From the Guidelines
Dialysis patients should avoid using nitrofurantoin, tetracyclines, and aminoglycoside antibiotics due to potential toxicity or ineffectiveness, as recommended by the most recent guidelines 1. When prescribing antibiotics to dialysis patients, it's essential to consider the potential risks and benefits, as well as the patient's individual needs and medical history.
- Nitrofurantoin should be avoided completely as it accumulates in renal failure, providing minimal antimicrobial activity while increasing the risk of peripheral neuropathy and pulmonary toxicity.
- Tetracyclines, particularly doxycycline and minocycline, can worsen uremia and should generally be avoided, though doxycycline may occasionally be used with careful monitoring as it has non-renal clearance pathways.
- Aminoglycoside antibiotics should be avoided in CKD patients due to their nephrotoxicity. Other antibiotics, such as fluoroquinolones (e.g., ciprofloxacin and levofloxacin), trimethoprim-sulfamethoxazole, and macrolides (e.g., clarithromycin), may require dose adjustments or careful monitoring to minimize the risk of adverse effects. The choice of antibiotics and dose adjustments should be made based on comments from the patient’s nephrologist before the treatment, and current dosing guidelines should be consulted to ensure the best possible outcomes for dialysis patients 1.
- The American Heart Association recommends that prophylactic antibiotics are used before invasive dental procedures for patients with high risks of infection, and suggests using amoxicillin or clindamycin with careful consideration of the patient's renal function 1. It's crucial to weigh the potential benefits of antibiotic treatment against the potential risks and to choose antibiotics with hepatic rather than renal clearance whenever possible, to minimize the risk of adverse effects in dialysis patients.
From the Research
Oral Antibiotics to Avoid in Dialysis Patients
When it comes to dialysis patients, certain oral antibiotics should be avoided or used with caution due to the risk of nephrotoxicity or other adverse effects.
- The following antibiotics may require dose adjustment or should be avoided in dialysis patients:
- Penicillins and cephalosporins, especially those with a high risk of neurotoxicity or bleeding 2
- Third-generation cephalosporins with N-methylthiotetrazole side chain, which may cause problems with hemostasis 2
- Antibiotics with a high risk of nephrotoxicity, such as those that can cause acute interstitial nephritis, acute tubular necrosis, or intratubular crystal deposition 3
Considerations for Antibiotic Use in Dialysis Patients
When prescribing antibiotics to dialysis patients, the following considerations should be taken into account:
- Accurate assessment of renal function and the influence of renal replacement therapy on antibiotic clearance 4
- The potential for antibiotic dose-related toxicity and the need for therapeutic drug monitoring 4
- The risk of adverse drug events, including adverse drug reactions and infections with Clostridioides difficile and antibiotic-resistant bacteria 5
Strategies for Improving Antibiotic Use in Dialysis Patients
To improve antibiotic use in dialysis patients, the following strategies can be employed:
- Expanding infection and sepsis prevention activities 5
- Standardizing blood culture collection processes 5
- Treating methicillin-susceptible Staphylococcus aureus infections with β-lactams 5
- Optimizing communication between nurses and prescribing providers 5
- Improving data sharing across transitions of care 5