antibiotics 1
TRANSCRIPT
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Mohammed Adel, B.Sc., PharmDClinical Pharmacy Department
Al-Ahrar General Hospital
Antibiotics:Optimization of use & excellence of
outcome
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• Principles of antibiotic use• Time dependent activity • Conc. Dependent activity•Dual activity• Indications for prophylaxis
Content
Antimicrobi
al Pattern
of killing
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•Vancomycin:• Mechanism of action • Indications • Dosing • ADR
Content
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Principles of antibiotic use
Drug
Dose
Delivery
Duration
De-escalation
The fiveDs
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Principles of antibiotic use
• Prevent infectionProphylactic
• Abort infectionPreemptive
• Initial control of infectionEmpiric
• Cure infection of know etiology Definitive
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Principles of antibiotic use
• Prevent endocarditis• Surgical prophylaxis
Prophylactic
• Against cytomegalovirus in immune suppressed Pts
Preemptive
• CAP / HAP / VAPEmpiric • Known etiologic
organism & susceptibility
Definitive Pt= Patient CAP= Community Acquired pneumonia HAP= Hospital Acquired pneumonia VAP=Ventilator Acquired pneumonia
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Principles of antibiotic use
• Initiate appropriate Abx therapy ASAPEvery 1 Hr delay = 8% increase in
mortality•Be aware of the site of infection
Local controlTreating most likely organism
ABX= antibiotics ASAP= as soon as possible
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Principles of antibiotic use
• Possibility of resistance Abx exposureKnown resistant colonizationExposure to heath care facilitiesLocal Abx resistance pattern
•Host factor:Allergy Organ function status
ABX= antibiotics
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Principles of antibiotic use
• Severity of illnessUsing IV vs POChoosing upper end of the dosing range
Consider loading dose Consider combination therapy
ABX= antibiotics IV= Intravenous PO= Oral route
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Principles of antibiotic use
• Treat infection… not colonization• Cultures before Abx
Without delay•Administer the 1st dose ASAP•Monitor response to your Abx therapy
After 48-72 HrsTake routine Abx time out
ABX= antibiotics ASAP= as soon as possible
Recommendati
on for practice
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Principles of antibiotic use
•What is time out?? – Time out is the check point at which the physician should answer these questions:Does this patient have an infection that will
respond to antibiotics?
Is the patient on the right antibiotic(s), dose, and route of administration?
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Principles of antibiotic use
•What is time out?? – Time out is the check point at which the physician should answer these questions:Can a more targeted antibiotic be used to treat
the infection?
How long should the patient receive the antibiotic(s)?
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Principles of antibiotic use
•Re-evaluation of therapy depends on:– Clinical response– Microbiologic dataOrganism IDLocal anti-biogramIsolate susceptibility
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Principles of antibiotic use
Chk your Pt-ve Culture
No change Worse Improve
d
+ve Culture
Optimize
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Principles of antibiotic use
Improving ptRe-evaluate the dose
Evaluate Adverse effects
1- If culture +ve: refine your regimen2- If culture –ve: decide the duration
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Principles of antibiotic use
Refining / de-
escalating regimen
• Resolve bug drug mismatch
• Plan the likely duration• De-escalation:
• Narrowing spectrum• Eliminate
redundancies• Consider PO route
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Time dependent activity
• Antibiotic needs more time to achieve 99.9% kill target• Serum conc. Is not important• Observed in:
– β-lactams– Macrolides– Clindamycin – Glycopeptides • How to optimize time dependent effect?
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Time dependent activity
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Concentration dependent activity• Antibiotic needs higher concentration to achieve 99.9% kill target• Time of exposure Is not important• Observed in:
– Aminoglycosides – Fluoroquinolones – Daptomycin – Metronidazole • How to optimize conc. dependent effect?
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Concentration dependent activity
This is Genta !
:D
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Concentration dependent activity
Which kill better?
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Mixed pattern activity• Fluoroquinolones differs in it’s pattern• It uses AUC24:MIC ratio
– For gm -ve ---< 125 for Cipro/Levo– For gm +ve ---< 30 for Levo
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Mixed pattern activity
Also:DaptomycinTigecyclinevancomycin
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Indications for antibiotic prophylaxis
•Before dental procedures against IE•Before surgical procedures•Before GI endoscopy• For SBP• For recurrent UTIIE= infective endocarditis GI= Gastro-intestinal SBP= Spontaneous Bacterial Pretonitis UTI= Urinary tract infection
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Vancomycin
•Glycopeptide antibiotic•Mostly effective against Gm+ve Bacteria•Always reserved for complicated or multidrug resistant infections• Characterized with mixed time/concentration killing pattern
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Vancomycin
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Vancomycin
• Against MRSA in HAP/VAP• For bacterial IE•GI chemosterlization (PO)• Prosthetic joint infection• CDAD
HAP= Hospital Acquired Pneumonia VAP= Ventilator Acquired Pneumonia IE=Infective Endocarditis GI=Gastrointestinal CDAD=C.difficile-Associated Diarrhea
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Vancomycin
•Manufacturer’s labeling: Usual dose: 500 mg every 6 hours or 1,000 mg every 12 hours
•Alternate recommendations*: 15 to 20 mg/kg/dose every 8 to 12 hours
*(ASHP/IDSA/SIDP [Rybak, 2009]);
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Vancomycin
• *Complicated infections in seriously ill patients: A loading dose of 25 to 30 mg/kg (based on actual body weight)
*(ASHP/IDSA/SIDP [Rybak, 2009]);
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Vancomycin
• Injection:– More than10%:
Cardiovascular: Hypotension accompanied by flushing
Dermatologic: Erythematous rash on face and upper body (red neck or red man syndrome - infusion rate related)
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Vancomycin
• Injection:– From 1% to 10%:Central nervous system: Chills, drug feverDermatologic: RashHematologic: Eosinophilia, reversible
neutropeniaLocal: Phlebitis
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Vancomycin
•Oral:– More than10%: Gastrointestinal: Abdominal pain, bad
taste (with oral solution), nausea
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Thank
you