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View Full Version : [Infectious Diseases] UCSF Program - Guidelines for Antimicrobial Use in Adults



TomHsiung
Mon 21st January '13, 11:01am
This dose recommendation has been out of date. See Posts #2 and #3 for latest version of dosage guideline.



Drug
CrCl >50 mL/min
CrCl 10 - 50 mL/min
CrCl <10 mL/min
(ESRD not on HD)
HD dosing (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/hddosing.htm)


Acyclovir


Dose on ideal body weight

ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)(IV)
Herpes simplex infections
5 mg/kg/dose IV Q8h

HSV encephalitis/ Herpes zoster
10 mg/kg/dose IV Q8h
5 mg/kg/dose IV Q12 - 24h



10 mg/kg/dose IV Q12 - 24h
2.5 mg/kg IV Q24h


5 mg/kg IV
Q24h


Amoxicillin
500-1000 mg po TID
250-500mg po BID
250-500mg po QD


Amphotericin B

Dose on total body weight
0.6 - 1.0 mg/kg IV Q24h
No Change No Change
Dosage reductions in renal disease are not necessary. However, due to the nephrotoxic potential of the drug, reducing the dose or holding the drug in the setting of a rising serum creatinine may be warranted.


Amphotericin B Lipid
Preparations

ID approval: UCSF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/ucsf_restrict.htm#AmBisome) SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Amphotericin_B) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)

Dose on total body weight
Invasive fungal infections
3-5 mg/kg IV Q24h

Prophylaxis (heme-onc)
1 mg/kg IV Q24h
No Change No Change
Dosage reductions in renal disease are not necessary. However, due to the nephrotoxic potential of the drug, reducing the dose or holding the drug in the setting of a rising serum creatinine may be warranted.


Amikacin

See Aminoglycoside Dosing & Monitoring (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/aminoglycoside_dosing.htm) section

Consultation with ID/ID pharmacy recommended before use. Dose is based on ideal body weight (IBW) except in obese patients or those under their ideal body weight. Use actual body weight if patient weight is less than IBW. Use adjusted body weight (ABW) in patients who are obese. Amikacin is generally used as a second-line aminoglycoside because of its increased cost and need to send out levels
≥ 60 mL/min
15-20 mg/kg/dose IV Q24h
The total daily dose of amikacin can be administered as a single daily dose (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/aminoglycoside_dosing.htm#Once-Daily) in patients with normal renal function (CrCl � 60 mL/min). Patients with decreased renal function or abnormal body composition should have their doses adjusted according to the recommendations adjacent. Turnaround time for amikacin levels is usually 2-4 days. Peak levels are not useful with this dosing regimen; trough levels are recommended and should be <5mg/L.
40-60 mL/min 20-40mL/min 5-7.5 5
mg/kg mg/kg
IV Q12h IV Q12-24h


With traditional dosing of amikacin, peak (20-30 mg/L) and trough (<8mg/L) levels are recommended in patients anticipated to receive aminoglycosides for severe Gram (-) infection. Those patients with CrCl <60 mL/min, obesity or increased fluid volume should be monitored with serum amikacin levels.
< 20 mL/min
5 mg/kg loading dose(Consult pharmacy for maintenance dose)


Ampicillin
Meningitis or endovascular infection
2 g IV Q4h

Uncomplicated Infection
2 g IV Q6h
2 g IV Q6h
1g IV Q6h
1g IV Q8h
1 g IV Q12h


Ampicillin/sulbactam
ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
1.5-3 g IV Q6h
1.5 g IV Q6-8h
1.5 g IV Q12h


Aztreonam
ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Amphotericin_B) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
2 g IV Q8h
2 g IV Q12h
1 g IV Q12h


Cefazolin
Gram Negative or Complicated Gram-Positive
2 g IV Q8h


Uncomplicated Gram-Positive
1-2g IV Q8h
1 - 2 g IV Q12h
1 g IV Q24h


Caspofungin
ID approval: UCSF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/ucsf_restrict.htm#Caspofungin) SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)

For severe hepatic dysfunction give 70mg IV x1 then 35mg IV daily.
LD=70 mg x1, No Change No Change
then 50 mg Q24h
Increase maintenance dose to 70mg when given with phenytoin, rifampin, carbamezapine, dexamethasone, nevirapine, or efavirenz.


Cefepime
ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
> 60 mL/min
2 g IV Q12h
30-60 mL/min 10-30mL/min
2g IV 1 g IV
Q24h Q24h
0.5 g IV Q24h


Febrile Neutropenia, Meningitis,Pseudomonas infections, Critically ill patients
2 g IV Q8h
2 g IV 2 g IV
Q12h Q24h
1 g IV Q24h


Ceftazidime

ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
2 g IV Q8h
2 g IV Q12 - 24h
0.5 g IV Q24h


Ceftriaxone
ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
1 g IV Q24h
No Change
No Change


Meningitis:
ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Ceftriaxone)
2 g IV Q12h


Endocarditis & Osteomyelitis:
ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Ceftriaxone)
2 g IV q24h


Cefuroxime
0.75 - 1.5 g IV Q8h
0.75 - 1.5 g IV Q12 - 24h
0.5 g IV Q24h


Ciprofloxacin

ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Ciprofloxacin)(IV) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
.
400 mg IV Q12h

500 - 750 mg po Q12h
30-50 mL/min 10-30mL/min
No Change 200-400 mg IV
Q12h

No Change 250-500 mg po
Q12h
200 mg IV Q12h
250 mg po Q12h


Pseudomonas infections
400mg IV q8h
750mg po Q12h
30-50 mL/min 10-30mL/min
No Change 200-400 mg IV
Q12h

No Change 250-500 mg po
Q12h
200 mg IV Q12h
250 mg po Q12h


Clindamycin

ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
600 - 900 mg IV Q8h
300-450mg po TID-QID
No Change
No Change


Colistin

Dose on ideal body weight
5mg/kg IV x1 loading dose, then contact ID Pharmacy for maintenance dosing recommendations


Daptomycin

Dose on total body weight

Not effective for treatment of pneumonia

ID approval: UCSF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/ucsf_restrict.htm#Daptomycin) SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
6-10 mg/kg IV Q24h
Dose depends on indication & pathogen.
<30 ml/min
6-10 mg/kg IV Q48h


Doxycycline
100 mg po/IV Q 12h
No Change
No Change


Ethambutol
15-20 mg/kg po daily
<30 ml/min
15 - 25 mg/kg po three times per week


Ertapenem
ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
1g IV Q24h
<30 ml/min
500mg IV Q24h


Fluconazole
ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Fluconazole)(IV) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)

Oral formulation is 100% bioavailable. IV use should be restricted to patients unable to take oral medications.
100 - 400 mg po/IV Q24h
Oropharyngeal Candidiasis: 100mg daily
Esophageal Candidiasis: 200mg daily
Severe Infections : 400mg daily
50 - 200 mg po/IV Q24h
50 - 100 mgpo/IV Q24h


Flucytosine (5FC)


Dose on ideal body weight

Steady-state serum 5-FC level measurements are difficult to obtain. However, they may be useful in guiding dosing of 5-FC in anuria. Bone marrow suppression has been associated with 2 hour post dose 5-FC peaks of >100 mg/L
25mg/kg
po Q6h
25-50 mL/min 10-25mL/min
25 mg/kg 25mg/kg
po Q12h po Q24h
12.5 mg/kg
po Q24h


Ganciclovir

ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
> 70mL/min 50-69mL/min
5mg/kg/dose 2.5mg/kg/dose IV Q12h IV Q12h
25-49 mL/min 10-24mL/min
2.5 1.25
mg/kg mg/kg
IV Q24h IV Q24h


Gentamicin

See Aminoglycoside Dosing & Monitoring (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/aminoglycoside_dosing.htm) section

For underweight patients, use total body weight to calculate dose. For patients whose weight is 1-1.2 times their ideal body weight, use ideal body weight. For patients weighing >1.2 times ideal body weight, useadjusted body weight. Those patients with CrCl <60 mL/min, obesity or increased fluid volume should be monitored with serum gentamicin levels.
≥ 60 mL/min
7 mg/kg/dose IV Q24h
or
1.6 mg/kg/dose IV Q8h (total 5mg/kg/day)
The total daily dose of gentamicin can be administered as a single daily dose (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/aminoglycoside_dosing.htm#Once-Daily) in patients with normal renal function (CrCl � 60 mL/min). SeeAminoglycoside Dosing & Monitoring (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/aminoglycoside_dosing.htm) section for monitoring recommendations. Divided dosing is recommended for patients with decreased renal function or abnormal body composition.
40-60 mL/min 20-40mL/min 1.2-1.5 1.2-1.5
mg/kg mg/kg
IV Q12h IV Q12-24h

With traditional dosing (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/aminoglycoside_dosing.htm#Traditional)of gentamicin, peak (5-8 mg/L) and trough (<2mg/L) levels are recommended in patients anticipated to receive aminoglycosides for �7 days for severe Gram (-) infection. Lower doses (1mg/kg/dose Q8h) are suggested when aminoglycosides are used synergistically in Gram (+) infections (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/aminoglycoside_dosing.htm#Traditional). Goals for Gram (+) synergy dosing are peak 3-4mg/L and trough <1 mg/L.
< 20 mL/min
2 mg/kg loading dose(Consult pharmacy for maintenance dose)


Imipenem

ID approval: UCSF SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Meropenem) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
500 mg IV Q6-8h
max 50 mg/kg/day
500 mg IV Q8h
< 20 mL/min
250-500 mg IV Q12h


Isoniazid
300 mg po daily
No Change
No Change


Levofloxacin
ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Levofloxacin)(IV)
VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm) (IV)
250 - 500 mg po/IV Q24h
LD=500 mg x1, then 250 mg po/IV Q24h
LD=500 mg x1, then 250 mg po/IV Q48h


Nosocomial pneumonia/ Pseudomonas infections
750mg po/IV Q24h
LD=750 mg x1, then 750 mg po/IV Q48h
LD=750 mg x1, then 500 mg po/IV Q48h


Linezolid
ID approval: UCSF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/ucsf_restrict.htm#Voriconazole) SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
600mg IV/po Q12h
No Change
No Change


Meropenem
ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Meropenem) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
0.5-1 g IV Q8h
25-50 mL/min 10-25mL/min
0.5 - 1 g 0.5g
IV Q12h IV Q12h

2g IV Q12h 1g IV Q12h
0.5 g IV Q24h



1 g IV Q24h


Meningitis, documented or suspected Pseudomonasinfections, critical illness
2 g IV Q8h


Metronidazole
500 mg po/IV Q8h
500 mg po/IV Q8h
500 mg po/IV Q12h
Adjustment for ESRD only for patients not receiving hemodialysis.


Moxifloxacin
400mg po/IV Q24h
No Change
No Change


Nafcillin
Meningitis, osteomyelitis, or endovascular infection
2 g IV Q4h

Uncomplicated infection
1-2g IV Q6h
No Change
No Change


Penicillin G
Meningitis or endovascular infection
3 MU IV Q4h

Uncomplicated infection
2-3 MU IV Q4-6h
1 - 2 MU IV Q4 - 6h
1 MU IV Q6h


Piperacillin/Tazobactam (Zosyn�)
3.375g IV Q6h
3.375g IV Q6-8h
2.25g IV Q8h


Documented/suspected Pseudomonasinfections
4.5g IV Q6h for ClCr > 20 mL/min


Posaconazole
ID approval: UCSF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/ucsf_restrict.htm#Synercid) SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
Must be administered with a high-fat meal or nutritional shake (e.g. Ensure)
Treatment of invasive fungal infections
400 mg po Q12h or 200mg po Q6h
Neutropenia/GVHD prophylaixis
200mg po Q8h
No Change
No Change


Pyrazinamide
20 - 25 mg/kg po daily
<30 ml/min
25 - 35 mg/kg po three times per week


Quinupristin/dalfopristin (Synercid)
ID approval: UCSF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/ucsf_restrict.htm#Synercid) SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
Dose varies by indication.


Rifampin
ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Rifampin)(IV)
Check for drug interactions
600 mg po daily
No Change
No Change


Prosthetic valve endocarditis
300 mg po Q8h
No Change
No Change


Prosthetic joint infections
450 mg po Q12h
No Change
No Change


TigecyclineID approval: UCSF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/ucsf_restrict.htm#Synercid) SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
Severe hepatic disease: 100mg IV x1, then 25mg IV q12h
100mg IV x1, then 50mg IV Q12h
No Change
No Change


Tobramycin

ID approval: SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm#Rifampin)
See Gentamicin and Aminoglycoside Dosing (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/aminoglycoside_dosing.htm)Section


TMP/SMX


Dose on adjusted body weight

TMP/SMX is �90% bioavailable orally. When switching to oral therapy, consider that a single-strength tablet has 80mg of TMP, a double-strength tablet 160mg of TMP.
Systemic GNR infections
10 mg TMP/kg/day IV
divided Q6 - 12h

Pneumocystis pneumonia
15 - 20 mg TMP/kg/day IV
divided Q6 - 12h
5 - 7.5 mg TMP/kg/day IV
divided Q12 - 24h


10 - 15 mg TMP/kg/day IV
divided Q12 - 24h
2.5 - 5.0 mg TMP/kg IV Q24h


5 - 10 mg TMP/kg IV Q24h


Voriconazole

ID approval: UCSF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/ucsf_restrict.htm#Voriconazole) SFGH (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/sfgh_restrict.htm) VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)


Check for drug interactions.

Dose on adjusted body weight. In obese patients consider using a weight-based PO regimen (4mg/kg Q12h) using ABW, consult ID/ID-pharmacy for assistance.

PO should be used when possible, as oral bioavailability >95%.

May require dose adjustment in hepatic dysfunction. Consult ID pharmacy.
Oral
LD=400 mg po Q12h x 1 day,
then 200 mg po Q12h
No Change
No Change


IV dosing
LD=6 mg/kg/dose IV Q12h x 2 doses, then 4mg/kg/dose IV Q12h
The use of IV should be avoided if possible in patients with CrCl<50 mL/min due to the accumulation of the intravenous vehicle and is contraindicated in ESRD.


Vancomycin

ID approval: VASF (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vasf_restrict.htm)
Uncomplicated infections
Serious infections
Round dose to 250mg, 500mg, 750mg, 1g, 1.25g, 1.5g, 1.75g, or 2g (maximum 2g/dose).
For expanded information on dosing and monitoring, see Vancomycin Monitoring (http://clinicalpharmacy.ucsf.edu/idmp/adult_guide/vanco_dosing.htm)section.
>60 mL/min

Uncomplicated Infections
10 - 15 mg/kg IV Q12h

Serious Infections
Considerloading doseof 25mg/kg IV x1 followed by 15 - 20 mg/kgIV Q8-12h
40-60mL/min



10 - 15mg/kgIV Q12-24h
20-40 mL/min



5 - 10mg/kg
IV Q24h
10-20mL/min



5 - 10 mg/kg
IV Q24-48h
<10 mL/min


10 - 15 mg/kg IV



loading dose x1, redose according to serum levels


Trough levels should be obtained within 30 minutes before 4th dose or a new regimen or dosage change. Vancomycin troughs are not recommended in patients in whom anticipated duration of therapy is less than 3 days. For patients with uncomplicated infections, trough levels of 10-15 mcg/ml are recommended. For patients with serious infections due to MRSA (central nervous system infections, endocarditis, ventilator-associated pneumonia, bacteremia, or osteomyelitis), trough levels of 15-20 mcg/ml are recommended. ID CONSULT IS RECOMMENDED



This information comes from the website of UCSF School of Pharmacy. For more information you can find them here IDMP Homepage (http://clinicalpharmacy.ucsf.edu/idmp/)

CheneyHsiung
Mon 1st December '14, 3:54pm
Note that Infectious Diseases Management Program at UCSF has upraded. Source: What's New | Infectious Diseases Management Program at UCSF (http://idmp.ucsf.edu)

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CheneyHsiung
Mon 1st December '14, 4:20pm
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admin
Sun 17th January '16, 11:23am
Well, this dosage guideline is very useful and helpful for clinicians. Please feel free to use it whenever you need.

TomHsiung
Sun 17th January '16, 5:09pm
Fantastic thread. All common antibiotics are listed here.