Antibiotic Stewardship

Question 1

How many more microbial cells than human cells are there in our bodies?

Answer 1

10 times more

Question 2

What is the problem with having a natural flora when prescribing antibiotics?

Answer 2

They might attack our healthy flora, and lead to pathogenic colonisation by a different bacteria instread

Question 3

What is the most narrow spectrum antibiotic?

Answer 3

Penicillin V

- streptococcus and some aneorobic action

Question 4

List four penicillins in order of most narrow spectrum to most wide spectrum.

Answer 4

Penicillin V
Flucloxacillin
Amoxicillin
Co-amoxiclav

Question 5

In what way are broad spectrum antibiotic bad?

Answer 5

It will not only get rid of the causative organism, but cause damage to the natural flora if they fit into any of the other categoires that the antibiotic also effects

Question 6

What are the effects on the individual if given too wide a range antibiotic?

Answer 6

Resistance
Drug reaction/interactions/ toxicity
- particularly macrolides
C.diff infection
Vascular site infection

Question 7

What are the effects on the population if lots of people are given too wide a range antibiotic?

Answer 7

Resistance

C.diff infections increase

Question 8

What is antibiotic stewardship and why is it useful?

Answer 8

Programme to ensure safe and appropriate antibiotic use

• optimize outcome
• minimise collateral damage
• reduce resistance and C.diff

Question 9

How is antibiotic stewardship achieved?

Answer 9

Monitoring 
Guidelines
Specific restrictions
Specific interventions 
Multidisciplinary work
Both in the hospital and in the community

Question 10

How is antibiotic prescription regulated?

Answer 10

Efficacy of the drug - give the appropriate treatment 
Realise when they aren't needed
Choice of agent
- likely organism and resistance 
- C.Diff risk
- cost
Duration - people are leaning towards high doses for shorter periods of time
Antibiotic review
- IVOST
- simplification
- stop (esp in hospitals)
- escalation 
Protected agents (meropenem)
Indications for specialist input

Question 11

What is the role of the lab in the AMS programme?

Answer 11

Optimisation of diagnosis - minimisation of over diagnosis
Restriction of reporting organisms to prevent over treatment
Restricted reporting of sensitivities to reduce use of inappropriate agents
Co-ordination of clinical advice with guidance

Question 12

When should antibiotics not be prescribed? (in community and hospital)

Answer 12

Viral infection
Self limiting RTIs (50% of inappropriate prescribing)
Asymptomatic bacteruria, uncomplicated cystitis (self-limiting and often viral)
Ingrowing toe nail
Varicose eczema - mistaken for cellulitis
Systemic inflammatory response due to cancer, ischaemia or inflammation

Question 13

When should you take a urine sample from someone to test for a UTI and why?

Answer 13

You should take it only if they have urinary symptoms because 40% of elderly women have asymptomatic bacteruria, which doesn’t need to be identified and treated

Question 14

How should an uncomplicated UTI be managed?

Answer 14

NSAIDs are just as effective as antibiotics

Antibiotics are only given if the patient doesn’t get better, or gets worse

Question 15

How should a catheter associated UTI be managed?

Answer 15

Remove the catheter and wait

Treat with antibiotics only if the patient has symptoms or becomes septic

Question 16

When should non-antibiotic measures be taken?

Answer 16

Mainly in primary care
Requires reassurance and explanation
Management of the symptoms is still needed
- fluids and analgesia
Set up a delayed script in case their symptoms don’t get better
Set up a review date/opportunity

Question 17

When should antibiotics be given?

Answer 17

When there is a strong suspicion of a bacterial infection

Question 18

What localising symptoms/signs are you looking for that would suggest antibiotic treatment?

Answer 18

Dysuria and frequency
Dyspnoea, cough, green/brown sputum and crepitations
Erythema, heat and swelling
Sore throat with exudate and adenopathy

Question 19

What antibiotics should be used for a non severe infection?

Answer 19

Narrow spectrum agents
LRT - amoxicillin or doxycycline
Lower UTI - trimethoprim or nitrofurantoin
Cellulitis - flucloicillin or clarithromycin

Question 20

What kinds of antibiotic therapy are used for severe/life threatening infections?

Answer 20

IV combined treatment (often a beta-lactam and gentamicin)
Use of protected antibiotics
Within an hour of admission

Question 21

Which antibiotics are particularly implicated in causing C.diff infections?

Answer 21

Cephalosporins
Ciprofloxacin
Co-amoxiclav (beta-lactam-betalactamase inhibitors)
Clindamycin
Carbapenems

Question 22

What are the first antibiotic treatments given to a person if the causative organism isnt know?

Answer 22

IV Benzylpenicllin - streptococcus species
IV Flucloxicillin - MSSA
IV Gentamicin - gram negative cover

Question 23

How do you assess response to antibiotic treatment?

Answer 23

Clinical, micro results
De-escalate (simplify, switch, stop)
Review IV daily - switch to oral
Duration depends on the infection
Specialist input
Source control - catheter etc

Question 24

What are the toxicity problems of Gentamicin?

Answer 24

Renal dysfunction
Shouldn’t be given for more than three days
Has a very narrow therapeutic range

Question 25

Which infections do need longer term antibiotic treatment?

Answer 25

Cellulitis 
Bacterial meningitis
Staph aureus bacteraemia 
Bone-joint infections 
Infective endocarditis
Tuberculosis