Renal dosing of antimicrobials: Difference between revisions

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==Calculating Creatinine Clearance (CrCl)==

{{#widget:CrCl}}
{{#widget:CrCl}}


Estimate the creatinine clearance using the [https://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation Cockroft-Gault equation] (uses kg and mcmol/L):
== Calculating Creatinine Clearance (CrCl) ==


<math>CrCl_{Male} = \frac{1.2 \times (140 - age) \times weight}{creatinine}</math>
Estimate the creatinine clearance using the [https://www.mdcalc.com/creatinine-clearance-cockcroft-gault-equation Cockroft-Gault equation]:


<math>CrCl_{Male} = \frac{1.2 \times (140 - age) \times weight\ (kg)}{Serum\ creatinine\ (\mu mol/L)} \ CrCl_{Female} = 0.85 \times CrCl_{Male}</math>
<math>CrCl_{Female} = 0.85 \times CrCl_{Male}</math>


Use Ideal Body Weight (IBW) or Adjusted Body Weight (ABW) if patient is obese (i.e. TBW &gt; 30% over IBW)
Use Ideal Body Weight (IBW) or Adjusted Body Weight (ABW) if patient is obese (i.e. TBW &gt; 30% over IBW) (uses kg for weight):


<math>IBW_{Male} = 50\ kg + 2.3\ kg\ per\ inch\ over\ 5\ ft\ IBW_{Female} = 45.5\ kg + 2.3\ kg\ per\ inch\ over\ 5\ ft</math>
<math>IBW_{Male} = 50 + 2.3 \times (\text{inches over 5 ft})</math>
<math>ABW = IBW + 0.4 \times (TBW - IBW)</math>


<math>IBW_{Female} = 45.5 + 2.3 \times (\text{inches over 5 ft})</math>


<math>ABW = IBW + 0.4 \times (TBW - IBW)</math>


==Antibiotics==
== Dosing Guidelines ==
===β-lactams===

=== Penicillins ===
====Penicillins====
{| class="wikitable" style="width:100%"

!Drug
{|
!Usual Dose
! Drug
!Mild (30-49)
! Usual Dose
! Mild (30-49)
!Moderate (10-29)
! Moderate (10-29)
!Severe (&lt;10)
!HD
! Severe (&lt;10)
! HD
!PD
!CRRT
! PD
! CRRT
|-
|-
| Amoxicillin PO
|[[Amoxicillin]] PO
| 250-500 mg q8h
| colspan="2" |250-500 mg q8h
| Same dose q8h
|Same dose q12h
| Same dose q12h
|Same dose q24h
|500 mg q24h; after dialysis on dialysis days
| Same dose q24h
|500 mg q12h
| 500 mg q24h; after dialysis on dialysis days
|Usual dose
| 500 mg q12h
| Usual dose
|-
|-
| Amox/Clav PO
| rowspan="2" |[[Amoxicillin-clavulanic acid|Amox/Clav]] PO
| 500/125 mg q8h
| colspan="2" |500/125 mg q8h
|250/125 mg q12h
| Usual dose
| 250/125 mg q12h
|250/125 q24h
| 250/125 q24h
|250/125 q24h; after dialysis on dialysis days
| 250/125 q24h; after dialysis on dialysis days
|250/125 mg q12h
|Usual dose
| 250/125 mg q12h
| Usual dose
|-
|-
| colspan="2" |875/125 mg q12h
| Amox/Clav PO
| 875/125 mg q12h
|500/125 mg q12h
|500/125 mg q24h
| Usual dose
| 500/125 mg 112h
|500/125 mg q24h; after dialysis on dialysis days
| 500/125 mg q24h
|250/125 mg q12h
|Usual dose
| 500/125 mg q24h; after dialysis on dialysis days
| 250/125 mg q12h
| Usual dose
|-
|-
|[[Amoxicillin-clavulanic acid|Amox/Clav]] IV
| Ampicillin IV
| 1-2 g q4-6h
| colspan="2" |1 g IV q8h
|1 g load then 500 mg q12h
| Same dose q6-8h
|1 g load then 500 mg q24h
| Same dose q8-12h
|1 g load then 500 mg q24h; after dialysis on dialysis days
| Same dose q12h
|
| Same dose q12h; after dialysis on dialysis days
|
| 500-1000 mg q12h
| Usual dose
|-
|-
| Cloxacillin IV
|[[Ampicillin]] IV
| 1-2 g q4-6h
|1-2 g q4-6h
| Usual dose
|Same dose q6-8h
| Usual dose
|Same dose q8-12h
| Usual dose
|Same dose q12h
|Same dose q12h; after dialysis on dialysis days
| Usual dose
|500-1000 mg q12h
| Usual dose
| Usual dose
|Usual dose
|-
|-
| Penicillin G IV
|[[Cloxacillin]] IV
| 2-4 MU q4-6h
| colspan="7" |1-2 g q4-6h
| Usual dose
| 75% of usual dose
| 25-50% of usual dose
| 25-50% of usual dose; after dialysis on dialysis days
| 25-50% of usual dose
| Usual dose
|-
|-
|[[Penicillin]] G IV
| Pip/Tazo IV
| 4.5 g q8h
|2-4 MU q4-6h
|Usual dose
| 4.5 g q8h
|75% of usual dose
| &gt;20: 4.5 g q8h
|25-50% of usual dose
| &lt;20: 3.375 g q8h
|25-50% of usual dose; after dialysis on dialysis days
| 2.25 g q8h
| 2.25 g q8h
|25-50% of usual dose
|Usual dose
| 4.5 g q8h
|-
|-
| rowspan="2" |[[Piperacillin-tazobactam|Pip/Tazo]] IV
| Pip/Tazo IV (Pseudomonas)
| 4.5 g q6h
| colspan="2" |3.375 g IV q6h
| 4.5 g q6h
|20-40: 2.25 g q6h
| &gt;20: 4.5 g q6h
|&lt;20: 2.25 q8h
| &lt;20: 4.5 g q8h
| colspan="2" |2.25 g q8h
| 2.25 g q6h
|3.375 g q6h
|-
| 2.25 g q6h
| 4.5 g q6h
| colspan="2" |4.5 g q6h (pseudomonal)
|20-40: 3.375 g q6h
|&lt;20: 2.25 q6h
| colspan="2" |2.25 g q6h
|4.5 g q6h
|}
|}


=== Carbapenems ===
====Cephalosporins====
{| class="wikitable" style="width:100%"

!Drug
{|
!Usual Dose
! Drug
!Mild (30-49)
! Usual Dose
! Mild (30-49)
!Moderate (10-29)
! Moderate (10-29)
!Severe (&lt;10)
!HD
! Severe (&lt;10)
! HD
!PD
!CRRT
! PD
! CRRT
|-
|-
|[[Cephalexin]] PO
| Ertapenem IV
| colspan="3" |500 mg q6h
| 1 g q24h
| Usual dose
|Usual dose q8-12h
|500 mg q8-12h; after dialysis on dialysis days
| 500 mg q24h
| 500 mg q24h
|500 mg q12-24h
|Usual dose
| 500 mg q24h; after dialysis on dialysis days
| 500 mg q24h
| 500 mg q24h
|-
|-
|[[Cefadroxil]] PO
| Meropenem IV
| 500 mg q6h
| colspan="2" |500 mg q12h
| 500 mg q6-8h
|500 mg q24h
| 500 mg q8-12h
|500 mg q36h
|
| 500 mg q12-24h
|
| 500 mg q12-24h; after dialysis on dialysis days
|
| 500 mg q12-24h
| 500 mg q6-8h
|-
|-
|[[Cefazolin]] IV
| Meropenem IV<br/>CNS or CF
| 2 g q8h
| colspan="2" |1-2 g q8h
|1-2 g q12h
| Usual dose
| 2 g q12h
|1-2 g q24h
| 2 g q24h
|1-2 g q24h, or 1-2 g post-HD
|1 g q12h
| 2 g q24h; after dialysis on dialysis days
|Usual dose
| 2 g q24h
| 2 g q8-12h
|-
|-
|[[Cefuroxime]] IV
| Meropenem IV<br/>Febrile neutropenia
| 1 g q8h
| colspan="2" |750-1500 mg q8h
|750-1500 mg q12h
| Usual dose
|750-1500 mg q24h
| 1 g q12h
|750-1500 mg q24h; after dialysis on dialysis days
| 1 g q24h
|750-1500 mg q24h
| 1 g q24h; after dialysis on dialysis days
|Usual dose
| 1 g q24h
| 1 g q8-12h
|}

=== Cephalosporins ===

{|
! Drug
! Usual Dose
! Mild (30-49)
! Moderate (10-29)
! Severe (&lt;10)
! HD
! PD
! CRRT
|-
|-
| Cephalexin PO
|[[Cefuroxime]] PO
| 500 mg q6h
| colspan="4" |500 mg q12h
|500 mg q12h; after dialysis on dialysis days
| Usual dose
| colspan="2" |500 mg q12h
| Usual dose
| Usual dose q8-12h
| 500 mg q8-12h; after dialysis on dialysis days
| 500 mg q12-24h
| Usual dose
|-
|-
|[[Cefprozil]] PO
| Cefazolin IV
| 1-2 g q8h
|250-500 mg q12h
| Usual dose
| colspan="3" |50% of usual dose
|50% of usual dose; after dialysis on dialysis days
| 1-2 g q12h
| colspan="2" |50% of usual dose
| 1-2 g q24h
| 1-2 g q24h, or 1-2 g post-HD
| 1 g q12h
| Usual dose
|-
|-
| Cefuroxime IV
|[[Ceftazidime]] IV
| 750-1500 mg q8h
|1-2 g q8h
|1-2 g q8-12h
| Usual dose
|1-2 g q12-24h
| 750-1500 mg q12h
| 750-1500 mg q24h
|1-2 g q24h
| 750-1500 mg q24h; after dialysis on dialysis days
|Usual dose q24h; after dialysis on dialysis days
| 750-1500 mg q24h
|1 g q24h
| Usual dose
|Usual dose
|-
|-
|[[Ceftriaxone]] IV
| Cefuroxime PO
| colspan="7" |1-2 g q12-24h
| 500 mg q12h
|}
| 500 mg q12h

| 500 mg q12h
====Carbapenems====
| 500 mg q12h
{| class="wikitable" style="width:100%"
| 500 mg q12h; after dialysis on dialysis days
!Drug
| 500 mg q12h
!Usual Dose
| 500 mg q12h
!Mild (30-49)
!Moderate (10-29)
!Severe (&lt;10)
!HD
!PD
!CRRT
|-
|-
|[[Ertapenem]] IV
| Cefprozil PO
| colspan="2" |1 g q24h
| 250-500 mg q12h
| colspan="2" |500 mg q24h
| 50% of usual dose
|500 mg q24h; after dialysis on dialysis days
| 50% of usual dose
| colspan="2" |500 mg q24h
| 50% of usual dose
| 50% of usual dose; after dialysis on dialysis days
| 50% of usual dose
| 50% of usual dose
|-
|-
| rowspan="3" |[[Meropenem]] IV
| Ceftazidime IV
| 1-2 g q8h
|500 mg q6h
| 1-2 g q8-12h
|500 mg q6-8h
| 1-2 g q12-24h
|500 mg q8-12h
|500 mg q12-24h
| 1-2 g q24h
| Usual dose q24h; after dialysis on dialysis days
|500 mg q12-24h; after dialysis on dialysis days
|500 mg q12-24h
| 1 g q24h
|500 mg q6-8h
| Usual dose
|-
|-
| colspan="2" |2 g q8h (CNS/CF)
| Ceftriaxone IV
| 1-2 g q12-24h
|2 g q12h
| Usual dose
|2 g q24h
|2 g q24h; after dialysis on dialysis days
| Usual dose
| Usual dose
|2 g q24h
|2 g q8-12h
| Usual dose
|-
| Usual dose
| colspan="2" |1 g q8h (febrile neutropenia)
| Usual dose
|1 g q12h
|1 g q24h
|1 g q24h; after dialysis on dialysis days
|1 g q24h
|1 g q8-12h
|}
|}


=== Quinolones ===
===Quinolones===
{| class="wikitable" style="width:100%"

!Drug
{|
!Usual Dose
! Drug
!Mild (30-49)
! Usual Dose
! Mild (30-49)
!Moderate (10-29)
! Moderate (10-29)
!Severe (&lt;10)
!HD
! Severe (&lt;10)
! HD
!PD
!CRRT
! PD
! CRRT
|-
|-
| Ciprofloxacin PO
|[[Ciprofloxacin]] PO
| 500-750 mg q12h
|500 mg q12h
| Usual dose
|Usual dose
| Usual dose q24h (q12h for Pseudo)
| colspan="4" |Usual dose q24h
| Usual dose q24h (q12h for Pseudo)
|Usual dose
| Usual dose q24h (q12h for Pseudo)
| Usual dose q24h (q12h for Pseudo)
| Usual dose
|-
|-
| Ciprofloxacin IV
|[[Ciprofloxacin]] IV
| 400 mg q12h (q8h for Pseudo)
|400 mg q12h
| Usual dose
|Usual dose
| Usual dose q24h (q12h for Pseudo)
| colspan="2" |Usual dose q24h (q12h in critical illness)
| Usual dose q24h (q12h for Pseudo)
| colspan="2" |Usual dose q24h
| Usual dose q24h (q12h for Pseudo)
|Usual dose
| Usual dose q24h (q12h for Pseudo)
| Usual dose
|-
|-
|[[Ciprofloxacin]] PO (high dose)
| Levofloxacin PO/IV
| 500 mg q24h
|750 mg q12h
| Usual dose
|Usual dose
| colspan="4" |Usual dose q24h
| 500 mg q48h
|Usual dose
| 500 mg q48h
| 500 mg q48h
| 500 mg q48h
| Usual dose
|-
|-
|[[Ciprofloxacin]] IV (high dose)
| Levofloxacin PO/IV
| 750 mg q24h
|400 mg q8h
|Usual dose
| 750 mg x1 then 500 mg q24h
| colspan="2" |Usual dose q12h (q8h in critical illness)
| 750 mg q48h
| colspan="2" |Usual dose q12h
| 750 mg q48h
|Usual dose
| 750 mg q48h
| 750 mg q48h
| Usual dose
|-
|-
| Moxifloxacin PO/IV
|[[Levofloxacin]] PO/IV
| 400 mg q24h
|750 mg q24h
|750 mg x1 then 500 mg q24h
| Usual dose
|750 mg q48h
| Usual dose
| colspan="3" |750 mg x1 then 500 mg q48h
| Usual dose
| Usual dose
|Usual dose
|-
| Usual dose
|[[Moxifloxacin]] PO/IV
| Usual dose
| colspan="7" |400 mg q24h
|}
|}


=== Macrolides ===
===Macrolides===


{| class="wikitable"
{|
! Drug
!Drug
! Usual Dose
!Usual Dose
! Mild (30-49)
!Mild (30-49)
! Moderate (10-29)
!Moderate (10-29)
! Severe (&lt;10)
!Severe (&lt;10)
! HD
!HD
! PD
!PD
! CRRT
!CRRT
|-
|[[Azithromycin]] PO/IV
| colspan="7" |250-500 mg q24h
|-
|-
|[[Clarithromycin]] (XL) PO
| Azithromycin PO/IV
| 250-500 mg q24h
| colspan="2" |250-500 mg q12h (1 g daily)
|500 mg daily (avoid XL)
| Usual dose
|250-500 mg daily (avoid XL)
| Usual dose
|250-500 mg daily (avoid XL); after dialysis on dialysis days
| Usual dose
|250-500 mg daily (avoid XL)
| Usual dose
|Unclear
| Usual dose
| Usual dose
|}
|}


=== Tetracyclines ===
===Tetracyclines===


{| class="wikitable" style="width:100%"
{|
! Drug
!Drug
! Usual Dose
!Usual Dose
! Mild (30-49)
!Mild (30-49)
! Moderate (10-29)
!Moderate (10-29)
! Severe (&lt;10)
!Severe (&lt;10)
! HD
!HD
! PD
!PD
! CRRT
!CRRT
|-
|-
| Doxycycline PO
|[[Doxycycline]] PO
| 100 mg q12h
| colspan="7" |100 mg q12h
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
|-
|-
| Tetracycline PO
|[[Tetracycline]] PO
| 250-500 mg q6h
|250-500 mg q6h
| Same dose q6-8h
|Same dose q6-8h
| Same dose q12-24h
|Same dose q12-24h
| Same dose q24h
|Same dose q24h
| N/A
| colspan="3" |N/A
| N/A
| N/A
|}
|}


=== Miscellaneous ===
===Aminoglycosides===
{| class="wikitable" style="width:100%"
!Drug
!Usual Dose
!Mild (30-49)
!Moderate (10-29)
!Severe (&lt;10)
!HD
!PD
!CRRT
|-
| rowspan="2" |[[Amikacin]] IV
|5-7.5 mg/kg q8h
|
|
|
|Pre-HD levels; post-HD doses
|
|
|-
|15 mg/kg q24h (extended interval)
|40-59: Same dose q36h
|20-39: Same dose q48h
|Avoid
|Pre-HD levels; post-HD doses
|
|
|-
| rowspan="2" |[[Tobramycin]] IV
|1.7 mg/kg q8h
|
|
|
|Pre-HD levels; post-HD doses
|
|
|-
|7 mg/kg q24h (extended interval)
|40-59: Same dose q36h
|20-39 Same dose q48h
|Avoid
|Pre-HD levels; post-HD doses
|
|
|-
| rowspan="2" |[[Gentamicin]] IV
|1.7 mg/kg q8h
|
|
|
|Pre-HD levels; post-HD doses
|
|
|-
|7 mg/kg q24h (extended interval)
|40-59: Same dose q36h
|20-39 Same dose q48h
|Avoid
|Pre-HD levels; post-HD doses
|
|
|}


===Miscellaneous===
{|
{| class="wikitable" style="width:100%"
! Drug
!Drug
! Usual Dose
!Usual Dose
! Mild (30-49)
! Moderate (10-29)
!Mild (30-49)
! Severe (&lt;10)
!Moderate (10-29)
!Severe (&lt;10)
! HD
! PD
!HD
!PD
! CRRT
!CRRT
|-
|[[Clindamycin]] PO
|300-450 mg q6-8h
| colspan="6" |Usual dose
|-
|[[Clindamycin]] IV
|600-900 mg q8h
| colspan="6" |Usual dose
|-
|[[Vancomycin]] PO
| colspan="7" |Usual dose
|-
|-
|[[Vancomycin]] IV
| Clindamycin PO
| 300-450 mg q6-8h
|15 mg/kg q12h
| Usual dose
|Same dose q24h
|Same dose q48h; get pharmacy involved
| Usual dose
|Loading dose then check level at 48 hours
| Usual dose
| colspan="3" |See [[vancomycin]]-specific dosing
| Usual dose
| Usual dose
| Usual dose
|-
|-
| rowspan="2" |[[Daptomycin]] IV
| Clindamycin IV
|4 mg/kg q24h (SSTI)
| 600-900 mg q8h
| Usual dose
|Usual dose
| Usual dose
| colspan="2" |Same dose q48h
|Same dose q48h; after dialysis on dialysis days
| Usual dose
| Usual dose
|Same dose q48h
| Usual dose
|Usual dose
| Usual dose
|-
|-
|6 mg/kg q24h
| Daptomycin IV
|Usual dose
| 4 mg/kg q24h (SSTI)
| Usual dose
|Same dose q48h
| Same dose q48h
|Same dose q48h
| Same dose q48h
|Same dose q48h; after dialysis on dialysis days
| Same dose q48h; after dialysis on dialysis days
|Same dose q48h
| Same dose q48h
|Usual dose
| Usual dose
|-
|-
|[[Linezolid]] PO/IV
| Daptomycin IV
| 6 mg/kg q24h
|600 mg q12h
| Usual dose
| colspan="6" |Usual dose
| Same dose q48h
| Same dose q48h
| Same dose q48h; after dialysis on dialysis days
| Same dose q48h
| Usual dose
|-
|-
| Linezolid PO/IV
|[[Metronidazole]] PO/IV
| 600 mg q12h
|500 mg q8-12h
| Usual dose
| colspan="6" |Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
|-
|-
|[[Nitrofurantoin]] PO
| Metronidazole PO/IV
| 500 mg q8-12h
|50-100 mg q12h
|Avoid &lt;40
| Usual dose
| colspan="5" |Avoid
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
|-
|-
| rowspan="2" |[[Trimethoprim-sulfamethoxazole|TMP-SMX]] PO/IV
| Nitrofurantoin PO
|8-12 mg/kg/day in 2-4 doses
| 50-100 mg q12h
|Usual dose
| Avoid &lt;40
|75% of usual dose
| Avoid
|Avoid; if needed, 50% of usual dose
| Avoid
|50% of usual dose; after dialysis on dialysis days
| Avoid
|—
| Avoid
|7.5 mg/kg/day in 2-4 doses
| Avoid
|-
|-
|15-20 mg/kg/day in 2-4 doses (PJP)
| [TMP-SMX](Trimethoprim-sulfamethoxazole (TMP-SMX).md) PO/IV
|Usual dose
| 8-12 mg/kg/day in 2-4 doses
|12-15 mg/kg/day in 2-4 doses
| Usual dose
| 75% of usual dose
|Avoid; if needed, 50% of usual dose
| Avoid; if needed, 50% of usual dose
|50% of usual dose; after dialysis on dialysis days
|—
| 50% of usual dose; after dialysis on dialysis days
|15 mg/kg/day in 2-4 doses
| —
| 7.5 mg/kg/day in 2-4 doses
|-
|-
|[[Colistin]]
| [TMP-SMX](Trimethoprim-sulfamethoxazole (TMP-SMX).md) PO/IV for PJP
|5 mg CBA/kg IBW x1 loading (max 300 mg) followed by 5 mg/kg/day divided q8h
| 15-20 mg/kg/day in 2-4 doses
|Loading dose followed by 3.5 mg/kg/day divided q12h
| Usual dose
| 12-15 mg/kg/day in 2-4 doses
|Loading dose followed by 2.5 mg/kg/day divided q12h
| colspan="2" |Loading dose followed by 1.5 mg/kg/day q24h
| Avoid; if needed, 50% of usual dose
|—
| 50% of usual dose; after dialysis on dialysis days
| —
|—
| 15 mg/kg/day in 2-4 doses
|}
|}


=== Antifungals ===
==Antifungals==


{| class="wikitable" style="width:100%"
{|
! Drug
!Drug
! Usual Dose
!Usual Dose
! Mild (30-49)
!Mild (30-49)
! Moderate (10-29)
!Moderate (10-29)
! Severe (&lt;10)
!Severe (&lt;10)
! HD
!HD
! PD
!PD
! CRRT
!CRRT
|-
|-
| Liposomal Amphotericin B IV
|Liposomal [[Amphotericin]] B IV
| 3-5 mg/kg q24h
| colspan="7" |3-5 mg/kg q24h
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
|-
|-
| Caspofungin IV
|[[Caspofungin]] IV
| 70 mg then 50 mg q24h
| colspan="7" |70 mg then 50 mg q24h
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
|-
|-
| Anidulafungin IV
|[[Anidulafungin]] IV
| 200 mg then 100 mg q24h
| colspan="7" |200 mg then 100 mg q24h
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
|-
|-
| Fluconazole PO/IV
|[[Fluconazole]] PO/IV
| Invasive candidiasis: 12 mg/kg then 6 mg/kd q24h
|Invasive candidiasis: 12 mg/kg then 6 mg/kg q24h
| Usual dose
|Usual dose
| Usual load then 50% q24h
|Usual load then 50% q24h
| 50% of usual dose q24h
|50% of usual dose q24h
| Usual dose post-dialysis or q24h
|Usual dose post-dialysis or q24h
| Usual LD then 50% q24h
|Usual LD then 50% q24h
| Usual dose
|Usual dose
|-
|-
| Fluconazole PO/IV
|[[Fluconazole]] PO/IV
| Esophageal: 200 mg q24h<br/>Oropharyngeal: 100 mg q24h
|Esophageal: 200 mg q24h<br />Oropharyngeal: 100 mg q24h
| Usual dose
|Usual dose
| 50% of usual dose q24h
| colspan="2" |50% of usual dose q24h
| 50% of usual dose q24h
|Usual dose post-dialysis or q24h
|50% q24h
| Usual dose post-dialysis or q24h
|Usual dose
| 50% q24h
| Usual dose
|-
|-
| Itraconazole PO
|[[Itraconazole]] PO
| 100-200 mg q24h
| colspan="7" |100-200 mg q24h
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
| Usual dose
|-
|-
| Voriconazole PO/IV
|[[Voriconazole]] PO/IV
| 6 mg/kg q12h x2 then 4 mg/kg q12h
|6 mg/kg q12h x2 then 4 mg/kg q12h
| PO preferred
| colspan="6" |PO preferred
| PO preferred
| PO preferred
| PO preferred
| PO preferred
| PO preferred
|}
|}


=== Antivirals ===
==Antivirals==


{| class="wikitable" style="width:100%"
{|
! Drug
!Drug
! Usual Dose
!Usual Dose
! Mild (30-49)
!Mild (30-49)
! Moderate (10-29)
!Moderate (10-29)
! Severe (&lt;10)
!Severe (&lt;10)
! HD
!HD
! PD
!PD
! CRRT
!CRRT
|-
|-
| Acyclovir IV
|[[Acyclovir]] IV
| 5-10 mg/kg IBW q8h
|5-10 mg/kg IBW q8h
| Same dose q12h
|Same dose q12h
| Same dose q24h
|Same dose q24h
| 50% of usual dose q24h
|50% of usual dose q24h
| 50% of usual dose q24h; after dialysis on dialysis days
| colspan="2" |50% of usual dose q24h; after dialysis on dialysis days
|Usual dose
| 50% of usual dose q24h; after dialysis on dialysis days
| Usual dose
|-
|-
| Acyclovir PO
| rowspan="2" |[[Acyclovir]] PO
| 200-400 mg 5x/day
|200-400 mg 5x/day
| Usual dose
|Usual dose
| Usual dose
|Usual dose
| Same dose q12h
|Same dose q12h
| 50% of usual dose q24h; after dialysis on dialysis days
| colspan="2" |50% of usual dose q24h; after dialysis on dialysis days
|Usual dose
| 50% of usual dose q24h; after dialysis on dialysis days
| Usual dose
|-
|-
| Acyclovir PO<br/>High dose
|800 mg 5x/day (high dose)
|Usual dose
| 800 mg 5x/day
| Usual dose
|Same dose q8h
| Same dose q8h
|Same dose q12h
| colspan="2" |50% of usual dose q24h; after dialysis on dialysis days
| Same dose q12h
|Usual dose
| 50% of usual dose q24h; after dialysis on dialysis days
| 50% of usual dose q24h; after dialysis on dialysis days
| Usual dose
|-
|-
| Ganciclovir IV<br/>Induction
| rowspan="2" |[[Ganciclovir]] IV
| 5 mg/kg q12h
|5 mg/kg q12h (induction)
| 50-69: 2.5 mg/kg q12h<br/>25-49: 2.5 mg/kg q24h
|50-69: 2.5 mg/kg q12h<br />25-49: 2.5 mg/kg q24h
| 10-24: 1.25 mg/kg q24h
|10-24: 1.25 mg/kg q24h
| &lt;10: 1.25 mg/kg 3x/week
|&lt;10: 1.25 mg/kg 3x/week
| 1.25 mg/kg 3x/week post-dialysis
|1.25 mg/kg 3x/week post-dialysis
| 1.25 mg/kg 3x/week; after dialysis on dialysis days
|1.25 mg/kg 3x/week; after dialysis on dialysis days
| 2.5 mg/kg q12h
|2.5 mg/kg q12h
|-
|-
|5 mg/kg q24h (maintenance)
| Ganciclovir IV<br/>Maintenance
| 5 mg/kg q24h
|50-69: 2.5 mg/kg q24h<br />25-49: 1.25 mg/kg q24h
| 50-69: 2.5 mg/kg q24h<br/>25-49: 1.25 mg/kg q24h
|10-24: 0.625 mg/kg 3x/week
| 10-24: 0.625 mg/kg 3x/week
|&lt;10: 0.625 mg/kg 3x/week
| &lt;10: 0.625 mg/kg 3x/week
|0.625 mg/kg 3x/week post-dialysis
| 0.625 mg/kg 3x/week post-dialysis
|0.625 mg/kg 3x/week; after dialysis on dialysis days
|2.5 mg/kg q24h
| 0.625 mg/kg 3x/week; after dialysis on dialysis days
| 2.5 mg/kg q24h
|-
|-
| Oseltamivir PO
|[[Oseltamivir]] PO
| Treatment: 75 mg q12h
|Treatment: 75 mg q12h
| Usual dose
|Usual dose
| 75 mg q24h
|75 mg q24h
| 75 mg q48h
|75 mg q48h
| 75 mg q48h, or 3x/week post-dialysis
|75 mg q48h, or 3x/week post-dialysis
| 75 mg q48h, or 3x/week after dialysis on dialysis days
|75 mg q48h, or 3x/week after dialysis on dialysis days
| Usual dose
|Usual dose
|}
|}


[[Category:Antimicrobial Handbook]]
[[Category:Antimicrobials]]

Latest revision as of 19:24, 16 July 2024

Calculating Creatinine Clearance (CrCl)

Creatinine Clearance (CrCl) Calculator
years
mL/min

Estimate the creatinine clearance using the Cockroft-Gault equation (uses kg and mcmol/L):

Use Ideal Body Weight (IBW) or Adjusted Body Weight (ABW) if patient is obese (i.e. TBW > 30% over IBW) (uses kg for weight):

Antibiotics

β-lactams

Penicillins

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Amoxicillin PO 250-500 mg q8h Same dose q12h Same dose q24h 500 mg q24h; after dialysis on dialysis days 500 mg q12h Usual dose
Amox/Clav PO 500/125 mg q8h 250/125 mg q12h 250/125 q24h 250/125 q24h; after dialysis on dialysis days 250/125 mg q12h Usual dose
875/125 mg q12h 500/125 mg q12h 500/125 mg q24h 500/125 mg q24h; after dialysis on dialysis days 250/125 mg q12h Usual dose
Amox/Clav IV 1 g IV q8h 1 g load then 500 mg q12h 1 g load then 500 mg q24h 1 g load then 500 mg q24h; after dialysis on dialysis days
Ampicillin IV 1-2 g q4-6h Same dose q6-8h Same dose q8-12h Same dose q12h Same dose q12h; after dialysis on dialysis days 500-1000 mg q12h Usual dose
Cloxacillin IV 1-2 g q4-6h
Penicillin G IV 2-4 MU q4-6h Usual dose 75% of usual dose 25-50% of usual dose 25-50% of usual dose; after dialysis on dialysis days 25-50% of usual dose Usual dose
Pip/Tazo IV 3.375 g IV q6h 20-40: 2.25 g q6h <20: 2.25 q8h 2.25 g q8h 3.375 g q6h
4.5 g q6h (pseudomonal) 20-40: 3.375 g q6h <20: 2.25 q6h 2.25 g q6h 4.5 g q6h

Cephalosporins

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Cephalexin PO 500 mg q6h Usual dose q8-12h 500 mg q8-12h; after dialysis on dialysis days 500 mg q12-24h Usual dose
Cefadroxil PO 500 mg q12h 500 mg q24h 500 mg q36h
Cefazolin IV 1-2 g q8h 1-2 g q12h 1-2 g q24h 1-2 g q24h, or 1-2 g post-HD 1 g q12h Usual dose
Cefuroxime IV 750-1500 mg q8h 750-1500 mg q12h 750-1500 mg q24h 750-1500 mg q24h; after dialysis on dialysis days 750-1500 mg q24h Usual dose
Cefuroxime PO 500 mg q12h 500 mg q12h; after dialysis on dialysis days 500 mg q12h
Cefprozil PO 250-500 mg q12h 50% of usual dose 50% of usual dose; after dialysis on dialysis days 50% of usual dose
Ceftazidime IV 1-2 g q8h 1-2 g q8-12h 1-2 g q12-24h 1-2 g q24h Usual dose q24h; after dialysis on dialysis days 1 g q24h Usual dose
Ceftriaxone IV 1-2 g q12-24h

Carbapenems

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Ertapenem IV 1 g q24h 500 mg q24h 500 mg q24h; after dialysis on dialysis days 500 mg q24h
Meropenem IV 500 mg q6h 500 mg q6-8h 500 mg q8-12h 500 mg q12-24h 500 mg q12-24h; after dialysis on dialysis days 500 mg q12-24h 500 mg q6-8h
2 g q8h (CNS/CF) 2 g q12h 2 g q24h 2 g q24h; after dialysis on dialysis days 2 g q24h 2 g q8-12h
1 g q8h (febrile neutropenia) 1 g q12h 1 g q24h 1 g q24h; after dialysis on dialysis days 1 g q24h 1 g q8-12h

Quinolones

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Ciprofloxacin PO 500 mg q12h Usual dose Usual dose q24h Usual dose
Ciprofloxacin IV 400 mg q12h Usual dose Usual dose q24h (q12h in critical illness) Usual dose q24h Usual dose
Ciprofloxacin PO (high dose) 750 mg q12h Usual dose Usual dose q24h Usual dose
Ciprofloxacin IV (high dose) 400 mg q8h Usual dose Usual dose q12h (q8h in critical illness) Usual dose q12h Usual dose
Levofloxacin PO/IV 750 mg q24h 750 mg x1 then 500 mg q24h 750 mg q48h 750 mg x1 then 500 mg q48h Usual dose
Moxifloxacin PO/IV 400 mg q24h

Macrolides

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Azithromycin PO/IV 250-500 mg q24h
Clarithromycin (XL) PO 250-500 mg q12h (1 g daily) 500 mg daily (avoid XL) 250-500 mg daily (avoid XL) 250-500 mg daily (avoid XL); after dialysis on dialysis days 250-500 mg daily (avoid XL) Unclear

Tetracyclines

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Doxycycline PO 100 mg q12h
Tetracycline PO 250-500 mg q6h Same dose q6-8h Same dose q12-24h Same dose q24h N/A

Aminoglycosides

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Amikacin IV 5-7.5 mg/kg q8h Pre-HD levels; post-HD doses
15 mg/kg q24h (extended interval) 40-59: Same dose q36h 20-39: Same dose q48h Avoid Pre-HD levels; post-HD doses
Tobramycin IV 1.7 mg/kg q8h Pre-HD levels; post-HD doses
7 mg/kg q24h (extended interval) 40-59: Same dose q36h 20-39 Same dose q48h Avoid Pre-HD levels; post-HD doses
Gentamicin IV 1.7 mg/kg q8h Pre-HD levels; post-HD doses
7 mg/kg q24h (extended interval) 40-59: Same dose q36h 20-39 Same dose q48h Avoid Pre-HD levels; post-HD doses

Miscellaneous

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Clindamycin PO 300-450 mg q6-8h Usual dose
Clindamycin IV 600-900 mg q8h Usual dose
Vancomycin PO Usual dose
Vancomycin IV 15 mg/kg q12h Same dose q24h Same dose q48h; get pharmacy involved Loading dose then check level at 48 hours See vancomycin-specific dosing
Daptomycin IV 4 mg/kg q24h (SSTI) Usual dose Same dose q48h Same dose q48h; after dialysis on dialysis days Same dose q48h Usual dose
6 mg/kg q24h Usual dose Same dose q48h Same dose q48h Same dose q48h; after dialysis on dialysis days Same dose q48h Usual dose
Linezolid PO/IV 600 mg q12h Usual dose
Metronidazole PO/IV 500 mg q8-12h Usual dose
Nitrofurantoin PO 50-100 mg q12h Avoid <40 Avoid
TMP-SMX PO/IV 8-12 mg/kg/day in 2-4 doses Usual dose 75% of usual dose Avoid; if needed, 50% of usual dose 50% of usual dose; after dialysis on dialysis days — 7.5 mg/kg/day in 2-4 doses
15-20 mg/kg/day in 2-4 doses (PJP) Usual dose 12-15 mg/kg/day in 2-4 doses Avoid; if needed, 50% of usual dose 50% of usual dose; after dialysis on dialysis days — 15 mg/kg/day in 2-4 doses
Colistin 5 mg CBA/kg IBW x1 loading (max 300 mg) followed by 5 mg/kg/day divided q8h Loading dose followed by 3.5 mg/kg/day divided q12h Loading dose followed by 2.5 mg/kg/day divided q12h Loading dose followed by 1.5 mg/kg/day q24h — —

Antifungals

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Liposomal Amphotericin B IV 3-5 mg/kg q24h
Caspofungin IV 70 mg then 50 mg q24h
Anidulafungin IV 200 mg then 100 mg q24h
Fluconazole PO/IV Invasive candidiasis: 12 mg/kg then 6 mg/kg q24h Usual dose Usual load then 50% q24h 50% of usual dose q24h Usual dose post-dialysis or q24h Usual LD then 50% q24h Usual dose
Fluconazole PO/IV Esophageal: 200 mg q24h
Oropharyngeal: 100 mg q24h 		Usual dose 50% of usual dose q24h Usual dose post-dialysis or q24h 50% q24h Usual dose
Itraconazole PO 100-200 mg q24h
Voriconazole PO/IV 6 mg/kg q12h x2 then 4 mg/kg q12h PO preferred

Antivirals

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Acyclovir IV 5-10 mg/kg IBW q8h Same dose q12h Same dose q24h 50% of usual dose q24h 50% of usual dose q24h; after dialysis on dialysis days Usual dose
Acyclovir PO 200-400 mg 5x/day Usual dose Usual dose Same dose q12h 50% of usual dose q24h; after dialysis on dialysis days Usual dose
800 mg 5x/day (high dose) Usual dose Same dose q8h Same dose q12h 50% of usual dose q24h; after dialysis on dialysis days Usual dose
Ganciclovir IV 5 mg/kg q12h (induction) 50-69: 2.5 mg/kg q12h
25-49: 2.5 mg/kg q24h 		10-24: 1.25 mg/kg q24h <10: 1.25 mg/kg 3x/week 1.25 mg/kg 3x/week post-dialysis 1.25 mg/kg 3x/week; after dialysis on dialysis days 2.5 mg/kg q12h
5 mg/kg q24h (maintenance) 50-69: 2.5 mg/kg q24h
25-49: 1.25 mg/kg q24h 		10-24: 0.625 mg/kg 3x/week <10: 0.625 mg/kg 3x/week 0.625 mg/kg 3x/week post-dialysis 0.625 mg/kg 3x/week; after dialysis on dialysis days 2.5 mg/kg q24h
Oseltamivir PO Treatment: 75 mg q12h Usual dose 75 mg q24h 75 mg q48h 75 mg q48h, or 3x/week post-dialysis 75 mg q48h, or 3x/week after dialysis on dialysis days Usual dose
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