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From the desk of Melinda Muller, M.D., interim Chief Medical Officer, Legacy Health

Legacy Health Formulary Changes

The Legacy Health Pharmacy and Therapeutics Committee approved several antibiotic formulary changesThese formulary changes were vetted by infectious diseases physicians and surgeon leads at each site.

Nafcillin to Oxacillin conversion (Go live 11/12/2020)


Nafcillin to Oxacillin are interchangeable for invasive MSSA infection. Oxacillin decreasesthe incidence of acute kidney injury and hypokalemia by three times compared to Nafcillin. Infectious diseases recommended a formulary conversion to oxacillin to minimize safety concerns with nafcillin. Pharmacists will convert to oxacillin per Therapeutic Interchange protocol.

Zosyn (piperacillin-tazobactam) removal from formulary (Go live 12/2/2020)


Infectious Diseases is leading the initiative to remove Zosyn from formulary because data showsits use increases the incidence of acute kidney injury. Pseudomonas and enterobacterales species have similar cefepime susceptibility compared to Zosyn. Order sets have been updated and pharmacists will use the Therapeutic Interchange protocol to convert to an alternative regimen of cefepime and metronidazole for anaerobic coverage.

Extended Infusion Cefepime (Go live 12/2/2020)


Dose optimization is an essential part of antimicrobial stewardship in an era of increasing bacterial resistance. Extended infusion (EI) dosing of cefepime has been associated with a decrease in mortality and shorter ICU length of stay in patients with gram negative infections.


Cefepime EI will be the standard administration method in the ICU areas at Legacy Health. Critically ill, pseudomonal infections will be automatically interchanged to EI by the pharmacist. Cefepime 1 gm IV q6h will be the standard dose for empiric therapy for patients in non-ICU areas. EI started in the ICU will be continued if the patient is transferred to non-ICU units andID may recommend EI regardless of patient’s location. 


Remdesivir (Go live immediately)


Remdesivir was approved for the treatment of COVID-19 in hospitalized adults and pediatrics 12 years of age weighing > 40 kg. Prescribing is restricted to infectious diseases physicians during hours of 8:00-5:00p.m.A five-day course of therapy is recommended for patients with a positive COVID-19 test and symptom onset less than or equal to 10 days.


Arformoterol tartrate (Brovana)


Arformoterol (long-acting nebulized beta agonist) was approved as an addition to formulary for use in the ICU/IMCU setting and for continuation of patient home therapy.


Diastat (rectal diazepam)


Removal from formulary




Removal from formulary



With any questions about antimicrobial changes, please contact Infectious Disease

Questions about other changes, please contact Michelle Murray at mmurray@lhs.org.