Antimicrobial Stewardship
Antimicrobial Stewardship Studies have estimated that 30 50% of antibiotics prescribed in acutecare hospitals are unnecessary or inappropriate 1 Antimicrobial stewardship definition: Coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration 2 Objectives of stewardship: Achieving the best clinical outcomes related to antimicrobial use while minimizing toxicity and other adverse events, thereby limiting the selective pressures that drive the emergence of antimicrobial resistant strains of bacteria 1. National Quality Forum. Antimicrobial Stewardship in Acute Care: A Practical Playbook. Accessed 10 June 2016. 2. Infectious Diseases Society of America. http://www.idsociety.org/stewardship_policy/. Accessed 27 March 2017.
Antibiotic Resistance: A Growing Crisis U.S. national estimates CDC: Threats URGENT CDC. Antibiotic Resistance Threats in the United States, 2013. https://www.cdc.gov/drugresistance/pdf/ar threats 2013 508.pdf
Superbugs Antibiotic resistance is outpacing new antibiotic development
CDC: Four Core Actions
Antimicrobial Stewardship at Salinas Valley Memorial Healthcare SVMH has developed a multi disciplinary, evidencebased stewardship program SVMH s team Infectious Disease specialists Pharmacy Microbiology Infection Prevention Nursing Quality Improvement Informatics
Stewardship Interventions Pre authorization of restricted and broad spectrum antibiotics Audit and feedback ICU multidisciplinary rounds Housewide antibiotic reviews with ID and pharmacy Pharmacy review of cultures and sensitivity results Rapid testing of blood cultures that yields results within hours (Verigene) IV to PO conversions Informal and formal ID consults generated from stewardship Pharmacokinetic dosing and monitoring of high risk antimicrobials
Strategies for Improved Antimicrobial Prescribing 1. Ensure antibiotics are indicated 2. Select an appropriate antibiotic with a narrow spectrum if possible to minimize collateral damage 3. Ensure that antibiotic durations are evidence based and take into account clinical response. Use the shortest appropriate length of therapy 4. Remember to re evaluate therapy based on culture results, laboratory data, clinical status, etc. De escalate therapy, convert IV to PO, and discontinue therapy when appropriate
Are Antibiotics Needed? https://www.cdc.gov/features/getsmart/
Are Antibiotics Needed? Correlate clinical signs with laboratory and imaging data Take into account colonization and contamination versus infections (sterile sites vs. non sterile sites) Wieczorkiewicz SM and Sincak CA. The Pharmacist s Guide to Antimicrobial Therapy and Stewardship. Amer Soc of Health System (2016).
Avoid Antibiotics for Acute Bronchitis Clinical guidelines do not support antibiotics for otherwise healthy adults with acute bronchitis due to the viral origin of acute bronchitis (usually self limiting) Patients with chronic bronchitis, COPD or other chronic comorbidity may be treated with a short course of antibiotics Consider antibiotics for suspected pneumonia For COPD exacerbations, consider antibiotics if at least two of the following: increased dyspnea, increased sputum volume or purulence, or severe airflow obstruction. Recommend a course of <5 days for mild to moderate cases Gonzales R., D.C. Malone, J.H. Maselli, et al, 2001
Avoid Antibiotics for Low Colony Urine Counts Antibiotics are not indicated for asymptomatic bacteriuria (except in pregnant and neutropenic patients) and for treating low colony urine counts 2014 study at NorthShore University Health System Urine culture laboratory reporting criteria for voided and foley catheter samples from hospitalized patients with a length of stay of >2 days were modified For these patients, a positive test consisted of 1 2 organisms at >10 5 CFU/ml. Any other colony count or mixture of bacteria was reported as Negative for Nosocomial UTI (NNUTI) Using this revised reporting criteria the system accurately reported the absence of a UTI in >98% of samples that had bacterial counts of <10 5 CFU/ml Schora, D MT (ASCP), et al. New Urine Interpretation Criteria to Accurately Report Nosocomial Clinical Urinary Tract Infection. Department of Infectious Disease Research NorthShore University HealthSystem.
For Clean Surgeries, Avoid Continuing Prophylactic Antibiotics after Surgical Closure Surgeries are generally considered clean if respiratory, alimentary, genital, or urinary tracts are not entered Examples of clean procedures that usually do not require continuing antibiotics after the procedure: orthopedic surgeries, ophthalmic surgeries, plastic surgeries, laminectomies, spinal fusions, pacemaker surgeries, etc. Exclusions (cases that may require post op antibiotics) Non clean cases in which respiratory, alimentary, genital or urinary tracts are entered Cardiothoracic surgeries Antibiotics not used for peri operative prophylaxis (e.g. initiated for treatment of active infections) https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
Appropriate Antibiotic Selection Based on evidence based guidelines, e.g. from the Infectious Diseases Society of America Based on local resistance patterns
SVMH Antibiogram Available on MEMnet, in physician s lounge, or contact Microbiology Department for a copy Includes empiric therapy recommendations, tailored therapy recommendations for Verigene results, and stewardship clinical pearls
Tailored Therapy Based on Verigene New molecular blood culture test implemented at SVMH Rapidly identifies gram positive and gram negative bacteria in a few hours Improved turnaround time of blood culture tests by 30 40 hours compared to standard methods These tests, when acted upon in a timely manner, have been shown to improve patient outcomes (decreased lengths of stay, cost savings)
Verigene Verigene detects 12 different gram positive and 8 gram negative organisms as well as genetic markers for antibiotic resistance Differentiates methicillin sensitive staphylococcus aureus (MSSA) from methicillin resistant Staphylococcus aureus (MRSA) by identifying the resistance conferring meca gene Differentiates vancomycin sensitive Enterococci from vancomycinresistant Enterococci (VRE) Detects genetic resistance markers such as those associated with extended spectrum beta lactamases (ESBL)
SVMH Antibiogram. Published 2017
Intravenous to Oral Therapy Converting IV to PO maintains efficacy while Supporting earlier ambulation Decreasing complications from IV lines (thrombophlebitis, infections) Decreasing lengths of stay Decreasing equipment and drug costs Saving personnel time (nursing administration time, pharmacy compounding time)
IV to PO Conversions Patients can be considered for IV to PO conversions when they are: Taking other oral medications Improving clinically (normal vital signs, hemodynamically stable, improving WBC, etc.) Have no conditions that might affect GI absorption of medications (e.g. persistent nausea/vomiting, ileus, active GI bleed, etc.)
Examples of IV to PO Conversions Sequential Therapy (same agent but changing from IV to PO dosage form with the same or orally equivalent dose) Azithromycin (35-50% oral bioavailability but has excellent distribution to the lungs) Clindamycin (~90% oral bioavailability) Doxycycline (~90% oral bioavailability) Famotidine (~50% oral bioavailability) Fluconazole (>90% oral bioavailability) Levofloxacin (~99% oral bioavailability) Levothyroxine (~50% oral bioavailability) Linezolid (~100% oral bioavailability) Metronidazole (~80% oral bioavailability) Pantoprazole (~80% oral bioavailability) Rifampin (~90-95% oral bioavailability) Sulfamethoxazole/trimethoprim (90-100% oral bioavailability) Step-Down Antimicrobial Therapy (conversion to a different agent that offers a similar spectrum of activity) Ampicillin amoxicillin Ampicillin/sulbactam amoxicillin/clavulanate Aztreonam ciprofloxacin or levofloxacin Cefazolin cephalexin Cefotaxime or ceftriaxone cefpodoxime or cefuroxime axetil Ceftazidime or cefepime ciprofloxacin or levofloxacin Piperacillin/tazobactam levofloxacin + metronidazole, or levofloxacin + amoxicillin/clavulanate
Shorter Durations of Therapy Recent studies have shown that shorter antibiotic courses often work just as well, and may be preferred to longer courses due to a reduced risk of developing resistance and developing superinfections
Shorter Durations of Antibiotics Acute Exacerbations of Chronic Bronchitis Community acquired Pneumonia (CAP) Hospital acquired and Ventilator associated Pneumonia (HAP and VAP) Usually viral and self limiting Consider antibiotics for suspected pneumonia or at least two of the following: increased dyspnea, increased sputum volume or purulence, or severe airflow obstruction. Recommend a course of <5 days for mild to moderate cases Recommend at least 5 days of antibiotics Consider stopping antibiotics after five days if patient afebrile for 48 to 72 hours and have <1 CAP associated instability factor (e.g., heart rate >100 beats per minute, respiratory rate >24 breaths per minute, systolic blood pressure <90 mmhg) Recommend 7 days of antibiotics for both HAP and VAP Use clinical criteria (e.g., cultures, fever) and consider using procalcitonin (PCT) levels (if available) to determine when antibiotics can be stopped Consider discontinuing within one day of negative quantitative bronchoscopy cultures Cellulitis Recommend 5 days of antibiotic therapy for most patients with uncomplicated cellulitis if clinical improvement observed Longer durations of therapy may be necessary if infection is not improved within five days, or in immunocompromised patients Intra abdominal Recommend 4 to 5 days of antibiotic therapy if the infection source is controlled Infections Uncomplicated Adult Recommend short courses of antibiotics for uncomplicated cystitis (3 to 5 days) Urinary Tract In non pregnant, non neutropenic patients avoid treating asymptomatic bacteria and low colony urine Infections (UTI) counts (less than 100,000 CFU s ml) Pyelonephritis Consider a short course (7 days) Uncomplicated Uncomplicated bacteremia: No evidence of endocarditis, no implanted prosthesis, blood cultures 2 4 days Bacteremia after initial positive set show no growth, defervescence within 72 hours of initiating effective therapy, no evidence of metastatic sites of infection MRSA Bacteremia: 14 days Gram negative infections: 7 to 14 days Complicated infections: 4 6 weeks Antibiotic Therapy: When Are Shorter Courses Better? Pharmacist s Letter/Prescriber s Letter. November 2016.
Situations where shorter durations are not better Which Infections Require Completion of the Prescribed Duration of Antibiotics? Don t stop antibiotics even if symptoms resolve for the following conditions: Active tuberculosis Endocarditis Osteomyelitis Strep throat Complete the prescribed duration of therapy in the following potentially asymptomatic conditions: Asymptomatic bacteriuria during pregnancy Latent tuberculosis Which Characteristics May NOT be Appropriate for Shorter Antibiotic Courses? Immunosuppression Recurrent infections Signs and symptoms of active infection (e.g., fever, elevated white blood cell count, positive cultures) Antibiotic Therapy: When Are Shorter Courses Better? Pharmacist s Letter/Prescriber s Letter. November 2016.
Reducing Clostridium Difficile Infections Prevention Hand hygiene Isolation Environmental decontamination Improve prescribing Minimize the use of excessively broad spectrum antimicrobials when treating infections to lessen the disruption of gastrointestinal normal flora. Minimize the use of drugs commonly associated with c. diff (clindamycin, levofloxacin and other fluoroquinolones, etc.) Minimize antibiotic exposures to the shortest reasonable duration Avoid gastric acid suppression, such as with Proton Pump Inhibitors, unless clinically indicated (e.g. mechanical ventilation, coagulopathy, high dose corticosteroids, sepsis, history of GI bleed, traumatic brain, spinal cord, or burn injury, etc.)
Review Questions 1. Patient GH is being treated with Vancomycin for bacteremia. Blood cultures were drawn prior to starting vancomycin. Three hours later, microbiology calls with the Verigene culture results and it shows staphylococcus aureus meca( ). GH has no known drug allergies. What would be the preferred course of action for this patient? A. Continue IV vancomycin B. Change to IV cefazolin for MSSA 2. True or False? For an intraabdominal infection that was drained adequately, antibiotics can be discontinued 4 5 days following source control if the patient is clinically improved.
Review Questions 3. True or False? Acute bronchitis is usually viral in origin and normally does not require treatment with antibiotics. 4. True or False? For non neutropenic, non pregnant individuals, low colony urine counts (< 100,000 CFU s/ml) should not be considered an infection without clinical symptoms and should not be treated with antibiotics. 5. Which of the following interventions does NOT decrease risk for c.diff infections? a. Avoiding gastric acid suppressive therapy if not needed b. Using the narrowest spectrum antibiotic possible to decrease collateral damage c. Longer durations of antibiotic therapy d. Good hand hygiene techniques