What Augmentin (amoxicillin‑clavulanate) dose should be given to an adult with end‑stage renal disease and acute bacterial sinusitis, and how should it be adjusted for hemodialysis or peritoneal dialysis?

Augmentin Dosing for ESRD Patient with Sinus Infection

For an adult with end‑stage renal disease on hemodialysis and acute bacterial sinusitis, prescribe amoxicillin‑clavulanate 875 mg/125 mg once daily immediately after each dialysis session (typically three times per week), continuing for 5–10 days or until symptom‑free for 7 consecutive days. 1, 2

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Renal Dose Adjustment Rationale

• Both amoxicillin and clavulanate are removed by hemodialysis, with fractional drug removal during a 4‑hour dialysis session reaching approximately 64 % for amoxicillin and 65 % for clavulanate. 3
• Administering the dose immediately after dialysis maintains therapeutic drug levels throughout the interdialytic interval and prevents premature removal of the antibiotic during the next session. 1, 3
• The FDA label specifies that hemodialysis patients should receive 500 mg/125 mg or 250 mg/125 mg every 24 hours depending on infection severity, with an additional dose both during and at the end of dialysis. 2 However, current guideline evidence supports 875 mg/125 mg post‑dialysis dosing (three times per week) for acute bacterial sinusitis to achieve the 90–92 % predicted clinical efficacy seen in patients with normal renal function. 1
• Do not use standard twice‑daily dosing in ESRD; it leads to drug accumulation, gastrointestinal adverse effects (diarrhea in ~40 % of patients), and potential toxicity. 1

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Confirming the Diagnosis Before Prescribing

• Acute bacterial rhinosinusitis is diagnosed when any one of the following is present:
  • Persistent symptoms ≥ 10 days without improvement (purulent nasal discharge plus obstruction or facial pain/pressure). 1
  • Severe symptoms ≥ 3–4 consecutive days with fever ≥ 39 °C, purulent discharge, and facial pain. 1
  • "Double sickening"—initial improvement from a viral URI followed by worsening within 10 days. 1
• Approximately 98–99.5 % of acute rhinosinusitis cases are viral and resolve spontaneously within 7–10 days; antibiotics should not be prescribed for symptoms < 10 days unless severe features are present. 1

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Treatment Duration and Monitoring

• Continue therapy for 5–10 days or until the patient is symptom‑free for 7 consecutive days (typically a total of 10–14 days). 1
• Reassess at 3–5 days: If there is no clinical improvement (persistent purulent drainage, unchanged facial pain, or worsening), switch to a respiratory fluoroquinolone with appropriate renal dosing (e.g., levofloxacin 250 mg every 48 hours for CrCl < 50 mL/min). 4, 1
• Reassess at 7 days: Persistent or worsening symptoms should prompt confirmation of diagnosis, exclusion of complications (orbital cellulitis, meningitis, intracranial abscess), and consideration of imaging or ENT referral. 1

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Essential Adjunctive Therapies

• Intranasal corticosteroids (e.g., mometasone, fluticasone, budesonide) administered twice daily significantly reduce mucosal inflammation and accelerate symptom resolution; supported by strong evidence from multiple randomized controlled trials. 1
• Saline nasal irrigation performed 2–3 times daily provides symptomatic relief and helps clear purulent secretions. 1
• Analgesics (acetaminophen or ibuprofen) may be used for pain and fever; NSAIDs should be used cautiously in ESRD because of fluid retention and cardiovascular risk. 1

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Alternative Regimens for Penicillin Allergy

Non‑Severe (Non‑Type I) Penicillin Allergy

• Use a second‑ or third‑generation cephalosporin (e.g., cefuroxime, cefpodoxime, cefdinir) because cross‑reactivity with penicillin is negligible. 1
• Renal dosing for cephalosporins: Adjust according to creatinine clearance; for example, cefpodoxime 200 mg every 24 hours for CrCl 10–30 mL/min. 4

Severe (Type I/Anaphylactic) Penicillin Allergy

• Respiratory fluoroquinolones (levofloxacin or moxifloxacin) provide 90–92 % predicted efficacy against multidrug‑resistant Streptococcus pneumoniae and β‑lactamase‑producing organisms. 1
• Levofloxacin renal dosing: For CrCl 10–50 mL/min, give a 500 mg loading dose followed by 250 mg every 48 hours. 4

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Critical Pitfalls to Avoid

• Always administer antibiotics immediately after dialysis; dosing before dialysis results in drug removal and sub‑therapeutic levels. 1, 3
• Do not use the 875 mg/125 mg dose in patients with CrCl < 30 mL/min who are not on dialysis; the FDA label contraindicates this dose in severe renal impairment without dialysis. 2
• Ensure adequate treatment duration (≥ 5 days) to prevent relapse. 1
• Reassess renal function periodically during treatment, especially in patients with fluctuating renal function; adjust dosing as needed. 5

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Referral to Otolaryngology

• Refer urgently if any of the following occur:
  • No improvement after 7 days of appropriate second‑line antibiotic therapy. 1
  • Worsening symptoms at any point (increasing facial pain, fever, purulent drainage). 1
  • Suspected complications such as orbital cellulitis, meningitis, severe headache, visual changes, periorbital swelling, altered mental status, or cranial nerve deficits. 1
  • Recurrent sinusitis (≥ 3 episodes per year) suggesting underlying immunodeficiency or anatomic abnormality. 1

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Special Considerations for ESRD Patients

• Patients with ESRD often have decreased non‑renal clearance (hepatic impairment), which further prolongs drug half‑life; the terminal half‑life of amoxicillin in ESRD is approximately 13.6 hours (vs. 1–2 hours in normal renal function). 3
• Consult with infectious disease specialists or clinical pharmacists for optimal antimicrobial selection in patients with severe infections and significant renal impairment. 5
• Consider respiratory fluoroquinolones (with appropriate renal dose adjustments) as alternative agents when treating respiratory infections in patients with renal impairment. 5