Adult Antimicrobial Dosing, Non-dialysis

These dosing recommendations are meant as guidance based on available literature and should not replace clinical judgement. Antimicrobial dosing should take into account factors specific to the patient (weight, renal function), antimicrobial (pharmacokinetics, pharmacodynamics, toxicity) and disease-state.

72 Drugs

Acyclovir

Indication

CrCl > 50 mL/min

25 - 50 mL/min

10 - 25 mL/min

< 10 mL/min 

Non-CNS HSV Infections 5 mg/kg IV q8h 5 mg/kg IV q12h 5 mg/kg IV q24h 2.5 mg/kg IV q24h
HSV encephalitis/ Disseminated VZV 10 mg/kg IV q8h 10 mg/kg IV q12h 10 mg/kg IV q24h 5 mg/kg IV q24h

*If Total BW > 1.2 times Ideal BW, use Adj BW

AmBisome (liposomal amphotericin B)

Indication

Dose

Notes

Invasive fungal infections 5 mg/kg IV q24h

No adjustment for renal dysfunction; monitor serum creatinine and electrolytes

Prophylaxis (Heme/BMT) 3 mg/kg IV q24h

*Use Total Body Weight if Total Body Weight < Ideal Body Weight.  If Total Body Weight >1.2 times Ideal Body Weight, use Adjusted Body Weight

IV Fluids: Give 500mL Normal Saline before and after AmBisome administration if able to tolerate

Unrestricted Indications
1) Documented or suspected fungal pneumonia in a patient intolerant of or with contraindications to azoles

2) Prophylaxis against fungal infections in patients on the hematology/BMT service or lung transplant service

3) Empiric therapy for prolonged febrile neutropenia in hematology/oncology/BMT patient

All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow

Amikacin

Indication CrCl > 60 mL/min 40 - 60 mL/min 20 - 40 mL/min < 20 mL/min
High-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded 15 mg/kg IV q24h

Use traditional dosing or consult ID pharmacy for guidance

Traditional dosing: patients who do not qualify for high-dose extended interval dosing 5-7.5 mg/kg IV q8h 5-7.5 mg/kg IV q12h 5-7.5 mg/kg IV q24h 5-7.5 mg/kg IV x1 & consult ID pharmacy for maintenance dose

Monitoring

Indication

Monitoring

High-dose extended interval ("once-daily")

Single level: Check random drug level 6-14 hours after the start of infusion.  Compare to nomogram (below)

Paired levels: Check peak drug level 2 hours after and random level 6-14 hours after infusion.  Consult ID pharmacy for assistance.

Traditional dosing Paired levels: Check peak drug level 30 minutes after end of infusion (goal 20-30 mg/L) and trough level immediately before next dose (goal <4 mg/L).

Nomogram:

 

 

 

 

 

 

 

**If amikacin 20 mg/kg is used. Adjust the measured level with the following equation before plotting the level onto the Amikacin 15mg/kg Extended Interval Nomogram Level for the plot = Measured level x 0.75

All use of intravenous amikacin requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Amoxicillin/clavulanate

Indication CrCl > 30 mL/min 10 - 30 mL/min < 10 mL/min
All Indications 875/125 mg PO q12h 500/125 mg PO q12h 500/125 mg PO q24h

Ampicillin

Indication

CrCl > 50 mL/min

10 - 50 mL/min

< 10 mL/min

Uncomplicated infection 2 g IV q6h 1 g IV q6h 1 g IV q12h
Meningitis or endovascular infection 2 g IV q4h 2 g IV q6h 1 g IV q8h 

Ampicillin/sulbactam (Unasyn)

Indication CrCl > 30 mL/min

15 – 30 mL/min

< 15 mL/min

All indications 3 g IV q6h 3 g IV q12h 3 g IV q24h

Artesunate

Indication Dose
All Indications 2.4 mg/kg IV at 0 hours, 12 hours, and 24 hours, followed by 2.4 mg/kg IV q24h

Non-formulary. Requires approval from ID consult service and pharmacy manager.

Azithromycin

Indication Dose Notes
Community-acquired pneumonia, ICU 500 mg IV/PO q24h No adjustment for renal dysfunction
Community-acquired pneumonia, non-ICU 500 mg IV/PO x1 then 250 mg IV/PO q24h

Aztreonam

Indication

CrCl > 50 mL/min

10 - 50 mL/min < 10 mL/min
All indications

2 g IV q8h 

2 g IV q12h 1 g IV q12h  

Aztreonam lacks cross-reactivity with most other beta-lactams; however, most patients who have a recorded beta-lactam allergy can receive another beta-lactam through screening, test dosing, or skin testing. See Inpatient Allergy Guidelines

Baloxavir marboxil

Indication Dosage Notes
Influenza treatment, uncomplicated, 40-79kg 40 mg PO x1 No renal dose adjustment
Influenza treatment, uncomplicated, >80kg 80 mg PO x1

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Caspofungin

Indication Dose Notes
All indications 70 mg IV x 1, then 50 mg IV q24h No renal dose adjustment. Increase maintenance dose to 70 mg when given with CYP3A4 inducers (phenytoin, rifampin, carbamazepine, dexamethasone, or efavirenz). 

Unrestricted Indications (select indication on order entry):

1) Documented sterile site (not urine or respiratory) infection  with microbiologically confirmed Candida glabrata or Candida kruseii

2) Documented sterile site infection (not urine or respiratory) infection with yeast, pending species identification

3) Prophylaxis against fungal infections in patients on the hematology/oncology/BMT service with intolerance of or contraindications to azoles

4) Empiric therapy for prolonged febrile neutropenia in hematology/oncology/BMT patient

All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow

Cefazolin

Indication CrCl > 35 mL/min 10 - 35 mL/min < 10 mL/min
Uncomplicated Gram-Positive Infection 1 g IV q8h 1 g IV q12h 1 g IV q24h
Gram-Negative or Complicated Gram-Positive Infection 2 g IV q8h 2 g IV q12h 1 g IV q24h

Cefepime

Indication CrCl > 60 mL/min 30 - 60 mL/min 10 - 29 mL/min < 10 mL/min
Typical dosing 2 g IV q12h 2 g IV q24h 1 g IV q24h 500 mg IV q24h
Febrile neutropenia, meningitis, Pseudomonas aeruginosa 2 g IV q8h 2 g IV q12h 2 g IV q24h 1 g IV q24h

Cefiderocol

Indication CrCl >120 mL/min 60-119 mL/min 30-59 mL/min 15-29 mL/min <15 mL/min
All Indications 2 g IV q6h infused over 3 hours 2 g IV q8h infused over 3 hours 1.5 g IV q8h infused over 3 hours 1 g IV q8h infused over 3 hours 750 mg IV q12h infused over 3 hourse

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ceftaroline

Indication CrCl >50 mL/min 30-50 mL/min 15-30 mL/min <15 mlL/min
Skin/Soft Tissue Infections or Community-acquired Pneumonia with low MRSA risk 600 mg IV q12h 400 mg IV q12h 300 mg IV q12h 200 mg IV q12h
Severe Infections, Pneumonia with documented or suspected MRSA 600 mg IV q8h 600 mg IV q12h 400 mg IV q12h 300 mg IV q12h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ceftazidime

Indication CrCl > 50 mL/min 31 - 50 mL/min 15 - 30 mL/min < 15 mL/min
All Indications 2 g IV q8h 2 g IV q12h 2 g IV q24h 1 g IV q24h

Ceftazidime/avibactam (Avycaz)

Indication CrCl > 50 mL/min 31 - 50 mL/min 16 - 30 mL/min 6 - 15 mL/min < 5 mL/min
All Indications 2.5 g IV q8h 1.25 g IV q8h 0.94 g IV q12h 0.94 g IV q24h 0.94 g IV q48h

 Dosage recommendations are expressed as total grams of the ceftazidime/avibactam combination.

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ceftolozane/tazobactam (Zerbaxa)

Indication CrCl >50 mL/min 30-50 mL/min 15-29 mL/min
Complicated urinary tract infection 1.5 g IV q8h 750 mg IV q8h 375 mg IV q8h
Pneumonia, severe infections 3 g IV q8h 1.5 g IV q8h 750 mg IV q8h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ceftriaxone

Indication Dose Notes
Usual dose 1 g IV q24h No renal dose adjustment
Endocarditis & Osteomyelitis 2 g IV q24h  No renal dose adjustment

Meningitis & Enteroccocal Endocarditis (in combination with ampicillin)

2 g IV q12h No renal dose adjustment

Cidofovir

Indication Criteria to initiate: CrCl >55 mL/min, SCr<1.5 mg/dL, urine protein <100mg/dL Increase in SCr of 0.3-0.4 mg/dL Increase in SCr of >0.5 mg/L or 3+ proteinuria
Systemic Infections: Induction 5 mg/kg IV once weekly WITH probenecid 3 mg/kg IV ever week WITH probenecid Discontinue
Systemic Infections: Maintenance 5 mg/kg IV once every 2 weeks WITH probenecid 3 mg/kg IV every 2 weeks WITH probenecid Discontinue
BK viruria in kidney or bone marrow transplant patients 0.25 - 0.5 mg/kg IV once weekly WITHOUT probenecid

Unrestricted Indications (select on order entry):

1) Unrestricted use on the hematology/oncology/BMT service

All other use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ciprofloxacin

Indication CrCl > 30 mL/min 10 - 29 mL/min < 10 mL/min
Standard Dose

400 mg IV q12h

750 mg PO q12h

400 mg IV q12h

500 mg PO q12h

200 mg IV q12h

250 mg PO q12h

Pseudomonas infections

400 mg IV q8h

750 mg PO q12h

400 mg IV q12h

500 mg PO q12h

200 mg IV q12h

250 mg PO q12h

Clindamycin

Indication Dose Notes
Uncomplicated Infection

600 mg IV q8h

450 mg PO q8h

No renal dose adjustment
Necrotizing Soft Tissue Infection & Group A Streptococcus Infection 900 mg IV Q8h No renal dose adjustment

Clofazimine

Indication Dosing Notes
All Indications 100 mg PO q24h No adjustment for renal function

Colistin IV

Indication Dosing
All IV Indications 5 mg/kg IV x1 loading dose, then contact ID pharmacy for maintenance dose recommendations

Dosing for inhaled colistin per primary team protocols

Other more effective, less-toxic agents are available for most serious Gram-negative rod infections.  In cases where an IV polymyxin is necessary, polymyxin B should be used preferentially for non-urinary tract infections in adults.

All use of IV colistin requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow.  Inhaled use of colistin is allowed for unrestricted use in prophylaxis in lung transplant.

Dalbavancin

Indication CrCl >30 mL/min <30 mL/min
Single-dose regimen (skin/soft tissue infection) 1500 mg IV x1 dose 1125 mg IV x1 dose
Two-dose regimen (skin/soft tissue infection) 1000 mg IV x1 then 500 mg IV x1 7 days later 750 mg IV x1, then 375 mg IV x1 7 days later

Other dosing strategies used for treatment of bone/joint infections or bacteremia.

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Daptomycin

Indication CrCl > 30 mL/min < 30 mL/min
All indications 8 – 10 mg/kg IV q24h 8 – 10 mg/kg IV q48h

*If Total BW >1.2 times ideal body weight, use adjusted body weight

Not effective in treatment of pneumonia.

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Doxycycline

Indication Dose Notes
All indications 100 mg IV/PO q12h No renal dose adjustment

Eravacycline

Indication Dosing Notes
All Indications

1mg/kg IV q12h

Concomitant strong CYP3A4 Inducers: 1.5 mg/kg IV q12h

No dose adjustment for renal dysfunction

Severe hepatic impairment: 1 mg/kg IV q12h x2 doses, then 1 mg/kg IV q24h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ertapenem

Indication CrCl > 30 mL/min < 30 mL/min
All indications 1 g IV q24h 500 mg IV q24h

Ethambutol

Weight CrCl > 30 mL/min < 30 mL/min
40 kg - 55 kg 800 mg PO q24h 800 mg PO three times weekly
56 kg - 75 kg 1200 mg PO q24h 1200 mg PO three times weekly
76 kg - 90 kg 1600 mg PO q24h 1600 mg PO three times weekly

Dose based on ideal body weight. Drug is available in 400mg and 100mg tablets.

Fidaxomicin

Indication Dosing Notes
Clostridium difficile infection 200 mg PO q12h No adjustment for renal dysfunction

All use requires authorization from the Antimicrobial Stewardship Program or the consulting ID fellow

Fluconazole

Indication CrCl > 50 mL/min 10 – 50 mL/min < 10 mL/min
Oropharyngeal Infection 100 mg IV/PO q24h 50 mg IV/PO q24h 50 mg IV/PO q24h
Esophageal Infection 200 mg IV/PO q24h 100 mg IV/PO q24h 50 mg IV/PO q24h
Candidasis  400 mg IV/PO q24h 200 mg IV/PO q24h 100 mg IV/PO q24h
Severe Infections

≤ 80 kg: 400mg IV/PO q24h

81 – 100 kg: 600 mg IV/PO q24h

> 100 kg: 800 mg IV/PO q24h

≤ 80 kg: 200mg IV/PO q24h

81 – 100 kg: 300 mg IV/PO q24h

> 100 kg: 400 mg IV/PO q24h

≤ 80 kg: 100mg IV/PO q24h

81 – 100 kg: 150 mg IV/PO q24h

> 100 kg: 200 mg IV/PO q24h

Flucytosine

Indication CrCl >40 mL/min 20-40 mL/min 10-20 mL/min <10 mL/min
All Indications 25 mg/kg PO q6h 25 mg/kg PO q12h 25 mg/kg PO q24h 25 mg/kg PO q48h

Foscarnet

Unrestricted Indications (select on order entry):

1) Use on hematology/oncology/BMT service

All other use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Fosfomycin

Indication CrCl > 50 mL/min < 50 mL/min
Uncomplicated cystitis 3 g PO x 1 dose 3 g PO x 1 dose
Complicated cystitis 3 g PO every 2 days x 3 doses 3 g PO every 3 days x 3 doses

Ganciclovir

Indication CrCl >70 mL/min 50-69 mL/min 25-49 mL/min 10-24 mL/min
CMV Induction 5 mg/kg IV q12h 2.5 mg/kg IV q12h 2.5 mg/kg IV q24h 1.25 mg/kg IV q24h
CMV Maintentance 2.5 mg/kg IV q12h 2.5 mg/kg IV q24h 1.25 mg/kg IV q24h 0.625 mg/kg IV q24h

Gentamicin

Use traditional dosing or consult ID pharmacy for guidance

Indication CrCl > 60 mL/min 40-60 mL/min 20-40 mL/min <20 mL/min
Gram-positive synergy 1 mg/kg IV Q8h Contact pharmacy for assistance
Gram-negative infections, high-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded.  5-7 mg/kg IV q24h Use traditional dosing or contact pharmacy for assistance
Gram-negative infections, traditional dosing: patients who do not qualify for high-dose extended interval dosing 1.6 mg/kg IV q8h 1.5 mg/kg IV q12h 1.5 mg/kg IV q12-24h 2 mg/kg loading dose IV x1, contact pharmacy for maintenance

*If Total BW > 1.2 times Ideal BW, use Adj BW.

Monitoring:

Indication

Monitoring

Gram-positive synergy Paired levels: Check peak drug level 30 minutes after end of infusion (goal 3-4 mg/L) and trough immediately before next dose (goal <1 mg/L)
Gram-negative high-dose extended interval ("once-daily")

Single level: Check random drug level 6-14 hours after the start of infusion.  Compare to nomogram below.

Paired levels: Check peak drug level 1 hour after end of infusion and random level 6-14 hours after infusion.  Consult ID pharmacy for assistance.

Gram-negative traditional dosing Paired levels: Check peak drug level 30 minutes after end of infusion (goal 5 - 8 mg/L) and trough level immediately before next dose (goal <2 mg/L).

Nomogram:

Imipenem/cilastatin

Indication CrCl >90 mL/min 60-90 mL/min 30-60 mL/min 15-30 mL/min
Gram-negative or Nocardia infections 500 mg IV q6h 400 mg IV q6h 300 mg IV q6h 200 mg IV q6h
Nontuberculous mycobacterial infections Consult ID/ID Pharmacy for dosing recommendations

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Imipenem/cilastatin/relebactam

Indication CrCl >90 mL/min 60-90 mL/min 30-60 mL/min 15-30 mL/min

All Indications

1.25g = 500mg imipenem + 500 mg cilastatin + 250mg relebatam

1.25 g IV q6h 1 g IV q6h 750 mg IV q6h 500 mg IV q6h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Isavuconazole

Indication Dose Notes
All Indications 372 mg IV/PO Q8h x 6 doses (total of 48h), then 372 mg Q24h No renal dose adjustment

372mg of isavucazonium (prodrug) = 200mg of isavuconazole

Unrestricted Indications: 1) Documented or suspected fungal pneumonia in a patient with prolonged QT interval 2) Prophylaxis against fungal infections on the hematology/oncology/BMT service or lung transplant service in a patient with prolonged QT interval All other use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Isoniazid

Indication Dosing Notes
All Indications 300 mg PO Q24h No renal dose adjustment

Letermovir

Indication CrCl >10 mL/min <10 mL/min
All Indications

480 mg IV/PO q24h

With concomitant cyclosoprine: 240 mg IV/PO q24h

No dosing recommendations available

Unrestricted Indications (provide on order entry):

1) CMV prophylaxis on heme/BMT service

All other use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Levofloxacin

Indication CrCl > 50 mL/min 20-49 mL/min <20mL/min
Standard Dosing 500mg IV/PO Q24h 500 mgx1, then 250mg IV/PO Q24h 500mg x1, then 250mg IV/PO Q48h
Pneumonia or Pseudomonas infections 750mg IV/PO Q24h 750mg IV/PO Q48h 750mg x1, then 500mg IV/PO Q48h

Avoid co-administration of the oral formulation with divalent/trivalent cations (e.g. calcium, magnesium, zinc) - separate by at least 2 hours.

Linezolid

Indication Dose Notes
All Indications 600mg IV/PO q12h No renal dose adjustment

Unrestricted Indications (indicate on order entry):

1) Documented infection of a sterile site (not urine or respiratory) with microbiologically confirmed vancomycin-resistant Enterococcus

2) Documented infection of a sterile site (not urine or respiratory) with Enterococcus or streptococci pending speciation and susceptibility in a solid organ transplant or BMT patient

3) Suspected or documented Gram-positive infection in patient with severe vancomycin allergy

All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow

Meropenem

Indication > 50mL/min 25-50 mL/min 10-15mL/min < 10mL/min
Standard Dosing 1 g IV q8h 1 g IV q12h 500 mg IV q12h 500 mg IV q24h
Meningitis, Cystic Fibrosis 2 g IV q8h 2 g IV q12h 1 g IV Q12h 1 g IV q24h

Meropenem/vaborbactam

Indication eGFR >50mL/min/1.73m2 30-50 mL/min/1.73m2 15-30 mL/min/1.73m2 <15 mL/min/1.73m2

All Indications

4g = 2g meropenem + 2g vaborbactam

4 g IV q8h over 3 hours 2 g IV q8h over 3 hours 2 g IV q12h over 3 hours 1 g IV q12h over 3 hours

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Metronidazole

Indication CrCl >10 mL/min CrCl < 10 mL/min
All Indications 500 mg IV/PO Q8h 500 mg IV/PO Q12h

Minocycline

Indication Dosing Notes
All Indications 200 mg IV/PO x1, then 100 mg IV/PO q12h No adjustment for renal dysfunction

Moxifloxacin

Indication Dosing Notes
All Indications 400 mg IV/PO q24h No adjustment for renal dysfunction

Nafcillin

Indication Dosing Notes
Meningitis, osteomyelitis or endovascular infection 2 g IV Q4h

 

No renal dose adjustment

Uncomplicated infection 1 g IV Q6h

Nitrofurantoin (Macrobid)

Indication CrCl > 60 mL/min < 60 mL/min
Cystitis Treatment 100 mg PO q12h Data limited for CrCl<60 mL/min; consider alternatives
Cystitis Prophylaxis 100 mg PO q24h

Omadacycline

Indication Dosing Notes

All Indications

PO: must fast for at least 4 hours before and 2 hours after dose

200 mg IV x1, then 100 mg IV q24h

450 mg PO daily x2 doses, then 300 mg PO daily

No adjustment for renal dysfunction

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Oritavancin

Indication Dosing Notes
All Indications 1200 mg IV x1 over 3 hours No adjustment for renal dysfunction

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Oseltamivir

Indication CrCl > 60 mL/min 31-60mL/min 10-30mL/min
Influenza treatment 75 mg PO BID 30 mg PO BID 30 mg PO BID
Influenza prophylaxis 75mg PO daily 30mg PO daily 30mg PO every other day

Penicillin G

Indication CrCl > 50 mL/min CrCl 10 – 50 mL/min CrCl < 10 mL/min
Meningitis, endovascular 4 million units IV q4h 4 million units IV q6h 4 million units IV q8h
Uncomplicated infection 2 million units IV q6h 2 million units IV q8h 2 million units IV q12h

Peramivir

Indication CrCl >50 mL/min 30-50 mL/min 10-30 mL/min <10 mL/min
All Indications 600 mg IV q12h 200 mg IV q24h 100 mg IV q24h 100 mg IV x1, then 15 mg IV q24h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Piperacillin/tazobactam (Zosyn) EXTENDED INFUSION

Indication CrCl > 20 mL/min <20 mL/min

All Infections, including documented/suspected Pseudomonas 

Exclusion criteria for EXTENDED INFUSION: resistant or intermediate susceptibility organism, cystic fibrosis, peri-procedural areas, insufficient IV access

Loading dose = 4.5 g IV over 30 min x1, then 4.5 g IV infused over 4h every 8h (starting 4h after loading dose) Use SHORT INFUSION piperacillin/tazobactam

UCSF: PREFERRED dosing strategy if no exclusions

Piperacillin/tazobactam SHORT Infusion (SI) (Zosyn)

Indication  > 50 mL/min 10 – 50 mL/min < 10 mL/min
NOTE: (UCSF Only) Use SHORT INFUSION only for patients excluded from EXTENDED INFUSION dosing

Non-Pseudomonas infections

3.375 g IV q6h

3.375 g IV q8h

2.25 g IV q8h
Documented/Suspected Pseudomonas aeruginosa infection

CrCl > 20 mL/min:

4.5 g IV q6h

CrCl < 20 mL/min:

3.375 g IV q8h

 

ONLY for patients excluded from EI dosing at UCSF. Exclusion criteria for EI: Resistant or intermediate organism, cystic fibrosis, periprocedural areas, insufficient IV access 

Plazomicin

Indication CrCl >60 mL/min 30-60 mL/min 15-30 mL/min <15 mL/min
All Indications 15 mg/kg IV q24h 10 mg/kg IV q24h 10 mg/kg IV q48h Not studied

If Total BW >1.2 times Ideal BW, use Adjusted BW

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Polymyxin B

Indication Dosing Note
All Indications 2.5 mg/kg IV x1, then 1.5 mg/kg IV q12h No renal dose adjustment

There are other more effective, less toxic alternatives for most multidrug-resistant Gram-negative infections.  If a polymyxin is required, polymyxin B is preferred for intravenous treatment of systemic infections in adults. For treatment of urinary tract infections, or use via inhalation, use colistin (polymyxin E).

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Posaconazole

Indication Dosing Notes
All Indications (IV or Delayed-release tablet) 300 mg IV/PO q12h x 2 doses, then 300 mg IV/PO q24h No renal dose adjustment (avoid IV if possible in patients with CrCl <50 mL/min due to accumulation of IV vehicle)

Take with food.  Posaconazole SOLUTION has more frequent dosing, low bioavailability, and significant food restrictions.  Do not substitute SOLUTION for TABLETS or IV without discussion with ID Pharmacy.

Review medications for potential drug interactions.

Posaconazole trough levels should be obtained in most patients, whether receiving the agent for prophylaxis or treatment of fungal infections.  Trough samples should be obtained 5-7 days after: 
-start of therapy
-change in dose
-change in route of administration
-change in potentially interacting drugs

See UCSF Lab Posaconazole Recommendations  for specifics of monitoring.

Unrestricted indications:

1) Prophylaxis against fungal infections in patients on the hematology/oncology/BMT service or lung transplant service with intolerance of or contraindications to voriconazole

All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow

Pyrazinamide

Indication CrCl > 30 mL/min < 30 mL/min
All Indications

20-25 mg/kg PO q24h:

40 – 55 kg: 1000mg q24h

56 – 75 kg: 1500mg q24h

76 – 90 kg: 2000mg q24h

25 – 35mg/kg PO three times weekly

Supplied as 500mg tablets

Ribavirin

Indication CrCl >50 mL/min <50 mL/min
All Indications

>=75 kg: 800 mg PO q12h

<75 kg: 600 mg PO q12h

Contact ID pharmacy for recommendations

Rifampin

Indication Dosing Notes
Mycobacterial infections 600 mg IV/PO q24h

 

No renal dose adjustment

Prosthetic device infections 300 mg IV/PO q12h
Endocarditis 300 mg IV/PO q8h

Review medications for potential drug interactions.

Tedizolid

Indication Dosing Notes
All Indications 200 mg IV/PO q24h No adjustment for renal dysfunction

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Tigecycline

Indication Dosing Notes
All Indications 100 mg IV x1, then 50 mg IV q12h

No adjustment for renal dysfunction

Severe hepatic dysfunction: 100 mg IV x1, then 25 mg IV q12h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

TMP/SMX (trimethoprim/sulfamethoxazole)

Indication CrCl > 50 mL/min 10 – 50 mL/min < 10 mL/min
Systemic GNR infections 10mg TMP/kg/day IV/PO divided Q6-12h 5-7.5mg TMP/kg/day IV divided Q12-24h 2.5-5mg TMP/kg IV Q24h
Pnemocytisis pneumonia  15 - 20mg TMP/kg/day IV/PO divided Q6 – 12h 10-15mg TMP/kg/day IV divided Q12-24h 5-10mg TMP/kg IV Q24h

Single-strength (SS) tablet contains 80 mg trimethoprim (TMP)

Double-strength (DS) tablet contains 160 mg trimethoprim (TMP)

*May consider Total BW for serious infections

Tobramycin

Use traditional dosing or consult ID pharmacy for guidance

Indication CrCl > 60 mL/min 40-60 mL/min 20-40 mL/min <20 mL/min
High-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded.  7 mg/kg IV q24h Use traditional dosing or contact pharmacy for assistance
Traditional dosing: patients who do not qualify for high-dose extended interval dosing 1.6 mg/kg IV q8h 1.5 mg/kg IV q12h 1.5 mg/kg IV q12-24h 2 mg/kg loading dose IV x1, contact pharmacy for maintenance

*If Total BW > 1.2 times Ideal BW, use Adj BW.

Monitoring:

Indication

Monitoring

Gram-negative high-dose extended interval ("once-daily")

Single level: Check random drug level 6-14 hours after the start of infusion.  Compare to nomogram.

Paired levels: Check peak drug level 1 hour after end of infusion and random level 6-14 hours after infusion.  Consult ID pharmacy for assistance.

Gram-negative traditional dosing Paired levels: Check peak drug level 30 minutes after end of infusion (goal 5 - 8 mg/L) and trough level immediately before next dose (goal <2 mg/L). 

Valganciclovir (Valcyte)

Indication CrCl > 60 mL/min 40 - 59 mL/min 25 - 39 mL/min 10 - 24 mL/min
CMV Induction 900 mg PO q12h 450 mg PO q12h 450 mg PO q24h 450 mg PO q24h
CMV Maintenance 900 mg PO q24h 450 mg PO q24h 450 mg PO q48h 450 mg PO twice weekly

CMV prophylaxis: refer to individual service protocol 

Take with food

Vancomycin IV

 

Body Weight**

CrCl (mL/min) < 60 kg 60-80 kg 81-100kg > 100kg
>90 mL/min (complicated* infection & age < 65) 750mg IV q8h 1000mg IV q8h 1250mg IV q8h 1500mg IV q8h
>90 mL/min (complicated* infection & age > 65 or uncomplicated infection & age < 65) 1000mg IV q12h 1250mg IV q12h 1500mg IV q12h 1750mg IV q12h
50-90 mL/min 750mg IV q12h 1000mg IV q12h 1250mg IV q12h 1500mg IV q12h

Complicated* & age <65

1000mg IV q8h

15-49 ml/min 750mg IV q24h 1000mg IV q24h 1250mg IV q24h 1500mg IV q24h
<15 ml/min not on dialysis 10-15mg/kg IV x1 then redose according to levels

*Complicated infections: CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis

**Use Total Body Weight for patients <120% of Ideal Body Weight. Use Adjusted Body Weight for patients >120% of Ideal Body Weight.

Recommend loading dose (20-25 mg/kg IV x1) for serious infections including CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis

Contact pharmacy for maintenance dose and consider vancomycin per pharmacy (UCSF only).

See Vancomycin Dosing and Monitoring page for more detail.

Round to nearest 250mg increment. Max: 2g/dose

*If Total BW > 1.2 times Ideal BW, use Adj BW

Recommend loading dose (20-25 mg/kg IV x1) for serious infections including CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis

Vancomycin PO

Indication Dose Notes
Clostridioides difficile infection: uncomplicated 125 mg PO QID No renal dose adjustment
Clostridioides difficile infection: complicated 500 mg PO QID

PO vancomycin is NOT sufficiently absorbed to treat systemic infections

Voriconazole

Indication Dosing Notes
All Indications, IV Route 6mg/kg IV Q12h x 2 doses, then 4mg/kg IV Q12hr Risk/benefit consideration for IV formulation for CrCl<50 mL/min, as IV vehicle accumlates; consider PO

All Indications, PO Route

In obese patients consider a weight-based PO regimen (4mg/kg q12H ADJ BW), Consult ID or ASP for assistance. 

400mg PO Q12h x doses, then 200mg PO Q12* No renal dose adjustment

Review medications for potential drug interactions.

Voriconazole has high inter- and intra-patient variability.  Voriconazole trough levels should be obtained in most patients, whether receiving the agent for prophylaxis or treatment of fungal infections.  Trough samples should be obtained 3-5 days after: 
-start of therapy
-change in dose
-change in route of administration
-change in potentially interacting drugs

See UCSF Lab Voriconazole Recommendations  for specifics of monitoring.

Unrestricted Indications:

1) Prophylaxis against fungal infections on the hematology/BMT/lung transplant services 

2) Suspected or documented fungal pneumonia in the hematology/BMT/lung tranpslant services

3) Empiric therapy for prolonged febrile neutropenia in hematology/oncology/BMT patient

All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow