What is the recommended intravenous (IV) dosing regimen for cefuroxime in a patient with impaired renal function?

Cefuroxime IV Dosing

For adults with normal renal function, administer cefuroxime 750 mg to 1.5 grams IV every 8 hours, with dosing adjusted based on infection severity; for patients with impaired renal function, reduce the frequency to every 12 hours when creatinine clearance is 10-20 mL/min and to every 24 hours when creatinine clearance is below 10 mL/min. 1

Standard Adult Dosing (Normal Renal Function)

• Mild to moderate infections (uncomplicated UTIs, skin/soft tissue infections, uncomplicated pneumonia): 750 mg IV every 8 hours 1
• Severe or complicated infections (bone/joint infections): 1.5 grams IV every 8 hours 1
• Life-threatening infections or less susceptible organisms: 1.5 grams IV every 6 hours may be required 1
• Bacterial meningitis: Up to 3 grams IV every 8 hours (maximum dose) 1
• Uncomplicated gonorrhea: 1.5 grams IM as a single dose at 2 different sites with 1 gram oral probenecid 1

Surgical Prophylaxis Dosing

• Clean-contaminated or potentially contaminated procedures: 1.5 grams IV administered 30-60 minutes before initial incision, followed by 750 mg IV/IM every 8 hours for prolonged procedures 1
• Open heart surgery: 1.5 grams IV at induction of anesthesia, then every 12 hours for total of 6 grams 1

Renal Impairment Dosing Algorithm

The FDA label provides explicit dosing adjustments based on creatinine clearance 1:

• CrCl >20 mL/min: Standard dosing (750 mg to 1.5 grams every 8 hours) 1
• CrCl 10-20 mL/min: 750 mg every 12 hours 1
• CrCl <10 mL/min: 750 mg every 24 hours 1
• Hemodialysis patients: Give an additional dose at the end of dialysis, as cefuroxime is dialyzable 1, 2

Research demonstrates that elimination half-life increases dramatically with declining renal function—from 4.2 hours at CrCl 23 mL/min to 22.3 hours at CrCl 5 mL/min 2. The extrarenal clearance is only 8.24 mL/min, confirming that dose reduction is essential in renal impairment 2.

Pediatric Dosing (>3 Months of Age)

• Most infections: 50-100 mg/kg/day IV divided every 6-8 hours 1
• Severe or serious infections: 100 mg/kg/day (not exceeding maximum adult dose) 1
• Bone and joint infections: 150 mg/kg/day divided every 8 hours (not exceeding maximum adult dose) 1
• Bacterial meningitis: 200-240 mg/kg/day IV divided every 6-8 hours 1
• Pediatric renal insufficiency: Modify frequency consistent with adult recommendations 1

Preparation and Administration

• For IV bolus: Reconstitute 750 mg vial with 8.3 mL Sterile Water for Injection (concentration: 90 mg/mL); reconstitute 1.5 gram vial with 16 mL Sterile Water for Injection (concentration: 90 mg/mL) 1
• For IM injection: Reconstitute 750 mg vial with 3 mL Sterile Water for Injection (concentration: 225 mg/mL); results in a suspension that must be shaken gently and withdrawn completely 1
• IM administration: Inject deep into large muscle mass (gluteus or lateral thigh) with aspiration before injection to avoid inadvertent intravascular administration 1

Duration of Therapy

• Continue for minimum 48-72 hours after patient becomes asymptomatic or bacterial eradication is documented 1
• Streptococcus pyogenes infections: Minimum 10 days to prevent rheumatic fever or glomerulonephritis 1
• Chronic UTIs: May require several months of follow-up with frequent bacteriologic assessment 1
• Typical course for most infections: 5-10 days 1

Critical Pharmacokinetic Considerations

Recent pharmacodynamic modeling reveals important limitations: with a target of time above MIC >50%, cefuroxime achieves >99% probability of target attainment for Streptococcus pneumoniae at 750 mg every 12 hours, but even 1500 mg every 6 hours provides <90% PTA for E. coli and K. pneumoniae 3. For S. aureus, 1500 mg every 8 hours achieves 97% PTA 3. This underscores that cefuroxime has limited utility against common gram-negative uropathogens despite adequate tissue penetration 3, 4.

Common Pitfalls to Avoid

• Do not use doses smaller than recommended—inadequate dosing leads to treatment failure 1
• Do not forget the post-dialysis dose—cefuroxime is significantly removed by hemodialysis 1, 2
• Do not use for drug-resistant S. pneumoniae—cefuroxime has no clinically significant activity against DRSP 5, 6
• Do not rely on cefuroxime for E. coli or K. pneumoniae in seriously ill patients—pharmacodynamic data show inadequate target attainment even at maximum doses 3
• Surgical drainage must be performed when pus collections are present—antibiotics alone are insufficient 1