ANTIBIOTICS TREATMENT

AND MANAGEMENT
SITI NUR BAITI BINTI SHAIK
KHAMARUDIN

OUTLINE

Monomicrobial vs Polymicrobial
Selecting and initiating antibiotic regimen
Factors influencing antibiotic choice
Antimicrobial combination
Host factors
Duration
Oral vs Intravenous therapy
Misuse

Manner of therapy is employed depends on

whether infection is monomicrobial or
polymicrobial.

 Monomicrobial infections
Nosocomial which occurred in postoperative
patients, e.g. UTI, pneumonia, catheterrelated infection, bacteremia
Culture and sensitivity tests

Polymicrobial infections
culture results less helpful

POLYMICROBIAL
Antibiotic regimen should not be modified in the
basis of culture.
E.g., patient who undergoes appendectomy for
gangrenous perforated appendicitis/bowel resection
for intestinal perforation should receive antibiotic for
3-5 days occasionally longer.
If he regains bowel function during this time,
convert from IV to oral which is safer, earlier
discharge.

SELECTING AND INITIATING

ANTIBIOTIC REGIMEN
(A)Obtaining an Accurate Diagnosis
Determining site of infection, define the
host (immunocompromised, diabetic,
advanced age) & establish a microbiological
diagnosis.
Diagnostic specimens are properly obtained
and promptly submitted.
Detailed exposure history.

 Sometimes diagnosis can be concluded

from clinical presentation, cultural testindependent.
Cellulitis
Assumed caused by streptococci or staphylococci
Antibacterial treatment without positive cultures.

Community acquired pneumonia

Treated empirically with macrolides & FQ
Without specific diagnostic test

Finally non-infectious conditions to be

ruled out for unclear diagnosis.

(B) Timing of Initiation

Critically ill

Empiric therapy
should be initiated
immediately after or
concurrently with
collection of
specimen.
E.g.: septic shock,
febrile neutropenic,
bacterial meningitis.

Stable

Abx therapy should

be withheld until
appropriate
specimens collected
and submitted.
E.g.: Subacute
bacterial
endocarditis,
vertebral
osteomyelitis/diskitis

(C) Empiric vs Definitive Therapy

Microbiological results are not available
24 to 72 hours
o we choose empiric initial therapy guided by
clinical presentation.

Broad spectrum antimicrobial agents,

sometimes combination.
Cover multiple possible pathogens
community & hospital acquired infections
Bacterial meningitis: Strep pneumoniae and
Neisseria meningitidis
3rd gen
cephalosporin + vancomycin

 Hospital-acquired infection
Related to invasive devices and procedures
Intravascular catheter-associated bacteremia,
ventilator-associated pneumonia and
catheter-associated UTI.
Drug-resistant gram-positive (MRSA) and
gram-negative bacteria (Pseudomonas
aeruginosa)

FACTORS INFLUENCING
ANTIBIOTIC CHOICE
1) Site of infection & organisms likely to
colonize

IV catheter-associated bacteremia, staphylococcus

on skin

2) Prior knowledge of bacteria known to

colonize

Screening nasal swab before admit to ICU, MRSA

colonization.

3) Local bacteria resistance pattern

Antibiograms

ANTIMICROBIAL
COMBINATIONS
When to use?
1. Agents exhibit synergistic activity against
microorganisms
Penicillin and gentamicin to treat endocarditis caused
by Enterococcus spp.
Penicillin +gentamycin

2. Critically ill patients

Health-care associated caused by resistant to multiple
abx.
To ensure at least 1 agent will be activated against
organisms.

 Example, patient hospitalized for weeks

develops septic shock, blood cultures
gram negative bacilli
Initial therapy with 2 agents against particular
P aeruginosa, a common nosocomial and
multiple-drug resistant.
Antipseudomonal -lactam + FQ or
aminoglycoside

3. To extend antimicrobial spectrum for

polymicrobial infections.
Combination will extend the spectrum beyond
that achieved by single agent.

4. Prevent emergence of resistance.

The result of selective pressure from
antimicrobial therapy.
Combination will provide better chance at
least one drug will be effective.
E.g.: standard tx in TB and HIV where
duration of tx is prolonged and resistance
emerged, limited therapeutic.

HOST FACTORS
Renal & hepatic function
Concerned with dose reduction to prevent
accumulation and toxicity

Age/conditons
Pediatrics: dose guided by weight
Geriatrics: depends on age and weight, not
creatinine clearance solely for kidney function
Obese: depends on fat percentage

 Genetic variation
Susceptibility to drug ADR
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Avoid certain antimicrobials like dapsone, primaquine and
nitrofurantoin.
Result in hemolysis.

History of allergy or intolerance

True allergic symptoms (urticaria, bronchospasm or other
similar manifestation / dyspepsia, nausea).
Routinely obtained in evaluation and management

History of recent antimicrobial use

Past 3 months
Microorganisms in current episode emerge under previous
pressure
Might be resistant to the drug

DURATION
If cultures are negative, empirical
antibiotic therapy should be stopped 48
to 72 hours.
Unnecessity

risk of MDR infections

If infection is evident, treatment is continued as indicated.

5 days or less
Clinical response should not be a sole determinant
Host response might not be as rapid as the bacterial
killing response
- If patient still has SIRS at predetermined end point,
more useful to stop therapy & reevaluate for:
- Persistence
- New infection
- MDR pathogens
- Noninfectious causes

MONOMICROBIAL
Standard guideline:
3-5 days for UTI
7-10 days for pneumonia
7-14 days for bacteremia
Longer course do not result in improved care
and associated with increase risk of
superinfection by resistant microorganism.

POLYMICROBIAL
Studies focused on patients with peritonitis.
Satisfactory outcomes:
12 to 24 hours for penetrating gestrointestinal trauma
with absence of extensive contamination
3 to 5 days for perforated/gangrenous appendicitis
5 to 7 days for peritoneal soilage due to perforated viscus
with moderate contamination.
7 to 14 days for adjunct therapy of extensive peritoneal
soilage (feculent peritonitis) or that of in
immunosuppressed host.

Later phases of post-operative antibiotic

treatment of serious intra-abdominal
infection
Signs show infection eradicated:
Absence of elevated WBC count
Lack of band forms of PMNs on peripheral
smear
Lack of fever (<38oC)

ORAL VS INTRAVEOUS
THERAPY
Patients hospitalized with infections always
treated with intravenous abx
Prompted by severity of infection

Patients with mild to moderate infection,

admit for other reasons (dehydration, pain
control) & normal GI function
Well-absorbed oral abx

Initially parenteral can safely switched to oral

When clinically stable

 Should select drugs with excellent

absorption for invasive infections
Pyelonephritis or abscess

In serious infection i.e. infective

endocarditis and CNS infection
Require high serum or CSF drug conc.
Oral therapy is less reliable

MISUSE
Scenarios:
Prolonged empiric therapy without clear
evidence of infection,
Failure to narrow antimicrobial therapy
when causative organism is identified.
Data available narrowest for continuation

Prolonged prophylactic therapy.

Excessive use of certain antimicrobial
agents.

Actions by a responsible practitioner:

Limits prophylaxis to the period during
operative procedure
Does not convert prophylaxis into empirical
except under well-defined conditions
Sets duration of antibiotic from beginning.
Curtails when there are non-supporting clinical
and microbiological evidence of infection.

REFERENCE
Mayo Clinic article http
://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/
Schwartzs Principles of Surgery, Tenth Edition
Sabiston Textbook of Surgery, 19th Edition