Renal Dosing Protocol Drug List (revised 8/04)

DrugAcyclovir (IV) AHerpes SimplexEncephalitisAcyclovir (PO) AHerpes SimplexInfectionAcyclovir (PO) AHerpes ZosterAmoxicillin (PO) ABRenal Dosing Protocol Drug List (revised 8/04)Based on the ICU Renal Dosing Protocol, for ICU patients drugs on this list may be automaticallydose-adjusted by the Clinical Pharmacist according to the patient’s renal function.Estimated CrCl and Recommended Renal Dosing>30 >50mL/min mL/min 25 mL/min800 mg Q4H 5X per Day250-500mgQDayAmoxicillin/Clavulanat 250-500 mge (PO) AQDayAmpicillin (IV) B 2g Q12-24H 10-50ml/min2g Q 6-12HAmpicillin/Sulbactam 1.5-3g Q24-48(IV) B HAztreonam (IV) P 250-500 mgInitial loading dose 1-2g Q 8 HCefazolin (IV) S 1-2gQ 24-48HCefepime (IV) P 250-500 mgNormal Dosing Q 24 H10-30 mL/min250-500 mg BID10-30 mL/min250-500 mg BID10-50 mL/min1.5-3g Q 12-24H10-30 mL/min500-1000 mg Q 8 H10-50 mL/min1-2g Q12H11-29 mL/min500 mg-1g Q 24 HCefepime (IV) P 1g Q 24 H 11-29 mL/minFebrile Neutropenia2g Q 24HCefotaxime (IV) D 1-2 g Q24H 10-50 mL/min1-2g Q8-12H> 30 mL/min250-500 mg TID> 30 mL/min875 mg BIDCefoxitin (IV) 1 g Q 24-48 H 1-2 g Q 12-24 H 1-2 gQ 8-12 HCefpodoxime < 30 mL/min(PO) P100-400 mg QDCeftazidime (IV) B 1-2g Q 48 H < 15 mL/min 10-50 mL/min1g load 1-2g Q 24-48 Hthen 500mgQ 24HCeftriaxone (IV) PCefuroxime (IV) P 750 mg Q 24H 10-20ml/min750mgQ 12 HCephalexin (PO) A250mg Q 12 H< 5 mL/min:250mg Q 24 HCiprofloxacin (IV) B 200mg Q 12 H 10-50 mL/min200-300 mg Q 12 HCiprofloxacin(PO) BIf CrCl < 30mL/min donot use 750mg tabs250mg Q12H30-60mL/min10-15 mg/kg Q8H>50ml/minNormalRenalFunction2g Q 6H> 50 mL/min1.5-3g Q 6-8 H> 30 mL/min1g Q 8 H> 50 mL/min1-2g Q8H (2g only if severe)> 30 mL/min100-400 mg BIDNo renal adjustment necessary 1-2g Q24H>20ml/min750 mg-1.5g Q 8 H10-50 mL/min250-500 mg Q 12 H11 - 40 mL/min500 mg Q 8-12 H500mg-2gQ 24 H2gQ 12 H>60 mL/min500mg-2g Q12 H>60 mL/min2g Q 8 H> 50 mL/minModerate-Severe: 1-2g Q 8-12 HSevere: 2g Q 6-8 HLife Threatening:2g IV Q 4 H (12g Max)1-2 g Q 8H> 50 mL/min1-2g Q 8-12 H> 40 mL/min500 mg QID> 50 mL/min400 mg Q 12 HSevere or febrile neutropenia:400 mg Q 8 H> 50 mL/min500-750 mg Q 12 HG:\Share\Pharmacy Admin\Policy & Procedure Manual\Ready to sign\Ready for FormWeb\Renal Dosing Protocol Drug List .docRevised 6/04

DrugClarithromycin(PO) DEnoxaparin (SQ) PLovenox ®Ertapenem (IV) PErythromycinLactobionate (IV) SMonitor for signs ofototoxicityErythromycin Base(PO) SMonitor for signs ofototoxicityFamotidine (IV/PO) PPepcid ®Fluconazole(IV/PO) AGanciclovir (IV) APInduction CMV retinitisGanciclovir (IV) DMaintenance CMVretinitisGanciclovir (PO) AMaintenance CMVretinitisImipenem/Cilastatin(IV) S Primaxin ®Should be use withcaution, if at all, in renalfailure due to anincreased risk of seizures.Meropenem is preferredin renal failure.Ketorolac (IM/IV) PToradol ®Combined use of IV/POshould not exceed 5 daysLevofloxacin(IV/PO) DMeropenem (IV) PMetoclopramide(IV/PO) PReglan ®Metronidazole(IV) BSEstimated CrCl and Recommended Renal Dosing30 >50 mL/min Normal RenalFunctionmL/min mL/min mL/min< 30 mL/min≥ 30 mL/min125-250 mg Q 12 H250-500 mg Q 12 Hor 250-500 mg Q 24 H< 30 mL/minProphylaxis: 30 mg Q 24 HTreatment: 1 mg/kg Q 24 H< 30 mL/min500 mg Q 24 H125-375mg ≥ 10 mL/minQ 6 H 250-500 mg Q 6 H125-375mgQ 6 H≥ 10 mL/min250-500 mg Q 6 H< 50 mL/min20 mg Q 24 Hor ½ dose recommended for indication< 50 mL/min200-400 mg load,then 50-100 mg QDay125-250 mgQ 12 H1.25 mg/kgQ 24H0.625 mg/kgQ 24 H500 mgQDay10-49 mL/min250 mg Q 6-12 H25-49 mL/min2.5 mg/kgQ 24 H25-49 mL/min1.25 mg/kgQ 24 H25-49 mL/min500 mgBIDContraindicated in patients with advanced renal impairment andpatients at risk for renal failure because of volume depletion.< 20 mL/min500 mg load,then 250 mg Q 48 H500mg 500mgQ 24 H Q 12 H< 40 mL/min5-10 mg Q 6 H< 10 mL/min50% ofUsual DoseSee Note20-49 mL/min500 mg load,then 250 mgQ 24 H26-50 mL/min1g Q 12 H> 30 mL/minProphylaxis: 40 mg QDay or 30mg BIDTreatment: 1mg/kg Q 12H or 1.5mg/kg QDay> 30 mL/min1g Q 24 H> 50 mL/min20 mg Q12 H> 50 mL/min200-400 mg load,then 100-200 mg QDaySevere: 800 mg load,then 400 mg QDay50-69 mL/min2.5 mg/kg Q 12 H50-69 mL/min2.5 mg/kg Q 24 H50-69 mL/min500 mg TID> 50 mL/min250-500 mg Q 6-8 H≥ 50 mL/min15-30 mg Q 6 H> 50 mL/min500 mg Q24H> 50 mL/min1g Q 8 H> 40mL/min10-20 mg Q 6 H> 10 mL/min100% of usual doseNote: Usual dose per reference: 7.5mg/kg (~500mg) Q 6 HOther doses are commonly used in clinical practice> 70 mL/min5 mg/kgQ 12 H> 70 mL/min5mg/kgQ 24 H> 70 mL/min1g TIDG:\Share\Pharmacy Admin\Policy & Procedure Manual\Ready to sign\Ready for FormWeb\Renal Dosing Protocol Drug List .docRevised 6/04

Drug< 10mL/minEstimated CrCl and Recommended Renal Dosing25-50 >30 >50mL/min mL/min mL/min10-25mL/min30-60mL/minNitrofurantoin Not recommended with CrCl ≤ 50mL/min > 50 mL/min(PO) B 50-100 mg Q 6 HProphylaxis: 100mg QDayNitrofurantoin ER Not recommended with CrCl ≤ 50mL/min > 50 mL/min(PO) B 100 mg BIDPenicillin G (IV) ANormal DosePenicillin G (IV) ASerious InfectionsPenicillin V (PO) DPiperacillin (IV) D1-4 MillionunitsQ 12-18 H500,000 -2Million UnitsQ 4 H< 10 mL/min250-500 mgQ 8 H 10 mL/min250-500 mg Q 6 HPiperacillin/ 2.25g Q8H 10-49 mL/minTazobactam (IV) S 2.25g Q6HRifampin≤ 50 mL/min(IV)/(PO) BD 300-600mg Q 24 HEndocarditis requiresspecial dosingTrimethoprim/Sulfamethoxazole(TMP/Sulfa) DDosing based on TMP --For PCP TreatmentTrimethoprim/Sulfamethoxazole(TMP/Sulfa) DDosing based on TMPComponent --For PCPProphylaxisTrimethoprim/Sulfamethoxazole(TMP/Sulfa) DDosing based on TMPComponentVancomycin (IV)Adult weight >60kg*Vancomycin (IV)Adult weight 50 mL/min1-4 Million Units Q 6-8 H> 50 mL/min1-4 Million Units Q 4 H> 40 mL/min3-4g Q 4-6 H> 50 mL/min3.375g Q 6 H> 50 mL/min600mg Q 24 H> 30 mL/min15-20 mg/kg/day divided Q 6-8 H>30 mL/min5mg/kg Q 24 H for 3-7doses/weekNormalRenalFunction> 30 mL/min8-12 mg/kg/day divided Q 12 H X 14 daysthen 4-6 mg/kg Q 24 H30-60 mL/min1g Q 24H30-60 mL/min15mg/kg Q 24 H(round to 250mg increments)ReferencesAMcEvoy G, ed. AHFS Drug Information. Bethesda, MD: American Society of Health-Systems Pharmacists, Inc; 2003.BBennett GR, Arnoff TA, Golper et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults, 4 th ed. Philadelphia:American College of Physicians; 1999.DGelman CR, Rumack BH, Hutchison TA, eds. Drugdex ® System. Englewood, CO: Micromedex, Inc. Edition Expires 03/2003.PPhysicians’ Desk Reference. 51 st ed. Montvale, NJ: Medical Economics Company, Inc; 2003.SGilbert D. Moellering R. Sande M. The Sanford Guide to Antimicrobial Therapy. Hyde Park, VT: Antimicrobial Therapy Inc; 2003.≥ 60 mL/min1g Q 12 H≥ 60 mL/min15mg/kg Q12 H (roundto 250mgincrements)G:\Share\Pharmacy Admin\Policy & Procedure Manual\Ready to sign\Ready for FormWeb\Renal Dosing Protocol Drug List .docRevised 6/04