In an adult patient with end‑stage renal disease on dialysis who has an upper‑respiratory infection, which antibiotics are appropriate and how should they be dosed?

Upper Respiratory Infection in ESRD Patients: Antibiotic Selection and Dosing

Primary Recommendation

Antibiotics are not recommended for uncomplicated upper respiratory infections in ESRD patients on dialysis, as these infections are predominantly viral and antibiotic treatment does not enhance illness resolution or prevent complications. 1

When Antibiotics Are NOT Indicated

• Nonspecific upper respiratory tract infections (URIs) in immunocompetent adults without comorbid conditions should not be treated with antibiotics, regardless of ESRD status. 1

• Purulent nasal discharge or sputum does not predict bacterial infection and does not justify antibiotic use. 1

• Most uncomplicated URIs resolve spontaneously within 1-2 weeks, with most patients improving within the first week. 1

• Antibiotic therapy does not decrease symptom duration, lost work time, or prevent rare complications such as bacterial sinusitis or pneumonia. 1

When Antibiotics ARE Indicated

If the clinical picture progresses to bacterial complications (bacterial sinusitis, bacterial pneumonia, or exacerbation of chronic bronchitis with increased sputum purulence, volume, and dyspnea), then antibiotic therapy becomes appropriate. 1

For Bacterial Sinusitis or Lower Respiratory Tract Infection in ESRD:

First-line options with ESRD-appropriate dosing:

• Amoxicillin 500-1000 mg every 8 hours (no dose adjustment required for ESRD; administer after dialysis on dialysis days) 1

• Amoxicillin-clavulanate 1 g every 8 hours orally (administer after dialysis on dialysis days) 1

• Cefuroxime axetil 750 mg every 12 hours orally (for creatinine clearance <20 mL/min, reduce to 750 mg every 24 hours; give after dialysis on dialysis days) 1, 2

• Azithromycin 500 mg on day 1, then 250 mg daily for 4 days (no dose adjustment required for ESRD) 1

• Clarithromycin 250-500 mg every 12 hours for at least 5 days (no dose adjustment required for ESRD) 1

For Fluoroquinolone Use in ESRD (if indicated):

• Levofloxacin 750-1000 mg three times per week (not daily), administered after each dialysis session 1, 3

• Moxifloxacin 400 mg once daily (no dose adjustment required; administer after dialysis on dialysis days) 1, 4

• Ciprofloxacin 500 mg every 12 hours (for creatinine clearance <30 mL/min, extend to every 18-24 hours; administer after dialysis) 5

Critical Dosing Principles for ESRD Patients

The fundamental principle is to extend dosing intervals rather than reduce individual doses, particularly for concentration-dependent antibiotics (fluoroquinolones, aminoglycosides). 3 Reducing individual doses leads to subtherapeutic peak concentrations and treatment failure. 3

All antibiotics should be administered immediately after hemodialysis sessions on dialysis days to prevent premature drug removal during dialysis and to facilitate directly observed therapy. 1, 3

Antibiotics to AVOID in ESRD

• Never use aminoglycosides as first-line therapy in hemodialysis patients due to substantial risk of irreversible ototoxicity. 4, 3

• Avoid nephrotoxic drug combinations (vancomycin + aminoglycosides, colistin) that could cause further kidney damage. 4

• Tetracyclines require dose reduction when GFR <45 mL/min because they can exacerbate uremic toxicity. 5

Common Clinical Pitfalls

ESRD patients receive antibiotics at nearly twice the rate of non-ESRD patients (520 vs 296 per 1000 patients), with respiratory infections being a top indication. 6 This suggests significant overprescribing for viral URIs in this population.

In one study, 36% of trimethoprim-sulfamethoxazole prescriptions exceeded recommended ESRD dosing guidelines, highlighting the need for careful dose adjustment. 6

Infections are the second leading cause of mortality in ESRD patients, but this primarily reflects sepsis from vascular access sites rather than respiratory infections. 7 The decision to use antibiotics should be based on clear evidence of bacterial infection, not viral URI symptoms.

Treatment Duration

Treat bacterial complications for at least 7 days (except azithromycin and clarithromycin, which have specified shorter courses). 1

Reassess clinical response at days 5-7 for improvement of symptoms. 1