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Antibiotic alternatives to Fluoroquinolones- GENERAL CARE

Antibiotic alternatives to Fluoroquinolones- GENERAL CARE - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Infection and Isolation, Related


Appendix C. Antibiotic alternatives to Fluoroquinolones
From: PK/PD Dose Optimization of Antibiotics for the Treatment of Gram-negative Infections – Adult – Inpatient Clinical Practice Guideline
Last Reviewed 1/2017; Last Updated 1/2017
Contact information: Lucas Schulz, PharmD, Phone Number: (608)890-8617, LSchulz2@uwhealth.org
Table 1. Recommended alternative EMPIRIC regimens – GENERAL CARE
Diagnosis Historical Empiric Therapy Proposed New Empiric Therapy Comments/Step Down Therapy
A
Cystitis or
Uncomplicated
Urinary Tract Infection
Ciprofloxacin OR
Levofloxacin
Nitrofurantoin
Fosfomycin
Cefpodoxime
Do not treat asymptomatic bacteruria
Base on final culture results:
nitrofurantoin, fosfomycin, TMP/SMX,
cefpodoxime
Ceftriaxone susceptibility predicts
activity for cefpodoxime
Pyelonephritis Ciprofloxacin OR
Levofloxacin
No risk for MDRO: cefpodoxime or ceftriaxone
If no oral options, page 3333 for
fluoroquinolone approval
Tailor therapy based on final culture
results
Ceftriaxone susceptibility predicts
activity for cefpodoxime
With risk factors for MDRO: cefepime and vancomycinB
With risk factors for MDRO and IgE-mediated or severe reaction to
β-lactam: gentamicin OR TMP/SMX
Spontaneous
bacterial peritonitis
(SBP) prophylaxis
Ciprofloxacin Oral therapy: TMP/SMX OR cefpodoxime
Intravenous therapy: ceftriaxone
May transition to oral equivalent of
empiric regimen OR to ciprofloxacin at
discharge
Intra-abdominal
infection – community
or healthcare
associated
Ciprofloxacin AND
metronidazole
No risk factors for MDRO:
ξcefpodoxime AND metronidazole OR
ξceftriaxone AND metronidazole
Base on final culture results, some
examples of potential oral options:
ξcefpodoxime OR cefuroxime PLUS
metronidazole
ξamoxicillin/clavulanic acid
If final culture results require
fluoroquinolone step down (e.g.
Pseudomonas) single oral dose prior
to discharge is acceptable
Vancomycin PLUS
Piperacillin/
tazobactam AND
Ciprofloxacin
With risk factors for MDRO or severe community-acquired
infection:
ξvancomycinB PLUS piperacillin/tazobactam OR
ξvancomycinB PLUS cefepime AND metronidazole
With risk factors for MDRO and IgE-mediated or severe reaction to
β-lactam: vancomycinB PLUS aztreonam PLUS metronidazole
Copyright © 2017 Univ ersity of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Diagnosis Historical Empiric Therapy Proposed New Empiric Therapy Comments/Step Down Therapy
A

Community-acquired
PneumoniaD
Moxifloxacin OR
Levofloxacin
No risk factors for MDRO:
ξ ceftriaxone PLUS doxycycline OR
ξ ceftriaxone PLUS azithromycin
Potential oral options: cefpodoxime
OR cefuroxime PLUS azithromycin OR
doxycycline

If no oral options, page 3333 for
fluoroquinolone approval
For patients with IgE-mediated or severe reaction to β-lactam:
vancomycinB PLUS aztreonamC
Healthcare-associated
PneumoniaD
Vancomycin PLUS
Cefepime AND
Ciprofloxacin
With risk factors for MDRO: vancomycinB PLUS cefepime

If patient in septic shock: ADD tobramycin (Pending transfer to
higher care level)

If concern for atypical bacteria: ADD azithromycin
Double coverage for Pseudomonas is
not required in clinically stable, general
care patient

If no oral options, page 3333 for
fluoroquinolone approval For patients with IgE-mediated or severe reaction to β-lactam:
vancomycinB PLUS aztreonamC
Sepsis (without septic
shock) of urinary
origin/pyelonephritis
Vancomycin
AND/OR
ciprofloxacin
No risk factors for MDRO: ceftriaxone

With risk factors for MDRO: vancomycinB PLUS cefepime

For patients with IgE-mediated or severe reaction to β-lactam:
vancomycinB PLUS tobramycin

Septic Shock –
unknown origin
empiric coverage of
Pseudomonas
Vancomycin PLUS
Piperacillin/tazoba
ctam AND
Ciprofloxacin
ξ VancomycinB PLUS piperacillin/tazobactam PLUS tobramycin
OR
ξ VancomycinB PLUS cefepime PLUS tobramycin

For patients with IgE-mediated or severe reaction to β-lactam:
VancomycinB PLUS aztreonamC PLUS tobramycin PLUS
metronidazole

A Base step down therapy on culture results, if no oral step down therapy except fluoroquinolones exist, please page 3333 for approval or other
options
B
Vancomycin therapy targeted to trough goal of 15-20 mcg/mL
C Empiric aztreonam use is approved for 72 hours. Further therapy with aztreonam will require approval via 3333 pager or ID consult
D
If severe or immediate IgE-mediated beta-lactam allergy, please page 3333 for alternative options
MDRO: Multidrug-resistant organism
TMP/SMX: trimethoprim/sulfamethoxazole

Copyright © 2017 Univ ersity of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org