UCSF Children’s Hospital

Pediatric Antimicrobial Dosing Guideline for Infants And Children > 1 Month Of Age

Approved by the Antibiotic Advisory Subcommittee and the Pharmacy and Therapeutics Committee (11/98) Rev 6/2013

For assistance in antimicrobial dosing and selection, contact Infectious Diseases Pharmacy (443-9421). For diagnosis and management recommendations or formal consultation, contact Pediatric ID fellow (443-2384).

 

Shaded boxes indicate ID-Restricted agents (ID-R). Call ID Pharmacy (443-9421) for prior approval 8am-10pm. Orders will NOT be processed without approval (exceptions for certain agents noted in APEX). 10pm to 8am a single dose will be released; further doses require approval.

pdf version

 

DRUG

Creatinine Clearance

>50ml/min/1.73m2

 

OR

Renal Function > 50% of Normal

Creatinine Clearance

=10-50ml/min/1.73m2

OR

 

Renal Function =  

10-50% of Normal

Creatinine Clearance

<10ml/min/1.73m2

(ESRD not on dialysis)

OR

Renal Function <10% of Normal

 

MAXIMUM

DAILY DOSE

Acyclovir IV

Non-CNS HSV infection:

5-10mg/kg/dose q8h

               

 

 

25-50% of normal clearance

5-10mg/kg/dose q12h

 

10-25% of normal clearance

5-10mg/kg/dose q24h

2.5-5mg/kg/dose q24h

 

 

 

 

 

Herpes Zoster

10-20 mg/kg/dose q8h or

or 500 mg/m2/dose q8h (immunocompromised host)

 

25-50% of normal clearance

10-20mg/kg/dose q12h 

or 500 mg/m2/dose q12h

(immunocompromised host)

 

10-25% of normal clearance

10-20mg/kg/dose q24h

or 500 mg/m2/dose q24h

(immunocompromised host)

5-10mg/kg/dose q24h

or 250 mg/m2/dose q24h

(immunocompromised host)

 

 

HSV encephalitis,

all neonatal infections:

20mg/kg/dose q8h 

or 500 mg/m2/dose q8h 

(immunocompromised host)

25-50% of normal clearance

20mg/kg/dose q12h 

or 500 mg/m2/dose q12h

(immunocompromised host)

 

10-25% of normal clearance

20mg/kg/dose q24h 

or 500 mg/m2/dose q24h

(immunocompromised host)

10mg/kg/dose q24h

or 250 mg/m2/dose q24h

(immunocompromised host)

Amphotericin B

Liposomal

(AmBisome®;

per ID approval except for Heme-Onc)

Invasive yeast infections

3mg/kg/dose IV q24h

Invasive mold infections

5mg/kg/dose 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.

Amoxicillin PO

20mg/kg/dose q12h

 

Otitis Media/Pneumonia/ Osteomyelitis 

45-50mg/kg/dose q12h

30-50% of normal clearance No change

10-30% of normal clearance 50% normal dose q12h

 

50% normal dose q24h

 

4g/DAY

 

Ampicillin IV

50mg/kg/dose q6h

25mg/kg/dose q6h

25mg/kg/dose q8-12h

2gm q4h

Meningitis:

100mg/kg/dose q6h

 

50mg/kg/dose q6h

 

25mg/kg/dose q8-12h

Ampicillin/ sulbactam (Unasyn) 50 mg ampicillin/kg/dose q6h 25 mg ampicillin/kg/dose q6h  25 mg ampicillin/kg/dose q8-12h 2 gm ampicillin q6h

Caspofungin IV

(per ID approval except Pedatric Heme-Onc/BMT)

<3 mo old: 25mg/ m2/dose q24h

≥3 mo old:

LD 70mg/m2 x1, then 50mg/m2 q24h

No change

No change

LD: 70mg

MD: 50mg

Cefazolin

25mg/kg/dose q8

25mg/kg/dose q12h

25mg/kg/dose q24h

2gm q8h

Cephalexin PO

10 mg/kg/dose PO q6-8h

 

Otitis Media

20-25 mg/kg/dose PO q6h

Osteomyelitis

25-30 mg/kg/dose PO q6h

10 mg/kg/dose PO q8h-q12h 10mg/kg/dose PO q12h-q24h 4 gm/day

Cefepime

50mg/kg/dose q12h

>30% of normal clearance

50mg/kg/dose q24h

 

10-30% of normal clearance

25mg/kg/dose q24h

12.5mg/kg/dose q24h

2gm q12h

 

 

Febrile neutropenia:

50mg/kg/dose q8h

 

>30% of normal clearance

50mg/kg/dose q12h

 

10-30% of normal clearance

50mg/kg/dose q24h

25mg/kg/dose q24h

2gm q8h

Cystic Fibrosis:

50mg/kg/dose q8h

 

Not documented

 

Not documented

 

50mg/kg/dose q8h

Cefotaxime

50mg/kg/dose q8h

50mg/kg/dose q8-12h

25mg/kg/dose q12h

2gm q6h

 

Meningitis: 50mg/kg/dose q6h

 

50mg/kg/dose q8h

 

50mg/kg/dose q12h

Ceftazidime

50mg/kg/dose q8h

50mg/kg/dose q12h

50mg/kg/dose q24-48h

2gm q8h

Cystic fibrosis:

75mg/kg/dose q8h

 

Not documented

 

Not documented

 

2gm q8h

Burkholderia cepacia co-infected with Pseudomonas aeruginosa: 75mg/kg/dose q8h 3gm q8h

Ceftriaxone

50mg/kg/dose q24h

No change

No change

1gm q24h

Meningitis:  50mg/kg/dose q12h

 

No change

 

No change

 

2gm q12h

Cefuroxime IV

50mg/kg/dose q8h

50mg/kg/dose q12h

50mg/kg/dose q24h

1.5gm q8h

Ciprofloxacin IV

>30% of normal clearance

10-15mg/kg/dose q12h

10-30% of normal clearance

7.5mg/kg/dose q12h

7.5mg/kg/dose q12h

 

400mg q12h

Cystic fibrosis: 

15mg/kg/dose q12h

 

Not documented

 

Not documented

 

600mg q12h

Clindamycin IV

10mg/kg/dose q8h

No change

No change

900mg q8h

Clindamycin PO

2-8mg/kg/dose q6-8h

 

Osteomyelitis

10-12 mg/kg/dose PO q6-q8h

 

No change

450mg q6h

Ertapenem IV

15mg/kg/dose q12h

>13 years old: 1 gm daily

<30ml/min/1.73m2

Decrease dose 50%

1 gm q24h

Erythromycin IV

5-10mg/kg/dose q6h

No change

No change

1gm q6h

Ethambutol PO

15mg/kg/dose q24h

7.5mg/kg/dose q24h

5mg/kg/dose q24h

2.5gm q24h

Fluconazole IV/PO

(All patients who are able to tolerate PO should receive PO fluconazole.)

6-12mg/kg/dose q24h

3-6mg/kg/dose q24h

3-6mg/kg/dose q24h

400mg q24h

Fungal prophylaxis:

3mg/kg/dose q24h

 

No change No change  

Ganciclovir IV

>80% of normal clearance

5mg/kg/dose q12h 

 

79-50% of normal clearance

2.5mg/kg/dose q12h

25-50% of normal clearance

2.5mg/kg/dose q24h

 

10-25% of normal clearance 1.25mg/kg/dose q24h

1.25mg/kg/dose q24h

 

Gentamicin

2.5mg/kg/dose q8h

 

**consult with pharmacist for dose adjustment/level assessment**

2.5mg/kg/dose q12h

2.5mg/kg/dose q24h

 

Imipenem

(per ID approval)

20mg/kg/dose q6h

10mg/kg/dose q6-8h

10mg/kg/dose q12h

 

1gm q6h

Isoniazid

Treatment:

5mg/kg/dose daily-bid

No change

No change

300mg daily

Prophylaxis:

10mg/kg/dose daily

No change No change

Levofloxacin IV-PO

 

< 5 yo: 10mg/kg/dose q12h

 

≥ 5 yo: 10mg/kg/dose q24h

30-50% of normal clearance

No change

 

10-30% of normal clearance

5-10mg/kg/dose q24h

5-10mg/kg/dose q48h

 

750mg q24h

 

Linezolid IV/PO (per ID approval)

<5 yo: 10mg/kg/dose q8h

>5 yo: 10mg/kg/dose q12h

No change

No change

600mg q12h

Meropenem IV

 

20mg/kg/dose q8h

25-50% of normal clearance

20mg/kg/dose q12h

 

10-25% of normal clearance

10mg/kg/dose q12h

10mg/kg/dose q24h

1gm q8h

 

 

Meningitis:

40mg/kg/dose q8h

25-50% of normal clearance 40mg/kg/dose q12h

 

10-25% of normal clearance

20mg/kg/dose q12h

20mg/kg/dose q24h

2gm q8h

 

Metronidazole IV/PO

10mg/kg/dose q8h

No change

10mg/kg/dose q12h

500mg q6h

Nafcillin IV

25-50mg/kg/dose q6h

No change

No change

2gm q4h

Penicillin G IV

100,000 - 250,000 units/kg/DAY divided doses q4-6h

75,000 - 175,000 units/kg/DAY divided doses q8h

 

50,000-125,000 units/kg/DAY divided doses q12h

4 million units q4h

Severe Infection:

250,000-400,000

units/kg/DAY divided dose q4-6h

 

175,000 - 300,000

units/kg/DAY divided doses q8h

 

125,000-200,000

units/kg/DAY divided doses q12h

Piperacillin/

Tazobactam IV (Zosyn)

80mg piperacillin/ kg/dose q6-8h*

 

*Serious infections including Pseudomonas: consider q6h

30-50% of normal clearance

50mg piperacillin kg/dose q6-8h

 

10-30% of normal clearance

50mg piperacillin /kg/dose q8h

 

 

50mg piperacillin/ kg/dose q8h

 

4 gm piperacillin q6h

Cystic fibrosis:

100mg piperacillin/ kg/dose q6h

Not documented Not documented

4gm piperacillin q6h

Pyrazinamide PO

15-30mg/kg/dose daily

No change

No change

 

Rifampin IV/PO

5-10mg/kg/dose daily-bid

No change

No change

600mg daily

Tobramycin IV

see gentamicin

 

Cystic fibrosis:

Once daily dosing 10mg/kg/dose q24h

see gentamicin

 

Not documented

see gentamicin

 

Not documented

 

TMP/SMX (Septra) IV/PO

When switching to oral therapy, consider that a single-strength tablet has 80mg of TMP, a double-strength tablet 160mg of TMP, oral suspension has 40 mg TMP per 5 ml

Mild to moderate systemic bacterial infection:

5mg TMP/kg/dose q12h

2.5mg TMP/kg/dose q12h

 

2.5-5mg TMP/kg/dose q24h

 

 

 

Serious systemic bacterial infection:

5mg TMP/kg/dose q6-8h

5mg TMP/kg/dose q8-12h 5mg TMP/kg/dose q12-24h  

Pneumocystis carinii pneumonia prophylaxis:

2.5mg TMP/kg/dose q12h

three days per week.

2.5mg TMP/kg/dose q12h

three days per week. 

2.5mg TMP/kg/dose q24h

three days per week. 

160mg TMP bid

 

Vancomycin

Peak levels are not recommended.  Trough levels (< 30 min before next dose) should be 5-20 mg/L depending on the severity of infection. Specifically, 15-20 for meningitis, sepsis and pneumonia

15mg/kg/dose q6h

 

15 mg/kg/dose q8-12h

15 mg/kg/dose q12-24h

 1 gm IV q8h

CNS/Osteo/Serious infections:

20mg/kg/dose q6h

20mg/kg/dose q8h 20mg/kg/dose q12h 1 gm IV q6h

 

Voriconazole

IV/PO   

(per ID approval                  

except for Heme-Onc/BMT)

 

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

 

Presumed/Empiric Treatment

LD=6mg/kg q12h x2 doses

MD=4mg/kg q12h

 

Documented Infections

LD=7mg/kg q12h x 2 doses

MD=5-7mg/kg q12h

 

Higher doses may be required based on therapeutic drug monitoring (consultation with Pedi-ID recommended)

No change No change  

 

Estimate of Creatinine Clearance using Schwartz’s equation:

CLcr = K x L/Scr (Creatinine clearance in ml/minute/1.73m2)

 

K = Constant of proportionality that is age specific

                    Age                                            K_ 

                    Preterm infants up to 1year       0.33

                    Full-term infants up to 1 year     0.45

                    2-12 years                               0.55

                    13-21 years female                  0.55

                    13-21 years male                     0.7

                    1-16 years with CKD                0.413

L = Length or height in cm

Scr = Serum creatinine concentration in mg/dL

 

Normal Serum Creatinine Concentrations at Different Ages

Age

Average Serum Creatinine (mg/dL)

Range (mg/dL)

Premature (<34 weeks GA)

<2 weeks old

>2 weeks old

 

0.9

0.8

 

0.7-1.4

0.7-0.9

Term neonates (>34 weeks GA)

<2 weeks old

>2 weeks old

 

0.5

0.4

 

0.4-0.6

0.3-0.5

2 weeks–5 years

0.4

0.2-0.5

5–10 years

0.6

0.3-1.0

>10 years

0.9

0.6-1.4

Reference – available upon request

For information regarding the dosing of antimicrobial agents in the setting of dialysis or hepatic failure, contact Infectious Diseases Pharmacy for further assistance.  ID Pharmacy 443-9421 Pediatric ID fellow 443-2384