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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84 Drugs

Acyclovir

Indication

CrCl > 50 mL/min

25 - 50 mL/min

10 - 25 mL/min

< 10 mL/min 

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

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.

 

AmBisome (liposomal amphotericin B)

Indication

Dose

Notes

Invasive fungal infections 5 mg/kg IV q24h

No adjustment for renal dysfunction; monitor serum creatinine and electrolytes

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

Restricted to ID or Antimicrobial Stewardship except:

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

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

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

Amikacin

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

Use traditional dosing or consult ID pharmacy for guidance

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

Monitoring

Indication

Monitoring

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

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

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

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

Nomogram:

 

 

 

 

 

 

 

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

Restricted to ID or Antimicrobial Stewardship for IV amikacin 

Amoxicillin/clavulanate

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

Ampicillin

Indication

CrCl > 50 mL/min

10 - 50 mL/min

< 10 mL/min

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

Ampicillin/sulbactam (Unasyn)

Indication CrCl > 30 mL/min

15 – 30 mL/min

< 15 mL/min

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

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) 

Artesunate

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

Restricted to ID or Antimicrobial Stewardship

Azithromycin

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

Aztreonam

Indication

CrCl > 50 mL/min

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

2 g IV q8h*

2 g IV q12h 1 g IV q12h  

*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

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

Restricted to ID or Antimicrobial Stewardship

Bezlotoxumab

Indication Dose  Notes 
Secondary prevention from C. difficile infection  10 mg/kg x 1 cumulative life time dose 

No renal adjustment

In patients with a history of heart failure, bezlotoxumab use should be reserved for situations when the benefits outweigh risks.

Restricted to ID or Antimicrobial Stewardship

Additonal criteria for inpatient administration: Must be expected to be hospitalized > 14 days after C. difficile episode 

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

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 

Cefiderocol

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

Restricted to ID or Antimicrobial Stewardship

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

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

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

Ceftazidime/avibactam (Avycaz)

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

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

Restricted to ID or Antimicrobial Stewardship

Ceftolozane/tazobactam (Zerbaxa)

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

Restricted to ID or Antimicrobial Stewardship

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

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

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

Cidofovir

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.  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.  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

Ciprofloxacin

Indication CrCl > 50 mL/min 30 - 50 mL/min < 30 mL/min
 

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

400 mg IV q8h

750 mg PO q12h

400 mg IV q12h

500 mg PO q12h

400 mg IV q24h

500 mg PO daily

Clindamycin

Indication Dose Notes
 

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

Clofazimine

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

Colistin IV

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

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.

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

Daptomycin

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.

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

Not effective in treatment of pneumonia.

Restricted to ID or Antimicrobial Stewardship

Doxycycline

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

Eravacycline

Indication Dosing Notes
All Indications

1mg/kg IV q12h

Concomitant strong CYP3A4 Inducers: 1.5 mg/kg IV q12h

No dose adjustment for renal dysfunction

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

ZSFG: Non-formulary

Restricted to ID or Antimicrobial Stewardship 

Ertapenem

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

Ethambutol

Weight CrCl > 30 mL/min < 30 mL/min
30-40 kg 600 mg PO q24h 20-25 mg/kg PO three times weekly
41-50 kg 800 mg PO q24h 20-25 mg/kg PO three times weekly
51-60 kg 1000 mg PO q24h 20-25 mg/kg PO three times weekly
61-70 kg 1200 mg PO q24h 20-25 mg/kg PO three times weekly
71-80 kg 1400 mg PO q24h 20-25 mg/kg PO three times weekly
81-90 kg 1600 mg PO q24h 20-25 mg/kg PO three times weekly
> 91 kg Consult ID or ID pharmacy Consult ID or ID pharmacy

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. 

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

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

Fidaxomicin

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

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

Fluconazole

Indication CrCl > 50 mL/min 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

*Higher doses may be necessary in some circumstances

Flucytosine

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

Foscarnet

Restricted to ID or Antimicrobial Stewardship except 

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

 

Fosfomycin

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

Ganciclovir

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

Gentamicin

Use traditional dosing or consult ID pharmacy for guidance

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

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

Monitoring:

Indication

Monitoring

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

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

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

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

Hartford Nomogram (7 mg/kg)

 

Urban-Craig Nomogram (5 mg/kg)

 

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 

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 

Isavuconazole

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

372mg of isavuconazonium=200mg of isavuconazole

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

Restricted to ID or Antimicrobial Stewardship except:​

1) Documented or suspected fungal pneumonia 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.

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

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

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.

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.

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

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 

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 except:

1) Continuation of prior therapy

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

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

Restricted to ID or Antimicrobial Stewardship except:

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

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

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

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

Miltefosine

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 

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.

Molnupiravir

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

Moxifloxacin

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

Nafcillin

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

No renal dose adjustment

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.

Nitrofurantoin (Macrobid)

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

Omadacycline

Indication Dosing Notes

All Indications

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

200 mg IV x1, then 100 mg IV q24h

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

No adjustment for renal dysfunction

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

Oritavancin

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

Restricted to ID or Antimicrobial Stewardship 

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

Penicillin G

Indication CrCl > 50 mL/min CrCl 10 – 50 mL/min CrCl < 10 mL/min
Neurosyphilis, meningitis 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

Pentamidine IV

Indication CrCl > = 10 ml/min CrCl < 10 ml/min
Pneumocystis pneumonia 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 

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 

Piperacillin/tazobactam (Zosyn) EXTENDED INFUSION

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

UCSF: All Infections, including documented/suspected Pseudomonas 

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 or ID fellow

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

See Adult Extended Infusion Piperacillin/Tazobactam Protocol for additional details.

UCSF: PREFERRED dosing strategy if no exclusions

ZSFG: Available upon ID pharmacy or ID fellow recommendation

Piperacillin/tazobactam SHORT Infusion (SI) (Zosyn)

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

Non-Pseudomonas infections

3.375 g IV q6h

3.375 g IV q8h

2.25 g IV q8h
Documented/Suspected Pseudomonas aeruginosa infection

CrCl > 20 mL/min:

4.5 g IV q6h

CrCl < 20 mL/min:

3.375 g IV q8h

 

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

Plazomicin

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

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

Restricted to ID or Antimicrobial Stewardship 

Polymyxin B

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

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

Restricted to ID or Antimicrobial Stewardship 

Posaconazole

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

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

Review medications for potential drug interactions.

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

See UCSF Lab Posaconazole Recommendations  for specifics of monitoring.

IV formulation - Restriced to ID or Antimicrobial Stewardship 

PO formulation - Restricted to ID or Antimicrobial Stewardship except:

1) For prophylaxis against fungal infections in prophylaxis against fungal infections in patients on a hematology/BMT or lung transplant service with intolerance or contraindications to voriconazole 

Pyrazinamide

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

20-25 mg/kg PO q24h:

36-39 kg: 750 mg PO q24h

40-50 kg: 1000mg PO q24h

51-59 kg: 1250 mg PO q24h

60-70 kg: 1500mg PO q24h

71-80 kg: 1750 mg PO q24h

> 81 kg: 2000 mg PO q24h

25-30 mg/kg PO three times weekly

Supplied as 500 mg tablets

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

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

Remdesivir

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

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.

Rifampin

Indication Dosing Notes
Mycobacterial infections 600 mg IV/PO q24h

 

No renal dose adjustment

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

Review medications for potential drug interactions.

Tedizolid

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

Restricted to ID or Antimicrobial Stewardship 

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 

TMP/SMX (trimethoprim/sulfamethoxazole)

Indication CrCl > 30 mL/min 15-30 mL/min < 15 mL/min
Systemic GNR infections, Nocardia 10 mg TMP/kg/day divided Q6-12h 5 mg TMP/kg/day divided Q6-12h 2.5 mg TMP/kg Q24h
Pneumocystis pneumonia, CNS infections 15 - 20 mg TMP/kg/day divided Q6 – 12h 7.5-10 mg TMP/kg/day  divided Q12-24h 4 - 5 mg TMP/kg Q24h

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

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

*May consider Total BW for serious infections

Tobramycin

 

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

 

Monitoring:

Indication

Monitoring

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

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

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

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

Hartford Nomogram (7 mg/kg) for Tobramycin & Gentamicin

How to use Hartford nomogram

- Using the time of serum level (between 6 and 14 hours after dose) and the resultant serum concentration (mcg/mL), locate the intersecting point on the nomogram. Wherever this point lies is the recommended dosing interval for the aminoglycoside. 

- If the serum level falls on the line between intervals, choose the longer interval to ensure an adequate drug-free period after each dose.

- If the serum level is above the q48h interval, convert the patient to conventional dosing. 

Valganciclovir (Valcyte)

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

Vancomycin IV

Refer to UCSF Adult Vancomycin Interim Guidance. ZSFG: Click here for initial dosing guidance.

Use Vancomycin Dosing Calculator (Excel file) for more precise dose calculation and level-based adjustment.

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

Voriconazole

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

All Indications, PO Route

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

400mg PO Q12h x 2 doses, then 200mg PO Q12* No renal dose adjustment

Review medications for potential drug interactions.

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

See UCSF Lab Voriconazole Recommendations  for specifics of monitoring.

Note: 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).

Restricted to ID or Antimicrobial Stewardship except:

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

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

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

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