Stanford Hospital & Clinics Antimicrobial Dosing Reference Guide 2013

Stanford Hospital & Clinics Antimicrobial Dosing Reference Guide 2013
This document is also located on the SHC Intranet (http://portal.stanfordmed.org/depts/pharmacy)

and http://bugsanddrugs.stanford.edu ABX Subcommittee Approved: May 08, 2013
Formulas for dosing weights: Ideal body weight IBW (male) = 50kg + (2.3 x height in inches > 60 inches)
Ideal body weight IBW (female) = 45kg + (2.3 x height in inches > 60 inches) Adjusted Body Weight ABW (kg) = IBW + 0.4 (TBW IBW)
CrCl >50 mL/min
CrCl 1050 mL/min
CrCl <10 mL/min
Intermittent
Hemodialysis (IHD)
CRRT
Acyclovir (IV)1,4,5, 6,7,8

(Use ideal BW for
obese)
HSV: 5 mg/kg q8h

HSV encephalitis/zoster:
10 mg/kg q8h
Same dose
CrCl 2550: q12h
CrCl 1025: q24h
HSV:
2.5 mg q24h
5 mg/kg q24h
HSV: 2.5 mg/kg q24h

5 mg/kg q24h
Dose after HD on HD days
HSV: 5 7.5 mg/kg q24h

7.5 10 mg/kg q12h
CrCl > 25
CrCl 1025
CrCl <10
Acyclovir (PO)1,5
HSV mucocutaneous
400 mg q8h
200 mg q8h
200 mg q12h
See CrCl < 10 mL/min

Administer after HD on HD days
No Data
VZV, HSV zoster
800 mg q4h (or 5x daily)
800 mg q8h
800 mg q12h
No change
No change
5 7.5 mg/kg post HD only
10 mg/kg load,
then 7.5 mg/kg q2448h
Drug
Amphotericin B
Liposomal1
Amikacin1,2,3,7
(Use ideal BW; use
adjusted BW in
morbidly obese)
See appendix for
complete guidelines
3 6 mg/kg/day
Conventional
dosing
High-dose
extendedinterval dosing
No change
No change
CrCl >60
5 7.5 mg/kg
q8h
CrCl 4060:
5 7.5 mg/kg
q12h
CrCl 2040
5 7.5 mg/kg
q24h
15 20 mg/kg
q24h
15 mg/kg
q36h
CrCl > 30:

15 mg/kg q48h
CrCl < 30:
Not recommended
1 2 g q46h
Meningitis/endocarditis:
2 g q4h
Azithromycin (IV/PO)1
500 mg q24h
Aztreonam1,2, 6
Severe: pseudomonas,
meningitis
1 2 g q8h
Severe: 2 g q68h
CrCl 10 30: 1 g q8h

Severe: 1 g q68h
3 g q6h
6,7
Cefazolin1,2, 5, 6,7, 8
Cefepime
1,4, 5, 6, 7
consult pharmacist
same dose q12h

2 g q12h
CrCl <15
3 g q24h
No change
1 g q12h
2 g q12h
3 g q1224h
No change
1 2 g q68h
2 g q6h
500 mg q8h
Severe: 500 mg q68h
12g LD, then 500mg q12h

Severe: 1 2 g LD, then 500
mg q8h
1 g q8h
- or 2 g q12h
No change
No change
1 g q24h
2 g q12h
General: 1 g q24h
General:
1 g q8h
70 mg x 1, then 50 mg q24h
Consider 70 mg x 1, then 35 mg q24h if severe hepatic dysfunction (ChildPugh score >7);
70 mg q24h if on phenytoin, rifampin, other strong enzyme inducers
CrCl 35:
CrCl 10 34:
Mild/moderate: 1 g q8h
Mild/moderate: 1 g q12h
1 g q24h
Severe: 2 g q8h
Severe: 1 2 g q12h
General
CNS/FN
CrCl >60
1 g q8h or
2 g q12h
CrCl 30 60:
1 g q12h or
2 g q24h
2 g q8h
2 g q12h
CrCl < 30
1 g q24h
1 g q12h or
2 g q24h
Ceftaroline1
(SHC Restriction)
600 mg q12h
Ceftriaxone1, 5, 9
1 2 g q24h
Endocarditis, osteomyelitis: 2 g q24h
Meningitis, E. faecalis endocarditis: 2 g q12h
Ciprofloxacin (IV/PO)1,2,
consult pharmacist
Timing of levels: Draw trough 30 min prior to 4 dose. Draw peak 30 min after infusion ends
Once daily dosing: goal peak 3560; goal trough <4. Consult Hartford Nomogram
Conventional dosing: goal peak 2535 for serious infections; 1520 for UTI goal trough:<5-8
Ampicillin/sulbactam1,2,4,
Caspofungin1
(Hepatic adjustment)
5 mg/kg
load, then
by level
th
same dose q612h

2 g q6h
CrCl <50: 3 g q8h
CrCl <30: 3 g q12h
No change
Ampicillin (IV)1,3,4,6
CrCl < 20
General infections
5, 6, 8
Pseudomonas,
severe
CrCl 30-50: 400 mg q12h

CrCl 15-30: 300 mg q12h
CrCl >50
400 mg IV q12h
500 mg PO q12h
400 mg IV q8h
750 mg PO q12h
CrCl 30 50
same
400 mg IV q812h
500 mg PO q12h
General:
0.5 g q24h
Severe infections/CNS/FN:
1 g q24h
CNS/FN: 2 g q24h
Give post HD on HD days
3 g q68h
No change
Severe infections:
2 g q12h
CrCl <15: 200 mg q12h
200 mg q12h
No Data
No change
No Change
No Change
CrCl < 30
400 mg IV q24h
500 mg PO q24h
400 mg IV q24h
500 mg PO q24h
400 mg IV q24h
500 mg PO q24h
400 mg IV q1224h
500 mg PO q1224h
600 900 mg IV q8h

150 450 mg PO q6h
No change
No change
No change
No change
1.25 2.5 mg/kg q12h
Scr 1.3 1.5:

1.25 1.9 mg/kg q12h
Scr 1.62.5: 2.5mg/kg q24h
Scr 2.6 4:
1.5 mg/kg q24h
1.5 mg/kg q24h
2.5 mg/kg q1224h
Daptomycin1, 10, 11, 21

(SHC Restriction)
(Use adjusted BW in
obese)
Skin/Soft tissue:
4 6 mg/kg q24h
Endocarditis/Bacteremia:
6 8 mg/kg q24h
CrCl < 30:

Same dose q48h
Same dose q48h
Doxycycline (IV/PO)1
100 mg q12h
No change
No change
1 g q24h
CrCl <30: 500 mg q24h
500 mg q24h
Dose by ideal body weight:

40 55 kg: 800 mg q24h
56 75 kg: 1200 mg q24h
76 90 kg: 1600 mg q24h
(max dose: 1600 mg/day)
Same dose q24-36h
Fidaxomicin (PO)
(SHC Restriction)
200 mg q12h x 10 days
Fluconazole (IV/PO)1,5,6, 8
Dose by indication. Load
800 mg for candidemia
200 400 mg q24h

Severe/CNS infections:
up to 800 mg q24h
Clindamycin1,2
1,5,6
Colistin (IV)
(SHC Restriction)
(Use ideal BW in obese)
Ertapenem (IV/IM)1
Ethambutol (PO)1,7
(Use ideal body weight)
Same dose q48h

4 8 mg/kg q48h
alt: 6 mg/kg post-HD only

No change
500 mg q24h
No change
Same dose q48h
Same dose post HD only
Same dose q24-36h
No change
No change
No change
No change
100 200 mg (50% of

normal dose) q24h
50 100 mg (25% of
normal dose) q24h
Dose by indication:
200 800 mg post HD only
400 800 mg q24h
1 g q24h
Drug
CrCl >50 mL/min
CrCl 1050 mL/min
ClCr(mL/min/kg)
CMV induction
60 mg/kg q8h
45 mg/kg q8h
90 mg/kg q12h
70 mg/kg q12h
90 mg/kg q24h
70 mg/kg q24h
> 0.8 1.0
50 mg/kg q12h
50 mg/kg q12h
40 mg/kg q12h
80 mg/kg q24h
60 mg/kg q24h
60 mg/kg q24h
50 mg/kg q24h
50 mg/kg q24h
Not recommended
Not recommended
60 90 mg/kg loading dose (post-HD),
then 45 60 mg/kg/dose post-HD only
IHD
CMV
Induction (I)
Maintenance
(M)
HSV
120 mg/kg q24h

90 mg/kg q24h
40 mg/kg q12h
30 mg/kg q12h
40 mg/kg q8h
30 mg/kg q8h
50 mg/kg q24h
65 mg/kg q24h
20 mg/kg q12h
35 mg/kg q12h
80 mg/kg q48h
60 mg/kg q48h
50 mg/kg q48h
Not recommended
105 mg/kg q48h

80 mg/kg q48h
65 mg/kg q48h
Not recommended
35 mg/kg q24h
25 mg/kg q24h
20 mg/kg q24h
Not recommended
25 mg/kg q12h
40 mg/kg q24h
35 mg/kg q24h
Not recommended
No data
No data
No data
No data
No data Dose as for CrCL 10 50 mL/min
CRRT
Ganciclovir1, 6
Consider loading dose of
5mg/kg for all patients
CRRT
CMV maintenance
> 1.4
> 1.0 1.4
> 0.6 0.8
> 0.5 0.6
0.4 0.5
< 0.4
Foscarnet1, 5
Intermittent
Hemodialysis (IHD)
CrCl <10 mL/min
CrCl >70*
5 mg/kg
q12h
5 mg/kg
q24h
CrCl >50
2.5 mg/kg
q12h
2.5 mg/kg
q24h
CrCl >25
2.5 mg/kg
q24h
1.25 mg/kg
q24h
CrCl >10
1.25 mg/kg
q24h
0.625 mg/kg
q24h
CrCl <10
1.25 mg/kg
3x/wk
0.625 mg/kg
3x/wk
LD 5mg/kg, then
I: 1.25 mg/kg post HD only
M: 0.625 mg/kg post HD only
LD 5mg/kg, then
I: 2.5 mg/kg q1224h
M: 1.25 2.5 mg/kg q24h
*Manufacturers CrCl cutoffs. Please refer to BMT protocols if applicable
Gram negative
Gentamicin6
(SHC interchange to
tobramycin. Exception:
gram positive synergy)
See appendix for
complete guidelines
CrCl >60
CrCl 4059
1.7 mg/kg q8h

or
4 7 mg/kg q24h
(high-dose
extended-interval*)
1.7 mg/kg q12h

or
4 7 mg/kg q36h
(high-dose
extended-interval*)
CrCl 2039
1.7 mg/kg q24h
or
CrCl > 30:
4 7 mg/kg q48h
CrCl < 30:
Not recommended
(high-dose extended-interval*)
CrCl <20
HD
CRRT
2 mg/kg
loading dose,
then per level
2 mg/kg loading
dose, then 1.5
mg/kg post HD
1.52.5 mg/kg
q2448h
1 mg/kg q48-72h;
1mg/kg q24h,
consider redosing
then per level
when level <1 mg/L
Goal levels:
(Gram-negative infections): Goal peak for traditional dosing (48mg/L), trough (<1-2mg/L) for treatment.
(Gram-positive synergy): Goal peak 35mg/L (3-4 if using IDSA endocarditis guidelines). Goal trough <1 mg/L
Timing of levels: Draw trough 30 min prior to 4th dose. Draw peak 30 minutes after infusion ends (4 th dose). (For CrCL <20, may check levels sooner than 4th
dose)
For once-daily dosing, draw a single random level 8 to 12 hours after dose given adjustments are made based on a published Hartford
nomogram.
For HD, draw trough pre-HD, and peak 30 min after end of each infusion
** Streptococci, Streptococcus bovis, Strep. viridans endocarditis: optional dosing 3mg/kg q24h for CrCl > 60
Gram positive
synergy
1 mg/kg q8h**
1 mg/kg q12h
1 mg/kg q24h
1 mg/kg load,
then by level
Imipenem/Cilastatin1,2, 6
(Non-formulary)
500 mg q6h
500 mg q8h
250 500 mg q12h
250 500 mg q12h

500 mg q8h
Severe: 500 mg q6h
Isoniazid1
300 mg q24h
No change
No change
No change
No change
Levofloxacin (IV/PO)1,2, 5,
CrCl 50
CrCl 2049:
General
250 500 mg q24h
250 500 mg q48h
Pseudomonas
/CAP:
750 mg q24h
750 mg q48h
CrCl < 20
500 mg x1,
then 250 mg q48h
750 mg x1,
then 500 mg q48h
6, 8
Linezolid (IV/PO)1,4
(SHC Restriction)
600 mg q12h
No change
CrCl >50
Meropenem1,2, 6, 8, 18
(SHC Restriction)
General
1 g q8h
Severe/CF/CNS
Metronidazole (IV/PO)
Moxifloxacin (IV/PO)
Nafcillin
Oseltamivir (PO)1,2, 15,16,17
Penicillin G (IV)1, 5, 6
Piperacillin/tazobactam
1,2,4, 5, 6, 8, 22
2 g q8h
CrCl 2650:
1 g q12h or
0.5 g q6h
2 g q12h
No change
CrCl 1025
CrCl <10
0.5 g q812h
0.5 g q1224h
1 g q12h or 0.5
g q8h
0.5 g q1224h
No change
Severe hepatic impairment: can consider 500 mg q12h
500 mg q6 8h
500 mg q48h
See CrCl < 20 ml/min
Pseudomonas/CAP:
750 mg LD, then 250 750
mg q24h
No change. Dose after HD on

HD days
No change
500 mg q24h
1 g q12h
- or 500 mg q6h
Severe/CF/CNS: 1 g q24h
Severe/CF/CNS: 2g q12h
500 mg q8h
500 mg q68h
400 mg IV/PO q24h
No change
No change
No change
No change
2 g q4h
Mild infections: 1gm q4h
No change
No change
No change
No change
Treatment/prophylaxis:
30 mg after every other session
Severe/ICU:
60 mg after every other session
Prophylaxis: 75 mg q24h
Treatment: 75 mg BID
Severe/ICU: 150 mg BID
4mu x1, then 1 2 mu q6h
4mu x1, then 2 3 mu q6h
CrCl 30
CrCl < 30
Prophylaxis
75 mg q24h
75 mg q48h
2 4 mu q4h
General
Pseudomonas/
nosocomial PNA/
severe:
Treatment
75 mg q12h
75 mg q24h
2 3mu q4h
CrCl >40
CrCl 2040
3.375 g q6h
2.25 g q6h
4.5 g q6h
3.375 g q6h
Extended infusion for CrCl > 20:
3.375 4.5 g q8h over 4h
Posaconazole (PO)1,2, 22
(SHC Restriction)
Treatment: 200 mg q6h

or 400 mg q12h
Pyrazinamide (PO)1, 5, 12
(Use ideal BW)
Round to nearest tablet
size
Dose by ideal body weight:

40 55 kg: 1000 mg
56 75 kg: 1500 mg
76 90 kg: 2000 mg
(max 2000 mg/day)
Rifampin (IV/PO)1, 13, 14
TB: 600 mg q24h

Endocarditis: 300 mg q8h
Treatment (severe/ICU)
150 mg q12h
150 mg q24h
1 2mu q6h
CrCl <20:
2.25 g q8h
2.25 g q6h
3.375 g q12h over 4h
General: 2.25 g q12h

Pseudomonas/PNA/ severe
infections:
2.25 g q8h
3.375 g q6h or
Extended infusion
3.375 g q8h
(infused over 4 h)
No change. Posaconazole levels shown to have great degree of interpatient variability.

Many clinicians would recommend blood levels to assess efficacy. Consider drawing a trough 4 - 7 days after initiating dose
CrCl < 30:

Same dose 3 times per week
No change
No change
Same dose administer

after HD only
No data
No change
No change
Drug
CrCl >50 mL/min
CrCl 1050 mL/min
CrCl >60
Tobramycin20
(Use ideal or adjusted
BW for obese)
See appendix for
complete guidelines
Trimethoprim (TMP)/
Sulfamethoxazole
(IV/PO)1, 5, 6
(Dose by ideal or
adjusted BW in obese)
SS = 80 mg TMP = 10 ml po soln
DS =160 mg TMP = 20ml po soln
1.7 mg/kg q8h

or
4 7 mg/kg q24h
(high-dose extendedinterval*)
CrCl 2040
CrCl <20
HD
CRRT
1.7 mg/kg q12h

or
4 7 mg/kg q36h
(high-dose extendedinterval*)
1.7 mg/kg q24h

or
CrCl > 30:
4 7 mg/kg q48h
CrCl < 30:
Not recommended
(high-dose extended-interval*)
2 mg/kg loading
dose, then per level
2 mg/kg loading
dose, then 1.5
mg/kg post HD
1.5 2.5 mg/kg

q2448h
2.5 5 mg/kg TMP q24h*
5 10 mg/kg/day TMP divided

q68h
PCP/Stenotrophomonas:
15 20 mg/kg/day TMP
divided q6-8h
Valacyclovir (PO)1
Please refer to
transplant protocols if
applicable
Suppressive
Consider loading dose

of 2530 mg/kg (max 2
g) for severe infections
and ICU
Vancomycin PO1
(SHC Restriction:
capsules restricted)
Oral solution formulary
Voriconazole
(IV/PO)1,22,23
(SHC Restriction)
(Dose by adjusted BW
in obese)
CRRT
CrCl 4060
CrCl < 30: 2.5 5 mg/kg/day TMP divided q8 12h

PCP/Stenotrophomonas: 7.5 10 mg/kg/day TMP divided
q812h
PCP/ Stenotrophomonas:
7.5 10 mg/kg TMP q24h*
*Give after HD on HD days
CrCl >30:
Vancomycin (IV)6, 19, 21

(Use actual body
weight)
Intermittent
Hemodialysis (IHD)
Goal levels:
Goal peak for traditional dosing (48mg/L), and trough (<1-2mg/L) for treatment.
*certain qualifications for oncedaily dosing
Timing of levels: Draw trough 30 min prior to 4th dose. Draw peak 30 minutes after infusion ends (4 th dose). (For CrCL <20, may check levels sooner than 4th
dose)
For once-daily dosing, draw a single random level 8 to 12 hours after dose given adjustments are made based on a published Hartford
nomogram.
For HD, draw trough pre-HD, and peak 30 min after end of each infusion.
Treatment
Valganciclovir (PO)1
Please refer to
transplant protocols if
applicable
CrCl <10 mL/min
CrCl 10-30:
HSV/VZV:
1 g q24h
HSV/VZV:
500 mg q24h
Genital herpes:
1 g q12h
Genital herpes:
1 g q24h
Genital herpes:
500 mg q24h
Herpes labialis:
CrCl >50: 2 g q12h x 2
doses
CrCl 30-50: 1g q12h x 2
doses
HSV/VZV: 500 mg q8-12h
Genital herpes: 1000 mg q24h
Herpes labialis: 1g q12h x 2
doses
Herpes labialis:
500 mg q12h x
2 doses
Herpes labialis:
500 mg x 1 dose
500 mg q24h
No Data
CrCl <30:
HSV/VZV: 500 mg q2448h
CrCl > 60
CrCl 40 59
CrCl 25 39:
CrCl 10 24
Induction (14-21 days)
900 mg q12h
450 mg q12h
450 mg q24h
450 mg q48h
Maintenance/ prophylaxis
900 mg q24h
450 mg q24h
450 mg q48h
450 mg twice/week
CrCl >50
CrCl 3049
CrCl 1529
CrCl <15
15 20 mg/kg
15 20 mg/kg
10 15 mg/kg
10 15 mg/kg
q812h
q24h
q24h
q2448h
Goal trough 1015 mcg/ml (cellulitis, skin/soft tissue infections)
Goal trough 1520 mcg/ml (pneumonia, bacteremia, endocarditis, osteomyelitis)
Timing of levels: Draw trough< 30 minutes before 4th dose of new regimen. When SCr
acutely rises, hold dose, restart when level <15 - 20
See appendix for complete guidelines
Poor systemic absorption- used for the treatment of Clostridium difficile-associated diarrhea
General: 125 250 mg QID
Severe/complicated: 500 mg QID
400 mg PO q12h x 2,
then 200 mg PO q12h
PCP/ Stenotrophomonas:
10 15mg/kg/day TMP
divided q12h
<10
HSV/VZV:
CrCl >50: 1 g q8h
CrCl 30-50: 1g q12h
6 mg/kg IV q12h x 2,
then 4 mg/kg IV q12h
5 10 mg/kg/day TMP
divided q12h
CrCl < 10, IHD, CRRT

Not recommended, use ganciclovir
20 25 mg/kg LD,
then redose with
10 15mg/kg post dialysis
when level <15 20
No change
15 25mg/kg LD, then

10 15mg/kg q24h
Draw level prior to 3rddose.
Adjust to levels
No change
IVPO conversion 1:1 (round to nearest tablet size- available in 200 mg and 50 mg tablets)
Caution with IV: accumulation of IV vehicle cyclodextran occurs. Consider PO unless benefits justify risks of IV use.
Levels shown to have great degree of interpatient variability. Many clinicians would recommend blood levels to assess efficacy.
Consider drawing a trough 4 - 7 days after new dose
Abbreviations: SCr = serum creatinine; LD = loading dose; MU= million units; PNA = pneumonia; HD = hemodialysis; CAP = community acquired pneumonia; CRRT = continuous renal
replacement therapy; TMP = trimethoprim; PCP: pneumocystis jiroveci pneumonia; TB = tuberculosis; UF = ultrafiltration
CRRT dosing: doses listed are for CVVHDF and CVVHD modalities, which are the most common modes at SHC. Note that these are generally higher than doses used in CVVH.
References:
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Taylor RJ et al. Oseltamivir is adequately absorbed following nasogastric administration to adult patients with severe H5N1 influenza. PLoS ONE 2008;3:e3410.
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Stanford Hospital & Clinics Antimicrobial Dosing Reference Guide 2013

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CrCl 1050 mL/min

CrCl <10 mL/min

Acyclovir (IV)1,4,5, 6,7,8

HSV: 5 mg/kg q8h

HSV: 2.5 mg/kg q24h

HSV: 5 7.5 mg/kg q24h

See CrCl < 10 mL/min

VZV, HSV zoster

800 mg q4h (or 5x daily)

5 7.5 mg/kg post HD only

CrCl > 30:

CrCl 10 30: 1 g q8h

same dose q12h

12g LD, then 500mg q12h

same dose q612h

CrCl 30-50: 400 mg q12h

CrCl <15: 200 mg q12h

600 900 mg IV q8h

1.25 2.5 mg/kg q12h

Scr 1.3 1.5:

1.5 mg/kg q24h

2.5 mg/kg q1224h

Daptomycin1, 10, 11, 21

CrCl < 30:

Same dose q48h

CrCl <30: 500 mg q24h

Dose by ideal body weight:

Same dose q24-36h

200 mg q12h x 10 days

200 400 mg q24h

Same dose q48h

alt: 6 mg/kg post-HD only

Same dose q48h

Same dose post HD only

Same dose q24-36h

100 200 mg (50% of

400 800 mg q24h

CrCl >50 mL/min

CrCl 1050 mL/min

> 0.8 1.0

120 mg/kg q24h

105 mg/kg q48h

No data Dose as for CrCL 10 50 mL/min

CrCl <10 mL/min

*Manufacturers CrCl cutoffs. Please refer to BMT protocols if applicable

1.7 mg/kg q8h

1.7 mg/kg q12h

250 500 mg q12h

250 500 mg q12h

250 500 mg q24h

250 500 mg q48h

Oseltamivir (PO)1,2, 15,16,17

No change. Dose after HD on

400 mg IV/PO q24h

4mu x1, then 1 2 mu q6h

4mu x1, then 2 3 mu q6h

Treatment: 200 mg q6h

Dose by ideal body weight:

Rifampin (IV/PO)1, 13, 14

TB: 600 mg q24h

General: 2.25 g q12h