White Book - MGB Antimicrobial Dosing June 2023 (2024)

Table of Contents

Acyclovir IV: disseminated HSV, HSV encephalitis, visceral zoster, VZV/HSV retinal necrosis Acyclovir IV: localized HSV: genital, perirectal, mucosal, or cutaneous HSV Acyclovir PO: HSV labialis, mild genital/perirectal HSV Acyclovir PO: herpes zoster Acyclovir PO: prophylaxis/suppression Acyclovir IV: prophylaxis/suppression Albendazole PO: ancylostomiasis, necatoriasis, cutaneous larva migrans, or enterobiasis Albendazole PO: echinococcosis or neurocysticercosis Amikacin ✱ID✱ Amoxicillin PO Amoxicillin PO: procedure prophylaxis for infective endocarditis, dental procedures Amoxicillin-clavulanate PO Amoxicillin-clavulanate PO XR: community acquired pneumonia, acute bacterial sinusitis Liposomal Amphotericin B IV: candidemia, febrile neutropenia, cryptococcosis ✱ID✱ Liposomal Amphotericin B IV: aspergillosis, mucormycosis ✱ID✱ Liposomal Amphotericin B Inhaled: prophylaxis for Aspergillus ✱ID✱ Amphotericin B lipid complex (Abelcet) Inhaled: prophylaxis for Aspergillus ✱ID✱ Amphotericin B deoxycholate IV ✱ID✱ Ampicillin IV: bacteremia and other systemic infections Ampicillin IV: bacterial meningitis, endocarditis, or Listeria Ampicillin PO: Mild GI, GU, and upper respiratory tract infections Ampicillin-sulbactam IV: Acinetobacter baumannii, Enterococcal endocarditis Ampicillin-sulbactam IV: Skin and soft tissue infections, intra-abdominal infections, pelvic inflammatory disease Artemether-lumefantrine PO: P. falciparum malaria for patients weighing >35kg Atovaquone PO: Pneumocystis jirovecii pneumonia prophylaxis Atovaquone PO: Pneumocystis jirovecii pneumonia treatment or prophylaxis, babesiosis treatment Atovaquone PO: toxoplasmosis treatment Atovaquone-proguanil PO: P. falciparum malaria treatment Atovaquone-proguanil PO: P. falciparum malaria prophylaxis Azithromycin PO/IV: bacterial sinusitis, community acquired pneumonia, skin and soft tissue infections, pertussis Azithromycin PO: MAC prophylaxis Aztreonam IV ✱ID✱ Baloxavir PO ✱ID✱ Bedaquiline PO Bezlotoxumab IV: CDI recurrence ✱ID✱ Cefaclor PO Cefadroxil PO Cefazolin IV Cefdinir PO Cefepime IV: febrile neutropenia, pneumonia, cystic fibrosis, non-UTI Pseudomonas aeruginosa Cefepime IV: other infections Cefepime IV: alternative dosing; may replace 2gm Q8H and 2gm Q12H dosing; EXCEPT for febrile neutropenia and CNS infections Cefiderocol IV ✱ID✱ Cefixime PO Cefixime PO: uncomplicated gonorrhea Cefotaxime IV Cefotetan IV Cefoxitin IV Cefoxitin IV: nontuberculous mycobacterial infections Cefpodoxime PO Cefprozil PO: acute bacterial exacerbation of chronic bronchitis, uncomplicated skin and soft tissue infection Cefprozil PO: pharyngitis, tonsillitis Ceftaroline fosamil IV: community acquired pneumonia, skin and soft tissue infections ✱ID✱ Ceftaroline fosamil IV: MRSA bacteremia, MRSA pneumonia, severe MRSA infections ✱ID✱ Ceftazidime IV: febrile neutropenia, pneumonia, bacteremia, sepsis Ceftazidime IV: UTI, if urosepsis follow above dosing recommendations Ceftazidime-avibactam IV ✱ID✱ Ceftolozane-tazobactam IV: complicated urinary tract infections and complicated intra-abdominal infections ✱ID✱ Ceftolozane-tazobactam IV: ventilator-associated pneumonia or MDRO pathogens ✱ID✱ Ceftriaxone IV: bloodstream infections, bone or joint infections, pneumonia, intra-abdominal infections, Lyme disease Ceftriaxone IV: urinary tract infections, skin and soft tissue infections, pneumonia, intra-abdominal infections, SBP prophylaxis Ceftriaxone IV: bacterial meningitis or Enterococcal endocarditis Ceftriaxone IM: gonorrhea Cefuroxime IV Cefuroxime PO Cephalexin PO Chloramphenicol IV Chloroquine Phosphate PO: malaria treatment Chloroquine Phosphate PO: malaria prophylaxis Cidofovir IV ✱ID✱ Cidofovir IV: BK virus nephropathy ✱ID✱ Ciprofloxacin IV Ciprofloxacin PO Ciprofloxacin PO: Spontaneous Bacterial Peritonitis Prophylaxis Clarithromycin PO Clindamycin PO: mild-to-moderate infections Clindamycin PO: complicated skin and soft tissue infections, pneumonia, or bone & joint infections due to MRSA Clindamycin Phosphate IV Clofazimine PO: nontuberculous mycobacterial infections Colistimethate IV ✱ID✱ Cycloserine PO: tuberculosis ✱ID✱ Dalbavancin IV: MRSA skin and soft tissue infection ✱ID✱ Dalbavancin IV: osteomyelitis ✱ID✱ Dapsone PO: Pneumocystis jirovecii pneumonia treatment or prophylaxis Dapsone PO: Pneumocystis jirovecii pneumonia prophlaxis alternate dosing Daptomycin IV: MRSA bacteremia or endocarditis ✱ID✱ Daptomycin IV: VRE bacteremia or endocarditis ✱ID✱ Daptomycin IV: Skin and soft tissue infections ✱ID✱ Delafloxacin PO: pneumonia, skin and soft tissue infections ✱ID✱ Delafloxacin IV: pneumonia, skin and soft tissue infections ✱ID✱ Dicloxacillin Sodium PO Doxycycline PO/IV Eravacycline IV ✱ID✱ Ertapenem IV ✱ID✱ Erythromycin Lactobionate IV Erythromycin Lactobionate IV: GI motility Erythromycin PO tablets Erythromycin Ethylsuccinate PO solution Ethambutol PO: tuberculosis Ethionamide PO: tuberculosis Famciclovir PO: herpes zoster Famciclovir PO: HSV-recurrent genital herpes Famciclovir PO: Suppression for HSV-recurrent orolabial and genital HSV infection in HIV-infected patients Famciclovir PO: MGH-only – HSV/VZV prophylaxis in low CMV risk kidney, liver, and heart transplants Fidaxomicin PO: Clostridioides difficile infection ✱ID✱ Fidaxomicin PO: Pulse dosing for recurrent Clostridioides difficile infection ✱ID✱ Fluconazole PO/IV: invasive candidiasis treatment Fluconazole PO/IV: invasive candidiasis treatment, alternative weight-based treatment for extremes in body weight Fluconazole PO: vagin*l candidiasis Fluconazole PO/IV: thrush/oropharyngeal candidiasis Fluconazole PO/IV: prophylaxis dosing Flucytosine PO: cryptococcal meningitis Foscarnet IV: CMV induction, HHV-6 ✱ID✱ Foscarnet IV: CMV maintenance ✱ID✱ Foscarnet IV: HSV-1 or -2 infection ✱ID✱ Fosfomycin PO: uncomplicated UTI Fosfomycin PO: complicated UTI, prostatitis Ganciclovir IV: CMV, induction ✱ID✱ Ganciclovir IV: CMV, maintenance or prophylaxis ✱ID✱ Gentamicin IV Griseofulvin Microsize: tinea barbae, tinea capitis, tinea corporis, tinea cruris Griseofulvin Microsize: tinea pedis, tinea unguium Griseofulvin Ultramicrosize: tinea barbae, tinea capitis, tinea corporis, tinea cruris Griseofulvin Ultramicrosize: tinea pedis, tinea unguium Hydroxychloroquine PO: malaria treatment Hydroxychloroquine PO: malaria prophylaxis Imipenem-cilastatin IV: most bacterial infections ✱ID✱ Imipenem-cilastatin IV: most mycobacterial infections ✱ID✱ Imipenem-cilastatin IV: Bacterial or mycobacterial infections with intermediate susceptibility to imipenem ✱ID✱ Imipenem-cilastatin and relebactam IV: most bacterial infections ✱ID✱ Isavuconazonium sulfate PO/IV: invasive aspergillosis, mucormycosis ✱ID✱ Isoniazid PO: tuberculosis Itraconazole PO suspension: aspergillosis, cryptococcosis, febrile neutropenia, histoplasmosis Ivermectin PO: Strongyloidiasis, cutaneous larva migrans Lefamulin PO ✱ID✱ Lefamulin IV ✱ID✱ Letermovir PO/IV: CMV prophylaxis in patients post-allogeneic hematopoietic stem cell transplant ✱ID✱ Levofloxacin PO/IV: nosocomial and community acquired pneumonia, complicated skin and soft tissue infections, MDR tuberculosis Levofloxacin PO/IV: sinusitis, uncomplicated skin and soft tissue infections, UTI Linezolid PO/IV ✱ID✱ Linezolid PO/IV: mycobacterial infections ✱ID✱ Maribavir PO: CMV treatment ✱ID✱ Mebendazole PO: Ascariasis, trichuriasis Mefloquine PO: Malaria treatment Mefloquine PO: Malaria prophylaxis Meropenem IV: febrile neutropenia, pneumonia, bacteremia, sepsis, UTIs, gynecologic infections, intra-abdominal infections, mycobacterial infections ✱ID✱ Meropenem IV: bacterial meningitis, cystic fibrosis, infection with confirmed elevated MIC to meropenem ✱ID✱ Meropenem IV: alternative dosing; may replace 1gm Q8H dosing; EXCEPT for febrile neutropenia and CNS infections ✱ID✱ Meropenem-vaborbactam IV ✱ID✱ Metronidazole PO/IV: most indications Metronidazole PO/IV: C. difficile, CNS anaerobic infections Micafungin IV: febrile neutropenia, candidemia, invasive candidiasis, Candida peritonitis, or abscesses ✱ID✱ Micafungin IV: esophageal candidiasis, refractory aspergillosis, consider for fungal endocarditis ✱ID✱ Minocycline HCl PO/IV: most indications Moxifloxacin PO/IV ✱ID✱ Nafcillin IV: MSSA bacteremia, endocarditis, meningitis, and pneumonia Nitazoxanide PO: cryptosporidiosis, giardiasis Nitrofurantoin PO (Macrobid SR): uncomplicated female or male UTI Nitrofurantoin PO (Macrobid IR): uncomplicated female or male UTI Nystatin PO: intestinal infections Omadacycline IV ✱ID✱ Omadacycline PO ✱ID✱ Oritavancin IV: MRSA skin and soft tissue infection ✱ID✱ Oseltamivir Phosphate PO: influenza treatment Oseltamivir Phosphate PO: influenza treatment (ONLY FOR SITES THAT DO NOT STOCK 30mg CAPSULES) Oseltamivir Phosphate PO: influenza prophylaxis Oseltamivir Phosphate PO: influenza prophylaxis (ONLY FOR SITES THAT DO NOT STOCK 30mg CAPSULES) Oxacillin Sodium IV: MSSA bacteremia, endocarditis, pneumonia, meningitis Paromomycin PO: intestinal amebiasis Penicillin G IV: endocarditis, bacteremia, neurosyphilis, pneumonia, sepsis Penicillin G IV 24H continuous infusion: endocarditis, bacteremia, neurosyphilis, pneumonia, sepsis Penicillin G IV Penicillin V PO (Pen-VK, Veetids): pneumococcal respiratory tract infection, otitis media, pharyngitis, gingivitis, staphylococcal skin and soft tissue infection Penicillin V PO (Pen-VK, Veetids): prophylaxis for rheumatic fever, chorea, or meningococcal disease post-eculizumab Penicillin G Benzathine IM (Bicillin L-A) Penicillin G Procaine IM (Wycillin, Bicillin C-R): neurosyphilis Penicillin G Procaine IM (Wycillin, Bicillin C-R): other infections Pentamidine IV/IM: Pneumocystis jirovecii pneumonia treatment Pentamidine IV/IM/inhalation: Pneumocystis jirovecii pneumonia prophylaxis Peramivir IV: influenza, acute, uncomplicated Piperacillin-tazobactam IV: nosocomial pneumonia, febrile neutropenia, cystic fibrosis exacerbations, endometritis Piperacillin-tazobactam IV: appendicitis, peritonitis, pelvic inflammatory disease, complicated skin and soft tissue infections Piperacillin-tazobactam IV: site-specific extended infusion dosing Plazomicin IV ✱ID✱ Polymyxin B Sulfate IV ✱ID✱ Posaconazole PO: prophylaxis or treatment ✱ID✱ Posaconazole IV: prophylaxis or treatment ✱ID✱ Posaconazole PO oral suspension: treatment ✱ID✱ Posaconazole PO oral suspension: prophylaxis ✱ID✱ Primaquine Phosphate PO: malaria Pyrantel PO Pyrazinamide PO: tuberculosis Pyrimethamine PO: toxoplasmosis treatment ✱ID✱ Pyrimethamine PO: toxoplasmosis or Pneumocystis jirovecii pneumonia prophylaxis ✱ID✱ Quinine PO: malaria, babesiosis treatment Quinupristin-dalfopristin IV: complicated skin infections due to MRSA ✱ID✱ Quinupristin-dalfopristin IV: bacteremia due to vancomycin-resistant E. faecium ✱ID✱ Remdesivir IV: COVID-19 Rifabutin PO: treatment for tuberculosis or disseminated MAC Rifampin PO/IV: tuberculosis ✱ID✱ Rifampin PO/IV: prosthetic joint infections ✱ID✱ Rifampin PO/IV: prosthetic valve endocarditis ✱ID✱ Rifapentine PO: tuberculosis, intensive phase ✱ID✱ Rifapentine PO: tuberculosis, continuation phase ✱ID✱ Rifaximin PO: recurrent Clostridioides difficile infection Rifaximin PO: hepatic encephalopathy Rifaximin PO: traveler's diarrhea Sulfadiazine PO: Toxoplasma gondii encephalitis, acute infection Sulfadiazine PO: Toxoplasma gondii encephalitis, chronic maintenance therapy Streptomycin IM/IV Streptomycin IM/IV: gentamicin-resistant enterococcal endocarditis dosing Tedizolid PO/IV: MRSA skin and soft tissue infection ✱ID✱ Telavancin IV: Serious Gram-positive infections refractory to first-line agents ✱ID✱ Terbinafine PO: Fusarium, cutaneous and lymphocutaneous Sporotrichosis Terbinafine PO: onychomycosis Tetracycline PO Tigecycline IV ✱ID✱ Tigecycline IV: nontuberculous mycobacterial infections ✱ID✱ Tinidazole PO: amebiasis, bacterial vaginosis Tinidazole PO: giardiasis, trichom*oniasis Tobramycin IV Trimethoprim-sulfamethoxazole PO/IV: Pneumocystis jirovecii pneumonia, severe Nocardia infections, treatment dosing Trimethoprim-sulfamethoxazole PO/IV: Treatment of Stenotrophom*onas maltophilia or other systemic infections Trimethoprim-sulfamethoxazole PO: urinary tract infections Trimethoprim-sulfamethoxazole PO: uncomplicated skin and soft tissue infections Trimethoprim-sulfamethoxazole PO: lung transplant or HIV-infected Pneumocystis jirovecii pneumonia prophylaxis Trimethoprim-sulfamethoxazole PO: renal transplant Pneumocystis jirovecii pneumonia prophylaxis Valacyclovir PO: Zoster/HSV treatment Valacyclovir PO: prophylaxis/suppression, including lung transplant prophylaxis Valacyclovir PO: Renal Transplant prophylaxis Valganciclovir PO: Renal transplant prophylaxis Valganciclovir PO: maintenance/suppression/prophylaxis Valganciclovir PO: CMV treatment Vancomycin IV: systemic infections Vancomycin PO: Clostridioides difficile treatment ONLY Vancomycin PO: Clostridioides difficile prophylaxis ONLY Voriconazole PO ✱ID✱ Voriconazole IV ✱ID✱ Zanamivir Inhalation: influenza treatment ✱ID✱ FAQs

Adapted from MGB guidelines, June 2023. Please refer to the original source for definitive guidance.
✱ID✱ indicates that Infectious Disease approval is required, unless otherwise noted by the individual hospital protocol.
Renal dosing adjustments should be calculated by the co*ckcroft-Gault Equation, not estimated GFR, unless otherwise noted.

ACYCLOVIR Sitavig, Zovirax

Acyclovir IV: disseminated HSV, HSV encephalitis, visceral zoster, VZV/HSV retinal necrosis

CrCl ≥50	10mg/kg	Q8H
26–49	10mg/kg	Q12H
10–25	10mg/kg	Q24H
<10	5mg/kg	Q24H
Hemodialysis
Peritoneal dialysis
CVVH	See CVVH Dosing

Maintain adequate hydration; BMI<25: use actual body weight; BMI≥25: use adjusted bodyweight; Discuss doses ≥1,000mg with ID; On dialysis days give post-HD