Infectious Diseases Management Program at UCSF

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

Indication	Dose	Notes
Invasive fungal infections	5 mg/kg IV q24h	No adjustment for renal dysfunction; monitor serum creatinine and electrolytes
Mold 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

IV formulation - Restricted to ID or Antimicrobial Stewardship except:

1) Documented or suspected serious fungal infection 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

See the AmBisome (liposomal amphotericin B) detail page.

Amikacin

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

For UCSF pharmacists, access the pharmacy guidance manual click here

Do not use high-dose extended interval dosing strategy (using Barnes Jewish nomogram) in the following populations:

- Cr Cl ≤ 20 ml/min

- Aminoglycoside t ½ > 4.5 hours

- Patients with burns > 20% total burn surface area (TBSA)

- Ascites

- Cystic Fibrosis (CF) patients

- Pregnancy (outside of surgical prophylaxis)

- Spinal cord injury

High-dose extended dosing strategy (Barnes Jewish nomogram):

Indication	CrCl > = 60 mL/min	40-59 mL/min	21-39 mL/min	CrCl < = 20 mL/min	Comments
Cystitis	15 mg/kg x 1	15 mg/kg x1	15 mg/kg x 1	Use conventional/traditional dosing	No nomogram or levels needed
Non-TB mycobacerium	20 mg/kg thrice weekly	20 mg/kg thrice weekly	20 mg/kg thrice weekly	Use conventional traditional dosing	Use 15 mg/kg dosing for elderly/frail/small patients Contact ID pharmacy for suggested monitoring and therapeutic drug targets
Other infections (exclude CF)	15 mg/kg IV q 24h	15 mg/kg IV q36h	15 mg/kg IV q 48h	Use conventional/traditional dosing	Obtain 6-14 hour random amikacin level after first dose to inform future dosing interval Consider consulting pharmacy to assist with suggested dosing and monitoring Use Barnes Jewish dosing nomogram Do not use this dosing in CF patients

Indication

CrCl > = 60 mL/min

40-59 mL/min

21-39 mL/min

CrCl < = 20 mL/min

Comments

Cystitis

15 mg/kg x 1

15 mg/kg x1

15 mg/kg x 1

Use conventional/traditional dosing

No nomogram or levels needed

Non-TB mycobacerium

20 mg/kg thrice weekly

Use conventional traditional dosing

Use 15 mg/kg dosing for elderly/frail/small patients

Contact ID pharmacy for suggested monitoring and therapeutic drug targets

Other infections (exclude CF)

15 mg/kg IV q 24h

15 mg/kg IV q36h

15 mg/kg IV q 48h

Use conventional/traditional dosing

Obtain 6-14 hour random amikacin level after first dose to inform future dosing interval

Consider consulting pharmacy to assist with suggested dosing and monitoring

Use Barnes Jewish dosing nomogram

Do not use this dosing in CF patients

Conventional/traditional dosing:

Please consult pharmacy to help with dosing and monitoring plan. Below are suggested peak and trough goals based upon infection:

Conventional/Traditional Dosing for Amikacin
Infection	Extrapolated Peak Goal	Extrapolated Trough Goal
Abdominal Infections (including peritonitis)	35 (25-35)	< 5
Bacteremia	25 (20-30)	< 5
Empiric therapy for Cystic Fibrosis (if cannot do high-dose extended interval dosing)	35 (25-35)	< 5
Febrile Neutropenia	35 (25-35)	< 5
Pneumonia	35 (25-35)	< 5
Skin and soft tissue infections	25 (20-30)	< 5
Urinary tract infections (including pyelonephritis)	15-20	< 5

Cystic fibrosis (CF) patients:

Prior to choosing a dosing regimen the clinical pharmacist should review the patient’s previous aminoglycoside regimen(s) to determine if information from previous courses of therapy can aid n selecting dosing for a new course of treatment. Please contact pharmacy for assistance. If no history of previous doses and levels, then follow the below:

Indication	CrCl > = 60 mL/min	40-59 mL/min	21-39 mL/min	CrCl < = 20 mL/min	Comments
CF exacerbation	20 mg/kg IV q 24h	20 mg/kg IV q36h	20 mg/kg IV q48h	Use conventional/traditional dosing	Do not use Barnes Jewish nomogram With first dose, obtain two serum concentrations 2 hours and 6 hours (10 hours in impaired renal function, elderly), counting from the start of the infusion. This typically allows for 2 half-lives to pass between levels. Periodically, it may help to have a third level (trough) if needed for additional calculations. Consult pharmacy to assist.

Indication

CrCl > = 60 mL/min

40-59 mL/min

21-39 mL/min

CrCl < = 20 mL/min

Comments

CF exacerbation

20 mg/kg IV q 24h

20 mg/kg IV q36h

20 mg/kg IV q48h

Use conventional/traditional dosing

Do not use Barnes Jewish nomogram

With first dose, obtain two serum concentrations 2 hours and 6 hours (10 hours in impaired renal function, elderly), counting from the start of the infusion. This typically allows for 2 half-lives to pass between levels. Periodically, it may help to have a third level (trough) if needed for additional calculations. Consult pharmacy to assist.

Aminoglycoside for CF	Target peak	Target trough
Amikacin	35-45 mcg/mL*	< 5 mcg/mL

*There may be instances (e.g., elevated MIC) where the targeted peak may need to go up to 40- 60 mcg/mL - contact adult ID pharmacist.

Advise caution in individuals with myasthenia gravis. Aminoglycosides should never be used as monotherapy except in the setting for a urinary tract infection (UTI).

Restricted to ID or Antimicrobial Stewardship for IV amikacin

See the Amikacin detail page.

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

See the Amoxicillin/clavulanate detail page.

Ampicillin

*Note: These dosing recommendations were updated in 1/2025 to better align with available evidence

Indication	CrCl > 50 mL/min	30 - 49 mL/min	15 - 29 mL/min	< 15 mL/min
UTI, chorioamnionitis, latency antibiotics for PPROM	2 g IV q6h	2 g IV q8h	2 g IV q12h	2 g IV q24h
Other infections	2 g IV q4h	2 g IV q6h	2 g IV q8h	2 g IV q12h
GBS prophylaxis	2 g IV x 1 followed by 1 gram IV q4h	2 g IV x 1 followed by 1 gram IV q6h	2 g IV x 1 followed by 1 gram IV q6h	2 g IV x 1 followed by 1 gram IV q8h

Indication

CrCl > 50 mL/min

30 - 49 mL/min

15 - 29 mL/min

< 15 mL/min

UTI, chorioamnionitis, latency antibiotics for PPROM

2 g IV q6h

2 g IV q8h

2 g IV q12h

2 g IV q24h

Other infections

2 g IV q4h

2 g IV q6h

2 g IV q8h

2 g IV q12h

GBS prophylaxis

2 g IV x 1

followed by

1 gram IV q4h

2 g IV x 1

followed by

1 gram IV q6h

2 g IV x 1

followed by

1 gram IV q6h

2 g IV x 1

followed by

1 gram IV q8h

See the Ampicillin detail page.

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
Carbapenem-resistant Acinetobacter baumannii	3 g IV q4h	3 g IV q8h	3 g IV q12h

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

Carbapenem-resistant

Acinetobacter baumannii

3 g IV q4h

3 g IV q8h

3 g IV q12h

Extended Infusion Dosing (if recommended by ID or ID pharmacy)

Indication	CrCl > 60 mL/min	30-59 mL/min	<30mL/min
Carbapenem-resistant Acinetobacter baumannii	9 gram IV q 8h (over 4 hours)	6 grams IV q 8h (over 4 hours)	Short infusion (follow the dosing recs of 3 g IV q 4h schematic)

Indication

CrCl > 60 mL/min

30-59 mL/min

<30mL/min

Carbapenem-resistant Acinetobacter baumannii

9 gram IV q 8h (over 4 hours)

6 grams IV q 8h (over 4 hours)

Short infusion

(follow the dosing recs of 3 g IV q 4h schematic)

See the Ampicillin/sulbactam (Unasyn) detail page.

Artesunate

Total Body Weight

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

Restricted to ID or Antimicrobial Stewardship

See the Artesunate detail page.

Atovaquone

Indication	Dose	Notes
Pneumocystis PROPHYLAXIS	1500 mg PO Q24H with food	For patients who are intolerant of TMP-SMX
Pneumocystis TREATMENT (mild disease)	750 mg PO Q12H with food	For patients who are intolerant of TMP-SMX Mild disease (A-a O₂ gradient < 35 mmHg and PAO₂ >70 mmHg)

Indication

Dose

Notes

Pneumocystis PROPHYLAXIS

1500 mg PO Q24H with food

For patients who are intolerant of TMP-SMX

Pneumocystis TREATMENT (mild disease)

750 mg PO Q12H with food

For patients who are intolerant of TMP-SMX

Mild disease (A-a O₂ gradient < 35 mmHg and PAO₂ >70 mmHg)

See the Atovaquone detail page.

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	No adjustment for renal dysfunction

See the Azithromycin detail page.

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

*2 g IV q6h may be considered for meningitis in select patients based on clinical judgement (e.g. obesity, young age, augmented renal clearance, etc), or in select resistant gram-negative infections in combination with ceftazidime-avibactam (infuse both over 3 hours).
If used in combination with ceftazidime-avibactam and dosing intervals are the same, simultaneous administration is preferred.

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

See the Aztreonam detail page.

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	No renal dose adjustment

Restricted to ID or Antimicrobial Stewardship

See the Baloxavir marboxil detail page.

Cefazolin

Indication	CrCl > 30 mL/min	10 - 29 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

See the Cefazolin detail page.

Cefdinir

Indication	CrCl ≥ 30 mL/min	CrCl < 30 mL/min
Prophylaxis in neutropenic fever in patients who are intolerant of fluoroquinolones AND no history of ESBL/CRE organisms	300 mg po q12h	300 mg po q24h

See the Cefdinir detail page.

Cefepime

Short Infusion Dosing (PREFERRED)

Indication	CrCl > 60 mL/min	30 - 60 mL/min	10 - 29 mL/min	< 10 mL/min
Non-severe infections including cystitis	2 g IV q12h	2 g IV q24h	1 g IV q24h	500 mg IV q24h
Severe infections including febrile neutropenia, meningitis, Pseudomonas aeruginosa	2 g IV q8h	2 g IV q12h	2 g IV q24h	1 g IV q24h

Extended Infusion Dosing (if recommended by ID, ID pharmacy, or clinical pharmacy for select populations)

Indication	CrCl > 60 mL/min	30 - 60 mL/min	< 30 mL/min
Loading Dose*	2 g x1 (over 30 minutes)	2 g x1 (over 30 minutes)	Use short infusion
Maintenance: All Indications**	2 g IV q8h (over 4 hours)	2 g IV q12h (over 4 hours)	Use short infusion

*Recommended to start maintenance dose 4 hours after loading dose
**Extended infusion data in meningitis are limited and may require further discussion with ID/ASP providers

See the Cefepime detail page.

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 hours

Restricted to ID or Antimicrobial Stewardship

See the Cefiderocol detail page.

Cefoxitin

Indication	CrCl >50 mL/min	CrCl 30-50 mL/min	CrCl 10-29 mL/min	CrCl <10 mL/min
Standard dosing, NTM infection	2 g IV q6h	2 g IV q8h	2 g IV q12h	1 g IV q24h

See the Cefoxitin detail page.

Cefpodoxime

Indication	CrCl ≥ 30 mL/min	CrCl < 30 mL/min
Prophylaxis in neutropenic fever in patients who are intolerant of fluoroquinolones AND no history of ESBL/CRE organisms	200 mg po q 12h	200 mg po q 24h

See the Cefpodoxime detail page.

Ceftaroline

Indication	CrCl > 50 mL/min	30-50 mL/min	15-30 mL/min	< 15 mL/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	400 mg IV q8h	300 mg IV q8h	200 mg IV q8h

Serious infections: ceftaroline dosed q12h may be an option in certain situations for CrCl < 50 mL/min and in iHD. Contact ID pharmacy for assistance.

Restricted to ID or Antimicrobial Stewardship

See the Ceftaroline detail page.

Ceftazidime

Short Infusion Dosing (PREFERRED)

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

Extended Infusion Dosing (if recommended by ID, ID pharmacy, or clinical pharmacy for select populations)

Indication	CrCl > 50 mL/min	31 - 50 mL/min	< 31 mL/min
Loading Dose*	2 g x1 (over 30 minutes)	2 g x1 (over 30 minutes)	Use short infusion
Maintenance: All Indications	2 g IV q8h (over 4 hours)	2 g IV q12h (over 4 hours)	Use short infusion

*Recommended to start maintenance dose 4 hours after loading dose

See the Ceftazidime detail page.

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 infused over 3 hours	1.25 g IV q8h infused over 3 hours	0.94 g IV q12h infused over 3 hours	0.94 g IV q24h infused over 3 hours	0.94 g IV q48h infused over 3 hours

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

If aztreonam used in combination with ceftazidime-avibactam and dosing intervals are the same, simultaneous administration is preferred.

Restricted to ID or Antimicrobial Stewardship

See the Ceftazidime/avibactam (Avycaz) detail page.

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 (infused over 3 hours)	750 mg IV q8h (infused over 3 hours)	375 mg IV q8h (infused over 3 hours)
Pneumonia, severe infections	3 g IV q8h (infused over 3 hours)	1.5 g IV q8h (infused over 3 hours)	750 mg IV q8h (infused over 3 hours)

Restricted to ID or Antimicrobial Stewardship

See the Ceftolozane/tazobactam (Zerbaxa) detail page.

Ceftriaxone

Indication	Dose	Notes
Standard Dose	1 g IV q24h	No renal dose adjustment
Serious Infections, Non-enterococcal Endocarditis, Osteomyelitis, Septic Arthritis, Epidural Abscess, Intra-abdominal Infections, Liver Abscesses, Septic Shock	2 g IV q24h	No renal dose adjustment
Meningitis & Enteroccocal Endocarditis (in combination with ampicillin)	2 g IV q12h	No renal dose adjustment

See the Ceftriaxone detail page.

Cefuroxime axetil

Indication	CrCl >30 mL/min	10-29 mL/min	<10 mL/min
All indications	500 mg PO BID	250 mg PO BID	250 mg PO daily

See the Cefuroxime axetil detail page.

Cephalexin

Indication	>30 mL/min	15-29 mL/min	<15 mL/min
Most Indications	500 mg PO QID or 1000 mg PO TID	250-500 mg PO TID	250-500 mg PO BID
Uncomplicated Cystitis or Streptococcal Pharyngitis	500 mg PO BID	250 mg PO BID	250 mg PO daily

See the Cephalexin detail page.

Cidofovir

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

Adenovirus*

High Dose Strategy	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
Induction (initial dosing)	5 mg/kg IV once weekly WITH probenecid x 2 doses	3 mg/kg IV once weekly WITH probenecid x 2 doses	Discontinue
Maintenance	5 mg/kg IV once every 2 weeks WITH probenecid	3 mg/kg IV every 2 weeks WITH probenecid	Discontinue

*There may be alternative dosing available, particularly in renal impairment. Discuss with ID pharmacist to evaluate if patient meets criteria.

At UCSF, there is an adult inpatient order set available for use – IP Adult Cidofovir (VISTIDE) Order set

BK virus*

High Dose Strategy	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
Induction (initial dosing) for BK viruria (hemorrhagic cystitis) in hematopoietic cell transplant recipients	5 mg/kg IV once weekly WITH probenecid x 2 doses	3 mg/kg IV once weekly WITH probenecid x 2 doses	Discontinue
Maintenance for BK viruria (hemorrhagic cystitis) in hematopoietic cell transplant recipients	5 mg/kg IV once every 2 weeks WITH probenecid	3 mg/kg IV every 2 weeks WITH probenecid	Discontinue

Low Dose Strategy	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
BK viremia (BK nephropathy) in kidney transplant	0.25 - 0.5 mg/kg IV once weekly WITHOUT probenecid	0.25 - 0.5 mg/kg IV once weekly WITHOUT probenecid	Discontinue

*There may be alternative dosing available, particularly in renal impairment. Discuss with ID pharmacist to evaluate if patient meets criteria.

At UCSF, there is an adult inpatient order set available for use – IP Adult Cidofovir (VISTIDE) Order set

Cytomegalovirus (CMV)

	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
Induction (initial dosing)	5 mg/kg IV once weekly WITH probenecid x 2 doses	3 mg/kg IV once weekly WITH probenecid x 2 doses	Discontinue
Maintenance	5 mg/kg IV once every 2 weeks WITH probenecid	3 mg/kg IV every 2 weeks WITH probenecid	Discontinue

At UCSF, there is an adult inpatient order set available for use – IP Adult Cidofovir (VISTIDE) Order set

IV Fluids: Give 1L NS over 30 minutes prior to cidofovir administration. If able to tolerate, give an additional 1L NS at the start or immediately after cidofovir administration.

Probenecid: 2g PO 3 hours prior to cidofovir, then 1g PO 2 and 8 hours after cidofovir (total 4g)

Restrict to ID or Antimicrobial Stewardship except:

1) For treatment or prophylaxis against viral infection in a BMT patient

See the Cidofovir detail page.

Ciprofloxacin

Indication	CrCl > 50 mL/min	30 - 50 mL/min	< 30 mL/min
Standard dosing	400 mg IV q12h 500 mg PO BID	400 mg IV q12h 500 mg PO BID	400 mg IV q24h 500 mg PO daily
Pseudomonas infections, bloodstream infections, & induction therapy for Staphylococcus hardware infections +/- rifampin	400 mg IV q8h 750 mg PO q12h	400 mg IV q12h 500 mg PO q12h	400 mg IV q24h 500 mg PO daily

Indication

CrCl > 50 mL/min

30 - 50 mL/min

< 30 mL/min

Standard dosing

400 mg IV q12h

500 mg PO BID

400 mg IV q12h

500 mg PO BID

400 mg IV q24h

500 mg PO daily

Pseudomonas infections, bloodstream infections, & induction therapy for
Staphylococcus hardware infections +/- rifampin

400 mg IV q8h

750 mg PO q12h

400 mg IV q12h

500 mg PO q12h

400 mg IV q24h

500 mg PO daily

See the Ciprofloxacin detail page.

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, Pelvic Inflammatory Disease	900 mg IV Q8h	No renal dose adjustment

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, Pelvic Inflammatory Disease

900 mg IV Q8h

No renal dose adjustment

See the Clindamycin detail page.

Clofazimine

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

See the Clofazimine detail page.

Colistin IV

Ideal Body Weight when patient weight >120% of ideal body weight

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

ZSFG: Non-formulary

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.

Restricted to ID or Antimicrobial Stewardship

*Inhaled use of colistin is allowed for unrestricted use in prophylaxis in lung transplant.

See the Colistin IV detail page.

Dalbavancin

Indication	CrCl > 30 mL/min	<30 mL/min
Single-dose regimen (skin/soft tissue infection)	1500 mg IV x 1 dose	1000 mg IV x 1 dose
Two-dose regimen (skin/soft tissue infection)	1000 mg IV x 1 dose on day 1, then 500 mg IV X 1 on day 8	750 mg IV x 1 dose on day 1, then 375 mg IV X 1 on day 8
Complicated Gram-positive infections (e.g. Native osteomyelitis)*	1500 mg IV on days 1 & 8	1000 mg IV on days 1 & 8
ID consult highly recommended for patient-specific recommendations. For dosing in other complicated indications, contact ID or ID pharmacy.

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

Restricted to ID or Antimicrobial Stewardship

See the Dalbavancin detail page.

Dapsone

Indication	Dose	Notes
Pneumocystis pneumonia (PROPHYLAXIS)	100 mg PO Q24H	Use in patients who are intolerant of sulfa No renal adjustment Rule out G6PD deficiency prior to treatment initiation Dapsone monotherapy does not provide prophylaxis for Toxoplasmosis

Indication

Dose

Notes

Pneumocystis pneumonia (PROPHYLAXIS)

100 mg PO Q24H

Use in patients who are intolerant of sulfa

No renal adjustment

Rule out G6PD deficiency prior to treatment initiation

Dapsone monotherapy does not provide prophylaxis for Toxoplasmosis

See the Dapsone detail page.

Daptomycin

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

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

*Doses up to 12 mg/kg may be indicated in treatment of some VRE infections - confer with ID/ID pharmacy.

Not effective in treatment of pneumonia.

Restricted to ID or Antimicrobial Stewardship

See the Daptomycin detail page.

Doxycycline

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

See the Doxycycline detail page.

Eravacycline

Total Body Weight

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

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

ZSFG: Non-formulary

Restricted to ID or Antimicrobial Stewardship

ZSFG: Non-formulary

See the Eravacycline detail page.

Ertapenem

Adjusted Body Weight when BMI >30

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

See the Ertapenem detail page.

Ethambutol

Total Body Weight when BMI <=30

This dosing aligns with current practices at the SFDPH TB Clinic (as of 5/2025) for treatment of tuberculosis. For patients in other counties, contact the respective TB clinics for dosing recommendations.

Indication	CrCl > 30 mL/min	< 30 mL/min
Tuberculosis	20 - 24 mg/kg PO daily Max starting dose = 1600 mg. For patients > 80 kg, contact ID pharmacy for dosing advice.	20 - 24 mg/kg PO three times weekly
Non-tuberculous mycobacteria (MAC)	15 mg/kg PO daily	15 mg/kg PO three times weekly

Indication

CrCl > 30 mL/min

< 30 mL/min

Tuberculosis

20 - 24 mg/kg PO daily

Max starting dose = 1600 mg. For patients > 80 kg, contact ID pharmacy for dosing advice.

20 - 24 mg/kg PO three times weekly

Non-tuberculous mycobacteria (MAC)

15 mg/kg PO daily

15 mg/kg PO three times weekly

Therapeutic drug monitoring may be utilized under the guidance of SF TB Clinic, ID, and/or ID/ASP Pharmacy. Higher dosing may be required.

Drug is available in 400mg and 100mg tablets.

This dosing aligns with current practices at the SFDPH TB Clinic (as of 5/2023) for treatment of tuberculosis. For patients in other counties, contact the respective TB clinics for dosing recommendations.

See the Ethambutol detail page.

Fecal microbiota spores, live—brpk (Vowst)

Indication	Dose	Notes
Secondary prevention from C. difficile infection	Take 4 capsules taken orally once daily for 3 consecutive days - Refer to prescribing information for administration considerations	No renal adjustment

Indication

Dose

Notes

Secondary prevention from C. difficile infection

Take 4 capsules taken orally once daily for 3 consecutive days -

Refer to prescribing information for administration considerations

No renal adjustment

Restricted to ID/ASP for use in select adults with recurrent CDI who are expected to be hospitalized > 14 days after C. difficile episode.

ZSFG: Non-formulary

See the Fecal microbiota spores, live—brpk (Vowst) detail page.

Fidaxomicin

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

For UCSF, please refer to local Adult CDI guidelines.

For ZSFGH, please refer to local CDI guidelines.

See the Fidaxomicin detail page.

Fluconazole

Ideal Body Weight when patient weight >120% of ideal body weight

Indication	CrCl > 50 mL/min	CrCl 10 - 50 mL/min	CrCl < 10 mL/min
Oropharyngeal Infection	100 mg IV/PO q24h	50% of target dose IV/PO q24h	25% of target dose IV/PO q24h
Esophageal Infection	200 mg IV/PO q24h	50% of target dose IV/PO q24h	25% of target dose IV/PO q24h
Systemic/Severe Infections*	≤ 80 kg: 400mg IV/PO q24h 81 – 100 kg: 600 mg IV/PO q24h > 100 kg: 800 mg IV/PO q24h	50% of target dose IV/PO q24h	25% of target dose IV/PO q24h
Prophylaxis for Heme-BMT patients	400 mg PO/IV q24h	50% of target dose IV/PO q24h	25% of target dose IV/PO q24h

*Higher doses may be necessary in some circumstances such as obese patients with severe infections

See the Fluconazole detail page.

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

See the Flucytosine detail page.

Foscarnet

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

All dosing for foscarnet is done by the foscarnet CrCl, which is calculated using the modified Cockcroft-Gault equation above. Note that no weight is used in this calculation.
Do NOT use the CrCl calculated by Cockcroft-Gault equation.
Dose-related nephrotoxicity occurs commonly; monitor and evaluate SCr daily, and recalculate foscarnet CrCl for acute changes in SCr to evaluate need for renal-dose adjustments.

Indication	Foscarnet CrCl - use equation above
Indication	> 1.4 mL/min/kg	> 1.0 - 1.4 mL/min/kg	> 0.8 - 1.0 mL/min/kg	> 0.6 - 0.8 mL/min/kg	> 0.5 - 0.6 mL/min/kg	≥ 0.4 - 0.5 mL/min/kg	< 0.4 mL/min/kg
CMV Treatment duration depends on clinical response	90 mg/kg IV q12h	70 mg/kg IV q12h	50 mg/kg IV q12h	80 mg/kg IV q24h	60 mg/kg IV q24h	50 mg/kg IV q24h	Not recommended
CMV Prophylaxis*	90 mg/kg IV q24h	70 mg/kg IV q24h	50 mg/kg IV q24h	80 mg/kg IV q48h	60 mg/kg IV q48h	50 mg/kg IV q48h	Not recommended
Acyclovir-Resistant Mucocutaneous HSV*	40 mg/kg IV q8h	30 mg/kg IV q8h	35 mg/kg IV q12h	25 mg/kg IV q12h	40 mg/kg IV q24h	35 mg/kg IV q24h	Not recommended

*There may be alternative dosing strategies available or situations that may benefit from higher/lower dosing. Speak to ASP/ID pharmacy if needed.

At UCSF, there is an adult inpatient order panel available for use – Foscarnet (FOSCAVIR) IV Panel (adult)

IV Fluids: IV hydration lowers risk for nephrotoxicity and penile ulcerations. Give 750 - 1000 mL normal saline or 500 mL normal saline for doses ≤ 60 mg/kg before each dose.

Restricted to ID or Antimicrobial Stewardship except:

1) For treatment or prophylaxis against viral infection in BMT patient

See the Foscarnet detail page.

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

See the Fosfomycin detail page.

Ganciclovir

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

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

See the Ganciclovir detail page.

Gentamicin

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

For UCSF pharmacists, access the pharmacy guidance manual click here

Do not use high-dose extended interval dosing strategy (using Hartford nomogram) in the following populations:

- Cr Cl ≤ 20 ml/min

- Aminoglycoside t ½ > 4.5 hours

- Patients with burns > 20% total burn surface area (TBSA)

- Ascites

- Cystic Fibrosis (CF) patients

- Pregnancy (outside of surgical prophylaxis)

- Spinal cord injury

High-dose extended dosing strategy:

Indication

CrCl > = 60 mL/min

40-59 mL/min

21-39 mL/min

CrCl < = 20 mL/min

Comments

Cystitis

5 mg/kg x 1

Use conventional/traditional dosing

No nomogram or levels needed

Other infecions (exclude CF)

7 mg/kg IV q24h

7 mg/kg IV q 36h

7 mg/kg IV q 48h

Use conventional/traditional dosing

Obtain 6-14 hour random gentamicin level after first dose to inform future dosing interval

Consider consulting pharmacy to assist with suggested dosing and monitoring

Use Harford dosing nomogram

Do not use this dosing in CF patients

Hartford dosing nomogram (gentamicin/tobramycin 7 mg/kg)

Urban Craig (5 mg/kg) dosing nomogram:

Chart

Description automatically generated

Conventional/traditional dosing:

Please consult pharmacy to help with dosing and monitoring plan. Below are suggested peak and trough goals based upon infection:

Conventional/traditional dosing
Gentamicin/Tobramycin
Infection	Extrapolated Peak Goal	Extrapolated Trough Goal
Abdominal Infections (including peritonitis)	6-8	< 1 (0.5)
Bacteremia	6-8	< 1 (0.5)
Empiric therapy for Cystic Fibrosis (if cannot do high-dose extended interval dosing)	Extended interval preferred but if impaired renal function consider 8-12 for peak and < 1 (0.5) for trough
Endocarditis Gram positive (‘synergy in divided doses’) * Gram negative	3-4 8-10	< 1 (0.5) < 1 (0.5)
Neutropenic Fever	6-10	< 1 (0.5)
Pneumonia	8-10	< 1 (0.5)
Skin and soft tissue infections	6-8	< 1 (0.5)
Urinary tract infections (including pyelonephritis)	4-6	< 1 (0.5)

Indication	CrCl > = 60 mL/min	40-59 mL/min	21-39 mL/min	CrCl < = 20 mL/min	Comments
Gram-positive synergy infective endocarditis (IE) involving Staphylococcus spp. and Enterococcus spp.	1 mg/kg IV q 8h consult pharmacy to assist with pharmacokinetics calculations	1 mg/kg IV q 12h consult pharmacy to assist with pharmacokinetics calculations	Use conventional/traditional dosing	Use conventional/traditional dosing
Gram-positive syngergy in Streptococcus spp. infective endocarditis (IE)	3 mg/kg IV q 24h	Use conventional/traditional dosing			Do not use this dosing strategy in Staphylococcus and Enterococcus spp. IE No optimal drug concentrations identified with this dosing strategy – contact ID pharmacy for guidance

Cystic fibrosis (CF) patients:

Gentamicin is not a preferred agent to be used in Pseudomonas aeruginosa infections - avoid use.

Advise caution in individuals with myasthenia gravis. Aminoglycosides should never be used as monotherapy except in the setting for a urinary tract infection (UTI).

See the Gentamicin detail page.

Imipenem/cilastatin

Indication	CrCl > 60 mL/min	30-60 mL/min	15-30 mL/min	< 15 mL/min
Gram-negative or Nocardia infections*	500 mg IV q6h	250 mg IV q6h	250 mg IV q8h	Use alternative of consult ID pharmacy
Nontuberculous Mycobacteria**	1000 mg IV q12h	500 mg IV q12h	250 mg IV q12h	Use alternative or consult ID pharmacy

*There may be situations that Adult ID/ASP may recommend extended infusion in certain clinical scenarios

**Higher doses may be required for elevated imipenem MICs (8-16)

Restricted to ID or Antimicrobial Stewardship

See the Imipenem/cilastatin detail page.

Imipenem/cilastatin/relebactam

Indication

CrCl >90 mL/min

60-90 mL/min

30-60 mL/min

15-30 mL/min

All Indications

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

1.25 g IV q6h

1 g IV q6h

750 mg IV q6h

500 mg IV q6h

Restricted to ID or Antimicrobial Stewardship

See the Imipenem/cilastatin/relebactam detail page.

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

General Considerations

- For assistance with therapeutic drug monitoring (TDM), see Azole TDM Reference Document.
- Review medications for potential drug interactions.
- 372 mg of isavuconazonium = 200 mg of isavuconazole.

Restricted to ID or Antimicrobial Stewardship except:

1) Documented or suspected serious fungal infection in a patient with prolonged QTc interval

2) Prophylaxis against fungal infections in patients on the hematology/BMT service or lung transplant service with prolonged QTc interval or concurrent QTc prolonging medications.

See the Isavuconazole detail page.

Isoniazid

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

Any patients with confirmed or suspected active TB disease are required by law to be reported within 1 working day of identification to the TB Control Section. For more detail see: https://www.sfcdcp.org/tb-control/tuberculosis-information-for-medical-providers/reporting-tb-to-the-health-department/#:~:text=Reporting%20TB%20to%20the%20Health%20Department&text=Call%20(628)%20206-3398,554-3613%20for%20urgent%20reporting

See the Isoniazid detail page.

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

ZSFG: Non-formulary

Restricted to ID or Antimicrobial Stewardship except for:

1) Adult malignant hematology service - for prophylaxis only per service guidelines
2) Prophylaxis of CMV disease in high-risk kidney transplant recipients
3) Continuation of current outpatient therapy

ZSFG: Non-formulary

See the Letermovir detail page.

Levofloxacin

Indication	CrCl > 50 mL/min	20-49 mL/min	<20mL/min
Urinary tract infections	500mg IV/PO Q24h	500 mgx1, then 250mg IV/PO Q24h	500mg x1, then 250mg IV/PO Q48h
Other indications	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.

See the Levofloxacin detail page.

Linezolid

Indication	Dose	Notes
All Indications	600 mg IV/PO q12h	No renal dose adjustment*
Mycobacterial Infections	600 mg IV/PO q24h	No renal dose adjustment

*In clinically stable patients with CrCl <30 mL/minute and an anticipated treatment course >10 days, some experts suggest reducing dose to 300 mg IV/PO twice daily after 72 hours to reduce the risk of thrombocytopenia. Therapeutic drug monitoring may be utilized. Contact ID or ID pharmacy for assistance.

All use in pediatric patients at UCSF requires approval from the Pediatric Antimicrobial Stewardship Program or pediatric ID physician

All use at ZSFG requires approval by ID pharmacist or ID fellow.

See the Linezolid detail page.

Maribavir

Indication
All Indications	400 mg PO BID	No adjustment for renal dysfunction

Dose increase required when administered with drug metabolizing enzyne inducers.

Restricted to ID or Antimicrobial Stewardship except:

1) Continuation of prior therapy

ZSFG: Non-formulary

See the Maribavir detail page.

Meropenem

Short Infusion Dosing (PREFERRED)

Indication	> 50mL/min	26 - 50 mL/min	10 - 25 mL/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

Extended Infusion Dosing (if recommended by ID, ID pharmacy, or clinical pharmacy for select populations)

Indication	> 50mL/min	26 - 50 mL/min	< 26 mL/min
Loading Dose*	1 g x1 (over 30 minutes)	1 g x1 (over 30 minutes)	Use short infusion
Maintenance: Standard Dosing	1 g IV q8h (over 3 hours)	1 g IV q12h (over 3 hours)	Use short infusion
Maintenance: Meningitis**, Cystic Fibrosis	2 g IV q8h (over 3 hours)	2 g IV q12h (over 3 hours)	Use short infusion

*Recommended to start maintenance dose 4 hours after loading dose
**Extended infusion data in meningitis are limited and may require further discussion with ID/ASP providers

See the Meropenem detail page.

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

4 g = meropenem 2 g + vaborbactam 2 g

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

Restricted to ID or Antimicrobial Stewardship

See the Meropenem/vaborbactam detail page.

Metronidazole

Indication	CrCl >10 mL/min	CrCl < 10 mL/min
Standard Dose	500 mg IV/PO Q8h	500 mg IV/PO Q12h
Bacterial vaginosis	500 mg IV/PO Q12h	500 mg IV/PO Q12h
Intra-abdominal infections (excluding C. difficile)	500 mg IV/PO Q12h	500 mg IV/PO Q12h
Vaginal Trichomoniasis	500 mg IV/PO Q12h	500 mg IV/PO Q12h

See the Metronidazole detail page.

Micafungin

Indication

Dose

Notes

Esophageal candidiasis

150 mg IV daily

Dosage adjustment not required in renal or hepatic dysfunction

*Prophylaxis against Candida in patients with HSCT, neutropenia, hematologic malignancy, or solid organ transplant

50-100 mg IV daily

Candidemia

Invasive candidiasis

Empiric treatment, febrile neutropenia

Empiric treatment, non-neutropenic ICU patients

100 mg IV daily

* If patient does not have a drug interaction with an azole, but needs micafungin as prophylaxis, these are the lab thresholds: AST or ALT > 3x ULN + new symptoms OR AST or ALT >5 x ULN OR T bilirubin ≥ 3 mg/dL

Restricted to ID or Antimicrobial Stewardship except:

1) Documented sterile site (not urine or respiratory) infection with microbiologically confirmed Candida spp (ID/ASP approval required for durations exceeding 48h)

2) Documented sterile site infection (not urine or respiratory) infection with yeast, pending species identification (ID/ASP approval required for durations exceeding 48h)

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

See the Micafungin detail page.

Miltefosine

Total Body Weight

Indication

Dose

Notes

Amebic meningoencephalitis

< 45 kg: 50 mg PO twice daily with food

>= 45 kg: 50 mg PO three times daily with food

No renal adjustment

Leishmaniasis

30-44 kg: 50 mg PO twice daily with food

>= 45 kg: 50 mg PO three times daily with food

No renal adjustment

Restricted to ID or Antimicrobial Stewardship with exceptions:

1) Continuation of therapy

ZSFG: Non-formulary

See the Miltefosine detail page.

Minocycline

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

*There may be certain situations that may require higher dosing (200 mg IV/PO q12h). Speak to ASP/ID pharmacy if needed.

See the Minocycline detail page.

Molnupiravir

Indication	CrCl >50 mL/min	CrCl <50 mL/min
All Indications	800 mg PO q12h	No renal dose adjustment

See the Molnupiravir detail page.

Moxifloxacin

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

See the Moxifloxacin detail page.

Nafcillin

Indication	Dosing	Notes
Meningitis, osteomyelitis, bloodstream infection, or endovascular infection	2 g IV Q4h	No renal dose adjustment

See the Nafcillin detail page.

Nirmatrelvir/ritonavir (Paxlovid)

Indication	CrCl >60 mL/min	30-60 mL/min	<30 mL/min
All Indications	300/100 mg PO BID	150/100 mg PO BID	Not recommended

Review medications for potential drug interactions.

Restricted to ASP or ID consult service (with exceptions):

- Inpatients (or those in the ED pending admission) with mild-moderate COVID-19 with symptom onset within 5 days and high-risk for progression who are admitted for reasons other than COVID-19 (see CDC Website for high-risk criteria)

See the Nirmatrelvir/ritonavir (Paxlovid) detail page.

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	Data limited for CrCl<60 mL/min; consider alternatives

See the Nitrofurantoin (Macrobid) detail page.

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

Loading doses may not be required when used for non-tuberculous mycobacterial infections

Oral formulation

Restricted to ID or Antimicrobial Stewardship except:

1) Continuation of prior therapy

ZSFG: Non-formulary

See the Omadacycline detail page.

Oritavancin

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

Restricted to ID or Antimicrobial Stewardship

ZSFG: Non-formulary

See the Oritavancin detail page.

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 daily
Influenza prophylaxis	75mg PO daily	30mg PO daily	30mg PO every other day

See the Oseltamivir detail page.

Penicillin G (IV)

Indication	CrCl > 50 mL/min	CrCl 10 – 50 mL/min	CrCl < 10 mL/min
Neurosyphilis, meningitis, necrotizing SSTI, toxic shock syndrome	4 million units IV q4h	3 million units IV q4h	3 million units IV q6h
Endovascular, bacteremia	3 million units IV q4h	3 million units IV q6h	2 million units IV q6h

See the Penicillin G (IV) detail page.

Penicillin VK (oral)

Indication

Dose

Notes

Meningococcal prophylaxis in patients in addition to meningococcal vaccination;

Patients on a C5 inhibitor

500 mg po q12h

No renal adjustment needed

See the Penicillin VK (oral) detail page.

Pentamidine (aerosolized)

Indication	Notes
Pneumocystis pneumonia PROPHYLAXIS	Please contact ID/ASP if this agent being considered

See the Pentamidine (aerosolized) detail page.

Pentamidine IV

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

Indication	CrCl > = 10 ml/min	CrCl < 10 ml/min
Pneumocystis pneumonia TREATMENT	4 mg/kg IV q24h	4 mg/kg IV q36h

*The current prescribing information does not provide specific renal adjustments and may need to consider other dosing outside of these recommendations.

Restricted to ID or Antimicrobial Stewardship

See the Pentamidine IV detail page.

Peramivir

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

Restricted to ID or Antimicrobial Stewardship

ZSFG: Non-formulary

See the Peramivir detail page.

Piperacillin/tazobactam (Zosyn)

Extended Infusion Dosing (PREFERRED for UCSF)

Indication

CrCl > 20 mL/min

<20 mL/min

UCSF: All Infections, including documented/suspected Pseudomonas

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

ZSFG: Use EXTENDED INFUSION when recommended by ID pharmacist, clinical pharmacist, or ID fellow

Loading dose = 4.5 g IV over 30 min x1, then 4.5 g IV infused over 4h every 8h (starting immediately after loading dose)

Use SHORT INFUSION piperacillin/tazobactam

See Adult Extended Infusion Piperacillin-Tazobactam protocol for additional details

Short Infusion Dosing

Indication

> 50 mL/min

10 – 50 mL/min

< 10 mL/min

UCSF: Use SHORT INFUSION only for patients excluded from EXTENDED INFUSION dosing

ZSFG: Use SHORT INFUSION unless EXTENDED infusion is recommended by ID or clinical pharmacy (ID, ICU, etc)

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

Extended-infusion piperacillin-tazobactam at various hospitals:

UCSF: Extended infusion is the PREFERRED dosing strategy if no exclusions

ZSFG: Available upon ID pharmacy, clinical pharmacy (ICU, medicine, etc), or ID fellow recommendation

See the Piperacillin/tazobactam (Zosyn) detail page.

Plazomicin

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

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

Restricted to ID or Antimicrobial Stewardship

ZSFG: Non-formulary

See the Plazomicin detail page.

Polymyxin B

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

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).

Restricted to ID or Antimicrobial Stewardship

ZSFG: Non-formulary

See the Polymyxin B detail page.

Posaconazole

Adjusted Body Weight when BMI >30

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)

General Considerations

- For assistance with therapeutic drug monitoring (TDM), see Azole TDM Reference Document.
- 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.

IV formulation - Restriced to ID or Antimicrobial Stewardship except:

Inability to tolerate or absorb enteral medications and one of the following:

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

2) Suspected or documented serious fungal infection in the hematology/BMT or lung transplant services

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

PO formulation - Restricted to ID or Antimicrobial Stewardship except:

See the Posaconazole detail page.

Pyrazinamide

Total Body Weight when BMI <=30

Indication

CrCl > 30 mL/min

< 30 mL/min

All Indications

20 mg/kg PO daily

For patients >80 kg, contact ID pharmacy for dosing advice

20 mg/kg PO three times weekly

Supplied as 500 mg tablets

This dosing aligns with current practices at the SFDPH TB Clinic (as of 5/2025). For patients in other counties, contact the respective TB clinics for dosing recommendations.

See the Pyrazinamide detail page.

Remdesivir

Indication	CrCl >30 mL/min	CrCl <30 mL/min
All Indications	200 mg IV x1 then 100 mg IV q24h	No adjustment required; vehicle may accumulate in renal dysfunction - consider risk/benefit

See the Remdesivir detail page.

Remdesivir

CrCl>30 ml/min	CrCl<30 ml/min
200 mg IV x1 then 100 mg IV q24h	No dosage required; consider risk/benefit

See the Remdesivir detail page.

Ribavirin

Indication

CrCl ≥50 mL/min

30-49 mL/min

10-29 mL/min

<10 mL/min

Respiratory Syncytial Virus (RSV)

Use total body weight for dosing

40-49 kg = 400 mg PO q12h

50-59 kg = 400 mg PO qAM PLUS 600 mg PO qPM

60-69 kg = 600 mg PO q12h

70-79 kg = 600 mg PO qAM PLUS 800 mg PO qPM

80-89 kg = 800 mg PO q12h

90 kg or greater = 600 mg PO q8h

40-59 kg = 200 mg PO q12h

60 kg or greater = 200 mg PO q8h

200 mg PO daily

200 mg PO daily (consider contacting ID/ASP pharmacist)

Hepatitis C

Dosing is highly individualized. Refer to www.hcvguidelines.org for detailed information on appropriate indications for ribavirin in the treatment of hepatitis C infection.

For treatment of respiratory syncytial virus (RSV) in adult patients at UCSF, refer to the RSV Treatment Guideline.

See the Ribavirin detail page.

Rifabutin

Indication	CrCl > or = 30 mL/min	CrCl < 30 mL/min
Mycobacterial infections	300 mg PO q24h	150 mg PO q24h

Review medications for potential drug interactions.

See the Rifabutin detail page.

Rifampin

Indication

Dosing

Notes

Mycobacterial infections (non-CNS)

600 mg IV/PO q24h

No renal dose adjustment

Prosthetic device infections

300 mg IV/PO q12h

600 mg IV/PO q24h

Endocarditis

300 mg IV/PO q8h

Review medications for potential drug interactions.

See the Rifampin detail page.

Sulbactam/durlobactam

Indication

CrCl > 130 mL/min

45-130 mL/min

30-44 mL/min

15-29 mL/min

<15 mL/min

All indications

2 g = sulbactam 1g + durlobactam 1g

2 g IV q4h

2 g IV q6h

2 g IV q8h

2 g IV q12h

2g IV q24h*

*If new start, load with 2g IV q12h x3 doses prior to starting q24h regimen

Restricted to ID/ASP approval for CR-ABC infections

ZSFG: Non-formulary

See the Sulbactam/durlobactam detail page.

Tedizolid

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

Restricted to ID or Antimicrobial Stewardship

ZSFG: Non-formulary

See the Tedizolid detail page.

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

*There may be certain situations that may require higher dosing (200 mg IV x 1, then 100 mg IV q 12h). Speak to ASP/ID pharmacy if needed.

Restricted to ID or Antimicrobial Stewardship

See the Tigecycline detail page.

TMP/SMX (trimethoprim/sulfamethoxazole)

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

Indication	CrCl > 30 mL/min	15-30 mL/min	< 15 mL/min
Bone and joint infections	8 mg TMP/kg/day divided Q8-12h	4 mg TMP/kg/day divided Q12-24h	2 mg TMP/kg Q24h
Systemic GNR infections, Nocardia, Stenotrophomonas maltophilia*	10 mg TMP/kg/day divided Q8-12h	5 mg TMP/kg/day divided Q12-24h	2.5 mg TMP/kg Q24h
Pneumocystis pneumonia, CNS infections	15 mg TMP/kg/day divided Q8 – 12h	7.5 mg TMP/kg/day divided Q12-24h	5 mg TMP/kg Q24h
Prophylaxis for Pneumocystis pneumonia (Heme-BMT)	1 DS tablet thrice weekly	1 SS tablet thrice weekly
Prophylaxis for Pneumocystis pneumonia (SOT)	1 DS tablet thrice weekly

*Certain clinical situations may require double coverage. If this is being considered, please contact adult ID or adult ASP.

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

See the TMP/SMX (trimethoprim/sulfamethoxazole) detail page.

Tobramycin

Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

For UCSF pharmacists, access the pharmacy guidance manual click here

Do not use high-dose extended interval dosing strategy (using Hartford nomogram) in the following populations:

- Cr Cl ≤ 20 ml/min

- Aminoglycoside t ½ > 4.5 hours

- Patients with burns > 20% total burn surface area (TBSA)

- Ascites

- Cystic Fibrosis (CF) patients

- Pregnancy (outside of surgical prophylaxis)

- Spinal cord injury

High-dose extended dosing strategy (Hartford nomogram):

Indication

CrCl > = 60 mL/min

40-59 mL/min

21-39 mL/min

CrCl < = 20 mL/min

Comments

Cystitis

5 mg/kg x 1

Use conventional/traditional dosing

No nomogram or levels needed

Other infecions (exclude CF)

7 mg/kg IV q24h

7 mg/kg IV q 36h

7 mg/kg IV q 48h

Use conventional/traditional dosing

Obtain 6-14 hour random gentamicin level after first dose to inform future dosing interval

Consider consulting pharmacy to assist with suggested dosing and monitoring

Use Harford dosing nomogram

Do not use this dosing in CF patients

Hartford dosing nomogram (gentamicin/tobramycin 7 mg/kg)

Urban Craig (5 mg/kg) dosing nomogram:

Chart

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Conventional/traditional dosing:

Please consult pharmacy to help with dosing and monitoring plan. Below are suggested peak and trough goals based upon infection:

Conventional/traditional dosing
Gentamicin/Tobramycin
Infection	Extrapolated Peak Goal	Extrapolated Trough Goal
Abdominal Infections (including peritonitis)	6-8	< 1 (0.5)
Bacteremia	6-8	< 1 (0.5)
Empiric therapy for Cystic Fibrosis (if cannot do high-dose extended interval dosing)	Extended interval preferred but if impaired renal function consider 8-12 for peak and < 1 (0.5) for trough
Endocarditis Gram positive (‘synergy in divided doses’) * Gram negative	3-4 8-10	< 1 (0.5) < 1 (0.5)
Neutropenic Fever	6-10	< 1 (0.5)
Pneumonia	8-10	< 1 (0.5)
Skin and soft tissue infections	6-8	< 1 (0.5)
Urinary tract infections (including pyelonephritis)	4-6	< 1 (0.5)

Cystic fibrosis (CF) patients:

Indication

CrCl > = 60 mL/min

40-59 mL/min

21-39 mL/min

CrCl < = 20 mL/min

Comments

CF exacerbation

10 mg/kg IV q 24h

10 mg/kg IV q 36h

10 mg/kg IV q 48h

Use conventional/traditional dosing

Do not use Hartford nomogram

Aminoglycoside for CF	Target peak	Target trough
Tobramycin	20-35 mcg/mL*	< 1 mcg/mL

*There may be instances (e.g., elevated MIC) where the targeted peak may need to go up to 40- 60 mcg/mL - contact adult ID pharmacist.

See the Tobramycin detail page.

Valacyclovir

Indication	CrCl ≥ 50 mL/min	30 - 49 mL/min	10 - 29 mL/min	< 10 mL/min
Orolabial/genital HSV infection (initial episode) OR recurrent episode treatment in people with HIV	1000 mg PO q12h	1000 mg PO q12h	1000 mg PO q24h	500 mg PO q24h
Orolabial/genital HSV suppression OR recurrent episode treatment	500 mg PO q12h	500 mg PO q12h	500 mg PO q24h	500 mg PO q24h
Primary Varicella/Herpes Zoster Infection	1000 mg PO q8h	1000 mg PO q12h	1000 mg PO q24h	500 mg PO q24h
Immunocompromised Prophylaxis	500 mg PO q12h	500 mg PO q12h	500 mg PO q24h	500 mg PO q24h

See the Valacyclovir detail page.

Valganciclovir (Valcyte)

ZSFG: Click here for initial dosing guidance.

Indication	CrCl > 60 mL/min	40 - 59 mL/min	25 - 39 mL/min	10 - 24 mL/min
CMV Treatment	900 mg PO q12h	450 mg PO q12h	450 mg PO q24h	450 mg PO every other day
CMV Prophylaxis	900 mg PO q24h	450 mg PO q24h	450 mg PO q48h	450 mg PO twice weekly

*IV ganciclovir prefferred for initiation of therapy for unstable renal function or in dialysis

Take with food

See the Valganciclovir (Valcyte) detail page.

Vancomycin IV

Refer to UCSF Adult Vancomycin Interim Guidance located on Sharepoint.

Use the Vancomycin Adult Dosing Calculator for more precise dose calculation and level-based adjustment (UCSF login required)

See the Vancomycin IV detail page.

Vancomycin PO

Indication	Dose	Notes
Clostridioides difficile infection: initial episode, non-fulminant	125 mg PO QID	No renal dose adjustment
Clostridioides difficile infection: fulminant	500 mg PO QID*	No renal dose adjustment

*Consider additional rectal instillation

See IDMP guidelines for greater detail and vancomycin taper dosing: https://idmp.ucsf.edu/content/management-clostridium-difficile-infection-adults

PO vancomycin is NOT sufficiently absorbed to treat systemic infections

See the Vancomycin PO detail page.

Voriconazole