4.09 - Urology Infections

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Peritoneal Dialysis Related Infection


PD-related Peritonitis

Intra-peritoneal Cefazolin
1 gm single dose then
250 mg q6H
+
Intra-peritoneal Ceftazidime 1 gm single dose then
250 mg q6H

 
Intra-peritoneal Cloxacillin
1 gm single dose then
250 mg q6H
+
Intra-peritoneal Ceftazidime 1 gm single dose then
250 mg q6H


Cefazolin is preferred over Cloxacillin for its longer drug stability after preparation.

International Society of Peritoneal Dialysis guideline recommends coverage for both gram positive and negative organisms.

Anti-fungal Prophylaxis for high risk PD patients
 
Fluconazole 200 mg PO q48H until the antibiotic therapy is completed
 
High risk patients will include those who are exposed to prolonged IP antibiotic usage.

ISPD recommends use of prophylactic antifungal drug to prevent deadly fungal peritonitis in high risk patients.

 
Surgical prophylaxis for Tenckhoff catheter insertion
 
Cefazolin 1 gm IV 30 minutes before the surgery
 
Vancomycin 1 gm IV 30 minutes before surgery if penicillin allergy

 
 
PD-related exit site infection

Co-amoxiclav 625 mg PO q12H

   

Hemodialysis Catheter Related Infections

 
Exit site infection

 
Topical mupirocin ointment
   
Screen for Staphylococcus aureus nasal carrier and nasal carriage eradication if positive (intra-nasal mupirocin ointment q12H for 5 days).
 
Unresolved infection with topical treatment or accompanied purulent discharge

 
Cloxacillin 500 mg PO q6H
OR
Cefazolin 2 gm IV after each dialysis (3 times / week) or 1 gm IV q24H after dialysis on HD days

 
Cloxacillin 1 gm IV q6H
 
Tunnel infection
Localized infection


Cefazolin 2 gm IV after each dialysis (3 times / week) or 1 gm IV q24H after dialysis on HD days

 
Cloxacillin 1 gm IV q6H
 
Require removal of catheter within 24 hours.

In systemic infection with following condition (s):
1. Critically ill
2. Severe sepsis
3. Neutropenia

 
Piperacillin / Tazobactam 2.25 gm IV q8H
 
Ceftazidime 2 gm IV after each dialysis session (3 times / week)
+
Cloxacillin 1 gm IV q6H OR [Cefazolin 2 gm after each dialysis (3 times / week) or 1 gm IV q24H after dialysis on HD days]

 
Dialysis catheter-related bloodstream infection (CRBSI)
<48 hours
 
Cefazolin 2 gm IV after each dialysis (3 times / week) or 1 gm IV q24H given after dialysis on HD day
 
Cloxacillin 1 gm IV q6H
 

Severely ill patients, with any of the following condition (s):
1. Critically ill
2. Severe sepsis
3. Neutropenia
 
Piperacillin / Tazobactam 2.25 gm IV q8H
 
Ceftazidime 2 gm IV after each dialysis session (3 times / week)
+
Cloxacillin 1 gm IV q6H OR [Cefazolin 2 gm after each dialysis session (3 times / week) or 1 gm IV q24H given after dialysis]

 
 
If >48 hours
 
Add Vancomycin 1 gm IV q3-5 days according to TDM
 
Imipenem 250 mg - 500 mg IV q12H
+ Vancomycin 1 gm IV q3-5days according to TDM

 
Suspected catheter-related 
 
Fluconazole 200 mg IV q24H
 
Risk factors for catheter related candidemia:
1. Prolonged use of broad spectrum antibiotics
2. Colonization due to Candida species at multiple       sites

Kidney Transplantation


Prophylatic antibiotic post kidney transplantation

 
Cefuroxime 750 mg IV q8H
 
Cefazolin 1 gm IV q8H
 
Duration: 7 days

 
Pneumocystis jirovecii prophylaxis

Trimethoprim / Sulphamethoxazole (TMP-SMX) (TMP 80 mg / SMX 400 mg) PO 1 tablet q24H

 
Nebulised pentamidine 300 mg can be used monthly if patient can’t tolerate TMP-SMX
 
Duration: 6 months

 
CMV prophylaxis

 
Ganciclovir 5 mg/kg/day IV

Valganciclovir PO

The dose depends on the GFR:
>60 ml / min 900 mg q24H
40 - 59 ml / min 450 mg q24H
25 - 39 ml / min 450 mg q48H
10 - 24 ml / min 450 mg twice weekly

 
Duration: 100 days 

CMV status - Donor Negative Recipient Negative:

Prophylaxis is not necessarily required, however valacyclovir cover can be given for the first 3 months.
 
TB prophylaxis

 
Isoniazide 300 mg PO q24H + Pyridoxine 10 mg PO q24H

   
Duration: 6 months
 
Empirical treatment for neutropenic sepsis post-transplant

 
Piperacillin / Tazobactam
4.5 g IV q8H
 
Imipenem 500 mg IV q6H
 

Urinary Tract Infections

 
Acute Cystitis
Uncomplicated

 
Co-amoxiclav  625 mg PO q12H
OR
Cefalexin 500 mg PO q8H for pregnancy

 
Cefuroxime 250 mg PO q12H

Duration:
Women: 5 - 7 days
Men: 7 - 14 days

Recurrent UTI: prophylactic antibiotics lead to resistance.
Specific cases may benefit from short term prophylactic antibiotic, but should be discussed with ID.
 
Complicated

 
Piperacillin / Tazobactam 
4.5 g IV q8 - 6H

 
Imipenem 500 mg IV q6H
 
Pyelonephritis
Mild

 
Co-amoxiclav 1.2 g IV q8H OR 625 mg PO q12H

Ceftriaxone 1 - 2 g IV q24H OR Cefuroxime 500 mg PO q12H


Duration: 10 days
Switch IV to oral after patient improved.

Carbapenem and cephalosporin does not cover enterococcus sp.
 
Severe

 
Piperacillin / Tazobactam 
4.5 g IV q8 - 6H

 
Imipenem 500 mg IV q6H

Prostatitis
< 35 years old / STD risk


 
Ceftriaxone 250 mg IM single dose
+ Azithromycin 2 g IV single dose


Ceftriaxone 250 mg IM single dose
+ Doxycycline 100 mg PO q12H for 7 days
 
Duration: 10 - 14 days, 1 month if chronic.

A thorough sexual history needs to be elicited regardless of age.

Test for STD in all (HIV / Hep B / C / Syphilis test/ Gonorrhea).

>35 years old / low STD risk 


 
Trimethoprim / Sulfamethoxazole (TMP-SMX) (TMP 80 mg /
SMX 400 mg) 2 tablet q12H

 
Co-amoxiclav 625 mg PO q12H
 
Asymptomatic bacteriuria

 
No treatment usually required.


Pregnant lady
Cephalexin 500 mg PO q8H

GUT procedures
Tailor to previous C&S and give antibiotic according to the C&S night before or immediately before procedure

 
If no culture: Trimethoprim / Sulfamethoxazole
1 tab PO q12H for 3 days.

B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

 
Acute Cystitis
E. Coli, Proteus sp

 
Trimethoprim 4 mg / kg PO q12H for 1 week

Cephalexin 12.5 mg / kg PO q6H
OR
Cefuroxime 10 - 15 mg / kg PO q12H
can be used in children who had prior antibiotics

 
Check G6PD status.

Trimethoprim (as a single agent) is not available in UMMC. In older children, Co-trimoxazole may be used but should be avoided in infants less than 8 weeks old.
 
Acute Pyelonephritis
E. Coli, Proteus sp

 
Cefotaxime 25 mg / kg q8H for 10 - 14 days
 
Cefuroxime 25 mg / kg IV q8H
OR
Gentamicin 5 - 7 mg / kg IV q24H for 10 - 14 days


Repeat culture within 48 hours if poor response.

Antibiotic may be change according to culture and sensitivity. Suggest to continue IV antibiotic until afebrile 2-3 days then change to appropriate oral antibiotic after culture results.

 
Asymptomatic bacteriuria

 
No treatment recommended
   
 
Antibiotic prophylaxis

 
Trimethoprim 1 - 2 mg / kg PO q24H

 
Nitrofurantoin 1 - 2 mg / kg PO q24H
OR
Cephalexin 5 mg / kg PO q24H

 
Indications :
- Infants / Children with recurrent symptomatic UTI
- VUR grade III and above

A child who develops an infection while on prophylaxis, treatment should be with a different antibiotic.

Check G6PD status.

Trimethoprim (as a single agent) is not available in UMMC. In older children, Co-trimoxazole may be used but should be avoided in infants less than 8 weeks old.