Dose in Renal Impairment | Blackpool Teaching Hospitals NHS Foundation Trust

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).

Creatinine Clearance Calculator

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.

The dosing regimes below are for patients who are NOT on dialysis. For dialysis patients, please consult pharmacy.

Aciclovir (IV)

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

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

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

Aciclovir (oral)

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

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

GFR <10 mL/min
Herpes simplex 200mg 12 hourly
Herpes zoster 400mg – 800mg 12 hourly

Amoxicillin

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

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

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

Amphotericin (IV) Ambisome (liposomal)

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

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

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

Benzylpenicillin

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

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

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

Caspofungin

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

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

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

Cefalexin

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

GFR 10-20 mL/min
250-500mg 8 hourly or 12hourly

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

Cefixime

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

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

GFR <10 mL/min
200mg daily

Cefotaxime

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

GFR 5-20 mL/min
Dose as in normal renal function

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

Ceftazidime

GFR 31-50 mL/min
1 – 2g 12 hourly

GFR 16-30 mL/min
1 – 2g every 24hours

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

Ceftriaxone

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

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

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

Cefuroxime (IV)

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

GFR 10-20 mL/min
750mg-1.5g 12 hourly

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

Ciprofloxacin

GFR 30-50 mL/min
Dose as in normal renal function

GFR 10-30 mL/min
50-100% of normal dose

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

Claithromycin (IV)

GFR 30-50 mL/min
Dose as in normal renal function

GFR 10-30 mL/min
250-500mg 12 hourly

GFR <10 mL/min
250 – 500mg 12 hourly

Clarithromycin (oral)

GFR 30-50 mL/min
Dose as in normal renal function

GFR 10-30 mL/min
250-500mg 12 hourly

GFR <10 mL/min
250mg – 500mg 12 hourly

Co-amoxiclav (IV)

GFR 30-50 mL/min
Dose as in normal renal function

GFR 10-30 mL/min
1.2g 12 hourly

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

1.2g BD Can be used

Co-amoxiclav (oral)

GFR 30-50 mL/min
Dose as in normal renal function

GFR 10-30 mL/min
Dose as in normal renal function

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

Erythromycin

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

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

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

Ethambutol

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

GFR 10-20 mL/min
15mg/kg every 24-36 hours

Another option is 7.5-15mg/kg/day

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

Another option is 5-7.5mg/kg/day

Flucloxacillin

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

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

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

Fluconazole

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

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

GFR <10 mL/min
50% of normal dose

Gentamicin

Refer to Gentamicin Monitoring Guidelines Summary
Once Daily Gentamicin
Traditional Multiple Daily Dosing gentamicin

Isoniazid

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

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

GFR <10 mL/min
200-300mg daily

Linezolid

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

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

GFR <10 mL/min
Dose as in normal renal function – but monitor closely

Meropenem

GFR 26-50ml/min
500mg-2g 12 hourly

GFR 10-25ml/min
500mg-1g 12 hourly or 500mg 8 hourly

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

Metronidazole

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

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

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

Nitrofurantoin

GFR >45 mL/min
Dose as in normal renal function

GFR <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.