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Principles of Antimicrobial Therapy: By: Herri S. Sastramihardja
Principles of Antimicrobial Therapy: By: Herri S. Sastramihardja
Principles of Antimicrobial Therapy: By: Herri S. Sastramihardja
THERAPY
By :
Herri S. Sastramihardja
Prof.,DR.,Dr.,SpFK
Introduction
AM drugs are effective in the treatment
of
Selection of AM agent
Requires information about :
THE TYPES OF AM
THERAPY
1. Directed (definitive) AM therapy
base on identification & susceptibility test
interpreted in the context of the overall
clinical picture
directed to specific organisms
most effective, least toxic, narrowest
3. Prophylactic AM therapy
restricted to certain situation
Empiric therapy :
Coverage by a combination of
antibiotics such as, clindamycin plus
gentamicin, effective against gram
possitive, gram negative and
anaerobes, or a single broad
spectrum antibiotic, such as
imipenem cilastatin
If mixed
If Gram
positive only
Continue gram
positive coverage
discontinue gram
negative and
anaerobic coverage
If Gram
negative only
Continue therapy as
initiated
If anaerobic only
Continue gram
negative coverage
discontinue gram
positive and
anaerobic coverage
Continue anaerobic
coverage,
discontinue gram
positive and gram
negative coverage
Conclusive diagnosis
culture (disk diffusion) methode
various concentration
(broth/dilution methode)
Safety of AM agent
Related to :
Inherent nature of AM
Patient factors that can predispose to toxicity
Penicillins
Choramphenicol
least toxic
potential for serious
toxicity
Immune system :
Immunocompromised host
Alcoholism
Diabetes
HIV
Malnutrition
Advanced age
Therapy with immunosuppresive drugs
bactericidal AM
Renal dysfunction:
Accumulation of AM that are ordinary
eliminated by renal
Elderly
vulnerable to accumulation
Controlled by:
Adjusting the dose/dosage schedule
Monitoring serum levels
Used AM that undergo extensive
metabolism / billiary excretion
Hepatic dysfunction
AM that are concentrated/eliminated by
the liver are contraindicated
Erythromycin, tetracycline, quinolone,
choramphenicol
Genetic factor
Enzym deficient
potential for
toxicity of certain agent
Sulfonamid, nitrofurantoin in G-6PD
deficient people
hemolysis
Pregnancy
Most of AM cross the placenta to some
degrees
The problem are teratogenic/toxic effect
Metronidazol, rifampicin, trimetoprim
teratogenic
Tetracycline
tooth dysplasia + bone
growth inhibition
Aminoglycosides
ototoxic to the fetus
Lactation
Many AM are excreted in breast milk
new borns microflora distorted
act as a sensitizer future allergy
Age :
Most AM eliminated by the renal; renal
function changes with age
Renal/hepatic elimination in newborns <
Neonates particularly vulnerable to :
Chloramphenicol
Sulphonamides
Tetracyclines
Fluoroquinolones (>< cartilage growth)
Bacteriostatic AM:
Choramphenicol, erythromycin,
clindamycin, lincomycin, sulfonamide,
trimetoprim
Bactericidal AM:
Penicillins, cephalosporins, carbapenem,
aminoglycosides, quinolones, vancomycin
Tetracycline
Metronidazole
Bismuth
subsalicylate
Amoxicillin
Clarithromycin
$5
$6
$11
$17
$120
inappropriate drug
inadequate dose
improper route of adm.
malabsorption
accelerated inactivation
poor penetrate
Host
Pathogens
drug resistence
superinfection
dual infection initially
Laboratory
erroneous report of
susceptible pathogen
Misuses of AM
Treatment of untreatable infections
Therapy of fever of unknown arigin
Short duration
Persisting 2 weeks
Improper dosage
Inappropriate reliance an AM alone
Lack of adequate bacteriological information
Mixed infection
Synergism effect
Risk of developing resistant organisms
Antibiotics coverage
or
Infections of unknown origin
Disadvantages of AM combinations
Risk of toxicity
The
selection of multiple-drug
resistant (=MDR) pathogens
Antagonism of AM effect
(bacteriostatic + bactericidal)
NRC WOUND
CLASSIFICATION
CRITERIA
1. Clean
- elective, primarily closed procedure
- expected infection rate 2%
2. Clean contaminated
- urgent or emergency case that is otherwise
clean
- expected infection rate 10 %
3. Contaminated
4. Dirty
Disadvantages to prophylactic AM
1.
2.
3.
4.
Toxic/allergic reactions
Superinfection with more resintence flora
Infection temporarily masked
Ecology of the hospital flora may be altered
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