Approved Hospital Formulary
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Approved Hospital Formulary
Renal Dose Adjustments

Renal Dose Adjustments

The following medications may be adjusted automatically by pharmacy based on the patient’s renal function.

Ampicillin

Ampicillin/sulbactam (Unasyn®)

Aztrenoam (Azactam®)

Baricitinib (Olumiant®)

Cefazolin (Ancef®)

Cefepime (Maxipime®)

Cefoxitin (Mefoxin)

Ceftaroline (Teflaro®)

Ceftazidime/avibactam (Avycaz®)

Ceftolozane/tazobactam (Zerbaxa®)

Ciprofloxacin (Cipro®)

Clindamycin (Cleocin®)

Enoxaparin (Lovenox®)

Famotidine (Pepcid®)

Fluconazole (Diflucan®) – IV only

Fondaparinux (Arixtra®)

Levofloxacin (Levaquin®)

Meropenem (Merrem®)

Meropenem/vaborbactam (Vabomere®)

Oseltamivir (Tamiflu®)

Piperacillin/tazobactam (Zosyn®)

CRRT Antibiotic Dosing Guidelines

 

The following medications are not adjusted automatically by pharmacy, but renal guidelines are included here for reference.

Acyclovir (Zovirax®)

Apixaban (Eliquis®)

Dabigatran (Pradaxa®)

Edoxaban (Savaysa®)

Rivaroxaban (Xarelto®)

 

Ampicillin

CrCl (ml/min)

Uncomplicated Infection

Meningitis or Endovascular infection

> 50

2 gm IV Q 6 hrs

2 gm IV Q 4 hrs

10-50

1 gm IV Q 6 hrs

2 gm IV Q 6 hrs

<10

1 gm IV Q 12 hrs

1 gm IV Q 8 hrs

HD

1-2 gm IV Q 12 hrs

CRRT

See CRRT dosing

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Ampicillin/Sulbactam (Unasyn®)

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

See CRRT dosing

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Aztreonam (Azactam®)

CrCl (ml/min)

UTI

Systemic infection

≥ 30

1 gm IV Q 8 hrs

2 gm IV Q 8 hrs
(q6h is OK in life threatening infections)

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

See CRRT dosing

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Baricitinib (Olumiant®)

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

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Cefazolin (Ancef®)

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
(For outpatient use: 2 gm IV post-HD only)

CRRT

See CRRT dosing

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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Cefepime (Maxipime®)

CrCl (ml/min)

Febrile Neutropenia
or
Treatment of recent or confirmed infection with a GNR with an MIC of 8, critically ill with BMI ≥ 30

UTI, no sepsis

All other indications

> 50

2 gm Q 8 hrs

1 gm Q 12 hrs

1 gm Q 6 hrs

30-49

2 gm Q 12 hrs

1 gm Q 24 hrs

1 gm Q 8 hrs

11-29

2 gm Q 24 hrs

1 gm Q 12 hrs

≤ 10 or HD

1 gm Q PM
(give after dialysis)

CRRT

See CRRT dosing

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Cefoxitin (Mefoxin®)

 

CrCl (ml/min)

Uncomplicated

Moderate to Severe Infection

 

≥ 50

1 gm IV Q 6 hrs

2 gm IV Q 6 hrs
(doses up to 2g IV q4h or 3g IV q6h have been used)

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

 

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Ceftaroline (Teflaro®)

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

See CRRT dosing

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Ceftazidime/Avibactam (Avycaz®)

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

See CRRT dosing

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Ceftolozane/Tazobactam (Zerbaxa®)

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

See CRRT dosing

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Ciprofloxacin (Cipro®)

CrCl (ml/min)

Renal Adjustment

≥ 30

500 mg PO Q 12 hrs,
400 mg IV Q 12 hrs

< 30

500 mg PO once daily
400 mg IV once daily

Hemodialysis

500 mg PO once daily
400 mg IV once daily
On dialysis days, give after dialysis.

CRRT

See CRRT dosing

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Clindamycin (Cleocin®) IV

Standard Dose

600 mg IV Q 8 hrs

No adjustment for renal dysfunction

Necrotizing fasciitis

900 mg IV Q 8 hrs

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Enoxaparin (Lovenox®)

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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Famotidine (Pepcid®)

CrCl (ml/min)

Renal Adjustment

≥ 50

20 mg PO/IV BID

< 50

20 mg PO/IV daily

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Fluconazole (Diflucan) – IV only
Low dose IV fluconazole (< 200 mg) will be interchanged to the smallest commercially available bag (200 mg) when oral formulation is not an option.

CrCl (ml/min)

Renal Adjustment

> 10

< 200 mg IV daily ordered

&

Tablet or Suspension is not an option due to intolerability or questionable GI absorption

200 mg IV daily

Hemodialysis

400 mg IV post-HD only

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Fondaparinux (Arixtra®)
(contraindicated in patients with CrCl < 30 ml/min)

For patients with CrCl < 30 ml/minute who are on the prophylactic dose of Arixtra (2.5 mg daily), pharmacy will automatically change to Lovenox 30 mg daily.

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Levofloxacin (Levaquin®)
Pertains to IV or PO dosing.

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

See CRRT dosing

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Meropenem (Merrem®)

Creatinine clearance

(ml/min)

Treatment of confirmed or recent

infection with Acinetobacter or Pseudomonas with MIC >2

All other diagnoses

> 50

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)
On dialysis days, give after dialysis.

500 mg IV QPM (1800)
On dialysis days, give after dialysis.

CRRT

See CRRT dosing

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Meropenem/vaborbactam (Vabomere®)

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

See CRRT dosing

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Oseltamivir (Tamiflu®)

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
(initial dose may be given immediately with subsequent doses after each dialysis)

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Piperacillin/Tazobactam (Zosyn®) Extended Infusion
Pharmacy will adjust all doses to extended infusion as outlined below.

Piperacillin/Tazobactam (Zosyn®)

Loading Dose

BMI < 30

BMI ≥ 30

CrCl > 20 ml/min or CRRT

4.5 gm IV x 1 dose (30min infusion),  followed by BMI based dosing strategy

3.375 gm IV q 8 hrs
(4 hour infusion)

4.5 gm IV q 8 hrs
(4 hour infusion)

CrCl ≤ 20 or HD or peritoneal dialysis

3.375 gm IV q 12 hrs
 (4 hour infusion)

CRRT

See CRRT dosing

 

 

Piperacillin/Tazobactam (Zosyn®) Standard Infusion
Standard Infusion will only be used when IV compatibility/line access issues preclude the use of extended 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
no additional bolus dose

2.25 gm IV Q 8 hrs
no additional bolus dose

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Drug

Loading Dose

Maintenance Dosage for CRRT

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

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Acyclovir (Zovirax®) IV dosing only

Use IBW; if TBW >20% IBW, use adjBW

CrCl (ml/min)

HSV encephalitis/Herpes zoster

Herpes simplex infections

Prevention of HSV/VZV when unable to tolerate PO

> 50

10mg/kg/dose IV q8h

5mg/kg/dose IV q8h

5mg/kg/dose IV q12

25-50 or CRRT

10mg/kg/dose IV q12h

5mg/kg/dose IV q12h

5mg/kg/dose IV q24

10-24

10mg/kg/dose IV q24h

5mg/kg/dose IV q24h

2.5mg/kg/dose IV q24h

<10 or HD

5mg/kg/dose IV q24h

2.5mg/kg/dose IV q24h

* 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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Apixaban (Eliquis®)
Nonvalvular Atrial Fibrillation

Normal Dose

5 mg BID
(may be taken without regard to food)

TWO of the following:
Age ≥ 80 years
Body weight ≤ 60 kg
Serum creatinine ≥ 1.5

2.5 mg BID
(may be taken without regard to food)

 

 

Apixaban (Eliquis®)
Postoperative Thromboprophylaxis (Knee or Hip)

Normal Dose

2.5 mg BID

Initiate therapy after hemostasis established (~12-24 hours post-op).
Use for 12 days for knee replacement.
Use for 35 days for hip replacement.

 

Apixaban (Eliquis®)
DVT/PE Treatment

Treatment Dose

10 mg BID x 7 days,
then 5 mg BID.

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.

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Dabigatran (Pradaxa®)
Nonvalvular Atrial Fibrillation

CrCl (ml/min)

Recommended Dose

> 30

150 mg BID

15-30

75 mg BID

< 15 or HD patient

Not recommended

 

Dabigatran (Pradaxa®)
DVT/PE Treatment

CrCl (ml/min)

Recommended Dose

> 30

Parenteral anticoagulant x 5-10 days,
then 150 mg BID

< 50 + PGP inhibitors

Avoid Use

< 30 or HD patient

Avoid Use (not studied)

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Edoxaban (Savaysa®)
Nonvalvular Atrial Fibrillation

CrCl (ml/min)

Recommended Dose

> 95

Avoid Use
Increased risk of ischemic stroke compared to warfarin

51-95

60 mg daily

15-50

30 mg daily

< 15 or HD patient

Avoid Use

 

Edoxaban (Savaysa®)
DVT/PE Treatment

CrCl (ml/min)

Recommended Dose

> 50

Parenteral anticoagulant x 5-10 days, then
60 mg daily if weight > 60 kg
30 mg daily if weight ≤ 60 kg

> 50 + PGP inhibitor
(verapamil, quinidine, or short-term use azithromycin, clarithromycin, erythromycin, itraconazole, ketoconazole)

30 mg daily

15-50

Parenteral anticoagulant x 5-10 days, then
30 mg daily

< 15 or HD patient

Avoid Use

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Rivaroxaban (Xarelto®)
Nonvalvular Atrial Fibrillation

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®)
Postoperative Thromboprophylaxis

CrCl (ml/min)

Recommended Dose

> 30

10 mg daily

< 30

Avoid Use

Initiate therapy after hemostasis established (~10 hours post-op).
Use for 12-14 days for knee replacement.
Use for 35 days for hip replacement.

 

Rivaroxaban (Xarelto®)
DVT/PE Treatment

CrCl (ml/min)

Recommended Dose

> 30

15 mg BID x 21 days,
then 20 mg daily (with food)

< 30

Avoid Use

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Pharmacy Phone Numbers
Memorial Pharmacy (Glenwood) 423-495-8380
Memorial Hixson Pharmacy 423-495-7137
Stat 423-495-7470
Outpatient 423-495-8981
Chemo 423-495-7475
Surgery 423-495-8779

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