Last revised 06/2013

2345678--*`
.001/
HMC / UWMC Adult Antimicrobial Renal Dosing Guidelines
(All doses are listed for IV, unless otherwise stated). These dosing recommendations are based on published literature and clinical experiences. They should not replace
clinical judgment and are intended to provide initial guidance, and may be modified depending on individual patient. Call pharmacy for additional questions.
Drug Dose for Normal Renal
Function
CrCl (mL/min)
10 - 50
CrCl (mL/min)
<10
Hemodialysis
+
Acyclovir (IV)
For obese pts, dose based
on Ideal Body Weight. IF pt
is morbidly obese AND has
life-threatening infection,
then use adjusted weight.
Herpes simplex
5mg/kg q8h
Herpes zoster /
encephalitis
10mg/kg q8h

Herpes simplex
25-50: 5mg/kg q12h
10-25: 5mg/kg q24h
Herpes zoster / encephalitis
25-50: 10mg/kg q12h
10-25: 10mg/kg q24h
Herpes simplex
2.5mg/kg q24h
Herpes zoster / encephalitis
5mg/kg q24h

Same as CrCl<10
Acyclovir (PO)

See specific transplant
guidelines for
prophylaxis dosing
recommendations.
Herpes Simplex
200 400mg 5x/day (PO)
Herpes zoster
800mg q4h (PO)
HSV prophylaxis:
SOT: 400mg BID (PO)
SCCA: 800mg BID (PO)
Herpes Simplex
10-25: 200 400mg q8h (PO)
Herpes zoster
10-25: 800mg q8h (PO)
HSV prophylaxis:
SOT: 10-25: 400mg BID(PO)
SCCA:10-25: 800mg daily(PO)
Herpes Simplex
200mg q12h (PO)
Herpes zoster
800mg q12h (PO)
HSV prophylaxis:
SOT<10: 200mg BID (PO)
or 400mg daily (PO)
SCCA: <10: 800mg daily(PO)
Herpes Simplex & Herpes
Zoster: Same as CrCl<10


HSV prophylaxis (give after
dialysis):
SOT: 400mg daily (PO) SCCA:
400mg daily(PO)
Aminoglycosides Consult pharmacy for dosing recommendations for amikacin, gentamicin, tobramycin, or streptomycin.
Amphotericin B

0.5 1mg/kg q24h No Changes No Changes No Changes
*Depending on severity of infection, dosage reduction, extending dosing interval may be warranted if rising SCr.
Amphotericin B lipid 3 - 5 mg/kg q24h, based on total body weight. Consult pharmacy for dosing recommendations.
Ampicillin 1 2g q4-6h 1 2g q6-12h 1 2g q12-24h 1 2g q24h
Ampicillin /Sulbactam 1.5 3g q6h 30-50: 1.5 3g q6-8h
15-29: 1.5 3g q12h
14: 1.5 3g q24h 1.5 - 3g q24h
Amoxicillin (PO) 250 1000mg q8h 10-30: 250 1000mg q12h 250 1000mg q24h 250 500mg q24h, (250-500mg
SD)
Amoxicillin/
Clavulanate (PO)
875mg q12h 10-30: 500mg q12h 500mg q24h 500mg q24h (500mg SD)
Azithromycin (IV/PO) 500mg x1day, 250
500mg q24h
No changes No changes No changes
Aztreonam 1 2g q6-8h
Neutropenic fever: 2g q8h
31-60: 0.75 1.5g q8h
10-30: 0.5 1g q8h
500mg q8h 500mg q8h (500mg SD)
Cefazolin 1g q6-8h or 2g q8h 10-30: 1 2g q12h 0.5 1g q24h 2gm on days of HD, 3gm if 3days
b/w HD
Cefepime Neutropenic fever/Serious
infection: 2g q8h
30-60: 1 2g q12-24h
11-29: 0.5 2g q24h
250mg 1g q24h

1g x1day, then 0.5 1g q24h
OR 2g post HD session
Cefotaxime 1 2g q6-8h 1 2g q8-12h 1 2g q24h 1 2g q24h (1g SD)
Cefotetan 1 2g q12h 10-30: 0.5 1g q12h 250 500mg q12h 500mg 1g on days of HD, 250-
500mg on days off HD
Ceftazidime 1 2g q8h
Neutropenic fever: 2g q8h
31-50: 1 2g q12h
10-30: 1 2g q24h
1g q24-48h

1g x1day, then 1g on days of HD
Ceftriaxone 1 2g q12-24h
Meningitis: 2g q12h
No change No change No change
Cefuroxime (IV) 0.75 1.5g q8h 10-20: 750mg q12h 750mg q24h 750mg q24h (750mg SD)
Cephalexin 250 500mg q6h 250 500mg q12h 250 500mg q12h 250 500mg q12h
Cefpodoxime (PO) 200 400mg q12h 10-30: 200 400mg q24h 200 400mg q24-48h 200 400mg on days of HD
Ciprofloxacin (IV)
(PO)
200 400mg q8-12h
250 750mg q12h
10-30: 200 400mg q12h
10-30: 250 500mg q12h
200mg q12h
250mg q12h
400mg q24h
250 500mg q24h
Clindamycin (IV)
(PO)
600 900mg q8h
150 450mg q6h
No changes
No changes
No changes
No changes
No changes
No changes
Dalfopristin /Quinupristin 7.5mg/kg q8-12h No changes No changes No changes
Dapsone 100mg daily No changes No changes No changes
Daptomycin
*Use Total Body Weight*
Serious or bacteremia:
6mg/kg q24h

<30: 6mg/kg q48h

6mg/kg q48h
6mg/kg q48h OR
7mg/kg on days of HD,
9 mg/kg if 3d b/w HD
Doxycycline (IV/PO) 100mg q12h No changes No changes No changes
Ethambutol (PO) 15 25mg/kg q24h 15 25mg/kg q24-36h 15 25mg/kg q48h 15-25mg/kg on days of HD
Ertapenem 1g q24h <30: 500mg q24h 500mg q24h 500mg q24h (150mg SD if dose
given within 6h)
Fluconazole (IV/PO) 100 400mg q24h 50 200mg q24h 50 200mg q24h 100-400mg on days of HD
Flucytosine (PO)
*Use I deal Body Weight*
12.5 37.5mg/kg q6h
based on ideal body weight
20-50:12.5 37.5mg/kg q12h
<20:12.5 37.5mg/kg q24h
12.5 37.5mg/kg q24h 25 37.5 mg/kg on days of HD
Foscarnet Consult pharmacy for dosing recommendations.
Ganciclovir
(I = induction dose)
(M= maintenance dose)
*Use Total Body Weight*

>70: 5mg/kg q12h (I)
5mg/kg q24h (M)
50-69: 2.5mg/kg q12h (I)
2.5mg/kg q24h (M)
25-49: 2.5mg/kg q24h (I)
1.25mg/kg q24h (M)
10-24: 1.25mg/kg q24h (I)
0.625mg/kg q24h (M)
1.25mg/kg 3x/week (I)
0.625mg/kg 3x/week (M)
1.25mg/kg on days of HD (I)
0.625mg/kg on days of HD (M)

Ganciclovir (PO) >70: 1g q8h
50-69: 500mg q8h
25-49: 500mg q12h
10-24: 500mg q24h
500mg 3x/week 500mg on days of HD
Imipenem/Cilastatin 500mg q6h 500mg q8-12h 250 500mg q12h 250 500mg q12h
Isoniazid (IV/PO) 300mg q24h No changes No changes No changes
Last revised 06/2013

HMC / UWMC Adult Antimicrobial Renal Dosing Guidelines
(All doses are listed for IV, unless otherwise stated). These dosing recommendations are based on published literature and clinical experiences. They should not replace
clinical judgment and are intended to provide initial guidance, and may be modified depending on individual patient. Call pharmacy for additional questions.
Drug Dose for Normal Renal
Function
CrCl (mL/min)
10 - 50
CrCl (mL/min)
<10
Hemodialysis
+
Levofloxacin (IV/PO) 250mg q24h

500mg q24h

Serious or pneumonia:
750mg q24h
250mg q24h

20-49: 500mg x1, 250mg
q24h on day 2

20-49: 750mg q48h

250mg q48h

<19: 500mg x1, 250mg
q48h on day 3

<19: 750mg x1, 500mg
q48h on day 3
250mg q48h

500mg x1, 250mg q48h on day 3

750mg x1, 500mg q48h on day 3
Linezolid (IV/PO) 600mg q12h No changes No changes No changes
Meropenem Neutropenic fever &sepsis:
1g q8h
Cystic fibrosis / meningitis:
2g q8h
26-50: 1 2g q12h
10-25: 500mg 1g q12h

500mg 1g q24h


500mg 1g q24h


Metronidazole (IV/PO) 500mg q8h No changes No changes No changes
Micafungin

Prophylaxis:50mg q24h
Candidemia:100mgq24h
Esophgeal candidiasis:
150mg q24h
No changes No changes No changes
Minocycline (IV/PO) 200mg x1, then 100mg q12 No changes No changes No changes
Moxifloxacin (IV/PO) 400mg q24h No changes No changes No changes
Nafcillin 1 2g q4-6h No changes No changes unless hepatic
failure and CrCl<10: 0.5
1g q4-6h
No changes
Oseltamivir (PO)
(T = treatment)
(P= prophylaxis)

Non-ICU: 75mg q12h (T)
ICU: 150mg q12h (T)

75mg q24h (P)
<30: Non-ICU: 75mg q24h
(T)
< 30: ICU: 150mg q24h (T)

< 30: 75mg q48h or 30mg
daily (P)
Same as CrCl < 30 Non-ICU: 30mg 2x weekly (alternate
HD session) x2 doses total (T)
ICU: 60mg 2x weekly (alternate HD
session) x4 doses total (T)
(e.g. MWF dialysis, then give dose on
M and F for week 1)
30mg 2x weekly (alternate HD
session) x2 doses total (P)
(e.g. MWF dialysis, then give dose on
M and F)
Penicillin G Potassium 2 4 mU q4-6h
(max 24 mU/day)
1 2 mU q4-6h 1 mU q6h (max dose
6mU/day in ESRD)
1 mU q6h
Piperacillin / Tazobactam
(prolonged infusion)
4.5g X 1, then 4 hr later
start 3.375g IV infused
over 4 hours q8h
< 20:
3.375g IV q12h infused over 4 hours
HD:
3.375g IV q12h infused over 4
hours
Posaconazole (PO)
(T = treatment)
(P= prophylaxis)
200mg po QID (T)
200mg po TID (P)
Give with fatty meals
No changes No changes No changes
Pyrazinamide (PO) 15 30mg/kg q24h
(max 2g/dose)
15 30mg/kg q24h 15mg/kg q24h 15 30mg/kg on days of HD
Rifampin (IV/PO) 600mg q24h No changes No changes unless hepatic
failure and CrCl<10:
300mg q24h
Same as CrCl <10
Rimantadine (PO) 100mg q12h <30 or age >65: 100mg q24h <30 or age >65: 100mg
q24h
Limited data; use with caution
Ticarcillin / Clavulanate 3.1g q4-6h 30-60: 2g q4-6h
10-30: 2g q8h
2g q12h 2g q12h (3.1g SD)
Tigecycline 100mg x1, 50mg q12h No changes No changes No changes
Trimethoprim/
sulfamethoxazole
(TMP/SMX) (PO/IV)

Dosing based on the TMP
component
10mg TMP/kg/day divided
q6-8h
PCP Treatment
15-20mg TMP/kg/day
divided q6-8h
PCP Prophylaxis
1 SS or 1 DS tab q24h
5-7.5mg TMP/kg/day divided
q12h
PCP Treatment
10-15mg TMP/kg/day divided
q12h
PCP Prophylaxis
50-80: 1 SS tab q24h
10-50: 1 SS tab q24-48h
2.5-5mg TMP/kg q24h

PCP Treatment
5-10mg TMP/kg q24h

PCP Prophylaxis
1 SS tab q48h
2.5-5mg TMP/kg q24h

PCP Treatment
5-10mg TMP/kg q24h

PCP Prophylaxis
1 SS tab q48h
Valacyclovir (PO)
(I = initial episode)
(R= recurrent episode)
Herpes zoster
1g q8h
Genital herpes
1g q12h (I)
500mg q12h (R)
Herpes zoster
30-50: 1g q12h
10-29: 1g q24h
Genital herpes
10-30: 1g q24h (I)
10-30: 500mg q24h (R)
Herpes zoster
500mg q24h
Genital herpes
500mg q24h (I)
500mg q24h (R)
Same as CrCl<10
Valganciclovir (PO)
(T = treatment)
(P= prophylaxis)
>60: 900mg q12h (T)
900mg q24h (P)
40-59: 450mg q12h (T)
450mg q24h (P)
25-39: 450mg q24h (T)
450mg q48h (P)
10-24: 450mg q48h (T)
450mg 2x/week (P)
Not recommended Not recommended
*Contact Stewardship or Transplant
Pharmacy for alternate dosing*
Vancomycin 15mg/kg q12h Consult pharmacy for dosing in renal insufficiency
Voriconazole (IV/PO) 6mg/kg q12h x 1 day, then
4mg/kg q12h
<50: Consider oral tablets due to accumulation of IV vehicle, SBECD, for long-term therapy. No
dosing adjustment is required for renal failure.
Cockcroft-Gault: CrCl (mL/min) = (140 age) x WT (kg) .............................................................. (for females multiply by 0.85)
72 x SCr (mg/dL)
Dosing recommendation is based on CrCl calculation using Cockcroft-Gault equation, However, PowerChart reports CrCl based on MDRD, which may vary slightly from Cockcroft-Gault. Dosing recommendation for
hemodialysis may not be applicable to all types of dialysis such as extended dialysis or dialysis with high flux membranes, or continuous renal replacement therapy (i.e. CVVH, CVVHD, CVVHDF)
+
Give scheduled dose(s) after hemodialysis unless otherwise specified; SD = supplemental dose in addition to scheduled dose(s) after each dialysis; Contact antimicrobial stewardship with questions or concerns.