Stanford Hospital & Clinics Antimicrobial Dosing Reference ...

Stanford Hospital & Clinics Antimicrobial Dosing Reference Guide 2014

This document is also located on the SHC Intranet ()

and ABX Subcommittee Approved: January 30, 2014

Formulas for dosing weights: Ideal body weight IBW (male) = 50kg + (2.3 x height in inches > 60 inches) ?

Ideal body weight IBW (female) = 45kg + (2.3 x height in inches > 60 inches) ? Adjusted Body Weight ABW (kg) = IBW + 0.4 (TBW ¨C IBW)

Intermittent

Drug

CrCl >50 mL/min

CrCl 10¨C50 mL/min

CrCl 25

CrCl 10¨C25

CrCl 60

5 ¨C 7.5 mg/kg

q8h

CrCl 40¨C60:

5 ¨C 7.5 mg/kg

q12h

CrCl 20¨C40

5 ¨C 7.5 mg/kg

q24h

15 ¨C 20 mg/kg

q24h

15 mg/kg

q36h

CrCl > 30:

15 mg/kg q48h

CrCl < 30:

Not recommended

Dose daily, but after HD on HD days

CVVH: 5-10mg/kg q24h

CVVHD/F: 5-10mg/kg q12h

(meningoencephalitis/VZV:

10mg/kg q12h)

See CrCl < 10 mL/min

No Data

No change

No change

5 ¨C 7.5 mg/kg post HD only

10 mg/kg load,

then 7.5 mg/kg q24¨C48h

HSV: 2.5 mg/kg q24h

HSV encephalitis/zoster:

5 mg/kg q24h

CrCl < 20

5 mg/kg

load, then

by level

consult pharmacist

consult pharmacist

th

Timing of levels: Draw trough 30 min prior to 4 dose. Draw peak 30 min after infusion ends

Once daily dosing: goal peak 35¨C60; goal trough 0.5 ¨C 0.6

¡Ý 0.4 ¨C 0.5

< 0.4

Foscarnet1, 5

40 mg/kg q12h

80 mg/kg q24h

60 mg/kg q24h

60 mg/kg q24h

50 mg/kg q24h

50 mg/kg q24h

Not recommended

Not recommended

60 ¨C 90 mg/kg loading dose (post-HD),

then 45 ¨C 60 mg/kg/dose post-HD only

IHD

CMV

Ganciclovir1, 6(IV)

Maintenance

(M)

HSV

120 mg/kg q24h

90 mg/kg q24h

40 mg/kg q12h

30 mg/kg q12h

40 mg/kg q8h

30 mg/kg q8h

50 mg/kg q24h

65 mg/kg q24h

20 mg/kg q12h

35 mg/kg q12h

80 mg/kg q48h

60 mg/kg q48h

50 mg/kg q48h

Not recommended

105 mg/kg q48h

80 mg/kg q48h

65 mg/kg q48h

Not recommended

35 mg/kg q24h

25 mg/kg q24h

20 mg/kg q24h

Not recommended

25 mg/kg q12h

40 mg/kg q24h

35 mg/kg q24h

Not recommended

No data

No data

No data

No data

No data ¨C Dose as for CrCL 10 ¨C 50 mL/min

CRRT

Induction (I)

1 g q24h

Dose daily, but after HD on HD days

CrCl >70*

5 mg/kg

q12h

5 mg/kg

q24h

CrCl >50

2.5 mg/kg

q12h

2.5 mg/kg

q24h

CrCl >25

2.5 mg/kg

q24h

1.25 mg/kg

q24h

CrCl >10

1.25 mg/kg

q24h

0.625 mg/kg

q24h

CrCl 60

CrCl 40¨C59

1.7 mg/kg q8h

or

4 ¨C 7 mg/kg q24h

(high-dose

extended-interval*)

1.7 mg/kg q12h

or

4 ¨C 7 mg/kg q36h

(high-dose

extended-interval*)

CrCl 20¨C39

1.7 mg/kg q24h

or

CrCl > 30:

4 ¨C 7 mg/kg q48h

CrCl < 30:

Not recommended

(high-dose extended-interval*)

CrCl 60

CrCl 40 ¨C 59

CrCl 25 ¨C 39:

CrCl 10 ¨C 24

Induction (14-21 days)

900 mg q12h

450 mg q12h

450 mg q24h

450 mg q48h

Maintenance/ prophylaxis

900 mg q24h

450 mg q24h

450 mg q48h

450 mg twice/week

Consider loading dose of 25¨C30 mg/kg (max 2 g) for severe infections and ICU

CrCl >50

CrCl 30¨C49

CrCl 15¨C29

CrCl ................
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