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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78 Drugs
Acyclovir IV
|
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 |
| Prophylaxis for Heme-BMT patients |
62.5 mg/m2/dose IV q 24h |
125 mg/m2/dose 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.
Acyclovir PO
|
Indication |
Intermittent Hemodialysis |
Continuous Hemodialysis |
|---|---|---|
| Immunocompromised Prophylaxis | 200 mg PO daily |
Insufficient data; contact ID pharmacy for more information |
| HSV Infection | 200 mg PO q12h | |
| VZV Infection | 800 mg PO q12h | |
| Consider supplemental dose after hemodialysis |
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 |
|---|---|---|
| UTI, chorioamnionitis, latency antibiotics for PPROM | 2 g IV x1 now, then qPM | 2 g IV q8h |
| Other infections | 2 g IV q12h | 2 g IV q6h |
| GBS prophylaxis |
2 g IV x 1 followed by 1 gram IV q12h |
2 g IV x 1 followed by 1 gram 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 infused over 3 hours Alternative for minimal residual kidney function & less severe infections: 0.94 g IV q48h in evening infused over 3 hours |
2.5 g IV q8h infused over 3 hours |
Ceftolozane/tazobactam (Zerbaxa)
|
Indication |
Intermittent Hemodialysis |
Continuous Hemodialysis |
|---|---|---|
| Complicated urinary tract infection | 750 mg IV x1 (infused over 3 hours), then 150 mg IV q8h (infused over 3 hours) | No data |
| Pneumonia, severe infections | 2.25 g IV x1 (infused over 3 hours), then 450 mg IV q8h (infused over 3 hours) | 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 |
Therapeutic drug monitoring may be utilized under the guidance of SF TB Clinic, ID, and/or ID/ASP Pharmacy. Higher dosing may be required.
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 |
| Prophylaxis for Heme-BMT patients | 200 mg IV/PO x1 then post-HD | 400 mg IV/PO q 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 |
Use conventional/traditional dosing Consult pharmacy to assist |
Consult pharmacy to assist with dosing strategy |
Advise caution in individuals with myasthenia gravis. Aminoglycosides should never be used as monotherapy except in the setting for a urinary tract infection (UTI).
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 |
1 g IV q12h (on HD days, administer one of the two doses after HD) | 2 g IV q8h |
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 |
* Micafungin can be used as an alternative to azole prophylaxis in the setting of drug interaction or hepatotoxicity beyond these lab thresholds: AST or ALT > 3x ULN with new symptoms OR AST or ALT >5 x ULN OR T bilirubin ≥ 3 mg/dL
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, necrotizing SSTI, toxic shock syndrome |
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)
|
Indication |
Intermittent Hemodialysis |
Continuous Hemodialysis |
|---|---|---|
|
UCSF: All Infections, including documented/suspected Pseudomonas UCSF: Exclusion criteria for EXTENDED INFUSION: resistant or intermediate susceptibility organism, cystic fibrosis, peri-procedural areas, insufficient IV access |
2.25 g IV q8h (SHORT infusion over 30 minutes) |
UCSF: Loading dose = 4.5 g IV over 30 min x1, then 4.5 g IV infused over 4h every 8h (starting immediately after loading dose) ZSFG: 4.5 g IV q8h (SHORT infusion over 30 minutes) |
UCSF: Extended infusion is the PREFERRED dosing strategy if no exclusions
ZSFG: Available upon ID pharmacy or ID fellow recommendation
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 |
Rifabutin
| Indication | Intermittent hemodialysis | Continuous hemodialysis |
|---|---|---|
| Mycobacterial infections | No data | No data |
Review medications for potential drug interactions.
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 |
| Prophylaxis for Pneumocystis pneumonia (Heme-BMT) | 1 SS tablet thrice weekly | 1 DS tablet thrice weekly |
| Prophylaxis for Pneumocystis pneumonia (SOT) | 1 DS tablet thrice weekly | |
*Certain clinical situations may require double coverage. If this is being considered, please contact adult ID or adult ASP.
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
Valacyclovir
|
Indication |
Intermittent Hemodialysis |
Continuous Hemodialysis |
|---|---|---|
| HSV Infection |
500 mg PO qPM |
Insufficient data; contact ID pharmacy for more information |
| VZV Infection | ||
| Immunocompromised Prophylaxis |
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).