Role Of Pharmacist

Question 1

Give some roles of the specialist antimicrobial pharmacist

Answer 1

Encourage optimum use of antimicrobial
Antimicrobial stewardship
Guideline development and implementation 
Microbiology/pharmacy ward rounds
Audit and usage data
Education

Question 2

What is the start smart then focus 2015 NICE?

Name the other popular guideline development paper

Answer 2

A comprehensive guide to antimicrobial stewardship
Has evidenced based guidelines
What the CQC would use

Specialist advisory committee on antimicrobial resistance (SACAR) antimicrobial

Question 3

Audit and feedback are recommended as part of the stewardship

What aspects should be included in an audit?

Answer 3

Compliance with guidelines and prescribing policy
Documentation of indication and duration
Prompt de-escalation of spectrum and IV-PO switch
Appropriate total duration
Peri-operative prophylaxis

Question 4

What type of bacteria is clostridium difficile

Answer 4

Gram +be spore forming rods

Present in the gut of up to 3% or healthy adults

Question 5

Explain the C.Diff cycle (simple)

Answer 5

Environment
Stomach kills vegetative bacteria
Spores travel to intestine to germinate. With altered gut flora (Abx) colonisation and toxin production can cause disease.
Excreted to cause further environmental contamination

Question 6

What type of faeces does C.diff cause?

Answer 6

Type 6- fluffy and mushy

Type 7 - water, no solid pieces, entirely liquid

Question 7

What context is c.diff found?

What symptoms show?

Answer 7

Generally elderly
Recent antibiotic use (broad spectrum)

Diarrhoea (Bristol Stool Chart Type 6-7)
Often with mucus
Offensive smell (often distinctive)

Possible symptoms:
Raised CRP/WCC (inflammatory markers)
Pyrexia
Toxic confusional state in elderly

Question 8

Describe the difference between mild disease and severe c.diff disease?

Answer 8

Mild disease - self limiting
Severe disease- pseudomembraneous colitis
Damaged mucosa pseudomembranes
Clinical signs- abdominal distension, high WCC, usually diarrhoea

Question 9

How to you diagnose c.diff disease and what do you do in case of severe morbidity?

Answer 9

Diagnosed with flexi-sigmoidoscopy

Need life saving colectomy

Question 10

Outlin the c.diff management plan

Answer 10

Stool sample for toxin
Patient isolation, strict enteric precautions, perfect hand hygiene
Stool chart and monitoring
Stop offending antibiotics (that they may have come in with)
Review drugs that may cause diarrhoea (PPIs, laxatives)
Avoid loperamide and if possible opioids

Question 11

List the standard treatment of C.diff disease

Answer 11

PO vancomycin (NOT IV)
Main treatment 

PO Fidaxomicin
Lower relapse rate
Consider if severe disease in patients w concurrent abx, and co-morbidities or recurrence

Others

• rifaximim
• IV immunoglobulins
• bezlotoxumab
• faecal microbiota transplants

Question 12

Are all antibiotics to blame for c.diff?

Answer 12

Most antibiotics can cause antibiotic associated diarrhoea and c.diff
High risk mainly broad spectrum: 4C’s. Clindamycin, cephalosporins, co-moxiclav and carbapenems
Erythromycin can also cause diarrhoea

Lower risk for narrow spectrum antibiotics that can bypass the gut, leaving most bacteria there alone

Longer the duration and greater your age, higher risk of c.diff

Question 13

Other risk factors of c.diff

Answer 13

NG-tubes

PPIs -Acid suppression

Question 14

Why use aminoglycosides

Answer 14

Effective against most gram -ve bacteria (incl MRSA)
Sufficient peak for efficacy
Low trough before re-dosing to reduce toxicity

Question 15

Exaplain gentamicin TDM

Answer 15

Monitor renal function!
Major cause of preventable drug related toxicity (nephro and oto) risk increased by other nephrotoxic drugs (NSAIDs and vancomycin)