Antimicrobial Dosing Recommendations in Renal Insufficiency

ANTIMICROBIAL CLCr 50-20 ml/min CLCr 19-10 ml/min CLCr <10 ml/min
Acyclovir 5-10 mg/kg Q12H 5-10 mg/kg Q24H 2.5mg/kg Q24H
5-10 mg/kg Q8H; (VZV: 12-15 mg/kg Q 8 H) 5 mg/kg Q24H (VZV)
Acyclovir-VZV Usual Dose 800 mg po q 8-12 H 400-800 mg po Q 12H
800 mg po q4 h (5x/day)
Ampicillin Usual Dose 1-2 gm Q6-8H 1-2 gm Q8-12H
2 gm Q6H / 2 gm Q4H~
Amp/Sulbactam 3 gm Q8H 1.5-3 gm Q12H 1.5 gm Q12H, or
3 gm Q6H 1.5-3 gm Q24H
Amox/clavulanate Usual Dose 875/125 mg Q24H 500/125 mg Q24
875/125 mg Q12H
Aztreonam 1-2 gm Q 8 H 1-2 gm Load then 0.5-1 gm Q8H 1-2 gm Load then 250-500 mg q 8 H
1-2 gm Q6-8H
Cefazolin (doses > 1 gm restricted) 1 gm Q8-12H 0.5-1 gm Q12H 0.5-1 gm Q24H
1 gm Q8H / 2 gm Q8H~
Cefepime 1 gm Q12H / 2 gm Q12H* 1 gm Q24H / 2 gm q24* 500 mg Q24H / 1 gm Q24H*
1-2 gm Q12H / 2g Q8H*
Cefixime No Change 300 mg Q24H 200 mg Q24H
400 mg Q24H or 200 mg Q12H
Cefotetan No Change 1 gm Q12H 1-2 gm Load then 500 mg q 12
1-2 gm Q12H
Cefoxitin 1-2 gm Q8H 1-2 gm Q12H 1 gm Q24H
1-2 gm Q6H / 2 gm Q4H~
Ceftazidime (non formulary) 1 gm Q12H 1 gm Q24H 1 gm load then 0.5gm Q24H
1-2 gm Q8H
Ceftizoxime (non-formulary) 1 gm Q12H 0.5-1 gm Q12H 1 gm load then 0.5 gm Q24H
1-2 gm Q8H
Ceftriaxone Usual Dose Usual Dose No Change, consider 2 gm Max/d if liver +
1-2 gm Q12-24H renal
Cefuroxime (non-formulary) Usual Dose 0.75 gm Q12H 0.75 gm Q24H
0.75-1.5 gm Q8H
Cephalexin Usual Dose 250-500 mg po Q 8-12 H 250-500 mg po Q 12-24H
250-500 mg po Q`6H
Cidofovir: 5 mg/kg Q Week x2 (Induction) Not Recommended Not Recommended Not Recommended
Ciprofloxacin 400 mg IV Q 12 400 mg IV Q18H 400 mg IV Q24H
400 mg Q 12 (Q8 for selected indications)
500-750 mg po Q 12 H 500 mg po Q 12 H 500 mg po Q12 H 500 mg po Q24H
Clarithromycin
250-500 mg po Q12H OR Usual Dose 500 mg Load, 250 mg Q12H 500 mg Load, 250 mg Q12H
1 gm XL po Q24H
Ertapenem 500mg Q24H (CrCl<30 ml/min) 500mg Q24H 500mg Q24H
1 gm IV or IM Q24H
Erythromycin Usual Dose Usual Dose 0.5 gm Q6H
0.5-1 gm Q6H
Ethambutol Usual Dose 15-25 mg/kg Q 36 15-25 mg/kg Q 48
15-25 mg/kg Q day
Ethionamide: 0.5­1 gm Q24H Usual Dose Usual Dose Usual Dose
Famciclovir
500 Q 8H (zoster) 500 mg Q 12H 500 mg Q24H 250 mg Q 48H
125 Q 12H (HSV) 125 mg Q 12H 125 mg Q24H 125 mg Q 48H
Fluconazole 200–400 mg Q 24 200 mg q 24 100-200 mg Q24H
12 mg/kg IV load on day one, 400 mg Q 24H
Flucytosine 25-37.5 mg/kg Q 6H 25 mg/kg Q12H 25 mg/kg Q24H 25 mg/kg Q24H-48 (adjust using Cp)
(2 hr post dose goal­50­100 mcg/ml)
Foscarnet (dose based on CrCl/70kg) Foscarnet (dose based on CrCl/70kg) Do not use Do not use
HSV, VZV 60 mg/kg Q12H • HSV, VZV 
• 49 mg/kg Q12 CrCl 90-100 • 21 mg/kg Q12 CrCl 35-60
• 35 mg/kg Q12H CrCl 60-90 CMV
CMV Induction
90 mg/kg Q12H (induction) CrCl>100 • 57 mg/kg Q12H CrCl 35-60
• 78 mg/kg Q12 CrCl 90-100 • 50 mg/kg Q24H CrCl 20-35
• 71 mg/kg Q12H CrCl 60-90 Maintenance
90-120 mg/kg Q 24H (maintenance) • 76 mg/kg Q24 CrCl 35-60
• 78-104 mg/kg Q24 CrCl 90-100 • 65 mg/kg Q 48 CrCl 20-35
• 71-94 mg/kg Q24H CrCl 60-90

Ganciclovir CrCl 50-80: 2.5 mg/kg Q12(I); 2.5 mg/kg Q24(M) 1.25 mg/kg Q24H (I) 1.25 mg/kg TIW (I)
5 mg/kg Q12H induction (I) CrCl 25-50: 2.5 mg/kg Q24H (I); 0.625 mg/kg Q24H (M) 0.625 mg/kg TIW (M)
5 mg/kg Q24H maintenance (M) 1.25 mg/kg Q24H (M)
Gatifloxacin Cr Cl < 40—400 mg load then 200 mg Q24H 400 mg load then 200 mg Q24H 400 mg load then 200 mg Q24H
400 mg Q24H
Imipenem 500 mg Q8H OR 250 mg Q6H 250 mg Q8H 0.25 gm Q12H
0.5 gm Q6H
Isoniazid: 300 mg po q 24 Usual Dose No Change 150 mg in slow acetylators
Itraconazole Usual Dose Usual Dose IV not recommended Cr Cl < 30 (cyclodextrin
200 mg Q12H PO OR —although accumulation occurs, low toxicity
IV Q12H x 4 doses then Q24H potential of HPβCD)
Linezolid No Change No Change No Change
600 mg Q12H
Meropenem (non-formulary) 1 gm Q12H 0.5-1 gm Q12H 0.5 Q24H
1 gm Q8H (2 gm Q8H meningitis)
Metronidazole: 500 mg Q8H Usual Dose Usual Dose
Mezlocillin: 3 gm Q 4H (non-formulary) 3 gm Q 6H 3 gm Q 8H 2 gm Q 8H
Penicillin G CrCl 40-60: 1-2 MU Q 4 1-2 MU Q6 1 MU Q6
1-4 MU Q4H (Max: 24 MU/day) CrCl 20-40: 1-2 MU Q 6
Pentamidine 4 mg/kg Q24 4 mg/kg Q24H 4 mg/kg Q24-36H (<5 % drug cleared renally)
4 mg/kg/d Q24H
Piperacillin 3-4 gm Q6H 3-4 gm Q8H 3 gm Q8H or 3-4 gm Q 12
3-4 gm Q 4 H
Pip/Tazo 3.375 gm Q6H or 4.5 gm Q 8 H 3.375 gm Q8H or 4.5 gm Q 12 2.25 gm Q8H
3.375-4.5 gm Q6H (Pseudomonas—3.375 gm Q 4 H)

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 Antimicrobial Dosing Recommendations in Renal Insufficiency
Quinine Usual Dose 7.5-10 mg/kg Q12H 7.5-10 mg/kg Q24H
7.5­10 mg/kg Q8H  Metabolic Cl; inc binding to AAP; 3OH Metabolic Cl; inc binding to AAP; 3 OH
(650 mg po Q8H) accumulates—dec dose by 1/3 after 3 days accumulates—dec dose by 1/2 after 3 days
Quinupristin/Dalfopristin Usual Dose Usual Dose Usual Dose
7.5 mg/kg Q8H
Ticarcillin/Clavulanate 3.1 gm Q6H 2 gm Q8H OR 2 gm Q12H
3.1 gm Q4-6H 3.1 gm Q12H
Trimethoprim/Sulfa ** CrCl 20-30: 7.5 mg TMP/kg/d divided Q12H 5 mg TMP/kg/d Q24H 3 mg TMP/kg/d Q24H
10 mg TMP/kg/d divided Q8H PCP: 10-15 mg TMP/kg/day divided Q 8H PCP 7.5 mg/kg TMP Q 12-24H PCP 5-7.5 mg/kg TMP Q 24
PCP: 15-20 mg/kg/day divided Q 6-8H
Trimetrexate Usual Dose 50-100% No Data; ? avoid
1.2 mg/kg Q24H/ 45 mg/m2 Q24H + Leucovorin
Valganciclovir
900 mg po Q 12H (induction) Cr Cl 40-60: 450 mg Q 12H (I); 450 mg Q 24H (M) 450 mg Q 48H (I); 450 mg twice weekly (M) Not recommended
900 mg Q 24H (maintenance) CrCl 25-40: 450 mg Q24H (I); 450 mg Q 48H (M)
Vancomycin Cr Cl 40-60: 15 mg/kg Q24H 15 mg/kg Q48-72H (monitor Cp) 15 mg/kg Q4-7d (monitor Cp)
1-1.5 gm Q12H (based on TBW) Cr Cl 20-40: 15 mg/kg load then 7.5 mg/kg Q24H
Voriconazole IV-Not recommended† IV-Not recommended† IV-Not recommended†
IV-6mg/kg q12h x 24hr, then 3-4mg/kg/dose q12h Po-unchange PO-unchange Po-unchange
PO-200-300mg q12h

The following drugs do NOT need dosage adjustment in renal failure: amphotericin B (any formulation), atovaquone, azithromycin, caspofungin, , chloramphenicol (increased bioavailability of chloramphenicol from
succinate ester), clindamycin, clofazamine dapsone, dicloxacillin, dirithromycin, doxycycline, linezolid, mefloquine, minocycline, nafcillin, oxacillin, primaquine, pyrimethamine, quinupristin/dalfopristin, rifampin, rifabutin,
rifapentine
*Neutropenic Dosing
**TMP/SMX listed dosing is for GNR infections other than Stenotrophomonas. Pneumocystis treatment dose is 15 mg TMP/kg/d divided Q6-8H. Stenotrophomonas infection dose is 15-20 mg TMP/kg/d divided Q6H.
^Dosages are not necessarily appropriate for endocarditis, consider Infectious Disease Consultation if concerns or questions.
^^Dosages given are for parenteral therapy.
~Maximum recommended dose.
 
†Not recommended unless an assessment of the benefit/risk to the patient justifies the use of intravenous voriconazole (due to accumulation of intravenous vehicle, SBECD)
Italicized antibiotics are restricted to Infectious Disease or HIV Service approval.
Infectious Disease Consultation Service beeper ‘BUGS’
HIV Consultation Service beeper ‘AIDS’
The following drugs may require dosage adjustment in hepatic failure: caspofungin, voriconazole, cefoperazone, ceftriaxone, chloramphenicol, clindamycin, isoniazid, itraconazole, metronidazole, nafcillin, rifampin,
rimantidine.

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 Antimicrobial Dosing Recommendations in Renal Insufficiency

ANTIMICROBIAL Peritoneal Dialysis Hemodialysis Dose CRRT Dose

(AD=After dialysis) (CVVHD, CAVHD)
Systemic Dosing Loading Dose Maintenance Dose (IP)
IP (mg/L) CAPD Intermittent
(mg/L) (1 bag/day)
Acyclovir 2.5 mg/kg Q 24H 2.5- 5 mg/kg IV q 24 (AD) 3.5 mg/kg/d
5 mg/kg Q 24H (VZV)
Aminoglycosides Follow Levels ½ Full Dose AD & Follow Levels Follow Levels
Amikacin 25 15 2 mg/kg
Gentamicin 8 4 0.6 mg/kg
Ampicillin 250 mg po Q12H 250-500 125 2 gm IV q 12 (AD) 2 gm IV q 6H
Amp/Sulbactam 1.5-3 gm Q24H 1000 100 3 gm q 12-24H (AD) 1.5 gm Q8H
Amox/clavulanate 250/125 mg Q12H Dose AD 875/125 mg po Q 12
Azithromycin Usual Dose Usual Dose Usual Dose
Aztreonam 1-2 gm Load, 250-500 q 8H 500 250 1 gm 1-2 gm Load then 250-500 mg q 8 H (1 dose 1-2 gm Q8H
AD or supplement with 500 mg)
Cefazolin 0.5 gm Q12H 500 125 1 gm 1 gm Q 24H (Dose AD or supplement with 1 gm Q12H
.5-1 gm AD)
Cefepime 500 mg Q24H 500 125 1 gm 2 gm load, then 0.5 gm Q24H; and 1 gm AD Not recommended
supplement
Cefixime 200 mg Q 24H Supplement 300 mg AD Not recommended
Cefotetan 1-2 gm Load, 0.5 gm Q 12- 500 mg q 24 and Supplement 1 gm AD 0.75 gm Q12H
24
Cefoxitin 1 gm Q24H 200-500 100 1 gm Q 24 (Dose AD or Supplement with 1 2 gm Q 12H
gm AD)
Ceftazidime 1 gm Load, 0.5 gm Q24H 250 125 1 gm 1 gm Load and Supplement 1 gm AD 1 gm Q 24H
Ceftizoxime 0.5-1 gm Q24H 250 125 1 gm 1 gm Q 24H (dose AD or Supplement 1 gm 1 gm Q12 H
AD)
Ceftriaxone 1 gm Q 12H 250-500 125 1 gm Usual Dose Usual Dose
Cefuroxime Na 0.75 gm Q 24 H 200 100 400 mg 0.75 gm Q 24H (Dose AD) 1 gm Q12H
Cidofovir No Data No Data Avoid Use
Ciprofloxacin 400 mq IV Q18H 10-20 400 mg IV Q 24 (dose AD) 200 mg IV Q 12H
500 mg po Q18H 50 500 mg po Q 24H (dose AD)
Clarithromycin 500 mg Load, 250 mg Q 500 mg Q 24H (dose AD) 500 mg Load, 250 mg Q 12H
12H
Clindamycin Usual Dose 300 150 Usual Dose Usual Dose
Ertapenem No data 150mg supplemental dose if dose given No data
within 6 hrs of HD: No supplement dose if
dose given >6 hrs apart from HD
Erythromycin 500 mg q 6H 150 75 500 mg q 6H 500 mg q 6H
Ethambutol 15-25 mg/kg Q48H 15 mg/kg 3x/week AD 15 mg/kg Q 24H
Ethionamide Usual Dose Usual Dose Usual Dose
Famciclovir No Data 250 mg Q 48H AD (VZV) 500 mg Q12-24H
(no data) 125 mg Q 48H AD (HSV) 125 mg Q12-24H
Fluconazole 100-200 mg Q 24H 200 mg q 200 mg AD 200 mg Q 24
24
Flucytosine (2 hr post dose 0.5-1 gm Q24H (adjust using 25 mg/kg AD (adjust using Cp) 25 mg/kg Q 24H (adjust using Cp)
goal-50-100 mcg/ml) Cp)
Foscarnet 65 mg/kg Q 48H 60 mg/kg AD Would not use
Ganciclovir Induction: Induction: Induction
1.25 mg/kg TIW 1.25 mg/kg TIW AD 2.5 mg/kg Q24H
Maintenance Maintenance Maintenance
0.625 mg/kg TIW 0.625 mg/kg TIW AD 1.25 mg/kg Q24H (M)
Gatifloxacin 400 mg load then 200 mg 400 mg Load, 200 mg q 24 400 mg load then 200 mg Q24H
Q24H
Imipenem 250 mg Q 12H 500 200 1 gm q 12 h 250 mg Q 12H AD 250 mg Q 6-8H
Itraconazole Usual Dose 100 mg Q24 AD Usual Dose
Linezolid No Change?? 600 mg Q12H, dose AD No Data
Meropenem 0.5 gm Q 24 0.5 gm Q 24 Dose AD or supplement with 0.5 0.5-1 gm Q 12H
gm AD
Metronidazole 500 mg IV/PO q 8H 10 500 mg IV/PO q 8H 500 mg IV/PO q 8H
Mezlocillin 3 gm Q12H 1000 250 3-4 gm Q 12H, dose AD 3 gm Q 8H
Nafcillin Usual Dose 1000 125 Usual Dose Usual Dose
Penicillin G 1 MU Q 6H 1 MU 50,000 U 1 MU Q 6H Dose AD or Supplement 0.5 MU 2 MU Q 6H
AD
Pentamidine 4 mg/kg Q 24-36H 4 mg/kg Q 24-36H 4 mg/kg Q 24-36H
Piperacillin 3 gm Q 8H 1000 250 4 gm q 12 h 2-3 gm Q 8H, dose AD or Supplement 1 gm 3 gm Q 6H
AD
Pip/Tazo 2.25 gm Q 8H 2.25 gm Q 8H, dose AD or Supplement with 4.5 gm Q 8 H (JAC 48:881)
0.75 gm AD
Quinine 7.5-10 mg/kg Q24H; dec 7.5-10 mg/kg Q24H AD 7.5-10 mg/kg Q12H
dose by 1/2 after 3 days Metabolic Cl; inc binding to AAP; 3 OH Metabolic Cl; inc binding to AAP; 3OH
accumulates—dec dose by 1/2 after 3 days accumulates—dec dose by 1/3 after 3 days
Quinupristin/Dalfopristin Usual Dose (low IP Usual Dose
concentrations)
Ticarcillin/Clavulanate 2 gm Q 12H 2 gm Q 12 H plus supplement 3.1 gm AD 3.1 gm Q 6H
Trimethoprim/Sulfa ** 0.16/0.8 gm Q48H 320/1600 80/400 5 mg TMP/kg Q 24H (dose AD or No Data, some recommendQ 18H (3 mg/kg q
supplement with 2.5 mg/kg AD) 12H may be reasonable)
Trimetrexate No Data No Data No Data
Valganciclovir 450 mg AD
Vancomycin 15 mg/kg Q 4-7 days 1000 15 15-30 15 mg/kg Q 4-7 days (monitor Cp) 15 mg/kg Q 24-72 H (monitor Cp)
(monitor Cp) mg/kg q 5-7
days
Voriconazole (IV only) No Data No data No data

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Nucleoside Analogs (NRTIs)-Renal Dosage Adjustment

NRTIs, CrCl (ml/min) Any weight <60 Kg >60 Kg
Zidovudine (Retrovir®, AZT, ZDV)
>50 300mg BID
10­50 300mg BID
<10 300mg QD
HD 300mg QD
PD 300mg QD
Didanosine (Videx®, DDI)
>50 125mg q12h or 250mg q24h 200mg q12h or 400mg q24h
30­49 125mg q24h 200mg q24h
10­29 50mg q24h 100mg q24h
<10 50mg q24h 100mg q24h
HD 100mg q24h* 100mg q24h*
PD 100mg q24h 100mgq24h
Zalcitabine (Hivid®, DDC)
10­40 0.75mg TID
<10 0.75mg BID
HD No Data
PD No Data
Stavudine (Zerit®, D4T)
>50 30mg q12h 40mg q12h
26­49 15mg q12h 20mg q12h
<10­25 15mg q24h 20mg q24h
HD 15mg q24h* 20mg q24h*
PD 15mg q24h 20mg q24h
Lamivudine (Epivir®, 3TC)
26­49 150mg q24h
10­25 100mg q24h
<10 150 mg QOD or 150mg, then 
50mg QD or 300mg Q72­96 
Hrs
HD 150mg, then 50 mg QD
PD 50mg QD
Abacavir (Ziagen®, ABC) No renal dose adjustment 
Tenofovir (Viread®)
>50 300mg QD
30­50 300mg Q2days
10­29 300mg Q3­4days
<10 300mg Q7days
HD 300mg Q7days*
PD No Data­Avoid

*Give Post­Dialysis
Adapted from Medical Management of HIV Infection, 2003. J.Bartlett et al.

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 Antimicrobial Dosing Recommendations in Renal Insufficiency

Authors: Aric Gregson, MD

Karen Plaisance, Pharm.D.
Shannon Chan, Pharm.D.

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