RECOMMENDATIONS FOR DOSE ADJUSTMENT IN PATIENTS WITH RENAL DYSFUNCTION
Maximum
Usual Adult Dose1
Adult Daily
(CrCL > 50 ml/min)
Dose
PENICILLINS
Amoxicillin (PO)
Amoxicillin/clavulanate (PO)
(Augmentin)
Ampicillin/sulbactam (IV)
(Unasyn)
Ampicillin (IV)
3
Oxacillin (IV)
3
Penicillin G (IV)
Piperacillin/tazobactam (IV)
(Zosyn)
CEPHALOSPORINS
Cefazolin (IV)
Cephalexin (PO)
Cefoxitin (IV)
Cefuroxime (IV)
Ceftriaxone (IV) 3
Cefpodoxime (PO)
Ceftazidime (IV)
Cefepime (IV)
MONOBACTAM
3
Aztreonam (IV)
CARBAPENEMS
Imipenem (IV)
Meropenem (IV)
QUINOLONES
Levofloxacin (PO/IV)
Amphotericin B (IV)
3
Caspofungin (IV)
Lipid amphotericin B
(Abelcet) (IV)
ANTIVIRALS
Acyclovir (IV)
Famciclovir (PO)
Valacyclovir (PO)
Ganciclovir (IV)
250 to 500 mg q12h
250 to 500 mg q24h
500 mg q24h
250 mg q12h
500 mg q24h
500 mg q12h
500 mg q24h
500 mg q24h
250 mg q12h
500 mg q24h
1.5 to 3 g q6h
12 g
(amp/sulb)
1.5 to 3 g q6h
1.5 to 3g q12h
1.5 to 3 g q24h
3 g q24h
ND
ND
1 to 2 g q4-6h
1 to 2 g q4-6h
12 g
12 g
1 to 2 g q6-8h
1 to 2 g q8-12h
1 to 2 g q4-6h
1 to 2 g q12h
1 to 2 g q12h
1 to 2 g q4-6h
250 mg q12h
1 to 2 g q4-6h
1 to 2 g q8-12h
1 to 2 g q4-6h
2 to 4 MU q4h
30 MU
1 MU q4h
1 MU q4h
1 MU q4h
1 to 2 MU q4h
4.5 g q8h OR
4.5 g q6h
27 g
(pip/tazo)
4.5 g q 12h OR
4.5 g q8h
2.25 g q8h OR
4.5 g q12h
2.25 g q8h OR
4.5 g q12h
4.5 g q8-12h
1 g q8h
500 mg q6h
2 g q6h
750 mg q8h
1 g q24h
200 mg q12h
1 to 2 g q8h
1 to 2 g q12h
8g
4g
12 g
6g
4g
800 mg
6g
6g
1 g q8h
500 mg q6h
1 to 2 g q8-12h
750 mg q8h
1 g q24h
500 mg q24h
1 g q24-48h
750 mg q24h
1 g q24h
200 mg q48h
500 mg to 1 g q48h
500 mg q24h
500 mg q12h
500 mg q12-24h
1 g q24h
750 mg q24h
1 g q24h
500 mg q24h
500 mg q48h
1 g q12h
ND
1 g q8-12h
750 mg q12h
1 g q24h
ND
1 to 2 g q24h
1 to 2 g q24h
1 g q8h
8g
1 g q8h
1 g q12h
1 g q24h
1g q24h
250 mg q8-12h
1 to 2 g q12h
500 mg q6h
1 g q8h
4g
6g
500 mg q8h
1 g q12h
500 mg q12h
500 mg q12h
250 mg q12h
500 mg q24h
500 mg q12h
500 mg q24h
250 mg q12h
500 mg q24h
500 mg q8-12h
1 g q12h
250 mg q24h
500 mg q24h
750 mg
250 mg q24h
250 mg q24h
250 mg q48h
250 mg q48h
250 mg q48h
250 mg q48h
250 mg q48h
250 mg q48h
250 mg q24h
250 mg q24h
500 mg q48h
500 mg q48h
500 mg q48h
500 mg q24h
500 mg q24h
500 mg q24h
500 mg to 1 g q6h
500 mg q24h
500 mg q24h
500 mg to 1 g q6h
500 mg q24h
500 mg q24h
500 mg to 1 g q6h
0.5 to 1 mg/kg q24h
0.5 to 1 mg/kg q24h
500 mg
1g
4g
0.5 to 1 mg/kg q24h
1.5 mg/kg
70 mg x 1, then 50 mg q24h
70 mg
5 mg/kg
q24h
1.6 g
150 mg/kg
5 mg/kg q12h
5 mg/kg q24h
10 mg/kg
900 mg q12h
Linezolid (IV, PO)
Metronidazole (IV, PO)
3
Polymyxin B (IV)
Quinupristin/dalfopristin (IV)
3
Trimethoprim/sulfa (IV, PO)
ANTIRETROVIRALS
Abacavir (PO)
Didanosine (PO) 3
(≥60kg)
(<60kg)
Lamivudine (PO) 3
Stavudine (PO) 3
(≥60kg)
(<60kg)
Tenofovir (PO)
Zalcitabine (PO)
3
Zidovudine(PO)
1
2
3
4
2.25 g q8h OR
4.5 g q12h
1 g q12h
1 g q24h
500 mg q8-12h
500 mg q12-24h
1 to 2 g q12-24h
1 to 2 g q24-48h
750 mg q12h
750 mg q24h
1 g q24h
200 mg q24h
1 to 2 g q24h
1 to 2 g q48h
500 mg to 1 g q24h
500 mg q24h
200 mg q12h
1 to 2 g q12h
1 to 2 g q24h
500 mg q24h
500 mg q12h
500 mg to 1 g q6h
1.8 g
900 mg q24h
500 mg q24h
0.5 to 1 mg/kg q24h
(consider 500 mL-1 L NS pre- or divided pre- and post- infusion to ↓ risk of nephrotoxicity)
70 mg x 1, then 50 mg q24h 70 mg x 1, then 50 mg q24h
70 mg x 1, then 50 mg q24h
5 mg/kg q24h
5 mg/kg q24h
5 mg/kg q24h
(consider 500 mL-1 L NS pre- or divided pre- and post- infusion to ↓ risk of nephrotoxicity)
200 to 400 mg q24h
100 to 200 mg q24h
200 to 400 mg q24h
100 to 200 mg q24h
12.5 to 37.5 mg/kg
q24h-48h
12.5 to 37.5 mg/kg q12-24h
12 mg/kg
Induction
Maintenance
15 to 25 mg/kg q24h
5 mg/kg q24h
15 to 30 mg/kg q24h
2 MU q4h
750 mg q48h
500 mg q24h
500 mg q12h
500 mg to 1 g q6h
Valganciclovir (PO) Induction
MISCELLANEOUS
3
Clindamycin (IV)
Doxycycline (IV, PO)
CONTINUOUS RENAL
REPLACEMENT THERAPY
4
(CRRT)
875 mg q12h
30 mg/kg
1.5 g
3g
Maintenance
PERITONEAL DIALYSIS
250 to 500 mg q8h
5 to 10 mg/kg q8h
500 mg q8-12h
1 g q8-12h
ANTITUBERCULOSIS
Ethambutol (PO)
3
Isoniazid (PO)
Pyrazinamide (PO)
3
Rifampin (IV, PO)
2
3g
12.5 to 37.5 mg/kg
q6h
6 mg/kg q12h, then
4 mg/kg q12h
3
Voriconazole (IV)
HEMODIALYSIS
1.75 g
(amoxicillin)
200 to 400 mg q24h
Flucytosine (PO)
CrCL
< 10 ml/min
875 mg q12h
5 mg/kg q24h
Fluconazole (PO/IV)
CrCL
10 to 30 ml/min
250 to 500 mg q8h
750 mg q24h
MACROLIDES
Azithromycin (IV)
Clarithromycin (PO)
Erythromycin (PO/IV)
ANTIFUNGALS
CrCL
30 to 50 ml/min
6 mg/kg q12h, then 4 mg/kg q12h
1.25 mg/kg 3x/week
0.625 mg/kg 3x/week
1.25 mg/kg 3x/week
0.625 mg/kg 3x/week
2.5 mg/kg q24h
1.25 mg/kg q24h
Not Recommended
Not Recommended
Not Recommended
4g
2.5 - 3 mg/kg q24h
(can divide dose q12h)
3 mg/kg
Not Recommended
Not Recommended
Not Recommended
Not Recommended
15 to 25 mg/kg q48h
5 mg/kg q24h
15 to 30 mg/kg q24h
300 to 600 mg q12-24h
15 to 25 mg/kg q48h
5 mg/kg q24h
15 to 30 mg/kg q24h
300 to 600 mg q12-24h
15 to 25 mg/kg q24-36h
5 mg/kg q24h
15 to 30 mg/kg q24h
300 to 600 mg q12-24h
600 to 900 mg q8h
100 mg q12h
600 to 900 mg q8h
100 mg q12h
600 to 900 mg q8h
100 mg q12h
7.5 mg/kg q8h
22.5 mg/kg
2.5 to 5 mg/kg q6-12h
(TMP)
20 mg/kg
(TMP)
300 mg q12h
600 mg
200 mg q12h
125 mg q12h
150 mg q12h
40 mg q12h
30 mg q12h
300 mg q24h
0.75 mg q8h
300 mg q12h
600 mg
300 mg
80 mg
300 mg
1.5 mg
600 mg
500 mg q8-12h
2.5 to 3 mg/kg load x1,
then 1 to 1.5 mg/kg q24h
500 mg q12h
2.5 to 3 mg/kg load x 1, then 1 to 1.5 mg/kg q2-3 days
7.5 mg/kg q8h
2.5 to 5 mg/kg q12-24h
5 to 10 mg/kg q24h
ND
500 mg q24h
15 to 25 mg/kg q48h
600 mg q12h
(preferred for VRE infections and for MRSA infections if intolerance/allergy to vancomycin)
1.2 g
2.5 to 5 mg/kg q24h
300 mg q12h
Monitor LFTs; significant drug interaction potential
600 mg q12h
600 mg q12h
Monitor CBC; consider PO therapy
(~100% bioavailability)
500 mg q8-12h
Monitor mental status changes
2.5 to 3 mg/kg load x 1, 2.5 to 3 mg/kg load x 1, then
then 1 mg/kg q3-5 days
1 mg/kg q3-5 days
2.5 to 3 mg/kg load x 1, then 1
mg/kg q3-5 days
7.5 mg/kg q8h
7.5 mg/kg q8h
7.5 mg/kg q8h
2.5 to 5 mg/kg q24h
2.5 to 5 mg/kg q24h
2.5 to 5 mg/kg q24h
300 mg q12h
300 mg q12h
300 mg q12h
150 mg q24h
100 mg q24h
100 mg q24h
100 mg q24h
100 mg q24h
75 mg q24h
25 to 50 mg q24h
50 to 75 mg q24h
25 to 50 mg q24h
75 mg q24h
25 to 50 mg q24h
75 mg q24h
50 to 150 mg q24h
20 mg q24h
20 mg q24h
ND
15 mg q24h
300 mg q7 days
0.75 mg q24h
100 mg q8h
15 mg q24h
ND
0.75 mg q24h
100 mg q8h
ND
ND
ND
100 mg q8h
15 mg q24h
300 mg q3-4 days
300 mg q7 days
0.75 mg q12h
0.75 mg q24h
300 mg q12h
100 mg q8h
Monitor uric acid, LFTs; vision test
Monitor LFTs
Monitor LFTs
500 mg q8-12h
100 mg q24h
100 mg q24h
15 mg q12h
300 mg q48h
Monitor SCr, WBC
Monitor SCr, WBC; Use IV ganciclovir for
patients with CrCL <10 ml/min and/or receiving
dialysis
600 mg q12h
100 mg q12h
20 mg q24h
Monitor SCr, WBC, mental status changes
Monitor SCr, CBC, mental status changes
500 mg q8-12h
75 mg q12h
150 mg q24h
20 mg q12h
Monitor LFTs; consider PO therapy (>90% bioavailability)
12.5 to 37.5 mg/kg
Monitor SCr, CBC
q12-24h
6 mg/kg q12h, then 4 mg/kg Significant drug interaction potential.
PO
dosing: ≥ 40 kg: 200 mg q12h; < 40 kg: 100 mg q12h
q12h
1.25 mg/kg 3x/week
0.625 mg/kg 3x/week
600 to 900 mg q8h
100 mg q12h
Monitor mental status changes; Mg+2, Ca+2, Al+3
containing antacids, iron, zinc, and sucralfate ↓ PO
quinolone absorption >90% (separate administration
times by ≥ 2 hrs)
Monitor SCr, K+, Mg++, PO4; Administer in D5W over 2
hrs
Not Recommended
4.8 g
300 mg
Monitor renal function (SCr)
Monitor renal function (SCr)
5 mg/kg q24h
200 to 400 mg q24h
450 mg q48h
600 to 900 mg q8h
100 mg q12h
Dose 2 g q8h for febrile neutropenia
Monitor SCr, K+, Mg++, PO4; Administer in D5W
over 4 to 6 hrs
1.25 mg/kg q24h
0.625 mg/kg q24h
300 to 600 mg q12-24h
600 mg q12h
2.5 mg/kg q24h
ND
500 mg q48h
Dose 2 g q12h for meningitis
Decrease daily dose to 35 mg q24h in moderate liver disease
2.5 mg/kg q24h
1.25 mg/kg q24h
450 mg q12h (CrCL 40-59)
450 mg q24h (CrCL 25-39)
450 mg q24h (CrCL 40-59)
450 mg q48h (CrCL 25-39)
2.5 g
300 mg
2g
600 mg
500 mg q8-12h
6 mg/kg q12h, then
4 mg/kg q12h
Initial dose adjustment when CrCL<40 ml/ min; next
adjustment when CrCL<20 ml/min
0.5 to 1 mg/kg q24h
5 to 10 mg/kg q24h
500 mg q24h
1 g q24h
450 mg twice weekly
2.5 to 5 mg/kg q24h
250 mg q48h
500 mg q24h
500 mg to 1 g q24h
Monitor LFTs, WBC
70 mg x 1, then 50 mg q24h
5 to 10 mg/kg q12h
500 mg q12-24h
1 g q12h
15 to 25 mg/kg q24-36h
5 mg/kg q24h
12 to 20mg/kg q24h
300 to 600 mg q12-24h
2.5 to 5 mg/kg q24h
250 mg q48h
500 mg q24h
12.5 to 37.5 mg/kg
q24h-48h
6 mg/kg q12h, then
4 mg/kg q12h
COMMENTS
Reduce dose when CrCL< 80 ml/min; 1 mg = 10,000
units; Dilute each 50 mg in at least 300 mL D5W;
monitor SCr, electrolytes, neuromuscular blockade
Monitor LFTs, arthralgias/myalgias
Monitor SCr, WBC, platelet count
Monitor for hypersensitivity reaction
Monitor amylase, lipase
Monitor amylase, lipase
Monitor SCr
Monitor CBC
The dosing recommendations presented here are for ~70 kg adults with moderate to severe infections based on published literature and clinical experience. These recommendations should only be used as guidelines and dosing based on pharmacokinetic and clinical evaluation is suggested where possible;
For antimicrobials dosed every 24 hours in patients on hemodialysis, doses should be administered after dialysis on dialysis days. Alternatively, all doses may be administered once daily in the evening to ensure administration after dialysis on dialysis days;
Dosing adjustment may be necessary in patients with severe liver dysfunction;
For patients receiving continuous veno-venous haemofiltration (CVVH) or continuous veno-venous haemodiafiltration (CVVHDF) at 1L/h; ND = no data available