Antibiotics Delivered by: Jennifer Dodd Written by: Michelle Wong - - PowerPoint PPT Presentation

Antibiotics

Written by: Michelle Wong Lead Pharmacist – Antimicrobials Delivered by: Jennifer Dodd

In the next 30 minutes

 How to access the Antimicrobial Formulary  What is expected for every antibiotic

prescription

 MCQs  Audit

What antibiotic information is available?

 Antimicrobial Formulary for adults (plus summary)

and paediatrics available on the Intranet

 Vancomycin and gentamicin dosing guidelines  Surgical prophylaxis guidelines  Contact consultant microbiologists for antibiotic

advice

 Ward pharmacists  BNF

Antimicrobial Formularies

Antimicrobial Formularies

 Contents page – Hyperlinks to empiric

treatment for each type of infection

 Lists ‘High risk C difficile antibiotics’, and risk

factors

 C Diff treatment - also CDI policy  Principles of good antimicrobial prescribing  Restricted antimicrobial list: Red, Amber

Tips….

 Change from IV to oral guide  Microbiological specimens  Management of MRSA  Dosing in Renal Impairment  Vancomycin/gentamicin guideline  Antimicrobial prophylaxis post-splenectomy

Antibiotic Prescribing Tips

 Allergy box completed  Antibiotic, route, dose and frequency  Review date at 48 hours/72 hours  Stop date (5 days if empiric)  Use the shortest duration of treatment suitable for

the infection

 Indication recorded on prescription chart, as well as

medical notes

 IV antimicrobials review after 48 hours – to oral?  Printed Name and bleep number

Is this OK?

Good example

Therapeutic Drug Monitoring

Vancomycin Monitoring

Gentamicin monitoring

 80 year old male, 80kg (not obese)  Urosepsis  Creatinine 112micromole/L (CrCl 53ml/min)  Gentamicin level at 9:00am 2/1/12 = 3.1mg/l  What do you do?

Gentamicin monitoring

 Taken too early - insignificant  Should be taken 1-4 hours before the 2nd

dose

 Repeat level at ~6-9pm  Nursing to document time of administration

and time of sample in the medical notes

GDH + & C. Difficile + Patients

GDH – Glutamate Dehydrogenase

 GDH –ve  GDH +ve + C. Diff toxin –ve  GDH +ve and C. Diff toxin +ve

Key top interactions…

 Antifungals/quinolones/rifamycins – LOTS of

interactions!

 Most antimicrobials – Warfarin  Macrolides/Daptomycin/Fusidic Acid –

Statins

 Daptomycin – Measure CK  Trimethoprim – Methotrexate  Aminoglycosides – IV diuretics

Question 1

Which ONE of the following is the most likely pathogen in Community acquired pneumonia?

a)

Streptococcus pneumoniae

b)

Pseudomonas aeruginosa

c)

Moraxella catarrhalis

d)

E.coli

e)

Streptococcus pyogenes

Question 2

Which ONE of the following is the most likely pathogen in exacerbation of COPD?

a)

Streptococcus pneumoniae

b)

Staphylococcus aureus

c)

Haemophilus influenzae

d)

Anaerobes

Question 3a

A 78 year old lady is admitted to hospital with SOB, and coughing up green sputum. CXR showed right basal consolidation. Ur: 8.8, BP: 80/40, AMT: 10, RR: 23. What is the severity of this patient’s pneumonia?

a)

Mild

b)

Moderate

c)

Severe

Question 3b

For the same patient, what antimicrobial treatment would you commence them on? (Patient has no known drug allergies)

a)

IV Co-amoxiclav + IV Clarithromycin

b)

Oral Amoxicillin alone

c)

Oral Amoxicillin + Oral Clarithromycin

Question 3c

For the same patient, which of the following Microbiological specimens should you take?

a.

Pneumococcal urinary antigen

b.

Legionella urinary antigen – after speaking to microbiologist

c.

Blood culture

d.

Sputum sample

e.

All of the above

Question 3d

The first results that come back for the patient are Pneumococcal Ag +ve, Legionella Ag-ve, what changes could you make to the patient’s treatment, if any?

a)

Continue with same regimen

b)

Stop IV Clarithromycin

c)

Switch IV Co-amoxiclav to oral Amoxil

d)

IV to oral switch for both Co-amoxiclav and Clarithromycin

Question 4

A patient is admitted with non-severe cellulitis and has a MRSA screen, the screen is positive. What antibiotic treatment would be appropriate?

a)

Doxycycline

b)

Flucloxacillin

c)

Clarithromycin

d)

Cefalexin

Question 5

Which of the following antibiotics are high- risk for precipitating C. difficile infection?

a)

Co-amoxiclav

b)

Ciprofloxacin

c)

Ceftriaxone

d)

All of the above

Question 6



Which ONE of the following is a risk factor for Clostridium difficile infection?

a)

Morphine sulphate

b)

Loperamide

c)

Omeprazole

d)

Paracetamol

e)

Dalteparin

Question 7

A patient is receiving IV Vancomycin 1g OD for a MRSA wound infection, your SHO asks you to switch to oral treatment. Which of the following is the most suitable action?

a)

Sodium fusidate 500mg po tds

b)

Rifampicin 600mg po bd + Doxycycline 100mg po bd

c)

Vancomycin 250mg po qds

d)

Flucloxacillin 500mg po qds

e)

Contact microbiologist

Question 8

A patient is receiving Vancomycin 1g IV bd, a pre-dose level is taken before the 4th dose, the level is 25.0mg/L, what action would you take?

a)

Continue with current regimen

b)

Stop IV Vancomycin

c)

Reduce dose to 1g OD

d)

Increase dose to 1.5g BD

Question 9

Your SHO asks you to prescribe gentamicin for a 50year male patient with suspected urosepsis? Seen on A+E. What information do you need?

1.

Weight

2.

Renal function

3.

Previous A+E documention

4.

All of above

Question 10

Your patient has been diagnosed with severe Hospital Acquired Pneumonia. Has been started on co-amoxiclav IV 1.2g TDS. History of CDT. What do you do?

a)

Speak to microbiologist regarding management

b)

Add in metronidazole

c)

Continue with co-amoxiclav

d)

All of above

Audit

 Data on compliance with the antibiotic

formulary done quarterly.

 If interested in participating in an audit

contact antimicrobial pharmacist/microbiologist

WHO definition - HAI

 Patient admitted for reason other than Infection  Infection was not present or incubating at admission  Develops over 48 hours after admission  Develops post discharge  Also includes occupational infections in HCW

Screening

 MRSA (Limited)  CPC (All those admitted to other hospital in

last 12m)

 VRE (Known positives and those admitted

from units with high prevalence

Sister Staff nurse Student nurse Consultant Senior doctor Junior doctor HCA Allied Porter 100 200 300 400 500 600 700

Total Opportunites, Hand Hygiene Events, and Percent

Opportunities Hygiene Percent

HAND HYGIENE

 We do not wash our hands as often we think

we do

 Single most important thing you can do to

prevent the spread of infection.

 Hand hygiene SAVES LIVES.  Single most effective intervention during XDR

bacterial outbreaks.

Good luck

Any questions???