Common Oral Antimicrobial Therapy

Dosage Adjustments For Renal Function

< 10 mL/min
Medication > 50mL/min 30-50mL/min 10-30mL/min (non- HD1 CAPD2 Comments
dialysis)
• Higher single
doses (eg. 2 g
250-500mg 250-500mg 250-500mg 250-500mg 250-500mg 250-500mg po 1 hr prior to
Amoxicillin
TID TID BID daily to BID BID3 BID dental surgery)
are fine for all
CKD stages
Amoxicillin/ 250-500 mg 250-500 mg
250-500 mg 250-500mg 250-500 mg 250-500 mg
Clavulanate TID or TID or
BID daily to BID BID BID
(Clavulin®) 875 mg BID 875 mg BID
250-500mg
Azithromycin No dosage adjustments
daily
200 mg • Give post HD on
Cefixime 400mg daily 400mg daily 200 mg daily 200 mg daily 200 mg daily
daily dialysis days
250-500mg 250-500mg 250-500 mg 250-500 mg 250-500 mg 250-500 mg
Cefuroxime axetil BID BID
BID to TID BID to TID BID BID
250-500mg 250-500mg 250-500mg 250-500mg 250-500mg 250-500mg
Cephalexin
QID TID to QID BID to TID daily to BID BID BID
• May prolong QTc
• Space doses
apart from Ca++,
250-750mg 250-750mg 500-750mg 250-500mg 500-750mg 500-750mg
Ciprofloxacin Iron and Al+++ by
BID BID daily daily daily daily
at least 3 hours
• Give post HD on
dialysis days
• May prolong QTc
250-500 mg 250-500 mg • Use regular re-
Clarithromycin/ 250-500mg 250-500mg 250-500mg
BID BID 500mg daily lease format with
Clarithromycin XL daily daily daily
(1g daily XL) (1g daily XL) eGFR < 30 mL/
min (not XL)
300 - 600mg
Clindamycin No dosage adjustments
TID
500 - 1000mg
Cloxacillin No dosage adjustments
QID
• May cause rise in
serum potassium
and creatinine
• Risk of crystal-
Cotrimoxazole luria, esp. with
(DS3 = TMP4 dehydration
DS daily or Avoid - See DS daily3 or
160mg; DS BID DS BID SS BID • Review drug
SS BID Comments SS BID3
SS5= TMP5 80mg) interactions
• interactions
• - Higher doses
may be used for
severe systemic
infections
• Doxycycline is
preferred tetracy-
cline in CKD
100mg daily
Doxycycline No dosage adjustments • Space doses
to BID
apart from Ca++,
Iron and Al+++ by
at least 3 hours

BC Provincial Renal Agency • BCRenalAgency.ca February 2018

Approved by the BCPRA Pharmacy and Formulary Committee, May 2017 (version 1)
Page 1 of 2
 < 10 mL/min
Medication > 50mL/min 30-50mL/min 10-30mL/min (non- HD1 CAPD2 Comments
dialysis)
250-500mg • May prolong QT
Erythromycin No dosage adjustments
QID
100-200mg • May prolong QTc
daily or 200- • Give post HD on
100-400mg 100-400mg 100-200mg 100-200mg 400mg post 100-200mg dialysis days
Fluconazole
daily daily daily daily HD on HD daily
days (ie.3x/
wk)
• May prolong QTc
< 20 mL/min 750mg, • Space doses
20-50 mL/min 750mg, then 750mg, then
Levofloxacin 750mg daily 750mg, then then 500mg apart from Ca++,
750mg Q48h 500mg Q48H 500mg QHD
500mg Q48H Q48H Iron and Al+++ by
at least 3 hours
• Need special
600mg po authority for
Linezolid No dosage adjustments
BID coverage
• Expensive
• Courses longer
than 2 weeks
500mg BID in CKD may
Metronidazole No dosage adjustments
to TID increase risk
peripheral neu-
ropathy
• May prolong QTc
• Space doses
Moxifloxacin 400mg daily No dosage adjustments apart from Ca++,
Iron and Al+++ by
at least 3 hours
• Metabolites
accumulate;
50-100mg 50-100mg
increasesed risk
QID (100mg QID
Nitrofurantoin Avoid of neurotoxicity
BID Macro- (100mg BID
• Efficacy reduced
BID®) MacroBID®)
with eGFR < 30
mL/min
300-600mg
Penicillin VK No dosage adjustments
BID-QID
>80mL/min: • Doxycycline is
250-500mg preferred tetracy-
QID; cline in CKD
250-500mg 250-500mg
Tetracycline 50-80 mL/ Avoid
daily to BID daily to BID
min: 250-
500mg BID
to TID
500-1000mg 500-1000mg 500-1000mg 500-1000mg 500-1000mg • Give post HD on
Valacyclovir 500mg daily
BID to TID BID to TID BID daily daily dialysis days
• Oral route used
only for treatment
of C.difficile
• Vancomycin lev-
Vancomycin 125mg QID No dosage adjustments els NOT needed
for oral route
• Need special
authority

HD = hemodialysis; 2CAPD = continuous ambulatory peritoneal dialysis; 3DS = Double Strength; 4TMP = trimethoprim; 5SS = Single Strength
1

BC Provincial Renal Agency • BCRenalAgency.ca February 2018

Approved by the BCPRA Pharmacy and Formulary Committee, May 2017 (version 1)
Page 2 of 2