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)

SF: Contact via Voalte

OAK: 510-801-BUGS

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

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

None

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

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:

300 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

Adjust for

CrCl < 30 ml/min/1.73m²

Usual Max

1000 mg bid

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: 1000 mg bid

Tablet: 875 mg 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

50 mg/kg/dose tid

Adjust for

CrCl < 50 ml/min/1.73m²

Usual Max

500 mg/dose

Usual Max

(Severe Infection)

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

Drug

Usual Dose

Dose Adjustment

Maximum Dose

Ceftriaxone IV

50 mg/kg/dose q24h

Meningitis

50 mg/kg/dose q12h

No adjustment

2000 mg/dose q24h

Meningitis:
2000 mg/dose q12h

Ciprofloxacin IV/PO

*IV:PO Ratio 1:1 until adult doses, then 4:5

Enteral: 15 mg/kg/dose enterally bid

IV: 10 mg/kg/dose IV q8h

Cystic Fibrosis

Enteral: 20 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

Cystic Fibrosis

1000 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 tid

IV: 900 mg q8h

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

Synergy: 3 mg/kg/dose IV q24h

Treatment: 7 mg/kg/dose IV q24h

Adjust for

CrCl < 50 ml/min/1.73m²

None

**Consult pharmacist for dose adjustment/level assessment**

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 q24h

Meropenem IV

20 mg/kg/dose q8h

Cystic Fibrosis/Meningitis

40 mg/kg/dose q8h

Adjust for

CrCl < 50 ml/min/1.73m²

1000 mg q8h

CF/Meningitis

2000 mg q8h

Metronidazole IV/PO

10 mg/kg/dose q8h

Appendicitis

30 mg/kg/dose q24h

Adjust for

CrCl < 10 ml/min/1.73m²

500 mg q8h

Appendicitis

1500 mg q24h

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

Piperacillin/

Tazobactam IV (Zosyn®)

80 mg piperacillin/kg/dose q6h
 

CF/Pseudomonas/Serious Infection

100 mg piperacillin/kg/dose q6h

Adjust for

CrCl < 50 ml/min/1.73m²

4000 mg piperacillin q6h

Tobramycin IV

7 mg/kg/dose q24h

Cystic Fibrosis

10 mg/kg/dose q24h

Adjust for

CrCl < 50 ml/min/1.73m²

None

**Consult pharmacist for dose adjustment/level assessment**

TMP/SMX IV/PO

 (Bactrim®, Septra®)

Mild to Moderate Infection

5 mg/kg/dose TMP bid

CF/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

(no max for severe)

Vancomycin IV

< 1 mo: Refer to Neonatal Dosing Guidelines

1 to 2 mo: 15 mg/kg/dose IV q6h

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

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

Consider q8h to q12h interval for Cardiac Dysfunction/CICU

Initial Max

4000 mg/day

**Consult pharmacist for dose adjustment/level assessment**

Voriconazole IV/PO

^ID-R

 < 50 kg:

 9 mg/kg/dose q12h

>= 50 kg:

Loading Dose (LD): 6 mg/kg/dose q12h x 2 doses, then

Maintenance Dose (MD): 4 mg/kg/dose q12h

No adjustment for renal dysfunction but avoid IV formulation if

CrCl < 50 ml/min/1.73m²

Avoid if severe hepatic dysfunction

Initial Max

< 50 kg:

PO/IV: 400 mg/dose

>= 50 kg:

PO LD: 400 mg/dose

PO MD: 200 mg/dose

IV: 400 mg/dose

**For IV and PO, therapeutic drug monitoring recommended with first trough level after ~5 days on stable dose – consult pharmacist for guidance**