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Antibiotics Of Choice In Ckd

Types Of Uti And Treatment Implications

Antibiotic Classes in 7 minutes!!

The comments that follow focus on urethritis, cystitis, and pyelonephritis. The management of asymptomatic bacteriuria, chronic Foley catheterârelated bacteriuria, and prostatitis is not discussed.

A long-standing issue is whether UTI represent surface mucosal or parenchymal infections or both. Infections of the urethra are viewed as superficial, whereas pyelonephritis is considered a parenchymal infection. Cystitis ranges from mild to invasion of the wall of the bladder. So, which is more important: Adequate urine or serum concentrations of antimicrobial agents?

Data from UTI in animal models are helpful. High urine drug concentrations are necessary to sterilize urine for pyelonephritis, it is necessary to have effective tissue concentrations of the antimicrobial agent. The serum concentrations of anti-infectives correlate with the drug concentration in renal tissue . Glomerular filtration ± net tubular secretion determines urine concentration. Thus, for patients who have renal insufficiency with therapeutic serum drug levels and adequate arterial perfusion of the renal parenchyma, the delivery of therapeutic drug concentrations to both the parenchyma and the urine should not be a problem. For patients with chronic insufficiency and cystitis, there is a possibility that the urine drug concentration may be too low to eradicate the etiologic organism.

Optimal Antibiotic Dosage For Chronic Kidney Disease Patient: A Pharmacological Manual For Oral Clinicians

Volume 10, Issue 2, 2015

Page: Pages: 11


Chronic kidney disease, a gradual and inevitable deterioration in renalfunction, is the disease with the most associations in dentistry. Dosage adjustment is oneamongst the vital elements to be familiar with during their oral care. CKD patients take extendedduration to filter out medications, therefore dosage must always be tailored under thesupervision of nephrologist. The relished benefits from antibiotic could transform as anti-microbial resistanceon their abuse and nephrotoxic when contraindicated drugs are encouraged. New patented drug belonging tooxazoliodine group has driven the researchers to handle the emerging AMR. The present communication discussesthe pharmacological factors influencing in prescribing the antibiotics for CKD patient from the dentistspoint of view. The formulas destined for calculating the optimal dosage of antibiotics have been documentedto aid oral physicians.

Recent Patents on Anti-Infective Drug Discovery

Title:Optimal antibiotic dosage for chronic kidney disease patient: a pharmacological manual for oral clinicians

Volume: 10Issue: 2

Ramasamy Chidambaram


Keywords:Antibiotics, chronic kidney disease, dentist, dosage adjustment, glomerular filtration rate, nephrologist.

Why Does It Not Matter For Some Antibiotics

  • This applies to time-dependent killers which are not especially toxic.
  • Strictly speaking, β-lactams and carbapenems fall into the category of dose adjusted drugs, but realistically one can adjust either the dose OR the interval, because the risk of toxicity is rather low, and the patients tend to tolerate high peaks of concentration.
  • Practically speaking, β-lactams are usually interval-adjusted. This is actually a case of historical inertia. Back in the day, a bottle of Timentin cost a few hundred dollars, and rather than draw up a carefully dose-adjusted amount the penny-pinching intensivists would try to maximise the bacterial-death-toll-per-dollar-spent by interval adjusting it instead.

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Principles Governing The Adjustment Of Antibiotic Dose In Renal Failure

The main issue to keep mindful of is the reliance of the drug on renal excretion. The greatest disadvantage here is not to antimicrobial efficacy, but to the patient – accumulation will result in toxicity.

A peripheral issue is the killing characteristic of that drug in renal failure the concentration-dependent killers are largely unaffected, whereas the time-dependent killers enjoy a prolonged period of time at a satisfactory concentration over MIC.

Publications On Antibiotic Use And Stewardship Initiatives In Dialysis

SGLT2 inhibitors: a novel choice for the combination therapy in ...
  • Apata IW, Kabbani S, Neu AM, Kear TM, DAgata EMC, Levenson DJ, Kliger AS, Hicks LA, Patel PR. Opportunities to Improve Antibiotic Prescribing in Outpatient Hemodialysis Facilities AJKD 2020.
  • Hahn PD, Figgatt M, Peritz T, Coffin SE. Inappropriate intravenous antimicrobial starts: An antimicrobial stewardship metric for hemodialysis facilities.Infect Control Hosp Epidemiol. 2019:1-3.
  • DAgata EMC, Lindberg CC, Lindberg CM, et al. The positive effects of an antimicrobial stewardship program targeting outpatient hemodialysis facilities.Infect Control Hosp Epidemiol. 2018 39:1400-1405.
  • DAgata EMC, Tran D, Bautista J, Shemin D, Grima D. Clinical and Economic Benefits of Antimicrobial Stewardship Programs in Hemodialysis Facilities: A Decision Analytic Model.Clin J Am Soc Nephrol. 2018 13:1389-1397
  • Nguyen DB, Shugart A, Lines C, et al. National Healthcare Safety Network Dialysis Event Surveillance Report for 2014. Clin J Am Soc Nephrol. 2017 12:1139-1146.
  • Hui K, Nalder M, Buising K, et al. Patterns of use and appropriateness of antibiotics prescribed to patients receiving haemodialysis: an observational study.BMC Nephrol. 2017 18:156.
  • Snyder GM, Patel PR, Kallen AJ, Strom JA, Tucker JK, DAgata EM. Factors associated with the receipt of antimicrobials among chronic hemodialysis patients. Am J Infect Control. 2016 44:1269-1274.
  • St. Peter WL SC. Outpatient IV antibiotic use in the U.S. hemodialysis population, 1995 to 2007.

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Antibiotic Stewardship In Dialysis

CDC and partners published a white paper, Opportunities to Improve Antibiotic Prescribing in Outpatient Hemodialysis Facilities, external iconhighlighting opportunities and strategies to optimize antibiotic use in outpatient hemodialysis facilities.

To establish a framework to improve antibiotic use across different healthcare settings, CDC released the Core Elements of Antibiotic Stewardship. The Core Elements offer providers and facilities a set of principles to improve antibiotic use, optimize patient safety, and improve outcomes. There are no Core Elements specific to the outpatient dialysis setting. However, strategies that have been successful in other settings can be adapted to the outpatient dialysis setting and can improve antibiotic prescribing in this setting.

Some unique characteristics in outpatient dialysis settings that may inform these strategies include:

Drug Dosing In Chronic Kidney Disease

Aka: Drug Dosing in Chronic Kidney Disease, Medication Dosing in Chronic Kidney Disease, Renal Dosing, Antibiotic Dose Adjustments in Impaired Renal Function, Antihypertensive Dose Adjustments in Impaired Renal Function, Analgesic Dose Adjustments in Impaired Renal Function, ACE Inhibitor and Angiotensin Receptor Blocker Adjustments in Impaired Renal Function, End Stage Renal Disease Medication Dosing, Drug Dosing in ESRD, Drug Dosing in Renal Failure

  • 24 Hour Urine Creatinine Clearance
  • More accurate than CG when GFR < 60 ml/min/1.73 m2
  • Interpretation of GFR
  • Glomerular Filtration Rate> 50 ml/min/1.73 m2
  • III. Precautions: General

  • Loading doses require no renal dose adjustment
  • For patients on renal replacement
  • Dialyzed medications should be taken after Hemodialysis run for the day
  • Peritoneal Dialysis does not affect the timing of medications
  • For patients on Phosphate Binders
  • Take medications one hour before or 3 hours after Phosphate Binder dose
  • Maintenance doses can be adjusted in 2 ways
  • Reduce each dose, but maintain same dose interval
  • Risks toxicity due to drug accumulation
  • Maintain same dose, but lengthen dosing interval
  • Risks sub-therapeutic dosing
  • ACE Inhibitors or Angiotensin Receptor Blockers
  • Preferred agents in CRF
  • Moderate dose in most patients
  • Lower dose with severe Chronic Kidney Disease, CHF or age over 80 years
  • Anticipate a 15% increase in Serum Creatinine in week 1
  • Level usually returns to baseline by 4-6 weeks
  • Week 1-2 after each dose change, then
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    The Treatment Of Comorbidity In Ckd

    The treatment of comorbidity in patients with chronic renal insufficiency becomes an important issue no later than when CKD stage 4 is reached, with a GDR below 30 mL/min. The evidence grade and recommendation strength for the various treatment options can be derived from Cochrane Reviews and published meta-analyses .

    Are There Vitamins I Should Not Take

    Antibiotic Choices for Common Infections: Antibiotics Mnemonic How to Choose an Antibiotic

    Tell your doctor about all of the vitamins you are taking. If you have CKD, you should not take vitamins A, D, E and K unless your doctor prescribes them. These vitamins can build up in your system if your kidneys are not working well to filter extra vitamins out.

    If you start dialysis, your vitamin needs may change. Talk to your doctor about any changes you should make if your treatment plan changes.

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    Antibiotic Dosing In Renal Failure

    This has come up in Question 15.2 from the second paper of 2013. Question 13 from the first paper of 2010 also mentions it on a tangent. An excellent resource exists, which has more information on this topic. One can also pay eighty quid to publishers of the Renal Drug Database. The information below relates more to patients with renal impairment, rather than those who are subjected to regular or continuous dialysis .

    In brief:

    • Beta-lactams can be either dose-adjusted or interval-adjusted
    • Carbapenems can be either dose-adjusted or interval-adjusted
    • Aminoglycosides keep the same dose, and are interval-adjusted
    • Fluoroquinolones keep the same dose, and are interval-adjusted
    • Glycopeptides keep the same dose, and are interval-adjusted

    A List Of Toxic Antibiotics Which Rely Significantly On Renal Excretion:

    • β-lactams, cephalosporins, carbapenems: apart from notable exceptions , they are all reliant on renal clearance.
    • Aminoglycosides: gentamicin and amikacin are both filtered freely by the glomerulus, and not reabsorbed.
    • Fluconazole unlike all the other “azoles”.
    • Aciclovir, gancyclovir
    • Vancomycin which is itself reasonably nephrotoxic

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    Renal Dosing For Commonly Used Oral Antibiotics

    The kidneys are one of the most important organs responsible for eliminating substances from the body. Structural damage to the excretion mechanisms of the kidneys slows the filtration and elimination process down, allowing drug metabolites to stay in the body for longer periods of time. For some medications with inactive and harmless metabolites, this is not a relevant issue. However, for medications with active metabolites or medications that are not completely metabolized by the liver, this poses a potentially significant problem. The inability to efficiently eliminate active drug molecules puts patients at risk for harmful adverse effects. Antibiotics are particularly interesting in this regard. When dosed appropriately and efficiently eliminated by the body, side effect profiles are often mild and harmless. However, when dosed inappropriately in a patient with renal impairment, active drug molecules or metabolites can build up and may induce or exacerbate neurological, cardiac, or pulmonary comorbid conditions.

    The table below provides a foundation for dosing common antibiotics in patients with renal impairment. It is important to utilize this table in the manner in which it was intended purely as a reference point. Individualize treatment based on the patient and the indication that is being treated.

    Special Aspects Of Pharmacotherapy In Renal Insufficiency

    SGLT2 inhibitors: a novel choice for the combination therapy in ...

    If the GFR is below 60 mL/min, i.e., if the patient is in CKD stage 3 or higher, certain drugs should no longer be given, either because they tend to damage the kidneys or because they are insufficiently eliminated by poorly functioning kidneys and will therefore accumulate in the body and cause toxic side effects on other organs . Radiological contrast media containing iodine should be given to patients with renal insufficiency only after prophylactic hydration. In order to prevent contrast-medium toxicity, the authors additionally give 1600 mg of MESNA in 500 mL of normal saline 0.9% intravenously immediately before and during the contrast study . In CKD stage 4 and above, magnetic resonance imaging with gadolinium is no longer a risk-free alternative to iodinated media. In these stages of CKD, gadolinium preparations can cause a serious condition known as nephrogenic systemic fibrosis. Thus, if the GFR is under 30 mL/min, gadolinium should be eliminated from the body with hemodialysis immediately after the MRI study .

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    Why Would You Dose

    • This is most relevant to time-dependent killers which have significant toxicity associated with high concentration peaks.
    • Fluoroquinolones are the classical example.
    • The most important objective is to remain above the MIC for the longest possible time.
    • With impaired renal clearance mechanisms, the drug virtually does this all by itself.
    • All you need to do is give a loading dose, and then ensure that small regular doses are given to maintain the concentration above MIC. This way, the concentration remains adequate, but small regular doses ensure that high peak levels are not achieved

    Antibiotics And Kidney Disease

    Surgical patients with renal disease offer special challenges to the treating doctor. Antibiotic coverage during the perioperative period if merited should be carefully chosen. These general guidelines listed are no substitute for a nephrology consultation prior to surgery. The renal specialist plays an important role in medication choice and dosage.

    SAFE ANTIBIOTICSMetronidazole: Normal dose for Mild/Mod. diseaseVancomycin Pulvules

    Metronidazole: Prolong interval for severe diseaseIV Vancomycin: Avoid1)Pen VK: INTERVAL PROLONGED DOSE UNCHANGED

    a)Serum Creatinine < 2.0 mg/dL or the CrCl is > 50 mL/minute:Pen VK is dosed normally at 250-500 mg PO q6hb)S. Creatinine 2.0 mg/dL to Predialysis or CrCl 10-50 mL/minute:Pen VK is dosed at 250-500 mg q8-12hc)Patient on Dialysis:Pen VK is dosed at 250-500 q12-16h


    a)Serum Creatinine below 3.3 mg/dL or Cr Cl > 30 ml/minute:Dispense the normal dose of Amoxicillin: 250-500 mg PO q8hb)Serum Creatinine above 3.3 mg/dL to Predialysis or Cr Cl 10-30 ml/minute:Prolong the interval and dispense: 250-500 mg PO q12hAvoid using the 875 mg tabletc)Cr Cl < 10 ml/minute or the Dialysis Patient:Prolong the interval and dispense: 250-500 mg PO q24hThe dose must be administered after dialysis completion

    3)Augmentin:Decrease the total dosage by 50% in the renal compromised patient

    7)Doxycycline:No dose change needed with kidney/live/kidney & liver disease

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    A List Of Antibiotics Which Do Not Require Any Dose Adjustment In Renal Failure:

    • Linezolid: it is cleared by both renal and nonrenal mechanisms.

    Chertow, Glenn M., et al. “Guided medication dosing for inpatients with renal insufficiency.” Jama 286.22 : 2839-2844.

    Linton, A. L., and D. H. Lawson. “Antibiotic therapy in renal failure.”Proceedings of the European Dialysis and Transplant Association. Vol. 1. 1970.

    Bekersky, Ihor, et al. “Pharmacokinetics, excretion, and mass balance of liposomal amphotericin B and amphotericin B deoxycholate in humans.” Antimicrobial agents and chemotherapy 46.3 : 828-833.

    Atkinson, Arthur J., and John E. Bennett. “Amphotericin B pharmacokinetics in humans.” Antimicrobial agents and chemotherapy 13.2 : 271-276.

    Paeske, B., and P. Koeppe. “Pharmacokinetics of azithromycin in normal and impaired renal function.” Infection 23.6 : 356-361.

    Patel, I. H., et al. “Pharmacokinetics of ceftriaxone in humans.” Antimicrobial agents and chemotherapy 20.5 : 634-641.

    Kasten, Mary Jo. “Clindamycin, metronidazole, and chloramphenicol.” Mayo Clinic Proceedings. Vol. 74. No. 8. Elsevier, 1999.

    Estimating Gfr And Creatinine Clearance

    What are the Best Antibiotics for a Kidney Infection

    Dosages of drugs cleared renally are based on renal function . These calculations are valid only when renal function is stable and the serum creatinine level is constant.

    The K/DOQI clinical practice guideline advocates using the traditional Cockcroft-Gault equation or the Modification of Diet in Renal Disease study equation for routine estimation of GFR.1 However, in patients with a GFR lower than 60 mL per minute per 1.73 m2, the MDRD equation has been shown to be superior to the Cockcroft-Gault equation.2

    Because the production and excretion of creatinine declines with age, normal serum creatinine values may not represent normal renal function in older patients. The MDRD equation has been shown to be the best method for detecting a GFR lower than 90 mL per minute per 1.73 m2 in older patients.3

    Age, weight, sex, serum creatinine Nephron Information Center Web site:
    Modification of Diet in Renal Disease Age, sex, race, serum urea nitrogen, serum albumin, serum creatinine National Kidney Disease Education Program Web site:
    Nephron Information Center Web site:

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    How Will I Know Which Medicines Are Right For Me

    The only way to know which medicines are right for you is to talk to your doctor. Your doctor will choose medicines for you based on many factors, including:

    • Other medicines you are taking

    Talk to your doctor and other health care providers to understand all your prescribed medicines:

    • Learn the names of the medicines your doctor prescribes
    • Understand how each medicine works to keep you healthy
    • Know when to take different medicines, such as before bed or after eating
    • Know which medicines you can or cannot take together

    Always talk to your doctor before you start or stop any medicines, including any vitamins and supplements.

    Antibiotics Are They Safe If You Have Chronic Kidney Disease

    Emily Cahill

    Many drugs have the ability to damage the kidneys and some are better known for doing this than others. Certain antibiotics fall into this category and are classified as nephrotoxic medications. Lets take a closer look at which antibiotics carry a greater risk of causing kidney damage, how this happens and importantly what you can do to reduce this risk.

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    Medications & Kidney Disease

    People with chronic kidney disease are often prescribed multiple medications. Understand the impact of medications plus which ones to avoid.

    If you have chronic kidney disease you can often be prescribed multiple medications, some of which can slow down the damage being caused to your kidneys. It’s important to understand the impact these can have on your kidneys.

    If you’re living with chronic kidney disease, your health professional may prescribe several medications including:

    • anti-hypertensives to control your blood pressure
    • medications to keep your heart healthy, for example cholesterol tablets
    • medications to control other health conditions you may be living with such as diabetes, thyroid disorders, pain and arthritis
    • diuretics to increase your urine output
    • phosphate binders to control your phosphate levels
    • vitamin D to maintain strong bones and other benefits
    • injections, including erythropoeitin and iron, to control anaemia

    The medications you’re prescribed will depend on your overall health, the stage of chronic kidney disease you have and your treatment options. The medications you take will also adapt over time as your overall condition and health change.

    Some medications, such as certain medications for blood pressure and diabetes, can actually slow down the damage to your kidneys. Each medication is given for a particular reason and should be taken as directed.

    To get the full benefits of your medications, it’s important to:

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