Version May 2024
| Bacteria | Antibiotic | Pediatric dose* | Adult dose | Comments |
| Staphylococcus aureus (methicillin-sensitive) | Cefazolin | 100 mg/kg per day in 3 or 4 divided doses | 1.5 g every 6 hours or 2 g every 8 hours | Maximum 6 g per day. |
| or | ||||
| Nafcillin | 100 to 200 mg/kg per day in 4 or 6 divided doses | 2 g every 4 to 6 hours | Maximum 12 g per day. | |
| Oral regimens (for mild exacerbations)¶ | ||||
One of the following, guided by susceptibility testing:
| ||||
| S. aureus (methicillin-resistant)[1] | Vancomycin◊ | 60 mg/kg per day in 3 (or 4) divided doses | 45 to 60 mg/kg per day in 3 divided doses | Maximum 3.6 g per day for children and 4.0 g per day for adults. These doses are for patients with normal kidney function. Dose and frequency are adjusted based on serum vancomycin concentrations, using either trough-directed or AUC-guided dosing§. To reduce the risk of kidney toxicity, a beta-lactam other than piperacillin-tazobactam should be selected when being used in combination with vancomycin and tobramycin[2]. |
| or | ||||
| Linezolid | Children <12 years: Use adult dose | 600 mg intravenously or orally every 12 hours | Risk of myelosuppression (most commonly thrombocytopenia) with treatment >14 days or when kidney function impairment is present[3]. | |
| or | ||||
| Ceftaroline | 45 mg/kg per day intravenously in 3 divided doses | 600 mg intravenously every 8 hours | Maximum 1800 mg per day. | |
| Oral regimens¶ | ||||
One of the following, guided by susceptibility testing:
| ||||
| Pseudomonas aeruginosa | One of the following: | |||
| Piperacillin-tazobactam¥‡ | 350 to 450 mg/kg† per day in 4 divided doses | 4.5 g every 6 hours | Maximum 16 g† per day. | |
| Ceftazidime¥ | 150 to 200 mg/kg per day in 3 or 4 divided doses | 2 g every 6 to 8 hours | Maximum 8 g per day. | |
| Cefepime | 150 mg/kg per day in 3 divided doses | 2 g every 8 hours | Maximum 6 g per day. | |
| Imipenem-cilastatin | 60 to 100 mg/kg per day in 4 divided doses | 0.5 to 1 g every 6 hours | Maximum 4 g per day. | |
| Meropenem | 120 mg/kg per day in 3 divided doses | 2 g every 8 hours | Maximum 6 g per day. | |
| Ticarcillin-clavulanate¥‡ | 400 mg/kg** per day in 4 or 6 divided doses | 3.1 g every 4 to 6 hours | Maximum 18 g** per day. | |
| Plus | ||||
| Ciprofloxacin | Oral dose: 30 mg/kg per day in 3 divided doses | Oral dose: 400 mg every 8 to 12 hours | Maximum dose:
Can be used in preference to aminoglycoside or colistin due to less toxicity, particularly when Pseudomonas is sensitive. | |
| or | ||||
| Levofloxacin | Oral and intravenous dose:
| Oral and intravenous dose:
| Maximum dose:
Can be used in preference to an aminoglycoside or colistin due to less toxicity, particularly when in vitro testing demonstrates that the P. aeruginosa is sensitive to levofloxacin. | |
| or | ||||
| Tobramycin¶¶ | 10 mg/kg every 24 hours (adjust dose for overweight patients)ΔΔ | 10 mg/kg every 24 hours (adjust dose for overweight patients)ΔΔ | Refer to the UpToDate topic on treatment of acute pulmonary exacerbations for a discussion of serum concentration monitoring for aminoglycosides and for dose and interval adjustment for kidney function impairment. Dose and frequency from a previous course that achieved the therapeutic range may be considered for determining the initial dose. | |
| or | ||||
| Amikacin¶¶ | 30 to 35 mg/kg every 24 hours (adjust dose for overweight patients)ΔΔ | 30 to 35 mg/kg every 24 hours (adjust dose for overweight patients)ΔΔ | ||
| or | ||||
| Colistin (colistimethate sodium) | 2.5 to 5 mg/kg◊◊ (colistin base activity§§) per day in 3 divided doses | 2.5 to 5 mg/kg◊◊ (colistin-base activity§§) per day in 3 divided doses | Maximum 300 mg per day (colistin-base activity§§). Colistin is a second-line drug that may be useful when the P. aeruginosa demonstrates in vitro resistance to all aminoglycosides or when the patient fails to improve on an aminoglycoside-containing regimen. IMPORTANT: Dose units and recommended dosing regimens vary by product and country. Doses shown here are specific to United States-licensed information for Coly-Mycin M, which labels its product as units of "colistin-base activity"§§. Consult local official product information for details before using this agent. Adverse effects include kidney and neurotoxicities. | |
| S. aureus (methicillin-sensitive) and P. aeruginosa | Same antibiotics shown above for P. aeruginosa alone EXCEPT that ceftazidime should not be used, because of poor activity against S. aureus. | |||
| S. aureus (methicillin-resistant) and P. aeruginosa | Same antibiotics shown above for P. aeruginosa alone. | |||
| Plus one of the following (3 antibiotics total): | ||||
| Vancomycin◊ | 60 mg/kg per day in 3 (or 4) divided doses | 45 to 60 mg/kg per day in 3 divided doses | Maximum 3.6 g per day for children and 4.0 g per day for adults. These doses are for patients with normal kidney function. Dose and frequency are adjusted based on serum vancomycin concentrations, using either trough-directed or AUC-guided dosing§. To reduce the risk of kidney toxicity, a beta-lactam other than piperacillin-tazobactam should be selected when being used in combination with vancomycin and tobramycin[2]. | |
| or | ||||
| Linezolid | Children <12 years: Use adult dose | 600 mg intravenously or orally every 12 hours | Risk of myelosuppression (most commonly thrombocytopenia) with treatment >14 days or when kidney function impairment is present[3]. | |
The table contains recommended choices of antibiotics based on the type of bacteria isolated. The selection should be modified based on results of sensitivity testing and kidney function. The doses given here are typical for patients with cystic fibrosis. Higher and/or more frequent dosing of some antibiotics is often required for cystic fibrosis patients as compared with patients without cystic fibrosis, and a wider range of dose requirements is to be expected. Note that these dosing recommendations do not apply to cystic fibrosis patients who have undergone lung transplantation.
For most of these antibiotics, dosing reflects recommendations from a comprehensive review of antipseudomonal antibiotics in cystic fibrosis[4]. For a few of the antibiotics (piperacillin-tazobactam, ticarcillin-clavulanate, and ceftazidime), the review recommends much higher doses for cystic fibrosis patients than are used for patients without cystic fibrosis. These are based primarily on pharmacokinetic and pharmacodynamic considerations, but clinical trial data for these very high doses are lacking. Therefore, we suggest intermediate doses for these drugs, as shown in the table above. Many clinicians are prescribing beta-lactam antibiotics to be administered by prolonged or continuous infusion, based on a strong theoretical basis and pharmacokinetic analysis of drug levels in patients with cystic fibrosis.AUC: area under the time-concentration curve; MIC: minimum inhibitory concentration; MSSA: methicillin-sensitive S. aureus.
* The dose given to children generally should not exceed the dose for adults.
¶ The severity of an exacerbation is typically based on changes in clinical symptoms and pulmonary function tests compared with the patient's own baseline.
Δ For trimethoprim-sulfamethoxazole, dosing for patients with cystic fibrosis may need to be higher than that recommended for non-cystic fibrosis patients (refer to the UpToDate topic on treatment of acute pulmonary exacerbations in cystic fibrosis).
◊ For vancomycin, some clinicians target a lower serum trough level of 10 to 15 mg/mL since this reduces the risk for nephrotoxicity, and pharmacokinetic/pharmacodynamic studies showed that this approach achieves the desired target of AUC/MIC ≥400 in children and adolescents[5].
§ For therapeutic monitoring of vancomycin, either trough-directed or AUC-guided strategies may be used. AUC-guided dosing requires support from a clinical pharmacist, and was endorsed by a consensus guideline.[5] Refer to UpToDate content on treatment of pulmonary exacerbations in cystic fibrosis.
¥ For piperacillin-tazobactam, ticarcillin-clavulanate, and ceftazidime, higher doses than those shown may be considered on a case-by-case basis to optimize pharmacodynamic targets in patients with multidrug-resistant pathogens and poor clinical response to initial treatment[4]. Many clinicians are prescribing beta-lactam antibiotics to be administered by prolonged or continuous infusion, based on a strong theoretical basis and pharmacokinetic analysis of drug levels. Ticarcillin-clavulanate is no longer available in North America, Australia, the United Kingdom, and most of Europe.
‡ For treatment of P. aeruginosa without MSSA, piperacillin without tazobactam or ticarcillin without clavulanate can be used where available (in combination with ciprofloxacin, an aminoglycoside, or colistin, depending on reported susceptibilities).
† Of piperacillin component. Doses >600 mg/kg/day may be considered on a case-by-case basis, but increased risk of toxicity is expected, including serum sickness, anemias, and bone marrow suppression.
** Of ticarcillin component.
¶¶ Monitor aminoglycoside blood levels and creatinine to ensure efficacy and avoid toxicity. The dose and frequency from a previous course of treatment may be used initially if serum concentrations were in the target range and if creatinine clearance is not substantially changed, but drug levels should still be monitored.
ΔΔ For patients with total body weight greater than 120% of ideal body weight, initial dose selection should be based on adjusted body weight or dosing weight. A calculator for ideal body weight and dosing weight in adults is available in UpToDate.
◊◊ If the patient is overweight, the initial dose of colistin should be based on ideal body weight. A calculator for ideal body weight in adults is available in UpToDate.
§§ For an explanation of our recommended colistin dosing for people with cystic fibrosis, refer to the UpToDate content on antibiotic therapy in cystic fibrosis. Conversions: 1 mg colistin-base activity (CBA; United States product) = 30,000 international units of colistimethate sodium (CMS; European Union product).Many but not all of the dosing recommendations in this table are reflected in the following source: Zobell JT, Young DC, Waters CD, et al. Optimization of anti-pseudomonal antibiotics for cystic fibrosis pulmonary exacerbations: VI. Executive Summary. Pediatr Pulmonol 2013; 48:525.
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
