Important antimicrobial dosing considerations for transitions of care: Focus on thrice-weekly dosing in hemodialysis.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The objective of this clinical review is to evaluate current literature and propose optimal dosing strategies for thrice-weekly postdialytic administration of select antimicrobial agents in individuals receiving chronic intermittent hemodialysis (iHD). The optimization of outpatient parenteral antimicrobial therapy (OPAT) for patients receiving chronic iHD presents a prime opportunity for stewardship intervention. By utilizing the existing vascular hemodialysis access instead of inserting an additional peripheral catheter for antimicrobial administration, the risk for potential clinical complications (e.g. vein thrombosis, catheter-associated infections) can be minimized. In addition to vancomycin and aminoglycosides, literature evidence also supports the use of thrice-weekly cefazolin, ceftazidime, cefepime, ertapenem, and daptomycin given after dialysis sessions. Optimal dosing strategies of antimicrobials during transitions-of-care are imperative, especially in those receiving OPAT with iHD. While different dosing strategies may exist for each antimicrobial agent, other factors such as the modality of hemodialysis and site/severity of infection should be considered when choosing the optimal dosing regimen.

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