Renal dosing of antimicrobials

Calculating Creatinine Clearance (CrCl)

Estimate the creatinine clearance using the Cockroft-Gault equation (uses kg and mcmol/L):

Failed to parse (syntax error): {\displaystyle CrCl_{Male} = \frac{1.2 \times (140 - age) \times weight}{creatinine}\\ 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) (uses kg for weight):

Failed to parse (syntax error): {\displaystyle IBW_{Male} = 50 + 2.3 \times (\text{inches over 5 ft})\\ IBW_{Female} = 45.5 + 2.3 \times (\text{inches over 5 ft})\\ ABW = IBW + 0.4 \times (TBW - IBW) }

Antibiotics

β-lactams

Penicillins

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Amoxicillin PO	250-500 mg 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		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		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
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		>20: 4.5 g q8h	<20: 3.375 g q8h	2.25 g q8h		4.5 g q8h
Pip/Tazo IV (Pseudomonas)	4.5 g q6h		>20: 4.5 g q6h	<20: 4.5 g q8h	2.25 g q6h		4.5 g q6h

Cephalosporins

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Cephalexin PO	500 mg q6h			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		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		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; after dialysis on dialysis days	500 mg q12h
Cefprozil PO	250-500 mg q12h	50% of usual dose			50% of usual dose; after dialysis on dialysis days	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

Carbapenems

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Ertapenem IV	1 g q24h		500 mg q24h		500 mg q24h; after dialysis on dialysis days	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		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		1 g q12h	1 g q24h	1 g q24h; after dialysis on dialysis days	1 g q24h	1 g q8-12h

Quinolones

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

Macrolides

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Azithromycin PO/IV	250-500 mg q24h
Clarithromycin (XL) PO	250-500 mg q12h (1 g daily)		500 mg daily (avoid XL)	250-500 mg daily (avoid XL)	250-500 mg daily (avoid XL); after dialysis on dialysis days	250-500 mg daily (avoid XL)	Unclear

Tetracyclines

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

Aminoglycosides

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD
Amikacin IV q8h	5-7.5 mg/kg q8h				Pre-HD levels; post-HD doses
Amikacin IV extended	15 mg/kg q24h	40-59: Same dose q36h	20-39: Same dose q48h	Avoid	Pre-HD levels; post-HD doses
Tobramycin IV q8h	1.7 mg/kg q8h				Pre-HD levels; post-HD doses
Tobramycin IV extended	7 mg/kg q24h	40-59: Same dose q36h	20-39 Same dose q48h	Avoid	Pre-HD levels; post-HD doses
Gentamicin IV q8h	1.7 mg/kg q8h				Pre-HD levels; post-HD doses
Gentamicin IV extended	7 mg/kg q24h	40-59: Same dose q36h	20-39 Same dose q48h	Avoid	Pre-HD levels; post-HD doses

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
Vancomycin PO	Usual dose
Vancomycin IV	15 mg/kg q12h	Same dose q24h	Same dose q48h; get pharmacy involved	Loading dose then check level at 48 hours	See vancomycin-specific dosing
Daptomycin IV	4 mg/kg q24h (SSTI)	Usual dose	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
Metronidazole PO/IV	500 mg q8-12h	Usual dose
Nitrofurantoin PO	50-100 mg q12h	Avoid <40	Avoid
TMP-SMX 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 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
Colistin	5 mg CBA/kg IBW x1 loading (max 300 mg) followed by 5 mg/kg/day divided q8h	Loading dose followed by 3.5 mg/kg/day divided q12h	Loading dose followed by 2.5 mg/kg/day divided q12h	Loading dose followed by 1.5 mg/kg/day q24h		—	—

Antifungals

Drug	Usual Dose	Mild (30-49)	Moderate (10-29)	Severe (<10)	HD	PD	CRRT
Liposomal Amphotericin B IV	3-5 mg/kg q24h
Caspofungin IV	70 mg then 50 mg q24h
Anidulafungin IV	200 mg then 100 mg q24h
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		Usual dose post-dialysis or q24h	50% q24h	Usual dose
Itraconazole PO	100-200 mg q24h
Voriconazole PO/IV	6 mg/kg q12h x2 then 4 mg/kg q12h	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		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		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		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