What antibiotic can I prescribe to a patient with a bacterial upper respiratory infection and impaired renal function (GFR of 20)?

From the Guidelines

For a patient with a bacterial upper respiratory infection and impaired renal function (GFR of 20), I would recommend doxycycline 100 mg twice daily for 7-10 days, as it does not require dose adjustment in renal impairment, according to the British Thoracic Society guideline for bronchiectasis in adults 1. This medication is appropriate because it is effective against common bacterial pathogens causing upper respiratory infections, such as Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

• The British Thoracic Society guideline recommends doxycycline as a first-line treatment for these infections, with a suggested duration of 14 days 1.
• Additionally, doxycycline is primarily eliminated through biliary excretion rather than renal clearance, making it a safer choice for patients with impaired renal function.
• In contrast, other antibiotics such as amoxicillin, amoxicillin-clavulanate, and fluoroquinolones require significant dose adjustments in patients with a GFR of 20, as outlined in the guidelines for preventing opportunistic infections among HIV-infected persons 1.
• When treating these patients, it's essential to monitor for signs of clinical improvement and adjust the treatment plan as needed.
• The choice between doxycycline and other antibiotics should be guided by local resistance patterns and patient-specific factors like allergies or medication interactions.
• It's also crucial to reassess the patient after 48-72 hours to ensure clinical improvement and adjust the treatment plan accordingly.

From the Research

Antibiotic Options for Patients with Impaired Renal Function

When prescribing antibiotics to patients with impaired renal function, such as a GFR of 20, it is essential to consider the dosage adjustments to prevent adverse effects and ensure efficacy.

• The study by 2 suggests that prolongation of the administration interval may be the preferable dose adjustment method in renal failure with ciprofloxacin.
• According to 3, a working group of infectious disease specialists and nephrology pharmacists reviewed the indications, dosing regimens, administration modalities, and dose adjustments of antibiotics marketed in France for patients with renal failure, providing an evidence-based update of infectious disease recommendations.
• The systematic review by 4 found that there is inconsistency between many guidelines in the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function, and no good-quality evidence on the recommended dose reduction of renally cleared antibiotics in patients with impaired renal function is present, with the exception of meropenem.
• The study by 5 assessed the influence of various degrees of renal insufficiency on the pharmacokinetics of amoxicillin and clavulanic acid, suggesting dosage recommendations to prevent undue accumulations of amoxicillin while maintaining adequate concentrations of clavulanic acid.
• Amoxicillin/clavulanate (Augmentin) is a broad-spectrum antibacterial that has been available for clinical use in a wide range of indications, including community-acquired respiratory tract infections, as discussed in the review by 6.

Considerations for Specific Antibiotics

• Ciprofloxacin: Prolongation of the administration interval may be the preferable dose adjustment method in renal failure 2.
• Meropenem: Drug exposure is 158% to 286% higher in patients with impaired renal function receiving reduced doses compared to patients with adequate renal function receiving regular doses 4.
• Amoxicillin/clavulanate (Augmentin): Dosage recommendations are suggested to prevent undue accumulations of amoxicillin while maintaining adequate concentrations of clavulanic acid in patients with impaired renal function 5.