{"id":97,"date":"2019-09-28T22:03:00","date_gmt":"2019-09-28T16:33:00","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=97"},"modified":"2019-09-28T22:03:00","modified_gmt":"2019-09-28T16:33:00","slug":"appropriate-antibiotic-prescribing","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/appropriate-antibiotic-prescribing\/","title":{"rendered":"Appropriate Antibiotic Prescribing"},"content":{"rendered":"\n<p>With increasing bacterial resistance, companies are pulling out of antibiotic research and fewer new antibiotics are approved<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"471\" height=\"246\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image.png?w=471\" alt=\"\" class=\"wp-image-99\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image.png 471w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-300x157.png 300w\" sizes=\"(max-width: 471px) 100vw, 471px\" \/><\/figure>\n\n\n\n<p>Antibiotic overprescribing in both hospital\nand community settings has significant consequences \u2013 often prescribed\nunnecessarily for viral upper respiratory tract infections<\/p>\n\n\n\n<p>Most overprescribing for respiratory\ninfections is in Primary Care \u2013 in particular for patients presenting with an\nacute cough<\/p>\n\n\n\n<ul><li>Resistance \u2013 resistant organisms\/superbugs<\/li><li>Changes in normal microbial flora \u2013 mild \u2013 thrush, severe and sometimes life-threatening \u2013 <em>Clostridium difficile<\/em><\/li><li>Side effects of medication<\/li><li>In current times of austerity cost also plays a part<\/li><\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">The consequences of indiscriminate antibiotic prescription <\/h2>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"\"><tbody><tr><td> Patient-level<\/td><td> Community-level <\/td><\/tr><tr><td> \u2022 Adverse events <\/td><td> \u2022 Increased antibiotic resistance<\/td><\/tr><tr><td> \u2022 Unnecessary cost <\/td><td> \u2014 Infections becoming more difficult <\/td><\/tr><tr><td> \u2022 Drug-drug interactions <\/td><td> \u2014 Epidemics harder to control <\/td><\/tr><tr><td> \u2022 Increased risk of infection with an antibiotic-resistant strain <\/td><td> \u2022 Increased healthcare cost <\/td><\/tr><tr><td> \u2022 Fewer effective therapeutic  options  <\/td><td><\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<pre class=\"wp-block-preformatted\">Principles of appropriate antibiotic prescribing \n\nTREAT:  Bacterial infection only \nOPTIMISE:  Diagnosis\/severity assessment \nMAXIMISE:  Bacterial eradication only (or reduction) \nRECOGNISE:  (Local) resistance prevalence \nUTILISE:  PK\/PD \u2014 effective choice agent and dose \nINTEGRATE: Local resistance, effcacy, cost &amp; effectiveness \n\nAppropriate prescribing conforms to these criteria <\/pre>\n\n\n\n<p><strong>Treat Bacterial Infections only<\/strong><\/p>\n\n\n\n<p><strong>Acute respiratory tract infections &#8211; When\nare antibiotics indicated?<\/strong><\/p>\n\n\n\n<p><strong><em>Inappropriate prescribing of\nantibiotics for acute RTIs contributes to the increasing prevalence of\nantibiotic resistance.<\/em><\/strong><\/p>\n\n\n\n<ul><li>More than half of all\nantibiotics prescribed for acute RTIs are unnecessary because these infections\nare most likely viral and therefore not treatable with antibiotics<\/li><li>Clinicians in ambulatory-care\nsettings prescribe antibiotics for patients with a viral acute RTI <strong>in 40% to 50% of cases<\/strong><\/li><li>Studies have demonstrated that\nclinician and patient education is a vital component of reducing inappropriate\nantibiotic use <\/li><\/ul>\n\n\n\n<p><strong>Clinical Practice Guideline (Update):\nAdult Sinusitis<\/strong><\/p>\n\n\n\n<ul><li>Emphasis on <strong>patient education and counseling<\/strong> with\nnew explanatory tables<\/li><li>Extension of <strong>watchful waiting (without antibiotic\ntherapy)<\/strong> as an initial management strategy to all patients with\nuncomplicated acute bacterial rhinosinusitis (ABRS) regardless of severity, not\njust patients with \u201cmild illness\u201d (prior guideline)<\/li><\/ul>\n\n\n\n<p><strong>Colonization vs. infection: common clinical scenario<\/strong><\/p>\n\n\n\n<ul><li>Sputum\/respiratory specimen showing organisms in a patient with suspected pneumonia. <ul><li>Assessing sputum quality uses a grading system based on neutrophils, epithelial cells, and mucus<\/li><\/ul><ul><li>This helps to interpret results of sputum culture (distinguish commensals from saliva vs. pathogens from sputum)<\/li><\/ul><\/li><\/ul>\n\n\n\n<p><strong>Bartlett\u2019s grading system for evaluating the quality of sputum samples.<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"\"><tbody><tr><td> No. of neutrophils\/low-power field <\/td><td> Grade<\/td><\/tr><tr><td>&lt;10<\/td><td>0<\/td><\/tr><tr><td>10-25<\/td><td>+1<\/td><\/tr><tr><td>&gt;25<\/td><td>+2<\/td><\/tr><tr><td>Presence of mucus threads<\/td><td> +1<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"\"><tbody><tr><td><strong> No. of epithelial cells\/low-power field <\/strong><\/td><td>Number<\/td><\/tr><tr><td>&lt;10<\/td><td>0<\/td><\/tr><tr><td>10-25<\/td><td>-1<\/td><\/tr><tr><td>&gt;25<\/td><td>-2<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p>Average the number of epithelial cells and neutrophils in about 20 or 30 separate low-power fields and then calculate the total. A final score of\u00a0 0\u00a0or less indicates a lack of active inflammation or contamination with saliva. <\/p>\n\n\n\n<p>Some common clinical scenarios which\nrequire this differentiation are : patients with burns, chronic wounds like\nosteomyelitis with\/without a draining sinus and diabetic foot ulcers, cultures\nfrom postoperative drains, positive urine cultures in an asymptomatic patient\nand in a catheterised patient sputum\/respiratory specimen showing organisms in\na patient with suspected pneumonia, blood cultures in a patient with indwelling\ncentral venous catheter, arterial line, hemodialysis catheter.<\/p>\n\n\n\n<p>The points which help distinguish colonization versus invasion are related to the findings at the site, the characteristics of the patient, the organism and on follow up.<\/p>\n\n\n\n<p><strong>OPTIMISE &#8211; ACCURATE DIAGNOSIS AND SEVERITY\nASSESSMENT<\/strong><\/p>\n\n\n\n<p><strong><em>Accurate clinical diagnosis is key to\nlimit antibiotic prescribing<\/em><\/strong><\/p>\n\n\n\n<ul><li>Guidelines should offer practical criteria to identify those bacterial infections requiring antibiotic therapy<\/li><li>Most guidelines recommend antibiotics to be reserved for moderate to severe infections<\/li><li>A study from the United States (led by a family physician) shows that antibiotics are prescribed for 65% of episodes of URTI, 78% of acute bronchitis, 65% of acute pharyngitis, and 81% of acute sinusitis<\/li><\/ul>\n\n\n\n<pre class=\"wp-block-preformatted\">\u2022 Determining the Likelihood of a Bacterial Infection \nMore than 90% of otherwise healthy patients presenting to their outpatient providers with an acute cough have a syndrome caused by a virus \n\n\u2022 Appropriate Management Strategies \nA randomized, placebo.controlled trial (not included in the Cochrane review) comparing ibuprofen, amoxicillin-clavulanlc acid. and placebo showed no significant differences in the number of days to cough resolution Although macrolides azithromyCin are frequently prescribed for patients With a cough. one study showed that patients with acute bronchitis treated with a macrolide had significantly more adverse events than those receiving placebo.\n\nClinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected <\/pre>\n\n\n\n<p>The <strong>Centor criteria<\/strong> are a set of criteria which may be used to identify the likelihood of a bacterial infection in adult patients complaining of a sore throat.<\/p>\n\n\n\n<p>The <strong>Centor criteria<\/strong> are a set of criteria which may be used to identify the likelihood of a bacterial infection in adult patients complaining of a sore throat.<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"\"><tbody><tr><td> Criteria  <\/td><td> Points  <\/td><\/tr><tr><td> Absence of Cough<\/td><td>1<\/td><\/tr><tr><td> Swollen and Tender Anterior Cervical Nodes <\/td><td>1<\/td><\/tr><tr><td> Temp of &gt; 100.4\u2022 F (38\u2022C) <\/td><td>1<\/td><\/tr><tr><td> Tonsillar Exudates or Swelling <\/td><td>1<\/td><\/tr><tr><td> Age  <\/td><td><\/td><\/tr><tr><td> 3-14 years <\/td><td>1<\/td><\/tr><tr><td> 15-44 years <\/td><td>0<\/td><\/tr><tr><td> 45+<\/td><td>-1<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<p>Antibiotics should not be used in patients with a less severe presentation of sore throat, e.g. 0\u20132 Centor criteria to relieve symptoms<\/p>\n\n\n\n<p><strong>MAXIMISE<br>\n&nbsp;<br>\n<em>Therapy should reduce maximally or eradicate the bacterial load<\/em><\/strong><\/p>\n\n\n\n<p>Inappropriate therapy fails to eradicate the causative pathogens but may provide an environment that selects for resistant bacterial strains. Resistant bacteria may then spread, increasing the prevalence of resistance, the risk of resistance-related treatment failure and treatment costs. Without appropriate antibacterial therapy, this cycle of continued infection, resistance emergence, and treatment failure cannot be broken.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"471\" height=\"263\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-2.png?w=471\" alt=\"\" class=\"wp-image-102\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-2.png 471w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-2-300x168.png 300w\" sizes=\"(max-width: 471px) 100vw, 471px\" \/><\/figure>\n\n\n\n<p>Appropriate\nantibacterial therapy results in bacterial eradication, thus maximizing\nclinical cure and minimizing the potential for the development and spread of\nresistance.<\/p>\n\n\n\n<p><strong>RECOGNISE- ANTIBIOTIC CHOICES MUST\nREFLECT LOCAL RESISTANCE PREVALENCE<br>\n<br>\n<em>Take account of local susceptibility data and their resistance patterns when\nselecting an antibiotic<\/em><br>\nFor both hospitals and community<\/strong><\/p>\n\n\n\n<ul><li>Systematic monitoring and\nsurveillance of antibiotic susceptibility of bacterial pathogens<\/li><li>This information would enable authorities to design and implement\nearly interventions that halt the spread of such strains<\/li><\/ul>\n\n\n\n<p><strong>UTILISE- PK\/PD \u2013 EFFECTIVE CHOICE OF AGENT AND DOSE<br> <br> <em>Apply pharmacodynamic parameters in choice of effective agents and dosage<\/em><\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"555\" height=\"376\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-3.png?w=555\" alt=\"\" class=\"wp-image-103\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-3.png 555w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-3-300x203.png 300w\" sizes=\"(max-width: 555px) 100vw, 555px\" \/><\/figure>\n\n\n\n<p><strong>DURATION OF THERAPY <br>\n<\/strong>Defining the optimal duration of antibiotic\ntreatment is often a dilemma<\/p>\n\n\n\n<ul><li>Longer than a necessary duration of antibiotics can result in:<ul><li>greater risk of toxicity, a higher rate of adverse events<\/li><\/ul><ul><li>increased risk of resistance <\/li><\/ul><ul><li>increased days of hospitalization, morbidity or mortality<\/li><\/ul><ul><li>reduction in patient compliance \u2013 compliance is better with a shorter course<\/li><\/ul><\/li><\/ul>\n\n\n\n<p>Meta-analyses of Acute Otitis Media (AOM), Acute Bacterial sinusitis (ABS), acute exacerbation of chronic bronchitis (AECB), Community-acquired pneumonia (CAP)<\/p>\n\n\n\n<ul><li>AOM: 5 vs. 8\u201310 day therapy: No\nsignificant difference in clinical outcomes<\/li><li>ABS: 3\u20137 vs. 6\u201310d NS (AE less\nin former) <\/li><li>COPD: 5 vs. 7\u201310d NS (AE less\nin former)<\/li><li>CAP: Adults: 3-7 vs. 7-10d: NS<\/li><li>The above meta-analyses\nindicate that a <strong>short-duration<\/strong> treatment seems to be <strong>as effective as\na longer course <\/strong>of antibiotic treatment in such infections as acute otitis\nmedia, acute bacterial sinusitis, CAP and infectious exacerbations of chronic\nbronchitis<\/li><\/ul>\n\n\n\n<p><strong>GUIDELINES &#8211; <em>Implementation in\nclinical practice<\/em><\/strong><\/p>\n\n\n\n<p><strong>Reasons why antibiotic prescribing guidelines are not followed<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"523\" height=\"76\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-4.png?w=523\" alt=\"\" class=\"wp-image-104\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-4.png 523w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-4-300x44.png 300w\" sizes=\"(max-width: 523px) 100vw, 523px\" \/><figcaption><br><\/figcaption><\/figure>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"573\" height=\"370\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-5.png?w=573\" alt=\"\" class=\"wp-image-105\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-5.png 573w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-5-300x194.png 300w\" sizes=\"(max-width: 573px) 100vw, 573px\" \/><\/figure>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"470\" height=\"279\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-6.png?w=470\" alt=\"\" class=\"wp-image-106\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-6.png 470w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2019\/09\/image-6-300x178.png 300w\" sizes=\"(max-width: 470px) 100vw, 470px\" \/><\/figure>\n\n\n\n<p><strong>Embrace antibiotic stewardship<\/strong><\/p>\n\n\n\n<ul><li>Improve antibiotic use in private practice as well as in hospitals\u2014regardless of size\u2014through stewardship interventions and programs, which will:<ul><li>improve individual patient outcomesreduce the overall burden of antibiotic resistancesave healthcare cost<\/li><\/ul><\/li><li>Refer to standard treatment guidelines<\/li><li>Practice rational use of antibiotics<\/li><\/ul>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>With increasing bacterial resistance, companies are pulling out of antibiotic research and fewer new antibiotics are approved Antibiotic overprescribing in both hospital and community settings has significant consequences \u2013 often prescribed unnecessarily for viral upper respiratory tract infections Most overprescribing for respiratory infections is in Primary Care \u2013 in particular for patients presenting with an[&#8230;]\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/97"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=97"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/97\/revisions"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=97"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=97"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=97"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}