5- antibiotic stewardship

Question 1

what antibiotic is used to cover gram negatives?

Answer 1

gentamicin

Question 2

what antibiotic is used to cover anaerobes?

Answer 2

metronidazole (good narrow spectrum)

Question 3

what antibiotic is used to cover enterococcus?

Answer 3

amoxicillin

Question 4

is allergic to amoxicillin what should you swap to to treta entyerococcus?

Answer 4

vancomycin

Question 5

what are normal flora of mouth? (commensals there)

Answer 5

• strep viridans
• neisseria
• anaerobes
• candida
• staphylococci

Question 6

what are normal flora in stomach?

Answer 6

• a few candida
• a few staphylococci

= less as low pH

Question 7

what are normal flora in jejunum?

Answer 7

• small numbers of coliforms & anaerobes
  (more than stomach)

Question 8

what is normal flora found in colon?

Answer 8

• large numbers of coliforms (like e.coli and other commensals), anaerobes & enterococcus

Question 9

what are normal flora in bile ducts?

Answer 9

normally sterile

Question 10

what are the most important anaerobes to know about that live in the gut?

Answer 10

• bacteroides = most important one
• also clostridium and anaerobic cocci

Question 11

what is primary peritonitis?

Answer 11

bacterial translocations like ascites translocating bacteria into sterile peritoneum (doesn’t involve a break in integrity of GI tract)→can be just 1 bacteria but also can be more = can do narrow spectrum antibiotic to treat once know bug

Question 12

what is secondary peritonitis?

Answer 12

when some sort of leak of GI tract in peritoneum - will have all bugs as things from inside colon to outside colon = will need to cover big range (wider spectrum over antibiotics)
e.g. like if diverticulum perforated

Question 13

what is tertiary peritonitis?

Answer 13

persistent or recurrent infection of peritoneum after treatment of secondary →less important

Question 14

what is involved in treatment for secondary peritonitis - perforated gut?

Answer 14

the antibiotics discussed before (amoxicillin, metronidazole and gentamicin) alongside things like surgeons, radiologists, ICU etc = big range, not just antibiotics

Question 15

is peritonitis infection, what is the step down after first 3 antibiotics (when get a bit better)?

Answer 15

move to oral co-trimoxazole & metronidazole

(swap amoxicillin & gentamicin to co-trimoxazole and from IV to oral)

Question 16

what antibiotics should be given to treat c.difficile infection?

Answer 16

vancomycin

Question 17

what antibiotics should be given for acute gastroeneteritis?

Answer 17

none

Question 18

what antibiotics should be given for acute pancreatitis?

Answer 18

none

Question 19

what antibiotics should be given for proven spontaneous bacterial peritonitis? (for mild & severe)

Answer 19

• mild = co-trimoxazole
• severe = piperacillin or tazobactam IV then step down to co-trimoxazole

Question 20

what are some good practice points for good prescribing? (like what we aim for)

Answer 20

• if pus = get pus out
• take cultures before antibiotics
• narrower spectrum the better
• only certain circumstances use broad spectrum to start with e.g. neutropenic sepsis (start broad and then narrow) →everything else start narrow
• each hospital has ALERT antibiotics which are some that can only be prescribed with speaking to specialists
• if possible oral better than IV (as soon as ready, use oral over IV)

Question 21

what is antibiotic stewardship?

Answer 21

set of coordinated outcomes to enhance patient outcomes and reduce resistance

Question 22

do you give antibiotics for viral infections?

Answer 22

no

Question 23

what are the 4 C’s?

Answer 23

1. co-amoxiclav
2. clindamycin
3. cephalosporin
4. ciprofloxacin (any quinolones)

Question 24

what antibiotics have very good bioavailability?

Answer 24

metronidazole, quinolone (but don’t like), doxycycline, co-trimoxazole

Question 25

what is MALDI-TOF?

Answer 25

- uses a database to distinguish between highly genetically similar organisms - amazing →many bugs we used to think were one but using this discovered it was 3 etc - but does have problems e.g. can’t tell between salmonella & shigella

Question 26

what is serotyping?

Answer 26

lab technique to specify microorganisms e.g good for salmonella, shigella, e.coli 0157 (where get 0157 from)

Question 27

what happens in antibiotic resistance?

Answer 27

1. antibiotics are only able to kill some strains of bacteria 2. bacteria with certain traits survive 3. these bacteria now able to multiply & colonise = resistance increases length of hospital stays & kills people

Question 28

what are mechanisms involved in antibiotic resistance? (i.e. what do bacteria do to make resistance) - 5

Answer 28

- inactivating enzymes →some bacteria produce enzymes that inactivate antibiotics - alternative enzymes →some bacteria develop alternative metabolic pathways that bypass the target of the antibiotic - target alterations →some bacteria modify the target site of antibiotic - decreased uptake →bacteria may develop mechanisms to decrease uptake of antibiotics into their cells - efflux pumps →some bacteria have efflux pumps that actively pump out bacteria out of bacterial cell

Question 29

what are risk factors for c.difficile?

Answer 29

PPI, age, comorbidities, previous c.diff, 4C antibiotics

Question 30

what is treatment of c.difficile infection?

Answer 30

vancomycin, fidaxomicin, faecal transplant 1st episode = vancomycin

Question 31

what is life threatening c.diff infection and what's treatment?

Answer 31

when admission to ICU, hypotension, ileus, significant abdominal distension, mental status changes - give vancomycin & metronidazole

Question 32

what antibiotics can give c.diff?

Answer 32

ANY antibiotic including ones used to treat it - 4C biggest ones though = want to give narrowest for shortest time possible