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Empiric Antimicrobial Guide for Adult Outpatient Hemodialysis Patients

VANCOMYCIN 25 mg/kg IV loading dose* x 1, then 10 mg/kg IV qHD run (round to nearest 250mg)

  • Change to CEFAZOLIN 2 g IV qHD run if C+S shows organism is sensitive to cefazolin (cefazolin is more active against Staphylococcus than vancomycin)

If patient is acute ill or hemodynamically unstable or if gram-negative infection is suspected, consider adding:

  • GENTAMICIN 2 mg/kg IV post HD x 1 dose, then reassess

OR

  • CEFTAZIDIME 2 g IV post HD x 1 dose, then reassess

Consult clinical pharmacist regarding antibiotic IV lock if trying to salvage line

Pneumonia (Health-Care Associated Pneumonia)

 

Mild/Moderate:

  • DOXYCYCLINE 200 mg PO loading dose x 1, then 100 mg PO BID for 7 days
  • Avoid giving with phosphate binders
  • Will provide coverage for CA-MRSA

OR

  • MOXIFLOXACIN 400 mg PO daily for 7 days
    • Only if no fluoroquinolone exposure in past 3 months

 

If severe COPD with multiple (≥4 per year) episodes of pneumonia, ADD coverage for SPACE organisms (Serratia, Pseudomonas/Proteus, Acinetobacter, Citrobacter, Enterobacter):

  • CIPROFLOXACIN 750 mg PO daily

OR

  • CEFTAZIDIME 2 g IV qHD run

OR

MEROPENEM 1000 mg IV Q24H

 

Duration of Therapy

Generally, complete total course of 7 days.

Certain organisms may warrant extended treatment course:

  • Up to 15 days for Pseudomonas aeruginosa
  • Up to 21 days for MRSA

Clostridium difficile Associated Diarrhea (CDAD)

 

Mild/moderate: METRONIDAZOLE 500 mg PO TID for 10-14 days

Severe: VANCOMYCIN 125 mg PO QID for 14 days

Fulminant: METRONIDAZOLE 500 mg IV Q8H + VANCOMYCIN 125 mg PO QID for 14 days

Recurrent: VANCOMYCIN 125mg PO QID for 14 days (also see tapering/pulse regimen as per Fraser Health C. difficile guidelines)

Special Authority required for vancomycin PO to be covered by PharmaCare

Definitions

Mild/moderate: ≥3 unformed/watery stool in 24 hours, with no features of severe or fulminant infection

Severe: Pseudomembranous colitis OR ICU admission OR clinical judgment OR any 2 of the following:

  • Age > 60 years
  • Temp > 38.4°C
  • WBC > 15 x 109
  • Albumin £ 25 g/L

Fulminant: Ileus OR toxic megacolon OR perforation OR peritonitis OR septic shock OR hypotension

Cystitis (Symptomatic)

  • AMOXICILLIN-CLAVULANIC ACID 500 mg PO daily (administer after HD run on HD days)

OR

  • CIPROFLOXACIN 500 mg PO daily (administer after HD run on HD days)

OR

  • CO-TRIMOXAZOLE (Septra DS ®) 800/160mg PO daily (administer after HD run on HD days)

If Candida species growing in urine greater than 100 mCFU/L AND organism is sensitive to fluconazole AND patient is symptomatic with no other organisms identified:

FLUCONAZOLE 400 mg PO qHD run (given post-HD) for 2 weeks

Duration of Therapy

  • In general, consider treating for 7 days
  • For recurrent cystitis: 7-10 days recommended
  • For male patients: 7-10 days recommended
  • If catheterized, consider treating for 10-14 days

 

Cellulitis

 

CEFAZOLIN 2 g IV qHD run

If penicillin or cephalosporin allergy, use:

CLINDAMYCIN 450 mg PO TID

If MRSA risk, use:

VANCOMYCIN 25 mg/kg IV loading dose* x 1, then 10 mg/kg IV qHD run (round to nearest 250mg)

Osteomyelitis

VANCOMYCIN 25 mg/kg IV loading dose* x 1, then 10 mg/kg IV qHD run (round to nearest 250 mg)

 

Diabetic Foot Related Infection

Initial: CIPROFLOXACIN 750 mg PO daily PLUS [CLINDAMYCIN 450 mg PO Q8H or AMOXICILLIN-CLAVULANIC ACID (Clavulin®) 500 mg PO Q12H]

  • If using Clavulin® and concerned about CA-MRSA, consider adding CO-TRIMOXAZOLE (Septra DS ®) 800/160mg PO BID

 

Recurrent/Refractory: VANCOMYCIN 25 mg/kg IV loading dose* x 1, then 10 mg/kg IV qHD run (round to nearest 250 mg) PLUS [PIPERACILLIN-TAZOBACTAM 4.5 g IV Q12H OR MEROPENEM 500 mg IV Q24H]

 

PIPERACILLIN-TAZOBACTAM 4.5g IV Q12H (schedule dose after HD run)

If MRSA risk, add VANCOMYCIN:

  • 25 mg/kg IV loading dose* x 1, THEN 10mg/kg IV qHD run (round to nearest 250mg)

Consult clinical pharmacist for monitoring

Sepsis Criteria: Signs of infection PLUS 2 or more of the following. Consider admission.

  • Temp < 36°C or > 38°C
  • RR > 22/min or pCO2 <32 if mechanically ventilated
  • HR > 90

WBC <4 or > 12 and >10% immature neutrophils

Revised September 2013

This resource only serves as a reference. Clinical judgment is warranted in all cases.