Antimicrobial Prescribing

General Antimicrobial Advice
  • Seek out source of infection with appropriate examination and investigations
  • Prescribe treatment based upon antimicrobial guidelines and / or by referring to results of (previous) investigations 
  • If empirical treatment prescribed, ensure this is appropriate when investigation results are available.

For most infections, it would be appropriate to refer to the NHS Lothian Antimicrobial Prescribing Guidelines in the first instance, for more information, click here. Please ensure that drugs doses are adjusted according to renal function as per the BNF or Renal Drug Handbook.

Haemodialysis Catheter (Tunneled Line) Infections

Infections are a common complication among patients on chronic haemodialysis. Haemodialysis patients with a tunnelled dialysis line, or PermCath, have a 2-3 fold increased risk of hospitilisation for infection compared to those with an arterio-venous fistula or graft (reference). For this reason, we strive to have AV fistulas created for as many patients as possible, with the Renal Association guidelines recommended that 60% of patients have a mature AV fistula ready for use by the time they commence dialysis (reference – Renal Association).  Infections associated with tunneled dialysis catheters can be fatal. The most common causative pathogens are Gram-positive bacteria, with Staphylococcus aureus and coagulase-negative staphylococci accounting for the majority of infections.

Please click here for more information on the investigation and management for suspected line infections.

PD Peritonitis
  • Bacterial

Signs and symptoms of PD peritonitis include abdominal pain, pyrexia, and/or cloudy PD effluent, but these may not all be present. Patients with any of these features must be reviewed as soon as possible, with sampling of fluid from their PD bag.

Diagnosis of PD peritonitis requires a fluid white cell count of ≥100/mm3, or a differential WCC of >50% neutrophils. Initial microscopy is often not helpful, and treatment should not be delayed once cultures are sent.

Immediate anti-microbial management includes:

  • Vancomycin intra-peritoneally, as a single 6 hour dwell. Vancomycin dose should be calculated according to the patient’s residual urine output as follows: Residual urine <200 ml/day, give 30mg/kg dry body weight, residual urine >200 ml/day, give 37.5mg/kg dry body weight, and:
  • Oral ciprofloxacin 500mg BD.

Most patients are allowed home, but admission may be required for pain control, systemic upset etcDecision regarding duration of therapy and subsequent management will be made by the PD team on the basis of culture results and sensitivities. For patients who are allergic to, or intolerant of, the above antimicrobials, advice should be sought from one of the PD Consultants and the Microbiology team.

In recurrent or relapsing peritonitis, PD catheter removal may be required. Keep in mind that not all peritonitis in PD patients will be related to their PD, and when there is failure of clinical improvement, particularly with Gram-negative or mixed organisms, alternative surgical causes of peritonitis should be sought.

  • Fungal

Fungal peritonitis is rare but serious, with high morbidity and mortality. The priority is catheter removal. Pending surgery, yeasts should be treated with oral fluconazole 200 mg daily, continued for 2 weeks after catheter removal; other fungi may require amphotericin. If in doubt, speak with the on-call Microbiology team for advice.

 

PD Catheter Infection (“Tunnelitis”)

Infection of the PD catheter tunnel is typically caused by staphylococcal organisms which are resident on the skin, and therefore the treatment of choice is usually flucloxacillin. This is dosed at 500mg QDS for a total of 14 days. For more severe infections, or when the patients is intolerant of or allergic to flucloxacillin, advice should be sought from one of the PD Consultants and the Microbiology team. When there is failure to resolve infection or repeated bouts of infection, consideration should be given to PD catheter removal.

 

Treatment of Influenza in Renal Patients

We have specific policies for the treatment of Influenza A and B in Renal patients, particularly those within the haemodialysis units. To download the PDF, click here.

 

Vancomyin Prescribing in Haemodialysis

Please click the following link for guidance on how to prescribe and monitor vancomycin for patients on haemodialysis: Vancomycin in Haemodialysis

 

Gentamicin Prescribing in Haemodialysis

Please click the following link for guidance on how to prescribe and monitor gentamicin for patients on haemodialysis: Gentamicin in Haemodialysis

 

Acknowledgements:   Lorna Thomson was the main author for this page. It was first published in October 2001. It was revised in 2019 by Ashley Simpson. The last modified date is shown in the footer.