From the Guidelines
Patients with stage 4 Chronic Kidney Disease (CKD) can safely use certain antibiotics with appropriate dose adjustments to prevent toxicity. The most recent and highest quality study 1 provides guidance on antibiotic use in patients with CKD. Safe options include:
- Macrolides like azithromycin, which require no dose adjustment as they are primarily eliminated through the liver.
- Cephalosporins such as cefazolin and ceftriaxone, which can be used with reduced dosing (e.g., cefazolin at 1g every 24 hours instead of every 8 hours).
- Penicillins like amoxicillin, which should be dosed at 250-500mg every 12-24 hours rather than the standard 8-hour interval.
- Fluoroquinolones such as levofloxacin, which require significant reduction (250-500mg every 48 hours).
- Vancomycin, which can be used but requires careful monitoring with trough levels and extended dosing intervals (15mg/kg every 3-7 days). Antibiotics to avoid or use with extreme caution include:
- Aminoglycosides (gentamicin, tobramycin), which are nephrotoxic.
- Nitrofurantoin, which is contraindicated in CKD stage 4. The kidney's reduced filtration capacity in stage 4 CKD (GFR 15-29 mL/min) means drugs eliminated renally accumulate, potentially causing toxicity, while also potentially reducing efficacy of some antimicrobials that require renal activation. Consultation with a pharmacist for precise dosing based on the patient's exact GFR is always recommended. Some key points to consider when choosing antibiotics for patients with stage 4 CKD include:
- Avoiding nephrotoxic drugs
- Adjusting doses based on renal function
- Monitoring for signs of toxicity
- Considering alternative antibiotics when necessary
- Consulting with a pharmacist or nephrologist for guidance on antibiotic use in patients with CKD.
From the Research
Antibiotics Safe in Stage 4 CKD
The following antibiotics can be used in patients with stage 4 Chronic Kidney Disease (CKD), but it is essential to note that dose adjustments are often necessary to avoid accumulation and toxicity:
- Cephalosporins: commonly used, but dose adjustment is required based on the glomerular filtration rate (GFR) 2
- Penicillins: widely used, but 39.8% of patients received them without renal dose adjustments, highlighting the need for careful dosing 3
- Glycopeptides: may not require dose adjustment in some cases, but caution is advised due to potential nephrotoxicity 2
Dose Adjustment Considerations
When prescribing antibiotics to patients with stage 4 CKD, it is crucial to consider the following:
- Dose adjustment according to the GFR to prevent toxicity and ensure efficacy 2, 4
- Use of online resources, such as Lexicomp or SiteGPR, to guide dose adjustments and ensure appropriate prescribing 2, 4, 3
- Collaboration with clinical pharmacists and nephrologists to optimize antibiotic dosing and minimize the risk of adverse effects 3
Specific Antibiotics and CKD
Some antibiotics may require special consideration in patients with stage 4 CKD:
- Ceftolozane/tazobactam, ceftazidime/avibactam, and telavancin: may carry precautionary statements for reduced clinical response in patients with baseline creatinine clearance of 30-50 mL/min, potentially due to unnecessary dose reduction in the setting of acute kidney injury (AKI) 5
- Piperacillin/tazobactam: frequently prescribed without renal dose adjustment, highlighting the need for careful dosing and monitoring 3