1. Restricted Antimicrobial Pager 2013-2014

2. Restricted Antimicrobials Amikacin* Amphotericin, liposomal Amphotericin (Inhaled) Artemether/lumefantrine Atovaquone Aztreonam Cefotaxime Ceftaroline Ceftazidime Cidofovir* Colistin (IV)* Daptomycin Entecavir Ertapenem Fidaxomicin Foscarnet* Ganciclovir Imipenem Itraconazole Ivermectin Linezolid Maraviroc Meropenem Micafungin Moxifloxacin Nitazoxanide Pentamidine Posaconazole* Quinine Quinupristin/dalfopristin Ribavirin (Inhaled)* Rimantadine Ticarcillin/Clavulanate Tigecycline Tobramycin (Inhaled) Voriconazole

3. Approximately 5-6 pages per day 8AM-8PM Most Commonly Requested Antimicrobials

4. Updated: Selected Antimicrobials That Should Not be Approved by Pager Service Agents are marked with asterisk in policy document Agents chosen due to toxicity or cost Amikacin Cidofovir Colistin (IV) Foscarnet Posaconazole Ribavirin (Inhaled)

5. Approval Log Located in MGH ASP (antimicrobial stewardship) folder –Daily (if possible) upload or email to Christy Purpose: –To keep an accurate log of approvals/indications –Stewardship team insight (since lack of formal note providing indication/purpose) –Follow up on empiric approvals (either you or Christy)

6. Approval Log

7. Approval Log (VPN View) Network Places or Computer  MGH_ASP  Approval Pager

8. Approval Log

9. Empty form = spreadsheet for you to fill out Master List = all previous requests (updated by Christy) Upload your file with your name & date as seen below

10. Approval Log Can’t find the ASP folder?  Email your approval log to Christy –Q 24h-48hrs preferred Feel free to email Christy requests to follow up –i.e. did team D/C my antibiotic as I requested? –i.e. did team narrow therapy when cultures finalized?

11. Stewardship Strategies Bring forward questions or unusual practices so we can work on unifying approval process –Ex. In previous year, rising number of requests for linezolid based on VRE rectal swab Give durations of 72 hrs with empiric approvals with request to follow up with you or ID consult

12. Common Requests and Clinical Pearls

13. Linezolid VRE UTI (30% of requests) –Clarify if true infection –If susceptible, amoxicillin, doxycycline and fosfomycin are less expensive alternatives Positive VRE rectal swab –Low PPV 25%, high NPV 98% –If approving, limit to 72hr approval only

14. Linezolid HCAP –No mortality benefit in linezolid vs vancomycin for nosocomial PNA Vanco allergy and wound infection/cellulitis –Recommend ceftaroline if possible ($80 vs $200) Wunderlink et al. Clin Infect Dis. 2012 Mar 1;54(5):621-9

15. Linezolid Recommend PO if patient has no GI absorption issues (highly bioavailable) –If sepsis, consider IV for first dose, and PO for remaining IV to PO ratio is 1:1, goal is 1:4

16. Carbapenems Necrotizing pancreatitis –No evidence carbapenem is clinically superior (OK to use in culture documented/history of ESBL) –Agents with best penetration: fluoroquinolones, imipenem, ceftazidime, cefepime, metronidazole, clindamycin, chloramphenicol, doxycycline, and fluconazole PCN or cephalosporin allergy –Run through PCN & Ceph Hypersensitivity Pathway Powell JJ et al. Br J Surg. 1998;85:582-587. Buchler M, et al. Gastroenterology. 1992;103:1902-1908. Gloor B et al. 2003;26:117-121. Shrikhande S et al. Antimicrob Agents Chemother. 2000;44:2569-2571. Bassi C et al. Antimicrob Agents Chemother. 1994;38:830-836.

17. Aztreonam PCN or cephalosporin allergy –Run through PCN & Ceph Hypersensitivity Pathway PSA: –76% susceptible to aztreonam –89% susceptible to cefepime –91% susceptible to ceftazidime

18. Micafungin QT prolongation fear with azoles –Usually due to drug interactions and multiple QT prolonging drugs with underlying pt risk factors –Azoles unlikely to prolong QT on their own Resistant Candida in urine –Does NOT penetrate into urine –May be okay in upper UTIs

19. Ceftazidime Globe rupture – approve CNS – approve HD dosing –Renal service likes ceftaz 2g q HD –Note: can also give cefepime 2g q HD Perez, K. Am J Kidney Dis. 2012;59(5):738-742

20. Voriconazole Resistant UTIs –Does NOT reach urine –May be okay for upper UTIs

21. Moxifloxacin Restricted to Tuberculosis More costly than other quinolones “Anaerobic coverage” –Poor; recommend levofloxacin/ciprofloxacin plus metronidazole/clindamycin

22. Other Tips Curbsides: defer to ID consult pager Ask if attending of record has ID privileges –i.e. SICU, MICU, cystic fibrosis, lung transplant –Refer to restricted antimicrobial policy for list of ID approvers Posaconazole is restricted to transplant ID only