Dr.

Soulat Hafeez
House Officer
Medical Unit 4
Definition Of Antibiotic
A chemical substance produced by micro
organisms, which has the capacity to inhibit the
growth of or to kill other micro organisms
Antibiotic Therapy
Ideally is determined by isolation and antibiotic susceptibility
of the offending.
Usually not available in ER.
Abx treatment initiated on clinical diagnosis and likely
organism involved.
Early empirical treatment may be lifesaving.
THERAPY BASED ON
1. Site of infection
2. Safety of the agent
3. State of the patient (age, renal, hepatic funtions etc)
4. Cost of the therapy
Appropriate Use of Abx
Employ empirically when there is a reasonable
clinical suspicion of infection
Choose antibiotics active against the most likely
organism(s)
Choose antibiotics known to penetrate involved
tissue
Use correct doses of antibiotics – don’t underdose
Appropriate Use of Abx…cont’d
Know when bacterostatic antibiotics are adequate or
bacterocidal drugs are required
In serious, potentially life-threatening infections,
start broad, then de-escalate after cultures back
Stop antibiotics when infection resolved or when
evidence accumulates against existence of infection
Inappropriate Use of Abx
Wong antibiotic
Wrong dose of right drug
Using a 2nd or 3rd line drug when a first line drug could still be
used
Using antibiotics in situations when antibiotics are not
indicated
Continuing antibiotics when infection is resolved or not likely
Keeping coverage broad when cultures reveal a single organism
Reacting to culture results by starting antibiotics without
considering the significance of the culture
Common Mistakes in Diagnosing Infection
Base diagnosis on a single positive data point when
other data points are negative
 React to a positive culture when there is no clinical
evidence of infection
Use serial cultures to determine when infection has
resolved
Obtain cultures randomly when clinical suspicion of
infection is low
First Step: Determine Whether
Culture Represents Real Pathogen
Colonizer: Any organism actually present in or on
patient, but does not invade tissue or cause clinical
disease

Contaminant: Any organism growing in culture that

is not actually present in or on the patient, but came
from the environment into the culture medium
 Three Examples
1. A +ve sputum culture taken from a patient without fever,
leukocytosis, new infiltrate or pulmonary symptoms
should be taken as a colonizer
2. A +ve urine culture taken from a patient without dysuria,
frequency, and with a small to moderate amount of WBC
in the U/A has asymptomatic bacteriuria
3. A +ve wound culture taken from a clean appearing,
granulating wound that is not painful, has no purulence in
a patient with no fever and a normal WBC, represents a
colonizer (rather than a true pathogen) and should not be
treated
 Sputum Culture
Pathogen if:
Sputum is grossly
purulent
Patient is febrile
Infiltrates on CXR
> 5-10 WBC per hpf
< 5-10 epithelial cells per
hpf
Colonizer if:
Sputum is scant, clear or
white
Patient is afebrile
No infiltrates on CXR
< 5-10 WBC per hpf
> 5-10 epithelial cells per
hpf
 Urine Culture
Pathogen if: Contaminant if:
> 100,000 cfu 10,000 cfu or less
If urinalysis reveals: If urinalysis reveals:
> 10 WBC < 10 WBC
Pos. Leuk. Esterase Neg. Leuk. Esterase
Pos. nitrite Neg. nitrite
Few or no epi’s Many epi’s
If patient symptomatic If patient asymptomatic
Drugs Absolutely C/I in Pregnancy
----- “Category X Drugs”
Mnemonic “SAFE Mom Takes Really Good Care”

SULFONAMYIDES, AMINOGLYCOSIDES,
FLUOROQUINOLONES, ERYTHROMYCIN.
METRONIDAZOLE
TETRACYCLINE
RIBAVIRIN
GRISEOFULVIN
CHLORAMPHENICOL
ABX TO AVOID IN CHILDREN
UNDER 18
Abx TO AVOID IN LACTATING
MOTHERS
ABX TO AVOID IN RENAL FAILURE
Note, here add drugs that are contraindicated and
drugs that can be administered but with reduced
dose.
ABX TO AVOID IN HEPATIC
FAILURE.
SAME AS FOR RENAL FAILURE.
Meningitis
Principles of Management
1. Initiate Empirical Antibiotic Therapy
2. All patients with head trauma, immunocmpromised
states, known malignancies, or focal nerological
findings (including stupor/coma) should undergo
neuroimaging study prior to Lumbar Puncture
3. Obtain CSF D/R sample, if not C/I
4. If Bacterial Meningitis is suspected, initiate
empirical antibiotic therapy even prior to Imaging
and LP
Clinical Features
Fever, Headache, Neck stiffness, and Change in
Mental Status
75% of patients have atleast 2 out of these 4 features
 Antibiotics for Empirical Treatment of
Bacterial Meningitis
Infants < 3 months Ampicillin + Cefotaxime

Adults < 55 years Ceftriaxone + Vancomycin

Adults with Alcoholism or Ceftriaxone + Vancomycin+

debilitating illness Ampicillin

Hospital acquired, post neuro- Ceftazidime + Vancomycin+

surgery, neutropenic patients Ampicillin
Pneumonia
Principles of Management
Classify the pneumonia :
1. Community Acquired, or
2. Health-Care Associated
 Hospital Acquired
 Ventilator Associated
Determine severity:
 CURB 65
 Pneumonia Severity Index
Definition of Health-Care
Associated Pneumonia
Health-Care Associated Pneumonia has any one of
the following features:
Hospitalization for > 48 hours
Hospitalization for > 2 days in prior 3 months
Antibiotic therapy in prior 3 months
Chronic dialysis
Home wound care
Contact with a family member who has MDR infection
Severity of Pneumonia
CURB 65
Confusion
Urea > 7 mmol
R/R > 30
BP : Systolic < 90 ; Diastolic < 60 mmHg
Age > 65 years
Score: 0- 1 --------- Out- patient treatment
2 --------- In patient: Non ICU
>2 --------- ICU care
 Empirical Antibiotic Treatment of
Community Acquired Pneumonia
Outpatients 1. Macrolide ( Clarithro or Azithro)
2. Doxycycline
3. Respiratory FQ ( Moxi or Gemi or Levo)
4. B-Lactam plus Macrolide
In Patients: Non ICU 1. Respiratory FQ ( Moxi or Gemi or Levo)
2. B-Lactam plus Macrolide

In Patients : ICU 1. B-Lactam plus Macrolide

2. B-Lactam plus FQ

If Pseudomonas is 1. B-Lactam plus FQ

suspected 2. B-Lactam plus Aminoglycoside
3. B-Lactam plus FQ plus Aminoglycoside

If MRSA is suspected Add Linezolid or Vancomycin

 Empirical Antibiotic Treatment of
Health Care Associated Pneumonia

No risk for MDR Pathogens 1. B – Lactam ( Ceftriaxone 2 gm IV OD) alone

2. FQ alone
3. Ertapenem alone

Risk Factors for MDR 1. B – Lactam ( 3rd / 4th Gen Cephalosporin or

pathogens Tazocin) plus FQ / Aminoglycoside plus
Linezolid/ Vancomycin
Urinary Tract Infections
Principles of Management
Always obtain Urine C/S ( except in uncomplicated
cystitis in women)
Identify and Correct (if possible) predisposing factors
Relief of symptoms does not indicate bacteriologic
cure
Each course of treatment should be classified as a
Cure or Failure
Treatment Regimens for Bacterial UTI