簡孝文醫師 撰文
2023年09月19日
辛醫師完成3年的住院醫師訓練，也順利取得內科專科醫師的執照，然後選擇在腎臟內科接受為期2年的進修，以期未來考取腎臟科的執照。
腎臟內科的訓練範圍很廣，包括回覆別科醫師對腎臟科的會診。
簡醫師：
最近看會診，有遇到什麼問題嗎？
辛醫師：
會遇到很多腎功能不好的患者住在他科病房，要使用抗生素，但不知道要如何調整劑量？
簡醫師：
對於某些抗生素的劑量，我曾整理過，現在將這份資料寄給你，可能還是有所不足或有謬誤，如果你發現了，請回饋讓我知道。
辛醫師：
謝謝老師。
簡醫師：
當中有一些縮寫。
GFR腎絲球過濾率
HD血液透析
PD腹膜透析
* Amikacin藥物劑量的調整:
= 正常腎臟功能: 5mg/kg q8h
= GFR > 50 ml/min: 70-80% q8-12h
= 50 > GFR > 10 ml/min: 30-70% q12h
= GFR < 10 ml/min: 20-30% QD-Q2D
= supply 2/3 dose after HD
= 30% dose QD for CAPD
* Gentamicin藥物劑量的調整:
= 正常腎臟功能: 1mg/kg q8h
= GFR > 50 ml/min: 70-80% q8-12h
= 50 > GFR > 10 ml/min: 30-70% q12h
= GFR < 10 ml/min: 20-30% QD-Q2D
= supply 2/3 dose after HD
= 30% dose QD for CAPD
* Doripenem (Fininbax)藥物劑量的調整:
= 正常腎臟功能: 0.5g q8h
= 50 > GFR > 30 ml/min: 0.25g q8h
= GFR < 30 ml/min: 0.25g q12h
* Cefazolin藥物劑量的調整:
= 正常腎臟功能: 0.5-1.5g q6h
= GFR > 50 ml/min: q6-8h
= 50 > GFR > 10 ml/min: q12h
= GFR < 10 ml/min: QD-Q2D
= dosing after HD
* Cefmetazole (Cefmetazon)藥物劑量的調整:
= 正常腎臟功能: 2g q8h
= GFR > 50 ml/min: q8-12h
= 50 > GFR > 10 ml/min: q12-24h
= GFR < 10 ml/min: QD
= dosing after HD
* Ceftazidime (Fortum)藥物劑量的調整:
= 正常腎臟功能: 1g q8-12h
= GFR > 50 ml/min: q8-12h
= 50 > GFR > 10 ml/min: qd-qod
= GFR < 10 ml/min: q2-3d
= 1g dosing after HD
= for CAPD, dosing as GFR 10-50 ml/min
* Ceftriaxone (Rocephin)藥物劑量的調整:
= 正常腎臟功能: 1g q12h
= GFR > 50 ml/min: the same
= 50 > GFR > 10 ml/min: the same
= GFR < 10 ml/min: the same
= for HD and PD: the same
* Clindamycin (Cleocin)口服藥物劑量的調整:
= 正常腎臟功能: 150-450mg q6h
= GFR > 50 ml/min: the same
= 50 > GFR > 10 ml/min: the same
= GFR < 10 ml/min: the same
= for HD and PD: the same
* Clindamycin (Cleocin)針劑藥物劑量的調整:
= 正常腎臟功能: 300-900mg q6-8h
= GFR > 50 ml/min: the same
= 50 > GFR > 10 ml/min: the same
= GFR < 10 ml/min: the same
= for HD and PD: the same
* Oxacillin藥物劑量的調整:
= 正常腎臟功能: 0.5-2.0g q4-6h
= GFR > 50 ml/min: 0.5-2.0g q4-6h
= 50 > GFR > 10 ml/min: 0.5-2.0g q4-6h
= GFR < 10 ml/min: reduce dose
= HD: 0.5-2.0g q4-6h
* Amoxicillin (Augmentin)藥物劑量的調整:
= 正常腎臟功能: 0.5g q8h
= GFR > 50 ml/min: 0.5g q8h
= 50 > GFR > 10 ml/min: 0.5g q8-12h
= GFR < 10 ml/min: 0.5g q12h
= dosing after HD
= for CAPD, dosing as GFR 10-50 ml/min
* Ampicillin (Unasyn)藥物劑量的調整:
= 正常腎臟功能: 1.5-3g q6h
= 50 > GFR > 30 ml/min: q6-8h
= 30 > GFR > 15 ml/min: q12h
= GFR < 15 ml/min: qd
= dosing after HD
= for CAPD, 0.25g q12h
* Penicillin G藥物劑量的調整:
= 正常腎臟功能: 0.5-4 MU q6h
= GFR > 50 ml/min: the same
= 50 > GFR > 10 ml/min: 75% q6h
= GFR < 10 ml/min: 25-50% q6h
= dosing after HD
= for CAPD, dosing as GFR < 10 ml/min
* Piperacillin (Tazocin)藥物劑量的調整:
= 正常腎臟功能: 3-4g q4h
= GFR > 50 ml/min: 3-4g q4-6h
= 50 > GFR > 10 ml/min: 3-4g q6-8h
= GFR < 10 ml/min: 3-4g q8h
= dosing after HD
= for CAPD, dosing as GFR < 10 ml/min
* Ciprofloxacin藥物劑量的調整:
= 正常腎臟功能: 0.5-0.75g q12h
= GFR > 50 ml/min: the same
= 50 > GFR > 10 ml/min: 50% q12h
= GFR < 10 ml/min: 33% q12h
= supply 0.25 g after HD
= for CAPD, dosing as GFR 10-50 ml/min
* Levofloxacin藥物劑量的調整:
= GFR > 50 ml/min: 0.5g + 0.5g QD
= 50 > GFR > 20 ml/min: 0.5g + 0.25g QD
= 20 > GFR > 10 ml/min: 0.5g + 0.25g QOD
= GFR < 10 ml/min(包括 HD, CAPD): 0.5g + 0.125-0.25g QOD
* Imipenem (Tienam)藥物劑量的調整:
= 正常腎臟功能: 0.25-1g q6h
= GFR > 50 ml/min: the same
= 50 > GFR > 10 ml/min: 50% q6h
= GFR < 10 ml/min: 25% q6h
= dosing after HD
= for CAPD, dosing as GFR < 10 ml/min
* Teicoplanin (Targocid)藥物劑量的調整:
= 正常腎臟功能: 6mg/kg/d
= GFR > 50 ml/min: q24h
= 50 > GFR > 10 ml/min: q48h
= GFR < 10 ml/min: q72h
= for HD: dosing as GFR < 10 ml/min
= for CAPD, dosing as GFR < 10 ml/min
* Ertapenem (Invanz)藥物劑量的調整:
= 正常腎臟功能: 1g qd
= GFR > 50 ml/min: 1g qd
= 50 > GFR > 10 ml/min: 0.5g qd
= GFR < 10 ml/min: 0.5g qd
= for HD and CAPD: dosing as GFR < 10 ml/min
* Vancomycin藥物劑量的調整:
= 正常腎臟功能: 1g q12h
= GFR > 50 ml/min: 1g q12-24h
= 50 > GFR > 10 ml/min: 1g q2-7d
= GFR < 10 ml/min: 1g q7-10d
= for HD, dosing as GFR < 10 ml/mi
= for CAPD, dosing as GFR 10-50 ml/min
* Amphotericin (Fungizone)藥物劑量的調整:
= 正常腎臟功能: 0.3-0.5g mg/kg/d
= GFR > 50 ml/min: the same
= 50 > GFR > 10 ml/min: the same
= GFR < 10 ml/min: the same
= for HD, dosing as GFR < 10 ml/mi
= for CAPD, dosing as GFR 10-50 ml/min
* Fluconazole藥物劑量的調整:
= 正常腎臟功能: 50-200 mg/d
= GFR > 50 ml/min: 100%
= 50 > GFR > 10 ml/min: 50%
= GFR < 10 ml/min: 25%
= for HD, dosing after HD
= for CAPD, dosing as GFR < 10 ml/min
* Acyclovir (Zovirax)藥物劑量的調整:
= 正常腎臟功能: 5 mg/kg q8h
= GFR > 50 ml/min: 5 mg/kg q8-12h
= 50 > GFR > 10 ml/min: 5 mg/kg q12-24h
= GFR < 10 ml/min: 2.5 mg/kg q24h
= for HD, dosing after HD
= for CAPD, dosing as GFR < 10 ml/min
* Zidovudine (AZT)藥物劑量的調整:
= 正常腎臟功能: 200 mg q4h
= GFR > 50 ml/min: the same
= 50 > GFR > 10 ml/min: the same
= GFR < 10 ml/min: 50% q4h
= for HD, dosing after HD
= for CAPD, dosing as GFR < 10 ml/min
* Flomoxef (Flumarin)藥物劑量的調整:
= 正常腎臟功能: daily dose 1-2 g
= 80 > GFR > 60 ml/min: 75% q8-12h
= 60 > GFR > 40 ml/min: 50% q8-12h
= 40 > GFR > 20 ml/min: 40% q8-12h
= 20 > GFR ml/min: 20% QD
辛醫師：
謝謝老師不藏私的分享。
簡醫師：
如果你的能力強，可以幫我很多忙，我會比較輕鬆，而且等我年長之後，你可能是照顧我的主治醫師。
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