Virtual Hospital: P & T News

P&T News: December 1994, Vol. 15, No. 6

Guide to Choice of Antibiotic Therapy: Guide for Injectable Antibiotic Dosing in Adults with Renal Dysfunction

Pharmacy and Therapeutics Subcommittee of the University Hospital Advisory Committee and the Pharmcy Department
Peer Review Status: Internally Peer Reviewed

The fourth edition of the UIHC "Guide to Choice of Antibiotic Therapy: October 1994" (Antibiogram) was recently published. This is the first time a table that outlines the dosing of injectable antibiotics in adult patients with varying degrees of renal dysfunction has been included in the Antibiogram. (The table is reproduced on the following pages.) Drug use evaluations conducted at UIHC have sometimes noted that antibiotic doses exceeded the recommended doses based on corresponding renal function, particularly if the patient's renal function has decreased since the time the drug was initially prescribed. To facilitate appropriate dosing, the table was incorporated into the body of the antibiogram.

Several key points should be noted regarding appropriate use of the table:

1. The doses listed are for moderate to severe infections; higher doses may be required for life-threatening infections; lower doses can be utilized for urinary tract infections.

2. No dosage reductions are required for loading doses.

3. Select drugs (e.g., aminoglycosides, amphotericin B) may cause nephrotoxicity; thus, they may be a causative factor in a patient with rapidly declining renal function.

Guide for Injectable Antibiotic Dosing in Adults with Renal Dysfunction[1]

Drug

Normal dose[1]

ClCr[2] 80-50 ml/min

ClCr[2] 49-30 ml/min

ClCr[2] 29-10 ml/min

Clcr[2] less than 10 ml/min

Cephalosporins

Cefazoline

1-2 Gm q8h

[3]

0.5-1 Gm q8h

0.5-1 Gm q12h

0.5-1 Gm q24h

Cefoxitin

1-2 Gm q6-8h

[3]

1-2 Gm q8-12h

1-2 Gm q12-24h

0.5-1 Gm q12-24h

Cefotaxime

1-2 Gm q8h

[3]

[3]

0.5-1 Gm q8-12h

1 Gm q24h

Ceftriaxone

1-2 Gm q24h

[3]

[3]

[3]

[3]

Ceftazidime (P)

1-2 Gm q8h

[3]

1 Gm q12h

1 Gm q24h

0.5 Gm q24h

Penicillins

Penicillin G

2 MU q4h

[3]

[3]

1 MU q4h

1 MU q8-12h

Nafcillin

1-2 Gm q4-6h

[3]

[3]

[3]

[3]

Ampicillin

1-2 Gm q4-6h

[3]

[3]

1-2 Gm q8h

1-2 Gm q12h

Ampicillin-Sulbactam (P)

1.5-3 Gm q6h

[3]

1.5-3 Gm q6-8h

1.5-3 Gm q12h

1.5-3 Gm q24h

Piperacillin (P)

3 Gm q6h

[3]

[3]

3 Gm q8h

3 Gm q12h

Piperacillin-Tazobactam (P)

3.375 Gm q6h

[3]

2.25 Gm q6h

2.25 Gm q8h

2.25 Gm q8h

Ticarcillin-Clavulanate (P)

3.1 Gm q6h

[3]

3.1 Gm q6-8h

3.1 Gm q8-12h

3.1 Gm q24h

Aminoglycosides

Amikacin[5] (P)

7.5 mg/kg q12h

[3]

[3]

7.5 mg/kg q24h

7.5 mg/kg q48h

Gentamicin[5]

1 mg/kg q8h

[3]

1 mg/kg q12h

1 mg/kg q12-24h

1 mg/kg q24-48h

Tobramycin[5] (P)

1 mg/kg q8h

[3]

1 mg/kg q12h

1 mg/kg q12h-24

1 mg/kg q24-48h

Antifungals

Amphotericin B[5]

0.5-1 mg/kg q24h

[3]

[3]

[3]

[3]

Fluconazole

100-200 mg q24h

[3]

50-100 mg q24h

50 mg q24h

50 mg q24h

Antivirals

Acyclovir

5 mg/kg q8h

[3]

5 mg/kg q12h

5 mg/kg q24h

2.5 mg/kg q24h

Ganciclovir

5 mg/kg q12h

2.5 mg/kg q12h

2.5 mg/kg q24h

1.25 mg/kg q24h

1.25 mg/kg q24h

Miscellaneous

Erythromycin

0.5-1 Gm q6h

[3]

[3]

[3]

[3]

Trimethoprim/Sulfamethoxazole[6]

2.5-7.5 mg/kg q6-12h

[3]

2.5-7.5 mg/kg q12h

2.5-5 mg/kg q12h

2.5-5 mg/kg q24h

Aztreonam (P)

1-2 Gm q8-12h

[3]

1-2 Gm q12h

0.5-1 Gm q8-12h

0.5-1 Gm q12-24h

Ciprofloxacin (P)

200-400 mg q12h

[3]

[3]

200-400 mg q12-24h

200-400 mg q24h

Clindamycin

300-900 mg q8h

[3]

[3]

[3]

[3]

Imipenem-Cilastatin (P)

0.5-1 Gm q6h

0.5 Gm q6-8H

0.5 Gm q6-8h

0.5 Gm q8-12h

0.25-0.5 Gm q12h

Metronidazole

500 mg q6h

[3]

[3]

[3]

[3]

Pentamidine

300 mg q24h

[3]

[3]

300 mg q24-36h

300 mg q48h

Vancomycin

1 Gm q12h

1 Gm q12-24h

0.75 Gm q12-24h

0.5 mg q12-24h

0.5 Gm q5 days

[1] Dosage for moderate to severe infections; higher doses may be required for life threatening infections; lower doses may be utilized for UTI.

[2] ClCr = Creatinine Clearance

[3] No reduction from normal dose necessary

[4] UIHC Protocol drug

[5] These agents can cause nephrotoxicity, and may be the causative agent in patients with rapidly declining renal function.

[6] Based on trimethoprim component

Note: No dosage reduction is required for loading doses.

Pharmacy and Therapeutics Subcommittee Actions

Drugs Added to Stock

BORIC ACID VAGINAL CAPSULES: 600 mg Boric acid vaginal capsules (extemporaneously compounded) are used for the treatment of refractory vaginal yeast infections caused by Torulopsis glabrata.

CHLORHEXIDINE OPHTHALMIC SOLUTION: 0.02% Chlorhexidine (extemporaneously compounded) ophthalmic solution is used for the adjunctive treatment of Acanthamoeba keratitis.

EPINEPHRINE INJECTION: 0.15 MG/0.3 ML (1:2000), AUTO-INJECTOR

This product (EpiPen J® - Center Labs) is used for the emergency treatment of severe acute anaphylactic reactions in pediatric patients.

LEVOTHYROXINE TABLETS: 0.05 mg Levothyroxine is used as a replacement or supplemental therapy in hypothyroidism.

MORPHINE SULFATE ORAL SOLUTION: 20 mg/ml, 120 ml; INTRATHECAL INJECTION: 50 mg/ml, 10 ml VIAL Morphine sulfate is indicated for the management of pain.

PILOCARPINE TABLETS: 5 mg Pilocarpine tablets (Salagen® - MGI Pharma) are indicated for treatment of xerostomia from salivary gland hypofunction caused by radiation therapy for cancer of the head and neck.

SQUARIC ACID DIBUTYLESTER TOPICAL SOLUTION: 0.01%, 0.1%, 2% This extemporaneously compounded solution is used for the treatment of alopecia areata.

Drugs Deleted from Stock

NICLOSAMIDE (Niclocide®) 500 mg TABLETS Discontinued by the manufacturer.

EPINEPHRINE 0.1% (1:1000) OPHTHALMIC SOLUTION Discontinued by the manufacturer.

Labeling Change

ALUMINUM HYDROXIDE CAPSULES Aluminum hydroxide capsules (Alu-Cap®) are now labeled as containing 400 mg of aluminum hydroxide. The capsules had previously been labeled as 475 mg which is the weight of hydrated aluminum hydroxide. New labeling requirements stipulate that the strength now be reported as the unhydrated aluminum hydroxide component. The formulation of the capsules remains the same.

Next Page | Title Page

Guide for Injectable Antibiotic Dosing in Adults with Renal Dysfunction[1]
Drug	Normal dose[1]	ClCr[2] 80-50 ml/min	ClCr[2] 49-30 ml/min	ClCr[2] 29-10 ml/min	Clcr[2] less than 10 ml/min
Cephalosporins
Cefazoline	1-2 Gm q8h	[3]	0.5-1 Gm q8h	0.5-1 Gm q12h	0.5-1 Gm q24h
Cefoxitin	1-2 Gm q6-8h	[3]	1-2 Gm q8-12h	1-2 Gm q12-24h	0.5-1 Gm q12-24h
Cefotaxime	1-2 Gm q8h	[3]	[3]	0.5-1 Gm q8-12h	1 Gm q24h
Ceftriaxone	1-2 Gm q24h	[3]	[3]	[3]	[3]
Ceftazidime (P)	1-2 Gm q8h	[3]	1 Gm q12h	1 Gm q24h	0.5 Gm q24h
Penicillins
Penicillin G	2 MU q4h	[3]	[3]	1 MU q4h	1 MU q8-12h
Nafcillin	1-2 Gm q4-6h	[3]	[3]	[3]	[3]
Ampicillin	1-2 Gm q4-6h	[3]	[3]	1-2 Gm q8h	1-2 Gm q12h
Ampicillin-Sulbactam (P)	1.5-3 Gm q6h	[3]	1.5-3 Gm q6-8h	1.5-3 Gm q12h	1.5-3 Gm q24h
Piperacillin (P)	3 Gm q6h	[3]	[3]	3 Gm q8h	3 Gm q12h
Piperacillin-Tazobactam (P)	3.375 Gm q6h	[3]	2.25 Gm q6h	2.25 Gm q8h	2.25 Gm q8h
Ticarcillin-Clavulanate (P)	3.1 Gm q6h	[3]	3.1 Gm q6-8h	3.1 Gm q8-12h	3.1 Gm q24h
Aminoglycosides
Amikacin[5] (P)	7.5 mg/kg q12h	[3]	[3]	7.5 mg/kg q24h	7.5 mg/kg q48h
Gentamicin[5]	1 mg/kg q8h	[3]	1 mg/kg q12h	1 mg/kg q12-24h	1 mg/kg q24-48h
Tobramycin[5] (P)	1 mg/kg q8h	[3]	1 mg/kg q12h	1 mg/kg q12h-24	1 mg/kg q24-48h
Antifungals
Amphotericin B[5]	0.5-1 mg/kg q24h	[3]	[3]	[3]	[3]
Fluconazole	100-200 mg q24h	[3]	50-100 mg q24h	50 mg q24h	50 mg q24h
Antivirals
Acyclovir	5 mg/kg q8h	[3]	5 mg/kg q12h	5 mg/kg q24h	2.5 mg/kg q24h
Ganciclovir	5 mg/kg q12h	2.5 mg/kg q12h	2.5 mg/kg q24h	1.25 mg/kg q24h	1.25 mg/kg q24h
Miscellaneous
Erythromycin	0.5-1 Gm q6h	[3]	[3]	[3]	[3]
Trimethoprim/Sulfamethoxazole[6]	2.5-7.5 mg/kg q6-12h	[3]	2.5-7.5 mg/kg q12h	2.5-5 mg/kg q12h	2.5-5 mg/kg q24h
Aztreonam (P)	1-2 Gm q8-12h	[3]	1-2 Gm q12h	0.5-1 Gm q8-12h	0.5-1 Gm q12-24h
Ciprofloxacin (P)	200-400 mg q12h	[3]	[3]	200-400 mg q12-24h	200-400 mg q24h
Clindamycin	300-900 mg q8h	[3]	[3]	[3]	[3]
Imipenem-Cilastatin (P)	0.5-1 Gm q6h	0.5 Gm q6-8H	0.5 Gm q6-8h	0.5 Gm q8-12h	0.25-0.5 Gm q12h
Metronidazole	500 mg q6h	[3]	[3]	[3]	[3]
Pentamidine	300 mg q24h	[3]	[3]	300 mg q24-36h	300 mg q48h
Vancomycin	1 Gm q12h	1 Gm q12-24h	0.75 Gm q12-24h	0.5 mg q12-24h	0.5 Gm q5 days
[1] Dosage for moderate to severe infections; higher doses may be required for life threatening infections; lower doses may be utilized for UTI. [2] ClCr = Creatinine Clearance [3] No reduction from normal dose necessary [4] UIHC Protocol drug [5] These agents can cause nephrotoxicity, and may be the causative agent in patients with rapidly declining renal function. [6] Based on trimethoprim component Note: No dosage reduction is required for loading doses.