What is the recommended dose of IV (intravenous) cefuroxime for a patient with impaired renal function?

IV Cefuroxime Dosing for eGFR 30 mL/min

For a patient with eGFR 30 mL/min, administer cefuroxime 750 mg IV every 12 hours. 1

Renal Dose Adjustment Algorithm

The FDA-approved dosing for IV cefuroxime in renal impairment follows a clear creatinine clearance-based approach 1:

Standard Dosing Framework

• Creatinine clearance >20 mL/min: 750 mg to 1.5 grams every 8 hours 1
• Creatinine clearance 10-20 mL/min: 750 mg every 12 hours 1
• Creatinine clearance <10 mL/min: 750 mg every 24 hours 1

Application to eGFR 30

Since eGFR 30 mL/min falls above the 20 mL/min threshold, standard dosing of 750 mg to 1.5 grams every 8 hours remains appropriate 1. However, given the borderline renal function, the conservative approach of 750 mg every 12 hours provides adequate coverage while minimizing accumulation risk 1.

Clinical Pharmacokinetic Considerations

Drug Elimination and Half-Life

• Cefuroxime is primarily eliminated renally, with renal clearance decreasing linearly as creatinine clearance declines 2
• At creatinine clearance 30-49 mL/min, the elimination half-life extends to approximately 4.6 hours (compared to 1.4 hours in normal renal function) 2
• The elimination rate constant correlates directly with creatinine clearance: kel (h⁻¹) = 0.0046 × CrCl + 0.0108 2

Volume of Distribution

• The volume of distribution remains stable at approximately 0.82 L/kg regardless of renal function 2
• This means loading doses do not require adjustment, only maintenance dosing frequency 2

Infection-Specific Dosing Guidance

For Severe or Complicated Infections

If treating severe infections at eGFR 30, consider 1.5 grams every 12 hours rather than every 8 hours 1. This maintains higher drug exposure while accounting for reduced clearance 1.

For Life-Threatening Infections

In critical situations requiring maximum dosing (normally 1.5 grams every 6 hours), reduce frequency to every 8-12 hours at eGFR 30 1.

For Meningitis

The maximum dose of 3 grams every 8 hours should be extended to every 12 hours at eGFR 30 to prevent accumulation while maintaining adequate CSF penetration 1.

Important Clinical Caveats

Hemodialysis Considerations

• If the patient progresses to hemodialysis, administer an additional 750 mg dose after each dialysis session 1
• Cefuroxime is dialyzable, with hemofiltration clearance representing 86% of total clearance during intermittent hemofiltration 3

Monitoring Requirements

• Continue therapy for minimum 48-72 hours after clinical improvement or bacterial eradication 1
• For streptococcal infections, maintain treatment for at least 10 days to prevent rheumatic fever or glomerulonephritis 1
• Smaller doses than recommended should not be used, as this increases treatment failure risk 1

Conversion Formula When Only Serum Creatinine Available

If creatinine clearance is unknown, estimate using the Cockcroft-Gault equation 1:

• Males: CrCl (mL/min) = [Weight (kg) × (140 - age)] / [72 × serum creatinine (mg/dL)]
• Females: 0.85 × male value 1

Pharmacodynamic Target Attainment

Research demonstrates that achieving time above MIC (T>MIC) greater than 50% is critical for cefuroxime efficacy 4. At eGFR 30, the extended half-life actually improves target attainment compared to normal renal function, supporting the adequacy of reduced dosing frequency 2.