Note: The dosing recommendations are not intended for treatment of endocarditis or central nervous system infections.
| Drug | CrCL >50 | CrCL 30-49 | CrCL 10-29 | CrCL <10 | |
|---|---|---|---|---|---|
| acyclovir (IV)* | 5-10 mg/kg IV q8h | 5-10 mg/kg IV q12h | 5-10 mg/kg IV q24h | 2.5-5 mg/kg IV q24h | |
acyclovir (PO) (genital herpes) |
400 mg PO q8h | NO CHANGE NEEDED | 200 mg PO q12h | ||
acyclovir (PO) (varicella zoster) |
800 mg PO 5 times per day | NO CHANGE NEEDED | 800 mg PO q8h | 800 mg PO q12h | |
| aminoglycosides | Refer to aminoglycoside dosing guidelines for conventional & extended interval dosage regimens | ||||
| amoxicillin | 500-1000 mg PO q8h | NO CHANGE NEEDED | 500-1000 mg PO q12h | 500-1000 mg PO daily | |
| amoxicillin/clavulanic acid | 875/125 mg PO q12h | NO CHANGE NEEDED | Not recommended | ||
| 500/125 mg PO q8h | NO CHANGE NEEDED | 500/125 mg PO q12h | 500/125 mg PO daily | ||
| amphotericin B (non-lipid formulation) | 0.25-1.5 mg/kg IV q24h | NO CHANGE NEEDED | Not recommended† | ||
| amphotericin B (liposomal) | 3-6 mg/kg IV q24h | NO CHANGE NEEDED | 3-6 mg/kg IV q24-36h | ||
ampicillin (dose dependent on indication) |
1-2 g IV q4-6h | 1-2 g IV q6-8h | 1-2 g IV q8-12h | 1-2 g IV q12-24h | |
| azithromycin | 250-500 mg IV/PO q24h | NO CHANGE NEEDED | |||
| caspofungin | 70 mg IV on Day 1, then 50 mg IV q24h | NO CHANGE NEEDED | |||
cefazolin (dose dependent on indication) |
1-2 g IV q8h | >35 mL/min: NO CHANGE NEEDED | 10-34 mL/min: 1-2 g IV q12h | 1-2 g IV q24h | |
| cefotaxime | 1-2 g IV q8h | 1-2 g IV q8-12h | 1-2 g IV q8-12h | 1-2 g IV q24h | |
| cefOXitin | 1-2 g IV q6-8h | 1-2 g IV q8-12h | 1-2 g IV q12-24h | 1-2 g IV q24h | |
| cefTAZidime | 1-2 g IV q8h | 1-2 g IV q12h | 1-2 g IV q24h | 1-2 g IV q24-48h | |
| cefTRIAXone | 1-2 g IV q24h | NO CHANGE NEEDED | |||
| cefuroxime axetil (PO) | 500 mg PO q12h | NO CHANGE NEEDED | 500 mg PO q24h | ||
| cephalexin | 500-1000 mg PO q6h | 500-1000 mg PO q8h | 500-1000 mg PO q12h | 500-1000 mg PO q12-24h | |
| ciprofloxacin (IV) | 400 mg IV q12h | NO CHANGE NEEDED | 400 mg IV q24h | ||
| ciprofloxacin (PO) | 500-750 mg PO q12h | NO CHANGE NEEDED | 500-750 mg PO daily | ||
| clarithromycin | 250-500 mg PO q12h | 250-500 mg PO q12h | 250-500 mg PO daily | ||
| clindamycin (IV) | 600-900 mg IV q8h | NO CHANGE NEEDED | |||
| clindamycin (PO) | 300-450 mg PO q6h | NO CHANGE NEEDED | |||
| cloxacillin (IV) | 1-2 g IV q4-6h | NO CHANGE NEEDED | |||
| cloxacillin (PO) | 500-1000 mg PO q6h | NO CHANGE NEEDED | |||
co-trimoxazole (IV) (trimethoprim [TMP]/ sulfamethoxazole [SMX]) (not for PCP treatment) |
8-10 mg of TMP component/kg/day IV in 2-4 divided doses | 50% of daily dose IV in 2-4 divided doses | 50% of daily dose IV in 2-4 divided doses | Not recommended† | |
Double strength (DS) = (Trimethoprim [TMP] 160 mg/ Sulfamethoxazole [SMX] 800 mg) Single strength (SS) = TMP 80 mg/ SMX 400 mg) |
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| co-trimoxazole (PO) (not for PCP treatment) | 1 DS (160/800 mg) PO q12h | NO CHANGE NEEDED | 50% of dose (1 SS) PO q12h | Not recommended† | |
| co-trimoxazole for Pneumocystis jirovecii (carinii) treatment |
15-20 mg TMP/kg/day PO/IV divided q6-8h | NO CHANGE NEEDED | 50% of daily dose IV/PO in 2-4 divided doses | 5-10 mg TMP/kg IV/PO in 1-2 divided doses | |
| DAPTOmycin | 4-10 mg/kg IV q24h | NO CHANGE NEEDED | 4-10 mg/kg IV q48h | ||
| doxycycline | 100 mg PO q12-24h | NO CHANGE NEEDED | |||
| ertapenem | 1 g IV q24h | NO CHANGE NEEDED | 500 mg IV q24h | ||
| ethambutol | 15-25 mg/kg PO q24h (max 2g/day) |
NO CHANGE NEEDED | 15-25 mg/kg PO three times per week | ||
| fluconazole | 200-800 mg IV/PO q24h | 50% of dose IV/PO q24h | 25% of dose IV/PO q24h | ||
| flucytosine | 25 mg/kg PO q6h | 25 mg/kg PO q12-24h | 25 mg/kg PO q24-48h | ||
| isoniazid | 5 mg/kg PO q24h (max 300 mg) | NO CHANGE NEEDED | |||
| itraconazole | 100-200 mg PO q12-24h | NO CHANGE NEEDED | |||
| levoFLOXacin‡ | 750 mg IV/PO q24h | 20-49 mL/min: 750 mg IV/PO q48h | <20 mL/min: 750 mg IV/PO initially, then 500 mg IV/PO q48h | ||
| 500 mg IV/PO q24h | 20-49 mL/min: 500 mg IV/PO initially, then 250 mg IV/PO q24h | <20 mL/min: 500 mg IV/PO initially, then 250 mg IV/PO q48h | |||
| linezolid | 600 mg IV/PO q12h | NO CHANGE NEEDED | |||
| meropenem | 1-2 g IV q8h | 1-2 g IV q12h | 500 mg IV q12h | 500 mg IV q24h | |
| 500 mg IV q6h | 500 mg IV q8h | ||||
| metronidazole | 500 mg IV/PO q12h C. difficile: 500 mg IV/PO q8h |
NO CHANGE NEEDED | |||
| moxifloxacin‡ | 400 mg IV/PO q24h | NO CHANGE NEEDED | |||
| nitrofurantoin macrocrystals (Macrobid®) | 100 mg PO q12h | <50 mL/min: avoid | |||
| nitrofurantoin | 50 - 100 mg PO q6h (for feeding tube administration) |
<50 mL/min: avoid | |||
oseltamivir (treatment dose) |
>60 mL/min: 75 mg PO q12h x 5 days | 30-60 mL/min: 75mg PO q24h x5 days 30mg PO q12h x 5 days |
10-30 mL/min: 30 mg PO q24h x 5 days | Use with caution: Single 75mg PO once only | |
oseltamivir (prophylaxis dose) |
>60 mL/min: 75 mg PO q24h until outbreak is over | 30-60 mL/min: 30mg PO q24h until outbreak is over | 10-30 mL/min: 30 mg PO q48h until outbreak is over | Use with caution: single 30mg PO once only | |
| penicillin G (IV) | 2-4 Million Units (MU) IV q4-6h | 2-4 MU IV q6-8h | 2-4 MU IV q8-12h | ||
| penicillin V (PO) | 250-500 mg PO q6h | NO CHANGE NEEDED | 250-500 mg PO q8h | ||
| piperacillin/tazobactam | 3.375 g IV q6h | 41-50 mL/min: NO CHANGE NEEDED 20-40 mL/min: 2.25 g q6h <20 mL/min: 2.25 g q8h |
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| piperacillin/tazobactam (for nosocomial pneumonia treatment) | 4.5 g IV q6h | 41-50 mL/min: NO CHANGE NEEDED 20-40 mL/min: 3.375 g q6h <20 mL/min: 2.25 g q6h |
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| pyrazinamide | 15-30 mg/kg PO q24h (max 2.5 g) |
15-30 mg/kg three times per week (max 2.5 g) |
|||
rifAMPin (tuberculosis dosing) |
10 mg/kg PO q24h (max 600 mg q24h) | NO CHANGE NEEDED | 5 mg/kg PO q24h | ||
| tigecycline | 100 mg IV load, then 50 mg IV q12h | NO CHANGE NEEDED | |||
| vancomycin (IV) | Refer to vancomycin dosing guidelines | ||||
| vancomycin (PO) (for C.difficile treatment) |
125-500 mg PO q6h | NO CHANGE NEEDED | |||
| voriconazole (IV) | 6 mg/kg IV q12h x 2 doses, then 4 mg/kg IV q12h | Not recommended due to accumulation of vehicle | |||
| voriconazole (PO) | 200-300 mg PO q12h | NO CHANGE NEEDED | |||
* In obese patients, consider dosing acyclovir IV with knowledge of both ideal body weight and adjusted body weight, to avoid overdosing and subsequent toxicity, as well as underdosing and lower systemic exposure.
† Please consult Infectious Diseases to discuss therapeutic alternatives.
‡ Moxifloxacin is the respiratory fluoroquinolone on formulary at Niagara Health
Blondel-Hill E, Fryters S, editors. Bugs and Drugs. Edmonton: Capital Health; 2012.
Aronoff GR et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults, Fourth Edition. Philadelphia, PA: American College of Physicians. 2002.
Aoki FY, Allen UD, Mubareka S, Papenburg J, Stiver HG, Evans GA. Use of antiviral drugs for seasonal influenza: foundation document for practitioners–Update 2019. J Assoc Med Microbiol Infect Dis Can. 2019;4(2):60–82. https://doi.org/10.3138/jammi.2019.02.08
UpToDate. Wolters Kluwer Health. http://www.uptodate.com/contents/search (accessed January 18, 2023)
Sunnybrook Antimicrobial Handbook (accessed via Metrodis Jan 2023)