...an educational memo from your Therapeutics Committee

May, 2001

Piperacillin/Tazobactam is a combination of an extended-spectrum penicillin antibiotic and a beta-lactamase inhibitor. Until now ticarcillin/clavulanate (Timentin) was the preferred antimicrobial of this class, but due to an increasing antimicrobial resistance pattern, especially with Pseudomonas sp., and the potential to reduce costs, the Pharmacy and Therapeutics Committee agreed to approving piperacillin/tazobactam to the Formulary. The P&T Committee also agreed to an autosubstitution by the pharmacist to convert timentin/clavulanate orders to piperacillin/tazobactam and to delete ticarcillin/clavulanate from the Formulary except for children aged 12 years or less.

Based upon pharmacokinetic analysis, clinical comparative trials and personal communication with the OSF Medical Center and other infectious disease consultants, the following piperacillin/tazobactam dosing will provide effective antimicrobial therapy. This dosing will provide the same or more drug per day as the dosing regimens provided by package insert and be less costly. The P&T Committee approved an autosubstitution by the pharmacist to one of the following most appropriate dosing regimen.

Creatinine clearance > 40 ml/min:

Moderate to severe infections……………. Piperacillin/tazobactam (Zosyn) 4.5 gm every 8 hours

Life-threatening, nosocomial pneumonia.......... "           "           "                      4.5 gm every 6 hours

Creatinine clearance 20-40 ml/min………....… "           "           "                      3.375 gm every 8 hours

Creatinine clearance < 20 ml/min………......… "           "           "                      3.375 gm every 12 hours

Based upon the majority of prescribing of ticarcillin/clavulanate is 3.1gm every 6 hours, it is anticipated that piperacillin/tazobactam (Zosyn) 4.5gm every 8 hours will be the most common regimen utilized.

The Pharmacy and Therapeutics Committee voted to have pantoprazole as the preferred oral proton pump inhibitor on the Formulary. Omeprazole (Prilosec) will be available for children 16 years and younger and for preparation of oral suspensions. Pharmacists will be able to autosubstitute pantoprazole 40mg once a day for most PPI orders and doses. If part of an H pylori treatment regimen, twice-daily omeprazole 20mg or lansoprazole (Prevacid) 30mg will be changed to pantoprazole 40mg twice a day. Other oral PPIs include rabeprazole (Aciphex) and esomeprazole (Nexium).

Nebulized budesonide solution has received approval to the Formulary and restricted to children who are unable to effectively use a metered dose inhaler. To date, no clear advantage over a metered-dose inhaler has documented and the cost is considerably higher for the nebulized solution.

Rapacuronium (Raplon) has been recalled due to deaths associated with bronchospasms. Succinlycholine, another neuromuscular blocker is in short supply. Also in short supply for the next 12 months are tetanus toxoid and dexamethasone injection. The FDA has approved the import from a Canadian manufacturer of naloxone (Narcan) 0.4 mg/ml to help alleviate the shortage in the US.