Antimicrobial Stewardship Program

(ASP)

M-F 8:00 am to 4:30 pm for focused questions on antimicrobial selection, dose, monitoring, duration of therapy and for approvals (Voalte: Pediatric Antimicrobial Stewardship Team - ID/ASP Pharmacist or Provider)

Oak/SF: Contact via Voalte

Pediatric ID Consult Service

For cases requiring in depth review and physician consultation

Online Resources

Pediatric Empiric Antimicrobial Therapy Guidelines, Clinical Pathways, Detailed Guidelines, Antimicrobial Susceptibility Profiles

idmp.ucsf.edu

Shaded boxes indicate ID-Restricted agents (ID-R). Other restricted agents are noted in APeX.

An approving clinician’s ID number is needed to order a restricted agent. To obtain approval for a restricted agent,

call Pediatric ASP between 8:30 am to 5:00 pm M-F. For off-hours approval (until 9:00 pm) contact the Pediatric ID Consult Service. From 9:00 pm to 8:00 am, use approval ID# 11111 for release of a single dose, then contact ASP for approval of subsequent doses.

Drug

Usual Dose

Dose Adjustment

Maximum Dose

Acyclovir IV

Note: Use adjusted body weight for dosing in patients with obesity

Mucocutaneous HSV Infection

Immunocompetent Host ≥ 3 mo

5 mg/kg/dose q8h

CNS HSV Infection >= 3 mo to < 12 yo

15 mg/kg/dose q8h

CNS HSV >= 12 yo,

HSV in Immunocompromised Host, or VZV Infection

10 mg/kg/dose q8h

HSV Infection < 3 mo

20 mg/kg/dose q8h

 Adjust for

CrCl < 50 ml/min/1.73m²

Usual Max

1000 mg/dose

Acyclovir PO preferred for non-invasive infection in immunocompetent host > 3 months old – refer to Pediatric EATG or Lexi-Comp for dose

Amphotericin B

Liposomal IV ^ID-R

(Ambisome®)

5 mg/kg/dose q24h

No recommended dose adjustment for renal dysfunction, but drug should be used with caution due to nephrotoxicity risk

None

Ampicillin IV

50 mg/kg/dose q6h

Endocarditis, Meningitis:

400 mg/kg/day divided q4h to q6h

Adjust for

CrCl < 50 ml/min/1.73m²

2000 mg/dose

Ampicillin-

sulbactam IV

(Unasyn®)

50 mg ampicillin/kg/dose q6h

Adjust for

CrCl < 30 ml/min/1.73m²

Usual Max

2000 mg ampicillin/dose

Amoxicillin PO

22.5 mg/kg/dose bid

High Dose (Pneumococcal)

45 mg/kg/dose bid

Strep pharyngitis:

50 mg/kg/dose qday

Adjust for

CrCl < 30 ml/min/1.73m²

Usual Max

1000 mg/dose

Amoxicillin-clavulanate PO

(Augmentin®)

< 3 mo: 15 mg amox/kg/dose bid

(Use 250 mg/5 mL suspension)

Standard Dose >= 3 mo

22.5 mg amox/kg/dose bid

High Dose (Pneumococcal) >= 3 mo

45 mg amox/kg/dose bid

Adjust for

CrCl < 30 ml/min/1.73m²

Usual Max

Susp: 840 mg/dose or 880 mg/dose depending on concentration

Tablet: 875 mg/dose bid

Cefazolin IV

Mild-Moderate Infection

25 mg/kg/dose q8h

Severe Infection

50 mg/kg/dose q8h

Adjust for

CrCl < 50 ml/min/1.73m²

Mild-Moderate

1000 mg/dose

Severe

2000 mg/dose

Cephalexin PO

Mild-Moderate Infection

25 mg/kg/dose tid

Severe Infection

e.g. osteomyelitis/pyelonephritis

50 mg/kg/dose tid

Adjust for

CrCl < 50 ml/min/1.73m²

Mild-Moderate

500 mg/dose

Severe

1000 mg/dose

Cefepime IV

50 mg/kg/dose q8h

Adjust for

CrCl < 60 ml/min/1.73m²

2000 mg/dose

Ceftazidime IV

50 mg/kg/dose q8h

Adjust for

CrCl < 50 ml/min/1.73m²

2000 mg/dose

Ceftriaxone IV

50 mg/kg/dose q24h

Meningitis

50 mg/kg/dose q12h

No adjustment

2000 mg/dose

Ciprofloxacin IV/PO

Enteral: 15 mg/kg/dose enterally bid

IV: 10 mg/kg/dose IV q8h

Adjust for

CrCl < 30 ml/min/1.73m²

750 mg enterally bid

400 mg IV q8h

Clindamycin IV/PO

10 mg/kg/dose q8h

Bone/Joint Infection

13 mg/kg/dose q8h

No adjustment

Usual max

Enteral: 600 mg/dose

IV: 600 mg dose

IV necrotizing fasciitis: 900 mg/dose

Fluconazole IV/PO

Invasive Candidiasis

12 mg/kg/dose q24h

Adjust for

CrCl < 50 ml/min/1.73m²

Usual max

800 mg q24h

Varies by site and severity

Gentamicin IV

 Note: Use adjusted body weight for dosing in patients with obesity

Monitoring:  

Oak: contact pharm for dosing adjustments 

SF: dosing per pharm 

Synergy: 3 mg/kg/dose IV q24h

Treatment < 3 mo OR < 52 weeks PMA:

5 mg/kg/dose IV q24h

Treatment >= 3 mo AND >= 52 weeks PMA: 7 mg/kg/dose IV q24h

Adjust for

CrCl < 50 ml/min/1.73m²

Usual Max

1000 mg/dose

Levofloxacin IV/PO

6 mo to < 5 yo: 10 mg/kg/dose q12h

>= 5 yo: 10 mg/kg/dose q24h

Adjust for

CrCl < 30 ml/min/1.73m²

750 mg/dose

Meropenem IV

20 mg/kg/dose q8h

Meningitis

40 mg/kg/dose q8h

Adjust for

CrCl < 50 ml/min/1.73m²

2000 mg/dose

Metronidazole IV/PO

10 mg/kg/dose q8h

Appendicitis

30 mg/kg/dose q24h

Adjust for

CrCl < 10 ml/min/1.73m²

500 mg/dose

Appendicitis

1500 mg/dose

Nafcillin or Oxacillin IV

50 mg/kg/dose q6h

Adjust for concurrent hepatic and renal dysfunction

Individual Dose

2000 mg/DOSE

Daily Dose

12,000 mg/DAY

Penicillin G IV (aqueous)

Mild-Moderate Infection

200,000 units/kg/day divided q4h

Severe Infection

eg endocarditis, meningitis

400,000 units/kg/day divided q4h

Adjust for

CrCl < 10 ml/min/1.73m²

4 million units/dose

Piperacillin/

Tazobactam IV (Zosyn®)

100 mg piperacillin/kg/dose q6h

Adjust for

CrCl < 40 ml/min/1.73m²

4000 mg piperacillin/dose

Tobramycin IV

Note: Use adjusted body weight for dosing in patients with obesity

Monitoring:  

Oak: contact pharm for dosing adjustments 

SF: dosing per pharm 

Treatment < 3 mo OR < 52 weeks PMA:

5 mg/kg/dose IV q24h

Treatment >= 3 mo AND >= 52 weeks PMA: 7 mg/kg/dose IV q24h

Adjust for

CrCl < 50 ml/min/1.73m²

None

TMP/SMX IV/PO

 (Bactrim®, Septra®)

Mild to Moderate Infection

5 mg/kg/dose TMP bid

Serious Infection/PCP

5 mg/kg/dose TMP q6h to q8h

Adjust for

CrCl < 30 ml/min/1.73m²

Mild-Moderate

160 mg TMP/dose

Severe

Enteral: 320 mg TMP/dose

IV: 480 mg TMP/dose

Vancomycin IV

Oak: contact pharm for dosing adjustments 

SF: dosing per pharm 

< 1 mo: Refer to Neonatal Dosing Guidelines

1 mo to < 3 mo (PMA 45 weeks to <= 52 weeks): 15 mg/kg/dose IV q8h

>= 3 mo to < 12 yo: 17.5 mg/kg/dose IV q6h

>= 12 yo to < 15 yo: 15 mg/kg/dose IV q6h

>= 15 yo: 15 mg/kg/dose IV q8h

CICU/cardiac dysfunction initial dosing:

< 6 months: 15 mg/kg/dose IV q12h

>= 6 months: 15 mg/kg/dose IV q8h

Initial Max

1000 mg/dose

Voriconazole IV/PO

^ID-R

Empiric dosing if unknown pharmacogenomics (PGx):

< 12 yo

10 mg/kg/dose enterally/IV bid

>= 12 yo

6 mg/kg/dose enterally/IV bid

Empiric dosing if known PGx

No adjustment for renal dysfunction but avoid IV formulation if

CrCl < 50 ml/min/1.73m²

Avoid if severe hepatic dysfunction

Initial Max:

400 mg/dose