|
Antimicrobial Agents |
Usual Dosage |
Renally adjusted dosage
(based on CrCl ml/min) |
Hemodialysis |
|
Ampicillin (IV) |
1-2 g q4-6h |
>50: no change
30-50: q6-8h
10-29: q8-12h
<10: q12-24h
|
Dose as for CrCl<10, on dialysis days
dose AD |
|
Ampicillin (PO)
Back
|
250-500mg q6h |
>30: no change
10-30: q8-12h
<10: q12-24h
|
Dose as for CrCl<10, on dialysis days
dose AD |
|
Ampicillin/Sulbactam (IV) (Unasyn
® )
Back |
1.5-3 g q6-8h |
>30: no change
15-30: q12h
<15: q24h
|
Dose as for CrCl<10, on dialysis days
dose AD |
|
Amoxicillin (PO) |
875mg q12h
250-500mg q8-12h |
>30: no change
10-30: q8-12h
<10: q24h
|
Dose as for CrCl<10, on dialysis days
dose AD |
|
Amoxicillin/Clavulanate
(PO) (Augmentin ® ) |
875/125mg q12h or
250/125 to 500/125mg q8h |
>30: no change
10-30: q12h
<10:q24h
**875 mg dose not recommended for CrCl <30 ml/min**
|
250/125- 500/125mg q24h, on dialysis days
dose AD |
|
Azithromycin (PO)
Back |
- CAP: 500mg x1, then 250mg qd x4days
- STD: chlamydia: 1g once, uncomplicated
Gonococcus: 2 g once (not a preferred tx due to hi GI intolerance)
- MAC prophylaxis: 1200mg q week |
No adjustment in renal failure |
No adjustment |
|
Azithromycin (IV) |
- CAP: 500mg IV >/= 2 days, then 500mg
(IV/PO) qd, total 7-10days
- PID: 500mg IV 1-2days, then 250mg (IV/PO)
for total 7 days |
No adjustment in renal failure |
No adjustment |
|
Aztreonam (IV)
Back |
- UTI: 500mg - 1g q8-12h
- Moderate systemic infxn: 1-2g q8h
- Severe/life-threatening infxn: 2g q6-8h |
>30: no change
10-30: 1-2g x 1, then 50% of usual dose at
same interval (e.g., 0.5-1g q6-8h)
<10: 1-2g x 1, then 25% of usual dose at
same interval (e.g., 0.5 g q6-12h) |
1-2g x 1, then 25% of usual dose at same
interval (e.g. , 0.5 q6-12h)
–for serious infxn: may supplement 250 mg
AD) |
|
Cefaclor (PO)
(Ceclor ® )
Back |
250-500mg q8h |
>/= 10:
no change
<10: 50% at same interval |
250mg after each dialysis |
|
Cefadroxil (PO)
(Duricef ® ) |
1-2g per day divided qd or q12h |
>/= 10:
no change
<10: 50% at same interval |
0.5-1g after each dialysis |
|
Cefazolin (IV)
Back |
500mg-1g q8h (up to 2g q8h) |
>30: no change
10-30: 1g q12h
<10: 1g q24h |
1g q24h, on dialysis days dose AD |
|
Cefdinir (po)
(Omnicef ® ) |
300mg q12h |
>/= 30:
no change
<30: q24h |
300mg qod, on dialysis days give 300mg AD |
|
Cefepime (IV)
Back
|
Non-neutropenic: 1-2g q12h
Febrile neutropenia: 2g q8h |
Non-neutropenic: Neutropenic:
>60: 1-2g q12h >60: 2g q8h
30-60: 1-2g q24h 30-60: 2g q12h
10-29: 500mg-1g q24h 10-29: 2g q24h
<10: 250-500mg q24h <10: 1g q24h |
Dose as for CrCl<10 q24h, on dialysis
day dose AD |
|
Cefixime (PO)
(Suprax ® ) |
400mg q24h or 200mg q12h |
>60: 400mg/day
21-60: 300mg/day
</= 20: 200mg/day |
200-300mg divided qd or bid
|
|
Cefoperazone (IV)
Back |
1-2g q8-12h |
No dosage adjustment with normal hepatic fx.
If hepatic disease and severe renal
failure (CrCl<10) max dose of 1-2g/day
If hepatic disease or biliary obstruction,
max dose of 4g/day |
No adjustment |
|
Cefotaxime (IV) |
1-2g q6-8h
(Life-threatening up to maximum of 12g/day
e.g., 2g q4h) |
>50: no change
10-50: 1-2g q8-12h
<10: 1-2g q24h |
Dose as for CrCl <10, supplement 1g AD |
|
Cefotetan (IV)
Back |
1-2g q12h |
>30: no change
10-30: 1-2g q24h or 500mg-1g q12h
<10: 1-2g q48h or 250-500mg q24h |
Dose as for CrCl<10, supplement 1g AD |
|
Cefoxitin (IV)
Back
|
1-2g q6-8h |
>50: no change
30-50: 1-2g q8-12h
10-30: 1-2g q12-24h
<10: 500mg-1g q24-48h |
Dose as for CrCl<10, supplement 1g AD |
|
Cefpodoxime (PO)
(Vantin ® ) |
100-200mg q12h |
>/= 30:
no change
<30: 100-200mg q24h |
200 –400mg 3 times a week, dose AD |
|
Cefprozil (PO)
(Cefzil ® )
Back |
250-500mg q12h |
>/= 30:
no change
10-30: 50% of usual dose q12h
<10: 50% of usual dose 12-24h |
Dose as for CrCl<10, supplement 250mg AD |
|
Ceftazidime (IV) |
1-2g q8-12h
Febrile neutropenia: 2g q8h |
>50: no change
30-50: 1g q12h
10-29: 1g q24h
<10: 1g q48h |
Dose as for CrCl<10, on dialysis days
supplement 1g AD |
|
Ceftibuten (PO)
(Cedax ® )
Back |
400mg q24h |
>50: no change
30-50: 200mg q24h
<30: 100mg q24h |
400mg after each dialysis |
|
Ceftizoxime (IV) |
1-2g q8-12h
(severe or life-threatening 3-4g q8h =
maximum 12g /day) |
>30: no change
10-30: 1g q12h
<10: 1g q24h |
Dose as for CrCl<10, supplement 1g AD |
|
Ceftriaxone (IV)
Back |
1-2g q24h, q12h only for CNS infection |
No adjustment in renal failure |
No adjustment, on dialysis days give AD |
|
Cefuroxime (IV)
Back |
750mg to 1.5 g q8h |
>20: no change
10-20: 750mg q12h
<10: 750mg q24h |
Dose as for CrCl<10, supplement 750mg AD |
|
Cefuroxime (PO)
(Ceftin ® ) |
250-500mg q12h |
>30: no change
10-29: 250-500mg q12-24h
<10: 250mg q24h |
No adjustment, on dialysis days dose AD |
|
Cephalexin
(PO)
(Keflex ® )
Back |
250-500mg q6h
|
>30: no change
10-30: 250-500mg q8-12h
<10: 250mg q12-24h |
Dose as for CrCl<10, on dialysis days
dose AD |
|
Chloramphenicol
(IV or PO)
( only IV is formulary)
Back |
50-100mg/kg/day divided every 6 hours
(CNS or highly resistant infections:
100mg/kg/day in divided doses q6h) |
No dosage adjustment in renal failure
(If both hepatic dysfx and significant
renal disease, limit dose to 2g/day) |
No adjustment |
|
Ciprofloxacin (PO)
(Cipro ® ) |
250-750mg po q12h
|
>/= 30:
no change
<30: q24h |
- 250 q12h, OR, 250-500mg q24h, Dose AD on
dialysis days |
|
Ciprofloxacin (IV)
Back |
200-400mg IV q12h
( Febrile neutropenia/severe complicated
infxn: 400mg q8h IV) |
>/= 30:
no change
<30: q24h |
- 200mg q12h OR
- 200-400mg q24h
(on dialysis days dose AD) |
|
Clarithromycin (PO)
(Biaxin ® ) |
250-500mg q12h |
>/= 30:
no change
<30: 500mg x 1, then 250 mg q12-24h |
Dose as for CrCl<30, on dialysis days
dose AD |
|
Clindamycin (IV) |
300-900mg q6-8h |
No adjustment in renal failure |
No adjustment |
|
Clindamycin (PO)
(Cleocin ® )
Back |
150-450mg q6h |
No adjustment in renal failure |
No adjustment |
|
Cloxacillin (PO)
(Cloxapen ® ) |
250-500mg q6h |
No adjustment in renal failure |
No adjustment |
|
Dapsone (PO) |
100mg q24h |
Probably no dosage adjustment needed, some
sources recommend decreased dosage but no specific recommendation |
No adjustment (please see comments in renal
impairment section) |
|
Dicloxacillin (PO)
(Dynapen ® , Dycill ® ) |
125-500mg q6h |
No adjustment in renal failure |
No adjustment |
|
Doxycycline (PO or IV)
Back |
100mg q12h
(Less serious infxn: 100mg q12h on day 1,
then 100mg/day divided q12h or q24h) |
No adjustment in renal failure |
No adjustment |
|
Fosfomycin (PO)
(Monurol ® ) |
Mix 3g of powder in 3-4 ounces of water and
drink x 1 dose |
half-life increases with renal impairment-
consider alternative therapy |
|
|
Erythromycin (PO)
Back |
250-500mg base q6-12h, maximum 4g/day
400mg of Erythromycin ethyl succinate (EES)
= 250mg of base, or stearate |
>/= 10:
no change
<10: 50-75% of dose at same interval
|
Dose as for CrCl <10ml/min |
|
Erythromycin (IV) |
500mg q6h (severe/life-threatening or
Legionella infxn: 1g q6h)
|
>/= 10:
no change
<10: 500mg q6-8h (maximum 2g/day) |
Dose as for CrCl <10ml/min |
|
Ethambutol (PO) |
15-25mg/kg q24h (maximum 2500mg/day)
(round to nearest 100mg) |
>/= 10:
no change
<10: q48h |
Dose as for CrCl<10, on dialysis days
dose AD |
|
Gatifloxacin (PO)
(Tequin ® )
Back |
400mg q24h |
>/= 40:
no change
<40: 400mg x 1, then 200mg q24h |
400mg initial dose, then 200 mg q24h,
dose AD |
|
Imipenem/Cilastatin (IV)
(Primaxin ® ) |
250mg-1g q6h based on severity of Dx
(maximum dose is 50mg/kg/day or 4g/day,
whichever is lowest , in divided doses)
|
Based on disease severity with ¯ interval
>/= 70:
usual dose q6h
30-70: usual dose q8h
20-30: usual dose q12h
<20: 1/2 usual dose q12h |
125 –250mg q12h, on dialysis days dose AD
|
|
Isoniazid (PO or IV)
Back |
300mg po qd |
No adjustment in renal failure |
No adjustment, on dialysis days dose AD |
|
Levofloxacin (PO or IV)
(Levaquin ® ) |
500mg q24h
(UTI/acute pyelonephritis): 250mg q24h |
>/= 50:
no change
20-49: 500mg x1, then 250mg q24h
10-19: 500mg x 1, then 250m q48h
<10: 500mg x 1, then 125-250mg q48h |
500mg x1, then 250mg q48h, on dialysis days
dose AD
|
|
Linezolid (PO or IV)
Back |
400-600mg q12h |
No adjustment in renal failure |
No adjustment, on dialysis days dose AD |
|
Loracarbef (PO)
(Lorabid ® )
Back |
200-400mg q12h |
>50: no change
10-50: 200-400mg q24h
<10: 200-400mg q3-5 days |
Dose as for CrCl <10ml/min, on dialysis
days dose AD |
|
Meropenem (IV)
(Merrem® ) |
1g q8h
|
>50: no change
26-50: 1g q12h
10-25: 500mg q12h
<10: 500mg q24h |
0.5g q24h, on dialysis days dose AD |
|
Metronidazole (PO or IV)
Back |
500mg q6-8h |
>/= 10:
no change
<10: 500mg q8-12h
adjust for hepatic failure |
Dose as for CrCl <10ml/min, on dialysis
days dose AD |
|
Minocycline (PO
or IV)
(only PO on formulary) |
200mg x 1, then 100mg q12h
|
No adjustment in renal failure |
No adjustment |
|
Moxifloxacin (PO)
(Avelox ® )
Top |
400mg q24h |
No adjustment in renal failure
|
Insufficient data |
|
Nitrofurantoin (PO)
(Macrodantin® )
(Macrobid® , non-formulary)
Back |
Macrodantin® :50-100mg q6h
(UTI prophylaxis: 50-100mg q24h)
(Macrobid® : 100mg q12h) |
>/= 60:
usual dose
<60: avoid usage |
Avoid usage |
|
Nafcillin (IV) |
1-2g q4-6h |
No adjustment in renal failure |
No adjustment |
|
Norfloxacin (PO)
(Noroxin ® ) |
400mg q12h |
>/= 50:
no change
10-50: q 12-24h
<10: q24h |
Dose as for CrCl<10ml/min |
|
Penicillin (IV)
Back |
1-4 mu q4-6h
(may up to q2-3h, max dose 24mu/day) |
>/= 50:
no change
10-50: 1-4 mu q4-6h, OR,
75% of normal dose, same interval
<10: 0.5-2 mu q4-6h, OR,
20-50% of normal dose, same interval |
Dose as for CrCl <10 ml/min, on dialysis
days dose AD |
|
Penicillin V potassium (PO) |
250-500mg q6h |
>/= 10:
no change
<10: 250-500mg q8h |
250-500mg q8h, on dialysis days give dose
AD |
|
Piperacillin (IV)
Back |
12-18g in divided dose q 4 to 6 h: ( 3g q4h
OR 4g q6h) |
>40: no change
20-40: 3-4g q8h
<20: 3-4g q12h |
3 to 4 g q8-12h, on dialysis days dose AD |
|
Piperacillin/Tazobactam (IV) (Zosyn ® ) |
3.375g q6h
(Max. q4h for serious/life-threatening
infxn) |
>/= 40:
no change
20-40: 2.25 q6h
<20: 2.25 q8h |
Maximum dose of 2.25 q8h, supplemental dose
of 0.75g AD |
|
Pyrazinamide (PO)
Back |
15-30mg/kg po q24h
(maximum 2g per day) |
>10: no change
<10: 12-25mg/kg q24h
(Caution: impairs urate excretion. May
precipitate gout) |
Avoid if possible. If unavoidable, 40mg/kg
3x/week OR 60mg/kg 2x/week, given 24 hrs prior to each dialysis |
|
Quinupristin/Dalfopristin (IV) (Synercid ®
) |
7.5mg/kg q8h ( vancomycin-resistant E. faecium)
|
No adjustment in renal failure |
No data |
|
Rifampin (PO or IV)
Back |
600mg q24h |
>/= 10:
no change
<10: May give 1/2 usual dose |
Same as for Crcl <10
ml/min
|
|
Tetracycline (PO) |
250-500mg po q6h |
>/= 50:
no change
10-50: q12-24h
<10: q24h
** Avoid if possible due to risk of
liver toxicity- use doxycyline instead at usual doses |
Dose as for CrCl <10 ml/min
**Avoid use- give doxycyline instead at
usual doses |
|
Ticarcillin (IV)
Back
|
3g q4h |
>60: no change
30-60: 2g q4h
10-30: 2g q8h
<10: 2g q12h
<10 and hepatic dysfx: 2g q24h |
1-2g q12h , supplement 3g AD |
|
Ticarcillin/Clavulanate
(IV) (Timentin ® )
Back |
3.1 q4h |
>60: no change
30-60: 2g q4h or 3.1g q8h
10-30: 2g q8h or 3.1g q12h
<10: 2g q12h
<10 and hepatic dysfx: 2g q24h
(based on ticarcillin component) |
2g q12h, supplement 2gm AD
(based on ticarcillin component) |
|
TMP/SMX* (PO)
(Bactrim ® , Septra ® )
Single strength (SS) = 80mg TMP/400mg SMX
Double strength (DS) = 160mg TMP/ 800mg SMX
Back |
Non-PCP: one tablet ( regular or double
strength) every 12 hours
PCP treatment : same as for IV dose
PCP prophylaxis: one DS tablet three times
weekly or daily |
Non PCP:
>30: no change
15-30: one DS tablet 24h OR one SS
tablet q12h
<15: (Avoid if possible) one tablet (SS
or
DS q24h
PCP:
Same as IV dose for PCP below– round to
nearest 160mg or TMP component |
Avoid if possible.
If unavoidable, give one SS/DS q24h.
On dialysis days dose AD |
|
TMP/SMX* (IV)
Back |
Non-PCP: 10mg/kg/day ( based on TMP
component) divided q6h or q8h or q12h
PCP: 15-20mg/kg/day (based on TMP
component) divided q6h |
Non-PCP:
>/= 30:
no change
15-30: 5 mg/kg/day q12h
<15: 2.5mg/kg q24h (Avoid if possible
due to risk of crystalluria/
nephrolithiasis)
PCP:
>/= 50:
no change
15-30: 5mg/kg q12h
<15: 5mg/kg q24h (Avoid if possible
due to risk of crystalluria/
nephrolithiasis) |
Avoid if possible.
If unavoidable, give 5mg/kg q24h.
On dialysis days dose AD |
|
Trimethoprim (PO)
Back |
100mg q12h , or 200mg q24h |
>/= 30:
no change
<30: 100mg q24h |
100mg q24h, on dialysis days dose AD |
| *AD=
after dialysis, CAP= community-acquired pneumonia, CrCl=
creatinine clearance, Fx= function, HD= hemodialysis, MD=
maintenance dose, PID= pelvic inflammatory disease, Pt=
patient, SMX= sulfamethoxazole, TMP= trimethoprim, Tx=
treatment, Uncomp=uncomplicated |
