›Antibiotic strategy principles
›Broad spectrum anti pseudomonal coverage
›Gram negative sepsis risk including Pseudomonas
›First dose target within 60 minutes
›Regimen selection drivers
›Hemodynamic status
›Local antibiogram
›Prior resistant organisms
›High risk inpatient IV monotherapy options
›Cefepime IV
›2 g IV every 8 hours if normal renal function
›Renal dose adjustment per local protocol
›Neurotoxicity risk in renal impairment
›Piperacillin tazobactam IV
›4.5 g IV every 6 hours if normal renal function
›Extended infusion option per local protocol
›Anaerobe coverage benefit in abdominal source concern
›Meropenem IV
›1 g IV every 8 hours if normal renal function
›ESBL coverage
›Seizure risk consideration in CNS disease history
›Escalation to dual coverage in shock or high resistance settings
›Add aminoglycoside option
›Gentamicin IV
›5 to 7 mg/kg IV once daily dosing strategy
›Therapeutic drug monitoring requirement
›Nephrotoxicity and ototoxicity risk
›Add fluoroquinolone option if not on prophylaxis and susceptibility supports
›Ciprofloxacin IV
›400 mg IV every 8 to 12 hours if normal renal function
›QT prolongation risk
›MRSA and gram positive add on criteria
›Vancomycin indications
›Suspected catheter related infection
›Skin or soft tissue infection
›Pneumonia
›Hemodynamic instability
›Known MRSA colonization with severe presentation
›Vancomycin dosing
›15 to 20 mg/kg IV per dose using actual body weight
›Trough or AUC monitoring per local protocol
›Renal dose adjustment requirement
›Alternatives when vancomycin unsuitable
›Linezolid IV or PO
›600 mg every 12 hours
›Thrombocytopenia risk with prolonged use
›Daptomycin IV
›6 to 10 mg/kg daily depending on severity
›Not for pneumonia
Low risk outpatient antibiotics
›Oral regimens when outpatient criteria met
›Ciprofloxacin plus amoxicillin clavulanate
›Ciprofloxacin 500 to 750 mg PO every 12 hours
›Amoxicillin clavulanate 875 mg PO every 12 hours
›Penicillin allergy alternative for beta lactam component per local guidance
›Levofloxacin monotherapy in selected settings
›750 mg PO daily
›Avoid if fluoroquinolone prophylaxis
›Local resistance constraints
›First dose in ED
›Oral first dose observed
›Tolerance verification
›Early adverse reaction screen
Antifungal and antiviral considerations
›Persistent fever strategy
›Empiric antifungal trigger
›Persistent fever after 4 to 7 days of broad spectrum antibiotics
›High risk prolonged neutropenia
›Echinocandin option
›Micafungin IV
›100 mg IV daily
›Hepatic monitoring
›Azole option when appropriate
›Voriconazole IV or PO
›Loading and maintenance per local protocol
›QT prolongation and drug interactions
›Amphotericin option for suspected mucormycosis or refractory infection
›Liposomal amphotericin B IV
›3 to 5 mg/kg daily typical range
›Electrolyte and renal monitoring
›Viral reactivation and treatment
›HSV coverage when suspected
›Acyclovir IV
›10 mg/kg IV every 8 hours for severe disease
›Renal dose adjustment requirement
›Influenza treatment when indicated
›Oseltamivir PO
›75 mg PO every 12 hours
›Renal dose adjustment requirement
Source control and adjuncts
›Source directed actions
›Central line management
›Early infectious diseases input for suspected CLABSI
›Removal consideration with persistent bacteremia or tunnel infection
›Obstruction management
›Urology consult for obstructed infected collecting system
›Decompression timing urgency
›Typhlitis management
›Bowel rest
›Surgical consult for perforation or necrosis concern
›Hematologic adjuncts
›G CSF considerations
›Severe sepsis or septic shock
›Expected prolonged neutropenia
›Pneumonia or invasive fungal infection concern
›Transfusion thresholds per oncology service
›Symptomatic anemia
›Severe thrombocytopenia with bleeding risk