1
Q
use the traffic light system to triage this case:
A 2 year old child is brought to the pharmacy by a concerned grandparent. The child has had a temperature of 38.5°C for the last 24 hours. The grandparent is worried because the child has an unusual high-pitched cry, seems very drowsy, and cannot stay awake for more than a few minutes. He is breathing rapidly and has recently vomited
A
red → high risk of illness
The child’s high-pitched cry and extreme drowsiness are indications of a high risk of serious illness
2
Q
Pyrexia / Pyrexic
(what do both of these mean?)
A
- pyrexia = a raised body temperature; fever
- pyrexic = feverish
3
Q
what are 3 of the most common antibiotic resistant infections?
A
- methicillin resistant staphylococcus aureas (MRSA) (commonly known as the hospital “superbug”)
- extended specturm beta-lactamases (ESBL-E)
- vancomycin resistant enterococci (VRE)
4
Q
Who are the most at risk of illness due to resistant bacteria?
A
- hospital patients who are elderly or very sick
- hospital patients who have an open wound (bedsore) or a tube going into their body (like a urinary catheter or on dialysis)
- people undergoing treatment for cancer
- organ transplant patients
- women needing Caeserean-sections during childbirths
5
Q
antibiotic stewardship meaning
A
- ‘stewardship’ describes the careful and responsible management of something entrusted in one’s care.
- For antibiotics, this means appropriate use to improve patient outcomes while minimising the development and spread of antimicrobial resistance (AMR).
- Antibiotic stewardship uses processes designed to measure use of antibiotic and optimise appropriate practices.
6
Q
what do global/international level AMR programmes focus on?
A
how new antibiotics are introduced to the market, labelled, priced and distributed
7
Q
what do national level AMR programmes focus on?
A
legislation, regulation & national treatment guidelines
8
Q
what do hospital level AMR programmes focus on?
A
optimizing the use of antibiotics for patients in hospitals
9
Q
what do community level AMR programmes focus on?
A
- fostering access & appropriate use in primary health care settings & in animal health through awareness raising and targeted interventions
10
Q
what are the five strategic objectives for tackling AMR for the global action plan on antimicrobial resistance (WHO)
A
- Increase global awareness and understanding about AMR
- Use surveillance and research to strengthen knowledge on AMR
- Reduce the incidence of infections through hygiene, sanitation and other infection preventative measures
- Optimise the use of antimicrobial agents- targeted use
- Increase investments in countering AMR - new medicines, diagnostic tools, vaccines
11
Q
what are the 5 key objections of New Zealands antimicrobial resistance action plan?
A
- awareness & understanding
- surveillance & research
- infection prevention & control
- antimicrobial stewardship
- governance, collaberation & investment
12
Q
steps that can be taken by individuals to reduce the impact and limit AMR
A
- Only use antibiotics when prescribed and follow instructions on how to take them by your health care professional.
- Do not insist on antibiotics if your HCP says you do not need them and never share or use leftover antibiotics.
- Take any unused antibiotics back to your pharmacy so they are disposed of safely and don’t enter the environment.
- Prevent infections by regular hand washing, practising food hygiene, avoid close contact with sick people, practising safer sex, and keeping vaccinations up to date.
13
Q
steps that can be taken by policy makers to reduce the impact and limit AMR
A
- Ensure a robust national action plan to tackle AMR
- Improve surveillance of antibiotic-resistant infections
- Implement infection prevention and control measures
- Regulate and promote appropriate use and disposal of quality medicines
- Make information available on the impact of AMR
14
Q
steps that can be taken by healthcare professions (HCP) to reduce the impact and limit AMR
A
- Prevent infections by ensuring hands, instruments, and environment are clean.
- Only prescribe and dispense antibiotics when they are needed, according to current guidelines
- Report antibiotic-resistant infections to surveillance teams.
- Talk to your patients about how to take antibiotics correctly, AMR and the dangers of misuse
- Talk to your patients about preventing infections (vaccination, hand washing, safer sex and covering nose and mouth when sneezing)
15
Q
steps that can be taken by the healthcare industry to reduce the impact and limit AMR
A
- invest in research and development of new antibiotics, vaccines, diagnostics & other tools
16
Q
to reduce AMR - primary healthcare professionals should only prescribe antibiotics for bacterial infections if…
A
- symptoms are significant and sever
- there is a high risk of complications
- the infection is not resolving or is unlikely to resolve
17
Q
antibiotic-resitsance bacteria can spread to humans through:
A
- contact with a person who has an antibiotic-resistant infection
- contact with something that has been touched by a person who has an antibiotic-resistance infections (e.g. health workers hands or instruments in a hospital with poor hygiene)
- contact with a live animal, food or water carrying antibiotic-resistant bacteria
18
Q
what is cellulitis?
A
an acute infection of skin involving deep dermis and subcutaneous fat
19
Q
where should adults and children with uncomplicated cellulitis be best managed?
A
most uncomplicated cellulitus cases can be managed in the community after the involvement of a GP
20
Q
what are the high risk co-morbidies associated with a higher risk of getting a cellulitis infection? (10 of them)
A
- eczema
- lymphodema
- obesity
- tinea pedis
- ulcers
- venous insufficiency
- previous episode of cellulitis
- peripheral artery disease
- diabetes
- pregnancy
21
Q
empiric therapy for cellulitis will likely involve antibiotic/s that are effective against
A
streptococci
22
Q
what is the main purpose of white blood cells (WBC)?
A
to fight infection
23
Q
of the five different types of white blood cells, what type is the majority?
A
neutrophils
24
Q
what sort of scenarios can raise neutrophil levels?
A
- excessive exercise
- high stress level
- infection
- injury/surgery
- non-infectious inflammation
- smoking cigarettes
- steriod use
25
main clinical features of cellulitis
* cellulitis can affect any site, but most often affects the limbs
* is usually unilateral
* can occur by itself or complicate an underlying skin condition or wound
* the **first sign** of the illness is often f**eeling unwell, with fever, chills & shakes** (due to bacteria in the bloodstream - bacteraemia)
* systemic symptoms are soon followed by the development of a localised area of painful, red, swollen skin
26
other signs of cellulitis
* dimpled skin
* warmth
* blistering
* erosions & ulceration
* abscess formation
27
complications of cellulitis
* necrotising fasciitis (a more serious soft tissue infection)
* gas gangrene
* severe sepsis (blood poisoning)
* infection of other organs e.g. pneumonia, osteomyelitis, meningitis
* endocarditis (heart valve infection)
28
treatment of uncomplicated cellulitis:
(i.e. how would you treat)
If there are no signs of systemic illness or extensive infection, patients with mild cellulitis can be t**reated with oral antibiotics at home, for a minimum of 5–10 days**. In some cases, antibiotics are continued until all signs of infection have cleared (redness, pain and swelling), sometimes for several months. Treatment should also include:
* analgesia to reduce pain
* adequate water/fluid intake
* management of co-existing skin conditions
29
treatment of cellulitis with systemic illness:
(i.e. how would you treat)
More severe cellulitis and systemic symptoms should be **treated with fluids, intravenous antibiotics and oxygen**. The **choice of antibiotics depends on local protocols** based on prevalent organisms and their resistance patterns and may be altered according to culture/susceptibility reports.
Treatment may be switched to oral antibiotics when the fever has settled, cellulitis has regressed, & CRP is reducing.
30
types of antibiotics used to treat cellulitis
* **penicilli-based** antibiotics are often chosen (e.g. penicillin G or flucloxacillin)
* **amoxicilllin & clavulanic acid provide broad-spectrum** cover if unusual bacteria are suspected
* **cephalosporins** are also commonly used (e.g. ceftriaxone, cefotazime or cefazolin)
* **clindamycin, sulfamethoxazole/trimethoprim, doxycycline & vancomycin are used in patients with penicillin or cephalosporin allergy, or where infection with methicillin-resistant Staphylococcus aureus (MRSA) is suspected**
* Broad-spectrum antibiotics may also include linezolid, ceftaroline, or daptomycin
31
multidisciolinary care for cellulitis
* an internal medicine physician is consulted to assess & manage sepsis
* the infectious diseases service can advise on microbiology & choice of antibiotic
* a surgeon is called to drain an abscess, debride necrotic tissue, & relieve compression symptoms, e.g. compartment syndrome
* An ophthalmologist should be involved in the case of orbital cellulitis.
* A dermatologist may be called to confirm the diagnosis of cellulitis or suggest alternative diagnoses.
* Specialist nurses may advise on dressings and bandaging.
32
what is the management of recurrent cellulitis?
* Avoid trauma, wear long sleeves and pants in high-risk activities, such as gardening
* Keep skin clean and well moisturised, with nails well tended
* Avoid having blood tests taken from the affected limb
* Treat fungal infections of hands and feet early
* Keep swollen limbs elevated during rest periods to aid lymphatic circulation.
* Those with chronic lymphoedema may benefit from compression garments.
* patients with 2 or more episodes of cellulitis may benefit from chronic suppressive antibiotic treatment with low-dose penicillin V or erythromycin, for one to two years
33
diagnosis of cellulitis
* Cellulitis can usually be diagnosed **clinically by the presence of localised pain, swelling, erythema and heat**
* The **white blood cell count can be expected to be elevated** in almost half of patients with cellulitis, and approximately two-thirds of patients can be expected to have an **elevated CRP** → Neither marker is sensitive or specific enough to be used diagnostically for cellulitis, although an **elevated CRP is a more reliable indicator of bacterial infection than an elevated white blood cell count**.
34
red flags for hopsital admission for cellulitis
It is recommended that patients with cellulitis and any of the following features should be referred to hospital; a lower threshold for referral is appropriate for young children, e.g. aged less than one year, and frail older people:
* **Signs of systemic involvement or haemodynamic instability**, e.g. tachycardia, hypotension, severe dehydration
* **A progressing infection despite prior antibiotic treatment,** e.g. spreading margins or worsening lymphangitis
* **Pain suggestive of necrotising fasciitis,** e.g. the patient appears in severe pain or describes their pain as rapidly and dramatically worsening
* **Unstable co-morbidities** that may complicate the patient’s condition, e.g. diabetes, vascular disease or heart failure
* ** Immunosuppression**, e.g. a history of immunodeficiency illness, currently undergoing chemotherapy or taking immunosuppressant medicines such as prednisone, methotrexate, ciclosporin
* **An animal or human bite wound requiring surgical debridement**
* **A large abscess formation requiring general surgical drainage**
* **Orbital involvement** unless cellulitis is very mild
35
what is empiric antibiotic therapy?
empiric therapy is medical treatment or therapy based on experience and, more specifically, therapy begun on the basis of a clinical "educated guess" in the absence of complete or perfect information
36
what factors relating to the suspected "BUG" need to be considered before starting Empiric antibiotic therapy?
* likely organism and location
* severity of infection: systemic? localised?
37
what factors relating to the first line DRUG need to be considered before starting therapy?
* spectrum of activity (broad vs narrow)
* PK/PD: distribution, half life
* toxicity and ADR profile (risk/benefit)
* local sensitivities
* formulations available
* funding considerations
38
what PATIENT factors need to be considered before starting empiric therapy?
* Allergy status
* Age – neonates, elderly
* Renal function
* Hepatic function
* Co-morbidities (including immunosuppression)
* Pregnancy/Breastfeeding
* History of MDR infection
* Drug interactions
* Clinical setting: inpatient/outpatient
* Site of infection: eg: CNS infection vs eye infection
39
Southern DHB - treatment of cellulitis in the community (outpatient) for adults
* The mainstay of treatment for outpatient cellulitis is **HIGH DOSE ORAL antibiotics plus probenecid.**
* Traditionally, **once daily IV cefazolin with a stat dose of probenecid** was the first line treatment.
* One of the goals of cellulitis treatment is to avoid hospital admission unless that patient is critically unstable
40
Southern DHB - treatment for moderately severe cellulitis
* **Flucloxacillin 1g QID PO plus probenecid 500mg QID PO.**
* High dose flucloxacillin should be advised to be taken WITH FOOD to reduce gastrointestinal side effects like nausea.
* Probenecid is NOT an antibiotic. It is given as an adjunct to oral flucloxacillin regimen because it reduces the renal excretion of flucloxacillin and therefore increases its plasma concentration, similar to that achieved with IV flucloxacillin.
41
important points regarding probenecid
* Probenecid is NOT an antibiotic. It is given as an adjunct to oral flucloxacillin regimen because it reduces the renal excretion of flucloxacillin and therefore increases its plasma concentration, similar to that achieved with IV flucloxacillin.
* Probenecid MUST NOT be prescribed with methotrexate as toxic accumulation of methotrexate can occur
* Probenecid is not required if creatinine clearance is <30mL/min since higher plasma levels of flucloxacillin is retained.
* probenecid is a masking agent of performance enhancing drugs and will be detected by urine test. This may be a problem is patient is involved in professional sport.
42
probenecid delays the renal excretion of what oral antibiotics?
* amoxicillin
* cefazolin
* flucloxacillin
43
in which situations would once daily IV cefazolin still be warranted?
* Inpatient treatment when cellulitis has not responded to oral first line treatment
* patient cannot take medicines by mouth e.g. dysphagia.
* Patient is unlikely to be compliant with oral antibiotic regimen e.g. dementia.
44
What is the preferred antibiotic to treat outpatient cellulitis if patient is mildly allergic to flucloxacillin?
if the allergy is mild, use **ceflexin 1g QID PO plus Probenecid 500g QID PO**
45
What is the recommended antibiotic treatment for outpatient cellulitis if patient has a history of anaphylaxis or other severe reaction to flucloxacillin?
prescribe a macrolide antibiotic like erythromycin or use clindamycin 600 TDS PO
PHCY220
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