Rational use of antibiotics in community clinics: an intervention and evaluation in Bangladesh
Antibiotics - A Rational Approach
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Transcript of Antibiotics - A Rational Approach
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Dr. Soulat Hafeez
House Officer
Medical Unit 4
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Definition Of Antibiotic
A chemical substance produced by micro organisms, which has the capacity to inhibit the growth of or to kill other micro organisms
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Antibiotic TherapyIdeally is determined by isolation and antibiotic susceptibility
of the offending.Usually not available in ER.Abx treatment initiated on clinical diagnosis and likely
organism involved.Early empirical treatment may be lifesaving.
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THERAPY BASED ON
1. Site of infection
2. Safety of the agent
3. State of the patient (age, renal, hepatic funtions etc)
4. Cost of the therapy
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Appropriate Use of AbxEmploy empirically when there is a
reasonable clinical suspicion of infectionChoose antibiotics active against the most
likely organism(s)Choose antibiotics known to penetrate
involved tissueUse correct doses of antibiotics – don’t
underdose
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Appropriate Use of Abx…cont’d
Know when bacterostatic antibiotics are adequate or bacterocidal drugs are required
In serious, potentially life-threatening infections, start broad, then de-escalate after cultures back
Stop antibiotics when infection resolved or when evidence accumulates against existence of infection
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Inappropriate Use of AbxWong antibioticWrong dose of right drugUsing a 2nd or 3rd line drug when a first line drug
could still be usedUsing antibiotics in situations when antibiotics are not
indicatedContinuing antibiotics when infection is resolved or
not likelyKeeping coverage broad when cultures reveal a single
organismReacting to culture results by starting antibiotics
without considering the significance of the culture
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Common Mistakes in Diagnosing InfectionBase diagnosis on a single positive data point
when other data points are negative React to a positive culture when there is no
clinical evidence of infectionUse serial cultures to determine when
infection has resolved Obtain cultures randomly when clinical
suspicion of infection is low
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First Step: Determine WhetherCulture Represents Real PathogenColonizer: Any organism actually present in
or on patient, but does not invade tissue or cause clinical disease
Contaminant: Any organism growing in culture that is not actually present in or on the patient, but came from the environment into the culture medium
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Three Examples1. A +ve sputum culture taken from a patient without
fever, leukocytosis, new infiltrate or pulmonary symptoms should be taken as a colonizer
2. A +ve urine culture taken from a patient without dysuria, frequency, and with a small to moderate amount of WBC in the U/A has asymptomatic bacteriuria
3. A +ve wound culture taken from a clean appearing, granulating wound that is not painful, has no purulence in a patient with no fever and a normal WBC, represents a colonizer (rather than a true pathogen) and should not be treated
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Sputum CulturePathogen if:Sputum is grossly
purulentPatient is febrileInfiltrates on CXR> 5-10 WBC per hpf< 5-10 epithelial
cells per hpf
Colonizer if:Sputum is scant,
clear or whitePatient is afebrileNo infiltrates on
CXR< 5-10 WBC per hpf> 5-10 epithelial
cells per hpf
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Urine CulturePathogen if:> 100,000 cfuIf urinalysis reveals:
> 10 WBCPos. Leuk. EsterasePos. nitriteFew or no epi’s
If patient symptomatic
Contaminant if:10,000 cfu or lessIf urinalysis reveals:
< 10 WBCNeg. Leuk. EsteraseNeg. nitriteMany epi’s
If patient asymptomatic
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Drugs Absolutely C/I in Pregnancy ----- “Category X Drugs”Mnemonic “SAFE Mom Takes Really Good
Care”
SULFONAMYIDES, AMINOGLYCOSIDES, FLUOROQUINOLONES, ERYTHROMYCIN.
METRONIDAZOLETETRACYCLINERIBAVIRINGRISEOFULVINCHLORAMPHENICOL
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ABX TO AVOID IN CHILDREN UNDER 18
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Abx TO AVOID IN LACTATING MOTHERS
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ABX TO AVOID IN RENAL FAILURENote, here add drugs that are
contraindicated and drugs that can be administered but with reduced dose.
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ABX TO AVOID IN HEPATIC FAILURE.SAME AS FOR RENAL FAILURE.
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Meningitis
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1. Initiate Empirical Antibiotic Therapy2. All patients with head trauma,
immunocmpromised states, known malignancies, or focal nerological findings (including stupor/coma) should undergo neuroimaging study prior to Lumbar Puncture
3. Obtain CSF D/R sample, if not C/I4. If Bacterial Meningitis is suspected, initiate
empirical antibiotic therapy even prior to Imaging and LP
Principles of Management
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Clinical FeaturesFever, Headache, Neck stiffness, and Change
in Mental Status75% of patients have atleast 2 out of these 4
features
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Antibiotics for Empirical Treatment of Bacterial Meningitis
Infants < 3 months Ampicillin + Cefotaxime
Adults < 55 years Ceftriaxone + Vancomycin
Adults with Alcoholism or debilitating illness
Ceftriaxone + Vancomycin+ Ampicillin
Hospital acquired, post neuro- surgery, neutropenic patients
Ceftazidime + Vancomycin+ Ampicillin
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Pneumonia
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Principles of ManagementClassify the pneumonia :
1. Community Acquired, or2. Health-Care Associated
Hospital Acquired Ventilator Associated
Determine severity: CURB 65 Pneumonia Severity Index
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Definition of Health-Care Associated Pneumonia Health-Care Associated Pneumonia has any
one of the following features:Hospitalization for > 48 hoursHospitalization for > 2 days in prior 3 monthsAntibiotic therapy in prior 3 monthsChronic dialysisHome wound careContact with a family member who has MDR
infection
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Severity of PneumoniaCURB 65
ConfusionUrea > 7 mmolR/R > 30BP : Systolic < 90 ; Diastolic < 60 mmHgAge > 65 years
Score: 0 - 1 --------- Out- patient treatment
2 --------- In patient: Non ICU >2 --------- ICU care
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Empirical Antibiotic Treatment of Community Acquired Pneumonia
Outpatients 1. Macrolide ( Clarithro or Azithro)2. Doxycycline3. Respiratory FQ ( Moxi or Gemi or Levo)4. B-Lactam plus Macrolide
In Patients: Non ICU 1. Respiratory FQ ( Moxi or Gemi or Levo)2. B-Lactam plus Macrolide
In Patients : ICU 1. B-Lactam plus Macrolide2. B-Lactam plus FQ
If Pseudomonas is suspected
1. B-Lactam plus FQ2. B-Lactam plus Aminoglycoside3. B-Lactam plus FQ plus Aminoglycoside
If MRSA is suspected Add Linezolid or Vancomycin
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Empirical Antibiotic Treatment of Health Care Associated Pneumonia
No risk for MDR Pathogens
1. B – Lactam ( Ceftriaxone 2 gm IV OD) alone
2. FQ alone3. Ertapenem alone
Risk Factors for MDR pathogens
1. B – Lactam ( 3rd / 4th Gen Cephalosporin or Tazocin) plus FQ / Aminoglycoside plus Linezolid/ Vancomycin
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Urinary Tract Infections
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Principles of ManagementAlways obtain Urine C/S ( except in
uncomplicated cystitis in women)Identify and Correct (if possible)
predisposing factorsRelief of symptoms does not indicate
bacteriologic cureEach course of treatment should be classified
as a Cure or Failure
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Treatment Regimens for Bacterial UTI
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