Pediatric Pharmacy #: 984-974-6679 Blue Team Pharmacist Pager #: 123-7108 Antimicrobial Medication Guide for Pediatric Cystic Fibrosis Patients Oral Antibiotics *See NTM section for organism-specific dosing for mycobacterial infections. Drug Dosing Maximum Available preparations Other considerations single dose Amoxicillin/ 15 mg/kg TID 2000 mg 500mg*, 875mg tablets* 600mg/5mL for high clavulanic acid (standard dose) or 45 200mg, 400mg chewables* dose only mg/kg BID (high dose) XR tablets 1000mg 200mg/5mL, 400 mg/5mL suspension* ES suspension: 600 mg/5mL (less clavulanic acid) Cefpodoxime 5 mg/kg BID 200 mg 100mg, 200mg tablets 50mg/5mL, 100mg/5mL suspension Cefuroxime axetil 10-15 mg/kg BID 500 mg 125mg, 250mg*, 500mg Suspension and tablet (suspension) or tablets* are not interchangable 250-500mg BID 125mg/5mL, 250mg/5mL Suspension must be (tablet) suspension administered with food Cephalexin 25 mg/kg QID 1000 mg 250*, 500mg capsules* 125mg/5mL, 250mg/5mL suspension* Ciprofloxacin 20 mg/kg BID 1000 mg 100mg, 250mg*, 500mg*, Do not give oral 750mg tablets* suspension via G-tube 100 mg/mL, 250mg/5mL or NG tube suspension Hold tube feeds 1 hr 500mg, 1000mg XR tablets before and 2 hrs after administration Clindamycin 40 mg/kg/day divided 600 mg 75mg, 150mg*, 300mg capsules TID 75mg/5mL suspension* Dicloxacillin2 6.25-12.5mg/kg QID 500 mg 125mg, 250mg*, 500mg capsules* Doxycycline 1-2 mg/kg BID 100 mg 50mg, 100mg capsules* Avoid within 2hrs of 25mg/5mL suspension* antacids, Ca, Fe, Mg, and cholestyramine Levofloxacin < 5 yo: 10 mg/kg BID 750 mg 250mg*, 500mg*, 750mg Suspension should be > 5 yo: 10 mg/kg daily tablets* administered 1 hr 25mg/mL solution* before or 2hrs after eating Linezolid < 12 yo: 10 mg/kg Q8 600 mg 600mg tablet* Consider continuing q8 > 12yo: 10 mg/kg Q12 100mg/5mL suspension* hour dosing if > 12 yr but less than 45 kg Minocycline 4 mg/kg once, then 2 100 mg 50mg*, 75mg, 100mg capsules* Avoid within 2hrs of mg/kg Q12 antacids, Ca, Fe, Mg, and cholestyramine Rifampin 10 mg/kg Q12 600mg 150mg*, 300mg capsules* Do not use as 25mg/mL suspension* monotherapy; for synergy only Sulfamethoxazole/ 15-20 mg TMP/kg/day 320mg TMP 80 mg TMP+400 mg SMX tab*, Trimethoprim (SMX/TMP) divided Q8-Q12 160 mg TMP+800 mg SMX DS tab* 40mg TMP+200mg SMX/5mL suspension* Tedizolid^ 200 mg once daily+ 200 mg 200 mg tablet ^Requires approval by ID consult or Pediatric ID Stewardship for inpatient use *Indicates UNC formulary item + Adult dosing (pediatric dosing not available): for patients <40kg, consult pediatric pulmonary and/or ID/ASP pharmacist for dosing 1 Pediatric Pharmacy #: 984-974-6679 Blue Team Pharmacist Pager #: 123-7108 Intravenous Antibiotics *See NTM section for organism-specific dosing for mycobacterial infections. • Double-cover Pseudomonas, but do not combine anti-pseudomonal beta lactams, as they can be antagonistic • Initial doses for Tobramycin and Amikacin should be based on patients’ previous doses; see pharmacist consult note for past dosing information • If patient has not received aminoglycosides in the past, use the following guide for dosing Consider alternative dosing regimens for patients with lack of response to antibiotic expected to have activity – consult service pharmacist for appropriateness and availability Drug Traditional Dosing Alternative Dosing Maximum single Other considerations dose Aztreonam1,2* 50-75 mg/kg Q6 8-12 g/day Cefepime1,3* 50 mg/kg Q8 Intermittent: 50 mg/kg Q6 2000 mg Extended: 50 mg/kg Q8 (infused over 4 hours) Ceftaroline4* < 6 years: 8 mg/kg Q8 600mg > 6 years and <33 kg: 15 mg/kg Q8 > 33 kg (adolescent/adult): 600 mg Q8 Ceftazidime1,3* 200-400 mg/kg/day divided Continuous: 100-200 8-12 g/day Q6-8 mg/kg/day Ceftazidime/ 2.5 g q8+ (2g ceftazidime/500 2.5 g Only for MDR Gram negative avibactam*^ mg avibactam) pathogens; susceptibility must be documented prior to use Ceftolozane/ 3 g Q8+ (2g ceftolozane/1 g 3 g Only for MDR Gram negative tazobactam5*^ tazobactam) pathogens; susceptibility must be documented prior to use Cefuroxime* 75 mg/kg Q8 1500 mg Ciprofloxacin1,6* 10 mg/kg Q8 400 mg Clindamycin* 40 mg/kg/day divided Q8 2700 mg/day Colistin1,7*^ 3-5 mg/kg/day divided Q8 100mg Monitor renal function closely Can use up to 8 mg/kg/day Only for MDR Gram negative pathogens; susceptibility must be requested/ documented prior to use Imipenem/ 25 mg/kg Q6 1000 mg Cilastatin1,2* Levofloxacin1,6* < 5 yo: 10 mg/kg Q12 750 mg > 5 yo: 10 mg/kg daily Linezolid* < 12 yo: 10 mg/kg Q8 600 mg Consider continuing q 8 hour ≥ 12 yo: 10 mg/kg Q12 dosing if > 12 yr but less than 45 kg Meropenem1,2* 40 mg/kg Q8 Extended: 40 mg/kg q8h 2000 mg (infused over 3 hours) Oxacillin1* 50 mg/kg Q6 Continuous: 200mg/kg/day 2000 mg Piperacillin/ 100 mg/kg Q6 Extended: 100 mg/kg Q6 4000mg All doses are based on Tazobactam1,3,25* (infused over 3 hours) piperacillin (4.5g piperacillin component Continuous: 200-300 Zosyn®) mg/kg/day Tedizolid^ 200mg Q24 200mg Tobramycin* 10 mg/kg Q24 or previous total Draw levels at 2 and 8 hours (extended interval) daily dose after 2nd dose started Vancomycin11, 22* 15-20 mg/kg Q6-8 Continuous: 55-60 2000 mg Intermittent: Draw trough mg/kg/day (intermittent) prior to 4th dose; goal 15-20 mg/L Continuous: Draw random level after 24 hours; goal 20- 25 mg/L ^Requires approval by ID consult or Pediatric ID Stewardship for inpatient use *Indicates UNC formulary item + Adult dosing (pediatric dosing not available): for patients <40kg, consult pediatric pulmonary and/or ID/ASP pharmacist for dosing 2 Pediatric Pharmacy #: 984-974-6679 Blue Team Pharmacist Pager #: 123-7108 Nontuberculous Mycobacterium – Antibiotics *Typically start only one drug each day to assess for adverse effects from each drug Recommended Initial Regimen for Mycobacterium abscessus: 1. Clarithromycin or azithromycin 2. Amikacin 3. Cefoxitin, imipenem/cilastatin, tigecycline, or linezolid Recommended Initial Regimen for Mycobacterium avium complex (MAC): 1. Azithromycin 2. Ethambutol 3. Rifampin Drug Dosing Maximum dose Other considerations Amikacin13 (IV) 10-15 mg/kg IV daily 1500mg/dose Draw 2 and 8 hour levels with 2nd or 3rd dose; goal peak = 20-30 mg/L Audiology consult required at initiation Thrice weekly dosing can be considered for unique patient cases Amikacin21(inhalation) 250-500 mg inhaled daily-BID 500mg/dose Arikayce®: 590mg inhaled daily Azithromycin13,21 10-12 mg/kg PO daily 500mg/dose Consider obtaining drug levels at 2 and 6 hours Bedaquiline24^ Weeks 1-2: 400 mg PO daily Reserve for refractory NTM cases Weeks 3 and onward: 200 mg TIW Weight 20-32 kg: 200 mg PO daily x 2 weeks, then 100 mg TIW Weight > 32 kg: 400 mg PO daily x 2 weeks, then 200 mg TIW Cefoxitin13,21 Children: 50mg/kg IV TID 12g/day Adults: 200 mg/kg/day IV divided TID Clarithromycin13,21 7.5 mg/kg PO BID 500mg/dose Consider obtaining drug levels at 2 and 6 hours Clofazimine^ 50-100 mg PO daily 150 mg Reserve for refractory NTM cases (requires an IRB and IND) Ethambutol21 15 mg/kg PO daily Consider obtaining drug levels at 2 and 6 hours Imipenem/ cilastatin13,21(IV) 15-20 mg/kg IV BID 1000mg/dose Linezolid13,21(PO, IV) < 12 yo: 10 mg/kg Q8 600mg 1:1 PO to IV conversion ≥ 12 yo: 10 mg/kg daily-BID Consider concomitant vitamin B6 Minocycline21 Children: 2 mg/kg PO daily 200mg/dose Adults: 100mg PO BID Moxifloxacin21 7.5-10 mg/kg PO daily 400mg/dose Rifampin21 10-20 mg/kg PO daily < 50 kg: 450mg/day Significant potential for drug > 50 kg: 600mg/day interactions Consider obtaining drug levels at 2 and 6 hours SMX/TMP21 (PO, IV) 10-20 mg/kg TMP BID PO: 160mg TMP/dose Consider fluid status of patient when IV: 1440mg/dose utilizing IV formulation Tedizolid (PO, IV) 200 mg once daily PO/IV: 200 mg Tigecycline13,14,21 < 10 yo: 1.2 mg/kg IV Q12 50mg Recommend pre-medication with > 10 yo: 100mg loading dose, then ondansetron or other antiemetic 50mg IV daily-BID ^Requires approval by ID consult or Pediatric ID Stewardship for inpatient use *Indicates UNC formulary item + Adult dosing (pediatric dosing not available) 3 Pediatric Pharmacy #: 984-974-6679 Blue Team Pharmacist Pager #: 123-7108 Antifungals *These have lots of drug interactions! *Consult pharmacy for assistance transitioning between dosage forms. Drug Dosing Maximum Available oral initial preparations single dose Fluconazole 12 mg/kg x 1, then 6-12 mg/kg IV/PO 800mg 50mg*, 100mg*, 150mg*, Q24 200 mg tablets* 40mg/mL suspension* Itraconazole 5 mg/kg PO Q12 200 mg 100mg capsules* 50mg/5mL solution* Voriconazole (PO/IV) Loading doses: 350 mg 50mg*, 200mg tablets* < 12 yo OR 12-14 yo AND < 50 kg: 9 40mg/mL suspension* mg/kg IV Q12 x 2 doses > 12 yo AND > 50kg: 6 mg/kg IV Q12 x 2 doses Maintenance doses: < 12 yo: 9 mg/kg IV Q12 > 12 yo AND > 50kg: 4 mg/kg IV Q12 Posaconazole20 Suspension: 18-24 mg/kg/day divided Suspension: 40mg/mL suspension* QID 400mg 100mg DR tablet* Tablets: <13 yo: 10-15 mg/kg/day divided BID Tablets: > 13 yo: 6-8 mg/kg BID x 1 day, then 6- 300mg 8 mg/kg daily IV: 10-12 mg/kg BID x 1 day, then 10- 12 mg/kg daily Considerations for antifungal therapies: Fluconazole Itraconazole Posaconazole Voriconazole Renally Dose Yes No No No, but do not use IV Adjust formulation if CrCl<50 Drug PPIs: May decrease PPIs: May decrease PPIs: May decrease PPIs: May increase Interactions fluconazole levels itraconazole levels posaconazole levels voriconazole levels Meals Capsules: food increases Capsules: food increases Suspension: best absorption Food may decrease absorption absorption with a hiGh-fat meal and voriconazole absorption acidic beverage Solution: food decreases Solution: food decreases Give 1 hour before or 1 hour absorption.