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.
79 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
Unrestricted Indications 1) Documented or suspected fungal pneumonia in a patient intolerant of or with contraindications to azoles 2) Prophylaxis against fungal infections in patients on the hematology/BMT service or lung transplant service 3) Empiric therapy for prolonged febrile neutropenia in hematology/oncology/BMT patient All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow
Amikacin
| Indication | CrCl > 60 mL/min | 40 - 60 mL/min | 20 - 40 mL/min | < 20 mL/min |
|---|---|---|---|---|
| High-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded | 15 mg/kg IV q24h |
Use traditional dosing or consult ID pharmacy for guidance |
||
| Traditional dosing: patients who do not qualify for high-dose extended interval dosing | 5-7.5 mg/kg IV q8h | 5-7.5 mg/kg IV q12h | 5-7.5 mg/kg IV q24h | 5-7.5 mg/kg IV x1 & consult ID pharmacy for maintenance dose |
Monitoring
|
Indication |
Monitoring |
|---|---|
| High-dose extended interval ("once-daily") |
Single level: Check random drug level 6-14 hours after the start of infusion. Compare to nomogram (below) Paired levels: Check peak drug level 2 hours after and random level 6-14 hours after infusion. Consult ID pharmacy for assistance. |
| Traditional dosing | Paired levels: Check peak drug level 30 minutes after end of infusion (goal 20-30 mg/L) and trough level immediately before next dose (goal <4 mg/L). |
Nomogram:
**If amikacin 20 mg/kg is used. Adjust the measured level with the following equation before plotting the level onto the Amikacin 15mg/kg Extended Interval Nomogram Level for the plot = Measured level x 0.75
All use of intravenous amikacin requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Amoxicillin/clavulanate
| Indication | CrCl > 30 mL/min | 10 - 30 mL/min | < 10 mL/min |
|---|---|---|---|
| All Indications | 875/125 mg PO q12h | 500/125 mg PO q12h | 500/125 mg PO q24h |
Ampicillin
| Indication |
CrCl > 50 mL/min |
10 - 50 mL/min |
< 10 mL/min |
|---|---|---|---|
| Uncomplicated infection | 2 g IV q6h | 1 g IV q6h | 1 g IV q12h |
| Meningitis or endovascular infection | 2 g IV q4h | 2 g IV q6h | 1 g IV q8h |
Ampicillin/sulbactam (Unasyn)
| Indication | CrCl > 30 mL/min |
15 – 30 mL/min |
< 15 mL/min |
|---|---|---|---|
| All indications | 3 g IV q6h | 3 g IV q12h | 3 g IV q24h |
Artesunate
| Indication | Dose |
|---|---|
| All Indications | 2.4 mg/kg IV at 0 hours, 12 hours, and 24 hours, followed by 2.4 mg/kg IV q24h |
Non-formulary. Requires approval from ID consult service and pharmacy manager.
Azithromycin
| Indication | Dose | Notes |
|---|---|---|
| Community-acquired pneumonia, ICU | 500 mg IV/PO q24h | No adjustment for renal dysfunction |
| Community-acquired pneumonia, non-ICU | 500 mg IV/PO x1 then 250 mg IV/PO q24h |
Aztreonam
| Indication |
CrCl > 50 mL/min |
10 - 50 mL/min | < 10 mL/min |
|---|---|---|---|
| All other indications |
2 g IV q8h |
2 g IV q12h | 1 g IV q12h |
| Meningitis | 2 g IV q6h | 2 g IV q12h | 1 g IV q12h |
Aztreonam lacks cross-reactivity with most other beta-lactams; however, most patients who have a recorded beta-lactam allergy can receive another beta-lactam through screening, test dosing, or skin testing. See Inpatient Allergy Guidelines
Baloxavir marboxil
| Indication | Dosage | Notes |
|---|---|---|
| Influenza treatment, uncomplicated, 40-79kg | 40 mg PO x1 | No renal dose adjustment |
| Influenza treatment, uncomplicated, >80kg | 80 mg PO x1 |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Caspofungin
| Dose | Notes | |
|---|---|---|
| All indications | 70 mg IV x 1, then 50 mg IV q24h | No renal dose adjustment. Increase maintenance dose to 70 mg when given with CYP3A4 isnducers (phenytoin, rifampin, carbamazepine, dexamethasone, or efavirenz). |
| Endovascular or cardiac device-sassociated infection | 150 mg IV q24h |
ZSFG: Non-formulary; see micafungin
UCSF Unrestricted Indications (select indication on order entry):
1) Documented sterile site (not urine or respiratory) infection with microbiologically confirmed Candida glabrata or Candida kruseii
2) Documented sterile site infection (not urine or respiratory) infection with yeast, pending species identification
3) Prophylaxis against fungal infections in patients on the hematology/oncology/BMT service with intolerance of or contraindications to azoles
4) Empiric therapy for prolonged febrile neutropenia in hematology/oncology/BMT patient
All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow
Cefazolin
| Indication | CrCl > 35 mL/min | 10 - 35 mL/min | < 10 mL/min |
|---|---|---|---|
| Uncomplicated Gram-Positive Infection | 1 g IV q8h | 1 g IV q12h | 1 g IV q24h |
| Gram-Negative or Complicated Gram-Positive Infection | 2 g IV q8h | 2 g IV q12h | 1 g IV q24h |
Cefepime
| Indication | CrCl > 60 mL/min | 30 - 60 mL/min | 10 - 29 mL/min | < 10 mL/min |
|---|---|---|---|---|
| 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 |
Cefiderocol
| Indication | CrCl >120 mL/min | 60-119 mL/min | 30-59 mL/min | 15-29 mL/min | <15 mL/min |
|---|---|---|---|---|---|
| All Indications | 2 g IV q6h infused over 3 hours | 2 g IV q8h infused over 3 hours | 1.5 g IV q8h infused over 3 hours | 1 g IV q8h infused over 3 hours | 750 mg IV q12h infused over 3 hourse |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Ceftaroline
| Indication | CrCl > 50 mL/min | 30-50 mL/min | 15-30 mL/min | < 15 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 | 600 mg IV q12h | 400 mg IV q12h | 300 mg IV q12h |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Ceftazidime
| Indication | CrCl > 50 mL/min | 31 - 50 mL/min | 15 - 30 mL/min | < 15 mL/min |
|---|---|---|---|---|
| All Indications | 2 g IV q8h | 2 g IV q12h | 2 g IV q24h | 1 g IV q24h |
Ceftazidime/avibactam (Avycaz)
| Indication | CrCl > 50 mL/min | 31 - 50 mL/min | 16 - 30 mL/min | 6 - 15 mL/min | < 5 mL/min |
|---|---|---|---|---|---|
| All Indications | 2.5 g IV q8h | 1.25 g IV q8h | 0.94 g IV q12h | 0.94 g IV q24h | 0.94 g IV q48h |
Dosage recommendations are expressed as total grams of the ceftazidime/avibactam combination.
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Ceftolozane/tazobactam (Zerbaxa)
| Indication | CrCl >50 mL/min | 30-50 mL/min | 15-29 mL/min |
|---|---|---|---|
| Complicated urinary tract infection | 1.5 g IV q8h | 750 mg IV q8h | 375 mg IV q8h |
| Pneumonia, severe infections | 3 g IV q8h | 1.5 g IV q8h | 750 mg IV q8h |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Ceftriaxone
| Indication | Dose | Notes |
|---|---|---|
| Standard Dose | 1 g IV q24h | No renal dose adjustment |
| Serious Infections, Non-enterococcal Endocarditis, Osteomyelitis, Septic Arthritis | 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
| Indication | Criteria to initiate: CrCl >55 mL/min, SCr<1.5 mg/dL, urine protein <100mg/dL | Increase in SCr of 0.3-0.4 mg/dL | Increase in SCr of >0.5 mg/L or 3+ proteinuria |
|---|---|---|---|
| Systemic Infections: Induction | 5 mg/kg IV once weekly WITH probenecid | 3 mg/kg IV ever week WITH probenecid | Discontinue |
| Systemic Infections: Maintenance | 5 mg/kg IV once every 2 weeks WITH probenecid | 3 mg/kg IV every 2 weeks WITH probenecid | Discontinue |
| BK viruria in kidney or bone marrow transplant patients | 0.25 - 0.5 mg/kg IV once weekly WITHOUT probenecid | ||
IV Fluids: Give 1L NS over 1-2 hours 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)
Unrestricted Indications (select on order entry):
1) Unrestricted use on the hematology/oncology/BMT service
All other use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Ciprofloxacin
| Indication | CrCl > 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 | 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.
All use of IV colistin requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow. Inhaled use of colistin is allowed for unrestricted use in prophylaxis in lung transplant.
Dalbavancin
| Indication | CrCl >30 mL/min | <30 mL/min |
|---|---|---|
| Single-dose regimen (skin/soft tissue infection) | 1500 mg IV x1 dose | 1125 mg IV x1 dose |
| Two-dose regimen (skin/soft tissue infection) | 1000 mg IV x1 then 500 mg IV x1 7 days later | 750 mg IV x1, then 375 mg IV x1 7 days later |
Other dosing strategies used for treatment of bone/joint infections or bacteremia.
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Daptomycin
| Indication | CrCl > 30 mL/min | < 30 mL/min |
|---|---|---|
| All indications | 8 – 10* mg/kg IV q24h | 8 – 10* mg/kg IV q48h |
*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.
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Doxycycline
| Indication | Dose | Notes |
|---|---|---|
| All indications | 100 mg IV/PO q12h | No renal dose adjustment |
Eravacycline
| Indication | Dosing | Notes |
|---|---|---|
| All Indications |
1mg/kg IV q12h Concomitant strong CYP3A4 Inducers: 1.5 mg/kg IV q12h |
No dose adjustment for renal dysfunction Severe hepatic impairment: 1 mg/kg IV q12h x2 doses, then 1 mg/kg IV q24h |
ZSFG: Non-formulary
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Ertapenem
| Indication | CrCl > 30 mL/min | < 30 mL/min |
|---|---|---|
| All indications | 1 g IV q24h | 500 mg IV q24h |
Ethambutol
| Weight | CrCl > 30 mL/min | < 30 mL/min |
|---|---|---|
| 41-53 kg | 800 mg PO q24h | 15-25 mg/kg PO three times weekly |
| 54-67 kg | 1000 mg PO q24h | 15-25 mg/kg PO three times weekly |
| 68-80 kg | 1200 mg PO q24h | 15-25 mg/kg PO three times weekly |
| 81-94 kg | 1400 mg PO q24h | 15-25 mg/kg PO three times weekly |
| 95-107 kg | 1600 mg PO q24h | 15-25 mg/kg PO three times weekly |
| >108 kg | Consult ID or ID pharmacy | Consult ID or ID pharmacy |
Dose based on ideal body weight. Drug is available in 400mg and 100mg tablets.
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
Unrestricted Indications (select on order entry):
1) Use on hematology/oncology/BMT service
All other use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Fosfomycin
| Indication | CrCl > 50 mL/min | < 50 mL/min |
|---|---|---|
| Uncomplicated cystitis | 3 g PO x 1 dose | 3 g PO x 1 dose |
| Complicated cystitis | 3 g PO every 2 days x 3 doses | 3 g PO every 3 days x 3 doses |
Ganciclovir
| Indication | CrCl >70 mL/min | 50-69 mL/min | 25-49 mL/min | 10-24 mL/min |
|---|---|---|---|---|
| CMV 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). |
Nomogram:
Imipenem/cilastatin
| Indication | CrCl >90 mL/min | 60-90 mL/min | 30-60 mL/min | 15-30 mL/min |
|---|---|---|---|---|
| Gram-negative or Nocardia infections | 500 mg IV q6h | 400 mg IV q6h | 300 mg IV q6h | 200 mg IV q6h |
| Nontuberculous mycobacterial infections | Consult ID/ID Pharmacy for dosing recommendations | |||
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Imipenem/cilastatin/relebactam
| Indication | CrCl >90 mL/min | 60-90 mL/min | 30-60 mL/min | 15-30 mL/min |
|---|---|---|---|---|
|
All Indications 1.25 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 |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Isavuconazole
| Indication | Dose | Notes |
|---|---|---|
| All Indications | 372 mg IV/PO Q8h x 6 doses (total of 48h), then 372 mg Q24h | No renal dose adjustment |
372mg of isavuconazonium=200mg of isavuconazole
372mg of isavucazonium (prodrug) = 200mg of isavuconazole
Unrestricted Indications: 1) Documented or suspected fungal pneumonia in a patient with prolonged QT interval 2) Prophylaxis against fungal infections on the hematology/oncology/BMT service or lung transplant service in a patient with prolonged QT interval All other use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Isoniazid
| Indication | Dosing | Notes |
|---|---|---|
| All Indications | 300 mg PO Q24h | No renal dose adjustment |
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
Unrestricted Indications (provide on order entry):
1) CMV prophylaxis on heme/BMT service
All other use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Levofloxacin
| Indication | CrCl > 50 mL/min | 20-49 mL/min | <20mL/min |
|---|---|---|---|
| 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 |
Use in Adults at UCSFMC hospitals is not restricted.
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.
Meropenem
| 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 |
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 |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Metronidazole
| Indication | CrCl >10 mL/min | CrCl < 10 mL/min |
|---|---|---|
| All Indications | 500 mg IV/PO Q8h | 500 mg IV/PO Q12h |
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 |
UCSF Unrestricted Indications (select indication on order entry):
1) Documented sterile site (not urine or respiratory) infection with microbiologically confirmed Candida glabrata or Candida kruseii
2) Documented sterile site infection (not urine or respiratory) infection with yeast, pending species identification
3) Prophylaxis against fungal infections in patients on the hematology/oncology/BMT service with intolerance of or contraindications to azoles
4) Empiric therapy for prolonged febrile neutropenia in hematology/oncology/BMT patient
All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow
Minocycline
| Indication | Dosing | Notes |
|---|---|---|
| All Indications | 200 mg IV/PO x1, then 100 mg IV/PO q12h | No adjustment for renal dysfunction |
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 |
| Uncomplicated infection | 1 g IV Q6h |
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 potenital 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
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Oritavancin
| Indication | Dosing | Notes |
|---|---|---|
| All Indications | 1200 mg IV x1 over 3 hours | No adjustment for renal dysfunction |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Oseltamivir
| Indication | CrCl > 60 mL/min | 31-60mL/min | 10-30mL/min |
|---|---|---|---|
| Influenza treatment | 75 mg PO BID | 30 mg PO BID | 30 mg PO BID |
| Influenza prophylaxis | 75mg PO daily | 30mg PO daily | 30mg PO every other day |
Penicillin G
| Indication | CrCl > 50 mL/min | CrCl 10 – 50 mL/min | CrCl < 10 mL/min |
|---|---|---|---|
| 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 |
| Less serious infections | 3 million units IV q6h | 2 million units IV q6h | 1 million units IV q6h |
Peramivir
| Indication | CrCl >50 mL/min | 30-50 mL/min | 10-30 mL/min | <10 mL/min |
|---|---|---|---|---|
| All Indications | 600 mg IV q12h | 200 mg IV q24h | 100 mg IV q24h | 100 mg IV x1, then 15 mg IV q24h |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Piperacillin/tazobactam (Zosyn) EXTENDED INFUSION
| Indication | CrCl > 20 mL/min | <20 mL/min |
|---|---|---|
|
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 |
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
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Polymyxin B
| Indication | Dosing | Note |
|---|---|---|
| All Indications | 2.5 mg/kg IV x1, then 1.5 mg/kg IV q12h | No renal dose adjustment |
There are other more effective, less toxic alternatives for most multidrug-resistant Gram-negative infections. If a polymyxin is required, polymyxin B is preferred for intravenous treatment of systemic infections in adults. For treatment of urinary tract infections, or use via inhalation, use colistin (polymyxin E).
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Posaconazole
| Indication | Dosing | Notes |
|---|---|---|
| All Indications (IV or Delayed-release tablet) | 300 mg IV/PO q12h x 2 doses, then 300 mg IV/PO q24h | No renal dose adjustment (avoid IV if possible in patients with CrCl <50 mL/min due to accumulation of IV vehicle) |
Take with food. Posaconazole SOLUTION has more frequent dosing, low bioavailability, and significant food restrictions. Do not substitute SOLUTION for TABLETS or IV without discussion with ID Pharmacy.
Review medications for potential drug interactions.
Posaconazole trough levels should be obtained in most patients, whether receiving the agent for prophylaxis or treatment of fungal infections. Trough samples should be obtained 5-7 days after:
-start of therapy
-change in dose
-change in route of administration
-change in potentially interacting drugs
See UCSF Lab Posaconazole Recommendations for specifics of monitoring.
Unrestricted indications:
1) Prophylaxis against fungal infections in patients on the hematology/oncology/BMT service or lung transplant service with intolerance of or contraindications to voriconazole
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
All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow
Pyrazinamide
| Indication | CrCl > 30 mL/min | < 30 mL/min |
|---|---|---|
| All Indications |
20-25 mg/kg PO q24h: 45 – 54 kg: 1250mg q24h 55 – 64 kg: 1500mg q24h 66 - 75 kg: 1750mg q24h >=76 kg: 2000mg q24h |
25 – 35mg/kg PO three times weekly |
Supplied as 500mg tablets
Remdesivir
| CrCl>30 ml/min | CrCl<30 ml/min |
|---|---|
| 200 mg IV x1 then 100 mg IV q24h | No dosage required; consider risk/benefit |
All use requires approval by COVID attending
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 |
Ribavirin
| Indication | CrCl >50 mL/min | <50 mL/min |
|---|---|---|
| All Indications |
>=75 kg: 800 mg PO q12h <75 kg: 600 mg PO q12h |
Contact ID pharmacy for recommendations |
Rifampin
| Indication | Dosing | Notes |
|---|---|---|
| Mycobacterial infections | 600 mg IV/PO q24h |
No renal dose adjustment |
| Prosthetic device infections | 300 mg IV/PO q12h | |
| Endocarditis | 300 mg IV/PO q8h |
Review medications for potential drug interactions.
Tedizolid
| Indication | Dosing | Notes |
|---|---|---|
| All Indications | 200 mg IV/PO q24h | No adjustment for renal dysfunction |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
Tigecycline
| Indication | Dosing | Notes |
|---|---|---|
| All Indications | 100 mg IV x1, then 50 mg IV q12h |
No adjustment for renal dysfunction Severe hepatic dysfunction: 100 mg IV x1, then 25 mg IV q12h |
All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow
TMP/SMX (trimethoprim/sulfamethoxazole)
| Indication | CrCl > 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 |
| Pnemocytisis 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
Use traditional dosing or consult ID pharmacy for guidance
| Indication | CrCl > 60 mL/min | 40-60 mL/min | 20-40 mL/min | <20 mL/min |
|---|---|---|---|---|
| High-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded. | 7 mg/kg IV q24h | Use traditional dosing or contact pharmacy for assistance | ||
| Traditional dosing: patients who do not qualify for high-dose extended interval dosing | 1.6 mg/kg IV q8h | 1.5 mg/kg IV q12h | 1.5 mg/kg IV q12-24h | 2 mg/kg loading dose IV x1, contact pharmacy for maintenance |
*If Total BW > 1.2 times Ideal BW, use Adj BW.
Monitoring:
|
Indication |
Monitoring |
|---|---|
| Gram-negative high-dose extended interval ("once-daily") |
Single level: Check random drug level 6-14 hours after the start of infusion. Compare to nomogram. Paired levels: Check peak drug level 1 hour after end of infusion and random level 6-14 hours after infusion. Consult ID pharmacy for assistance. |
| Gram-negative traditional dosing | Paired levels: Check peak drug level 30 minutes after end of infusion (goal 5 - 8 mg/L) and trough level immediately before next dose (goal <2 mg/L). |
Valganciclovir (Valcyte)
| Indication | CrCl > 60 mL/min | 40 - 59 mL/min | 25 - 39 mL/min | 10 - 24 mL/min |
|---|---|---|---|---|
| CMV 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
|
Body Weight** |
||||
|---|---|---|---|---|
| CrCl (mL/min) | < 60 kg | 60-80 kg | 81-100kg | > 100kg |
| >90 mL/min (complicated* infection & age < 65) | 750mg IV q8h | 1000mg IV q8h | 1250mg IV q8h | 1500mg IV q8h |
| >90 mL/min (complicated* infection & age > 65 or uncomplicated infection & age < 65) | 1000mg IV q12h | 1250mg IV q12h | 1500mg IV q12h | 1750mg IV q12h |
| 50-90 mL/min | 750mg IV q12h | 1000mg IV q12h | 1250mg IV q12h | 1500mg IV q12h |
|
Complicated* & age <65 1000mg IV q8h |
||||
| 15-49 ml/min | 750mg IV q24h | 1000mg IV q24h | 1250mg IV q24h | 1500mg IV q24h |
| <15 ml/min not on dialysis | 10-15mg/kg IV x1 then redose according to levels | |||
*Complicated infections: CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis
**Use Total Body Weight for patients <120% of Ideal Body Weight. Use Adjusted Body Weight for patients >120% of Ideal Body Weight.
Recommend loading dose (20-25 mg/kg IV x1) for serious infections including CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis
Use Vancomycin Dosing Calculator (Excel file) for more precise dose calculation and level-based adjustment.
Round to nearest 250mg increment. Max: 2g/dose
*If Total BW > 1.2 times Ideal BW, use Adj BW
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 doses, then 200mg PO Q12* | No renal dose adjustment |
Review medications for potential drug interactions.
Voriconazole has high inter- and intra-patient variability. Voriconazole trough levels should be obtained in most patients, whether receiving the agent for prophylaxis or treatment of fungal infections. Trough samples should be obtained 3-5 days after:
-start of therapy
-change in dose
-change in route of administration
-change in potentially interacting drugs
See UCSF Lab Voriconazole Recommendations for specifics of monitoring.
Unrestricted Indications:
1) Prophylaxis against fungal infections on the hematology/BMT/lung transplant services
2) Suspected or documented fungal pneumonia in the hematology/BMT/lung tranpslant services
3) Empiric therapy for prolonged febrile neutropenia in hematology/oncology/BMT patient
All other indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow