UCSF Benioff Childrens 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
Pediatric Infectious Diseases Consult
ID Physician Consult Services
Antimicrobial Stewardship Program (ASP)
For assistance in antimicrobial dose/selection or authorization of ID-Restricted agents
ID Pharmacists
Infectious Diseases Consult Team
Shaded boxes indicate ID-Restricted agents (ID-R).
ID-R orders will NOT be processed without approving clinicians ID number (Exceptions noted in APeX).
From 10pm to 8am, use approval ID# 11111 for release of a single dose. Continued use will require ASP review and approval.
UCSF/SFGH Joint Guidelines for Antimicrobial Use: clinicalpharmacy.ucsf.edu/idmp
IV-PO = High oral bioavailability Consider IV to PO Switch

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

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
10-20mg/kg/dose q8h

Acyclovir IV

Immunocompromised Host:
500mg/m2/dose q8h

HSV encephalitis,
all neonatal infections:
20mg/kg/dose q8h

Immunocompromised Host:
500mg/m2/dose q8h

Amphotericin B
Liposomal IVID-R
(AmBisome)

Ampicillin IV
Ampicillinsulbactam IV
(Unasyn)

Amoxicillin PO

Caspofungin IVID-R

Cefazolin IV

Invasive yeast infections:

3mg/kg/dose IV q24h
Invasive mold infections:
5mg/kg/dose IV q24h
50mg/kg/dose q6h

25-50% of normal clearance

10-20mg/kg/dose q12h
10-25% of normal clearance
10-20mg/kg/dose q24h

443-2384
443-9421
443-2151

MAXIMUM
DAILY DOSE

5-10mg/kg/dose q24h

Immunocompromised Host:
25-50% of normal clearance
500mg/m2/dose q12h
10-25% of normal clearance
500mg/m2/dose q24h
25-50% of normal clearance
20mg/kg/dose q12h
10-25% of normal clearance
20mg/kg/dose q24h

Immunocompromised Host:
250mg/m2/dose q24h

Immunocompromised Host:
25-50% of normal clearance
500mg/m2/dose q12h
10-25% of normal clearance
500mg/m2/dose q24h

Immunocompromised Host:
250mg/m2/dose q24h

10mg/kg/dose q24h

Dosage reductions in renal disease are not necessary. Due to the

nephrotoxic potential of the drug, reducing the dose or holding the drug
may be warranted in the setting of rising serum creatinine.
25mg/kg/dose q6h

25mg/kg/dose q8-12h

Meningitis:
100mg/kg/dose q6h

50mg/kg/dose q6h

25mg/kg/dose q8-12h

50mg ampicillin/kg/dose q6h

25mg ampicillin/kg/dose q6h

25mg ampicillin/kg/dose q8-12h

2g ampicillin q6h

20mg/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

Otitis Media/ Pneumonia/

Osteomyelitis
45-50mg/kg/dose q12h
<3 mo old: 25mg/ m2/dose q24h
3 mo old: LD 70mg/m2/dose x1
Then 50mg/m2/dose q24h
25mg/kg/dose q8h

2g q4h

No dose adjustment for renal dysfunction

2

Adjustment for severe hepatic dysfunction: 70mg/m x1, then 35mg/m

q24h
25mg/kg/dose q12h
25mg/kg/dose q24h

LD: 70mg
MD: 50mg q24h
2g q8h

10mg/kg/dose PO q6-8h
Cephalexin PO

Otitis Media/ Severe infections

20-25mg/kg/dose PO q6h

50% normal dose q8-12h

50% normal dose q12-24h

30-50% of normal clearance

50mg/kg/dose q24h
10-30% of normal clearance
25mg/kg/dose q24h

12.5mg/kg/dose q24h

4g/DAY

Osteomyelitis
25-30mg/kg/dose PO q6h
50mg/kg/dose q12h

Cefepime IV

Febrile Neutropenia:
50mg/kg/dose q8h
Cystic Fibrosis:
50mg/kg/dose q8h
50mg/kg/dose q8h

Cefotaxime IV

Ceftazidime IV

30-50% of normal clearance

25mg/kg/dose q24h
50mg/kg/dose q12h
10-30% of normal clearance
50mg/kg/dose q24h
Renal dose adjustments not documented in cystic fibrosis
50mg/kg/dose q8h-12h
25 mg/kg/dose q12h
50mg/kg/dose q8h

50mg/kg/dose q12h

50mg/kg/dose q12h

50mg/kg q24-48h

Cystic Fibrosis:
50mg/kg/dose q8h

Renal dose adjustments not documented in cystic fibrosis

CiprofloxacinIV-PO*
*IV:PO Ratio 1:1 until
adult doses, then 4:5
Clindamycin IV-PO*
*Doses >1.8 g/DAY
should be left IV.
Ertapenem IV
Fluconazole IV-PO

Meningitis:
50mg/kg/dose q12h
15mg/kg/dose q12h

Cystic Fibrosis:
15 mg/kg/dose q12h
5-10mg/kg/dose q6-8h

No change

30-50% of normal clearance

7.5mg/kg/dose q12h
No change
10-30% of normal clearance
7.5 mg/kg/dose q12h
Renal dose adjustments not documented in cystic fibrosis
No change

< 30ml/min/1.73m2
Decrease dose 50%
3-6mg/kg/dose q24h
3-6mg/kg/dose q24h

2g q8h
Cystic Fibrosis:
2g q8h

Meningitis
2g q12h
400mg IV q12h
500mg PO q12h
Cystic Fibrosis:
600mg IV q12h
1.8g PO/DAY
900mg IV q8h
1g q24h

400mg q24h

Fungal prophylaxis:
3mg/kg/dose q24h
>70% of normal clearance
5mg/kg/dose q12h

25-50% of normal clearance

2.5mg/kg/dose q24h

70-50% of normal clearance

2.5mg/kg/dose q12h

10-25% of normal clearance

1.25mg/kg/dose q24h

2.5mg/kg/dose q8h

2.5mg/kg/dose q12h

No change

Ganciclovir IV

Gentamicin IV

Cystic Fibrosis:
2g q8h

1g q24h
No change

No change
Osteomyelitis
10-12 mg/kg/dose q6-8h
< 13 yo: 15 mg/kg/dose q12h
13 yo: 1g q24h
6-12mg/kg/dose q24h

2g q8h

2g q6h

Meningitis:
50mg/kg/dose q6h
50mg/kg/dose q8h

50mg/kg/dose q24h
Ceftriaxone IV

2g q12h

No change

1.25mg/kg/dose q24h

2.5mg/kg/dose q24h

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

ImipenemcilastatinID-R IV

20mg imipenem/kg/dose q6h

< 5 yo: 10mg/kg/dose q12h

Levofloxacin IV-PO
5 yo: 10mg/kg/dose q24h

10mg imipenem/kg/dose q6-8h

10mg imipenem/kg/dose q12h

1g imipenem q6h

30-50% of normal clearance

No change
10-30% of normal clearance
5-10mg/kg/dose q24h

5-10mg/kg/dose q48h

750mg q24h

No change

No change

600mg q12h

25-50% of normal clearance

20mg/kg/dose q12h
10-25% of normal clearance
10mg/kg/dose q12h
25-50% of normal clearance
40mg/kg/dose q12h
10-25% of normal clearance
20mg/kg/dose q12h

10mg/kg/dose q24h

1g q8h

20mg/kg/dose q24h

Meningitis:
2g q8h

< 12 yo: 10mg/kg/dose q8h

LinezolidID-R, IV-PO
12 yo: 10mg/kg/dose q12h
20mg/kg/dose q8h

Meropenem IV
Meningitis:
40mg/kg/dose q8h

DRUG

MetronidazoleIV-PO

Creatinine Clearance
>50ml/min/1.73m2
OR
Renal Function > 50% of
Normal
10mg/kg/dose q8h

Creatinine Clearance
10-50ml/min/1.73m2
OR
Renal Function = 10-50% of
Normal
No change

Creatinine Clearance
<10ml/min/1.73m2
(ESRD not on dialysis)
OR
Renal Function <10% of Normal
10mg/kg/dose q12h

25-50mg/kg/dose q6h
100,000 - 250,000
units/kg/DAY q4-6h

No change
75,000-175,000
units/kg/DAY q4-6h

No change
50,000-125,000
units/kg/DAY q6h

Nafcillin IV

Penicillin G IV

Severe Infection:
250,000-400,000
units/kg/DAY q4-6h
80mg piperacillin/kg/dose q6-8h*
*Serious Infections including
Pseudomonas: consider q6h

Piperacillin/
Tazobactam IV
(Zosyn )

Tobramycin IV

175,000-300,000
units/kg/DAY q4-6h
30-50% of normal clearance
50mg piperacillin/kg/dose q6-8h
10-30% of normal clearance
50mg piperacillin/kg/dose q8h

SS Tablet:
80mg TMP
DS Tablet:
160mg TMP
Oral Suspension:
40mg TMP / 5mL

125,000-200,000
units/kg/DAY q6h
4g piperacillin q6h
50mg piperacillin/kg/dose q8h
Cystic Fibrosis:
4g piperacillin q6h
600mg q24h
or 900mg/DAY q8-12h

No change

No change

2.5mg/kg/dose q12h

2.5mg/kg/dose q24h

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

Renal dose adjustments not documented in cystic fibrosis

Mild to moderate systemic

bacterial infection:
5mg/kg/dose TMP q12h

2.5mg/kg/dose TMP q12h

2.5-5mg/kg/dose TMP q24h

Serious systemic bacterial

infection:
5mg/kg/dose TMP q6-8h

5mg/kg/dose TMP q8-12h

5mg/kg/dose TMP q12-24h

2.5mg/kg/dose TMP q12h

three days per week
15mg/kg/dose q8-12h

2.5mg/kg/dose TMP q24h three

days per week
15mg/kg/dose q12-24h

Pneumocystis carinii
pneumonia prophylaxis:
2.5mg/kg/dose TMP q12h
three days per week
15mg/kg/dose q6h*
*Cardiac Dysfunction/CICU
consider q8-12h

Vancomycin IV

2g q4h

Renal dose adjustments not documented in cystic fibrosis

Cystic Fibrosis:
10mg/kg/dose q24h

TMP/SMX IV-PO
(Septra )

500mg q6h

4 million units q4h

Cystic Fibrosis:
100mg piperacillin/kg/dose q6h
10-20mg/kg/DAY in 1-3 divided
doses
2.5mg/kg/dose q8h

Rifampin IV-PO

MAXIMUM
DAILY DOSE

Prophylaxis:
160mg TMP q12h
1g q8h

CNS/Osteo/Serious Infections:
20mg/kg/dose q6h
20mg/kg/dose q8h
20 mg/kg/dose q12h
1g q6h
Peak levels are not recommended. Trough levels ( 30 min before next dose) should be 10-20 mg/L depending on infection severity.
Specifically, 15-20 for meningitis, sepsis and pneumonia
Presumed/Empiric Infection
No adjustment for renal dysfunction**
LD = 6mg/kg/dose q12h x 2
Then MD = 4mg/kg/dose* q12h
VoriconazoleID-R,IV-PO

**The IV formulation should be avoided if possible in patients with CrCl<50 mL/min due to the
Documented Infections
accumulation of the IV vehicle
LD = 7mg/kg/dose q12h x 2
then MD = 5-7mg/kg/dose* q12h
*Higher doses may be required based on therapeutic drug monitoring (consultation with Pedi-ID recommended)
Estimate of Creatinine Clearance using Schwartzs equation:
CLcr = K x L/Scr (Creatinine clearance in ml/minute/1.73m2)
L = Length or height in cm
K = Age specific constant of proportionality
Scr = Serum creatinine concentration in mg/dL
Age
Pre-term infants up to 1 year
Full-term infants up to 1 year
1-12 years
13-21 years female
13-21 years male
1-16 years with Chronic Kidney Disease

Age
Premature (<34 weeks GA)
<2 weeks old
2 weeks old
Term (>34 weeks GA)
<2 weeks old
2 weeks old
2 weeks to 5 years
5 to 10 years
>10 years

K
0.33
0.45
0.55
0.55
0.7
0.413

Average SCr (mg/dL)

Range (mg/dL)

0.9
0.8

0.7-1.4
0.7-0.9

0.5
0.4
0.4
0.6
0.9

0.4-0.6
0.3-0.5
0.2-0.5
0.3-1
0.6-1.4

UCSF PEDIATRIC INPATIENT SUSCEPTIBILITY DATA 2012

N/A-testing NOT APPLICABLE to organism. CZOL-cefazolin, CTRX-ceftriaxone, CTAZ-ceftazidime, CFPM-cefepime,
GEN-gentamicin, TOB-tobramycin, T/S-trimethoprim/sulfamethoxazole, CIP-ciprofloxacin, MER- meropenem, P/T-piperacillin-tazobactam,
PCN-penicillin, NAF-nafcillin, ERY-erythromycin, CLIN-clindamycin, DOX-doxycycline, VANC-vancomycin

Total isolates include Floor Isolates and ICU Isolates from UCSF Childrens Hospital (Does not include Outpatient)

Gram-negative isolates (% strains susceptible, tested from all sites)

Organism
Acinetobacter baumannii
Citrobacter freundii
Enterobacter aerogenes
Enterobacter cloacae
Escherichia coli*
EColi-URINE
EColi-NON URINE
Klebsiella oxytoca
Klebsiella pneumoniae
Proteus mirabilis
Pseudomonas aeruginosa**
PICU+ICN
PEDS
Serratia marcescens

Total
isolates
3
5
4
22
83
60
25
17
30
4
20
9
14
13

CZOL

CTRX

CTAZ

CFPM

GEN

TOB

T/S

CIP

P/T

N/A
N/A
N/A
N/A
70
68
72
24
73
0
N/A
N/A
N/A
N/A

0
80
50
32
95
97
92
88
90
100
N/A
N/A
N/A
100

100
80
50
41
98
100
92
100
90
100
95
100
93
100

100
100
100
100
98
98
96
100
100
100
95
100
93
100

100
80
100
86
94
93
96
100
87
100
100
100
100
100

100
60
100
82
93
93
92
100
83
100
100
100
100
100

100
60
100
73
71
72
68
82
67
100
N/A
N/A
N/A
92

100
100
100
95
93
95
88
94
90
100
100
100
93
100

100
100
50
64
95
97
88
88
100
100
100
89
100
100

MER
100
100
100
95
100
100
100
100
100
100
95
100
93
100

** Pseudomonas aeruginosa isolates do not include isolates from cystic fibrosis patients

*Escherichia coli outpatient

urine isolates

Cefazolin/cephalexin susceptibility is 78%. TMP/SMX susceptibility is 69%. Ciprofloxacin

susceptibility is 93%. Nitrofurantoin susceptibility is 100% and should only be used for uncomplicated
UTIs in patients with CrCl >60 mL/min.

Haemophilus influenzae

National incidence of -lactamase production is 37% (2010).

Routine antimicrobial susceptibility testing is performed on sterile sites and cystic fibrosis isolates.
TMP/SMX is the most active agent versus this organism.

Stenotrophomonas
maltophilia

Total isolates include Floor Isolates and ICU Isolates from UCSF Childrens Hospital (Does not include Outpatient)

Gram-positive isolates (% strains susceptible, tested from all sites)

Organism
Staphylococcus aureus*
MRSA
MSSA
Staphylococcus epidermidis
Streptococcus pneumoniae

Total
Isolates

PCN

NAF

ERY

CLIN

CIP

DOX

T/S

VANC

127
39
88
44
32

0
NA
0
0
See below

69
NA
100
30
NA

54
5
75
25
75

71
38
85
70
60

75
38
91
65
NA

91
97
88
86
76

92
87
94
45
29

99
100
99
100
100

*Staphylococcus aureus

Outpatient Nafcillin susceptibility is 74% (Nafcillin resistance predicts cephalosporin resistance).

Enterococcus spp.

Enterococcus faecalis species are 100% ampicillin susceptible. Of 18 enterococcal bacteremias in

2012, 3 were due to Enterococcus faecium, 2 of which were vancomycin resistant (11% of all
enterococcal bloodstream isolates were VRE). The addition of gentamicin (1 mg/kg Q8h) is required for
bactericidal activity in serious systemic enterococcal infections (e.g. endocarditis).

Streptococcus pneumoniae

25% (8/32 isolates) were PCN non-susceptible. 60% of isolates tested (6/10) were susceptible to
CTRX. All isolates were susceptible to levofloxacin.
NOTE: For the treatment of meningitis, pending susceptibilities VANCOMYCIN empirically should be added
to the regimen since failures (due to highly resistant isolates) have been reported with ALL third generation
cephalosporins.