In the setting of rapidly improving/worsening renal function, calculations of eGFR are inaccurate, and dosing should be based on estimated renal function instead.

If worsening renal function, actual GFR is likely lower than calculated.

If improving renal function, actual GFR is likely higher than calculated eGFR.

Not On Dialysis

eGFR 0 - 10

1-2g IV q24h

eGFR 10 - 40

1-2g IV q12h

eGFR 40 - 60

1-2g IV q8h

eGFR > 60

2g IV q8h

Intermittent Dialysis

1-2g IV q24-48h given post-HD on dialysis days ---- NOTE: Higher doses may be recommended in cases of serious infections

Continuous Dialysis

1-2g IV q12h