Progress Note for Ceftriaxone Initiation in 93-Pound Patient with Mild Renal Impairment
Antibiotic Selection and Dosing
No dose adjustment of ceftriaxone is required for this patient with mild renal impairment, and standard dosing should be administered. 1, 2
Key Documentation Elements:
Baseline Assessment:
- Weight: Document actual body weight (93 pounds = 42.2 kg) for dosing calculations 1
- Renal function: Record baseline creatinine clearance (CrCl) and serum creatinine to establish mild impairment category 3
- Hepatic function: Document liver function tests, as dose adjustment is only needed if BOTH severe renal AND hepatic dysfunction are present 1, 2
Dosing Rationale:
- Ceftriaxone undergoes dual elimination (50-60% biliary, 30-50% renal), which minimizes need for dose adjustment in mild-moderate renal impairment 2
- Standard adult dosing (1-2g daily) maintains therapeutic levels even with CrCl >30 mL/min 4
- Do NOT reduce dose unless CrCl <15 mL/min AND significant hepatic dysfunction are both present 1, 2
Monitoring Parameters to Document:
- Hydration status: Ensure adequate hydration documented to prevent ceftriaxone-calcium precipitates in urinary tract 1
- Renal function: Plan serial creatinine monitoring every 2-3 days during therapy 1
- Neurologic assessment: Document baseline mental status, as neurologic toxicity (encephalopathy, seizures, myoclonus) can occur with overdosing in renal impairment 1, 5
- Urinary output: Monitor for oliguria or signs of urolithiasis (flank pain, hematuria) 1
Critical Safety Considerations:
- Maximum dose: Do not exceed 2g daily if both hepatic dysfunction and significant renal disease present 1
- No supplemental dosing needed post-dialysis if patient requires dialysis 1
- Prothrombin time: Monitor if patient has impaired vitamin K synthesis, chronic liver disease, or malnutrition 1
- Gallbladder/urinary precipitates: Document plan to discontinue if patient develops abdominal pain, oliguria, or sonographic evidence of precipitates 1
Pharmacokinetic Justification:
- Half-life increases modestly from 8 hours (normal) to approximately 12 hours with mild renal impairment 2, 4
- Protein binding is saturable; single daily dosing is pharmacologically superior to divided doses 2
- Ceftriaxone clearance in mild renal impairment remains adequate without dose reduction 6, 4
Plan Statement: "Initiating ceftriaxone [specify dose, typically 1-2g IV daily] without dose adjustment given mild renal impairment with preserved nonrenal clearance. Will ensure adequate hydration, monitor renal function serially, assess for neurologic changes, and discontinue if signs of urolithiasis or gallbladder precipitates develop." 1, 2