Antimicrobial Dosing and Dialysis
Loading dose, first 48 hours and maintenance, adjusted for renal function and dialysis · v3.4- Enter the patient and the renal function, choose the agent, then the indication.
- You get the dose and interval for that clearance or dialysis modality, the loading dose where one is published, and the ceiling beside every weight-based figure.
- Renal dose reduction is deferred through the first 48 hours. The evidence for that, its limits, and the guidance that takes the opposite view are printed with the result.
- Read the ceiling beside every weight-based figure before writing the order.
- Avoid, Not established and Contraindicated are refusals, and never carry a dose or an interval.
- Paediatric dosing. The age field starts at 18.
- The choice of agent. It doses the agent you have already chosen, and the empirical pathway tool is where selection is worked through.
- Therapeutic drug monitoring for vancomycin, the aminoglycosides, teicoplanin or voriconazole. Where an assay exists, the assay governs.
- Effluent-stratified continuous renal replacement dosing for any agent but cefiderocol. Every other CRRT figure here is a single representative regimen and is marked as one.
- Duration of therapy. Dose and duration are separate decisions and only one of them is held here.
1. Patient
Adults only, 18 years and over. This tool holds no paediatric doses.
2. Renal Clearance
Cockcroft-Gault, from a single steady-state creatinine.
3. Antimicrobial Agent
Ward abbreviations, class names and the trade names in common use all match, though this tool prints only the generic name. Leave it blank and use the class filter instead. Enter picks the first match; the arrow keys move through the list.
4. Indication
5. Pharmacokinetic Phase
The first dose is given at full strength whatever the creatinine.
RRT Reference: Select an antimicrobial and a dialysis modality. This tab returns how far the drug is removed by the circuit, how much of it protein binding keeps out of reach, and what supplemental dose is due after a session.
Agent
1. Errors That Recur on the Ward
- Vd shifts in sepsis. Fluid resuscitation expands the volume of distribution for the hydrophilic drugs, which is where the beta-lactams, aminoglycosides and vancomycin sit. The same milligrams then reach a lower concentration, so the first priority is getting to a therapeutic level quickly. Do not renally adjust in the first 48 hours of septic shock.
- Weight-based dosing errors. Acyclovir, colistin maintenance and daptomycin do not take the same weight as each other: ideal body weight, actual body weight and a calculated dosing weight are all in use. Reaching for the wrong one is a toxicity error and not a rounding error. The tool selects the weight each drug requires and shows you which one it used.
- Two amphotericins, five times apart. Deoxycholate is dosed near 1 mg/kg and liposomal near 5 mg/kg. Writing "amphotericin 5 mg/kg" on a chart where the pharmacy dispenses deoxycholate is the single most reported error with this drug. Name the formulation on every order.
- Vancomycin safety limits. A rapid infusion releases histamine and produces flushing. The infusion rate must never exceed 1 g/hour.
- A product containing sulbactam is not an Acinetobacter drug. Carbapenem-resistant Acinetobacter needs 6 to 9 g of sulbactam a day, which is an order of magnitude more than ceftriaxone-sulbactam delivers at 0.5 to 1 g per dose. Reaching for a product because the name contains the word is the error to avoid.
2. Indian Antimicrobial Resistance Context
The Indian Council of Medical Research antimicrobial resistance surveillance network reports the resistance patterns below from tertiary centres across India. Empirical therapy in an Indian ICU has to account for them.
- Enterobacterales: extended-spectrum beta-lactamase production is very common. Routine ceftriaxone for a hospital-acquired Gram-negative is explicitly discouraged.
- Carbapenem-resistant Enterobacterales: driven by NDM and OXA-48-like carbapenemases, frequently co-produced in the same isolate. This matters for agent choice: vaborbactam and avibactam do nothing against a metallo-beta-lactamase, so a ceftazidime-avibactam order against an NDM producer is a correctly dosed inactive drug.
- Acinetobacter baumannii: often pan-drug resistant. High-dose ampicillin-sulbactam or a polymyxin forms the backbone, and almost always in combination rather than alone.
The precise gene frequencies move year to year and differ between centres. Read your own hospital's antibiogram before the national figures.
3. Combinations This Tool Cannot Dose as a Single Order
The selector returns one agent at a time. Several of the most consequential inpatient decisions in India are combinations, and dosing one component correctly while leaving the other unstated is its own error. Select each component in turn, and read this table for what holds them together.
| Situation | Components | What the tool cannot tell you |
|---|---|---|
| Metallo-beta-lactamase producer NDM, VIM, IMP |
Ceftazidime-avibactam 2.5 g q8h over 3 h plus aztreonam 2 g q8h over 3 h | The two are given simultaneously through a Y-site. That is part of the recommendation, not a nursing detail. Both step down on their own renal ladders, so select each in turn. |
| Carbapenem-resistant Acinetobacter | A polymyxin plus high-dose sulbactam, or plus minocycline | Monotherapy is not supported for any single agent here. Where nothing tests susceptible, adding a second inactive drug does not help and adds toxicity. |
| Enterococcus faecalis endocarditis | Ampicillin 2 g q4h plus ceftriaxone 2 g q12h, or ampicillin plus gentamicin | The q12h ceftriaxone belongs to this combination specifically. For viridans streptococcal endocarditis ceftriaxone is 2 g once daily, and using the enterococcal interval there doubles the dose. |
| Cryptococcal meningitis | Amphotericin B plus flucytosine, induction; then fluconazole consolidation, then maintenance | This is a three-phase regimen over months, not a dose. The tool gives the induction figures; the sequence and its durations come from the guideline. |
4. Pharmacokinetic Principles
| Killing Profile | Target Metric | Clinical Strategy |
|---|---|---|
| Time-dependent (Beta-lactams, cephalosporins, carbapenems) |
Time > MIC | Frequent dosing, or extended and continuous infusions, to hold serum levels above the MIC. It matters most against the high-MIC organisms common in India. |
| Concentration-dependent (Aminoglycosides, fluoroquinolones) |
Cmax / MIC | Large, infrequent doses, such as once-daily amikacin, to reach a high peak, then a drug-free period that limits toxicity. |
| Exposure-dependent (Vancomycin) |
AUC / MIC | Maximise total area under the curve over 24 h. Monitoring to an AUC/MIC of 400 to 600 is what corrects the empirical dose and limits nephrotoxicity. |
5. What This Tool Does Not Do
- It holds no paediatric dose. The age field starts at 18.
- It does not choose the agent. It doses the agent you have chosen. The empirical pathway tool is where selection is worked through.
- It does not replace therapeutic drug monitoring for vancomycin, the aminoglycosides, teicoplanin or voriconazole. Where an assay exists, the assay governs.
- Continuous renal replacement dosing depends on effluent rate, filter and residual renal function. Only cefiderocol carries an effluent-stratified table on its label. Every other CRRT figure here is a single representative regimen and is marked as such.
- It holds no duration of therapy. Dose and duration are separate decisions and only one of them is here.
Abbreviations: AKI (Acute Kidney Injury) · APE (Acinetobacter, Pseudomonas, Enterococcus (The Ertapenem Coverage Gap)) · AUC (Area Under the Curve) · BBW (Black Box Warning) · BW (Body Weight) · CAPD (Continuous Ambulatory Peritoneal Dialysis) · CBA (Colistin Base Activity) · CDSCO (Central Drugs Standard Control Organisation) · CLSI (Clinical and Laboratory Standards Institute) · Cmax (Maximum Plasma Concentration) · CMS (Colistimethate Sodium) · CMV (Cytomegalovirus) · CNS (Central Nervous System) · CPK (Creatine Phosphokinase) · CrCl (Creatinine Clearance) · CRE (Carbapenem-Resistant Enterobacterales) · CRRT (Continuous Renal Replacement Therapy) · CSF (Cerebrospinal Fluid) · CVVH (Continuous Veno-Venous Haemofiltration) · CVVHD (Continuous Veno-Venous Haemodialysis) · CVVHDF (Continuous Veno-Venous Haemodiafiltration) · CYP2C19 (Cytochrome P450 2C19) · CYP3A4 (Cytochrome P450 3A4) · DNA (Deoxyribonucleic Acid) · DOAC (Direct Oral Anticoagulant) · ECG (Electrocardiogram) · ECMM (European Confederation of Medical Mycology) · EDTA (Ethylenediaminetetraacetic Acid) · ESBL (Extended-Spectrum β-Lactamase) · ESRD (End-Stage Renal Disease) · EUCAST (European Committee on Antimicrobial Susceptibility Testing) · FDA (United States Food and Drug Administration) · GFR (Glomerular Filtration Rate) · HAP (Hospital-Acquired Pneumonia) · HD (Haemodialysis) · IBW (Ideal Body Weight) · ICMR (Indian Council of Medical Research) · ICU (Intensive Care Unit) · IDSA (Infectious Diseases Society of America) · IHD (Intermittent Haemodialysis) · IM (Intramuscular) · IMP (Imipenemase) · IP (Intraperitoneal) · ISPD (International Society for Peritoneal Dialysis) · IV (Intravenous) · KPC (Klebsiella pneumoniae Carbapenemase) · MAOI (Monoamine Oxidase Inhibitor) · MBL (Metallo-β-Lactamase) · MDR (Multidrug-Resistant) · MDRD (Modification of Diet in Renal Disease) · MHRA (Medicines and Healthcare Products Regulatory Agency) · MIC (Minimum Inhibitory Concentration) · MIU (Million International Units) · MRSA (Methicillin-Resistant Staphylococcus aureus) · MSSA (Methicillin-Susceptible Staphylococcus aureus) · MU (Million Units) · NDM (New Delhi Metallo-β-Lactamase) · NMTT (N-methylthiotetrazole) · OXA-48 (Oxacillinase-48) · PO (Per Os) · QTc (Corrected QT Interval) · RNA (Ribonucleic Acid) · RRT (Renal Replacement Therapy) · SBECD (Sulfobutyl Ether Beta-Cyclodextrin) · SBP (Spontaneous Bacterial Peritonitis) · sCr (Serum Creatinine) · SJS (Stevens-Johnson Syndrome) · SSRI (Selective Serotonin Reuptake Inhibitor) · TCA (Tricyclic Antidepressant) · TDM (Therapeutic Drug Monitoring) · TMP-SMX (Trimethoprim-Sulfamethoxazole) · UTI (Urinary Tract Infection) · VAP (Ventilator-Associated Pneumonia) · Vd (Volume of Distribution) · VIM (Verona Integron-Encoded Metallo-β-Lactamase) · VRE (Vancomycin-Resistant Enterococcus) · WHO (World Health Organization)
References
- ICMR Antimicrobial Resistance Surveillance Network (AMRSN) annual reports, and ICMR guidance on the diagnosis and management of carbapenem-resistant organisms.
- Tamma PD, Bonomo RA, Heil EL, Justo JA, Satlin MJ, Mathers AJ. Infectious Diseases Society of America 2026 Guidance on the Treatment of Antimicrobial-Resistant Gram-Negative Infections. Clin Infect Dis. 2026. doi:10.1093/cid/ciag481.
- The Sanford Guide to Antimicrobial Therapy, current edition, and Ashley C, Dunleavy A. The Renal Drug Handbook, current edition. These two are the reference for the renal replacement therapy entries.
- Chen S. Retooling the creatinine clearance equation to estimate kinetic GFR when the plasma creatinine is changing acutely. J Am Soc Nephrol. 2013;24(6):877-888. doi:10.1681/ASN.2012070653.
- Crass RL, Rodvold KA, Mueller BA, Pai MP. Renal dosing of antibiotics: are we jumping the gun? Clin Infect Dis. 2019;68(9):1596-1602. doi:10.1093/cid/ciy790.
- Roberts JA, Paul SK, Akova M, et al; DALI Study. DALI: defining antibiotic levels in intensive care unit patients: are current beta-lactam antibiotic doses sufficient for critically ill patients? Clin Infect Dis. 2014;58(8):1072-1083. doi:10.1093/cid/ciu027.
- Aldardeer NF, Alshreef MM, Alharbi EA, et al. Early versus late antipseudomonal beta-lactam antibiotic dose adjustment in critically ill sepsis patients with acute kidney injury: a prospective observational cohort study. Open Forum Infect Dis. 2024;11(3):ofae059. doi:10.1093/ofid/ofae059.
- Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: a revised consensus guideline of ASHP, IDSA, PIDS and SIDP. Am J Health Syst Pharm. 2020;77(11):835-864.
- Tsuji BT, Pogue JM, Zavascki AP, et al. International consensus guidelines for the optimal use of the polymyxins. Pharmacotherapy. 2019;39(1):10-39.
- Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the ECMM in cooperation with the MSG-ERC. Lancet Infect Dis. 2019;19(12):e405-e421.
- World Health Organization. Guidelines for diagnosing, preventing and managing cryptococcal disease among adults, adolescents and children living with HIV. 2022.
- National Vector Borne Disease Control Programme. Guidelines for diagnosis and treatment of malaria in India, and Operational guidelines on kala-azar elimination.
- Li J, Nation RL, Turnidge JD, et al. Use of international units when dosing colistin will help decrease confusion related to various formulations of the drug around the world. Antimicrob Agents Chemother. 2006;50(12):4231-4232.
- Individual product labelling: United States FDA prescribing information, EMA summaries of product characteristics, MHRA labelling, and the Indian prescribing information for those agents licensed only in India.
How to Cite This Tool
DOIhttps://doi.org/10.5281/zenodo.22401550
AMA Style:Umakanth S. Antimicrobial Dosing and Dialysis. Version 3.4. MEDiscuss Clinical Decision Support System. Published 2026. Accessed . https://mediscuss.org/cdss/antimicrobial-dosing. doi:10.5281/zenodo.22401550
Vancouver Style:Umakanth S. Antimicrobial Dosing and Dialysis [Internet]. Version 3.4. MEDiscuss.org; 2026 [cited ]. Available from: https://mediscuss.org/cdss/antimicrobial-dosing. doi:10.5281/zenodo.22401550
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Category Therapeutic & Management PathwaysGuide
Specialties Internal Medicine, Infectious Diseases
Status Essential