Antibiotic Policy

Antibiotic policy

Abbreviated medical protocols from EdREN, the website of the Renal Unit of the Royal Infirmary of Edinburgh

Note: these protocols are local and not necessarily suitable for other centres Common infections

Dose adjustments for renal failure

Opportunistic and 'dialysis' infections

Therapeutic drug monitoring

Prophylactic regimens Infection control policies are listed on another page

Common infections The following are all initial therapy pending microbiology reports. Treatment should be changed according to sensitivities. ADJUST

= Adjust dose for renal function; see foot of page (or follow link)

Infection

Recommendations

Length of Course

Comments

UTI uncomplicated Co-amoxiclav 375mg tid if 3 days pencillin allergic 3 days if hospital acquired Ciprofloxacin 250mg bd systemic upset

Co amoxiclav 375mg tid

10-14 days

or Ciprofloxacin 250mg bd prophylaxis

Co-amoxiclav 375mg at night or Cephalexin 250mg at night

Pneumonia

6 relapse or months reinfection seek specialist advice

Community acquired

Amoxicillin 500mg tid orally ADJUST oral

IV therapy only in patients who are severely ill

Penicillin allergic Clarithromycin 500mg bd ADJUST

Hospital acquired

Ceftriaxone 1-2g bd

Aspiration

Co Amoxiclav 1.2g tid IV

ADJUST

plus Clarithromycin 500mg bd IV ADJUST ADJUST

plus Metronidazole 500mg tid ADJUST

Clarithromycin if penicillin allergy

Septicaemia Septicaemia

Gentamicin IV ADJUST plus Amoxicillin IV 1g tid ADJUST

plus MetronidazoleIV 500mg tid ADJUST Cellulitis

Serious infection

Amoxicillin 500mg tid oral ADJUST Flucloxacillin 500mg qid oral

Clarithromycin if penicillin allergy

Flucloxacillin 1g qid IV

Opportunistic and dialysis-related infections Clostridium difficile Clostridium difficile

metronidazole 400mg 10 days tid oral vancomycin 125mg qid oral

if no response to metronidazole

Candidiasis Oral

Nystatin 100,000u 1ml qid

Vaginal

Clotrimazole 500mg PV

stat stat

Fluconazole 150mg

for recurrent infection

oral Line and Exit Site Infections - HD and CAPD catheters uncomplicated flucloxacillin 500mg exit site qid oral infection systemic upset/sepsis

vancomycin 15mg/kg IV plus gentamicin 1.5mg/kg iv

7 days

clarithromycin if penicillin allergy. doses according to blood levels

ADJUSTADJUST

A-V fistula infection Flucloxacillin 250mg qid oral Penicillin V 250mg qid oral

IV if indicated. Vancomycin if MRSA carrier.

Vancomycin 30mg/kg as single dose 6 hour dwell.

Do not measure vanc. levels, send fluid for WCC, gram stain and culture. Change APD to standard 4 exchange CAPD

PD Peritonitis Bacterial

plus Ciprofloxacin oral 500mg twice daily Fungal Yeast

amphotericin 0.5mg/l/ exchange IP plus Flucytosine 50mg/l/exchange Oral fluconazole 200mg

Can be The priority is up to six usually catheter weeks removal, and this is then 2 weeks temporising therapy. See section on PD peritonitis.

Nasal Carrier Staph Aureus

Mupirocin 2% bd to both nostrils

5/7 per Screen PD pt month prior to catheter indefinite insertion; treat if 2/3 swabs positive

MRSA

Mupirocin 2% tid to both nostrils

5/7 per Screen PD pt month prior to catheter indefinite insertion; treat if 2/3 swabs positive

Hepatitis Immunisation Hepatitis B

HBvaxPRO 40mcg/ml

0, 1, and 6 months

All patients on RRT or whom RRT is likely should be immunised. Booster if level <10 at 8 months

Dosage Reduction Required for Renal Failure (For further advice contact the clinical pharmacist - bleep 8006/2294) Drug

Creatinine Dose Clearance ml/min

Aciclovir

25-50

IV

10-25

Oral

<10 dial

Comments

5-10mg/kg 12hrly 5-10mg/kg daily 2.5-5mg/kg daily IV

10-20 <10 dial

Amoxicillin

< 10 ml/min

2.5-5mg/kg daily IV 200mg 68hrly 400800mg 8hrly (zoster) 200mg 12 hrly (simplex) 400-800mg 12 hrly (zoster) 200/400mg 12 hrly 250mg tid

On HD days give a dose after dialysis, not during/just before Give after HD On HD days give a dose after dialysis, not during/just before

Benzylpenicillin 10-20

75% normal <10 or dial dose

On HD days give a dose after dialysis, not during/just before

20-50% normal dose max 3.6g per day Ceftazidime

31-50

1g bd

16-30

1g daily

6-15

0.5-1g every 24hrs

<6 or dial

500mg - 1g On HD days give a dose every 48 after dialysis, not hrs during/just before Cefotaxime

<10 or dial 0.5 -1g 8- On HD days give a dose 12 hourly after dialysis, not during/just before

Clarithromycin < 10 or dial 100mg bd IV 250mg bd oral Ciprofloxacin

<20 or dial 100mg bd IV 250mg bd oral

Co-amoxiclav

On HD days give a dose after dialysis, not during/just before

On HD days give a dose after dialysis, not during/just before

10-30

1.2g 12 hourly IV, <10 or dial or 375mg 8 hourly oral 1.2g stat then 600mg1.2g every 12 hrd 375mg 8 hourly

On HD days give a dose after dialysis, not during/just before

Flucloxacillin

<10 ml/min as in normal renal function max 4g daily

Flucytosine

20-40

50mg/kg 12 hourly

10-20 50mg/kg < 10 or dial every 24 hrs 50mg/kg Aim for trough 25once, then 50microg/l (0.5-1g doses by levels normally adequate) Gentamicin

Meropenem

< 20

10-20

1.5mg/kg (after dialysis if on HD)

Dose interval according to levels

500mg 8 hourly

<10 or dial 500mg daily

On HD days give a dose after dialysis, not during/just before

Metronidazole

< 10

500 mg IV bd or Recommended no reduction if on dialysis, 400mg bd but give dose after, not oral during/just before.

Trimethoprim

15-25

200mg bd for 3 days

<15 or dial - then 100mg daily 100mg daily Vancomycin

On HD days give a dose after dialysis, not during/just before

15mg/kg for IV Dose interval according 30mg/kg to levels (except in PD for PD fluid use)

CrCl / eGFR – for historical reasons manufacturers have made dosage recommendations by CrCl rather than eGFR. Using eGFR is usually more accurate than using estimated CrCl in most stable patients. eGFR DOES NOT ACCURATELY INDICATE RENAL FUNCTION IN ARF or severe illness, or in unusual circumstances (amputation, wasting). The same applies to Cockcroft-Gault or other estimates of CrCl. Patients with changing renal function are particularly likely to be over- or under-dosed and treatments should be reviewed frequently. Dialysis Note that ‘dialysis’ in the table above assumes minimal residual native renal function. In general, drugs that are removed by HD or HDF should be administered after a treatment. Some drugs (e.g. vancomycin) may be removed by haemofiltration even though they have negligible clearance by conventional dialysis. Check with pharmacists or a reference source if in doubt.

Therapeutic drug monitoring VANCOMYCIN

PEAK 20-30 mg/l TROUGH < 10mg/l

Peritoneal fluid single dose

Do not measure levels

IV treatment

Take PEAK level 2 hours after the end of the FIRST infusion Take 2nd level 24 hours after the start of the infusion From these levels it is possible to predict when the blood level will be under 10mg/L Check blood level and redose Vancomycin is not removed by dialysis but it is removed by haemofiltration, shorter dosing intervals required on CVVH.

GENTAMICIN

PEAK 8-12 mg/ml TROUGH < 2mg/ml

IV treatment

Check PEAK 1 hour after injection/infusion Take 2nd level 24 hours after the injection From these levels it is possible to predict when the blood level will be under 2mg/l Check blood level and redose Gentamicin is removed by dialysis (one dialysis session approximately equal to one half-life)

Lorna Thomson was the main author for this page. It was first published in October 2001 and updated in November 2006, last amended Monday, October 15, 2007. NOTE that the accuracy of any statements in this information CANNOT be guaranteed. It is published in the belief that it is correct, and we endeavour to keep it so - but we do make mistakes. Furthermore, over some subjects there are differing opinions, or differing degrees of certainty. We have usually not attempted to discuss these here because the aim has been to provide an immediate and brief guide. In all areas, prior medical knowledge is assumed. The EdRenHANDBOOK is not suitable for use by those without such a background. Contact us by email or at the address given at the foot of the contents page with any comments or corrections.

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