From the FDA Drug Label
In adult patients with renal impairment (creatinine clearance ≤ 40 mL/min) and dialysis patients (hemodialysis and CAPD), the intravenous dose of piperacillin and tazobactam for injection should be reduced based on the degree of renal impairment
The recommended daily dosage of piperacillin and tazobactam for injection for patients with renal impairment administered by intravenous infusion over 30 minutes is described in Table 1
Table 1: Recommended Dosage of Piperacillin and Tazobactam for Injection in Patients with Normal Renal Function and Renal Impairment
For patients on hemodialysis, the maximum dose is 2.25 g every twelve hours for all indications other than nosocomial pneumonia and 2.25 g every eight hours for nosocomial pneumonia.
Since hemodialysis removes 30% to 40% of the administered dose, an additional dose of 0.75 g piperacillin and tazobactam for injection (0. 67 g piperacillin and 0.08 g tazobactam) should be administered following each dialysis period on hemodialysis days.
The renal dose of Zosyn (piperacillin/tazobactam) for ESRD (End-Stage Renal Disease) patients is as follows:
- For patients on hemodialysis, the maximum dose is 2.25 g every 12 hours for all indications other than nosocomial pneumonia and 2.25 g every 8 hours for nosocomial pneumonia.
- An additional dose of 0.75 g should be administered following each dialysis period on hemodialysis days.
- For CAPD (Continuous Ambulatory Peritoneal Dialysis) patients, the dose is 2.25 g every 12 hours for all indications other than nosocomial pneumonia and 2.25 g every 8 hours for nosocomial pneumonia 1.
From the Research
For patients with end-stage renal disease (ESRD) requiring Zosyn (piperacillin-tazobactam), the recommended dose is 2.25 grams (2 grams piperacillin/0.25 grams tazobactam) administered every 8 hours. For patients on hemodialysis, an additional dose of 0.75 grams should be given after each dialysis session since approximately 30-40% of the drug is removed during a 4-hour hemodialysis session 2. This dosing adjustment is necessary because Zosyn is primarily eliminated by the kidneys, and patients with ESRD have severely impaired renal function that significantly reduces drug clearance. Without appropriate dose adjustment, the medication could accumulate to toxic levels. It's essential to monitor the patient for adverse effects such as seizures, which can occur with excessive blood levels of the drug. The dosing should be based on the patient's actual clinical condition, and may need to be adjusted based on the specific infection being treated and the patient's response to therapy. Some studies suggest that the dose of Zosyn may need to be adjusted in patients with ESRD, but the optimal dosing strategy is not well established 3, 4. However, the study by 2 provides the most recent and relevant guidance on the use of Zosyn in patients with ESRD. Key considerations in the management of patients with ESRD include:
- Monitoring for signs of protein-energy wasting and malnutrition 3
- Controlling blood pressure in patients receiving dialysis to improve mortality 3
- Preserving peripheral veins for those with stage III to V chronic kidney disease 4
- Referral to nephrology to optimize disease management 3
- Vaccination against seasonal influenza, tetanus, hepatitis B, human papillomavirus, and Streptococcus pneumoniae 3. In patients with ESRD, the half-life of certain medications can be significantly prolonged, and hemodialysis may be necessary to improve rapid excretion of the drug and promote rapid recovery from adverse effects 5. Overall, the management of patients with ESRD requires a comprehensive approach that takes into account the patient's clinical condition, renal function, and potential interactions with other medications.