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Home | Articles | Infectious Diseases | Antibiotics and the Kidney

Antibiotics and the Kidney

Last updated 3rd December 2020

Introduction

  1. Problems can arise either because the antibiotic is nephrotoxic (eg gentamicin),because serum levels increase and cause other side effects (e.g. levofloxacin) or because the antibiotic may be less effective (e.g. nitrofurantoin)
  2. The Renal Drug Handbook is available on Ward D8, RU and CC and by clicking the link below. It is also possible to request access to www.renaldrugdatabase.co.uk through the knowledge network. The doses from this reference source may not always mirror those in the BNF or other reference sources, but are taken from practice and considered to be the most reliable available.
  3. Note Renal Drug Handbook doses are based on Cockcroft-Gault creatinine clearance and not eGFR, since the majority of published information available is based on creatinine clearance. Note both eGFR and CC perform less well at extremes of body weight and are much less accurate when renal function is not stable. Review doses frequently to ensure an appropriate response..
  4. Doses are based on chronic renal impairment. In the early stages of AKI, it may be more appropriate to give full doses of some antibiotics especially where severe infection or sepsis is involved. If in doubt, ask for advice.
  5. Doses for patients on renal replacement therapies (RRT) are not given here. The monographs for many of the drugs recommend dosing as for eGFR <10, however different types of RRT have different effects on drug clearance so it is best to check with the renal team before prescribing
  6. Doses below are taken from the online Renal Drug database accessed 1st August 2020 with the exception of levofloxacin which is taken from the SPC

Aciclovir for Herpes Simplex or Zoster (Oral)

Renal FunctionDose (Simplex)Dose (Zoster)
Normal200-400mg 5x daily for 5 days800mg 5x daily for 7 days
GFR 25 - 50Dose as in normal renal functionDose as in normal renal function
GFR 10 - 25200mg every 6-8 hours800mg every 8-12 hours
GFR<10200mg every 12 hours400-800mg every 12 hours

Aciclovir for HSV Encephalitis IV

Renal FunctionDose
Normal10mg/kg every 8 hours for 10 days
GFR 25-505 - 10mg/kg every 12 hours for 10 days
GFR 10 - 255 - 10mg/kg every 24 hours for 10 days
GFR <102.5 - 5mg/kg every 24 hours for 10 days
Note there is no suitable oral switch – 10 day course should be completed IV when diagnosis confirmed. Patient should be well hydrated to avoid precipitation of crystals in renal tubules causing reversible AKI

Benzylpenicillin IV

Renal FunctionDose
Normal2.4 - 14.4g daily in 4-6 divided doses
GFR 20 - 50Dose as in normal renal function
GFR 10 - 20600mg - 2.4g every 6 hours depending on severity of infection
GFR <10600mg - 1.2g every 6 hours depending on severity of infection

Cefotaxime IV

Renal FunctionDose
Normal1g every 12 hours (mild), 1g every 8 hours (moderate), 2g every 6 hours (severe) and up to 12g daily in 3 - 4 divided doses for life threatening infection
GFR 5 - 50Dose as in normal renal function
GFR <5Reduce dose by 50% but keep frequency the same

Ceftazidime IV

Renal FunctionDose
Normal1 - 2g every 8 - 12 hours. severe infection 3g every 12 hours, Pseudomonas lung infection in CF 100 - 150mg/kg daily in 3 divided doses
GFR 31 - 501 - 2g every 12 hours
GFR 16 - 301 - 2g every 24 hours
GFR 6 - 15500mg - 1g every 24 hours
GFR <5500mg - 1g every 48 hours

Ceftriaxone IV

Renal FunctionDose
Normal1g every 24 hours (moderate), 2 - 4g every 24 hours (severe infection)
GFR 10 - 50Dose as in normal renal function
GFR <10 Dose as in normal renal function, max dose 2g daily

Ciprofloxacin Oral/IV

Renal FunctionDose
NormalORal 250 - 750mg every 12 hours, IV 100 - 400mg every 8 - 12 hours
GFR 30 - 50Dose as in normal renal function
GFR 10 - 3050 - 100% of normal dose
GFR <1050% of normal dose, 100% dose may be given for short periods in exceptional circumstances
Patients with renal impairment are at increased risk of rare but serious adverse effects of quinolones: Drug Safety Update so use with caution
Note bioavailability of oral ciprofloxacin if high - 70-80%

Clarithromycin

Renal FunctionDose
NormalOral & IV 500mg every 12 hours
GFR 30 - 50Dose as in normal renal function
GFR 10 - 30250 - 500mg every 12 hours
GFR <10250 - 500mg every 12 hours - vomiting may be a problem with higher dose
Use oral route where possible as IV Clarithromycin can be irritant to the veins. Many drug interactions some serious so check before prescribing

Clindamycin Oral/IV

Renal FunctionDose
NormalOral 150 - 450mg every 6 hours, IV 600mg - 4.8g daily in 2 - 4 divided doses
eGFR 10 - 50Dose as in normal renal function
eGFR <10Dose as in normal renal function but prolonged half life may require a reduced dose

Co-amoxiclav Oral/IV

Renal FunctionDose
NormalOral 375 - 625mg every 8 hours, IV 1.2g every 8 hours increased to every 6 hours in severe infection
GFR 30 - 50Dose as in normal renal function
GFR 10 - 30IV 1.2g every 12 hours, Oral dose as in normal renal function
GFR <10IV 1.2g stat followed by 600mg every 8 hours or 1.2g every 12 hours, Oral dose as in normal renal function

Flucloxacillin Oral/IV

Renal FunctionDose
NormalOral 500mg every 6 hours, IV 1 - 2g every 6 hours
GFR 10 - 50Dose as in normal renal function
GFR <10Dose as in normal renal function, maimum 4g daily
Monitor for deterioration in renal function on 2g dose and consider reducing to 1g if necessary. For patients <50kg, usual maximum 4g daily.

Fluconazole Oral/IV

Renal FunctionDose
Normal50 - 400mg daily (up to 800mg has been used, but unlicensed)
GFR 10 - 5050-100% of normal dose
GFR <1050% of normal dose
Oral bioavailability 90%. No dose adjustment required for single dose therapy. many drug interactions so always check before prescribing

Gentamicin IV

Click here to see the section on Gentamicin

Levofloxacin Oral/IV

Normal renal function: Oral/IV 250-500mg every 12-24 hours

Dose Regimen
250mg/24 hours500mg/24 hours500mg/12 hours
Creatinine ClearanceFirst dose: 250mgFirst dose: 500mgFirst dose: 500mg
50-20ml/minthen: 125mg/24 hoursthen: 250mg/24 hoursthen: 250mg/12 hours
19-10ml/minthen: 125mg/48 hoursthen: 125mg/24 hoursthen: 125mg/12 hours
<10ml/minthen: 125mg/48 hoursthen: 125mg/24 hoursthen: 125mg/24 hours

Patients with renal impairment are at increased risk of rare but serious adverse effects of quinolones: Drug Safety Update so use with caution.

Meropenem IV

Renal FunctionDose
Normal500mg - 1g every 8 hours up to 2g every 8 hours in meningitis and CF
GFR 26 - 50500mg - 2g every 12 hours
GFR 10 - 25500mg - 1g every 12 hours or 500mg every 8 hours
GFR <10500mg - 1g every 24 hours

Metronidazole Oral/IV

Renal FunctionDose
NormalOral 200 - 400mg every 8 hours, IV 500mg every 8 hours
GFR <10 - 50Dose as in normal renal function

Increased incidence of GI reactions and vestibular toxicity in renal failure.

Nitrofurantoin Oral

Renal FunctionDose
NormalOral 50mg immediate release (IR) qds
GFR 45 - 60Dose as in normal renal function but see caution below
GFR <45Avoid

Anecdotally, nitrofurantoin may be used at GFR 40 – 60ml/min but with increased risk of treatment failure due to inadequate urine concentration and side effects.

Rifampicin Oral/IV

Renal FunctionDose
Normal300 - 600mg every 12 hours
GFR 10 - 50Dose as in normal renal function
GFR <1050 - 100% of normal dose

Reduce dose if LFTs are abnormal or patient <45kg.  Check for drug interactions before prescribing as rifampicin is a strong inducer of CYP450 and has many serious drug interactions.

Tazocin (Piperacillin/Tazobactam) IV

Renal FunctionDose
Normal4.5g every 8 hours, increase to every 6 hours in neutropenic sepsis
GFR 40 - 50Dose as in normal renal function
GFR 20 - 404.5g every 8 hours
GFR <204.5g every 12 hours

Patients with renal impairment are at a greater risk of neuromuscular excitability or convulsions that are associated with overdose.

Trimethoprim Oral

Renal FunctionDose
NormalTreatment: 200mg every 12 hours, Prophylaxis: 100mg nocte
GFR 15 - 50Dose as in normal renal function
GFR <1550 - 100% of dose

Serum creatinine may rise due to competition for renal secretion.  Hyperkalaemia is common in CKD 5 and transplant patients.  Short term folic acid supplementation may be prescribed in patients with CKD 4-5 to cover antifolate effects of treatment dose.

Vancomycin IV

Click here to see the section on Vancomycin

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