| Penicilinas, monobactámicos, carbapenemas | |||
| Antimicrobiano | ClCr ml/min | ||
| >30 | 10-30 | <10 | |
| Penicilina G sódica/Bencilpenicilina | 1-3 M UI/2-6 h | 1-3 M UI/8 h | 1-2 M UI/12h |
| Ampicilina | 1-2g /4-6h | 1-2 g/8h | 1 g/12h |
| Cloxacilina | 1-2g/4h | Igual | Igual |
| Amoxicilina / clavulánico | 1-2 g/6-8h | 0,5 g/12h | 0,5 g/24h |
| Piperacilina / tazobactam | 2-4 g/6-8h | 2 g/6h | 2 g/8h |
| Aztreonam* | 1-2 g/8-12h | 0,5-1 g/8-12h | 0,5 g/8-12h |
| Ertapenem | 1 g/24 | 0,5 g/24h | 0,5 g/24h |
| Imipenem-cilastatina | 0,5-1 g/6-8h | 0,5 g/8h | 0,25-0,5 g/12h |
| Meropenem | 1 g/8h | 1 g/12h | 1 g/24h |
| Cefalosporinas | |||
| Antimicrobiano | ClCr ml/min | ||
| >30 | 10-30 | <10 | |
| Cefazolina | 1-2 g/8h | 1-2 g/12h | 1-2 g/24h |
| Cefuroxima | 0,75-1,5 g/8h | 0,75-1,5 g/12h | 0,75-1,5 g/24h |
| Cefuroxima-axetilo | 0,25-0,5 g/8-12h | Igual | 0,5 g/24h |
| Ceftriaxona | 1-2 g/12-24h | Igual | 1g/24h |
| Cefotaxima | 1-2 g/6-8h | Igual | 2 g/24h |
| Ceftazidima | 1-2 g/8-12h | 1 g/24h | 1 g/24-48h |
| Ceftazidima-avibactam | igual que ceftazidima | igual que ceftazidima | igual que ceftazidima |
| Cefepima | 1-2 g/8-12h | 1 g/12h | 1 g/24h |
| Ceftolozano-Tazobactam | 750mg (500/250)/8h | 375mg (250/125)/8h | 150mg (100/50)/8h |
| Ceftarolina | 400mg/8-12h | 300mg/8-12h | 200mg/8-12h |
| Ceftobiprole | 500/12h | 250mg/12h | 250mg/12h |
| Otros | |||
| Antimicrobiano | ClCr ml/min | ||
| >30 | 10-30 | <10 | |
| Gentamicina* | 5-7 mg/kg/24h | 5 mg/kg/48h | 3 mg/kg/48h |
| Tobramicina | 5-7 mg/kg/24h | 5 mg/kg/48h | 3 mg/kg/48h |
| Amikacina* | 15-20 mg/kg/24h | 12 mg/kg/24h | 7,5-10 mg/kg/48h |
| Ciprofloxacino | 400 mg/8-12h | 200 mg/8-12h | 400 mg/24h |
| Levofloxacino | 500-750 mg/24h | 250-500 mg/24h | 250 mg/48h |
| Moxifloxacino | 400 mg/24h | Igual | Igual |
| Vancomicina | 15-20 mg/kg/8-12h | 1g /2 días | 1 g/3 días |
| Teicoplanina | 6 mg/kg/24h | 6 mg/kg/72h | 6 mg/kg/72h |
| Dalvabancina | sin cambios | 750mg el 1º día seguido de 350mg al 8º
o 1000mg el 1º día (DOSIS ÚNICA) |
|
| Doxiciclina | 100 mg/12-24h | Igual | Igual |
| Tigeciclina* | 50 mg/12h | Igual | Igual |
| Claritromicina* | 500 mg/12h | 500 mg/24h | 500 mg/24h |
| Cotrimoxazol* | 160-800 mg/8-12h | 160-800 mg/24h | 80-400 mg/24h |
| Clindamicina* | 600 mg/6-8h | Igual | Igual |
| Metronidazol* | 500 mg/8h | Igual | 500 mg/12h |
| Colistina | 4,5 MU/12h | 4,5 MU/24h | 3 MU/24h |
| Linezolid | 600 mg/12h | Igual | Igual |
| Tedizolid | sin cambios | ||
| Daptomicina* | 6-10 mg/kg/24h | 6-8 mg/kg/48h | 4-6 mg/kg/48h |
| Isoniacida* | 300mg/dia | Igual | Igual |
| Rifampicina* | 600-1200 mg/24h | 600 mg/24h | 600 mg/24h |
| Pirazinamida* | 25-35 mg/kg/24h | 25-35 mg/kg/3d por sem | 25-35 mg/kg/3d por sem |
| Antifúngicos | |||
| Antimicrobiano | ClCr ml/min | ||
| >30 | 10-30 | <10 | |
| Fluconazol* | 50-800 mg/24h | 100-400 mg/24h | 100-400 mg/24h |
| Voriconazol* | 6-4 mg/kg/12h | Evitar FG<50 (acumulación diluyente) | Evitar FG<50 (acumulación diluyente) |
| Posaconazol* | 200 mg/8h | Igual | Igual |
| Itraconazol* | 100-200 mg/12h | Igual | Evitar FG<30 (acumulación diluyente) |
| Isavuconazol | sin cambios | ||
| Anfot. B complejo lipídico | 5 mg/kg/24h | Igual | Igual |
| Anfot. B liposomal | 3-5 mg/kg/24h | Igual | 3 mg/kg/24h |
| Caspofungina* | 70-50 mg/24h | Igual | Igual |
| Micafungina* | 100-150 mg/24 | Igual | Igual |
| Anidulafungina | 100 mg/24 | Igual | Igual |
| Flucitosina | 25 mg/kg/6h | 37,5 mg/kg/24h | 37,5 mg/kg/24-48h |
| Antivirales | |||
| Antimicrobiano | ClCr ml/min | ||
| >30 | 10-30 | <10 | |
| Aciclovir | 5-15 mg/kg/8h | 5-10 mg/kg/24h | 2,5-5 mg/kg/24h |
| Cidofovir | 5 mg/kg/7-14 d | Evitar | Evitar |
| Ganciclovir | 5 mg/kg/12h | 2,5 mg/kg/24h | 1,25 mg/kg/24h |
| Oseltamivir | 75mg/12h | 75mg/24h | 30mg/24h |
*Requiere ajuste por Insuficiencia hepática (IH). Ver siguiente tabla
Dosis en Insuficiencia Renal
