Montefiore

Renal Dosing Guideline

by Kelsie Cowman last updated 2022-06-23 14:00:32.364186-04:00

Department of Pharmacy/Antimicrobial Stewardship Program (June 2021)

Antimicrobial Renal Dosing Guideline

 

 

Acyclovir IV

500 mg/vial

Usual Dose (normal renal function) CrCl (ml/min) Dosage Adjustment

5 (10*) mg/kg IV q8h

*Use 10 mg/kg for CNS infection or herpes zoster
Dose based on ideal body wt (not actual body wt), use adjusted body wt for BMI > 30

^Ensure adequate hydration to prevent AKI

25-50 5 (10*) mg/kg IV q12h
10-24 5 (10*) mg/kg IV q24h

<10 or HD

2.5 (5*) mg/kg IV q24h (give after HD on dialysis days, e.g. 10PM)
CRRT 5 (10*) mg/kg IV q12-24h

 

Aminoglycosides IV

(Gentamicin, Tobramycin, Amikacin)

Please see Aminoglycoside Dosing Guidelines for full recommendations (e.g. conventional dosing in special populations, dosage adjustments for renal replacement therapy, peak and trough monitoring, etc.) on Sanford Guide via intranet.
  Gentamicin/Tobramycin Amikacin
CrCl (ml/min) For all infections except UTI or synergy in staphylococcal/enterococcal infection
>60 5-7 mg/kg IV q24h 15-20 mg/kg IV q24h
>30-59 5-7 mg/kg IV q48h 15-20 mg/kg IV q48h
<30 1.5-2 mg/kg IV q24h 5 mg/kg IV q24h
HD 1.5-2 mg/kg IV after HD 5-7.5 mg/kg IV after HD
  For UTI
>30 3 mg/kg IV q24h 10 mg/kg IV q24h
<30 1.5 mg/kg IV q24h 5 mg/kg IV q24h
HD 1-1.5 mg/kg IV after HD 5-7.5 mg/kg IV after HD
  For synergy in staphylococcal or enterococcal infections (gentamicin only)
>60 1mg/kg IV q8h

 

N/A

>30-59 1 mg/kg IV q12h
20-30 1mg/kg IV q24h
<20 1mg/kg IV (Dose by level)
HD 1 mg/kg IV after HD

 

Ampicillin IV

1 gm, 2 gm

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

1-2 gm IV q6h

 

10-30 Normal dose IV q8h
<10 or HD Normal dose IV q12h
CRRT Normal dose IV q6-8h

 

*2 gm IV q4h for Listeria meningitis, Enterococcal endocarditis

30- <50 2 gm IV q6h
10- <30 2 gm IV q8h
<10 or HD 2 gm IV q12h
CRRT 2 gm IV q4-6h

Ampicillin/Sulbactam IV

3 gm

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

3 gm IV q6h

15-29 3 gm IV q12h
<15 or HD 3 gm IV q24h (give after HD on dialysis days, e.g. 10PM)
CRRT 3 gm IV q8h

Amphotericin B Liposomal

(Ambisome)

50 mg/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

3-5 mg/kg IV q24h

<10 Normal dose IV q48h
HD No dose adjustment

Artemether/Lumefantrine

(Coartem)

Tablet: Artemether 20mg/Lumefantrine 120mg

Usual Dose (Normal Renal Function) Dosage Adjustment

4 tablets (total artemether 80 mg/lumefantrine 480 mg ORALLY),

4 tablets again after 8 hours, then 4 tablets q12h for the next 2 days
(total course is 6 doses=24 tablets)

No renal adjustment necessary

Artesunate IV

Please contact ID pharmacist ASAP if you are requesting Artesunate IV. Please see Malaria Treatment Guidelines for indication, dosing, and monitoring.

Aztreonam IV

1 gm, 2 gm

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

1-2 gm IV q8h

10-30 Normal dose IV q12h
<10 or HD Normal dose IV q24h (give after HD on dialysis days, e.g. 10PM)
CRRT Normal dose IV q12h

Cefazolin IV

1 gm, 2 gm

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

1-2 gm IV q8h

10-35 Normal dose IV q12h
<10 1 gm IV q24h
HD

1 gm IV q24h (give after HD on dialysis days, e.g. 10PM)

or

2gm/2gm/3gm IV after HD (M/W/F or T/Th/Sat)

CRRT 2 gm IV q12h

Cefdinir PO

Capsule: 300 mg 

Suspension: 50 mg/ml

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

 300 mg PO q12h

 

<30 or HD

 

300 mg PO q24h (give after HD on dialysis days, e.g. 10PM)

Cefepime IV

1 gm, 2 gm

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

 

 

1 gm IV q8h or 2 gm IV q12h  

10-29 1 gm IV q24h

 

HD

1 gm IV q24h or 2gm IV after HD

*For stable patients or upon discharge for mild to moderate infections. This dosing strategy should NOT be used in severe infections (i.e. morbidly obese, sepsis, CNS infection, etc.)

CRRT  2 gm IV q12h

 

1 gm IV q6H (Pseudomonas with MIC < 4)  

 30-50 1 gm IV q8h 
10-29  1 gm IV q12h 
<10 or HD 1 gm IV q24h (give after HD on dialysis days, e.g. 10PM) 
CRRT 1 gm IV q8h

 

2 gm IV q8h (Neutropenic Fever, Pseudomonas, CNS Infection)

30-60 2 gm IV q12h
10-29 1 gm IV q12h or 2 gm IV q24h
HD

1-2 gm IV q24h (give after HD on dialysis days, e.g. 10PM) 

CRRT 2 gm IV q12h

Cefiderocol IV

1 gm, $228/vial
Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

 

2 gm IV q8h

>120 2 gm IV q6h
30-60 1.5 gm IV q8h
15-30 1 gm IV q8h
<15 750 mg IV q12h
HD 750 mg IV q12h
CRRT 2 gm IV q12h

Cefoxitin IV

1 gm, 2gm

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

1-2 gm IV q8h

10-29 1-2 gm IV q12h-q24h
< 10 1gm IV q24h
HD 1 gm IV q24h (give after HD on dialysis days, e.g. 10PM)

Ceftaroline IV

400 mg, 600 mg, $116/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

600 mg IV q12h

30-49 400 mg IV q12h
15-29 300 mg IV q12h
<15 or HD 200 mg IV q12h
CRRT 400 mg IV q12h
If susceptible-dose-dependent (SDD) with MIC 2-4 or persistent bacteremia, consider 600 mg IV q8h 30-49 400 mg IV q8h
15-29 300 mg IV q8h
<15 or HD 200 mg IV q8h
CRRT 400 mg IV q8h

Ceftazidime/Avibactam IV (Avycaz)

2.5 gm, $300/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

 

2.5 gm IV q8h

31-50 1.25 gm IV q8h
<30, HD 0.94 gm IV q12h
CRRT 1.25-2.5 gm IV q8h

Ceftolozane/Tazobactam IV (Zerbaxa)

1.5 gm, $91/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment
1.5 gm IV q8h 30-50 750 mg IV q8h
15-29 375 mg IV q8h
HD

750 mg IV x 1,
then 150 mg IV q8h

CRRT

1.5 gm IV q8h

 

For pneumonia: 3 gm IV q8h

30-50 1.5 gm IV q8h
15-29 750 mg IV q8h
HD 2.25 gm IV x 1,
then 450mg IV q8h
CRRT 1.5 gm IV q8h

Cephalexin PO

Capsule: 250 mg, 500 mg 

Suspension: 50 mg/ml

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

 

500 mg PO q6h or

1 gm PO q8h

10-29 500 mg PO q8h or 1 gm PO q12h
<10 500 mg PO q12h
HD 500 mg PO q24h (give after HD on dialysis days, e.g. 10PM)

Cidofovir IV

375 mg/vial, $441/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

5 mg/kg IV once weekly x 2 weeks, then 5 mg/kg IV every other week.

Give with saline hydration and probenecid 2 gm PO 3 hrs before and 1 gm at 2 hrs and 8 hrs after (total 4gm)
Low dose:  0.5-1 mg/kg IV weekly (BK virus), probenecid is optional

Dose based on actual body wt, use adjusted body wt for BMI >30

 

 

CKD or ESRD

 

 

3mg/kg IV every other week

 

Intravesicular instillation: 5mg/kg once a week in 60 ml normal saline instill through a foley catheter over 15 min and clamp for 1 hr.

 

No renal adjustment needed

 

Ciprofloxacin IV, PO

Tablet: 250 mg, 500 mg

IV: 200 mg, 400mg

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment
400 mg IV q12h (q8h-Pseudomonas) <30 or HD 400 mg IV q24h
CRRT 400 mg IV q8-12h

500 mg PO q12h (750mg-Pseudomonas)

<30 or HD 500 mg PO q24h (give after HD on dialysis days, e.g. 10PM)
CRRT 500 mg PO q12h

Daptomycin IV

500 mg/vial, $301/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 4 mg/kg IV q24h (SSTI, UTI)

8-10 mg/kg IV q24h (bacteremia/endocarditis)
*Enterococcal bacteremia/endocarditis: start 8 mg/kg IV q24h

 

Dose based on actual body wt, use adjusted body wt for BMI >30

<30 Normal dose IV q48h
HD Normal dose IV q48h (give after HD on dialysis days, e.g. 10PM)
CRRT Normal dose IV q24h

Fluconazole IV, PO

Tablet: 50 mg, 100 mg, 200 mg;
IV: 100 mg, 200 mg, 400 mg

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

100-400* mg IV/PO q24h

Susceptible-dose-dependent (SDD) C. glabrata: 800 mg IV/PO q24h
*Consider giving loading dose (2 x normal dose) as first dose if severe infection (max dose 800 mg)

<50 50% of normal dose IV/PO q24h
HD 50% of normal dose IV/PO q24h (give after HD on dialysis days, e.g. 10PM)
CRRT 400 mg IV/PO q24h
Note: 150 mg x 1 dose for vaginal candidiasis or 100mg/day – no renal adjustment necessary

Flucytosine PO

Capsule: 250mg, 500mg

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

25 mg/kg PO q6h

Dose based on ideal body wt

20-40 Normal dose PO q12h
10-20 Normal dose PO q24h
<10 Normal dose PO q48h
HD 25-50 mg/kg/dose PO q48h

Foscarnet IV

6 gm/vial, $221/vial

Usual Dose (Normal Renal Function) CrCl (ml/min/kg) Dosage Adjustment

 

 

Induction: 90 mg/kg IV q12h

 
Maintenance: 90 mg/kg IV q24h

Dose based on actual body wt, use adjusted body wt for BMI >30

^Ensure adequate hydration to prevent AKI

Induction Maintenance
>1-1.4 70 mg/kg IV q12h 70 mg/kg IV q24h
>0.8-1 50 mg/kg IV q12h 50 mg /kg IV q24h
>0.6-0.8 80 mg/kg IV q24h 80 mg/kg IV q48h
>0.5-0.6 60 mg/kg IV q24h 60 mg/kg IV q48h
>0.4-0.5 50 mg/kg IV q24h 50 mg/kg IV q48h
<0.4 No data No data
HD 45-60 mg/kg/dose after HD

Ganciclovir IV

500 mg/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

 

Induction: 5 mg/kg IV q12h*

 
Maintenance or Prophylaxis: 5 mg/kg IV q24h

*High dose induction: 10 mg/kg IV q12h for low level CMV resistant strain with UL97 mutation, EC 50 < 5 x normal

 

Dose based on actual body wt, use adjusted body wt for BMI >30

  Induction Maintenance or Prophylaxis
50-69 2.5 mg/kg IV q12h 2.5 mg/kg IV q24h
25-49 2.5 mg/kg IV q24h 1.25 mg/kg IV q24h
10-24 1.25 mg/kg IV q24h 0.625 mg/kg IV q24h
HD 1.25 mg/kg IV after HD 0.625 mg/kg IV after HD
CVVH 2.5 mg/kg IV q24h 1.25 mg/kg IV q24h
CVVHD, CVVHDF 2.5 mg/kg IV q12h 2.5 mg/kg IV q24h

Imipenem/Cilastatin/ Relebactam IV

1.25 gm, $330/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

1.25 gm IV q6h

60-89 1 gm IV q6h
30-59 750 mg IV q6h
15-29 500 mg IV q6h
<15 ON HD 500 mg IV q6h

IVIG

2.5 gm, 5 gm, 10 gm, 20 gm, 40 gm
$77/gm (i.e. $2000-5500/dose for a 70kg patient)

Toxic shock (GAS, MRSA): 1 gm/kg IV on day 1, 0.5 gm/kg IV on days 2 and 3.
Last resort C. difficle colitis: 400 mg/kg IV once
Measles post-exposure for high risk patient: 400mg/kg IV once
(Use ideal body wt for dosing, use adjusted body wt for BMI >30; round the dose to the nearest 5 gm)

Levofloxacin IV, PO

Tablet: 500 mg, 750mg
IV: 500 mg, 750mg

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

 750 mg IV/PO q24h

**500 mg IV/PO q24h (if CrCl <20, use q48h) for prophylaxis regimens**

20-49 750 mg IV/PO q48h
10-19, HD 750 mg IV/PO x1, then 500 mg IV/PO q48h
CRRT 750 mg IV/PO q48h

Meropenem IV

500 mg, 1 gm

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

500 mg IV q6h

31-49 500 mg IV q8h
<30 500 mg IV q12h
<10 or HD 500 mg IV q24h (give after HD on dialysis days, e.g. 10PM)
CRRT 1 gm IV q12h

 

2 gm IV q8h (Meningitis, intermediately sensitivity of carbapenem)

31-49 1 gm IV q8h
<30 1 gm IV q12h
<10 or HD 1 gm IV q24h (give after HD on dialysis days, e.g. 10PM)
CRRT 1 gm IV q8h

Meropenem / Vaborbactam IV

2 gm, $247/vial

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

4 gm IV q8h

**Dose using eGFR instead of CrCl**

eGFR 30-49 or CRRT 2 gm IV q8h
eGFR 15-29 2 gm IV q12h
eGFR <15 or HD 1 gm IV q12h

Oseltamivir PO

Capsule: 75 mg, 30 mg
Suspension: 6 mg/1ml

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

Treatment: 75 mg PO q12h

 
Prophylaxis: 75 mg PO daily

  Treatment Prophylaxis
30-60 30 mg PO q12h 30 mg PO daily
< 30 30 mg PO daily 30 mg PO q48h
HD 30 mg PO after HD 30 mg PO after every other HD session

Penicillin G IV

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

2-4 million units IV q4h

10-50 Normal dose q8-6h
<10 or HD Normal dose q12h
CRRT 4 million units IV x1, then normal dose IV q4h-q6h

Piperacillin/Tazobactam IV

4.5 gm

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

Standard 4-hour Extended Infusion (Preferred for all indications)

4.5 gm IV q8h

<20 or HD 4.5 gm IV q12h
CRRT 4.5 gm IV q8h

Limited IV Access: 30-minute Infusion (Pseudomonas, nosocomial pneumonia, or organism MIC 16)

4.5 gm IV q6h

20-40 4.5 gm IV q8h
<20 or HD 4.5 gm IV q12h
CRRT 4.5 gm IV q8h

Limited IV Access: 30-minute Infusion (All other indications)

4.5 gm IV q8h

<20 or HD 4.5 gm IV q12h
CRRT 4.5 gm IV q8h

Polymyxin B IV

500,000 units/vial

Usual Dose (Normal Renal Function) Dosage Adjustment

12,500 units/kg IV q12h(Use total body wt if < 100 kg or adjusted body wt if > 100 kg)Single maximum dose: 1.5 million units

No renal adjustment necessary

Monitor Cr, urine output

Ribavirin for RSV, PO

Capsule: 200 mg

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment
20 mg/kg/day PO divided in 2-3 doses
Maximum dose: 1800 mg/day
(Monitor Hgb closely)

 

<30

 

Normal dose PO q12-24h

Sulfamethoxazole/ Trimethoprim IV, PO

SS: trimethoprim 80 mg
DS: trimethoprim 160 mg

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

 

Dose based on trimethoprim component
UTI/ SSTI: 1 DS (160 mg) - 2 DS (320 mg) IV/PO q12h
PCP: 15 mg/kg/day IV/PO divided in q8-6h
Serious systemic infection: 5 mg/kg IV/PO q12h

 

 

 

10-30 or HD

 

UTI/ SSTI:  1 DS (160 mg) IV/PO q24h

PCP: 5-7.5 mg/kg/day IV/PO divided in q12-24h

Others: 5 mg/kg/day IV/PO q24h

CRRT

 No dosage adjustment required

Valganciclovir

tablet: 900 mg, 450 mg

Usual Dose (Normal Renal Function) CrCl (ml/min) Dosage Adjustment

Induction: 900 mg PO q12h

 

Maintenance: 900 mg PO q24h

 
Prophylaxis: 450 mg PO q12h or 900 mg PO q24h

  Induction Maintenance or Prophylaxis
40-59 450 mg PO q12h 450 mg PO q24h
25-39 450 mg PO q24h 450 mg PO q48h
10-24 450 mg PO q48h 450 mg PO twice weekly
HD 450 mg PO after HD 450mg PO after HD

 

Vancomycin IV

Please see Vancomycin Dosing Guidelines for full recommendations (e.g. dosing in HD, monitoring, etc.) on Sanford Guide via intranet.

**Patients with CrCl < 30 and actual body weight (ABW) less than 50kg, consider dosing vancomycin by level

    Creatinine Clearance (ml/min) Estimated by CG Equation
    ≥30-39 40-49 50-59 60-69 70-79 80-89 90-99 ≥100

 

 

 

 

 

Actual Body Weight (kg)

50-59 1g
q24h
1g
q24h
1g
q24h
0.75g
q12h
0.75g
q12h
1g
q12h
1g
q12h
1g
q12h
60-69 1g
q24h
1g
q24h
1g
q24h
0.75g
q12h
1g
q12h
1g
q12h
1g
q12h
1g
q12h
70-79 1g
q24h
1g
q24h
1g
q12h
1g
q12h
1g
q12h
1g
q12h
1g
q12h
1g
q8h
80-89 1g
q24h
1g
q24h
1g
q12h
1g
q12h
1g
q12h
1g
q12h
1g
q8h
1g
q8h
90-99 1g
q24h
1.5g
q24h
1g
q12h
1g
q12h
1g
q12h
1g
q8h
1g
q8h
1g
q8h
100-109 1.5g
q24h
1.5g
q24h
1g
q12h
1g
q12h
1g
q8h
1g
q8h
1g
q8h
1g
q8h
110-119 1.5g
q24h
1.5g
q24h
1g
q12h
1g
q12h
1g
q8h
1g
q8h
1g
q8h
1g
q6h
120-129 1.5g
q24h
1g
q12h
1g
q12h
1g
q8h
1g
q8h
1g
q8h
1g
q6h
1g
q6h
130-130 1.5g
q24h
1g
q12h
1g
q12h
1g
q8h
1g
q8h
1g
q8h
1g
q6h
1g
q6h
140-150 1.5g
q24h
1g
q12h
1g
q12h
1g
q8h
1g
q8h
1g
q6h
1g
q6h
1g
q6h

 

 

 

 Antibiotics that Do NOT Require Renal Adjustment

  • Azithromycin

  • Ceftriaxone

  • Chloramphenicol

  • Clindamycin

  • Dicloxacillin

  • Doxycycline

  • Eravacycline
  • Linezolid
  • Metronidazole
  • Micafungin

  • Nafcillin/Oxacillin

  • Voriconazole

  • Posaconazole (dosing for delayed release tablet and suspension formulations are NOT interchangeable)

 

Prepared by:

Yi Guo, PharmD, BCIDP

Hongkai (Jack) Bao, PharmD, BCIDP

Mei Chang, PharmD, BCIDP, BCCCP

Terrence McSweeney, PharmD

Austin Golia, PharmD