Antimicrobial Stewardship in daily practice

Question 1

What should you use before starting antibiotics?

Answer 1

Clinical judgement and testing.

If not very ill, reasonable to test accordingly and wait for results prior to starting antibiotics/antivirals (Ie. rapid strep test, rapid influenza test). Also reasonable to “watch and wait” for viral infections and AOM’s

Ensure you have signs and symptoms, don’t just treat lab results, as samples can be contaminated.

Question 2

What do you need to diagnose UTI?

Answer 2

Signs of infection (Ie. Fever, dysuria, frequency), signs of inflammation (WBC, leukocytes, nitrites), and a significant amount of a uropathogen.

Need all three

Question 3

How does an Ig-E mediated antibiotic allergy present?

Answer 3

Urticaria, pruritis, bronchospasm, angioedema, hypotension –> All within 1 hour of drug administration and is a contraindication to the drug. Other contraindications include Stevens-Johnson syndrome or TEN secondary to the antibiotic.

Ask about history of drug allergies, most “allergies” are not true allergies, and likely just reactions to the drug.

Question 4

What is the crossreactivity between penicillin allergy and cephalosporin? If a patient has a penicillin allergy what is your next step?

Answer 4

2% (extremely low).

If a patient has a history of true penicillin allergy, skin prick testing should be done, and if negative, the label of penicillin allergy can be removed.

Question 5

What is a useful lab tool to help with antibiotic selection

Answer 5

Antibiogram. It will show regional resistance patterns and will help select antibiotics.

Question 6

Once an organism is identified, what should be done to antibiotic treatment?

Answer 6

Narrow the spectrum and optimize the dosing. Always use the higher end of the dosing recommendation for the infection if normal kidney and renal function.

Know the antibiotic’s pharmicokinetics (Ie 1/2 life) and whether dose dependent (Ie Aminoglycosides –> q 24 hour) or time dependent (Ie penicillins, cephalosporins, with short half life, therefore shorter interval)

Question 7

What is the benefit to short antibiotic courses?

Answer 7

Fewer adverse events and less development of resistance.

penicillin for pharyngitis –> 10 days
AOM failing watch and wait –> 5 days
Uncomplicated pneumonia –> 7 days

Question 8

What is the preferred antibiotic for GAS or Strep Pneumoniae?

Answer 8

Beta-lactam NOT macrolides

Question 9

What is the preferred antibiotic for S aureus?

Answer 9

cloxacillin if simple and no risk factors for MRSA. If high risk, try drainage alone, TMP/SMX or Vancomycin if severe