Antimicrobial treatment of tunneled hemodialysis catheter-related bloodstream infection^[1-4]

Treatment	Dose and schedule for adult patients*	Administration
Vancomycin^¶	High flux: 20 mg/kg IV loading dose, then 1 g IV in last hour of each HD session Low flux: 500 mg in last hour of each HD session	Use actual (ie, estimated dry) body weight to determine loading dose
Ceftazidime	1 g IV post-HD	Some centers administer a 2 g dose when the next HD session is 72 hours later
Cefepime	1.5 to 2 g IV post-HD	Alternative if ceftazidime is unavailable Risk of neurotoxicity in drug accumulation 2 g dose for pathogen MIC ≥4 mcg/mL or when next HD session is 72 hours later^[1,2]
Cefazolin	2 g IV post-HD	For pathogen-directed therapy of MSSA Some centers administer a 3 g dose when the next HD session is 72 hours later
Gentamicin or tobramycin	1 to 2 mg/kg IV in last hour of each HD session (not to exceed 100 mg per dose)^Δ	Alternative in settings with elevated rates of resistance to ceftazidime or severe hypersensitivity to third generation cephalosporins^◊ Ototoxicity in up to 20% when used >48 to 72 hours, particularly in combination with vancomycin Weight scalar to determine dose: Underweight: Use actual (dry) body weight Normal weight or overweight: Use IBW Obese (ie, >1.25 IBW): Use ABW A calculator for estimating IBW and ABW is available separately in UpToDate
Daptomycin	High flux: 9 mg/kg IV in last hour of each HD session Low flux: 7 mg/kg in last hour of each HD session	For pathogen-directed therapy or history of vancomycin-resistant Enterococcus and an alternative in patients with documented vancomycin hypersensitivity (excluding vancomycin flushing syndrome)

Above dosing recommendations are based upon thrice weekly HD sessions. For empiric therapy, an appropriate combination of the above agents is necessary. For approach to antimicrobial selection and tailoring, as well as issues surrounding removal of the dialysis catheter and use of adjunctive antibiotic locks, refer to the UpToDate review of tunneled hemodialysis catheter-related bacteremia.

IV: intravenous; HD: hemodialysis; MIC: minimum inhibitory concentration; MSSA: methicillin-sensitive Staphylococcus aureus; IBW: ideal body weight; ABW: adjusted body weight.
* General recommendation on dose schedule shown. Schedule may require adjustment based upon clinical setting; ie, doses may be administered either in the last hour of dialysis session or after dialysis depending upon practical considerations.
¶ This dosing may be used when serum vancomycin concentrations are unavailable. Dose recommendations based upon serum concentration monitoring are provided in a separate UpToDate topic review and table of vancomycin parenteral dosing and monitoring.
Δ In patients who require an aminoglycoside for >48 to 72 hours, UpToDate contributors obtain predialysis serum concentrations to guide adjustment of the postdialysis dose until a stable dose regimen is established. Recommendations for dose adjustment based upon serum concentrations are provided in a separate UpToDate topic review of dosing and administration of parenteral aminoglycosides.
◊ Patients with a history of mild to moderate allergy (eg, mild rash) or intolerance to penicillins or first generation cephalosporins can usually tolerate ceftazidime. Refer to separate UpToDate topic review of cephalosporin hypersensitivity and cross-reactivity.

References:

Descombes E, Martins F, Hemett OM, et al. Three-times-weekly, post-dialysis cefepime therapy in patients on maintenance hemodialysis: a retrospective study. BMC Pharmacol Toxicol 2016; 17:4.
Allon M. Treatment guidelines for dialysis catheter-related bacteremia: an update. Am J Kidney Dis 2009; 54:13.
Schmaldienst S, Traunmüller F, Burgmann H, et al. Multiple-dose pharmacokinetics of cefepime in long-term hemodialysis with high-flux membranes. Eur J Clin Pharmacol 2000; 56:61.

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Antimicrobial treatment of tunneled hemodialysis catheter-related bloodstream infection[1-4]

Antimicrobial treatment of tunneled hemodialysis catheter-related bloodstream infection^[1-4]