Kingdom of Saudi Arabia

Ministry of higher Education

King Saud University
Collage of medicine &
King Khalid University Hospital

Adult Antimicrobial Dosing Recommendations in Renal Dysfunction

Antimicrobial

Usual Dose*

CrCl50

49-30

29-10

< 10

HD

CRRT

PD

Acyclovir [IV]

5-10 mg/kg

Q8H

Q12H

Q24H

50% Q24H

Q24H

50% Q24H

Adefovir[PO]

10mg

Q24H

Q48H

Q72H

No data

No data

100-200mg

Q12H

Q24-48HR

200mg
Q7days

Ampicillin [IV]

1-2 g

Q4-6H

200mg day 1
then 100mg
Q24H
Q6H

Q48H
(Q72H if
<20ml/min.)
200mg day 1
then 100mg
Q48H
Q12H

50% Q24H
post dialysis
10mg
Q7days
Post dialysis
200mg
Q7days

Q6-12H

250mg Q12H

Augmentin [IV]

1.2g

Q8H

Q8H

1.2 g stat
then 600 mg
Q12H

No data

No data

Augmentin [PO]

250-500 mg

Q8H

Q8H

Q12H

Q24H

Q24H

Aztreonam [IV]

1-2 g

Q6-12H

50% Q6-12H

Q12H

25% Q6-12H

Cefazolin [IV]

1-2 g

Q8H

50% Q12H

50%Q24H

Q12H

0.5g Q12H

Cefepime [IV]

1-2 g

Q8-12H

50% Q12H
Or
100% Q24H

50-100%
Q24H

25-50%
Q24H

Q12H

50% Q24H
Or
100% Q48H

Cetazidime [IV]

1-2g

Q8-12H

Q12H

Q24H

Q48H

Q12H

0.5g Q24H

Cefuroxime [IV]

750 mg-1.5 g

1 g Q12H

Q24H

200mgQ12H
Or
400mgQ24H

200-400mg
Q24H

Amantadine[PO]

Ciprofloxacin [IV]

400 mg

Q8H

Q12H

Q12H

200mg
Q7days
Q12- 24H

Q12- 24H
post dialysis
1.2g stat
1.2g stat
then 600 mg then 600 mg
Q24H
Q24H
Additional
600 mg may
be given
post dialysis
Q24H
Q24H, post
dialysis
25% Q6-12H

Q8H if
Q24H
(CrCl 20)
Q12H if
(CrCl 10-20)
200-400mg Q18-24H

0.5-1g Q24H
Or
1-2gm Q48H
0.5-1g Q24H
Or
1-2g Q4872H
1g post
dialysis
Dose post
dialysis

200- 400mg
Q24H

Antimicrobial

Usual Dose*

CrCl50

49-30

29-10

Ciprofloxacin [PO]

500-750 mg

Q12H

250-500mg Q12H

Clarithromycin [PO]

250-500 mg

Colistin [IV]

1-2 M.Unit

Q12H
2 M.Unit Q24H

0.5-1mg

1-2 M.Unit
Q8-12H
Q24H

Erythromycin [PO]

250-500 mg

Q6H

Q6H

Ethambutol [PO]

15-25mg/kg

Q24H

Q 24-36H

Fluconazole [IV/PO]

400-800 mg

Q24H

Entecavir[PO]

Imipenem [IV]

Meropenem [IV]
Nitrofurantoin [PO]

1-2 g

Penicillin G [IV]

0.5-4 million U

Pyrazinamide [PO]

25mg/kg (1-2g)

Tenofovir[PO]

125-250 mg Q12H Or
250-500 mg Q24H
2 M.Unit
2 M.Unit
Q24-36H
Q36H
30% Q24H Or
10% Q24H
100% Q72HR
Or 100%
Q7days
Q6H
50-75%
Q 24-36H

Q 48 H

200-400mg Q24H

Q8H

Q12H

50-100 mg Q6H
Treatment: 75mg Q12H
Prophylaxis: 75mg Q24H

Teicoplanin [IV]

250-500mg Q18H

Refer to Appendix 1

Oseltamivir[PO]

Ribavirin[PO]

50% Q24H Or
100% Q48H

< 10

50% Q12H

50% Q24H

HD

CRRT

PD

250- 500mg
Q24H
Dose post
dialysis
1 M.Unit
Q24H
10% Q24H
Or 100%
Q7days
Q6H

No data

250-500mg
Q24H
No data

Q 48 H post
dialysis
100% post
dialysis
250-500mg
Q12H
500mg Q24H

Q12H
2 M.Unit
Q24H
No data

No data
10% Q24H Or
100% Q7days

Q6H

Q6H

Q24-36 H

Q 48 H

200-400mg
Q24H
500mg
Q6-8H

50% Q24H
250-500mg
Q12H

0.5-1g
Q8-12H

100%Q24H

Treatment:
75mg Q12H
Prophylaxis:
75mg Q24H
75%

30mg once
weekly

NO
adjustment

NO
adjustment

100% Q12H

Not
recommended

Not recommended with CrCl 60 ml/min

Treatment:
75mg Q12H
Prophylaxis:
75mg Q24H
0.5-4 million U
Q 4-6 H
Q24H

Treatment: 75mg
Q12H
Prophylaxis:
75mg Q24H
75%

Treatment:
75mg Q24H
Prophylaxis:
75mg Q48H
75%

No data

30 mg once
weekly

20-50%

Q24H

25-35
mg/kg/dose 3
times per wk

25-35
mg/kg/dose
3 times per
wk

20-50% post
dialysis
25-35
mg/kg/dose
3 times per
wk after
dialysis

400mg Q12H up to
1400mg/day (if obese)

100% Q12H

6mg/kg
(400 mg)
300 mg

Q 24H

200mg
alternating with
400mg every
other day
Q48H

Q48H

Q72H

Q72 H

Q48H

Q72 H

Q24H

Q48H

Q72-96H

No data

Q7days

No data

No data

Not recommended

20-50%

Trimethoprim/
Sulfamethoxazole[IV]

5-20mg/kg/day (Q6-12H)

5-20mg/kg/day (Q6-12H)

5-10mg/kg
Q12H

Not recommended
If used: 5-10mg/kgQ24H or
5-20mg/kg 3X weekly post
dialysis
500mg Q24H

Valacyclovir [PO]

1g

Q8-12H

Q12H

Q24H

Antimicrobial

Usual dose*

CrCl 50

49-30

29-15

14-5

Lamivudine [PO]
for (HIV or HIV/HBV
coinfection)

150mg

Q12H

Q24H

150mg for 1
dose then
100mg Q24H

150mg for 1
dose then
50mg Q24H

Lamivudine for HBV [PO]

100 mg

Q24H

100mg for 1 dose

then 50mg Q24H

100mg for 1
dose then
25mg Q24H

35mg for 1
dose then
15mg Q24H

Antimicrobial
Piperacillin/tazobactam [IV]
(Pseudomonas or
nosocomial pneumonia)
Piperacillin/tazobactam
(other infections) [IV]

5mg/kg
Q12H

5-10mg/kg
Q24H

1gm Q12-24

50% Q24H

<5 or HD

CRRT

PD

50mg for 1
dose then
25mg Q24H
(post
dialysis)
35mg for 1
dose then
10mg Q24H
(post
dialysis)

100 mg for
1 dose then
50mg Q24H

50mg for 1
dose then
25mg Q24H

No data

35mg for 1
dose then
10mg Q24H

Usual dose*

CrCl 40

39-20

<20

HD

CRRT

PD

4.5 g Q6H

4.5 g Q6H

3.375 g Q6H

2.25 g Q6H

2.25 g Q8H

4.5g Q8H or
3.375 g Q6H

2.25 g Q8H

3.375 g Q6H

3.375 g Q6H

2.25 g Q6H

2.25 g Q8H

2.25 g Q12H

CVVH: 2.253.375g Q68H

CVVHD:
2.25-3.375g
Q6H
CVVHDF:
3.375g Q6h

2.25 g Q12H

Usual Dose*

CrCl 60

40-59

25-39

10-24

<10

HD

CRRT

PD

Valganciclovir (induction)
[PO]

900 mg

Q12H

450 mg
Q12H

450mg
Q24H

450mg Q48H

Valganciclovir
(maintenance/prophylaxis)
[PO]

900 mg

Q24H

450mg
Q24H

450mg
Q48H

450mg twice
weekly

Avoid it
Use IV
ganciclovir
instead
Avoid it
Use IV
ganciclovir
instead

Avoid it
Use IV
ganciclovir
instead
Avoid it
Use IV
ganciclovir
instead

Avoid it
Use IV
ganciclovir
instead
Avoid it
Use IV
ganciclovir
instead

Avoid it
Use IV
ganciclovir
instead
Avoid it
Use IV
ganciclovir
instead

Antimicrobial

*When ranges for doses and/or dosing intervals exist, disease severity, site of infection, patient body weight, and clinical response should be taken into
consideration when choosing an appropriate regimen.

Antimicrobials that do not Require Dose Adjustments for Renal Dysfunction

Antimicrobial
Amphotericin B Liposomal [IV]
Azithromycin [IV/PO]
Ceftriaxone [IV]
Clindamycin

Usual Dose *
5 mg/kg Q24H
500 mg Q24H
1-2 g Q24H (2 g Q12H for meningitis)
IV: 600-900 mg Q8H
PO: 300-450 mg Q6-8H
100 mg Q12H
5mg /kg/day
In hemodialysis give dose post dialysis
200 mg Q12-24H
600 mg Q12H
500 mg Q8H
400 mg Q24H
300 mg Q8-12H
100 mg x 1, then 50 mg Q12H
IV: 6 mg/kg Q12H x 2, then 4 mg/kg Q12H
Avoid IV formulation in CrCl <50 ml/min
PO: 200 mg Q12H

Doxycycline [IV/PO]
Isoniazide[PO]
Itraconazole [PO]
Linezolid [IV/PO]
Metronidazole [IV/PO]
Moxifloxacin [IV/PO]
Rifampicin [PO]
Tigecycline [IV]
Voriconazole

References:
1. Micromedex Healthcare Series Vol. 155, 2013
st
2. Drug Information Handbook, Lexicomp, 21 edition, 2012-2013
3. The Sanford Guide to Antimicrobial Therapy, 2010
th
4. Drug Prescribing in Renal Failure; Dosing Guidelines for Adults and Children, 5 edition, 2007

Prepared by: Muneera AL-Jelaify AND Ghaidaa Al-Mashhadani, MSc Pharm, Apr/2013
Reviewed by: Amani Hamad, MSc Pharm, Apr/2013
Drug & Poison Information Center
Apr/2013

Appendix 1**

st

**Adopted from Drug Information Handbook, Lexicomp, 21 edition, 2012-2013