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, Choix de l'antimicrobien -conforme aux lignes directrices et contexte clinique

, Afin de standardiser les lignes directrices auxquelles chaque pharmacien se rapporte, voici les références suggérées : -Lignes directrices CHUM : infections urinaires, neutropénie fébrile, méningite -IDSA : Pneumonie acquise en communauté et nosocomiale

, Pour "fonction rénale", inscrire la valeur de la créatinine ou de la clairance à la créatinine. Pour le poids, l'inscrire s'il est disponible ou faire peser le patient si cela vous semble pertinent pour l'adaptation de la posologie. Cocher "adéquat" si la posologie prescrite est adéquate, Posologie Les items "fonctions rénales", "fonctions hépatiques" et "poids" sont des éléments de réflexions pour le choix de la posologie

R. Dans-les, Dans ce cas, cochez la case "à optimiser

, Interaction(s) médicamenteuse(s)

&. Cocher and . Oui, ou "non" la présence de tout type d'interaction médicamenteuse. Décrire le mécanisme de l'interaction et la résultante (effet additif QTc

, Durée prévue

, Si le prescripteur indique une durée de traitement lors de la prescription initiale, il est possible de l'inscrire sur la liste. Aussi, si le diagnostic est déjà posé par l'équipe traitante, il est possible de tout est conforme

, Le remplissage de la liste ne remplace pas vos interventions. Penser à faire vos suggestions dans les ordonnances médicales

, Indiquer tous les antimicrobiens (antibiotiques, antifongiques et antiviraux, quelle que soit la voie

, ) posé(s) par l'équipe médicale et inscrit(s) dans les notes d'évolution ou sur une feuille d'ordonnance médicale. Voici la marche à suivre suggérée pour quelques situations particulières : 1-Diagnostic non indiqué au dossier: inscrire "non précisé, 2-Plusieurs origines infectieuses suspectées: énumérer les différents foyers infectieux séparés d'un "ou

, Plusieurs infections en même temps requérant un traitement différent: indiquer les différentes indications (par exemple : cystite et cellulite)

, Choix de l'antimicrobien -Spectre d'activité adapté aux résultats de culture

, Ecrire les résultats de culture s'il y en a. Cocher "oui" s'il y a des résultats de culture

, Pour le poids, l'inscrire s'il est disponible ou faire peser le patient si cela vous semble pertinent pour l'adaptation de la posologie. Cocher "adéquat" si la posologie prescrite est adéquate. Il est possible de justifier un ajustement qui diffère de ce qui est suggéré dans les références, Posologie Les items "fonctions rénales", "fonctions hépatiques" et "poids" sont des éléments de réflexions pour le choix de la posologie

, Pour tous les autres, cocher S/O et passer à l'item suivant. -pour le pic : inscrire la valeur obtenue du dernier prélèvement de Cmax disponible -pour le creux : inscrire la valeur du dernier prélèvement de Cmin disponible -cible visée : selon la

, Si la cible visée est atteinte, cocher "adéquat". Sinon, "à optimiser" et faites vos suggestions pour la conduite à tenir dans la partie

, Voie d'administration GB : noter la dernière valeur de globules blancs disponible à partir de Oacis® T : noter la dernière valeur de température obtenue notée au dossier Per os possible : si patient non intubé

, Cocher "oui" si présence de tout type d'interaction médicamenteuse. Décrire l'interaction médicamenteuse, son mécanisme et la résultante (effet additif QTc, changement de concentrations plasmatiques, variation INR, etc) dans la partie adéquate

, Durée prévue

&. Cocher and . Oui, si le médecin a déjà prévu une durée de thérapie. Cochez "S/O" si traitement empirique ou infection non encore documentée donc impossibilité de prévoir une durée. En proposer une, si possible, si aucune durée inscrite

, Le remplissage de la liste ne remplace pas vos interventions. Penser à faire vos suggestions dans les ordonnances médicales

, Penser à signer votre liste de vérification