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Table 2 Prescription of Selected Anti-infective Agents for Critically Ill Patients Receiving PIRRT

From: How I prescribe prolonged intermittent renal replacement therapy

Anti-infective Agent [Relevant REFs]

Suggested Dosing Regimen*

Comments

Vancomycin [22, 23]

Loading dose of 2400 mg then 1600 mg post-treatment

Clearance with PIRRT is ~ 3X higher than is described for CRRT

Ongoing dosing guided by post-PIRRT trough levels

Piperacillin [24, 25]

3 g every 8 h for susceptible organisms with MIC ≤ 16 mg/L OR

9 g dose as a continuous infusion every 24 h for susceptible organisms with MIC ≤ 32 mg/L

PIRRT reduces penicillin and carbapenem concentrations by approximately 50%. If pre-treatment concentration is ≥ 2X breakpoint of target attainment before treatment, subtherapeutic levels will generally be prevented

Meropenem [23, 25,26,27]

Maintenance dose of 1 g every 8 h or every 12 h

Wide variation across institutions; most frequently recommended regimen: 1 g every 12 h [26]

Fluconazole [28]

Loading dose of 800 mg followed by 400 mg twice daily (q12h or pre- and post- PIRRT)

Recommendation based on Monte Carlo simulations using a pharmacokinetic model of PIRRT. Directly measured pharmacokinetic data for fluconazole (and most anti-infective agents) are limited in this setting

  1. REFs, references; MIC, minimum inhibitory concentration; PIRRT, prolonged intermittent renal replacement therapy; CRRT, continuous renal replacement therapy
  2. *Suggested dosing is based on an assumption that PIRRT is provided as sustained low-efficiency dialysis using a dialyzer with a surface area of 0.7 m2, Blood Flow Rate (Qb) of 200 ml/min, Dialyzate Flow Rate (Qd) of 300 ml/min and prescribed as 8-h sessions once daily. Dosing regimens should be adjusted according to the relative efficiency/clearance mode(s) of PIRRT being provided, residual kidney function and other standard dosing considerations (e.g., patient weight, volume of distribution, etc.). A more detailed summary of anti-infective dosing studies across various forms of PIRRT can be found in other reviews [29, 30]. We suggest that all anti-infective agents for critically ill patients receiving PIRRT are prescribed in conjunction with a critical care pharmacist and guided by directly measured levels, whenever possible
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Critical Care

ISSN: 1364-8535