Last year, an 88-year-old female patient was admitted to the Princess Margaret Hospital (PMH) due to acute pulmonary edema and pneumonia. At first, her doctor prescribed her with azithromycin and Augmentin. Yet, the patient’s condition continued to deteriorate and five days later, the doctor decided to switch to Tazocin, the ‘big-gun’ antibiotics. Unfortunately, the patient still passed away four days later due to pneumonia and heart failure.

Upon applying for medical reports from the hospital, the patient’s daughter, a retired nurse, later realised the decision made by the doctor regarding the switch to Tazocin. She described the incident as putting her mother under a drug trial, and accused the doctor of a ‘delayed’ prescription of ‘big gun’ antibiotics, which led to her mother’s death.

Is it a delayed prescription?

Nevertheless, both drug trial and delayed prescription are not the reasons to explain why the doctor used azithromycin and Augmentin at first. Rather, it is because the doctor has followed the antibiotics guideline where amoxicillin/clavulanate ± a macrolide is the preferred regimens. Meanwhile, Tazocin is only considered under certain circumstances.

Guidelines for empirical therapy. Source: IMPACT Fourth Edition (version 4.0)
Guidelines for empirical therapy. Source: IMPACT Fourth Edition (version 4.0)

Such guideline encourages a more prudent use of antimicrobial antibiotics in order to slow down the growing threat of antimicrobial resistance (AMR).

Based on British Thoracic Society’s Guidelines for the Management of Community Acquired Pneumonia in Adults, oral therapy with amoxicillin and a macrolide such as azithromycin is preferred for patients with moderate severity CAP who require hospital admission. This aligns with the Interhospital Multi-disciplinary Programme on Antimicrobial Chemo Therapy (IMPACT) in Hong Kong.

In addition, it is noteworthy that this does not limit doctors’ choices in prescribing antibiotics. More importantly, it does not mean that the doctor has to completely rely on this antibiotics guideline during the treatment.

Ultimately, the decision of whether a switch is needed relies on the doctor’s clinical judgement and immediate concurrent feedback (ICF) provided by the antimicrobial stewardship (ASP) team.

Antimicrobial stewardship (ASP) is for the best benefits of patients

To control the emergence and spread of AMR, the Hospital Authority (HA) and the Centre for Health Protection (CHP) jointly launched the territory-wide Health Protection Programme on Antimicrobial Resistance (HPPAR) in 2006. The major component of the HPPAR is to introduce the Antibiotic Stewardship Programme to public hospitals.

According to IMPACT, the term antimicrobial stewardship (ASP) is defined as the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance.

Therefore, it is wrong to view ASP as a strategy for keeping cost under control. On the contrary, by minimising exposure to drugs by using the appropriate drug, dose and duration, reducing redundant therapy and targeting therapy to the likely pathogens, such activities can be viewed as a strategy to enhance patient safety and maximise patients’ benefits. MIMS

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