L09 - Role of the Pharmacist in Supporting Good Prescribing Practice

Question 1

What are the key papers regarding antimicrobial guidelines?

Answer 1

Start Smart then Focus, DH (2011)

SACAR Antimicrobial Framework (2007)

Question 2

Why do we have guidelines?

Answer 2

To improve overall clinical management

To provide a standard of care to measure against

Question 3

Why do restrictive guidelines exist for certain antimicrobials?

Answer 3

To slow the development of resistance

There are more suitable alternatives that are less expensive/toxic

Question 4

How are clinical guidelines developed?

Answer 4

Evidence based, relevant to local healthcare setting, take into account local resistance

Question 5

Describe Clostridium difficile

Answer 5

Gram+ve spore forming rods
3% of healthy adults
Inhibited by normal gut flora

Question 6

Describe the C. diff life cycle

Answer 6

Bacteria ingested
Stomach kills vegetative bacteria
Spores travel to intestine and germinate
Altered gut flora causes colonisation, toxin production and disease
Excreted into environment

Question 7

Describe the Bristol Stool Chart

Answer 7

Type 1 - Separate hard lumps
Type 2 - Lumpy sausage
Type 3 - Cracked sausage
Type 4 - Smooth sausage
Type 5 - Soft blobs 
Type 6 - Fluffy pieces
Type 7 - Liquid

Question 8

What factors predispose C. diff infection?

Answer 8

Elderly

Recent antibiotic use

Question 9

What are the symptoms of C. diff infection?

Answer 9

Diarrhoea (BSC 6-7) w/ Mucus
Offensive smell
Raised CRP/WCC
Pyrexia
Toxic confusional state

Question 10

What are the two main disease types caused by C. diff?

Answer 10

Mild - Self limiting

Severe - Pseudomembranous Colitis

Question 11

What are the clinical signs of PMC?

Answer 11

Abdominal distension
High WCC
Diarrhoea

Question 12

How is PMC diagnosed?

Answer 12

Flexi-sigmoidoscopy

Question 13

What is the standard non pharmacological approach for management of C. diff?

Answer 13

Stool sample for toxin
Patient isolation, enteric precautions
Daily monitoring of stools
Stop offending antibiotics
Review drugs that can cause diarrhoea

Question 14

What are the three main treatments for C. diff?

Answer 14

PO Vancomycin - Main treatment, oral, better efficacy in severely ill
PO Metroidazole - Similar efficac as Vanc. i.v. an option
PO Fidaxomicin - Lower relapse rate, consider for severe disease/recurrence (more expensive)

Question 15

What are three emerging treatments for C. diff?

Answer 15

Rifaximin - Chaser therapy post Vanc. reduces relapse
IV Immunoglobulins - Treatment if life threatening, prevents relapse
Faecal Microbiotia Transplants - to replace IVIG

Question 16

What is the most common cause of C. diff infection?

Answer 16

Antibiotic associated, damage to flora

Question 17

What four types of antibiotic are high risk for AAD?

Answer 17

Clindamycin
Cephalosporins
Broad spectrum penicillins
Quinolones

Question 18

What antibiotics are low risk for AAD?

Answer 18

Tetracyclines
Metronidazole
Glycopeptides
Aminoglycosides
Trimethoprim
Narrow spectrum penicillins

Question 19

What other risk factors exist for C. diff infection?

Answer 19

NG-tubes (bypass stomach)

PPIs (raise pH)

Question 20

Define TDM

Answer 20

Therapeutic Drug Monitoring

Question 21

When should TDM be used?

Answer 21

When the drug in question has a narrow therapeutic index

Question 22

Give two examples of antibiotics that should undergo TDM

Answer 22

Aminoglycosides

Gentamicin