Page 16 - Parkview Antimicrobial Stewardship Guidebook_Neat

Medication Dosing Adjustment Comments
Oseltamivir Normal dose: Treatment: 75 mg PO BID x5-10 days Initiate
(Tamiflu) Prophylaxis: 75 mg PO daily x7-10 days prophylaxis
within 48h of
Renal Impairment: contact with
CrCl > 60 mL/min Normal dose infected
CrCl 31-60 mL/min Tx: 30 mg PO bid x5 days individual
Px: 30 mg PO daily
CrCl >10-30 mL/min Tx: 30 mg PO daily x5 days
Px: 30 mg PO every other day
CrCl <10 mL/min Not recommended
Hemodialysis 30 mg PO after every HD session x5 days

Piperacillin/ Normal dose: 3.375-4.5 g IV q6-8h (q6h unless CrCl < 20) *Preferred dose =
tazobactam no less than 2.25
(Zosyn) Renal Impairment: g q8h
CrCl > 40 mL/min Normal dose
CrCl 20-40 mL/min 2.25 g IV q6h (except nosocomial PNA 3.375 g IV q6h)
CrCl < 20 mL/min 2.25 g IV q8h (except nosocomial PNA 2.25 g q6h)
Hemodialysis 2.25 g q12h (except nosocomial PNA 2.25 g q8h) plus
may give 0.75 g after each dialysis session
Trimethoprim/ Normal dose: IV: 8-20 mg/kg/day divided q6-12h Dose based on
sulfamethoxazole PO: 1-2 tabs q12-24h trimethoprim
(Bactrim, Septra)
Renal Impairment: Unique dosing for
CrCl > 30 mL/min Normal dose PCP
CrCl 15-30 mL/min 50% of recommended dose
CrCl < 15 mL/min Avoid use
Hemodialysis 2.5-10 mg/kg IV q24h

References:
1. Uptodate online (accessed 1/2017)
2. Micromedex online (accessed 1/2017)