5.2 Patient-level interventions

Antimicrobial prescription needs to be monitored at the level of each individual patient for the benefit of that patient, and to reduce the selection pressure that leads to the development of resistance.

Figure 3 shows the sequence of decisions that may be needed at the level of patient treatment.

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Figure 3 The sequence of decision-making in the treatment of an individual patient. (STG = standard treatment guideline; CAI = community-acquired infection; HAI = hospital-acquired infection.)
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The first stage in the sequence is to ask: ‘Does the patient need an antimicrobial?’ There is a clinical evaluation of patient’s condition, and the appropriate diagnostics needed to support that decision, based on STG, are identified. You should take the appropriate culture before the first dose.

The second stage of the sequence is that if the patient does need an antimicrobial, which antimicrobial is most appropriate? This is followed by empiric therapy based on site, CAI, HAI and local hospital epidemiology.

The third stage of the sequence is to ensure appropriate administration of the antimicrobial (considering administering the antimicrobial early, delivery/route, dose, and duration).

The fourth stage of the sequence is to review the need for an antimicrobial every day (considering delivery/route, dose, duration and de-escalation, where you review an antibiogram from cultures).

Figure 3 The sequence of decision-making in the treatment of an individual patient. (STG = standard treatment guideline; CAI = ...

Choosing the correct drug for empirical treatment depends on clinical assessment and the local antimicrobial susceptibility data. Once culture and antimicrobial susceptibility test results are available for an individual patient, the antimicrobial with the narrowest spectrum of activity should be used as a treatment. If no organism is cultured from the samples, clinical reassessment determines the course of action.

Choosing the best strategy

Dosing and dose adjustment