Antibacterial Dosing Guide for Patients with

Reduced Renal Function

Livingstone Tertiary Hospital
2020

▪ Rationale
Patients with reduced renal function, either acute or chronic, are often under or overdosed at
Livingstone Hospital. A standardised guide is warranted to ensure safe and effective antibacterial dosing
across all departments.

▪ Scope
This guideline aims to provide clinicians and pharmacists with up-to-date information on renal dose
adjustments of systemic antibacterial agents available at Livingstone Hospital and is based on current
international and national references. Certain specific patient populations and regimens are not
included in this document (patients in ICU, dialysis patients and constant infusion regimens) . It should
be noted that the list of indications is not exhaustive. Indications not listed, multidrug resistant
infections and complicated infections should be discussed with the ID unit as dosing recommendations
may differ in these populations.

This document serves to improve current antimicrobial practices; it does not replace sound clinical
judgement.

▪ Caveat
Caution is advised in the setting of acute kidney injury where rapid resolution of renal impairment is
predicted. In this clinical scenario, dose adjustments might lead to underdosing and subsequent
subtherapeutic concentrations. For this reason, renal function should be monitored on a daily basis and
doses readjusted based on most recent creatinine trends. The same principle applies to patients with
deteriorating renal function.

▪ Note well: The first dose of an antimicrobial is almost always the usual dose as for normal
renal function. Thereafter, maintenance dosing is adjusted as per the guideline below.

▪ Antibacterial agents are listed alphabetically.

▪ Doses recommended are for adult patients.
▪ Abbreviations, formulae and references are listed on last page.

1
Antibacterial agent Usual dosing (normal renal function) Renal dosing
Abacavir 300 mg PO q12h / 600 mg PO q24h Not renally adjusted
Aciclovir • Herpes simplex virus (HSV): GFR 10 - 50 mL/min
• Primary episode 400 mg PO q8h • Usual dose q12 - 24h
• Recurrent 400 mg - 800 mg q8h GFR < 10 mL/min
• Severe HSV/ Varicella Zoster Virus (VZV) (CNS • 50 % of dose q24h
infections): 5 - 12.5 mg/kg IV q8h
• VZV and Herpes Zoster:
800 mg PO q4h (5 times-a-day)
Albendazole • Usual dose: 400 mg PO q12 - 24h Not renally adjusted
• Hydatid disease: 10 - 15 mg/kg/day in divided
doses
• Neurocysticercosis: 15 mg/kg/day (max. 1200
mg/day if used alone or max. 800 mg/day
with praziquantel 50 mg/kg/day)
Amikacin • 15 - 20 mg/kg IV q24h GFR < 60 mL/min
Overweight patients: • Consult ID unit
- < 20% over Ideal Body Weight (IBW):
use Actual Body Weight
- > 20% over IBW: use Adjusted Body
Weight (see formulae)
Amoxicillin • 500 mg - 1 g PO q8h GFR 10 - 30 mL/min
• H. pylori eradication: 1 g PO q12h (in • 250 - 500 mg q12h
combination with macrolide). GFR < 10 mL/min
• 500 mg - 1 g q24h
Amphotericin B • Usual dosing range: 0.3 - 1.5 mg/kg IV q24h GFR < 10 mL/min
• Cryptococcal meningitis: 1 mg/kg IV q24h • Consult ID unit
(together with flucytosine or fluconazole as
per hospital protocol)
• Obese patients: Calculate dose using actual
body weight
Amphotericin B • Cryptococcal meningitis: 3 - 4 mg/kg IV q24h Not renally adjusted
(liposomal) (together with flucytosine or fluconazole as
per hospital protocol)
Ampicillin • Usual dose: 1 - 2 g IV q4-6h GFR 50 - 80 mL/min
• Listeria monocytogenes meningitis: 2 g IV • 1 - 2 g IV q4-6h
q4h for 21 days GFR 10 - 50 mL/min
• 1 - 2 g IV q6-8h
GFR < 10 mL/min
• 1 - 2 g IV q8-12h
Atazanavir • 300 mg PO q24h (with ritonavir 100 mg Not renally adjusted
q24h)
Azithromycin • 500 mg IV / PO q24h Not renally adjusted – no data
• Obese patients*: 500 - 600mg IV / PO q24h
Bedaquiline • 400mg PO q24h for 2 weeks, then GFR < 10 mL/min
200mg three times a week (M/W/F) for 22 • Caution
weeks
Benzathine Penicillin • 1.2 - 2.4 MU IM ONLY GFR 10 – 50 mL/min
• 75% of dose
GFR <10 mL/min
• 50% of dose

2
Benzyl Penicillin • 200 000 U - 4 MU IV q4h GFR 10 - 50 mL/min
(Syn. Penicillin G) • Mild to moderate infections: 1 - 1.5
MU IV q4h
1 MU = 600 mg • Severe infections (e.g. neurosyphilis,
endocarditis): 2 - 3 MU IV q4h
GFR < 10 mL/min
• Mild to moderate infections: 1 MU IV
q6h
• Severe infections (e.g. neurosyphilis,
endocarditis): 2 MU IV q4h - q6h.
Caspofungin • 70 mg IV loading dose D1, then Not renally adjusted
50 mg IV q24h
• Obese patients: 70 mg IV q24h
Cefazolin • Usual dose: 1 - 2 g IV q8h (max 12 g/d) GFR 10 - 50 mL/min
• MSSA bacteraemia, endocarditis: 2 g IV q8h • 1 - 2 g IV q12h
• Obese patients*: 2 g IV q6h GFR < 10 mL/min
• 1 - 2 g IV q24h
Cefepime • Mild to moderate infections: 1 g IV q12h GFR > 60 mL/min
• Severe infections (CNS, bacteraemia and • Severe infections: 2 g IV q8h
Pseudomonas): 2 g IV q8h GFR 30 - 60 mL/min
• Severe infections: 1 g IV q8h
• Mild to moderate infections: 1 g IV
q12h
GFR 10 - 29 mL/min
• Severe infections: 1 g IV q12h
• Mild to moderate infections: 1 g IV
q24h
GFR < 10 mL/min
• 1 g IV q24h
Ceftazidime • Mild to moderate infections: 1 g IV q8h - 12h GFR 30 - 50 mL/min
• Severe infections (bone & joint infections, CNS • 1 g IV q12h
infections, Pseudomonal infections): 2 g IV q8h • Severe or CNS infections: 2 g IV q12h
GFR 10 - 29 mL/min
• 1 g IV 24 hourly
• Severe or CNS infections: 2 g IV q24h
GFR < 10 mL/min
• 500 mg IV q24h
• Severe or CNS infections: 1 g IV q24h
Ceftriaxone • Most infections: 1 - 2 g IV q24h Not renally adjusted
• Bacterial meningitis: 2 g IV q12h
Ciprofloxacin • Most infections: 400 mg IV q8h - q12h / 500 GFR 10 - 50 mL/min
mg PO q12h • Most infections: 400 mg IV q24h / 250
• Severe infections (including Pseudomonas): mg PO q12h
400 mg IV q8h / 750 mg PO q12h • Severe infections (including
Pseudomonas): 400 mg IV q12h / 500
mg PO q12h
GFR < 10 mL/min
• 400 mg IV q24h / 500 mg PO q24h
Clarithromycin • 500 mg PO q12h Not renally adjusted
Clindamycin • Most infections: 600 mg IV q8h / 300 - 450 mg Not renally adjusted
PO q6h - q8h
• Severe infections (including pelvic
inflammatory disease, necrotising fasciitis,
osteomyelitis): 600 - 900 mg IV q8h / 300 mg -
450 mg q6h

3
Clofazimine • 100mg PO q24h Not renally adjusted
Cloxacillin • Usual dose: 1 - 3 g IV q6h Not renally adjusted
• Bone & joint infections: 2 g IV q6h
• Endocarditis/CNS infection: 3 g IV q6h
Co-amoxyclav • 1.2 g IV q6h - q8h / 1g PO q12h GFR 10 - 30 mL/min
• 1.2 g IV q12h / 500 mg PO q12h
GFR < 10 mL/min
• 1.2 g IV q24h / 500 mg PO q24h
Co-trimoxazole All doses based on trimethoprim component GFR 10 - 50 ml/min
(each tablet & • Usual dose: 8 - 20 mg/kg/day in divided doses • 75% of dose
ampoule = • Pneumocystis pneumonia (5 mg/kg q6h for 21 GFR < 10 ml/min
trimethoprim 80 mg / days) • 50% of dose
sulfamethoxazole 400 - < 40 kg: 2 tablets/ampoules PO/IV q6h
mg) - 40 - 56 kg: 3 tablets/ampoules PO/IV q6h
- > 56 kg: 4 tablets/ampoules PO/IV q6h
• Cerebral Toxoplasmosis: 4 tablets/ampoules
PO/IV q12h for 28 days, thereafter; 2 tablets PO
q12h for 3 months.
• Isosporiasis: 4 tablets/ampoules q12h for 10
days
• Bone & joint infections: 5 mg/kg q12h
Colistin • 4.5 MU IV q12h GFR 31 - 60 ml/min
• Seriously ill patients - give loading dose • 3 MU IV q12h
• IBW 55 kg: 9 MU IV GFR 10 - 30 ml/min
• IBW 70 kg: 12 MU IV • 2 MU IV q12h
1MU = 80 mg CMS = 30 mg colistin base GFR < 10 ml/min
• 1 MU IV q12h
Dapsone • PCP prophylaxis: 100 mg PO q24h GFR < 10 mL/min
• No data (may need adjustment)
Darunavir • Therapy experienced: 600 mg PO q12h (with Not renally adjusted
ritonavir 100 mg q12h)
• Therapy naïve: 800/100 mg PO q24h
Delamanid • 100mg PO q12h for 24 weeks GFR < 10 mL/min
• No data (not recommended)
Dolutegravir • 50 mg PO q24h Not renally adjusted
• With:
• Rifampicin: DTG 50 mg q12h
• Carbamazepine: DTG 50 mg q12h
Doxycycline • 100 mg PO q12h Not renally adjusted
Efavirenz • >40kg: 600mg PO q24h (at night) Not renally adjusted
<40kg: 400mg PO q24h
Ertapenem • 1 g IV / IM q24h GFR < 30 mL/min
• 500 mg IV q24h
Ethambutol • 15 - 20 mg/kg PO q24h GFR < 30mL/min
(not > 1600 mg/dose) • 15 - 20 mg/kg per dose three times a
week (M/W/F)
Ethionamide • Usual dosing range 500 - 750 mg GFR < 10 mL/min
(15 - 20 mg/kg) PO q24h - max. 1 g / day • 50% dose (250 - 500 mg q24h)
Etravirine • 200 mg PO q12h Not renally adjusted
Flucloxacillin • Skin & soft tissue infections: 500 mg PO q6h Not renally adjusted
• Bone & joint infection: 1 g PO q6h

4
Fluconazole • Oesophageal candidiasis: 200 - 400 mg PO GFR < 50 mL/min
q24h • 50% of dose
• Oropharyngeal candidiasis: 100 - 200 mg PO
q24h
• Candidemia and disseminated candidiasis: 800
mg IV / PO stat then 400 mg q24h
• Cryptococcosis:
• Non-meningeal
800mg q24h for 2 weeks, then 400 mg
q24h for 10 weeks, then 200 mg q24h
• Meningeal (together with amphotericin B
or flucytosine as per hospital protocol)
Induction phase: 1.2 g PO q24h
Consolidation phase: 800 mg q24h
Maintenance phase: 200 mg q24h
Flucytosine • 25 mg/kg PO q6h GFR > 40 mL/min
(together with amphotericin B or fluconazole • 25 mg/kg q6h
as per hospital protocol) GFR 20 - 40 mL/min
• 25 mg/kg q12h
GFR 10 - 20 mL/min
• 25 mg/kg q24h
GFR < 10 mL/min
• 25 mg/kg > 48h
Fosfomycin • Uncomplicated UTI: 3 g PO x 1 dose GFR 10 - 50 mL/min
• Complicated UTI: 3 g PO q72h X 3 doses • No data
• Prostatitis: 3 g PO q72h X 7 doses GFR < 10 mL/min
• No data - dose adjust or avoid
Ganciclovir Induction: Induction:
• 5 mg/kg IV q12h (2 - 6 weeks) GFR 50 - 70 mL/min
• 2.5 mg/kg q12h
GFR 25 - 49 mL/min
• 2.5 mg/kg q24h
GFR 10 - 24mL/min
• 1.25 mg/kg q24h
GFR < 10 mL/min
• 1.25 mg/kg three times a week
Maintenance: Maintenance:
• 5 mg/kg q24h GFR 50 - 70 mL/min
• 2.5 mg/kg q24h
GFR 25 - 49 mL/min
• 1.25 mg/kg q24h
GFR 10 - 24 mL/min
• 0.625 mg/kg q24h
GFR < 10 mL/min
• 0.625 mg/kg three times a week
Gentamicin • 5 - 7 mg/kg IV q24h GFR < 60 mL/min
• Consult ID unit
Imipenem • 500 mg IV q6h OR 1 g IV q8h GFR 41 - 70 mL/min
• Intermediate susceptibility & obesity: 1 g IV • Moderate infection: 500 mg IV q8h
q6h • Severe infections: 500 g IV q6h
GFR 21 - 40 mL/min
• Moderate infections: 250 mg IV q6h
• Severe infection: 500 mg IV q8h
GFR <20 mL/min
• Moderate infections: 250 mg IV q12h
• Severe infection: 500 mg IV q12h
5
Isoniazid • 5 mg/kg PO q24h Not renally adjusted
• INH resistance: 10 - 15 mg/kg PO q24h
(ONLY if inhA mutation is present alone)
Itraconazole • Usual dose: 200 mg PO q12 - 24h GFR ≤ 10 mL/min
• 50% of dose
Ketoconazole • Usual dosing range: 200 - 400 mg PO q12 - 24h Not renally adjusted
Lamivudine • 150 mg PO q12h / 300 mg PO q24h GFR 10 - 50 mL/min
• 150 mg q24h
GFR < 10 mL/min
• 50 mg q24h
Levofloxacin • Usual dose range: 250 mg - 750 mg PO q24h GFR 50 - 80 mL/min
• TB: 500 mg - 1 g PO q24h • 750 mg PO q24h
• Severe infections (including pneumonia, bone GFR 20 - 49 mL/min
& joint infections, complicated skin & soft • 750 mg PO stat, then 750 mg q48h
tissue infections): 750 mg PO q24h GFR < 20 mL/min
• Obese patients*: 750 mg PO q24h • 750 mg stat, then 500mg q48h
Linezolid • 600mg IV / PO q12h Not renally adjusted
• Severe infections in obesity: consider 600 mg
IV / PO q8h
Lopinavir/ritonavir • 400/100 mg PO q12h Not renally adjusted
• With:
• Rifampicin: LPV/r 800/200 mg q12h
Mebendazole • 100 mg PO q12h / 500 mg PO as a single dose Not renally adjusted
Meropenem • Mild to moderate infections: 1 g IV q8h GFR 26 - 50 mL/min
• Severe infections & CNS infections: 2 g IV q8h • Mild to moderate infections: 1 g IV
q12h
• Severe infections & CNS infections: 1 g
IV q8h
GFR 10 - 25 mL/min
• Mild to moderate infections: 500 mg IV
q12h
• Severe infections & CNS infections: 1 g
IV q12h
GFR < 10 mL/min
• Mild to moderate infections: 500 mg IV
q24h
• Severe & CNS infections: 1 g IV q24h
Metronidazole • 500 mg IV q6h - 8h / 400 mg PO q8h Not renally adjusted
Micafungin • Usual dosing range: 100 - 150 mg IV q24h Not renally adjusted
• Obese patients: may require higher doses
Moxifloxacin • 400mg IV / PO q24h Not renally adjusted
(obese patients* - consider 600 mg q24h)
• TB and MAC: 400 mg PO q24h (consider 600 -
800 mg q24h in combination with rifampicin)
• TB meningitis: 800 mg IV/PO (monitor QTc)
Nevirapine • 200mg PO q24h for 14 days, then Not renally adjusted
200 mg q12h
Nitrofurantoin • 50 - 100 mg PO q6h GFR 50 - 80mL/min
• Suppression therapy for recurrent UTI: 50 - • Usual dose
100mg PO q24h GFR < 50mL/min
• Not recommended
Oseltamivir • 75 mg PO q12h GFR 10 - 30mL/min
• 75 mg PO q24h

6
Para-amino salicylic • 4 g PO q12h GFR < 10 mL/min
acid • 4 g q24h
Phenoxymethyl- • 250 - 500 mg PO q6 - 8h Not renally adjusted
penicillin (syn. Penicillin
V)
Piperacillin-Tazobactam • 4.5 g IV q6h GFR 20 – 40 mL/min
• 2.25 g q6h
GFR < 20 mL/min
• 2.25 g IV q8h
Pyrazinamide • 25 mg/kg PO q24h GFR < 30 mL/min
(not > 2000 mg/dose) • 25 mg/kg three times a week (M/W/F)
Raltegravir • 400 mg PO q12h Not renally adjusted
Rifabutin • Active TB and MAC: 5 mg/kg PO q24h GFR < 30 mL/min
(usually 300 mg) • 50% of dose q24h
• With:
• PIs: Rifabutin 150 mg q24h
• EFV: Rifabutin 450 - 600 mg q24h
• NVP or ETR: Rifabutin 300 mg q24h
• DTG or RAL: Rifabutin 300 mg q24h
Rifampicin • TB: 10 mg/kg PO q24h (max. 600 mg) Not renally adjusted
• TB meningitis: 13 - 15 mg/kg PO q24h (max.
600 mg q12h)
• N. meningitidis prophylaxis: 600 mg q12h for
2 days
• Bone & joint infection (not to be used as
monotherapy): 10 mg/kg (max. 900 mg q12h)
Stavudine • 30 mg PO q12h GFR 10 - 50 mL/min
• 15 mg q12h
GFR < 10 mL/min
• 15 mg q24h
Teicoplanin • Bone & joint infections and endocarditis GFR 10 – 50 mL/min
(severe infections): 12 mg/kg q12h x 3 doses • 6 mg/kg q48h
(loading), then 12 mg/kg q24h GFR <10 mL/min
• All other infections: 6 mg/kg q24h • 6 mg/kg q72h
Tenofovir • 300mg PO q24h GFR < 50 mL/min
• AVOID
Terizidone • 15 - 20 mg/kg PO q24h GFR < 30 mL/min
- 33 - 50 kg: 500 - 750 mg • No data (not recommended - high risk
- 51 - 70 kg: 750 mg of CNS toxicity)
- > 70 kg: 750 - 1000 mg
Tigecycline • 100 mg IV loading, then 50 mg IV q12h Not renally adjusted
• MDR infections: 200 mg IV loading, then 100
IV q12h
Valganciclovir • Treatment (induction): 900 mg PO q12h GFR 40 - 59 mL/min
• Prophylaxis (maintenance): 900 mg PO q24h • 450 mg PO q24h
GFR 25 - 39 mL/min
• 450 mg q48h
GFR 10 - 24 mL/min
• 450 mg twice a week

7
Vancomycin • 15 - 20 mg/kg q8h - q12h GFR ≥ 90 mL/min
• Complicated infection - give loading 25 - 30 • 15 - 20 mg/kg q8h
mg/kg IV stat) GFR 60 - 90 mL/min
• 15 - 20 mg/kg q12h
Contact Pharmacy for Livingstone’s Vancomycin GFR 30 - 59 mL/min
Dosing and Monitoring Guide • 15 - 20 mg/kg q24h
GFR 10 - 29 mL/min
• 15 - 20 mg/kg q48h
GFR < 10 mL/min
• 15 - 20 mg/kg q96h
Zidovudine • 300 mg PO q12h GFR < 10 mL/min
• 300 mg q24h
Abbreviations/acronyms: CNS = central nervous system, CMS = Colisitimethate sodium, GFR = glomerular filtration rate, IBW
= ideal body weight, ID = infectious diseases, MAC = Mycobacterium avium complex, max = maximum, MDR = multi-drug
resistant, MSSA = methicillin-sensitive Staphylococcus aureus, syn. = synonym, TB = tuberculosis, UTI = urinary tract infection.

Formulae:

Adjusted body weight = IBW + 0.4(actual body weight - IBW)

Definition:

Obese patients*: BMI > 30

References:

Craig, W.A. 2011. Optimizing aminoglycoside use. Critical Care Clinics, 27:107-121.

Johns Hopkins Antibiotic Guide, 2019. POC-IT Guides Johns Hopkins Medicine. Unbound Medicine.
https://www.hopkinsguides.com/hopkins/index/Johns_Hopkins_ABX_Guide/All_Topics/A

Hughes, J. and Osman, M. 2014. Diagnosis and management of drug-resistant tuberculosis in South African adults. SAMJ,
104(12): 894

Mase, S. et al. 2013. Provisional CDC Guidelines for the Use and Safety Monitoring of Bedaqualine Fumarate (Situro) for the
Treatment of Multidrug-Resistant Tuberculosis. Centers for Disease Control and Prevention, MMWR Recomm Rep., 62(RR-09):
1-12

SAMF (South African Medicines Formulary), 2016. Health and Medical Publishing Group.

Sanford Guide, 2019. Antimicrobial Therapy, Inc. https://www.sanfordguide.com/products/digital-subscriptions/sanford-

guide-to-antimicrobial-therapy-mobile/