Hmc Antibiotic Renal Dosing Guidelines printable pdf download

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HMC / UWMC Adult Antimicrobial Renal Dosing Guidelines

(All doses are listed for IV, unless otherwise stated). These dosing recommendations are based on published literature and clinical experiences. They should not replace

clinical judgment and are intended to provide initial guidance, and may be modified depending on individual patient. Call pharmacy for additional questions.

Drug

Dose for Normal Renal

CrCl (mL/min)

Hemodialysis

Function

10 - 50

<10

Acyclovir (IV)

Same as CrCl<10

Herpes simplex

For obese pts, dose based

5mg/kg q8h

25-50: 5mg/kg q12h

2.5mg/kg q24h

on Ideal Body Weight. IF pt

Herpes zoster /

10-25: 5mg/kg q24h

Herpes zoster / encephalitis

is morbidly obese AND has

encephalitis

Herpes zoster / encephalitis

5mg/kg q24h

life-threatening infection,

10mg/kg q8h

25-50: 10mg/kg q12h

then use adjusted weight.

10-25: 10mg/kg q24h

Acyclovir (PO)

Herpes Simplex

Herpes Simplex & Herpes

200 – 400mg 5x/day (PO)

10-25: 200 – 400mg q8h (PO)

200mg q12h (PO)

Zoster: Same as CrCl<10

See specific transplant

Herpes zoster

800mg q4h (PO)

guidelines for

10-25: 800mg q8h (PO)

800mg q12h (PO)

HSV prophylaxis:

prophylaxis dosing

HSV prophylaxis:

HSV prophylaxis (give after

SOT: 400mg BID (PO)

SOT: 10-25: 400mg BID(PO)

recommendations.

SOT<10: 200mg BID (PO)

dialysis):

SCCA:10-25: 800mg daily(PO)

SCCA: 800mg BID (PO)

or 400mg daily (PO)

SOT: 400mg daily (PO) SCCA:

SCCA: <10: 800mg daily(PO)

400mg daily(PO)

Aminoglycosides

Consult pharmacy for dosing recommendations for amikacin, gentamicin, tobramycin, or streptomycin.

0.5 – 1mg/kg q24h

Amphotericin B

No Changes

*Depending on severity of infection, dosage reduction, extending dosing interval may be warranted if rising SCr.

Amphotericin B lipid

3 - 5 mg/kg q24h, based on total body weight. Consult pharmacy for dosing recommendations.

1 – 2g q4-6h

1 – 2g q6-12h

1 – 2g q12-24h

1 – 2g q24h

Ampicillin



1.5 – 3g q6h

30-50: 1.5 – 3g q6-8h

14: 1.5 – 3g q24h

Ampicillin /Sulbactam

1.5 - 3g q24h

15-29: 1.5 – 3g q12h

250 – 1000mg q8h

10-30: 250 – 1000mg q12h

250 – 1000mg q24h

250 – 500mg q24h, (250-500mg

Amoxicillin (PO)

SD)

Amoxicillin/

875mg q12h

10-30: 500mg q12h

500mg q24h

500mg q24h (500mg SD)

Clavulanate (PO)

500mg x1day, 250 –

Azithromycin (IV/PO)

No changes

500mg q24h

1 – 2g q6-8h

31-60: 0.75 – 1.5g q8h

Aztreonam

500mg q8h

500mg q8h (500mg SD)

10-30: 0.5 – 1g q8h

Neutropenic fever: 2g q8h

10-30: 1 – 2g q12h

0.5 – 1g q24h

Cefazolin

1g q6-8h or 2g q8h

2gm on days of HD, 3gm if 3days

b/w HD

30-60: 1 – 2g q12-24h

250mg – 1g q24h

1g x1day, then 0.5 – 1g q24h

Cefepime

Neutropenic fever/Serious

11-29: 0.5 – 2g q24h

infection: 2g q8h

OR 2g post HD session

1 – 2g q6-8h

1 – 2g q8-12h

1 – 2g q24h

1 – 2g q24h (1g SD)

Cefotaxime

1 – 2g q12h

10-30: 0.5 – 1g q12h

250 – 500mg q12h

500mg – 1g on days of HD, 250-

Cefotetan

500mg on days off HD

1 – 2g q8h

31-50: 1 – 2g q12h

Ceftazidime

1g q24-48h

1g x1day, then 1g on days of HD

10-30: 1 – 2g q24h

Neutropenic fever: 2g q8h

1 – 2g q12-24h

Ceftriaxone

No change

Meningitis: 2g q12h

0.75 – 1.5g q8h

Cefuroxime (IV)

10-20: 750mg q12h

750mg q24h

750mg q24h (750mg SD)

250 – 500mg q6h

250 – 500mg q12h

Cephalexin

200 – 400mg q12h

10-30: 200 – 400mg q24h

200 – 400mg q24-48h

200 – 400mg on days of HD

Cefpodoxime (PO)

200 – 400mg q8-12h

10-30: 200 – 400mg q12h

Ciprofloxacin (IV)

200mg q12h

400mg q24h

250 – 750mg q12h

10-30: 250 – 500mg q12h

250 – 500mg q24h

(PO)

250mg q12h

600 – 900mg q8h

Clindamycin (IV)

No changes

150 – 450mg q6h

(PO)

No changes

Dalfopristin /Quinupristin

7.5mg/kg q8-12h

No changes

Dapsone

100mg daily

No changes

Daptomycin

Serious or bacteremia:

6mg/kg q48h OR

6mg/kg q24h

<30: 6mg/kg q48h

6mg/kg q48h

7mg/kg on days of HD,

Use Total Body Weight*

9 mg/kg if 3d b/w HD

Doxycycline (IV/PO)

100mg q12h

No changes

15 – 25mg/kg q24h

15 – 25mg/kg q24-36h

15 – 25mg/kg q48h

Ethambutol (PO)

15-25mg/kg on days of HD

Ertapenem

1g q24h

<30: 500mg q24h

500mg q24h

(150mg SD if dose

given within 6h)

100 – 400mg q24h

50 – 200mg q24h

Fluconazole (IV/PO)

100-400mg on days of HD

12.5 – 37.5mg/kg q6h

20-50:12.5 – 37.5mg/kg q12h

12.5 – 37.5mg/kg q24h

25 – 37.5 mg/kg on days of HD

Flucytosine (PO)

<20:12.5 – 37.5mg/kg q24h

*Use Ideal Body Weight*

based on ideal body weight

Foscarnet

Consult pharmacy for dosing recommendations.

Ganciclovir

>70: 5mg/kg q12h (I)

25-49: 2.5mg/kg q24h (I)

1.25mg/kg 3x/week (I)

1.25mg/kg on days of HD (I)

(I = induction dose)

5mg/kg q24h (M)

1.25mg/kg q24h (M)

0.625mg/kg 3x/week (M)

0.625mg/kg on days of HD (M)

(M= maintenance dose)

50-69: 2.5mg/kg q12h (I)

10-24: 1.25mg/kg q24h (I)

*Use Total Body Weight*

2.5mg/kg q24h (M)

0.625mg/kg q24h (M)

Ganciclovir (PO)

>70: 1g q8h

25-49: 500mg q12h

500mg 3x/week

500mg on days of HD

50-69: 500mg q8h

10-24: 500mg q24h

250 – 500mg q12h

Imipenem/Cilastatin

500mg q6h

500mg q8-12h

Isoniazid (IV/PO)

300mg q24h

No changes

Last revised 06/2013

Hmc Antibiotic Renal Dosing Guidelines

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