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Nottingham Antimicrobial Guidelines Committee March 2009 Review March 2011
ANTIMICROBIAL DOSES FOR ADULTS IN RENAL IMPAIRMENT
Version 3.
Date ratified March 2009
Review date March 2011
Ratified by • Nottingham University Hospitals Antimicrobial
Guidelines Committee
• Nottingham University Hospitals Joint Drugs and
Therapeutics Committee
Authors Annette Clarkson Microbiology pharmacist
Judith Gregory Renal pharmacist
Consultation Nottingham University hospitals Antibiotic
Guidelines Committee members
Nottingham University Hospitals NHS Trust Drugs
and Therapeutics Committee
Renal consultants
Evidence base • Renal drug handbook 3
rd
Edition 2009
• Summary of product characteristics for the
individual drugs
• Recommended best practice based on clinical
experience of guideline developers
Changes from previous
Guideline
• Updated dosing advice for a number of
antibiotics in line with the updated renal drug
handbook 2009
• Removal of the definitions mild, moderate and
severe renal failure in line with the BNF
• Addition of azithromycin, daptomycin,
posaconazole, foscarnet, ganciclovir,
valganciclovir, valaciclovir, chloramphenicol and
cefalexin
Inclusion criteria Adult patients with renal impairment
Distribution - Pharmacists/Medicines Information
- Clinical Effectiveness Database
- Renal Unit doctors handbook distributed to all
SHOs and SpRs
- Junior doctors handbook available via the
intranet
- NUH Antibiotic Guidelines intranet site
http://nuhnet/diagnostics_clinical_support/antibio
tics
Local contacts Dr V Weston Consultant Microbiologist
Annette Clarkson Microbiology pharmacist
Judith Gregory Renal pharmacist
This guideline has been registered with the Trust.
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. Caution is advised when using guidelines after a review date.
Nottingham Antimicrobial Guidelines Committee March 2009 Review March 2011
ANTIMICROBIAL DOSES FOR ADULTS IN RENAL IMPAIRMENT
Assessing Renal Function
The Cockcroft-Gault equation (below) should be used to calculate creatinine clearance and gives an
estimate of kidney function for the purposes of drug dosing in renal impairment. Cockcroft-Gault
CrCl estimates should be used for drug dosing rather than the automated MDRD eGFR
produced by the clinical chemistry laboratory available on NOTIS/HISS. There can be a
significant difference between the results of the two calculations.
CrCl (ml/min) = F x (140-age) x weight (kg)
serum creatinine (micromol/L)
- If patient is anuric, morbidly obese or in acute renal failure (ARF), this equation will NOT give a
true reflection of creatinine clearance.
- For those who are morbidly obese, ideal body weight should be calculated
o IBW for males = 50 + (2.3xheight in inches >60inches);
o IBW for female = 45 + (2.3xheight in inches>60inches)
- Anuric and oliguric (<500ml/day) patients can be assumed to have a CrCl < 10ml/min (severe
renal impairment)
† Many elderly patients have a CrCl below 50ml/min, which, because of reduced muscle mass, may
not be indicated by a raised creatinine level. It is therefore especially prudent to calculate the CrCl
as outlined above for this patient group.
Renal dosing monographs
- The doses recommended are derived from the references stated and represent those commonly used in Nottingham (these may vary from Data Sheet recommendations)
- If 50% quoted, give half the dose but retain the normal frequency
- For dosing advice in haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients at both QMC and NCH: refer to Renal Pharmacist (bleep 80-7078)
- For dosing advice in continuous veno-venous haemofiltration (CVVH): refer to Critical Care Pharmacist (City campus bleep 80-6914 or QMC campus bleep 80-6315)
- Drugs marked * = Contact microbiologist for advice on assays where appropriate.
- The sodium content of some IV antibiotic preparations may be significant (refer to ward pharmacist or Medicines Information)
- 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. Contact microbiology or pharmacy for advice on dosing in renal impairment for any antimicrobial agents that are not included in the table below
where F
= 1.23 (male)
= 1.04 (female)
Nottingham Antimicrobial Guidelines Committee March 2009 Review March 2011
Creatinine clearance (ml/min)
Antimicrobial
Comments
Doxycycline Normal Normal Normal
All other tetracyclines contraindicated in renal impairment
Ertapenem CrCl 30-50 ml/min Normal
CrCl 10-30 ml/min 50-100% of dose
50% of dose or 1g three times a week
Give post HD
Erythromycin po Normal Normal 250-500mg qds
Normal 7.5-15mg/kg/day 5-7.5mg/kg/day
*Ethambutol Monitor levels if Crcl < 30ml/min (contact Micro)
Give post HD
Flucloxacillin IV+po Normal Normal Normal Max 4g/day
Fluconazole Normal Normal
Oral dose min 50mg
Give post HD No adjustments for single doses required
*Flucytosine 50mg/kg 12h 50mg/kg 24h 50mg/kg stat then dose according to levels.
Give post HD. Monitor pre-dialysis levels
Foscarnet Dose reduction required seek further advice from pharmacy/renal drug handbook Fusidic acid Normal Normal Normal
Ganciclovir Dose reduction required seek further advice from pharmacy/renal drug handbook
1) Gentamicin
ONCE DAILY
CrCl 10–40ml/min 3mg/kg (max 300mg) Check levels 18-24 hours after first dose. Re-dose only when level < 1mg/L.
CrCl<10ml/min 2 mg/kg (max 200mg) re-dose according to levels
2) Gentamicin
CONVENTIONAL
80mg 12h (60mg if <60kg)
80mg 24h (60mg if <60kg)
80mg 48h (60mg if <60kg) HD:1-2 mg/kg post HD redose according to levels
BOTH METHODS:
Give post HD
Monitor blood levels & adjust dose as required. For further advice see monitoring guidance on the antibiotic website http://nuhweb/antibiotics Isoniazid Normal Normal 200mg-300mg 24h Give post HD Itraconazole Normal Normal Normal
Levofloxacin 500mg stat then 250mg bd**
500mg stat then 125mg bd**
500mg stat then 125mg od
** Applies if full dose is 500mg bd. If full dose 500mg od give the reduced dose daily Linezolid Normal Normal Normal Give post HD Meropenem Higher doses needed in CNS infection d/w micro
500mg-2g bd 500mg-1g bd 500mg-1g od Give post HD
Metronidazole Normal Normal Normal Give post HD
Nitrofurantoin Use at normal dose with caution Contraindicated Contraindicated
Monitor for toxicity e.g blood dyscrasias, neuropathy
Oseltamivir (treatment dose)
CrCl >30ml/min 75mg bd
CrCl 10-30ml/min 75mg od 30mg stat
HD: 30mg after alternate dialysis sessions Penicillin V Normal Normal Normal Give post HD Piperacillin/ Tazobactam (Tazocin)
Normal 4.5g 8-12h 4.5g 12h Give post HD
Posaconazole Normal Normal Normal
Pyrazinamide Normal Normal Normal
Rifampicin Normal Normal 50-100%
Nottingham Antimicrobial Guidelines Committee March 2009 Review March 2011
Creatinine Clearance (ml/min)
Antimicrobial
Comments
Teicoplanin* Normal
Normal loading dose then 200- 400mg every 24- 48h
Normal loading dose then 200-400mg every 48-72h
Normal Loading dose 400mg every 12 hours for 3 doses Monitor levels
Tetracycline Use Doxycycline see above Tigecycline Normal Normal Normal
Trimethoprim Normal
Use alternative agent if possible Normal
Ineffective for UTI, other indications: Normal but use alternative agent if possible
Give post HD Consider short term folic acid supplementation. NB May cause temporary rise in creatinine due to reduced creatinine secretion rather than a fall in CrCl
Valaciclovir CrCl 30-50ml/min Normal
Dose reduction required for Crcl<30ml/min seek further advice from pharmacy/renal drug handbook Valganciclovir Dose reduction required seek further advice from pharmacy/renal drug handbook
Vancomycin
1g od Check pre dose level before 3rd^ dose.
1g 48 h Check pre dose level before 2nd^ dose
1g stat (or 15mg/kg max 2g). Check level after 4-5 days. ONLY re-dose when level <12mg/L. If deep seated when <15mg/L
Monitor blood levels & adjust dose as required
Voriconazole Normal Normal Normal
Give post HD Caution in the use of IV in renal impairment due to accumulation of vehicle-discuss with pharmacy
Evidence base of guideline
Information derived from standard reference sources:
1. BMA and RPSGB. British National Formulary. Number 57. March 2009
2. Summary of Product Characteristics from electronic Medicines Compendium for individual drugs.
Available from http://emc.medicines.org.uk Datapharm Communications Ltd.
3. Ashley C and Currie A. The Renal Drug Handbook. 3
rd
edition 2009. Radcliffe Publishing Ltd.
Oxford.
