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)
|
|
Ertapenem 1
|
>50
|
1 gm q24h
|
|
10-50
|
CrCl < 30:500 mg q24h
|
||
<
10
|
500 mg q24h
|
||
HD
|
500 mg q24h Give post HD on HD days
|
||
CRRT
|
1
gm q24h
|
||
Ethambutol
(PO) 1,7
|
>50
|
15 – 25 mg/kg q24h
|
|
10-50
|
15 – 25 mg/kg q24 – 36h
|
||
<
10
|
15 – 25 mg/kg q48h
|
||
HD
|
15 – 25 mg/kg post HD only
|
||
CRRT
|
15 – 25 mg/kg q24 – 36h
|
||
Fluconazole(IV/PO) 1,5,6,
8
Load 800 mg for
candidemia
|
>50
|
200 –400 mg q24h
Severe/CNS infections: up to 800 mg
q24h
|
|
10-50
|
100 – 200 mg (50% of normal dose)
q24h
|
||
<
10
|
50–100 mg (25% of normal dose) q24h
|
||
HD
|
200 - 400 mg post HD only
|
||
CRRT
|
400mg q24h (800 mg q24h for less
susceptible organisms)
|
||
Foscarnet 1
|
>50
|
Please see Lexi-comp or Micromedex for renal dosing
table. Note that dosing is by CrCl per kg (ml/min/kg)
CrCl/kg > 1.4: CMV Induction
treatment: 60 mg/kg q8h or 90 mg/kg q12h x 14-21 days
|
|
10-50
|
|||
<
10
|
|||
HD
|
|||
CRRT
|
|||
Ganciclovir 1, 6
Consider loading dose
of 5mg/kg for all patients
|
>70
|
CMV: Induction (I) 5 mg/kg q12h
Maintenance (M) 5 mg/kg q24h
|
|
51-70
|
CMV: Induction (I) 2.5 mg/kg q12h
Maintenance (M) 2.5 mg/kg q24h
|
||
26-50
|
CMV: Induction (I) 2.5 mg/kg q24h
Maintenance (M) 1.25 mg/kg q24h
|
||
11-25
|
CMV: Induction (I) 1.25 mg/kg q24h
Maintenance (M) 0.625 mg/kg q24h
|
||
<
10
|
CMV: Induction (I) 1.25 mg/kg 3x/wk
Maintenance (M) 0.625 mg/kg 3x/wk
|
||
HD
|
LD 5mg/kg, then
I: 1.25 mg/kg post HD only
M:0.625 mg/kg post HD only
|
||
CRRT
|
LD 5mg/kg, then
I: 2.5 mg/kg q12–24h
M:1.25 –2.5 mg/kg q24h
|
||
Gentamicin 6
(SHC interchange to
tobramycin. Exception:
gram positive synergy)
|
>60
|
1mg/kg q8h*
|
Timing of levels:
Draw trough 30 min prior to 4th dose. Draw peak 30 min after infusion ends (4th
dose). (For CrCl < 60, check levels sooner than 4th dose)
In HD, check trough before each HD session, and peak
30 minutes after each dose.
Goal levels: For
synergy,goal peak 3–5mg/L (3-4 if using IDSA endocarditis guidelines). Goal
trough < 1 mg/L
* Streptococci, Streptococcus bovis, Strep. viridans endocarditis:
optional dosing 3mg/kg q24h for CrCl > 60
|
40-59
|
1mg/kg q12h
|
||
20-39
|
1mg/kg q24h
|
||
<
20
|
1mg/kg load, then by level
|
||
HD
|
1mg/kg load, then 1mg/kg post HD
only
|
||
CRRT
|
1mg/kg q12h, then per level
|
||
Imipenem/Cilastatin 1,2,
6
(Nonformulary)
|
>50
|
500 mg q6h
|
|
10-50
|
500 mg q8h
|
||
<
10
|
250– 500 mg q12h
|
||
HD
|
250 – 500 mg q12h
Dose after HD on HD days q24h
|
||
CRRT
|
500 mg q8h
Severe: 500 mg q6h
|
||
Isoniazid 1
|
>50
|
300 mg q24h
|
|
10-50
|
No change
|
||
<
10
|
No change
|
||
HD
|
No change
Dose after HD on HD days
|
||
CRRT
|
No change
|
||
Levofloxacin
(IV/PO) 1,2, 5, 6, 8
|
>50
|
General : 250 – 500 mg q24h
Pseudomonas/CAP: 750 mg q24h
|
|
20-50
|
General : 250 – 500 mg q48h
Pseudomonas/CAP: 750 mg q48h
|
||
<
20
|
General : 500 mg x1, then 250 mg q48h
Pseudomonas/CAP: 750 mg x1, then 500
mg q48h
|
||
HD
|
See CrCl < 20 ml/min
Dose after HD on HD days
|
||
CRRT
|
500 mg q48h
Pseudomonas/CAP: 750 mg LD, then 500
mg q24h
or 750 mg q48h
|
||
Linezolid(IV/PO) 1,4
(SHC Restriction)
|
>50
|
600 mg q12h
|
|
10-50
|
No change
|
||
<
10
|
No change
|
||
HD
|
No change
Dose after HD on HD days
|
||
CRRT
|
No change
|
||
Drug
|
CrCl
(mL/min)
|
Dosage Adjustment (in Renal Insufficiency)
|
|
Meropenem 1,2, 6,
8, 18
(SHC Restriction)
Consider extended
infusion (3 hours) or
more
frequent dosing
intervals
for pseudomonas or
resistant
pathogens
|
>50
|
General: 1 gm q8h or extended
infusion 3 hr
Severe/CF/CNS: 2 gm q8h
|
|
26-50
|
General: 1 gm q12h or 0.5gm q6h
Severe/CF/CNS: 2 gm q12h
|
||
10-25
|
General: 0.5gm q8 –12h
Severe/CF/CNS: 1 gm q12h or 0.5gm
q8h
|
||
<
10
|
General: 0.5gm q12– 24h
Severe/CF/CNS: 0.5gmq12– 24h
|
||
HD
|
500 mg q24h Give post HD on HD days
Severe/CF/CNS: 1gm q24h Give post HD
on HD days
|
||
CRRT
|
1 gm q12h or 500 mg q6h
Severe/CF/CNS:
2g q12h
|
||
Nafcillin
1
|
>50
|
2 gm q4h
Mild infections: 1gm q4h
|
|
10-50
|
No
change
|
||
<
10
|
No
change
|
||
HD
|
No
change
|
||
CRRT
|
No
change
|
||
Oseltamivir
(PO) 1,2, 15,16,17
|
≥ 30
|
Prophylaxis: 75mg q24h
Treatment: 75mg BID
Treatment (severe/ICU): 150 mg BID
|
|
<
30
|
Prophylaxis: 75mg q48h
Treatment: 75mg q24h
Treatment (severe/ICU): 150 mg q24h
|
||
HD
|
Treatment/ prophylaxis: 30 mg
Severe/ICU: 60 mg
Give after every other HD session
|
||
CRRT
|
Prophylaxis: 75mg q24h
Treatment: 75mg BID
Severe/ICU: 150 mg BID
|
||
Penicillin G (IV) 1, 5, 6
|
>50
|
2 – 4 mu q4h
|
|
10-50
|
2– 3mu (75% of dose) q4h
|
||
<
10
|
1– 2 mu (25-50% of dose) q6h
|
||
HD
|
4mu x1, then 1 – 2 mu q6h
|
||
CRRT
|
4mu x1, then 2 – 3 mu q6h
|
||
Piperacillin/ tazobactam 1,2,4,
5, 6, 8
|
>40
|
General: 3.375gm q6h
Pseudomonas/nosocomial PNA/severe: 4.5
gm q6h
Extended infusion for CrCl > 20:
3.375 gm q8h over 4h
|
|
20-40
|
General: 2.25gm q6h
Pseudomonas/nosocomial PNA/severe: 3.375gm
q6h
Extended infusion for CrCl > 20:
3.375 gm q8h over 4h
|
||
<
20
|
General: 2.25 gm q8h
Pseudomonas/nosocomial PNA/severe: 2.25
gm q6h
|
||
HD
|
2.25gm q12h
Pseudomonas/PNA/severe infections: 2.25gm
q8h
|
||
CRRT
|
3.375 gm q6h or
Extended infusion 3.375 gm q8h (infused
over 4 h)
|
||
Posaconazole
(PO) 1,2, 22
(SHC Restriction)
|
>50
|
Treatment: 200 mg q6h or 400 mg q12h
|
|
10-50
|
No change.
Posaconazole levels shown to have great degree of
interpatient variability. Many clinicians would recommend blood levels to
assess efficacy. Consider drawing a trough 4 - 7 days after initiating dose
|
||
<
10
|
|||
HD
|
|||
CRRT
|
|||
Pyrazinamide
(PO) 1, 5, 12
(Use ideal BW)
Round to nearest tablet
size
|
≥ 30
|
20 – 25mg/kg IBW q24h (max 2000
mg/day)
|
|
<
30
|
25 – 35 mg/kg IBW 3 times per week
|
||
HD
|
25 –30 mg/kg IBW after HD only
|
||
CRRT
|
No data
|
||
Rifampin
(IV/PO) 1, 13, 14
|
>50
|
TB: 600 mg q24h
Endocarditis: 300 mg q8h
|
|
10-50
|
No change
|
||
<
10
|
No change
|
||
HD
|
No change
|
||
CRRT
|
No change
|
||
Tobramycin 20
(Use ideal or adjusted
BW for obese)
|
>60
|
1.7 mg/kg q8h –or–
7mg/kg q24h (once-daily dosing*)
|
Goal levels: Goal peak (4–8mg/L), and trough (< 1-2mg/L)
for treatment. *certain qualifications for once–daily dosing
Timing of levels: Draw
trough 30 min prior to 4th dose. Draw peak 30 minutes after infusion ends (4th
dose). (For CrCL < 20, may check levels sooner than 4th dose)
For once-daily dosing, draw a single random level 8
to 12 hours after dose given adjustments are made based on a published Hartford
nomogram.
For HD, draw trough pre-HD, and peak 30 min after
end of each infusion
|
40-59
|
1.7 mg/kg q12h
|
||
20-39
|
1.7 mg/kg q24h
|
||
<
20
|
2 mg/kg loading dose, then per
level
|
||
HD
|
2 mg/kg loading dose, then
1.5 – 2 mg/kg post HD
|
||
CRRT
|
1.5 - 2 mg/kg
q24 - 48h,
|
||
Trimethoprim (TMP)/
Sulfamethoxazole 1,
5,6 (Dose by ideal or
adjusted BW in obese)
SS = 80 mg TMP = 10 ml
po soln
DS =160 mg TMP = 20ml po
soln
|
≥ 30
|
5 – 10 mg/kg/day TMP divided q6 – 8h
PCP/Stenotrophomonas: 15 – 20
mg/kg/day TMP divided q6-8h
|
|
<
30
|
2.5 – 5 mg/kg/day TMP divided q8 –
12h
PCP/Stenotrophomonas: 7.5 – 10
mg/kg/day TMP divided q8 –12h
|
||
HD
|
2.5 – 5 mg/kg TMP q24h*
PCP/ Stenotrophomonas: 7.5 –10 mg/kg
TMP q24h*
*Give after HD on HD days
|
||
CRRT
|
5 – 10 mg/kg/day TMP divided q12h
PCP/ Stenotrophomonas:
10 –15mg/kg/day TMP divided q12h
|
||
Valganciclovir(PO) 1
Please refer to
transplant protocols if applicable
|
>60
|
Induction (14-21 days) : 900 mg q12h
Maintenance/ ppx : 900 mg q24h
|
|
40-59
|
Induction (14-21 days) : 450 mg q12h
Maintenance/ ppx : 450 mg q24h
|
||
25-39
|
Induction (14-21 days) : 450 mg q24h
Maintenance/ ppx : 450 mg q48h
|
||
10-24
|
Induction (14-21 days) : 450 mg q48h
Maintenance/ ppx : 450 mg twice/week
|
||
CrCl
< 10, IHD, CRRT
|
Not recommended, use ganciclovir
|
||
Vancomycin 6, 19,
21
(Use actual body
weight)
Consider loading dose
of 20–25mg/kg (max
2gm) for severe
infections and ICU
|
>50
|
15 – 20 mg/kg
q8 – 12h
|
Goal levels: Goal trough 10–15 mcg/ml (cellulitis,
skin/soft tissue infections)
Goal trough 15–20 mcg/ml (pneumonia, bacteremia,
endocarditis, osteomyelitis)
Timing of levels: Draw
trough < 30 minutes before 4th dose of new regimen. When SCr acutely rises,
hold dose, restart when level < 15 – 20
|
30-49
|
15 – 20 mg/kg q24h
|
||
15-29
|
10 – 15 mg/kg q24h
|
||
<
15
|
10 – 15 mg/kg q24 – 48h
|
||
HD
|
20 – 25mg/kg LD, then redose with
10 – 15mg/kg post dialysis when
level < 15 – 20
|
||
CRRT
|
20 – 25mg/kg LD, then
10 – 15mg/kg q24h
Draw level prior to 3rddose. Adjust to levels
|
||
Voriconazole (IV/PO) 1,22
(SHC Restriction)
|
>50
|
6 mg/kg IV q12h x 2, then 4 mg/kg IV
q12h
400 mg PO q12h x 2, then 200 mg PO
q12h
|
|
10-50
|
Caution with IV:
accumulation of IV vehicle cyclodextran occurs. Consider PO unless benefits
justify risks of IV use.
Levels shown to have great degree of interpatient
variability. Many clinicians would recommend blood levels to assess efficacy.
Consider drawing a trough 4 - 7 days after new dose
|
||
<
10
|
|||
HD
|
|||
CRRT
|
|||
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 CVVHDF and 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
Dikutip dari Stanford Hospital &
Clinics Antibiotic Dosing Reference Guide
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.
1 komentar:
Terima kasih ya dok. Lengkap banget nih.. :)
Post a Comment