The liver is the main pathway for drug metabolism or clearance, and the selection and dosage of antimicrobial drugs may need to be adjusted when liver function is reduced. Chronic liver insufficiency can lead to the reduction of liver metabolism and clearance ability and lead to the accumulation of antimicrobial drugs, and acute liver injury mainly affects the metabolism and clearance of intravenous antimicrobial drugs.
This article reviews the use of antibiotics in patients with different conditions of liver disease for clinicians' reference.
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Antimicrobial drugs are mainly cleared or metabolized by the liver, and the clearance is reduced when the liver function is reduced, and can cause toxic reactions, so avoid the use of erythromycin esterification, amphotericin B, tetracyclines, sulfonamides, etc. Antimicrobial drugs without obvious toxicity can be used normally in liver disease, but they need to be used with caution and reduce the dose if necessary, such as clindamycin, erythromycin and other macrolides (excluding esters), lincomycin, etc.
Severe liver disease
Antimicrobial drugs are cleared by the liver and kidney, and the blood concentration of severe liver diseases, especially in patients with liver and kidney dysfunction at the same time, is particularly high, and it is necessary to reduce the dose of penicillin drugs such as piperacillin, meloxicillin, and aloxillin, ceftriaxone, cefoperazone, cefotaxime, fluoroquinolone fleroxacin, pefloxacin, and aztreonam. Antimicrobial drugs are mainly excreted by the kidneys, and there is no need to adjust the dose when liver function is reduced, such as penicillin, cefazolin, glycopeptides, ceftazidime, aminoglycosides (gentamicin, tobramycin, amikacin), etc.
Acute liver injury
In acute liver injury, antimicrobial drugs take biliary excretion and clearance as the main metabolic pathway, which can lead to a decrease in clearance, such as cephalosporins (ceftriaxone, cefoperazone), ciprofloxacin, etc. Antimicrobial drugs that are not metabolized by the liver do not need to adjust the dose, such as glycopeptides, aminoglycosides, etc. Acute liver injury should be avoided as much as possible, and hepatotoxic antibacterial drugs such as macrolides, tetracyclines, sulfonamides, and most antifungal drugs should be used with caution. Amoxicillin-clavulanate, tetracyclines, erythromycin, clindamycin, and sulfonamides can cause acute liver injury.
The application of antimicrobial drugs in patients with reduced liver function is recommended in the Guidelines for the Clinical Application of Antimicrobial Drugs
The Expert Consensus on the Clinical Application of Antimicrobial Pharmacokinetics/Pharmacodynamics Theories recommends dose adjustment according to the Child-Purh gradation
bibliography
1. Guidelines for the clinical application of antimicrobial drugs (2015 edition) - Annex to Guo Wei Ban Yi Fa [2015] No. 43
2. Expert consensus on the clinical application of antimicrobial pharmacokinetics/pharmacodynamics theory[J].Chinese Journal of Tuberculosis and Respiration,2018,41(6):409-443
3. National guidelines for antimicrobial therapy (3rd edition)[M].Beijing:People's Medical Publishing House,2023:296-306
Source: Yimaitong Hepatology