Antimicrobial Dosage Adjustments in Renal Impairment For Formulary

Antimicrobial dosage adjustments in renal impairment
The dosing tables below reflects current practice in RLBUHT and is based on a combination of the
following reference sources and clinical experience: The Renal Drug Handbook (Online), Individual
Summary of Product Characteristics and British National Formulary (Online).
First doses of antibiotics can often be given at full treatment dosages as explained previously.
Patients who are extremely unwell or immunosuppressed may need doses at the higher end of the
ranges stated. Do not wait (e.g. until after dialysis) to administer antibiotics if patient is acutely
unwell.
In ‘acute on chronic’ renal impairment associated with sepsis, the initial dosing regimen should be
according to the baseline level of renal function. It should be noted that haemodiafiltration (HDF)
removes drugs more efficiently than HD, although there is limited information on this.
There is a traffic light coding system for dose adjustments of antimicrobials in AKI.
Safe in AKI
: No dose adjustment needed in AKI or CKD
Review at 48h in AKI

: Dose adjustment generally required in CKD patients. In patients with new
renal dysfunction or AKI, the antimicrobial should be dose based on baseline kidney function (GFR)
for the first 48 hours. After 48 hours, the kidney function should be reassessed and if no recovery of
function, a dose reduction based on current GFR is advised.
Caution in AKI
: This category of antimicrobials should be cautioned in AKI. Medication in this
group can result in:
 Sub-therapeutic levels in AKI (e.g. nitrofurantoin)
 Nephrotoxicity and should be avoided unless no other alternatives exist (e.g.
aminoglycosides)
 Accumulation and therefore an immediate dose reduction is required (e.g. vancomycin)
Useful contacts:
Anne Neary (Lead antimicrobial and infectious diseases pharmacist) Bleep 4502
Danielle Lucy (Senior antimicrobial pharmacist) Bleep 5067
Ward pharmacists Via bleeps
Medical microbiology Ext 4410
Renal pharmacists Ext 3318

Quick reference guide for dosing of antimicrobials in acute kidney injury (AKI)
Safe in AKI Review at 48h in AKI Caution in AKI

No dose reduction needed in Dose as per baseline* GFR for
Dose reduce (or avoid if
AKI/CKD 48 hours then review
possible)
Give STAT dose of gentamicin
and review with levels
Azithromycin Penicillins Aminoglycosides ~
Chloramphenicol Carbapenems (gentamicin and
Clindamycin Cephalosporins amikacin)
Dapsone Clarithromycin Known nephrotoxic: however
single doses in sepsis are
Doxycycline Fosfomycin advised even in AKI patients.
Erythromycin Quinolones Toxicity is associated with
Linezolid Teicoplanin prolonged courses.
Metronidazole
Moxifloxacin Colomycin ~
Rifampicin Co-trimoxazole *
Tigecycline Daptomycin
Antifungals Nitrofurantoin #
Fluconazole Trimethoprim #
Voriconazole Vancomycin
Antifungals Known nephrotoxic: give a
Anidulafungin loading dose and review
Itraconazole therapeutic drug levels.
Caspofungin
Posaconazole Antifungals
Ambisome
Flucytosine
Antivirals
Aciclovir
Foscarnet
Ganciclovir
Oseltamivir
*In PCP treatment, discuss with medical microbiology or antimicrobial pharmacist

# Risk of treatment failure
~ Known nephrotoxic; however single doses in sepsis are advised even in AKI patients.
Please note the tables below relates to intravenous (IV) administration of commonly used
antibiotics that require dose adjustments in renal impairment.
Caution in AKI
Amikacin
Indications as per Trust formulary: On advice of medical microbiology or infectious diseases only.
Please seek specialist advice from antimicrobial pharmacist or medical microbiology.

Amoxicillin
Indications as per Trust formulary: Severe CAP, aspiration pneumonia: hospital acquired, lung
abscess community acquired and indolent presentation, intra-abdominal infection: non-healthcare
associated, meningitis: over 55 years of age or immunosuppressed.
Creatinine clearance (CrCl) Recommended dose

>10 ml/min No dose adjustment required
<10 ml/min Max 1g every 8 hours (Discuss with medical
microbiology or antimicrobial pharmacist if high
doses required for endocarditis)
Intermittent haemodialysis Max 1g every 8 hours (Dialysed – give after
dialysis)
Intermittent haemodiafiltration (HDF) Max 1g every 8 hours (Dialysed – give after
dialysis)
Continuous ambulatory peritoneal dialysis Max 1g every 8 hours (Not dialysed)
(CAPD)
Continuous renal replacement therapy (CRRT) Seek specialist advice from critical care
pharmacist
Safe in AKI
Aztreonam

>30 ml/min 1g every 8 hours (up to 2g every 6 hours in
severe infections)
10-30 ml/min 1-2g STAT loading dose and then 1g every 12
hours (maintenance)
<10 ml/min 1-2g STAT loading dose and then 1g daily
(maintenance)
Intermittent haemodialysis 1-2g STAT loading dose and then 1g daily
(Dialysed – give after dialysis)
Intermittent haemodiafiltration (HDF) 1-2g STAT loading dose and then 1g daily
Continuous ambulatory peritoneal dialysis 1-2g STAT loading dose and then 1g daily (Not
(CAPD) dialysed)
pharmacist
Benzylpenicillin
Indications as per Trust formulary: Hospital acquired pneumonia (HAP)(Onset >48 hours and <5
days after admission), peritonsillar abscess,

>50 ml/min 2.4g every 6 hours
20-50 ml/min 2.4g every 6 hours
<10 ml/min 1.2g every 6 hours
Intermittent haemodialysis 1.2g every 6 hours (Dialysed – give after
dialysis)
Intermittent haemodiafiltration (HDF) 1.2g every 6 hours (Dialysed – give after
dialysis)
Continuous ambulatory peritoneal dialysis 1.2g every 6 hours (Dialysed – give after
(CAPD) dialysis)
pharmacist

Ceftazidime
Indications as per Trust Formulary: Infective exacerbation of bronchiectasis (minor penicillin allergy)

>50 ml/min 100-150mg/kg every 8 hours (max 9g/day)
31-50 ml/min 1-2g every 12 hours
16-30 ml/min 1-2g every 24 hours
6-15 ml/min 500mg – 1g every 24 hours
<5 ml/min 500mg – 1g every 48 hours
Intermittent haemodialysis 500mg – 1g every 48 hours or post dialysis
(Dialysed)
Intermittent haemodiafiltration (HDF) 500mg-2g every 48 hours or post dialysis
(Dialysed)
Continuous ambulatory peritoneal dialysis 500mg – 1g every 24 hours (Dialysed – give
(CAPD) after dialysis)
pharmacist
Ceftazidime/avibactam
dialysis)
Intermittent haemodiafiltration (HDF) 1.25g every 48 hours (Dialysed –give after
dialysis)
Continuous ambulatory peritoneal dialysis 1.25g every 48 hours
(CAPD)
pharmacist

Ceftriaxone
Indications as per Trust Formulary: Acute orbital cellulitis, meningitis unknown aetiology,
epiglottitis, on advice of OPAT service.

>50 ml/min 2g every 12-24 hours
20-50 ml/min 2g every 12-24 hours
10-20 ml/min 2g every 12-24 hours
<10 ml/min 1g every 12-24 hours (max 2g daily)
Intermittent haemodialysis 1g every 12-24 hours (Not dialysed)
Intermittent haemodiafiltration (HDF) 1g every 12-24 hours (unknown dialysability)
Continuous ambulatory peritoneal dialysis 1g every 12-24 hours (Not dialysed)
(CAPD)
pharmacist
Cefuroxime
Indications as per Trust Formulary: Urosepsis, prophylaxis in orthopaedic and spine surgery,
treatment escalation of severe CAP.

10-20 ml/min 750mg - 1.5g every 12 hours
<10 ml/min 750mg - 1.5g every 24 hours
Intermittent haemodialysis 750mg - 1.5g every 24 hours (Dialysed – give
after dialysis)
Intermittent haemodiafiltration (HDF) 750mg-1.5g every 24 hours (Dialysed – give
after dialysis)
Continuous ambulatory peritoneal dialysis 750mg – 1.5g every 24 hours (Dialysed – give
(CAPD) after dialysis)
pharmacist
Safe in AKI
Chloramphenicol
Indications as per Trust Formulary: Meningitis unknown aetiology in severe penicillin allergy.
Note: Please use ideal body weight in obese patients (see charts in appendix 1) when dosing IV
chloramphenicol.
(Obese patients are those who are 20% heavier than their ideal body weight)

>10 ml/min 25mg/kg every 6 hours (max 4g daily)
Intermittent haemodialysis 25mg/kg every 6 hours (Dialysed – give after
dialysis)
Intermittent haemodiafiltration (HDF) 25mg/kg every 6 hours (Dialysed – give after
dialysis)
Continuous ambulatory peritoneal dialysis 25mg/kg every 6 hours (Not dialysed)
(CAPD)
pharmacist
Ciprofloxacin
Indications as per Trust Formulary: HAP onset >48 hours and < 5 days, infective exacerbation of
bronchiectasis (second line – severe penicillin allergy), catheter associated UTI,
pyelonephritis/urinary sepsis, epididymo-orchitis (low suspicion of sexually transmitted pathogen) ,
second line – infected animal and human bites, diabetic foot ulcer – second line

>60 ml/min 400mg every 12 hours
30-60 ml/min 400mg every 12 hours
10-30 ml/min 200-400mg every 12 hours
<10 ml/min 200mg every 12 hours (100% dose may be
given for short periods of time under
exceptional circumstances)
Intermittent haemodialysis 200mg every 12 hours (Not dialysed)
Intermittent haemodiafiltration (HDF) 200mg every 12 hours (unknown dialysability)
Continuous ambulatory peritoneal dialysis 200mg every 12 hours (Not dialysed)
(CAPD)
pharmacist

Clarithromycin
Indications as per Trust Formulary: Severe CAP, acute bacterial parotitis, aspiration pneumonia –
community/hospital acquired (penicillin allergy),

10-30 ml/min 250 - 500mg every 12 hours
<10 ml/min 250 – 500mg every 12 hours
Intermittent haemodialysis 250 – 500mg every 12 hours (Not dialysed)
Intermittent haemodiafiltration (HDF) 250 - 500mg every 12 hours (unknown
dialysability)
Continuous ambulatory peritoneal dialysis 250 - 500mg every 12 hours (Not dialysed)
(CAPD)
pharmacist
Safe in AKI
Clindamycin
Indications as per Trust Formulary: Peritonsillar abscess (penicillin allergy), spreading cellulitis,
necrotising fasciitis.

>30ml/min 450mg - 1.2g every 8 hours
10-30 ml/min 450mg – 1.2g every 6-8 hours (dosage may
require reduction due to prolonged half-life)
Intermittent haemodialysis 450mg – 1.2g every 6-8 hours (Not dialysed)
Intermittent haemodiafiltration (HDF) 450mg – 1.2g every 6-8 hours (unknown
dialysability)
Continuous ambulatory peritoneal dialysis 450mg – 1.2g every 6-8 hours (Not dialysed)
(CAPD)
pharmacist

Co-amoxiclav
Indications as per Trust Formulary: Escalation of treatment in severe CAP, prophylaxis in theatre.

>30ml/min 1.2g every 8 hours
<10ml/min 1.2g every 12 hours
dialysis)
Intermittent haemodiafiltration (HDF) 1.2g every 12 hours (Dialysed – give after
dialysis)
Continuous ambulatory peritoneal dialysis 1.2g every 12 hours (Dialysed –give after
(CAPD) dialysis)
pharmacist
Caution in AKI
Co-trimoxazole
Indications as per Trust Formulary: Treatment of Pneumocystis jirovecii pneumonia (PJP) formally
(PCP).
Note: Use adjusted body weight in obese patients (Appendix 2).
>50 ml/min 120mg/kg in divided doses for 3 days
If patient improved 90mg/kg in divided doses if
patient improved
30-50 ml/min 120mg/kg in divided doses
If patient improved 90mg/kg in divided doses if
patient improved
15-30 ml/min 60mg/kg every 12 hours for 3 days
If patient improved 30mg/kg every 12 hours
<15 ml/min 30mg/kg every 12 hours (this should only be
given if haemodialysis facilities are available)
Intermittent haemodialysis 30mg/kg every 12 hours (Dialysed)
Intermittent haemodiafiltration (HDF) 30mg/kg every 12 hours (Dialysed)
(CAPD)
pharmacist
Caution in AKI
Daptomycin
Indications as per Trust Formulary: On advice of medical microbiology or infectious diseases only.
Dose using total body weight.
Note: Monitor creatinine kinase at baseline and at least weekly throughout the duration of
treatment.
Higher (unlicensed) doses may be used if recommended by medical microbiology or infectious
diseases.

>30 ml/min 4-6mg/kg once daily
<30 ml/min 4-6mg/kg every 48 hours
Intermittent haemodialysis 4-6mg/kg every 48 hours (Not dialysed)
Intermittent haemodiafiltration (HDF) 4-6mg/kg every 48 hours (Dialysed – give after
dialysis)
Continuous ambulatory peritoneal dialysis 4-6mg/kg every 48 hours (Not dialysed)
(CAPD)
pharmacist

Ertapenem

>30 ml/min 1g once daily
10-30 ml/min 1g once daily for 48 hours and then reduce to
1g every 48 hours
<10ml/min 1g once daily for 48 hours and then reduce to
1g three times a week
Intermittent haemodialysis 1g once daily for 48 hours and then reduce to
1g three times a week (Dialysed – give after
dialysis)
Intermittent haemodiafiltration (HDF) 1g once daily for 48 hours and then reduce to
1g three times a week (Dialysed – give after
dialysis)
Continuous ambulatory peritoneal dialysis 1g once daily for 48 hours and then reduce to
(CAPD) 1g three times a week (Dialysed – give after
dialysis)
pharmacist
Flucloxacillin
Indications as per Trust Formulary: Acute bacterial parotitis, malignant otitis externa, cellulitis,
animal and human bites.

>10 ml/min 1g-2g every 6 hours
<10 ml/min 1g every 6 hours (Max 4g daily)
Intermittent haemodialysis 1g every 6 hours (Not dialysed)
Intermittent haemodiafiltration (HDF) 1g every 6 hours (Not dialysed)
Continuous ambulatory peritoneal dialysis 1g every 6 hours (Not dialysed)
(CAPD)
pharmacist
Caution in AKI
Gentamicin
Indications as per Trust Formulary: Sepsis, catheter associated UTI, abdominal collection.
Please refer to Trust gentamicin calculator and monitor using the nomogram.
For patients where the gentamicin calculator is not appropriate, an initial STAT dose of 5mg/kg
should be prescribed based on ideal body weight. No further doses of gentamicin should be
prescribed until levels are reported as <1mg/ml.
Note: for further advice please contact pharmacy or medical microbiology.
Safe in AKI
Linezolid

<10 ml/min 600mg every 12 hours (if platelets drop on this
dose consider reduction to 600mg daily)
Intermittent haemodialysis 600mg every 12 hours (if platelets drop on this
(Dialysed –give after dialysis)
Intermittent haemodiafiltration (HDF) 600mg every 12 hours (if platelets drop on this
Continuous ambulatory peritoneal dialysis 600mg every 12 hours (if platelets drop on this
(CAPD) dose consider reduction to 600mg daily)
(Likely to be dialysed)
pharmacist
Meropenem
Indications as per Trust Formulary: Bacterial endocarditis: native valve and severe sepsis,
necrotising fasciitis, hospital acquired pneumonia (HAP) onset >5 days (second line in minor
penicillin allergy), neutropenic sepsis (second line),

>50 ml/min 1g-2g every 8 hours
26-50 ml/min 500mg-2g every 12 hours
10-25 ml/min 500mg-1g every 12 hours or 500mg every 8
hours
<10 ml/min 500mg-1g every 24 hours
Intermittent haemodialysis 500mg-1g every 24 hours (Dialysed – give after
dialysis)) or 1-2g post dialysis
Intermittent haemodiafiltration (HDF) 500mg-1g every 24 hours (Dialysed – give after
dialysis)
Continuous ambulatory peritoneal dialysis 500mg-1g every 24 hours (Dialysed – give after
(CAPD) dialysis)
pharmacist
Safe in AKI
Metronidazole
Indications as per Trust Formulary: Aspiration pneumonia community/hospital acquired, acute
bacterial parotitis, intra-abdominal infections (non-healthcare associated), acute orbital cellulitis,
peritonsillar abscess.

<10 ml/min 500mg every 8 hours
Intermittent haemodialysis 500mg every 8 hours (Dialysed – give after
dialysis)
Intermittent haemodiafiltration (HDF) 500mg every 8 hours (Dialysed –give after
dialysis)
Continuous ambulatory peritoneal dialysis 500mg every 8 hours (Not dialysed)
(CAPD)
pharmacist
Piperacillin and tazobactam (Tazocin)
Indications as per Trust Formulary: Decompensated chronic liver disease, spontaneous bacterial
peritonitis, hospital acquired pneumonia (HAP) – onset > 5days, acute severe diabetic foot infection,
neutropenic sepsis, infective exacerbations of bronchiectasis

dialysis)
Intermittent haemodiafiltration (HDF) 4.5g every 12 hours (Dialysed –give after
dialysis)
Continuous ambulatory peritoneal dialysis 4.5g every 12 hours (Not dialysed)
(CAPD)
pharmacist

Teicoplanin
Indications as per Trust Formulary: Sepsis, Severe community acquired pneumonia – second line,
hospital acquired pneumonia >5 days – second line, intra-abdominal infections (non-healthcare
associated) - second line
Loading regime. Table 1
Days 1-2 12mg/kg
(round to the nearest 200mg vial)
Days 3-4 12mg/kg OD
(round to the nearest 200mg vial)
Take pre-dose (trough) level on day 4.

Continue to administer teicoplanin whilst
waiting for level results
Day 5 onwards Adjust dose according to renal function (see
table 2) and review with levels.
Maintenance dose (based on renal function). Table 2

>60 ml/min Continue 12mg/kg OD
30-60 ml/min 6mg/kg OD
<30 ml/min 4mg/kg OD or
12mg/kg three times a week
Haemodialysis 12mg/kg three time a week after dialysis
N.B. In patients who are >100kg, discuss dosing with Pharmacy during working hours ( doses should
be capped at 2g per single dose)
A protocol is now available on EPMA to facilitate prescribing of the loading and maintenance doses
and therapeutic drug monitoring.
Temocillin
Indications as per Trust Formulary: Hospital acquired aspiration pneumonia (>48 hours after
admission)

>60 ml/min 2g every 12 hours
30-60 ml/min 1g every 12 hours
10-30 ml/min 1g every 24 hours
<10 ml/min 1g every 48 hours or 500mg every 24 hours
Intermittent haemodialysis 1g every 24 hours or 2g every 48 hours or 3g
every 72 hours depending on dialysis frequency
(Dialysed)
Intermittent haemodiafiltration (HDF) 1g every 24 hours or 2g every 48 hours or 3g
every 72 hours depending on dialysis frequency
(Dialysed)
Continuous ambulatory peritoneal dialysis 1g every 24 hours (Dialysed)
(CAPD)
pharmacist
Safe in AKI
Tigecycline
Indications as per Trust Formulary: Intra-abdominal collection, Intra-abdominal infection (hospital
acquired)

>10 ml/min 100mg STAT, then 50mg every 12 hours
<10 ml/min 100mg STAT, then 50mg every 12 hours
Intermittent haemodialysis 100mg STAT, then 50mg every 12 hours (Not
dialysed)
Intermittent haemodiafiltration (HDF) 100mg STAT, then 50mg every 12 hours
(unknown dialysability)
Continuous ambulatory peritoneal dialysis 100mg STAT, then 50mg every 12 hours (Not
(CAPD) dialysed)
pharmacist
Caution in AKI
Vancomycin
Antifungals
Caution in AKI
Liposomal amphotericin (Ambisome)
No dose adjustment required in renal impairment. Ambisome is nephrotoxic, monitor renal function
closely.
Use total body weight for dosing.
Safe in AKI
Anidulafungin
No dose adjustment required in renal impairment.
Safe in AKI
Caspofungin

Fluconazole

>50 ml/min 50-400mg once daily
<20-50 ml/min 50-400mg once daily (50-100% of normal dose)
<10ml/min 50-200mg once daily (50% of normal dose)
Intermittent haemodialysis 50% of normal dose daily or 100% of normal
dose three times a week after dialysis
(Dialysed)
Intermittent haemodiafiltration (HDF) 50% of normal dose daily or 100% of normal
dose three times a week after dialysis
(Dialysed)
Continuous ambulatory peritoneal dialysis 50-200mg once daily
(CAPD)
pharmacist
Caution in AKI
Flucytosine
Note: Dose as per ideal body weight. Ensure therapeutic drug monitoring is carried out in
course >5 days in renal impairment.

>40 ml/min 50mg/kg every 6 hours
<20-40 ml/min 50mg/kg every 12 hours
10-20ml/min 50mg/kg every 24 hours
<10ml/min 50mg/kg STAT, then 500mg-1g daily (discuss
with pharmacy or medical microbiology) Ensure
levels are taken
Intermittent haemodialysis 50mg/kg STAT, then 500mg-1g daily (discuss
with pharmacy or medical microbiology)
(Dialysed- give after dialysis) Ensure levels are
taken
Intermittent haemodiafiltration (HDF) 50mg/kg STAT, then 500mg-1g daily (discuss
with pharmacy or medical microbiology)
(Dialysed- give after dialysis) Ensure levels are
taken
Continuous ambulatory peritoneal dialysis 12.5mg/kg every 6 hours
(CAPD) Ensure levels are taken
pharmacist
Safe in AKI
Isavuconazole
Safe in AKI
Itraconazole
Safe in AKI
Posaconazole

Voriconazole
Note: Dose as per ideal/adjusted body weight.
Only use IV if patient is unable to tolerate oral (oral bioavailability is 96%), as the intravenous vehicle
(SBECD) accumulates in renal failure.

>20 ml/min 6mg/kg every 12 hours for 24 hours (loading
dose) then reduce to 4mg/kg every 12 hours
(maintenance)
10-20 ml/min 6mg/kg every 12 hours for 24 hours (loading
(maintenance) Caution: prolonged courses (>5
days) may results in accumulation of SBECD
<10ml/min 6mg/kg every 12 hours for 24 hours (loading
(maintenance) Caution: prolonged courses (>5
days) may results in accumulation of SBECD
Intermittent haemodialysis 6mg/kg every 12 hours for 24 hours (loading
(maintenance) (Dialysed – give after dialysis)
Intermittent haemodiafiltration (HDF) 6mg/kg every 12 hours for 24 hours (loading
(maintenance) (Dialysed – give after dialysis)
Continuous ambulatory peritoneal dialysis 6mg/kg every 12 hours for 24 hours (loading
(CAPD) dose) then reduce to 4mg/kg every 12 hours
(maintenance) (Probably dialysed – give after
dialysis)
pharmacist
Antivirals
Caution in AKI
Aciclovir
Indications as per Trust formulary: Viral encephalitis, for other indications please consult summary
of product characteristics (SPC).
Please use ideal body weight in obese patients (see charts in appendix 1) when dosing IV aciclovir.
(Obese patients are those who are 20% heavier than their ideal body weight)

>50 ml/min 10mg/kg every 8 hours
25-50 ml/min 10mg/kg every 12 hours
10-25 ml/min 10mg/kg every 24 hours
<10 ml/min 5mg/kg every 24 hours
Intermittent haemodialysis 5mg/kg every 24 hours (Dialysed – give after
dialysis)
Intermittent haemodiafiltration (HDF) 5mg/kg every 24 hours (Dialysed – give after
dialysis)
(CAPD)
pharmacist
Appendix One
Useful equations
a). Creatinine clearance (CrCl) using Cockcroft-gault:
CrCl (ml/min) = F x [140-Age (years) x IBW (kg)
Serum creatinine (micromole/L)
F = 1.23 for males or 1.04 for females
b) Ideal body weight (IBW) equation
Male : IBW (kg) = 50kg + (2.3 x number of inches over 5ft)
Female : IBW (kg) = 45.5kg + (2.3 x number of inches over 5ft)
Weight categorisation graph for male patients

Weight categorisation chart for female patients
Key:
c). Adjusted body weight calculation

For obese patients (actual body weight (ABW) Is >20% above IBW)
Adjusted body weight(kg) = IBW + [0.4 x(ABW – IBW)]

References
1. The renal drug database. Accessed via: https://renaldrugdatabase.com/ (22/10/19)
2. Aciclovir 250mg powder for solution for infusion summary of product characteristics.
Bowmed Ibisqus Limited. Accessed via:
https://www.medicines.org.uk/emc/product/9651/smpc (22/10/19)
3. Ceftazidime 1g powder for solution for injection/infusion summary of product
characteristics. Consilient Health Ltd. Accessed via:
4. Ciproxin solution for infusion summary of product characteristics. Bayer plc. Accessed via:
5. Co-trimoxazole for infusion 16mg/80mg per ml for infusion summary of product
characteristics. Aspen. Accessed via:
6. Meropenem 1g powder for solution for injection or infusion summary of product
characteristics. Aurobindo Pharma – Milpharm Ltd. Accessed via:
7. Tazocin 4g/0/5g powder for solution for infusion summary of product characteristics. Pfizer
limited. Accessed via: https://www.medicines.org.uk/emc/product/1267/smpc (25/10/19)
8. Negaban 1g, powder for solution for injection/infusion summary of product characteristics.
Eumedica SA. Accessed via: https://www.medicines.org.uk/emc/product/466 (25/10/19)
9. Chelsea and Westminister hospital, Adult antimicrobial dosing guidelines. December 2017.

Antimicrobial Dosage Adjustments in Renal Impairment For Formulary

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Antimicrobial dosage adjustments in renal impairment

Review at 48h in AKI

Danielle Lucy (Senior antimicrobial pharmacist) Bleep 5067

Ward pharmacists Via bleeps

Medical microbiology Ext 4410

Renal pharmacists Ext 3318

Safe in AKI Review at 48h in AKI Caution in AKI

*In PCP treatment, discuss with medical microbiology or antimicrobial pharmacist

Review at 48h in AKI

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Review at 48h in AKI

Creatinine clearance (CrCl) Recommended dose

Review at 48h in AKI

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Review at 48h in AKI

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Review at 48h in AKI

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Review at 48h in AKI

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Review at 48h in AKI

Take pre-dose (trough) level on day 4.

Maintenance dose (based on renal function). Table 2

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

No dose adjustment required in renal impairment.

No dose adjustment required in renal impairment.

Review at 48h in AKI

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

No dose adjustment required in renal impairment.

No dose adjustment required in renal impairment.

No dose adjustment required in renal impairment.

Creatinine clearance (CrCl) Recommended dose

Creatinine clearance (CrCl) Recommended dose

F = 1.23 for males or 1.04 for females

b) Ideal body weight (IBW) equation

Male : IBW (kg) = 50kg + (2.3 x number of inches over 5ft)

Female : IBW (kg) = 45.5kg + (2.3 x number of inches over 5ft)

Weight categorisation graph for male patients

c). Adjusted body weight calculation

Adjusted body weight(kg) = IBW + [0.4 x(ABW – IBW)]

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