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Intraperitoneal antibiotic dosing recommendations for intermittent administration in peritoneal dialysis patients (adult)

	IP dose instilled in the longest dwell of the day of at least six hours
Aminoglycosides*
Amikacin	2 mg/kg in one exchange per day^¶
Gentamicin	0.6 mg/kg in one exchange per day^¶
Netilmicin^Δ	0.6 mg/kg in one exchange per day^¶
Tobramycin	0.6 mg/kg in one exchange per day^¶
Carbapenems
Imipenem	500 mg in alternate exchanges
Meropenem	1 gram in one exchange per day
Cephalosporins^¶
Cefazolin	15 to 20 mg/kg in one exchange per day
Cefepime	1 gram in one exchange per day
Cefotaxime	500 to 1000 mg in one exchange per day
Ceftazidime	1 to 1.5 grams in one exchange per day
Ceftizoxime	1 gram in one exchange per day
Ceftriaxone	1 gram in one exchange per day
Glycopeptides
Vancomycin	25 mg/kg ideal body weight; re-dose once serum level is ≤15 mcg/mL^◊
Teicoplanin^Δ	15 mg/kg in one exchange every five days
Penicillins
NOTE: For dosing of most penicillins for IP administration, refer to separately available table for continuous administration of IP antibiotics.
Ampicillin-sulbactam	3 grams every 12 hours
Other
Aztreonam	2 grams in one exchange per day
Quinupristin-dalfopristin	25 mg per liter of dialysate in alternate exchanges^§
Ciprofloxacin^¥	ORAL: 250 mg once or twice per day depending on residual kidney function
Linezolid	ORAL: 600 mg twice per day
Moxifloxacin^¥	ORAL: 400 mg once per day
Trimethoprim-sulfamethoxazole (co-trimoxazole)	ORAL: One double-strength tablet (trimethoprim 160 mg and sulfamethoxazole 800 mg) two times per day
Antifungal
Fluconazole	200 mg in one exchange every 24 to 48 hours
Voriconazole	2.5 mg/kg in one exchange per day

This table shows the suggested dose of antibiotics for intermittent IP administration (except where noted as "oral") in peritoneal dialysate for continuous ambulatory peritoneal dialysis-associated peritonitis without signs of systemic infection. Intermittent IP-administered regimens are preferred over continuous administration (ie, antibiotics in all exchanges) for initial therapy and should be used for the duration of treatment of two to three weeks or more in patients who are responding clinically. In patients who are not improving on intermittent therapy with agent(s) that should be effective based on microbiologic data, it is reasonable to increase frequency of intermittent dosing or switch to a continuous IP dosing regimen as listed on a separately available table. Refer to UpToDate topic on microbiology and therapy of peritonitis in continuous peritoneal dialysis for considerations in selection of antimicrobials and dosing strategy.

IP: intraperitoneal.
* To determine weight-based dose of aminoglycosides in patients who are overweight, use "ideal body weight"; if obese, use "dosing weight." A calculator for determining "ideal body weight" and "dosing weight" based on inputs of actual body weight and height is available in UpToDate.
¶ Loss of residual kidney function is not generally associated with a brief course of an IP-administered aminoglycoside. However, systemic toxicity can occur with prolonged or repeated course(s), but serum concentration monitoring is of limited utility for preventing toxicity and assuring efficacy. Once culture and sensitivity results are available, early switch to another appropriate class of antibiotic (eg, third-generation cephalosporin) is suggested to decrease the risk of toxicity. Refer to UpToDate topics on microbiology and therapy of peritonitis in peritoneal dialysis.
Δ Not available in the United States.
◊ Obtain daily vancomycin serum levels. Re-dose once the serum level reaches ≤15 mcg/mL, which usually occurs within four to seven days following an IP-administered dose. If serum levels are available only once every two to three days, it is reasonable to re-dose once the level reaches ≤20 mcg/mL. Supplemental doses may be needed in patients receiving machine-assisted automated peritoneal dialysis.
§ Given in conjunction with 500 mg intravenous twice daily.
¥ Empiric use of oral fluoroquinolones is not recommended, unless local resistance patterns show >90% susceptibility of common gram-negative pathogens. We generally avoid IP administration of fluoroquinolones. Refer to UpToDate topics on microbiology and therapy of peritonitis in peritoneal dialysis.

Adapted from:

Li PK, Szeto CC, Piraino B, et al. Peritoneal Dialysis-Related Infections Recommendations: 2010 Update. Perit Dial Int 2010; 30:393.
Li PK, Szeto CC, Piraino B, et al. ISPD peritonitis recommendations: 2016 update on prevention and treatment. Perit Dial Int 2016; 36:481.

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