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Antibiotics used for the treatment of Pseudomonas aeruginosa infections in adults

Antibiotics used for the treatment of Pseudomonas aeruginosa infections in adults
Class Agent Dose
Penicillin-beta-lactamase combinations*

Piperacillin-tazobactam

4.5 g IV every 6 hours
Ticarcillin-clavulanate (not available in the United States or Canada) 3.1 g IV every 4 hours
Cephalosporins Ceftazidime 2 g IV every 8 hours
Cefepime 2 g IV every 8 or 12 hours
Cefoperazone  2 g IV every 12 hours 
CefiderocolΔ 2 g IV every 8 hours
Monobactams Aztreonam 2 g IV every 8 hours
Fluoroquinolones◊ Ciprofloxacin 400 mg IV every 8 to 12 hours or 750 mg orally every 12 hours
Levofloxacin 750 mg IV or orally once daily
Carbapenems§ Meropenem 1 g IV every 8 hours
Doripenem 500 mg IV every 8 hours 
Imipenem 500 mg IV every 6 hours¥
Advanced beta-lactamase inhibitor combinationsΔ Ceftazidime-avibactam 2.5 g IV every 8 hours
Ceftolozane-tazobactam 1.5 to 3 g IV every 8 hours‡
Imipenem-cilastatin-relebactam 1.25 g IV every 6 hours
Aminoglycosides† Tobramycin Dosing of aminoglycosides is discussed in detail in a dedicated topic
Gentamicin
Amikacin
Plazomicin
Polymyxins** Colistin Dosing of polymyxins is discussed in detail in a dedicated topic
Polymyxin B
Doses refer to intravenous administration. Doses listed are for patients with normal renal function; dose adjustments may be warranted for renal impairment.
IV: intravenous; MIC: minimum inhibitory concentration.
* Ticarcillin (3 g every 4 hours) and piperacillin (4 g every 4 hours) each have antipseudomonal activity but are not available in the United States as single agents without the beta-lactamase inhibitor.
¶ We aim to use the higher dose, particularly for severe infections or neutropenic patients, but dosing should take into account the condition treated, the MIC of the isolate, the potential for toxicity, and other patient specific factors.
Δ The novel cephalosporin cefiderocol and combination agents that include a cephalosporin or carbapenem plus a beta-lactamase inhibitor are generally reserved for infections resistant to other agents. The addition of vaborbactam to meropenem does not enhance the clinical activity of meropenem against carbapenem-resistant P. aeruginosa.
◊ Fluoroquinolones are the only class of antibiotics with antipseudomonal activity that have an oral formulation.
§ Carbapenems given as a single therapy have the propensity to induce resistance during treatment.
¥ Among the carbapenems, we favor meropenem or doripenem over imipenem, which has a higher propensity to induce resistance during treatment. For severe infection (eg, septic shock), imipenem can be given up to a dose of 1 g every 8 hours. 
‡ Pulmonary infections are treated with the 3 g every 8 hour dose.
† Aminoglycosides are generally used in combination with a beta-lactam and should NOT be used as a single agent for infections other than those of the lower urinary tract. When using an aminoglycoside as part of therapy for an infection with a high risk of P. aeruginosa, we favor tobramycin over gentamicin as it has greater intrinsic antipseudomonal activity; however, it may not be widely available.
** Polymyxins are generally reserved for the treatment of serious infections caused by P. aeruginosa isolates resistant to other agents. In such cases, they are often administered in combination with other antimicrobial agents and with a loading dose preceding the standing dose. Refer to other UpToDate content for more details on polymyxin dosing.
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