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45 Cards in this Set

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  • Back
 Ampho B, Lipid Complex B Liposomal Ampho B
o ID service should be aware of all patients on systemic ampho B antifungals
o Lipid forms of ampho B are very expensive
o Potential Adverse reactions/toxicity (renal, electrolyte, infusion related side effects)
Ampho B, Lipid Complex B Liposomal Ampho B
dosing info
Dosing info:
• If renal dysfunction is due to the drug, the daily total can be decreased by 50% or the dose can be given qod; IV
• Therapy may take several months
• Liposomal – no adjustments necessary; effects of renal impairment are not currently known
 Amikacin
o Aminoglycoside – requires levels/dosage adjustment
o Gentamicin is our usual first choice aminoglycoside
o Reserve for use with organisms resistant to gentamicin (eg Acinetobacter)
o Aminoglycoside related toxicity (renal, ototoxicity, vestibular toxicity)
amikacin dosing info
• Give a loading dose of 5-7.5mg/kg; subsequent dosages and frequency of administration are best determined by measurement of serum levels and assessment of renal insufficiency
• Dialyable (50-100%)
• Some patients may require larger or more frequent doses if serum levels document the need (eg cystic fibrosis or febrile granulocytopenic patients)
 Azithromycin
o Reserve 2nd generation macrolide for MAC, special circumstances (pertussis prophylaxis, pediatric use, PROM etc)
o Not 1st line in pneumonia guidelines
o More expensive vs erythomycin
o 5 days treatment will have enough blood levels for 10-14 days
Azithromycin dosing info
 Use caution in patients with CrCL: <10ml/min
o Same side chian as Ceftazidime – same gram negative coverage, including enhanced antipseduomonal coverage
o No appreciable gram positive activity
o Reserved for use for susceptible organisms – in patients with ceph allergy
o Cefepime/aztreonam may be considered for dual antipseudomonal coverage
aztreonam dosing info
 CrCL: 10-30mL/min: 50% of usual dose give at the usual interval
 CrCL: <10ml/min: 25% of usual dose given at the usual interval
o Use on systemic antifungal for serious infections (febrile neutropenia) esp non-ablicans Candida spp
o Monitor for development of resistance
caspofungin dosing info
 Mild hepatic insufficiency (Child-Pugh score 5-6) no adjustment necessary
 Moderate hepatic insufficiency (Child-Pugh score 7-9) 35mg/day; initial 70mg loading dose should still be administered in treatment of invasive infections
 Severe heaptic insufficiency (Child-Pugh score >9): no clinical experience
 Cefepime:
o Very similar coverage to ceftaxidime; occasional discord with organsims (including psudomonas)
o Consider use when:
 Recent ceftazidime use
 Know sensitivity to cefpime, but resistant to ceftazidime
 Combination of cefepime and aztreonam for psuomonas
cefepime dosing info
 Adults: recommended maintenance schedule based on creatinine clearance (ml/min) compared to nomral dosing
o Similar coverage to ceftriaxone (enhanced pneumoccocal coverage)
o Has been replaced by ceftriaxone in guidelines (CNS, GI)
cefotaxime dosing info
 CrCL: <20ml/min Reduce dose 50%
 Moderately dialyzable (20-50%)
 Ceftazidime (>1g)
o See cefepime
o Ceftazidime has been the hospitals 3rd generation of choice for <10 years
 Relatively little change in resistance pattern
ceftazidime >1g dosing info
 CrCL: 31-50ml/min admin q12h
 crCL: 10-30ml/min admin q24h
 crCL: <10 ml/min admin q24-48h
 dialyzable (50-100%)
 ceftriaxone (>1g)
o appropriate for CNS coverage, endocarditis, osteomyelitis – otherwise, 1g doses appropriate for pneumonia, GI, GU infections
 ceftriaxone (>1g) dosing info
 Hemodialysis: not dialyable (0-5%) admin dose postdailysis
 Peritoneal dialysis: admin 750mg q12h
 Clarithromycin
o See azithromycin
 Reserved for specific infections: MAC, H pylori other atypical mycobacteria
clarithromycin dosing info
 CrCL: <30 ml/min half the normla dose or double the dosing interval
 In combination with ritonavir
• crCL:30-60ml/min decrease clarithromycin dose by 50%
• crCL: <30ml/min: decrease clarithromycin dose by 75%
 Daptomycin
o No to be used for Pneumonia due to poor penetration into lung tissue
o Fairly expensive (but less than linezolid)
o IV only
o ID should be contacted
daptomycin dosing info
 CrCL: <30ml/min; 4mg/kg q48h
 Hemodylasis (admin after HD) and/or CAPD: doses as in crCL<30ml/min
o Most cost-effective carbapenem, but must confirm that organism is sensitive
o Unlike meropenem or imipenem does not have enhanced activity against pseudomonas
o Once a day dosing
ertapenem dosing info
 Adjustments cannot be recommeded (lack of experience and resear in this patient population)
fluconazole IV
o Look for opportunitis to convert to po when possibel due to excellent po bioavailbility and cost
o No adjustment for vagninal candidiasis single-dose therpay
fluconazole dosing info
 For mulitple dosing, administer usual load then adjust daily doses
 CrCL: 11-50ml/min: admin 50% of recommended dose or admin q48h
 HD: one dose after each dialysis
 Imipenem:
o Meropenem is our carbapenem of choice because of reduce risk of seizures
o Rarely, an isolate may be sensitive to imipenem and resistant to meropenem
o Usually, we use imipenem when meropenem is not avialble for the manufacture
imipenem dosing info
 Patients with a CrCL <5ml/min/1.73 m2 should bot receive imipenem/cilastatin unless HD is instituted within 48hrs
 Patients weighing <30kg with impaired renal function should not receive imipenem/cilastatin
 HD: use the dosing recommendation for patients with crCL: 6-20ml/min
o Marker for non-albicans candida spp in hospital setting
o Usual empiric choice for suspected funagl UTI until cultures return
o If C. albicans change to fluconazole
o IV form expensive; if serious fungal infection, consider caspofungin
o Check that po form administered is liquid, not capsule (porr biavailability
Itraconazole Dosing
 Injection is not recommeded in patients with CrCL<30ml/min; hydroypropyl-B-cyclodextrin (the excipeient) is eleiminated primarily by the kidneys
 Hemodialysis: not dialyzable
 Levofloxacin
 Levofloxacin
o Our later generation fluoroquinolone of choice is Moxofiloxacin as it may take a 2 step mutation to cuase resistance, as opposed to a 1 step mutation for levofloxacin
Levofloxacin dosing info
 Chronic bronchitis, acute bacterial sinusitis, uncomplicated skin infection, CAP, chronic bacterial, prostatitis, or inhalation anthrax: initial 500mg then as follows
• crCL: 20-49ml/min 250mg q24h
• crCL:10-19ml/min 250mg q48h
• HD/CAPD: 250mg q48h
o Uncomplicated UTI: no dose adjustment required
o Complicated UTI actue pyelonephritis: crCL: 10-19ml/min: 250mg q48h
o Complicated skin infection, acute bacterial sinusitis, CAP, or nosocominal pneumonia: initial 750mg then
• crCL: 20-49ml/min 750mg q24h
• crCL:10-19ml/min 500mg q48h
• HD/CAPD: 500mg q48h
 Linezolid
o Drug of choice for VRE
o Drug of chice for serious MRSA infections in pt’s unable or unwilling to receive IV vancomycin
o Converte IV to PO when possible ude to excellent po bioavailability
o Very expensive 10 day course (check Rx coverage before considering outpatient Rx)
Linezolid dosing info
 No specific adjustment recommended. The two primary metabolites may accumulate in patients with renal impariment but the clincial significance is unkown. Weigh the risk of accumulation of metabolites vs the benefit of therapy. Both linezolid and the two metabilites are eliminated by dailysi. Linezolid should be given after HD
 Meropenem:
o Our carbapenem of choice
o Carbapenam class is being kept as 2nd line agent in our hospital in order to a “class” of abx in reserve and to preserve the hosptial ecology if possible
o Excellent anaerobic activity, metronidazole may be unnecessary
Meropenem dosing info
 Dosage should be reduce when crCL<15ml/min – consult appropriate refernce for dosage
• Adults
o CrCL: 26-50ml/min: admin 1-2g q12h
o crCL: 10-25 admin 500mg to 1g q12h
o crcL: <10ml/min admin 500mg to 1g q24h
o HD: meropenem and its metabolites are readily dialyzable
 Moxifloxacin
o Our later generation fluoroquinolone of choice for PNA and selected other diagnosis (eg PID)
o Convert to IV to PO when possible
o Look to confirm PNA diagnosis; we don’t want this drug to become the next “bronchitis/sinusitis/URI’ med
moxifloxacin dosing info
• No dosage adjustment required
 Timentin (ticarcillin/clavulanate)
o PIP/tazo is our IV beta lactamase inhibitor of choice due to broader coverage
Timentin dosing info
 crCL: 30-60ml/min admin 2g q4h or 3.1g q8h
 crcL 10-30 ml/min admin 2g q8h or 3.1g q12h
 crCL: <10ml/min admin 2g q12h
 moderatley dialyzable (20%-50%)
 Voriconazole
o Serious fungal infections need to be know to ID
o Very expensive
o Itraconazole/Fluconazole are usual antifungals recommended for fungal UTI’s/less serious fungal infections
o Look to convert IV to PO when possible
o Caspofungin is our usual antifungal of choice for suspected or known fungal infections
voriconazole dosing info
 In patients with CrCL <50ml/min accumulation of the intravenous vehicle (SBECD) occurs. After initial loading dose, oral voriconazole should be administered to these patients, unless an assessment of the benefit: risk to the patient justifies the use of IV voriconazole. Monitor serum creatinine and change to oral voriconazole therapy when possible
 Piperacillin
o See Pip/Tazo
piperacillin dosing info
o Dosing info
 crCL: 20-40ml/min admin 2/0.25g q6h
 CrCL: <20ml/min Admin 2/0.25g q8h
 HD: admin 2/0.25g q8h with an additional dose of 0.75g after each dialysis
 Pip/Tazo (Zosyn)
o Becoming more recommended we’d like to track it’s use
o Q4h dosing for antipsudomonal Rx otherwise q6h