How to use the table for Renal Dosage Adjustment
Male CrCL (mL/min) = (140-age) x (weight in kg) x 1.2 / Scr (μmol/L)
Female CrCL = 0.85 x male CrCL
Use Ideal Body Weight (IBW) or Adjusted Body Weight (ABW) if patient is obese (i.e. TBW > 30% over IBW)
IBW (male) = 50kg + 2.3kg (each inch > 5 ft)
IBW (female) = 45.5 + 2.3kg (each inch > 5 ft)
Adjusted Body Weight (ABW) = IBW + 0.4 (TBW – IBW)
- Anti- infective agents are listed alphabetically by generic name, by class
- Recommendations for dose adjustment are made for different degrees of renal insufficiency:
- 30-49mL/min: mild renal insufficiency
- 10-29mL/min: moderate renal insufficiency
- < 10mL/min: severe renal disease
On Hemodialysis, Peritoneal Dialysis or Continuous Renal Replacement Therapy
NOTE: the dose information in this table is based on Cockcroft- Gault creatinine clearance and not eGFR. These recommendations should only be used as guidelines and dosing based on pharmacokinetics and clinical evaluation is recommended where possible
Guidelines for Antibiotic Dosing
Penicillins
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Amoxicillin: PO | 250-500mg q8h | Same dose q8h | Same dose q12h | Same dose q24h | 500mg q24h: on dialysis days, schedule routine dose after dialysis | 500mg q12h | Usual dose |
| Amoxicillin + Clavunate: PO | 500/125mg q8h | Usual dose | 250/125mg q12h | 250/125mg q24h | Dose as CrCl <10: on dialysis days, schedule routine dose after dialysis | 250/125mg q12h | Usual dose |
| Amoxicillin + Clavunate: PO | 875/125mg q12h | Usual dose | 500/125mg q12h | 500/125mg q24h | Dose as CrCl <10: on dialysis days, schedule routine dose after dialysis | 250/125mg q12h | Usual dose |
| Ampicilln: IV | 1-2g q4-6h | Same dose q6- 8h | Same dose q8- 12h | Same dose q12h | Same dose q12h: on dialysis days, schedule routine dose after dialysis | 500-1000mg q12h | Usual dose |
| Cloxacillin: IV | 1-2g q4-6h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
| Penicillin G: IV | 2-4MU q4-6h | Usual dose | 75% of usual dose | 25-50% of usual dose on dialysis days, schedule routine dose after dialysis | 25-50% of usual dose on dialysis days, schedule routine dose after dialysis | 25-50% of usual dose on dialysis days, schedule routine dose after dialysis | Usual dose |
| Piperacillin + Tazobactam: IV | Traditional: 4.5g q8h | > 20: 4.5 g q8h < 20: 3.375 g q8h | > 20: 4.5 g q8h < 20: 3.375 g q8h | > 20: 4.5 g q8h < 20: 3.375 g q8h | 2.25 g q8h | 2.25 g q8h | 4.5 g q8h |
| Piperacillin + Tazobactam: IV | Documented pseudomonas infection: 4.5g q6h | > 20: 4.5 g q6h < 20: 4.5g q8h | > 20: 4.5 g q6h < 20: 4.5g q8h | > 20: 4.5 g q6h < 20: 4.5g q8h | 2.25 g q6h | 2.25 g q6h | 4.5 g q6h |
Carbapenems
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Ertapenem: IV (restricted to ID) | 1g q24h | Usual dose | 500mg q24h: on dialysis days, schedule routine dose after dialysis | 500mg q24h: on dialysis days, schedule routine dose after dialysis | 500mg q24h: on dialysis days, schedule routine dose after dialysis | 500mg q24h: on dialysis days, schedule routine dose after dialysis | 500mg q24h: on dialysis days, schedule routine dose after dialysis |
| Meropenem: IV (restricted to ID) | Standard: 500mg q6h | 500mg q6-8h | 500mg q8-12h | 500mg q12-24h: on dialysis days, schedule routine dose after dialysis | 500mg q12-24h: on dialysis days, schedule routine dose after dialysis | 500mg q12-24h: on dialysis days, schedule routine dose after dialysis | 500mg 6-8h |
| Meropenem: IV (restricted to ID) | CNS & CF infection: 2g q8h | Usual dose | 2g q12h | 2g q24h: on dialysis days, schedule routine dose after dialysis | 2g q24h: on dialysis days, schedule routine dose after dialysis | 2g q24h: on dialysis days, schedule routine dose after dialysis | 2g IV q8-12h |
| Meropenem: IV (restricted to ID) | Febrile neutropenia: 1g IV q8h | Usual dose | 1g q12h | 1g q24h: on dialysis days, schedule routine dose after dialysis | 1g q24h: on dialysis days, schedule routine dose after dialysis | 1g q24h: on dialysis days, schedule routine dose after dialysis | 1g IV q8-12h |
1st Gen Cephalosporins
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Cephalexin: PO | 500mg q6h | Usual dose | Usual dose | Usual dose 8- 12h | 500mg q8-12h; on dialysis days, schedule routine dose after dialysis | 500mg q12- 24h | Usual dose |
| Cefazolin: IV | 1-2g q8h | Usual dose | 1-2 g q12h | 1-2g q24h | 1-2g post HD on dialysis days OR q24h | 1g q12h | Usual dose |
2nd Gen Cephalosporins
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Cefuroxime: IV | 750-1500mg q8h | Usual dose | 750-1500 mg q12h | 750-1500 mg q24h | 750-1500mg q24h: on dialysis days, schedule routine dose after dialysis | 750-1500 mg q24h | Usual dose |
| Cefuroxime: PO | 500mg q12h | No adjustment necessary: on dialysis days, schedule routine dose after dialysis | No adjustment necessary: on dialysis days, schedule routine dose after dialysis | No adjustment necessary: on dialysis days, schedule routine dose after dialysis | No adjustment necessary: on dialysis days, schedule routine dose after dialysis | No adjustment necessary: on dialysis days, schedule routine dose after dialysis | No adjustment necessary: on dialysis days, schedule routine dose after dialysis |
| Cefprozil: PO | 250-500mg q12h | 50% of usual dose: on dialysis days, schedule routine dose after dialysis | 50% of usual dose: on dialysis days, schedule routine dose after dialysis | 50% of usual dose: on dialysis days, schedule routine dose after dialysis | 50% of usual dose: on dialysis days, schedule routine dose after dialysis | 50% of usual dose: on dialysis days, schedule routine dose after dialysis | 50% of usual dose: on dialysis days, schedule routine dose after dialysis |
3rd Gen Cephalosporins
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Ceftazidime: IV | 1-2g q8h | 1-2g q8-12h | 1-2g q12-24h | 1-2g q24h | Usual dose q24h: on dialysis days, schedule routine dose after dialysis | 1g q24h | Usual dose |
| Ceftriaxone: IV | 1-2g q12-24h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
Quinolones
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Ciprofloxacin: PO/IV | 500-750mg PO q12h | Usual dose | Usual dose once daily (documented pseudomonas: q12h) | Usual dose once daily (documented pseudomonas: q12h) | Usual dose once daily (documented pseudomonas: q12h) | Usual dose once daily (documented pseudomonas: q12h) | Usual dose |
| Ciprofloxacin: PO/IV | 400mg q12h IV (q8h: documented pseudomonas) | Usual dose | Usual dose once daily (documented pseudomonas: q12h) | Usual dose once daily (documented pseudomonas: q12h) | Usual dose once daily (documented pseudomonas: q12h) | Usual dose once daily (documented pseudomonas: q12h) | Usual dose |
| Levofloxacin PO/IV (HHS) (restricted at SJH) | 500mg q24h | Usual dose | 500mg q48h | 500mg q48h | 500mg q48h | 500mg q48h | Usual dose |
| Levofloxacin PO/IV (HHS) (restricted at SJH) | 750mg q24h | 750mg x 1 then 500 mg q24h | 750mg q48h | 750mg q48h | 750mg q48h | 750mg q48h | Usual dose |
| Moxifloxacin: PO/IV (SJH only) | 400mg q24h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
Macrolides
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Azithromycin: PO/IV | 250-500mg q24h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
Tetracyclines
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Doxycycline: PO | 100mg q12h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
| Tetracycline: PO | 250-500mg q6h | Same dose q6- 8h | Same dose q12-24h | Same dose q24h | Not applicable | Not applicable | Not applicable |
Miscellaneous
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Clindamycin: PO/IV | 300-450mg PO q6- 8h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
| Clindamycin: PO/IV | 600-900mg IV q8h (900mg is usually used for necrotizing fasciitis) | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
| Daptomycin: IV (restricted to ID) | Skin/soft tissue: 4mg/kg q24h | Usual dose | Same dose q48h | Same dose q48h | Same dose q48h: post HD on dialysis days *alternate dosing strategy may be used | Same dose q48h | Usual dose |
| Daptomycin: IV (restricted to ID) | 6mg/kg q24h *higher doses may be used | Usual dose | Same dose q48h | Same dose q48h | Same dose q48h: post HD on dialysis days *alternate dosing strategy may be used | Same dose q48h | Usual dose |
| Linezolid: PO/IV (restricted to ID) | 600mg q12h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
| Metronidazole: PO/IV | 500mg q8-12h | Usual dose | Usual dose | Usual dose | Usual dose | Usual dose | Usual dose |
| Nitrofurantoin: PO | 50-100mg q12h | AVOID: not recommended for CrCl < 40ml/min and in dialysis | AVOID: not recommended for CrCl < 40ml/min and in dialysis | AVOID: not recommended for CrCl < 40ml/min and in dialysis | AVOID: not recommended for CrCl < 40ml/min and in dialysis | AVOID: not recommended for CrCl < 40ml/min and in dialysis | AVOID: not recommended for CrCl < 40ml/min and in dialysis |
| Trimethoprim + Sulfamethoxazole: PO/IV | *please see section on weight-based dosing | *please see section on weight-based dosing | *please see section on weight-based dosing | *please see section on weight-based dosing | *please see section on weight-based dosing | *please see section on weight-based dosing | *please see section on weight-based dosing |
Antifungal Agents
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Liposomal Amphotericin B | 3-5mg/kg q24h | No adjustment necessary but highly nephrotoxic: May consider 500mL-1L NS pre- or divided pre-/post-infusion to decrease nephrotoxicity risk | No adjustment necessary but highly nephrotoxic: May consider 500mL-1L NS pre- or divided pre-/post-infusion to decrease nephrotoxicity risk | No adjustment necessary but highly nephrotoxic: May consider 500mL-1L NS pre- or divided pre-/post-infusion to decrease nephrotoxicity risk | No adjustment necessary but highly nephrotoxic: May consider 500mL-1L NS pre- or divided pre-/post-infusion to decrease nephrotoxicity risk | No adjustment necessary but highly nephrotoxic: May consider 500mL-1L NS pre- or divided pre-/post-infusion to decrease nephrotoxicity risk | No adjustment necessary but highly nephrotoxic: May consider 500mL-1L NS pre- or divided pre-/post-infusion to decrease nephrotoxicity risk |
| (Ambisome): IV Restricted to ID | |||||||
| Caspofungin: IV (HHS: febrile neutropenia) | 70mg LD then 50mg q24h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
| Anidulafungin: IV (HHS only for nonneutropenia; restricted to ID) (non-formulary at SJH) | 200mg LD then 100mg q24h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
| Fluconazole: PO/IV | Invasive candidiasis: 12mg/kg LD then 6mg/kg MD PO/IV q24h | Usual dose | Usual LD then 50% MD q24h | Usual LD then 50% MD q24h | Usual dose post HD on dialysis days OR q24h | Usual LD then 50% of usual dose q24h | Usual dose |
| Fluconazole: PO/IV | Esophageal candidiasis: 200mg PO/IV q24h | Usual dose | 50% of usual dose q24h | 50% of usual dose q24h | Usual dose post HD on dialysis days or q24h | 50% usual dose q24h | Usual dose |
| Fluconazole: PO/IV | Oropharyngeal candidiasis: 100mg q24h | Usual dose | 50% of usual dose q24h | 50% of usual dose q24h | Usual dose post HD on dialysis days or q24h | 50% usual dose q24h | Usual dose |
| Itraconazole: PO | 100-200mg q24h | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary | No adjustment necessary |
| Voriconazole: PO/IV (restricted to ID) | 6mg/kg q12h x 2 then 4mg/kg q12h | PO: No adjustment necessary * Oral therapy is preferred over IV due to accumulation of intravenous cyclodextrin vehicle | PO: No adjustment necessary * Oral therapy is preferred over IV due to accumulation of intravenous cyclodextrin vehicle | PO: No adjustment necessar * Oral therapy is preferred over IV due to accumulation of intravenous cyclodextrin vehicle | PO: No adjustment necessary * Oral therapy is preferred over IV due to accumulation of intravenous cyclodextrin vehicle | PO: No adjustment necessary * Oral therapy is preferred over IV due to accumulation of intravenous cyclodextrin vehicle | PO: No adjustment necessary * Oral therapy is preferred over IV due to accumulation of intravenous cyclodextrin vehicle |
Antiviral Agents
| Drug: Form | Usual Dose | Mild 30-49 mL/min | Moderate 10-29 mL/min | Severe < 10 mL/min | Hemodialysis | Peritoneal Dialysis | CRRT |
|---|---|---|---|---|---|---|---|
| Acyclovir: IV | 5-10mg/kg q8h (based on IBW) | same dose q12h | same dose q24h | 50% of usual dose q24h | 50% of usual dose q24h (give dose post HD on dialysis days). | 50% of usual dose q24h (give dose post HD on dialysis days). | dose as usual |
| Acyclovir: PO | 200-400 mg 5x/day | Usual dose | Usual dose | same dose q12h | 50% of usual dose q24h (give dose post HD on dialysis days). | 50% of usual dose q24h (give dose post HD on dialysis days). | dose as usual |
| Acyclovir: PO | 800mg 5x/day | usual dose | same dose q8h | same dose q12h | 50% of usual dose q24h (give dose post HD on dialysis days). | 50% of usual dose q24h (give dose post HD on dialysis days). | dose as usual |
| Ganciclovir: IV | Induction: 5mg/kg q12h | 50-69: 2.5 mg/kg q12h 25-49: 2.5 mg/kg q24h 10-24: 1.25 mg/kg q24h < 10: 1.25 mg/kg 3x/week | 50-69: 2.5 mg/kg q12h 25-49: 2.5 mg/kg q24h 10-24: 1.25 mg/kg q24h < 10: 1.25 mg/kg 3x/week | 50-69: 2.5 mg/kg q12h 25-49: 2.5 mg/kg q24h 10-24: 1.25 mg/kg q24h < 10: 1.25 mg/kg 3x/week | Dose as CrCL < 10: post HD on dialysis days | Dose as CrCL < 10: post HD on dialysis days | 2.5 mg/kg q12h |
| Ganciclovir: IV | Maintenance: 5mg/kg q24h | 50-69: 2.5 mg/kg q24h 25-49: 1.25 mg/kg q24h 10-24: 0.625 mg/kg 3x weekly < 10: 0.625 mg/kg 3x/week | 50-69: 2.5 mg/kg q24h 25-49: 1.25 mg/kg q24h 10-24: 0.625 mg/kg 3x weekly < 10: 0.625 mg/kg 3x/week | 50-69: 2.5 mg/kg q24h 25-49: 1.25 mg/kg q24h 10-24: 0.625 mg/kg 3x weekly < 10: 0.625 mg/kg 3x/week | Dose as CrCL < 10: post HD on dialysis days | Dose as CrCL < 10: post HD on dialysis days | 2.5 mg/kg q24h |
| Oseltamivir: PO | Treatment: 75mg q12h | Usual dose | 75mg q24h | 75mg q48h (or 3x/week after each HD) | 75mg q48h (or 3x/week after each HD) | 75mg q48h (or 3x/week after each HD) | Usual dose |
| Oseltamivir: PO | Prevention: 75mg q24h | Usual dose | 75mg q48h | 75mg q48h (or 3x/week after each HD) | 75mg q48h (or 3x/week after each HD) | 75mg q48h (or 3x/week after each HD) | Usual dose |