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Antibiotic Stewardship: the 3 D's

Antibiotic Stewardship
by

Teresa Williams

on 21 February 2014

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Transcript of Antibiotic Stewardship: the 3 D's

Antibiotic Stewardship
Objectives
Define stewardship
Understand the importance of stewardship and our role as physicians
Education: Infection Guidelines
GHS specific resistance patterns
Steps to stewardship moving forward

What is Stewardship?
Coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing:
1. patient outcomes
2. reducing resistance
3. decreasing unnecessary costs

Why is this important?
Teresa Williams, MD, MPH
PGY-2
The 3 D's of the
War on Drugs
The right
D
rug, at the right
D
ose, for the right
D
uration
I have no financial disclosures
Patient Outcomes
Increased risk of diarrhea
Increased risk of associated infections (c.diff, resistance)
Increased risk of return visits
Increased length of stay
Increased risk of ICU transfer
Increased cost
142,000 visits to ERs in 2008 for adverse events related to antibiotics
Shehab N et al. Clinical Infectious Diseases 2008; 15:735-43
Resistance
Antibiotic resistance is increasing over time
VRE leads to decreased survival (24% vs 59%), increased
hospital stay (34.8 vs 16.7 days), and cost of $27,190 per episode, with excess mortality of 30%
DiazGranados CA, Zimmer SM, Klein M, Jernigan JA. Comparison of mortality associated with vancomycin-resistant and vancomycin-susceptible enterococcal bloodstream infections: a meta-analysis. Clin Infect Dis 2005;41:327-33.
Healthcare Costs
Up to 50% of antibiotic use is inappropiate
Accounts for up to 30% of hospital pharmacy budgets
Cost of resistant organism infection annually is estimated to be $4-$5 billion
Stewardship programs have saved institutions $200,000-$400,000 annually
University of Maryland demonstrated savings of $17 million over 8 years.
Costs rose $1 million after program was
discontinued (23% increase) and
continued to rise the following year
What is Our Role?
Is this a bacterial infection?
What is the correct treatment?
Educate patients and families
Culture prior to starting antibiotics
De-escalate as appropriate

IDSA Guidelines for CAP in Adults
The Right Drug
Previously healthy, no antibiotics in the past 3 months:
Macrolide or doxycycline
Comorbidities, previous antibiotic use in the last 3 months, or high community rate of macrolide resistant strep pneumo:
Respiratory fluoroquinolone OR macrolide + beta-lactam
Outpatient
Inpatient, non-ICU
Respiratory fluoroquinolone OR macrolide + beta-lactam
Inpatient, ICU
Beta-lactam (ceftriaxone, cefotaxime, or ampicillin-sulbactam) + either azithromycin OR respiratory fluoroquinolone
Pencillin allergic: aztreonam + fluoroquinolone
Special Considerations
Pseudomonas: zosyn, cefepime, imipenem, or meropenem + either (cipro or levofloxacin) OR (aminoglycoside + azithromycin) OR (aminoglycocide + fluoroquinolone)
MRSA: Add vancomycin or linezolid
The Right Dose
Outpatient
Amoxicillin 1g TID or Augmentin 2g BID
Fluoroquinolones 750mg q day
Inpatient
Switch from IV to PO when hemodynamically stable, normally functioning GI tract, and clinically improving
Discharge home after the above, no need to watch on PO therapy
The Right Duration
Patients should be treated for minimum of 5 days, be afebrile for 48-72 hours and have no more than 1 sign of clinical instability
Longer duration if initial choice was not active against pathogen or complicated by extrapulmonary infection
IDSA Guidelines for CAP in Children
The Right Drug
The Right Dose
The Right Duration
Preschool Age
No antibiotic recommended: viral pathogen likely
Outpatient < 5 years
Amoxicillin
Alternative: Augmentin
If atypical suspected: Azithromycin
Outpatient > 5 years
Amoxicillin + Azithromycin unless atypical not supected
Inpatient: Immunized
Ampicillin or Pen G
Macrolide if atypical suspected
Levoquin for those unable to tolerate macrolides
Vancomycin or Clindamycin if MRSA suspected
Inpatient: Unimmunized
Ceftriaxone or Cefotaxime
Macrolide if atypical suspected
Levoquin for those unable to tolerate macrolides
Vancomycin or Clindamycin if MRSA suspected
Oral
Amoxicillin/Augmentin: 90mg/kg/day BID or 45mg/kg/day TID
MAX: 2g BID
Azithromycin 10mg/kg/day x 1, then 5mg/kg/day x 4
MAX: 500mg x 1, 250mg x 4
Omnicef: 14mg/kg/day q day or BID
MAX: 300mg q day
Levofloxacin: 16-20mg/kg/day BID for children 6 months - 5 years, 8-10mg/kg/day q day for children 5 - 16 years
MAX: 750mg q day
Clindamycin: 30-40mg/kg/day TID
MAX: 300mg TID
IV
Ampicillin 150-200mg/kg/day q 6hr
300-400mg/kg/day IV q 6r if pen resistant
MAX: 6-12g/day
Pencillin: 200,000-250,000 unit/kg/day q 4-6 hr
MAX: 24 million units q day
Ceftriaxone 50-100mg/kg/day q day
MAX: 2g q day
Vancomycin: 15mg/kg/dose
MAX: 2g q day
Azithromycin, Levofloxacin, Clindamycin:
all the same as PO dosing
Few studies, but 10 days is best supported
Shorter courses for milder infection may be warranted
Longer courses for MRSA or complicated pneumonia may be warranted
IDSA Guidelines for Sinusitis
The Right Diagnosis
Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for
>10 days
without any evidence of clinical improvement

Onset with
severe symptoms or signs of high fever (≥39°C [102°F]) and purulent nasal
di
scharge or facial pain lasting for at least
3–4 consecutive days
at the beginning of illness

Onset with worsening symptoms or signs characterized by the
new onset of fever, headache, or increase in nasal discharge
following a typical viral upper respiratory infection (URI) that lasted
5–6 days
and were initially improving (“double-sickening”)
The Right Drug
Augmentin is the drug of choice for both children and adults
Doxycycline may be used as an alternative
Macrolides are NOT recommended due to strep pneumo resistance (~30%)
Bactrim is NOT recommended due to strep pneumo and h. flu resistance (~30-40%)
2nd or 3rd generation cephalosporins alone are NOT recommended due to strep pneumo resistance
For penicillin allergic patients: 2nd or 3rd generation cephalosporin + clindamycine OR respiratory fluoroquinolone
The Right Dose
Standard dose if no resistant strep pneumo (500mg TID or 875mg BID or 45mg/kg/day BID)
High dose if resistant strep pneumo (2g BID or 90mg/kg/day BID)
The Right Duration
Adults: 5-7 days
Children: 10-14 days
IDSA Guidelines for UTI
The Right Drug
Nitrofurantoin
or
Bactrim
are appropriate first line choices
Fosfomycin
is an appropriate choice but may be less efficacious
Fluoroquinolones
are efficacious, but should be reserved for other uses
Beta-lactams
have lower efficacy and more side effects
Amoxicillin
or
ampicillin
should not be used
The Right Dose
Nitrofurantoin: 100mg BID
Bactrim: 160/800mg BID
Fosfomycin: 3g once
The Right Duration
Nitrofurantoin: 5 days
Bactrim: 3 days
Fosfomycin: 1 dose
Fluoroquinolones: 3 days
Beta-lactams: 3-7 days
At 20% local resistance of an organism,
an agent is no longer recommended
as first line therapy
For simple cystitis in women
AAP Guidelines for Febrile UTI
For children ages
2 months to 2 years
The Right Drug
Ceftriaxone
Cefotaxime
Ceftazidime
Gentamicin
Tobramycin
Piperacillin
Amoxicillin-clavulanate
Sulfonamide
    Trimethoprim-sulfamethoxazole
    Sulfisoxazole
Cephalosporin
    Cefixime
    Cefpodoxime
    Cefprozil
    Cefuroxime axetil
    Cephalexin
IV
PO
Local resistance patterns should guide treatment
If patients are unable to reliable take PO, antibiotics should be given IV until clinically improved
Antibiotics that do not achieve high concentration in the blood (i.e. nitrofurantoin) should not be used for febrile children because of the possibility for pyelonephritis or urosepsis
In a study of 309 febrile infants with UTIs, only 3 (1%) were deemed too ill to be assigned randomly to either parenteral or oral treatment
Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics. 1999;104(1):79–86
The Right Dose
Ceftriaxone 75 mg/kg, every 24 h
Cefotaxime 150 mg/kg per d, divided every 6–8 h
Ceftazidime 100–150 mg/kg per d, divided every 8 h
Gentamicin 7.5 mg/kg per d, divided every 8 h
Tobramycin 5 mg/kg per d, divided every 8 h
Piperacillin 300 mg/kg per d, divided every 6–8 h
Amoxicillin-clavulanate 20–40 mg/kg per d in 3 doses
Sulfonamide
    Trimethoprim-sulfamethoxazole 6–12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per d in 2 doses
    Sulfisoxazole 120–150 mg/kg per d in 4 doses
Cephalosporin
    Cefixime 8 mg/kg per d in 1 dose
    Cefpodoxime 10 mg/kg per d in 2 doses
    Cefprozil 30 mg/kg per d in 2 doses
    Cefuroxime axetil 20–30 mg/kg per d in 2 doses
    Cephalexin 50–100 mg/kg per d in 4 doses

PO
IV
The Right Duration
Minimum of 7 days up to 14 days
No clear data to support 7 vs 10 vs 14 day courses
IDSA Guidelines for Skin and Soft Tissue Infections
The Right Diagnosis
Abscesses: I and D +/- antibiotics
Cellulitis/Erysipelas: antibiotics +/- steroids
Animal bites: antibiotics
Need antibiotics/culture:
presence of multiple lesions
cutaneous gangrene
severely impaired host defenses
extensive surrounding cellulitis
severe systemic manifestations of infection, such as high fever
The Right Drug/Dose
The Right Duration
Simple cellulitis: 5 day courses are as effective as 10 day courses
Animal/human bite: 5-10 days if infected
3-5 days for prophylaxis of "clean" wounds
GHS Resistance Patterns
Elements of an effective
antimicrobial stewardship program
Education
Education alone without incorporation does not have sustained impact
During the period of active intervention, 25% of antimicrobial orders were modified (86% resulted in less expensive therapy, and 47% resulted in use of a drug with a narrower spectrum of activity), resulting in a significant increase in microbiologically based prescribing (63% vs. 27%)
Bantar C, Sartori B, Vesco E, et al. A hospitalwide intervention program to optimize the quality of antibiotic use: impact on prescribing practice, antibiotic consumption, cost savings, and bacterial resistance. Clin Infect Dis 2003;37:180-6
Local Guidelines and Clinical Pathways
GHS has order sets for CAP, HAP, Pylenephritis, Neutropenic Fever, Sepsis, Pediatric UTI, Pediatric Skin and Soft Tissue Infection, and Pediatric Fever Without a Source
Streamlining and De-escalating
Dose Optimization
Parenteral to Oral Conversion
Conclusions
Stewardship is an important part of our practice, prescribe only when necessary!
Keep in mind the 3 D's
Use guidelines with local resistance patterns in mind
Make use of the resources we have avaliable
Resources
Questions?
In the hospital setting, as cultures become avaliable or clinical picture changes, antibiotics should be tailored appropiately
Review by a pharmacist and an infectious diseases physician of 625 patients receiving combination antimicrobial therapy led to streamlining recommendations in 54% of antimicrobial courses over 7 months, resulting in a projected annual savings of $107,637
Briceland LL, Nightingale CH, Quintiliani R, Cooper BW, Smith KS. Antibiotic streamlining from combination therapy to monotherapy utilizing an interdisciplinary approach. Arch Intern Med 1988;148:2019-22.
Dosing should take into consideration:
age
weight
renal function
site of infection
pharmocokinetics of the drug
This can result in reduced length of hospital stay, health care costs, and potential complications due to intravenous access.
Enhanced oral bioavailability: fluoroquinolones, metronidazole, clindamycin, trimethoprim-sulfamethoxazole, fluconazole, and voriconazole
Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship
http://m.cid.oxfordjournals.org/content/44/2/159.full
Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults
http://m.cid.oxfordjournals.org/content/44/Supplement_2/S27.full
The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America
http://m.cid.oxfordjournals.org/content/early/2011/08/30/cid.cir531.full?sid=f62e95e9-9713-4a72-bf19-80b329afed38
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults
http://m.cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full
International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases
http://m.cid.oxfordjournals.org/content/52/5/e103.full?ijkey=Evn1QGFzwH8Xrj3&keytype=ref
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months
http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330
Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections
http://m.cid.oxfordjournals.org/content/41/10/1373.full
CDC Get Smart for HealthCare
http://www.cdc.gov/getsmart/healthcare/
Full transcript