Intraperitoneal antibiotic dosing recommendations for intermittent administration in adult patients on peritoneal dialysis

	IP dose instilled in the longest dwell of the day of at least 6 hours
Aminoglycosides^*
Amikacin	2 mg/kg in one exchange per day^¶
Gentamicin	0.6 mg/kg in one exchange per day^¶
Netilmicin^Δ	0.6 mg/kg in one exchange per day^¶
Tobramycin	0.6 mg/kg in one exchange per day^¶
Carbapenems
Imipenem-cilastatin	500 mg in alternate exchanges^◊
Meropenem	1 gram in one exchange per day
Cephalosporins^¶
Cefazolin	15 to 20 mg/kg in one exchange per day
Cefepime	1 gram in one exchange per day
Cefotaxime	500 to 1000 mg in one exchange per day
Ceftazidime	1 to 1.5 grams in one exchange per day
Ceftriaxone	1 gram in one exchange per day
Glycopeptides
Vancomycin	25 mg/kg ideal body weight; re-dose once serum level is ≤15 mcg/mL^§
Teicoplanin^Δ	15 mg/kg in one exchange every 5 days
Penicillins
NOTE: For dosing of most penicillins for IP administration, refer to separately available UpToDate table for continuous administration of IP antibiotics.
Amoxicillin	Oral: 500 mg every 8 hours
Ampicillin^¥	4 grams in one exchange per day
Other
Aztreonam	2 grams in one exchange per day
Ciprofloxacin^‡	Oral: 250 mg twice per day
Daptomycin	300 mg in one exchange per day
Fosfomycin^†	4 grams in one exchange per day
Linezolid	Oral: 600 mg twice per day
Moxifloxacin^‡	Oral: 400 mg once per day
Trimethoprim-sulfamethoxazole (co-trimoxazole)	Oral: One double-strength tablet (trimethoprim 160 mg and sulfamethoxazole 800 mg) two times per day
Antifungal
Fluconazole	200 mg in one exchange every 24 to 48 hours
Voriconazole	2.5 mg/kg in one exchange per day

This table shows the suggested dose of antibiotics for intermittent IP administration (except where noted as "oral") in peritoneal dialysate for continuous ambulatory peritoneal dialysis-associated peritonitis without signs of systemic infection. Intermittent IP-administered regimens are preferred over continuous administration (ie, antibiotics in all exchanges) for initial therapy and should be used for the duration of treatment of 2 to 3 weeks or more in patients who are responding clinically. In patients who are not improving on intermittent therapy with agent(s) that should be effective based on microbiologic data, it is reasonable to increase frequency of intermittent dosing or switch to a continuous IP dosing regimen as listed on a separately available UpToDate table. Refer to UpToDate topic on microbiology and therapy of peritonitis in continuous peritoneal dialysis for considerations in selection of antimicrobials and dosing strategy.

IP: intraperitoneal.

* To determine weight-based dose of aminoglycosides in patients who are overweight, use "ideal body weight"; if obese, use "dosing weight." A calculator for determining "ideal body weight" and "dosing weight" based on inputs of actual body weight and height is available in UpToDate.

¶ Systemic toxicity can occur with prolonged or repeated course(s) of IP-administered aminoglycosides. Once culture and sensitivity results are available, early switch to another appropriate class of antibiotic is suggested to decrease the risk of toxicity. Refer to UpToDate topics on microbiology and therapy of peritonitis in peritoneal dialysis.

Δ Not available in the United States.

◊ Dose is expressed as mg of imipenem.

§ Obtain daily vancomycin serum levels. Re-dose once the serum level reaches ≤15 mcg/mL, which usually occurs within 4 to 7 days following an IP-administered dose. If serum levels are available only once every 2 to 3 days, it is reasonable to re-dose once the level reaches ≤20 mcg/mL. Supplemental doses may be needed in patients receiving machine-assisted automated peritoneal dialysis.

¥ For enterococcal peritonitis, we avoid ampicillin because some in vitro data suggest that its activity against Enterococcus may be limited in peritoneal fluid.

‡ We generally avoid fluoroquinolones because they have significant adverse effects, increase the risk of Clostridioides difficile infection, and have numerous drug interactions (including with oral phosphate binders). Refer to UpToDate topics on microbiology and therapy of peritonitis in peritoneal dialysis.

† In the United States, fosfomycin is not available in the formulation necessary for intraperitoneal use.

Adapted from:

Li PK, Szeto CC, Piraino B, et al. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int 2010; 30:393.
Li PK, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int 2022; 42:110.

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Intraperitoneal antibiotic dosing recommendations for intermittent administration in adult patients on peritoneal dialysis