What is the recommended intravenous (IV) dose of ceftriaxone (a third-generation cephalosporin antibiotic) for a 73-year-old male (YOM) with impaired renal function, specifically an estimated glomerular filtration rate (eGFR) of 49, and suspected urosepsis?

From the FDA Drug Label

Patients with Renal or Hepatic Impairment Ceftriaxone is excreted via both biliary and renal excretion (see CLINICAL PHARMACOLOGY). Therefore, patients with renal failure normally require no adjustment in dosage when usual doses of ceftriaxone are administered

Compared to that in healthy adult subjects, the pharmacokinetics of ceftriaxone were only minimally altered in elderly subjects and in patients with renal impairment or hepatic dysfunction (Table 4); therefore, dosage adjustments are not necessary for these patients with ceftriaxone dosages up to 2 grams per day

The standard IV dose of ceftriaxone for a patient with an eGFR of 49 and suspected urosepsis is 1-2 grams every 12-24 hours.

• Key considerations:
  • No dose adjustment is necessary for patients with renal impairment.
  • Ensure adequate hydration to minimize the risk of urolithiasis.
  • Monitor for signs of superinfection, gallbladder disease, and coagulopathy. 1 1

From the Research

For a 73-year-old male with suspected urosepsis and an eGFR of 49 mL/min, the recommended ceftriaxone IV dose is 1-2 grams once daily, as ceftriaxone is primarily eliminated through biliary excretion with only about 33-67% excreted unchanged in urine 2, 3.

Key Considerations

• No dose adjustment is required for this level of renal impairment.
• The higher dose of 2 grams daily would be appropriate for severe infections like urosepsis, especially in the initial treatment phase.
• Administration should be via slow IV infusion over 30 minutes.
• Monitor renal function during treatment, as well as clinical response and potential side effects.
• Blood cultures should be obtained before starting antibiotics if possible, and therapy may need adjustment based on culture results.
• Ensure adequate hydration and consider adding an aminoglycoside for broader coverage if the patient is critically ill, pending culture results.
• Treatment duration typically ranges from 7-14 days depending on clinical response and source control.

Rationale

The provided evidence does not directly address the dosing of ceftriaxone in patients with renal impairment, but it does emphasize the importance of early and effective antimicrobial therapy in the treatment of urosepsis 4, 5.

Additional Considerations

• Recent studies have highlighted the potential risks of certain antibiotics, including piperacillin/tazobactam, cefepime, and meropenem, in terms of acute kidney injury and Clostridioides difficile infection 6.
• However, these studies do not directly impact the recommended dosing of ceftriaxone in this patient population.
• The most recent and highest quality study relevant to this question is not explicitly provided, but based on general medical knowledge and the principles of antibiotic dosing in renal impairment, the recommended dose of ceftriaxone remains appropriate.