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Year 3 - Script > Prescribing in Infection > Flashcards

Prescribing in Infection Flashcards

1
Q

what is AMR

A
  • This is the ability of a microorganism to resist the action of one or more antimicrobial agents
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2
Q

What are the key drivers in the development of antimicrobial resistance

A
  • indiscriminate or inappropriate use of antimicrobials
  • patients not taking prescribed antimicrobials as directed
  • poor hygiene practices in healthcare settings
  • poor personal hygiene practises
  • lack of new antimicrobials being developed
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3
Q

How do you define antimicrobial stewardship

A
  • An organisation or healthcare system wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness
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4
Q

What is the aim of antimicrobial prescribing and stewardship

A
  • improve the safety and quality of patient care
  • reduce the risks of inadequate, inappropriate and ill effects of treatment
  • contribute to the reduction in emergence and spread of antimicrobial resistance
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5
Q

What are the 5 domains to be considered in antimicrobial prescribing

A
  1. infection prevention and control
  2. antimicrobial resistance and antimicrobials
  3. prescribing antimicrobials
  4. Antimicrobial stewardship
  5. monitoring and learning
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6
Q

What is Start Smart - Then Focus

A
  • this is a toolkit developed by pubic health England to reduce inappropriate prescribing and optimise the use of antimicrobials in hospitals
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7
Q

What happens in start SMART

A
  • obtain cultures prior to starting treatment where appropriate
  • take a drug allergy history
  • start antimicrobials within one hour of recognition of red flag sepsis, septic shock or life threatening infections
  • comply with local antimicrobial prescribing guidelines
  • document the indication for treatment, severity of the infection, dose, route, and frequency on both the prescription an din the medical notes
  • state a review or stop date
  • consult the microbiologists and/or antimicrobial pharmacist for advice where appropriate
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8
Q

What happens in Then FOCUS

A

At 48-72 hours review the patient and make (and document) the management plan, including the next review or stop date

  • stop treatment (e.g. if there is no evidence of infection)
  • switch from intravenous to oral treatment
  • change the antimicrobial
  • continue the current treatment plan
  • refer for outpatient parenteral antibiotic therapy (OPAT)
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9
Q

What organisms appear negative on the gram stain

A
  • Gram negative organisms such as Escherichia coli
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10
Q

Why are gram negative organisms negative on the gram stain

A
  • have a thiner cell wall that can be de stained
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11
Q

What are gram positive organisms positive on the gram stain

A
  • these have a thick cell wall that retains the gram stain and renders them positive
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12
Q

describe the differences and similarities in terms of the wall on the gram positive and gram negative organisms

A

Similarities

  • cell membrane consisting of a phospholipid bilayer
  • layer of peptidoglycan on the outside

Differences

  • gram negative has a thin peptidoglycan layer and a second membrane
  • Gram positive - lacks the 2nd membrane but has a much thicker peptidoglycan layer
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13
Q

vancomycin has…

A

no activity against gram negative

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14
Q

ciprofloxacin …

A

has poor gram positive activity

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15
Q

What is a cell wall

A
  • rigid structure which maintains the cell shape and high osmotic pressure inside the organism
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16
Q

What does disruption to the cell wall result in

A
  • disruption of the cell wall leads to lysis of the cell and subsequent death of the organism
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17
Q

What antibacterials inhibit cell wall formation and result in cell death

A

beta lactam antibacterials - such as penicillins, cephalosporins, and carbapenems

  • Glycopetpide antibacterials such as vancomycin and teicoplanin inhibit a different stage of cell wall formation nd when given in high concentration can cause death
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18
Q

What bacteriostatic antibacterials inhibit protein synthesis

A
  • Macrolides (such as clarithromycin) and tetracyclines ( such as doxycycline) are bacteriostatic agent’s
  • they inhibit protein synthesis but do not kill the cell but do stop it from growing
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19
Q

What bactericidal antibacterials inhibit protein synthesis

A
  • Aminoglycosides such as gentamicin are bactericidal agents
  • these inhibit a vital cellular process which leads to cell death
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20
Q

What do quinolone do

A

They interfere with DNA synthesis

21
Q

what antibacterial is only active against anaerobic bacteria

A
  • Metronidazole
22
Q

What does trimethoprim do

A
  • interferes with bacterial folate metabolism and results in a lack of purine analogues for DNA synthesis
23
Q

What does Daptomycin do

A
  • binds to bacterial membranes, leads to depolarisation of the membrane, causes rapid inhibition of protein, DNA and RNA synthesis and therefore cell death
24
Q

What are defensive strategies that bacterial have developed against antibacterials

A
  • Efflux pumps = can pump any antibacterial which has passed through the outer membrane back out before they reach the target site
  • Antibacterial modifying enzymes = destroy the antibacterial before it reaches its target within the cells
  • Mutations - in the target site of antibacterial prevent it binding
25
Q

What factors do you consider when prescribing an antimicrobial

A
  • national/local antimicrobial prescribing guidelines
  • spectrum of antimicrobial activity
  • site of infection
  • cultures and sensitivities
  • patient factors
  • route of administration
  • duration of treatment/intended review date
26
Q

What are factors that can influence antimicrobial prescribing decisions

A
  • patient expectations
  • prescriber fear that they may miss a significant bacterial infection leading to patient deterioration
  • difficulty distinguishing between a viral and bacterial infection
  • day of the week
  • pressure from colleagues
  • influences of colleagues prescribing practise
27
Q

why should you follow local guidelines for prescribing antibacterials

A
  • Local guidelines will have taken into account local resistance pattern
  • based on evidence, national guides and represent the preferred choice of the turst
  • limit the inappropraite use of broad spectrum agents helping to prevent resistance development and secondary infections due to resistant organisms
  • local guidelines will recommend the use of agetns that are available in the hospital
  • promote the use of cost effecitve agents
28
Q

How do you treat infection when a person first arises with an infection

A
  • Broad spectum anitbitoic which covers all of the most common causative organisms
29
Q

What can broad spectrum anitbotics result in

A

Multi drug resistant strains and clostridioides difficile

30
Q

What should you clearly document in antibiotics

A
  • indication for antibacterials in the notes and on the drug chart
  • intended route and duration
31
Q

What infection is Co-Amoxiclav associated with

A

C.difficile infection

32
Q

How can you calculate renal function

A

Cockcroft-Gault equation

creatine clearance = Fx(140-age(years)) x weight (kg) / serum creatine (micromol/litre)

F = 1.04 in women 
F = 1.23 in men
33
Q

when must IV antimicrobials be prescribed within 1 hour

A
  • In the management of sepsis IV antimicrobials have to be administered and prescribied within 1 hour of diagnosis
34
Q

what happens if you have uneven distribution of dosing

A
  • this leads to supra-therapeutic concentrations, this increases the risk of toxic effects or subtherapeutic causing the concentration to fall below the one deemed effective
35
Q

When are IV antibiotics required

A
  • if there is a systemic infection

- when patient cannot tolerate oral route

36
Q

what should you also consider when administring the drug and the route you administer the drug to

A
  • does it have good oral bioavailability
37
Q

What is bioavailability

A
  • extent to which a drug reaches the systemic circulation where is is avaliable to act as the effector site
38
Q

When does a drug have a bioavailability of 100%

A

when it is administered IV

39
Q

When can the IV to oral switch be made

A
  • can be made 24-48 hours of treatment in most infections
40
Q

What conditions can need long lasting IV antibitoics

A
  • infective endocarditis

- osteomyelitis

41
Q

What can happen when antibiotics are given for longer than required

A
  • nasuea
  • antibiotic associated diarrhoea
  • development of clostridioides difficile infection
42
Q

In order to de-escalate therapy what 5 presribing decisions should be made 48 hours after initiating IV antibiotics

A
  • stop the antibacterials
  • swtich IV therapy to oral route
  • change the antibacterial
  • continue and review again in 72 hours
  • refer for outpatient parenteral therapy
43
Q

what can patients have that do not require antibacterials

A
  • acute cough
  • acute otitis media
  • acute sinusitis
  • acute sore throat
44
Q

What are the self care counselling points for all self limiting infections

A
  • drinking plenty of fluids
  • simple analgesia as appropriate
  • rest
45
Q

urine dipstick tests are an …

A

unreliable diagnostic method for catheter related UTIs - urinary catheters quickly become colonised with bacteria and the dipstick will only detect their presence

46
Q

How should you treat someone who has an UTI from a catheter

A
  • antibacterials should be prescribed
  • urinary catheter should be removed in possible
  • urine sample can then be collected as this remains a focus of infection
47
Q

Name an antibacterial drug that must be avoided with alcohol

A

Metronidazole - and for 48 hours after completing the course
- infection causes a disulfiram like reaction occuring causing flushing, shortness of breath and a throbbing headache

48
Q

what do super resistant organisms produce

A
  • carbapenemases
49
Q

Why are some antibacterials restricted agents

A
  • they are broad spectrum agents - where inappropriate use would promote development of resistance
  • need to be resereved for serious infections where multi-drug resistant organisms are known to be present or suspected
  • may be potentially toxic and use may be limited in duration or they require specialist monitoring
  • may be expensive and inappropriate use may waste limited resources

Year 3 - Script (11 decks)

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