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Mr Anote’s story Part 2

Clip 2 from the African Scenario
After a long time in the ICU, the doctors finally released him to the general ward and changed the drugs to another one, which is also given by drip. It was very, very difficult for us by that time. If we had only been told. Were there no cheaper versions of the drugs we were told to buy?
Sometimes we should be courageous enough to tell the consultants one or two things. It was obvious that there were financial constraints from the family side. Even though it’s not the best to treat the patient based on financial consideration, Up till Anote died, there was no sensitivity done to confirm if he was on the best antibiotic regimen. After the ICU care, he was transferred to the general ward, where you have nursing staff that were not sufficient enough to care for the bedsores and do normal wound dressing. Even the consultant microbiologist visited and recommend a much cheaper antibiotic than the one he was on. But no consultants changed the treatments on the charts. The surgery was done 36 hours after admission.
On admission, he had been placed on intravenous ceftriaxone, 500 milligrams and intravenous metronidazole, 500 milligrams eight-hourly. During the surgery, no sample of the peritoneal fluid collection was sent to the lab for culture. The patient was then commenced on intravenous meropenem, 2 grams eight-hourly. Add together with the metronidazole, and the ceftriaxone was discontinued. He was admitted into the ICU for ventilatory support. The medical microbiologist reviewed his case, as medical microbiologists review antibiotics of patients in the ICU. And he recommended that meropenem be reduced to 1 gram eight-hourly, and metronidazole be discontinued. However, the managing team continued with meropenem two hours eight-hourly, and metronidazole, 500 milligrams eight-hourly.
While in the ICU, he developed some complications, and a second laparotomy was required to repair an anastomotic leak. This was done seven days after the first operation. And meropenem, 2 grams eight-hourly, and metronidazole, 500 milligrams eight-hourly, was still being administered. Once again, no sample of the peritoneal fluid was take to the microbiology lab for culture. He continued to receive meropenem and metronidazole intravenously for 20 more days while on admission in the ICU. He was then discharged into the ward as soon as he no longer needed ventilatory support and could take his antibiotics orally. His antibiotic regimen then changed to intravenous levofloxacin, 500 milligrams daily, and metronidazole, 500 milligrams eight-hourly.
This was then reviewed after 10 days and changed to intravenous amoxiclav and metronidazole. The basis of changing these antibiotics from one antibiotic to another was not apparent, and there was no clinical indication either for continuing the antibiotics. The managing team felt they needed to give him antimicrobial cover to prevent infection from the slowly healing wound until he was discharged from the hospital. His antibiotic regimen then changed again after three days, to intravenous amoxiclav, ciprofloxacin, and Flagyl. He went on to develop bed sores and fever. And his antibiotics were changed to intravenous levofloxacin, 500 milligrams daily, and metronidazole, 500 milligrams eight-hourly, and gentamicin, 80 milligrams eight-hourly. He continued to deteriorate, despite these antibiotics, and later died from sepsis.

Now watch this clip from the scenario video and identify any further failings in the stewardship of Mr Anote’s case.

Take notes as before.

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Antimicrobial Stewardship for Africa

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