Hmc Antibiotic Renal Dosing Guidelines (Page 2 of 2) in pdf

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

Levofloxacin (IV/PO)

250mg q24h

250mg q48h

500mg q24h

20-49: 500mg x1, 250mg

< 19: 500mg x1, 250mg

500mg x1, 250mg q48h on day 3

q24h on day 2

q48h on day 3

Serious or pneumonia:

750mg x1, 500mg q48h on day 3

750mg q24h

20-49: 750mg q48h

< 19: 750mg x1, 500mg

q48h on day 3

Linezolid (IV/PO)

600mg q12h

No changes

26-50: 1 – 2g q12h

500mg – 1g q24h

Meropenem

Neutropenic fever &sepsis:

10-25: 500mg – 1g q12h

1g q8h

Cystic fibrosis / meningitis:

2g q8h

Metronidazole (IV/PO)

500mg q8h

No changes

Micafungin

Prophylaxis:50mg q24h

No changes

Candidemia:100mgq24h

Esophgeal candidiasis:

150mg q24h

Minocycline (IV/PO)

200mg x1, then 100mg q12

No changes

Moxifloxacin (IV/PO)

400mg q24h

No changes

1 – 2g q4-6h

Nafcillin

No changes

No changes unless hepatic

No changes

failure and CrCl<10: 0.5 –

1g q4-6h

Oseltamivir (PO)

Non-ICU: 75mg q12h (T)

<30: Non-ICU: 75mg q24h

Same as CrCl < 30

Non-ICU: 30mg 2x weekly (alternate

HD session) x2 doses total (T)

(T = treatment)

ICU: 150mg q12h (T)

(T)

ICU: 60mg 2x weekly (alternate HD

(P= prophylaxis)

< 30: ICU: 150mg q24h (T)

session) x4 doses total (T)

75mg q24h (P)

(e.g. MWF dialysis, then give dose on

< 30: 75mg q48h or 30mg

M and F for week 1)

daily (P)

30mg 2x weekly (alternate HD

session) x2 doses total (P)

(e.g. MWF dialysis, then give dose on

M and F)

2 – 4 mU q4-6h

1 – 2 mU q4-6h

Penicillin G Potassium

1 mU q6h (max dose

1 mU q6h

(max 24 mU/day)

6mU/day in ESRD)

Piperacillin / Tazobactam

4.5g X 1, then 4 hr later

< 20:

HD:

(prolonged infusion)

start 3.375g IV infused

3.375g IV q12h infused over 4 hours

3.375g IV q12h infused over 4

over 4 hours q8h

hours

Posaconazole (PO)

200mg po QID (T)

No changes

(T = treatment)

200mg po TID (P)

(P= prophylaxis)

Give with fatty meals

15 – 30mg/kg q24h

15 – 30mg/kg on days of HD

Pyrazinamide (PO)

15mg/kg q24h

(max 2g/dose)

Rifampin (IV/PO)

600mg q24h

No changes

No changes unless hepatic

Same as CrCl <10

failure and CrCl<10:

300mg q24h

Rimantadine (PO)

100mg q12h

< 30 or age > 65: 100mg q24h

< 30 or age > 65: 100mg

Limited data; use with caution

q24h

Ticarcillin / Clavulanate

3.1g q4-6h

30-60: 2g q4-6h

2g q12h

2g q12h (3.1g SD)

10-30: 2g q8h

Tigecycline

100mg x1, 50mg q12h

No changes

Trimethoprim/

10mg TMP/kg/day divided

5-7.5mg TMP/kg/day divided

2.5-5mg TMP/kg q24h

sulfamethoxazole

q6-8h

q12h

(TMP/SMX) (PO/IV)

PCP Treatment

15-20mg TMP/kg/day

10-15mg TMP/kg/day divided

5-10mg TMP/kg q24h

Dosing based on the TMP

divided q6-8h

q12h

component

PCP Prophylaxis

1 SS or 1 DS tab q24h

50-80: 1 SS tab q24h

1 SS tab q48h

10-50: 1 SS tab q24-48h

Valacyclovir (PO)

Same as CrCl<10

Herpes zoster

(I = initial episode)

1g q8h

30-50: 1g q12h

500mg q24h

(R= recurrent episode)

10-29: 1g q24h

Genital herpes

1g q12h (I)

500mg q24h (I)

Genital herpes

500mg q12h (R)

10-30: 1g q24h (I)

500mg q24h (R)

10-30: 500mg q24h (R)

Valganciclovir (PO)

>60: 900mg q12h (T)

25-39: 450mg q24h (T)

Not recommended

(T = treatment)

900mg q24h (P)

450mg q48h (P)

*Contact Stewardship or Transplant

Pharmacy for alternate dosing*

(P= prophylaxis)

40-59: 450mg q12h (T)

10-24: 450mg q48h (T)

450mg q24h (P)

450mg 2x/week (P)

Vancomycin

15mg/kg q12h

Consult pharmacy for dosing in renal insufficiency

Voriconazole (IV/PO)

6mg/kg q12h x 1 day, then

<50: Consider oral tablets due to accumulation of IV vehicle, SBECD, for long-term therapy. No

4mg/kg q12h

dosing adjustment is required for renal failure.

(140 – age) x WT (kg) .............................................................. (for females multiply by 0.85)

Cockcroft-Gault: CrCl (mL/min) =

72 x SCr (mg/dL)

Dosing recommendation is based on CrCl calculation using Cockcroft-Gault equation, However, PowerChart reports CrCl based on MDRD, which may vary slightly from Cockcroft-Gault. Dosing recommendation for

hemodialysis may not be applicable to all types of dialysis such as extended dialysis or dialysis with high flux membranes, or continuous renal replacement therapy (i.e. CVVH, CVVHD, CVVHDF)

Give scheduled dose(s) after hemodialysis unless otherwise specified; SD = supplemental dose in addition to scheduled dose(s) after each dialysis; Contact antimicrobial stewardship with questions or concerns.

Last revised 06/2013

Hmc Antibiotic Renal Dosing Guidelines Page 2

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