What is the recommended dosing of Augmentin (amoxicillin-clavulanate) for a patient with End-Stage Renal Disease (ESRD) and a Urinary Tract Infection (UTI)?

Augmentin Dosing in ESRD Patients with UTI

For patients with end-stage renal disease (ESRD) and urinary tract infection (UTI), Augmentin (amoxicillin-clavulanate) should be dosed at 250/125 mg every 24 hours after dialysis sessions for hemodialysis patients.

Pharmacokinetics in ESRD

• Both amoxicillin and clavulanic acid have significantly prolonged half-lives in ESRD patients - approximately 13.6 hours for amoxicillin and 3.05 hours for clavulanic acid on non-dialysis days 1
• Both components are effectively removed during hemodialysis, with fractional removal rates of 64% for amoxicillin and 65% for clavulanic acid 1
• Total serum clearance is significantly reduced in ESRD patients compared to those with normal renal function 1

Dosing Recommendations

• Standard Augmentin dosing for UTI in patients with normal renal function is 375-500 mg three times daily 2, 3
• For ESRD patients on hemodialysis, the dose should be reduced to 250/125 mg once daily 1
• Administration should occur after hemodialysis sessions to prevent premature removal of the drug 4
• Supplemental doses are not required after dialysis if the medication is administered post-dialysis 1

Clinical Efficacy in UTI

• Despite dose reduction, Augmentin remains effective for UTI treatment in patients with impaired renal function 5, 6
• The combination of amoxicillin with clavulanic acid is particularly valuable for treating UTIs caused by resistant organisms 2, 3
• Clinical trials have shown success rates of approximately 70-87.5% even against amoxicillin-resistant organisms 2, 6

Important Considerations

• Monitor for adverse effects, particularly gastrointestinal symptoms, which occur in approximately 20% of patients but are typically mild 3
• For patients on peritoneal dialysis, specific data are limited - begin with the same dosing as for hemodialysis patients but monitor closely 4
• Non-renal clearance may also be impaired in ESRD patients, suggesting some degree of hepatic impairment that could affect drug metabolism 1

Potential Pitfalls

• Underdosing may lead to treatment failure and promote antimicrobial resistance 7
• Overdosing increases the risk of adverse effects without improving efficacy 1
• Failure to administer the medication after dialysis may result in subtherapeutic levels 4
• The combination of amoxicillin-clavulanate is particularly important for treating resistant organisms, which are more common in ESRD patients with recurrent UTIs 3, 5