Renal dosing of antimicrobials

Calculating Creatinine Clearance (CrCl)

Estimate the creatinine clearance using the Cockroft-Gault equation:

$CrCl_{Male}={\frac {1.2\times (140-age)\times weight\ (kg)}{Serum\ creatinine\ (\mu mol/L)}}\ CrCl_{Female}=0.85\times CrCl_{Male}$

Use Ideal Body Weight (IBW) or Adjusted Body Weight (ABW) if patient is obese (i.e. TBW > 30% over IBW)

$IBW_{Male}=50\ kg+2.3\ kg\ per\ inch\ over\ 5\ ft\ IBW_{Female}=45.5\ kg+2.3\ kg\ per\ inch\ over\ 5\ ft$ $ABW=IBW+0.4\times (TBW-IBW)$

Dosing Guidelines

Penicillins

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Amoxicillin PO	250-500 mg q8h	Same dose q8h	Same dose q12h	Same dose q24h	500 mg q24h; after dialysis on dialysis days	500 mg q12h	Usual dose
Amox/Clav PO	500/125 mg q8h	Usual dose	250/125 mg q12h	250/125 q24h	250/125 q24h; after dialysis on dialysis days	250/125 mg q12h	Usual dose
Amox/Clav PO	875/125 mg q12h	Usual dose	500/125 mg 112h	500/125 mg q24h	500/125 mg q24h; after dialysis on dialysis days	250/125 mg q12h	Usual dose
Ampicillin IV	1-2 g q4-6h	Same dose q6-8h	Same dose q8-12h	Same dose q12h	Same dose q12h; after dialysis on dialysis days	500-1000 mg q12h	Usual dose
Cloxacillin IV	1-2 g q4-6h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Penicillin G IV	2-4 MU q4-6h	Usual dose	75% of usual dose	25-50% of usual dose	25-50% of usual dose; after dialysis on dialysis days	25-50% of usual dose	Usual dose
Pip/Tazo IV	4.5 g q8h	4.5 g q8h	>20: 4.5 g q8h	<20: 3.375 g q8h	2.25 g q8h	2.25 g q8h	4.5 g q8h
Pip/Tazo IV (Pseudomonas)	4.5 g q6h	4.5 g q6h	>20: 4.5 g q6h	<20: 4.5 g q8h	2.25 g q6h	2.25 g q6h	4.5 g q6h

Carbapenems

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Ertapenem IV	1 g q24h	Usual dose	500 mg q24h	500 mg q24h	500 mg q24h; after dialysis on dialysis days	500 mg q24h	500 mg q24h
Meropenem IV	500 mg q6h	500 mg q6-8h	500 mg q8-12h	500 mg q12-24h	500 mg q12-24h; after dialysis on dialysis days	500 mg q12-24h	500 mg q6-8h
Meropenem IV CNS or CF	2 g q8h	Usual dose	2 g q12h	2 g q24h	2 g q24h; after dialysis on dialysis days	2 g q24h	2 g q8-12h
Meropenem IV Febrile neutropenia	1 g q8h	Usual dose	1 g q12h	1 g q24h	1 g q24h; after dialysis on dialysis days	1 g q24h	1 g q8-12h

Cephalosporins

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Cephalexin PO	500 mg q6h	Usual dose	Usual dose	Usual dose q8-12h	500 mg q8-12h; after dialysis on dialysis days	500 mg q12-24h	Usual dose
Cefazolin IV	1-2 g q8h	Usual dose	1-2 g q12h	1-2 g q24h	1-2 g q24h, or 1-2 g post-HD	1 g q12h	Usual dose
Cefuroxime IV	750-1500 mg q8h	Usual dose	750-1500 mg q12h	750-1500 mg q24h	750-1500 mg q24h; after dialysis on dialysis days	750-1500 mg q24h	Usual dose
Cefuroxime PO	500 mg q12h	500 mg q12h	500 mg q12h	500 mg q12h	500 mg q12h; after dialysis on dialysis days	500 mg q12h	500 mg q12h
Cefprozil PO	250-500 mg q12h	50% of usual dose	50% of usual dose	50% of usual dose	50% of usual dose; after dialysis on dialysis days	50% of usual dose	50% of usual dose
Ceftazidime IV	1-2 g q8h	1-2 g q8-12h	1-2 g q12-24h	1-2 g q24h	Usual dose q24h; after dialysis on dialysis days	1 g q24h	Usual dose
Ceftriaxone IV	1-2 g q12-24h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose

Quinolones

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Ciprofloxacin PO	500-750 mg q12h	Usual dose	Usual dose q24h (q12h for Pseudo)	Usual dose q24h (q12h for Pseudo)	Usual dose q24h (q12h for Pseudo)	Usual dose q24h (q12h for Pseudo)	Usual dose
Ciprofloxacin IV	400 mg q12h (q8h for Pseudo)	Usual dose	Usual dose q24h (q12h for Pseudo)	Usual dose q24h (q12h for Pseudo)	Usual dose q24h (q12h for Pseudo)	Usual dose q24h (q12h for Pseudo)	Usual dose
Levofloxacin PO/IV	500 mg q24h	Usual dose	500 mg q48h	500 mg q48h	500 mg q48h	500 mg q48h	Usual dose
Levofloxacin PO/IV	750 mg q24h	750 mg x1 then 500 mg q24h	750 mg q48h	750 mg q48h	750 mg q48h	750 mg q48h	Usual dose
Moxifloxacin PO/IV	400 mg q24h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose

Macrolides

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Azithromycin PO/IV	250-500 mg q24h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose

Tetracyclines

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Doxycycline PO	100 mg q12h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Tetracycline PO	250-500 mg q6h	Same dose q6-8h	Same dose q12-24h	Same dose q24h	N/A	N/A	N/A

Miscellaneous

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Clindamycin PO	300-450 mg q6-8h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Clindamycin IV	600-900 mg q8h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Daptomycin IV	4 mg/kg q24h (SSTI)	Usual dose	Same dose q48h	Same dose q48h	Same dose q48h; after dialysis on dialysis days	Same dose q48h	Usual dose
Daptomycin IV	6 mg/kg q24h	Usual dose	Same dose q48h	Same dose q48h	Same dose q48h; after dialysis on dialysis days	Same dose q48h	Usual dose
Linezolid PO/IV	600 mg q12h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Metronidazole PO/IV	500 mg q8-12h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Nitrofurantoin PO	50-100 mg q12h	Avoid <40	Avoid	Avoid	Avoid	Avoid	Avoid
[TMP-SMX](Trimethoprim-sulfamethoxazole (TMP-SMX).md) PO/IV	8-12 mg/kg/day in 2-4 doses	Usual dose	75% of usual dose	Avoid; if needed, 50% of usual dose	50% of usual dose; after dialysis on dialysis days	—	7.5 mg/kg/day in 2-4 doses
[TMP-SMX](Trimethoprim-sulfamethoxazole (TMP-SMX).md) PO/IV for PJP	15-20 mg/kg/day in 2-4 doses	Usual dose	12-15 mg/kg/day in 2-4 doses	Avoid; if needed, 50% of usual dose	50% of usual dose; after dialysis on dialysis days	—	15 mg/kg/day in 2-4 doses

Antifungals

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Liposomal Amphotericin B IV	3-5 mg/kg q24h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Caspofungin IV	70 mg then 50 mg q24h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Anidulafungin IV	200 mg then 100 mg q24h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Fluconazole PO/IV	Invasive candidiasis: 12 mg/kg then 6 mg/kd q24h	Usual dose	Usual load then 50% q24h	50% of usual dose q24h	Usual dose post-dialysis or q24h	Usual LD then 50% q24h	Usual dose
Fluconazole PO/IV	Esophageal: 200 mg q24h Oropharyngeal: 100 mg q24h	Usual dose	50% of usual dose q24h	50% of usual dose q24h	Usual dose post-dialysis or q24h	50% q24h	Usual dose
Itraconazole PO	100-200 mg q24h	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose	Usual dose
Voriconazole PO/IV	6 mg/kg q12h x2 then 4 mg/kg q12h	PO preferred	PO preferred	PO preferred	PO preferred	PO preferred	PO preferred

Antivirals

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Acyclovir IV	5-10 mg/kg IBW q8h	Same dose q12h	Same dose q24h	50% of usual dose q24h	50% of usual dose q24h; after dialysis on dialysis days	50% of usual dose q24h; after dialysis on dialysis days	Usual dose
Acyclovir PO	200-400 mg 5x/day	Usual dose	Usual dose	Same dose q12h	50% of usual dose q24h; after dialysis on dialysis days	50% of usual dose q24h; after dialysis on dialysis days	Usual dose
Acyclovir PO High dose	800 mg 5x/day	Usual dose	Same dose q8h	Same dose q12h	50% of usual dose q24h; after dialysis on dialysis days	50% of usual dose q24h; after dialysis on dialysis days	Usual dose
Ganciclovir IV Induction	5 mg/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	1.25 mg/kg 3x/week post-dialysis	1.25 mg/kg 3x/week; after dialysis on dialysis days	2.5 mg/kg q12h
Ganciclovir IV Maintenance	5 mg/kg q24h	50-69: 2.5 mg/kg q24h 25-49: 1.25 mg/kg q24h	10-24: 0.625 mg/kg 3x/week	<10: 0.625 mg/kg 3x/week	0.625 mg/kg 3x/week post-dialysis	0.625 mg/kg 3x/week; after dialysis on dialysis days	2.5 mg/kg q24h
Oseltamivir PO	Treatment: 75 mg q12h	Usual dose	75 mg q24h	75 mg q48h	75 mg q48h, or 3x/week post-dialysis	75 mg q48h, or 3x/week after dialysis on dialysis days	Usual dose