Clinical use of antimicrobials (DONE)

Question 1

How do you identify infection?

Answer 1

Temperature
Site specific response
Blood tests: CRP, ESR (erythrocyte sedimentation rate), WCC

Question 2

How do we treat infection?

Answer 2

Symptomatic treatment- paracetamol
Support the immune system- nutrition, keep warm
Give it something to kill the pathogen or stop it growing

Question 3

Why use guidelines?

Answer 3

Maximise chance of successful treatment
Reflect local patterns of sensitivity
Advice on doses, course lengths, route, monitoring etc.
Minimise bad practice

Question 4

Limitations of guidelines

Answer 4

Underlying lung disease e.g. bronchiectasis, COPD
Aspiration- GI tract contents into lungs
Hospital acquired infections- often non-socomial pneumonias

Question 5

Cultures

Answer 5

Sample of blood, urine or swab
C&S: culture and sensitivity
Take before any antibiotics given
Provides ID of organisms (48 hours) and sensitivities (at least 5 days or longer)

Question 6

Sensitivities

Answer 6

Can take at least 5 days
Most labs will test for a wide range of antibiotics
Will only report a small selection
Aims: reduce resistance, reduce C. difficile, save stronger antibiotics

Question 7

Common infections (community)

Answer 7

Upper respiratory tract infection (URTI)
Lower respiratory tract infection (LRTI)
Urinary tract infection (UTI)

Question 8

URTIs

Answer 8

Common cold, acute sinusitis, influenza, sore throat, otitis media, tonsillitis
Likely viral, low severity, unlikely to benefit from antibiotics

Question 9

Otitis media

Answer 9

Common in children (especially after a cold)
No distinguishing features between bacterial and viral
60% resolve within 24 hours without antibiotics
Treatment: symptomatic, antibiotics may be considered if bilateral, bulging membranes, discharge

Question 10

LRTI

Answer 10

Likely to be acute exacerbation of COPD or community acquired pneumonia
More likely to be bacterial, more severe illnesses, benefit from antibiotics

Question 11

Pneumonia symptoms

Answer 11

Dry or productive cough 
Difficulty breathing
Rapid heartbeat
Fever
Feeling generally unwell
Sweating and shivering
Loss of appetite
Chest pain

Question 12

Pneumonia treatment

Answer 12

Paracetamol/ibuprofen, fluids, stop smoking, avoid cough medicines
Amoxicillin, doxycycline, clarithromycin

Question 13

CURB-65

Answer 13

Confusion
Urea
Respiratory rate >30/min
BP systolic <90mmHg
Age >65

Question 14

Amoxicillin for pneumonia

Answer 14

Active against the main causative organisms
Distributed into lung tissue
Well tolerated
Convenient to administer

Question 15

Counselling CAP patients

Answer 15

Symptoms should improve after starting treatment
1 week- fever should resolve
4 weeks- chest pain and sputum production should have substantially reduced
6 weeks- cough and breathlessness should reduce
3 months- most symptoms should resolve but fatigue may still be present

Question 16

UTI symptoms

Answer 16

Frequency
Urgency
Dysuria
Suprapubic discomfort
Polyuria
Haematuria

Question 17

Complicated UTI

Answer 17

Pregnant
Male
Children
Elderly
Impaired renal function

Question 18

UTI treatment

Answer 18

Trimethoprim- caution in pregnancy, blood dyscrasias
Nitrofurantoin- renal impairment
Amoxicillin- penicillin allergy
Cephalosporin- cross resistance to penicillin

Question 19

Antibiotic side effects

Answer 19

Gentamicin- renal toxicity
Rifampicin- orange urine
Ciprofloxacin- pre-disposure to seizures
Nitrofurantoin- confusion in elderly
Tetracycline- discolouration of teeth

Question 20

Hospital infections

Answer 20

More serious
Need IV treatment
Developed in hospital
Different organisms involved

Question 21

Role of pharmacist

Answer 21

Appropriate drug choice (dose and route)
Allergies
Interactions
Contraindications
Follow up C&S results
Monitor progress
Monitor duration
Patient education
Audit

Question 22

Resistance

Answer 22

Makes diseases more difficult to treat and prevent
Increase length and severity of disease
Increase spread of disease
Affect diagnostic techniques
Use of alternative with lesser known safety profiles
Financial implications

Question 23

HAP treatment

Answer 23

Most likely organisms: S. aureus, Klebsiella, Pseudomonas

Treatment: sputum culture, piperacillin/tazobactam, meropenem

Question 24

MRSA

Answer 24

Resistance due to overuse of methicillin
Healthy people often carriers- nose, throat, perineum
Vulnerable patients become infected

Question 25

MRSA treatment

Answer 25

Vancomycin, teicoplanin, rifampicin, trimethoprim, sodium fusidate
Combinations used to prevent further resistance
Isolate patients
Infection control procedures
Decolonisation

Question 26

C. difficile

Answer 26

Anaerobic bacteria in large intestine
Diarrhoea
Most at risk: recently had broad spectrum antibiotics, other underlying illnesses
Spread through faeces (airborne spores)

Question 27

C. difficile treatment

Answer 27

Reduce unnecessary antibiotics
Isolate patient
Cleaning and hand washing technique
Medication review- PPIs, laxatives
Treatment- metronidazole, oral vancomycin

Question 28

Meningitis

Answer 28

Bacterial or viral
Symptoms: high temperature, vomiting, severe headache, neck stiffness, photophobia, blotchy red rash
Organisms: N. meningitides, Strep. pneumonia, H. influenzae

Question 29

Prophylaxis

Answer 29

Surgery: open wounds- high infection risk, contamination- gut contents, surgical team, consequence of infection- high in bones
Depends on type of surgery, most likely pathogens and guidelines