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​Antimicrobials in renal impairment

Intravenous antimicrobial dosage adjustments in renal impairment

The dosing tables below reflects current practice in Liverpool FT and is based on a combination of the following reference sources and clinical experience: The Renal Drug Handbook (Online), Individual Summary of Product Characteristics (SPC) and British National Formulary (Online). The following guidance is for intravenous antimicrobials only.

First doses of antibiotics can often be given at full treatment dosages as explained previously. Patients who are extremely unwell or immunosuppressed may need doses at the higher end of the ranges stated. Do not wait (e.g. until after dialysis) to administer antibiotics if patient is acutely unwell.

In Acute Kidney Injury (AKI) on Chronic Kidney Disease (CKD) associated with sepsis, the initial dosing regimen should be according to the baseline level of renal function.  It should be noted that haemodiafiltration (HDF) removes drugs more efficiently than HD, although there is limited information on this.


Further information can be found in the following document: Intravenous antimicrobial dosing in renal impairment guide.pdfIntravenous antimicrobial dosing in renal impairment guide.pdf

There is a traffic light coding system for dose adjustments of antimicrobials in AKI or CKD.


safe in aki.png​​

No dose adjustment needed in AKI or CKD


adjust in aki.png 

Dose adjustment generally required in CKD patients. In patients with new renal dysfunction or AKI, the antimicrobial should be dose based on baseline kidney function (Creatinine clearance) for the first 48 hours.

​A single loading dose may be appropriate in some cases of severe infection to ensure therapeutic drug levels, consult with microbiology or pharmacy for advice. After 48 hours, the kidney function should be reassessed and if no recovery of function, a dose reduction based on current GFR is advised.


caution in aki.png

This category of antimicrobials should be cautioned in AKI. Medication in this group can result in:

·         Sub-therapeutic levels in AKI (e.g. nitrofurantoin)

·         Nephrotoxicity and should be avoided unless no other alternatives exist (e.g. aminoglycosides)

·         Accumulation and therefore an immediate dose reduction is required (e.g. vancomycin)

·         Adverse drug reactions such as peripheral neuropathy

 

For further information on any of the below antimicrobials please review monograph on the renal drug database, available via: https://renaldrugdatabase.com/. Username and password available via library services on the intranet.  Or via the summary of product characteristics available via: https://www.medicines.org.uk/emc .​ 


Guides for antimicrobials in renal impairment

Antibiotics in renal impairment: Antibiotics in renal impairment.pdfAntibiotics in renal impairment.pdf


Antifungals in renal impairment:Antifungals in renal impairment.pdfAntifungals in renal impairment.pdf


Antivirals in renal impairment:Antivirals in renal impairment.pdfAntivirals in renal impairment.pdf


Useful equations:Appendix One - useful equations.pdfAppendix One - useful equations.pdf



Quick reference guide for dosing of intra-venous antimicrobials in acute kidney injury (AKI)



 ​safe in aki.png

No dose reduction needed in AKI/CKD

 

adjust in aki.png

Dose as per baseline* GFR for 48 hours then review


 
caution in aki.png Dose reduce (or avoid if possible)

Azithromycin

Chloramphenicol

Clindamycin

Dapsone

Doxycycline

Erythromycin

Linezolid

Metronidazole

Moxifloxacin

Rifampicin

Tigecycline

 

 

 

Antifungals

Caspofungin

Posaconazole

 

 

Penicillins

Carbapenems

Cephalosporins

Clarithromycin

Fosfomycin

Quinolones

Teicoplanin

 

 

 

 

Antifungals

Fluconazole

Voriconazole

 

 

 

                   

Aminoglycosides ~ (gentamicin and amikacin)

Give STAT dose of gentamicin and review with levels

 

Known nephrotoxic: however single doses in sepsis are advised even in AKI patients. Toxicity is associated with prolonged courses.

Don’t use gentamicin calculator if creatinine clearance is below 20ml/min

 

Colomycin ~

Co-trimoxazole *

Daptomycin

Nitrofurantoin #

Trimethoprim #

Vancomycin

Known nephrotoxic: give a loading dose and review therapeutic drug levels.

 

Antifungals

Ambisome

Flucytosine

 

Antivirals

Aciclovir

Foscarnet

Ganciclovir

Oseltamivir

 

*In PCP treatment, discuss with medical microbiology or antimicrobial pharmacist

# Risk of treatment failure due to reduced renal secretion into the urinary tract, leading to reduced antibacterial efficacy and increased risk of side effects.

~ Known nephrotoxic; however single doses in sepsis are advised even in AKI patients.



References

1.       The renal drug database. Accessed via: https://renaldrugdatabase.com/

2.       Chelsea and Westminister hospital, Adult antimicrobial dosing guidelines. December 2017.

3.       Summary of product characteristics for all antimicrobials. Accessed via: https://www.medicines.org.uk/emc/product/9651/smpc