Results 1 to 5 of 5

Thread: UCSF Program - Guidelines for Antimicrobial Use in Adults

  1. #1
    PharmD Year 1 TomHsiung's Avatar
    Join Date
    Jan 2013
    Location
    Chengdu, Sichuan, China
    Posts
    594

    Exclamation UCSF Program - Guidelines for Antimicrobial Use in Adults

    This dose recommendation has been out of date.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
    Acyclovir


    Dose on ideal body weight

    ID approval: VASF(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 SFGH VASF

    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 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 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
    1.5-3 g IV Q6h 1.5 g IV Q6-8h 1.5 g IV Q12h
    Aztreonam
    ID approval: SFGH VASF
    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 SFGH VASF

    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
    > 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
    2 g IV Q8h 2 g IV Q12 - 24h 0.5 g IV Q24h
    Ceftriaxone
    ID approval: VASF
    1 g IV Q24h No Change No Change
    Meningitis:
    ID approval: SFGH
    2 g IV Q12h
    Endocarditis & Osteomyelitis:
    ID approval: SFGH
    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(IV) VASF
    .
    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
    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 SFGH VASF
    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
    1g IV Q24h <30 ml/min
    500mg IV Q24h
    Fluconazole
    ID approval: SFGH(IV) VASF

    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
    > 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 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 in patients with normal renal function (CrCl � 60 mL/min). SeeAminoglycoside Dosing & Monitoring 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 dosingof 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. 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 VASF
    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(IV)
    VASF (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 SFGH VASF
    600mg IV/po Q12h No Change No Change
    Meropenem
    ID approval: SFGH VASF
    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 SFGH VASF
    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 SFGH VASF
    Dose varies by indication.
    Rifampin
    ID approval: SFGH(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 SFGH VASF
    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
    See Gentamicin and Aminoglycoside Dosing 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 SFGH VASF


    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
    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 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
    Last edited by admin; Fri 8th January '16 at 9:47pm.

  2. #2

    Default

    Note that Infectious Diseases Management Program at UCSF has upraded. Source: What's New | Infectious Diseases Management Program at UCSF







    Last edited by CheneyHsiung; Mon 1st December '14 at 4:07pm.
    Clinical Pharmacy Specialist - Hematology

  3. #3

    Default




    Clinical Pharmacy Specialist - Hematology

  4. #4
    Administrator admin's Avatar
    Join Date
    Jan 2013
    Location
    Chengdu, Sichuan, China
    Posts
    304

    Default

    Well, this dosage guideline is very useful and helpful for clinicians. Please feel free to use it whenever you need.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease. Chengdu, Sichuan, China.

    Blog: http://www.tomhsiung.com
    Facebook: http://www.facebook.com/TomHsiung
    Twitter: @TomHsiung
    Sina Microblog (Weibo): http://weibo.com/xiongliang0



  5. #5
    PharmD Year 1 TomHsiung's Avatar
    Join Date
    Jan 2013
    Location
    Chengdu, Sichuan, China
    Posts
    594

    Default

    Fantastic thread. All common antibiotics are listed here.
    B.S. Pharm, West China School of Pharmacy, Class of 2007, Health System Pharmacist, RPh. Hematology, Infectious Disease.

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •