pneumovax®23) implant AThe issecond ACIPnot required. PPSV23(Advisory for Committee patients≥65. Revaccinationwith on Immunizationcerebrospinal is not Practices)fluid necessary. leak, recommends orL cochlearT implant only 1E isdose not ofrequired. PPSV23 at ageAdults ≥65. Revaccination ≥19 Years is not necessary. A T 1-4 COLLEGE OF M H DRUG INFORMATION A M H DRUG INFORMATION Pneumococcal § A secondPneumococcal PPSV23 PPSV23 for patients with cerebrospinal fluid leak, or cochlear (Pneumovax®23) implant§ is not required. Vaccina>on Vaccina>on R E O F Adults(Including updated≥19 Years recommendations Informa>on for the Informa>on use of PCV13 in Adults)PHARMACY SERVICES Sheet Sheet PCV13 (Prevnar13®) PPSV23=23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax ® 23) PPSV23 A second PPSV23 for patients with cerebrospinal fluid leak, E or cochlearE® NimplantT F is not required. SERVICES Manufacturer: Pneumococcal PPSV23 (Pneumovax®23) =23-Valent Pneumococcal Polysaccharide Vaccina>on T Vaccine (Pneumovax N 23)T O (Including updated recommendations for the use of PCV13 Informa>on in Adults) 401-874-9188 Manufacturer: Sheet PCV13 (Prevnar13®) PCV13 PCV13 (Prevnar (Prevnar 13®) 13®) and M H and PPSV23 PPSV23 (Pneumovax® 23) (Pneumovax® DRUG 23) INFORMATION401-874-9188 PPSV23 ® ® E F ® (Including® updated recommendations for the use of PCV13 in Adults) PCV13=13-Valent=23-ValentMerck Manufacturer: PCV13 Pneumococcal Pneumococcal Conjugate Polysaccharide Vaccine (Prevnar Vaccine (Prevnar (Pneumovax 13 ) 23) PCV13PPSV23=13-Valent=23-Valent Pneumococcal Pneumococcal 13®) Conjugate Polysaccharide Vaccine Vaccine (PrevnarN T O (Pneumovax and 13 ) © 201423) Rhode Island Board PPSV23 of Education (Pneumovax® © SERVICES2014 23) Rhode Island Board of EducationPfizer Manufacturer: Manufacturer: ® Healthy Adults ≥ 65 401-874-9188 Manufacturer: PCV13=13-Valentwww.merckvaccines.comMerck Pneumococcal Conjugate Vaccine (Prevnar 13 ) PCV13=13-Valent Pneumococcal/ Conjugate Vaccine (Prevnar 13PCV13®) © and 2014 PPSV23 Rhode IslandIndications Board forof EducationAdults ≥ 19 Years* by Risk Group 2,3 © 2014 Rhode Island Board of Educationwww.pfizerpro.comPfizer PCV13 PCV13 / (Prevnar13®) (Prevnar13®) PPSV23 www.merckvaccines.comMerck PPSV23 (Pneumovax®23) (Pneumovax®23) / www.pfizerpro.comPfizer / How www.merckvaccines.com PPSV23 Supplied: (Pneumovax®23) / Pneumococcal VaccinationHealthy AdultsPreviously ≥ 65 vaccinated with Previously vaccinated with How www.pfizerpro.com Supplied: PCV13 / (Prevnar13®) Manufacturer: Manufacturer: Pneumococcal Vaccina>on ® Informa>on ® Manufacturer: Manufacturer: Sheet 0.5ml How Supplied: Single Dose Vial Naive or Unknown History PPSV23 PCV13 (Prevnar13 at age) ≥65 PPSV23 (PneumovaxPPSV2323) before age 65 Prefilled How Supplied: Syringe Merck Merck How Manufacturer: PCV13 Supplied: (Prevnar 13®) Pneumococcal and Vaccination Previously PPSV23 vaccinated with Previously vaccinated (Pneumovax® 23) with Pfizer Pfizer How Manufacturer: Supplied: Mul@-­‐Dose 0.5ml Single (5 Dose dose Vial Vial) Risk Group Underlying Medical Condition (10 Prefilled per Syringe Package) 0.5ml Merck Single Dose Vial Revaccinate 5 years Prefilled Pfizer Syringe www.merckvaccines.comwww.merckvaccines.com/ / Naive or Unknown History PPSV23 at age ≥65 Recommended RecommendedPPSV23 before ≥ 1age year 65 after PPSV23www.pfizerpro.comwww.pfizerpro.com/ / Mul@-­‐Dose (5 dose Vial) after first dose (10 per Package) Storage Mul@-­‐Dose www.merckvaccines.com and (5 Handling dose : Vial) / Storage (10 www.pfizerpro.com per and Package) Handling/ : How How PPSV23 Supplied: Supplied: (Pneumovax®23) How How Supplied: Supplied: PCV13 (Prevnar13®) Refrigerate Storage and on Handling Arrival : GIVE: PCV13 Storage Refrigerate and on Handling Arrival : 0.5ml 0.5ml Storage How Single Supplied: Single and Dose Dose Handling Vial : Vial Persons with normal Cigarette smoker ≥ 1 year after PPSV23 ≥ 1✓ year afterGIVE PPSV23: PCV13 if not previously givenPrefilled Prefilled Storage How Supplied: Syringe Syringe and Handling: Store Manufacturer: Refrigerate at 2◦C on to 8◦C Arrival immune function Manufacturer: Store Refrigerate at 2◦C on to 8◦C Arrival Mul@-­‐Dose Mul@-­‐Dose Refrigerate 0.5ml Single (5 on (5 dose Dose Arrival Vial) dose Vial Vial) (10 (10 Prefilled Refrigerate per per Package) Syringe Package) on Arrival DO Merck Store NOT at 2◦C FREEZE to 8◦C GIVE: PCV13 Wait ≥ 1 year*Chronic heart disease† ✓ Wait ≥ 1 year* Pfizer DO Store NOT at 2◦C FREEZE to 8◦C Store Mul@-­‐Dose at 2◦C (5 to 8◦C dose Vial) GIVE: PCV13 if not previously given (10 Store per at 2◦C Package) to 8◦C www.merckvaccines.comDO NOT FREEZE / ≥ 1 year after PPSV23 (and ≥ 5 years after PPSV23) www.pfizerpro.comDO NOT FREEZE / Storage Storage Discard and aYer and Handling the Handling: : expira@on date § Storage Storage Discard and aYer and Handling the Handling: : expira@on date DO NOT FREEZE Chronic lung disease ✓ DO NOT FREEZE Refrigerate Refrigerate Storage Discard aYer on and on Arrival the Handling Arrival : expira@on Wait date ≥ 1 year* Wait ≥ 1 year* Refrigerate Refrigerate Storage Discard aYer on and on Arrival the Handling Arrival : expira@on date How Discard Special Pneumococcal Supplied: instruc7ons: aYer the expira@on Vaccina>on date GIVE: PPSV23† GIVE: PCV13 if not previously Informa>on given GIVE: PPSV23† How Special Discard Supplied: Sheet instruc7ons: aYer the expira@on date Store Store Refrigerate Pneumococcal at at 2◦C 2◦C on to 8◦C to 8◦C Arrival Vaccina>on Diabetes mellitus Informa>on (and ≥✓ 5 years after PPSV23) Store Store Refrigerate at at Sheet 2◦C 2◦C on to 8◦C to 8◦C Arrival 0.5ml None Special PCV13 Pneumococcal Single instruc7ons: (Prevnar Dose Vial 13®) Vaccina>on and PPSV23 Informa>on (Pneumovax® 23) Prefilled Shake Special Sheet well instruc7ons: Syringe to obtain a homogeneous white suspension DO DO Store Special PCV13 NOT NOT at instruc7ons: (Prevnar FREEZE 2◦C FREEZE to 8◦C 13®) and PPSV23 (Pneumovax® 23) DO DO Special Store NOT NOT at instruc7ons: FREEZE 2◦C FREEZE to 8◦C Mul@-­‐Dose None PCV13 (Prevnar (5 dose 13®) Vial) and ADULTSCerebrospinal ≥ 19 with PPSV23 fluid leakUNDERLYING MEDICAL CONDITIONS (see (Pneumovax® chart 23) on back) (10 Shake per well Package) to obtain a homogeneous white suspension DO None NOT FREEZE GIVE: PPSV23† if not previously given ✓ ✓GIVE: PPSV23† Shake DO NOT well FREEZE to obtain a homogeneous white suspension Discard Discard Route PPSV23 aYer of aYer the (Pneumovax®23) Administra7on: the expira@on expira@on date date GIVE: PCV13 Discard Discard Route aYer of aYer the Administra7on: PCV13 the expira@on expira@on date (Prevnar13®) date Storage Discard 0.5mL Route of IM aYer and or Administra7on: SQ the Handling: expira@on date OR£ who SMOKE or live in a NURSING HOME Storage 0.5mL Route Discard of IM aYer and Administra7on: ONLY PCV13 the Handling: expira@on (Prevnar13®) date Route PPSV23 of (Pneumovax®23) Administra7on: Cochlear implant ✓ ✓ Route of Administra7on: PCV13 (Prevnar13®) Special Special Refrigerate 0.5mL Pneumococcal PPSV23 instruc7ons: IM instruc7ons: on (Pneumovax®23) or SQ Arrival Vaccina>on Informa>on Special Special Refrigerate 0.5mL instruc7ons: Sheet IM instruc7ons: on ONLY Arrival Manufacturer: Special instruc7ons: ADULTS ≥Pneumococcal 19 with UNDERLYING Vaccination MEDICALPreviously CONDITIONS vaccinated (see with onechart on back) Manufacturer: Special instruc7ons: None None Manufacturer: 0.5mL PCV13 IM (Prevnar or SQ 13®) and Alcoholism PPSV23 ✓ (Pneumovax® 23) Shake Shake Manufacturer: 0.5mL well well IM to ONLY to obtain obtain a a homogeneous homogeneous white suspension white suspension Merck Manufacturer: Store at 2◦C to 8◦C Naive or Unknown HistoryInsurance dose PPSV23 Carrier Pfizer Manufacturer: Store at Informa>on: 2◦C to 8◦C Merck None OR who SMOKE or live in a NURSING HOME Vaccination is NOT Pfizer Shake well to obtain a homogeneous white suspension Route Route www.merckvaccines.comMerck DO of NOT of Administra7on: FREEZE Administra7on: / Insurance Carrier Route Route www.pfizerpro.comPfizer DO of NOT of Informa>on: Administra7on: FREEZE Administra7on: / www.merckvaccines.com/ Chronic liver disease,Insurance cirrhosis ✓ indicated for healthy Carrier persons www.pfizerpro.com Informa>on:/ 0.5mL 0.5mL www.merckvaccines.comDiscard Route PPSV23 IM of IM aYer or SQ or (Pneumovax®23) SQ Administra7on: the / expira@on Pneumococcal date Medicare Vaccination Previously vaccinated www.medicarenhic.com with one 0.5mL 0.5mL www.pfizerpro.comRoute Discard IM of IM aYer ONLY ONLY Administra7on: PCV13 1-­‐866-­‐801-­‐5304 the / expira@on (Prevnar13®) date How Pneumococcal Supplied: Medicare Vaccina>on Medicare Part B www.medicarenhic.com reimburses Informa>on 19 - 64 years of age for How both Supplied: Sheet the cost 1-­‐866-­‐801-­‐5304 of the vaccine and its administraDon How 0.5mL Supplied: IM or SQ Naive or Medicare UnknownPersons Historywith functionalGIVE or: PPSV23Sickle cell diseasedose or other PPSV23 www.medicarenhic.com✓ Vaccination✓ is NOT✓ How 0.5mL Supplied: IM ONLY 1-­‐866-­‐801-­‐5304 0.5ml How Manufacturer: Special PCV13 Supplied: Single instruc7ons: (Prevnar Dose Vial 13®) Medicare and anatomical Part asplenia hemaglobinopathy PPSV23 B ∞ reimburses (Pneumovax® 23) for Prefilled How Manufacturer: Special both Supplied: instruc7ons: the Syringe cost of the vaccine and its administraDon 0.5ml Single Dose Vial Medicare Part Insurance Insurance B reimburses Carrier Carrier for Prefilled both Informa>on: Informa>on: the Syringe cost of the vaccine and its administraDon Mul@-­‐Dose 0.5ml Merck None Single (5 Dose dose Vial Vial) (Please refer to reference 3 for indicated for healthyWhile PCV13 persons is FDA-approved for (10 Prefilled Pfizer Shake per well Syringe Package) to obtain a homogeneous white suspension ∞ Mul@-­‐Dose (5 dose BCBS Vial) of specific RI www.bcbsri.com/providers guidance.) Congenital or Insurance acquired asplenia ✓ 19✓ - 64 yearspersons of age ✓> 50 years, the Carrier Advisory (10 per Informa>on: 401-­‐274-­‐4848 Package) 1-­‐800-­‐230-­‐9050 Mul@-­‐Dose www.merckvaccines.com (5 dose BCBS Vial) / of GIVE: PPSV23 RI www.bcbsri.com/providers(10 www.pfizerpro.com per 401-­‐274-­‐4848 Package) PCV13 / (Prevnar13®) 1-­‐800-­‐230-­‐9050 Storage Route PPSV23 of and (Pneumovax®23) Administra7on: Handling: Medicare Medicare At Age ≥65 www.medicarenhic.com www.medicarenhic.comAt Age ≥65 Committee on Immune Practices Storage Route of and 1-­‐866-­‐801-­‐5304 Administra7on: 1-­‐866-­‐801-­‐5304 Handling: Pneumococcal BCBS Vaccina>on of Medicare RI www.bcbsri.com/providers Congenital or acquired www.medicarenhic.com Informa>on Sheet 401-­‐274-­‐4848 1-­‐866-­‐801-­‐5304 1-­‐800-­‐230-­‐9050 Storage 0.5mL IM and or SQ HandlingMedicare : UnitedHealthCare Medicare Part Immunocompromised GIVE: Part PCV13 ≥ 1 B year after PPSV23 B www.unitedhealthcareonline.comGIVE: reimburses PCV13 reimburses ≥ 1year after PPSV23 does not provide for guidance for for use both Storage 0.5mL both the IM the and cost ONLY cost Handling of : 1-­‐877-­‐842-­‐3210 of the the vaccine and its administraDon vaccine and its administraDon Refrigerate Storage How Supplied: and on Handling Arrival : ¶ ✓ ✓ ✓ Storage How Refrigerate Supplied: and on Handling Arrival : Refrigerate Manufacturer: PCV13 (Prevnar on Arrival UnitedHealthCare 13®) Medicare and persons THEN: Part PPSV23† ≥immunodeficiency 1 year* after PPSV23 B www.unitedhealthcareonline.comTHEN: PPSV23 reimburses † ≥ 1 year* afterWhile PCV13 is (Pneumovax® FDA-approved 23) for for Manufacturer: Refrigerate both the on cost Arrival 1-­‐877-­‐842-­‐3210 of the vaccine and its administraDon Store Refrigerate 0.5ml at Single 2◦C on Dose to 8◦C Arrival Vial in this population. Prefilled Store Refrigerate at Syringe 2◦C on to 8◦C Arrival Merck UnitedHealthCare (PleasePCV13 refer to reference and 3≥ for 5 years after PPSV23 www.unitedhealthcareonline.comPCV13 and ≥ 5 years after PPSV23persons > 50 years, the Advisory Pfizer 1-­‐877-­‐842-­‐3210 Store at 2◦C to 8◦C RI Department of Health Store State at 2◦C Supplied to 8◦C Vaccina7on Program DO Store Mul@-­‐Dose NOT at 2◦C FREEZE (5 BCBS to 8◦C dose BCBS Vial) of of RI www.bcbsri.com/providersAt Agespecific ≥65 RI www.bcbsri.com/providers guidance.) HIV infection Insurance At Age ≥65 ✓ ✓ ✓ Carrier (10 DO Store per NOT 401-­‐274-­‐4848 at Informa>on: 401-­‐274-­‐4848 2◦C Package) FREEZE to 8◦C 1-­‐800-­‐230-­‐9050 1-­‐800-­‐230-­‐9050 DO www.merckvaccines.com PPSV23 NOT FREEZE (Pneumovax®23) BCBS / RI of Department RI www.bcbsri.com/providers of Committee on Immune Practices Health www.pfizerpro.comDO State NOT 401-­‐274-­‐4848 FREEZE Supplied PCV13 / (Prevnar13®) Vaccina7on Program 1-­‐800-­‐230-­‐9050 Discard DO NOT aYer FREEZE the expira@on RI GIVE: PCV13 date Department ≥ 1 year afterwww.health.ri.gov/resources/immuniza>on/ PPSV23 GIVE: PCV13 ≥ 1year after PPSV23 of does not provide guidance for use Health Discard DO State NOT aYer FREEZE Supplied the expira@on date Vaccina7on Program Storage Discard Pneumococcal aYer and the Handling: expira@on Vaccina>on date Medicare Chronic renal failure www.medicarenhic.com✓ Informa>on ✓ ✓ Storage Discard Sheet aYer and 1-­‐866-­‐801-­‐5304 the Handling: expira@on date Discard How Supplied: aYer the UnitedHealthCare UnitedHealthCare expira@on THEN: PPSV23 date † ≥ 1 year*ADULTSwww.health.ri.gov/resources/immuniza>on/ after ≥ 19 with www.unitedhealthcareonline.comTHEN: IMMUNE PPSV23 www.unitedhealthcareonline.comCOMPROMISING† ≥ 1 year* after CONDITIONS (see chart on back), OR ASPLENIA How Discard Supplied: aYer the 1-­‐877-­‐842-­‐3210 1-­‐877-­‐842-­‐3210 expira@on date Refrigerate Manufacturer: Special PCV13 instruc7ons: (Prevnar on Arrival UnitedHealthCare 13®) Medicare and Part www.health.ri.gov/resources/immuniza>on/ PPSV23 B www.unitedhealthcareonline.com reimburses in this population. (Pneumovax® 23) for Manufacturer: Special Refrigerate both instruc7ons: the on cost Arrival 1-­‐877-­‐842-­‐3210 of the vaccine and its administraDon 0.5ml Special Single instruc7ons: Dose Vial PCV13 and ≥ 5 years after(including PPSV23 Contraindica>ons sicklePCV13 cell anemia), and ≥ 5 years CEREBROSPINAL after PPSV23 FLUID LEAK, or COCHLEAR IMPLANT Prefilled Special and instruc7ons: Syringe Precau>ons: Store Merck None Special at instruc7ons: 2◦C to 8◦C Nephrotic syndrome ✓ ✓ ✓ Pfizer Shake Special Store at well instruc7ons: 2◦C to to 8◦C obtain a homogeneous white suspension Mul@-­‐Dose None (5 dose RI Vial) RI Department Department Contraindica>ons of of Health Health (10 Shake State and State per well Supplied Precau>ons: Package) Supplied to obtain Vaccina7on Program Vaccina7on a Program homogeneous white suspension •DO www.merckvaccines.comNone PPSV23 Do NOT not FREEZE (Pneumovax®23) give / RI PPSV23 Department Contraindica>ons or PCV13 of Health to www.pfizerpro.comShake DO pa@ents and State NOT well Precau>ons: who FREEZE have a history of serious Supplied to PCV13 / obtain reac@on (Prevnar13®) Vaccina7on a Program (e.g., homogeneous anaphylaxis) white suspension aYer Route of Administra7on: BCBS of www.health.ri.gov/resources/immuniza>on/ RI www.bcbsri.com/providersPneumococcalwww.health.ri.gov/resources/immuniza>on/ VaccinationLeukemia Previously vaccinated✓ with one✓ Previously✓ vaccinated with Route of 401-­‐274-­‐4848 Administra7on: 1-­‐800-­‐230-­‐9050 •Storage Discard Route Do of not aYer and Administra7on: give the Handling: expira@on PPSV23 ADULTS date ≥ 19 with IMMUNE COMPROMISING or CONDITIONS PCV13 (see chart on back), OR ASPLENIA to Storage Route Discard pa@ents of aYer and who have a history of serious Administra7on: the Handling: expira@on reac@on date (e.g., anaphylaxis) aYer •How 0.5mL Route a Do Supplied: previous of IM not or Administra7on: SQ give dose PPSV23 of Naivewww.health.ri.gov/resources/immuniza>on/ or Unknown PCV13, History or dose PPSV23 PCV13 PPSV, two doses of PPSV23 to or How 0.5mL Route pa@ents one Supplied: of IM of their components. who have a history of serious Administra7on: ONLY reac@on (e.g., anaphylaxis) aYer Refrigerate Manufacturer: 0.5mL a previous IM on or SQ Arrival dose of Lymphoma PCV13, ✓ PPSV, ✓ ✓ or Manufacturer: 0.5mL Refrigerate one IM of their components. on ONLY Arrival 0.5ml 0.5mL Special Single IM instruc7ons: or SQ Dose UnitedHealthCare Vial (including sickleContraindica>ons cell anemia),Contraindica>ons CEREBROSPINAL www.unitedhealthcareonline.com FLUID LEAK, or COCHLEAR IMPLANT and Prefilled 0.5mL Special and IM instruc7ons: Precau>ons: Syringe Precau>ons: ONLY 1-­‐877-­‐842-­‐3210 Store Merck a previous at 2◦C to 8◦C dose of PCV13, ≥ 1 year after PPSV23 PPSV, or Pfizer Store one at of their components. 2◦C to 8◦C Mul@-­‐Dose •None Do not (5 give dose Vial) PPSV23 GIVE:Contraindica>ons PCV13Hodgkin disease and ✓ PCV13 ✓ ✓ simultaneously. (10 Shake and per well Precau>ons: Package) to For pa@ents who need obtain both a PCV13 homogeneous and white suspension PPSV23, give • ••DO www.merckvaccines.comDo Do Do NOT not not not give FREEZE give give / PPSV23 RI PPSV23 Pneumococcal Department Vaccination or Previously or and Insurance vaccinated PCV13 with one PCV13 PCV13 of Previously vaccinated to Health with Carrier to simultaneously. pa@ents www.pfizerpro.comDO pa@ents State NOT Informa>on: who have a history of serious who FREEZE have a history of serious Supplied For pa@ents who need / reac@on both reac@on Vaccina7on PCV13 Program (e.g., (e.g., and anaphylaxis) anaphylaxis) PPSV23, give aYer aYer PCV13 first, followed ≥8 by weeks* later Insurance a dose Carrier of PPSV23 Informa>on: at least 8 weeks later. Give adults PCV13 12 months aYer the Storage Discard • Do not aYer and give the Handling: expira@on PPSV23 date and Insurance GIVE: PCV13 if not previously PCV13 given Carrier simultaneously. Storage Discard Informa>on: aYer and For pa@ents who need the Handling : both expira@on date PCV13 and PPSV23, give a How •Route a most PCV13 Do previous Supplied: previous of not recent first, Administra7on: give dose dose followed dose PPSV23 of Naive or of Medicare Unknown of Historywww.health.ri.gov/resources/immuniza>on/ PCV13, PPSV23. by Generalized PCV13, or malignancydose PPSV23 a www.medicarenhic.com PPSV, ✓ PCV13 PPSV, dose two✓ doses of PPSV23≥ 1 or year✓ after PPSV23 or to of How Route one pa@ents PPSV23 one of their components. Supplied: of of their components. at who have a history of serious Administra7on: 1-­‐866-­‐801-­‐5304 least reac@on 8 weeks (e.g., later. anaphylaxis) Give adults PCV13 12 months aYer the aYer Refrigerate 0.5mL a PCV13 previous IM first, on or SQ Arrival dose followed Medicare of by PCV13, If ≥65 a www.medicarenhic.com PPSV, dose of or 0.5mL Refrigerate PPSV23 one IM of their components. at on ONLY 1-­‐866-­‐801-­‐5304 Arrival least 8 weeks later. Give adults PCV13 12 months aYer the 0.5ml Special most Single instruc7ons: recent Dose Vial Medicare dose Medicare of Part If < 65 PPSV23. latrogenic immunosuppression** B www.medicarenhic.com reimburses for Prefilled Special both instruc7ons: the Syringe cost 1-­‐866-­‐801-­‐5304 of the vaccine and its administraDon Store most at recent 2◦C to 8◦C Medicare dose of Part PPSV23. ≥ B 1 year after PPSV23≥8 weeks* reimburses later for Store both at the 2◦C cost to 8◦C of the vaccine and its administraDon • ••Mul@-­‐Dose None Do Do PCV13 not not give and (5 give dose Medicare PPSV23 Vial) PPSV23 PPSV23 GIVE: PCV13 GIVE: Part are PPSV23 and Contraindica>ons and B both PCV13 reimburses ✓ PCV13 ✓ inac@vated simultaneously. ✓ simultaneously. for (10 Shake both and vaccines. per well the Precau>ons: Package) For pa@ents who need You can give all to cost For pa@ents who need other both obtain of both recommended the PCV13 a PCV13 vaccine and its administraDon homogeneous and and vaccina@ons PPSV23, give white suspension PPSV23, give at DO NOT FREEZE (Both high and low level immunosuppression) DO NOT FREEZE • PCV13 Do not and give PPSV23 PPSV23 are and Insurance both PCV13 inac@vated GIVE: PCV13 if not Carrier previously simultaneously. given vaccines. Informa>on: You can give all For pa@ents who need other both recommended PCV13 and vaccina@ons PPSV23, give at PCV13 PCV13 the same first, first, visit followed BCBS followed EXCEPT of ≥8 weeks* by RI www.bcbsri.com/providers later by if a a If < 65 the and dose If ≥65 dose person of of PPSV23 PPSV23 is at 401-­‐274-­‐4848 a at least candidate least 8 8 for weeks weeks 1-­‐800-­‐230-­‐9050 MCV4 later. later. and Give adults PCV13 12 months aYer the PCV13. If using MCV4-­‐D (Menactra®) Give adults PCV13 12 months aYer the Storage Discard • PCV13 aYer and and the Handling: PPSV23 expira@on date are GIVE: PCV13 both if not≥ previously 5 years after given inac@vated Storage Discard vaccines. aYer and You can give all other the Handling: expira@on recommended date vaccina@ons at most •Route most the PCV13 Do of recent same not recent first, Administra7on: give visit dose BCBS followed dose PPSV23 EXCEPT of of PPSV23. of RI www.bcbsri.com/providers PPSV23. by Solid organ or if transplant a the ✓ PCV13 dose ≥ 1✓ year after person PPSV23✓ to of Route pa@ents PPSV23 is of 401-­‐274-­‐4848 a at who have a history of serious Administra7on: candidate least reac@on 8 for weeks (e.g., 1-­‐800-­‐230-­‐9050 MCV4 later. anaphylaxis) and PCV13. If using MCV4-­‐D (Menactra®) Give adults PCV13 12 months aYer the aYer Refrigerate 0.5mL the give IM same PCV13 on or SQ Arrival visit BCBS first, EXCEPT of wait Medicare RI www.bcbsri.com/providers If < 65 and if 4 www.medicarenhic.comPPSV23 the weeks person and 0.5mL Refrigerate then is IM 401-­‐274-­‐4848 a give on ONLY 1-­‐866-­‐801-­‐5304 candidate Arrival MCV4-­‐D. for 1-­‐800-­‐230-­‐9050 MCV4 If using and PCV13. If using MCV4-­‐D (Menactra®) MCV4-­‐CRM (Menveo®) both can be given Special give most a previous instruc7ons: PCV13 recent UnitedHealthCare first, dose dose If < 65 wait of of ≥If 5 years ≥65 after PPSV23. PCV13, 4 www.unitedhealthcareonline.com weeks PPSV, or and Special then one instruc7ons: of their components. give 1-­‐877-­‐842-­‐3210 MCV4-­‐D. If using MCV4-­‐CRM (Menveo®) both can be given Store give at at the PCV13 2◦C same to 8◦C UnitedHealthCare first, Medicare visit. wait Part PPSV23 You Multiple myeloma B ≥8 4 weeks* www.unitedhealthcareonline.com GIVE: later cannot second reimburses ✓ weeks ✓ ✓ give and for Store both then PCV13 at the 2◦C give and PPSV23 simultaneously. cost to 8◦C 1-­‐877-­‐842-­‐3210 of MCV4-­‐D. the vaccine and its administraDon If using MCV4-­‐CRM (Menveo®) both can be given • •None PCV13 PCV13 and and PPSV23 UnitedHealthCare PPSV23 GIVE: PPSV23 are are both www.unitedhealthcareonline.com both § inac@vated inac@vated Shake vaccines. vaccines. well You can give all You can give all other to other obtain 1-­‐877-­‐842-­‐3210 recommended recommended a homogeneous vaccina@ons vaccina@ons white suspension at at DO at NOT the FREEZE same visit. GIVE: second You PPSV23 cannot give DO PCV13 NOT FREEZE and PPSV23 simultaneously. • at PCV13 Do the not and give same PPSV23 visit. RI PPSV23 Department are You Hematopoietic and Insurance stem cell transplant both cannot Please refer PCV13 to of reference 3 for specific inac@vated guidance Health give Carrier simultaneously. PCV13 State vaccines. Informa>on: You can give all and PPSV23 simultaneously. Supplied For pa@ents who need other both recommended Vaccina7on PCV13 Program and vaccina@ons PPSV23, give at the Discard Route the same of same aYer Administra7on: visit the visit expira@on RI EXCEPT EXCEPT date Department PPSV23 § if If if < 65 and the If the ≥65 of GIVE person : PCV13Side person if not previously Health given Route Discard is Effects: is State a of aYer a candidate Administra7on: Supplied the candidate expira@on for for date Vaccina7on Program MCV4 MCV4 and and PCV13. If using MCV4-­‐D (Menactra®) PCV13. If using MCV4-­‐D (Menactra®) the PCV13 same first, visit BCBS followed RI EXCEPT of Department RI www.bcbsri.com/providers by ≥ if 5 years after a the of dose person Health of PPSV23 is State 401-­‐274-­‐4848 a at Supplied candidate least 8 for Vaccina7on Program weeks 1-­‐800-­‐230-­‐9050 MCV4 later. and PCV13. If using MCV4-­‐D (Menactra®) Give adults PCV13 12 months aYer the give 0.5mL give PCV13 IM PCV13 or SQ first, first, wait wait Medicare † Including congestivewww.health.ri.gov/resources/immuniza>on/ heart failure and cardiomyopathies, 4 excluding 4 hypertension. www.medicarenhic.com weeks weeks Side and and then 0.5mL Effects: then IM give give ONLY 1-­‐866-­‐801-­‐5304 MCV4-­‐D. MCV4-­‐D. If If using using MCV4-­‐CRM (Menveo®) both can be given MCV4-­‐CRM (Menveo®) both can be given Special instruc7ons: If < 65 and £ If feasible, www.health.ri.gov/resources/immuniza>on/administer PCV13 and PPSV23 ≥ 2 weeksPPSV23 before planned cochlear implant surgery at appropriate intervals as described in the algorithm Side on the front page. Special Effects: instruc7ons: • give most Most PCV13 recent common first, dose side ≥ 5 years after wait of effects www.health.ri.gov/resources/immuniza>on/ PPSV23. 4 from weeks either and then PPSV23 give or PCV13 are soreness and MCV4-­‐D. redness If at using the injec@on site, MCV4-­‐CRM (Menveo®) both can be given at at the the same same visit. UnitedHealthCare Medicare visit. ∞ You For PPSV23 Part naive patients You planning splenectomy: Give B PCV13; cannot wait at www.unitedhealthcareonline.com least 8 weeks cannot then give PPSV23. reimburses Do not give PPSV23 within 2 weeks of planned splenectomy. give give for PCV13 both PCV13 the and PPSV23 simultaneously. and PPSV23 simultaneously. cost 1-­‐877-­‐842-­‐3210 of the vaccine and its administraDon None Most common side At effects Age ≥65 GIVE: second At Age ≥65 from At Age either ≥ 65 Shake PPSV23 well to or PCV13 are soreness obtain and redness a homogeneous at the white suspension injec@on site, • las@ng at the 1-­‐2 same days. visit. PPSV23 § Including chronic obstructive You pulmonaryContraindica>ons disease, emphysema, and† asthma. cannot GIVE: PPSV23† give and PCV13 Precau>ons: and PPSV23 simultaneously. • Most common side effects GIVE: PPSV23PPSV23Insurance § from either † Carrier PPSV23 Informa>on: or PCV13 are soreness and redness at the injec@on site, • las@ng PCV13 1-­‐2 and days. PPSV23 GIVE: second ¶ IncludesGIVE: B- are (humoral) PPSV23 or T-lymphocyte† Contraindica>ons deficiency, complement deficiencies both (particularlyGIVE: C1,PPSV23 C2, C3, and †C4 deficiencies),≥5 andyears phagocytic after disorders (excluding inac@vated GIVE: chronic granulomatous PPSV23 disease). ≥ 8 weeks* after and vaccines. Precau>ons: You can give all other recommended vaccina@ons at Route of Administra7on: BCBS RI of Department ** Those RI www.bcbsri.com/providers requiring≥ 5 years treatment after with immunosuppressive drugs, including long-term systemic≥ 5 years corticosteroids after and radiation. of Side Side PCV13 and ≥ Health 5 years after PPSV23 Effects: Route Effects: State of 401-­‐274-­‐4848 Administra7on: Supplied Vaccina7on Program 1-­‐800-­‐230-­‐9050 las@ng 1-­‐2 days. § PPSV23 • the Do same not give visit Drug PPSV23 Informa>on EXCEPT PPSV23 Medicare PPSV23 or if www.medicarenhic.comPPSV23 the PCV13 Services Side person to 401-­‐874-­‐9188 Effects: pa@ents is a who have a history of serious 1-­‐866-­‐801-­‐5304 candidate reac@on Monday-­‐Friday for 8:30 am-­‐4:00 (e.g., pm MCV4 EST anaphylaxis) and PCV13. If using MCV4-­‐D (Menactra®) aYer •0.5mL Do IM not or SQ give PPSV23 REFERENCES:www.health.ri.gov/resources/immuniza>on/ or PCV13 to 0.5mL pa@ents IM who have a history of serious ONLY reac@on (e.g., anaphylaxis) aYer • •Most Most a give previous common PCV13 common Drug UnitedHealthCare first, dose side Medicare side Informa>on effects wait of 1. Immunization Part effects Services Division, National PCV13, Center for Immunizatio B 4 n and www.unitedhealthcareonline.comRespiratory from Diseases, CDC. Advisory from reimburses Services weeks Committee on PPSV, Immunization Practices (ACIP) either either or and for 401-­‐874-­‐9188 both then PPSV23 one PPSV23 the of their components. give or PCV13 are soreness cost or PCV13 are soreness and 1-­‐877-­‐842-­‐3210 and of MCV4-­‐D. redness the Monday-­‐Friday redness 8:30 am-­‐4:00 vaccine and its administraDon at pm If at EST the using the injec@on site, injec@on site, MCV4-­‐CRM (Menveo®) both can be given Source a of previous informa@on; Drug dose Immuniza@on Informa>on of Recommended Immunization Ac@on Schedules PCV13, for Persons Aged 0 Coali@on (www.immunize.org Through 18 years and Adults Aged 19 Years Services and Older - United PPSV, States, 2013. ) or in 401-­‐874-­‐9188 collabora@on one of their components. with the Na@onal Monday-­‐Friday 8:30 am-­‐4:00 Adult pm and EST Influenza Immuniza@on Summit las@ng •(www.preven@nfluenza.org las@ng at a Most previous the 1-­‐2 common 1-­‐2 same days. ); dose days. accessed visit. side of September effects You PCV13, 4, cannot from PPSV, 2013. either give MMWR or 2012; PCV13 one 61(40):816-­‐819. PPSV23 of their components. and PPSV23 simultaneously. or PCV13 are soreness and redness at the injec@on site, Source of informa@on; Immuniza@on At Age ≥65 * MinimumMMWR Morb interval MortalGIVE: between Wkly PPSV23 Rep. Ac@on sequentialContraindica>ons 2013;62(Suppl):9-19. administrationAt Age Insurance of Coali@on (www.immunize.org ≥65PCV13 and PPSV23 is 8 weeks in immunocompromised patients. At Age ≥ 65 ) Carrier in collabora@on and Informa>on: Precau>ons: with the Na@onal Adult and Influenza Immuniza@on Summit •Source (www.preven@nfluenza.org las@ng Do of not informa@on; 1-­‐2 give ); days. accessed Immuniza@on PPSV23 2. ForCDC.GIVE: September Medicare Use of PPSV23 13-valent reimbursement pneumococcal † Ac@on interval conjugate must be and vaccine 11 full and months. Coali@on (www.immunize.org 23-val entPlease pneumococcal refer GIVE: to 4, page polysaccharide 4. PPSV23 vaccine † for adults PCV13 with immuno 2013. compromising conditions: ) MMWR simultaneously. in collabora@on 2012; 61(40):816-­‐819. with For pa@ents who need the both Na@onal PCV13 Adult and and Influenza Immuniza@on Summit PPSV23, give • Do not give BCBS RI PPSV23 of Department RI www.bcbsri.com/providers and PCV13 of GIVE: PPSV23† ≥ 8 weeks* Health after simultaneously. State 401-­‐274-­‐4848 Supplied For pa@ents who need both Vaccina7on PCV13 Program 1-­‐800-­‐230-­‐9050 and PPSV23, give •(www.preven@nfluenza.org Do not give ); accessed PPSV23 GIVE: PPSV23 † † Therecommendations September ACIP (Advisory of the Committee Advisory Committee on Immunization GIVE: on and Immunization PPSV23 Practices) Practices recommends† (ACIP). MMWR 4, ≥5 only years Morb 1 dose Mortal afterof WklyPPSV23 Rep. 2012;61(40):816-819.at PCV13 age ≥65. Revaccination 2013. is not necessary. MMWR simultaneously. 2012; 61(40):816-­‐819. For pa@ents who need both PCV13 and PPSV23, give • PCV13 Do not first, give Drug Drug followed Informa>on PPSV23 Informa>on ≥ 5 years after Medicare by or ≥ 5 years after a www.medicarenhic.com Services PCV13 Services dose Side to of 401-­‐874-­‐9188 401-­‐874-­‐9188 Effects: pa@ents PPSV23 at who have a history of serious 1-­‐866-­‐801-­‐5304 least reac@on Monday-­‐Friday 8:30 am-­‐4:00 8 Monday-­‐Friday 8:30 am-­‐4:00 weeks pm (e.g., pm EST EST later. anaphylaxis) Give adults PCV13 12 months aYer the aYer PCV13 first, followed §3. ACDC. second Use PPSV23ofwww.health.ri.gov/resources/immuniza>on/ 13-valent for pneumococcal by patients with conjugate cerebrospinal vaccine andfluid 23-val leak,ent or pneumococcal a cochlear implant polysaccharidePPSV23 is not required. vaccine among adultsPCV13 aged dose ≥ 19 years:and Recommendations≥ 5 years after of the AdvisoryPPSV23 of PPSV23 at least 8 weeks later. Give adults PCV13 12 months aYer the most PCV13 recent first, Drug followed Medicare dose Informa>on PPSV23 Committee of Part on Immunization PPSV23. by Practices (ACIP). MMWR Morb B Mortal Wkly Rep. a 2014;63(37):822-825.® reimburses Services dose of for 401-­‐874-­‐9188 PPSV23 both the at cost least of the 8 Monday-­‐Friday 8:30 am-­‐4:00 weeks vaccine and its administraDon pm EST later. Give adults PCV13 12 months aYer the Source Source a of of previous informa@on; informa@on; UnitedHealthCare dose Immuniza@on Immuniza@on of PPSV23 Ac@on =23-Valent Pneumococcal Ac@on Coali@on (www.immunize.org Polysaccharide PCV13, PPSV23 Vaccine Coali@on (www.immunize.org (Pneumovax www.unitedhealthcareonline.com23) PPSV, ) in ) or in collabora@on collabora@on one with of their components. with the the Na@onal 1-­‐877-­‐842-­‐3210 Na@onal Adult Adult and and Influenza Influenza Immuniza@on Summit Immuniza@on Summit most recent dose 4. Kobayashi of M, Bennett PPSV23. NM, Gierke R, et al. Intervals between PCV13 and ®PPSV23 vaccines: Recommendations of the Advisory Committee in Immunization Practice (ACIP) (www.preven@nfluenza.org(•www.preven@nfluenza.org most Most recent common ); ); accessed dose accessed side September PCV13 of September =13-Valent effects Pneumococcal PPSV23. Conjugate Vaccine 4, (Prevnar 13 ) 4, from 2013. 2013. MMWR © 2014 either Rhode MMWR Island Board of Education 2012; 2012; 61(40):816-­‐819. 61(40):816-­‐819. PPSV23 or PCV13 are soreness and redness at the injec@on site, Source of informa@on; Immuniza@on MMWR Morb Mortal Wkly Rep. Ac@on Contraindica>ons 2015; 64(34): 944-947. Coali@on (www.immunize.org) in collabora@on and Precau>ons: with the Na@onal Adult and Influenza Immuniza@on Summit •(www.preven@nfluenza.org las@ng PCV13 1-­‐2 and ); days. PPSV23 accessed RI Department September are both 4, of 2013. inac@vated Health MMWR 2012; State 61(40):816-­‐819. vaccines. You can give all Supplied other recommended Vaccina7on Program vaccina@ons at • PCV13 Do not and give BCBS PPSV23 PPSV23 Minimum of interval between sequential5. Rubin RI www.bcbsri.com/providers administration LG, Levin are MJ, Davies of PCV13 EG, et al.and 2013 IDSA and clinical practice guideline both for vaccination of the immunocompromised PCV13 host. Clin Infect Dis. 2014;58:e44-e100. inac@vated doi: 10.1093/cid/cit684. simultaneously. vaccines. 401-­‐274-­‐4848 You can give all For pa@ents who need other both recommended PCV13 1-­‐800-­‐230-­‐9050 and vaccina@ons PPSV23, give at • the Do PCV13 same not and give visit PPSV23 PPSV23 * EXCEPT GIVE: PPSV23 are PPSV23 or if is 8 weeks in immunocompromised both the patients. PCV13 inac@vated person to pa@ents is vaccines. a who have a history of serious You can give all other candidate reac@on recommended for (e.g., MCV4 vaccina@ons anaphylaxis) and PCV13. If using MCV4-­‐D (Menactra®) at aYer the PCV13 same first, visit followed For Medicare EXCEPT reimbursement interval must www.health.ri.gov/resources/immuniza>on/be 11 full months. by Please refer to if page 4. a the dose person of PPSV23 is a at candidate least 8 for weeks MCV4 later. and PCV13. If using MCV4-­‐D (Menactra®) Give adults PCV13 12 months aYer the a give the previous same PCV13 visit Drug UnitedHealthCare first, dose † The ACIP Informa>on EXCEPT (Advisory Committee wait of on Immunization Practices) recommends PCV13, if only 1 dose 4 of PPSV23 www.unitedhealthcareonline.com at age ≥65. the Revaccination Services weeks is not necessary. PPSV, person PAGE 33 or and 401-­‐874-­‐9188 then is one of their components. a give candidate 1-­‐877-­‐842-­‐3210 MCV4-­‐D. Monday-­‐Friday for 8:30 am-­‐4:00 pm MCV4 If EST using and PCV13. If using MCV4-­‐D (Menactra®) MCV4-­‐CRM (Menveo®) both can be given give most PCV13 recent first, dose § A second PPSV23 for wait patients with of cerebrospinal PPSV23. fluid leak, or cochlear implant is 4 not required. weeks and then give MCV4-­‐D. If using MCV4-­‐CRM (Menveo®) both can be given Source give of informa@on; PCV13 first, Immuniza@on wait Ac@on Coali@on (www.immunize.org 4 weeks ) in and collabora@on then give with the MCV4-­‐D. Na@onal Adult If and using Influenza Immuniza@on Summit MCV4-­‐CRM (Menveo®) both can be given at the same visit. PPSV23=23-Valent Pneumococcal Polysaccharide You VaccineContraindica>ons (Pneumovax®23) cannot give and PCV13 Precau>ons: and PPSV23 simultaneously. (www.preven@nfluenza.orgat the same ); accessed visit. RI Department September You 4, cannot of 2013. Health give MMWR 2012; PCV13 State 61(40):816-­‐819. and PPSV23 simultaneously. Supplied Vaccina7on Program • at PCV13 Do the not and give same PPSV23 visit. PPSV23 PCV13=13-Valent Pneumococcal Conjugate are Vaccine You (Prevnar 13® ) and both cannot PCV13 inac@vated © 2014 Rhode Island Board of Education give simultaneously. PCV13 vaccines. You can give all and PPSV23 simultaneously. For pa@ents who need other both recommended PCV13 and vaccina@ons PPSV23, give at Do not give PPSV23 or PCV13 to pa@ents who have a history of serious reac@on (e.g., anaphylaxis) aYer • the PCV13 same first, visit followed EXCEPT www.health.ri.gov/resources/immuniza>on/ by if a the dose Side person of Effects: PPSV23 is a at candidate least 8 for weeks MCV4 later. and PCV13. If using MCV4-­‐D (Menactra®) Give adults PCV13 12 months aYer the a previous dose of PCV13, PPSV, Side or Effects: one of their components. give most PCV13 recent first, dose wait of PPSV23. 4 weeks Side and Effects: then give MCV4-­‐D. If using MCV4-­‐CRM (Menveo®) both can be given • Most common side effects from either PPSV23 or PCV13 are soreness and redness at the injec@on site, • Most common side effects Contraindica>ons from either and PPSV23 Precau>ons: or PCV13 are soreness and redness at the injec@on site, • las@ng at PCV13 Most Do the not common 1-­‐2 and give same days. PPSV23 visit. side PPSV23 effects are You and both cannot from PCV13 inac@vated either give simultaneously. PCV13 vaccines. PPSV23 You can give all and PPSV23 simultaneously. For pa@ents who need other or PCV13 are soreness and both recommended redness PCV13 at and vaccina@ons the PPSV23, give at injec@on site, las@ng Do not 1-­‐2 give days. PPSV23 or PCV13 to pa@ents who have a history of serious reac@on (e.g., anaphylaxis) aYer • the las@ng PCV13 same 1-­‐2 first, visit days. followed EXCEPT by if a the dose person of PPSV23 is a at candidate least 8 for weeks MCV4 later. and PCV13. If using MCV4-­‐D (Menactra®) Give adults PCV13 12 months aYer the a previous dose of PCV13, PPSV, Side or Effects: one of their components. give most PCV13 recent Drug first, dose Informa>on wait of PPSV23. 4 Services weeks and 401-­‐874-­‐9188 then give MCV4-­‐D. Monday-­‐Friday 8:30 am-­‐4:00 pm If EST using MCV4-­‐CRM (Menveo®) both can be given Drug Informa>on Services 401-­‐874-­‐9188 Monday-­‐Friday 8:30 am-­‐4:00 pm EST •Source at Do Most of the not informa@on; common give same visit. Immuniza@on side PPSV23 effects You Ac@on and Coali@on (www.immunize.org cannot from PCV13 ) either give simultaneously. in collabora@on PCV13 PPSV23 with and PPSV23 simultaneously. For pa@ents who need or PCV13 are soreness the and both Na@onal redness PCV13 Adult and at and Influenza the Immuniza@on Summit PPSV23, give injec@on site, •Source (www.preven@nfluenza.org PCV13 of informa@on; and ); PPSV23 accessed Immuniza@on September are Ac@on Coali@on (www.immunize.org both 4, 2013. inac@vated ) MMWR in collabora@on 2012; 61(40):816-­‐819. vaccines. with You can give all other the Na@onal recommended Adult and Influenza vaccina@ons Immuniza@on Summit at Source (www.preven@nfluenza.orglas@ng of informa@on; 1-­‐2 ); days. accessed Immuniza@on September Ac@on Coali@on (www.immunize.org 4, 2013. ) MMWR in collabora@on 2012; 61(40):816-­‐819. with the Na@onal Adult and Influenza Immuniza@on Summit (www.preven@nfluenza.orgthe PCV13 same first, visit ); followed accessed EXCEPT September by if a 4, the dose 2013. Side person MMWR of Effects: 2012; PPSV23 is 61(40):816-­‐819. a at candidate least 8 for weeks MCV4 later. and PCV13. If using MCV4-­‐D (Menactra®) Give adults PCV13 12 months aYer the most recent dose of PPSV23. give PCV13 Drug first, Informa>on wait 4 Services weeks and 401-­‐874-­‐9188 then give MCV4-­‐D. Monday-­‐Friday 8:30 am-­‐4:00 pm If EST using MCV4-­‐CRM (Menveo®) both can be given • at Most the common same visit. side effects You cannot from either give PCV13 PPSV23 and PPSV23 simultaneously. or PCV13 are soreness and redness at the injec@on site, •Source PCV13 of informa@on; and PPSV23 Immuniza@on are Ac@on Coali@on (www.immunize.org both inac@vated ) in collabora@on vaccines. with You can give all other the Na@onal recommended Adult and Influenza vaccina@ons Immuniza@on Summit at (www.preven@nfluenza.orglas@ng 1-­‐2 ); days. accessed September 4, 2013. MMWR 2012; 61(40):816-­‐819. the same visit EXCEPT if the Side person Effects: is a candidate for MCV4 and PCV13. If using MCV4-­‐D (Menactra®) give PCV13 Drug first, Informa>on wait 4 Services weeks and 401-­‐874-­‐9188 then give MCV4-­‐D. Monday-­‐Friday 8:30 am-­‐4:00 pm If EST using MCV4-­‐CRM (Menveo®) both can be given • at Most the common same visit. side effects You cannot from either give PCV13 PPSV23 and PPSV23 simultaneously. or PCV13 are soreness and redness at the injec@on site, Source of informa@on; Immuniza@on Ac@on Coali@on (www.immunize.org) in collabora@on with the Na@onal Adult and Influenza Immuniza@on Summit (www.preven@nfluenza.orglas@ng 1-­‐2 ); days. accessed September 4, 2013. MMWR 2012; 61(40):816-­‐819. Side Effects: Drug Informa>on Services 401-­‐874-­‐9188 Monday-­‐Friday 8:30 am-­‐4:00 pm EST • Most common side effects from either PPSV23 or PCV13 are soreness and redness at the injec@on site, Source of informa@on; Immuniza@on Ac@on Coali@on (www.immunize.org) in collabora@on with the Na@onal Adult and Influenza Immuniza@on Summit (www.preven@nfluenza.orglas@ng 1-­‐2 ); days. accessed September 4, 2013. MMWR 2012; 61(40):816-­‐819. Drug Informa>on Services 401-­‐874-­‐9188 Monday-­‐Friday 8:30 am-­‐4:00 pm EST

Source of informa@on; Immuniza@on Ac@on Coali@on (www.immunize.org) in collabora@on with the Na@onal Adult and Influenza Immuniza@on Summit (www.preven@nfluenza.org); accessed September 4, 2013. MMWR 2012; 61(40):816-­‐819. Pneumococcal Vaccine Pneumococcal Vaccination Information Sheet ®) and PPSV23 (Pneumovax® 23) PCV13 (Prevnar 13 COLLEGE OF PHARMACY

Facts About Pneumococcal Disease: • Streptococcus pneumoniae bacteria (i.e., pneumococci) are usually found in the upper respiratory tract of most people.

• Pneumococcal disease most commonly presents as a serious infection in the lungs (pneumonia), blood (bacteremia), or brain (meningitis). The annual U.S. case estimate for invasive pneumococcal disease (bacteremia and/or meningitis) is 40,000 and 4,250 deaths.

• Pneumococcal disease most often occurs in older people as well as in people with a predisposing condition (e.g., immunosuppression, pulmonary disease, heart disease, diabetes). The disease rates for adults in these groups can be more than 20 times those for adults without high-risk medical conditions.

• PPSV23 is 60–70% effective in preventing serious pneumococcal disease; it does not provide substantial protection against all types of pneumonia (viral and bacterial). It is not a “pneumonia” vaccine.

Frequently Asked Questions: Question: Can I get the influenza and pneumococcal vaccines at the same time? Yes. These vaccines can be given at the same time. If giving two IM vaccinations, separate by one inch in the body muscle to reduce likelihood of local reactions overlapping.

Question: If patients who are in a recommended risk group for PPSV23 or PCV13 aren’t sure if they have previously received these vaccines, should healthcare providers vaccinate them? Yes. If patients do not have a documented vaccination history for these two vaccines and their records are not readily obtainable, you should administer the recommended doses. Extra doses will not cause harm to the patient.

Question: Is an egg allergy a contraindication for PCV13 or PPSV23? No. Both vaccinations are safe for persons with egg allergies.

Question: If my state has a registry, do I still need to give patients vaccine record cards? Yes. Patient-held cards are an extremely important part of a person’s medical history. The person may move to an area without a registry, and a personal record may be the only vaccination record available. In addition, even within a state, all healthcare providers may not participate in the registry, and the personal record card would be needed.

Question: My patient has had laboratory-confirmed pneumococcal pneumonia. Does he/she still need to be vaccinated with PPSV23? Yes. There are more than 90 known serotypes of pneumococcus (23 serotypes are in the current vaccine). Infection with one serotype does not necessarily produce immunity to other serotypes. As a result, if the person is a candidate for vaccination, he/she should receive it even after one or more episodes of invasive pneumococcal disease.

Question: Why is pneumococcal vaccination recommended for smokers and asthmatics? In 2008, the Advisory Committee on Immunization Practices (ACIP) reviewed new information that suggests that asthma is an independent risk factor for pneumococcal disease among adults. ACIP also reviewed new information that demonstrates an increased risk of pneumococcal disease among smokers. Consequently, ACIP recommends to include both asthma and cigarette smoking as risk factors for pneumococcal disease among adults age 19 through 64 years and as indications for PPSV23.

Acquired from www.immunize.org on September 4, 2013. We thank the Immunization Action Coalition. MMWR Morb Mortal Wkly Rep 2012; 61(40):816-819.

PAGE 34 Pneumococcal Vaccine

Pneumococcal Vaccination Information Sheet PCV13 (Prevnar 13®) and PPSV23 (Pneumovax® 23) COLLEGE OF PHARMACY

PPSV23 (Pneumovax®23) PCV13 (Prevnar13®) Manufacturer: Manufacturer: Merck Pfizer www.merckvaccines.com/Products/Pneumovax/Pages/home http://www.pfizerpro.com/hcp/prevnar13

How Supplied: How Supplied: 0.5mL Single Dose Vial Prefilled Syringe Multi-Dose (5 dose Vial) (10 per Package)

Storage and Handling: Storage and Handling: Refrigerate on Arrival Refrigerate on Arrival Store at 2◦C to 8◦C Store at 2◦C to 8◦C DO NOT FREEZE DO NOT FREEZE Discard after the expiration date Discard after the expiration date

Special instructions: Special instructions: None Shake well to obtain a homogeneous white suspension

Route of Administration: Route of Administration: 0.5mL IM or SQ 0.5mL IM ONLY Insurance Carrier Information: Medicare www.medicarenhic.com 1-866-801-5304* BCBS of RI www.bcbsri.com/providers 401-274-4848 1-800-230-9050 UnitedHealthCare www.unitedhealthcareonline.com 1-877-842-3210 RI Department of Health State Supplied Vaccination Program www.health.ri.gov/resources/immunization/ Contraindications and Precautions: • Do not give PPSV23 or PCV13 to patients who have a history of a serious reaction (e.g., anaphylaxis) after a previous dose of PCV13, PPSV23, or one of their components.

• Do not give PPSV23 and PCV13 simultaneously. For vaccine naive patients, give PCV13 first, followed by a dose of PPSV23 ≥ 1 year† (unless patient in a population specified by ACIP to require shorter interval, see page 1). For patients who have already received PPSV23, give PCV13 12 months after the most recent dose of PPSV23.

• Vaccine Co-administration: (1) all vaccines used for routine vaccination in the United States can be given on the same day; (2) an inactivated vaccine can be administered either on the same day as or at any time before or after another inactivated or a live vaccine; and (3) any 2 LIVE vaccines that are not given on the same day must be spaced at least 4 weeks apart. Zoster vaccine is a live, attenuated vaccine; injectable influenza vaccine and pneumococcal polysaccharide vaccine are inactivated vaccines. So these 3 vaccines can be given on the same day or at any time before or after each other. They should be given as separate injections, not combined in the same syringe.

Side Effects: • Most common side effects from either PPSV23 or PCV13 are soreness and redness at the injection site, lasting 1-2 days. Drug Information Services 401-874-9188 Monday-Friday 8:30 am - 4:00 pm EST * An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered). Please note that the “interval” between the two different pneumococcal vaccines must be at least 11 full months or greater for Medicare reimbursement, not the shorter “interval” recommended for specific populations identified by ACIP. Acquired from www.immunize.org on September 4, 2013. We thank the Immunization Action Coalition. † Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23 vaccines: Recommendations of the Advisory Committee in Immunization Practice (ACIP) MMWR Morb Mortal Wkly Rep. 2015; 64(34): 944-947.

PAGE 35 Antibiogram

95 75

Vancomycin 100 100 100 100

Sulfamethoxazole 98 66 89 /Trimethoprim 100

0 86 10

29 98 98 86 38

Tetracycline 100

0 28 10

Penicillin G 100

0 47

Oxacillin 100

0 99 95 98

Nitrofurantoin 100

Moxifloxacin 100

Isolates)

73 99 97 86

Gentamicin 100

7 72 30

Erythromycin 100 100

Clindamycin 79 63 52

0 Ciprofloxacin 64

Chloramphenicol 75

Cefotaxime 100

Ampicillin 99 25

4* 7* Percent Susceptible (2015 Susceptible Percent 74

Individual Isolates 126 124 111 extrapolating results; datamay be inconclusive therapeuticfor efficacy and

:

resistant (MRSA) resistant -

patient/Outpatient patient/Outpatient Gram Positive Gram Organisms In 2015 Isolates fecalis Enterococcus faecium Enterococcus aureus Staphylococcus (MSSA) aureus, Staphylococcus Methicillin epidermidis Staphylococcus pneumoniae Streptococcus

*If < 30 isolates use caution selection of empiric treatment. PAGE 36 Antibiogram

3 8

0 0 0 0

Tobramycin 2 75 50 9 100

Sulfamethoxazole 79 67 78 72 91 57 76 93 /Trimethoprim 100 100 100

Tetracycline 64 and

Piperacillin/ 73 94 97 94 52 96 tazobactam 100 100 100 100

0 0 0 0

Nitrofurantoin 93 26 97 37 83

Imipenem 86 96 95 100 100 100 100 100 100 100 100

Gentamicin 89 96 88 96 71 92 77 92 100 100 100

Ciprofloxacin 83 78 94 75 91 86 65 78 91 93 100

7 0

Cefuroxime 33 83 36 85 81 92 68

Ceftriaxone 67 84 92 94 86 94 79 86 100

Ceftazidime 83 89

Cefotaxime 55 67 82 92 94 86 94 52 100

Cefepime 79 89 90 92 95 86 94 93 96 89 100 ata may be inconclusiveata therapeuticfor efficacy

0 0 6 7 0

Cefazolin 85 89 82 36

2

Aztreonam 78 82 92 91 86 86 70 71 8 100

Ampicillin 7 0 33 50 36 58 78 88 61

Percent Susceptible (2015 Isolates) (2015 Susceptible Percent /Sulbactam

8 0 7 0 0

Ampicillin 11 10 52 71 72

.

Amikacin 99 93 100 100 100 100 100 100 100 100 100

* * * * * * 9 3 4 4 5 8 9 8 Individual Isolates 4 79 49 2 1 12 * 1 2 2 109 246

e caution extrapolating results; d

bacter aerogenes o bacter cloacae o bacter patient/Outpatient patient/Outpatient selection of empiric treatment *If < 30 isolates us Gram Negative Gram Organisms: In 2015 Isolates Acinetobacter baumanni freundii Citrobacter Enter Enter coli Escherichia pneumoniae Klebsiella morganii Morganella mirabilis Proteus marcescens Serratia influenzae Haemophilus oxytoca Klebsiella Stenotrophomonas maltophilia

PAGE 37 GuidelinesGuidelines for forRestricted Restricted Antimicrobials Antimicrobials

I. The use of the following formulary antimicrobial agents are restricted

Antibiotics Antifungals  Ceftaroline (Teflaro®)  Amphotericin B lipid complex  Ceftazidime/avibactam (Avycaz®) (AmBisome®)  Ceftolozane/tazobactam (Zerbaxa®)  Caspofungin (Cancidas ®)  Colistin (Polymyxin E)  Isavuconazonium sulfate (Cresemba®)  Dalbavancin (Dalvance®)  Voriconazole (V-Fend®)  Daptomycin (Cubicin®)  Ertapenem (Invanz®)  Fidaxomicin (Dificid®)  Fosfomycin (Monurol®)  Linezolid (Zyvox®)  Oritavancin (Orbactiv®)  Colistin (Polymyxin E)  Tedizolid (Sivextro®)  Tigecycline (Tygacil®)

II. To ensure the rational use of formulary, restricted, or non-formulary antimicrobial agents, the following policies and procedures are to be used:

1. When a prescriber wishes to prescribe a restricted or non-formulary antimicrobial agent, he/she shall indicate the “approved” reason (see following pages) in the comments section of the order form. If the use is outside of an approved indication, the physician MUST obtain approval of use. This approval must be obtained from the Infectious Diseases consult team, by directly contacting the on-call Infectious Diseases physician/fellow or by calling the Department of Medicine who will contact the on-call Infectious Diseases physician/fellow. 2. When pharmacy receives an order for a restricted antimicrobial agent, the pharmacist will verify the “approved” reason for use and if applicable, fill the order. If the pharmacy receives an order for a restricted or non-formulary antimicrobial agent and the ordering box does not indicate an approved reason for use, the pharmacist will immediately contact the prescriber to obtain “criteria for use of a restricted agent.” 3. If the prescriber cannot be reached, the pharmacist will dispense a maximum 24 hour supply of the drug. The pharmacist MUST notify the prescriber that the further drug will be dispensed only when the completed order form or ID approval is received. It is up to the prescriber to obtain authorization from the Infectious Diseases fellow or Infectious Diseases consult team.

PAGE 38 CeftarolineCeftaroline (Teflaro (Teflaro®)®) IV Only Use requires formal ID Consult Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus pneumoniae, most gram-negatives, and some gram-positive anaerobic bacteria NOT ACTIVE against Pseudomonas spp., Acinetobacter spp., or Enterococcus spp. Criteria for Use:  Acute bacterial skin and skin structure infection (ABSSSI) caused by MRSA +/- bacteremia or community-acquired bacterial pneumonia (CABP)  Unable to use vancomycin (VAN; due to intolerance, MIC ≥ 2 mg/mL, or infection unresponsive to VAN despite therapeutic concentrations)  Unable to use other agents (refer to empiric therapy for ABSSSI/CABP) Unacceptable Uses:  Treatment of P. aeruginosa, Enterococcus spp., or Acinetobacter spp. Infections (limited to no activity)  Treatment of ESBL producing organisms, such as E. coli or Klebsiella spp. (inactivated by AmpC and ESBL beta-lactamases)  Known serious hypersensitivity to ceftaroline or other members of the class. Cross-reactivity may occur in patients with a history of other beta-lactam allergies Dosing in Adults:  Standard dose: 600 mg IV Q12H For MSSA/MRSA bacteremia consider: 600 mg IV Q8H  Renal dose adjustment: CrCl 30-50 mL/min: 400 mg IV Q12H CrCl 15-30 mL/min: 300 mg IV Q12H CrCl <15 mL/min: 200 mg IV Q12H Hemodialysis: 200 mg IV Q12H  All infusions should be over 1 hour  No hepatic dose adjustment Monitoring:  Monitor CBC for drug-induced hemolytic anemia (none observed in studies, but seroconversion from negative to positive Direct Coombs’ Test is observed in 10.8% on ceftaroline vs 4.4% on comparator) ABSSSI= Acute bacterial skin and skin structure infection; CABP= community-acquired bacterial pneumonia; CBC= Complete blood count; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= infectious diseases; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; Q= every; spp= Species; VAN= vancomycin

PAGE 39 Ceftazidime/avibactamCeftazidime/avibactam (Avycaz®) (Avycaz®) IV Only Use requires formal ID Consult Use reserved for patients who have limited or no alternative treatment options since it was approved based upon limited clinical safety and efficacy data Activity: Coverage against many resistant gram-negatives such as Enterobacteriaceae and Pseudomonas aeruginosa, including some ESBL producers (e.g. CTX-M), carbapenemases (e.g. KPC, some OXA ), and AmpCs NOT ACTIVE against MBLs or gram-negatives that overexpress efflux pumps or have porin mutations, and most anaerobic bacteria Criteria for Use:  Treatment of cIAI (in combination with metronidazole) or cUTI, including pyelonephritis, caused by MDR gram-negative organisms Unacceptable Uses:  Empiric use without confirmed susceptibility  Treatment of cIAI and cUTI with other available treatment options  Known serious hypersensitivity to the components of ceftazidime/avibactam, avibactam-containing products, or other members of the cephalosporin class. Cross-reactivity may occur in patients with a history of penicillin allergy

Dosing in Adults:  Standard dose: 2.5gm IV Q8H For cIAI must use in combination with metronidazole  Renal dose adjustment: CrCl 31 - 50 mL/min: 1.25gm IV Q8H CrCl 16-30 mL/min: 0.94gm IVQ12H CrCl 6-15 mL/min: 0.94gm IV Q24H CrCl <5 mL/min: 0.94gm IV Q48H Administer after hemodialysis  No hepatic dose adjustment anticipated

Monitoring:  Scr/BUN at baseline and daily; adjust dose accordingly. CBC with differential. Monitor for signs of anaphylaxis with first dose Considerations for Use:  Decreased efficacy in patients with = CrCl 30-50 mL/min in clinical trials  CNS reactions have been reported in patients treated with ceftazidime, particularly in the setting of renal impairment BUN= blood urea nitrogen; CBC= Complete blood count; cIAI= Complicated intraabdominal infections; CNS= Central nervous system; CrCl= Creatinine clearance; cUTI= complicated urinary tract infections; ESBL= extended-spectrum beta-lactamases; H= hour(s); ID= infectious diseases; IV= Intravenous; KPC= carbapenemases; MBL= metallo-beta- lactamases; MDR= multi-drug resistant; Q= every; Scr= Serum creatinine

PAGE 40 Ceftolozane/tazobactamCeftolozane/tazobactam (Zerbaxa®) (Zerbaxa®)

IV Only Use requires formal ID Consult Activity: Coverage against many MDR gram-negatives such as Enterobacteriaceae and Pseudomonas aeruginosa. Potent in vitro activity against most P. aeruginosa isolates, including some MDR and carbapenem-resistant strains. Inhibits many Enterobacteriaceae, including some ESBL producers (e.g. CTX-M) and some AmpCs NOT ACTIVE against serine carbapenemases (e.g. KPCs or MBLs) Criteria for Use:  Treatment of cIAI (in combination with metronidazole) or cUTI, including pyelonephritis, caused by MDR gram-negative organisms Unacceptable Uses:  Empiric use without confirmed susceptibility  Treatment of cIAI and cUTI with other available treatment options  Known serious hypersensitivity to ceftolozane/tazobactam, piperacillin/tazobactam, or other members of the beta-lactam class

Dosing in Adults:  Standard dose: 1500 mg IV Q8H For cIAI must use in combination with metronidazole  Renal dose adjustment: CrCl 30-50 mL/min: 750 mg IV Q8H CrCl 15-29 mL/min: 375 mg IV Q8H Hemodialysis: 750mg IV ONCE (load), then 150mg IV Q8H after dialysis  No hepatic dose adjustment anticipated

Monitoring:  Scr/BUN, CBC with differential at baseline and daily Considerations for Use:  Package insert states decreased efficacy seen in patients with a baseline CrCl <50mL/min or patients >65 years of age, in the cIAI trial  May have a role in the treatment of other infections caused by multidrug resistant gram-negatives, however alternate dosing may be recommended depending on site of infection. ID team must be consulted for all potential on and off label use

BUN= blood urea nitrogen; CBC= Complete blood count; cIAI= Complicated intraabdominal infections; CrCl= Creatinine clearance; cUTI= complicated urinary tract infections; ESBL= extended-spectrum beta-lactamases; ID= infectious disease; IV= Intravenous; KPC= Klebsiella pneumoniae carbapenemases; MBL= metallo-beta-lactamases; MDR= multi-drug resistant; Q= every; H= hour(s); Scr= Serum creatinine

PAGE 41 DalbavancinDalbavancin (Dalvance (Dalvance®)®) IV Only Use requires formal ID Consult Activity: Coverage against Staphylococcus aureus (including MSSA and MRSA), Streptococcus pyogenes, Streptococcus agalactiae (Group B Strep.) and Streptococcus anginosus group (including S. anginosus, S. intermedius, S. constellatus) No clinical data, but activity in vitro vs. (vancomycin-susceptible strains only), Enterococcus faecium (vancomycin-susceptible strains only), vancomycin-intermediate S. aureus (not vancomycin-resistant strains) Criteria for Use:  Treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible gram-positive isolates  Unable to use vancomycin (due to intolerance, MIC >2mg/L, or infection unresponsive to vancomycin despite therapeutic concentrations)  Unable to use other agents (refer to empiric therapy for ABSSSI) Unacceptable Uses:  Infections due to vancomycin-resistant enterococci  Contraindicated in patients with known hypersensitivity to dalbavancin. Due to the possibility of cross-reactivity to glycopeptide, avoid in patients with previous glycopeptide hypersensitivity due to long half-life Dosing in Adults:  Standard dose: Administration should be over 30 minutes 1 Dose Regimen: 1500mg IV once 2 Dose Regimen: 1000mg IV once, then 500mg IV on day 8  Renal dose adjustment: 1 Dose Regimen CrCl <30 mL/min 1125 mg IV 2 Dose Regimen CrCl <30 mL/min: 750mg IV once, then 325mg IV day 8 If receiving regularly scheduled hemodialysis: No dosage adjustment  No hepatic dose adjustment anticipated

Monitoring:  Baseline BUN/Scr, AST/ALT/bili, CBC w/ diff, infusion-related reactions Considerations for Use:  In clinical trials, 6 (0.9%) patients in the dalbavancin arm had ALT elevations greater than 5x ULN including 3 with ALT >10x ULN. No subjects in the comparator arm had this degree of ALT elevations

ABSSSI= acute bacterial skin and skin structure infections; ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; bili= Bilirubin; BUN= Blood urea nitrogen; CBC= Complete Blood Count; CrCl= Creatinine clearance; ID= infectious diseases; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; SCr= Serum creatinine; ULN= Upper Limit of Normal

PAGE 42 DaptomycinDaptomycin (Cubicin®) (Cubicin®) IV Only Use requires formal ID Consult Activity: Coverage against most gram-positive bacteria (including MRSA and VRE) NOT ACTIVE against gram-negative bacteria Criteria for Use:  MRSA bacteremia and/or endocarditis and unable to use vancomycin (due to intolerance, MIC ≥ 2 mg/L, or infection unresponsive to vancomycin despite therapeutic concentrations)  MRSA skin and skin structure infections in patients with true, serious allergic reaction to vancomycin or linezolid  Patients receiving vancomycin for > 72 h for resistant staphylococcal skin and skin structure infection without clinical improvement  VRE confirmed bacteremia (see dosing below, use high doses) Formal ID consult for use in or complicated skin and soft tissue infection and all indications that are not listed above Unacceptable Uses:  Empiric therapy  Pneumonia (lung surfactant inactivates daptomycin) or any lower respiratory tract infection Dosing in Adults:  Standard dose: 6-10 mg/kg IV Q24H of actual body weight (ABW) May be dosed 8-10 mg/kg for Enterococcus (safety data for healthy volunteers up to 12 mg/kg/day)  Renal dose adjustment: CrCl < 30 mL/min: 8 mg/kg IV Q48H Hemodialysis: 8 mg/kg IV Q48H  No hepatic dose adjustment Monitoring:  Obtain CPK at baseline and weekly. Monitor for muscle pain or weakness, and for signs/symptoms of eosinophilic pneumonia Considerations for Use:  Consider discontinuation of concurrent statin therapy while on daptomycin due to additive muscle toxicity

ABW= Actual Body Weight; CPK= Creatine phosphokinase; CrCl= Creatinine clearance; H= hour(s); ID= Infectious Disease; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; VRE= Vancomycin-resistant enterococci

PAGE 43 ErtapenemErtapenem (Invanz®) (Invanz®)

IV and IM Only Use requires formal ID Consult Activity: Coverage against many gram-negatives (including those that produce ESBL), gram-positives, and anaerobes NOT ACTIVE against Pseudomonas spp., Acinetobacter spp., MRSA, or Enterococcus spp. Criteria for Use:  Outpatient treatment of community acquired infections; outpatient settings Unacceptable Uses:  Caution use of ertapenem in organisms producing AmpC beta-lactamase without testing the organisms specifically against ertapenem susceptibility  Contraindicated in patients with documented hypersensitivity to beta-lactams  Treatment of P. aeruginosa, Acinetobacter spp., MRSA, or Enterococcus spp. Infections

Dosing in Adults:  Standard dose: 1 gm IV or IM Q24H  Renal dose adjustment: CrCl < 30 mL/min: 500 mg IV or IM Q24H Hemodialysis: 500 mg IV or IM Q24H; supplemental dose of 150 mg after dialysis if last 500 mg dose given within 6 hours prior to dialysis, no supplemental dose necessary if last 500 mg dose given at least 6 hours prior to dialysis  No hepatic dose adjustment Monitoring:  Fever, CBC, hepatic function, pulmonary function (in pneumonia) CBC= Complete blood count; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= Infectious Disease; IM= Intramuscular; IV= Intravenous; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; Spp= Species

PAGE 44 FidaxomicinFidaxomicin (Dificid®) (Dificid®)

PO Only Use requires formal ID Consult Patients with multiple Clostridium difficile infection (CDI) recurrences (i.e. severe or mild-moderate CDI with greater than 2 and 3 recurrences, respectively) or severe, complicated CDI should obtain ID and/or GI consult for optimal therapy Criteria for Use:  Patient with severe CDI with a 2nd recurrence (previously received appropriate therapy [i.e., vancomycin 125 mg PO Q6H for initial and 1st recurrence]). Alternatively, a provider has the option to prescribe a vancomycin taper for a 2nd recurrence OR  Patients with mild-moderate CDI with a 3rd recurrence (previously received appropriate therapy i.e., vancomycin 125 mg PO Q6H for initial and 1st recurrence and then a vancomycin taper for the 2nd recurrence) Unacceptable Uses:  Treatment of systemic infections  Treatment of severe, complicated CDI (i.e., life-threatening or fulminant CDI or toxic megacolon)  Use in combination with PO vancomycin or PO metronidazole

Dosing in Adults:  Standard dose: 200 mg PO Q12H for 10 days  No renal or hepatic dose adjustment  May be given with or without food; systemic absorption is minimal

Considerations for Use:  Fidaxomicin was only studied in patients with an initial episode or 1st recurrence (defined as within 3 months of initial episode). Recurrence rates in both phase III studies were significantly lower in patients treated with fidaxomicin. However, in a subgroup analysis, recurrence rates were NOT significantly lower in fidaxomicin-treated patients who had the hypervirulent BI/NAP1/027 strain  The Society for Healthcare Epidemiology in America (SHEA) and Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for CDI recommend to discontinue therapy with the inciting antimicrobial as soon as possible, as this may influence the risk of CDI recurrence

CDI= Clostridium difficile infection; FDA= Food and Drug Administration; GI= gastrointestinal; H= hour(s); ID= infectious diseases; IDSA= Infectious Diseases Society of America; PO= Oral; Q= every; SHEA= Society for Healthcare Epidemiology in America

PAGE 45 FosfomycinFosfomycin (Monurol (Monurol®)®) PO Only Use requires formal ID Consult Activity: Coverage against many gram-negatives (including ESBL-producing and carbapenem-resistant Enterobacteriaceae [such as E. coli, Klebsiella spp.]) and gram- positives (including MRSA and VRE) NOT ACTIVE against Acinetobacter spp. In the United States only the oral formulation is available. Criteria for Use:  Management of uncomplicated UTI in patients with multiple antibiotic allergies and/or when no other oral therapy options are available  Uncomplicated UTI due to VRE  Salvage therapy for UTI due to multi-drug resistant organisms (e.g. ESBL, VRE, +/- Pseudomonas; confirm fosfomycin susceptibility prior to initiation of therapy) Unacceptable Uses:  Management of any infections outside of the urinary tract. Oral fosfomycin does not achieve adequate concentrations at other sites  Treatment of asymptomatic bacteriuria

Dosing in Adults:  Standard dose: Uncomplicated UTI: 3 gm (1 sachet) PO once Complicated UTI: 3 gm (1 sachet) PO every 2 to 3 days (up to 21 days of treatment) Powder should be mixed with 90-120 mL of cool water, stirred to dissolve and administered immediately. May be administered with or without food  Renal dose adjustment: CrCl < 50 mL/min: Frequency adjustment may be necessary; contact antimicrobial stewardship team  No hepatic dose adjustment Monitoring:  Signs and symptoms of urinary tract infection

CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; ID= Infectious Disease; MRSA= Methicillin-resistant Staphylococcus aureus; PO= Oral; Spp= Species; UTI= Urinary Tract Infection; VRE= Vancomycin-resistant enterococci

PAGE 46 LinezolidLinezolid (Zyvox (Zyvox®)®) IV and PO Only Use requires formal ID Consult Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus pneumoniae, VRE Criteria for Use:  Vancomycin (VAN) MIC ≥ 2 mg/L in MRSA pneumonia  Patient with allergy to beta-lactams/vancomycin and organism resistant to other antimicrobials  Significant VRE infections (i.e. isolated from a sterile site: blood, abscess)  Infections due to MRSA in patient with well documented intolerance to VAN (NOTE: Red man syndrome is not a serious intolerance to VAN) Formal ID consult for use in osteomyelitis or complicated skin and soft tissue infection and all indications that are not listed above Unacceptable Uses:  Empiric use when VRE has not been cultured or documented  Uncomplicated urinary tract infection  Positive respiratory culture for VRE  VRE colonization Dosing in Adults:  Standard dose: 600 mg PO or IV Q12H In patients tolerating PO medications, should be given orally Oral formulation is completely absorbed and has 100% availability  No renal or hepatic dose adjustment Monitoring:  CBC at baseline and weekly (MONITOR platelets at baseline and weekly) Considerations for Use:  Caution in patients with thrombocytopenia. 3 percent of patients were noted to have a platelet decrease <75% of baseline or lower limit of normal in controlled trials (therapy <28 days, most < 21 days. Thrombocytopenia is reversible upon discontinuation and is correlated with duration  Linezolid is a weak MAOI. Use in caution with decongestants (i.e. pseudoephedrine) and serotonergic agents (i.e. SSRIs [fluoxetine, escitalopram, sertraline, paroxetine, citalopram]) Warn patients to avoid large quantities of tyramine containing foods

CBC= Complete blood count; H= hour(s); ID= infectious disease; IV= Intravenous; MAOI= Monoamine oxidase inhibitors; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; PO= Oral; Q= every; SSRI= serotonin-specific reuptake inhibitors; VAN= Vancomycin; VRE= Vancomycin- resistant enterococci

PAGE 47 OritavancinOritavancin (Orbactiv (Orbactiv®)®)

IV Only Use requires formal ID Consult Activity: Coverage against Staphylococcus aureus (MSSA and MRSA), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus dysgalactiae, Streptococcus anginosus group and vancomycin-susceptible Enterococcus faecalis No clinical data, but activity in vitro vs. vancomycin-resistant enterococci and vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus Criteria for Use:  Treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible gram-positive isolates  Unable to use vancomycin (due to intolerance, MIC >2, or infection unresponsive to vancomycin despite therapeutic concentrations)  Unable to use other agents (refer to empiric therapy for ABSSSI) Unacceptable Uses:  Patients with suspected osteomyelitis. If OM is suspected, alternative antibacterial therapy should be initiated  Contraindicated in patients with known hypersensitivity to oritavancin. Due to the possibility of cross-reactivity to glycopeptide, avoid in patients with previous glycopeptide hypersensitivity due to long half-life. Dosing in Adults:  Standard dose: 1200mg dose IV over 3 hours x1  No renal or hepatic dose adjustment

Monitoring:  SCr/BUN, AST, ALT, bilirubin, infusion-related reactions (pruritus, urticaria, flushing), hypersensitivity reactions, signs/symptoms of OM Considerations for Use:  The use of unfractionated heparin is contraindicated for 48 hours after oritavancin administration due to artificial prolongation of aPTT  Co-administration of oritavancin and warfarin may result in higher exposure of warfarin, which may increase the risk of bleeding  Oritavancin can artificially prolong aPTT for up to 120 Hr, and may prolong PT and INR for up to 12 Hr and ACT for up to 24 Hrs

ABSSSI= acute bacterial skin and skin structure infections; ACT= Activated clotting time; ALT= Alanine aminotransferase; aPTT= Activated partial thromboplastin time; AST= Aspartate aminotransferase; BUN= Blood urea nitrogen; ID= Infectious Disease; INR= International normalized ratio; IV= Intravenous; MIC= Minimum inhibitory concentration; MRSA= Methicillin- resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; OM= osteomyelitis; PT= Prothrombin time; SCr= Serum creatinine

PAGE 48 PolymyxinPolymyxin B B

IV Only Use requires formal ID Consult Polymyxin B and Colistin (also known as Polymyxin E or Colistimethate) are the two polymyxin antibiotics. Their spectrum of activity is similar. However, their pharmacology is very different. Polymyxin B is administered as the active drug and is not cleared renally. Colistin is a prodrug (Colistimethate sodium) and is cleared renally. The product vials may be labeled as International Units (IU) or mg. To avoid major dosing errors, carefully read vial labels. Recommend that all doses be converted to mg. Conversion: 10,000 International Units = 1 mg

Activity: Coverage against most gram-negatives, including many multi-drug resistant (MDR) Enterobacteriaceae (such as E. coli, Klebsiella spp.; including ESBL-producing and carbapenem-resistant Enterobacteriaceae), Pseudomonas spp., and Acinetobacter spp. NOT ACTIVE against Proteus, Serratia, Providencia, Burkholderia, Stenotrophomonas, gram-negative cocci, gram-positive organisms, or anaerobes Criteria for Use:  Treatment of infections due to MDR Enterobacteriaceae, Pseudomonas spp., and Acinetobacter spp. with no other treatment options Unacceptable Uses:  Empiric treatment of suspected gram-negative infections  Monotherapy for serious infections due to rapid resistance development  Treatment of UTIs. Colistin preferred over polymyxin B for UTIs Dosing in Adults: Optimal dosing regimens are not well established  Standard dose: 2.5 mg/kg IV as a 2 hr infusion ONCE (load), then 12 hours later start 1.5 mg/kg IV as a 1 hr IV infusion. Repeat Q12H  No renal or hepatic dose adjustment  Use actual body weight for dosing  Caution in use > maximum product recommended daily dose (300mg) Monitoring:  BUN/ SCr at baseline and at least twice weekly Considerations for Use:  The most important side effect of IV polymyxin B is nephrotoxicity (20-40% of patients); less frequently reported concerns include neurotoxicity and neuromuscular blockade  Recent literature suggests that nephrotoxicity rates may be lower with polymyxin B as compared to colistin BUN= Blood urea nitrogen; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= Infectious Diseases; IU= international Units; IV= Intravenous; MDR= multi-drug resistant; Q= every; SCr= Serum creatinine; spp= Species; UTI= Urinary tract infection

PAGE 49 ColistinColistin (Polymyxin (Polymyxin E or Colistimethate) E or Colistimethate) IV Only Use requires formal ID Consult Colistin (also known as Polymyxin E or Colistimethate) and Polymyxin B are the two different polymyxin antibiotics. Colistin is a prodrug (Colistimethate sodium). The product vials may be labeled as International Units (IU) of prodrug, or mg of the active product: colistin base activity (CBA). To avoid major dosing errors, carefully read vial labels. Recommend that all doses be converted to mg of CBA. Conversion: 1,000,000 units of Colistimethate (prodrug) = 80 mg of Colistimethate (prodrug) = 30 mg of colistin base activity (CBA) Activity: Coverage against most gram-negatives, including many multi-drug resistant (MDR) Enterobacteriaceae (such as E. coli, Klebsiella spp.; including ESBL-producing and carbapenem-resistant Enterobacteriaceae), Pseudomonas spp., and Acinetobacter spp. NOT ACTIVE against Proteus spp., Serratia spp., Providencia spp, Burkholderia spp, Stenotrophomonas spp, gram-negative cocci, gram-positive organisms, or anaerobes Criteria for Use:  Treatment of infections due to MDR Enterobacteriaceae, Pseudomonas spp., and Acinetobacter spp. with no other treatment options  Treatment of UTI. Colistin preferred over polymyxin B for UTIs Unacceptable Uses:  Empiric treatment of suspected gram-negative infections  Use as monotherapy due to rapid resistance development Dosing in Adults: Optimal dosing regimens are not well established  Standard dose: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q12H  Renal dose adjustment: CrCl 20-50 mL/min: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q24H CrCl < 20 mL/min: 5 mg CBA/kg ONCE (load), then 2.5 mg CBA/kg Q48H Hemodialysis: 5 mg CBA/kg ONCE (load), then 30 mg CBA IV Q12H, AD  No hepatic dose adjustment  Use ideal body weight in obese patients for dosing  Caution in use > max product recommended daily dose (300 mg CBA) Monitoring:  BUN/ SCr at baseline and at least twice weekly Considerations for Use:  The most important side effect of IV colistin is nephrotoxicity (rates 50-60% of patients); less frequently reported concerns include neurotoxicity and neuromuscular blockade AD= After dialysis; BUN= Blood urea nitrogen; CBA= Colistin base activity; CrCl= Creatinine clearance; ESBL= Extended spectrum beta-lactamase; H= hour(s); ID= infectious diseases; IU= international units; IV= Intravenous; MDR= multi-drug resistant; Q= every; SCr= Serum creatinine; spp= species; UTI= Urinary tract infection

PAGE 50 TedizolidTedizolid (Sivextro (Sivextro®)®) IV and PO Only Use requires formal ID Consult Activity: Coverage includes Staphylococcus aureus (MSSA and MRSA), Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus anginosus group, and Enterococcus faecalis Criteria for Use:  Treatment of adult patients with acute bacterial skin and skin structure infections (ABSSSI) caused by susceptible gram-positive isolates  Unable to use vancomycin (due to intolerance, MIC >2, or infection unresponsive to vancomycin despite therapeutic concentrations)  Unable to use other agents (refer to empiric therapy for ABSSSI) Unacceptable Uses:  Infections for other indications not listed above  Patients with neutropenia. Safety and efficacy in patients with neutrophil counts <1000 cells/mm3 have not been assessed. Decreased activity in the absence of granulocytes in animal models Dosing in Adults:  Standard dose: 200 mg IV/PO once daily for 6 days  No renal or hepatic dose adjustment  No dose adjustment is necessary when changing from IV to PO

Monitoring:  CBC with differential Considerations for Use:  Tedizolid has been shown to be a reversible inhibitor of monoamine oxidase (MAO) in vitro, but no restrictions exist for concomitant use of drugs with serotonergic and adrenergic activity or tyramine containing foods. Of note, patients taking such medications were excluded from clinical trials. In vitro, in vivo, and clinical studies indicate weak MAO inhibition and a low potential for serotonergic adverse consequences  In phase 3 trials, reduction in hemoglobin, reduction in platelet count, and reduction in absolute neutrophil count were similar between tedizolid and linezolid  In phase 3 trials, adverse effects associated with neurologic and optic nerve disorders did not differ between tedizolid and linezolid

ABSSSI= acute bacterial skin and skin structure infections; CBC= Complete Blood Count; ID= Infectious Disease; IV= Intravenous; MAO= monoamine oxidase; MIC= Minimum inhibitory concentration; MRSA= Methicillin-resistant Staphylococcus aureus; MSSA= Methicillin-susceptible Staphylococcus aureus; PO= By Mouth

PAGE 51 TigecyclineTigecycline (Tygacil®) (Tygacil®)

IV Only Use requires formal ID Consult Activity: Coverage against MRSA, VRE, most gram-negatives, and anaerobes NOT active against Pseudomonas aeruginosa or Proteus spp. Criteria for Use:  Alternative therapy in patients with mixed aerobic-anaerobic infections and severe allergy to beta-lactam agents, if VRE or MRSA are involved  Alternative therapy for patients with systemic infections due to ESBL-producing organisms (Klebsiella spp., E. coli) with severe allergies to first-line therapy (imipenem/cilastatin or meropenem)  Alternative therapy for selected isolates of Acinetobacter, Stenotrophomonas, and VRE  Treatment of documented VRE infections in patients unable to take linezolid Unacceptable Uses:  Treatment of P. aeruginosa or Proteus spp. infections  Urinary tract infections (low urinary concentrations)  Peak serum concentrations do not exceed 1 mcg/mL, which limits its use for treatment of bacteremia Dosing in Adults:  Standard dose: 100 mg IV load x1, then 50 mg IV Q12H (use higher doses for infections due to Acinetobacter and other MDR organisms) Infuse each dose over 30 to 60 minutes  No renal dose adjustment Supplemental dosing is not necessary following hemodialysis  Hepatic dose adjustment: Severe hepatic disease (Child Pugh C): 100mg IV load x1, then 25 mg IV Q12H Important Side Effects:  Nausea and vomiting (most common in first 1-2 days of therapy)  To minimize GI side effects avoid fasting state administration  Prolonging the infusion time (>1 hour) may make GI side effects worse  Shortening infusion time (<30 minutes) may increase the incidence of infusion related reactions (inflammation, pain, phlebitis, other) Management of tigecycline-induced nausea and vomiting:  Ondansetron (Zofran®): Single dose of 8-12 mg IV or 8-24 mg PO

ESBL= Extended spectrum beta-lactamase; GI= Gastrointestinal; H= hour(s); ID= infectious diseases; IV= Intravenous; MDR= multi- drug resistant; MRSA= Methicillin-resistant Staphylococcus aureus; PO= by mouth; Q= every; spp= species; VRE= Vancomycin- resistant enterococci

PAGE 52 LiposomalLiposomal AmphotericinAmphotericin BB (L(L-AMB)(AmBisome®)-AmB)(AmBisome®)

IV Only Use requires formal ID Consult Activity: Broad-spectrum antifungal activity with in vitro activity against Candida, Cryptococcosis, Aspergillus, Zygomycosis, and Fusarium Dosing of AmBisome and Amphotericin B deoxycholate is significantly different and not interchangeable. Do not use AmBisome doses when ordering Amphotericin B deoxycholate and vice versa Criteria for Use:  Pre-existing renal insufficiency defined as SCr of ≥ 2 mg/dL or calculated CrCl of ≤ 25 mL/min, or SCr doubled from baseline  Patient refractory to or cannot tolerate conventional amphotericin B deoxycholate  SCr > 1.5 mg/dL and receiving concomitant cyclosporine or tacrolimus  Patients with irreversible ESRD on chronic HD or PD should receive amphotericin B deoxycholate Dosing in Adults:  Standard dose: Febrile neutropenia: 3 mg/kg/day, may consider 5 mg/kg/day in patients with neutropenia > 10 days, evidence of fungal infection, or clinically unstable Documented yeast (Candida spp., others) infection: 3-5 mg/kg/day Documented mold (Aspergillus spp., others) infection: 3-5 mg/kg/day Endopthalmitis: 5 mg/kg/day ± Flucytosine 25 mg/kg PO Q6H Endocarditis: 5 mg/kg/day Cryptococcal meningitis: 4 mg/kg/day ± Flucytosine 25 mg/kg PO Q6H  No renal/ hepatic dose adjustment Monitoring:  BUN/SCr, K, Mg, Phos at baseline and daily in hospitalized patients; AST/ALT at baseline and every 1-2 weeks

ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; BUN= Blood urea nitrogen; CrCl= Creatinine clearance; ESRD= End-stage renal disease; H= hour(s); HD= Hemodialysis; ID= infectious diseases; IV= Intravenous; K= Potassium; Mg= Magnesium; PD= Peritoneal dialysis; Phos= Phosphorus; PO= by mouth; Q= every; SCr= Serum creatinine; spp= species

PAGE 53 Caspofungin Caspofungin (Cancidas®) (Cancidas®)

IV Only Use Requires Formal ID Consult Criteria for Use: Invasive Aspergillosis:  Patients refractory to or who cannot tolerate conventional amphotericin B, liposomal amphotericin B, or voriconazole  In combination with voriconazole or amphotericin B in patients with documented invasive aspergillosis Systemic Candida infections:  Systemic Candida infections secondary to C. glabrata or C. kruseii and other non-Candida albicans (pending fluconazole susceptibility testing)  Patients unable to tolerate conventional amphotericin B or patients with concomitant renal insufficiency as per liposomal amphotericin B guidelines  Patients unable to tolerate fluconazole as defined by a serious rash, tripling of baseline LFTs, or other adverse reaction  Empiric use until non-albicans is confirmed

Dosing in Adults:  Standard dose: 70 mg IV x1, then 50 mg IV Q24H  No renal dose adjustment  Hepatic dose adjustment: Moderate hepatic impairment: 70 mg IV x1, then 35 mg IV Q24H  Patients receiving rifampin or phenytoin: Consider 70 mg IV Q24H (due to enzyme induction effect)

Monitoring:  Aspartate aminotransferase (AST)/ Alanine aminotransferase (ALT) at baseline and weekly

ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; H= hour(s); ID= infectious diseases; IV= Intravenous; LFTs= Liver Function Tests; PO= by mouth; Q= every

PAGE 54 IsavuconazoniumIsavuconazoniumsulfate sulfate (Cresemba (Cresemba®)®)

IV and PO Only Use requires formal ID Consult Activity: Coverage against most strains of the following microorganisms, both in vitro and in clinical infections: Aspergillus flavus, Aspergillus fumigatus, Aspergillus niger, and Mucorales such as Rhizopus oryzae and Mucormycetes species Criteria for Use:  Treatment of invasive aspergillosis  Treatment of invasive mucormycosis Unacceptable Uses:  Treatment for other fungal infections (Blastomyces, Histoplasma, etc.)  Contraindicated with known hypersensitivity to isavuconazole. Caution in use in patients with hypersensitivity to other azoles  Contraindicated in patients with familial short QT syndrome (shortens the QTc interval in a concentration-related manner) Dosing in Adults:  Standard dose: 372 mg IV/PO Q8H x 6 doses (48 hours; load), then 372 mg Q24H starting 12-24 hours after last loading dose  No renal or hepatic dose adjustment  IV must be administered via an infusion set with in-line filter (pore size 0.2-1.2 micron) and should be infused over a minimum of 1 hour  No dose adjustment is necessary when changing from IV to PO

Monitoring:  AST/ALT/bilirubin at baseline and every 1-2 weeks after Considerations for Use:  Elevated LFTs have been reported in clinical trials. Elevations generally reversible and do not require discontinuation  May cause fetal harm when administered to a pregnant woman Important note regarding drug interactions:  Isavuconazole is a substrate/inhibitor of CYP3A4 and has multiple drug interactions that may affect its levels and/or those of co-administered drugs. Dose adjustment may be necessary  Some drugs with interactions of major significance include: − Carbamazepine − Cyclosporine − Rifampin/ − Warfarin − Ritonavir − Tacrolimus − Sirolimus − Phenytoin

ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; H= hour(s); ID= infectious diseases; IV= Intravenous; LFT’s= Liver Function Tests; PO= by mouth; Q= every

PAGE 55 VoriconazoleVoriconazole (V-Fend®) (V-Fend®) IV and PO Only Use requires formal ID Consult Activity: Does not cover zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.). Criteria for Use:  Treatment of documented invasive aspergillosis  Used in combination with caspofungin in microbiologically or radiographically confirmed Aspergillus  Serious mycosis infections due to Fusarium spp., Scedosporium apiospermum

Dosing in Adults:  Standard dose: PO: 400 mg PO x2 doses (load), then 200 mg PO Q12H (oral formulation may be used without dose adjustment) IV: 6 mg/kg IV x2 doses (load), then 4 mg/kg IV Q12H In patients tolerating PO medications, should be given orally Voriconazole oral formulation is >95% bioavailable  Renal dose adjustment: IV voriconazole should be avoided in patients with CrCl < 50 mL/min due to visual disturbances and accumulation of cyclodextran vehicle (excipient)  Hepatic dose adjustment: Moderate hepatic impairment: ½ maintenance dose (PO: 100mg PO q12H; IV: 2 mg/kg IV Q12H) Monitoring:  Aspartate aminotransferase (AST)/ Alanine aminotransferase (ALT)/ bilirubin at baseline and every 1-2 weeks after Important note regarding drug interactions:  Voriconazole has multiple drug interactions that may affect its levels and/or those of co-administered drugs. Dose adjustment may be necessary  Some drugs with interactions of major significance include: − Carbamazepine − Tacrolimus − Rifampin/rifabutin − Cyclosporine − Ritonavir − Warfarin − Sirolimus − Phenytoin

ALT= Alanine aminotransferase; AST= Aspartate aminotransferase; CrCl= Creatinine Clearance; H= hour(s); ID= infectious diseases; IV= Intravenous; PO= by mouth; Q= every; spp= species

PAGE 56 Guidelines for Vancomycin Dosing and Determination of Trough Levels in GuidelinesAdult Patients for forVancomycin VancomycinDosing andDosing Determination and Determination of Trough Levels in ofAdult Trough Patients Levels in Adult Patients Refer to Vancomycin Dosing Nomogram OR calculate dose as described below: I.ReferHow to to Vancomycin calculate a vancomycinDosing Nomogramdose: OR calculate dose as described below: I. Howa) toObtain calculate actual a vancomycin body weightdose: (ABW) a)NOTE:Obtain do not actual calculate body weight dose based (ABW) on lean body weight; if morbidly obese use NOTE:ABW for do initial not calculate loading dose andbased monitor on lean trough body weight;or consult if morbidly ID. obese use b)ABWLoading for initial Dose loading(LD): For dose more andsevere monitorinfections trough or(i.e., consult Meningitis, ID. endocarditis, b) Loadingpneumonia, Dose etc.)(LD): consider For more a loadingsevere infectionsdose of 25 (i.e.,-30 mg/kg Meningitis, ABW endocarditis, pneumonia,LD = 25-30 mg/kg etc.) consider (Use ACTUAL a loading body dose weight) of 25-30 mg/kg ABW c) MaintenanceLD = 25-30 mg/kg dose (Use(MD): ACTUAL Calculate body each weight) maintenance dose: c) MaintenanceMD = 15 mg/kg dose (Use(MD): ACTUAL Calculate body each weight) maintenance dose: d.) SpecialMD = 15 Populations: mg/kg (Use ACTUAL body weight) d.) SpecialMorbid Populations: obesity ( 130% of IBW) use 30 mg/kg/day divided Q8H as obese patientsMorbid obesityoften require ( 130% more of IBW)frequent use dosing30 mg/kg/day intervals divided (i.e., Q8H) Q8H1,2,3 asObese obese patients rarelyoften requireneed doses more in frequent excess of dosing 3.5 gm intervalsper day. (i.e., Suggest Q8H) starting1,2,3 Obese at 1 patientsto 1.25 gm rarelyQ8H need and dosesadjust inupward excess if of necessary. 3.5 gm per day. Suggest starting at 1 Roundto 1.25 calculated gm Q8H dose and: adjustdoses shouldupward be if necessary.rounded to the nearest 250 mg incrementRound calculated (i.e., 500 dose mg,: doses750 mg, should 1000 be mg, rounded 1250 mg, to the1500 nearest mg, etc.) 250 mg II. Estimateincrement patient’s (i.e., 500creatinine mg, 750 clearance mg, 1000 (CrCl mg,) 1250 mg, 1500 mg, etc.) II. EstimateUse the patient’s Cockcroft creatinine-Gault equation. clearance (See (CrCl Pharmacokinetic) Section for equation) III. SelectUse dosingthe Cockcroft interval-Gault basedequation. on CrCl (See Pharmacokinetic Section for equation) III. Select dosing interval based on CrCl Estimated CrCl (mL/min) Dosing interval to consider Estimated≥100 CrCl (mL/min) Dosing intervalQ8H to consider 80≥100-99 Q8H Q8Hor Q12H 5080-7999 Q8HQ12H or Q12H 2550-4979 Q18HQ12H or Q24H <2525 mL/min-49 Q36HQ18H or Q48HQ24H Hemodialysis<25 mL/min Q36H or Q48H Give an initial loading dose of (checkHemodialysis pre-dialysis level) 15-20 mg/kg (check pre-dialysis level) Give an initial loading dose of Peritoneal dialysis Re-dose patient15 with-20 15mg/kg mg/kg when serum (IVPeritoneal administration) dialysis Re-dose patientlevel with ≤ 20 15 mcg/mL mg/kg when serum (IV administration) level ≤ 20 mcg/mL If the estimated renal function (CrCl) is near the border of two dosing intervals, it may be Ifreasonable the estimated to begin renal with function the more (CrCl aggressive) is near the interval; border the of two dose dosing can then intervals, be modified it may ifbe reasonablenecessary according to begin withto serum the more levels. aggressive interval; the dose can then be modified if necessaryABW= Actual bodyaccording weight; CrCl to =serum Creatinine levels. clearance; H= hour(s); IBW= ideal body weight; ID= infectious diseases; LD= loading dose; MD= maintenance dose; Q= every ABW= Actual body weight; CrCl= Creatinine clearance; H= hour(s); IBW= ideal body weight; ID= infectious diseases; LD= loading dose; MD= maintenance dose; Q= every References: 1. Bauer LA, Black DJ, Lill JS. Vancomycin dosing in morbidly obese patients. Eur J Clin Pharmacol. 1998 Oct;54(8):621-5. References:2. Vance-Bryan K, Guay DR, Gilliland SS, et al. Effect of obesity on vancomycin pharmacokinetic parameters as determined by using a Bayesian forecasting1. Bauer LA, technique. Black DJ, Lill AntimicrobJS. VancomycinAgentsdosing Chemother in morbidly. 1993 Mar;37(3):436obese patients.-40 Eur. J Clin Pharmacol. 1998 Oct;54(8):621-5. 3.2. VanceBlouin-BryanRA, Bauer K, Guay LA, MillerDR, Gilliland DD, et SS,al. Vancomycinet al. Effect ofpharmacokinetics obesity on vancomycin in normalpharmacokinetic and morbidly obeseparameters subjects. as determinedAntimicrob Agentsby using Chemother a Bayesian. 1982forecasting Apr;21(4):575 technique.-80. Antimicrob Agents Chemother. 1993 Mar;37(3):436-40. 3. Blouin RA, Bauer LA, Miller DD, et al. Vancomycin in normal and morbidly obese subjects. Antimicrob Agents Chemother. 1982 Apr;21(4):575-80. PAGE 57 GuidelinesGuidelines for Vancomycin for VancomycinDosing and Dosing Determination and Determination of Trough Levels in Adultof Trough Patients Levels in Adult Patients IV. Vancomycin Levels Vancomycin levels are NOT needed in patients with stable renal function who are on standard doses of vancomycin AND are on therapy for less than 5 days. Vancomycin peak levels are rarely, if ever, indicated. NOTE: Vancomycin demonstrates concentration-independent killing; therefore, peak concentrations are NOT useful or correlated to clinical outcomes. Measure Trough Concentrations Only if:  Patient is receiving vancomycin therapy > 5 days  Patient has unstable renal function  Patient is on an unusual/aggressive dosing regimen  Patient is morbidly obese (> 130% of IBW)  Patient has severe or life threatening infection and is receiving concomitant nephrotoxic drugs (i.e., cyclosporine, amphotericin B, aminoglycosides) V. Implications for NURSING Vancomycin needs to accumulate (steady state concentration) in order to obtain an accurate concentration. Please DO NOT order a plasma level unless 3 doses have been administered on a given schedule (i.e., order trough prior to the 4th dose) Exception: Dosing interval of 24 hours or longer Trough level should be drawn within 30 minutes of the next dose • Check what time the previous vancomycin dose (prior to the trough) was administered • Calculate how many hours are between the dose and level • Interpret the level in the context of recent vancomycin doses Example: If the patient is on 1gm Q12H and received a dose at 11pm, then a level taken at 6am is 7 hours post-dose and is NOT a trough level. • Be careful NOT to adjust OR hold vancomycin doses based on incorrectly drawn levels • Do NOT hold the next dose while waiting for trough results (sub-therapeutic levels <15mcg/mL are not effective and can lead to resistant pathogens)

H= hour(s); IBW= Ideal body weight; Q= every

PAGE 58 Guidelines for Vancomycin Dosing and Determination Guidelines for Vancomycin Dosing and Determination of Trough Levels in Adultof Trough Patients Levels in Adult Patients VI. Target Trough Vancomycin Level

Type of Infection Target Trough Vancomycin Level

MRSA pneumonia, CNS infection (meningitis), bacteremia, endocarditis, 15-20 mcg/mL osteomyelitis Endovascular Infection 15-20 mcg/mL Maintain 15-20 mcg/mL Check pre-dialysis level, re-dose when Hemodialysis ≤ 20 mcg/mL Often recommend to load with 15 – 20 mg/kg and re-dose Serious infection and renal dysfunction If ≥ 24H dosing check trough at 24 hours (CrCl < 25mL/min) Maintain 15-20 mcg/mL VII. Adjusting a vancomycin dose (Recommendations) Trough is too low- change the interval, keep the dose • If the level is < 5 mcg/mL, the dosing INTERVAL should be shortened Example: Trough level after 5 days of treatment reported as 3 mcg/mL on a regimen of 1000 mg Q12H, the interval should be shortened to 1000 mg Q8H Trough is too high- decrease the dose, keep the interval • If the trough level is >25 mcg/mL, the DOSE should be decreased 50% Example: Trough level after 5 days of treatment is reported as 29 mcg/mL on a regimen of 1000 mg Q12H; the dose should be decreased to 500 mg Q12H VIII. Monitoring (Inpatient) • Baseline weight, BUN, serum creatinine, WBC, temperature, cultures, and sensitivities should be taken every other day in stable patients • Daily urinary IN’s and OUT’s, CBC, and temperature should be monitored; should be performed in patients admitted to the ICU BUN= Blood urea nitrogen; CBC= Complete Blood Count; CNS= Central nervous system; CrCl= Creatinine clearance; H= hour(s); ICU= Intensive Care Unit; MRSA= Methicillin-resistant Staphylococcus aureus; Q= every; WBC= White blood cells

PAGE 59 Vancomycin Dosing Nomogram

≥100 1g q8h 1g q8h 1g q8h

1.5g q8h 1.25g q8h 1.25g q8h 1.25g q8h 1.25g q8h 500mg q8h 500mg q8h 500mg q8h 750mg q8h 750mg q8h 750mg q8h

90 500mg q8/12h 500mg q8/12h 500mg q8/12h 750mg q8/12h 750mg q8/12h 750mg q8/12h 1.5g q8h 1.25g q8h 1.25g q8h 1.25g q8h 1g q8/12h 1g q8/12h 1g q8/12h 1.25g q8/12h

80 q8/12h 500mg q8/12h 500mg q8/12h 500mg q8/12h 750mg q8/12h 750mg q8/12h 750mg q8/12h 1.5g q8h 1g 1g q8/12h 1g q8/12h

1.25g q8/12h 1.25g q8/12h 1.25g q8/12h 1.25g q8/12h

70 1g q8h 1g q12h 1g q12h 1g q12h 1g q12h 1.25g q12h 1.25g q12h 1.25g q12h 1.25g q12h 500mg q12h 500mg q12h 500mg q12h 750mg q12h 750mg q12h

If Patient is obese: 30mg/kg/day in divided doses q8h doses in divided 30mg/kg/day obese: is Patient If

60 1g q8h 1g q12h 1g q12h 1g q12h 1g q12h 1.25g q12h 1.25g q12h 1.25g q12h 1.25g q12h 750mg q12h 750mg q12h 500mg q12h 500mg q12h 500mg q12h Cr Cl inCr mL/min

50 1g q8h 1g q12h 1g q12h 1g q12h 1g q12h 1.25g q12h 1.25g q12h 1.25g q12h 1.25g q12h 500mg q12h 500mg q12h 500mg q12h 750mg q12h 750mg q12h

40 1g q24h 1g q24h 1g q24h 1g q24h 1.5g q24h 1.25g q24h 1.25g q24h 1.25g q24h 1.25g q24h 500mg q24h 500mg q24h 500mg q24h 750mg q24h 750mg q24h

30 q24h q24h q24h q24h q24h 500mg 500mg 500mg 750mg 750mg 1g q24h 1g q24h 1g q24h 1g q24h 1.5g q24h 1.25g q24h 1.25g q24h 1.25g q24h 1.25g q24h Contact Antimicrobial Stewardship Team Contact Antimicrobial Stewardship

30 35 40 45 50 55 60 65 70 75 80 85 90 95 ≥100 CrCl (mL/min)

Weight (kg) Vancomycin Dosing Nomogram weight in kg

PAGE 60 Guidelines for forAdministration Administration of High Dose of OnceHigh Daily Dose Once Daily Aminoglycosides (HDOD) (HDOD) High Dose Once Daily Aminoglycosides (HDOD) are considered safe and effective in patients with stable renal function Exclusion Criteria for HDOD: If patients fall into the following categories, use traditional/conventional dosing since there is limited data using HDOD in the following patient populations

Acute renal failure OR CrCl < 20 mL/min Age < 18 OR > 90 Half-life (t1/2) ≥ 4 hours Severe burns Dialysis Ascites To use Traditional Dosing Methods, see www.globalrph.com “medical calculator” For AMG dosing, contact the Antimicrobial Stewardship team or follow the steps below: I. Calculate the patient’s Ideal Body Weight (IBW) Male: 50 kg + [2.3 kg for each inch over 5 feet] Female: 45 kg + [2.3 kg for each inch over 5 feet] II. Determine the dose based on the table below (round dose to the nearest 20 mg) Aminoglycoside Maintenance Dose Tobramycin 5 mg/kg (IBW) Gentamicin 5 mg/kg (IBW)

• Dose is based on IBW except in obese patients OR those under their IBW • Use ABW if patient weight is less than IBW • Use AdjBW in patients who are obese (≥ 130% of IBW) Adjusted Body Weight (AdjBW) Calculation AdjBW = 0.4 (ABW – IBW) + IBW III. Estimate the patient’s creatinine clearance (CrCl) using the Cockcroft and Gault equation (refer to Pharmacokinetic Section) IV. Select dosing interval based on calculated CrCl from the tables below: CrCl (mL/min) Estimated Dosing Interval ≥ 60 Every 24 hours 40–59 Every 36 hours 20–39 Every 48 hours ≤ 20 Use traditional dosing method, see www. Globalrph.com “medical calculator” ABW= Actual Body Weight; AdjBW= Adjusted Body Weight; AMG= aminoglycosides (i.e., gentamicin and tobramycin); CrCl= Creatinine clearance; HDOD= High Dose Once Daily Aminoglycosides; IBW= Ideal Body Weight (in kg); t1/2= half life

PAGE 61 GuidelinesGuidelines for Administration for Administration of High Dose of Once High Daily Dose Once Daily AminoglycosidesAminoglycosides (HDOD) (HDOD) V. Commonly Targeted Peak and Trough Concentrations in HDOD Disease State Gentamicin/Tobramycin Amikacin

Recommended Estimated mg/kg Recommended Estimated mg/kg Peak (mcg/mL) (IBW) Peak (mcg/mL) (IBW) Cystitis 6–8 2–3 30-40 10–15 Gram-Positive 6–8 2–3 30–40 10–15 Synergy Pyelonephritis 12–14 3–4 60–70 20 Pneumonia 16–20 5–6 60–80 20–25

Sepsis 10–12 3–4 60–70 20 Intra-abd/SSTI 12–16 4–5 60–70 20 Clinical Considerations Trough should not exceed 0.3 mcg/mL Trough should not exceed 1 mcg/mL VI. Monitoring of serum levels and dosage adjustments a. First-dose levels are NOT routinely needed  First-dose levels may be indicated in patients with variable volume of distribution or unstable renal function (sepsis or post-operatively) to assess clearance b. Serum levels should be performed routinely by day 3 of therapy only once it has been determined that aminoglycoside therapy is to continue  Example: empiric therapy for sepsis from a UTI awaiting culture results does not require peak/trough levels c. Peak and trough serum levels: 1–2 hours post-end of infusion (peak) and immediately prior to the next dose  Document actual time medication was hung  Obtain peak level 1-2 hour post infusion (very important for distribution phase); 2 hr preferred if dose > 400 mg  Use pharmacokinetic formulas (or www.globalrph.com “medical calculator”), to extrapolate peaks and troughs  Extrapolated trough concentrations should not exceed 0.30 mg/mL  Dosage or interval adjustments should be made at this time d. Once stabilized, if therapy is to continue > 1 week, obtain the following laboratory values:  SCr and BUN levels to monitor renal function (every other day)  Peak and trough levels (efficacy and no toxicity), twice per week e. If there is a suggested change in renal function OR other nephrotoxic agents (e.g., cisplatin, amphotericin B, pentamidine, vancomycin) are being used concurrently, more frequent levels of BUN, SCr, and monitoring may be necessary BUN= Blood urea nitrogen; HDOD= high dose once daily; IBW= ideal body weight; SCr= Serum creatinine; SSTI= skin and soft tissue infection; UTI= Urinary tract infection

PAGE 62 Antimicrobial Dosing Guidelines for Adult Patients Antimicrobial Dosing Guidelines for Adult Patients BasedBased on on Renal Function Function CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD ACYCLOVIR IV >50 5 mg/kg Q8H 10 mg/kg Q8H* 30-50 5 mg/kg Q12H 10 mg/kg Q12H* D 10-29 5 mg/kg Q24H 10 mg/kg Q24H* <10 2.5 mg/kg Q24H 5 mg/kg Q24H* Dose using ideal body weight *Use maximum dose for meningitis/encephalitis and varicella in immunocompromised host AMOXICILLIN PO > 30 250 mg Q8H 500 mg Q8H MD 10-29 250 mg Q12H 500 mg Q12H <10 500 mg Q24H 500 mg Q24H AMOXICILLIN/CLAVULANATE PO > 30 500 mg Q8-12H* 875 mg Q12H MD 10-29 500 mg Q12H 875 mg Q12H <10 500 mg Q24H 875 mg Q24H *Use 500 mg Q8H for osteomyelitis for CrCl ≥ 30 mL/min AMPICILLIN IV >50 1 gm Q4-6H 2 gm Q4-6H* 30-50 1 gm Q8H 2 gm Q6-8H MD 10-29 1 gm Q12H 2 gm Q8-12H <10 1 gm Q24H 2 gm Q24H *Use 2 gm Q4H for meningitis AMPICILLIN/SULBACTAM IV >50 1.5 gm Q6H 3 gm Q6H* 30-50 1.5 gm Q8H 3 gm Q8H* MD 10-29 1.5 gm Q12H 3 gm Q12H* <10 1.5 gm Q24H 3 gm Q24H* *Use 3 gm if penetration is an issue (abscess/diabetic foot /vascular insufficiency/ osteomyelitis/intra-abdominal) AZTREONAM IV >50 1 gm Q8H 2 gm Q6H 30-50 1 gm Q12H 1 gm Q8H MD 10-29 1 gm Q24H 1 gm Q12 <10 500 mg Q24H 1 gm Q24H CEFAZOLIN IV >50 1 gm Q8H 2 gm Q8H 30-50 1 gm Q8H 2 gm Q8H MD 10-29 1 gm Q12H 2 gm Q12H <10 1 gm Q24H (2gm 2 gm Q24H Q48H) PAGE 63 Antimicrobial Dosing Guidelines for Adult Patients Antimicrobial Dosing Guidelines for Adult Patients BasedBased onon Renal Function Function CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD CEFEPIME IV >50 1 gm Q12H 2 gm Q12H 30-50 1 gm Q24H 2 gm Q24H D 10-29 1 gm Q24H 1 gm Q24H <10 0.5-1 gm Q24H 1 gm Q24H Pseudomonal Coverage or Febrile Neutropenia: >50: 2gm Q8H; 30-50: 2gm Q12H; 10-29: 1gm Q12H; < 10: 1gm Q24H CEFPODOXIME PO 30 100 – 200 mg Q12H 400 mg Q12H <30 100 – 200 mg Q24H 400 mg Q24H MD HD 100 – 200 mg 3 times 400 mg 3 times per per week week CEFUROXIME PO 20 250 mg Q12H 500 mg Q12H MD < 20 250 mg Q24H 500 mg Q24H CEFTRIAXONE IV >50 1 gm Q24H 2 gm Q24H* SD <50-5 (INCLUDING HD) No Change No Change *All indications are dosed at 1gm Q24H with the exception of meningitis (2 gm Q12H) and osteomyelitis (2 gm Q24H) CEPHALEXIN PO >30 250 mg Q6H 500 mg Q6H MD 10-29 250 mg Q8H 500 mg Q8H <10 250 mg Q12H 500 mg Q12H CIPROFLOXACIN IV >30 400 mg Q12H* 400 mg Q8H* SD 10-29 400 mg Q24H 400 mg Q12H <10 400 mg Q24H 400 mg Q24H *Use Q8H dosing only for Pseudomonas aeruginosa CIPROFLOXACIN PO >30 500 mg Q12H 750 mg Q8H SD 10-29 500 mg Q24H 750 mg Q12H <10 250 mg Q24H 500 mg Q24H CLINDAMYCIN IV >50 600 mg Q8H 900 mg Q8H ND <50 No Change No Change CLINDAMYCIN PO >50 300 – 450 mg Q8H 450 mg Q6H ND <50 No Change No Change

PAGE 64 Antimicrobial Dosing Guidelines for Adult Patients AntimicrobialAntimicrobial DosingDosing Guidelines for for Adult Adult Patients Patients Based on Renal Function BasedBased on on Renal Function Function CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD DICLOXACILLIN PO ND >50 250 – 500 mg Q6H 250 – 500 mg Q6H <50 No Change No Change DOXYCYCLINE PO >50 100 mg Q12H 100 mg Q12H ND <50 No Change No Change FLUCONAZOLE IV/PO* >30 200 mg Q24H 400 mg Q24H** MD 10-29 100 mg Q24H 200 mg Q24H <10 100 mg Q48H 200 mg Q48H *RECOMMENDATIONS FOR SYSTEMIC INFECTION ONLY, NOT FUNGURIA. Give PO if patient has functioning GI tract **May require dosages up to 800 mg/d depending on Candida species/sensitivities GANCICLOVIR IV >50 2.5-5*mg/kg Q24H 5 mg/kg Q12H 30-50 1.25 mg/kg Q24H 2.5 mg/kg Q24H D 10-29 0.625 mg/kg Q24H 1.25 mg/kg Q24H <10 0.625 mg/kg Q48H 1.25 mg/kg Q48H *5 mg/kg for CrCl ≥70 mL/min, 2.5 mg/kg for CrCl 50-69 mL/min GANCICLOVIR PO >50 1 gm Q8H 30-50 1-1.5 gm Q24H D 10-29 500 mg Q24H <10 500 mg Q48H IMIPENEM/CILASTATIN >50 500 mg Q6H 1 gm Q6H* 30-50 500 mg Q8H 500 mg Q6H* MD 10-29 500 mg Q12H 500 mg Q8H* <10 250 mg Q12H 500 mg Q12H* For suspected pseudomonas or ESBL infection use max doses MEROPENEM IV > 50 1 gm Q8H 2 gm Q8H 26 – 50 1 gm Q12H 1 gm Q8H MD 10 – 25 500 mg Q12H 1 gm Q12H <10 OR HD* 500 mg Q24H 1 gm Q24H *If patient on HD schedule daily dose to be administered immediately after dialysis. METRONIDAZOLE IV/PO* >10 500 mg Q8H 500 mg Q8H MD <10 500 mg Q12H 500 mg Q12H *No indication for Q6H dosing

PAGE 65 Antimicrobial Antimicrobial DosingDosing GuidelinesGuidelines for for Adult Adult Patients Patients Based Based on on Renal Renal FunctionFunction CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD MOXIFLOXACIN IV/PO >50 400 mg Q24H 400 mg Q24H ND <50 No Change No Change NAFCILLIN/OXACILLIN >50 1 gm Q4H 2 gm Q4H ND <50-5 (Including HD) No Change No Change NITROFURANTOIN* >50 100 mg Q12H N/A <50 Not Recommended *Do not use in systemic infections. Drug is ineffective with CrCl < 40mL/min due to inadequate urinary concentrations. OSELTAMIVIR PO > 60 75 mg Q12H 75 mg Q12H >30-60 30 mg Q12H 30 mg Q12H N/A >10-30 30 mg Q24H 30 mg Q24H PIPERACILLIN/TAZOBACTAM* >50 3.375 gm Q6H 3.375 gm Q4H 30-50 3.375 gm Q6H 3.375 gm Q6H MD 10-29 3.375 gm Q8H 3.375 gm Q6H <10 3.375 gm Q12H 3.375 gm Q8H *Use for maximal dose for empiric therapy or treatment of Pseudomonas aeruginosa. If polymicrobial infection without P. aeruginosa is suspected, consider using ampicillin/sulbactam RIFAMPIN PO >10 10 mg/kg Q24H 10 mg/kg Q12H N/A <10 10 mg/kg Q24H 10 mg/kg Q24H SULFAMETHOXAZOLE/ TRIMETHOPRIM IV Non-PCP PCP >50 2.5 mg/kg Q12H 5 mg/kg Q6H MD 30-50 2.5 mg/kg Q12H 5 mg/kg Q6H 10-29 2.5 mg/kg Q12H 5 mg/kg Q12H <10 2.5 mg/kg Q24H 5 mg/kg Q24H* Dosing based on trimethoprim (TMP) component. *Avoid if possible, not recommended by manufacturer for CrCl <15 mL/min due to nephrolithiasis.

PAGE 66 AntimicrobialAntimicrobial DosingDosing Guidelines for for Adult Adult Patients Patients BasedBased on on Renal Function Function CRCL (ML/MIN) STANDARD DOSE MAXIMAL DOSE HD SULFAMETHOXAZOLE/ TRIMETHOPRIM PO (Equal to IV Dose) >50 1-2 DS Q8-12H 5 mg/kg Q6H MD 30-50 1-2 DS Q12H 5 mg/kg Q6H 10-29* 1-2 DS Q12H* 5 mg/kg Q12H* <10* 1-2 DS Q24H* 5 mg/kg Q24H* Dosing based on trimethoprim (TMP) component. Round to the nearest 160 mg of TMP component. *Not recommended by manufacturer for CrCl <15 mL/min due to nephrolithiasis VANCOMYCIN PO ** >50 125 mg Q6H ND <50 No Change **For C. difficile only in patients with sdevere disease or failed metronidazole therapy *For IV dosing see vancomycin dosing guidelines Dosing based on Cockcroft and Gault Equation

D= Dialyzed 50 – 100%; HD= Hemodialysis; MD= Moderately dialyzed 20-49%; N/A= No information available; ND= Not dialyzed 0-5%

PAGE 67 AntimicrobialAntimicrobial Duration Duration of Therapy of Therapy

STRENGTH OF INFECTIOUS DISEASE RECOMMENDED DURATION OF THERAPY RECOMMENDATION Clostridium difficile Mild-moderate (initial episode) 10 – 14 days (vancomycin) A-I Severe, uncomplicated 10 – 14 days (vancomycin) B-I (initial episode) First recurrence (based on severity) 10 – 14 days A-II (C-III) Skin and Skin Structure 5 days (may require additional therapy NA Uncomplicated cellulitis depending on patient’s response) Complicated MRSA (deeper soft 7-14 days (based on patient’s NA tissue infections, surgical/traumatic response) wound infection, major abscesses, cellulitis, and infected ulcers and burns) Genitourinary Catheter-associated urinary tract 7 days if prompt resolution of A-III infection symptoms OR 10-14 days for delayed clinical response 5 days if using levofloxacin in a patient B-III who is not seriously ill 3 days in a female ≤ 65 years old B-II without upper urinary tract symptoms after catheter has been removed Asymptomatic bacteriuria in a 3 -7 days A-III pregnant female

Acute uncomplicated cystitis in an Nitrofurantoin: 5 days A-I adult female Trimethoprim-sulfamethoxazole: A-I 3 days Fosfomycin: 1 dose A-I Intra-abdominal Established intra-abdominal 4-7 days A-III infection where source control is achieved Acute stomach and proximal jejunal 24 hours of therapy B-II perforations where source control is achieved within 24 hours, in the absence of acid-reducing therapy or malignancy Acute appendicitis without evidence ≤24 hours A-I of perforation, abscess, or local peritonitis Bowel injuries attributable to ≤24 hours A-I penetrating, blunt, or iatrogenic trauma that are repaired within 12h and any other intraoperative contamination of the operative field by enteric contents MRSA= Methicillin-Resistant S. aureus; NA= not applicable

PAGE 68 AntimicrobialAntimicrobial Duration Duration of Therapy of Therapy STRENGTH OF INFECTIOUS DISEASE RECOMMENDED DURATION OF THERAPY STRENGTH OF INFECTIOUS DISEASE RECOMMENDED DURATION OF THERAPY RECOMMENDATION RECOMMENDATION Pneumonia Community--acquired pneumonia Minimum of 5 days B--I/III/II -- Should be afebrile for 48–72 H AND have ≤ 1 associated sign of clinical instability before discontinuation of therapy Hospital--acquired, ventilator-- 14 to 21 days 14 to 21 days Level II associated, and healthcare-- - As short as 7 days, provided that associated pneumonia - As short as 7 days, provided that associated pneumonia thethe targetedtargeted pathogenpathogen isis identifiedidentified based on bronchoscopy and thethe etiologic pathogen is not P. aeruginosa,, andand thatthat thethe patientpatient has a good clinical response with resolution of clinical features of infectioninfection Diabetic Foot General recommendation Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed Specific situations: Mild DFI 1--2 weeks (though some require an A--IIII additional 1--2 weeks) Moderate to severe DFI 2--4 weeks A--IIII ((without osteomyelitis) Diabetic Foot Infection with 4--6 weeks B--IIII Osteomyelitis -- shorter if entire infectedinfected bonebone isis removed and probably longer if bone remains Catheter--related Bloodstream InfectionsInfections (CRBSI)(CRBSI) Uncomplicated CRBSI due to 5--7 days OR observation alone (if(if nono B--IIIIII coagulase negative staphylococci intravascularintravascular oror orthopedicorthopedic hardwarehardware isis C--IIIIII present and additional blood cultures other than S. lugdunensislugdunensis present and additional blood cultures are obtained after catheter withdrawal (catheter(catheter removed)removed) are obtained after catheter withdrawal toto confirmconfirm thethe absenceabsence ofof bacteremia)bacteremia) 4-6 weeks from first negative blood CRBSI with persistent bacteremia 4-6 weeks from first negative blood A--IIII forfor culture following catheter removal and fungemiafungemia > 72H following culture following catheter removal S.. aureus;; catheter removal, associated C--IIIIII forfor otherother endocarditis, or supportive pathogens thrombophlebitis 6-8 weeks from first negative blood CRBSI with associated 6-8 weeks from first negative blood A--IIII culture following catheter removal osteomyelitis culture following catheter removal 7-10 days following catheter removal A--IIII Catheter--associated exit site or 7-10 days following catheter removal and incision and drainage (if tunnel infection without and incision and drainage (if indicated) associated bacteremia or indicated) fungemiafungemia CRBSI= Catheter-related Bloodstream Infections; DFI= Diabetic foot infections; H= hour(s) CRBSI= Catheter-related Bloodstream Infections; DFI= Diabetic foot infections; H= hour(s) PAGE 69 AntimicrobialAntimicrobial Duration Duration of Therapy of Therapy

This guidance is adopted from the National Antimicrobial Stewardship Taskforce

References: 1. Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010;50:625-63. 2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005;40:643-54. 3. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011;52(5):e103-e120. 4. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010;50:133-64. 5. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2): S27-S72. 6. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital- acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416. 7. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004;39:885- 910. 8. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1-45. 9. Jenkins TC, Knepper BC, Sabel AL, et al. Decreased Antibiotic Utilization After Implementation of a Guideline for Inpatient Cellulitis and Cutaneous Abscess. Arch Intern Med. 2011;171(12):1072-79. 10. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31(5):431-55. 11. Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis 2011;52:1-38. 12. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52.

PAGE 70 IVIV to to PO PO Antibiotic Antibiotic Step- DownStep-Down Guidelines Guidelines

Candidates for Antimicrobial Step-Down therapy:  Patient is able to tolerate PO medication AND has a functioning GI tract  The infection is treatable with oral antimicrobial therapy AND the indications and spectrum of activity are identical or similar between alternative drugs  No evidence of malabsorption, dysphagia, or gastrointestinal bleed  Patient is hemodynamically stable with improving body temperature and WBC  High risk patients who MAY NOT be candidates for PO step-down may be identified by: − Pulse >125bpm − RR >30bpm − Systolic BP < 90 mmHg o o − T < 35 C OR >40 C, altered mental status Contraindications to Antimicrobial Step-Down therapy:  Serious infections concomitant with chemotherapy induced severe neutropenia  Infections caused by resistant organisms (i.e. MRSA, VRE) unresponsive to >1 course of antimicrobials  Situations where oral antimicrobials may not achieve adequate drug concentrations at the site of infection (i.e. meningitis, endocarditis)  Oral antimicrobial therapy may be used in neutropenic patients with negative blood cultures, temperatures < 38oC, and no indication of clinical sepsis Table 1. IV to PO Antimicrobial Step-Down Options IV Antimicrobial PO Antimicrobial Ampicillin/sulbactam Amoxicillin/clavulanate Azithromycin Azithromycin Cefazolin/Ceftazidime Cephalexin/Cephadrine Ciprofloxacin Ciprofloxacin* Ceftriaxone Cefuroxime Clindamycin Clindamycin* Doxycycline Doxycycline Fluconazole Fluconazole* Moxifloxacin Moxifloxacin * Metronidazole Metronidazole* Dicloxacillin Trimethoprim/sulfamethoxazole Trimethoprim/sulfamethoxazole* *Oral drugs which achieve serum levels similar to the parenteral dose form BP= blood pressure; bpm= beats/breaths per minute; GI= Gastrointestinal; IV= intravenous; MRSA= Methicillin-resistant Staphylococcus aureus; PO= by mouth; RR= Respiratory rate; T= temperature; VRE= Vancomycin-resistant enterococci; WBC= White blood cells

PAGE 71 TwelveTwelve Steps Steps to toPrevent Prevent Antimicrobial Antimicrobial Resistance Resistance Twelve Steps to Prevent Antimicrobial Resistance 1. Wash your hands! 8. Know when to say “NO” to broad spectrum 1. Wash your hands! 8. Know when to say “NO” to broad spectrum 2. Vaccinate agents 2. Vaccinate agents 3. Get the catheters out 9. Treat infection - not colonization 3. Get the catheters out 9. Treat infection - not colonization 4. Obtain cultures 10. Treat infection - not contamination 4. Obtain cultures 10. Treat infection - not contamination 5. Target the pathogen 11. Stop treatment when infection is cured 5. Target the pathogen 11. Stop treatment when infection is cured 6. Seek expert input or unlikely 6. Seek expert input or unlikely 7. Know the local sensitivity patterns 12. Prevent transmission 7. Know the local sensitivity patterns 12. Prevent transmission Adopted from the Centers for Disease Control Campaign for Clinicians Adopted from the Centers for Disease Control Campaign for Clinicians Contact Precautions ContactContact Precautions Precautions TYPES OF CONTACT PRECAUTIONS FOR INFECTION CONTROL TYPES OF CONTACT PRECAUTIONS FOR INFECTION CONTROL Precaution Gowns Gloves Masks Hands Conditions StandardPrecaution If splatteringGowns For contactsGloves If Masks WASHHands upon ALL patientsConditions Standard ofIf splattering body fluids withFor contacts mucous aerosolizationIf enteringWASH upon and ALL patients orof bodyblood fluids is membranes,with mucous oraerosolization splattering leavingentering room and likelyor blood is nonmembranes,-intact skin ofor bodysplattering fluids leaving room likely andnon -ALLintact body skin orof bodyblood fluids is fluidsand ALL body likelyor blood is Use Standard Precautions on all patients.fluids Use Transmissionlikely Based Precautions below in addition to Standard Use Standard Precautions on all patients. Use TransmissionPrecautions Based Precautions below in addition to Standard Precautions CATEGORY SPECIFIC ISOLATION PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS CATEGORY SPECIFIC ISOLATION PRECAUTIONS/TRANSMISSION BASED PRECAUTIONS Approved, Tuberculosis or rule prefittedApproved, WASH upon outTuberculosis tuberculosis. or rule respiratorprefitted Airborne Not necessary Not necessary enteringWASH upon and Respiratoryout tuberculosis. phase of protectionrespirator and Airborne Not necessary Not necessary leavingentering room and measlesRespiratory and phase chicken of requiredprotection N -and95 leaving room poxmeasles and chicken required N-95 mask pox mask Infected or colonized patients,Infected orwhether colonized Upon entering bedriddenpatients, whether or roomUpon andentering for all For suctioning, if WASH upon ambulatory,bedridden or with Contact contactsroom and with for all Upon entering organismFor suctioning, is in if enteringWASH upon and woundsambulatory, or diarrhea: with Contact patientcontacts and with patientUpon entering room sputumorganism is in leavingentering room and multiwounds-resistant or diarrhea: surfacespatient and or patient room sputum leaving room organisms,multi-resistant MRSA, VRE, equipmentsurfaces or in C.organisms, difficile diarrhea MRSA, VRE, or roomequipment in ESBLC. difficile diarrhea or room MRSAESBL in sputum, To handle NeisseriaMRSA in sputum,meningitidis , Within three feet WASH upon respiratoryTo handle drugNeisseria resistantmeningitidis , Droplet Not necessary ofWithin the patient three feet enteringWASH upon and secretionsrespiratory or pneumococcidrug resistant, Droplet Not necessary (regularof the patient masks) leavingentering room and suctioningsecretions or diptheriapneumococci, pertussis, , (regular masks) leaving room suctioning influenzadiptheria, pertussis, WASH upon influenza Protective Neutropenia (< 1000 Not necessary Not necessary Not necessary enteringWASH upon and Protective neutrophilsNeutropenia), ANC(< 1000 <100 Environment Not necessary Not necessary Not necessary leavingentering room and Environment neutrophils), ANC <100 Refer to Policy MCM 111-P26 Standard and Transmission leavingBased Precautions room ReferCall to Infection Policy MCM Prevention 111-P26 and Standard Control and for Transmission further guidance Based at extPrecautions 2654 Call Infection Prevention and Control for further guidance at ext 2654

PAGE 72 Pharmacokinetic Calculations PharmacokineticPharmacokinetic Calculations Calculations Ideal Body Weight (IBW) Calculation: IdealMale: Body Weight (IBW) Calculation:50 kg + [2.3 kg for each inch over 5 feet] Male:Female: 5045 kg + [2.3 kg for each inch over 5 feet] CreatinineFemale: Clearance (CrCl45) using kg + [2.3Cockcroft kg for- eachGault inchEquation: over 5 feet] Creatinine isClearance expressed (CrCl in mL/min) using Cockcroft-Gault Equation: Creatinine is expressed in mL/min CrCl (mL/min) =(140 – age) (IBW in kg)* CrCl (mL/min) =(14072 – (age)SCr in(IBW mg/ indL kg))‡ * NOTE: For Females72 multiply(SCr in mg/ bydL 0.85)‡ NOTE: For Females multiply by 0.85 CrCl for elderly patients or when no height is available: CrCl for elderly patients or when no height is available: CrCl (mL/min) =(114 – (0.8 *age)) CrCl (mL/min) =(114SCr –in(0.8 mg/ *dLage))‡ NOTE: For femalesSCr multiplyin mg/dL by‡ 0.9 NOTE: For females multiply by 0.9 *If patients actual body weight is less than IBW, use actual body weight to calculate CrCl*If patients actual body weight is less than IBW, use actual body weight to calculate CrCl‡If patient is underweight/cachectic, may consider rounding SCr up to 1 mg/dL.1,2 ‡DoIf patient not round is underweight/cachectic, to 1 mg/dL for all patients may >consider 60 years rounding of age.3- 5SCr up to 1 mg/dL.1,2 3-5 AdjustedDo not round Body to Weight 1 mg/ dL(aminoglycosidefor all patients dosing)> 60 years of age. AdjustedUse adjusted Body body Weight weight (aminoglycoside (AdjBW) when dosing) actual body weight (ABW) is ≥ 30% of ideal Usebody adjusted weight (IBW) body weight (AdjBW) when actual body weight (ABW) is ≥ 30% of ideal body weight (IBW) AdjBW = 0.4 (ABW - IBW) + IBW AdjBW = 0.4 (ABW - IBW) + IBW IBW= Ideal Body Weight (in kg); AdjBW= Adjusted Body Weight; ABW= Actual Body Weight; CrCl= Creatinine clearance; SCr= serum creatinine IBW= Ideal Body Weight (in kg); AdjBW= Adjusted Body Weight; ABW= Actual Body Weight; CrCl= Creatinine clearance; SCr= serum creatinine

References: 1. Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med. References: 1993;21(10):1487-1495. 1. Robert S, Zarowitz BJ, Peterson EL, Dumler F. Predictability of creatinine clearance estimates in critically ill patients. Crit Care Med. 2. Khuu T, Bagdasarian G, Leung J, et al. Estimating aminoglycoside clearance and creatinine clearance in underweight patients. Am J Health- 1993;21(10):1487-1495. Sys Pharm. 2010;67(4):274-279. 2. Khuu T, Bagdasarian G, Leung J, et al. Estimating aminoglycoside clearance and creatinine clearance in underweight patients. Am J Health- 3. Bertino JS. Measured versus estimated creatinine clearance in patients with low serum creatinine values. Ann Pharmacother. Sys Pharm. 2010;67(4):274-279. 1993;27(12):1439-1442. 3. Bertino JS. Measured versus estimated creatinine clearance in patients with low serum creatinine values. Ann Pharmacother. 4. Smythe M, Hoffman J, Kizy K, Dmuchowski C. Estimating creatinine clearance in elderly patients with low serum creatinine concentrations. 1993;27(12):1439-1442. Am J Hosp Pharm. 1994;51(2):198-204. 4. Smythe M, Hoffman J, Kizy K, Dmuchowski C. Estimating creatinine clearance in elderly patients with low serum creatinine concentrations. 5. Dowling TC, Wang E-S, Ferrucci L, Sorkin JD. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals Am J Hosp Pharm. 1994;51(2):198-204. Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy. 2013;33(9):912-921. 5. Dowling TC, Wang E-S, Ferrucci L, Sorkin JD. Glomerular Filtration Rate Equations Overestimate Creatinine Clearance in Older Individuals Enrolled in the Baltimore Longitudinal Study on Aging: Impact on Renal Drug Dosing. Pharmacotherapy. 2013;33(9):912-921. PAGE 73 COLLEGE OF PHARMACY

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