Meropenem Dosing for Hemodialysis Patients
For patients on hemodialysis, administer meropenem 500 mg after each dialysis session (typically 3 times per week), with the dose given immediately following dialysis completion. 1
Core Dosing Strategy
The fundamental principle for meropenem in hemodialysis is to extend the dosing interval rather than reduce the dose amount, which maintains adequate peak concentrations while avoiding toxicity 1. This approach leverages the concentration-dependent killing characteristics of beta-lactam antibiotics 1.
Standard Regimen
- Dose: 500 mg intravenously
- Frequency: After each hemodialysis session (3 times weekly for most patients) 1
- Timing: Immediately post-dialysis 1, 2
The post-dialysis timing is critical because:
- Approximately 50% of meropenem is removed during a hemodialysis session 3, 4
- Dialysis clearance ranges from 79-81 mL/min 4, 5
- Administering before dialysis wastes medication and leaves patients undertreated 2
- Post-dialysis dosing facilitates directly observed therapy 1, 2
Pharmacokinetic Rationale
In end-stage renal disease patients not on dialysis, meropenem's elimination half-life extends dramatically from 1 hour in healthy individuals to 6.8-13.7 hours in anuric patients 3, 4, 5. During hemodialysis, the half-life shortens from approximately 7 hours to 2.9 hours 6, demonstrating substantial drug removal.
The metabolite ICI 213,689 accumulates significantly in renal failure (half-life up to 35 hours) but is also effectively cleared by dialysis 4, 5.
Alternative Dosing for Severe Infections
For critically ill patients or those with life-threatening infections requiring higher drug exposure:
- Higher dose option: 1 gram every 12 hours for patients on extended daily dialysis 1
- More frequent dosing: 500 mg every 12 hours (given on non-dialysis days as well) 1
This approach is supported by pharmacokinetic studies showing that critically ill patients may require dose increases of up to 100% to avoid underdosing 7.
Critical Pitfalls to Avoid
Do not reduce the milligram dose when adjusting for renal impairment—only extend the interval 1. Smaller doses compromise the concentration-dependent bactericidal effect and may lead to treatment failure 3.
Do not administer immediately before dialysis, as this results in premature drug removal and subtherapeutic levels 2, 6.
Monitor for underdosing in patients receiving continuous renal replacement therapy, as these modalities remove 25-53% of meropenem depending on the specific technique used 3. The 500 mg post-dialysis dose is specifically for intermittent hemodialysis, not continuous therapies.
Monitoring Considerations
While meropenem has an excellent tolerability profile 3, the risk of underdosing is greater than the risk of toxicity in dialysis patients. Peak plasma concentrations after 500 mg in hemodialysis patients reach approximately 53 mg/L 3, which is adequate for most susceptible organisms but may be insufficient for less susceptible pathogens or deep-seated infections.