Adult Inpatient Antibiogram Antimicrobial Susceptibilities of Frequently Recovered Clinical Isolates January to December 2016 Department of Pathology Camille Hamula, PhD Director, Clinical Microbiology Laboratory Department of Medicine, Division of Infectious Diseases Judith Aberg, MD Chief, Infectious Diseases Gopi Patel, MD MS Director, Antimicrobial Stewardship Program Hospital Epidemiologist Meena Rana, MD Associate Director, Antimicrobial Stewardship Program Department of Pharmacy Joanne Meyer, MS PharmD Chief Pharmacy Officer, Mount Sinai Health System Patricia L. Saunders-Hao, PharmD Gargi Patel, PharmD Polina Lerner, PharmD ID Clinical Pharmacists, Antibiotic Stewardship Program Contact Information: Microbiology Ext. 88168 Infection Prevention Ext. 89450 Antibiotic Approval Pager 9407
Agent (avg. cost/day) Dosing Recommendations Based on Renal Function Estimated CrCl (ml/min) >50 30-50 10-30 <10 Supplement for HD/CAPD/CVVH/CAVH Ampicillin/ sulbactam ($14) Aztreonam ($198) Cefazolin ($9) Cefepime ($21) Colistin 2 ($18) Daptomycin 3 ($260) Ertapenem ($90) Fluconazole 4 ($3 IV/ $ 3 PO) Imipenem/ cilastatin ($40) Levofloxacin ($3 IV/ $0.37 PO) Meropenem ($30) Piperacillin/ tazobactam ($40) q8-12h 5 in 2-3 1g IV 200 400 mg 500 750 mg 1-2g IV 3.375-4.5 g IV 2.5 3.8 in 2 mg/kg IV 1 g IV 500-750 mg 1-2g IV 1-2g IV 1.5 in 2 0.5g IV 750 mg x1, then 500 mg (CrCl < 20) 0.5 1g IV 1-2g IV 1g IV or 2g IV 0.5g - 1g IV 1.5 mg/kg IV q36h 2 0.5g IV 250 mg IV 750 mg x1, then 250-500 mg 0.5-1g IV CAPD: 3g IV CVVH/CAVH: 3g IV q8-12h, Extra 0.5g AD 1 CVVH/CAVH: CAPD: 500mg IV CVVH/CAVH: 1-2g IV CAPD: 1-2 g IV CVVH/CAVH: 1-2g 1 HEMO: 2.5 mg/kg AD CVVH: 2.5 divided in 2 doses HEMO (MWF or TThSa): 6 mg/kg post HD for 2 sessions; 9mg/kg post HD for 3 rd session HEMO (PRN): 6mg/kg post HD CAPD: mg/kg CVVH: mg/kg ; if dosed <6 hrs prior to HD, give 150 mg supplement AD* HEMO: 100% of dose AD 1 CAPD: 100 200 mg CVVH: 200 400 mg HEMO: CAPD: 250 mg IV CVVH/CAVH: 500mg IV CVVH/CAVH: 500-750 mg CVVH/CAVH: 1g CVVH/CAVH: 2.25 3.375g IV 1 AD= after dialysis; Antibiotics should be dosed after dialysis on HD days. If dose is given right before HD, then a supplemental dose may be required. 2 Always consider using loading dose on day one: 5 x IBW (max of 300mg); wait 24hrs before giving next dose 3 Dosing (6-12mg/kg) depends on severity and pathogen consult ID 4 Consider loading dose (12mg/kg max) for treatment of invasive candidiasis infections FORMULARY ANTIMICROBIAL AGENTS REQUIRING APPROVAL AT ALL TIMES (24/7) Acyclovir IV (pediatrics only) Foscarnet Voriconazole Amphotericin B Isavuconazole Caspofungin Linezolid Antimalaria medications: Ceftaroline Pentamidine inhaled - Atovaquone/proguanil Cidofovir Polymyxin B - Primaquine Colistin Posaconazole - Quinidine IV (if for malaria) Cytomegalovirus IVIG Tigecycline - Quinine Daptomycin Varicella Zoster IVIG
VANCOMYCIN DOSING CrCl (ml/min) Vancomycin Dosing > 70 ml/min 15 mg/kg every 8-12 40 69 ml/min 15 mg/kg every 12-24 20 39 ml/min 15 mg/kg every 24-48 <20 ml/min 15 mg/kg x 1, then re-dose by level HD/CAPD CVVH 15 mg/kg x 1, then re-dose by level 1 g IV every 24 Doses are based on actual body weight Doses should be rounded to the nearest 250 mg (maximum 2 g per dose) Consultation with an Infectious Disease specialist is strongly recommended for Staphylococcus aureus bacteremia (irrespective of source and susceptibilities) Am J Health-Syst Pharm. 2009; 66:82-98 VANCOMYCIN MONITORING Trough serum concentrations are the most accurate and practical method for monitoring efficacy and avoiding adverse effects Troughs should be obtained just prior to the next dose when patient at steady-state (usually before 4 th or 5 th dose) o Minimum serum trough levels should always be maintained > 10 mg/l o Minimum serum trough levels of 15-20 mg/l are recommended for complicated infections (endocarditis, osteomyelitis, meningitis, and staphylococcal pneumonia)
ADULT AMINOGLYCOSIDE DOSING Once daily dosing of aminoglycosides is recommended for the treatment of Gram-negative infections. An Infectious Diseases (ID) or ID Pharmacist consultation is recommended. Exclusions to Once Daily Dosing Avoid aminoglycosides in neuromuscular disease Traditional dosing is preferred for: o CrCl < 20ml/min or HD o Burns (involving >20% BSA) o Pregnancy o Significant ascites or patients with significant third spacing Calculating Dose Dosing is based on Ideal Body Weight (IBW) In obese patients (>120% IBW) use Adjusted Body Weight (ABW) o ABW= IBW + 0.4(actual body weight IBW) If actual body weight is under IBW, use actual body weight CrCl (ml/min) Aminoglycoside Once Daily Initial Dose Gentamicin OR > 60 7 mg/kg every 24 15 mg/kg every 24 40 to 59 7 mg/kg every 36 15 mg/kg every 36 20-39 7 mg/kg every 48 15 mg/kg every 48 <20 or HD Use traditional AG dosing protocol
ONCE DAILY AMINOGLYCOSIDE MONITORING Order a random level 8-10 after the beginning of the infusion. Please communicate with the nursing staff. Plot the level on the nomogram below based on when it was drawn. Nomogram for Gentamicin & at 7mg/kg**: If the point is near the line, the longer interval is chosen to avoid drug accumulation and provide sufficient drug-free period. If the random level is off (i.e., above) the nomogram between the 6- and 14- hr time points, the scheduled therapy is discontinued and the drug concentration is monitored to determine appropriate time of the next dose (i.e,concentration of <1 µg/ml) If level falls in area designated, the dosing interval is (the same applies for the areas q36h and ) Adopted from Hartford Hospital **: Divide amikacin level by 2 and plot above TIPS ON EVALUATING LEVELS AND REPEAT MONITORING: If the level falls on a line, the longer dosage interval should be selected. If the level falls above the Q 48H line: The drug should be held. o Serial random levels should be followed until <1mcg/mL If initial level falls below the nomogram, consider going to traditional dosing Repeat serum AG levels as necessary, with significant changes in CrCl or when therapy continues beyond 96 after previous level and every 96 to minimize toxicity. Patients on concurrent nephrotoxic agents (diuretics, vancomycin, contrast, etc) o Recommend monitor level twice a week and monitor BUN and Cr daily CrCl (ml/min) Traditional Aminoglycoside Dosing Gentamicin**/ **For Gram-positive endocarditis, use 1mg/kg Monitoring Traditional Dosing Gentamicin/ > 60 1-2mg/kg every 8 5mg/kg every 8 Target Peaks/Troughs: 40-60 20-40 <20 1-2mg/kg every 12 1-2mg/kg every 24 1-2mg/kg every 48 5mg/kg every 12 5mg/kg every 24 5mg/kg loading dose, then monitor levels <10 1-2mg/kg after HD 5mg/kg after HD Sepsis/Pneumonia: 7-10/ <2 OB-GYN: 5-7/ <2 **Synergy for Enterococcal or Streptococcal Endocarditis (Gent 1mg/kg): 2-4/ <1 Target Peaks/Troughs: Sepsis/Pneumonia: 20-30/ <10 UTI/Cystitis: 10-15/ <7 5/ <7