Piperacillin-Tazobactam Dosing in Pediatric Patients
For pediatric patients with complicated intra-abdominal infections or nosocomial pneumonia, administer piperacillin-tazobactam at 100 mg/kg (of the piperacillin component) every 6-8 hours, with the specific interval and infusion duration dependent on age and infection severity. 1
Standard Dosing by Age Group
Neonates and Young Infants
- Postmenstrual age ≤30 weeks: 80 mg/kg/dose IV every 8 hours 1
- Postmenstrual age >30 weeks: 80 mg/kg/dose IV every 6 hours 1
- 2-9 months of age: 80 mg/kg (piperacillin component) every 8 hours for appendicitis/peritonitis; every 6 hours for nosocomial pneumonia 2
Infants and Children
- >9 months to 6 years: 100 mg/kg (piperacillin component) every 8 hours for appendicitis/peritonitis; every 6 hours for nosocomial pneumonia 2
- Children >40 kg: Use adult dosing of 3.375 g every 6 hours (or 4.5 g every 6 hours for nosocomial pneumonia) 2
Alternative Dosing Recommendations from Guidelines
The 2010 IDSA/SIS guidelines for complicated intra-abdominal infections recommend a broader range of 200-300 mg/kg/day of the piperacillin component, divided every 6-8 hours 1. This higher total daily dose aligns with more recent pharmacokinetic studies suggesting that standard dosing may be inadequate for critically ill children or infections with higher MIC organisms 3, 4.
Optimized Dosing for Severe Infections
Recent pharmacokinetic research indicates that standard dosing may not achieve adequate drug exposure for organisms with MICs at the upper end of the susceptibility range (16-32 mg/L for Pseudomonas aeruginosa) 4. For critically ill children ages 1-6 years with severe infections:
- 100 mg/kg every 6 hours as a 3-hour prolonged infusion achieves optimal probability of target attainment (≥90%) at MIC 16 mg/L 4
- Alternatively, 400 mg/kg/day as continuous infusion after a loading dose provides similar coverage 4
For infants 2-6 months, 75 mg/kg/dose every 4 hours infused over 0.5 hours optimizes pharmacodynamic targets 3. For children >6 months to 6 years, 130 mg/kg/dose every 8 hours infused over 4 hours is optimal 3.
Maximum Daily Dose
The maximum daily dose should not exceed 24,000 mg/day (24 g) of piperacillin 1. For children weighing >40 kg, this translates to the adult maximum of 18 g/day for standard indications or up to 18 g/day (4.5 g every 6 hours) for nosocomial pneumonia 2.
Administration Guidelines
- Infusion duration: Administer over 30 minutes for standard dosing 1, 2
- Extended infusions: Consider 3-4 hour infusions for critically ill patients or infections with higher MIC organisms 3, 4
- Continuous infusion: May be used in perioperative or ICU settings with appropriate loading dose 5
Renal Impairment Adjustments
Dosing adjustments are required for pediatric patients with renal impairment, though specific pediatric guidelines are not established 2. In adults, doses are reduced by approximately 25-50% when creatinine clearance falls below 40 mL/min 2. Extrapolating to pediatrics, consider dose reduction or interval extension in children with significant renal dysfunction, guided by therapeutic drug monitoring when available.
Common Pitfalls
- Underdosing in critically ill children: Standard weight-based dosing (80-100 mg/kg/day) may be insufficient for severe infections or organisms with MICs >8 mg/L 4
- Inadequate infusion duration: Short 30-minute infusions may not optimize time above MIC for beta-lactam antibiotics; consider extended infusions (3-4 hours) for severe infections 3, 4
- Ignoring age-dependent clearance: Infants <6 months have reduced renal clearance and require lower mg/kg doses (80 mg/kg vs 100 mg/kg) 2, 6
- Concomitant furosemide: Increases piperacillin clearance and may necessitate higher doses or more frequent administration 3