A to Z on antimicrobial prescription



Dr Wadanamby J.M.R.W.W
Head of department of Microbiolog
Lanka hospital diagnostics




Antimicrobial resistance is a major global threat that we encountered during this decade.

Many organizations, societies, committees individually and collectively are trying

to combat this threat worldwide. CDC recently published a lists of urgent threats, serious threats, concerned threats and watch list of those microbes who are already identified and causing problems worldwide1.

I am going to share a lecture which I conducted to Lanka hospital doctor’s forum, where I used the 26 letters of the alphabet to discuss ways to minimize resistance while prescribing antibiotics for infections to cure patients. This lecture was done on 23/01/2020. Further this article was appeared as a blog in AMR insight web site as well.

  • Assess the need of antimicrobials,

Identify the infection, sort whether it is viral, bacterial or others,

Use sepsis scores to assess the severity, SOFA, qSOFA, NEWS, LODS, ProCESS,


  • Bypass peer pressures

Patient requests/ expectations, drug companies, conflict of interests

  • Correct choice

Antiviral, anti-parasitic, anti-fungal, antibiotic. Local, Oral or systemic route.

Which group of antibiotic and its PK/PD. Consider patient’s tolerance, allergy and

concentration in serum and at the site.

  • Diagnostics-Microbiology and others,

Identify the type of microbe and susceptibilities. Identify toxicity, virulence, expected

dangers and get the supporting markers

  • Evaluate the clinical and laboratory findings to initiate therapy and throughout until the cure. Empirical therapy-> change to appropriate based on evidence .

 F -  Follow the guidelines, protocols, policies and experience plus “ gut feelings”

G -Good intension in changing, switching antimicrobials. Based on evidence escalation,

de-escalation, intravenous to oral etc.

 H-  Hold up unwanted antibiotics. Hild poly pharmacy.

  • Investigate adequately and cost effectively
  • Justice and justification at all levels of infection management to the patient, institute, population, nation and the world.
  • Knowledge on infection management should be updated every day.
  • Levels of antimicrobials should be done adequately based on individual needs of the patient.
  • Microbiome of the gut. It is very important to preserve, replace and maintain patients’ microbiome which is a key area of resistance development and spread.
  • Nutritional status of the patient should be maintained appropriately.
  • Organ functions are to be assessed at the early phase for the sepsis scores and monitor during management for drug toxicities and dosing purposes.
  • Preventive aspects of infections. Transmission based precautions, source isolation, outbreak prevention etc.
  • Question the need of the antibiotic every day and do not be hesitant to stop them when the satisfactory cure is achieved.
  • Resist resistance development utilizing/ practicing all the available measures.
  • Surveillance to be carried out for resistance development detection and infection detection.
  • Therapeutic index and therapeutic window should be known by the prescribers.
  • Underline diseases/conditions should be assessed and monitored.
  • Venous access management is very important in preventing line infections, phlebitis etc.( Bundle care is preferred)
  • Washing hands and monitoring adherence to the practice at all levels is very important.
  • Extreme caution for MDR and XDR
  • Yearly antimicrobial susceptibility patterns of the institute is very useful in combatting AMR.
  • Zero tolerance rule for prescription pressures at all levels and stick to the absolute necessity of the antimicrobials.



  1. https://WWW.cdc.gov/drug resistance/resources/publication.html 05/11/2019

Author: Roshan jayasuriya