Antimicrobial policies

 
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 pencillin allergic:
Ciprofloxacin 250mg bd

3 days

3 days
 

 
systemic upset Co amoxiclav 375mg tid

or Ciprofloxacin 250mg bd

10-14 days  
prophylaxis Co-amoxiclav 375mg at night

or Cephalexin 250mg at night

Review need after 6 months relapse or reinfection seek specialist advice
Pneumonia
Community acquired Amoxicillin 500mg tid orally
ADJUST oral

Penicillin allergic:
Clarithromycin 500mg bd
ADJUST

 5-7 days Consider IV co-amoxiclav +/- clarithromycin in patients who are severely ill (e.g. CURB>2)
Hospital acquired Early onset (hospital stay <5 days)

no previous antibiotics; no MRSA, no contraindicating microbiology results:

Co-amoxiclav 625mg tid orally, or 1.2g tid IV unable to tolerate oral
ADJUST

previous antibiotics; no MRSA, no contraindicating microbiology results:

Piperacillin/tazobactam 4.5g tid IV
ADJUST

Late onset (hospital stay >5 days)
 

piperacillin/tazobactam 4.5g tid IV
ADJUST

MRSA pneumonia suspected:
Add IV vancomycin 15mg/kg
ADJUST

 5-7 days See
UHD Antimicrobial Prescribing Guidelines for further details and if penicillin allergy

Dose according to levels
 

Aspiration Co Amoxiclav 1.2g tid IV
ADJUST
 5-7 days See
UHD Antimicrobial Prescribing Guidelines for further details and if penicillin allergy
Septicaemia
Septicaemia Gentamicin IV
ADJUST

plus Amoxicillin IV 1g tid
ADJUST

plus MetronidazoleIV 500mg tid
ADJUST
   
Cellulitis

 

Amoxicillin 500mg tid oral
ADJUST

Flucloxacillin 500mg qid oral Flucloxacillin 1g qid IV if severe (refer to UHD APG if necrotising fasciitis suspected)

Vancomycin 15mg/kg IV if MRSA positive

  Clarithromycin if penicillin allergy

 

Opportunistic and dialysis-related infections

Clostridium difficile
Clostridium difficile Mild/moderate CDI

metronidazole 400mg tid oral

Severe CDI

vancomycin 125mg qid oral

10-14  days Please refer to
UHD Antimicrobial Guidelines for severity assessment and further information regarding management of CDI
Stop at 10 days if recovered
Candidiasis
Oral Nystatin 100,000u  1ml qid    
Vaginal Clotrimazole 500mg PV

Fluconazole 150mg oral

stat

stat

 

for recurrent infection

Line and Exit Site Infections – HD and CAPD catheters
See page on
Line Infection
A-V fistula infection
  Flucloxacillin 500mg qid oral

Penicillin V 250mg qid oral

  IV if severe infection

Vancomycin if MRSA carrier

PD Peritonitis
Bacterial (empirical treatment) Vancomycin 30mg/kg as single dose 6 hour dwell.

plus Ciprofloxacin oral 500mg twice daily

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

See section on PD peritonitis

Fungal Yeast Amphotericin 0.5mg/l/ exchange IP 

plus
Flucytosine 50mg/l/exchange

Oral fluconazole 200mg

Can be up to six weeks

2 weeks

The priority is usually catheter removal, and this is then temporising therapy

See section on PD peritonitis.

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

 

Prophylactic regimens

Prophylaxis for PD insertion
Flucloxacillin 1g IV

Penicillin allergic:
Teicoplanin 400mg IV

   
Vascular catheter insertion
Flucloxacillin 1g IV

Penicillin allergic:
Teicoplanin 400mg IV

   

 

Dosage Reduction Required for Renal Failure

(For further advice contact the clinical pharmacist – bleep 8006/2294)

Drug Creatinine Clearance ml/min Dose Comments
Aciclovir

IV

Oral

25-50

10-25

<10

dial

10-20

<10

dial

5-10mg/kg 12hrly

5-10mg/kg daily

2.5-5mg/kg daily

IV 2.5-5mg/kg daily

IV 200mg 6-8hrly
400-800mg 8hrly

(zoster) 200mg 12 hrly
(simplex) 400-800mg 12 hrly

(zoster) 200/400mg 12 hrly

On HD days give a dose after dialysis, not during/just before
Give after HD
Amoxicillin < 10 ml/min 250mg tid On HD days give a dose after dialysis, not during/just before
Benzylpenicillin 10-20

<10 and HD

600mg-2.4g every 6 hours depending on severity

600mg-1.2g every 6 hours depending on severity

On HD days give a dose after dialysis, not during/just before
Clarithromycin <10 and HD 250-500mg 12 hourly On HD days give a dose after dialysis, not during/just before
Ciprofloxacin <10 and HD 50% of dose 100% under exceptional circumstances

250-500mg oral 12 hourly

100-200mg IV 12 hourly

On HD days give a dose after dialysis, not during/just before
Co-amoxiclav 10-30

<10 and HD

IV 1.2g every 12 hours
Oral normal dose

IV 1.2g stat dose then 600mg every 8 hours or 1.2g every 12 hours
Oral normal dose

On HD days give a dose after dialysis, not during/just before
Flucloxacillin <10 ml/min as in normal renal function max 4g daily  
Fluconazole <10 and HD 50% of normal dose  
Flucytosine 20-40

10-20

< 10 or dial

50mg/kg 12 hourly

50mg/kg every 24 hrs

50mg/kg once, then by levels

Aim for trough 25-50microg/l (0.5-1g doses normally adequate)
Gentamicin < 20 2mg/kg (after dialysis if on HD) Dose interval according to levels
Meropenem 20-50

10-20

<10 and HD

500mg every 12 hours or 500mg 8 hourly depending on severity

500mg-1g 12 hourly depending on severity

500mg-1g daily depending on severity

 

 

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

Piperacillin/tazobactam <10 and HD 4.5g every 12 hours
or 2.25mg 8 hourly
 
 
Vancomycin   15mg/kg for IV 30mg/kg for PD fluid Dose interval according to levels (except in PD 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, so shorter dosing intervals required on CVVH.

 

GENTAMICIN PEAK  8-12 mg/L  TROUGH  < 2mg/L
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)

 

Other info

Please see here for a link to
Lothian policies.

 

Acknowledgements:   Lorna Thomson was the main author for this page. It was first published in October 2001. Major update by Kristjan Helgason. The last modified date is shown in the footer.

 

 

 

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