Antimicrobial Dosing in Intermittent & Continuous Hemodialysis

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

Continuous hemodialysis assumes an ultrafiltration rate of 2L/h and dialysate flow rate of 1L/h with CVVHDF and residual native GFR of <10ml/min.

Drug

Intermittent Hemodialysis

Continuous Renal Replacement Therapy

Acyclovir IBW ID-R:VASF

 

     Herpes simplex infections

2.5 mg/kg IV x1 now then 2.5 mg/kg IV qPM 5 mg/kg IV q24h

     HSV encephalitis or herpes zoster

5 mg/kg IV x1 now then 5 mg/kg IV qPM 5-10 mg/kg IV q12-24h
Amphotericin B Lipid Formulations

TBW ID-R: UCSF SFGH VASF

No adjustment for hemodialysis

Monitor electrolytes closely

Ampicillin

1-2 g IV q12h 1-2 g IV q6h
Ampicillin/sulbactam (Unasyn) 1.5-3 g IV q12h 1.5-3 g IV q6h
Aztreonam ID-R: SFGH VASF 1 g x1 then 1 g IV qPM 2 g IV q12h

Caspofungin ID-R: UCSF SFGH VASF

No adjustment for hemodialysis

Increase maintenance dose to 70 mg when given with phenytoin, rifampin, carbamazapine, dexamethasone, nevirapine, efavirenz

Decrease dose maintenance dose to 35 mg IV q24h for severe hepatic dysfunction

Cefazolin 2 g IV x1 then 2 g IV post HD only 2 g IV q12h
Cefepime 2 g IV x1 then 2 g IV post HD only 2 g IV q12h  
Ceftazidime  1 g IV x1 then 1 g IV post HD only 2 g IV q12h
Ceftriaxone No adjustment for hemodialysis 
Ciprofloxacin IV-PO

 400 mg IV qPM/500 mg PO qPM

400 mg IV q12h
Clindamycin

No adjustment for hemodialysis

Colistin IBW ID-R:_____ 5 mg/kg IV x 1 loading dose, then contact ID Pharmacy for maintenance dosing recommendations 

Daptomycin TBW ID-R_____

Not effective in treatment of pneumonia

6-10 mg/kg IV q48h

Consult ID pharmacy for outpatient HD recommendations

8-10 mg/kg IV q48h
Doxycycline IV-PO No adjustment for hemodialysis
Ertapenem 500 mg IV qPM 500 mg IV q24h
Ethambutol IBW 15-25 mg/kg three times weekly post HD 15-25 mg/kg po three times weekly
Fluconazole IV-PO 400 mg IV/PO x1 then 400 mg IV/PO post HD only  400-800 mg IV q24h
Flucytosine (5FC) IBW 12.5- 25 mg/kg/dose PO qPM 12.5-37.5 mg/kg PO q12-24h  
Ganciclovir TBW 1.25 mg/kg IV x1, then 1.25 mg/kg post HD only

2.5-5 mg/kg IV q24h

 

Gentamicin IBW*

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

 

2 mg/kg x1, then 1 mg/kg IV post HD

 

2 mg/kg x1, then 1.5 mg/kg IV q24h

 
Isoniazid  No adjustment for hemodialysis  
Levofloxacin IV-PO          500mg x1, then 250mg IV/PO Q48h

 

750mg x1, then 250-500mg IV/PO Q24h  
Linezolid IV-PO ID-R_____  No adjustment for hemodialysis 
Meropenem 

500mg IV QPM 

1g IV Q8-12h*

*1 g Q8h for CVVHD ultrafiltration rates > 2 L/hr

 
Metronidazole IV-PO  500 mg IV/PO Q8h 
Moxifloxacin IV-PO    No adjustment for hemodialysis    
Nafcillin    No adjustment for hemodialysis     
Penicillin G

1 MU IV Q6h

2 MU IV Q4-6h   
Piperacillin/ tazobactam   2.25g IV Q8h 4.5g IV Q8h or 3.375 g IV Q6h

Posaconazole ID-R____ 

No dosage adjustment for hemodialysis

 
Pyrazinamide IBW   25-35 mg/kg PO three times weekly post-HD

25-35 mg/kg PO three times weekly   

Rifampin

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

 

No adjustment for hemodialysis

 
TigecyclineID-R______     No adjustment for hemodialysis     
  Severe hepatic dysfunction: 100 mg IV x1, then 25 mg IV Q12h  
Tobramycin  See Gentamicin    

TMP/SMX IV-PO, ABW*

SS Tablet: 80 mg TMP

DS Tablet: 160 mg TMP

*May consider TBW for serious infections

 

2.5-5 mg TMP/kg IV/PO QPM 

 

5-7.5 mg TMP/kg/day IV/PO divided Q12-24h

 

VancomycinTBW

Round dose to nearest 250mg increment

Maximum: 2g/dose

  

 

15-20 mg/kg loading dose x1 followed by

500 mg post HD only

 

10-15 mg/kg IV Q24h

 

Monitor trough levels if anticipated duration of therapy is ≥ 3 days.  For intermittent hemodialysis, obtain a pre-dialysis level; target range is 15-25mcg/mL.  For continuous hemodialysis obtain level within 30 minutes before the 4th dose for a new regimen or dose change; target trough is 10-15 mcg/mL in uncomplicated infections, 15-20 mcg/mL for patients with serious MRSA infections (i.e. CNS infections, endocarditis, pneumonia, bacteremia, or osteomyelitis). ID consult recommended for serious MRSA infections.

 

 

VoriconazoleIV-PO, ABW ID-R_____

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

 

 No dosage adjustment for hemodialysis**

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

**IV formulation should be avoided if possible in patients with CrCl<50 mL/min due to the accumulation of the IV vehicle, which is not substantially removed by hemodialysis.

Recommend monitoring trough levels with serious infections.  Consult ID or ASP for assistance with monitoring parameters.