What is the appropriate antibiotic regimen for an adult with end‑stage renal disease on dialysis who develops a urinary‑tract infection?

UTI Treatment for ESRD Patients on Dialysis

First-Line Antibiotic Recommendation

For adult ESRD patients on dialysis with UTI, use fluoroquinolones as first-line therapy: ciprofloxacin 250-500 mg orally every 12 hours or levofloxacin 500 mg loading dose followed by 250 mg every 48 hours, administered after each dialysis session. 1, 2

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Fluoroquinolone Dosing Algorithm

Ciprofloxacin (Preferred for Simplicity)

• Dose: 250-500 mg orally every 12 hours 1, 2
• Duration: 7-14 days (use 14 days if prostatitis cannot be excluded in males) 2
• Timing: Administer after hemodialysis sessions to prevent drug removal during dialysis 1
• Rationale: Does not require dose reduction for creatinine clearance >10 mL/min, making it straightforward in ESRD 2

Levofloxacin (Alternative Once-Daily Option)

• Loading dose: 500 mg once 1, 2
• Maintenance: 250 mg every 48 hours 1, 2
• Timing: Give after dialysis sessions 1

Critical principle: Extend dosing intervals rather than reduce doses for fluoroquinolones to maintain peak, concentration-dependent bactericidal activity 1

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Alternative Agent: Trimethoprim-Sulfamethoxazole

• Dose: One single-strength tablet (80/400 mg) daily—half the standard adult dose 1, 2
• Indication: Use only when local fluoroquinolone resistance is <20% or fluoroquinolones are contraindicated 1
• Duration: 7-14 days 2
• Caution: For CrCl <30 mL/min or hemodialysis, consider alternative agents due to accumulation risk 1

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Antibiotics to Strictly Avoid in ESRD

Absolutely Contraindicated

• Nitrofurantoin: Insufficient efficacy data in renal impairment and high risk of peripheral neuritis in CKD 1, 2
• Oral fosfomycin: Insufficient efficacy data for complicated UTIs 2
• Pivmecillinam: Insufficient efficacy data for complicated UTIs 2

Use Only with Extreme Caution

• Aminoglycosides (gentamicin, amikacin): Generally contraindicated due to nephrotoxicity and ototoxicity; may be used only as single-dose therapy for uncomplicated cystitis with therapeutic drug monitoring 1, 2
• Tetracyclines: Require dose reduction when GFR <45 mL/min as they exacerbate uremic toxicity 1

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Pre-Treatment and Monitoring Steps

Before Starting Antibiotics

• Obtain urine culture to guide targeted therapy, as resistance rates are higher in dialysis patients 2
• Replace indwelling catheters that have been in place ≥2 weeks at treatment onset to improve efficacy 2

During Treatment

• Reassess at 72 hours if no clinical improvement occurs 2
• Monitor for fluoroquinolone-specific adverse effects: Tendon disorders (especially with concurrent corticosteroids), particularly in elderly patients 1

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Special Considerations for Complicated Infections

For Multidrug-Resistant Organisms

• ESBL-producing organisms: Use carbapenems or ceftazidime-avibactam 2.5 g IV every 8 hours with renal dose adjustment 1
• Carbapenem-resistant Enterobacterales (CRE): Use ceftazidime-avibactam 2.5 g IV every 8 hours with renal dose adjustment 1

For Suspected Cyst Infection (Polycystic Kidney Disease)

• Use lipid-soluble antibiotics: Trimethoprim-sulfamethoxazole or fluoroquinolones penetrate cysts better 1
• Duration: 4-6 weeks for confirmed kidney cyst infection 1

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Common Pitfalls to Avoid

• Do not reduce fluoroquinolone doses—extend intervals instead to preserve concentration-dependent killing 1
• Do not give antibiotics before dialysis—administer after sessions to prevent drug removal and facilitate directly observed therapy 1
• Do not use smaller doses of concentration-dependent antibiotics (fluoroquinolones, aminoglycosides), as this significantly reduces efficacy 1
• Do not assume hepatically-metabolized drugs are safe—monitor for drug accumulation even with these agents, as renal failure increases toxicity risk through altered metabolism 1