Antibiotic Use in Renal Impairment

Introduction to Antibiotic Use

The American Thoracic Society recommends that Isoniazid (INH) and Rifampin (RIF) can be used at conventional doses in patients with renal insufficiency, as they are metabolized by the liver and require minimal or no dose adjustments 1
Ethionamide does not require dose adjustment in renal impairment, as it is not cleared by the kidneys or removed by hemodialysis 1

Piperacillin/Tazobactam can be used in renal impairment with dose adjustment, according to the Infectious Diseases Society of America 2, 3
Aminoglycosides can be used with careful monitoring and extended dosing intervals in patients with creatinine clearance <30 mL/min, with a recommended dose of 12-15 mg/kg/dose two or three times per week 1
Levofloxacin requires substantial dose reduction in renal impairment, with a recommended dose of 250 mg once daily for creatinine clearance 20-49 mL/min 4

Nitrofurantoin is not recommended when creatinine clearance is <30 mL/min, according to the American Urological Association 4
Ethambutol requires dosing interval extension to three times weekly in renal impairment, as it is about 80% cleared by the kidneys 1
Eptifibatide is contraindicated in patients with creatinine clearance <30 mL/min, as recommended by the European Society of Cardiology 6

For patients with creatinine clearance <30 mL/min or on hemodialysis, Isoniazid can be administered at 300 mg once daily or 900 mg three times weekly, and Rifampin can be administered at 600 mg once daily or 600 mg three times weekly 1
Pyrazinamide can be administered at 25-35 mg/kg per dose three times weekly in patients with creatinine clearance <30 mL/min 1
Ethambutol can be administered at 15-25 mg/kg per dose three times weekly in patients with creatinine clearance <30 mL/min 1

For patients on hemodialysis, antibiotics should be administered after dialysis to avoid drug removal during the procedure, as recommended by the National Kidney Foundation 1
Aminoglycosides should be administered with once-daily dosing and extended intervals between doses to minimize nephrotoxicity, according to the Critical Care Medicine society 5
Vancomycin requires careful monitoring of trough levels to avoid further renal damage, as recommended by the Infectious Diseases Society of America 5

Regular assessment of renal function during antibiotic therapy is recommended by the American College of Clinical Pharmacy 4
Therapeutic drug monitoring for Aminoglycosides and Vancomycin is recommended by the Critical Care Medicine society 5
Monitoring for signs of drug toxicity is recommended, especially with drugs that have narrow therapeutic windows, as advised by the American Thoracic Society 1