Antimicrobial stewardship in daily practice: managing an important resource

Question 1

What is antimicrobial stewardship?

Answer 1

“a collection of inventions geared toward optimizing the prescribing of anti-microbials, and includes the appropriate selection, dosing, route, and duration of antimicrobial therapy with the goal of optimizing patient outcomes and decreasing adverse events related to antimicrobial therapy”

Question 2

When should testing occur before prescribing empiric therapy?

Answer 2

In well children:

1. AOM (wait 24-48h)
2. Pharyngitis (swab first)
3. Potential lobar pneumonia (CXR)

Question 3

What are some principles of antimicrobial stewardship?

Answer 3

1. Use clinical judgment and test judicially
2. Treat infection, not contamination
3. Take a careful history of potential antibiotic side effects and, if possible, confirm an antimicrobial allergy
4. Utilize local, age-specific antibiograms to guide antibiotic choices
5. Narrow the spectrum of antimicrobials when a causative organism is identified
6. Optimize the dosing of antimicrobials to obtain maximal benefit
7. Use the shortest recommended course of therapy for uncomplicated infections
8. Take care not to change or prolong antimicrobial therapy unnecessarily
9. promote vaccination to reduce likelihood of clinical disease

Question 4

What is the cross-reactivity to cephalosporins if a patient has an IgE mediated allergy to pencillin?

Answer 4

2%

Question 5

What are other CPS suggestions for antimicrobial stewardship?

Answer 5

1. Always document child’s vital signs, physical examination and why you are prescribing antibiotics in your note
2. In well children schedule clinical f/u instead of starting antibiotics
3. Detail a suspected drug reactions and consider allergy consult
4. Ensure minimum diagnostic criteria for diagnosis of UTI are met before starting antibiotics and always send a urine culture
5. Treat infectious syndromes causes by Strep pneumo or GAS w/ penicillin not macrolides
6. Treat S. aureus use cloxacillin or cephalexin unless high risk for MRSA then treat w/ drainage and septra PO or vanco IVif severe
7. Do not perform throat cultures on children w/ sore throat and cold symptoms as likely positive GAS would be carrier
8. Always use the correct weight based dose and optimize the frequency and duration
9. Most outpatient antibiotic prescriptions should be for 5-7d
10. CAP treat w/ ampicillin IV or amoxicillin PO (TID)
11. CAP w/ mycoplasma or chlamydia presentations are the only ones who should be treated w/ a macrolide
12. CXR should be performed to diagnose pneumonia before starting antibiotics
13. Children w/ wheezing almost never need antibotics
14. Know the typical bacteria that cause common outpatients
15. Most skin and soft tissue infections are due to S. aureus or GAS and respond to cephalexin
16. If site is draining or purulent culture it
17. Minor skin and wound infections treat with topical therapy