antibiotics_renal

					Medication                  Dosing in renal impairment                            Dosing in RRT                                     Note
Beta-lactams
Piperacillin/tazobactam     usual dose: 2.25-4.5 gm Q6-8H                         HD: 2.25 gm Q8H-12H + 0.75 gm AD                  Moderate
(Tazocin®)                  10-50: 2.25-3.375 gm Q6H                              CAPD: 2.25 gm Q8-12H                              dialyzable
(2 gm/250 mg per vial)      <10: 2.25-3.375 gm Q8H                                CVVH: 4.5 gm Q12H or 2.25 gm Q8H (AAC.            (30-50%)
                                                                                  2002; 46: 1557-60.)
                                                                                  CVVHD or CVVHDF: 2.25-3.375 gm Q6H
Ticarcillin/clavulanic      usual dose: 1.6-3.2 gm Q6-8H (max: 3.2 gm Q4H)        HD: 1.6 gm Q12H + 3.2 gm AD                       Moderate
acid                        10-50: 1.6-3.2 gm Q8H                                 CAPD: 3.1 gm Q12H                                 dialyzable
(Timentin®)                 <10: 1.6-3.2 gm Q12H                                  CVVH: 1.6 gm Q6-8H                                (20-50%)
(1.5 gm/100 mg per vial)    hepatic impairment: 3.2 gm Q24H                       CVVHD or CVVHDF: 3.1 gm IV Q6H
Amoxicillin/clavulanate     usual dose: 600-1200 mg Q8H                           HD: 300-600 mg Q24H                               Moderate
(Augmentin®)                10-50: 600-1200 mg Q12H                               CAPD: 300 mg Q12H                                 dialyzable
(500/100mg per vial)        <10: 600-1200 mg Q24H                                 CVVH: no data                                     (20-50%)
Piperacillin (Pitamycin®)   usual dose: 3-4 gm Q4-6H (max: 24 gm/day)             HD: 2 gm Q8H and 1 gm AD                          Moderate
(500 mg/vial)               10-50: 3-4 gm Q6-8H                                   CAPD, CVVH: 3-4 gm Q8H                            dialyzable
                            <10: 3-4 gm Q8H                                                                                         (20-50%)
Sulbactam (Maxtam®)         usual dose: 0.75-1.5 gm Q6-8H (for PDRAB)             HD: 0.75-1.5 gm Q24H AD
(500 mg/vial)               10-50: 0.75-1.5 gm Q12-24H                            CAPD: 0.75-1.5 gm Q24H
                            <10: 0.75-1.5 gm Q24-48H                              CVVH: 0.75-1.5 gm Q12H
Cephalosporins
Ceftazidime (Fortum®)       usual dose: 250-500 mg Q8-12H (UTI)                   HD: 1 gm loading then 1 gm AD                     Dialyzable
(500 mg/vial)               2 gm Q8H (intra-abdominal infection, meningitis, or   IP for peritonitis: 1-1.5 gm/exchange, Q24H       (50-100%)
                            severe pneumonia)                                     (intermittent); 500 mg/L loading, then 125 mg/L
                            30-50 mg/kg Q8H (P. aeruginosa pneumonia, max.        (continuous)
                            6 gm/day)                                             CVVH: 0.25-0.75 gm Q12H
                            10-50: 1-2 gm Q24-48H                                 CVVHD: 0.5-1.0 gm Q12H (AAC. 2000;
                            <10: 1-2 gm Q48H                                      44:1639-44.)
Ceftizoxime (Epocelin®)     usual dose: 1-2 gm Q8-12H to 2 gm Q4H or 4 gm         HD: 500 mg Q24H or 1 gm AD                        Moderate
(250 mg/vial)               Q8H (life-threatening infections)                     CAPD: 0.5-1 gm Q24H                               dialyzable
                            10-50: 1-2 gm Q12-24H                                 IP for peritonitis: 1 gm/exchange, Q24H           (20-50%)
                            <10: 1-2 gm Q24H                                      (intermittent); 250 mg/L loading, then 125 mg/L
                                                                                  (continuous)
                                                                                  CVVH: 1-2 gm Q12-24H
Ceftriaxone (Rocephin®)     usual dose: 1-2 gm Q12H                               HD: no dose adjustment is necessary               Not dialyzable
(500 mg/vial)               No dose adjustment needed (Hepatic metabolism         CAPD: 750 mg Q12H                                 (0-5%)
                            and elimination)                                      CVVH, CVVHD or CVVHDF: 2 gm Q12-24H
Cefotaxime (Claforan®)      usual dose: 1 gm Q8-12H (moderate to severe           HD: 1-2 gm Q24H + 1 gm AD                         Moderate
(250 mg/vial)               infection) to 2 gm Q6-8H (sepsis or septic shock)     CAPD: 0.5-1 gm Q24H                               dialyzable
                            10-50: 1-2 gm Q8-12H                                  CVVH: 1-2 gm Q12H                                 (20-50%)
                            <10: 1-2 gm Q24H                                      CVVHD or CVVHDF: 2 gm Q12H
Cefepime (Maxipime®)        usual dose: 0.25-2 gm Q8-12H                          HD: 1 gm loading then 0.5-1 gm Q24H AD            Moderate
(500 mg/vial)               0.5-1 gm Q12H (UTI)                                   CAPD: 1-2 gm Q48H (AAC. 1992; 36:1387-91)         dialyzable
                            2 gm Q8H (febrile neutropenia)                        IP for peritonitis: 1 gm/exchange, once daily     (40-65%)
                            10-50: 0.25-2 gm Q16-24H                              (intermittent); 500 mg/L loading, then 125 mg/L
                            <10: 0.25-2 gm Q24H                                   (continuous)
                                                                                  CVVH, CVVHD or CVVHDF: 1 gm Q12H or 2
                                                                                  gm Q24H (AAC. 2001;45: 3148-55.)
Cefuroxime (Zinacef®)       usual does: 500-750 mg Q8H (CBAE, pneumonia,          HD: 750 mg Q24H                                   Moderate
(750 mg/vial)               or UTI) to 1.5 gm Q6-8H (severe infection)            CAPD: 0.75-1.5 gm Q24H                            dialyzable
                            10-50: 0.75-1.5 gm Q8-12H                             CVVH: 0.75-1.5 gm Q12H                            (25%)
                            <10: 0.75-1.5 gm Q24H
Cefmetazole                 usual dose: 1-2 gm Q6-12H (max dose: 8 gm/day)        HD: 1-2 gm Q48H (AAC. 1990;34: 519-23.)           Moderate
(Cefmetazon®)               10-50: 1-2 gm Q24H                                    CAPD: 1-2 gm Q48H                                 dialyzable
(500 mg/vial)               <10: 1-2 gm Q48H                                      CVVH: 1-2 gm Q24H                                 (~60%)
Flomoxef                    usual dose: 1-2 gm Q12H (max dose: 4 gm/day)          HD: 0.5-1.0 gm AD                                 Moderate
(Flumarin®)                 40-60: 50% dose Q8-12H                                CAPD: 1 gm Q24H                                   dialyzable
(500 mg/vial)               20-40: 40% dose Q8-12H                                CVVH: no data                                     (~80%)
                            <20: 20% dose Q24H
Aminoglycosides
Amikacin (Amikin®)          usual dose: 5-7.5 mg/kg Q8H                           HD: supply 50-75% dose AD                         Moderate
(250 mg/vial)               >60: 100% dose Q8H                                    1-2 mg/kg for gentamicin                          dialyzable
                            40-60: 100% dose Q12H                                 5-7 mg/kg for amikacin                            (~50-75%)
                            20-40: 100% dose Q24H                                 suggest monitor serum concentration
                            <20: 100% dose Q24-48H                                CVVH: supply following dose during CVVH
Gentamicin (Genta-C®)       usual dose: 2-2.5 mg/kg (severe infection), 1.5       2.5 mg/kg for gentamicin
(80 mg/vial)                mg/kg (UTI) to 1 mg/kg (syngerstic dose) Q8H          4.0 mg/kg for amikacin
                            >60: 100% dose Q8H                                    suggest monitor serum concentration
                            40-60: 100% dose Q12H                                 (adapted from Gerald L. Mandell, et al.,
                            20-40: 100% dose Q24H                                 Principles and Practice of Infectious Diseases)
                            <20: 100% dose Q24~48H
Isepamicin (Exacin®)        usual dose: 8 mg/kg Q12H or 15 mg/kg Q24H             HD: 7.5 mg/kg AD (Clin Pharmacokinetics           Moderate
(200 mg/amp)                40-59: 8 mg/kg Q24H                                   2000; 38: 205-33.)                                dialyzable
                            20-39: 8 mg/kg Q48H                                   CVVH: 15 mg/kg but the dosing interval should     (~60%)
                            10-19 : 8 mg/kg Q72H                                  be determined by monitoring plasma
                            6-9: 8 mg/kg Q96H (Clin Pharmacokinetics 2000;        concentration (AAC. 1999;43:2409-11.)
                            38: 205-33.)
Antifungal Agents
Fluconazole (Diflucan®)    usual dose: 400-800 mg Q24H (blood-stream            HD: 200 mg AD CAPD: 200 mg Q24-48H (Ann           Moderate
(50 mg/cap, 100 mg/vial)   infection); 200 mg Q24H (UTI)                        Pharmacother. 1998; 32: 1284-9.)                  dialyzable
                           10-50: 50% dose Q24H                                 CVVH: 200-400 mg Q12H                             (~50%)
                           <50: 50% dose Q24H                                   CVVHD or CVVHDF: 400-800 mg Q24H
                                                                                (Eur J Clin Pharmacol. 2000; 56: 671-8.)
Amphotericin B             usual dose: 0.25-1.5 mg/kg Q24H                      HD, CAPD, CVVH, CVVHD, or CVVHDF:                 Poor dialyzable
(Fungizon®)                10-50: 100% dose Q24H                                0.4-1.0 mg/kg Q24H
(50 mg/vial)               <10: 100% dose Q24-36H
Caspofungin                usual dose: 70 mg and then 50 mg Q24H (for aspergillosis and Candidasis)
(Cancidas®)                No specific dosage adjustment is required
(50 mg/vial)
Fluoroquinolones
Ciprofloxacin              usual dose: 400 mg Q8-12H (NP or severe              HD: 200 mg Q12H or 400 mg Q24H                    Poor dialyzable
(Ciproxin®)                complicated infection)                               CAPD: 400 mg Q24H (AAC. 2001;                     (<10%)
(100 mg/bot)               100-250 mg Q12H (UTI)                                45:2949-54)
                           10-50: 200-300 mg Q12H                               CCPD: 600 mg Q12H (Perit Dial Int. 2004; 24:
                           <10: 200 mg Q12H                                     447-53.)
                                                                                IP for peritonitis: no data (intermittent); 50
                                                                                mg/L loading, then 25 mg/L (continuous)
                                                                                CVVH: 200 mg Q12H
                                                                                CVVHD or CVVHDF: 200-400 mg Q12H
Levofloxacin (Cravit®)     usual dose: 500-750 mg Q24H (pneumonia,              HD or CAPD: load 500 mg, then 250 mg
(250 mg/bot)               CBAE); 250 mg Q24H (UTI)                             Q48H; 750 mg, then 500 mg Q48H (for NP)
                           20-50: 500 mg loading then 250 mg Q24H               CVVH, CVVHD or CVVHDF: 250 mg Q24H
                           (moderate infection); 750 mg loading then 750 mg
                           Q48H (severe infection)
                           <20: 500 mg loading then 250 mg Q48H (moderate
                           infection); 750 mg loading then 500 mg Q48H
                           (severe infection)
Moxifloxacin (Avelox®)     usual dose: 400 mg Q24H
(400 mg/bot)               No dose adjustment is necessary in renal impairment patients
Carbapenems
Ertapenem (Invanz®)        usual dose: 1 gm Q24H (intra-abdominal, skin         HD: 500 mg Q24H + 150 mg AD (Drugs. 2003;
(1 gm/vial)                infection, CAP or UTI)                               63:1855-78)
                           >30: 1 gm Q24H                                       CAPD, CVVH, CVVHD or CVVHDF: no data
                           <30: 500 mg Q24H
Meropenem (Mepem®)         usual dose: 1-2 gm Q8H for susceptible infection     HD: 500 mg Q24H                                   50% dialyzed by
(500 mg/vial)              26-50: 0.5-2 gm Q12H                                 (Clin Pharmacokinet. 2000; 39:271-9)              intermittent HD;
                           10-25: 0.25-1 gm Q12H                                CAPD: 250-500 mg Q24H                             25-50%
                           <10: 0.25-1 gm Q24H                                  CVVH, CVVHD or CVVHDF: 0.75 gm-1 gm               eliminated by
                           (Clin Pharmacokinet. 2000; 39:271-9)                 Q12H (Crit Care Med. 2000; 28:632-7)              CVVH
Imipenem and cilastatin    usual dose: 750 mg Q12H (moderate infection)         HD: 500 mg Q12H + 250-500 mg AD                   73% imipenem/
(Tienam®)                  250-500 mg Q6H (for UTI); 0.5-1 gm Q6-8H             CAPD: 0.25-1 gm Q6H                               32% cilastatin
(250 mg/vial)              (severe infection; max. 50 mg/day or 4 gm/day)       CVVH: 500 mg Q12H (AAC. 2005; 49: 2421-8.)        were dialyzed
                           10-50: usual dose Q6-12H                             CVVHD, CVVHDF: 250 mg Q6H or 500 mg               during 4 hr HD
                           <10: usual dose mg Q12H                              Q8H
Aztreonam (Azactam®)       usual dose : 0.5-1.0 gm Q8-12H (UTI)                 HD: 500 mg AD                                     Moderate
(1 gm/vial)                2 gm Q6-8H (severe infection)                        CAPD: 0.25-2 gm then 125-500 mg Q8-12H            dialyzable
                           10-49: 50-75% dose Q8H                               CVVH: 1-2 gm Q12H                                 (27-58%)
                           <10: 25% dose Q8H                                    CVVHD, CVVHDF: 2 gm Q12H
Glycopeptides
Vancomycin (Vancocin®)     usual dose: 1.0 gm Q12H or 10-15 mg/kg/dose          HD: 500 mg BIW or 1 gm QW                         Not dialyzable
(500 mg/vial)              10-50: 0.5-1 gm Q24-48H                              CAPD: 0.5-1 gm Q2-3H                              (except high-flux
                           <10: 0.5-1 gm Q48-96H                                IP for peritonitis: 15-30 mg/kg Q5-7D             HD)
                                                                                (intermittent); 1000 mg/L loading, then 25 mg/L
                                                                                (continuous)
                                                                                CVVH: 1 gm Q48H
                                                                                CVVHD or CVVHDF: 1 gm Q24H
Teicoplanin (Targocid®)    usual dose:                                          HD: 6 mg/kg (400 mg) Q72H (Clin
(200 mg/vial)              6 mg/kg (~400 mg) Q12H for 3 doses, then 6 mg/kg Pharmacokinetics 2000; 39: 167-83.)
                           (~400 mg) Q24H                                       CAPD: 20 mg/L in each bag for 10 days for
                           12 mg/kg (~800 mg) Q12H for 3 doses, then 12         peritonitis (AAC. 1996; 40: 1971-2.)
                           mg/kg (~800 mg) Q24H (septic arthritis, burn, or IE) 10 mg/kg Q24H for systematic infection (Perit
                           40-60: 100% dose Q48H                                Dial Int. 2003;23:127-31.)
                           <40: 100% dose Q72H                                  CVVH: no data
Linezolid (Zyvox®)         usual dose: 600 mg Q12H (for MRSA, VRE infection)                                                      Hepatic
(600 mg/ vial)             No dosage adjustment is necessary in renal impairment or patients receiving hemodialysis               metabolism
Miscellaneous
Clindamycin (Clincin®)     usual dose: 600-900 mg Q8H (max: 4.8 gm/day)         HD, CAPD, CVVH, CVVHD or CVVHDF: No
(300 mg/amp)               No dosage adjustment is necessary                    dose adjustment is necessary
Metronidazole (SABS®)      usual dose: 7.5 mg/kg Q6H (max: 4 gm/day)            HD, CAPD: 7.5 mg/kg Q12H AD                       extensive
(500 mg/bot)               <10: 75% dose Q6-12H                                 CVVH: 7.5 mg/kg Q6-12H                            dialyzable
SMX-TMP                    usual dose: 160/800 mg Q12H (Pneumonia or            HD: 160/800 mg Q24H                               44% TMP and
(Cotrimoxazole®)           URI); 4-5/20-25 mg/kg Q6H (P. carinii pneumonia)     CAPD, CVVH, CVVHD or CVVHDF: no data              57% SMX
(80 mg SMX 400 mg          15-25: 160/800 mg Q12H for 3 days then Q24H                                                            dialyzed during
TMP/vial)                  <15: NOT recommended, except for HD patients                                                           4 h HD

				
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