What are the recommended doses of cefazolin and ceftazidime (Cephalosporins) for treating Catheter-Related Bloodstream Infections (CRBSI) in patients with End-Stage Renal Failure (ESRF)?

Dosing of Cefazolin and Ceftazidime for CRBSI in ESRF Patients

For patients with end-stage renal failure (ESRF) who have catheter-related bloodstream infections (CRBSI), cefazolin should be dosed at 20 mg/kg (actual body weight) rounded to the nearest 500 mg increment after each dialysis session, while ceftazidime should be administered at 0.5-1 g after each hemodialysis session.

Cefazolin Dosing for CRBSI in ESRF

• Cefazolin is recommended for CRBSI due to methicillin-susceptible Staphylococcus aureus (MSSA) and should replace vancomycin when susceptibility is confirmed 1
• The appropriate dosage for cefazolin in hemodialysis patients is 20 mg/kg (actual body weight), rounded to the nearest 500 mg increment, administered after each dialysis session 1
• This dosing regimen ensures adequate serum concentrations between dialysis sessions while preventing drug accumulation 2
• For patients with persistent bacteremia (>72 hours) despite appropriate therapy, a 4-6 week course of antibiotics is recommended 1

Ceftazidime Dosing for CRBSI in ESRF

• For gram-negative CRBSI in ESRF patients, ceftazidime can be used as part of empirical coverage based on local antibiogram data 1
• In ESRF patients on hemodialysis, ceftazidime should be administered at 0.5-1 g after each hemodialysis session 3, 4
• A study evaluating post-hemodialysis dosing of ceftazidime found that 1 g was sufficient to maintain therapeutic concentrations throughout the interdialytic period (both 48 and 72-hour intervals) 4
• The 2 g dose provided higher concentrations but was not necessary for maintaining therapeutic levels 4

Management Approach for CRBSI in ESRF

Initial Assessment and Treatment

• Empirical antibiotic therapy should include vancomycin and coverage for gram-negative bacilli (such as ceftazidime) based on local antibiogram data 1
• If blood cultures reveal MSSA, switch from vancomycin to cefazolin 1
• For gram-negative CRBSI (except Pseudomonas species), initiate appropriate antibiotics without immediate catheter removal 1

Catheter Management

• For CRBSI due to S. aureus or Pseudomonas species, catheter removal is recommended 1
• For other pathogens, if symptoms resolve within 2-3 days of antibiotic therapy and there's no evidence of metastatic infection, the catheter can be exchanged over a guidewire 1
• Alternatively, if symptoms resolve quickly, the catheter can be retained with adjunctive antibiotic lock therapy for 10-14 days 1

Duration of Therapy

• Standard CRBSI treatment duration is 10-14 days 1
• For persistent bacteremia (>72 hours), endocarditis, or suppurative thrombophlebitis, extend treatment to 4-6 weeks 1
• For osteomyelitis, extend treatment to 6-8 weeks 1

Special Considerations

• Infectious disease consultation is highly recommended for managing infections caused by multidrug-resistant organisms in ESRF patients 1
• Surveillance blood cultures should be obtained one week after completing antibiotic therapy if the catheter has been retained 1
• If follow-up blood cultures remain positive, the catheter should be removed and a new one placed after obtaining negative blood cultures 1
• Antibiotic lock therapy should be used as adjunctive therapy with systemic antibiotics when attempting catheter salvage 1

Monitoring and Follow-up

• Monitor for clinical improvement within 48-72 hours of initiating appropriate antibiotic therapy 1
• For patients with retained catheters, obtain surveillance blood cultures one week after completing antibiotic therapy 1
• If symptoms persist or worsen despite appropriate antibiotic therapy, catheter removal should be considered 1
• Be vigilant for signs of metastatic infection such as endocarditis, osteomyelitis, or septic thrombophlebitis, which would require extended antibiotic courses 1