Low Albumin in the ICU: When to Adjust Ceftriaxone or Ertapenem

In an interview with Pharmacy Times, Christina O'Connor, PharmD, BCPS, RPh, BCIDP, an infectious disease clinical pharmacist at Mayo Clinic in Rochester, Minnesota, discussed a practical framework for dosing ertapenem (Invanz; Merck) and ceftriaxone (Rocephin; Roche) in patients with low albumin and the research needed to settle the debate. The discussion is based off her presentation during the “Treatment Conundrums—Not Always Black & White” session at IDWeek 2026, taking place October 21–24 in Washington, DC.

O'Connor described her approach as a common-sense framework based on current evidence that pharmacists can adapt as new data emerge. The first question, she said, is whether the patient is critically ill or stable on the floor, because available literature suggests any interaction between albumin and free drug exposure is most relevant in critically ill patients.

For stable patients, O'Connor said dosing can likely be based on the usual considerations, such as the syndrome being treated and the patient's renal function. In her view, a low albumin level alone does not necessarily mean the dose needs to be increased or that the patient needs to be switched off ertapenem or ceftriaxone.

For critically ill patients, where she said the evidence may have its best support, albumin can be considered as an additional factor in clinical decision-making. She highlighted intensive care unit patients with augmented renal function; when that occurs alongside low albumin, clinicians should consider increased doses or other drugs. For ceftriaxone, she recommended no less than 2 g every 24 hours, potentially up to every 12 hours for patients with a combination of low albumin, augmented renal function, and possibly a higher minimum inhibitory concentration. For ertapenem in patients with those risk factors, she pointed to the Infectious Diseases Society of America recommendation to consider an alternative, such as meropenem (Merrem; Pfizer) or imipenem.

Looking ahead, O'Connor called for studies in the gram-negative space that pair clinical outcomes data with therapeutic drug monitoring. Such studies, she said, could show whether patients with low albumin who fare worse also have low drug concentrations, which could help settle the debate.