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Guidelines for calculating creatinine clearance and dosing antimicrobial agents for adults with renal impairment, including specific dosing recommendations for various antimicrobials and special considerations for haemodialysis, continuous ambulatory peritoneal dialysis, and continuous veno-venous haemofiltration patients.
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Nottingham Antimicrobial Guidelines Committee March 2009 Review March 2011
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Nottingham Antimicrobial Guidelines Committee March 2009 Review March 2011
Nottingham Antimicrobial Guidelines Committee March 2009 Review March 2011
Doxycycline Normal Normal Normal
All other tetracyclines contraindicated in renal impairment
Ertapenem CrCl 30-50 ml/min Normal
CrCl 10-30 ml/min 50-100% of dose
50% of dose or 1g three times a week
Give post HD
Erythromycin po Normal Normal 250-500mg qds
Normal 7.5-15mg/kg/day 5-7.5mg/kg/day
*Ethambutol Monitor levels if Crcl < 30ml/min (contact Micro)
Give post HD
Flucloxacillin IV+po Normal Normal Normal Max 4g/day
Fluconazole Normal Normal
Oral dose min 50mg
Give post HD No adjustments for single doses required
*Flucytosine 50mg/kg 12h 50mg/kg 24h 50mg/kg stat then dose according to levels.
Give post HD. Monitor pre-dialysis levels
Foscarnet Dose reduction required seek further advice from pharmacy/renal drug handbook Fusidic acid Normal Normal Normal
Ganciclovir Dose reduction required seek further advice from pharmacy/renal drug handbook
1) Gentamicin
ONCE DAILY
CrCl 10–40ml/min 3mg/kg (max 300mg) Check levels 18-24 hours after first dose. Re-dose only when level < 1mg/L.
CrCl<10ml/min 2 mg/kg (max 200mg) re-dose according to levels
2) Gentamicin
CONVENTIONAL
80mg 12h (60mg if <60kg)
80mg 24h (60mg if <60kg)
80mg 48h (60mg if <60kg) HD:1-2 mg/kg post HD redose according to levels
Give post HD
Monitor blood levels & adjust dose as required. For further advice see monitoring guidance on the antibiotic website http://nuhweb/antibiotics Isoniazid Normal Normal 200mg-300mg 24h Give post HD Itraconazole Normal Normal Normal
Levofloxacin 500mg stat then 250mg bd**
500mg stat then 125mg bd**
500mg stat then 125mg od
** Applies if full dose is 500mg bd. If full dose 500mg od give the reduced dose daily Linezolid Normal Normal Normal Give post HD Meropenem Higher doses needed in CNS infection d/w micro
500mg-2g bd 500mg-1g bd 500mg-1g od Give post HD
Metronidazole Normal Normal Normal Give post HD
Nitrofurantoin Use at normal dose with caution Contraindicated Contraindicated
Monitor for toxicity e.g blood dyscrasias, neuropathy
Oseltamivir (treatment dose)
CrCl >30ml/min 75mg bd
CrCl 10-30ml/min 75mg od 30mg stat
HD: 30mg after alternate dialysis sessions Penicillin V Normal Normal Normal Give post HD Piperacillin/ Tazobactam (Tazocin)
Normal 4.5g 8-12h 4.5g 12h Give post HD
Posaconazole Normal Normal Normal
Pyrazinamide Normal Normal Normal
Rifampicin Normal Normal 50-100%
Nottingham Antimicrobial Guidelines Committee March 2009 Review March 2011
Teicoplanin* Normal
Normal loading dose then 200- 400mg every 24- 48h
Normal loading dose then 200-400mg every 48-72h
Normal Loading dose 400mg every 12 hours for 3 doses Monitor levels
Tetracycline Use Doxycycline see above Tigecycline Normal Normal Normal
Trimethoprim Normal
Use alternative agent if possible Normal
Ineffective for UTI, other indications: Normal but use alternative agent if possible
Give post HD Consider short term folic acid supplementation. NB May cause temporary rise in creatinine due to reduced creatinine secretion rather than a fall in CrCl
Valaciclovir CrCl 30-50ml/min Normal
Dose reduction required for Crcl<30ml/min seek further advice from pharmacy/renal drug handbook Valganciclovir Dose reduction required seek further advice from pharmacy/renal drug handbook
Vancomycin
1g od Check pre dose level before 3rd^ dose.
1g 48 h Check pre dose level before 2nd^ dose
1g stat (or 15mg/kg max 2g). Check level after 4-5 days. ONLY re-dose when level <12mg/L. If deep seated when <15mg/L
Monitor blood levels & adjust dose as required
Voriconazole Normal Normal Normal
Give post HD Caution in the use of IV in renal impairment due to accumulation of vehicle-discuss with pharmacy
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