What is the recommended dose adjustment of cefuroxime (Cefuroxime) for a urinary tract infection (UTI) in patients with chronic kidney disease (CKD) and chronic liver disease (CLD)?

Cefuroxime Dose Adjustment for UTI in CKD and CLD

Direct Recommendation

For UTI treatment with cefuroxime in patients with CKD, reduce the dose to 750 mg every 12 hours when creatinine clearance is 10-20 mL/min, and to 750 mg every 24 hours when creatinine clearance is below 10 mL/min; no dose adjustment is required for chronic liver disease alone. 1

Dosing Algorithm Based on Renal Function

Standard Dosing (CrCl >20 mL/min)

• 750 mg every 8 hours for uncomplicated UTI in patients with normal or mildly impaired renal function 1
• This represents the baseline regimen from which adjustments are made 1

Moderate Renal Impairment (CrCl 10-20 mL/min)

• 750 mg every 12 hours 1
• This extends the dosing interval by 50% to account for reduced renal clearance 1

Severe Renal Impairment (CrCl <10 mL/min)

• 750 mg every 24 hours 1
• An additional dose should be administered after hemodialysis sessions, as cefuroxime is dialyzable 1

Calculating Creatinine Clearance

• When only serum creatinine is available, use the Cockcroft-Gault formula: Males: CrCl (mL/min) = [Weight (kg) × (140 - age)] / [72 × serum creatinine (mg/dL)] 1
• For females, multiply the male value by 0.85 1
• The serum creatinine must represent steady-state renal function for accurate estimation 1

Chronic Liver Disease Considerations

• No dose adjustment is required for cefuroxime in patients with chronic liver disease alone, as cefuroxime is primarily eliminated renally rather than hepatically 1, 2
• The extrarenal clearance of cefuroxime is minimal (approximately 8.24 mL/min), confirming that hepatic metabolism plays a negligible role 3

Clinical Evidence Supporting Adjusted Dosing

Pharmacokinetic Data in Severe CKD

• In patients with severe renal impairment (CrCl ≤23 mL/min), the elimination half-life of cefuroxime increases dramatically from 4.2 hours (CrCl 23 mL/min) to 22.3 hours (CrCl 5 mL/min) 3
• Despite this prolonged half-life, 750 mg once or twice daily (depending on CrCl) achieved clinical cure in UTI patients with severe renal dysfunction without nephrotoxicity 3

Safety Profile

• Clinical trials demonstrated good tolerability with adjusted dosing regimens, with no evidence of nephrotoxicity even when cefuroxime was combined with furosemide 3
• Pathogens were successfully eradicated with no relapses observed during 3-month follow-up periods 3

Critical Pitfalls to Avoid

Do Not Use Standard Dosing in Advanced CKD

• Continuing 750 mg every 8 hours in patients with CrCl <20 mL/min risks drug accumulation and potential toxicity 1
• The linear correlation between cefuroxime clearance and creatinine clearance means that failure to adjust doses will result in 2-3 fold higher drug exposure 3

Hemodialysis Patients Require Supplemental Dosing

• Always administer an additional 750 mg dose after each hemodialysis session, as cefuroxime is removed by dialysis 1
• Failure to provide post-dialysis supplementation may result in subtherapeutic levels and treatment failure 1

Do Not Confuse with Other Cephalosporins

• Unlike cefoperazone and ceftriaxone (which have significant biliary excretion), cefuroxime depends almost entirely on renal elimination 4
• Dosing adjustments for other cephalosporins should not be extrapolated to cefuroxime 4

Treatment Duration

• Continue therapy for a minimum of 48-72 hours after the patient becomes asymptomatic or after bacterial eradication is documented 1
• Chronic UTIs may require treatment for several weeks with frequent bacteriologic monitoring 1