What are the recommended antibiotics and dosing regimens for patients with impaired renal function (IRF) undergoing dialysis?

From the Guidelines

Antibiotic dosing for patients with impaired renal function undergoing dialysis should be carefully adjusted to prevent toxicity while maintaining efficacy, with dosing regimens guided by the most recent and highest quality evidence, such as the guidelines provided by 1 and 1. When considering antibiotic therapy for dialysis patients, it's crucial to adjust dosages according to the patient's renal function to avoid toxicity and ensure efficacy.

• For patients undergoing hemodialysis, antibiotics like Ciprofloxacin can be given as 250-500mg after each dialysis session, as indicated in 1.
• Levofloxacin is typically dosed at 250-500mg every 48 hours for patients with creatinine clearance less than 50 mL/min, as recommended by 1.
• Trimethoprim-sulfamethoxazole should be dosed at half the normal dose for patients with creatinine clearance between 15-30 mL/min, and half the dose or an alternative agent for those with creatinine clearance less than 15 mL/min, according to 1 and 1.
• Valacyclovir dosing should be adjusted to 500mg every 24-48 hours for patients with creatinine clearance less than 30 mL/min, as suggested by 1. The timing of antibiotic administration relative to dialysis sessions is critical, as many antibiotics are removed during dialysis.
• Drug levels should be monitored when possible, especially for antibiotics with narrow therapeutic windows, to ensure adequate antimicrobial coverage while minimizing toxicity. It's essential to consult the most recent guidelines and adjust dosing regimens accordingly to optimize outcomes for patients with impaired renal function undergoing dialysis, as recommended by 1 and 1.

From the FDA Drug Label

Adult Patients: No dosage adjustment is required in adult patients with creatinine clearance (CLCR) greater than or equal to 30 mL/min The recommended dosage regimen for daptomycin for injection in adult patients with CLCR less than 30 mL/min, including adult patients on hemodialysis or continuous ambulatory peritoneal dialysis (CAPD), is 4 mg/kg (cSSSI) or 6 mg/kg (S. aureus bloodstream infections) once every 48 hours When possible, daptomycin for injection should be administered following the completion of hemodialysis on hemodialysis days

The recommended antibiotic for patients with impaired renal function (IRF) undergoing dialysis is daptomycin.

• The dosing regimen for adult patients with CLCR less than 30 mL/min, including those on hemodialysis, is 4 mg/kg once every 48 hours for complicated skin and skin structure infections (cSSSI) or 6 mg/kg once every 48 hours for S. aureus bloodstream infections.
• It is recommended to administer daptomycin following the completion of hemodialysis on hemodialysis days 2.

From the Research

Antibiotic Dosing for Dialysis Patients

• The recommended antibiotics and dosing regimens for patients with impaired renal function (IRF) undergoing dialysis vary depending on the type of dialysis and the antibiotic used 3, 4, 5, 6, 7.
• For patients on high-flux hemodialysis, cefepime is a suitable option, with a recommended dose of 1 g before every 48-h interval and 1.5 g before every 72-h interval for infections with highly susceptible pathogens 3.
• For patients with infections caused by less susceptible pathogens, such as Pseudomonas aeruginosa, higher initial doses of cefepime may be necessary, with adaptation according to subsequent pre-dialysis trough serum levels 3.
• In patients receiving continuous renal replacement therapy (CRRT), antibiotic dosing recommendations are different from those for intermittent hemodialysis, and doses should be adjusted accordingly 5.
• A study on sustained low efficiency dialysis (SLED) found that antibiotic dosing was frequently inadequate, especially for antibiotics requiring more frequent dosing, suggesting a high potential for subtherapeutic levels during the majority of time critically ill patients are requiring SLED 7.

Specific Antibiotic Dosing Recommendations

• Cefepime: 1 g before every 48-h interval and 1.5 g before every 72-h interval for infections with highly susceptible pathogens, with higher initial doses for less susceptible pathogens 3.
• Vancomycin: dosing recommendations vary depending on the type of dialysis and the patient's renal function, with a recommended dose of 1 g every 48-72 hours for patients on high-flux hemodialysis 4, 5.
• Other antibiotics: dosing recommendations vary depending on the type of dialysis and the patient's renal function, with a need for careful monitoring and adjustment of doses to ensure adequate therapy 5, 6, 7.

Considerations for Dialysis Patients

• Patients on dialysis require careful monitoring of antibiotic levels to ensure adequate therapy and prevent toxicity 3, 4, 5, 6, 7.
• The type of dialysis and the patient's renal function should be taken into account when selecting an antibiotic and determining the dosing regimen 3, 4, 5, 6, 7.
• Antibiotic dosing recommendations for dialysis patients may vary depending on the specific clinical situation and the patient's individual needs 3, 4, 5, 6, 7.