Guideline for antimicrobial dosing for adults with renal impairment
Full Title of Guideline:
Author (include email and role):
Division & Speciality:
Scope (Target audience, state if Trust
wide):
Review date (when this version goes out September 2019
of date):
Explicit definition of patient group
to which it applies (e.g. inclusion and
exclusion criteria, diagnosis):
Changes from previous version (not
applicable if this is a new guideline, enter
below if extensive):
Guideline for antimicrobial dosing for adults with renal
impairment
Annette Clarkson Specialist Clinical pharmacist antimicrobials
and Infection Control (Annette.clarkson@nuh.nhs.uk)
Ian Hogg Specialist Clinical Pharmacist Renal (adult)
(ian.hogg@nuh.nhs.uk)
Riya Savjani, Antimicrobial Pharmacist
(riya.savjani@nuh.nhs.uk)
All adult directorates
Doctors, pharmacists
All adult patients with renal impairment who are prescribed an
antimicrobial.
Assessing Renal function – wording amended to include
CKD-Epi
Aciclovir PO – prophylaxis dose added
Amikacin, Ceftazidime, Daptomycin, Ertapenem – HD
info added
Azithromycin – CrCl <10 treatment dose to discuss with
Renal/Abx pharmacist
Aztreonam nebulised added as separate entry
Benzylpenicillin dosing amended for CrCl 10-20
Cefoxitin added
Ciprofloxacin – comments re-worded
Clarithromycin – Interaction info removed
Colisitin IV – Dosing updated
Colistin PO – Removed as no longer available
Dapsone – Malaria prophylaxis no dose adjustment
needed in CrCl <10
Erythromycin – Side effect info added
Ethambutol and Isoniazid – HD info added for supervised
TB treatment
Gentamicin- updated info on dosing in HD
Isavuconazole added
Itraconazole IV, Posaconazole IV, Voriconazole IV –
Separate entries added from PO and info re IV vehicle
added
Linezolid – Monitor for side effects in CrCl <10
Nitrofurantoin – comments wording amended
Pivmecillinam – Dosing updated for CrCl <10
Rifabutin – Dosing clarified for CrCl 10-30 and <10
Rifampicin – CrCl <10 max dose added
Temocillin added
Timentin – dosing amended for CrCl 10-30 and <10
All “sepsis” wording amended to high risk red sepsis
Tobramycin – updated dosing in HD patients
Vancomycin- updated dosing in HD patients
Summary of evidence base this o BMA and RPSGB. British National Formulary. Available
guideline has been created from: from https://www.medicinescomplete.com/mc/bnf/current/
Accessed 20/06/2017
o Summary of Product Characteristics from electronic
Medicines Compendium for individual drugs. Available
from http://emc.medicines.org.uk Datapharm
Communications Ltd. Accessed 20/06/2017
o Ashley C and Dunleavy A. The Renal Drug database.
Available at http: https://www.renaldrugdatabase.com.
Accessed 15/09/2017
o Recommended best practice based on clinical experience
of guideline developers
o Nov 2016 – Supporting evidence for meropenem
therapeutic interchange and dosing substitution policy. The
Nebraska Medical Center. Available from
www.nebraskamed.com. Accessed 02/11/2016
o John Hopkins guide. Available at
https://www.hopkinsguides.com/hopkins
th
o The Sanford Guide to Antimicrobial Therapy 2014 44
Edition
o Summary of product characteristics for Cefoxitin. Held on
file with author, can access via antibiotic website A-Z
cefoxitin page.

This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.

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 ANTIMICROBIAL DOSES FOR ADULTS WITH RENAL IMPAIRMENT

Assessing Renal Function

Renal function in adults is now commonly reported via NOTIS on the basis of estimated glomerular
filtration rate (eGFR) normalised to a body surface area of 1.73m2 which is calculated by the Chronic
Kidney Disease Epidemiology Collaboration (CKD-Epi)( formula (mL/min/1.73m2) Not valid in acute
kidney injury, dialysis and pregnancy. Published information on the effects of renal impairment on
drug elimination has historically been stated in terms of creatinine clearance (not normalised for body
surface area). The Cockgroft-Gault formula has been used to estimate this and advice is to continue
to use Cockcroft-Gault estimates of creatinine for drug dosing in renal impairment. The Cockcroft
Gault equation is shown below and there is a calculator on the antibiotic website.
where F
CrCl (ml/min) = F x (140-age) x weight (kg)
= 1.23 (male)
serum creatinine (micromol/L)
= 1.04 (female)

The latest edition of the British National Formulary gives dosage adjustments for many drugs
expressed in terms of eGFR rather than creatinine clearance. Although the two equations are not
interchangeable, there is relatively good correlation between the two for calculating renal function in
patients of average build and height, and either could be used for the majority of drugs. However,
eGFR should not be used for calculating drug doses in patients at extremes of body weight (BMI of
less than 18.5 kg/m2 or greater than 30 kg/m2), or for potentially toxic drugs of a narrow
therapeutic index. In these cases, the correlation between the two measures can be significant and
potential drug over/under doses could arise.
BMI = Weight (kg)
[Height (m)]2

• eGFR should not be used for calculating drug doses in patients at extremes of body weight (BMI
of less than 18.5 kg/m2 or greater than 30 kg/m2) therefore for those who are obese (>20% above
IBW) ideal body weight should be calculated and then used to calculate a creatinine clearance
using Cockcroft-Gault.
• IBW for males = 50 + (2.3 x (height in inches - 60))

• IBW for female = 45 + (2.3 x (height in inches - 60))

• Equally for those patients who have a BMI<18.5kg/m2 creatinine clearance using
Cockcroft-Gault should be calculated.
• eGFR should not be used for calculating drug doses for potentially toxic drugs of a
narrow therapeutic index. For the purposes of this guideline creatinine clearance using
Cockcroft-Gault should always be used for vancomycin, gentamicin, amikacin,
foscarnet, ganciclovir, valganciclovir.
• Neither equation is a perfect marker of renal function. When using the equation, creatinine
levels should be stable and the clinical picture should always be taken into account.
• Patients that are oligoanuric or dialysis dependent should be assumed to have a GFR <10 ml/min
and neither equation is valid.

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Renal dosing monographs

• The doses recommended are derived from the references stated and represent those commonly
used in Nottingham (these may vary from the SPC)

Dosing in renal replacement therapy

• Give post HD (haemodialysis): If patient is on daily or alternate day therapy this advice refers
only to administration on dialysis days: ie on non-dialysis days the drug is given at the normal
time.

For dosing advice in continuous veno-venous haemofiltration (CVVH): refer to Critical Care
Pharmacist

Contact pharmacy for advice on dosing in renal impairment for any antimicrobial agents that
are not included in the table below.

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 Drugs marked * = Contact microbiologist for advice on assays where appropriate

Creatinine clearance (CrCl) (ml/min)

Antimicrobial Comments
50-20 20-10 <10
CrCl 25-50 CrCl 10-25 The higher dose should be used for those patients with
2.5-5mg/kg every
*Aciclovir IV 5-10mg/kg 5-10mg/kg encephalitis and those who are immunocompromised. PD
24h
every 12h every 24h same as <10. HD give doses post HD
Cr-Cl 10-25
Simplex: 200mg qds
Simplex: 200mg bd
Zoster: 800mg tds Zoster: 800mg bd
CrCl 25-50
Aciclovir po Prophylaxis: Prophylaxis: Doses should be given post HD
Normal
Reduce dose by Reduce normal
50% dose by 50%
Therapeutic drug monitoring required, refer to antibiotic
2mg/kg 24-48h
website. Subsequent doses should be adjusted according to
Amikacin 5-6 mg/kg 12h 3-4 mg/kg 24h levels.
HD: 5mg/kg post
If HD more than 3 times a week, contact Renal Pharmacist
each HD session
for dosing.
Give post HD. For endocarditis and CrCl <10, maximum
dose of 6g per day this should be given as 1g four hourly. All
Amoxicillin IV and PO Normal Normal 250mg-1g 8h
cases of endocarditis should be discussed with microbiology.

Amphotericin is highly NEPHROTOXIC.

Lipid associated Amphotericin IV Daily monitoring of renal function is essential
Normal Normal Normal
(Abelcet© and Ambisome©) For further advice on dosing and administration see antibiotic
website, local guidelines and Trust IV guide
Anidulafungin Normal Normal Normal HD or PD: Not dialysed. Dose as in normal renal function.
Normal for
Give doses after HD.
prophylaxis (see
Azithromycin Normal Normal If using as treatment dose in CrCl <10ml/min, discuss with
notes for treatment
Renal or Antimicrobial Pharmacist.
dose)
CrCl 10-30
CrCl 30-50 Give 1-2g loading
Give 1-2g loading
Aztreonam (IV) dose then 250- Usual dose in normal renal function is 1-2g 8h. Give post HD
dose then
Normal 500mg 8h
500mg-1g 8h
Aztreonam (nebulised) Normal Normal Normal
For endocarditis if CrCl <10, maximum dose of 4.8g per day
600mg-2.4g every 600mg-1.2g every this should be given as 1.2g qds. All cases of endocarditis
Benzylpenicillin Normal
6 hours 6 hours should be discussed with microbiology. Give post HD

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 Drugs marked * = Contact microbiologist for advice on assays where appropriate
Creatinine clearance (CrCl) (ml/min)
Antimicrobial Comments
50-20 20-10 <10
Caspofungin Normal Normal Normal Can reduce tacrolimus levels
250-500mg every 250-500mg every
Cefalexin Normal Give post HD
8-12 hours 8-12hr
CrCl 5-10
1-2g loading dose
then 0.5-1g 12-24 [Dose depends on indication, refer to antibiotic website A-Z
CrCl 30-50 CrCl 10-30
hourly page for cefoxitin)
1-2g loading 1-2g loading dose
Cefoxitin
dose then 1-2g then 1-2g 12-24
CrCl<5 If HD more than 3 times a week, contact Renal Pharmacist
8-12 hourly hourly
1-2g loading dose for dosing.
then 0.5-1g 24-48
hourly
CrCl 6-15 For Haemodialysis give 500mg-2g every 48h or post dialysis.
CrCl 31-50 CrCl 16-30 500mg-1g 24h
Ceftazidime
1-2g 12h 1-2g 24h CrCl<5 If HD more than 3 times a week, contact Renal Pharmacist
500mg-1g 48h for dosing.
CrCl <15
HD: Single loading dose of 500mg ceftolozane/250mg
No dosing
CrCl 30-50 CrCl 15-29 tazobactam followed after 8 hours by 100mg
information
500mg 250mg ceftolozane/50mg tazobactam every 8 hours. On HD days,
Ceftolozane/tazobactam available from
ceftolozane/250 ceftolozane/125mg give the dose immediately post HD.
(Zerbaxa®) manufacturer.
mg tazobactam tazobactam every
Contact renal or
every 8 hours 8 hours PD- No dosing information available from manufacturer
antimicrobial
contact renal/antimicrobial pharmacist for advice.
pharmacist
Normal
Ceftriaxone Normal Normal
Max 2g/day
Cefuroxime IV Normal 750mg – 1.5g 12h 750mg 12h Give post HD
Give post HD, levels can be checked, see antibiotic website
Chloramphenicol Normal Normal Normal
for further information.
Avoid, manufacturers and renal drug handbook advise to If use is considered essential, contact antimicrobial or renal
Cidofovir
avoid in CrCl <55 pharmacist.
For CrCl <10mL/min 250mg bd PO or 200mg bd IV should
routinely be used, increase dose if high risk red sepsis or
PO 250-500mg PO 250mg-500mg
treating pseudomonas.
12h 12h
Ciprofloxacin IV+po Normal IV only if PO unavailable or 1st dose when high risk red sepsis
IV 200mg-400mg IV 200mg-
– good bioavailability.
12h 400mg12h
Interacts with phosphate binders, see mineral bone disease
guidelines on intranet.
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 Drugs marked * = Contact microbiologist for advice on assays where appropriate
Creatinine clearance (CrCl) (ml/min)
Antimicrobial Comments
50-20 20-10 <10
Clarithromycin CrCl 30-50 CrCl 10-30 Give post HD.
250-500mg 12h
IV + po Normal 250-500mg 12h .
Clindamycin
Normal Normal Normal
IV +po
Co-Amoxiclav IV CrCl 30-50 CrCl 10-30
1.2g 12h Give post HD
Normal 1.2g 12h
Co-Amoxiclav po Normal Normal Normal Give post HD
Colistin (colistimethate sodium) Standard dosing is 3 million units 8 hourly in those with
CrCl 30-50 CrCl 10-30 CrCl <10
IV normal renal function, lower dosing is used in cystic fibrosis
due to problems in tolerating the drug due to side effects.
In patients on critical care, give a loading dose of 9 million
units. The same loading dose applies to those with normal
3.5 million units 2.5 million units 1.75 million units and impaired renal function, including those on renal
12h 12h 12h replacement therapy.
Standard dose: Colistin IV 3 Start the maintenance dose 12 hours after the loading dose in
million units 8h Normal loading Normal loading Normal loading those with CrCl <50ml/min.
dose in critical dose in critical care dose in critical care
care patients patients patients HD patients: 1.5million units twice a day, where possible give
post dialysis. Note this dose differs to renal drug database,
but has been adapted for ease of dosing administration.
Cystic fibrosis dosing: Colistin IV 1 million units
1 million units 12h
1-2 million units TDS or if <60kg every 24h or if
Normal or if <60kg 50% of
50,000-75,000 units/kg in three <60kg 30% of
normal dose
divided doses normal dose
Give post HD
CrCl 30–50 CrCl 15-30 CrCl <15 Monitor sulfamethoxazole levels
*Co-trimoxazole IV + po PCP: Normal for 3/7 PCP 30mg/kg 12h
(Treatment doses only) then 30mg/kg 12h Other infections:
Normal Other infections: 50% of normal dose Co-trimoxazole 960mg and 480mg tablets can be halved.
50% of normal dose
In those with CrCl<10 monitor FBC.
Dapsone Normal Normal 50-100mg 24h No dose adjustment required for malaria prophylaxis if CrCl
<15.
Patients on haemodialysis should be discussed with
pharmacy. Dose varies dependent on indication, 6mg/kg is
CrCl 30-50
Daptomycin CrCl<30 4-8mg/kg every 48 hours used in bacteraemia and up to 8mg/kg in endocarditis.
4-8mg/kg 24h
Monitor CK levels speak to pharmacy. If HD more than 3
times a week, contact Renal Pharmacist for dosing.
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 Drugs marked * = Contact microbiologist for advice on assays where appropriate
Creatinine clearance (CrCl) (ml/min)
Antimicrobial Comments
50-20 20-10 <10
All other tetracyclines contraindicated in renal impairment.
Doxycycline Normal Normal Normal Interacts with phosphate binders, separate doses by 2 hours
before and after
Give post HD.
CrCl 30-50 CrCl 10-30 50% of dose or 1g
Ertapenem
Normal 50-100% of dose three times a week If HD more than 3 times a week, contact Renal Pharmacist
for dosing.
Increased risk of ototoxicity in renal impairment especially at
Erythromycin po Normal Normal 250-500mg qds high doses.

Give post HD
Monitor levels if CrCl<30ml/min (contact micro).
*Ethambutol Normal 7.5-15mg/kg/day 5-7.5mg/kg/day
If supervised TB treatment (i.e. 3 x a week) and on HD,
discuss with renal Pharmacist
Normal up to max
Flucloxacillin IV+po Normal Normal
4g/day
50% of normal
Give post HD
dose
Fluconazole (IV + PO) Normal Normal Dose is dependent on indication. No adjustments for single
Oral dose min
doses required
50mg
50mg/kg immediately
CrCl 20-40
*Flucytosine 50mg/kg 24h then dose according Give post HD. Monitor pre-dialysis levels
50mg/kg 12h to levels.
Dose reduction required seek further advice from
Foscarnet
pharmacy/renal drug handbook
CrCl >40
Normal
CrCl 30-40
8g loading dose 4g loading dose 2g loading dose HD- 2g loading dose and then 2g at the end of each dialysis
Fosfomycin IV
then 4g 8h then 2g 8h then 1g 8h session.
CrCl 20-30
6g loading dose
then 3g 8h
Fosfomycin oral Normal 3g single dose Not recommended

Fusidic acid (sodium fusidate) Normal Normal Normal

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 Drugs marked * = Contact microbiologist for advice on assays where appropriate
Creatinine Clearance (CrCl) (ml/min)
Antimicrobial Comments
50-20 20-10 <10
Dose reduction required seek further advice from
Ganciclovir
pharmacy/renal drug handbook

CrCl<10 BOTH METHODS:

CrCl 10–40
2 mg/kg (max For dosing in HD patients- follow the dosing regime within the
1) Gentamicin 3mg/kg (max 300mg)
200mg) re-dose Guideline for the Diagnosis and Treatment of Central Venous
Check levels 18-24 hours
according Catheter Related Infections in Haemodialysis Patients.
ONCE DAILY after first dose.
to levels Monitor blood levels & U&Es. See antibiotic website. In the
Re-dose only when level < 1mg/L.
obese use a dose determining weight- see antibiotic website.
80mg 48h
2) ) Gentamicin 80mg 12h 80mg 24h
(60mg if <60kg) .
Multiple daily dosing regimen (60mg if <60kg) (60mg if <60kg)
Give post HD.
Isoniazid Normal Normal 200mg-300mg 24h
If supervised TB treatment (i.e. 3 x a week) and on HD,
discuss with renal Pharmacist

Normal
Isavuconazole (IV +PO) Normal Normal Not readily dialysable

Normal Normal Normal Not removed by HD.

Itraconazole (PO)
For IV Sporanox brand: Hydroxypropyl-β-cyclodextrin, a
CrCl 30-50 CrCl <30 component of Sporanox intravenous formulation, is
Itraconazole (IV) eliminated through glomerular filtration. In patients with CrCl
Normal See comments <30 mL/min use of itraconazole IV is contra-indicated.
Discuss with Antimicrobial Pharmacist
If normal dose
500mg od give If normal dose
500mg 500mg od give
immediately 500mg immediately
then 250mg od then 125mg od 500mg immediately
Levofloxacin
If normal dose If normal dose then 125mg od
500mg bd give 500mg bd give
500mg 500mg immediately
immediately then 125mg bd
then 250mg bd
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 Drugs marked * = Contact microbiologist for advice on assays where appropriate

Creatinine Clearance (CrCl) (ml/min)

Antimicrobial Comments
50-20 20-10 <10
Normal (but Give post HD
Linezolid Normal Normal monitor for MAOI If CrCl<10 monitor platelets
side effects) Be alert to drug interactions
Meropenem CrCl 50-25
CrCl 25-10 ml/min CrCl <10ml/min
Adjust depending on normal dose: ml/min
Meropenem
500mg TDS 500mg BD 500mg–1gram OD
500mg QDS
Meropenem
1gram BD 500mg BD 500mg–1gram OD Give post HD
1g TDS
Meropenem
2gram BD 1gram BD 500mg–1gram OD
2g TDS
Metronidazole Normal Normal Normal Give post HD
Interacts with phosphate binders, separate doses by 2 hours
Moxifloxacin (IV and PO) Normal Normal Normal
before and after
CrCl >45
Normal dose for
• Nitrofurantoin is contra-indicated in patients with
cystitis (lower CrCl<30 mL/min as the drug is ineffective due to
UTI) only
inadequate urine concentrations, and increased risk of
adverse effects.
CrCl 30-45 CrCl<30 CrCl<30
Nitrofurantoin • Unsuitable for pyelonephritis or patients with high risk
Only if no other Contraindicated Contraindicated
red sepsis of a likely urinary origin.
agents suitable
• Use for short courses of 3-7 days, if using for long
and on the
term prophylaxis do not use in CrCl <45mL/min.
advice of
microbiology for • Nitrofurantoin gives false positive urinary glucose
3-7 days only
Post HD
Ofloxacin 200-400mg od 200-400mg od 200mg od Interacts with phosphate binders, separate doses by 2 hours
before and after
HD: 30mg immediately then 30mg after each dialysis session
CrCl 30-60 PD: 30mg single dose, if duration of treatment continues for
CrCl 10-30
Oseltamivir (treatment dose) 30mg 12h 30mg single dose more than 5 days give a further 30mg dose on day 7.
30mg 24h
CVVH: Seek advice from critical care pharmacist if need for
treatment arises.

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 Drugs marked * = Contact microbiologist for advice on assays where appropriate

Creatinine Clearance (CrCl) (ml/min)

Antimicrobial Comments
50-20 20-10 <10
HD: 30mg immediately then 30mg after each 2nd dialysis session
30mg single dose
Oseltamivir PD: 30mg on day 1, and then further 30mg dose on day 7.
CrCl 30-60 CrCl 10-30 on day 1 then a
(prophylaxis (remains in body for 7 days)
30mg 24h 30mg 48h further 30mg on a
dose) CVVH: Seek advice from critical care pharmacist if need for
day 7
treatment arises.
Penicillin V Normal Normal Normal Give post HD
Piperacillin/
Tazobactam Normal 4.5g 12h 4.5g 12h Give post HD
(Tazocin)
Not Works by renal excretion into the bladder so unlikely to work in
Pivmecillinam Normal Normal
recommended those with little residual function
Posaconazole
Normal Normal Normal
PO
In patients with CrCl <50ml/min accumulation of the intravenous
Posaconazole Normal (see Normal (see vehicle (Betadex Sulfobutyl Ether Sodium (SBECD) is expected
Normal (see comments)
IV comments) comments) to occur (e.g. Noxafil brand). Avoid unless benefit outweighs the
risk.
Use 50-100% of
Pyrazinamide Normal Normal Post HD. Can precipitate gout as impairs urate excretion.
dose
CrCl 10-30 CrCl <10
CrCl 30-50 Use 50% of dose. Use 50% of dose.
Rifabutin
Normal Maximum 300mg Maximum 300mg
daily daily
50-100% (max
Rifampicin Normal Normal
dose 600mg)
Use actual body weight and round dose to the nearest 200mg.
For patients greater than 125kg contact your pharmacist for
CrCl 30-80 CrCl <30 dosing advice.
Loading dose: normal Dosing in normal renal function as follows:
Loading dose: normal Day 3 and 4 maintenance dose: normal Cellulitis: Loading dose 6mg/kg every 12 hours for 3 doses then
Day 3 and 4 maintenance dose: Day 5 onwards: One third of normal maintenance dose 6mg/kg once daily.
Teicoplanin
normal maintenance dose (max 800mg) Bone and joint infection/endocarditis: Loading dose 12mg/kg
Day 5 onwards: 50% of normal (round dose to nearest 200mg) (no maximum dose) every 12 hours for 3 doses then
maintenance dose (max 800mg) Give post HD maintenance dose 12mg/kg once daily. (Maximum starting
(round dose to nearest 200mg) maintenance dose 800mg daily).
Monitor levels- see antibiotic website

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 Drugs marked * = Contact microbiologist for advice on assays where appropriate
Creatinine Clearance (CrCl) (ml/min)
Antimicrobial Comments
50-20 20-10 <10

HD – dialysed. Administer 1g every 48 hrs preferably at the end

CrCl 30-60 CrCl 10-30 CrCl <10 of HD. If daily HD, 500mg after each HD session.
Temocillin
1g BD 1g OD 1g every 48 hrs If HD more than 3 times a week, contact Renal Pharmacist for
or 500mg OD dosing.

Tetracycline Use Doxycycline see above

Tigecycline Normal Normal Normal

Timentin
(Ticarcillin
CrCl 30-60 CrCl 10-30 CrCl<10
with Post HD
3.2g 8h 1.6g 8h 1.6g 12h
Clavulanic
Acid)
CrCl 10–40 CrCl<10 For dosing in HD patients- use the same dosing as gentamicin
3mg/kg (max 300mg) 2 mg/kg (max within the Guideline for the Diagnosis and Treatment of Central
Tobramycin IV
Check levels 18-24 hours 200mg). Re-dose Venous Catheter Related Infections in Haemodialysis Patients.
ONCE DAILY
after first dose. only when level Cystic fibrosis- see separate dosing guidance
Re-dose only when level < 1mg/L. <1mg/L
Give post HD

NB May cause temporary rise in creatinine due to reduced

creatinine secretion rather than a fall in CrCl, therefore avoid in
CrCl 15-20 those where acute rises in creatinine would complicate the
CrCl <15
Trimethoprim Normal Normal (see clinical picture.
Avoid
comments)
Can cause hyperkalaemia, do not use in patients with
CrCl<30ml/min where hyperkalaemia is a problem or if they are
on other medications which can cause hyperkalaemia (e.g. ACE
inhibitor, spironolactone).
CrCl 30-50 Dose reduction required for CrCl<30 seek
Valaciclovir Zoster: 1g bd further advice from pharmacy/renal drug Post HD
Simplex: Normal handbook
Post HD
Dose reduction required seek further advice from pharmacy/renal drug
Valganciclovir
handbook
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 Drugs marked * = Contact microbiologist for advice on assays where appropriate
Creatinine Clearance (CrCl) (ml/min)
Antimicrobial Comments
50-20 20-10 <10
Monitor blood levels & adjust dose as required see antibiotic
Refer to vancomycin dosing guideline or the antibiotic website or the
website.
vancomycin dosing calculator on the antibiotic website. Patients should
Vancomycin For dosing in HD patients- follow the dosing regime within the
receive a loading dose followed by a maintenance dose based on Creatinine
Guideline for the Diagnosis and Treatment of Central Venous
Clearance.
Catheter Related Infections in Haemodialysis Patients.
Normal Normal Normal
Voriconazole
PO
Consider oral preparation as first choice in patients with renal
impairment i.e. CrCl <50ml/min (oral preparation has 96%
bioavailability). Accumulation of the vehicle, sulfobutyl ether-B-
Voriconazole Normal (see Normal (see
Normal (see comments) cyclodextrin, occurs but this does not appear to lead to any toxic
IV comments) comments)
effects.
If IV preparation indicated discuss with Pharmacist and use with
caution

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