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Antibiotic guidelines

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Antibiotic guidelines
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  Treatment Recommendations For Adult Inpatients Also available online at insidehopkinsmedicine.􀀰rg/amp Antibiotic Guidelines 󰀲󰀰󰀱󰀵-󰀲󰀰󰀱󰀶  1. Introduction  ............................................................................................ 32. Johns Hopkins Hospital formulary and restriction status  .................... 6 2.1 Obtaining ID approval ........................................................................62.2 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 ...................................................143.2 Antifungals.....................................................................................16 AmBisome® ................................................................................16 Micafungin ...................................................................................17 Posaconazole ..............................................................................18 Voriconazole ................................................................................19 Azole drug interactions .................................................................203.3 Vaccines .......................................................................................23 Pneumococcal vaccines ...............................................................23 4. Organism-specific guidelines  .............................................................. 24 4.1 Anaerobes .....................................................................................244.2 Propionibacterium acnes  ................................................................254.3 Streptococci..................................................................................274.4 Multi-drug resistant Gram-negative rods ..........................................28 5. Microbiology information  .................................................................... 31 5.1 Interpreting the microbiology report ................................................315.2 Spectrum of antibiotic activity .........................................................325.3 Interpretation of rapid diagnostic tests ............................................345.4 Johns Hopkins Hospital antibiogram ...............................................36 6. Guidelines for the treatment of various infections ...........................396.1    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)  ............................................ 476.3 Infectious diarrhea  ..................................................................... 516.4 H. pylori    infection  ....................................................................... 546.5 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 1    T  a   b   l  e  o   f  c  o  n   t  e  n   t  s (continued on next page)  6.7 Endocarditis  ................................................................................ 656.8 Pacemaker/ICD infections ......................................................... 716.9 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) .....................................786.11 Orbital cellulitis .....................................................................806.12 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  ......................... 936.14 Tuberculosis (TB)  ........................................................................ 956.15 Sepsis with no clear source  ....................................................... 996.16 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  ............................ 1156.19 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 ....................................1398.2 Infection control precautions .......................................................1418.3 Disease-specific infection control recommendations .....................142 10. Appendix:  A. Aminoglycoside dosing and therapeutic monitoring ........................145B. Vancomycin dosing and therapeutic monitoring ..............................150C. Antimicrobial therapy monitoring ...................................................153D. Oral antimicrobial use ...................................................................154E. Antimicrobial dosing in renal insufficiency .......................................155F. Cost of select antimicrobial agents ................................................159 2    T  a   b   l  e  o   f  c  o  n   t  e  n   t  s  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 PharmacistAssociate Director, Antimicrobial Stewardship Program Kate Dzintars, Pharm.D. ID Pharmacist Janessa Smith, Pharm.D. ID Pharmacist 3    1 .   I  n   t  r  o   d  u  c   t   i  o  n

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