University of Pennsylvania Medical Center Guidelines for Antibiotic Use

Liposomal Amphotericin B (AmBisome®)Guidelines

  1. Renal insufficiency:
  • If baseline SCr < 1.2 mg% on conventional amphotericin B (CAB), switch to liposomal amphotericin B (LAB) when SCr increases to > 2.5 mg% or
  • If baseline SCr > 1.2mg% on CAB, switch to LAB when SCr doubles or
  • If est CrCl < 30 mL/min on CAB, switch to LAB

Bone marrow transplant (BMT) and solid organ transplant (SOT) patients with baseline SCr > 2.5 mg% or est CrCl < 30 mL/min may receive LAB without a trial of CAB.

In all other patients with baseline SCr < 2.5 mg% and est CrCl < 30 mL/min, a trial of CAB should be attempted. If there is a 20% increase in SCr on CAB, the patient may be switched to LAB. (Note that the day-to-day variation of the laboratory assay for serum creatinine can be as much as 10%.)

Patients with end-stage renal disease (ESRD) on chronic peritoneal dialysis (PD) or hemodialysis (HD) will receive CAB.

Patients will be assessed weekly for improvments in renal function on LAB. Patients whose SCr has returned to baseline will receive another trial of CAB.

  1. Infusion-related toxicity secondary to CAB:
  1. Anaphylactoid reaction, including hypoxia and hypotension
  1. Rigors that are refractory to 3 days of meperidine or the patient is unable to receive meperidine

Patients who are converted to LAB for rigors will receive another trial of CAB after 1 week.

  1. Severe electrolyte abnormalities secondary to CAB:
  • Hypokalemia, hypomagnesemia, hypophosphatemia refractory to supplementation
  1. Failure of CAB for biopsy proven disease:
  1. After a minimum of 500 mg or 7 mg/kg of CAB
  1. Undocumented/unproven cases require an ID consult
  1. Dosing:
Indication
Dose
Empiric therapy in febrile neutropenia
1 mg/kg/day
Dose increase from 1 mg/kg/day to 3 mg/kg/day

Persistent fever after 5 days of therapy at 1 mg/kg/day

Evidence of definitive fungal infection

Yeasts/molds
3 mg/kg/day
Dose increase from 3 mg/kg/day to 5 mg/kg/day (for biopsy proven infection)

After a minimum course of 1500 mg or 21 mg/kg of LAB

Undocumented/unproven cases require an ID consult

Central nervous system infections with Aspergillus sp.
5 mg/kg/day

 

Written by Ann Marie Marr 7/10/06

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