APPROACH TO ANTIMICROBIAL TREATMENT

have to consider the safety of your

OUTLINE drugs and the appropriateness of the
drug for the patient who have the
I. Approach to Antimicrobial Treatment infection
a. Key Concepts ● Guiding principle: (1) right diagnoses, (2)
b. Normal Flora in the body
Avoid Harm
II. Approach in identifying the infectious
agent
III. Antibiotic Considerations Consider this two when choosing the right
a. Treatment Approach antibiotic:
b. Effects on non-targeted floras ○ Right diagnosis for right treatment (most
c. Single or combination therapy effective drug for the situation)
d. Antimicrobial dose ○ Avoid harm, prevent the adverse effect of
e. Pharmacokinetic properties
the antibiotics (choosing the drug that is
f. Pharmacodynamics
g. Cost safe)
IV. Patient Considerations
a. modifying empirical therapy ● Pathogenic bacteria should be the target
based on culture and clinical of antibiotic treatment, colonizing flora
response should be left intact
b. Treatment failure ○ You have to know which of the
c. Antibiotic stewardship bacteria is causing the infection
d. Patient Care Process ○ The most essential normal flora are
found in the stomach
APPROACH TO ANTIBIOTIC TREATMENT ■ Ex. GI infection in the small
intestine, the antibiotic
KEY CONCEPTS should target that bacteria
● Antimicrobial resistance that is causing the infection
○ As much as possible we should be or the problem
using the right antibiotic to the right ○ As much as possible we spare the
infection, if you fail to give the normal flora
correct antibiotic for the correct ○ Consider the spectrum of activity of
infection, you could have the antibiotic, it should be the
antimicrobial resistance appropriate antibiotic for that specific
○ As a Pharmacist this is the primary infection
goal which is to prevent the
emergence of antimicrobial ● Bacterial culture should be obtained
resistance before therapy in patients with (1)
systemic inflammatory response, (2) risk
● Antibiotics exert action on the bacteria, factors of antibiotic resistance infection
not the host where diagnoses and antimicrobial
○ Whenever you select the antibiotic it susceptibility is uncertain.
is geared toward the bacteria, but ○ (1)Those who with a severe infection
does not disregard the patient that resulted to a severe
receiving the antibiotic because you inflammatory response

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 ■ Ex. Meningitis due to the
severity of CNS infection
already have inflamed
meninges
○ (2) Risk factors - Obtain bacterial
culture for Patients who have been
using antibiotic recently or previously
but is still not cured
○ (3) Do a bacterial culture if you do
not know the causative agent that is
causing the infection and do not
know the susceptibility of that
bacteria
● Empirical therapy should be based on
patient- & antimicrobial-specific factors
(e.g. anatomic location of the infection,
likely pathogen associated with
presentation, the spectrum of activity &
potential adverse effects)
○ Empirical therapy- you are guided
by the clinical practice guidelines,
you know the specific bacteria that is
causing the infection
○ Things to consider when performing
empirical therapy:
■ Give antibiotic based on
experience or based on the
most common causative
agent for that specific
infection
■ Ex. Most common causative
agents of Pneumonia are
(streptococcus pneumoniae,
Moraxella catarrhalis, and
Haemophilus influenzae)
○ If you already know the specific bacteria
that is causing the infection you could start
with narrow spectrum antibiotic instead of
the broad spectrum
○ Consider the potential adverse effect/side
effects of the antibiotics
● Drug-specific considerations in drug
selection: effects on non-targeted flora,
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the spectrum of activity, appropriate
dose, pharmacokinetic and
pharmacodynamic properties, ADR,
Cost, and drug interaction profile
○ Choose a drug that is based on its
Effects on non- targeted flora- when
selecting a drug as much as
possible you know the causative
agent, you spare the normal flora, so
most likely there is less emergence
of antibiotic resistance if you are
using a narrow-spectrum.
○ Consider lessening the exposure of
the normal flora that don't need
killing
○ Consider the cost, because the
patient’s compliance to the
medication would be affected by the
cost of the drug
○ Drug interaction profile- consider
the current medication of the patient
because there could be drug
interaction that can affect the safety
and drug efficacy
● Key patient-specific considerations in
drug selection include previous
antimicrobial exposure, identification of
the anatomic location of the infection,
history of allergies, organ function
affecting drug clearance,
immunosuppression, compliance, and
pregnancy
○ Previous antimicrobial exposure-
patient factors
■ Ex. For UTI, the patient used
ciprofloxacin last week. The
problem currently is still UTI
and the patient has not
improved even after 2 weeks
of treatment. That would
suggest to choose another
class of antibiotic
○ Is it an infection in the lungs, urinary
tract, GI, or skin?
○ Use SAMPLE
 ○ Patient may have kidney or liver
problem: (1) Toxicity from antibiotic
or (2) Treatment Failure because of
elimination
○ Immunosuppression
■ Ex. the patient has HIV, is
immunocompromised, or has
been taking steroids (which
lessen the immune
response)
○ Compliance
■ Cost, cultural background,
elderly? forgetful? Do you
need to educate regards to
medication?
○ Pregnancy
● Patient education, de-escalation of
antimicrobial therapy based on culture
results, monitoring of clinical response,
adverse effects, and appropriate
duration of therapy are important
components
○ Patient education- Give patient
education to improve compliance,
and for the patient to be
knowledgeable of what to do when
there are possible side effects.
○ De-escalation of antimicrobial
therapy based on culture results
○ Monitoring of clinical response-
check if there is an improvement in
clinical response
○ Adverse effects and appropriate
duration of therapy
● Common cause of antimicrobial failure
include poor diagnosis, poor initial
antimicrobial selection, new infection
with a resistant organism, poor source
control
○ Poor diagnosis
○ Poor initial antimicrobial selection
○ New infection with a resistant
organism
○ Poor source control
IS IT OF INFECTIOUS ORIGIN?
● Step 1: Is there a need for a drug?
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● Signs and symptoms (e.g., fever, swelling,
presence of pus/nana)
○ Fever: common presentation of
infection
○ Swelling: Cellulitis (wound infections
or acne)
○ Odor: smells bad (sign of infection)
ANTIBIOTIC COVERAGE
● Step 2: selecting the drug
● Broad-spectrum - severe
● Narrow-spectrum - mild
POINTS TO CONSIDER WHEN CHOOSING
BETWEEN NARROW AND BROAD
SPECTRUM ANTIBIOTIC
● Kill the causative agent
● Emergence of antimicrobial resistant non
targeted pathogens
SELECTION OF ANTIBIOTIC
● Right diagnosis = right antibiotic=
EFFECTIVE
● Avoid harm = minimize the risk of adverse
drug effects = SAFE
● Ex.
○ Aminoglycosides - avoid having
kidney failure
○ Penicillin - avoid having anaphylactic
reactions
○ Gentamycin - kidney damage,
nephrotoxicity
○ When there is an emergent adverse
effect you could discontinue or
change the antibiotic
PATHOPHYSIOLOGY
● Microbiome- microbes colonizing the
human body
○ There is normal flora in the skin, oral
cavity, and on the GI tract
● Endogenous infection - infection arising
from one’s own flora
○ Ex. There is S. aureus in the skin,
when there is a wound infection and
failed to clean the normal flora might
 be the one causing the wound
infection.

Points to consider
● Alterations of normal flora - This can arise
from antibiotic use (e.g., use of clindamycin)
Alteration of the normal flora can happen
○ Clindamycin is known to cause
pseudomembranous colitis, could kill
the normal flora
● Disruption of host defenses(e.g.,
cryptococcus in HIV patients, breakage of
the skin, smoking)
○ When there is immunocompromised
defenses this could lead to the
growth of cryptococcus to the CNS
○ Smokers higher risk to Pneumonia
compared to non smokers
○ prone to infection in the lungs
○ smoking destroys the
epithelial lining that is
supposed to protect you
against bacteria
● Know the normal flora
○ To know what antibiotic to give
● Which anatomic site is normally sterile
○ Ex. The pH of a woman’s vagina is
acidic that is a defense mechanism it
lessen the growth of bacteria in the
vagina
○ Ex. Lungs, no bacteria or in the
bloodstream
■ Sepsis - bacteria in the
bloodstream
NORMAL FLORA IN THE BODY
● If the number grow more than the range that
will already lead to infection
Skin 10^5 - 10^7
● Staphylococcus epidermidis - cause
phlebitis, infection from IV insertion
● Staphylococcus aureus and
propionibacterium spp- skin infection, Part
of the normal flora that causes acne
Lower Respiratory Tract
● Normally sterile
● if there is bacteria it is Pneumonia and
should be treated
Mouth 10^9 - 10^11
● Viridans streptococci
● Oral anaerobes
Upper Respiratory Tract: 10^5 - 10^9
● Oral anaerobes
● Streptococcus spp
● Staphylococcus spp
● Neisseria spp
● Diphtheroids
● Haemophilus sp
● Streptococcus pneumonia

Stomach: <10^3
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 ● Streptococcus spp ○ Ex. normal flora- colonizes in the
● Lactobacillus small intestine but does not cause a
problem.
Small Intestine:
POINTS TO CONSIDER
Duodenum/Jejunum: 10^3 - 10^10^5
● Target only bacteria that cause the disease
● Lactobacillus and leave the non-disease-producing
● Streptococcus spp colonizing flora intact
● Enterococcus ● Emergence of antimicrobial resistance
● Enterobacteriaceae ○ Ex. GI Infection- If antibiotics are
● Diphtheroids taken, normal flora also gets
exposed to the antibiotic. If it is the
● few anaerobes
one causing the infection, since they
already have exposure to the
Ileum: 10^4 - 10^6 (Aerobes), 10^5 - 10^7 antibiotic, it will result in antimicrobial
Anaerobes resistance.
● Enterococcus ■ This is the reason why we
● Enterobacteriaceae hesitate in giving broad-
● Peptostreptococcus spectrum antibiotics, unless
necessary or life-threatening.
● Anaerobes including Bacteriodes sp and
Clostridium sp
● Exogenous infection – infection from an
external source (mode of transmission,
● Ruptured appendicitis- There is a hole in triad: host, pathogen, environment)
the small intestine so the normal flora will go ○ Ex. STDs- Neisseria gonorrhoeae
out and infect the abdominal cavity which is are not part of normal flora. It can
sterile only be transmitted sexually.
○ Plasmodium vivax/malariae- Not
● Prior to the operation we do bowel
normally inhabited in the body. Can
preparation - Give antibiotics to lessen the only be transmitted through
colony of bacteria in the small intestine prior mosquito bites
to operation. ○ During the rainy season, dengue is
also prevalent which is caused by a
Large Intestine: 10^4 - 10^6 (Aerobes), 10^5 - flavivirus.
10^7 Anaerobes ○ Also consider the host-infection
response, if there is an infection,
● Enterobacteriaceae
increase host defenses by giving
● Enterococcus insect repellants
● Pseudomonas
● Streptococcus spp ● Virulence – pathogenicity or disease
● Anaerobes including Bacteriodes sp and severity produced by an organism (e.g., V.
Clostridium sp cholera, enterotoxins)
● Resistance – the ability of the pathogen to
avoid host immune responses (e.g., HIV,
KEY TERMS PTB)
● Infection- the presence of bacteria causing ○ HIV incorporates with T-cells
a disease ○ PTB incorporates with macrophages
○ There’s a causative agent causing
■ If an antibiotic chosen is
the problem.
exogenous, it won’t kill
● Colonization- presence of bacteria does
not causing a disease bacteria inside the

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 macrophages so also POINTS TO CONSIDER
consider the resistance of the ● Is it from infection? (malignancy,
pathogen. hyperthyroidism, allergy from penicillin)
○ To check if the antibiotic is still
APPROACH IN IDENTIFYING THE needed
INFECTIOUS AGENT ● Elderly may be afebrile
● Physical Examination- Anatomic location ○ Problems with thermoregulation
of infection → endogenous or exogenous ● Neutropenic (undergoing chemotherapy, low
flora which is the causative agent WBC count) may not have a typical clinical
○ Clinical manifestation, and do picture of infection (pus) (but there is
S.A.M.P.L.E., Physical Examination infection)
is under S. (Signs and symptoms)
■ To also know the family ● Imaging Studies
history or if its an ○ CXR (Chest X-Ray) - Pneumonia
endogenous or exogenous
infection.
○ Ex. Pneumonia- has two kinds,
Community acquired pneumonia
(CAP) and Hospital acquired
pneumonia (HAP)
■ If it's HAP, it can be
aspiration pneumonia.
Patients with stroke get food
from a nasogastric tube
(NGT), there's a chance that
they vomit the food and if the
vomited food gets in the
lungs, it is aspiration
pneumonia caused by
enterobacteriaceae.
■ If it's CAP, from the oral
cavity (ammonia, Moraxella
catarrhalis, Haemophilus
influenzae), Exogenous
infection, the causes are
there were more bacteria or ○ Normally, lungs are dark/black
from other sources from because of air but in the given CXR-
other people in the it is radiolucent that indicates there
household like one are infiltrates which is the clue that
pulmonary tuberculosis and there is an infection in the lungs.
has a clinical manifestation of ○ Imaging is just an add-on to the
coughing for two weeks via diagnosis or determination. The
airborne transmission main foundation is to assess the
○ Ex. If there’s pus in the penis it could clinical signs and symptoms.
be severe gonorrhea ■ Coughing with phlegm, fever
● Fever ■ Imaging (radiographic
○ Sign of infection appearance) also helps to
○ Consider if the fever is from find the location of infection
infection? and its causative agent.
● Non- microbiologic studies

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 ○ WBC (from CBC)
○ Differential count (high neutrophil –
bacterial, high lymphocyte – TB,
viral, high eosinophil – parasitic,
hypersensitivity)
■ Bacterial if there is high
neutrophil, high segmenters
or shift to the left of
differential count = acute
bacterial
■ High lymphocyte or shift to
the right it is chronic disease,
TB or viral infection
■ High eosinophil-parasitic like
ascariasis or
hypersensitivity
○ C-reactive protein (CRP),
● WBC = small purple dots (presence of this
erythrocyte sedimentation rate
indicates inflammatory process)
(ESR) – acute phase reactants,
● N. gonorrhoeae is an STD
infection or tissue injury
● From the picture, it indicates that there are
■ Not specific test but is helpful
pus that will come out of the penis due to
in finding infection
gonorrhoea also known as penile discharge
■ acute phase reactants are
● Yellow colored phlegm that comes out
early onset of the infection,
during cough or mucus indicates WBC or
ESR would be higher than
neutrophils and macrophages
normal
● Not clear colored. Clear means that there
are no inflammatory cells.
● Microbiologic studies ● Nasal discharge from colds or fever that are
○ Gram- stain clear could also mean a viral infection
■ To know if gram-positive or
gram-negative
■ If bacteria still unknown or if
you want to know the specific
species switch to alternative
stain
○ Alternative stain (e.g., acid-fast stain
= M. tuberculosis)

POINTS TO CONSIDER
● Presence of WBC = inflammation =
pathogenic bacteria

● Acid-fast stain of M. tuberculosis

● M. tuberculosis are found inside the WBC or
neutrophils and macrophages

○ Culture & sensitivity

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 ○ MIC – lowest conc. of antimicrobial
that inhibits visible bacterial growth
after approximately 24 hours
○ Susceptible – above breakpoint
○ Resistant – below breakpoint
○ Bacterial cultures should be
obtained before initiating antibiotics
in px with systemic inflammatory
response, risk of antibiotic
resistance, or uncertain
diagnosis/antimicrobial susceptibility
■ 3 indications or instances to
when to have a bacterial
culture

● Important to know whether bacteria is gram

positive or gram negative and if it is a cocci
or bacilli since there are antibiotics that are
specific to each kind.

TREATMENT APPROACH
● Example of culture & sensitivity
● A bacteria that is culturally grown and is
impregnated with different antibiotic disks.
● We measure the zone of inhibition with a
vernier caliper.
● If there is no zone of inhibition, it is
resistant.
● If there is a large zone of inhibition, it is
susceptible.
● This is a way to know which antibiotic to
use.
● Source control – remove the source of
infection (e.g. IV catheter in phlebitis)
○ In cases of pus or abscess in
wounds, even if antibiotics are
administered, it won’t be gone so
incision and drainage must be done.
Wound cleaning must also be done.
○ Black or dead skin or tissues can
also be a source of infection and
must have wound debridement
performed by surgeons by giving
anesthesia and removing the dead
skin or tissues.
● Non-antimicrobial treatment – hydration,
ventilatory support, antipyretics
○ Ex. patient has infectious disease
like:
■ infectious diarrhea, provide
hydration to the patient.

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 ■ pneumonia and there is
difficulty breathing and thick
secretions give ventilatory
support or suctioning to clear
the airway.
■ fever, give antipyretic like
paracetamol 500mg (around
the clock). If fever is not
treated, patients may have
convulsions or brain
manifestations due to fever.
ANTIBIOTIC CONSIDERATION
Considerations in antimicrobial selection
● Spectrum of activity (broad or narrow
spectrum?)
● Effects on non-targeted microbial flora
● Appropriate dose
● Pharmacokinetic properties
● Pharmacodynamic properties
● Adverse effect
● Drug interaction profile (other drugs taken
by patient)
● Cost
○ would affect patients adherence or
compliance to treatment especially
long-term treatments such as
Anti-TB medications, 6 months
minimum and antivirals for herpes
zoster which is acyclovir that is
expensive.
○ Find medication that is cheaper,
affordable by the patient and still
has the same efficacy
TREATMENT APPROACH
● Empiric therapy
○ sometimes culture sensitivity would
take time before you know the
results
○ sometimes we also give antibiotic
even if the type of bacteria is still
unknown when results take too long
○ depends on the case (if it is really
severe)
■ If threatening, you should
start immediately. through the
course of treatment, you just
change it.
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● C & S does not have sufficient time in
identifying the pathogen
POINT TO CONSIDER
● If empiric, note the location of the infection,
clinical presentation, potential adverse
effects, and spectrum
○ Be guided by the most common
causative agent, given the clinical
presentation. Weigh in the potential
adverse effects and spectrum of
antibiotic.
● Broad or narrow-spectrum? → most likely
pathogen and severity of illness
○ Ex. Gonorrhea: DOC - Doxycycline
and ceftriaxone
■ But if during the course, the
patient did not improve, that
is the time you perform
culture sensitivity
○ In the severity of illness, if it is
complicated - life-threatening, w/
comorbidities, or using the ventilator
already, consider choosing a
stronger one or from the broad
spectrum.
○ If not severe and no comorbidities,
maybe start with narrow.
■ as long as you know the
common pathogen is
EFFECTS ON NON-TARGETED FLORAS
● Clostridium difficile after fluoroquinolone
treatment
● common with oral antibiotics, wherein they
destroy the normal flora (especially if you
are taking the oral antibiotics treatment for
weeks, it could disrupt normal flora)
○ Normal flora usually prevent the
growth of other opportunistic
bacteria
○ Problem: When the normal flora is
disrupted, it can cause the
emergence of opportunistic infection
SINGLE OR COMBINATION THERAPY
● Double? synergistic, decrease the chance
of resistance, and improve treatment
outcome by ensuring activity against
infective pathogen.
 ○ Decrease the chance of resistance fluoroquinolones, metronidazole, and
bc the bacteria is exposed to aminoglycosides)
different types of antibiotic with ○ Proportional
different mechanisms of action ● Conc. independent (time-dependent)
● E.g. Triple or quadruple anti-Koch’s antimicrobial activity - increase in dose will
medication (TB) - to prevent the emergence have minimal increase in rate and extent
of antibiotic resistance of bacterial killing (e.g. beta-lactam,
○ Triple: Isoniazid, Rifampicin, glycopeptide antibiotics)
Pyrazinamide ○ need to be prolonged exposure of
○ Quadruple: Isoniazid, Rifampicin, bacteria to the antibiotic, for it to
Pyrazinamide, Ethambutol work
● Bactericidal - kills the bacteria
ANTIMICROBIAL DOSE ○ Ex. Cell wall synthesis inhibitors
● What dose are you going to give? such as Penicillin and
● depends on the indication or location of cephalosporins
infection ● Bacteriostatic - inhibits the growth of
● Choose the right dose that is effective bacteria
(very crucial), especially in children and ○ the host has to have a working
patients with kidney problems response, for it to be effective
● Efficacy (treat) and safety (minimize ○ Ex. Tetracycline, Azithromycin,
adverse drug events) Macrolides

PHARMACOKINETIC PROPERTIES COST

● Intracellular or extracellular concentrations ● Cost vs. benefit consideration
of the antibiotic ○ Even if the medicine is expensive,
○ If the bacteria is intracellular, maybe will my patient have more benefit in
need to increase the dose for it to be treating the infection?
effective
● Factors that affect its absorption (e.g. Table 1. Comparison of Cost vs Benefit
stomach pH) DRUG A DRUG B
○ Ex. Oral antibiotic, if an antibiotic is Efficacy =
destroyed in an acidic medium, Cost Php 100 Php 50
consider giving in oral route ● As much as possible, if both drugs have
○ Drug interactions equal efficacy choose Drug B, which has
● Drug disposition (e.g. urinary conc. of the lower cost (affordable), for your patient
antibiotic effective for complicated UTI) to be compliant and adherent to their
○ Take into consideration the medication
distribution of the drug ● If there is only one medication that can treat
○ Ex. Those antibiotics whose urinary the infection of the patient but it is
conc is accumulating in the kidneys expensive, you have no choice but to give it.
or urinary bladder = urinary tract To comply, financial support is needed
infection.
○ Ex. Penicillin is effective in PATIENT CONSIDERATION
meningitis, bc it can distribute in that
area during inflammation HOST FACTORS:
● Age
PHARMACODYNAMICS ○ In giving antibiotics, it should be safe
● Conc. dependent antimicrobial activity - and effective.
high conc. of antibiotic would cause a ○ Customize to the patient (Is my dose
greater bacterial killing (e.g. correct for this age?)
● Hepatic and Renal Function
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 ○ Should I do an adjustment if the
patient has hepatic or renal
problems?
● Disrupted host defenses (e.g. burns,
traumas, surgery, chemotherapy, organ
transplant recipient)
○ Chemotherapy - low WBC count
○ Organ transplant recipient -
receives immunosuppressives
● History of recent antimicrobial use
○ Ex. If the patient has a history of
taking ciprofloxacin last week, but
is not yet treated/cured, Then there
is a new infection. You may no
longer give ciprofloxacin, choose
another antibiotic (usually more
expensive ones)
● History of drug allergy
○ will guide you in the selection of
drug.
○ Ex. If there is anaphylaxis to
penicillin, next time the patient is
sick, you can no longer give
penicillin
● Concomitant administration of other drugs
(e.g. warfarin and cephalosporins)
○ Consider the drug interactions
○ Ex. when you combine oral
cephalosporins with warfarin, you
could result to bleeding
● Pregnant/breastfeeding (teratogenicity,
increased CL and Vd)
○ Consider that some drugs are
prohibited for pregnant women
○ Cl = clearance; Vd = Volume
distribution
● Patient adherence (adherence)
○ Is your patient educated or not?
○ Educate them on how to take the
medication or what are the signs for
them to recognize the adverse
effect, so that they may report it
when it arises
MODIFYING EMPIRICAL THERAPY BASED
ON CULTURE AND CLINICAL RESPONSE
● During the course of treatment, monitor
● Antibiotic de-escalation: discontinuation
of antibiotics that are providing a spectrum
of activity greater than necessary to treat an
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infection, discontinuation of the duplicative
spectrum of antibiotics, switching to a
narrow spectrum once the patient is
clinically stable
● Examples:
○ Stop the antibiotic - when the patient
is continously improving
○ 3 antibiotics to one antibiotic
○ Broad spectrum to narrow spectrum
■ ex. Culture sensitivity result:
susceptible to amoxicillin
(Narrow spectrum) = make
use of narrow spectrum
○ Giving of the broad spectrum when
narrow spectrum is already enough
TREATMENT FAILURE
● Did the antibiotic fail?
● Inadequate diagnosis (poor initial antibiotic
drug selection, poor coverage)
○ maybe increase the coverage
○ add dose or antibiotic
● Poor source control
○ Ex. pus or skin was not cleaned,
dead tissues were not removed, that
is why there is still bacterial growth
or foreign body
● Development of new infection with resistant
organism
ANTIBIOTIC STEWARDSHIP
● Promotes optimal use of antimicrobial
agents to reduce the emergence of resistant
pathogens, improve quality of patient care
and safety, reduce costs
○ be aware of your antibiotics and
guided in the route of administration
○ Patient care - the patient has been
cured with minimal to no side effects
○ Reduce costs - choose a more
affordable drug if same efficacy w
the other one
● Provide optimal use of antibiotics (i.e. right
dose, route, and duration of therapy)
○ If vomiting, DO NOT USE ORAL,
use IV but consider the duration of
therapy
○ Should you give it 7 days? 10 days
to treat the infection?
 ○ Should you extend it to 2 more ● Review patient labs including labs obtained
weeks? Will it affect your treatment? for specific infectious syndromes and vital
○ Would you have antibiotic resistance signs
if you extend it? ● Determine if patient may have any potential
○ Should you change the antibiotic? sources for infection (e.g. central venous
Should you add another antibiotic? catheter, urinary catheter)
● Assess the severity of illness
Table 2. CDC Core elements of Antibiotic ● Assess patient-specific risk factors based
Stewardship Programs on infection type to aid in determining
CDC Core elements of antibiotic stewardship appropriate empirical therapy
programs ● Review local antibiotic susceptibility
Leadership commitment patterns including hospital antibiograms
Accountability
Drug Expertise DEVELOP A CARE PLAN
Key support groups - infection control committee ● Based on proposed infectious diagnosis
Action (implement policies/interventions to combined with above data assessed, select
improve patient care) empirical antibiotic regimen
Tracking/reporting antimicrobial use and ● Consider additional diagnostics and culture
outcomes and susceptibility reports
Education
IMPLEMENT THE CARE PLAN:
Table 3. Considerations for selecting antimicrobial ● Timely antibiotics are required, especially in
regimens critically ill patients, including those with
Drug Specific Patient Specific sepsis

Spectrum of activity Anatomic location of FOLLOW-UP: MONITOR AND EVALUATE

and effects on infection ● Follow-up on culture and susceptibility
nontargeted flora Antimicrobial history reports to determine opportunities to
Dosing Drug allergy history streamline antibiotic therapy
Pharmacokinetic Renal and Hepatic ● Some antibiotics may require therapeutic
properties function drug monitoring (e.g vancomycin) to
Pharmacodynamic Concomitant evaluate for safety and effectiveness
properties medications ● Duration of therapy should be determined
Adverse-effect potential Pregnancy or lactation based on several factors including but not
Drug-interaction Compliance Potential limited to infection type, culture results, host
potential immune status, and source control (e.g
Cost removal of a central venous catheter)

References:
PATIENT CARE PROCESS

COLLECT INFORMATION: Notes from: Asynch Discussion of Doc

● Review pertinent patient medical history Tanodra
including significant comorbid conditions PPT from: Doc Tanodra
● Determine patient allergy histories
(including reactions and timing)
● Determine and document recent antibiotic
exposure

ASSESS THE INFORMATION

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