Antibiotic Guidelines 2015-2016 - Johns Hopkins

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Treatment Recommendations 
For Adult Inpatients
Also available online at 
insidehopkinsmedicine.0rg/amp
Antibiotic Guidelines 
2015-2016
1. Introduction ............................................................................................ 3
2. Johns Hopkins Hospital formulary and restriction status .................... 6
2.1 Obtaining ID approval ........................................................................6
2.2 Formulary .........................................................................................7
3. Agent-specific guidelines ...................................................................... 8
3.1 Antibiotics ........................................................................................8
 Ceftaroline ......................................................................................8
 Ceftolozane/tazobactam .................................................................8
 Colistin ...........................................................................................9
 Daptomycin ................................................................................. 10
 Ertapenem ................................................................................... 11
 Fosfomycin .................................................................................. 11
 Linezolid ...................................................................................... 12
 Tigecycline .................................................................................. 13
 Trimethoprim/sulfamethoxazole ................................................... 14
3.2 Antifungals..................................................................................... 16
 AmBisome® ................................................................................ 16
 Micafungin ................................................................................... 17
 Posaconazole .............................................................................. 18
 Voriconazole ................................................................................ 19
 Azole drug interactions ................................................................. 20
3.3 Vaccines ....................................................................................... 23
 Pneumococcal vaccines ............................................................... 23
4. Organism-specific guidelines ..............................................................24
4.1 Anaerobes ..................................................................................... 24
4.2 Propionibacterium acnes ................................................................ 25
4.3 Streptococci.................................................................................. 27
4.4 Multi-drug resistant Gram-negative rods .......................................... 28
5. Microbiology information ....................................................................31
5.1 Interpreting the microbiology report ................................................ 31
5.2 Spectrum of antibiotic activity ......................................................... 32
5.3 Interpretation of rapid diagnostic tests ............................................ 34
5.4 Johns Hopkins Hospital antibiogram ............................................... 36
6. Guidelines for the treatment of various infections ...........................39
6.1 Abdominal infections .............................................................39
 Biliary tract infections ................................................................... 39
 Diverticulitis ................................................................................. 40
 Pancreatitis ................................................................................. 41
 Peritonitis (including SBP, GI perforation and peritonitis 
 related to peritoneal dialysis) ........................................................ 42
6.2 Clostridium difficile infection (CDI) ............................................47
6.3 Infectious diarrhea .....................................................................51
6.4 H. pylori infection .......................................................................54
6.5 Gynecologic and sexually transmitted infections .....................56
 Pelvic inflamatory disease ............................................................ 56
 Endomyometritis .......................................................................... 56
 Bacterial vaginosis ....................................................................... 57
 Trichomoniasis ............................................................................ 57
 Uncomplicated gonococcal urethritis, cervicitis, proctitis ............... 57
 Syphilis ........................................................................................ 58
6.6 Catheter-related bloodstream infections ..................................60
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6.7 Endocarditis ................................................................................65
6.8 Pacemaker/ICD infections.........................................................71
6.9 Central nervous system (CNS) infections .................................73
 Meningitis .................................................................................... 73
 Encephalitis ................................................................................. 75
 Brain abscess .............................................................................. 76
 CNS shunt infection ...................................................................... 76
 Antimicrobial doses for CNS infections .......................................... 77
6.10 Acute bacterial rhinosinusitis (ABRS) .....................................78
6.11 Orbital cellulitis .....................................................................80
6.12 Pulmonary infections ..................................................................82
 COPD exacerbations .................................................................... 82
 Community-acquired pneumonia ................................................... 83
 Healthcare-acquired pneumonia. ................................................... 87
 Ventilator-associated pneumonia ................................................... 88
 Cystic fibrosis .............................................................................. 91
6.13 Respiratory virus diagnosis and management .........................93
6.14 Tuberculosis (TB) ........................................................................95
6.15 Sepsis with no clear source .......................................................99
6.16 Skin, soft-tissue, and bone infections ......................................100
 Cellulitis ..................................................................................... 100
 Cutaneous abscess .................................................................... 101
 Management of recurrent MRSA infections .................................. 102
 Diabetic foot infections ............................................................... 103
 Surgical-site infections ................................................................ 105
 Serious, deep soft-tissue infections (necrotizing fasciitis).............. 107
 Vertebral osteomyelitis, diskitis, epidural abscess ....................... 108
6.17 Urinary tract infections (UTI) ....................................................110
 Bacterial UTI (including pyelonephritis and urosepsis) ................... 110
6.18 Candidiasis in the non-neutropenic patient ............................115
6.19 Guidelines for the use of prophylactic antimicrobials .................121
 Pre-operative and pre-procedure antibiotic prophylaxis .................121
 Prophylaxis against bacterial endocarditis .................................. 125
 Prophylactic antimicrobials for patients with 
solid organ transplants ............................................................... 126
6.20 Guidelines for the use of antimicrobials in 
neutropenic hosts. ....................................................................129
 Treatment of neutropenic fever ................................................... 129
 Prophylactic antimicrobials for patients with 
expected prolonged neutropenia ................................................ 131
 Use of antifungal agents in hematologic 
malignancy patients ............................................................. 133
 7. Informational guidelines .................................................................137
7.1 Approach to the patient with a history of penicillin allergy ................ 137
 8. Infection control ..............................................................................139
8.1 Hospital Epidemiology & Infection Control .................................... 139
8.2 Infection control precautions ....................................................... 141
8.3 Disease-specific infection control recommendations ..................... 142
10. Appendix:
 A. Aminoglycoside dosing and therapeutic monitoring ........................ 145
B. Vancomycin dosing and therapeutic monitoring .............................. 150
C. Antimicrobial therapy monitoring ................................................... 153
D. Oral antimicrobial use ................................................................... 154
E. Antimicrobial dosing in renal insufficiency ....................................... 155
F. Cost of select antimicrobial agents ................................................ 159
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Introduction
Antibiotic resistance is now a major issue confronting healthcare 
providers and their patients. Changing antibiotic resistance patterns, 
rising antibiotic costs and the introduction of new antibiotics have 
made selecting optimal antibiotic regimens more difficult now than 
ever before. Furthermore, history has taught us that if we do not 
use antibiotics carefully, they will lose their efficacy. As a response 
to these challenges, the Johns Hopkins Antimicrobial Stewardship 
Program was created in July 2001. Headed by an Infectious Disease 
physician (Sara Cosgrove, M.D., M.S.) and an Infectious Disease 
pharmacist (Edina Avdic, Pharm.D., M.B.A), the mission of the 
program is to ensure that every patient at Hopkins on antibiotics 
gets optimal therapy. These guidelines are a step in that direction. 
The guidelines were initially developed by Arjun Srinivasan, M.D., and 
Alpa Patel, Pharm.D., in 2002 and have been revised and expanded 
annually.
These guidelines are based on current literature reviews, including 
national guidelines and consensus statements, current microbiologic 
data from the Hopkins lab, and Hopkins’ faculty expert opinion. 
Faculty from various departments have reviewed and approved these 
guidelines. As you will see, in addition to antibiotic recommendations, 
the guidelines also contain information about diagnosis and other 
useful management tips.
As the name implies, these are only guidelines, and we anticipate 
that occasionally, departures from them will be necessary. When these 
cases arise, we will be interested in knowing why the departure is 
necessary. We want to learn about new approaches and new data as 
they become available so that we may update the guidelines as needed. 
You should also document the reasons for the departure in the patient’s 
chart.
Sara E. Cosgrove, M.D., M.S. 
Director, Antimicrobial Stewardship Program
Edina Avdic, Pharm.D., M.B.A
ID Pharmacist
Associate Director, Antimicrobial Stewardship Program
Kate Dzintars, Pharm.D.
ID Pharmacist
Janessa Smith, Pharm.D.
ID Pharmacist
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1.
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n The following people served as section/topic reviewers
N. Franklin Adkinson, M.D. (Allergy/Immunology)
Paul Auwaerter, M.D. (Infectious Diseases)
Robin Avery, M.D. (Infectious Diseases)
John Bartlett, M.D. (Infectious Diseases)
Dina Benani, Pharm. D. (Pharmacy)
Michael Boyle, M.D. (Pulmonary)
Roy Brower, M.D. (Critical Care and Pulmonary)
Karen Carroll, M.D. (Pathology/Infectious Diseases)
Michael Choi, M.D. (Nephrology)
John Clarke, M.D. (Gastroenterology)
Todd Dorman, M.D. (Critical Care)
Christine Durand, M.D. (Infectious Diseases)
Khalil Ghanem, M.D. (Infectious Diseases)
James Hamilton, M.D. (Gastroenterology)
Carolyn Kramer, M.D. (Medicine)
Pam Lipsett, M.D. (Surgery and Critical Care)
Colin Massey, M.D. (Medicine)
Lisa Maragakis, M.D. (Infectious Diseases)
Kieren Marr, M.D. (Infectious Diseases)
Robin McKenzie, M.D. (Infectious Diseases)
Michael Melia, M.D. (Infectious Diseases)
George Nelson, M.D. (Infectious Diseases)
Eric Nuermberger, M.D. (Infectious Diseases)
Trish Perl, M.D., M.Sc. (Infectious Diseases)
Stuart Ray, M.D. (Infectious Diseases)
Anne Rompalo, M.D. (Infectious Diseases)
Annette Rowden, Pharm.D. (Pharmacy)
Paul Scheel, M.D. (Nephrology)
Cynthia Sears, M.D. (Infectious Diseases)
Maunank Shah, M.D. (Infectious Diseases)
Tiffeny Smith, Pharm.D. (Pharmacy)
Jennifer Townsend, M.D. (Infectious Diseases)
Robert Wise, M.D. (Pulmonary)
Frank Witter, M.D. (OB-GYN)
How to use this guide
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dose of antibiotics for the particular infection. 
UÊALL DOSES IN THE TEXT ARE FOR ADULTS WITH NORMAL 
RENAL AND HEPATIC FUNCTION.
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please refer to the sections on antibiotic dosing to determine the 
correct dose.
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some important treatment notes that explain a bit about WHY the 
particular antibiotics were chosen and that provide some important 
tips on diagnosis and management. PLEASE glance at these notes 
1.
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when you are treating infections, as we think the information will prove 
helpful. All references are on file in the office of the Antimicrobial 
Stewardship Program (7-4570).
Contacting us 
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they are part of an approved order. 
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A word from our lawyers
The recommendations given in this guide are meant to serve as 
treatment guidelines. They should NOT supplant clinical judgment or 
Infectious Diseases consultation when indicated. The recommendations 
were developed for use at The Johns Hopkins Hospital and thus may 
not be appropriate for other settings. We have attempted to verify 
that all information is correct but because of ongoing research, things 
may change. If there is any doubt, please verify the information in the 
}Ո`iÊLÞÊV>ˆ˜}Ê̅iÊ>˜ÌˆLˆœÌˆVÃÊ«>}iÀÊÕȘ}Ê*� �Ê­Ãi>ÀV…ʺ>˜ÌˆLˆœÌˆV»®ÊœÀÊ
Infectious Diseases.
Also, please note that these guidelines contain cost information 
that is confidential. Copies of the book should not be distributed 
outside of the institution without permission.
Obtaining ID approval
The use of restricted and non-formulary antimicrobials requires pre-
approval fromInfectious Diseases. This approval can be obtained by any 
of the following methods.
Approval method Notes
*� �\ʺ>˜ÌˆLˆœÌˆV»Ê Ê/…iÊ«>}iÀʈÃÊ>˜ÃÜiÀi`ÊLiÌÜii˜ÊnÊ>°“°Ê
and 10 p.m. PING the ID consult pager 
if you fail to get a response from the ID 
approval pager within 10 minutes.
Overnight Approval Restricted antibiotics ordered between 
10 p.m. and 8 a.m. must be approved 
by noon the following morning.
Ê UÊÊ*i>ÃiÊÀi“i“LiÀÊ̜ÊÈ}˜ÊœÕÌÊ̅iʘii`Ê
for approval if you go off shift before 
8 a.m.
Ordersets (e.g. neutropenic These forms are P&T-approved for 
fever, etc.) specific agents and specific indications.
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usSelected formulary antimicrobials 
and restriction status
The following list applies to ALL adult floors and includes the status of 
both oral and injectable dosage forms, unless otherwise noted.
Unrestricted
Amoxicillin
Amoxicillin/clavulanate
Ampicillin/sulbactam 
(Unasyn®)
Ampicillin IV
Azithromycin 
Cefazolin
Cefdinir
Cefotetan
Cefpodoxime
Ceftriaxone
Cefuroxime IV
Cephalexin
Clarithromycin
Clindamycin 
Dicloxacillin
Doxycycline
Ertapenem
Erythromycin
Gentamicin
Metronidazole
Minocycline
Nitrofurantoin
Oxacillin
Penicillin V/G
Ribavirin oral
Rifampin
Streptomycin
Tobramycin
Trimethoprim/ 
sulfamethoxazole 
Amphotericin B 
deoxycholate 
(Fungizone®)
Flucytosine
Itraconazole oral solution
 
Restricted (requires ID 
approval)
Amikacin
Aztreonam
Cefepime
Ceftaroline1
Ceftazidime
Ceftolozane/tazobactam1
Ciprofloxacin
Colistin IV 
Cytomegalovirus Immune 
Globulin (Cytogam®)2
Daptomycin1
Fosfomycin3
Linezolid
Meropenem
Moxifloxacin
Nitazoxanide4
Palivizumab (Synagis®)5
Piperacillin/tazobactam 
­<œÃޘ®)
Quinupristin/ 
dalfopristin (Synercid®)
Ribavirin inhaled5
Telavancin1
Tigecycline
Vancomycin
Liposomal amphotericin B 
(AmBisome®)
Micafungin
Fluconazole6
Posaconazole
Voriconazole
1Approval must be obtained from Antimicrobial Stewardship Program 24h/7 days a week
2Approval required, except for solid organ transplant patients
3Approval must be obtained 24h/7 days a week
4Approval must be obtained from Polk Service or ID Consult
5Approval must be obtained from ID attending physician 24h/7 days a week
6 Oral Fluconazole, when used as a single-dose treatment for vulvovaginal candidiasis or when 
used in compliance with the SICU/WICU protocol, does not require ID approval
Restricted antimicrobials that are ordered as part of a P&T-approved critical pathway or order 
set do NOT require ID approval.
REMINDER: the use of non-formulary antimicrobials is strongly discouraged. ID 
approval MUST be obtained for ALL non-formulary antimicrobials.
NOTE: Formulary antivirals (e.g. Acyclovir, Ganciclovir) do NOT require ID approval.
Antibiotics
Ceftaroline 
Ceftaroline is a cephalosporin with in vitro activity against staphylococci 
(including MRSA), most streptococci, and many Gram-negative bacteria. 
It does NOT have activity against Pseudomonas spp. or Acinetobacter 
spp. or Gram negative anaerobes.
Acceptable uses (Cases must be discussed with Infectious Diseases 
and Antimicrobial Stewardship Program) 
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Gram negative coverage is also needed 
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Unacceptable uses
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and soft tissue infections (SSTI) where other more established and 
less expensive options are available 
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Dose 
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serious infections
UÊ Must adjust for worsening renal function and dialysis (see p. 155 for 
dose adjustment recommendation).
Laboratory interactions 
UÊÊ
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hemolytic anemia. However, if drug-induced hemolytic anemia is 
suspected, discontinue Ceftaroline. 
Ceftolozane/tazobactam 
Ceftolozane/tazobactam is a novel cephalosporin and β-lactamase-
inhibitor combination. It has activity against Gram-negative organisms 
and some strains of multi-resistant Pseudomonas spp. It does NOT have 
activity against carbapenemase-producing Enterobacteriaceae. It also 
has in vitro activity against some streptococci and some Gram-negative 
anaerobes, but it does not have reliable Staphylococcus spp. activity. 
8
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Acceptable uses (Cases must be discussed with Infectious Diseases 
and Antimicrobial Stewardship Program) 
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spp. infections on a case by case basis 
Unacceptable uses
UÊÊ
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or complicated urinary tract infections (cUTI) as current standard 
regimens are sufficient for coverage of the typical pathogens involved 
in these infections and less expensive options are available 
Dose
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metronidazole for cIAI
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for dose adjustment recommendation).
Colistin (Colistimethate) 
Colistin is a polymixin antibiotic. It has in vitro activity against 
Acinetobacter spp. and Pseudomonas spp. but does NOT have activity 
against Proteus, Serratia, Providentia, Burkholderia, Stenotrophomonas, 
Gram-negative cocci, Gram-positive organisms, or anaerobes. 
Acceptable uses
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and Pseudomonas on a case by case basis. 
Unacceptable uses 
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Dose
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renal function and dialysis (see p. 155 for dose adjustment 
recommendation). 
Toxicity
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Daptomycin 
Daptomycin is a lipopeptide antibiotic. It has activity against most strains 
of staphylococci and streptococci (including MRSA and VRE). It does 
NOT have activity against Gram-negative organisms. 
Acceptable uses (Cases must be discussed with Infectious Diseases 
and Antimicrobial Stewardship Program)
UÊÊ	>VÌiÀi“ˆ>ʜÀÊi˜`œV>À`ˆÌˆÃÊV>ÕÃi`ÊLÞÊ�,-�ʜÀÊ�i̅ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊ
coagulase-negative staphylococci in a patient with serious allergy to 
Vancomycin
UÊÊ	>VÌiÀi“ˆ>ʜÀÊi˜`œV>À`ˆÌˆÃÊV>ÕÃi`ÊLÞÊ�,-�ʈ˜Ê>Ê«>̈i˜ÌÊv>ˆˆ˜}Ê
6>˜Vœ“ÞVˆ˜Ê̅iÀ>«ÞÊ>ÃÊ`iw˜i`ÊLÞ\Ê
UÊÊ
ˆ˜ˆV>Ê`iVœ“«i˜Ã>̈œ˜Ê>vÌiÀÊÎq{Ê`>ÞÃ
UÊÊ�>ˆÕÀiÊ̜ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ>vÌiÀÊÇÊ`>ÞÃÊ`iëˆÌiÊ6>˜Vœ“ÞVˆ˜Ê
ÌÀœÕ}…ÃʜvÊ£xqÓäʓV}ɓ�Ê­…ˆ}…ÊÀˆÃŽÊœvÊ�>«Ìœ“ÞVˆ˜ÊÀiÈÃÌ>˜ViÆÊ
check Daptomycin MIC and obtain follow up blood cultures)
UÊÊ��
ʜvÊ6>˜Vœ“ÞVˆ˜ÊˆÃÊÓʓV}ɓ�
UÊÊ/…iÀ>«ÞÊvœÀÊ6,
ʈ˜viV̈œ˜Ãʜ̅iÀÊ̅>˜Ê«˜iՓœ˜ˆ>]ʜ˜Ê>ÊV>ÃiÊLÞÊV>ÃiÊL>ÈÃ
Unacceptable uses
UÊÊ�>«Ìœ“ÞVˆ˜ÊŜՏ`Ê "/ÊLiÊÕÃi`ÊvœÀÊÌÀi>̓i˜ÌʜvÊ«˜iՓœ˜ˆ>Ê`ÕiÊ̜Ê
its inactivation by pulmonary surfactant. 
UÊÊ�˜ˆÌˆ>ÊÌiÀ>«ÞÊvœÀÊ�À>“‡«œÃˆÌˆÛiʈ˜viV̈œ˜ÃÊ
UÊÊ6,
ÊVœœ˜ˆâ>̈œ˜ÊœvÊ̅iÊÕÀˆ˜i]ÊÀiëˆÀ>̜ÀÞÊÌÀ>VÌ]Êܜ՘`Ã]ʜÀÊ`À>ˆ˜ÃÊ
Dose
UÊÊ	>VÌiÀi“ˆ>\ÊÈq£Óʓ}Ɏ}Ê�6Ê+ÊÓ{�
UÊÊ
˜`œV>À`ˆÌˆÃ\ÊÈq£Óʓ}Ɏ}Ê�6Ê+ÊÓ{�
UÊÊ�œÃiÊ>`ÕÃ̓i˜ÌʈÃʘiViÃÃ>ÀÞÊvœÀÊ
À
Ê� 30 ml/min (see p. 155 for 
dose adjustment recommendation). 
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10
Hidden Content
- JHH Internal use only
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sToxicity
UÊÊ�ޜ«>̅ÞÊ­`iw˜i`Ê>ÃÊ
�� 10 times the upper limit of normal without 
symptoms or � 5 times the upper limit of normal with symptoms).
UÊÊ
œÃˆ˜œ«…ˆˆVÊ«˜iՓœ˜ˆ>
UÊÊ�œ˜ˆÌœÀˆ˜}\Ê
�ÊÜiiŽÞ]ʓœÀiÊvÀiµÕi˜ÌÞÊ`ÕÀˆ˜}ʈ˜ˆÌˆ>Ê̅iÀ>«Þ°Ê
,iviÀi˜Vi\Ê
Daptomycin in S. aureusÊL>VÌiÀi“ˆ>Ê>˜`ʈ˜viV̈ÛiÊi˜`œV>À`ˆÌˆÃ\Ê Ê
˜}Ê�Ê�i`ÊÓääÈÆÊ
Îxx\ÊÈxÎqÈx°
Ertapenem
Ertapenem is a carbapenem antibiotic. It has in vitro activity against 
many Gram-negative organisms including those that produce extended 
spectrum beta-lactamases (ESBL), but it does not have activity against 
Pseudomonas spp. or Acinetobacter spp. Its anaerobic and Gram-
positive activity is similar to that of other carbapenems, except it does 
not have activity against Enteroccocus spp. 
Acceptable uses
UÊÊ�ˆ`Ê̜ʓœ`iÀ>Ìiʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜ÃÊ­Lˆˆ>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ã]Ê
diverticulitis, secondary peritonitis/GI perforation) 
UÊÊ�œ`iÀ>ÌiÊ`ˆ>LïVÊvœœÌʈ˜viV̈œ˜ÃÊ܈̅œÕÌʜÃÌiœ“ÞiˆÌˆÃ
UÊÊ�œ`iÀ>ÌiÊÃÕÀ}ˆV>‡ÃˆÌiʈ˜viV̈œ˜ÃÊvœœÜˆ˜}ÊVœ˜Ì>“ˆ˜>Ìi`Ê«ÀœVi`ÕÀi
UÊ*iÛˆVʈ˜y>““>̜ÀÞÊ`ˆÃi>Ãi
UÊÊ1Àˆ˜>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜ÃÊV>ÕÃi`ÊLÞÊ
-	�‡«Àœ`ÕVˆ˜}ʜÀ}>˜ˆÃ“ÃÊ
UÊÊ*Þiœ˜i«…ÀˆÌˆÃʈ˜Ê>Ê«>̈i˜ÌÊ܅œÊˆÃʘœÌÊÃiÛiÀiÞʈ
Unacceptable uses
UÊÊ-iÛiÀiʈ˜viV̈œ˜Ãʈ˜Ê܅ˆV… Pseudomonas spp. are suspected. 
Dose
UÊÊ£Ê}Ê�6ʜÀÊ��Ê+Ó{�]ʓÕÃÌÊ>`ÕÃÌÊvœÀÊܜÀÃi˜ˆ˜}ÊÀi˜>Êv՘V̈œ˜Ê>˜`Ê
dialysis (see p. 155 for dose adjustment recommendation)
Toxicity
UÊÊ�ˆ>ÀÀ…i>]ʘ>ÕÃi>]ʅi>`>V…i]Ê«…iLˆÌˆÃÉ̅Àœ“Lœ«…iLˆÌˆÃ
Fosfomycin 
Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in 
vitro activity against large number of Gram-negative and Gram-positive 
organisms including E. coli, Klebsiella spp., Proteus spp., Pseudomonas 
spp., and VRE. It does not have activity against Acinetobacter spp. 
Fosfomycin is available in an oral formulation only in the U.S. and its 
pharmacokinetics allow for one-time dosing.
Acceptable uses
UÊÊ�>˜>}i“i˜ÌʜvÊ՘Vœ“«ˆV>Ìi`Ê1/�ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʓՏ̈«iÊ>˜ÌˆLˆœÌˆVÊ
allergies and/or when no other oral therapy options are available.
UÊÊ1˜Vœ“«ˆV>Ìi`Ê1/�Ê`ÕiÊ̜Ê6,
UÊÊÊ->Û>}iÊ̅iÀ>«ÞÊvœÀÊ1/�Ê`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊ�À>“‡˜i}>̈ÛiÊ
organisms (e.g. Pseudomonas spp.) on case by case basis. 
 NOTE: Susceptibility to Fosfomycin should be confirmed prior to 
initiation of therapy. 
Unacceptable uses
UÊÊ�œÃvœ“ÞVˆ˜ÊŜՏ`Ê "/ÊLiÊÕÃi`ÊvœÀʓ>˜>}i“i˜ÌʜvÊ>˜Þʈ˜viV̈œ˜ÃÊ
outside of the urinary tract because it does not achieve adequate 
concentrations at other sites.
UÊÊ/Ài>̓i˜ÌʜvÊ>Ãޓ«Ìœ“ˆVÊL>VÌiÀˆÕÀˆ>Ê­ÃiiÊ«°Ê££ä®
Dose
UÊÊ1˜Vœ“«ˆV>Ìi`Ê1/�\ÊÎÊ}Ê­£ÊÃ>V…iÌ®Ê*"ʜ˜Vi°Ê
UÊÊ
œ“«ˆV>Ìi`Ê1/�\ÊÎÊ}Ê­£ÊÃ>V…iÌ®Ê*"ÊiÛiÀÞÊ£‡ÎÊ`>ÞÃÊ­Õ«Ê̜ÊÓ£Ê`>ÞÃʜvÊ
treatment) 
UÊÊ�ÀiµÕi˜VÞÊ>`ÕÃ̓i˜Ìʓ>ÞÊLiʘiViÃÃ>ÀÞʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê
À
Ê 50 
mL/min. Contact the ID Pharmacist for dosing recommendations. 
UÊÊ*œÜ`iÀÊŜՏ`ÊLiʓˆÝi`Ê܈̅ʙäq£Óäʓ�ʜvÊVœœÊÜ>ÌiÀ]ÊÃ̈ÀÀi`Ê̜Ê
dissolve and administered immediately. 
Toxicity 
UÊÊ�ˆ>ÀÀ…i>]ʘ>ÕÃi>]ʅi>`>V…i]Ê`ˆâ∘iÃÃ]Ê>Ã̅i˜ˆ>Ê>˜`Ê`Þëi«Ãˆ>
Linezolid
Acceptable uses
UÊÊ�œVՓi˜Ìi`Ê6>˜Vœ“ÞVˆ˜Êˆ˜ÌiÀ“i`ˆ>ÌiÊStaphylococcus aureus (VISA) 
or Vancomycin resistant Staphylococcus aureus (VRSA) infection
UÊÊ�œVՓi˜Ìi`Ê�,-�ʜÀÊ�i̅ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊ
staphylococcal infection in a patient with serious allergy to Vancomycin
UÊÊ�œVՓi˜Ìi`Ê�,-�ʜÀÊ�i̅ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊ
staphylococcal infection in a patient failing Vancomycin therapy (as 
`iw˜i`ÊLiœÜ®\Ê
UÊÊ	>VÌiÀi“ˆ>Éi˜`œV>À`ˆÌˆÃ\Êv>ˆÕÀiÊ̜ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ>vÌiÀÊ 
ÇÊ`>ÞÃÊ`iëˆÌiÊ6>˜Vœ“ÞVˆ˜ÊÌÀœÕ}…ÃʜvÊ£xqÓäʓV}ɓ�°Ê-…œÕ`ÊLiÊ
used in combination with another agent
UÊÊ*˜iՓœ˜ˆ>\ÊܜÀÃi˜ˆ˜}ʈ˜wÌÀ>ÌiʜÀʫՏ“œ˜>ÀÞÊÃÌ>ÌÕÃʈ˜Ê>Ê«>̈i˜ÌÊ
with documented MRSA pneumonia after 2 to 3 days or if the 
MIC of Vancomycin is 2 mcg/mL, or if achieving appropriate 
vancomycin trough is unlikely (e.g., obesity)
UÊÊ
>ÃiÃÊŜՏ`ÊLiÊ`ˆÃVÕÃÃi`Ê܈̅Ê�˜viV̈œÕÃÊ�ˆÃi>ÃiÃʜÀÊ
Antimicrobial stewardship
UÊ High suspicion of CA-MRSA necrotizing pneumonia in a seriously 
ill patient
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13
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sÊUÊÊ�œVՓi˜Ìi`Ê6,
ʈ˜viV̈œ˜Ê
UÊÊ�À>“‡«œÃˆÌˆÛiÊVœVVˆÊˆ˜ÊV…>ˆ˜Ãʈ˜ÊLœœ`ÊVՏÌÕÀiÃʈ˜Ê>˜Ê�
1]ʜÀʜ˜Vœœ}ÞÊ
transplant patient known to be colonized with VRE
Unacceptable uses
UÊÊ*Àœ«…ޏ>݈Ã
UÊÊ�˜ˆÌˆ>Ê̅iÀ>«ÞÊvœÀÊÃÌ>«…ޏœVœVV>Êˆ˜viV̈œ˜
UÊÊ6,
ÊVœœ˜ˆâ>̈œ˜ÊœvÊ̅iÊÃ̜œ]ÊÕÀˆ˜i]ÊÀiëˆÀ>̜ÀÞÊÌÀ>VÌ]Êܜ՘`Ã]ʜÀÊ`À>ˆ˜Ã
Dose
UÊÊÈääʓ}Ê�6É*"Ê+£Ó�
UÊÊ-Žˆ˜Ê>˜`ÊΈ˜‡ÃÌÀÕVÌÕÀiʈ˜viV̈œ˜Ã\Ê{ääʓ}Ê�6É*"Ê+£Ó�
Toxicity
UÊÊ	œ˜iʓ>ÀÀœÜÊÃÕ««ÀiÃȜ˜Ê­ÕÃÕ>ÞʜVVÕÀÃÊ܈̅ˆ˜ÊwÀÃÌÊÓÊÜiiŽÃʜvÊ̅iÀ>«Þ®
UÊÊ"«ÌˆVʘiÕÀˆÌˆÃÊ>˜`ʈÀÀiÛiÀÈLiÊÃi˜ÃœÀÞʓœÌœÀÊ«œÞ˜iÕÀœ«>̅ÞÊ­ÕÃÕ>ÞÊ
occurs with prolonged therapy > 28 days)
UÊÊ
>ÃiÊÀi«œÀÌÃʜvʏ>V̈VÊ>Vˆ`œÃˆÃ
UÊÊ
>ÃiÊÀi«œÀÌÃʜvÊÃiÀœÌœ˜ˆ˜ÊÃޘ`Àœ“iÊ܅i˜ÊVœ‡>`“ˆ˜ˆÃÌiÀi`Ê܈̅Ê
serotonergic agents (SSRIs, TCAs, MAOIs, etc.)
UÊÊ�œ˜ˆÌœÀˆ˜}\Ê
	
ÊÜiiŽÞ
Tigecycline
Tigecycline is a tetracycline derivative called a glycylcycline. It has in 
vitro activity against most strains of staphylococci and streptococci 
(including MRSA and VRE), anaerobes, and many Gram-negative 
organisms with the exception of Proteus spp. and Pseudomonas 
aeruginosa. It is FDA approved for skin and skin-structure infections and 
intra-abdominal infections. 
NOTE: Peak serum concentrations of Tigecycline do not exceed 
1 mcg/mL which limits its use for treatment of bacteremia
Acceptable uses
UÊÊ�>˜>}i“i˜Ìʜvʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜Ãʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê
contraindications to both beta-lactams and fluoroquinolones
UÊÊ�>˜>}i“i˜Ìʜvʈ˜viV̈œ˜ÃÊ`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊ�À>“‡˜i}>̈ÛiÊ
organisms including Acinetobacter spp. and Stenotrophomonas 
maltophilia on a case by case basis
UÊÊ->Û>}iÊ̅iÀ>«ÞÊvœÀÊ�,-�É6,
ʈ˜viV̈œ˜Ãʜ˜Ê>ÊV>ÃiÊLÞÊV>ÃiÊL>ÈÃ
Dose
UÊÊ£ääʓ}Ê�6ʜ˜Vi]Ê̅i˜Êxäʓ}Ê�6Ê+£Ó�
UÊÊ£ääʓ}Ê�6ʜ˜Vi]Ê̅i˜ÊÓxʓ}Ê�6Ê+£Ó�ʈvÊÃiÛiÀiʅi«>̈Vʈ“«>ˆÀ“i˜ÌÊ
­
…ˆ`ʇÊ*Õ}…Ê£äq£x®
Toxicity
UÊÊ >ÕÃi>Ê>˜`Êۜ“ˆÌˆ˜}Ê
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s Trimethoprim/sulfamethoxazole 
(Bactrim®, TMP/SMX)
Trimethoprim/sulfamethoxazole is a sulfonamide antibiotic. It has in vitro 
activity against Enterobacteriaceae spp., B. cepacia, S. maltophilia, 
Acinetobacter spp., Achromobacter spp., Nocardia spp., Listeria, 
Pneumocystis jirovecii (PCP), staphylococci (including S. aureus and 
Coagulase-negative staph), but does NOT cover Pseudomonas spp. 
It has variable activity against streptococci and no activity against 
anaerobes. 
Acceptable uses 
UÊ1Àˆ˜>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜ÃÊ­1/�®
UÊS. aureus skin and soft-tissue infections (SSTI)
UÊPneumocystis jirovecii pneumonia (PCP) treatment and prophylaxis 
UÊS. maltophilia infections 
UÊ œV>À`ˆ>ʈ˜viV̈œ˜ÃÊ
UÊ�À>“‡˜i}>̈ÛiÊL>VÌiÀi“ˆ>Ê܅i˜ÊœÀ}>˜ˆÃ“ʈÃÊÃÕÃVi«ÌˆLiÊ
UÊÊ->Û>}iÊ̅iÀ>«ÞÊvœÀÊ�,-�ÊL>VÌiÀi“ˆ>ʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê>˜œÌ…iÀÊ
agent 
UÊÊ
“«ˆÀˆVÊVœÛiÀ>}iʜvÊListeria meningitis in patients with penicillin 
allergies 
UÊÊ-Õ««ÀiÃÈÛiÊ̅iÀ>«ÞÊ>˜`ʈ˜ÊܓiÊV>ÃiÃÊÌÀi>̓i˜ÌÊvœÀÊLœ˜iÊ>˜`ʍœˆ˜ÌÊ
infections 
Unacceptable uses
UÊ�œ˜œÌ…iÀ>«ÞÊvœÀÊS. aureus bacteremia 
Dose
UÊTrimethoprim/sulfamethoxazole dosing is based on trimethoprimcomponent 
UÊ/�*É-�8ʅ>ÃÊiÝVii˜ÌÊLˆœ>Û>ˆ>LˆˆÌÞ]Ê̅ÕÃÊVœ˜ÛiÀȜ˜ÊvÀœ“Ê�6Ê̜Ê*"Ê
ˆÃÊ£\£Ê­näÉ{ääʓ}Ê�6ÊrÊ£Ê--ÊÌ>LÆÊ£ÈäÉnääʓ}Ê�6ÊrÊ£Ê�-ÊÌ>L®Ê
UÊ1ÃiÊ>`ÕÃÌi`Ê	7rÊQ�	7ʳÊä°{Ê­�	7ʇÊ�	7®Rʈ˜ÊœLiÃiÊ«>̈i˜ÌÃÊ­€Îä¯Ê
over IBW)
Treatment 
UÊ1/�\Ê£Ê�-ÊÌ>LÊ+£Ó�Ê
UÊ--/�\Ê£‡ÓÊ�-ÊÌ>LÊ+£Ó�
UÊ*
*\£x‡Óäʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n�®
UÊ�,-�ÊL>VÌiÀi“ˆ>\£ä‡£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n�®
UÊS. maltophiliaʈ˜viV̈œ˜Ã\£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n�®Ê
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sUÊ œV>À`ˆ>ʈ˜viV̈œ˜Ã\Ê£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n�®ÆʏœÜiÀÊ
doses (5-10 mg/kg/day) can be used after several weeks of therapy 
or cutaneous infections 
UÊ�i˜ˆ˜}ˆÌˆÃ\ÊÓäʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+È�®
UÊ"̅iÀʈ˜viV̈œ˜Ã\Ên‡£äʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ£Ó�®
UÊ�ÕÃÌÊ>`ÕÃÌÊ`œÃiÊvœÀÊܜÀÃi˜ˆ˜}ÊÀi˜>Êv՘V̈œ˜Ê>˜`Ê`ˆ>ÞÈÃÊ­ÃiiÊ«°£xxÊ
for dose adjustment recommendation).
Prophylaxis 
UÊ*
*\Ê£Ê--Ê`>ˆÞʜÀÊ£Ê�-ÊÎÊ̈“iÃÉÜiiŽÊ
UÊ/œÝœ«>ӜÈÃ\Ê£Ê�-Ê`>ˆÞÊ
Toxicity
UÊ
œ““œ˜\ʅޫiÀÃi˜ÃˆÌˆÛˆÌÞÊ­£°È‡n¯®]Ê��‡Õ«ÃiÌ]Ê«ÃiÕ`œÊiiÛ>̈œ˜Êˆ˜Ê
VÀi>̈˜ˆ˜iÊ­£n¯®Ê
UÊ
œ““œ˜Ê܈̅ʅˆ}…iÀÊ`œÃiÃ\ʅޫiÀŽ>i“ˆ>]ʓÞiœÃÕ««ÀiÃȜ˜
UÊ"VV>Ȝ˜>\ʘi«…ÀœÌœÝˆVˆÌÞ]Ê«…œÌœÃi˜ÃˆÌˆÛˆÌÞ]ʓi̅i“œ}œLˆ˜i“ˆ>ʭ܈̅Ê
severe G6PD deficiency) 
UÊ,>Ài\Ê>Ãi«ÌˆVʓi˜ˆ˜}ˆÌˆÃ]ʅi«>̜̜݈VˆÌÞ]Ê̜݈VÊi«ˆ`iÀ“>Ê˜iVÀœÞÈÃÊ
(TEN), SJS, Sweet’s syndrome
Drug Interaction
UÊ7>Àv>Àˆ˜]ʓi̅œÌÀiÝ>Ìi]Ê«…i˜Þ̜ˆ˜]Ê`ˆ}œÝˆ˜]ÊÃՏvœ˜ÞÕÀi>Ã]Ê
procainamide, oral contraceptives 
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Antifungals
Liposomal Amphotericin B (AmBisome®)
NOTES:
UÊÊ�œÃˆ˜}ʜvÊ�“	ˆÃœ“iÊ>˜`Ê�“«…œÌiÀˆVˆ˜Ê	Ê`iœÝÞV…œ>ÌiʈÃÊ
significantly different. Do not use AmBisome doses when 
ordering Amphotericin B deoxycholate and vice versa.
UÊÊ�“«…œÌiÀˆVˆ˜Ê	Ê`iœÝÞV…œ>ÌiʈÃÊ«ÀiviÀÀi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅Êi˜`‡
stage renal disease on dialysis who are anuric.
AmBisome, like all Amphotericin B products, has broad spectrum 
antifungal activity with in vitro activity against Candida, Aspergillus, 
Zygomycosis and Fusarium. 
Acceptable uses 
UÊ
>˜`ˆ`>Êi˜`œ«Ì…>“ˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]Ê
 -ʈ˜viV̈œ˜qwÀÃÌʏˆ˜iÊ̅iÀ>«Þ
UÊ
Àޫ̜VœVVÕÃʓi˜ˆ˜}ˆÌˆÃ‡wÀÃÌʏˆ˜iÊ̅iÀ>«ÞÊÊ
UÊ<Þ}œ“ÞVœÃiÃÊ­Mucor, Rhizopus, Cunninghamella®qwÀÃÌʏˆ˜iÊ̅iÀ>«ÞÊ
UÊÊ iÕÌÀœ«i˜ˆVÊviÛiÀʈvÊÀiViˆÛˆ˜}Ê6œÀˆVœ˜>✏iʜÀÊ*œÃ>Vœ˜>✏iÊ
prophylaxis
UÊ�ÌiÀ˜>̈ÛiÊÌÀi>̓i˜Ìʜvʈ˜Û>ÈÛiÊ>ëiÀ}ˆœÃˆÃ
UÊÊ�ÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊV>˜`ˆ`i“ˆ>]ÊV>˜`ˆ`>Ê«iÀˆÌœ˜ˆÌˆÃÊ
Dose 
UÊÊ
>˜`ˆ`i“ˆ>]ʅˆÃ̜«>ӜÈÃ]ʜ̅iÀʘœ˜‡ˆ˜Û>ÈÛiÊV>˜`ˆ`>ʈ˜viV̈œ˜Ã\Ê 
3 mg/kg/day
UÊÊ
>˜`ˆ`>Êi˜`œ«Ì…>“ˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]Ê
 -ʈ˜viV̈œ˜]ÊC. krusei 
V>˜`ˆ`i“ˆ>\Êxʓ}Ɏ}É`>Þ
UÊ�˜Û>ÈÛiÊw>“i˜ÌœÕÃÊv՘}ˆ\Êxʓ}Ɏ}É`>Þ
UÊ iÕÌÀœ«i˜ˆVÊviÛiÀ]ÊV>˜`ˆ`i“ˆ>ʈ˜Ê˜iÕÌÀœ«i˜ˆVÊ«>̈i˜Ì\ÊÎqxʓ}Ɏ}É`>Þ
UÊ
Àޫ̜VœVV>Ê“i˜ˆ˜}ˆÌˆÃ\ÊÎq{ʓ}Ɏ}É`>Þ
Toxicity 
UÊ�˜vÕȜ˜‡Ài>Ìi`ÊÀi>V̈œ˜Ã\ÊviÛiÀ]ÊV…ˆÃ]ÊÀˆ}œÀÃ]ʅޫœÌi˜Ãˆœ˜
UÊÊ,i˜>Êˆ“«>ˆÀ“i˜ÌÊ­i˜…>˜Vi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊVœ˜Vœ“ˆÌ>˜Ìʘi«…ÀœÌœÝˆVÊ
drugs)
UÊ
iVÌÀœÞÌiʈ“L>>˜ViÃ
UÊÊ*Տ“œ˜>ÀÞÊ̜݈VˆÌÞÊ­V…iÃÌÊ«>ˆ˜]ʅޫœÝˆ>]Ê`Þë˜i>®]Ê>˜i“ˆ>]ÊiiÛ>̈œ˜Êˆ˜Ê
hepatic enzymes-rare
UÊÊ�œ˜ˆÌœÀˆ˜}\Ê	1 ÉVÀi>̈˜ˆ˜i]Ê�]Ê�}]Ê*…œÃÊ>ÌÊL>Ãiˆ˜iÊ>˜`Ê`>ˆÞʈ˜Ê
…œÃ«ˆÌ>ˆâi`Ê«>̈i˜ÌÃÆÊ�-/É��/Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£‡ÓÊÜiiŽÃÊ
Micafungin
NOTE: Micafungin does not have activity against Cryptococcus. 
Aspergillosis
UÊ�VVi«Ì>LiÊÕÃiÃ
UÊÊ�˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê6œÀˆVœ˜>✏iÊvœÀÊVœ˜wÀ“i`ʈ˜Û>ÈÛiÊ
aspergillosis (see p. 133)
UÊÊ,ivÀ>V̜ÀÞÊ`ˆÃi>Ãi‡ÊvœÀÊÕÃiʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê6œÀˆVœ˜>✏i]Ê
Posaconazole or AmBisome® for confirmed invasive aspergillosis. 
UÊ1˜>VVi«Ì>LiÊÕÃiÃ
UÊÊ�ˆV>v՘}ˆ˜Ê>œ˜iʜÀʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅ʜ̅iÀÊ>˜Ìˆv՘}>Ê>}i˜ÌÃʈÃÊ
not recommended for empiric therapy in patients with CT findings 
suggestive of aspergillosis (e.g., possible aspergillosis) without 
plans for diagnostic studies.
UÊÊ�ˆV>v՘}ˆ˜Ê`œiÃʘœÌʅ>ÛiÊ}œœ`Êin vitro activity against 
zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.). 
Candidiasis
UÊ�VVi«Ì>LiÊÕÃiÃ
UÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃÊ`ÕiÊ̜ÊC. glabrata or C. krusei.
UÊÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>ÀiÊ "/ÊVˆ˜ˆV>ÞÊ
stable due to candidemia or have received prior long-term azole 
therapy.
UÊ�ÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊÀiVÕÀÀi˜ÌÊiÜ«…>}i>ÊV>˜`ˆ`ˆ>Èð
UÊ�ÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊi˜`œV>À`ˆÌˆÃ°
UÊ1˜>VVi«Ì>LiÊÕÃiÃ
UÊÊ�ˆV>v՘}ˆ˜Ê…>ÃÊ«œœÀÊ«i˜iÌÀ>̈œ˜Êˆ˜ÌœÊ̅iÊ
 -Ê>˜`ÊÕÀˆ˜>ÀÞÊÌÀ>VÌ°Ê�ÌÊ
should be avoided for infections involving those sites.
Neutropenic fever
UÊÊ�ˆV>v՘}ˆ˜ÊV>˜ÊLiÊÕÃi`ÊvœÀʘiÕÌÀœ«i˜ˆVÊviÛiÀʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>ÀiʘœÌÊ
suspected to have aspergillosis or zygomycosis.
Dose
UÊÊ
>˜`ˆ`i“ˆ>]ʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃ]ʘiÕÌÀœ«i˜ˆVÊviÛiÀ\Ê£ääʓ}Ê�6Ê
Q24H
UÊ
>˜`ˆ`>Êi˜`œV>À`ˆÌˆÃ\Ê£xäʓ}Ê�6Ê+Ó{�
UÊ,iVÕÀÀi˜ÌÊiÜ«…>}i>ÊV>˜`ˆ`ˆ>ÈÃ\Ê£xäʓ}Ê�6Ê+Ó{�
UÊ�˜Û>ÈÛiÊ>ëiÀ}ˆœÃˆÃ\Ê£ääq£xäʓ}Ê�6Ê+Ó{�
UÊ"LiÃiÊ«>̈i˜ÌÃ
UÊÊ£ääq£xäʎ}\Ê£xäʓ}Ê�6Ê+Ó{
UÊÊ> £xäʎ}\Ê
œ˜ÃՏÌÊ��Ê*…>À“>VˆÃÌ
Drug Interactions
UÊÊ
œÃiʓœ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`Ê܅i˜Ê�ˆV>v՘}ˆ˜ÊˆÃÊÕÃi`Ê܈̅Ê̅iÊ
vœœÜˆ˜}Ê>}i˜ÌÃÊVœ˜Vœ“ˆÌ>˜ÌÞ\
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UÊÊ-ˆÀœˆ“ÕÃÊqʏiÛiÃʜvÊ-ˆÀœˆ“ÕÃʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ
Sirolimus toxicity
UÊÊ ˆvi`ˆ«ˆ˜iÊqʏiÛiÃʜvÊ ˆvi`ˆ«ˆ˜iʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ
Nifedipine toxicity
UÊÊ�ÌÀ>Vœ˜>✏iÊqʏiÛiÃʜvÊ�ÌÀ>Vœ˜>✏iʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ
Itraconazole toxicity
Toxicity
UÊÊ�˜vÕȜ˜‡Ài>Ìi`ÊÀi>V̈œ˜ÃÊ­À>Å]Ê«ÀÕÀˆÌˆÃ®]Ê«…iLˆÌˆÃ]ʅi>`>V…i]ʘ>ÕÃi>Ê
and vomiting, and elevations in hepatic enzymes.
UÊ�œ˜ˆÌœÀˆ˜}\Ê�-/É��/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ°
Posaconazole
Posaconazole is a broad spectrum azole anti-fungal agent. It has in vitro 
activity against Candida, Aspergillus, Zygomycosis and Fusarium spp.
Acceptable uses
UÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊâÞ}œ“ÞVœÃˆÃʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê�“«…œÌiÀˆVˆ˜Ê	
UÊÊ�œ˜œÌ…iÀ>«ÞÊvœÀÊâÞ}œ“ÞVœÃˆÃÊ>vÌiÀÊÇÊ`>ÞÃʜvÊVœ“Lˆ˜>̈œ˜Ê̅iÀ>«ÞÊ
with Amphotericin B
UÊ*Àœ«…ޏ>݈Ãʈ˜Ê«>̈i˜ÌÃÊ܈̅ʅi“>̜œ}ˆVʓ>ˆ}˜>˜VÞ
UÊ/Ài>̓i˜ÌʜvÊ>ëiÀ}ˆœÃˆÃʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê6œÀˆVœ˜>✏iʈ˜ÌœiÀ>˜Vi
 Unacceptable uses
UÊ
>˜`ˆ`ˆ>ÈÃÉ iÕÌÀœ«i˜ˆVÊviÛiÀ
UÊ�ˆÀÃ̇ˆ˜iÊÌÀi>̓i˜ÌʜvÊ>ëiÀ}ˆœÃˆÃ
Dose
 "/
-\Ê 
UÊÊ
>V…Ê`œÃiʜvÊÃÕëi˜Ãˆœ˜ÊŜՏ`ÊLiÊ}ˆÛi˜Ê܈̅Ê>ÊvՏÊ“i>ÊœÀÊ܈̅ʏˆµÕˆ`Ê
nutritional supplements if patients cannot tolerate full meals. Can also 
be given with an acidic beverage (e.g. ginger ale).
UÊÊ�i>Þi`ÊÀii>ÃiÊÌ>LiÌÃÊ>˜`ʜÀ>ÊÃÕëi˜Ãˆœ˜ÊV>˜˜œÌÊLiÊÕÃi`Ê
interchangeably due to differences in the dosing of each formulation.
Prophylaxis
UÊ"À>Ê-Õëi˜Ãˆœ˜\ÊÓääʓ}Ê*"Ê+n�
UÊ
ÝÌi˜`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääʓ}Ê*"Ê`>ˆÞ
Treatment
UÊÊ"À>Ê-Õëi˜Ãˆœ˜\ÊÓääʓ}Ê*"Ê+È�ÊvœÀÊÇÊ`>ÞÃ]Ê̅i˜Ê{ääʓ}Ê*"Ê 
Q8-Q12H
UÊÊ
ÝÌi˜`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääʓ}Ê*"Ê+£Ó�ÊvœÀÊ£Ê`>Þ]Ê̅i˜ÊÎääʓ}Ê
PO daily
Therapeutic monitoring:
UÊ*œÃ>Vœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>Ài\
UÊ œÌÊÀi뜘`ˆ˜}Ê̜Ê̅iÀ>«ÞÊvœÀÊ>Ìʏi>ÃÌÊÇÊ`>ÞÃ
UÊ	iˆ˜}ÊÌÀi>Ìi`ÊvœÀÊ՘Vœ““œ˜ÊœÀʏiÃÃÊÃÕÃVi«ÌˆLiʜÀ}>˜ˆÃ“Ã
UÊ
Ý«iÀˆi˜Vˆ˜}ʓÕVœÃˆÌˆÃʜÀʓ>>LÜÀ«Ìˆœ˜ÊÃޘ`Àœ“i
UÊ1˜>LiÊ̜ÊVœ˜ÃՓiʅˆ}…Êv>Ìʓi>ÃÊ­ˆvÊÀiViˆÛˆ˜}Ê̅iÊÃÕëi˜Ãˆœ˜®
Drug Interactions: See Table on p. 21
Toxicity
UÊÊ��ÊÕ«ÃiÌÊ­H{䯮]ʅi>`>V…iÃ]ÊiiÛ>̈œ˜Êˆ˜Ê…i«>̈VÊi˜âޓiðÊ,>ÀiÊLÕÌÊ
serious effects include QTc prolongation.
UÊÊ�œ˜ˆÌœÀˆ˜}\Ê�-/É��/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ
,iviÀi˜ViÃ\
ˆ˜ˆV>ÊivwV>VÞʜvʘiÜÊ>˜Ìˆv՘}>Ê>}i˜ÌÃ\Ê
ÕÀÀÊ"«ˆ˜Ê�ˆVÀœLˆœ°ÊÓääÈƙ\{n·nn°
*œÃ>Vœ˜>✏i\Ê>ÊLÀœ>`ÊëiVÌÀՓÊÌÀˆ>✏iÊ>˜Ìˆv՘}>\Ê�>˜ViÌÊ�˜viVÌÊ�ˆÃ°ÊÓääxÆÊx\ÇÇx‡nx°
Voriconazole
NOTE: Voriconazole does not cover zygomycoses (Mucor, 
Rhizopus, Cunninghamella, etc.).
Acceptable uses
UÊ Aspergillosis
UÊ Scedosporium apiospermum
UÊProphylaxis inpatients with hematologic malignancy
Unacceptable uses
UÊÊCandidiasis / Neutropenic fever 
Voriconazole should not be used as first-line therapy for the treatment 
of candidiasis or for empiric therapy in patients with neutropenic fever.
Dose
UÊÊ�œ>`ˆ˜}Ê`œÃi\ÊÈʓ}Ɏ}Ê�6É*"Ê+£Ó�ÊÝÊÓÊ`œÃiÃ
UÊ�>ˆ˜Ìi˜>˜ViÊ`œÃi\Ê{ʓ}Ɏ}Ê�6É*"Ê+£Ó�
UÊÊ�œÃiÊ>`ÕÃ̓i˜ÌʈÃʘiViÃÃ>ÀÞÊvœÀʅi«>̈Vʈ˜ÃÕvwVˆi˜VÞ\
UÊ
…ˆ`ʇÊ*Õ}…Ê­�ʜÀÊ	®\Ê↓ “>ˆ˜Ìi˜>˜ViÊ`œÃiÊLÞÊxä¯
UÊÊ
…ˆ`ʇÊ*Õ}…Ê­
®\Ê1Ãiʜ˜ÞʈvÊLi˜iwÌÃʜÕÌÜiˆ}…ÊÀˆÃŽÃ°Ê
œ˜ÃՏÌÊ
ID pharmacist for dose adjustment recommendations.
UÊÊ�œÃiÊiÃV>>̈œ˜Ê“>ÞÊLiʘiViÃÃ>ÀÞÊvœÀÊܓiÊ«>̈i˜ÌÃÊ`ÕiÊ̜Ê
subtherapeutic levels.
UÊÊ�œÃiÊL>Ãi`ʜ˜Ê>VÌÕ>ÊLœ`ÞÊÜiˆ}…ÌÊ՘iÃÃÊ«>̈i˜ÌʀÎä¯ÊœÛiÀÊ�	7ÆÊ
then use adjusted body weight. (Adj. BW).
�`°Ê	7ÊrÊQ�	7ʳÊä°{Ê­�	7ʇÊ�	7®R
IBW - Ideal Body Weight
ABW - Actual Body Weight
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Therapeutic monitoring
UÊÊ6œÀˆVœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>Ài\
UÊÊ œÌÊÀi뜘`ˆ˜}Ê̜Ê̅iÀ>«ÞÊ>vÌiÀÊ>Ìʏi>ÃÌÊxÊ`>ÞÃʜvÊ̅iÀ>«ÞÊÕȘ}Ê>Ê
mg/kg dosing strategy
UÊÊ,iViˆÛˆ˜}ÊVœ˜Vœ“ˆÌ>˜ÌÊ`ÀÕ}ÃÊ̅>Ìʓ>Þʈ˜VÀi>ÃiʜÀÊ`iVÀi>ÃiÊ
Voriconazole levels
UÊÊ
Ý«iÀˆi˜Vˆ˜}Ê>`ÛiÀÃiÊiÛi˜ÌÃÊ`ÕiÊ̜Ê6œÀˆVœ˜>✏i
UÊÊ
Ý«iÀˆi˜Vˆ˜}Ê��Ê`ÞÃv՘V̈œ˜
UÊÊ6œÀˆVœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊŜՏ`ÊLiʜLÌ>ˆ˜i`ÊxqÇÊ`>ÞÃÊ>vÌiÀÊÃÌ>ÀÌʜvÊ
̅iÀ>«ÞÊ­«iÀvœÀ“i`Ê�q�®°
UÊÊ�œ>ÊÌÀœÕ}…\ÊÓqx°xʓV}ɓ�°Ê�iÛiÃʐʣʓV}ɓ�ʅ>ÛiÊLii˜Ê
associated with clinical failures and levels >5.5 mcg/mL with toxicity. 
Drug Interactions: See Table on p. 21
Toxicity
UÊÊ6ˆÃÕ>Ê`ˆÃÌÕÀL>˜ViÃÊ­HÎ䯮ÊÕÃÕ>ÞÊÃiv‡ˆ“ˆÌi`]ÊÀ>Å]ÊviÛiÀ]ÊiiÛ>̈œ˜ÃÊ
in hepatic enzymes.
UÊÊ�œ˜ˆÌœÀˆ˜}\Ê�-/É��/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ
,iviÀi˜ViÃ\
6œÀˆVœ˜âœi\Ê
ˆ˜Ê�˜viVÌÊ�ˆÃÊÓääÎÆÊÎÈ\ÈÎä°
6œÀˆVœ˜>✏iʈ˜Ê˜iÕÌÀœ«i˜ˆVÊviÛiÀ\Ê Ê
˜}Ê�Ê�i`ÊÓääÓÆÎ{È­{®\ÓÓx°Ê
6œÀˆVœ˜>✏iÊ/��\Ê
ˆ˜Ê�˜viVÌÊ�ˆÃÊÓäänÆÊ{È\Ó䣰
Azole drug interactions
The following list contains major drug interactions involving drug 
metabolism and absorption. This list is not comprehensive and is 
intended as a guide only. You must check for other drug interactions 
when initiating azole therapy or starting new medication in patients 
already receiving azole therapy. 
Drug metabolism: 
Þ̜V…Àœ“iÊ­
9*®Ê*{xäʈ˜…ˆLˆÌœÀÃ\Ê`iVÀi>ÃiÊ̅iʓiÌ>LœˆÃ“ÊœvÊViÀÌ>ˆ˜Ê
drugs (CYP450 substrates) resulting in increased drug concentrations in 
the body (occurs immediately)
Þ̜V…Àœ“iÊ­
9*®Ê*{xäʈ˜`ÕViÀÃ\ʈ˜VÀi>ÃiÊ̅iʓiÌ>LœˆÃ“ÊœvÊViÀÌ>ˆ˜Ê
drugs (CYP450 substrates) resulting in decreased drug concentrations 
in the body (may take up to 2 weeks for upregulation of enzymes to 
occur)
Drug absorption/penetration:
*‡}ÞVœ«ÀœÌiˆ˜Ê­*‡}«®Êˆ˜…ˆLˆÌœÀ\Ê`iVÀi>ÃiÊ̅iÊv՘V̈œ˜ÊœvÊ̅iÊivyÕÝʫՓ«]Ê
resulting in increased absorption/penetration of P-gp substrates
*‡}ÞVœ«ÀœÌiˆ˜Êˆ˜`ÕViÀ\ʈ˜VÀi>ÃiÊ̅iÊv՘V̈œ˜ÊœvÊ̅iÊivyÕÝʫՓ«]Ê
resulting in decreased absorption/penetration of P-gp substrates
PotencyʜvÊ
Þ̜V…Àœ“iÊ*{xäʈ˜…ˆLˆÌˆœ˜\Ê6œÀˆVœ˜>✏iʀÊ�ÌÀ>Vœ˜>✏iʀÊ
Posaconazole > Fluconazole
21
3.
2 
Ag
en
t-s
pe
ci
fic
 g
ui
de
lin
es
: A
nt
ifu
ng
al
s
PO
SA
C
O
N
AZ
O
LE
 (s
ub
st
ra
te
 a
nd
 in
hi
bi
to
r 
fo
r 
P-
gp
 e
ffl
ux
, i
nh
ib
ito
r 
of
 C
YP
3A
4)
 
D
ru
g 
Re
co
m
m
en
da
tio
ns
C
on
tr
ai
nd
ic
at
ed
 
œ
“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ s
iro
lim
us
 
Do
 n
ot
 u
se
 
�i
ÃÃ
ÊV
œ“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ c
is
ap
rid
e,
 e
rg
ot
 a
lk
al
oi
ds
, p
im
oz
id
e,
 
 
qu
in
id
in
e,
 tr
ia
zo
la
m
W
ar
ni
ng
/p
re
ca
ut
io
n 
Cy
cl
os
po
rin
e 
↓ c
yc
lo
sp
or
in
e 
do
se
 to
 3 ⁄
4 a
nd
 m
on
ito
r l
ev
el
s
 
M
et
oc
lo
pr
am
id
e,
 p
ro
to
n 
pu
m
p 
in
hi
bi
to
rs
 
M
ay
 ↓ 
po
sa
co
na
zo
le
 c
on
ce
nt
ra
tio
ns
 w
he
n 
us
in
g 
su
sp
en
si
on
 
M
id
az
ol
am
 
Co
ns
id
er
 d
os
e 
re
du
ci
ng
 
Ta
cr
ol
im
us
 
↓ t
ac
ro
lim
us
 d
os
e 
to
 1 ⁄
3 a
nd
 m
on
ito
r l
ev
el
s
 
Ci
m
et
id
in
e,
 e
fa
vir
en
z,
 p
he
ny
to
in
, r
ifa
bu
tin
, r
ifa
m
pi
n 
 Av
oi
d 
co
nc
om
ita
nt
 u
se
 u
nl
es
s 
be
ne
fit
 o
ut
w
ei
gh
s 
ris
k 
If 
us
ed
 to
ge
th
er
, m
on
ito
r e
ffe
ct
s 
of
 d
ru
gs
 a
nd
 c
on
si
de
r d
ec
re
as
in
g 
do
se
 
w
he
n 
po
sa
co
na
zo
le
 is
 a
dd
ed
 
Am
io
da
ro
ne
, a
ta
za
na
vir
, d
ig
ox
in
, e
ry
th
ro
m
yc
in
, a
ll c
al
ci
um
 c
ha
nn
el
 b
lo
ck
er
s,
 
M
on
ito
r e
ffe
ct
 o
f d
ru
gs
 a
nd
 c
on
si
de
r d
ec
re
as
in
g 
do
se
 w
he
n 
 
 
rit
on
av
ir,
 s
ta
tin
s 
(a
vo
id
 lo
va
st
at
in
 a
nd
 s
im
va
st
at
in
), 
vin
ca
 a
lk
al
oi
ds
 
po
sa
co
na
zo
le
 is
 a
dd
ed
IT
R
AC
O
N
AZ
O
LE
 a
nd
 m
aj
or
 m
et
ab
ol
ite
 h
yd
ro
xy
itr
ac
on
az
ol
e 
(s
ub
st
ra
te
 a
nd
 in
hi
bi
to
r 
of
 C
Y
P3
A4
 a
nd
 P
-g
p 
ef
flu
x)
 
D
ru
g 
Re
co
m
m
en
da
tio
ns
C
on
tr
ai
nd
ic
at
ed
 
œ
“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ s
ta
tin
s 
(lo
va
st
at
in
, s
im
va
st
at
in
) 
Do
 n
ot
 u
se
 
�i
ÃÃ
ÊV
œ“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ c
is
ap
rid
e,
 d
of
et
ilid
e,
 e
rg
ot
 a
lk
al
oi
ds
, 
 
ni
so
ld
ip
in
e,
 o
ra
l m
id
az
ol
am
, p
im
oz
id
e,
 q
ui
ni
di
ne
, t
ria
zo
la
m
W
ar
ni
ng
/p
re
ca
ut
io
n 
œ
“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ a
to
rv
as
ta
tin
, b
en
zo
di
az
ep
in
es
, c
he
m
ot
he
ra
py
 
 
pl
as
m
a 
co
nc
en
tra
tio
n 
of
 th
e 
in
te
ra
ct
in
g 
dr
ug
, m
on
ito
r l
ev
el
s 
w
he
n 
 
 
(b
us
ul
fa
n,
 d
oc
et
ax
el
, v
in
ca
 a
lk
al
oi
ds
), 
cy
cl
os
po
rin
e,
 d
ig
ox
in
, e
fa
vir
en
z,
 
po
ss
ib
le
, m
on
ito
r f
or
 d
ru
g 
to
xic
ity
 a
nd
 c
on
si
de
r d
os
e 
re
du
ct
io
n 
 
el
et
rip
ta
n,
 fe
nt
an
yl,
 o
ra
l h
yp
og
lyc
em
ic
s,
 in
di
na
vir
, I
V 
m
id
az
ol
am
, 
 
ni
fe
di
pi
ne
, r
ito
na
vir
, s
aq
ui
na
vir
, s
iro
lim
us
, t
ac
ro
lim
us
, v
er
ap
am
il, 
st
er
oi
ds
 
 
(b
ud
es
on
id
e,
 d
ex
am
et
ha
so
ne
, fl
ut
ic
as
on
e,
 m
et
hy
lp
re
dn
is
ol
on
e)
, w
ar
fa
rin
 
�i
ÃÃ
ÊV
œ“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ a
lfe
nt
an
il, 
bu
sp
iro
ne
, c
ilo
st
az
ol
, d
is
op
yr
am
id
e,
 
 
fe
lo
di
pi
ne
, t
rim
et
re
xa
te
 
œ
“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ c
arba
m
az
ep
in
e,
 e
fa
vir
en
z,
 is
on
ia
zid
, n
ev
ira
pi
ne
, 
↓ p
la
sm
a 
co
nc
en
tra
tio
n 
of
 it
ra
co
na
zo
le
, i
f p
os
si
bl
e 
av
oi
d 
co
nc
om
ita
nt
 
 
ph
en
ob
ar
bi
ta
l, 
ph
en
yt
oi
n,
 ri
fa
bu
tin
, r
ifa
m
pi
n,
 a
nt
ac
id
s,
 H
2 
re
ce
pt
or
 
us
e 
or
 m
on
ito
r i
tra
co
na
zo
le
 le
ve
ls
 
 
an
ta
go
ni
st
s,
 p
ro
to
n 
pu
m
p 
in
hi
bi
to
rs
 
 
Cl
ar
ith
ro
m
yc
in
, e
ry
th
ro
m
yc
in
, f
os
am
pr
en
av
ir,
 in
di
na
vir
, r
ito
na
vir
, s
aq
ui
na
vir
 
 
pl
as
m
a 
co
nc
en
tra
tio
n 
of
 it
ra
co
na
zo
le
, m
on
ito
r i
tra
co
na
zo
le
 le
ve
ls
 a
nd
 
m
on
ito
r f
or
 to
xic
ity
 
↓↓
3.
2 
Ag
en
t-s
pe
ci
fic
 g
ui
de
lin
es
: A
nt
ifu
ng
al
s
22
VO
R
IC
O
N
AZ
O
LE
 (s
ub
st
ra
te
 a
nd
 in
hi
bi
to
r 
of
 C
Y
P2
C
19
, C
Y
P2
C
9,
 a
nd
 C
Y
P3
A4
)
 
D
ru
g 
Re
co
m
m
en
da
tio
ns
C
on
tr
ai
nd
ic
at
ed
 
œ
“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ c
ar
ba
m
az
ep
in
e,
 ri
fa
bu
tin
, r
ifa
m
pi
n,
 
Do
 n
ot
 u
se
 
 
rit
on
av
ir 
40
0 
m
g 
Q1
2H
 
 
�i
ÃÃ
ÊV
œ“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ l
on
g-
ac
tin
g 
ba
rb
itu
ra
te
s,
 c
is
ap
rid
e,
 
 
er
go
t a
lk
al
oi
ds
, p
im
oz
id
e,
 q
ui
ni
di
ne
, S
t. 
Jo
hn
’s 
W
or
t
W
ar
ni
ng
/p
re
ca
ut
io
n 
Cy
cl
os
po
rin
e 
↓ c
yc
lo
sp
or
in
e 
do
se
 to
 1 ⁄
2 a
nd
 m
on
ito
r l
ev
el
s
 
Ef
av
ire
nz
 
 
↓ vo
ric
on
az
ol
e 
do
se
 to
 5
 m
g/
kg
 IV
/P
O 
Q1
2H
 a
nd
 ↓ 
ef
av
ire
nz
 to
 3
00
 m
g 
 
PO
 d
ai
ly
 
Ta
cr
ol
im
us
 
↓ t
ac
ro
lim
us
 d
os
e 
to
 1 ⁄
3 a
nd
 m
on
ito
r l
ev
el
s
 
Si
ro
lim
us
 
↓ÊÃ
ˆÀœ
ˆ“
ÕÃ
Ê`
œÃ
iÊ
LÞ
ÊÇ
x¯
Ê>
˜`
ʓ
œ˜
ˆÌœ
Àʏ
iÛ
i
Ã
 
Om
ep
ra
zo
le
 
↓ o
m
ep
ra
zo
le
 d
os
e 
to
 1 ⁄
2 
 
M
ar
av
iro
c 
 
↓ m
ar
av
iro
c 
do
se
 to
 1
50
 m
g 
tw
ic
e 
da
ily
 
M
et
ha
do
ne
 
M
on
ito
r e
ffe
ct
 o
f t
he
 in
te
ra
ct
in
g 
dr
ug
 a
nd
 c
on
si
de
r d
ec
re
as
in
g 
do
se
 
Ph
en
yt
oi
n 
 
↓ vo
ric
on
az
ol
e 
to
 5
 m
g/
kg
 IV
/P
O 
Q1
2H
 a
nd
 m
on
ito
r l
ev
el
s
 
Ri
to
na
vir
 lo
w
 d
os
e 
(1
00
 m
g 
Q1
2H
) 
Av
oi
d 
th
is
 c
om
bi
na
tio
n 
un
le
ss
 b
en
efi
ts
 o
ut
w
ei
gh
 ri
sk
s
 
W
ar
fa
rin
 
M
on
ito
r I
NR
 le
ve
ls
 
œ
“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ a
ll b
en
zo
di
az
ep
in
es
 (a
vo
id
 m
id
az
ol
am
 a
nd
 tr
ia
zo
la
m
), 
 M
on
ito
r e
ffe
ct
 o
f d
ru
gs
 a
nd
 c
on
si
de
r d
ec
re
as
in
g 
do
se
 w
he
n 
vo
ric
on
az
ol
e 
 
 
al
l c
al
ci
um
 c
ha
nn
el
 b
lo
ck
er
s,
 fe
nt
an
yl,
 o
xy
co
do
ne
 &
 o
th
er
 lo
ng
 a
ct
in
g 
op
io
id
s,
 is
 a
dd
ed
 
 
NS
AI
Ds
, o
ra
l c
on
tra
ce
pt
ive
s,
 s
ta
tin
s 
(a
vo
id
 lo
va
st
at
in
 a
nd
 s
im
va
st
at
in
), 
 
 
 
su
lfo
ny
lu
re
as
, v
in
ca
 a
lk
al
oi
ds
, p
om
al
id
om
id
e,
 s
im
ep
re
vir
, b
oc
ep
re
vir
, t
el
ap
re
vir
 
�i
ÃÃ
ÊV
œ“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ a
lfe
nt
an
il
FL
U
C
O
N
AZ
O
LE
 (s
ub
st
ra
te
 o
f C
Y
P3
A4
 a
nd
 in
hi
bi
to
r 
of
 C
Y
P3
A4
, C
Y
P2
C
9,
 a
nd
 C
Y
P2
C
19
, i
nt
er
ac
tio
ns
 a
re
 o
ft
en
 d
os
e 
de
pe
nd
en
t)
 
D
ru
g 
Re
co
m
m
en
da
tio
ns
C
on
tr
ai
nd
ic
at
ed
 
Ci
sa
pr
id
e 
Do
 n
ot
 u
se
W
ar
ni
ng
/p
re
ca
ut
io
n 
œ
“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ c
yc
lo
sp
or
in
e,
 g
lip
izi
de
, g
lyb
ur
id
e,
 p
he
ny
to
in
, 
↓
 
pl
as
m
a 
co
nc
en
tra
tio
n 
of
 th
e 
in
te
ra
ct
in
g 
dr
ug
, m
on
ito
r l
ev
el
s 
w
he
n 
 
 
rif
ab
ut
in
, t
ac
ro
lim
us
, w
ar
fa
rin
 
po
ss
ib
le
, m
on
ito
r f
or
 d
ru
g 
to
xic
ity
 a
nd
 c
on
si
de
r d
os
e 
re
du
ct
io
n
 
�i
ÃÃ
ÊV
œ“
“
œ˜
ÞÊ
«À
iÃ
VÀ
ˆL
i`
\ o
ra
l m
id
az
ol
am
, t
he
op
hy
llin
e,
 to
lb
ut
am
id
e
 
Ri
fa
m
pi
n 
↓ p
la
sm
a 
co
nc
en
tra
tio
n 
of
 fl
uc
on
az
ol
e,
 c
on
sid
er
 in
cr
ea
sin
g 
flu
co
na
zo
le
 d
os
e
23
3.
3 
 A
ge
nt
-s
pe
ci
fic
 g
ui
de
lin
es
: V
ac
ci
ne
sPneumococcal vaccination 
There are two types of pneumococcal vaccines that are recommended 
LÞÊ�
�*Ê}Ո`iˆ˜iÃÊvœÀÊ>`ՏÌÊ«>̈i˜ÌÃ\Ê*˜iՓœVœVV>Ê«œÞÃ>VV…>Àˆ`iÊ
(Pneumovax 23®, PPV23) and Pneumococcal conjugate vaccine (Prevnar 
13®, PCV13). Most patients should receive both vaccines in sequential 
order, but NEVER together. See table below for indications for each vaccine. 
Indications for pneumococcal vaccines for adults ≥ 19 years of age
Risk group Prevnar 13® Pneumovax 23®
All adults ≥ 65 years of age Yes Yes
CSF leak or cochlear implants Yes Yes
Functional or anatomic asplenia Yes Yes, revaccinate 5 
years after first dose
Immunocompetent persons with certain 
chronic medical conditions (e.g. heart 
disease*, lung disease†, liver disease, 
DM), alcoholism, cigarette smoking 
No Yes 
�““Õ˜œVœ“«Àœ“ˆÃi`ʅœÃÌ\ÊVœ˜}i˜ˆÌ>É
acquired immunodeficiencies, HIV, 
chronic renal failure, nephrotic 
syndrome, hematologic malignancies, 
organ transplant, long-term 
immunosuppressive therapy (e.g. 
steroids, active chemotherapy, radiation)
Yes Yes, revaccinate 5 
years after first dose
I�˜VÕ`ˆ˜}Ê
��]ÊV>À`ˆœ“Þœ«>̅ˆiÃ]ÊiÝVÕ`ˆ˜}ʅޫiÀÌi˜Ãˆœ˜ÆÊa�˜VÕ`ˆ˜}Ê
"*�]Êi“«…ÞÃi“>]Ê
asthma 
Timing and sequential administration of pneumococcal vaccines 
UÊ œÊ…ˆÃ̜ÀÞʜÀÊ՘Ž˜œÜ˜Ê…ˆÃ̜ÀÞʜvÊ«˜iՓœVœVV>ÊÛ>VVˆ˜>̈œ˜Ê>˜`ÊLœÌ…Ê
vaccines are indicated, patient should receive Prevnar 13® first followed 
by Pneumovax 23® at a minimum of 8 weeks later (ideally 6-12 months) 
UÊ�vÊ«>̈i˜Ìʅ>ÃÊÀiViˆÛi`Ê*˜iՓœÛ>ÝÊÓή and both vaccines are indicated, 
the patient should receive Prevnar 13® (minimum 1 year separation) 
UÊ�vÊ«>̈i˜Ìʅ>ÃÊÀiViˆÛi`Ê*Àiۘ>Àʣή ≥ 8 weeks ago, and both vaccines 
are indicated, the patient should receive Pneumovax 23® (minimum 8 
weeks separation)
UÊ�vÊ«>̈i˜Ìʅ>ÃÊÀiViˆÛi`ÊLœÌ…ÊÛ>VVˆ˜iÃÊ≥ 5 years ago and revaccination 
is needed with Pneumovax 23®, a second dose should be administered 
(minimum 5 yearsapart) 
UÊ*>̈i˜ÌÃÊ܅œÊ>ÀiÊÃiÛiÀiÞʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê­i°}°Ê	�/]Ê܏ˆ`ʜÀ}>˜Ê
transplant) should follow institutional policy when available or consult ID 
for optimal timing of vaccine administration
,iviÀi˜Vi\Ê
�
�*Ê,iVœ““i˜`>̈œ˜Ã\Ê��7,ÊÓä£{ÆÈέÎÇ®ÆnÓӇnÓxÊ>˜`Ê��7,ÊÓä£ÓÆÈ£­{ä®Æn£È‡n£™°Ê
4.
1 
O
rg
an
is
m
-s
pe
ci
fic
 g
ui
de
lin
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24
Organism-specific guidelines 
Anaerobes
Although anaerobic bacteria dominate the human intestinal microbiome 
only a few species seem to play an important role in human infections. 
Infections caused by anaerobes are often polymicrobial. 
UÊÊ�À>“‡˜i}>̈ÛiÊL>VˆˆÊ‡ÊBacteroides spp., Prevotella spp., 
Porphyromonas spp., Fusobacterium spp.
UÊÊ�À>“‡˜i}>̈ÛiÊVœVVˆÊ‡ÊVeillonella spp.
UÊÊ�À>“‡«œÃˆÌˆÛiÊL>VˆˆÊ‡ÊPropionibacterium spp., Lactobacillus spp., 
Actinomyces spp., Clostridium spp.
UÊÊ�À>“‡«œÃˆÌˆÛiÊVœVVˆÊ‡ÊPeptostreptococcus spp. and related genera
Clinical diagnosis of anaerobic infections should be suspected in the 
presence of foul smelling discharge, infection in proximity to a muco sal 
surface, gas in tissues or negative aerobic cultures. Proper spec i men 
VœiV̈œ˜ÊˆÃÊVÀˆÌˆV>ÆÊÀiviÀÊ̜ÊëiVˆ“i˜ÊVœiV̈œ˜Ê}Ո`iˆ˜iÃÊ>ÌʅÌÌ«\ÉÉ
www.hopkinsmedicine.org/microbiology/specimen/index.html 
Treatment Notes
 
 
. 
UÊÊ-ÕÀ}ˆV>Ê`iLÀˆ`i“i˜ÌʜvÊ>˜>iÀœLˆVʈ˜viV̈œ˜ÃʈÃʈ“«œÀÌ>˜ÌÊLiV>ÕÃiÊ
anaerobic organisms can cause severe tissue damage.
UÊÊ�“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê>˜`Ê
ˆ˜`>“ÞVˆ˜Ê>ÀiÊVœ˜Ãˆ`iÀi`Ê̜ÊLiÊivviV̈ÛiÊ
empiric therapy against Gram-positive anaerobes seen in infections 
 
 
 
 
 
 
 
 
 
 
 
M
etronidazole
C
lindam
ycin
Ertapenem
C
efotetan
Pip/Tazo
Am
ox/C
lav
Penicillin
# Patients
Hidden Content
- JHH Internal use only
25
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esabove the diaphragm. Metronidazole is not active against 
microaerophilic streptococci (e.g. S. anginosus group) and should not 
be used for these infections. 
UÊÊ6>˜Vœ“ÞVˆ˜ÊˆÃÊ>ÃœÊ>V̈ÛiÊ>}>ˆ˜ÃÌʓ>˜ÞÊ�À>“‡«œÃˆÌˆÛiÊ>˜>iÀœLiÃÊ­i°}°Ê
Clostridium spp., Peptostreptococcus spp., P. acnes). 
UÊÊ
“«ˆÀˆVÊ`œÕLiÊVœÛiÀ>}iÊ܈̅Ê�iÌÀœ˜ˆ`>✏iÊ� �ÊV>ÀL>«i˜i“ÃÊ
(Meropenem, Ertapenem) or beta-lactam/beta-lactamase inhibitors 
(Ampicillin/Sulbactam, Piperacillin/Tazobactam, Amoxicillin/Clavulanic 
acid) is NOT recommended given the excellent anaerobic activity of 
these agents. 
UÊÊB. fragilis group resistance to Clindamycin, Cefotetan, Cefoxitin, and 
Moxifloxacin has increased and these agents should not be used 
empirically for treatment of severe infections where B. fragilis is 
suspected (e.g. intra-abdominal infections). 
UÊÊ�œÃÌÊÀiÈÃÌ>˜Viʈ˜Ê̅iÊB. fragilis group is caused by beta-lactamase 
production, which is screened for by the JHH micro lab.
UÊÊBacteroides thetaiotaomicron is less likely to be susceptible to 
*ˆ«iÀ>Vˆˆ˜É/>âœL>VÌ>“ÆÊ̅iÀivœÀi]Ê܅i˜Ê̅ˆÃʜÀ}>˜ˆÃ“ʈÃʈ܏>Ìi`Ê
or strongly suspected (e.g. Gram negative rods in anaerobic blood 
cultures in a patient on Piperacillin/tazobactam) alternative agents 
with anaerobic coverage should be used until susceptibilities are 
confirmed. 
UÊÊ/ˆ}iVÞVˆ˜iʈÃÊ>V̈ÛiÊ>}>ˆ˜ÃÌÊ>Ê܈`iÊëiVÌÀՓʜvÊ}À>“‡«œÃˆÌˆÛiÊ>˜`Ê
gram-negative anaerobic bacteria in vitro but clinical experience with 
this agent is limited. 
Propionibacterium acnes 
Indications for consideration of testing for P. acnes:
UÊ
 -ÊÅ՘Ìʈ˜viV̈œ˜Ã
UÊ*ÀœÃ̅ïVÊŜՏ`iÀʍœˆ˜Ìʈ˜viV̈œ˜ÃÊ
UÊ"̅iÀʈ“«>˜Ì>LiÊ`iۈViʈ˜viV̈œ˜Ã
Diagnosis
UÊÊ
ՏÌÕÀiÃÊŜՏ`ÊLiʅi`ÊvœÀʣ䇣{Ê`>ÞÃʈvʅˆ}…ÊÃÕëˆVˆœ˜ÊvœÀÊP. acnes 
as growth is slow 
UÊÊ
œiV̈œ˜ÊœvÊ̈ÃÃÕiÊ>˜`ÊyՈ`ÊëiVˆ“i˜ÃÊvœÀÊVՏÌÕÀiʈÃÊ«ÀiviÀÀi`°Ê�œÊ˜œÌÊ
send swabs for culture
UÊÊ�Տ̈«iÊÀi«ÀiÃi˜Ì>̈ÛiÊëiVˆ“i˜ÃÊ­«ÀiviÀ>LÞÊήÊŜՏ`ÊLiÊÃi˜ÌÊ
for shoulder joint infections to assist in distinguishing contaminants 
from pathogenic isolates — these could include synovial fluid, any 
inflammatory tissue, and synovium
U Tissue specimens should also be sent for histopathology
26
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UÊÊ*i˜ˆVˆˆ˜Ê�ÊӇÎʓˆˆœ˜Ê՘ˆÌÃÊ�6Ê+{�Ê­«ÀiviÀÀi`® 
OR
UÊ*
 Ê>iÀ}ÞÊ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
NOTES
UÊÊ��ÊVœ˜ÃՏÌÊÀiVœ““i˜`i`ÊvœÀÊ>ÃÈÃÌ>˜ViÊ܈̅ÊV…œˆViÊ>˜`Ê
duration of antibiotic therapy
UÊÊP. acnes is usually a contaminant in blood culture specimens. Draw 
repeat cultures and consider clinical context before treatment
UÊÊ,>ÀiÊÀi«œÀÌÃʜvÊ눘>Êˆ˜viV̈œ˜Ãʅ>ÛiÊLii˜Ê˜œÌi`ÊvœÀÊP. acnes
UÊÊ�ÊP. acnes isolutes at JHH are susceptible to Penicillin (see anaerobic 
antibiogram p. 24)
UÊÊ�iÌÀœ˜ˆ`>✏iÊ`œiÃʘœÌʅ>ÛiÊ>V̈ۈÌÞÊ>}>ˆ˜ÃÌÊP. acnes. Tetracyclines 
are not routinely tested and resistance rates are variable.
UÊÊ	Àœ>`iÀÊëiVÌÀՓÊ>}i˜ÌÃÊÃÕV…Ê>ÃÊ�iÀœ«i˜i“Ê>˜`Ê*ˆ«iÀ>Vˆˆ˜É
tazobactam would be expected to be active for Penicillin susceptible 
isolates, but these are not first-line therapy
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊ`>Ì>ÊŜՏ`ÊLiÊÕÃi`Ê̜ʅi«Ê}Ո`iÊ̅iÀ>«iṎVÊ`iVˆÃˆœ˜Ã
U Consider removal of associated hardware
Streptococci
Viridans group Streptococci (alpha-hemolytic streptococci) 
 œÀ“>Ê“ˆVÀœLˆœÌ>ʜvÊ̅iʜÀ>ÊV>ۈÌÞÊ>˜`Ê��ÊÌÀ>VÌÆÊȘ}iÊLœœ`ÊVՏÌÕÀiÃÊ
growing these organisms often represent contamination or transient 
bacteremia
Five groups
UÊÊS. anginosus group (contains S. intermedius, anginosus, and 
constellatus®\ÊÊVœ““œ˜ÞÊV>ÕÃiÊ>LÃViÃÃiÃÆʓ>œÀˆÌÞÊ>ÀiÊ*i˜ˆVˆˆ˜Ê
susceptible
UÊÊS. bovisÊ}ÀœÕ«ÊQVœ˜Ì>ˆ˜ÃÊS. gallolyticus subspecies gallolyticus 
(associated with colon cancer—colonoscopy mandatory, endocarditis 
>ÃœÊ«ÀiÃi˜Ìʈ˜Ê€Êxä¯ÊœvÊV>ÃiîÊ>˜`ÊÃÕLëiVˆiÃÊpasteurinus 
­>ÃÜVˆ>Ìi`Ê܈̅ʅi«>̜Lˆˆ>ÀÞÊ`ˆÃi>Ãi]Êi˜`œV>À`ˆÌˆÃʏiÃÃÊVœ““œ˜®RÆÊ
majority are Penicillin susceptible
UÊ S. mitis group (contains S. mitis, oralis, gordonii, and sanguinous®\Ê
Vœ““œ˜ÞÊV>ÕÃiÊL>VÌiÀi“ˆ>ʈ˜Ê˜iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ>˜`Êi˜`œV>À`ˆÌˆÃÆÊ
many have Penicillin resistance
UÊÊS. salivariusÊ}ÀœÕ«\ʏiÃÃÊVœ““œ˜ÊV>ÕÃiʜvÊi˜`œV>À`ˆÌˆÃÆʓ>œÀˆÌÞÊ>ÀiÊ
Penicillin susceptible
UÊÊS. mutansÊ}ÀœÕ«\ÊVœ““œ˜ÊV>ÕÃiʜvÊ`i˜Ì>ÊV>ÀˆiÃÆÊ՘Vœ““œ˜ÊV>ÕÃiÊ
œvÊi˜`œV>À`ˆÌˆÃÆʓ>œÀˆÌÞÊ>ÀiÊ*i˜ˆVˆˆ˜ÊÃÕÃVi«ÌˆLi
Beta-hemolytic Streptococci
All are susceptible to Penicillin
6>Àˆ>LiÊÀ>ÌiÃʜvÊÀiÈÃÌ>˜ViÊ̜Ê
ˆ˜`>“ÞVˆ˜ÆÊ>ÎÊ̅iʓˆVÀœLˆœœ}ÞÊ
laboratory to perform susceptibility testing if you plan to use 
Clindamycin or macrolides for moderate to severe infections. 
While anti-staphylococcal penicillins (Oxacillin and Nafcillin) are the 
agents of first choice for susceptible S. aureus infections, their activity 
against streptococci is sub-optimal
�ˆ}…ÊÀ>ÌiÃʜvÊÀiÈÃÌ>˜ViÊ̜ÊÌiÌÀ>VÞVˆ˜iÃÊ>˜`Ê/�*É-�8Ê«ÀiVÕ`iÊ̅iˆÀÊ
empiric use for infections suspected to be caused by beta-hemolytic 
streptococci
UÊÊS. pyogenesÊ­}ÀœÕ«Ê�ÊÃÌÀi«®\Ê«…>Àޘ}ˆÌˆÃ]ÊΈ˜Ê>˜`ÊÜvÌÊ̈ÃÃÕiÊ
ˆ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ÊiÀÞÈ«i>Ã]ÊViÕˆÌˆÃ]ʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃÆÊ
ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜Ê£°x‡x°Ó¯Æʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜Ê{‡Ç¯°Ê
UÊÊS. agalactiaeÊ­}ÀœÕ«Ê	ÊÃÌÀi«®\ʘiœ˜>Ì>Êˆ˜viV̈œ˜Ã]ʈ˜viV̈œ˜ÃʜvÊ̅iÊ
vi“>iÊ}i˜ˆÌ>ÊÌÀ>VÌ]ÊΈ˜Ê>˜`ÊÜvÌÊ̈ÃÃÕiʈ˜viV̈œ˜Ã]ÊL>VÌiÀi“ˆ>ÆÊ
ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜Ê£È‡ÓȯÆʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜ÊLJÎÓ¯°Ê
4.
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Antibiotic Susceptible Intermediate Resistant
Penicillin (oral) ≤ 0.06 0.12-1 ≥ 2
Penicillin (parenteral)
 Non-CNS ≤ 2 4 ≥ 8
 CNS ≤ 0.06 ≥ 0.12
Ceftriaxone
 Non-CNS ≤ 1 2 ≥ 4
 CNS ≤ 0.5 1 ≥ 2
UÊÊ�``ˆÌˆœ˜ÊœvÊ6>˜Vœ“ÞVˆ˜Ê̜ÊivÌÀˆ>ݜ˜iʈÃʘœÌʈ˜`ˆV>Ìi`ʈ˜Ê̅iÊi“«ˆÀˆVÊ
treatment of non-CNS infections caused by S. pneumoniae due to low 
rates of resistance
Multi-drug resistant Gram-negative rods
Patients with infection or colonization with the resistant 
organisms listed below should be placed on CONTACT 
precautions (see isolation chart on p. 141)
Extended spectrum beta-lactamase (ESBL)-producing organisms
UÊÊ
-	�ÃÊ>ÀiÊi˜âޓiÃÊ̅>ÌÊVœ˜viÀÊÀiÈÃÌ>˜ViÊ̜Ê>Ê«i˜ˆVˆˆ˜Ã]Ê
cephalosporins, and Aztreonam.
UÊÊ/…iÞÊ>ÀiʓœÃÌÊVœ““œ˜ÞÊÃii˜Êˆ˜ÊK. pneumoniae and K. oxytoca, 
E. coli, and P. mirabilis, and these organisms are automatically 
screened by the JHH microbiology lab for the presence of ESBLs. 
UÊÊ�ÀœÕ«Ê
Ê>˜`Ê�ÊÃÌÀi«ÌœVœVVˆ\ʈ˜viV̈œ˜ÃÊȓˆ>ÀÊ̜ÊS. pyogenes and 
S. agalactiaeÆÊ>ÃÜVˆ>Ìi`Ê܈̅Ê՘`iÀÞˆ˜}Ê`ˆÃi>ÃiÃÊ­i°}°Ê`ˆ>LiÌiÃ]Ê
“>ˆ}˜>˜VÞ]ÊV>À`ˆœÛ>ÃVՏ>ÀÊ`ˆÃi>Ãi®ÆÊ
ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜ÊH£È¯Ê
œvÊ}ÀœÕ«Ê
Ê>˜`ÊHÎίʜvÊ}ÀœÕ«Ê�ʈ܏>ÌiÃÆʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜Ê 
HÓx¯ÊœvÊ}ÀœÕ«Ê
Ê>˜`ÊHÓn¯ÊœvÊ}ÀœÕ«Ê�ʈ܏>ÌiðÊ
Streptococcus pneumoniae
UÊÊ
œ““œ˜ÊV>ÕÃiʜvÊÀiëˆÀ>̜ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ʜ̈̈Ãʓi`ˆ>]Ê
ȘÕÈ̈Ã]Ê«˜iՓœ˜ˆ>Êۈ>ʏœV>ÊëÀi>`ÊvÀœ“Ê̅iʘ>Ü«…>ÀޘÝÆʈ˜viV̈œ˜ÃÊ
involving the CNS, bones/joints and endocarditis via hematogenous 
spread
UÊÊ�i˜ïV>Þ]ÊS. pneumoniae is in the S. mitis group of viridans group 
ÃÌÀi«ÌœVœVVˆÆÊVœ˜ÃiµÕi˜ÌÞ]ÊÀ>«ˆ`ʓœiVՏ>ÀÊÌiÃÌÃʓ>ÞʘœÌÊLiÊ>LiÊ̜Ê
distinguish S. pneumoniae and streptococci in the S. mitis group.
UÊÊ*i˜ˆVˆˆ˜ÊˆÃÊ̅iÊ>}i˜ÌʜvÊwÀÃÌÊV…œˆViÊvœÀÊÃiÀˆœÕÃÊS. pneumoniae 
infections when it is susceptible
UÊÊ*i˜ˆVˆˆ˜Ê>˜`Ê
ivÌÀˆ>ݜ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊLÀi>Ž«œˆ˜ÌÃÊ>ÀiÊ`ˆvviÀi˜ÌÊvœÀÊ
CNS and non-CNS sites
MIC breakpoints for Penicillin and Ceftriaxone against 
S. pneumoniae 
UÊÊ,ˆÃŽÊv>V̜ÀÃÊvœÀʈ˜viV̈œ˜ÊœÀÊVœœ˜ˆâ>̈œ˜\ÊÀiVi˜ÌʅœÃ«ˆÌ>ˆâ>̈œ˜Ê>ÌÊ>˜Ê
institution with a high rate of ESBLs, residence in a long-term care 
facility and prolonged use of broad spectrum antibiotics.
/Ài>̓i˜Ì\
UÊÊ�iÀœ«i˜i“Ê£Ê}Ê�6Ê+n�Ê­ÓÊ}Ê�6Ê+n�ÊvœÀÊ
 -ʈ˜viV̈œ˜Ã®ÊŜՏ`ÊLiÊ
used for ALL severe infections if the organism is susceptible.
UÊÊ
ÀÌ>«i˜i“Ê£Ê}Ê�6Ê+Ó{�ÊV>˜ÊLiÊÕÃi`ÊvœÀÊ՘Vœ“«ˆV>Ìi`Ê1/�ʜÀÊÜvÌÊ̈ÃÃÕiÊ
infection with adequate source control if the organism is susceptible.
UÊÊ
ˆ«ÀœyœÝ>Vˆ˜ÊœÀÊ/�*É-�8ÊV>˜ÊLiÊÕÃi`Ê>ÃÊ>ÌiÀ˜>̈ÛiÃÊ̜Ê
ÀÌ>«i˜i“Ê
for uncomplicated UTI or soft tissue infection with adequate source 
control if the organism is susceptible. Nitrofurantoin may also be used 
for uncomplicated UTI if the organism is susceptible. 
Carbapenemase-producing Enterobacteriacae (CRE)
UÊ
>ÀL>«i˜i“>ÃiÃÊ>ÀiÊi˜âޓiÃÊ̅>ÌÊVœ˜viÀÊÀiÈÃÌ>˜ViÊ̜Ê>Ê«i˜ˆVˆˆ˜Ã]Ê
cephalosporins, carbapenems and Aztreonam. 
UÊ���ʓˆVÀœLˆœœ}Þʏ>LʈÃʘœÊœ˜}iÀÊ«iÀvœÀ“ˆ˜}Ê̅iʓœ`ˆwi`Ê�œ`}iÊÌiÃÌ
UÊ�vÊV>ÀL>«i˜i“ʈÃÊÀiÈÃÌ>˜ÌÊ���ʓˆVÀœLˆœœ}Þʏ>LÊ܈ÊÀi«œÀÌʜÀ}>˜ˆÃ“Ê
>ÃʺV>ÀL>«i˜i“ÊÀiÈÃÌ>˜Ì»ÆʅœÜiÛiÀ]Ê̅iÊiÝ>VÌʓiV…>˜ˆÃ“ÊœvÊ
resistance is not tested for at this time.
/Ài>̓i˜Ì\Ê
UÊ�iÀœ«i˜i“ÊÓÊ}Ê�6Ê+n�ʈ˜vÕÃi`ʜÛiÀÊÎʅœÕÀÃÊŜՏ`ÊLiʈ˜VÕ`i`Ê
in most regimens based on data from small, retrospective studies 
showing benefit even when the isolate is intermediate or resistant.
UÊ�Ìʏi>ÃÌʜ˜iÊ>``ˆÌˆœ˜>Ê>}i˜ÌÊŜՏ`ÊLiÊ>``i`ÊL>Ãi`ʜ˜ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ
(e.g. Amikacin, Tigecycline, Colistin) except for UTI.
Multi-drug resistant (MDR) gram-negative organisms: defined as 
organisms susceptible to NO MORE than ONE of the following antibiotic 
V>ÃÃiÃ\ÊV>ÀL>«i˜i“Ã]Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]Êy՜ÀœµÕˆ˜œœ˜iÃ]Ê«i˜ˆVˆˆ˜Ã]Ê
or cephalosporins. Note: susceptibility to sulfonamides, tetracyclines, 
polymixins, and Sulbactam are NOT considered in this definition
Treatment
MDR Pseudomonas aeruginosa MDR Acinetobacter baumannii/calcoaceticus 
 complex
UÊÊ
iv̜œâ>˜iÉÌ>âœL>VÌ>“ÊÊ UÊ�-lactam PLUS aminoglycoside if synergy expected
 (if susceptible) OR
 ORÊ UÊÊ
œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê
UÊÊ�˜Ìˆ‡«ÃiÕ`œ“œ˜>Ê�-lactam PLUS OR
ÊÊÊ>“ˆ˜œ}ÞVœÃˆ`iʈvÊÃޘiÀ}ÞÊ«Ài`ˆVÌi`ÊÊ UÊÊ�“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê­ˆvÊÃÕÃVi«ÌˆLi®ÊPLUS
 or confirmed aminoglycoside (Sulbactam component has in vitro 
 OR activity against Acinetobacter spp.) 
UÊÊ
œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê ÊÊÊOR
Ê UÊÊ/ˆ}iVÞVˆ˜iÊ­ˆvÊÃÕÃVi«ÌˆLiÆÊvœÀʈ˜viV̈œ˜Ãʜ̅iÀÊ̅>˜Ê
bacteremia)
*Combination therapy should be considered in severe infections.
4.
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30
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ro
ds Synergy: 
UÊ�vÊ̅iʜÀ}>˜ˆÃ“ʈÃʈ˜ÌiÀ“i`ˆ>ÌiÊ̜Ê>ÊLiÌ>‡>VÌ>“Ê>˜`ÊÃÕÃVi«ÌˆLiÊ̜Ê
aminoglycosides, synergy can be assumed. 
UÊ/…iʓˆVÀœLˆœœ}Þʏ>LÊ`œiÃʘœÌÊ«iÀvœÀ“ÊÃޘiÀ}ÞÊÌiÃ̈˜}°Ê
Antibiotic doses for MDR and carbapenemase-producing 
infections – normal renal and hepatic function
UÊ�iÀœ«i˜i“\ÊÓÊ}Ê�6Ê+n�]ʈ˜vÕÃiʜÛiÀÊÎʅœÕÀÃÊ
UÊ
ivi«ˆ“i\ÊÓÊ}Ê�6Ê+n�]ʈ˜vÕÃiʜÛiÀÊÎʅœÕÀÃ
UÊ
ivÌ>âˆ`ˆ“iÉ
ivi«ˆ“i\ÊÓÊ}Ê�6ÊLœÕÃʏœ>`ˆ˜}Ê`œÃiʜÛiÀÊÎäʓˆ˜ÕÌiÃ]Ê
then 6 g IV as continuous infusion over 24 hours 
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“\ÊΰÎÇxÊ}Ê�6ÊLœÕÃʏœ>`ˆ˜}Ê`œÃiʜÛiÀÊÎäÊ
minutes, then continuous infusion 3.375 g IV Q4H infused over 4 
hours OR 4.5 g IV Q6H, infuse over 4 hours
UÊ
œˆÃ̈˜\Êxʓ}Ɏ}ʜ˜Vi]Ê̅i˜ÊÓ°xʓ}Ɏ}Ê�6Ê+£Ó�Ê­vœÀÊ>``ˆÌˆœ˜>Ê
information, see p. 9)
UÊ�“«ˆVˆˆ˜ÉÃՏL>VÌ>“\ÊÎÊ}Ê�6Ê+{�Ê­vœÀÊ��,ÊA. baumannii only)
UÊ�“ˆ˜œ}ÞVœÃˆ`iÃÊ­vœÀÊ`œÃˆ˜}]ÊÃiiÊ«°Ê£{È®
UÊ/ˆ}iVÞVˆ˜i\Ê£ä䇣xäʓ}Ê�6Ê+£Ó�Ê
UÊ
iv̜œâ>˜iÉÌ>âœL>VÌ>“Ê£°x‡ÎÊ}Ê�6Ê+n�
,iviÀi˜ViÃ\Ê
-	�ÃÊ>˜`ÊVˆ˜ˆV>ÊœÕÌVœ“iðÊ
ˆ˜Ê�˜viVÌÊ�ˆÃÊÓä£x\ÊÈ䭙®\ʣΣ™\Óx°
Current therapies for P. aeruginosa°Ê
ÀˆÌÊ
>ÀiÊ
ˆ˜ÊÓäänÆÓ{\ÓÈ£°Ê
œ“Lˆ˜>̈œ˜Ê̅iÀ>«ÞÊvœÀÊ
,
°Ê
ˆ˜Ê�ˆVÀœLˆœÊ�˜viVÊÓä£{ÆÓä\ÊnÈӇÇÓ°
Interpreting the microbiology report
Interpretation of preliminary microbiology data
Gram-positive cocci Gram-negative cocci 
Aerobic
In clusters
UÊ
œ>}Տ>ÃiÊ­³®\ÊS. aureus
UÊÊ
œ>}Տ>ÃiÊ­q®\ÊS. epidermidis, 
S. lugdunensis
In pairs/chains 
UÊÊ�ˆ«œVœVVÕÃ]Ê+ÕiÕ˜}Ê«œÃˆÌˆÛi\Ê 
S. pneumoniae
UÊÊ�«…>‡…i“œÞ̈V\Ê6ˆÀˆ`>˜ÃÊ}ÀœÕ«ÊÊ 
Streptococci, Enterococcus 
(faecalis and faecium)
UÊÊ	iÌ>‡…i“œÞ̈V\Ê 
Group A strep (S. pyogenes), 
Group B strep (S. agalactiae), 
Group C, D, G strep
Anaerobic: Peptostreptococcus spp. Anaerobic: Veillonella spp.
Gram-positive rods Gram-negative rods
Aerobic
�>À}i\ Bacillus spp.
œVVœ‡L>VˆÕÃ\ÊListeria monocytogenes, 
Lactobacillus spp. 
-“>]Ê«iœ“œÀ«…ˆV\ Corynebacterium spp.
	À>˜V…ˆ˜}Êw>“i˜ÌÃ\ Nocardia spp., 
Streptomyces spp. 
 
 
 
 
 
Anaerobic
�>À}i\ÊClostridium spp.
Small, pleomorphic: P. acnes, Actinomyces 
spp.
* Serratia spp. can appear initially as non-lactose fermenting due to slow fermentation. 
The Johns Hopkins microbiology laboratory utilizes standard reference 
methods for determining susceptibility. The majority of isolates are 
tested by the automated system. 
The minimum inhibitory concentration (MIC) value represents the 
concentration of the antimicrobial agent required at the site of infection 
for inhibition of the organism. 
The MIC of each antibiotic tested against the organism is reported 
with one of three interpretations S (susceptible), I (intermediate), or 
R (resistant). The highest MIC which is still considered susceptible 
represents the breakpoint concentration. This is the highest MIC which 
is usually associated with clinical efficacy. MICs which are 1⁄2q1⁄8 the 
Aerobic
�ˆ«œVœVVÕÃ\ÊN. meningiditis, N. 
gonorrhoeae, Moraxella catarrhalis
œVVœ‡L>VˆÕÃ\ H. flu, Acinetobacter spp., 
HACEK organisms 
Aerobic
Lactose fermenting: Citrobacter spp., 
Enterobacter spp., E. coli, Klebsiella 
spp., Serratia spp.*
Non-lactose fermenting 
UÊÊ"݈`>ÃiÊ­q®: Acinetobacter spp., 
Burkholderiaspp., E. coli (rare), Proteus 
spp., Salmonella spp., Shigella spp., 
Serratia spp.*, Stenotrophomonas 
maltophilia
UÊÊ"݈`>ÃiÊ ­³®\Ê P. aeruginosa, Aeromonas 
spp., Vibrio spp., Campylobacter spp. 
(curved)
Anaerobic: Bacteroides spp., 
Fusobacterium spp., Prevotella spp.
5.
1 
In
te
rp
re
tin
g 
th
e 
m
ic
ro
bi
ol
og
y 
re
po
rt
31
5.
1 
In
te
rp
re
tin
g 
th
e 
m
ic
ro
bi
ol
og
y 
re
po
rt
32
breakpoint MIC are more frequently utilized to treat infections where 
antibiotic penetration is variable or poor (endocarditis, meningitis, 
osteomyelitis, pneumonia, etc.). Similarly, organisms yielding antibiotic 
MICs at the breakpoint frequently possess or have acquired a low-level 
resistance determinant with the potential for selection of high-level 
expression and resistance. This is most notable with cephalosporins 
and Enterobacter spp., Serratia spp., Morganella spp., Providencia 
spp., Citrobacter spp. and Pseudomonas aeruginosa. These organisms 
all possess a chromosomal beta-lactamase which frequently will be 
over-expressed during therapy despite initial in vitro susceptibility. The 
intermediate (I) category includes isolates with MICs that approach 
attainable blood and tissue levels, but response rates may be lower than 
fully susceptible isolates. Clinical efficacy can potentially be expected in 
body sites where the drug is concentrated (e.g., aminoglycosides and 
beta-lactams in urine) or when a higher dose of the drug can be used 
(e.g., beta-lactams). The resistant (R) category indicates the organism 
will not be inhibited by usually achievable systemic concentrations of the 
antibiotic of normal doses. 
NOTE: MIC values vary from one drug to another and from one 
bacterium to another, and thus MIC values are NOT comparable 
between antibiotics or between organisms.
Spectrum of antibiotic activity
The spectrum of activity table is an approximate guide of the activity of 
commonly used antibiotics against frequently isolated bacteria. It takes 
into consideration JHH specific resistance rates, in vitro susceptibilities 
and expert opinion on clinically appropriate use of agents. For antibiotic 
recommendations for specific infections refer to relevant sections of the 
JHH Antibiotic Guidelines.
33
5.
2 
Sp
ec
tr
um
 o
f a
nt
ib
io
tic
 a
ct
iv
ity
 
Pe
ni
ci
llin
 G
 
Am
pi
ci
llin
 
Am
pi
ci
llin
/s
ul
ba
ct
am
 
Ox
ac
illi
n/
Na
fc
illi
n
 Pi
pe
ra
ci
llin
/t
az
ob
ac
ta
m
 
Ce
fa
zo
lin
 
Ce
fo
te
ta
n
 
Ce
ftr
ia
xo
ne
 
Ce
fe
pi
m
e
 
Az
tre
on
am
 
Er
ta
pe
ne
m
 
M
er
op
en
em
 
M
ox
ifl
ox
ac
in
 
Ci
pr
ofl
ox
ac
in
 
Az
ith
ro
m
yc
in
 G
en
t/
To
br
a/
Am
ik
ac
in
 
Va
nc
om
yc
in
 
Li
ne
zo
lid
 
Da
pt
om
yc
in
Ê
/�
*É
-�
8
 
Cl
in
da
m
yc
in
 
Do
xy
cy
cl
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Co
lis
tin
 
M
et
ro
ni
da
zo
le
 
G
RA
M
-P
O
SI
TI
VE
 
G
RA
M
-N
EG
AT
IV
E
No
t a
ct
ive
Le
ss
 a
ct
ive
 o
r p
ot
en
tia
l r
es
is
ta
nc
e
Ac
tiv
e
Atypicals
Abdominal anaerobes 
Oral anaerobes 
Pseudomonas spp.
Enterobacter spp. 
Serratia spp.
Proteus spp. 
Kebsiella spp. 
E. coli
H. influenzae 
Viridans strep. 
S. pneumoniae 
�-hemolytic strep. 
Coag. neg. staph 
MSSA 
MRSA
E. faecalis
VRE
5.
3 
In
te
rp
re
ta
tio
n 
of
 r
ap
id
 d
ia
gn
os
tic
 te
st
s
34
Interpretation of rapid diagnostic tests
The JHH microbiology lab performs rapid nucleic acid microarray testing 
on blood cultures growing Gram-positive organisms and peptide nucleic 
acid fluorescence in situ hybridization (PNA-FISH) testing on blood 
cultures growing yeast. 
Nucleic acid microarray testing (Verigine®) for Gram-positive 
cocci in blood cultures
UÊÊ�iÌiVÌÃÊ>˜`ʈ`i˜ÌˆwiÃÊ̅iʘÕViˆVÊ>Vˆ`ÃʜvÊ£ÓÊ�À>“‡«œÃˆÌˆÛiÊL>VÌiÀˆ>Ê
genera/species and 3 resistance markers. 
UÊÊ	>VÌiÀˆ>ÊëiVˆiÃ\ÊS. aureus, Coagulase-negative staphylococci, S. 
lugdunensis, Staphylococcus spp. E. faecalis, E. faecium, S. pyogenes 
(group A streptococci), S. agalactiae (group B streptococci), S. 
pneumoniae, S. anginosus, Streptococcus spp. (e.g.,group C and G 
streptococci, viridans group streptococci, etc.), Listeria spp. 
UÊ,iÈÃÌ>˜Viʓ>ÀŽiÀÃ\ʓiV�]ÊÛ>˜�]ÊÛ>˜	
Ê UÊÊ�vÊS. aureus is mecA positive the organism is resistant to Methicillin 
and is reported as MRSA
Ê UÊÊ�vÊS. aureus is mecA negative the organism is susceptible to 
Methicillin and is reported as MSSA 
Ê UÊÊ�vÊ
°Êfaecalis/faecium is vanA/B positive the organism is resistant 
̜Ê6>˜Vœ“ÞVˆ˜ÊÊ>˜`ʈÃÊÀi«œÀÌi`Ê>ÃÊ6,
ÆʘœÌiÊ̅>ÌÊ>Ê6>˜Vœ“ÞVˆ˜‡
resistant E. faecalis are susceptible to Ampicillin at JHH
UÊÊ,iÃՏÌÃʜvÊ̅iÊÌiÃÌÊ>ÀiÊÀi«œÀÌi`Ê܈̅ˆ˜Ê·{ʅœÕÀÃÊ>vÌiÀÊ̅iÊLœœ`Ê
cultures turn positive 
UÊ/iÃ̈˜}ʈÃÊ«iÀvœÀ“i`ʜ˜Þʜ˜Ê̅iÊwÀÃÌÊ«œÃˆÌˆÛiÊLœœ`ÊVՏÌÕÀiÊ
UÊÊ/iÃ̈˜}ʈÃÊ "/Ê«iÀvœÀ“i`ʜ˜ÊLœœ`ÊVՏÌÕÀiÃÊ}ÀœÜˆ˜}ʓœÀiÊ̅>˜Êœ˜iÊ
Gram positive organism but is performed on blood cultures growing 
both Gram positive and negative organisms
UÊÊ�vÊ̅iÊÌiÃÌʈÃʘi}>̈ÛiʈÌÊ܈ÊLiÊÀi«œÀÌi`Ê>Ãʘi}>̈ÛiÊvœÀÊ̅iÊvœœÜˆ˜}Ê
œÀ}>˜ˆÃ“Ã\Ê-Ì>«…ޏœVœVVÕÃÊë«]ÊStreptococcus spp., E. faecalis, E. 
faecium, Listeria spp. 
35
5.
3 
In
te
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of
 r
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sOrganism Preferred empiric therapy Alternative empiric therapy 
 (% susceptible in blood at JHH) if PCN allergic 
MSSA Ê "Ý>Vˆˆ˜Ê­£ää¯®Ê œ˜‡ÃiÛiÀiÊ*
 Ê>iÀ}Þ\Ê
iv>✏ˆ˜Ê 
Ê Ê -iÛiÀiÊ*
 Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
MRSAÊ 6>˜Vœ“ÞVˆ˜Ê­£ää¯®Ê �>«Ìœ“ÞVˆ˜
Ê -ˆ˜}iÊ«œÃˆÌˆÛiÊVՏÌÕÀiÃÊ>ÀiʜvÌi˜Ê>ÊVœ˜Ì>“ˆ˜>˜ÌÆʘœÊÌÀi>̓i˜ÌÊ 
Coagulase-negative recommended. See p. 60 of the JHH Antibiotic Guidelines for 
staphylococci information and indications for treatment. Call the microbiology lab for 
 more information and further work up if infection suspected (5-6510).
S. lugdunensisÊ 6>˜Vœ“ÞVˆ˜Ê­£ä䯮2Ê "Ý>Vˆˆ˜Ê­™È¯®ÊœÀÊ�>«Ìœ“ÞVˆ˜Ê
E. faecalisÊ �“«ˆVˆˆ˜Ê­™n¯®Ê 6>˜Vœ“ÞVˆ˜Ê­™x¯®1
E. faecium (VRE)Ê �ˆ˜i✏ˆ`Ê­nǯ®3Ê �>«Ìœ“ÞVˆ˜Ê­™Ç¯®
E. faecium (not VRE)Ê6>˜Vœ“ÞVˆ˜Ê­£ä䯮3 Linezolid
Streptococcus spp.Ê œ˜‡œ˜Vœœ}ÞÊ«>̈i˜Ì\Ê
ivÌÀˆ>ݜ˜i4 -iÛiÀiÊ*
 Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1 
Ê "˜Vœœ}ÞÊ«>̈i˜Ì\Ê6>˜Vœ“ÞVˆ˜4
S. anginosus Ê *i˜ˆVˆˆ˜Ê�Ê­£ää¯®Ê œ˜‡ÃiÛiÀiÊ*
 Ê>iÀ}Þ\Ê
ivÌÀˆ>ݜ˜i 
Ê Ê -iÛiÀiÊ*
 Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
S. pyogenes Ê *i˜ˆVˆˆ˜Ê�Ê­£ää¯®Ê œ˜‡ÃiÛiÀiÊ*
 Ê>iÀ}Þ\Ê
iv>✏ˆ˜ 
(group A strep) -iÛiÀiÊ*
 Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
S. agalactiae Ê *i˜ˆVˆˆ˜Ê�Ê­£ää¯®Ê œ˜‡ÃiÛiÀiÊ*
 Ê>iÀ}Þ\Ê
iv>✏ˆ˜ 
(group B strep) Ê -iÛiÀiÊ*
 Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
S. pneumoniae Ê 
ivÌÀˆ>ݜ˜iÊ­£ä䯮4Ê -iÛiÀiÊ*
 Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1 
(not meningitis)
S. pneumoniae Ê 
ivÌÀˆ>ݜ˜iʳÊ6>˜Vœ“ÞVˆ˜ÊÊ -iÛiÀiÊ*
 Ê>iÀ}Þ\Ê 
(meningitis) 
…œÀ>“«…i˜ˆVœÊ³Ê6>˜Vœ“ÞVˆ˜1 
Listeria spp. Ê �“«ˆVˆˆ˜Ê­£ää¯®Ê /Àˆ“i̅œ«Àˆ“ÉÃՏv>“i̅œÝ>✏i
1Consult allergy for skin testing /desensitization
2Narrow to Oxacillin if found to be susceptible
3Narrow to Ampicillin if found to be susceptible
4Narrow to Penicillin G if found to be susceptible
PNA-FISH for yeast 
UÊÊ�vÊ* �‡��-�ÊŜÜÃÊC. albicans, most non-oncology patients without 
prior azole exposure can be treated with fluconazole. For more 
information see p. 117 and 134. 
UÊÊ�vÊ* �‡��-�ÊŜÜÃÊC. glabrata, treat with Micafungin until 
susceptibilities available. For more information see p. 117 and 134. 
UÊÊ�vÊ* �‡��-�ʘi}>̈ÛiÊvœÀÊC. albicans or C. glabrata, most cases can be 
treated as unspeciated candidemia, unless cryptococcus is