What antibiotics are safe for patients with End-Stage Renal Disease (ESRD) undergoing dialysis?

From the Guidelines

Patients with End-Stage Renal Disease (ESRD) undergoing dialysis can be safely treated with antibiotics such as vancomycin, cefazolin, and ceftriaxone, with dosing adjustments made according to the patient's residual kidney function and dialysis schedule, as recommended by the Infectious Diseases Society of America 1.

Key Considerations

• The choice of antibiotic should be based on the suspected or confirmed pathogen, as well as the patient's allergy history and renal function.
• Dosage adjustments are crucial to avoid toxicity, as kidney failure alters drug clearance.
• Aminoglycosides, such as gentamicin and tobramycin, should be used with caution and close monitoring of drug levels due to their potential nephrotoxicity.
• The timing of antibiotic administration relative to dialysis sessions is important, as some antibiotics may be removed during dialysis and require supplemental doses.

Recommended Antibiotics

• 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.
• Cefazolin: 20 mg/kg iv after each dialysis session 1.
• Ceftriaxone: can be used with adjusted dosing, but specific guidelines are not provided in the available evidence.
• Daptomycin, linezolid, and azithromycin: can be used with minimal or no dose adjustment, but may not be suitable for all types of infections.

Important Precautions

• Consultation with a nephrologist or pharmacist is essential to determine the optimal antibiotic regimen based on the specific infection, dialysis modality, and individual patient factors.
• Patients on hemodialysis should be closely monitored for signs of infection and toxicity, and antibiotic therapy should be adjusted accordingly.
• The use of nephrotoxic antibiotics, such as aminoglycosides and tetracyclines, should be avoided or used with caution in patients with ESRD undergoing dialysis 1.

From the FDA Drug Label

The pharmacokinetic profile of tigecycline was not significantly altered in any of the renally impaired patient groups, nor was tigecycline removed by hemodialysis. No dosage adjustment of tigecycline is necessary in patients with renal impairment or in patients undergoing hemodialysis

Tigecycline is safe for patients with End-Stage Renal Disease (ESRD) undergoing dialysis, as it is not removed by hemodialysis and no dosage adjustment is necessary in patients with renal impairment or in patients undergoing hemodialysis 2.

From the Research

Antibiotics Safe for Patients with End-Stage Renal Disease (ESRD) Undergoing Dialysis

• Cefepime is a fourth-generation cephalosporin that can be used in patients with ESRD undergoing dialysis, with a recommended dose of 1 g before every 48-h interval and 1.5 g before every 72-h interval for highly susceptible pathogens 3.
• For 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.
• Other antibiotics, such as vancomycin, cefazolin, and aminoglycosides, may also be used in patients with ESRD, but require careful dosing and monitoring due to the risk of toxicity and altered pharmacokinetics in renal failure 4, 5.
• Sustained low-efficiency dialysis (SLED) can significantly remove common antimicrobial agents, including cefepime, meropenem, piperacillin-tazobactam, and vancomycin, and modification of the dosing regimen may be necessary to avoid subtherapeutic concentrations 6.
• Target-controlled dialysis is a novel technique that can help maintain therapeutic concentrations of antibiotics in patients undergoing renal replacement therapy, and has been shown to be effective in vitro for several antibiotics, including ceftazidime, meropenem, and vancomycin 7.

Considerations for Antibiotic Use in ESRD Patients

• Patients with ESRD undergoing dialysis require careful consideration of antibiotic dosing and monitoring due to altered pharmacokinetics and the risk of toxicity 4, 5.
• The use of serum levels and newer strategies for dosing, such as target-controlled dialysis, may help optimize antibiotic therapy in these patients 3, 7.
• The choice of antibiotic and dosing regimen should be individualized based on the patient's specific needs and the susceptibility of the infecting organism 3, 6.