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