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
Dose adjustments for renal
Common infections
failure
Opportunistic and 'dialysis'
Therapeutic drug monitoring
infections
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)

Length
Infection Recommendations of Comments
Course
UTI
uncomplicated Co-amoxiclav 375mg tid if 3 days
pencillin allergic
3 days if hospital
Ciprofloxacin 250mg bd acquired
systemic Co amoxiclav 375mg tid 10-14
upset days
or Ciprofloxacin 250mg
bd
prophylaxis Co-amoxiclav 375mg at 6 relapse or
night months reinfection
seek specialist
or Cephalexin 250mg at advice
night
Pneumonia
 Community Amoxicillin 500mg tid IV therapy only
acquired orally ADJUST oral in patients who
are severely ill
Penicillin allergic

Clarithromycin 500mg bd
ADJUST

Hospital Ceftriaxone 1-2g bd

ADJUST
acquired
plus Clarithromycin
500mg bd IV ADJUST
Aspiration Co Amoxiclav 1.2g tid IV Clarithromycin
ADJUST
if penicillin
plus Metronidazole allergy
500mg tid ADJUST
Septicaemia
Septicaemia Gentamicin IV ADJUST
plus Amoxicillin IV 1g tid
ADJUST
plus MetronidazoleIV
500mg tid ADJUST
Cellulitis
Amoxicillin 500mg tid oral Clarithromycin
ADJUST Flucloxacillin if penicillin
Serious 500mg qid oral allergy
infection
Flucloxacillin 1g qid IV

Opportunistic and dialysis-related infections

Clostridium difficile
Clostridium metronidazole 400mg 10 days
difficile tid oral

vancomycin 125mg if no response to

qid oral metronidazole
Candidiasis
Oral Nystatin 100,000u
1ml qid
Vaginal Clotrimazole 500mg stat
PV
stat for recurrent
Fluconazole 150mg infection
 oral

Line and Exit Site Infections - HD and CAPD catheters

uncomplicated flucloxacillin 500mg 7 days clarithromycin if
exit site qid oral penicillin allergy.
infection
systemic vancomycin 15mg/kg doses according
upset/sepsis IV to blood levels
plus gentamicin
1.5mg/kg iv
ADJUSTADJUST

A-V fistula infection

Flucloxacillin 250mg IV if indicated.
qid oral Vancomycin if
Penicillin V 250mg MRSA carrier.
qid oral
PD Peritonitis
Bacterial Vancomycin 30mg/kg Do not measure
as single dose 6 hour vanc. levels,
dwell. send fluid for
WCC, gram stain
plus Ciprofloxacin and culture.
oral 500mg twice Change APD to
daily standard 4
exchange CAPD
Fungal amphotericin 0.5mg/l/ Can be The priority is
exchange IP up to six usually catheter
Yeast plus weeks removal, and this
Flucytosine is then
50mg/l/exchange 2 weeks temporising
therapy. See
Oral fluconazole section on PD
200mg peritonitis.
Nasal Carrier
Staph Aureus Mupirocin 2% bd to 5/7 per Screen PD pt
both nostrils month prior to catheter
indefinite insertion; treat if
2/3 swabs
positive
MRSA Mupirocin 2% tid to 5/7 per Screen PD pt
both nostrils month prior to catheter
indefinite insertion; treat if
2/3 swabs
positive
 Hepatitis Immunisation
Hepatitis B HBvaxPRO 40mcg/ml 0, 1, All patients on
and 6 RRT or whom
months 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 Comments

Clearance
ml/min
Aciclovir 25-50 5-10mg/kg
12hrly
IV 10-25
5-10mg/kg
Oral <10 daily

dial 2.5-5mg/kg
daily IV
10-20
2.5-5mg/kg
<10 daily IV

dial 200mg 6-
8hrly 400-
800mg
8hrly
(zoster)
200mg 12
hrly
(simplex)
400-800mg On HD days give a dose
12 hrly after dialysis, not
(zoster) during/just before
200/400mg
12 hrly Give after HD
Amoxicillin < 10 250mg tid On HD days give a dose
ml/min after dialysis, not
during/just before
Benzylpenicillin 10-20 75% On HD days give a dose
normal after dialysis, not
<10 or dial dose 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
<6 or dial 24hrs

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
On HD days give a dose
250mg bd after dialysis, not
oral during/just before
Ciprofloxacin <20 or dial 100mg
bd IV
On HD days give a dose
250mg bd after dialysis, not
oral during/just before
Co-amoxiclav 10-30 1.2g 12
hourly IV,
<10 or dial or 375mg 8
hourly oral

1.2g stat
then
600mg-
1.2g every
12 hrd
On HD days give a dose
375mg 8 after dialysis, not
hourly 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 25-

once, then 50microg/l (0.5-1g doses
by levels normally adequate)
Gentamicin < 20 1.5mg/kg
(after
dialysis if Dose interval according
on HD) to levels
Meropenem 10-20 500mg 8
hourly
<10 or dial On HD days give a dose
500mg after dialysis, not
daily 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
On HD days give a dose
100mg after dialysis, not
daily during/just before
Vancomycin 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
Do not measure levels
single dose
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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