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The Sanford Guide to Antimicrobial Therapy mobile app includes all the content from the print edition, plus expanded digital-only content, multi-term search. Localized antimicrobial stewardship apps via Stewardship Assist and continually updated clinical content via app, web, and API. This document is also located on the SHC Intranet (sppn.info depts/AntimicrobialStewardshipProgram) and.

Sanford Antimicrobial Pdf

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Treatment Recommendations. For Adult Inpatients. Also available online at insidehopkinsmedicine.0rg/amp. Antibiotic Guidelines. De-escalation to the narrowest antimicrobial as soon as microbiology and . http ://sppn.info sppn.info AND. The 48th edition of the leading clinical reference on treatment of infectious diseases and anti-infective drug information. Helpful in day-to-day.

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Helpful in day-to-day practice and as a component of your organization's antimicrobial stewardship program, the Sanford Guide provides valuable guidance in the age of antibiotic resistance.

Popular with physicians, pharmacists, physician assistants, nurse practitioners, and other clinicians, the Sanford Guide to Antimicrobial Therapy provides information that is convenient, concise, and reliable. SlideShare Explore Search You. Submit Search. Successfully reported this slideshow.

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Sanford Guide to Antimicrobial Therapy Free PDF

Upcoming SlideShare. Like this presentation? Why not share! An annual anal Embed Size px. Start on. Show related SlideShares at end. First, other things being equal, an agent that requires less frequent administration is preferred.

For example, for the treatment of osteomyelitis or other serious infections caused by methicillin- or oxacillin-sensitive S aureus, cefazolin is frequently used in favor of nafcillin or oxacillin because it allows administration every 8 hours. Its use makes treatment outside the hospital setting much more feasible than the administration every 4 hours required for the other drugs.

Agents with once- or twice-daily dosing have gained popularity for OPAT and include ceftriaxone, ertapenem, vancomycin, and daptomycin. Second, the agent must possess chemical stability and should last for about 24 hours after mixing to allow enough time for delivery and administration.

As an important illustration of the principle, the use of intravenous ampicillin for OPAT via self-administration or continuous infusion is often precluded because of a short approximately 8-hour stability period at room temperature.

Ampicillin or penicillin in combination with an aminoglycoside is the drug of choice for endocarditis caused by penicillin-sensitive enterococci; therefore, OPAT for this type of infection usually necessitates either nursing home stay or investment in a continuous infusion device for penicillin only.

Third, agents with minimal toxicity or predictable toxicity amenable to monitoring are preferred as OPAT is generally used in the context of longer-term antimicrobial therapy. Use of Therapeutic Drug Monitoring Monitoring serum concentrations for drugs is most useful for medications that have a fairly narrow therapeutic index, which is the ratio of the toxic to the therapeutic dose.

Fortunately, most antimicrobial agents have a wide therapeutic index, 20 allowing standard doses to be used, with predictable modifications on the basis of age, weight, and renal and hepatic function. However, certain antimicrobial agents require monitoring of serum levels because the therapeutic window is narrow. This could be due primarily to toxicity at high levels eg, aminoglycosides 21 or therapeutic failure at low drug levels eg, vancomycin 22 , 23 but is usually a combination of both eg, voriconazole.

In view of the deleterious effects of prolonged courses of antimicrobial agents, including the potential for adverse reactions, problems with adherence, selection of antibiotic-resistant organisms, and high cost, a number of studies have tried to define the optimal duration of therapy, with an emphasis on shorter courses of therapy.

For example, evidence supports limiting treatment of uncomplicated UTI in women to 3 days, 25 community-acquired pneumonia to 5 days, 26 and ventilator-associated pneumonia to 8 days. For example, in the study of short-course treatment for ventilator-associated pneumonia, 27 the 8-day course was not sufficient for the treatment of infections due to P aeruginosa or in immunocompromised patients.

In other situations, a longer duration of therapy is clearly warranted eg, weeks for endocarditis, osteomyelitis, and intra-abdominal abscesses, and weeks to months for invasive fungal infections to achieve cure and prevent relapse.

In many such infections, treatment duration has to be carefully individualized on the basis of clinical and radiologic response and may require the guidance of an expert in infectious diseases. Assessment of Response to Treatment Response to treatment of an infection can be assessed using both clinical and microbiological parameters. Clinical parameters of improvement include symptoms and signs eg, a decrease in fever, tachycardia, or confusion , laboratory values eg, decreasing leukocyte count , and radiologic findings eg, decrease in the size of an abscess.

Although radiologic criteria are commonly used in assessing response to infectious disease therapy, radiologic improvement can frequently lag behind clinical improvement, and routine radiographic follow-up of all infections is not always necessary. In fact, several weeks or even months may be required before chest radiography or computed tomography shows complete resolution of an infiltrate.

Bacteremia is the most common scenario in which microbiological response is closely assessed because clearance of the bloodstream is as important as clinical improvement. Persistent bacteremia can often be the only clue to the presence of an inadequately treated source or to the existence or development of endovascular infection such as endocarditis or an intravascular device infection.

Persistent bacteremia can also be associated with the emergence of antimicrobial resistance and should always be investigated. Open in a separate window Allergic or hypersensitivity reactions can be either immediate IgE-mediated or delayed and usually manifest as a rash; anaphylaxis is the most severe manifestation of IgE-mediated allergy.

Although no single test or clinical finding leads to a diagnosis of antibiotic allergy, a negative skin test best described for penicillin can reliably exclude the possibility of developing an IgE-mediated reaction such as anaphylaxis and help optimize antibiotic use. If an ongoing reaction is attributed to an antimicrobial drug allergy, this usually requires discontinuation of the offending agent.

Related drugs eg, cephalosporins in patients with a history of penicillin allergy can be used under careful observation, provided that the reaction is not severe or the skin test is negative. In some cases, if the offending agent is the only or highly preferred agent, desensitization may be necessary. Examples include nephrotoxicity with aminoglycosides, neurotoxicity of penicillins, and peripheral neuropathy with prolonged use of metronidazole; these potential adverse effects need to be discussed with patients before initiation of therapy.

In addition, drug doses should be adjusted in response to changes in creatinine level to avoid toxicity and attain optimal serum concentrations.

Many antimicrobial agents interact with other drugs to increase or decrease their serum levels and effects. Clinicians should always remain alert to the possibility of such interactions of antimicrobial agents with other drugs, and it is advisable to review a patient's medication list when prescribing antimicrobial agents.

Certain drug combinations can also cause additive toxicity, as exemplified by the concomitant use of amphotericin and gentamicin, which can significantly increase the risk of nephrotoxicity.

An unfortunate consequence of this increased use is the emergence of infections associated with the placement of such devices, involving both temporary eg, urinary catheter, central venous catheter and permanent eg, prosthetic joint, artificial heart valve implants. However, because of the difficulty of eradicating infections with antimicrobial therapy alone, removal of the implant is often necessary for cure.

As an alternative, for patients unable to tolerate implant removal, long-term suppressive antimicrobial therapy is sometimes used, with variable success.

It is advisable to involve an infectious diseases expert in the management of infections associated with implanted foreign bodies. Use of Antimicrobial Agents as Prophylactic or Suppressive Therapy In an ideal scenario for use of an antimicrobial agent as prophylactic treatment, the infection would occur predictably in a certain setting and would be well known to be associated with a specific organism or organisms, and an effective antimicrobial agent would be available with no or limited long-term toxicity and with little likelihood of leading to the emergence of resistance.

However, antimicrobial prophylaxis is appropriate in some instances, a discussion of which follows. Presurgical Antimicrobial Prophylaxis. Antimicrobial prophylaxis is used to reduce the incidence of postoperative surgical site infections. Patients undergoing procedures associated with high infection rates, those involving implantation of prosthetic material, and those in which the consequences of infection are serious should receive perioperative antibiotics.

The antibiotic s should cover the most likely organisms and be present in the tissues when the initial incision is made, and adequate serum concentrations should be maintained during the procedure. A single dose of a cephalosporin such as cefazolin administered within 1 hour before the initial incision is appropriate for most surgical procedures; this practice targets the most likely organisms ie, skin flora , while avoiding unnecessary broad-spectrum antimicrobial therapy.

Duration of prophylaxis for surgical site infection should not exceed 24 hours in most cases. In these specific settings, evidence supports the use of prolonged antimicrobial prophylaxis until immune markers are restored eg, trimethoprim-sulfamethoxazole to prevent Pneumocystis pneumonia Antimicrobial agents can be prescribed prophylactically to prevent transmission of pathogens to susceptible contacts; for example, antiviral agents can be used to limit the spread of influenza in nursing home residents, ciprofloxacin can be given to close contacts of a patient with meningitis caused by N meningitidis, and macrolides can be prescribed to reduce transmission of pertussis.

It should be noted that guidelines recommending antimicrobial prophylaxis in this setting have recently been updated and limit such use to only a few very high-risk scenarios—prosthetic valves, prior endocarditis, or congenital heart disease before surgical correction. No consensus has yet been reached on the use of antimicrobial prophylaxis in some other settings, such as before invasive procedures in patients with prosthetic joints.

Nonantimicrobial Therapy for Infections Antimicrobial therapy is usually, but not always, the most important therapy for infectious diseases. This procedure is useful when the organism burden is very high or in the management of abscesses, for which the penetration and activity of antimicrobial agents are often inadequate.

Other therapies used in the treatment of infectious diseases involve modulating the host inflammatory response to infection. Systemic corticosteroids, thought to act by decreasing the deleterious effects of the host inflammatory response, have been found beneficial when used in conjunction with antimicrobial therapy for the treatment of bacterial meningitis, 46 tuberculous meningitis, 47 and Pneumocystis pneumonia in patients with AIDS.

Similarly, granulocyte colony—stimulating factor is sometimes administered to patients with prolonged neutropenia who develop invasive infections with filamentous fungi. One strategy that can significantly reduce cost is the switch from intravenous to oral therapy. Oral therapy is generally less expensive, potentially associated with fewer adverse effects, and can result in considerable cost savings by facilitating earlier dismissal and a shortened hospital stay.

This has been demonstrated for oral linezolid when compared with intravenous vancomycin for the treatment of complicated skin and soft tissue infections caused by MRSA. Some components recommended for these programs include the following: prospective audit and feedback of antimicrobial prescriptions to clinicians, formulary restriction, education, use of clinical order sets and guidelines, de-escalation of therapy, and intravenous to oral antimicrobial conversion when appropriate.

Preventing Emergence of Antibiotic Resistance The widespread—and often inappropriate—use of antimicrobial agents is the single most important cause of the emergence of drug resistance, both in the community and hospital settings. Prior antibiotic exposure has been shown to be the most frequent risk factor for the development of community-acquired respiratory infections caused by drug-resistant S pneumoniae.

In the past few years, interest has been increasing in the development of rapid and accurate diagnostic tests for detection of viral respiratory pathogens with the ability to distinguish between viral and bacterial infections, such as measurement of procalcitonin levels and nucleic acid tests.

Although not yet widely available in clinical practice, these tests have the potential to curtail the use of antibacterial agents for clinical syndromes that are clearly caused by viruses. Common Misuses of Antibiotics In some settings, the use of antibiotics is clearly inappropriate.

General Principles of Antimicrobial Therapy

A discussion follows of some of the typical scenarios in which they are contraindicated. One of the most common mistakes in antimicrobial use is continuing to add or switch antibiotics when a patient does not appear to be responding to therapy, even though there is no clear evidence of an infectious disease.

Many noninfectious, inflammatory, or neoplastic syndromes can present with symptoms and signs that mimic infectious diseases. Examples include adult-onset Still disease and other connective tissue disorders that can present with high fever; drug-induced fever; the fever associated with pulmonary embolism; lymphoma; and Wegener granulomatosis, which can present with fever, cavitary pulmonary nodules, and recurrent sinusitis.

Colonization with potentially pathogenic organisms without any associated manifestation of disease occurs frequently in certain populations eg, colonization of the urinary tract in women of advanced age or in the presence of an indwelling urinary catheter, colonization of endotracheal tubes in mechanically ventilated patients, and colonization of chronic wounds.

As already discussed, initial therapy is often empiric and relies on broad-spectrum agents until culture or other tests help determine the microbiological etiology. Once culture and susceptibility data are available, an antibiotic with the narrowest possible spectrum should be selected for continuation of therapy.

Often, however, this does not occur, particularly if the patient has improved while receiving empiric therapy, and the physician is uncomfortable about changing therapy in the face of clinical improvement.

Sanford Guide Collection

Prolonged Prophylactic Therapy. As already discussed, infection can be prevented in certain situations by the prophylactic use of antimicrobial agents eg, presurgical prophylaxis. However, in most cases, guidelines support the use of a single, preoperative dose of an antimicrobial agent. For example, the common practice of prolonging antimicrobial therapy until the removal of surgical drains is not evidence based.

Excessive Use of Certain Antimicrobial Agents. The frequent use of certain agents or classes of antimicrobial agents in a hospital or other health care setting can result in selection of organisms that are resistant to that particular antibiotic.

For example, the increased use of fluoroquinolones during the past decade is thought to be, in part, responsible for the epidemic of a fluoroquinolone-resistant strain of C difficile, 58 the most common cause of nosocomial infectious diarrhea. More recently, an increase in levofloxacin use as initial therapy for UTI as a result of policy change at a single institution was found to have led to a rapid increase in fluoroquinolone resistance among outpatient urinary E coli isolates at that institution.

In addition, nonantimicrobial interventions, such as abscess drainage, are equally or more important in some cases and should be pursued diligently in comprehensive infectious disease management.

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Notes On completion of this article, you should be able to: 1 determine the appropriate timing of initiation of antimicrobial therapy, 2 recognize different types of adverse effects of antimicrobial agents and modify antimicrobial therapy as appropriate, and 3 identify clinical scenarios in which use of antimicrobial agents is inappropriate. For CME credit, see the link on our Web site at mayoclinicproceedings.

Clin Infect Dis. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients.

Practice guidelines for the management of bacterial meningitis. General principles of antimicrobial therapy.

The Sanford Guide to Antimicrobial Therapy 48th Edition Pdf

Mayo Clin Proc. Vol 1 7th ed. Drusano GL. Human pharmacodynamics of beta-lactams, aminoglycosides and their combination. Scand J Infect Dis Suppl. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association.

Levison ME. Pharmacodynamics of antimicrobial drugs. Infect Dis Clin North Am. Micromedex Healthcare Series [Internet database]. Updated periodically ed. The Sanford Guide to Antimicrobial Therapy Antibacterial medication use during pregnancy and risk of birth defects: National Birth Defects Prevention Study. Arch Pediatr Adolesc Med.

Czock D, Rasche FM. Dose adjustment of ciprofloxacin in renal failure: reduce the dose or prolong the administration interval?Br J Clin Pharmacol. Are you sure you want to Yes No.

Sonia Tindall Last. Helpful in day-to-day practice and as a component of your organization's antimicrobial stewardship program, the Sanford Guide provides valuable guidance in the age of antibiotic resistance. Premature initiation of antimicrobial therapy in these circumstances can suppress bacterial growth and preclude the opportunity to establish a microbiological diagnosis, which is critical in the management of these patients, who require several weeks to months of directed antimicrobial therapy to achieve cure.