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Renal dosing and insufficiency: Drug dosing considerations

Acyclovir IV

Dosing

  • Usual Dosage: 5 - 10 mg/kg q8h
  • CrCl 30 - 49 mL/min: Usual dose q12h
  • CrCl 10 - 29 mL/min: Usual dose q24h
  • ESRD (CrCl < 10 mL/min): 50% of usual dose q24h
    • Monitor for CNS toxicity
  • PD: 50% of usual dose q24h
    • Monitor for CNS toxicity
  • HD: 50% of usual dose q24h
    • On dialysis days, give daily dose towards the end of HD
    • Monitor for CNS toxicity
  • CRRT: Usual dose q12h

Administration:  To reduce the risk of crystalline nephropathy, infuse 500 mL normal saline before starting acyclovir infusion. Infuse NS at 100 mL/h for a total infusion time of 5 hours.

*Restricted to Critical Care Medicine, Infectious Diseases and Neurology/Neurosurgery for herpes encephalitis

Acyclovir ORAL

Dosing

  • Usual Dosage: Variable
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: 800 mg q8h. Max 2400 mg per day.
  • ESRD (CrCl < 10 mL/min): 800 mg q12h. Max 1600 mg per day.
    • Monitor for CNS toxicity
  • PD: 800 mg q12h. Max 1600 mg per day.
    • Monitor for CNS toxicity
  • HD: 800 mg q12h. Max 1600 mg per day.
    • On dialysis days, give one of the doses after HD
    • Monitor for CNS toxicity
  • CRRT: Usually IV acyclovir is used

Amantadine

Dosing

  • Usual Dosage: 100 mg q12h
  • CrCl 60 - 79 mL/min: 200 mg q2days (i.e., day 1, 3, 5, etc) alternating with 100 mg q2days (i.e., day 2, 4, 6, etc)
  • CrCl 40 - 59 mL/min: 100 mg daily
  • CrCl 30 - 39 mL/min: 100 mg 4 days per week
  • CrCl 20 - 29 mL/min: 100 mg 3 days per week
  • CrCl 10 - 19 mL/min: 200 mg q2weeks (i.e., week 1, 3, 5, etc) alternating with 100 mg q2weeks (i.e., week 2, 4, 6, etc)
  • ESRD (CrCl < 10 mL/min): 100 mg once weekly
  • PD: 100 mg once weekly
  • HD: 100 mg once weekly (not significantly dialyzed)
  • CRRT: 100 mg q48h

Amikacin

Please refer to the guideline for aminoglycosides.

Amoxicillin

Dosing

  • Usual Dosage: 500 mg q8h
  • ESRD (CrCl < 10 mL/min): Usual dosage
  • PD: Usual dosage
  • HD: Usual dosage
    • On dialysis days, give one of the doses towards the end of HD (removed by HD)
  • CRRT: Usual dosage

Amoxicillin + clavulanic acid

Dosing

Oral Formulation: 

  • Dose adjustment not required

IV Formulation:

  • > 30 mL/min: No change
  • 10-30 mL/min: 1000 mg/200 mg followed by 500 mg/100 mg every 12 hours
  • < 10 mL/min: 1000 mg/200 mg followed by 500 mg/100 mg every 24 hours
  • Hemodialysis: 1000 mg/200 mg followed by 500 mg/100 mg 24 hourly, plus a dose of 500 mg/100 mg at the end of dialysis (as serum concentrations of both amoxicillin and clavulanic acid are decreased)

Amphotericin B

Dosing

  • Usual Dosage: 0.5 to 1 mg/kg q24h
  • No dosage adjustment for renal impairment or dialysis

Amphotericin B Liposomal

Dosing

  • Usual Dosage: 3 to 5 mg/kg q24h
  • No dosage adjustment for renal impairment or dialysis

*Restricted to Infectious Diseases

Ampicillin IV

Dosing

  • Usual Dosage: 2 g q4 - 6h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: 2 g IV q6h
  • ESRD (CrCl < 10 mL/min): 2 g q8 - 12h
  • PD: 2 g q8 - 12h
  • HD: 2 g q8 - 12h
    • On dialysis days, give one of the doses towards the end of HD (removed by HD)
  • CRRT: 2 g q4 - 6h
  • SLED: 2 g q4 - 6h on dialysis days; and ESRD dosing on non-dialysis days

Atovaquone

Dosing

  • Usual Dosage: Variable
  • No dosage adjustment for renal impairment or dialysis

Azithromycin

Dosing

  • Usual Dosage: 250 to 500 mg q24h
  • No dosage adjustment for renal impairment or dialysis

Caspofungin

Dosing

  • Usual Dosage: 70 mg load, then 50 mg q24h
  • No dosage adjustment for renal impairment or dialysis

* Restricted to Infectious Diseases

Cefazolin

Dosing

  • Usual Dosage: 1 to 2 g q8h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: 1 to 2 g q12h
  • ESRD (CrCl < 10 mL/min): 1 to 2 g q24h
  • PD: 1 to 2 g q24h
  • HD: 1 to 2 g 3 days per week towards the end of HD (removed by HD).
    • No dose on non-dialysis days.
  • CRRT: Usual dosage
  • SLED: 1 to 2 g q8h on dialysis days; and ESRD dosing on non-dialysis days

Ceftazidime

Dosing

  • Usual Dosage: 2 g q8h
  • CrCl 30 - 49 mL/min: 2 g q8h
  • CrCl 10 - 29 mL/min: 2 g q12h
  • ESRD (CrCl < 10 mL/min): 2 g q24h
  • PD: 2 g q24h
  • HD: 2 g q24h
    • On dialysis days, give dose towards the end of HD (removed by HD).
  • CRRT: Usual dosage
  • SLED: 2 g q8h on dialysis days; and ESRD dosing on non-dialysis days

Ceftriaxone

Dosing

  • Usual Dosage: 1 g q24h (Exceptions: 2 g q12h for meningitis, infective endocarditis, osteomyelitis)
  • No dosage adjustment for renal impairment or dialysis

Cefuroxime ORAL

Dosing

  • Usual Dosage: 500 mg q12h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dosage
  • ESRD (CrCl < 10 mL/min): Usual dosage
  • PD: Usual dosage
  • HD: Usual dosage
    • On dialysis days, give one of the doses after HD (removed by HD).
  • CRRT: Usual dosage

Cephalexin

Dosing

  • Usual Dosage: 500 mg q6h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dosage
  • ESRD (CrCl < 10 mL/min): Usual dosage
  • PD: Usual dosage
  • HD: Usual dosage
    • On dialysis days, give one of the doses after HD (removed by HD).
  • CRRT: Usual dosage

Ciprofloxacin

Dosing

Creatinine Clearance ≥ 30 mL/min

Usual Dose:

  • Oral: 500 mg PO q12h
  • IV: 400 mg IV q12h

High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

  • Oral: 750 mg PO q12h
  • IV: 400 mg IV q8h

Creatinine Clearance < 30 mL/min

Usual Dose:

  • Oral: 500 mg PO q24h
  • IV: 400 mg IV q 24h*

*In critical illness use 400mg IV q12h1,2

High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

  • Oral: 750 mg PO q24h
  • IV: 400 mg IV q12h*

*In critical illness use 400mg IV q8h1,2

Automatic Substitution Policy:

  • Orders for 200 mg IV q12h will be converted to 400 mg IV q24h

Peritoneal Dialysis (PD)

Usual Dose:

  • Oral: 500 mg PO q24h*
  • IV: 400 mg IV q24h*

*In peritoneal dialysis related peritonitis higher doses of 500mg PO q12h or 400mg IV q12h can be considered3,4

High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

  • Oral: 750 mg PO q24h*
  • IV: 400 mg IV q12h*

*In peritoneal dialysis related peritonitis higher doses of 750mg PO q12h or 400mg IV q8h should be considered3,4

Hemodialysis (HD)

Usual Dose:

  • Oral: 500 mg PO q24h
  • IV: 400 mg IV q24h
  • Schedule without regard to time of HD, since only about 10% is removed with HD

High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

  • Oral: 750 mg PO q24h
  • IV: 400 mg IV 12h
  • Schedule without regard to time of HD

Continuous Renal Replacement Therapy (CRRT)

Usual Dose:

  • Oral: 500 mg PO q12h
  • IV: 400 mg IV q12h

High-Dose Therapy (i.e., for Pseudomonas or bone and joint infections):

  • Oral: 750 mg PO q12h
  • IV: 400 mg IV q8h

References:

  1. de Vroom SL, et al. Pharmacokinetic/pharmacodynamic target attainment of ciprofloxacin in adult patients on general wards with adequate and impaired renal function. Int J Antimicrob Agents. 2020 Nov;56(5):106166
  2. Gieling EM, et al. Higher Dosage of Ciprofloxacin Necessary in Critically Ill Patients: A New Dosing Algorithm Based on Renal Function and Pathogen Susceptibility. Clin Pharmacol Ther. 2020 Oct;108(4):770-774.
  3. Yeung SM, et al. Pharmacokinetics of oral ciprofloxacin in continuous cycling peritoneal dialysis. Perit Dial Int. 2004 Sep-Oct;24(5):447-53.
  4. Lee C, et al. Steady-State Pharmacokinetics of Oral Ciprofloxacin in Continuous Cycling Peritoneal Dialysis Patients: Brief Report. Perit Dial Int. 2018 Jan-Feb;38(1):73-76
  5. Brown P, et al. Principles of Drug Dosing in Sustained Low Efficiency Dialysis (SLED) and Review of Antimicrobial Dosing Literature. Pharmacy (Basel). 2020 Mar 9;8(1):33

Clarithromycin

Dosing

  • Usual Dosage: 500 mg q12h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dosage
  • ESRD (CrCl < 10 mL/min): 500 mg load, then 250 mg q12h
  • PD: 500 mg load, then 250 mg q12h
  • HD: 500 mg load, then 250 mg q12h
  • CRRT: Usual dosage

Clindamycin

Dosing

Usual Dosage:
  • Intravenous: 600 mg IV q8h*
  • Oral: 300 – 450 mg PO q6h
  • *Exception: 900 mg IV q8h in combination with beta-lactam for necrotizing skin and soft tissue infection

No dosage adjustment for renal impairment or dialysis

Cloxacillin IV

Dosing

  • Usual Dosage: 2 g IV q4 - 6h
  • No dosage adjustment for renal impairment or dialysis

Colistin

Dosing

Loading dose (for all patients): 300 mg IV x1; then followed with maintenance dosing:

Maintenance Dose (for non-dialysis): Dose based on calculated creatinine clearance

Creatinine Clearance (mL/min)

Dose Recommendation*

0 67.5 mg Q12H
5 to <10 75 mg Q12H
10 to <20 82.5 mg Q12H
20 to <30 90 mg Q12H
30 to <40 97.5 mg Q12H
40 to <50 112.5 mg Q12H
50 to <60 120 mg Q12H
60 to <70 135 mg Q12H
70 to <80 150 mg Q12H
80 to <90 172.5 mg Q12H
≥ 90 180 mg Q12H

*Given normal and expected fluctuations in creatinine during therapy, consider dose adjustments only when there is a clear trend of change in renal function.

Maintenance Dose in Dialysis:

  • IHD:
    • Non-dialysis days: 67.5 mg IV Q12H
    • Dialysis days: 90 mg IV Q12H (one dose given before dialysis, the other following dialysis)
  • SLED: dose similarly to iHD (assumes a 3-4 hour session)*
    *If SLED is longer than 4 hours, Infectious Diseases/ pharmacy for dosing assistance
  • CRRT: 217.5 mg IV Q12H
  • PD: 82.5 mg IV Q12H

  • For the Treatment of Pneumonia
    • Consider the addition of inhaled colistimethate 75 mg inhaled BID

References:

  1. International Consensus Guidelines for the Optimal Use of the Polymyxins: Endorsed by the American College of Clinical Pharmacy (ACCP), European Society of Clinical Microbiology and Infectious Diseases (ESCMID), Infectious Diseases Society of America (IDSA), International Society for Antiinfective Pharmacology (ISAP), Society of Critical Care Medicine (SCCM), and Society of Infectious Diseases Pharmacists (SIDP). Pharmacotherapy. 2019 Jan;39(1):10-39.
  2. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment. Perit Dial Int. 2016;36 (5): 481-508

Co-trimoxazole (TMP/SMX)

Dapsone

Dosing

  • Usual Dosage: Dose varies with indication
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dosage
  • ESRD (CrCl < 10 mL/min): Usual dosage
  • PD: Usual dosage
  • HD: Usual dosage
    • On dialysis days, give dose after HD (removed by HD).
  • CRRT: Usual dosage

Daptomycin

Dosing

  • Usual Dosage:
    • 4 to 6 mg/kg q24h for skin and soft tissue infections
    • 6 to 10 mg/kg q24h for bloodstream infections
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: 4 to 6 mg/kg q48h
  • ESRD (CrCl < 10 mL/min): 4 to 6 mg/kg q48h
  • PD: 4 to 6 mg/kg q48h
  • HD: 4 to 6 mg/kg q48h
  • CRRT: Usual dosage
  • SLED: Limited data supports extensive elimination via SLED
    • 4 to 6 mg q24h on SLED days; and ESRD dosing on non-dialysis days
    • If patient receiving SLED every second day, then give 4 – 5 mg q24h on SLED day, and no drug on off day.

* Restricted to Infectious Diseases

Doxycycline

Dosing

  • Usual Dosage: 100 to 200 mg/day
  • No dosage adjustment for renal impairment or dialysis

Ertapenem

Dosing

  • Usual Dosage: 1 g q24h
  • CrCl 30 - 49 mL/min: Usual dose
  • CrCl 10 - 29 mL/min: 500 mg q24h
  • ESRD (CrCl < 10 mL/min): 500 mg q24h
  • PD: 500 mg q24h
  • HD: 500 mg q24h
    • On dialysis days, give dose towards the end of HD.
  • CRRT: Usual dose
  • SLED: 1 g IV q24h on dialysis days; and ESRD dosing on non-dialysis days

Erythromycin

Dosing

  • Usual Dosage: 500 mg q6h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dosage
  • ESRD (CrCl < 10 mL/min): Usual dosage
  • PD: Usual dosage
  • HD: Usual dosage.
  • CRRT: Max 2 g/day

Ethambutol

Dosing

  • Usual Dosage: 15 to 25 mg/kg q24h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dose 3 days per week
  • ESRD (CrCl < 10 mL/min): Usual dose 3 days per week
  • PD: Usual dose 3 days per week
  • HD: Usual dose 3 days per week after HD
  • CRRT: 15 mg/kg q24h

Fluconazole

Dosing

  • Usual Dosage: 200 to 800 mg q24h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dose q48h
  • ESRD (CrCl < 10 mL/min): Usual dose q48h
  • PD: Usual dose q48h
  • HD: Usual dose 3 days per week
    • If IV, give towards the end of HD
    • If PO, give after HD
  • CRRT: 600 mg q24h

* Restricted to Critical Care Medicine and Infectious Diseases

Foscarnet

Ganciclovir

Dosing

Usual Dosage:

  • Induction: 5 mg/kg q12h
  • Maintenance: 5 mg/kg q24h
Induction Maintenance
CrCl 50 - 69 mL/min: 2.5 mg/kg q12h 2.5 mg/kg q24h
CrCl 30 - 49 mL/min: 2.5 mg/kg q24h 1.25 mg/kg q24h
CrCl 10 - 29 mL/min: 1.25 mg/kg q24h 0.625 mg/kg q24h
ESRD (CrCl < 10 mL/min): 1.25 mg/kg 3 days per week 0.625 mg/kg 3 days per week
PD: 1.25 mg/kg 3 days per week 0.625 mg/kg 3 days per week
HD:

1.25 mg/kg 3 days per week

Give dose towards the end of HD.

0.625 mg/kg 3 days per week

Give dose towards the end of HD
CRRT: 2.5 mg/kg q12h
2.5 mg/kg q24h


 *Restricted to Infectious Diseases

Gentamicin

Please refer to the guideline for aminoglycosides.

Isoniazid

Dosing

  • Usual Dosage: 5 mg/kg q24h. Max 300 mg.
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dosage
  • ESRD (CrCl < 10 mL/min): Usual dosage
  • PD: Usual dosage
  • HD: Usual dosage
    • On dialysis days, give dose after HD.
  • CRRT: Usual dosage

Itraconazole

Dosing

  • Usual Dosage: 100 to 200 mg q12h
  • No dosage adjustment for renal impairment or dialysis

* Restricted to Infectious Diseases

Levofloxacin

Dosing

  • Usual Dosage: 750 mg q24h
  • CrCl 30 - 49 mL/min: 750 mg load; then 500 mg q24h
  • CrCl 10 - 29 mL/min: 750 mg q48h
  • ESRD (CrCl < 10 mL/min): 750 mg load, then 500 mg q48h
  • PD: 750 mg load, then 500 mg q48h
  • HD: 750 mg load, then 500 mg q48h
    • Schedule dose without regard to time of HD.
  • CRRT: Usual dosing

Linezolid

Dosing

  • Usual Dosage: 600 mg q12h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dosage
  • ESRD (CrCl < 10 mL/min): Usual dosage
  • PD: Usual dosage
  • HD: Usual dosage (see below)
    • If IV, on dialysis days, give one of the doses towards the end of HD
    • If PO, on dialysis days, give one of the doses after HD.
  • CRRT: Usual dosage
  • SLED: Usual dosage (see below)
    • If IV, on dialysis days, give one of the doses towards the end of SLED
    • If PO, on dialysis days, give one of the doses after SLED.

* Restricted to Infectious Diseases

Meropenem

Dosing

Usual Dosage:

  • Non-Deep Seated Infection: 500 mg q6h
  • Deep Seated Infections (meningitis, endocarditis, or osteomyelitis): 2 g q8h
Non-Deep Seated Infection Deep Seated Infection 
CrCl 30 - 49 mL/min: Usual dose 2 g load; then 500mg q6h
CrCl 10 - 29 mL/min: 500 mg q8h 2 g load; then 500 mg q6h
ESRD (CrCl < 10 mL/min): 500 mg q12h 1 g load; then 500 mg q8h
PD: 500 mg q12h 1 g load; then 500 mg q8h
HD:

500 mg q12h

On dialysis days, give one of the doses towards the end of HD.

1 g load; then 500 mg q8h

On dialysis days, give one of the doses towards the end of HD.

CRRT: Usual dose Usual dose
SLED: Usual dose on dialysis days; and ESRD dosing on non-dialysis days Usual dose on dialysis days; and ESRD dosing on non-dialysis days


* Restricted to Critical Care Medicine and Infectious Diseases

Metronidazole

Dosing

  • Usual Dosage: 500 mg q12h (Exception: 500 mg q8h for C. difficile infection, brain abscess)
  • No dosage adjustment for renal impairment or dialysis

Moxifloxacin

Dosing

  • Usual Dosage: 400 mg q24h
  • No dosage adjustment for renal impairment or dialysis

Nitrofurantoin

Dosing

  • CrCl < 40 mL/min: Avoid (due to lack of efficacy) 
  • ESRD (CrCl < 10 mL/min): Avoid
  • PD: Avoid
  • HD: Avoid
  • CRRT: Avoid

Oseltamivir

Dosing

Usual Dosage:

Treatment Prophylaxis
CrCl unknown 75 mg BID; to be re-assessed when CrCl known 75 mg now; then 75 mg once daily; to be re-assessed when CrCl known
CrCl > 60 mL/min 75 mg BID 75 mg now; then 75 mg once daily
CrCl 30 - 60 mL/min: 45 mg BID 45 mg now; then 45 mg once daily
CrCl 10 - 29 mL/min: 45 mg once daily 45 mg now; then 45 mg q 2 days
ESRD (CrCl < 10 mL/min): 75 mg now; then one additional 75 mg dose on day 3 45 mg now; then 45 mg q 3 days
PD: 75 mg now; then one additional 75 mg dose on day 3 45 mg now; then 45 mg q 3 days
HD:

75 mg now; then 75 mg after each of the next 2 HD

45 mg now; then 45 mg post-HD x 3 doses per week

CRRT: 45 mg BID 45 mg now; then 45 mg once daily

Penicillin IV

Dosing

  • Usual Dosage: 2 to 4 MU q4 - 6h (no dosage reduction for oral)
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Max 16 MU/day (e.g., 4 MU q6h)
  • ESRD (CrCl < 10 mL/min): Max 12 MU/day (e.g., 4 MU q8h)
  • PD: Max 12 MU/day (e.g., 4 MU q8h)
  • HD: Max 12 MU/day (e.g., 4 MU q8h)
    • On dialysis days, give one of the doses towards the end of IHD.
  • CRRT: Usual dosage

Pentamidine

Dosing

  • Usual Dosage: 4 mg/kg q24h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dosage
  • ESRD (CrCl < 10 mL/min): Usual dose q24 - 36h
  • PD: Usual dose q24 - 36h
  • HD: Usual dose q24 - 36h
  • CRRT: Usual dosage

* Restricted to Infectious Diseases

Piperacillin + Tazobactam

Dosing

  • Usual Dosage:
    • Non-Pseudomonas Therapy: 3.375 g q6h
    • Pseudomonas Therapy: 4.5 g q6h
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dose q8h
  • ESRD (CrCl < 10 mL/min): Usual dose q12h
  • PD: Usual dose q12h
  • HD: Usual dose q12h
    • On dialysis days, give one of the doses towards the end of HD
  • CRRT: Usual dosage
  • SLED: Usual dosage on dialysis days; ESRD dosing on non-dialysis days

Posaconazole

Dosing

  • Usual Dosage: Variable
  • No dosage adjustment for renal impairment or dialysis

Primaquine

Dosing

  • Usual Dosage: 15 to 30 mg q24h
  • No dosage adjustment for renal impairment or dialysis

Pyrazinamide

Dosing

  • Usual Dosage: 25 to 35 mg/kg q24h. Max 2.5 g.
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: Usual dose 3 days per week
  • ESRD (CrCl < 10 mL/min): Usual dose 3 days per week
  • PD: Usual dose 3 days per week
  • HD: Usual dose 3 days per week on HD days to be given after HD
  • CRRT: Usual dosage

Pyrimethamine

Dosing

  • Usual Dosage: 50 to 75 mg q24h
  • No dosage adjustment for renal impairment or dialysis

Rifampin

Dosing

  • Usual Dosage: 600 mg q24h
  • No dosage adjustment for renal impairment or dialysis

Tetracycline

Dosing

  • Usual Dosage: Dose varies with indication
  • CrCl 30 - 49 mL/min: Avoid
  • CrCl 10 - 29 mL/min: Avoid
  • ESRD (CrCl < 10 mL/min): Avoid
  • PD: Avoid
  • HD: Avoid
  • CRRT: Avoid

Ticarcillin + Clavulanate

Dosing

  • Usual Dosage: 3.1 g q6h
  • CrCl 30 - 49 mL/min: 3.1 g q6h
  • CrCl 10 - 29 mL/min: 3.1 g q8h
  • ESRD (CrCl < 10 mL/min): 3.1 g q12h
  • PD: 3.1 g q12h
  • HD: 3.1 g q12h
    • On dialysis days, give one of the doses towards the end of HD
  • CRRT: 3.1 g q6h

* Non-Formulary. Restricted to Infectious Diseases for Stenotrophomonas infections.

Tigecycline

Dosing

  • Usual Dosage: 100 mg load; then 50 mg q12h
  • No dosage adjustment for renal impairment or dialysis

*Non-Formulary. Restricted to Infectious Diseases

Tobramycin

Please refer to the guideline for aminoglycosides.

Trimethoprim

Dosing

  • Usual Dosage: 100 mg q12h (monotherapy for uncomplicated UTI)
  • CrCl 30 - 49 mL/min: Usual dosage
  • CrCl 10 - 29 mL/min: 75% of the usual total dose per day
  • ESRD (CrCl < 10 mL/min): 100 mg q24h
  • PD: 100 mg q24h
  • HD: 100 mg q24h
  • CRRT: Usual dosage

Valacyclovir

Dosing

  • Usual Dosage: 1 g q8 - 12h
  • CrCl 30 - 49 mL/min: 1 g q12h.
  • CrCl 10 - 29 mL/min: 500 mg q8h.
  • ESRD (CrCl < 10 mL/min) or PD: 1 g q24h.
    • Monitor for CNS toxicity.
  • PD: 1 g q24h.
    • Monitor for CNS toxicity.
  • HD: 1 g q24h.
    • On dialysis days, give daily dose after HD.
    • Monitor for CNS toxicity.
  • CRRT: Usually use IV acyclovir

Vancomycin IV

Please refer to the Vancomycin Antimicrobial Guideline.

Voriconazole PO

Dosing

  • Usual Dosage: 6 mg/kg q12h x 2 doses; then 4 mg/kg q12h*
  • CrCl 30 - 49 mL/min: Usual dosage*
  • CrCl 10 - 29 mL/min: Usual dosage*
  • ESRD (CrCl < 10 mL/min): Usual dosage*
  • PD: Usual dosage*
  • HD: Usual dosage*
  • CRRT: Usual dosage*

* Tablets available in 50 mg and 200 mg strength. Round dose to the nearest 50 mg.
** Restricted to Infectious Diseases; also Hematology-Oncology (for prophylaxis in patients receiving AML-type chemotherapy)

Voriconazole IV

Dosing

  • Usual Dosage: 6 mg/kg q12h x 2 doses; then 4 mg/kg q12h
  • CrCl 30 - 49 mL/min: Usual dosage (oral preferred – see below)
  • CrCl 10 - 29 mL/min: Usual dosage (oral preferred – see below)
  • ESRD (CrCl < 10 mL/min) or PD: Usual dosage (oral preferred – see below)
  • PD: Usual dosage (oral preferred – see below)
  • HD: Usual dosage (oral preferred – see below)
  • CRRT: Usual Dosage*

NOTE: If CrCl < 50 mL/min, oral therapy is preferred since the IV product contains an ingredient that accumulates in renal insufficiency. If the oral route is not an option, weigh the benefits and potential risks when considering IV therapy.

* Restricted to Infectious Diseases; also Hematology-Oncology (for prophylaxis in patients receiving AML-type chemotherapy