Appendix 1 ANTIMICROBIAL STEWARDSHIP GUIDELINES FOR ANTIMICROBIAL USE The Stoplight Formulary System was designed to preserve certain antimicrobials and/or provide alerts for adverse effects. Contained in this document are guidelines for appropriate use and safety precautions for the yellow and red antimicrobials. Spectrum of Activity* - the listed microorganism are what is expected coverage based on intrinsic properties of the antimicrobial. For specific sensitivities in your areas please see your local antibiograms. For safety of antimicrobials in pregnancy/breastfeeding or for appropriate use and dosing in pediatrics please refer to the IWK Spectrum app. This is available for free for iPhone and Android devices 1 Contents Amikacin ....................................................................................................................................................... 4 Amoxicillin-Clavulanate ............................................................................................................................... 5 Amphotericin B deoxycholate ..................................................................................................................... 6 Amphotericin B Liposomal (Ambisome) ...................................................................................................... 7 Azithromycin ................................................................................................................................................ 8 Caspofungin .................................................................................................................................................. 9 Cefepime ..................................................................................................................................................... 10 Cefixime ...................................................................................................................................................... 11 Cefotaxime.................................................................................................................................................. 12 Cefoxitin ...................................................................................................................................................... 13 Ceftazidime ................................................................................................................................................. 14 Ceftolozane-Tazobactam ........................................................................................................................... 15 Ceftriaxone ................................................................................................................................................. 16 Cephalexin .................................................................................................................................................. 17 Cidofovir ..................................................................................................................................................... 18 Ciprofloxacin ............................................................................................................................................... 19 Clarithromycin ............................................................................................................................................ 20 Clindamycin ................................................................................................................................................ 21 Colistin ........................................................................................................................................................ 22 Dapsone ...................................................................................................................................................... 23 Daptomycin ................................................................................................................................................ 24 Ertapenem .................................................................................................................................................. 25 Erythromycin .............................................................................................................................................. 26 Fidaxomicin................................................................................................................................................. 27 Fosfomycin .................................................................................................................................................. 28 Ganciclovir .................................................................................................................................................. 29 Gentamicin ................................................................................................................................................. 30 Imipenem and cilastatin............................................................................................................................. 31 Levofloxacin ................................................................................................................................................ 32 Linezolid ...................................................................................................................................................... 33 Meropenem ................................................................................................................................................ 34 Neomycin .................................................................................................................................................... 35 Oseltamivir ................................................................................................................................................. 36 2 Pentamidine ............................................................................................................................................... 37 Piperacillin-Tazobactam ............................................................................................................................. 38 Pyrimethamine ........................................................................................................................................... 39 Tigecycline .................................................................................................................................................. 40 Tobramycin ................................................................................................................................................. 41 Trimethoprim ............................................................................................................................................. 42 Trimethoprim-sulfamethoxazole (co-trimoxazole) ................................................................................... 43 Valganciclovir ............................................................................................................................................. 44 Vancomycin ................................................................................................................................................ 45 Voriconazole ............................................................................................................................................... 46 3 Amikacin Spectrum of Activity* Gram-negative microorganisms, including Pseudomonas Mycobacteria Indications Treatment of Gram negatives resistant to other antimicrobials Treatment of Mycobacterium tuberculosis (TB) and nontuberculous mycobacterial infections (such as M. avium complex (MAC), M. abscessus) in which amikacin is indicated because of lack of response, resistance or adverse reactions to other treatments Not indicated Anaerobic bacteria are not susceptible to aminoglycosides Safety Considerations See aminoglycoside guidelines in handbook Cranial nerve VIII toxicity: cochlear and vestibular. Audiometry monitoring is recommended for courses longer than 2 weeks. Nephrotoxicity: increased risk in patients with renal dysfunction, advanced age, dehydration, prolonged therapy, concomitant nephrotoxins Therapeutic drug monitoring is recommended Neuromuscular blockade and respiratory paralysis are rare, especially when used concomitantly with anesthetic agents or neuromuscular blockers or in patients with myasthenia gravis or parkinsonism Renal Dosing Dose adjustments required for renal impairment Other Considerations 4 Amoxicillin-Clavulanate Spectrum of Activity* Broad oral antibiotic with activity against Gram-positive microorganisms, including Staphylococcus aureus (MSSA), many Gram-negatives (not Pseudomonas), and anaerobes including Bacteroides. Indications Primary: Polymicrobial infections with no other oral therapeutic options either alone or in combination. Infections with microorganisms resistant to first line agents. Bite prophylaxis (when indicated) or bite infections. Not indicated Safety Considerations Diarrhea is common, less likely with twice daily regimen. C. difficile risk Hepatotoxicity secondary to clavulanate is rare and usually mild. Renal Dosing Dose adjustments required for renal impairment Other Considerations 5 Amphotericin B deoxycholate Spectrum of Activity* Cryptococcus neoformans Mucormycosis (Mucor, Rhizomucor, Rhizopus) Aspergillus sp. (except A. terreus) Candida sp.