4.0 - 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

15 mg/kg q24H (max 1.5 gm/day)

Normal

7.5 mg/kg q24H

7.5 mg/kg q48 - 72H


7.5 mg/kg q48 - 72H (dose after dialysis)
OR add supplemental dose 3.25 mg/kg after dialysis on dialysis day (50% dose dialyzable)


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

7.5 mg/kg q24H

    Multiple Daily Dosing
    > 50 mL/min                    7.5 mg/kg q12H
    10 - 50 mL/min                 7.5 mg/kg q24H
    < 10 mL/min                    7.5 mg/kg q48H


Gentamicin IV

3 - 5 mg/kg q24H (in septic shock, up to 7 mg/kg q24H)
¤

 
Normal
¤
 
40 - 59 mL/min: 
3 - 5 mg/kg q36H

20 - 39 mL/min: 
3 - 5 mg/kg q48H

<20 mL/min: 
3 - 5 mg/kg single dose and monitor serum levels
¤

 
3 - 5 mg/kg single dose and monitor serum levels
¤

 
2 - 3 mg/kg loading dose, then 1 - 2 mg/kg q48 - 72H (dose after dialysis)
 
OR

Add supplemental dose 0.5 - 1 mg/kg after dialysis on dialysis day (50% dose dialyzable)
¤
 

No data

 

3 - 5 mg/kg single dose and monitor serum levels
¤

 
2 - 3 mg/kg loading dose, then 1 - 2.5 mg/kg q24 - 48H
¤
 
    Multiple Daily Dosing
    > 50 mL/min                    1 - 1.7 mg/kg q8H
    10 - 50 mL/min            1 - 1.7 mg/kg q12 - 48H
    < 10 mL/min                1 - 1.7 mg/kg q48 - 72H

    ¤


Streptomycin IV / IM


15 mg/kg (max 1 gm) q24H
¤
 
Normal
¤
 
15 mg/kg q24 - 72H
¤
 
15 mg/kg q72 - 96H
¤
 
7.5-15 mg/kg  (max 1 gm) q48 -72H, dose after dialysis only on dialysis days
¤
 
15 mg/kg  (max 1 gm) q72 - 96H

+

20 - 40 mg lost per litre dialysate per
day¤

 
15 mg/kg q24 - 72H
¤
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
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 supplemental dose 150 mg after dialysis)

 
0.5 gm q24H
 
0.5 - 1 gm q24H
 
Meropenem IV
 
1 gm q8H

Meningitis/CRE combination with other antibiotic: 
2 gm q8H
 
Normal
 
26 - 50 mL/min:
Usual:
1 gm q12H

Meningitis/CRE combination with other antibiotic
2 gm q12H


10 - 25 mL/min:
Usual:
500 mg q12H

Meningitis/CRE combination with other antibiotic: 
1 gm q12H


 
Usual:
500 mg q24H

Meningitis/CRE combination with other antibiotic: 
1 gm q24H
 
Usual:
500 mg q24H, dose after dialysis on dialysis days

Meningitis/CRE combination with other antibiotic
1 gm q24H, dose after dialysis on dialysis days
 
Usual:
500 mg q24H

Meningitis/CRE combination with other antibiotic:
1 gm q24H
 
Usual:
1 gm q8 - 12H

Meningitis/CRE combination with other antibiotic:
500mg-1000mg q8-12H
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
Cephalosporin

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

 
Normal
 

>35ml/min:

1 - 2 gm q8H 

11-34ml/min:

0.5 – 1 gm q12H

 

0.5 – 1 gm q24H
 

2 gm after dialysis if next dialysis expected in 48 hours, and 3 gm after dialysis is expected in 72 hours

OR

1 gm q24H

OR

2 gm q48 - 72H, dose after dialysis only on dialysis days

 

 
0.5 gm q12H

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

 
Cefalexine PO

 
250 - 1000 mg q6H (max 4 gm/day)

Normal 
 
250 - 1000 mg q12H 
 
250 - 500 mg q12H
 
250-500 mg q12H,
give one of the dialysis day doses after dialysis 

 
500mg-1000mg q12H
 
No data
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 on dialysis days

 
750 - 1500 mg q24H
 
750 - 1500 mg q8 - 12H
 
Cefuroxime PO
 
250 - 500 mg q12H
 
Normal
 
10 - 29 mL/min: 250 - 500 mg q24H

OR

Normal

¥


 
250 - 500 mg q48H

OR

Normal

¥

 
250 - 500 mg q48H, add supplemental dose 250 - 500 mg after dialysis on dialysis days

OR

Normal

¥

 
No data¤

OR

Normal

¥

 
No data


 
Ceftriaxone IV

 
1 - 2 gm q12 - 24H

 
Normal
 
Normal

Normal 

Normal 
No supplemental dose necessary after dialysis

 
Normal
 
Normal

Ceftazidime
IV

 
1 - 2 gm q8H
 
Normal
 
31 - 50 mL/min:
1 - 2 gm q12H

16 - 30 mL/min:
1 - 2 gm q24H
¤

 
0.5 - 1 gm q24H
¤
 
0.5-1 gm q24H
or 
2 gm q48 - 72H, dose after dialysis only on dialysis days
¤

 
1gm q24H
¤
 
1 - 2 gm q8H
¤
 
Cefoperazone
IV

 
1 - 2 gm q12H
 
Normal
 
Normal
 
Normal

Normal
No supplemental dose necessary after dialysis 


Normal 


Normal 
 
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 supplemental dose 1 gm after dialysis on dialysis days
 
1 - 2 gm q48H
 
2 gm q8 - 12H
¤
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
Fluoroquinolone
 
Ciprofloxacin IV

 
200 - 400 mg q12H
 
Normal
 
> 30 mL/min:
Normal

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

 
200mg q12H or 400 mg q24H¤
 
200 mg q12H or 400 mg q24H, dose after dialysis on dialysis days¤
 
200mg q12H ¥
 
400 mg q12H
 
Ciprofloxacin
PO

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

 
250 - 500 mg q24H ¤

250mg q8-12H  ¥

 
250 - 500 mg q12H
 
Levofloxacin
IV / PO

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

10 - 19 mL/min:
250 - 500 mg q48H

 
Load 500 - 750 mg, 

then 250 - 500 mg q48H
 
Load 500 - 750 mg,

then 250 - 500 mg q48H, dose after dialysis on dialysis days
 
Load 500 - 750 mg,

then 250 - 500 mg q48H
 
Load 500 - 750 mg,

then 250 - 750 mg q24H
 
Moxifloxacin PO

 
400 mg q24H
 
Normal

Normal 
 
Normal
 
Normal
No supplemental dose necessary after dialysis

 
Normal
 
Normal
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
Macrolide
 
Azithromycin IV / PO
 
500 mg q24H


 
Normal
 
Normal
 
Normal

 
Normal
No supplemental dose necessary after dialysis

 
Normal
 
Normal
 
Erythromycin PO

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

 
Normal
 
Normal
 
Clarithromycin PO
 
250 - 500 mg q12H
 
Normal
 

> 30 mL/min: 
Normal

¤

<30 ml/min:

500 mg q24H


 
500 mg q24H
 
500 mg q24H, dose after dialysis on dialysis days

 
250 - 500 mg q24H
 
250 - 500 mg q12 - 24H
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
Penicillin
 
Amoxicillin PO

 
Usual dose of 250 - 500 mg q8H, up to 1000 mg q8H

 
No
rmal
 

> 30 mL/min: 
Normal

¤

<30 ml/min:

250 - 500 mg q12H

 
250 - 500 mg q24H
 
250 - 500 mg q24H, dose after dialysis on dialysis days
 
250 mg q12H
 
250 - 500 mg q8 - 12H
 
Co-amoxiclav
PO

 
625 mg q8-12H







Deep seated infection:

1g q12-8H (875/125mg)

 
Normal
 

> 30 mL/min: 
Normal

 

<30 ml/min:

625 mg q12-24H

¤

 


> 30 mL/min: 
Normal

 

<30 ml/min:

contraindicated to use 1g formulation


 
250 - 500 mg (Amoxicillin component) q24H

625 mg q24H

 

 

 




contraindicated to use 1g formulation
 
625 mg q24H, dose after dialysis on dialysis days













contraindicated to use 1g formulation
 
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 q12H 
¥

OR

1.2 gm stat then 600 mg q24H 
£

OR
 
1.2 gm stat then 600 mg q8H 

¥

 

1.2 gm q12H

¥

OR

1.2 gm stat then 600 mg q24H, add supplemental dose 600 mg after dialysis on dialysis days
£


 

1.2 gm q12H 
¥

OR

1.2 gm stat then 600 mg q24H 
£

OR
 
1.2 gm stat then 600 mg q8H 

¥
 
1.2 gm q8 - 12H 
¥
 
Ampicillin IV

 
1 - 2 gm q6H, up to 2 gm q4H
(max 12 gm/day)


 
Normal
 
30 - 50 mL/min:
1 - 2 gm q6-8H

10 - 30 mL/min:
1 - 2 gm q8-12H
 
1 - 2 gm q12H
 
1 - 2 gm q12H, dose after dialysis on dialysis days
 
500 - 1000 mg q12H
 
1 - 2 gm q6 - 8H
¤
 
Ampicillin / Sulbactam IV


Usual dose:
1.5 - 3 gm q6 - 8H

 
Normal

>30 mL/min:

Normal

 

15-29 mL/min:

1.5 - 3 gm q8 - 12H

¤
 
1.5 - 3 gm q12 - 24H
 
1.5 - 3 gm q12 - 24H, dose after dialysis
 
1.5 - 3 gm q12 - 24H
 
1.5 - 3 gm q6 - 8H
¤

Multidrug resistant acinetobacter:
3 gm q3-4H

 
Normal
 

>30 mL/min:

Normal

 

15-29 mL/min:

3 gm q4-6H


 
3 gm q6-8H
 
3 gm q6-8H, dose after dialysis on dialysis days
 
3 gm q6-8H
 
3 gm q3-4H
 
Benzylpenicillin IV

 
1 - 4 MU q4 - 6H
¤
 
Normal
 
75% of dose q4 - 6H 
¤

 
20 - 50% of dose q4 - 6H 
¤
 
25 - 50% of dose q4 - 6H, dose after dialysis 
¤

 
25 - 50% of dose q4 - 6H 
¤
 
2 - 4 MU q4 - 6H
¤
 
Cloxacillin IV / PO

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


4.5 gm q6H 
 
Normal
 
20 - 40 mL/min:
4.5 gm q8H

10 - 20 mL/min:
2.25 gm q6H

 
2.25 gm q6H
 
2.25 gm q8H, add supplemental dose 0.75 gm after dialysis on dialysis days
 
2.25 gm q8H
 
4.5 gm q8H
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
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
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
Miscellaneous
 
Clindamycin
IV / PO

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

Normal 

Normal 
 
Colistin IV 
Ω Ψ

 

LD (based on IBW)

>75kg-9 MU

61-74kg- 8MU

51-60kg- 7MU

<50kg- 6MU


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 supplemental dose 0.8 MU after dialysis on dialysis days

 
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 (max 4 gm/day)

 
Normal
 
Normal
 
500 mg q8 - 12H or 7.5 mg/kg q12H
 
500 mg q8 - 12H or 7.5 mg/kg q12H, dose after dialysis

 
500 mg q8 - 12H or 7.5 mg/kg q12H
 
500 mg q6 - 12H or 7.5 mg/kg q6H
 
Polymyxin B
IV

 
Loading Dose:
2.5 mg/kg STAT over 2 hours

Maintenance Dose, to start 12 hours after loading dose:
1.5 mg/kg BD, each dose over 1 hour
(Obese patient: consider using adjusted body weight)

 
Normal
 
Normal
 
Normal
 
Normal

 
Normal
 
Normal
 
Trimethoprim / Sulfamethoxazole
IV / PO

 
Treatment:
Trimethoprim component
8 - 20 mg/kg/day
divided to q6 - 12H

 
Normal

 
30 - 50 mL/min:
Normal

10 - 29 mL/min:
Trimethoprim component
2.5 - 5 mg/kg q12H

 
Use not recommended, but if required, Trimethoprim component
5 - 10 mg/kg q24H
 
Use not recommended, but if required, Trimethoprim component 
5 - 10 mg/kg q24H
 
Use not recommended, but if required, Trimethoprim component
5 - 10 mg/kg q24H
 
Trimethoprim component
5 - 10 mg/kg q12H
¤
 
Prophylaxis:
1 - 2 tabs PO q24H

 
Normal

 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Vancomycin
IV

 

 15 - 20 mg/kg q8 - 12H

If loading dose required, 20mg/kg single dose (Max 2 gm/dose)

Max infusion rate:
1 gm/hour

Max dilution concentration: 1 gm/100mL

 

>60 ml/min 


>90kg   
:1000mg q8H

75-89kg
:750mg q8H

60-74kg :1000mg q12H

50-59kg
:750mg q12H

30-49kg
:
500mg q12H
 
40-59 ml/min

>90kg   :750mg q12H
75-89kg :750mg q12H
60-74kg :500mg q12H
50-59kg :750mg q24H
30-49kg :500mg q24H


20-39 ml/min


>90kg   :750mg q24H
75-89kg :750mg q24H
60-74kg :500mg q24H
50-59kg :500mg q24H
30-49kg :
500mg q24H

 

<20 ml/min

Loading dose 20mg/kg single dose (Max 2 gm/dose), then send random TDM sample next morning

If TDM is not available the next day, give 7.5-10mg/kg stat dose 24 hours after loading dose. Send random TDM sample next working day.


Loading dose, 20mg/kg single dose (Max 2 gm/dose), then send random TDM sample next morning.

If TDM is not available the next day, give 7.5-10mg/kg stat dose 24 hours after loading dose. Send random TDM sample next working day.

ß
 
 

Loading dose, 20mg/kg single dose (Max 2 gm/dose), then send random TDM sample next working day

ß
 

20 – 25mg/kg (Max 2 gm/ dose) loading dose, then 7.5 - 10 mg/kg q12 - 24H

Refer to pharmacy if in doubt
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
Antifungal
 
Amphotericin B deoxycholate
IV

 
0.3 - 1 mg/kg q24H
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
Amphotericin B lipid complex IV

 5mg/kg q24H Normal Normal Normal Normal Normal Normal
 
Fluconazole 
IV / PO

 
100 - 400 mg q24H
 
Normal
 
50 - 200 mg q24H
 
50 - 200 mg q24H
 
50 - 200 mg q24H, dose after dialysis on dialysis days

OR

100 - 400 mg q48 - 72H, dose after dialysis 

 
50 - 200 mg q24H
 
200 - 400 mg q24H
 
Itraconazole 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 due to accumulation of IV vehicle (cyclodextrin), oral route preferred
 
Not recommended due to accumulation of IV vehicle (cyclodextrin), oral route preferred

 
No data. Oral route preferred
 
No data. Oral route preferred
 
No data. Oral route preferred
 
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
 
Micafungin IV

 
100mg q24H

 
Normal
 
Normal
 
Normal
 
Normal
 
Normal
 
150-200mg q24H
 
Flucytosine PO

 
25mg/kg q6H

 25mg/kg q6H
 
25mg/kg q12H

 25mg/kg q24H
 
25mg/kg q24H
 
0.5 – 1 gram q24H
 
25mg/kg q12H


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
Antiparasitic
 
Pentamidine IV

 
4 mg/kg q24H


 
Normal

Normal 
 
4 mg/kg q24 - 36H

 
4 mg/kg q48H, dose after dialysis
 
4 mg/kg q24 - 36H
 
4 mg/kg q24H
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
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 mL/min:
15 - 25 mg/kg q24H

10 - 30 mL/min:
20 - 25 mg/kg 3x/week

¤
 

20 - 25 mg/kg 3x/week

¤
 

20 - 25 mg/kg 3x/week after dialysis on dialysis days

¤
 

20 - 25 mg/kg 3x/week

¤
 
15 - 25 mg/kg q24H
 
Pyrazinamide PO

 
20 - 25 mg/kg q24H (max 2.5 gm/day)


Normal 
 >30 mL/min:
20 - 25 mg/kg q24H

 < 30 mL/min: 
25 - 35 mg/kg 3x/week 
¤

 
25 - 35 mg/kg 3x/week 
¤
 
25 - 35 mg/kg 3x/week after dialysis
¤
 
20 - 25 mg/kg q24H 
¤
 
20 - 25 mg/kg q24H 
¤
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
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, dose after dialysis 
¤
 
2.5 - 5 mg/kg q24H 
¤
 
5 - 10 mg/kg q12 - 24H 
¤
 
Acyclovir PO

 
200 - 800 mg q8H or 5 times 
¤

 
Normal
 >25mL/min:
Normal

10 - 25 mL/min:
200 - 800 mg q8H 
¤

 
200 - 800 mg q12H 
¤
 
200 - 800 mg q12H, dose after dialysis on dialysis days
¤
 
200 - 800 mg q12H
¤
 
No data
 
Ganciclovir IV

 Induction Dose
 
5 mg/kg q12H

 
> 70 mL/min:
Normal

50 - 69 mL/min:
2.5 mg/kg q12H

 
25 - 49 mL/min:
2.5 mg/kg q24H

10 - 24 mL/min:
1.25 mg/kg q24H
 
1.25 mg/kg 3x/week
 
1.25 mg/kg 3x/week, dose after dialysis on dialysis days
 
1.25 mg/kg 3x/week
 
2.5 mg/kg q12H
¤
 Maintenance Dose
 
5 mg/kg q24H

 
> 70 mL/min:
Normal

50 - 69 mL/min:
2.5 mg/kg q24H

 
25 - 49 mL/min:
1.25 mg/kg q24H

10 - 24 mL/min:
0.625 mg/kg q24H
 
0.625 mg/kg 3x/week
 
0.625 mg/kg 3x/week, dose after dialysis on dialysis days
 
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
 

30 -49mL/min:

Hepatitis B:

100mg stat then 50 mg q24H


HIV:
50-150 mg q24H

 

15-29mL/min:

Hepatitis B:
100mg stat then 25 mg q24H

HIV:
150 mg stat then 100 mg q24H

 

5-14mL/min:

Hepatitis B:
35mg stat then 15 mg q24H

 

<5 mL/min:

Hepatitis B:
35mg stat then 10 mg q24H

HIV:
50 mg stat then 25 mg q24H

 
Hepatitis B:
35 mg stat then 10  mg q24H, dose after dialysis on dialysis days

HIV:
50 mg stat then 25 mg q24H, dose after dialysis on dialysis days
 

Hepatitis B:
35mg stat then 10 mg q24H

HIV:
50 mg stat then 25 mg q24H

 
100 mg stat then then 50 mg q24H
 
Oseltamivir PO

 
75 mg q12H
 
Normal
 
30 - 60 mL/min:
30 mg q12H

10 - 29 mL/min:
30 mg q24H

 
75mg single dose ¥
 
30 mg stat then 30 mg after each dialysis day, no drug on non-dialysis days.


Treatment duration not to exceed 5 days.

Assumes 3 HD sessions in 5 days period.

¥

 
30 mg single dose to provide a 5-day duration
 
75mg q24H or 30mg q12H ¥
 
Telbivudine PO

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

10 - 29 mL/min:
600 mg q72H

 
600 mg q96H
 
600 mg q96H, dose after dialysis on dialysis days
 
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
¤
 
Zidovudine PO

 
300 mg q12H
 
Normal
 
>15 mL/min:
300 mg q12H
 
< 15 mL/min:
100 mg q8H
or
300 mg q24H

 
100 mg q8H, dose after dialysis on dialysis days
 
100 mg q8H
 
300 mg q12H

Reference:

The Sanford Guide to Antimicrobial Therapy 2019

¤ UpToDate version 3.18.4-3 (15.12.2019)

α Therapeutic Guideline, Antibiotic Version 14, 2010

¥ The Renal Drug Handbook 5th edition 2019

£ 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

ß Clinical Pharmacokinetics Pharmacy Handbook. Second edition 2019. Pharmacy Practice & development division Ministry of Health Malaysia

Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Rybak et al. Am J Health Syst Pharm (2020)