ANTIBIOTIC
DOSING GUIDELINES FOR RENAL IMPAIRMENT
Formulas for dosing weights: Ideal body
weight IBW (male) = 50 kg + (2.3 x height in inches > 60 inches)·
IBW (female) = 45 kg + (2.3 x height inches > 60 inches);
Adjusted
BW (kg) = IBW + 0.4 (TBW – IBW)
CrCL
(mL/min) = (140 – age) x IBW ( x 0.85 for
females )
SCr x 72
Drug
|
CrCl
(mL/min)
|
Dosage Adjustment (in Renal
Insufficiency)
|
Acyclovir (IV) 1,4,5,
6,7,8
(Use ideal BW for
Obese
|
>50
|
HSV:5
mg/kg q8h
HSV encephalitis/zoster:10 mg/kg q8h
|
10-50
|
Same
dose
CrCl 25–50: q12h
CrCl 10 – 25: q24h
|
|
<
10
|
HSV:
2.5 mg q24h
HSVencephalitis/zoster: 5 mg/kg q24h
|
|
HD
|
HSV:
2.5mg/kg q24h
HSV encephalitis/zoster: 5mg/kg q24h
Dose after HD on HD days
|
|
CRRT
|
HSV:
5 – 7.5 mg/kg q24h
HSV encephalitis/zoster:7.5–10 mg/kg
q12h
|
|
Acyclovir
(PO) 1,5
|
>50
|
HSV
mucocutaneous: 200 mg q4h (or 5x daily)
VZV, HSV zoster: 800 mg q4h (or
5x/day)
|
10-50
|
Same dose q8h
|
|
<
10
|
Same dose q12h
|
|
HD
|
Same dose q12h
|
|
CRRT
|
n/a
|
|
Ambisome 1 (Ampho
BLiposomal)
|
>50
|
3 –6 mg/kg/day
|
10-50
|
No change (caution: nephrotoxic)
|
|
<
10
|
No change
|
|
HD
|
No change
|
|
CRRT
|
No change
|
|
Amikacin 1,2,3, 7
(Use ideal or adjusted BW
for obese)
|
>60
|
5 - 7.5 mg/kg q8h
Once daily dosing: 15–20 mg/kg q24h
|
40-60
|
5 – 7.5 mg/kg q12h
Once daily dosing: 15–20 mg/kg q36h
|
|
20-40
|
5 – 7.5 mg/kg q24h
Once daily dosing: 15–20 mg/kg q48h
|
|
<
20
|
5 mg/kg load, Once daily dosing:
then by level
|
|
Timing
of levels: Draw trough 30 min
prior to 4th dose. Draw peak 30 min after infusion ends
Once
daily dosing: goal peak 35–60; goal
trough < 4. Consult Hartford Nomogram
Conventional
dosing: goal peak 25–35 for serious
infections, 15–20 for UTI
goal trough: < 5-8
|
||
HD
|
5 – 7.5mg/kg post HD only
|
|
CRRT
|
10 mg/kg load,then 7.5mg/kg q24-48h
|
|
Ampicillin
(IV) 1,3,4,6
|
>50
|
1 – 2 gm q4 – 6h
Meningitis/endocarditis: 2 gm q4h
|
10-50
|
same dose q6 – 12h
Meningitis/endocarditis: 2gm q6h
|
|
<
10
|
same dose q12h
Meningitis/endocarditis: 2gm q12h
|
|
HD
|
1gmq12h
Meningitis/endocarditis: 2gm q12h
|
|
CRRT
|
1gm q6 –8h
Meningitis/endocarditis: 2gm q6h
|
|
Ampicillin/
sulbactam 1,2,4,
6,7
(SHC Restriction)
|
>50
|
3 gm q6h
|
15-50
|
CrCl < 50: 3gm q8h
CrCl < 30: 3gm q12h
|
|
<
15
|
3gm q24h
|
|
HD
|
3 gm q12–24h Dose after HD on HD
days
|
|
CRRT
|
3gm q6 –8h
|
|
Azithromycin (IV/PO) 1
|
>50
|
500 mg q24h
|
10-50
|
No change
|
|
<
10
|
No change
|
|
HD
|
No change
|
|
CRRT
|
No change
|
|
Aztreonam 1,2,6
Severe: pseudomonas,
Meningitis
|
>50
|
1 – 2 gm q8h
Severe: 2gm q6–8h
|
10-50
|
CrCl 10 – 30: 1gm q8h
Severe: 1gm q6 – 8h
|
|
<
10
|
500 mg q8h
Severe: 500 mg q6 – 8h
|
|
HD
|
1–2gmLD, then 500 mg q12h
Severe: 1–2gm LD, then 500 mg q8h
|
|
CRRT
|
1gm q8h or 2 gm q12h
|
|
Drug
|
CrCl
(mL/min)
|
Dosage Adjustment (in Renal
Insufficiency)
|
Caspofungin 1
(Hepatic
adjustment)
|
>50
|
70 mg x1, then 50 mg q24h
Consider 70 mg x 1, then 35mg q24h
if severe hepatic dysfunction (Child–Pugh score >7);
70 mg q24h if on phenytoin,
rifampin, other strong enzyme inducers
|
10-50
|
||
<
10
|
||
HD
|
No
change
|
|
CRRT
|
No
change
|
|
Cefazolin
1,2, 5, 6,7,8
|
>50
|
UTI/mild: 1 gm q8h
General: 2 gm q8h
|
10-50
|
UTI/mild: 1 gm q12h
General: 2 gm q12h
|
|
<
10
|
1 gm q24h
|
|
HD
|
1 gm q24h
Dose after HD on HD days
|
|
CRRT
|
2 gm q12h
|
|
Cefepime 1,4, 5, 6,
7
(SHC Interchange)
Severe: endocarditis/CF
febrile neutropenia/
pneumonia/ meningitis/
pseudomonas
|
>60
|
General
: 2 gm q12h or 1gm q6h
Severe : 2 gm q8h
|
30-60
|
General
: 2 gm q24h or 1gm q12h
Severe : 2 gm q12h
|
|
10-30
|
General
: 1gm q24h
Severe : 2 gm q24h
|
|
<
10
|
0.5
gm q24h
Severe infections: 1 gm q24h
|
|
HD
|
0.5
gm q24h
Severe: 1 gm q24h Give post HD on HD
days
|
|
CRRT
|
1gm
q8h
Severe infections: 2 gm q12h
|
|
Ceftriaxone 1, 5, 9
|
>50
|
1 – 2 gm q24h
Endocarditis, osteomyelitis: 2 gm
q24h
Meningitis, E. faecalis endocarditis:
2 gm q12h
|
10-50
|
||
<
10
|
No change
|
|
HD
|
No Change Dose after HD on HD days
|
|
CRRT
|
No Change
|
|
Ciprofloxacin(IV/PO)1,2, 5, 6,
8
|
>50
|
General
infections: 400 mg IV q12h; 500 mg PO q12h
Pseudomonas severe : 400 mg IV q8h;
750 mg PO q12h
|
30-50
|
General
infections : same
Pseudomonas severe : 400 mg IV q8 –
12h;
500 mg PO q12h
|
|
<
30
|
General
infections : 400 mg IV q24h; 500 mg PO q24h
Pseudomonas severe : 400 mg IV q24h;
500 mg PO q24h
|
|
HD
|
General
infections : 400 mg IV q24h
Pseudomonas severe : 500 mg PO q24h
Give post HD on HD days
|
|
CRRT
|
General
infections : 400 mg IV q12h
Pseudomonas severe : 500 mg PO q12h
|
|
Clindamycin 1,2
(caution in severe hepatic
disease)
|
>50
|
600– 900 mg IV q8h
150 – 450 mg PO q6h
|
15-50
|
No Change
|
|
<
15
|
No Change
|
|
HD
|
No Change
|
|
CRRT
|
No Change
|
|
Colistin 1,5,6
(Use ideal BW in obese)
|
>50
|
1.25 – 2.5mg/kg q12h
|
10-50
|
Scr 1.3 – 1.5: 1.25 - 1.9 mg/kg q12h
Scr 1.6 – 2.5: 2.5 mg/kg q24h
|
|
<
10
|
Scr 2.6–4: 1.5 mg/kg q24h
|
|
HD
|
1.5 mg/kg q24h
|
|
CRRT
|
2.5mg/kg q12–24h
|
|
Daptomycin 1,10,11,
21 (Use adjusted BW in
obese)
(SHC Restriction)
|
>50
|
Skin/Soft tissue:4 mg/kg q24h
Endocarditis/Bacteremia: 6 – 8 mg/kg
q24h
|
10-50
|
(Calculate CrCl using IBW)
CrCl < 30: Same dose
q48h
|
|
<
10
|
Same dose q48h
|
|
HD
|
Same dose q48h
Give post HD on HD days
|
|
CRRT
|
4 –8mg/kg q48h
|
|
Doxycycline
(IV/PO) 1
|
>50
|
100 mg q12h
|
10-50
|
No change
|
|
<
10
|
No change
|
|
HD
|
No change
|
|
CRRT
|
No change
|
|
>50
|
No change
|
Abbreviations: SCr = serum creatinine LD = loading dose; MU= million units; PNA
= pneumonia; HD = hemodialysis; CAP = community acquired pneumonia; CRRT =
continuous renal
replacement therapy; TMP =
trimethoprim; PCP: pneumocystis jiroveci pneumonia TB = tuberculosis; UF =
ultrafiltration
CRRT dosing: doses listed are for CVVHDFand CVVHD modalities, which are the
most common modes at SHC. Note that these are generally higher than doses used
in CVVH.
All SHC formulary
Restrictions/Interchange program descriptions can be accessed using Lexi-Comp
and the intranet under pharmacy policies (intranet > Departments >
Pharmacy)
References:
1.
Lexi–Drug, Lexi–Comp®
[Internet database]. Hudson, OH: Lexi–Comp, Inc. Available at
http://www.crlonline.com. Accessed March, 2011
2.
The Sanford Guide to
Antimicrobial Therapy, 39th ed. Sperryville, VA: Antimicrobial Therapy. 2009
3.
Drug Prescribing in
Renal Failure, 5th ed. Philadelphia, PA: Dosing Guidelines for Adults and
Children, 2007
4.
McEvoy G (Ed). American
Hospital Formulary Service Drug Information. Bethesda, MD: American Society of
Health–System Pharmacists; 2008
5.
Micromedex® Healthcare
Series [Internet database]. Greenwood Village, CO: Thomson Reuters
(Healthcare), Inc. Available at http://www.thomsonhc.com/hcs/librarian.
Accessed March, 2011
6.
Heinz et al.,
Antimicrobial Dosing Concepts and Recommendations forCritically Ill Adult
Patients Receiving Continuous Renal Replacement Therapy or Intermittent
Hemodialysis, Pharmacotherapy 2009
7.
Aranoff GR et al., Drug
Prescribing in Renal Failure, 5th edition, American College of Physicians, Philadephia,
2007
8.
Trotman RL et al,
Antibiotic Dosing in Critically Ill Adult Patients Receiving Continuous Renal
Replacement Therapy, CID 2005
9.
Guglielmo BJ et al.,
Ceftriaxone Therapy for Staphylococcal Osteomyelitis, CID 2000
10.
Pai MP et al, Influence
of Morbid Obesity on the Single–Dose Pharmacokinetics of Daptomycin,AAC 2007
11.
Dvorchik BH and
Damphousse,D,The Pharmacokinetics of Daptomycin in Moderately Obese, Morbidly
Obese, and Matched Nonobese Subjects, Journal of Clinical Pharmacology, 2005
12.
ATS Guidelines for
Treatment of Tuberculosis, Am J RespirCrit Care Med Vol 167. pp 603–662, 2003
13.
Baddour et al ,
Infective Endocarditis: Diagnosis and Management, Circulation. 2005
14.
Zimmerli W et al., Role
of Rifampin for Treatment of Orthopedic Implant–Related Staphylococcal
Infections, JAMA 1998
15.
http://www.cdc.gov/H1N1flu/recommendations.htm
16.
Robson R, et al. The
pharmacokinetics and tolerability of oseltamivir suspension in patients on
hemodialysis and continuous ambulatory peritoneal dialysis Nephrol Dial
Transplant 2006;21:2556–62.
17.
Taylor RJ et al.
Oseltamivir is adequately absorbed following nasogastric administration to
adult patients with severe H5N1 influenza. PLoS ONE 2008;3:e3410.
18.
Kuti et al., Use of
Monte Carlo Simulation to Design an Optimized Pharmacodynamic Dosing Strategy
for Meropenem, J ClinPharmacol2003 43: 1116
19.
Rybak M, Lomaestro B,
Rotschafer JC et al. Therapeutic monitoring of vancomycin in adult patients: A
consensus review of the American Society of Health–System Pharmacists, the
Infectious Diseases Society of America, and the Society of Infectious Diseases
Pharmacists. Am J Health–Syst Pharm. 2009; 66:82–98
20.
Nicolau DP et al,
Experience with a Once–Daily Aminoglycoside Program Administered to 2,184 Adult
Patients, AAC 1995; 39(3): 650–65
21.
Liu et al, Clinical
Practice Guidelines by the Infectious Diseases Society of America for the
Treatment of Methicillin–Resistant Staphylococcus Aureus Infections in Adults
and Children, Clinical Infectious Diseases 2011;1–38
22.
Andes D, Pascual A, and
Marchetti O. Antifungal therapeutic drug monitoring: established and emerging
indications. Antimicrob Agents Chemother 2009; 53:24-34
Posted By INDRA WS
Jika artikel ini bermanfaat bagi anda jangan lupa klik g +1 agar blog ini semakin mudah untuk ditemukan di google. About me me
Terimakasih atas kunjungannya.
0 komentar:
Post a Comment