Drug |
CrCl >50 mL/min |
CrCl 10 - 50 mL/min |
CrCl <10 mL/min (ESRD not on HD) |
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|
Acyclovir
Dose on ideal body weight
ID approval: VASF(IV) |
Herpes simplex infections 5 mg/kg/dose IV Q8h
HSV encephalitis/ Herpes zoster 10 mg/kg/dose IV Q8h |
5 mg/kg/dose IV Q12 - 24h
10 mg/kg/dose IV Q12 - 24h |
2.5 mg/kg IV Q24h
5 mg/kg IV Q24h |
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|
Amoxicillin |
500-1000 mg po TID |
250-500mg po BID |
250-500mg po QD
|
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Amphotericin BDose on total body weight |
0.6 - 1.0 mg/kg IV Q24h |
No Change No Change Dosage reductions in renal disease are not necessary. However, due to the nephrotoxic potential of the drug, reducing the dose or holding the drug in the setting of a rising serum creatinine may be warranted. |
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|
Amphotericin B Lipid Preparations
Dose on total body weight |
Invasive fungal infections 3-5 mg/kg IV Q24h
Prophylaxis (heme-onc) 1 mg/kg IV Q24h
|
No Change No Change Dosage reductions in renal disease are not necessary. However, due to the nephrotoxic potential of the drug, reducing the dose or holding the drug in the setting of a rising serum creatinine may be warranted.
|
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AmikacinSee Aminoglycoside Dosing & Monitoring section
Consultation with
ID/ID pharmacy recommended before use. Dose is based on ideal body
weight (IBW) except in obese patients or those under their ideal body
weight. Use actual body weight if patient weight is less than IBW. Use
adjusted body weight (ABW) in patients who are obese. Amikacin is
generally used as a second-line aminoglycoside because of its increased
cost and need to send out levels
|
≥ 60 mL/min 15-20 mg/kg/dose IV Q24h The total daily dose of amikacin can be administered as a single daily dose in patients with normal renal function (CrCl ³ 60 mL/min). Patients with decreased renal function or abnormal body composition should have their doses adjusted according to the recommendations adjacent. Turnaround time for amikacin levels is usually 2-4 days. Peak levels are not useful with this dosing regimen; trough levels are recommended and should be <5mg/L. |
40-60 mL/min 20-40 mL/min 5-7.5 5 mg/kg mg/kg IV Q12h IV Q12-24h
With traditional dosing of amikacin, peak (20-30 mg/L) and trough
(<8mg/L) levels are recommended in patients anticipated to receive
aminoglycosides for severe Gram (-) infection. |
< 20 mL/min 5 mg/kg loading dose (Consult pharmacy for maintenance dose) |
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Ampicillin |
Meningitis or endovascular infection 2 g IV Q4h
Uncomplicated Infection 2 g IV Q6h
|
2 g IV Q6h 1g IV Q6h |
1g IV Q8h 1 g IV Q12h |
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|
Ampicillin/sulbactam ID approval: VASF
|
1.5-3 g IV Q6h | 1.5 g IV Q6-8h | 1.5 g IV Q12h | |||
|
Aztreonam
|
2 g IV Q8h | 2 g IV Q12h | 1 g IV Q12h | |||
|
Gram Negative or Complicated Gram-Positive 2 g IV Q8h
Uncomplicated Gram-Positive 1-2g IV Q8h
|
1 - 2 g IV Q12h |
1 g IV Q24h |
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|
For severe hepatic dysfunction give 70mg IV x1 then 35mg IV daily. |
LD=70 mg x1, No Change No Change then 50 mg Q24h Increase maintenance dose to 70mg when given with phenytoin, rifampin, carbamezapine, dexamethasone, nevirapine, or efavirenz. |
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|
Cefepime ID approval: VASF |
> 60 mL/min 2 g IV Q12h |
30-60 mL/min 10-30 mL/min 2g IV 1 g IV Q24h Q24h |
0.5 g IV Q24h |
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|
Febrile Neutropenia, Meningitis, Pseudomonas infections, Critically ill patients |
2 g IV Q8h |
2 g IV 2 g IV Q12h Q24h |
1 g IV Q24h |
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CeftazidimeID approval: VASF |
2 g IV Q8h |
2 g IV Q12 - 24h |
0.5 g IV Q24h |
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|
Ceftriaxone ID approval: VASF |
1 g IV Q24h |
No Change |
No Change
|
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Meningitis: ID approval: SFGH |
2 g IV Q12h |
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|
Endocarditis & Osteomyelitis: ID approval: SFGH |
2 g IV q24h |
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Cefuroxime |
0.75 - 1.5 g IV Q8h |
0.75 - 1.5 g IV Q12 - 24h |
0.5 g IV Q24h |
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Ciprofloxacin. |
400 mg IV Q12h
500 - 750 mg po Q12h
|
30-50 mL/min 10-30 mL/min No Change 200-400 mg IV Q12h
No Change 250-500 mg po Q12h |
200 mg IV Q12h 250 mg po Q12h |
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|
Pseudomonas infections |
400mg IV q8h 750mg po Q12h |
30-50 mL/min 10-30 mL/min No Change 200-400 mg IV Q12h
No Change 250-500 mg po Q12h |
200 mg IV Q12h 250 mg po Q12h
|
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ClindamycinID approval: VASF |
600 - 900 mg IV Q8h 300-450mg po TID-QID |
No Change |
No Change |
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ColistinDose on ideal body weight |
5mg/kg IV x1 loading dose, then contact ID Pharmacy for maintenance dosing recommendations |
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|
Daptomycin
Dose on total body weight
Not effective for treatment of pneumonia
|
6-10 mg/kg IV Q24h Dose depends on indication & pathogen.
|
<30 ml/min 6-10 mg/kg IV Q48h |
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| Doxycycline | 100 mg po/IV Q 12h | No Change | No Change | |||
|
Ethambutol |
15-20 mg/kg po daily |
<30 ml/min 15 - 25 mg/kg po three times per week
|
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|
Ertapenem ID approval: VASF
|
1g IV Q24h |
<30 ml/min 500mg IV Q24h |
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|
Oral formulation is 100% bioavailable. IV use should be restricted to patients unable to take oral medications.
|
100 - 400 mg po/IV Q24h
Oropharyngeal Candidiasis: 100mg daily Esophageal Candidiasis: 200mg daily Severe Infections : 400mg daily
|
50 - 200 mg po/IV Q24h |
50 - 100 mg po/IV Q24h |
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Flucytosine (5FC)
Dose on ideal body weight
Steady-state serum 5-FC level measurements are difficult to obtain. However, they may be useful in guiding dosing of 5-FC in anuria. Bone marrow suppression has been associated with 2 hour post dose 5-FC peaks of >100 mg/L
|
25mg/kg po Q6h |
25-50 mL/min 10-25mL/min 25 mg/kg 25mg/kg po Q12h po Q24h |
12.5 mg/kg po Q24h |
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GanciclovirID approval: VASF |
> 70mL/min 50-69mL/min 5mg/kg/dose 2.5mg/kg/dose IV Q12h IV Q12h |
25-49 mL/min 10-24 mL/min 2.5 1.25 mg/kg mg/kg IV Q24h IV Q24h |
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GentamicinSee Aminoglycoside Dosing & Monitoring section
For underweight patients, use
total body weight to calculate dose. For patients whose weight is
1-1.2 times their ideal body weight, use ideal body weight. For
patients weighing >1.2 times ideal body weight, use adjusted body
weight. Those patients with CrCl <60 mL/min, obesity or increased
fluid volume should be monitored with serum gentamicin levels.
|
≥ 60 mL/min 7 mg/kg/dose IV Q24h or 1.6 mg/kg/dose IV Q8h (total 5mg/kg/day) The total daily dose of gentamicin can be administered as a single daily dose in patients with normal renal function (CrCl ³ 60 mL/min). See Aminoglycoside Dosing & Monitoring section for monitoring recommendations. Divided dosing is recommended for patients with decreased renal function or abnormal body composition.
|
40-60 mL/min 20-40 mL/min 1.2-1.5 1.2-1.5 mg/kg mg/kg IV Q12h IV Q12-24h
With traditional dosing of gentamicin, peak (5-8 mg/L) and trough (<2mg/L) levels are recommended in patients anticipated to receive aminoglycosides for ³7 days for severe Gram (-) infection. Lower doses (1mg/kg/dose Q8h) are suggested when aminoglycosides are used synergistically in Gram (+) infections. Goals for Gram (+) synergy dosing are peak 3-4mg/L and trough <1 mg/L. |
< 20 mL/min 2 mg/kg loading dose (Consult pharmacy for maintenance dose) |
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Imipenem
|
500 mg IV Q6-8h max 50 mg/kg/day |
500 mg IV Q8h |
< 20 mL/min 250-500 mg IV Q12h |
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Isoniazid |
300 mg po daily |
No Change |
No Change |
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|
Levofloxacin ID approval: SFGH(IV) VASF (IV) |
250 - 500 mg po/IV Q24h |
LD=500 mg x1, then 250 mg po/IV Q24h |
LD=500 mg x1, then 250 mg po/IV Q48h
|
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|
Nosocomial pneumonia/ Pseudomonas infections |
750mg po/IV Q24h |
LD=750 mg x1, then 750 mg po/IV Q48h |
LD=750 mg x1, then 500 mg po/IV Q48h
|
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|
Linezolid
|
600mg IV/po Q12h |
No Change |
No Change |
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|
Meropenem
|
0.5-1 g IV Q8h |
25-50 mL/min 10-25 mL/min 0.5 - 1 g 0.5g IV Q12h IV Q12h
2g IV Q12h 1g IV Q12h |
0.5 g IV Q24h
1 g IV Q24h
|
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|
Meningitis, documented or suspected Pseudomonas
infections, critical illness
|
2 g IV Q8h |
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|
Metronidazole
|
500 mg po/IV Q8h |
500 mg po/IV Q8h |
500 mg po/IV Q12h Adjustment for ESRD only for patients not receiving hemodialysis. |
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Moxifloxacin |
400mg po/IV Q24h |
No Change |
No Change |
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Nafcillin |
Meningitis, osteomyelitis, or endovascular infection 2 g IV Q4h
Uncomplicated infection 1-2g IV Q6h
|
No Change |
No Change |
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|
Penicillin G |
Meningitis or endovascular infection 3 MU IV Q4h
Uncomplicated infection 2-3 MU IV Q4-6h
|
1 - 2 MU IV Q4 - 6h |
1 MU IV Q6h |
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|
Piperacillin/Tazobactam (ZosynÒ) |
3.375g IV Q6h |
3.375g IV Q6-8h |
2.25g IV Q8h
|
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|
Documented/suspected Pseudomonas infections |
4.5g IV Q6h for ClCr > 20 mL/min |
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|
Posaconazole Must be administered with a high-fat meal or nutritional shake (e.g. Ensure)
|
Treatment of invasive fungal infections 400 mg po Q12h or 200mg po Q6h Neutropenia/GVHD prophylaixis 200mg po Q8h
|
No Change |
No Change |
|||
Pyrazinamide |
20 - 25 mg/kg po daily |
<30 ml/min 25 - 35 mg/kg po three times per week
|
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|
Quinupristin/dalfopristin (Synercid)
|
Dose varies by indication. |
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|
Rifampin ID approval: SFGH(IV) Check for drug interactions
|
600 mg po daily |
No Change |
No Change |
|||
| Prosthetic valve endocarditis |
300 mg po Q8h |
No Change |
No Change |
|||
| Prosthetic joint infections |
450 mg po Q12h |
No Change |
No Change |
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|
Tigecycline
Severe hepatic disease: 100mg IV x1, then 25mg IV q12h
|
100mg IV x1, then 50mg IV Q12h |
No Change |
No Change |
|||
TobramycinID approval: SFGH
|
See Gentamicin and Aminoglycoside Dosing Section |
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TMP/SMX
Dose on adjusted body weight
TMP/SMX is »90% bioavailable orally. When switching to oral therapy, consider that a single-strength tablet has 80mg of TMP, a double-strength tablet 160mg of TMP.
|
Systemic GNR infections 10 mg TMP/kg/day IV divided Q6 - 12h
Pneumocystis pneumonia 15 - 20 mg TMP/kg/day IV divided Q6 - 12h |
5 - 7.5 mg TMP/kg/day IV divided Q12 - 24h
10 - 15 mg TMP/kg/day IV divided Q12 - 24h |
2.5 - 5.0 mg TMP/kg IV Q24h
5 - 10 mg TMP/kg IV Q24h |
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VoriconazoleID approval: UCSF SFGH VASF
Check for drug interactions.
Dose on adjusted body weight. In obese patients consider using a weight-based PO regimen (4mg/kg Q12h) using ABW, consult ID/ID-pharmacy for assistance.
PO should be used when possible, as oral bioavailability >95%.
May require dose adjustment in hepatic dysfunction. Consult ID pharmacy.
|
Oral LD=400 mg po Q12h x 1 day, then 200 mg po Q12h |
No Change |
No Change |
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|
IV dosing LD=6 mg/kg/dose IV Q12h x 2 doses, then 4mg/kg/dose IV Q12h |
The use of IV should be avoided if possible in patients with CrCl<50 mL/min due to the accumulation of the intravenous vehicle and is contraindicated in ESRD. |
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VancomycinID approval: VASF Uncomplicated infections Serious infections Round dose to 250mg, 500mg, 750mg, 1g, 1.25g, 1.5g, 1.75g, or 2g (maximum 2g/dose). For expanded information on dosing and monitoring, see Vancomycin Monitoring section. |
>60 mL/min
Uncomplicated Infections 10 - 15 mg/kg IV Q12h
Serious Infections Consider loading dose of 25mg/kg IV x1 followed by 15 - 20 mg/kg IV Q8-12h
|
40-60mL/min
10 - 15mg/kg IV Q12-24h |
20-40 mL/min
5 - 10mg/kg IV Q24h |
10-20 mL/min
5 - 10 mg/kg IV Q24-48h |
<10 mL/min
loading dose x1, redose according to serum levels |
|
| Trough levels should be obtained within 30 minutes before 4th dose or a new regimen or dosage change. Vancomycin troughs are not recommended in patients in whom anticipated duration of therapy is less than 3 days. For patients with uncomplicated infections, trough levels of 10-15 mcg/ml are recommended. For patients with serious infections due to MRSA (central nervous system infections, endocarditis, ventilator-associated pneumonia, bacteremia, or osteomyelitis), trough levels of 15-20 mcg/ml are recommended. ID CONSULT IS RECOMMENDED | ||||||