L16-18 Practice Points on Antimicrobials (Practice Points) PDF

COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been copied and communicated to you by or on behalf of the University of Sydney pursuant to Part VB of the Copyright Act 1968. (The Act). The material...

COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been copied and communicated to you by or on behalf of the University of Sydney pursuant to Part VB of the Copyright Act 1968. (The Act). The material in this communication may be subject to copyright under the Act. Any further copying or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Practice points on antimicrobials – 1 Dr Jonathan Penm [email protected] @JonPenm Learning objectives To know the essential strategies for an antimicrobial stewardship program and how the improve appropriate antimicrobial usage To be familiar with common pathogens in infectious disease To identify which conditions/pathogens β-lactams cover To compare and identify the difference between the β-lactams To apply formulary restrictions to β-lactams Previous Lectures Paul Groundwater Antimicrobial resistance is a local and global problem Science behind antimicrobial resistance This lecture series focuses on the practical elements Antimicrobial stewardship programs Point of care interventions Empirical vs directed therapy IV to oral conversion When to use which antimicrobial Spectrum of activity Guidelines Formulary restrictions based on guidelines Antimicrobial stewardship programs Required for all accredited hospitals in Australia Australian Commission on Safety and Quality in Health Care What does it look like? Multidisciplinary team that oversees antimicrobial use Must include a lead doctor and pharmacist Updates policies Educates staff Evaluates antimicrobial use Evaluates resistance patters Why? Shown to reduce antimicrobial use by 22-36% Reduces resistance rates and mortality Empirical vs directed therapy Key principles of antimicrobial stewardship Empirical therapy Treat based on most likely organisms and susceptibility E.g. we know it is usually caused by an organism sensitive to benzylpenicillin, so we use benzylpenicillin Aim to use narrowest spectrum agent first Directed therapy Based on culture and susceptibility test E.g. organism culture is grown and shown to be sensitive to benzylpenicillin, so we use benzylpenicillin Antimicrobial stewardship programs Essential strategies 1. Guidelines based on local microbiology and susceptibility 2. Formulary restrictions 3. Reviewing antimicrobial prescribing Direct feedback to prescribers 4. Point of care interventions IV oral switch Directed therapy Dose optimisation (TDM monitoring) 5. Clinical microbiology 6. Monitor antimicrobial use and outcomes Sepsis When do we use broad spectrum agents? Life threatening e.g. sepsis Sepsis Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.1 Body system affected Measured by Respiratory PaO2 (partial pressure of oxygen in the alveoli) Cognition Glasgow coma scale Cardiovascular Mean arterial pressure Coagulation Platelets Liver Bilirubin Kidneys Creatinine 1. Singer M et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315(8):801-10  Which antimicrobial to use? The basics What are we treating Hans Christian Gram stain Image fr om http://ca reman.file s.wordpre ss.com/2011 /04 /an tibio tics-18.jpg http://www.b ode-scie nce-center.co m/uplo ads/pics/Hans-Christia n-Joachim-Gr am_02.jpg http://upload.wikime dia.org/wikiped ia/commons/8/8 f/Gra m_ stain_0 1.jp g Which antimicrobial to use? Peptidoglycan mainly in Gram +ve organisms Gram stain Rod Coccus Neg Pos Gram stain – Gram positive Rod Coccus Neg Staphylococcus Pos Streptococcus Enterococcus Gram stain – Gram negative Enterobacteriaceae Common ones Rod E.Coli Klebsiella Neg ESCAPPMs (inducible β-lactamse) Enterobacter Serratia Pos Citrobacter Aeromonas Environmental Providencia Acinetobacter Proteus Pseudomonas Morganella Gram stain - Anaerobes Bowel/mouth Rod Coccus Neg Pos Actinomyces Bacteroides Peptostreptococcus spp. Clostridium difficile (not all anaerobes are rods) Gram positive bacteria  β-lactams Penicillins Cephalosporins Monobactams Carbapenems Image from http://careman.files.wordpress.com/2011/04/antibiotics-18.jpg  -lactams Images from: http://water.me.vccs.edu/courses/env108/Lesson5_print.htm Penicillins Oral Intravenous Natural Penicillins Phenoxymethylpenicillin Benzylpenicillin Penicillinase-resistant Penicillins Dicloxacillin/ Flucloxacillin Dicloxacillin/ Flucloxacillin Aminopenicillins Amoxicillin (Amoxycillin) Ampicillin Natural Penicillins Active against cocci eg. Streptococcus When 1st used, active against Staphylococcus Now most produce Penicillinases Oral Phenoxymethylpenicillin aka. Penicillin V Ideal for Strep Throat (Streptococcal pharyngitis/tonsillitis if bacterial) IV/IM Benzylpenicillin aka. Penicillin G Penicillinase-resistant penicillins Active against G+ve cocci eg. Streptococcus + Staphylococcus Flucloxacillin/Dicloxacillin Available oral + IV Ideal for Staph infections eg. Cellulitis Aminopenicillins Active against Some G+ve cocci e.g. Strep few G-ve rods e.g. Haemophilus influenza Broken down by β-lactamases/penicillinases Oral Amoxicillin (Amoxycillin) IV Ampicillin Ideal for pneumonia Mainly caused by Strep. Pneumoniae and H. influenzae   -lactamase inhibitors -lactamases break down -lactams -lactamase inhibitors Clavulanic acid Tazobactam ‘Suicide’ inhibitors Add to a penicillin to increase their Gram -ve activity Images from: http://www.mayoclinicproceedings.org/cms/attachment/221956/1379092/gr4.gif Penicillin + β-lacatmase inhibitors Extended spectrum of action Covers aerobic G+ve and G-ve bacteria + anaerboes Bowel/mouth Rod Coccus Neg Pos Actinomyces Bacteroides Peptostreptococcus spp. Clostridium difficile (not all anaerobes are rods) Penicillin + β-lacatmase inhibitors Oral/IV Amoxicillin (Amoxycillin) + Clavulanic acid Does not cover pseudomonas spp. IV Ticarcillin + Clavulanic acid IV Piperacillin + Tazobactam Covers pseudomonas spp. Ideal if the infection from numerous types of organisms Eg. Diabetic foot infection, animal bites Cephalosporins Classified into generations. Higher the generation -  G-ve cover Oral IV 1st generation Cefalexin (Cephalexin) Cefaxzolin/Cefalotin (Cephazolin)/(Cefalothin) 2nd generation Cefaclor/Cefuroxime 3rd generation Ceftriaxone/Cefotaxime Ceftazidime 4th generation Cefepime Cephalosporins Usually, reserved for non-immediate penicillin allergy 1st generation cephalosporins G +ve coverage eg. Strep + Staph Some G-ve e.g. E. Coli 3rd generation cephalosporins Strep and G –ve coverage Does not cover pseudomonas None of the Cephalosporins cover enterococcus -lactam allergies IgE-mediated Immediate hypersensitivity reactions Urticaria/Angioedema Bronchospasm Anaphylaxis occurs 1 in 10 000 courses occurs w/i 1-2 hours 10% of cases are fatal Severe immediate hypersensitivity (extensive urticaria etc) Avoid both penicillin and cephalosporin Delayed reaction Rashes occur several days AFTER treatment. Usually T-cell mediated (can be severe and non-severe) Cross reactivity between  -lactams Old theory: Due to beta-lactam ring 10% allergic to penicillin also allergic to cephalosporins Recent evidence: Due to R1 side chain Avoid cefalexin or cefaclor in those allergic to amoxicillin Cefazolin has no common side-chains with other beta lactams Can use in immediate non-severe allergy (e.g. mild urticaria/rash)  ESBL Extended Spectrum -Lactamase producing organism Gene transfer Not specified to 1 organism can inactive All penicillins and cephalosporins Including penicillin + β-lacatmase inhibitors 3rd and 4th generation cephalosporin Has been found in G-ve: E.Coli Klebsiella Acinetobacter Enterobacter Image from: http://www.bugstoppers.co.uk/images/15-ESBL-Character290_278.gif Carbapenems Imipenem Meropenem Ertapenem Covers G+ve, G-ve and anaerobes Except MRSA Primarily reserved for bacteria with ESBL Or need broad coverage but allergic to: penicillin + β-lacatmase inhibitors 3rd and 4th generation cephalosporin Class questions Download Socrative app or visit www.socrative.com > Student login Room name: USYDPHARM Summary Gram positive cocci Gram negative bacilli Anaerobes Staph Strep Common Pseud ESCAPPM Antimicrobial stewardship programs Essential strategies 1. Guidelines based on local microbiology and susceptibility 2. Formulary restrictions 3. Reviewing antimicrobial prescribing Direct feedback to prescribers 4. Point of care interventions IV oral switch Directed therapy Dose optimisation (TDM monitoring) 5. Clinical microbiology 6. Monitor antimicrobial use and outcomes Formulary restrictions Formulary lists medicines kept at an organisation/hospital Only keep those with proven efficacy and safety Reviewed annual to reflect current evidence/guidelines Traffic light system – commonly used Medicine can be prescribed anytime (No supply restriction) Medicine can be prescribed in specific conditions. Approval from Infectious Disease team required after 48 hours (supply restricted) Medicine can only be used with approval from Infectious Disease team (supply highly restricted) Formulary restrictions Formulary restrictions Example of this given here: http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0003/25872 6/QUAH-AMS-Toolkit-List-of-Recommended-Antimicrobial- Restrictions-FEB-2017.pdf  COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been copied and communicated to you by or on behalf of the University of Sydney pursuant to Part VB of the Copyright Act 1968. (The Act). The material in this communication may be subject to copyright under the Act. Any further copying or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Practice points on antimicrobials – 2 Dr Jonathan Penm [email protected] @JonPenm Learning objectives To know the common uses of glycopeptides, quinolones and aminoglycosides To know the common adverse drug reactions from glycopeptides, quinolones and aminoglycosides To know when and how to monitor glycopeptides and aminoglycosides To know about oral to IV conversion of antimicrobials To apply formulary restrictions for antimicrobials MRSA Methicillin-resistant Staphylococcus aureus (MRSA) Resistant to all β-lactams 1. ACSQHC AURA 2021 Image from: http://www.healthalternativesonline.com/images/mrsa3.jpg  Glycopeptides Vancomycin – IV and oral Tecioplanin – IV only Images from: Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12e  Glycopeptides Inhibit transpeptidase to crosslink peptidoglycan Images from: http://micro.digitalproteus.com/morphology3.php  Glycopeptides Covers G+ve bacteria Including MRSA! Given IV for MRSA ADRs Nephrotoxicity Ototoxicity (Dizziness, vertigo, tinnitus) Rash with eosinophilia and systemic symptoms Thrombocytopenia, neutropenia, leucopenia Images from: http://micro.digitalproteus.com/morphology3.php  Glycopeptides Vancomycin flushing (red man) syndrome Due to infusion being given too quickly Not an allergic reaction Symptoms include Fever Chills Erythema Facial/upper torso rash Hypotension, angioedema, itch Vancomycin: Give 500 mg over at least 1 hour Recommended dose is 1.5g bd 6 hours a day on an infusion. Vancomycin monitoring Monitoring is recommended in all patients on > 48 hours Either measure AUC or trough level Reduce under dosing and prevent toxicity AUC/MIC ratio best predicts vancomycin efficacy AUC is preferred BUT Needs two plasma concentrations 30 mins after dosing 6 to 14 hours after dosing  Vancomycin monitoring Manual AUC is time consuming  Vancomycin monitoring Computerised methods to calculate AUC adjust for variation in Vd and elimination rate. Aladdin (www.asainc.net.au) TCIWorks (www.tciworks.info/) Both Australian Free programs Used in many hospitals New dose = Old dose x Target AUC measured AUC Target AUC = 400 mg.hr/L Vancomycin monitoring Trough levels often used Only 1 level needed Take just before next dose Needs to be at stead state – after 4th dose when used twice a day Target trough 10-14 mg/L for uncomplicated infection 15-20 mg/L for complicated infections new dose= old dose (target conc/measured conc) Eg. Level of 8mg/L while on 1g q12h (Target = 15mg/L) 15/8 x 1 g = 1.9 g Change to 2g q12h Gram negative bacteria Gram stain Rod Coccus Neg Pos Gram stain Enterobacteriaceae Common ones Rod E.Coli Klebsiella Neg ESCAPPMs (inducible β-lactamse) Enterobacter Serratia Pos Citrobacter Aeromonas Environmental Providencia Acinetobacter Proteus Pseudomonas Morganella  Quinolones Norfloxacin Ciprofloxacin Moxifloxacin Images from: http://www.atsu.edu/faculty/chamberlain/Website/Lects/metab9a.jpg  Quinolones Cipro/Norflox used for G-ve coverage Including pseudomonas Moxifloxacin covers nearly everything G+ve, G-ve, anaerobes, atypicals Less pseudomonas activity ADRs Peripheral neuropathy (tingling/pins and needles) Tendon damage Images from: http://flipper.diff.org/app/items/info/3457 Quinolones Norfloxacin has low serum levels Mainly used for UTIs Ciprofloxacin is widely distributed in body tissues Good G-ve coverage, including pseudomonas An oral antibiotic  Quinolones Resistance  around the world1 Australia, 1998-20192 Ecoli: Resistance 1% → 12% 1. Murray CJ et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet. 2022. 2. AURA 2021: Fourth Australian report on antimicrobial use and resistance in human health Image from: http://mettahu.files.wordpress.com/2014/03/world-2.jpg  Quinolones 1. Cheng 2012 Emerging infectious Diseases Image from: http://mettahu.files.wordpress.com/2014/03/world-2.jpg Aminoglycosides  Aminoglycosides Amikacin Gentamicin Tobramycin Aminosugars Linked by glycosidic bonds Polycations None absorbed orally (all injections) Severe G-ve rod infection E.g. severe pyelonephritis (kidney infection) Images from: Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12e  Aminoglycosides - ADRs Nephrotoxicity Usually reversible anticipate if treatment >7–10 days Ototoxicity Vestibular ototoxicity nausea, vomiting, vertigo, nystagmus, difficulties with gait Cochlear ototoxicity noticeable hearing loss, tinnitus, feeling of fullness in ear Occur in 2–4% of treated people.  Aminoglycosides - monitoring Therapeutic drug monitoring >48 hours use – must monitor prevent underdosing and ↓ risk of toxicity No need to monitor if used for 48 hours or less Given once a day Trough concentrations often below the level of laboratory detection but still high enough to increase the risk of toxicity Peak levels Always high – does not show anything  Aminoglycosides AUC is preferred Needs two plasma concentrations 30 mins after dosing 6 to 14 hours after dosing Class questions Download Socrative app or visit www.socrative.com > Student login Room name: USYDPHARM  Gram positive cocci Gram negative bacilli Anaerobes MRSA MSSA Streps Common Pseud ESCAPPM Moxifloxacin Clinical use Sepsis Life threatening Want to give medicine fast (via IV) Treat based on source if source is unknown, want to cover Gram +ve and -ve What would you expect to use if source is unknown? Clinical use Febrile Neutropenia Treat broadly Gram +ve, Gram –ve and anaerobes Pseudomonas aeruginosa - associated with ↑ rates of morbidity/mortality What would you expect to use if severe? IV to oral switch Can go home sooner ↑ time in hospital = ↑ risk of infection from resistant bacteria IV to oral switch Febrile neutropenia in cancer patients MASCC risk index - https://www.mdcalc.com/mascc-risk-index- febrile-neutropenia MASCC = Multinational Association for Supportive Care in Cancer Identifies if IV or oral medicines ANC = Absolute neutrophil count MASCC risk index = out of 26 Low risk ≥ 21 High risk < 21 IV to oral switch IV to oral switch Febrile neutropenia in cancer patients What oral therapy would you recommend? Hint: Treat broadly Gram +ve, Gram –ve and anaerobes Pseudomonas aeruginosa - associated with ↑ rates of morbidity/mortality eTG does not give specific advice refers to Australian Consensus guideline Tam CS et al. Use of empiric antimicrobial therapy in neutropenic fever. Australian Consensus Guidelines 2011 Intern Med. Antimicrobial stewardship programs Essential strategies 1. Guidelines based on local microbiology and susceptibility 2. Formulary restrictions 3. Reviewing antimicrobial prescribing Direct feedback to prescribers 4. Point of care interventions IV oral switch Directed therapy Dose optimisation (TDM monitoring) 5. Clinical microbiology 6. Monitor antimicrobial use and outcomes Formulary restrictions  COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been copied and communicated to you by or on behalf of the University of Sydney pursuant to Part VB of the Copyright Act 1968. (The Act). The material in this communication may be subject to copyright under the Act. Any further copying or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Practice points on antimicrobials – 3 Dr Jonathan Penm [email protected] @JonPenm Learning objectives To know the common uses of antifolate, nitroimidazoles, lincosamides, macrolides and tetracyclines To know the common adverse effects of antifolate, nitroimidazoles, lincosamides, macrolides and tetracyclines To know what causes C.difficile and how to treat it To know how clinical microbiology improves antimicrobial use Antifolate drugs  Antifolate drugs Sulfamethoxazole Trimethoprim Image from: http://o.quizlet.com/7XXGv55vnINYi-vDjXeGZg_m.png http://www.scrigroup.com/files/limba/engleza/health/81_poze/image003.jpg Trimethoprim Primarily active against some G-ve bacteria Concentrates in: Urine/Prostatic fluid/Vaginal fluid Mainly used in urinary tract infections 70-90% caused by E. Coli Used at night  urinary concentration (7 days for men) Anaerobic bacteria  Rod Coccus Neg Pos Anaerobes Bowel/mouth Rod Coccus Neg Pos Actinomyces Bacteroides Peptostreptococcus spp. Clostridium difficile (not all anaerobes are rods) Nitroimidazoles  Nitroimidazoles Metronidazole Tinidazole Anti-protozoa Image from: http://upload.wikimedia.org/wikipedia/commons/thumb/0/05/Nitroimidazoles.svg/721px -Nitroimidazoles.svg.png  Nitroimidazoles Prodrug Image from: http://watcut.uwaterloo.ca/webnotes/Pharmacology/graphics/metronidazole-redox-pic-6691f.png Nitroimidazoles Treatment of choice for anaerobes Often found in Gastro-intestinal tract E.g. 1st line for necrotising gingivitis Can add to other antimicrobials to get anaerobic cover eg. Aspiration pneumonia Pneumonia caused by material from stomach/mouth entering lungs  Nitroimidazoles Peripheral neuropathy Avoid alcohol during treatment and for 24 hours after finishing the course? Can cause nausea, vomiting, flushing, headache and palpitations. Evidence1 12 male volunteers Given metronidazole and ethanol 0.4g/kg No signs of a reaction Literature review2,3 based on laboratory experiments and individual case histories No evidence of a reaction with alcohol 1. Visappa 2002 Ann Pharmacother 2. Fjeld 2014 Tidsskr Nor Laegeforen. 3. Onysko 2016. Journal of Family Practice. Lincosamides  Lincosamides Clindamycin Lincomycin Irreversibly binds to the 50S ribosomal subunit Image from: http://www.antibiotics-info.org/images/clindamycin_clip_image004.jpg  Lincosamides Active against G+ve (some MRSA) + Anaerobes (except C.difficle) Can give if allergic immediate hypersensitivity to penicillin E.g.Erysipelas (superficial cellulitis) Image from: http://www.antibiotics-info.org/images/clindamycin_clip_image004.jpg  Lincosamides Severe diabetic foot infection Lincosamides G+ve (some MRSA) + Anaerobes (except C. difficile) ADR C.difficile-associated disease (G+ve anaerobe) Can also occur with broad spectrum antimicrobials Causes most severe antibiotic related diarrhoea → fatal Spores can survive for months Stop if you develop diarrhoea  Clostridium difficile Toxin A + B →Pseudomembranous colitis Image from: http://www.human-healths.com/clostridium-difficile-2/clostridium-difficile.php http://img.medscape.com/pi/emed/ckb/gastroenterology/169972-186458-3532tn.jpg  C.difficile G+ve anaerobe 1st line - metronidazole If resistant to metronidazole: Vancomycin orally Large molecule - not absorbed, remains in gut IV treatment is ineffective Vials often used over tablets as its cheaper 35% of patients – recurrence due to spores Image from: http://www.human-healths.com/clostridium-difficile-2/clostridium-difficile.php http://www.medicinescomplete.com/mc/hplc/current/images/p2001448ag853001.jpg C.difficile  C.difficile Resistant cases Faecal transplantation Healthy donor stool is made into a suspension NG tube, gastroscopy, colonoscopy or enema Aim: re-colonize normal bacterial flora – prevent relapse Minimal ADR’s reported1 94% of patients experienced resolution1 Cf 31% w/ oral vanc Spouse preferable1 1. Gough E. Clin Infect Dis 2011; 53:994-1002 2. van Nood E, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med 2013;368:407-15. Image from http://www.healthyeatingaustralia.com/images/Poo%20on%20plate.jpg Crapsules Class questions Download Socrative app or visit www.socrative.com > Student login Room name: USYDPHARM  Gram positive cocci Gram negative bacilli Anaerobes MRSA MSSA Streps Common Pseud ESCAPPM Nitroimidazoles  Macrolides Azithromycin Clarithromycin Erythromycin Roxithromycin Macrocyclic lactone ring Image from: http://o.quizlet.com/rONGUFs67EjL33KI20wzCw_m.png  Macrolides Affects some G+ve and G-ve bacteria Mainly aerobic G +ve Can use in penicillin/cephalosporin allergies Also covers Atypical bacteria Mycoplasma spp. Legionella spp. Chlamydophila, Chlamydia spp. Initially thought not to be bacteria 15-20% of Pneumonia caused by atypical bacteria Can also use in pneumonia Image from: http://o.quizlet.com/rONGUFs67EjL33KI20wzCw_m.png Macrolides Interactions ↑ QT interval Clarithromycin and Erythromycin Inhibit CYP3A4 Clarithromycin, Erythromycin and Azithromycin Inhibit P-gp Clarithromycin Inhibit organic anion transporting polypeptide (OATP) 1B1  Macrolides – other uses Immunomodulatory and anti-inflammatory effects diffuse panbronchiolitis cystic fibrosis Prokinetic Diabetic gastroparesis  Biofilm production Image from: http://www.humanillnesses.com/original/images/hdc_0001_0001_0_img0072.jpg  Tetracyclines Tetracycline Minocycline Doxycycline Image from: http://www.antibiotics-info.org/images/doxycycline_clip_image004.jpg  Tetracyclines Affects some G+ve and G-ve bacteria Also covers Atypical bacteria Mycoplasma spp. Legionella spp. Chlamydophila, Chlamydia spp. Rickettsia No intravenous form for tetracyclines in Australia Image from: http://o.quizlet.com/rONGUFs67EjL33KI20wzCw_m.png  Pneumonia Mild Pneumonia Amoxicillin (covers strep) OR Doxycycline (some strep resistance) If Atypical are suspected Doxycycline OR Clarithromycin (If can’t tolerate doxy) If not improving in 48 hours Use both Amoxicillin + Doxy 1. Charles P et al. Clin Infect Dis 2008 Image from: http://www.whatispneumonia.org/wp-content/uploads/2011/09/pneumonia-xray.jpg Tetracyclines counselling Do not take antacids, Fe, Ca or Zn within 2 hours  absorption Binds to calcium deposits C/I in children 18 weeks – safe in first 18 weeks Take with food (or milk w/ doxy or minocycline) Reduce stomach upset Epigastric burning Must remain upright for 30 minutes after the dose Best taken in the morning May increase sensitivity to sunlight Protective clothing + sunscreen Antimicrobial stewardship programs Essential strategies 1. Guidelines based on local microbiology and susceptibility 2. Formulary restrictions 3. Reviewing antimicrobial prescribing Direct feedback to prescribers 4. Point of care interventions IV oral switch Directed therapy Dose optimisation (TDM monitoring) 5. Clinical microbiology 6. Monitor antimicrobial use and outcomes Clinical microbiology Clinical microbiology Limit results seen by a clinician Encourage appropriate use E.g. E. coli sensitivity Ampicillin R R=Resistant Amoxycillin (amoxicillin) + clavulanate S S=Sensitive Gentamicin S Trimethoprim S Nitrofurantoin S Ceftriaxone S Norfloxacin S Piperacillin + tazobactam S Clinical microbiology E.g. E. coli sensitivity Ampicillin R R=Resistant Amoxycillin (amoxicillin) + clavulanate R S=Sensitive Gentamicin R Trimethoprim R Nitrofurantoin R Ceftriaxone S Norfloxacin S Piperacillin + tazobactam S Antimicrobial stewardship programs Essential strategies 1. Guidelines based on local microbiology and susceptibility 2. Formulary restrictions 3. Reviewing antimicrobial prescribing Direct feedback to prescribers 4. Point of care interventions IV oral switch Directed therapy Dose optimisation (TDM monitoring) 5. Clinical microbiology 6. Monitor antimicrobial use and outcomes Class questions Download Socrative app or visit www.socrative.com > Student login Room name: USYDPHARM