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 OR 600 mg PO q24h 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 dose adjustment necessary
0 - 10 200 mg PO q12h
400 mg PO q4 (5x daily) - 12h > 10 no dose adjustment necessary
0 - 10 200 - 400 mg PO q12h
800 mg PO q4 (5x daily) - 12h > 25 no dose 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 no dose adjustment necessary
20 - 49 10 mg PO q48h
10 - 19 10 mg PO q72h
HD 10 mg PO every 7 days, if dose is due on day of dialysis, then give dose after dialysis
AMINOGLYCOSIDES (gentamicin, 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 + supplemental 250 - 500 mg after each HD
AMOXICILLIN/CLAVULANATE 500 - 875 mg PO q12h > 15 no dose adjustment necessary
5 - 15 500 - 875 mg q24h
< 5 250 - 500 mg q24h
HD 250 - 500 mg q24h + supplemental 250 - 500 mg after each HD

 

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSAGE ADJUSTMENT (in renal insufficiency)
AMPHOTERICIN B

Refer to amphotericin B dosing and administration page by clicking here

* not to exceed total daily dose of 1.5 mg/kg

no change no change
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 gm 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
ATAZANAVIR 300 - 400 mg PO q24h no change no change
AZITHROMYCIN 500 mg IV/PO q24h no change no change
AZTREONAM 1 - 2 gm IV q8h > 30 no dose adjustment necessary
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 250 - 500 mg after HD
CEFADROXIL 1-2 gm/day in single or divided doses (500 mg - 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 q24h
<10 1 gm x 1, then 500 mg PO q36h
HD 500 mg - 1 gm PO after each HD
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

 

 

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG DOSE USUAL DOSE (Normal renal function) CrCl (ml/min) DOSAGE ADJUSTMENT (in renal insufficiency)
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 + supplemental 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 + supplemental 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 + supplemental 500 mg after each HD
CEFIXIME 400 mg PO q12h

> 60

no dose adjustment necessary

21 - 60 or HD administer 75% of normal dose q12h
≤ 20 or CAPD administer 50% of normal dose q12h
CEFTRIAXONE 1 - 2 gm 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 no dose adjustment necessary
< 10 250 mg PO q24h
CEPHALEXIN 250 - 500 mg PO q6h > 40 no dose adjustment necessary
11 - 40 250 - 500 mg PO q8 - 12h
< 10 250 - 500 mg PO q12 - 24h
CHLORAMPHENICOL 50 mg/kg/day 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 q2 weeks Use CONTRAINDICATED with a SCr >1.5 mg/dl or CrCl < 55 ml/min or proteinuria > 2+ (100 mg/dL)
CLARITHROMYCIN 250 - 500 mg PO q12h ≥ 30 no dose adjustment necessary
< 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

 

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSE ADJUSTMENT (in renal insufficiency)
COLISTIN METHANE SULPHONATE 5 mg/kg/day in 2-4 divided doses SCr < 1.3 no dose adjustment necessary
SCr 1.3 - 1.5 2.5 - 3.8 mg/kg/day divided q12h
SCr 1.6 - 2.5 2.5 mg/kg/day divided q12-24h
SCr > 2.5 2.25 mg/kg q24h
CrCl < 10 ml/min or anuric 1.5 - 2 mg/kg q24h
HD 1.5 - 2 mg/kg IVq24h (give dose after dialysis on dialysis days)
DAPTOMYCIN 4 - 6 mg/kg IV q24h ≥ 30 no dose adjustment necessary
< 30 normal dose q48h
HD or CAPD dose as in CrCl < 30
DARUNAVIR 600 mg PO q12h no change no change
DICLOXACILLIN 125 - 500 mg PO q6h no change no change
DIDANOSINE (ddI)

≥ 60 kg: 400 mg PO q24h (EC capsule)

< 60 kg: 250 mg PO q24h (EC capsule)

≥ 60 no dose adjustment necessary
30 - 59

≥ 60 kg: 200 mg PO q24h (EC capsule)

< 60 kg: 125 mg PO q24h (EC capsule)

10 - 29

≥ 60 kg: 125 mg PO q24h (EC capsule)

< 60 kg: 100 mg PO q24h (powder for oral solution)

< 10

≥ 60 kg: 125 mg PO q24h (EC capsule)

< 60kg: 75 mg PO q24h (powder for oral solution)

HD or CAPD dose as in CrCl < 10
DOXYCYCLINE 100 mg IV/PO q12h no change no change
EFAVIRENZ 600 mg PO q24h no change no change
EFAVIRENZ/EMTRICITABINE/TENOFOVIR (ATRIPLA™) 1 tablet PO q24h not recommended in fixed combination for CrCl < 50 ml/min

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSE ADJUSTMENT (in renal insufficiency)
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, then give dose after dialysis
EMTRICITABINE/TENOFOVIR (TRUVADA™) 1 tablet PO q24h > 50 no dose adjustment necessary
30 - 49 1 tablet PO q48h
< 30 not recommended in fixed combination
ENFUVIRTIDE 90 mg SQ q12h no change no change
ENTECAVIR 0.5 - 1 mg PO q24h > 50 no dose adjustment necessary
30 - 49 administer normal dose q48h
10 - 29 administer normal dose q72h
< 10 administer normal dose every 7 days
HD or CAPD administer normal dose every 7 days, if dose is due on day of dialysis, then give dose after dialysis
ERYTHROMYCIN 250 - 500 mg PO q6 - 12h OR 15 - 20 mg/kg/day IV divided q6h no change no change
ETRAVIRINE 200 mg PO q12h no change no change
ETHAMBUTOL 15 - 25 mg/kg PO q24h > 50 no dose adjustment necessary
10 - 50 normal dose q24 - 36h
< 10 normal dose q48h
HD normal dose after each HD
FLUCONAZOLE 100 - 800 mg IV/PO q24h ≥ 50 no dose adjustment necessary
< 50 50% of normal dose q24h
HD normal dose after each HD
FLUCYTOSINE (5-FC) 50 - 150 mg/kg/day PO divided q6h > 40 no dose adjustment necessary
20 - 40 25 - 75 mg/kg/day PO divided q12h
10 - 20 12.5 - 37.5 mg/kg PO q24h
< 10 12.5 - 37.5 mg/kg PO q24 - 48h
HD 25 - 50 mg/kg after each HD
FOSAMPRENAVIR 1400 mg PO q12h (note dosing differs when combined with ritonavir) no change no change

 

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSE ADJUSTMENT (in renal insufficiency)
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

 

 

 

 

 

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSAGE ADJUSTMENT (in renal insufficiency)
GANCICLOVIR IV Induction: 5 mg/kg IV q12h x 14 - 21 days > 70 no dose adjustment necessary
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 after each HD
Maintenance: 5 mg/kg IV q24h > 70 no dose adjustment necessary
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 after each HD
GANCICLOVIR PO 1 gm PO q8h OR  500mg PO q3h, 6x/day ≥ 70 no dose adjustment necessary
50 - 69 1.5 gm PO q24h or 500 mg PO q8h
25 - 49 1 gm PO q24h or 500 mg PO q12h
10 - 24 500 mg PO q24h
< 10 500 mg PO three times weekly
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 q6h, 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 CrCl of 6-20 ml/min, the 500 mg IV q 12 hour dose should be reserved for treatment of severe infections. Patients with CrCl < 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 q8h no change no change
ISONIAZID 300 mg PO q24h no change no change

 

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSAGE ADJUSTMENT (in renal insufficiency)
ITRACONAZOLE 100 - 200 mg PO (capsule/solution) q12h              no change              no change
LAMIVUDINE (EPIVIR® formulation) 150 mg PO q12h or 300 mg PO q24h > 50 no dose adjustment necessary
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 PO q24h > 50 no dose adjustment necessary
30 - 49 100 mg x 1, then 50 mg PO q24h
15 - 29 100 mg x 1, then 25 mg PO q24h
5 - 14 35 mg x 1, then 15 mg PO q24h
< 5 & HD 35 mg x 1, then 10 mg PO q24h
LAMIVUDINE/ZIDOVUDINE (COMBIVIR®) 1 tablet PO q12h not recommended in fixed combination for CrCl < 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 q48h
If normal dose 750 mg IV/PO q24h (note that the 500 mg q24h dosage schedule shown above should be used if the levofloxacin MIC is ≤ 0.5 mcg/ml) > 50 750 mg q24h
20 - 49 750 mg q48h
< 20 and HD 750 mg x 1, then 500 mg q48h
CVVHD 750 mg q48h
LINEZOLID 600 mg IV/PO q12h no change no change
MARAVIROC 150 mg - 600 mg PO q12h ≥ 50 no dose adjustment necessary
< 50 consult ID
MEROPENEM 1 gm IV q8h - (note that meningitis dose is higher, 2 gm q8h, with normal renal function) > 50 no dose adjustrment necessary
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

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSE ADJUSTMENT (in renal insufficiency)
METRONIDAZOLE 500 mg IV/PO q12h no change no change
500 mg IV/PO q8h  (C. difficile diarrhea) no change no change
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 IR (MACROCRYSTALS) 50 - 100 mg PO q6h > 60 no dosage adjustment necessary
< 60 avoid use: therapeutic levels not attained in the urine
NITROFURANTOIN SR (MONOHYDRATE/MACROCRYSTALS) 50 - 100 mg PO q12h > 60 no dosage adjustment necessary
< 60 avoid use: therapeutic levels not attained in the urine
NORFLOXACIN 400 mg PO q12h ≥ 30 no dosage adjustment necessary
< 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 no dosage adjustment necessary
10 - 50 normal dose q24 - 36h
< 10 normal dose q48h
HD dose for CrCL < 10 ml/min

 

 

 

 

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSE ADJUSTMENT (in renal insufficiency)
PIPERACILLIN 3 - 4 gm IV q6h (non-P. aeruginosa) > 40 no dosage adjustment necessary
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 no dosage adjustment necessary
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 no dosage adjustment necessary
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 no dosage adjustment necessary
20 - 40 4.5 gm q8h
< 20 2.25 gm q6h
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 no dosage adjustment necessary
20 - 40 3.375 gm q6h
< 20 3.375 gm q8h
HD 2.25 gm q8h + 1.125 gm supplemental dose after each HD
POSACONAZOLE 200 mg PO q6h OR 400 mg PO q12h no change no change
PYRAZINAMIDE

15 - 30 mg/kg PO q24h (maximum 2 gm/day)

> 10 no dosage adjustment necessary
< 10 25 - 30 mg/kg three times weekly
HD 25 - 30 mg/kg after each HD
PYRIMETHAMINE 25 - 75 mg PO q24h no change no change

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

DRUG NAME USUAL DOSE (Normal renal function) CrCl (ml/min) DOSE ADJUSTMENT (in renal insufficiency)
QUINUPRISTIN/DALFOPRISTIN 7.5 mg/kg IV q8h no change no change
RALTEGRAVIR 400 mg PO q12h 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 no dosage adjustment necessary
26 - 49 normal dose q24h
< 25 and HD 50% normal dose q24h (give after dialysis on dialysis days)
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 gm PO q6h no change no change
TELBIVUDINE 600 mg PO q24h ≥ 50 no dosage adjustment necessary
30 - 49 600 mg PO q48h
< 30 600 mg PO q72h
ESRD or HD 600 mg PO q96h
TENOFOVIR 300 mg PO q24h > 49 no dosage adjustment necessary
30 - 49 normal dose q48h
10 - 29 normal dose twice weekly
< 10, not on HD consult Antimicrobial Stewardship (215) 306-0336
HD normal dose weekly (assuming thrice weekly HD), if dose is due on day of dialysis, then give dose after dialysis
TETRACYCLINE 250 - 500 mg PO q6h > 50 normal dose q8 - 12h
10 - 49 normal dose q12 - 24h
< 10 normal dose q24h
TIGECYCLINE 100 mg IV x 1 then 50 mg IV q12h no change no change

 

 

 

 

ANTIBIOTIC DOSING IN RENAL IMPAIRMENT1

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;

suspension = 40 mg TMP/5 ml

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 -12h)

Pneumocystis carinii Pneumonia

15 - 20 mg/kg/day of trimethoprim component given q6-8h

> 30 normal dose
15 - 30 normal dose divided q12h x 48 - 72 hrs then 50% of normal daily dose given q24h
< 15 NOT ADVISED - consult Antimicrobial Stewardship (215) 306-0336
HD NOT ADVISED - consult Antimicrobial Stewardship (215) 306-0336
VALACYCLOVIR Primary Genital Herpes Simplex 1 gm PO q12h > 30 no doasge adjustment necessary
10 - 29 1 g PO q24h
< 10 500 mg q24h
HD 500 mg q24 hrs (give after dialysis on dialysis days)
Recurrent Herpes Simplex (genital) 500 mg PO q12h > 30 no dosage adjustment necessary
< 29 500 mg PO q24h
HD dose for CrCl < 29 (give after dialysis on dialysis days)
Herpes zoster: 1 gm PO q8h > 50 no dosage adjustment necessary
30 - 49 1 gm PO q12h
10 - 29 1 gm PO q24h
< 10 500 mg PO q24h
HD dose for CrCl < 10 (give after dialysis on dialysis days)
VALGANCICLOVIR 900 mg PO q12 - 24h   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 q48h
10 - 24 450 mg PO q48h 450 mg PO twice weekly
HD do not use in patients on hemodialysis
VANCOMYCIN Refer to vancomycin dosing recommendation page by clicking here
ZIDOVUDINE 300 mg PO q12h > 15 no dosage adjustment necessary
< 15 and HD 300 mg q24h

 

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 9/23/08 by Shawn Binkley

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