The following medications may be adjusted automatically by pharmacy based on the patient’s renal function.
Ampicillin/sulbactam (Unasyn®)
Ceftazidime/avibactam (Avycaz®)
Ceftolozane/tazobactam (Zerbaxa®)
Fluconazole (Diflucan®) – IV only
Meropenem/vaborbactam (Vabomere®)
Nirmatrelvir/ritonavir (Paxlovid®)
Piperacillin/tazobactam (Zosyn®)
CRRT Antibiotic Dosing Guidelines
The following medications are not adjusted automatically by pharmacy, but renal guidelines are included here for reference.
Sulbactam/durlobactam (Xacduro®)
CrCl (ml/min) |
Uncomplicated Infection |
Meningitis or Endovascular infection |
> 50 |
2 gm IV Q 6 hrs |
2 gm IV Q 4 hrs |
30-50 |
2 gm IV Q 8 hrs |
2 gm IV Q 6 hrs |
10-29 |
2 gm IV Q 12 hrs |
2 gm IV Q 8 hrs |
<10 or HD |
1 gm IV Q 12 hrs |
2 gm IV Q 12 hrs |
CRRT |
CrCl (ml/min) |
Renal Adjustment |
> 50 |
3 gm IV Q 6 hrs |
10-50 |
1.5 gm IV Q 6 hrs |
<10 |
1.5 gm IV Q 12 hrs |
HD |
1.5-3 gm IV Q 12 hrs |
CRRT |
CrCl (ml/min) |
UTI |
Systemic infection |
≥ 30 |
1 gm IV Q 8 hrs |
2 gm IV Q 8 hrs |
10-30 |
1 gm IV Q 12 hrs |
2 gm IV Q 12 hrs |
< 10 |
1 gm IV Q 24 hrs |
1 gm IV Q 12 hrs |
Hemodialysis |
1 gm IV x 1 dose, then 1 g IV Q pm |
|
CRRT |
Estimated glomerular filtration rate (eGFR) |
Renal Adjustment |
≥60 mL/min/1.73 m2 |
4 mg once daily |
30 to 60 mL/min/1.73 m2 |
2 mg once daily |
15 to 30 mL/min/1.73 m2 |
1 mg once daily |
<15 mL/min/1.73 m2 |
Not recommended |
CrCl (ml/min) |
UTI (no sepsis); Uncomplicated ABSSSI |
All other indications |
Treatment of confirmed GNR from a non-urinary source and MIC > 2 |
> 30 |
1 gm IV Q 8 hrs |
2 gm IV Q 8 hrs |
Contact stewardship pharmacist as cefazolin may not be the best drug for the patient |
10-30 |
1 gm IV Q 12 hrs |
2 gm IV Q 12 hrs |
|
<10 |
1 gm IV Q 24 hrs |
||
HD |
1 gm IV Q PM |
||
CRRT |
Note: The MIC > 2 comment in the last column only applies to gram-negative infections.
Continue using the dosing strategies listed in the first two columns for gram-positive infections.
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CrCl (ml/min) |
Febrile Neutropenia, critically ill with BMI ≥ 30, or recent or confirmed infection with below organisms &/or MIC* |
UTI, no sepsis |
All other indications |
|
> 50 |
2 gm IV x 1 dose (IVP) |
**2 gm Q 8 hrs (4 hour infusion) |
1 gm Q 12 hrs (IVP) |
1 gm Q 6 hrs (IVP) |
30-49 |
**2 gm Q 12 hrs (4 hour infusion) |
1 gm Q 24 hrs (IVP) |
1 gm Q 8 hrs (IVP) |
|
11-29 |
**2 gm Q 24 hrs (4 hour infusion) |
1 gm Q 12 hrs (IVP) |
||
≤ 10 or HD |
1 gm Q PM (IVP) |
|||
CRRT |
*Excluding treatment of lower UTIs: GNR with an MIC of 4, Pseudomonas spp., Acinetobacter spp., Hafnia alvei, Enterobacter cloacae, Citrobacter freundii, Klebsiella aerogenes, or Serratia marcescens.
**Extended infusion doses to begin 8 hours after the IV push loading dose.
|
|||
CrCl (ml/min) |
Uncomplicated |
Moderate to Severe Infection |
|
≥ 50 |
1 gm IV Q 6 hrs |
2 gm IV Q 6 hrs |
|
30-49 |
1 gm IV Q 8 hrs |
2 gm IV Q 8 hrs |
|
10-29 |
1 gm IV Q 12 hrs |
2 gm IV Q 12 hrs |
|
< 10 |
0.5 gm IV Q 24 hrs |
1 gm IV Q 24 hrs |
|
Hemodialysis |
2 gm IV x 1 dose, then 1 g IV Q pm |
|
|
CRRT |
1-2 gm IV Q 8 hrs |
|
CrCl (ml/min) |
Uncomplicated Infection |
Pneumonia, Severe Infections |
> 50 |
600 mg IV Q 12 hrs |
600 mg IV Q 8 hrs |
30-50 |
400 mg IV Q 12 hrs |
600 mg IV Q 12 hrs |
15-29 |
300 mg IV Q 12 hrs |
400 mg IV Q 12 hrs |
<15 or HD |
200-300mg IV Q 12 hrs |
|
CRRT |
CrCl (ml/min) |
Renal Adjustment |
> 50 |
2.5 gm IV Q 8 hrs |
31-50 |
1.25 gm IV Q 8 hrs |
16-30 |
0.94 gm IV Q 12 hrs |
6-15 |
0.94 gm IV Q 24 hrs |
≤ 5 or HD |
0.94 gm IV Q 48 hrs |
CRRT |
CrCl (ml/min) |
Uncomplicated Infection |
Pneumonia, Severe Infections |
> 50 |
1.5 gm IV Q 8 hrs |
3 gm IV Q 8 hrs |
30-50 |
750 mg IV Q 8 hrs |
1.5 gm IV Q 8 hrs |
15-29 |
375 mg IV Q 8 hrs |
750 mg IV Q 8 hrs |
HD |
750 mg IV x 1 dose, then 150mg IV q8h |
2.25g IV x 1 dose, then 450mg IV q8h |
CRRT |
CrCl (ml/min) |
Renal Adjustment |
≥ 30 |
500 mg PO Q 12 hrs, |
< 30 |
500 mg PO once daily |
Hemodialysis |
500 mg PO once daily |
CRRT |
Standard Dose |
600 mg IV Q 8 hrs |
No adjustment for renal dysfunction |
Necrotizing fasciitis |
900 mg IV Q 8 hrs |
CrCl (ml/min) |
Prophylactic Dose |
Treatment Dose |
≥ 30 |
40 mg daily |
1 mg/kg BID* |
< 30 |
30 mg daily |
1 mg/kg daily* |
* If CrCl < 20 ml/min and on treatment dose, dose will be decreased to once daily and
anti-factor Xa level drawn 4 hours post-dose to evaluate if continued Lovenox use is appropriate.
* If patient weight > 190 kg and on treatment dose, pharmacy will automatically
obtain anti-factor Xa level 4 hours post-dose.
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CrCl (ml/min) |
Renal Adjustment |
≥ 50 |
20 mg PO/IV BID |
< 50 |
20 mg PO/IV daily |
CrCl (ml/min) |
Initial Dose |
Subsequent Doses |
≥ 50 |
750 mg |
750 mg q 24 hrs |
20-49 |
750 mg |
750 mg q 48 hrs |
10-19 |
750 mg |
500 mg q 48 hrs |
Hemodialysis |
750 mg |
500 mg q 48 hrs |
CRRT |
Creatinine clearance (ml/min) |
Excluding treatment of lower UTIs (no sepsis): Confirmed or recent infection with a GNR with MIC ≥ 2, Pseudomonas spp., or Acinetobacter spp. |
All other diagnoses |
|
> 50 |
1 gm IV x 1 dose (IVP) |
*1 gm IV q 8 hrs (over 3 hrs) |
500 mg IV q 6 hrs |
26 – 50 |
*1 gm IV q 12 hrs (over 3 hrs) |
500 mg IV q 8 hrs |
|
10 – 25 |
500 mg IV q 12 hrs |
500 mg IV q 12 hrs |
|
< 10 |
500 mg IV daily |
500 mg IV daily |
|
Hemodialysis |
500 mg IV QPM (1800) |
500 mg IV QPM (1800) |
|
CRRT |
*Extended infusion doses to begin 4 hours after the IV push loading dose.
eGFR (ml/min/1.73m) |
Renal Adjustment |
≥ 50 |
4 gm IV q 8 hrs |
30 – 49 |
2 gm IV q 8 hrs |
15 – 29 |
2 gm IV q 12 hrs |
< 15 or HD |
1 gm IV q 12 hrs |
CRRT |
Estimated glomerular filtration rate (eGFR) |
Renal Adjustment |
≥ 60 |
300/100 mg BID x 5 days |
≥ 30 to < 60 |
150/100 mg BID x 5 days |
< 30 or HD |
300/100 mg x 1 dose, then |
CrCl (ml/min) |
Renal Adjustment |
> 60 |
75 mg BID |
30 – 60 |
75 mg DAILY |
< 30 |
30 mg DAILY |
CRRT |
75 mg BID |
Hemodialysis |
30 mg post HD only |
*Extended infusion doses to begin 4 hours after the loading dose given over 30 minutes.
Piperacillin/Tazobactam (Zosyn®) Standard Infusion |
||
CrCl (ml/min) |
All Other Indications |
Nosocomial Pneumonia |
> 40 |
3.375 gm IV Q 6 hrs |
4.5 gm IV Q 6 hrs |
20 – 40 |
2.25 gm IV Q 6 hrs |
3.375 gm IV Q 6 hrs |
< 20 |
2.25 gm IV Q 8 hrs |
2.25 gm IV Q 6 hrs |
Hemodialysis |
2.25 gm IV Q 12 hrs + 0.75 gm after each dialysis session |
2.25 gm IV Q 8 hrs + 0.75 gm after each dialysis session |
CAPD |
2.25 gm IV Q 12 hrs |
2.25 gm IV Q 8 hrs |
Drug |
Loading Dose |
High Dose* |
|||
CVVH |
CVVHD |
CVVHDF |
|||
Ampicillin |
2g |
1-2g q8-12h |
1-2g q8h |
1-2g q6-8h |
2g q4-6h |
Ampicillin/sulbactam |
3g |
1.5-3g q8-12h |
1.5-3g q8h |
1.5-3g q6-8h |
3g q6h |
Aztreonam |
2g |
1-2g q12h |
1g q8h or 2g q12h |
1g q8h or 2g q12h |
2g q8h |
Cefazolin |
2g |
1-2g q12h |
1g q8h or 2g q12h |
1g q8h or 2g q12h |
2g q8h |
Cefepime |
2g |
1-2g q12h |
1g q8h or 2g q12h |
1g q8h or 2g q12h |
1g q6h or 2g q8h |
Ceftaroline |
600mg |
400-600mg q12h |
600mg q8h |
||
Ceftazidime/avibactam |
2.5g |
1.25g IVq8h |
2.5g q8h (based on ceftazidime data) |
||
Ceftolozane/tazobactam |
3g |
750mg q8h |
1.5g q8h |
1.5g q8h |
1.5g q8h (data lacking for higher dose) |
Ciprofloxacin |
N/A |
400mg q12-24h |
400mg q12-24h |
400mg q12h |
400mg q8-12h |
Levofloxacin |
750mg |
750mg q48h |
750mg q48h |
750mg q24h |
750mg q24h |
Meropenem |
1g |
500mg-1g q12h |
500mg q8h/1g q12h |
500mg q8h/1g q12h |
500mg q6h/1g q8h |
Meropenem/vaborbactam |
4g |
1-2g q8h (extended) |
2g q8h (extended); based on meropenem data |
||
Piperacillin/tazobactam |
4.5g |
3.375-4.5g IV q8h (extended) |
*Parameters
· Ultrafiltration/dialysate flow rate of > 2 L/hr
· Residual renal function
* Please clarify indication with provider prior to selecting a dosing strategy
** When transitioning a patient from PO valacyclovir to IV acyclovir, please consider this conversion: Valacyclovir 1,000mg PO TID à Acyclovir 5mg/kg/dose IV q8h
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Normal Dose |
5 mg BID |
TWO of the following: |
2.5 mg BID
|
Apixaban (Eliquis®) |
|
Normal Dose |
2.5 mg BID |
Initiate therapy after hemostasis established (~12-24 hours post-op). |
Apixaban (Eliquis®) |
|
Treatment Dose |
10 mg BID x 7 days, |
Reduction in the risk of recurrence |
2.5 mg BID after at least 6 months of treatment for DVT/PE. |
Dose adjustment: None necessary; however, patients with a SCr > 2.5 or CrCl < 25 were excluded from the clinical trials. |
CrCl (ml/min) |
Recommended Dose |
> 30 |
150 mg BID |
15-30 |
75 mg BID |
< 15 or HD patient |
Not recommended |
Dabigatran (Pradaxa®) |
|
CrCl (ml/min) |
Recommended Dose |
> 30 |
Parenteral anticoagulant x 5-10 days, |
< 50 + PGP inhibitors |
Avoid Use |
< 30 or HD patient |
Avoid Use (not studied) |
CrCl (ml/min) |
Recommended Dose |
> 95 |
Avoid Use |
51-95 |
60 mg daily |
15-50 |
30 mg daily |
< 15 or HD patient |
Avoid Use |
Edoxaban (Savaysa®) |
|
CrCl (ml/min) |
Recommended Dose |
> 50 |
Parenteral anticoagulant x 5-10 days, then |
> 50 + PGP inhibitor |
30 mg daily |
15-50 |
Parenteral anticoagulant x 5-10 days, then |
< 15 or HD patient |
Avoid Use |
CrCl (ml/min) |
Recommended Dose |
> 50 |
20 mg daily (with evening meal) |
15-50 |
15 mg daily (with evening meal) |
< 15 or HD patient |
Avoid Use |
Rivaroxaban (Xarelto®) |
|
CrCl (ml/min) |
Recommended Dose |
> 30 |
10 mg daily |
< 30 |
Avoid Use |
Initiate therapy after hemostasis established (~10 hours post-op). |
Rivaroxaban (Xarelto®) |
|
CrCl (ml/min) |
Recommended Dose |
> 30 |
15 mg BID x 21 days, |
< 30 |
Avoid Use |
CrCl (ml/min) |
Renal Adjustment |
≥ 130 |
1 g sulbactam/1 g durlobactam q 4 hours |
45-129 |
1 g sulbactam/1 g durlobactam q 6 hours |
30-44 |
1 g sulbactam/1 g durlobactam q 8 hours |
15-29 |
1 g sulbactam/1 g durlobactam q 12 hours |
< 15 |
Initiation – 1 g sulbactam/1 g durlobactam q 12 hours for the first 3 doses, then q 24 hours after the third dose Continuation – 1 g sulbactam/1 g durlobactam q 24 hours |