Anti microbial stewardship

Question 1

How many deaths nationally are related to sepsis ?

Answer 1

one in five

Question 2

What is collateral resistance ?

Answer 2

this where you may treating a urine infection with an antibiotic

commensal flora e.g. E.coli in gut can develop resistance to antibiotic

Support new rational of discontinuing abx before full course taken

Question 3

what are the steps of START SMART in antimicrobial stewardship?

Answer 3

do not start antimicrobial therapy unless there is clear evidence of infection

take a thorough drug allergy history

initiate prompt effective antibiotic treatment within one hour of diagnosis (or as soon as
possible) in patients with severe sepsis or life-threatening infections

comply with local antimicrobial prescribing guidance

document clinical indication (and disease severity if appropriate), drug name, dose and
route on drug chart and in clinical notes

include review/stop date or duration

obtain cultures prior to commencing therapy where possible (but do not delay therapy)

prescribe single dose antibiotics for surgical prophylaxis where antibiotics have been
shown to be effective

document the exact indication on the drug chart (rather than stating long term
prophylaxis) for clinical prophylaxis

Question 4

The second step in antimicrobial stewardship THEN FOCUS, what are the steps/options

Answer 4

Clinical review and decision at 48-72 hours, check microbiology, clear plan, document- the ‘antimicrobial prescribing decision

FIVE prescribing descions

1. Stop if no evidence of infection
2. Switch I.V to oral
3. Change antibiotics – ideally to a narrower spectrum – or broader if required
4. Continue
5. Outpatient Parenteral Antibiotic Therapy (OPAT)

for all document decision and if applicable next review date or stop date

Question 5

what is the Defined Daily Dose (DDD)

Answer 5

The assumed average maintenance dose per day for a drug used for its main indication in adults

Question 6

What are the two mechanism of action of antibiotics?

Answer 6

Bactericidal- kills the bacterial load

E.g. Beta-lactams (penicillins, cephalosporins, carbapenems), Fluoroquinolones: Ciprofloxacin, levofloxacin, moxifloxacin

Bacteriostatic- inhibits the further growth of bacteria- human immune system kills the remaining bacteria

E.g. Chloramphenicol, Clindamycin, Macrolides

Question 7

why not treat an infection?

Answer 7

may be viral or fungal

Most just get better anyway

Cost- some are v expensive, some cheap

Adverse effects- are side effects worse than not treating- NNH vs NNT

Service cost

Dependence- expectation as had antibiotics before

Resistant organisms- over use can cause resistance including natural commensal flora

Question 8

which 3 factors affect choice of antibiotic treatment ?

Answer 8

1. What is the likely diagnosis?
   - Pathological
   - Microbiological
2. What are the alternative diagnoses?
   - Likely
   - Unlikely but important
3. Will microbiology help?
   - How easy/how soon?
   - How reliable?