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Pemilihan Regimen Antibiotika
Systematic Approach for Selection of
Antimicrobials
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Mengetahui adanya infeksi
1. Demam
Suhu tubuh di atas rentang normal (36.7-37
o
C)
Manifestasi dari penyakit lain.
Drug-induced fever.
2. Tanda dan gejala
WBC rentang normal 4000-10000/mm
3
, pada kondisi
infeksi jumlah leukosit perifer bisa mencapai 30000-4000/mm.
infeksi bakteri peningktan jumlah granulosit, often with
immature forms (band neutrophils) seen in peripheral blood
smears.
Leukositosis respon normal dari host terhadap infeksi.
3. Tanda-tanda Lokal
Nyeri dan Inflamasi swelling, erythema,
tenderness, and purulent drainage
infection is superficial or in a bone or joint
deep-seated infections meningitis,
pneumonia, endocarditis, and urinary tract
infection examining tissues or fluids.
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Identifikasi Patogen
Mengkultur bagian tubuh yg terinfeksi
sebelumdiberikan terapi antimikroba
mengetahui mikroba yg menjadi penyebab.
Jika setelah tx dikultur false negative
Dalampengambilan kultur, hati2 terhadap
kontaminasi.
Pemilihan terapi yang tepat
Select rational antimicrobial therapy for a given clinical
situation, a variety of factors must be considered.
These include the severity and acuity of the disease, host
factors, factors related to the drugs used, and the
necessity for using multiple agents
There are generally accepted drugs of choice for the
treatment of most pathogens
When selecting antimicrobial regimens, local susceptibility
data should be considered whenever possible rather than
information published by other institutions or national
compilations
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Host Factor
When evaluating a patient for initial or empiric therapy, the
following factors should be considered:
Allergy or history of adverse drug reactions
Age of patient
Pregnancy
Metabolic abnormalities
Renal and hepatic function
Concomitant drug therapy
Patients with diminished renal and/or hepatic function will
accumulate certain drugs unless dosage is adjusted. Any
concomitant therapy the patient is receiving may influence
the selection of drug therapy, the dose, and monitoring
Drug Factor
Integration of both pharmacokinetic and
pharmacodynamic properties of an agent is important
when choosing antimicrobial therapy to ensure efficacy and
prevent resistance
Antibiotics may demonstrate concentration-dependent
(aminoglycosides and fluoroquinolones) or time-
dependent (-lactams) bactericidal effects.
The importance of tissue penetration varies with the site of
infection
The most important pharmacodynamic relationship for
antimicrobials that display time-dependent bactericidal
effects is the duration that drug concentrations exceed the
MIC.
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COMBINATION ANTIMICROBIAL
THERAPY
Generally used to:
broaden the spectrum of coverage for empiric therapy
achieve synergistic activity against the infecting
organism
prevent the emergence of resistance
Increasing the coverage of antimicrobial therapy
is generally necessary in mixed infections where
multiple organisms are likely to be present
Synergism
Traditionally, combinations of aminoglycosides and -
lactams have been used since these drugs together
generally act synergistically against a wide variety of
bacteria.
Synergistic combinations may produce better results in
infections caused by Pseudomonas aeruginosa
The use of combinations to prevent the emergence of
resistance is widely applied but not often realized. The
only circumstance where this has been clearly effective
is in the treatment of tuberculosis
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Disadvantages of Combination
Therapy
increased cost
greater risk of drug toxicity
superinfection with even more resistant
bacteria
MONITORING THERAPEUTIC
RESPONSE
Culture and sensitivity reports from specimens
collected must be reviewed
Use of agents with the narrowest spectrum of activity
against identified pathogens is recommended
Patient monitoring should include a variety of
parameters, including white blood cell count,
temperature, signs and symptoms of infection,
appetite, radiologic studies as appropriate, and
determination of antimicrobial concentrations in
body fluids
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As the patient improves the route of antibiotic
administration should be reevaluated. Switch to
oral therapy is an accepted practice for many
infections. Criteria favoring switch to oral therapy
include:
Overall clinical improvement
Lack of fever for 8 to 24 hours
Decreased WBC
A functioning GI tract
FAILURE OF ANTIMICROBIAL THERAPY
disease is not infectious or nonbacterial in
origin
undetected pathogen
Laboratory error in identification and/or
susceptibility testing errors are rare.
drug selection
the host/pathogen.
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Failures Caused by Drug Selection
Inappropriate selection of drug, dosage, or
route of administration
Malabsorption of a drug product because of
GI disease or a drug interaction
Accelerated drug elimination
poor penetration into the site of infection
Failures Caused by Host Factors
Patients who are immunosuppressed (e.g.,
granulocytopenia from chemotherapy, acquired
immune deficiency syndrome) may respond poorly to
therapy because their own defenses are inadequate to
eradicate the infection despite seemingly adequate
drug regimens
Other host factors are related to the necessity for
surgical drainage of abscesses or removal of foreign
bodies and/or necrotic tissue. If these situations are
not corrected, they result in persistent infection and,
occasionally, bacteremia, despite adequate
antimicrobial therapy..
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Failures Caused by Microorganisms
Development of drug resistance during therapy.
Primary resistance refers to the intrinsic resistance of
the pathogens producing the infection. However,
acquisition of resistance during treatment has become
a major problem as well.
Resistance overuse of antimicrobials in the
community, as well as in hospitals, and the increasing
prevalence of immunosuppressed patients receiving
long-term suppressive antimicrobials for the
prevention of infections