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Note: these protocols are local and not necessarily suitable for other centres |
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| Common infections | Dose adjustments for renal failure |
| Opportunistic and 'dialysis' infections | Therapeutic drug monitoring |
| Prophylactic regimens | |
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Infection control policies are listed on another page |
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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 |
if hospital acquired |
| systemic upset | Co amoxiclav 375mg tid
or Ciprofloxacin 250mg bd |
10-14 days | |
| prophylaxis | Co-amoxiclav 375mg at night
or Cephalexin 250mg at night |
6 months | relapse or reinfection seek specialist advice |
| Pneumonia | |||
| Community acquired | Amoxicillin 500mg tid orally ADJUST oral
Penicillin allergic Clarithromycin 500mg bd ADJUST |
IV therapy only in patients who are severely ill | |
| Hospital acquired | Ceftriaxone 1-2g bd ADJUST plus Clarithromycin 500mg bd IV ADJUST |
||
| Aspiration | Co Amoxiclav 1.2g tid IV 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 Flucloxacillin 1g qid IV |
Clarithromycin if penicillin allergy | |
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Opportunistic and dialysis-related infections
| Clostridium difficile | |||
| Clostridium difficile |
metronidazole 400mg tid oral vancomycin 125mg qid oral |
10 days |
if no response to metronidazole |
| 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 | |||
| uncomplicated exit site infection | flucloxacillin 500mg qid oral | 7 days | clarithromycin if penicillin allergy. |
| systemic upset/sepsis | vancomycin 15mg/kg IV plus gentamicin 1.5mg/kg iv ADJUST |
doses according to blood levels | |
| A-V fistula infection | |||
| Flucloxacillin 250mg qid oral Penicillin V 250mg qid oral |
IV if indicated. Vancomycin if MRSA carrier. | ||
| PD Peritonitis | |||
| Bacterial |
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 |
|
| Fungal
Yeast |
amphotericin 0.5mg/l/ exchange IP 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. |
| Nasal Carrier | |||
| Staph Aureus | Mupirocin 2% bd to both nostrils |
5/7 per month indefinite |
Screen PD pt prior to catheter insertion; treat if 2/3 swabs positive |
| MRSA | Mupirocin 2% tid to both nostrils |
5/7 per month indefinite |
Screen PD pt prior to catheter 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 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 or dial |
75% normal dose
20-50% normal dose max 3.6g per day |
On HD days give a dose after dialysis, not during/just before |
| Ceftazidime |
31-50 16-30 6-15 <6 or dial |
1g bd 1g daily 0.5-1g every 24hrs 500mg - 1g every 48 hrs |
On HD days give a dose after dialysis, not during/just before |
| Cefotaxime | <10 or dial | 0.5 -1g 8-12 hourly | On HD days give a dose after dialysis, not during/just before |
| Clarithromycin | < 10 or dial | 100mg bd IV
250mg bd oral |
On HD days give a dose after dialysis, not during/just before |
| Ciprofloxacin | <20 or dial |
100mg bd IV 250mg bd oral |
On HD days give a dose after dialysis, not during/just before |
| Co-amoxiclav |
10-30 <10 or dial |
1.2g 12 hourly IV, or 375mg 8 hourly oral 1.2g stat then 600mg-1.2g 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 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 | 1.5mg/kg (after dialysis if on HD) | Dose interval according to levels |
| Meropenem | 10-20
<10 or dial |
500mg 8 hourly
500mg daily |
On HD days give a dose after dialysis, not during/just before |
| Metronidazole | < 10 |
500 mg IV bd or 400mg bd oral |
Recommended no reduction if on dialysis, but give dose after, not during/just before. |
| Trimethoprim |
15-25
<15 or dial |
200mg bd for 3 days - then 100mg daily 100mg daily |
On HD days give a dose after dialysis, not during/just before |
| 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.
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| 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) |
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