Spectrum: Local Antimicrobial Stewardship, for Prisma Health-Midlands

APBL-Resistant

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

MDR 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

OR

Meropenem 1 G IV Q8h

May also be considered in patients that have received recent therapies with cefepime AND piperacillin-tazobactam

PLUS

Tobramycin 5-7.5 mg/kg IV Q24h

  • For double Gram-negative coverage

  • Consider pharmacy consult to dose

PLUS

Vancomycin 15 mg/kg IV Q8-12h

Consider pharmacy consult to dose and discontinue if MRSA nasal swab PCR is negative

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

OR

Levofloxacin 750mg PO Q24h

For documented Legionella pneumonia

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.