Augmentin Dosing in Chronic Kidney Disease
For patients with CKD, Augmentin dosing must be adjusted based on creatinine clearance (CrCl), with the specific recommendation being 375 mg twice daily for CKD stage IIIb (GFR 30-44 mL/min), and further reductions required for more severe renal impairment. 1
Dosing Algorithm by Renal Function
Mild Renal Impairment (CrCl ≥60 mL/min)
- No dose adjustment required for standard Augmentin dosing 2
Moderate Renal Impairment - CKD Stage IIIb (CrCl 30-44 mL/min)
- Reduce to Augmentin 375 mg twice daily (instead of the standard three times daily dosing) 1
- This prevents drug accumulation and potential toxicity given that both amoxicillin and clavulanic acid are renally cleared 1
Severe Renal Impairment (CrCl <30 mL/min)
- Further dose reduction or extended interval dosing is required 1
- Consider reducing frequency to once daily or using lower doses with extended intervals 2
End-Stage Renal Disease (ESRD) on Hemodialysis
- Both amoxicillin and clavulanic acid are significantly removed by dialysis (fractional removal ~0.64-0.65) 3
- Administer supplemental doses after dialysis sessions 3
- The half-life during dialysis is markedly reduced (amoxicillin: 2.30 h; clavulanic acid: 1.19 h) compared to non-dialysis days 3
Key Clinical Considerations
Calculate Creatinine Clearance Accurately
- Use the MDRD equation or online calculators to estimate CrCl rather than relying on serum creatinine alone 2
- Serum creatinine alone is inadequate for dosing decisions in CKD patients 2
Common Pitfalls to Avoid
- Drug dosing errors are extremely common in patients with renal impairment and can cause adverse drug events 4
- Inappropriate dosing occurs in approximately 50% of prescriptions requiring renal adjustment when pharmacist oversight is absent 4
- Non-renal clearance is also reduced in ESRD patients, suggesting some degree of hepatic impairment that further complicates dosing 3
Monitoring Requirements
- Reassess renal function regularly as CKD can progress, requiring further dose adjustments 2
- Monitor for signs of drug accumulation including gastrointestinal symptoms and potential hepatotoxicity 4
Evidence Quality Note
The dosing recommendations are based on guideline-level evidence from the American College of Physicians and Infectious Diseases Society of America 1, supported by pharmacokinetic studies demonstrating significant renal clearance of both Augmentin components 3. The importance of dose adjustment is reinforced by research showing that pharmacist-guided renal dosing reduces adverse drug events by approximately 25% in hospitalized CKD patients 4.