Can intravenous (IV) antibiotics be administered through dialysis access?

From the Guidelines

Intravenous antibiotics should not be administered through dialysis access except in emergency situations when no other vascular access is available. Dialysis access sites, including arteriovenous fistulas, grafts, and central venous catheters for hemodialysis, are specifically designed for dialysis treatment and should be preserved solely for this purpose. Using these access points for medication administration increases the risk of infection, thrombosis, and access failure, which could compromise a patient's lifeline for renal replacement therapy.

Key Considerations

• If antibiotics must be administered intravenously, a separate peripheral IV line or non-dialysis central venous catheter should be used.
• For patients requiring both dialysis and IV antibiotics, coordination with the dialysis team is essential, as some antibiotics can be administered during dialysis sessions through the dialysis circuit.
• Common antibiotics given during dialysis include vancomycin, cefazolin, and gentamicin, with dosing adjusted for renal function and dialysis clearance, as outlined in guidelines such as those from the Infectious Diseases Society of America 1.

Administration Guidelines

• 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.
• The preservation of dialysis access is critical for long-term patient outcomes, as creating new access sites becomes increasingly difficult over time and may lead to significant morbidity if access options are exhausted.

Treatment Options for CRBSI

• Intravenous antibiotics alone are not a satisfactory approach, as bloodstream infection recurs in the majority of patients once the course of antibiotics has been completed 1.
• Prompt catheter removal with delayed placement of a new long-term catheter, exchange of the infected catheter with a new one over a guidewire, or use of systemic antibiotics and an antibiotic lock in the existing catheter are potential treatment options for patients with CRBSI involving long-term catheters 1.

From the FDA Drug Label

About 60% of an intraperitoneal dose of vancomycin administered during peritoneal dialysis is absorbed systemically in 6 hours. The FDA drug label does not answer the question.

From the Research

Administration of IV Antibiotics through Dialysis Access

• IV antibiotics can be administered through dialysis access, as evidenced by studies on the use of antibiotics in hemodialysis patients 2, 3, 4.
• The administration of antibiotics through dialysis access can help minimize the risk of potential clinical complications, such as vein thrombosis and catheter-associated infections 2.
• Certain antibiotics, such as vancomycin, cefazolin, ceftazidime, cefepime, ertapenem, and daptomycin, can be given thrice-weekly after dialysis sessions 2.
• The optimal dosing strategy for antibiotics in hemodialysis patients depends on various factors, including the type of antibiotic, the modality of hemodialysis, and the site and severity of infection 2, 3, 4.

Specific Antibiotics and Dosing Strategies

• Vancomycin can be administered during the last 60-90 minutes of hemodialysis to prevent vascular damage and preserve patients' vascular access 3.
• Cefepime can be administered post-dialysis three-times-weekly, with a fixed dose of 1 g before every 48-h interval and 1.5 g before every 72-h interval, without the need for routine monitoring of cefepime blood levels 4.
• The dosing strategy for vancomycin in hemodialysis patients involves a loading dose of 18-23 mg/kg, followed by a maintenance dose of 8-13 mg/kg administered in the last hour of dialysis 3.

Considerations for Antibiotic Administration

• The use of antibiotics in hemodialysis patients requires careful consideration of the potential risks and benefits, including the risk of allergic reactions, bacterial resistance, and increased costs of medical care 5, 6.
• The administration of antibiotics through dialysis access should be guided by evidence-based recommendations and individualized to the patient's specific needs and circumstances 2, 3, 4.