Contents

Renal Dosage Adjustment Guidelines for Antimicrobials

The pharmacists will automatically adjust the doses of any of the antimicrobials included in the protocol according to the estimated creatinine clearance (using the Cockroft-Gault equation for patients ≥ 18 years old and the Schwartz equation for patients < 18 years old). This protocol does NOT include neonates. When a change is necessary, the pharmacist will write a new order in the Orders section of the medical record indicating the new dosage “per protocol” and enter the order in Carecast as a protocol (“P”) order. No physician signature will be required to authorize the revised dosing order.

The adjustments listed below will be made unless the physician writes “Do not adjust” when ordering the antimicrobial.

The most current version of the Renal Dosage Adjustment Guidelines for Antimicrobials can be found online at http://www.nebraskamed.com/asp under “ASP News”.

Please note:

• If there are no clear recommendations available, do not attempt any automatic dosage adjustment. Consult with the physician.

Antimicrobial	Normal Dose	Renal Dosage Adjustment Based on CrCl Estimate (in ml/min)*
Abacavir	Adult 300 mg PO bid or 600 mg PO qday Pediatric 8 mg/kg PO bid	No adjustment necessary.
Acyclovir	Adult PO 200 mg PO 5x/day 400 mg PO 5x/day 800 mg PO 5x/day 400 mg PO bid IV 5-12.4 mg/kg IV q8h	CrCl 0-10: same dose bid CrCl 11-25: same dose tid CrCl 0-10: same dose bid CrCl 11-25: same dose tid CrCl 0-10: same dose bid CrCl 0-10: 200 mg PO bid CrCl 25-50: same dose q12h CrCl 10-24: same dose q24h CrCl <10: 2.5-6.2 mg/kg IV q24h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: dose as CrCl <10
	Pediatric PO 6.25-20 mg/kg PO qid IV 15-30 mg/kg IV q8h	CrCl 10-25: same dose tid CrCl <10: same dose bid CrCl 25-50: same dose q12h CrCl 10-24: same dose q24h CrCl <10: 50% IV q24h^Ŧ HD/CAPD: No data.
Amikacin	Adult 15 mg/kg/day IV divided q8h Monitoring of serum levels is recommended. Once daily dosing of aminoglycosides is adjusted based on the Hartford nomogram.	CrCl 51-90: 60-90% IV q12h^ŦCrCl 10-50: 30-70% IV q12-18h^ŦCrCl <10: 20-30% IV q24-48h^Ŧ HD/CAPD: Dose according to levels.
	Pediatric 5 mg/kg IV q8h	Adjustments made based on levels.
Amoxicillin	Adult 250-500 mg PO q8h Pediatric 12.5-45 mg/kg PO q8-12h (25-90 mg/kg/day)	Same for Adult & Pediatric CrCl 10-30: same dose q12h CrCl <10: same dose q24h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: 250 mg PO q12h No clear recommendations for pediatrics.
Amoxicillin/clavulanate	Adult 500/125 mg PO tid 875/125 mg PO bid 1000/62.5 mg PO bid (XR formulation)	CrCl 10-30: 250/125 mg PO bid CrCl <10: 250/125 mg PO qday CrCl 10-30: 500/125 mg PO bid CrCl <10: 500/125 mg PO qday XR formulation NOT recommended with CrCl < 30. HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: 250/62.5 mg PO q12h
	Pediatric 10-45 mg (amoxicillin component)/kg q8-12h [20-40 mg (amoxicillin component)/kg/day]	CrCl 10-30: same dose q12h CrCl <10: same dose q24h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: No clear recommendations.
Amphotericin B	Adult & Pediatric 1 mg/kg IV qday	CrCl <10: same dose q48h HD: No adjustment necessary. CAPD: Dose as CrCl <10.
Amphotericin B Lipid	Adult & Pediatric 5 mg/kg IV qday	CrCl <10: same dose q24-48h HD: No adjustment necessary. CAPD: Dose as CrCl <10.
Ampicillin	Adult PO 250-1000 mg PO q6h IV 250-1000 mg IV q6h 2 g IV q4h	CrCl <10: same dose q12h CrCl <10: same dose q12h CrCl 10-50: same dose q6h CrCl <10: same dose q12h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: 250 mg PO/IV q12h
	Pediatric PO 12.5-25 mg/kg PO qid IV 25-100 mg/kg IV q6h	CrCl <10: same dose q12h CrCl <10: same dose q12h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: No clear recommendations.
Ampicillin/sulbactam	Adult 1.5-3 g IV q6h	CrCl 30-50: same dose q8h CrCl 15-29: same dose q12h CrCl <15: same dose q24h HD: Dose as CrCl <15. Give after dialysis on dialysis days. CAPD: Dose as CrCl <15
	Pediatric 25-100 mg (ampicillin component)/kg IV q6h	CrCl 15-29: same dose q12h CrCl <15: same dose q24h HD: Dose as CrCl <15. Give after dialysis on dialysis days. CAPD: Dose as CrCl <15.
Atovaquone	Adult & Pediatric (>13yo) 1500 mg PO divided q12-24h Pediatric 20 mg/kg PO bid	No data.
Azithromycin	Adult 250-500 mg PO/IV qday Pediatric 5-10 mg/kg PO qday	No adjustment necessary. Caution advised if CrCl < 10 (AUC increased by 35%).
Aztreonam	Adult 1-2 g IV q8-12h	CrCl 10-30: 1-2 g IV x1, then 50% IV at same interval^Ŧ CrCl <10: 1-2 g IV x1, then 25% IV at same interval^Ŧ HD: Dose as for CrCl <10 with an extra 125-250 mg IV after dialysis. CAPD: Dose as CrCl <10
	Pediatric 30-60 mg/kg IV q6-8h	CrCl 10-30: 50% IV at same interval^Ŧ CrCl <10: 25% IV at same interval^Ŧ HD: Dose as for CrCl <10 with an extra 3.25-7.5 mg/kg IV after dialysis. CAPD: Dose as CrCl <10.
Caspofungin	Adult 70 mg IV x1, then 50 mg IV qday Pediatric 70 mg/m2 IV x1, then 50 mg/m2 IV qday	No adjustment necessary.
Cefazolin	Adult 1-2 g IV q8h	CrCl 10-50: same dose q12h CrCl <10: same dose q24h HD: 500 mg – 1 g IV given only after dialysis. CAPD: 500 mg IV q12h
	Pediatric 16.7-50mg/kg IV q8h	CrCl 10-30: same dose q12h CrCl <10: same dose q24h HD: 2.5-7.5 mg/kg IV given only after dialysis. CAPD: No adjustment necessary.
Cefepime	Adult 1-2 g IV q8-12h	CrCl 10-50: same dose q12 (for q8h dosing)-q24h (for q12h dosing) CrCl <10: same dose q24h (for q8h dosing) -q48h (for q12h dosing) HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: Dose for CrCl <10
	Pediatric 50 mg/kg IV q8-12h	CrCl 10-50: same dose q12 (for q8h dosing)-q24h (for q12h dosing) CrCl <10: 50% q24h^Ŧ HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: 50 mg/kg IV q48h
Cefotaxime	Adult 1-2 g IV q8h	CrCl 10-50: same dose q12h CrCl <10: same dose q24h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: 1 g IV q24h
	Pediatric 25-100mg/kg IV q6-8h (100-200mg/kg/day)	CrCl <20: same dose q24h HD: Dose as CrCl <20. Give after dialysis on dialysis days. CAPD: 50-100 mg/kg IV q24h
Cefoxitin	Adult 1-2 g IV q8h	CrCl 10-30: same dose q12h CrCl <10: same dose IV q24h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: 1 g IV q24h
	Pediatric 20-40mg/kg IV q6h	CrCl 51-90: same dose q8h CrCl 10-50: same dose q12h CrCl <10: same dose q24-48h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: No clear recommendations.
Ceftazidime	Adult 1-2 g IV q8-12h	CrCl 10-50: same dose q24h CrCl <10: same dose q48h HD: Dose as CrCl <10. Give after dialysis on dialysis days CAPD: 1 g IV x1, then 500 mg IV q24h
	Pediatric 30-50 mg/kg IV q8h	CrCl 30-50: same dose q12h CrCl 10-29: same dose q24h CrCl <10: same dose q48h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: 30-75 mg/kg IV x1, then 50% q24h^Ŧ
Ceftriaxone	Adult 1-2 g IV q12-24h	No adjustment necessary. CAPD: 750 mg IV q12h
	Pediatric 25-100mg/kg IV q12-24h (50-100mg/kg/day)	No adjustment necessary.
Cefuroxime	Adult PO 250-500 mg PO bid IV 750 mg – 1.5 g IV q8h	No adjustment necessary. HD: Give after dialysis on dialysis days. CrCl 10-20: same dose q12h CrCl <10: same dose q24h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: Dose as CrCl <10
	Pediatric PO Cefuroxime 10-15 mg/kg PO bid IV 25-50mg/kg IV q8h	No adjustment necessary. HD: Give after dialysis on dialysis days. CrCl 10-20: same dose q12h CrCl <10: same dose q24h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: Dose as CrCl <10.
Cephalexin	Adult 250 - 500 mg PO qid	CrCl 50-90: same dose PO tid CrCl <50: same dose PO bid HD: Dose as CrCl <50. Give after dialysis on dialysis days. CAPD: Dose as CrCl <50.
	Pediatric 6.25-37.5 mg/kg PO q6h	CrCl 10-40: same dose q8h CrCl >10: same dose q12h HD: Dose as CrCl <10. Give after dialysis on dialysis days. CAPD: Dose as CrCl <10.
Chloramphenicol	Adult 12.5-25 mg/kg IV q6h Pediatric 6.25-25 mg/kg