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Vancomycin Dosage

Medically reviewed on May 1, 2018.

Applies to the following strengths: 500 mg; 500 mg/6 mL; 125 mg; 250 mg; 250 mg/5 mL; 1 g; 10 g; 5%-500 mg/100 mL; 5 g; 5%-1 g/200 mL; 750 mg/150 mL-NaCl 0.9%; 750 mg/150 mL-D5%; 500 mg/100 mL-NaCl 0.9%; 1 g/200 mL-NaCl 0.9%; 750 mg; 1.25 g/250 mL-NaCl 0.9%; 1.5 g/250 mL-NaCl 0.9%; 2 g/500 mL- NaCl 0.9%; 2 g/250 mL-NaCl 0.9%; 1.25 g/150 mL-NaCl 0.9%; 1.25 g/250 mL-D5%; 1.5 g/500 mL-D5%; 1 g/250 mL-D5%; 1 g/150 mL-NaCl 0.9%; 500 mg/5 mL; 1 g/250 mL-NaCl 0.9%; 1.25 g/300 mL-NaCl 0.9%; 1.5 g/300 mL-NaCl 0.9%; 1.5 g/150 mL-NaCl 0.9%; 1.75 g/250 mL-NaCl 0.9%; 1.5 g/250 mL-D5%; 1.5 g/500 mL-NaCl 0.9%; 25 mg/mL; 50 mg/mL; 1.75 g/500 mL-NaCl 0.9%; 750 mg/250 mL-NaCl 0.9%

Usual Adult Dose for Bacterial Infection

500 mg IV every 6 hours OR 1 g IV every 12 hours

Comments:
-This drug should be administered at a rate up to 10 mg/min or over 1 hour, whichever is longer.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Use: Empirical treatment of serious/severe staphylococcal infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

Infectious Diseases Society of America (IDSA) Recommendations:
15 mg/kg IV every 12 hours

Comments:
-Treatment plus an aminoglycoside should be used for ampicillin-resistant, vancomycin-sensitive Enterococcus faecalis/Enterococcus faecium.

Uses:
-Preferred treatment for IV catheter-related bloodstream infections caused by methicillin-resistant Staphylococcus aureus (MRSA)/coagulase-negative staphylococci, ampicillin-resistant, vancomycin-sensitive E faecalis/E faecium, Corynebacterium jeikeium (Group JK)
-Alternative treatment for IV catheter-related bloodstream infections caused by methicillin-susceptible Staphylococcus aureus (MSSA)/coagulase-negative staphylococci, ampicillin-susceptible E faecalis/E faecium

Usual Adult Dose for Endocarditis

500 mg IV every 6 hours OR 1 g IV every 12 hours

Comments:
-This drug should be administered at a rate up to 10 mg/min or over 1 hour, whichever is longer.
-Doses should be determined by patient-specific factors (e.g., obesity, age).
-Successful treatment of diphtheroid endocarditis has been reported.

Uses:
-Empirical treatment of staphylococcal endocarditis caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment (with an aminoglycoside) of endocarditis caused by enterococci, Streptococcus bovis, or Streptococcus viridans
-Empirical treatment (with an aminoglycoside and/or rifampin) of early-onset prosthetic valve endocarditis caused by Staphylococcus epidermidis or diphtheroids

American Heart Association (AHA) and IDSA Recommendations:
15 to 20 mg/kg per day IV every 8 to 12 hours
-Maximum dose: 2 g/dose

Duration of treatment:
-Native Valve Endocarditis: At least 4 weeks
-Prosthetic Valve Endocarditis: At least 6 weeks

Comments:
-Patients may not require the addition of gentamicin or rifampin.
-Patients with native valve endocarditis caused by oxacillin-resistant staphylococci may require at least 6 weeks of treatment.

Uses:
-Treatment of endocarditis caused by highly penicillin-susceptible and relatively resistant to penicillin viridians group streptococci (VGS) and Streptococcus gallolyticus (bovis) in patients who cannot tolerate penicillin or ceftriaxone
-Treatment of endocarditis involving a prosthetic value/other prosthetic material caused by VGS and S gallolyticus (bovis)
-Alternative treatment of endocarditis caused by oxacillin-resistant staphylococci in patients with immediate-type hypersensitivity to beta-lactam antibiotics
-Treatment of penicillin-resistant endocarditis caused by enterococci in patients unable to tolerate beta-lactam antibiotics

Usual Adult Dose for Pseudomembranous Colitis

Clostridium difficile-associated diarrhea: 125 mg orally 4 times a day
-Duration of therapy: 10 days

Enterocolitis: 500 mg to 2 g orally per day, given in divided doses 3 to 4 times a day
-Maximum dose: 2 g/day
-Duration of therapy: 7 to 10 days

Comment: Formulations administered parenterally will not treat colitis.

Uses:
-Treatment of C difficile-associated diarrhea
-Treatment of enterocolitis caused by S aureus (including MRSA)

Society of Healthcare Epidemiology of America (SHEA) and IDSA Recommendations:
Initial treatment of severe C difficile infection (CDI): 125 mg orally 4 times a day
-Duration of therapy: 10 to 14 days

Severe, complicated CDI: 500 mg orally 4 times a day AND 500 mg (in 100 mL normal saline) rectally every 6 hours with/without IV metronidazole

Comments:
-Rectal formulations should be administered as a retention enema.
-The first recurrence of CDI may be treated with the initial treatment regimen; a second recurrence of CDI may be treated with a tapered/pulsed regimen of this drug.

Uses:
-Initial treatment of patients with severe CDI
-Initial treatment of patients with complicated, severe CDI

Usual Adult Dose for Enterocolitis

Clostridium difficile-associated diarrhea: 125 mg orally 4 times a day
-Duration of therapy: 10 days

Enterocolitis: 500 mg to 2 g orally per day, given in divided doses 3 to 4 times a day
-Maximum dose: 2 g/day
-Duration of therapy: 7 to 10 days

Comment: Formulations administered parenterally will not treat colitis.

Uses:
-Treatment of C difficile-associated diarrhea
-Treatment of enterocolitis caused by S aureus (including MRSA)

Society of Healthcare Epidemiology of America (SHEA) and IDSA Recommendations:
Initial treatment of severe C difficile infection (CDI): 125 mg orally 4 times a day
-Duration of therapy: 10 to 14 days

Severe, complicated CDI: 500 mg orally 4 times a day AND 500 mg (in 100 mL normal saline) rectally every 6 hours with/without IV metronidazole

Comments:
-Rectal formulations should be administered as a retention enema.
-The first recurrence of CDI may be treated with the initial treatment regimen; a second recurrence of CDI may be treated with a tapered/pulsed regimen of this drug.

Uses:
-Initial treatment of patients with severe CDI
-Initial treatment of patients with complicated, severe CDI

Usual Adult Dose for Pneumonia

500 mg IV every 6 hours OR 1 g IV every 12 hours

Comments:
-This drug should be administered at a rate up to 10 mg/min or over 1 hour, whichever is longer.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Use: Empirical treatment of lower respiratory tract infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

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

Usual Adult Dose for Nosocomial Pneumonia

500 mg IV every 6 hours OR 1 g IV every 12 hours

Comments:
-This drug should be administered at a rate up to 10 mg/min or over 1 hour, whichever is longer.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Use: Empirical treatment of lower respiratory tract infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

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

Usual Adult Dose for Osteomyelitis

500 mg IV every 6 hours OR 1 g IV every 12 hours

Comments:
-This drug should be administered at a rate up to 10 mg/min or over 1 hour, whichever is longer.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Use: Empirical treatment of bone infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

IDSA Recommendations:
15 to 20 mg/kg IV every 12 hours
-Duration of therapy: 4 to 6 weeks

Uses:
-First choice treatment for native vertebral osteomyelitis caused by oxacillin-resistant staphylococci, penicillin-resistant Enterococcus species
-Alternative treatment for native vertebral osteomyelitis caused by oxacillin-susceptible staphylococci
-Alternative treatment for native vertebral osteomyelitis caused by penicillin-susceptible Enterococcus species, Enterobacteriaceae, beta-hemolytic streptococci, or Propionibacterium acnes in patients allergic to penicillin

Usual Adult Dose for Sepsis

500 mg IV every 6 hours OR 1 g IV every 12 hours

Comments:
-This drug should be administered at a rate up to 10 mg/min or over 1 hour, whichever is longer.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Use: Empirical treatment of septicemia caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

Usual Adult Dose for Skin or Soft Tissue Infection

500 mg IV every 6 hours OR 1 g IV every 12 hours

Comments:
-This drug should be administered at a rate up to 10 mg/min or over 1 hour, whichever is longer.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Use: Empirical treatment of skin and skin structure infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

IDSA Recommendations:
15 mg/kg IV every 6 to 12 hours

Comment: Multidrug resistant organisms may require daily doses up to 60 mg/kg.

Uses:
-First-line treatment of treatment of skin and soft tissue infections (SSTIs) caused by MRSA in patients who require parenteral treatment
-Alternative treatment of SSTIs in patients with penicillin allergies
-Treatment of incisional surgical site infections of the lower trunk or extremity away from the axilla/perineum
-First-line treatment of necrotizing infections of the skin, fascia, and muscle caused by mixed infections

Usual Adult Dose for Bacteremia

IDSA Recommendations:
15 to 20 mg/kg IV every 8 to 12 hours
-Duration of treatment: Up to 6 weeks, depending on the severity of infection

Use: Treatment of bacteremia

Usual Adult Dose for Meningitis

IDSA, American Academy of Neurology (AAN), American Association of Neurological Surgeons (AANS), and Neurocritical Care Society (NCS) Recommendations:
30 to 60 mg/kg IV per day, given in divided doses every 8 to 12 hours
-Some experts recommend: 15 mg/kg IV once, followed by 60 mg/kg per day continuous infusion
-Maximum dose: 2 g/dose
-Duration of treatment: At least 2 weeks

Comment: Surgical evaluation is recommended for patients with septic thromboses, empyema, and/or abscesses.

Uses:
-Treatment of patients with healthcare-associated ventriculitis and meningitis caused by methicillin-resistant staphylococci
-In combination with a third-generation cephalosporin, treatment of patients with healthcare-associated ventriculitis and meningitis caused by Streptococcus pneumoniae
-Alternative treatment of patients with healthcare-associated ventriculitis and meningitis caused by methicillin-sensitive staphylococci or P acnes
-Treatment of patients with brain abscess, subdural empyema, and/or spinal epidural abscess
-Treatment of patients with septic thrombosis of cavernous/dural venous sinus

Usual Adult Dose for CNS Infection

IDSA, American Academy of Neurology (AAN), American Association of Neurological Surgeons (AANS), and Neurocritical Care Society (NCS) Recommendations:
30 to 60 mg/kg IV per day, given in divided doses every 8 to 12 hours
-Some experts recommend: 15 mg/kg IV once, followed by 60 mg/kg per day continuous infusion
-Maximum dose: 2 g/dose
-Duration of treatment: At least 2 weeks

Comment: Surgical evaluation is recommended for patients with septic thromboses, empyema, and/or abscesses.

Uses:
-Treatment of patients with healthcare-associated ventriculitis and meningitis caused by methicillin-resistant staphylococci
-In combination with a third-generation cephalosporin, treatment of patients with healthcare-associated ventriculitis and meningitis caused by Streptococcus pneumoniae
-Alternative treatment of patients with healthcare-associated ventriculitis and meningitis caused by methicillin-sensitive staphylococci or P acnes
-Treatment of patients with brain abscess, subdural empyema, and/or spinal epidural abscess
-Treatment of patients with septic thrombosis of cavernous/dural venous sinus

Usual Adult Dose for Febrile Neutropenia

National Comprehensive Cancer Network (NCCN) Recommendations:
15 mg/kg IV every 12 hours

Comments:
-This drug should not be used as routine therapy for febrile neutropenia.
-Empiric therapy should be reassessed within 2 to 3 days of initiation. If gram-positive organisms are not found, discontinuation of treatment should be considered.
-Patients with resolved fever and neutrophil counts of at least 500 cells/mcL may discontinue therapy.

Use: Empiric prophylaxis in patients at high-risk for febrile neutropenia caused by serious gram-positive infections

Usual Adult Dose for Intraabdominal Infection

Surgical Infection Society (SIS) and IDSA Recommendations:
15 to 20 mg/kg IV every 8 to 12 hours

Comment: Initial doses should be determined by total body weight.

Uses:
-Empiric treatment of complicated intra-abdominal infections
-Treatment of peritonitis caused by enterococci species or MRSA

International Society for Peritoneal Dialysis (ISPD) Recommendations:
Intermittent: 15 to 30 mg/kg intraperitoneally every 5 to 7 days

Duration of therapy:
-Enterococcal peritonitis: 3 weeks
-Culture-negative peritonitis: 2 weeks

Use: Treatment of bacterial peritonitis

Usual Adult Dose for Peritonitis

Surgical Infection Society (SIS) and IDSA Recommendations:
15 to 20 mg/kg IV every 8 to 12 hours

Comment: Initial doses should be determined by total body weight.

Uses:
-Empiric treatment of complicated intra-abdominal infections
-Treatment of peritonitis caused by enterococci species or MRSA

International Society for Peritoneal Dialysis (ISPD) Recommendations:
Intermittent: 15 to 30 mg/kg intraperitoneally every 5 to 7 days

Duration of therapy:
-Enterococcal peritonitis: 3 weeks
-Culture-negative peritonitis: 2 weeks

Use: Treatment of bacterial peritonitis

Usual Adult Dose for Prevention of Perinatal Group B Streptococcal Disease

US Centers for Disease Control and Prevention (US CDC) Recommendations:
1 g IV every 12 hours until delivery

Use: Prevention of early-onset Group B streptococcal disease in patients with penicillin hypersensitivity and susceptibility is unknown/not possible or the isolates are resistant to erythromycin or clindamycin

Usual Adult Dose for Shunt Infection

IDSA, AAN, AANS, and NCS Recommendations:
Patients with slit ventricles: 5 mg via intraventricular route (plus gentamicin)
Patients with normal-sized ventricles: 10 mg via intraventricular route (plus gentamicin)
Patients with enlarged ventricles: 15 to 20 mg via intraventricular route (plus gentamicin)

Frequency of dosing:
-External drain output less than 50 mL/day: Every 3 days
-External drain output 50 to 100 mL/day: Every 2 days
-External drain output 100 to 150 mL/day: Once a day
-External drain output 150 to 200 mL/day: Increase the dose by 5 mg (plus gentamicin) and give once a day
-External drain output 200 to 250 mL/day: Increase the dose by 10 mg (plus gentamicin) and give once a day

Use: Treatment of healthcare-associated ventriculitis and meningitis in patients who respond poorly to systemic antibiotics

Usual Adult Dose for Surgical Prophylaxis

American Society of Health-System Pharmacists (ASHP), IDSA, SHEA, and SIS Recommendations:
15 mg/kg IV once, within 120 minutes before surgery

Uses:
Alternative agent for surgical prophylaxis in patients who have a beta-lactam allergy and are undergoing:
-Cardiac procedures (e.g., coronary artery bypass, cardiac device insertion, ventricular assist devices)
-Neurosurgery (e.g., elective craniotomy and cerebrospinal fluid-shunting procedures, implantation of intrathecal pumps)
-Thoracic procedures (e.g., lobectomy, pneumonectomy, lung resection, thoracotomy, or video-assisted thorascopic surgery)
-Some orthopedic procedures (e.g., spinal procedures without instrumentation, hip fracture repair)
-Some urologic procedures (e.g., clean surgery without entry into urinary tract)
-Heart, lung, and heart-lung transplantation procedures (e.g., heart transplantation, lung and heart-lung transplantation)
-Clean-contaminated or clean plastic surgery procedures with risk factors

Alternative agent (in combination with an aminoglycoside, aztreonam, or fluoroquinolone) for surgical prophylaxis in patients who have a beta-lactam allergy and are undergoing:
-Gastroduodenal procedures (e.g., procedures involving entry in to the lumen of the gastrointestinal tract or procedures not entering the GI tract in high-risk patients)
-Some urologic procedures (e.g., clean surgery involving implanted prosthesis)

Usual Adult Dose for Head Injury

Armed Forces Infectious Disease Society (AFIDS), SIS, and IDSA Recommendations:
1 g IV every 12 hours plus ciprofloxacin
-Duration of therapy: 5 days OR until cerebrospinal fluid leak is closed, whichever is longer

Use: Antimicrobial prophylaxis for patients with penicillin allergies who have a penetrating brain or spinal cord injury

Usual Pediatric Dose for Bacteremia

Neonates:
Initial dose: 15 mg/kg IV ONCE
Maintenance dose:
-First week of life: 10 mg/kg IV every 12 hours
-After first week of life: 10 mg/kg IV every 8 hours

Pediatric patients: 10 mg/kg IV every 6 hours

Comments:
-This drug should be infused over 1 hour.
-Premature infants may require longer dosing intervals.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Uses:
-Empirical treatment of serious/severe staphylococcal infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment of septicemia caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment of bone infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

American Academy of Pediatrics (AAP) Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Bacterial Infection:
Neonates (Up to 28 postnatal days):
Loading dose: 20 mg/kg IV ONCE
Gestational age 28 weeks or less:
-Serum creatinine less than 0.5 mg/dL: 15 mg/kg IV every 12 hours
-Serum creatinine 0.5 to 0.7 mg/dL: 20 mg/kg IV every 24 hours
-Serum creatinine 0.8 to 1 mg/dL: 15 mg/kg IV every 24 hours
-Serum creatinine 1.1 to 1.4 mg/dL: 10 mg/kg IV every 24 hours
-Serum creatinine greater than 1.4 mg/dL: 15 mg/kg IV every 48 hours

Gestational age greater than 28 weeks:
-Serum creatinine less than 0.7 mg/dL: 15 mg/kg IV every 12 hours
-Serum creatinine 0.7 to 0.9 mg/dL: 20 mg/kg IV every 24 hours
-Serum creatinine 1 to 1.2 mg/dL: 15 mg/kg IV every 24 hours
-Serum creatinine 1.3 to 1.6 mg/dL: 10 mg/kg IV every 24 hours
-Serum creatinine greater than 1.6 mg/dL: 15 mg/kg IV every 48 hours

Pediatric patients greater than 28 days: 45 to 60 mg/kg IV per day, given in 3 to 4 divided doses

Nonmeningeal pneumococcal infections:
Infants and Children: 40 to 45 mg/kg IV per day, given in divided doses every 6 to 8 hours

Comment: Serum concentrations should be used to guide ongoing treatment.

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia, central nervous system [CNS] infections)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis (e.g., skin infection, cellulitis, osteomyelitis, pyarthrosis) when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin minimum inhibitory concentrations (MICs) of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of vancomycin-intermediately susceptible Staphylococcus aureus (VISA) infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Treatment of invasive pneumococcal infections

IDSA Recommendations:
Bacteremia:
15 mg/kg IV every 6 hours
-Duration of therapy: 2 to 6 weeks, depending on the severity of infection

Bacterial Infection:
7 days or less and less than 1200 g: 15 mg/kg IV every 24 hours
7 days or less than 1200 to 2000 g: 10 to 15 mg/kg IV every 12 to 18 hours
7 days or less than greater than 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours

8 to 30 days and less than 1200 g: 15 mg/kg IV every 24 hours
8 to 30 days and 1200 to 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours
8 to 30 days and greater than 2000 g: 15 to 20 mg/kg IV every 8 hours

1 month to 18 years: 10 to 13.33 mg/kg IV every 6 to 8 hours
-Maximum dose: 40 mg/kg/day

Uses:
-Preferred treatment for IV catheter-related bloodstream infections caused by MRSA/coagulase-negative staphylococci, ampicillin-resistant, vancomycin-sensitive E faecalis/E faecium, C jeikeium (Group JK)
-Alternative treatment for IV catheter-related bloodstream infections caused by MSSA/coagulase-negative staphylococci, ampicillin susceptible E faecalis/E faecium
-Treatment of bacteremia

Usual Pediatric Dose for Osteomyelitis

Neonates:
Initial dose: 15 mg/kg IV ONCE
Maintenance dose:
-First week of life: 10 mg/kg IV every 12 hours
-After first week of life: 10 mg/kg IV every 8 hours

Pediatric patients: 10 mg/kg IV every 6 hours

Comments:
-This drug should be infused over 1 hour.
-Premature infants may require longer dosing intervals.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Uses:
-Empirical treatment of serious/severe staphylococcal infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment of septicemia caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment of bone infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

American Academy of Pediatrics (AAP) Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Bacterial Infection:
Neonates (Up to 28 postnatal days):
Loading dose: 20 mg/kg IV ONCE
Gestational age 28 weeks or less:
-Serum creatinine less than 0.5 mg/dL: 15 mg/kg IV every 12 hours
-Serum creatinine 0.5 to 0.7 mg/dL: 20 mg/kg IV every 24 hours
-Serum creatinine 0.8 to 1 mg/dL: 15 mg/kg IV every 24 hours
-Serum creatinine 1.1 to 1.4 mg/dL: 10 mg/kg IV every 24 hours
-Serum creatinine greater than 1.4 mg/dL: 15 mg/kg IV every 48 hours

Gestational age greater than 28 weeks:
-Serum creatinine less than 0.7 mg/dL: 15 mg/kg IV every 12 hours
-Serum creatinine 0.7 to 0.9 mg/dL: 20 mg/kg IV every 24 hours
-Serum creatinine 1 to 1.2 mg/dL: 15 mg/kg IV every 24 hours
-Serum creatinine 1.3 to 1.6 mg/dL: 10 mg/kg IV every 24 hours
-Serum creatinine greater than 1.6 mg/dL: 15 mg/kg IV every 48 hours

Pediatric patients greater than 28 days: 45 to 60 mg/kg IV per day, given in 3 to 4 divided doses

Nonmeningeal pneumococcal infections:
Infants and Children: 40 to 45 mg/kg IV per day, given in divided doses every 6 to 8 hours

Comment: Serum concentrations should be used to guide ongoing treatment.

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia, central nervous system [CNS] infections)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis (e.g., skin infection, cellulitis, osteomyelitis, pyarthrosis) when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin minimum inhibitory concentrations (MICs) of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of vancomycin-intermediately susceptible Staphylococcus aureus (VISA) infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Treatment of invasive pneumococcal infections

IDSA Recommendations:
Bacteremia:
15 mg/kg IV every 6 hours
-Duration of therapy: 2 to 6 weeks, depending on the severity of infection

Bacterial Infection:
7 days or less and less than 1200 g: 15 mg/kg IV every 24 hours
7 days or less than 1200 to 2000 g: 10 to 15 mg/kg IV every 12 to 18 hours
7 days or less than greater than 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours

8 to 30 days and less than 1200 g: 15 mg/kg IV every 24 hours
8 to 30 days and 1200 to 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours
8 to 30 days and greater than 2000 g: 15 to 20 mg/kg IV every 8 hours

1 month to 18 years: 10 to 13.33 mg/kg IV every 6 to 8 hours
-Maximum dose: 40 mg/kg/day

Uses:
-Preferred treatment for IV catheter-related bloodstream infections caused by MRSA/coagulase-negative staphylococci, ampicillin-resistant, vancomycin-sensitive E faecalis/E faecium, C jeikeium (Group JK)
-Alternative treatment for IV catheter-related bloodstream infections caused by MSSA/coagulase-negative staphylococci, ampicillin susceptible E faecalis/E faecium
-Treatment of bacteremia

Usual Pediatric Dose for Bacterial Infection

Neonates:
Initial dose: 15 mg/kg IV ONCE
Maintenance dose:
-First week of life: 10 mg/kg IV every 12 hours
-After first week of life: 10 mg/kg IV every 8 hours

Pediatric patients: 10 mg/kg IV every 6 hours

Comments:
-This drug should be infused over 1 hour.
-Premature infants may require longer dosing intervals.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Uses:
-Empirical treatment of serious/severe staphylococcal infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment of septicemia caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment of bone infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

American Academy of Pediatrics (AAP) Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Bacterial Infection:
Neonates (Up to 28 postnatal days):
Loading dose: 20 mg/kg IV ONCE
Gestational age 28 weeks or less:
-Serum creatinine less than 0.5 mg/dL: 15 mg/kg IV every 12 hours
-Serum creatinine 0.5 to 0.7 mg/dL: 20 mg/kg IV every 24 hours
-Serum creatinine 0.8 to 1 mg/dL: 15 mg/kg IV every 24 hours
-Serum creatinine 1.1 to 1.4 mg/dL: 10 mg/kg IV every 24 hours
-Serum creatinine greater than 1.4 mg/dL: 15 mg/kg IV every 48 hours

Gestational age greater than 28 weeks:
-Serum creatinine less than 0.7 mg/dL: 15 mg/kg IV every 12 hours
-Serum creatinine 0.7 to 0.9 mg/dL: 20 mg/kg IV every 24 hours
-Serum creatinine 1 to 1.2 mg/dL: 15 mg/kg IV every 24 hours
-Serum creatinine 1.3 to 1.6 mg/dL: 10 mg/kg IV every 24 hours
-Serum creatinine greater than 1.6 mg/dL: 15 mg/kg IV every 48 hours

Pediatric patients greater than 28 days: 45 to 60 mg/kg IV per day, given in 3 to 4 divided doses

Nonmeningeal pneumococcal infections:
Infants and Children: 40 to 45 mg/kg IV per day, given in divided doses every 6 to 8 hours

Comment: Serum concentrations should be used to guide ongoing treatment.

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia, central nervous system [CNS] infections)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis (e.g., skin infection, cellulitis, osteomyelitis, pyarthrosis) when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin minimum inhibitory concentrations (MICs) of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of vancomycin-intermediately susceptible Staphylococcus aureus (VISA) infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Treatment of invasive pneumococcal infections

IDSA Recommendations:
Bacteremia:
15 mg/kg IV every 6 hours
-Duration of therapy: 2 to 6 weeks, depending on the severity of infection

Bacterial Infection:
7 days or less and less than 1200 g: 15 mg/kg IV every 24 hours
7 days or less than 1200 to 2000 g: 10 to 15 mg/kg IV every 12 to 18 hours
7 days or less than greater than 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours

8 to 30 days and less than 1200 g: 15 mg/kg IV every 24 hours
8 to 30 days and 1200 to 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours
8 to 30 days and greater than 2000 g: 15 to 20 mg/kg IV every 8 hours

1 month to 18 years: 10 to 13.33 mg/kg IV every 6 to 8 hours
-Maximum dose: 40 mg/kg/day

Uses:
-Preferred treatment for IV catheter-related bloodstream infections caused by MRSA/coagulase-negative staphylococci, ampicillin-resistant, vancomycin-sensitive E faecalis/E faecium, C jeikeium (Group JK)
-Alternative treatment for IV catheter-related bloodstream infections caused by MSSA/coagulase-negative staphylococci, ampicillin susceptible E faecalis/E faecium
-Treatment of bacteremia

Usual Pediatric Dose for Sepsis

Neonates:
Initial dose: 15 mg/kg IV ONCE
Maintenance dose:
-First week of life: 10 mg/kg IV every 12 hours
-After first week of life: 10 mg/kg IV every 8 hours

Pediatric patients: 10 mg/kg IV every 6 hours

Comments:
-This drug should be infused over 1 hour.
-Premature infants may require longer dosing intervals.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Uses:
-Empirical treatment of serious/severe staphylococcal infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment of septicemia caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment of bone infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

American Academy of Pediatrics (AAP) Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Bacterial Infection:
Neonates (Up to 28 postnatal days):
Loading dose: 20 mg/kg IV ONCE
Gestational age 28 weeks or less:
-Serum creatinine less than 0.5 mg/dL: 15 mg/kg IV every 12 hours
-Serum creatinine 0.5 to 0.7 mg/dL: 20 mg/kg IV every 24 hours
-Serum creatinine 0.8 to 1 mg/dL: 15 mg/kg IV every 24 hours
-Serum creatinine 1.1 to 1.4 mg/dL: 10 mg/kg IV every 24 hours
-Serum creatinine greater than 1.4 mg/dL: 15 mg/kg IV every 48 hours

Gestational age greater than 28 weeks:
-Serum creatinine less than 0.7 mg/dL: 15 mg/kg IV every 12 hours
-Serum creatinine 0.7 to 0.9 mg/dL: 20 mg/kg IV every 24 hours
-Serum creatinine 1 to 1.2 mg/dL: 15 mg/kg IV every 24 hours
-Serum creatinine 1.3 to 1.6 mg/dL: 10 mg/kg IV every 24 hours
-Serum creatinine greater than 1.6 mg/dL: 15 mg/kg IV every 48 hours

Pediatric patients greater than 28 days: 45 to 60 mg/kg IV per day, given in 3 to 4 divided doses

Nonmeningeal pneumococcal infections:
Infants and Children: 40 to 45 mg/kg IV per day, given in divided doses every 6 to 8 hours

Comment: Serum concentrations should be used to guide ongoing treatment.

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia, central nervous system [CNS] infections)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis (e.g., skin infection, cellulitis, osteomyelitis, pyarthrosis) when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin minimum inhibitory concentrations (MICs) of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of vancomycin-intermediately susceptible Staphylococcus aureus (VISA) infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Treatment of invasive pneumococcal infections

IDSA Recommendations:
Bacteremia:
15 mg/kg IV every 6 hours
-Duration of therapy: 2 to 6 weeks, depending on the severity of infection

Bacterial Infection:
7 days or less and less than 1200 g: 15 mg/kg IV every 24 hours
7 days or less than 1200 to 2000 g: 10 to 15 mg/kg IV every 12 to 18 hours
7 days or less than greater than 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours

8 to 30 days and less than 1200 g: 15 mg/kg IV every 24 hours
8 to 30 days and 1200 to 2000 g: 10 to 15 mg/kg IV every 8 to 12 hours
8 to 30 days and greater than 2000 g: 15 to 20 mg/kg IV every 8 hours

1 month to 18 years: 10 to 13.33 mg/kg IV every 6 to 8 hours
-Maximum dose: 40 mg/kg/day

Uses:
-Preferred treatment for IV catheter-related bloodstream infections caused by MRSA/coagulase-negative staphylococci, ampicillin-resistant, vancomycin-sensitive E faecalis/E faecium, C jeikeium (Group JK)
-Alternative treatment for IV catheter-related bloodstream infections caused by MSSA/coagulase-negative staphylococci, ampicillin susceptible E faecalis/E faecium
-Treatment of bacteremia

Usual Pediatric Dose for Endocarditis

Neonates:
Initial dose: 15 mg/kg IV ONCE
Maintenance dose:
-First week of life: 10 mg/kg IV every 12 hours
-After first week of life: 10 mg/kg IV every 8 hours

Pediatric patients: 10 mg/kg IV every 6 hours

Comments:
-This drug should be infused over 1 hour.
-Premature infants may require longer dosing intervals.
-Doses should be determined by patient-specific factors (e.g., obesity, age).
-Successful treatment of diphtheroid endocarditis has been reported.

Use:
-Empirical treatment of staphylococcal endocarditis caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs
-Empirical treatment (with an aminoglycoside) of endocarditis caused by enterococci, S bovis, or S viridans
-Empirical treatment (with an aminoglycoside and/or rifampin) of early-onset prosthetic valve endocarditis caused by S epidermidis or diphtheroids

AAP Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., endocarditis)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL

AHA Recommendations:
40 to 60 mg/kg IV per day, given in divided doses every 6 to 12 hours
-Maximum dose: 2 g/day

Duration of therapy:
-Empirical treatment: 4 to 6 weeks
-Staphylococci infection: 6 weeks

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

Uses:
-Treatment of native valve and prosthetic valve infective endocarditis
-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)
-Alternative treatment for streptococcal infections highly susceptible to penicillin G (e.g., Groups A, B, C, G nonenterococcal, Group D streptococci) and streptococci relatively resistant to penicillin (e.g., enterococci, less-susceptible S viridians)
-Alternative treatment for endocarditis caused by S aureus or coagulase-negative staphylococci susceptible or resistant to penicillin G and/or oxacillin in patients highly allergic to beta-lactam antibiotics

Usual Pediatric Dose for Pseudomembranous Colitis

Safety and efficacy of capsule formulations have not been established in patients younger than 18 years of age.

40 mg/kg orally in 3 to 4 divided doses
-Maximum dose: 2 g/day
-Duration of therapy: 7 to 10 days

Comment: Formulations administered parenterally will not treat colitis.

Uses:
-Treatment of C difficile-associated diarrhea
-Treatment of enterocolitis caused by S aureus (including MRSA)

AAP Recommendations:
Children:
FIRST OCCURRENCE:
Mild-moderate infection:
Failure to respond within 5 to 7 days, pregnant/breastfeeding, OR metronidazole-intolerant patients: 10 mg/kg orally every 6 hours
-Maximum dose: 125 mg/dose
-Duration of therapy: 10 days

Patients for whom oral therapy cannot reach colon: 500 mg (in 100 mL normal saline) rectally (as an enema) every 8 hours until symptoms improve PLUS oral metronidazole OR oral vancomycin

Severe infection: 10 mg/kg orally every 6 hours
-Maximum dose: 125 mg/dose
-Duration of therapy: 10 days

Severe and complicated infection:
No abdominal distention: 10 mg/kg orally every 6 hours PLUS metronidazole
-Maximum dose: 125 mg/dose
-Duration of therapy: 10 days

Complicated with ileus or toxic colitis and/or significant abdominal distention: 10 mg/kg orally every 6 hours PLUS 500 mg (in 100 mL normal saline) rectally (as an enema) every 8 hours until symptoms improve PLUS metronidazole
-Maximum oral dose: 500 mg/dose
-Duration of therapy: 10 days

FIRST RECURRENCE:
Mild-moderate infection:
Failure to respond within 5 to 7 days, pregnant/breastfeeding, OR metronidazole-intolerant patients: 10 mg/kg orally every 6 hours
-Maximum dose: 125 mg/dose
-Duration of therapy: 10 days

Patients for whom oral therapy cannot reach colon: 500 mg (in 100 mL normal saline) rectally (as an enema) every 8 hours until symptoms improve PLUS oral metronidazole OR oral vancomycin

Severe infection: 10 mg/kg orally every 6 hours
-Maximum dose: 125 mg/dose

SECOND RECURRENCE:
Tapered regimen:
-Week 1: 10 mg/kg orally 4 times a day for 7 days
-Week 2: 10 mg/kg orally 3 times a day for 7 days
-Week 3: 10 mg/kg orally 2 times a day for 7 days
-Week 4: 10 mg/kg orally once a day for 7 days
-Week 5: 10 mg/kg orally every other day for 7 days
-Week 6: 10 mg/kg orally every 72 hours for 7 days
-Maximum dose: 125 mg/dose

Alternative tapered regimen: 10 mg/kg orally 4 times a day for 14 days, then 10 mg/kg orally 2 times a day for 7 to 14 days, then 10 mg/kg orally every 2 to 3 days for 2 to 8 weeks
-Maximum dose: 125 mg/dose

Pulse regimen: 10 mg/kg orally 4 times a day, then rifaximin OR nitazoxanide
-Maximum dose: 125 mg/dose
-Duration of therapy: 14 days

Comments:
-Severe infection should be considered in the presence of leukocytosis, leukopenia, and/or worsening renal function.
-Severe and complicated infection is defined as intensive care unit admission, hypotension/shock, pseudomembranous colitis by endoscopy, ileus, or toxic megacolon.

Use: Treatment of C difficile infection

Usual Pediatric Dose for Enterocolitis

Safety and efficacy of capsule formulations have not been established in patients younger than 18 years of age.

40 mg/kg orally in 3 to 4 divided doses
-Maximum dose: 2 g/day
-Duration of therapy: 7 to 10 days

Comment: Formulations administered parenterally will not treat colitis.

Uses:
-Treatment of C difficile-associated diarrhea
-Treatment of enterocolitis caused by S aureus (including MRSA)

AAP Recommendations:
Children:
FIRST OCCURRENCE:
Mild-moderate infection:
Failure to respond within 5 to 7 days, pregnant/breastfeeding, OR metronidazole-intolerant patients: 10 mg/kg orally every 6 hours
-Maximum dose: 125 mg/dose
-Duration of therapy: 10 days

Patients for whom oral therapy cannot reach colon: 500 mg (in 100 mL normal saline) rectally (as an enema) every 8 hours until symptoms improve PLUS oral metronidazole OR oral vancomycin

Severe infection: 10 mg/kg orally every 6 hours
-Maximum dose: 125 mg/dose
-Duration of therapy: 10 days

Severe and complicated infection:
No abdominal distention: 10 mg/kg orally every 6 hours PLUS metronidazole
-Maximum dose: 125 mg/dose
-Duration of therapy: 10 days

Complicated with ileus or toxic colitis and/or significant abdominal distention: 10 mg/kg orally every 6 hours PLUS 500 mg (in 100 mL normal saline) rectally (as an enema) every 8 hours until symptoms improve PLUS metronidazole
-Maximum oral dose: 500 mg/dose
-Duration of therapy: 10 days

FIRST RECURRENCE:
Mild-moderate infection:
Failure to respond within 5 to 7 days, pregnant/breastfeeding, OR metronidazole-intolerant patients: 10 mg/kg orally every 6 hours
-Maximum dose: 125 mg/dose
-Duration of therapy: 10 days

Patients for whom oral therapy cannot reach colon: 500 mg (in 100 mL normal saline) rectally (as an enema) every 8 hours until symptoms improve PLUS oral metronidazole OR oral vancomycin

Severe infection: 10 mg/kg orally every 6 hours
-Maximum dose: 125 mg/dose

SECOND RECURRENCE:
Tapered regimen:
-Week 1: 10 mg/kg orally 4 times a day for 7 days
-Week 2: 10 mg/kg orally 3 times a day for 7 days
-Week 3: 10 mg/kg orally 2 times a day for 7 days
-Week 4: 10 mg/kg orally once a day for 7 days
-Week 5: 10 mg/kg orally every other day for 7 days
-Week 6: 10 mg/kg orally every 72 hours for 7 days
-Maximum dose: 125 mg/dose

Alternative tapered regimen: 10 mg/kg orally 4 times a day for 14 days, then 10 mg/kg orally 2 times a day for 7 to 14 days, then 10 mg/kg orally every 2 to 3 days for 2 to 8 weeks
-Maximum dose: 125 mg/dose

Pulse regimen: 10 mg/kg orally 4 times a day, then rifaximin OR nitazoxanide
-Maximum dose: 125 mg/dose
-Duration of therapy: 14 days

Comments:
-Severe infection should be considered in the presence of leukocytosis, leukopenia, and/or worsening renal function.
-Severe and complicated infection is defined as intensive care unit admission, hypotension/shock, pseudomembranous colitis by endoscopy, ileus, or toxic megacolon.

Use: Treatment of C difficile infection

Usual Pediatric Dose for Skin or Soft Tissue Infection

Neonates:
Initial dose: 15 mg/kg IV ONCE
Maintenance dose:
-First week of life: 10 mg/kg IV every 12 hours
-After first week of life: 10 mg/kg IV every 8 hours

Pediatric patients: 10 mg/kg IV every 6 hours

Comments:
-This drug should be administered over 1 hour.
-Premature infants may require a longer dosing interval.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Use:
-Empirical treatment of skin and skin structure infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

AAP Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IM or IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IM or IV every 6 to 8 hours

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis (e.g., skin infection, cellulitis) when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL

IDSA Recommendations:
10 to 15 mg/kg IV 3 to 4 times a day

Comments:
-Patients with necrotizing infections may require up to a 13 mg/kg dose given IV every 8 hours plus piperacillin.
-Patients with necrotizing infections caused by resistant S aureus may require 15 mg/kg given IV every 6 hours.

Use:
-First-line treatment of treatment of SSTIs caused by MRSA in patients who require parenteral treatment
-Alternative treatment of SSTIs in patients with penicillin allergies
-First-line treatment of necrotizing infections of the skin, fascia, and muscle caused by mixed infections

Usual Pediatric Dose for Pneumonia

Neonates:
Initial dose: 15 mg/kg IV ONCE
Maintenance dose:
-First week of life: 10 mg/kg IV every 12 hours
-After first week of life: 10 mg/kg IV every 8 hours

Pediatric patients: 10 mg/kg IV every 6 hours

Comments:
-This drug should be administered over 1 hour.
-Premature infants may require a longer dosing interval.
-Doses should be determined by patient-specific factors (e.g., obesity, age).

Use: Empirical treatment of lower respiratory tract infections caused by susceptible strains of methicillin-resistant staphylococci in patients who are allergic to penicillin, failed to respond/cannot receive other drugs (e.g., penicillins, cephalosporins), and/or to treat organisms that are resistant to other drugs

Pediatric Infectious Diseases Society (PIDS) and IDSA Recommendations:
10 to 20 mg/kg every 6 to 8 hours

Uses:
-Alternative treatment of community acquired pneumonia caused by S pneumoniae with penicillin MICs of less than or equal to 2 mcg/mL, S pneumoniae resistant to penicillin (MICs at least 4 mcg/mL), Group A Streptococcus, or MSSA
-Preferred treatment of community acquired pneumonia caused by MRSA (with/without susceptibility to clindamycin)

Usual Pediatric Dose for Intraabdominal Infection

AAP Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis (e.g., pyarthrosis) when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL

SIS and IDSA Recommendations:
40 mg/kg IV per day, divided and given every 6 to 8 hours

Comment: This drug should be given as a 1-hour infusion.

Uses:
-Treatment of complicated intra-abdominal infections
-Treatment of peritonitis caused by Enterococci species or MRSA

ISPD Recommendations:
Prophylaxis: 25 mg/L intraperitoneally once

Treatment: 30 mg/kg intraperitoneally once, then 15 mg/kg intraperitoneally every 3 to 5 days

Uses:
-Prophylaxis against peritonitis in patients with known MRSA colonization at risk of touch contamination during instillation of peritoneal dialysis fluid after system disconnection OR disconnection during peritoneal dialysis
-Treatment of bacterial peritonitis

Usual Pediatric Dose for Peritonitis

AAP Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis (e.g., pyarthrosis) when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL

SIS and IDSA Recommendations:
40 mg/kg IV per day, divided and given every 6 to 8 hours

Comment: This drug should be given as a 1-hour infusion.

Uses:
-Treatment of complicated intra-abdominal infections
-Treatment of peritonitis caused by Enterococci species or MRSA

ISPD Recommendations:
Prophylaxis: 25 mg/L intraperitoneally once

Treatment: 30 mg/kg intraperitoneally once, then 15 mg/kg intraperitoneally every 3 to 5 days

Uses:
-Prophylaxis against peritonitis in patients with known MRSA colonization at risk of touch contamination during instillation of peritoneal dialysis fluid after system disconnection OR disconnection during peritoneal dialysis
-Treatment of bacterial peritonitis

Usual Pediatric Dose for Surgical Prophylaxis

AAP Recommendations:
Neonates (72 hours) or older: 15 mg/kg IV ONCE

Uses:
Alternative agent for surgical prophylaxis in patients undergoing:
-Cardiac surgical procedures (e.g., prosthetic valve/pacemaker, ventricular assist devices) where Staphylococcus epidermidis (including methicillin-resistant Staphylococcus epidermidis [MRSE]), Staphylococcus aureus (including MRSA), Corynebacterium species, and/or enteric gram-negative bacilli are likely
-Neurosurgery (e.g., craniotomy, intrathecal baclofen shunt/ventricular shunt placement) where S epidermidis (including MRSE) or S aureus (including MRSA) are likely
-Orthopedic (e.g., internal fixation of fractures, implantation of materials including prosthetic joint and spinal procedures with/without instrumentation) where S epidermidis (including MRSE) or S aureus (including MRSA) are likely
-Thoracic (noncardiac) where S epidermidis S aureus (including MRSA), streptococci, or gram-negative enteric bacilli are likely

ASHP, IDSA, SHEA, and SIS Recommendations:
15 mg/kg IV once, within 120 minutes before surgery

Uses:
Alternative agent for surgical prophylaxis in patients who have a beta-lactam allergy and are undergoing:
-Cardiac procedures (e.g., coronary artery bypass, cardiac device insertion, ventricular assist devices)
-Neurosurgery (e.g., elective craniotomy and cerebrospinal fluid-shunting procedures, implantation of intrathecal pumps)
-Thoracic procedures (e.g., lobectomy, pneumonectomy, lung resection, thoracotomy, or video-assisted thorascopic surgery)
-Some orthopedic procedures (e.g., spinal procedures without instrumentation, hip fracture repair)
-Some urologic procedures (e.g., clean surgery without entry into urinary tract)
-Heart, lung, and heart-lung transplantation procedures (e.g., heart transplantation, lung and heart-lung transplantation)
-Clean-contaminated or clean plastic surgery procedures with risk factors

Alternative agent (in combination with an aminoglycoside, aztreonam, or fluoroquinolone) for surgical prophylaxis in patients who have a beta-lactam allergy and are undergoing:
-Gastroduodenal procedures (e.g., procedures involving entry in to the lumen of the gastrointestinal tract or procedures not entering the GI tract in high-risk patients)
-Some urologic procedures (e.g., clean surgery involving implanted prosthesis)

Usual Pediatric Dose for Meningitis

AAP Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Infants and Children:
Meningitis: 60 mg/kg IV per day, given in divided doses every 6 hours

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia, CNS infections)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Treatment of invasive pneumococcal meningitis

IDSA, AAN, AANS, and NCS Recommendations:
60 mg/kg IV per day, given in divided doses every 6 hours
-Duration of therapy: 2 weeks

Use: Treatment of patients with healthcare-associated ventriculitis and meningitis

Usual Pediatric Dose for CNS Infection

AAP Recommendations:
Empiric treatment:
Life-threatening infections: 15 mg/kg IV every 6 hours PLUS nafcillin OR oxacillin
Non-life-threatening infections without signs of sepsis: 15 mg/kg IV every 6 to 8 hours

Infants and Children:
Meningitis: 60 mg/kg IV per day, given in divided doses every 6 hours

Uses:
-Drug of choice for the treatment of life-threatening infections (e.g., septicemia, CNS infections)
-Drug of choice for the treatment of non-life-threatening infection without signs/symptoms of sepsis when rates of MRSA colonization and infection in the community are substantial.
-Alternative treatment of MSSA in patients with serious penicillin and cephalosporin allergy
-Drug of choice (with gentamicin) for the treatment of healthcare-associated, multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Drug of choice (with gentamicin) for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug for the treatment of community-associated, not multi-drug resistant MRSA infections and oxacillin MICs of 4 mcg/mL or greater
-Alternative drug (with linezolid with/without gentamicin) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Alternative drug (with sulfamethoxazole-trimethoprim) for the treatment of VISA infections with MICs of 4 to 16 mcg/mL
-Treatment of invasive pneumococcal meningitis

IDSA, AAN, AANS, and NCS Recommendations:
60 mg/kg IV per day, given in divided doses every 6 hours
-Duration of therapy: 2 weeks

Use: Treatment of patients with healthcare-associated ventriculitis and meningitis

Usual Pediatric Dose for Shunt Infection

IDSA, AAN, AANS, and NCS Recommendations:
Patients with slit ventricles: 5 mg via intraventricular route (plus gentamicin)

Patients with normal-sized ventricles: 10 mg via intraventricular route (plus gentamicin)

Patients with enlarged ventricles: 15 to 20 mg via intraventricular route (plus gentamicin)

Frequency of dosing:
-External drain output less than 50 mL/day: Every 3 days
-External drain output 50 to 100 mL/day: Every 2 days
-External drain output 100 to 150 mL/day: Once a day
-External drain output 150 to 200 mL/day: Increase the dose by 5 mg (plus gentamicin) and give once a day
-External drain output 200 to 250 mL/day: Increase the dose by 10 mg (plus gentamicin) and give once a day

Comment: Some experts recommend decreasing the dose by 60% when treating infants to account for lower cerebrospinal fluid volume (compared to adults).

Use: Treatment of healthcare-associated ventriculitis and meningitis in patients who respond poorly to systemic antibiotics

Usual Pediatric Dose for Head Injury

AFIDS, SIS, and IDSA Recommendations:
60 mg/kg, divided and given every 6 to 8 hours
-Duration of therapy: 5 days OR until cerebrospinal fluid leak is closed, whichever is longer

Use: Antimicrobial prophylaxis for patients with penicillin allergies who have a penetrating brain or spinal cord injury

Renal Dose Adjustments

Mild to moderate renal dysfunction:
-Initial dose: 15 mg/kg IV ONCE
-Maintenance dose: The manufacturer product information should be consulted regarding dose adjustments in patients with this level of renal dysfunction.

Severe renal dysfunction and functionally anephric patients:
-Initial dose: 15 mg/kg IV ONCE
-Maintenance dose: 1.9 mg/kg IV every 24 hours OR 250 to 1000 mg IV once every several days

Patients with anuria:
-Initial dose: 15 mg/kg IV ONCE
-Maintenance dose: 1000 mg IV once every 7 to 10 days

Liver Dose Adjustments

Data not available

Dose Adjustments

Elderly patients: Dosing may be determined based on renal function.

Therapeutic drug monitoring/range: 10 to 20 mcg/mL (trough)

AAP Recommendations:
Invasive MRSA infections: At least a 400 mg*hr/L 24-hour AUC to MIC ratio is recommended.
Neonates with a MIC 1 mg/L: 10 to 12 mg/L (trough)

Precautions

CONTRAINDICATIONS:
-Hypersensitivity to the active component or any of the ingredients

Safety and efficacy of capsule formulations have not been established in patients younger than 18 years.

Consult WARNINGS section for additional precautions.

Dialysis

IDSA Recommendations:
Hemodialysis:
-Empirical dosing for bacterial infections: 20 mg/kg loading dose IV (infused during the last hour of the dialysis session), then 500 mg IV during the last 30 minutes of each subsequent dialysis session

ISPD Recommendations:
Peritoneal Dialysis:
Pediatric patients:
-High-risk gastrointestinal procedures: 10 mg/kg IV ONCE (Maximum dose: 1 g)

Other Comments

Administration advice:
-This drug should be infused over at least 1 hour.
-Lyophilized powder for injection may be mixed and given orally or via nasogastric tube.

Storage requirements:
-Injection solutions: The manufacturer produce information should be consulted.
-Lyophilized powder for injection: Vials may be stored in a refrigerator for up to 48 hours once reconstituted.
-Oral solution: Store in refrigerated conditions (2 to 8C); protect from light and do not freeze. Reconstituted solutions should be discarded after 14 days, if the solution appears hazy, or contains particles.

Reconstitution/preparation techniques:
-Lyophilized powder for injection: Flavoring syrups may be added to the formulation to improve taste.

IV compatibility: The manufacturer product information should be consulted.

General:
-Oral capsule formulations are not systemically absorbed, and should be reserved for the treatment of staphylococcal enterocolitis and C difficile-associated diarrhea.
-Parenteral formulations should not be used intravenously to treat staphylococcal enterocolitis and C difficile-associated diarrhea.
-Limitations of use: Safety and efficacy of intrathecal (intralumbar/intraventricular) and peritoneal administration have not been established.

Monitoring:
-GENERAL: Trough blood levels
-GENITOURINARY: Periodic urinalysis
-HEMATOLOGIC: Periodic leukocyte counts, especially in patients receiving concomitant neutropenia-inducing drugs and/or those undergoing prolonged treatment
-HEPATIC: Periodic liver function tests
-LOCAL: Localized infusion reactions
-RENAL: Renal function, especially in patients with renal dysfunction, those given high doses and/or in patients with high troughs
-OTHER: Hearing tests, especially in patients given high doses and/or those over 60 to 65 years of age

Patient advice:
-Patients should be advised to avoid missing doses and to complete the entire course of therapy.
-Patients should be instructed to report signs/symptoms of C difficile (e.g., watery/bloody stools, stomach cramps, fever), for up to 2 months after stopping treatment.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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