Usual Adult Dose for Bacteremia

2 grams via IV injection over 3 to 5 minutes every 8 hours

Comments:

• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by Pseudomonas aeruginosa and Streptococcus pneumoniae.
• IV administration should be used in patients with bacterial septicemia, meningitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by Escherichia coli, Haemophilus influenzae, Klebsiella species, P aeruginosa, Serratia species, methicillin-susceptible Staphylococcus aureus (MSSA), and/or S pneumoniae
• Treatment of central nervous system (CNS) infections (e.g., meningitis) caused by Haemophilus influenzae and Neisseria meningitidis

Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), American Association of Neurological Surgeons (AANS), and Neurocritical Care Society (NCS) Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 2 grams IV every 8 hours

• Maximum dose: 6 grams/day

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or Propionibacterium acnes with no/minimal cerebrospinal fluid (CSF) pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, Staphylococcus aureus or gram-negative bacilli with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• Streptococcus agalactiae: 14 to 21 days
• Aerobic gram-negative bacilli: 21 days
• Listeria monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunctive empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa
• Alternative empiric treatment for meningitis caused by H influenzae or E coli
• Adjunctive empirical treatment of patients with penetrating head trauma and purulent meningitis caused by S aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), and/or aerobic gram-negative bacilli (e.g., Pseudomonas aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic gram-negative bacilli (e.g., P aeruginosa), and/or P acnes
• Standard treatment of bacterial meningitis caused by P aeruginosa

IDSA:
2 grams IV every 8 hours with/without aminoglycoside

Comment: Preferred treatments may be given with or without aminoglycosides.

Uses:

• Adjunctive preferred treatment of IV catheter-related bloodstream infections caused by P aeruginosa
• Alternative treatment of IV catheter-related bloodstream infections caused by Enterobacter species and Serratia marcescens

Usual Adult Dose for Meningitis

2 grams via IV injection over 3 to 5 minutes every 8 hours

Comments:

• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by Pseudomonas aeruginosa and Streptococcus pneumoniae.
• IV administration should be used in patients with bacterial septicemia, meningitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by Escherichia coli, Haemophilus influenzae, Klebsiella species, P aeruginosa, Serratia species, methicillin-susceptible Staphylococcus aureus (MSSA), and/or S pneumoniae
• Treatment of central nervous system (CNS) infections (e.g., meningitis) caused by Haemophilus influenzae and Neisseria meningitidis

Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), American Association of Neurological Surgeons (AANS), and Neurocritical Care Society (NCS) Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 2 grams IV every 8 hours

• Maximum dose: 6 grams/day

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or Propionibacterium acnes with no/minimal cerebrospinal fluid (CSF) pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, Staphylococcus aureus or gram-negative bacilli with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• Streptococcus agalactiae: 14 to 21 days
• Aerobic gram-negative bacilli: 21 days
• Listeria monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunctive empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa
• Alternative empiric treatment for meningitis caused by H influenzae or E coli
• Adjunctive empirical treatment of patients with penetrating head trauma and purulent meningitis caused by S aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), and/or aerobic gram-negative bacilli (e.g., Pseudomonas aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic gram-negative bacilli (e.g., P aeruginosa), and/or P acnes
• Standard treatment of bacterial meningitis caused by P aeruginosa

IDSA:
2 grams IV every 8 hours with/without aminoglycoside

Comment: Preferred treatments may be given with or without aminoglycosides.

Uses:

• Adjunctive preferred treatment of IV catheter-related bloodstream infections caused by P aeruginosa
• Alternative treatment of IV catheter-related bloodstream infections caused by Enterobacter species and Serratia marcescens

Usual Adult Dose for Sepsis

2 grams via IV injection over 3 to 5 minutes every 8 hours

Comments:

• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by Pseudomonas aeruginosa and Streptococcus pneumoniae.
• IV administration should be used in patients with bacterial septicemia, meningitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by Escherichia coli, Haemophilus influenzae, Klebsiella species, P aeruginosa, Serratia species, methicillin-susceptible Staphylococcus aureus (MSSA), and/or S pneumoniae
• Treatment of central nervous system (CNS) infections (e.g., meningitis) caused by Haemophilus influenzae and Neisseria meningitidis

Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), American Association of Neurological Surgeons (AANS), and Neurocritical Care Society (NCS) Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 2 grams IV every 8 hours

• Maximum dose: 6 grams/day

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or Propionibacterium acnes with no/minimal cerebrospinal fluid (CSF) pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, Staphylococcus aureus or gram-negative bacilli with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• Streptococcus agalactiae: 14 to 21 days
• Aerobic gram-negative bacilli: 21 days
• Listeria monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunctive empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa
• Alternative empiric treatment for meningitis caused by H influenzae or E coli
• Adjunctive empirical treatment of patients with penetrating head trauma and purulent meningitis caused by S aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), and/or aerobic gram-negative bacilli (e.g., Pseudomonas aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic gram-negative bacilli (e.g., P aeruginosa), and/or P acnes
• Standard treatment of bacterial meningitis caused by P aeruginosa

IDSA:
2 grams IV every 8 hours with/without aminoglycoside

Comment: Preferred treatments may be given with or without aminoglycosides.

Uses:

• Adjunctive preferred treatment of IV catheter-related bloodstream infections caused by P aeruginosa
• Alternative treatment of IV catheter-related bloodstream infections caused by Enterobacter species and Serratia marcescens

Usual Adult Dose for Endometriosis

2 grams IM OR via IV injection over 3 to 5 minutes every 8 hours

Comments:

• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of gynecologic infections (including endometritis, pelvic cellulitis, and other infections of the female genital tract) caused by E coli

Usual Adult Dose for Pelvic Inflammatory Disease

2 grams IM OR via IV injection over 3 to 5 minutes every 8 hours

Comments:

• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of gynecologic infections (including endometritis, pelvic cellulitis, and other infections of the female genital tract) caused by E coli

Usual Adult Dose for Pelvic Infections

2 grams IM OR via IV injection over 3 to 5 minutes every 8 hours

Comments:

• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of gynecologic infections (including endometritis, pelvic cellulitis, and other infections of the female genital tract) caused by E coli

Usual Adult Dose for Endometritis

2 grams IM OR via IV injection over 3 to 5 minutes every 8 hours

Comments:

• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of gynecologic infections (including endometritis, pelvic cellulitis, and other infections of the female genital tract) caused by E coli

Usual Adult Dose for Joint Infection

2 grams via IV injection over 3 to 5 minutes every 12 hours

Comments:

• IV administration every 8 hours should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains

IDSA Recommendations:
Treatment: 2 grams IV every 8 hours

• Severe diabetic foot infection (soft tissue only): 2 to 4 weeks
• Residual infected, but viable, bone in diabetic foot infection: 4 to 6 weeks
• Prosthetic joint infection: 4 to 6 weeks
• Native vertebral osteomyelitis: 6 weeks
• Non-surgical patients or postoperative residual dead bone in diabetic foot infection: 3 months or longer

Comments:

• Patients with diabetic foot infections should be started on parenteral treatment and should be switched to oral formulations when possible.
• Obligate anaerobe coverage should be considered in patients with severe diabetic foot infections.

Uses:

• Alternative treatment of native vertebral osteomyelitis caused by P aeruginosa
• Alternative treatment of prosthetic joint infection caused by P aeruginosa
• Empiric adjunctive treatment of severe diabetic foot infections (with vancomycin) caused by methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae, P aeruginosa, and/or obligate anaerobes

Usual Adult Dose for Osteomyelitis

2 grams via IV injection over 3 to 5 minutes every 12 hours

Comments:

• IV administration every 8 hours should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains

IDSA Recommendations:
Treatment: 2 grams IV every 8 hours

• Severe diabetic foot infection (soft tissue only): 2 to 4 weeks
• Residual infected, but viable, bone in diabetic foot infection: 4 to 6 weeks
• Prosthetic joint infection: 4 to 6 weeks
• Native vertebral osteomyelitis: 6 weeks
• Non-surgical patients or postoperative residual dead bone in diabetic foot infection: 3 months or longer

Comments:

• Patients with diabetic foot infections should be started on parenteral treatment and should be switched to oral formulations when possible.
• Obligate anaerobe coverage should be considered in patients with severe diabetic foot infections.

Uses:

• Alternative treatment of native vertebral osteomyelitis caused by P aeruginosa
• Alternative treatment of prosthetic joint infection caused by P aeruginosa
• Empiric adjunctive treatment of severe diabetic foot infections (with vancomycin) caused by methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae, P aeruginosa, and/or obligate anaerobes

Usual Adult Dose for Intraabdominal Infection

2 grams via IV injection over 3 to 5 minutes every 8 hours

Comments:

• Many strains of Bacteroides fragilis are resistant.
• IV administration should be used in patients with peritonitis or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:
Treatment of intraabdominal infections, including:

• Peritonitis caused by E, Klebsiella species, and MSSA
• Polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species

Surgical Infection Society (SIS) and IDSA Recommendations:
Initial dose: 2 grams IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae or P aeruginosa, or gram-negative bacilli (GNB) less than 20% resistant to this drug and metronidazole

International Society for Peritoneal Dialysis (ISPD) Recommendations:
Intermittent (1 exchange daily): 1000 to 1500 mg intraperitoneally once a day

Continuous (all exchanges):

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Duration of therapy: 3 weeks

Comments:

• Intermittent dosing is recommended and should be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use: Adjunctive treatment of peritonitis caused by P aeruginosa

Usual Adult Dose for Peritonitis

2 grams via IV injection over 3 to 5 minutes every 8 hours

Comments:

• Many strains of Bacteroides fragilis are resistant.
• IV administration should be used in patients with peritonitis or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:
Treatment of intraabdominal infections, including:

• Peritonitis caused by E, Klebsiella species, and MSSA
• Polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species

Surgical Infection Society (SIS) and IDSA Recommendations:
Initial dose: 2 grams IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae or P aeruginosa, or gram-negative bacilli (GNB) less than 20% resistant to this drug and metronidazole

International Society for Peritoneal Dialysis (ISPD) Recommendations:
Intermittent (1 exchange daily): 1000 to 1500 mg intraperitoneally once a day

Continuous (all exchanges):

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Duration of therapy: 3 weeks

Comments:

• Intermittent dosing is recommended and should be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use: Adjunctive treatment of peritonitis caused by P aeruginosa

Usual Adult Dose for Pneumonia

empiric MRSA coverage and double antipseudomonal/gram-negative coverage are appropriate
Uncomplicated pneumonia: 500 mg to 1 gram IM OR via IV injection over 3 to 5 minutes every 8 hours
Lung infections caused by Pseudomonas: 30 to 50 m/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Bacteriologic cure may not be expected in patients with chronic respiratory disease and/or cystic fibrosis.
• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, Proteus mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae

IDSA Recommendations:
15 mg/kg IV every 8 to 12 hours

• Some experts recommend a loading dose of 25 to 30 mg/kg IV ONCE (severe illness)

Uses:

• Empiric treatment of clinically suspected ventilator-associated pneumonia where MRSA coverage is appropriate
• Add-on empiric treatment of hospital-acquired pneumonia in patients not at high risk of mortality but with MRSA risk factors
• Add-on empiric treatment of hospital-acquired pneumonia in patients at high risk of mortality or with receipt of IV antibiotics within the previous 90 days

American Thoracic Society (ATS) and IDSA Recommendations:
2 grams IV every 8 hours

Uses:

• Initial empiric treatment for hospital-acquired pneumonia (non-ventilator-associated pneumonia) in patients not at high-risk of mortality, but with factors increasing the likelihood of methicillin-resistant MRSA (e.g., previous IV antibiotic treatment within 90 days, treatment in a unit where the prevalence of MRSA among Staphylococcus aureus isolates is unknown OR greater than 20%)
• Initial empiric treatment for hospital-acquired pneumonia (non-ventilator-associated pneumonia) in patients at high-risk of mortality or receipt of IV antibiotics during the prior 90 days
• Adjunctive empiric treatment for suspected ventilator-associated pneumonia in units where empiric MRSA coverage and double antipseudomonal/gram-negative coverage are appropriate

Usual Adult Dose for Pneumonia with Cystic Fibrosis

empiric MRSA coverage and double antipseudomonal/gram-negative coverage are appropriate
Uncomplicated pneumonia: 500 mg to 1 gram IM OR via IV injection over 3 to 5 minutes every 8 hours
Lung infections caused by Pseudomonas: 30 to 50 m/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Bacteriologic cure may not be expected in patients with chronic respiratory disease and/or cystic fibrosis.
• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, Proteus mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae

IDSA Recommendations:
15 mg/kg IV every 8 to 12 hours

• Some experts recommend a loading dose of 25 to 30 mg/kg IV ONCE (severe illness)

Uses:

• Empiric treatment of clinically suspected ventilator-associated pneumonia where MRSA coverage is appropriate
• Add-on empiric treatment of hospital-acquired pneumonia in patients not at high risk of mortality but with MRSA risk factors
• Add-on empiric treatment of hospital-acquired pneumonia in patients at high risk of mortality or with receipt of IV antibiotics within the previous 90 days

American Thoracic Society (ATS) and IDSA Recommendations:
2 grams IV every 8 hours

Uses:

• Initial empiric treatment for hospital-acquired pneumonia (non-ventilator-associated pneumonia) in patients not at high-risk of mortality, but with factors increasing the likelihood of methicillin-resistant MRSA (e.g., previous IV antibiotic treatment within 90 days, treatment in a unit where the prevalence of MRSA among Staphylococcus aureus isolates is unknown OR greater than 20%)
• Initial empiric treatment for hospital-acquired pneumonia (non-ventilator-associated pneumonia) in patients at high-risk of mortality or receipt of IV antibiotics during the prior 90 days
• Adjunctive empiric treatment for suspected ventilator-associated pneumonia in units where empiric MRSA coverage and double antipseudomonal/gram-negative coverage are appropriate

Usual Adult Dose for Nosocomial Pneumonia

empiric MRSA coverage and double antipseudomonal/gram-negative coverage are appropriate
Uncomplicated pneumonia: 500 mg to 1 gram IM OR via IV injection over 3 to 5 minutes every 8 hours
Lung infections caused by Pseudomonas: 30 to 50 m/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Bacteriologic cure may not be expected in patients with chronic respiratory disease and/or cystic fibrosis.
• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, Proteus mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae

IDSA Recommendations:
15 mg/kg IV every 8 to 12 hours

• Some experts recommend a loading dose of 25 to 30 mg/kg IV ONCE (severe illness)

Uses:

• Empiric treatment of clinically suspected ventilator-associated pneumonia where MRSA coverage is appropriate
• Add-on empiric treatment of hospital-acquired pneumonia in patients not at high risk of mortality but with MRSA risk factors
• Add-on empiric treatment of hospital-acquired pneumonia in patients at high risk of mortality or with receipt of IV antibiotics within the previous 90 days

American Thoracic Society (ATS) and IDSA Recommendations:
2 grams IV every 8 hours

Uses:

• Initial empiric treatment for hospital-acquired pneumonia (non-ventilator-associated pneumonia) in patients not at high-risk of mortality, but with factors increasing the likelihood of methicillin-resistant MRSA (e.g., previous IV antibiotic treatment within 90 days, treatment in a unit where the prevalence of MRSA among Staphylococcus aureus isolates is unknown OR greater than 20%)
• Initial empiric treatment for hospital-acquired pneumonia (non-ventilator-associated pneumonia) in patients at high-risk of mortality or receipt of IV antibiotics during the prior 90 days
• Adjunctive empiric treatment for suspected ventilator-associated pneumonia in units where empiric MRSA coverage and double antipseudomonal/gram-negative coverage are appropriate

Usual Adult Dose for Febrile Neutropenia

2 g IV every 8 hours

Therapy should be continued for approximately 14 days, or until more specific therapy may be substituted for a proven infection, or until the patient is afebrile for 24 hours after the absolute neutrophil count is greater than 500/mm3. The total duration of therapy depends on the nature and severity of the infection.

Usual Adult Dose for Skin or Soft Tissue Infection

Mild infections: 500 to 1 gram IM OR via IV injection over 3 to 5 minutes every 8 hours
Very severe life-threatening infections: 2 grams via IV injection over 3 to 5 minutes every 8 hours

Comments:

• IV administration should be used in patients with severe or life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and Streptococcus pyogenes (group A beta-hemolytic streptococci)

Usual Adult Dose for Cystitis

Uncomplicated Infections: 250 mg IM OR via IV injection over 3 to 5 minutes every 12 hours
Complicated infections: 500 mg IM OR via IV injection over 3 to 5 minutes every 8 to 12 hours

Comments:

• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of complicated/uncomplicated urinary tract infections (UTIs) caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa

Usual Adult Dose for Urinary Tract Infection

Uncomplicated Infections: 250 mg IM OR via IV injection over 3 to 5 minutes every 12 hours
Complicated infections: 500 mg IM OR via IV injection over 3 to 5 minutes every 8 to 12 hours

Comments:

• IV administration should be used in patients with severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Use: Treatment of complicated/uncomplicated urinary tract infections (UTIs) caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa

Usual Adult Dose for Endocarditis

American Heart Association (AHA) and IDSA Recommendations:
Early, culture-negative endocarditis: 2 grams IV 3 times per day PLUS vancomycin, gentamicin, AND rifampin

• Maximum dose: 6 grams/day

Duration of therapy:

• Empirical treatment: 4 to 6 weeks
• Staphylococci infection: 6 weeks

Comment: Gentamicin should be added to patients with enterococcal infections.

Uses:

• Empirical alternative treatment (with gentamicin) of community-acquired native valve or late prosthetic valve (over 1 year after surgery) endocarditis
• Empirical treatment of nosocomial endocarditis associated with vascular cannulae or early prosthetic valve endocarditis (1 year or less after surgery)
• Adjunctive empirical treatment of nosocomial endocarditis associated with gram-negative enteric bacilli
• Empirical treatment in early, culture-negative, prosthetic valve endocarditis

Usual Pediatric Dose for Bacteremia

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Cystitis

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Intraabdominal Infection

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Joint Infection

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Meningitis

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Osteomyelitis

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Peritonitis

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Pneumonia

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Pneumonia with Cystic Fibrosis

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Pyelonephritis

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Septicemia

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Urinary Tract Infection

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Skin and Structure Infection

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Nosocomial Pneumonia

Neonates (0 to 4 weeks): 30 mg/kg via IV injection over 3 to 5 minutes every 12 hours
Infants and children (1 month to 12 years): 30 to 50 mg/kg via IV injection over 3 to 5 minutes every 8 hours

• Maximum dose: 6 grams/day

Comments:

• Higher doses in infants and children should be limited to patients who are immunocompromised and/or have meningitis or cystic fibrosis.
• In a limited number of patients, this drug has been successfully used to treat of meningitis caused by P aeruginosa and S pneumoniae.
• Many strains of B fragilis are resistant.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Uses:

• Alone or in combination with other antibacterial agents for the treatment of confirmed/suspected sepsis
• Concomitantly with aminoglycosides, clindamycin, and vancomycin to treat severe or life-threatening infections and/or in patients who are immunocompromised
• Treatment of bacterial septicemia caused by E coli, H influenzae, Klebsiella species, P aeruginosa, Serratia species, MSSA, and/or S pneumoniae
• Treatment of bone and joint infections caused by Enterobacter species, Klebsiella species, P aeruginosa, and MSSA strains
• Treatment of CNS infections (e.g., meningitis) caused by H influenzae and N meningitidis
• Treatment of complicated/uncomplicated UTIs caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive species), and P aeruginosa
• Treatment of intraabdominal infections, including peritonitis caused by E coli, Klebsiella species, and MSSA OR polymicrobial infections caused by aerobic/anaerobic organisms and Bacteroides species
• Treatment of lower respiratory tract infections (e.g., pneumonia) caused by Citrobacter species, Enterobacter species, E coli, H influenzae (including ampicillin-resistant strains), Klebsiella species, P mirabilis, P aeruginosa and other Pseudomonas species, Serratia species, MSSA, and/or S pneumoniae
• Treatment of skin and structure infections caused by Enterobacter species, E coli, Klebsiella species, Proteus species (including P mirabilis and indole-positive strains), P aeruginosa, Serratia species, MSSA, and S pyogenes (group A beta-hemolytic streptococci)

IDSA, AAN, AANS, and NCS Recommendations:
Healthcare-Associated Ventriculitis and Meningitis: 200 mg/kg IV per day, given in divided doses every 8 hours

Duration of therapy:

• N meningitis or H influenzae: 7 days
• Coagulase-negative staphylococcus or P acnes with no/minimal CSF pleocytosis, normal CSF glucose, few symptoms/systemic features: 10 days
• Coagulase-negative staphylococcus or P acnes with significant CSF pleocytosis, S aureus or GNB with/without significant CSF pleocytosis, CSF hypoglycorrhachia, or symptoms/systemic features: 10 to 14 days
• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days
• L monocytogenes: At least 21 days
• Repeatedly positive CSF cultures on appropriate antimicrobial treatment: Continue treatment for 10 to 14 days after the last positive culture

Uses:

• Adjunct empiric treatment for healthcare-associated ventriculitis and meningitis
• Standard treatment of healthcare-associated ventriculitis and meningitis caused by P aeruginosa

IDSA:
Bacterial meningitis:
Neonates 0 to 7 days: 100 to 150 mg/kg IV per day, given in divided doses every 8 to 12 hours
Neonates 8 to 28 days: 50 mg/kg IV every 8 hours
Infants and children: 50 mg/kg IV every 8 hours

Duration of therapy:

• S pneumoniae: 10 to 14 days
• S agalactiae: 14 to 21 days
• Aerobic GNB: 21 days

Comments:

• Neonates weighing less than 2000 grams may require lower doses and/or longer dosage intervals.
• The duration of treatment in neonates should be 2 weeks beyond the first sterile CSF culture OR at least 3 weeks of treatment, whichever is longer.

Uses:

• Standard treatment of bacterial meningitis caused by P aeruginosa
• Adjunctive empiric treatment of penetrating head trauma and purulent meningitis with vancomycin caused by S aureus coagulase-negative staphylococci (especially S epidermidis), aerobic gram-negative bacilli (e.g., P aeruginosa)
• Adjunctive empiric treatment of postneurosurgery patients with purulent meningitis caused by aerobic gram-negative bacilli (e.g., P aeruginosa), S aureus, and/or coagulase-negative staphylococci, especially S epidermidis
• Adjunctive empiric treatment of patients with CSF shunt and purulent meningitis caused by coagulase-negative staphylococci (especially S epidermidis), S aureus, aerobic GNB (e.g., P aeruginosa), and/or P acnes

ISPD Recommendations:
Continuous peritoneal dialysis:

• Loading dose: 500 mg/L
• Maintenance dose: 125 mg/L

Intermittent peritoneal dialysis: 20 mg/kg intraperitoneally once a day

Duration of therapy:

• E coli or Klebsiella species: 2 weeks
• Acinetobacter species: 2 to 3 weeks
• Enterobacter, Citrobacter, Serratia, and Proteus species: At least 2 to 3 weeks
• Pseudomonas species: 3 weeks

Comments:

• If initial cultures remain sterile at 72 hours and signs/symptoms of peritonitis improve, treatment may continue for 2 weeks.
• Continuous: Loading doses should be allowed to dwell for at least 3 to 6 hours.
• Intermittent: Doses should be administered via the long-dwell (unless otherwise specified) and be allowed to dwell for at least 6 hours.
• Prolonged courses of treatment should be avoided.

Use:

• Adjunctive empiric treatment of peritonitis with a first-generation cephalosporin OR an aminoglycoside if cefepime is unavailable
• Treatment of peritonitis caused by susceptible gram-negative bacteria (e.g., E coli, Proteus species, or Klebsiella species)
• Adjunctive treatment of peritonitis caused by P aeruginosa

SIS and IDSA Recommendations:
Initial dose: 50 mg/kg IV every 8 hours PLUS metronidazole

Comment: Maintenance doses should be based on adjusted body weight and serum drug concentrations.

Use: Empiric combination treatment of complicated extra-biliary community-acquired intraabdominal infections in patients with severe physiologic disturbance, advanced age, or immunocompromised stage caused by ESBL-producing Enterobacteriaceae or P aeruginosa, or GNB less than 20% resistant to this drug and metronidazole

IDSA:
Neonates

• Postnatal age 0 to 4 weeks and less than 1200 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and 1200 to 2000 grams: 50 mg/kg IV every 12 hours
• Postnatal age 7 days or less and greater than 2000 grams: 50 mg/kg per day every 8 to 12 hours
• Postnatal 7 days or more and 1200 grams or more: 50 mg/kg IV per day, given every 8 hours

Infants and children:

• 12 years and less: 50 mg/kg IV every 8 hours

Maximum dose: 6 grams/day

Duration of therapy:

• Uncomplicated infections with catheter removal: 5 to 7 days
• Uncomplicated infections with antibiotic lock therapy: 10 to 14 days

Use: Empirical treatment for catheter-related bloodstream infections

Usual Pediatric Dose for Bacterial Infection

American Academy of Pediatrics (AAP) Recommendations:
Gestational age (GA) younger than 32 weeks:

• Postnatal age (PNA) younger than 14 days: 50 mg/kg IV OR IM every 12 hours
• PNA 14 days or older: 50 mg/kg IV OR IM every 8 hours

GA 32 weeks or older:

• PNA 7 days or younger: 50 mg/kg IV OR IM every 12 hours
• PNA older than 7 days: 50 mg/kg IV OR IM every 8 hours

Pediatric patients beyond the newborn period:
Infections: 90 to 150 mg/kg IV OR IM per day, given in 3 divided doses

• Maximum dose: 6 grams/day

Pseudomonal infections: 200 to 300 mg/kg IV OR IM per day, given in 3 divided doses

• Maximum dose: 12 grams/dose

Usual Pediatric Dose for Endocarditis

AHA and IDSA Recommendations:
Early, culture-negative endocarditis: 100 to 150 mg/kg IV per day, given in divided doses every 8 hours PLUS vancomycin AND gentamicin

• Maximum dose: 2 to 4 grams/day

Duration of therapy: At least 6 weeks

Comment: Gentamicin should be added to patients with enterococci infections.

Uses:

• Empirical alternative treatment (with gentamicin) of community-acquired native valve or late prosthetic valve (over 1 year after surgery) endocarditis
• Empirical treatment of nosocomial endocarditis associated with vascular cannulae or early prosthetic valve endocarditis (1 year or less after surgery)
• Adjunctive empirical treatment of nosocomial endocarditis associated with gram-negative enteric bacilli
• Empirical treatment in early, culture-negative, prosthetic valve endocarditis

Renal Dose Adjustments

Children: Dose adjustment(s) may be required; however, no specific guidelines have been suggested. Caution recommended.

Adults:
Loading dose: 1 gram IM OR via IV injection over 3 to 5 minutes ONCE

Mild to moderate infections:

• Glomerular filtration rate (GFR) 31 to 50 mL/min: 1 gram IM OR via IV injection over 3 to 5 minutes every 12 hours
• GFR 16 to 30 mL/min: 1 gram IM OR via IV injection over 3 to 5 minutes every 24 hours
• GFR 6 to 15 mL/min: 500 mg IM OR via IV injection over 3 to 5 minutes every 24 hours
• GFR less than 5 mL/min: 500 mg IM OR via IV injection over 3 to 5 minutes every 48 hours

Severe infections: Patients requiring doses of 6 grams/day should increase the daily dose by 50% OR increase the frequency accordingly; subsequent dosing should be determined by monitoring levels, infection severity, and the susceptibility of causative organism.

Comments:

• The lowest dosage should be used.
• IV administration should be used in patients with bacterial septicemia, meningitis, peritonitis, or severe/life-threatening infections or in those with diabetes, heart failure, malignancy, malnutrition, surgery, or trauma, especially if shock is present/pending.
• The Cockcroft-Gault equation may be used when only the patient's serum creatinine is available.
• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.

Liver Dose Adjustments

No adjustment recommended.

Precautions

CONTRAINDICATIONS:

• Hypersensitivity to the active component, the cephalosporin group of antibiotics, or to any of the ingredients

Consult WARNINGS section for additional precautions.

Dialysis

Hemodialysis:

• Loading dose: 1 gram IM OR via IV injection over 3 to 5 minutes ONCE
• Maintenance dose: 1 gram IM OR via IV injection over 3 to 5 minutes after each dialysis session

Intraperitoneal dialysis AND continuous ambulatory peritoneal dialysis:

• Loading dose: 1 gram via IV injection over 3 to 5 minutes ONCE
• Maintenance dose: 500 mg via IV injection over 3 to 5 minutes every 24 hours

Comments:

• This drug should be continued for 2 days after signs/symptoms of infection have disappeared; however, the duration of treatment may be longer in severe infection.
• When necessary, this drug may be incorporated into dialysis fluid at a concentration of 250 mg per 2 L of dialysis fluid.

IDSA:

• Empirical dosing: 1 gram IV after each dialysis session

Comment: Patients with persistent bacteremia, with endocarditis, or suppurative thrombophlebitis should continue treatment for 4 to 6 weeks after hemodialysis catheter removal; those with osteomyelitis should continue treatment for 6 to 8 weeks.

Uses:

• Adjunctive preferred treatment of IV catheter-related bloodstream infections caused by Pseudomonas aeruginosa
• Alternative treatment of IV catheter-related bloodstream infections caused by Enterobacter species and Serratia marcescens

Other Comments

Administration advice:

• IM: This drug should be given deep into a large muscle (e.g., upper outer quadrant of the gluteus maximus, lateral thigh).
• IV: This drug may be given via IV injection (over 3 to 5 minutes) OR infusion; intraarterial administration should be avoided.

Storage requirements:

• The manufacturer product information should be consulted.

Reconstitution/preparation techniques:

• The manufacturer product information should be consulted.

IV compatibility:

• Compatible diluents and IV solutions: 1/6 M sodium lactate, 10% dextrose, 10% invert sugar in water, 0.45% sodium chloride, 5% dextrose, 5% dextrose and 0.225% sodium chloride, 5% dextrose and 0.45% sodium chloride, 5% dextrose and .09% sodium chloride, 0.9% sodium chloride, Lactated Ringer's, lidocaine (lignocaine), Normosol-M in 5% dextrose, Ringer's injection, sterile water for injection
• Incompatible: Aminoglycosides, aminophylline, pentamidine, sodium bicarbonate, vancomycin

General:

• Local epidemiological and susceptibility patterns should be used to guide treatment selection in the absence of patient-specific culture and susceptibility information.
• Spectrum of Activity: This drug has shown activity in vitro and in clinical infections against most isolates of Citrobacter species (including Citrobacter koseri, Enterobacter species, Escherichia coli, Haemophilus influenzae, Klebsiella species, Moraxella catarrhalis, Neisseria meningitidis, Pasteurella multocida, Proteus mirabilis, Proteus vulgaris, Pseudomonas aeruginosa, some Bacteroides isolates, Serratia species, Staphylococcus aureus (methicillin-sensitive), Streptococcus agalactiae, Streptococcus pneumoniae (penicillin-susceptible or highly susceptible), Streptococcus pyogenes,
• Limitations of use: There are limited susceptibility data for the following: Acinetobacter species (including Acinetobacter baumannii), most Bacteroides isolates (especially Bacteroides fragilis), Burkholderia cepacian, Chlamydia species, Citrobacter diversus, Citrobacter freundii, Clostridium species (e.g., Clostridium perfringens, NOT Clostridium difficile), Enterobacter aerogenes, Enterobacter cloacae, Enterococcus species (e.g., Enterococcus faecalis, Enterococcus faecium), Fusobacterium species, Haemophilus parainfluenzae, Klebsiella pneumoniae, Klebsiella species (other), Legionella species, Listeria species, Morganella morganii, Mycoplasma species, Neisseria gonorrhoeae, Peptostreptococcus species, Providencia species (e.g., Providencia rettgeri), Salmonella species, Shigella species, Staphylococcus aureus (methicillin-resistant), Staphylococcus epidermidis, Streptococcus pneumoniae (penicillin-resistant or intermediately susceptible), Viridans group Streptococcus (VGS), and/or Yersinia enterocolitica

Monitoring:

• RENAL: Renal function tests, especially in patients receiving prolonged treatment and/or concomitant aminoglycoside administration

Patient advice:

• Inform patients that this drug may cause dizziness, and they should avoid driving or operating machinery if these side effects occur.
• Advise patients to speak to their healthcare provider if they become pregnant, intend to become pregnant, or are breastfeeding.
• Patients should be directed to take the full course of treatment, even if they feel better.
• Patients should be instructed to report signs/symptoms of Clostridium difficile (e.g., watery/bloody stools, stomach cramps, fever), for up to 2 months after stopping treatment.