A POCKET GUIDE TO ANTIBIOTICS - Ministry Of Health
A POCKETGUIDE TOANTIBIOTICSPHARMACY DEPARTMENTSARAWAK GENERAL HOSPITAL1st edition (2015)
AcknowledgementThe completion of this pocket guide could not have been possible withoutthe contributions of the following individuals from Sarawak GeneralHospital: Andrew G Tan Hua Kiong (Pharmacist)Charles Goh (Science Officer)Chua Hock Hin, Dr (Infectious Disease Consultant)Irene Chieng Yee Yew (Pharmacist)Jaime Chan Yoke May (Pharmacist)Ngua Ching Zin (Pharmacist)Nicole Foo Yen Fei (Pharmacist)Oh Ai Ling (Pharmacist)Rachel Tan Yi Ting (Pharmacist)Sim Shyang Jiun (Pharmacist)Yong Zai Yang (Pharmacist)Their contributions are sincerely appreciated and gratefully acknowledged.
Contents1. Bacterial Classificationp.12. Pharmacology & Mechanism of Actionp.33. Activity Spectrap.44. Antibiotics with good anaerobic coveragep.75. The PK/PD conceptp.86. Renal/Hepatic adjustments of antibioticsp.107. Therapeutic Drug Monitoring of antibiotics in SGHp.168. IV-to-Oral Switch Protocolp.179. Surgical Antibiotic Prophylaxisp.1910. Bits and Pieces from Microbiology Laboratoryp.2011. Do’s and Don’ts In Antibiotic Prescribingp.2112. SGH Antimicrobial Formulary Restriction List (updated June 2015)p.2213. SGH Antibiogramp.23
1. Bacterial ClassificationGRAM POSITIVECOCCIAEROBICIn cluster:Staphylococcus aureusStaphylococcus epidermidisIn chain:Streptococcus pneumoniaViridans strepStreptococcus pyogenes(Group A)Streptococcus agalactiae(Group B)Enterococcus sp.ANAEROBICPeptostreptococcusBACILLI (ROD)AEROBICBacillus anthracisBacillus cereusLactobacillus sp.Listeria monocytogenesNorcadia sp.Rhodococcus equi(coccobacillus)Corynebacterium diptheriaeANAEROBICActinomyces sp.Clostridium botulinumClostridium difficileClostridium perfringensClostridium tetaniPropionibacterium acnes1
GRAM NEGATIVECOCCIAEROBICMoraxella catarrhalisNeisseria meningitidesNeisseria gonorrhoeaeANAEROBICVeillonella sp.BACILLI (ROD)AEROBICEnterobacteriaceae(Escherichia coli, Klebsiella,Enterobacter, Citrobacter,Proteus, Serratia, Salmonella,Shingella, Morganella,Providencia)Campylobactersp.Pseudomonas sp.Helicobacter sp.Haemophilus sp. (coccobacillimorphology)Legionella sp.Acinetobacter baumanniiANAEROBICBacteroides (Bacteroidesfragilis, Bacteroidesmelaninogenicus)Fusobacterium sp.Prevotella sp.Reference: Mary Anne Koda-Kimble et al. Applied Therapeutics. The Clinical Use of Drugs. 9th Edition. Lipincott Williams & Wilkins; 2009.2
2. Pharmacology and Mechanism of ActionInhibition of Cell WallSynthesis/ FunctionBeta LactamsPenicillin Benzylpenicillin (CPen) Procaine penicillin Benzathine penicillin Penicillin V Cloxacillin Amoxicillin Ampicillin Bacampicillin PiperacillinCephalosporin Cephalexin Cefazolin Cefuroxime Ceftriaxone Ceftazidime Cefoperazone Cefotaxime Cefepime CeftarolineCarbapenem Meropenem Imipenem ErtapenemDisruption of Cell Membrane FunctionPolymyxinFolateInhibition of Nucleic AcidSynthesis/ FunctionQuinolone Ciprofloxacin Ofloxacin Levofloxacin MoxifloxacinRifampicinMetronidazoleInhibition of ProteinSynthesisInhibits 50S subunitMacrolides Azithromycin Erythromycin ClarithromycinClindamycinLinezolidInhibits 30S subunitAminoglycosides Amikacin Gentamicin Streptomycin NetilmicinTetracyclines DoxycyclineTigecyclineInhibition of Folic Acid erence: Paul H.Axelsenl. Essentials of Antimicrobial Pharmacology: A Guide to Fundamental Practice. 1st edition. Springer Science and BusinessMedia; 2002.3
3. Activity nGRAM POSITIVECiprofloxacinGRAM NEGATIVEMeropenemANAEROBESImipenem 000 0 0 0 0 0 No . Group (A, B, C, G) Strep. pneumoniae Viridans Strep. Enterococcus faecalis 0 Staph. aureus (MSSA)00 00 Staph. aureus (MRSA)000000Staph. epidermidis00 000N. gonorrhea00000 N. meningitidis 00 M. catarrhalis00000 H. influenza000 E. coli000 Klebsiella sp.00000 E. coli/Klebs sp ESBL 000000Enterobacter sp.000000Serratia sp.000000Salmonella sp.000 Shigella sp.000 Proteus mirabilis000 Citrobacter sp.000000Acinetobacter sp.000000P. aeruginosa000000Bacteroides fragilis0 000 Clostridium difficile Clostridium (not difficile) Usually Susceptible, Variably Susceptible/Resistant, 0 Usually eAmoxicillinAmpicillinCloxacillinPenicillin VPenicillin GOrganismsCarbapenems 0 0 00 0 0 0 0 0 0 0 000 000 Reference: Sanford Guide4
inDaptomycinVancomycinGRAM POSITIVEAmikacinGRAM rolineStrep. Group (A, B, C, G) Strep. pneumoniae Viridans Strep. Enterococcus faecalis000000Staph. aureus (MSSA) Staph. aureus (MRSA)000000Staph. epidermidis N. gonorrhea0 N. meningitidis00 M. catarrhalis0 H. influenza0 E. coli Klebsiella sp. E. coli/Klebs sp ESBL 000000Enterobacter sp.00 Serratia sp.000 Salmonella sp.0 Shigella sp.0 Proteus mirabilis Citrobacter sp.00 Acinetobacter sp.00000 P. aeruginosa000 Bacteroides fragilis000000Clostridium difficile0Clostridium (not difficile) Usually Susceptible, Variably Susceptible/Resistant, 0 Usually inoglycosides 0 0 0 0 0000 000 No data 0 00 0 00 0 00 000 0 00000000 00 00000 0 00 0000000 00000000000 000000000000000 00000000 Reference: Sanford Guide5
MiscellaneousLinezolidColistinMetronidazoleGRAM POSITIVERifampicinGRAM NEGATIVEFusidic AcidANAEROBESClindamycinStrep. Group (A, B, C, G) 0Strep. pneumoniae Viridans Strep.Enterococcus faecalis0 00Staph. aureus (MSSA) Staph. aureus (MRSA) Staph. epidermidis0 N. gonorrhea 0 N. meningitidis M. catarrhalis H. influenza E. coli Klebsiella sp. E. coli/Klebs sp ESBL Enterobacter sp.0 Serratia sp.0 0 Salmonella sp. Shigella sp. Proteus mirabilisCitrobacter sp.Acinetobacter sp.0 0 P. aeruginosa0000Bacteroides fragilis 0Clostridium difficileClostridium (not difficile) Usually Susceptible, Variably Susceptible/Resistant, 0 Usually lineDoxycyclineOrganisms 0000 0 0000000000000 0000000000000 0000000 00000000000000000 0000 0 0 No data 0 000000000 0 00 Reference: Sanford Guide6
4. Antibiotics with good anaerobic coverageANTIBIOTICS WITH GOOD ANAEROBIC COVERAGE1. PENICILLINS Amoxycillin/clavulanate Ampicillin/sulbactam Piperacillin/tazobactam Ticarcillin/clavulanate2. CEPHALOSPORINS Cefoxitin Cefotetan3. CARBAPENEMS Imipenem/cilastatin Meropenem Doripenem Ertapenem4. CLINDAMYCIN5. TIGECYCLINE6. MOXIFLOXACIN7. METRONIDAZOLEReference: The Nebraska Medical Center. Double Anaerobic Coverage: What is the role in clinicalpractice? Omaha, NE. 2010 [Updated June 2010; Cited 5 November 2015]. Available from:http://www.nebraskamed.com/app robiccoverage.pdf7
5. The Pharmacokinetics/Pharmacodynamics (PKPD)ConceptPharmacokinetics: Cmax – peak serum concentration Cmin – serum trough concentration AUC – area under the serum concentration-time curvePharmacodynamics: MIC – Minimum Inhibitory Concentration Concentration-dependent killing Time-dependent killing8
PK/PD IndexDrugsBacterial killing &Persistence ofkilling effectConcentrationdependent killingwith prolongedpersistent effectPeak/MICAUC24/MIC Aminoglycosides Fluoroquinolones MetronidazoleDaptomycin KetolidesT MIC e-dependentkilling with nopersistent effectAUC24/MIC lidTedizolidTigecyclineTime-dependentkilling withmoderate to longpersistent effectGoal of therapyAim for aadequately highpeak serumconcentration(ensure sufficientunit dose withappropriatedosing interval)Ensure longduration ofexposure(prolonged orcontinuousinfusion/shortdosing interval)Enhance amountof drug(ensure sufficienttotal daily dosewith appropriatedosing interval)Reference: Sanford Guide: Antimicrobial Therapy (updated 22/7/2015)9
6. Renal / Hepatic Adjustments of illin G / Benzyl Yes. CrCl 50NoPenicillinml/minPenicillin GBenzathineNo. Use withcautionNoPenicillin GProcaineNoNoPenicillin VNoNoCloxacillinNoNoAmpicillinYes. CrCl 50ml/minNoAmpicillin/SulbactamYes. IV: CrCl 30 Noml/minOral: NoAmoxycillinYes. CrCl 30ml/minNoAmoxycillin/Clavulanic acidYes. CrCl 30ml/minNo. Use withcautionPiperacillin/TazobactamYes. CrCl 40ml/minNoCefazolinCEPHALOSPORINSYes. CrCl 35Noml/minCephalexinYes. CrCl 50ml/minNoDialyzability ofDrugsHD C: YesHD HP: Likely YesPD: NoHD C: YesHD HP: Likely YesPD: NoHD C: YesHD HP: Likely YesPD: NoHD C: YesHD HP: Likely YesPD: NoHD C: NoHD HP: No DataPD: NoHD C: YesHD HP: Likely YesPD: No(Sulbactam)HD C: YesHD HP: Likely YesPD: NoHD C: YesHD HP: Likely YesPD: NoClavulanic AcidHD C: YesHD HP: Likely YesPD: YesHD C: YesHD HP: Likely YesPD: NoHD C: YesHD HP: YesPD: NoHD C: YesHD HP: Likely YesPD: No10
CefuroximeYes.Oral: CrCl 30ml/minIV: CrCl 20ml/minNo. Max 2g/dayin patient withconcurrentrenal andhepaticimpairmentYes. CrCl 50ml/minNoHD C: YesHD HP: Likely YesPD: NoNo. Max 2g/dayin patient withconcurrentrenal andhepaticimpairmentNoHD C: NoHD HP: No DataPD: NoCeftazidimeYes. CrCl 50ml/minNoCefoperazoneNo. Cautionwith patientwith concurrentrenal andhepaticimpairmentYes. CrCl 30ml/minNo. Cautionwith patientwith concurrentrenal andhepaticimpairmentYes. Doseadjustmentrequired insevere one/SulbactamCefepimeYes. CrCl 60ml/minCeftarolineYes. CrCl 50ml/minAmikacinGentamicinNoAMINOGLYCOSIDESYes. CrCl 60Noml/minYes. CrCl 60ml/minNoHD C: YesHD HP: Likely YesPD: NoHD C: YesHD HP: Likely YesPD: YesHD C: NoHD HP: No DataPD: No(Sulbactam)HD C: YesHD HP: Likely YesPD: NoHD C: YesHD HP: Likely YesPD: YesHD C: YesHD HP: YesPD: Likely YesHD C: YesHD HP: Likely YesPD: YesHD C: YesHD HP: YesPD: Yes11
TobramycinYes. CrCl 60ml/minNoNetilmicinYes. CrCl PTIDESYes. CrCl 50Noml/minYes. CrCl 30ml/minNo. No data inChild Pugh classCMACROLIDESNoAzithromycinNoClarithromycinYes. CrCl vofloxacinMoxifloxacinFLUOROQUINOLONESYesNo. Use withOral: CrCl 50caution inml/minsevereIV : CrCl 30impairmentml/minYes. CrCl 50Yes. Max 400mgml/mindaily in severeliverimpairment.Yes. CrCl 50Noml/minNoNoHD C: YesHD HP: Likely YesPD: YesHD C: YesHD HP: Likely YesPD: YesHD C: NoHD HP: YesPD: YesHD C: NoHD HP: Likely YesPD: NoHD C: YesHD HP: Likely YesPD: NoHD C: No DataHD HP: No DataPD: No DataHD C: NoHD HP: No DataPD: NoHD C: NoHD HP: No DataPD: NoHD C: YesHD HP: YesPD: NoHD C: UnlikelyHD HP: NoPD: NoHD C: No DataHD HP: No DataPD: No12
DoxycyclineNoTigecyclineNoTETRACYCLINENoYes. Child-Pughclass CHD C: NoHD HP: No DataPD: NoHD C: NoHD HP: No DataPD: UnlikelyCARBAPENEMErtapenemYes. CrCl 30No. Limited data HD C: Yesml/minHD HP: Likely YesPD: NoNoHD C: YesImipenem/Cilastatin Yes. CrCl 70HD HP: Likely Yesml/min.PD: YesAdjustmentdepends also onbody weightMeropenemYes. CrCl 50NoHD C: Yesml/minHD HP: Likely YesPD: No DataDoripenemYes. CrCl 50NoHD C: Yesml/minHD HP: YesPD: No DataFusidic AcidNoOTHERSNoHD C: NoHD HP: No DataPD: NoHD C: YesHD HP: Likely YesPD: NoSulfamethoxazole / Yes. CrCl 30Trimethoprimml/min(Bactrim)No. Use withcautionNitrofurantoinYes. CrCl 60ml/minNo.HD C: YesHD HP: Likely YesPD: No DataMetronidazoleYesYes. ChildPugh Class CHD C: YesHD HP: YesPD: No13
LinezolidNo. Use withcautionNo. No data inChild Pugh classCHD C: YesHD HP: Likely YesPD: No DataPolymyxin E(Colistin)Yes. CrCl 80ml/minNoHD C: NoHD HP: No DataPD: NoClindamycinNoYes. Use withcaution andmonitor liverenzymes insevere liverdiseaseHD C: NoHD HP: No DataPD: NoFluconazoleANTIFUNGALYes. CrCl 50No. Use withml/mincaution.ItraconazoleNo. Use withcautionNo. Use withcautionVoriconazoleYesAnidulafunginYes (IV only).CrCl 50 ml/min50% of the totaldaily dose ifrenaldysfunction isdue to the drugNoCaspofunginNoYesMicafunginNoNoAmphotericin BNoNoHD C: YesHD HP: Likely YesPD: YesHD C: NoHD HP: NoPD: UnlikelyHD C: NoHD HP: NoPD: NoHD C: NoHD HP: NoPD: NoHD C: NoHD HP: UnlikelyPD: UnlikelyHD C: NoHD HP: UnlikelyPD: UnlikelyHD C: UnlikelyHD HP: UnlikelyPD: Unlikely14
AcyclovirGanciclovirValganciclovirANTIVIRALYes.No. Use withOral: CrCl 25caution inml/minsevereIV: CrCl 50impairmentml/minYes. CrCl 70Noml/minYes. CrCl 60ml/minNoHD C: YesHD HP: Likely YesPD: NoHD C: YesHD HP: Likely YesPD: No DataHD C: YesHD HP: No DataPD: No DataHD C: Hemodialysis conventionalHD HP: Hemodialysis High PermeabilityPD: Peritoneal DialysisReferences:1. Lexi-Comp2. Sanford Guide: Antimicrobial Therapy 20153. George RB and Nancy AM. 2013 Dialysis of Drugs. Renal Pharmacy Consultants; 2013.15
7. Therapeutic Drug Monitoring of antibiotics in SGHDrugVancomycinAmikacinGentamicinWhen to monitor(After initiation/dose change)24 hours (Pediatric)48 hours (Adult)Sampling Time24 hoursPre : 30 minutes before next doseandPost : 1 hour after the end of infusionOD : 2 hours and 6 hours post-dose24 hoursBD/TDS: Pre (30 minutes before nextdose) ANDPost (1 hour post-dose)OD: 2 hours and 6 hours post-doseBD/TDS/36or 48-Hrly: Pre (30 minutes before nextdose) ANDPost (1 hour post dose)Targeted Therapeutic RangePrePost10 – 20µg/ml20 – 40µg/ml 5 µg/ml(Pediatric)20 – 40µg/ml 10 µg/ml (Adult) 1µg/ml(Pediatric) 2µg/ml (Adult)(up to 60µg/ml forAdult with ODdosing)5 – 10µg/ml(up to 20 µg/ml forAdult with ODdosing)For enquiries, please call TDM Pharmacy at Ext: 107116
8. IV-To-Oral Switch Protocol (IVOS)Consider IVOS if patient is on IV antibiotics 24-48 hours and fulfillsCOMS criteriaCClinical improvement observedOOral route is not compromised (vomiting, malabsorption, strictNPO, swallowing problems, unconscious, severe diarrhoea etc.)and suitable oral antibiotic option available (see Appendix 1)NB: if NG/PEG feeding please D/W ward pharmacistMMarkers showing a trend towards normal:Afebrile: Temp 36-38 oC for at least 24-48 hoursPLUS not more than one of Heart Rate 90 bpm Respiratory Rate 20 bpm Blood Pressure unstable Total White Count 4 or 12 (if abnormal, a trend towardsnormal and without neutropenia is acceptable)SSpecific exclusions (Refer Exclusion List)Exclusion ListSpecial indication requiring high dose IV therapy E.g. endocarditis, meningitis, Staph aureus bacteremia,immunosuppression, bone/joint infection, deep abscess, cystic fibrosis,prosthetic infection, empyemaFebrile neutropeniaHypotension/shock A low blood pressure is associated with reduced blood flow to the gut andreduced/unpredictable drug absorptionFor skin and soft tissue infections: For oral switch, it is recommended that signs and symptoms are improving,with a reduction in heat, erythema and indurationReference: NHS Calderdale and Huddersfield: Antibiotic Management Policy. Amended January 2010; and NHSGrampian Staff Guidance for IV to Oral Antibiotic Switch Therapy (IVOST) in Adults - Version 317
Appendix 1*Choice should ALWAYS take into consideration of culture & sensitivity resultsOR intended spectrum of microbial coverage(may also use antimicrobials not listed in this table)IV AntibioticsSuggested Oral thylpenicillin xiclav /Ampicillin-sulbactamCefazolinCo-amoxiclav / av / loxacinAzithromycinAzithromycinPip-tazo / Cefepime cin (if PAE) / others*Sulfamethoxazole-trimethoprim18
9. Surgical Antibiotic ProphylaxisAim: To prevent surgical site infections (SSIs)Class of Surgery: Clean surgery or Clean-contaminated surgeryCleanOperations in which no inflammation is encountered and therespiratory, alimentary or genitourinary tracts are not entered.There is no break in aseptic operating theatre technique.CleanOperations in which the respiratory, alimentary or genitourinarycontaminated tracts are entered but without significant spillage.*This document not applicable to contaminated or dirty surgeries in which antibiotic treatment isrequired.General points:1. Not all surgeries require antibiotic prophylaxis Recommendation depends on evidence of clinical effectiveness ofprophylactic antibiotics in reducing incidence of SSIs. Antibiotic prophylaxis should be used where evidence of benefit existsand should not be considered if there is evidence of a lack of efficacy.This helps to avoid unnecessary use of antibiotics.2. Preoperative-dose timing for antibiotic The antimicrobial agent should be given within 60 minutes beforesurgical incision. Except for fluoroquinolones and vancomycin, which requireadministration over 1 to 2 hours, the administration of these agentsshould begin within 120 minutes before surgical incision. This is important to ensure adequate serum and tissue concentration ofthe antimicrobial at the time of incision.3. Intra-operative re-dosing Re-dosing is required when duration of procedure exceeds two half-livesof the antimicrobial or When there is excessive blood loss during procedure i.e. more than 1.5Lof blood in adult or more than 25ml/kg in children. This is important to ensure adequate serum and tissue concentration ofantimicrobial throughout surgery.4. Duration of prophylaxis Generally requires only a single dose pre-op or continuation for not morethan 24 hours.5. References1) Clinical practice guidelines for antimicrobial prophylaxis in surgery.Bratzler et al. Am J Health-Syst Pharm. 2013; 70:195-283.2) Sign 104. Antibiotic Prophylaxis in Surgery 2014.19
10. Bits and Pieces from Microbiology LaboratoryMAXIMUM TRANSPORTATION TIME TO MICROBIOLOGY LABORATORYTYPES OF SPECIMENSPECIMENS WITHOUT PRESERVATIVESUrine, Sputum, Body Fluid, Tissue, etcSPECIMENS WITH PRESERVATIVESBlood & SwabsPertussis CultureTIME TO THE LABWithin 4 hoursBlood – Within 48 hoursSwabs – Within 18 hoursImmediatelyRemember: Sending cultures ASAP to the microbiology lab: helps to reduce contamination risk and allows for an earlier positive growth (if any) to further guideantimicrobial therapyLABORATORY TURN AROUND TIME (TAT) FOR NEGATIVE RESULTSTESTURINEWOUND, SPUTUM, TISSUE, SWABS, ASPIRATES,BAL, STOOL, RECTAL, STERILITYCSF, BODY FLUID & GENITALBLOODFUNGALTB CULTURETAT24 HOURS48 HOURS72 HOURS120 HOURS (5 DAYS)14 DAYS8 WEEKSREJECTION CRITERIA FOR CULTURE SAMPLES Unlabeled SpecimenLeakages from SpecimenSpecimen without request formRequest form without specimenPatient’s Name on request form differs from label on specimenIncorrect containers used for specimen storageFor enquiries, please call microbiology lab at Ext: 3019 or 302220
11. Do’s and Don’ts In Antibiotic PrescribingDO DON’T ASK yourself if the patient is having bacterial infection PRESCRIBE antibiotic for viral infectionbefore starting antibiotic CHOOSE antibiotic based on the likely bacteria you PRESCRIBE antibiotic just because patient has feverare targeting and the likely resistance patternor high TWC TAKE appropriate culture before starting broad USE broad spectrum antibiotic unnecessarilyspectrum antibiotics LABEL culture bottles and forms properly to avoid USE antibiotic with collateral damage if possiblerejectione.g. cephalosporin and quinolone group SEND collected sample especially urine and body FORGET to stop the antibiotics when the bacterialfluids to laboratory within 2 hours of collection to avoidinfection has resolved or is unlikelybacteria contamination TRACE culture result on daily basis especially for FORGET to ask for proper drug allergy historypatient with broad spectrum antibiotics DE-ESCALATE to narrow spectrum antibiotic once FORGET to adjust dose of antibiotic in presence ofculture result availablerenal or liver impairment CHANGE to oral antibiotics for patient who fulfil IVOS FORGET to refer if unsure what to use or do for thecriteriapatientsABOVE ALL, ALWAYS REMEMBER to perform 5 moments of hand hygiene andcontact precaution to prevent spread of drug resistant organisms21
12. SGH Antimicrobial Formulary Restriction List(updated June 2015)CATEGORY IPREAUTHORIZATION*All carbapenemsPolymyxin cafunginCan only be cations.*Refer to carbapenempreauthorization and72-hour review policy2011CATEGORY IICONDITIONALAll carbapenemsPiperacillin/TazobactamCefepimeInj. CiprofloxacinVancomycinCATEGORY IIIAVAILABLEAll other antimicrobialsDescriptionCan be prescribed only Donotfor specific indications. approvalWill auto‐generate areferraltothestewardshipteamwhich will review thepatientwithin3working days.require22
13. SGH Antibiogram (data till September 2015)% RESISTANCE OF ACINETOBACTERBAUMANNII - SGH2015 (229)44.45328.638.758.865.85256.857.16270.42014 (142)5068.966.758.261.861.3562013 (24)44.452.144.444.553.868.82012 ASYN2015 (1248)5.23.66.92014 (2265)25.421.421.222.33027.82824.62013 (681)31.22.21.61.221.221.619.517.62012 (1522)26.523.520.720.1% RESISTANCE OF ESCHERICHIA COLI - SGH23
% RESISTANCE OF KLEBSIELLAPNEUMONIAE - 8.114.712.62015 (2488)26.927.52014 (3576)27.32013 (1126)26.321.525.426.92012 (2453)% RESISTANCE OF PSEUDOMONASAERUGINOSA - SGH2013 (713)2014 (2730)2015 6.25.97.292012 CIN24
% RESISTANCE OF STAPHYLOCOCCUSAUREUS - SGH2014 (1968)2015 (1120)10.92013 12 (1518)OXACILLINBACTRIMUNASYNCLINDAMYCINFor enquiries, please call microbiology lab at Ext: 3019 or 302225
4. Antibiotics with good anaerobic coverage p.7 5. The PK/PD concept p.8 6. Renal/Hepatic adjustments of antibiotics p.10 7. Therapeutic Drug Monitoring of antibiotics in SGH p.16 8. IV-to-Oral Switch Protocol p.17 9. Surgical Antibiotic Prophylaxis p.19 10. Bits and Pieces from Microbiology Laboratory p.20 11. Do’s and Don’ts In Antibiotic .
Pocket WSL-PK-35-XX Same size pocket as Roller 64 6 in. x 9 in. (152 mm x 229 mm) Dual Pocket WSL-PK-6-9-XX Same size pocket as Roller 64 2 in. Flap (51 mm) (must be 3.5 in. pocket compatible) WSL-FLP-2-XX Attached to the hanger that is built into pocket Use 3 in. (76 mm) Flap for Dual Pocket Roller
1. Only prescribe antibiotics for bacterial infections if: Symptoms are significant or severe There is a high risk of complications The infection is not resolving or is unlikely to resolve 2. Use first-line antibiotics first 3. Reserve broad spectrum antibiotics for indicated conditions only The following information is a consensus guide.
Get well soon without antibiotics Product Code: 284682 If a cold is making you feel under the weather, antibiotics aren't going to help Product Code: 290982 Remember, antibiotics won't help your defences against a cold (poster) Product Code: 290981 Unfortunately no amount of antibiotics will ge
What is Antibiotic “Overuse”? 50% of all antimicrobial use is inappropriate* 30-50% of hospitalized pts receive antibiotics Antibiotics account for 30% of hospital pharmacy costs USA one of world’s top spenders on antibiotics page 3
Pocket PC HP hx 4700 ARM Pocket PC 2003 SE Pocket PC TDS Recon ARM Windows Mobile 5 / 6 Pocket PC TDS Ranger ARM Windows Mobile 5 / 6 Pocket PC Topcon FC-250 ARM Windows Mobile 6 Pocket PC TDS Nomad ARM Windows Mobile 6 Handheld PC Trimble TsCE ARM Windows CE 3.0 Handheld
SDH Pocket Guide revised version Vol. 1 Please ask for: Vol.2 Pocket Guide GSM Fundamentals in Mobile Radio Networks Vol.3 Pocket Guide SONET Fundamentals and SONET Testing Vol.4 Pocket Guide ATM Fundamentals and ATM Testing Vol.5 Pocket Guide E1 The World of E1 Subject to change without notice Nominal charge US 10 - TP/EN/PG01/0400/AE repl .
Practical Guide to Responsible Use of Antibiotics on Pig Farms These guidelines offer advice on using antibiotics when your veterinary surgeon recommends them to be appropriate for your farm and the current health situation in your pigs. Antibiotic treatment should only be i
OF ARCHAEOLOGICAL ILLUSTRATORS & SURVEYORS LSS OCCASIONAL PAPER No. 3 AAI&S TECHNICAL PAPER No. 9 1988. THE ILLUSTRATION OF LITHIC ARTEFACTS: A GUIDE TO DRAWING STONE TOOLS FOR SPECIALIST REPORTS by Hazel Martingell and Alan Saville ASSOCIATION OF ARCHAEOLOGICAL ILLUSTRATORS & SURVEYORS THE LITHIC STUDIES SOCIETY NORTHAMPTON 1988 ISBN 0 9513246 0 8 ISSN 0950-9208. 1 Introduction This booklet .
