AJUSTE POR INSUFICIENCIA RENAL (DCr ml/min)

MEDICAMENTO DOSIS CON FUNCIÓN RENAL NORMAL

> 50-90 10.- 50 < 10
DCr 30-50: 7.5 mgTkg/24h 7.5 mg/Kg/72 hrs.
Amikacina 7.5 mg/kg /12 hrs. o 15 mg/kg/24h 7.5mg/kg/c/24 hrs o 15mg/kg/24h
DCr:10-30: 7.5 mg/kg/48h
AMINOGLUCOCIDOS
Gentamicina 1.7 mg/kg/8 hrs. 5-7mg/kg/24h o 1.7-2.3 mg/kg/8h 1.7 mg/kg/12–48h 1.7 mg/kg/48–72h
Estreptomicina 15 mg por kg (máx. 1g) c/24 h dosis única diaria 15 mg/kg/24h 15 mg/kg/24–72 h. 15 mg/kg/72–96 h
Imipenem 0.5 g c/6 hrs. 200-500 mg c/6–8 hrs. 250 mg c/6 – 8 hrs. 125-250 mg/12 hrs.
CARBAPENEMICOS Meropenem 1 g c/8 hrs. 1 g/8 hrs. 1 g c/12 hrs 0.5 g c/24 hrs.
Ertapenem 1 g c/24 hrs. 1 g c/24 hrs. 0.5 g c/24 hrs. 0.5 g c/24 hrs.
Cefazolina 1 - 2 g c/8 hrs. c/8 hrs. c/12 hrs. c/24–48 hrs.
Cefepima 2g c/8 hrs. (dosis máxima) 2g c/8 hrs. 2 g c/12–24 hrs. 1g c/24 hrs.
Cefotaxima, Ceftizoxima 2 g c/8 hrs. c/8–12 hrs. c/12–24 hrs. c/24 hrs.
CEFALOSPORINAS Cefotetán 1 - 2 g c/12 hrs. 1 - 2 g c/12 hrs. 1-2 g c/24 hrs. 1 - 2 g c/48 hrs.
Cefoxitina 2 g c/8 hrs. c/8 hrs. c/8–12 hrs. c/24–48 hrs.
Ceftazidima 2 g c/8 hrs. c/8–12 hrs c/12–24 hrs. c/24–48 hrs.
Cefuroxima 0.75–1.5 g c/8 hrs. c/8 hrs c/8–12 hrs. c/24 hrs.
Ciprofloxacina 500-750 mg po (o 400 mg IV) c/12 hrs. 100% 400 mg IV c/24 hrs. 50%
Gatifloxacina 400 mg po/IV c/24 hrs. 400 mg c/24 hrs. 400mg, luego 200mg/24 h 400mg, luego 200mg/24 h
FLUOROQUINOLONAS < 20: 750mg una vez,
Levofloxacina 750 mg c/24 hrs. IV, po 750 mg c/24h 20-49: 750 mg c/48 hrs.
después 500mg/48H
Ofloxacina 200-400 mg c/12 hrs. 200-400 mg c/12 hrs. 200-400 mg c/24 hrs. 200mg c/24 hrs.
Claritromicina 0.5 -1 g c/12 hrs. 100% 75% 50-75%
MACROLIDOS Eritromicina 250-500 mg c/6 hrs. 100% 100% 50-75%
Linezolid 600 mg po/IV c/12 hrs. 600 mg c/12 hrs. 600 mg c/12 hrs. 600 mg c/12 hrs.
Metronidazol 7.5 mg por kg c/6 hrs. 100% 100% 50%
Nitrofurantoína 50-100 mg 100% Evitar Evitar
Sulfametoxazol (SMX) 1 g c/8 hrs. c/12 hrs. c/18 hrs. c/24 hrs.
ATB ANTIBACTERIANOS 30-50: No ajuste de dosis No se recomienda; si se
Trimetoprima-sulfametazol 5-20 mg/kg/día divididos c/6-12 hrs. Ningún ajuste de dosis
10-29: Reducir dosis al 50% emplea: 5-10 mg/kg c/24h
Profilaxis con TMP-SMX 1 tab po c/24 hrs. o 3 veces por semana 100% 100% 100%
Vancomicina 1 g c/12 hrs. 1 g c/12 hrs. 1 g c/24–96 hrs. 1g c/4–7 dias
Amoxicilina 250-500 mg c/8 hrs. c/8 hrs. c/8 – 12 hrs. c/24 hrs.
Ampicilina 250 mg-2 g c/6 hrs. c/6 hrs. c/6 – 12 hrs. c/12–24 hrs.
Amoxicilina/Clavulanato 500/125 mg c/8 hrs. 500/125 mg c/8 hrs. 250-500 mg c/12 hrs. 250-500 mg c/24 hrs.
Ampicilina (AM/Sulbactam[SB]) 2g AM + 1 g SB c/6 hrs. c/6 hrs. c/8–12 hrs c/24 hrs.
Aztreonam 2g c/8 hrs. 100% 50-75% 25%
PENICILINAS Bencilpenicilina 0.5-4 millones de U c/4 hrs. 100% 75% 20- 50%
Piperacilina 3-4 g c/4–6 hrs. c/4 – 6 hrs. c/6–8 hrs. c/8 hrs.
2.25 g c/6 hrs.
Pip (P)/Tazo (T) 3.375-4.5 g c/6–8 hrs. 100% 2.25 g c/8 hrs.
< 20: c/8 hrs.
Ticarcilina 3 g c/4 hrs. 1–2 g c/4 hrs. 1-2 g c/8 hrs. 1-2 g c/12 hrs.
Ticarcilina/Clavulanato 3.1 g c/4 hrs. 3.1 g c/4 hrs. 3.1 g c/ 8-12 hrs. 2 g c/12 hrs.
TETRACICLINAS Tetraciclina 250-500 mg qid c/8-12h c/12-24h c/24 h
No lipídica:
0.4-1 mg/kg/día
Anfotericina B y anfo B c/24 hrs. c/24 hrs. c/24 hrs.
ABCL: 5 mg/kg/día
ANTIMICÓTICOS ABL: 3-5 mg/kg/día
Fluconazol 100-400 mg c/24 hrs. 100% 50% 50%
Itraconazol, oral 100-200 mg c/12 hrs. 100% 50% 50%
Itraconazol, IV 200 mg IV c/12 hrs. 200 mg IV bid No usar, si DCr < 30 debido acumulación de ciclodextrina
Terbinafina 250 mg po por día c/24 hrs. no ha sido estudiado. Se recomienda evitar
Pentamidina 4 mg por kg por día c/24 hrs. c/24 hrs. c/24–36 hrs.
ANTIPARASITARIOS
Quinina 650 mg c/8 hrs. 650 mg c/8 hrs. 650 mg c/8–12 hrs. 650 mg c/24 hrs.
ANTIVIRALES Aciclovir, IV 5-12.4 mg por kg c/8 hrs. 100% c/8 hrs. 100% c/12–24 hrs. 50% c/24 hrs.
 FÁRMACOS CUYA DOSIS NO ES PRECISO AJUSTAR EN CASO DE INSUFICIENCIA RENAL
Antibacterianos Antimicóticos Antituberculosos Antivirales
Azitromicina Minociclina Anidulafungina Etionamida Abacavir Lopinavir
Ceftriaxona Moxifloxacino Caspofungina Isoniazida Atazanavir Nelfinavir
Cloranfenicol Nafcilina Itraconazol solución oral Rifampicina Darunavir Nevirapina
Ciprofloxacina LP Polimixina BKetoconazol Rifabutina Delavirdina Raltegravir
Clindamicina Pirimetamina Micafungina Rifapentina Efavirenz Ribavirina
Doxiciclina Rifaximina Voriconazol, sólo po Enfuvirtida1 Saquinavir
Linezolid Tigeciclina Fosamprenavir Tipranavir
Indinavir

ANTIMICROBIANOS Y HEPATOPATÍA: AJUSTE DE DOSIS

Antibacterianos Antimicóticos Antivirales
Ceftriaxona Nafcilina Caspofungina Abacavir Indinavir
Cloranfenicol Rifabutina Itraconazol Atazanavir Lopinavir/ritonavir
Clindamicina Rifampicina Voriconazol Darunavir Nelfinavir
Ácido fusídico Synercid Delavirdina Nevirapina
Isoniazida Telitromicina Efavirenz Rimantadina
Metronidazol Tigeciclina Enfurvitida Ritonavir
Tinidazol Fosamprenavir Stribild