Antibiotic Dosing Esrd

UNIVERSITY OF MARYLAND MEDICAL CENTER DEPARTMENT OF PHARMACY SERVICES Pharmacotherapeutic Considerations for Patients with End Stage Renal Disease End stage renal disease (ESRD) patients are followed closely by nephrology as outpatients. Therefore, many of the manifestations of ESRD are managed long-term in the outpatient setting. The following "guidelines" will be useful in caring for these patients while they are inpatients at UMMC. (Epoetin alfa and calcitriol dosing is done by nephrology. Intact PTH, aluminum levels, and iron studies are checked quarterly. These values may be obtained by calling the patient’s dialysis center.) A. Drug Dosing Considerations: 1) Assume a creatinine clearance < 5 mL/min for hemo- and peritoneal dialysis patients. 2) Refer to your pharmacist (8-5644) to ensure appropriate renal dosing of all medications. B. Anemia: 1) Blood should be transfused during hemodialysis. 2) Epoetin alfa: see guidelines for use in UMMC formulary for appropriate dosing. 3) Virtually all patients on epoetin alfa may require iron therapy (i.e. ferrous sulfate or ferrous gluconate 325 mg PO daily - TID). 4) Goal iron stores: Transferrin saturation > 20 % and Ferritin > 100 ng/mL. C. Secondary Hyperparathyroidism: 1) Calcium phosphate product > 65-70: results in soft tissue and vascular calcification/deposition. 2) Phosphate binders must be given with meals and bedtime snacks to bind dietary phosphate. Hold phosphate binders if patient is NPO. a) Calcium phosphate product < 65-70: Give calcium carbonate 650 -1300 mg PO with meals and bedtime snack b) Calcium phosphate product > 65-70: Give aluminum hydroxide 1920 – 3840 mg(30-60 cc) PO with meals and bedtime snack c) If calcium phosphate product is > 65-70 and the patient has symptomatic hypocalcemia: give aluminum hydroxide PO with meals and treat the hypocalcemia with CaCO3 500 mg elemental calcium PO TID with meals or IV calcium gluconate as needed. d) Hold phosphate binder if serum PO4 < 3. 3) Calcitriol: a) if PTH < 3 X normal: do not give calcitriol b) if PTH > 3 X normal: administer calcitriol 0.25 - 0.5 mcg PO daily

c) Hold calcitriol when calcium phosphate product > 65-70 and/or if patient is hyperphosphatemic. D. Miscellaneous: 1) All dialysis patients should receive Nephro-vite one tablet PO daily for vitamin supplementation. 2) Pain Relief: try acetaminophen first before non-steroidal anti-inflammatory agents or aspirin because of increased risk of bleeds with these agents. AVOID Meperidine (Demerol ): accumulation of active metabolite will result in SEIZURES. 3) Goal Albumin: > 3.5 gm/dl 4) AVOID antacids, etc... containing aluminum and/or magnesium since they will accumulate in ESRD patients. 5) AVOID potassium supplements or high sodium content products. However, CAPD patients may often require potassium supplementation. E. Dietary considerations: The following are general recommendations. All are subject to individualization, based on each patient's nutritional status. Contact the Registered Dietitian (R.D.) for patient specific recommendations.

CRF without Dialysis CRF on Hemodialysis CRF on CAPD

PROTEIN g/kg/day (based on dry wt) 0.8 - 1 1 - 1.2 (nonstressed) 1.2 - 1.5

Na+ 2 - 4g 2 - 4g 4g

K+ < 3g if high serum levels 2 - 3g No restriction unless serum levels high.

FLUID Individualize 700-1000cc + 24h U.O.P. Unrestricted if wt and BP controlled.

ANTIMICROBIAL DOSAGE ADJUSTMENT FOR ADULT DIALYSIS PATIENTS ANTIBIOTICS

HEMODIALYSIS (HD)

Acyclovir (PO) HSV: 200 mg q12h and after HD HZV: 400 - 800 mg q12h and after HD HSV encephalitis: 800 mg q12h and after HD Acyclovir (IV) HSV: 2.5 mg/kg/d and after HD HZV + HSZ encephalitis: 5 mg/kg/d and after HD Amikacin 5-7.5 mg/kg load, then dose per levels after HD Amoxicillin 250 - 500 mg q24h and (PO) 250 mg after HD Amoxicillin/ 250 - 500 mg q12-24h Clavulanate and 250 mg after HD (Augmentin) (PO) Amphotericin No Dosage Adjustment B (IV) Necessary Ampicillin 250 - 500 mg q12-24h (PO) and after HD Ampicillin (IV) 1 - 2 g q12h and after HD Ampicillin/ 1.5 - 3 g q24h and after Sulbactam HD (Unasyn) (IV) Aztreonam 1 - 2 g load, then 250 – (IV) 500 mg q8-12h and after HD Cefamandole 1 - 2 g load, then 250 – (IV) 750 mg q12h and after HD Cefazolin (IV) 0.5 - 1 g q24h and after HD

PERITONEAL DIALYSIS (CAPD)

PERITONITIS: DOSE PER EACH 2L EXCHANGE (give IP)*

HSV: 200 mg q12h HZV: 400 - 800 mg q12h HSV encephalitis: 800 mg q12h HSV: 2.5 mg/kg/d HZV + HSV encephalitis: 5 mg/kg/d 5-7.5 mg/kg load, then dose per levels 250 mg q12h 250 mg q12h

No Dosage Adjustment Necessary 250 mg q12h 1 - 2 g q12h 1.5 - 3 g q24h 1-2 g load, then 250 500 mg q8-12h

Load: 1 g Maint: 500 mg

250 - 1000 mg q12h

Load: 1 g Maint: 500 mg

0.5 g q12h

Load: 0.5 - 1 g Maint: 250 500 mg

Cefepime (IV) 1-2 g load then 250-500 mg q24h and 1-2 gm after HD Cefixime 300 mg after HD (PO) Cefotetan HD days: 500 mg - 2g (IV) q24h Non-HD days: 250 mg - 1 g q24h Cefoxitin (IV) 0.5 - 1 g q24h and 1 - 2 g after HD Cefpodoxime 200 mg after HD, three (PO) days per week Ceftriaxone No Dosage Adjustment (IV) Necessary Cephalexin (PO) Ciprofloxacin (PO) Ciprofloxacin (IV) Clarithromycin (PO) Dicloxacillin (PO) Didanosine (DDI) (PO) Dicloxacillin (PO) Didanosine (DDI) (PO) Erythromycin (PO/IV)

1-2 g q 48h 200 mg q24h 1 g q24h

1 g q24h 200 mg q24h No Dosage Adjustment Necessary

250 - 500 mg q12h and 250 - 500 mg q12h after HD 250 - 500 mg qPM 250 - 500 mg q12h (severe infection: 750 mg) (severe infection: 750 mg) 200 - 400 mg q24h 200 - 400 mg q24h 250 - 500 mg q24h and after HD No Dosage Adjustment Necessary <60 kg: 125 mg after HD >60 kg: 200 mg after HD No Dosage Adjustment Necessary <60 kg: 125 mg after HD >60 kg: 200 mg after HD No dosage adjustment necessary, but may consider q8-12h dosing interval.

Load: 1 g Maint: 200 mg

250 - 500 mg q24h No Dosage Adjustment Necessary < 60 kg: 125 mg q48h > 60 kg: 200 mg q48h No Dosage Adjustment Necessary < 60 kg: 125 mg q48h > 60 kg: 200 mg q48h No dosage adjustment necessary, but may consider q8-12h dosage interval.

Load: 1 g Maint: 250 500 mg

Load: 500 mg PO Maint: 50 mg

Ethambutol Famciclovir (PO) Fluconazole (PO/IV) Flucytosine (PO) Foscarnet (IV) Ganciclovir (PO/IV)

Gatifloxacin (IV/PO) Gentamicin (IV/IM)

Imipenem/ Cilastatin (Primaxin) (IV) INH (Isoniazid) Itraconazole/ Ketoconazole Levofloxacin (PO/IV) Linezolid (PO/IV) Metronidazole (PO/IV)

15 mg/kg after HD (three times per week) Zoster: 250 mg after HD 3x/week Simplex: 125 mg after HD 3x/week Normal loading dose, then normal dose after HD only

15 mg/kg QOD

25 mg/kg q24h and after HD (Adjust dose to keep Cp peak < 100). Dose Unknown in Hemodialysis Induction: 2.5 mg/kg after HD and on a day off HD day. Maintenance: 1.25 mg/kg after HD and on a day off HD day. Load: 400 mg; then 200 mg q24h after HD Load: 2 mg/kg; then 1 1.5 mg/kg after HD if Serum Concentration < 2 mcg/mL.

25 mg/kg q24h (Adjust dose to keep Cp peak <100). Dose Unknown in CAPD

125 mg - 250 mg q12h and after HD No Dose Adjustment Necessary; dose qPM (removed by HD) No Dosage Adjustment Necessary 250 mg q48h after HD 600 mg q12h and 200 mg after HD No Dosage Adjustment Necessary

Dose Unknown in CAPD

25% of normal dose q24h or 50% of dose q48h

100 mg PO qd or 150 mg IP QOD Load: 2 g PO Maint: 1 g PO qd

Induction: 2.5 mg/kg QOD Maintenance: 1.25 mg/kg QOD Load: 400 mg; then 200 mg q24h Load: 2 mg/kg; then 1 1.5 mg/kg q 2-3 days when serum concentration <2 mcg/mL. 125 - 500 mg q12h No Dose Adjustment Necessary No Dosage Adjustment Necessary 250 mg q48h after dialysis No Dosage Adjustment Necessary

Load: 2 mg/kg Maint: 8 - 12 mg Load: 1 g Maint: 200 mg

Nafcillin (IV) No Dosage Adjustment Necessary Penicillin V 250 mg q6h (PO) Penicillin G 2 - 4 mu q8h and 500,000 (IV) mu after HD Pentamidine No Dosage Adjustment (IV) Necessary Piperacillin 3 g q12h and 1 g after HD (IV) Piperacillin/ 2.25 g q8h and 0.75 g after Tazobactam HD (Zosyn) IV Pyrazinamide 15 mg/kg/day qPM (removed by HD) Dalfopristin/ No Dosage Adjustment Quinupristin Necessary (Synercid) (IV) Rifampin No Dosage Adjustment (PO/IV) Necessary (max dose per day = 600 mg). SMX-TMP Bacterial Infx: 2.5 mg/kg (Bactrim) q12-24h and after HD (IV/PO) PCP: 5 mg/kg q12h Tetracycline 250-500 mg qhs (PO) Ticarcillin/ 2 g q12h and 3.1 g after Clavulanate HD (Timentin) (IV) Tobramycin Load: 2 mg/kg; then 1 (IV) 1.5 mg/kg after HD if Serum Concentration < 2 mcg/mL. Trimethoprim 100 - 200 mg qPM (IV) Vancomycin 1 g q 5-7d when random (IV) level is < 15 mcg/ml

No Dosage Adjustment Necessary 250 mg q6h 2 - 4 mu q8h No Dosage Adjustment Necessary 3 - 4 g q12h

Load: 4 g IV Maint: 500 mg

2.25 g q8h 15 mg/kg/day No Dosage Adjustment Necessary No Dosage Adjustment Necessary (Max dose per day = 600 mg). Bacterial Infx: 2.5 mg/kg q12-24h PCP: 5 mg/kg q12h 250-500 mg q24h 3.1 g q12h

Load: 2 mg/kg; then 1 1.5 mg/kg after HD if Serum Concentration < 2 mcg/mL. 100 - 200 mg q24h 1 g (IV / IP) q 5-7d when random level is < 15 mcg/ml 0.75 mg qPM

Zalcitabine 0.75 mg qPM (DDC) (PO) Zidovudine 100 mg q8h 100 mg q8h (AZT) (PO) * Doses given IP unless otherwise noted.

2 g IP q 5-7 days