Kiribati Antibiotic Guidelines#2

98 Pages·2013·1.23 MB·English

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