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Renal Dosing Protocols

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  Calculators:  CrCl Adult  CRCl - Obese Pt

Older Guidelines

 
 
Antifungals Amphotericin B Fluconazole
(Diflucan)
Flucytosine
(Ancobon)
Itraconazole
(Sporanox)
Terbinafine
(Lamisil)
       

 
Antivirals Acyclovir
(Zovirax)
Amantadine
(Symmetrel)
Famciclovir
(Famvir)
Rimantadine
(Flumadine)
Valacyclovir
(Valtrex)
       

 
H2 Antagonists Cimetidine
(Tagamet)
Famotidine
(Pepcid)
Nizatidine
(Axid)
Ranitidine
(Zantac)

 
 
Agent Usual Dosage Renal Dosing
AMPICILLIN

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Mild to moderate infection: 500mg to 2g ivpb q6h. Severe infection: 2g ivpb q4h (150-200mg/kg/day) >50/ q6h || 10-50/ q6-12h || <10/ q12-24 hours || Hemodialysis: Dose after dialysis || PD: 250mg q12h.
AMPICILLIN (Oral) Usual dose: 250mg to 1g po q6h (50-100mg/kg/ day). >50/ no changes || 10-50/ q6-12h || <10/ q12h
AMPICILLIN - SULBACTAM (UNASYN) Usual dose: 1.5 to 3g ivpb q6h >30/ q6-8h || 15-29/ q12h || 5-14/ q24h
AUGMENTIN (Oral)

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Usual dose: 875mg po q12h or 250-500mg po q8h >30/ no change || 10-30/ 250-500mg q12h || <10/ 250-500mg po q24h
AZACTAM Mild infection (i.e. UTI): 500mg to 1g ivpb q8-12h. Usual dose: 1-2g ivpb q8-12h. Severe or life threatening: 2g ivpb q6-8h. Max 8g/day >30/ no change || 10-30/ 50% of usual dose q6-8h || <10/ 25% of usual dose q6-8h || HD/PD: see <10 guidelines. (HD: 500mg AD) Give loading dose of 1-2g before starting regimens above.
AZITHROMYCIN (ZITHROMAX)


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Usual oral dose: 500mg x 1, then 250mg po qd x 4 days. Chlamydia: 1gram po x 1. MAC prevention: 1200mg qwk or 500mg po TTW. PID or CAP: 500mg ivpb qd x 2 days or more than 500mg po qd. Uncomplicated gonococcal infection: 2 grams orally x1 *(see comments) No adjustments required in renal failure. Cannot be given IM. *Because of the high incidence of gastric upset with the 2 gram dose--this is the least preferred regimen for treatment of uncomplicated gonococcal infections.
BACTRIM


IV: Usual dose: 8-10mg/kg/day divided q6h, q8h or q12h. PCP: 15-20mg/kg/day in 3 or 4 divided doses. Oral: UTI: 1 DS tab (160mg TMP/800mg SMX) po q12h. >30/ no change || 15-30/ 50% of usual dose q12h-alternatively: 8-10mg/kg/day divided q12h x 1-2 days, then 4-6mg/kg q24h. ||   <15/ not recommended by manufacturer. Alternatively: 8-10mg/kg/dose q48h or 4-6 mg/kg/day.
CEFAZOLIN

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Usual: 500mg to 1g ivpb 8h. Severe: 1.5g ivpb q6h. Life threatening: 6-12g/day. >55/q6-8h || 35-54/q8h || 11-34/ 50% usual dose q12h || <10 ml/min/ 50% to full dose q24-48h. || Hemodialysis: 0.5-1 gram after dialysis
CEFEPIME (MAXIPIME) Mild to moderate infection: 500mg to 2g ivpb q12h. Severe: 2g ivpb q8h. >60/ 0.5-2g q12h || 30-60/ 0.5g-2g q24h || 11-29/ 0.5g-1g q24h || <10/ 250-500mg q24h or 0.5-2g q48h. || HD: 1g AD || PD: 1-2 grams q48h
CEFOTETAN (IV) Usual dose: 1g ivpb q12h. Severe: 2-3g ivpb q12h. (Max 6g/day) >30/ Usual dose || 10-30/ 50% of dose q12h || <10/ 25% of dose q12h.|| Hemodialysis or PD: 50% of usual dose q24h
CEFOXITIN (IV)
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Mild infection: 1g ivpb q6-8h Moderate-severe: 1g ivpb q4h or 2g ivpb q6-8h. Life-threatening: 2g ivpb q4h or 3g ivpb q6h. 10-50/ q8-12h || <10/ q24-48h || HD: give 1g after Dialysis: e.g. Give Cefoxitin 1g ivpb M-W-F after dialysis + a supplemental dose on Sunday.
CEFOTAXIME (IV)

Mild infection: 1-2g ivpb q12h. Moderate: 1-2g ivpb q8h; Severe: 2g ivpb q6-8h; Life threatening: 2g ivpb q4h (Max dose/day= 12g) >50/ Usual dose || 10-50/ q8-12h || <10/ q24h || HD: 0.5 to 2g ivpb q24h AD. || PD: 1g ivpb q24h.
CEFUROXIME (IV) Usual: 750mg to 1.5g ivpb q8h. Severe: 1.5g ivpb q6-8h. >20/q8h || 10-20/ q12h || <10/ 750mg q24h. || Hemodialysis: Give single dose after dialysis or give 750mg q12h. || PD: 750mg-1.5g q24h
CEFTIN (ORAL)

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Usual dose: 250-500mg po q12h No changes req'd (usual oral doses are not significant).
CEFTRIAXONE (IV) Usual dose: 1-2g ivpb q24h. Severe: 2g ivpb q12h No dosage adjustments req'd in renal failure. PD: 750mg ivpb q12h
CEFTAZIDIME (IV)

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Usual dose: 1g ivpb q8-12h. Severe: 2g ivpb q8-12h. (Max dose/day= 6 grams). Crcl 30-50/ q12h   ||  10-30/ q24h  || <10/ q48h
CEPHALEXIN KEFLEX/VELOSEF Usual dose: 250-500mg po q6h; 500mg-1g q12h. Keflex: 10-50/ q6-12h || <10/ q12-24h . Velosef: >20/ no change || 5-20/ 250mg q6h || < 5/ 250mg q12h
CIPROFLOXACIN (CIPRO)

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Oral dosing: 250-750mg po q12h; cystic fibrosis: 750mg po q8h. IV dosing: 200-400mg ivpb q12h. Febrile neutrapenic pt: 400mg ivpb q8h >50/ no change || 10-50/ 50-75% of usual dose q12h || <10/50% of usual dose q12. Alternatives: [200mg ivpb or 250mg po q12h] or [400 mg ivpb or 500mg po q24h]. || HD/PD: 250-500mg po or 200-400mg ivpb q24h AD or 200mg ivpb or 250mg po q12h.
CLARITHROMYCIN (BIAXIN) Usual dose: 250-500mg orally q12h. Severe (Legionella): 500-1000 mg po q12h. Helicobacter: 500mg po tid. Severe renal dysfunction: decrease dose or increase interval. [crcl < 30 ml/min:  500mg loading dose, then 250 mg once or twice daily.]
CLINDAMYCIN (IV/PO)

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Usual oral dose: 150-400mg  po q6h. Usual IV dose: 600mg ivpb q6-8h or 900mg ivpb q8h. Maximum daily dose= 4800mg No dosage adjustments required for renal failure
DICLOXACILLIN (Oral) Usual dose: 250-500mg po q6h No changes required for renal insufficiency.
DOXYCYCLINE (VIBRAMYCIN) Usual dose: 100mg po bid x1 f/b 100mg qd or divided bid (if severe: 100mg po bid) or 100-200mg ivpb qd or divided doses q12h. No dosage adjustments required for renal failure
ERYTHROMYCIN

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Usual oral dose: 500mg to 1g po q12h or 250mg to 1g po q6h. Usual IV dose: 250mg to 1g q6h. Max 4 g/day. >10/ No change || <10/ 50-75% of usual dose. Max 2 grams/day. || Hemo: no supplement.
IMIPENEM (PRIMAXIN)

Mild to moderate infection: 250-500mg ivpb q6-8h. Severe infection: 500mg to 1g ivpb q6-8h. Max dose/day= 50mg/kg/day or 4g/day 31-70/ 500mg q6-8h || 21-30/ 500mg q8-12h max || 0-20/ 250-500mg q12h max. || HD: 250 mg AD + q12h. || PD: max dose= 1gram/day i.e. 500mg ivpb q12h.
LEVOFLOXACIN (LEVAQUIN) Usual dose: 500mg po or ivpb q24h. UTI or pyelonephritis: 250mg po/ivpb q24h. >50/ no change || 20-49/ 500mg x 1 then 250mg q24h || <19/HD/PD: 500mg x 1 then 250mg q48h
METRONIDAZOLE (FLAGYL)

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IV: 1 gram or 15 mg/kg load IV, then 500mg or 7.5 mg/kg q6h (range: q6-12h --long T ½ ). Oral: 250-750mg po tid. (occasionally bid). Max 4g/day. > 10/ no change || <10/ 500mg ivpb q12h.
NAFCILLIN Mild to moderate infection: 500mg to 1g ivpb q4h or 1-2g ivpb q6h. Severe: 1-2g ivpb q4h No dosage changes req'd for renal failure. || Renal + Hepatic dysfcn: decrease dose by 50%.
OFLOXACIN (FLOXIN) Usual dose: 200-400mg po/IV q12h. >50/ no change || 10-50/ usual dose q24h || <10/ 100-200mg q24h
PENICILLIN G (Aqueous)

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Usual dose: 0.5 to 4 mu q4-6h. Severe infection: Dosing interval q2-3h (i.e. 3mu q3h). Max dose per day: up to 30 million units >50/ Usual dose || 10-50/ 75% of usual dose || <10/ 20-50% of usual dose. || Hemo/PD: 20-50% of dose usually q6h. Max dose in ESRD: 6 mu/day.
PEN VK (Oral) Usual dose: 250-500mg po q6h >10/ No Changes || <10/ 250-500mg po q8h
PENICILLIN G BENZATHINE
Peak: 12-24hrs
Duration: 1-4 wks.

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Group A strept URI: 1.2 mu IM x 1. Prophylaxis of recurrent rheumatic fever: 1.2mu q3-4wks. Early syphilis: 2.4mu x 1 (in 2 injection sites). Late syphilis (> 1yr): 2.4 mu (in 2 sites) qwk x 3. Administer by deep IM in the upper outer quadrant of the buttock. Not indicated as single drug tx of neurosyphilis, but may be given 1 time/wk x 3 weeks following IV tx. Levels: (time to peak): 12-24hrs. Levels are detectable for 1-4 wks. Higher doses increase duration not peak. Use a PCN-procaine/benzathine combination (bicillin) to achieve early peak levels in acute infections. [Supplied: 600,000 u/ml (1ml., 2ml, 4ml)
PENICILLIN G PROCAINE

Peak: 1-4 hrs
Duration: 15-24 hours

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Dosing: 0.6 to 4.8 mu/day in 1-2 dd. Uncomplicated gonorrhea: 1g probenecid f/b 4.8mu divided into 2 inj sites 30min later. Endocarditis (strept): 1.2 mu q6h x 2-4wks. Neurosyphilis: 2-4 mu/day + 500mg probenecid qid x 10-14days(Note: IV Pcn is D.O.C) Time to peak: 1-4 hrs. Duration: 15 to 24 hours. Supplied: 600,000 u/ml (1 ml, 2ml, 4ml). 300,000u/ml-10ml vial.
PIPERACILLIN Mild infection: 3-4g ivpb q6-8h Serious infection: 3-4g ivpb q4-6h (200-300mg/kg/day) Max 24g/day >40/ No change || 20-40/ 4g q8h || <20/ 4g q12h || HD/PD: 2g q8h. || Alternatively: >50/q4-6h || 10-50/ q6-8h || <10/ q8h
PIPERACILLIN-TAZOBACTAM (ZOSYN)
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Mild infection: 3.375g ivpb q6h Moderate to severe: 3.375g ivpb q4h >40/ 3.375g q6h || 20-40/ 2.25g q6h || <20/ 2.25g q8h || HD: Max 2.25g q8h. 0.75g AD. || PD: 2.25g q8h
SYNERCID 7.5 mg/kg ivpb q8-12h (usually q8h). Dilute dose in 250ml D5W and infuse over 1 hour.
TETRACYCLINE Usual dose: 250-500mg po/iv q6h. 50-90/ q8-12h || 10-50/ q12-24h || <10/ q24h (use not recommended)
TIMENTIN

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Usual dose: 3.1g ivpb q4-6h >60/ 3.1g q4-6h || 30-60/q8-12h || 10-30/ q12-24h or 2g ivpb q8h || <10/ 2g q12h or 3.1g q24-48h || <10 + hepatic dysfcn/ 2g q24h || PD: 3.1g q12h || Hemodialysis: 2g q12h + 3.1g after dialysis.
ANTIFUNGALS    
AMPHOTERICIN B



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Test dose: (optional): 1 mg/20-50 ml D5W over 10-30 min. Monitor temp, pulse, RR and BP q30min x 4 hours. Do not give premeds with test dose. Maintenance dose: Initially give 0.25-0.3 mg/kg/day. Increase as tolerated by an equivalent amountqd. Usual daily dose: 0.5-1 mg/kg/day or up to 1.5 mg/kg qod. For life-threatening infection may give full dose the first day (usually 0.6-0.7 mg/kg IBW on Day # 1). Premedication: Prevention of fever/chills: Tylenol 650mg PO/PR + Benadryl 25-50mg PO/IVP 60min prior to maintenance infusion. May also add: Hydrocortisone 25-50mg IV/IM +/- Demerol 50mg IV. Renal dosing: <10/ q24-36h. During therapy if the BUN increases above 40 mg/dl or the serum creatinine exceeds 2.5-3 mg/dl, Hold Ampho B until renal function improves, then restart at a reduced dose or change to QOD dosing until Serum creatinine/BUN improve. Bladder irrigation: Add 30-50mg Ampho B to 1000ml (or less) sterile H2O administered intermittently or continuously for 2 to 14 days. (Note: use of D5W for Bladder irrigations is not recommended because of the possibility of enhancing microbial and fungal growth in the bladder).
FLUCONAZOLE (DIFLUCAN)



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Oral: Oropharyngeal candidiasis: 200mg po x 1, f/b 100mg po qd. Esophageal candidiasis: 100-200 mg po qd (up to 400mg/day). Cryptococcal meningitis: 400mg po x 1, f/b 200mg po qd x 10-12 weeks (Suppression: 50-200mg po qd). Onychomycosis: 200-300mg qweek or 100-200mg po qod (further studies needed). IV: since oral absorbtion is rapid and essentially complete-IV dose=oral dose. >50/ no change || <50 / 50% of usual dose. || Alternatively: 20 to 50/ give normal dose q48h. || <20 / 50% of usual dose q48h. || Hemodialysis: give 100-200mg after each dialysis. || CAPD: give 50% of usual dose at usual interval.
FLUCYTOSINE (ANCOBON Dosing: 12.5 to 37.5 mg/kg po q6h (50 to 150mg/kg/day). Doses up to 250 mg/kg/day have been used in severe infections. Capsules should be taken a few at a time over 15 min to minimize N&V. >50 / no change || 10 to 50/ q12-24 hrs || <10 / q24-48 hrs. || Hemodialysis: Single doses after dialysis || CAPD: 500mg to 1 gram q24h
ITRACONAZOLE (SPORANOX)


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Systemic mycosis: 200mg po qd with food (up to max of 400mg/day if unsatisfactory clinical response with lower dose). Doses >200mg are given in 2 divided doses. Onychomycosis: 200mg po bid for 1 week each month x 2 months (fingernails); x 3-4 months (toenails). Oropharyngeal candidiasis: 200mg (20ml)-oral solution-swish vigorously then swallow once daily x 1-2 weeks. Esophageal candidiasis: 100mg (10ml) oral soln-swish and swallow qd x 3 weeks. May increase to 200mg/day. Life-threatening infections: Loading dose: 200mg po tid should be given for the first 3 days of therapy, then 200-400mg/day. No adjustments necessary in renal insufficiency.Duration of therapy: Oral candidiasis, Tinea Corporis, and Tinea Cruris: 15 days. Tinea Pedis: 30 days. Tinea Capitis: 4-8 weeks.[100mg capsule; 10 mg/ml oral soln]
TERBINAFINE (LAMISIL)

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Superficial mycoses(tinea corporus, cruris, pedis, capitis; cutaneous candidiasis): 250 mg po qd. Onychomycosis: (fingernails) 250mg po qd x 6 weeks or pulse dosing: 500mg po qd for 1st week of month x 2 months. (Toenails): 250mg po qd x 12 weeks or pulse dosing: 500mg po qd for 1st week of month x 4 months. Systemic mycosis: 250-500mg po qd. Specific guidelines are not available for renal or hepatic insufficiency. [250mg tab]
ANTIVIRALS
ACYCLOVIR (ZOVIRAX)



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Mucocutaneous herpes simplex: IV: 5 mg/kg/dose q8h x 5-10 days. Encephalitis: 10mg/kg/dose IV q8h. Primary HSV infection-genital (Oral tx): 200mg q4h while awake (5x/day) or 400mg po tid x 10 days. Recurrent genital: 400mg po tid x 5 days. Herpes Zoster: 800mg po q4h while awake (5x/day) x 7 days. If severe give 10-12 mg/kg IV q8h x 7-14 days. Chronic suppression (genital herpes): 400mg po bid. Zovirax ointment: apply ½" q3h (6 x/day). 50 - 90/ 5 to 12.4 mg/kg q8h || 10-50 / 5-12.4 mg/kg q12-24h || <10 / 2.5 to 6 mg/kg q24h. Alternatively: (Oral): 10-25 / dose q8h || <10 / dose q12h. (IV): 25-50/ 5-10mg/kg q12h || 10-25/ 5-10mg/kg q24h || <10/ 2.5 to 5mg/kg IV q24h. || HD: dose after dialysis || CAPD: see < 10.
FAMCICLOVIR (FAMVIR)

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Herpes Zoster: 500mg po q8h x 7 days. Recurrent herpes simplex(genital): 125 mg po bid x 5 days. Primary Genital herpes simplex: 250 mg po tid x 5-10 days. Genital-chronic suppression: 250 mg po bid. [125mg, 250mg, 500mg tablet] >60/ no change || 40-59/ 500mg q12h || 11-39/ 500mg q24h || <10/ 250 mg q48h || HD: 250mg after dialysis.
VALACYCLOVIR (VALTREX) Herpes zoster: 1000mg po tid x 7 days. Primary genital herpes: 1000mg po bid x 10 days. Recurrent genital: 500mg po bid x 5 days. Genital-chronic suppression: 500mg po qd [500mg caplet] >50/ no change || 30-49/ 1 gram q12h || 10-29/ 1 gram q24h || <10/ 500mg q24h. || HD: dose after dialysis. || CAPD: 500mg q24h.
AMANTADINE (SYMMETREL Parkinsons dx: 100mg po bid. Influenza A viral infection: 200mg/day in 1-2 divided doses. 50-60/ 200mg alternating c 100mg po qd || 30-50/ 100mg qd || 20-30/ 200mg twice weekly || 10-20/ 100mg 3x/week || <10/ 200 mg alternating c 100mg q7 days. || HD/PD: No supplemental dose req'd.
RIMANTADINE (FLUMADINE)

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Prophylaxis and treatment of influenza A virus. Dosing: 100mg po bid. [100mg tab; 50mg/5ml syrup] > 10/ no change || <10/ 100mg po qd
H2 Antagonists    
Cimetidine (Tagamet) Active ulcer: Oral: 800 mg orally at bedtime or 300mg orally four times daily  or 400 mg orally twice daily. IM/IV: 300mg every 6 hours or 37.5 mg/hr continuous infusion. Active bleed: 37.5 mg/hr continuous IV (maximum 2400mg/day). Maintanance (duodenal ulcer prophylaxis): 400mg orally at bedtime. Gastric hypersecretory conditions: 300-600mg every 6 hours. CRCL  (> 40ml/min) / 300mg q6-8h ;    (20-40 ml/min) / 300 mg q8h ;   (5-20ml/min) /200-300mg q12h;   (< 5ml/min) / 200mg q12h.
Famotidine (Pepcid) Usual dose (Acute): 40mg orally at bedtime or 20mg orally twice daily. Maintenance: 20 mg orally at bedtime. Hypersecretory conditions: 20mg orally every 6 hours. May increase up to 160mg orally every 6 hours CRCL > 50 ml/min: No changes (40mg IV/PO qd or 20mg q12h.)  ||    CRCL < 50 ml/min: Oral: 20mg qd or 40mg qod.  IV: 20mg q24h. 
[Since CNS adverse effects have been reported in patients with moderate and severe renal insufficiency, to avoid excess accumulation of the drug in patients with moderate or severe renal insufficiency, the dose of PEPCID may be reduced to half the dose or the dosing interval may be prolonged to 36-48 hours as indicated by the patient's clinical response.]
Nizatidine (Axid) Usual: 300mg orally at bedtime or 150 mg orally twice daily.  Maintenance: 150mg orally at bedtime.  Supplied:  [150, 300mg capsule] CRCL > 50 ml/min: Usual dose   ||  CRCL 20-49 ml/min: 150mg qd.   ||  CRCL < 20 ml/min: 150mg qod.
Ranitidine (Zantac) Usual dose: 150mg orally twice daily or 300mg orally at bedtime.   Maintenance: 150mg orally at bedtime. Gastric hypersecretory conditions: 150mg orally 2 to 4 times daily.   IVPB: 50mg every 6 to 8 hours (Maximum: 400mg/day)  Continuous infusion: (preferred in actively bleeding patients): 6.25 mg/hr titrated to gastric pH >4 for prophylaxis or >7.0 for treatment. CRCL (ml/min) >50/ no change;   10-50:  Administer at 75% of normal dose or administer 50mg IV or 150mg orally every 18-24 hours.   CRCL <10 mL/minute: Administer at 50% of normal dose or administer 50mg IV every 18-24 hours or 150mg orally q24h.   || Hemodialysis: Slightly dialyzable (5% to 20%). Give dose at end of dialysis session.
References
1.  American Hospital Formulary Service. Drug Information. Bethesda, MD: ASHP, 1997.
2.  Bartlett JG.1998 Pocket Book of Infectious Disease Therapy., Ninth Edition. Baltimore,MD: Williams&Wikins,1998.
3.  Bennett, WM, Aronoff, GR et. al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults. Fourth Edition, 1999.
4.  Drug Information Handbook, 5th Ed. 1997, Lexi-Comp inc.
5.  Gilbert DN, Moellering RC, Sande MA. The Sanford Guide to Antimicrobial Therapy 2000. 30th ed. Hyde Park,VT: Antimicrobial Therapy, Inc.; 2000.

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