9/30/2016. Dr. Janell Mayer, Pharm.D., CGP, BCPS Dr. Lindsey Votaw, Pharm.D., CGP, BCPS

Transcription

1 Dr. Janell Mayer, Pharm.D., CGP, BCPS Dr. Lindsey Votaw, Pharm.D., CGP, BCPS 1

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3 Untoward Effects of Antibiotics Antibiotic resistance Adverse drug events (ADEs) Hypersensitivity/allergy Drug side effects Clostridium difficile infections Increased health care cost Annual Burden of Antibiotic Resistance in the United States 3

4 Mechanism of DNA Transfer Conjugation: Main mechanism for spread of resistance Direct physical interaction between cells Transduction Least clinical problem Virus mediated transfer of DNA between bacteria Transformation Less common method DNA released into the environment by dead bacterium which is then taken up by bacteria in the area. 4

5 Mechanism of Antibiotic Resistance Enzymatic inactivation Destroy the antibiotic Decreased permeability Restrict accesses of the antibiotic Efflux pump Get rid of the antibiotic Alteration of target site Change the targets for the antibiotic Enzymatic alteration Change the antibiotic Mechanisms of Antibiotic Resistance Enzymatic inactivation S. aureus, H. influenzae, N. gonorrhoeae, E. coli, Klebsiella sp., Enterobacter sp., Serratia sp., other enteric bacteria, anaerobes Β-lactam antibiotics Mechanisms of Antibiotic Resistance Decreased Permeability Pseudomonas spp. Affects many antibiotics including carbapenems Efflux pumps Pseudomonas spp. Tetracyclines Macrolides 5

6 Mechanisms of Antibiotic Resistance Alteration of Target Site DNA gyrase Fluoroquinolones Many gram-negatives, S. pneumoniae Penicillin-binding protein Methicillin-resistant S. aureus (MRSA) Penicillin-resistant S. pneumoniae Gram positive cell wall Vancomycin Enterococcus spp Ribosome Tetracyclines Macrolides S. pneumoniae, Staphylococcus sp., N. gonorrhoeae, enteric gramnegative rods Mechanism of Antibiotic Resistance Enzymatic Alterations S. aureus, Serratia marcescens, Pseudomonas spp. Aminoglycosides 6

7 Antibiotic Resistance Threats in the U.S. U.S. Department of Health and Human Services Centers for Disease Control and Prevention Released April 2013 Antibiotic resistance today and consequences for future Increase awareness and encourage action Antibiotic Resistance Threats in the U.S. Three sections Background, overview of resistance in the U.S. Burden of illness Level of concern Available antibiotics Initiatives to fight this threat Summary of each bacteria in the report CDC Level of Concern Urgent threats Immediate public health threats requiring urgent and aggressive action Serious threats Serious concern requiring prompt and sustained action Concerning threats Concerning; careful monitoring and prevention action needed 7

8 CDC Level of Concern - Urgent CDC Level of Concern - Serious CDC Level of Concern - Concerning 8

9 Urgent Threat Clostridium difficile (C. difficile) Spore-forming, Gram-positive, anaerobic Toxin A and Toxin B Epidemic strain (BI/NAP1/027) Additional binary toxin Life-threatening diarrhea Accounts for 15-25% of all antibioticassociated diarrhea Urgent Threat - C. difficile Risk Factors Antimicrobial exposure Advanced age (>65 years) Acid suppressive therapy Gastrointestinal surgery, nasogastric tube feeding Extended stay in healthcare settings Urgent Threat - C. difficile Resistance At this time not an issue Threat Updated information as of ,000 infections per year in the U.S. 15,000 deaths per year $3,800,000,000 in excess medical costs per year 9

10 Urgent Threat Carbapenem-Resistant Enterobacteriaceae (CRE) Carbapenems Broad spectrum Antibiotic of last resort Doripenem Ertrapenem Imipenem Meropenem Enterobacteriaceae Gram negative bacilli Escherichia coli (E. coli) Klebsiella Urinary Tract Infections Bloodstream infections Pneumonia Intra-abdominal infections Urgent Threat - CRE Risk Factors Antimicrobial exposure Healthcare exposure Intensive Care Unit Long-term care settings Poor functional status Mechanical ventilation Urinary catheter or retention Urgent Threat - CRE Resistance Resistant to nearly all available antibiotics Threat ~9,000 CRE infections per year in the U.S. ~600 deaths per year in the U.S High mortality rate 10

11 Urgent Threat Drug-Resistant Neisseria Gonorrhoeae Cause of sexually transmitted disease gonorrhea Reproductive tract, mouth, throat, eyes, rectum Asymptomatic or mild nonspecific symptoms If left untreated Pelvic inflammatory disease Epididymitis Disseminated gonococcal infection Spread to newborn Urgent Threat Drug-Resistant Neisseria Gonorrhoeae Risk Factors Sexual activity Resistance Resistance to nearly all antibiotics used for gonorrhea treatment IM Ceftriaxone + oral Azithromycin Urgent Threat Drug-Resistant Neisseria Gonorrhoeae Threat ~820,000 gonococcal infections per year in U.S. ~246,000 (30%) drug-resistant gonorrhea infections Widespread cephalosporin resistance ~75,000 additional PID cases ~15,000 additional epididymitis cases ~222 additional HIV infections 11

12 Serious Threats Multidrug-resistant Acinetobacter Drug-resistant Campylobacter Fluconazole-resistant Candida Extended spectrum B- lactamase producing Enterobacteriaceae (ESBLs) Vancomycin-resistant Enterococcus (VRE) Multidrug-resistant Pseudomonas aeruginosa Drug-resistant Non-typhoidal Salmonella Drug-resistant Salmonella Typhi Drug-resistant Shigella Methicillin-resistant Staphylococcus aureus (MRSA) Drug-resistant Streptococcus pneumoniae Drug-resistant tuberculosis Concerning Threats Vancomycin-resistant Staphylococcus aureus (VRSA) Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus 12

13 Antibiotic use in the United States Outpatient million courses of antibiotics annually ~50% inappropriate Hospital 20-50% of use is unnecessary or inappropriate Long Term Care 70% of nursing home residents receive at least one course of antibiotics per year 40-75% unnecessary or inappropriate Antibiotic Stewardship A set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Outcomes of Antibiotic Stewardship Reducing unnecessary antibiotic use can Decrease antibiotic resistance Decrease C. difficile infections Decrease healthcare costs Improve patient outcomes 13

14 Support for Antibiotic Stewardship The White House Centers for Disease Control and Prevention Agency for Healthcare Research and Quality (AHRQ) World Health Organization Infectious Diseases Society of America Society for Healthcare Epidemiology of America The Joint Commission Centers for Medicare & Medicaid Services The list goes on and on.. CDC Core Elements for Antibiotic Stewardship Education Leadership commitment Reporting Accountability Tracking Drug expertise Action 14

15 Leadership Commitment Writing formal statements of support Communicating facility policies and expectations with staff and prescribers Including stewardship-related duties in job descriptions and performance reviews Providing time and financial support toward stewardship efforts Supporting training and education Creating a culture which promotes antibiotic stewardship Accountability Identify a leader Training in infectious disease and/or antibiotic stewardship Multidisciplinary support team Clinicians and department heads Infection prevention coordinator and hospital epidemiologists Quality improvement staff Laboratory Information technology staff Nurses Drug Expertise Appoint a pharmacist leader Partner with program leads at local hospitals Develop relationships with infectious disease consultants in your community 15

16 Action Implement at least one policy or practice Stepwise fashion Specific interventions Broad Pharmacy driven Infection and syndrome specific Prioritize interventions Action Policies that support optimal antibiotic use Document dose, duration, and indication Implement facility-specific treatment recommendations Apply current medication safety policies to antibiotic use Medication regimen review Action Interventions to improve antibiotic use Broad Pharmacy-driven Infection and Syndrome specific Improve evaluation and communication of clinical signs and symptoms Optimize use of diagnostic testing Automatic time out Prior authorization Prospective audit and feedback IV to PO Dose adjustments and optimization Duplicative therapy Automatic stop orders Drug interactions Asymptomatic bacteriuria, UTI prophylaxis C. Difficile Community acquired pneumonia Skin and soft tissue infections 16

17 Tracking and Reporting Monitor prescribing Process measures How and why antibiotics are prescribed Are policies and guidelines being followed Use measures How often and how many antibiotics prescribed Hospital: days of therapy or defined daily dose LTC: point prevalence, antibiotic starts, days of therapy Tracking and Reporting Monitor Outcomes Impact of interventions Clostridium difficile rates Adverse drug reactions Antibiotic resistance Costs related to antibiotic use Education and Feedback What Resistance patterns Prescribing patterns Who Clinicians Nursing staff Patients Families How Flyers Pocket-guides Newsletters Electronic communications Face-to-face 17

18 Improving Prescribing Audit and Feedback Promotes adherence to evidence based practices Compares individual prescribing to co-workers or expected prescribing rates based on clinical practice guidelines Effective when combined with clinician education 18

19 Clinical Decision Support Provides information to facilitate accurate diagnosis diagnoses and treatment Clinical information entered to determine if antibiotic is needed Delayed Prescribing Practices Writing a post-dated prescription Re-contacting a patient after a clinical visit Providing a prescription and giving a verbal order to fill the prescription after a pre-determined length of time if symptoms do not improve Poster Based Interventions Antibiotic use posters on display Educating patients and clinicians Reducing patient expectation for an antibiotic Advertising clinician commitment to judicious antibiotic prescribing to patients and office staff 19

20 Get Smart About Antibiotics Week November Resources Centers for Disease Control (CDC): The White House: National Strategy for Combating Antibiotic-Resistant Bacteria: AHA Antimicrobial Stewardship Program AHRQ Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship AMDA Choose Wisely Program Association for Professionals In Infection Control and Epidemiology: Antimicrobial Stewardship Questions 20