Rational Used

of Antibiotics

Nur Farhanah
Division of Infectious Diseases and Tropical Medicine,
Dept of Internal Medicine
Diponegoro University/Kariadi Hospital
 Introduction

 50% of all medicines (Antibiotics) are prescribed

inappropriately.
 half of all patients fail to take medicines correctly.
 > 50% failure to prescribe in accordance with
clinical guidelines .
 The overuse, underuse or misuse of medicines
harms people and wastes resources.
• Antimicrobial resistance.
Resistance patterns vary
– From country to country
– From hospital to hospital in the same country
– From unit to unit in the same hospital
– With time
• Antibiotic associated infection.
• Adverse drug reactions and medication errors.
• Lost resources.
• Eroded patient confidence
 Considerations before
prescribing

1. Is an antibiotic necessary?
2. What is the most appropriate antibiotic?
3. What dose, frequency, route and
duration?
4. How to improve the chances that the
tretament will be effective?
 Is an antibiotic necessary?

• Useful only for the treatment of bacterial infections

• Not all fevers are due to infection
• Not all infections are due to bacteria
• There is no evidence that antibiotics will prevent
secondary bacterial infection in patients with viral
infection
• The treatment of certain infections might be better
achieved with such as debridement
 Choice of antibiotics : Based on three main factors

Etiological agent Patient-related Antibiotic-related

Site of infection, factors factors
host, based on Age, comorbidities, • PK/PD
epidemiology and renal and hepatic • Toxicity/adverse
clinical function,pregnancy, effect
experience,micro allergies, genetic • Drug interaction
biology • cost
diagnosis,local
data
 Principles on choosing an antibiotic for therapy

• Timing of initiation
- bacterial infection, sepsis, febrile neutropenia, bacterial
meningitis  Iniatiated immediately (after collection of
diagnostic specimen)
• Therapeutic or prophylaxis
- AB prescribing should be based on evidence of infection by
clinical criteria (majority) and lab
- Prophylaxis
• Presurgical
• Medical : immunocompromised patients, susceptible IE
before dental or other invasive procedures, malaria
• Empirical or Definitive antibiotic
- initial therapy is often empiric (microbiological results don’t
become available for 24-72 hr)
- based on severity, site of infection, host,local data
- the result sampling (+) confirm the infection, continue empiric
or alternative therapy
• Bactericidal or Bacteriostatic AB
- Bactericidal ABcauses death and disruption of the bacterial
cell
 act on the cell wall (eg, β-lactams),
 cell membrane (eg, daptomycin),
 or bacterial DNA (eg, fluoroquinolones)
- Bacteriostatic AB inhibit bacterial replication without killing
( sulfonamides, tetracyclines, and macrolides )
• Narrow or Broad spectrum antibiotic
consider combination when :
When agents exhibit synergistic activity
against a bacteria.
When critically ill patients before etiology
and/or AB susceptibility can be determined
To extend the AB spectrum beyond that
achieved by use of a single agent for
treatment of polymicrobial infections
To prevent emergence of resistance.
• Oral vs Intravenous therapy
Patients hospitalized with infections are often treated with i.v AB
(prompted by the severity of their infection)
Patients with mild to moderate infections who require
hospitalization for other reasons (eg, dehydration, pain
control, cardiac arrhythmias) and have normal gastrointestinal
function are  treatment with well-absorbed oral AB
Becoming stable  i.v switch to oral immediately.
Oral therapy is less expensive, fewer adverse effects, cost
savings and a shortened LOS.
 Pharmacodynamic Characteristics

concept of time-dependent vs concentration-dependent

killing

time-dependent activity (β-lactams and vancomycin) slow

bactericidal action important that the serum
concentration exceeds the MIC for the duration of the
dosing interval (via continuous infusion or frequent dosing).
concentration-dependent activity (aminoglycosides,
fluoroquinolones, metronidazole, and daptomycin) 
enhanced bactericidal activity as the serum concentration
is increased ( “peak” serum concentration)
The relatioship between PK profile of an AB and MIC against a hypothetical
target organism

Cohen, powderly, Opal. Principles of anti-infective therapy.

Infectious Diseases. 2010;1275-87
 Host Factors to Be Considered in Selection of
Antibiotics
• Renal and Hepatic Function.
- important to determine the functioning during AB adm
- dose reduction to prevent accumulation and toxicity
with reduced renal or hepatic function
- increased to avoid underdosing (Rif)
• Age (young age vs old age, gastric acidity, CCT ).
• Genetic Variation (def G6PD, HLA B5701, Cyp450).
• Pregnancy and Lactation
• History of Allergy .
• History of Recent AB Use.
 Common Misuses of Antibiotics

• Prolonged antibiotic treatment without clear

evidence of infection.
• Failure to narrow antimicrobial therapy when
a causative organism is identified.
• Prolonged prophylactic therapy.
• Excessive use of certain antibiotic agents.
 Conclusion
Appropriate use of AB need :
• an accurate diagnosis,
• determining the need for ,
• timing of antimicrobial therapy,
• host characteristics,
• narrowest spectrum AB and shortest duration of therapy,
and switching to oral agents
• Non-antimicrobial interventions, such as abscess drainage,
are important in management.
• Education to patients (hand washing, vaccination, covering
mouth/nose when sneezing)
Thank you for your attention

Appropriate Antibiotic Use

Saves lives, saves money,
makes sense