Tag Archives: antibiotic reporting

“Use it or Lose it? Listen to yourself.”

Antimicrobial Resistance, Confessions of a Microbiologist,

Take for example a couple of the latest antibiotics on the block, tigecycline and ceftaroline.

As new, broad spectrum anti-microbials they should be given the utmost protection in order to prevent selection of antibiotic resistance, only being used in cases where there are few or no other reasonable options available. 

The pharmaceutical companies will not tell you this however. They would like you to use the drug as much as possible, for obvious reasons.

…and sometimes general physicians will have heard of these new antibiotics and because they are new, assume they are the best, and seek to use them.

… and sometimes Clinical Microbiologists and ID physicians like to use new antibiotics like these because it makes them look clever, or in order to stay ahead of “the game”.

….and sometimes pharmacists feel the compulsion to stock a few vials of all the exotic antibiotics, just in case…

….and sometimes the CEO will want these antibiotics used in his/her hospital, because other neighbouring hospitals are using them.

….and sometimes the patient will have heard of the latest new antibiotic on the news or internet, and demand its use.

Protection of antibiotics like these starts in the laboratory, with focused testing and reporting. It always has done, always will do. If you test or report any such antibiotics on a routine basis, you need to take a long hard look at your laboratory policy.

 I have hardly ever reported or advised the use of these antibiotics, because in the area of the world I work in, there is very little need for them. I suspect this will be the case for the vast majority of us.

When we make decisions on which antibiotics to test, which to report, which to advise etc, there may be several opinions given to you, or subtle pressure applied from various sources.

Listen to the advice, be aware of the agendas, and always, always make up your own mind. 

Michael

 

“Damage Limitation…”

Confessions of a Microbiologist, The Science of Microbiology,

Bacteriology laboratories vary hugely in the number of antibiotics they release to the clinicians…

Some laboratories release up to 20 antibiotics on every reported isolate (particularly those ones with Vitek/Phoenix systems)

In contrast, some laboratories release as few antibiotics as possible to the requestors.

Personally I am very much in the latter camp. I strongly believe that it is the laboratory’s responsibility to guide the clinicians as much as possible in their antibiotic choices in order that the patient gets the most appropriate therapy and the unnecessary use of broad spectrum antibiotics is minimised.

For example:

i) A coagulase negative staphylococcus isolated from one bottle of a blood culture set: In the absence of prosthetic material or severe immunocompromise this is almost certainly going to be a contaminant. It should thus be reported as such and no antibiotics released.

ii) A Staphylococcus aureus isolated from a blood culture: Unless there is a history of allergy this should be reported with flucloxacillin alone (if it is susceptible to this). Flucloxacillin (or whatever your equivalent is (cloxacillin, dicloxacillin) is well established as the optimal treatment for Staphylococcus aureus bacteraemia. If you start releasing antibiotics such as erythromycin, ciprofloxacin etc on all such isolates you can be sure that somewhere along the line a clinician will elect to use one of these drugs. (possibly due to lack of knowledge or interest in microbiology).

iii) A Pseudomonas aeruginosa isolated from a chronic leg ulcer. In the vast majority of cases this will be colonising only. If the laboratory starts releasing ciprofloxacin (and other antibiotics) for all such isolates, then there will inevitably be a lot of inappropriate quinolone use.

iv) An amoxycillin susceptible E.coli isolate in a blood culture. Why report meropenem when it is amoxycillin susceptible?

These are only a few examples amongst many…

I strongly believe that the laboratory has a role in “focusing” the anti-microbial prescribing of clinicians. It is also important to note there will be the odd occasion where a coagulase negative staphylococcus bacteraemia does need treated, where a Staph. aureus bacteraemia does need something apart from flucloxacillin, where a pseudomonas is causing problem in a leg ulcer. In these cases the laboratory should ensure it is easily accessible to the clinician so that further antibiotics can be tested/reported.

To those laboratories that insist on reporting all antibiotics on everything, I would encourage that you review this practice. You may find that by careful and appropriate restriction of antimicrobial reporting, the clinicians (and patients) will eventually thank you for it….

Michael