Plasmapheresis and Antibiotic Therapy: What Patients Should Know

If you or someone you care for is scheduled for plasmapheresis and antibiotic therapy at the same time, you may be wondering whether the two treatments can safely coexist and whether one might interfere with the other. It is a clinically important question, and one that is not always addressed in plain language.

Therapeutic plasma exchange (TPE), commonly called plasmapheresis, works by filtering blood plasma and replacing it with a substitute fluid. This process is highly effective at removing harmful substances from the bloodstream but it can also remove medications, including certain antibiotics. Understanding how plasmapheresis and antibiotic therapy interact is essential for anyone managing a complex treatment plan.

‍How Plasmapheresis Works

During plasmapheresis, blood is drawn from the body and passed through a machine that separates plasma from blood cells. The plasma which carries proteins, antibodies, and other circulating substances is discarded and replaced with either albumin solution or fresh frozen plasma. The treated blood is then returned to the body.

A standard single-volume exchange removes at least 60% of the original plasma volume (Krzych et al., Pharmaceutics, 2020). This makes TPE highly effective for removing large, circulating molecules such as harmful autoantibodies but it also means that drugs circulating in the plasma may be removed along with them.

For a broader overview of the procedure, see how plasmapheresis works and its general benefits.

‍Can Plasmapheresis Remove Antibiotics From Your Blood?

The short answer is: it depends on the antibiotic.

Research indicates that a drug's susceptibility to removal during plasma exchange depends on several pharmacokinetic properties (Ibrahim et al., Pharmacotherapy, 2007):

• Protein binding: Drugs that bind tightly to plasma proteins (>80% binding) are more likely to be removed along with the plasma

• Volume of distribution (Vd): Drugs with a low Vd meaning most of the drug stays in the bloodstream rather than distributing into tissues are more susceptible to removal

• Half-life and endogenous clearance: Drugs with low natural clearance and longer half-lives are more vulnerable to extraction

A critical review published in the American Journal of Clinical Pathology identified approximately 60 peer-reviewed publications on this topic and found that no randomized controlled trials have directly evaluated drug removal during TPE  meaning most guidance is based on case reports and smaller clinical studies (Cheng et al., AJCP, 2017). That said, the existing evidence is sufficient to guide clinical decision-making in most situations.

‍Which Antibiotics Are Most Affected During Plasma Exchange?

Research on plasma exchange and antibiotics has identified meaningful differences in how specific drugs are affected during TPE (Krzych et al., Pharmaceutics, 2020):

• Ceftriaxone  High protein binding (~90%) is associated with significant removal during TPE; dosing adjustments may be considered

• Vancomycin  A single standard plasmapheresis session is associated with removal of approximately 6.3% of total body vancomycin stores, which is generally considered clinically insignificant; supplemental dosing is typically not required (McClellan et al., Ann Pharmacother, 1997)

• Teicoplanin Approximately 20% may be removed during a session; monitoring is advisable

• Amphotericin Approximately 40% removal has been reported, which is considered clinically significant; dose adjustment or post-procedure supplementation may be warranted

• Cefepime Minimal removal due to its lower protein binding

Clinicians managing patients on concurrent antibiotics and plasmapheresis are advised to evaluate each drug's pharmacokinetic profile individually when planning the treatment schedule.

When Are Plasmapheresis and Antibiotic Therapy Used Together?

There are two primary clinical scenarios where plasmapheresis and antibiotic therapy may be used at the same time.

‍1. Patients on Antibiotics Who Need Plasmapheresis for Another Condition

Some patients undergoing TPE for autoimmune or neurological conditions may simultaneously be prescribed antibiotics for an unrelated infection. In these cases, the antibiotic regimen does not typically need to be discontinued but the care team should be informed of all medications in order to plan dosing timing appropriately.

‍2. Plasmapheresis as Adjunct Therapy in Sepsis

Plasmapheresis sepsis treatment represents a growing area of clinical investigation. In severe sepsis and septic shock, even optimal antibiotic therapy may be insufficient to control the body's inflammatory response. TPE has been studied as a supportive adjunct  not a replacement for antibiotics aimed at removing inflammatory mediators, circulating cytokines, and bacterial toxins from the bloodstream.

The American Society for Apheresis (ASFA) 2023 guidelines classify sepsis with multiorgan failure as a Category III indication for TPE, meaning the optimal role has not been firmly established and decisions should be individualized (Connelly-Smith et al., J Clin Apher, 2023).

Recent meta-analyses suggest potential benefit. A 2024 systematic review and meta-analysis including five RCTs and fifteen matched cohort studies found that adjunct TPE was associated with a significant reduction in short-term mortality compared to standard care alone (risk ratio 0.59; 95% CI 0.47-0.74) (Kuklin et al., Crit Care, 2024). A separate 2023 meta-analysis of 14 studies involving more than 50,000 patients found lower mortality risk in adults with severe sepsis treated with TPE using fresh frozen plasma as replacement fluid (RR 0.64; 95% CI 0.49-“0.84) (Lee et al., J Intensive Care Med, 2023).

These findings are promising, but researchers note that larger, well-designed trials are needed before definitive clinical recommendations can be made.

Explore therapeutic plasma exchange at Humanaut Health to learn how this evidence-based therapy is offered in a concierge longevity care setting.

‍How to Time Antibiotic Dosing Around Plasmapheresis

When managing plasmapheresis and antibiotic therapy concurrently, current evidence suggests that the safest approach is to complete the TPE session before administering antibiotics, where clinically feasible (Krzych et al., Pharmaceutics, 2020). This minimizes the risk of the antibiotic being partially removed before it can act.

When urgent treatment is necessary and optimal timing is not possible, clinicians may:

• Delay antibiotic infusion until after the drug has passed through its initial distributive phase

• Monitor serum drug concentrations for medications with narrow therapeutic indices

• Consider post-procedure dose supplementation for drugs with documented clinically significant removal (e.g., amphotericin B)

Patients are encouraged to inform their healthcare team of every medication they are taking - including prescription antibiotics, over-the-counter drugs, and supplements - before any scheduled plasmapheresis session.

‍Safety Considerations

Plasmapheresis is generally well-tolerated, but patients and providers should be aware of several safety considerations (Sergent & Ashurst, StatPearls, 2023):

• ACE inhibitors are a relative contraindication patients should not receive ACE inhibitors within 24 hours before the procedure, due to the risk of bradykinin-mediated reactions with some filter membranes

• Hypocalcemia may occur when citrate is used as the anticoagulant during the procedure

• Transient hypotension is a possible complication, particularly in critically ill or hemodynamically unstable patients

• All concurrently administered medications including antibiotics should be disclosed and reviewed by the care team prior to each session

Key Takeaways

• Plasmapheresis and antibiotic therapy can be used concurrently, but require careful coordination from the care team

• Whether an antibiotic is removed during plasma exchange depends primarily on its protein binding, volume of distribution, and half-life

• Vancomycin removal during a single TPE session is generally clinically insignificant; amphotericin B removal (~40%) may require dose adjustment

• TPE is studied as an adjunct to antibiotics in severe sepsis (ASFA 2023 Category III); recent meta-analyses indicate a potential mortality benefit in adults

• The safest approach is to administer antibiotics after not before the TPE session is complete

• Always disclose all medications to your care team before undergoing plasmapheresis

Frequently Asked Questions

Does plasmapheresis remove antibiotics from the body?

It depends on the specific antibiotic's pharmacokinetic properties. Drugs with high plasma protein binding (>80%) and low volume of distribution are most susceptible to removal during TPE. Your care team can evaluate your specific antibiotic regimen before the procedure (Krzych et al., Pharmaceutics, 2020).

Can I continue my antibiotic treatment while undergoing plasmapheresis?

In most cases, yes antibiotic therapy generally does not need to be stopped. When managing plasma exchange and antibiotics concurrently, timing adjustments are often recommended. Completing the TPE session before antibiotic administration helps protect therapeutic drug concentrations (Krzych et al., Pharmaceutics, 2020).

Does plasmapheresis affect vancomycin levels?

Research suggests that a single standard TPE session removes approximately 6.3% of total body vancomycin stores, an amount considered clinically insignificant. Supplemental dosing after the procedure is generally not required, though post-procedure redistribution of serum concentrations may occur (McClellan et al., Ann Pharmacother, 1997).

Is plasmapheresis used to treat sepsis?

TPE is investigated as an adjunct to standard antibiotic therapy in severe sepsis and septic shock not as a replacement for antibiotics. As a form of plasmapheresis sepsis treatment, it is classified under ASFA 2023 guidelines as a Category III indication (individualized decision-making). Recent meta-analyses suggest it may be associated with improved survival in adults with severe sepsis (Kuklin et al., Crit Care, 2024; Lee et al., J Intensive Care Med, 2023).

Which antibiotics are most affected by plasma exchange?

Ceftriaxone and amphotericin B show the most significant removal due to high protein binding and low volume of distribution. Vancomycin and cefepime show minimal clinically relevant removal under standard conditions (Krzych et al., Pharmaceutics, 2020).

Should I tell my doctor about antibiotics before plasmapheresis?

Yes always disclose all medications, including prescription antibiotics, supplements, and over-the-counter drugs, before undergoing a plasmapheresis session. The care team needs this information to plan dosing timing and monitor drug levels appropriately.

Can plasma exchange replace antibiotic therapy in infections?

No. TPE is not a replacement for antibiotics. In the context of sepsis, it is studied as a supportive, adjunctive therapy that may help manage the inflammatory response while antibiotics remain the cornerstone of antimicrobial treatment (Kuklin et al., Crit Care, 2024).

What is the safest way to time antibiotics with plasmapheresis?

Where clinically feasible, administering antibiotics after the TPE session is complete is the recommended approach. For narrow-therapeutic-index drugs, drug level monitoring may also be advisable (Krzych et al., Pharmaceutics, 2020).

Explore Therapeutic Plasma Exchange at Humanaut Health

If you are considering therapeutic plasma exchange as part of a personalized longevity or wellness plan, explore our TPE program at Humanaut Health and connect with our concierge care team.

References

1. Krzych LJ, Czok M, Putowski Z. "Is Antimicrobial Treatment Effective During Therapeutic Plasma Exchange? Investigating the Role of Possible Interactions." Pharmaceutics. 2020;12(5):395. DOI: 10.3390/pharmaceutics12050395

2. Ibrahim RB, Liu C, Cronin SM, Murphy BC, Cha R, Swerdlow P, Edwards DJ. "Drug removal by plasmapheresis: an evidence-based review." Pharmacotherapy. 2007;27(11):1529 1549. DOI: 10.1592/phco.27.11.1529

3. Cheng CW, Hendrickson JE, Tormey CA, Sidhu D. "Therapeutic Plasma Exchange and Its Impact on Drug Levels: An ACLPS Critical Review." Am J Clin Pathol. 2017;148(3):190 198. DOI: 10.1093/ajcp/aqx056

4. McClellan SD, Whitaker CH, Friedberg RC. "Removal of vancomycin during plasmapheresis." Ann Pharmacother. 1997;31(10):1132 1136. DOI: 10.1177/106002809703101003

5. Kuklin V, Sovershaev M, Bjerner J, et al. "Influence of therapeutic plasma exchange treatment on short-term mortality of critically ill adult patients with sepsis-induced organ dysfunction: a systematic review and meta-analysis." Crit Care. 2024;28(1):12. DOI: 10.1186/s13054-023-04795-x

6. Lee OPE, Kanesan N, Leow EH, et al. "Survival Benefits of Therapeutic Plasma Exchange in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis." J Intensive Care Med. 2023;38(7):598611. DOI: 10.1177/08850666231170775

7. Connelly-Smith L, Alquist CR, Aqui NA, et al. "Guidelines on the Use of Therapeutic Apheresis in Clinical Practice Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Ninth Special Issue." J Clin Apher. 2023;38(2):77278. DOI: 10.1002/jca.22043

8. Sergent SR, Ashurst JV. "Plasmapheresis." In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560566/