Pharmacy-to-dose renal adjustment for common antimicrobials

ClinDose template

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Pharmacists may adjust doses of the antimicrobials below for kidney function. Doses are quoted from each FDA label; review and adapt to your institution.

Piperacillin and tazobactam

CrCl (mL/min)Dose
Above 40All Indications (except nosocomial pneumonia): 3.375 g every 6 hours; Nosocomial Pneumonia: 4.5 g every 6 hoursFDA label
20 to 40All Indications (except nosocomial pneumonia): 2.25 g every 6 hours; Nosocomial Pneumonia: 3.375 g every 6 hoursFDA label
0 to 19All Indications (except nosocomial pneumonia): 2.25 g every 8 hours; Nosocomial Pneumonia: 2.25 g every 6 hoursFDA label

Cefepime

CrCl (mL/min)Dose
Above 60Recommended Maintenance Schedule: 500 mg every 12 hours; 1 g every 12 hours; 2 g every 12 hours; 2 g every 8 hoursFDA label
30 to 60Recommended Maintenance Schedule: 500 mg every 24 hours; 1 g every 24 hours; 2 g every 24 hours; 2 g every 12 hoursFDA label
11 to 29Recommended Maintenance Schedule: 500 mg every 24 hours; 500 mg every 24 hours; 1 g every 24 hours; 2 g every 24 hoursFDA label
0 to 10Recommended Maintenance Schedule: 250 mg every 24 hours; 250 mg every 24 hours; 500 mg every 24 hours; 1 g every 24 hoursFDA label

Meropenem

CrCl (mL/min)Dose
Above 50Dose (dependent on type of infection): Recommended dose (500 mg cSSSI and 1 gram Intra-abdominal); Dosing Interval: Every 8 hoursFDA label
26 to 50Dose (dependent on type of infection): Recommended dose; Dosing Interval: Every 12 hoursFDA label
10 to 25Dose (dependent on type of infection): One-half recommended dose; Dosing Interval: Every 12 hoursFDA label
0 to 9Dose (dependent on type of infection): One-half recommended dose; Dosing Interval: Every 24 hoursFDA label

Levofloxacin

CrCl (mL/min)Dose
50 and aboveUsual dose for the indicationPlaceholder
20 to 49750 mg every 24 hours: 750 mg every 48 hours; 500 mg every 24 hours: 500 mg initial dose, then 250 mg every 24 hours; 250 mg every 24 hours: No dosage adjustment requiredFDA label
10 to 19750 mg every 24 hours: 750 mg initial dose, then 500 mg every 48 hours; 500 mg every 24 hours: 500 mg initial dose, then 250 mg every 48 hours; 250 mg every 24 hours: 250 mg every 48 hours. If treating uncomplicated UTI, then no dosage adjustment is requiredFDA label

Ciprofloxacin

CrCl (mL/min)Dose
Above 50Dose: See Usual Dosage.FDA label
30 to 50Dose: 250 to 500 mg every 12 hoursFDA label
5 to 29Dose: 250 to 500 mg every 18 hoursFDA label

Ampicillin and sulbactam

CrCl (mL/min)Dose
30 and aboveRecommended Ampicillin and Sulbactam for Injection Dosage: 1.5 g to 3 g every 6 to 8 hoursFDA label
15 to 29Recommended Ampicillin and Sulbactam for Injection Dosage: 1.5 g to 3 g every 12 hoursFDA label
5 to 14Recommended Ampicillin and Sulbactam for Injection Dosage: 1.5 g to 3 g every 24 hoursFDA label

Fluconazole

CrCl (mL/min)Dose
Above 50Recommended Dose (%): 100FDA label
0 to 50Recommended Dose (%): 50FDA label

Acyclovir

CrCl (mL/min)Dose
Above 50Percent of Recommended Dose: 100%; Dosing Interval (hours): 8FDA label
25 to 50Percent of Recommended Dose: 100%; Dosing Interval (hours): 12FDA label
10 to 24Percent of Recommended Dose: 100%; Dosing Interval (hours): 24FDA label
0 to 9Percent of Recommended Dose: 50%; Dosing Interval (hours): 24FDA label

Daptomycin

CrCl (mL/min)Dose
30 and aboveDosage Regimen: 4 mg/kg once every 24 hours; 6 mg/kg once every 24 hoursFDA label
0 to 29Dosage Regimen: 4 mg/kg once every 48 hours*; 6 mg/kg once every 48 hours*FDA label

Restriction criteria

  • Who can orderPharmacists, under the pharmacy-to-dose policy approved by your committee
  • ApprovalNot required
  • Reassess when kidney function changes

Sources