NotationsPath
Acyclovir

Indication

CrCl > 50 mL/min

25 - 50 mL/min

10 - 25 mL/min

< 10 mL/min 

Non-CNS HSV Infections 5 mg/kg IV q8h 5 mg/kg IV q12h 5 mg/kg IV q24h 2.5 mg/kg IV q24h
HSV encephalitis/ Disseminated VZV 10 mg/kg IV q8h 10 mg/kg IV q12h 10 mg/kg IV q24h 5 mg/kg IV q24h

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
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

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.

 

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AmBisome (liposomal amphotericin B)ID-R: ZSFG, ID-R: UCSF
Indication

Dose

Notes

Invasive fungal infections 5 mg/kg IV q24h

No adjustment for renal dysfunction; monitor serum creatinine and electrolytes

Mold prophylaxis (Heme/BMT) 3 mg/kg IV q24h

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
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

*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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AmikacinID-R: UCSF, ID-R: ZSFG
Indication CrCl > 60 mL/min 40 - 60 mL/min 20 - 40 mL/min < 20 mL/min
High-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded 15 mg/kg IV q24h

Use traditional dosing or consult ID pharmacy for guidance

Traditional dosing: patients who do not qualify for high-dose extended interval dosing 5-7.5 mg/kg IV q8h 5-7.5 mg/kg IV q12h 5-7.5 mg/kg IV q24h 5-7.5 mg/kg IV x1 & consult ID pharmacy for maintenance dose

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 5-7.5 mg/kg IV x1, re-dose based on levels Loading dose of 10 mg/kg IV x1, then 7.5 mg/kg IV q24-48h
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

Monitoring

Indication

Monitoring

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 2 hours after and random level 6-14 hours after infusion.  Consult ID pharmacy for assistance.

Traditional dosing Paired levels: Check peak drug level 30 minutes after end of infusion (goal 20-30 mg/L) and trough level immediately before next dose (goal <4 mg/L).

Nomogram:

 

 

 

 

 

 

 

**If amikacin 20 mg/kg is used. Adjust the measured level with the following equation before plotting the level onto the Amikacin 15mg/kg Extended Interval Nomogram Level for the plot = Measured level x 0.75

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Amoxicillin/clavulanate
Indication CrCl > 30 mL/min 10 - 30 mL/min < 10 mL/min
All Indications 875/125 mg PO q12h 500/125 mg PO q12h 500/125 mg PO q24h

Indication

Intermittent Hemodialysis

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

CrCl > 50 mL/min

10 - 50 mL/min

< 10 mL/min

Uncomplicated infection 2 g IV q6h 1 g IV q6h 1 g IV q12h
Meningitis or endovascular infection 2 g IV q4h 2 g IV q6h 1 g IV q8h 

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
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Ampicillin/sulbactam (Unasyn)
Indication CrCl > 30 mL/min

15 – 30 mL/min

< 15 mL/min

All indications 3 g IV q6h 3 g IV q12h 3 g IV q24h

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 3g IV q12h 3g IV q6h
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ArtesunateID-R: UCSF, ID-R: ZSFG
Indication Dose
All Indications 2.4 mg/kg IV at 0 hours, 12 hours, and 24 hours, followed by 2.4 mg/kg IV q24h
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
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AzithromycinIV-PO
Indication Dose Notes
Community-acquired pneumonia, ICU 500 mg IV/PO q24h No adjustment for renal dysfunction
Community-acquired pneumonia, non-ICU 500 mg IV/PO x1 then 250 mg IV/PO q24h
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
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AztreonamID-R: ZSFG
Indication

CrCl > 50 mL/min

10 - 50 mL/min < 10 mL/min
All other indications

2 g IV q8h 

2 g IV q12h 1 g IV q12h  
Meningitis 2 g IV q6h  2 g IV q12h 1 g IV q12h

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

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Baloxavir marboxilID-R: UCSF
Indication Dosage Notes
Influenza treatment, uncomplicated, 40-79kg 40 mg PO x1 No renal dose adjustment
Influenza treatment, uncomplicated, >80kg 80 mg PO x1
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
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Cefazolin
Indication CrCl > 30 mL/min 10 - 29 mL/min < 10 mL/min
Uncomplicated Gram-Positive Infection 1 g IV q8h 1 g IV q12h 1 g IV q24h
Gram-Negative or Complicated Gram-Positive Infection 2 g IV q8h 2 g IV q12h 1 g IV q24h

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
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Cefepime
Indication CrCl > 60 mL/min 30 - 60 mL/min 10 - 29 mL/min < 10 mL/min
Non-severe infections including cystitis 2 g IV q12h 2 g IV q24h 1 g IV q24h 500 mg IV q24h
Severe infections including febrile neutropenia, meningitis, Pseudomonas aeruginosa 2 g IV q8h 2 g IV q12h 2 g IV q24h 1 g IV q24h

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
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CefiderocolID-R: UCSF
Indication CrCl >120 mL/min 60-119 mL/min 30-59 mL/min 15-29 mL/min <15 mL/min
All Indications 2 g IV q6h infused over 3 hours 2 g IV q8h infused over 3 hours 1.5 g IV q8h infused over 3 hours 1 g IV q8h infused over 3 hours 750 mg IV q12h infused over 3 hourse

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

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CeftarolineID-R: UCSF, ID-R: ZSFG
Indication CrCl > 50 mL/min 30-50 mL/min 15-30 mL/min < 15 mL/min
Skin/Soft Tissue Infections or Community-acquired Pneumonia with low MRSA risk 600 mg IV q12h 400 mg IV q12h 300 mg IV q12h 200 mg IV q12h
Severe Infections, Pneumonia with documented or suspected MRSA 600 mg IV q8h 400 mg IV q8h 300 mg IV q8h 200 mg IV q8h

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. 

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CeftazidimeID-R: ZSFG
Indication CrCl > 50 mL/min 31 - 50 mL/min 15 - 30 mL/min < 15 mL/min
All Indications 2 g IV q8h 2 g IV q12h 2 g IV q24h 1 g IV q24h

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 1 g IV x1 now and post-HD 2 g IV q12h
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Ceftazidime/avibactam (Avycaz)ID-R: UCSF, ID-R: ZSFG
Indication CrCl > 50 mL/min 31 - 50 mL/min 16 - 30 mL/min 6 - 15 mL/min < 5 mL/min
All Indications 2.5 g IV q8h 1.25 g IV q8h 0.94 g IV q12h 0.94 g IV q24h 0.94 g IV q48h

 Dosage recommendations are expressed as total grams of the ceftazidime/avibactam combination.

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
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Ceftolozane/tazobactam (Zerbaxa)ID-R: UCSF, ID-R: ZSFG
Indication CrCl >50 mL/min 30-50 mL/min 15-29 mL/min
Complicated urinary tract infection 1.5 g IV q8h 750 mg IV q8h 375 mg IV q8h
Pneumonia, severe infections 3 g IV q8h 1.5 g IV q8h 750 mg IV q8h

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
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Ceftriaxone
Indication Dose Notes
Standard Dose 1 g IV q24h No renal dose adjustment
Serious Infections, Non-enterococcal Endocarditis, Osteomyelitis, Septic Arthritis 2 g IV q24h  No renal dose adjustment

Meningitis & Enteroccocal Endocarditis (in combination with ampicillin)

2 g IV q12h No renal dose adjustment
Indication Dose Notes
Usual dose 1 g IV q24h

 

No dose adjustment for hemodialysis

Endocarditis & Osteomyelitis 2 g IV q24h 

Meningitis & Enteroccocal Endocarditis (in combination with ampicillin)

2 g IV q12h
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Cefuroxime axetil
Indication CrCl >30 mL/min 10-29 mL/min <10 mL/min
All indications 500 mg PO BID 250 mg PO BID 250 mg PO daily

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All indications 250 mg PO daily No data
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Cephalexin
Indication >30 mL/min 15-29 mL/min <15 mL/min
Most Indications 500 mg PO QID or 1000 mg PO TID 250-500 mg PO TID 250-500 mg PO BID
Uncomplicated Cystitis or Streptococcal Pharyngitis 500 mg PO BID 250 mg PO BID 250 mg PO daily

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Most Indications 250 mg PO BID No data
Uncomplicated Cystitis or Streptococcal Pharyngitis 250 mg PO daily No data
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CidofovirID-R: UCSF, ID-R: ZSFG
Indication Criteria to initiate: CrCl >55 mL/min, SCr<1.5 mg/dL, urine protein <100mg/dL Increase in SCr of 0.3-0.4 mg/dL Increase in SCr of >0.5 mg/L or 3+ proteinuria
Systemic Infections: Induction 5 mg/kg IV once weekly WITH probenecid 3 mg/kg IV ever week WITH probenecid Discontinue
Systemic Infections: Maintenance 5 mg/kg IV once every 2 weeks WITH probenecid 3 mg/kg IV every 2 weeks WITH probenecid Discontinue
BK viruria in kidney or bone marrow transplant patients 0.25 - 0.5 mg/kg IV once weekly WITHOUT probenecid

Indication

Intermittent Hemodialysis

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

IV Fluids: Give 1L NS over 1-2 hours 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)

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CiprofloxacinIV-PO
Indication CrCl > 50 mL/min 30 - 50 mL/min < 30 mL/min
 

400 mg IV q12h

500 mg PO BID

400 mg IV q12h

500 mg PO BID

400 mg IV q24h

500 mg PO daily

Pseudomonas infections & bloodstream infections

400 mg IV q8h

750 mg PO q12h

400 mg IV q12h

500 mg PO q12h

400 mg IV q24h

500 mg PO daily

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 400 mg IV qPM or 500 mg PO qPM 400 mg IV q12h or 500 mg PO q12h
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ClindamycinIV-PO
Indication Dose Notes
 

600 mg IV q8h

450 mg PO q8h

No renal dose adjustment
Necrotizing Soft Tissue Infection & Group A Streptococcus Infection 900 mg IV Q8h No renal dose adjustment
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 900 mg IV Q8h
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ClofazimineID-R: ZSFG
Indication Dosing Notes
All Indications 100 mg PO q24h No adjustment for renal function
Indication Dosing Notes
All Indications 100 mg PO q24h No adjustment for dialysis
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Colistin IVID-R: UCSF
Indication Dosing
All IV Indications 5 mg/kg IV x1 loading dose, then contact ID pharmacy for maintenance dose recommendations

ZSFG: Non-formulary

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All IV Indications 5 mg/kg IV x1 loading dose, then contact ID pharmacy for dosing recommendations
Ideal Body Weight when patient weight >120% of ideal body weight

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.

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DalbavancinID-R: UCSF, ID-R: ZSFG
Indication CrCl >30 mL/min <30 mL/min
Single-dose regimen (skin/soft tissue infection) 1500 mg IV x1 dose 1125 mg IV x1 dose
Two-dose regimen (skin/soft tissue infection) 1000 mg IV x1 then 500 mg IV x1 7 days later 750 mg IV x1, then 375 mg IV x1 7 days later
Indication Dose Notes
Single-dose regimen (skin/soft tissue infection) 1500 mg IV x1 dose No dose adjustment necessary for hemodialysis
Two-dose regimen (skin/soft tissue infection) 1000 mg IV x1 then 500 mg IV x1 7 days later

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

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DaptomycinID-R: UCSF, ID-R: ZSFG
Indication CrCl > 30 mL/min < 30 mL/min
All indications 8 – 10* mg/kg IV q24h 8 – 10* mg/kg IV q48h

*Doses up to 12 mg/kg may be indicated in treatment of some VRE infections - confer with ID/ID pharmacy.

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.

Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

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

Not effective in treatment of pneumonia.

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DoxycyclineIV-PO
Indication Dose Notes
All indications 100 mg IV/PO q12h No renal dose adjustment
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)
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EravacyclineID-R: UCSF
Indication Dosing Notes
All Indications

1mg/kg IV q12h

Concomitant strong CYP3A4 Inducers: 1.5 mg/kg IV q12h

No dose adjustment for renal dysfunction

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

ZSFG: Non-formulary

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

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Ertapenem
Indication CrCl > 30 mL/min < 30 mL/min
All indications 1 g IV q24h 500 mg IV q24h

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.

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Ethambutol
Weight CrCl > 30 mL/min < 30 mL/min
30-40 kg 600 mg PO q24h 20-25 mg/kg PO three times weekly
41-50 kg 800 mg PO q24h 20-25 mg/kg PO three times weekly
51-60 kg 1000 mg PO q24h 20-25 mg/kg PO three times weekly
61-70 kg 1200 mg PO q24h 20-25 mg/kg PO three times weekly
71-80 kg 1400 mg PO q24h 20-25 mg/kg PO three times weekly
81-90 kg 1600 mg PO q24h 20-25 mg/kg PO three times weekly
> 91 kg Consult ID or ID pharmacy Consult ID or ID pharmacy

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 20-25 mg/kg PO x1 now and post-HD 15-20 mg/kg PO q24h
Ideal Body Weight when patient weight >120% of ideal body weight

Dose based on ideal body weight. Dosing in obesity (BMI > 30): use lean body weight (see online calculator).

Drug is available in 400mg and 100mg tablets.

This dosing aligns with current practices at the SFDPH TB Clinic (as of 8/2022). For patients in other counties, contact the respective TB clinics for dosing recommendations. 

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FidaxomicinID-R: UCSF, ID-R: ZSFG
Indication Dosing Notes
Clostridioides difficile infection 200 mg PO q12h No adjustment for renal dysfunction
Indication Dosing Notes
Clostridioides difficile infection 200 mg PO q12h No adjustment for hemodialysis
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FluconazoleIV-PO
Indication CrCl > 50 mL/min CrCl 10 - 50 mL/min CrCl < 10 mL/min
Oropharyngeal Infection 100 mg IV/PO q24h 50% of target dose IV/PO q24h 25% of target dose IV/PO q24h
Esophageal Infection 200 mg IV/PO q24h 50% of target dose IV/PO q24h 25% of target dose IV/PO q24h
Systemic/Severe Infections*

≤ 80 kg: 400mg IV/PO q24h

81 – 100 kg: 600 mg IV/PO q24h

> 100 kg: 800 mg IV/PO q24h

50% of target dose IV/PO q24h

25% of target dose IV/PO q24h

*Higher doses may be necessary in some circumstances

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. 

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Flucytosine
Indication CrCl >40 mL/min 20-40 mL/min 10-20 mL/min <10 mL/min
All Indications 25 mg/kg PO q6h 25 mg/kg PO q12h 25 mg/kg PO q24h 25 mg/kg PO q48h

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 25 mg/kg PO x1 now and post-HD No data; consult ID pharmacy
Ideal Body Weight when patient weight >120% of ideal body weight
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FoscarnetID-R: UCSF, ID-R: ZSFG

Refer to Guidelines on Foscarnet Dosing and Monitoring

Refer to Guidelines on Foscarnet Dosing and Monitoring

Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight
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FosfomycinID-R: ZSFG
Indication CrCl > 50 mL/min < 50 mL/min
Uncomplicated cystitis 3 g PO x 1 dose 3 g PO x 1 dose
Complicated cystitis 3 g PO every 2 days x 3 doses 3 g PO every 3 days x 3 doses

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Uncomplicated cystitis 3 g PO x1 dose; administer after HD No data
Complicated cystitis 3g PO every 3 days x3 doses; administer after HD No data
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GanciclovirID-R: ZSFG
Indication CrCl >70 mL/min 50-69 mL/min 25-49 mL/min 10-24 mL/min
CMV Treatment 5 mg/kg IV q12h 2.5 mg/kg IV q12h 2.5 mg/kg IV q24h 1.25 mg/kg IV q24h
CMV Prophylaxis 2.5 mg/kg IV q12h 2.5 mg/kg IV q24h 1.25 mg/kg IV q24h 0.625 mg/kg IV q24h

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
CMV Treatment 1.25 mg/kg IV x1 now and post-HD 2.5-5 mg/kg IV q12-24h
CMV Prophylaxis 0.625 mg/kg IV x1 now and post-HD No data
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight
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Gentamicin

Use traditional dosing or consult ID pharmacy for guidance

Indication CrCl > 60 mL/min 40-60 mL/min 20-40 mL/min <20 mL/min
Gram-positive synergy 1 mg/kg IV Q8h Contact pharmacy for assistance
Gram-negative infections, high-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded.  5-7 mg/kg IV q24h Use traditional dosing or contact pharmacy for assistance
Gram-negative infections, traditional dosing: patients who do not qualify for high-dose extended interval dosing 1.6 mg/kg IV q8h 1.5 mg/kg IV q12h 1.5 mg/kg IV q12-24h 2 mg/kg loading dose IV x1, contact pharmacy for maintenance

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
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

*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)

 

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Imipenem/cilastatinID-R: UCSF, ID-R: ZSFG
Indication CrCl > 60 mL/min 30-60 mL/min 15-30 mL/min < 15 mL/min
Gram-negative or Nocardia infections 500 mg IV q6h 250 mg IV q6h 250 mg IV q8h Use alternative of consult ID pharmacy

Nontuberculous Mycobacteria*

1000 mg IV q12h 500 mg IV q12h 250 mg IV q12h Use alternative or consult ID pharmacy

*Higher doses may be required for elevated imipenem MICs (8-16)

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
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Imipenem/cilastatin/relebactamID-R: UCSF, ID-R: ZSFG
Indication CrCl >90 mL/min 60-90 mL/min 30-60 mL/min 15-30 mL/min

All Indications

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

1.25 g IV q6h 1 g IV q6h 750 mg IV q6h 500 mg IV q6h

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
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IsavuconazoleID-R: UCSF, ID-R: ZSFG, IV-PO
Indication Dose Notes
All Indications 372 mg IV/PO Q8h x 6 doses (total of 48h), then 372 mg Q24h No renal dose adjustment

372mg of isavuconazonium=200mg of 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

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Isoniazid
Indication Dosing Notes
All Indications 300 mg PO Q24h No renal dose adjustment

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

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LetermovirID-R: UCSF
Indication CrCl >10 mL/min <10 mL/min
All Indications

480 mg IV/PO q24h

With concomitant cyclosoprine: 240 mg IV/PO q24h

No dosing recommendations available

ZSFG: Non-formulary

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

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LevofloxacinIV-PO
Indication CrCl > 50 mL/min 20-49 mL/min <20mL/min
Urinary tract infections 500mg IV/PO Q24h 500 mgx1, then 250mg IV/PO Q24h 500mg x1, then 250mg IV/PO Q48h
Other indications 750mg IV/PO Q24h 750mg IV/PO Q48h 750mg x1, then 500mg IV/PO Q48h

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.

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LinezolidID-R: ZSFG, IV-PO
Indication Dose Notes
All Indications 600 mg IV/PO q12h No renal dose adjustment
Indication Dose Notes
All Indications 600 mg IV/PO q12h No dose adjustment in hemodialysis
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MaribavirID-R: UCSF
Indication    
All Indications 400 mg PO BID No adjustment for renal dysfunction

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.

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MeropenemID-R: ZSFG
Indication > 50mL/min 26 - 50 mL/min 10 - 25 mL/min < 10mL/min
Standard Dosing 1 g IV q8h 1 g IV q12h 500 mg IV q12h 500 mg IV q24h
Meningitis, Cystic Fibrosis 2 g IV q8h 2 g IV q12h 1 g IV Q12h 1 g IV q24h

Indication

Intermittent Hemodialysis

Continuous Hemodialysis (CVVHD)
Standard Dosing 500 mg IV x1 now, then qPM 1 g IV q8h
Meningitis, Cystic Fibrosis 1000 mg IV x1 now, then qPM 1 g IV q8h & consult ID pharmacy
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Meropenem/vaborbactamID-R: UCSF, ID-R: ZSFG
Indication eGFR >50mL/min/1.73m2 30-50 mL/min/1.73m2 15-30 mL/min/1.73m2 <15 mL/min/1.73m2

All Indications

4 g = meropenem 2 g + vaborbactam 2 g

4 g IV q8h over 3 hours 2 g IV q8h over 3 hours 2 g IV q12h over 3 hours 1 g IV q12h over 3 hours

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
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MetronidazoleIV-PO
Indication CrCl >10 mL/min CrCl < 10 mL/min
Standard Dose  500 mg IV/PO Q8h 500 mg IV/PO Q12h
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

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
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MicafunginID-R: UCSF
Indication Dose Notes
Esophageal candidiasis 150 mg IV daily

 

 

Dosage adjustment not required in renal or hepatic dysfunction

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
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
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MinocyclineIV-PO
Indication Dosing Notes
All Indications 200 mg IV/PO x1, then 100 mg IV/PO q12h No adjustment for renal dysfunction
Indication Dosing Notes
All Indications 200 mg IV/PO x1, then 100 mg IV/PO q12h No adjustment for hemodialysis
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Molnupiravir
Indication CrCl >50 mL/min CrCl <50 mL/min
All Indications 800 mg PO q12h No renal dose adjustment

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications No renal dose adjustment No renal dose adjustment
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MoxifloxacinID-R: ZSFG, IV-PO
Indication Dosing Notes
All Indications 400 mg IV/PO q24h No adjustment for renal dysfunction
Indication Dosing Notes
All Indications 400 mg IV/PO q24h No adjustment for renal dysfunction
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Nafcillin
Indication Dosing Notes
Meningitis, osteomyelitis, bloodstream infection, or endovascular infection 2 g IV Q4h

 

No renal dose adjustment

Uncomplicated infection 1 g IV Q6h
Indication Dosing Notes
Meningitis, osteomyelitis, bloodstream infection, or endovascular infection 2 g IV Q4h

 

No dose adjustment in hemodialysis

Uncomplicated infection 1 g IV Q6h
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Nirmatrelvir/ritonavir (Paxlovid)ID-R: UCSF
Indication CrCl >60 mL/min 30-60 mL/min <30 mL/min
All Indications 300/100 mg PO BID 150/100 mg PO BID Not recommended

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications No data No data

Review medications for potenital drug interactions.

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Nitrofurantoin (Macrobid)
Indication CrCl > 60 mL/min < 60 mL/min
Cystitis Treatment 100 mg PO q12h Data limited for CrCl<60 mL/min; consider alternatives
Cystitis Prophylaxis 100 mg PO q24h
Indication Intermittent Hemodialysis Continuous Hemodialysis
Cystitis Treatment

 

Data limited for dosing in hemodialysis; consider alternatives

Cystitis Prophylaxis
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OmadacyclineID-R: UCSF
Indication Dosing Notes

All Indications

PO: must fast for at least 4 hours before and 2 hours after dose

200 mg IV x1, then 100 mg IV q24h

450 mg PO daily x2 doses, then 300 mg PO daily

No adjustment for renal dysfunction

Loading doses may not be required when used for non-tuberculous mycobacterial infections

Indication Dosing Notes

All Indications

PO: must fast for at least 4 hours before and 2 hours after dose

200 mg IV x1, then 100 mg IV q24h

450 mg PO daily x2 doses, then 300 mg PO daily

No adjustment for hemodialysis
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OritavancinID-R: UCSF
Indication Dosing Notes
All Indications 1200 mg IV x1 over 3 hours No adjustment for renal dysfunction
Indication Dosing Notes
All Indications 1200 mg IV x1 over 3 hours No adjustment for hemodialysis
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Oseltamivir
Indication CrCl > 60 mL/min 31-60mL/min 10-30mL/min
Influenza treatment 75 mg PO BID 30 mg PO BID 30 mg PO daily
Influenza prophylaxis 75mg PO daily 30mg PO daily 30mg PO every other day

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
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Penicillin G
Indication CrCl > 50 mL/min CrCl 10 – 50 mL/min CrCl < 10 mL/min
Neurosyphilis, meningitis 4 million units IV q4h 3 million units IV q4h 3 million units IV q6h
Endovascular, bacteremia 3 million units IV q4h 3 million units IV q6h 2 million units IV q6h
Less serious infections 3 million units IV q6h 2 million units IV q6h 1 million units IV q6h

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Neurosyphilis, meningitis 2 million units IV q6h 3 million units IV q4h
Endovascular, bacteremia 2 million units IV q8h 3 million units IV q6h
Less serious infection 2 million units IV q12h 2 million units IV q6h
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PeramivirID-R: UCSF
Indication CrCl >50 mL/min 30-50 mL/min 10-30 mL/min <10 mL/min
All Indications 600 mg IV q24h 200 mg IV q24h 100 mg IV q24h 100 mg IV x1, then 15 mg IV q24h

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 100 mg on Day 1, then 100 mg given 2 hrs after each HD session Consult ID pharmacy
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Piperacillin/tazobactam (Zosyn) EXTENDED INFUSIONID-R: ZSFG
Indication CrCl > 20 mL/min <20 mL/min

UCSF: All Infections, including documented/suspected Pseudomonas 

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

ZSFG: Use EXTENDED INFUSION when recommended by ID pharmacist or ID fellow

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) Use SHORT INFUSION piperacillin/tazobactam

See Adult Extended Infusion Piperacillin/Tazobactam Protocol for additional details.

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

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Piperacillin/tazobactam SHORT Infusion (SI) (Zosyn)ID-R: ZSFG
Indication  > 50 mL/min 10 – 50 mL/min < 10 mL/min

UCSF: Use SHORT INFUSION only for patients excluded from EXTENDED INFUSION dosing

ZSFG: Use SHORT INFUSION unless EXTENDED infusion is recommended by ID

Non-Pseudomonas infections

3.375 g IV q6h

3.375 g IV q8h

2.25 g IV q8h
Documented/Suspected Pseudomonas aeruginosa infection

CrCl > 20 mL/min:

4.5 g IV q6h

CrCl < 20 mL/min:

3.375 g IV q8h

 

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 

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PlazomicinID-R: UCSF
Indication CrCl >60 mL/min 30-60 mL/min 15-30 mL/min <15 mL/min
All Indications 15 mg/kg IV q24h 10 mg/kg IV q24h 10 mg/kg IV q48h Not studied

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications Data is limited for all forms of dialysis; consider alternatives or contact ID pharmacy  
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

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

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Polymyxin BID-R: UCSF
Indication Dosing Note
All Indications 2.5 mg/kg IV x1, then 1.5 mg/kg IV q12h No renal dose adjustment
Indication Dosing Note
All Indications 2.5 mg/kg IV x1, then 1.5 mg/kg IV q12h No dose adjustment for hemodialysis
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

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).

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PosaconazoleID-R: UCSF
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 renal dose adjustment (avoid IV if possible in patients with CrCl <50 mL/min due to accumulation of IV vehicle)
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.

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Pyrazinamide
Indication CrCl > 30 mL/min < 30 mL/min
All Indications

20-25 mg/kg PO q24h:

36-39 kg: 750 mg PO q24h

40-50 kg: 1000mg PO q24h

51-59 kg: 1250 mg PO q24h

60-70 kg: 1500mg PO q24h

71-80 kg: 1750 mg PO q24h

> 81 kg: 2000 mg PO q24h

20-25 mg/kg PO three times weekly

Dosing in obesity (BMI > 30): use lean body weight (see online calculator).

Supplied as 500mg tablets

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

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 20-25 mg/kg PO x1 now and post-HD 20-25 mg/kg PO q24h
Ideal Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight
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Remdesivir
Indication CrCl >30 mL/min CrCl <30 mL/min
All Indications 200 mg IV x1 then 100 mg IV q24h No adjustment required; vehicle may accumulate in renal dysfunction - consider risk/benefit

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
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RemdesivirID-R: UCSF
CrCl>30 ml/min CrCl<30 ml/min
200 mg IV x1 then 100 mg IV q24h No dosage required; consider risk/benefit

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
  No adjustment for dialysis No adjustment for dialysis
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Ribavirin
Indication CrCl >50 mL/min <50 mL/min
All Indications

>=75 kg: 800 mg PO q12h

<75 kg: 600 mg PO q12h

Contact ID pharmacy for recommendations

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications Contact ID pharmacy for recommendations
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RifampinID-R: ZSFG, IV-PO
Indication Dosing Notes
Mycobacterial infections 600 mg IV/PO q24h

 

No renal dose adjustment

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

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TedizolidID-R: UCSF, IV-PO
Indication Dosing Notes
All Indications 200 mg IV/PO q24h No adjustment for renal dysfunction
Indication Dosing Notes
All Indications 200 mg IV/PO q24h No adjustment for hemodialysis
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TigecyclineID-R: UCSF
Indication Dosing Notes
All Indications 100 mg IV x1, then 50 mg IV q12h

No adjustment for renal dysfunction

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

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

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TMP/SMX (trimethoprim/sulfamethoxazole)IV-PO
Indication CrCl > 30 mL/min 15-30 mL/min < 15 mL/min
Systemic GNR infections, Nocardia 10 mg TMP/kg/day divided Q6-12h 5 mg TMP/kg/day divided Q6-12h 2.5 mg TMP/kg Q24h
Pnemocytisis pneumonia , CNS infections 15 - 20 mg TMP/kg/day divided Q6 – 12h 7.5-10 mg TMP/kg/day  divided Q12-24h 4 - 5 mg TMP/kg Q24h

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Systemic GNR Infections 2.5 - 5 mg TMP/kg x1 now and qPM 5 - 7.5 mg TMP/kg/day divided q12h
Pneumocystis pneumonia 5 - 10 mg TMP/kg IV x1 now and qPM 10 - 15 mg TMP/kg/day IV divided q6h - q12h
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

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

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Tobramycin

Use traditional dosing or consult ID pharmacy for guidance

Indication CrCl > 60 mL/min 40-60 mL/min 20-40 mL/min <20 mL/min
High-dose extended interval ("once-daily"): patients with normal renal function who are not morbidly obese or fluid overloaded.  7 mg/kg IV q24h Use traditional dosing or contact pharmacy for assistance
Traditional dosing: patients who do not qualify for high-dose extended interval dosing 1.6 mg/kg IV q8h 1.5 mg/kg IV q12h 1.5 mg/kg IV q12-24h 2 mg/kg loading dose IV x1, contact pharmacy for maintenance

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
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

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

Monitoring:

Indication

Monitoring

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.

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). 
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Valganciclovir (Valcyte)
Indication CrCl > 60 mL/min 40 - 59 mL/min 25 - 39 mL/min 10 - 24 mL/min
CMV Treatment 900 mg PO q12h 450 mg PO q12h 450 mg PO q24h 450 mg PO every other day
CMV Prophylaxis 900 mg PO q24h 450 mg PO q24h 450 mg PO q48h 450 mg PO twice weekly

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

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Vancomycin IV
 

Body Weight**

CrCl (mL/min) < 60 kg 60-80 kg 81-100kg > 100kg
>90 mL/min (complicated* infection & age < 65) 750mg IV q8h 1000mg IV q8h 1250mg IV q8h 1500mg IV q8h
>90 mL/min (complicated* infection & age > 65 or uncomplicated infection & age < 65) 1000mg IV q12h 1250mg IV q12h 1500mg IV q12h 1750mg IV q12h
50-90 mL/min 750mg IV q12h 1000mg IV q12h 1250mg IV q12h 1500mg IV q12h

Complicated* & age <65

1000mg IV q8h

15-49 ml/min 750mg IV q24h 1000mg IV q24h 1250mg IV q24h 1500mg IV q24h
<15 ml/min not on dialysis 10-15mg/kg IV x1 then redose according to levels

*Complicated infections: CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis

**Use Total Body Weight for patients <120% of Ideal Body Weight. Use Adjusted Body Weight for patients >120% of Ideal Body Weight.

Recommend loading dose (20-25 mg/kg IV x1) for serious infections including CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis

Use Vancomycin Dosing Calculator (Excel file) for more precise dose calculation and level-based adjustment.

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 15 - 20 mg/kg IV x 1 then 500 mg IV post-HD only 10 - 15 mg/kg IV q24h
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

Round to nearest 250mg increment. Max: 2g/dose

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

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Vancomycin PO
Indication Dose Notes
Clostridioides difficile infection: initial episode, non-fulminant 125 mg PO QID No renal dose adjustment
Clostridioides difficile infection: fulminant 500 mg PO QID*
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

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VoriconazoleID-R: UCSF, ID-R: ZSFG, IV-PO
Indication Dosing Notes
All Indications, IV Route 6mg/kg IV Q12h x 2 doses, then 4mg/kg IV Q12hr Risk/benefit consideration for IV formulation for CrCl<50 mL/min, as IV vehicle accumlates; consider PO

All Indications, PO Route

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

400mg PO Q12h x doses, then 200mg PO Q12* No renal dose adjustment
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
Adjusted Body Weight when patient weight >120% of ideal body weight
Total Body Weight when <=120% of ideal body weight

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).

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