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Antibiotic Dose in Renal Impairment

Renal Impairment

The following antibiotics may require dose adjustment in patients with reduced renal function.  Recommendations are based on creatinine clearance (CrCl), which is an estimate of renal function (GFR). 

Note: This calculation is based on the Cockcroft and Gault formula and is suitable for adults only.  Creatinine Clearance is an estimation of GFR, but if the patient is morbidly obese, anuric or in acute renal failure, this equation will not give a true reflection of GFR.

Anuric patients can be assumed to have a CrCl<10mL/min.

For deep seated infections or multi-drug resistant organisms please discuss with a consultant microbiologist. The general advice on doses in renal impairment in the table below may not always be appropriate in these situations. Examples include, but are not limited to:

Meningitis

Infective Endocarditis

Prosthetic Joint Infections

Pacemaker Infections

Please bear in mind that sepsis can commonly cause acute kidney injuries. If this is likely, full doses of antibiotics without narrow therapeutic index may be used in the first 24 hours and then adjust according to subsequent renal function.

This list is NOT exhaustive, but includes the most commonly used antibiotics at this Trust that require dose adjustment in renal impairment.  Please refer to the electronic Medicines Compendium for advice on antibiotic doses in renal impairment if antibiotic not listed here.

 

Antibiotic Doses in
Renal Impairment

Aciclovir (IV)

GFR (mL/min) 25-50
5-10mg/kg every 12 hours

GFR (mL/min) 10-25
5-10mg/kg every 24 hours

GFR (mL/min) <10
2.5-5mg/kg every 24 hours

Aciclovir (oral)

GFR (mL/min) 25-50
Dose as in normal renal function

GFR (mL/min) 10-25
Herpes simplex 200mg 8 hourly or 6 hourly
Herpes zoster 800mg 8 hourly or 12 hourly

GFR (mL/min) <10
Herpes simplex 200mg 12 hourly
Herpes zoster 400mg - 800mg 12 hourly

Amoxicillin

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
250mg – 1g 8 hourly
(max 6g per day in endocarditis)

Amphotericin (IV) Ambisome (liposomal)

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function

Benzylpenicillin

GFR (mL/min)
20-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-20ml/min: 600mg – 2.4g every 6 hours
depending on severity of infection

GFR (mL/min) <10
600mg – 1.2g every 6 hours
depending on severity of infection

Caspofungin

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function

Cefalexin

GFR (mL/min)
20-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-20ml/min: 250-500mg 8 hourly or 12hourly

GFR (mL/min) <10
250-500mg 8 hourly or 12hourly

Cefixime

GFR (mL/min)
20-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-20ml/min: Dose as in normal renal function

GFR (mL/min) <10
200mg daily

Cefotaxime

GFR (mL/min)
20-50ml/min: Dose as in normal renal function

GFR (mL/min)
5-20ml/min: Dose as in normal renal function

GFR (mL/min)
<5ml/min: reduce dose by 50% and keep the frequency the same

Ceftazidime

GFR (mL/min)
31-50ml/min: 1 - 2g 12 hourly

GFR (mL/min)
16-30ml/min: 1 - 2g every 24hours

GFR (mL/min)
6-15ml/min: 500mg – 1g every 24hours
<5ml/min: 500mg-1g 48 hourly

Ceftriaxone

GFR (mL/min)
20-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-20ml/min: Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function (maximum 2g daily)

Cefuroxime (IV)

GFR (mL/min)
20-50ml/min: Dose as in normal renal function.

GFR (mL/min)
10-20ml/min:750mg-1.5g 12 hourly

GFR (mL/min) <10
750mg-1.5g 24 hourly

Ciprofloxacin

GFR (mL/min)
30-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-30ml/min: 50-100% of normal dose

GFR (mL/min) <10
50% of normal dose. 100% of normal dose may be given for short periods in acceptional circumstances.

Claithromycin (IV)

GFR (mL/min)
30-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-30ml/min: 250-500mg 12 hourly

GFR (mL/min) <10
250 - 500mg 12 hourly

Clarithromycin (oral)

GFR (mL/min)
30-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-30ml/min: 250-500mg 12 hourly

GFR (mL/min) <10
250mg - 500mg 12 hourly

Co-amoxiclav (IV)

GFR (mL/min)
30-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-30ml/min: 1.2g 12 hourly

GFR (mL/min) <10
1.2g stat, then 600mg 8 hourly

1.2g BD Can be used

Co-amoxiclav (oral)

GFR (mL/min)
30-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-30ml/min: Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function

Erythromycin

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function

Ethambutol

GFR (mL/min)
20-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-20ml/min: 15mg/kg every 24-36 hours

Another option is 7.5-15mg/kg/day

GFR (mL/min) <10
15mg/kg every 48 hours

Another option is 5-7.5mg/kg/day

Flucloxacillin

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function up to a total daily dose of 4g

Fluconazole

GFR (mL/min) 20-50
50-100% of normal dose.

GFR (mL/min) 10-20
50-100% of normal dose.

GFR (mL/min) <10
50% of normal dose

Gentamicin

GFR (mL/min)
Refer to Gentamicin Monitoring Guidelines Summary
Once Daily Gentamicin
Traditional Multiple Daily Dosing gentamicin

Isoniazid

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
200-300mg daily

Linezolid

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function - but monitor closely

Meropenem

GFR (mL/min)
26-50ml/min: 500mg-2g 12 hourly

GFR (mL/min)
10-25ml/min: 500mg-1g 12 hourly or 500mg 8 hourly

GFR (mL/min) <10
500mg-1g 24 hourly

Metronidazole

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function

Nitrofurantoin

GFR (mL/min)
>45ml/min: Dose as in normal renal function

GFR (mL/min)
<45ml/min - Contraindicated

However, a short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 ml/min/1.73m2. Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects.


Rifampicin

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
50-100% of normal dose

Sodium fusidate

GFR (mL/min) 20-50
Dose as in normal renal function

GFR (mL/min) 10-20
Dose as in normal renal function

GFR (mL/min) <10
Dose as in normal renal function

Piperacillin-tazobactam

GFR (mL/min)
40-50ml/min: Dose as in normal renal function

GFR (mL/min)
20-40ml/min: 4.5g 8 hourly

GFR (mL/min)
<20ml/min: 4.5g 12 hourly

Teicoplanin

GFR (mL/min)
>80ml/min: Dose as in normal renal function

GFR (mL/min)
30-80ml/min: Give as normal for 4 days. On the 5th day reduce dose by 50% OR give current dose every 48hrs.

GFR (mL/min)
<30ml/min: Give as normal for 4 days. On the 5th day reduce dose by 66% OR give current dose every 72hrs.

Tigecycline

GFR (mL/min)
20-50ml/min: Dose as in normal renal function

GFR (mL/min)
10-20ml/min: Doses as in normal renal function.

GFR (mL/min)
<10ml/min: Doses as in normal renal function.

Trimethoprim

GFR (mL/min) 25-50
Dose as in normal renal function

GFR (mL/min) 15-25
Dose as in normal renal function

GFR (mL/min) <15
50-100% of normal dose

Vancomycin (IV)

GFR (mL/min) >70
1g BD

GFR (mL/min) 30-70
1g OD

GFR (mL/min) <30
As advised by Microbiology