A-Z on Antimicrobial Prescribing
Guest-blog by Dr. Rohini Wadanamby, Consultant clinical microbiologist, Lanka hospital diagnostics, Lanka Hospital, Sri Lanka.
Rohini is AMR Insights Ambassador since 2019.
Antimicrobial resistance is a huge threat that we are facing globally during this decade. Worldwide many organizations, societies, committees individually and collectively are trying to combat this threat. CDC recently published a list of urgent threats, serious threats, concerned threats and watch list of those microbes who are already identified and causing problems worldwide (05/11/2019).
I am going to share a lecture I did using 26 letters of the alphabet to discuss a way to minimize resistance while prescribing for infections to cure patients. This was done on 23/01/202 at the doctors forum of Lanka hospital. Sri Lanka.
- Assess the need of antimicrobial: Identify the infection, sort whether it is viral, bacterial or others. Local or systemic. Use sepsis scores to assess the severity, SOFA, qSOFA, NEWS, LODS, ProCESS, ARISE, ProMISE etc
- Bypass peer pressures: Patient requests/ expectations, drug companies, conflict of interests
- Correct choice: Antiviral, anti-parasitic, anti-fungal, antibiotic. Local, Oral or systemic route. Which group of antibiotic and its PK/PD. Consider patient’s tolerance, allergy and concentration in serum and at the site.
- Diagnostics-Microbiology and others: Identify the type of microbe and susceptibilities. Identify toxicity, virulence, expected dangers and get the supporting markers
- Evaluate the clinical and laboratory finding to initiate therapy and throughout until the cure.
- Follow the guidelines, protocols, policies and experience plus “ gut feelings”.
- Good intension in changing, switching antimicrobials. Based on evidence escalation, de-escalation, intravenous to oral etc.
- Hold up unwanted antibiotics. Avoid poly pharmacy. Empirical therapy change to appropriate based on evidence.
- Investigate adequately and cost effectively.
- Justice and justification at all levels of infection management to the patient, institute, population, nation and the world.
- Knowledge on infection management should be updated every day.
- Levels of antimicrobials should be done adequately based on individual needs of the patient.
- Microbiome of the gut. It is very important to preserve, replace and maintain patients’ microbiome which is a key area of resistance development and spread.
- Nutritional status of the patient should be maintained appropriately.
- Organ functions are to be assessed at the early phase for the sepsis scores and monitor during management for drug toxicities and dosing purposes.
- Preventive aspects of infections. Transmission based precautions, source isolation, outbreak prevention etc
- Question the need of the antibiotic every day and do not be hesitant to stop them when the satisfactory cure is achieved.
- Resist resistance development utilizing / practicing all the available measures.
- Surveillance to be carried out for resistance development detection and infection detection.
- Therapeutic index and therapeutic window should be known by the prescribers.
- Underline diseases/conditions should be assessed and monitored.
- Venous access management is very important in preventing line infections, phlebitis etc. (Bundle care is preferred).
- Washing hands and monitoring adherence to the practice at all levels is very important.
- Extreme caution for MDR and XDR.
- Yearly antimicrobial susceptibility patterns of the institute is very useful in combatting AMR.
- Zero tolerance rule for prescription pressures at all levels and stick to the absolute necessity of the antimicrobials.
(C) Dr Rohini Wadanamby; all rights reserved