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Antibiotic | GFR (mL/min) | Comments | ||
---|---|---|---|---|
Mild
50-20 |
Moderate
20-10 |
Severe
< 10 |
||
*Aciclovir | Normal dose every 12h | normal dose every 24h | 50% of normal dose every 24h | Give postHD |
Aciclovir po | normal | Herpes simplex: normal Herpes zoster: 800mg Total Dissolved Solids tds | Herpes simplex: 200mg bid Herpes zoster: 800 mg bd | Give postHD |
Amikacin | 5-6mg/kg 12h | 3-4mg/ kg 24h HD: 5mg/ kg post HD and monitor levels | 2mg/kg 24-48h | Give post-HD Monitor preand 1h postdose levels after 3rd dose and adjust dose as required |
Amoxicillin po | normal | normal | 250mg 8h (normal) | Give postHD |
Amphotericin | normal | normal | normal | |
(Liposonal+ lipid complex) | Amphotericin is highly NEPHROTOXIC. Consider using liposomal/lipid complex amphotericin. Daily monitoring of renal function (GFR) essential. | |||
Ampicillin IV | normal | 250-500mg 6h | 250mg 6h (500mg 6h) | Give postHD |
Benzylpenicillin | Normal | 75% | 0-50% Max. 3.6g/ day (1.2g qds) | Give postHD Refer to microbiology for dosing in SBE |
Caspofungin | normal | normal | normal | |
Cefotaxime | normal | normal | 1g stat then 50% | Give postHD |
Cefradine | normal | normal | 250mg 6h | Give postHD |
Ceftazidime | 1g 12h | 1g 24h | 500mg 24h (1g 24h) | Give postHD |
Ceftriaxone | normal | normal | normal Max. 2g/day | |
Cefuroxime IV | normal | 750mg-1.5g 12h | 750mg 24h (750mg 12h) | Give postHD |
Ciproflazin IV+po | normal | 50% | 50% | |
Clarithromycin IV+po | normal | normal | 50% | Give postHD |
Clindamycin IV+po | normal | normal | normal | |
Coamoxiclav IV (Augmentin) | normal | 1.2 stat then 50% 12h (1.2g 12h) | 1.2 stat then 50% 24h (1.2g stat then 600mg 12h) | Give postHD |
Coamoxiclav po (Augmentin) | normal | 375-625mg 12h (375mg 8h) | 375mg 12h (375mg 8h) | Give postHD |
Cotrimoxazole IV | normal | Normal for 3/7 then 50% | 50% | Give postHD |
Doxycycline contraindicated | normal | normal | normal | All other tetracyclines contraindicated in renal impairment |
Erythromycin IV+po | normal | normal | normal Max. 1.5g/ day (500mg qds) * | |
*Ethambutol | normal | 24-36h | 48h | Give postHD |
Monitor levels if GFR < 30mL/min (contact Mirco) | ||||
Flucloxacillin IV+po | normal | normal | normal Max. 4g/day | |
Fluconazole | normal | normal | 50% | Give post-HD No adjustments in single-dose therapy required |
*Flucytosine | 50mg/kg 12h | 50mg/kg 24h | 50mg/kg stat thendose according to levels | Give post-HD Levels should be monitored predialysis. |
Fusidic acid | normal | normal | normal | |
1) Gentamicin ONCE DAILY | GFR 10-40mL/min
3mg/kg stat (max. 300mg) Check pre-dose levels 18- 24h after first dose Redose only when level < 1mg/L |
GFR < 10mL/ min
2mg/kg (max. 200mg) redose according to levels |
BOTH METHODS Give postHD
Monitor blood levels: | |
2) Gentamicin CONVENTIONAL | 80mg 12h 80mg 48h | 80mg 24h HD: 1-2mg/ kg
Post-HD: redose according to levels |
Once daily: pre only
Conventional: pre and 1 h post level required. | |
Imipenem | 500mg 8-12h | 250-500mg bid | Risk of convulsions - use Meropenem: see below | Give postHD |
Isoniazid | normal | normal | 200-300mg 24h | Give postHD |
Itraconazole | normal | normal | normal | |
Levoflaxacin | 500mg stat then 250mg bid** | 500mg stat then 125mg bid** | 500mg stat then 125mg od | **Applies if full dose is 500 mg bid If full dose is 500 mg od, five reduced doses daily |
Linezolid | normal | normal | normal | Give postHD |
Meropenem | 12h | 50% 12h | 50% 24h | Give postHD |
Metronidazole | normal | normal | 12h (normal) | Give postHD |
Nitrofurantoin | Do NOT use in renal impairment | |||
Penicillin V | normal | normal | normal | Give postHD |
Piperacillin/ Tazobactam (Tazocin) | 4.5g 8h | 4.5g 12h | 4.5g 12h | Give postHD |
Pyrazinamide | normal | normal | normal | |
Rifampicin | normal | normal | 50-100% | |
*Teicoplanin | 100% 48h | 100% 72h | 100% 72h | Dose reduction after day 3 of therapy |