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.

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92 Drugs

Acyclovir IV

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

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
Prophylaxis for Heme-BMT patients

250 mg/m2/dose IV q12h

 125 mg/m2/dose IV q12h 125 mg/m2/dose IV q24h 62.5 mg/m2/dose q24h

Dosing weights for acyclovir are controversial. The original package insert recommends dosing on ideal body weight in obesity.  Subsequent studies suggest adjusted body should be used to reduce risk of underdosing.  We recommend initial use of adjusted body weight in obesity with careful monitoring of renal function and mental status with potential for dose reduction as needed.

 

See the Acyclovir IV detail page.

Acyclovir PO

Indication CrCl > 25 mL/min 10 - 25 mL/min  < 10 mL/min
Immuncompromised Prophylaxis 400 PO q12h 200 mg PO q 12h 200 mg PO q 12h

Orolabial/genital HSV Infection (initial episode)

 400 mg PO q8h 400 mg PO q8h

 

200 mg PO q12h
Genital HSV Infection (recurrent episode) 800 mg PO q12h 800 mg PO q12h
Orolabial/genital HSV Suppression 400 mg PO q12h  400 mg PO q12h 

VZV infection (mild)

 800 mg PO 5-times daily 800 mg PO q8h

400 mg PO q12h
See the Acyclovir PO detail page.

AmBisome (liposomal amphotericin B)

ID-R: UCSF
ID-R: ZSFG
Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight
Indication

Dose

Notes
Cryptococcal meningitis

4 mg/kg IV q 24h

(in combination with flucytosine)

 

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

ID-R: UCSF
ID-R: ZSFG
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

 

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.
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
Most Indications 875/125 mg PO BID 500/125 mg PO BID 500/125 mg PO daily
Gram-Negative Bloodstream Infection 875/125 mg PO TID 875/125 mg PO BID 875/125 mg PO daily

 

See the Amoxicillin/clavulanate detail page.

Ampicillin

 

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

 

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) 
See the Ampicillin/sulbactam (Unasyn) detail page.

Artesunate

ID-R: UCSF
ID-R: ZSFG
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)
See the Atovaquone detail page.

Azithromycin

IV-PO
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
See the Azithromycin detail page.

Aztreonam

ID-R: ZSFG
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

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

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

ID-R: UCSF
ID-R: ZSFG
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

ID-R: UCSF
ID-R: ZSFG
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

ID-R: ZSFG

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)

ID-R: UCSF
ID-R: ZSFG
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)

ID-R: UCSF
ID-R: ZSFG
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

*In patients with obesity (defined as BMI >30 kg/m2), recommend using a minimum of 2 g daily.

** In patients with obesity (defined as BMI >30 kg/m2), higher dosing may be indicated based on patient-specific factors, contact ID/ASP pharmacy for assistance.

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 >50 mL/min 50-30 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
Gram-Negative Bloodstream Infection 1,000 mg PO QID 1,000 mg PO TID 1,000 mg PO BID 500 mg PO TID
See the Cephalexin detail page.

Cidofovir

ID-R: UCSF
ID-R: ZSFG
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

IV-PO
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, Gram-Negative Bloodstream Infection, & 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

IV-PO
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

ID-R: ZSFG
Indication Dosing Notes
All Indications 100 mg PO q24h No adjustment for renal function
See the Clofazimine detail page.

Colistin IV

ID-R: UCSF
ID-R: ZSFG
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

ID-R: UCSF
ID-R: ZSFG
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
See the Dapsone detail page.

Daptomycin

ID-R: UCSF
ID-R: ZSFG
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

IV-PO
Indication Dose Notes
All indications 100 mg IV/PO q12h No renal dose adjustment
See the Doxycycline detail page.

Eravacycline

ID-R: UCSF
ID-R: ZSFG
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

ZSFG: Non-formulary

Restricted to ID or Antimicrobial Stewardship 

ZSFG: Non-formulary

See the Eravacycline detail page.

Ertapenem

ID-R: ZSFG
Indication CrCl > 30 mL/min < 30 mL/min
All indications 1 g IV q24h 500 mg IV q24h
See the Ertapenem detail page.

Ethambutol

Adjusted Body Weight when BMI >30
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

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)

ID-R: UCSF
ID-R: ZSFG
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

ID-R: ZSFG
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

IV-PO
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

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

ID-R: UCSF
ID-R: ZSFG
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

  > 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

ID-R: ZSFG
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

ID-R: ZSFG
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  5 mg/kg x 1 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)

hartford.jpg

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

ID-R: UCSF
ID-R: ZSFG
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

ID-R: UCSF
ID-R: ZSFG
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

ID-R: UCSF
ID-R: ZSFG
IV-PO
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

ID-R: UCSF
ID-R: ZSFG
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:

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

IV-PO
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, including Gram-Negative Bloodstream Infection 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

ID-R: ZSFG
IV-PO
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

ID-R: UCSF
ID-R: ZSFG
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

ID-R: ZSFG

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

ID-R: UCSF
ID-R: ZSFG
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

IV-PO
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

ID-R: UCSF
ID-R: ZSFG
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

ID-R: UCSF
ID-R: ZSFG
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

IV-PO
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

ID-R: ZSFG
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

ID-R: ZSFG
IV-PO
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)

ID-R: UCSF
ID-R: ZSFG
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
See the Nitrofurantoin (Macrobid) detail page.

Omadacycline

ID-R: UCSF
ID-R: ZSFG
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

ID-R: UCSF
ID-R: ZSFG
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
Group B Streptococcus (GBS) Prophylaxis (until delivery)

5 million units x 1 then 

followed by 3 million units IV q4h

5 million units x 1 then 

followed by 3 million units IV q4h

5 million units x 1 then 

followed by 3 million units IV q6h
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

ID-R: UCSF
ID-R: ZSFG
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. 

*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

ID-R: UCSF
ID-R: ZSFG
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

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: Extended infusion pip-tazo is available upon ID pharmacy, clinical pharmacy (ICU, medicine, etc), or ID fellow recommendation; short infusion is the default 

See the Piperacillin/tazobactam (Zosyn) detail page.

Plazomicin

ID-R: UCSF
ID-R: ZSFG
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

ID-R: UCSF
ID-R: ZSFG
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

ID-R: UCSF
ID-R: ZSFG
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:

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

See the Posaconazole detail page.

Pyrazinamide

Adjusted Body Weight when BMI >30
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

ID-R: ZSFG
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

ID-R: ZSFG
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

ID-R: ZSFG
IV-PO
Indication Dosing Notes
Mycobacterial infections (non-CNS) 600 mg IV/PO q24h

 

No renal dose adjustment
Prosthetic device infections

300 mg IV/PO q12h

OR

600 mg IV/PO q24h
Endocarditis 300 mg IV/PO q8h

Review medications for potential drug interactions.

See the Rifampin detail page.

Sulbactam/durlobactam

ID-R: UCSF
ID-R: ZSFG
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 or Antimicrobial Stewardship approval for CR-ABC infections

ZSFG: Non-formulary

See the Sulbactam/durlobactam detail page.

Tedizolid

ID-R: UCSF
ID-R: ZSFG
IV-PO
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

ID-R: UCSF
ID-R: ZSFG
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)

IV-PO
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 including GNR Bloodstream Infection, 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 (HIV/AIDS) 

 I DS tablet daily 1 SS tablet daily 1 SS tablet thrice weekly
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  5 mg/kg x 1 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)

hartford.jpg

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) 

 

 

 

 

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 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

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
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)

ID-R: ZSFG
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.

ZSFG: Click here for initial dosing guidance.

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*

*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

ID-R: UCSF
ID-R: ZSFG
IV-PO
Use total body weight, except if total body weight is >120% of ideal body weight, then use adjusted body weight

 

*Note: These dosing recommendations were updated in 2/2025 to better align with available evidence & clinical practice

Indication Dosing Notes
Prophylaxis for Heme/BMT patients, all routes 200 mg IV/PO Q12h* No renal dose adjustment†

Treatment indications, all routes

 

 6mg/kg IV/PO Q12h x 2 doses, then 4mg/kg IV/PO Q12hr^ No renal dose adjustment†

*In patients with obesity (BMI >/= 30 kg/m2), consider a weight-based regimen (4mg/kg q12h based on adjusted body weight), Consult ID or ASP for assistance.
^Consider tablet size(s) when determining dose. Voriconazole comes in 50 mg and 200 mg PO tablets. Oral suspension is also available.
†The manufacturer recommends avoiding IV voriconazole in patients with renal impairment due to potential accumulation of the excipient sulfobutylether-beta-cyclodextrin, which may lead to kidney injury. However, limited data suggest that patients with baseline kidney impairment may safely receive short durations of IV voriconazole (Kim 2016; Lilly 2013; Neofytos 2012; Oude Lashof 2012).

General Considerations

- For assistance with therapeutic drug monitoring (TDM), see Azole TDM Reference Document.
- Review medications for potential drug interactions.

Restricted to ID or Antimicrobial Stewardship except:

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

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

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

See the Voriconazole detail page.
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