October 26, 2000



DATE___________________ TIME__________________

1. Administer antimicrobials per the following:

• Cefazolin ______ g I V Q ___ hrs

• Cefepime _______g IV Q ___ hrs

• Ceftriaxone ______g IV Q ___ hrs

• Cephalexin _______ mg PO Q ___ hrs

• Ciprofloxacin _______ mg IV or PO Q ___ hrs

• Amoxicillin ________ mg PO Q______ hrs

• Daptomycin _______ mg IV Q 24 hrs

• Doxycycline 100 mg PO Q 12 hrs

• Ertapenem ____g IV Q 24 hrs

• Fluconazole ______ mg PO Q ___ hrs

• Linezolid 600 mg PO or IV Q 12 hrs

• Meropenem _____g IV Q ___ hrs

• Metronidazole 500 mg IV or PO Q ___ hrs

• Augmentin 875-125 mg PO Q 12 hrs

• Nafcillin 12 g IV continuous infusion over 24 hrs

• Vancomycin 125mg PO Q6hrs (For C. Diff treatment only)

• Unasyn 3gm IV q_________

• Penicillin G _____ million units IV continuous infusion over 24 hrs

• Piperacillin/ tazobactam (Zosyn) 9 g or 13.5 g or 18 g IV continuous infusion over 24 hrs

• Posaconazole _____ mg PO Q 24 hrs

• Rifampin _____ mg PO Q ___ hrs

• Vancomycin _________ gm IV continuous infusion over 24 hrs or _______ mg IV Q _______hrs

• Voriconazole _____ mg PO Q 12 hrs

• Other ___________________________________________________________________________________________

2. Labs/Imaging to be done by the facility and results faxed weekly to 272-1920

[pic] CBC with diff [pic] Chem 7 [pic] LFTs [pic] ESR [pic] CRP [pic] CK (creatinine phosphokinase)

[pic] Vancomycin level, random via a peripheral draw [pic] Vancomycin trough draw at : ___________

[pic] other _____________________________________________________________________

3. Next PICC dressing change is due on ____________________________________________

4. Please send with each visit: current medication administration record, all ordered laboratory/imaging results, & most recent provider note since last OPAT appointment.

5. Next OPAT Appointment date ____________________ time_______________

PROVIDER SIGNATURE________________________________________ Provider Name _________________________

Contracting Pharmacy___________________________________________ Contracting HHC__________________________________________________[pic]

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Attach patient label

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5ACC Internal Medicine Clinics – Outpatient Treatment Center

2211 Lomas Blvd NE, Albuquerque, NM 87106,

Phone (505) 272-2472, Fax (505) 272-1920

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