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Beta-lactam dose reductions in critically ill patients with acute kidney injury: a scoping review
M M B Horstink1,2, W J R Rietdijk3, D R Geel4,3
1Department of Intensive Care, Maasstad Hospital, Rotterdam, The Netherlands. m.horstink@erasmusmc.nl.
Background:
Acute kidney injury is a common complication in critically ill patients, often coinciding with the need for antibiotic therapy. The dose of beta-lactam antibiotics is frequently adjusted and often reduced based on estimated Glomerular Filtration Rate. However, early dose reductions may lead to underdosing, especially during the critical first 48 h of infection treatment, when acute kidney injury may be transient and adequate antibiotic treatment is critical. While some reviews suggest delaying dose reductions improves clinical outcomes, evidence remains limited. This scoping review evaluates the current literature on beta-lactam dosing strategies in critically ill patients with acute kidney injury, focusing on pharmacological and clinical outcomes.
Methods:
We conducted a systematic scoping review following PRISMA-ScR guidelines. We searched Medline, Embase, Web of Science, Cochrane CENTRAL, and Google Scholar from database inception through March 24, 2025. Two reviewers independently screened all articles and assessed study quality using ROB-2 and ROBINS-E tools. Eligible studies included critically ill adult patients with acute kidney injury, receiving beta-lactams, and reporting clinical or pharmacological outcomes. Data were extracted using a standardized template and categorized by pharmacological or clinical outcomes. Further stratification by antibiotic type or patient characteristics was not feasible.
Results:
Out of the 1,436 screened articles, 11 studies involving 1,407 patients were included. The risk of bias was high in most studies. Most studies were observational; one was a randomized controlled trial. Seven studies reported beta-lactam plasma concentrations. Higher concentrations were generally observed in patients with acute kidney injury, even though dosages were oftentimes already reduced. One study associated early dose reductions with lower rates of neurotoxicity. One study reported higher rates of treatment failure with early dose reductions and three studies linked delayed dose reductions to reduced mortality.
Conclusions:
Current evidence on beta-lactam dose reduction in critically ill patients with acute kidney injury is limited and of low quality. Delaying reductions may improve clinical outcomes, but further prospective studies are urgently needed.
Trial Registration:
The protocol for this scoping review was not prospectively registered.
Insights
Dosing of beta-lactam antibiotics in acute kidney injury (AKI) is complex. Delaying dose reductions in critically ill patients with AKI may improve outcomes, but more research is needed.
Area of Science:
- Pharmacology
- Nephrology
- Critical Care Medicine
Background:
- Acute kidney injury (AKI) is common in critically ill patients requiring antibiotics.
- Beta-lactam antibiotic doses are often reduced based on estimated Glomerular Filtration Rate (eGFR).
- Early dose reductions may lead to underdosing, especially in the first 48 hours of treatment.
Purpose of the Study:
- To evaluate current literature on beta-lactam dosing strategies in critically ill patients with AKI.
- To focus on pharmacological and clinical outcomes related to dose adjustments.
- To assess the impact of dose reduction timing on patient outcomes.
Main Methods:
- Systematic scoping review following PRISMA-ScR guidelines.
- Searched multiple databases (Medline, Embase, Web of Science, Cochrane CENTRAL, Google Scholar) up to March 24, 2025.
- Included 11 studies (1,407 patients) with high risk of bias; mostly observational, one RCT.
Main Results:
- Higher beta-lactam concentrations observed in AKI patients despite dose reductions.
- One study linked early dose reduction to lower neurotoxicity.
- One study reported higher treatment failure with early reduction; three studies linked delayed reduction to reduced mortality.
Conclusions:
- Evidence on beta-lactam dose reduction in AKI is limited and low quality.
- Delaying dose reductions might improve clinical outcomes.
- Further prospective studies are urgently needed to guide optimal dosing strategies.
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