Canterbury DHB

Post-TRUS sepsis

Follow this guideline to treat sepsis after a Transrectal Ultrasound-guided Prostate (TRUS) biopsy.

• Consult urgently with Infectious Diseases/Clinical Microbiology if severe infection and recent admission to overseas healthcare facility or carbapenemase-producing organisms positive.

Pathogen:

E. coli

Empiric

piperacillin+tazobactam HMLNZFPMLnoids Piperacillin+Tazobactam F: n/a Half life: 1 hour Elimination: renal fe: 0.8/0.6

IV 4 g/500 mg every eight hours

• If still on piperacillin+tazobactam beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
• fe (piperacillin) = 0.8, fe (tazobactam) = 0.6, consider adjusting dose if CrCl reduced.

Mild penicillin allergy or risk factors for multidrug-resistant gram-negative bacilli (MDR-GNB):

meropenem HMLNZFPMLnoids Meropenem F: n/a Half life: 1 hour Elimination: renal; hydrolysis fe: 0.7

IV 1 g every eight hours

• Meropenem rapidly and significantly reduces sodium valproate concentrations. Concomitant administration may precipitate seizures in patients with a pre-existing seizure disorder. Discuss alternative antibiotic options with Infectious Diseases/Clinical Microbiology.
• If still on meropenem beyond 48 hours, consider measuring a trough concentration. Consult Infectious Diseases for interpretation.
• fe = 0.7, start with full dose initially then consider extending dose interval and/or decreasing dose for subsequent doses if CrCl is reduced (< 30 mL/min). Consult pharmacist.

Severe penicillin allergy

Consult Infectious Diseases/Clinical Microbiology.

Oral follow-on

• Based on susceptibilities, if available.
• Do not use nitrofurantoin as serum and prostate concentrations are very poor and inadequate to treat an infection in these sites.

If susceptibilities are not available

amoxicillin+clavulanic acid HMLSchedNZFPMLnoids Amoxicillin+Clavulanic Acid F: 0.9 / 0.5 Half life: 2 hours / 1 hour Elimination: renal fe: 0.9 / 0.5

PO 500 mg/125 mg three times a day

• fe (amoxicillin) = 0.9, fe (clavulanic acid) = 0.5, consider adjusting dose if CrCl reduced.

Mild penicillin allergy

cefalexin HMLSchedNZFPML Cefalexin F: 0.9 Half life: 1 hour Elimination: renal fe: 0.9

PO 1000 mg four times a day

• fe = 0.9, consider adjusting dose if CrCl is reduced.

If proven susceptibility

ciprofloxacin HMLSchedNZFPMLnoids Ciprofloxacin F: 0.7 Half life: 4 hours Elimination: renal fe: 0.5 Additional points: Inhibits CYP1A2 and 3A. Antacids, milk, and enteral feeds ↓ absorption.

PO 500 mg twice a day

• fe = 0.5, consider adjusting dose if CrCl reduced.
• Inhibits CYP1A2 (strong) and 3A.
• Subject to OAT and OATP (transporter) inhibition.

OR

trimethoprim+sulfamethoxazole HMLSchedNZFPMLnoids Trimethoprim+Sulfamethoxazole F: 0.8 Half life: 9 hours / 12 hours Elimination: CYP2C8/9 acetylated fe: 0.3 / 0.7 (co-trimoxazole)

PO 160 mg/800 mg twice a day

• fe (trimethoprim) = 0.7, fe (sulfamethoxazole) = 0.3, consider adjusting dose if CrCl reduced.
• Sulfamethoxazole is metabolised by CYP2C8/9 and conjugation.

must be prescribed or recommended by a consultant.

Topic Code: 606698