Antibiotics – When and where to use?

Antibiotics - When and where to use?Medical professionals especially doctors and nurses are the people who seeks various antibiotics for even simple ailments. Do you know what all treatments are/should be prescribed for simple health problems? This article is based on the antibiotic policy developed by Christian Medical College Vellore and which they are practicing at CMC Vellore.

Antibiotic policy of CMC Vellore 2018

We are just giving an outline of the usual health problems and their management. Detailed description can be found in the PDF file attached below this article.

Good antibiotic prescription practices include:

1. Prescribing empiric antibiotics for suspected bacterial infections only if:

Symptoms are significant or severe
There is a high risk of complications
The infection is not resolving or is unlikely to resolve

2. Using first-line antibiotics first

3. Reserving broad spectrum antibiotics for specifically indicated conditions

Principles of rational antibiotic prescribing

1. Empiric antimicrobial treatment should be limited to conditions where immediate / early initiation of antimicrobials has been shown to be beneficial. Some examples are:

Severe sepsis (sepsis-induced tissue hypoperfusion or organ dysfunction) and septic shock

Acute bacterial meningitis

Community acquired pneumonia

Ventilator associated pneumonia

Necrotizing fasciitis

Febrile neutropenia

2. Fever, leukocytosis or elevated c reactive protein (CRP) levels by themselves should not be considered indications for starting empiric antimicrobials, as these have been shown to have very poor specificity to diagnose bacterial sepsis. Always consider multiple data points (history, physical findings and investigation reports) together to make an accurate diagnosis.

3. Incomplete or inaccurate diagnosis is the most important reason for inappropriate use of antimicrobials.

4. Always obtain cultures (two sets of blood cultures and other appropriate samples as clinically indicated – e.g. normally sterile body fluids, deep pus etc.) before starting empiric antimicrobial treatment.

Avoid the practice of obtaining “pan cultures” unless clinically indicated

5. Avoid sending cultures from superficial wounds, decubitus ulcers, and chronic wounds and draining sinuses. Surface swab cultures are either inadequate or provide misleading information regarding diagnosis (as they cannot differentiate infection from colonization/contamination).

6. When starting antimicrobials, use full therapeutic doses, paying close attention to dose, frequency, and route of administration and duration of treatment.

7. Review all antimicrobial prescriptions after 48 to 72 hours (“antimicrobial timeout”) with a view to modify or stop the initial empiric therapy.

8. De-escalate (targeted or pathogen specific therapy) the antimicrobial regimen once culture and susceptibility reports are available, and the patient is showing signs of improvement with the initial empiric broad spectrum antimicrobials.

Examples of optimization include switch
i. To a narrow-spectrum antimicrobial,
ii. From combination to single agent,
iii. To less toxic or expensive drug, or
iv. From i.v. to an oral formulation.

9. Stop antimicrobials if the cause of initial symptoms is found
to be non-infectious

10. The doses mentioned in these guidelines are for patients with
normal renal function. The doses have to be modified for those
with renal insufficiency.

Note – The following information is intended to serve as a guide, to aid in the selection of an appropriate antimicrobial for patients with infections commonly seen in clinical practice. Individual patient circumstances and resistance patterns may alter treatment choices.

Common Ailments and Management

GI and intra-abdominal infections

1. Acute • Viral gastroenteritis (calciviruses, (acute onset rotaviruses) nausea, • Entero-vomit’ng, toxigenic and diarrhea) entero-pathogenic E. colt • Salmonella spp.
Antibiotics – None indicated
• Rehydration • Symptomatic treatment

2. Acute watery diarrhea, cholera suspected (Vibrio cholerae)
– First line – Doxycycline 300 mg p.o. x 1 doses
If not subsiding,
Azithromycin 1 g p.a. x 1 dose • Ciprofloxacin 500 mg p.o. BID x 3 days
Prompt rehydration essential

3. Bacillary dysentery (acute onset fever and bloody diarrhea)
• Campylobacter spp. • Shigella spp.

Antibiotics – None needed for previously healthy patient with mild symptoms

– Treat patients with Severe symptoms or Immuno-compromised status. In that case, Ciprofloxacin 500 mg p.o. BID x 3 days • Azithromycin 500 mg p.o. OD x 3 days and prompt rehydration is essential.

Common Respiratory Viruses

1. Strep pneumontae • Mycoplasma pneumonee• Chlamydophila

First line – Amoxicillin 500 mg p.o. TID x 5 days

If not subsiding,
1. Azithromycin 500 mg p.o. OD x 5 days 2. Doxycycline 100 mg p.o. BID x 5 days 3. Levofloxacin 750 mg p.o. OD

2. Strep pneumoniae • Mi.plasma, Chlamydophila pneumontae • Legionella

Penicillin G 20 L i.v. Q4H + Azithromycin 500 mg i.v. OD x 5 – 7 days +Oseltamivir 75 mg p.o. BID x 5 days Ceftriaxone 1 g i.v. OD + Azithromycin 500 mg iv. cm x 5 – 7 days + 0seltamivir 75 mg p.o. BID x 5 days
• Antiviral treatment might still be beneficial in patients with severe, complicated, or pro-gressive illness and in hOSpi-talized patients when started after 48 hours of illness onset, indicated by observational studies (CDC, 2013) • Discontinue oseltamivir if PC R negative o Continue if clinical sus-picion of influenza high
• No virological or clinical ad-vantages with double dose oseltamivir compared with standard dose in patients with severe influenza admitted to hospital.

3. Strep. pneumoniae • Legionella • Klebsiella Pneunvniae • H influenzae • Respiratory wlises• P. influenza

Piperacillin-Tazobactam 4.5 g i.v. Q.+ Azithromycin 500 mg i.v. OD x 5 – 7 day, Oseltamivir 75 mg p.o. BID x 5 days

Some other common conditions

1. Acute pharyngitis • Group A streptococcus (GAS) • Respiratory viruses

First line – Amoxicillin 500 mg p.o. T1D x 10 days

If not subsiding,
1. Azithromycin 500 mg p.o. OD o5 days 2. Penicillin 250 mg p.o. Q1D x 10 days *

– Limit antibiotic prescriptions to patients who are rnost likely to have GAS infection (identified by Centor criteria fever, no cough, tonsillar exudates, & tender anterior cervical lyrnphadenopathy)

– The large majority of adults with acute pharyngitis have a self-lirnited viral illness, for which supportive care (analgesics, antipyretics, saline gargles) only is needed

2. Acute epiglotitis

3. Acute bronchitis (If viral)
Antibiotics – None needed
• Symptomatic treatment only

5. Acute bacterial rhinosinusitis (Antimcrobials if symptoms of fever, facial pain, purulent nasal discharge persists >7 days)

Causative organisms – Strep pneumoniae H. influenzae M. catarrhalis

Antibiotics preferred – Amoxicillin-Clavulanate 1 g p.o. BID x 7 days

Detailed Guidelines can be found atDownload Now

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