Homework

Literature Reading

Microbiology, Infections and Antibiotic Therapy

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Duration of antibiotic therapy
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Duration of antibiotic therapy depends on several factors, such as clinical diagnosis and
severity of the disease, the drug was used, and the sensitivity of the microorganism to the
drug. Underuse of antibiotics leads to clinical failure and overuse of antibiotics leads to rising
rates of antimicrobial drug resistance.
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Among bacteremic patients receiving shorter (5-7 days) versus longer (7-21 days) antibiotic
therapy, no significant difference was detected with respect to rates of clinical cure.
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To figure out how long antibiotics need to be given, use the following rules:
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1. Choose a multiple of 5 (fingers of the hand) or 7 (days of the week).
2. Is it an outpatient problem that is relatively mild? If so, choose something less than 10
days. After application of our multiples rule, this should be 5 or 7 days.
3. Is it really mild, so much so that antibiotics probably arent needed at all but clinician or
patient are insistent? Break the 5/7 rule and go with 3 days.
4. Is it a serious problem that occurs in the hospital or could end up leading to
hospitalization? With the exception of community-acquired pneumonia (5 or 7 days), 10
days is the minimum.
5. Patient not doing better at the end of some course of therapy? Extend treatment, again
using a multiple of 5 or 7 days.
6. Does the infection involve a bone or a heart valve? Four weeks (28 days) at least, often 6
weeks (42 days). Note that 5 weeks (35 days) is not an option here the 5s and 7s
cancel each other out, and chaos ensues.
7. The following lengths of therapy are inherently weird, and should generally be avoided:
2, 4, 6, 8, 9, 11, 12, 13 days.

Principles of surgical antibiotic prophylaxis
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Decide if prophylaxis is appropriate
Determine the bacterial flora most likely to cause postoperative infection (not every
species needs to be covered)
Choose an antibiotic, based on the steps above, with the narrowest antibacterial spectrum
required
Choose the less expensive drug if two drugs are otherwise of equal antibacterial spectrum,
efficacy, toxicity, and ease of administration
Administer dose at the right time
Administer antibiotics for a short period (one dose if surgery of four hours duration or
less)
Avoid antibiotics likely to be of use in the treatment of serious sepsis
Do not use antibiotic prophylaxis to overcome poor surgical technique
Review antibiotic prophylaxis protocols regularly as both cost and hospital antibiotic
resistance patterns may change
Duration of surgical antibiotic prophylaxis administration
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Persistence of tissue concentrations past the period of surgery and recovery of normal
physiology following anaesthesia does not improve efficacy and increases toxicity and cost.
If the operation lasts four hours or less, one antibiotic dose is usually sufficient. In prolonged
surgery of greater than four hours, further antibiotic doses may be required to maintain the
concentration, particularly if the antibiotic has a short half-life. Continuing antibiotic
prophylaxis until surgical drains have been removed is illogical and also of unproven
benefit.
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Amoxicillin-clavulanate Dosing
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Amoxicillin-clavulanate is an extremely effective drug for the treatment of respiratory tract
infections generally and otitis media specifically due to its spectrum of activity which
includes Streptococcus pneumoniae and -lactamase-producing Haemophilus influenzae and
Moraxella catarrhalis. High dose amoxicillin/clavulanate (90/6.4 mg/kg/day three times
daily) was highly efficacious in children with respiratory tract infections, especially Acute
Otitis Media.
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REFERENCES

1. John Paul et al., What is the optimal duration of antibiotic therapy?. BMJ
2006;332:1358.
2. Havey TC, Fowler RA, Daneman N., Duration of antibiotic therapy for bacteremia: a
systematic review and meta-analysis. Crit Care. 2011;15(6):R267.
3. Paul Sax. How to Figure Out the Length of Antibiotic Therapy. Journal Watch. Accessed
August 10
th
, 2012, from : http://jwatch.org/hiv-id-observations/index.php/how-to-figure-
out-the-length-of-antibiotic-therapy/2010/10/22.
4. Wendy Munckhof et al., Antibiotics for surgical prophylaxis. Aust Prescr 2005;28:38-40.
5. National Institute of Health. Guide to Amoxicillin Clavulanate Potassium. November
2006.