4 - Approach to the Patient With Infection Flashcards
List 2 treatment objectives for patients with an infectious disease.
Cure Infection
Prevent & Minimize Complications
Infxn Related Examples:
UTI –> Kidney Failure
Meningitis –> Neuro Dmg
Treatment Related:
Drug Toxicity
Selection of pathogenic or resistant organisms
State the primary goal of antimicrobial stewardship.
- *Optimize clinical outcomes** while
- minimizing unintended consequences* of AB use like:
resistance / toxcity / selection of pathogenic organisms
Discuss the meaning of the 5-D’s of Antimicrobial Stewardship
Choosing the RIGHT:
Diagnosis
Drug
Dose
De-escalation
Duration
Discuss the meaning of the 5-D’s of Antimicrobial Stewardship
DIAGNOSIS
Presumptive Diagnosis:
Subjective = Patient Complaints
Objective = Physical exam + labs
Discuss the meaning of the 5-D’s of Antimicrobial Stewardship
DRUG
Empiric AB Choice:
best GUESS of the MOST LIKELY PATHOGEN
Lower MORTALITY with adequate initial (empiric best guess) regimen
Site of Infection
likely pathogens
Pertinent PMH
increase risk for specific pathogens
Discuss the meaning of the 5-D’s of Antimicrobial Stewardship
Choosing the RIGHT:
Diagnosis
Drug
Dose
De-escalation
Duration
Discuss the meaning of the 5-D’s of Antimicrobial Stewardship
Choosing the RIGHT:
Diagnosis
Drug
Dose
De-escalation
Duration
Discuss the meaning of the 5-D’s of Antimicrobial Stewardship
Choosing the RIGHT:
Diagnosis
Drug
Dose
De-escalation
Duration
List 3 risk factors for infection with
antimicrobial resistant pathogens.
recent HOSPITALIZATION
NURSING HOME resident
recent ANTIBIOTIC USE
Discuss why knowledge of the patient’s medication list helps in the selection of appropriate antibiotic regimens.
Previous Antibiotics used
Drug Interactions
Avoid OVER-LAPPING TOXICITIES
Side Effects
- Discuss why knowledge of the patient’s serum creatinine and liver function tests helps in the selection of an appropriate antibiotic regimen.
Reduce Dose
Dose Adjustments
Creatinine Clearance
Explain the rationale for calculating a patient’s creatinine clearance.
Determines rate of the drug cleared from the body
DOSAGE REDUCTION
Cockroft Gault Equation
140-age x IBW (0.85 if female)
(serum creatinine x 72)
- Explain what is meant by the term
* *“empiric antibiotic therapy.”**
EDUCATED GUESS
of the
most likely pathogen
to make a PRESUMPTIVE DIAGNOSIS
Lower mortality with an adequate INITIAL (empiric) regimen
- Describe how you would use an antibiogram to help in the selection of appropriate empiric antibiotic regimens.
To determine the
SUSCEPTIBILITY OF AN ORGANISM
to a
SPECIFIC ANTIBIOTIC
Helps select an:
EMPIRIC AB white awaiting culture results
- Discuss one limitation of using an antibiogram to help in the selection of appropriate empiric antibiotic regimens.
Susceptibility between intitutions may VARY
Institution specific antibiograms preferred
- Discuss the situations in which you would select the intravenous (IV) route, or the oral route to administer antibiotics.
IV = Hospitilized / Severe Infxn
IM = avoid with HTN due to reduced absorption
Oral = need adequate GI absorption
- Discuss how you would
* *evaluate a patient’s response to therapy.**
↓Patient Complaints
Normalization of Lab tests
↓WBC & ↓Temp
- is it causing HARM?*
- New complaints / Worsening Lab test*s
- Discuss how you would use culture and susceptibility data.
See what Bacteria is SUSCEPTIBLE to each Antibiotic
DE-ESCALATION
Change to NARROW-SPECTRUM AB to:
minimize resistant bacteria
Toxicity and Costs
Know that selection of an optimal antibiotic regimen requires the selection of the
appropriate antibiotic, dose, route, frequency of administration, and duration of therapy
List 5 manifestations of an
unsatisfactory response to antibiotic therapy.
Unsatisfactory improvement of “Patient Complaints”
Persistant Fever
Unsatisfactory Normalization of Tests
Persistantly positive CULTURES
Esp from sterile body sites
Onset of new “Patient Complaints** or **Lab Tests
List 7 possible reasons for an
unsatisfactory response to antibiotic therapy
Suboptimal AB choice
resistant bacteria –> check Cultures
Suboptimal Regimen
Dose / Route / Frequency / Duration
Actually Recieving AB?
Toxicity
Surgical Intervention?
Incorrect Diagnosis
Disreprency in in-vitro susceptibility & outcome
drug does not reach adequate levels @ site of infxn = CNS
BacteriCIDAL AB’s required for selected infxn = endocarditis
Describe the presentation of patients with drug fever.
Beta-Lactams / Sulfonamides
AmphoTERicin B + others
- *7-10 days** after exposure to drug
- sooner if PRIOR EXPOSURE*
Resolves within 48hrs of drug DC
- *PATIENTS GENERALLY FEEL WELL**
- do NOT notice the fever*
- Discuss the reason why not all positive cultures requires treatment with antibiotics to eliminate the identified organisms.
NORMAL BACTERIAL FLORA
are protective
CONTAMINATED SPECIMEN
por technique , etc
Dose Selection for Renally Eliminated Drugs:
Renal Insufficiency
Elderly
Lower CrCl –> slower elimination
Lower Daily Dose
Dose Selection for Renally Eliminated Drugs:
Trauma / Burn
Pregnancy
Children
HIGHER CrCl –> FASTER ELIMINATION
HIGHER DAILY DOSE
Criteria to:
SWITCH from IV –> ORAL AB
De-Escalation
Criteria for Oral AB:
Patient Improvement
Afebrile for 24-48 Hours
↓WBC count
Functioning GI tract
Drugs with good oral Bioavailability:
Fluoroquinolones, metronidazole, linezolid, Trimethoprim/sulfamethoxazole, fluconazole, others
