Antibiotics and chronic kidney disease: Dose adjustment update for infectious disease clinical practice

ECEIM consensus statement on equine kidney disease

The aim of this consensus statement is to summarize and appraise scientific evidence and combine this with the clinical experience of a panel of experts to optimize recommendations on how to recognize and manage kidney disease in horses.

Prospective Comparison of Urinary Measured Creatinine Clearance With eGFR and Cystatin C Based Cis-eGFR, Including Kinetic eGFR in the Immediate Post-transplant Period With Prompt Allograft Function

BACKGROUND

The estimated glomerular filtration rate (eGFR) and kinetic estimated glomerular filtration rate (KeGFR) have not been compared, with urinary measured creatinine clearance (mCrCl) or serum cystatin C (CysC) eGFR, soon after kidney transplantation (KTx) with prompt primary function. This study aims to compare post-KTx, urinary mCrCl, and eGFR CysC with eGFR and KeGFR.

METHODS

Post-KTx, urine was collected every 12 hours from 25 of the 34 consenting subjects to calculate mCrCl and compare with Modification of Diet in Renal Disease (MDRD)-4, Jelliffe eGFR, Cockcroft-Gault creatinine clearance (CrCl), and KeGFR by Chen and Brater formulae. Serum CysC levels were also measured in the last 14 subjects to compare with creatinine, mCrCl, and eGFR CysC. RESULTS: At 12 to 96 hours post-KTx (n = 25), mCrCl was 55.8% to 13.6% higher than MDRD-4 eGFR. The mean CysC level (n = 14) was 58% to 14% lower than creatinine for up to 3.0 days post-KTx, with higher MDRD-4 eGFR CysC. Chen and Brater KeGFR were significantly lower than mCrCl and eGFR (Fig 1B, Table 1). Within 3 days post-KTx, a 50% decrease in creatinine provided ≥ 50 mL/min CrCl in 90% of cases (mean mCrCl 61.7 ± 22.8). This difference was greater when the initial creatinine was higher with the rapid decrease in creatinine.

CONCLUSIONS

(1) Post-KTx eGFR/KeGFR formulae underestimated mCrCl. (2) Serum CysC levels were lower than creatinine, corresponding with higher eGFR CysC. (3) A 50% decrease from initial serum creatinine; mean mCrCl was 61.7 ± 22.8 mL/min, and 90% of them have mCrCl > 50 mL/min. Post-KTx, until creatinine is stabilized, recipients are often receiving subtherapeutic dosing of renally adjusted medications. More prospective studies are necessary, including radioisotope clearance.

Frequency and Risk Factor Analysis for Metronidazole-Associated Neurologic Adverse Events

BACKGROUND

Little is known about the risk factors and frequency of metronidazole-associated neurological adverse events.

OBJECTIVE

To investigate the risk factors and frequency of metronidazole-associated neurological adverse events.

DESIGN

This retrospective study contained two parts. First, we investigated metronidazole treatment-associated neurologic adverse events by performing a population-based cohort study using the Korea Adverse Event Reporting System (KAERS) database from January 2011 to December 2020. Second, we conducted a matched case-control study based on a retrospective cohort of patients treated with metronidazole between January 2006 and July 2021 at a tertiary hospital in South Korea. The data analysis was performed from August 2021 to April 2022.

PARTICIPANTS

In the case-control study, case patients were defined as those diagnosed with metronidazole-associated encephalopathy or peripheral neuropathy during the study period with causal assessment based on the clinical diagnoses and findings from associated tests. In a ratio of 1:3, case patients were compared to a control group of patients prescribed metronidazole without neurologic adverse events matched for age and cumulative dose of metronidazole.

MAIN MEASURES

Frequency and risk factors for metronidazole-associated neurological adverse events.

KEY RESULTS

Overall, 2,309 cases of neurologic adverse events were reported to the KAERS from 2011 to 2020, and the number of reported neurological adverse events showed an increasing trend. Further, 92,838 patients were prescribed metronidazole during the study period at the Severance Hospital; 54 patients were diagnosed with metronidazole-associated encephalopathy or peripheral neuropathy, 40 with central and 28 with peripheral nervous system adverse events. Liver cirrhosis, chronic kidney disease, intravenous administration, and lower body weight were identified as risk factors for these adverse events.

CONCLUSIONS

The number of reported metronidazole-associated neurological adverse events are increasing. Prolonged metronidazole treatment in patients with the aforementioned factors requires careful examination for neurological adverse events.

Helicobacter pylori Eradication Therapy in Patients with Decreased Renal Function: A Systematic Review

Background: There are concerns that Helicobacter pylori eradication therapy may worsen kidney function in patients with decreased renal function. This study aimed to systematically review the literature regarding Helicobacter pylori eradication in patients with renal impairment. Methods: PubMed, the Cochrane Library, and Igaku Chuo Zasshi were searched for comparative studies on H. pylori eradication in patients with renal impairment. Results: Five articles were included in this systematic review. According to a randomized trial comparing a proton pump inhibitor (PPI) + clarithromycin + metronidazole and PPI + clarithromycin + amoxicillin in patients with decreased renal function, the incidence of acute renal failure was significantly lower in PPI + clarithromycin + metronidazole (2%: 1/44) than in PPI + clarithromycin + amoxicillin (18%: 8/44). The eradication rate in PPI + clarithromycin + metronidazole (92.5%) was significantly better than that in PPI + clarithromycin + amoxicillin (76.3%). According to four reports on eradication treatment using PPI + clarithromycin + amoxicillin in patients with and without decreased renal function, the eradication rates and adverse effects were similar in both groups. Regarding dose adjustment, three reports reduced the dose of antibiotics by half in patients with a creatinine clearance of 30 mL/min or less. Conclusions: The regimen with PPIs, clarithromycin, and metronidazole is recommended for renal impairment. The combination of PPIs, clarithromycin, and amoxicillin, at reduced doses depending on the renal function, is also a potential option.

Practice guidelines for the management of Helicobacter pylori infection: The Saudi H. pylori Working Group recommendations

The eradication rates for Helicobacter pylori globally are decreasing with a dramatic increase in the prevalence of antibiotic resistant bacteria all over the world, including Saudi Arabia. There is no current consensus on the management of H. pylori in Saudi Arabia. The Saudi Gastroenterology Association developed these practice guidelines after reviewing the local and regional studies on the management of H. pylori. The aim was to establish recommendations to guide healthcare providers in managing H. pylori in Saudi Arabia. Experts in the areas of H. pylori management and microbiology were invited to write these guidelines. A literature search was performed, and all authors participated in writing and reviewing the guidelines. In addition, international guidelines and consensus reports were reviewed to bridge the gap in knowledge when local and regional data were unavailable. There is limited local data on treatment of H. pylori. The rate of clarithromycin and metronidazole resistance is high; therefore, standard triple therapy for 10-14 days is no longer recommended in the treatment of H. pylori unless antimicrobial susceptibility testing was performed. Based on the available data, bismuth quadruple therapy for 10-14 days is considered the best first-line and second-line therapy. Culture and antimicrobial susceptibility testing should be considered following two treatment failures. These recommendations are intended to provide the most relevant evidence-based guidelines for the management of H. pylori infection in Saudi Arabia. The working group recommends further studies to explore more therapeutic options to eradicate H. pylori.

Preventive Action of Beta-Carotene against the Indoxyl Sulfate-Induced Renal Dysfunction in Male Adult Zebrafish via Regulations of Mitochondrial Inflammatory and β-Carotene Oxygenase-2 Actions

Indoxyl sulfate (IS) is a metabolic byproduct of indole metabolism. IS readily interacts with the mitochondrial redox metabolism, leading to altered renal function. The β-carotene oxygenase-2 (BCO2) enzyme converts carotenoids to intermediate products. However, the role of β-carotene (BC) in IS-induced renal dysfunction in zebrafish and their modulatory action on BCO2 and mitochondrial inflammations have not been explored yet. Hence, the present study is designed to investigate the role of BC in the attenuation of IS-induced renal dysfunction via regulations of mitochondrial redox balance by BCO2 actions. Renal dysfunction was induced by exposure to IS (10 mg/L/hour/day) for 4 weeks. BC (50 and 100 mg/L/hour/day) and coenzyme Q10 (CoQ10; 20 mg/L/hour/day) were added before IS exposure. BC attenuated the IS-induced increase in blood urea nitrogen (BUN) and creatinine concentrations, adenosine triphosphate (ATP), and complex I activity levels, and the reduction of renal mitochondrial biomarkers, i.e., BCO2, superoxide dismutase-2 (SOD2), glutathione peroxidase-1 (GPX1), reduced and oxidized glutathione (GSH/GSSG) ratio, and carbonylated proteins. Moreover, renal histopathological changes were analyzed by the eosin and hematoxylin staining method. As a result, the administration of BC attenuated the IS-induced renal damage via the regulation of mitochondrial function.

The roles of gut microbiota and its metabolites in diabetic nephropathy

Diabetic nephropathy (DN) is a severe microvascular complication of diabetes, which increases the risk of renal failure and causes a high global disease burden. Due to the lack of sustainable treatment, DN has become the primary cause of end-stage renal disease worldwide. Gut microbiota and its metabolites exert critical regulatory functions in maintaining host health and are associated with many pathogenesis of aging-related chronic diseases. Currently, the theory gut-kidney axis has opened a novel angle to understand the relationship between gut microbiota and multiple kidney diseases. In recent years, accumulating evidence has revealed that the gut microbiota and their metabolites play an essential role in the pathophysiologic processes of DN through the gut-kidney axis. In this review, we summarize the current investigations of gut microbiota and microbial metabolites involvement in the progression of DN, and further discuss the potential gut microbiota-targeted therapeutic approaches for DN.

Physiologically-based pharmacokinetic modeling for single and multiple dosing regimens of ceftriaxone in healthy and chronic kidney disease populations: a tool for model-informed precision dosing

Introduction: Ceftriaxone is one of commonly prescribed beta-lactam antibiotics with several label and off-label clinical indications. A high fraction of administered dose of ceftriaxone is excreted renally in an unchanged form, and it may accumulate significantly in patients with impaired renal functions, which may lead to toxicity. Methods: In this study, we employed a physiologically-based pharmacokinetic (PBPK) modeling, as a tool for precision dosing, to predict the biological exposure of ceftriaxone in a virtually-constructed healthy and chronic kidney disease patient populations, with subsequent dosing optimizations. We started developing the model by integrating the physicochemical properties of the drug with biological system information in a PBPK software platform. A PBPK model in an adult healthy population was developed and evaluated visually and numerically with respect to experimental pharmacokinetic data. The model performance was evaluated based on the fold error criteria of the predicted and reported values for different pharmacokinetic parameters. Then, the model was applied to predict drug exposure in CKD patient populations with various degrees of severity. Results: The developed PBPK model was able to precisely describe the pharmacokinetic behavior of ceftriaxone in adult healthy population and in mild, moderate, and severe CKD patient populations. Decreasing the dose by approximately 25% in mild and 50% in moderate to severe renal disease provided a comparable exposure to the healthy population. Based on the simulation of multiple dosing regimens in severe CKD population, it has been found that accumulation of 2 g every 24 h is lower than the accumulation of 1 g every 12 h dosing regimen. Discussion: In this study, the observed concentration time profiles and pharmacokinetic parameters for ceftriaxone were successfully reproduced by the developed PBPK model and it has been shown that PBPK modeling can be used as a tool for precision dosing to suggest treatment regimens in population with renal impairment.

Pharmacokinetics of Antibacterial Agents in the Elderly: The Body of Evidence

Infections are important factors contributing to the morbidity and mortality among elderly patients. High rates of consumption of antimicrobial agents by the elderly may result in increased risk of toxic reactions, deteriorating functions of various organs and systems and leading to the prolongation of hospital stay, admission to the intensive care unit, disability, and lethal outcome. Both safety and efficacy of antibiotics are determined by the values of their plasma concentrations, widely affected by physiologic and pathologic age-related changes specific for the elderly population. Drug absorption, distribution, metabolism, and excretion are altered in different extents depending on functional and morphological changes in the cardiovascular system, gastrointestinal tract, liver, and kidneys. Water and fat content, skeletal muscle mass, nutritional status, use of concomitant drugs are other determinants of pharmacokinetics changes observed in the elderly. The choice of a proper dosing regimen is essential to provide effective and safe antibiotic therapy in terms of attainment of certain pharmacodynamic targets. The objective of this review is to perform a structure of evidence on the age-related changes contributing to the alteration of pharmacokinetic parameters in the elderly.

Safety and Tolerability of Antimicrobial Agents in the Older Patient

Older patients are at high risk of infections, which often present atypically and are associated with high morbidity and mortality. Antimicrobial treatment in older individuals with infectious diseases represents a clinical challenge, causing an increasing burden on worldwide healthcare systems; immunosenescence and the coexistence of multiple comorbidities determine complex polypharmacy regimens with an increase in drug-drug interactions and spread of multidrug-resistance infections. Aging-induced pharmacokinetic and pharmacodynamic changes can additionally increase the risk of inappropriate drug dosing, with underexposure that is associated with antimicrobial resistance and overexposure that may lead to adverse effects and poor adherence because of low tolerability. These issues need to be considered when starting antimicrobial prescriptions. National and international efforts have been made towards the implementation of antimicrobial stewardship (AMS) interventions to help clinicians improve the appropriateness and safety of antimicrobial prescriptions in both acute and long-term care settings. AMS programs were shown to decrease consumption of antimicrobials and to improve safety in hospitalized patients and older nursing home residents. With the abundance of antimicrobial prescriptions and the recent emergence of multidrug resistant pathogens, an in-depth review of antimicrobial prescriptions in geriatric clinical practice is needed. This review will discuss the special considerations for older individuals needing antimicrobials, including risk factors that shape risk profiles in geriatric populations as well as an evidence-based description of antimicrobial-induced adverse events in this patient population. It will highlight agents of concern for this age group and discuss interventions to mitigate the effects of inappropriate antimicrobial prescribing.

Physiologically based pharmacokinetic-pharmacodynamic evaluation of meropenem in CKD and hemodialysis individuals

Objective: Chronic kidney disease (CKD) has significant effects on renal clearance of drugs. The application of antibiotics in CKD patients to achieve the desired therapeutic effect is challenging. This study aims to determine meropenem plasma exposure in the CKD population and further investigate optimal dosing regimens. Methods: A healthy adult PBPK model was established using the meropenem's physicochemical parameters, pharmacokinetic parameters, and available clinical data, and it was scaled to the populations with CKD and dialysis. The differences between the predicted concentration, C_max, and AUC_last predicted and observed model values were assessed by mean relative deviations (MRD) and geometric mean fold errors (GMFE) values and plotting the goodness of fit plot to evaluate the model's performance. Finally, dose recommendations for CKD and hemodialysis populations were performed by Monte Carlo simulations. Results: The PBPK models of meropenem in healthy, CKD, and hemodialysis populations were successfully established. The MRD values of the predicted concentration and the GMFE values of C_max and AUC_last were within 0.5-2.0-fold of the observed data. The simulation results of the PBPK model showed the increase in meropenem exposure with declining kidney function in CKD populations. The dosing regimen of meropenem needs to be further adjusted according to the renal function of CKD patients. In patients receiving hemodialysis, since meropenem declined more rapidly during the on-dialysis session than the off-dialysis session, pharmacodynamic evaluations were performed for two periods separately, and respective optimal dosing regimens were determined. Conclusion: The established PBPK model successfully predicted meropenem pharmacokinetics in patients with CKD and hemodialysis and could further be used to optimize dosing recommendations, providing a reference for personalized clinical medication.

Antibiotic utilization study in a teaching hospital in Nigeria

Background

Antibiotics have been the bedrock of modern medical care, particularly bacterial infections. However, globally, antimicrobial resistance has become a well-recognized public health threat in recent years, and interventions to reduce its burden have been launched worldwide.

Objectives

The present study evaluated antibiotic utilization in both hospitalized patients and outpatients in a University Hospital in Nigeria.

Methods

In a 3 year retrospective study between January 2017 and December 2019, 246 case files of patients were selected for the study based on inclusion and exclusion criteria. In addition, the antibiotic consumption rate for hospitalized and outpatients was determined.

Results

The total antibiotic consumption for hospitalized patients in this study was 260.9 DDD/100 bed-days, while the outpatient department’s patients were 72.3 DDD/1000 inhabitants per day. Peptic ulcer disease was the most frequent indication for antibiotic use for outpatients, with the fluoroquinolones and macrolides being the most prescribed antibiotic class and antibiotic class with the highest DDD, respectively. The most frequent indication for antibiotic use for hospitalized patients was chronic kidney diseases, with the fluoroquinolones and second-generation cephalosporins being the most prescribed antibiotic class and antibiotic class with the highest DDD, respectively. DDD per 100 bed-days and DDD per 1000 patient-days were highest in 2018. The P values for the years were 0.019, 0.195 and 0.001 for 2017, 2018 and 2019, respectively.

Conclusions

Our findings revealed irrationality in antibiotic use. Therefore, antimicrobial stewardship programmes should be implemented.

Drug-Dosing Adjustment in Dogs and Cats with Chronic Kidney Disease

Chronic kidney disease is a common kidney disorder in adult and aged dogs and cats; the management of associated complications and comorbidities generally requires a life-long medical treatment to ensure a good quality of life of affected patients. However, indications and the literature on drug dosing in dogs and cats with chronic kidney disease are often lacking. The aim of this review is to revise the current literature on drug dosing in canine and feline patients with renal impairment, with a special focus on the most commonly used medications to manage chronic kidney disease and possible comorbidities.

Antibiotic dosing adjustments in hospitalized patients with chronic kidney disease: a retrospective chart review

BACKGROUND

Infections in patients with chronic kidney disease (CKD) are a major cause of hospitalization. The pharmacokinetics of renally eliminated antibiotics may lead to drug accumulation, resulting in potential toxicity. The renal dosing adjustment of antibiotics is crucial to avoid toxicity and decrease mortality. In Lebanon, limited data are available on antibiotic dose adequacy in CKD.

OBJECTIVES

To estimate the prevalence of inappropriately dosed antibiotics in non-dialysis CKD patients and to identify possible risk factors that may be associated with unadjusted renal dosing.

METHODS

A retrospective chart review was conducted at two tertiary-care hospitals in Lebanon. International Statistical Classification of Diseases (ICD-10) code for CKD was used to search the databases. Demographic and clinical data were collected for patients who received antibiotics that requires renal dosing adjustment. Lexi-Comp online Drug Information database was the guideline used to evaluate the appropriateness of dosing.

RESULTS

A total of 495 antibiotic orders were dispensed to 190 patients. 51.6% of patients received antibiotics without renal dose adjustments. The most inappropriately dosed class was penicillins (39.8%), while fluoroquinolones were the most adequately adjusted. Piperacillin/tazobactam was the most frequently prescribed drug (30.6%) without renal dose adjustment. Respiratory infections (OR 1.301, CI 95% 1.327-1.915) and multimorbidity (OR 1.183, CI 95% 1.358-2.081) were statistically highly significant associations for unadjusted antibiotic dosing from the fitted multivariable-adjusted logistic models.

CONCLUSION

Our study revealed a high frequency of guideline-discordant antibiotic dosing in patients with CKD. This dosing error is preventable by increasing awareness of prescribing physicians and collaborating with clinical pharmacists.