| Original Order | Substitution |
|---|---|
| Amoxicillin-Clavulanate-250 (250mg/125mg) PO tid in adults | Amoxicillin-Clavulanate-500 (500 mg/125mg) PO bid |
| Amoxicillin-Clavulanate-500 (500mg/125mg) PO tid in adults With CrCl greater than 30mL/min | Amoxicillin-Clavulanate- 875 (875 mg/125mg) PO bid |
| Amoxicillin-Clavulanate 125 or 250 suspension (4:1) PO bid in pediatrics | Amoxicillin-Clavulanate 400 suspension ( 7:1) PO bid ( same dose of amoxicillin) |
| Amoxicillin-Clavulanate 125 or 250 suspension (4:1) PO tid in pediatrics | Amoxicillin-Clavulanate 400 suspension (7:1) PO tid (same dose of amoxicillin) |
| Ampicillin IV 500mg in adults | Ampicillin 1g IV |
| Ampicillin PO qid | Amoxicillin PO tid at same dose excluding shigellosis |
| Anidulafungin 200mg IV in adults | Caspofungin 70mg IV in adults **excluding patients with Child-Pugh scores greater than 9 |
| Anidulafungin 100mg IV in adults | Caspofungin 50mg IV in adults **excluding patients with Child-Pugh scores greater than 9 |
| Cefaclor 250mg PO tid in adults | Cefuroxime axetil 250mg PO bid |
| Cefaclor 500mg PO tid in adults | Cefuroxime axetil 500mg PO bid |
| Cefaclor PO in pediatrics | Ceprozil q12h same dose |
| Cefazolin IV q6h | Cefazolin IV q8h at same dose EXCEPT ID consulted patients, septic arthritis, S. aureus bacteremia or obesity |
| Cefoxitin in surgical prophylaxis | Cefazolin 2g IV + metronidazole 500mg IV |
| Cefotetan | Cefazolin 2g IV q8h + metronidazole 500mg IV q12h |
| Cefotaxime 1g IV q8h in adults | Ceftriaxone 1g q24h |
| Cefotaxime 2q IV q8h in adults | Ceftriaxone 2g q24h |
| Cefotaxime 2g IV q6h in adults | Ceftriaxone 2g q12h |
| Cefotaxime xmg IV q8h in pediatrics (neonates excluded) | Ceftriaxone xmg q24h same mg dose |
| Cefotaxime xmg IV q6h in pediatrics (neonates excluded) | Ceftriaxone xmg q12h same mg dose |
| Cefriaxone IV q12h in adults EXCEPT CNS infection and Enterococcal endocarditis for synergy | Ceftriaxone IV q24h same mg dose |
| Ciprofloxacin 200mg IV q12h in adults | Ciprofloxacin 400mg IV q24h |
| Clindamycin IV q6h | Clindamycin IV q8h at same dose |
| Clindamycin IV > 600mg per dose ** Excluding necrotizing fasciitis or streptococcal toxic shock syndrome | Clindamycin IV 600mg |
| Imipenem IV | Meropenem IV same dose |
| Meropenem IV 1gm q8h | Meropenem IV 500mg q6h **Except CNS infections and febrile neutropenia |
| Metronidazole IV q6-8h in adults | Metronidazole IV q12h at same dose excluding subdural empyema or brain abscess (use q8h) and excluding C-difficile (can use q6-8h) |
| Nitrofurantoin macrocrystals (shortacting) – ordered as QID | Please contact prescriber to change to Macrobid bid For patients whose medications required crushing (i.e. tube feeding), can automatically autosubstitute with short-acting nitrofurantoin microcrystals tablets at same dose and frequency |
| Norfloxacin 400mg PO | Ciprofloxacin 250mg PO same frequency |
| Oseltamivir in doses >75mg BID x 5 days in adults | Oseltamivir 75 mg BID for 5 days |
| Penicillin G K+ PO | Penicillin V K+ PO at equivalent dosage and form |