# 제균치료시 항생제 용량 조절 (2020.02.13. from www.uptodate.com ) 1) amoxicillin Dosing: Renal Impairment: Adult Oral: Immediate-release: Note: Avoid immediate-release 875 mg tablet in patients with GFR <30 mL/minute. GFR ≥30 mL/minute: No dosage adjustment necessary. GFR 10 to 30 mL/minute: 250 to 500 mg every 12 hours GFR <10 mL/minute: 250 to 500 mg every 24 hours Hemodialysis: Moderately dialyzable (20% to 50%); ~30% removed by 3-hour hemodialysis: 250 to 500 mg every 24 hours; administer after dialysis on dialysis days (Aronoff 2007) Extended-release: CrCl ≥30 mL/minute: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied). CrCl <30 mL/minute: Not recommended Hemodialysis: Not recommended. Dosing: Hepatic Impairment: Adult There are no dosage adjustments provided in the manufacturer's labeling. 2) clarithromycin Dosing: Renal Impairment: Adult CrCl ≥30 mL/minute: No dosage adjustment necessary. CrCl <30 mL/minute: Decrease clarithromycin dose by 50% Hemodialysis: Administer after HD session is completed (Aronoff 2007). In combination with atazanavir or ritonavir: CrCl 30 to 60 mL/minute: Decrease clarithromycin dose by 50%. CrCl <30 mL/minute: Decrease clarithromycin dose by 75%. Dosing: Hepatic Impairment: Adult No dosage adjustment necessary if renal function is normal; however, in patients with hepatic impairment and concomitant severe renal impairment, a dosage reduction or prolonged dosing intervals may be appropriate. 3) Metronidazole Dosing: Renal Impairment: Adult Manufacturer’s labeling: Mild to moderate impairment: There are no dosage adjustments provided in the manufacturer’s labeling; however, decreased renal function does not alter the single-dose pharmacokinetics. Severe impairment: There are no dosage adjustments provided in the manufacturer’s labeling; metronidazole metabolites may accumulate; monitor for adverse events. ESRD requiring dialysis: Metronidazole metabolites may accumulate; monitor for adverse events. Accumulated metabolites may be rapidly removed by dialysis: Intermittent hemodialysis (IHD): If administration cannot be separated from hemodialysis, consider supplemental dose following hemodialysis. Peritoneal dialysis (PD): No dosage adjustment necessary. Alternative dosing: Intermittent hemodialysis (IHD) (administer after hemodialysis on dialysis days): Dialyzable (50% to 100%): 500 mg every 8 to 12 hours. Note: Dosing regimen highly dependent on clinical indication (trichomoniasis vs C. difficile colitis) (Heintz 2009). Note: Dosing dependent on the assumption of thrice-weekly, complete IHD sessions. Dosing: Hepatic Impairment: Adult Manufacturer’s labeling: Mild or moderate impairment (Child-Pugh class A or B): No dosage adjustment necessary; use with caution and monitor for adverse events. Severe impairment (Child-Pugh class C): Capsules: Amebiasis: 375 mg 3 times daily Trichomoniasis: 375 mg once daily Tablets, injection: Reduce dose by 50% 4) tetracycline Dosing: Renal Impairment: Adult Manufacturer’s labeling: There are no specific dosage adjustments provided in the manufacturer’s labeling; decrease dose and/or extend dosing interval. Alternative dosing (Aronoff 2007): Note: Renally adjusted dose recommendations are based on doses of 250 mg to 500 mg twice daily to 4 times daily. GFR >50 mL/minute: Administer recommended dose based on indication every 8 to 12 hours. GFR 10 to 50 mL/minute: Administer recommended dose based on indication every 12 to 24 hours. GFR <10 mL/minute: Administer recommended dose based on indication every 24 hours. Dosing: Hepatic Impairment: Adult There are no dosage adjustments provided in the manufacturer’s labeling. 5) levofloxacin Dosing: Renal Impairment: Adult IV, Oral: Normal renal function dosing of 250 mg daily: CrCl 20 to 49 mL/minute: No dosage adjustment required. CrCl 10 to 19 mL/minute: Administer 250 mg every 48 hours (except in uncomplicated UTI, where no dosage adjustment is required). Hemodialysis/chronic ambulatory peritoneal dialysis (CAPD): No information available. Normal renal function dosing of 500 mg daily: CrCl 20 to 49 mL/minute: Administer 500 mg initial dose, followed by 250 mg every 24 hours. CrCl 10 to 19 mL/minute: Administer 500 mg initial dose, followed by 250 mg every 48 hours. Hemodialysis/chronic ambulatory peritoneal dialysis (CAPD): Administer 500 mg initial dose, followed by 250 mg every 48 hours; supplemental doses are not required following either hemodialysis or CAPD Normal renal function dosing of 750 mg daily: CrCl 20 to 49 mL/minute: Administer 750 mg every 48 hours. CrCl 10 to 19 mL/minute: Administer 750 mg initial dose, followed by 500 mg every 48 hours. Hemodialysis/chronic ambulatory peritoneal dialysis (CAPD): Administer 750 mg initial dose, followed by 500 mg every 48 hours; supplemental doses are not required following either hemodialysis or CAPD. Normal renal function dosing of 750 or 1,000 mg daily (treatment of tuberculosis only) (CDC 2003): CrCl <30 mL/minute: Administer 750 or 1,000 mg 3 times per week (in hemodialysis patients administer after dialysis on dialysis days). Continuous renal replacement therapy (CRRT) (Heintz 2009; Trotman 2005): Drug clearance is highly dependent on the method of renal replacement, filter type, and flow rate. Appropriate dosing requires close monitoring of pharmacologic response, signs of adverse reactions due to drug accumulation, as well as drug concentrations in relation to target trough (if appropriate). The following are general recommendations only (based on dialysate flow/ultrafiltration rates of 1 to 2 L/hour and minimal residual renal function) and should not supersede clinical judgment: CVVH: Loading dose of 500 to 750 mg followed by 250 mg every 24 hours. CVVHD: Loading dose of 500 to 750 mg followed by 250 to 500 mg every 24 hours. CVVHDF: Loading dose of 500 to 750 mg followed by 250 to 750 mg every 24 hours. Dosing: Hepatic Impairment: Adult IV, Oral: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied). However, dosage adjustment unlikely due to limited hepatic metabolism.