Dosage of Antimicrobial Drugs in Adult Patients with Renal Impairment

Aminoglycosides

Amikacin

I

7.5mg/kg q12h

7.5mg/kg q24h

7.5mg/kg q48h

Gentamicin

I

1.7-2.0mg/kg q8h

1.7-2.0mg/kg q12h-24h

1.7-2.0mg/kg q8h

CrCl 60-80

CrCl 40-60

CrCl 30-40

Gentamicin

4 mg/kg q24h

3.5 mg/kg q24h

2.5 mg/kg q24h

Isepamicin

8 mg/kg q24h

8 mg/kg q24h

8mg/kg q48h

Amikacin Streptomycin

12 mg/kg q24h

7.5 mg/kg q24h

4 mg/kg q24h

Carbapenem

Doripenem

D, I

500mg q8h

30-50: 250mg q8h;

10-30: 250mg q12h

No data

Ertapenem

D

1g q24h

<30: 0.5g q24h

0.5g q24h

Imipenem

D, I

250-500mg q6-8h

250mg Q8-12h

125-250mg q12h

Meropenem

D, I

1 g q8h

25-50: 1 g q12h; 

10-25: 0.5g q12h

0.5g q24h

Cephalosporin, parenteral

Cefazolin

I

1-2g q8h

1-2g q12h

1-2g q24-48h

Cefepime

D, I

>60: 2g q8-12h

30-60: 2g q12h

11-29: 2g q24h

1g q24h

Cefotaxime

I

2g q8-12h

2q12-24h

2g q24h

Cefoxitin

I

2g q8h

2g q8-12h

2g q24-48h

Ceftazidime

I

2g q8-12h

2g q12-24h

2g q24-q48h

Ceftizoxime

I

2g q8h-12h

2g q12h-24h

2g q24h

Ceftriaxone

I

1-2g q12-24h

1-2g q12-24h

1-2g q12-24h

Cefuroxime

I

0.75-1.5g q8h

0.75-1.5g q8-12h

0.75-1.5g q24h

Flouroquinolone

Ciprofloxacin

D

400mg q12h

400mg q24h

400mg q24h

Gemifloxacin

D

320mg q24h

160mg q24h

160mg q24h

Levofloxacin

D, I

750mg q24h

20-49: 750mg q48h

< 20: 750mg once,

then 500mg q48h

Ofloxacin

D

200-400mg q12h

200-400mg q24h

200mg q24h

Macrolide

Clarithromycin

D

500mg q12h

500mg q12-24h

500mg q24h

Erythromycin

D

100%

100%

50-75%

Penicillins

Ampicillin

I

1-2g q4-6h

30-50 1-2g q6–8h

10-30: 1-2g q8-12h

1-2g q12h

Amoxicillin

I

250-500mg q8h

250-500mg q8-12h

250-500mg q24h

Ampicillin/

Sulbactam

I

3g q6h

3g q8-12h

3g q24h

Amoxicillin/

Clavulanate

D, I

500/125mg q8h

250-500mg q12h

(amox component)

250-500mg q24h

(amox)

Piperacillin/

Tazobactam

(non-pseudomonas dose)

D, I

>40: 3.375g q6h

20-40: 2.25g q6h;

< 20: 2.25g q8h

2.25g q8h

Piperacillin/

Tazobactam (pseudomonas dose)

D, I

>40: 4.5g q6h

20-40: 3.375g q6h;

< 20: 2.25g q6h

2.25g q6h

Ticarcillin

D, I

1-2gm q4h

1-2gm q8h

1-2gm q12h

Tetracycline

Tetracycline

I

250-500mg q8-12h

250-500mg q12-24h

250-500mg q24h

Micellaneous Antibacterial

Colistin base

D, I

Daily maintenance dose = 2.5*[(1.5*CrCln)+30]

Divide and give q8h-12h, max 475mg/day

CrCln = CrCl * (pt BSA /1.73 m² )

Daptomycin

I

4-6mg/kg/d

30-49: 4-6mg/kg q24h; < 30 : 6mg/kg q48h

Linezolid

–

600mg q12h

600mg q12h

600mg q12h

Teicoplanin

I

6mg/kg q24h

6mg/kg q48h

6mg/kg q72h

TMP-SMX
(treatment)

I

5-20mg/kg/d q6-12h

30-50: 5-20 mg/kg q6-12h

10-29: 5-10 mg/kg q12h

Not recommended

Vancomycin

D, I

15-30mg/kg q12h

15mg/kg q24-96h

7.5mg/kg Q2-3d

Antifungal

Fluconazole

D

100-400mg q24h%

50-200mg q24h

50-200mg q24h

Itraconazole

D

200mg q12h

Do not IV if CrCl < 30 due to accumulation of cyclodextrin vehicle.

Metronidazole

D

7.5mg/kg q6h

7.5mg/kg q6h

7.5mg/kg q12h

Voriconazole

I

6mg/kg IV 12h*2doses,

then 4mg/kg q12h

If CrCl <50, IV vehicle (cyclodextrin) accumulates. Use oral or discontinue.

Antituberculous

Ethambutol

I

15-25mg/kg q24h

30-50:

15-25mg/kg q24-36h

10-30:

15-25mg/kg q36-48h

15mg/kg q48h

Isoniazid

D

5mg/kg q24h

5mg/kg q24h

5mg/kg q24h

Pyrazinamide

D

25mg/kg q24h

21-50: 25mg/kg q24h; 10-20: 25mg/kg q48h;

25mg/kg q48h

Rifabutin

D

300mg q24h

300mg q24h

300mg q24h

Rifampin

D

600mg q24h

300-600mg q24h

300-600mg q24h

Antiviral agents

Abacavir

PO

600mg q24h

600mg q24h

600mg q24h

Acyclovir

D, I

5-12.5mg/kg q8h

5-12.5mg/kg q12-24h

2.5-6.25mg q24h

Adefovir

I

10mg q24h

10mg q48-72h

10mg q72h

Amantadine

I

100mg q12h

100mg q24-48h

100mg weekly

Atripla

I

1 tab q24h

Do not use

Do not use

Combivir

PO

1 tab q12h

Do not use

Do not use

Didanosine

D

400mg EC q24h

125-200mg EC q24h

Do not use

Entecavir

D

0.5mg q24h

0.15-0.25mg q24h

0.05mg q24h

Famciclovir

D, I

500mg q8h

500mg q12-24h

250mg q24h

Ganciclovir

(IV induction)

D, I

70-90: 5mg/kg q12h

50-69: 2.5mg/kg q12h

25-49: 2.5mg/kg q24h;

10-24: 1.25mg/kg

q24h

1.25mg/kg 3x/week

Ganciclovir

(IV maintenence)

D, I

2.5-5mg/kg q24h

0.625-1.25mg/kg q24h

0.625mg/kg 3x/week

Ganciclovir

D, I

0.5-1g q8h

0.5-1g q24h

0.5g 3x/week

Lamivudine

D, I

300mg q24h

50-150 mg q24h

25-50 mg q24h

Oseltamivir

I

>60: 75mg q12h

31-60: 30mg bid;

10- 30: 30mg qd

Not recommended

Ribavirin

No dosage adjustment

Use with caution

Use with caution

Sofosbuvir

PO

400mg q24h

Use with caution

(no data for use in patients with CrCl<30)

Stavudine

D, I

30-40mg q12h

15-20mg q12h

≧ 60 kg: 20mg q24h; < 60 kg: 15mg q24h

Telbivudine

I

600mg q24h

30-49: 600mg q48h; 10-30: 600mg q72h

600mg q96h

Valaciclovir

D, I

1g q8h

1g q12-24h

0.5g q24h