The Nevada Adult Outpatient Empiric Prescribing Guidelines (2017) Background These empiric prescriber guidelines were produced by the AntiMicrobial Stewardship Summit (AMSS) series led by the University of Nevada Reno. The work of the AMSS series is in direct response to the ongoing national antimicrobial resistance crisis and the clear need for stewardship to protect our ability to continue using these medications in the future. The data used in these guidelines were provided courtesy of Quest Laboratories and analyzed with the UNR Antimicrobial Resistance Intelligence System (ARIS). With these guidelines, we are hopeful that our state will be able to work together and show national leadership to positively influence a change in the current trajectory of antimicrobial resistance. Acknowledgements This document is the culmination of input by local, state, and national level peer review by infectious disease pharmacists and one adult infectious disease physician: Mike Stander, PharmD (Reno, NV), Jessica Thompson, PharmD, BCPS (AQ-ID) (Renown Regional Medical Center, Reno, NV), Kim Jacques, PharmD, AAHIVP (VA Sierra Nevada Health Care System, Reno, NV), Jeffrey Jansen, PharmD (St Vincent Healthcare, Billings, MT), Annie Stock, PharmD, BCPS-AQID (Columbus Regional Hospital, Columbus, IN), Rick Watkins, MD, MS, FACP, FIDSA (Cleveland Clinic Akron General, Akron, OH), James Wilson, MD FAAP (University of Nevada-Reno, Reno, NV) The three out-of-state experts in antimicrobial stewardship were recruited by our team from the Infectious Diseases Society of America. We thank the Society for their incredible assistance in this matter. Context The state of Nevada, as with the rest of the country, is experiencing a crisis of antimicrobial resistance that is not limited to the recent fatal panresistant Klebsiella case reported in Washoe County, NV. Clostridium difficile infection, a key indicator of high community level drug resistance, is a significant problem in many healthcare facilities in Nevada. Two of our most common outpatient pathogens, for example: E. coli (a primary pathogen for urinary tract infections), there is progressive resistance observed with fluoroquinolones (ciprofloxacin, levofloxacin) and trimethoprim-sulfamethoxazole. Excellent susceptibilities have been observed for nitrofurantoin. The state is projected to be at-threshold susceptibility for amoxicillin-clavulanic acid and the 1 st, 2 nd, 3 rd, and 4 th generation cephalosporins within the next 5-10 years if stewardship and preservation is not implemented. S. aureus (a primary pathogen for skin infections), there is progressive resistance observed with oxacillin (i.e. methicillin), clindamycin, and fluoroquinolones (ciprofloxacin, levofloxacin). Excellent susceptibilities are noted for gentamicin, rifampin, tetracycline, and trimethoprimsulfamethoxazole. Antimicrobial stewardship is critical at this juncture. Consideration of these clinical guidelines are strongly recommended to avoid further degradation of antimicrobial susceptibilities in the state of Nevada.
The adult empiric outpatient antibiotic prescriber guidance is intended for primary care providers who lack access to an institutional lead (i.e. inhouse pharmacists) who may provide them with more specific information. Contact Feedback from both all users of this guidance is encouraged and recommended. Please contact James M. Wilson, MD FAAP (jamesmwilson@unr.edu) with any comments. Cost $= <$20, $$= $20-50, $$$= >$50