SHC ABX Dosing Guide
SHC ABX Dosing Guide
SHC ABX Dosing Guide
Intermittent
Drug CrCl > 50 mL/min CrCl 10 – 50 mL/min CrCl < 10 mL/min CRRT
Hemodialysis (IHD)
CrCL > 50 CrCL 25 – 50 CrCL < 25 CrCL < 10 IHD CRRT
Prophylaxis
BMT 250 mg/m2 q12h 125 mg/m2 q12h 125 mg/m2 q24h 62.5 mg/m2 q24h 62.5 mg/m2 q24h 125 mg/m2 q12h
Hematology/Oncology 2 mg/kg q12h 2 mg/kg q12h 2 mg/kg q24h 1 mg/kg q24h 1 mg/kg q24h 2 mg/kg q12h
Acyclovir (IV) 1–7
Treatment
(Use adjusted BW for
obese) General
(e.g. mucocutaneous 5 mg/kg q8h 5 mg/kg q12h 5 mg/kg q24h 2.5 mg/kg q24h 2.5 mg/kg q24h 5 – 10 mg/kg q12h
HSV)
Severe (e.g. CNS/
5 mg/kg q24h
ocular/disseminated 10 mg/kg q8h 10 mg/kg q12h 10 mg/kg q24h 5 mg/kg q24h 10 mg/kg q12h
HSV infections, Zoster)
Uncomplicated cystitis:
100 mg q12h
Cefpodoxime (PO)1,2 CAP/bronchitis: 200 mg q12h CrCl < 30: same dose q24h Same dose, post-HD only No data
Skin/skin structure:
400 mg q12h
Dose by indication.
Load 800 mg for severe
infections
CMV CrCl >70* CrCl >50 CrCl >25 CrCl >10 CrCl <10
Ganciclovir (IV)1,2 5 mg/kg 2.5 mg/kg 2.5 mg/kg 1.25 mg/kg 1.25 mg/kg
Induction (I) I: 1.25 mg/kg post HD only I: 2.5 mg/kg q12–24h
(Consider adjusted BW q12h q12h q24h q24h 3x/week
M: 0.625 mg/kg post HD only M: 1.25 – 2.5 mg/kg q24h
in obese) 5 mg/kg 2.5 mg/kg 1.25 mg/kg 0.625 mg/kg 0.625 mg/kg
Maintenance (M)
q24h q24h q24h q24h 3x/week
*Manufacturer’s CrCl cutoffs. Please refer to BMT protocols if applicable
No change
Metronidazole (IV/PO)1,2 500 mg q6–8h 500 mg q8h 500 mg q6–8h
Severe hepatic impairment: can consider 500 mg q12h
Valganciclovir (PO)1,2 CrCl > 60 CrCl 40 – 59 CrCl 25 – 39 CrCl 10 – 24 CrCl < 10; IHD CRRT
Please refer to Induction (14-21 days) 900 mg q12h 450 mg q12h 450 mg q24h 450 mg q48h 200 mg 3x/week after HD only No data
transplant protocols if
applicable Maintenance/ prophylaxis 900 mg q24h 450 mg q24h 450 mg q48h 450 mg twice/week 100 mg 3x/week after HD only No data
1,2,61,62
Vancomycin (IV)
(Use actual body See Vancomycin Dosing Protocol
weight)
Poor systemic absorption- used for the treatment of Clostridium difficile-associated diarrhea
Vancomycin PO1,2,63 Mild/moderate/severe: 125 mg PO q6h No change No change
Severe complicated (CDI-related septic shock, ileus, toxic megacolon): 500 mg PO q6h
IVPO conversion 1:1 (round to nearest tablet size- available in 200 mg and 50 mg tablets)
Voriconazole IV: 6 mg/kg IV q12h x 2,
(IV/PO)1,2,64,65 then 4 mg/kg IV q12h Caution with IV: accumulation of IV vehicle cyclodextrin occurs.
Consider PO if CrCl < 50 mL/min unless benefits justify risks of IV use.
(Dose by adjusted BW PO: 400 mg PO q12h x 2,
in obese) then 200 mg PO q12h Levels shown to have great degree of interpatient variability. Consider drawing a trough 4 – 7 days after new dose.
Please refer to Antifungal TDM Guide
Abbreviations: CAP = community acquired pneumonia; CRRT = continuous renal replacement therapy; FN = febrile neutropenia; HD = hemodialysis; LD = loading dose; MU = million
units; PCP = pneumocystis jiroveci pneumonia; PNA = pneumonia; SCr = serum creatinine; TB = tuberculosis; TMP = trimethoprim; UF = ultrafiltration
CRRT dosing: doses listed are for CVVHDF and CVVHD modalities, which are the most common modes at SHC. Note that these are generally higher than doses used in CVVH.
LBW (men) = (1.10 x Weight(kg)) - 128 x (Weight2/(100 x Height(m))2)
LBW (women) = (1.07 x Weight(kg)) - 148 x (Weight2/(100 x Height(m))2)
LBW online calculator: http://www.empr.com/medical-calculators/lean-body-weight-calculator/article/170219/
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A. Original Author/Date
Department of Pharmacy; 07/1998
B. Gatekeeper
Stanford Antimicrobial Stewardship Safety and Sustainability Program
E. Approvals
Antimicrobial Subcommittee 09/2004, 04/2007, 01/2009, 11/2010, 03/2011, 05/2012, 05/2013, 01/2014, 03/2017, 07/2019, 10/2019; 01/2020, 09/2020
Pharmacy & Therapeutics Committee 04/2007, 02/2009, 04/2010, 05/2011, 08/2012, 09/2012, 08/2013, 02/2014, 04/2017, 11/2019; 02/2020, 10/2020