Considerations for Antibiotic Dosing in Critically Ill Patients Requiring Sustained-Low Efficiency Dialysis

1. What are the goals of kidney replacement therapy?

a) Volume control
b) Drug/toxin and solute removal
c) Correction of acid-base imbalances
d) Correction of electrolyte disturbances
e) All of the above

2. Which of the following is true regarding Acute Kidney Injury?

a) AKI is not associated with increased risk for mortality in the ICU
b) In many instances, acute kidney injury can be managed with kidney replacement therapy and can be reversible
c) AKI develops over weeks
d) A and B
e) All of the above

3. Which of the following are true regarding sepsis/septic shock?

a) Fluid resuscitation is a common therapy used in the management of sepsis/septic shock
b) Serum concentrations of drugs can be difficult to predict in septic shock
c) Septic shock can cause multi-organ failure and is a primary contributor to AKI in the ICU
d) All of the above
e) None of the above

4. Which of the following are true related to mechanisms of solute removal in dialysis:

a) Ultrafiltration – the transfer of solute across the membrane along with the bulk-flow of fluid
b) Convection – the process of removing fluid from the patient
c) Diffusion – solute transfer across the membrane down a concentration gradient
d) None of the above
e) All of the above

5. Sustained-low efficiency dialysis is advantageous to intermittent hemodialysis in critically ill as it:

a) Uses higher blood and dialysate flow rates for a shorter duration of time to promote better hemodynamic stability
b) Uses lower blood and dialysate flow rates for a longer period of time to promote better hemodynamic stability
c) Using machines requiring a lower level of technical expertise comparted to intermittent hemodialysis
d) Does not require systemic anticoagulation like in intermittent hemodialysis
e) Allows for supplementary investigations between dialysis sessions

6. Which of the following antibiotics are is most likely to be dialyzed?

a) Doxycycline (>90% protein binding, 33-45% excreted in urine, volume of distribution = 0.7L/kg)
b) Meropenem (2% protein binding, 70% excreted in urine, volume of distribution = 0.35L/kg)
c) Azithromycin (12-52% protein binding, 6-12% excreted in urine, Volume of distribution = 31.1L/kg)
d) All of the above are drugs are poorly dialyzed
e) All of the above are likely to be dialyzed

7. KL is a 72 year old woman admitted recently admitted to the ICU for a community acquired pneumonia. Which of the following antibiotic therapy would be most appropriate?

a) Ceftriaxone + Azithromycin given intravenously
b) Ceftriaxone given intramuscularly
c) Amoxicillin/clavulanic acid given orally
d) Doxycycline given orally
e) Amoxicillin given orally

8. Which of the following factors can change the protein binding of pipercillin/tazobactam (a hydrophilic and acid antibiotic), and what is the resultant effect on the extent to which the antibiotic is dialyzed?

a) Fluid overload which can increase the amount a drug is dialyzed
b) Capillary leak syndrome which can increase the amount a drug is dialyzed
c) Metabolic acidosis which can decrease the extent the drug is dialyzed
d) Hypoalbuminemia which can increase the extent the drug is dialyzed
e) None of the above

9. In which of the following antibiotics is therapeutic drug monitoring recommended?

a) Vancomycin
b) Gentamicin
c) Meropenem
d) A and B
e) All of the above

10. AS is a 32 year old patient being treated for an MRSA bacteremia secondary to a central line infection. He is on vancomycin 1g every 24 hours, is on 8-SLED every day, and is not producing any urine. His vancomycin level is at target and the last dose of vancomycin and SLED therapy was yesterday. However, today, his blood pressure is 90/50 and the team has decided to withhold SLED. How should Mr. AS’s vancomycin be managed?

a) Continue vancomycin as planned, administer vancomycin 1g today
b) Increase the dose of vancomycin to 1.5g every 24 hours
c) Increase the frequency of vancomycin to 1g every 12 hours
d) Hold today’s dose of vancomycin and reassess if vancomycin should resume tomorrow
e) Decrease the vancomycin dose to 750mg every 24 hours

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