From the Guidelines
For cellulitis in patients on dialysis, vancomycin is the recommended first-line antibiotic choice, typically dosed at 20-mg/kg loading dose infused during the last hour of the dialysis session, and then 500 mg during the last 30 min of each subsequent dialysis session, as suggested by the study 1.
Antibiotic Options
- Vancomycin: 20-mg/kg loading dose infused during the last hour of the dialysis session, and then 500 mg during the last 30 min of each subsequent dialysis session 1
- Gentamicin (or tobramycin): 1 mg/kg, not to exceed 100 mg after each dialysis session 1
- Ceftazidime: 1 g iv after each dialysis session 1
- Cefazolin: 20 mg/kg iv after each dialysis session 1
Considerations
- The choice of antibiotic should be guided by local resistance patterns, severity of infection, and patient-specific factors such as allergies 1
- Regular monitoring of the infection site, inflammatory markers, and potential drug side effects is essential during treatment 1
- Duration of therapy typically ranges from 5-14 days depending on clinical response, as recommended by the study 1
MRSA Coverage
- Daptomycin (4-6 mg/kg every 48 hours) or linezolid (600 mg twice daily, no dose adjustment needed) can be used for MRSA coverage 1
- Clindamycin (300-450 mg three times daily) may be considered for less severe cases without dose adjustment 1
From the FDA Drug Label
Adults with cSSSI Adult patients with clinically documented complicated skin and skin structure infections (cSSSI) Patients could switch to oral therapy after a minimum of 4 days of IV treatment if clinical improvement was demonstrated. Patients known to have bacteremia at baseline were excluded Patients with creatinine clearance (CL CR) between 30 and 70 mL/min were to receive a lower dose of daptomycin for injection as specified in the protocol;
Daptomycin can be used for the treatment of complicated skin and skin structure infections (cSSSI), including cellulitis.
- The dose of daptomycin should be adjusted for patients with renal impairment, such as those on dialysis.
- However, the label does not provide specific dosing recommendations for patients on dialysis.
- Vancomycin and anti-staphylococcal semi-synthetic penicillins (e.g. nafcillin, oxacillin, cloxacillin, or flucloxacillin) are also options for the treatment of cSSSI, including cellulitis.
- The choice of antibiotic should be based on the suspected or confirmed pathogen and its susceptibility pattern, as well as the patient's renal function and other clinical factors 2.
From the Research
Antibiotic Options for Cellulitis in Patients on Dialysis
- Cefazolin is a safe and effective alternative to vancomycin for empiric treatment of infections in chronic hemodialysis patients, including those with cellulitis of the legs 3, 4.
- Cefazolin plus gentamicin may provide broader coverage than vancomycin alone, making it a suitable option for patients with suspected or documented infections 3.
- For patients with non-purulent, uncomplicated cellulitis, oral antibiotics such as penicillin, amoxicillin, and cephalexin may be sufficient, as they provide targeted coverage against β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus 5.
- However, it is essential to consider the possibility of calciphylaxis, a rare and serious disorder seen in end-stage renal disease patients on dialysis, which can mimic cellulitis 6.
- Ceftaroline in combination with daptomycin may exhibit a synergistic effect against methicillin-resistant Staphylococcus aureus (MRSA) strains, but its use in patients on dialysis requires careful consideration of the patient's specific needs and the potential for drug interactions 7.