Antimicrobiano

ClCr ml/min

>50

10-50

<10

Penicilinas, monobactámicos, carbapenemas

Penicilina G sódica

2-4 M UI/4-6 h

3-4 M UI/8 h

2-3 M UI/8h

Ampicilina

0,5-2g /6-8h

0,5-2 g/12h

0,5-2 g/12-24h

Cloxacilina

0,5-2g/4-6h

0,5-2g/4-6h 

0,5-2 g/6-8h

Amoxicilina / clavulánico

1-2 g/6-8h

0,5-1 g/12-18h

0,5-1 g/24h

Piperacilina / tazobactam

4 g/4-6h

1,5-3 g/6-8h

3-4 g/12h

Aztreonam

1-2 g/6-8h

1-2 g/12-18h

1-2 g//24h

Ertapenem

1 g/24

0,5 g/24h

0,5 g/24h

Imipenem-cilastatina

0,5-1 g/6h

0,5-1 g/8-12h

0,25-0,5 g/12h

Meropenem

1-2 g/8h

0,5-1 g/12h

0,5-1 g/24h

Antimicrobiano

ClCr ml/min

>50

10-50

<10

Cefalosporinas

Cefazolina

0,5-2 g/6-8h

0,5-1 g/8-12h

0,25-0,5 g/24h

Cefuroxima

0,75-1,5 g/8h

0,75 g/12h

0,75 g/12h

Ceftriaxona

1-2 g/24h

1-2 g/24h

1-2 g/24h

Cefotaxima

1-2 g/4-8h

1-2 g/6-12h

1-2 g/12-24h

Ceftazidima

1-2 g/8h

1-2 g/12h

1 g/24-48h

Cefepima

1-2 g/12h

1 g/24h

0,5 g/24h

Antimicrobiano

ClCr ml/min

>50

10-50

<10

Otros

Gentamicina

5 mg/kg/24h

1,5 mg/kg/24h

1,5 mg/kg/24-48h

Tobramicina

5 mg/kg/24h

1,5 mg/kg/24h

1,5 mg/kg/24-48h

Amikacina

15 mg/kg/24h

9-12mg/kg/24h

2-4 mg/kg/24h

Ciprofloxacino

400 mg/8-12h

400 mg/12h

400 mg/24h

Levofloxacino

500-750 mg/24h

250-500 mg/24h

250-500 mg/48h

Moxifloxacino

400 mg/24h

Igual

Igual

Vancomicina

15 mg/kg/12h*

1g /3-10 días*

1 g/5-10 días*

Teicoplanina

6-10 mg/kg/24h*

6-10 mg/kg/48h*

6-10 mg/kg/72h*

Doxiciclina

100 mg/12-24h

100 mg/24h

100 mg/24h

Tigeciclina

50 mg/12h*

Igual*

Igual*

Claritromicina

500 mg/8-12h

250 mg/12-24h

250 mg/24h

Cotrimoxazol

160-80 mg/12h

80-40 mg/12h

80-40 mg/24h

Clindamicina

300-900 mg/8h

Igual

Igual

Metronidazol

500 mg/8h

Igual

Igual

Colistina

3 MU/8h*

3 MU/12-24h*

3 MU/36h*

Linezolid

600 mg/12h

Igual

Igual

Daptomicina

4-6 mg/kg/24h

4-6 mg/kg/24h

4-6 mg/kg/48h

Isoniacida          

300mg/dia

Igual

Igual

Rifampicina

600 mg/24h

300-600 mg/24h

300-600 mg/24h

Pirazinamida

15 mg/kg/24h

Igual

Evitar

Antimicrobiano

ClCr ml/min

>50

10-50

<10

Antifúngicos

Fluconazol

3-12 mg/kg/24h*

1-4 mg/kg/24h*

1-4 mg/kg/24h*

Voriconazol

4 mg/kg/12h*

4 mg/kg/12h*

Evitar

Posaconazol

400 mg/12h*

Igual

Igual

Itraconazol

200 mg/12h*

200 mg/12h*

Evitar

Anfot. B complejo lipídico

5 mg/kg/24h

Igual

Igual

Anfot. B liposomal

3-5 mg/kg/24h

Igual

Igual

Caspofungina

50 mg/24h*

Igual*

Igual*

Micafungina

100 mg/24

Igual

Igual

Anidulafungina

100 mg/24

Igual

Igual

Flucitosina

37,5-50 mg/kg/6h

37,5-50 mg/kg/12-24h

37,5-50 mg/kg/48h

Antimicrobiano

ClCr ml/min

>50

10-50

<10

Antivirales

Aciclovir

5 mg/kg/12h

5 mg/kg/24h

2,5 mg/kg/24h

Cidofovir

5 mg/kg/semana

Evitar

Evitar

Ganciclovir

2,5-5 mg/kg/12h

2,5 mg/kg/24h

1,25 mg/kg/24h