Antibiotic dosing in renal impairment demands a precision-based approach to maximise efficacy while minimising toxicity. This review synthesises current evidence and practical strategies for optimising antimicrobial therapy across the spectrum of renal dysfunction, including acute kidney injury (AKI), acute kidney disease (AKD), chronic kidney disease (CKD), and end-stage renal disease (ESRD) on renal replacement therapy (RRT). We describe phase-specific considerations in AKI - oliguric, anuric, diuretic, and recovery phases and highlight the transitional AKD period, where dosing often aligns with CKD principles but requires dynamic reassessment. Limitations of estimated glomerular filtration rate (eGFR) equations are discussed, including the role of gold-standard measures such as inulin clearance and 24-hour creatinine clearance in special populations. Pharmacokinetic/pharmacodynamic (PK/PD) integration serves as the cornerstone of dose optimisation, with emphasis on maintaining time-dependent and concentration-dependent targets despite fluctuating renal function. Model-informed precision dosing (MIPD) platforms and emerging biosensor technologies capable of real-time drug and biomarker monitoring (e.g., NGAL) are explored as tools for individualised therapy. The role of therapeutic drug monitoring (TDM) is underscored for agents with a narrow therapeutic window. Dialysis-specific strategies are detailed for intermittent haemodialysis (IHD), peritoneal dialysis (PD), and continuous renal replacement therapy (CRRT), summarising commonly used antibiotic regimens. This review proposes an integrated framework that combines PK/PD principles, AKI phase-specific dosing, dose adjustments in dialysis, and precision tools to guide antimicrobial therapy in renal impairment, enabling safer and more effective treatment in this complex patient population.

Over the last three to four decades, Therapeutic Drug Monitoring (TDM) has shaped itself as therapeutic drug management (TDM), an integral component of precision medicine. The practice of TDM is not extensive in India, despite being one of the fastest growing economies in the world. It is currently limited to a few academic medical centers and teaching hospitals. Apart from the immunosuppressive drugs, several other therapeutic areas like anticancer, antifungals, antibiotics and antitubercular have demonstrated great potential to improve the patient outcomes in the Indian settings. Factors like higher prevalence of nutritional deficiencies, tropical diseases, widespread use of alternative medicines, unalike pharmacogenomics, and sparse population specific data available on therapeutic ranges of several drugs, makes in the population of this subcontinent unique regarding the relevance of TDM. Despite the impact of TDM in clinical science and it’s widespread application, TDM has failed to receive the attention it deserves in India. This review intends to bring out a strength-weakness-opportunity and threats (SWOT) analysis for TDM in India so that appropriate steps for fostering growth of TDM could be envisioned. The need of the hour is creation of a cooperative group including all the stake holders like TDM professionals, clinicians and the government and devising a National Action Plan to strengthen TDM. Nodal TDM centres should be established and pilot programs should be rolled out for identifying the thrust areas for TDM in the country, capacity building and creating awareness to integrate TDM into mainstream clinical medicine.