Calculating Creatinine Clearance (CrCl)
Estimate the creatinine clearance using the Cockroft-Gault equation (uses kg and mcmol/L):
Failed to parse (syntax error): {\displaystyle CrCl_{Male} = \frac{1.2 \times (140 - age) \times weight}{creatinine}\\ CrCl_{Female} = 0.85 \times CrCl_{Male} }
Use Ideal Body Weight (IBW) or Adjusted Body Weight (ABW) if patient is obese (i.e. TBW > 30% over IBW) (uses kg for weight):
Failed to parse (syntax error): {\displaystyle IBW_{Male} = 50 + 2.3 \times (\text{inches over 5 ft})\\ IBW_{Female} = 45.5 + 2.3 \times (\text{inches over 5 ft})\\ ABW = IBW + 0.4 \times (TBW - IBW) }
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
|
| 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
|
4.5 g q8h
|
>20: 4.5 g q8h
|
<20: 3.375 g q8h
|
2.25 g q8h
|
4.5 g q8h
|
| 4.5 g q6h (pseudomonal)
|
>20: 4.5 g q6h
|
<20: 4.5 g q8h
|
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
|
| 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
|
500-750 mg q12h
|
Usual dose
|
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
|
| Levofloxacin PO/IV
|
500 mg q24h
|
Usual dose
|
500 mg q48h
|
Usual dose
|
| 750 mg q24h
|
750 mg x1 then 500 mg q24h
|
750 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
|
Usual dose
|
Usual dose
|
Usual dose
|
Usual dose
|
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
|
