2b. antibiotics - michelle wong · antibiotic prescribing tips allergy box completed antibiotic,...
TRANSCRIPT
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Michelle WongLead Antimicrobial Pharmacist
Antibiotics
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Aims and Objectives
How to access the Antimicrobial Formulary What is expected for every antibiotic
prescription MCQs Audit
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What are the signs of infection?
Systemic– Fever, rigors, delirium, chills, myalgia, headache,
anorexia, malaise Peripheral/local
– Erythema, pain, heat, swelling, pus Vital signs
– Temperature, tachycardia, hypotension, tachypnoea
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Is an antibiotic indicated?
Evidence of infection– Clinical signs/symptoms– Laboratory
Biochemistry Haematology Microbiology – previous results are very important
– Medical imaging SAMPLE SAMPLE SAMPLE – allows for
targeted therapy
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Empirical therapy
Grenade vs sniper approach
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Broad vs narrow spectrum antibiotics
Broad spectrum antibiotics
– Co-amoxiclav– Quinolones– Cephalosporins– Tetracyclines– Macrolides– Piperacillin/tazobactam– Meropenem
Narrow spectrum antibiotics
– Trimethoprim– Benzylpenicillin/Phenoxymethylpenicillin– Flucloxacillin– Fusidic acid– Vancomycin – Gentamicin
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General drug selection criteria
Age, weight (especially extremes), gender Cautions/contraindications
– Allergy (nature – to establish true allergy – cost of allergy, if penicillin- explore previous cephalosporins/carbapenem use), ADR, pregnancy/breastfeeding
Renal and hepatic function Interactions – e.g antibiotics and warfarin,
oxycodone and clarithromycin Route and bioavailability Dose, frequency, duration
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What antibiotic information is available?
Antimicrobial Formulary for adults and paediatrics available on the Intranet
AM apphttp://www.bfwh.nhs.uk/mobile/amformulary/index.shtml
Vancomycin and gentamicin dosing guidelines Gentamicin calculator for treatment initial doses:
http://fcvmsrv243/gentcalc/ Surgical prophylaxis guidelines Contact consultant microbiologists for antibiotic advice Ward pharmacists BNF
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Antibiotic Prescribing Tips
Allergy box completed Antibiotic, route, dose and frequency Review date at 48 hours – sign and GMC number 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
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Antibiotic Prescribing Tips
Change from IV to oral guide CHORAL Microbiological specimens Time is essential Management of MRSA/CPE – contact
microbiology Dosing in Renal Impairment Antimicrobial prophylaxis post-splenectomy
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Prescribing Tips
RAG antibiotics list Don’t forget incision and drainage/surgical
intervention may be the only option
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Start smart then focus
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CQUIN 2018-19
24-72hours review and document outcome and new stop/review date– Stop – Continue– Switch – escalate/de-escalate, as per culture– IV to Oral– OPAT
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If to remain on IV AB – state reason
NBM/malabsorption No oral AB alternative Not clinically improving Deep seated infection Based on microbiology, infection pharmacist
advice
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Is this OK?
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Good example
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?Appropriate choice for UTI
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Amoxicillin Resistance – January 2013 to December 2016
(% formulated using Resistant and Sensitive results on gram negative organisms.)
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Trimethoprim Resistance – January 2013 to December 2016
(% formulated using Resistant and Sensitive results on gram negative organisms.)
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Nitrofurantoin Resistance – January 2013 to December 2016
(% formulated using Resistant and Sensitive results on gram negative organisms.)
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Sample sensitivity review
MUST review relevant previous/current sample sensitivity
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High risk antibiotics for C difficile
Co-amoxiclav Cephalosporins (especially 2nd/3rd
generations) Ciprofloxacin (quinolones) ?Clindamycin (high dose used at BTH as
protective effect to CDT) Not same as clarithromycin
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GDH + & C. Difficile + Patients
GDH – Glutamate Dehydrogenase
GDH –ve GDH +ve + C. Diff toxin –ve GDH +ve and C. Diff toxin +ve
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Therapeutic Drug Monitoring
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Glycopeptide
1st choice – vancomycin Used intravenously for MRSA infections,
alternative to penicillins for gram positive cover
Requires renal function and therapeutic drug monitoring
Max rate of administration 10mg/min Oral - not absorbed Teicoplanin higher dose used –no routine
level
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Vancomycin Monitoring + sheet coming soon
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Aminoglycoside
Gentamicin, tobramycin, amikacin Nephrotoxic and ototoxic Mainly use once daily except for infections
e.g. endocarditis Requires renal function and therapeutic drug
monitoring High level – don’t ignore it-review it Rarely used for longer than 48-72hours
except for endocarditis Extremes of weight – contact pharmacy
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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?
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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
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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
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Clarithromycin and oxycodone/fentanyl patch
Clarithromycin is strong CYP3A4 inhibitors INHIBITOR interaction is SIGNIFICANT May increase the concentration of
oxycodone/fentanyl Major incidents in real patients at BTH with
respiratory depression needing reversal with naloxone
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Audit
Data on compliance with the antibiotic formulary done quarterly.
If interested in participating in an audit contact antimicrobial pharmacist/microbiologist
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Any questions???Good luck