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Intravenous Antibiotics in the Community Lilian Li Principal Microbiology Pharmacist Imperial College Healthcare NHS Trust St Mary’s Hospital Thanks to.

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Presentation on theme: "Intravenous Antibiotics in the Community Lilian Li Principal Microbiology Pharmacist Imperial College Healthcare NHS Trust St Mary’s Hospital Thanks to."— Presentation transcript:

1 Intravenous Antibiotics in the Community Lilian Li Principal Microbiology Pharmacist Imperial College Healthcare NHS Trust St Mary’s Hospital Thanks to Jan Hitchcock, Dr Hand & Dr Conlon

2 Aim & Objectives To improve knowledge on intravenous (IV) antibiotics used in the community To improve knowledge on intravenous (IV) antibiotics used in the community Become familiar with some of the infections treated Become familiar with some of the infections treated Become familiar with some of the pathogenic micro-organisms involved Become familiar with some of the pathogenic micro-organisms involved List the ideal properties of a suitable antibiotic for use in the community List the ideal properties of a suitable antibiotic for use in the community List the most common antibiotics used List the most common antibiotics used State how to administer those antibiotics State how to administer those antibiotics Be familiar the side-effects associated with these antibiotics to be monitored Be familiar the side-effects associated with these antibiotics to be monitored List sources of support List sources of support

3 Gram +ve Cocci (spherical) StaphylococciStreptococciEnterococciPeptococci/Peptostreptococci* Gram -ve Cocci Neisseria meningitidis Neisseria gonorrhoea Moraxella catarrhalis Acinetobacter (coccobacillus) Gram +ve Rods Clostridia* Corynebacteria (diphtheroids) ListeriaBacillus*Anaerobes Gram -ve Rods Bacteroides* Lactose-fermenting coliforms E coli, Klebsiella, Enterobacter E coli, Klebsiella, Enterobacter Non lactose-fermenting coliforms Proteus, Salmonella, Shigella Proteus, Salmonella, ShigellaPseudomonasHaemophilus Helicobacter, Campylobacter Legionella

4 Cert Gram +ve Skin & mucous membranes Gram -ve GI-tract Anaerobes Mouth, teeth, throat, sinuses & lower bowel Generally... Atypicals Chest and genito-urinary

5 The perfect IV antibiotic for use in the community Efficacy, safety, cost Efficacy, safety, cost Ease of administration Ease of administration –bolus vs. infusion Pharmacokinetics Pharmacokinetics –long half-life allows once or twice daily dosing Stability Stability –dry or diluted –room temperature or refrigerated Compatibility Compatibility –with other antibiotics –with saline and heparin flushes

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7 Pattern of Activity Antibiotics Goal of Therapy PK/PD Parameter Type I Concentration- dependent killing & Prolonged persistent effects Aminoglycosides Daptomycin Fluoroquinolones Ketolides Maximize concentrations 24h- AUC/MIC Peak/MIC Type II Time-dependent killing and Minimal persistent effects Carbapenems Cephalosporins Erythromycin Linezolid Penicillins Maximize duration of exposure T>MIC Type III Time-dependent killing and Moderate to prolonged persistent effects. Azithromycin Clindamycin Oxazolidinones Tetracyclines Vancomycin Maximize amount of drug 24h- AUC/MIC

8 Extract from Table 5. Tice AD et al. CID 2004, 38:

9 Which antibiotics? Ceftriaxone Ceftriaxone Teicoplanin Teicoplanin Ertapenem Ertapenem Ceftazidime Ceftazidime Meropenem Meropenem Gentamicin Gentamicin

10 Ceftriaxone 3 rd generations cephalosporin 3 rd generations cephalosporin Activity: Gram negative and positive bacteria Activity: Gram negative and positive bacteria 5-10% cross sensitivity to penicillins 5-10% cross sensitivity to penicillins Side-effects Side-effects –GI upset, diarrhoea, n&v (precipitation in gall bladder) Administration Administration –Bolus reconstitute 1g with 10ml WFI & infuse over 3-5 minutes reconstitute 1g with 10ml WFI & infuse over 3-5 minutes –Intermittent infusion Reconstitute 2g with 40ml N/Saline & infuse over 30 minutes Reconstitute 2g with 40ml N/Saline & infuse over 30 minutes

11 Teicoplanin Glycopeptide Glycopeptide Activity: Serious Gram positive infection resistant to other antibiotics Activity: Serious Gram positive infection resistant to other antibiotics Contra-indicated if patient vancomycin allergic Contra-indicated if patient vancomycin allergic Side-effects Side-effects –Rash, n&v, hearing impairment, renal impairment Administration Administration –Bolus Reconstitute vial with 3ml WFI, roll & rest. Infuse over 3-5 minutes Reconstitute vial with 3ml WFI, roll & rest. Infuse over 3-5 minutes

12 Ertapenem Carbapenem Carbapenem Activity: broad spectrum (Gram +ve/-ve and anaerobes) Activity: broad spectrum (Gram +ve/-ve and anaerobes) CARE! Sodium valproate / valproic acid CARE! Sodium valproate / valproic acid Contra-indication Contra-indication –Anaphylaxis to β-lactams Side-effects Side-effects –Rash, n&v,  LFTs,  platelets Administration Administration –Reconstitute 1g with 10ml WFI, dilute up to 50ml with N/Saline. Infuse over 30 minutes.

13 Ceftazidime 3 rd generations cephalosporin 3 rd generations cephalosporin Activity: Gram -ve and +ve bacteria Activity: Gram -ve and +ve bacteria 5-10% cross sensitivity to penicillins 5-10% cross sensitivity to penicillins Side-effects Side-effects –GI upset, diarrhoea, n&v Administration Administration –Bolus reconstitute with 10ml WFI or N/Saline & infuse over 3-5 minutes reconstitute with 10ml WFI or N/Saline & infuse over 3-5 minutes

14 Meropenem Carbapenem Carbapenem Activity: broad spectrum (Gram +ve/-ve and anaerobes) Activity: broad spectrum (Gram +ve/-ve and anaerobes) Contra-indication Contra-indication –Anaphylaxis to β-lactams Side-effects Side-effects –GI upset, injection site reactions, headache Administration Administration 500mg vial with 10ml WFI, infuse over 5 minutes.

15 Gentamicin Aminoglycoside Aminoglycoside Activity: Gram -ve Activity: Gram -ve Side-effects Side-effects –Ototoxicity, nephrotoxicity Administration Administration –Dilute 1g with 10ml N/Saline, infuse over 3-5 minutes. TDM TDM –Pre-dose = trough –Aim < l mg/L

16 peak trough Dose time Serum concentration If one dose is given…

17 Dose time Serum concentration What we want… Dose trough

18 time Serum concentration If doses too close together Dose trough

19 How often should gentamicin be given

20 Infusion Devices Human with syringe and needle Human with syringe and needle Gravity drip Gravity drip IVAC pump IVAC pump Syringe driver Syringe driver Elastomeric device (e.g. Intemate) Elastomeric device (e.g. Intemate) CADD (programmable portable device) CADD (programmable portable device)

21 OPAT complications Drug-associated GI upset RashFeverNeutropeniaAnaphylaxisRenal Line-associatedInfectionLeakagePhlebitisThrombosis Other Rx related Unrelated

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23 OPAT team BNF BNF Drug monographs Drug monographs Community chemist Community chemist CNS Nurses CNS Nurses –Anu Viljanen –Jan Hitchcock Microbiology Pharmacists Microbiology Pharmacists –Tracy Lyons –Lilian Li Medicines information Medicines information –

24 Summary Safe and effective Safe and effective Saves thousands of bed days Saves thousands of bed days Highly dependent on liaison nurses Highly dependent on liaison nurses –Number of nurses are rate-limiting High patient satisfaction High patient satisfaction A model for NHS hospital / community cooperation


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