Renal Dosage Adjustment Guidelines For Antimicrobials

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Renal Dosage Adjustment Guidelines for AntimicrobialsThe pharmacists will automatically adjust the doses of any of the antimicrobials included in theprotocol according to the estimated creatinine clearance (generally using the Cockroft-Gaultequation for patients 18 years old and the Schwartz equation for patients 18 years old). Thisprotocol does NOT include patients in the neonatal intensive care unit. For other pediatricpatients less than 1 year of age the pharmacist must discuss the dose adjustment with themedical team who initiated the order. When a change is necessary, the pharmacist will write anew order in the Orders section of the medical record indicating the new dosage “per protocol”and enter the order in Carecast as a protocol (“P”) order. No physician signature will be requiredto authorize the revised dosing order.The adjustments listed in the dosing guidelines will be made unless the physician writes “Do notadjust” when ordering the antimicrobial. For vancomycin and the aminoglycosides, apharmacokinetic consult will be performed by the pharmacist, and the ordering physician will becontacted for dosage changes unless ordered as “pharmacy to dose.” If written as “pharmacy todose” dosing will be ordered by the pharmacist.The most current version of the Renal Dosage Adjustment Guidelines for Antimicrobials andassociated antimicrobial policies can be found online at the antimicrobial stewardship program(ASP) website: www.nebraskamed.com/aspPlease note: If there are no clear recommendations available, the pharmacist will not perform anyautomatic dosage adjustment. Consult with the physician. Accurate estimation of creatinine clearance and glomerular filtration rate from theCockroft-Gault and Schwartz equations require serum creatinine concentrations to be atsteady-state. Acute changes in renal function (indicated by changes in urine output &serum creatinine) render the Cockroft-Gault and Schwartz equations unreliable as serumcreatinine is a delayed indicator of renal function. Furthermore, CrCl calculations may besignificantly overestimated in patients with decreased muscle mass (e.g. elderly,paralysis). The pharmacist should use their clinical judgment regarding these changesand communicate their recommendations with the team as appropriate. Inclusion of an agent within this guideline does not necessarily indicate TNMC formularystatusAntimicrobialNormal DoseRenal Dosage Adjustment Basedon CrCl Estimate (in ml/min)*Abacavir (ABC)Adult600 mg PO q24h or 300 mg PO q12hNo adjustment necessary.Pediatric8 mg/kg PO q12hAcyclovirAdultPO200 mg PO 5x/dayCrCl 0-10: same dose q12h400 mg PO 5x/dayCrCl 11-25: same dose q8hCrCl 0-10: same dose q12h800 mg PO 5x/dayCrCl 11-25: same dose q8hCrCl 0-10: same dose q12h400 mg PO q12hCrCl 0-10: 200 mg PO q12hIVMucocutaneous

5 mg/kg IV q8hImmunocompromised: 6.2 mg/kg q8hHSV encephalitis or varicella zoster virus10 mg/kg IV q8hImmunocompromised: 12.4 mg/kg IV q8h---------------------PediatricPO6.25-20 mg/kg PO q6hIV15-20 mg/kg IV q8hCrCl 25-50: same dose q12hCrCl 10-24: same dose q24hCrCl 10: 2.5-3.1 mg/kg IV q24hCrCl 25-50: same dose q12hCrCl 10-24: same dose q24hCrCl 10: 5-6.2 mg/kg IV q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: dose as CrCl 10--------------------CrCl 10-25: same dose q8hCrCl 10: same dose q12hCrCl 25-50: same dose q12hCrCl 10-24: same dose q24hŦCrCl 10: 50% IV q24hHD/CAPD: No data.AmantadineAdult100 mg PO q12h or 200 mg dailyCrCl 30-50: Administer 200 mg on day1, then 100 mg/dayCrCl 15-29: Administer 200 mg on day1, then 100 mg on alternate daysCrCl 15: Administer 200 mg every 7days---------------------Pediatric1-9 years: 5 mg/kg/day PO in 2 divided doses(maximum dose: 150 mg/day)HD: Administer 200 mg every 7 daysCAPD: No supplemental dose isneeded.--------------------No clear recommendations. 10 years and 40 kg: 5 mg/kg/day PO in 2divided doses (maximum dose: 150 mg/day)Amikacin 10 years and 40 kg: 100 mg PO q12hAdultExtended interval dosing (most indications*):15 mg/kg once daily adjusted by serum level 6-14 hrs afterstart of infusion and Hartfordnomogram (see PK training packet§on ASP website )10 mg/kg/day may be used for UTIsExtended interval dosing frequencydetermined by levels/Hartfordnomogram

---------------------Traditional dosing 5 mg/kg IV q8hMonitoring of serum levels is recommended.*Refer to TNMC PK training packet on ASP§website for exclusions to ricTraditional dosing 5 mg/kg IV q8hAmoxicillinAdult250-1000 mg PO q8hPediatric12.5-25 mg/kg PO q8-12h(25-90 mg/kg/day)AOM: 90 mg/kg/day PO divided q8-12hAmoxicillin/clavulanateAdult500/125 mg PO q8h---------------------Traditional dosing (empiric, beforelevels):ŦCrCl 51-90: 60-90% IV q12hŦCrCl 10-50: 30-70% IV q12-18hŦCrCl 10: 20-30% IV q24-48hHD/CAPD: Dose according to levels.Same for Adult & PediatricCrCl 10-30: same dose q12hCrCl 10: same dose q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: 250 mg PO q12hCrCl 10-30: 250/125 mg PO q12hCrCl 10: 250/125 mg PO q24h875/125 mg PO q12hCrCl 10-30: 500/125 mg PO q12hCrCl 10: 500/125 mg PO q24h1000/62.5 mg PO q12h (XR formulation)XR formulation NOT recommendedwith CrCl 30.---------------------Pediatric15-45 mg (amoxicillin component)/kg 12hAOM: 22.5-45 mg/kg q12h[30-90 mg (amoxicillin component)/kg/day]HD: Dose as daily CrCl 10. Giveafter dialysis on dialysis days.CAPD: 250/62.5 mg PO q12h--------------------CrCl 10-30: same dose q12hCrCl 10: same dose q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: No clear recommendations.Amphotericin B deoxycholateAmphotericin B LiposomalAdult & Pediatric0.7-1 mg/kg IV q24hNo adjustment necessaryAdult & Pediatric3 mg/kg IV q24hNo adjustment necessary(Automatic dose substitution to 3 mg/kg, refer§to policy on ASP website )AmpicillinAdultPO250-1000 mg PO q6hPOCrCl 10: same dose q12hIV1-2 g IV q4-6hIVCrCl 30-50: same dose q8h

CrCl 30: same dose q12h---------------------PediatricPO12.5-25 mg/kg PO q6hIV25-100 mg/kg IV q6hAmpicillin/sulbactamAdult1.5-3 g IV q6h---------------------Pediatric25-100 mg (ampicillin component)/kg IV q6hHD: Dose as CrCl 10. Give afterdialysis on dialysis days.CAPD: 250 mg PO/IV q12h--------------------PO/IVCrCl 10: same dose q12hHD: Dose as CrCl 10. Give afterdialysis on dialysis days.CAPD: No clear recommendations.CrCl 30-50: same dose q8hCrCl 15-29: same dose q12hCrCl 15: same dose q24hHD: Dose daily as CrCl 15. Giveafter dialysis on dialysis days.CAPD: Dose as CrCl 15.--------------------CrCl 15-29: same dose q12hCrCl 15: same dose q24hHD: Dose as daily CrCl 15. Giveafter dialysis on dialysis days.CAPD: Dose as CrCl 15.Atazanavir (ATV)RTV ritonavirPPI: proton pump inhibitorH2RA: histamine 2 receptorantagonistEFV: efavirenzTDF:tenofovirAUC: area under the curveNaïveAdultATV RTV 300/100mg daily w/foodUnable to tolerate RTV and/or on H2RA: ATV400mg daily w/foodWith TDF, H2RA or PPI: ATV RTV300/100mg daily w/foodWith EFV: ATV RTV: 400/100mg dailyw/foodPediatric 6yr: 15-24kg; ATV RTV 150/80mg daily;25-31kg: 200/100mg daily; 32-38kg250/100mg daily; 39kg 300/100mg dailyw/food 13yr, 39kg and unable to tolerate RTV:ATV 400mg daily w/foodExperiencedAdultOn H2RA: ATV RTV 300/100mg dailyw/foodNo renal adjustment necessary.PPI contraindicated in treatmentexperienced patients (packagelabeling) due to decrease in AUC by75%. In naïve patients PPI should notexceed 20 mg omeprazole/day orequivalent. PPI should be given 12hours prior to ATV.H2RA dose should not exceedequivalent of famotidine 20 mg q12h.ATV/RTV should be administeredsimultaneously with or 10 hours afterH2RAATV 400 mg once daily should beadministered at least 2 hours beforeand at least 10 hours after the H2RA

With TFV and H2RA: ATV RTV 400/100mgdaily w/foodNOTE: PPI and EFV are contraindicated intreatment-experienced patients Pediatric 6yr: 25-31kg: ATV RTV 200/100mg daily;32-38Kg: 250/100mg daily; 39kg 300/100mgdaily w/foodAdult & Pediatric ( 13yo)1500 mg PO divided q12-24hPediatric20 mg/kg PO q12hAdult250-500 mg PO/IV q24hPediatric5-10 mg/kg PO q24hAdult1 g IV q8hAnti-pseudomonal/moderate-severe infection:2 gm IV q8hr---------------------Pediatric30-60 mg/kg IV q6-8hNo data.No adjustment necessary.Caution advised if CrCl 10 (AUCincreased by 35%).CrCl 10-30: same dose IV q12hCrCl 10: same dose IV q24hHD: Dose daily as for CrCl 10 andadminister after dialysis on dialysisdays.CAPD: Dose as CrCl 10.--------------------CrCl 10-30: 50% IV at same intervalŦCrCl 10: 25% IV at same intervalŦHD: Dose as for CrCl 10 with anextra 3.25-7.5 mg/kg IV after dialysis.CAPD: Dose as CrCl 10.CefazolinAdult2 g IV q8h (All Gram-negative infections, S.aureus bloodstream infections, moderatesevere infections, patients 80kg)1 g IV q8h (surgical prophylaxis for patients 80kg, simple urinary tract /kg IV q8hCrCl 10-50: same dose q12hCrCl 10: 1-2 g q24hHD: 1 gm IV q24hr, administered afterHD -OR- 2 gm ( 20 mg/kg) IV aftereach HD three times weeklyCAPD: 500 mg IV q12h--------------------CrCl 10-30: same dose q12hCrCl 10: same dose q24hHD: 2.5-7.5 mg/kg IV given only afterdialysis.CAPD: No adjustment necessary.CefepimeRefer to dosing protocol on§ASP websiteAdult1 g IV q6hCrCl 30-50: 1 g IV q8hCrCl 10-29: 1 g IV q12hCrCl 10: 1 g IV q24h

le Neutropenia: 2 g IV Mild-moderate UTI or community-acquiredpneumonia not caused by P. aeruginosa:1 g IV q12hr-------------------------------------CrCl 30-50: 2 g IV q12hCrCl 10-29: 1 g IV q12hCrCl 10: 1 g IV q24h--------------------------------------CrCl 10-50: 1 g IV q24hCrCl 10: 500 mg IV q24hHD: Dose daily as CrCl 10.Administer after dialysis on dialysisdays.CAPD: Dose for CrCl 10.---------------------PediatricPediatric 40 kg: see adult dosePediatric 40 kg:50 mg/kg IV q8-12hCefotaximeAdult1-2 g IV q8h (Therapeutic interchange toceftriaxone in adults, see cephalosporintherapeutic interchange policy)--------------------CrCl 10-50: same dose q12 (for q8hdosing)-q24h (for q12h dosing)ŦCrCl 10: 50% q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: 50 mg/kg IV q48hCrCl 10-50: same dose q12hCrCl 10: same dose q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: 1 g IV q24h---------------------Pediatric25-100mg/kg IV q6-8h(100-200mg/kg/day)CefoxitinAdult1-2 g IV q8hFor coverage of Enterobacteriaceae (E. coli,Klebsiella sp. Proteus sp. etc.):2 g IV q6h---------------------Pediatric20-40mg/kg IV q6h--------------------CrCl 20: same dose q24hHD: Dose daily as CrCl 20. Giveafter dialysis on dialysis days.CAPD: 50-100 mg/kg IV q24hCrCl 10-30: same dose q12hCrCl 10: same dose IV q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: 1 g IV q24h--------------------CrCl 51-90: same dose q8hCrCl 10-50: same dose q12hCrCl 10: same dose q24-48hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: No clear recommendations.

CeftazidimeAdult1 g IV q8h Anti-pseudomonal dosing: 2 gm IVq8hr---------------------Pediatric30-50 mg/kg IV q8hCrCl 10-30: same dose q12hCrCl 10: 1 gm q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: 1 g IV x1, then 500 mg IVq24h--------------------CrCl 30-50: same dose q12hCrCl 10-29: same dose q24hCrCl 10: same dose q48hHD: Dose as CrCl 10. Give afterdialysis on dialysis days.CAPD: 30-75 mg/kg IV x1, then 50%Ŧq24hCeftriaxoneAdult1 g IV q24hPatients 80 kg:2 g IV q24hNo adjustment necessary.CAPD: 1 g IV q12hMeningitis:2 g IV q12h---------------------Pediatric25-100mg/kg IV q12-24h(50-100mg/kg/day)CefuroximeAdultPO250-500 mg PO q12hIV1.5 g IV q8h--------------------No adjustment necessary.No adjustment necessary.CrCl 10-20: 1.5 gm IV q12hCrCl 10: 1.5 gm q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: Dose as CrCl tricPOCefuroxime 10-15 mg/kg PO q12hIV25-50mg/kg IV q8hNo adjustment necessary.HD: Give after dialysis on dialysisdays.CrCl 10-20: same dose q12hCrCl 10: same dose q24hHD: Dose daily as CrCl 10. Giveafter dialysis on dialysis days.CAPD: Dose as CrCl 10.

CephalexinAdult250 - 1000 mg PO q6h---------------------Pediatric6.25-37.5 mg/kg PO q6hCrCl 50-90: same dose PO q8hCrCl 50: same dose PO q12hHD: Dose as CrCl 50. Give afterdialysis on dialysis days.CAPD: Dose as CrCl 50.--------------------CrCl 10-40: same dose q8hCrCl 10: same dose q12hHD: Dose as CrCl 10. Give afterdialysis on dialysis days.CAPD: Dose as CrCl 10.ChloramphenicolAdult12.5-25 mg/kg IV q6hNo adjustment necessary.Pediatric6.25-25 mg/kg IV q6hCiprofloxacinAdultPO250-750 mg PO q12h (consider 750mg q8hfor pneumonia/severe infection)CrCl 30: same dose q24hHD/CAPD: Dose as CrCl 30 givenafter dialysis.IV400 mg IV q8-12h (q8h for iatricPO10-20 mg/kg PO q12hCrCl 30: same dose q12 (for q8hregimen)-24h (for q12h regimen)HD/CAPD: Dose as CrCl 30 givenafter dialysis.---------------------No clear recommendations.ClarithromycinIV10-15 mg/kg IV q8-12hAdult0.5 – 1 g PO q12hPediatric7.5 mg/kg PO q12hClindamycinSame for Adult & PediatricŦCrCl 30: 50% PO q12hHD: Dose as CrCl 30. Give afterdialysis on dialysis days.CAPD: No adjustment necessary.AdultPO150-450 mg PO q6-8hIVStandard dose: 600 mg IV q8hNecrotizing fasciitis: 900 mg IV q8hNo adjustment necessary.

PediatricPO2.5-10 mg/kg PO q6-8h(10-30 mg/kg/day)Colistin base IVRestricted to ID service orpulmonary service consultationIV6.25-10 mg/kg IV q6-8h(25-40 mg/kg/day)Adult5 mg/kg/day (lesser of actual or ideal bodyweight) colistin base IV divided in 2-3 dosesUse loading dose in renal dysfunction:Loading dose: 2.5 mg/kg IV q12h x2doses. Maintenance dosing begins24 hours after first loading doseCrCl 40: no adjustment neededŦCrCl 20-40: 75% IV q12hŦCrCl 10-19: 50% IV q12hCrCl 10, HD/CAPD: 50 mg IV q12h(after HD on HD days)SLED: While on SLED dose asCrCl 40While off SLED dose as CrCl 10Colistin base InhaledRestricted to ID service orpulmonary service consultationDapsoneDaptomycinRestricted to ID Service reviewand approval for non FDAapproved indicationsDarunavir (DRV)Adult75-150 mg inhaled q12hPediatric30-75 mg inhaled q12hSee colistin dosing and restriction§document available on ASP websiteNo adjustment necessarySee colistin dosing and restriction§document available on ASP websiteAdult50-100 mg PO q24hPediatric1-2 mg/kg PO q24hAdult6 mg/kg IV q24hUTI or skin/skin structure infection: 4 mg/kgIV q24hNo clear guidelines, but adjustmentrecommended.CrCl 30: same dose IV q48hHD: Dose as CrCl 30. Give afterdialysis on dialysis days.CAPD: Dose as CrCl 30.Safety and efficacy not established inpediatrics.NaïveAdultDRV RTV 800/100mg daily w/foodPediatric 6yrs; 20-29kg: DRV RTV 375/50mg Q12H;30-39Kg 450/60mg Q12H; 40kg 600/100mgQ12HExperiencedAdultDRV RTV 600/100mg Q12H w/foodPediatricNo recommendations.No adjustment necessary.

DicloxacillinAdult250-500 mg PO q6hNo adjustment necessary.Didanosine (enteric coated,DDI EC)Pediatric6.25-12.5 mg/kg PO q6hAdult 60kg 400 mg EC PO q24hif given with TDF: 250 mg PO q24h 60 kg: 250 mg EC PO q24hif given with TDF: 200 mg PO q24h---------------------Pediatric2100-120 mg/m PO q12hDoxycyclineEfavirenz (EFV)CrCl 30-59 & 60kg: 200 mg EC q24hCrCl 30-59 & 60kg: 125 mg EC q24hCrCl 10-29: 125 mg PO EC q24hCrCl 10, HD/CAPD: Dose as CrCl10-29 and if patient is 60kg use oralsolution instead of EC formulation--------------------No clear recommendations except forHD.ŦHD: 25% of total dose PO q24hAdult100 mg PO/IV q12hPediatric*not to be used in children 8yo1-4 mg/kg PO/IV q12-24h(2-4 mg/kg/day)Adult600 mg PO QHS (avoid food)No adjustment necessary.No adjustment necessary.Emtricitabine (FTC)ErtapenemPediatric200-600 mg PO q24hAdult:Capsule: 200 mg once dailySolution: 240 mg once daily---------------------Pediatric0-3 months: Solution: 3 mg/kg/day3 months to 17 years:Capsule: Children 33 kg: 200 mg oncedailySolution: 6 mg/kg oncedaily; maximum: 240mg/dayAdult1 g IV q24h---------------------Pediatric15 mg/kg IV q12hCrCl 30-49: Capsule: 200mg q48h;Solution: 120 mg q24hCrCl 15-29: Capsule: 200 mg q72h;Solution: 80 mg q24hCrCl 15: Capsule: 200 mg q96h;Solution: 60 mg q24hHD: Dose as CrCl 15. Give afterdialysis on dialysis days.--------------------No clear recommendationsCrCl 30: 500 mg IV q24hHD/CAPD: Dose as CrCl 30 givenafter dialysis on dialysis days.--------------------No clear recommendations.

ErythromycinAdultPO250-500 mg PO q6-12hIV15-20 mg/kg/day IV divided q6-8hSame for Adult & PediatricCrCl 10: 50% PO/IV at sameŦinterval.HD/CAPD: Dose as CrCl 10.PediatricPO7.5-16.7 mg/kg PO q6-8h(30-50 mg/kg/day)Erythromycin/sulfisoxazoleIV3.75-12.5 mg/kg IV q6hAdult400 mg (erythromycin component) PO q6hPediatric10-16.7 mg (erythromycin component)/kg POq6-8h[40-50 mg (erythromycin component)/kg/day]Adult15-25 mg/kg PO q24h (max. dose 2.5 grams)No clear recommendations.Pediatric15-25 mg/kg PO q24h (max. dose 2.5 grams)HD: Give dose only after dialysis.CAPD: Dose as CrCl 10.Etravirine (ETV)200 mg PO q12h with foodNo adjustment necessaryFamciclovirAdult500 mg PO q8h (varicella zoster virus)EthambutolSafety and efficacy not established inpediatrics.FluconazoleAdultInvasive candidiasis (susceptible C. albicans,C. tropicalis, C. parapsilosis):800 mg (12 mg/kg) load x1dose then 400 mg(6 mg/kg) PO/IV q24hSame for Adult & PediatricCrCl 10-50: same dose PO q24-36hCrCl 10: same dose PO q48hCrCl 40-59: same dose q12hCrCl 20-39: same dose q24hŦCrCl 20: 50% q24hHD: 50% after each dialysis session.CAPD: No clear recommendations.Invasive candidiasis:CrCl 10-29: 800 mg (12mg/kg) loadŦx1dose then 50% PO/IV q24hCrCl 10: 800 mg (12 mg/kg) loadŦx1dose then 25% PO/IV q24hHD: 800 mg (12mg/kg) load x1dosethen Then 400 mg (6 mg/kg) PO/IVafter HD three times weeklyŦCAPD: 50% PO/IV q24hEsophageal candidiasis: 200 mg PO/IV q24hOropharyngeal candidiasis: 100 mg q24hEsophageal/Oropharyngealcandidiasis:ŦCrCl 30: 50% PO/IV q24h----------------------HD: 100% PO/IV after each dialysisŦCAPD: 50% PO/IV q24h---------------------ŦŦ

Pediatric3-12 mg/kg/day PO/IV q24hFlucytosineAdult50-150 mg/kg/day PO divided q6h---------------------Pediatric25-37.5 mg/kg PO q6hFosamprenavir (FPV)RTV ritonavirEFV efavirenzŦCrCl 20-50: 50% PO/IV q24hŦCrCl 20: 25% PO/IV q24hHD: Give dose only after dialysis.ŦCAPD: 25% PO/IV q24hCrCl 10-50: same dose q12-24hCrCl 10: same dose q24hHD/CAPD: Give dose only afterdialysis.--------------------CrCl 20-40: same dose q12CrCl 10-19: same dose q24hCrCl 10: same dose q48hHD/CAPD: Give dose only afterdialysis.ARV NaïveAdultFPV 1400mg q12h OR 1400mg RTV200mg daily OR 1400mg RTV 100mg dailyOR 700mg RTV 100mg q12hWith EFV or NVP: 1400mg RTV 300mgdailyPediatric2-5yr: 30mg/kg q12h 6yr: 30mg/kg q12h OR FPV 18mg/kg RTV3mg/kg q12h; (maximum dose: FPV 1400mgor RTV 200mg/day)No adjustment necessary.ARV ExperiencedAdultFPV 700mg RTV 100mg q12hFoscarnetPediatric 6yr: FPV 18mg/kg RTV 3mg/kg q12h(maximum dose: 1400mg RTV 200mg/day)AdultMucocutaneous HSV:40 mg/kg IV q8hDisseminated CMV, induction:60 mg/kg IV q8hDisseminated CMV, maintenance:90-120 mg/kg IV q24hCrCl as ml/min/kg body weightCrCl 1.0-1.4: 30 mg/kg IV q8hCrCl 0.8-1.0: 35 mg/kg IV q12hCrCl 0.6-0.8: 25 mg/kg IV q12hCrCl 0.5-0.6: 40 mg/kg IV q24hCrCl 0.4-0.5: 35 mg/kg IV q24hCrCl 0.4: Not recommended.CrCl 1.0-1.4: 45 mg/kg IV q8hCrCl 0.8-1.0: 50 mg/kg IV q12hCrCl 0.6-0.8: 40 mg/kg IV q12hCrCl 0.5-0.6: 60 mg/kg IV q24hCrCl 0.4-0.5: 50 mg/kg IV q24hCrCl 0.4: Not recommended.CrCl 1.0-1.4: 70-90 mg/kg IV q24hCrCl 0.8-1.0: 50-65 mg/kg IV q24hCrCl 0.6-0.8: 80-105 mg/kg IV q48hCrCl 0.5-0.6: 60-80 mg/kg IV q48h

.CrCl 0.4-0.5: 50-65 mg/kg IV q48hCrCl 0.4: Not recommended.HD: 40-60 mg/kg IV after each tion60 mg/kg IV q8hMaintenance90-120 mg/kg IV q24h40-60 mg/kg IV q12h--------------------CrCl as ml/min/kg body weightInductionCrCl 1.6: 60 mg/kg/8hCrCl 1.5: 56.5 mg/kg/8hCrCl 1.4: 53 mg/kg/8hCrCl 1.3: 49.4 mg/kg/8hCrCl 1.2: 45.9 mg/kg/8hCrCl 1.1: 42.4 mg/kg/8hCrCl 1: 38.9 mg/kg/8hCrCl 0.9: 35.3 mg/kg/8hCrCl 0.8: 31.8 mg/kg/8hCrCl 0.7: 28.3 mg/kg/8hCrCl 0.6: 24.8 mg/kg/8hCrCl 0.5: 21.2 mg/kg/8hCrCl 0.4: 17.7 mg/kg/8hMaintenanceCrCl 1-1.4: 70-90 mg/kg IV q24hCrCl 0.8- 1: 50-65 mg/kg IV q24hCrCl 0.6- 0.8: 80-105 mg/kg IV q48hCrCl 0.5- 0.6: 60-80 mg/kg IV q48hCrCl 0.4- 0.5: 50-65 IV q48hCrCl 0.4: not recommendedHD/CAPD: No data.Fosfomycin sachetSusceptibility testing requiredfor use other than a one timedose for uncomplicated cystitisID Service consultationstrongly recommended for useother than uncomplicatedcystitisRefer to fosfomycin§information on ASP websiteAdultUncomplicated cystitis: 3g oral x 1 doseCrCl 50: same doseComplicated cystitis: 3 g oral q48hCrCl 50: 3g oral q72h---------------------PediatricPediatric 15 yrs: SEE ADULT DOSE---------------------Pediatric 14 yrs:Uncomplicated cystitis: 2g oral x 1 doseComplicated cystitis: 2g oral every 2 daysIf uncomplicated and CrCl 50: givesame dosePediatric 1 yr:Uncomplicated cystitis: 1g oral x 1 doseComplicated cystitis: 1g oral every 2 daysSEE ADULT DOSAGEIf complicated and CrCl 50:Age 14 yrs: 2g oral every 3 daysAge 1 yr: 1g oral every 3 days

GanciclovirAdultPO1 g PO q8hIVInduction:5 mg/kg IV q12hMaintenance5 mg/kg IV q24h---------------------PediatricPO30 mg/kg PO q8hIVInduction:5 mg/kg IV q12hMaintenance:5 mg/kg IV q24hGentamicinAdultExtended interval dosing (most indications*):7 mg/kg once daily adjusted by serum level 6-14 hrs afterstart of infusion and Hartfordnomogram (see PK training packet§on ASP website )CrCl 50-69: 1.5 g PO q24h or 500 mgPO q8hCrCl 25-49: 1 g PO q24hCrCl 10-24: 500 mg PO q24hCrCl 10: 500 mg PO 3x/weekCrCl 50-69: 2.5 mg/kg IV q12hCrCl 25-49: 2.5 mg/kg IV q24hCrCl 10-24: 1.25 mg/kg IV q24hCrCl 10:1.25 mg/kg IV 3x/weekCrCl 50-69: 2.5 mg/kg IV q24hCrCl 25-49: 1.25 mg/kg IV q24hCrCl 10-24: 0.625 mg/kg IV q24hCrCl 10: 0.625 mg/kg IV 3x/weekHD (PO/IV): Dose as CrCl 10 givenafter dialysis sessions.--------------------No clear recommendations.CrCl 50-69: 2.5 mg/kg IV q12hCrCl 25-49: 2.5 mg/kg IV q24hCrCl 10-24: 1.25 mg/kg IV q24hCrCl 10:1.25 mg/kg IV 3x/weekCrCl 50-69: 2.5 mg/kg IV q24hCrCl 25-49: 1.25 mg/kg IV q24hCrCl 10-24: 0.625 mg/kg IV q24hCrCl 10: 0.625 mg/kg IV 3x/weekHD (PO/IV): Dose as CrCl 10 givenafter dialysis sessions.Extended interval dosing frequencydetermined by levels/Hartfordnomogram5 mg/kg/day may be used for UTIs---------------------Traditional dosing 1.5-2.5 mg/kg IV q8hMonitoring of serum levels is recommended.---------------------Traditional dosing (empiric, beforelevels):ŦCrCl 51-90: 60-90% IV q8-12hŦCrCl 10-50: 30-70% IV q12h

*Refer to TNMC PK training packet on ASP§website for exclusions to --PediatricTraditional dosing 1.5-2.5 mg/kg IV q8hAdult500 mg IV q6hFor any other adult doses, use adjustmenttables provided by Micromedex.---------------------Pediatric15-25 mg/kg IV q6hIndinavirIsoniazidItraconazoleAdult800 mg PO q8h---------------------2Pediatric: 500 mg/m PO q8hAdult5 mg/kg PO q24h (max dose 300 mg daily)CrCl 10: 20-30% IV q24-48hŦHD/CAPD: Dose according to levels.Adjusted by weight and CrCl. SeeMicromedex for adjustment.HD: Dose as CrCl 20. Dose afterdialysis on dialysis days.CAPD: Dose as CrCl 10--------------------ŦCrCl 41-70: 50% IV q6hŦCrCl 21-40: 35% IV q8hŦCrCl 6-20: 25% IV q12hHD: Same dose q12h, given afterdialysis on dialysis days.CAPD: Dose as CrCl 6-20No adjustment necessary.--------------------No clear recommendations ( 20%renal elimination).No adjustment necessary.Pediatric10-15 mg/kg PO q24h (max dose 300 mgdaily)Adult100-200 mg PO q12hHD/CAPD: Give dose after dialysis ondialysis days.Endemic fungi (Histoplasmata sp.Coccidioides sp. Blastomycetes sp.):200 mg PO q8h x2days load then 200 mg POq12hAvoid concomitant proton pumpinhibitors or histamine receptorantagonistsPediatric3-5 mg/kg PO q24hNo renal adjustment necessary.Suspension should be administeredon an empty stomachCapsules should be administered withmeal or acidic beverageTherapeutic drug monitoring shouldbe considered. Goal steady-statetrough obtained after 5-7 days oftherapy for active disease 1mg/dL(sum of hyrdoxy-itraconazole anditraconazole)Lamivudine (3TC)Adult150 mg q12h OR 300 mg PO q24hCrCl 30-49: 150 mg PO q24hCrCl 15-29: 150 mg PO x1, then 100mg PO q24hCrCl 5-14: 150 mg PO x1, then 50 mgPO q24h

CrCl 5: 50 mg PO x1, then 25 mgPO q24h (Note: because lamivudineis well-tolerated and available in 100mg tablets, some practitioners willprescribe 50 mg PO daily (half of a100 mg tablet)Linezolid---------------------Pediatric2-4 mg/kg PO q12hAdult600 mg PO/IV q12hHD/CAPD: Dose as CrCl 5.--------------------No clear recommendations (70% renalelimination).No adjustment necessary.Lopinavir/ritonavir (LPV/r)Pediatric10 mg/kg PO/IV q8-12hAdult400/100 mg PO q12horNo clear recommendations, butadjustment probably not necessary( 3% renal elimination). Avoid oncedaily dosing in patients receiving HD800/200 mg PO q24h (do not use once dailydosing in pts with 2 lopinavir resistanceassociated substitutions, pregrancy, orpatients receiving EFV, NVP, NFV,carbamazepine, phenobarbital, or phenytoin)MaravirocPediatric10-13 mg (lopinavir component)/kg PO q12h150 mg PO q12h: when used concomitantlywith a potent CYP3A inhibitor (with or withouta CYP3A inducer) including proteaseinhibitors (except tipranavir/ritonavir),delavirdine, ketoconazole, itraconazole,clarithromycin, nefazadone, and telithromycinCaution in patients with hepaticimpairmentCaution in patients with CrCl 50600 mg PO q12h: when used concomitantlywith a potent CYP3A inducer (without astrong CYP3A inhibitor) including efavirenz,etravirine, rifampin, carbamazepine,phenobarbital, and phenytoin.300 mg PO q12h: when used concomitantlywith tipranavir/ritonavir, nevirapine,raltegravir, all nucleoside reversetranscriptase inhibitors, and enfuvirtideMeropenemRefer to dosing protocol on§ASP websiteAdultStandard dose:500 mg IV q6hSimple urinary tract infection:500 mg IV q8hsee next pageCrCl 25-49: 500 mg IV q8hCrCl 10-24: 500 mg IV q12hCrCl 10: 500 mg IV q24hCrCl 25-49: 500 mg IV q12hCrCl 10-24: 250 mg IV q12hCrCl 10: 500 mg IV q24h

MetronidazoleMeningitis, cystic fibrosis, meropenem MIC of4 mcg/mL2 g IV q8hCrCl 25-49: 2 g IV q12hCrCl 10-24: 1 g IV q12hCrCl 10: 1 g IV q24h---------------------Pediatric20-40 mg/kg IV q8h (q12h for neonates 7days old and under)HD/CAPD: Dose as CrCl 10 givenafter dialysis on dialysis days.--------------------No clear recommendations forneonates 7 days old under. For thoseover 7 days old:CrCl 10-24: Same dose IV q12hCrCl 10: Same dose IV q24hAdult500 mg PO/IV q8hHD/CAPD: Dose as CrCl 10 givenafter dialysis on dialysis days.Same for Adult & PediatricCrCl 10 or severe hepaticdysfunction: consider 50% at sameŦinterval if 14 day durationPediatric3.75-16.7 mg/kg PO/IV q6-8h(15-50 -150 mg IV q24h---------------------Pediatric1-4.5 mg/kg IV q24hAdult100 mg PO q12h (200 mg PO qhs)Pediatric*not to be used in children 8yo2 mg/kg PO q12h (4 mg/kg PO qhs)Adult400 mg PO/IV q24hHD/CAPD: Give after dialysis ondialysis days.No adjustment necessary.--------------------No clear recommendations.No adjustment necessary.No adjustment necessary.Nelfinavir (NFV)Safety and efficacy not established inpediatrics.Adult1250 mg PO q12hPediatric45-55 mg/kg PO q12hNevirapine (NVP)Adult200 mg PO q24h x14 days then increase to200 mg PO q12h (immediate release tab) or400 mg PO q24h (extended-release tab)Pediatric4-7 mg/kg PO q12hNitrofurantoinNo clear recommendations, butadjustment probably not necessary( 2% renal elimination).No adjustment necessary.Give dose after dialysis on dialysisdays.Avoid if naïve and CD4 count 2503cells/mm in women and 4003cells/mm in menAdult50-100 mg PO q12hPediatric1.25-1.75 mg/kg PO q6hCrCl 50, HD/CAPD: Use is notrecommended – will not reliably reachuseful concentrations in urine and willhave increased risk of toxicity

OseltamivirOxacillinAdult75 mg PO q12hPediatric30-75 mg PO q12hAdultMethicillin-susceptible S. aureus bloodstreaminfections:2g IV q4hSame for Adult & PediatricCrCl 10-30: same dose PO q24hCrCl 10, HD/CAPD: No data.No adjustment necessary.Non-bloodstream infections1-2g IV q4-6hPenicillin GPediatric16.7-50 mg/kg IV q4-6h(50-100 mg/kg/day)Adult2 – 4 million units IV q4h---------------------Pediatric25,000-100,000 units/kg IV q4-6h(100,000-400,000 units/kg/day)CrCl 10-50: 75% IV at same intervalCrCl 10: 2-4 million units q8hHD: Dose as CrCl 10. Give doseafter dialysis on dialysis days.CAPD: Dose as CrCl 10.--------------------CrCl 10-30: same dose q8hCrCl 10: same dose q12hHD: Dose as CrCl 10. Give doseafter dialysis on dialysis days.CAPD: Dose as CrCl 10.Penicillin VKPentamidinePiperacillinAdult250-500 mg PO q6-8hPediatric6.25-16.7 mg/kg PO q6-8h(25-50 mg/kg/day)Adult4 mg/kg IV q24h---------------------Pediatric4 mg/kg IV q24hAdult3-4 g IV q4-6h---------------------Pediatric33.3-75 mg/kg IV q4-6h(200-300 mg/kg/day)No adjustment necessary.HD: Give dose after dialysis ondialysis days.No adjustment necessary.--------------------CrCl 10-30: same dose q36hCrCl 10: same dose q48hCrCl 10-50: same dose IV q6-8hCrCl 10: same dose IV q8hHD: Dose as CrCl 10. Give doseafter dialysis on dialysis days.CAPD: Dose as CrCl 10.--------------------CrCl 20-40: same dose q8hCrCl 20: same dose q12hHD: Dose as CrCl 20. Give doseafter dialysis on dialysis days.CAPD: Dose as CrCl 20.Ŧ

Piperacillin/tazobactamSee dosing protocol on ASP§websiteAdultExtended 4hr infusion (standard at TNMC):4.5 g IV q8h, infused over 4hTraditional

400mg daily w/food With TDF, H2RA or PPI: ATV RTV 300/100mg daily w/food With EFV: ATV RTV: 400/100mg daily w/food Pediatric 6yr: 15-24kg; ATV RTV 150/80mg daily; 25-31kg: 200/100mg daily; 32-38kg 250/100mg daily; 39kg 300/100mg daily w/food 13yr, 39kg and unable to tolerate RTV: ATV 400mg daily w/food Experienced Adult

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