Stanford Health Care Antimicrobial Dosing Reference Guide

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Stanford Health Care Antimicrobial Dosing Reference GuideThis document is also located on the SHC Intranet StewardshipProgram) andhttp://bugsanddrugs.stanford.edu ؞ ABX Subcommittee Approved: September 2020Formulas for dosing weights: Ideal body weight IBW (male) 50kg (2.3 x height in inches 60 inches) Ideal body weight IBW (female) 45kg (2.3 x height in inches 60 inches) Adjusted Body Weight ABW (kg) IBW 0.4 (TBW – IBW)DrugCrCl 10 – 50 mL/minCrCl 50 mL/minAcyclovir (IV) 1–7(Use adjusted BW tGeneral(e.g. mucocutaneousHSV)Severe (e.g. CNS/ocular/disseminatedHSV infections, eneral(e.g. mucocutaneousHSV)Severe (e.g. CNS/ocular/disseminatedHSV infections, Zoster)Acyclovir (PO) 1,2,7Conventionaldosing1,2,5,8,9Amikacin(Use adjusted BW inobese)Refer to AminoglycosideDosing GuideHigh-doseextendedinterval dosingCrCl 10 mL/minCrCL 25 – 50CrCL 25CrCL 10IHDCRRT250 mg/m2 q12h2 mg/kg q12h125 mg/m2 q12h2 mg/kg q12h125 mg/m2 q24h2 mg/kg q24h62.5 mg/m2 q24h1 mg/kg q24h62.5 mg/m2 q24h1 mg/kg q24h125 mg/m2 q12h2 mg/kg q12h5 mg/kg q8h5 mg/kg q12h5 mg/kg q24h2.5 mg/kg q24h2.5 mg/kg q24h5 – 10 mg/kg q12h10 mg/kg q8h10 mg/kg q12h10 mg/kg q24h5 mg/kg q24hCrCL 50CrCL 25 – 50CrCL 25CrCL 10IHDCRRT800 mg BID400 mg BID400 mg BID400 mg BID200 mg BID200 mg BID200 mg daily200 mg daily200 mg daily200 mg dailyNo dataNo data400 mg q8hAlt: 200 mg 5x daily200 mg q8h200 mg q12h200 mg q12hNo data800 mg q4h (or 5x daily)Consider valacyclovir for lessfrequent dosing800 mg q8h800 mg q12h800 mg q12hNo dataCrCl 60CrCl 40 – 60CrCl 20 – 40CrCl 205 – 7.5 mg/kgq8h5 – 7.5 mg/kgq12h5 – 7.5 mg/kgq24h5 mg/kgload, thenby level15 mg/kg q36hCrCl 30:15 mg/kg q48hCrCl 30:Not recommended15 – 20 mg/kgq24halt: 7.5mg/kgq48–72h5 mg/kg q24h10 mg/kg q12h10 mg/kg load,then 7.5 mg/kg q24–48h5 – 7.5 mg/kg post HD onlyconsult pharmacistSevere/MDR organism:25 mg/kg q48hconsult pharmacistTiming of levels: Draw trough 30 min prior to 4th dose. Draw peak 30 min after infusion endsOnce daily dosing: goal peak 35 – 60 mcg/mL; goal trough 4 mcg/mLConventional dosing: goal peak 25 – 35 mcg/mL for serious infections; 15 – 20 mcg/mL forUTI; goal trough 4 – 8 mcg/mLCAP: 1,000 mg q8hCRRTCrCL 50Usual dose:500 – 1,000mg q8-12hor 875 mg q12hAmoxicillin (PO)1,2IntermittentHemodialysis (IHD)CrCl 10–30:250 – 500 mg q12h250 – 500 mg q24h250 – 500 mg q24h;administer additional dose atthe end of dialysisNo dataH pylori: 1,000 mg q12hProcedural ppx: 2,000 mg x 1Amoxicillin/clavulanate(PO)1,2Usual dose:250 – 500 mg q8hor 875 mg q12hCrCl 30: Do not use875 mg tabletCrCl 10 – 30:250 – 500 mg q12h250 – 500 mg q24h250 – 500 mg q24h;administer additional dose atthe end of dialysisNo dataAmphotericin BLiposomal1,2(Consider adjusted BWin obese)3 – 5 mg/kg/dayNo changeNo changeNo changeNo changeMild/uncomplicated:1 g q6–8hMild/uncomplicated:1 g q12hMeningitis/endovascular/PJI:2 g q4hMeningitis/endovascular/PJI:2 g q6–12hMeningitis/endovascular/PJI:2 g q12–24h; or 1 g q8h1.5 – 3 g q6hCrCl 30: 1.5 – 3 g q12hCrCl 15: 1.5 – 3 g q24hDose daily, but after HD on HDdays3 g q6–8h500 mg q24hNo changeNo changeNo changeNo change500 mg q8h1 g q24hSevere/Meningitis: 1g q12hSevere/Meningitis: 1 g q12h2 g load, then 1 g q8h– or –2 g q12hNo changeNo changeMild/uncomplicated:1 – 2 g q6hAmpicillin (IV)1–3Ampicillin/sulbactam1–3,5Azithromycin (IV/PO)1,2Aztreonam1–3,10Severe: pseudomonas, lifethreatening infectionsCaspofungin1,2,11,11–131 – 2 g q8hCrCl 30: 1 g q8hSevere/Meningitis:2 g q6–8hSevere/Meningitis:1 g q6–8hMild/uncomplicated:1 g q12hMeningitis/endovascular/PJI:2 g q12–24hCVVH: 2 g q8–12HCVVHDF: 2 g q6–8hMeningitis/endovascular/PJI:2 g q6h1.5 – 3 g q12–24h70 mg x 1, then 50 mg q24h70 mg q24h if on phenytoin, rifampin, other strong enzyme inducersEndocarditis/Endovascular: 150 mg q24hDosage adjustments are not required for Child-Pugh B or C cirrhosisCefazolin1–5,14CrCl 35:CrCl 10 – 34:Mild/moderate: 1 g q8hMild/moderate: 1 g q12hSevere: 2 g q8hSevere: 2 g q12h1 g q24hMild/moderate: 1g q24hSevere: 2 g q24hDose daily, but after HD on HDdaysalt: 2g/2g/3g post-HD only2 g q12h

DrugCrCl 10 – 50 mL/minCrCl 50 mL/minCrCl 10 mL/minExtended Infusion (4-hour infusion)CrCl 60CrCl 30 – 60GeneralCefepime1–3,5,15–17CrCl 11-291 g q8h or2 g q12h1 g q12h or2 g q24h1 g q24h2 g q8h2 g q12h1 g q12hSevere/CNS/FN/CF tentHemodialysis (IHD)CRRTCrCl 100.5 g q24h1 g q24h0.5 – 1 g q24hDose daily, but after HD on HDdays2 g load, then 1 g q8h (4hour infusion)alt: 2 g post-HD onlyUncomplicated cystitis:100 mg q12hCefpodoxime (PO)1,2CAP/bronchitis: 200 mg q12hCrCl 30: same dose q24hSame dose, post-HD onlyNo dataSkin/skin structure:400 mg q12hCeftaroline1,2,18(SHC Restriction)CrCl 50CrCl 30 – 50CrCl 15 – 30CrCl 15General600 mg q12h400 mg q12h300 mg q12h200 mg q12hEndocarditis/S.aureus bacteremia,Susceptible-dosedependent (SDD)600 mg q8hadministeredover 2-hr400 mg q8hadministeredover 2-hr300 mg q8hadministeredover 2-hr200 mg q8hadministeredover 2-hr200 mg q8–12hEndocarditis/S.aureusbacteremia/ SDD:200 mg q8–12hadministered over 2-hrNo data0.5 – 1 g q24hCeftazidime (IV)Usual dose: 1 – 2 g q8h1–3,19Severe: 2 g q8hCeftazidime/avibactam1,2,20–232.5 g q8h(SHC Restriction)CrCl 30 – 50: 1 – 2 g q12hCrCl 16 – 30: 1 – 2 g q24hCrCl 6 – 15: 0.5 – 1 g q24hCrCl 5: 0.5 g q24hCrCl 31 – 50: 1.25 g q8hCrCl 16 – 30: 0.94 g q12hCrCl 6 – 15: 0.94 g q24hCrCl 5: 0.94 g q48hCrCl 30 – 50CrCl 50Ceftolozane/tazobactam1,2,24–26(SHC Restriction)General1.5 g a750 mg q8h3 g q8h1.5 g q8halt: 1 – 2 g q48–72h or1 g post-HD only TIW0.94 g q24–48hCrCl 15 – 29750 mg q8hDose daily, but after HD on HDdays2 g load, then 1 g q8h– or –2 g q12h1.25g q8h2.5g q8h if MIC 4mcg/mL or deep-seatedCrCl 15750 mg load,then 150 mgq8h2.25 g load,then 450 mgq8h375 mg q8h1 – 2 g q24hEndovascular/osteomyelitis/PJI: 2 g q24hMeningitis, E. faecalis endocarditis: 2 g q12hCeftriaxone (IV)1,2,27Dose daily, but after HD on HDdaysNo changeGeneral: 750 mg load, then150 mg q8h1.5 – 3 g IV q8hHAP/VAP: 2.25 g load, then450 mg q8hNo changeNo change250 – 1000 mg q6hCephalexin (PO)500 mg q24hCrCl 15 – 29: 250 mg q8–12hCrCl 5 – 14: 250 mg q24hUncomplicated cystitis:500 mg q12h1,2,28Dose daily, but after HD on HDdaysNo dataCellulitis/SSTI: 500 mg q6hCiprofloxacin (IV/PO)1–General rCl 50400 mg IV q12h500 mg PO q12h400 mg IV q8h750 mg PO q12h600 – 900 mg IV q8h150 – 450 mg PO q6hU.S. FDA Package InsertCrCl 80LoadingDoseMaintenance1.25 – 2.5Dosemg/kg q12hColistin (IV)1–3,30–32(SHC Restriction)(Dosage expressed interms of colistin baseactivity [CBA]; Use idealBW in obese)1,2,33–39Daptomycin(SHC Restriction)(Use adjusted BW inobese)CrCl 30 – 50CrCl 30400 mg IV q24h500 mg PO q24h400 mg IV q24h500 mg PO q24hSame400 mg IV q8–12h500 mg PO q12hNo changeCrCl 50 – 79No changeCrCl 30 – 49E. faecium infections:10 – 12 mg/kg q24h; consultID400 mg IV q12h500 mg PO q12hDose daily, but after HD on HDdaysSevere infection withA.baumannii orP.aeruginosa:400 mg IV q8-12hNo changeNo changeCrCl 305 mg/kg x 1 (max dose: 300 mg)1.25 – 1.9mg/kg q12h2.5 mg/kgq24h1.5 mg/kgq36hPreferred Dosing for Critically Ill Patients (Consult ID Pharmacist)CrClDosing RegimenLoading Dose300 mg CBA x 1 90 mL/min180 mg q12h80 – 89 mL/min170 mg q12h70 – 79 mL/min150 mg q12h60 – 69 mL/min138 mg q12h50 – 59 mL/min122 mg q12hMaintenance40 – 49 mL/min110 mg q12hDose30 – 39 mL/min98 mg q12h20 – 29 mL/min88 mg q12h10 – 19 mL/min80 mg q12h5 – 9 mL/min72 mg q12h0 mL/min65 mg q12hSuggested loading dose and daily doses of colistimethate for desired target colistin Css,avg of2 mg/L (CID 2017:64. Nation et al)Skin/Soft tissue:4 – 6 mg/kg q24hBacteremia/Endovascular:8 mg/kg q24h200 – 400 mg IV q24h250 – 500 mg PO q24hCrCl 30:Same dose q48hSame dose q48hLoading Dose:300 mg CBA x 1Loading Dose:300 mg CBA x 1Maintenance Dose:130 mg CBA q24h; thensupplement an additional 40mg CBA (for a 3-hr IHDsession) or 50 mg CBA (for a4-hr IHD session) post-dialysisalt: 1.5 mg/kg q24hMaintenance Dose:220 mg CBA q12hAlt: 100 mg CBA q8hNote: These are generalrecommendations (basedon dialysisflow/ultrafiltration rates of1-2 L/hr and minimalresidual renal function.Refer to ESCMID/EUCASTguidelines6 – 8 mg/kg q24hSame dose q48hDose q48h, but after HD on HDdaysalt: 6 mg/kg post-HD only or6/6/9 mg/kg post-HD onlyDoses 8mg/kg q24hincreases the risk of CPKelevations and myopathy.Caution, clinical judgementand frequent monitoring forhigher doses

DrugDoxycycline (IV/PO)1,2CrCl 50 mL/minCrCl 10 – 50 mL/minCrCl 10 mL/minIntermittentHemodialysis (IHD)CRRT(Load: 200 mg x 1 for severeinfections)No changeNo changeNo changeNo change100 mg q12h500 mg q24hDose daily, but after HD on HDdaysErtapenem (IV/IM)1,2,40–421,5,43,44Ethambutol (PO)(Use lean BW if obese)(See footnote for lean BWequation)Fidaxomicin (PO)1,2(SHC Restriction)1 g q24hCrCl 30: 500 mg q24h500 mg q24h1 g q24hDose range:15 – 25 mg/kg/day(max dose: 1,600 mg/day)Lean bodyDoseweight40 – 55 kg800 mg56 – 75 kg1,200 mg76 – 90 kg1,600 mgCrCl 10 – 50:15 – 25 mg/kg q24–36hCrCl 10:15 – 25 mg/kg q48h15 – 25 mg/kg 3 times perweek post-HD200 mg q12h x 10 daysNo changeNo changeNo changeNo changeDose by indication;200 – 800 mg post HD onlyIf usual dose is 200mgdaily, use 400 daily.If usual dose is 400mgdaily, use 800 mg q24h in1-2 divided dosesIf usual dose is 800mgdaily, use 1200 mg q24h(in 2 divided doses)alt: 500 - 1000 mg post-HD(low vs. high-flux HD, degreeof renal failure, residual UOP)15 – 25 mg/kg q24–36hAdminister after HD only200 – 400 mg q24hFluconazole (IV/PO)1–C.glabrata800 mg q24h4,13,22,45Dose by indication. Load800 mg for candidemia1,2,46–48Foscarnet (IV)(Consider adjusted BWin obese)Adj CrCl (mL/min/kg)(50% of normal dose) q24hSevere/CNS/endovascularinfections:up to 800 mg q24hCrCl(mL/min/kg) 1.4 1.0 – 1.4 0.8 – 1.0 0.6 – 0.8 0.5 – 0.6 0.4 – 0.5 0.4IHDCMV inductionCMV maintenanceHSV60 mg/kg q8h90 mg/kg q12h45 mg/kg q8h70 mg/kg q12h50 mg/kg q12h50 mg/kg q12h40 mg/kg q12h80 mg/kg q24h60 mg/kg q24h60 mg/kg q24h50 mg/kg q24h50 mg/kg q24hNot recommended60 – 90 mg/kg loading dose,then 45 – 60 mg/kg/dose post-HD only90 mg/kg q24h120 mg/kg q24h70 mg/kg q24h90 mg/kg q24h50 mg/kg q24h65 mg/kg q24h80 mg/kg q48h105 mg/kg q48h60 mg/kg q48h80 mg/kg q48h50 mg/kg q48h65 mg/kg q48hNot recommended40 mg/kg q12h40 mg/kg q8h30 mg/kg q12h30 mg/kg q8h20 mg/kg q12h35 mg/kg q12h35 mg/kg q24h25 mg/kg q12h25 mg/kg q24h40 mg/kg q24h20 mg/kg q24h35 mg/kg q24hNot recommendedNo dataNo dataCRRTNo dataCMVGanciclovir (IV)1,2(Consider adjusted BWin obese)CrCl 70*Induction (I)Maintenance (M)5 mg/kgq12h5 mg/kgq24hCrCl 50CrCl 252.5 mg/kgq12h2.5 mg/kgq24h2.5 mg/kgq24h1.25 mg/kgq24hCrCl 10CrCl 101.25 mg/kgq24h0.625 mg/kgq24h1.25 mg/kg3x/week0.625 mg/kg3x/weekI: 1.25 mg/kg post HD onlyM: 0.625 mg/kg post HD onlyI: 2.5 mg/kg q12–24hM: 1.25 – 2.5 mg/kg q24h*Manufacturer’s CrCl cutoffs. Please refer to BMT protocols if applicableGram negativeGentamicin1,3,49(Use adjusted BW inobese)See appendix forcomplete guidelinesImipenem/Cilastatin(IV)1(SHC Restriction)Isoniazid (PO)1,2,43,441 mg/kg q8h**1 mg/kg q12h1 mg/kg q24hCrCL 60500 mg q6Hor1g q8hCrCL 30 – 59CrCL 15 – 29CrCL 10500 mg q8h500 mg q12h1,000 mg q12H750 mg q12H500 mg q12HNot recommendedunless dialysisinitiated within 48hrsGeneralCrCl 20IHDCRRT2 mg/kgloading dose,then per level2 mg/kg loadingdose, then 1.5mg/kg post HD1.5 – 2.5mg/kgq24–48h1 mg/kg load,then by level250 – 500 mg q12h1g load, then 500 mg q6hInitial: 372 mg q8h x 6 dosesMaintenance: 372 mg q24hNo changeNo changeNo changeNo change300 mg q24h(5 mg/kg/day)No changeNo changeNo changeNo changeCrCl 50General250 – 500 mg q24hLevofloxacin s:Linezolid (IV/PO)1,2(SHC Restriction)CrCl 20 – 391.7 mg/kg q24horCrCl 30: 5 – 7 mg/kg q48hCrCl 30: Not recommended(high-dose extended-interval)1 mg/kg q48–72h;consider redosing1 mg/kg q24h,when levelthen per level 1 mcg/LGoal levels:Gram-negative infections: Goal peak for traditional dosing 4 – 8 mcg/mL; goal trough 1 – 2 mcg/mLGram-positive synergy: Goal peak 3 – 4 mcg/mL; goal trough 1 mcg/mLTiming of levels: Draw peak 30 minutes after completion of 3rd dose. Draw trough 30 minutes prior to 4th dose (For CrCl 20 mL/min, may check levelssooner than 3rd/4th dose)For 7 mg/kg once-daily dosing, draw a single random level 8 – 12 hours after dose administration. Adjust based on Hartford nomogramFor HD, draw trough pre-HD (alternative: draw trough level 4-hr post-HD); and peak 30 minutes after end of each infusion** Streptococci, Streptococcus gallolyticus (bovis), Streptococcus viridans endocarditis: optional dosing 3 mg/kg q24h for CrCl 60 mL/min** Staphylococci; Enterococcus spp (strains susceptible to PCN and gentamicin) endocarditis: optional dosing 3 mg/kg in 2 or 3 equally divided dosesGram positivesynergyNTMIsavuconazole (IV/PO)1,2CrCl 40 – 591.7 mg/kg q12hor5 – 7 mg/kg q36h(high-doseextended-interval)CrCl 601.7 mg/kg q8hor5 – 7 mg/kg q24h(high-doseextended-interval)600 mg q12h750 mg q24hCrCl 20 – 49250 mg q24h- or 500 mg q48h750 mg q48hNo changeCrCl 20500 mg x1,then 250 mg q48h750 mg x1,then 500 mg q48hNo changeSee CrCl 20 ml/minDose q48h, but after HD on HDdaysNo change750 mg load,then 250 – 500 mg q24hNo change

DrugMeropenem1–4,50(SHC Restriction)3-hr extended infusionMetronidazole (IV/PO)1,2Moxifloxacin (IV/PO)CrCl 10 – 50 mL/minCrCl 50 mL/minCrCl 50CrCl 26 – 50CrCl 10 – 25CrCl 10Usual dose(FN, PNA,Pseudomonas)1 g q8h1 g q12h0.5 g q12h0.5 g q24hCF/Meningitis2 g q8h500 mg q6–8h1,2400 mg IV/PO q24h2 g q4hMild infections: 1 g q4hNafcillin1,2ProphylaxisOseltamivir (PO)1,2,51CrCl 10 mL/minTreatment2 g q12h1 g q12h1 g q24hNo changeSevere hepatic impairment: can consider 500 mg q12hNo changeNo changePenicillin G yxin B1,2,54,55(SHC Restriction)2 – 3 mu q4h1 – 2 mu q6hCrCl 40CrCl 20 – 40CrCl 20Intermittent DosingGeneral3.375 g q6h2.25 g q6h2.25 g q8hSevere/sepsis/CF/4.5 g q6h3.375 g q6h2.25 g q6hnosocomial PNAExtended-Infusion Dosing (4-hr infusion)General, CFExtended infusion for CrCl 20:Pseudomonas,3.375 g q12h over 4h3.375 – 4.5 g q8h over 4h*nosocomial PNA:*In select cases, higher piperacillin/tazobactam dosing may be warranted, e.g. sepsis,critically ill patients with severe or deep-seated infections, infections with MIC 16 mg/L,obesity with weight 120kg or BMI 40, CrCl 120 mL/min, or enhanced drug clearancesuch as those with cystic fibrosis: consider doses of 4.5 g q8h (infused over 4 hours) or q6h.Dosing presented as units (10,000 units 1 mg)20,000 – 25,000 units/kg load x 1, then 12,500 – 15,000 units/kg q12h(Use adjusted BW ifobese)CRRT500 mg q24hCF/CNS: 1 g q24hDose daily, but after HD on HDdays1 g q8hCF/CNS: 2 g q12h500 mg q8h500 mg q6–8hNo changeNo changeNo change for renal impairment.Hepatic Impairment: No specific dose adjustment provided by manufacturer. Dosage adjustment may be necessary in thesetting of concomitant renal impairment; nafcillin primarily undergoes hepatic metabolism.Prophylaxis:CrCl 60CrCl 30 – 60CrCl 10 – 3030 mg x 1, then 30 mg afterProphylaxis: 75 mg q24heveryother HD session75 mg q24h30 mg q24h30 mg q48hTreatment:Treatment: 75 mg q12h75 mg q12h30 mg q12h30 mg q24h30 mg x 1, then 30 mg postHD only2 – 4 mu q4hDose range: 12 – 24 millionunits/day continuous infusionor in divided doses every 4 to6 hoursIntermittentHemodialysis (IHD)Mild: 0.5 – 1 mu q4–6h;or 1 – 2 mu q8–12hSevere: 2 mu q4–6h;or 4 mu q8–12h4 mu q4–6hGeneral: 2.25 g q12hSevere infections:3.375 g q12h over 4-hralt: 2.25 g q8h3.375 g q6hExtended infusion:3.375 – 4.5 g q8h over 4-hrNo dataNo changeNo changeNo change25 mg/kg 3 times per weekAdminister after HD onlyNo dataNo changeNo changeNo changeNo changeNo changeNo change(maximum: 25,000 units/kg/day)Delayed-release tablet/ Intravenous solutionOral SuspensionProphylaxisTreatment1,2Posaconazole (PO/IV)(SHC Restriction [IV]) Rifampin(IV/PO)1,2,43,44,56–58Capsule size: 150mg, 300mgTedizolid (IV/PO)1,2,59(SHC Restriction)Tobramycin1,2,49300 mg q12h x 1 day,then 300 mg q24hNo renal adjustment Pyrazinamide (PO)1,2,43,44(Use lean BW if obese)(See footnote for lean BWequation)200 mg q8hUsual dose: 200 mg q6–8h or 400 mg q12hDelayed-release tablet and oral suspension are not interchangeablePosaconazole levels shown to have great degree of interpatient variability. Considerdrawing a trough 4 – 7 days after initiating dose.Please refer to Antifungal TDM GuideUsual Dose: 25 mg/kg q24h(max dose: 2,000 mg/day)Lean bodyweight40 – 55 kg56 – 75 kg76 – 90 kgDose1,000 mg1,500 mg2,000 mgCrCl 30:25 mg/kg 3 times per weekTB: 600 mg q24h ( 45 kg: 10 mg/kg q24h)Endocarditis: 300 mg q8hPJI: 300 – 450 mg q12hVertebral Osteomyelitis: 600 mg q24h200 mg q24hNo changeRefer to Gentamicin for dosing. See appendix for complete guidelines.Uncomplicated cystitis:1 DS tab PO BIDSSTI: 1 – 2 DS tab PO BIDTrimethoprim (TMP)/Sulfamethoxazole(IV/PO)1,2,4,60(Dose by adjusted BWin obese)SS 80 mg TMP 10 ml po solnDS 160 mg TMP 20ml po solnS. aureus (Bone/Joint):8-10 mg/kg/day TMP individed doses(2 DS tabs PO BID)Gram-negative bacteremia:8-10 mg/kg/day TMP individed doses(2DS tab PO BID)Stenotrophomonas:10-15 mg/kg/day TMPdivided q8-12hPCP: 15 mg/kg/day TMPdivided q8h ( 2 DS tab TID)2.5 – 5 mg/kg TMP q24hCrCl 15 – 30:Administer 50% ofrecommended doseCrCl 15:Use is not recommended,but if needed for PCP:5 – 8 mg/kg TMP q24hPCP:5 – 8 mg/kg TMP q24hDose daily, but after HD on HDdaysalt: 5 – 15 mg/kg TMP postHD only5 – 10 mg/kg/day TMPdivided q12hPCP/ Stenotrophomonas:15 mg/kg/day TMP dividedq8–12h

DrugVZVValacyclovir (PO)1,2Please refer totransplant protocols vir (PO)1,2Please refer totransplant protocols ifapplicableVancomycin (IV)1,2,61,62(Use actual bodyweight; Excel AUC dosecalculator encouraged,especially for obese.Vancomycin PO1,2,63Voriconazole(IV/PO)1,2,64,65(Dose by adjusted BWin obese)CrCl 10 – 50 mL/minCrCl 50 mL/minCrCl 10 mL/minCrCl 10 – 30CrCl 30CrCl 50: 1 g q8hCrCl 30-50: 1 g q12hInitial episode: 1 g q12hRecurrent episode:500 mg q12hCrCl 50:2 g q12h x 2 dosesCrCl 30 – 50:1 g q12h x 2 dosesIntermittentHemodialysis (IHD)CRRT 101 g q24h500 mg q24hInitial episode: 1 g q24hRecurrent: 500 mg q24hInitial/recurrentepisode:500 mg q24h500 mg q12h x 2 doses500 mg x 1 dose500 mg q24hNo dataDose daily, but after HD on HDdaysCrCl 60CrCl 40 – 59CrCl 25 – 39CrCl 10 – 24CrCl 10; IHDCRRTInduction (14-21 days)900 mg q12h450 mg q12h450 mg q24h450 mg q48h200 mg 3x/week after HD onlyNo dataMaintenance/ prophylaxis900 mg q24h450 mg q24h450 mg q48h450 mg twice/week100 mg 3x/week after HD onlyNo dataConsider loading dose of 20 – 35 mg/kg (max 3 g) for severe infectionsCrClDose & FrequencyTotal daily dose range(mL/min) 9015 mg/kg q8h – 12h; use AUC calculator30 – 45 mg/kg/day51 – 8910 – 20 mg/kg q12h; use AUC calculator20 – 40 mg/kg/day10 – 15 mg/kg q12h to 20 mg/kg q24h;30 – 5020 – 30 mg/kg/dayuse AUC calculator10 – 2910 – 15 mg/kg q24h to 15 mg/kg q48h 10 or AKI15 mg/kg x 1, then dose by levelGoal AUC/MIC ratio: 400-600 (most indications)Refer to Vancomycin Guide for complete guidelines7.5 – 15 mg/kg/dayN/APoor systemic absorption- used for the treatment of Clostridium difficile-associated diarrheaMild/moderate/severe: 125 mg PO q6hSevere complicated (CDI-related septic shock, ileus, toxic megacolon): 500 mg PO q6hIV: 6 mg/kg IV q12h x 2,then 4 mg/kg IV q12hPO: 400 mg PO q12h x 2,then 200 mg PO q12h15 – 20 mg/kg x 1,then re-dose per algorithm(see Appendix E ofVancomycin per PharmacyProtocol)No change20 mg/kg x 1, then15 mg/kg q24h or given as24h continuous infusionAdjust to levelsNo changeIV PO conversion 1:1 (round to ne

Dosing Guide Timing of levels: Draw trough 30 min prior to 4th dose. Draw peak 30 min after infusion ends Once daily dosing: goal peak 35 – 60 mcg/mL; goal trough 4 mcg/mL Conventional dosing: goal peak 25 – 35 mcg/mL for serious infections; 15 – 20 mcg/mL for UTI; goal trough 4 – 8 mcg/mL CrCl 60CrCl 40 – CrCl 2040 Conventional

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Antimicrobial Peptides 2 ANTIMICROBIAL PEPTIDES OFFERED BY BACHEM Ribosomally synthesized antimicrobial peptides (AMPs) constitute a structurally diverse group of molecules found virtually in all organisms. Most antimicrobial peptides contain less than 100 amino acid residues, have a net positive charge, and are membrane active. They are major

Anatomi jalan lahir penting untuk keberhasilan kelahiran . Jalan Lahir Bagian tulang terdiri atas tulang- tulang panggul. - os coxae - os sacrum - os coccygis Bagian lunak (Diafragma pelvis )terdiri atas otot- otot , jaringan, dan ligament. - Pars muskulus levator ani - Pars membranasea - Regio perineum Tulang panggul terdiri atas a. os. Coxae (inominata) - os. Ilium - os. Ischium - os. Pubis .