|
University of Pennsylvania Medical
Center Guidelines for Antibiotic Use
ANTIBIOTIC DOSING IN RENAL
IMPAIRMENT1
| DRUG NAME |
USUAL DOSE (Normal renal function) |
CrCl (ml/min) |
DOSAGE ADJUSTMENT (in renal insufficiency) |
| ABACAVIR |
300 mg PO q12h |
no change |
no change |
ABACAVIR/LAMIVUDINE
(EPZICOM) |
1 tablet PO q24h |
not recommended in
fixed combination for Clcr < 50 ml/min |
| ACYCLOVIR |
5 - 10 mg/kg IV q8h |
> 50 |
5 - 10 mg/kg IV q8h |
| 25-50 |
5- 10 mg/kg IV q12h |
| 10-24 |
5 - 10 mg/kg IV q24h |
| 0-9 |
2.5 -5 mg/kg IV q24h |
| HD |
2.5 - 5 mg/kg IV q24h (give dose after dialysis on dialysis days) |
| 200 mg PO q4h (5x daily) |
> 10 |
no adjustment necessary |
|
0-10 |
200 mg PO q12h |
| 400 mg PO q4 (5x daily) - 12h |
>10 |
no adjustment necessary |
|
0-10 |
200 - 400 mg PO q12h |
| 800 mg PO q4 (5x daily) - 12h |
> 25 |
no adjustment necessary |
|
10-25 |
800 mg PO q8 - 12h |
| 0-9 |
400 - 800 mg PO q12h |
| HD |
800 mg PO q12h (give dose after dialysis on dialysis days) |
| ADEFOVIR |
10 mg PO daily |
> 50 |
normal dose |
| 20 - 49 |
10 mg PO q48h |
| 10-19 |
10 mg PO q72h |
| HD |
10 mg PO every 7 days following dialysis |
ANTIBIOTIC DOSING IN RENAL IMPAIRMENT
| DRUG
NAME |
USUAL
DOSE (Normal renal function) |
CrCl
(ml/min) |
DOSAGE
ADJUSTMENT (in renal insufficiency) |
| AMINOGLYCOSIDES (gentamicin,
netilmicin, tobramycin, amikacin) |
Refer
to aminoglycoside dosing page by clicking here |
| AMOXICILLIN |
500 mg - 1 gm PO
q12h |
> 30 |
no dose adjustment necessary |
| 10 - 30 |
250 - 875 mg PO q12h |
| <10 |
250 - 875 mg PO q24h |
| HD |
250 - 875 mg PO q24h + 250 - 500 mg
after each HD |
| AMOXICILLIN +
CLAVULANATE |
500 - 875 mg PO q12h |
>15 |
normal dose and interval |
| 5 - 15 |
500 - 875 mg q24h |
| < 5 |
250 - 500 mg q24h |
| HD |
250 - 500 mg q24h + 250 - 500mg
after each HD |
| AMPHOTERICIN B |
0.25 - 1.5 mg/kg/day
* not to exceed total daily dose of 1.5 mg/kg |
no dose change necessary |
Refer to TableVIII for dosing
guidelines. |
| AMPICILLIN |
250 mg - 2 gm IV q4-6h |
> 30 |
no dose adjustment necessary |
| 10 - 30 |
normal dose q6 - 8h |
| < 10 |
normal dose q8h |
| HD |
normal dose q8h + supplemental dose
after each HD |
| AMPICILLIN /
SULBACTAM
|
1.5 - 3 gms IV q6h |
> 30 |
normal dose IV q6h |
| 15-30 |
normal dose IV q12h |
| < 15 |
normal dose IV q24h |
| HD |
normal dose q24h + supplemental
dose after each HD |
| DRUG
DOSE |
USUAL DOSE
(Normal renal function) |
CrCl
(ml/min) |
DOSAGE
ADJUSTMENT (in renal insufficiency) |
| AMPRENAVIR |
1200 mg PO q12h (capsule)
1400 mg PO q12h (oral solution) |
no change |
no change |
| ATAZANAVIR |
400 mg PO q24h |
no change |
no change |
AZITHROMYCIN |
500 mg IV/PO once daily for 3
days |
no change |
no change |
| AZTREONAM |
1 - 2 gms IV q8h |
> 30 |
normal dose |
| 10 - 30 |
load with 1-2 gm, then 500 mg - 1
gm IV q8h |
| <10 |
load with 1-2 gm, then 250 - 500 mg
IV q8h |
| HD |
dose for CrCl < 10 +
supplemental dose after HD |
| CEFADROXIL |
1-2 gm/day in single or
divided doses (500mg - 1 g PO BID) |
> 50 |
no dose adjustment necessary |
| 25-50 |
1 gm x 1, then 500 mg po BID |
| 10-25 |
1 gm x 1, then 500 mg po Q 24
h |
| <10 |
1 gm x 1, then 500 mg po Q 36
h |
| HD |
500 mg- 1 gm po after each
hemodialysis |
| CEFAZOLIN |
500 mg - 1 gm IV q8h |
> 35 |
no dose adjustment necessary |
| 10 - 35 |
500 mg - 1 gm q12h |
| < 10 |
500 mg - 1 gm q24h |
| HD |
2 gm after each HD |
| CEFEPIME |
1 - 2 gm IV q12h |
> 60 |
no dose adjustment necessary |
| |
30 - 60 |
1 - 2 gm q 24h |
| 11 - 29 |
500 mg - 1 gm q24h |
| < 11 |
250 - 500 mg q24h |
| HD |
dose for CrCl < 11 + 250 - 500 mg after each HD |
| 2 gm IV q8h (meningitis) |
> 60 |
no dose adjustment necessary |
| |
30-60 |
2 gm IV q12h |
| 11 - 29 |
2 gm IV q24h |
| < 11 |
1 gm IV q24h |
| HD |
dose for CrCl < 11 + 1 gm after each HD |
| 1 gm IV q8h (neutropenic
fever) |
> 60 |
no dose adjustment necessary |
| 30 - 60 |
1 gm IV q12h |
| 11 - 29 |
1 gm IV q24h |
| < 11 |
500 mg IV q24h |
| HD |
dose for CrCl < 11 + 500 mg
after each HD | <
ANTIBIOTIC DOSING IN RENAL IMPAIRMENT
| DRUG
NAME |
USUAL
DOSE (Normal renal function) |
CrCl
(ml/min) |
DOSE
ADJUSTMENT (in renal insufficiency) |
| CEFTRIAXONE |
1 - 2 gms IV q24h
* max. dose = 4
gm/day |
no change |
* adults with both renal
and hepatic failure should not receive more than 2
gm/day |
| CEFUROXIME
AXETIL |
250 - 500 mg PO q12h |
> 10 |
normal dose |
| < 10 |
250 mg PO q24h |
| CEPHALEXIN |
250 - 500 mg PO q6h |
> 40 |
normal dose |
| 11 - 40 |
250 - 500 mg PO q8 - 12h |
| 5-10 |
250 - 500 mg PO q12h |
| < 10 |
250 - 500 mg PO q12 - 24h |
| CHLORAMPHENICOL |
50 mg/kg/d IV in 3-4 divided doses
(some infections may require higher doses) |
Dosage adjustment is
required with hepatic dysfunction and severe renal
dysfunction. Click
this link for more detailed information |
| CIDOFOVIR |
5 mg/kg IV q 2 weeks |
Use
CONTRAINDICATED with a Scr >1.5 mg/dl or Clcr <
55 ml/min or proteinuria > 2+ (100 mg/dL) |
| CLARITHROMYCIN |
250 - 500 mg PO q12h |
> 30 |
normal dose |
| < 30 |
If normal dose is 500 mg PO q12h:
give load of 500 mg then 250 mg q12h
If normal dose is 250 mg PO q12h, give 250
mg q24h |
| CLINDAMYCIN |
600 mg IV
q8h OR
150 -
450 mg PO q6h |
no change |
no change |
| COLISTIN METHANE
SULPHONATE |
|
sCR<1.3 |
5 mg/kg/day in 2-4 divided doses |
| sCR 1.3-1.5 |
2.5-3.8 mg/kg/day divided Q12 hr |
| sCR 1.6 -2.5 |
2.5 mg/kg/day divided Q12-Q24 |
| sCR >2.5 |
2.25 mg/ Q36 hrs |
| CrCl <10 ml/min or anuric |
2-3 mg/kg Q 3 days |
| Hemodial |
2-3 mg/kg IV post hemodialysis |
| DARUNAVIR |
600 mg PO |
no change |
no change |
DICLOXACILLIN |
125 - 500 mg PO q6h |
no change |
no change |
ANTIBIOTIC DOSING IN RENAL IMPAIRMENT
| DRUG
NAME |
USUAL
DOSE (Normal renal function) |
CrCl
(ml/min) |
DOSAGE
ADJUSTMENT (in renal insufficiency) |
| DIDANOSINE
(ddI) |
> 60 kg: 200 mg PO
q12h OR
400 mg PO q24h (tablets)
<60kg: 125 mg PO q12h
OR
250 mg PO q24h (tablets) |
> 50 |
> 60
kg: normal dose
< 60 kg: normal dose |
| 26 - 49 |
> 60
kg: 100 mg PO q12h or 200 mg PO q24h (tablets)
< 60 kg: 75 mg PO q12h or 150 mg
PO q24h (tablets)
|
| 10 - 25 |
> 60
kg: 150 mg PO q24h (tablet)
< 60 kg: 100 mg PO q24h
(tablet) |
| < 10 |
> 60
kg: 100 mg PO q24h (tablet)
< 60 kg: 75 mg PO q24h (tablet)
|
| HD |
dose for CrCl < 10 |
| DOXYCYCLINE |
100 mg IV/PO q12h |
no change |
no change |
| EFAVIRENZ |
600 mg PO q24h |
no change |
no change |
TR> TR>
| EMTRICITABINE |
200 mg PO q24h |
> 50 |
no dose adjustment necessary |
| 30-49 |
200 mg PO q48h |
| 15-29 |
200 mg PO q72h |
| <15 |
200 mg PO q96h |
| HD |
200 mg PO q96h-if dose is due on day of dialysis, give dose post-dialysis |
|
TR>
EMTRICITABINE/TENOFOVIR
(TRUVADA)
| 1 tablet PO q24h |
> 50 |
normal dose |
| 30-49 |
1 tablet PO q48h |
| <30 |
not recommended in fixed combination |
EMTRICITABINE/TENOFOVIR/ EFAVIRENZ (ATRIPLA)
|
1 tablet PO q24h |
not recommended in
fixed combination for Clcr < 50 ml/min |
| ENFUVIRTIDE |
90 mg SQ q12h |
no change |
no change |
ENTECAVIR |
0.5-1 mg PO q24h |
> 50 |
no dose adjustment necessary |
| 30-50 |
0.25-0.5 mg PO q24h |
| 10-30 |
0.15-0.3 mg PO q24h |
| <10 |
0.05-0.1 mg PO q24h |
| HD |
0.05-0.1 mg daily given after dialysis on dialysis days |
ERYTHROMYCIN |
250 - 500 mg PO q6 -
12h OR 15 -
20 mg/kg/day IV divided q6h |
no change |
no change |
| ETHAMBUTOL |
15 - 25 mg/kg/day |
> 50 |
normal dose |
| 10 - 50 |
normal dose q24 - 36h |
| < 10 |
normal dose q48h |
| HD |
normal dose after each HD |
| FLUCONAZOLE |
Loading
Dose: 100 - 800 mg PO/IV q24h
Maintenance Dose: 50 - 800 mg PO/IV
q24h |
> 50 |
normal dose |
| < 50 (no HD) |
50% normal dose q24h |
| HD |
load with 100 - 400 mg, then
normal dose after each HD |
| FLUCYTOSINE
(5-FC) |
50 - 150 mg/kg/day PO
divided q6h |
> 40 |
normal dose |
| 20 - 40 |
12.5 - 37.5 mg/kg q12h |
| 10-20 |
12.5 - 37.5 mg/kg q24h |
| < 10 |
12.5 - 37.5 mg/kg q24 - 48h |
| HD |
If receiving HD q 48 - 72h then 20
- 50 mg/kg immediately after each HD |
ANTIBIOTIC DOSING IN RENAL IMPAIRMENT
| DRUG
NAME |
USUAL DOSE
(Normal renal function) |
CrCl
(ml/min) |
DOSE
ADJUSTMENT (in renal insufficiency) |
| FOSAMPRENAVIR |
1400 mg po twice daily (note dosing
differs when combined with ritonavir) |
not cleared by kidneys |
none needed |
| FOSCARNET |
Induction for
CMV: 60 mg/kg IV q8h OR 90
mg/kg q12h (infuse over 1 hour)
*IV hydration is recommended to reduce the risk of renal
toxicity |
> 1.4 ml/min/kg |
60 mg/kg q8h |
90 mg/kg q12h |
| > 1 - 1.4 ml/min/kg |
45 mg/kg q8h |
70 mg/kg q12h |
| > 0.8 - 1 ml/min/kg |
50 mg/kg q12h |
50 mg/kg q12h |
| > 0.6 - 0.8 ml/min/kg |
40 mg/kg q12h |
80 mg/kg q24h |
| > 0.5 - 0.6 ml/min/kg |
60 mg/kg q24h |
60 mg/kg q24h |
| > 0.4 - 0.5 ml/min/kg |
50 mg/kg q24h |
50 mg/kg q24h |
| < 0.4 ml/min/kg |
not recommended |
not recommended |
| Maintenance for
CMV: 90 mg/kg IV q24h OR 120 mg/kg
IV q24h (infuse over 2 hours)
*IV hydration is recommended to reduce the risk of renal
toxicity |
> 1.4 ml/min/kg |
90 mg/kg q24h |
120 mg/kg q24h |
| > 1 - 1.4 ml/min/kg |
70 mg/kg q24h |
90 mg/kg q24h |
| > 0.8 - 1 ml/min/kg |
50 mg/kg q24h |
65 mg/kg q24h |
| > 0.6 - 0.8 ml/min/kg |
80 mg/kg q48h |
105 mg/kg q48h |
| > 0.5 - 0.6 ml/min/kg |
60 mg/kg q48h |
80 mg/kg q48h |
| > 0.4 - 0.5 ml/min/kg |
50 mg/kg q48h |
65 mg/kg q48h |
| < 0.4 ml/min/kg |
not recommended |
not recommended |
| FOSCARNET |
Induction for
HSV: 40 mg/kg IV q12h
OR 40 mg/kg IV q8h |
> 1.4 ml/min/kg |
40 mg/kg q12h |
40 mg/kg q8h |
| > 1 - 1.4 ml/min/kg |
30 mg/kg q12h |
30 mg/kg q8h |
| > 0.8 - 1 ml/min/kg |
20 mg/kg q12h |
35 mg/kg q12h |
| > 0.6 - 0.8 ml/min/kg |
35 mg/kg q24h |
25 mg/kg q12h |
| > 0.5 - 0.6 ml/min/kg |
25 mg/kg q24h |
40 mg/kg q24h |
| > 0.4 - 0.5 ml/min/kg |
20 mg/kg q24h |
35 mg/kg q24h |
| < 0.4 |
not recommended |
not recommended |
| GANCICLOVIR
IV |
Induction: 5 mg/kg IV q12h x 14
- 21 days |
>70 |
5 mg/kg q12h |
| |
50-69 |
2.5 mg/kg q12h |
| 25-49 |
2.5 mg/kg q24h |
| <25 |
1.25 mg/kg q24h |
| HD |
1.25 mg/kg 3x/week with doses given
after HD |
| Maintenance: 5 mg/kg IV q24h |
>70 |
5 mg/kg q24h |
| |
50-69 |
2.5 mg/kg q24h |
| 25-49 |
1.25 mg/kg q24h |
| <25 |
0.625 mg/kg q24h |
| HD |
0.625 mg/kg 3x/week with doses given
after HD |
| DRUG
NAME |
USUAL DOSE
(Normal renal function) |
CrCl
(ml/min) |
DOSAGE
ADJUSTMENT (in renal insufficiency) |
| GANCICLOVIR PO |
1 gm PO q8h
OR 500mg PO q3h, 6x/day |
> 70 |
normal dose |
| 50 - 69 |
1.5 gm PO qd or 500 mg PO q8h |
| 25 - 49 |
1 gm PO qd or 500 mg PO q12h |
| 10 - 24 |
500 mg PO qd |
| < 10 |
500 mg PO 3x/week |
| HD |
dose for CrCl < 10, doses given
after HD |
IMIPENEM
(Refer to product information
for complete prescribing information for patients requiring
different total daily doses) |
500 mg IV q6h (2 g/day) [
Note that meningitis dose is higher (up to 1g q 6h,
depending on renal function- consult ID)] |
> 71 |
> 70 kg:
500
mg q6h
60 - 69
kg: 500 mg q8h
50 - 59
kg: 250 mg q6h
40 - 49
kg: 250 mg q6h
30 - 39
kg: 250 mg q8h
|
| 41 - 70 |
> 70 kg:
500
mg q8h
60 - 69 kg: 250
mg q6h
50 - 59 kg: 250
mg q6h
40 - 49 kg: 250
mg q8h
30 - 39 kg: 125
mg q6h |
| 21 - 40 |
> 70 kg:
250
mg q6h
60 - 69 kg: 250
mg q8h
50 - 59 kg: 250
mg q8h
40 - 49 kg: 250
mg q12h
30 - 39 kg: 125
mg q8h |
| 6 - 20 |
> 70 kg:
250
mg q12h
60 - 69 kg: 250
mg q12h
50 - 59 kg: 250
mg q12h
40 - 49 kg: 250
mg q12h
30 - 39 kg: 125
mg q12h |
| **In patients
undergoing hemodialysis or with a Clcr of 6-20 ml/min, the
500mg IV q 12 hour dose should be reserved for treatment of
severe infections. Patients with Clcr < 5 ml/min
should not receive imipenem/cilastatin unless dialysis is
going to be instituted within 48 hours. These patients
may be at an increased risk of seizures. |
| INDINAVIR |
800 mg PO q 8h |
no change |
no change |
| ISONIAZID |
300 mg PO daily |
no change |
no change |
| ITRACONAZOLE |
100 - 200 mg PO (capsule /
solution)
q12h
OR
200 mg IV q12h x 4 doses, then 200 mg IV q24h
***IV use NOT TO EXCEED 14 days*** |
PO: no change
|
PO: no change |
| IV: > 30 |
normal dose |
| IV: < 30 |
not recommended due to
injectable excipient |
| LAMIVUDINE (Epivir
formulation) |
150 mg po q
12h |
> 50 |
150 mg PO q12h |
| 30-49 |
150 mg PO q24h |
| 15-29 |
150 mg x 1,then 100 mg PO q24h |
| 5 - 14 |
150 mg x 1, then 50 mg PO q24h |
| < 5 |
150 mg x 1, then 25 mg PO q24h |
| HD |
150 mg x 1, then 25 - 50 mg PO
q24h |
| Lamivudine
(Epivir-HBV formulation) |
100 mg orally once daily |
> 50 |
100 mg once daily |
| 30-49 |
100 mg x 1 day, then 50 mg daily afterwards
|
| 15-29 |
100 mg x 1 day, then 25 mg daily
afterwards |
| 5-14 |
35 mg x 1 day, then 15 mg daily afterwards
|
| <5 & HD |
35 mg x 1 day, then 10 mg daily afterwards
|
| LAMIVUDINE/ZIDOVUDINE (COMBIVIR)
|
1 tablet PO q12h |
not recommended in
fixed combination for Clcr < 50 ml/min |
| LEVOFLOXACIN |
If normal
dose 250 mg IV/PO q24h |
> 20 |
250 mg q24h |
| < 20 and HD |
250 mg q48h |
| If normal dose 500
mg IV/PO q24h |
> 50 |
500 mg q24h |
| 20 - 49 |
500 mg q48h |
| < 20 and HD |
500 mg x 1, then 250 mg q48h |
| CVVHD |
500 mg q 48h |
| If normal dose 750 mg IV/POq24
h (note that the 500 mg q 24h dosage
schedule shown above should be used if the levofloxacin MIC is
<0.5 ug/ml) |
> 50 |
750 mg q24h |
| 20 - 49 |
750 mg q48h |
| < 20 and HD |
750 mg X 1, then 500 mg q48h |
| CVVHD |
750 mg q 48h |
| LINEZOLID |
600 mg IV/PO q12h |
no change |
no change |
| MEROPENEM |
1 gm IV q 8h - (note that
meningitis dose is higher, 2g q 8h, with normal renal
function) |
>50 |
normal dose |
| 26-50 |
normal dose q12h |
| 10-25 |
50% normal dose q12h |
| <10 |
50% normal dose q24h |
| HD |
50% normal dose q24h + 50% normal
dose after each HD |
| METRONIDAZOLE |
500 mg IV/PO q12h |
no change |
no change |
| 500 mg IV/PO q8h (C.
difficile diarrhea) |
no change |
no change |
ANTIBIOTIC DOSING IN RENAL IMPAIRMENT
| DRUG
NAME |
USUAL
DOSE (Normal renal function) |
CrCl
(ml/min) |
DOSE
ADJUSTMENT (in renal insufficiency) |
| NAFCILLIN |
2 gm IV q4-6h |
no change |
no change |
| NELFINAVIR |
1250 mg PO q12h |
no change |
no change |
| NEVIRAPINE |
200 mg PO q12h |
no change |
no change |
| NITROFURANTOIN |
50-100 mg PO q12h |
> 40 |
normal dose |
| < 40 |
avoid use: therapeutic levels not
attained in the urine |
| NORFLOXACIN |
400 mg PO q12h |
> 30 |
normal dose |
| < 30 |
normal dose PO q24h |
| PENICILLIN G |
2.0 - 4.0 million units IV q4h |
> 125 |
3.0 - 4.0 million units q4h |
| 60 - 124 |
1.8 - 2.0 million units q4h |
| 40 - 59 |
1.3 - 1.5 million units q4h |
| 20 - 39 |
800,000 - 1.0 million units
q4h |
| 10 - 19 |
800,000 - 1.0 million units
q6h |
| < 10 & HD |
500,000 - 800,000 units q6h |
| < 10 & ESLD |
500,000 units q8h |
| PENTAMIDINE |
4 mg/kg IV or IM q24h |
> 50 |
normal dose |
| 10-50 |
normal dose q24-36h |
| < 10 |
normal dose q48h |
| HD |
dose for CrCL < 10 ml/min |
| PIPERACILLIN |
3-4 gm IV q6h (non-P.
aeruginosa) |
>40 |
normal dose |
| 20-40 |
3-4 gm IV q8h |
| <20 |
3-4 gm IV q12h |
| HD |
2 gm IV q8h + 1 gm supplemental
dose after each HD |
| Pseudomonas aeruginosa
infections*: 3 gm IV q4h. * Combination therapy
with an aminoglycoside may be indicated, depending on
piperacillin MIC and site of infection. Treatment of
uncomplicated UTIs can be with "non-P. aeruginosa " dosages
shown above |
>40 |
normal dose |
| 20-40 |
3 gm IV q6h |
| <20 |
3 gm IV q8h |
| HD |
2 gm q8h + 1 gm supplemental dose
after each HD |
| PIPERACILLIN/TAZOBACTAM |
Mild to Moderate Infections
:4.5 gm IV q8h |
>40 |
normal dose |
| 20-40 |
2.25 gm q6h |
| <20 |
2.25 gm q8h |
| HD |
2.25 gm q8h + 1.125 gm supplemental
dose after each HD |
| Severe/life threatening
infections: 4.5 gm IV q6h |
>40 |
normal dose |
| 20-40 |
4.5 gm q8h |
| <20 |
4.5 gm q12h |
| HD |
2.25 gm q8h + 1.125 gm supplemental
dose after each HD |
| Pseudomonas aeruginosa
infections*: 3.375 gm IV q4h. * Combination therapy
with an aminoglycoside may be indicated, depending on
piperacillin MIC and site of infection. Treatment of
uncomplicated UTIs can be with "mild to moderate infection"
dosages |
>40 |
normal dose |
| 20-40 |
3.375 gm q6h |
| <20 |
3.375 gm q8h |
| HD |
2.25 gm q8h + 1.125 gm supplemental
dose after each HD |
ANTIBIOTIC DOSING IN RENAL IMPAIRMENT
| DRUG
NAME |
USUAL
DOSE (Normal renal function) |
CrCl
(ml/min) |
DOSE
ADJUSTMENT (in renal insufficiency) |
| POSACONAZOLE |
200 mg q6h or 400 mg PO q12h |
no change |
no change |
| PYRAZINAMIDE |
15-30 mg/kg/d (maximum 2 gm/day) |
> 10 |
normal dose |
| <10 |
25-30 mg/kg three times
weekly |
| HD |
25-30 mg/kg three times weekly,
post-dialysis |
| PYRIMETHAMINE |
25 - 75 mg PO q24h |
no change |
no change |
| QUINUPRISTIN/DALFOPRISTIN |
7.5 mg/kg IV q8h |
no change |
no change |
RIFABUTIN |
300 mg PO q24h |
no change |
no change |
| RIFAMPIN |
600 mg IV/PO q12 - 24h |
no change |
no change |
| RITONAVIR |
600 mg PO q12h |
no change |
no change |
| SAQUINAVIR |
1000 mg PO q12h plus ritonavir 100 mg PO q12h |
no change |
no change |
| STAVUDINE |
>
60kg: 40 mg PO q12h
< 60kg: 30 mg PO q12h |
> 50 |
normal dose |
| 26-49 |
normal dose q24h |
| < 25 and HD |
50% normal dose q24h |
| STREPTOMYCIN |
15 mg/kg/day IM |
> 80 |
normal dose |
| 50-80 |
1 gram loading dose, then 7.5 mg/kg q24h |
| 10-49 |
1 gram loading dose, then 7.5 mg/kg q24-72h |
| < 10 |
7.5 mg/kg q72-96h |
| HD |
give 50-75% of loading dose after each HD |
| SULFADIAZINE |
500 mg - 2 gms PO q6h |
no change |
no change |
| TELBIVUDINE |
600 mg PO q24h |
> 50 |
normal dose |
| 30 - 49 |
600 mg PO q48h |
| < 30 |
600 mg PO q72h |
| ESRD or HD |
600 mg PO q96h |
TENOFOVIR |
300 mg po q24h |
>49 |
normal dose |
| 30-49 |
normal dose q 48h |
| 10-29 |
normal dose twice weekly |
| <10, not on HD |
consult Antibiotic
Management 215 3060336 |
| HD |
normal dose weekly, assuming thrice weekly HD
|
| TETRACYCLINE |
250 - 500 mg PO q6h |
> 50 |
normal dose q8-12h |
| 10-49 |
normal dose q12-24h |
| < 10 |
normal dose q24h |
| TIGECYCLINE |
100 mg x 1 then 50 mg IV Q 12 hr |
NA |
no adjustment needed for renal
insufficiency |
ANTIBIOTIC DOSING IN RENAL IMPAIRMENT
| DRUG
NAME |
USUAL DOSE (Normal renal
function) |
CrCl
(ml/min) |
DOSE ADJUSTMENT (in renal
insufficiency) |
| TMP/SMX
(Bactrim, Septra)
1SS tablet = 80 mg TMP;
1DS tablet =160 mg TMP;
1 ampule(5 ml) = 80 mg TMP |
Urinary Tract
Infections:
5 mg/kg/day of trimethoprim component given in divided
doses
Serious
Systemic Infections:
8-10 mg/kg/day of trimethoprim component given in divided
doses (q 6 -12hr)
Pneumocystis carinii Pneumonia
15-20 mg/kg/day of trimethoprim component given q 6-8hr
|
> 30 |
normal dose |
| 15 - 30 |
normal dose divided q12h x
48-72h then 50% of normal daily dose given q24h |
| < 15 |
NOT ADVISED-consult
Antibiotic Management 215 3060336 |
| HD |
NOT ADVISED-consult
Antibiotic Management 215 3060336 |
| VALACYCLOVIR |
Primary Genital Herpes
Simplex 1 gm PO q12hrs |
> 30 |
normal dose |
| 10-29 |
1 g q24 hrs |
| <10 |
500 mg q24
hrs |
| HD |
500 mg q24 hrs
dosed post-dialysis |
| Recurrent Herpes Simplex
(genital) 500 mg PO q12h |
> 30 |
normal dose |
| < 29 |
500 mg PO
q24h |
| HD |
dose for Clcr
< 29, given after HD |
| Herpes zoster: 1 gm PO
q8h |
> 50 |
normal dose |
| 30-49 |
1 gm PO
q12h |
| 10-29 |
1 gm PO
q24h |
| <10 |
500 mg PO
q24h |
| HD |
dose for Clcr
< 10, given after HD |
| VALGANCICLOVIR |
900 mg po q12h |
|
INDUCTION |
MAINTENANCE |
| > 60 |
900 mg po q12h |
900 mg po q24h |
| 40 - 59 |
450 mg po q12h |
450 mg po q24h |
| 25 - 39 |
450 mg po q24h |
450 mg po q2days |
| 10 - 24 |
450 mg po q2days |
450 mg po twice weekly |
| HD |
do not use in patients on
hemodialysis |
| VANCOMYCIN |
Refer to
vancomycin dosing recommendation page by clicking here
|
| ZIDOVUDINE |
200 mg PO q8h |
> 26 |
normal dose |
| < 25 and HD |
100 mg
q8h |
1Recommendations adapted from pharmaceutical company product information; McEvoy GK, ed. AmericanHospital Formulary Service-2001. Bethesda: American Society of Health-Systems Pharmacists, 2001:49-858;Aronoff GR, Berns JS, Brier ME, Golper TA, Morrison G, Singer I, Swan SK, Bennett WM. Drug Prescribingin Renal Failure, Dosing Guidelines for Adults. 4th Ed. Philadelphia: American College of Physicians,1999:39-62.
modified 7/24/07 by Ann Marie Marr
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