Antimicrobial dosages for adults with impaired kidney function: C

Table 1. Antimicrobial dosages for adults with impaired kidney function: C
[NB1]
caspofungin cefalexin cefazolin cefepime cefotaxime cefoxitin ceftazidime ceftriaxone	cefuroxime cidofovir ciprofloxacin intravenous ciprofloxacin oral clarithromycin clindamycin cotrimoxazole (see trimethoprim+sulfamethoxazole)
caspofungin
Dosage adjustment based on GFR [NB2]
more than 50 mL/min	normal
10 to 50 mL/min	normal
less than 10 mL/min	normal
Dosages for dialysis [NB2]
intermittent haemodialysis	normal
peritoneal dialysis	normal
continuous renal replacement therapy	normal
cefalexin
Dosage adjustment based on GFR [NB2] [NB3]
more than 50 mL/min	normal
10 to 50 mL/min	normal
less than 10 mL/min	50 to 100% 8- to 12-hourly
Dosages for dialysis [NB2]
intermittent haemodialysis	as for GFR less than 10 mL/min
peritoneal dialysis
continuous renal replacement therapy	normal
cefazolin
2 g loading dose may be required
Dosage adjustment based on GFR [NB2] [NB3]
more than 40 mL/min	normal
20 to 40 mL/min	50% 8-hourly or 100% 12-hourly
less than 20 mL/min	25% 12-hourly or 50% 24-hourly
Dosages for dialysis [NB3]
intermittent haemodialysis	as for GFR less than 20 mL/min; dose after dialysis, or 100% three times per week on dialysis days only; dose after dialysisDuke 2024 Renaud 2011
peritoneal dialysis	as for GFR less than 20 mL/min
continuous renal replacement therapy	100% 12-hourly
cefepime
1 to 2 g loading dose may be required
Dosage adjustment based on GFR [NB2] [NB3]
more than 50 mL/min	normal
10 to 50 mL/min	50 to 100% 12- to 24-hourly (see product information)
less than 10 mL/min	25 to 50% 24-hourly (see product information)
Dosages for dialysis [NB3]
intermittent haemodialysis	25 to 50% 24-hourly (see product information); dose after dialysis
peritoneal dialysis	1 g loading dose then 500 mg 24-hourly
continuous renal replacement therapy	50 to 100% 12-hourly
cefotaxime
2 g loading dose may be required
Dosage adjustment based on GFR [NB2] [NB3]
more than 50 mL/min	normal
20 to 50 mL/min	100% 8- to 12-hourly
less than 20 mL/min	50% 8- to 12-hourly
Dosages for dialysis
intermittent haemodialysis	as for GFR less than 20 mL/min; dose after dialysis
peritoneal dialysis	as for GFR less than 20 mL/min
continuous renal replacement therapy	as for GFR 20 to 50 mL/min
cefoxitin
2 g loading dose may be required
Dosage adjustment based on GFR [NB2] [NB3]
more than 80 mL/min	normal
30 to 80 mL/min	50 to 100% 8- to 12-hourly
10 to 29 mL/min	50 to 100% 12- to 24-hourly
less than 10 mL/min	50% 12- to 24-hourly
Dosages for dialysis [NB3]
intermittent haemodialysis	50% 24- to 48-hourly; dose after dialysis
peritoneal dialysis	50% 24-hourly
continuous renal replacement therapy	as for GFR 30 to 80 mL/min
ceftazidime [NB4]
1 to 2 g loading dose may be required
Dosage adjustment based on GFR [NB2] [NB3]
more than 50 mL/min	normal
31 to 50 mL/min	50% 8-hourly
16 to 30 mL/min	50% 12-hourly
less than 16 mL/min	25 to 50% 24-hourly
Dosages for dialysis [NB3]
intermittent haemodialysis	500 to 1000 mg 24-hourly; dose after dialysis, or 1 to 2 g three times a week on dialysis days; dose after dialysis. Consider patient factors (eg severity of infection) when determining dose. Daily dosing may be preferred in critically ill patients, patients with deep-seated infections or patients with resistant organisms because daily dosing is more likely to reach pharmacokinetic/pharmacodynamic targets.
peritoneal dialysis	as for GFR less than 16 mL/min
continuous renal replacement therapy	50 to 100% 12-hourly
ceftriaxone
Dosage adjustment based on GFR [NB2]
more than 50 mL/min	normal
10 to 50 mL/min	normal
less than 10 mL/min	normal
Dosages for dialysis [NB2]
intermittent haemodialysis	normal some centres use 3 times a week post-dialysis dosing [NB5]
peritoneal dialysis	normal
continuous renal replacement therapy	normal
cefuroxime
Dosage adjustment based on GFR [NB2] [NB3]
more than 50 mL/min	normal
10 to 50 mL/min	normal
less than 10 mL/min	100% 24-hourly
Dosages for dialysis [NB2]
intermittent haemodialysis	as for GFR less than 10 mL/min; dose after dialysis
peritoneal dialysis	as for GFR less than 10 mL/min
continuous renal replacement therapy	normal
cidofovir
Dosage adjustment based on GFR [NB2]
more than 55 mL/min	normal
10 to 55 mL/min	avoid; seek expert advice
less than 10 mL/min
Dosages for dialysis
intermittent haemodialysis	avoid; seek expert advice
peritoneal dialysis
continuous renal replacement therapy	avoid; if essential, 2 mg/kg weekly; seek expert advice
ciprofloxacin intravenous
for dosage adjustment in patients with infections caused by Pseudomonas aeruginosa, seek expert adviceShah 1996
Dosage adjustment based on GFR [NB2] [NB3]
more than 50 mL/min	normal
31 to 50 mL/min	normal
10 to 30 mL/min	100% 24-hourly
less than 10 mL/min	100% 24-hourly
Dosages for dialysis [NB3]
intermittent haemodialysis	as for GFR less than 10 mL/min; dose after dialysis
peritoneal dialysis	as for GFR less than 10 mL/min
continuous renal replacement therapy	50 to 100% 12-hourly
ciprofloxacin oral
for dosage adjustment in patients with infections caused by Pseudomonas aeruginosa, seek expert advice
Dosage adjustment based on GFR [NB2] [NB3]
more than 50 mL/min	normal
31 to 50 mL/min	normal
10 to 30 mL/min	100% 24-hourly
less than 10 mL/min	500 mg 24-hourly
Dosages for dialysis
intermittent haemodialysis	as for GFR less than 10 mL/min; dose after dialysis
peritoneal dialysis	as for GFR less than 10 mL/min
continuous renal replacement therapy	250 to 500 mg 12-hourly
clarithromycin
Dosage adjustment based on GFR [NB2] [NB3]
more than 50 mL/min	normal
30 to 50 mL/min	normal
less than 30 mL/min	50% 12-hourly
Dosages for dialysis [NB3]
intermittent haemodialysis	as for GFR less than 30 mL/min
peritoneal dialysis
continuous renal replacement therapy	50 to 100% 12-hourly
clindamycin
Dosage adjustment based on GFR [NB2]
more than 50 mL/min	normal
10 to 50 mL/min	normal
less than 10 mL/min	normal
Dosages for dialysis [NB2]
intermittent haemodialysis	normal
peritoneal dialysis	normal
continuous renal replacement therapy	normal
cotrimoxazole
see trimethoprim+sulfamethoxazole
Note: GFR = glomerular filtration rate NB1: Dosing in patients with kidney impairment is complex. This table is intended as a guide only, see General considerations for antimicrobial dosage modification in kidney impairment. If relevant, see Dialysis and continuous renal replacement therapy for further guidance on using this table. NB2: ‘Normal’ indicates that the standard dosage regimen for the specific indication in these guidelines should be used. NB3: For multiple-daily doses, percentage dosage adjustments are calculated using the intermittent dose rather than the total daily dose (eg if standard dosing for drug X is 500 mg 6-hourly, then 50% at normal dosing interval = 250 mg 6-hourly, and 100% 12-hourly = 500 mg 12-hourly). NB4: Higher doses ceftazidime may be required for the treatment of melioidosis, consult local protocols or seek specialist advice. NB5: When treating an infection with a minimum inhibitory concentration of 1 mg/L or more in patients with a serum bilirubin less than 10 micromol/L, 2 g three times a week post-haemodialysis may be considered where post-dialysis dosing is desirableTsai 2023.

caspofungin

cefalexin

ciprofloxacin intravenous

ciprofloxacin oral

clarithromycin

clindamycin

cotrimoxazole (see trimethoprim+sulfamethoxazole)

caspofungin

Dosage adjustment based on GFR [NB2]

more than 50 mL/min

normal

10 to 50 mL/min

normal

less than 10 mL/min

normal

Dosages for dialysis [NB2]

intermittent haemodialysis

normal

peritoneal dialysis

normal

continuous renal replacement therapy

normal

cefalexin

Dosage adjustment based on GFR [NB2] [NB3]

more than 50 mL/min

normal

10 to 50 mL/min

normal

less than 10 mL/min

50 to 100% 8- to 12-hourly

Dosages for dialysis [NB2]

intermittent haemodialysis

as for GFR less than 10 mL/min

peritoneal dialysis

continuous renal replacement therapy

normal

cefazolin

2 g loading dose may be required

Dosage adjustment based on GFR [NB2] [NB3]

more than 40 mL/min

normal

20 to 40 mL/min

50% 8-hourly or 100% 12-hourly

less than 20 mL/min

25% 12-hourly or 50% 24-hourly

Dosages for dialysis [NB3]

intermittent haemodialysis

as for GFR less than 20 mL/min; dose after dialysis, or

100% three times per week on dialysis days only; dose after dialysisDuke 2024 Renaud 2011

peritoneal dialysis

as for GFR less than 20 mL/min

continuous renal replacement therapy

100% 12-hourly

cefepime

1 to 2 g loading dose may be required

Dosage adjustment based on GFR [NB2] [NB3]

more than 50 mL/min

normal

10 to 50 mL/min

50 to 100% 12- to 24-hourly (see product information)

less than 10 mL/min

25 to 50% 24-hourly (see product information)

Dosages for dialysis [NB3]

intermittent haemodialysis

25 to 50% 24-hourly (see product information); dose after dialysis

peritoneal dialysis

1 g loading dose then 500 mg 24-hourly

continuous renal replacement therapy

50 to 100% 12-hourly

cefotaxime

2 g loading dose may be required

Dosage adjustment based on GFR [NB2] [NB3]

more than 50 mL/min

normal

20 to 50 mL/min

100% 8- to 12-hourly

less than 20 mL/min

50% 8- to 12-hourly

Dosages for dialysis

intermittent haemodialysis

as for GFR less than 20 mL/min; dose after dialysis

peritoneal dialysis

as for GFR less than 20 mL/min

continuous renal replacement therapy

as for GFR 20 to 50 mL/min

cefoxitin

2 g loading dose may be required

Dosage adjustment based on GFR [NB2] [NB3]

more than 80 mL/min

normal

30 to 80 mL/min

50 to 100% 8- to 12-hourly

10 to 29 mL/min

50 to 100% 12- to 24-hourly

less than 10 mL/min

50% 12- to 24-hourly

Dosages for dialysis [NB3]

intermittent haemodialysis

50% 24- to 48-hourly; dose after dialysis

peritoneal dialysis

50% 24-hourly

continuous renal replacement therapy

as for GFR 30 to 80 mL/min

ceftazidime [NB4]

1 to 2 g loading dose may be required

Dosage adjustment based on GFR [NB2] [NB3]

more than 50 mL/min

normal

31 to 50 mL/min

50% 8-hourly

16 to 30 mL/min

50% 12-hourly

less than 16 mL/min

25 to 50% 24-hourly

Dosages for dialysis [NB3]

intermittent haemodialysis

500 to 1000 mg 24-hourly; dose after dialysis, or

1 to 2 g three times a week on dialysis days; dose after dialysis.

Consider patient factors (eg severity of infection) when determining dose. Daily dosing may be preferred in critically ill patients, patients with deep-seated infections or patients with resistant organisms because daily dosing is more likely to reach pharmacokinetic/pharmacodynamic targets.

peritoneal dialysis

as for GFR less than 16 mL/min

continuous renal replacement therapy

50 to 100% 12-hourly

ceftriaxone

Dosage adjustment based on GFR [NB2]

more than 50 mL/min

normal

10 to 50 mL/min

normal

less than 10 mL/min

normal

Dosages for dialysis [NB2]

intermittent haemodialysis

normal

some centres use 3 times a week post-dialysis dosing [NB5]

peritoneal dialysis

normal

continuous renal replacement therapy

normal

cefuroxime

Dosage adjustment based on GFR [NB2] [NB3]

more than 50 mL/min

normal

10 to 50 mL/min

normal

less than 10 mL/min

100% 24-hourly

Dosages for dialysis [NB2]

intermittent haemodialysis

as for GFR less than 10 mL/min; dose after dialysis

peritoneal dialysis

as for GFR less than 10 mL/min

continuous renal replacement therapy

normal

cidofovir

Dosage adjustment based on GFR [NB2]

more than 55 mL/min

normal

10 to 55 mL/min

avoid; seek expert advice

less than 10 mL/min

Dosages for dialysis

intermittent haemodialysis

avoid; seek expert advice

peritoneal dialysis

continuous renal replacement therapy

avoid; if essential, 2 mg/kg weekly; seek expert advice

ciprofloxacin intravenous

for dosage adjustment in patients with infections caused by Pseudomonas aeruginosa, seek expert adviceShah 1996

Dosage adjustment based on GFR [NB2] [NB3]

more than 50 mL/min

normal

31 to 50 mL/min

normal

10 to 30 mL/min

100% 24-hourly

less than 10 mL/min

100% 24-hourly

Dosages for dialysis [NB3]

intermittent haemodialysis

as for GFR less than 10 mL/min; dose after dialysis

peritoneal dialysis

as for GFR less than 10 mL/min

continuous renal replacement therapy

50 to 100% 12-hourly

ciprofloxacin oral

for dosage adjustment in patients with infections caused by Pseudomonas aeruginosa, seek expert advice

Dosage adjustment based on GFR [NB2] [NB3]

more than 50 mL/min

normal

31 to 50 mL/min

normal

10 to 30 mL/min

100% 24-hourly

less than 10 mL/min

500 mg 24-hourly

Dosages for dialysis

intermittent haemodialysis

as for GFR less than 10 mL/min; dose after dialysis

peritoneal dialysis

as for GFR less than 10 mL/min

continuous renal replacement therapy

250 to 500 mg 12-hourly

clarithromycin

Dosage adjustment based on GFR [NB2] [NB3]

more than 50 mL/min

normal

30 to 50 mL/min

normal

less than 30 mL/min

50% 12-hourly

Dosages for dialysis [NB3]

intermittent haemodialysis

as for GFR less than 30 mL/min

peritoneal dialysis

continuous renal replacement therapy

50 to 100% 12-hourly

clindamycin

Dosage adjustment based on GFR [NB2]

more than 50 mL/min

normal

10 to 50 mL/min

normal

less than 10 mL/min

normal

Dosages for dialysis [NB2]

intermittent haemodialysis

normal

peritoneal dialysis

normal

continuous renal replacement therapy

normal

cotrimoxazole

see trimethoprim+sulfamethoxazole

Note:

GFR = glomerular filtration rate

NB1: Dosing in patients with kidney impairment is complex. This table is intended as a guide only, see General considerations for antimicrobial dosage modification in kidney impairment. If relevant, see Dialysis and continuous renal replacement therapy for further guidance on using this table.

NB2: ‘Normal’ indicates that the standard dosage regimen for the specific indication in these guidelines should be used.

NB3: For multiple-daily doses, percentage dosage adjustments are calculated using the intermittent dose rather than the total daily dose (eg if standard dosing for drug X is 500 mg 6-hourly, then 50% at normal dosing interval = 250 mg 6-hourly, and 100% 12-hourly = 500 mg 12-hourly).

NB4: Higher doses ceftazidime may be required for the treatment of melioidosis, consult local protocols or seek specialist advice.

NB5: When treating an infection with a minimum inhibitory concentration of 1 mg/L or more in patients with a serum bilirubin less than 10 micromol/L, 2 g three times a week post-haemodialysis may be considered where post-dialysis dosing is desirableTsai 2023.