Pathogen

Antibiotic and routine dosage

Alternative antibiotics

Staphylococcus aureus and methicillin-susceptible coagulase-negative staphylococci

Cloxacillin 2 g IV every 4 h

Cefazolin 2 g IV every 8 h

Vancomycin

MRSA and methicillin-resistant coagulase-negative staphylococci

Vancomycin 15-20 mg/kg every 12 hb

Daptomycin (use for MRSA if vancomycin MIC ≥2 microg/mL)

Ampicillin-sensitive Enterococcus spp

Ampicillin 2 g IV every 6 h

Vancomycin

Ampicillin-resistant Enterococcus spp

Vancomycin (as above)

Daptomycin

VRE

Daptomycin 8-12 mg/kg IV daily

Linezolid

Pseudomonas aeruginosa

Ceftazidime 2 g IV every 8 h or piperacillin/tazobactam 4.5 g IV every 6-8 h

Aminoglycosides

Imipenem

Meropenem

Cefepime

Ciprofloxacin

“SPICE” organisms (Serratia spp, Providencia spp, Proteus vulgaris, Citrobacter spp [non-koseri], Enterobacter spp), ESBL-producing organisms

Ertapenem 1 g IV daily empirically, then based on susceptibilities

Meropenem

Imipenem

Other gram-negative organisms (eg, Escherichia coli, Klebsiella spp)

Based on susceptibilities

Candida spp

Anidulafungin 200 mg IV on day 1, then 100 mg IV daily, or caspofungin 70 mg IV on day 1, then 50 mg IV daily, empirically; then based on species and susceptibilitiesc

Fluconazole

Amphotericin

a Recommendations should be further guided by susceptibility testing as available. Doses indicated assume normal renal function and body mass.

b Serum trough levels suggested with first trough prethird or prefourth dose: levels should be 15-20 microg/mL for S aureus infection and 10-20 microg/mL for other pathogens.

c Fluconazole is suboptimal therapy in Candida krusei and Candida glabrata; use an echinocandin instead. For Candida parapsilosis, use fluconazole instead of an echinocandin.