Renal dosing of antimicrobials: Difference between revisions

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= Calculating Creatinine Clearance (CrCl) =
== Calculating Creatinine Clearance (CrCl) ==


Estimate the creatinine clearance using the Cockroft-Gault equation:
Estimate the creatinine clearance using the Cockroft-Gault equation:
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<math>ABW = IBW + 0.4 \times (TBW - IBW)</math>
<math>ABW = IBW + 0.4 \times (TBW - IBW)</math>


= Dosing Guidelines =
== Dosing Guidelines ==


== Penicillins ==
=== Penicillins ===


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== Carbapenems ==
=== Carbapenems ===


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== Cephalosporins ==
=== Cephalosporins ===


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== Quinolones ==
=== Quinolones ===


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


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


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== Miscellaneous ==
=== Miscellaneous ===


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


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


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Revision as of 20:18, 15 August 2019

Calculating Creatinine Clearance (CrCl)

Estimate the creatinine clearance using the Cockroft-Gault equation:

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

Dosing Guidelines

Penicillins

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Amoxicillin PO 250-500 mg q8h Same dose 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 Usual dose 250/125 mg q12h 250/125 q24h 250/125 q24h; after dialysis on dialysis days 250/125 mg q12h Usual dose
Amox/Clav PO 875/125 mg q12h Usual dose 500/125 mg 112h 500/125 mg q24h 500/125 mg q24h; after dialysis on dialysis days 250/125 mg q12h Usual dose
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 Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose
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 4.5 g q8h 4.5 g q8h >20: 4.5 g q8h <20: 3.375 g q8h 2.25 g q8h 2.25 g q8h 4.5 g q8h
Pip/Tazo IV (Pseudomonas) 4.5 g q6h 4.5 g q6h >20: 4.5 g q6h <20: 4.5 g q8h 2.25 g q6h 2.25 g q6h 4.5 g q6h

Carbapenems

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Ertapenem IV 1 g q24h Usual dose 500 mg q24h 500 mg q24h 500 mg q24h; after dialysis on dialysis days 500 mg q24h 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
Meropenem IV
CNS or CF 		2 g q8h Usual dose 2 g q12h 2 g q24h 2 g q24h; after dialysis on dialysis days 2 g q24h 2 g q8-12h
Meropenem IV
Febrile neutropenia 		1 g q8h Usual dose 1 g q12h 1 g q24h 1 g q24h; after dialysis on dialysis days 1 g q24h 1 g q8-12h

Cephalosporins

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

Quinolones

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

Macrolides

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Azithromycin PO/IV 250-500 mg q24h Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose

Tetracyclines

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

Miscellaneous

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Clindamycin PO 300-450 mg q6-8h Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose
Clindamycin IV 600-900 mg q8h Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose
Daptomycin IV 4 mg/kg q24h (SSTI) Usual dose Same dose q48h Same dose q48h Same dose q48h; after dialysis on dialysis days Same dose q48h Usual dose
Daptomycin IV 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 Usual dose Usual dose Usual dose Usual dose Usual dose
Metronidazole PO/IV 500 mg q8-12h Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose
Nitrofurantoin PO 50-100 mg q12h Avoid <40 Avoid Avoid Avoid Avoid Avoid
[TMP-SMX](Trimethoprim-sulfamethoxazole (TMP-SMX).md) 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
[TMP-SMX](Trimethoprim-sulfamethoxazole (TMP-SMX).md) PO/IV for PJP 15-20 mg/kg/day in 2-4 doses 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

Antifungals

Drug Usual Dose Mild (30-49) Moderate (10-29) Severe (<10) HD PD CRRT
Liposomal Amphotericin B IV 3-5 mg/kg q24h Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose
Caspofungin IV 70 mg then 50 mg q24h Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose
Anidulafungin IV 200 mg then 100 mg q24h Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose
Fluconazole PO/IV Invasive candidiasis: 12 mg/kg then 6 mg/kd 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 50% of usual dose q24h Usual dose post-dialysis or q24h 50% q24h Usual dose
Itraconazole PO 100-200 mg q24h Usual dose Usual dose Usual dose Usual dose Usual dose Usual dose
Voriconazole PO/IV 6 mg/kg q12h x2 then 4 mg/kg q12h PO preferred PO preferred PO preferred PO preferred PO preferred 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 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 50% of usual dose q24h; after dialysis on dialysis days Usual dose
Acyclovir PO
High dose 		800 mg 5x/day Usual dose Same dose q8h Same dose q12h 50% of usual dose q24h; after dialysis on dialysis days 50% of usual dose q24h; after dialysis on dialysis days Usual dose
Ganciclovir IV
Induction 		5 mg/kg q12h 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
Ganciclovir IV
Maintenance 		5 mg/kg q24h 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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