Appendix 1 - Antibiotic administration and dose reduction in renal impairment summary (H@H)

Antimicrobial prescribing: NHS Lothian
NHS Lothian

Drug

Administration

Dosage reduction in renal impairment

Availability of suspension

Additional information

Amoxicillin

Dilute the IV dose to 100mL in sodium chloride 0.9% and give by infusion over 30 to 60 minutes

No dose reduction required with initial STAT IV dose at any level of renal impairment.

 

Amoxicillin 250mg/5ml (100ml)

 

 Clarithromycin

 Oral only

 

No reduction to oral doses.

Clarithromycin 250mg/5ml (70ml)

Check BNF for interactions, particularly with statins, warfarin, quinolones and steroids

 Co-trimoxazole

 Oral only

 

Use half normal dose (480mg twice daily) if
eGFR 15–30 mL/minute/1.73 m2.

Avoid if eGFR less than 15 mL/minute/1.73 m2

Co-trimoxazole suspension 480mg/5ml
(100ml)

 

Doxycycline

 Oral

No dose reduction required.

Dispersible tablets (100mg)

Swallow with plenty fluid in upright position.

If gastric irritation - give with food or milk.

Flucloxacillin

 Oral

No reduction to oral doses.

 

30 minutes to 1 hour before meals

Fosfomycin

 Oral

Contraindicated if CrCl <10ml/min (due to prolonged half-life)

 

Dissolve granules in water and take immediately, on an empty stomach (about 2–3 hours before or after a meal), ideally before bedtime, after emptying the bladder.

Gentamicin

IV infusion: Give over 30 minutes as per the NHS Lothian Gentamicin Policy. Dilute with 50 to 100ml Sodium Chloride 0.9% or Glucose 5%

Use calculator

n/a

 

Metronidazole

 Oral / PR

No dose reduction required.

Metronidazole 200mg/5ml (100ml)

Suppositories 1g

With/ after food, with water.

Avoid alcohol.

Nitrofurantoin

 Oral

In patients with an eGFR of less than 45 ml/minute. Nitrofurantoin may be used with caution for short-course therapy only in uncomplicated lower urinary tract infection, with eGFR 30-44 ml/min to treat resistant pathogens, when the benefits are expected to outweigh the risks.

Do not use suspension due to cost >£400.  Non m/r formulation may be more appropriate for some patients.

With food or meals

Pivmecillinam

 Oral

No dose reduction required.

 

Tablets should be swallowed whole with plenty of fluid during meals while sitting or standing.

Teicoplanin

See NHS Lothian IV handbook for reconstitution guidance:

Doses ≤800mg as IV infusion in 100ml over 30 minutes

Doses ≥800mg as IV infusion in 100ml over one hour

The teicoplanin dosing regimen adapted for H@H is based on the patient creatinine clearance.

 

n/a

Note while OPAT may bolus doses this is not advised for H@H situations. The H@H teicoplanin regimen is not for deep-seated infections- if this is a concern please contact an infection specialist.

Trimethoprim

 Oral

Use half normal dose after 3 days if eGFR 15–30 mL/minute/1.73 m2. Raised serum creatinine and blood urea nitrogen levels.

Use half normal dose if eGFR less than 15 mL/minute/1.73 m2.(BNF)

Note: Trimethoprim inhibits the tubular creatinine secretion leading to a rapid but reversible increase in serum creatinine, independent of any changes in GFR. This translates into falsely low estimates of GFR when creatinine based equations are used. See publication below.

Nephron Clin Pract 2011;119:c187–c194

Trimethoprim suspension 50mg/5ml (100ml)

Causes hyperkalaemia