michelle wong lead antimicrobial pharmacist · antibiotic prescribing tips allergy box completed...
TRANSCRIPT
Michelle Wong
Lead Antimicrobial Pharmacist
Antibiotics
Aims and Objectives
How to access the Antimicrobial Formulary
What is expected for every antibiotic
prescription
MCQs
Audit
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
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
Empirical therapy
Grenade vs sniper approach
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
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
Glycopeptide
1st choice – vancomycin – local shortage
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
Aminoglycoside
Gentamicin, tobramycin, amikacin
Nephrotoxic and ototoxic
Mainly use once daily except for infections such as endocarditis
Requires renal function and therapeutic drug monitoring
Rarely used for longer than 5-7days except for endocarditis
Extremes of weight – contact pharmacy
Calculator coming soon
What antibiotic information is available?
Antimicrobial Formulary for adults (plus summary) and
paediatrics available on the Intranet
AM app
http://www.bfwh.nhs.uk/mobile/amformulary/index.shtml
Vancomycin and gentamicin dosing guidelines
Surgical prophylaxis guidelines
Contact consultant microbiologists for antibiotic advice
Ward pharmacists
BNF
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
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
Vancomycin/gentamicin guideline
Antimicrobial prophylaxis post-splenectomy
Start smart then focus
Prescribing Tips
48hours review and document outcome
– Stop
– Continue
– Switch
– IV to Oral
– OPAT
Prescribing Tips
RAG antibiotics list
Don’t forget incision and drainage/surgical
intervention may be the only option
Is this OK?
Good example
?Appropriate choice for UTI
Amoxicillin Resistance – January 2013 to December 2016
(% formulated using Resistant and Sensitive results on gram negative
organisms.)
Trimethoprim Resistance – January 2013 to December 2016
(% formulated using Resistant and Sensitive results on gram negative
organisms.)
Nitrofurantoin Resistance – January 2013 to December 2016
(% formulated using Resistant and Sensitive results on gram negative
organisms.)
Sample sensitivity review
MUST review relevant previous/current
sample sensitivity
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
GDH + & C. Difficile + Patients
GDH – Glutamate Dehydrogenase
GDH –ve
GDH +ve + C. Diff toxin –ve
GDH +ve and C. Diff toxin +ve
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
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
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
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 or CURB 3 and above
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) Stop IV Co-amoxiclav
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
e) Speak to microbiologist
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
Any questions???
Good luck