Antibiotic selection part 1

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Antibiotic selection part 1

  1. 1. Antibiotic Selection. Part 1 What Drug for What Bug Dr.T.V.Rao M D Professor, Department of Microbiology Jubilee Mission Medical College, and Research Institute, Thrissur, Kerala. India E mail ;tvraodoctor2000@yahoo.co.in
  2. 2. Basic Principles. <ul><li>Proper use Favorable results </li></ul><ul><li>Indiscriminate use Drug Resistance </li></ul><ul><li>Emerging Problem </li></ul><ul><li>May produce Adverse Reactions. </li></ul>
  3. 3. Decision Making. <ul><li>Decide first that one is treating a Bacterial </li></ul><ul><li>Infection. </li></ul><ul><li>Mild Wait </li></ul><ul><li>Moderate Consider starting earliest </li></ul><ul><li>Severe Don’t loose time </li></ul><ul><li>( Best guess is life saving ) </li></ul>
  4. 4. Skills In Antibiotic Therapy. <ul><li>Seniors - Colleagues – Juniors Follow </li></ul><ul><li>Most General Practitioners </li></ul><ul><li>Dangerous trend Promotional </li></ul><ul><li>Best way learn your own skills. </li></ul>
  5. 5. Etiological Diagnosis <ul><li>Do we need to know about causative agent always ? No </li></ul><ul><li>Development of skills apply to the situation. </li></ul><ul><li>But the following conditions warrant a good knowledge on causative agent. </li></ul><ul><li>CNS, Hepatobiliary,Renal Systemic infections, Bacteremias Cardiac infections. </li></ul>
  6. 6. What is best guess. <ul><li>Past experience of Antibiotic therapy, </li></ul><ul><li>Basic principles of antibiotic therapy, </li></ul><ul><li>Many times best guess is life saving. </li></ul><ul><li>Many surveys prove -- Physicians in Developing Nations </li></ul><ul><li>Depending on Best guess. </li></ul>
  7. 7. Role of Microbiological Diagnosis. <ul><li>Start collecting desired samples before starting antibiotic therapy. </li></ul><ul><li>Consider the Technical soundness of the Laboratories. </li></ul><ul><li>Many times Normal flora are reported as pathogens, and misguide the Junior Physicians. </li></ul>
  8. 8. Judgment on Clinical response. <ul><li>In routine circumstances if the best guess </li></ul><ul><li>works ignore Microbiological reports </li></ul><ul><li>In Poor response consider evaluation of Microbiology reports. </li></ul>
  9. 9. Adherence to Microbiology Reports <ul><li>Isolates from </li></ul><ul><li>Blood, CSF,Body Fluids, </li></ul><ul><li>A significant finding. </li></ul><ul><li>Implement the Microbiology </li></ul><ul><li>Reports </li></ul>
  10. 10. Dealing with unexpected results. <ul><li>When the isolates from </li></ul><ul><li>Respiratory tract, GUT system </li></ul><ul><li>Surface lesions. </li></ul><ul><li>Think before changing Antibiotics </li></ul><ul><li>Many occasions Specimens are not properly collected. </li></ul><ul><li>Major failures are attributed to collecting and sending a ideal Sample. </li></ul>
  11. 11. Drug susceptibility Testing. <ul><li>Always needed ? No </li></ul><ul><li>e.g. Group A hemolytic streptococci. </li></ul><ul><li>Clostridial infection, </li></ul>
  12. 12. Drug susceptibility Testing. <ul><li>Most Important in </li></ul><ul><li>Enterobacteriaceae </li></ul><ul><li>Majority of times stick to antibiotic sensitivity patterns, </li></ul>
  13. 13. Current Trends <ul><li>Get familiar with your own ward reports. </li></ul><ul><li>All the knowledge from Journals </li></ul><ul><li>May not suit local situations </li></ul><ul><li>Get familiar with Daily isolates and the Antibiotic patters, </li></ul><ul><li>eg Pneumococcus,Enterococci </li></ul><ul><li>Be familiar with Changing pattern of resistance </li></ul><ul><li>e.g. Penicillin's ,Aminoglycosides,Vancomycin. </li></ul>
  14. 14. Failed Responses. <ul><li>One May not be treating a Bacterial Infection. </li></ul><ul><li>Selection of Inappropriate Drug, Dosage, </li></ul><ul><li>Improper Administration. </li></ul><ul><li>Missing a Pocket of Localized pus, </li></ul><ul><li>Poorly diffusing drugs </li></ul><ul><li>Don't reach target, e.g. Cefoperazone in meningitis, </li></ul>
  15. 15. Failed responses( Cont ) <ul><li>Super infection replacing primary infection, </li></ul><ul><li>Suppression of Normal Flora. </li></ul><ul><li>Fast emerging drug resistant strains, </li></ul><ul><li>Two or More pathogens present </li></ul><ul><li>But treating one only. </li></ul><ul><li>Growing problems with </li></ul><ul><li>Immune deficiencies,Diabetus. </li></ul>
  16. 16. Failed Response (Cont ) <ul><li>Treating non infectious disorders with </li></ul><ul><li>Antibiotics eg Autoimmune disorders. </li></ul><ul><li>Slow Responses </li></ul><ul><li>Osteomyletis,Endocarditis, </li></ul><ul><li>Slow responding microbes, </li></ul><ul><li>Staphylococcus, Fungal </li></ul><ul><li>Mycobacterial infections. </li></ul><ul><li>Fast Responders Viridians Streptococci. </li></ul>
  17. 17. Estimation of Antibiotic Levels. <ul><li>Important on prolonged usage. </li></ul><ul><li>e.g. Amino glycosides,Flucytosine, </li></ul><ul><li>In all cases of altered clearance. (Renal Diseases.) </li></ul>
  18. 18. Duration of Antibiotic Therapy. <ul><li>No specified guidelines in Major Infections. </li></ul><ul><li>Author variation is wide Controversial. </li></ul><ul><li>Most Important. </li></ul><ul><li>Effective clinical response. </li></ul><ul><li>Eg Clinical laboratory parameters in UTI </li></ul><ul><li>Location of infection </li></ul><ul><li>Endocarditis,Osteomyletis. </li></ul>
  19. 19. Oral or Parental Route <ul><li>Note </li></ul><ul><li>Oral Antibiotic therapy is equal to parental therapy. </li></ul><ul><li>Oral Drugs now have excellent Bioavailability. </li></ul>
  20. 20. Advantages of Oral therapy. <ul><li>Less expensive. </li></ul><ul><li>Early discharge from Hospital. </li></ul><ul><li>Reduction in Health care costs. </li></ul><ul><li>Avoid Chemical phlebitis. </li></ul><ul><li>Eliminate I,V line infections. </li></ul><ul><li>It is proved that I.V offers no advantage than oral therapy, except in critically ill. </li></ul><ul><li>A sense of security in patients. </li></ul>
  21. 21. Most prominent oral Antibiotics. <ul><li>Doxycycline, </li></ul><ul><li>Clindamycin. </li></ul><ul><li>Metronidazole. </li></ul><ul><li>Levofloxacin. </li></ul><ul><li>Chloramphenicol. </li></ul><ul><li>TMX-SMX. </li></ul><ul><li>Acyclovir. </li></ul><ul><li>Fluconazole. </li></ul><ul><li>Linezolid. </li></ul>
  22. 22. New Uses of Old Antibiotics. <ul><li>Still useful on many occasions. </li></ul><ul><li>eg Doxycycline in Malaria. </li></ul><ul><li>Chloramphenicol – VRE. </li></ul>
  23. 23. Role of Newer Antibiotics. <ul><li>Do not come to prompt conclusions. </li></ul><ul><li>Consider- </li></ul><ul><li>1. Cost. </li></ul><ul><li>2 .Resistance potential. </li></ul><ul><li>3.Years of use. </li></ul><ul><li>4.Side effects. </li></ul><ul><li>5.Compare with current popular drugs. </li></ul><ul><li>6.Consider the profile of last 2 years </li></ul><ul><li>usage. </li></ul>
  24. 24. New Facts on Antibiotic Resistance. <ul><li>Drug resistance </li></ul><ul><li>Not related to </li></ul><ul><li>1.Volume of use. </li></ul><ul><li>2.Years of Use. </li></ul><ul><li>3.Class of Antibiotics </li></ul><ul><li>eg Cephalosporin's. </li></ul><ul><li>But agent specific. </li></ul><ul><li>Ceftazidime. </li></ul>
  25. 25. New Uses of Older Antibiotics. <ul><li>> 1980 Beta lactum / Quinolones. </li></ul><ul><li>Dominates the Antibiotic prescriptions. </li></ul>
  26. 26. Less Commonly Used, <ul><li>Doxycycline, </li></ul><ul><li>Minocycline, </li></ul><ul><li>Clindamycin, </li></ul><ul><li>TMP-SMX </li></ul><ul><li>Nitrofurantoin. </li></ul>
  27. 27. Tetracycline and related. Doxycycline,Minocycline, <ul><li>Can be used as first line Drugs in </li></ul><ul><li>Atypical pneumonia, </li></ul><ul><li>Chronic Bronchitis, </li></ul><ul><li>Leptospirosis, </li></ul><ul><li>Non gonococcal urethritis, </li></ul><ul><li>C.trachomatis, </li></ul><ul><li>Syphilis,Leptospirosis ( Penicillin Allergy ) </li></ul>
  28. 28. Trimethoprim-Sulfamethoxazole <ul><li>Broad spectrum – Inexpensive. </li></ul><ul><li>Still useful in, </li></ul><ul><li>H.influenzae, </li></ul><ul><li>Moraxella, </li></ul><ul><li>E.coli. </li></ul><ul><li>Proteus mirabilis, </li></ul><ul><li>K.pneumoniae, </li></ul><ul><li>Shigella, </li></ul><ul><li>E.coli ( E.T ) </li></ul><ul><li>Toxoplasmosis </li></ul><ul><li>MRSA ( some ) </li></ul>
  29. 29. Clindamycin. <ul><li>Serious Anaerobic infections. </li></ul><ul><li>Polymicrobial osteomyletis. </li></ul><ul><li>Infections associated with Diabetic foot. </li></ul><ul><li>Don't Cross into CSF. </li></ul>
  30. 30. Metronidazole. <ul><li>Anaerobic bacterial infections, </li></ul><ul><li>Protozoal infections. </li></ul><ul><li>Anaerobic brain abscess. </li></ul><ul><li>H.pylori. </li></ul><ul><li>Clostridium difficile, </li></ul>
  31. 31. Chloramphenicol. <ul><li>Pneumococcal infections., </li></ul><ul><li>Meningococcal infections. </li></ul><ul><li>H.influenzae, </li></ul><ul><li>Anaerobic activity, </li></ul><ul><li>VRE Enterococcus,, </li></ul>
  32. 32. Rationalism on use of Newer Antibiotics <ul><li>Do not choose in Hurry, </li></ul><ul><li>Should posses unique attributes, </li></ul><ul><li>At least 2 years of experience before a routine choice, </li></ul><ul><li>Many newer formulations have less side effects and improved tolerability. </li></ul>
  33. 33. Conclusion Antibiotics are life saving pearls, Let use them precisely, wisely to a appropriate situation Dr.T.V.Rao.M D.

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