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ANTIBIOTICS TREATMENT
AND MANAGEMENT
SITI NUR BAITI BINTI SHAIK
KHAMARUDIN
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OUTLINE
Monomicrobial vs Polymicrobial
Selecting and initiating antibiotic regimen
Factors inl!encing antibiotic c"oice Antimicrobial combination
Host actors
D!ration #ral vs Intraveno!s t"era$y
Mis!se
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Manner o t"era$y is em$loyed de$ends on%"et"er inection is monomicrobialor
polymicrobial&
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Monomicrobial infections
Nosocomial %"ic" occ!rred in postoperative
$atients' e&g& UTI' $ne!monia' cat"eter(
related inection' bacteremia
)!lt!re and sensitivity tests
Polymicrobial infections
c!lt!re res!lts less "el$!l
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POLYMICROBIAL
Antibiotic regimen should not be modified in t"e
basis o culture&
*&g&' $atient %"o !ndergoes a$$endectomy or
gangreno!s $erorated a$$endicitis+bo%el resection
or intestinal $eroration s"o!ld receive antibiotic or
,(- days occasionally longer&
I "e regains bo%el !nction d!ring t"is time'
convert rom I. to oral %"ic" is saer' earlier
disc"arge&
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SELECTING AND INITIATING
ANTIBIOTIC REGIMEN
(A)Obtaining an Accurate Diagnosis
/ Determining site of infection' deine t"e
host0imm!nocom$romised' diabetic'advanced age1 2 establis" a microbiological
diagnosis.
/ Diagnostic s$ecimens are properly obtained
and promptly submitted&
/ Detailed e3$os!re history&
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Sometimes diagnosis can be concl!ded
rom clinical $resentation' cultural test-independent& Cellulitis
Ass!med ca!sed by stre$tococci or sta$"ylococci
Antibacterial treatment %it"o!t $ositive c!lt!res&
Community acuired pneumonia Treated em$irically %it" macrolides 2 F4
5it"o!t s$eciic diagnostic test
Finally non-infectiousconditions to be
r!led o!t or !nclear diagnosis&
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(!) "iming of #nitiation
)ritically ill Stable
/ *m$iric t"era$y
s"o!ld be initiatedimmediately ater or
conc!rrently %it"
collection o
s$ecimen&
/ *&g&6 se$tic s"oc7'
ebrile ne!tro$enic'
bacterial meningitis&
/ Ab3 t"era$y s"o!ld
be %it""eld !ntila$$ro$riate
s$ecimens collected
and s!bmitted&
/ *&g&6 S!bac!te
bacterial
endocarditis'
vertebral
osteomyelitis+dis7itis
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(C) $mpiric vs Definitive "herapy
Microbiological res!lts are not available89 to :8 "o!rso %e c"oose em$iric initial t"era$y g!ided by
clinical $resentation&
!road spectrum antimicrobial agents'sometimes combination&
)over multiple possible pathogens;
comm!nity 2 "os$ital ac
Neisseria meningitidis ,rdgen
ce$"alos$orin = vancomycin
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%ospital-acuired infection
Related to invasive devices and procedures Intravasc!lar cat"eter(associated bacteremia'
ventilator(associated $ne!monia and
cat"eter(associated UTI&
Dr!g(resistant gram($ositive 0MRSA1 and
gram(negative bacteria 0Pseudomonas
aeruginosa1
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FACTORS INFLUENCING
ANTIBIOTIC CHOICE
&) 'ite of infection organisms liely to
coloni*e
/ I. cat"eter(associated bacteremia' sta$"ylococc!s
on s7in+) Prior no,ledge of bacteria no,n to
coloni*e
/ Screening nasal s%ab beore admit to I)U' MRSA
coloni>ation&
) ocal bacteria resistance pattern
/ Antibiograms
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ANTIMICROBIAL
COMBINATIONS5"en to !se?
&. Agents e/hibit synergistic activity against
microorganisms
Penicillin and gentamicin to treat endocarditisca!sedby Enterococcuss$$&
Penicillin =gentamycin
+. Critically ill patients
Healt"(care associated ca!sed by resistant to m!lti$leab3&
To ens!re at least @ agent %ill be activated against
organisms&
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/ *3am$le' $atient hospitali*ed for ,ees
develo$s septic shoc' blood c!lt!res ;
gram negative bacilli
#nitial therapy %it" 8 agents against $artic!lar
P aeruginosa' a common nosocomial and
m!lti$le(dr!g resistant&
Anti$se!domonal (lactam = F4 or
aminoglycoside
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. "o e/tend antimicrobial spectrum for
polymicrobial infections.
/ )ombination %ill e3tend t"e s$ectr!m beyondt"at ac"ieved by single agent&
0. Prevent emergence of resistance.
/ T"e res!lt o selective pressure romantimicrobial t"era$y&
/ )ombination %ill $rovide better c"ance at
least one dr!g %ill be eective&
/ *&g&6 standard t3 in TB and HI. %"ere
d!ration o t3 is $rolonged and resistance
emerged' limited t"era$e!tic&
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HOST FACTORS
1enal hepatic function )oncerned %it" dose reduction to $revent
acc!m!lation and to3icity
Age2conditons Pediatrics6 dose g!ided by %eig"t
3eriatrics6 de$ends on age and %eig"t' not
creatinine clearance solely or 7idney !nction Obese6 de$ends on at $ercentage
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3enetic variation S!sce$tibility to drug AD1
l!cose(C($"os$"ate de"ydrogenase 0CPD1 deiciency Avoid certain antimicrobials li7e da$sone' $rima
nitro!rantoin&
Res!lt in "emolysis&
%istory of allergy or intolerance Tr!e allergic sym$toms 0!rticaria' bronc"os$asm or ot"er
similar maniestation2 dyspepsia4 nausea1&
Ro!tinely obtained in eval!ation and management
%istory of recent antimicrobial use
Past , mont"s Microorganisms in c!rrent e$isode emerge !nder $revio!s
$ress!re
Mig"t be resistant to t"e dr!g
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DURATION
I cultures are negative' em$irical
antibiotic t"era$y s"o!ld be sto$$ed ; 9to :8 "o!rs& Unnecessity ris7 o MDR inections
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I infection is evident' treatment is contin!ed as indicated&
- days or less
)linical res$onse should not be a sole determinant
Host res$onse mig"t not be as ra$id as t"e bacterial
7illing res$onse
- I $atient still "as SIRS at $redetermined end $oint'
more !se!l to stop therapy reevaluate or6
- Persistence
- Ne% inection
- MDR $at"ogens
-
Noninectio!s ca!ses
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MONOMICROBIAL
Standard g!ideline6
,(- days or 5"#
:(@E days or pneumonia
:(@9 days or bacteremia
/ onger course do not res!lt in im$roved care
and associated %it" increase ris7 o
s!$erinection by resistant microorganism&
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POLYMICROBIAL
St!dies oc!sed on $atients %it" peritonitis&
Satisactory o!tcomes6
@8 to 89 "o!rs or penetrating gestrointestinal trauma
%it" absence o e3tensive contamination
, to - days or perforated2gangrenous appendicitis
- to : days or peritoneal soilage d!e to $erorated visc!s
%it" moderate contamination&
: to @9 days or ad6unct therapy o e3tensive $eritoneal
soilage 0ec!lent $eritonitis1 or t"at o in
imm!nos!$$ressed "ost&
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ater phases o $ost(o$erative antibiotic
treatment o serious intra-abdominal
infection
Signs s"o% inection eradicated6Absence o elevated 7!C count
ac7 o band forms o PMNs on $eri$"eral
smear
ac7 o fever0G,o)1
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ORAL VS INTRAVEOUS
THERAPY Patients "os$itali>ed %it" inections al%ays
treated %it" intraveno!s ab3 Prompted by severity o inection
Patients %it" mild to moderate infection'admit or other reasons 0de"ydration' $ain
control1 2 normal I !nction 5ell(absorbed oral ab3
#nitially parenteral can saely s%itc"ed to oral 5"en clinically stable
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S"o!ld select dr!gs %it" e3cellent
absor$tion or invasive infections Pyelone$"ritis or abscess
In serious infection i&e& inective
endocarditis and )NS inection Re
Oral therapy is less reliable
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MISUSE
'cenarios8
Prolonged em$iric t"era$y %it"o!t clear
evidence of infection'
9ailure to narro, antimicrobial t"era$y
%"en ca!sative organism is identiied&
/ Data available ; narro%est or contin!ation
Prolonged prophylactic t"era$y&
$/cessive use o certain antimicrobial
agents&
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Actions by a res$onsible $ractitioner6
imits prophyla/is to t"e $eriod d!ring
o$erative $roced!re
Does not convert prophyla/is into em$irical
e3ce$t !nder %ell(deined conditions
'ets duration o antibiotic rom beginning&
Curtails%"en t"ere are non(s!$$orting clinicaland microbiological evidence o inection&
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REFERENCE
Mayo )linic article "tt$6++%%%&ncbi&nlm&ni"&gov+$mc+articles+PM),E,@998 +
Sc"%art>s Princi$les o S!rgery' Tent" *dition
Sabiston Te3tboo7 o S!rgery' @t"*dition
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/