5.0 - Antibiotic Doses in Adults With Impaired Renal Function

Antibiotic  Dose for Normal Renal Function Dosage Adjustment For Renal Failure According to Estimated Creatinine Clearance Doses For Dialysis
> 50 mL/min  10 - 50 mL/min  < 10 mL/min  HD CAPD   CRRT
Aminoglycosides

Amikacin IV

Traditional dosing 7.5 mg/kg q12H or once daily dosing 15 mg/kg q24H (max 1.5 gm/day)

Normal

7.5 mg/kg q24H

7.5 mg/kg q48 - 72H


Dialyzable,
7.5 mg/kg q48H (dose before dialysis). Extra 3.25 mg/kg AD on dialysis day


7.5 mg/kg q48 - 72H
+
15 - 20 mg lost per L dialysate per day

7.5 mg/kg q24 - 48H

    Once daily dosing regimen
    > 80 mL/min                15 mg/kg q24H
    60 - 80 mL/min            12 mg/kg q24H
    40 - 60 mL/min            7.5 mg/kg q24H
    30 - 40 mL/min            4 mg/kg q24H
    20 - 30 mL/min            7.5 mg/kg q48H
    10 - 20 mL/min            4 mg/kg q48H
    < 10 mL/min                3 mg/kg q72H and AD


Gentamicin IV

Traditional dosing 2 mg/kg loading dose, 1.7 mg/kg q8H
or 
Once daily dosing 4 - 7 mg/kg/dose once daily

 
Normal
 
1.7 mg/kg q12 - 48H

 
1.7 mg/kg q48 - 72H
 
Dialyzable, 
1.7 mg/kg q48H (dose before dialysis). Extra 0.85 mg/kg AD on dialysis day
 
1.7 mg/kg q48 - 72H
3 - 4 mg lost per L dialysate per day
 
1.7 mg/kg q24H
 
    Once daily dosing regimen
    > 80 mL/min                5.1 mg/kg q24H
    60 - 80 mL/min            4 mg/kg q24H
    40 - 60 mL/min            3.5 mg/kg q24H
    30 - 40 mL/min            2.5 mg/kg q24H
    20 - 30 mL/min            4 mg/kg q48H
    10 - 20 mL/min            3 mg/kg q48H
    < 10 mL/min                2 mg/kg q72H and AD


Streptomycin IV / IM


15 mg/kg (max 1 gm) q24H
 
Normal
 
15 mg/kg q24 - 72H
 
15 mg/kg q72 - 96H
 
7.5 mg/kg AD
 
15 mg/kg q72 - 96H
20 - 40 mg lost per L dialysate per day

 
15 mg/kg q24 - 72H
Carbapenem

Ertapenem IV


1 gm q24H
 
Normal
 
30 - 50 mL/min:
1 gm q24H
< 30 mL/min:
0.5 gm q24H

 
0.5 gm q24H
 
0.5 gm q24H (if dose < 6 hours prior to HD, add 150 mg AD)
 
0.5 gm q24H
 
0.5 - 1 gm q24H
 
Imipenem / Cilastatin IV

 
500 mg q6H
 
Normal
 
> 40 mL/min:
250 mg q6H or 500 mg q8H
21 - 40 mL/min:
250 mg q8H or 500 mg q8H
6 - 20 mL/min:
250 - 500 mg q12H

 
250 - 500 mg q12H
 
250 - 500 mg q12H (AD on dialysis days)

 
250 - 500 mg q12H
 
LD 1 gm followed by 500 mg q6 - 8H
¤
 
Meropenem IV
 
1 gm q8H
Meningitis:
2 gm q8H
 
Normal
 
26 - 50 mL/min:
1 - 2 gm q12H
10 - 25 mL/min:
0.5 - 1 gm q12H

 
0.5 - 1 gm q24H
¤
 
0.5 - 1 gm q24H, dose AD
 
0.5 - 1 gm q24H
 
1 - 2 gm q8 - 12H
Cephalosporin

Cefazolin IV
 
1 - 2 gm q8H
(max 12 gm/day)

 
Normal
 
1 - 2 gm q12H
 
1 - 2 gm q24 - 48H
 
2 gm AD only
 
0.5 gm q12H

Loading dose 2gm 
¤, 1 gm q8H or 2gm q12H

 
Cefalexine PO

 
250 - 1000 mg q6H (max 4 gm/day)

Normal 
 
250 - 1000 mg q12H 
 
125 - 500 mg q12H
 
250 mg q12 - 24H
give dose after dialysis

 
250 - 1000 mg q12H
 
Normal 
α
 
Cefuroxime
IV

 
750 - 1500 mg q6 - 8H
 
Normal
 
20 - 50 mL/min:
750 - 1500 mg q8H
10 - 20 mL/min:
750 - 1500 mg q12H 
¤

 
750 - 1500 mg q24H
 
750 - 1500 mg q24H, dose after dialysis

 
750 - 1500 mg q24H
 
750 - 1500 mg q8 - 12H
 
Cefuroxime PO
 
250 - 500 mg q12H
 
Normal
 
250 - 500 mg q12H
 
250 - 500 mg q24H
 
250 - 500 mg AD
 
250 - 500 mg q24H
 
No data


 
Ceftriaxone IV

 
1 - 2 gm q12 - 24H

 
Normal
 
Normal

Normal 

Normal 
 
Normal
 
Normal
 
Cefotaxime
IV

 
1 - 2 gm q4 - 12H usual dose at 2 gm q8H


Normal 
 
2 gm q12 - 24H
 
2 gm q24H
 
1 - 2 gm q24H dose AD on dialysis days 
¤
 
0.5 - 1 gm q24H
 
1 - 2 gm q6 - 8H

Ceftazidime
IV

 
1 - 2 gm q8H
 
Normal
 
1 - 2 gm q12 - 24H
 
1 - 2 gm q24 - 48H
 
1 - 2 gm q24 - 48H
Add 0.5 - 1 gm AD

 
500 mg q24H
 
1 - 2 gm q8H
 
Cefoperazone
IV

 
1 - 2 gm q12H
 
Normal
 
Normal
 
Normal

Normal 


Normal 


Normal 
 
Cefoperazone 500 mg / Sulbactam 500 mg IV

 
2 gm (combination) q6 - 8H
 
Normal
 
15 - 30 mL/min:
2 gm q12H
< 15 mL/min:
1 gm q12H
 
1 gm q12H
 
No information
 
No information
 
No information
 
Cefepime IV
 
2 gm q8H (max dose)
 
Normal
 
30 - 60 mL/min:
2 gm q12H
11 - 29 mL/min:
2 gm q24H

 
1 gm q24H
 
1 gm q24H
Add 1 gm AD
 
1 - 2 gm q48H
 
2 gm q24H
Fluoroquinolone
 
Ciprofloxacin IV

 
200 - 400 mg q12H
 
Normal
 
> 30 mL/min:
Normal
5 - 29 mL/min:
200 mg q12H or 400 mg q24H 
¤

 
200 - 400 mg q24H
 
200 - 400 mg q24H dose AD on dialysis days
 
200 - 400 mg q24H α
 
200 - 400 mg q12H
 
Ciprofloxacin
PO

 
500 - 750 mg q12H
 
Normal
 
250 - 500 mg q12H
 
250 mg q12H or 500 mg q24H
 
250 - 500 mg q24H, dose AD on dialysis days

 
250 - 500 mg q12H
 
250 - 500 mg q12H
 
Levofloxacin
PO

 
500 - 750 mg q24H
 
Normal
 
Load patient 500 - 750 mg, then:
20 - 49 mL/min:
250 mg q24H or 750 mg q48H
10 - 19 mL/min:
250 mg q48H or 500 mg q48H

 
Load patient 500 - 750 mg, 
followed by 250 - 500 mg q48H
 
Load patient 500 - 750 mg, followed by 250 - 500 mg q48H

Administer AD on dialysis day
 
Load patient 500 - 750 mg, followed by 250 - 500 mg q48H
 
250 - 750 mg q24H
 
Moxifloxacin PO

 
400 mg q24H
 
Normal

Normal 
 
Normal
 
Normal
No supplemental dose necessary AD

 
Normal
 
Normal
Macrolide
 
Azithromycin IV / PO
 
500 mg q24H


 
Normal
 
Normal
 
Normal
Use with caution
 
Normal
No supplemental dose necessary AD

 
Normal
 
Normal
 
Erythromycin PO

 
400 - 800 mg q6 - 12H
 
Normal
 
Normal
 
Normal
 
Normal
No supplemental dose necessary AD

 
Normal
 
Normal
 
Clarithromycin PO
 
250 - 500 mg q12H
 
Normal
 
250 - 500 mg q24H

 
250 - 500 mg q24H
 
250 - 500 mg q24H Dose AD on HD days
 
250 - 500 mg q24H
 
250 - 500 mg q12H
Penicillin
 
Amoxicillin PO

 
250 - 1000 mg q8H
Usual dose of 250 - 500 mg q8H

 
Normal
 
250 - 500 mg q8 - 12H
 
250 - 500 mg q24H
 
250 - 500 mg q24H
Dose AD on HD days
 
250 mg q12H
 
250 - 500 mg q8 - 12H
 
Co-amoxiclav
PO

 
625 mg q8H
 
Normal
 
250 - 500 mg (Amoxicillin component) q12H

 
250 - 500 mg (Amoxicillin component) q24H
 
250 - 500 mg (Amoxicillin component) q24H AD

 
No data

No data 
 
Co-amoxiclav IV

 
1.2 gm q8H
 
Normal

30 - 50 mL/min: Normal
10 - 30 mL/min:
1.2 gm q12H
¥
 
 
1.2 gm stat then 600 mg q24H 
£
OR 
1.2 gm stat 600 mg q8H OR
1.2 gm q12H 
¥

 
1.2 gm stat then 600 mg q24H
Add 600 mg AD 
£
 
1.2 gm stat then 600 mg q8H or 1.2 gm q12H ¥
 
1.2 gm q8 - 12H 
¥
 
Ampicillin IV

 
1 - 2 gm q4 - 6H
(max 12 gm/day)
Usual dose at 250 mg - 2 gm q6H

 
Normal
 
1 - 2 gm q6 - 12H
 
1 - 2 gm q12 - 24H
 
1 - 2 gm q12 - 24H AD
 
250 - 500 mg q12H
 
1 - 2 gm q6 - 8H
 
Ampicillin / Sulbactam IV


Usual dose:
1.5 gm q8H
Severe infection:
3 gm q4 - 6H

 
Normal
 
1.5 gm - 3 gm q8 - 12H
 
1.5 gm - 3 gm q12 - 24H
 
1.5 gm - 3 gm q12 - 24H
Dose AD
 
3 gm q24H
 
3 gm q4 - 8H
 
Benzylpenicillin IV

 
0.5 - 4 MU q4 - 6H
 
Normal
 
75% of dose q4 - 6H 
¤
 
25% of dose q4 - 6H ¤
 
25% of dose q4 - 6H 
dose AD ¤

 
25% of dose q4 - 6H ¤
 
75% of dose q4 - 6H
 
Cloxacillin IV / PO

 
1 - 2 gm q4 - 6H
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Piperacillin / Tazobactam IV


4.5 gm q6 - 8H 
 
Normal
 
20 - 50 mL/min:
2.25 gm q6H
or 4.5 gm q8H
10 - 20 mL/min:
2.25 gm q6 - 8H

 
2.25 gm q6 - 8H
 
2.25 gm q8H
Add 0.75 gm AD
 
4.5 gm q12H
 
2.25 gm - 4.5 gm q6 - 8H
Tetracycline

Doxycycline PO

 
100 mg q12H
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Minocycline
PO

 
LD 200 mg, 100 mg q12H
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
Miscellaneous
 
Clindamycin
IV / PO

 
600 mg q6 - 8H or 900 mg q8H
 
Normal
 
Normal
 
Normal
 
Normal

Normal 

Normal 
 
Colistin IV 
Ω Ψ

 
LD 9 MU, then start maintenance 4.5 MU q12H 24 hours after LD

 
Normal
 
20 - 50 mL/min:
4.5 MU q24H
< 20 mL/min:
4.5 MU q48H
 
2.5 MU q24H
 
2.5 MU q24H
Add 0.8 MU supplemental dose AD
 
No data
 
4.5 MU q12H
 
Linezolid
IV / PO

 
600 mg q12H
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Metronidazole
IV

 
500 mg q6 - 12H or 7.5 mg/kg q6H
 
Normal
 
Normal
 
500 mg q8 - 12H or 3.75 mg/kg q6H
 
500 mg q8 - 12H or 3.75 mg/kg q6H dose AD

 
500 mg q8 - 12H or 3.75 mg/kg q6H
 
500 mg q6 - 12H or 7.5 mg/kg q6H
 
Nitrofuraintoin
PO

 
50 - 100 mg q6H
 
Normal
 
Contraindicated
 
Contraindicated
 
Contraindicated
 
Contraindicated
 
Contraindicated
 
Trimethoprim / Sulfamethoxazole
IV / PO

 
Treatment:
TMP 8 - 20 mg/kg/day
Divided q6 - 12H

 
Normal

 
30 - 50 mL/min:
5 - 7.5 mg/kg q8H
10 - 29 mL/min:
5 - 10 mg/kg q12H
 
Use not recommended, but if required,
5 - 10 mg/kg q24H
 
Use not recommended, but if required,
5 - 10 mg/kg q24H
 
Use not recommended, but if required,
5 - 10 mg/kg q24H
 
2.5 - 7.5 mg/kg q12H
 
Prophylaxis:
1 - 2 tabs PO q24H

 
Normal

 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Vancomycin
IV

 
LD 25 - 30 mg/kg
then 15 - 20 mg/kg q8 - 12H

 
Normal
 
15 mg/kg q24 - 96H

 
7.5 mg/kg q2 - 3 days

7.5 mg/kg q2 - 3 days AD on dialysis days
 
 
7.5 mg/kg q2 - 3 days
 
7.5 - 10 mg/kg q12 - 24H
Refer to pharmacy if in doubt
Antifungal
 
Amphotericin B
IV

 
0.3 - 1 mg/kg q24H
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Fluconazole 
IV / PO

 
100 - 400 mg q24H
 
Normal
 
50 - 200 mg q24H
 
50 - 200 mg q24H
 
100 - 400 mg AD
Or 50 - 200 mg q24H

 
50 - 200 mg q24H
 
200 - 400 mg q24H
 
Itroconazole PO

 
100 - 200 mg q12H 
(max 600 mg/day)

 
Normal
 
Normal
 
No data
 
No data

 
100 mg q12 - 24H
 
100 - 200 mg q12H
 
Voriconazole IV

 
6 mg/kg q12H for 2 doses then 4 mg/kg q12H

 
Normal
 
Not recommended
 
Not recommended
 
No data
 
No data
 
No data
 
Voriconazole PO
 
> 40 kg: 400 mg q12H for 2 doses, then 200 mg q12H
< 40 kg: 200 mg q12H then 100 mg q12H

 
Normal

 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Caspofungin IV

 
70 mg on D1,
followed by 50 mg q24H

 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
Antiparasitic
 
Pentamidine IV

 
4 mg/kg q24H
 
Normal

Normal 
 
4 mg/kg q24 - 36H
 
4 mg/kg q48H AD
 
4 mg/kg q24 - 36H
 
4 mg/kg q24H
Antituberculous
 
Rifampicin PO

 
10 mg/kg q24H
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Isoniazide PO
 
5 mg/kg q24H

 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Ethambutol PO

 
15 - 25 mg/kg q24H

 
Normal
 
30 - 50 mL/min:
15 - 25 mg/kg q24 - 36H
10 - 30 mL/min:
15 - 25 mg/kg q24 - 48H

 
15 - 25 mg/kg q48H
 
15 - 25 mg/kg q48H AD
 
15 - 25 mg/kg q48H
 
15 - 25 mg/kg q24H
 
Pyrazinamide PO

 
20 - 25 mg/kg q24H
(max 2.5 gm/day)


Normal 
 
< 30 mL/min: 
25 - 35 mg/kg 3x/week 
¤
 
25 - 35 mg/kg 3x/week ¤
 
25 - 35 mg/kg 3x/week AD ¤
 
20 - 25 mg/kg q24H 
¤
 
20 - 25 mg/kg q24H ¤
Antiviral
 
Acyclovir IV

 
5 - 10 mg/kg q8H 
¤
 
 
Normal
 
25 - 50 mL/min:
5 - 10 mg/kg q12H
10 - 25 mL/min:
5 - 10 mg/kg q24H 
¤

 
2.5 - 5 mg/kg q24H 
¤
 
2.5 - 5 mg/kg q24H AD ¤
 
2.5 - 5 mg/kg q24H ¤
 
5 - 10 mg/kg q12 - 24H ¤
 
Acyclovir PO

 
200 - 800 mg 5 times 
¤

 
Normal
 
10 - 25 mL/min:
200 - 800 mg q8H 
¤

 
200 - 800 mg q12H ¤
 
No data
 
No data
 
No data
 
Ganciclovir IV

 
Induction dose:
5 mg/kg q12H

 
Induction dose:
70 - 90 mL/min:
5 mg/kg q12H
50 - 69 mL/min:
2.5 mg/kg q12H

 
Induction dose:
25 - 49 mL/min:
2.5 mg/kg q24H
10 - 25 mL/min:
1.25 mg/kg q24H
 
Induction dose:
1.25 mg/kg 3x/week
 
Induction dose:
1.25 mg/kg 3x/week
Dose AD on dialysis days
 
Induction dose:
1.25 mg/kg 3x/week
 
2.5 mg/kg q12H
 
Maintenance dose:
5 mg/kg q24H

 
Maintenance dose:
2.5 - 5 mg/kg q24H

 
Maintenance dose:
0.6 - 1.25 mg/kg q24H
 
Maintenance dose:
0.625 mg/kg 3x/week
 
0.6 mg/kg AD
 
0.625 mg/kg 3x/week
 
2.5 mg/kg q24H
 
Lamivudine PO

 
Hepatitis B:
100 mg q24H
HIV: 
150 mg q12H or
300 mg q24H

 
Normal
 
Hepatitis B:
15 - 50 mg q24H
HIV:
50 - 150 mg q24H
 
Hepatitis B:
10 - 15 mg q24H
HIV:
25 - 50 mg q24H
 
Hepatitis B:
10 - 15 mg q24H AD
HIV:
25 - 50 mg q24H AD

 
Hepatitis B:
10 - 15 mg q24H 
HIV:
25 - 50 mg q24H
 
100 mg first day, then 50 mg/day
 
Oseltamivir PO

 
75 mg q12H
 
Normal
 
30 - 50 mL/min:
75 mg q12H
10 - 30 mL/min:
75 mg q24H

 
No data
 
30 mg on non dialysis days
 
30 mg once a week
 
75 mg q12H
 
Telbivudine PO

 
600 mg q24H
 
Normal
 
30 - 49 mL/min:
600 mg q48H
10 - 30 mL/min:
600 mg q72H

 
600 mg q96H
 
600 mg q96H
 
No data
 
No data
 
Tenofovir PO

 
300 mg q24H
 
Normal
 
30 - 49 mL/min:
300 mg q48H
10 - 29 mL/min:
300 mg q72 - 96H

 
No data
 
300 mg after every 3rd dialysis or every 7 days if no dialysis
 
No data
 
No data
 
Tenofovir / Emtricitabine PO

 
300 / 200 mg (1 tab) q24H 
¤
 
Normal ¤
 
30 - 49 mL/min:
1 tab q48H
< 30 mL/min:
Not recommended 
¤

 
Not recommended ¤
 
Not recommended ¤
 
Not recommended ¤
 
Not recommended ¤
 
Valacyclovir PO

 
1 gm q8H
 
Normal
 
1 gm q12 - 24H
 
500 mg q24H
 
500 mg q24H AD
 
500 mg q24H
 
1 gm q12 - 24H
 
Zidovudine PO

 
300 mg q12H
 
Normal
 
300 mg q12H
 
100 mg q8H or
300 mg q24H

 
100 mg q8H AD
 
No data
 
300 mg q12H

Reference:
The Sanford Guide to Antimicrobial Therapy 2014
¤ Lexicomp Version 2.0.1 (165)
α Therapeutic Guideline, Antibiotic Version 14, 2010
¥ Renal Handbook
£ Product insert
Ω Garonzik et al. Population Pharmacokinetics of Colistin Methanesulfonate and Formed Colistin in Critically Ill Patients from a Multicenter Study Provide 
Dosing Suggestions for Various Categories of Patiens. Antimicrob Agents Chemother 2011 Jul;55(7):3284-94
Ψ Karvanen et al. Colistin Methanesulfonate and Colistin Pharmacokinetics in Critically Ill Patients Receiving COntinous Venovenous Hemodiafiltration.
Antimicrob Agents Chemother 2013; 57(1): 668-671