| Agent | Usual Adult Dosage | Adverse Effects/Comments |
| Penicillins |
| -Lactamase Susceptible, Nonantipseudomonal Penicillins |
| Penicillin G | IV low dose: 600,000 1,200,000 U/d
IV high dose: 4M U load, then 1M U q1h | Hypersensitivity: drug fever, rash
Anaphylactic reactions (approximately 1 in 10,000)
Blood: positive Coombs, hemolytic anemia, cytopenia, nephrotoxicity, seizures, phlebitis at IV site
Use pump for infusion to avoid inadvertent bolus
2 mEq Na+/MU of penicillin G sodium |
| Benzathine penicillin | IM: 600,000 1,200,000 U qd | As with penicillin G, plus local reactions at injection site; not for IV administration |
| Ampicillin | IV: 1 3 g q4 6h | Rash
Urticarial rash, often not true penicillin allergy: especially patients with infectious mononucleosis, lymphocytic leukemia, or those on allopurinol
Fever, low WBC, high SGOT (rare), anaphylactic reactions; convulsions (with excessively rapid infusions)
Interstitial nephritis
2.9 mEq Na+/g |
| -Lactamase Susceptible, Antipseudomonal Penicillins |
| Piperacillin | IV: 2 4 g q4 6h
Urinary tract: IV: 2 g q6h | Similar to other penicillins
1.85 mEq Na+/g |
| Combination -Lactamase Inhibitors and -Lactam Agents |
| Ticarcillin-clavulanic acid | IV: 3.1 g q4 6h | Similar to ticarcillin alone
4.75 mEq Na+/g |
| Ampicillin-sulbactam | IV: 1.5 3 g q6h | Similar to ampicillin alone
5 mEq Na+/1.5g |
| Piperacillin-tazobactam | IV: 3.375 g q4 6h | Similar to piperacillin alone
2.35 mEq Na+/g piperacillin
For pseudomonas; use q4h regimen |
| -Lactamase Resistant Penicillins |
| Nafcillin | Moderate infection: IV/IM: 1 g q4h
Severe infection: IV: 2 g q4h | Phlebitis, rash, drug fever, eosinophilia, hemolytic anemia, neutropenia, interstitial nephritis, elevated SGOT, nausea, diarrhea
2.9 mEq Na+/g |
| Oxacillin | Moderate infection: IV/IM: 1 g q4h
Severe infection: IV: 2 g q4h | Similar to nafcillin (neutropenia less frequent)
2.5 mEq Na+/g |
| Cephalosporins/Cephamycins/Carbacephem |
| Parenteral |
| Cefazolin | IV/IM: 0.5 3 g q6 8h | Rash, elevated SGOT, elevated alkaline phosphatase, phlebitis (less than with cephalothin), positive Coombs
2 mEq Na+/g |
| Cefepime | IV/IM: 2 g q12h | Rash
Cefepime is sodium free |
| Cefotaxime | Moderate infection: IV/IM: 1 g q8 12h
Life-threatening infection: IV/IM: 2 g q4h | Phlebitis, rash, eosinophilia, positive Coombs, neutropenia
Elevated SGOT, diarrhea
2.2 mEq Na+/g |
| Cefoxitin | IV/IM: 1 2 g q4 6h | Phlebitis, pruritus, rash, fever, eosinophilia, positive Coombs (without hemolysis), leukopenia, mildly elevated BUN
Falsely elevated serum creatinine
Transiently elevated SGOT, SGPT, LDH, alkaline phosphatase
2.3 mEq Na+/g |
| Ceftazidime | IV/IM: 0.5 2 g q8 12h | Phlebitis
Hypersensitivity: rash, eosinophilia, fever
Positive Coombs, neutropenia, thrombocytosis
Elevated SGOT
Diarrhea, elevated BUN
2.3 mEq Na+/g |
| Ceftriaxone | IV/IM: 0.5 2 g q12 24h | Phlebitis
Hypersensitivity: rash, eosinophilia, fever
Neutropenia, thrombocytosis
Elevated SGOT
Pseudocholelithiasis secondary to sludge in gallbladder
3.6 mEq Na+/g |
| Cefuroxime | IV/IM: 0.75 1.5 g q8h | Phlebitis, rash, positive Coombs, lowered hematocrit, eosinophilia, neutropenia
Elevated SGOT, alkaline phosphatase, LDH, bilirubin
Diarrhea, nausea
2.4 mEq Na+/g |
| Carbapenems |
| Ertapenem | IV: 1 g q24h | Similar to meropenem, imipenem
6.0 mEq Na+/g |
| Imipenem-cilastatin | IV: 0.5 1 g q6 8h | Phlebitis
Hypersensitivity: rash, pruritus, eosinophilia
Positive Coombs, neutropenia
Oliguria
Elevated SGOT, SGPT, alkaline phosphatase
Confusion, seizures, myoclonus
Nausea, vomiting (especially with too rapid IV infusion), diarrhea, pseudomembranous colitis
In elderly patients with poor renal function, cerebrovascular disease, or seizure disorders, consider avoiding this agent because of high risk of neurological side effects
1.6 mEq Na+/500 mg |
| Meropenem | IV: 1 2 g q8h | Similar to imipenem but less contraindicated for patients with renal, cerebrovascular, or seizure disorders
3.92 mEq Na+/500 mg |
| Monobactams |
| Aztreonam | Moderately severe infection: IV: 1 g q8h
Life-threatening infection: IV: 2 g q6h | Phlebitis
Hypersensitivity, rash (no cross-reactivity with penicillin G), eosinophilia
Elevated SGOT
Diarrhea, nausea, vomiting
Seizures
Aztreonam is sodium-free |
| Aminoglycosides and Related Antibiotics (See Table 10.4) |
| Amikacin | IV: 15 mg/kg/d divided q8h
IV: for extended interval (i.e., q24h) see Table 10.4 | Nephrotoxicity (proteinuria, elevated BUN), ototoxicity
Eosinophilia, arthralgia, fever, skin rash, probable neuromuscular blockade
q24h regimen not as well studied, but can be given at high doses at extended intervals, i.e., 20 32 mg/kg q24h if renal function is normal (see Table 10.4) |
| Gentamicin | IV: For extended interval (i.e., q24h) see Table 10.4
IV: 3 5 mg/kg/d divided q8h or given q24h
Intrathecal: 4 mg q12h (Preservative free) | Nephrotoxicity (proteinuria, elevated BUN), ototoxicity (especially vestibular), fever, rash, neuromuscular blockade
q24h regimen not well studied for life-threatening disease; but can be given as high doses at extended intervals, i.e., 5 8 mg/kg q24h (see Table 10.4) |
| Neomycin sulfate | Hepatic coma: PO 4 12 g/d
Enteropathogenic E. coli: PO 100 mg/kg/d | Nausea, vomiting, diarrhea, malabsorption
Ototoxicity, nephrotoxicity, neuromuscular blockade if sufficiently absorbed |
| Streptomycin | IM/IV: 0.5 2 g/d | Ototoxicity (vestibular, auditory) nephrotoxicity, drug fever, neuromuscular blockade, rash, circumoral paresthesias
Often in short supply |
| Tobramycin | IV: 3 5 mg/kg/d divided q8h | Nephrotoxicity, ototoxicity, (dizziness, hearing loss) neuromuscular blockade, rash |
| Macrolides, Cloramphenicol Glycopeptides, and Others |
| Azithromycin | IV: 500 mg qd 1 2 d | Diarrhea, nausea, abdominal pain, pain at infusion site
If unable to convert to PO therapy, reduce IV dose to 100 mg IV qd; provides approximately same systemic expose as 250 mg PO daily, with oral bioavailability equal to 37% |
| Chloramphenicol | IV: 50 mg/kg/d | Rarely used except in unusual circumstances because of risk of aplasia or litigation or both
Decreased RBC in approximately one-third of patients; aplastic anemia incidence of 1 of 21,000 courses
Fever, skin rash, anaphylactoid reactions, optic atrophy or neuropathy, digital paresthesias, minor disulfiramlike reactions
2.3 mEq Na+/g |
| Clindamycin | IV: 150 900 mg q8h | Diarrhea, pseudomem-branous colitis with toxic megacolon
Rash, neutropenia, eosinophilia
Occasional elevated SGOT and alkaline phosphatase
Neuromuscular blockade |
| Erythromycin | IV: 500 mg 1 g q6h | Nausea, vomiting, abdominal cramps (both PO and IV), diarrhea, phlebitis at infusion site
Rare rash, elevated SGOT, cholestatic jaundice (especially with erythromycin estolate; rare with erythromycin ethyl succinate)
Reversible deafness (high dose), PVCs, torsade de pointes
For legionellosis, 1g IV q6h is preferred over lower doses |
| Spectinomycin | IM: 2 g once | Rash, drug fever, local pain on injection
Anaphylaxis |
| Synercid (Quinupristin-Dalfopristin) | IV: 7.5 mg/kg q8 12h | Myalgias |
| Vancomycin | IV: 1 g q12h
PO: 125 500 mg q6h
Intrathecal: 5 10 mg q48 72h | Phlebitis, fever, rash, nausea, ototoxicity
Neutropenia, eosinophilia, anaphylactoid reactions
Red man syndrome (flushing over upper chest) rate dependent
Hypotension with rapid IV push
Oral doses not absorbed systemically; oral therapy limited to treatment of antibiotic associated diarrhea due to C. difficile |
| Tetracyclines |
| Doxycycline | IV: 100 mg q12h on 1st day then 100 200 mg/d | Hepatotoxicity, negative nitrogen balance, pseudotumor cerebri; phlebitis (central line preferred) |
| Tigecycline | IV: 100 mg 1 then 50 mg q12h | Nausea, vomiting
Avoid in pregnancy |
| Fluoroquinolones |
| Ciprofloxacin | IV: 400 mg q8 12h | Nausea, diarrhea, vomiting, abdominal pain
Headache, insomnia, nightmares, toxic psychosis, confusion, seizures
Rash, angioedema
Elevated SGOT, alkaline phosphatase, WBC, creatinine |
| Gatifloxacin | IV: 200 400 mg qd | Similar to ciprofloxacin |
| Levofloxacin | IV: 500 750 mg qd | Similar to ciprofloxacin
Use higher dose for most ICU settings |
| Moxifloxacin | IV: 400 mg qd | Similar to ciprofloxacin |
| Ofloxacin | IV: 200 400 mg q12h | Similar to ciprofloxacin |
| Miscellaneous Antibacterial Agents |
| Colistin | IV: 1.25 2.5 mg/kg q12h | Nephrotoxicity, abnormal vision, paresthesias, confusion |
| Daptomycin | IV: 4 6 mg/kg qd | Myalgias |
| Linezolid | IV/PO: 600 mg q12h | Thrombocytopenia
Neuropathies (prolonged use)
Serotonin syndrome |
| Metronidazole | IV: 500 mg q6h | Nausea, vomiting, diarrhea, metallic taste, headache, rare paresthesias, ataxia, seizures, urticaria, phlebitis at injection site
14 mEq Na+/500 mg |
| Tinidazole | PO: 2 g once or qd | Similar to metronidazole |
| Trimethoprim (TMP)-sulfamethoxazole (SMX) | IV: TMP 320 mg/SMX 1,600 mg q8h | Urticaria, maculopapular and morbilliform rashes, nausea, vomiting, diarrhea
Glossitis, rare jaundice
Headache, depression, rare hallucinations, pseudotumor cerebri
Renal: falsely elevated creatinine, renal failure, hyperkalemia
Neutropenia, thrombocytopenia, agranulocytosis
May trigger asthma in sulfite-sensitive individuals |
| Antifungals |
| Amphotericin B | IV: 0.5 1.5 mg/kg qd | Premeds: diphenhydramine 50 mg IV, meperidine 50 mg IV, acetaminophen 650 mg PO
Hydration: 500 ml 0.9% NaCl pre- and postinfusion
Administer in D5W, not in electrolyte solutions
Administer over 1 4 h (1 h may be as well tolerated as 4 h)
Hydrocortisone: 25 100 mg IV if fever, chills not controlled by other premeds
Toxicity: renal (dose related elevation of creatinine), renal tubular wasting, lowered K, lowered Mg, fever, chills, nausea, vomiting, phlebitis, anemia, headache
Initiating doses in stepwise fashion (1 mg, 5 mg, 10 mg, etc.) is probably unnecessary |
| Bladder irrigation: 50 mg/ 1,000 cc sterile water |
| ABLC (Abelcet) | IV: 5 mg/kg qd | Same as amphotericin B but less frequent
ABLC (amphotericin B lipid complex) |
| Liposomal ampho B (AmBisome) | IV: 5 7.5 mg/kg qd | Same as amphotericin B but less common
Higher doses have been used |
| Anidulafungin | IV: 35 mg qd | Minimal to date |
| Caspofungin | IV: 70 mg 1 d then 50 mg qd | Elevated transaminase |
| Fluconazole | IV/PO: 400 mg q24h | Histamine release
Nausea, vomiting, diarrhea
Elevated ALT/AST, confusion, rash, eosinophilia |
| Flucytosine | PO: 37.5 mg/kg q6h | Nausea, vomiting, diarrhea, leukopenia, thrombocytopenia
Elevated ALT/AST
Rash
Falsely elevated creatinine if EKTACHEM analysis used |
| Itraconazole | PO: 200 mg bid
IV: 200 mg PO bid 4 doses then 200 mg qd | Nausea, abdominal pain, rash, edema, hypokalemia, hepatitis
Administer capsule with meals, administer oral solution on an empty stomach |
| Micafungin | IV: 150 mg qd (acute therapy) | Leukopenia
Histamine release |
| Posaconazole (Investigational) | PO: 400 mg q12h | Elevated ALT/AST |
| Voriconazole | IV: 6 mg/kg q12h 24 h then 4 mg/kg q12h
PO: 400 mg q12h 1 d then 200 mg q12h (if >40 kg body weight) | Elevated transaminase
Visual disturbances
Rash
Thrombocytopenia |
| Antiretroviral | Should discontinue all antiretrovirals if adherence or gastrointestinal absorption not ensured
No intravenous preparations are available |
| Anti-HIV nucleosides/nucleotides | All drugs in this class can cause hepatic steatosis and lactic acidosis |
| Abacavir | PO: 300 mg bid/600 mg qd | Rash, myalgia, fever: never rechallenge after stopping for rash, fever, or myalgias |
| Didanosine (ddl) | PO: 400 mg qd | Pancreatitis, peripheral neuropathy |
| Emtricitabine (FTC) | PO: 200 mg qd | Few |
| Lamivudine (3TC) | PO: 150 mg bid | Toxicities are rare |
| Stavudine (d4T) | PO: 30 40 mg bid | Pancreatitis, peripheral neuropathy |
| Tenofovir | PO: 300 mg qd | Renal tubular dysfunction
If stopped, beware hepatitis B flare |
| Anti-HIV Nonnucleosides |
| Efavirenz | PO: 600 mg qd | CNS effects (e.g., insomnia, vivid dreams), rash, drug interactions |
| Anti-HIV Proteases | Drug interactions with agents metabolized by cytochrome P450 system can be significant |
| Lopinavir-Ritonavir | PO: 3 capsules bid or 2 tablets bid or 6 capsules qd or 4 tablets qd | Diarrhea, nausea, hypertriglyceridemia, elevated transaminase |
| Antivirals (Nonantiretrovirals) |
| Acyclovir | PO (HSV): 200 mg 5 doses/day
PO (VZV): 800 mg 5 doses/day
IV (most HSV): 5 mg/kg q8h
IV (HSV encephalitis or disseminated VZV): 10 12 mg/kg IV q8h | Phlebitis (IV)
Lethargy
Tremors/seizures
Confusion
Crystalluria
Elevated ALT/AST
4.2 mEq Na+/g |
| Adefovir | PO: 10 mg PO qd | Few |
| Cidofovir | IV: 5 mg/kg qw 2, then qow | Nephrotoxicity, neutropenia, hypotony
Given with oral probenecid 2 g at 2 h predose infusion, and administer 1 g orally at 2 and 8 h postinfusion
Given with 1 liter 0.9% NaCl preinfusion |
| Foscarnet | IV: 60 mg/kg q8h or 90 mg/kg q12h (acute) 90 120 mg/kg q24h (chronic) | Infuse over 2 h after 1 L 0.9% NaCl load
Nephrotoxicity
Nausea, vomiting
Headache, seizures
Leukopenia, anemia
Elevated SGOT
Penile ulcers |
| Ganciclovir | IV: 5 mg/kg q12h (acute) 5 mg/kg q24h (chronic) | Leukopenia
Thrombocytopenia
Fever
Rash
Elevated ALT/AST
46 mEq Na+/500 mg vial |
| Palivizumab | IV: 15 mg/kg IM (pediatric) | Elevated ALT/AST
Allergic response to Ig |
| Ribavirin | Aerosol: 6g over 12 18 h per day
IV: Investigational | Bronchospasm, environmental hazard precautions
Hemolytic anemia
Concentration 20 mg/ml (6 g in 300 ml sterile H2O without preservatives) |
| Trifluridine topical | 1 drop of 1% q2h (max 9 drops/d) | Burning, edema, hypersensitivity |
| Interferon alpha | SC/IM (hepatitis B): 5M U qd
SC/IM (hepatitis C): 3M U qd | Fever
Myalgia, fatigue
Headache
Anorexia
Rash
Leukopenia, thrombocytopenia |
| Antiparasitics |
| Chloroquine | PO: 600 mg base at T = 0, then 300 mg base at 6 h, 24 h, 48 h for malaria | Nausea, vomiting, pruritus, rash, hemolytic anemia, leukopenia, thrombocytopenia |
| Ivermectin | PO: 12 mg PO qd 2 d | Headache, fever, abdominal pain |
| Pentamidine | IV: 4 mg/kg q24h | Infuse over 1 h
Nephrotoxicity
Hyperglycemia followed by hypoglycemia
Torsades de pointes
Can be given IM but causes sterile abscesses |
| Pyrimethamine | PO: 100 mg/d 1 then 25 100 mg qd | Leukopenia, rash, ataxia, tremors, seizures |
| Quinine | PO: 600 mg tid | Tinnitus, headache, nausea, hemolysis |
| Quinidine | IV: 10 mg/kg load (maximum 600 mg) in 0.9% NaCl over 1 h followed by 0.02 mg/kg/min 72 h, then oral quinine 600 mg tid to complete 7 d for malaria | More available than quinine
IV: hypotension |
| Sulfadiazine | PO: 1 2 g PO q6h
IV: none (consider using TMP/SMX) | Rash, fever, nephritis, nausea, hemolysis |
| Antimycobacterials |
| Capreomycin | IV: 1 g qd | Nephrotoxicity |
| Isoniazid | PO/IM/IV: 300 mg qd | Administer with pyridoxine
Hepatitis, neuropathy, rash, fever, headache, psychosis, seizures |
| Rifabutin | PO: 300 mg qd | Myalgias, arthralgias, leukopenia, neuritis |
| Rifampin | PO/IV: 600 mg qd | Orange urine and secretions, hepatitis, fever, nausea |
| Ethambutol | PO: 15 25 mg/kg qd | Rash, optic neuritis, confusion, gout |
| Pyrazinamide | PO: 15 30 mg/kg qd | GI intolerance, rash, arthralgia, hepatotoxicity, hyperuricemia |
| Streptomycin | IM/IV: 15 mg/kg (adult <40 y), qd
10 mg/kg (>40 y) qd | Ototoxicity, nephrotoxicity
Call (800) 254 4445 to obtain from Pfizer |
| ALT, aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; CNS, central nervous system; ICU, intensive care unit; IM, intramuscular; IV, intravenous; HSV, herpes simplex virus; LDH, lactate dehydrogenase; PO, by mouth; PVC, premature ventricular contractions; RBC, red blood cells; SGOT, serum glutamic-oxaloacetic transaminase; SGPT, serum glutamic-pyruvic transaminase; VZV, varicella zoster virus; WBC, white blood cells |
