Intravenous Antibiotic Dosing in Renal Impairment in Adults
The chart below provides information to help clinicians craft intravenous antibiotic dosing regimens for patients with renal impairment, including those receiving intermittent hemodialysis or continuous renal replacement therapies. Use of clinical judgment is paramount; much dosing information in these populations is based on pharmacokinetics and expert experience and opinion. Most published doses assume that CRRT patients have minimal residual renal function and are getting an ultrafiltration and dialysis flow rate of 1 to 2 L/h. They also assume intermittent hemodialysis session are three times per week.^{11} Use the information in this chart as a guide to get the antibiotic started and consider infectious disease consult.
Some general considerations regarding renal replacement that might help in making dosing decisions include:
 Consider aggressive dosing in CRRT; data suggest that some recommended dosing in the literature may lead to underdosing.^{11} Weigh risks of drug toxicity vs risk of therapeutic failure.
 When dosing is unavailable (e.g., new drug), some clinicians dose empirically as for a CrCl of about 30 to 50 mL/min.^{15}
 Use therapeutic drug monitoring to guide therapy for drugs for which there is good data for an association between serum levels and efficacy/toxicity.^{11}
 CRRT modality (CVVH, CVVHD, CVVHDF) may affect dosing, but total effluent volume is the most important factor in drug removal.^{14}
 If CRRT is held, the dose may need to be held or reduced.^{11 }In these cases, dose as per any residual renal function.^{3}
 SLED: Less is known about its effects on antibiotic pharmacokinetics vs other renal replacement therapies. Consider dosing as for
CrCl 60 mL/min while on SLED, and as for CrCl <10 mL/min off SLED.^{10 }For patients on SLED for six to 12 hours/day, dose as for CrCl 10 to 50 mL/min.^{12} Ensure nurses are aware of any postSLED doses ordered.^{12 }Try to schedule 12 hour dosing so that a dose is given immediately postSLED.^{12 }For antibiotics dosed every 24 hours, try to schedule the dose immediately postSLED, or if that is not possible, consider giving a supplemental dose immediately postSLED.^{12}
Abbreviations: CRRT = continuous renal replacement therapy; CVVH = continuous venovenous hemofiltration; CVVHD = continuous venovenous hemodialysis CVVHDF = continuous venovenous hemodiafiltration; eGFR = estimated glomerular filtration rate; MDRD = Modification of Diet in Renal Disease; MIC = minimum inhibitory concentration; SLED: sustained lowefficiency dialysis (also called SLEDD = slow extended daily dialysis); UTI = urinary tract infection
Drug  Adult Dosing Information for Intravenous Formulation (treatment doses) 
Aminoglycosides (Plazomicin covered below)  A complete discussion of aminoglycoside dosing is beyond the scope of this document, but some general practice tips include: Loading dose (for treatment) tobramycin or gentamicin 2 to 3 mg/kg (amikacin 10 mg/kg), then:^{3,11,16}
Renal impairment, nondialysis (maintenance dosing): Hemodialysis (maintenance dosing): CRRT: For treatment of gram negative infections, typical dosing for gentamicin or tobramycin might be 2 mg/kg every 24 to 48 hours, or for amikacin, 7.5 mg/kg every 24 to 48 hours.^{2} Redose when level is tobramycin/gentamicin ≤3 mg/L for systemic gram negative infections, or <1 to 2 mg/L for cystitis, or <1 mg/L for synergy.^{11 }To check an aminoglycoside peak, wait two hours after administration to allow for delayed distribution.^{11 }Alternatively, provide loading dose, then dose based on levels.^{3} SLED: gentamicin or tobramycin: consider starting critical care patients with 6 mg/kg lean body weight (adjusted weight if obese) every 48 hours starting one hour before SLED. Consider starting noncritical care patients with 2 to 2.5 mg/kg every 24 hours. Amikacin: start with 15 to 20 mg/kg every 48 hours. Redose as warranted by post SLED levels.^{12} ^{} 
Ampicillin  Renal impairment, nondialysis:
Hemodialysis: Give recommended dose every 12 to 24 hours. Schedule such that a dose is given immediately after dialysis.^{1} CVVH: 1 to 2 g every 8 to 12 hours (flow rate 1 to 2 L/h).^{11} CVVHD: 2 g every 6 hours (dialysate flow rate <2 L/h); or 2 g every 4 hours (dialysate flow rate 2 to <6 L/h).^{9} CVVHDF: 1 to 2 g every 6 to 8 hours (dialysate flow rate 1 to 2 L/h).^{11} ^{} 
Ampicillin/  Renal impairment, nondialysis:
Hemodialysis: Give recommended dose every 12 to 24 hours. Schedule such that a dose is given immediately after dialysis.^{1} CVVH: 1.5 to 3 g every 8 to 12 hours.^{3} CVVHD: 1.5 to 3 g every 8 hours^{ }(dialysate flow rate 1 L/h); 1.5 to 3 g every 6 to 8 hours (dialysate flow rate 2 L/h); or 1.5 to 3 g every 6 h (dialysate flow rate 3 to 4 L/h).^{3} CVVHDF: 1.5 to 3 g every 6 to 8 hours (dialysate flow rate 1 to 2 L/h).^{11} Note: 3 g contains 2 g ampicillin plus 1 g sulbactam; 1.5 g ampicillin/sulbactam contains 1 g ampicillin plus 500 mg sulbactam. 
Azithromycin  No dose reduction advised for renal impairment or renal replacement.^{5} ^{} 
Aztreonam  Renal impairment, nondialysis:
Hemodialysis: Dose as for CrCl <10 mL/min. For serious infections, give oneeighth of the dose after each dialysis session in addition to maintenance dosing.^{1} CVVH: 2 g x 1, then 1 g every 8 hours (flow rate 1 L/h); 2 g every 12 hours (flow rate 2 L/h); 2 g every 8 hours (flow rate 3 L/h); or 2 g every 6 hours (flow rate 4 L/h).^{3} CVVHD: 2 g x 1, then 1 g every 8 hours or 2 g every 12 hours (dialysate flow rate 1 to 2 L/h); or 2 g every 8 hours (dialysate flow rate 3 to <6 L/h).^{3,9} CVVHDF: 2 g x 1, then 1 g every eight hours or 2 g every 12 hours (dialysate flow rate 1 to 2 L/h).^{11} ^{} 
Cefazolin  Renal impairment, nondialysis:
Hemodialysis: 2 g x 1, then 2 g postdialysis.^{17} CVVH: 2 g x 1, then 1 g every 12 hours (flow rate 1 to 2 L/h); or 1 g every 8 hours (flow rate 3 to 4 L/h).^{3} CVVHD: 2 g x 1, then 1 g every 8 hours or 2 g every 12 hours (dialysate flow rate 1 to 2 L/hour); or 2 g every 8 hours (dialysate flow rate 3 to <6 L/h).^{3,9} CVVHDF: 2 g x 1, then 1 g every 8 hours or 2 g every 12 hours (dialysate flow rate 1 to 2 L/h).^{11} 
Cefepime  Renal impairment, nondialysis:
Hemodialysis: 1 g every 24 hours.^{11 }Give postdialysis on dialysis days.^{1} CVVH or CVVHD: 2 g every 12 hours (febrile neutropenia and flow rate 1 to 2 L/h); 2 g every 8 hours (febrile neutropenia and flow rate 3 to 4 L/h OR other indication and flow rate 3 to 4 L/h); 2 g x 1, then 1 g every 8 hours (nonneutropenic and flow rate 1 L/h); or 2 g x 1, then 1 g every 6 hours (nonneutropenic and flow rate 2 L/h).^{3} Consider 2 g every 8 hours for gram negatives with MIC ≥4 mcg/mL.^{11 } CVVHDF: 2 g x 1, then 1 g every 8 hours or 2 g every 12 hours (dialysate flow rate 1 to 2 L/h).^{11 }2 g every 8 hours recommended for gram negatives with MIC 4 mcg/mL.^{11} 
Cefotaxime  Renal impairment, nondialysis: CrCl ≤20 mL/min: reduce dose by 50%.^{1} Hemodialysis: 2 g every 24 hours, plus 1 gram postdialysis.^{5} CVVH: 1 to 2 g every 8 to 12 hours (flow rate 1 to 2 L/hr).^{11} CVVHD: 2 g every 12 hours,^{2 }or 1 to 2 g every 8 hours (dialysate flow rate 1 to 2 L/h).^{11} CVVHDF: 1 to 2 g every 8 hours (dialysate flow rate 1 to 2 L/h).^{11} ^{} 
Cefotetan  Renal impairment, nondialysis:
Hemodialysis 1 to 2 g every 24 hours plus extra 1 g after dialysis.^{5} CRRT: 1 to 2 g every 24 hours.^{1} 
Cefoxitin  Renal impairment, nondialysis:
Hemodialysis: Maintenance dose per residual renal function, plus 1 to 2 g postdialysis.^{1} CRRT: 1 to 2 g every 8 to 12 hours.^{1} 
Ceftaroline  Renal impairment, nondialysis:
Hemodialysis: 200 mg every 12 hours. Schedule such that a dose is given immediately after dialysis.^{1} CRRT: no data. 
Ceftazidime  Renal impairment, nondialysis:^{1}
Hemodialysis: 1 to 2 g every 24 to 48 hours, plus 1 g postdialysis.^{1,5} CVVH: 2 g x 1 then 1 g every 12 hours (flow rate 1 L/h); 2 g every 12 hours (flow rate 2 L/h); or 2 g every 8 hours (flow rate 3 to 4 L/h).^{3} CVVHD: 2 g x 1 then 1 g every 8 hours or 2 g every 12 hours (dialysate flow rate 1 to 2 L/h); or 2 g every 8 hours (dialysate flow rate 3 to 4 L/h).^{3 }Alternatively, 2 g every 12 hours (dialysate flow rate <2 L/h) or 2 g every 8 hours (dialysate flow rate 2 to <6 L/h).^{9} CVVHDF: 2 g x 1, then 1 g every 8 hours or 2 g every 12 hours (dialysate flow rate 1 to 2 L/h).^{11} Consider 2 g x 1, then 3 g as a continuous infusion over 24 hours will keep plasma concentration at least 4 times the MIC for all susceptible bacteria.^{11 }2 g every 8 hours recommended for gram negatives with MIC ≥4 mcg/mL.^{11} 
Ceftazidime/  Renal impairment, nondialysis:
Hemodialysis: Dose per residual renal function. Schedule such that dose is given immediately after dialysis.^{1} CVVH: 1.25 g every 8 hours or 0.94 g every 12 hours.^{15} ^{} 
Ceftolozane/  Renal impairment, nondialysis:
Hemodialysis: 750 mg x 1, then 150 mg every 8 hours. Schedule such that a dose is given immediately after dialysis.^{1} CVVH or CVVHD: 1.5 g x 1 then 375 mg every 8 hours (flow rate 1 L/h); 1.5 g x 1 then 750 mg every 8 hours (flow rate 2 L/h); or 1.5 g every 8 hours (flow rate 3 to 4 L/h). Data based on CVVH, flow rate 2 L/h.^{3} Note: each dose is 2/3 ceftolozane and 1/3 tazobactam (e.g., 750 mg = 500 mg ceftolozane and 250 mg tazobactam). 
Ceftriaxone  Renal impairment, nondialysis: No dose adjustment needed.^{1} Hemodialysis: No dose adjustment needed.^{1} CRRT: No dose adjustment needed.^{2} ^{} 
Cefuroxime  Renal impairment, nondialysis:
Hemodialysis: 750 to 1,500 mg every 24 hours. Schedule such that dose is given immediately after dialysis.^{5} CRRT: 750 to 1,500 mg every 8 to 12 hours.^{5} ^{} 
Chloramphenicol  Renal impairment, nondialysis: Consider dose reduction based on drug levels.^{1} Hemodialysis: Consider dose reduction based on drug levels.^{1} CRRT: No dose reduction advised.^{5} 
Ciprofloxacin  Renal impairment, nondialysis: 200 mg every 12 hours to 200 or 400 mg every 18 to 24 hours.^{1} Hemodialysis: Dose as for renal impairment, above, but schedule such that dose is given immediately after dialysis.^{1} CVVH: 200 to 400 mg every 12 to 24 hours.^{11} CVVHD: 400 mg every 12 to 24 hours (dialysate flow rate 1 to 2 L/h).^{11} CVVHDF: 400 mg every 12 hours (dialysate flow rate 1 to 2 L/h).^{11} ^{} 
Clindamycin  Renal impairment, nondialysis: No dose adjustment needed for mild or moderate impairment, and most clinicians do not adjust the dose for severe renal impairment.^{1} Hemodialysis: Not removed by dialysis.^{1} CRRT: No dose reduction advised.^{5} ^{} 
Colistin  See our chart, Resistant GramNegative Bacterial Infection, for information. 
Dalbavancin  Renal impairment, nondialysis:
Hemodialysis: nonregular: 750 mg x 1, then 375 mg IV one week later.^{5} regular: 1,000 mg x 1, then 500 mg one week later.^{5} CRRT: Full dose probably appropriate.^{1} 
Daptomycin  Renal impairment, nondialysis:
Hemodialysis: Dose as for renal impairment, above. Schedule such that dose is given immediately after dialysis.^{1} CVVH: Dose as for renal impairment, above.^{3} CVVHD: 4 to 6 mg/kg every 24 hours (dialysate flow rate 1 L/h); 6 mg/kg every 24 hours (dialysate flow rate 2 L/h); or SLED: Dose every 24 hours on SLED, every 48 hours off SLED.^{10} ^{} 
Delafloxacin  Renal impairment, nondialysis:
Hemodialysis: not recommended due to lack of information.^{1} CRRT: No data.^{5} ^{} 
Doripenem  Renal impairment, nondialysis:
Hemodialysis: 250 mg every 24 hours; or 500 mg every 12 hours x 1 day, then every 24 hours (Pseudomonas).^{18} CVVHDF: 500 mg every 8 hours.^{19} 
Doxycycline  Renal impairment, nondialysis: No dosage adjustment needed.^{1} Hemodialysis: No dosage adjustment needed.^{1} CRRT: No dosage adjustment needed.^{5} 
Ertapenem  Renal impairment, nondialysis:
Hemodialysis: 500 mg every 24 hours. If given within 6 hours before dialysis, give an additional 150 mg immediately postdialysis.^{1} CVVHD: 500 mg to 1 g every 24 hours.^{3,5 }Reduce dose only if anticipated clearance is <30 mL/min.^{1} ^{} 
Imipenem/  Renal impairment, nondialysis:
Hemodialysis: Dose as for CrCl 15 to 29 mL/min. Schedule such that dose is given immediately postdialysis.^{1} CVVH, CVVHD, or CVVHDF: 1 g x 1, then 500 mg every 8 to 12 hours.^{6,11} For bacteria with higher MIC (4 to 8 mcg/mL), a dose of 1 g every 12 hours or 500 mg every 6 hours could be considered, but weigh risk of neurotoxicity vs benefit.^{6,11} SLED: 500 mg every 6 hours while on SLED if weight >70 kg.^{10} ^{} 
Levofloxacin  Renal impairment, nondialysis:
Hemodialysis: Dose as for CrCl 10 to 19 mL/min.^{1} CVVH: 250 mg every 24 hours^{3 }(If usual dose is 500 mg or 750 mg, give a 500 mg or 750 mg loading dose.^{11}) CVVHD: If usual dose is 750 mg every 24 hours, give 750 mg x 1, then 500 mg every 48 hours (dialysate flow rate <2 L/h) or every 24 hours (dialysate flow rate 2 to <6 L/h). If usual dose is 500 mg every 24 hours, give 500 mg x 1, then 250 mg every 24 hours (dialysate flow rate ≥1 L/h). If usual dose is 250 mg every 24 hours, give 250 mg every 24 hours (dialysate flow rate ≥1 L/h).^{9} CVVHDF: 250 to 750 every 24 hours.^{1} ^{} 
Linezolid  Renal impairment, nondialysis: No dosage adjustment needed.^{1} Hemodialysis: Schedule such that dose is given immediately after dialysis.^{1} CVVHD: 600 mg every 12 hours for pathogen with MIC up to 2 mcg/mL.^{1 }Standard dosing might not be sufficient for bacteria with higher MICs.^{1} SLED: Consider supplemental dose or dosing every 8 hours while on SLED.^{10} 
Meropenem  Renal impairment, nondialysis:
Hemodialysis: 500 mg every 24 hours. Schedule such that dose is given immediately postdialysis.^{5} CVVH, standard dose: 1 to 2 g x 1 then 500 mg every 12 hours (flow rate 1 L/h); 1 to 2 g x 1, then 500 mg every 8 hours (flow rate 2 L/h); or 1 to 2 g x 1 then 500 mg every 6 hours (flow rate 3 to 4 L/h).^{3} CVVH, high dose (cystic fibrosis, meningitis, pathogen with MIC 4 mcg/mL): 2 g every 12 hours (flow rate 1 to 2 L/h); or 2 g every 8 hours (flow rate 3 to 4 L/h).^{3 }Alternatively, 2 g every 8 hours for flow rates 2 to <6 L/h.^{9} CVVHD, standard dose: 1 to 2 g x 1, then 500 mg every 8 hours (dialysate flow rate 1 to 2 L/h); or 1 to 2 g x 1, then 500 mg every 6 hours (dialysate flow rate 3 to 4 L/h).^{3 }Alternatively, 1 g every 12 hours (dialysate flow rate <2 L/h) or 1 g every 8 hours (dialysate flow rate 2 to <6 L/h).^{9} CVVHD, high dose (cystic fibrosis, meningitis, pathogen with MIC 4 mcg/mL): 2 g every 12 hours (dialysate flow rate 1 to 2 L/h); or 2 g every 8 hours (dialysate flow rate 3 to 4 L/h).^{3} CVVHDF: 500 mg every 6 to 8 hours, 750 mg every 8 hours, 500 mg to 1 g every 8 to 12 hours, or 1.5 g every 12 hours (dialysate flow rate 1 to 2 L/h).^{11} SLED: 500 mg to 1 g every 8 hours while on SLED.^{10} ^{} 
Meropenem/  Renal impairment, nondialysis:
Hemodialysis: 1 g (0.5 g meropenem/0.5 g vaborbactam) every 12 hours. Schedule such that dose is given immediately postdialysis.^{5}^{} CRRT: No data. Note: each dose is 50% meropenem (2 g = 1 g meropenem and 1 g vaborbactam). 
Metronidazole  Renal impairment, nondialysis:
Hemodialysis: Dose as for renal impairment, above, but schedule such that dose is given immediately postdialysis.^{1,5} CRRT: No dosage adjustment needed.^{1} 
Minocycline  Do not exceed a total daily dose of 200 mg in renal impairment.^{1} ^{} 
Moxifloxacin  Renal impairment, nondialysis: No dosage adjustment needed.^{1} Hemodialysis: No dosage adjustment needed.^{1} CRRT: No dosage adjustment needed.^{5} 
Nafcillin  Renal impairment, nondialysis: No dosage adjustment needed.^{1} Hemodialysis: No dosage adjustment needed.^{5} CRRT: No dosage adjustment needed.^{5} 
Oxacillin  Renal impairment, nondialysis: No dosage adjustment needed.^{5} Hemodialysis: No dosage adjustment recommended.^{5} CRRT: No data. 
Oritavancin  Renal impairment, nondialysis: No dosage adjustment needed, but use caution in severe impairment due to lack of data.^{1} Hemodialysis: Not removed by dialysis.^{1} CRRT: No data. 
Penicillin G  Renal impairment, nondialysis:
Hemodialysis: Give recommended dose every 12 hours. Schedule such that a dose is given immediately postdialysis.^{5} CVVH: 4 million units x 1, then 2 million units every 4 to 6 hours.^{a,1} CVVHD: 4 million units x 1, then 2 to 3 million units every 4 to 6 hours.^{a,1 }Another maintenance option is 2 million units every 6 hours for dialysate flow rate <2L/h, or 2 million units every 4 hours for dialysate flow rate 2 to <6 L/h.^{9} CVVHDF: 4 million units x 1, then 2 to 4 million units every 4 to 6 hours.^{a,1}

Piperacillin/  Renal impairment, nondialysis:
Hemodialysis: 4.5 g (over four hours) every 12 hours.^{20} CRRT (including SLED): 4.5 g (over four hours) every 8 hours.^{20}^{} Note: oneeighth of each piperacillin dose is tazobactam (e.g., 4.5 g = 4 g piperacillin plus 0.5 g tazobactam).^{7} ^{} 
Plazomicin  Renal impairment, nondialysis:^{13}
∗Use total body weight in CockcroftGault equation, but if total body weight is >25% over ideal body weight, use ideal body weight. ∗∗Weight is total body weight, or adjusted weight if >25% over ideal body weight. Adjusted weight = Hemodialysis: No data. CRRT: No data. 
Polymyxin B  Renal impairment, nondialysis: See our chart, Resistant GramNegative Bacterial Infection, for information. Hemodialysis: No dosage adjustment needed.^{5} CRRT: No dosage adjustment needed.^{5} ^{} 
Quinupristin/  Renal impairment, nondialysis: No dose adjustment needed.^{1} Hemodialysis: No dose adjustment needed.^{1} CRRT: No dosage adjustment needed.^{5} ^{} 
Sulfamethoxazole/  Renal impairment, nondialysis:
Hemodialysis: Not recommended, but if used, consider 5 to 10 mg/kg (trimethoprim) every 24 hours, scheduled such that dose is given immediately postdialysis.^{5} CRRT: Avoid if possible because clearance varies for each component. Specialist consultation suggested.^{9 }Doses below are for treatment of serious infections, not prophylaxis.^{3 } CVVH: 2.5 to 7.5 mg/kg (trimethoprim) every 12 hours.^{3} CVVHD: 5 mg/kg (trimethoprim) every 12 hours.^{3 }Alternatively, for dialysate flow rate <2 L/h, 10 to 15 mg/kg/day (trimethoprim) divided every 8 hours x 48 hours, then reassess. For dialysate flow rate 2 to <6 L/h, 15 to 20 mg/kg/day (trimethoprim) divided every 6 to 8 hours x 48 hours, then reassess.^{9} CVVHDF: 2.5 to 7.5 mg/kg (trimethoprim) every 12 hours.^{1 }Patients with Pneumocystis jirovecii may need 10 mg/kg (trimethoprim) every 12 hours.^{11} Note: Use actual body weight for dosing.^{9} ^{} 
Tedizolid  Renal impairment, nondialysis: No dose adjustment needed.^{1} Hemodialysis: No dose adjustment needed.^{1} CRRT: No dose adjustment needed.^{5} 
Telavancin  Renal impairment, nondialysis:
Hemodialysis: No data.^{5} CRRT: No data.^{5} 
Tigecycline  Renal impairment, nondialysis: no dose adjustment needed.^{1} Hemodialysis: no dose adjustment needed.^{1} CRRT: no dose adjustment needed.^{5} 
Vancomycin  Renal impairment, nondialysis: See our commentary, Vancomycin Dosing and Monitoring for Adults. Expect dosing frequencies of every 24 to 96 hours.^{5} Hemodialysis: 15 to 25 mg/kg x 1, then 5 to 10 mg/kg postdialysis.^{11 }For the third postdialysis dose, consider dosing per predialysis levels as follows: <10 mg/L, give 1 g immediately postdialysis; 10 to 25 mg/L, give 500 to 750 mg immediately postdialysis; >25 mg/L, hold vancomycin.^{11} (Some clinicians will give a reduced dose for a level >25 mg/L). Alternatively, consider giving 500 mg to 1 g for a postdialysis level 10 to 15 mg/L.^{11 }Check postdialysis vancomycin level 4 to 6 hours postdialysis to allow for redistribution.^{11} Note that for CRRT, some clinicians use firstdose levels to guide dosing. CVVH: 15 to 25 mg/kg x 1, then 10 to 15 mg/kg every 24 to 48 hours.^{11 }Adjust per desired target level.^{11} CVVHD: 15 to 25 mg/kg x 1, then 10 to 15 mg/kg every 24 hours or 7.5 mg/kg every 12 hours.^{11 }Adjust per desired target level.^{11} CVVHDF: 15 to 25 mg/kg x 1, then 7.5 to 10 mg/kg every 12 hours.^{11 }Adjust per desired target level.^{11} SLED: 15 to 25 mg/kg every 24 to 72 hours. Redose as warranted by postSLED level.^{12} 
Project Leader in preparation of this clinical resource (340819): Melanie Cupp, Pharm.D., BCPS
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Cite this document as follows: Clinical Resource, Intravenous Antibiotic Dosing in Renal Impairment in Adults. Hospital Pharmacist’s Letter/Prescriber’s Letter. August 2018.