Augmentin Dosing in ESRD on Hemodialysis
For patients with end-stage renal disease on hemodialysis, administer Augmentin (amoxicillin/clavulanate) at a reduced dose of 250-500 mg every 24 hours, with supplemental dosing immediately after each dialysis session.
Pharmacokinetic Rationale
The dosing adjustment is necessary because both amoxicillin and clavulanic acid are significantly removed during hemodialysis:
Amoxicillin has a dialysis clearance of 77.1 mL/min, with 64% of the drug removed during a 4-hour hemodialysis session, and a prolonged half-life of 13.6 hours on non-dialysis days (compared to 1-1.5 hours in normal renal function) 1
Clavulanic acid has a dialysis clearance of 92.8 mL/min, with 65% removed during dialysis, and a half-life of 3.05 hours on non-dialysis days 1
Both components demonstrate reduced non-renal clearance in ESRD patients, suggesting some degree of hepatic impairment that further necessitates dose reduction 1
Specific Dosing Recommendations
Standard Dosing Schedule
Dialysis days: Administer the regular dose plus a supplemental dose (250-500 mg) immediately after the dialysis session 3, 1
Timing Considerations
Post-dialysis administration prevents premature drug removal by the dialysis machine and facilitates directly observed therapy 3
Administering before dialysis wastes drug and reduces therapeutic efficacy 4
Dosage Adjustment Principles
The general rule for antibiotics in renal impairment is to reduce the dose by approximately 30% for each level of renal impairment 2. For ESRD specifically:
The dose reduction accounts for the dramatically prolonged elimination half-life (nearly 10-fold increase for amoxicillin) 1
Hemodialysis efficiently clears both components due to their low molecular weight, reduced protein binding, and small volume of distribution 2
Clinical Monitoring
Renal function monitoring is essential, though in ESRD patients this primarily involves tracking dialysis adequacy 5
Watch for signs of drug accumulation, particularly on non-dialysis days when clearance is minimal 1
The drug is generally well-tolerated even in patients with chronic renal insufficiency, though careful monitoring remains important 6
Common Pitfalls to Avoid
Do not use standard dosing (875 mg twice daily or 500 mg three times daily) as this will lead to excessive drug accumulation and potential toxicity 1, 5
Do not administer before dialysis as this results in immediate drug removal and therapeutic failure 3, 4
Do not assume peritoneal dialysis requires the same approach—peritoneal dialysis removes substantially less drug than hemodialysis, and dosing for pre-dialysis ESRD patients may be more appropriate 7