Page 15 - Parkview Antimicrobial Stewardship Guidebook_Neat

Medication Dosing Adjustment Comments
Famciclovir Normal dose: 250-1500 mg PO BID-TID Not effective in
(Famvir) the treatment of
Renal Impairment: CMV
CrCl > 50 mL/min Normal dose
CrCl 10-50 mL/min 500 mg q12-24h
CrCl <10 mL/min 250 mg q24h
Hemodialysis 250 mg given after dialysis (3 times weekly)
Fluconazole Normal dose (IV or Load: 200-800 mg *Consider 50%
(Diflucan) PO): Maintenance: 200-800 mg Q24h reduction to be
from 400 mg max
Renal Impairment (IV dose (eg 100 mg
or PO): q24 with CrCl 40
CrCl < 50 mL/min Reduce dose by 50% would leave as
Hemodialysis Load 50-400 mg; usual dose after each HD and 50% 100 mg q24h)
dose on non HD days
Ganciclovir Normal dose: 5-6 mg/kg/dose IV q12h Administer by
(Cytovene) slow IV infusion
Renal Impairment: over at least an
Induction: hour. Too rapid
CrCl 50-69 mL/min 2.5 mg/kg/dose IV q12h infusion can
CrCl 25-49 mL/min 2.5 mg/kg/dose IV q24h cause increased
CrCl 10-24 mL/min 1.25 mg/kg/dose IV q24h toxicity and
CrCl < 10 mL/min 1.25 mg/kg/dose IV 3x/week after dialysis excessive plasma
Maintenance: levels.
CrCl 50-69 mL/min 2.5 mg/kg/dose IV q24h
CrCl 25-49 mL/min 1.25 mg/kg/dose IV q24h
CrCl 10-24 mL/min 0.625 mg/kg/dose IV q24h
CrCl < 10 mL/min 0.625 mg/kg/dose IV 3x/week after dialysis

Levofloxacin *Preferred to
Creatinine Dosing Regimen
(Levaquin) change interval
Clearance rather than dose
(ml/min) *PNA/Sepsis *UTI

≥ 50 750 mg Q24H 500 mg Q24H 250 mg Q24H

500 mg initial, 250
20-49 750 mg Q48H 250 mg Q24H
mg Q24H
10-19 and 750 mg initial, 500 mg initial, 250
250 mg Q48H
Hemodialysis 500mg Q48H mg Q48H

Meropenem Normal dose: 500 mg-2 g IV q8h *Preferred dose
(Merrem) underlined
Renal Impairment:
CrCl > 50 mL/min Normal dose
CrCl 26-50 mL/min Extend interval q12h
CrCl 10-25 mL/min 50% of dose q12h (1 g q12h)
CrCl < 10 mL/min 50% of dose q24h (1g q24h)
Hemodialysis 500 mg IV q24h (after dialysis on dialysis days)