Renal adjusted antibiotics
Revision as of 12:18, 30 August 2025 by Ostermayer (talk | contribs)
Antibiotics Requiring Renal Dosing
| Antibiotic | Class | Normal Dose (CrCl >60 mL/min) | Renal Adjustment Examples |
|---|---|---|---|
| Vancomycin | Glycopeptide | 15-20 mg/kg IV every 8-12 hours (target trough 10-20 mcg/mL for serious infections) | - CrCl 30-60: 10-15 mg/kg every 12-24 hours - CrCl 10-30: 10 mg/kg every 24-48 hours - CrCl <10: 10 mg/kg every 48-72 hours or based on levels Monitor trough levels closely to avoid nephrotoxicity. |
| Gentamicin | Aminoglycoside | 5-7 mg/kg IV once daily (extended-interval) or 1-2 mg/kg every 8 hours (traditional) | - CrCl 40-60: 3-5 mg/kg every 24-36 hours - CrCl 20-40: 2-3 mg/kg every 36-48 hours - CrCl <20: Load 2 mg/kg, then based on levels (trough <1 mcg/mL) Peak/trough monitoring essential. |
| Tobramycin | Aminoglycoside | Similar to gentamicin: 5-7 mg/kg IV once daily | - CrCl 40-60: 4-5 mg/kg every 24-36 hours - CrCl 20-40: 3-4 mg/kg every 36-48 hours - CrCl <20: Load 2 mg/kg, then per levels Adjust for cystic fibrosis or other indications. |
| Amikacin | Aminoglycoside | 15 mg/kg IV once daily | - CrCl 40-60: 10-12 mg/kg every 24-36 hours - CrCl 20-40: 7.5-10 mg/kg every 36-48 hours - CrCl <20: Load 7.5 mg/kg, then based on levels (trough <4-8 mcg/mL) Higher risk of ototoxicity; monitor closely. |
| Ciprofloxacin | Fluoroquinolone | 400 mg IV every 12 hours or 500-750 mg PO every 12 hours | - CrCl 30-50: No change or extend to every 18-24 hours - CrCl <30: 400 mg IV every 24 hours or 250-500 mg PO every 24 hours Not dialyzable; adjust for UTI vs. systemic use. |
| Levofloxacin | Fluoroquinolone | 500-750 mg IV/PO once daily | - CrCl 20-50: 500-750 mg every 48 hours (or half dose daily) - CrCl <20: 250-500 mg every 48 hours (load with full dose) Monitor for QT prolongation in renal impairment. |
| Cefepime | Cephalosporin (4th gen) | 1-2 g IV every 8-12 hours | - CrCl 30-60: 1-2 g every 12 hours - CrCl 11-29: 1-2 g every 24 hours - CrCl <11: 0.5-1 g every 24 hours Increase for Pseudomonas infections. |
| Ceftazidime | Cephalosporin (3rd gen) | 1-2 g IV every 8 hours | - CrCl 31-50: 1-2 g every 12 hours - CrCl 16-30: 1 g every 24 hours - CrCl <15: 0.5 g every 24 hours Used for gram-negative coverage. |
| Piperacillin-Tazobactam | Penicillin/Beta-lactamase inhibitor | 3.375-4.5 g IV every 6 hours | - CrCl 20-40: 3.375 g every 8 hours - CrCl <20: 2.25 g every 8 hours (or every 12 hours for severe impairment) Extended infusion may be used for optimization. |
| Meropenem | Carbapenem | 1 g IV every 8 hours | - CrCl 26-50: 1 g every 12 hours - CrCl 10-25: 0.5 g every 12 hours - CrCl <10: 0.5 g every 24 hours Short half-life; adjust for CNS infections. |
| Acyclovir (antiviral) | Nucleoside analog | 5-10 mg/kg IV every 8 hours | - CrCl 25-50: Every 12 hours - CrCl 10-25: Every 24 hours (half dose) - CrCl <10: 2.5-5 mg/kg every 24 hours PO doses also adjusted; hydrate to prevent crystalluria. |