Updated February 2019

Full antibiogram available electronically on the intranet. For a printed copy of the antibiogram, please contact pharmacy or infection prevention.

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Clinical information

Clinical Pearls
Infection type Clinical information
Asymptomatic bacteriuria
  • Positive urine cultures (even if >100,000 cfu) without presence of symptoms do not require antibiotic treatment unless the patient is pregnant or undergoing urinary surgery
  • Document as asymptomatic bacteriuria
Urinary tract infections
  • Since E. coli is the most common cause of UTI, consider using ceftriaxone for empiric therapy as opposed to levofloxacin or ciprofloxacin
  • E. coli is 100% susceptible to ceftriaxone and only 60% susceptible to levofloxacin and ciprofloxacin*
Skin and soft tissue infections
  • Clindamycin combination therapy is only indicated in Group A Streptococcus infections
  • Purulent infection, moderate to severe: consider MRSA coverage with vancomycin
  • Non-purulent or diffuse infections, mild to moderate: β-lactam (cefazolin) is preferred. Consider clindamycin as an allergic alternative
  • Avoid using trimethoprim/sulfamethoxazole empirically due to lack of Streptococcus coverage
Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Cefazolin (IV) or cephalexin (PO) are the drugs of choice
  • Nafcillin is an alternative
Methicillin-resistant Staphylococcus aureus (MRSA)
  • Of the 771 Staphylococcus aureus isolates, 68% (528) were MRSA.*
  • Vancomycin IV is the drug of choice
Enteroccocal infections
  • Ampicillin (IV) or amoxicillin (PO) are the drugs of choice, unless resistant
    • Enterococcus faecalis is 100% susceptible to ampicillin*
  • Adding a β-lactamase inhibitor (ampicillin/sulbactam or amoxicillin/clavulanate) does not add any benefit, as this is not the resistance mechanism of Enterococcus
  • Cephalosporins do not cover Enterococcus
Extended-spectrum beta- lactamase producers (ESBLs)
  • Meropenem is the preferred drug for ESBLs
  • Only 18% of E. coli were ESBLs in 2018*
Haemophilus influenza and Moraxella catarrhalis
  • 25% of H. influenzae and 88% of M. catarrhalis are β-lactamase producing
  • Preferred therapy includes:
    • IV: ceftriaxone or ampicillin/sulbactam
    • PO: cefuroxime or amoxicillin/clavulanate
Candida infections
  • Fluconazole is the drug of choice for C. albicans
  • For fungemia, consider micafungin empirically and narrowing to fluconazole if C. albicans is isolated
  • Micafungin is the echinocandin on formulary

*data based on 2019 antibiogram at Rapides Regional Medical Center

De-escalation tips

  • Evaluate the patient at 48 hours (at a minimum) to determine if antibiotics can be de-escalated
  • De-escalation can occur both when specific organisms have been isolated or when no specific organism has been isolated
  • When narrowing based on reported sensitivities, do not compare MIC values. MIC values are organism and drug specific. A lower MIC does not necessarily mean a better agent.
Consider the following additional tips:
If the following is the case: Then the proper procedure is:
Viral panel is positive stop antibiotics
S. aureus is not isolated DC vancomycin
Resistant gram-negative organisms are not isolated (e.g. Pseudomonas, Enterobacter) De-escalate from piperacillin/tazobactam or cefepime to ampicillin/sulbactam or ceftriaxone
No isolate is identified or normal flora is identified De-escalate to an oral antibiotic if patient is clinically stable to do so
Isolate is susceptible to a 1st generation cephalosporin Do not use a 3rd generation cephalosporin (e.g. ceftriaxone), de-escalate to the narrowest spectrum (e.g. cefazolin)

Oral vs IV information

IV and Oral equivalents
# IV antibiotic Oral equivalent
1 Ampicillin Amoxicillin
2 Ampicillin/sulbactam Amoxicillin/clavulanate
3 Ceftriaxone Cefdinir
3 Cefazolin Cephalexin

C. difficile colitis risk

C. difficile colitis risk and antibiotic selection.
# Antibiotic Risk Ratio
1 Penicillin 1.9
2 Beta-lactamase combinations 2.3
3 1st and 2nd generation cephalosporins 2.4
4 3rd and 4th generation cephalosporins 3.1
5 Clindamycin 1.9 - 16.8
6 Fluoroquinolones 4 - 5.5

C. difficile risk increases with antibiotic days*

  • 4-7 days = 40%
  • 8-18 days = 300%
  • >18 days = 78%
*1 day = 1 day per drug (1 day of triple-drug therapy = 3 antibiotic days), Stevens V, et al. Clin Infect Dis. 2011; 53:42-48, Brown KA, et al. Antimicrob Agents Chemother. 2013; 57:2326-32

Preferred Antimicrobial List for Selected Disease States in Adults

Please Note: This is only a guide, designed to assist healthcare providers in selecting an appropriate, empiric antimicrobial regimen and may or may not be appropriate for all patients. Ultimately the antibiotic course depends upon culture results and the patient’s clinical course. For additional information, please contact the pharmacy.

*All dosing assumes normal renal and hepatic function

C difficile1

  • Common Pathogens
    • Initial episode: Mild, Moderate, Severe
    • Initial episode: fulminant
    • First recurrence
    • Second or subsequent recurrences
  • Adult Empiric Therapy*
    • Initial episode: Mild, Moderate, Severe - Vancomycin 125 mg PO Q6 hours
    • Initial episode: fulminant - Vancomycin 500 mg PO Q6 hours + Metronidazole 500 mg IV Q8 hours
    • First recurrence - Vancomycin 125 mg PO Q6 hours x 10-14 days then prolonged taper and pulsed dosed regimen for 2-8 weeks
    • Second or subsequent recurrences - Vancomycin 125 mg PO Q6 hours x 10-14 days then prolonged taper and pulsed dosed regimen for 2-8 weeks
  • Duration of Therapy
    • Initial episode: Mild, Moderate, Severe - 10 days
    • Initial episode: fulminant - 10 – 14 days
    • First recurrence - See empiric therapy column
    • Second or subsequent recurrences - See empiric therapy column

Diabetic Foot Infections2

  • Common Pathogens (polymicrobial)
    • β-hemolytic Strep
    • S. aureus
    • Pseudomonas
    • Gram-negative rods
    • Anaerobes
  • Adult Empiric Therapy*
    • Ampicillin/Sulbactam 3 gm IV Q6 hours
    • Or, if Pseudomonas concern: Piperacillin/Tazobactam extended infusion 3.375gm IV Q8 hours +/-
    • Or, if MRSA concern Vancomycin (20-25 mg/kg load plus RX to dose)
  • Duration of Therapy
    • Patient and pathogen dependent

Intra-abdominal infections3

  • Common Pathogens
    • Abscess
    • Cholecystitis
    • Diverticulitis
    • Enterococcus
    • Enterobacteriaceae
    • Anaerobes
  • Adult Empiric Therapy*
    • Mild to moderate: Ceftriaxone 1 gm IV Q24 hours + Metronidazole 500 mg PO Q12 hours
    • Severe: Piperacillin/Tazobactam extended infusion 3.375gm IV Q8 hours
  • Duration of Therapy
    • After source control: 4-7 days
    • Abscess: Varies based on patient response

Meningitis (community acquired)4

  • Common Pathogens
    • Age < 50 yrs
      • S. pneumoniae
      • N. meningitides
    • Age > 50 yrs
      • S. pneumoniae
      • N. meningitides
      • Listeria
  • Adult Empiric Therapy*
    • Age < 50 yrs
      • Ceftriaxone 2 gm IV Q12 hours + Vancomycin (20-25 mg/kg load plus RX to dose)
      • +/- Ampicillin 2gm IV Q4 hours if Listeria concern
    • Age > 50 yrs
      • Ceftriaxone 2gm IV Q12 hours + Vancomycin (20-25mg/kg load plus Rx to Dose) + Ampicillin 2gm IV Q4 hours
  • Duration of Therapy
    • Patient and pathogen dependent

Neutropenic Fever5

  • Common Pathogens
    • S. epidermidis
    • K. pneumonia
    • P. aeruginosa
    • S. aureus
    • E. coli
  • Adult Empiric Therapy*
    • Zosyn 3.375 gm IV Q8 hours
    • +/- Vancomycin (20-25mg/kg load plus Rx to Dose)
    • +/- Levofloxacin 750 mg IV q24h
  • Duration of Therapy
    • Continue until neutropenia subsides (ANC ≥ 500 cells/mm3) and afebrile or longer if clinically necessary depending on symptoms and pathogens

Pneumonia6-10

  • Common Pathogens
    • Community Acquired (CAP)
      • S. pneumoniae
      • M. pneumoniae
      • C. pneumoniae
      • H. influenzae
    • Aspiration
      • Anaerobes
    • Hospital Acquired (HAP/Ventilator Associated (VAP)
      • P. aeruginosa
      • K. pneumoniae
      • Acinetobacter
      • S. aureus (MRSA)
  • Adult Empiric Therapy*
    • Community Acquired (CAP)
      • Ceftriaxone 1 gm IV Q24 hours + Azithromycin 500 mg IV/PO daily
      • Cephalosporin allergy:
        • Non-ICU: Levofloxacin 750 mg IV/PO Q24 hours
        • ICU: Aztreonam 1gm IV Q8 hours + Levofloxacin 750mg IV/PO Q24 hours
    • Aspiration
      • Ampicillin/Sulbactam 3gm IV Q6 hours
      • Or Clindamycin 600mg IV Q8 hours
      • Or Metronidazole 500mg IV Q6 hours + Ceftriaxone 1gm IV Q24 hours
      • Or if cephalosporin allergy Levofloxacin 750 mg IV Q24 hours
    • Hospital Acquired (HAP/Ventilator Associated (VAP)
      • Piperacillin/Tazobactam 3.375gm IV Q8 hours or Ceftazidime 2 gm IV Q8 hours +/- (if MRSA likely): Vancomycin (20-25 mg/kg load plus RX to dose) +/- (Consider adding if patient has high risk of mortality or has received IV antibiotics during the previous 90 days): Amikacin RX to dose OR Tobramycin RX to dose or Levofloxacin 750mg IV daily
  • Duration of Therapy
    • CAP = 5 days (longer courses may be clinically necessary depending on symptoms and pathogens)
    • Aspiration = 5 days
    • HAP/VAP = 7 days

Septic Joint11

  • Common Pathogens
    • STD risk: N. gonorrhoeae, S. aureus, Streptococcus
    • Low STD risk: S. aureus
  • Adult Empiric Therapy*
    • Ceftriaxone 1g IV Q24 hours + Vancomycin (20-25 mg/kg load plus Rx to dose)
    • +/- Azithromycin 1gm PO once if STD risk to cover Chlamydia trachomatis
  • Duration of Therapy
    • Patient and pathogen dependent

SSTI: Cellulitis and Erysipelas12

  • Common Pathogens
    • NonPurulent/Erysipelas: β-hemolytic streptococcus, S. aureus
    • Purulent/Abscess or Risk of MRSA: S. aureus
  • Adult Empiric Therapy*
    • Non-Purulent/Erysipelas
      • Mild to Moderate: Cefazolin 1gm IV Q8 hours or Nafcillin 1gm IV Q4 hours
      • Severe: Vancomycin (20-25 mg/kg load plus pharmacy protocol)+ Piperacillin/Tazobactam extended infusion 3.375gm IV Q8 hours
    • Purulent/Abscess or Risk of MRSA
      • Vancomycin (20-25 mg/kg load plus pharmacy protocol)
  • Duration of Therapy
    • Uncomplicated: 5 days
    • Abscess/Complicated: 7-10 days
    • Longer courses may be clinically necessary depending on symptoms and pathogens

Surgical Prohylaxis13

  • Common Pathogens
    • Pre-operative
    • Post-operative
  • Adult Empiric Therapy*
    • Pre-operative: See: Guidelines for Antimicrobial Prophylaxis for Adult Surgery
    • Post-operative: No antibiotic prophylaxisis necessary to be continued post-op. If it is clinically necessary to continue antibiotics for prophylaxis do not exceed 24 hours post-op and 48 hoursfor cardiac surgeries.
  • Duration of Therapy
    • Pre-operative: See: Guidelines for Antimicrobial Prophylaxis for Adult Surgery
    • Post-operative: No antibiotic prophylaxisis necessary to be continued post-op. If it is clinically necessary to continue antibiotics for prophylaxis do not exceed 24 hours post-op and 48 hoursfor cardiac surgeries.

Urinary Tract Infections14

  • Common Pathogens
    • Cystitis
      • E. coli
      • Proteus
      • Klebsiella
      • Enterococcus
    • Pyelonephritis
      • E. coli
      • Proteus
      • Klebsiella
      • Enterococcus
  • Adult Empiric Therapy*
    • Cystitis
      • Uncomplicated: Nitrofurantoin 100 mg PO BID OR Cephalexin 500 mg PO Q6 hours if resistance or allergy
      • Complicated: Ampicillin 2gm IV Q6 hours + Gentamicin 5mg/kg IV Q24 hour (or per pharmacy protocol) OR Piperacillin/Tazobactam extended infusion 3.375gm IV Q8 hours
    • Pyelonephritis
      • Ceftriaxone 1 gm IV Q24 hours
  • Duration of Therapy
    • Uncomplicated: 3-5 days
    • Complicated: 7-10 days
    • Complicated with structural abnormalities or pyelonephritis: 14 days

References: 1IDSA/SHEA C difficile Guidelines. CID 2018; 66:987-994. 2Diagnosis and treatment of diabetic foot infections. CID 2012; 54: e132-73. 3Intra-abdominal infection guidelines. CID 2010; 50: 133-164. 4Guidelines for bacterial meningitis. CID 2004; 39: 1267-84. 5 IDSA guidelines on Antimicrobial agent in Neutropenic Patients. CID 2011; 52:62-111. 6 IDSA/ATS guidelines on CAP in adults. CID 2007; 44: S27-72. 7ATS, IDSA. Guidelines for adults with HAP, VAP, HCAP pneumonia. Am J Respir Crit Care Med 2005; 171: 388-416. 8Management of Adults With Hospital-acquired and Ventilatorassociated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016 Sep 1;63(5):e61-e111. 9Gross AE et al. Epidemiology and Predictors of Multidrug-Resistant Community-Acquired and Health Care-Associated Pneumonia. Antimicrob Agents Chemother. 2014; 58(9):5262. 10Attridge RT, et al. Health careassociated pneumonia in the intensive care unit: Guideline-concordant antibiotics and outcomes. J Crit Care. 2016 Aug 11. doi:10.1016/j.jcrc.2016.08.004. [Epub ahead of print]. 11Guidelines for the diagnosis and management of prosthetic join infection. CID 2013; 56: 1-25. 12Guidelines SSTI infections. CID 2014; 59: 10-52. 13Antimicrobial prophylaxis in surgery. AJHP. 2013; 70:195-283. 14Guidelines for uncomplicated acute bacterial cystitis and acute pyelonephritis in women. CID 2011; 52:e103-2.

Preferred Antimicrobial List for Selected Disease States in Pediatrics

Please Note: This is only a guide, designed to assist healthcare providers in selecting an appropriate, empiric antimicrobial regimen and may or may not be appropriate for all patients. Ultimately the antibiotic course depends upon culture results and the patient’s clinical course. For additional information, please contact the pharmacy.

*All dosing assumes normal renal and hepatic function

Intra-abdominal Infections1,2

  • Common Pathogens
    • Abscess
    • Cholecystitis
    • Diverticulitis
    • Enterococcus
    • E. coli
    • Enterobacteriaceae
    • Anaerobes
  • Pediatric Empiric Therapy*
    • Ceftriaxone 50 mg/kg (max dose 2000mg) IV Q12 hours + Metronidazole 10 mg/kg (max dose 500mg) IV Q8 hours
  • Duration of Therapy
    • After source control: 4-7 days
    • Abscess: Varies based on patient response

Meningitis3

  • Common Pathogens
    • Age < 1 month
      • S. agalactiae
      • E. coli
      • Listeria
    • Age 1 month to 18 years
      • S. pneumonia
      • N. meningitides
      • H. influenzae
  • Pediatric Empiric Therapy*
    • Age < 1 month
      • Ampicillin 50-100 mg/kg IV Q6 hours + Cefotaxime 50 mg/kg IV Q6 hours
      • Or Gentamicin 4 mg/kg Q24 hours
    • Age 1 month to 18 years
      • Ceftriaxone 50mg/kg (max dose 2000mg) IV Q12 hours
        • + (1 month-12 years:) Vancomycin: 15 mg/kg Q6 hours
        • + (> 12 years:) 20 mg/kg Q8 hours
      • or Vancomycin per pharmacy protocol
  • Duration of Therapy
    • Patient and pathogen dependent

Neutropenic Fever4

  • Common Pathogens
    • S. epidermidis
    • K. pneumonia
    • P. aeruginosa
    • S. aureus
    • E. coli
  • Pediatric Empiric Therapy*
    • Ceftriaxone 50 mg/kg IV Q12 hours ± Vancomycin 1 month-12 years: 15 mg/kg Q6 hours, Vancomycin >12 years: 20 mg/kg Q8 hours
    • Vancomycin per pharmacy protocol
  • Duration of Therapy
    • Continue until neutropenia subsides (ANC ≥ 500 cells/mm3) and afebrile or longer if clinically necessary depending on symptoms and pathogens

Pneumonia5,6

  • Common Pathogens
    • Community Acquired (CAP)
      • S. pneumoniae
      • M. pneumoniae
      • C. pneumoniae
      • H. influenza
      • C. trachomatis
    • VAP, Risk of Pseudomonas or MRSA
      • K. pneumonia
      • Acinetobacter
      • P. aeruginosa
      • S. aureus (MRSA)
  • Pediatric Empiric Therapy*
    • Community Acquired (CAP)
      • Simple, Untreated, Immunized: Ampicillin 100 mg/kg (max dose 2000 mg) IV Q6-8 hours
      • Non Fully Immunized, High–Level Penicillin Resistance to Pneumococcal Strains, Life-Threatening Infections OR failed outpatient treatment: Ceftriaxone 100 mg/kg (max dose 2000 mg) IV Q24 hours
      • Optional Additional Coverage:
        • Concern for Atypical Pathogens: Azithromycin I0 mg/kg (max dose 500 mg) IV Q24 hours x 2 doses, then 5 mg/kg (max dose 250 mg) IV daily x 3 doses
        • Concern for S. aureus:
          • Vancomycin 1 month-12 years: 15 mg/kg Q6 hours
          • Vancomycin >12 years: 20 mg/kg Q8 hours
          • Or Vancomycin per pharmacy protocol
          • Or Clindamycin 10 mg/kg (max dose 600mg) IV Q6 hours
    • VAP, Risk of Pseudomonas or MRSA
      • Ceftazidime 50 mg/kg Q8 hours or Piperacillin/Tazobactam per pharmacy to dose
        • Age <2 months: 80 mg of piperacillin/kg Q6 hours
        • Age 2 - 9 months: 80 mg of piperacillin/kg IV Q8 hours
        • Age >9 months: 100 mg/kg of piperacillin (max 4000 mg) IV Q8 hours
      • + Vancomycin
        • Vancomycin 1 month-12 years: 15 mg/kg Q6 hours
        • Vancomycin >12 years: 20 mg/kg Q8 hours
        • or Vancomycin per pharmacy protocol
      • Gentamicin
        • Age < 1 month: per neonatal protocol
        • Age > 1 month: per pharmacy protocol
  • Duration of Therapy
    • 7 days

SSTI: Cellulitis/Erysiplas7

  • Common Pathogens
    • Non-Purulent/Erysipelas
      • β-hemolytic streptococcus
      • S. aureus
    • Purulent/Abscess or Risk of MRSA
      • S. aureus
  • Pediatric Empiric Therapy*
    • Non-Purulent/Erysipelas
      • Mild to Moderate:
        • Cefazolin 30mg/kg (max dose 1000mg) IV Q8 hours
        • or Clindamycin 10 mg/kg IV Q6 hours
      • Severe:
        • Vancomycin 15 mg/kg (max dose 1000 mg) IV Q6 hours
        • + Piperacillin/tazobactam 75mg of piperacillin/kg IV Q6 hours
    • Purulent/Abscess or Risk of MRSA
      • Vancomycin 15 mg/kg(max dose 1000 mg) IV Q6 hours
  • Duration of Therapy
    • Uncomplicated: 5 days
    • Abscess/Complicated: 7-10 days

Urinary Tract Infections8

  • Common Pathogens
    • E. coli
    • Proteus
    • Klebsiella
  • Pediatric Empiric Therapy*
    • Age less than 2 months: Ampicillin 100 mg/kg IV Q6-8 hours + Cefotaxime 30-50 mg/kg IV Q8 hours + Gentamicin per pharmacy protocol
    • Age greater than 2 months: Cephalexin 50 mg/kg/day (max dose 500mg/dose) PO divided Q6-8 hours or Ceftriaxone 25-37.5 mg/kg (max dose 2000mg) IV Q12 hours
  • Duration of Therapy
    • 10 – 14 days

References: 1Intra-abdominal infection guidelines. CID 2010; 50: 133-164. 2Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection. NEJM 2015; 372:1996-2005. 3Guidelines for bacterial meningitis. CID 2004; 39:1267-84. 4IDSA guidelines on Anitmicrobial agent in Neutropenic Patients. CID 2011; e56-93. 5IDSA guidelines on CAP in infants and children. CID 2011; e1-52. 6Sandora TJ, Harper MB. Pneumonia in hospitalized children. PediatrClin North Am 2005; 52:1059. 7Guidelines SST infections. CID 2005; 41: 1373-406. 8 Guidelines for uncomplicated acute bacterial cystitis and acute pyelonephritis in women. CID 2011; 52:e103-2.. Adapted from Wesley Medical Center.

Guidelines for Antimicrobial Prophylaxis for Adult Surgery

Prophylactic antibacterial agents should be initiated 1 hour prior to surgical incision and within 2 hours if vancomycin is used.
Procedure Recommended Prophylaxis Alternative Prophylaxis
Cardiac: Pacemaker ICD Cefazolin* Clindamycin or Vancomycin1
Cardiac Surgery [Complete MRSA/MSSA culture and MRSA/MSSA PCR screening] Cefazolin* Clindamycin + Gentamicin2, Vancomycin1 + Gentamicin2
Vascular: Carotid Endarterectomy, Vascular Bypass, AAA Repair Endovascular, AAA Repair Cefazolin Clindamycin or Vancomycin1
Thoracic: Thoracotomy Cefazolin Clindamycin + Gentamicin2, Vancomycin1 + Gentamicin2
Gastroduodenal: Bariatric: Use antimicrobial prophylaxis in high risk patients: increased gastric pH (receiving acid-suppression therapy), gastroduodenal perforation, decreased motility, gastric outlet obstruction, gastric bleeding, morbid obesity, ASA classification >3, and cancer Cefazolin Clindamycin + Gentamicin, Vancomycin1 + Gentamicin
Biliary Tract: Lap Chole, Cholecystectomy Cefazolin Clindamycin + Gentamicin
Appendectomy Cefoxitin or Cefotetan Metronidazole + Gentamicin
Colorectal: Bowel Resection Cefoxitin or Cefotetan Clindamycin + Gentamicin, Metronidazole + Gentamicin
Colorectal Cefoxitin or Cefotetan Clindamycin + Gentamicin, Metronidazole + Gentamicin
Neurosurgery: Craniotomy Cefazolin Clindamycin or Vancomycin1
Cesarean Delivery: OB C Section Cefazolin Clindamycin + Gentamicin
GYN General Surgery: Vaginal or Abdominal Hysterectomy Cefazolin or Cefotetan Clindamycin + Gentamicin
Orthopedic: Ortho, Spine Surg, Laminectomy [Complete MRSA/MSSA culture and MRSA/MSSA PCR screening] Cefazolin* + Gentamicin2 Clindamycin + Gentamicin2, Vancomycin1 + Gentamicin2
Extremity FX, Upper Extremity FX, Total Shoulder, Hip, & Knee, Hip Pelvic Fx Cefazolin* Clindamycin or Vancomycin1
Urologic: Cystoscopy TURP, Prostatectomy, TUR Bladder Tumor Gentamicin or Ceftriaxone N/A
Breast Surgery Cefazolin Clindamycin or Vancomycin1

1Vancomycin can be used in patients with beta-lactam allergy in settings where infections with MRSA are prevalent, or if patient has known MRSA colonization or recent history of MRSA infection (must document justification for use). 2Add gentamicin when gram-negative pathogens are a concern. *Add vancomycin to cefazolin if MRSA nasal carriage is confirmed or unknown