Chapter 3: Issues to Be Considered During Use of This Guideline
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In this Antibiotic Guideline, recommendations are made as simple format, however the following issues are important to be considered while using this guideline:
- Consider this antibiotic guideline according to the patient care setting and the type of infection
- Identify the patient type (Type 1, Type 2, Type 3, Type 4 as mentioned below) as per Antibiotic Guideline for a given infection type in a given patient care setting.
- Physician may use his/her discretion, though the selection of antibiotic should be rational.
- Selecting appropriate antibiotic after getting the culture sensitivity report considering the aware classification.
3.1. Setting
3.1.1 Outdoor Patient Department (OPD)
3.1.2 Indoor Patient Department (IPD)
3.2. Categories of infections
3.2.1. Blood Stream Infections (BSI);
3.2.2. Urinary Tract Infections (UTI);
3.2.3. Respiratory Infections (RI);
3.2.4. Skin and Soft tissue Infections (SSTI);
3.2.5. Sexually Transmitted Infections (STI)
3.3. Patient Risk Stratification
3.3.1. Patient Type 1 (CAI):
3.3.1.1. No contact with health care system
3.3.1.2. No prior antibiotic treatment in last 90 days
3.3.1.3. Patient young with no co-morbid conditions
3.3.2. Patient Type 2 (HCAI):
3.3.2.1. Recent contact with health care system (e.g., recent hospital admission, nursing home, CAPD) without/minimal invasive procedures
3.3.2.2. Antibiotic therapy in last 90 days
3.3.2.3. Patient old (> 65 years) with few co-morbidities
3.3.3. Patient Type 3 (NI)
3.3.3.1. Hospitalization >5 days and or infections following invasive procedures
3.3.3.2. Recent & multiple antibiotic therapies
3.3.3.3. Patient with multiple Co-morbidities e.g.: cystic fibrosis, structural lung disease, advanced AIDS, neutropenia, other severe immunodeficiency
3.3.4. Patient Type 4 (NI)
3.3.4.1. Type 3 patient with fever despite antibiotic therapy (>5 days) with no obvious source / after appropriate source control
3.3.4.2. ± severe sepsis/septic shock
3.3.4.3. PLUS ≥ 1 of the following factors (but not limited to) for invasive fungal infections: TPN, Hemodialysis, Immunodeficiency of variable origin, Major Abdominal surgery, Multi-focal candida colonization, Diabetes
3.4 Sending the Sample
If laboratory facilities are available, send respective cultures before starting empiric/presumptive antibiotic therapy. Clinicians are expected to send sample for culture and sensitivity before starting empiric/presumptive antibiotic therapy.
3.5. Evaluation and decision about antibiotic therapy
Once the culture sensitivity report is available, consider the following steps:
3.5.1. The empiric/presumptive antibiotic therapy may be continued
3.5.2. The empiric/presumptive antibiotic therapy may be deescalated
3.5.3. The empiric/presumptive antibiotic therapy may be escalated
3.6. Operational definitions for De-escalation and Escalation for patient receiving empiric antibacterial agents
3.6.1. De-escalation:
- Withdrawal of one or more antimicrobial agent from empirical therapy
- Withdrawal of at least one antimicrobial agent plus addition of narrow spectrum antimicrobial agents
- Stopping empirical therapy and switching to narrow spectrum antimicrobial agent
3.6.2. Escalation:
- Addition of one or more antimicrobial agent to empiric antimicrobial therapy
- Switching from narrow spectrum to broad-spectrum antimicrobial agents
- Withdrawal of one or more antimicrobial agent from empirical therapy, but addition of one or more broad-spectrum antimicrobial agent to antimicrobial therapy
3.7. Intrinsic antibiotic resistance:
- Intrinsic antibiotic resistance is a naturally occurring phenomenon that is independent of previous antibiotic exposure and is not caused by a horizontal gene transfer. This phenomenon is also known as inherent resistance or innate resistance.
- In addition to the intrinsic resistance mediated by the bacterial outer membrane and active efflux, studies have shown that a surprising number of additional genes and genetic loci also contribute to this phenotype.
- Therapeutic failure often occurs due to treatment with antibiotic for this intrinsic resistance.