From the FDA Drug Label
When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy. 2.3 Dosage in Adult Patients with Renal Impairment In adult patients with renal impairment (creatinine clearance ≤ 40 mL/min) and dialysis patients (hemodialysis and CAPD), the intravenous dose of piperacillin and tazobactam for injection should be reduced based on the degree of renal impairment The recommended daily dosage of piperacillin and tazobactam for injection for patients with renal impairment administered by intravenous infusion over 30 minutes is described in Table 1 Creatinine clearance, mL/min All Indications (except nosocomial pneumonia) Nosocomial Pneumonia Less than 20 mL/min* 2.25 every 8 hours 2.25 every 6 hours For patients on hemodialysis, the maximum dose is 2.25 grams every twelve hours for all indications other than nosocomial pneumonia and 2.25 grams every eight hours for nosocomial pneumonia. 1.2 Urinary Tract Infections (complicated and uncomplicated) Imipenem and Cilastatin for Injection, USP (I.V.) is indicated for the treatment of urinary tract infections (complicated and uncomplicated) caused by susceptible strains of Enterococcus faecalis, Staphylococcus aureus (penicillinase-producing isolates), Enterobacter species, Escherichia coli, Klebsiella species, Morganella morganii, Proteus vulgaris, Providencia rettgeri, Pseudomonas aeruginosa.
For a patient with a history of stage 5 Chronic Kidney Disease (CKD) and a CAUTI (Catheter-Associated Urinary Tract Infection) caused by Pseudomonas, the recommended antibiotic treatment should be chosen based on susceptibility patterns and adjusted for renal impairment.
- Piperacillin-tazobactam can be used to treat Pseudomonas infections, but the dose needs to be adjusted for renal impairment. For a patient with a creatinine clearance of less than 20 mL/min, the recommended dose is 2.25 grams every 8 hours for urinary tract infections.
- Imipenem-cilastatin is also effective against Pseudomonas and can be used for complicated urinary tract infections. However, the dosing for imipenem-cilastatin in patients with renal impairment, especially those on hemodialysis, requires careful consideration and adjustment. Given the patient's stage 5 CKD, it is crucial to monitor renal function closely and adjust the antibiotic dose accordingly to avoid toxicity while ensuring effective treatment of the infection. Key considerations:
- Dose adjustment for renal impairment
- Monitoring of renal function
- Susceptibility patterns of the infecting organism
- Potential for drug toxicity in renal impairment 1 2
From the Research
For a catheter-associated urinary tract infection (CAUTI) caused by Pseudomonas in a patient with stage 5 chronic kidney disease (CKD), I recommend ceftazidime or cefepime with appropriate renal dose adjustments, as supported by the most recent study 3. The treatment options for CAUTI caused by Pseudomonas include:
- Ceftazidime: 1g IV every 24-48 hours
- Cefepime: 1g IV every 24 hours Alternative options include:
- Piperacillin-tazobactam: 2.25g IV every 8-12 hours
- Meropenem: 500mg IV every 24 hours Treatment duration should be 7-10 days. Removal of the urinary catheter is essential if possible, as this alone can resolve symptoms in many cases. Pseudomonas is intrinsically resistant to many antibiotics, so therapy should be guided by culture and sensitivity results once available. The severe renal impairment in stage 5 CKD necessitates dose adjustments to prevent drug accumulation and toxicity, as highlighted in the study 4. Monitor renal function closely during treatment and adjust doses as needed. For patients on dialysis, administer antibiotics after dialysis sessions to avoid drug removal during treatment. It is also important to consider the prevention of CAUTIs, as discussed in the study 5, which can be achieved through the use of catheter-associated urinary tract infection prevention guides, such as the one introduced in the study 6. However, the primary focus should be on treating the current infection, and the most recent study 3 provides the best guidance on this.