Adult Antimicrobial Dosing, Non-dialysis

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Creatinine Clearance Calculator & Ideal Body Weight Calculator (powered by MDCalc)

Notations: ID-R: restricted antimicrobial (follow link for details) IV-PO: similar drug levels obtained with IV or PO administration

Dosing Weights: IBW=ideal body weight (use TBW if IBW is greater than patient's weight) ABW=adjusted body weight  TBW=total body weight

 Drug

 CrCl >50 mL/min

  CrCl 10-50 mL/min

 CrCl <10 ml/min 

Acyclovir IBW ID-R: VASF        
     Herpes simplex infections 5 mg/kg/dose IV q8h

25-50 mL/min

5 mg/kg/dose IV q12h

10-25 mL/min

5mg/kg/dose IV q24h

2.5 mg/kg IV q24h
     HSV encephalitis/Herpes zoster  10 mg/kg/dose IV q8h

25-50 mL/min

10 mg/kg/dose IV q12h

10-25 mL/min

10mg/kg/dose IV q24h

5 mg/kg IV q24h

Amphotericin B Lipid Formulations

TBW/ABW*  ID-R: UCSF SFGH VASF

    *Use Total Body Weight if Total Body Weight < Ideal Body Weight.  If Total Body Weight >1.2 times Ideal Body Weight, use Adjusted Body Weight

     IV Fluids: Give 500mL Normal Saline before and after AmBisome administration if able to tolerate

     Invasive fungal infections 3 - 5 mg/kg IV q24h No adjustment for renal dysfunction
     Prophylaxis (heme-onc) 1 mg/kg IV q24h    No adjustment for renal dysfunction
Ampicillin        
     Meningitis or endovascular infection 2 g IV q4h 2 g IV q6h 1 g IV q8h  
     Uncomplicated Infection 2 g IV q6h 1 g IV q6h 1 g IV q12h
Ampicillin/sulbactam

>30 mL/min

3 g IV q6h

15-30 mL/min

1.5 g IV q6h

<15 mL/min

1.5 g IV q12h  

Azithromycin

Community acquired pneumonia

ICU: 500mg IV/PO q24h

Non-ICU: 500mg IV/PO x1 then 250mg IV/PO q24h

 

No adjustment for renal dysfunction

Aztreonam ID-R: SFGH VASF 2 g IV q8h  2 g IV q12h  1 g IV q12h  
Caspofungin ID-R: UCSF SFGH VASF

Loading Dose=70 mg x1, then 50 mg IV q24h
Increase maintenance dose to 70 mg when given with phenytoin, rifampin, carbamazapine, dexamethasone, nevirapine, efavirenz   

Severe hepatic dysfunction: 70 mg Loading Dose x1, then 35 mg IV q24h

 

 No adjustment for renal dysfunction

Cefazolin        
     Gram Negative or Complicated Gram Positive 2 g IV q8h

 

1 – 2 g IV q12h

 

1 g IV q24h

     Uncomplicated Gram Positive 1 – 2 g IV q8h
 Cefepime ID-R: SFGH VASF

> 60 mL/min

2 g IV q12h

30-60 mL/min

2 g IV q24h

10-29 mL/min

1 g IV q24h

<10 mL/min

500 mg IV q24h

     Febrile neutropenia, meningitis, Pseudomonas, critically-ill 

2 g IV q8h 2 g IV q12h 2 g IV q24h 1 g IV q24h 

Ceftazidime

ID-R: SFGH VASF

 

2 g IV q8h

31-50 mL/min

2 g IV q12

15-30 mL//min

2g IV q24h

<15 mL/min

500 mg IV q24h

Ceftriaxone        
     Standard Dose (e.g. Pneumonia) 1 g IV q24h

 

No adjustment for renal dysfunction

     Meningitis 2 g IV q12h
     Endocarditis & Osteomyelitis 2 g IV q24h   
Ciprofloxacin IV-PO  ID-R: VASF

>30 mL/min

400 mg IV q12h

500-750 mg PO q12h

10-30 mL/min

200-400 mg IV q12h

250-500 mg PO q12h

<10 mL/min

200 mg IV q12h

250 mg PO q12h

     Pseudomonas infections

>30 mL/min

400 mg IV q8h
750 mg PO q12h

10-30 mL/min

200-400 mg IV q12h

250-500 mg PO q12h

<10 mL/min

200 mg IV q12h

250 mg PO q12h

Clindamycin ID-R: VASF  600 – 900 mg IV q8h   No adjustment for renal dysfunction
Colistin IBW ID-R: UCSF SFGH VASF 5 mg/kg IV x 1 loading dose, then contact ID Pharmacy for maintenance dosing recommendations    
Daptomycin TBW ID-R: UCSF SFGH VASF

Not effective in treatment of pneumonia.  Round dose to nearest 250mg increment.

6 – 10 mg/kg IV q24h
Dose depends on indication & pathogen

<30 mL/min

6 – 10 mg/kg IV Q48h

Doxycycline IV-PO 100 mg IV/PO q12h   No adjustment for renal dysfunction
Ertapenem

 >30 mL/mIn

1 g IV q24h

<30 mLmin

500 mg IV q24h

Ethambutol IBW

15-20 mg/kg PO q24h

40-55 kg: 800 mg

56-75 kg: 1200 mg

76-90 kg: 1600 mg

<30 mlLmin

15-25 mg/kg PO three times weekly

Fluconazole IV-PO      
     Candidiasis 100–400 mg IV/PO q24h 50 – 200 mg IV/PO q24h 50 -100 mg IV/PO q24h
         Oropharyngeal 100 mg IV/PO q24h
         Esophageal 200 mg IV/PO q24h
    Severe Infections

<= 80kg: 400 mg IV/PO q24h

81-100kg: 600mg IV/PO q24h

>100kg 800mg IV/PO q24h

Flucytosine (5FC)IBW

> 50 mL/min

25 mg/kg/dose PO q6h

25-50 mL/min 

25 mg/kg/dose PO q12h

10-25 mL/min

25 mg/kg/dose
PO q24h

<10 mL/min

12.5 mg/kg/dose po Q24h

Ganciclovir TBW ID-R: SFGH VASF

> 70 mL/min 

5 mg/kg/dose IV q12h

50 - 69 mL/min

2.5 mg/kg/dose IV q12h 

25-49 mL/min

2.5 mg/kg/dose IV q24h

10-24 mL/min

1.25 mg/kg/dose IV 

Gentamicin IBW*

*Use TBW if < IBW. If TBW > 1.2 times IBW, use ABW

See also Aminoglycoside Dosing & Monitoring Recommendations

    

>60 mL/min

7mg/kg/dose IV Q24h

See Below
Use once-daily dosing in patients with normal renal function, who are not morbidly obese or fluid overloaded. Check serum drug level 6-14 hours after start of infusion. Consult pharmacy or ID pharmacy for level interpretation or see Aminoglycoside Dosing & Monitoring Recommendations
Use traditional dosing regimen for patients who do not qualify for once-daily dosing.

>60 mL/min

1.6 mg/kg IV q8h

40-60 mL/min

1.2 - 1.5 mg/kg IV q12h

20-40 mL/min

1.2 - 1.5 mg/kg IV q12-24h

< 20 mL/min

2 mg/kg Loading Dose (Consult pharmacy for maintenance)

In traditional dosing for gram (-) infections, monitor peak (5-8 mg/L) and trough (< 2 mg/L) levels.
Lower doses of 1 mg/kg q8h are used for gram (+) synergy; monitor peak (3-4 mg/L) and trough (< 1 mg/L).  See also Aminoglycoside Dosing & Monitoring Recommendations
Isoniazid 300 mg PO q24h No adjustment for renal dysfunction 
Levofloxacin IV-PO ID-R: VASF        
     Urinary tract infections 250-500 mg IV/PO q24h

20-49 mL/min

500 mg x1, then 250 mg IV/PO q24h

<20 mL/min

500 mg x1, then 250 mg IV/PO q48h

     Non-urinary tract infections 750 mg IV/PO q24h

20-49 mL/min

750 mg IV/PO q48h 

<20 mL/min

750 mg x1, then 500 mg IV/PO q48h 

Linezolid IV-PO ID-R: UCSF SFGH VASF 600 mg IV/PO q12h No adjustment for renal dysfunction 
Meropenem
ID-R: SFGH VASF

> 50 mL/min

0.5-1 g IV q8h

26 - 50 mL/min

0.5-1 g IV q12h

10-25 mL/min

0.5 g IV q12h

< 10 mL/min

0.5 g IV q24h

     Meningitis, cystic fibrosis 2 g IV q8h 2 g IV q12h  1 g IV q12h 1 g IV q24h
Metronidazole IV-PO 500 mg IV/PO q8h 500 mg IV/PO q12h
Moxifloxacin IV-PO  ID-R: SFGH VASF 400 mg IV/PO q24h No adjustment for renal dysfunction
Nafcillin        
     Meningitis, osteomyelitis or endovascular infection  2 g IV q4h  No adjustment for renal dysfunction
     Uncomplicated infection  1-2 g IV q6h
Penicillin G ID-R: SFGH          
     Meningitis, endovascular infection 3 - 4 MU IV q4h

 

1 - 2 MU IV q4 - 6h  

 

1 MU IV q6h  

     Uncomplicated infection 2 - 3 MU IV q4 - 6h

EXTENDED INFUSION Piperacillin/ tazobactam (Zosyn)ID-R: SFGH

PREFERRED dosing strategy if no exclusions

Full policy & procedure here

All infections, including documented/suspected Pseudomonas infections

CrCl >= 20 mL/min

4.5g IV over 30 minutes x1, then 4.5g IV over 4 hours q8h starting 4h after loading dose

2.25 g IV q8h

SHORT INFUSION Piperacillin/ tazobactam (Zosyn)ID-R: SFGH

ONLY for patients meeting exclusions for extended infusion

3.375 g IV q6h 3.375 g IV q6-8h 2.25g IV q8h
     Documented/suspected Pseudomonas infections: 4.5 g IV q6h for CrCl  >20 mL/min
Posaconazole SUSPENSION ID-R: UCSF SFGH VASF

Must be administered with high-fat meal or nutritional shake i.e Ensure

       
     Treatment of invasive fungal infections 400 mg PO q12h or 200 mg PO q6h

 

 No adjustment for renal dysfunction

     Neutropenia/GVHD prophylaxis 200 mg PO q8h

Posaconazole TABLETS

ID-R: UCSF SFGH VASF

Take with food

  300mg PO q12h x2 doses, then 300mg po q24h No adjustment for renal dysfunction
Pyrazinamide IBW

20-25 mg/kg PO q24h

40-55 kg: 1000 mg

56-75 kg: 1500 mg

76-90 kg: 2000 mg

<30 mL/min

25-35 mg/kg po three times weekly

Rifampin ID-R: SFGH VASF

Strongly recommended review of concurrent medications due to many potential drug interactions

     
     Mycobacterial infections  600 mg IV/PO q24h      

 

No adjustment for renal dysfunction

     Prosthetic device infections 300 mg PO q12h  
     Endocarditis

300 mg PO q8h   

Hold rifampin until negative blood cultures

Tigecycline ID-R: UCSF SFGH VASF

100 mg IV x 1, then 50 mg IV q12h    

Severe hepatic dysfunction: 100 mg IV x1, then 25 mg IV q12h 

 

No adjustment for renal dysfunction

 
Tobramycin See Gentamicin     
TMP/SMX IV-PO, ABW*

SS Tablet: 80mg TMP

DS Tablet: 160 TMP

*May consider TBW for serious infections

       
     Systemic GNR infections 10 mg TMP/kg/day IV/PO divided q6-12h 5-7.5 mg TMP/kg/day IV/PO divided q12-24h 2.5-5 mg TMP/kg IV/PO Q24h
     Pneumocystis pneumonia 15-20 mg TMP/kg/day IV/PO divided q6-12h 10-15 mg TMP/kg/day IV/PO divided q12-24h 5-10 mg TMP/kg IV/PO q24h

Valganciclovir

    CMV Treatment   

     Induction

     Maintenance

 

 >= 60mL/min

900mg PO q12h

900mg PO q24h

 

 50-59 mL/min

450mg PO q12h

450mg PO q24h

 

25-39 mL/min

450mg PO q24h

450mg PO q48h

 

10-24 mL/min

450mg PO q48h

450mg PO twice weekly

 

 Not recommended; consider IV ganciclovir

    CMV Prophylaxis

    Refer to individual service protocol

VancomycinTBW

See Vancomycin Dosing and Monitoring Recommendations

VoriconazoleIV-PO, ABW

ID-R: UCSF SFGH VASF

Strongly recommended review of concurrent medications due to many potential drug interactions 

400 mg PO q12h x 2 doses,
then 200 mg PO q12h*  

Mild-to-moderate hepatic dysfunction: Consider reduction of maintenance dosage by 50%

No adjustment for renal dysfunction**

 

 

IV dose: LD=6 mg/kg/dose q12h x 2 doses, then 4 mg/kg/dose (ABW) Q12h.

*In obese patients consider a weight-based PO regimen (4 mg/kg q12h ABW), consult ID or ASP for assistance.

**IV formulation should be avoided if possible in patients with CrCl<50 mL/min due to the accumulation of the IV vehicle.

Monitor trough levels for treatment of serious infections, therapy failure, or signs of toxicity; obtain trough level on day 5 of therapy for a new regimen or dose change.