Infectious Disease I:
Overview of
Infectious Diseases
Courses in Therapeutics and Disease State Management
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Learning Objectives
• Recognize general signs, symptoms, laboratory, and
microbiologic findings of a patient with an infection
• Apply susceptibility data from an institution’s antibiogram in
choosing presumptive antimicrobial therapy
• Select antimicrobial(s) of choice based on organism and
infectious disease
• Design an appropriate antimicrobial regimen for a patient-based
allergy profile, age, renal and liver function, concomitant
disease states, and infection
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Learning Objectives
• Propose alternative antimicrobial therapy for a patient with a
penicillin allergy
• Discuss metabolic and host genetic variations that may affect
antimicrobial therapy
• Explain key pharmacodynamic relationships to optimize
antimicrobial dosing
• Recommend antimicrobial agents based on tissue or fluid
penetration and site of infection
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Learning Objectives
• Debate advantages and disadvantages of using combination
antimicrobial therapy
• Formulate a monitoring plan to assess therapeutic response after
initiation of antimicrobial therapy
• Evaluate issues including drug selection, host factors, and
pathogen(s) in a patient lacking clinical response to antimicrobial
therapy
• List clinical parameters to consider when switching from parenteral
to oral therapy
• List clinical parameters to consider when switching from parenteral
to oral therapy.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Required and Recommended Reading
Required Reading
Lee GC, Burgess DS. Chapter 83. Antimicrobial Regimen Selection. In:
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds.
Pharmacotherapy: A Pathophysiologic Approach, 9e.` New York, NY:
McGraw-Hill; 2014.
Recommended Readings
• Lampiris HW, Maddix DS. Clinical Use of Antimicrobial Agents. In: Katzung
BG, Trevor AJ. eds. Basic & Clinical Pharmacology, 13e. New York, NY:
McGraw-Hill; 2015.
• Rybak MJ, Aeschlimann JR, LaPlante KL. eChapter 25. Laboratory Tests
to Direct Antimicrobial Pharmacotherapy. In: DiPiro JT, Talbert RL, Yee GC,
Matzke GR, Wells BG, Posey L. eds. Pharmacotherapy: A
Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; 2014.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Selection of Antimicrobial Agents
• Infectious diseases generally are acute, and a delay in
antimicrobial therapy can result in serious morbidity or even
mortality
• Antimicrobial therapy must be initiated swiftly and appropriately
in order to prevent serious complications from infectious
process and the antimicrobial therapy itself
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Selection of Antimicrobial Agents
Consider the following three patients:
• Patient # 1: A 35-year-old female presents to the emergency room with complaints of
fever, cough, and increased green sputum production. She has decreased lung
sounds at the bases of his lungs. She does not have a significant past medical
history. She has received a 3-day course of levofloxacin for a urinary tract infection
three weeks ago. A complete blood count with differential reveals an elevated white
blood cell count of 11,000 cells/mm3
• Patient # 2: A 45-year-old male presents to the emergency room with complaints of
fever, cough, increased green sputum production. He has decreased lung sounds at
the bases of his lungs. He has a past medical history significant for HTN, hypothyroid,
and atrial fibrillation. He has not had any antibiotics in the past 6 months. A complete
blood count with differential reveals an elevated white blood cell count of 14,000
cells/mm3
• Patient # 3: 62-year-old male presents to the emergency room with complaints of
fever, cough, increased sputum production. He has decreased lung sounds at the
bases of his lungs. He has a past medical history of COPD, Diabetes, and HTN. He
has not had any antibiotics in the past year. A complete blood count with differential
reveals an elevated white blood cell count of 12,000 cells/mm3
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Selection of Antimicrobial Agents
• Confirm the presence of infection
• Careful history and physical examination
• Signs and symptoms
• Predisposing factors
• Identification of the pathogen (see Chap. e24)
• Collection of infected material
• Stains
• Serologies
• Culture and sensitivity
• Selection of presumptive therapy considering every infected site
• Host factors
• Drug factors
• Monitor therapeutic response
• Clinical assessment
• Laboratory tests
• Assessment of therapeutic failure
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Selection of Antimicrobial Agents
Drawbacks to not following a systematic process include:
• Unnecessary use of broad-spectrum antimicrobial therapy
that leads to widespread resistance and difficult-to-treat
superinfections
• Overuse of more expensive or potentially more toxic
antimicrobial agents
• Administration of antimicrobial agents to patients with
infectious processes that are self-limiting (e.g. colds or viral
gastritis)
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Confirming the Presence of Infection
Signs and Symptoms: Fever
• Average normal body temperatures by site are defined as
• Oral: 36.7°C (98°F)- 37°C (98.6°F)
• Rectal: 37.3°C (99°F)- 37.6°C (99.6°F)
• Axillary: 36.1°C (97°F)- 36.4°C (97.6°F)
• Regulation of body temperature is a complex process,
controlled by the hypothalamus, that follows a circadian rhythm
• An elevation in temperature above the generally acceptable
ranges is considered a hallmark of an infectious process
• Clinicians should be aware that there are many non-infectious origins
for fever
• Medications can prevent a fever in patients with an infectious process
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Confirming the Presence of Infection
Signs and Symptoms: White Blood Cell
Count
• Normal White Blood Cell (WBC) Count range: 4,000 - 10,000
cells/mm3 (4 × 109 -10 × 109/L)
• Infections will normally result in a leukocytosis (elevated WBC
count) due to an increased production and mobilization of
granulocytes and lymphocytes
• Patients may have an infection without a leukocytosis
• Patients may have a leukocytosis without an infection
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Confirming the Presence of Infection
Signs and Symptoms: Local Signs
• Pain and inflammation
• Swelling
• Erythema
• Tenderness
• Purulent Drainage
• Examination of tissues and fluids
• Organ specific symptoms
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Confirming the Presence of Infection
Signs and Symptoms
• All three of the patients in the previous example are presenting
with fever as a non-specific symptom of an infection
• Each of the patients has an elevated white blood cell count
• Patient # 1: 11,000 cells/mm3
• Patient # 2: 14,000 cells/mm3
• Patient # 3: 12,000 cells/mm3
• The following signs and symptoms are more organ specific to
respiratory infections
• Cough
• Increased mucous production
• Decreased lung sounds
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Identification of the Pathogen
Laboratory Tests: Gram’s Stain
•
•
•
•
One of the initial tests completed on a specimen
Differentiates between gram-positive and gram-negative organisms
Describes the morphology of organisms
The Gram’s stain and morphology characteristics of the isolated
organisms can be used to categorize stained the organisms into
groups
• Routinely performed on
• Sputum
• Cerebral spinal fluid
• Blood
• Bronchial aspirates
• Urine
• Mucosal Scrapings
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Identification of the Pathogen
Laboratory Tests: Gram’s Stain
Link: Figure on Laboratory Tests to Direct
Antimicrobial Pharmacotherapy
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Identification of the Pathogen
Laboratory Tests: Culture
• Identification of the infecting pathogen by culture is the most definitive
method available for the diagnosis and treatment of infection
• Samples of fluid or tissues collected from an infected patient will be used
to inoculate several types of artificial growth media to identify the causative
pathogen
• Routinely performed on
•
•
•
•
•
•
•
•
Blood
Sputum
Bronchial aspirates
Urine
Cerebral spinal fluid
Stool
Joint fluid
Wound or sinus drainage
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Identification of the Pathogen
Laboratory Tests: Other Tests
• Rapid Diagnostic Technologies
• Can have results within 15 minutes to 4 hours
• Genomic testing methodologies
• Immunologic Assays
• Rapid Strep Test
• Rapid Influenza diagnostic test
• Enzyme-linked immunosorbent assay (ELISA) tests
• Hybridization DNA Probes
• Peptide nucleic acid fluorescence in situ hybridization (PNA-FISH) assay
• Branched DNA (bDNA) probe system
• Nucleic Acid Amplification Methods
• polymerase chain reaction (PCR)
• Rapid PCR (rPCR)
• Mass spectrometry
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Identification of the Pathogen
Laboratory Tests: Interpreting Results
• Positive results from a Gram stain and/or a culture do not
always indicate an infectious process
• True pathogen vs. Contamination vs. Normal Flora
Gram-Positive
Gram-Negative
Cocci
Rods
Skin
Staphylococcus spp. (e.g., S.
epidermidis), Streptococcus
spp.
Corynebacterium spp., Propi
onibacterium spp.
Oropharynx
Streptococci—viridans
group Micrococcus
Corynebacterium spp.
GI tract
Enterococcus spp., Peptostre Lactobacillus, Clostridium
ptococcus spp.
Bacteroides spp., Enteric
bacilli (E. coli,
Klebsiella spp.)
Genital tract
Streptococcus spp., Staphylo
coccus spp.
Enterobacteriacea, Prevotell
a spp., Candidia spp.
Lactobacillus,
Corynebacterium spp.
Cocci
Rods
Other
Enteric bacilli (some
sites), Acinetobacter spp.
(Coccobacilli)
Neisseria
Haemophilus spp.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Spirochetes
Mycoplasma
Identification of the Pathogen
Laboratory Tests: Patient Examples
• Link: Laboratory Tests to Direct Antimicrobial Pharmacotherapy
• Sputum gram stain results for the patients were as follows:
• Patient #1: Gram negative coccobacilli
• Patient #2: Gram positive cocci arranged in pairs
• Patient #3: No organism identified
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Selection of Presumptive Therapy
• After identifying the signs and symptoms of infection and attempting
to identify a pathogen, empirical antimicrobial therapy may be
initiated depending on
•
•
•
•
Disease severity and acuity
Patient specific factors
Medication related issues
Need for multiple antimicrobial agents
• Empiric antimicrobial therapy is directed at organisms that are known
to cause the infection
• Generally accepted drugs of first choice for specific infections are
based on several factors
• Infection Specific Guidelines
• Local antimicrobial susceptibility data via antibiograms
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Selection of Presumptive Therapy
Patient Factors
• Allergy
• Careful assessment of listed medication allergies and reactions must be
completed
• An “allergy” to a medication with a reaction of nausea is not an allergy
• Penicillin allergies are common
• Serious reactions (anaphylaxis, laryngospasm, throat swelling) may prevent use of
penicillin related compounds
• Patients with less serious reactions (rash) may be able to take penicillin related
compounds under close supervision
• Age
• Certain infections are cause by different pathogens based on the patient’s
age
• Meningitis
• Osteomyelitis
• Certain medications cannot be processed appropriately in neonates due to
underdeveloped hepatic and liver function
• Renal function declines with age, which would cause decreased drug
clearance in older patients
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Selection of Presumptive Therapy
Patient Factors
• Pregnancy
• Risk of harm to the fetus with teratogenic medications
• Altered pharmacokinetics in pregnant patients
• Increased intravascular volume
• Increased glomerular filtration
• Higher hepatic clearance of medication
• Metabolic or Genetic Variation
• Depending on the genetic variation could lead to increased or
decreased drug metabolism
• Certain medications require screening for specific genetic variation
prior to administration
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Selection of Presumptive Therapy
Patient Factors
• Organ Dysfunction
• Decreases in the renal and/or hepatic function of a patient can lead to
accumulation of medications
• Medication specific recommendation should be followed when organ
dysfunction is present
• Concomitant Drugs/ Disease States
• Any antimicrobial agent should be screened against a patient’s past
medical history and current medication list for drug disease and drugdrug interactions, respectively
• Certain disease states will predispose a patient to specific infections
and/or pathogens
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Selection of Presumptive Therapy Drug Factors:
Pharmacokinetic and Pharmacodynamic
Considerations
• Pharmacokinetics is used to describe how a medication is processed
by the body
• Area under the curve (AUC)
• Maximum observed concentration (peak)
• Half life (t1/2)
• Pharmacodynamics describes the relationship between drug
concentration and the effects on the microorganism
• AUC: Minimal inhibitory concentration (MIC) ratio (AUC:MIC ratio)
• Peak: MIC ratio
• Time (T) the concentration is above the MIC (T>MIC)
• Utilizing these tools has altered the methods employed to dose and
administer medications
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Selection of Presumptive Therapy
Drug Factors
• Tissue Penetration
• Antimicrobial therapy must be able to get to the site of infection and be
active once there
• Serious infections are generally treated using intravenous antimicrobial
therapy
• Outpatient treatment of less serious infectious diseases can be
managed using oral medications
• Drug Toxicity
• Toxicities should be avoided at all costs
• Certain medications will require a risk vs. benefit analysis prior to
starting therapy
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Antimicrobial Regimen Selection
Link: Antimicrobial Regimen Selection Table
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Selection of Presumptive Therapy
Combination Antimicrobial Therapy
• Broadening the Spectrum of Coverage
• Required for infections caused by multiple pathogens
• Required for patients with two concurrent infections with different pathogens
• Synergism
• Controversial data exists with the use of two antimicrobial agents with
differing mechanism of action against a pathogen
• Endocarditis is often treated with a combination of an antimicrobial agent that
targets the cell wall with an aminoglycoside.
• Preventing Resistance
• Combining antimicrobials may decrease the development of bacterial
resistance
• Frequently utilized in the treatment of tuberculosis
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Selection of Presumptive Therapy
Disadvantages of Combination Therapy
• Increased Cost
• Greater risk of drug toxicity
• Superinfection
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Selection of Presumptive Therapy
Patient Examples
• Patient #1:
•
•
•
•
•
35-year-old female (not pregnant)
PMH: not significant
Current Medications: none
Past medications: levofloxacin
Allergies: none
• Possible bacteria for community acquired pneumonia:
•
•
•
•
Streptococcus pneumonia
Mycoplasma pneumonia*
Haemophilus influenza *
Chlamydophila pneumonia
• Gram stain: Gram negative coccobacilli *
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Selection of Presumptive Therapy
Patient Examples
• Patient #2: 45-year-old male
•
•
•
•
PMH: Hypertension, hypothyroidism, atrial fibrillation
Current Medications: levothyroxine, lisinopril, warfarin,
Past medications: no recent antibiotics
Allergies: tetracycline (upset stomach)
• Possible bacteria for community acquired pneumonia:
•
•
•
•
Streptococcus pneumonia*
Mycoplasma pneumonia
Haemophilus influenza
Chlamydophila pneumonia
• Gram stain: Gram positive cocci arranged in pairs *
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Selection of Presumptive Therapy
Patient Examples
• Patient #3: 62-year-old male
•
•
•
•
PMH: COPD, Diabetes, and Hypertension
Current Medications: tiotropium , albuterol, valsartan, metformin, insulin
Past medications: no recent antibiotics
Allergies: none
• Possible bacteria for community acquired pneumonia:
•
•
•
•
•
•
•
Haemophilus influenzae
Pseudomonas aeruginosa
Legionella species
Streptococcus pneumonia
Morexella cararrhalis
Chlamydophila pneumonia
Different pathogens due to history of COPD
• Gram stain: No organism identified
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Monitoring Therapeutic Response
• Patient should be monitored for clinical improvements
for two to three days following the initiation of
antimicrobial therapy
• Decrease in signs and symptoms of infection
• Absence of fevers
• Correction of WBC count
• Patients that fail to respond to therapy should be
reevaluated closely
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Monitoring Therapeutic Response
Switching from IV to Oral Therapy
• Patients with an overall clinical improvement should be
considered to be switched from parenteral to oral antimicrobial
therapy
• Patients should meet the following criteria
• Lack of fever for 8 to 24 hours
• Decreased WBC count
• Have a functioning Gastrointestinal tract
• Oral antimicrobial therapy should have excellent oral
bioavailability and activity against the suspected or isolated
pathogen
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Monitoring Therapeutic Response
Failure of Antimicrobial Therapy
• Drug Selection
•
•
•
•
Inappropriate Drug Selection
Incorrect dosage
Incorrect route
Poor penetration into the site of infection
• Patient Factors
• Immunosuppression
• Need for surgical intervention to control source of infection
• Microorganisms
• Intrinsic resistance
• Acquired Resistance
•
•
•
•
Alteration in the target site
Change in membrane permeability
Efflux pump
Drug inactivation
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Antibiograms
• Institutional differences in pathogen susceptibility
• An antibiogram is a periodic summary of antimicrobial
susceptibilities of local bacterial isolates submitted to
the hospital's clinical microbiology laboratory
• The information in the antibiogram aid clinicians in the
empiric selection of antimicrobial therapies.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Antimicrobial Stewardship
• Multidisciplinary team that ensures appropriate and
judicious use of antimicrobial therapy in an institution
• Make formulary recommendations
• Restrict antimicrobial therapies to infectious disease
specialists
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Copyright © 2017 McGraw-Hill Education. All rights reserved
Common Bacteria
Link: Drugs of Choice, First Choice, Alternative(s)
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
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Summary
• Confirm the presence of infection
• Nonspecific signs and symptoms of infection
• Fever
• WBC count
• Pain and inflammation
• Site specific symptoms
• Identify of the pathogen
• Gram Stain
• Culture
• Rapid test
• Select empiric antimicrobial therapy based on suspected infection, patient,
medication factors, and local resistance
• Monitoring therapeutic response
• Improvement of signs and symptoms
• Consider changing patient from parenteral to oral therapy
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved
References
• Lee GC, Burgess DS. Chapter 83. Antimicrobial Regimen
Selection. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells
BG, Posey L. eds. Pharmacotherapy: A Pathophysiologic
Approach, 9e.` New York, NY: McGraw-Hill; 2014.
• Lampiris HW, Maddix DS. Clinical Use of Antimicrobial
Agents. In: Katzung BG, Trevor AJ. eds. Basic & Clinical
Pharmacology, 13e. New York, NY: McGraw-Hill; 2015.
• Rybak MJ, Aeschlimann JR, LaPlante KL. eChapter 25.
Laboratory Tests to Direct Antimicrobial
Pharmacotherapy. In: DiPiro JT, Talbert RL, Yee GC, Matzke
GR, Wells BG, Posey L. eds. Pharmacotherapy: A
Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill;
2014.
Author: Michael W. Perry PharmD, BCPS, BCCCP; Assistant Clinical Professor of Pharmacy Practice; Mylan School of Pharmacy
http://accesspharmacy.mhmedical.com/qa.aspx#tab6
Copyright © 2017 McGraw-Hill Education. All rights reserved