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Hand Hygiene Koass

Jun 01, 2018

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    Reducing nosocomial infection andimproving rational antibiotic use in

    children

    at the Dr Sardjito teaching hospital,

    Indonesia

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    HospitalizedChildren

    Infection

    Antibiotic

    Use

    AntibioticResistance

    NosocomiaI

    Infection(

    NI)

    CostHospital

    stay(Biersi et al! "##$% &aconelli et al! "##$% 'adani

    et al! "##$)

    Contaminated cltre

    reslt

    DirectContact

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    Increase mortality rate (*+, -,.+/)

    Increase len0th of stay (1+$ - "days)

    Increase health cost (2 .$1 to 23#!### per case)

    (Biersi et al! "##$% &aconelli et al! "##$% 'adani et

    al! "##$)

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    4ey factor of a 0ood 5ality ofhealthcare

    3#/ of NIs can be pre6ented

    &o pre6entable casal factors7&ransmission of infection by health

    or8ers Inappropriate antibiotic se

    (Wenzel, 1987; Damani, 2007)

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    THE UNWASHED HAND!

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    Ignaz ili"" Semmel#ei$

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    Semmelweis IP, 1861

    (%)

    &a'enal m'ali'* a'e$,

    +i$' an Se-n ./$'e'i-$ lini-$,

    ENEA3 H.SITA3 .+ 4IENNA, 18516185

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    In'een'in

    S'en'$ an -'$ #ee e:ie '-lean 'ei an$ #i' a -lina'e lime

    $l'in #en en'eing 'e la/ m

    in "a'i-la #en ming

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    &a'enal m'ali'* a'e$,

    +i$' an Se-n ./$'e'i-$ lini-$,

    ENEA3 H.SITA3 .+ 4IENNA, 1851618=0

    Intervention

    Semmelweis IP, 1861

    May 15, 1847

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    Ignaz Philipp Semmelweis before and after he insisted that

    students and doctors clean their hands with a chlorine solution

    between each patient

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    Eien-e < ela'in$i">e'#een Han H*giene an

    Heal'-ae6A$$-ia'eIn

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    9per:cial layer Colonisation of transient ;ora from contact ith

    patient or inanimate ob

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    Pathogen Type of Frequency of colonized hands Survival on hands Survival on an inanimate object

    Gram positive bacteria

    S. aureus SSI !TI septicaemia pneumonia "#$%&' ( ")# min * + , % mo

    -nterococcus sp !TI *"' # min ) d , * mo

    Gram negative bacteria

    -. coli !TI /0!TI un1no+n $2# min 3 h $ mo

    P. aeruginosa Pneumonia "$3)' 4#$ min h$" mo

    0cinetobacter 4$")' ( ")# min 4 d , ) mo

    S. marcescens Septicemia !TI SSI pneumonia

    meningitis

    ")$3*' ( 4# min 4 d , 3 mo

    5lebsiella sp. !TI "%' !p to 3 h 3 h , 4# mo

    Spore forming bacteria

    /. difficile 6iarrhea "*$)2' un1no+n ( 3* h , ) mo

    Fungi

    /. albicans Septicaemia !TI SSI 34$&"' " h "$")# d

    7iruses

    Influenza Parainfluenza un1no+n "#$") min "3$*& h

    807 un1no+n Several hours 3 h , # d

    8/7 &$3*' un1no+n un1no+n

    9hinovirus !p to )' un1no+n 3 h$ % d9otavirus 3#$%2' !p to 3# min $# d

    #re$uency and survival of nosoco%ial &athogens on the health 'or(ers) hands

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    W* #e n?' #a$ an$

    T /$*@in$

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    Table 1. Compliance with hand hgienein di!erent hospital settings before intervention

    *a+le . istri+ution of factors associated

    'ith non-co%&liance 'ith hand hygiene

    Source /ittet , 0oyce M 236* Infect is 1

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    Compliance @ sin0 hand hy0iene prodctsappropriately

    Non compliance @ failre to apply hand

    hy0iene prodcts at the appropriate time Is hen HH is considered necessary

    classi:ed accordin0 to one of the .'oments

    &otal moments obser6ed@

    Actal moments performed@

    E##/@/ rate of HH compliance

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    #oment $IC% Infectiousward

    &on'infectious

    ward

    Rate ofHandhy0ienecompliance(/)

    " "+. ".+"

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    Hand Hy0ienea 0eneral term that applies to either handashin0!antiseptic handash! antiseptic hand rb or sr0ical handantisepsis+

    Handashin0ashin0 hands ith plain ( ie+ non=antimicrobial) soap andater+

    Decontaminationto redce bacterial conts on the hands by performin0antiseptic hand rb or antiseptic handash+

    Fide for Hand Hy0iene in Healthcare 9ettin0s7 ''GR "##"% 6ol+.! no+ RR=

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    Han#a$ing Al-l6/a$e Han//ing

    Elimina'in < 'an$ien'

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    Time S"en' lean$ing Han$

    .ne n$e "e 8 $i

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    In all clinical sitations C&7

    Ghen yor hands are 6isibly soiled

    Ghen a sr0ical scrb is re5ired

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    hen hands are 6isiblycontaminated ith bloodbody ;ids

    to remo6e Jbild=pK from thealcohol 0elrinse

    before eatin0

    after sin0 the restroom

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    Colonised or infected patients represent the main

    reser6oir for healthcare associated micro=

    or0anisms

    n6ironment in the healthcare facility contains aide 6ariety of diLerent healthcare=associated

    micro=or0anisms and represents a secondary

    sorce for transmission to patients

    &he immediate patient en6ironment becomes

    colonised by the patient ;ora

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    Mr0anisms present on patient s8in orthe immediate en6ironment

    Mr0anism transfer from patient toHCGs handsMr0anism sr6i6al on HCGs hands Incorrect hand cleansin0Oailre to cleanse hands drin0

    patient care reslts in ithin=patientcross=transmission

    .gani$m$ "e$en' n "a'ien' $in 'e immeia'e eninmen'

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    A /eien "a'ien' -lnize #i' am6"$i'ie ---i, in "a'i-la a' na$al, "eineal,

    an inginal aea$ (n' $#n), a$ #ell a$ aillae an ""e e'emi'ie$C Sme

    eninmen'al $

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    .gani$m 'an$

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    (A) &i-gani$m$ (in 'i$ -a$e am6"$i'ie ---i)

    $ie n an$C

    (>) Wen g#ing -ni'in$ ae "'imal ('em"ea'e,

    mii'*, a/$en-e < an -lean$ing,

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    In-e-' an -lean$ing

    Ina"""ia'e an#a$ing -an e$l' in an$ emaining -n'amina'e; in 'i$ -a$e,

    #i' am6"$i'ie ---iC e"in'e

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    $$i/le -$$ -n'amina'in

    /e'#een a'ien' A an a'ien' >+aile ' -lean$e an$ e$l'$ in

    /e'#een6"a'ien' -$$6'an$mi$$in

    (A) Te -' a a "lnge -n'a-' #i' "a'ien' A -lnize #i' am6"$i'ie ---i an

    -n'amina'e i$ an$C (>) Te -' i$ n# ging ' ae ie-' -n'a-' #i' "a'ien' > #i''

    -lean$ing i$ an$ in /e'#eenC $$6'an$mi$$in < am6"$i'ie ---i 'g 'e HW?$ an$ i$ liel* ' --C e"in'e

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    +aile ' -lean$e an$ ing "a'ien' -ae e$l'$ in #i'in6"a'ien' -$$6

    'an$mi$$in

    Te -' i$ in -l$e -n'a-' #i' 'e "a'ien'C He '-e 'e ina* -a'e'e /ag

    "ei$l* an i$ an$ ae -n'amina'e #i' am6nega'ie $

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    + Cross colonisation of clients

    "+ ndo0enos and eEo0enos infection in clients

    1+ Infection in HCGs

    3+ Cross=colonisation of the healthcare

    en6ironment incldin0 HCGs

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    (hen Hand Hy0iene before tochin0 a patient

    Hand Hy0iene on enterin0 the patients room(h&o protect the patient a0ainst ac5irin0 harmfl

    0erms from the hands of the HCG

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    Hand hy0iene before7Any personal care acti6itiesAny non=in6asi6e obser6ationsAny non=in6asi6e treatmentreparation and administration of

    oral medications

    Mral care and feedin0

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    1. Cross colonisation of clients

    "+ ndo0enos and eEo0enos infection in clients

    1+ Infection in HCGs

    3+ Cross=colonisation of the healthcare

    en6ironment incldin0 HCGs

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    Mften clients are in close contact itheach other and share the sameen6ironment

    dcation is the 8ey

    Co6er non intact s8in on eEposed hands

    AI'7

    &o de6elop maintain an on0oin0edcation pro0ramme to initiate sstain hand hy0iene beha6iorchan0e+

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    (hen

    Hand Hy0iene immediately prior to a procedre Mnce Hand Hy0iene has been done! nothin0 else in the

    patients en6ironment shold be toched prior to theprocedre startin0

    (h &o protect the patient from harmfl 0erms (incldin0 their

    on) from enterin0 their body drin0 a procedre

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    Is an act of care for a patienthere there is a ris8 of direct

    introdction of a patho0en intothe patients body+

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    Hand hy0iene before7

    Insertion of a needle into a patients s8in! or intoan in6asi6e medical de6ice

    reparation and administration of anymedications 0i6en 6ia an in6asi6e medicalde6ice! or preparation of a sterile :eld

    Administration of medications here there isdirect contact ith mcos membranes

    Insertion of! or disrption to! the circit of an

    in6asi6e medical de6ice Any assessment! treatment and patient carehere contact is made ith non=intact s8in ormcos membranes

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    + Cross colonisation of clients

    ). *ndogenous and e+ogenous infection in

    clients1+ Infection in HCGs

    3+ Cross=colonisation of the healthcare

    en6ironment incldin0 HCGs

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    (hen

    Hand Hy0iene immediately after a procedre ora body ;id eEposre ris8 As hands are li8ely to be contaminated ith body ;id

    (h&o protect yorself and the healthcare

    srrondin0s from harmfl patient 0erms

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    An* $i'a'in #ee -n'a-' #i' /*

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    Hand hy0iene7

    After any procedre After any potential body ;id eEposre

    P Blood! ?ochia

    P 9ali6a or tearsP 'cos! aE! or psP Breast mil8! ColostrmP QomitsP Urine! faeces! semen! or meconim

    P leral ;id! ascitic ;id or C9OP &isse samples! incldin0 biopsy specimens! or0ans!

    bone marro!cell samples

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    + Cross colonisation of clients

    "+ ndo0enos and eEo0enos infection in clients

    /. Infection in 0C(s. Cross'colonisation of the healthcare

    environment including 0C(s

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    (hen Hand Hy0iene after tochin0 a patient Hand Hy0iene before yo lea6e the patient

    room(h&o protect yorself and the healthcare

    srrondin0s from harmfl patient 0erms

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    erform Hand Hy0iene on enterin0 thestaL area! prior to tochin0 anythin0 else

    Cleanin0 yor hands before after

    tochin0 a client is one of the mostimportant measres for pre6entin0 the

    spread of micro or0anisms+ ersonal ABHR pac8s can assist ith

    correct hand hy0iene beteen clients 'ay not be able to be performed in front

    of the client

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    9hy

    T "'e-' *$el< an 'e eal'-ae $ning$

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    INCREASE INCREASE DECREASE

    HH Compliance Aareness Healthcareassociated

    infections

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    ?imit

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    ;Heal'-ae #e$ in a m#i' a $eni $'a

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    ' is an important barrier to compliance= is more fre2uent with soap and waterthan with handrubs

    = is reduced and can be treated b

    emollient'containing solutions

    Sinirritation

    >*-e e' alC Inf Contr Hosp Epi

    2000;21552Kame e' alC ! Hosp Infect 2002;

    =1115

    3a$n e' alC Heart "ung 2000; 291B9

    i''e'C Emerging Inf #is 2001; 22B5

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    le $e

    Han *giene i$ e:ie egale$$ < #e'egle$ ae $e -ange

    +aile ' eme gle$ a

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    B0s are on the handsHand hy0iene can easily remo6es

    those b0sHand hy0iene7 the simplest and most

    eLecti6e measre for pre6entin0nosocomial infections

    Hand ashin07 6isibly dirty!contaminated! or soiled handsHand rbbin07 6isibly clean hands. moments for hand hy0iene

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    Hand Hy0iene Astralia! a6ailable at7+hha+or0+a

    Fideline for Hand Hy0iene in Health=Care 9ettin0s+MMWR"##"%.7RR=+

    ittet D+ Inf Control Hosp Epidemiol."###%"71*=

    1*+ Qoss A and Gidmer AO!Inf. Control Hospital

    Epidemiology$$,7*7"#.="#* HHA 5 Moments for Hand Hygiene! Ad6anced draft!

    A0st "##* WHO uidelines on Hand Hygiene in Health Care

    (Ad6anced Draft) April "## Boyce et al+ Inf Control Hosp Epidemiol. "###%"733" 4ramer et at. ! Hosp Inf. "##"%.73

    ?arson et al+ Heart ?n0+ "###%"$71$ ittet D+ Emer in Inf "is."## "7"13

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    Rational antibiotic sehen patients recei6e antibiotic

    appropriate to their clinical needs! inade5ate doses and dration! and atthe loest cost

    Gorld Health Mr0anization(GHM)

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    A practice that ensres the optimalselection! dose! and dration ofan antibiotic therapy that leads tothe best clinical otcome for thetreatment or pre6ention of infectionhile prodcin0 the feest toEic

    eLects and the loest ris8 forsbse5ent resistance

    (Ferdin0! "##)

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    limitin0 the de6elopment ofresistance

    redcin0 antibiotic resistant nosocomialinfection

    impro6in0 patient safetyminimizin0 nnecessary costs

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    re6alence of antibiotic se inhospitalized patients in de6elopin0contries7 1,/ = .3/

    &he rates of irrational antibiotic se7#/

    &he se of irrational antibiotic is

    more pre6alent in de6elopin0 (31/ =.3+1/) than de6eloped contries(. ### patient days)

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    Irrational antibiotic se mortality resltin0 from infection

    Irrational antibiotic se antibioticresistanceantibiotic resistant nosocomial infection(mch more diclt to eradicate)

    Irrational antibiotic se

    not only cases antibiotic resistance! bt alsoindces its spread+

    A sstained antibiotic control pro0ram

    nosocomial infections

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    Nosocomial infections are increasin0lycased by mltidr0=resistant patho0ens+ Coa0lase=ne0ati6e staphylococci B9I in

    ICUs 'ethicillin=resistant S. aureus ('R9A)!

    6ancomycin=resistant enterococci andEntero#acter spp+ nosocomial patho0ens in

    the pediatric settin0 )le#siella and (seudomonas spp+ common

    cases of nosocomial in the pediatricpoplation

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    &here are to mechanisms of de6elopin0antibiotic=resistant nosocomial infection! hichthro0h7 cross transmission antibiotic eEposre+

    Cross transmission occrs 6ia person=to=persontransmission hich hands of the healthor8ers as a 6ehicle+

    Colonization of the antimicrobial=resistant

    patho0en sally happens before de6elopin0nosocomial infection+ &he colonization can occr in the hands and other

    inanimate ob

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    Antimicrobial resistance can beinherent or it can be ac5ired+re6entin0 or minimizin0 ac5iredresistance is the formidable 0oal ofan A9

    Natrally! resistance can happen

    Irrational antibiotic se indces itsoccrrence and spread

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    Central 6enos catheters B9I'echanical 6entilation QAUrinary catheters CAU&I be sed only hen there is an indication be remo6ed asap

    Uses of in6asi6e de6ices the se6erity of illness

    prolon0ed len0th of stay increased possibility of sin0 antibiotics increased ris8 of de6elopin0 antibiotic=

    resistant nosocomial infection

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    Initial choice of empiric antibiotics is based on7 patients dia0nosis the most li8ely patho0en cased the disease se6erity of the disease local data on pre6alent patho0ens and its antimicrobial

    ssceptibility tests+ Antibiotics for children ith sspected bacterial

    infection+ 9hold be discontined hen there is no bacterial 0ro

    from a cltre reslt or there is e6idence of 6iral infection Ghen cltre reslts are a6ailable! clinicians shold

    narro the spectrm of antibiotics+ Combination therapy shold be sed only hen

    indicated bacterial endocarditis 0ram=ne0ati6e menin0itis bacterial infections in immnocompromised patients

    absces brain or abdominal

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    A6oid sin0 nnecessary antibiotics and theemer0ence of bacterial resistance+

    Coa0lase=ne0ati6e staphylococci blood stream infections mltidr0=resistant+ Disinfection of the insertion site sin0 aseptic

    techni5es can redce contamination+&here are se6eral approaches in

    diLerentiatin0 tre infection ithcontamination inclde7a)performin0 to separate sites of blood cltre

    and treatin0 hen or0anism 0ros from bothcltres

    b)eEaminin0 the time to positi6ity if becase trepatho0ens are detected earlier

    c)eEaminin0 the tre infection mar8er namely

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    mpiric therapy is based on7 directin0 co6era0e a0ainst the most liel

    pathogens dr0 aller0y history Hepaticrenal fnction ossible antibiotic side eLects Resistance potential Cost

    'oderately or se6erely ill

    IQ 'ildly ill M

    Cltres of appropriate clinical specimensshold be obtained prior to administratin0antibiotics+

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    9pectrm Ran0e of microor0anism an antibiotic is

    sally eLecti6e a0ainst! is the basis for

    empiric antibiotic therapy Concentration=dependent7 display

    increasin0 8illin0 ith increasin0

    concentration abo6e 'IC of or0anism%e07 5inolones! amino0lycosides

    &ime=dependent7 do not% e07 beta=lactams! 6ancomycin

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    &isse penetration Antibiotics that are eLecti6e a0ainst a

    microor0anism in=6itro bt nable toreach the site of infection are of little orno bene:t to the host7

    L Antibiotic7 lipid solbility! moleclar size

    L&isse7 ade5acy of blood spply! presence ofin;ammation

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    Renal insciency 'ost antibiotics eliminated by the

    8idneys ha6e a ide VtoEic=to=therapetic

    ratio! dosin0 strate0ies are based onformla=deri6ed estimates of creatinineclearance! rather than precise5antitation of 0lomerlar :ltration rates+

    Dosa0e ad

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    If creatinine clearance 3#=# mlmin Decrease dose of renally eliminated antibiotic

    by .#/ and maintain the sal dosin0 inter6al

    If creatinine clearance #=3# mlmin Decrease dose of renally eliminated antibiotic

    by .#/ and doble the dosin0 inter6al

    Alternati6e7 se antibioticeliminatedinacti6ated by the hepaticrote in sal dose

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    Ucr E Q cr

    creatinine concentration in the collected rinesample (UCr)!

    the plasma concentration (Cr)+ rine ;o rate(Q) XYml#minZ

    Creatinine clearance (mlmin)

    @ X(3# - a0e) E ei0ht (80)Z X," Esermcreatinine (m0d?)Z

    If female! mltiply by #+*.

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    Antibiotic dosin0 for patients ithhepatic dysfnction is problematic!since there is no hepatic conterpart

    to the serm creatinine to accratelyassess li6er fnction+

    ractically it is based on clinical

    assessment of the se6erity of li6erdisease! only for se6ere hepaticinsciency+

    http://en.wikipedia.org/wiki/Urine_flow_rate
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    Decrease total daily dose ofhepatically=eliminated antibiotic by.#/ in presence of clinically se6ere

    li6er diseaseAlternati6e7 se antibiotic

    eliminatedinacti6ated by the renal

    rote in sal dose

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    If renal insciency is orse thanhepatic insciency Antibiotics eliminated by the li6er are

    often administered at half the total dailydose+

    If hepatic insciency is more se6ere

    than renal insciency Renally=eliminated antibiotics are oftenadministered and dosed in proportion torenal fnction+

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    Renal

    'ost beta lactams Amino0lycosides

    &'=9' Carbapenems Colistin Cipro;oEacin Nitrofrantoin

    Oosfomicin Olconazole Acyclo6ir tetracycline

    0epatobiliar

    Chloramphenicol DoEycycline

    'acrolides Clindamycin 'etronidazole INHRIOpyrazinamide

    4etoconazole

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    Intra6enos 6s oral sitch therapy(sally ithin ," hors after clinical

    impro6ement)7 Redced cost

    arly hospital dischar0e ?ess need for home i6 therapy Qirtal elimination of i6 line infections

    Dr0s for IQ=to=M sitch7L DoEycycline!

    L clindamycin!L metronidazole!L chloramphenicol!L amoEicillin!L &'=9'!L 5inolones+

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    'ost infectios diseases shold betreated orally nless7 Critically ill

    Cannot ta8e antibiotics by moth Cannot absorb oral antibiotics

    &here is no e5i6alent oral antibioticGhen sitchin0 from IQ to M therapy!

    the oral antibiotic chosen shold achie6ethe same blood and tisse le6els as thee5i6alent IQ antibiotic

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    'ost bacterial infections in normal hosts aretreated ith antibiotics for =" ee8s+

    &he dration of therapy may need to beeEtended in patients ith7

    L impaired immnity (e0+ Diabetes! 9?! netropenia!

    diminished splenic fnction)

    L Chronic bacterial infections (endocarditis! osteomyelitis)

    L Chronic 6iral and fn0al infections

    L Certain bacterial intracelllar patho0ens

    Antibiotic therapy shold not be contined formore than " ee8s! e6en if lo=0rade fe6erspersist

    rolon0ed therapy oLers no bene:t! andincrease the ris8 of ad6erse side eLects! dr0

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    'ost common error in themana0ement of apparent antibioticfailre is chan0in0 addin0

    additional antibiotics instead ofdeterminin0 the case+

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    'icrobiolo0ic factors In=6itro ssceptibility bt ineLecti6e in=6i6o Antibiotic tolerance ith 0ram=positi6e cocci&reatin0 colonization (not infection)

    Antibiotic factors Inade5ate co6era0espectrm Inade5ate antibiotic blood le6els Inade5ate antibiotic tisse le6els

    Decreased antibiotic acti6ity in tisse Dr0=dr0 interactions

    L Antibiotic inacti6ationL Antibiotic anta0onism

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    Antibiotic penetration problems Undrained abscess Oorei0n body=related infection rotected focs (e0+ C9O)

    Mr0an hypoperfsiondiminished blood spplyL Chronic osteomyelitisL Chronic pyelonephritis

    Non=infectios disease 'edical disorders mimic8in0 infection (e0+ 9?) Dr0 fe6er

    Antibiotic=nresponsi6e infectios diseases Qiral infections On0al infections

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    Hospital CareS$# ID6I

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    9' 9ard1 months7 Ampicillin ##m080day

    \chloramphenicol##m080day MR CeftriaEone if

    se6ereempyema MRclindamisin if aler0ypenicillin

    Hospital Care

    'ild7 CotrimoEazole (3 m0 &'80E

    e6ery " h) MR amoEicillin ".m080E po e6ery " h for 1 d

    9e6ere7 AmpicillinamoEicillin ".=

    .#m040E i6im e6ery hors If better ithin "3=," hors!

    contine for . daysIf 0ettin0 orse7 Add Chloramphenicol

    ".m040E e6ery * hors!performed chest E=ray

    Qery se6ere7

    Ampicillin andchloramphenicol MR Ampicillinand 0entamicin

    Alternati6ely7 CeftriaEone *#=##m080 imi6

    E daily

    S$# ID6I

    [1 months7 Am"i-illin 100mg@g@a* M

    gen'ami-in =mg@g@a*

    .Am"i-illin 100mg@g@a* M

    -lam"eni-l100mg@g@a*

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    Hospital CareS$# ID6I

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    9' 9ard

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    9' 9ard

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    9' 9ard

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    9' 9ard

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    9' 9ard

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    Use antibiotics rationally7 JDoin0 ri0ht at the :rsttimeK

    'inimizin0 se of in6asi6e de6ices

    Applyin0 dia0nostic test

    &reatin0 only infectin0 a0ent &reat infection not colonization and contamination

    Oactors in antibiotics selection

    9pectrm

    &isse penetration Antibiotic resistance

    9afety pro:le and cost Oactors in antibiotics dosin0

    Renal insciency or hepatic insciency

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    'icrobiolo0y and ssceptibility testin0 ?imitations

    Dration of antibiotics 'ono 6s combination therapy Bactericidal 6s bacteriostatic Rote of antibiotics deli6ery Antibiotics failre

    mpiric antibiotics7

    directin0 co6era0e a0ainst the most lielpathogens dr0 aller0y history Hepaticrenal fnction ossible antibiotic side eLects

    Resistance potential

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    Robert C+ Mens r! Antimicrobial steardship7concepts and strate0ies in the "st centry!Dia0nostic 'icrobiolo0y and Infectios Disease ("##*) #- "*

    Ferdin0 DN! ohnson 9! eterson ?R! 'lli0an '!

    9il6a r ($$.) Clostridim dicile=associateddiarrhea and colitis+ Infect Control Hosppidemiol 73.$]3,,+

    'asterton R! Drsano F! aterson D?! ar8 F+Appropriate antimicrobial treatment in nosocomialinfections=the clinical challen0es+ ornal ofHospital Infection+ "##1%..7 = "+

    4ti ?! atel AA! Coleman CI+ Impact ofinappropriate antibiotic theapy on mortality in

    patients ith 6entilator=associated pnemonia and

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    Antibiotic ssentialsar6is GR+ Controllin0 Healthcare=

    Associated Infections7 &he Role ofInfection Control and AntimicrobialUse ractices+ 9eminars in ediatricInfectios Diseases+ "##3%.()71# -

    3#GHM+ &he poc8et boo8 of hospital

    care for limited resorces+ "##.+

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    Oor more information 6isit

    +ashp+or0+a

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    http://www.washup.org.au/