NORTH SHORE – LONG ISLAND JEWISH HEALTH SYSTEM

SCHNEIDER CHILDREN’S HOSPITAL PHARMACY AND THERAPEUTICS

Guideline Title: ANTIMICROBIAL DOSING - PEDIATRICS: COMBINED APPROVED,
RESTRICTED, (Includes CYSTIC FIBROSIS)
Prepared by: Mark Kurot RN, NNP
Director Nursing Standards and Budgets
Effective Date: 6 / 28 / 09 Total Pages: 12

General Statement of Purpose:

1. To standardize antimicrobial dosing for pediatric patients admitted to Schneider Children’s Hospital.
2. To establish a process for the use of restricted antimicrobials for pediatric patients admitted to Schneider
Children’s Hospital.

Guideline Statement:
These guidelines have been established to assist the physician in selecting a dosing regimen for
antimicrobials to be administered to pediatric patients. Doses may have been modified from the references
listed based on past hospital practice and / or attaining therapeutic levels. Doses of antimicrobials given in
the Harriet Lane Handbook or other sources may differ significantly from these guidelines or a range may
be specified rather than a specific dose –use these guidelines or discuss dosing with the Infectious Diseases
service.

At Schneider Children’s Hospital, restricted antimicrobials require approval by the Pediatric Infectious
Diseases service before they can be prescribed. Certain restricted antimicrobials are pre-approved for
certain indications as described below. To avoid the need to call the Pediatric Infectious Diseases service
for approval, the pre-approved indication / diagnosis must be specified on the order sheet - e.g.,
cefotaxime 1,000 mg IV q 8 hours (225 mg / kg / day; diagnosis: meningitis). Pharmacy will not dispense
a restricted antimicrobial if the diagnosis is not designated on the order sheet.

Scope:
This policy applies to all members of the Schneider Children’s Hospital interdisciplinary health care team
which includes but is not limited to: Physicians, Nurse Practitioners, Physician Assistants, Nurses, and
Pharmacists performing work for or at Schneider Children’s Hospital.

Notes:
*For use of antimicrobials indicated with an asterisk (*) in patients younger than 30 days AND less
than or equal to 44 6/7 weeks corrected gestational age, refer to SCH Antibiotic Dosing: Neonatal for
antibiotic dosing guidelines.

Assumes normal renal function

Cystic fibrosis: If different (higher) doses of a particular antimicrobial are indicated for cystic fibrosis
patients, the recommended dose is described. Restricted antimicrobials prescribed by Pulmonary
Medicine for cystic fibrosis patients do not need ID approval.

This document is intended as a general guideline. 1

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
Acyclovir:
Intravenous:
Infants less than 6 weeks of age with suspected neonatal Herpes simplex infection:
60 mg / kg / day divided q 8 hours (20 mg / kg / dose).
Older infants and children (dosage for obese patients should be based on ideal body weight)
• for Herpes simplex encephalitis: 30 mg / kg / day divided q 8 hours (10 mg / kg / dose)
• for non-CNS Herpes simplex infection: 15 mg / kg / day divided q 8 hours (5 mg / kg / dose)
• for varicella-zoster infection: 1500 mg / M2 / day divided q 8 hours (500 mg / M2 / dose)
• ensure adequate hydration for patients on IV acyclovir to minimize risk of renal
dysfunction due to drug crystallization in the kidneys.
Oral:
For varicella or zoster: 80 mg / kg / day divided q 6 hours (maximum 800 mg / dose)
For Herpes simplex: 60 mg / kg / day divided q 6 hours (maximum 400 mg / dose)
Oral acyclovir should not be used for HSV encephalitis.

Amikacin IV (or IM): RESTRICTED ANTIMICROBIAL

Age less than or equal to 7 days: 10 mg / kg loading dose, then 15 mg / kg / day divided
q 12 hours
Age 8 to 28 days: 10 mg / kg loading dose, then 22.5 mg / kg / day divided q 8 hours
Infants and children younger than 5 years: 22.5 mg / kg / day divided q 8 hours
Children 5 years and older, adolescents, and adults: 15 mg / kg / day once daily (maximum
initial daily dose: 1.5 gm / day)
Oncology patients of all ages with fever and neutropenia: 22.5 mg / kg / day divided q 8 hours
Cystic fibrosis patient (does not need ID approval) Higher than standard dose: 30 mg / kg /
day (10 mg / kg / dose) divided q 8 hours. Maximum dose of 1.5 gm / day may be exceeded based
on results of therapeutic monitoring.
Note: For extremely obese children, use adjusted body weight in dose calculation.
Adjusted body weight = ideal body weight + 0.4 (actual body weight – ideal body weight).
For ideal body weight, use 50 percentile for age and sex.
Note: Therapeutic monitoring for amikacin (and other aminoglycosides) should be performed on
all patients receiving therapy for greater than 48 hours. At minimum, a trough
concentration should be obtained to ensure the concentration is not excessive. Peak is
obtained 30 minutes after completion of a 30 minute infusion.
Monitoring: Peak 20 to 30 micrograms / mL; trough 5 to 10 micrograms / mL.
For patients receiving once daily amikacin, check trough concentration
only and value should be less than 2.5 micrograms / mL.

* Amoxicillin Oral:
Infants and children:
45 mg / kg / day PO divided bid
90 mg / kg / day PO divided bid: for patients with severe infections or suspicion of infection with
penicillin-resistant pneumococci (e.g., recent antimicrobial therapy, day care center attendance).
50 mg / kg once daily (maximum 1 gm) for streptococcal pharyngitis
Adults: 500 to 875 mg every 12 hours; maximum: 2 gm q 12 hours (4 gm per day)
1 gm once daily for streptococcal pharyngitis

This document is intended as a general guideline. 2

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
* Amphotericin B Deoxycholate (conventional amphotericin B) IV
Initial daily dose (all ages): 0.5 mg / kg / dose over 1 to 3 hours on day 1. May increase to
maximum dose of 1 mg / kg / dose on subsequent days
Notes:
1. Pretreat (other than neonate) with acetaminophen and diphenhydramine (Benadryl) to decrease
infusion related adverse events.
2. Consider pretreatment with 10 ml/kg normal saline bolus to decrease nephrotoxicity.
3. Causes renal wasting of Na+, K+, and Ca++. Monitor Na+, K+, and Ca++ concentrations.
Consider increasing daily doses of Na+, K+, and Ca++ in anticipation of increased renal losses.

Amphotericin B, Liposomal (Ambisome®) IV: RESTRICTED ANTIMICROBIAL

Neonate: 5 mg / kg over 1 hour once daily
Other than neonate:
Empiric therapy for febrile neutropenia or candidiasis: 3 mg / kg over 1 hour once daily
Suspected aspergillosis infection: 5 mg / kg over 1 hour once daily

Note: Pretreatment with acetaminophen and diphenhydramine is generally unnecessary.

*Ampicillin IV:
Infants and Children (Age greater than 7 days):
150 mg / kg / day divided q 6 hours (meningitis not present).
300 mg / kg / day divided q 6 hours (meningitis)
Adults: 2 gm q 6 hours; maximum: 2 gm q 4 hours (12 gm per day)

Ampicillin / sulbactam (Unasyn®) - IV: RESTRICTED ANTIMICROBIAL

dosing based on ampicillin content
Infants and Children (Age greater than 7 days): 200 mg ampicillin component / kg / day divided
q 6 hours
Adults: 2 gm ampicillin component q 6 hours; maximum: 2 gm ampicillin component q 4 hours (12
gm per day)

Azithromycin RESTRICTED ANTIMICROBIAL

For pneumonia:
PO: 10 mg / kg q day (Maximum dose 500mg) x 5 – 10 days
IV: 10 mg / kg q day (Maximum dose 500 mg) x 5 – 10 days
Adults: 500 mg IV or PO once daily
Pre-approved indications for azithromycin: pneumonia

Aztreonam RESTRICTED ANTIMICROBIAL:

Age less than or equal to 7 days: 90 mg / kg / day divided q 8 hours
Age 7 – 30 days: 120 mg / kg / day divided q 8 hours
Infants and children: 120 mg / kg / day divided q 8 hours
Adults: 2 gm q 8 hours; maximum 8 gm / day (2 gm q 6 hours)
Cystic fibrosis patient (does not need ID approval) - Higher than standard dose: 150 mg / kg /
day IV divided in four doses daily (every 6 hours); maximum dose: 12 gm/day

This document is intended as a general guideline. 3

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
Caspofungin IV: RESTRICTED ANTIMICROBIAL
Age 3 months and older:
Loading dose: 70 mg / M2 / dose (maximum dose: 70mg / day)
Maintenance dose: 50mg / M2 / dose (maximum dose: 50mg / day)

*Cefazolin (Ancef®, Kefzol®) – IV

Infants and children: 100 mg / kg / day divided q 8 hours
Adults: 2 gm q 8 hours; maximum 12 gm / day

Cefepime (Maxipime®) IV: RESTRICTED ANTIMICROBIAL

Fever and neutropenia oncology patient: 150 mg / kg / day divided q 8 hours;
maximum dose: 2 gm q 8 hours
Other than fever / neutropenia: 100 mg / kg / day divided q 12 hours
Adults: 2 gm q 8 hours (fever / neutropenia); 2 gm q 12 hours (other uses)
Pre-approved indications for cefepime:
1. Fever and neutropenia in an oncology patient
2. Empiric therapy of nosocomial pneumonia (including ventilator-associated pneumonia)

*Cefotaxime IV: RESTRICTED ANTIMICROBIAL

Infants and children (Age greater than 30 days):
225 mg / kg / day divided q 8 hours – proven or suspected meningitis
150 mg / kg / day divided q 8 hours – sepsis
Adults: 2 gm q 8 hours; maximum 12 gm / day
Note: The meningitis dose should be prescribed for an infant less than 2 months of age with
suspected sepsis pending culture results.

Pre-approved indications for ceftriaxone / cefotaxime:

1. Fever / suspected sepsis in the following situations:
A. Neonate (outside of NICU)
B. Asplenia
C. HIV infection
D. Sickle cell disease
2. Pneumonia: After completion of IV antimicrobial, the usual oral antimicrobial is amoxicillin,
the most active of oral beta-lactam antimicrobials against pneumococcus.
3. Meningitis (with or without vancomycin)
4. Epiglottitis
5. Gonococcal infection
6. Lyme disease
7. Periorbital or orbital cellulitis (alone or in combination with nafcillin or clindamycin)
8. Pyelonephritis (alone or in combination with ampicillin for enterococci)

(*Ceftazidime IV: [150 mg / kg / day divided q 8 hours] should no longer be routinely prescribed due to
possible induction of antimicrobial resistance to gram-negative bacilli via extended spectrum
beta-lactamases to a greater extent than other antimicrobials such as cefepime, ticarcillin / clavulanate
[Timentin®], piperacillin / tazobactam [Zosyn®], meropenem, and imipenem / cilastatin [Primaxin®].)

This document is intended as a general guideline. 4

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
Ceftriaxone IV / IM: RESTRICTED ANTIMICROBIAL

CAUTION: As of 4 / 14 / 09 the FDA has indicated that ceftriaxone and calcium-containing

products may be used concomitantly in patients greater than 28 days of age. Previously, the FDA
recommended against using ceftriaxone in patients receiving intravenous or oral calcium
supplementation. However, all cases with an adverse event associated with ceftriaxone and calcium
supplementation have occurred in patients younger than 1 month of age.

In rare cases, ceftriaxone has been associated with massive intravascular hemolysis, often with a fatal
outcome. Essentially all of these cases have occurred in patients receiving more than course of ceftriaxone
and many of the cases have occurred in pediatric patients with a sickle cell disease. Patients receiving
ceftriaxone who develop signs of acute hemolysis (dark urine, tachycardia, anemia) should be appropriately
evaluated (CBC and examination of blood smear for evidence of hemolysis). In there is evidence of hemolysis, the
ceftriaxone should be discontinued, and consideration should be given to the administration of corticosteroids, and if
necessary, the transfusion of blood.

Age less than 30 days: Not generally recommended

Age 7 to 30 days: Use of ceftriaxone can be considered if the patient does not have indirect
hyperbilirubinemia and is not receiving intravenous or oral calcium
supplementation. Please contact the Infectious Disease service to discuss the
usage and dosage recommendations
Infants and children (Age greater than or equal to 30 days):
Meningitis: 100 mg / kg / day q 24 hours (maximum 2 gm per dose. If dose exceeds
2 grams, then divide dose q 12 hours), maximum dose: 4 gm / day
Other than meningitis: 75 mg / kg / day q 24 hours, maximum 2 gm
Otitis media: 50 mg / kg / day q 24 hours x 1 to 3 days
Adults:
Meningitis: 2 gm q 12 hours, maximum dose: 2 gm q 12 hours
Other than meningitis: 1 to 2 gm q 24 hours, maximum: 2 gm q 24 hours
Lyme meningitis: 2 gm q 24 hours
Note: Generally, the meningitis dose should be prescribed for an infant less than 2 months of age
with suspected sepsis pending culture results.

Pre-approved indications for ceftriaxone / cefotaxime:

1. Fever / suspected sepsis in the following situations:
A. Neonate (outside of NICU)
B. Asplenia
C. HIV infection
D. Sickle cell disease
2. Pneumonia. After completion of IV antimicrobial, the usual oral antimicrobial is amoxicillin,
the most active of oral beta-lactam antimicrobials against pneumococcus.
3. Meningitis (with or without vancomycin)
4. Epiglottitis
5. Gonococcal infection
6. Lyme disease
7. Periorbital or orbital cellulitis (alone or in combination with nafcillin or clindamycin)
8. Pyelonephritis (alone or in combination with ampicillin for enterococci)
This document is intended as a general guideline. 5
The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
Ciprofloxacin (Cipro®): RESTRICTED ANTIMICROBIAL

Not FDA-approved for age less than 18 years old except for: children with complicated E. coli
urinary tract infections due to antimicrobial – resistant bacteria; published data supports usage in
special clinical situations.
Infants and children less than 18 years of age:
PO: 30 mg / kg / day divided q 12 hours (PO maximum 1.5 gm / day)
IV: 30 mg / kg / day divided q 8 hours, (IV maximum 1.2 gm / day).
Adults:
PO: 500 mg q 12 hours, maximum 1.5 gm / day
IV: 400 mg q 12 hours, maximum 800 mg / day; for severe or complicated infections: 400
mg q 8 hours Maximum 1.2 gm / day

Note: Maximum dose for children is higher than adult maximum due to more rapid clearance in
children.

*Clindamycin:
IV:
Infants and children (older than 30 days): 40 mg / kg / day divided q 8 hours
(maximum 900 mg q 8 hours)
Adults: 900 mg IV q 8 hours (maximum 4.8 gm / day)
PO:
Infants and children: 25 mg / kg / day divided q 8 hours
Adults: 300-600 mg PO q 8 hours (maximum 1.8 gm / day)

Ertapenem (Invanz®): – RESTRICTED ANTIMICROBIAL

Age less than 3 months: not recommended
Age 3 months to 12 years: 30 mg / kg / day divided q 12 hours (maximum 1 gm per day)
Adults: 1 gm IV q 24 hours (maximum 1 gm / day)

*Fluconazole:
Age greater than 30 days, infants, children:
Systemic candidiasis in children: 12 mg/kg/day once daily (maximum dose, 800 mg / day)
Urinary Tract Infection, Oropharyngeal Candidiasis, Esophageal Candidiasis: 6 mg / kg /
day (maximum dose, 400 mg)
Adults: 200 mg once, then 100 mg once daily; invasive infection: 400 to 800 mg once daily

This document is intended as a general guideline. 6

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
*Gentamicin IV / IM: (for patients with normal renal function)
Infants and children: 31 days through 4 years of age and all oncology patients with fever and
neutropenia: 7.5 mg / kg / day divided q 8 hours
Children 5 years and older, adolescents, and adults: 6 mg / kg / day once daily
(maximum initial daily dose: 450 mg / day)

Cystic fibrosis patient: Higher than standard dose:

Age less than 5 years: 10 mg / kg/ day in 3 doses every 8 hours
Age greater than or equal to 5 years: 7.5 mg / kg / day once daily;
maximum initial dose, 450 mg daily

Note: For extremely obese children, use adjusted body weight in dose calculation. Adjusted body
weight = ideal body weight + 0.4 (actual body weight – ideal body weight). For ideal body
weight, use 50th percentile for age and sex.
Note: Therapeutic monitoring for gentamicin (and other aminoglycosides) should be performed on
all patients receiving therapy for greater than 48 hours. At minimum, a trough
concentration should be obtained to ensure the concentration is not excessive.
Peak is obtained 30 minutes after completion of a 30 minute infusion. If the infection is not
clinically resolving, a peak concentration should be obtained.
Monitoring: peak 5 to 10 micrograms / mL; trough 0.5 to 2 micrograms / mL.
For patients receiving once daily gentamicin, check trough concentration only
and value should be less than 0.5 micrograms / mL.

*Imipenem / cilastatin (Primaxin®) IV: RESTRICTED ANTIMICROBIAL

Age 1 month to 3 years: 100 mg / kg / day divided q 6 hours
Age greater than 3 years: 60 mg / kg / day divided q 6 hours
Adult: 500 mg q 6 hours (maximum 4 gm / day)

Levofloxacin (Levaquin®): RESTRICTED ANTIMICROBIAL; NON-FORMULARY

IV and PO are bioequivalent:
Not approved for age less than 18 years; published data supports usage in special clinical situations.
Infants and children greater than 6 months to 4 years of age: 20 mg / kg / day divided q 12
hours IV or PO (maximum dosing: 500 mg / day).
Children 5 years of age and older: 10 mg / kg once daily (maximum dose 500 mg)
Adult: 500 mg q 24 hours (pneumonia, sinusitis); (Pseudomonas aeruginosa pneumonia: 750 mg /
day)

Linezolid (Zyvox®) – RESTRICTED ANTIMICROBIAL

IV and PO are bioequivalent; PO route preferred
Age less than 12 years: 30 mg / kg / day divided q 8 hours
Age greater than or equal to 12 years: 20 mg / kg / day divided q 12 hours,
maximum dose 600 mg per dose
Adult: 600 mg q 12 hours

This document is intended as a general guideline. 7

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
Meropenem (Merrem®) IV: RESTRICTED ANTIMICROBIAL
Age less than or equal to 60 days: generally use meningitis dose,
120 mg / kg / day divided q 8 hours
[Meningitis excluded: Age less than or equal to 7 days: 40 mg / kg / day divided q 12 hours]
[Meningitis excluded: Age 7 - 30 days: 60 mg / kg / day divided q 8 hours]
Infants and children greater than or equal to 3 months:
60 mg / kg / day divided q 8 hours (no meningitis)
120 mg / kg / day divided q 8 hours (meningitis)
Adult: 1 gm q 8 hours (maximum dose: 6 gm per day)

Metronidazole IV (Flagyl®):
Age less than 7 days: 15 mg / kg day divided q 12 hours
Age 7 to 30 days: 30 mg / kg / day divided q 12 hours
Infants and children: 15 mg / kg loading dose, then 30 mg / kg / day divided q 6 hours
Adult: 500 mg q 8 hours
Metronidazole oral (Flagyl®) for C. difficile colitis:
Infant and children: 30 mg / kg / day PO divided q 8 hours
Adult: 125 to 500 mg PO tid, maximum dosing: 4 gm / day

Moxifloxacin (Avelox®): RESTRICTED ANTIMICROBIAL

IV and PO are bioequivalent; PO route preferred
Not FDA approved for age less than 18 year of age.
Adolescents and adults: 400 mg q 24 hours
*Nafcillin IV:
Infants and children: 150 mg / kg / day divided q 6 hours (other than meningitis)
200 mg / kg / day divided q 6 hours (meningitis)
Adults: 2 gm q 6 hours (maximum: 12 gm / day)

Oseltamivir:
Treatment of influenza: twice daily for 5 days
Age less 3 months: 12 mg twice daily
Age 3 through 5 months: 20 mg twice daily
Age 6 through 11 months: 25 mg twice daily
Body weight less than or equal to 15 kg, age 12 months or greater: 30 mg twice daily
Body weight greater than 15 to 23 kg: 45 mg twice daily
Body weight greater than 23 to 40 kg: 60 mg twice daily
Body weight greater than 40 kg and adults: 75 mg twice daily

Prophylaxis of influenza: once daily for 10 days

Age less 3 months: generally not recommended
Age 3 through 5 months: 20 mg once daily
Age 6 through 11 months: 25 mg once daily
Body weight less than or equal to 15 kg, age 12 months or greater: 30 mg once daily
Body weight greater than 15 to 23 kg: 45 mg once daily
Body weight greater than 23 to 40 kg: 60 mg once daily
Body weight greater than 40 kg and adults: 75 mg once daily

This document is intended as a general guideline. 8

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
*Penicillin G IV aqueous (available as penicillin G potassium or penicillin G sodium):
Infants and children: 200,000 units / kg / day divided q 6 hours (other than meningitis)
300,000 units / kg / day divided q 6 hours (meningitis)
Adult: 2 million units q 4 to 6 hours (maximum: 24 million units per day)

*Piperacillin / Tazobactam (Zosyn®) - IV – RESTRICTED ANTIMICROBIAL

Age less than 6 months: 240 mg of piperacillin component / kg / day divided q 8 hours
Infants and children age greater than or equal to 6 months:
320 mg of piperacillin component / kg / day divided q 6 hours
Adult: 3.375 gm (3 gm piperacillin / 0.375 gm tazobactam) q 6 hours (q 4 hours for pneumonia
due to Pseudomonas aeruginosa)
Cystic fibrosis patient: (does not need ID approval). Higher than standard dose: 400 mg of
piperacillin component / kg / day IV divided every 6 hours (as inpatient) and every 8 hours at home
(maximum dose, 18 gm as piperacillin per day).
Pre-approved indications for piperacillin/tazobactam:
1. Fever and neutropenia in an oncology patient
2. Empiric therapy of nosocomial pneumonia including ventilator-associated pneumonia
3. Empiric therapy of intra-abdominal sepsis, e.g., appendicitis

Posaconazole – oral suspension only – RESTRICTED ANTIMICROBIAL; NON-FORMULARY

13 years and above
Indications:
1. Oropharyngeal candidiasis: 100 mg PO bid x 1 day;
followed by 100 mg PO once daily x 13 days
2. Oropharyngeal candidiasis refractory to fluconazole or itraconazole: 400 mg PO bid

Ribavirin Inhalation: RESTRICTED ANTIMICROBIAL

Preparation: 6 grams in 100 mL sterile water. Give as 3 doses of approximately 2 grams per dose
via nebulizer for 2 hours on, 6 hours off and repeat 2 more cycles within 24 hours using a SPAG
aerosol generator.

Rifampin PO or IV; PO preferred if tolerated

Infants and children: 15 mg / kg / day in one or two doses (usual adult maximum dose, 600 mg;
maximum adult dose, 1,200 mg).
For meningococcal prophylaxis/eradication: 20 mg / kg / day (maximum, 600 mg / dose)
q 12 hours for 4 doses
For Haemophilus influenzae type b prophylaxis/eradication: 20 mg / kg once daily
(maximum, 600 mg / dose) for 4 days
Meningococcal prophylaxis/eradication: 10 mg / kg / day q 12 hours for 4 doses
Haemophilus influenzae type b prophylaxis/eradication: 10 mg / kg once daily for 4 days
Adults: 600 mg in one or 2 doses (maximum adult dose, 1,200 mg).
For meningococcal prophylaxis/eradication: 600 mg q 12 hours for 4 doses
For Haemophilus influenzae type b prophylaxis/eradication: 600 mg once daily for 4 days

This document is intended as a general guideline. 9

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
Ticarcillin / Clavulanate (Timentin®): RESTRICTED ANTIMICROBIAL
Infants and children: 250 mg ticarcillin component / kg day divided q 6 hours (300 mg ticarcillin
component / kg / day divided q 4 hours for very severe infections)
Adult: 3.1 gm (3 gm ticarcillin / 0.1 gm clavulanic acid) q 6 hours (3.1 gm q 4 hours for very
severe infection; maximum 24 gm / day)
Cystic fibrosis patient - (does not need ID approval). Higher than standard dose: 400 mg of
ticarcillin component / kg / day IV divided every 6 hours (as inpatient) and every 8 hours at home
(maximum dose, 24 gm per day).

Timentin® (see Ticarcillin / Clavulanate)

*Tobramycin: RESTRICTED ANTIMICROBIAL (for patients with normal renal function)

Infants, children younger than 5 years, and all oncology patients with fever and neutropenia:
7.5 mg / kg / day divided q 8 hours
Children 5 years and older, adolescents, and adults: 6 mg / kg / day once daily
maximum initial daily dose: 450 mg / day
Cystic fibrosis patient(does not need ID approval):
Age less than 5 years: 10 mg / kg/ day in 3 doses every 8 hours
Age greater than or equal to 5 years: 7.5 mg / kg / day once daily; maximum initial dose,
450 mg daily

Note: For extremely obese children, use adjusted body weight in dose calculation.
Adjusted body weight = ideal body weight + 0.4 (actual body weight – ideal body weight).
For ideal body weight, use 50 percentile for age and sex.
Note: Therapeutic monitoring for gentamicin (and other aminoglycosides) should be performed on
all patients receiving therapy for greater than 48 hours. At minimum, a trough concentration should
be obtained to ensure the concentration is not excessive. Peak is obtained 30 minutes after
completion of a 30 minute infusion. If the infection is not clinically resolving, a peak concentration
should be obtained.
Monitoring: peak 5 to 10 micrograms / mL; trough 0.5 to 2 micrograms / mL.
If once daily therapy is used (for large adolescent/adult), check trough concentration only and value
should be less than 0.5 micrograms / mL.
Note: Dosing and monitoring is identical to gentamicin

Trimethoprim-sulfamethoxazole (Bactrim, Septra) trimethopim, 1: sulfamethoxazole, 5 fixed ratio;

dosing based on trimethoprim content, PO or IV
Age less than 28 days: generally not used (displaces bilirubin binding to albumin)
Infants and children:
Non-CNS infection: 10 mg / kg / day divided q 12 hours
Pneumocystis pneumonia; serious infection: 20 mg / kg / day divided q 6 hours
Adolescents and adults:
Non-CNS infection:
Body weight 70 kg or less: 160 mg TMP / 800 mg sulfa (double strength tablet)
PO q 12 hours
Body weight over 70 kg: 320 mg TMP / 1,600 mg sulfa (two double strength tablets)
PO q 12 hours
Pneumocystis pneumonia; serious infection: 20 mg / kg / day divided q 6 hours

This document is intended as a general guideline. 10

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
*Vancomycin IV: RESTRICTED ANTIMICROBIAL:
Infants and children: 45 mg / kg / day divided q 8 hours (non-CNS infection)
60 mg / kg / day divided q 6 hours (meningitis / CNS infection)
Adolescents and adults: 45 mg / kg / day divided q 8 hours (CNS or non-CNS infection;
for obese patients use actual body weight)
Note: It is unnecessary to routinely obtain vancomycin levels in patients with normal renal function
who are responding to treatment. Obtain trough levels in patients with: endocarditis, central nervous
system infection, abnormal renal function, or with proven infection but an inadequate or incomplete
response to vancomycin. In patients treated with vancomycin for endocarditis, central nervous
system infection including meningitis, or Staphylococcus aureus pneumonia, target trough
concentration range is 15 to 20 micrograms / mL. In other patients, target trough concentration
range is 10 to 20 micrograms / mL.

Pre-approved indications for intravenous vancomycin:

1. Empiric therapy of suspected bacterial meningitis: pre-approved for 48 hours only
2. Empiric therapy of sepsis syndrome or septic shock.
3. Late onset sepsis in NICU: pre-approved for 48 hours only
4. Suspected vascular catheter related infection: approved for 48 hours only

Vancomycin oral for C. difficile colitis: RESTRICTED ANTIMICROBIAL:

PO:
Children weighing less than 10 kg - C. difficile colitis is rare:
45 mg / kg / day divided q 6 hours
Children weighing 10 kg or more, adolescents, and adults:
125 mg PO 4 times a day,
maximum 500 mg / day for 7 to 10 days

Voriconazole: RESTRICTED ANTIMICROBIAL

Children 2 through 11 years: 7 mg / kg / dose every 12 hours (14 mg / kg / day)
12 years and above:
Loading dose: IV (preferred): 6mg / kg / dose IV every 12 hours for 2 doses;
Oral: Less than 40 kg: 200 mg PO q12 hours x 2 doses
Greater than or equal to 40 kg: 400 mg PO q12 hour x 2 doses

Maintenance dose:
Oral dosing (preferred):
Less than 40 kg: 100 mg orally every 12 hours
Greater than 40 kg: 200 mg orally every 12 hours
IV: 4mg / kg / dose every 12 hours

*Zosyn®: (see Piperacillin / Tazobactam)

This document is intended as a general guideline. 11

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)
 Guideline: Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic
Fibrosis)
Date
Created by: Pharmacy and Therapeutics Committee
6 / 2000
History: Implemented: 6 / 2000; Revised 7 / 2003; Revised 6 / 2006; Revised 1 / 2007;
Revised 2 / 2008; Implemented 3 / 2008, Revised 12 / 2008: Revised 6 / 2009
Approved Lorry Rubin, MD Signature

By: Chairman Signature on File

Pharmacy and Therapeutics Committee
Schneider Children’s Hospital
James Abberton, M.S., R.Ph Signature

Director Pharmacy Services Signature on File

Long Island Jewish Medical Center

General References:
Lexi-Comp’s Pediatric Dosage Handbook, 15th edition, 2008-2009.

Bradley JS, Sauberan J. Antimicrobial Agents. In: Long S, Pickering LK, Prober CG, eds. Principles and
Practice of Pediatric Infectious Diseases. 3rd ed. Philadelphia, PA: Churchill Livingstone; 2008; 1420-
1452

Steinbach WJ, Dvorak CC. Antifungal agents. In: Long S, Pickering LK, Prober CG, eds. Principles and
Practice of Pediatric Infectious Diseases. 3rd ed. Philadelphia, PA: Churchill Livingstone; 2008; 1452-
1460

Rybak M, Lomaestro B, Rotschafer J, et al. Therapeutic monitoring of vancomycin in adult patients: A

consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society
of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm 2009; 66 (1):82-
98

Gerber MA, Baltimore RS, Eaton CB. Et al. Prevention of Rheumatic Fever and Diagnosis and Treatment
of Acute Streptococcal Pharyngitis. A Scientific Statement From the American Heart Association
Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular
Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology,
and the Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation 2009;119:1541-
1551

This document is intended as a general guideline. 12

The healthcare professional must use the appropriate judgment dependent on the particular clinical situation.

Antimicrobial Dosing - Pediatrics: Combined Approved, Restricted, (Includes Cystic Fibrosis), June 28, 2009 (Total pages 12)