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.

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