MGB Antimicrobial Dosing June 2023

Adapted from MGB guidelines, June 2023. Please refer to the original source for definitive guidance.
✱ID✱ indicates that Infectious Disease approval is required, unless otherwise noted by the individual hospital protocol.
Renal dosing adjustments should be calculated by the Cockcroft-Gault Equation, not estimated GFR, unless otherwise noted.

• ACYCLOVIR Sitavig, Zovirax

• Acyclovir IV: disseminated HSV, HSV encephalitis, visceral zoster, VZV/HSV retinal necrosis

  CrCl ≥50	10mg/kg	Q8H
  26–49	10mg/kg	Q12H
  10–25	10mg/kg	Q24H
  <10	5mg/kg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  Maintain adequate hydration; BMI<25: use actual body weight; BMI≥25: use adjusted body weight; Discuss doses ≥1,000mg with ID; On dialysis days give post-HD

  ACYCLOVIR [#grey] | Sitavig, Zovirax

• Acyclovir IV: localized HSV: genital, perirectal, mucosal, or cutaneous HSV

  CrCl ≥50	5mg/kg	Q8H
  26–49	5mg/kg	Q12H
  10–25	5mg/kg	Q24H
  <10	2.5mg/kg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  Maintain adequate hydration; BMI<25: use actual body weight; BMI≥25: use adjusted body weight; Discuss doses ≥1,000mg with ID; On dialysis days give post-HD

  ACYCLOVIR [#grey] | Sitavig, Zovirax

• Acyclovir PO: HSV labialis, mild genital/perirectal HSV

  CrCl ≥25	400mg	Q8H
  10–25	400mg	Q12H
  <10
  Hemodialysis
  Peritoneal dialysis	600–800mg	Q24H
  CVVH	NO DATA

  ACYCLOVIR [#grey] | Sitavig, Zovirax

• Acyclovir PO: herpes zoster

  CrCl ≥25	800mg	5x/day
  10–25	800mg	Q8H
  <10	800mg	Q12H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  ACYCLOVIR [#grey] | Sitavig, Zovirax

• Acyclovir PO: prophylaxis/suppression

  CrCl ≥25	400mg	Q8H–Q12H
  10–25	400mg	Q12H
  <10	200–400mg	Q12H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  ACYCLOVIR [#grey] | Sitavig, Zovirax

• Acyclovir IV: prophylaxis/suppression

  CrCl ≥50	200mg	Q8H–Q12H
  26–49	200mg	Q12H
  10–25	200mg	Q24H
  <10	100mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	200mg	Q24H

  ACYCLOVIR [#grey] | Sitavig, Zovirax
• ALBENDAZOLE Albenza

• Albendazole PO: ancylostomiasis, necatoriasis, cutaneous larva migrans, or enterobiasis

  All CrCl	400mg	1x or Q24H
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  ALBENDAZOLE [#grey] | Albenza

• Albendazole PO: echinococcosis or neurocysticercosis

  All CrCl	400mg	Q12H
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  If <60kg: 15mg/kg/day divided into 2 doses, max 400 mg/dose

  ALBENDAZOLE [#grey] | Albenza
• AMIKACIN Amikin

• Amikacin ✱ID✱

  Please refer to Site-Specific Aminoglycoside Dosing Guidelines, when available.

  Please contact pharmacy department for help with monitoring serum concentrations and dosage adjustments

  AMIKACIN [#grey] | Amikin
• AMOXICILLIN Amoxil, Trimox, Moxatag

• Amoxicillin PO

  CrCl >30	500–1000mg	Q8H–Q12H
  10–30	500–1000mg	Q12H
  <10	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis	250mg	Q12H
  CVVH	NO DATA

  On dialysis days give post-HD

  AMOXICILLIN [#grey] | Amoxil, Trimox, Moxatag

• Amoxicillin PO: procedure prophylaxis for infective endocarditis, dental procedures

  All CrCl	2000mg	x1
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Administer 30-60 minutes prior to procedure (use of IE Abx prophylaxis for Dental procedures limited to: pts with prosthetic valve, h/o IE, CHD, heart transplant recipients)

  AMOXICILLIN [#grey] | Amoxil, Trimox, Moxatag
• AMOXICILLIN-CLAVULANATE Augmentin ER, Augmentin XR

• Amoxicillin-clavulanate PO

  CrCl >30	500–875mg	Q8H–Q12H
  10–30	500mg	Q12H
  <10	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis	250mg	Q12H
  CVVH	NO DATA

  On dialysis days give post-HD; Some patients may require higher dosing despite renal function; Dosing based on amoxicillin component

  AMOXICILLIN-CLAVULANATE [#grey] | Augmentin ER, Augmentin XR

• Amoxicillin-clavulanate PO XR: community acquired pneumonia, acute bacterial sinusitis

  CrCl ≥30	2gm	Q12H
  <30	AVOID

  Dosing based on amoxicillin component

  AMOXICILLIN-CLAVULANATE [#grey] | Augmentin ER, Augmentin XR
• AMPHOTERICIN B AmphoB, AmBisome, Fungizone, Amphocin

• Liposomal Amphotericin B IV: candidemia, febrile neutropenia, cryptococcosis ✱ID✱

  All CrCl	3–5mg/kg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Infuse over 2–4 hours; On dialysis days give post-HD

  AMPHOTERICIN B [#grey] | AmphoB, AmBisome, Fungizone, Amphocin

• Liposomal Amphotericin B IV: aspergillosis, mucormycosis ✱ID✱

  All CrCl	5mg/kg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Infuse over 2–4 hours; On dialysis days give post-HD

  AMPHOTERICIN B [#grey] | AmphoB, AmBisome, Fungizone, Amphocin

• Liposomal Amphotericin B Inhaled: prophylaxis for Aspergillus ✱ID✱

  All CrCl	25mg	TIW
  Hemodialysis
  Peritoneal dialysis
  CVVH

  AMPHOTERICIN B [#grey] | AmphoB, AmBisome, Fungizone, Amphocin

• Amphotericin B lipid complex (Abelcet) Inhaled: prophylaxis for Aspergillus ✱ID✱

  All CrCl	50mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Adjustments per transplant team

  AMPHOTERICIN B [#grey] | AmphoB, AmBisome, Fungizone, Amphocin
• AMPHOTERICIN B DEOXYCHOLATE AmphoB, AmBisome, Fungizone, Amphocin

• Amphotericin B deoxycholate IV ✱ID✱

  All CrCl	0.25–1.5mg/kg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  May administer as continuous infusion over 24 hours; On dialysis days give post-HD. Due to high toxicity associated with the systemic use of this agent, this formulation is not recommended

  AMPHOTERICIN B DEOXYCHOLATE [#grey] | AmphoB, AmBisome, Fungizone, Amphocin
• AMPICILLIN

• Ampicillin IV: bacteremia and other systemic infections

  CrCl >50	2gm	Q6H
  10–50	2gm	Q8H–Q12H
  <10	2gm	Q12H
  Hemodialysis	2gm	Q8H–Q12H
  Peritoneal dialysis	2gm	Q12H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  AMPICILLIN [#grey]

• Ampicillin IV: bacterial meningitis, endocarditis, or Listeria

  CrCl >50	2gm	Q4H
  10–50	2gm	Q6H–Q8H
  <10	2gm	Q12H
  Hemodialysis	2gm	Q8H–Q12H
  Peritoneal dialysis	2gm	Q12H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  AMPICILLIN [#grey]

• Ampicillin PO: Mild GI, GU, and upper respiratory tract infections

  CrCl >50	250-500mg	Q6H
  10–50	250-500mg	Q6H–Q12H
  <10	250-500mg	Q12H–Q24H
  Hemodialysis	250-500mg	Post-HD
  Peritoneal dialysis	250mg	Q12H
  CVVH	NO DATA

  Oral dosing not recommended in hospitalized patients

  AMPICILLIN [#grey]
• AMPICILLIN-SULBACTAM Unasyn ADD-Vantage, amp-sulbactam

• Ampicillin-sulbactam IV: Acinetobacter baumannii, Enterococcal endocarditis

  CrCl >30	3gm (2gm/1gm)	Q4H–Q6H
  15–30	3gm (2gm/1gm)	Q6H–Q8H
  <15	3gm (2gm/1gm)	Q8H–Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  Higher doses may be considered in certain MDR infections per IDSA guidelines. Discuss with ID Pharmacy or ID for dosing recommendations.

  AMPICILLIN-SULBACTAM [#grey] | Unasyn ADD-Vantage, amp-sulbactam

• Ampicillin-sulbactam IV: Skin and soft tissue infections, intra-abdominal infections, pelvic inflammatory disease

  CrCl >30	3gm (2gm/1gm)	Q6H
  15–30	3gm (2gm/1gm)	Q8H-12H
  <15	3gm (2gm/1gm)	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  AMPICILLIN-SULBACTAM [#grey] | Unasyn ADD-Vantage, amp-sulbactam
• ARTEMETHER-LUMEFANTRINE Coartem

• Artemether-lumefantrine PO: P. falciparum malaria for patients weighing >35kg

  All CrCl, weight >35kg	80mg/480mg	✱Q12H x 3 days
  All CrCl, weight 25–35kg	60mg/360mg	✱Q12H x 3 days
  Hemodialysis	See above dosing based on weight
  Peritoneal dialysis	See above dosing based on weight
  CVVH	See above dosing based on weight

  ✱On day one, give second dose 8 hours after first dose. Total course is 6 doses.

  ARTEMETHER-LUMEFANTRINE [#grey] | Coartem
• ATOVAQUONE Mepron

• Atovaquone PO: Pneumocystis jirovecii pneumonia prophylaxis

  All CrCl.	1500mg	Q24H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	1500mg	Q24H

  ATOVAQUONE [#grey] | Mepron

• Atovaquone PO: Pneumocystis jirovecii pneumonia treatment or prophylaxis, babesiosis treatment

  All CrCl.	750mg	Q12H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	750mg	Q12H

  ATOVAQUONE [#grey] | Mepron

• Atovaquone PO: toxoplasmosis treatment

  All CrCl.	1500mg	Q12H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	1500mg	Q12H

  ATOVAQUONE [#grey] | Mepron
• ATOVAQUONE-PROGUANIL Malarone

• Atovaquone-proguanil PO: P. falciparum malaria treatment

  All CrCl	1000mg/400mg	Q24H x3 days
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  ATOVAQUONE-PROGUANIL [#grey] | Malarone

• Atovaquone-proguanil PO: P. falciparum malaria prophylaxis

  CrCl ≥30	250mg/100mg	Q24H
  CrCl <30	AVOID
  Hemodialysis	AVOID
  Peritoneal dialysis	AVOID
  CVVH	AVOID

  ATOVAQUONE-PROGUANIL [#grey] | Malarone
• AZITHROMYCIN Azasite, Zithromax TRI-PAK, Zithromax Z-Pak, Zmax

• Azithromycin PO/IV: bacterial sinusitis, community acquired pneumonia, skin and soft tissue infections, pertussis

  All CrCl	250–500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  On dialysis days give post-HD

  AZITHROMYCIN [#grey] | Azasite, Zithromax TRI-PAK, Zithromax Z-Pak, Zmax

• Azithromycin PO: MAC prophylaxis

  All CrCl	1200mg	QWEEK
  Hemodialysis
  Peritoneal dialysis
  CVVH

  AZITHROMYCIN [#grey] | Azasite, Zithromax TRI-PAK, Zithromax Z-Pak, Zmax
• AZTREONAM Azactam

• Aztreonam IV ✱ID✱

  CrCl >50	2gm	Q8H
  10–50	1gm	Q8H
  <50	500mg	Q8H
  Hemodialysis	1–2gm x1, then 500mg	Q8H
  Peritoneal dialysis	500mg	Q8H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  AZTREONAM [#grey] | Azactam
• BALOXAVIR Xofluza

• Baloxavir PO ✱ID✱

  CrCl ≥50, weight ≥80kg	80mg	x1
  ≥50, weight <80kg	40mg	x1
  <50	NO DATA
  Hemodialysis	NO DATA
  Peritoneal dialysis.	NO DATA
  CVVH	NO DATA

  BALOXAVIR [#grey] | Xofluza
• BEDAQUILINE Sirturo

• Bedaquiline PO

  All CrCl	400mg Q24H x2 weeks, then 200mg	Three times weekly
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  Only able to be obtained through Metro Medical Speciality Pharmacy after consultation with MTB expert

  BEDAQUILINE [#grey] | Sirturo
• BEZLOTOXUMAB Zinplava

• Bezlotoxumab IV: CDI recurrence ✱ID✱

  All CrCl	10mg/kg	x1
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Not generally used for inpatients, please follow local guidelines

  BEZLOTOXUMAB [#grey] | Zinplava
• CEFACLOR Ceclor Pulvules, Ceclor CD, Raniclor

• Cefaclor PO

  All CrCl	250–500mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH	NO DATA

  CEFACLOR [#grey] | Ceclor Pulvules, Ceclor CD, Raniclor
• CEFADROXIL Duricef

• Cefadroxil PO

  CrCl >50	500–1000mg	Q12H
  25–50	500mg	Q12H
  10–25	500mg	Q24H
  <10	500mg	Q36H
  Hemodialysis	500–1000mg	Post-HD
  Peritoneal dialysis	500mg	Q24H
  CVVH	NO DATA

  CEFADROXIL [#grey] | Duricef
• CEFAZOLIN Ancef, Kefzol

• Cefazolin IV

  CrCl >50	2gm	Q8H
  10–50	2gm	Q12H
  <10	2gm	Q24H
  Hemodialysis	1gm Q24H OR 2–3gm Post-HD
  Peritoneal dialysis	1gm	Q24H
  CVVH	See CVVH Dosing

  For Post-HD dosing, consider using 2gm and 3gm with the 48- and 72-hr interdialytic periods, respectively; On dialysis days give post-HD

  CEFAZOLIN [#grey] | Ancef, Kefzol
• CEFDINIR Omnicef Omni-Pac

• Cefdinir PO

  CrCl ≥30	300mg	Q12H
  <30	300mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	NO DATA

  On dialysis days give post-HD

  CEFDINIR [#grey] | Omnicef Omni-Pac
• CEFEPIME Maxipime ADD-Vantage

• Cefepime IV: febrile neutropenia, pneumonia, cystic fibrosis, non-UTI Pseudomonas aeruginosa

  CrCl ≥60	2gm	Q8H
  30–59	2gm	Q12H
  10–29	2gm	Q24H
  <10	1gm	Q24H
  Hemodialysis	1gm Q24H OR 2gm Post-HD
  Peritoneal dialysis	1gm	Q24H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  CEFEPIME [#grey] | Maxipime ADD-Vantage

• Cefepime IV: other infections

  CrCl ≥60	1gm / 2gm	Q8H / Q12H
  30–59	1gm / 2gm	Q12H / Q24H
  10–29	1gm	Q24H
  <10
  Hemodialysis	1gm Q24H OR 2gm Post-HD
  Peritoneal dialysis	1gm x1, then 0.5gm	Q24H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  CEFEPIME [#grey] | Maxipime ADD-Vantage

• Cefepime IV: alternative dosing; may replace 2gm Q8H and 2gm Q12H dosing; EXCEPT for febrile neutropenia and CNS infections

  CrCl ≥50	1gm	Q6H
  30–49	1gm	Q8H
  10–29	1gm	Q12H
  <10	1gm	Q24H
  Hemodialysis	1gm Q24H OR 2gm Post-HD
  Peritoneal dialysis	1gm	Q24H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  CEFEPIME [#grey] | Maxipime ADD-Vantage
• CEFIDEROCOL Fetroja

• Cefiderocol IV ✱ID✱

  CrCl ≥120	2gm	Q6H
  60–119	2gm	Q8H
  30–59	1.5gm	Q8H
  15–29	1gm	Q8H
  <15	0.75gm	Q12H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  CEFIDEROCOL [#grey] | Fetroja
• CEFIXIME Suprax

• Cefixime PO

  CrCl ≥60	400mg	Q24H
  21–59	300mg	Q24H
  ≤20	200mg	Q24H
  Hemodialysis	300mg	Q24H
  Peritoneal dialysis	200mg	Q24H
  CVVH	NO DATA

  CEFIXIME [#grey] | Suprax

• Cefixime PO: uncomplicated gonorrhea

  All CrCl	400mg	x1
  Hemodialysis
  Peritoneal dialysis
  CVVH	NO DATA

  CEFIXIME [#grey] | Suprax
• CEFOTAXIME Claforan ADD-Vantage

• Cefotaxime IV

  CrCl >50	2gm	Q6H
  10–50	2gm	Q8H
  <10	2gm	Q24H
  Hemodialysis	0.5–2gm	Q24H
  Peritoneal dialysis	1gm	Q24H
  CVVH	See CVVH Dosing

  2gm Q4H in severe infections; On dialysis days give post-HD

  CEFOTAXIME [#grey] | Claforan ADD-Vantage
• CEFOTETAN Cefotan

• Cefotetan IV

  CrCl >30	1–2gm	Q12H
  <30	1–2gm	Q24H
  Hemodialysis	1gm	Post-HD
  Peritoneal dialysis	1gm	Q24H
  CVVH	1–2gm	Q24h

  On dialysis days give post-HD

  CEFOTETAN [#grey] | Cefotan
• CEFOXITIN Mefoxin

• Cefoxitin IV

  CrCl >50	1–2gm	Q6–Q8H
  10–50	1–2gm	Q8–12H
  <10	1–2gm	Q24–48H
  Hemodialysis	1gm	Post-HD
  Peritoneal dialysis	1gm	Q24H
  CVVH	1–2gm	Q8–12H

  On dialysis days give post-HD

  CEFOXITIN [#grey] | Mefoxin

• Cefoxitin IV: nontuberculous mycobacterial infections

  CrCl >50	3gm / 2gm	Q6H / Q4H
  10–50	3gm / 2gm	Q8H / Q6H
  <10	3gm	Q24H–Q48H
  Hemodialysis	3gm	Post-HD
  Peritoneal dialysis	3gm	Q24H
  CVVH	3gm / 2gm	Q12H / Q8H

  On dialysis days give post-HD

  CEFOXITIN [#grey] | Mefoxin
• CEFPODOXIME Vantin

• Cefpodoxime PO

  CrCl ≥30	200–400mg	Q12H
  <30	200–400mg	Q24H
  Hemodialysis	200–400mg	Post-HD
  Peritoneal dialysis	200–400mg	Q24H
  CVVH	NO DATA

  On dialysis days give post-HD

  CEFPODOXIME [#grey] | Vantin
• CEFPROZIL Cefzil

• Cefprozil PO: acute bacterial exacerbation of chronic bronchitis, uncomplicated skin and soft tissue infection

  CrCl ≥50	500mg	Q12H
  <50	250mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	NO DATA

  On dialysis days give post-HD

  CEFPROZIL [#grey] | Cefzil

• Cefprozil PO: pharyngitis, tonsillitis

  CrCl ≥50	500mg	Q24H
  <50	250mg	Q24H
  Hemodialysis	250mg	Post-HD
  Peritoneal dialysis	250mg	Q24H
  CVVH	NO DATA

  On dialysis days give post-HD

  CEFPROZIL [#grey] | Cefzil
• CEFTAROLINE FOSAMIL Teflaro

• Ceftaroline fosamil IV: community acquired pneumonia, skin and soft tissue infections ✱ID✱

  CrCl ≥50	600mg	Q12H
  30–49	400mg	Q12H
  10–29	300mg	Q12H
  <10	200mg	Q12H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  CEFTAROLINE FOSAMIL [#grey] | Teflaro

• Ceftaroline fosamil IV: MRSA bacteremia, MRSA pneumonia, severe MRSA infections ✱ID✱

  CrCl ≥50	600mg	Q8H
  30–49	400mg	Q8H
  10–29	300mg	Q8H
  <10	200mg	Q8H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; Consider Q12H in cases of Gram positive synergy dosing

  CEFTAROLINE FOSAMIL [#grey] | Teflaro
• CEFTAZIDIME Fortaz, Tazicef, Ceptaz, Tazidime, Tazicef Novaplus

• Ceftazidime IV: febrile neutropenia, pneumonia, bacteremia, sepsis

  CrCl >50	2gm	Q8H
  31–50	2gm	Q12H
  16–30	2gm	Q24H
  5–15	2gm x1, then 1gm	Q24H
  <5	2gm x1, then 1gm	Q48H
  Hemodialysis	2gm x1, then 1gm Q24H OR 2gm Post-HD
  Peritoneal dialysis	2gm x1, then 1gm	Q24H
  CVVH	See CVVH Dosing

  Max dose 8gm/day; Meningitis max dose up to 2gm Q6H; On dialysis days give post-HD

  CEFTAZIDIME [#grey] | Fortaz, Tazicef, Ceptaz, Tazidime, Tazicef Novaplus

• Ceftazidime IV: UTI, if urosepsis follow above dosing recommendations

  CrCl >50	1gm	Q8H
  31–50	1gm	Q12H
  5–30	1gm	Q24H
  <5	1gm	Q48H
  Hemodialysis	1gm x1, then 0.5gm	Q24H
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  CEFTAZIDIME [#grey] | Fortaz, Tazicef, Ceptaz, Tazidime, Tazicef Novaplus
• CEFTAZIDIME-AVIBACTAM Avycaz ceftaz-avi

• Ceftazidime-avibactam IV ✱ID✱

  CrCl >50	2.5gm	Q8H
  31–50	1.25–2.5gm x1 then 1.25 gm	Q8H
  16–30	1.25gm	Q12H
  5–15	1.25gm	Q24H
  <5	1.25gm	Q48H
  Hemodialysis (CrCl 6–15 mL/min)	1.25gm	Q24H
  Hemodialysis (CrCl ≤5 mL/min)	1.25gm	Q48H
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; Each 2.5gm vial contains 2gm of ceftazidime and 0.5gm of avibactam

  CEFTAZIDIME-AVIBACTAM [#grey] | Avycaz ceftaz-avi
• CEFTOLOZANE-TAZOBACTAM Zerbaxa ceftolo-tazo

• Ceftolozane-tazobactam IV: complicated urinary tract infections and complicated intra-abdominal infections ✱ID✱

  CrCl >50	1500mg	Q8H
  30–50	750mg	Q8H
  15–29	375mg	Q8H
  <15	NO DATA
  Hemodialysis	750mg x1 then 150mg	Q8H
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; Each 1500mg vial contains 1000mg of ceftolozane and 500mg of tazobactam

  CEFTOLOZANE-TAZOBACTAM [#grey] | Zerbaxa ceftolo-tazo

• Ceftolozane-tazobactam IV: ventilator-associated pneumonia or MDRO pathogens ✱ID✱

  CrCl >50	3000mg	Q8H
  30–50	1500mg	Q8H
  15–29	750mg	Q8H
  <15	NO DATA
  Hemodialysis	2250mg x1 then 450mg	Q8H
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; Each 1500mg vial contains 1000mg of ceftolozane and 500mg of tazobactam

  CEFTOLOZANE-TAZOBACTAM [#grey] | Zerbaxa ceftolo-tazo
• CEFTRIAXONE Rocephin ADD-Vantage

• Ceftriaxone IV: bloodstream infections, bone or joint infections, pneumonia, intra-abdominal infections, Lyme disease

  All CrCl	2gm	Q24H
  Hemodialysis
  Peritoneal dialysis	1gm	Q12–24H
  CVVH	2gm	Q24H

  On dialysis days give post-HD

  CEFTRIAXONE [#grey] | Rocephin ADD-Vantage

• Ceftriaxone IV: urinary tract infections, skin and soft tissue infections, pneumonia, intra-abdominal infections, SBP prophylaxis

  All CrCl	1gm	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	2gm	Q24H

  On dialysis days give post-HD

  CEFTRIAXONE [#grey] | Rocephin ADD-Vantage

• Ceftriaxone IV: bacterial meningitis or Enterococcal endocarditis

  All CrCl	2gm	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  On dialysis days give post-HD

  CEFTRIAXONE [#grey] | Rocephin ADD-Vantage

• Ceftriaxone IM: gonorrhea

  All CrCl	500mg	x1
  Hemodialysis
  Peritoneal dialysis
  CVVH

  For patients ≥150kg, ceftriaxone 1000 mg should be administered

  CEFTRIAXONE [#grey] | Rocephin ADD-Vantage
• CEFUROXIME Ceftin, Kefurox, Zinacef, Zinacef ADD-Vantage, Zinacef TwistVial

• Cefuroxime IV

  CrCl >20	750–1500mg	Q8H
  10–20	750–1500mg	Q12H
  <10	750–1500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  CEFUROXIME [#grey] | Ceftin, Kefurox, Zinacef, Zinacef ADD-Vantage, Zinacef TwistVial

• Cefuroxime PO

  CrCl ≥10	250–500mg	Q12H
  <10	250–500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  CEFUROXIME [#grey] | Ceftin, Kefurox, Zinacef, Zinacef ADD-Vantage, Zinacef TwistVial
• CEPHALEXIN Keflex, Biocef, Zartan, Panixine, Daxbia

• Cephalexin PO

  CrCl >50	500–1000mg	Q6H
  10–50	500–1000mg	Q8H
  <50	250–500mg	Q12–24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	NO DATA

  On dialysis days give post-HD. Consider higher doses in obesity; Max dose 4 gm/day.

  CEPHALEXIN [#grey] | Keflex, Biocef, Zartan, Panixine, Daxbia
• CHLORAMPHENICOL

• Chloramphenicol IV

  All CrCl	12.5–25mg/kg	Q6H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  CHLORAMPHENICOL [#grey] |
• CHLOROQUINE PHOSPHATE Aralen Phosphate, Aralen Hydrochloride

• Chloroquine Phosphate PO: malaria treatment

  All CrCl | 1gm x1, then 500mg at 6, 24, and 48h after initial dose Hemodialysis | 1gm x1, then 500mg at 6, 24, and 48h after initial dose Peritoneal dialysis | 1gm x1, then 500mg at 6, 24, and 48h after initial dose CVVH | 1gm x1, then 500mg at 6, 24, and 48h after initial dose

  500mg of chloroquine phosphate salt is equivalent to 300mg of chloroquine base

  CHLOROQUINE PHOSPHATE [#grey] | Aralen Phosphate, Aralen Hydrochloride

• Chloroquine Phosphate PO: malaria prophylaxis

  All CrCl	500mg	once weekly
  Hemodialysis
  Peritoneal dialysis
  CVVH

  500mg of chloroquine phosphate salt is equivalent to 300mg of chloroquine base; Start 1-2 weeks before arrival to endemic area, continue weekly during travel and for 4 weeks after leaving endemic area

  CHLOROQUINE PHOSPHATE [#grey] | Aralen Phosphate, Aralen Hydrochloride
• CIDOFOVIR Vistide

• Cidofovir IV ✱ID✱

  CrCl ≥55	5mg/kg	Qweek x2 doses, then Q2weeks
  <55	Consult ID
  Hemodialysis	AVOID
  Peritoneal dialysis	AVOID
  CVVH	See CVVH Dosing

  Consider dose adjustments in discussion with ID in patients with severe renal dysfunction; Pre and post hydration with sodium chloride 0.9%; Probenecid 2gm 3 hours prior to and 1gm 2hr and 8h post infusion

  CIDOFOVIR [#grey] | Vistide

• Cidofovir IV: BK virus nephropathy ✱ID✱

  CrCl ≥10	0.25–1mg/kg	x1
  CrCl <10	NO DATA

  Repeat doses will be determined by the renal transplant team in conjunction with ID. Probenecid should not be co-administered with cidofovir when it is being used to treat BK nephropathy

  CIDOFOVIR [#grey] | Vistide
• CIPROFLOXACIN Cipro, Proquin XR

• Ciprofloxacin IV

  CrCl ≥30	400mg	Q8–12H
  <30	400mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; If critically ill or treating pneumonia, q8h can be used

  CIPROFLOXACIN [#grey] | Cipro, Proquin XR

• Ciprofloxacin PO

  CrCl ≥30	500–750mg	Q12H
  <30	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	500–750mg	Q24H

  Consider higher dose for PsA, MDR, critically ill, or PNA. Consider 250-500 mg for empiric UTI coverage. On dialysis days give post-HD.

  CIPROFLOXACIN [#grey] | Cipro, Proquin XR

• Ciprofloxacin PO: Spontaneous Bacterial Peritonitis Prophylaxis

  All CrCl	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  On dialysis days give post-HD

  CIPROFLOXACIN [#grey] | Cipro, Proquin XR
• CLARITHROMYCIN Biaxin XL

• Clarithromycin PO

  CrCl ≥30	500mg	Q12H
  <30	250mg	Q12H
  Hemodialysis	500mg	Q24H
  Peritoneal dialysis	NO DATA
  CVVH	250–500mg	Q12H

  On dialysis days give post-HD

  CLARITHROMYCIN [#grey] | Biaxin XL
• CLINDAMYCIN Biaxin XL

• Clindamycin PO: mild-to-moderate infections

  All CrCl	150–450mg	Q6–8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  CLINDAMYCIN [#grey] | Biaxin XL

• Clindamycin PO: complicated skin and soft tissue infections, pneumonia, or bone & joint infections due to MRSA

  All CrCl	600mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  CLINDAMYCIN [#grey] | Biaxin XL

• Clindamycin Phosphate IV

  All CrCl	600–900mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Serious life threatening infections up to 2,700mg daily

  CLINDAMYCIN [#grey] | Biaxin XL
• CLOFAZIMINE Biaxin XL

• Clofazimine PO: nontuberculous mycobacterial infections

  All CrCl	100mg	Q24H
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  Available for compassionate use for MDR MAC; Requires emergency IRB for dispensing, ID consult recommended

  CLOFAZIMINE [#grey] | Biaxin XL
• COLISTIN Coly Mycin M

• Colistimethate IV ✱ID✱

  CrCl ≥70	300mg x1, then 150mg	Q12H
  60–69	300mg x1, then 140mg	Q12H
  50–59	300mg x1, then 125mg	Q12H
  40–49	300mg x1, then 110mg	Q12H
  30–39	300mg x1, then 100mg	Q12H
  20–29	300mg x1, then 90mg	Q12H
  10–19	300mg x1, then 80mg	Q12H
  <10
  Hemodialysis	300mg x1, then 130–170mg✱	Q24H
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  Dose in terms of colistin base activity (CBA). 1 vial = 150mg CBA = 360mg colistimethate sodium (CMS) = 4.5million units CMS; Dose based on ideal body weight in obesity; ✱Give 130mg on non-HD days and 170mg on HD days; on dialysis days give post-HD; See MGH Dosing Guidelines

  COLISTIN [#grey] | Coly Mycin M
• CYCLOSERINE PO Seromycin

• Cycloserine PO: tuberculosis ✱ID✱

  CrCl ≥10	250mg	Q24H
  <10	250–500mg	Q36–48H
  Hemodialysis	250mg	Q24H
  Peritoneal dialysis	NO DATA
  CVVH	250–500mg	Q24H

  TDM goal peak is <35 mcg/mL, dose may be escalated over 2-week period to a max dose of 1000mg/day; dosing should always be discussed with MTB expert; Consider supplemental pyridoxine

  CYCLOSERINE PO [#grey] | Seromycin
• DALBAVANCIN Dalvance

• Dalbavancin IV: MRSA skin and soft tissue infection ✱ID✱

  CrCl ≥30	1500mg	x1
  <30	1125mg	x1
  Hemodialysis	1500mg	x1
  Peritoneal dialysis	NO DATA
  CVVH	1125mg	x1

  Dalbavancin is not removed by hemodialysis

  DALBAVANCIN [#grey] | Dalvance

• Dalbavancin IV: osteomyelitis ✱ID✱

  CrCl ≥30	1500mg	qweek x2
  <30	NO DATA
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  Based on Rappo et al. OFID. 2018;6(1):ofy331; Dalbavancin is not removed by hemodialysis

  DALBAVANCIN [#grey] | Dalvance
• DAPSONE PJP PCP

• Dapsone PO: Pneumocystis jirovecii pneumonia treatment or prophylaxis

  All CrCl	100mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Treatment requires addition of trimethoprim 5mg/kg TID. Consider G6PD testing in high risk patients.

  DAPSONE [#grey] | PJP PCP

• Dapsone PO: Pneumocystis jirovecii pneumonia prophlaxis alternate dosing

  All CrCl	50mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Consider G6PD testing in high risk patients.

  DAPSONE [#grey] | PJP PCP
• DAPTOMYCIN Cubicin RF

• Daptomycin IV: MRSA bacteremia or endocarditis ✱ID✱

  CrCl ≥30	8mg/kg	Q24H
  <30	8mg/kg	Q48H
  Hemodialysis	8mg/kg Q48H OR 8–12mg/kg post-HD
  Peritoneal dialysis	8mg/kg	Q48H
  CVVH	See CVVH Dosing

  Do not use for pulmonary infections. For Post-HD dosing, consider using 8 and 12mg/kg with the 48- and 72-hr interdialytic period, respectively. Round dose to the nearest 50mg.

  DAPTOMYCIN [#grey] | Cubicin RF

• Daptomycin IV: VRE bacteremia or endocarditis ✱ID✱

  CrCl ≥30	8–12mg/kg	Q24H
  <30	8–12mg/kg	Q48H
  Hemodialysis	8–12mg/kg Q48H OR 8–12mg/kg post-HD
  Peritoneal dialysis	8–12mg/kg	Q48H
  CVVH	See CVVH Dosing

  Do not use for pulmonary infections. For Post-HD dosing, consider using 8 and 12mg/kg with the 48- and 72-hr interdialytic period, respectively. Round dose to the nearest 50mg.

  DAPTOMYCIN [#grey] | Cubicin RF

• Daptomycin IV: Skin and soft tissue infections ✱ID✱

  CrCl ≥30	4mg/kg	Q24H
  <30	4mg/kg	Q48H
  Hemodialysis	4mg/kg Q48H OR 4–6mg/kg post-HD
  Peritoneal dialysis	4mg/kg	Q48H
  CVVH	See CVVH Dosing

  Do not use for pulmonary infections. For Post-HD dosing, consider using 4 and 6mg/kg with the 48- and 72-hr interdialytic period, respectively. Round dose to the nearest 50mg.

  DAPTOMYCIN [#grey] | Cubicin RF
• DELAFLOXACIN Baxdela

• Delafloxacin PO: pneumonia, skin and soft tissue infections ✱ID✱

  eGFR ≥15	450mg	Q12H
  <15	Not recommended
  Hemodialysis	Not recommended

  MDRD eGFR (mL/min/1.73m2) = 175 x (serum creatinine) - 1.154 x (age) - 0.203 x (0.742 if female) x (1.212 if African American); MDCalc calculator

  DELAFLOXACIN [#grey] | Baxdela

• Delafloxacin IV: pneumonia, skin and soft tissue infections ✱ID✱

  eGFR ≥30	300mg	Q12H
  15–29	200mg	Q12H
  <15	Not recommended
  Hemodialysis	Not recommended

  MDRD eGFR (mL/min/1.73m2) = 175 x (serum creatinine) - 1.154 x (age) - 0.203 x (0.742 if female) x (1.212 if African American); MDCalc calculator

  DELAFLOXACIN [#grey] | Baxdela
• DICLOXACILLIN Dycill, Dynapen

• Dicloxacillin Sodium PO

  All CrCl	125–500mg	Q6H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Max dose 2gm/day

  DICLOXACILLIN [#grey] | Dycill, Dynapen
• DOXYCYCLINE Acticlate, Adoxa CK, Adoxa Pak, Adoxa TT, Alodox, Avidoxy, Doryx, Mondoxyne NL, Monodox, Morgidox, Okebo, Oracea, Oraxyl, Periostat Targadox, Vibramycin calcium, Vibramycin Hyclate, Vibramycin monohydrate, Vibra-Tabs

• Doxycycline PO/IV

  All CrCl	100mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  DOXYCYCLINE [#grey] | Acticlate, Adoxa CK, Adoxa Pak, Adoxa TT, Alodox, Avidoxy, Doryx, Mondoxyne NL, Monodox, Morgidox, Okebo, Oracea, Oraxyl, Periostat Targadox, Vibramycin calcium, Vibramycin Hyclate, Vibramycin monohydrate, Vibra-Tabs
• ERAVACYCLINE Xerava

• Eravacycline IV ✱ID✱

  All CrCl	1mg/kg	Q12H
  Severe hepatic impairment (Child-Pugh C)	1mg/kg Q12H x2, then 1mg/kg	Q24H
  Concomitant strong CYP3A inducer	1.5mg/kg	Q12H
  Hemodialysis	1mg/kg	Q12H
  CVVH

  ERAVACYCLINE [#grey] | Xerava
• ERTAPENEM Invanz ADD-Vantage

• Ertapenem IV ✱ID✱

  CrCl ≥30	1gm	Q24H
  <30	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  ERTAPENEM [#grey] | Invanz ADD-Vantage
• ERYTHROMYCIN EES, EryPed, Ery-Tab, Erythrocin Lactobionate, Erythrocin Stearate Filmtab

• Erythromycin Lactobionate IV

  CrCl ≥10	15–20mg/kg	Q6H
  <10	7.5–10mg/kg	Q6H
  Hemodialysis
  Peritoneal dialysis
  CVVH	15–20mg/kg	Q6H

  Max dose 4gm/day

  ERYTHROMYCIN [#grey] | EES, EryPed, Ery-Tab, Erythrocin Lactobionate, Erythrocin Stearate Filmtab

• Erythromycin Lactobionate IV: GI motility

  All CrCl	70–200mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  ERYTHROMYCIN [#grey] | EES, EryPed, Ery-Tab, Erythrocin Lactobionate, Erythrocin Stearate Filmtab

• Erythromycin PO tablets

  All CrCl	250–500mg	Q6H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Extended release and film coated tablets should be dosed off of the erythromycin base component

  ERYTHROMYCIN [#grey] | EES, EryPed, Ery-Tab, Erythrocin Lactobionate, Erythrocin Stearate Filmtab

• Erythromycin Ethylsuccinate PO solution

  All CrCl	400–800mg	Q6H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  ERYTHROMYCIN [#grey] | EES, EryPed, Ery-Tab, Erythrocin Lactobionate, Erythrocin Stearate Filmtab
• ETHAMBUTOL Myambutol

• Ethambutol PO: tuberculosis

  CrCl ≥30	15–25mg/kg	Q24H
  <30	15–25mg/kg	3x/week
  Hemodialysis	15–25mg/kg	Q6H
  Peritoneal dialysis
  CVVH	NO DATA

  Max Dose 2.5gm/day; On dialysis days give post-HD (supplemental doses for additional sessions not required)

  ETHAMBUTOL [#grey] | Myambutol
• ETHIONAMIDE Trecator, Trecator-SC

• Ethionamide PO: tuberculosis

  All CrCl	250mg	Q12–24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Dose may be escalated over 2-week period to a max dose of 1000mg/day; dosing should always be discussed with MTB expert; Consider supplemental pyridoxine

  ETHIONAMIDE [#grey] | Trecator, Trecator-SC
• FAMCICLOVIR Famvir

• Famciclovir PO: herpes zoster

  CrCl ≥60	500mg	Q8H
  40–59	500mg	Q12H
  20–39	500mg	Q24H
  <20	250mg	Q24H
  Hemodialysis	250mg	Post-HD
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  On dialysis days give post-HD

  FAMCICLOVIR [#grey] | Famvir

• Famciclovir PO: HSV-recurrent genital herpes

  CrCl ≥60	1000mg	Q12H x1d
  40–59	500mg	Q12H x1d
  20–39	500mg	x1
  <20	250mg	x1
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  On dialysis days give post-HD

  FAMCICLOVIR [#grey] | Famvir

• Famciclovir PO: Suppression for HSV-recurrent orolabial and genital HSV infection in HIV-infected patients

  CrCl >60	250mg	Q12H
  20–40	125mg	Q12H
  <20	125mg	Q24H
  Hemodialysis	125mg	Post-HD
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  On dialysis days give post-HD

  FAMCICLOVIR [#grey] | Famvir

• Famciclovir PO: MGH-only – HSV/VZV prophylaxis in low CMV risk kidney, liver, and heart transplants

  CrCl ≥30	500mg	Q24H
  <30	250mg	Q24H

  On dialysis days give post-HD

  FAMCICLOVIR [#grey] | Famvir
• FIDAXOMICIN Dificid

• Fidaxomicin PO: Clostridioides difficile infection ✱ID✱

  All CrCl	200mg	Q12H x10d
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Please refer to the MGB C. difficile management guidelines for criteria for use

  FIDAXOMICIN [#grey] | Dificid

• Fidaxomicin PO: Pulse dosing for recurrent Clostridioides difficile infection ✱ID✱

  All CrCl	200mg	Q12H x5d, then every other day x20d
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Please refer to the MGB C. difficile management guidelines for criteria for use

  FIDAXOMICIN [#grey] | Dificid
• FLUCONAZOLE Diflucan

• Fluconazole PO/IV: invasive candidiasis treatment

  CrCl ≥50	800mg x1, 400mg	Q24H
  <50	400mg x1, 200mg	Q24H
  Hemodialysis	400–800mg x1, 200mg Q24H OR 400–800mg x1, 400mg post-HD
  Peritoneal dialysis	400mg x1, 200mg	Q24H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  FLUCONAZOLE [#grey] | Diflucan

• Fluconazole PO/IV: invasive candidiasis treatment, alternative weight-based treatment for extremes in body weight

  CrCl ≥50	12mg/kg x1, 6mg/kg	Q24H
  <50	6mg/kg x1, 3mg/kg	Q24H
  Hemodialysis	6mg/kg x1, 3mg/kg Q24H OR 6mg/kg x1, 6mg/kg post-HD
  Peritoneal dialysis	6mg/kg x1, 3mg/kg	Q24H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; round doses to nearest 50mg

  FLUCONAZOLE [#grey] | Diflucan

• Fluconazole PO: vaginal candidiasis

  CrCl ≥50	150mg	Q72H x1–3 doses
  <50
  Hemodialysis
  Peritoneal dialysis
  CVVH

  On dialysis days give post-HD

  FLUCONAZOLE [#grey] | Diflucan

• Fluconazole PO/IV: thrush/oropharyngeal candidiasis

  CrCl ≥50	200mg	Q24H
  <50	200mg x1, then 100mg	Q24H
  Hemodialysis	200mg x1, then 200mg	Post-HD
  Peritoneal dialysis	200mg x1, then 100mg	Q24H
  CVVH	400mg	Q24H

  On dialysis days give post-HD

  FLUCONAZOLE [#grey] | Diflucan

• Fluconazole PO/IV: prophylaxis dosing

  CrCl ≥50	200–400mg	Q24H
  <50	100–200mg	Q24H
  Hemodialysis	400mg	Post-HD
  Peritoneal dialysis	100–200mg	Q24H
  CVVH	200–400mg	Q24H

  On dialysis days give post-HD

  FLUCONAZOLE [#grey] | Diflucan
• FLUCYTOSINE Ancobon

• Flucytosine PO: cryptococcal meningitis

  CrCl ≥40	25mg/kg	Q6H
  20–39	25mg/kg	Q12H
  10–19	25mg/kg	Q24H
  <10	25mg/kg	Q24–48H
  Hemodialysis	25mg/kg	Q24H✱ OR post-HD
  Peritoneal dialysis	25mg/kg	Q48–72H
  CVVH	See CVVH Dosing

  ✱For severe infections. Consider TDM to guide dosing (goal 2-hour post dose level 30-80 mcg/mL). On dialysis days give post-HD; Use in combination with systemic Liposomal Amphotericin B

  FLUCYTOSINE [#grey] | Ancobon
• FOSCARNET Foscavir

• Foscarnet IV: CMV induction, HHV-6 ✱ID✱

  CrCl >1.4mL/min/kg✱	60mg/kg	Q8H
  1.0–1.4mL/min/kg✱	45mg/kg	Q8H
  0.8–1.0mL/min/kg✱	50mg/kg	Q12H
  0.6–0.8mL/min/kg✱	40mg/kg	Q12H
  0.5–0.6mL/min/kg✱	60mg/kg	Q24H
  0.4–0.5mL/min/kg✱	50mg/kg	Q24H
  <0.4mL/min/kg✱	Avoid or Consult ID
  Hemodialysis	45–60mg/kg	Post-HD
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; ✱To calculate modified creatinine clearance MDCalc: MALES, mL/min/kg = (140 - age)/(serum creatinine x 72); FEMALES, Use above formula and multiply by 0.85

  FOSCARNET [#grey] | Foscavir

• Foscarnet IV: CMV maintenance ✱ID✱

  CrCl >1.4mL/min/kg✱	120mg/kg/day	Q12–24H
  1.0–1.4mL/min/kg✱	90mg/kg/day	Q12–24H
  0.8–1.0mL/min/kg✱	65mg/kg/day	Q12–24H
  0.6–0.8mL/min/kg✱	105mg/kg/day	Q48H
  0.5–0.6mL/min/kg✱	80mg/kg/day	Q48H
  0.4–0.5mL/min/kg✱	65mg/kg/day	Q48H
  <0.4mL/min/kg✱	Avoid or Consult ID
  Hemodialysis	45–60mg/kg	Post-HD
  Peritoneal dialysis	NO DATA
  CVVH	60mg/kg	Q48H

  On dialysis days give post-HD; ✱To calculate modified creatinine clearance MDCalc: MALES, mL/min/kg = (140 - age)/(serum creatinine x 72); FEMALES, Use above formula and multiply by 0.85

  FOSCARNET [#grey] | Foscavir

• Foscarnet IV: HSV-1 or -2 infection ✱ID✱

  CrCl >1.4mL/min/kg✱	40mg/kg	Q8H
  1.0–1.4mL/min/kg✱	30mg/kg	Q8H
  0.8–1.0mL/min/kg✱	35mg/kg	Q12H
  0.6–0.8mL/min/kg✱	25mg/kg	Q12H
  0.5–0.6mL/min/kg✱	40mg/kg	Q24H
  0.4–0.5mL/min/kg✱	35mg/kg	Q24H
  <0.4mL/min/kg✱	Avoid or Consult ID
  Hemodialysis	45–60mg/kg	Post-HD
  Peritoneal dialysis	NO DATA
  CVVH	40mg/kg	Q24H

  On dialysis days give post-HD; ✱To calculate modified creatinine clearance MDCalc: MALES, mL/min/kg = (140 - age)/(serum creatinine x 72); FEMALES, Use above formula and multiply by 0.85

  FOSCARNET [#grey] | Foscavir
• FOSFOMYCIN Dificid

• Fosfomycin PO: uncomplicated UTI

  All CrCl	3gm	x1
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Dissolve 3gm dose in 3-4 oz of water

  FOSFOMYCIN [#grey] | Dificid

• Fosfomycin PO: complicated UTI, prostatitis

  All CrCl	3gm	Q 2–3 days
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Dissolve 3gm dose in 3-4 oz of water

  FOSFOMYCIN [#grey] | Dificid
• GANCICLOVIR Cytovene

• Ganciclovir IV: CMV, induction ✱ID✱

  CrCl ≥70	5mg/kg	Q12H
  50–69	5mg/kg x1, 2.5mg/kg	Q12H
  25–49	5mg/kg x1, 2.5mg/kg	Q24H
  10–24	5mg/kg x1, 1.25mg/kg	Q24H
  <10	5mg/kg x1, 1.25mg/kg	3x/week
  Hemodialysis	5mg/kg x1, 1.25mg/kg	Post-HD
  Peritoneal dialysis	5mg/kg x1, 1.25mg/kg	3x/week
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  GANCICLOVIR [#grey] | Cytovene

• Ganciclovir IV: CMV, maintenance or prophylaxis ✱ID✱

  CrCl ≥70	5mg/kg	Q24H
  50–69	5mg/kg x1, 2.5mg/kg	Q24H
  25–49	5mg/kg x1, 1.25mg/kg	Q24H
  10–24	5mg/kg x1, 0.625mg/kg	Q24H
  <10	5mg/kg x1, 0.625mg/kg	3x/week
  Hemodialysis	5mg/kg x1, 0.625mg/kg	Post-HD
  Peritoneal dialysis	5mg/kg x1, 0.625mg/kg	3x/week
  CVVH	See CVVH Dosing

  No load necessary for valganciclovir to IV transition; On dialysis days give post-HD

  GANCICLOVIR [#grey] | Cytovene
• GENTAMICIN Garamycin, Cidomycin

• Gentamicin IV

  Please refer to Site-Specific Aminoglycoside Dosing Guidelines, when available.

  Please contact pharmacy department for help with monitoring serum concentrations and dosage adjustments.

  GENTAMICIN [#grey] | Garamycin, Cidomycin
• GRISEOFULVIN Grifulvin V, Fulvicin P/G, Fulvicin U/F, Gris-PEG, Grisactin Ultra, Grisactin 250, Grisactin 500, Griseofulicin, Griseofulvic

• Griseofulvin Microsize: tinea barbae, tinea capitis, tinea corporis, tinea cruris

  All CrCl	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Take after meal with high fat content

  GRISEOFULVIN [#grey] | Grifulvin V, Fulvicin P/G, Fulvicin U/F, Gris-PEG, Grisactin Ultra, Grisactin 250, Grisactin 500, Griseofulicin, Griseofulvic

• Griseofulvin Microsize: tinea pedis, tinea unguium

  All CrCl	1000mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Take after meal with high fat content

  GRISEOFULVIN [#grey] | Grifulvin V, Fulvicin P/G, Fulvicin U/F, Gris-PEG, Grisactin Ultra, Grisactin 250, Grisactin 500, Griseofulicin, Griseofulvic

• Griseofulvin Ultramicrosize: tinea barbae, tinea capitis, tinea corporis, tinea cruris

  All CrCl	375mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Take after meal with high fat content

  GRISEOFULVIN [#grey] | Grifulvin V, Fulvicin P/G, Fulvicin U/F, Gris-PEG, Grisactin Ultra, Grisactin 250, Grisactin 500, Griseofulicin, Griseofulvic

• Griseofulvin Ultramicrosize: tinea pedis, tinea unguium

  All CrCl	750mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Take after meal with high fat content

  GRISEOFULVIN [#grey] | Grifulvin V, Fulvicin P/G, Fulvicin U/F, Gris-PEG, Grisactin Ultra, Grisactin 250, Grisactin 500, Griseofulicin, Griseofulvic
• HYDROXYCHLOROQUINE Plaquenil, Quineprox

• Hydroxychloroquine PO: malaria treatment

  All CrCl | 800mg x1, then 400mg at 6, 24, and 48h after initial dose Hemodialysis | 800mg x1, then 400mg at 6, 24, and 48h after initial dose Peritoneal dialysis | 800mg x1, then 400mg at 6, 24, and 48h after initial dose CVVH | 800mg x1, then 400mg at 6, 24, and 48h after initial dose

  Total dose: 2 grams

  HYDROXYCHLOROQUINE [#grey] | Plaquenil, Quineprox

• Hydroxychloroquine PO: malaria prophylaxis

  All CrCl	400mg	weekly
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Start 1-2 weeks before arrival to endemic area, continue weekly during travel and for 4 weeks after leaving endemic area

  HYDROXYCHLOROQUINE [#grey] | Plaquenil, Quineprox
• IMIPENEM-CILASTATIN Primaxin ADD-Vantage

• Imipenem-cilastatin IV: most bacterial infections ✱ID✱

  CrCl ≥60	500mg	Q6H
  30–59	500mg	Q8H
  15–29	500mg	Q12H
  <15	AVOID
  Hemodialysis	500mg	Q12H
  Peritoneal dialysis	250mg	Q12H
  CVVH	See CVVH Dosing

  Each 500mg vial contains 500mg of imipenem and 500mg of cilastatin; On dialysis days give post-HD

  IMIPENEM-CILASTATIN [#grey] | Primaxin ADD-Vantage

• Imipenem-cilastatin IV: most mycobacterial infections ✱ID✱

  CrCl ≥30	1000mg	Q12H
  15–29	500mg	Q12H
  <15	AVOID
  Hemodialysis	500mg	Q12H
  Peritoneal dialysis	250mg	Q12H
  CVVH	See CVVH Dosing

  Each 500mg vial contains 500mg of imipenem and 500mg of cilastatin; On dialysis days give post-HD

  IMIPENEM-CILASTATIN [#grey] | Primaxin ADD-Vantage

• Imipenem-cilastatin IV: Bacterial or mycobacterial infections with intermediate susceptibility to imipenem ✱ID✱

  CrCl ≥90	750–1000mg	Q6H
  60–89	750mg	Q8H
  30–59	500mg	Q6H
  15–29	500mg	Q12H
  <15	AVOID
  Hemodialysis	500mg	Q12H
  Peritoneal dialysis	250mg	Q12H
  CVVH	See CVVH Dosing

  Each 500mg vial contains 500mg of imipenem and 500mg of cilastatin; On dialysis days give post-HD

  IMIPENEM-CILASTATIN [#grey] | Primaxin ADD-Vantage
• IMIPENEM-CILASTATIN AND RELEBACTAM Recarbrio

• Imipenem-cilastatin and relebactam IV: most bacterial infections ✱ID✱

  CrCl ≥90	1.25gm	Q6H
  60–89	1gm	Q6H
  30–59	0.75gm	Q6H
  15–29	0.5gm	Q6H
  <15	AVOID
  Hemodialysis	0.5gm	Q6H
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  Each 1.25gm vial contains 500mg of imipenem, 500mg of cilastatin, and 250mg of relebactam

  IMIPENEM-CILASTATIN AND RELEBACTAM [#grey] | Recarbrio
• ISAVUCONAZOLE Cresemba

• Isavuconazonium sulfate PO/IV: invasive aspergillosis, mucormycosis ✱ID✱

  All CrCl	372mg Q8H x6 doses, then 372mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  372 mg isavuconazonium sulfate (prodrug of isavuconazole) = 200 mg of isavuconazole

  ISAVUCONAZOLE [#grey] | Cresemba
• ISONIAZID Nydrazid

• Isoniazid PO: tuberculosis

  All CrCl	300mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Consider supplemental pyridoxine 50-100mg to prevent neurotoxicity; Dosing may be higher in MDR tuberculosis cases; Administer post-HD on dialysis days

  ISONIAZID [#grey] | Nydrazid
• ITRACONAZOLE Sporanox, Tolsura, Onmel, PulsePak

• Itraconazole PO suspension: aspergillosis, cryptococcosis, febrile neutropenia, histoplasmosis

  All CrCl	200mg Q8H x9 doses, then 200mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Monitoring of serum concentrations is recommended for all serious systemic infections. Target serum concentration: >1mcg/ml after 14 days of therapy

  ITRACONAZOLE [#grey] | Sporanox, Tolsura, Onmel, PulsePak
• IVERMECTIN Stromectol

• Ivermectin PO: Strongyloidiasis, cutaneous larva migrans

  All CrCl	200mcg/kg/dose	Q24H x1
  Hemodialysis
  Peritoneal dialysis
  CVVH

  If any stool re-examinations following treatment show signs of recrudescence of larvae, re-treatment is indicated; For patients with hyperinfection and dissemination, daily drug administration until symptoms resolve with negative laboratory tests for larvae for at least two weeks is recommended; Up to 400mcg/kg x1 dose for Bancroft's filariasis.

  IVERMECTIN [#grey] | Stromectol
• LEFAMULIN Xenleta

• Lefamulin PO ✱ID✱

  All CrCl	600mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Not studied in and not recommended for patients with moderate (Child-Pugh Class B) or severe hepatic impairment (Child-Pugh Class C).

  LEFAMULIN [#grey] | Xenleta

• Lefamulin IV ✱ID✱

  All CrCl	150mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH
  Severe hepatic impairment (Child-Pugh C)	150mg	Q24H

  LEFAMULIN [#grey] | Xenleta
• LETERMOVIR Prevymis

• Letermovir PO/IV: CMV prophylaxis in patients post-allogeneic hematopoietic stem cell transplant ✱ID✱

  CrCl >10	480mg	Q24H
  ≤10	NO DATA
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  In patients with CrCl<50 mL/min, accumulation of the IV vehicle, hydroxypropyl betadex, may occur. Oral dosing is preferred when able. Check for drug interactions for potential dose adjustments prior to initiation

  LETERMOVIR [#grey] | Prevymis
• LEVOFLOXACIN Levaquin

• Levofloxacin PO/IV: nosocomial and community acquired pneumonia, complicated skin and soft tissue infections, MDR tuberculosis

  CrCl ≥50	750mg	Q24H
  20–49	750mg	Q48H
  <20	750mg x1, 500mg	Q48H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; Doses up to 1000mg may be given for MDR TB, discuss with MTB expert

  LEVOFLOXACIN [#grey] | Levaquin

• Levofloxacin PO/IV: sinusitis, uncomplicated skin and soft tissue infections, UTI

  CrCl ≥50	500mg	Q24H
  20–49	500mg x1, 250mg	Q24H
  <20	500mg x1, 250mg	Q48H
  Hemodialysis
  Peritoneal dialysis
  CVVH	250mg	Q24H

  On dialysis days give post-HD; Doses up to 1000mg may be given for MDR TB, discuss with MTB expert

  LEVOFLOXACIN [#grey] | Levaquin
• LINEZOLID Zyvox

• Linezolid PO/IV ✱ID✱

  All CrCl	600mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  LINEZOLID [#grey] | Zyvox

• Linezolid PO/IV: mycobacterial infections ✱ID✱

  All CrCl	600mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  Consider supplemental pyridoxine

  LINEZOLID [#grey] | Zyvox
• MARIBAVIR Livtencity

• Maribavir PO: CMV treatment ✱ID✱

  All CrCl	400mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  MARIBAVIR [#grey] | Livtencity
• MEBENDAZOLE Emverm, Vermox

• Mebendazole PO: Ascariasis, trichuriasis

  All CrCl	100mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Most parasitic Infections use the 100mg BID dose, but some may require higher dosing.

  MEBENDAZOLE [#grey] | Emverm, Vermox
• MEFLOQUINE Lariam

• Mefloquine PO: Malaria treatment

  All CrCl | 750mg x1, then 500mg 12h later Hemodialysis | 750mg x1, then 500mg 12h later Peritoneal dialysis | 750mg x1, then 500mg 12h later CVVH | 750mg x1, then 500mg 12h later

  Alternate dosing: 1250mg x1 dose

  MEFLOQUINE [#grey] | Lariam

• Mefloquine PO: Malaria prophylaxis

  All CrCl	250mg	weekly
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Start ≥2 weeks before arrival to endemic area, continue weekly during travel and for 4 weeks after leaving endemic area

  MEFLOQUINE [#grey] | Lariam
• MEROPENEM Merrem Novaplus

• Meropenem IV: febrile neutropenia, pneumonia, bacteremia, sepsis, UTIs, gynecologic infections, intra-abdominal infections, mycobacterial infections ✱ID✱

  CrCl >50	1000mg	Q8H
  26–50	1000mg	Q12H
  10–25	500mg	Q12H
  <10	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  MEROPENEM [#grey] | Merrem Novaplus

• Meropenem IV: bacterial meningitis, cystic fibrosis, infection with confirmed elevated MIC to meropenem ✱ID✱

  CrCl >50	2000mg	Q8H
  26–50	2000mg	Q12H
  10–25	1000mg	Q12H
  <10	1000mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  MEROPENEM [#grey] | Merrem Novaplus

• Meropenem IV: alternative dosing; may replace 1gm Q8H dosing; EXCEPT for febrile neutropenia and CNS infections ✱ID✱

  CrCl >50	500mg	Q6H
  26–50	500mg	Q8H
  10–25	500mg	Q12H
  <10	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  On dialysis days give post-HD

  MEROPENEM [#grey] | Merrem Novaplus
• MEROPENEM-VABORBACTAM Vabomere

• Meropenem-vaborbactam IV ✱ID✱

  eGFR ≥50	4gm	Q8H
  30–49	2gm	Q8H
  15–29	2gm	Q12H
  <15	1gm	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  Each 4gm dose contains 2gm of meropenem and 2gm of vaborbactam; MDRD eGFR (mL/min/1.73m2) = 175 x (serum creatinine) - 1.154 x (age) - 0.203 x (0.742 if female) x (1.212 if African American); MDCalc calculator; On dialysis days give post-HD.

  MEROPENEM-VABORBACTAM [#grey] | Vabomere
• METRONIDAZOLE Flagyl ER, RTU, Likmez, Metro, Protostat, Metryl

• Metronidazole PO/IV: most indications

  All CrCl	500mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  METRONIDAZOLE [#grey] | Flagyl ER, RTU, Likmez, Metro, Protostat, Metryl

• Metronidazole PO/IV: C. difficile, CNS anaerobic infections

  All CrCl	500mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  METRONIDAZOLE [#grey] | Flagyl ER, RTU, Likmez, Metro, Protostat, Metryl
• MICAFUNGIN Mycamine

• Micafungin IV: febrile neutropenia, candidemia, invasive candidiasis, Candida peritonitis, or abscesses ✱ID✱

  All CrCl	100mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  MICAFUNGIN [#grey] | Mycamine

• Micafungin IV: esophageal candidiasis, refractory aspergillosis, consider for fungal endocarditis ✱ID✱

  All CrCl	150mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  MICAFUNGIN [#grey] | Mycamine
• MINOCYCLINE Dynacin, Minocin, Minocin PAC, Minolira, Solodyn, Ximino, Vectrin, Myrac

• Minocycline HCl PO/IV: most indications

  All CrCl	200mg x1, then 100mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Check with pharmacy for IV availability; Higher doses may be considered in certain MDR infections per IDSA guidance. Discuss with ID Pharmacy or ID for dosing recommendations

  MINOCYCLINE [#grey] | Dynacin, Minocin, Minocin PAC, Minolira, Solodyn, Ximino, Vectrin, Myrac
• MOXIFLOXACIN Avelox

• Moxifloxacin PO/IV ✱ID✱

  All CrCl	400mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  MOXIFLOXACIN [#grey] | Avelox
• NAFCILLIN Unipen, Nallpen

• Nafcillin IV: MSSA bacteremia, endocarditis, meningitis, and pneumonia

  All CrCl	2g	Q4H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  NAFCILLIN [#grey] | Unipen, Nallpen
• NITAZOXANIDE Alinia

• Nitazoxanide PO: cryptosporidiosis, giardiasis

  All CrCl	500mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Can potentially increase to 1000mg q12h in immunocompromised patients

  NITAZOXANIDE [#grey] | Alinia
• NITROFURANTOIN Macrobid SR, Macrobid IR

• Nitrofurantoin PO (Macrobid SR): uncomplicated female or male UTI

  CrCl ≥30	100mg	Q12H
  <30	AVOID
  Hemodialysis	AVOID
  Peritoneal dialysis	AVOID
  CVVH	AVOID

  Nitrofurantoin is not indicated for the treatment of pyelonephritis or perinephric abscesses

  NITROFURANTOIN [#grey] | Macrobid SR, Macrobid IR

• Nitrofurantoin PO (Macrobid IR): uncomplicated female or male UTI

  CrCl ≥30	50-100mg	Q6H
  <30	AVOID
  Hemodialysis	AVOID
  Peritoneal dialysis	AVOID
  CVVH	AVOID

  Nitrofurantoin is not indicated for the treatment of pyelonephritis or perinephric abscesses

  NITROFURANTOIN [#grey] | Macrobid SR, Macrobid IR
• NYSTATIN Nyamyc, Nystop, Mycostatin Topical, Pedi-Dri, Pediaderm AF

• Nystatin PO: intestinal infections

  CrCl >50	500,000–1,000,000 U	Q8H
  ≤50	NO DATA
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  NYSTATIN [#grey] | Nyamyc, Nystop, Mycostatin Topical, Pedi-Dri, Pediaderm AF
• OMADACYCLINE Nuzyra

• Omadacycline IV ✱ID✱

  All CrCl	200mg x1, then 100mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  OMADACYCLINE [#grey] | Nuzyra

• Omadacycline PO ✱ID✱

  All CrCl	200mg IV x1 OR 450mg PO Q24H x2, followed by 300mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  An initial IV loading dose is required for respiratory infections. Oral loading doses are appropriate for SSTI

  OMADACYCLINE [#grey] | Nuzyra
• ORITAVANCIN Kimyrsa, Orbactiv

• Oritavancin IV: MRSA skin and soft tissue infection ✱ID✱

  CrCl ≥10	1200mg	x1
  <10	NO DATA
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  Oritavancin is not removed by HD. Oritavancin may interfere with coagulation assays.

  ORITAVANCIN [#grey] | Kimyrsa, Orbactiv
• OSELTAMIVIR Tamiflu

• Oseltamivir Phosphate PO: influenza treatment

  CrCl >60	75mg	Q12H x5 days
  30–60	30mg	Q12H x5 days
  10–30	30mg	Q24H x5 days
  <10	Not Recommended
  Hemodialysis	30mg x1, then 30mg	Post-HD x5 days
  Peritoneal dialysis	30mg	x1 dose
  CVVH	See CVVH Dosing

  For HD patients, give loading dose immediately, then dose after each hemodialysis session.

  OSELTAMIVIR [#grey] | Tamiflu

• Oseltamivir Phosphate PO: influenza treatment (ONLY FOR SITES THAT DO NOT STOCK 30mg CAPSULES)

  CrCl >30	75mg	Q12H x5 days
  10–30	75mg	Q24H x5 days
  <10
  Hemodialysis	75mg x1, then 75mg	Post-HD x5 days
  Peritoneal dialysis	75mg	x1 dose
  CVVH	See CVVH Dosing

  For HD patients, give loading dose immediately, then dose after each hemodialysis session.

  OSELTAMIVIR [#grey] | Tamiflu

• Oseltamivir Phosphate PO: influenza prophylaxis

  CrCl >60	75mg	Q24H
  30–60	30mg	Q24H
  10–30	30mg	Q48H
  <10	Not Recommended
  Hemodialysis	30mg x1, then 30mg after alternate HD sessions	Post-HD x5 days
  Peritoneal dialysis	30mg	x1 dose
  CVVH	75mg	Q24H

  For HD patients, give dose after dialysis session

  OSELTAMIVIR [#grey] | Tamiflu

• Oseltamivir Phosphate PO: influenza prophylaxis (ONLY FOR SITES THAT DO NOT STOCK 30mg CAPSULES)

  CrCl >30	75mg	Q24H
  10–30	75mg	Q48H
  <10
  Hemodialysis	75mg x2	Q5 days
  Peritoneal dialysis	75mg	x1 dose
  CVVH	75mg	Q24H

  For HD patients, give dose after dialysis session

  OSELTAMIVIR [#grey] | Tamiflu
• OXACILLIN Oxacillin Sodium ADD-Vantage, Bactocill

• Oxacillin Sodium IV: MSSA bacteremia, endocarditis, pneumonia, meningitis

  All CrCl	2gm	Q4H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  OXACILLIN [#grey] | Oxacillin Sodium ADD-Vantage, Bactocill
• PAROMOMYCIN Humatin, Paromycin

• Paromomycin PO: intestinal amebiasis

  All CrCl	500mg	Q6H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  PAROMOMYCIN [#grey] | Humatin, Paromycin
• PENICILLIN

• Penicillin G IV: endocarditis, bacteremia, neurosyphilis, pneumonia, sepsis

  CrCl >50	4 million units	Q4H
  10–50	3 million units	Q4H
  <10	3 million units	Q8–12H
  Hemodialysis	2 million units	Q4–6H
  Peritoneal dialysis	2 million units	Q6H
  CVVH	See CVVH Dosing

  PENICILLIN [#grey]

• Penicillin G IV 24H continuous infusion: endocarditis, bacteremia, neurosyphilis, pneumonia, sepsis

  CrCl >50	18-24 million units	Continuous infusion Q24H
  10–50
  <10
  Hemodialysis	AVOID – NO DATA
  Peritoneal dialysis	AVOID – NO DATA
  CVVH	AVOID – NO DATA

  PENICILLIN [#grey]

• Penicillin G IV

  CrCl >50	2–4 million units	Q4H
  10–50	2–3 million units	Q6H
  <10	1–2 million units	Q8H
  Hemodialysis	1–2 million units	Q4–6H
  Peritoneal dialysis	1–2 million units	Q6H
  CVVH	See CVVH Dosing

  PENICILLIN [#grey]

• Penicillin V PO (Pen-VK, Veetids): pneumococcal respiratory tract infection, otitis media, pharyngitis, gingivitis, staphylococcal skin and soft tissue infection

  CrCl ≥10	250–500mg	Q6–8H
  <10	250–500mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  On dialysis days give post-HD

  PENICILLIN [#grey]

• Penicillin V PO (Pen-VK, Veetids): prophylaxis for rheumatic fever, chorea, or meningococcal disease post-eculizumab

  All CrCl	250–500mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  On dialysis days give post-HD

  PENICILLIN [#grey]

• Penicillin G Benzathine IM (Bicillin L-A)

  CrCl ≥50	1.2–2.4 million units	Varies
  Hemodialysis
  Peritoneal dialysis
  CVVH

  NOT for neurosyphilis; on dialysis days give post-HD

  PENICILLIN [#grey]

• Penicillin G Procaine IM (Wycillin, Bicillin C-R): neurosyphilis

  CrCl ≥50	2.4 million units	Q24H
  10–49	75% of normal dose	Q24H
  <10	50% of normal dose	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	75% of normal dose	Q24H

  Plus probenecid 500 mg PO 4x/day; On dialysis days give post-HD. IV penicillin G is preferred for neurosyphilis

  PENICILLIN [#grey]

• Penicillin G Procaine IM (Wycillin, Bicillin C-R): other infections

  CrCl ≥50	600,000–1 million units	Q24H
  10–49	75% of normal dose	Q24H
  <10	50% of normal dose	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH	75% of normal dose	Q24H

  Administer post-HD

  PENICILLIN [#grey]
• PENTAMIDINE PJP, PCP, Nebupent, Pentam 300

• Pentamidine IV/IM: Pneumocystis jirovecii pneumonia treatment

  All CrCl	4mg/kg	Q24H x21 days
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Infuse IV over 60min; monitor for hypoglycemia

  PENTAMIDINE [#grey] | PJP, PCP, Nebupent, Pentam 300

• Pentamidine IV/IM/inhalation: Pneumocystis jirovecii pneumonia prophylaxis

  All CrCl	300mg	Q4weeks
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Infuse IV over 60min; monitor for hypoglycemia

  PENTAMIDINE [#grey] | PJP, PCP, Nebupent, Pentam 300
• PERAMIVIR Rapivab

• Peramivir IV: influenza, acute, uncomplicated

  CrCl >50	600mg	x1
  30–49	200mg	x1
  10–29	100mg	x1
  <10
  Hemodialysis	100mg	x1 Post HD
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  PERAMIVIR [#grey] | Rapivab
• PIPERACILLIN-TAZOBACTAM Zosyn piptazo pip-tazo

• Piperacillin-tazobactam IV: nosocomial pneumonia, febrile neutropenia, cystic fibrosis exacerbations, endometritis

  CrCl >40	4.5gm	Q6H
  20–40	3.375gm	Q6H
  <20	2.25gm	Q6H
  Hemodialysis	2.25gm	Q8H
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  For elevated MICs, extended infusion dosing is recommended

  PIPERACILLIN-TAZOBACTAM [#grey] | Zosyn piptazo pip-tazo

• Piperacillin-tazobactam IV: appendicitis, peritonitis, pelvic inflammatory disease, complicated skin and soft tissue infections

  CrCl >40	3.375gm	Q6H
  20–40	2.25gm	Q6H
  <20	2.25gm	Q8H
  Hemodialysis
  Peritoneal dialysis	2.25gm	Q12H
  CVVH	See CVVH Dosing

  PIPERACILLIN-TAZOBACTAM [#grey] | Zosyn piptazo pip-tazo

• Piperacillin-tazobactam IV: site-specific extended infusion dosing

  CrCl ≥20	3.375–4.5gm	Q8H
  <20	3.375–4.5gm	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	See CVVH Dosing

  First dose infused over 30 minutes, followed 6 hours later by extended infusion regimen (each dose infused over 4 hours); 4.5gm doses may be used in select critically ill patients; Doses of 2.25gm are not needed if utilizing extended infusion protocol

  PIPERACILLIN-TAZOBACTAM [#grey] | Zosyn piptazo pip-tazo
• PLAZOMICIN Zemdri

• Plazomicin IV ✱ID✱

  Please refer to Site-Specific Aminoglycoside Dosing Guidelines, when available.

  Please contact pharmacy department for help with monitoring serum concentrations and dosage adjustments

  PLAZOMICIN [#grey] | Zemdri
• POLYMIXIN Nuzyra

• Polymyxin B Sulfate IV ✱ID✱

  All CrCl	2–2.5 mg/kg x1, then 1.25–1.5 mg/kg	Q12H
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	See CVVH Dosing

  1 mg = 10,000 IU polymyxin B; see MGH dosing guidelines (Protected Antimicrobial Policy)

  POLYMIXIN [#grey] | Nuzyra
• POSACONAZOLE Noxafil

• Posaconazole PO: prophylaxis or treatment ✱ID✱

  All CrCl	300mg Q12H x2, then 300mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Tablets & oral suspension cannot be used interchangeably. Tablets cannot be crushed.

  POSACONAZOLE [#grey] | Noxafil

• Posaconazole IV: prophylaxis or treatment ✱ID✱

  CrCl ≥50	300mg Q12H x2, then 300mg	Q24H
  <50	IV not recommended, however clinical situations may warrant therapy; consult ID
  Hemodialysis	IV not recommended, however clinical situations may warrant therapy; consult ID
  Peritoneal dialysis	IV not recommended, however clinical situations may warrant therapy; consult ID
  CVVH	IV not recommended, however clinical situations may warrant therapy; consult ID

  Accumulation of IV vehicle Betadex Sulfobutyl Ether Sodium (SBECD) can occur in patients with CrCl < 50 mL/min; avoid IV formulation unless benefit outweighs risk.

  POSACONAZOLE [#grey] | Noxafil

• Posaconazole PO oral suspension: treatment ✱ID✱

  All CrCl	200mg	Q6H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Tablets & oral suspension cannot be used interchangeably. Must be taken with high fat meal. Dosing for the treatment of refractory oropharyngeal candidiasis may vary.

  POSACONAZOLE [#grey] | Noxafil

• Posaconazole PO oral suspension: prophylaxis ✱ID✱

  All CrCl	200mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Tablets & oral suspension cannot be used interchangeably. Must be taken with high fat meal.

  POSACONAZOLE [#grey] | Noxafil
• PRIMAQUINE

• Primaquine Phosphate PO: malaria

  All CrCl	30mg	Q24H
  Hemodialysis
  Peritoneal dialysis	NO DATA
  CVVH	30mg	Q24H

  Dose according to mg of base (30mg base = 52.6mg primaquine phosphate)

  PRIMAQUINE [#grey]
• PYRANTEL Pin-Away, Pinworm Medicine, Antiminth, Pin-X, Ascarel, Pinworm Caplets

• Pyrantel PO

  All CrCl	11mg/kg base	Q24H
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  Max dose 1gm/day

  PYRANTEL [#grey] | Pin-Away, Pinworm Medicine, Antiminth, Pin-X, Ascarel, Pinworm Caplets
• PYRAZINAMIDE

• Pyrazinamide PO: tuberculosis

  CrCl ≥30	25–40mg/kg	Q24H
  <30	25–40mg/kg	3x/week
  Hemodialysis
  Peritoneal dialysis	25–40mg/kg	Q24H
  CVVH	NO DATA

  Max dose 2gm/day; Administer post-HD on dialysis days (supplemental doses may be required if additional dialysis sessions)

  PYRAZINAMIDE [#grey]
• PYRIMETHAMINE Daraprim, PCP, PJP

• Pyrimethamine PO: toxoplasmosis treatment ✱ID✱

  All CrCl	200mg x1, then 50–75mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Use 75mg maintenance dose if patient is >60kg

  PYRIMETHAMINE [#grey] | Daraprim, PCP, PJP

• Pyrimethamine PO: toxoplasmosis or Pneumocystis jirovecii pneumonia prophylaxis ✱ID✱

  All CrCl	50–75mg	Qweek
  Hemodialysis
  Peritoneal dialysis
  CVVH

  PYRIMETHAMINE [#grey] | Daraprim, PCP, PJP
• QUININE Qualaquin, QM-260, Quinamm

• Quinine PO: malaria, babesiosis treatment

  CrCl >50	648mg	Q6–8H
  10–50	648mg	Q8–12H
  <10	648mg x1, then 324mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	648mg	Q8–12H

  Dosage expressed in terms of salt. 1 capsule = 324mg of quinine sulfate = 269mg of quinine base; On dialysis days give post-HD

  QUININE [#grey] | Qualaquin, QM-260, Quinamm
• QUINUPRISTIN-DALFOPRISTIN Synercid

• Quinupristin-dalfopristin IV: complicated skin infections due to MRSA ✱ID✱

  All CrCl	7.5mg/kg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Each 500mg vial contains 150mg of quinupristin and 350mg of dalfopristin; Not stocked, call for availability prior to ordering.

  QUINUPRISTIN-DALFOPRISTIN [#grey] | Synercid

• Quinupristin-dalfopristin IV: bacteremia due to vancomycin-resistant E. faecium ✱ID✱

  All CrCl	7.5mg/kg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Each 500mg vial contains 150mg of quinupristin and 350mg of dalfopristin; Not active against Enterococcus faecalis; Not stocked, call for availability prior to ordering.

  QUINUPRISTIN-DALFOPRISTIN [#grey] | Synercid
• REMDESIVIR Veklury

• Remdesivir IV: COVID-19

  All CrCl	200mg x1, then 100mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  If eGFR <30 mL/min, discuss initiation with ID and/or nephrology given off-label use

  REMDESIVIR [#grey] | Veklury
• RIFABUTIN Mycobutin

• Rifabutin PO: treatment for tuberculosis or disseminated MAC

  All CrCl	300mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Consider TDM (goal peak 0.45-0.9) and/or decrease dose if toxicity suspected. Check for drug interactions for potential dose adjustments prior to initiation

  RIFABUTIN [#grey] | Mycobutin
• RIFAMPIN Rifadin, Rimactane

• Rifampin PO/IV: tuberculosis ✱ID✱

  All CrCl	600mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Use IV only when patient is NPO; Consider TDM in at-risk groups (diabetes, HIV, etc, goal peak 8-24)

  RIFAMPIN [#grey] | Rifadin, Rimactane

• Rifampin PO/IV: prosthetic joint infections ✱ID✱

  All CrCl	300–450mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Rifampin is generally initiated several days after other active antistaphylococcal agents have been administered

  RIFAMPIN [#grey] | Rifadin, Rimactane

• Rifampin PO/IV: prosthetic valve endocarditis ✱ID✱

  All CrCl	300mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Rifampin is generally initiated several days after other active antistaphylococcal agents have been administered

  RIFAMPIN [#grey] | Rifadin, Rimactane
• RIFAPENTINE Priftin

• Rifapentine PO: tuberculosis, intensive phase ✱ID✱

  All CrCl	600mg	twice a week
  Hemodialysis
  Peritoneal dialysis
  CVVH

  May consider TDM (goal peak 8-30)

  RIFAPENTINE [#grey] | Priftin

• Rifapentine PO: tuberculosis, continuation phase ✱ID✱

  All CrCl	600mg	once weekly
  Hemodialysis
  Peritoneal dialysis
  CVVH

  RIFAPENTINE [#grey] | Priftin
• RIFAXIMIN Xifaxan

• Rifaximin PO: recurrent Clostridioides difficile infection

  All CrCl	400mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  ID consult strongly recommended

  RIFAXIMIN [#grey] | Xifaxan

• Rifaximin PO: hepatic encephalopathy

  All CrCl	550mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  RIFAXIMIN [#grey] | Xifaxan

• Rifaximin PO: traveler's diarrhea

  All CrCl	200mg	Q8H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Treatment duration is usually 3 days

  RIFAXIMIN [#grey] | Xifaxan
• SULFADIAZENE

• Sulfadiazine PO: Toxoplasma gondii encephalitis, acute infection

  CrCl >50	1000–1500mg	Q6H
  10–50	1000–1500mg	Q8–12H
  <10	1000–1500mg	Q12–24H
  Hemodialysis	1000–1500mg	Q24H
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  Give with pyrimethamine and leucovorin. On dialysis days give post-HD. Use 1500mg for >60kg

  SULFADIAZENE [#grey]

• Sulfadiazine PO: Toxoplasma gondii encephalitis, chronic maintenance therapy

  CrCl >50	500–1000mg	Q6H
  10–50	500–1000mg	Q8–12H
  <10	500–1000mg	Q12–24H
  Hemodialysis	500–1000mg	Q24H
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  Give with pyrimethamine and leucovorin. On dialysis days give post-HD

  SULFADIAZENE [#grey]
• STREPTOMYCIN

• Streptomycin IM/IV

  CrCl >50	15mg/kg	Q24H
  10–50	15mg/kg	Q24–72H
  <10	15mg/kg	Q72–96H
  Hemodialysis	15mg/kg	Post-HD
  Peritoneal dialysis	20–40mg/L/day
  CVVH	15mg/kg	Q24H

  Target peak 35-45mcg/mL, goal trough <5mcg/mL; Alternative dosing for mycobacterial infections is 25mg/kg 3x/week; On dialysis days give post-HD

  STREPTOMYCIN [#grey]

• Streptomycin IM/IV: gentamicin-resistant enterococcal endocarditis dosing

  CrCl >50	7.5mg/kg	Q12H
  10–50	7.5mg/kg	Q12–36H
  <10	7.5mg/kg	Q36–48H
  Hemodialysis	7.5mg/kg	Post-HD
  Peritoneal dialysis	20–40mg/L/day
  CVVH	7.5mg/kg	Q24H

  Target peak = 20-35 mcg/mL, target trough <10 mcg/mL (per 2015 AHA guidelines); On dialysis days give post-HD

  STREPTOMYCIN [#grey]
• TEDIZOLID Sivextro

• Tedizolid PO/IV: MRSA skin and soft tissue infection ✱ID✱

  All CrCl	200mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Not recommended in neutropenic patients

  TEDIZOLID [#grey] | Sivextro
• TELAVANCIN Vibativ

• Telavancin IV: Serious Gram-positive infections refractory to first-line agents ✱ID✱

  CrCl >50	10mg/kg	Q24H
  31–50	7.5mg/kg	Q24H
  10–30	10mg/kg	Q48H
  <10	NO DATA
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  May interfere with coagulation assays

  TELAVANCIN [#grey] | Vibativ
• TERBINAFINE Lamisil

• Terbinafine PO: Fusarium, cutaneous and lymphocutaneous Sporotrichosis

  CrCl ≥50	500mg	Q12H
  <50	NO DATA
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  Continue for 2 to 4 weeks after all lesions have healed

  TERBINAFINE [#grey] | Lamisil

• Terbinafine PO: onychomycosis

  CrCl ≥50	250mg	Q24H
  <50	NO DATA
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  6 weeks of therapy for fingernails; 12 weeks for toenails

  TERBINAFINE [#grey] | Lamisil
• TETRACYCLINE Ala-Tet, Brodspec, Panmycin, Sumycin, Tetracap, Tetracon, Robitet 500, Emtet-500

• Tetracycline PO

  CrCl ≥80	250–500mg	Q6H
  50–79	250–500mg	Q8H
  10–49	250–500mg	Q12H
  <10	250–500mg	Q24H
  Hemodialysis	NO DATA
  Peritoneal dialysis	NO DATA
  CVVH	NO DATA

  TETRACYCLINE [#grey] | Ala-Tet, Brodspec, Panmycin, Sumycin, Tetracap, Tetracon, Robitet 500, Emtet-500
• TIGECYCLINE Tygacil

• Tigecycline IV ✱ID✱

  All CrCl	100mg x1, then 50mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Higher doses may be considered in certain MDR infections per IDSA guidance. Discuss with ID Pharmacy or ID for dosing recommendation

  TIGECYCLINE [#grey] | Tygacil

• Tigecycline IV: nontuberculous mycobacterial infections ✱ID✱

  All CrCl	50mg	Q12–24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Consider dose escalating based on tolerance, starting with 12.5–25mg daily and increasing as tolerated

  TIGECYCLINE [#grey] | Tygacil
• TINIDAZOLE Tindamax, Fasigyn

• Tinidazole PO: amebiasis, bacterial vaginosis

  All CrCl	2gm	Q24H x2–3d
  Hemodialysis	2gm	See note
  Peritoneal dialysis	2gm	Q24H x2–3d
  CVVH

  If administered on a day before dialysis, a dose equivalent to 1/2 the usual dose should be given post-HD

  TINIDAZOLE [#grey] | Tindamax, Fasigyn

• Tinidazole PO: giardiasis, trichomoniasis

  All CrCl	2gm	x1
  Hemodialysis
  Peritoneal dialysis
  CVVH

  On dialysis days give post-HD

  TINIDAZOLE [#grey] | Tindamax, Fasigyn
• TOBRAMYCIN Tobramycin Sulfate ADD-Vantage

• Tobramycin IV

  Please refer to Site-Specific Aminoglycoside Dosing Guidelines, when available.

  Please contact pharmacy department for help with monitoring serum concentrations and dosage adjustments

  TOBRAMYCIN [#grey] | Tobramycin Sulfate ADD-Vantage
• TRIMETHOPRIM-SULFAMETHOXAZOLE Bactrim DS, Sulfatrim Pediatric, Septra, Sulfatrim, Bethaprim, Cotrim, Uroplus, Uroplus DS, Cotrim DS, Septra I.V., Bactrim I.V., Bactrim Pediatric, Bethaprim Pediatric, Sulfatrim Suspension, Cotrim Pediatric, Septra DS, SMZ-TMP, PJP, PCP, trim-sulfa, trimsulfa

• Trimethoprim-sulfamethoxazole PO/IV: Pneumocystis jirovecii pneumonia, severe Nocardia infections, treatment dosing

  CrCl >30	12–20mg/kg/day	Divided Q6–8H
  15–30	12–20mg/kg/day x24h, then 6–10mg/kg/day	Q6–8H x24hr, then Q8–12H
  <15	5–7.5mg/kg/day divided Q12H OR 12–20mg/kg Q48H
  Hemodialysis	7.5mg/kg/day	Divided Q12–24H
  Peritoneal dialysis	12–20mg/kg/day x24h, then 6–10mg/kg/day	Q6–8H x24hr, then Q8–12H
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; Dose always based upon trimethoprim; Indication-dependent dosing; Consider loading doses of 15mg/kg/day x24hrs for severe infection despite renal function

  TRIMETHOPRIM-SULFAMETHOXAZOLE [#grey] | Bactrim DS, Sulfatrim Pediatric, Septra, Sulfatrim, Bethaprim, Cotrim, Uroplus, Uroplus DS, Cotrim DS, Septra I.V., Bactrim I.V., Bactrim Pediatric, Bethaprim Pediatric, Sulfatrim Suspension, Cotrim Pediatric, Septra DS, SMZ-TMP, PJP, PCP, trim-sulfa, trimsulfa

• Trimethoprim-sulfamethoxazole PO/IV: Treatment of Stenotrophomonas maltophilia or other systemic infections

  CrCl >30	8–12mg/kg/day	Divided Q8–12H
  15–30	Load 8–12mg/kg/day x24h, then 4–6mg/kg/dose	Divided Q12H x24hr, then QD
  <15	4–6mg/kg/day	Divided Q12–24H
  Hemodialysis	4–6mg/kg/day	Q12–24H
  Peritoneal dialysis	Load 8–12mg/kg/day x24h, then 4–6mg/kg/dose	Divided Q12H x24hr, then QD
  CVVH	See CVVH Dosing

  On dialysis days give post-HD; Dose always based upon trimethoprim; Indication-dependent dosing

  TRIMETHOPRIM-SULFAMETHOXAZOLE [#grey] | Bactrim DS, Sulfatrim Pediatric, Septra, Sulfatrim, Bethaprim, Cotrim, Uroplus, Uroplus DS, Cotrim DS, Septra I.V., Bactrim I.V., Bactrim Pediatric, Bethaprim Pediatric, Sulfatrim Suspension, Cotrim Pediatric, Septra DS, SMZ-TMP, PJP, PCP, trim-sulfa, trimsulfa

• Trimethoprim-sulfamethoxazole PO: urinary tract infections

  CrCl ≥30	1 DS tablet	Q12H
  <30	1 SS tablet	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	1 DS tablet	Q12H

  TRIMETHOPRIM-SULFAMETHOXAZOLE [#grey] | Bactrim DS, Sulfatrim Pediatric, Septra, Sulfatrim, Bethaprim, Cotrim, Uroplus, Uroplus DS, Cotrim DS, Septra I.V., Bactrim I.V., Bactrim Pediatric, Bethaprim Pediatric, Sulfatrim Suspension, Cotrim Pediatric, Septra DS, SMZ-TMP, PJP, PCP, trim-sulfa, trimsulfa

• Trimethoprim-sulfamethoxazole PO: uncomplicated skin and soft tissue infections

  CrCl ≥30	1–2 DS tablets	Q12H
  <30	1 DS tablet	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH	1–2 DS tablets	Q12H

  Consider 2 DS tablets in patients >100kg; On dialysis days give post-HD

  TRIMETHOPRIM-SULFAMETHOXAZOLE [#grey] | Bactrim DS, Sulfatrim Pediatric, Septra, Sulfatrim, Bethaprim, Cotrim, Uroplus, Uroplus DS, Cotrim DS, Septra I.V., Bactrim I.V., Bactrim Pediatric, Bethaprim Pediatric, Sulfatrim Suspension, Cotrim Pediatric, Septra DS, SMZ-TMP, PJP, PCP, trim-sulfa, trimsulfa

• Trimethoprim-sulfamethoxazole PO: lung transplant or HIV-infected Pneumocystis jirovecii pneumonia prophylaxis

  CrCl ≥30	1 DS tablet TIW or Q24H, OR 1 SS tablet Q24H
  <30	1 SS tablet	TIW
  Hemodialysis	1 DS tablet	TIW
  Peritoneal dialysis	1 SS tablet	TIW
  CVVH	1 DS tablet TIW OR 1 SS tablet Q24H

  On dialysis days give post-HD; TIW = 3x weekly; Lung transplant: continue indefinitely after transplant, defer to institutional guidelines

  TRIMETHOPRIM-SULFAMETHOXAZOLE [#grey] | Bactrim DS, Sulfatrim Pediatric, Septra, Sulfatrim, Bethaprim, Cotrim, Uroplus, Uroplus DS, Cotrim DS, Septra I.V., Bactrim I.V., Bactrim Pediatric, Bethaprim Pediatric, Sulfatrim Suspension, Cotrim Pediatric, Septra DS, SMZ-TMP, PJP, PCP, trim-sulfa, trimsulfa

• Trimethoprim-sulfamethoxazole PO: renal transplant Pneumocystis jirovecii pneumonia prophylaxis

  CrCl ≥50	1 SS tablet	Q24H
  <50	1 SS tablet	Q48H
  Hemodialysis	1 SS tablet	2x weekly
  Peritoneal dialysis	1 SS tablet	Q48H
  CVVH	1 SS tablet	2x weekly

  Pneumocystis jirovecii pneumonia prophylaxis will continue for 12 months after renal transplant, defer to institutional guidelines

  TRIMETHOPRIM-SULFAMETHOXAZOLE [#grey] | Bactrim DS, Sulfatrim Pediatric, Septra, Sulfatrim, Bethaprim, Cotrim, Uroplus, Uroplus DS, Cotrim DS, Septra I.V., Bactrim I.V., Bactrim Pediatric, Bethaprim Pediatric, Sulfatrim Suspension, Cotrim Pediatric, Septra DS, SMZ-TMP, PJP, PCP, trim-sulfa, trimsulfa
• VALACYCLOVIR Valtrex

• Valacyclovir PO: Zoster/HSV treatment

  CrCl ≥50	1000mg	Q8H
  30–49	1000mg	Q12H
  10–29	1000mg	Q24H
  <10	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  On dialysis days, give post-HD

  VALACYCLOVIR [#grey] | Valtrex

• Valacyclovir PO: prophylaxis/suppression, including lung transplant prophylaxis

  CrCl ≥30	500mg	Q12H
  <30	500mg	Q24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Lung transplant: prophylaxis will continue for 3 months post transplant, defer to institutional guidelines; on dialysis days give post-HD

  VALACYCLOVIR [#grey] | Valtrex

• Valacyclovir PO: Renal Transplant prophylaxis

  CrCl ≥50	1000mg	Q24H
  <50	1000mg	Q48H
  Hemodialysis	500mg	Q24H
  Peritoneal dialysis
  CVVH

  Used in renal transplant recipients for 6 months post transplant; on dialysis days give post-HD

  VALACYCLOVIR [#grey] | Valtrex
• VALGANCICLOVIR Valcyte

• Valganciclovir PO: Renal transplant prophylaxis

  CrCl ≥40	450mg	Q24H
  25–39	450mg	Q48H
  10–24	450mg	2x/week
  <10
  Hemodialysis	450mg	Post-HD
  Peritoneal dialysis	450mg	2x/week
  CVVH	450mg	Q48H

  Prophylaxis will continue for 6 months post renal transplant

  VALGANCICLOVIR [#grey] | Valcyte

• Valganciclovir PO: maintenance/suppression/prophylaxis

  CrCl ≥60	900mg	Q24H
  40–59	450mg	Q24H
  25–39	450mg	Q48H
  <25	450mg	2x/week
  Hemodialysis	450mg	Post-HD
  Peritoneal dialysis	AVOID – NO DATA
  CVVH	450mg	Q48H

  Please Refer to the BWH or MGH Lung Transplant Manual for prophylactic dosing

  VALGANCICLOVIR [#grey] | Valcyte

• Valganciclovir PO: CMV treatment

  CrCl ≥60	900mg	Q12H
  40–59	450mg	Q12H
  25–39	450mg	Q24H
  <25	450mg	Q48H
  Hemodialysis	450mg	Post-HD
  Peritoneal dialysis	Use IV ganciclovir for induction
  CVVH	Use IV ganciclovir for induction

  VALGANCICLOVIR [#grey] | Valcyte
• VANCOMYCIN Firvanq

• Vancomycin IV: systemic infections

  MGB Guidance and MGH-specific guidance

  Please contact the pharmacy department for help with monitoring serum concentrations and dosage adjustments; Round all doses to nearest 250 mg

  VANCOMYCIN [#grey] | Firvanq

• Vancomycin PO: Clostridioides difficile treatment ONLY

  All CrCl	125mg	Q6H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  500mg may be used in select fulminant C. difficile cases; also refer to C. diff treatment guideline

  VANCOMYCIN [#grey] | Firvanq

• Vancomycin PO: Clostridioides difficile prophylaxis ONLY

  All CrCl	125mg	Q12–24H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Data on the use of oral vancomycin for C. difficile prophylaxis is conflicting

  VANCOMYCIN [#grey] | Firvanq
• VORICONAZOLE VFEND

• Voriconazole PO ✱ID✱

  All CrCl	400mg Q12H x2, then 200–300mg	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  Suggested therapeutic range 1.5–5 mcg/mL. If level is subtherapeutic, can consider increasing frequency to q8h. Please refer to local guidelines for specific dose adjustments

  VORICONAZOLE [#grey] | VFEND

• Voriconazole IV ✱ID✱

  CrCl ≥50	6mg/kg Q12H x2, then 4mg/kg	Q12H
  Hemodialysis	IV not recommended, however clinical situations may warrant therapy; consult ID
  Peritoneal dialysis	IV not recommended, however clinical situations may warrant therapy; consult ID
  CVVH	IV not recommended, however clinical situations may warrant therapy; consult ID

  Suggested therapeutic range 1.5-5 mcg/mL; Switch to PO when stable or CrCl < 50. Please refer to local guidelines for specific dose adjustments

  VORICONAZOLE [#grey] | VFEND
• ZANAMIVIR Relenza

• Zanamivir Inhalation: influenza treatment ✱ID✱

  All CrCl	10mg (2 inhalations)	Q12H
  Hemodialysis
  Peritoneal dialysis
  CVVH

  ZANAMIVIR [#grey] | Relenza
• ABOUT THIS PAGE
• created by Theodore Pak (tpak [at] mgh)