GUIDELINES FOR ANTIBIOTIC DOSING IN RENAL FAILURE AND DIALYSIS

NOTE: the dosage information in this table is based on Cockgroft -Gault creatinine clearance and not eGFR since the majority of the published information is based on creatinine clearance.
This table is not intended to offer definitive advice and is subject to the experiences and practise of the renal team at CHUFT as well as advice from the renal handbook and individual SPCs.

Drug Dose in normal Mild Moderate Severe Haemodialysis Peritoneal

renal function (GFR 20 – 50ml/min) (GFR 10 – 20ml/min) (GFR <10ml/min) dialysis
ACICLOVIR oral 1,2 200 – 400mg Dose as in normal 200mg tds or qds 200mg bd 200mg bd 200mg bd
(SIMPLEX treatment) five times a day renal function Give after dialysis
ACICLOVIR oral 1,3 800mg Dose as in normal 400 – 800mg tds 400 – 800mg bd 400 – 800mg bd 400 – 800mg bd
(ZOSTER treatment) five times a day renal function Give after dialysis
ACICLOVIR IV 1,6 5 – 10 mg/kg 5 – 10 mg/kg 5 – 10 mg/kg 2.5 – 5 mg/kg 2.5 – 5 mg/kg 2.5 – 5 mg/kg
every 8 hours every 12 hours every 24 hours every 24 hours every 24 hours every 24 hours
Give after dialysis
AMOXICILLIN PO and IV1, 4 250mg – 1g tds Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
(avoid if penicillin allergic) (endocarditis: max 12g renal function renal function renal function renal function renal function
in 24 hours) (endocarditis: Give after dialysis (endocarditis: max
max 6g in 24 (endocarditis: max 6g in 24 hours)
hours) 6g in 24 hours)
AMPHOTERICIN IV 1,5 1 – 3 mg/kg/day (higher ***HIGHLY NEPHROTOXIC*** Dose as in normal Dose as in normal
(Ambisone) as unlicensed use) No reduction in dose is required but only use if medical condition is renal function renal function
(warning: nephrotoxic) See individual product extremely severe and there is no suitable alternative
data sheet
AMPHOTERICIN IV 250mcg – 1.5 ***HIGHLY NEPHROTOXIC*** Dose as in normal Dose as in normal
(Fungizone) 1,7 mg/kg/day No reduction in dose is required but only use if medical condition is renal function renal function
(warning: nephrotoxic) See individual product extremely severe and there is no suitable alternative
data sheet
AMPICILLIN 1 PO: 250mg – 1g qds Dose as in normal 250mg – 2g 250mg – 1g 250mg – 1g 250mg – 1g
(warning: nephrotoxic) IV: 500mg – 2g renal function every 6 hours every 6 hours every 6 hours every 6 hours
(avoid if penicillin allergic) every 4 – 6 hours (monitor closely for (monitor closely for Give after dialysis
nephrotoxicity) nephrotoxicity)
AZITHROMYCIN 1 500mg daily for 3 days Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
renal function renal function renal function renal function renal function
BENZYLPENICILLIN IV 1 2.4g – 14.4g in 4-6 Dose as in normal 600mg – 2.4g every 6 600mg – 1.2g 600mg – 1.2g 600mg – 1.2g every
(avoid if penicillin allergic) divided doses renal function hours every 6 hours every 6 hours 6 hours
CASPOFUNGIN 1,8 70mg day 1 followed Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
by 50mg daily renal function renal function renal function renal function renal function
thereafter (70mg daily
if > 80kg)
Drug Dose in normal Mild Moderate Severe Haemodialysis Peritoneal
renal function (GFR 20 – 50ml/min) (GFR 10 – 20ml/min) (GFR <10ml/min) dialysis
CEFOTAXIME 1,9 1 – 2g Dose as in normal Dose as in normal 1g every 1g every 1g every
every 6 – 12 hours renal function renal function 8 – 12 hours 8 – 12 hours 8 – 12 hours
Life-threatening up to Give after dialysis
12g in 3-4 divided
doses
CEFTAZIDIME1,23 0.5 – 2g GFR: 31 – 50ml/min GFR: 6 – 15ml/min GFR <5ml/min 500mg – 1g 500mg – 1g
See datasheet for neutropenic every 8 – 12 hours 1 – 2g every 12 hours 500mg – 1g 500mg – 1g every 24 - 48 hours every 24 hours
patients (reference 23)
Severe infections: 3g GFR: 16 – 30ml/min every 24 hours every 48 hours Give after dialysis (dialysed)
every 12 hours 1 – 2g every 24 hours (2g after every HD
in exceptional
circumstances)
CEFTRIAXONE IV1,24 1g daily Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
Severe infections renal function renal function renal function renal function renal function
2 – 4g daily (Maximum (Maximum (Maximum
2g daily) 2g daily) 2g daily)
CIPROFLOXACIN 1 PO: 250 – 750mg bd Dose as in normal 50 – 100% of normal 50% of normal PO: 250-500mg bd PO: 250mg bd/tds
IV: 100 – 400mg bd renal function dose dose IV: 200mg bd IV: 200mg bd
CLARITHROMYCIN oral 1 250 – 500mg bd Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
renal function renal function renal function renal function renal function
CLARITHROMYCIN IV 1 500mg bd Dose as in normal 250 – 500mg bd 250 – 500mg bd 250 – 500mg bd 250 – 500mg bd
renal function
CLINDAMYCIN 1,10, 11 PO:150 – 450mg qds Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
IV: 300mg – 1.2g qds renal function renal function renal function renal function renal function
CO-AMOXICLAV oral 1 375mg – 625mg tds Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
(avoid if penicillin allergic) renal function renal function renal function renal function renal function
CO-AMOXICLAV IV 1 1.2g tds Dose as in normal 1.2g bd 1.2g bd 1.2g bd 1.2g bd
(avoid if penicillin allergic) renal function Give after dialysis
CO-TRIMOXAZOLE 1 480mg – 960mg daily Dose as in normal 480mg daily or 480mg daily or 480mg daily or 480mg daily or
oral prophylaxis or renal function 480mg alternate days 480mg alternate 480mg alternate 480mg alternate
960mg alternate days days days days
CO-TRIMOXAZOLE 1 60mg/kg bd or 30mg/kg Dose as in normal 60mg/kg bd for 3 30mg/kg bd 30mg/kg bd 30mg/kg bd
PCP treatment qds renal function days then 30mg/kg Give after dialysis
bd
Drug Dose in normal Mild Moderate Severe Haemodialysis Peritoneal
renal function (GFR 20 – 50ml/min) (GFR 10 – 20ml/min) (GFR <10ml/min) dialysis
DOXYCYCLINE 1,13 200mg on day 1 then Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
100mg daily renal function renal function renal function renal function renal function
severe 200mg daily
ERTAPENEM 1 1g daily Dose as in normal 50 – 100% of normal 50% of normal 1g 3 times a week 50% of normal
renal function dose dose or Give after dialysis dose
1g 3 times a week
ERYTHROMYCIN 1,14 Oral: 250 – 500mg qds Dose as in normal Dose as in normal 50 – 75% of 50 – 75% of 50 – 75% of normal
IV: 25 – 50 mg/kg/day renal function renal function normal dose normal dose dose
(max 4g daily) (max 2g daily) (max 2g daily) (max 2g daily)
ETHAMBUTOL 1 15mg/kg/day or Dose as in normal 15mg/kg every 24 – 15mg/kg every 48 25mg/kg 3 times a 15mg/kg every 48
30mg/kg 3 times a renal function 36 hours or hours or week after each hours or
week 7.5 – 15mg/kg/day 5 – 7.5mg/kg/day dialysis 5 – 7.5mg/kg/day
FLUCLOXACILLIN oral 1,15 250mg – 500mg qds Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
(avoid if penicillin allergic) renal function renal function renal function renal function renal function
(max 4g daily) (max 4g daily) (max 4g daily)
FLUCLOXACILLIN IV 1,16 250mg – 2g qds Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
(avoid if penicillin allergic) (endocarditis 2g every 4 renal function renal function renal function renal function renal function
hours if > 85kg) (max 4g daily) (max 4g daily) (max 4g daily)
FLUCONAZOLE 1 50 – 400mg daily Dose as in normal Dose as in normal 50% of dose 50% of dose daily 50% of dose
renal function renal function (no adjustment for or 100% 3 times a (no adjustment for
single dose) week single dose)
Give after dialysis
(no adjustment for
single dose)
FUSIDIC ACID 1,17,18 Oral: 0.5 – 1g tds Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
(Sodium fusidate) IV: 500mg tds renal function renal function renal function renal function renal function
GENTAMICIN IV 1 See Trust Protocol See protocol 2mg/kg stat then
Note: weight is based on ideal body http://intranet.rde.local/intranet/documents/183/2075/Gentamicin%20Prescribing.pdf http://rdecghweb01 redose 1mg/kg
weight and not actual body weight
Calculating IBW: /intranet/document when level is <2
(warning: nephrotoxic) http://intranet.rde.local/intranet/documents/183/2073/Gentamicin%20Dosing%20in%20Obese s/340/3276/Visio- (IP – see local
%20Patients.pdf systemic%20infecti policy)
ons%202011.pdf
IMIPENEM/CILASTATIN1,19 250mg – 1g every 6 – 8 500mg every 8hours 500mg 250 – 500mg 250 – 500mg 250 – 500mg
(Primaxin) hours every 12 hours every 12 hours every 12 hours every 12 hours
(increased risk of Give after dialysis Give after dialysis
convulsions with
500mg bd)
Drug Dose in normal Mild Moderate Severe Haemodialysis Peritoneal
renal function (GFR 20 – 50ml/min) (GFR 10 – 20ml/min) (GFR <10ml/min) dialysis
ISONIAZID 1 PO: 5mg/kg (max Dose as in normal Dose as in normal 200 – 300mg daily 200 – 300mg daily 200 – 300mg daily
300mg) daily renal function renal function Give after dialysis
IV: 200 – 300mg daily
ITRACONAZOLE 1 100 – 200mg every Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
12 – 24 hours renal function renal function renal function renal function renal function
LEVOFLOXACIN 1, 12 250mg daily 250mg stat then 250mg stat then 250mg stat then 250mg stat then 250mg stat then
(dose and frequency depend on 125mg daily 125mg alternate days 125mg alternate 125mg alternate 125mg alternate
indication)
days days days
500mg daily 500mg stat then 500mg stat then 500mg stat then 500mg stat then 500mg stat then
250mg daily 125mg daily 125mg daily 125mg daily 125mg daily
500mg twice a day 500mg stat then 500mg stat then 500mg stat then 500mg stat then 500mg stat then
250mg twice a day 125mg twice a day 125mg once a day 125mg once a day 125mg once a day
LINEZOLID 1,20 600mg bd Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
renal function renal function renal function renal function renal function
(use with caution – Give after dialysis
metabolites may
accumulate)
MEROPENEM 1,25 500mg – 1g tds 500mg – 2g 500mg - 1g every 12 500mg – 1g daily 1 – 2g 3 times a 500mg – 1g daily
(severe up to 2g tds) every 12 hours hours or week post dialysis
500mg every 8 hours
METRONIDAZOLE 1,21 Oral: 200 – 400mg Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
every 8 – 12 hours renal function renal function renal function renal function renal function
IV: 500mg tds Give after dialysis
PR: 1g bd - tds
NITROFURANTOIN 1 50 – 100mg qds Dose as in normal Contraindicated Contraindicated Contraindicated Contraindicated
prophylaxis: 50 – renal function
100mg at night
OFLOXACIN1 200 – 400mg daily 200 – 400mg 200 – 400mg 200mg 200mg 200mg
(can be increased to once daily once daily once daily once daily once daily
400mg twice daily) Give after dialysis
PENICILLIN V 1 500mg – 1g Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
(Phenoxymethylpenicillin) every 6 hours renal function renal function renal function renal function renal function
(avoid if penicillin allergic)
PIPERACILLIN/ 1,22 4.5g Dose as in normal 4.5g 4.5g 4.5g every 12 4.5g every 12 hours
TAZOBACTAM (Tazocin) every 6 – 8 hours renal function every 8 – 12 hours every 12 hours hours. Dialysed –
(avoid if penicillin allergic) give after dialysis
Drug Dose in normal Mild Moderate Severe Haemodialysis Peritoneal
renal function (GFR 20 – 50ml/min) (GFR 10 – 20ml/min) (GFR <10ml/min) dialysis
PYRAZINAMIDE 1 1.5 – 2g daily Dose as in normal Dose as in normal 50 – 100% of dose 50 – 100% of dose 50 – 100% of dose
renal function renal function daily or 25 –
30mg/kg 3 times a
week post-dialysis
RIFABUTIN 1 150 – 450mg daily Dose as in normal Max 300mg daily Max 300mg daily Max 300mg daily Max 300mg daily
renal function
RIFAMPICIN 1 300 – 600mg bd Dose as in normal Dose as in normal 50 – 100% of 50 – 100% of 50 – 100% of
renal function renal function normal dose normal dose normal dose
TEICOPLANIN 1 400mg bd for 3 doses Dose as in normal Give normal loading Give normal Give normal Give normal
then 200 – 400mg daily renal function dose, then 200 – loading dose, then loading dose, then loading dose, then
(10mg/kg/day in life 400mg every 24 – 48 200 – 400mg every 200 – 400mg every 200 – 400mg every
threatening infections) hours 48 - 72 hours 48 - 72 hours 48 - 72 hours
TICARCILLIN/ 3.2g every 6 – 8 hours GFR 30 - 50ml/min: GFR 10 – 30ml/min: 1.6g 1.6g 1.6g every 12 hours
CLAVULANIC ACID 1,26 (every 4 hours if severe 3.2g every 8 hours 1.6g every 8 hours every 12 hours every 12 hours
(Timentin) infection) give after dialysis
(avoid if penicillin allergic)
TRIMETHOPRIM 1 200mg every 12 hours Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
(can increase serum creatinine) renal function renal function renal function* renal function* renal function*
VANCOMYCIN IV 1 1g every 12 hours 0.5 – 1g 1g then redose when 1g then redose See line sepsis 1g then redose
(warning: nephrotoxic) every 12 – 24 hours level < 10 when level < 10 protocol when level < 10
http://rdecghweb01 (IP – see local
/intranet/document policy)
s/340/3276/Visio-
systemic%20infecti
ons%202011.pdf
VANCOMYCIN PO 1 125 – 500mg every 6 Dose as in normal Dose as in normal Dose as in normal Dose as in normal Dose as in normal
hours renal function renal function renal function renal function renal function
* Reduce the dose by 50% if nausea and vomiting occurs.

References:
1. Ashley C, Currie A. The Renal Drug Handbook. Radcliffe Medical Press, Oxon. 3rd Edition 2009
2. SPC Zovirax 200mg tablets http://www.medicines.org.uk/EMC/medicine/9273/SPC/Zovirax+200mg+Tablets/ – last updates 16th December 2008
3. SPC Zovirax 800mg tablets http://www.medicines.org.uk/EMC/medicine/9275/SPC/Zovirax+800mg+Tablets/ – last updated 16th December 2008
4. SPC Amoxicillin sodium for injection (Wockhardt UK Ltd) http://www.medicines.org.uk/EMC/medicine/5359/SPC/Amoxicillin+Sodium+for+Injection+(Wockhardt+UK+Ltd)/ – last updated 6th Dec 2010
5. SPC AmBisome http://www.medicines.org.uk/EMC/medicine/1236/SPC/AmBisome/ – last updated 18th May 2011
6. SPC Zovirax IV 250mg, 500mg http://www.medicines.org.uk/EMC/medicine/2191/SPC/Zovirax+IV+250mg%2c+500mg/ – last updated 12th August 2008
7. SPC Fungizone 50mg powder for sterile conc http://www.medicines.org.uk/EMC/medicine/559/SPC/Fungizone+50mg+Powder+for+Sterile+Concentrate/ – last updated 28th July 2010
8. SPC Cancidas (formerly Caspofungin MSD) http://www.medicines.org.uk/EMC/medicine/12843/SPC/CANCIDAS+(formerly+Caspofungin+MSD)/ – last updated 19th Jan 2011
 9. SPC Cefotaxime powder for solution for injection or infusion (wockhardt UK Ltd)
http://www.medicines.org.uk/EMC/medicine/7339/SPC/Cefotaxime+Powder+for+solution+for+injection+or+infusion++(Wockhardt+UK+Ltd)/ – last updated 29 August 2008
10. SPC Dalacin C Phosphate http://www.medicines.org.uk/EMC/medicine/1495/SPC/Dalacin+C+Phosphate/ – last updated 21st May 2010
11. SPC Dalacin C 150mg Capsules http://www.medicines.org.uk/EMC/medicine/12425/SPC/Dalacin+C+Capsules+75mg+and+150mg/ – last updated 21st May 2010
12. SPC Tavanic 500mg tablets http://www.medicines.org.uk/EMC/medicine/12796/SPC/Tavanic+500mg+tablets/ - last updated 21st Feb 2011
13. SPC Vibramycin D tablets 100mg http://www.medicines.org.uk/EMC/medicine/20879/SPC/Vibramycin-D+Dispersible+Tablets+100mg/ – last updated 5th Jan 2009
14. SPC Erythromycin 250mg BP tablets http://www.medicines.org.uk/EMC/medicine/23032/SPC/Erythromycin+250mg+Tablets/ – last updated 13th May 2010
15. SPC Floxapen 500mg capsules http://www.medicines.org.uk/EMC/medicine/20393/SPC/Floxapen+Capsules+500mg/ – last updated 21st May 2010
16. SPC Flucloxacillin for injection 500mg (wockhardt UK Ltd) http://www.medicines.org.uk/EMC/medicine/13036/SPC/Flucloxacillin+500mg+Powder+for+Solution+for+Injection+or+Infusion/ – last updated 30th Jun 2009
17. SPC Fucidin talblets http://www.medicines.org.uk/EMC/medicine/2448/SPC/Fucidin+Tablets/ - last updated 16th April 2008
18. SPC Sodium Fusidate 500mg for intravenous infusion http://www.medicines.org.uk/EMC/medicine/1017/SPC/Sodium+Fusidate+500mg+for+Intravenous+Infusion/ – last updated 6th July 2009
19. SPC Primaxin IV injection http://www.medicines.org.uk/EMC/medicine/7456/SPC/Primaxin+IV+Injection/ – last updated 11th May 2010
20. SPC Zyvox 600mg film coated tablets http://www.medicines.org.uk/EMC/medicine/9857/SPC/Zyvox+600+mg+Film-
Coated+Tablets%2c+100+mg+5+ml+Granules+for+Oral+Suspension%2c+2+mg+ml+Solution+for+Infusion/ – last updated 23rd June 2011
21. SPC Flagyl 500mg/100ml solution for infusion http://www.medicines.org.uk/EMC/medicine/8049/SPC/Flagyl+500mg+100ml+Solution+for+Infusion/ – last updated 17th May 2011
22. SPC Tazocin powder for solution for injection or infusion http://www.medicines.org.uk/EMC/medicine/2239/SPC/Tazocin+2g+0.25g+and+4g+0.5g+Powder+for+Solution+for+Injection+or+Infusion/ – last updated 23rd
June 2011
23. SPC Ceftazidime 2g powder for solution for injection or infusion (Wockhardt UK Ltd)
http://www.medicines.org.uk/EMC/medicine/21131/SPC/Ceftazidime+2g+Powder+for+solution+for+injection+or+infusion+(Wockhardt+UK+Ltd)/ - last updated 2nd Sept 2008
24. SPC Ceftriaxone 2g powder for solution for injection/infusion http://www.medicines.org.uk/EMC/medicine/5470/SPC/Ceftriaxone+2g+Powder+for+solution+for+injection+infusion/ - last updated 19th Jan 2011
25. SPC Meronem IV 500mg and 1g http://www.medicines.org.uk/EMC/medicine/11215/SPC/Meronem+IV+500mg+%26+1g/ - last updated 21st June 2010
26. SPC Timentin http://www.medicines.org.uk/EMC/medicine/2059/SPC/Timentin+0.8+G%2c+1.6+G%2c+3.2+G/ - last updated 18th Feb 2009

Version 2
Written and updated by:
Jackie Wallis – Renal Pharmacist, Colchester General Hospital

Verified by:
Medicines information, Colchester General Hospital

Last updated: August 2011

Reviewed by:
Dr Cserep – Consultant Nephrologist, Colchester General Hospital
Dr Sinnamon – Consultant Nephrologist, Colchester General Hospital
Dr Elston – Consultant Microbiologist, Colchester General Hospital
Dr Urwin - Consultant Microbiologist, Colchester General Hospital

Approved for use by:

Last approved NEEMMC: August 2011