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Selection
Upon completion of the chapter, the reader will be able to:
1. Recognize that antimicrobial resistance is an inevitable
consequence of antimicrobial therapy.
2. Describe how antimicrobials differ from other drug
classes in terms of their effects on individual
patients as well as on society as a whole.
3. Identify two guiding principles to consider when treating
patients with antimicrobials, and apply
these principles in patient care.
4. Differentiate between microbial colonization and infection
based on patient history, physical
examination, and laboratory and culture results.
5. Evaluate and apply at least six major drug-specific
considerations when selecting antimicrobial
therapy.
6. Evaluate and apply at least seven major patient-specific
considerations when selecting
antimicrobial therapy.
7. Select empirical antimicrobial therapy based on
spectrum-of-activity considerations that provide a
measured response proportional to the severity of illness.
Provide a rationale for why a measured
response in antimicrobial selection is appropriate.
8. Identify and apply five major principles of patient
education and monitoring response to
antimicrobial therapy.
9. Identify two common causes of patients failing to improve
while on antimicrobials
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
AND DIAGNOSIS
Physical Examination
Imaging Studies
Laboratory Studies
Common nonmicrobiological laboratory tests include the
white blood cell count (WBC) and differential, erythrocyte
sedimentation rate (ESR), and determination of biomarkers
C-reactive protein (CRP) or procalcitonin levels. In most
cases, the WBC count is elevated in response to infection,
but it may be decreased owing to overwhelming or
longstanding
infection. The differential is the percentage of each
type of WBC (Table 691). In response to physiologic stress,
neutrophils leave the bloodstream and enter the tissue to
fight against the offending pathogens (i.e., leukocytosis).
It is important to recognize that leukocytosis is nonspecific
for infection and may temporarily occur in response to
noninfectious
conditions such as acute myocardial infarction.
During an infection, immature neutrophils (e.g., bands) are
Microbiologic Studies
TREATMENT
Nonantimicrobial Treatment
While selection of antimicrobial therapy may be a major
consideration in treating infectious diseases, it may not be
the only therapeutic intervention. Other important therapies
may include adequate hydration, ventilatory support, and
other supportive medications. In addition, antimicrobials are
unlikely to be effective if the process or source that leads to
the infection is not controlled. Source control refers to this
process
and may involve removal of prosthetic materials such as
catheters and infected tissue or drainage of an abscess.
Source
control considerations should be a fundamental component
of
any infectious diseases treatment. It is also important to
recognize
that there may be many different antimicrobial regimens
that may cure the patient. While the following therapy
sections
provide factors to consider when selecting antimicrobial
regimens,
an excellent and more in-depth resource for selecting
antimicrobial regimens for a variety of infectious diseases
are
the Infectious Diseases Society of America Guidelines.10
Antimicrobial Considerations
in Selecting Therapy
6 Drug-specific considerations in antimicrobial selection
include spectrum of activity, effects on nontargeted
microbial
flora, appropriate dose, pharmacokinetic and
pharmacodynamic
properties, adverse-effect and drug-interaction profile,
and cost (Table 692).
Antimicrobial Dose
Pharmacokinetic Properties
Pharmacodynamic Properties
Antimicrobial Cost
Patient Considerations in
Antimicrobial Selection
8 Key patient-specific considerations in antimicrobial
selection include recent previous antimicrobial exposures,
identification of the anatomic location of infection through
physical examination and diagnostic imaging, history of
drug
allergies, pregnancy or breast-feeding status, organ
dysfunction
that may affect drug clearance, immunosuppression,
compliance,
and the severity of illness (see Table 692).
Host Factors
OUTCOME EVALUATION
Figure 694 provides an overview of patient- and
antimicrobial
agentspecific factors to consider when selecting
an antimicrobial regimen. It further delineates monitoring
of therapy and actions to take depending on the patients
response to therapy. The duration of therapy depends on
patient response and type of infection being treated.
CONCLUSION
Antimicrobial regimen selection is a complex process
involving
the integration of a multitude of factors. The guiding
principles
to make the diagnosis and do no harm must be considered
when choosing an antimicrobial for a given patient.
In summary, when infection is suspected, rapid and
accurate
diagnosis should be followed by early intervention that
includes administration of appropriately dosed antibiotics
with appropriate empirical spectra. De-escalation to suitable
narrow-spectrum antibiotics if susceptibilities are known
should occur as soon as possible, and therapy should be
stopped as soon as the patient is cured. These fundamental
actions improve infectious disease outcomes and minimize
collateral damage and adverse effects.
Regimen antimikroba
Pilihan
PATOFISIOLOGI
Flora normal dan Infeksi endogen
Banyak area tubuh manusia dijajah dengan bacteriaini dikenal sebagai flora normal. Infeksi sering muncul dari
sendiri Flora seseorang normal (juga disebut infeksi
endogen).
Infeksi endogen dapat terjadi ketika ada perubahan
dalam flora normal (misalnya, penggunaan antimikroba
baru-baru ini mungkin
memungkinkan untuk pertumbuhan berlebih dari flora
normal lainnya) atau gangguan
pertahanan host (misalnya, istirahat atau entri di kulit).
Mengetahui
apa organisme berada dengan di mana dapat membantu
untuk memandu antimikroba empiris
Terapi (Gbr. 69-1). Selain itu, itu bermanfaat
tahu apa situs anatomi biasanya steril. Ini
termasuk cairan serebrospinal, darah, dan urin.
Studi mikrobiologis
Studi mikrobiologi yang memungkinkan untuk pemeriksaan
langsung dari
kerentanan ditetapkan.
antimikroba Dosis
Dokter harus menyadari bahwa dosis rejimen dengan
obat yang sama mungkin berbeda tergantung pada proses
infeksi.
Misalnya, ciprofloxacin, fluorokuinolon, memiliki berbagai
rejimen dosis berdasarkan tempat infeksi. The dosis untuk
rumit ISK adalah 250 mg dua kali sehari selama 3 hari.
Untuk rumit
UTI, dosisnya adalah 500 mg dua kali sehari selama 7
sampai 14 hari.
Pneumonia rumit parah memerlukan regimen dosis 750 mg
dua kali sehari selama 7 sampai 14 hari. Dokter didorong
menggunakan rejimen dosis dirancang untuk pengobatan
spesifik
didiagnosis infeksi karena mereka telah menunjukkan
terbukti
khasiat dan yang paling mungkin untuk meminimalkan
kerugian.
farmakokinetik Properti
Sifat farmakokinetik antimikroba mungkin
penting dalam rejimen antimikroba. Farmakokinetik
mengacu
untuk metode matematis menggambarkan obat pasien
host Faktor
Faktor host dapat membantu untuk memastikan pemilihan
yang paling tepat
agen antimikroba. Umur merupakan faktor penting dalam
antimikroba
seleksi. Berkenaan dengan dosis dan selang, ginjal dan
fungsi hati bervariasi dengan usia. Populasi dengan
berkurangnya
fungsi ginjal termasuk neonatus dan orang tua. Fungsi hati
pada neonatus belum sepenuhnya dikembangkan, dan
obat-obatan yang
dimetabolisme atau dihilangkan dengan rute ini dapat
menghasilkan
dampak buruk. Misalnya, sulfonamid dan ceftriaxone
mungkin bersaing dengan bilirubin untuk situs mengikat
dan dapat mengakibatkan
di hiperbilirubinemia dan kernikterus. Keasaman lambung
juga
tergantung pada usia; dan anak-anak tua muda dari 3 tahun
usia cenderung achlorhydric. Obat-obatan yang perlu
lingkungan asam
(misalnya, ketoconazole) tidak diserap dengan baik, dan
mereka