Antibiotic dose adjustment during desensitization for patient on hemodialysis
Question:
5/12/2017
We have a 59 year-old female patient with sarcoidosis s/p lung transplant and ESRD on intermittent hemodialysis admitted to hospital for Pseudomonas infection and ID wants her to have cefepime. She has multiple drug allergies, usually rashes and at one time hypotension. We plan to do rapid drug desensitization protocol against cefepime in her. Is there any recommendations that would be different for a desensitization protocol in an end stage renal disease patient on dialysis?
Answer:
Unfortunately, a quick review of the literature does not seem to address this situation in which a patient with renal failure on intermittent hemodialysis who needs to undergo an antibiotic desensitization. Micromedex recommends under the dosage adjustment during dialysis for cefepime hydrochloride “During a 3-hour hemodialysis session, 68% of a dose of cefepime is removed. The recommended dose of cefepime in patients undergoing hemodialysis is 1 gram on day 1 followed by 500mg every 24 hours for the treatment of all infections except febrile neutropenia” compared to 2 grams IV every 8 hours. Hence, assuming that there is no contraindication for the cefepime desensitization due to the type of reaction to cephalosporin/s previously, the only change to the desensitization to cefepime protocol is to adjust the target dose based on the patient’s end stage renal disease per guidance of the pharmacist and infectious disease consultant. The patient may need to be monitored a little more closely than someone who does not have such significant comorbidities and would advise that the desensitization be done in the ICU.
We hope this helps.
Patricia McNally, MD, FAAAAI