Prisma Health Adult Antimicrobial Guidebook 2021
Prisma Health Adult Antimicrobial Guidebook 2021
Health
Adult
Antimicrobial
Guidebook
2021
Antimicrobial stewardship in 2021
Table of contents
The current pandemic brought additional challenges to
antimicrobial stewardship teams. Seasonal variations in Guidelines................................................................................................2
antibiotic use and resistance are well-described phenomena. Gram-negative bloodstream infections......................................................... 2
Antibiotic use usually picks up in the winter months during the Bloodstream infection de-escalation guide................................................. 6
peak of acute respiratory tract infections and starts declining as Staphylococcus aureus bloodstream infections....................................... 14
temperature warms up. The COVID‑19 pandemic has created Intra-abdominal infections...............................................................................17
unusual circumstances of steady number of acute respiratory Skin and soft tissue infections.........................................................................22
infections throughout the spring and into the summer months. Diabetic foot infections.....................................................................................26
The pain from this pandemic has been felt at every level in Clostridioides difficile testing algorithm UPDATED.................................30
the community and healthcare systems. Even in the most Clostridioides difficile infection management UPDATED.....................32
robust settings, antimicrobial stewardship continues to face Acute cystitis and pyelonephritis: Inpatient................................................34
unprecedented challenges. During these trying times, we ask all Acute cystitis and pyelonephritis: Outpatient............................................40
our colleagues to help us minimize unnecessary and excessive Community-onset bacterial pneumonia.....................................................48
antibiotic use. Hospital-acquired, ventilator-associated bacterial pneumonia...........50
Community-onset pneumonia in the ED/Ambulatory setting.............58
Pneumonia de-escalation guide....................................................................66
The Antimicrobial Guidebook features multiple institutional
Neutropenic fever...............................................................................................70
guidelines for management of infections, including
Neutropenic fever de-escalation guide.......................................................72
community‑onset and hospital-onset pneumonia. These
Ambulatory acute sinusitis................................................................................76
guidelines are derived from the clinical and microbiological
data of our local population. Building on previous success Patient-specific antibiograms.......................................................... 80
of utilizing precision medicine in the selection of antibiotic Pseudomonas aeruginosa prediction score..............................................80
therapy, a new clinical tool for prediction of antimicrobial Risk of β-lactam resistant Pseudomonas aeruginosa.............................81
resistance has been added. We will continue to work hard and ESBL prediction score........................................................................................84
collaborate with our colleagues in every discipline to optimize Fluoroquinolone resistance score.................................................................86
antimicrobial therapy and patient care throughout and after the Trimethoprim/Sulfamethoxazole resistance tool NEW..........................87
end of this pandemic. Prisma Health antibiogram for 2021.............................................. 88
Gram-negative ALL sources.............................................................................89
Gram-positive ALL sources..............................................................................90
Prisma Health Antimicrobial Stewardship Gram-negative ICU ALL sources....................................................................91
Gram-positive ICU ALL sources......................................................................92
Gram-positive/Gram-negative Systemic – Tuomey................................93
Gram-positive/Gram-negative Urine – Tuomey.......................................94
Antibiotic costs.................................................................................... 95
Prisma Health Antimicrobial Stewardship.....................................97
Gram-negative bloodstream infections
Definitions:
Guidelines • Hospital-acquired bloodstream infection (BSI): occurring ≥
48 hours after hospital admission
Prisma Health guidelines for the • Healthcare-associated BSI: prior hospitalization for ≥ 2 days
in the past 90 days, residence in nursing home or extended
management of gram‑negative bloodstream care facility, home infusion therapy (chemotherapy,
infections in adults intravenous antibiotics, etc.), chronic dialysis, or home
wound care within 30 days
Empiric antimicrobial therapy • Critically ill: intensive care unit admissions, high acute
Suspected or confirmed gram‑negative severity of illness score (Pitt bacteremia score ≥ 4) or
bloodstream infection (BSI) relatively high predicted mortality (BSI risk score ≥ 5)
Source of infection:
• Identification of primary source of infection is essential.
Hospital-acquired or Optimal management of BSI includes appropriate
Community-acquired
healthcare‑associated antimicrobial therapy as well as adequate source control
Cefepime 2g IV q8-12h* OR (relief of urinary or biliary obstruction; removal of infected
Piperacillin/tazobactam central venous catheters; drainage of intra-abdominal, pelvic
3.375–4.5gm IV q6h* or deep tissue abscesses, etc.).
• In patients with suspected intra-abdominal source of
infection, metronidazole should be added to ceftriaxone or
Critically ill cefepime for anaerobic coverage. Piperacillin-tazobactam
Non-critically ill
Cefepime 2gm IV q8–12h* OR provides adequate coverage for obligate anaerobes.
Ceftriaxone 2gm IV q24h
Piperacillin/tazobactam
3.375–4.5gm IV q6h* Penicillin allergy:
• Patients with penicillin allergy should not receive
piperacillin‑tazobactam.
Revise antimicrobial regimen based on identification of
microorganism, if needed. • In patients with minor penicillin allergies (nonspecific rashes,
intolerance, etc.), cross‑reactivity with 3rd and 4th generation
Streamline definitive therapy based on antimicrobial cephalosporins is low (< 3%). The benefit from beta‑lactam
susceptibility testing results. antibiotics outweighs the potential risk in these patients.5
*Higher doses of cefepime or piperacillin/tazobactam
may be used for patient‑specific factors, such as site of
infection (pulmonary, central nervous system, etc.) and/or
microorganism MIC.
Nimmich E, et al. Hosp Pharm 2017; 52: 691–697
2 3
• Treatment options in patients with serious reactions Severity of illness scores
(anaphylaxis, angioedema, breathing problems and
hives) include aztreonam, aminoglycosides (tobramycin, Pitt bacteremia score criterion* Points
gentamicin) or ciprofloxacin in the absence of prior exposure Fever
to the respective class of antibiotics in the past 90 days. ≤ 35 C (95 F) or ≥40 C (104 F) 2
35.1–36.0 C (95.1–96.9 F) or 39.0–39.9 C (102.1–103.9 F) 1
Consider consultation with an infectious diseases specialist
36.1–38.9 C (97–102 F) 0
for optimal empirical therapy.
Hypotension (defined by at least 1 of the following) 2
Acute hypotensive event with drop in SBP > 30 mmHg
Risk factors for antimicrobial resistance: and DBP > 20 mmHg
Extended-spectrum beta-lactamase producing Requirement for intravenous vasopressors
SBP < 90 mmHg
organisms (ESBL)
• Meropenem is preferred in patients with high risk of BSI due Mechanical ventilation 2
to ESBLs, including: Cardiac arrest 4
- Documentation of prior infections or colonization with Mental status
ESBL‑producing organisms in the past 12 months. Alert 0
Disoriented 1
- Receipt of multiple courses of beta-lactam and Stuporous 2
fluoroquinolone antibiotics in the past 90 days. Comatose 4
Carbapenem-resistant Enterobacteriaceae (CRE) or *All criteria are graded within 48 hours before or on the day of first
multi‑drug resistant (MDR) Pseudomonas aeruginosa positive culture. The highest point scored during that time is recorded.
• Combination therapy is preferred in patients at high risk of Modified from Paterson DL, et al. Ann Intern Med 2004;140:26-32
BSI due to CRE or MDR P. aeruginosa, including:
- Documentation of prior infections or colonization with
CRE or MDR P. aeruginosa in the past 12 months.
Bloodstream infection mortality risk score
- Receipt of ≥ 7 days of carbapenems in the past 90 days.
• Please consult Antimicrobial Stewardship and Support Team Risk factor Points
(ASST) during business hours or an infectious diseases Malignancy 3
specialist for optimal empirical antimicrobial therapy.
Liver cirrhosis 4
High inoculum infection* 4
Pitt bacteremia score
0–1 0
2–3 2
≥4 5
*High inoculums infection represents source of bloodstream infection
other than urinary tract or central venous catheter infection.
Al-Hasan MN, et al. Clin Microbial Infect 2013; 19: 948-954.
4 5
Bloodstream infection de-escalation guide
Enterobacteriaceae (Escherichia coli, Klebsiella species and
urinary source)
gram‑negative bloodstream isolates.
Ciprofloxacin
Ciprofloxacin
Ciprofloxacin
Levofloxacin
Levofloxacin
Piperacillin/tazobactam Levofloxacin
de‑escalation options • Patients with an ESBL prediction score <1 (no known
Susceptibility-based
inoculum infections)
to ceftriaxone is recommended in these patients based on
(narrowest‑spectrum
Ampicillin/sulbactam
Ampicillin/sulbactam
MALDI-TOF
or P. mirabilis.
• Ertapenem is the preferred agent in patients with high
Ceftriaxone
Ceftriaxone
Ceftriaxone (refer to ESBL Ampicillin
Ampicillin
Cefepime
Cefepime
Cefazolin
Enterobacteriaceae (CAE):
de‑escalation options
Cefepime
Haemophilus influenzae
Neisseria meningitidis
Gram‑negative bacteria
Enterobacter cloacae
Serratia marcescens
Enterobacteriaceae
(non‑fermenters)
(page 81).
6 7
8
(page 12).
infections (BSI):
susceptible isolates.
Susceptibility‑based
Gram‑positive bacteria BCID‑based de‑escalation options de‑escalation options
Staphylococcus aureus
MSSA (MecA not detected) Cefazolin or nafcillin Cefazolin or nafcillin
MRSA (MecA detected) Vancomycin Vancomycin
Staphylococcus species (S. aureus not Clinical correlation is required to differentiate skin contamination from
detected), coagulase‑negative staphylococci bloodstream infection*
Beta‑hemolytic streptococci
Streptococcus pyogenes (group A) Penicillin G Penicillin G
Streptococcus agalactiae (group B) Cefazolin (for penicillin allergy)+ Cefazolin (for penicillin allergy)
Streptococcus pneumoniae Ceftriaxone Penicillin G
Ampicillin
Ceftriaxone
Enterococcus species
Non‑VRE (VanA/B not detected) Ampicillin Ampicillin
Vancomycin (for penicillin allergy) Vancomycin (for penicillin allergy)
VRE (VanA/B detected) Daptomycin Daptomycin
Linezolid
*Growth of coagulase‑negative staphylococci (CONS) in 1 out of 2 sets of blood cultures usually represents skin contamination;
however, growth in 2 of 2 sets in the presence of symptoms and signs of bloodstream infection (e.g., fever, hypotension) in the
appropriate clinical setting (suspicion of central line or surgical site infection) likely represents a bloodstream infection and warrants
antimicrobial therapy similar to S. aureus as above. S.lugdunensis should not be disregarded as a contaminant and should be
treated similar to S.aureus. Note: CONS deemed a contaminant may be either methicillin‑susceptible (MEC A Not‑ Detected) or
Methicillin‑resistant (MEC A Detected).
+Penicillin Allergy Skin Testing may be considered. Please consult Prisma Health Antimicrobial Stewardship and Support Team for patient
qualification and testing.
9
Oral antimicrobial options for gram‑positive 4. Foster RA, Troficanto C, Kohn J, et al. Utility of combination
antimicrobial therapy for bloodstream infections due to
bloodstream infections (BSI): Enterobacteriaceae and non‑fermenting gram‑negative bacilli.
• Oral antimicrobial agents are not recommended in patients Antibiotics 2019; 8: e15.
with S. aureus BSI. Please see guidelines for management 5. Kutob LF, Justo JA, Bookstaver PB, et al. Effectiveness of oral
antibiotics for definitive therapy of gram‑negative bloodstream
of staphylococcus aureus bloodstream infections in adults. infections. Int J Antimicrob Agents 2016; 48: 498‑503.
(page 14). 6. Nelson AN, Justo JA, Bookstaver PB, et al. Optimal duration of
• Oral levofloxacin is a reasonable option for definitive therapy antimicrobial therapy for uncomplicated gram‑negative bloodstream
of BSI due to S. pneumoniae. infections. Infection 2017; 45: 613‑20.
7. Watson CM, Al‑Hasan MN. Bloodstream infections and central
• High‑quality data on effectiveness of oral antimicrobials line‑associated bloodstream infections. Sur Clin N Am 2014; 94:
for definitive therapy of BSI due to other gram‑positive 1233‑1244.
cocci are lacking. Infectious Diseases consultation is
highly recommended in these settings.
10 11
Customized antimicrobial treatment durations Early clinical failure criteria
for uncomplicated gram‑negative bloodstream These criteria are evaluated after 72–96 hours of gram‑negative
infections BSI. Presence of ≥2 criteria predict poor outcomes of patients
with gram‑negative BSI such as high mortality or prolonged
A “one‑size‑fits‑all” treatment duration for gram‑negative
hospitalization.
bloodstream infections (BSI) does not fit our high standards
of antimicrobial therapy in the era of precision medicine. Early clinical failure criteria within Point
These customized treatment durations are derived from 72–96 hours of BSI allocation
a recent clinical trial results and re‑analysis of our local
Systolic blood pressure <100 mmHg or vasopressor use 1
data after stratification based on clinical response to
antimicrobial therapy within the first 4 days of BSI. Heart rate >100 beats/minute 1
Respiratory rate ≥22 breaths/minute or mechanical 1
ventilation
Short duration Moderate duration Long duration
(7–8 days) (9–11 days) (12–14 days) Altered mental status from baseline 1
Patients meeting all of Patients not meeting Patients meeting any Peripheral white blood cell count >12,000/mm 3
1
the following criteria: all criteria for short of the following
• Women with urinary duration or any criteria:
criteria for long Rac H, et al. Clin Microbiol Infect 2020; 26: 73‑7.
source of BSI • Men with urinary
duration of therapy source of BSI
• Early clinical failure
criteria <2 • Early clinical failure References:
• Optimal source criteria ≥2 1. Yahav D, et al. Seven versus fourteen days of antibiotic therapy
control* • Suboptimal source for uncomplicated gram‑negative bacteremia: A non‑inferiority
• First episode of BSI control* randomized controlled trial. Clin Infect Dis 2019; 69: 1091‑8
• No major risk • Recurrent episodes 2. Nelson AN, et al. Optimal duration of antimicrobial therapy
factors for recurrent of BSI for uncomplicated gram‑negative bloodstream infections.
infections+ • Major risk factors for Infection 2017; 45: 613‑20.
• Antimicrobial recurrent infections+ 3. Al‑Hasan MN, et al. Reply to comments: Duration of antimicrobial
therapy with first‑line • Antimicrobial therapy therapy for gram‑negative bacteremia secondary to urinary source
agents# with second‑line of infection. Infection 2018; 46: 283‑4.
agents# 4. Rac H, et al. Evaluation of early clinical failure criteria for
gram‑negative bloodstream infections. Clin Microbiol Infect 2020;
*Optimal source control implies either no opportunities for source 26: 73‑7.
control (e.g., acute pyelonephritis in the absence of ureteric stones)
or complete source control (e.g., removal of gall bladder or central
venous catheter, etc.).
+Major risk factors for recurrent infections include liver cirrhosis,
end-stage renal diseases and immune compromising conditions
(neutropenia, transplant recipients, recent high dose steroids, etc.).
#First-line therapy includes susceptible intravenous antimicrobial
agents or oral fluoroquinolones (e.g., levofloxacin 750 mg daily).
Second-line therapy includes oral agents other than fluoroquinolones
(e.g., trimethoprim/sulfamethoxazole or amoxicillin/clavulanate).
12 13
Staphylococcus aureus bloodstream
Prisma Health
infections guidelines for the Highly recommended regimens:
• Cefazolin 2g IV q8h (For hemodialysis: 2gm/2gm/3gm IV
management of Staphylococcus aureus
3X weekly)
bloodstream infections in adults • Nafcillin 2g IV q4h OR continuous infusion of 12g over
24 hours OR
The following evidence‑based interventions have been
demonstrated to improve the quality of care and patient MRSA isolates, Mec A DETECTED by BCID, OR severe
outcomes with this condition: Beta‑lactam allergy
• Vancomycin dosed to optimize drug exposure: 20mg/kg IV
1. ID consultation
loading dose
Can help identify complications, optimize source control,
• Recommend Pharmacy consult for vancomycin dosing to
define type of indicated echocardiography, determine
achieve goal trough concentrations: 12–18 mg/L (surrogate
duration of antimicrobial therapy and manage outpatient
for target AUC/MIC >400).
antibiotics.
6. A
ppropriate duration of antimicrobial therapy
2. Document microbiological clearance of bloodstream (ID consultation is highly recommended to determine
Follow‑up blood cultures drawn 48–96 h after starting optimal duration of therapy)
appropriate antimicrobial therapy.
Note: If a central venous catheter (CVC) is required, ideally Uncomplicated bacteremia (such as nosocomial S. aureus
await documentation of microbiological clearance of the bacteremia secondary to CVC infection s/p early removal, rapid
bloodstream prior to placing a new CVC. clinical response to therapy, clearance of bloodstream within
3. Early source control within 72 h of presentation, such 72 h, and no vegetations on echocardiography):
as removal of vascular catheters, drainage of abscesses, • At least 14 days of adequate IV antimicrobial therapy.
debridement of infected wounds or ulcers, etc.
4. Echocardiography, i.e., TTE and/or TEE based on
Complicated bacteremia (such as endocarditis, septic joints,
patient‑specific risk for infective endocarditis.
osteomyelitis, etc.) or risk factors for complicated bacteremia,
5. For MSSA isolates, early use of IV anti‑staphylococcal defined by presence of any of the below criteria:
beta‑lactams (e.g., nafcillin, cefazolin) (Staphylococcus • >2 weeks of adequate IV antimicrobial therapy depending
aureus DETECTED, but Mec A NOT DETECTED by BCID) on ID consult recommendations and clinical response to
therapy.
14 15
Intra-abdominal infections
Risk factors for complicated bacteremia: Prisma Health guidelines for
• Persistent bacteremia > 72 h management of intra-abdominal
• Persistent fever > 72 h
infections (IAI) in hospitalized adults:
• Janeway lesions, Osler nodes or other cutaneous/mucosal
lesions suggestive of acute systemic infection Empiricantimicrobial therapy
• Permanent cardiac and orthopedic prosthetic devices
• Device‑related infections where device could not be Suspected or confirmed
removed within 72 h intra-abdominal infection (IAI)
• Chronic hemodialysis
16 17
• Please refer to Guidelines for management of Alternative antimicrobial regimens:
gram‑negative bloodstream infections in adults for further
Beta‑lactam allergy
guidance (page 2).
• Patients with penicillin allergy should not receive
• The non‑stratified use of fluoroquinolones for empirical
piperacillin‑tazobactam.
therapy of hospitalized adults with IAI is not recommended
due to increasing rates of antimicrobial resistance • In patients with minor penicillin allergies (nonspecific
among E. coli and other gram‑negative isolates.5 rashes, intolerance, etc.), cross‑reactivity with 2nd, 3rd and
(See fluoroquinolone resistance score.) 4th generation cephalosporins is low (< 3%).10 The benefit
from beta‑lactam antibiotics outweighs the potential risk in
these patients.11
*Critically ill and previous MRSA infections: Consider adding
vancomycin# 15 mg/kg IV Q8h–Q12h (consider Pharmacy consult • In patients with serious reactions to β‑lactams (anaphylaxis,
for dosing). angioedema, breathing problems and hives), levofloxacin
#If adding vancomycin, consider using cefepime + metronidazole 750 mg PO/IV Q24h + metronidazole 500 mg PO/IV Q8h is
regimen. Concomitant use of vancomycin and piperacillin/tazobactam preferred in the absence of nursing home residence or prior
is associated with an increased risk of nephrotoxicity.6‑8 exposure to a fluoroquinolone in the past six months (i.e.,
fluoroquinolone resistance score <2).12
Definitions: Hyperbilirubinemia (total bilirubin >4 mg/dL) precluding
• Hospital‑acquired infection: symptom onset >5 days after ceftriaxone use or metronidazole intolerance
hospital admission. • Cefoxitin 2g IV Q8h may be used in mild IAI in the absence
• Critically ill: persistent hypotension, unexplained metabolic of prior exposure to beta‑lactam antibiotics within the past
acidosis, ICU admission, qSOFA score ≥2, or Pitt bacteremia one month.1,13,14
score ≥4.9
• Severely immunocompromised host: Chemotherapy,
neutropenia, transplant recipient, treatment with high dose References:
steroids (>20 mg of prednisone equivalents daily for >2 1. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and
management of complicated intra‑abdominal infection in adults
weeks) or other immunosuppressive medications within and children: guidelines by the Surgical Infection Society and the
one month. Infectious Diseases Society of America. Clin Infect Dis 2010; 50:
133‑64.
Source control: 2. Gomi H, Solomkin JS, Takada T, et al; Tokyo Guideline Revision
Committee. TG13 antimicrobial therapy for acute cholangitis and
• Optimal management of IAI includes appropriate cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20: 60‑70.
antimicrobial therapy as well as adequate source control 3. Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short‑course
(relief of biliary obstruction, drainage of intra‑abdominal or antimicrobial therapy for intra‑abdominal infection. N Engl J Med
pelvic abscesses, etc.). 2015; 372:1996‑2005.
4. Nelson A, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al‑Hasan MN.
Optimal duration of antimicrobial therapy for bloodstream infections
due to gram‑negative bacilli. Infection 2017; 45: 613‑20.
18 19
5. Al‑Hasan MN, Lahr BD, Eckel‑Passow JE, Baddour LM. Antimicrobial
resistance trends of Escherichia coli bloodstream isolates: a
population‑based study, 1998‑2007. J Antimicrob Chemother 2009;
64: 169‑74.
6. Justo JA, Dickert EL, Kohn J, Bookstaver PB. Comparative
risk of acute kidney injury in patients receiving vancomycin
monotherapy or vancomycin and beta‑lactam combination
therapy. 54th Interscience Conference on Antimicrobial Agents
and Chemotherapy, Washington DC, 5‑9 September 2014. Abstract
#2544.
7. Gomes DM, Smotherman C, Birch A, et al. Comparison of acute
kidney injury during treatment with vancomycin in combination with
piperacillin‑tazobactam or cefepime. Pharmacotherapy 2014; 34:
662‑9.
8. Burgess LD, Drew RH. Comparison of the incidence of
vancomycin‑induced nephrotoxicity in hospitalized patients with
and without concomitant piperacillin‑tazobactam. Pharmacotherapy
2014; 34: 670‑6.
9. Singer M, Deutschman CS, Seymour CW, et al. The third international
consensus definitions for sepsis and septic shock (Sepsis‑3). JAMA
2016; 315: 801‑10.
10. Pichichero ME. Cephalosporins can be prescribed safely for
penicillin‑allergic patients. J Fam Pract 2006; 55: 106‑12.
11. Jeffres MN, Narayanan PP, Shuster JE, Schramm GE. Consequences
of avoiding β‑lactams in patients with β‑lactam allergies. J Allergy
Clin Immunol 2016; 137: 1148‑53.
12. Dan S, Shah A, Justo JA, et al. Prediction of fluoroquinolone
resistance in gram‑negative bacteria causing bloodstream
infections. Antimicrob Agents Chemother 2016; 60: 2265‑72.
13. Hammer KL, Stoessel A, Justo JA, et al. Association between chronic
hemodialysis and bloodstream infections due to chromosomally
mediated AmpC‑producing Enterobacteriaceae. Am J Infect Control
2016; 44: 1611‑6.
14. Augustine MR, Testerman TL, Justo JA, et al. Clinical risk score
for prediction of extended‑spectrum beta‑lactamase‑producing
Enterobacteriaceae in bloodstream isolates. Infect Control Hosp
Epidemiol 2017; 38: 266‑72.
20 21
Skin and soft tissue infections
Footnotes:
streptococci (grp A,
PLUS clindamycin 5
to beta‑hemolytic
Necrotizing
PLUS clindamycin
to penicillin G7 4
non‑necrotizing
De-escalation
fasciitis
1. Use 2G of weight >80kg
infections
Same as
B, etc.)
2. Please send deep tissue cultures at the time of surgical debridement.
Prisma Health guidelines for the management of skin and soft tissue
infection (SSTI) in hospitalized adults: Empiric antimicrobial therapy
Q8h
3. Vancomycin loading dose of 20mg/kg once is recommended; Q8h
dosing of vancomycin is preferred in young adults.
4. Alternative regimens include those for patients with severe penicillin
Urgent surgical
consultation 2
allergy (i.e., anaphylaxis, angioedema, hives).
5. Limit clindamycin duration to 5 days for suppression of toxin
Cefepime 2G iV Q8–12h
De-escalate to narrower
15mg/kg IV Q8–12h
6. De-escalation to an oral antibiotic should occur when fever
PLUS Vancomycin3
subsides, and signs and symptoms of skin infection improve. The
Alternative4:
total duration of therapy for uncomplicated cellulitis is 7 days. Longer
Q6H
Non-necrotizing
OR
duration may be required in complicated cases (deep abscesses or
necrotizing infections) and depending on clinical response.
infection
Doxy/Minocycline 100mg PO All dosages assume normal renal and hepatic renal function.
Clindamycin 300–450mg
SSTI
Q6–8h
Q12h
15mg/kg Q8–12h
Purulent cellulitis
OR
OR
600–900mg IV
Clindamycin
Alternative4:
Definitions:
Clindamycin 300–450mg PO Q6-8h
Clindamycin 600–900mg IV Q8h
indicated2
De-escalate to PO antibiotics :
Alternative:
OR
OR
22 23
Penicillin allergy:
• Patients with penicillin allergy should not receive nafcillin
or piperacillin/tazobactam. In patients with minor
penicillin allergies (non-specific rashes, intolerances, etc.),
cross‑reactivity with 3rd and 4th generation cephalosporins
is low (<3%). 2 In critically ill patients, the benefit from beta-
lactam antibiotics may outweigh the potential risk.
24 25
Diabetic foot infections
Prisma Health guidelines for the management of diabetic foot infections Footnotes:
PLUS vancomycin3-4
15mg/kg IV Q8–12h
Limb-threatening
2. Use 2G if weight >80kg
Alternative 5:
3. If methicillin-resistant Staphylococcus aureus (MRSA) is suspected
OR
(known colonization, prior MRSA infections, etc.)
4. Vancomycin loading dose of 20mg/kg once is recommended; Q8h
dosing of vancomycin is preferred in young adults.
(DFI) in hospitalized adults empiric antimicrobial therapy
debridement 1
5. Alternative regimen for patients with severe penicillin allergy (i.e.,
Urgent
De‑escalation based on
Ceftriaxone 2G IV Q24h
Alternative 5-6:
PO Q8h
OR
culture results.
Definitions:
• Superficial: Limited in size and depth, erythema >0.5cm to
Debridement
if indicated1
De-escalation to PO antibiotics:
Vancomycin3-4 15mg/kg IV Q8H
OR
OR
Superficial
26 27
Management of special situations
Scenario Treatment
Human/Animal bites • Irrigation, debridement, and updating
Cat bites are more likely tetanus toxoids, if indicated
to cause deep infections • Ampicillin/sulbactam 3G IV Q6h OR
including osteomyelitis/ • Cefoxitin 2G IV Q6–8h
septic joints
• De‑escalation to oral antibiotics based
on tissue cultures:
‑ Amoxicillin‑clavulanate 875mg PO
Q12h, if cultures show no growth
Suspicion for water • Ceftriaxone 2G IV q24h OR
pathogens • Levofloxacin 750mg IV/PO Q24h
(Aeromonas hydrophilia, • ID consult
Vibrio Vulnificus)
Cellulitis surrounding sacral • Ceftriaxone 2G IV Q24h PLUS
decubitus metronidazole 500mg IV/PO Q8h1 OR
Ulcers • Levofloxacin PLUS metronidazole1
(as above) OR
‑ Cefoxitin (as above)
1. Levofloxacin and metronidazole may be given orally in
hemodynamically stable patients who can otherwise tolerate oral
medications.
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 by the Infectious Diseases Society of America. Clin Infect Dis
2014; 59: e10‑52.
2. Pichichero ME. Cephalosporins can be prescribed safely for
penicillin‑allergic patients. J Fam Pract 2006; 55: 106‑112.
3. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases
Society of America Clinical Practice Guideline for the Diagnosis
and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012; 54:
132–173.
28 29
30
Clostridiodes difficile infection (CDI) testing algorithm
Should a test be
ordered?
Retesting
Test of cure is not recommended
Consider ID HIGH LOW
Consult
(a) Patients with severe CDI with ileus and/or toxic megacolon may not experience diarrhea. Consider ID consult for
such cases.
(b) F or additional information, please see www.cdc.gov/hai/
(c) See Complete treatment guidelines in Prisma Health Antimicrobial Guidebook at phformulary.net under
Antimicrobial Stewardship-Adults.
Fulminant/Critically ill
Mild-severe CDI Severe disease + hypotension or shock; ileus; megacolon;
Mild-moderate/Non-severe: WBC≤ 15 cells/mm3; OR admission to the ICU secondary to CDI
SCr <1.5 mg/dl
Severe: WBC >15 cells/mm3; SC >1.5 mg/dl (or 1.5 X
baseline); endoscopic or radiographic evidence of Vancomycin 125–500 mg PO Q6hb,d
Pseudomembranous colitis +
Metronidazole 500mg IV q8h for
10–14 days
Initial episode?a
Additional orders/Recommendations:
• C onsider discontinuation of concomitant systemic antimicrobial therapy. If the patient must remain on antibiotics, de‑escalate/
change to an antibiotic that is low‑risk for CDI such as aminoglycosides, tetracyclines, macrolides, sulfonamides (SMZ‑TMP).
• Discontinue bowel regimens including stool softeners, laxatives, antiperistaltic agents (e.g., docusate, sennosides, loperamide,
metoclopramide, polyethylene glycol)
• Consider discontinuation of ALL acid‑suppressing agents (PPI risk > H2 antagonist)
• Concurrent cholestyramine and oral vancomycin are not recommended due to extensive binding and inactivation of vancomycin.
• Combo therapy strongly discouraged for non‑critically ill patients. Data does not support increased effectiveness but increased
adverse events. When combination therapy used in fulminant disease, consider discontinuation of metronidazole following
discharge from ICU.
a
Recurrence/relapse is limited to 90 days from initial episode. Onset beyond this threshold should be treated as initial episode.
b
Extended courses of oral vancomycin may be considered if multi‑recurrent CDI or when concomitant broad‑spectrum antibiotics are
necessary (e.g. >10days)
c
Fidaxomicin requires Antimicrobial Stewardship and Support Team (PHASST/ID/GI) approval. Patients at high risk for recurrence:
Active cancer, s/p transplant on immunosuppression, HIV/AIDS, h/o recurrence, receiving broad spectrum antibiotics and unable to
de‑escalate/discontinue.
d
Intracolonic delivery of vancomycin 500mg in 100ml saline every 6–12 hours via retention enema may be considered in critically ill
patients without oral access or those with blind rectal pouch.
e
500mg oral vancomycin doses may be considered in critically ill patients with suspected or identified bowel obstruction. Doses can be
decreased (e.g., 125mg) once GI motility established.
f
Openbiome® (i.e., fecal microbiota transplant) recommended for patients with at least 3 CDI (≥2 recurrences) who have failed
antibiotic treatment.
Please contact the Prisma Health Antimicrobial Stewardship and Support Team (PHASST) for assistance.
33
34
Prisma Health guidelines for acute cystitis and pyelonephritis: Inpatient
management in adults
Uncomplicated Complicated cystitis No risk factors Risk factors for Risk factors for
cystitis Defined as: for drug-resistant P.aeruginosa ESBL‑producing
Defined as: • >2 UTIs in past bacteria (Any of the following) bacteria
• Female of 12 months • Severely immune (Any of the following)
childbearing • Urologic compromised • Colonization with
potential abnormalities • Currently ESBLs in past
• No urologic • (e.g., stones) hospitalized >5 12 months
abnormalities • Males days • ≥2 courses of
• Indwelling • Beta-lactam use beta‑lactams or
catheters within past 90 days fluoroquinolones
• Colonization with in past 90 days
P.aeruginosa in
past 12 months
Acute cystitis and pyelonephritis: Inpatient
1
Nitrofurantoin should be avoided in patients with CrCl <30 ml/min.
2
Fosfomycin is not recommended as a first‑line therapy in patients with complicated disease. If used for complicated disease, should
repeat Q72h for 2–3 doses.
3
SMZ‑TMP can be used in patients with decreased renal function. If CrCl <30 ml/min, reduce dose to 1 SS PO Q12h. SMZ‑TMP should be
used with caution in pregnancy.
4
If CrCl <20‑49ml/min, give 750mg Q48h, and if <20 ml/min, give 750mg followed by 500mg Q48h.
5
If CrCl <30 ml/min, give 250mg Q12h.
35
Definitions: dehydration, electrolyte abnormalities, medications
• Severely immune compromised host: chemotherapy, (e.g., narcotics, etc.), liver failure, renal failure, blood sugar
neutropenia, transplant recipient, treatment with high dose issues, sleep deprivation, stroke and other infections.
steroids (20mg of prednisone equivalents daily for >2 weeks) • Urine cultures should not be done after treatment of cystitis or
or other immunosuppressive medications within one month. pyelonephritis to document cure.
• A prior course of antibiotics should be at least 24h or longer;
short‑term perioperative antibiotics do not qualify as a course. Treatment:
• >2 courses of β‑lactams or fluoroquinolones have to be at least • Asymptomatic bacteriuria
3 days apart; concurrent or sequential therapy is considered *Treatment of asymptomatic bacteriuria is strongly
one course. discouraged because antibiotics may lead to harmful effects
to patient (e.g., Clostridium difficile infection, induction
Diagnosis: of antimicrobial resistance) that cannot be justified based
on lack of any treatment benefits. The only exceptions are
• Urinalysis and urine culture should be obtained prior to
pregnant women and before transurethral resection of the
initiating antibiotics in patients with recurrent infections,
prostate or other urologic procedures for which mucosal
urologic abnormalities, pregnancy and in males.
bleeding is anticipated.
• Urinalysis, urine culture and blood cultures should be obtained
prior to initiating antibiotics in all patients in the emergency • Acute cystitis
room or hospital with acute pyelonephritis. ‑ Fluoroquinolone (ciprofloxacin, levofloxacin) use is
• For patients with indwelling catheters in place for >2 weeks strongly discouraged for the treatment of acute cystitis
from onset of symptoms, catheter should be replaced prior because the risk of harmful adverse effects (e.g., C.difficile
to obtaining urinalysis and urine culture. If possible, catheter infection; tendonitis; neurotoxicity; QTc prolongation;
should be discontinued, and a culture of a voided midstream induction of antimicrobial resistance) exceeds
urine specimen should be obtained. potential benefit.
• Consider imaging in males and patients with recurrent urinary ‑ Similarly, oral 3rd generation cephalosporins (e.g., cefdinir,
infections. cefpodoxime) should be AVOIDED due to low urinary
• Presence of pyuria on urinalysis without symptoms does not concentrations and high risk of adverse events, including
indicate a urinary tract infection. Absence of pyuria is indicative induction of antimicrobial resistance.
that a urinary tract infection is not present with the exception of ‑ If IV antibiotics are continued, transition to a less broad
acute pyelonephritis with complete uretic obstruction. agent (ampicillin, cefazolin, etc.) based on culture and
• Patients with non‑specific symptoms: susceptibility data is appropriate. If IV antibiotics are used
‑ Change in urine color, odor or turbidity are typically due to for uncomplicated cystitis, limit duration to 3 days.
dehydration and not indicators for urinalysis or urine culture.
‑ Behavioral changes including worsening mental or functional Alternative oral regimens for cystitis:
status do not on their own indicate a urinary tract infection. • Contraindications to first‑line therapy
These patients should be monitored and encouraged to have ‑ In patients with contraindications to all first‑line therapies
increased fluid intake, if possible. Other causes of mental (e.g., complicated cystitis AND CrCl <30 mL/min AND
status change should be assessed including constipation, SMZ‑TMP allergy), cephalexin 500 mg PO Q8h or
36 37
amoxicillin/clavulanic acid 500 mg/125 mg PO Q12h for fluoroquinolones are used. For males, on fluoroquinolones
7–10 days may be used. or all patients on SMZ‑TMP, 14 days of therapy is preferred.
‑ Fluoroquinolones are considered only as last resort ‑ If IV antibiotics are continued in the hospital, transition to a
options in patients with cystitis in the absence of narrower spectrum agent (ampicillin, ampicillin‑sulbactam,
risk factors for fluoroquinolone resistance. May use cefazolin, etc.) based on final culture and in vitro
ciprofloxacin 250 mg PO Q12h x 3 days. antimicrobial susceptibility data as appropriate.
• Extended‑spectrum β–lactamase (ESBL)‑producing ‑ Transition to oral therapy such as fluoroquinolones
Enterobacteriaceae or SMZ‑TMP is appropriate based on culture and
‑ Non‑β‑lactam antibiotics (nitrofurantoin, fosfomycin and susceptibility data.
SMZ‑TMP) often retain activity against ESBL‑producing ‑ Use of oral 3rd generation cephalosporins (e.g., cefdinir,
Enterobacteriaceae if not previously used and may be cefpodoxime) is highly discouraged due to low urinary
considered therapeutic options for suspected cystitis concentrations and higher risk of treatment failure in
due to ESBL‑producing Enterobacteriaceae. Fosfomycin comparison to fluoroquinolones and SMZ‑TMP.
should be given 3 G PO Q72h x 3 doses. ‑ Nitrofurantoin and fosfomycin should be AVOIDED in
• Vancomycin‑resistant Enterococcus (VRE) patients with suspected documented pyelonephritis.
‑ Growth of VRE in a urine culture often indicates urinary These antibiotics do not concentrate outside the urine,
colonization due to recent use of antibiotics, rather than including the interstitial cells of the kidney.
a urinary infection. However, when treatment is indicated β‑lactam allergy with pyelonephritis:
-
in symptomatic patients, fosfomycin retains good activity • In patients with minor penicillin allergies (e.g., itching,
and may be considered a therapeutic option for suspected nonspecific rash), cross‑reactivity with 3rd and
cystitis due to VRE. Fosfomycin should be given 3 G PO 4th generation cephalosporins is low (<3%). The benefit
Q72h x 2 doses. of β‑lactam antibiotics outweighs the potential risk.
• Acute pyelonephritis • In patients with severe β‑lactam allergies (e.g.,
‑ In critically ill patients with acute pyelonephritis anaphylaxis) and low risk of fluoroquinolone resistance
(qSOFA ≥2), please refer to Guidelines for management (no prior fluoroquinolone use within past 12 months,
of gram‑negative bloodstream infections for non‑residents of a nursing home or skilled nursing
recommendations on empirical antimicrobial therapy facility, etc.), ciprofloxacin 400 mg IV Q8‑12h is
(page 2). recommended.
‑ **In patients with concurrent gram‑negative bloodstream • In patients who have severe β‑lactam allergies and risk
infection, levofloxacin 750 mg daily is the preferred oral factors for fluoroquinolone resistance, please contact
agent for definitive therapy in susceptible bloodstream Prisma Health‑Midlands Antimicrobial Stewardship
isolates. Please refer to Customized antimicrobial and Support Team (PHASST) during business hours or
treatment duration for uncomplicated gram‑negative BSI an infectious diseases specialist for optimal empirical
(page 12). antimicrobial therapy or penicillin skin testing (PHR
‑ **For acute pyelonephritis without bloodstream infection, pager 803‑352‑1322).
7 days of therapy is typically appropriate for females, if
38 39
40
Acute cystitis and pyelonephritis: Outpatient
Prisma Health guidelines for acute cystitis and pyelonephritis:
Outpatient management in adults
Do NOT treat asymptomatic patients NO Urinary symptoms YES
with positive urine cultures*
1
Nitrofurantoin should be avoided in patients with CrCl <30 ml/min.
2
Fosfomycin is not recommended as a first-line therapy in patients with complicated disease. If used for complicated disease, should
repeat Q72h for 2–3 doses.
3
SMZ-TMP can be used in patients with decreased renal function. If CrCl <30 ml/min, reduce dose to 1 SS PO Q12h. SMZ-TMP should be
used with caution in pregnancy.
4
If CrCl <20–49ml/min, give 750mg Q48h, and if <20 ml/min, give 750mg followed by 500mg Q48h.
5
If CrCl <30 ml/min, give 250mg Q12h.
41
Diagnosis: Treatment:
• Urinalysis and urine culture should be obtained prior to • Asymptomatic bacteriuria
initiating antibiotics in patients with recurrent infections, *Treatment of asymptomatic bacteriuria is strongly
urologic abnormalities, pregnancy and in males. discouraged because antibiotics may lead to harmful effects
• Urinalysis, urine culture and blood cultures should be to patient (e.g., Clostridium difficile infection, induction of
obtained prior to initiating antibiotics in patients with acute antimicrobial resistance, etc.) that cannot be justified based
pyelonephritis, when feasible. on lack of any treatment benefits. The only exceptions are
• For patients with indwelling catheters in place for > 2 weeks pregnant women and before transurethral resection of the
from onset of symptoms, catheter should be replaced prior prostate or other urologic procedures for which mucosal
to obtaining urinalysis and urine culture. If possible, catheter bleeding is anticipated.
should be discontinued, and a culture of a voided midstream • Acute cystitis
urine specimen should be obtained. ‑ Fluoroquinolone (ciprofloxacin, levofloxacin) use is
• Consider imaging in males and patients with recurrent strongly discouraged for the treatment of acute cystitis
urinary infections. because the risk of harmful adverse effects (e.g., C. difficile
• Presence of pyuria on urinalysis without symptoms does infection; tendonitis; neurotoxicity; QTc prolongation;
not indicate a urinary tract infection. Absence of pyuria induction of antimicrobial resistance) exceeds
is indicative that a urinary tract infection is not present potential benefit.
with the exception of acute pyelonephritis with complete ‑ Similarly, oral 3rd generation cephalosporins (e.g., cefdinir,
uretic obstruction. cefpodoxime) should be AVOIDED due to low urinary
• Patients with non‑specific symptoms: concentrations and high risk of adverse events, including
‑ Change in urine color, odor or turbidity are typically induction of antimicrobial resistance.
due to dehydration and not indicators for urinalysis or ‑ Alternative oral regimens for cystitis:
urine culture.
• Contraindications to first‑line therapy
‑ Behavioral changes including worsening mental or
functional status do not on their own indicate a urinary - In patients with contraindications to all first‑line
tract infection. These patients should be monitored and therapies (e.g., complicated cystitis AND CrCl
encouraged to have increased fluid intake, if possible. <30 mL/min AND SMZ‑TMP allergy), cephalexin
Other causes of mental status change should be 500 mg PO Q8h or amoxicillin/clavulanic acid 500
assessed including constipation, dehydration, electrolyte mg/125 mg PO Q12h for 7–10 days may be used.
abnormalities, medications (e.g., narcotics, etc.), liver ‑ Fluoroquinolones are considered only as last resort
failure, renal failure, blood sugar issues, sleep deprivation, options in patients with cystitis in the absence of
stroke, and other infections. risk factors for fluoroquinolone resistance. May use
• Urine cultures should not be done after treatment of cystitis ciprofloxacin 250 mg PO Q12h x 3 days.
or pyelonephritis to document cure.
42 43
Extended‑spectrum β–lactamase (ESBL)‑producing
• Estimated probability of fluoroquinolone resistance is
bacteria 20–40%. Urine culture would need follow‑up.
‑
Non‑β‑lactam antibiotics (nitrofurantoin, fosfomycin • Patients with fluoroquinolones use within the past
and SMZ‑TMP) often retain activity against 3 months or multiple risk factors for resistance
ESBL‑producing Enterobacteriaceae if not previously have >50% probability of pyelonephritis due to
used and may be considered therapeutic options fluoroquinolone‑resistant bacteria. Fluoroquinolone
for suspected cystitis due to ESBL‑producing empirical therapy is discouraged in this group. There
Enterobacteriaceae. Fosfomycin should be given 3 G are currently insufficient data to recommend alternative
PO Q72h x 3 doses. oral antibiotics for acute pyelonephritis in these
patients. Observation/admission may be considered
• Vancomycin‑resistant Enterococcus (VRE)
while receiving IV ceftriaxone, awaiting blood and urine
‑ Growth of VRE in a urine culture often indicates culture results.
urinary colonization due to recent use of antibiotics,
rather than a urinary infection. However, when References:
treatment is indicated in symptomatic patients, 1. Gupta K, Hooton TM, Naber KG, et al. International clinical practice
guidelines for the treatment of acute uncomplicated cystitis and
fosfomycin retains good activity and may be pyelonephritis in women: A 2010 update by the Infectious Diseases
considered a therapeutic option for suspected cystitis Society of America and the European Society for Microbiology and
due to VRE. Fosfomycin should be given 3 G PO Q72h Infectious Diseases. Clin Infect Dis 2011; 52: e103‑20.
x 2 doses. 2. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of
America guidelines for the diagnosis and treatment of asymptomatic
• Acute pyelonephritis bacteriuria in adults. Clin Infect Dis 2006; 40: 643‑54.
‑ Nitrofurantoin and fosfomycin should be AVOIDED in 3. FDA updates warnings for fluoroquinolone antibiotics. U.S. Food
patients with suspected of documented pyelonephritis. & Drug Administration. Released 26 July 2016. Available at: http://
www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/
These antibiotics do not concentrate outside the urine, ucm513183.htm
including the interstitial cells of the kidney. 4. Dan S, Shah A, Justo JA, et al. Prediction of fluoroquinolone
‑ Use of oral 3rd generation cephalosporins (e.g., cefdinir, resistance in gram‑negative bacteria causing bloodstream
infections. Antimicrob Agents Chemother 2016; 60: 2265‑72.
cefpodoxime) is highly discouraged due to low urinary
5. Shah A, Justo JA, Bookstaver PB, et al. Application of
concentrations and higher risk of treatment failure in fluoroquinolone resistance score in management of complicated
comparison to fluoroquinolones and SMZ‑TMP. urinary tract infections. Antimicrob Agents Chemother 2017; 61:
e02313‑16.
‑ If a patient meets any of the criteria for fluoroquinolone
6. Falagas ME, Kastoris AC, Kapaskelis AM, Karageorgopoulos DE.
resistance, but SMZ‑TMP cannot be used due to allergy or Fosfomycin for the treatment of multidrug‑resistant, including
high risk of resistance: extended‑spectrum beta‑lactamase producing, Enterobacteriaceae
infections: a systematic review. Lancet Infect Dis 2010; 10: 43‑50.
• Consider oral ciprofloxacin or levofloxacin following
7. Veve MP, Wagner JL, Kenny RM, et al. Comparison of fosfomycin
ceftriaxone 1g IV/IM dose as long as patient has only to ertapenem for outpatient or step‑down therapy of
one risk factor for fluoroquinolone resistance and prior extended‑spectrum beta‑lactamase urinary tract infection. Int J
fluoroquinolone use was within the past 3–12 months. Antimicrob Agents 2016; 48: 56‑60.
44 45
8. Hayes JE, O’Quinn B, Lu K, et al. Fosfomycin resistance among
vancomycin‑resistant enterococcal isolates at a tertiary care medical
center. Presented at American College of Clinical Pharmacy 2016;
Abstract #176.
9. Hammer KL, Justo J, Bookstaver PB, et al. Differential effect of prior
β‑lactams and fluoroquinolones on risk of bloodstream infections
secondary to Pseudomonas aeruginosa. Diagn Microbiol Infect Dis
2017; 87: 87‑91.
10. Augustine M, Testerman TL, Justo J, et al. Clinical risk score for
prediction of extended‑spectrum beta‑lactamase‑producing
Enterobacteriaceae in bloodstream isolates. Infect Control Hosp
Epidemiol 2017; 38: 266‑272.
11. Pichichero ME. Cephalosporins can be prescribed safely for
penicillin‑allergic patients. J Fam Pract 2006; 55: 106‑12.
12. Jeffres MN, Narayanan PP, Shuster JE, Schramm GE. Consequences
of avoiding β‑lactams in patients with β‑lactam allergies. J Allergy
Clin Immunol 2016; 137: 1148‑53.
13. Hoang P, Salbu RL. Updated nitrofurantoin recommendations in the
elderly: a closer look at the evidence. Consult Pharm 2016; 31: 381‑4.
14. Nelson AN, Justo JA, Bookstaver PB, et al. Optimal duration of
antimicrobial therapy for uncomplicated gram‑negative bloodstream
infections. Infection 2017; 45: 613‑20.
15. Kutob LF, Justo JA, Bookstaver PB, et al. Effectiveness of oral
antibiotics for definitive therapy of gram‑negative bloodstream
infections. Int J Antimicrob Agents 2016; 48: 498‑503.
16. Falagas ME, et al. Fosfomycin for the treatment of
multidrug‑resistant, including extended‑spectrum beta‑lactamase
producing Enterobacteriaceae infections: a systematic review.
Lancet Infect Dis 2010; 10: 43‑50.
17. Veve MP, et al. Comparison of fosfomycin to ertapenem for
outpatient or step‑down therapy of extended‑spectrum
beta‑lactamase urinary tract infection. Int J Antimicrob Agents 2016;
48: 56‑60.
18. Sanasi‑Bhola K, et al. Fosfomycin in vitro activity against extended
spectrum beta‑lactamase positive and carbapenem resistant
Enterobacteriaceae urine isolates. Presented at IDWeek 2014.
Abstract #40851.
19. Nieuwkoop C, van der Starre WE, Stalenhoef JE, et al. Treatment
duration of febrile urinary tract infection: a pragmatic randomized,
double‑blind, placebo‑controlled non‑inferiority trial in men and
women. BMC Medicine 2017; 15: 70.
20. Johnson JR, Russo TA. Acute pyelonephritis in adults. N Engl J Med
2018; 378: 48‑59.
46 47
48
Prisma Health inpatient management of community‑onset bacterial
pneumonia in adults
Suspected or confirmed pneumonia
• Radiographic infiltrate AND
• 2 of 3 clinical features: fever (>38 C or >100.4 F), leukocytosis or leukopenia, purulent sputum
Type of pneumonia
• CAP: Symptom onset occurring in the community setting or <48hrs after hospital admission
• HCAP: Use of this term is no longer recommended due to poor predictive performance for drug resistance.
Diagnostics to consider:
CXR, Vitals, ABG/O2sat, CBC, respiratory Gram stain and culture, blood culture from 2 sites, Streptococcus
pneumoniae and Legionella urinary antigens, MRSA nasal swab for PCR, Influenza A & B PCR
No risk factors Risk factors for Antipseudomonal (APBL)‑susceptible Risk factors for
Pseudomonas aeruginosa APBL‑resistant Pseudomonas aeruginosa
• Interstitial lung disease (e.g., severe pulmonary fibrosis, but • Cystic fibrosis or bronchiectasis3
excluding COPD or asthma) • Prior APBL 2 use for ≥ 48hrs within
• Prior use of non-APBL 2 within last 3–30 days (e.g., AMC, CRO) 3–30 days (e.g., TZP, FEP, CAZ)
Community-onset bacterial pneumonia
• Prior airway colonization with P. aeruginosa susceptible • Prior airway colonization with
to APBL (e.g., TZP, FEP, CAZ) within the last 12 months P. aeruginosa resistant to APBL (e.g.,
• Severe immune compromise (neutropenia, steroids, etc.) TZP, FEP, CAZ) within the last 12 months
Abbreviations:
APBL: Antipseudomonal beta-lactam
AMC: Amoxicillin-clavulanate
FEP: Cefepime
CRO: Ceftriaxone
CAZ: Ceftazidime
TZP: Piperacillin-tazobactam
49
50
Prisma Health inpatient management of hospital‑acquired,
ventilator‑associated bacterial pneumonia in adults
Suspected or confirmed pneumonia
• Radiographic infiltrate AND
• 2 of 3 clinical features: fever (>38 C or >100.4 F), leukocytosis or leukopenia, purulent sputum
Type of pneumonia
• HAP: Symptom onset occurring ≥48hrs after hospital admission
• VAP: Symptom onset occurring ≥48hrs after endotracheal intubation
bacterial pneumonia
Diagnostics to consider:
CXR, Vitals, ABG/O2sat, CBC, respiratory Gram stain and culture, blood culture from 2 sites, Streptococcus
pneumoniae and Legionella urinary antigens, MRSA nasal swab for PCR, Influenza A & B PCR
No risk factors Risk factors for antipseudomonal (APBL)‑susceptible Risk factors for APBL‑resistant
AND Pseudomonas aeruginosa Pseudomonas aeruginosa
hospitalization • Interstitial lung disease (e.g., severe pulmonary fibrosis, but • Cystic fibrosis or bronchiectasis3
≤5 days excluding COPD or asthma) • Prior APBL 2 use for ≥ 48hrs within 3–30
• Prior use of non‑APBL2 within last 3–30 days (e.g., AMC, CRO) days (e.g., TZP, FEP, CAZ)
• Prior airway colonization with P. aeruginosa susceptible to • Prior airway colonization with
Hospital-acquired, ventilator-associated
APBL (e.g., TZP, FEP, CAZ) within the last 12 months P. aeruginosa resistant to APBL (e.g.,
• Severe immune compromise TZP, FEP, CAZ) within the last 12 months
• Prolonged hospitalization of >5 days at symptom onset
Abbreviations:
APBL: Antipseudomonal beta-lactam
AMC: Amoxicillin-clavulanate
FEP: Cefepime
CRO: Ceftriaxone
CAZ: Ceftazidime
TZP: Piperacillin-tazobactam
51
Footnotes: Definitions:
1. Use of clinical judgment is encouraged when selecting empiric • Severe immune compromise: neutropenia
therapy for a patient, including consideration of severity of
illness, prior microbiology and prior antimicrobial history. Revise (ANC <500 cells/mm3), HIV/AIDS (CD4 < 200 cells/
antimicrobial regimen based on microorganism identification (e.g., mm3), or immunocompromising medications within the
culture, PCR) and antimicrobial susceptibility testing results. last 30 days (e.g., high‑dose corticosteroids of ≥ 20 mg
2. Prior antibiotics defined as a duration ≥48 hours (excludes one‑time daily prednisone‑equivalents ≥2 weeks, chemotherapy,
doses and/or most surgical prophylaxis). calcineurin inhibitors)
3. Patients with cystic fibrosis or bronchiectasis may have extensive
histories of multidrug‑resistant organisms and may require • Critical illness: Intensive care unit admission, need for
customized therapy. Strongly consider consulting with infectious mechanical ventilation or vasopressors, or other severe
diseases, the Prisma Health Antimicrobial Stewardship and complications of pneumonia (e.g., empyema)
Support Team (PHASST), and/or pulmonology for assistance with
antimicrobial selection.
4. Standard coverage for early onset (≤5 days) pathogens:
Local risk factors vs. historical
Streptococcus pneumoniae, Haemophilus influenzae, MSSA, healthcare‑associated pneumonia (HCAP)
Enterobacteriaceae (e.g., E. coli, Klebsiella spp.) risk factors
5. Add if atypical pneumonia (e.g., Legionella spp., Mycoplasma
spp., Chlamydia spp.) is suspected. If azithromycin cannot be • These guidelines are based on local studies and national
used, consider doxycycline 100 mg PO Q12h as an alternative clinical guidelines for pneumonia.1‑3
(or levofloxacin 750 mg PO Q24h for documented Legionella • Historical risk factors for healthcare‑associated pneumonia
pneumonia).
(HCAP) were published in a previous version of ATS/IDSA
6. Consider transition to oral therapy once clinically improved/stable.
Depending on causative pathogen, oral options may be even HAP/VAP/HCAP Guidelines from 2005.4
narrower spectrum than those presented herein. Narrowest effective ‑ HCAP risk factors: residence in a nursing home or
therapy is generally preferred to minimize adverse effects and extended care facility; hospitalization for ≥2 days in the
emergence of resistance.
preceding 90 days; home infusion therapy, home wound
7. Provides coverage for late onset (>5 days) pathogens: Early onset
organisms PLUS P. aeruginosa, resistant Enterobacteriaceae, care or chronic dialysis within 30 days; or family member
Acinetobacter spp., etc. with a multidrug‑resistant (MDR) organism.
8. Cefepime generally preferred to minimize risk of acute kidney injury • Subsequent research demonstrated HCAP risk factors had
with concomitant vancomycin and piperacillin/tazobactam
a limited ability to predict for MDR organisms and, due to
9. Duration of therapy may be extended (e.g., total 10–14 days) for
patients who fail to respond clinically and/or are definitely diagnosed their low specificity, favored unnecessary overutilization of
with pneumonia due to non‑lactose fermenting gram‑negative broad‑spectrum antibiotics.3,5,6
bacteria (e.g., P. aeruginosa) or Legionella spp. ‑ Thus, the HCAP designation was omitted from the
10. Provides coverage for multidrug‑resistant (MDR) gram‑negative current 2016 IDSA/ATS HAP/VAP Guidelines, and the panel
pathogens: MDR P. aeruginosa, MDR Acinetobacter spp., etc.
stated further recommendations for community‑onset
11. Avoid using same APBL the patient was recently exposed to or
that recent organism was resistant to (e.g., if recent TZP exposure, pneumonia will likely be based on validated risk factors
select FEP); antipseudomonal carbapenems (e.g., meropenem) may for MDR organisms.3 These recommendations are
also be considered as the APBL component for patients eligible for expected in a pending update to the 2007 IDSA/ATS
APBL‑resistant pseudomonal coverage. Community‑acquired Pneumonia Guidelines.2
12. All dosages provided assume normal renal and hepatic function.
52 53
• Current national guidelines strongly encourage Empiric levofloxacin use:
customization of local guidelines based on local • Given the importance of fluoroquinolones in the
epidemiology and antimicrobial resistance data.3 In 2018, management of serious infections and their relative
a local study was published evaluating pneumonia in adult toxicity (e.g., dysglycemias, CNS side effects, muscle
hospitalized patients at Palmetto Health.1 It identified local injury, tendonitis) compared to alternative agents, it is
risk factors to predict for both susceptible and resistant recommended to reserve fluoroquinolones for select
Pseudomonas aeruginosa, respectively, compared to other patient cases where benefit outweighs the risk (e.g., severe
respiratory bacterial pathogens. These local guidelines beta‑lactam allergy, oral antipseudomonal coverage).
reflect the risk factors identified in this study combined with
• Avoid levofloxacin for gram‑negative bacterial coverage
other local data on predicting antimicrobial resistance.7,11,12
if patient had prior fluoroquinolone use, particularly
within the past 3 months (risk of infections due to
Beta‑lactam allergy:
fluoroquinolone‑resistant bacteria may persist for up to
• Minor penicillin allergies (nonspecific or maculopapular 12 months from fluoroquinolone use).
rashes, intolerance, etc.): Consider a cephalosporin, such
as ceftriaxone (or cefepime if antipseudomonal coverage Aspiration pneumonia:
is needed). Cross‑reactivity with 3rd and 4th generation
• Add metronidazole to either cephalosporins or levofloxacin
cephalosporins is low (<3%) in patients with minor penicillin
to include coverage for obligate anaerobic bacteria. The use
allergies, and the benefit from beta‑lactam antibiotics
of clindamycin is discouraged due to added risk of C. difficile
outweighs the potential risk in these patients.
infection when combined with other broad‑spectrum
• Serious penicillin allergies (anaphylaxis, angioedema, agents. Piperacillin‑tazobactam and carbapenems provide
breathing problems and hives): Consider a respiratory adequate anaerobic coverage if selected for empirical
fluoroquinolone, such as levofloxacin 750 mg IV Q24h, in the therapy of P. aeruginosa or MDR gram‑negative bacteria,
absence of prior exposure to fluoroquinolones in the past respectively.
12 months. Ciprofloxacin 400 mg IV Q8h can be considered
if antipseudomonal coverage is needed, but does not provide Renal impairment:
adequate gram‑positive coverage (e.g., Streptococcus
• If tobramycin is recommended above, consider replacing
pneumoniae, MRSA) and may need to be coupled with
this agent with an antipseudomonal fluoroquinolone (i.e.,
vancomycin. Consider consultation with an infectious
ciprofloxacin or levofloxacin) in the absence of recent
diseases specialist or PHASST for optimal empirical therapy
fluoroquinolone use within the past 3 months. Inhaled
or penicillin skin testing.
tobramycin may be considered in patients with renal
impairment who received fluoroquinolones recently.
54 55
De‑escalation tips: influenza A or B virus, supportive care for rhinovirus) or atypical
Atypical coverage: bacterial pneumonia management (e.g., azithromycin).
• If diagnostics for atypical bacteria are negative (e.g., atypical
bacteria on the respiratory viral PCR panel, Legionella urinary Additional risk factors for antimicrobial
antigen), consider discontinuing atypical coverage altogether. resistance:
• If Legionella is highly suspected (recent outbreak or classic • Extended‑spectrum beta‑lactamase (ESBL)‑producing
clinical and laboratory manifestations for Legionella organisms
pneumonia, e.g., high fever, severe hypoxia, hyponatremia, ‑ Carbapenems are preferred in patients with high risk of
elevated liver enzymes), consider levofloxacin or pneumonia due to ESBL‑producing bacteria, including:
azithromycin over doxycycline as atypical coverage. • Documentation of prior infections or colonization with
• The recommended duration of azithromycin therapy varies ESBL‑producing bacteria in the past 12 months.
based on dosage and is often shorter than a concomitant • Receipt of multiple courses of broad‑spectrum
beta‑lactam antibiotic agent. Two acceptable regimens antibiotics (piperacillin‑tazobactam, cefepime, etc.) in
include either: the past 90 days.12
‑ Azithromycin 500mg IV/PO Q24h x total 3 days • Consult PHASST during business hours or an infectious
OR diseases specialist for assistance determining optimal
‑ Azithromycin 500mg IV/PO x 1 day, then 250 mg IV/PO empirical antimicrobial therapy.
Q24h x 4 days (x total 5 days)
‑ For Legionella pneumonia: Duration of azithromycin
therapy may be extended to total 10–14 days,
particularly for cases of severe illness and/or slow clinical
improvement
MRSA nasal swab PCR:
This test typically demonstrates a negative predictive value
of >95% for ruling out MRSA as a causative pathogen for
pneumonia.8‑10 This is a useful diagnostic in patients at
increased risk of MRSA pneumonia at baseline (e.g., residence
in a long‑term care facility, wound care in the last 30 days, prior
MRSA infection/colonization within 90 days).
56 57
58
Prisma Health guidelines for community-onset pneumonia in adults in
the ED/Ambulatory setting
Suspected or confirmed pneumonia
• Radiographic infiltrate AND
• 2 of 3 clinical features: fever (>38 C or >100.4 F), leukocytosis or leukopenia, purulent sputum
Type of pneumonia
• CAP: Symptom onset occurring in the community setting or <48hrs after hospital admission
Ambulatory setting
• HCAP: Use of this term is no longer recommended by clinical guidelines due to poor predictive
performance for drug resistance.
Diagnostics to consider:
CXR, Vitals, ABG/O2sat, CBC, respiratory Gram stain and culture, blood culture from 2 sites, Streptococcus
pneumoniae and Legionella urinary antigens, MRSA nasal swab for PCR, Influenza A & B PCR
Consider outpatient management Consider observation/admission to floor Consider admission (possibly to ICU)
NO
Pseudomonal coverage Standard coverage: Low severity Standard coverage: Moderate severity
Levofloxacin Amoxicillin-clavulanate Ceftiaxone 2G IV Q24h
750mg IV/PO Q24h 500mg/125mg Q8h
± Atypical coverage:
(Low CURB‑65 use PO,
Mod. CURB‑65 use IV) ± Atypical coverage: Azithromycin 500mg IV/PO Q24h
OR
Azithromycin 500mg PO X1, Doxycycline 100mg IV/PO Q12h
Total duration: 7 days Then 250mg PO Q24h
OR Potential PO transition
Doxycyline 100mg PO Q12h Amoxicillin-clavulanate 500mg/125mg Q8h
± Atypical coverage:
Total duration: 5–7 days Azithromycin 500mg PO X1, Then 250mg PO Q24h
OR
Doxycyline 100mg PO Q12h
Common pathogens Total duration: 5-7 days
Typical bacteria Atypical bacteria
S.pneumoniae Legionella spp.
H.influenzae Mycoplasma spp.
M.catarrhalis Chlamydia spp. See Guidelines for inpatient community-onset bacterial pneumonia in adults (page 48).
59
Footnotes: Definitions:
1. Use of clinical judgment is encouraged when selecting empiric • Severe immune compromise: neutropenia (ANC
therapy for a patient, including consideration of severity of
illness, prior microbiology and prior antimicrobial history. Revise <500 cells/mm3), HIV/AIDS (CD4 <200 cells/mm3), or
antimicrobial regimen based on microorganism identification (e.g., immunocompromising medications within the last 30
culture, PCR) and antimicrobial susceptibility testing results. days (e.g., high‑dose corticosteroids of ≥20 mg daily
2. Patients with cystic fibrosis or bronchiectasis may have extensive prednisone‑equivalents ≥2 weeks, chemotherapy,
histories of multidrug‑resistant organisms and may require calcineurin inhibitors)
alternative therapy aside from levofloxacin monotherapy. Strongly
consider consulting with infectious diseases, the Prisma Health
Antimicrobial Stewardship and Support Team (PHASST), and/or
pulmonology for assistance with antimicrobial selection. CURB‑65 score: Sum of each of the following characteristics
3. All dosages provided assume normal renal and hepatic function.
Characteristic Points
Confusion (defined by one of the following): 1
Abbreviated Mental Test Score <8
New disorientation in person, place or time
Uremia (BUN >19 mg/dL) 1
Respiratory rate ≥30 breaths/min 1
Blood pressure (SBP <90 mmHg or DBP ≤60 mmHg) 1
Age ≥65 years 1
60 61
- HCAP risk factors: residence in a nursing home or • Serious penicillin allergies (anaphylaxis, angioedema,
extended care facility; hospitalization for ≥2 days in the breathing problems and hives): Consider a respiratory
preceding 90 days; home infusion therapy, home wound fluoroquinolone, such as levofloxacin 750 mg PO Q24h, in
care or chronic dialysis within 30 days; or family member the absence of prior exposure to fluoroquinolones in the
with a multidrug‑resistant (MDR) organism. past 12 months. Consider consultation with an infectious
• Subsequent research demonstrated HCAP risk factors had diseases specialist or PHASST for optimal empirical therapy
a limited ability to predict for MDR organisms and, due to or penicillin skin testing.
their low specificity, favored unnecessary overutilization of
broad‑spectrum antibiotics.3,5,6 Empiric levofloxacin use:
- Thus, the HCAP designation was omitted from the current • Given the importance of fluoroquinolones in the
2016 IDSA/ATS HAP/VAP Guidelines, and the panel management of serious infections and their relative
stated further recommendations for community‑onset toxicity (e.g., dysglycemias, CNS side effects, muscle
pneumonia will likely be based on validated risk factors injury, tendonitis) compared to alternative agents, it is
for MDR organisms.3 These recommendations are recommended to reserve fluoroquinolones for select patient
expected in a pending update to the 2007 IDSA/ATS cases where the benefit outweighs the risk (e.g., severe
Community‑acquired Pneumonia Guidelines.2 beta‑lactam allergy, oral antipseudomonal coverage).
• Current national guidelines strongly encourage • Avoid levofloxacin for gram‑negative bacterial coverage
customization of local guidelines based on local if patient had prior fluoroquinolone use, particularly
epidemiology and antimicrobial resistance data.3 In 2018, within the past 3 months (risk of infections due to
a local study was published evaluating pneumonia in adult fluoroquinolone‑resistant bacteria may persist for up to 12
hospitalized patients at Prisma Health in the Midlands.1 It months from fluoroquinolone use).
identified local risk factors to predict for both susceptible • If antipseudomonal or other gram‑negative bacterial
and resistant Pseudomonas aeruginosa, respectively, coverage is warranted and an oral fluoroquinolone is not
compared to other respiratory bacterial pathogens. These reliable empiric coverage, the patient may require hospital
local guidelines reflect the risk factors identified in this study admission for further work‑up and consultation with an
combined with other local data on predicting antimicrobial infectious diseases specialist or PHASST to determine
resistance.7,11,12 optimal empirical therapy.
62 63
• If Legionella is highly suspected (recent outbreak or classic
clinical and laboratory manifestations for Legionella
pneumonia, e.g., high fever, severe hypoxia, hyponatremia,
elevated liver enzymes), consider azithromycin or
levofloxacin over doxycycline as atypical coverage.
• The recommended duration of azithromycin therapy varies
based on dosage and is often shorter than a concomitant
beta‑lactam antibiotic agent. Two acceptable regimens
include either:
- Azithromycin 500mg IV/PO Q24h x total 3 days
OR
- Azithromycin 500mg IV/PO x 1 day, then 250 mg IV/PO
Q24h x 4 days (x total 5 days)
- For Legionella pneumonia: Duration of azithromycin
therapy may be extended to total 10–14 days,
particularly for cases of severe illness and/or slow clinical
improvement
MRSA nasal swab PCR:
• This test typically demonstrates a negative predictive value
of >95% for ruling out MRSA as a causative pathogen for
pneumonia.8‑10 This is a useful diagnostic in patients at
increased risk of MRSA pneumonia at baseline (e.g., residence
in a long‑term care facility, wound care in the last 30 days,
prior MRSA infection/colonization within 90 days).
Respiratory viral PCR panel:
• This test, which is designed for upper respiratory tract
infections, includes both viral and atypical bacterial targets
for community‑acquired pneumonia. If the patient is
unlikely to have a secondary bacterial pneumonia, consider
streamlining to appropriate viral pneumonia management
(e.g., oseltamivir for influenza A or B virus, supportive care
for rhinovirus) or atypical bacterial pneumonia management
(e.g., azithromycin).
64 65
Pneumonia de-escalation guide
Pneumonia de‑escalation guide De‑escalation options De‑escalation options
based on rapid based on susceptibility
Organism diagnostic testing testing
De‑escalation options De‑escalation options
based on rapid based on susceptibility Other Enterobacteriaceae (with potential chromosomal AmpC production)
Organism diagnostic testing testing
Enterobacter cloacae Cefepime -- Cefepime Levofloxacin
IV PO IV PO Klebsiella (formerly
Enterobacter)
Typical gram‑positive bacteria aerogenes
Serratia marcescens
Streptococcus Ampicillin- Amoxicillin- Penicillin G Amoxicillin
pneumoniae sulbactam clavulanate Ampicillin Amoxicillin- Non-lactose-fermenting gram-negative bacteria
Ceftriaxone Ampicillin- clavulanate
sulbactam Pseudomonas Cefepime -- Cefepime Ciprofloxacin
Ceftriaxone aeruginosa Piperacillin- Piperacillin- Levofloxacin
Acinetobacter tazobactam tazobactam
Typical gram‑negative bacteria baumannii
66 67
7. Hammer KL, Justo JA, Bookstaver PB, Kohn J, Albrecht H, Al‑Hasan
MN. Differential effect of prior β‑lactams and fluoroquinolones
on risk of bloodstream infections secondary to Pseudomonas
aeruginosa. Diagn Microbiol Infect Dis 2017; 87: 87‑91.
8. Langsjoen J, Brady C, Obenauf E, Kellie S. Nasal screening is
useful in excluding methicillin‑resistant Staphylococcus aureus in
ventilator‑associated pneumonia. Am J Infect Control 2014; 42:
1014‑5.
9. Hiett J, Patel RK, Tate V, Smulian G, Kelly A. Using active
methicillin‑resistant Staphylococcus aureus surveillance nasal swabs
to predict clinical respiratory culture results. Am J Health Syst Pharm
2015; 72 (Suppl 1): S20‑4.
10. Smith MN, Brotherton AL, Lusardi K, Tan CA, Hammond DA.
Systematic review of the clinical utility of Methicillin‑Resistant
Staphylococcus aureus (MRSA) nasal screening for MRSA
pneumonia. Ann Pharmacother 2019; 53: 627‑638.
11. Dan S, Shah A, Justo JA, Bookstaver PB, Kohn J, Albrecht H,
Al‑Hasan MN. Prediction of fluoroquinolone resistance in
gram‑negative bacteria causing bloodstream infections. Antimicrob
Agents Chemother 2016; 60: 2265‑72.
12. Augustine MR, Testerman TL, Justo JA, Bookstaver PB, Kohn J,
Albrecht H, Al‑Hasan MN. Clinical risk score for prediction of
extended‑spectrum beta‑lactamase producing Enterobacteriaceae
in bloodstream isolates. Infect Control Hosp Epidemiol 2017; 38:
266‑72.
68 69
70
Prisma Health neutropenic fevera empiric treatment guideline
Diagnostics to consider: procalcitonin, CBC, BMP, blood cultures X 2 sites, MRSA nasal swab for PCR
NO YES
Refer to de-escalation algorithm Anidulafungin 200mg IV X 1 dose Voriconazole 6mg/kg IV Q12H X 2 doses,
then 100mg IV Q24H then 4 mg/kg IV/PO Q12H
footnote g.
YES
YES
b) Clinical indications for coverage of ESBL‑producing bacteria:
• Documentation of prior infections or colonization with
<0.25ng/mL i
ESBL‑producing organisms in past 12 months OR
prophylaxis regimen
Clinical improvement indicated by afebrile ≥48 hours
• Receipt of ≥2 courses of beta‑lactam/fluoroquinolone antibiotics
(pip‑tazo, cefepime, levofloxacin, etc.) in past 90 days
• Receipt of fluoroquinolone prophylaxis or as a single course is not
an indicator for ESBL risk.
piperacillin‑tazobactam.
• In patients with minor penicillin allergies (nonspecific rashes,
intolerance, etc.), cross‑reactivity with 3rd and 4th generation
cephalosporins is low (<3%). The benefit from beta‑lactam
Neutropenic fever de‑escalation algorithm
• Hemodynamic instability OR
De‑escalate to most effective and
Following completion of
OR consider initiation of
OR
prophylactic regimen if
72 73
f) Clinical indications for aspergillosis coverage:
Discontinue antibiotics
• Chest or sinus CT with macronodules with or without halo sign OR
OR
• HSCT recipients with anticipated prolonged neutropenic periods
of at least 14 days
baseline
g) If cultures are negative, patient afebrile ≥ 48 hours, and their
when:
reason for hospital admission was not febrile neutropenia,
consider de‑escalation to fluoroquinolone prior to completion
of 5 days of empiric therapy if patient was not previously on
fluoroquinolone prophylaxis.
Days 2–3
of document. Discontinuation of therapy recommended for PCT
<0.25 ng/mL OR a decrease of ≥80% from baseline.
j) In patients deemed at intermediate or high risk, the NCCN Guidelines
Panel advises that fluoroquinolone prophylaxis (levofloxacin is
to antibiotics
74 75
Ambulatory acute sinusitis
Prisma Health guidelines for management Diagnosis:
of ambulatory acute sinusitis in adults • The majority of patients with minor symptoms (clear nasal
drainage, cough, etc.) have self‑limiting viral rhinosinusitis.
• The diagnosis of allergic rhinosinusitis should be considered
Symptoms/signs consistent with acute bacterial sinusitis in patients with prolonged minor symptoms and pale nasal
• Severe symptoms for >3–4 days: fever ≥102 F or facial
pain/pressure/tenderness plus purulent (e.g., green, mucosa on physical examination, particularly in patients with
NO yellow) nasal drainage history of chronic perennial rhinosinusitis or during pollen
OR
• Persistent symptoms >10 days without improvement:
activity in patients with seasonal allergies.
Nasal drainage and daytime cough • Secondary bacterial sinusitis is suggested in patients with
double sickening, that is acute worsening of symptoms
(fever ≥102 F or facial pain/pressure or tenderness in
Viral rhinosinusitis YES
(≥98% of acute sinusitis addition to purulent nasal drainage for >3–4 days) after initial
cases are caused by viruses) improvement from viral upper respiratory tract infection.
Precise estimation of symptom onset • Physical examination is essential to confirm the diagnosis
verified to meet >3–4 days duration if
severe of >10 days if persistent of acute bacterial sinusitis, rule out more serious infections
Symptomatic treatment: such as pneumonia or meningitis, and determine the need
Saline nasal irrigation, for imaging in patients with high risk for complications such
analgesics, intranasal
steroids, antihistamines, etc. as intracranial abscesses, sagittal sinus thrombosis, etc.
NO YES
Symptomatic treatment:
• Nasal saline irrigation may provide relief with low risk of
adverse effects.
Symptomatic treatment (as above) Symptomatic treatment (as above)
• Analgesics/antipyretics (e.g., acetaminophen, NSAIDs) may
PLUS watchful waiting PLUS antibiotics improve symptoms of pain and fever.
• Follow-up visit for clinical • Amoxicillin/clavulanate • Intranasal steroids (e.g., fluticasone) may improve symptoms
evaluation in few days (preferred) 875mg/125mg PO BID X 7 days of facial pain and nasal congestion.
OR OR • Oral antihistamines (e.g., diphenhydramine, cetirizine) may
improve symptoms of excessive secretions and sneezing.
• Communicate plan for antibiotic • Doxycycline 100mg PO BID X
prescription if patient calls back 7 days (if penicillin allergy or recent • Oral decongestants (e.g., pseudoephedrine) may improve
without improvement (preferred) amoxicillin use) nasal congestion – should be used for <5 days and in
OR the absence of co‑morbidities such as uncontrolled
hypertension or anxiety.
• Antibiotic prescription with
instructions: ”Do not fill until • Topical decongestants (e.g., oxymetazoline,
[specified future date]” tetrahydrazoline) may improve nasal congestion – use should
not exceed 3–5 days to prevent rebound congestion.
76 77
Antibiotic comments: References:
1. Chow AW, et al. IDSA clinical practice guideline for acute bacterial
• The risks of antibiotics (Clostridium difficile infection, etc.)
rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:
exceed any potential benefits in patients with likely acute e72‑e112.
viral sinusitis based on symptoms and signs as previously 2. Rosenfeld RM, et al. Clinical practice guideline (update): adult
described. sinusitis. Otolaryngol Head Neck Surg 2015; 152: S1‑S39.
• Prescribing antibiotics on the phone without an initial patient 3. Lemiengre MB, et al. Antibiotics for clinically diagnosed acute
rhinosinusitis in adults. Cochrane Database Syst Rev 2012;
encounter and physical examination to confirm the diagnosis
10:CD006089.
and rule out complications as previously described is highly
4. Young J, et al. Antibiotics for adults with clinically diagnosed acute
discouraged. rhinosinusitis: a meta‑analysis of individual patient data. Lancet
• Counseling points: 2008; 371: 908‑914.
5. Falagas ME, et al. Comparison of antibiotics with placebo for
‑ Amoxicillin/clavulanic acid is better tolerated when taken
treatment of acute sinusitis: a meta‑analysis of randomized
with food. controlled trials. Lancet 2008; 8: 543‑552.
‑ Advise patients to drink enough fluids when taking 6. FDA updates warnings for fluoroquinolone antibiotics. U.S. Food and
Drug Administration. Released 26 July 2016.
doxycycline and avoid taking the evening dose within
Available at: http://www.fda.gov/NewsEvents/Newsroom/
2 hours of going to bed to reduce the risk of pill‑induced PressAnnouncements/ucm513183.htm.
esophagitis.
• Macrolides (e.g., azithromycin): Use discouraged due
to increasing antimicrobial resistance rates among
Streptococcus pneumoniae, the most common bacterial
etiology of acute sinusitis. Macrolide therapy should be
limited to patients with no prior macrolide use within the
past 3 months and allergy/intolerance or prior use of both
amoxicillin and doxycycline.
• Fluoroquinolones (e.g., levofloxacin, moxifloxacin): According
to recent FDA warning, fluoroquinolones should not be
used in patients with upper respiratory tract infections,
including acute bacterial sinusitis, due to high risk of adverse
events. Their use should be reserved for severely immune
compromised patients (neutropenia, etc.) or those who have
failed first‑line therapy.
• Second‑ and third‑generation cephalosporins (e.g.,
cefuroxime, cefdinir): Similarly, cephalosporin use is not
recommended due to high risk of adverse events and
induction of antimicrobial resistance. Their use should be
limited to patients who have failed first‑line options.
78 79
Pseudomonas aeruginosa prediction score Risk of β-lactam resistant Pseudomonas
aeruginosa
Risk of beta‑lactam‑resistant Pseudomonas
Patient-specific antibiograms aeruginosa
Pseudomonas aeruginosa risk score (PARS) This model predicts the risk of resistance to antipseudomonal
beta‑lactams among respiratory and bloodstream isolates
This score predicts the probability of Pseudomonas aeruginosa of Pseudomonas aeruginosa and other non‑fermenting
bloodstream isolates in patients with suspected or confirmed gram‑negative bacilli (NFGN) such as Acinetobacter baumanii,
gram-negative bloodstream infections (BSI). It may be utilized etc. It is particularly useful in critically ill patients with risk of
in hospitalized patients with complicated urinary tract or infections due to P. aeruginosa or NFGN in the respiratory tract
intra-abdominal infections. Pseudomonas aeruginosa risk (ventilator‑associated pneumonia) or bloodstream (prolonged
score is calculated by adding the number of risk factors in each hospitalization or severely immune compromised hosts with
individual patient. qSOFA score ≥2).
Point Risk factors for beta-lactam-resistant Pseudomonas aeruginosa
Risk factors for P. aeruginosa BSI Allocation
• Bronchiectasis/cystic fibrosis
Severely immune compromised host 1
• Prior infections or colonization with beta-lactam resistant
Hospital-acquired BSI after >5 days of 1 P. aeruginosa within past 12 months
hospitalization
• Prior use of antipseudomonal beta-lactams for >48 hours within
Prior use of beta-lactam antibiotics within 1 3–30 days of index infection
3–90 days of BSI
Severely immune compromised hosts include those with neutropenia, Antipseudomonal beta‑lactams include piperacillin‑tazobactam,
recent chemotherapy, high dose steroids, etc. Beta‑lactam antibiotics
include penicillins, cephalosporins, carbapenems, monobactams and ceftazidime, cefepime, meropenem and imipenem. Resistance
beta‑lactam/beta‑lactamase inhibitors. to any of these agents confers beta‑lactam‑resistant
P. aeruginosa.
100%
Probability of P. aeruginosa
80%
60% 45%
40%
BSI
21%
20% 8%
1%
0%
0 1 2 3
Pseudomonas aeruginosa Risk Score
Hammer KL, et al. Diagn Microbiol Infect Dis 2017; 87: 87-91.
80 81
Antimicrobial susceptibility of respiratory and bloodstream Antimicrobial susceptibility of respiratory and bloodstream
isolates of Pseudomonas aeruginosa and NFGN in the isolates of Pseudomonas aeruginosa and NFGN to
presence or absence of risk factors for beta‑lactam resistance beta‑lactam monotherapy and combination regimens in the
presence of risk factors for beta‑lactam resistance
Pip-tazo 78
92 Pip-tazo+FQ 78 91
Ceftazidime 78
91 Cefepime+FQ 83 90
Cefepime 83
95 Meropenem +FQ 77 92
77 Pip-tazo+AGS 78 96
Meropenem
94
0 10 20 30 40 50 60 70 80 90 100 Cefepime+AGS 83 98
Susceptibility (%)
n ≥1 risk factor n No risk factors Meropenem +AGS 77 97
82 83
ESBL prediction score
ESBL prediction score (ESBL‑PS) Algorithm for application of ESBL prediction score in
management of patients with suspected or confirmed
This score predicts probability of extended‑spectrum gram‑negative BSI
beta‑lactamase (ESBL)‑producing Enterobacteriaceae
bloodstream isolates in patients with suspected or confirmed Risk of BSI due to ESBLE
gram‑negative bloodstream infections (BSI). The ESBL
prediction score is calculated by adding allocated points for
each risk factor if present in a particular patient.
Low: <1% Moderate: 5–10% High: ≥20%
Point
Risk factors for BSI due to ESBLs Allocation ESBL-PS: 0 ESBL-PS: 1-2 ESBL-PS: ≥3
(74% of cohort) (20% of cohort) (6% of cohort)
Outpatient GI/GU procedure within past 30 days 1
Number of beta-lactam/fluoroquinolone courses
within 3–90 days of BSI
No need for Start
0 0
carbapenems carbapenems
1 1
≥2 3
Documented colonization or infections with
ESBLs within past 12 months 4 Non-critically ill: Critically ill:
GI: gastrointestinal, GU: genitourinary; BSI: bloodstream infection. Pitt score <4 Pitt score ≥4
Short‑term perioperative antibiotics do not qualify as a course of (16% of cohort) (4% of cohort)
antibiotics. Multiple courses of antibiotics have to be at least 3 days
apart; concurrent or sequential therapy is considered one course.
Defer Consider
carbapenems carbapenems
Probability of BSI due to ESBLs
100% 93%
84%
84 85
Trimethoprim/Sulfamethoxazole resistance
Fluoroquinolone resistance score
tool NEW
Fluoroquinolone resistance score (FQRS) Trimethoprim/sulfamethoxazole (SMX/TMP)
The score predicts probability of fluoroquinolone‑resistant
resistance tool
gram‑negative bacilli in patients with bloodstream infections This simple clinical tool predicts probability of SMX/TMP
(BSI) and complicated urinary tract infections (cUTI). It is resistance among gram‑negative urinary isolates in patients
particularly useful in patients with gram‑negative BSI who have with acute cystitis and pyelonephritis. This tool is particularly
severe β‑lactam allergy and in patients with acute pyelonephritis useful in patients with acute cystitis who may not be candidates
who do not otherwise require hospitalization. Fluoroquinolones for first‑line therapy with nitrofurantoin. It is also helpful in
are not recommended for acute cystitis. The FQRS is calculated ambulatory management of acute pyelonephritis in patients
by adding allocated points for each risk factor if present. whom empirical treatment with fluoroquinolones is not ideal
Risk factors for fluoroquinolone resistance Point allocation due to allergies, potential drug‑drug interactions or high
Male sex 1 predicted risk of fluoroquinolone resistance. See Outpatient
Diabetes mellitus 1 management guidelines for acute cystitis and pyelonephritis
Residence in a skilled nursing facility 2 (page 40).
Outpatient procedure within past 30 days 3
Prior fluoroquinolone use within 12 months Risk factors for SMX/TMP resistance
None 0 • Prior SMX/TMP use within past 12 months
Within 3 months 5 • Prior urinary infections/colonization with SMX/
TMP‑resistant (SMX/TMP‑R) bacteria within past 12 months
Within 3–12 months 3
GI: gastrointestinal, GU: genitourinary.
Fluoroquinolones include ciprofloxacin, levofloxacin and moxifloxacin. Predicted risk of SMX/TMP resistance based on risk factors:
Probability of fluoroquinolone-
95% 100%
100% 89%
84%
74%
resistant bacteria
Resistance %
60%
60% 60%
45%
86 87
Gram-negative ALL sources
86
91 90 90 94
91 84 35 82
93
76 97 75
18
Doxycylineb
0
Prisma Health antibiogram
for 2021
100
99 100
88
94
98
64 96
62
65
86 87
90 81
SMZ-TMP
100
100
60
99
95
76
71
Levofloxacin
100
98
99
89
58
85
85
82
95
70
97
91
Ciprofloxacin
100
90
98
98
98
98
96
94
99
95
92
97
Tobramycin
100
100
80
96
94
96
96
99
95
93
97
91
Gentamicin
100
100
100
100
100
100
100
100
98
89 64 98
99
99
Amikacin
Standards Institute (CLSI), only the first isolate of a given species per
patient was used to compile the data.
Aztreonama
100
100
100
100
100
Reported results are based on available susceptibility data.
96 96
99
99
99
97
75
Meropenem
100
100
100
100
98
99
99
93
97
Ertapenem
information on a low number of isolates. (<30 isolates per CLSI
72 75 100
92 92 100
230 89 97 100 93 94 99 99 100
1346 48 78 96 83 87 89 89 96
70 71 99
96 99 99
58 58
98 98 95
71 73 95
89 92
87 91 83 91 86 85 93
Guidelines M39).
90 91 59 97 88 91 97
Cefepime
Gray shading indicates intrinsic resistance and/or not recommended for use.
Numbers reported in each cell represents the percentage of
98 98
27
Ceftazidime
60
98
96
69
73
75
91
Piperacillin/tazobactam
45 60 89
Amoxicillin/clavulanate
have been utilized for this report.
407
Enterobacter cloacae complex 132
573
40
48
Stenotrophomonas maltophilia 45
58
43
83
47
72
Number of Isolates
patients with meningitis is ≤0.5 mcg/ml for ceftriaxone and ≤0.6
mcg/ml for penicillin (IV).
Susceptibility breakpoints for Streptococcus pneumoniae
organisms — ALL sources
Prisma Health (Midlands)
Acinetobacter baumanniic
Pseudomonas aeruginosa
Klebsiella pneumoniae
Morganella morganii
Serratia marcescens
Citrobacter freundii
ceftriaxone and ≤2 mcg/ml for penicillin (IV) or ≤0.06 mcg/ml for
Proteus mirabilis
penicillin (oral).
Escherichia coli
Gram‑negative
b
c
a
88 89
90
Gram‑positive organisms — ALL sources
Number of Isolates
Ampicillin
Oxacillin
Penicillin
Cefazolina
Ceftriaxone
Gentamicin (synergy)
Erythromycin
Clindamycin
Linezolid
Levofloxacin
SMZ-TMP
Nitrofurantoin
Rifampin (synergy)
Doxycyclineb
Vancomycin
Gray shading indicates intrinsic resistance and/or not recommended for use.
a
Deduced frm oxacillin
b
Deduced from tetracycline
c
Rate of Methicillin-resistant Staphylococcus aureus (MRSA) = 42%
SMZ-TMP: trimethoprim-sulfamethoxazole
Gram‑negative organisms —
ALL sources Prisma Health
Number of Isolates
Ampicillin
Amoxicillin/clavulanate
Piperacillin/tazobactam
Cefazolin
Cefoxitin
Ceftriaxone
Ceftazidime
Cefepime
Ertapenem
Meropenem
Aztreonama
Amikacin
Gentamicin
Tobramycin
Ciprofloxacin
Levofloxacin
SMZ-TMP
Nitrofurantoin
Doxycylineb
(Midlands) ICU 2020
Acinetobacter baumanniic 5 60 40 40 80 100 60 100 60 60 60
Citrobacter freundii 8 38 38 38 100 100 100 100 100 100 100 100 100
Citrobacter koseri 6 100 100 100 100 100 100 100 100 100 100 100 100 100
Enterobacter aerogenes 10 90 90 90 100 100 100 100 100 100 100 100 100 100
Enterobacter cloacae complex 29 55 52 52 66 83 97 100 86 72 62 92 71 79
Escherichia coli 155 37 61 90 76 84 81 81 88 98 98 99 91 90 61 57 70 99 75
Haemophilus influenzae 16 69 88 100 100 56
Klebsiella oxytoca 3 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100
Klebsiella pneumoniae 93 71 89 71 98 73 73 86 100 100 100 82 78 70 70 74 19 73
Morganella morganii 9 100 89 100 100 100 100 100 100 100 67 67 89 0
Gram-negative ICU ALL sources
Gray shading indicates intrinsic resistance and/or not recommended for use.
a
Few isolates tested
b
Deduced from tracycline Rate of E.coli ESBL = 18%
c
Includes Acinetobacter baumannii complex Rate of Klebsiella ESBL = 26%
SMZ-TMP: trimethoprim-sulfamethoxazole Rate of Proteus ESBL = 0%
91
92
Gram‑positive organisms — ALL sources
Number of Isolates
Ampicillin
Oxacillin
Penicillin
Cefazolina
Ceftriaxone
Gentamicin (synergy)
Erythromycin
Clindamycin
Linezolid
Levofloxacin
SMZ-TMP
Nitrofurantoin
Rifampin (synergy)
Doxycyclineb
Vancomycin
Gray shading indicates intrinsic resistance and/or not recommended for use.
a
Deduced frm oxacillin
b
Deduced from tetracycline
c
Gram-positive ICU ALL sources
ANTIBIOGRAM – Systemic
Percent Susceptible (January – December 2020)
Antibiotic Tested
Organism
(# Isolates)
Meropenem
Nafcillin / Oxacillin
Penicillin
Piperacillin /
tazobactam
Tetracycline
Tobramycin
TMP/SMX
Vancomycin
Amoxicillin /
clavulanate
Ampicillin
Ampicillin /
sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefepime
Ceftriaxone
Cefuroxime
Ciprofloxacin
Clindamycin
Ertapenem
Erythromycin
Gentamicin
Levofloxacin
Linezolid
Amikacin
Ceftazidime
Tuomey
Gram Negative
Acinetobacter baumannii/hemolyticus (33) 97 91 82 85 48 91 94 97 97 91 85 85
Citrobacter freundii (13) 100 0 0 0 69 0 100 77 69 100 100 92 100 100 92 92 85 85
Enterobacter aerogenes (18) 100 0 0 0 83 0 94 78 72 89 100 94 94 100 83 94 100 89
Enterobacter cloacae (62) 100 0 0 0 89 0 95 92 87 100 95 98 100 100 94 ## 94 92
Escherichia coli (190) 98 87 42 53 82 59 84 83 83 74 100 89 74 100 97 89 64 64
Haemophilus influenzae (2) 100 100 100 50
Klebsiella oxytoca (30) 100 93 9 63 83 3 83 83 83 92 100 100 97 100 97 87 ## 97
Klebsiella pneumoniae (108) 98 94 0 79 82 82 84 84 84 86 99 98 87 100 96 82 94 81
Morganella morganii (47) 100 0 0 11 83 0 98 77 81 79 100 89 89 100 98 51 94 77
Proteus mirabilis (110) 100 98 85 96 92 76 95 95 95 84 100 97 88 100 100 0 96 93
Ps. fluor / putida (9) 100 44 100 100 100 100 100 89 100 89
Pseudomonas aeruginosa (144) 97 81 89 90 86 88 83 94 92 99
Salmonella sp. (5) 100 100 100 100 100 100 100 100 100 100 100 100 100 100
Serratia marcescens (52) 100 0 0 0 67 0 96 67 71 96 98 100 96 98 73 2 87 100
Stenotrophomonas (Xanthomonas)
maltophilia (29) 45 90 100
Gram Positive
Amikacin
Amoxicillin /
clavulanate
Ampicillin
Ampicillin /
sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefepime
Ceftazidime
Ceftriaxone
Cefuroxime
Ciprofloxacin
Clindamycin
Ertapenem
Erythromycin
Gentamicin
Levofloxacin
Linezolid
Meropenem
Nafcillin / Oxacillin
Penicillin
Piperacillin /
tazobactam
Tetracycline
Tobramycin
TMP/SMX
Vancomycin
Streptococcus pyogenes (2) 100 100 100 100 100 ## 100 100 100 100
Streptococcus pneumoniae (13) 100 50 92 83 67 50 100 83 50 67 67 100
> 10 % Decrease in susceptibility > 10% Increase in susceptibility
* Gentamicin is only for synergy dosing in gram-positive organisms – it should NOT be used as monotherapy.
93
94
ANTIBIOGRAM – Urine
Percent S usceptible (January – December 2020)
Antibiotic Tested
Organism
(# Isolates)
Amikacin
Amoxicillin /
clavulanate
Ampicillin
Ampicillin /
sulbactam
Azithromycin
Aztreonam
Cefazolin
Cefepime
Ceftazidime
Ceftriaxone
Cefuroxime
Ciprofloxacin
Ertapenem
Erythromycin
Gentamicin
Levofloxacin
Linezolid
Meropenem
Nafcillin / Oxacillin
Nitrofurantoin
Penicillin
Piperacillin /
tazobactam
Tetracycline
Tobramycin
TMP/SMX
Vancomycin
Tuomey
Gram Negative
Acinetobacter baumannii/hemolyticus (13) 100 85 69 85 69 92 69 85 69 92
Citrobacter freundii (11) 100 0 0 0 91 0 100 100 91 91 100 100 91 100 100 100 82 91 82
Citrobacter koseri (11) 100 96 0 100 96 96 100 100 100 100 100 100 100 100 61 100 91 100 100
Enterobacter aerogenes (24) 100 0 0 0 92 0 96 88 88 96 96 100 96 100 8 92 92 100 96
Enterobacter cloacae (35) 100 0 0 0 66 0 83 66 60 80 69 91 89 100 20 71 71 89 77
Escherichia coli (894) 99 88 47 54 91 66 93 91 91 78 99 90 78 100 98 98 78 91 76
Klebsiella oxytoca (15) 100 87 7 47 87 13 100 100 93 87 100 93 100 100 93 93 100 93 87
Klebsiella pneumoniae (314) 99 92 0 79 89 82 89 89 89 90 99 94 94 99 39 97 81 93 86
Morganella morganii (22) 100 0 0 9 86 0 100 82 86 59 100 82 73 100 0 100 45 95 64
P. stuartii (11) 100 0 0 0 82 0 100 82 82 36 100 0 45 100 0 91 0 0 91
Proteus mirabilis (121) 99 99 88 97 90 77 95 95 95 77 100 97 82 100 0 98 0 93 87
Pseudomonas aeruginosa (99) 95 75 84 87 76 79 72 96 95 97
Serratia marcescens (13) 100 0 0 0 69 0 100 69 69 100 100 100 100 100 0 85 0 85 100
Gram Positive
Nitrofurantoin
Cefuroxime
Ciprofloxacin
Amikacin
Ampicillin /
sulbactam
Azithromycin
Cefepime
Ceftazidime
Ceftriaxone
Erythromycin
Gentamicin
Levofloxacin
Linezolid
Meropenem
Nafcillin / Oxacillin
Penicillin
Piperacillin /
tazobactam
Tetracycline
Tobramycin
TMP/SMX
Amoxicillin /
clavulanate
Ampicillin
Aztreonam
Cefazolin
Vancomycin
Ertapenem
Susceptibility key (change from previous year) – May not be statistically significant if <30 isolates
> 10 % Decrease in susceptibility > 10% Increase in susceptibility
* Gentamicin is only for synergy dosing in gram-positive organisms – it should NOT be used as monotherapy.
500mg
Ampicillin/
Nafcillin 2g
Cefoxtin 2g
Cefazolin 2g
Cefepime 2g
Levofloxacin
Ampicillin 2g
Ceftolozane/
sulbactam 3g
IV antibiotic
Ertapenem 1g
Penicillin 5MU
Ceftriaxone 2g
750mg/500mg
Meropenem 1g
tazobactam 1.5g
Ceftaroline 600mg
Imipenem/cilastatin
Ciprofloxacin 400mg
Antibiotic costs
$
$
$
$
$$
$$
$$
$$
$$
cost
$$$
$$$
$$$
$$$
Daily
$$$$
$$$$$$
500mg
Amoxicillin/
Levofloxacin
750mg/500mg
PO antibiotic
Penicillin 500mg
Cefuroxime axetil
Amoxicillin 500mg
clavulanate 875mg
Cephalexin 500mg
Ciprofloxacin 500mg
$
$
¢
¢
¢
¢
¢
cost
Daily
95
Daily Daily
IV antibiotic cost PO antibiotic cost Prisma Health Antimicrobial
Piperacillin/
tazobactam 4.5g
$$$
Stewardship
Amikacin 500mg $ Julie Ann Justo, PharmD, MS, FIDSA, BCPS, AQ‑ID
Clinical Associate Professor
Department of Clinical Pharmacy and Outcome Sciences
Cost indicator USC College of Pharmacy
96 97
Prisma Health Baptist Hospital: Ambulatory Antimicrobial Stewardship
803‑250‑9380 (cell) 352‑0697 (pager) M–F 8a–5p Hana Winders, PharmD, BCIDP
Emily Youngue, PharmD, BCPS Ambulatory Antimicrobial Stewardship Pharmacist
Casey Troficanto, PharmD, BCPS 803‑434‑3592
Antimicrobial Stewardship and Support
Critical Care
Prisma Health Baptist Hospital Upstate
Columbia, South Carolina John Schrank, MD
Medical Director, Antimicrobial Stewardship
Prisma Health Baptist Parkridge Hospital: Assistant Professor, Medicine
803‑315‑4305 (cell) 352‑1596 (pager) M–F 8a–5p University of South Carolina School of Medicine Greenville
Krishnan Brown, PharmD
Carmen M Faulkner‑Fennell, PharmD, BCPS, BCIDP
Infectious Diseases/Antimicrobial Stewardship and Support
Clinical Pharmacy Specialist, Antimicrobial Stewardship
Prisma Health Baptist Parkridge Hospital
Program
Clinical Assistant Professor
Prisma Health Tuomey Hospital:
University of South Carolina School of Medicine Greenville
803‑774‑9054 M–Sn 8a–5p
864‑455‑3738
Chad Jolly, PharmD, BCCCP, BCIDP
Yorika Hammett, PharmD Sarah Withers, PharmD, MS, BCPS
Prisma Health Tuomey Hospital Clinical Pharmacy Specialist, Infectious Diseases
Sumter, South Carolina Greenville Campus Coordinator, Affiliate Assistant Professor
University of South Carolina College of Pharmacy
University of South Carolina School of Medicine Greenville
864‑455‑6651
98 99
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21-1260 | 07/21 | Reorders available on DigiPath.
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