Antimicrobial Renal Dosing

Antimicrobial Dosing Recommendations in Renal Insufficiency ANTIMICROBIAL Acyclovir 5-10 mg/kg Q8H; (VZV: 12-15 mg/kg Q 8 H) Acyclovir-VZV 800 mg po q4 h (5x/day) Ampicillin 2 gm Q6H / 2 gm Q4H~ Amp/Sulbactam 3 gm Q6H Amox/clavulanate 875/125 mg Q12H Aztreonam 1-2 gm Q6-8H Cefazolin (doses > 1 gm restricted) 1 gm Q8H / 2 gm Q8H~ Cefepime 1-2 gm Q12H / 2g Q8H* Cefixime 400 mg Q24H or 200 mg Q12H Cefotetan 1-2 gm Q12H Cefoxitin 1-2 gm Q6H / 2 gm Q4H~ Ceftazidime (non formulary) 1-2 gm Q8H Ceftizoxime (non-formulary) 1-2 gm Q8H Ceftriaxone 1-2 gm Q12-24H Cefuroxime (non-formulary) 0.75-1.5 gm Q8H Cephalexin 250-500 mg po Q`6H Cidofovir: 5 mg/kg Q Week x2 (Induction) Ciprofloxacin 400 mg Q 12 (Q8 for selected indications) 500-750 mg po Q 12 H Clarithromycin 250-500 mg po Q12H OR 1 gm XL po Q24H Ertapenem 1 gm IV or IM Q24H Erythromycin 0.5-1 gm Q6H Ethambutol 15-25 mg/kg Q day Ethionamide: 0.5­1 gm Q24H Famciclovir 500 Q 8H (zoster) 125 Q 12H (HSV) Fluconazole 12 mg/kg IV load on day one, 400 mg Q 24H Flucytosine 25-37.5 mg/kg Q 6H (2 hr post dose goal­50­100 mcg/ml) Foscarnet (dose based on CrCl/70kg) HSV, VZV 60 mg/kg Q12H • 49 mg/kg Q12 CrCl 90-100 • 35 mg/kg Q12H CrCl 60-90 CMV 90 mg/kg Q12H (induction) CrCl>100 • 78 mg/kg Q12 CrCl 90-100 • 71 mg/kg Q12H CrCl 60-90 90-120 mg/kg Q 24H (maintenance) • 78-104 mg/kg Q24 CrCl 90-100 • 71-94 mg/kg Q24H CrCl 60-90

CLCr 50-20 ml/min 5-10 mg/kg Q12H

CLCr 19-10 ml/min 5-10 mg/kg Q24H

Usual Dose

800 mg po q 8-12 H

CLCr <10 ml/min 2.5mg/kg Q24H 5 mg/kg Q24H (VZV) 400-800 mg po Q 12H

Usual Dose

1-2 gm Q6-8H

1-2 gm Q8-12H

3 gm Q8H

1.5-3 gm Q12H

Usual Dose

875/125 mg Q24H

1.5 gm Q12H, or 1.5-3 gm Q24H 500/125 mg Q24

1-2 gm Q 8 H

1-2 gm Load then 0.5-1 gm Q8H

1-2 gm Load then 250-500 mg q 8 H

1 gm Q8-12H

0.5-1 gm Q12H

0.5-1 gm Q24H

1 gm Q12H / 2 gm Q12H*

1 gm Q24H / 2 gm q24*

500 mg Q24H / 1 gm Q24H*

No Change

300 mg Q24H

200 mg Q24H

No Change

1 gm Q12H

1-2 gm Load then 500 mg q 12

1-2 gm Q8H

1-2 gm Q12H

1 gm Q24H

1 gm Q12H

1 gm Q24H

1 gm load then 0.5gm Q24H

1 gm Q12H

0.5-1 gm Q12H

1 gm load then 0.5 gm Q24H

Usual Dose

Usual Dose

Usual Dose

0.75 gm Q12H

No Change, consider 2 gm Max/d if liver + renal 0.75 gm Q24H

Usual Dose

250-500 mg po Q 8-12 H

250-500 mg po Q 12-24H

Not Recommended 400 mg IV Q 12

Not Recommended 400 mg IV Q18H

Not Recommended 400 mg IV Q24H

500 mg po Q 12 H

500 mg po Q12 H

500 mg po Q24H

Usual Dose

500 mg Load, 250 mg Q12H

500 mg Load, 250 mg Q12H

500mg Q24H (CrCl<30 ml/min)

500mg Q24H

500mg Q24H

Usual Dose

Usual Dose

0.5 gm Q6H

Usual Dose

15-25 mg/kg Q 36

15-25 mg/kg Q 48

Usual Dose

Usual Dose

Usual Dose

500 mg Q 12H 125 mg Q 12H 200–400 mg Q 24

500 mg Q24H 125 mg Q24H 200 mg q 24

250 mg Q 48H 125 mg Q 48H 100-200 mg Q24H

25 mg/kg Q12H

25 mg/kg Q24H

25 mg/kg Q24H-48 (adjust using Cp)

Foscarnet (dose based on CrCl/70kg) • HSV, VZV  • 21 mg/kg Q12 CrCl 35-60 CMV Induction • 57 mg/kg Q12H CrCl 35-60 • 50 mg/kg Q24H CrCl 20-35 Maintenance • 76 mg/kg Q24 CrCl 35-60 • 65 mg/kg Q 48 CrCl 20-35

Do not use

Do not use

Ganciclovir 5 mg/kg Q12H induction (I) 5 mg/kg Q24H maintenance (M) Gatifloxacin 400 mg Q24H Imipenem 0.5 gm Q6H Isoniazid: 300 mg po q 24 Itraconazole 200 mg Q12H PO OR IV Q12H x 4 doses then Q24H Linezolid 600 mg Q12H Meropenem (non-formulary) 1 gm Q8H (2 gm Q8H meningitis) Metronidazole: 500 mg Q8H Mezlocillin: 3 gm Q 4H (non-formulary) Penicillin G 1-4 MU Q4H (Max: 24 MU/day) Pentamidine 4 mg/kg/d Q24H Piperacillin 3-4 gm Q 4 H Pip/Tazo 3.375-4.5 gm Q6H (Pseudomonas—3.375 gm Q 4 H)

CrCl 50-80: 2.5 mg/kg Q12(I); 2.5 mg/kg Q24(M) CrCl 25-50: 2.5 mg/kg Q24H (I); 1.25 mg/kg Q24H (M) Cr Cl < 40—400 mg load then 200 mg Q24H

1.25 mg/kg Q24H (I) 0.625 mg/kg Q24H (M)

1.25 mg/kg TIW (I) 0.625 mg/kg TIW (M)

400 mg load then 200 mg Q24H

400 mg load then 200 mg Q24H

500 mg Q8H OR 250 mg Q6H

250 mg Q8H

0.25 gm Q12H

Usual Dose Usual Dose

No Change Usual Dose

No Change

No Change

150 mg in slow acetylators IV not recommended Cr Cl < 30 (cyclodextrin —although accumulation occurs, low toxicity potential of HPβCD) No Change

1 gm Q12H

0.5-1 gm Q12H

0.5 Q24H

Usual Dose 3 gm Q 6H CrCl 40-60: 1-2 MU Q 4 CrCl 20-40: 1-2 MU Q 6 4 mg/kg Q24

Usual Dose 3 gm Q 8H 1-2 MU Q6

2 gm Q 8H 1 MU Q6

4 mg/kg Q24H

4 mg/kg Q24-36H (<5 % drug cleared renally)

3-4 gm Q6H

3-4 gm Q8H

3 gm Q8H or 3-4 gm Q 12

3.375 gm Q6H or 4.5 gm Q 8 H

3.375 gm Q8H or 4.5 gm Q 12

2.25 gm Q8H

Aric Gregson, Karen Plaisance, Shannon Chan 11/10/2008

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Antimicrobial Dosing Recommendations in Renal Insufficiency Quinine 7.5­10 mg/kg Q8H  (650 mg po Q8H) Quinupristin/Dalfopristin 7.5 mg/kg Q8H Ticarcillin/Clavulanate 3.1 gm Q4-6H Trimethoprim/Sulfa ** 10 mg TMP/kg/d divided Q8H PCP: 15-20 mg/kg/day divided Q 6-8H Trimetrexate 1.2 mg/kg Q24H/ 45 mg/m2 Q24H + Leucovorin Valganciclovir 900 mg po Q 12H (induction) 900 mg Q 24H (maintenance) Vancomycin 1-1.5 gm Q12H (based on TBW) Voriconazole IV-6mg/kg q12h x 24hr, then 3-4mg/kg/dose q12h PO-200-300mg q12h

Usual Dose

7.5-10 mg/kg Q12H Metabolic Cl; inc binding to AAP; 3OH accumulates—dec dose by 1/3 after 3 days

7.5-10 mg/kg Q24H Metabolic Cl; inc binding to AAP; 3 OH accumulates—dec dose by 1/2 after 3 days

Usual Dose

Usual Dose

Usual Dose

3.1 gm Q6H

2 gm Q12H

CrCl 20-30: 7.5 mg TMP/kg/d divided Q12H PCP: 10-15 mg TMP/kg/day divided Q 8H

2 gm Q8H OR 3.1 gm Q12H 5 mg TMP/kg/d Q24H PCP 7.5 mg/kg TMP Q 12-24H

Usual Dose

50-100%

No Data; ? avoid

Cr Cl 40-60: 450 mg Q 12H (I); 450 mg Q 24H (M) CrCl 25-40: 450 mg Q24H (I); 450 mg Q 48H (M) Cr Cl 40-60: 15 mg/kg Q24H Cr Cl 20-40: 15 mg/kg load then 7.5 mg/kg Q24H IV-Not recommended† Po-unchange

450 mg Q 48H (I); 450 mg twice weekly (M)

Not recommended

15 mg/kg Q48-72H (monitor Cp)

15 mg/kg Q4-7d (monitor Cp)

IV-Not recommended† PO-unchange

IV-Not recommended† Po-unchange

3 mg TMP/kg/d Q24H PCP 5-7.5 mg/kg TMP Q 24

The following drugs do NOT need dosage adjustment in renal failure: amphotericin B (any formulation), atovaquone, azithromycin, caspofungin, , chloramphenicol (increased bioavailability of chloramphenicol from succinate ester), clindamycin, clofazamine dapsone, dicloxacillin, dirithromycin, doxycycline, linezolid, mefloquine, minocycline, nafcillin, oxacillin, primaquine, pyrimethamine, quinupristin/dalfopristin, rifampin, rifabutin, rifapentine *Neutropenic Dosing **TMP/SMX listed dosing is for GNR infections other than Stenotrophomonas. Pneumocystis treatment dose is 15 mg TMP/kg/d divided Q6-8H. Stenotrophomonas infection dose is 15-20 mg TMP/kg/d divided Q6H. ^Dosages are not necessarily appropriate for endocarditis, consider Infectious Disease Consultation if concerns or questions. ^^Dosages given are for parenteral therapy. ~Maximum recommended dose. †Not recommended unless an assessment of the benefit/risk to the patient justifies the use of intravenous voriconazole (due to accumulation of intravenous vehicle, SBECD) Italicized antibiotics are restricted to Infectious Disease or HIV Service approval. Infectious Disease Consultation Service beeper ‘BUGS’ HIV Consultation Service beeper ‘AIDS’ The following drugs may require dosage adjustment in hepatic failure: caspofungin, voriconazole, cefoperazone, ceftriaxone, chloramphenicol, clindamycin, isoniazid, itraconazole, metronidazole, nafcillin, rifampin, rimantidine.

 

Aric Gregson, Karen Plaisance, Shannon Chan 11/10/2008

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Antimicrobial Dosing Recommendations in Renal Insufficiency ANTIMICROBIAL

Peritoneal Dialysis Systemic Dosing

Acyclovir Aminoglycosides Amikacin Gentamicin Ampicillin Amp/Sulbactam Amox/clavulanate Azithromycin Aztreonam

Loading Dose IP (mg/L)

Hemodialysis Dose (AD=After dialysis) Maintenance Dose (IP) CAPD Intermittent (mg/L) (1 bag/day)

2.5 mg/kg Q 24H 5 mg/kg Q 24H (VZV) Follow Levels 250 mg po Q12H 1.5-3 gm Q24H 250/125 mg Q12H Usual Dose 1-2 gm Load, 250-500 q 8H

25 8 250-500 1000

15 4 125 100

2 mg/kg 0.6 mg/kg

500

250

1 gm

Cefazolin

0.5 gm Q12H

500

125

1 gm

Cefepime

500 mg Q24H

500

125

1 gm

Cefixime Cefotetan Cefoxitin

200 mg Q 24H 1-2 gm Load, 0.5 gm Q 1224 1 gm Q24H

200-500

100

Ceftazidime Ceftizoxime

1 gm Load, 0.5 gm Q24H 0.5-1 gm Q24H

250 250

125 125

1 gm 1 gm

Ceftriaxone Cefuroxime Na Cidofovir Ciprofloxacin

1 gm Q 12H 0.75 gm Q 24 H No Data 400 mq IV Q18H 500 mg po Q18H 500 mg Load, 250 mg Q 12H Usual Dose No data

250-500 200

125 100

1 gm 400 mg

Clarithromycin Clindamycin Ertapenem Erythromycin Ethambutol Ethionamide Famciclovir (no data) Fluconazole

500 mg q 6H 15-25 mg/kg Q48H Usual Dose No Data

Flucytosine (2 hr post dose goal-50-100 mcg/ml) Foscarnet Ganciclovir

Imipenem Itraconazole Linezolid Meropenem

0.5-1 gm Q24H (adjust using Cp) 65 mg/kg Q 48H Induction: 1.25 mg/kg TIW Maintenance 0.625 mg/kg TIW 400 mg load then 200 mg Q24H 250 mg Q 12H Usual Dose No Change?? 0.5 gm Q 24

Metronidazole Mezlocillin Nafcillin Penicillin G

Gatifloxacin

10-20 50

300

150

150

75

100-200 mg Q 24H

200 mg q 24

500

200

500 mg IV/PO q 8H 3 gm Q12H Usual Dose 1 MU Q 6H

1000 1000 1 MU

10 250 125 50,000 U

Pentamidine Piperacillin

4 mg/kg Q 24-36H 3 gm Q 8H

1000

250

Pip/Tazo

2.25 gm Q 8H

Quinine

7.5-10 mg/kg Q24H; dec dose by 1/2 after 3 days

Quinupristin/Dalfopristin

Usual Dose (low IP concentrations) 2 gm Q 12H 0.16/0.8 gm Q48H

Ticarcillin/Clavulanate Trimethoprim/Sulfa ** Trimetrexate Valganciclovir Vancomycin

No Data

Voriconazole (IV only)

No Data

15 mg/kg Q 4-7 days (monitor Cp)

Aric Gregson, Karen Plaisance, Shannon Chan 11/10/2008

CRRT Dose (CVVHD, CAVHD)

320/1600

80/400

1000

15

1 gm q 12 h

4 gm q 12 h

15-30 mg/kg q 5-7 days

2.5- 5 mg/kg IV q 24 (AD)

3.5 mg/kg/d

½ Full Dose AD & Follow Levels

Follow Levels

2 gm IV q 12 (AD) 3 gm q 12-24H (AD) Dose AD Usual Dose 1-2 gm Load then 250-500 mg q 8 H (1 dose AD or supplement with 500 mg) 1 gm Q 24H (Dose AD or supplement with .5-1 gm AD) 2 gm load, then 0.5 gm Q24H; and 1 gm AD supplement Supplement 300 mg AD 500 mg q 24 and Supplement 1 gm AD

2 gm IV q 6H 1.5 gm Q8H 875/125 mg po Q 12 Usual Dose 1-2 gm Q8H

1 gm Q 24 (Dose AD or Supplement with 1 gm AD) 1 gm Load and Supplement 1 gm AD 1 gm Q 24H (dose AD or Supplement 1 gm AD) Usual Dose 0.75 gm Q 24H (Dose AD) No Data 400 mg IV Q 24 (dose AD) 500 mg po Q 24H (dose AD) 500 mg Q 24H (dose AD)

2 gm Q 12H

Usual Dose 150mg supplemental dose if dose given within 6 hrs of HD: No supplement dose if dose given >6 hrs apart from HD 500 mg q 6H 15 mg/kg 3x/week AD Usual Dose 250 mg Q 48H AD (VZV) 125 mg Q 48H AD (HSV) 200 mg AD

Usual Dose No data

25 mg/kg AD (adjust using Cp)

25 mg/kg Q 24H (adjust using Cp)

60 mg/kg AD Induction: 1.25 mg/kg TIW AD Maintenance 0.625 mg/kg TIW AD 400 mg Load, 200 mg q 24

Would not use Induction 2.5 mg/kg Q24H Maintenance 1.25 mg/kg Q24H (M) 400 mg load then 200 mg Q24H

250 mg Q 12H AD 100 mg Q24 AD 600 mg Q12H, dose AD 0.5 gm Q 24 Dose AD or supplement with 0.5 gm AD 500 mg IV/PO q 8H 3-4 gm Q 12H, dose AD Usual Dose 1 MU Q 6H Dose AD or Supplement 0.5 MU AD 4 mg/kg Q 24-36H 2-3 gm Q 8H, dose AD or Supplement 1 gm AD 2.25 gm Q 8H, dose AD or Supplement with 0.75 gm AD 7.5-10 mg/kg Q24H AD Metabolic Cl; inc binding to AAP; 3 OH accumulates—dec dose by 1/2 after 3 days Usual Dose

250 mg Q 6-8H Usual Dose No Data 0.5-1 gm Q 12H

2 gm Q 12 H plus supplement 3.1 gm AD 5 mg TMP/kg Q 24H (dose AD or supplement with 2.5 mg/kg AD) No Data 450 mg AD 15 mg/kg Q 4-7 days (monitor Cp)

3.1 gm Q 6H No Data, some recommendQ 18H (3 mg/kg q 12H may be reasonable) No Data

No data

No data

1 gm Q12H Not recommended Not recommended 0.75 gm Q12H

1 gm Q 24H 1 gm Q12 H Usual Dose 1 gm Q12H Avoid Use 200 mg IV Q 12H 500 mg Load, 250 mg Q 12H

500 mg q 6H 15 mg/kg Q 24H Usual Dose 500 mg Q12-24H 125 mg Q12-24H 200 mg Q 24

500 mg IV/PO q 8H 3 gm Q 8H Usual Dose 2 MU Q 6H 4 mg/kg Q 24-36H 3 gm Q 6H 4.5 gm Q 8 H (JAC 48:881) 7.5-10 mg/kg Q12H Metabolic Cl; inc binding to AAP; 3OH accumulates—dec dose by 1/3 after 3 days

15 mg/kg Q 24-72 H (monitor Cp)

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Antimicrobial Dosing Recommendations in Renal Insufficiency

Nucleoside Analogs (NRTIs)-Renal Dosage Adjustment NRTIs, CrCl (ml/min)

Any weight

Zidovudine (Retrovir®, AZT, ZDV) >50 10­50 <10 HD PD

Zalcitabine (Hivid®, DDC) 10­40 <10 HD PD

Abacavir (Ziagen®, ABC)

125mg q12h or 250mg q24h 125mg q24h 50mg q24h 50mg q24h 100mg q24h* 100mg q24h

200mg q12h or 400mg q24h 200mg q24h 100mg q24h 100mg q24h 100mg q24h* 100mgq24h

30mg q12h 15mg q12h 15mg q24h 15mg q24h* 15mg q24h

40mg q12h 20mg q12h 20mg q24h 20mg q24h* 20mg q24h

0.75mg TID 0.75mg BID No Data No Data

Stavudine (Zerit®, D4T) >50 26­49 <10­25 HD PD

HD PD

>60 Kg

300mg BID 300mg BID 300mg QD 300mg QD 300mg QD

Didanosine (Videx®, DDI) >50 30­49 10­29 <10 HD PD

Lamivudine (Epivir®, 3TC) 26­49 10­25 <10

<60 Kg

150mg q24h 100mg q24h 150 mg QOD or 150mg, then  50mg QD or 300mg Q72­96  Hrs 150mg, then 50 mg QD 50mg QD No renal dose adjustment 

Tenofovir (Viread®) >50 30­50 10­29 <10 HD PD

300mg QD 300mg Q2days 300mg Q3­4days 300mg Q7days 300mg Q7days* No Data­Avoid

*Give Post­Dialysis Adapted from Medical Management of HIV Infection, 2003. J.Bartlett et al.

Aric Gregson, Karen Plaisance, Shannon Chan 11/10/2008

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Antimicrobial Dosing Recommendations in Renal Insufficiency

Authors: Aric Gregson, MD Karen Plaisance, Pharm.D. Shannon Chan, Pharm.D.

Aric Gregson, Karen Plaisance, Shannon Chan 11/10/2008

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