What is the recommended dose adjustment of ceftazidime (Ceftazidime) and sulbactam (Sulbactam) for patients with impaired renal function (Chronic Kidney Disease, CKD)?

Ceftazidime-Sulbactam Dosing in Chronic Kidney Disease

For patients with CKD, ceftazidime requires dose reduction based on creatinine clearance, with intervals extended from every 8 hours to every 48 hours depending on severity of renal impairment. Note that sulbactam is not a standard combination with ceftazidime—the question likely refers to ceftazidime alone or possibly ceftazidime-avibactam.

Standard Ceftazidime Dosing Algorithm by Renal Function

Loading Dose

• All CKD patients should receive an initial loading dose of 1 gram regardless of renal function to achieve therapeutic levels quickly 1

Maintenance Dosing Based on Creatinine Clearance

For CrCl 50-31 mL/min (Mild Impairment):

• 1 gram every 12 hours 1, 2

For CrCl 30-16 mL/min (Moderate Impairment):

• 1 gram every 24 hours 1, 2

For CrCl 15-6 mL/min (Severe Impairment):

• 500 mg every 24 hours 1
• Alternative: 1 gram every 36 hours 2

For CrCl <5 mL/min (End-Stage Renal Disease):

• 500 mg every 48 hours 1
• Alternative: 1 gram every 48 hours 3, 2

Hemodialysis Patients

Ceftazidime is significantly removed by hemodialysis (55% of dose in 4 hours), requiring supplementation:

• Loading dose: 1 gram before or after first dialysis session 1, 4
• Maintenance: 1 gram after each hemodialysis session 1, 4
• During a 4-hour dialysis, the elimination half-life drops from 33.6 hours to 3.3 hours 4
• Dialyzer clearance is approximately 55.6 mL/min 4

Peritoneal Dialysis Patients

For continuous ambulatory peritoneal dialysis (CAPD):

• Loading dose: 1 gram IV (or 10 mg/kg) 1, 3
• Maintenance: 500 mg every 24 hours IV 1
• Alternative intraperitoneal dosing: 250 mg per 2 liters of dialysis fluid, or continuous 5 mg/kg into each dialysis cavity 1, 3

Critical Dosing Considerations

Severe Infections in Renal Impairment

• For patients who would normally require 6 grams daily but have renal insufficiency, increase the unit dose by 50% or increase dosing frequency appropriately 1
• This applies to immunocompromised patients, meningitis, or severe Pseudomonas infections 1

Pharmacokinetic Rationale

• Ceftazidime is almost entirely excreted by glomerular filtration with minimal metabolism 1, 3, 2
• Protein binding is low (typically <10%), making it highly dialyzable 5
• Elimination half-life increases from 1.5-2 hours in normal renal function to 33-45 hours in severe renal failure 3, 5

Important Caveats

If the standard dosing recommendation for the infection type is lower than the renal-adjusted dose, use the lower dose 1. For example, if treating uncomplicated UTI (standard dose 250 mg q12h) in a patient with CrCl 40 mL/min (renal dose 1g q12h), use 250 mg q12h.

Pediatric patients require creatinine clearance adjusted for body surface area or lean body mass, with proportional dose reductions 1

No hepatic dose adjustment is needed as ceftazidime undergoes negligible hepatic metabolism 1

Avoid intra-arterial administration due to safety concerns 1