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- 2. Course content Course roadmap Basic concepts Common infections 1
- 3. “Antimicrobial resistance poses a fundamental threat to human health, development, and security. The commitments made today must now be translated into swift, effective, lifesaving actions across the human, animal, and environmental health sectors. We are running out of time." Dr. Margaret Chan September 2016 2
- 4. Core competencies for antimicrobial prescribing C1: Understands the patient and the patient’s clinical needs C2: Understands treatment options and how they support the patient’s clinical needs C3: Works in partnership with the patient and other healthcare professionals to develop and implement a treatment plan C4: Communicates the treatment plan and its rationale clearly to the patient and other health professionals C5: Monitors and reviews the patient’s response to treatment 3 Core Competencies
- 5. Objectives • Recognize the limited number of acute diarrheal clinical scenarios that require antimicrobial therapy. • Use microbiologic susceptibility data to determine the appropriate empiric therapy for traveler’s diarrhea and when clinician-prescribed, self-treatment is indicated. • Understand role of clinicians in reducing the use of antimicrobials purchased without a prescription for acute diarrhea in some settings. 4
- 7. Increasing resistance 6 • Complicates treatment when antibiotics are indicated
- 8. Increasing resistance 7 • Among gram-negative organisms: • Shigella • Salmonella • Campylobacter • Self-treatment exposes patients to harm U.S. Centers for Disease Control and Prevention – Medical Illustrator
- 9. 8
- 10. Case 1 Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 9
- 11. 18 year-old female with: 1 day of fever, abdominal complaints no vomiting diarrhea - watery, non-bloody recent travel normal exam 10
- 12. Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 11 Should she be given empiric antimicrobial therapy?
- 13. Diarrheal diseases • Watery vs. bloody • Exposure history • Immune status 12 Most likely pathogen?
- 14. Epidemics 13 Watery diarrhea Bloody diarrhea Norovirus Vibrio cholera Shiga-toxin producing E. coli Shigella dysenteriae
- 15. Empiric antibiotics 14 Rehydration Watchful waiting without empiric antibiotics sufficient for most cases of watery diarrhea
- 16. Empiric antibiotics 15 For patients with bloody diarrhea, decisions regarding empiric therapy must be individualized.
- 17. Traveler’s diarrhea Self-limited diarrhea with symptoms lasting 1-5 days. 16 Enterotoxigenic E. coli Shigella norovirus Enteroaggregative E. coli Campylobacter Salmonella
- 18. Pre-travel antibiotics 17 • Bring in case develop symptoms while traveling • Choice of agent depends upon destination locale • Reserve for severe disease • Preventive measures
- 19. An informed choice Severity Source Drug resistance Patient factors Cultures Core Competencies 1 & 2 Optimal antibiotics 18
- 20. Severity Source Drug resistance Patient factors Cultures Not severe How severe is the patient’s condition? 19
- 21. Severity Source Drug resistance Patient factors Cultures • Traveler’s diarrhea • Most commonly bacterial pathogen 20 What is the cause of the patient’s diarrhea?
- 22. Severity Source Drug resistance Patient factors Cultures Possible How likely is resistance? 21
- 23. Severity Source Drug resistance Patient factors Cultures Likely not necessary Do I need cultures? 22
- 24. Severity Source Drug resistance Patient factors Cultures Core Competencies 1 & 2 No antimicrobials 23
- 25. Case 2 Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 24 Core Competencies 1 & 2
- 26. 66 year-old female with: 1 day of fever, abdominal cramping bloody diarrhea vomiting recent lake trip moderate dehydration, diffuse abdominal tenderness 25
- 27. Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 26 Should she be given empiric antimicrobial therapy?
- 28. Empiric antibiotics 27 For patients with bloody diarrhea, decisions regarding empiric therapy must be individualized.
- 29. Empiric antibiotics: bloody diarrhea 28 Infants < 3 months of age Immuncompetent Ill patients with suspected shigellosis Patients with epidemiologic risk factors & sepsis Immunocompromised patients with fever & severe illness
- 30. Severity Source Drug resistance Patient factors Cultures Moderate – severe invasive disease How severe is the patient’s condition? 29
- 31. Severity Source Drug resistance Patient factors Cultures Acute bloody diarrhea with fever 30 What is the cause of the patient’s diarrhea?
- 32. Severity Source Drug resistance Patient factors Cultures Possible, but depends upon local resistance rates How likely is resistance? 31
- 33. Severity Source Drug resistance Patient factors Cultures • Stool culture • Blood cultures Do I need cultures? 32
- 34. Severity Source Drug resistance Patient factors Cultures Core Competencies 1 & 2 fluoroquinolone 33
- 35. Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 34 Case 2: re-evaluation Stool culture: Shigella flexneri Core Competencies 1, 2, 3, 4 & 5
- 36. Shigellosis 35 • Self-limited • Antibiotics not required to cure diarrhea, but shorten duration of asymptomatic shedding U.S. Centers for Disease Control and Prevention – Medical Illustrator
- 37. Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 36 Case 2: alternative ending Persistently febrile Severe abdominal pain Non-bloody diarrhea Core Competencies 1, 2, 3, 4 & 5
- 38. Case 2: alternative ending 37
- 39. Severity Source Drug resistance Patient factors Cultures Severe How severe is the patient’s condition? 38
- 40. Severity Source Drug resistance Patient factors Cultures Acute watery diarrhea with fever: bacterial pathogens 39 What is the cause of the patient’s diarrhea?
- 41. Severity Source Drug resistance Patient factors Cultures Likely – progressed despite taking fluoroquinolones How likely is resistance? 40
- 42. Severity Source Drug resistance Patient factors Cultures • Stool culture • Blood cultures Do I need cultures? 41
- 43. Severity Source Drug resistance Patient factors Cultures ceftriaxone 42 Core Competencies 1, 2, 3, 4 & 5
- 44. Case 2: re-evaluation Subsequent evaluation Initial evaluation Clinical assessment Diagnostic work-up Patient education Therapeutic decisions Modify antimicrobials Data review Clinical re-assessment 43 Blood and stool cultures: Salmonella enteritidis Core Competencies 1, 2, 3, 4 & 5
- 45. Salmonellosis 44 Gastroenteritis Typhoid fever Non-typhoidal Salmonella Salmonella typhi Salmonella paratyphi
- 46. Salmonellosis 45
- 47. Salmonellosis 46 • Extremes of age are risk factors for invasive disease. • Resistance varies markedly depending on geographic region. U.S. Centers for Disease Control and Prevention – Medical Illustrator
- 48. Review: Acute Infectious Diarrhea Drug Dose Duration Route prescription ............. ............. ............. 47
- 49. Review: Acute Infectious Diarrhea Drug Dose Duration Route prescription ............. ............. ............. • Antibiotics not indicated for patients with mild, watery diarrhea.
- 50. Review: Acute Infectious Diarrhea • Antibiotics not indicated for patients with mild, watery diarrhea. • Antibiotics may be indicated for patients with evidence of invasive disease. Drug Dose Duration Route prescription ............. ............. .............
- 51. Review: Acute Infectious Diarrhea Drug Dose Duration Route prescription ............. ............. ............. • Antibiotics are not indicated for patients with mild, watery diarrhea. • Antibiotics may be indicated for patients with evidence of invasive disease. • Clinicians must educate patients to avoid self- treatment.
- 52. Quiz time! Please click “Next” to proceed.