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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
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CrCl <10 ml/min |
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| 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 | |||
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Amphotericin B Lipid Formulations *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 |
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| Invasive fungal infections | 5 mg/kg IV q24h | No adjustment for renal dysfunction, monitor serum creatinine and electrolytes | |||||
| Prophylaxis (heme-onc) | 3 mg/kg IV q24h | ||||||
| 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 3 g IV q12h |
<15 mL/min 1.5 g IV q24h |
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| 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 |
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*Consider reviewing beta-lactam allergies guideline before use |
2 g IV q8h
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2 g IV q12h | 1 g IV q12h | ||||
| Caspofungin ID-R: UCSF SFGH VASF |
Loading Dose=70 mg x1, then 50 mg IV q24h Severe hepatic dysfunction: 70 mg Loading Dose x1, then 35 mg IV q24h |
No adjustment for renal dysfunction |
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| Cefazolin | >35 mL/min | 10-35 mL/min | |||||
| Gram Negative or Complicated Gram Positive | 2 g IV q8h |
2 g IV q12h
1 g IV a12h |
1 g IV q24h |
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| Uncomplicated Gram Positive | 1 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 |
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Febrile neutropenia, meningitis, Pseudomonas, critically-ill |
2 g IV q8h | 2 g IV q12h | 2 g IV q24h | 1 g IV q24h | |||
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Ceftazidime |
2 g IV q8h |
31-50 mL/min 2 g IV q12 |
15-30 mL//min 2 g IV q24h |
<15 mL/min 1 g IV q24h |
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| Ceftriaxone | |||||||
| Standard Dose (e.g. Pneumonia) | 1 g IV q24h |
No adjustment for renal dysfunction |
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| Meningitis & Enterococcal endocarditis (when combined with ampiciliin) | 2 g IV q12h | ||||||
| Endocarditis & Osteomyelitis | 2 g IV q24h | ||||||
| Ciprofloxacin IV-PO ID-R: VASF |
>30 mL/min 400 mg IV q12h 750 mg PO q12h |
10-29 mL/min 400 mg IV q12h 500 mg PO q12h |
<10 mL/min 200 mg IV q12h 250 mg PO q12h |
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| Pseudomonas infections |
>30 mL/min 400 mg IV q8h |
10-29 mL/min 400 mg IV q12h 500 mg PO q12h |
<10 mL/min 200 mg IV q12h 250 mg PO q12h |
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| Clindamycin ID-R: VASF | 600 mg IV q8h / 450 mg po q8h | No adjustment for renal dysfunction | |||||
| Necrotizing fasciitis & Group A streptococcal infection |
900 mg IV q8h | ||||||
| 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/Adju BW* ID-R: UCSF SFGH VASF *If Total BW >1.2 times ideal body weight, use adjusted body weight Not effective in treatment of pneumonia. |
6 mg/kg IV q24h |
<30 mL/min 6 – 8 mg/kg IV Q48h |
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| MRSA or VRE Bacteremia | 10mg/kg IV q24h |
<30 mL/min 8 – 10 mg/kg IV Q48h
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| 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 |
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| Ethambutol IBW |
15-20 mg/kg PO q24h 40-55 kg: 800 mg 56-75 kg: 1200 mg 76-90 kg: 1600 mg |
<30 ml/min 40-55 kg: 800 mg three times weekly 56-75 kg: 1200 mg three times weekly 76-90 kg: 1600 mg three times weekly |
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| Fluconazole IV-PO | |||||||
| Systemic candidiasis | 400 mg IV/PO q24h | 200 mg IV/PO q24h | 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 |
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| 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 |
<10 mL/min 12.5 mg/kg/dose po Q24h |
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| 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 |
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| Gentamicin IBW* *Use TBW if < IBW. If TBW > 1.2 times IBW, use ABW See also Aminoglycoside Dosing & Monitoring Recommendations
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>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. | |||||||
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>60 mL/min 1.6 mg/kg IV q8h |
40-60 mL/min 1.5 mg/kg IV q12h |
20-40 mL/min 1.5 mg/kg IV q12-24h |
< 20 mL/min 2 mg/kg Loading Dose (Consult pharmacy for maintenance) |
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| 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 |
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| Isoniazid | 300 mg PO q24h | No adjustment for renal dysfunction | |||||
| Levofloxacin IV-PO ID-R: VASF | |||||||
| Urinary tract infections | 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 |
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| 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 |
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| Linezolid IV-PO ID-R: UCSF SFGH VASF | 600 mg IV/PO q12h | No adjustment for renal dysfunction | |||||
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Meropenem |
> 50 mL/min 1 g IV q8h |
26 - 50 mL/min 1 g IV q12h |
10-25 mL/min 500 mg IV q12h |
< 10 mL/min 500 mg IV q24h |
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| 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 | |||||
| Minocycline IV-PO | 200mg IV/PO x1 then 100mg IV/PO q12h | No adjustment for renal dysfunction | |||||
| 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 g IV q6h | ||||||
| Oseltamivir | |||||||
| Influenza treatment (for prophylactic doses see influenza guidelines section) |
> 60 mL/min 75mg PO BID |
31-60 mL/min 30mg PO BID |
10-30 mL/min 30mg PO daily |
No data for ESRD patients not on HD |
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| Penicillin G ID-R: SFGH | |||||||
| Meningitis, endovascular infection | 4 MU IV q4h |
4 MU IV q6h |
4 MU IV q8h |
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| Uncomplicated infection | 2 MU IV q6h |
2 MU IV q8h |
2 MU IV q12h |
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EXTENDED INFUSION Piperacillin/ tazobactam (Zosyn) ID-R: SFGH PREFERRED dosing strategy if no exclusions: resistant or intermediate organism, cystic fibrosis, peri-procedural areas, insufficient IV access Full policy & procedure here |
All infections, including documented/suspected Pseudomonas infections CrCl >= 20 mL/min or CRRT 4.5g IV over 30 minutes x1, then 4.5g IV over 4 hours q8h starting 4h after loading dose |
Use SHORT infusion piperacillin/tazobactam | |||||
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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 q8h |
Non-Pseudomonas infections: 2.25g IV q8h
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| Documented/suspected Pseudomonas infections: | 4.5 g IV q6h for CrCl >20 mL/min |
Documented/suspected Pseudomonas infections: 3.375 g IV q8h |
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| Posaconazole SUSPENSION ID-R: UCSF SFGH VASF Must be administered with high-fat meal or nutritional shake i.e Ensure |
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| Treatment of invasive fungal infections | 400 mg PO q12h or 200 mg PO q6h |
No adjustment for renal dysfunction |
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| Neutropenia/GVHD prophylaxis | 200 mg PO q8h | ||||||
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Posaconazole DELYAED-RELEASE TABLETS 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 |
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Strongly recommended review of concurrent medications due to many potential drug interactions |
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| Mycobacterial infections | 600 mg IV/PO q24h |
No adjustment for renal dysfunction |
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| Prosthetic device infections | 300 mg IV/PO q12h | ||||||
| Endocarditis |
300 mg IV/PO q8h Hold rifampin until negative blood cultures |
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| 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 |
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| Tobramycin | See Gentamicin | ||||||
| TMP/SMX IV-PO, ABW* SS Tablet: 80mg TMP DS Tablet: 160 TMP *May consider TBW for serious infections |
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| 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 | ||||
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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 |
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CMV Prophylaxis |
Refer to individual service protocol | ||||||
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VancomycinTBW |
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VoriconazoleIV-PO, Adj BW Strongly recommended review of concurrent medications due to many potential drug interactions |
IV: 6 mg/kg/dose q12h x 2 doses, then 4 mg/kg/dose Q12h. PO: 400 mg PO q12h x 2 doses, Mild-to-moderate hepatic dysfunction: Consider reduction of maintenance dosage by 50% |
No adjustment for renal dysfunction**
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*In obese patients consider a weight-based PO regimen (4 mg/kg q12h Adj BW), 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 or signs of toxicity; obtain trough level on day 5 of therapy for a new regimen or dose change. |
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