Renal dosing of antimicrobials

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Calculating Creatinine Clearance (CrCl)

Creatinine Clearance (CrCl) Calculator
years
mL/min

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

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

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
875/125 mg q12h 500/125 mg q12h 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
4.5 g q6h (pseudomonal) >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
2 g q8h (CNS/CF) 2 g q12h 2 g q24h 2 g q24h; after dialysis on dialysis days 2 g q24h 2 g q8-12h
1 g q8h (febrile neutropenia) 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) Severe (<10) HD PD 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
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 PD CRRT
Amikacin IV 5-7.5 mg/kg q8h Pre-HD levels; post-HD doses
15 mg/kg q24h (extended interval) 40-59: Same dose q36h 20-39: Same dose q48h Avoid Pre-HD levels; post-HD doses
Tobramycin IV 1.7 mg/kg q8h Pre-HD levels; post-HD doses
7 mg/kg q24h (extended interval) 40-59: Same dose q36h 20-39 Same dose q48h Avoid Pre-HD levels; post-HD doses
Gentamicin IV 1.7 mg/kg q8h Pre-HD levels; post-HD doses
7 mg/kg q24h (extended interval) 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
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
15-20 mg/kg/day in 2-4 doses (PJP) 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/kg 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
800 mg 5x/day (high dose) Usual dose Same dose q8h Same dose q12h 50% of usual dose q24h; after dialysis on dialysis days Usual dose
Ganciclovir IV 5 mg/kg q12h (induction) 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
5 mg/kg q24h (maintenance) 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