Antimicrobial stewardship Flashcards
What is antimicrobial resistance?
Resistance of a microorganism to an antimicrobial medicine to which it was originally sensitive.
What are the consequences of antimicrobial resistance?
- Prolonged illness
- Greater risk of spread
- Increased morbidity
- Higher mortality
- Socioeconomic implications
What is antimicrobial stewardship?
- Measures used to select the best therapy for patients for best clinical outcome and minimised toxicity.
- Aims to prevent overuse and inappropriate use of antibiotics to reduce resistance
- Using the correct dose, duration etc
What is the TARGET toolkit?
A guide for GPs and other healthcare professionals to stop antibiotic overprescribing in community care.
Treat
Antibiotics
Responsibly
Guidance
Education
Tools
What is the golden hour?
This is the rule that sepsis patients should be on antibiotics and IV fluid within 1 hour.
What are the outcomes for the 48 hour review of the ‘Start smart and then review’ protocol?
- Stop if not needed- e.g. if not a bacterial infection
- Switch from IV to oral
- Change to a more specific antibiotic- narrow spectrum
- Continue and review after 24 hours
- OPAT- OutPatient Antibiotic Therapy- once a day IV infusion antibiotic given at home.
What methods are used to identify that a patient has an infection?
- Near patient investigations e.g. fever, urinalysis ( dipstick tests not for over 65)
- Microbiology investigations e.g. bacteria account for UTI is greater than 10^5 organisms per ml
What does ‘S’ and ‘R’ mean on a sensitivities culture?
S = sensitive
R= resistant
When should a sample for sensitivities/ microbiology cultures be taken?
Before starting empirical treatment
When should empirical treatment be started?
In severe conditions, empirical treatments should be started without waiting for microbiology results.
What can be used to demonstrate presence of infections?
- White cell count (WCC)- by taking a blood test
Normal range= 4-11 x10^9/L
if this is raised, it can indicate infection
in some cases it won’t raise e.g. accesses, bacterial endocarditis
- C Reactive protein (CRP)- measure the acute phase protein that is made by the liver after infection.
normal range = 0-10
non-specific- could mean infection but also could indicate inflammation - Creatinine levels
Measure kidney function
can be raised in UTIs or sepsis
near-bed observations- fever, temperature, other symptoms
When does targeted treatment begin?
Once microbiology results are available.
What is empiric treatment?
Starting treatment according to signs and symptoms and then using hospital guidelines before receiving any test results.
Where do anaerobes bacteria tend to effect and what kind of conditions do they cause?
Mouth, throat, sinus, Lowe bowel
- Abscesses
- Dental infection
- Peritonitis
- Appendicitis
Where do Gram positive bacteria tend to effect and what kind of conditions do they cause?
Skin, mucous membranes
- Pneumonia
- sinusitis
- Cellulitis
- Osteomyelitis
Where do Gram negative bacteria tend to effect and what kind of conditions do they cause?
Gi tract
- peritonitis
- pancreatitis
- UTI
- PID
Where do atypical bacteria tend to effect and what kind of conditions do they cause?
Chest, genito-urinary
- Pneumonia
- Urethritis
- PID
What are broad spectrum antibiotics and give examples…
Antibiotics that can treat both gram-positive and gram-negative bacteria.
e.g. Co-amoxiclav
meropenem
ceftriaxone
diptazobactam
amoxicllin
doxycycline
Examples of bacteria for gram-positive infections?
Vancomycin
Daptomycin
Flucloxacillimn
Examples of bacteria for gram-negative infections?
Ceftazidime
colistrin
gentamicin
What two factors determine how effective empirical treatment will be?
- Local pathogen epidemiology
- Local antibiotic sensitivity data
What does it mean to ‘Streamline’ in antibiotic treatment?
To go from a broad spectrum antibiotic to a narrow spectrum antibiotic when sensitivities data becomes available.
What organism factors determine antibiotic choice?
- ‘Best guess’ prior to cultures and sensitivities
- Site of infection- ensure the antibiotic will penetrate to the site. e.g. if needed in the brain must be able to cross the blood:brain barrier
- Effect of drug on organism e.g. kill it= bactericidal or stop growth= bacteriostatic
What does a Bactericidal antibiotic do?
Kill the organism
What does bacteriostatic antibiotics do?
Stop the growth of the bacteria
Need to ensure patient has a good immune system as this is required to kill the organism after.
What is an example of an antibiotic that induces resistance very quickly?
Sodium fusidate
Therefore, this drug must be used in combination usually with flucloxacillin.
What patient factors determine antibiotic choice?
- Severity of infection
- Immune status
- Pharmacokinteic factors e.g. renal function, liver function, age e.g. gentamicin is nephrotic so wouldn’t give if patient has a bad creatinine clearance
- Epidemiology- Recent travel, occupation, school
- Past medical history- Diabetes, heart valve replacement
- Allergy status
What drug factors determine antibiotic choice?
- Activity
- Route, dose, frequency of administration
- Pharmacokinetics
- Drug interactions
- Adverse effect profile
- Cost
- Formulary
- Sodium content- IV medications can contain high levels of sodium each is not good for those on a fluid-restricted diet.
If a patient says they are allergic to penicillin but can’t remember what happened when they had it, do you treat them as allergic?
Yes
Is GI disturbances a sign of a penicillin allergy?
NO
What are symptoms/signs that a patient may have community-acquired pneumonia?
- Focal signs on chest exam
- Shadowing on x-ray at base of a lung, basal consolidation
- No sore throat or runny nose
- Cough, chest pain, breathlessness
How do you diagnose community-acquired pneumonia?
- With a chest exam- focal signs
- Chest xray- shadowing at base of lung
What two bacterias are the most common cause of community acquired pneumonia?
- Streptococcus pneumonia (40%)
- Haemophilus influenzae
What is the treatment for non-severe community acquired pneumonia?
- Amoxicillin +/- clarithromycin (if suspecting still atypical bacteria) for 5-7 days
if penicillin allergy- can give doxycycline
What is the treatment for severe community acquired pneumonia?
IV antibiotic Benzylpenicillin + Clarithromycin (Iv or oral, but oral is preferred unless cant swallow due to IV being toxic to veins)
7-10 days
What bacteria normally causes UTIs?
Gram negative
E.coli (75%)
Proteus
How do you diagnose a UTI?
- In under 65 year olds, can use urine dipsticks
- In over 65 year olds, CAN’T use a dipstick as there is a high rate of asymptomatic bacteria, so use a ‘Midstream urine sample’
UTI= >10^5 organisms/mL
What are the symptoms of a UTI?
Dysuria- burning and discomfort on urination
Haematuria- Blood in the urine
needing to urinate more frequently
Urine that looks cloudy, dark or smelly
What is the treatment for an uncomplicated UTI?
Trimethoprim (200mg BD) or Nitrofurantoin (50mg QDS) or co-amoxiclav
3 days for women
7 days for men
What is the treatment for pyelonephritis?
( Kidney infection/ upper UTI)
IV gentamicin, tazocin, meropenem, ciprofloxacin
7-10 days
If a patient with a UTI has poor renal function, what would you not give and give?
Wouldn’t give nitrofurantoin as secretion is reduced causing toxicity and side effects.
Would give trimethoprim instead.
What is cellulitis?
A bacterial skin infection causing redness, swelling, pain, tenderness and erythema (skin rash).
May also cause local accesses.
How is cellulitis monitored in a hospital setting?
Use a pen and draw round the red area. If the antibiotics are working, the red area would be seen to shrink.
What bacteria are the main causes of cellulitis?
Gram-positive bacteria
Group A streptococcus (68%)
Staphylococcus aureus (12%)
What is the treatment of cellulitis?
Flucloxacillin (500mg qds?) either IV or oral depending on severity
7-14 days also depending on severity
if penicillin allergy, use clarithromycin +/- metronidazole or doxycycline (200mg for 1st day then 100mg OD)
