The doses below are taken from the Strama Stockholm recommendations 2025/2026 and are given for absolute eGFR in mL/min, not eGFR relative to 1.73 m². Recalculate in patients who are markedly larger or smaller than average. Higher doses may be required in the critically ill patient.
Intravenous antibiotics
| Drug | eGFR >90 | 60-89 | 30-59 | 15-29 | <15 |
|---|---|---|---|---|---|
| Benzylpenicillin | 1-3 g three times daily | 1-3 g three times daily | 1-3 g three times daily | 1-3 g twice daily (if <20) | 1-3 g twice daily (if <20) |
| Ampicillin | 2 g three times daily | 2 g three times daily | 2 g three times daily | 2 g twice daily (if <20) | 1 g twice daily |
| Cloxacillin | 2 g three to four times daily | 2 g three to four times daily | 2 g three to four times daily | 2 g three times daily | 1-2 g three times daily |
| Piperacillin-tazobactam | 4 g three times daily | 4 g three times daily | 4 g three times daily | 4 g twice daily (if <20) | 4 g twice daily |
| Cefotaxime | 1 g three times daily | 1 g three times daily | 1 g three times daily | 1 g three times daily | 1 g two to three times daily |
| Meropenem | 1 g three times daily | 1 g three times daily | 1 g three times daily | 1 g twice daily (if <20) | 1 g twice daily |
| Imipenem | 1 g three times daily | 1 g three times daily | 1 g three times daily | 0.25-0.5 g twice daily | 0.25 g twice daily |
| Ciprofloxacin | 400 mg twice daily | 400 mg twice daily | 400 mg twice daily | 400 mg once daily | 400 mg once daily |
Oral antibiotics
| Drug | eGFR >90 | 60-89 | 30-59 | 15-29 | <15 |
|---|---|---|---|---|---|
| Phenoxymethylpenicillin | 1-3 g three times daily | 1-3 g three times daily | 1-3 g three times daily | 1-3 g twice daily (if <20) | 1-3 g twice daily (if <20) |
| Amoxicillin | 500-750 mg three times daily | 500-750 mg three times daily | 500-750 mg three times daily | 500 mg three times daily | 500 mg twice daily |
| Amoxicillin-clavulanate | 875/125 mg three times daily | 875/125 mg three times daily | 875/125 mg three times daily | 500/125 mg three times daily | 500/125 mg twice daily |
| Flucloxacillin | 1 g three times daily | 1 g three times daily | 1 g three times daily | 1 g three times daily | 1 g two to three times daily |
| Pivmecillinam | Dosed independently of renal function for a single course of treatment | ||||
| Trimethoprim | 160 mg twice daily | 160 mg twice daily | 160 mg twice daily | 100 mg twice daily | Do not use |
| Trimethoprim-sulfamethoxazole | 160/800 mg twice daily | 160/800 mg twice daily | 160/800 mg twice daily | 80/400 mg twice daily | Do not use |
| Ciprofloxacin | 500 mg twice daily | 500 mg twice daily | 500 mg twice daily | 500 mg once daily | 500 mg once daily |
| Nitrofurantoin | 50 mg three times daily | 50 mg three times daily | See note | Do not use | Do not use |
Nitrofurantoin: as a general rule the drug is contraindicated at an eGFR <45 mL/min. A short course (no more than 7 days) may be given to selected patients with an eGFR of 30-40 mL/min for lower urinary tract infection. At an eGFR <30 mL/min the antibacterial effect is lost.
Dosed independently of renal function
Doxycycline, erythromycin, clindamycin, metronidazole, moxifloxacin and fusidic acid. All have good absorption and are best given orally when gut function is intact. Oral vancomycin (only for C. difficile) is likewise dosed independently of renal function.
Require drug concentration monitoring
| Drug | Comment |
|---|---|
| Vancomycin (intravenous) | Loading dose by weight, maintenance dose by renal function and drug concentration |
| Gentamicin and other aminoglycosides | A single dose initially. If treatment is continued, dosing is guided by drug concentration measurement. At a creatinine clearance <20 mL/min, consider an alternative treatment |
In aminoglycoside treatment of obese patients, an adjusted body weight is used: adjusted weight = ideal weight + 0.4 x (actual weight minus ideal weight).
Red flags and pitfalls
- Creatinine is a poor measure in the frail and the elderly. A normal creatinine can conceal markedly reduced renal function.
- Acute kidney injury changes clearance from day to day. Reassess the dose daily and follow creatinine.
- Underdosing in sepsis is more dangerous than exceeding the upper dose limit during the first 24 hours. Give the full loading dose regardless of renal function, and reduce the maintenance dose first.
- Dialysis has its own dosing rules; see sls.se/raf or contact an infectious diseases consultant.
- Forgetting to restore the dose once renal function improves.
Sources
- Strama Stockholm. Empirical antibiotic treatment of adults in hospital and in residential care (SÄBO) 2025/2026.
- Referensgruppen för antibiotikafrågor (RAF), sls.se/raf, standard- and high-dose tables and dosing in dialysis.
