Fogel M A, Nussbaum P B, Feintzeig I D, Hunt W A, Gavin J P, Kim R C
Nephrology Associates, PC, and Gambro Health Care, Bridgeport, CT 06606, USA.
Am J Kidney Dis. 1998 Sep;32(3):401-9. doi: 10.1053/ajkd.1998.v32.pm9740155.
Vancomycin use is common in hemodialysis patients, due in part to the ease of dosing, but can lead to the development of resistant organisms, including vancomycin-resistant enterococcus. Alternate antibiotics may be equally effective and allow similar dosing in the chronic hemodialysis population. A retrospective review of culture results from a 217-patient, non-hospital-based outpatient hemodialysis center was performed over a 7-month period. Wound and blood culture sensitivity to cefazolin, vancomycin, cefazolin plus gentamicin, and vancomycin plus gentamicin was analyzed. Cefazolin was equivalent to vancomycin for empiric treatment of clinically significant infections in a population with a low rate of methicillin-resistant Staphylococcus aureus infection. Cefazolin plus gentamicin was superior to vancomycin alone. The vancomycin plus gentamicin combination did provide minimally broader coverage than the cefazolin plus gentamicin combination. A prospective pharmacokinetic analysis of postdialysis cefazolin dosing was performed in anuric chronic hemodialysis patients dialyzed with polysulfone dialyzers. Peak, predialysis, and postdialysis cefazolin levels were obtained. Nondialysis clearance of cefazolin was sufficiently low (k(e), 0.027; t(1/2), 26.4 hours) and dialysis clearance sufficiently high (k(e), 0.254; t(1/2), 3.19 hours) to provide for safe and effective peak and trough cefazolin levels with postdialysis dosing in anuric hemodialysis patients. In conclusion, cefazolin alone or with gentamicin in an appropriate empiric antibiotic choice in chronic hemodialysis patients dialyzed in a nonhospital setting with low methicillin-resistant S. aureus infection rates. For infections with documented sensitivity to cefazolin, a 1 g intravenous dose postdialysis (750 mg in patients weighing <50 kg) is safe and effective.
万古霉素在血液透析患者中使用普遍，部分原因是给药方便，但可能导致包括耐万古霉素肠球菌在内的耐药菌产生。其他抗生素可能同样有效，且在慢性血液透析人群中给药方式相似。对一家拥有217名患者的非医院门诊血液透析中心7个月期间的培养结果进行了回顾性分析。分析了伤口和血液培养对头孢唑林、万古霉素、头孢唑林加庆大霉素以及万古霉素加庆大霉素的敏感性。在耐甲氧西林金黄色葡萄球菌感染率较低的人群中，头孢唑林在经验性治疗具有临床意义的感染方面与万古霉素等效。头孢唑林加庆大霉素优于单用万古霉素。万古霉素加庆大霉素组合的覆盖范围确实比头孢唑林加庆大霉素组合略广。对使用聚砜透析器进行透析的无尿慢性血液透析患者进行了透析后头孢唑林给药的前瞻性药代动力学分析。获得了头孢唑林的峰浓度、透析前浓度和透析后浓度。头孢唑林的非透析清除率足够低（消除速率常数k(e)为0.027；半衰期t(1/2)为26.4小时），透析清除率足够高（k(e)为0.254；t(1/2)为3.19小时），以便在无尿血液透析患者透析后给药时提供安全有效的头孢唑林峰浓度和谷浓度。总之，在耐甲氧西林金黄色葡萄球菌感染率较低的非医院环境中进行透析的慢性血液透析患者，单用头孢唑林或与庆大霉素联用是合适的经验性抗生素选择。对于对头孢唑林有明确敏感性的感染，透析后静脉注射1g剂量（体重<50kg的患者为750mg）是安全有效的。
