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How to select antimicrobials ? Carlos A. DiazGranados, MD, MS Principle of Antibiotic Therapy #1- Is there an infectious syndrome ? Is an antibiotic indicated? Common situations where antimicrobials are used unnecessarily Treatment of asymptomatic bacteriuria or funguria 100% with chronic foley have bacteriuria Only Pregnant woman and persons undergoing urologic procedures should even be screened* Rx. of contaminant blood cultures Endotracheal colonization Noninfectious causes of fever Decubitus Ulcers Viral infections …Lets assume that an antibiotic is indicated … Decision making Important criteria for decision making Antimicrobial efficacy Antimicrobial toxicity Presumptive ecologic impact (antibiotic pressure to select or favor emergence of resistance) – Narrow vs. broad? Antimicrobial cost Antimicrobial efficacy Expected microbiology Probability of antimicrobial resistance of the suspected organism/organisms. Pharmacokinetics / Pharmacodynamics of antimicrobial options --- site of infection, etc Patient’s severity of illness Antimicrobial Agents:Overriding Premise for Use Because of the potential to develop resistance, antimicrobials are fundamentally different from all other classes of pharmacotherapy Antimicrobials should be viewed as medical treasures and a precious resource Antibiotics as “Common property resources” “Externality”: the use of an antibiotic by one person can affect others without their permission. Providing antibiotic to one patient today will affect the possibility of providing that antibiotic to someone else in the future (because antibiotic use leads to resistance to that antibiotic). Analogy - Fishery Only one fish stock with a limited number of fish. Many fishermen. A fisherman can overfish and diminish the future stock of fish for all other fishermen of the same fish stock. Components of Appropriate Antimicrobial Use Appropriate selection (usually empiric) Appropriate dosing and route Appropriate de-escalation