This document provides dosing guidelines for various antimicrobials, antifungals, and antivirals used at LPCHS. It notes that doses do not include adjustments for neonates, cystic fibrosis, or renal function. It also states that all inpatient restricted antimicrobial use requires approval from pediatric infectious disease and lists antimicrobials that require such approval. Therapeutic drug monitoring parameters are provided for some agents.

1. LPCHS Formulary Antimicrobials
 The doses provided are general recommendations
and do NOT include neonatal dosing, cystic fibrosis
dosing, or renal dose adjustment.
 Please refer to the Housestaff Manual or Neofax
for additional recommendations and indication-
specific dosing.
 Maximum individual doses in parentheses.
 Renal dose adjustment parameters indicated by
superscript:
1
Adjustment needed if CrCl < 70 mL/min
2
Adjustment needed if CrCl < 50 mL/min
3
Adjustment needed if CrCl < 30 mL/min
 All inpatient restricted antimicrobial use, including
continuation of home medications, requires Pedi-
atric Infectious Disease (ID) approval. Contact the
Pediatric ID fellow on-call for approval.
 For additional assistance, consider ASP or ID
consultation.
(ID) = Requires ID approval for use:
Colistin Linezolid Posaconazole
Cidofovir Micafungin Tigecycline
Daptomycin
(PI) = Prolonged infusion may be considered (i.e.,
extended infusion, continuous infusion)
(R) = Restricted indications (requires ID approval)
(TDM) = Therapeutic drug monitoring recommended
GENERAL INFORMATION
ABBREVIATIONS
THERAPEUTIC DRUG MONITORING
DRUG
DOSING
INTERVAL
TROUGH
(mcg/mL)
PEAK*
(mcg/mL)
Amikacin
Q8h
< 8
20—30
Q24h 30—55
Gentamicin
or
Tobramycin
Q8h
< 1
4—10
Q24h 15—25
Posaconazole Variable
Prophylaxis
>700 ng/mL
Treatment
>1250 ng/mL
N/A
Vancomycin
Usual
dosing
10—20 N/A
Voriconazole Q12h 1—6 N/A
*30min post end of 30 min infusion or 60 min post end of 60min infusion
PARENTERAL (IV) ANTIBIOTICS
DRUG DOSAGE
Amikacin2
(TDM)
7.5 mg/kg/dose q8h (500 mg)
15—20 mg/kg/dose q24h (1.5 g)
CF: 30 mg/kg/dose q24h
Ampicillin3
50—100 mg/kg/dose q6h (2g)
Ampicillin/
sulbactam3
50 mg/kg/dose q6h (2g) (dose based on
ampicillin)
Aztreonam3
30 mg/kg/dose q6h (2g)
CF: 50 mg/kg/dose q6h (2g)
Cefazolin3
16.5—50 mg/kg/dose q8h (2g)
Cefepime2
(PI) 50 mg/kg/dose q8h (2g)
Cefoxitin 40 mg/kg/dose q6-8h (2g)
Ceftazidime2
(PI)
50 mg/kg/dose q8h (2g)
Ceftriaxone 50—75 mg/kg/dose q24h (2g)
Meningitis: 50 mg/kg/dose q12h (2g)
Ciprofloxacin3
10—15 mg/kg/dose q8-12h (400mg)
Clindamycin 10—13 mg/kg/dose q8h (900mg)
Colistin (ID)1
1.7—2.5 mg/kg/dose q8-12h
Daptomycin3
(ID)
6—12 mg/kg/dose q24h
Doxycycline 2 mg/kg/dose q12h (100mg)
Gentamicin2
(TDM)
2—2.5 mg/kg/dose q8h
5—7.5 mg/kg/dose q24h
Synergy: 1—3 mg/kg/dose q8-24h
Levofloxacin2
<5yr: 8—10 mg/kg/dose q12h
>5yr: 10 mg/kg/dose q24h (750mg)
Linezolid (ID) <12yr: 10 mg/kg/dose q8h (600mg)
>12 yr: 10 mg/kg/dose q12h
(600mg)
Meropenem2
(PI)
20 mg/kg/dose q8h (1g)
Meningitis/CF: 40 mg/kg/dose q8h
(2g)
Metronida-
zole3
10 mg/kg/dose q8h (750mg)
Appendicitis: 30 mg/kg/dose q24h
(1g, unless >80kg, then 1.5g)
Nafcillin3
(PI) 33-50 mg/kg/dose q4-6h (2g)
Penicillin G3
25,000—66,000 units/kg/dose q4-6h
(4million units)
Piperacillin/
tazobactam2
(PI)
80—100 mg/kg/dose q6-8h (4g)
Tigecycline
(ID)
<40kg: 1.2 mg/kg/dose q12h(50mg)
>40kg: Load 1.2 mg/kg/dose (100
mg), followed by 50 mg q12h
Tobramycin2
2—2.5 mg/kg/dose q8h
5—7.5 mg/kg/dose q24h
Trimethoprim/
sulfamethoxa-
zole
3
(dose based
on trimethoprim)
Treatment: 3-6 mg/kg/dose q12h
(160mg)
Stenotrophomonas: 5 mg/kg/dose
q8h (320mg)
PCP: 5 mg/kg/dose q6-8h (320mg)
Vancomycin3
(TDM)
15—20 mg/kg/dose q6-8h (per
Pharmacy)
ENTERAL (PO) ANTIBIOTICS
Amoxicillin3
12.5—30 mg/kg/dose TID (1g)
S. pneumoniae: 40—45 mg/kg/dose
BID (2g)
Amoxicillin/
clavulanate3
12.5—30 mg/kg/dose TID (875mg)
S. pneumoniae: 40—45 mg/kg/dose
BID (2g) (dose based on amoxicillin)
Azithromycin Respiratory infection: 10 mg/kg
once on day 1 (500mg), then 5 mg/
kg (250mg) q24h on days 2-5
Cefdinir3
7 –14 mg/kg/dose daily—BID
(600mg/day)
Cefixime1
(R) 8 mg/kg/dose once daily (400mg)
Cefuroxime3
15 mg/kg/dose BID (500mg)
Cephalexin3
12.5—50 mg/kg/dose TID-QID (1g)
Ciprofloxacin3
10—15 mg/kg/dose BID (750mg)
Clindamycin3
7—10 mg/kg/dose TID (600mg)
Doxycycline 2 mg/kg/dose q12h (100mg)
Levofloxacin2
<5yr: 8—10 mg/kg/dose q12h
>5yr: 10 mg/kg/dose q24h (750mg)
Linezolid (ID) <12yr: 10 mg/kg/dose q8h (600mg)
>12yr:10 mg/kg/dose q12h (600mg)
Metronidazole 10 mg/kg/dose q8h (750mg)
Nitro-
furantoin1
(Macrodantin
®)
Treatment: 1.2—2.5 mg/kg/dose
QID (100mg)
Prophylaxis: 1—2 mg/kg/dose
daily—BID (100mg)
Penicillin3
12.5 mg/kg/dose QID (500mg)
Rifampin 5-10 mg/kg/dose daily-BID (600mg)
Trime-
thoprim /
sulfamethoxa-
zole3
Treatment: 3-6 mg TMP compo-
nent/kg/dose q12h (160mg)
Prophylaxis: 2-5mg TMP compo-
nent/kg/dose daily (160mg)
ANTIFUNGALS
Liposomal
amphotericin
IV: 3—5 mg/kg/dose q24h
Caspofungin Treatment: IV: Load 70 mg/m2
once
(70mg), then 50 mg/m2
daily (50mg)
Prophylaxis: IV: 1 mg/kg/dose q24h
(50mg)
Micafungin
(ID)
Treatment: IV: 2—4 mg/kg/dose q24h
(150mg)
Prophylaxis: IV: 1.5 mg/kg/dose q24h
(50mg)
Fluconazole2
IV/PO: Loading dose 6—12 mg/kg/
dose once, followed by 3– 12 mg/kg/
dose daily (800mg)
Posaconazole
(ID) (TDM)
Treatment (suspension): 5.5 mg/kg/
dose QID (200mg)
Prophylaxis (suspension): 4 mg/kg/
dose TID (200mg)
Treatment/Prophylaxis (tablet): 300mg
BID X 1 day, then 300mg once daily
Voriconazole
(TDM)
See age-specific HSM recommendation
Treatment: IV/PO: 6—9 mg/kg/dose
q12h x 2 doses, followed by 4—9 mg/
kg/dose q12h
Prophylaxis: IV/PO: 7 mg/kg/dose BID
(200mg)
ANTIVIRALS
Acyclovir2
>70kg: Use ideal body weight
Treatment: IV: 10—15 mg/kg/dose
q8h (800mg); PO:15—20 mg/kg/dose 3
-5x/day (800mg); hydration required
Prophylaxis: IV: 5 mg/kg/dose or 250
mg/m2
q8h (300mg); PO: 10—15 mg/
kg/dose TID (300mg)
Cidofovir (ID) 1—5 mg/kg/dose IV 1-3 x/week
(hydration required; +/- probenecid)
Ganciclovir1
Treatment: 5 mg/kg/dose IV q12h
Prophylaxis: 5 mg/kg/dose IV q24h
Oseltamivir3
(PO)
Treatment: 3 mg/kg/dose BID (75 mg)
Prophylaxis: 3 mg/kg/dose daily
(75mg)
Valacyclovir2
Treatment: 20 mg/kg/dose PO BID (1g)
Prophylaxis: 250—500 mg PO BID
Valgan-
ciclovir1
Treatment: 12—20 mg/kg/dose IV
q12h (900 mg)
Prophylaxis: 10—15 mg/kg/dose IV
daily (900mg)