Rational Use of Antibiotics
Rational Use of Antibiotics
Rational Use of Antibiotics
Contents
3. SURGICAL CHEMOPROPHYLAXIS
4. GUIDELINES FOR SURGICAL ANTIBIOTIC PROPHYLAXIS
Gynaecologic Surgery
General Surgery
Vascular Surgery
Cardiac Surgery
Thoracic Surgery
Orthopaedic Surgery
ENT Surgery
Neurosurgery
Urological surgery
Endoscopic procedures
Introduction
Antibiotics are one of the most commonly prescribed drugs today. Rational use of
antibiotics is extremely important as injudicious use can adversely affect the patient,
cause emergence of antibiotic resistance and increase the cost of health care.
Prescribing an antibiotic comprises several phases:
Is an antibiotic necessary?
Antibiotics are generally only useful for the treatment of bacterial infections. It is
important to remember that not all fevers are due to infections and not all infections
are caused by bacteria. The majority of infections seen in general practice are of viral
origin and antibiotics can neither treat viral infections nor prevent secondary
bacterial infections in these patients. Even where a bacterial aetiology is established,
an antibiotic may not be always necessary. Many bacterial infections resolve
spontaneously. Minor superficial skin infections may be more suitably treated with a
local antiseptic. Collections of pus should be drained surgically and if drainage is
adequate, antibiotics are often not required.
Choice of an antibiotic
The successful outcome of therapy would depend very much on the choice of the
antibacterial agent. In the process of selecting an antibiotic, three main factors need
to be considered; the aetiological agent, the patient and the antibiotic.
The aetiological agent
Determination of the aetiological agent depends on a combination of clinical acumen
and laboratory support. In many instances an antibiotic prescription has to be made
based on the clinical diagnosis (empirical therapy). Even where a bacteriology report
is available it is necessary to interpret the report. Bacterial isolates from culture
specimens may represent normal flora, colonisers or contaminants rather than true
pathogens. Sensitivity results when available are at best only a guide to treatment.
Laboratory reports should always be viewed in the light of clinical findings.
The patient
Several patient factors have to be considered in selecting an antibiotic. Age is an
important factor. The very young and the very old tend to be more prone to the
adverse effects of the antibiotics. Neonates have immature liver and renal functions
which affect their ability to metabolise or excrete antibiotics. Antibiotics and their
metabolites may adversely affect growing tissues and organs in children. Elderly
patients are more likely to suffer from nephrotoxicity and allergic reactions. Dosage
modifications would also have to be made in those patients with hepatic or renal
impairment. Antibiotics can also give rise to severe toxic reactions in patients with
certain genetic abnormalities eg sulphonamides in patients with glucose-6-phosphate
dehydrogenase deficiency. Antibiotics should as far as possible be avoided in
pregnancy and when it is necessary to use an antibiotic, betalactam antibiotics and
erythromycin are probably the safest. A history of allergy to antibiotics should always
be sought before administration. Routine intradermal test doses for penicillin allergy
is of little value and may even be dangerous. If in doubt avoid betalactams and use a
macrolide or tetracycline (in adults) instead. In serious infections like meningitis and
bacteraemic shock the immediate institution of the best available antibiotic for the
suspected pathogen(s) is imperative as delay in treatment will increase both
mortality and morbidity. In less serious situations such as otitis media where
spontaneous recovery is common, an antibiotic that covers for the predominant
organisms is adequate.
The antibiotic
The clinician should have adequate knowledge of the pharmacokinetic properties of
the antibiotic he uses. Antibiotics vary in their ability to be absorbed orally or to
cross the blood brain barrier and these factors will affect their routes of
administration. The ability of the antibiotic to achieve therapeutic concentrations at
the site of infection is another important consideration thus antibiotics used for
treating urinary infections should ideally be concentrated in urine. Some antibiotics
have very severe toxic effects and are best avoided in certain conditions. The doctor
should also be aware of drug-drug interactions since many antibiotics can interact
with other non-antibiotic drugs. Finally the cost of the antibiotic is also of major
concern. In calculating costs it is perhaps more reasonable to take into account the
total cost of treatment rather than just the actual cost of antibiotic per dose. The
route of administration, the necessity for monitoring antibiotic levels and the
patient's length of stay in hospital can affect the cost of treatment as well. The
patient's compliance to medication is an important factor for consideration in the
choice of antibiotics.
Choice of regimen
Parenteral or oral
Whether the route of administration should be oral or parenteral would depend on
whether the patient is able to take oral treatment reliably. In cases of severe sepsis
where rigors, hyperthermia/hypothermia, tachycardia and hypotension are present,
intravenous therapy should be instituted. When in doubt it would be safer to
commence intravenous treatment and review the treatment daily.
Duration of treatment
Except for a few conditions, the optimum duration of antibiotic treatment is
unknown. Many antibiotics are often presribed for a duration of 5-7 days.
Nevertheless it is reasonable to discontinue therapy even after a shorter period if the
patient's symptoms have resolved. There are however certain infections where
prolonged treatment is necessary (Table I). In some conditions eg uncomplicated
cystitis in women and gonococcal urethritis in males, single dose regimens have been
shown to be effective.
Table I. Conditions where a minimum duration of treatment has been
established.
Tuberculosis 4 -6 months
Endocarditis 4 weeks
Osteomyelitis 4 weeks
Monitoring efficacy
Early review of response
A routine early review ( 3 days after commencing treatment) of the patient's
response is important in order to ensure that the patient is receiving appropriate
treatment. After review the doctor will have to decide whether to:
The following guidelines are issued for the more common infections only. However
even for common infections they may not apply to certain patients. When in doubt
always seek a second opinion. The recommendations for first and second choice
regimens are based on a global assessment of efficacy, adverse effects , prevailing
sensitivity patterns and cost. It should also be noted that guidelines such as these
have to be reviewed and updated from time to time.
NOTE :
1o : First generation
2o : Second generation
3o : Third generation
Nosocomial pneumonia
Post-operative/coma Benzylpenicillin
(aerobic gram negative bacilli, and
streptococci, anaerobic mouth Gentamicin
flora, Staphylococcus aureus)
severe cases
where MRSA is
demonstrated or strongly
suspected 3o Cephalo-
sporin and If vancomycin is not available a
ventilated patients Gentamicin combination of fucidin and rifampicin
(Pseudomonas aeruginosa, Vancomycin may be used
other aerobic gram negative
bacilli)
Gentamicin
immunosuppressed and
(aerobic gram negative bacilli a 3o Cepha-
andStaphylo-coccus aureus losporin
Gentamicin Pneumonia in the immunocompromised
and may also be caused by a variety of non-
a 3o bacterial agents eg fungi (Candida,
Cephaloporin Aspergillus ),Toxoplasma,
or Pneumocystis and viruses.
Ureido-penicillin
or
Carbapenem
Lung abscess/
empyema
(mixed infection of Benzylpenicillin Empyema in childhood is nearly always
anaerobes,Staphylococcus and due to staphylococci. Where
aureus, Streptococcus Gentamicin staphylococci is suspected substitute
pneumoniae and aerobic and Metronida-zole cloxacillin for benzyl penicillin
gram negative bacilli)
Table 2. URINARY TRACT INFECTIONS
Acute urinary tract infection Cotrimoxa-zole 1o/2o cephalo- Many hospital acquired
(E. coli, Staphylococcus or sporin pathogens are now
saprophyticus) Trimethoprim resistant to ampicillin.
or In uncomplicated cystitis in
Ampicillin adults 4 tabs
or cotrimoxazole in a single
Nitrofurantoin dose has been shown to be
effective.
In pregnancy ampicillin
should be given for 10
days
Table 3. SKIN AND SOFT TISSUE INFECTIONS
Cellulitis/Erysipelas/ Benzylpenicillin
Lymphangitis or
(Strep pyogenes) Procaine Change to oral therapy once
Severe cases penicillin patient's condition improves.
If staphylococci suspected or
proven use a combination of
Penicillin V penicillin and cloxacillin
Mild to moderate cases or
Erythromycin
Facial and orbital cellulitis in
children (Haem influenzae)
2o or 3o Ceph-
alosporin
Lymphadenitis Cloxacillin
(Staph aureus, Strep pyogenes) or
Erythromycin
or
1oCephalosporin
Acute osteomyelitis Cloxacillin Fusidic acid For children < 5 yr use a combination
(Staph aureus of cloxacillin and 2o/ 3o Ceph-
-commonest; others alosporin
includeEnterobacteriaceae,
Pseudomonas)
In children < 5 yr
staphylococci,
streptococci andHaem
influenzae
Secondary
(polymicrobial infection due
toEnterobacteriaceae,
Enterococcus andBacteroides)
2o/3o Gentamicin
cephalo- and
sporin and Metronida-
methronida- zole
zole
Antibiotic associated colitis Vancomycin
(Clostridium difficile) (oral)
or
Metronidazole
Pelvic inflammatory
disease
(anaerobic bacteria,
streptococci,Entero-
bacteriaceae,
chlamydia,Neisseria
gonorrhoeae)
Mild to moderate
Doxycycline
and
Gentamicin
and
Severe Metronida-zole
Doxycycline
and
2o or 3o cephalo-
sporin
and
Metronida-zole
Vaginitis
Candidal
(Candida albicans, Candida Nystatin Fluconazole
tropicalis, otherCandida spp) or or Ketoconazole
Clotrimazole or Itraconazole
Trichomonal
(Trichomonas vaginalis)
Metronida-zole Metronidazole should be
Bacterial vaginosis or Tinidazole avoided during the first
(Gardnerella vaginalis, trimester.
Mobiluncus, Bacteroides sp)
Metronida-zole
or Ampicillin With recurrent infections
Tinidazole consider treatment for the
sexual partner as well.
Gonorrhoea
(Neisseria gonorrhoeae)
Uncomplicated urethritis, rectal Spectino-mycin For uncomplicated urethritis,
and pharyngeal gonorrhoea or rectal and pharyngeal
Ceftriaxone gonorrhoea single dose
or treatment is sufficient.
Ciprofloxacin
Pelvic inflammatory
disease
Spectino-mycin For other forms of
or gonorrhoea, three day
2o or 3o Cephalo-
Adult gonococcal sporin courses are required.
ophthalmia
Ceftriaxone
or
Spectino-mycin
Gonococcal ophthalmia
neonatorum
In gonococcal ophthalmia
parenteral antibiotics should
be accompanied by hourly
conjunctival irrigation with
saline or antibiotic eyedrops.
Congenital syphilis
Asymptomatic babies born of
syphilitic mothers should
also be treated
Intravascular lines Cloxacillin The infected line
(Staphylococci,Enterobacteriaceae) and should be
Gentamicin removed.
Where MRSA
and MRSE are
prevalent use
vancomycin or a
combination of
fucidic acid and
rifampicin.
Cholera Tetracycline
1 g daily for 5
days
or
Doxycycline 200
mg stat dose
Post splectomised Penicillin V 250 mg 12 hrly Pneumococcal vaccine should be given to the
children or patient one month before splenectomy
Benzathine penicillin 1.2 mega
monthly
Rifampicin
10 mg/kg/day
12 hrly for 4 days
SURGICAL CHEMOPROPHYLAXIS
The use of antibiotic prophylaxis has been shown to prevent post-surgical wound
infections. When employed rationally significant reductions in morbidity and mortality
and savings in resources can be achieved. However when used excessively and in
situations when its benefit has not been proven, perioperative antibiotics can lead to
unjustifiably high costs of medical care. Single dose regimens or very short courses
are unlikely to lead to emergence of bacterial resistance but routine prolonged
courses have been clearly associated with increased rates of resistance.
Gynaecologic surgery
General Surgery
Vascular Surgery
Cardiac Surgery
Thoracic Surgery
Orthopaedic Surgery
ENT Surgery
Neurosurgery
Urological surgery
Endoscopic procedures
Antibiotic prophylaxis for endoscopic procedures are given for 2 main reasons:
1) to prevent endocarditis (see table below for degree of risk)
2) to prevent infective complications
Prosthetic heart valves Mitral valve prolapse with Mitral valve prolapse
Previous endocarditis regurgitation without regurgitation
Cyanotic congenital heart Pure mitral stenosis Trivial valvular
failure Tricuspid valve disease regurgitation on
Patent ductus arteriosus Pulmonary stenosis echocardiography without
Aortic regurgitation Asymmetric septal structural abnormality
Aortic stenosis hypertrophy Isolated atrial septal
Mitral regurgitation Bicuspid aortic valve or defect
Mitral stenosis and calcific aortic sclerosis Arteriosclerotic plaques
regurgitation with minimal Coronary artery disease
Ventricular septal defect haemodynamic Cardiac pacemaker
Coartation of the aorta abnormality Surgically repaired
Surgically repaired Degenerative valvular intraccardiac lesions, with
intracardiac lesions with disease in elderly minimal or no
residual haemodynamic patients haemodynamic
abnormality Surgically repaired abnormality, more than
intracardiac lesions with six months after operation
no haemodynamic
abnormality, less than 6
months after the
operation
Note : The following dosing guidelines are the usually recommended regimens. They
may not apply to all patients nor to all infections. When in doubt always consult a
specialist.
Antibiotic Usual oral regimen Usual parenteral regimen
Cefoperazone 1 - 2 g 8 - 12 hrly
Cefotaxime 1 - 2 g 8 - 12 hrly
Ceftazidime 1 - 2 g 8 - 12 hrly
Piperacillin 3 - 4 gm 4 - 6 hrly
Aminoglycoside dosing : There is now evidence to show that once daily dosing is as
effective as multiple dosing.
Ampicillin <7 days : 150 mg/kg div. 100 mg/kg div. 12 hrly
8hrly
>7 days : 200 mg/kg div.
6 hrly
Cefotaxime <7 days : 100 mg/kg div. 100 mg/kg div. 12 hrly
12 hrly
>7 days : 150 mg/kg div.
8hrly
Ceftazidime <7 days : 100 mg/kg div. 100 mg/kg div. 12 hrly
12 hrly
>7 days : 150 mg/kg div.
8 hrly
Ceftriaxone <15 days : 20-50 mg/kg <15 days : 20-50 mg/kg once daily
once daily >15 days : 20-80 mg/kg once daily
>15 days : 20-80 mg/kg
once daily
Cloxacillin <10 days : 200 mg/kg <10 days (<2.5 kg) : 100 mg/kg div.
div. 8 hrly 8hrly; >10 days (<2.5 kg) : 100
>10 days : 200 mg/kg mg/kg div. 8 hrly
div. 6 hrly
Gentamicin <7 days : 5 mg/kg div. 5 mg/kg div. 8 hrly
12 hrly
>7 days : 7.5 mg/kg div.
8 hrly
Kanamycin <7 days : 20 mg/kg div. <3 days : 10 mg/kg once daily
12 hrly >3 days : 20 mg/kg div. 12 hrly
>7 days : 30 mg/kg div.
8 hrly