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cystitis / UWI - Carbapenem Resistente Enterobacteriaceae (CRE)

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Cystitis / Urineweginfectie - Carbapenem Resistente Enterobacteriaceae

General remarks:

  • Treatment only by or in close collaboration with infectious-disease specialist.
  • Aggressive source control is vital (removal of urine catheters, repeated drainage of abcesses, etc)
  • all MIC’s should be confirmed by e-testing, not only by Vitek.

Urinary tract infections

  1. Uncomplicated cystitis: fosfomycin 3 gram single dose oral, if sensitive. Otherwise: gentamicin monotherapy (see 2) 7-14 days
  2. Complicated urinary tract infection, not acutely ill: fosfomycin oral every 2 days OR gentamicin monotherapy, if sensitive. 7-14 days, with the shortest possible course when using gentamicin to avoid nephrotoxicity. Otherwise: see 3
  3. Complicated urinairy tract infection, acutely ill:
    • meropenem + colistine (NO polymyxine B).
    • If colistine R: meropenem + ertapenem (independent of meropenem MIC) + (give 1 of 2 options) gentamycine OR rifampicin. NB Double carbapenem dosing gives higher risk of seizures.

Doses:  (everything iv, except fosfomycine/rifampicin)

  • meropenem 3x2 gram, 4 hours per infusion. (put: ‘vertraagde infusie’, call hospital pharmacist and put on prescription who you talked to)

    • GFR 20-50: 2x2 gram, delayed infusion
    • GFR 10-20: 1x2 gram, delayed infusion
    • Hemodialysis: 1x2grams, delayed infusion. Dose after dialysis if dialysed that day
  • Gentamicin 1dd 5 mg/kg (als MIC < 0,5 ug/ml),  1dd 7 mg/kg (als MIC < 1- 2 ug/ml) (Drusano, CID 2007)
    • If trough levels  > 1 mg/l: raise dosing interval, do not lower total dose (that will only decrease the therapeutic effect) (Petrosillo, expert reviews 2014)
    • Renal failure:  dosing in accordance with hospital pharmacyst/nephrologist.
  • Rifampicine 2dd450mg (check interactions!) oral only.
    • No dose adjustments for renal failure or dialysis (renal drug handbook)
  • Fosfomycin 3 grams oral only. Once or every 2 days, only use in UTI.
    • Only use in GFR > 50, dosing in lower renal function unclear. (Kucers) Use gentamycine if dialysis or GFR < 50.
  • Colistine 9.000.000 IE loading dose, 12-24 hours later 2x4.500.000IE.
    • Renal failure: (SWABID)

      • GFR 30-50 ml/min: loading dose  9.000.000 IE, maintainance dose (12-24 hours later)  5.500.000-7.500.000 IE per day in 2 doses
      • GFR  10-30 ml/min: loading dose  9.000.000 IE, maintainance dose (12-24 hours later) 4.500.000-5.500.000 IE per dag in 2 doses
      • GFR <10 ml/min: loading dose: 9.000.000 IE, maintainance dose  (12-24 hours later) 3.500.000 IE per dag in 2 doses
      • Dialyse (hemodialysis, CVVH, PD and -hemo(dia)filtration): loading dose   9.000.000 IE, maintainance dose (12-24 hours later) 2.000.000-4.000.000 IE per dag in 1-2 doses
  • Ertapenem 1dd1 gram
    • GFR 10-50: give normal dose
    • GFR < 10: dose 1 grams, 3x/week
    • Hemodialysis:  1dd500mg. dose after dialysis if dialysed that day. (renal drug handbook)

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Swab vid: G-423909.3
Bijgewerkt: 05/21/2018 - 20:54
Status: Published