Grownup Antimicrobial Dosing, Non-dialysis | Infectious Ailments Administration Program at UCSF

Adult Antimicrobial Dosing, Non-dialysis | Infectious Diseases Management Program at UCSF
June 7, 2021 0 Comments

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

Dosing weight as follows:

  • Complete physique weight (TBW) < IBW: Use TBW
  • Complete physique weight 1-1.2x IBW: Use IBW
  •  If Complete BW > 1.2 occasions Ideally suited BW, use Adj BW

 

AmBisome (liposomal amphotericin B)

Indication

Dose

Notes

Invasive fungal infections 5 mg/kg IV q24h

No adjustment for renal dysfunction; monitor serum creatinine and electrolytes

Prophylaxis (Heme/BMT) 3 mg/kg IV q24h

*Use Complete Physique Weight if Complete Physique Weight < Ideal Body Weight.  If Total Body Weight >1.2 occasions Ideally suited Physique Weight, use Adjusted Physique Weight

IV Fluids: Give 500mL Regular Saline earlier than and after AmBisome administration if capable of tolerate

Unrestricted Indications
1) Documented or suspected fungal pneumonia in a affected person illiberal of or with contraindications to azoles

2) Prophylaxis in opposition to fungal infections in sufferers on the hematology/BMT service or lung transplant service

3) Empiric remedy for extended febrile neutropenia in hematology/oncology/BMT affected person

All different indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow

Amikacin

Indication CrCl > 60 mL/min 40 – 60 mL/min 20 – 40 mL/min < 20 mL/min
Excessive-dose prolonged interval (“once-daily”): sufferers with regular renal perform who should not morbidly overweight or fluid overloaded 15 mg/kg IV q24h

Use conventional dosing or seek the advice of ID pharmacy for steering

Conventional dosing: sufferers who don’t qualify for high-dose prolonged 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 & seek the advice of ID pharmacy for upkeep dose

Monitoring

Indication

Monitoring

Excessive-dose prolonged interval (“once-daily”)

Single stage: Test random drug stage 6-14 hours after the beginning of infusion.  Examine to nomogram (beneath)

Paired ranges: Test peak drug stage 2 hours after and random stage 6-14 hours after infusion.  Seek the advice of ID pharmacy for help.

Conventional dosing Paired ranges: Test peak drug stage half-hour after finish of infusion (purpose 20-30 mg/L) and trough stage instantly earlier than subsequent dose (purpose <4 mg/L).

Nomogram:

 

 

 

 

 

 

 

**If amikacin 20 mg/kg is used. Modify the measured stage with the next equation earlier than plotting the extent onto the Amikacin 15mg/kg Prolonged Interval Nomogram Stage for the plot = Measured stage x 0.75

All use of intravenous amikacin requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

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

Ampicillin

Indication

CrCl > 50 mL/min

10 – 50 mL/min

< 10 mL/min

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

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

Artesunate

Indication Dose
All Indications 2.4 mg/kg IV at 0 hours, 12 hours, and 24 hours, adopted by 2.4 mg/kg IV q24h

Non-formulary. Requires approval from ID seek the advice of service and pharmacy supervisor.

Azithromycin

Indication Dose Notes
Group-acquired pneumonia, ICU 500 mg IV/PO q24h No adjustment for renal dysfunction
Group-acquired pneumonia, non-ICU 500 mg IV/PO x1 then 250 mg IV/PO q24h

Aztreonam

Indication

CrCl > 50 mL/min

10 – 50 mL/min < 10 mL/min
All indications

2 g IV q8h 

2 g IV q12h 1 g IV q12h  

Aztreonam lacks cross-reactivity with most different beta-lactams; nevertheless, most sufferers who’ve a recorded beta-lactam allergy can obtain one other beta-lactam via screening, take a look at dosing, or pores and skin testing. See Inpatient Allergy Tips

Baloxavir marboxil

Indication Dosage Notes
Influenza therapy, uncomplicated, 40-79kg 40 mg PO x1 No renal dose adjustment
Influenza therapy, uncomplicated, >80kg 80 mg PO x1

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Caspofungin

Indication Dose Notes
All indications 70 mg IV x 1, then 50 mg IV q24h No renal dose adjustment. Enhance upkeep dose to 70 mg when given with CYP3A4 inducers (phenytoin, rifampin, carbamazepine, dexamethasone, or efavirenz). 

Unrestricted Indications (choose indication on order entry):

1) Documented sterile website (not urine or respiratory) an infection  with microbiologically confirmed Candida glabrata or Candida kruseii

2) Documented sterile website an infection (not urine or respiratory) an infection with yeast, pending species identification

3) Prophylaxis in opposition to fungal infections in sufferers on the hematology/oncology/BMT service with intolerance of or contraindications to azoles

4) Empiric remedy for extended febrile neutropenia in hematology/oncology/BMT affected person

All different indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow

Cefazolin

Indication CrCl > 35 mL/min 10 – 35 mL/min < 10 mL/min
Uncomplicated Gram-Optimistic An infection 1 g IV q8h 1 g IV q12h 1 g IV q24h
Gram-Damaging or Sophisticated Gram-Optimistic An infection 2 g IV q8h 2 g IV q12h 1 g IV q24h

Cefepime

Indication CrCl > 60 mL/min 30 – 60 mL/min 10 – 29 mL/min < 10 mL/min
Typical dosing 2 g IV q12h 2 g IV q24h 1 g IV q24h 500 mg IV q24h
Febrile neutropenia, meningitis, Pseudomonas aeruginosa 2 g IV q8h 2 g IV q12h 2 g IV q24h 1 g IV q24h

Cefiderocol

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

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ceftaroline

Indication CrCl >50 mL/min 30-50 mL/min 15-30 mL/min <15 mlL/min
Pores and skin/Smooth Tissue Infections or Group-acquired Pneumonia with low MRSA danger 600 mg IV q12h 400 mg IV q12h 300 mg IV q12h 200 mg IV q12h
Extreme Infections, Pneumonia with documented or suspected MRSA 600 mg IV q8h 600 mg IV q12h 400 mg IV q12h 300 mg IV q12h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ceftazidime

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

Ceftazidime/avibactam (Avycaz)

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 suggestions are expressed as complete grams of the ceftazidime/avibactam mixture.

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ceftolozane/tazobactam (Zerbaxa)

Indication CrCl >50 mL/min 30-50 mL/min 15-29 mL/min
Sophisticated urinary tract an infection 1.5 g IV q8h 750 mg IV q8h 375 mg IV q8h
Pneumonia, extreme infections 3 g IV q8h 1.5 g IV q8h 750 mg IV q8h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ceftriaxone

Indication Dose Notes
Regular dose 1 g IV q24h No renal dose adjustment
Endocarditis, Osteomyelitis, Septic Arthritis 2 g IV q24h  No renal dose adjustment

Meningitis & Enteroccocal Endocarditis (together with ampicillin)

2 g IV q12h No renal dose adjustment

Cidofovir

Indication Standards to provoke: CrCl >55 mL/min, SCr<1.5 mg/dL, urine protein <100mg/dL Enhance in SCr of 0.3-0.4 mg/dL Enhance in SCr of >0.5 mg/L or 3+ proteinuria
Systemic Infections: Induction 5 mg/kg IV as soon as weekly WITH probenecid 3 mg/kg IV ever week WITH probenecid Discontinue
Systemic Infections: Upkeep 5 mg/kg IV as soon as each 2 weeks WITH probenecid 3 mg/kg IV each 2 weeks WITH probenecid Discontinue
BK viruria in kidney or bone marrow transplant sufferers 0.25 – 0.5 mg/kg IV as soon as weekly WITHOUT probenecid

Unrestricted Indications (choose on order entry):

1) Unrestricted use on the hematology/oncology/BMT service

All different use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ciprofloxacin

Indication CrCl > 50 mL/min 30 – 50 mL/min < 30 mL/min
Pyelonephritis/Sophisticated UTI & Intra-abdominal Infections

400 mg IV q12h

500 mg PO BID

400 mg IV q12h

500 mg PO BID

400 mg IV q24h

500 mg PO day by day

Pseudomonas infections (non-urinary tract)

400 mg IV q8h

750 mg PO q12h

400 mg IV q12h

500 mg PO q12h

400 mg IV q24h

500 mg PO day by day

Clindamycin

Indication Dose Notes
Uncomplicated An infection

600 mg IV q8h

450 mg PO q8h

No renal dose adjustment
Necrotizing Smooth Tissue An infection & Group A Streptococcus An infection 900 mg IV Q8h No renal dose adjustment

Clofazimine

Indication Dosing Notes
All Indications 100 mg PO q24h No adjustment for renal perform

Colistin IV

Indication Dosing
All IV Indications 5 mg/kg IV x1 loading dose, then contact ID pharmacy for upkeep dose suggestions

Dosing for inhaled colistin per main crew protocols

Different simpler, less-toxic brokers can be found for many severe Gram-negative rod infections.  In circumstances the place an IV polymyxin is critical, polymyxin B needs to be used preferentially for non-urinary tract infections in adults.

All use of IV colistin requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow.  Inhaled use of colistin is allowed for unrestricted use in prophylaxis in lung transplant.

Dalbavancin

Indication CrCl >30 mL/min <30 mL/min
Single-dose routine (pores and skin/smooth tissue an infection) 1500 mg IV x1 dose 1125 mg IV x1 dose
Two-dose routine (pores and skin/smooth tissue an 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

Different dosing methods used for therapy of bone/joint infections or bacteremia.

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Daptomycin

Indication CrCl > 30 mL/min < 30 mL/min
All indications 8 – 10 mg/kg IV q24h 8 – 10 mg/kg IV q48h

*If Complete BW >1.2 occasions ideally suited physique weight, use adjusted physique weight

Not efficient in therapy of pneumonia.

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Doxycycline

Indication Dose Notes
All indications 100 mg IV/PO q12h No renal dose adjustment

Eravacycline

Indication Dosing Notes
All Indications

1mg/kg IV q12h

Concomitant sturdy CYP3A4 Inducers: 1.5 mg/kg IV q12h

No dose adjustment for renal dysfunction

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

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Ertapenem

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

Ethambutol

Weight CrCl > 30 mL/min < 30 mL/min
40 kg – 55 kg 800 mg PO q24h 800 mg PO thrice weekly
56 kg – 75 kg 1200 mg PO q24h 1200 mg PO thrice weekly
76 kg – 90 kg 1600 mg PO q24h 1600 mg PO thrice weekly

Dose based mostly on ideally suited physique weight. Drug is obtainable in 400mg and 100mg tablets.

Fidaxomicin

Indication Dosing Notes
Clostridium difficile an infection 200 mg PO q12h No adjustment for renal dysfunction

All use requires authorization from the Antimicrobial Stewardship Program or the consulting ID fellow

Fluconazole

Indication CrCl > 50 mL/min 10 – 50 mL/min < 10 mL/min
Oropharyngeal An infection 100 mg IV/PO q24h 50 mg IV/PO q24h 50 mg IV/PO q24h
Esophageal An infection 200 mg IV/PO q24h 100 mg IV/PO q24h 50 mg IV/PO q24h
Candidasis  400 mg IV/PO q24h 200 mg IV/PO q24h 100 mg IV/PO q24h
Extreme Infections

≤ 80 kg: 400mg IV/PO q24h

81 – 100 kg: 600 mg IV/PO q24h

> 100 kg: 800 mg IV/PO q24h

≤ 80 kg: 200mg IV/PO q24h

81 – 100 kg: 300 mg IV/PO q24h

> 100 kg: 400 mg IV/PO q24h

≤ 80 kg: 100mg IV/PO q24h

81 – 100 kg: 150 mg IV/PO q24h

> 100 kg: 200 mg IV/PO q24h

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

Foscarnet

Unrestricted Indications (choose on order entry):

1) Use on hematology/oncology/BMT service

All different use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Fosfomycin

Indication CrCl > 50 mL/min < 50 mL/min
Uncomplicated cystitis 3 g PO x 1 dose 3 g PO x 1 dose
Sophisticated cystitis 3 g PO each 2 days x 3 doses 3 g PO each 3 days x 3 doses

Ganciclovir

Indication CrCl >70 mL/min 50-69 mL/min 25-49 mL/min 10-24 mL/min
CMV Induction 5 mg/kg IV q12h 2.5 mg/kg IV q12h 2.5 mg/kg IV q24h 1.25 mg/kg IV q24h
CMV Maintentance 2.5 mg/kg IV q12h 2.5 mg/kg IV q24h 1.25 mg/kg IV q24h 0.625 mg/kg IV q24h

Gentamicin

Use conventional dosing or seek the advice of ID pharmacy for steering

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 help
Gram-negative infections, high-dose prolonged interval (“once-daily”): sufferers with regular renal perform who should not morbidly overweight or fluid overloaded.  5-7 mg/kg IV q24h Use conventional dosing or contact pharmacy for help
Gram-negative infections, conventional dosing: sufferers who don’t qualify for high-dose prolonged 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 upkeep

*If Complete BW > 1.2 occasions Ideally suited BW, use Adj BW.

Monitoring:

Indication

Monitoring

Gram-positive synergy Paired ranges: Test peak drug stage half-hour after finish of infusion (purpose 3-4 mg/L) and trough instantly earlier than subsequent dose (purpose <1 mg/L)
Gram-negative high-dose prolonged interval (“once-daily”)

Single stage: Test random drug stage 6-14 hours after the beginning of infusion.  Examine to nomogram beneath.

Paired ranges: Test peak drug stage 1 hour after finish of infusion and random stage 6-14 hours after infusion.  Seek the advice of ID pharmacy for help.

Gram-negative conventional dosing Paired ranges: Test peak drug stage half-hour after finish of infusion (purpose 5 – 8 mg/L) and trough stage instantly earlier than subsequent dose (purpose <2 mg/L).

Nomogram:

Imipenem/cilastatin

Indication CrCl >90 mL/min 60-90 mL/min 30-60 mL/min 15-30 mL/min
Gram-negative or Nocardia infections 500 mg IV q6h 400 mg IV q6h 300 mg IV q6h 200 mg IV q6h
Nontuberculous mycobacterial infections Seek the advice of ID/ID Pharmacy for dosing suggestions

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Imipenem/cilastatin/relebactam

Indication CrCl >90 mL/min 60-90 mL/min 30-60 mL/min 15-30 mL/min

All Indications

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

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

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Isavuconazole

Indication Dose Notes
All Indications 372 mg IV/PO Q8h x 6 doses (complete of 48h), then 372 mg Q24h No renal dose adjustment

372mg of isavucazonium (prodrug) = 200mg of isavuconazole

Unrestricted Indications: 1) Documented or suspected fungal pneumonia in a affected person with extended QT interval 2) Prophylaxis in opposition to fungal infections on the hematology/oncology/BMT service or lung transplant service in a affected person with extended QT interval All different use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Isoniazid

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

Letermovir

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 suggestions obtainable

Unrestricted Indications (present on order entry):

1) CMV prophylaxis on heme/BMT service

All different use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Levofloxacin

Indication CrCl > 50 mL/min 20-49 mL/min <20mL/min
Normal Dosing 500mg IV/PO Q24h 500 mgx1, then 250mg IV/PO Q24h 500mg x1, then 250mg IV/PO Q48h
Pneumonia or Pseudomonas infections 750mg IV/PO Q24h 750mg IV/PO Q48h 750mg x1, then 500mg IV/PO Q48h

Keep away from co-administration of the oral formulation with divalent/trivalent cations (e.g. calcium, magnesium, zinc) – separate by not less than 2 hours.

Linezolid

Indication Dose Notes
All Indications 600mg IV/PO q12h No renal dose adjustment

Use in Adults at UCSFMC hospitals isn’t restricted.

All use in pediatric sufferers at UCSF requires approval from the Pediatric Antimicrobial Stewardship Program or pediatric ID doctor

Meropenem

Indication > 50mL/min 26 – 50 mL/min 10 – 25 mL/min < 10mL/min
Normal 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

Meropenem/vaborbactam

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

4g = 2g meropenem + 2g vaborbactam

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

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Metronidazole

Indication CrCl >10 mL/min CrCl < 10 mL/min
All Indications 500 mg IV/PO Q8h 500 mg IV/PO Q12h

Minocycline

Indication Dosing Notes
All Indications 200 mg IV/PO x1, then 100 mg IV/PO q12h No adjustment for renal dysfunction

Moxifloxacin

Indication Dosing Notes
All Indications 400 mg IV/PO q24h No adjustment for renal dysfunction

Nafcillin

Indication Dosing Notes
Meningitis, osteomyelitis or endovascular an infection 2 g IV Q4h

 

No renal dose adjustment

Uncomplicated an infection 1 g IV Q6h

Nitrofurantoin (Macrobid)

Indication CrCl > 60 mL/min < 60 mL/min
Cystitis Therapy 100 mg PO q12h Information restricted for CrCl<60 mL/min; contemplate options
Cystitis Prophylaxis 100 mg PO q24h

Omadacycline

Indication Dosing Notes

All Indications

PO: should quick for not less than 4 hours earlier than and a couple of hours after dose

200 mg IV x1, then 100 mg IV q24h

450 mg PO day by day x2 doses, then 300 mg PO day by day

No adjustment for renal dysfunction

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Oritavancin

Indication Dosing Notes
All Indications 1200 mg IV x1 over 3 hours No adjustment for renal dysfunction

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Oseltamivir

Indication CrCl > 60 mL/min 31-60mL/min 10-30mL/min
Influenza therapy 75 mg PO BID 30 mg PO BID 30 mg PO BID
Influenza prophylaxis 75mg PO day by day 30mg PO day by day 30mg PO each different day

Penicillin G

Indication CrCl > 50 mL/min CrCl 10 – 50 mL/min CrCl < 10 mL/min
Meningitis, endovascular 4 million items IV q4h 4 million items IV q6h 4 million items IV q8h
Uncomplicated an infection 2 million items IV q6h 2 million items IV q8h 2 million items IV q12h

Peramivir

Indication CrCl >50 mL/min 30-50 mL/min 10-30 mL/min <10 mL/min
All Indications 600 mg IV q12h 200 mg IV q24h 100 mg IV q24h 100 mg IV x1, then 15 mg IV q24h

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Piperacillin/tazobactam (Zosyn) EXTENDED INFUSION

Indication CrCl > 20 mL/min <20 mL/min

All Infections, together with documented/suspected Pseudomonas 

Exclusion standards for EXTENDED INFUSION: resistant or intermediate susceptibility organism, cystic fibrosis, peri-procedural areas, inadequate IV entry

Loading dose = 4.5 g IV over 30 min x1, then 4.5 g IV infused over 4h each 8h (beginning 4h after loading dose) Use SHORT INFUSION piperacillin/tazobactam

UCSF: PREFERRED dosing technique if no exclusions

Piperacillin/tazobactam SHORT Infusion (SI) (Zosyn)

Indication  > 50 mL/min 10 – 50 mL/min < 10 mL/min
NOTE: (UCSF Solely) Use SHORT INFUSION just for sufferers excluded from EXTENDED INFUSION dosing

Non-Pseudomonas infections

3.375 g IV q6h

3.375 g IV q8h

2.25 g IV q8h
Documented/Suspected Pseudomonas aeruginosa an infection

CrCl > 20 mL/min:

4.5 g IV q6h

CrCl < 20 mL/min:

3.375 g IV q8h

 

ONLY for sufferers excluded from EI dosing at UCSF. Exclusion standards for EI: Resistant or intermediate organism, cystic fibrosis, periprocedural areas, inadequate IV entry 

Plazomicin

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

If Complete BW >1.2 occasions Ideally suited BW, use Adjusted BW

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Polymyxin B

Indication Dosing Be aware
All Indications 2.5 mg/kg IV x1, then 1.5 mg/kg IV q12h No renal dose adjustment

There are different simpler, much less poisonous options for many multidrug-resistant Gram-negative infections.  If a polymyxin is required, polymyxin B is most popular for intravenous therapy of systemic infections in adults. For therapy of urinary tract infections, or use through inhalation, use colistin (polymyxin E).

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Posaconazole

Indication Dosing Notes
All Indications (IV or Delayed-release pill) 300 mg IV/PO q12h x 2 doses, then 300 mg IV/PO q24h No renal dose adjustment (keep away from IV if attainable in sufferers with CrCl <50 mL/min as a consequence of accumulation of IV car)

Take with meals.  Posaconazole SOLUTION has extra frequent dosing, low bioavailability, and important meals restrictions.  Don’t substitute SOLUTION for TABLETS or IV with out dialogue with ID Pharmacy.

Overview drugs for potential drug interactions.

Posaconazole trough ranges needs to be obtained in most sufferers, whether or not receiving the agent for prophylaxis or therapy of fungal infections.  Trough samples needs to be obtained 5-7 days after: 
-start of remedy
-change in dose
-change in route of administration
-change in doubtlessly interacting medication

See UCSF Lab Posaconazole Suggestions  for specifics of monitoring.

Unrestricted indications:

1) Prophylaxis in opposition to fungal infections in sufferers on the hematology/oncology/BMT service or lung transplant service with intolerance of or contraindications to voriconazole

2) Suspected or documented fungal pneumonia within the hematology/BMT/lung transplant providers

3) Empiric remedy for extended febrile neutropenia in hematology/oncology/BMT affected person

All different indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow

Pyrazinamide

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

20-25 mg/kg PO q24h:

40 – 55 kg: 1000mg q24h

56 – 75 kg: 1500mg q24h

76 – 90 kg: 2000mg q24h

25 – 35mg/kg PO thrice weekly

Equipped as 500mg tablets

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 suggestions

Rifampin

Indication Dosing Notes
Mycobacterial infections 600 mg IV/PO q24h

 

No renal dose adjustment

Prosthetic machine infections 300 mg IV/PO q12h
Endocarditis 300 mg IV/PO q8h

Overview drugs for potential drug interactions.

Tedizolid

Indication Dosing Notes
All Indications 200 mg IV/PO q24h No adjustment for renal dysfunction

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

Tigecycline

Indication Dosing Notes
All Indications 100 mg IV x1, then 50 mg IV q12h

No adjustment for renal dysfunction

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

All use requires authorization from the Antimicrobial Stewardship Program or consulting ID fellow

TMP/SMX (trimethoprim/sulfamethoxazole)

Indication CrCl > 50 mL/min 10 – 50 mL/min < 10 mL/min
Systemic GNR infections 10mg TMP/kg/day IV/PO divided Q6-12h 5-7.5mg TMP/kg/day IV divided Q12-24h 2.5-5mg TMP/kg IV Q24h
Pnemocytisis pneumonia  15 – 20mg TMP/kg/day IV/PO divided Q6 – 12h 10-15mg TMP/kg/day IV divided Q12-24h 5-10mg TMP/kg IV Q24h

Single-strength (SS) pill comprises 80 mg trimethoprim (TMP)

Double-strength (DS) pill comprises 160 mg trimethoprim (TMP)

*Might contemplate Complete BW for severe infections

Tobramycin

Use conventional dosing or seek the advice of ID pharmacy for steering

Indication CrCl > 60 mL/min 40-60 mL/min 20-40 mL/min <20 mL/min
Excessive-dose prolonged interval (“once-daily”): sufferers with regular renal perform who should not morbidly overweight or fluid overloaded.  7 mg/kg IV q24h Use conventional dosing or contact pharmacy for help
Conventional dosing: sufferers who don’t qualify for high-dose prolonged 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 upkeep

*If Complete BW > 1.2 occasions Ideally suited BW, use Adj BW.

Monitoring:

Indication

Monitoring

Gram-negative high-dose prolonged interval (“once-daily”)

Single stage: Test random drug stage 6-14 hours after the beginning of infusion.  Examine to nomogram.

Paired ranges: Test peak drug stage 1 hour after finish of infusion and random stage 6-14 hours after infusion.  Seek the advice of ID pharmacy for help.

Gram-negative conventional dosing Paired ranges: Test peak drug stage half-hour after finish of infusion (purpose 5 – 8 mg/L) and trough stage instantly earlier than subsequent dose (purpose <2 mg/L). 

Valganciclovir (Valcyte)

Indication CrCl > 60 mL/min 40 – 59 mL/min 25 – 39 mL/min 10 – 24 mL/min
CMV Induction 900 mg PO q12h 450 mg PO q12h 450 mg PO q24h 450 mg PO each different day
CMV Upkeep 900 mg PO q24h 450 mg PO q24h 450 mg PO q48h 450 mg PO twice weekly

CMV prophylaxis: confer with particular person service protocol 

Vancomycin IV

 

Physique Weight**

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

Sophisticated* & 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 based on ranges

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

**Use Complete Physique Weight for sufferers <120% of Ideal Body Weight. Use Adjusted Body Weight for patients >120% of Ideally suited Physique Weight.

Suggest loading dose (20-25 mg/kg IV x1) for severe infections together with CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis

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

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

*If Complete BW > 1.2 occasions Ideally suited BW, use Adj BW

Vancomycin PO

Indication Dose Notes
Clostridioides difficile an infection: uncomplicated 125 mg PO QID No renal dose adjustment
Clostridioides difficile an infection: sophisticated 500 mg PO QID

PO vancomycin is NOT sufficiently absorbed to deal with systemic infections

Voriconazole

Indication Dosing Notes
All Indications, IV Route 6mg/kg IV Q12h x 2 doses, then 4mg/kg IV Q12hr Danger/profit consideration for IV formulation for CrCl<50 mL/min, as IV car accumlates; contemplate PO

All Indications, PO Route

In overweight sufferers contemplate a weight-based PO routine (4mg/kg q12H ADJ BW), Seek the advice of ID or ASP for help. 

400mg PO Q12h x doses, then 200mg PO Q12* No renal dose adjustment

Overview drugs for potential drug interactions.

Voriconazole has excessive inter- and intra-patient variability.  Voriconazole trough ranges needs to be obtained in most sufferers, whether or not receiving the agent for prophylaxis or therapy of fungal infections.  Trough samples needs to be obtained 3-5 days after: 
-start of remedy
-change in dose
-change in route of administration
-change in doubtlessly interacting medication

See UCSF Lab Voriconazole Suggestions  for specifics of monitoring.

Unrestricted Indications:

1) Prophylaxis in opposition to fungal infections on the hematology/BMT/lung transplant providers 

2) Suspected or documented fungal pneumonia within the hematology/BMT/lung tranpslant providers

3) Empiric remedy for extended febrile neutropenia in hematology/oncology/BMT affected person

All different indications require approval from the Antimicrobial Stewardship Program or consulting ID fellow

Leave a Reply

Your email address will not be published. Required fields are marked *