The Drug Monitor
Please read the Disclaimer
 

Antiinfectives

General Rx

Renal Rx

Transplant Rx

Pkinetics

Educational

KidneyWorks

Clinical Tools

Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid rules. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, clinical setting, the circumstances, and other factors, guidelines can and should be tailored to fit individual needs.

Renal Dosing of Antimicrobial Agents
Updated 7/7/2002
Nasr Anaizi, PhD

Related Information
 
Abbreviations and Conventions
  • Dose = Usual maintenance dose.
  • MDD = Maximum daily dose.
  • A loading dose is often necessary for patients with CLcr < 30 mL/min.
  • A patient with a CLcr < 15 mL/min is probably receiving dialysis
  • On dialysis days, the dose should be given after dialysis.
  • A supplementary dose may be necessary if a patient is dialyzed within a few hrs after receiving the routine dose.

Ampicillin Ampicillin/Sulbactam Aztreonam Cefazolin Cefepime
Cefotaxime Cefotetan Cefoxitin Cefpodoxime Ceftazidime
Cefuroxime Cephalexin Ciprofloxacin Fluconazole Imipenem
Meropenem Metronidazole Nitrofurantoin Ofloxacin Penicillin G
Piperacillin Piperacillin / Tazobactam Unasyn Vancomycin Zosyn

Ampicillin
Usual Dosage 1-2 g q 6 hrs
MDD = 12 grams (2 g q 4 hrs)
CLcr > 50 normal dosage
CLcr = 10 - 50100% of Dose q 8 hrs
CLcr < 10100% of Dose q 12 hrs
Dose should be given after dialysis or give supplementary dose after dialysis

Ampicillin/sulbactam, Unasyn
Usual Dosage = 1.5 to 3 g q 6 hrs
MDD = 12 grams (3 g q6h)
CLcr > 50 normal dosage
CLcr = 30 - 50100% of Dose q 8 hrs
CLcr = 15 -29100% of Dose q 12 hrs
CLcr < 15100% of Dose q 24 hrs
On dialysis days, the dose should be given after dialysis

Aztreonam, Azactam
Usual Dosage =0.5 to 1 g q 8 or q 12 hrs
MDD = 8 grams (2 g q6h)
CLcr > 50normal dosage
CLcr = 25 - 501 g q 12 hrs
CLcr = 10 - 241 g q 24 hrs
CLcr < 10 1 or 2 g load then 0.5 g post-dialysis

Cefazolin
Usual Dosage = 0.5 to 2 g q 8 hr
MDD = 12 grams (2 g q6h)
CLcr > 35normal dosage (1 g q 8 hrs)
CLcr = 15 - 35 1 g q 12 hrs
CLcr < 151 g q 24 hrs. On dialysis days, the dose should be given after dialysis

Cefepime
Usual Dosage = 1 or 2 g q 12 hr
For Pseudomonal infection: 1 or 2 g q8h
For Uncomplicated UTI: 0.5 g q12h
MDD = 6 grams (2 g q8h) (used for febrile neutropenia)
CLcr > 50normal dosage
CLcr = 30 - 50500 mg q 12 hrs
CLcr = 10 - 30500 mg q 24 hrs
CLcr < 10 1 g load then 250 mg q 24 hrs. On dialysis days, the dose should be given after dialysis
CVVH: 2 gram load followed by 1 gram q12h

Cefotaxime, Claforan
Usual Dosage = 1 to 2 g 8 hrs
Dosage for meningitis = 2 g q 4 hrs
MDD = 12 grams (2 g q4h)
CLcr > 50

normal dosage

CLcr =10 - 50

50% of MD q 8 hrs

CLcr < 10

1 g q 24 hrs On dialysis days, the dose should be given after dialysis

Cefotetan, Cefotan
Usual Dosage = 1 to 2 g q 12 hrs
MDD = 6 grams (2 g q8 hrs)
CLcr > 50normal dosage
CLcr =15 - 5050% of Dose q 12 hrs
CLcr < 1550% of Dose q 24 hrs. On dialysis days, the dose should be given after dialysis

Cefoxitin, Mefoxin
Usual Dosage =1 to 2 g q 6 - 8 hrs
MDD = 12 grams

 CLcr > 50

 normal dosage

 CLcr = 30 - 50

 50% of MD q 8 hrs

 CLcr =10 - 30

 50% of MD q 12 hrs

 CLcr < 10

 50% of MD q 24 hrs. On dialysis days, the dose should be given after dialysis

Cefpodoxime, Ventin
Usual Dosage = 100 to 400 mg q12 hrs

 CLcr > 30

 100% of MD q 12 hrs

 CLcr < 30

 100% of MD q 24 hrs. On dialysis days, the dose should be given after dialysis

Ceftazidime, Fortaz
Usual Dosage = 1 g q 8 hrs
MDD = 6 grams (2 g q 8 hrs)
CLcr > 50 normal dosage
CLcr = 31 - 501 g q 12 hrs
CLcr = 15 - 301 g q 24 hrs
CLcr < 15500 mg q 24 hrs or
1 g after each dialysis

Cefuroxime, Zinacef, Ceftin
Usual Dosage = 250 - 500 mg PO BID or 40 mg/kg/dose IV q 8 hrs; MDD = 6 g
CLcr  (mL/min)> 50 25 - 4910 - 24< 10
IV1.5 g
q 8 hrs
0.75 g
q 8 hrs
0.75 g
q 12 hrs
0.75 g
q 24 hrs
Oral  (mg)250 - 500 BID 250 BID250 BID250 QD

Cephalexin
Usual Dosage = 250 or 500 mg g q6 or q8 hrs
MDD = 2 g
CLcr > 50 100% of MD q 8 hrs
CLcr = 15 - 50100% of MD q 12 hrs
CLcr < 15100% of MD q 24 hrs
On dialysis days, the dose should be given after dialysis

Ciprofloxacin
Usual Dosage = 200 or 400 mg IV q12 hrs or 250 or 500 mg PO q 12 hrs
For Sepsis or nosocomial pneumonia: 400 mg IV q 8 hrs
MDD = 1200 mg (IV) or 1500 mg (PO)
Values below are for IV route.
PO dose = 1.25 x IV dose
CLcr > 50Usual Dosage
CLcr = 15 - 50200 or 400 mg q 24 hrs
CLcr < 15200 mg q 24 hrs
On dialysis days, the dose should be given after dialysis

Fluconazole, Diflucan
Usual Dosage =100 - 400 mg qday IV or PO
MDD = 400 mg
(Higher doses are sometimes used; monitor liver function)
A loading dose is often given; loading dose = 2 x maintenance dose
High doses may be required when administed with P450 inducers such as rifampin.
CLcr > 50 Usual dosage
CLcr = 20 - 5050% of MD qday
CLcr < 2025% of MD qday
or 100% of MD after each dialysis (a loading dose is necessary)

Imipenem, Primaxin
Usual Dosage = 500 mg q 6 hrs
MDD = 4 grams (1 g q6h)
Should not be used in patients with history of seizures or receiving tacrolimus (especially IV). Meropenem may be used for these patients.
CLcr >70Usual Dosage
CLcr = 31-70500 mg q 8 hrs
CLcr = 21-30250 mg q 8 hrs
CLcr = 10-20250 mg q 12 hrs
On dialysis days, the dose should be given after dialysis
CLcr < 10250 mg q12 hrs
Alternatively, 500 mg after each dialysis.

Meropenem, Merrem
Usual Dosage = 1 g q 8 hrs
MDD = 4 grams (1 g q6h)
Restricted to the treament of meningitis in pediatric patients.
CLcr > 50 1 g q 8 hrs
CLcr = 30 - 50500 mg q 8 hrs

 CLcr = 10 - 29

500 mg q 12 hrs
CLcr < 10 500 mg q 24 hrs

Metronidazole, Flagyl
Usual Dosage = 500 mg q 8 hrs
MDD = 2 g (500 mg q 6 hrs)
PO Dose = IV Dose
CLcr > 15500 mg q 8 hrs
CLcr < 15500 mg q 12 hrs or
500 mg after each dialysis

Nitrofurantoin
Usual Dosage = 50 - 100 mg q6 hrs
MDD = 400 mg (100 mg q6h)
Use only if CLcr > 50

Norfloxacin
Usual Dosage = 400 mg 12 hrs
MDD = 800 mg
CLcr > 50 400 mg q 12 hrs
CLcr =15 - 50400 mg q 24 hrs
CLcr < 15 Avoid

Ofloxacin
Usual Dosage = 400 mg 12 hrs
MDD = 800 mg (400 mg q12h)
PO Dose = IV Dose
CLcr > 50 Usual Dosage
CLcr = 15 - 50400 mg q q24 hrs
CLcr < 15 200 mg q 24 hrs

Penicillin G
Usual Dosage 1 to 4 million units q 4 hrs or q 6 hrs
MDD = 24 million units (4 million units q4h)
CLcr > 50Usual Dosage
CLcr =15 - 5075% of MD q 6 hrs
CLcr < 1550% of MD q 12 hrs
On dialysis days, the dose should be given after dialysis

Piperacillin
Usual Dosage = 3 or 4 g q 4 hrs or q 6 hrs
MDD = 24 grams (4 grams q 4 hrs)
CLcr > 40Usual Dosage
CLcr = 20 - 403 or 4 g q 8 hrs
CLcr < 203 g q 8 hrs
Plus 1 g after each dialysis.

Piperacillin / Tazobactam
Zosyn
Usual Dosage = 3.375 g q 6 hrs
MDD = 13.5 grams (3.375 q 6 hrs)
CLcr > 40Usual Dosage
CLcr = 20 - 402.25 g q6 hrs
CLcr < 202.25 g q8 hrs

Vancomycin
  • Usual Dosage = 15 mg per Kg actual body weight q 12 hrs
  • The suggested dosages below represent merely starting points.
  • Proper dosage depends on body weight (10 to 20 mg/kg) and CLcr.
  • Frequency should be adjusted to maintain the trough between 8 - 16 mg/L
  • CLcr > 80 Usual Dosage (15 mg/Kg q 12 hrs)
    CLcr = 40 - 80q 12 - 24 hrs
    CLcr = 30 - 40q 24 - 48 hrs
    CLcr = 20 - 30q 72 hrs
    CLcr < 20 Redose when level < 12 mg/L

     more on vanco 

     

    Pulse Dosing of Aminoglycosides

     

    Copyrights ® 1997-2002 the Drug Monitor