Antimicrobial Dosing in Intermittent & Continuous Hemodialysis

These dosing recommendations are meant as guidance based on available literature and should not replace clinical judgement. Antimicrobial dosing should take into account factors specific to the patient (weight, renal function), antimicrobial (pharmacokinetics, pharmacodynamics, toxicity) and disease-state.

Intermittent HD assumes high-flux hemodialysis. CRRT assumes CVVHD with ultrafiltration rate 2L/h and residual native GFR < 10 mL/min. For detailed view of dialysis dosing and evidence, see Dosing in Hemodialysis document.

63 Drugs

Acyclovir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Non-CNS HSV Infections 2.5 mg/kg IV x1 now, then qPM 5 mg/kg IV q24h
HSV encephalitis/ Disseminated VZV 5 mg/kg IV x1 now, then qPM 10 mg/kg IV q12h

*If Total BW > 1.2 times Ideal BW, use Adj BW


AmBisome (liposomal amphotericin B)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Invasive fungal infections 5 mg/kg IV q24h 5 mg/kg IV q24h
Prophylaxis (heme/BMT) 3 mg/kg IV q24h 3 mg/kg IV q24h

*Use Total Body Weight if Total Body Weight < Ideal Body Weight.  If Total Body Weight >1.2 times Ideal Body Weight, use Adjusted Body Weight

IV Fluids: Give 500mL Normal Saline before and after AmBisome administration if able to tolerate


Amoxicillin/clavulanate

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 500/125 mg PO x1 now, then qPM 500/125 mg PO q12h

Ampicillin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Uncomplicated Infection 2 g IV x1 now, then qPM 2 g IV q8h
Meningitis or endovascular infection 2 g IV q12h 2 g IV q6h

Ampicillin/sulbactam (Unasyn)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 3g IV q12h 3g IV q6h

Artesunate

Indication HD or CRRT
All Indications 2.4 mg/kg IV at 0 hours, 12 hours, and 24 hours, followed by 2.4 mg/kg IV q24h

Azithromycin

Indication Dose Notes
Community-acquired pneumonia, ICU 500 mg IV/PO q24h No adjustment for dialysis
Community-acquired pneumonia, non-ICU 500 mg IV/PO x1 then 250 mg IV/PO q24h

Aztreonam

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2 g IV x1 now, then qPM 2 g IV q12h

Aztreonam lacks cross-reactivity with most other beta-lactams; however, most patients who have a recorded beta-lactam allergy can receive another beta-lactam through screening, test dosing, or skin testing. See Inpatient Allergy Guidelines


Baloxavir marboxil

Indication Dosage Notes
Influenza treatment, uncomplicated, 40-79kg 40 mg PO x1 No dose adjustment in hemodialysis
Influenza treatment, uncomplicated, >80kg 80 mg PO x1

Caspofungin

Indication Dose Notes
All indications 70 mg IV x 1, then 50 mg IV q24h No dose adjustment in hemodialysis. Increase maintenance dose to 70 mg when given with CYP3A4 inducers (phenytoin, rifampin, carbamazepine, dexamethasone, or efavirenz). 

Cefazolin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications

2 g IV x1 now and post-HD

Alternative dosing for patients not on stable hemodialysis schedule: 1 g IV x 1 now, then qPM

2 g IV q12h

Cefepime

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications

2 g IV x1 now and post-HD

Alternative dosing for patients not on stable hemodialysis schedule: 1 g x1 now, then qPM

1 g IV q8h

Cefiderocol

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 750 mg IV q12h over 3 hours

Effluent flow rate 2 L/hr or less: 1.5 g IV every 12 hours over 3 hours

Effluent flow rate 2.1 - 3 L/hr: 2 g IV every 12 hours over 3 hours

Effluent flow rate 3.1 - 4 L/hr: 1.5 g IV every 8 hours over 3 hours

Effluent flow rate > 4 L/hr: 2 g IV every 8 hours over 3 hours


Ceftazidime

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 1 g IV x1 now and post-HD 2 g IV q12h

Ceftazidime/avibactam (Avycaz)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 0.94 g IV q48h No data

Ceftolozane/tazobactam (Zerbaxa)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Complicated urinary tract infection 750 mg IV x1, then 150 mg IV q8h No data
Pneumonia, severe infections 2.25 g IV x1, then 450 mg IV q8h No data

Ceftriaxone

Indication Dose Notes
Usual dose 1 g IV q24h

 

No dose adjustment for hemodialysis

Endocarditis & Osteomyelitis 2 g IV q24h 

Meningitis & Enteroccocal Endocarditis (in combination with ampicillin)

2 g IV q12h

Ciprofloxacin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 400 mg IV qPM or 500 mg PO qPM 400 mg IV q12h or 500 mg PO q12h

Clindamycin

Indication Dose Notes
Uncomplicated Infection

600 mg IV q8h

450 mg PO q8h

 

No dose adjustment in hemodialysis

Necrotizing Soft Tissue Infection & Group A Streptococcus Infection 900 mg IV Q8h

Clofazimine

Indication Dosing Notes
All Indications 100 mg PO q24h No adjustment for dialysis

Colistin IV

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All IV Indications 5 mg/kg IV x1 loading dose, then contact ID pharmacy for dosing recommendations

Dosing for inhaled colistin per primary team protocols

Other more effective, less-toxic agents are available for most serious Gram-negative rod infections.  In cases where an IV polymyxin is necessary, polymyxin B should be used preferentially for non-urinary tract infections in adults.


Dalbavancin

Indication Dose Notes
Single-dose regimen (skin/soft tissue infection) 1500 mg IV x1 dose No dose adjustment necessary for hemodialysis
Two-dose regimen (skin/soft tissue infection) 1000 mg IV x1 then 500 mg IV x1 7 days later

Other dosing strategies used for treatment of bone/joint infections or bacteremia.


Daptomycin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis*
All Indications

8-10 mg/kg IV x1 now and post-HD

Alternate for patients not on stable dialysis schedule: 8-10 mg/kg IV q48h

6 mg/kg IV q24h** or 8-10 mg/kg IV q48h

*These recommendations have not been evaluated for patients receiving continuous renal replacement therapy other than CVVHD (ex. CVVH). 

**Consider this dose for patients receiving high ultrafiltration rates (ex. CVVHD > 2L/hr) and/or patients with severe infections (ex. endocarditis) and/or receiving combination therapy (ex. with ceftaroline). ID pharmacy guidance is strongly recommended for complex cases and/or use in combination therapy.

*If Total BW >1.2 times ideal body weight, use adjusted body weight

Not effective in treatment of pneumonia.


Doxycycline

Indication Dose Notes
All indications 100 mg IV/PO q12h No adjustment for hemodialysis

Eravacycline

Indication Dosing Notes
All Indications

1mg/kg IV q12h

Concomitant strong CYP3A4 Inducers: 1.5 mg/kg IV q12h

No dose adjustment for hemodialysis

Severe hepatic impairment: 1 mg/kg IV q12h x2 doses, then 1 mg/kg IV q24h


Ertapenem

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications

500 mg IV x1 now then qPM

Alternate: 500 mg - 1 g IV x1 now, then post-HD*

1 g IV q24h

*Post-HD dosing strategy should be used on a case-by-case basis after careful consideration of the benefits of post-HD only dosing and risks of ertapenem toxicity, including advanced age and low body weight. Consult ID pharmacy for guidance.


Ethambutol

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 15 -25 mg/kg PO x1 now and post-HD 15-20 mg/kg PO q24h

Dose based on ideal body weight. Drug is available in 400mg and 100mg tablets.


Fidaxomicin

Indication Dosing Notes
Clostridium difficile infection 200 mg PO q12h No adjustment for hemodialysis

Fluconazole

Indication Intermittent Hemodialysis Continuous Hemodialysis*
Oropharyngeal Infection 100 mg IV/PO x1 now, then post-HD 200 mg IV/PO q24h
Esophageal Infection 200 mg IV/PO x1 now, then post-HD 400 mg IV/PO q24h
Candidasis  400 mg IV/PO x1 now, then post-HD 800 mg IV/PO q24h
Severe Infections

400 mg IV/PO x1 now, then post-HD

 

800 mg IV/PO q24h - 600mg IV/PO q12h

*Data suggests that fluconazole clearance in patients receiving CVVHD is higher than in patients with normal renal function, necessitating use of higher dosing. These recommendations have not been evaluated for other continuous renal replacement modalities (ex. CVVH) and may not apply. 


Flucytosine

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 25 mg/kg PO x1 now and post-HD No data; consult ID pharmacy

Ganciclovir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
CMV Induction 1.25 mg/kg IV x1 now and post-HD 2.5-5 mg/kg IV q12-24h
CMV Maintenance 0.625 mg/kg IV x1 now and post-HD No data

Gentamicin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2 mg/kg IV x1, then 1 mg/kg IV post-HD 2 mg/kg IV x1 then 1.5 mg/kg IV q24h

*If Total BW > 1.2 times Ideal BW, use Adj BW.

Monitoring:

Indication

Monitoring

Gram-positive synergy Paired levels: Check peak drug level 30 minutes after end of infusion (goal 3-4 mg/L) and trough immediately before next dose (goal <1 mg/L)
Gram-negative high-dose extended interval ("once-daily")

Single level: Check random drug level 6-14 hours after the start of infusion.  Compare to nomogram below.

Paired levels: Check peak drug level 1 hour after end of infusion and random level 6-14 hours after infusion.  Consult ID pharmacy for assistance.

Gram-negative traditional dosing Paired levels: Check peak drug level 30 minutes after end of infusion (goal 5 - 8 mg/L) and trough level immediately before next dose (goal <2 mg/L).

Nomogram:


Imipenem/cilastatin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Gram-negative or Nocardia infections 500 mg IV q12h 1000 mg IV x1 dose, then 250 mg IV q6h
Nontuberculous mycobacterial infections Consult ID/ID Pharmacy for dosing recommendations  

Imipenem/cilastatin/relebactam

Indication

Intermittent Hemodialysis

Continuous Hemodialysis

All Indications

1.25g = 500mg imipenem + 500 mg cilastatin + 250mg relebatam

500 mg IV q6h No data

Isavuconazole

Indication Dose Notes
All Indications 372 mg IV/PO Q8h x 6 doses (48h), then 372 mg IV/PO Q24h No dose adjustment in hemodialysis

372mg of isavucazonium (prodrug) = 200mg of isavuconazole


Isoniazid

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 300mg PO qPM 300mg PO q24h

Letermovir

Indication Dosing Notes
All Indications

480 mg IV/PO q24h

With concomitant cyclosoprine: 240 mg IV/PO q24h

No dosing recommendations available for hemodialysis

Levofloxacin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Standard Dosing 500mg x1, then 250mg IV/PO Q48h 750 mg IV/PO x1, then 250 mg IV/PO q24h
Pneumonia or Pseudomonas infections 750mg x1, then 500mg IV/PO Q48h 750 mg IV/PO x1, then 500 mg IV q24h

Avoid co-administration of the oral formulation with divalent/trivalent cations (e.g. calcium, magnesium, zinc) - separate by at least 2 hours.


Linezolid

Indication Dose Notes
All Indications 600mg IV/PO q12h No dose adjustment in hemodialysis

Meropenem

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Standard Dosing 500 mg IV x1 now, then qPM 1 g IV q8h
Meningitis, Cystic Fibrosis 500 mg IV x1 now, then qPM 1 g IV q8h & consult ID pharmacy

Meropenem/vaborbactam

Indication

Intermittent Hemodialysis

Continuous Hemodialysis

All Indications

4g = 2g meropenem + 2g vaborbactam

Adjust dose based on eGFR, dose post-HD No data

Metronidazole

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 500 mg IV/PO Q8h 500 mg IV/PO Q8h

Minocycline

Indication Dosing Notes
All Indications 200 mg IV/PO x1, then 100 mg IV/PO q12h No adjustment for hemodialysis

Moxifloxacin

Indication Dosing Notes
All Indications 400 mg IV/PO q24h No adjustment for renal dysfunction

Nitrofurantoin (Macrobid)

Indication Intermittent Hemodialysis Continuous Hemodialysis
Cystitis Treatment

 

Data limited for dosing in hemodialysis; consider alternatives

Cystitis Prophylaxis

Oritavancin

Indication Dosing Notes
All Indications 1200 mg IV x1 over 3 hours No adjustment for hemodialysis

Oseltamivir

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Influenza treatment 30 mg PO x1 now, then post-HD 75 mg PO BID
Influenza prophylaxis 30 mg po x1 dose per week 30 mg po daily

Penicillin G

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Meningitis, endovascular 2 million units IV q6h 3 million units IV q4h
Uncomplicated infection 2 million units IV q12h 2 million units IV q6h

Piperacillin/tazobactam (Zosyn) EXTENDED INFUSION

Indication

Intermittent Hemodialysis

Continuous Hemodialysis

All Infections, including documented/suspected Pseudomonas 

Exclusion criteria for EXTENDED INFUSION: resistant or intermediate susceptibility organism, cystic fibrosis, peri-procedural areas, insufficient IV access

Use SHORT INFUSION piperacillin/tazobactam Loading dose = 4.5 g IV over 30 min x1, then 4.5 g IV infused over 4h every 8h (starting 4h after loading dose)

UCSF: PREFERRED dosing strategy if no exclusions


Piperacillin/tazobactam SHORT Infusion (SI) (Zosyn)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2.25 g IV q8h Use EXTENDED infusion (UCSF): Loading dose of 4.5 g IV over 30 minutes x1, then 4.5 g IV q4h over 4h every 8h (starting 4 h after loading dose)

ONLY for patients excluded from EI dosing at UCSF. Exclusion criteria for EI: Resistant or intermediate organism, cystic fibrosis, periprocedural areas, insufficient IV access 


Plazomicin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications Data is limited for all forms of dialysis; consider alternatives or contact ID pharmacy  

If Total BW >1.2 times Ideal BW, use Adjusted BW


Polymyxin B

Indication Dosing Note
All Indications 2.5 mg/kg IV x1, then 1.5 mg/kg IV q12h No dose adjustment for hemodialysis

There are other more effective, less toxic alternatives for most multidrug-resistant Gram-negative infections.  If a polymyxin is required, polymyxin B is preferred for intravenous treatment of systemic infections in adults. For treatment of urinary tract infections, or use via inhalation, use colistin (polymyxin E).


Posaconazole

Indication Dosing Notes
All Indications (IV or Delayed-release tablet) 300 mg IV/PO q12h x 2 doses, then 300 mg IV/PO q24h No dose adjustment in hemodialysis

Take with food.  Posaconazole SOLUTION has more frequent dosing, low bioavailability, and significant food restrictions.  Do not substitute SOLUTION for TABLETS or IV without discussion with ID Pharmacy.

Review medications for potential drug interactions.

Posaconazole trough levels should be obtained in most patients, whether receiving the agent for prophylaxis or treatment of fungal infections.  Trough samples should be obtained 5-7 days after: 
-start of therapy
-change in dose
-change in route of administration
-change in potentially interacting drugs

See UCSF Lab Posaconazole Recommendations  for specifics of monitoring.


Pyrazinamide

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 25-35 mg/kg PO x1 now and post-HD 20-25 mg/kg PO q24h

Supplied as 500mg tablets


Rifampin

Indication Dosing Notes
Mycobacterial infections 600 mg IV/PO q24h

 

No adjustment in hemodialysis

Prosthetic device infections 300 mg IV/PO q12h
Endocarditis 300 mg IV/PO q8h

Review medications for potential drug interactions.


Tedizolid

Indication Dosing Notes
All Indications 200 mg IV/PO q24h No adjustment for hemodialysis

Tigecycline

Indication Dosing Notes
All Indications 100 mg IV x1, then 50 mg IV q12h

No adjustment for hemodialysis

Severe hepatic dysfunction: 100 mg IV x1, then 25 mg IV q12h


TMP/SMX (trimethoprim/sulfamethoxazole)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
Systemic GNR Infections 2.5 - 5 mg TMP/kg IV x1 now and qPM 5 - 7.5 mg TMP/kg/day IV divided q12h
Pneumocystis pneumonia 5 - 7.5 mg TMP/kg IV x1 now and qPM 10 - 15 mg TMP/kg/day IV divided q12h - q24h

Single-strength (SS) tablet contains 80 mg trimethoprim (TMP)

Double-strength (DS) tablet contains 160 mg trimethoprim (TMP)

*May consider Total BW for serious infections


Tobramycin

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 2 mg/kg IV x1, then 1 mg/kg IV post-HD 2 mg/kg IV x1 then 1.5 mg/kg IV q24h

*If Total BW > 1.2 times Ideal BW, use Adj BW.

Monitoring:

Indication

Monitoring

Gram-negative high-dose extended interval ("once-daily")

Single level: Check random drug level 6-14 hours after the start of infusion.  Compare to nomogram.

Paired levels: Check peak drug level 1 hour after end of infusion and random level 6-14 hours after infusion.  Consult ID pharmacy for assistance.

Gram-negative traditional dosing Paired levels: Check peak drug level 30 minutes after end of infusion (goal 5 - 8 mg/L) and trough level immediately before next dose (goal <2 mg/L). 

Valganciclovir (Valcyte)

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
CMV Induction 450 mg PO x1 now and post-HD (IV ganciclovir preferred) 450 mg PO q24h
CMV Maintenance 450 mg PO twice weekly 450 mg PO q48h

Take with food


Vancomycin IV

Indication

Intermittent Hemodialysis

Continuous Hemodialysis
All Indications 15 - 20 mg/kg IV x 1 then 500 mg IV post-HD only 10 - 15 mg/kg IV q24h

Contact pharmacy for maintenance dose and consider vancomycin per pharmacy (UCSF only).

See Vancomycin Dosing and Monitoring page for more detail.

Round to nearest 250mg increment. Max: 2g/dose

*If Total BW > 1.2 times Ideal BW, use Adj BW

Recommend loading dose (20-25 mg/kg IV x1) for serious infections including CNS infections, endocarditis, pneumonia, bacteremia, osteomyelitis and sepsis


Vancomycin PO

Indication Dose Notes
Clostridioides difficile infection: uncomplicated 125 mg PO QID No dose adjustment in hemodialysis
Clostridioides difficile infection: complicated 500 mg PO QID

Voriconazole

Indication Dosing Notes
All Indications, IV Route 6mg/kg IV Q12h x 2 doses, then 4mg/kg IV Q12hr No dose adjustment in hemodialysis

All Indications, PO Route

In obese patients consider a weight-based PO regimen (4mg/kg q12H ADJ BW), Consult ID or ASP for assistance. 

400mg PO Q12h x doses, then 200mg PO Q12 No dose adjustment in hemodialysis

Review medications for potential drug interactions.

Voriconazole has high inter- and intra-patient variability.  Voriconazole trough levels should be obtained in most patients, whether receiving the agent for prophylaxis or treatment of fungal infections.  Trough samples should be obtained 3-5 days after: 
-start of therapy
-change in dose
-change in route of administration
-change in potentially interacting drugs

See UCSF Lab Voriconazole Recommendations  for specifics of monitoring.