Calgary Zone Antimicrobial Formulary and Reference

2014
Prepared by the Calgary Antimicrobial Stewardship Committee
(CASC)
Infectious Disease Pharmacists
Bruce Dalton. Phone 403 944 8317 Pager 02829. bruce.dalton@albertahealthservice.ca

Renal Dose
(Clcr=1050mL/min)

ABC

Comments

Antimicrobial Formulary

No recommendations

Requires ID approval. ABSA

Use 50% normal dose in ESRD. Requires ID

approval. ABSA

Usual Adult Dose

$2

250 mg q6-12h

500 mg q24h
If Clcr<30

Agent

250-500 mg tid or 875

mg bid PO

$ 28

$ 51

Extended Spectrum -Lactams

Amoxicillin/
clavulanate

500 mg q6h

1 g q24h IV/IM

Requires ID or ICU approval. 500 mg IV q6h

therapeutically equivalent to 1 g q8h. ABSA

Ertapenem

q12-24h

Imipenemcilastatin

$ 40

Contains 54 mg sodium/g (1.9 mEq).

500 mg q6h

q6-8h
2.25 g q6-8h

Contains 109 mg sodium/g (4.75 mEq) and 6

mg potassium/g (0.15 mEq).

Meropenem

Deana Sabuda. Phone 403 944 1061 Pager 02833. deana.sabuda@albertahealthservices.ca

2.0 g
q4-12h IV

ABSA
Not covered by ABC
ABSA

500 mg once, then 250

mg daily x4d PO

$ 8.50

$ 0.80

50-75% dose

50% dose

ABC

ABC

Not covered by ABC

ABS

250 mg bid PO
200 mg q12h IV

$4

$ 60

500 mg x1, then

250 mg q24-48h

$15

3.1 g q4h IV

$ 14

$ 2.60
$ 3.50

3.375 g q6h - 4.5 g q8h

Quinolones
Ciprofloxacin
Levofloxacin

500 mg q24h IV

$1.10

$ 0.70

Macrolides

500-1,000 mg PO daily

IV only if patient NPO.

ABC (po only)

250-500 mg bid PO

IV formulation only for GI motility and Group B

strep prophylaxis at delivery in penicillin
allergic patients (order as no sub) ABC

Limited indications: necrotizing

fasciitis, severe penicillin allergy, ABC

No adjustment

No recommendations
Clarithromycin XL

$ 64

$ 0.40

Clarithomycin

250-500 mg qid PO

No adjustment

Avoid in renal
impairment

ABC. Check for G6P deficiency before use

Use 500 mg q8h for Clostridium difficile

infections or brain abscess. ABC
12.5 mg/kg q6h IV

$ 90

Avoid in pregnancy. ABC

$0.30 PO
No adjustment
$ 3 IV

$18

$ 1.60

500 mg q6h IV

300-450 mg qid PO
600 mg q8h IV
500 mg q8-12h IV or PO

Chloramphenicol

2.5-5 mg/kg/day base

divided q6-8h IV

No adjustment

$0.80

No adjustment

50-100% dose

ID approval required

Avoid in ESRD & pregnancy. ABC

ABSA

Avoid in pts with Clcr < 50 ml/min- increased

risk of toxicity and decreased efficacy.
Different formulations and dosages availableonly regular tablet on AHS formulary ABC
Many drug interactions -contact pharmacist

No adjustment
Colistin base

$ 0.20

$100

(colistimethate)

100 mg daily PO

Restricted to ID consulted patients. ABSA

50-100 mg bid-qid PO

$1

q12-24h

Oral forms no longer available. ABC

May cause neurologic and renal toxicity.
Consult ID. Beware dosing
recommendations based on total mg of salt.
Dose by base content only.
Dapsone

No adjustment

No adjustment

600 mg daily PO

$8

No adjustment

$195 IV

$ 0.20
$144 PO

Rifampin

300 mg daily PO

$165

$ 0.50

600 mg q12h IV or PO

100 mg bid PO
Linezolid

Rifabutin

250-500 mg qid PO
100 mg IV x1 then 50
mg q12h

Nitrofurantoin

Tetracycline
Tigecycline

$ 50

$ 0.10

q24-96h; adjust
based on levels

reduction
q18-24h

1 SS tablet bid
Base per kg doses on trimethoprim
PO
component.
5-10 mg/kg/d div. SS (single strength) tablet = 80 mg TMP/ 400
q12h IV
mg SMX. DS (double strength) tablet = 160
33-66%
mg TMP/ 800 mg SMX. Injection vehicle
contains ethanol and propylene glycol. ABC
1 DS tab bid PO
TMP/SMX
(Trimethoprim/

$ 40

$1

$100

10 mg TMP/kg/d q8h
IV

100-200 mg bid PO

PJP (Tx): 15-20mg

TMP/kg/d div q6-8h IV

Sulfamethoxazole,

Trimethoprim

15 mg/kg ABW
(nearest 250mg) q12h

Septra, SXT)

Vancomycin

ABC
Pre-dose levels only necessary in cases of
changing renal function or hemodialysis (goal
5-15 mg/L). Do not do routine post-dose
levels. ABC
Oral liquid (LPO) much less costly than
capsules. Minimal systemic absorption via
oral route. ABSA

G6P glucose 6 phosphatase

GFR glomerular filtration rate
IBW ideal body weight
ID Infectious Diseases service
IP&C Infection Prevention and Control
LPO oral liquid
PID pelvic inflammatory disease
PJP Pneumocystis jiroveci pneumonia
Rx pharmacy

$ 40 caps
No adjustment
$ 6 LPO

Abbreviations:
ABC Alberta Blue Cross Formulary
ABSA Blue Cross Special Authorization
ABW actual body weight
AG aminoglycoside
CAP community acquired pneumonia
CF cystic fibrosis
Clcr creatinine clearance
DW dosing weight. When pts ABW is >30%
of IBW: DW=IBW + [0.4 x (actual weight - IBW)]

125-250 mg qid PO (for

C.diff)

Not
recommended

Doxycycline

Miscellaneous Antibacterial Agents

Metronidazole

Clindamycin

Anaerobic agents

Erythromycin

Azithromycin

$ 3.40

3-4 g q4-6h IV

Comments

500-750 mg bid PO
400 mg q12h IV

Reviewed Early/Prescribed Surely

Renal Dose
(Clcr=1050mL/min)

Limited indications: Use in mycobacterial infection or

documented resistance to gentamicin or tobramycin.
ABC
Do NOT use once-daily dosing in ESRD, burns, for
synergy with -lactams or pregnancy. See reverse for
recommendations for serum levels. ABC
Traditional dosing- if patient has abnormal renal
function or is on AG for > 5 d, take pre-dose levels
with 3rd dose (goal trough < 2 mg/L, post-dose levels
not recommended). ABC
Limited Indications: suspected or proven
Pseudomonas or proven resistance to gentamicin;
otherwise Rx will autosub to gentamicin. Follow
levels as with gentamicin. ABC

500-750 mg daily PO

Piperacillin
Piperacillin/
tazobactam

Reassess initial diagnosis

Review all microbiology results
Tailor antimicrobials; choice & duration
Switch intravenous to oral route

$ 60

Antimicrobial Formulary

Infectious Diseases (ID) Restrictions

7.5 mg/kg IBW or DW

q12h IV
$ 30

Approx.
hospital
cost/day

Infectious diseases approval required for certain agents (see below)

Contact consultant or resident on call via switchboard or ROCA
Pharmacy will not delay first dose or 24h therapy while approval in process
Usual Adult Dose

5-7 mg/kg IBW or DW

daily IV

See comments

Q12-24h

Restricted to ID/Hematology/Oncology Services.

500-750 mg q24h IV

Ticarcillin/
clavulanate

Approx.
Hospital

Day 3 Bundle (D3B) for antimicrobials

Amikacin

Gentamicin
$10

$12

$5

$12

1-2 g q8h IV

ABC

Cefazolin

No adjustment

Rx will autosub higher doses to 750 mg q8h. ABC

No adjustment
Q8-12h

Q12-24h

$4
$ 0.50

$4

Q12-48h

400 mg q24h PO
500 mg qid PO

$15

Cefixime
Cephalexin

250-500 mg bid po

$18

No adjustment

Q12-24h

750mg q8h IV

1-2 g q24h

$ 10

Cefuroxime
axetil

1-2 g q8h IV

$3

2 g q6-8h IV

Cefuroxime

$60

Rx will autosub 500 mg doses or q6h schedules to 12 g q8h. ABC

ABC
ABC
Limited indications: PID, unable to tolerate
metronidazole, or pregnant; otherwise Rx will autosub
to cefazolin 1-2 g + metronidazole 500 mg

Ceftazidime

1 g q24h IV

Limited indications: CF patients, Pseudomonas

resistant to piperacillin, febrile neutropenia. ABC
Use once daily dosing for ceftriaxone unless
meningitis suspected (2 g q12h). ABC
2 g q8-12h IV

Rx will autosub PO to amoxicillin

IV contains 60 mg/g sodium. ABC
ABC
q12-24h

Contains 50 mg/g of sodium. ABC

$35

q12-24h

500 mg-2 g q6h IV

no adjustment

250-500 mg tid PO

$ 0.20

$ 20

Amoxicillin

Note penicillin G potassium has been discontinued by

the manufacturer. Sodium 46 mg/ MU. ABC

$ 0.25
$10 IV
$
0.60PO

50-75% dose

300 mg = 500,000 U. ABC

1-2 g q4-6h IV
500 mg qid PO

no rec.

Cloxacillin

300 mg qid PO

2-4 million U q4-6h IV

Penicillin V

Penicillin G
Sodium

Cefepime
Penicillins
Ampicillin

Ceftriaxone

Cefoxitin

5-7 mg/kg IBW or DW

daily IV
Tobramycin 1-2 mg/kg IBW or DW
q8h IV (traditional
dosing)
Cephalosporins

1-2 mg/kg IBW or DW

q8h IV (traditional
dosing)

Aminoglycosides (AG)

Agent

cost/day

Agent

0.4-1 mg/kg/d IV

$ 220

$ 440-735

$ 75

Comments

q48h with
ABC
ESRD
q48h with
Restricted to ID consulted patients.
ESRD
No adjustment
Restricted to ID. ABSA

Approx.
Renal Dose
Hospital
(Clcr=10-50
Cost/day
mL/min)
(usual dose)

3-5 mg/kg/d IV

Usual Adult Dose

Antifungal Agents
Amphotericin B
Liposomal
Amphotericin B
Caspofungin
200-800 mg/d PO or
IV

No adjustment

No adjustment
** Caution in renal impairment. IV formulation
contains vehicle which accumulates.** ABSA

No adjustment Only avail in oral liq formulation. Restricted to

Infectious Diseases for Rhizopus and Mucor.

ABC

200-400 mg/d
$ 3 PO
ABC
PO/IV
$15 IV
$16 (caps) No adjustment Restricted to ID. Use LPO cautiously in renal
impairment. Excipient may accumulate. ABC
$ 32 (LPO)
No adjustment

$82

$1

$ 41
$8
$4
$5
$ 92

q24-q7d

ABC

Beware sound alike drug ValGANciclovir.

Limited indication: treatment or prophylaxis of CMV
ABSA. Beware of sound alike drug valACYClovir.
Limited indication: Influenza treatment or
prophylaxis, on advice of infectious diseases
specialist.

Limited indication: treatment or prophylaxis of

CMV.
PO form no longer available. ABC
Limited indication: Influenza treatment or
prophylaxis, on advice of ID

q12-24h
consult
pharmacy

1.25-2.5
mg/kg q24h
0.6-1.25
mg/kg q24h
50% usual
dose

$ 45 IV Increase dose interval to q12-24h or lower dose to 2.5 mg/kg

$ 5 PO Increase dose interval to q8-12h. ABC

$100 PO
$ 300 IV

$ 188

$1

$100

70 mg IV load, then
50 mg q24h IV

Fluconazole
100-200 mg q12h PO

100,000-500,000 U
qid PO
200 mg qid or 400 mg
bid PO
6 mg/kg x 2 IV load
then 4 mg/kg q12h IV
or
200 mg PO bid

100 mg IV daily

Itraconazole
Micafungin
Nystatin
Posaconazole

Voriconazole

Induction: 5 mg/kg q12h IV

Varies by indication. Consult

reference such as Sanford
(pg 160 of 2013 Edition)
100 mg bid PO

Antiviral Agents
Acyclovir

Ganciclovir
Maintenance: 5 mg/kg q24h
IV
75 mg bid PO (treatment)
75 mg daily PO (prophylaxis)
500 mg bid, to 1 gram tid
900 mg bid PO

Amantadine

Oseltamivir
ValACYClovir
ValGANciclovir
No
$38 per adjustment
inhaler

Drug

Consider vancomycin if
severe illness and/or
MRSA risk factors

Comments

Zanamavir

10 mg inhaled bid (treatment)

10 mg inhaled daily
(prophylaxis)

Disease

Oral clarithromycin,
azithromycin or levofloxacin
IV cefuroxime + azithromycin

Empiric Therapy Suggestions

(Tailor therapy at earliest opportunity)

Community acquired
Pneumonia

ceftriaxone or
piperacillin/tazobactam

Consider ampicillin for

Listeria in elderly,
immuncompromised,
alcoholism

Ceftriaxone reserved for

pregnancy & increased
creatinine

Hospital acquired
pneumonia

piperacillin/tazobactam
cefepime
meropenem

piperacillin/tazobactam

cefazolin/metronidazole
piperacillin/tazobactam

ceftriaxone/vancomycin

ceftriaxone + vancomycin

trimethoprim/sulfamethoxazole
nitrofurantoin
gentamicin
Hospital acquired:
ceftriaxone or ciprofloxacin

Consider levofloxacin +
metronidazole if has had
lung abscess

Urinary tract
simple cystitis
pyelonephritis
pyelonephritis (hospital
acquired)
Endocarditis
(& Gram positive
bacteremia nyd)
Meningitis- community
acquired
Intra-abdominal infection
community acquired
hospital acquired
Cholangitis
Febrile neutropenia

Consider vancomycin and

antifungals in appropriate
patients. Antifungals
usually added after day 4
if non-responsive

Bioavailability

$ 0.20

N/A
[cefuroxime $18]

N/A
[ampicillin $35]

IV cost /day

Oral dose
74-92%

$ 2.30

$ 20

$ 22

Oral cost /day

250-500 mg tid
90-95%

$ 0.72

$2

Highly Bioavailable Oral Antimicrobial Agents

Amoxicillin
250-500 mg bid

50-85 %

90%

Drug

Cefprozil

250-750 mg bid

$ 24

$ 45

300-600 mg tid

$4

$6

Ciprofloxacin

99%

90%

Clindamycin

500 mg/day

100-400 mg/day

$3

$191

Levofloxacin

$ 0.50

$ 142

Fluconazole

80%

95-100%

$280

$55

250-500 mg tid

$ 100

$ 0.25

600 mg bid

96%

90-100%

Metronidazole

200 mg po bid

1 DS tab bid

Linezolid

Voriconazole

[Polysporin ]
Plain

Topical Antimicrobials

Steroid

framycetin - is specifically neomycin B

neomycin: A mixture of neomycin B

and C. Well-documented to cause
contact sensitivity. An aminoglycoside
active against many Gram-negative
bacteria but P. aeruginosa is
generally resistant. Some activity
against S. aureus. Minimal in vitro
activity against streptococci but at
concentrations on skin, S.pyogenes
are likely killed.

gramicidin: Gram positive activity

polymyxin B: Gram negative activity

(including P. aeruginosa), except
Proteus and poorly active against
Providencia, Burkholderia & Serratia

bacitracin: Primarily active against

Gram positives: staphylococci,
streptococci, corynebacteria,
clostridia. Can be sensitizing.

NOTES

ciprofloxacin, dexamethasone (drops)

[Ciprodex ]

framycetin, gramicidin,
dexamethasone (drops) [Sofracort ]

neomycin, polymyxin B,
hydrocortisone (drops) [Cortisporin ]

polymyxin B, gramicidin (drops)

[Polysporin ]

EAR

Relative contraindications to oral therapy

malabsorption syndromes or short gut
recovery from abdominal surgery (NPO period)
acute sepsis with low blood pressure or organ failure

TMP/SMX

[Maxitrol ]

neomycin, polymyxin B, dexamethasone (drops, oint) With

[Sofracort ]

framycetin, gramicidin, dexamethasone (drops)

moxifloxacin (drops), ofloxacin (drops)

ciprofloxacin (drops, oint), gatifloxacin (drops),

erythromycin (oint only)

tobramycin (drops, oint)

polymyxin B, bacitracin (oint)

polymyxin B, gramicidin (drops)

EYE

Advantages of oral administration

no intravenous access problems
no intravenous site infections or
thromboembolic complications
ease transition to outpatient therapy

Plain

With
Steroid

tobramycin, dexamethasone (drops, oint) [Tobradex ]

SKIN

polymyxin B, bacitracin, gramicidin (oint) [Polysporin Triple ]

polymyxin B, bacitracin (oint) [Polysporin ]

polymyxin B, gramicidin (cream) [Polysporin ]

mupirocin 2%(cream, oint) [Bactroban ]: active against MRSA, &

streptococci but not enterococci. Ointment contains PEG and is
not for mucous membranes.
silver sulfadiazine 1% (cream) [Flamazine ]: silver (active
moiety) slowly released; broad-spectrum including P.aeruginosa
and fungi
nystatin (cream, ointment, powder, vaginal cream): Candida only
terbinafine 1% (cream): highly active against dermatophytes but
less active against yeasts
clotrimazole (1% cream, 2% vaginal cream): active
vs.dermatophytes, Malassezia, Candida
permethrin (5% cream, 1% cream rinse)[Nix ]: scabicide
gentian violet 1% topical solution: effective against some yeast &
Gram positive bacteria, especially staphylococci

All information current as of Aug 2009