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  • Letter
  • Open Access

Colistin dosing for treatment of multidrug-resistant Pseudomonasin critically ill patients - please, be adequate!

  • 1Email author,
  • 1,
  • 1,
  • 1,
  • 1 and
  • 1
Critical Care201418:412

  • Published:


  • Public Health
  • Citrate
  • Replacement Therapy
  • Emergency Medicine
  • Renal Replacement Therapy

We read with great interest the article by Rocco and colleagues [1] that retrospectively evaluated risk factors for acute kidney injury in critically ill patients receiving colistin and the subsequent comments by Rachid and colleagues [2]. Although of considerable interest, we would like to challenge the paper by Rocco and colleagues regarding the administered colistin loading and maintenance doses, in particular during continuous renal replacement therapy. We agree with Rachid and colleagues [2] that recent pharmacokinetic data suggest the administration of higher and thus potentially more nephrotoxic, colistin doses for treatment of multidrug-resistant Pseudomonas species. In fact, the recommended loading and maintenance doses to adequately treat severe multidrug-resistant Pseudomonas infections should be, respectively, 9 million IU and 4.5 million IU twice a day [3], which is substantially higher than the doses used by Rocco and colleagues. From our experience, patients initiated on continuous veno-venous hemofiltration (CVVH) can receive even higher doses of colistin (a loading dose of 9 million IU, followed by a maintenance dose of up to 4.5 million IU three times a day) [4]. Treatment can be continued for a prolonged time period without increasing toxicity. As in patients without acute kidney injury, up to 80% of the filtered colistin dose undergoes tubular reabsorption [35]. Moreover, CVVH counteracts colistin accumulation because the drug is continuously filtered and significantly adsorbed in the bulk of the dialysis membrane [5]. Implementing such ‘CVVH rescue’ therapy does require the strict use of highly adsorptive CVVH membranes that enhance colistin adsorption in association with citrate anticoagulation to increase membrane performance [4, 5].



continuous veno-venous hemofiltration.


Authors’ Affiliations

Intensive Care Department, Universitair Ziekenhuis Brussel, VUB University, 101 Laarbeeklaan, 1090 Brussels, Belgium


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  2. Rashid S, Saro-Nunez L, Kumar A, Patel A, Parikh A: Acute kidney injury: taking aim at colistin. Crit Care. 2014, 18: 401-10.1186/cc13703.PubMed CentralView ArticlePubMedGoogle Scholar
  3. Mohamed AF, Karaiskos I, Plachouras D, Karvanen M, Pontikis K, Jansson B, Papadomichelakis E, Antoniadou A, Giamarellou H, Armaganidis A, Cars O, Friberg LE: Application of a loading dose of colistin methanesulfonate in critically ill patients: population pharmacokinetics, protein binding, and prediction of bacterial kill. Antimicrob Agents Chemother. 2012, 56: 4241-4249. 10.1128/AAC.06426-11.PubMed CentralView ArticlePubMedGoogle Scholar
  4. Honore PM, Jacobs R, Joannes-Boyau O, Boer W, De Waele E, Van Gorp V, Spapen HD: Continuous renal replacement therapy allows higher colistin dosing without increasing toxicity. J Transl Intern Med. 2013, 1: 6-8. 10.4103/2224-4018.124274.View ArticleGoogle Scholar
  5. Honore PM, Jacobs R, Lochy S, De Waele E, Van Gorp V, De Regt J, Martens G, Joannes-Boyau O, Boer W, Spapen HD: Acute respiratory muscle weakness and apnea in a critically ill patient induced by colistin neurotoxicity: key potential role of hemoadsorption elimination during continuous venovenous hemofiltration. Int J Nephrol Renovasc Dis. 2013, 6: 107-111.PubMed CentralView ArticlePubMedGoogle Scholar


© BioMed Central Ltd. 2014