InPHARMation. Pharmacy and Therapeutics Committee Update May 23 rd, 2018 Meeting

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1 VOLUME FOUR; ISSUE 5 May 23, 2018 Edited by: Gregory K. Perry, PharmD, BCPS-AQID

2 InPHARMation Pharmacy and Therapeutics Committee Update May 23 rd, 2018 Meeting The Pharmacy and Therapeutics Committee at Hendrick Medical Center is a Medical Staff Committee that meets the fourth Wednesday of each month with five physicians and one pharmacist serving as voting members. P and T is Medical Staff Committee. The current Chair of P and T is Charles W. Fuller, M.D. 1. Order Set Review: Beta-blocker/Calcium channel blocker overdose. A. Status: approved by P and T. The order set will be available in Apollo. If you would like a hard copy of this set please contact Greg Perry at gperry@hendrickhealth.org 2. Order Set Review: Multi-modal perioperative pain set for hip/knee replacement. A. Status: approved by the musculoskeletal section and P and T. The order set is specific to orthopedic surgeons. The order set will be available in Apollo. If you would like a hard copy of this set please contact Greg Perry at gperry@hendrickhealth.org 3. Formulary Delafloxacin (Baxdela) A. Status: P and T approved formulary addition with restrictions. Delafloxacin is a new fluoroquinolone that covers methicillin-resistant Stapylococcus aureus, Enterococcus faecalis, Pseuodomonas aeruginosa, enterics, anaerobes, and atypical pathogens such as Mycoplasama and Legionella. It is FDA indicated for acute bacterial skin and skin structure infections. It is available in both IV and oral presentations. B. Restrictions 1. Infectious Diseases only. 2. Documented polymicrobial infection (must have susceptible gram positive and negative pathogens) only day supply will be stocked in pharmacy. 4. Formulary Meropenem/vaborbactam (Vabomere) A. Status: P and T approved formulary addition with restrictions. Meropenem/vaborbactam is a combination of an existing carbapenem combined with a new beta-lactamase inhibitor. It covers all pathogens meropenem covers in addition to Enterobacteriaceae isolates, displaying carbapenem-resistant Enterobacteriaceae (CRE) and multidrug-resistant phenotypes. B. Restrictions 1. Infectious Diseases only. 2. Documented or history of CRE infection only day supply will be stocked in pharmacy. 5. Multidrug Resistant Infection Formulary all ID only. A. Ceftazidime/avibactam (Avycaz) specific for Pseudomonas aeruginosa infections suspected of expressing IMP and VIM resistance given with aztreonam. B. Meropenem/vaborbactam (Vabomere) specific for CRE as outlined above. 1

3 C. Ceftolozane/tazobactam (Zerbaxa) specific for Pseudomonas aeruginosa infection that are carbapenem resistant but not thought to be IMP or VIM expressing. 6. AMS Update: Year in Review April 2017 to April Utilization: 26% decrease. 2. Savings (actual hard cost acquisition): $196, Antimicrobial Stewardship Committee (AMS) Update: Utilization Reports through November 2017 CONGRATULATIONS: Antimicrobial use at HMC has decreased 26% compared to this time one year ago as it relates to Days of Therapy per 1000 patient days. Overall utilization of antimicrobials as defined by the CDC/NHSN indicates Hendrick Medical Center is potentially using to many antibiotics. The SAAR for April 2018 was for the system. The recommendation would be if you do not need therapy directed towards Pseudomonas aeruginosa then please avoid all anti-pseudomonal antibiotics if at all possible. The overall days of therapy per 1000 patient days represents a steady decline in antibiotic use over the past 12 months. If you would like to see a detailed report (Physician specific use, floor specific use, CDC specifics) please contact Greg Perry, PharmD, BCPS-AQID at gperry@hendrickhealth.org Always remember the premise of Antimicrobial Stewardship using the three R s. R = Right Drug. R = Right Dose. R = Right Duration of Therapy. 2

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8 Antimicrobial Stewardship Education by Jacquelyn Glockner, PharmD, PGY1 Resident HMC Bites (animal and human) and which bacteria to cover Animal bites account for approximately 1% of emergency visits nationwide. The majority of animal bites are from dogs however, cat bites generally penetrate deeper layers of tissue. There are a number of common pathogens isolated from cat and dog bites including Pasteurella, Staphylococci, Bacteriodes tectum, Fusobacterium, Capnocytophaga, and Prophyromonas species. The decision for the route of antibiotic administration either oral (PO) or intravenous (IV) is dependent on the depth, severity, and time from initial injury. First-line treatment for patients include amoxicillin-clavulanate or ampicillin-sulbactam. If a penicillin allergy is a concern, alternatives include doxycycline, trimethoprim-sulfamethoxazole plus anaerobic coverage (clindamycin or metronidazole), a fluoroquinolone plus anaerobic coverage, or ertapenem. Antibiotics are generally recommended for 5 days however if the patient presents with an infected wound a day course is recommended. Human bites are generally more serious than animal bites and can result from a clenched fist injury where contact is made between the fist of one individual and the teeth of another, or an occlusive injury which is a more traditional bite of human skin. The common pathogens from a human bite include normal oral flora as well as normal skin flora including Streptococci, Staphylococci, Haemophilus, Eikenella corrodens, Fusobacterium nucleatum, Peptostreptococci, Prevontella, and Prophyromonas species. Firstline antibiotics are similar to animal bites and include amoxicillin-clavulanate or ampicillin-sulbactam. For patients with a penicillin allergy, doxycycline, trimethoprim-sulfamethoxazole plus anaerobic coverage, a fluoroquinolone plus anaerobic coverage, or ertapenem are recommended alternative treatments. Generally 5-10 days of antibiotic therapy is adequate for either a cellulitis or an abscess resulting from a human bite. 7 Antibiotic Route Adult Dosing Recommendations Amoxicillin-clavulanate (Augmentin ) PO mg PO q12h Ampicillin-sulbactam (Unasyn ) IV g IV q6h for human bites q6-8h for animal bites Ertapenem (Invanz ) IV 1 g IV daily Doxycycline (Vibramycin ) PO 100 mg PO BID Trimethoprim-sulfamethoxazole (Bactrim ) Clindamycin (Cleocin ) Metronidazole (Flagyl ) Levofloxacin (Levaquin ) Clindamycin (Cleocin ) Metronidazole (Flagyl ) Ciprofloxacin (Cipro ) Clindamycin (Cleocin ) Metronidazole (Flagyl ) PO IV or PO IV or PO Trimethoprim-sulfamethoxazole : mg PO BID Clindamycin: 300 mg PO TID Metronidazole: mg PO 4 times daily Levofloxacin (IV/PO): 750 mg PO daily Either: Clindamycin IV:600 mg IV q6-8h Clindamycin PO:300 mg PO TID Either: Metronidazole IV:500 mg IV q8h Metronidazole PO: mg PO 4 times daily Ciprofloxacin IV: 400 mg q12h Ciprofloxacin PO: mg BID Either: Clindamycin IV:600 mg IV q6-8h Clindamycin PO:300 mg PO TID Either: Metronidazole IV:500 mg IV q8h Metronidazole PO: mg PO 4 times daily References: 1. Stevens D, Bisno A, Chambers H, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. CID. 2005;41(11):

9 2. Aziz H, Rhee, P, Pandit V, et al. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015; 78(3): Lexicomp Online, Therapeutically Speaking Test Your Knowledge: R.F., a 66-year-old man, presents to the ED with a 2-week history of low-grade fever, cough with putrid sputum, and night sweats. His physical examination is notable for gingivitis and decreased breath sounds on auscultation. His chest radiography reveals an irregularly shaped cavity with an air-fluid level in the upper left lobe surrounded by an infiltrate. His vital signs include temperature F (38 C), blood pressure 148/92 mm Hg, heart rate 88 beats/minute, respiratory rate 18 breaths/minute, and pain 2/10. His laboratory values include BUN 28 mg/dl, SCr 1.5 mg/dl, WBC 15 x 10 3 cells/mm 3, Hgb 12 g/dl, Hct 36%, and Plt 240,000 cells/mm 3. His medical history is significant for hypertension, dyslipidemia, depression, and chronic kidney disease. His current drugs include hydrochlorothiazide 25 mg/day, atorvastatin 20 mg/day, fluoxetine 40 mg/day, and duloxetine 60 mg/day. R.F. is given a diagnosis of a lung abscess and is admitted to the hospital for antibiotic administration. A nasal swab is negative for MRSA. 1. Which one of the following is the most likely cause of R.F. s lung abscess? A. Anaerobic bacteria and streptococci B. E. coli and K. pneumoniae C. M. tuberculosis and non-tubercular mycobacteria D. S. aureus and S. pneumoniae 2. Which one of the following is best to recommend as empiric therapy for R.F.? A. Clindamycin 600 mg intravenously every 8 hours B. Linezolid 600 mg orally every 12 hours C. Piperacillin/tazobactam 4.5 g intravenously every 6 hours D. Rifampin 600 mg orally daily plus isoniazid 300 mg orally daily plus pyrazinamide 1000 mg orally daily plus ethambutol 800 mg orally daily Test Your Knowledge Answer: Question 1: A if poor dentition then anaerobes. If dentition is good or the patient has no teeth then very little anaerobes so don t cover. Oral facultative Streptococci spp (anginosous) would be a concern. Note MRSA, Pseudomonas et al are not part of the differential in this case. The key is an aspiration event is not an aspiration pneumonia but seems to be treated as such many times. A negative CXR does not require treatment.just prevent future aspiration. In this case we have an obvious issue. Question 2: A You don t need MRSA coverage due to the negative predictive value of the MRSA nasal swab so linezolid is not a correct answer. Pseudomonas is not part of the differential so you don t need pip/tazo. TB is certainly not part of the equation so RIPE therapy is not indicated. Clindamycin would cover the oral strep pathogens and oral anaerobes. 8