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Contents
• “How to prescribe an antibiotic” session
• Why is it important?
• Background
• What must be included in an antibiotic prescription
• Audit
• Practical examples
• Gentamicin Prescribing
• Summary
Why is it important?• Department of Health Guidelines-(Advisory Committee on
antimicrobial resistance and healthcare associated Infection)-Nov 2011
• Antimicrobial stewardship- “start smart-then focus”-
• Want :
• Right Drug
• Right Dose
• Right Time
• Right Duration
• For Every Patient
Start Smart Is :
• Don’t start antibiotics in the absence of clinical evidence of bacterial infection
• If there is evidence or suspicion of bacterial infection-use local antibiotic guidelines to start treatment
• Document on drug chart Indication, duration/review date, route & dose
• Obtain cultures first
• Prescribe single dose antibiotics for surgical prophylaxis-where proven efficacy
Then Focus is:• Review clinical diagnosis and the coninuing need for antibiotics by
48 hours and make a clear plan of action- “the antimicrobial prescribing decision”
• 5 options
• 1. STOP
• 2. Switch i/v to oral
• 3. Change –ideally to narrower spectrum or broad if needed
• 4. Continue (review again at 72 hours)
• 5. Outpatient Parenteral antibiotics therapy (OPAT)
• Make sure review and decision is clearly documented in medical notes.
HPA & Dept of Health Guidelines 2009- C.difficile infection :How to deal with the problem
• Reduce use of Broad Spectrum Antibiotics especially:
• Cephalosporins
• Fluoroquinolones
• Clindamycin
• Aminopenicillins
• Carbapenems
Examples of Antibiotics less likely to cause C.diff infection
• Gentamicin
• Penicillin
• Anti-pseudomonal penicillins with or without a beta-lactamase inhibitor.
• vancomycin
Good Prescribing Practice
• Promotes Good Prescribing Practice- no missed doses, ensures continuity in care
• Adherence to Trust Antibiotic Policy
• Helps to Reduce Incidence of Clostridium difficile Infection
• Audit
Quarterly Audit-(overall Trust Data)
General Antibiotic Data
Feb-11 May-11 Oct-11 Feb-12
% Patients on antibiotics
33% 29% 31% 34%
% IV Antibiotics
47% 54% 54% 58%
% Oral Antibiotics
53% 46% 46% 42%
Specific Antibiotic MonitoringFeb-11 May-11 Oct-11 Feb-12
%i/v >48hrs 44% 44% 65% 43%%>5days but ≤ 7 days
3% 22% 10% 8%
% > 7 day course 14% 11% 16% 14%% > 7 day course appropriate
98% 95% 97% 100%
% Patients with allergy status documented
85% 81% 86% 92%
% Indication stated
31% 60% 91% 55%
% antibiotics prescribed appropriately when indication stated
97% 98% 96% 97%
% course length or review stated
28% 51% 57% 43%
Other Guidance
• All consultants need to be responsible for reviewing antibiotic prescriptions on all their ward rounds (as should their juniors)
• Antibiotics started inappropriately or without sufficient evidence should be stopped
• Follow Antibiotic Policy
Example 2
• Uncomplicated Cystitis
• Please write a prescription for a patient with uncomplicated cystitis
Gentamicin Prescribing
• 5 steps for safe gentamicin prescribing
• Usually gentamicin is only required for 24-48hrs.
• Course lengths for gentamicin should not exceed 5 days unless Microbiology have approved its use for extended durations (this may be indicated in some infections eg Endocarditis).
1. Weigh Patient:
• Weigh patient. If weighing is not possible, estimate weight using ideal body weight formulae (based on height and gender).
• For obese patients >120% ideal body weight use formula for dosing weight.-see below.
Equations for Ideal Body weight and Obese dosing
• Imperial• Ideal Body weight (Male) = 50 + (2.3 x inches over 5 feet)• Ideal Body weight (Female) = 45.5 + (2.3 x inches over 5 feet)• Or• Metric• Ideal Body weight (Male) = 50kg + 0.9kg for each cm above 150cm in
height• Ideal Body weight (Female) = 45.5Kg + 0.9kg for each cm above 150cm
in height• For Obese Patients (> 120% of ideal body weight) use obese dosing
weight calculation5 : • Obese Dosing Weight (in Kg) = ideal body weight + 0.4 (actual Body
weight – ideal body weight)
2. Calculate gentamicin Dose :
• Calculate the gentamicin dose using 5mg/Kg (maximum 400mg od)
• a)If normal body weight - use actual body weight value
• b)If Obese (> 120% of ideal body weight)- use obese dosing weight
• c) if weight unobtainable – calculate ideal body weight
3. Calculate creatinine clearance (CrCl) :• Calculate the creatinine clearance using Cockcroft and Gault equation
• Creatinine = (140-age in years) x weight in Kg(from step 1) x F
• clearance Serum Creatinine (in micromole/Litre)
• F=1.04 (female) or F=1.23 (male)
4. Check dosing Interval and when levels need to be done :
Creatinine Clearance
Dose Interval Pre-dose level check
> 60ml/min 24 hourly Before 2nd/3rd dose
41-60ml/min 36 hourly Before 2nd/3rd dose
21-40ml/min 48 hourly Before 2nd dose
< 21ml/min > 48 hourly Check level after 48 hours
Work out the dosing interval and when levels should be checked
5. Check gentamicin serum level
• If pre-dose gentamicin level is 1mg/L or less continue the original dosing regime
• If pre-dose gentamicin level is greater than 1mg/L, consult Microbiology or Pharmacy for advice.
Summary
• Background & Why appropriate prescribing is important
• “How to prescribe an Antibiotic” Session
• Audit
• Practical Examples
• Gentamicin prescribing