Bugs & Drugs Antimicrobial Pocket Reference 2001 FOREWORD Authors (unless otherwise noted) & Editors: Edith Blondel-Hill, MD, FRCP(C) Associate Medical Officer of Health Infectious Diseases Specialist/Medical Microbiologist Capital Health/DKML and Susan Fryters, B.Sc.Pharm. Antimicrobial Utilization/Infectious Diseases Pharmacist Capital Health in collaboration with: · Regional Antimicrobial Advisory Subcommittee · Antimicrobial Working Group (Dr. E. Blondel-Hill, S. Fryters, Dr. M. Foisy, Dr. E. Friesen, M. Gray, R. Muzyka, Dr. P. Robertson, C. Zenuk) · Therapeutic Drug Monitoring (TDM) Task Force (Dr. G. Blakney, Dr. E. Blondel-Hill, S. Fryters, M. Gray, Dr. D. LeGatt, Dr. N. Yuksel) · Antibiotics in Dentistry Working Group (Dr. E. Blondel-Hill, Dr. T. Carlyle, Dr. K. Compton, Dr. T. Debevc, S. Fryters, Dr. D. Gotaas, Dr. K. Kowalewska-Grochowska, Dr. K. Lung, Dr. T. Mather, Dr. H. McLeod, M. Mehta, Dr. J. Nigrin, Dr. S. Ponich, Dr. B. Preshing, Dr. J. Robinson, Dr. S. Shafran) · Divisions of Adult and Paediatric Infectious Diseases · Dynacare Kasper Medical Laboratories (DKML) · UAH Medical Microbiology Department · Regional Pharmacy Services · Regional Public Health · Antibiotics Working Group of AMA Clinical Practice Guidelines Program Secretarial Support: L. Clarke The authors are indebted to Laura Lee Clarke for her outstanding preparation of this manuscript. Editorial Contributions: Dr. J. Galbraith, Infectious Diseases/Medical Microbiologist Ms. M. Gray, BSP Dr. A. Joffe, Paediatric Infectious Diseases Dr. J. Nigrin, Medical Microbiologist Dr. S. Shafran, Adult Infectious Diseases Ms. C. Zenuk, BSP Cover Design: A. Hill Funding provided by: Capital Health Regional Pharmacy Services & Dynacare Kasper Medical Laboratories While every effort has been made to ensure the accuracy of the information presented, the authors, Capital Health, and DKML cannot accept liability for errors or any consequences arising from its use. Copyright © 2000 Capital Health All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means - electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors. PREFACE The information presented in this book is solely for educational purposes. Recommendations made in this book are based on our experience in infectious diseases, microbiology, and pharmacotherapy; an extensive review of the literature; consultation with multiple specialists; local antibiotic formularies; and local susceptibility patterns. We are extremely indebted to all our colleagues for their contributions. We would especially like to thank our secretary, Laura Lee Clarke. With this book we have attempted to provide physicians, pharmacists, and other health care professionals with sound recommendations for the management of patients with infectious diseases. The release of this 2001 edition coincides with the launch of the Do Bugs Need Drugs? project in Capital Health. This project attempts to address solutions to antibiotic resistance by promoting three key messages: 1. Handwashing is the most important way to stop the spread of infections. 2. Bacteria and viruses are different and antibiotics do not work against viruses. 3. Antibiotic resistance is a problem therefore antibiotics must be used wisely. As before, the work that has gone into this book is dedicated to our children. It is for all children that solutions to antibiotic resistance must be found. Edith Blondel-Hill Susan Fryters CLINICAL ANTIBIOTIC GUIDELINES† ACYCLOVIR IV*/PO *RESTRICTED TO ANTIBIOTIC FORM Predictable activity: Unpredictable activity: No activity: Herpes Simplex Cytomegalovirus Epstein Barr Virus Herpes Zoster Indicated: IV: 1. Therapy for suspected or documented Herpes simplex encephalitis 2. Therapy for suspected or documented Herpes simplex infection of a newborn or immunocompromised patient 3. Therapy for primary varicella infection in immunocompromised patients 4. Therapy for severe or disseminated varicella-zoster infections in immunocompromised or immunocompetent patient 5. Therapy for primary genital herpes with neurologic complications Oral: 1. Therapy for primary Herpes simplex infections (oral/genital) 2. Suppressive (preventative) therapy for recurrent (³ 6 episodes/year) severe Herpes simplex infections (oral/genital) 3. Episodic therapy for recurrent (³ 6 episodes/year) Herpes simplex genital infections (initiate within 24 hours of prodrome onset) 4. Prophylaxis for HSV in bone marrow transplants where patient is seropositive 5. Therapy and suppressive therapy for Eczema Herpeticum 6. Therapy for varicella-zoster infections in immunocompetent and immunocompromised patients (if not severe) 7. Therapy for primary varicella infections in pregnancy 8. Therapy for varicella in immunocompetent patients > 13 years old (initiate within 24 hours of rash onset) 9. Therapy for varicella in patients < 13 years old (initiate within 24 hours of rash onset) if there is a chronic cutaneous or pulmonary disorder, long term salicylate therapy, or short, intermittent or aerosolized corticosteroid use Not Indicated: 1. Therapy for acute Epstein-Barr infections (acute mononucleosis) 2. Therapy for documented CMV infections CLINICAL ANTIBIOTIC GUIDELINES† AMIKACIN RESTRICTED TO ANTIBIOTIC FORM Predictable activity: Unpredictable activity: No activity: Enterobacteriaceae Staphylococcus spp Streptococcus spp Pseudomonas spp Enterococcus spp some Mycobacterium spp Alcaligenes spp Anaerobes Indicated: 1. Therapy of gram-negative organisms that are resistant to gentamicin and tobramycin but susceptible to amikacin 2. As combination therapy for the treatment of some Mycobacteria spp. Not Indicated: 1. First line aminoglycoside therapy CLINICAL ANTIBIOTIC GUIDELINES† AMOXICILLIN-CLAVULANATE Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-I Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S Streptococcus pneumoniae Enterobacteriaceae producing inducible Pen-R Streptococcus pneumoniae b-haemolytic Streptococci b-lactamases* Enterococcus faecium Enterococcus faecalis Pseudomonas spp Escherichia coli Stenotrophomonas maltophilia Klebsiella spp Chlamydia spp Proteus mirabilis Mycoplasma spp Haemophilus influenzae Moraxella catarrhalis Neisseria spp Pasteurella spp Anaerobes * Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp Indicated: 1. Therapy of animal and human bite wound infections 2. Second line therapy of otitis media 3. Second line therapy of acute exacerbations of chronic bronchitis and acute sinusitis 4. Therapy/stepdown therapy of polymicrobial infections (e.g. skin and soft tissue, odontogenic, aspiration pneumonia, intra-abdominal) 5. Therapy of periorbital cellulitis in paediatric patients 6. Second line therapy of urinary tract infections in paediatric, elderly, or catheterized patients, where there is failure/resistance of first line agents Not Indicated: 1. Therapy of pneumonia where there is no suspicion of aspiration 2. First line therapy of upper respiratory tract infections (otitis media, pharyngitis, acute exacerbation of chronic bronchitis, acute sinusitis) 3. First line therapy of urinary tract infection 4. Therapy of chronic/asymptomatic bacteriuria in elderly or catheterized patients CLINICAL ANTIBIOTIC GUIDELINES† AMPHOTERICIN B, LIPID-COMPLEXED NON-FORMULARY – REQUIRES COMPLETION OF ANTIBIOTIC FORM Lipid-complexed amphotericin B formulations may minimize nephrotoxicity when compared to conventional amphotericin B. To date, there exists no strong evidence that these formulations are more efficacious than the conventional formulation. A therapeutic course may cost in excess of $30,000. Criteria for Lipid-Complexed Amphotericin B 1. Evidence of Systemic Fungal Infections · Culture positive for Candida at a normally sterile site (e.g. blood, CSF, deep tissue sample) OR · Evidence of Candida from > 3 separate body sites in patients at risk for disseminated Candidiasis (i.e. patients with neutropenia, patients on broad spectrum antibiotics, or patients with central venous lines) with clinical signs of active infection (e.g. fever and leucocytosis despite antibacterial therapy) OR · Histology proven evidence of disseminated Candidiasis OR · Histologic and/or culture evidence of another invasive fungal infection (e.g. aspergillosis, mucormycosis) OR · Compelling radiographic and clinical evidence of invasive fungal infection in consultation with Infectious Diseases (ID) specialists. AND 2. Evidence of deteriorating renal function · A tripling of the serum creatinine from the patient’s baseline value OR · A serum creatinine of greater than or equal to 250 mmol/L. AND 3. Procedure to be followed · To be ordered by an Infectious Diseases physician only. · Requests for lipid-complexed Amphotericin B require completion of the Antibiotic Form. · If criteria are met, Pharmacy will obtain and dispense a commercial preparation of lipid-complexed Amphotericin B for an initial 72 hours only. The lipid formulation dispensed will be decided based on discussions between Infectious Diseases and Pharmacist. · Each case will need to be reassessed, and the drug ordered, by an ID physician twice weekly. · Within one week of the initial order, an ad hoc Utilization Review group will review each case of lipid-complexed amphotericin B use. Membership on this group will consist of the