practical description of issues we faced in our antibiotic stewardship-bacterial resistance-culture & sensitivity test-antibiotic skin allergy test Lecture was presented on the 30th. Nov. 2020

1. Rational use of antibiotics
‫الحيوية‬ ‫للمضادات‬ ‫الرشيد‬ ‫االستخدام‬
part of our work & recommendations
in antibiotic stewardship
Alaa Fadhel Hassan (MSc. Pharmacology)
Drug Information Centre
Al Mahmoudiya General Hospital

2. Entrance
• I am going to tell you different points that may control
antibiotic use, decrease their side effect & increase their
benefit,,, you wont see scientific updates in this presentation
but rather something you may all know
• I need your help, cooperation and insistence to achieve the
best goal to us:
Improve Patient Health Care
Handle Antibiotics With Care

3. Antibiotic resistance
• Antibiotic resistance is worldwide problem. New strains of
resistant bacteria can cross international boundaries and
spread between continents with ease and remarkable speed.
“World health leaders have described antibiotic resistant
organism as nightmare bacteria that pose a catastrophic
threat to people in every country in the world”
• Sure now we have another threat called COVID-19 but this
never cancel the catastrophe of antibiotic resistance

4. Antibiotic resistance
• Giuliano C. et al. 2019, stated that approximately 50% of
hospitalized patients receive at least one antibiotic during their
inpatient stay, 30% of which includes broad-spectrum
antibiotics. Misuse of antibiotic was reported to be as high as
50% (same ref).
• Each year in US misuse of antibiotic lead to increased adverse
effects, secondary infections, drug interactions, additional
costs, prolonged lengths of stay, and hospital readmissions.
Furthermore, bacterial resistance will develop, that finally
leads to treatment failure

5. Antibiotic resistance

6. So the problem is: Antimicrobial Prescribing
Facts, the 30% Rule
• 30% of all hospitalized inpatients at any given time receive
antibiotics
• Over 30% of antibiotics are prescribed inappropriately in the
community
• Up to 30% of all surgical prophylaxis is inappropriate
• 30% of hospital pharmacy costs are due to antimicrobial use
• 10-30% of pharmacy costs can be saved by antimicrobial
stewardship programs

7. Culture & sensitivity test
• they are used to determine which specific antibiotics bacteria
is sensitive to. Results are commonly reported as the minimal
inhibitory concentration (MIC), a typical results contain a
quantitative result in µg/mL and a qualitative interpretation
• Cultures should be obtained quickly to guide therapy, identify
the offending organism, allow potential de-escalation through
proper treatment, (taking into consideration the importance of
prompt antibiotic administration - The 2016 Surviving Sepsis
Campaign guidelines recommend that antibiotics be
administered within one hour of sepsis diagnosis)

8. Culture & sensitivity test
• Cultures usual sites including those which are colonized with
bacteria (causes the risk of contamination from normal flora
and may lead to false results like sputum and nasal passages)
or sterile sites (typically include cerebral spinal fluid, blood,
and pericardial fluid)
• If cultures are drawn after-antibiotic administration, there may
be a decrease in the yielded blood-culture causing increase in
the cost and length of stay for the patient

9. Antibiogram
• periodic cumulative summary produced from analysis of
antibiotic susceptibilities on bacterial isolates from a particular
hospital in a defined period of time
• In our work its rather depend on resistant rather than
susceptible culture & sensitivity tests only, recently
• How calculated
𝐫𝐞𝐬𝐢𝐬𝐭𝐚𝐧𝐭 𝐛𝐚𝐜𝐭𝐞𝐫𝐢𝐚𝐥 𝐢𝐬𝐨𝐥𝐚𝐭𝐞 𝐨𝐟 𝐬𝐩𝐞𝐜𝐢𝐟𝐢𝐜 𝐚𝐧𝐭𝐢𝐛𝐢𝐨𝐭𝐢𝐜
𝐭𝐨𝐭𝐚𝐥 𝐛𝐚𝐜𝐭𝐞𝐫𝐢𝐚𝐥 𝐢𝐬𝐨𝐥𝐚𝐭𝐞 𝐨𝐟 𝐬𝐩𝐞𝐜𝐢𝐟𝐢𝐜 𝐬𝐩𝐞𝐜𝐢𝐞𝐬 𝐟𝐨𝐫 𝐬𝐚𝐦𝐞 𝐚𝐧𝐭𝐢𝐛𝐢𝐨𝐭𝐢𝐜
× 𝟏𝟎𝟎

10. Antibiogram, why we need it
• Support clinicians selecting empiric antibiotic therapy
• assess & compare local susceptibility/resistance rates
• track resistance trends over time within an institution at local
level
• infection-control interventions

11. Part of our work at 2019

12. Part of our work at 2020

13. Part of our work

14. Antibiotic allergy skin test
• Skin allergy test as important as you can imagine, its benefit to
avoid antibiotic allergic side effect in their mild- up to risky
form which may be anaphylaxis
• Its done routinely for penicillins & cephalosporins (Amoxicillin,
Ampicillin, Cefotaxime, Ceftriaxone & Ceftazidime)
• Its not recommended for Vancomycin, Carbapenems as
Meropenem & Aminoglycosides like Gentamicin & Amikacin to
avoid false results

15. Antibiotic allergy skin test
• 1st step: dilution
Dissolve vial with distilled water 10ml (cephalosporins) & 5ml
(penicillins)
Withdraw 10 unit utilizing insulin syringe, further dilution with 90
units distilled water (complete volume to 1ml again)
• 2nd step: injection & monitoring
Inject 10 units in the forearm intradermal, encircle with pen, wait
for 15-30 min & monitor injection area for any signs of allergic
reaction

16. Antibiotic stewardship,
algorithm of treatment & prophylaxis

17. References
• Antibiotics resistant threats in the united states. Department of Health & Human services, Centres for Disease
control & prevention, 2013
• Giuliano C., Patel C.R. &, Kale-Pradhan P.B. A Guide to Bacterial Culture Identification And Results Interpretation.
Pharmacy & Therapeutics P T. 2019 Apr; 44(4): 192–200
• Tyler Street, Eric B Staros et al. Antimicrobial susceptibility. Medscape website, last update Mar 13, 2014
• Joshi S. Hospital antibiogram: A necessity. Indian Journal of Medical Microbiology 2010;28:277-80
• Ma. Charmian M. Hufano, It More Fun Doing the Antibiogram: Proper Analysis and Optimization of Antibiotic
Use using the Antibiogram. pptx presentation
• Nonirritating intradermal skin test concentrations for commonly prescribed antibiotics. Journal of Allergy and
Clinical Immunology, vol. 112 no.3
• The Current Practice of Skin Testing for Antibiotics in Korean Hospitals. The Korean Journal of Internal Medicine
Vol. 25, No. 2
• Local instruction of antibiotic skin allergy test by directorate of technical affairs, department of pharmacy,
clinical pharmacy section.
• Dilip Nathwani, Jacqueline Sneddon. Practical Guide to antimicrobial stewardship in hospitals. UK
• Public Health England. Start Smart Then Focus Appendix 1 Resource Materials: Examples of audit tools, review
stickers and drug charts. Examples provided by English Hospitals

18. THANK YOU