Antimicrobial agents in adult patients with renal insufficiency: initial dosage and general recommendations

The dosage or the time interval of administration (or both) of many antimicrobial agents must be adjusted in anephric patients or those with compromised renal function. Antimicrobial agents that must have adjustment of dosages include most, but not all, of the penicillins and cephalosporins, the aminoglycosides, vancomycin, and trimethoprim-sulfamethoxazole. The maximal doses of these agents generally should be decreased in proportion with the extent of reduction in renal function. The dosage of chloramphenicol, clindamycin, rifampin, nafcillin, and ceftriaxone probably need not be adjusted if hepatic function is essentially normal. The suggested doses are relatively crude guidelines to initial antimicrobial therapy. Serum antimicrobial assays are frequently indicated for accurate adjustment of the dosage, especially with the amino-glycosides. The efficacy of therapy and the possible occurrence of toxicity should be monitored in all patients but particularly in those with renal insufficiency. Recommendations for patients undergoing peritoneal dialysis are not included in this article.