Spectrum: Local Antimicrobial Stewardship, for Markham Stouffville Hospital

Step-Down Therapy

Notes

Systemic exposure is not equivalent between oral and IV routes of the same antimicrobial in different dosage forms. Step-down therapy covers a similar spectrum of organisms as the IV route and should be chosen based on the type and site of infection.

Consult ASP for assistance in stepping down therapy as needed

IV Drugs

Acyclovir 5 mg/kg IV q8h

Oral Drug:

  • Acyclovir 400 mg q8h

OR

  • Valacyclovir 500 mg q12h

Ampicillin 1-2 g q6h

Oral Drug:

  • Amoxicillin 500 mg q8h

Cefazolin 1-2 g q8h

Oral Drug:

  • Cephalexin 500 mg q6h

Cefuroxime 750 mg q8h

Oral Drug:

  • Cefuroxime Axetil 500 mg q12h

Ceftazidime 1-2 g q8h

Oral Drug:

  • Ciprofloxacin 500-750 mg q12h

Ceftriaxone 1-2 g q24h

Oral Drug:

  • Amoxicillin/clavulanate 875/125 mg q12h

OR

  • Ciprofloxacin 500 mg q12h with or without Cephalexin 500 mg q6h

OR

  • Cefuroxime Axetil 500 mg q12h

Cloxacillin 1-2 g q6h

Oral Drug:

  • Cloxacillin 500 mg q6h

Penicillin sodium 4 million units q6h

Oral Drug:

  • Penicillin VK 300 mg q6h

Piperacillin/Tazobactam
4.5 g q8h

Oral Drug:

  • Consult ASP for assistance in stepping down

  • Amoxicillin/clavulanate 500/125 mg q8h AND Ciprofloxacin 500-750 mg q12h (if Pseudomonas coverage is required)