Kiribati Antibiotic Guidelines#2 PDF
Preview Kiribati Antibiotic Guidelines#2
First Edition 2013 1 Contents Kiribati Antibiotic Guidelines Acknowledgments 3 Foreword 4 Introduction 5 Anti-‐infectives available on Kiribati EML 5 Dosing of gentamicin 9 Antibiotics in pregnancy and breastfeeding 10 1. Infections in children 15 Cardiovascular system infections 15 Respiratory tract infections 17 Gastrointestinal infections 21 Central nervous system infections 22 Urinary tract infections, skin, muscle and bone infections 24 Neonatal infections 28 Malnourishment 29 Immunisation schedule 30 2. Respiratory tract infections 31 Upper respiratory tract infections 31 Bronchitis, pneumonia 33 Lung abscess and empyema 37 Bronchiectasis 38 3. Gastrointestinal and intra-‐abdominal infections 39 Candida oesophagitis, diarrhoeal diseases 39 Intra-‐abdominal infections, helicobacter pylori 41 Worms (helminths) 42 4. Cardiovascular system infections 43 5. Central nervous system infections 46 6. Urinary tract infections 50 7. Skin, muscle and bone infections 53 Skin infections 53 Bone infections (osteomyelitis, septic arthritis) 59 8. Septicaemia and generalised infections 61 9. Female genital tract and obstetric infections 64 Female genital tract infections 64 Infections in obstetric practice 65 10. Sexually transmitted infections 67 Gonococcal infections 67 Syphilis 69 Herpes simplex virus, trichomoniasis, 72 Vulvovaginal candidiasis, bacterial vaginosis, genital warts 73 Chancroid, lymphogranuloma venereum 74 11. Eye infections 75 12. Dental and oral infections 78 13. Antibiotic prophylaxis for medical conditions 81 Hepatitis B immunisation 81 HIV prophylaxis, meningococcal and H.influenzae meningitis 82 Rheumatic fever, infective endocarditis 83 Post splenectomy 84 Malaria 85 14. Antibiotic prophylaxis and treatment for surgery 87 15. Tuberculosis 91 16. Special infections 94 MRSA, leptospirosis 94 Filariasis 95 Leprosy, HIV/AIDS 96 References 98 Please note that detailed chapter references are only provided for longer chapters 2 Acknowledgements Kiribati Antibiotic Guidelines We acknowledge the support of the World Health Organisation and United Nations Population Fund for their support in the writing and printing of these guidelines. We acknowledge the contribution of all clinicians and pharmacists involved in the development of Kiribati Antibiotic Guidelines: • Dr Bwabwa Oten Director of Hospital Services • Dr Hilda Schutz General Practice • Dr Baranika Toromon Obstetrics and Gynaecology • Dr Ailsa Benati Obstetrics and Gynaecology • Dr Tibwerate Temboa General Medicine • Dr John Tekanene Surgery • Dr Turia Tekaai Paediatrics • Dr Noelio Paediatrics • Dr Burentau Terboriki Paediatrics • Dr Alan Gavez SPC HIV clinical adviser • Ioana Taakau Chief Pharmacist • Susanna Lake AYAD Pharmacist -‐ writer We also wish to thank the Australian Therapeutic Guidelines, Fiji Therapeutic Guidelines and SPC HIV section for allowing us to use their guidelines as the basis for developing these Kiribati Antibiotic Guidelines. 3 Foreword Kiribati Antibiotic Guidelines These antibiotic treatment guidelines outline the management of communicable diseases in Kiribati. The WHO in collaboration with the UNFPA recommended that a national antibiotic guideline be developed and implemented. Improvement in the quality of management of infectious diseases has been shown within countries that have developed and used antibiotic treatment guidelines. This document is the first edition of the national Kiribati Antibiotic Guidelines and is designed for use in a referral hospital setting. I believe that this document will benefit our health professionals by standardising the treatment practices for infectious disease and most importantly will ensure that patients receive quality treatment. Additionally, this antibiotic guideline will serve as a budgeting tool that will improve the management of the Ministry of Health’s expenditure on antibiotics and other medicines used in the treatment of communicable diseases. Therefore, I trust that these Kiribati Antibiotic Guidelines will be welcomed, implemented, monitored and evaluated for bi-‐annual revision and further expansion. I would personally like to give a big ‘thank you’ to those who have contributed to the first edition of these Kiribati Antibiotic Guidelines. Kam bati n rabwa. Doctor Kautu Tenaua Minister, Ministry of Health and Medical Services January 2013 4 Introduction Kiribati Antibiotic Guidelines This clinical practice guideline has been endorsed by the Minister for Health and should be followed by all prescribers in Kiribati. Antimicrobial resistance is a growing global health issue and these guidelines are designed to reduce the incidence of antimicrobial resistance in Kiribati. These guidelines are evidence based and offer the recommended first line and in some cases second and third line treatment for a patient. Antibiotic choice should always, where possible, be guided by bacterial culture and sensitivity. Sometimes these investigations will suggest an alternative antibiotic to those recommended in these guidelines, in these cases an evidence based dosing regimen should be chosen. Sometimes the recommended treatment is not available in Kiribati, we have endeavored to include an alternative in most cases. Where a drug that is not available in Kiribati is indicated a # has been used to signify this. ANTI-‐INFECTIVES CURRENTLY AVAILABLE ON THE KIRIBATI ESSENTIAL MEDICINES LIST ANTIBIOTICS Aminoglycosides Aminoglycosides cover gram-‐negative bacteria and are potentially ototoxic and nephrotoxic. Therapeutic drug levels must always be monitored but if this is not available patients should have their renal function and auditory function monitored. The dose of aminoglycosides must be calculated according to renal function (see page 9). Gentamicin Broad gram-‐negative cover including Pseudomonas aeruginosa. This is the drug of choice for severe gram-‐negative infections. Cephalosporins Cephalosporins act by interfering with bacterial cell wall peptidoglycan synthesis, which leads to bacterial cell lysis and death. There are a number of drugs in the cephalosporin class and they are grouped according to when they were developed (first, second, third generation). There is some cross-‐sensitivity between penicillin and cephalosporins therefore patients with a severe penicillin allergy should avoid cephalosporins. Cefalotin Surgical prophylaxis. Not on the Kiribati Essential Medicines List but may be brought in by visiting specialist teams. Cefixime Gonorrhea single dose treatment. Ceftriaxone Empirical treatment of severe infections including bacterial meningitis and pneumonia. Does not cover MRSA. Cephalexin Sensitive staphylococcal and streptococcal infections and UTIs due to susceptible Gram-‐ negative bacteria. 5 Introduction Kiribati Antibiotic Guidelines Macrolides This class is bacteriostatic and act by inhibiting bacterial protein synthesis. They are a useful alternative in patients with penicillin allergy. Azithromycin Chlamydia and gonorrhea single dose treatment. Erythromycin Respiratory tract infections, some skin infections and other sensitive infections in patients with penicillin allergy. Nitroimidazoles Active against anaerobic bacteria and some protozoa. Metronidazole Giardia, amoebic dysentery, aspiration pneumonia and a number of other infections due to anaerobic bacteria. Oral tablets should be taken with food to reduce stomach upset. Avoid any alcohol during treatment with metronidazole as it can cause a severe disulfiram reaction. Penicillins Penicillins are indicated for many bacterial infections but it must be kept in mind that there is a risk of anaphylaxis. Always monitor patients for penicillin allergy and change to a different class if needed. Penicillins are sometimes over used so they should only be prescribed where there is a clear indication. Amoxycillin Currently the most mis-‐prescribed drug in Kiribati. Amoxycillin should not be considered as a ‘cover all’ for any illness. Specific indications include otitis media and sinusitis. Amoxycillin and clavulanic acid Clavulanic acid extends coverage for beta lactamases. This drug is usually taken just twice a day with food. It may cause stomach upset. Ampicillin Moderate spectrum. Given parenterally. Benzathine benzylpenicillin Narrow spectrum. Must only be given intramuscularly. Provides low levels in the body for 4 weeks. 1.8 g is equivalent to 2.4 million units. Benzylpenicillin (penicillin G) Narrow spectrum. Administered parenterally by slow injection. 600 mg is equivalent to 1 million units. Cloxacillin Antistaphylococcal. Indicated for skin and soft tissue infections. Oral formulations should be taken on an empty stomach. Prolonged treatment may be associated with cholestatic jaundice. Phenoxymethylpenicillin (penicillin V) Given orally, food impairs absorption so should be given on an empty stomach. Not for severe infections, benzylpenicillin is preferred as it is more active. Procaine benzylpenicillin Narrow spectrum. Must only be given intramuscularly and provides cover for 24 hours. 1 g is equivalent to 1 million units. 6 Introduction Kiribati Antibiotic Guidelines Quinolones This class of drugs should be reserved for the treatment of infections that are resistant to lower cost, more readily available drugs. There is a risk of resistance to these drugs so they must only be used where indicated. Quinolones are contraindicated in pregnancy, breastfeeding, infants and children but may be used in children if essential. Ciprofloxacin Wide range of activity against gram-‐negative bacteria and some gram-‐positive bacteria including Pseudomonas aeruginosa and Haemophilus influenzae. Rifamycins Active against Gram-‐positive organisms and mycobacteria. Due to the risk of drug resistance developing they must always be used in combination with unrelated antimycobacterials. They induce CYP450, which may result in many drug interactions; advice should be sought from pharmacy. Rifampicin Used as a treatment for tuberculosis in Kiribati but may be prescribed for MRSA infections. Tetracyclines Tetracyclines have a broad spectrum of activity including gram-‐positive and gram-‐negative bacteria. This class is contraindicated in children under the age of 8 and in pregnant and breastfeeding women. Doxycycline Commonly used for malaria prophylaxis but may also be used for sensitive infections. Others Chloramphenicol A broad-‐spectrum antibiotic which covers gram-‐positive and gram negative bacteria. Oral administration gives similar bioavailability to the IV form. May cause dose-‐dependent bone marrow hypoplasia so patients should be monitored, especially if on long term treatment. In neonates it mat cause grey baby syndrome. Nitrofurantoin Indicated for the prophylaxis and treatment of lower urinary tract infections. Trimethoprim Indicated for the prophylaxis and treatment of lower urinary tract infection. Trimethoprim and sulphamethoxazole Should be restricted to infections where trimethoprim alone is not effective. The sulphamethoxazole carries a greater risk of serious adverse effects and hypersensitivity so the patient should be monitored for these. ANTIFUNGALS Griseofulvin Systemic treatment for fungal infections where topical treatment has failed or is inappropriate. Miconazole Topical antifungal for the treatment of tinea, cutaneous candidiasis, and pityriasis versicolor. Nystatin Oral drops for oropharyngeal candidiasis. 7 Introduction Kiribati Antibiotic Guidelines ANTIHELMINTICS Albendazole Covers a wide range of worms but is contraindicated in pregnancy (Cat D). Mebendazole Covers threadworm, roundworm, hookworm and whipworm and is safe to use after the first trimester of pregnancy. ANTIMYCOBACTERIALS Clofazamine Used as a component of a multidrug regimen to treat leprosy Dapsone Used as a component of a multidrug regimen to treat leprosy Ethambutol Used as a component of a multidrug regimen to treat tuberculosis Isoniazid Used as a component of a multidrug regimen to treat tuberculosis Pyrazinamide Used as a component of a multidrug regimen to treat tuberculosis Streptomycin Used to treat multi drug resistant tuberculosis ANTIVIRALS Aciclovir Treatment and prevention of herpes simplex and varicella zoster infection ANTIRETROVIRALS Efavirenz NNRTI for treatment of HIV Lamivudine NRTI for treatment of HIV Nevirapine NNRTI for treatment of HIV Ritonavir Protease inhibitor for treatment of HIV Stavudine NRTI for treatment of HIV Zidovudine NRTI for post exposure prophylaxis and treatment of HIV 8 Introduction Kiribati Antibiotic Guidelines DOSING OF GENTAMICIN The recommended initial dose of gentamicin is usually 4-‐6 mg/kg/day as a single daily dose given slowly over 20 minutes. The first dose is given irrespective of renal function as follows: AGE INITIAL DOSE OF Neonates <34 weeks post conception 3 mg/kg Neonates 34-‐44 weeks post conception 3.5 mg/kg Infants and children <10 years 7.5 mg/kg to a maximum of 320 mg 10-‐29 years 6 mg/kg to a maximum of 560 mg 30-‐59 years 5 mg/kg to a maximum of 480 mg Greater than 60 years 4 mg/kg to a maximum of 400 mg After the first dose, subsequent doses of the same size should be given at intervals determined by the patient’s renal function as follows: ESTIMATED CREATININE CLEARANCE DOSING INTERVAL MAXIMUM NUMBER OF DOSES Greater than 60 ml/min 24 hours 3 (at 0, 24 and 48 hours) 40-‐60 ml/min 36 hours 2 (at 0 and 36 hours) 30-‐40 ml/min 48 hours 2 (at 0 and 48 hours) Less than 30 ml/min No further doses 1 (at 0 hours) 9 Introduction Kiribati Antibiotic Guidelines ANTIBIOTICS IN PREGNANCY AND BREASTFEEDING (FROM ‘DRUGS AND PREGNANCY’) Drugs are classified into 7 different groups according to their safety in pregnancy. Category A -‐ Drugs which have been taken by a large number of pregnant women and women of childbearing age without any proven increase in the frequency of malformations or other direct or indirect harmful effects on the fetus having been observed. Category B1 -‐ Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have not shown evidence of an increased occurrence of fetal damage. Category B2 -‐ Drugs which have been taken by only a limited number of pregnant women and women of child bearing age, without an increase in the frequency of malformation or other direct or indirect harmful effect on the human fetus having been observed. Studies in animals are inadequate or may be lacking, but available data show no evidence of an increased occurrence of fetal damage. Category B3 -‐ Drugs which have been taken by only a limited number of pregnant women and women of childbearing age, without an increase in the frequency of malformation or other direct or indirect harmful effects on the human fetus having been observed. Studies in animals have shown evidence of an increased occurrence of fetal damage, the significance of which is considered uncertain in humans. Category C -‐ Drugs which, owing to their pharmacological effects, have caused or may be suspected of causing, harmful effects on the human fetus or neonate without causing malformations. These effects may be reversible. Accompanying texts should be consulted for further details. Category D -‐ Drugs which have caused, are suspected to have caused or may be expected to cause, an increased incidence of human fetal malformations or irreversible damage. These drugs may also have adverse pharmacological effects. Accompanying texts should be consulted for further details. Category X -‐ Drugs which have such a high risk of causing permanent damage to the fetus that they should not be used in pregnancy or when there is a possibility of pregnancy. When giving drugs to breastfeeding women two important issues must be considered. Firstly, the likely exposure of the drug to the infant and secondly, the likely effect the drug may have on milk supply. The infant should be fed just before the next dose (the medication given after a feed) so that feeding when concentration of the drug in the milk is highest is avoided. 10
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