Lecture 11 - Management of Infection Flashcards
What is pharmaceutical care?
a philosophy of practive in which the patient is the beneficiary of the pharmacists actions
What does pharmaceutical care focus?
the attitudes, behaviours, commitments, concerns, ethics, functions, knowledge, responsibilities and skills of the pharmacist on the provision of drug therapy with the goal of achieving definite therapeutic outcomes toward patient health and quality of life
What patients are at risk of infection?
immunocompromised patients
patients in ICU or post operation
malnourished
patients with cancer and diabetes
elderly or infirm
infants and neonates
Appropriate use of antibiotics?
correct diagnosis (known or presumed site of infection)
antibiotic culture and sensitivity
patient factors
site and severity
What patient factors need to be checked before treatment?
contraindications
interactions (medicines, foods)
allergies
renal and hepatic function
What is the preferred route of administration?
oral with adequate doses
What should be avoided when oral alternatives are available?
topical antibacterial agents
What is intravenous therapy needed for?
clinical symptoms of infection
CNS infection, joint infection, staph aureus bacteraemia, sepsis, oral route compromised
When should IV be used until?
there is clinical control of infection
indicators are returning to their reference range
What type of injection is more reliable?
IV more than IM
When should IV be switched to oral therapy?
in patients who have been on IV for 24-48 hours who have
settling temperature
falling indicators of infection
able to take oral therapy
oral therapy available
What is the BNF vs prescribed dose of penicillin?
BNF = 250-500mg four times a day
dose used = 500mg-1g four times a day
What is the BNF vs prescribed dose of gentamicin?
BNF = 80mg three times a day
dose used = 5-7mg/kg
What should patients therapy be modified based on?
patient factors
results of culture and sensitivity
patient response to therapy
therapeutic drug monitoring
Pharyngitis?
majority are viral, no antibiotic required
<20% bacterial
How to treat streptococcus pyogenes (pharyngitis)?
narrow spectrum penicillin
macrolide
Patient factors to consider with pharyngitis?
age - adult or child
penicillin allergy
oral administration (which formulation)
Otitis media?
usually viral or self limiting
symptoms for 2-3 days the they disappear
What causes otitis media and how to treat it?
haemophilus influenzae
penicillin e.g. amoxicillin
macrolide
Patient factors for otitis media?
normally a childhood condition
formulation
delayed prescribing - self limiting
surgical intervention (grommets)
What formulation is usually used for otitis media?
in a child so rarely use ear drops, liquid most likely
What causes sinusitis and how to treat it?
strep pneumoniae
haemophilus influenzae
penicillin e.g. amoxicillin
tetracycline
What is sinusitis?
sinuses are congested and infection grows
Patient factors of sinusitis?
nasal decongestants (potential rebound for congestion)
age
non drug treatments e.g. steam inhalation
Why is tetracycline contraindicated in children?
it can affect growing bones and teeth (can discolour teeth)
What are symptoms of COPD?
increased wheeze, increased shortness of breath, increased sputum volume and purulence
need 2/3 of these to have infective exacerbation of COPD
What is COPD?
chronic obstructive pulmonary disease
What causes exacerbation of COPD?
strep pneumoniae
haemophilus influenzae
moraxella catarrhalis
How to treat exacerbation of COPD?
penicillin
tetracycline
macrolide
What might be needed if exacerbation of COPD is severe?
IV therapy
Patient factors for lower respiratory tract infection?
possibility of recurrent infection previous therapy likely to be effective route of therapy (normally oral) patient age (likely to be older) other diseases (drug interactions)
What causes community acquired pneumonia?
strep pneumoniae
haemophilus influenzae
Treatment of non severe CAP?
penicillin e.g. amoxicillin
tetracycline
macrolide (clarithromycin)
Treatment of moderate CAP?
ask about foreign travel
possibility of legionella (esp if patient is confused)
penicillin e.g. amoxicillin and either tetracycline or macrolide
Severe CAP treatment?
consider legionella if patient is confused
macrolide (IV or oral as appropriate) and either penicillin (or penicillin with beta lactamase inhibitor)
quinolone may be used in a patient with true penicillin allergy
How to treat early HAP?
within 4 days of hospital admission - treat as CAP
How to treat HAP within 7 days of discharge or 5 days after admission?
CURB <2
penicillin with beta lactamase inhibitor
tetracycline
Within 7 days of discharge or 5 days after hospital admission (CURB<3)?
penicillin and extended spectrum penicillin
Pneumonia patient factors?
patient age - adult or child
severity of infection (need for IV)
severe infection may affect absorption
comorbidities
What might need to be done if patient has sepsis?
may need to withhold other meds e.g. antihypertensives
Treatment of UTI?
male, female and pregnant woman all need to be treated differently
Uncomplicated UTI in men ad non-pregnant women cause?
E. coli
proteus spp
enterococci
Uncomplicated UTI in men ad non-pregnant women treatment?
trimethoprim
nitrofurantoin
UTI in pregnant woman treatment?
nitrofurantoin
penicillin
Women with upper UTI without sepsis?
trimethoprim
nitrofurantoin
Men with upper UTI without sepsis?
trimethoprim
penicillin with beta lactamase inhibitor
Upper UTI with sepsis treatment?
Women, men and pregnant women
penicillin with beta lactamase inhibitor and aminoglycoside
UTI in pregnancy?
possibility of teratogenicity (much higher risk in 1st and 2nd trimester)
which trimester?
Catheter with a UTI?
makes it hard to eradicate the infection without removing the catheter
Length of treatment for a UTI?
3 days may be enough
Additional counselling for a patient with a UTI?
avoid perfumed wipes, hygiene, post coital infections, increase fluids, avoid coffee
What causes cellulitis?
staph aureus, strep pyogenes
Treatment of mild cellulitis/erysipelas?
narrow spectrum penicillin
tetracycline
macrolide
Treatment of moderate cellulitis?
narrow spectrum penicillin
glycopeptide IV
Treatment of human or animal bite?
penicillin with beta lactamase inhibitor
tetracycline and metronidazole
Patient factors for skin and soft tissue infections?
site of infection
comorbidities
age of the patient
is the infection bacterial only (possibility of viral or fungal infection at the same time)
is topical treatment possible
What is necrotising fasciitis?
a rapidly spreading infection caused by strep pyogenes
How to treat necrotising fascittis?
benzylpenicillin 2.4mg every 6 hours and flucloaxillin 2g every 4-6 hours
gentamicin IV and clindamycin IV every 6 hours and metronidazole IV 500mg every 8 hours
What might be needed in necrotising fasctiitis?
surgical treatment to cut the infection away to stop it extending
Pyrexia of unknown origin?
sepsis or severe sepsis
Treatment of pyrexia of unknown origin?
penicillin and aminoglycoside IV
glycopeptide IV and aminoglycoside iV
What might be difficult if a patient is hypertensive?
IV access
Clostridium difficile infection?
antibiotic associated diarrhoea
related to broad spectrum antibacterial therapy
Treatment of non severe C diff?
metronidazole 400mg every 8 hours
vancomycin 125mg every 6 hours
Treatment of severe C diff?
vancomycin 125mg every 6 hours
Treatment of complicated C diff?
vancomycin 125mg every 6 hours +/- metronidazole 400mg every 8 hours
Treatment of relapsing C diff?
consider faecal transplant, re-establishing the microbiome
Why is vancomycin given orally in C diff?
we want local treatment in the GI tract
Treatment of herpes simplex?
cold sores
aciclovir topically
Treatment of herpes zoster?
chickenpox, shingle
aciclovir 800mg five times a day
valaciclovir 1g every 8 hours
Patient factors for viral infections?
age
onset of symptoms
formulation of treatment
When is antiviral treatment not appropriate for chicken pox?
when the patient has had it for more than 72 hours
How to treat tinea causing athletes foot?
antifungal powders/ointment
How to treat ringworm?
topical antifungal
What does candida cause?
oral and vaginal infections
How to treat vaginal infections caused by candida?
azole antifungals - usually oral
e.g. fluconazole
Patient factors for candida infections?
age, other treatments e.g. inhaled or oral steroids
Prescribing factors?
allergies
sensitivities
under/over dosing
resistance local differences
side effects
