LEARNING OBJECTIVES ANTIMICROBIAL USES AND ABUSES Goodbye to the Antibiotic Era? Glenn D. Bedsole, MD, FACP Infectious Disease Consultant 1. Be able to list 6 examples of resistant bacteria that present a treatment challenge. 2. Be able to name 4 strategies for better use of antibiotics in clinical settings. 3. Given a case scenario, be able to appropriately apply at least two strategies and identify the advantages of the chosen interventions. INFECTIOUS DISEASE SCARES Ebola Weaponized agents, (anthrax) Bird flu Anything flesh eating SUPERBUGS! (ESKAPE)
2011 Alabama Antibiogram ESKAPE Pathogens Andrew Madon, PharmD Director, Clinical Specialty CareFusion, MedMined Services AHQI Statewide Antibiogram 4/17/2012 WHAT IS INCLUDED? COMMUNITY VERSUS HOSPITAL HOSPITAL ENTEROCOCCUS ISOLATES (NON-URINE) VANCOMYCIN RESISTANT E FAECIUM (HOSPITAL NON-URINE) 30% of Enterococcus isolates from 2010 and 2011 are the more resistant faecium strain
HOSPITAL MRSA (NON-URINE) MRSA NATIONWIDE COMPARISON http://www.gp-pathogens.com/data/default.cfm NATIONAL MRSA RATES MRSA HOSPITAL VERSUS COMMUNITY (NON-URINE) Rehm ClD 2010; 51(S2):S176 S182 KLEBSIELLA PNEUMONIA ISOLATES RESISTANT TO CARBAPENEMS (KPC) HOSPITAL NON-URINE A. BAUMANNII ISOLATES SUSCEPTIBLE TO MEROPENEM
HOSPITAL P. AERUGINOSA NON-URINE HOSPITAL P. AERUGINOSA NON-URINE HOSPITAL P. AERUGINOSA NON-URINE HOSPITAL P. AERUGINOSA NON-URINE EXTENDED SPECTRUM BETA- LACTAMASES PENICILLIN S, BETA-LACTAMASE ( ) STAPH. AUREUS ESBL ESBL positive ESBL negative ESBL producer ESBL non-producer Recommend hospital specific ESBL surveillance
METHICILLIN RESISTANT STAPH. AUREUS ESBL PRODUCING PROTEUS GIN AND TONIC, A CAUTIONARY TALE The Need for New Antibiotics Where are the new antibiotics? 1650 Franciscus Sylvius, Leyden, Holland spirits plus oil of juniper=genever 1700 s British troops in India how to make quinine more palatable Like gin and tonic, antibiotics can be overused, And, unlike many medicines, the more they are used the less effective they become. HISTORY: RESISTANCE TREATED WITH NEW ANTIBIOTICS NUMBER OF NEW ANTIBIOTICS 2010 CareFusion Corporation or one of 3 drugs with ESKAPE marginally enhanced gram Enterococcus faecium negative activity Staphyloccus aureus Klebsiella pneumoniae Acinetobacter baumannii Pseudomonas aeruginosa Enterobacter species Clinical Infectious Diseases 2008;46:155-164
ANTIMICROBIAL STEWARDSHIP An effort aimed to improve antimicrobial use in a clinical setting. It usually consists of a team comprised of a clinician with infectious disease expertise and a clinical pharmacist, preferably also with infectious disease expertise. ANTIBIOTIC CHOOSING What are you treating? Where, what organism? Likely efficacy of drug chosen consider studies and PK/PD of drugs, local resistance, (if resistance is >20%, not a good empiric choice) Risk of adverse effects Effect on the ecology, propensity to drive R Cost Drug availability STRATEGIES FOR ANTIMICROBIAL STEWARDSHIP (AMS) Restricted formularies Antibiotic cycling IV to PO Dose Optimization De-escalation Prospective review, 24 h, 72 h (avoid redundant coverage, ensure appropriate choices per culture data) Antibiotic order indications Discontinuation. Knowing when to say NO. HOT TOPICS IN AMS Molecular diagnostics Vancomycin dose optimization Resurrection of old drugs; colistin, minocycline, fosfomycin Use of new drugs: tigecycline (Tygacil), daptomycin (Cubicin), ceftaroline (Teflaro), telavancin (Vibativ), linezolid (Zyvox), fidaxomicin (Dificid) IV TO PO, HIGHLY BIOAVAILABLE metronidazole Flagyl flouroquinolones Cipro, Levaquin, Avelox linezolid Zyvox fluconazole Diflucan Sometimes there are reasons not to switch. VANCOMYCIN DOSING GUIDELINES For MRSA with MIC 1 achieve vancomycin trough 15-20 For MRSA with MIC of 2 or more, choose an alternate drug ( cannot reach AUC/MIC 400 or more in patients with normal renal function in these cases)
THE OLD DRUGS Colistin Minocycline Fosfomycin Nephrotoxic and neurotoxic. Active against many GNR s Mainly for staphylococci Simple uti
CMS ROLE IN AMS CAP SCIP ASB Antibiotic choice and timing Antibiotic choice and timing Recognition and avoiding RX AMS CASE SCENARIO 81 y caucasian female NH resident admitted via ED after developing diminished responsiveness along with temp of 99.5 F and loose stools. She had recently completed a 10 day course of ampicillin for UTI. Has a functional PEG. Nonfocal physical exam. No known allergies. BUN 31, Cr 1.7, WBC 15000, U/A 10-20 WBC/hpf and + nitrite and leuk est. CXR shows infiltrate RLL and? early cavity formation. RX: Pip/tazo, metronidazole, vancomycin, levofloxacin. Interventions? CASE SCENARIO (CONT.) 24 h post admission the patient is more responsive. Stool for C. diff by NAAT is negative. Blood cultures are growing gram negative rods. WBC is 12,000. Interventions?
CASE SCENARIO (CONT.) At 48 hours the organism in the blood culture has been identified as e. coli, ESBL +. WBC is back up to 15,000. Chest xray shows rapid clearing, no cavitation. Interventions?