Adult ORH Pharmacy Antimicrobial Dosing …

1 Adult ORH Pharmacy Antimicrobial Dosing Guideline chart (1/21/07) Antibiotic Name Usual Dose CrCl > 7574 - 50 49 - 30 29 - 10 < 10 HD CRRT Acyclovir (Zovirax) 5-10 mg/kg Q8H Q8H Q12H Q24H 50% Q24H 50% Q24H Q12H Ampicillin (Principen) 1-2g Q4-6H Q4-6H Q6H Q8H Q12H Q12H Q6H Ampicillin/Sulbactam (Unasyn) Q6H Q6H Q6-8H Q12H Q24H Q24H Q8H Aztreonam (Azactam) 1-2 g Q8H Q8H Q8H Q12H Q24H Q24H Q8H Cefazolin (Ancef) 1-2 g Q8H Q8H Q8H Q12H Q24H Q24H Q8H Cefepime (Maxipime) (Pseudomonas or serious infection) 1g Q6H Q6H Q8H Q12H Q24H Q24H Q8H Cefepime (Maxipime)

2 1g Q8H Q8H Q12H Q24H 500mg Q24H 500mg Q24H Q12H Cefotetan (Cefotan) 1g Q12H Q12H Q12H Q24H Q48H Dose after HDQ12H Cefuroxime (Zinacef) 750-1500 mg Q8H Q8H Q8H Q12H Q24H Dose after HDQ12H Ciprofloxacin (Cipro) 400 mg Q8H Q8H Q12H Q24H Q24H Q24H Q12H Daptomycin (Cubicin) 4-6 mg/kg Q24H Q24H Q24H Q48H Q48H Q48H Q48H Fluconazole (Diflucan) 400-800 mg Q24H Q24H Q24H 50% Q24H 25% Q24H 25% Q24h Q24h Ganciclovir (Cytovene) 5 mg/kg Q12H 50% Q12H 50% Q24H 25% Q24H 25% Q48H 25% and dose after HD 50% Q24h Imipenem (Primaxin) 500 mg Q6H Q8H Q8H Q12H 50% Q12H 50% Q12H Q8H Meropenem (Merrem)

3 500 mg Q6H Q6H Q6H Q8H Q12H Q12H Q6H Ticarcillin/Clavulanate (Timentin) g Q4H Q6H 2g Q4H 2g Q8H 2g Q12H 2g Q12H Q6H TMP/SMX (Bactrim) 5 mg/kg Q6-8H Q6-8H Q8H Q12H Q24H Q24H Q12H Valacyclovir (Valtrex) PO 1 g Q8-12H Q8-12H Q12H Q24H 50% Q24H 50% Q48H No data Valganciclovir (Valcyte) PO 900mg Q12H 50% Q12H 50% Q24H 50% Q48H Avoid: use ganciclovir Avoid.

4 Use ganciclovir No data Voriconazole (Vfend) IV 4 mg/kg after LD (6 mg/kg) Q12H Q12H Do not use IV dosage Do not use IV dosage Do not use IV dosage Do not use IV dosage Do not use IV dosage Adult ORH Pharmacy Antimicrobial Dosing Guideline chart (1/21/07) CrCl (ml/min) > 40 39 - 20 < 20 HD CRRT Piperacillin/Tazobactam (Zosyn) Pseudomonas or serious infection Q6H Q6H Q6H Q6H Q6H Piperacillin/Tazobactam (Zosyn) Other infections Q6H IV Q6H Q8H Q8H Q6H Drug Non-Obese Dosing Weight Morbid Obesity* Amikacin (Amikin) ABW Adjusted BW (see aminoglycoside protocol) TMP/SMX (Bactrim) ABW ABW Daptomycin (Cubicin) ABW ABW Gentamicin (Garamycin) ABW Adjusted BW (see aminoglycoside protocol) Dalfo/Quinu (Synercid) ABW ABW Tobramycin (Nebcin/Tobi) ABW Adjusted BW (see aminoglycoside protocol) Vancomycin (Vancocin) ABW ABW Antibacterials Colistin (Coly-Mycin)

5 IBW IBW Amphotericin B (Fungizone) IBW IBW Fluconazole (Diflucan) ABW ABW Antifungals Voriconazole (Vfend) ABW ABW Acyclovir (Zovirax) IBW IBW Antivirals Ganciclovir (Cytovene) ABW ABW *Patients with ABW > 150 kg may warrant a discussion with the on-call/satellite mentor clinical pharmacist Drugs that do not require renal Dosing Amphotericin B (Fungizone) Anidulafungin (Eraxis) Azithromycin (Zithromax) Caspofungin (Cancidas) Clindamycin (Cleocin) Dalfopristin/Quinupristin (Synercid) Doxycycline (Vibramycin) Ertapenem (Invanz) Linezolid (Zyvox) Lipid Complex Ampho B (Abelcet) Liposomal Ampho B (Ambisome) Metronidazole (Flagyl) Moxifloxacin (Avelox) Nafcillin (Nafcil) Oxacillin (Bactocill) Rifampin (Rifadin) Tigecycline (Tygacil) Adult ORH Pharmacy Antimicrobial Dosing Guideline chart (1/21/07) 1) Trotman RL, Williamson JC, Shoemaker DM, et al.

6 Antibiotic Dosing in critically ill Adult patients receiving continuous renal replacement therapy. CID 2005;41:1159-66. 2) Klasco RK (Ed): DRUGDEX System. Thomson Micromedex, Greenwood Village, Colorado (Edition expires 9/2006]). 3) Lexi-Comp, Inc. (Lexi-DrugsTM ). Lexi-Comp, Inc.; September 19, 2006. 4) Scheetz MH, Hurt KM, Noskin GA, et al. Applying Antimicrobial Pharmacodynamics to resistant gram-negative pathogens. Am J Health-Syst Pharm 2006;63:1346-59. 5) Lodise TP, Lomaestro BM, Drusano GL. Application of Antimicrobial pharmacodynamic concepts into clinical practice: focus on -lactam antibiotics.

7 Pharmacotherapy 2006;26(9):1320-32. 6) Tam VH, Adams S, LaRocco MT, et al. An integrated pharmacoeconomic approach to Antimicrobial formulary decision-making. Am J Health-Syst Pharm 2006;63:735-9. 7) Cappelletty D. Evaluation of several Dosing regimens of cefepime, with various simulations of renal function, against clinical isolates of Pseudomonas aeruginosa in a pharmacodynamic infection model. AAC 1999;43(1):129-33. 8) ATS/IDSA Committee. guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.

8 Am J Respir Crit Care Med 2005;171:388-416. 9) Yagasaki K, Gando S, Matsuda N, et al. Pharmacokinetics and the most suitable Dosing regimen of fluconazole in critically ill patients receiving continuous hemodiafiltration. Intensive Care Med 2003;29:1844-8.