Clarithromycin

PD Dialyzability: Uncertain

Pharmacokinetic Parameters [1] [2]

	Clarithromycin
Molecular Weight (Da)	747.95
Plasma Protein Binding (%)	70
Volume of Distribution (L/Kg)	No Data
Hepatic Metabolism	Clarithromycin is a CYP3A4 substrate as well as a strong CYP3A4 inhibitor
Excreted Unchanged (%)	20-30
Half-Life; Normal Renal Function (hours)	2.3-6.0
Half-Life; ESRD (hours)	No Data

CAPD Dosing: [3] [4] [5]

• 250mg PO BID

CCPD Dosing

• No literature identified. Extrapolate dosing from CAPD dosing recommendations

Indication Specific PD Dosing:

• Catheter-related infections: 500mg as loading dose, then 250mg PO BID X 2-3 Weeks (3 weeks if Pseudomonas aeruginosa) [6] [7]
• Surgical prophylaxis (dental, endoscopic, gynecological, abdominal, pelvic procedures): 500mg PO 1 hour preoperatively [8]

Literature Summary:

Title	Patient	Intervention	Outcome	Note
Mycobacterium avium complex-associated peritonitis in a patient on continuous ambulatory peritoneal dialysis. [9]	CAPD 64 year old male Presenting with weakness, worsening abdominal pain, hypotension and repeated falling Diagnosed with peritonitis due to Mycobacterium avium complex	Clarithromycin 250mg PO BID + Ethambutol 1.2g PO + Rifabutin 150mg PO x 2 weeks	Abdominal symptoms improved over 2 weeks 5 weeks later patient developed gangrene of right foot and passed away due to ongoing sepsis	No ADR reported Multiple antibiotic regimen employed
Successful treatment of Mycobacterium fortuitum peritonitis without Tenckhoff catheter removal in CAPD. [10]	CAPD 65 year old male Relapse of peritonitis due to Mycobacterium fortuitum	Clarithromycin 250mg PO BID + Levofloxacin 300mg PO daily	Peritoneal effluent became clear No further relapse thereafter	No ADR reported
Delusion of worm infestation associated with clarithromycin in a patient on peritoneal dialysis. [11]	CAPD 49 year old male presenting with delusions of worm infestation Started clarithromycin 1 week prior for unspecified chest infection	Clarithromycin 250mg PO TID + Terfenadine + Antitussives	Psychiatrist consulted Patient treated with low dose oral haloperidol until completion of antibiotic regimen and symptom improvement	Delirium and visual hallucination associated with clarithromycin regimen
Peritoneal catheter exit-site infections caused by rapidly-growing atypical mycobacteria. [12]	CAPD 5 patients presenting with exit-site infections	Clarithromycin 200mg PO Q12H	Symptom improvement	1 of 5 patients experienced gastric intolerance requiring discontinuation of clarithromycin regimen Duration of therapy ranged from 1.5-4 months
Clarithromycin-associated visual hallucinations in a patient with chronic renal failure on continuous ambulatory peritoneal dialysis. [13]	CAPD 50 year old male Presenting with sudden onset of visual hallucination hours after starting clarithromycin therapy Clarithromycin initially prescribed for treatment of acute bronchitis	Clarithromycin 500mg PO BID	Clarithromycin therapy was immediately discontinued Visual hallucination disappeared within 24 hours of stopping therapy	Visual hallucination associated with clarithromycin therapy
Campylobacter jejuni II peritonitis in a CCPD patient: Cure by oral clarithromycin. [14]	CCPD 38 year old male Presenting with symptoms of acute peritonitis Diagnosed with peritonitis due to Campylobacter jejuni	Clarithromycin 250mg PO BID x 12 days	Symptom improvement MIC attainment	No ADR reported
Successful treatment of severe Mycobacterium fortuitum exit-site infection with preservation of the Tenckhoff catheter. [15]	CCPD 43 year old female Presenting with two fluctuant masses from PD catheter site and purulent discharge Diagnosed with exit-site infection due to Mycobacterium fortuitum	Clarithromycin 500mg PO BID x 2 weeks	Wound healing Patient experienced nausea, vomiting, diarrhea while on clarithromycin therapy, resulting in change of antibiotic to levofloxacin.	Nausea, vomiting, diarrhea resulting in discontinuation of clarithromycin therapy.

References

[1]	Wishart DS, Knox C, Guo AC, Shrivastava S, Hassanali M, Stothard P, et al. DrugBank: a comprehensive resource for in silico drug discovery and exploration. Nucleic Acids Res. 2006 Jan 1;34(suppl_1):D668–72.

[2]

American Pharmacist Association. Drug information handbook: a comprehensive resource for all clinicians and healthcare professionals [Internet]. Hudson, Ohio: American Pharmacist association; 2012 [cited 2018 Jan 24]. Available from: http://online.lexi.com.login.ezproxy.library.ualberta.ca/lco/action/home?siteid=1

[3]	Gilbert B, Robbins P, Livornese LL. Use of Antibacterial Agents in Renal Failure. Med Clin North Am. 2011;95:677–702.

[4]	Aronoff GR. Drug prescribing in renal failure: dosing guidelines for adults and children. 5th ed. Philadelphia, PA: American College of Physicians; 2007.

[5]	Adjusting oral antibiotics to estimated creatinine clearance [Internet]. [cited 2018 Jan 24]. Available from: http://www.vhpharmsci.com/VHFormulary/Tools/ADJUSTING%20ORAL%20ANTIBIOTICS.pdf

[6]	Li PK-T, Szeto CC, Piraino B, Bernardini J, Figueiredo AE, Gupta A, et al. Peritoneal Dialysis-Related Infections Recommendations: 2010 Update. Perit Dial Int. 2010;30(4):393–423.

[7]	Szeto C-C, Li PK-T, Johnson DW, Bernardini J, Dong J, Figueiredo AE, et al. ISPD Catheter-Related Infection Recommendations: 2017 Update. Perit Dial Int. 2017 Mar 1;37(2):141–54.

[8]	Saxena R, West C. Peritoneal Dialysis: A Primary Care Perspective. J Am Board Fam Med. 2006;19(4):380–389.

[9]	Miyashita E, Yoshida H, Mori D, Nakagawa N, Miyamura T, Ohta H, et al. Mycobacterium avium complex-associated peritonitis with CAPD after unrelated bone marrow transplantation. Pediatr Int Off J Jpn Pediatr Soc. 2014;56(6):e96–8.

[10]	Tang S, Tang AW, Lam WO, Cheng YY, Ho YW. Successful treatment of Mycobacterium fortuitum without Tenckhoff catheter removal in CAPD. Perit Dial Int. 2003;23(3):304–305.

[11]	Tse KC, Li FK, Tang S, Lam MF, Chan TM, Lai KN. Delusion of worm infestation associated with clarithromycin in a patient on peritoneal dialysis. Perit Dial Int J Int Soc Perit Dial. 2001;21(4):415–6.

[12]	Hevia C, Bajo M. Peritoneal catheter exit-site infections caused by rapidly-growing atypical mycobacteria. Nephrol Dial Ldots. 2000;(May 1997):1458–1460.

[13]	Steinman MA, Steinman TI. Clarithromycin-associated visual hallucinations in a patient with chronic renal failure on continuous ambulatory peritoneal dialysis. Am J Kidney Dis. 1996;27(1):143–146.

[14]	Lang CL, Chiang CK, Hung KY, Wu KD. Campylobacter jejuni peritonitis and bacteremia in a patient undergoing continuous ambulatory peritoneal dialysis. Clin Nephrol. 2009;71(1):96–98.

[15]	Gourzelis N, Margassery S, Bastani B. Successful treatment of severe Mycobacterium fortuitum exit-site infection with preservation of the Tenckhoff catheter. Perit Dial Int. 2005;25(6):607–608.