(1346) Scoping Review of Non-Beta-Lactam Antibiotic Dosing in Sustained Low-Efficiency Dialysis

Introduction: Pharmacokinetics are altered in the critically ill and are further distorted by renal dysfunction or renal replacement therapy (RRT). Sustained low efficiency dialysis (SLED) is a RRT modality that is increasing in use in the critically ill to balance the pros and cons of intermittent hemodialysis and continuous RRT. Many antibiotics are dependent on renal elimination, but limited evidence is available assessing dosing in SLED. The goal of this review is to summarize the literature of non-beta-lactam antibiotic dosing in patients receiving SLED.

Methods: PubMed, Embase, and Scopus were used to identify studies that assessed patients on SLED and their medication dosing or pharmacokinetics. SLED was defined as dialysis sessions ranging from 6-18 hours. Non-original/non-English research, pediatric/animal studies, and studies assessing titratable medications were excluded. A two-phase, two-reviewer process was utilized to screen included studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for reporting.

Results: A total of 29 studies were included for analysis. Of the 16 non-beta-lactam antibiotic studies, 9 assessed vancomycin, 2 assessed fosfomycin, 2 assessed linezolid, and 1 study each assessed fluroquinolones, daptomycin, and colistin. All studies included critically ill adults on SLED for CKD or AKI with median SLED durations ranging from 6-8 hours. Dialysate and blood flow rates differed significantly, as well as number of patients in each study. Vancomycin dosing recommendations varied, with loading doses of 15-25mg/kg and post-SLED doses of 500-1000mg being common. Fosfomycin dosing was similar across studies, with a recommended 8g loading dose followed by 5g dose post-SLED. Conclusive dosing recommendations for other antibiotics included in this review could not be made. Each study recommended the use of therapeutic drug monitoring for all antibiotics in patients on SLED.

Conclusions: Antibiotic dosing in SLED is challenging and there is minimal evidence available to guide it. Of the available literature, there are variations in population, SLED characteristics, and dose recommendations making consensus difficult. Further studies are needed to determine non-beta-lactam antibiotic dosing recommendations in SLED.