Table 7.
Recommended dose adjustments of antibiotics according to various degrees of creatinine clearance
| Antibiotic | Route of administration | CrCl (mL/min/1.73 m2) and recommended dosage |
|---|---|---|
| β-Lactams | ||
| Amoxicillin [121] | PO |
> 30: 250–1000 mg q8h 10–30: 250–500 mg q12h < 10: 250–500 mg q24h |
| Amoxicillin/clavulanate [246] |
> 30: 875/125 mg q12h 10–30: 250–500/125 mg q12h < 10: 250–500/125 mg q24h |
|
| Ampicillin/sulbactam [122] | IV |
≥ 30: 1.5–3 g q6–8h 15–29: 1.5–3 g q12h < 15: 1.5–3 g q24h |
| Cefazolin [247] | IV |
> 54: 1–2 g q8h 35–54: 1–2 g q12 h 11–34: 0.5–1 g q12 h ≤ 10: 0.5–1 g q18–24h |
| Cefepime [248] | IV |
> 60: 0.5–2 g q8–12h 30–60: 0.5–2 g q12–24h 11–29: 0.5–2 g q24h ≤10: 0.25–1 g q24h |
| Cefotaxime [249] | IV |
≥ 20: 1–3 g q6–12h < 20: Change maintenance dose to 1–2 g q24h |
| Cefoxitin [250] | IV |
> 50: 1–2 g q8–12h 30–50: Change maintenance dose to 1–2 g q12–24h 10–29: Change maintenance dose to 0.5–1 g q12–24h < 10: Change maintenance dose to 0.5–1 g q24–48h |
| Ceftazidime [251] | IV |
> 50: 1–2 g q8h 31–50: 1 g q12h 16–30: 1 g q24h 6–15: 500 mg q24h < 6: 500 mg q48h |
| Ceftriaxone [252] | IV |
No adjustment needed 1–2 g q12–24h |
| Cefuroxime [253, 254] | PO | 250–500 mg q12h. No adjustment needed |
| IV |
> 20: 0.75–1.5 g q8h 10–20: 750 mg q12h < 10: 750 mg q24h |
|
| Cephalexin [255] | PO |
≥ 30: 0.25–1 g q6h 15–29: 250 mg q8–12h 6–14: 250 mg q24h < 6: 250 mg q48–60h |
| Ertapenem [259] | IV |
≥ 30: 1 g q24h < 30: 500 mg q24h |
| Imipenem and cilastatin [260] | IV |
≥ 90: 500–1000 mg q6–8h 60–89: 400–750 mg q6–8h 30–59: 300–500 mg q6–8h 15–29: 200–500 mg q6–12h < 15: Contraindicated unless dialysis is instituted within 48 h |
| Meropenem [262] | IV |
> 50: 500–1000 mg q6–8h 26–50: 500–1000 mg q12h 10–25: 250–500 mg q12h < 10: 250–500 mg q24h |
| Oxacillin [265] | IV |
No adjustment needed 250–1000 mg q4–6h |
| Piperacillin/tazobactam [263] | IV |
Traditional infusion > 40: 3.375 q6h or 4.5 g q8h 20–40: 2.25 g q6h < 20: 2.25 g q8h Extended 4-h infusion ≥ 20: 4.5 g q8h < 20: 4.5 g q12h Antipseudomonal infusion > 40: 4.5 g q6h 20–40: 3.375 g q6h < 20: 2.25 g q6h |
| Ticarcillin [266] | IV |
> 60: 3 g q24h 30–60: 2 g q4h 10–30: 2 g q8h < 10: 2 g q12h < 10 and hepatic dysfunction: 2 g q24h |
| Quinolones | ||
| Ciprofloxacin [123, 124] | PO |
> 50: 250–750 mg q8–12h 30–50: 250–500 mg q12h 5–29: 250–500 mg q18h < 5: 250–500 mg q24h |
| IV |
> 30: 200–400 mg q8–12h 5–29: 200–400 mg q18–24h |
|
| Levofloxacin [125] | PO/IV |
≥ 50: 250–750 mg q24h 20–49: 250–750 mg q24–48h < 20: 250–500 mg q48h |
| Moxifloxacin [126] | PO/IV |
No adjustment needed 400 mg q24h |
| Macrolides | ||
| Azithromycin [128] | PO/IV |
No adjustment needed 250–500 mg q24h |
| Clarithromycin [129] | PO |
≥ 30: 0.5–1 g q12h < 30: 0.25–0.5 g q12h |
| Erythromycin [130, 131] | PO |
≥ 10: 250–800 mg q6–12h < 10: 125–400 mg q6–12h |
| IV |
≥ 10: 15–20 mg/kg divided q6–8h < 10: 50% total dose at the same interval |
|
| Tetracyclines | ||
| Doxycycline [135, 136] | PO/IV |
No adjustment needed 50–100 mg q12h |
| Minocycline [137] | PO |
No adjustment needed Loading dose of 200 mg q24h followed by 100 mg q12h |
| Tetracycline [134] | PO |
> 50: 250–500 mg q6–12h 10–50: 250–500 mg q12–24h < 10: 250–500 mg q24h |
| Tigecycline [138] | IV |
No adjustment needed 100 mg followed by 50 mg q12h (decrease maintenance dose to 25 mg in hepatic dysfunction, Child–Pugh C) |
| Others | ||
| Clindamycin [256, 257] | PO |
No adjustment needed 150–450 mg q6–8h |
| IV |
No adjustment needed 600–1200 mg q6–12h |
|
| Daptomycin [258] | IV |
≥ 30: 4–6 mg/kg q24h < 30: 4–6 mg/kg q48h |
| Isoniazid [261] | PO |
No adjustment needed 5 mg/kg up to 300 mg q24h |
| Linezolid [127] | PO/IV |
No adjustment needed 400–600 mg q12h |
| Metronidazole [132] | PO/IV |
≥ 10: 500 mg q8h < 10, or severe hepatic impairment: consider 250 mg q8h if duration > 14 days |
| Nitrofurantoin [264] | PO |
≥ 60: 100 mg q12h < 60: Not recommended (poor effect and increased toxicity) |
| Rifampin [133] | PO/IV |
No adjustment needed 10 mg/kg up to 600 mg q24h |
| Trimethoprim/sulfamethoxazole [142] | PO |
> 30: 800/160 mg q12h 15–30: 400/80 mg q12h < 15: Not recommended |
| IV |
> 30: 8–20 mg/kg (based on trimethoprim component) administered in 2–4 doses q6–8h 15–30: Half the usual regimen < 15: Not recommended |
|
| Vancomycin [267, 268] | PO |
No adjustment needed 125 mg q6h |
| IV |
≥ 90: 15–20 mg/kg q12h 70–89: 15–20 mg/kg q8h 46–69: 15–20 mg/kg q12h 30–45: 15–20 mg/kg q18h 15–29: 15–20 mg/kg q24h < 15: Monitor levels to determine when to dose |
|
CrCl creatinine clearance, IV intravenously, PO orally, qxh every x hours