APBL-Resistant | Spectrum

Important

Cystic Fibrosis or Bronchiectasis

Patients with cystic fibrosis or bronchiectasis may have extensive histories of multidrug-resistant organisms and may require customized therapy.

Strongly consider consulting with infectious diseases, the Prisma Health-Midlands Antimicrobial Stewardship and Support Team (PHASST), and/or pulmonology for assistance with antimicrobial selection.

Microbiology

The regimen below provides coverage for multidrug-resistant (MDR) gram-negative pathogens

APBL-Resistant Pseudomonal Coverage

Cefepime 2 G IV Q8h

Generally preferred to minimize risk of acute kidney injury with concomitant vancomycin and piperacillin/tazobactam
Avoid using same APBL the patient was recently exposed to or if recent organism was resistant

OR

Piperacillin-tazobactam 4.5 G IV Q6h

Avoid using same APBL the patient was recently exposed to or if recent organism was resistant

PLUS

Tobramycin 5-7.5 mg/kg IV Q24h

For double Gram-negative coverage
Consider pharmacy consult to dose

WITH OR WITHOUT

Azithromycin 500mg IV/PO x 1

For atypical coverage
Continue if Legionella urinary antigen positive or if clinical suspicion high

OR

Doxycycline 100mg PO Q12h

If Azithromycin cannot be used

IF CRITICALLY ILL, ADD

Vancomycin 25 mg/kg IV OT as loading dose, THEN maintenance dose per PH Guidelines (consider pharmacy consult to dose)

D/C if MRSA nasal swab PCR is negative

Critical Illness

Intensive care unit admission
Need for mechanical ventilation or vasopressors
Other severe complications of pneumonia (e.g. empyema)

Potential PO Transition

Limited options, consult ID/ASST

Total Duration

7 Days

Duration of therapy may be extended (e.g. total 10-14 days) for patients who fail to respond clinically and/or are definitely diagnosed with pneumonia due to non-lactose fermenting gram-negative bacteria (e.g. P. aeruginosa) or Legionella spp.