Antimicrobial dose adjustment by renal function in adult Intensive Care Unit
DOI:
https://doi.org/10.30968/rbfhss.2023.142.0960Abstract
Objective: to identify antimicrobial dose adjustments according to renal function in prescriptions for patients hospitalized in an adult ICU of a general hospital in southern Brazil. Methods: observational, retrospective cross-sectional study, carried out in an adult ICU of a general hospital in southern Brazil from January to December 2021. All adult patients with ≥48 hours of ICU stay, creatinine clearance (CrCl) ≤60 mL/min/1.73 m2 and use of one or more of the following antimicrobials: amikacin, ampicillin, ampicillin/sulbactam, cefepime, ceftazidime/avibactam, fluconazole, levofloxacin, meropenem, piperacillin/tazobactam and/or voriconazole. Renal function was estimated from serum creatinine using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, and dose appropriateness was determined by comparing practice to specific guidelines. Sociodemographic variables (gender, age, ethnicity) were evaluated, in addition to the influence of possible determinants, such as: duration of antimicrobial use, length of stay, mortality, among others. Results: 151 patients were included, totaling 906 possibilities for adjusting the dose of antimicrobials based on renal function. Among the 906 possibilities, 546 (60.3%) were properly adjusted, 69 (7.6%) were inadequately adjusted, and 291 (32.1%) were not adjusted. Voriconazole was associated with a greater proportion of unadjusted doses 6/6 (100%), while piperacillin/tazobactam was associated with a greater proportion of adjustments not recommended in the literature 41/268 (15.3%). Fluconazole had its doses properly adjusted according to renal function in all situations 21/21 (100%). The duration of antimicrobial use between patients with dose adjustment and those treated with the usual dose was 10 and 11 days, respectively (p <0.001), and the length of ICU stay in the respective groups was 14 and 18 days ( p<0.001). Conclusions: Our findings revealed a high percentage of antimicrobial dose adjustment according to renal function for ICU patients compared to other studies that evaluated non-critical patients. The data suggest that the involvement of physicians and pharmacists to ensure adequate dosage of nephrotoxic antimicrobials according to renal function has significantly contributed to more favorable patient outcomes.
Downloads
References
Sousa PCP, Rocha MVAP, Sousa FSP, et al. Utilização de antibacterianos em Unidade de Terapia Intensiva. Rev Cient Inter. 2011;1(18):15.
Karpa K, Difelice R. Drug toxicity in kidney disease: A standardized patient case for clerkship students. Mededportal. 2016;12:1-7. DOI: 10.15766/mep_23748265.10464.
Getachew H, Tadesse Y, Shibeshi W. Drug dosage adjustment in hospitalized patients with renal impairment at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. BMC Nephrol. 2015;16(1):1-9. DOI: 10.1186/ s12882-015-0155-9.
Brito TNS, Oliveira ARA, Silva AKC. Glomerular filtration rate estimated in adults: characteristics and limitations of equations used. Rev Bras Anal Clin. 2016;1(48):7-12.
Matzke GR, Aronoff GR, Atkinson JAJ, et al. Drug dosing consideration in patients with acute and chronic kidney disease: Improving Global Outcomes (KDIGO). Kidney Int. 2011;80(11):1122-37. DOI: 10.1038/ki.2011.322.
Dorks M, Allers K, Schmiemann G, et al. Inappropriate medication in nonhospitalized patients with renal insufficiency: a systematic review. J Am Geriatr Soc. 2017;65(4): 853- 862. DOI: 10.1111/jgs.14809.
Fideles GMA, Alcantra NJM, Peixoto JAA, et al. Recomendações farmacêuticas em unidade de terapia intensiva: três anos de atividades clínicas. Rev Bras Ter Intensiva. 2015; 27(2):149-154. DOI: 10.5935/0103-507X.20150026.
Maes KA, Studer H, Berger J, et al. Documentation of pharmaceutical care: validation of a intervention oriented classification system. J Eval Clin Pract. 2017;23(6):1425-1432. DOI: 10.1007/s11096-017-0442-6.
Isaias MDF. Estudo das Intervenções Farmacêuticas em uma Unidade de Terapia Intensiva de um Hospital Privado de São Luís, Maranhão, Brasil. TCC (Graduação) - Curso de Farmácia, Universidade Federal do Maranhão, São Luís, 2019.
Santa Casa de Misericórdia de Porto Alegre. Sobre a Santa Casa. Available in: https://www.santacasa.org.br/pagina/sobre-a-santa-casa. Acessed on: 4th Oct 2021.
Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int (Suppl). 2013; 3:1-150.
Micromedex [Homepage na Internet]. Available in: https://psbe.ufrn.br/index.php?option=com_content&view=article&id=36&Itemid=248. Acessed on: 4th Oct 2021.
Up to date [Homepage na Internet]. Available in: https://www.uptodate.com/contents/search. Acessed on: 4th Oct 2021.
Gilbert DN, Chambers HF, Saag MS, et al. The Sanford guide to antimicrobial therapy. 51. ed. Sperryville: antimicrobial therapy, 2021.
Yang P, Chen N, Wang RR, et al. Inappropriateness of medication prescriptions about chronic kidney disease patients without dialysis therapy in a Chinese tertiary teaching hospital. Ther Clin Risk Manag. 2016;12:1517-1524. DOI: 10.2147/TCRM.S116789.
Saad R, Hallit S, Chahiane B. Evaluation of renal drug dosing adjustment in chronic kidney disease patients at two university hospitals in Lebanon. Pharm Pract (Granada). 2019; 17:1304. DOI: 10.18549/PharmPract.2019.1.1304.
Rodrigues GA, Alves JWS, Souza RML, et al. Ajuste de dose dos medicamentos de acordo com a função renal em um hospital universitário. Infarma Ciências Farmacêuticas. 2021; DOI:10.14450/2318-9312.v33.e3.a2021.pp269-275.
Saleem A, Masood I. Pattern and Predictors of Medication Dosing Errors in Chronic Kidney Disease Patients in Pakistan: A Single Center Retrospective Analysis. PLoS One. 2016;11(7):e0158677. DOI: 10.1371/journal.pone.0158677.
Decloedt E, Leisegang R, Blockman M, et al. Dosage adjustment in medical patients with renal impairment at Groote Schuur Hospital. S Afr Med J. 2010; 100(5):304-6. DOI: 10.7196/samj.3955.PMID: 20460024.
Sweileh WM, Janem SA, Sawalha AF, et al. Medication dosing errors in hospitalized patients with renal impairment: a study in Palestine. Pharmacoepidemiol Drug Saf. 2007; 16:908-912. DOI: 10.1002/pds.1412.
Prajapati A, Ganguly B. Appropriateness of drug dose and frequency in patients with renal dysfunction in a tertiary care hospital: A cross-sectional study. J Pharm Bioallied Sci. 2013; 5(2):136-40. DOI: 10.4103/0975-7406.111829.
Camargo MS, Mistro S, Oliveira MG, et al. Association between increased mortality rate and antibiotic dose adjustment in intensive care unit patients with renal impairment. Eur J Clin Pharmacol. 2019;75(1):119-126. DOI: 10.1007/s00228-018-2565-7.
Alahdal AM, Elberry AA. Evaluation of applying drug dose adjustment by physicians in patients with renal impairment. Saudi Pharm J. 2012; 20(3):217-20. DOI: 10.1016/j.jsps.2011.12.005.
Pillans PI, Landsberg PG, Fleming AM, et al. Evaluation of dosage adjustment in patients with renal impairment. Intern Med J. 2003; 33(1-2):10-3. DOI: 10.1046/j.1445-5994.2003.00330.x.
Agência Nacional de Vigilância Sanitária (ANVISA): Gerência de Vigilância e Monitoramento em Serviços de Saúde e Gerência Geral de Tecnologia em Serviços de Saúde. Diretriz nacional para elaboração de programa de gerenciamento do uso de antimicrobianos em serviços de saúde. Brasília: Anvisa; 2017. Available in: 1282f2bc- 2a62-5527-3e35-0732f1ac35bf. Acessed on: 24th Sept 2022.
Cabello-Muriel AJJ, Urbieta-Sanz E, Inistes-Navalón C. Effectiveness of pharmacist intervention in patients with chronic kidney disease. Int J Clin Pharm. 2014;36(5):896-903. DOI: 10.1007/s11096-014-0001-3.
Maxson R. Medications in kidney disease. J Nurse Pract. 2017;13(10): 687-692. DOI: 10.1016/j.nurpra.2017.07.023.
Castelino RL, Saunder T, Kitsos A, et al. Quality use of medicines in patients with chronic kidney disease. BMC Nephrol. 2020;21(1):1-9. DOI: 10.1186/s12882-020-01862-1.
Zarjou A, Agarwal A. Sepsis and acute kidney injury. J Am Soc Nephrol. 2011;22:999- 1006. DOI: 10.1681/ ASN.2010050484.
Roberts JA, Lipman J. Pharmacokinetic issues for antibiotics in the critically ill patient. Crit Care Med. 2009;37:840-51. DOI: 10.1097/CCM.0b013e3181961bff.
Finberg RW, Guharoy R. Clinical Use of Anti-infective Agents: A Guide on How to Prescribe Drugs Used to Treat Infections. New York: Springer; 2012.
Balkhy HH, El-Saed A, El-Metwally A, et al. Antimicrobial consumption in five adult intensive care units: a 33-month surveillance study. Antimicrob Resist Infect Control. 2018; 21;7:156. DOI: 10.1186/s13756-018-0451-9.
Dewitt KM, Weiss SJ, Rankin S, et al. Impact of an emergency medicine pharmacist on antibiotic dosing adjustment. Am J Emerg Med. 2016;34(6):980-984. DOI: 10.1016/j.ajem.2016.02.004.
Kiser HK, Tyree DN, Aquilante CL, et al. Evaluation of Sulfobutylether-β-Cyclodextrin (SBECD) Accumulation and Voriconazole Pharmacokinetics in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy. Critical Care. 2015; 3;19(1):32. DOI: 10.1186/s13054-015-0753-8.
Batista D, Oliveira-Lemos PM. Preparing and administering medications via enteral catheters: A guideline for the clinical pharmacists and the multi-professional team. Rev Bras Farm Hosp Serv Saude. 2021;12(2). DOI: 30968/rbfhss.2021.122.0600.
Sedaghat B, Abbasi S, Farsaei S. Identifying the pattern and risk factors for potential medication dosing erros in chronic renal impairment of critically ill patients. Trends Pharmacol Sci. 2021;7(4): 279-288. DOI: 10.30476/tips.2021.93228.1122.
Jiang SP, Zhu ZY, Wu XL, et al. Effectiveness of pharmacist dosing adjustment for critically ill patients receiving continuous renal replacement therapy: a comparative study. Ther Clin Risk Manag 2014; 10: 405–412. DOI: 10.2147/TCRM.S59187.
Jiang SP, Zhu ZY, Ma KF, et al. Impact of pharmacist antimicrobial dosing adjustments in septic patients on continuous renal replacement therapy in an intensive care unit. Scand J Infect Dis 2013;45(12):891–9. DOI: 10.3109/00365548.2013.827338.
Lazaryan M, Abu-Kishk I, Rosenfeld-Yehoshua N, et al. Pharmacist remote review of medication prescriptions for appropriatenessin pediatric intensive care unit. Front Pharmacol. 2019; 7(243):1-7. DOI: 10.3389/fphar.2016.00243.
Luyckx VA, Tonelli M, Stanifer JW. A carga global da doença renal e as metas de desenvolvimento sustentável. Bull World Health Organ. 2018;96(6):414D-422D. DOI: 10.2471/BLT.17.206441.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2023 Authors
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The authors hereby transfer, assign, or otherwise convey to RBFHSS: (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print republish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to RHFHSS with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Serlf-archiving policy
This journal permits and encourages authors to post and archive the final pdf of the articles submitted to the journal on personal websites or institutional repositories after publication, while providing bibliographic details that credit its publication in this journal.
