UCSF Children’s Hospital
Pediatric Antimicrobial Dosing Guideline for Infants And Children > 1 Month Of Age
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.
|
DRUG |
Creatinine Clearance >50ml/min/1.73m2 ORRenal 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) ORRenal 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. |
||
|
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) |
LD 70mg/m2 x1, then 50mg/m2 q24h |
No change |
No change |
70mg |
|
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 | ||
|
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 |
70,000 - 160,000 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 |
160,000 - 260,000 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 |
80mg piperacillin/ kg/dose q8h
|
80mg piperacillin/ kg/dose q12h
|
4.5gm q6h |
|
Cystic fibrosis: 100mg piperacillin/ kg/dose q6h |
Not documented | Not documented |
4.5gm 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
|
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