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4CPS-129 Adjust doses of antibiotics in patients with renal insufficiency
  1. R Castillejo,
  2. A Aguado Paredes,
  3. A Martinez Suarez,
  4. L Moñino Dominguez,
  5. L Martin Casado,
  6. M Romero Gonzalez
  1. Clinical Pharmacist, Hospital Universitario Virgen Macarena, Seville, Spain


Background and importance Antibiotics constitute one of the main groups of drugs prescribed for hospitalised patients. Many of them present renal elimination, which is why in cases of impaired renal function is necessary to adjust the dose.

Aim and objectives To evaluate physician acceptance of pharmacist recommendation (PR) in patients with renal insufficiency.

Material and methods Prospective interventional study from June to September 2021. We included all patients who started antibiotic treatment with a glomerular filtration rate less than 50 mL/min. Data were collected from the electronic medical record (DIRAYA) and the prescription program (PRISMA). Dose adjustment recommendations were made based on the antibiotic datasheets and the Sanford Guide to Antimicrobial Therapy.

Data collected: sex, age, clinical service, prescribed antibiotic.

Recommendations were reported in the clinical course of the patient. In the case of severe kidney failure, the prescribing doctor was notified directly. Descriptive statistics were used to analyse the results.

Results 40 patients (60% men) were analysed, with a median age of 78 (range 48–92) years. 42 dose adjustment recommendations were made. The antibiotics evaluated were: piperacillin/tazobactam (22), meropenem (9), amoxicillin/clavulanic (7), vancomycin (2), ertapenem (1) and ceftazidime (1). Clinical services involved were: Internal Medicine (19), Urology (10), Cardiology (3), Digestive (3) Oncology (3), Traumatology (3) and Pneumology (1).

The rate of acceptance of PR was 79.5%: 67.7% dose reduction and 33.3% dose increase. 7.1% of the PR cannot be valued due to a change in treatment.

Conclusion and relevance The hospital pharmacist plays an important role in the correct, effective and safe use of antibiotic therapy, especially, as occurs in our study, in elderly patients. Thanks to the pharmacist-doctor communication, the number of recommendations made decreased over time in certain clinical areas due to the correct dose adjustments by the prescribing doctors.

References and/or acknowledgements Sanford Guide to Antimicrobial Therapy.

Conflict of interest No conflict of interest

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