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Appendix: Survey
AKI Dialysis Antibiotics
Thank you for participating in this research project. We will use the information
collected from this survey to learn about how pharmacists make antibiotic dosing
recommendations in patients receiving novel renal replacement therapies (RRT) in the
intensive care unit. Study results may be presented in scientific conferences and/or
peer-reviewed journals. The information you provided will be recorded anonymously.
Directions
You will find the case of a highly catabolic critically ill patient with acute kidney injury
(AKI) and sepsis who will receive sustained low-efficiency dialysis (SLED) administered
daily to maintain metabolic and fluid control. There are few published recommendations
for SLED. Any available antibiotic dosing information from the package insert for IHD
3x/week will be provided. Published antibiotic dosing information for SLED will be
provided when available. There will be 6 antibiotics to consider for this patient. Please
provide your best recommendation even though you may not have experience in SLED.
This survey has 7 pages and will take approximately 30 minutes to complete.
If you have any questions regarding the survey, please contact the principal investigator
of this project Bruce A. Mueller at muellerb@med.umich.edu
Thank you again for your time.
Please press the button to proceed to the survey.
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CLINICAL CASE
Given the following hypothetical case, please provide the antibiotic dosing regimen you
would recommend for SLED below. A 58-year-old man (84 kg) is admitted to the ICU
from a nursing home for the treatment of septic shock and anuric acute kidney injury.
On admission, patient is febrile, BUN 90 mg/dL, blood pressure 90/60 mmHg, WBC
14x103/mm3. The patient is 10% fluid overloaded. Extended spectrum antibiotics need
to be initiated and the following are being considered for use: cefepime, ceftaroline,
daptomycin, levofloxacin, meropenem, piperacillin/tazobactam. Physicians intend to
achieve azotemic control and euvolemia with SLED.
SLED protocol: Daily for 8 hours using a F8 (low-flux) dialyzer
QB = 200 ml/min, QD = 200 ml/min
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Q1 Drug 1/6: Cefepime
FDA recommended dosing for IHD 3x/week: "1000mg on day 1, then 500 - 1000mg
every 24 hours thereafter. On dialysis days, cefepime should be administered following
dialysis at the same time each day if possible."
There is no literature-based cefepime dosing recommendation in SLED. Please provide
your recommended cefepime dosing for daily SLED for our hypothetical patient.
Dose and Interval (e.g. X mg every X hour) _________________________
Administration time relative to dialysis (e.g. immediately after dialysis)
______________________
Any dosing adjustments while SLED is running? _________________________
Additional comments regarding your regimen _________________________
Q2 Drug 2/6: Ceftaroline
FDA recommended dosing for IHD 3x/week: "200 mg IV (over 1 hour) every 12 hours
administer after dialysis on dialysis days"
There is no literature-based ceftaroline dosing recommendation in SLED. Please
provide your recommended ceftaroline dosing for daily SLED for our hypothetical
patient.
Dose and Interval (e.g. X mg every X hour) _________________________
Administration time relative to dialysis (e.g. immediately after dialysis)
______________________
Any dosing adjustments while SLED is running? _________________________
Additional comments regarding your regimen _________________________
Q3 Drug 3/6: Daptomycin
FDA recommended dosing for IHD 3x/week: "4 mg/kg (cSSSI) or 6 mg/kg (S. aureus
bloodstream infections) once every 48 hours following dialysis on dialysis days."
Published SLED recommendation: 6mg/kg over 30min daily. The SLED parameters
used in studies are: F60S (high-flux) dialyzer, QD 100mL/min, QB 200mL/min, a dialysis
duration of 12 hours (Reference 1, Reference 2). Please provide your recommended
daptomycin dosing for daily SLED for our hypothetical patient.
Dose and Interval (e.g. X mg every X hour) _________________________
Administration time relative to dialysis (e.g. immediately after dialysis)
______________________
Any dosing adjustments while SLED is running? _________________________
Additional comments regarding your regimen _________________________
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Reference 1. Burkhardt O, Joukhadar C, Traunmuller F, Hadem J, Welte T, Kielstein JT.
Elimination of daptomycin in a patient with acute renal failure undergoing extended daily
dialysis. J Antimicrob Chemother. 2008;61(1):224-225.
Reference 2. Kielstein JT, Eugbers C, Bode-Boeger SM, et al. Dosing of daptomycin in
intensive care unit patients with acute kidney injury undergoing extended dialysis--a
pharmacokinetic study. Nephrol Dial Transplant. 2010;25(5):1537-1541
Q4 Drug 4/6: Levofloxacin
FDA recommended dosing for IHD 3x/week: "500 mg initial dose, then 250 mg every
48 hours OR 750 mg initial dose, then 500 mg every 48 hours"
Published SLED recommendation: No specific dosing recommendation provided in the
published study. Levofloxacin should be administered after SLED (Reference 3)
Please provide your recommended levofloxacin dosing for daily SLED for our
hypothetical patient.
Dose and Interval (e.g. X mg every X hour) _________________________
Administration time relative to dialysis (e.g. immediately after dialysis)
______________________
Any dosing adjustments while SLED is running? _________________________
Additional comments regarding your regimen _________________________
Reference 3. Czock D, Husig-Linde C, Langhoff A, et al. Pharmacokinetics of
moxifloxacin and levofloxacin in intensive care unit patients who have acute renal failure
and undergo extended daily dialysis. Clin J Am Soc Nephrol. 2006;1(6):1263-1268.
Q5 Drug 5/6: Meropenem
FDA package insert data for dosing for IHD 3x/week: "There is inadequate information
regarding the use of meropenem in patients on hemodialysis. In patients with creatinine
clearance <10mL/min, half of the recommended dose should be given every 24
hours."
Published SLED recommendations: 0.5-1g q8hr, administer 6hrs before dialysis. SLED
parameters use in the study are: F60S (high-flux) dialyzer, mean QD and QB is
160mL/min, and a dialysis duration of 8 hours (Reference 4). 1g q12hr before dialysis.
SLED parameters used in the study are: mean QD is 170ml/min and QB is 160ml/min
for 8hr (Reference 5). Please provide your recommended meropenem dosing for
daily SLED for our hypothetical patient:
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Dose and Interval (e.g. X mg every X hour) _________________________
Administration time relative to dialysis (e.g. immediately after dialysis)
______________________
Any dosing adjustments while SLED is running? _________________________
Additional comments regarding your regimen _________________________
Reference 4. Kielstein JT, Czock D, Schopke T, et al. Pharmacokinetics and total
elimination of meropenem and vancomycin in intensive care unit patients undergoing
extended daily dialysis. Crit Care Med. 2006;34(1):51-56.
Reference 5. Deshpande P, Chen J, Gofran A, Murea M, Golestaneh L. Meropenem
removal in critically ill patients undergoing sustained low-efficiency dialysis (SLED).
Nephrol Dial Transplant. 2010;25(8):2632-2636.
Q6 Drug 6/6: Piperacillin/Tazobactam
FDA recommended dosing for IHD 3x/week: "Maximum dose is 2.25g q12hr for all
indications other than nosocomial pneumonia; 2.25g q8hr for nosocomial pneumonia.
An additional dose of 0.75 g should be administered following each dialysis period on
hemodialysis days."
There is no literature-based piperacillin/tazobactam dosing recommendation in SLED.
Please provide your recommended piperacillin/tazobactam dosing for daily SLED for
our hypothetical patient.
Dose and Interval (e.g. X mg every X hour) _________________________
Administration time relative to dialysis (e.g. immediately after dialysis)
______________________
Any dosing adjustments while SLED is running? _________________________
Additional comments regarding your regimen _________________________
Q7 Please list resources you would have used for your regimen recommendations
(published articles, peer advice, guideline for other RRT modality, clinical experience,
etc.)_______________
The short questions below will collect demographic information regarding your
pharmacy experience and the hospital where you practice.
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Q8 In your career as a pharmacist,
Yes, I do this
currently
Yes, in the past
No
Have you provided
dosing
recommendation for
patients receiving
IHD



Have you provided
dosing
recommendation for
patients receiving
SLED



Have you provided
dosing
recommendation for
patients receiving
CRRT



Q9 What post-graduate residency/fellowship have you completed (please specify which
specialty if you had completed a PGY2 or fellowship)?




No residency or fellowship
PGY1 (General Practice)
Fellowship ____________________
PGY2 (Specialty Practice) ____________________
Q10 How many years of CLINICAL pharmacy experience do you have (exclude years
spent in post-graduate training)? ______________
Q11 How many staffed beds are in your hospital?
 <300
 300-600
 >600
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Q12 Which of the following is the primary renal replacement therapy (RRT) employed in
your hospital’s ICU?
 Intermittent Hemodialysis
 Continuous RRT (CVVH, CVVHD, CVVHDF)
 Sustained Low Efficiency Dialysis (also known as prolonged intermittent RRT,
extended (daily) dialysis, slow continuous dialysis, go slow dialysis, etc.)
 Other ____________________