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Ten Commandments of Judicious Antibiotic Use

Dr. Yash Javeri, Dr. Omender Singh, Dr, Devan Juneja, Dr. Mohit Mathur, Dr. Prashant Nasa, Anisha Ghosh

"If you want to use Penicillin, use it in right dose"
Sir Alexander Fleming.

This adage was the basis of judicious antibiotic use and was seed for the concept of "Antibiotic Stewardship". The concept has been there for decades and with huge strides in pharmacokinetics and pharmacodynamics the concept is evolving with each passing day. We are cornered in war against infections. The microbes are always a step ahead then us. Still we have not learnt the science and art of judicious antibiotic use. Why are we scared to talk on this issue? Reason is twofold. Firstly, we want to curb the misuse of antibiotic. Secondly, it is the only therapeutic agent which apart from influencing the patient also influences the society at large.

Definition and understanding on adequate antibiotic therapy has evolved in last two decades. The widely accepted definition of "ADEQUATE" ANTIBIOTIC THERAPY is "Correct matching of sensitivity of the etiologic organism to the therapeutic agent an organism's susceptibility to the antibiotic chosen, optimal dose, administration by the route to ensure penetration at the site of infection, and use of combination therapy if necessary."

Antibiotic Care Bundles is a group of evidence based interventions in antibiotic therapy which leads to better outcome then when each intervention is followed alone.

The antibiotic care bundle involves grouping together key elements of care such as site of infection, risk stratification for MDRs, local microbiology data, de-escalation and the management of specific diagnosis in order to provide an "evidence based" antibiotic protocol that can improve and monitor the delivery of clinical care processes.

10 D's of Antibiotic use











10 Commandments of Appropriate Antibiotic use :-

  1. DRUG - Use the correct drug active against possible pathogen and achieving adequate concentration at the site of infection. We should be aware of antibiograms for infection syndrome from our institutes.
  2. DOSE AND DOSING FREQUENCY - We should be using the highest dose in life threatening infection. Dose should consider severity and organ dysfunction. Dosing schedule should be adjusted based on PK-PD principles.
  3. DURATION - Duration of therapy should neither be too short nor too long. However, it should be adequate enough to prevent metastatic seeding and relapse. For severe life threatening infection we should "Hit hard and Hit early". Start with antibiotics with maximum killing power at maximum doses and later streamline the therapy.
  4. DATA MICROBIOLOGY - Adequate institutionalized retrospective and prospective microbiological data, which should be periodically updated is a must for judicious antibiotic therapy. We should take patient's data in terms of antibiotic history and do risk stratification of patients. Relevant cultures and other surrogate makers for infection should be utilized.
  5. DRUG PENETRATION - The agent being used should have good penetration at the site of infection.
  6. DILUTION - The antibiotics should be diluted in appropriate IV fluids. Reconstitution and dilution are different processes for few drugs.
  7. DRUG RESISTANT - Some organisms like Pseudomonas may develop resistance while an antibiotic therapy. This must be kept in mind if we face treatment failure.
  8. DRUG TOXICITY - The common adverse effects should be known to clinicians and should be actively looked for especially in critically ill patients.
  9. DE-ESCALATION - De-escalation of antibiotic is as necessary as escalation. De-escalation is based on antibiograms, clinical conditions and surrogates for infection markers. Clinicians are often hesitant to change the winning combinations but studies have shown that prolonged or overuse of antibiotic is associated with poor outcome.
  10. DRUG INTERACTION - Drug interaction should be actively looked for patients receiving polypharmacy and should be specially screen for interaction by clinical pharmacist or clinicians and we should utilize software program for studying drug interaction.
  11. DISCUSS, DEBATE AND DISAGREEMENT - There are often interactions among stake holders to arrive at an appropriate antibiotic therapy. The clinical pharmacist, physician and clinical microbiologist should all act as a team while deciding an appropriate antibiotic therapy.

    Antibiotic selection is a precarious affair especially in critically ill patients. Clinicians often have dilemma in treating such patients. We need to strike a critical balance based on evidence based problems and such theoretical dilemmas.


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Authors :

Dr. Yash Javeri, Consultant, Department of Critical Care, Max Super Speciality Hospital, Saket, New Delhi, Mobile: 9818716943, Email: yash.javeri@maxhealthcare.com,
Dr. Omender Singh, Head of Department, Department of Critical Care, Max Super Speciality Hospital, Delhi, Mobile: 9810734246, Email: omender.singh@maxhealthcare.com,
Dr Deven Juneja, Consultant, Department of Critical Care, Max Super Speciality Hospital, Saket, New Delhi, Mobile: 9818290380, Email: deven_juneja@yahoo.com,
Dr. Mohit Mathur, Attending Consultant, Department of Critical Care, Max Super Speciality Hospital, Saket, New Delhi, Mobile: 9899159602, Email: drmohitmathur.1@gmail.com,
Dr. Prashant Nasa, Consultant, Department of Critical Care, Max Super Speciality Hospital, Saket, New Delhi, Mobile: 9818214931, Email: me_nasa@yahoo.com,
Ms. Anisha Ghosh, Clinical Research Coordinator, Dept. of Critical Care, Max Super Speciality Hospital, Saket, New Delhi, Mobile: 9582293540, Email: anisha_ghosh@yahoo.co.in


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