Download - Antibiotic Resistanace
Antibiotic ReviewAntibiotic Review
ObjectivesObjectives
Overview of Overview of organismsorganisms
Review of Review of AntibioticsAntibiotics
Surgical Surgical ProphylaxisProphylaxis
Review of Review of OrganismOrganism
ss
Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 4th ed. Stamford, CT: Appleton & Lange, 1999: 1600.Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 4th ed. Stamford, CT: Appleton & Lange, 1999: 1600.
““Normal” Normal” Colonizing Colonizing
FloraFlora
Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 4th ed. Stamford, CT: Appleton & Lange, 1999: 1599.Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 4th ed. Stamford, CT: Appleton & Lange, 1999: 1599.
Antibiotic ClassesAntibiotic Classes
PenicillinsPenicillins CephalosporinsCephalosporins Monobactam Monobactam CarbapenemCarbapenem GlycopeptideGlycopeptide OxazolidiononeOxazolidionone
AminoglycosidesAminoglycosides MacrolidesMacrolides TetracyclineTetracycline SulfonamideSulfonamide NitroimidazoleNitroimidazole QuinolonesQuinolones
Antibiotic Antibiotic SpectrumSpectrum
Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 53.Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 53.
Antibiotic Antibiotic SpectrumSpectrum
Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 54.Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 54.
AntibiotiAntibiotic c
SpectruSpectrumm
Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 55.Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy 2006. 36th ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 55.
Antibiotic SpectrumAntibiotic Spectrum P
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Naf
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in
Am
pici
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/am
oxic
illi
n
Aug
men
tin,
Una
syn
Tim
enti
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Zos
yn
Imip
enem
Azt
reon
am
Cip
rofl
oxac
in
Mox
iflo
xaci
n
Cef
azol
in
Cef
oxit
in
Cef
tria
xone
Cef
epim
e
Cep
hale
xin
Cef
urox
ime
Gen
tam
icin
, tob
ram
ycin
Cli
ndam
ycin
Van
com
ycin
Bac
trim
Met
roni
dazo
le
Lin
ezol
id
Gram Positive
+ + + + + + + - - + + + + + + + - + + + - +
Gram Negative
- - - + + + + + + + +/- + - + +/- +/- + - - + - -
Anaerobe
- - - + + + + - - +/- - + - + - - - + + - + -
Pseudo.
- - - - + + + + + - - - - + - - + - - - - -
Renal dose
+ - + + + + + + + - + + - + + + + - - + - -
Vancomycin Vancomycin Dosing Dosing
NomogramNomogram
VancomyciVancomycin Dosing n Dosing
NomogramNomogram
Aminoglycoside DosingAminoglycoside Dosing
Pre-Op Dosing: 160mg or 240mgPre-Op Dosing: 160mg or 240mg Post-Op Dosing/ Treatment DosingPost-Op Dosing/ Treatment Dosing
If CrCl > 30 ml/min give 5 or 7mg/kg doseIf CrCl > 30 ml/min give 5 or 7mg/kg dose Random Level 8 hours after infusionRandom Level 8 hours after infusion Pharmacy to follow dosing per TDM ServicePharmacy to follow dosing per TDM Service
If CrCl < 30 ml/min – contact pharmacy If CrCl < 30 ml/min – contact pharmacy for dosingfor dosing
2-3 mg/kg dose 2-3 mg/kg dose 2 random levels to be ordered by pharmacy2 random levels to be ordered by pharmacy
All aminoglycosides monitored by TDM All aminoglycosides monitored by TDM ServiceService
Sinai Sinai AntibiogrAntibiogr
amam
TherapeuticsTherapeutics
Determine Source/Site of infectionDetermine Source/Site of infection Identify suspected pathogensIdentify suspected pathogens Choose appropriate therapy based on Choose appropriate therapy based on
the abovethe above Determine duration of therapyDetermine duration of therapy
Surgical ProphylaxisSurgical Prophylaxis
GoalsGoals Selection of antimicrobial Selection of antimicrobial
agentsagents Timing of administrationTiming of administration Duration of administrationDuration of administration
Goals of Surgical Goals of Surgical ProphylaxisProphylaxis
Prevention of post-op infection at surgical Prevention of post-op infection at surgical sitesite
Prevention of post-op infections morbidity & Prevention of post-op infections morbidity & mortalitymortality
Reduction in duration and cost of health Reduction in duration and cost of health carecare
Produce no adverse effectsProduce no adverse effects Have no adverse consequences for the Have no adverse consequences for the
microbial flora of the patient or the hospitalmicrobial flora of the patient or the hospital
Goals of Surgical Goals of Surgical ProphylaxisProphylaxis
Active against pathogen that is most likely Active against pathogen that is most likely to contaminate the woundto contaminate the wound
Give at an appropriate dosage and at a Give at an appropriate dosage and at a time to ensure adequate concentrations at time to ensure adequate concentrations at the incision site during the period of the incision site during the period of potential contaminationpotential contamination
SafeSafe Administered for the shortest effective Administered for the shortest effective
period to minimize adverse effects, period to minimize adverse effects, development of resistance, and cost.development of resistance, and cost.
Goals of Surgical Goals of Surgical ProphylaxisProphylaxis
Antibiotic use for Dirty and contaminated Antibiotic use for Dirty and contaminated procedures is not classified as prophylaxis, procedures is not classified as prophylaxis, but treatment for presumed infection.but treatment for presumed infection.
Prophylaxis typically not indicated for Prophylaxis typically not indicated for clean proceduresclean procedures
Justified for procedures involving Justified for procedures involving prosthetic placementprosthetic placement
Cardiothoracic, GI tract, head and neck, Cardiothoracic, GI tract, head and neck, neurosurgical, obstetric or gynecologic, neurosurgical, obstetric or gynecologic, orthopedic, urologic and vascularorthopedic, urologic and vascular
Selection of Selection of Antimicrobial AgentsAntimicrobial Agents
Based on cost, adverse-effect profile, Based on cost, adverse-effect profile, ease of administration, pharmacokinetic ease of administration, pharmacokinetic profile, and antibacterial activityprofile, and antibacterial activity
Activity against most common surgical Activity against most common surgical wound pathogenswound pathogens Clean-contaminated: effective against GI/GU Clean-contaminated: effective against GI/GU
organismsorganisms Clean: effective against Staph and StrepClean: effective against Staph and Strep
Selection Selection of of
AntimicroAntimicrobial bial
AgentsAgents
Selection Selection of of
AntimicroAntimicrobial bial
AgentsAgents
Timing of Antibiotic Timing of Antibiotic ProphylaxisProphylaxis
Delivery of drug to operative site Delivery of drug to operative site before contamination occursbefore contamination occurs
Ideal timing is 30 minutes to one hour Ideal timing is 30 minutes to one hour prior to incision (at time of induction prior to incision (at time of induction of anesthesia)of anesthesia) Flagyl given 1 hour priorFlagyl given 1 hour prior Vancomycin given 2 hours priorVancomycin given 2 hours prior
Duration of Antibiotic Duration of Antibiotic ProphylaxisProphylaxis
24 hours or less24 hours or less Cardiothoracic procedures- up to 72 hoursCardiothoracic procedures- up to 72 hours Coverage must be provided from time of Coverage must be provided from time of
incision to closure of incisionincision to closure of incision Re-administer if short-acting agent used or Re-administer if short-acting agent used or
surgery lasting longer than 6-8 hourssurgery lasting longer than 6-8 hours Re-administer if excessive bleeding or change Re-administer if excessive bleeding or change
in half-life of drug (i.e. extensive burns)in half-life of drug (i.e. extensive burns) May avoid re-administration of half-life is May avoid re-administration of half-life is
extended ( i.e. renal insufficiency)extended ( i.e. renal insufficiency)
Biliary Tract SurgeryBiliary Tract Surgery
Cholecystetomy, exploration of common Cholecystetomy, exploration of common bile duct, choledochoenterostomybile duct, choledochoenterostomy
Risk of infection 5-20%Risk of infection 5-20% Higher risk of infection: bacteria in Higher risk of infection: bacteria in
bile, obesity, age > 70, acute episode of bile, obesity, age > 70, acute episode of cholecystitis or cholelithiasis within cholecystitis or cholelithiasis within previous 6 months, DM, h/o obstructive previous 6 months, DM, h/o obstructive jaundice or bile duct obstructionjaundice or bile duct obstruction
Biliary Tract SurgeryBiliary Tract Surgery
Organisms: E.coli, Klebsiella, Organisms: E.coli, Klebsiella, EnterococciEnterococci Less frequent: other gram negative, strep, Less frequent: other gram negative, strep,
staphstaph Occasionally: anaerobes (Clostridium sp.)Occasionally: anaerobes (Clostridium sp.)
Recommendation:Recommendation: Single dose of cefazolin at induction of Single dose of cefazolin at induction of
anesthesia for open procedures in biliary anesthesia for open procedures in biliary tracttract
No prophylaxis in laparoscopic No prophylaxis in laparoscopic cholecystectomiescholecystectomies
AppendectomyAppendectomy 80% are Uncomplicated (acute 80% are Uncomplicated (acute
inflammation)inflammation) Complicated (perforated or gangrenous; Complicated (perforated or gangrenous;
perotonitis, abcess formation)perotonitis, abcess formation) considered infection, not prophylaxisconsidered infection, not prophylaxis
9-30% risk of infection9-30% risk of infection Oragnisms: anaerobic and aerobic Oragnisms: anaerobic and aerobic
gram-negative enteric organismsgram-negative enteric organisms Bacteroides fragilis, E.coliBacteroides fragilis, E.coli Aerobic and anaerobic strep, staph and Aerobic and anaerobic strep, staph and
enterococcusenterococcus
AppendectomyAppendectomy
Recommendation:Recommendation: Cephalosporin with anaerobic and Cephalosporin with anaerobic and
aerobic activity at induction of aerobic activity at induction of anesthesiaanesthesia
For PCN allergy: metronidazole, For PCN allergy: metronidazole, gentamicin at induction of anesthesiagentamicin at induction of anesthesia
Colorectal SurgeryColorectal Surgery
30-60% risk of infection (<10% with 30-60% risk of infection (<10% with prophylaxis)prophylaxis) Rectal > intraperitoneal colon resectionRectal > intraperitoneal colon resection Surgeries > 3.5 hoursSurgeries > 3.5 hours Host defenses, age > 60, hypoalbuminemia, Host defenses, age > 60, hypoalbuminemia,
bacterial contamination of surgical wound, bacterial contamination of surgical wound, steroid therapy, malignancysteroid therapy, malignancy
Colorectal SurgeryColorectal Surgery
Organisms: B. fragilis, and other Organisms: B. fragilis, and other anaerobs (1,000-10,000 higher conc. anaerobs (1,000-10,000 higher conc. than aerobes), E.colithan aerobes), E.coli
Mechanical bowel preparation:Mechanical bowel preparation: Neomycin and erythromycin: 1gm 19, 18, 9 Neomycin and erythromycin: 1gm 19, 18, 9
hours before surgeryhours before surgery aerobic and anaerobic activity (Ancef, aerobic and anaerobic activity (Ancef,
Flagyl) at induction of anesthesiaFlagyl) at induction of anesthesia
ReferencesReferences Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells Dipiro, JT, Talbert RL, Yee GC, Matzke GR, Wells
BG, Posey LM, editors. Pharmacotherapy. A BG, Posey LM, editors. Pharmacotherapy. A Pathophysiologic Approach. 4Pathophysiologic Approach. 4thth ed. Stamford, CT: ed. Stamford, CT: Appleton & Lange, 1999: 1599-1600.Appleton & Lange, 1999: 1599-1600.
Gilbet DN, Moellering RC, Eliopoulos GM, Sande Gilbet DN, Moellering RC, Eliopoulos GM, Sande MA. The Sanford Guide to Antimicrobial Therapy MA. The Sanford Guide to Antimicrobial Therapy 2006. 362006. 36thth ed. Sperryville, VA: Antimicrobial ed. Sperryville, VA: Antimicrobial Therapy, INC., 2006: 53-55.Therapy, INC., 2006: 53-55.
ASHP Comission on Therapeutics. ASHP ASHP Comission on Therapeutics. ASHP Therapeutic Guidelines on Antimicrobial Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery. Am J Health Syst Pharm Prophylaxis in Surgery. Am J Health Syst Pharm 1999; 56(18): 1839-1888.1999; 56(18): 1839-1888.