ASP Policies

HS 1429Antimicrobial Stewardship Program (ASP) Plan
PROGRAMScope of Service
HS 1444Use of Protected Anti-Infectives
HS IC 020Outpatient Parenteral Antimicrobial Therapy (OPAT) Dosing and Monitoring Guidelines

Protected Anti-Infectives Policy HS 1444

HOW APPROVAL WORKS

  1. Request a formal Infectious Diseases consultation. Document the indication at order entry.
  2. The ID physician sees the patient and gives verbal or written approval.
  3. Pharmacy dispenses scheduled doses.

ORDERED AFTER HOURS (5 PM – 10 AM)

Pharmacy dispenses enough drug to last until the next day, with no consult needed. The pharmacist tells the prescriber the approval is temporary.

The ordering team must then get an ID consult to receive further doses.

All require Infectious Diseases consultation unless noted. NF FORM = Request for Non-Formulary Medication form required. EXCEPTION = consult not always required.

AGENTCRITERIA
Amphotericin B deoxycholate
Conventional		Does not apply to amphotericin B lock therapy.
Amphotericin B, liposomal
AmBisome		—
ArtesunateReserved for SEVERE malaria: ≥ 5% parasitemia; evidence of end-organ damage; impaired consciousness / coma; hemoglobin < 7 g/dL; circulatory collapse / shock, acidosis; disseminated intravascular coagulation.
Baloxavir marboxil
Xofluza		Case-by-case treatment of refractory documented influenza A or B in patients who failed conventional treatment (oseltamivir or peramivir).
Bedaquiline NF FORM
Non-formulary		Request for Non-Formulary Medication form must be completed. Reserved for multi-drug resistant tuberculosis (MDR TB) or other highly resistant mycobacterial infections, case by case.
CefiderocolReserved for infections caused by documented MDR/CRE organisms, or a RECENT history of MDR/CRE infection, as salvage therapy to other beta-lactam/beta-lactamase inhibitors.
Ceftaroline—
Ceftazidime/avibactamReserved for a DOCUMENTED susceptible MDR/carbapenem-resistant (CRE) organism or a RECENT history of MDR/CRE infection.
Ceftolozane/tazobactamReserved for a DOCUMENTED susceptible multi-drug resistant (MDR) organism or a RECENT history of MDR infection.
Cidofovir—
Colistimethate sodium
Colistin		Reserved for a documented susceptible multi-drug resistant (MDR) organism or a RECENT history of MDR infection.
Dalbavancin EXCEPTIONID must approve dalbavancin before initiation.
Exception: no ID consult needed in the ED if the patient meets both criteria:
  • Candidate for ≥ 24 h of IV antibiotics and “ineligible” for oral antibiotics
  • Infection highly suspected to be gram-positive (Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus spp., Streptococcus spp.)
“Ineligible” for oral antibiotics means any of:
  • History of medication adherence issues
  • No stable housing, so medication security is a concern
  • Cannot absorb oral antibiotics
  • Source control not achieved, and the patient cannot complete usual IV therapy because of patient-directed discharge
  • Source control not achieved, and the patient cannot be discharged to SNF or home on IV antibiotics for psychosocial reasons such as substance use disorder
Daptomycin EXCEPTIONException: no ID consult needed for a single dose in patients discharged from the ED to Next Day Clinic for skin and soft tissue or diabetic foot infections.
Eravacycline—
Ethambutol—
Fecal microbiota (live)
Rebyota® rectal · Vowst® oral		ID consultation by Drs Daniel Uslan or Otto Yang. Prescribed by an adult or pediatric ID provider within their ambulatory ID clinic. The inpatient ordering workflow is in Firstline – Clinical Decisions.
Indicated for more than one recurrent C. difficile infection (CDI) after a primary episode. Give 24–72 h after the last dose of a CDI-directed antibiotic regimen.
Foscarnet—
Imipenem/cilastatinPrimary indication: nontuberculous mycobacterial infections.
Imipenem/cilastatin/relebactam NF FORM
Non-formulary		Request for Non-Formulary Medication form must be completed. Reserved for a DOCUMENTED susceptible MDR/CRE organism or a RECENT history of MDR/CRE infection. Requires documented resistance to ceftazidime/avibactam and meropenem/vaborbactam.
Isavuconazole sulfate EXCEPTIONNo ID consult needed for antifungal prophylaxis in patients with hematologic malignancies or undergoing transplant.
Letermovir NF FORM
Formulary for HSCT · non-formulary otherwise		ID consult and a Non-Formulary Medication Request form are required outside these populations: adult CMV-seropositive [R+] allogeneic hematopoietic stem cell transplant recipients; [D+/R-] kidney transplant recipients. Only approved for CMV prophylaxis in high-risk patients with contraindications to formulary antivirals.
Maribavir NF FORM
Non-formulary		ID consult and a Non-Formulary Medication Request form are required PRIOR to initiation. Reserved for CMV infection caused by isolates resistant and/or refractory to first-line agents. Patient Access and Support is available.
Meropenem/vaborbactam
Vabomere		Reserved for a documented MDR/CRE organism or a RECENT history of MDR/CRE infection.
Micafungin EXCEPTIONID consult required after 72 hours of treatment. Not required for prophylaxis in solid organ or bone marrow transplant patients.
Minocycline
IV only		Reserved for documented carbapenem-resistant Enterobacterales or Stenotrophomonas.
MoxifloxacinReserved for documented moxifloxacin-susceptible nontuberculous mycobacterial infection.
Pentamidine
Inhaled		—
Plazomicin
Zemdri		Reserved for a documented susceptible multi-drug resistant (MDR) organism or a RECENT history of MDR infection.
Polymyxin BReserved for a documented susceptible multi-drug resistant (MDR) organism or a RECENT history of MDR infection.
Pyrazinamide—
Ribavirin NF FORM
Inhaled · non-formulary		Request for Non-Formulary Medication form must be completed. After approval, the ordering provider must notify the Director of Safety at the time of prescription.
Sulbactam/durlobactam
Xacduro®		—
TigecyclineBecause serum concentrations are poor, avoid tigecycline or use it with caution for endovascular infections.

PRESCRIBING PRINCIPLES: ALL ANTI-INFECTIVES

  • Prescribe the right drug, dose, and duration to maximize benefit while minimizing toxicity and resistance.
  • Review empiric therapy at 48–72 h (“antibiotic time out”), then follow microbiology and the clinical course.
  • Document the indication in the medical record for every prescription.
  • Follow UCLA treatment recommendations and the local susceptibility summary on the ASP website or in the Firstline – Clinical Decisions app.

POLICY RULES: PROTECTED AGENTS

  • Applies to all patients at all designated UCLA Health System hospitals.
  • After the first doses, the ordering team is responsible for getting ID consultation for continued therapy.
  • Using an ID physician’s name on an order without their approval violates hospital policy.
  • Use is audited by the ASP and reported to hospital committees.
  • During a CRITICAL shortage, the P&T Committee Chair or ASP Director(s) may temporarily add the affected agent to this policy.

FDA Drug Shortages Updated 9/18/26

Shortages that affect UCLA guidelines, with what to use instead.

SHORT DRUGUSE INSTEADGUIDANCE
Azithromycin IVPO azithromycin · DoxycyclineGive it PO once the patient takes pills, and stop at day 3 in CAP without suspected Legionella. Doxycycline covers atypicals.
Clindamycin IVLinezolidRarely needed. Can use linezolid for toxin inhibition in necrotizing fasciitis.
Vancomycin and linezolid IVDe-escalate · PO linezolidStop vancomycin at 48 h if the MRSA nasal PCR is negative. Linezolid PO is fully bioavailable, so switch as soon as the gut works.
Levofloxacin and moxifloxacin IVSame drug POBoth are fully bioavailable orally. Reserve IV fluoroquinolones for patients with GI absorption issues or who cannot take orals, and only when there are no alternatives.
Bicillin L-ADoxycycline · Lentocilin (import)Save it for pregnancy, congenital syphilis, and patients who can't take doxycycline. FDA is letting in imported Lentocilin. See the penicillin note below.
PRE-PEN (penicillin skin test)Oral amoxicillin challengeFor low-risk histories, go straight to an oral amoxicillin challenge. See the allergy pathway.

NOTE ON PENICILLIN

Penicillin is still the narrowest, most effective option for several syndromes, so choose substitutes on purpose, not by default.

  • Reserve Bicillin L-A for pregnant patients with syphilis and infants with congenital syphilis. These groups have no equivalent alternative.
  • Documented allergy, not pregnant: doxycycline is an acceptable substitute.
  • Everyone else: clarify the allergy or test for it. Don't default to a broader agent.

Before changing a regimen, confirm product availability in the ASHP shortage bulletins and with Pharmacy.

Live shortage sources

ASHP · CHECK BEFORE SUBSTITUTING
Current Drug Shortages Bulletins

Per-drug bulletins with available products, estimated resupply dates, and alternative agents. Updated more often than this page.

 FDA
Drug Shortage Database

Official FDA shortage and discontinuation postings, including why each shortage happened and whether it's resolved.

Shortage information reflects FDA and ASHP postings and UCLA Health supply as of the date shown. Confirm availability with Pharmacy before prescribing.