What antibiotic treatment is indicated for impaired renal function and septicemia?

From the Guidelines

Impaired renal function and septicemia require careful selection of antibiotics. The most appropriate antibiotic treatment for impaired renal function and septicemia is one that is effective against the likely pathogens, has adequate tissue penetration, and is dosed according to the patient's renal function.

Key Considerations

• Optimization of antimicrobial dosing is crucial in patients with sepsis and septic shock, particularly those with impaired renal function 1.
• Beta-lactam antibiotics are commonly used in the treatment of sepsis, but their dosing regimens may need to be adjusted in patients with impaired renal function 1.
• Aminoglycosides and fluoroquinolones require careful dosing and monitoring in patients with impaired renal function to minimize the risk of toxicity 1.

Recommended Antibiotics

• Vancomycin is a suitable option for patients with impaired renal function, but its dosing should be adjusted based on the patient's renal function and trough concentrations should be monitored 1.
• Piperacillin/tazobactam is another option, but its dosing regimen may need to be adjusted in patients with impaired renal function, and extended infusions may be beneficial for infections due to bacteria with high MIC 1.
• Cefepime and meropenem may also be used, but their dosing regimens should be adjusted based on the patient's renal function and PK-PD targets should be achieved 1.

Dosing Considerations

• Loading doses of antimicrobials with low volumes of distribution, such as vancomycin, are warranted in critically ill patients to rapidly achieve therapeutic drug levels 1.
• Extended infusions of beta-lactam antibiotics may be beneficial for infections due to bacteria with high MIC, particularly in patients with impaired renal function 1.
• Therapeutic drug monitoring is essential to ensure that the patient is receiving the optimal dose of the antibiotic and to minimize the risk of toxicity 1.

From the Research

Antibiotic Treatment for Impaired Renal Function and Septicemia

• The choice of antibiotic treatment for patients with impaired renal function and septicemia is crucial, as some antibiotics can be nephrotoxic 2.
• Factors to consider when prescribing antibiotic regimens in septic patients with acute renal failure include pharmacokinetics, weight, residual renal function, hepatic function, mode of renal replacement therapy, severity of illness, microorganism, minimum inhibitory concentration, and others 3.
• Beta-lactam dosing in critically ill patients with septic shock and continuous renal replacement therapy (CRRT) is complex, and current dosing recommendations are based on studies with limitations 4.
• Therapeutic drug monitoring of beta-lactams may be useful to individualize dosing and ensure optimal antibiotic exposure in patients with septic shock and CRRT 4.
• Some antibiotics, such as metronidazole or ampicillin in combination with sulbactam, may have a beneficial effect in patients with suspected sepsis, while others, such as netilmicin, cefepime, linezolid, or imipenem in combination with cilastatin, may worsen kidney function 5.
• The use of antibiotics in patients with impaired renal function and septicemia requires careful consideration of the potential risks and benefits, and dosing regimens should be adjusted according to the patient's renal function and CRRT settings 6.

Considerations for Antibiotic Dosing

• Antibiotic doses should be reduced in patients experiencing acute renal failure, in accordance with the glomerular filtration rate (GFR) 6.
• Posology should be increased in the case of CRRT, but identifying a standard dosage of antibiotics is difficult due to the variability in CRRT settings and patient factors 6.
• A loading dose may be required to compensate for the increased volume of distribution, regardless of impaired organ function, and an additional loading dose may be required when CRRT is initiated 4.
• Dosing must be adjusted to CRRT settings and residual renal function from day 2 onwards 4.

Potential Biomarkers for Acute Kidney Injury

• Non-protein-coding RNAs, such as microRNAs, may be useful biomarkers for acute kidney injury in septic patients treated with nephrotoxic antibiotic agents 2.
• Five microRNAs (miR-15a-5p, miR-192-5p, miR-155-5p, miR-486-5p, and miR-423-5p) have been identified as potential biomarkers for septic and toxic acute kidney injury in septic patients treated with vancomycin and gentamicin 2.