Renal dosing of antimicrobials: Difference between revisions
From IDWiki
mNo edit summary |
(→) |
||
Line 1: | Line 1: | ||
− | == |
+ | ==Calculating Creatinine Clearance (CrCl)== |
{{#widget:CrCl}} |
{{#widget:CrCl}} |
||
Line 18: | Line 18: | ||
</math> |
</math> |
||
− | == |
+ | ==Antibiotics== |
− | === |
+ | ===β-lactams=== |
− | ==== |
+ | ====Penicillins==== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Usual Dose |
− | ! |
+ | !Mild (30-49) |
− | ! |
+ | !Moderate (10-29) |
− | ! |
+ | !Severe (<10) |
− | ! |
+ | !HD |
− | ! |
+ | !PD |
− | ! |
+ | !CRRT |
|- |
|- |
||
− | | |
+ | |[[Amoxicillin]] PO |
− | | colspan=2 | |
+ | | colspan="2" |250-500 mg q8h |
− | | |
+ | |Same dose q12h |
− | | |
+ | |Same dose q24h |
− | | |
+ | |500 mg q24h; after dialysis on dialysis days |
− | | |
+ | |500 mg q12h |
− | | |
+ | |Usual dose |
|- |
|- |
||
− | | [[Amoxicillin-clavulanic acid|Amox/Clav]] PO |
+ | | rowspan="2" |[[Amoxicillin-clavulanic acid|Amox/Clav]] PO |
− | | colspan=2 | |
+ | | colspan="2" |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 |
|- |
|- |
||
⚫ | |||
− | | [[Amoxicillin-clavulanic acid|Amox/Clav]] PO |
||
− | | |
+ | |500/125 mg 112h |
− | | |
+ | |500/125 mg q24h |
− | | |
+ | |500/125 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 |
− | | colspan=7 | |
+ | | colspan="7" |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 |
|- |
|- |
||
− | | [[Piperacillin-tazobactam|Pip/Tazo]] IV |
+ | | rowspan="2" |[[Piperacillin-tazobactam|Pip/Tazo]] IV |
− | | colspan=2 | |
+ | | colspan="2" |4.5 g q8h |
− | | |
+ | |>20: 4.5 g q8h |
− | | |
+ | |<20: 3.375 g q8h |
− | | colspan=2 | |
+ | | colspan="2" |2.25 g q8h |
− | | |
+ | |4.5 g q8h |
|- |
|- |
||
+ | | colspan="2" |4.5 g q6h (pseudomonal) |
||
− | | [[Piperacillin-tazobactam|Pip/Tazo]] IV (Pseudomonas) |
||
− | | |
+ | |>20: 4.5 g q6h |
− | | |
+ | |<20: 4.5 g q8h |
− | | |
+ | | colspan="2" |2.25 g q6h |
− | | |
+ | |4.5 g q6h |
− | | 4.5 g q6h |
||
|} |
|} |
||
− | ==== |
+ | ====Cephalosporins==== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Usual Dose |
− | ! |
+ | !Mild (30-49) |
− | ! |
+ | !Moderate (10-29) |
− | ! |
+ | !Severe (<10) |
− | ! |
+ | !HD |
− | ! |
+ | !PD |
− | ! |
+ | !CRRT |
|- |
|- |
||
− | | |
+ | |[[Cephalexin]] PO |
− | | colspan=3 | |
+ | | colspan="3" |500 mg q6h |
− | | |
+ | |Usual dose q8-12h |
− | | |
+ | |500 mg q8-12h; after dialysis on dialysis days |
− | | |
+ | |500 mg q12-24h |
− | | |
+ | |Usual dose |
|- |
|- |
||
− | | |
+ | |[[Cefazolin]] IV |
− | | colspan=2 | |
+ | | colspan="2" |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 |
− | | colspan=2 | |
+ | | colspan="2" |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 |
− | | colspan=4 | |
+ | | colspan="4" |500 mg q12h |
− | | |
+ | |500 mg q12h; after dialysis on dialysis days |
− | | colspan=2 | |
+ | | colspan="2" |500 mg q12h |
|- |
|- |
||
− | | |
+ | |[[Cefprozil]] PO |
− | | |
+ | |250-500 mg q12h |
− | | colspan=3 | |
+ | | colspan="3" |50% of usual dose |
− | | |
+ | |50% of usual dose; after dialysis on dialysis days |
− | | colspan=2 | |
+ | | colspan="2" |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 |
− | | colspan=7 | |
+ | | colspan="7" |1-2 g q12-24h |
|} |
|} |
||
− | ==== |
+ | ====Carbapenems==== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Usual Dose |
− | ! |
+ | !Mild (30-49) |
− | ! |
+ | !Moderate (10-29) |
− | ! |
+ | !Severe (<10) |
− | ! |
+ | !HD |
− | ! |
+ | !PD |
− | ! |
+ | !CRRT |
|- |
|- |
||
− | | |
+ | |[[Ertapenem]] IV |
− | | colspan=2 | |
+ | | colspan="2" |1 g q24h |
− | | colspan=2 | |
+ | | colspan="2" |500 mg q24h |
− | | |
+ | |500 mg q24h; after dialysis on dialysis days |
− | | colspan=2 | |
+ | | colspan="2" |500 mg q24h |
|- |
|- |
||
− | | [[Meropenem]] IV |
+ | | rowspan="3" |[[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 |
|- |
|- |
||
+ | | colspan="2" |2 g q8h (CNS/CF) |
||
− | | [[Meropenem]] IV<br/>CNS or CF |
||
− | | |
+ | |2 g q12h |
− | | |
+ | |2 g q24h |
− | | |
+ | |2 g q24h; after dialysis on dialysis days |
− | | |
+ | |2 g q24h |
− | | |
+ | |2 g q8-12h |
− | | 2 g q8-12h |
||
|- |
|- |
||
− | | |
+ | | colspan="2" |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 |
− | | 1 g q8-12h |
||
|} |
|} |
||
− | === |
+ | ===Quinolones=== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Usual Dose |
− | ! |
+ | !Mild (30-49) |
− | ! |
+ | !Moderate (10-29) |
− | ! |
+ | !Severe (<10) |
− | ! |
+ | !HD |
− | ! |
+ | !PD |
− | ! |
+ | !CRRT |
|- |
|- |
||
− | | |
+ | |[[Ciprofloxacin]] PO |
− | | |
+ | |500-750 mg q12h |
− | | |
+ | |Usual dose |
− | | colspan=4 | |
+ | | colspan="4" |Usual dose q24h (q12h for Pseudo) |
− | | |
+ | |Usual dose |
|- |
|- |
||
− | | |
+ | |[[Ciprofloxacin]] IV |
− | | |
+ | |400 mg q12h (q8h for Pseudo) |
− | | |
+ | |Usual dose |
− | | colspan=4 | |
+ | | colspan="4" |Usual dose q24h (q12h for Pseudo) |
− | | |
+ | |Usual dose |
|- |
|- |
||
− | | [[Levofloxacin]] PO/IV |
+ | | rowspan="2" |[[Levofloxacin]] PO/IV |
− | | |
+ | |500 mg q24h |
− | | |
+ | |Usual dose |
− | | colspan=4 | |
+ | | colspan="4" |500 mg q48h |
− | | |
+ | |Usual dose |
|- |
|- |
||
⚫ | |||
− | | [[Levofloxacin]] PO/IV |
||
− | | |
+ | |750 mg x1 then 500 mg q24h |
− | | 750 mg |
+ | | colspan="4" |750 mg q48h |
⚫ | |||
⚫ | |||
⚫ | |||
|- |
|- |
||
− | | |
+ | |[[Moxifloxacin]] PO/IV |
− | | colspan=7 | |
+ | | colspan="7" |400 mg q24h |
|} |
|} |
||
− | === |
+ | ===Macrolides=== |
{| class="wikitable" |
{| class="wikitable" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Usual Dose |
− | ! |
+ | !Mild (30-49) |
− | ! |
+ | !Moderate (10-29) |
− | ! |
+ | !Severe (<10) |
− | ! |
+ | !HD |
− | ! |
+ | !PD |
− | ! |
+ | !CRRT |
|- |
|- |
||
− | | |
+ | |[[Azithromycin]] PO/IV |
− | | colspan=7 | |
+ | | colspan="7" |250-500 mg q24h |
|- |
|- |
||
− | | |
+ | |[[Clarithromycin]] (XL) PO |
− | | colspan=2 | |
+ | | colspan="2" |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=== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Usual Dose |
− | ! |
+ | !Mild (30-49) |
− | ! |
+ | !Moderate (10-29) |
− | ! |
+ | !Severe (<10) |
− | ! |
+ | !HD |
− | ! |
+ | !PD |
− | ! |
+ | !CRRT |
|- |
|- |
||
− | | |
+ | |[[Doxycycline]] PO |
− | | colspan=7 | |
+ | | colspan="7" |100 mg q12h |
|- |
|- |
||
− | | |
+ | |[[Tetracycline]] PO |
− | | |
+ | |250-500 mg q6h |
− | | |
+ | |Same dose q6-8h |
− | | |
+ | |Same dose q12-24h |
− | | |
+ | |Same dose q24h |
− | | colspan=3 | |
+ | | colspan="3" |N/A |
|} |
|} |
||
− | === |
+ | ===Aminoglycosides=== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Usual Dose |
− | ! |
+ | !Mild (30-49) |
− | ! |
+ | !Moderate (10-29) |
− | ! |
+ | !Severe (<10) |
− | ! |
+ | !HD |
− | ! |
+ | !PD |
− | ! |
+ | !CRRT |
|- |
|- |
||
− | | [[Amikacin]] IV |
+ | | rowspan="2" |[[Amikacin]] IV |
− | | |
+ | |5-7.5 mg/kg q8h |
| |
| |
||
| |
| |
||
| |
| |
||
− | | |
+ | |Pre-HD levels; post-HD doses |
| |
| |
||
| |
| |
||
|- |
|- |
||
− | | |
+ | |15 mg/kg q24h (extended interval) |
⚫ | |||
⚫ | |||
− | | |
+ | |20-39: Same dose q48h |
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
| |
| |
||
| |
| |
||
|- |
|- |
||
− | | [[Tobramycin]] IV |
+ | | rowspan="2" |[[Tobramycin]] IV |
− | | |
+ | |1.7 mg/kg q8h |
| |
| |
||
| |
| |
||
| |
| |
||
− | | |
+ | |Pre-HD levels; post-HD doses |
| |
| |
||
| |
| |
||
|- |
|- |
||
− | | |
+ | |7 mg/kg q24h (extended interval) |
⚫ | |||
⚫ | |||
− | | |
+ | |20-39 Same dose q48h |
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
| |
| |
||
| |
| |
||
|- |
|- |
||
− | | [[Gentamicin]] IV |
+ | | rowspan="2" |[[Gentamicin]] IV |
− | | |
+ | |1.7 mg/kg q8h |
| |
| |
||
| |
| |
||
| |
| |
||
− | | |
+ | |Pre-HD levels; post-HD doses |
| |
| |
||
| |
| |
||
|- |
|- |
||
− | | |
+ | |7 mg/kg q24h (extended interval) |
⚫ | |||
⚫ | |||
− | | |
+ | |20-39 Same dose q48h |
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
| |
| |
||
| |
| |
||
|} |
|} |
||
− | === |
+ | ===Miscellaneous=== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !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 |
− | | colspan=6 | |
+ | | colspan="6" |Usual dose |
|- |
|- |
||
− | | |
+ | |[[Vancomycin]] PO |
− | | colspan=7 | |
+ | | colspan="7" |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 |
− | | colspan=3 | |
+ | | colspan="3" |See [[vancomycin]]-specific dosing |
|- |
|- |
||
− | | [[Daptomycin]] IV |
+ | | rowspan="2" |[[Daptomycin]] IV |
− | | |
+ | |4 mg/kg q24h (SSTI) |
− | | |
+ | |Usual dose |
− | | colspan=2 | |
+ | | colspan="2" |Same dose q48h |
− | | |
+ | |Same dose q48h; after dialysis on dialysis days |
− | | |
+ | |Same dose q48h |
− | | |
+ | |Usual dose |
|- |
|- |
||
⚫ | |||
− | | [[Daptomycin]] IV |
||
⚫ | |||
⚫ | |||
− | | |
+ | |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 |
− | | colspan=6 | |
+ | | colspan="6" |Usual dose |
|- |
|- |
||
− | | |
+ | |[[Metronidazole]] PO/IV |
− | | |
+ | |500 mg q8-12h |
− | | colspan=6 | |
+ | | colspan="6" |Usual dose |
|- |
|- |
||
− | | |
+ | |[[Nitrofurantoin]] PO |
− | | |
+ | |50-100 mg q12h |
− | | |
+ | |Avoid <40 |
− | | colspan=5 | |
+ | | colspan="5" |Avoid |
|- |
|- |
||
− | | [[Trimethoprim-sulfamethoxazole|TMP-SMX]] PO/IV |
+ | | rowspan="2" |[[Trimethoprim-sulfamethoxazole|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 |
|- |
|- |
||
⚫ | |||
− | | [[Trimethoprim-sulfamethoxazole|TMP-SMX]] PO/IV for PJP |
||
⚫ | |||
⚫ | |||
⚫ | |||
⚫ | |||
+ | |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 |
||
⚫ | |||
⚫ | |||
⚫ | |||
|- |
|- |
||
− | | |
+ | |[[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 |
− | | colspan=2 | |
+ | | colspan="2" |Loading dose followed by 1.5 mg/kg/day q24h |
− | | |
+ | |— |
− | | |
+ | |— |
|} |
|} |
||
− | == |
+ | ==Antifungals== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !Drug |
− | ! |
+ | !Usual Dose |
− | ! |
+ | !Mild (30-49) |
− | ! |
+ | !Moderate (10-29) |
− | ! |
+ | !Severe (<10) |
− | ! |
+ | !HD |
− | ! |
+ | !PD |
− | ! |
+ | !CRRT |
|- |
|- |
||
− | | |
+ | |Liposomal [[Amphotericin]] B IV |
− | | colspan=7 | |
+ | | colspan="7" |3-5 mg/kg q24h |
|- |
|- |
||
− | | |
+ | |[[Caspofungin]] IV |
− | | colspan=7 | |
+ | | colspan="7" |70 mg then 50 mg q24h |
|- |
|- |
||
− | | |
+ | |[[Anidulafungin]] IV |
− | | colspan=7 | |
+ | | colspan="7" |200 mg then 100 mg q24h |
|- |
|- |
||
− | | |
+ | |[[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<br />Oropharyngeal: 100 mg q24h |
− | | |
+ | |Usual dose |
− | | colspan=2 | |
+ | | colspan="2" |50% of usual dose q24h |
− | | |
+ | |Usual dose post-dialysis or q24h |
− | | |
+ | |50% q24h |
− | | |
+ | |Usual dose |
|- |
|- |
||
− | | |
+ | |[[Itraconazole]] PO |
− | | colspan=7 |
+ | | colspan="7" |100-200 mg q24h |
|- |
|- |
||
− | | |
+ | |[[Voriconazole]] PO/IV |
− | | |
+ | |6 mg/kg q12h x2 then 4 mg/kg q12h |
− | | colspan=6 | |
+ | | colspan="6" |PO preferred |
|} |
|} |
||
− | == |
+ | ==Antivirals== |
{| class="wikitable" style="width:100%" |
{| class="wikitable" style="width:100%" |
||
− | ! |
+ | !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 |
− | | colspan=2 | |
+ | | colspan="2" |50% of usual dose q24h; after dialysis on dialysis days |
− | | |
+ | |Usual dose |
|- |
|- |
||
− | | [[Acyclovir]] PO |
+ | | rowspan="2" |[[Acyclovir]] PO |
− | | |
+ | |200-400 mg 5x/day |
− | | |
+ | |Usual dose |
− | | |
+ | |Usual dose |
− | | |
+ | |Same dose q12h |
− | | colspan=2 | |
+ | | colspan="2" |50% of usual dose q24h; after dialysis on dialysis days |
− | | |
+ | |Usual dose |
|- |
|- |
||
− | | |
+ | |800 mg 5x/day (high dose) |
⚫ | |||
− | | 800 mg 5x/day |
||
− | | |
+ | |Same dose q8h |
− | | |
+ | |Same dose q12h |
⚫ | |||
− | | Same dose q12h |
||
+ | |Usual dose |
||
− | | colspan=2 | 50% of usual dose q24h; after dialysis on dialysis days |
||
⚫ | |||
|- |
|- |
||
− | | [[Ganciclovir]] IV |
+ | | rowspan="2" |[[Ganciclovir]] IV |
− | | |
+ | |5 mg/kg q12h (induction) |
− | | |
+ | |50-69: 2.5 mg/kg q12h<br />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<br/>Maintenance |
||
− | | 5 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: 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 |
⚫ | |||
− | | 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 |
|} |
|} |
||
Revision as of 12:39, 9 March 2021
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 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 | ||||||
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/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 | 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 |