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Ampicillin Dose Adjustment:
This patient's Ampicillin dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Ampicillin/sulbactam (Unasyn) Dose Adjustment:
This patient's Ampicillin/sulbactam dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Alogliptin (Nesina) Dose Adjustment:
This patient's alogliptin dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Aztreonam (Azactam) Dose Adjustment:
This patient's Aztreonam dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Cefazolin (Ancef) Dose Adjustment:
This patient's cefazolin dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Cefepime (Maxipime) Dose Adjustment:
This patient's cefepime dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Ceftaroline (Teflaro) Dose Adjustment:
This patient's ceftaroline dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Ceftazidime/avibactam (Avycaz) Dose Adjustment:
This patient's ceftazidime/avibactam dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Ceftolozone/tazobactam (Zerbaxa) Dose Adjustment:
This patient's ceftazidime/avibactam dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Ciprofloxacin (Cipro) Dose Adjustment:
This patient's ciprofloxacin dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Clindamycin (Cleocin) Dose Adjustment:
This patient's clindamycin dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's indication.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Enoxaparin (Lovenox) Dose Adjustment:
Your patient is currently receiving Lovenox _________ & now has a CrCl of ______ ml/min.
Based on the patient's current renal function, the dose has been adjusted to ___________.

Per approval of the P&T committee, an order to increase or decrease your patient's dosage of Lovenox has been written in the chart based on the below dosing.

Prophylaxis Dosing:
CrCl >/= 30 ml/min: 40 mg Daily (30 mg BID - post op knee/hip surgery)
CrCl < 30 ml/min: 30 mg Daily

Treatment Dosing:
CrCl >/= 30 ml/min: 1 mg/kg BID
CrCl < 30 ml/min: 1 mg/kg Daily
** If CrCl < 20 ml/min, dose will be decreased & anti-factor Xa level drawn to evaluate if continued use of Lovenox is appropriate

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Enoxaparin (Lovenox) Obesity Dose Recommendation:
Your patient has a BMI >50 (___). Some studies support use of a higher prophylactic
dose of Enoxaparin, such as Enoxaparin 40 mg every 12 hours.

If you would like to order this on your patient, please do so by a written order.

Thank you for your assistance in our continuing effort to increase patient safety and reduce adverse events.
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Famotidine (Pepcid) Dose Adjustment:
Per P&T Committee, April of 2002, Pepcid doses in patients with CrCl << 50 ml/min will be reduced automatically to 20 mg once daily.

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Fondaparinux (Arixtra) Dose Adjustment:
For DVT prophylaxis in adults, the recommended dosage of Arixtra is 2.5 mg SubQ daily in patients with creatinine clearance > 30 ml/minute. Arixtra's use is contraindicated in renal impairment < 30 ml/minute. Your patient's creatinine clearance today falls in the range of 10-30 ml/minute.

Per Pharmacy & Therapeutics Committee approval 2010, an order for Lovenox 30 mg SubQ daily has been written in the chart. Any patient with a creatinine clearance < 10 ml/minute, a direct intervention with the physician will determine the proper therapy. If you wish to reverse this automatic conversion, please do so by a written order in the chart.

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Levofloxacin (Levaquin) Dose Adjustment:
This patient's Levaquin dose has been adjusted to ________________________________________.Per P&T, based on the recommendation of the Antimicrobial Stewardship Committee, Levaquin orders (regardless of indication) will automatically be converted to the appropriate renally adjusted dose of Levaquin (see chart below).

The utilization of the larger 750 mg dose regimen will assist in optimizing the activity of the drug and minimize the risk of bacterial resistance.

CRCL ( ml/min)   INITIAL DOSE      SUBSEQUENT DOSES
> 50                     750 mg              750 mg Q 24 hrs
20-49                750 mg              750 mg Q 48 hrs
10-19                750 mg              500 mg Q 48 hrs
Hemodialysis       750 mg              500 mg Q 48 hrs
CRRT                  750 mg              750 mg Q 24 hrs

If you wish to change this order, please do so by a written order in the chart.

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Meropenem (Merrem) Dose Adjustment:
This patient is currently receiving Meropenem __________________. Based on the patient's most recent creatinine clearance of ______ ml/min, Pharmacy has written an order to change the dose to ______________________. This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

Meropenem Renal Dose Adjustment for 500 mg Q 6 hr regimen:
CrCl > 50 ml/min: 500 mg Q 6 hr
26-50 ml/min: 500 mg Q 8 hr
10-25 ml/min: 500 mg Q 12 hr
< 10 ml/min: 500 mg Q 24 hr
HD: 500 mg Q 24 hr (given after HD on dialysis days)
CRRT: 500 mg Q 8 hr

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Oseltamivir (Tamiflu) Dose Adjustment:
This patient's oseltamivir dose has been adjusted to _______ to optimize the pharmacodynamic properties of the drug and to provide the most appropriate dose based on the patient's current renal function.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Piperacillin/tazobactam Dose Adjustment:
This patient is currently receiving Zosyn ______________. Based on patient's most recent creatinine clearance of ______ ml/minute, Pharmacy has written an order to change this Zosyn therapy to __________________. This has been approved by the Antimicrobial Stewardship Committee and the Pharmacy and Therapeutics Committee.
If you wish to change this, please do so by written order.

Extended Infusion Dosing:
CrCl >/= 20 ml/min 3.375 gm Q 8 hrs (each dose over 4 hrs)
CrCl < 20 ml/min 3.375 gm Q 12 hrs (each dose over 4 hrs)

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Promethazine (Phenergan) Dose Adjustment:
This patient has automatically had their Phenergan IV dose adjusted to 6.25-12.5 mg. This automatic adjustment was approved by P&T April 2007. This is consistent with Best Practice Recommendations for MHCS and endorsed by the Institute for Safe Medication Practices (ISMP) regarding serious tissue injury with IV promethazine.

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IV to PO

Azithromycin (Zithromax) IV to PO Conversion
This patient meets the Antimicrobial Stewardship Program (ASP) sub-committee and the Pharmacy and Therapeutics (P& T) Committee accepted criteria for Intravenous (IV) to Oral (PO) conversion. Oral azithromycin has pharmacokinetic (PK/PD) data demonstrating very good (80-90%) bioavailability. Therefore, an order has been written to convert azithromycin to oral therapy as follows:

Azithromycin _____mg q_____ hours, beginning at _____ hours on __________.

Note: If you feel it is in the best interest for the patient to remain on IV azithromycin, please write an order over-riding this substitution.

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Ciprofloxacin (Cipro) IV to PO Conversion:
This patient meets the Antimicrobial Stewardship Program (ASP) sub-committee and the Pharmacy and Therapeutics (P & T) Committee accepted criteria for Intravenous (IV) to Oral (PO) conversion.

Oral ciprofloxacin has pharmacokinetic (PK/PD) data demonstrating good (75-85%) bioavailability. Therefore, an order has been written to convert ciprofloxacin to oral therapy as follows:
Ciprofloxacin _____mg q_____ hours, beginning at _____ hours on __________.

Note: If you feel it is in the best interest for the patient to remain on IV ciprofloxacin, please write an order over-riding this substitution.

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Clindamycin (Cleocin) IV to PO Conversion:
This patient meets the Antimicrobial Stewardship Program (ASP) sub-committee and the Pharmacy and Therapeutics (P & T) Committee accepted criteria for Intravenous (IV) to Oral (PO) conversion.

IV doses will be converted to equivalent oral doses as follows:
300 mg every 8 hours --> 150 mg every 6 hours
600 mg every 8 hours --> 300 mg every 6 hours
900 mg every 8 hours --> 450 mg every 6 hours

Clindamycin _____mg q_____ hours, beginning at _____ hours on __________.

Note: If you feel it is in the best interest for the patient to remain on IV clindamycin, please write an order over-riding this substitution.

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Doxycycline (Vibramycin) IV to PO Conversion:
This patient meets the Antimicrobial Stewardship Program (ASP) sub-committee and the Pharmacy and Therapeutics (P & T) Committee accepted criteria for Intravenous (IV) to Oral (PO) conversion.

Oral doxycycline has pharmacokinetic (PK/PD) data demonstrating excellent (90-100%) bioavailability. Therefore, an order has been written to convert doxycycline to oral therapy as follows:

Doxycycline _____mg q_____ hours, beginning at _____ hours on __________.

Note: If you feel it is in the best interest for the patient to remain on IV doxycycline, please write an order over-riding this substitution.

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Famotidine (Pepcid) IV to PO Conversion:
This patient meets criteria for IV to PO conversion.
As part of P&T Committee approval, this patient's IV regimen has been converted as follows:
CURRENT IV REGIMEN : ______________________
CONVERTED TO ORAL REGIMEN: _____________________

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Fluconazole (Diflucan) IV to PO Conversion:
This patient meets the Antimicrobial Stewardship Program (ASP) sub-committee and the Pharmacy and Therapeutics (P & T) Committee accepted criteria for Intravenous (IV) to Oral (PO) conversion.

Oral fluconazole has pharmacokinetic (PK/PD) data demonstrating excellent (90-100%) bioavailability. Therefore, an order has been written to convert fluconazole to oral therapy as follows:

Fluconazole _____mg q_____ hours, beginning at _____ hours on __________.

Note: If you feel it is in the best interest for the patient to remain on IV fluconazole, please write an order over-riding this substitution.

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Levetiracetam (Keppra) IV to PO Conversion:
This patient meets P&T accepted criteria for IV to PO conversion. This patient has been targeted as being on a diet and receiving other medications via the oral or NGT/GI route. Oral Keppra has 100% bioavailability and equal efficacy as the intravenous form. Pharmacy has written an order to change to an equivalent oral dose 1:1.
This patient's IV regimen of Keppra has been converted as follows:
Current IV REGIMEN: _____________________
Conversion to ORAL REGIMEN: __________________

If this does not meet with your approval, you have the final decision to convert therapy back to the IV form via a written order.

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Levofloxacin (Levaquin) IV to PO Conversion:
This patient meets the Antimicrobial Stewardship Program (ASP) sub-committee and the Pharmacy and Therapeutics (P & T) Committee accepted criteria for Intravenous (IV) to Oral (PO) conversion.

Oral levofloxacin has pharmacokinetic (PK/PD) data demonstrating excellent (90-100%) bioavailability. Therefore, an order has been written to convert levofloxacin to oral therapy as follows:

Levofloxacin _____mg q_____ hours, beginning at _____ hours on __________.

Note: If you feel it is in the best interest for the patient to remain on IV levofloxacin, please write an order over-riding this substitution.

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Levothyroxine (Synthroid) IV to PO Conversion:
This patient meets criteria for IV to PO conversion.
As part of P&T Committee criteria, this patient's IV Synthroid regimen has been converted to an equivalent oral dose (IV dose = 50% of ORAL dose).
CURRENT IV REGIMEN: _______________
CONVERTED TO ORAL REGIMEN: __________________

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Linezolid (Zyvox) IV to PO Conversion:
This patient meets the Antimicrobial Stewardship Program (ASP) sub-committee and the Pharmacy and Therapeutics (P & T) Committee accepted criteria for Intravenous (IV) to Oral (PO) conversion.

Oral linezolid has pharmacokinetic (PK/PD) data demonstrating excellent (90-100%) bioavailability. Therefore, an order has been written to convert linezolid to oral therapy as follows:

Linezolid _____mg q_____ hours, beginning at _____ hours on __________.

Note: If you feel it is in the best interest for the patient to remain on IV linezolid, please write an order over-riding this substitution.

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Metronidazole (Flagyl) IV to PO Conversion:
This patient meets the Antimicrobial Stewardship Program (ASP) sub-committee and the Pharmacy and Therapeutics (P & T) Committee accepted criteria for Intravenous (IV) to Oral (PO) conversion.

Oral metronidazole has pharmacokinetic (PK/PD) data demonstrating excellent (90-100%) bioavailability. Therefore, an order has been written to convert metronidazole to oral therapy as follows:

Metronidazole _____mg q_____ hours, beginning at _____ hours on __________.

Note: If you feel it is in the best interest for the patient to remain on IV metronidazole, please write an order overriding this substitution.

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Multivitamin IV to PO Conversion:
This patient meets criteria for IV to PO conversion.
As part of P&T Committee criteria, this patient's IV MULTIVITAMIN regimen has been converted to an equivalent oral dose (1 amp IV MVI = 1 tab oral MVI).
CURRENT IV REGIMEN : ________________
CONVERTED TO ORAL REGIMEN: _________________

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Pantoprazole (Protonix) IV to PO Conversion:
This patient meets criteria for IV to PO conversion.
As part of P&T Committee approval, this patient's IV regimen has been converted as follows:
CURRENT IV REGIMEN: ________________
CONVERTED TO ORAL REGIMEN: _________________

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Thiamine IV to PO Conversion:
This patient meets criteria for IV to PO conversion. As part of P&T committee criteria, this patient's IV Thiamine has been converted to an equivalent oral dose (100 mg IV = 100 mg PO).
CURRENT IV REGIMEN: ____________
CONVERTED TO ORAL REGIMEN:______________

Note: If you feel it is in the best interest for the patient to remain on IV Thiamine, please write an order over-riding this substitution.

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Other

Acid Suppression Therapy – therapeutic duplications:
This patient has orders for both a PPI and an H2RA for acid suppression therapy. To avoid duplication of therapy, the less potent agent (the H2RA) has been discontinued. If you wish to restart this medication, please do so by writing an order.

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Azithromycin (Zithromax) Auto Stop:
Per P&T approved protocol, this patient's AZITHROMYCIN order will be discontinued following 5 days of therapy.

Due to the extremely long half life (~68 hrs), a 5 day course of azithromycin 500 mg daily will provide a therapeutic effect for 8-10 days for treatment of acute respiratory infection.

This has been approved by the Antimicrobial Stewardship Committee and the P&T Committee. If you wish to change this, please do so by written order.

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Levothyroxine IV Dosing:
When converting from oral to IV levothyroxine, the oral dose of levothyroxine will be given as IV every 48 hours to avoid waste.
(i.e. Levothyroxine 100 mcg PO daily = 100 mcg IV q 48 hrs)
PATIENT’S NORMAL PO REGIMEN:
CONVERTED TO IV REGIMEN:

This change has been approved by the P&T Committee. If you wish to change this, please do so by written order.

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Metformin (Glucophage) – ADE Prevention
Your patient's most recent CrCl is ______ . Metformin is contraindicated in the presence of renal dysfunction defined as CrCl < 30 ml/min. Please consider continued need for this therapy in light of the patient’s most recent estimated renal function.

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Methylnaltrexone (Relistor) – Consider Movantik as possible alternative:
This patient is currently on a scheduled dose of injectable Relistor (methylnaltrexone). A new oral peripheral acting mu-opioid receptor antagonist is now on formulary which may be a possible oral alternative - MOVANTIK (NALOXEGOL). Movantik has the same mechanism of action, similar time to peak concentration, and time to first spontaneous bowel movement.

If this patient can tolerate oral meds and continued therapy is necessary please consider Movantik as a possible alternative.

Cost per day of therapy: Movantik - $8 Relistor injection: $95

Movantik dose: 25 mg PO daily (12.5 mg daily for CrCl < 60 ml/min)

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Pharmacy Phone Numbers
Memorial Pharmacy (Glenwood) 423-495-8380
Memorial Hixson Pharmacy 423-495-7137
Stat 423-495-7470
Outpatient 423-495-8981
Chemo 423-495-7475
Surgery 423-495-8779

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