Antimicrobial Stewardship in the ER. Dr. Michael Armitage Maritime Trauma and EM Conference April 5, 2014

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1 Antimicrobial Stewardship in the ER Dr. Michael Armitage Maritime Trauma and EM Conference April 5, 2014

2 Declaration of Conflict of Interest I DO NOT have an affiliation(financial or otherwise) with a pharmaceutical, medical device, or communications organization.

3 Outline Describe antimicrobial stewardship and resistance Review Treatment Guidelines for UTI, Cellulitis and CAP (New Brunswick Antiinfective Stewardship Committee [ASC] and ASC Working Group, 2013)

4 What is Antimicrobial Stewardship? the limitation of inappropriate antimicrobial use while optimizing antimicrobial selection, dosing, route, and duration of therapy to maximize clinical cure or prevention of infection; while limiting unintended consequences, such as the emergence of resistance, adverse drug events, the selection of pathogenic organisms, and cost (Vancouver Coastal Health Antimicrobial Stewardship Treatment Guidelines for Common Infections, March 2011)

5 Why Stewardship? Widespread and suboptimal use of antibiotics has promoted the emergence of bacterial resistance resulting in infection related morbidity/mortality; also predisposition to secondary infections Factors that contribute to resistance propagation: inadequate hygiene, proximity of hospitalized patients, international travel. Must consider individual and public health consequences when writing a prescription for an antibiotic

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7 Effective Stewardship Prescribing Is an antibiotic indicated? Suspected pathogen? Spectrum of activity of antimicrobial? Local resistance patterns? Risk of resistance? Medical history? Pregnancy Others

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9 UTI: Guidelines for Treatment Classic Signs and Symptoms Dysuria, frequency, urgency, suprapubic/abdominal pain, gross hematuria F/S/C, N/V, flank pain, CVA tenderness Gross hematuria not a sign of complicated UTI, needing different empiric/prolonged Rx

10 Variations in UTI Presentation Isolated dysuria or frequency or urgency or abdominal/suprapubic pain or flank pain, or gross hematuria. Elderly or those with CNS or Spinal Cord Disease

11 Urinalysis (dip stick and microscope) Leukocyte esterase Nitrite Pyuria

12 Prevalence of Pyuria, IDSA Guidelines Pyuria? Pyuria : >10Lkc on microscopy Pyuria : presence or absence does not differentiate symptomatic from asymptomatic bactreiuria Pyuria :not an indication for antimicrobial therapy Pyuria: absence with symptoms consider alternate diagnoses Prevalence 32% of young women 30 70% of pregnant women 70% of diabetic women 90% of LTC men and women 90% of hemodialysis patient 30 75% ST catheters % LT catheters (Nicolle, LE, et al, CID 2005)

13 Urine Culture Resistance surveillance Atypical symptoms Persistent symptoms Recurrence Complicated infections Catheter in situ 2wk Not necessary post treat except in pregnancy and recurrences

14 Asymptomatic Bacteriuria (ASB) Isolation of a specified quantity of bacteriuria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection Women 2 specimens same species 10⁵ Men 1 specimen single species 10⁵ Catheter 1 specimen single species 10 (Nicolle,LE, et al CID 2005)

15 Prevalence of Asymptomatic Bacteriuria, (IDSA Guidelines, Nicolle, LE et al CID 2005)

16 Screening for and Treatment of ASB Not Recommended Premenopausal, nonpregnant women Diabetic women Older persons living in the community Elderly LTCF Persons with spinal cord injuries Catheterized patients, short or long term, while catheter is in situ Recommended Pregnant women, at least once early Before TURP or other urological procedures causing mucosal bleeding Asymptomatic women with catheter acquired bacteriuria 48h post catheter removal

17 Empiric Antimicrobial Therapy UTI Uncomplicated Cystitis (Lower UTI) E.coli Other Enterobacteria CoNS, particularly S.saprophyticus First Line Options Nitrofurantoin Macrocrystals 5 days Alternatives TMP SMX 3days Amoxicillin/clavulanate 7days Fosfomycin Pregnancy Nitrofurantoin (avoid near term, i.e weeks) Cephalexin 7days Cefixime 7days

18 Therapy for UTI Acute Uncomplicated Pyelonephritis E.coli, other Enterobacteria, CoNS Complicated UTI structural abnormality, obstruction, recent urogenital procedure, male, immunosuppression, poorly controlled diabetes, spinal cord injury, catheterization/urologic apparatus, or S+S 7 days) Above plus Ps., Enterococci, Grp B Strep

19 Systemically Well: Cefixime Ciprofloxacin TMP SMX Amoxicillin/clavulanate Empiric Therapy for UTI Systemically Unwell: Ceftriaxone Ampicillin + Gentamicin Piperacillin/tazobactam(if at risk of MDR organisms) Pregnant: Ceftriaxone Ampicillin + Gentamicin

20 Clinical Pearls for UTI Acute Uncomplicated Pyelonephritis: Outpatient management: option if 60 yo, female, not pregnant, no nausea/vomiting, no evidence of dehydration, sepsis or high fever Treat for 14 days Consider 7 days if: female, uncomplicated and using Ciprofloxacin or TMP SMX Complicated UTI: Treat 7 days if: prompt response, female and only lower urinary tract infection Treat 14 days if: delayed response, structural abnormality, male or upper tract symptoms Catheter Associated UTI: Pyuria not diagnostic, only treat if symptomatic Catheters frequently colonized, obtain culture through new catheter Change catheter if in place 2 weeks & stillrequired

21 Clinical Pearls for Empiric SSTI Therapy Basic Skin Infections Only: Any complicating features on history may require alternative management (specific but not exclusive examples include:, diabetic foot infections, cellulitis associated with a surgical site, penetrating trauma or animal/human bites, immunocompromised patients) Look for predisposing feature (e.g. Tinea pedis, trauma, eczema, lymphedema)

22 Purulent vs Non purulent Cellulitis Simple abscess without cellulitis no antibiotic coverage NON PURULENT β Hemolytic Strep/MSSA PURULENT MRSA/MSSA C&S if purulent and using an antibiotic, not responding, severe local infection, systemically unwell (IDSA CPG for MRSA: Liu K, et al CID 2011)

23 Clinical Pearls for Cellulitis MRSA 25% Staph isolates in Canada (CANWARD, Hoban,DJ and Zhanel,GG, J.Antimicrob. Chemothera., 2013,May) MRSA 50% have inducible Clindamycin resistance MRSA up to 20 30% resistance to Clindamycin (VIHA,2011; CANWARD, 2013)

24 MRSA Risk Factors (Baddour,LM, UpToDate 2014)

25 Empiric Cellulitis Therapy Mild Assess for MRSA Cephalexin 500 mg po QID* β lactam allergy: Clindamycin mg PO q6h MRSA : TMP SMX 800/160 mg to 1600/320 mg (1 or 2DS) po BID* or Doxycycline100 mg po BID

26 Empiric Cellulitis Therapy Moderate Assess for MRSA Cefazolin 2 g IV q8h* Alternative for outpatient management ( when outpt. use Cefazolin not possible): Ceftriaxone 1 g IV q24h* β lactam allergy: Clindamycin 600 mg IV q8h MRSA suspected: Vancomycin 15 mg/kg IV q12h*

27 Empiric Cellulitis Therapy Severe Sepsis/Septic Shock/ Necrotizing Fasciitis. Pipericillin Tazobactam g IV q6h* + Clindamycin 600 mg IV q8h

28 CAP Diagnosis and Treatment Considerations Diagnostic Triad 1) S+S of infection 2) S+S referable to Respiratory Tract 3) New/Changed infiltrate on CXR Treatment Triad 1) Choice of Antimicrobial 2) Extent of testing for etiology 3) Location of treatment

29 CAP Risk for HAP/MDR Wunderwink RG, et al,nejm, Feb.6,2014 ()

30 Clinical Pearls for CAP CURB65 calculator: 1) new Confusion 2) BUN >7mmol/L 3)RR >30 4)BP < 90mmHG systolic or <60mmHg diastolic 5)Age 65 Each criterion scores 0 or 1

31 IDSA ATS ICU Criteria for ICU Admission without Obvious Need (3 or Minor Criteria) (Wunderwink,RG et al NEJM Feb,2014)

32 Empiric Therapy for Community Acquired Pneumonia CURB65: 0 1 Low severity, mortality <3%, treatment at home or hospital (for reason other pneumonia) Amoxicillin 500 mg 1000 mg PO TID* Doxycycline 100 mg PO BID Macrolide: (Clarithromycin 500 mg PO BID or Azithromycin 500 mg PO first day followed by 250 mg once daily on days 2 5)* *Renal dose adjustment

33 CURB65: 2 Empiric Therapy for Community Acquired Pneumonia Moderate Severity, mortality risk 9%,treatment site: hospital Amoxicillin 1000 mg po TID*+ Macrolide* Ampicillin 2 g IV q6h* + Macrolide or Doxycycline 100mg po BID *renal dose adjustment

34 Empiric Therapy for Community CURB 65: 3 Acquired Pneumonia High severity, mortality risk 15 40%, treatment site: hospital, consider ICU Cefuroxime 1.5 g IV q8h* + (Macrolide or Doxycycline) Ceftriaxone 2 g IV once daily + (Macrolide or Doxycycline) Levofloxacin 750 mg IV once daily* + ampicillin 2 g IV q6h* If Legionellosis strongly suspected, consider using Levofloxacin *Renal dose adjustment

35 Simply Put.. Right drug at the right time at the right dose for the right duration (Dryden M et al. J Antimicrob Chemother 20011; 66:2441) Making sure patients get the right antibiotics when they need them (and only when they need them) (Dr Andrew Morris. Antimicrobial Stewardship: a New ROP for Acute Care Hospitals. Sept 20, 2012)

36 Parting Words Antimicrobials are a limited, nonrenewable resource. (Carlet, et al, 2011) Every antibiotic expected by a patient, every unnecessary prescription written by a doctor, every uncompleted course of antibiotic, and every inappropriate or unnecessary use in animals or agricultureis potentially signing a death warrant for a future patient (Dryden et al, 2009)

37 Questions

38 Intra abdominal Infections (IAI) CATEGORIAZATION: Community vs Hospital Acquired Mild/Moderate vs Severe Uncomplicated vs Complicated CORE PATHOGENS: Enterobacteria esp. E.coli Anaerobes esp. GNB eg Bacteroides Enterococci

39 Empiric Therapy for IAI s (Mild, Moderate, Severe) 1. Cipro/Flagyl 2. Cipro/Flagyl 3. Cipro/Flagyl

40 Diverticulitis Treatment VIHA,2012

41 Diverticulitis treatment VIHA 2012

42 Scenarios 0700 Monday TBS tracker is full 1 st patient: female, 2 day history of cough with yellow phlegm and SOB, getting worse. P100, RR26, T 39.1, O2 sat 94% on RA, AE right base, CXR infiltrate, RLL. 2 nd patient: 58 yo male with MS, ileoconduit ostomy attached to catheter drainage, bedridden; lethargic, poor appetite, febrile at home, no pain, no skin ago admission with UTI. P79, RR 18, T38.5, catheter urine cloudy, dipstick strongly positive for nitrites and LE, lungs clear, abdomen nontender. 3 rd patient: 23 yo male, painful swelling in left forearm for 3 days getting worse, felt feverish last night, healthy, no IV drug use. P65, RR12, T36.9, forearm red swollen, tender, 10cm with 2cm central fluctuant area.

43 Terminology Bacteria Gram Negative Bacilli(GNB) E.coli, Klebsiella, Proteus, Serratia, Morganella, Citrobactero, Enterobacter, Pseudomonas, Acinetobacter Enterobacteriacea Above except Ps., Acineto. Coagulase Negative Staph.(CoNS) S. Epidermidis, S. saprophyticus Enterococcus(GPC) species(urine), feacalis, feacium Anaerobic GNB: Bacteroides, Fusibacterium; GPC: Peptostreptococci; GPS Clostridium Gram Negative Cocci(GNC) H.flu, Nisseria, Legionella

10/13/14. Low: not well absorbed. Good: [blood and tissue] < than if given IV. High: > 90% absorption orally

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