Antimicrobial Stewardship Quiz

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Questions and Answers

What is the primary use of broad spectrum agents?

Provide coverage for life-threatening conditions (correct)

Prevent infections in non-immune patients

Target specific microorganisms

Treat routine infections

Which of the following is NOT an essential strategy of antimicrobial stewardship programs?

Guidelines based on local microbiology

Increased use of broad spectrum agents (correct)

Monitoring antimicrobial use and outcomes

Reviewing antimicrobial prescribing

What measurement is used to assess respiratory function in sepsis?

Creatinine levels

Platelet count

PaO2 levels (correct)

Bilirubin levels

What does TDM monitoring refer to in the context of antimicrobial stewardship?

Therapeutic drug monitoring Signup and view all the answers

Which of the following body systems is assessed by measuring creatinine levels?

Kidneys Signup and view all the answers

What is a common side effect of Vancomycin that occurs due to rapid infusion?

Red man syndrome Signup and view all the answers

Which of the following are monitored to ensure the safe use of Vancomycin?

AUC or trough levels Signup and view all the answers

What is the preferred method to predict Vancomycin efficacy?

AUC/MIC ratio Signup and view all the answers

What is the target AUC for Vancomycin therapy?

400 mg.hr/L Signup and view all the answers

What is the ideal trough level for Vancomycin in treating uncomplicated infections?

10-14 mg/L Signup and view all the answers

Which bacteria are primarily characterized as Gram positive cocci?

Streptococcus Signup and view all the answers

What type of penicillins are predominantly effective against Gram positive cocci?

Natural penicillins Signup and view all the answers

Which of the following statements about penicillinase-resistant penicillins is true?

They can be used orally or intravenously. Signup and view all the answers

Which of the following bacteria are classified as Gram negative rods?

Enterobacter Signup and view all the answers

What is the primary distinguishing feature of Clostridium difficile?

It is a Gram positive rod often related to bowel infections. Signup and view all the answers

Which Gram positive bacteria commonly cause Staph infections?

Staphylococcus Signup and view all the answers

Which of the following is NOT an example of a β-lactam antibiotic?

Vancomycin Signup and view all the answers

Which characteristic distinguishes Gram negative organisms from Gram positive organisms?

Presence of an outer membrane. Signup and view all the answers

Which of the following aminoglycosides is NOT listed in the content?

Streptomycin Signup and view all the answers

What type of toxicity is commonly associated with the prolonged use of aminoglycosides?

Nephrotoxicity Signup and view all the answers

Which method is preferred for therapeutic monitoring of aminoglycosides according to the content?

AUC (Area Under the Curve) Signup and view all the answers

What should be done if aminoglycosides are used for more than 48 hours?

Conduct therapeutic drug monitoring Signup and view all the answers

What is a common vestibular effect of ototoxicity from aminoglycosides?

Nausea and vertigo Signup and view all the answers

In the context of febrile neutropenia, which of the following is expected to be used for treatment?

Broad-spectrum antibiotics Signup and view all the answers

What is the recommended treatment for a severe Gram-negative rod infection like pyelonephritis?

Aminoglycosides Signup and view all the answers

Which of the following is true regarding the administration of aminoglycosides?

They can be given only as injections. Signup and view all the answers

Which type of bacteria are primarily affected by macrolides?

Aerobic Gram-positive bacteria Signup and view all the answers

What is one of the main benefits of using macrolides in patients with penicillin/cephalosporin allergies?

They can be used safely when other antibiotics are contraindicated. Signup and view all the answers

Which macrolide is known to inhibit CYP3A4?

Clarithromycin Signup and view all the answers

Which of the following is a known interaction of macrolides?

Inhibition of P-glycoprotein Signup and view all the answers

What is a notable use of macrolides beyond their antibiotic properties?

Immunomodulatory and anti-inflammatory effects Signup and view all the answers

Which of the following conditions can be treated with macrolides?

Diabetic gastroparesis Signup and view all the answers

Which atypical bacteria are covered by both macrolides and tetracyclines?

Legionella spp. Signup and view all the answers

Which of the following statements about macrolides is false?

They only inhibit anaerobic bacterial growth. Signup and view all the answers

What is a potential problem when taking tetracyclines?

Reduced absorption when taken with calcium Signup and view all the answers

Which antibiotic is recommended for mild pneumonia that covers strep?

Amoxicillin Signup and view all the answers

When should both Amoxicillin and Doxycycline be used together?

If no improvement is seen in 48 hours Signup and view all the answers

What is an important counseling point regarding the ingestion of tetracyclines?

They must remain upright for 30 minutes after ingestion Signup and view all the answers

Which strategy is NOT part of essential antimicrobial stewardship programs?

Increased antibiotic prescribing during emergencies Signup and view all the answers

What is the primary purpose of clinical microbiology in antimicrobial use?

To promote appropriate use through sensitivity testing Signup and view all the answers

Which of the following antibiotics is assessed as resistant to E. coli?

Ampicillin Signup and view all the answers

What type of feedback is commonly provided to prescribers in antimicrobial stewardship programs?

Direct feedback on antimicrobial prescribing behavior Signup and view all the answers

Study Notes

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Practice Points on Antimicrobials - 1

Presented by Dr. Jonathan Penm
Email: [email protected]
Twitter: @JonPenm

Learning Objectives

Understand antimicrobial stewardship program strategies and how to improve antimicrobial use.
Become familiar with common infectious disease pathogens.
Identify conditions/pathogens responsive to beta-lactams.
Compare and contrast beta-lactam drugs.
Apply formulary restrictions to beta-lactams.

Previous Lectures

Antimicrobial resistance is a global concern.
This lecture series focuses on practical antimicrobial stewardship programs, point-of-care interventions, empirical vs directed therapy, and IV-to-oral conversions.
Lectures will explain when to use specific antimicrobials, their spectrum of activity, and formulary restrictions.

Antimicrobial Stewardship Programs

Required for all Australian accredited hospitals.
Led by a multidisciplinary team, including a doctor and pharmacist, to manage antimicrobial use.
Improve appropriate use, updates policies and educates staff.
Evaluate antimicrobial use and resistance patterns.
Studies show they reduced antimicrobial use by 22-36% and resistance rates.

Empirical vs Directed Therapy

Empirical therapy: Treatment based on most likely pathogens and their susceptibility.
Directed therapy: Treatment based on the results of culture and susceptibility tests.

Essential Strategies for Antimicrobial Stewardship Programs

Guidelines based on local microbiology and susceptibility.
Formulary restrictions.
Reviewing antimicrobial prescribing.
Direct feedback to prescribers.
Point-of-care interventions (e.g., IV-to-oral switch, directed therapy, dose optimization).
Clinical microbiology monitoring.
Monitor antimicrobial use and outcomes.

When to Use Broad Spectrum Agents (e.g., Sepsis)

Often used in life-threatening conditions like sepsis.
The optimal time to start broad spectrum antimicrobial treatment is crucial for patient outcomes.

Sepsis

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection.
Measured by PaO2 (partial pressure of oxygen in the alveoli), Glasgow coma scale, mean arterial pressure, platelets, bilirubin, and creatinine.

Which Antimicrobial to Use?

Essential steps to determine appropriate treatment:
Identify the condition being treated.
Perform a Gram stain to classify bacteria as Gram-positive or Gram-negative.
The structure of peptidoglycan differs between Gram-positive and Gram-negative bacteria, affecting antimicrobial susceptibility.

Gram Stain

Used to classify bacteria as Gram-positive or Gram-negative.

Gram Stain - Gram Positive

Includes Staphylococcus, Streptococcus, and Enterococcus.

Gram Stain - Gram Negative

Includes Enterobacteriaceae (e.g., E. coli, Klebsiella), ESCAPPMs (e.g., Enterobacter, Serratia, Citrobacter, and others), and environmental bacteria (e.g., Acinetobacter, Pseudomonas, and Morganella.)

Gram Stain - Anaerobes

Includes both Gram-positive and Gram-negative types in various locations like the bowel and mouth.
Examples include Actinomyces, Bacteroides, and Peptostreptococcus spp. , and Clostridium difficile.

Beta-lactams

Include penicillins, cephalosporins, monobactams, and carbapenems.

Penicillins

Oral penicillins (natural and penicillinase-resistant)
Intravenous penicilins (natural and penicillinase-resistant)
Aminopenicillins are also included.

Penicillinase-Resistant Penicillins

Active against Gram-positive cocci, including Streptococcus and Staphylococcus species.
Available in oral and intravenous forms.
Ideal for Staphylococcus infections like cellulitis.

Aminopenicillins

Active against Gram-positive cocci (e.g., Streptococcus) and some Gram-negative rods (e.g., Haemophilus influenzae).
Common oral medications include Amoxicillin.
IV Ampicillin therapy is also available.
Used to treat pneumonia (often caused by Streptococcus pneumoniae and Haemophilus influenzae).

Beta-Lactamase Inhibitors

Clavulanic acid and Tazobactam are examples.
These are added to penicillins to enhance their effectiveness against bacteria that produce Beta-lactamases.
Extended spectrum of action, encompassing aerobic Gram-positive and Gram-negative bacteria.

Cephalosporins

Classified into generations, with higher generations covering more Gram-negative bacteria.
Commonly used for penicillin allergies.
Some examples of oral cephalosporins include Cefalexin and Cefaclor.
IV Cephazolin, and Cefotaxime.

Beta-lactam Allergies

IgE-mediated reactions (e.g., urticaria, angioedema, bronchospasm, anaphylaxis) can occur with beta-lactam use.
Delayed reactions (e.g., rashes) can also happen several days after treatment.
Avoid both penicillins and cephalosporins in patients with a history of these allergies.

Cross-reactivity Between Beta-lactams

Old theory linked cross-reactivity to the beta-lactam ring.
Modern evidence points to the R1 side chain as a more significant factor.
Cefazolin (R1 side chain) shows low cross-reactivity with other beta-lactams.

Extended Spectrum Beta-Lactamase (ESBL)

ESBL-producing organisms inactivate various beta-lactam antibiotics, including 3rd and 4th generation cephalosporins, penicillin and most beta-lactamases inhibitors.
They are often found in Gram-negative bacteria, such as E. coli, Klebsiella.
Additional treatment strategies are often needed in the case of ESBL and severe infection.

Carbapenems

Imipenem, meropenem, and ertapenem are examples.
Primarily reserved for treating bacteria that produce ESBL or when broad-spectrum coverage is necessary.
Effective against Gram negative, Gram positive, and anaerobic bacteria.

Macrolides

Azithromycin, Clarithromycin, Erythromycin, Roxithromycin are examples.
Primarily affects aerobic G-ve bacteria.
Can be used in penicillin allergies.
Also beneficial for atypical bacteria that cause pneumonia (e.g., Mycoplasma, Legionella, Chlamydia)
Interactions include elevated QT interval

Quinolones

Include Norfloxacin, Ciprofloxacin, Moxifloxacin.
Cipro/Norfloxacin is effective against Gram-negative bacteria, including Pseudomonas species
Moxifloxacin covers a wider range of bacteria (Gram-positive, Gram-negative, anaerobes, atypical bacteria) but has less activity against Pseudomonas.
Common side effects include peripheral neuropathy and tendon damage, therefore should be used carefully.

Aminoglycosides

Amikacin, Gentamicin, and Tobramycin are examples.
Used in severe Gram-negative bacterial infections.
Often given intravenously, not orally absorbed.
ADRs include nephrotoxicity and ototoxicity.

Vancomycin Monitoring

Monitoring is essential for >48 hours of use.
AUC/MIC ratio best predicts vancomycin efficacy.
Regular blood monitoring to track levels from 30 minutes to 14 hours after dosing is necessary and recommended.

IV to Oral Switch

Decisions on IV-to-oral switching rely on specific clinical criteria, including clinical improvement, resolution of fever and no instability.
Consider the duration of IV treatment with known potential risks.
Important to consider the patient's overall condition.

Clinical Use of Antimicrobials

Sepsis: Life-threatening requires rapid IV administration of broad spectrum coverage (e.g., gentamicin, flucloxacillin). Antibiotics should be chosen based on the suspected source/cause.
Febrile neutropenia: Treat broadly initially covering all Gram-positive, Gram-negative and anaerobes with the need to cover Pseudomonas aeruginosa more specifically

Formulary Restrictions

Hospital formulary listing only medicines with established efficacy and safety, reviewed annually to reflect current evidence.
Traffic light system to control the use of medications based on urgency and safety.

Summary Table (page 33)

Summary of bacteria types and associated coverage by various groups.

Class Questions

General questions related to the topic to be discussed in class.

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Description

Test your knowledge on antimicrobial stewardship, particularly focusing on Vancomycin and Gram positive cocci. This quiz covers essential strategies, monitoring, and efficacy of various antimicrobial agents. Enhance your understanding and application of these critical pharmacological concepts.