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antibiotic policy C.N.S..pptx
- 1. Antibiotic policy 2016 الحيوية المضادات العليا الجنة made by: مستشفى مدير او قسم رئيس كل من مرشح استف من تتكون التى + د . راشد جمال هللا هبة ومشر البكتريا استف ادارة على ف العدوى مكافحة + ..... + السابقة السنة خالل المزارع نتايج ومن
- 2. * Important * examples in C.N.S. departement
- 3. Drug Missusage = Drug resistance
- 6. • Avoid treating viral syndromes with antibiotics • choose the right antibiotic • Proper prophylaxis policy • Pay attention to dose and duration
- 9. Aim of Antibiotic Policy Reduce the Antimicrobial resistance. Practice best efforts, these resistance strains do not spill into critically ill patients in the Hospital. To prevent spill into Society, as they present as community associated infections.
- 10. Objectives of Antibiotic Policy Antibiotics should not be used if unnecessary. Policy emphasizes, avoiding the use of powerful Antibiotics in the Initial treatments. We should create awareness that we are sparing the powerful Broad spectrum Drugs for later treatment Patient saves Money Doctors save Lives
- 11. Hospital Antibiotic Committee *Clinicians / Microbiologists / Pharmacists and Nurses do take part. * Policies are framed on demands of the Clinical areas, depending on recent Infection surveillance data contributed from Microbiology Departments. - The Pharmacist who will report back to the Antibiotic Committee at each meeting on drug utilisation and cost. - The Microbiologist who will report on antibiotic susceptibility patterns of bacteria isolated from major infections. - Clinical doctors and nurses responsible for direct patient care who provide a link between clinical practice and the Antibiotic Committee - Manger(s) who will ensure the resources are available for implementation of the antibiotic policy. - Reciprocal Membership between the Infection Control Committee and the Drugs Committee should be ensured.
- 12. The policy should contain guidance on antibiotic prophylaxis (e.g. in surgery with details of timing, route, dosage and frequency) contain guidance on the choice of antibiotics for empirical and targeted therapy of major infections indicate first and second line therapy for common infections
- 13. Sample collection Proper specimen collection is combined responsibility of Clinical and Microbiological Departments. Continuous training of junior staff on sample collection, and is most neglected necessity A good clinical history is greatly helpful in differentiating community acquired infections from hospital acquired infections.
- 14. Staff Education on Antibiotic Policy Staff education is most Important principle in success Induction training for new staff Continuing Medical Education to both Junior and Senior practioners. Include nursing staff, pharmacists for the success of the Program
- 15. Antibiotic policy 2016 examples in C.N.S. departement
- 16. SECTION A ADULT
- 18. Comments Suggested Treatment Infection/ Condition & Likely organism Antibiotic treatment must be started immediately, regardless of any investigations undertaken…….. If no organism isolated and patient is responding, continue antibiotics for 14 days Alternative If no clinical response after 3 days of antibiotics: Meropenem 2.0gm IV q8h. Dexamethasone 10mg IV q6h is recommended to be administered 15 to 20 minutes before or at the time of first dose of antibiotics, for up to 4 days or until there is no evidence of pneumococcal meningitis. Preferred Empirical treatment on admission: Ceftriaxone 2gm IV q12h. OR Cefotaxime 2-4gm IV q8h Meningitis (acute) Common organisms: Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae Other organisms: Gram negative rods Leptospirosis Scrub typhus Melioidosis Mycoplasma pneumoniae
- 19. Comments Suggested Treatment Infection/ Condition & Likely organism Alternative Meropenem 2.0gm IV q8h OR Cefepime 2gm IV q12h. If organism is susceptible: Chloramphenicol 1gm IV q6h for 14 days. Preferred Ceftriaxone 2gm IV q12h OR Cefotaxime 2-4gm IV q8h OR Ceftazidime 2gm IV q8h. Duration of treatment: 10-14 days. (very ill patients may require treatment for 21 days.) Causative organism isolated: Haemophilus influenzae (Gram-ve bacilli)
- 20. Comments Suggested Treatment Infection/ Condition & Likely organism For penicillin resistant strains Vancomycin 1gm IV q12h PLUS Ceftriaxone 2gm IV q12h Relatively-resistant strains Ceftriaxone 2gm IV q12h Or Cefotaxime 2-4gm IV q8h OR (either) Cefotaxime 2-4gm IV q8h 1. Meropenem 2.0gm IV q8h for 10-14 days 2. Cefepime 2gm IV q12h. 3.Fluroquinolone PLUS Rifampicin Duration of treatment: 10-14 days. (very ill patients may require treatment for 21 days.) Penicillin- sensitive strains Benzylpenicill in 4MU IV q4- 6h for 10-14 days Causative organism isolated: Streptococcus pneumoniae (Gram +ve cocci)
- 21. Comments Suggested Treatment Infection/ Condition & Likely organism Close contacts are defined as those individuals who have had contact with oropharyngeal secretions either through kissing or by sharing toys, beverages, or cigarettes Alternative Chloramphenicol 1gm IV q6h. Ceftriaxone 250mg IM as single dose (especially in pregnancy); OR Azithromycin 500mg PO as single dose. Preferred Ceftriaxone 2gm IV q12 h OR Cefotaxime 2-4gm IV q8h OR Ceftazidime 2gm IV q8h. Ciprofloxacin 500mg PO as single dose; OR Rifampicin 600mg PO q12h for 2 days (4 doses) [not recommended in pregnant women]. Causative organism isolated: Neisseria meningitidis (Gram –ve cocci) Prophylaxis for household and close contacts for meningococcal meningitis
- 22. Comments Suggested Treatment Infection/ Condition & Likely organism Ceftriaxone 2gm IV q12 h OR Cefotaxime 2-4gm IV q8h. Duration of treatment: 10-14 days. (Very ill patients may require treatment for 21 days.) Causative organism isolated: Gram-negative Enterobacteriaceae
- 23. Comments Suggested Treatment Infection/ Condition & Likely organism Acyclovir 500mg IV q8h for 14-21 days. (Duration of treatment may be extended to 21 days in severe cases or in immunosuppressed patients. : Viral encephalitis Herpes simplex Herpes zoster
- 24. Comments Suggested Treatment Infection/ Condition & Likely organism Alternative Valganciclovir 900mg PO q12h Valganciclovir PO 900mg PO q24h for 6 months depending on severity of disease, time to response and end organ involvement. Preferred Ganciclovir 5mg/kg IV q12h for 21 Days Ganciclovir 5mg/kg IV q24h for 6 months depending on severity of disease, time to response and end organ involvement. May switch to oral. Causative organism isolated: Cytomegalovirus (CMV) In immunocompromised patients Induction phase: Maintenance phase:
- 25. Comments Suggested Treatment Infection/ Condition & Likely organism Intensive 2 months S/EHRZ and 10 months HR. • Isoniazid (H) 5 (4-6) mg/kg/24h PO (max: 300 mg/day) PLUS • Rifampicin (R) 10 (8-12) mg/kg/24h PO (max: 600 mg/day) PLUS • Pyrazinamide (Z) 25 (20-30) mg/kg/24h PO (max: 2000 mg/day) PLUS • Streptomycin (S) 15 (12-18) mg/kg/24h IM (max: 1000adults. mg/day) ? Meningitis (chronic) Tuberculous meningitis (Mycobacterium tuberculosis)
- 26. Comments Suggested Treatment Infection/ Condition & Likely organism End point of treatment: till at least total of 1.5-2.0gm of Amphotericin B given and CSF shows clearance of fungus by 2 negative C&S one month apart, and CSF Cryptococcal antigen titre becomes negative or at least 1:2 or shows a fourfold decrease. Liposomal Amphotericin may be used in cases of severe toxicity to Amphotericin B e.g. Abelcet 3-5mg/kg/day Alternative Fluconazole 400mg IV q24h initially and then 200-400mg IV q24h for 6-8 weeks. Fluconazole “consolidation” therapy may be continued for as long as 6-12 months, depending on the clinical status of the patient. Preferred Amphotericin B 0.7- 1.0mg/kg/24h IV PLUS 5-Flucytosine 100-150mg/kg/24h PO q6h for 2-4 weeks. Or Fluconazole 400mg PO q24h .(If Fluconazole is not tolerated: Itraconazole 200mg PO q12h) Fluconazole 400-800mg PO q24h for 8 weeks. Cryptococcal meningitis Cryptococcus neoformans Induction Therapy: Consolidation Therapy:
- 27. Comments Suggested Treatment Infection/ Condition & Likely organism • Repeat CSF examinations every 6 months. Consider retreatment if cell count is not decreased in 6 months or CSF is not entirely normal in 2 years • All patients with neurosyphilis should be considered for corticosteroid cover at the start of the therapy to prevent the Jarisch-Herxheimer reaction (Prednisolone 10-20mg PO q8h for 3 days commencing one day prior to syphilis treatment) Ceftriaxone 2gm IM (with Lidocaine as diluent) or IV (with water for injection as diluent) for 10-14 days (if no anaphylaxis to penicillin) Aqueous crystalline penicillin G, 18-4MU/day, administered 3 - 4 MU q4h IV for 14 days OR Procaine Penicillin 2.4MU IM q24h PLUS Probenecid 500mg PO q6h for 14 days Neurosyphilis
- 28. SURGICAL CHEMOPROPHYLAXIS It is the use of antibiotics to prevent infections at the surgical site. It should be considered when there is significant risk of post-operative infection or where post-operative infection would have severe consequences. Ideally, the prophylaxis when given intravenously should be given as soon as the patient is stabilized after induction. Usually a single dose is sufficient. Asecond dose may be required in the following situations: a. delay in start of surgery b. in prolonged operations when the time is more than half of the usual dosing interval of the antibiotic Pre-operative dose timing: The optimal time for administration of preoperative doses is within 60 minutes before surgical incision.…Some agents, such as Clindamycin, Fluoroquinolones, Gentamicin, Metronidazole and Vancomycin, require administration over one to two hours; therefore, the administration of these agents should begin within 120 minutes before surgical incision Giving more than 1 or 2 doses postoperatively is generally not advised. The practice of continuing prophylactic antibiotics until surgical drains have been removed is NOT RECOMMENDED.
- 29. Comments Suggested Treatment Infection/ Condition & Likely organism Ceftriaxone 2gm IV single dose one hour prior to skin incision Ceftriaxone 2gm IV one hour prior to skin incision, followed by repeat dose 1gm IV q12h till completion of Surgery β-Lactam Allergy: Clindamycin 900mg IV MRSA colonisation: Vancomycin 15mg/kg IV Cefuroxime 1.5gm IV single dose one hour prior to skin incision Cefuroxime 1.5gm IV one hour prior to skin incision, followed by repeat dose 750mg IV q8h till completion of surgery Clean (Craniotomy, burrhole for clean pathology) < 4 hours > 4 hours
- 30. Comments Suggested Treatment Infection/ Condition & Likely organism Ceftriaxone 2gm IV one hour prior to skin incision. β-Lactam Allergy: Clindamycin 900mg IV MRSA colonisation: Vancomycin 15mg/kg IV Cefuroxime 1.5gm IV single dose one hour prior to skin incision Clean + Implant (CSF diversion procedures e.g. Shunt, EVD, omaya, DBS, Titanium/acrylic craniplasty, artificial dura used) Ceftriaxone 2gm IV single dose one hour prior to skin incision followed by three repeated doses of 1gm IV q12h. β-Lactam Allergy: Clindamycin 900mg IV MRSA colonisation: Vancomycin 15mg/kg IV Cefuroxime 1.5gm IV single dose one hour prior to skin incision, followed by three repeated doses of 750mg IV q8h Clean contaminated (Transphenoidal, Acosutic neuroma, involving air sinuses)
- 31. Comments Suggested Treatment Infection/ Condition & Likely organism Ceftriaxone 2gmIV q12h PLUS/MINUS Metronidazole 500mg IV q8h for 72 hours. β-Lactam Allergy: Clindamycin 900mg IV MRSA colonisation: Vancomycin 15mg/kg IV Cefuroxime 1.5gm IV q8h PLUS/MINUS Metronidazole 500mg IV q8h for 72 hours Contaminated (Skull fracture, previous surgery, lacerated scalp) Meropenem 2gm IV q8h PLUS/MINUS Metronidazole 500mg IV q8h MRSA colonization: Vancomycin 20mg/kg IV Pseudomonas infection: Cefepime 2g IV q8h OR Ceftazidime 2g IV q8h Ceftriaxone 2gm IV q12h PLUS/MINUS Metronidazole 500mg IV q8h For 6-8 weeks depending on response. Dirty (brain abscess, subdural empyema, ventriculitis)
- 33. Comments Suggested Treatment Infection/ Condition & Likely organism Prophylaxis for all household contacts if there are unimmunised or partially immunised children < 4 years old. If suspected penicillin-resistant Strep pneumonia: Cefotaxime 50mg/kg IV q4-6h OR Ceftriaxone for 50- 75mg/kg IV q12-24h for 10-14 days PLUS Vancomycin 15mg/kg IV q6h Cefotaxime 50mg/kg IV q4- 6h OR Ceftriaxone 50- 75mg/kg IV q12- 24h for 10-14 days. If < 3 month-old, ADD: Benzylpenicillin 50mg/kg IVq4-6h OR Ampicillin 50mg/kg IV q4- 6h Meningitis empirical treatment
- 34. Comments Suggested Treatment Infection/ Condition & Likely organism Chloramphenicol 40mg/kg IV stat then 25mg/kg q6h for 10- 14 days; OR Cefepime 50mg/kg IV q8h for 10- 14 days Cefotaxime 50mg/kg IV q4-6h OR Ceftriaxone 50- 75mg/kg IV q12- 24h for 10-14 days..) Causative organism isolated: Haemophilus influenza Strepcoccus pneumoniae Prophylaxis for all household contacts and Health Care Workers involved in intubation and suctioning of airway Cefotaxime 50mg/kg IV q4- 6h OR Ceftriaxone 50-75mg/kg IV q12- 24h for 7 days. OR Chloramphenicol 40mg/kg stat Benzylpenicillin 50mg/kg IV q4-6h for 7 days Causative organism isolated: Neisseria meningitidis
- 35. Comments Suggested Treatment Infection/ Condition & Likely organism Amphotericin B 1.0mg/kg/24h IV PLUS/ MINUS 5-Flucytosine 400- 1200mg/m2 (max 2gm) PO in q6h for 2-4 weeks. Fluconazole 10- 12mg/kg/24h PO in q12h for 8 weeks. Causative organism isolated: Cryptococcal meningitis Cryptococcus neoformans Induction Therapy: Consolidation Therapy: Duration: for 14-21 days. Acyclovir: < 12 weeks old: 20mg/kg IV q8h 12 weeks-12 years old: 500mg/m2 IV q8h If > 12 years olds: 10mg/kg IV q8h HerpesSimplexEncephalitis
- 36. Comments Suggested Treatment Infection/ Condition & Likely organism Surgical drainage may be indicated if appropriate. Duration 6-8 weeks, depending on response as seen from neuroimaging. If secondary to trauma: ADD Cloxacillin 25- 50mg/kg IV q4-6h. Cefotaxime 50mg/kg IV q4-6h OR Ceftriaxone 50- 75mg/kg IV q12- 24h PLUS Metronidazole 15mg/kg IV stat then 7.5mg/kg IV q8h. BrainAbscess
- 37. Thank you