Duke University Hospital Duke Raleigh Hospital

Criteria & Principles

*DRAH Empiric Antibiotic Dosing BCID Condensed Table (BLOOD Cultures)

Rapid molecular diagnostic technologies for infectious diseases have dramatically reduced the time to pathogen identification thus allowing for earlier ‘targeting’ of therapy to the most effective agent. 

Please find information attached about our two newest rapid diagnostic technologies:

  • BioFire Blood Culture Identification Panel (BCID) - see above link or attachment for empiric antibiotic dosing recommendations 
  • BioFire Meninigitis/Encephalitis Panel
  • BioFire GI Panel

Microbiology is working with Pharmacy to alert providers of results to review and adjust empiric therapy based on DRAH antibiogram. See attached for DRAH Stewardship Pathway.

Diagnosis-Specific Information

Table 1. GRAM POSITIVE Blood Culture Empiric Treatment Recommendations

BCID Pathogen & Resistance Gene Target (Reported in Maestro Care) Preferred Therapy Penicillin Allergy
Alternative Therapy
Treatment Notes

Enterococcus species​[1]
● (Van A/B NOT detected)

Vancomycin Load then 15mg/kg IV q12h Linezolid 600mg IV q12h ● ID consult recommended
Enterococcus species​[1] (VRE)   
● (Van A/B DETECTED)
Linezolid 600mg IV q12h Daptomycin 10-12mg/kg IV q24 ● ID consult recommended
Staphylococcus aureus
● (mecA gene NOT detected) species is NOT Methicillin Resistant
*All require automatic ID Consult
Cefazolin 2g IV q8h OR Oxacillin 2g IV q4h
*All require automatic ID consult
Vancomycin Load then 15mg/kg IV q12h
● Oxacillin for meningitis/brain abscess
Staphylococcus aureus ​(MRSA)
(mecA gene DETECTED) Methicillin Resistant   
*All require automatic ID Consult
Vancomycin Load then 15mg/kg IV q12h
*All require automatic ID consult
Daptomycin 8-10mg/kg IV q24
● Daptomycin is inactivated by lung surfactant, do not use for pneumonia
Staphylococcus coagulase negative​[2]
● (mecA gene NOT detected) species is NOT Methicillin Resistant
Cefazolin 2g IV q8h OR Oxacillin 2g IV q4h Vancomycin Load then 15mg/kg IV q12h ● Evaluate clinically to determine if true pathogen (common contaminant)
● Oxacillin for meningitis/brain abscess
Staphylococcus coagulase negative​[2]​  
● (mecA gene detected) Methicillin Resistant
Vancomycin Load then 15mg/kg IV q12h Daptomycin 6mg/kg IV q24 ● Evaluate clinically to determine if true pathogen (common contaminant)
Streptococcus agalactiae (Group B) Penicillin G 2-4 million units IV q4h OR Ceftriaxone 2g IV q24h Vancomycin Load then 15mg/kg IV q12h  
Streptococcus pneumoniae Ceftriaxone 2g IV q24h
Ceftriaxone 2g IV q12h (meningitis only)
Vancomycin Load then 15mg/kg IV q12h ● Add vancomycin to ceftriaxone if meningitis suspected
Streptococcus pyogenes (Group A) Penicillin G 2-4 million units IV q4h OR Ceftriaxone 2g IV q24h Vancomycin Load then 15mg/kg IV q12h  
Streptococcus species​[3]
● Streptococcus without specific BCID species identification
Ceftriaxone 2g IV q24h Vancomycin Load then 15mg/kg IV q12h  
Listeria monocytogenes Ampicillin 2g IV q4h TMP/SMX 3-5mg/kg/day IV (TMP component) divided q6-12h ● ID consult recommended
GRAM STAIN RESULT ARE POSITIVE FOR: Gram positive cocci clusters OR Gram positive cocci pairs and chains OR Gram positive rod AND NO SPECIFIC TARGET IDENTIFIED
● Preferred Therapy: Vancomycin Load then 15mg/kg IV q12h 
● If gram positive rod AND high suspicion for Nocardia sp. (eg, immunosuppressed host) consult ID for evaluation/treatment recommendations

1. Detected: E. faecium, E. faecalis, E. avium, E. casseliflavus, E. durans, E. gallinarum, E. hirae, E. dispar, E. saccharolyticus
2. Detected: S. caprae, S. cohnii, S. epidermidis, S. haemolyticus, S. hominis, S. lugdunensis, S. xylosus, S. capitis, S. pasteuri, S. saprophyticus, S. simulans, S. warneri
3. Detected: S. anginosus, S. bovis, S. constellatus, S. dysgalactiae, S. equinis, S. gallolyticus, S. gordonii, S. intermedius, S. mitis, S. mutans, S. oralis, S. parasanguinis, S. pseduopneumoniae, S. salivarius, S. sanguinis

 

​Table 2. GRAM NEGATIVE Blood Culture Empiric Treatment Recommendations

BCID Pathogen & Resistance Gene Target
(Reported in Maestro Care)
Preferred Therapy Penicillin Allergy
Alternative Therapy
Acinetobacter baumannii
● (KPC NOT detected)
Ampicillin/Sulbactam 3gm IV q4h
● ID consult recommended
Meropenem 1g IV q8h extended infusion over 3h
● ID consult recommended
Acinetobacter baumannii
Carbapenem Resistance (KPC) gene DETECTED
ID Consult ID Consult
Enterobacter cloacae complex
● (KPC NOT detected)
Cefepime 1g IV q6h Ciprofloxacin 400mg IV q12h OR
Levofloxacin 750mg IV q24h
Enterobacter cloacae complex
Carbapenem Resistance (KPC) gene DETECTED.
ID Consult ID Consult
Enteric Gram Negative[1] (no specific species)
● (KPC NOT detected)
Piperacillin/tazobactam 3.375 IV q8h extended infusion over 4h Ciprofloxacin 400mg IV q12h OR
Aztreonam 2g IV q8h
Enteric Gram Negative​[1] (no specific species)
Carbapenem Resistance (KPC) gene DETECTED
ID Consult ID Consult
Escherichia coli
● (KPC NOT detected)
Ceftriaxone 2g IV q24h Piperacillin/Tazobactam 3.375 IV q8h extended infusion over 4h OR
Aztreonam 2g IV q8h
Escherichia coli
Carbapenem Resistance (KPC) gene DETECTED.
ID Consult ID Consult
Klebsiella oxytoca
● (KPC NOT detected)
Ceftriaxone 2g IV q24h OR
Cefepime 1g IV q6h (critically ill)
Levofloxacin 750mg IV q24h OR Aztreonam 2g IV q8h
Klebsiella oxytoca
Carbapenem Resistance (KPC) gene DETECTED
ID Consult ID Consult
Klebsiella pneumoniae
● (KPC NOT detected)
Ceftriaxone 2g IV q24h Ciprofloxacin 400mg IV q12h OR
Levofloxacin 750mg IV q24h
Klebsiella pneumoniae
Carbapenem Resistance (KPC) gene DETECTED.
ID Consult ID Consult
Serratia marcescens
● (KPC NOT detected)
Cefepime 1g IV q6h Ciprofloxacin 400mg IV q12h OR
Levofloxacin 750mg IV q24h
Serratia marcescens
Carbapenem Resistance (KPC) gene DETECTED
ID Consult ID Consult
Haemophilus influenzae Ceftriaxone 2g IV q24h Ciprofloxacin 400mg IV q12h
Neiserria meningitides Ceftriaxone 2g IV q24h Ciprofloxacin 400mg IV q12h
Pseudomonas aeruginosa
● (KPC NOT detected)
Piperacillin/tazobactam 3.375 IV q8h extended infusion over 4h
 
Meropenem 1g IV q8h extended infusion over 3h OR
Levofloxacin 750mg IV q24h AND Tobramycin 7mg/kg IV daily
Pseudomonas aeruginosa
● Carbapenem Resistance (KPC) gene DETECTED
ID Consult ID Consult
GRAM STAIN RESULT ARE POSITIVE FOR: Enteric Gram Negative Rods OR Gram Negative Rods AND NO SPECIFIC TARGET IDENTIFIED
● Preferred Therapy: Piperacillin/tazobactam 3.375 IV q8h extended infusion over 4h
● Penicillin Allergy/Alternative Therapy: Ciprofloxacin 400mg IV q12h OR Aztreonam 2g IV q8h +/- metronidazole 500mg IV q8h (if concern for anaerobic organism)
● If gram negative rod AND high suspicion for Stenotrophomonas: TMP/SMX IV 15-20mg/kg (TMP component) IV divided q8h
● If gram negative rod AND high suspicion for Burkholderia: Meropenem 500mg IV q6h

​1. Detected: Cedeceae davisiae, Citrobacter sp., Cronobacter sp., Enterobacter sp., Escherichia sp., Klebsiella sp., Kluyvera sp., Leclercia adecarbocylata,, Proteus spp, Raoultella sp., Salmonella sp., Shigella sp., Serratia marcescens/ficaria/entomophila, Yokenella regensbergei, Edwardsiella sp., Enterobacter gergoviae, Hafnia alvei, Pantoea sp., Salmonella bongori, Serratia fonticoloa/adorifera/rubidaeae

NOTE: If patient has history of an ESBL producing organism, meropenem 500mg IV q6h OR ertapenem 1g IV q24h are preferred therapy (ID consult recommended)

 

​Table 3. YEAST Blood Culture Empiric Treatment Recommendations

  BCID Pathogen Preferred Therapy
Yeast Candida albicans, Candida tropicalis, Candida parapsilosis, Candida glabrata, Candida krusei *All require automatic ID consult
Micafungin 100mg IV q24h OR 150mg IV q24 (intravascular disease; endocarditis)

No Target Identified

Yeast (Contact lab for fungal stain results)
Organism not identified by rapid BioFire FilmArray Blood Culture panel
*All require automatic ID consult
Amphotericin B (Ambisome) 3-5 mg/kg IV q24h
● Echinocandins do not have activity against Cryptococcus sp.