Published on Infectious Diseases Management Program at UCSF (http://idmp.ucsf.

edu)
Home > Antimicrobial Dosing Guidelines > Adult Antimicrobial Dosing, Non-dialysis

Adult Antimicrobial Dosing, Non-dialysis

Creatinine Clearance Calculator [1] & Ideal Body Weight Calculator [2] (powered by MDCalc)
Notations: ID-R: restricted antimicrobial (follow link for details) IV-PO: similar drug levels obtained with IV or PO administration
Dosing Weights: IBW=ideal body weight (use TBW if IBW is greater than patient's weight) ABW=adjusted body weight TBW=total
body weight

Drug

CrCl >50 mL/min

CrCl 10-50 mL/min

CrCl <10 ml/min

5 mg/kg/dose IV q8h

5 mg/kg/dose IV q12-24h

2.5 mg/kg IV q24h

10 mg/kg/dose IV
q8h

10 mg/kg/dose IV q12-24h

5 mg/kg IV q24h

Acyclovir IBW ID-R:VASF[3]

Herpes simplex infections
HSV encephalitis/Herpes zoster

Amphotericin B Lipid
Formulations
TBW ID-R:UCSF[4]SFGH[5]VASF[3]

Invasive fungal infections

Prophylaxis (heme-onc)

3 - 5 mg/kg IV q24h
1 mg/kg IV q24h

No adjustment for renal

dysfunction
No adjustment for renal
dysfunction

Ampicillin
Meningitis or endovascular
infection

2 g IV q4h

2 g IV q6h

1 g IV q8h

Uncomplicated Infection

2 g IV q6h

1 g IV q6h

1 g IV q12h

3 g IV q6h

1.5 g IV q6h

1.5 g IV q12h

Ampicillin/sulbactam

Community acquired pneumonia

Azithromycin

ICU: 500mg IV/PO q24h

Non-ICU: 500mg IV/PO x1 then 250mg IV/PO q24h

Aztreonam ID-R:SFGH[5]VASF[3]

Caspofungin ID-R:UCSF[4]SFGH[5]
VASF[3]

2 g IV q8h

2 g IV q12h

Loading Dose=70 mg x1, then 50 mg IV q24h

Increase maintenance dose to 70 mg when given with
phenytoin, rifampin, carbamazapine, dexamethasone,
nevirapine, efavirenz
Severe hepatic dysfunction: 70 mg Loading Dose x1, then 35
mg IV q24h

No adjustment for renal

dysfunction
1 g IV q12h

No adjustment for
renal dysfunction

Cefazolin
Gram Negative or Complicated
Gram Positive
Uncomplicated Gram Positive

2 g IV q8h
1 ? 2 g IV q8h

1 ? 2 g IV q12h

1 g IV q24h

> 60 mL/min
2 g IV q12h

30-60 mL/min

10-30 mL/min

<10 mL/min

2 g IV q24h

1 g IV q24h

500 mg IV q24h

2 g IV q12h

2 g IV q24h

1 g IV q24h

Cefepime ID-R:SFGH[5] VASF[3]

Febrile neutropenia, meningitis,

Pseudomonas, critically-ill
Ceftazidime
ID-R:SFGH[5]VASF[3]

2 g IV q8h

2 g IV q8h

2 g IV q12-24h

500 mg IV q24h

Ceftriaxone
Standard Dose (e.g. Pneumonia)

1 g IV q24h

Meningitis

2 g IV q12h

Endocarditis & Osteomyelitis

Ciprofloxacin IV-PO ID-R:VASF[3]

No adjustment for renal

dysfunction

2 g IV q24h
>30 mL/min

10-30 mL/min

<10 mL/min

400 mg IV q12h

200-400 mg IV q12h

200 mg IV q12h

500-750 mg PO q12h

250-500 mg PO q12h

250 mg PO q12h

>30 mL/min

Pseudomonas infections

400 mg IV q8h
750 mg PO q12h

<10 mL/min

200-400 mg IV q12h

200 mg IV q12h

250-500 mg PO q12h

250 mg PO q12h

No adjustment for renal

dysfunction

600 ? 900 mg IV q8h

Clindamycin ID-R:VASF[3]

Colistin IBW ID-R:UCSF[4]SFGH[5]VASF[3]

10-30 mL/min

5 mg/kg IV x 1 loading dose, then contact ID Pharmacy for maintenance dosing

recommendations

Daptomycin TBW ID-R: UCSF [4] SFGH

[5]

VASF [3]

Not effective in treatment of

pneumonia

6 ? 10 mg/kg IV q24h
Dose depends on
indication & pathogen

Doxycycline IV-PO

<30 mL/min
6 ? 10 mg/kg IV Q48h

No adjustment for renal

dysfunction

100 mg IV/PO q12h

<30 mLmin
Ertapenem
1 g IV q24h

500 mg IV q24h

15-20 mg/kg PO
q24h
40-55 kg: 800 mg
Ethambutol IBW

<30 mlLmin

56-75 kg: 1200 mg

76-90 kg: 1600 mg

15-25 mg/kg PO three times weekly

Fluconazole IV-PO
Candidiasis

100?400 mg q24h

Oropharyngeal

100 mg q24h

Esophageal

200 mg q24h

Severe Infections

400 mg q24h

Flucytosine (5FC)IBW

Ganciclovir TBW ID-R:SFGH[5]VASF[3]

50 ? 200 mg IV/PO q24h

50 -100 mg IV/PO q24h

> 50 mL/min

25-50 mL/min

10-25 mL/min

<10 mL/min

25 mg/kg/dose PO
q6h

25 mg/kg/dose PO
q12h

25 mg/kg/dose
PO q24h

12.5 mg/kg/dose po
Q24h

> 70 mL/min

50 - 69 mL/min

25-49 mL/min

5 mg/kg/dose IV
q12h

2.5 mg/kg/dose IV
q12h

2.5 mg/kg/dose IV
q24h

10-24 mL/min
1.25 mg/kg/dose IV

>60 mL/min
See Below
7mg/kg/dose IV Q24h

Gentamicin IBW*

*Use TBW if < IBW. If TBW > 1.2

times IBW, use ABW
See also Aminoglycoside Dosing &
Monitoring Recommendations [6]

Use once-daily dosing in patients with normal renal function, who are not morbidly obese
or fluid overloaded. Check serum drug level 6-14 hours after start of infusion. Consult
pharmacy or ID pharmacy for level interpretation or see Aminoglycoside Dosing &
Monitoring Recommendations [6]
< 20 mL/min
Use traditional dosing40-60
regimen
for patients who
domL/min
not qualify for once-daily
dosing.
mL/min
20-40
>60 mL/min
2 mg/kg Loading Dose
1.2 - 1.5 mg/kg IV
1.2 - 1.5 mg/kg IV
(Consult pharmacy for
1.6 mg/kg IV q8h
q12h
q12-24h
maintenance)

In traditional dosing for gram (-) infections, monitor peak (5-8 mg/L) and trough (< 2 mg/L)
levels.
Lower doses of 1 mg/kg q8h are used for gram (+) synergy; monitor peak (3-4 mg/L) and
trough (< 1 mg/L). See also Aminoglycoside Dosing & Monitoring Recommendations [7]
Isoniazid

300 mg PO q24h

No adjustment for renal

dysfunction

Levofloxacin IV-PO ID-R:VASF[3]

Urinary tract infections

250-500 mg IV/PO
q24h

500 mg x1, then 250 mg IV/PO q24h

500 mg x1, then 250

mg IV/PO q48h

Non-urinary tract infections

750 mg IV/PO q24h

750 mg IV/PO q48h

750 mg x1, then 500

mg IV/PO q48h

Linezolid IV-PO ID-R:UCSF[4]SFGH[5]

VASF[3]

600 mg IV/PO q12h

No adjustment for renal

dysfunction

> 50 mL/min
Meropenem

0.5-1 g IV q8h

ID-R: SFGH[5]VASF[3]

Meningitis, cystic fibrosis

2 g IV q8h

Metronidazole IV-PO
Moxifloxacin IV-PO ID-R:SFGH[5]VASF[3]

25 - 50 mL/min

10-25 mL/min

< 10 mL/min

0.5-1 g IV q12h

0.5 g IV q12h

0.5 g IV q24h

2 g IV q12h

1 g IV q12h

1 g IV q24h

500 mg IV/PO q8h

500 mg IV/PO q12h

400 mg IV/PO q24h

No adjustment for renal

dysfunction

Nafcillin
Meningitis, osteomyelitis or
endovascular infection

2 g IV q4h

Uncomplicated infection

1-2 g IV q6h

No adjustment for renal

dysfunction

Penicillin G ID-R:SFGH[5]
Meningitis, endovascular infection
Uncomplicated infection
Piperacillin/ tazobactam (Zosyn)IDR:SFGH[5]

Documented/suspected
Pseudomonas infections:

3 - 4 MU IV q4h
2 - 3 MU IV q4 - 6h
3.375 g IV q6h

1 - 2 MU IV q4 - 6h

1 MU IV q6h

3.375 g IV q6-8h

2.25 g IV q8h

4.5 g IV q6h for CrCl >20 mL/min

2.25g IV
q8h

Posaconazole SUSPENSION ID-R:

UCSF [4] SFGH [5] VASF [3]

Must be administered with high-fat

meal or nutritional shake i.e Ensure

Treatment of invasive fungal

infections

400 mg PO q12h or 200 mg PO q6h

Neutropenia/GVHD prophylaxis

No adjustment for
renal dysfunction

200 mg PO q8h

Posaconazole TABLETS ID-R:UCSF

[4]SFGH[5]VASF[3]

Neutropenia/GVHD
prophylaxis/Treatment of invasive
fungal infections

300mg PO q12h x2 doses, then 300mg po q24h

No adjustment for renal

dysfunction

20-25 mg/kg PO
q24h
Pyrazinamide IBW

40-55 kg: 1000 mg

56-75 kg: 1500 mg
76-90 kg: 2000 mg

<30 mL/min
25-35 mg/kg po three times weekly

Rifampin

ID-R:SFGH[5]VASF[3]

Strongly recommended review of

concurrent medications due to
many potential drug interactions

Mycobacterial infections

600 mg IV/PO q24h

Prosthetic device infections

450 mg PO q12h

Endocarditis

300 mg PO q8h

No adjustment for renal

dysfunction

Tigecycline ID-R:UCSF[4]SFGH[5]VASF
[3]

100 mg IV x 1, then 50 mg IV q12h

Severe hepatic dysfunction: 100 mg IV x1, then 25 mg IV q12h

Tobramycin
TMP/SMX IV-PO, ABW*

SS Tablet: 80mg TMP

DS Tablet: 160 TMP
*May consider TBW for serious
infections

See Gentamicin

No adjustment for renal

dysfunction

Systemic GNR infections

Pneumocystis pneumonia

10 mg TMP/kg/day
5-7.5 mg TMP/kg/day IV/PO divided q12IV/PO divided q6-12h
24h
15-20 mg
TMP/kg/day IV/PO
divided q6-12h

VancomycinTBW

2.5-5 mg TMP/kg
IV/PO Q24h

10-15 mg TMP/kg/day IV/PO divided q12- 5-10 mg TMP/kg IV/PO

24h
q24h

See Vancomycin Dosing and Monitoring Recommendations [8]

400 mg PO q12h x 2 doses,

then 200 mg PO q12h*

No adjustment for renal

dysfunction**

Mild-to-moderate hepatic dysfunction: Consider reduction of

maintenance dosage by 50%
VoriconazoleIV-PO, ABW ID-R:UCSF[4]
SFGH[5]VASF[3]

Strongly recommended review of

concurrent medications due to
many potential drug interactions

IV dose: LD=6 mg/kg/dose q12h x 2 doses, then 4 mg/kg/dose (ABW) Q12h.

*In obese patients consider a weight-based PO regimen (4 mg/kg q12h ABW), consult ID
or ASP for assistance.
**IV formulation should be avoided if possible in patients with CrCl<50 mL/min due to the
accumulation of the IV vehicle.
Monitor trough levels for treatment of serious infections, therapy failure, or signs of toxicity;
obtain trough level on day 5 of therapy for a new regimen or dose change.

University of California, San Francisco

About UCSF
Search UCSF
UCSF Medical Center

Contact Us
UCSF Main Site
2013 The Regents of the University of California
Source URL: http://idmp.ucsf.edu/adult-antimicrobial-dosing-non-dialysis?mag_q=printpdf/221
Links:
[1] http://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation/
[2] http://www.mdcalc.com/ideal-body-weight/
[3] http://idmp.ucsf.edu/restricted-antimicrobials-veterans-affairs-medical-center-san-francisco
[4] http://idmp.ucsf.edu/restricted-antimicrobials-ucsf-medical-center
[5] http://idmp.ucsf.edu/restricted-antimicrobials-san-francisco-general-hospital
[6] http://idmp.ucsf.edu/aminoglycoside-dosing-and-monitoring-recommendations
[7] http://idmp.ucsf.edu/aminoglycoside-dosing-and-monitoring-recommendationshttp://idmp.ucsf.edu/article/aminoglycoside-dosing-and-monitoringrecommendations
[8] http://idmp.ucsf.edu/vancomycin-dosing-and-monitoring-recommendations