The Nebraska Medical Center physicians specializing in infectious disease, microbiology, surgery and pediatric pulmonology have assessed the medications in the fluoroquinolone drug class. They have agreed that the once daily quinolones are therapeutically equivalent and are an appropriate drug class for therapeutic interchange. These physicians have designated moxifloxacin (Avelox) and ciprofloxacin (Cipro) as the fluoroquinolone antibiotics that will remain on the inpatient formulary. Moxifloxacin will be automatically dispensed for any once daily fluoroquinolone order^##.

Physicians may “opt out” of the therapeutic interchange program for clinical reasons by writing, “Do Not Substitute” in the Orders section of the chart.

Before activating this interchange it is necessary for the clinical pharmacist to verify that the fluoroquinolone has not been ordered to treat a urinary tract infection. Moxifloxacin is not cleared through the kidneys. Therefore, the drug does not concentrate in the kidneys, and drug levels there are not adequate to treat infection. This interchange is warranted only for those patients in whom the infection is believed to be located in a site other than the urinary tract. For urinary tract infections, the clinical pharmacist should recommend that ciprofloxacin be used.

Table 1 outlines how an order for a non-formulary fluoroquinolone will be automatically interchanged at The Nebraska Medical Center.

Table 1.

If a prescriber writes for:		The pharmacist will automatically interchange the order to:
Levofloxacin (Levaquin)	250-750 mg IV q24h (adult)* 250-750 mg PO q24h (adult)*	Moxifloxacin (Avelox)	400 mg IV q24h 400 mg PO q24h NO dosage adjustment necessary for renal or hepatic disease
Gatifloxacin (Tequin)	200- 400 mg IV q24h (adult)* 200- 400 mg PO q24h (adult)*

*dosing/frequency adjustment recommended for renal or hepatic disease

^##In patients with cystic fibrosis (CF), ciprofloxacin, instead of moxifloxacin, should be substituted for any order written for levofloxacin. The clearance of ciprofloxacin is affected by renal function; therefore, renal function must be considered prior to dosing.

Fluoroquinolones: Urinary Tract Infection or Pseudomonal Infection

Currently, The Nebraska Medical Center has an inpatient automatic interchange whereby levofloxaxin orders are converted to moxifloxacin when clinically appropriate. In general, most orders written for levofloxacin can be converted to moxifloxacin, and the safety and outcomes achieved from this automatic interchange have been satisfactory. However, in two specific scenarios, moxifloxacin is not a clinically appropriate substitute for levofloxacin. The two specific scenarios include:

· Levofloxacin ordered for treatment of urinary tract infection

· Levofloxacin ordered for treatment of infection caused by Pseudomonas, including pneumonia or for empiric therapy of suspected pseudomonal infections

Within the fluoroquinolone class, ciprofloxacin is indicated for the treatment of susceptible organisms causing urinary tract infection, and for the treatment of infections caused by Pseudomonas.

Dose Conversion^!!:

Order written for levofloxacin	Dispense ciprofloxacin
250mg IV qd	200mg IV q12h
500mg IV qd	400mg IV q12h
750mg IV qd	400mg IV q8h*

250mg PO qd	250mg PO q12h
500mg PO qd	500mg PO q12h
750mg PO qd	750mg PO q12h

^!!Ciprofloxacin dosing/frequency must be adjusted for renal impairment if needed

*dose typically used for pseudomonal pneumonia

Penicillins and Cephalosporins

Physicians may “opt out” of the therapeutic interchange program for clinical reasons by writing, “Do Not Substitute” in the Orders section of the chart.

Penicillins

if this is ordered,

this will be provided:

Cloxacillin (oral) (no longer manufactured)

Nafcillin (IM/IV)

Dicloxacillin (½ dose and same frequency)

Pediatrics: ½ dose and same frequency

Oxacillin (IM/IV) (same dose and frequency)

Pediatrics: same dose and frequency

Ticarcillin

TimentinÒ 3.1g iv q4-6h

Pediatrics: 200-300mg/kg/day (ticarcillin)
divided q4-8h

Piperacillin (same dose and frequency)

Pediatrics: same dose and frequency

ZosynÒ 3.375gm iv q6h

Pediatrics: 150-400mg/kg/day (piperacillin)
divided q8h

First-Generation Cephalosporins

If this is ordered:	this will be provided:
Intravenous
Cefazolin 1gm IV q6h Cefazolin 2gm IV q6h Pediatrics: 50-100mg/kg/day divided q6h	Cefazolin 1gm IV q8h Cefazolin 2gm IV q8h Pediatrics: 50-150mg/kg/day divided q8h
Oral
Cefadroxil 500 – 1000 mg po bid Pediatrics: 30mg/kg/day divided q12h	Cephalexin 250 - 500mg po q6h Pediatrics: 25-150mg/kg/day divided q6h

Second-Generation Cephalosporins

if this is ordered:

this will be provided:

Intravenous

Cefotetan 1gm iv q12h

Cefotetan 2gm iv q12h

Pediatrics: 40-80mg/kg/day divided q12h

Cefoxitin 1gm iv q6h

Cefoxitin 2gm iv q6h

Pediatrics: 80-160mg/kg/day divided q6h

Cefamandole 500mg-1gm iv q4-8h

Cefamandole 2 gm iv q4h

Pediatrics: 50-150mg/kg/day divided q6h

Cefuroxime 750mg iv q8h

Cefuroxime 1.5gm iv q8h

Pediatrics: 75-150mg/kg/day divided q8h

Oral tablets/capsules

Cefaclor 250mg po q8h

Cefaclor 500mg po q8h

Cefuroxime axetil 250mg po bid

Cefuroxime axetil 500mg po bid

Cefprozil 250mg po bid

Cefprozil 500mg po bid

Cefuroxime axetil 250mg po bid

Cefuroxime axetil 500mg po bid

Loracarbef 200mg po bid

Loracarbef 400mg po bid

Cefuroxime axetil 250mg po bid

Cefuroxime axetil 500mg po bid

Oral Suspensions (same conversions for pediatrics)

Cefaclor 10 mg/kg bid

Cefaclor 20 mg/kg bid

Cefuroxime 10mg/kg bid

Cefuroxime 15 mg/kg bid

Cefprozil 7.5 mg/kg bid

Cefprozil 15 mg/kg bid

Cefuroxime 10mg/kg bid

Cefuroxime 15 mg/kg bid

Loracarbef 7.5 mg/kg bid

Loracarbef 15 mg/kg bid

Cefuroxime 10mg/kg bid

Cefuroxime 15 mg/kg bid

Third- and Fourth-Generation Cephalosporins

If this is ordered:

this will be provided:

Intravenous

For any population older than 4 weeks of age*:

Cefotaxime 1g iv q8-12h

Cefotaxime 2g iv q8-12h

Pediatrics: 100-200mg/kg/day divided q6-
8h

Ceftriaxone 1g iv q24h

Ceftriaxone 2g iv q24h

Pediatrics: 50-100mg/kg/day divided q12-
24h

If meningitis is suspected or confirmed:

For any population older than 4 weeks of age*:

Cefotaxime 2g iv q4-6h

Pediatrics: 200mg/kg/day divided q6h

Ceftriaxone 2g iv q12h

Pediatrics: 100mg/kg/day divided q12-24h

Ceftizoxime 1gm iv q8-12h

Ceftizoxime 2gm iv q8-12h

Pediatrics: 150-200mg/kg/day divided q6-
8h

Ceftriaxone 1g iv q24h

Ceftriaxone 2g iv q24h

Pediatrics: 100mg/kg/day divided q12-24h

Oral tablets/capsules

Cefdinir 300mg po bid

Cefdinir 600mg po qd

Cefuroxime axetil 250mg po bid

Cefuroxime axetil 500mg po bid

Cefditoren 200mg po bid

Cefditoren 400mg po bid

Cefuroxime axetil 250mg po bid

Cefuroxime axetil 500mg po bid

Cefixime 200mg po q12h

Cefixime 400mg po q24h

Cefuroxime axetil 250mg po bid

Cefpodoxime 100mg po bid

Cefpodoxime 200mg po bid

Cefuroxime axetil 250mg po bid

Cefuroxime axetil 500mg po bid

Ceftibuten 400mg po qd

Cefuroxime axetil 250mg po bid

Cefuroxime axetil 500mg po bid

Oral Suspensions

(same conversions for pediatrics)

Cefdinir 7 mg/kg bid

Cefuroxime 15 mg/kg bid

Cefixime 4 mg/kg bid

Cefixime 8 mg/kg qd

Cefuroxime 10mg/kg bid

Cefuroxime 15 mg/kg bid

Cefpodoxime 5mg/kg bid

Cefuroxime 15 mg/kg bid

Ceftibuten 9 mg/kg qd

Cefuroxime 15 mg/kg bid

*Ceftriaxone should not be used in infants with hyperbilirubinemia because of a concern for kernicterus.