From the Guidelines
Ceftriaxone can be safely used in hemodialysis patients because it is unaffected by dialysis. According to the clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection, updated by the Infectious Diseases Society of America in 2009 1, antibiotic selection should be made on the basis of pharmacokinetic characteristics that permit dosing after each dialysis session, or antibiotics that are unaffected by dialysis, such as ceftriaxone, should be used.
Some key points to consider when using ceftriaxone in hemodialysis patients include:
- Ceftriaxone is primarily eliminated through biliary excretion rather than renal clearance, making it a convenient choice for dialysis patients.
- No supplemental dosing is required after dialysis sessions since only about 33% of the drug is removed during hemodialysis.
- In patients with both severe renal impairment and hepatic dysfunction, more cautious dosing may be warranted, with a maximum daily dose of 2 grams recommended.
- Monitoring for side effects is important, particularly for potential biliary complications since the drug concentrates in bile.
It is essential to consult with a nephrologist or pharmacist for patient-specific dosing recommendations, as individual factors may influence the optimal regimen 1. The use of ceftriaxone in hemodialysis patients can help manage catheter-related bloodstream infections (CRBSI) caused by various pathogens, including coagulase-negative staphylococci and S. aureus, which are common in this population 1.
From the FDA Drug Label
Patients with Renal or Hepatic Impairment Ceftriaxone is excreted via both biliary and renal excretion (see CLINICAL PHARMACOLOGY). Therefore, patients with renal failure normally require no adjustment in dosage when usual doses of ceftriaxone are administered Ceftriaxone is not removed by peritoneal- or hemodialysis In patients undergoing dialysis no additional supplementary dosing is required following the dialysis.
Ceftriaxone Safety in Hemodialysis Patients:
- Ceftriaxone is not removed by hemodialysis.
- No dosage adjustment is required for patients with renal failure.
- No additional supplementary dosing is needed after dialysis. However, caution should be exercised in patients with both hepatic dysfunction and significant renal disease, and the ceftriaxone dosage should not exceed 2 grams daily 2. In case of overdosage, drug concentration would not be reduced by hemodialysis or peritoneal dialysis 2.
From the Research
Safety of Ceftriaxone in Hemodialysis Patients
- Ceftriaxone is widely used clinically, but it can potentially cause ceftriaxone encephalopathy in individuals who are on dialysis 3.
- The pharmacokinetics of ceftriaxone in hemodialysis patients are considerably longer than in normal subjects, with an elimination half-life of 16 hours 4.
- High blood concentrations of ceftriaxone can lead to complications such as chorea-like symptoms and encephalopathy in patients undergoing hemodialysis 5, 6.
Pharmacokinetic Considerations
- The dose-interval between successive administrations of ceftriaxone 2g IV should be 48 hours in patients with chronic renal failure, and supplemental doses do not appear necessary after hemodialysis 4.
- A population pharmacokinetic study found that the terminal elimination half-life of ceftriaxone from plasma was 27.5 hours in haemodialysed patients 7.
- The study also found that the simulated free drug concentrations of ceftriaxone were below the minimum inhibitory concentration (MIC) in some patients, particularly if the second administration occurred 72 hours after the first dosing 7.
Clinical Implications
- Clinicians should be aware of the rare adverse reaction of ceftriaxone-induced encephalopathy in patients with end-stage renal disease (ESRD) on hemodialysis 6.
- Caution is necessary when administering ceftriaxone to patients with cholestasis undergoing hemodialysis, as blood ceftriaxone levels may rise unexpectedly and result in complications 5.
- A dose of ceftriaxone 2g intravenously is recommended immediately following dialysis, particularly in patients with severe infections or when the dosing interval will be higher than 48 hours 7.