Antimicrobials

Antibiotic Coverage Penetration PK Usual doses Renal adjustment KTPH formulary Warnings/ADRs Monitoring
Penicillin G Gram positive
E. faecalis
Strep
Penicillin V Strep
Ampicillin Listeria IV 1-2g q4-6h CrCl<50: q6-12h
Strep Max 12g/day CrCl<10: q12-24h
Amoxicillin Strep PO 250-500mg CrCl<30: q12h
q8-12h CrCl<10: q24h
Augmentin Gram pos IV 1.2g q8h CrCl<30: q12h
Gram neg PO 625mg q8h CrCl<10: q24h
Anaerobes
Cloxacillin Gram pos MSSA:
1st line for MSSA IV 2g q6h
PO 1g q6h
For 2-3 wks
Piptazo Gram pos 4.5g q6h CrCl<50: 4.5g q8h
Gram neg CrCl <30: 2.25g q6h
Anaerobes
Pseudomonas
Unasyn
Ertapenem Gram pos 1g q24h CrCl<30: 500mg q24h
Gram neg
Anaerobes
Imipenem Gram pos
Gram neg
Anaerobes
Acinetobacter
Pseudomonas
Meropenem Gram pos 1g q8h CrCl<50: q12h
Gram neg (500mg for UTI, CrCl<30: 50% q12h
Anaerobes non-pseudomonal CrCl<10: 50% q24h
Acinetobacter SSTI)
Pseudomonas
Aztreonam Gram neg
Pseudomonas
Cefazolin Gram pos 1g q8h CrCl<30: 1g q12h
MSSA (2g if >80kg, OM, CrCl<10: 1g q24h
2g: E.coli, proteus, for cover of E.coli,
Klebs proteus, Klebs)
Max 12g/day
Cephalexin Gram pos 250-1000mg q6h CrCl<60: max 1g/day
MSSA Max 4g/day CrCl<30: 250mg q8-12h
CrCl<15: 250mg q24h
Antibiotic Coverage Penetration PK Usual doses Renal adjustment KTPH formulary Warnings/ADRs Monitoring
Ceftriaxone Gram pos 1g q12h or 2g q24h
Gram neg 2g q12h for
meningitis
Ceftazidime Gram pos 2g q8h CrCl<50: 1g q8h
Gram neg CrCl<30: 1g q12h
Pseudomonas CrCl<10: 1g q24h
Cefepime Gram pos 2g q8h CrCl<60: q12h
Gram neg CrCl<30: q24h
Pseudomonas CrCl<10: 50% q24h
Ciprofloxacin Gram pos PO 500mg q12h CrCl<30: q24h
+/- against strep (750mg for
Gram neg pseudomonas)
Acinetobacter IV 400mg q8h
Pseudomonas
Levofloxacin Gram pos (wider 500mg q24h CrCl<30: q48h
than cipro) (750mg for
+/- against strep pseudomonas)
Gram neg
Acinetobacter
Pseudomonas
Erythromycin Gram neg 400 EES = 200 base
Atypicals
250-500mg
Q6-12h
Max 4g/day
Clarithromycin Gram neg 500mg q12h CrCl<30: 250mg q12h
Atypicals
Azithromycin Gram neg 500mg q24h
Atypicals
Amikacin Gram neg 15-20mg/kg/day Based on trough
Pseudomonas (UTI can go as low
as 10mg/kg/day)
Gentamicin Gram neg 5-7mg/kg/day Based on trough
Pseudomonas (UTI can go as low
as 3mg/kg/day)
Doxycycline Gram neg
Atypicals
Anaerobes
MRSA
Metronidazole Anaerobes 500mg q6h
Max 4g/day
Clindamycin Gram pos PO 150-450mg
Anaerobes IV 600mg
MRSA Q6h
Max 4800mg/day
Antibiotic Coverage Penetration PK Usual doses Renal adjustment KTPH formulary Warnings/ADRs Monitoring
Vancomycin Gram pos Load: 25-30mg/kg CrCl<50: q24h
MRSA Maintenance:
15-20mg/kg
Q8-12h
Linezolid MRSA
Nitrofurantoin E. faecalis, E. coli, 50-100mg q6h Contraindicated if
Klebs CrCl<60
(BEERS: CrCl<30)
Bactrim MRSA Single strength = CrCl<30: 50% dose
400mg CrCl<15: avoid (q48h)
Sulphamethoxazole
80mg
Trimethoprim

1 double strength
(960mg) q12-24h

CAP

HAP

VAP

Lung infections (pleural effusion, empyema, lung abscess)

UTI

SSTI / nec fasc

Intra-abdominal

OM / DM ulcers

Infective endocarditis

SBP

C. diff

Surgical prophylaxis

VTEP – VIRAL form

Medical patients: PADUA score (high risk is 4 or more OR solid tumour + 1 additional risk factor)
- Regimen
o Subcut Clexane: 40mg OM (CrCl<30: 20mg OM)
 o Subcut Heparin: 5000 units BD

Gen surg: CAPRINI score (high risk is 3 or more)

- 1-2: mechanical prophylaxis
- 3-4: pharm or mech
- 5 or more: pharm+mech
- Regimen (start 12h post op)
o Subcut clexane 40mg OM (CrCl<30: 20mg OM ; BMI>50: 60mg OM)
o Subcut heparin 5000 units TDS
Ortho: considered as high risk patients
- Regimen
o Start 12h post-op - Subcut clexane 40mg OM (CrCl<30: 20mg OM)
o Start 12h post-op – subcut heparin 5000 units TDS
o Start 6-8h post-op – rivaroxaban 10mg OM

Consider contraindications
- Absolute: history or current major bleeds, HIT, active intracranial lesions, craniotomy within 1mth
- Relative: Plt<50, sBP>230, ischemic stroke within past 72h

DOACs and VTEP / VTE

Rivaroxaban Apixaban
VTEP 10mg OD 2.5mg BD
Min 10-14/7 Min 10-14/7
Suggested up to 35/7 for ortho surg Suggested up to 12/7 (TKR) ; 35/7 (Hip)
VTE/PE 15mg BD x 21/7 10mg BD x 7/7
THEN THEN
20mg OD 5mg BD
AF 20mg OD 5mg BD

2.5mg BD if:
- 80yo or above
- SCr 1.5mg/dL or above
- BW 60kg or less

Pain management

ICH/SAH/SDH

Ischemic Stroke

Epilepsy

STEMI

ACS
SIHD

AF

HF

DVT/PE

Other heart conditions (LV thrombosis, AS)

HTN

Asthma/COPD

Cirrhosis

Hepatic encephalopathy

Alcohol withdrawal / refeeding syndrome

BGIT / PUD

Pancreatitis

IBD/UC/CD

CKD

DM

DKA / HHS

Gout

HLD

RA / osteoporosis / thyroid / adrenal

Poisoning

Dementia / BPSD

Palliative care

PD

Headache
Depression

Anxiety

Schizophrenia

Bipolar

Hepatitis