Pharmacokinetically guided Pre-dialytic Administration of Amikacin in a Haemodialysis Patient with Resistant Infections: A CARE-compliant Case Report

Introduction: Managing carbapenem-resistant Enterobacterales (CRE) in haemodialysis patients is challenging due to the narrow therapeutic index of aminoglycosides. We report a case of a 59-year-old Malaysian male with end-stage renal disease (ESRD) and a severe CRE Klebsiella pneumoniae infection who was managed with a pharmacokinetically guided pre-dialytic amikacin strategy. Case Presentation: The patient initially failed conventional post-dialysis dosing, resulting in sub-therapeutic peaks and a toxic trough of 15 µg/mL. We switched to a pre-dialytic regimen (6–7 mg/kg), utilising high-flux dialysis as a "controlled clearance" mechanism. This achieved a bactericidal Cmax of 29.6 µg/mL, a safe trough of 9.2 µg/mL, and average AUC24 ranging from 332-399.8 mg.h/L. The patient tolerated extended pre-dialysis drug exposure of up to 10.5 hours without clinically apparent ototoxicity. However, the patient was readmitted at Day 65 with septic shock and died at Day 82; this death was not attributed to amikacin toxicity. Conclusion: This case suggests that pre-dialytic dosing may provide a safe, operationally flexible method to achieve critical pharmacokinetic/pharmacodynamic (PK/PD) targets (Cmax/MIC 8-10) in complex CRE infections, warranting further investigation in larger studies.