Antimicrobial Dosing in Intermittent & Continuous Hemodialysis

These dosing recommendations are meant as guidance based on available literature and should not replace clinical judgement. Antimicrobial dosing should take into account factors specific to the patient (weight, renal function), antimicrobial (pharmacokinetics, pharmacodynamics, toxicity) and disease-state.

Intermittent HD assumes high-flux hemodialysis. CRRT assumes CVVHD with ultrafiltration rate 2L/h and residual native GFR < 10 mL/min.

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77 Drugs

Acyclovir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Non-CNS HSV Infections 2.5 mg/kg IV x1 now, then qPM 5 mg/kg IV q24h
HSV encephalitis/ Disseminated VZV 5 mg/kg IV x1 now, then qPM 10 mg/kg IV q12h

Dosing weights for acyclovir are controversial. The original package insert recommends dosing on ideal body weight in obesity.  Subsequent studies suggest adjusted body should be used to reduce risk of underdosing.  We recommend initial use of adjusted body weight in obesity with careful monitoring of renal function and mental status with potential for dose reduction as needed.

 


AmBisome (liposomal amphotericin B)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Invasive fungal infections 5 mg/kg IV q24h 5 mg/kg IV q24h
Prophylaxis (heme/BMT) 3 mg/kg IV q24h 3 mg/kg IV q24h

*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


Amoxicillin/clavulanate

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 500/125 mg PO x1 now, then qPM 500/125 mg PO q12h

Ampicillin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Uncomplicated Infection 2 g IV x1 now, then qPM 2 g IV q8h
Meningitis or endovascular infection 2 g IV q12h 2 g IV q6h

Ampicillin/sulbactam (Unasyn)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 3g IV q12h 3g IV q6h

Carbapenem-resistant 

Acinetobacter baumannii

3g IV q12h 3g IV 4h

Artesunate

Indication HD or CRRT
All Indications 2.4 mg/kg IV at 0 hours, 12 hours, and 24 hours, followed by 2.4 mg/kg IV q24h

Azithromycin

Indication Dose Notes
Community-acquired pneumonia, ICU 500 mg IV/PO q24h No adjustment for dialysis
Community-acquired pneumonia, non-ICU 500 mg IV/PO x1 then 250 mg IV/PO q24h

Aztreonam

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2 g IV x1 now, then qPM 2 g IV q12h

Aztreonam lacks cross-reactivity with most other beta-lactams; however, most patients who have a recorded beta-lactam allergy can receive another beta-lactam through screening, test dosing, or skin testing. See Inpatient Allergy Guidelines


Baloxavir marboxil

Indication Dosage Notes
Influenza treatment, uncomplicated, 40-79kg 40 mg PO x1 No dose adjustment in hemodialysis
Influenza treatment, uncomplicated, >80kg 80 mg PO x1

Cefazolin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications

2 g IV x1 now and post-HD

Alternative dosing for patients on stable hemodialysis schedule: 2 g IV / 2 g IV / 3 g IV post-HD

3 g given prior to 72hr intradialytic period; for example, after Friday dialysis for pts on MWF schedule

2 g IV q12h

Cefepime

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications

2 g IV x1 now and post-HD

Alternative dosing for patients not on stable hemodialysis schedule: 1 g x1 now, then qPM

1 g IV q8h*

*May infuse over 4 hours (extended infusion dosing) if recommended by ID, ID pharmacy, or clinical pharmacy for select populations. A loading dose (over 30 minutes) may be considered when initiating therapy in select patients. If a loading dose is given, start maintenance dose 4 hours after loading dose.


Cefiderocol

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 750 mg IV q12h over 3 hours

Effluent flow rate 2 L/hr or less: 1.5 g IV every 12 hours over 3 hours

Effluent flow rate 2.1 - 3 L/hr: 2 g IV every 12 hours over 3 hours

Effluent flow rate 3.1 - 4 L/hr: 1.5 g IV every 8 hours over 3 hours

Effluent flow rate > 4 L/hr: 2 g IV every 8 hours over 3 hours


Cefoxitin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Standard dosing, NTM infection 1 g q24h (on days of HD, give after HD) 2 g IV q8h*

*Limited data exist for CRRT dosing. Consider alternative antibiotic. May dose for CrCl 30 to 50 mL/minute if necessary.


Ceftaroline

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Skin/Soft Tissue Infections or Community-acquired Pneumonia with low MRSA risk 200 mg IV q12h 400 mg IV q12h
Severe Infections, Pneumonia with documented or suspected MRSA 200 mg IV q8h 600 mg IV q12h

Serious infections: ceftaroline dosed q12h may be an option in certain situations for CrCl < 50 mL/min and in iHD. Contact ID pharmacy for assistance. 


Ceftazidime

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 1 g IV x1 now and post-HD 2 g IV q12h*

*May infuse over 4 hours (extended infusion dosing) if recommended by ID, ID pharmacy, or clinical pharmacy for select populations. A loading dose (over 30 minutes) may be considered when initiating therapy in select patients. If a loading dose is given, start maintenance dose 4 hours after loading dose.


Ceftazidime/avibactam (Avycaz)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications

0.94 g IV x1 now then qPM

Alternative for minimal residual kidney function & less severe infections: 0.94 g IV q48h in evening

2.5 g IV q8h

Ceftolozane/tazobactam (Zerbaxa)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Complicated urinary tract infection 750 mg IV x1, then 150 mg IV q8h No data
Pneumonia, severe infections 2.25 g IV x1, then 450 mg IV q8h No data

Ceftriaxone

Indication Dose Notes
Standard dose 1 g IV q24h

 

No dose adjustment for hemodialysis

Serious Infections, Non-enterococcal Endocarditis, Osteomyelitis, Septic Arthritis, Epidural Abscess, Intra-abdominal Infections, Liver Abscesses, Septic Shock 2 g IV q24h 

Meningitis & Enteroccocal Endocarditis (in combination with ampicillin)

2 g IV q12h

Cefuroxime axetil

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All indications 250 mg PO daily No data

Cephalexin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Most Indications 250 mg PO BID No data
Uncomplicated Cystitis or Streptococcal Pharyngitis 250 mg PO daily No data

Cidofovir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications Minimal data; consult ID pharmacy for assistance

IV Fluids: Give 1L NS over 30 minutes prior to cidofovir administration.  If able to tolerate, give an additional 1L NS at the start or immediately after cidofovir administration.

Probenecid: 2g PO 3 hours prior to cidofovir, then 1g PO 2 and 8 hours after cidofovir (total 4g)


Ciprofloxacin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 400 mg IV qPM or 500 mg PO qPM 400 mg IV q8h or 500 mg PO q12h

Clindamycin

Indication Dose Notes
Uncomplicated Infection

600 mg IV q8h

450 mg PO q8h

 

No dose adjustment in hemodialysis

Necrotizing Soft Tissue Infection & Group A Streptococcus Infection, Pelvic Inflammatory Disease 900 mg IV Q8h

Clofazimine

Indication Dosing Notes
All Indications 100 mg PO q24h No adjustment for dialysis

Colistin IV

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All IV Indications 5 mg/kg IV x1 loading dose, then contact ID pharmacy for dosing recommendations

Dosing for inhaled colistin per primary team protocols

Other more effective, less-toxic agents are available for most serious Gram-negative rod infections.  In cases where an IV polymyxin is necessary, polymyxin B should be used preferentially for non-urinary tract infections in adults.


Dalbavancin

Indication Dose Notes
Complicated Gram-positive infections (e.g. Native osteomyelitis)* 1500 mg IV on days 1 & 8 No dose adjustment necessary for hemodialysis

*ID consult highly recommended for patient-specific recommendations.​

*For dosing in other complicated indications, contact ID or ID pharmacy.

Other dosing strategies used for treatment of bone/joint infections or bacteremia.


Daptomycin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis*
All Indications

8-10 mg/kg IV x1 now and post-HD

Alternate for patients not on stable dialysis schedule: 8-10 mg/kg IV q48h

6 mg/kg IV q24h** or 8-10 mg/kg IV q48h

*These recommendations have not been evaluated for patients receiving continuous renal replacement therapy other than CVVHD (ex. CVVH). 

**Consider this dose for patients receiving high ultrafiltration rates (ex. CVVHD > 2L/hr) and/or patients with severe infections (ex. endocarditis) and/or receiving combination therapy (ex. with ceftaroline). ID pharmacy guidance is strongly recommended for complex cases and/or use in combination therapy.

*If Total BW >1.2 times ideal body weight, use adjusted body weight

Not effective in treatment of pneumonia.


Doxycycline

Indication Intermittent Hemodialysis Continuous Hemodialysis*
All indications 100 mg IV/PO q12h (No adjustment for hemodialysis) 100 mg IV/PO q12h (No adjustment for hemodialysis)

Eravacycline

Indication Dosing Notes
All Indications

1mg/kg IV q12h

Concomitant strong CYP3A4 Inducers: 1.5 mg/kg IV q12h

No dose adjustment for hemodialysis

Severe hepatic impairment: 1 mg/kg IV q12h x2 doses, then 1 mg/kg IV q24h


Ertapenem

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications

500 mg IV x1 now then qPM

Alternate: 500 mg - 1 g IV x1 now, then post-HD*

1 g IV q24h

*Post-HD dosing strategy should be used on a case-by-case basis after careful consideration of the benefits of post-HD only dosing and risks of ertapenem toxicity. Consider 500 mg dose in advanced age and low body weight (< 40 kg). Consult ID pharmacy for guidance.


Ethambutol

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 20-25 mg/kg PO x1 now and post-HD 15-20 mg/kg PO q24h

Drug is available in 400mg and 100mg tablets.

This dosing aligns with current practices at the SFDPH TB Clinic (as of 5/2023) for treatment of tuberculosis. For patients in other counties, contact the respective TB clinics for dosing recommendations. 


Fecal microbiota spores, live—brpk (Vowst)

Indication

Dose

Notes 
Secondary prevention from C. difficile infection

Take  4 capsules taken orally once daily for 3 consecutive days - 

Refer to prescribing information for administration considerations

No renal adjustment

Fidaxomicin

Indication Dosing Notes
Clostridioides difficile infection 200 mg PO q12h No adjustment for hemodialysis

Fluconazole

Indication Intermittent Hemodialysis Continuous Hemodialysis*
Oropharyngeal Infection 100 mg IV/PO x1 now, then post-HD 200 mg IV/PO q24h
Esophageal Infection 200 mg IV/PO x1 now, then post-HD 400 mg IV/PO q24h
Severe Infections

400 mg IV/PO x1 now, then post-HD

 

800-1200 mg IV/PO per day, divided q12-24h

*Data suggests that fluconazole clearance in patients receiving CVVHD is higher than in patients with normal renal function, necessitating use of higher dosing. These recommendations have not been evaluated for other continuous renal replacement modalities (ex. CVVH) and may not apply. 


Flucytosine

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 25 mg/kg PO x1 now and post-HD No data; consult ID pharmacy

Ganciclovir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
CMV Treatment 1.25 mg/kg IV x1 now and post-HD 2.5 mg/kg IV q12h*
CMV Prophylaxis 0.625 mg/kg IV x1 now and post-HD 2.5 mg/kg IV q24h

*Higher or more frequent doses may be warranted for higher CVVHD flow rates. Lower frequency may be indicated for lower CVVHD flow rates.


Gentamicin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2 mg/kg IV x1, then 1 mg/kg IV post-HD 2 mg/kg IV x1 then 1.5 mg/kg IV q24h

*If Total BW > 1.2 times Ideal BW, use Adj BW.

Monitoring:

Indication

Monitoring

Gram-positive synergy Paired levels: Check peak drug level 30 minutes after end of infusion (goal 3-4 mg/L) and trough immediately before next dose (goal <1 mg/L)
Gram-negative high-dose extended interval ("once-daily")

Single level: Check random drug level 6-14 hours after the start of infusion.  Compare to nomogram below.

Paired levels: Check peak drug level 1 hour after end of infusion and random level 6-14 hours after infusion.  Consult ID pharmacy for assistance.

Gram-negative traditional dosing Paired levels: Check peak drug level 30 minutes after end of infusion (goal 5 - 8 mg/L) and trough level immediately before next dose (goal <2 mg/L).

Hartford Nomogram (7 mg/kg)

 

Urban-Craig Nomogram (5 mg/kg)

 


Imipenem/cilastatin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Gram-negative or Nocardia infections 500 mg IV q12h 1000 mg IV x1 dose, then 250 mg IV q6h
Nontuberculous mycobacterial infections 500 mg IV q12h 1000 mg IV x 1, then 250 mg IV q12h

Imipenem/cilastatin/relebactam

Indication

Intermittent Hemodialysis

Continuous Hemodialysis

All Indications

1.25 g = imipenem 500 mg + cilastatin 500 mg + relebatam 250 mg

500 mg IV q6h No data

Isavuconazole

Indication Dose Notes
All Indications 372 mg IV/PO Q8h x 6 doses (48h), then 372 mg IV/PO Q24h No dose adjustment in hemodialysis

372mg of isavuconazonium=200mg of isavuconazole

372mg of isavucazonium (prodrug) = 200mg of isavuconazole


Isoniazid

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 300mg PO qPM 300mg PO q24h

Any patients with confirmed or suspected active TB disease are required by law to be reported within 1 working day of identification to the TB Control Section.  For more detail see: https://www.sfcdcp.org/tb-control/tuberculosis-information-for-medical-providers/reporting-tb-to-the-health-department/#:~:text=Reporting%20TB%20to%20the%20Health%20Department&text=Call%20(628)%20206-3398,554-3613%20for%20urgent%20reporting


Letermovir

Indication Dosing Notes
All Indications

480 mg IV/PO q24h

With concomitant cyclosoprine: 240 mg IV/PO q24h

No dosing recommendations available for hemodialysis

ZSFG: Non-formulary


Levofloxacin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Standard Dosing 500mg x1, then 250mg IV/PO Q48h 750 mg IV/PO x1, then 250 mg IV/PO q24h
Pneumonia or Pseudomonas infections 750mg x1, then 500mg IV/PO Q48h 750 mg IV/PO x1, then 500 mg IV q24h

Avoid co-administration of the oral formulation with divalent/trivalent cations (e.g. calcium, magnesium, zinc) - separate by at least 2 hours.


Linezolid

Indication Dose Notes
All Indications 600 mg IV/PO q12h No dose adjustment in hemodialysis

Maribavir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications No data; consider using standard 400 mg PO BID No data; consider using standard 400 mg PO BID

Dose increase required when administered with drug metabolizing enzyne inducers.


Meropenem

Indication

Intermittent Hemodialysis

Continuous Hemodialysis (CVVHD)
Standard Dosing 500 mg IV x1 now, then qPM 1 g IV q8h*
Cystic Fibrosis 1000 mg IV x1 now, then qPM 2 g IV q12h*^
Meningitis 1000 mg IV x1 now, then qPM 2 g IV q12h^

*May infuse over 3 hours (extended infusion dosing) if recommended by ID, ID pharmacy, or clinical pharmacy for select populations. A loading dose (over 30 minutes) may be considered when initiating therapy in select patients. If a loading dose is given, start maintenance dose 4 hours after loading dose. Note that extended infusion data in meningitis is limited and may require further discussion with ID/ASP providers.

^If CVVHD flow rate exceeds 2 L/hr, discuss with ID/ASP pharmacy.


Meropenem/vaborbactam

Indication

Intermittent Hemodialysis

Continuous Hemodialysis

All Indications

4 g = meropenem 2 g + vaborbactam 2 g

Adjust dose based on eGFR, dose post-HD No data

Metronidazole

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Standard Dose 500 mg IV/PO Q8h 500 mg IV/PO Q8h
Bacterial vaginosis 500 mg IV/PO Q12h 500 mg IV/PO Q12h
Intra-abdominal infections (excluding C. difficile) 500 mg IV/PO Q12h 500 mg IV/PO Q12h
Vaginal Trichomoniasis 500 mg IV/PO Q12h 500 mg IV/PO Q12h

Micafungin

Indication Dose Notes
Esophageal candidiasis 150 mg IV daily

 

 

Dosage adjustment not required in hemodialysis

Prophylaxis against Candida in patients with HSCT, neutropenia, hematologic malignancy, or solid organ transplant 50-100 mg IV daily

Candidemia

Invasive candidiasis

Empiric treatment, febrile neutropenia

Empiric treatment, non-neutropenic ICU patients

100 mg IV daily

Miltefosine

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Amebic meningoencephalitis

< 45 kg:  50 mg PO twice daily with food

>= 45 kg:  50 mg PO three times daily with food 

(no adjustment for hemodialysis)

< 45 kg:  50 mg PO twice daily with food

>= 45 kg:  50 mg PO three times daily with food 

(no adjustment for hemodialysis)

Leishmaniasis

30-44 kg:  50 mg PO twice daily with food

>= 45 kg:  50 mg PO three times daily with food 

(no adjustment for hemodialysis)

30-44 kg:  50 mg PO twice daily with food

>= 45 kg:  50 mg PO three times daily with food 

(no adjustment for hemodialysis)


Minocycline

Indication Dosing Notes
All Indications 200 mg IV/PO x1, then 100 mg IV/PO q12h No adjustment for hemodialysis

*There may be certain situations that may require higher dosing (200 mg IV/PO q12h).  Speak to ASP/ID pharmacy if needed.


Molnupiravir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications No renal dose adjustment No renal dose adjustment

Moxifloxacin

Indication Dosing Notes
All Indications 400 mg IV/PO q24h No adjustment for renal dysfunction

Nafcillin

Indication Dosing Notes
Meningitis, osteomyelitis, bloodstream infection, or endovascular infection 2 g IV Q4h

No dose adjustment in hemodialysis


Nirmatrelvir/ritonavir (Paxlovid)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications No data No data

Review medications for potential drug interactions.


Nitrofurantoin (Macrobid)

Indication Intermittent Hemodialysis Continuous Hemodialysis
Cystitis Treatment

 

Data limited for dosing in hemodialysis; consider alternatives

Cystitis Prophylaxis

Oritavancin

Indication Dosing Notes
All Indications 1200 mg IV x1 over 3 hours No adjustment for hemodialysis

Oseltamivir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Influenza treatment 30 mg PO x1 now, then post-HD 75 mg PO BID
Influenza prophylaxis 30 mg po x1 dose per week 30 mg po daily

Penicillin G

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Neurosyphilis, meningitis 4 million units IV x1, then 2 million units IV q4h* 3 million units IV q4h
Endovascular, bacteremia 3 million units IV x1, then 2 million units IV q6h 3 million units IV q6h

*Penicillin G Potassium may contain clinically significant amounts of potassium; consider penicillin G sodium instead, if available.


Pentamidine IV

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Pneumocystis pneumonia 4 mg/kg IV q24h (no adjustment for hemodialysis) 4 mg/kg IV q24h (no adjustment for hemodialysis)

*The current prescribing information does not provide specific renal adjustments and may need to consider other dosing outside of these recommendations.   


Piperacillin/tazobactam (Zosyn) EXTENDED INFUSION

Indication

Intermittent Hemodialysis

Continuous Hemodialysis

All Infections, including documented/suspected Pseudomonas 

Exclusion criteria for EXTENDED INFUSION: resistant or intermediate susceptibility organism, cystic fibrosis, peri-procedural areas, insufficient IV access

Use SHORT INFUSION piperacillin/tazobactam

UCSF: Loading dose = 4.5 g IV over 30 min x1, then 4.5 g IV infused over 4h every 8h (starting 4h after loading dose)

ZSFG: Contact ID pharmacy

UCSF: PREFERRED dosing strategy if no exclusions

ZSFG: Available upon ID pharmacy or ID fellow recommendation


Piperacillin/tazobactam SHORT Infusion (SI) (Zosyn)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2.25 g IV q8h

UCSF: Use EXTENDED infusion: Loading dose of 4.5 g IV over 30 minutes x1, then 4.5 g IV over 4h every 8h (starting 4 hr after loading dose)

ZSFG: Contact ID pharmacy

ONLY for patients excluded from EI dosing at UCSF. Exclusion criteria for EI: Resistant or intermediate organism, cystic fibrosis, periprocedural areas, insufficient IV access 


Plazomicin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications Data is limited for all forms of dialysis; consider alternatives or contact ID pharmacy  

If Total BW >1.2 times Ideal BW, use Adjusted BW


Polymyxin B

Indication Dosing Note
All Indications 2.5 mg/kg IV x1, then 1.5 mg/kg IV q12h No dose adjustment for hemodialysis

There are other more effective, less toxic alternatives for most multidrug-resistant Gram-negative infections.  If a polymyxin is required, polymyxin B is preferred for intravenous treatment of systemic infections in adults. For treatment of urinary tract infections, or use via inhalation, use colistin (polymyxin E).


Posaconazole

Indication Dosing Notes
All Indications (IV or Delayed-release tablet) 300 mg IV/PO q12h x 2 doses, then 300 mg IV/PO q24h No dose adjustment in hemodialysis

Take with food.  Posaconazole SOLUTION has more frequent dosing, low bioavailability, and significant food restrictions.  Do not substitute SOLUTION for TABLETS or IV without discussion with ID Pharmacy.

Review medications for potential drug interactions.

Posaconazole trough levels should be obtained in most patients, whether receiving the agent for prophylaxis or treatment of fungal infections.  Trough samples should be obtained 5-7 days after: 
-start of therapy
-change in dose
-change in route of administration
-change in potentially interacting drugs

See UCSF Lab Posaconazole Recommendations  for specifics of monitoring.


Pyrazinamide

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 20-25 mg/kg PO x1 now and post-HD 20-25 mg/kg PO q24h

Remdesivir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 200 mg IV x1 then 100 mg IV q24h 200 mg IV x1 then 100 mg IV q24h

Rifampin

Indication Dosing Notes
Mycobacterial infections 600 mg IV/PO q24h

 

No adjustment in hemodialysis

Prosthetic device infections 300 mg IV/PO q12h
Endocarditis 300 mg IV/PO q8h

Review medications for potential drug interactions.


Sulbactam/durlobactam

Indication

Intermittent Hemodialysis

Continuous Hemodialysis

All indications

2 g = sulbactam 1g + durlobactam 1g

2g IV q12h x 3 doses, followed by 2g IV q24h* No data

*doses should be given after HD 


Tedizolid

Indication Dosing Notes
All Indications 200 mg IV/PO q24h No adjustment for hemodialysis

Tigecycline

Indication Dosing Notes
All Indications 100 mg IV x1, then 50 mg IV q12h

No adjustment for hemodialysis

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

*There may be certain situations that may require higher dosing (200 mg IV x 1, then 100 mg IV q 12h).  Speak to ASP/ID pharmacy if needed.

 


TMP/SMX (trimethoprim/sulfamethoxazole)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Bone and joint infections 2 mg TMP/kg x1 now and qPM 8 mg TMP/kg/day divided Q 8-12h
Systemic GNR Infections, Nocardia, Stenotrophomonas maltophilia 2.5 mg TMP/kg x1 now and qPM 10 mg TMP/kg/day divided q 8-12h
Pneumocystis pneumonia, CNS infections 5 TMP/kg IV x1 now and qPM 15 mg TMP/kg/day IV divided q8h - q12h

Single-strength (SS) tablet contains 80 mg trimethoprim (TMP)

Double-strength (DS) tablet contains 160 mg trimethoprim (TMP)

*May consider Total BW for serious infections


Tobramycin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2 mg/kg IV x1, then 1 mg/kg IV post-HD 2 mg/kg IV x1 then 1.5 mg/kg IV q24h

Valganciclovir (Valcyte)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
CMV Treatment 450 mg PO x1 now and post-HD 450 mg PO q24h
CMV Prophylaxis 450 mg PO twice weekly 450 mg PO q48h

*IV ganciclovir prefferred for initiation of therapy for unstable renal function or in dialysis

Take with food


Vancomycin IV

Refer to UCSF Adult Vancomycin Interim Guidance. ZSFG: Click here for initial dosing guidance.


Vancomycin PO

Indication Dose Notes
Clostridioides difficile infection: non-fulminant 125 mg PO QID No dose adjustment in hemodialysis
Clostridioides difficile infection: fulminant 500 mg PO QID

*Consider additional rectal instillation

See IDMP guidelines for greater detail and vancomycin taper dosing: https://idmp.ucsf.edu/content/management-clostridium-difficile-infection-adults


Voriconazole

Indication Dosing Notes
All Indications, IV Route 6mg/kg IV Q12h x 2 doses, then 4mg/kg IV Q12hr No dose adjustment in hemodialysis

All Indications, PO Route

In obese patients consider a weight-based PO regimen (4mg/kg q12H ADJ BW), Consult ID or ASP for assistance. 

400mg PO Q12h x doses, then 200mg PO Q12 No dose adjustment in hemodialysis

Review medications for potential drug interactions.

Voriconazole has high inter- and intra-patient variability.  Voriconazole trough levels should be obtained in most patients, whether receiving the agent for prophylaxis or treatment of fungal infections.  Trough samples should be obtained 3-5 days after: 
-start of therapy
-change in dose
-change in route of administration
-change in potentially interacting drugs

See UCSF Lab Voriconazole Recommendations  for specifics of monitoring.

Note: The manufacturer recommends avoiding IV voriconazole in patients with renal impairment due to potential accumulation of the excipient sulfobutylether-beta-cyclodextrin, which may lead to kidney injury. However, limited data suggest that patients with baseline kidney impairment may safely receive short durations of IV voriconazole (Kim 2016; Lilly 2013; Neofytos 2012; Oude Lashof 2012).