Dr.

Soulat Hafeez House Officer Medical Unit 4

Definition Of Antibiotic
A chemical substance produced by micro

organisms, which has the capacity to inhibit the growth of or to kill other micro organisms

Antibiotic Therapy
Ideally is determined by isolation and antibiotic susceptibility

of the offending. Usually not available in ER. Abx treatment initiated on clinical diagnosis and likely organism involved. Early empirical treatment may be lifesaving.

THERAPY BASED ON
1. Site of infection 2. Safety of the agent 3. State of the patient (age, renal, hepatic

funtions etc)
4. Cost of the therapy

Appropriate Use of Abx

Employ empirically when there is a

reasonable clinical suspicion of infection Choose antibiotics active against the most likely organism(s) Choose antibiotics known to penetrate involved tissue Use correct doses of antibiotics dont underdose

Appropriate Use of Abx

contd

Know when bacterostatic antibiotics are

adequate or bacterocidal drugs are required In serious, potentially life-threatening infections, start broad, then de-escalate after cultures back Stop antibiotics when infection resolved or when evidence accumulates against existence of infection

Inappropriate Use of Abx

Wong antibiotic Wrong dose of right drug Using a 2nd or 3rd line drug when a first line drug could

still be used Using antibiotics in situations when antibiotics are not indicated Continuing antibiotics when infection is resolved or not likely Keeping coverage broad when cultures reveal a single organism Reacting to culture results by starting antibiotics without considering the significance of the culture

Common Mistakes in Diagnosing Infection

Base diagnosis on a single positive data point

when other data points are negative React to a positive culture when there is no clinical evidence of infection Use serial cultures to determine when infection has resolved Obtain cultures randomly when clinical suspicion of infection is low

First Step: Determine Whether Culture Represents Real Pathogen

Colonizer: Any organism actually present in

or on patient, but does not invade tissue or cause clinical disease

Contaminant: Any organism growing in

culture that is not actually present in or on the patient, but came from the environment into the culture medium

Three Examples
1. A +ve sputum culture taken from a patient without fever, leukocytosis, new infiltrate or pulmonary symptoms should be taken as a colonizer 2. A +ve urine culture taken from a patient without dysuria, frequency, and with a small to moderate amount of WBC in the U/A has asymptomatic bacteriuria 3. A +ve wound culture taken from a clean appearing, granulating wound that is not painful, has no purulence in a patient with no fever and a normal WBC, represents a colonizer (rather than a true pathogen) and should not be treated

Sputum Culture
Pathogen if: Sputum is grossly purulent Patient is febrile Infiltrates on CXR > 5-10 WBC per hpf < 5-10 epithelial cells per hpf Colonizer if: Sputum is scant, clear or white Patient is afebrile No infiltrates on CXR < 5-10 WBC per hpf > 5-10 epithelial cells per hpf

Urine Culture
Pathogen if: > 100,000 cfu If urinalysis reveals:
> 10 WBC Pos. Leuk. Esterase Pos. nitrite Few or no epis

Contaminant if: 10,000 cfu or less If urinalysis reveals:

< 10 WBC Neg. Leuk. Esterase Neg. nitrite Many epis

If patient

If patient

symptomatic

asymptomatic

Drugs Absolutely C/I in Pregnancy ----- Category X Drugs

Mnemonic SAFE Mom Takes Really Good

Care
SULFONAMYIDES, AMINOGLYCOSIDES,

FLUOROQUINOLONES, ERYTHROMYCIN. METRONIDAZOLE TETRACYCLINE RIBAVIRIN GRISEOFULVIN CHLORAMPHENICOL

ABX TO AVOID IN CHILDREN UNDER 18

Abx TO AVOID IN LACTATING MOTHERS

ABX TO AVOID IN RENAL FAILURE

Note, here add drugs that are contraindicated

and drugs that can be administered but with reduced dose.

ABX TO AVOID IN HEPATIC FAILURE.

SAME AS FOR RENAL FAILURE.

Meningitis

Principles of Management
1. Initiate Empirical Antibiotic Therapy 2. All patients with head trauma,

immunocmpromised states, known malignancies, or focal nerological findings (including stupor/coma) should undergo neuroimaging study prior to Lumbar Puncture 3. Obtain CSF D/R sample, if not C/I 4. If Bacterial Meningitis is suspected, initiate empirical antibiotic therapy even prior to Imaging and LP

Clinical Features
Fever, Headache, Neck stiffness, and Change

in Mental Status 75% of patients have atleast 2 out of these 4 features

Antibiotics for Empirical Treatment of Bacterial Meningitis

Infants < 3 months Ampicillin + Cefotaxime

Adults < 55 years

Ceftriaxone + Vancomycin

Adults with Alcoholism or debilitating illness Hospital acquired, post neurosurgery, neutropenic patients

Ceftriaxone + Vancomycin+ Ampicillin Ceftazidime + Vancomycin+ Ampicillin

Pneumonia

Principles of Management
Classify the pneumonia : 1. Community Acquired, or 2. Health-Care Associated

Hospital Acquired Ventilator Associated CURB 65 Pneumonia Severity Index

Determine severity:

Definition of Health-Care Associated Pneumonia

Health-Care Associated Pneumonia has any

one of the following features:

Hospitalization for > 48 hours Hospitalization for > 2 days in prior 3 months Antibiotic therapy in prior 3 months Chronic dialysis Home wound care Contact with a family member who has MDR

infection

Severity of Pneumonia
CURB 65 Confusion Urea > 7 mmol R/R > 30 BP : Systolic < 90 ; Diastolic < 60 mmHg Age > 65 years Score: 0- 1 --------Out- patient

treatment 2 ICU >2 --------ICU care --------In patient: Non

Empirical Antibiotic Treatment of Community Acquired Pneumonia

Outpatients 1. 2. 3. 4. Macrolide ( Clarithro or Azithro) Doxycycline Respiratory FQ ( Moxi or Gemi or Levo) B-Lactam plus Macrolide

In Patients: Non ICU In Patients : ICU If Pseudomonas is suspected

1. Respiratory FQ ( Moxi or Gemi or Levo) 2. B-Lactam plus Macrolide 1. B-Lactam plus Macrolide 2. B-Lactam plus FQ 1. B-Lactam plus FQ 2. B-Lactam plus Aminoglycoside 3. B-Lactam plus FQ plus Aminoglycoside Add Linezolid or Vancomycin

If MRSA is suspected

Empirical Antibiotic Treatment of Health Care Associated Pneumonia

No risk for MDR Pathogens 1. B Lactam ( Ceftriaxone 2 gm IV OD) alone 2. FQ alone 3. Ertapenem alone

Risk Factors for MDR pathogens

1. B Lactam ( 3rd / 4th Gen Cephalosporin or Tazocin) plus FQ / Aminoglycoside plus Linezolid/ Vancomycin

Urinary Tract Infections

Principles of Management
Always obtain Urine C/S ( except in

uncomplicated cystitis in women) Identify and Correct (if possible) predisposing factors Relief of symptoms does not indicate bacteriologic cure Each course of treatment should be classified as a Cure or Failure

Treatment Regimens for Bacterial UTI