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
Renal Dosage Adjustment It is More Than Pharmacokinetics	Pulse Dosing of Aminoglycosides CVVH Initial Dosing Guidelines
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 - 50	100% of Dose q 8 hrs
CLcr < 10	100% 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 - 50	100% of Dose q 8 hrs
CLcr = 15 -29	100% of Dose q 12 hrs
CLcr < 15	100% 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 > 50	normal dosage
CLcr = 25 - 50	1 g q 12 hrs
CLcr = 10 - 24	1 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 > 35	normal dosage (1 g q 8 hrs)
CLcr = 15 - 35	1 g q 12 hrs
CLcr < 15	1 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 > 50	normal dosage
CLcr = 30 - 50	500 mg q 12 hrs
CLcr = 10 - 30	500 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 > 50	normal dosage
CLcr =15 - 50	50% of Dose q 12 hrs
CLcr < 15	50% 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 - 50	1 g q 12 hrs
CLcr = 15 - 30	1 g q 24 hrs
CLcr < 15	500 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 - 49	10 - 24	< 10
IV	1.5 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 BID	250 BID	250 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 - 50	100% of MD q 12 hrs
CLcr < 15	100% 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 > 50	Usual Dosage
CLcr = 15 - 50	200 or 400 mg q 24 hrs
CLcr < 15	200 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 - 50	50% of MD qday
CLcr < 20	25% 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 >70	Usual Dosage
CLcr = 31-70	500 mg q 8 hrs
CLcr = 21-30	250 mg q 8 hrs
CLcr = 10-20	250 mg q 12 hrs On dialysis days, the dose should be given after dialysis
CLcr < 10	250 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 - 50	500 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 > 15	500 mg q 8 hrs
CLcr < 15	500 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 - 50	400 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 - 50	400 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 > 50	Usual Dosage
CLcr =15 - 50	75% of MD q 6 hrs
CLcr < 15	50% 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 > 40	Usual Dosage
CLcr = 20 - 40	3 or 4 g q 8 hrs
CLcr < 20	3 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 > 40	Usual Dosage
CLcr = 20 - 40	2.25 g q6 hrs
CLcr < 20	2.25 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 - 80	q 12 - 24 hrs
CLcr = 30 - 40	q 24 - 48 hrs
CLcr = 20 - 30	q 72 hrs
CLcr < 20	Redose when level < 12 mg/L
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Pulse Dosing of Aminoglycosides