What antibiotic can be given to patients with severe renal impairment (GFR of 24)?

From the Guidelines

For patients with a GFR of 24, levofloxacin can be used at a dose of 250-500 mg every 48 hours, making it a suitable option with necessary dose adjustments. Several antibiotics can be safely administered to patients with severe renal impairment, though dose adjustments are typically necessary. According to the guidelines for preventing opportunistic infections among HIV-infected persons 1, levofloxacin can be used at a dose of 250-500 mg every 48 hours for patients with a GFR of 10-19, which can be applied to patients with a GFR of 24 with careful monitoring. Other suitable options include ceftazidime, meropenem, and ertapenem with reduced dosing. Linezolid and doxycycline are particularly good choices as they don't require dose adjustment in renal impairment. For patients on dialysis, timing antibiotics around dialysis sessions is important as some drugs are removed during dialysis. When prescribing any antibiotic in renal impairment, it's essential to monitor renal function regularly, watch for signs of drug toxicity, and adjust doses as needed. The reason dose adjustments are necessary is that the kidneys are the primary route of elimination for many antibiotics, and reduced renal function leads to drug accumulation, potentially causing toxicity if standard doses are used. Additionally, it's crucial to avoid nephrotoxic drugs, such as aminoglycoside antibiotics and tetracyclines, in patients with severe renal impairment 1.

Some key points to consider when choosing an antibiotic for patients with severe renal impairment include:

• The need for dose adjustments based on the patient's renal function
• The potential for drug accumulation and toxicity
• The importance of monitoring renal function and watching for signs of drug toxicity
• The need to avoid nephrotoxic drugs
• The choice of antibiotics that do not require dose adjustment in renal impairment, such as linezolid and doxycycline.

It's also important to note that the choice of antibiotics and dose adjustments should be made based on comments from the patient’s nephrologist before the treatment in order to decrease the side effects from CKD 1.

From the FDA Drug Label

Patients with impaired renal function do not generally require a reduction in dose unless the impairment is severe. Renal impairment patients with a glomerular filtration rate of less than 30 mL/min should NOT receive the 875 mg dose

Table 2 Dosing in Patients with Severe Renal Impairment Patients with Renal Impairment Dosage Regimen GFR 10 to 30 mL/min 500 mg or 250 mg every 12 hours, depending on the severity of the infection GFR less than 10 mL/min 500 mg or 250 mg every 24 hours, depending on severity of the infection

The patient has a GFR of 24, which falls into the category of severe renal impairment. According to the dosage recommendations, for a GFR of 10 to 30 mL/min, the dosage regimen is 500 mg or 250 mg every 12 hours, depending on the severity of the infection. Amoxicillin can be given to patients with severe renal impairment, with a GFR of 24, at a dose of 500 mg or 250 mg every 12 hours 2.

From the Research

Antibiotic Options for Patients with Severe Renal Impairment

For patients with a GFR of 24, which indicates severe renal impairment, the choice of antibiotic requires careful consideration to avoid potential toxicity and ensure effective treatment.

• Ciprofloxacin: According to 3, ciprofloxacin can be adjusted for renal failure by either reducing the dose or prolonging the administration interval. The study suggests that prolonging the administration interval may be the preferable method for dose adjustment in renal failure.
• Cefepime: Studies 4, 5, 6, and 7 discuss the use of cefepime in patients with renal impairment. 4 notes that patients with severe renal impairment (CLCr < 30 ml/minute) may accumulate cefepime, leading to neurotoxicity. 5 reports a case of neurotoxicity in a patient with severe renal impairment and suggests using lower doses or alternative antibiotics. 6 found that higher-dose cefepime exposure may increase the risk of neurotoxicity in critically ill adults with severe renal dysfunction. 7 concludes that renal failure is a risk factor for cefepime-induced encephalopathy, with a higher incidence in patients with lower GFR values.

Considerations for Antibiotic Selection

When selecting an antibiotic for patients with a GFR of 24, it is essential to consider the potential risks of neurotoxicity associated with certain antibiotics, such as cefepime. Alternative antibiotics with a lower risk of neurotoxicity, such as meropenem, may be preferred. Additionally, dose adjustments and close monitoring of renal function and antibiotic levels can help minimize the risk of toxicity and ensure effective treatment.