Drug | CrCl (mL/minute) | Usual adult dose | Frequency |
Penicillin | |||
Penicillin V potassium (oral) | No adjustment necessary[1]; excretion may be delayed in severe kidney impairment | 250 to 500 mg orally | Every 6 to 12 hours |
iHD*[1] | 250 to 500 mg orally | Every 6 to 12 hours* | |
Penicillin G (IV)¶ | ≥15 (non-uremic) | 2 to 5 million units IV | Every 4 to 6 hours (or total daily dose as a 24-hour continuous infusion) |
10 to <15 (uremic) | Loading dose: 2 to 5 million units IV once Maintenance dose: 1 to 2.5 million units IV | Every 4 to 5 hours (maintenance dose) | |
<10 | Loading dose: 2 to 5 million units IV once Maintenance dose: 1 to 2.5 million units IV | Every 8 to 10 hours (maintenance dose) | |
iHD*[1] | Loading dose: 2 to 5 million units IV once Maintenance dose: 0.5 to 2.5 million units IV | Every 4 to 6 hours (maintenance dose)* | |
CVVHD (1 to 2 L/hour)[2] | Loading dose: 4 million units IV once Maintenance dose: 2 to 3 million units IV | Every 4 to 6 hours (maintenance dose) | |
Penicillin G procaineΔ (intermediate-acting IM suspension) | No specific adjustment available; excretion may be delayed in severe kidney impairment | 600,000 to 2.4 million units IM | Every 24 hours (or divided every 12 hours) |
Penicillin G benzathine and penicillin G procaineΔ (mixture of intermediate- and long-acting IM suspension) | No specific adjustment available; excretion may be delayed in severe kidney impairment | 1.2 to 2.4 million units IM | Single dose or repeated after 2 to 3 days |
Penicillin G benzathineΔ (long-acting intramuscular suspension) | No specific adjustment available; excretion may be delayed in severe kidney impairment | 1.2 to 2.4 million units IM | Single dose or repeated weekly |
Antistaphylococcal penicillins | |||
Cloxacillin (oral)◊ | No adjustment necessary | 250 to 500 mg◊ | Every 6 hours |
Cloxacillin (IV)◊ | No adjustment necessary | 2 g IV◊ | Every 4 to 6 hours |
Dicloxacillin (oral) | No adjustment necessary | 250 to 500 mg orally | Oral: Every 6 hours |
Dicloxacillin (IV)◊ | No adjustment necessary | 1 to 2 g IV◊ | Every 4 to 6 hours |
Nafcillin (IV) | No adjustment necessary | 1 to 2 g IV | Every 4 to 6 hours (or total daily dose as a 24-hour continuous infusion) |
Oxacillin (IV) | No adjustment necessary; caution in end stage kidney disease§ | 1 to 2 g IV | Every 4 hours |
Second-generation penicillins (aminopenicillins) | |||
Amoxicillin (oral, immediate-release) | >30 | 500 mg to 1 g orally | Every 8 to 12 hours |
10 to 30 | 250 mg to 1 g orally | Every 12 hours | |
<10 | 250 to 500 mg orally | Every 12 to 24 hours | |
iHD* | 250 to 500 mg orally | Every 12 to 24 hours* | |
PD | 250 to 500 mg orally | Every 12 hours | |
Ampicillin (IV) | ≥50 | 1 to 2 g IV | Every 4 to 6 hours |
30 to <50 | 1 to 2 g IV | Every 6 to 8 hours | |
15 to <30 | 1 to 2 g IV | Every 8 to 12 hours | |
<15 | 1 to 2 g IV | Every 12 to 24 hours | |
iHD* | 1 to 2 g IV | Every 12 to 24 hours* | |
PD | 1 to 2 g IV | Every 12 to 24 hours | |
CVVHD[2,3] | 1 to 2 g IV | Every 6 to 12 hours | |
Ampicillin (oral)[2] | ≥50 | 250 to 500 mg orally | Every 6 hours |
10 to <50 | 250 to 500 mg orally | Every 6 to 12 hours | |
<10 | 250 to 500 mg orally | Every 12 to 16 hours | |
iHD* | 250 to 500 mg orally | Every 12 to 24 hours; supplemental dose after each dialysis session* | |
PD | 250 mg orally | Every 12 hours | |
Other broad-spectrum penicillin | |||
Piperacillin (IV)◊¥ | ≥40 | 3 to 4 g IV | Every 4 to 6 hours |
20 to 40 | 4 g IV | Every 8 hours | |
<20 | 4 g IV | Every 12 hours | |
iHD* | 2 g IV | Every 8 hours; 1 g supplemental dose after each dialysis session* | |
PD | 4 g IV | Every 12 hours | |
CRRT[1] | 4 g IV | Every 8 hours |
CrCl: creatinine clearance; CRRT: continuous renal replacement therapy; CVVHD: continuous veno-venous hemodialysis; iHD: intermittent hemodialysis; PD: peritoneal dialysis.
* Based on three times weekly dialysis sessions of 3 to 4 hours each; on dialysis days administer dose after dialysis. A loading dose or supplemental dose following dialysis may be warranted for some antibiotics depending on clinical scenario; refer to UpToDate Lexidrug monograph for detail.
¶ Alternative suggested adjustment for kidney impairment: GFR >50 mL/min: No adjustment; GFR 10 to 50 mL/min: 75% of indication-specific dose; GFR <10 mL/min: 20 to 50% of indication-specific dose.[1]
Δ Suspension formulations of penicillin are for intramuscular use only and must not be administered intravenously.
◊ Not available in the United States but may be available elsewhere.
§ For those with CrCl <10 mL/minute, on iHD, or on PD, monitor for signs of accumulation (eg, neurotoxicity) or consider alternatives.
¥ Dosing for severe infections; lower and/or less frequent dosing recommended in milder infections. For dosing of the combination piperacillin-tazobactam product available in the United States, refer to separate table in UpToDate and UpToDate Lexidrug monograph.Data from: UpToDate Lexidrug. More information available at https://online.lexi.com/.
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