Most common nephrotoxic antibiotics are aminoglycosides, vancomycin, polymyxins, amphotericin and some b-lactam antibiotics.
Treating clinician has to perform a balancing act of achieving therapeutic levels and at the same time avoiding nephrotoxicity.
Aminoglycosides have to be used as single daily dose and their trough levels have to be monitored. Trough level for gentamicin is to be maintained at <1-2 µg/mL.
Aminoglycosides are more toxic when used with other nephrotoxic antibiotics. Old age, obesity, diabetes, hypertension, hypokalemia, hypomagnesemia, renal failure, hypoalbuminema, long duration of treatment, high trough levels, concomitant use of nephrotoxic drugs and repeated exposure increase the toxicity.
Vancomycin should be used optimally with trough levels >10 mg/L and <15 mg/L. Liposomal and lipid-based amphotericin is less nephrotoxic. Use of piperacillin/tazobactam should be avoided along with vancomycin.
Daptomycin is a recent antibiotic as an alternative but can produce rhabdomyolysis and AKI. Ceftazidime can be used in renal failure but needs dose adjustment in CKD.
Nafcillin, ceftaroline, tigecycline, fosfomycin, linezolid, quinupristin/dalfopristin, N1 amikacin are alternative drugs with no nephrotoxicity.
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