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

SisterStaff nurse

Student nurseConsultant

Senior doctorJunior doctor

HCAAllied

Porter

0

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???