Renal replacement therapy

Antibiotic dosing on CRRT and SLED

Reviewed Nov 2026·1 references
New· views rounded down, updated weekly

Avoid underdosing: full loading doses, CRRT maintenance roughly equal to CrCl 25-50 mL/min, and timing doses around IHD/SLED.

Definition
CRRT at 20-25 mL/kg/h clears drugs roughly like a native CrCl of ~25-50 mL/min. Underdosing beta-lactams is common and dangerous in sepsis. IHD and SLED remove large amounts during sessions: give doses after the session.

At the bedside

  1. 1

    Give full loading doses

    Always the normal loading dose regardless of RRT.

  2. 2

    Maintenance on CRRT

    Dose for CrCl ~25-50 mL/min equivalent for renally cleared drugs; higher for very high effluent rates. Prefer extended/continuous infusion for beta-lactams.

  3. 3

    IHD / SLED timing

    Give doses after dialysis or SLED sessions (or supplement after). SLED clears drugs substantially - doses resemble CRRT or higher.

  4. 4

    Therapeutic drug monitoring

    Vancomycin and aminoglycosides by levels; beta-lactam TDM where available.

  5. 5

    Adjust when RRT stops or kidneys recover

    Re-dose to native function; avoid accumulation when CRRT is interrupted for long periods.

Carbapenem on CRRT

Meropenem

IV extended infusion
Dose
1 g q8h (2 g q8h for CNS/high MIC)
Preparation
1 g in 50 mL NS over 3 h
Worked example
70 kg on CVVHDF 25 mL/kg/h: 1 g q8h over 3 h

Antipseudomonal on CRRT

Piperacillin-tazobactam

IV extended infusion
Dose
4.5 g q8h (or 3.375 g q6h)
Worked example
4.5 g in 100 mL NS over 4 h every 8 h

MRSA on CRRT

Vancomycin

IV
Dose
Load 20-25 mg/kg then ~15 mg/kg q24h by levels
Worked example
70 kg: 1.75 g load, then 1 g q24h; trough before 3rd/4th dose

CRE on CRRT

Colistin (colistimethate sodium)

IV
Dose
Load 9 million units (300 mg CBA), maintenance increased for CRRT

Typical adult antimicrobial doses on CRRT (effluent 20-25 mL/kg/h)

DrugCRRT doseIHD dose (after session)
Meropenem1 g q8h (extended infusion)500 mg-1 g q24h
Piperacillin-tazobactam4.5 g q8h or 3.375 g q6h2.25 g q8-12h
Cefepime2 g q12h (1-2 g q8h if high effluent)1-2 g q24h
Ceftazidime-avibactam1.25 g q8h (CrCl 31-50 dose) - check effluent rate0.94 g q24-48h
VancomycinLoad 20-25 mg/kg; ~15 mg/kg q24h by levelsLoad; 500-1,000 mg after each session by levels
AmikacinLoad 25 mg/kg; redose by levels (q24-48h)Load; redose after HD by levels
Fluconazole800 mg q24h (or 400 mg q12h)100% dose after each session
Levetiracetam500-1,000 mg q12h500-1,000 mg q24h + 250-500 mg after HD
Polymyxin BNo adjustment (load 2-2.5 mg/kg, then 1.25-1.5 mg/kg q12h)No adjustment

Typical values from published reviews; verify against current references and local antibiogram.

Red flag · call your senior now
Septic patient on CRRT not improving: consider beta-lactam underdosing before adding more antibiotics.
Pitfall
Using 'dialysis doses' (designed for IHD 3x/week) for patients on 24-h CRRT.
Pitfall
Giving the daily dose just before an IHD/SLED session.
Pearl
Polymyxin B is not renally cleared and needs no CRRT adjustment; colistin is cleared and needs higher maintenance on CRRT.

References

  1. 1

    Hoff BM, Maker JH, Dager WE, Heintz BH. Antibiotic dosing for critically ill adult patients receiving intermittent hemodialysis, prolonged intermittent renal replacement therapy, and continuous renal replacement therapy: an update. Ann Pharmacother 2020;54:43-55.

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