Turning he Tide: How o Improve Anibioic Use and Sop a Killer Melinda. Joyce, Pharm.D., FAPhA, FAHE ommonwealh Healh orporaion Bowling Green, Kenucky mbjoyce@chc.ne Timohy P. Gauhier, Pharm.D., BPS-AQ ID Miami Veeran Affairs Healhcare Sysem TimohyPGauhier@gmail.com Social media: @IDsewardship 2 Disclosures Dr. Joyce and Dr. Gauhier declares no conflics of ineres, real or apparen, and no financial ineress in any company, produc, or service menioned in his program, including grans, employmen, gifs, sock holdings, and honoraria. Targe Audience: Pharmaciss APE#: 0202-0000-16-057-L01-P Aciviy Type: Knowledge-based The American Pharmaciss Associaion is accredied by he Accrediaion ouncil for Pharmacy Educaion as a provider of coninuing pharmacy educaion. 3 4 Learning Objecives 1. Describe curren paerns of anibioic resisance in he Unied Saes, including pahogens idenified by he eners for Disease onrol and Prevenion as urgen or serious hreas. Learning Objecives 3. Explain sraegies ha can be used by pharmaciss in healh sysems and oher seings o suppor appropriae anibioic use and reduce he developmen of anibioic resisance. 2. Describe incenives for implemening prescribing pracices ha reduce raes of anibioic resisance. 4. Given a clinical scenario, idenify sraegies which may be employed o achieve he primary goals of animicrobial sewardship. 5 6
1. The eners for Disease onrol (D) has idenified all of he following resisan organisms as urgen hreas excep A. losridium difficile B. arbapenem-resisan Enerobaceriaceae (RE). Neisseria gonorrhoeae D. Mehicillin-Resisan Saphylococcus aureus 2. Which of he following is rue regarding he goals of he Naional Acion Plan for ombaing Anibioic Resisan Baceria? A. Eradicae he emergence of resisan baceria B. urail he developmen of rapid diagnosic ess for idenificaion of resisan baceria. By 2020, decrease losridium difficile infecions by 50% as compared o 2011 esimaes D. Require all providers o obain a leas 2 hours of coninuing educaion on pruden animicrobial prescribing each year 7 8 3. Why are animicrobial drugs considered o be socieal in naure? A. They are used by mos people in sociey B. Use in one person can impac heir uiliy in ohers. They are expensive D. They can be oxic 4. Which of he following wo drug classes are highly associaed wih collaeral damage? A. Penicillins and eracyclines B. Fluoroquinolones and cephalosporins. Lincosamides and oxazolidinones D. Glycopepides and carbapenems 9 10 5. Uilizaion of an exended-infusion o enhance anibacerial killing is an example of which animicrobial sewardship aciviy? A. Dose opimizaion B. Educaion. Prospecive audi wih inervenion and feedback D. Formulary resricion OBJETIVE #1 Describe curren paerns of anibioic resisance in he Unied Saes, including pahogens idenified by he eners for Disease onrol and Prevenion as urgen or serious hreas. 11 12
Animicrobial Resisance Since he discovery of penicillin in 1928, anibioics have been a criical componen for he reamen of infecions The emergence of drug resisan baceria is quickly reversing he miracles ha have been seen from anibioics In fac, when Alexander Fleming made his accepance speech for he Nobel Prize, he warned of baceria becoming resisan o penicillin Some expers are predicing ha superbugs, hose muli-drug resisan microorganisms could kill more people han cancer by 2050 if more aggressive seps are no aken now o miigae he growh of anibioic-resisan baceria Since he 1990s, new anibioic developmen has fallen sharply while bacerial resisance coninues o increase Anibioic Use Leads o Anibioic Resisance Prescribing Agriculure Person o person spread 13 14 D Ho Lis for Resisan Organisms Urgen Threas losridium difficile arbapenem-resisan Enerobaceriaceae (RE) Neisseria gonorrhoeae www.cdc.gov/gesmar www.cdc.gov 16 D Ho Lis for Resisan Organisms Serious Threas Mulidrug-Resisan Acineobacer Drug-Resisan ampylobacer Fluconazole-Resisan andida Exended Specrum Enerobaceriaceae (ESBL) Vancomycin-Resisan Enerococcus (VRE) Mulidrug-Resisan Pseudomonas aeruginosa Drug-Resisan Non-Typhoidal Salmonella Drug-Resisan Salmonella Seroype Typhi Drug-Resisan Shigella Mehicillin-Resisan Saphylococcus aureus (MRSA) Drug-Resisan Srepococcus pneumoniae Drug-Resisan Tuberculosis www.cdc.gov 17 Wha is a Superbug Kirby Bauer Disc Plaes: a clear area around he disc represens zone of inhibiion or sensiive o ha anibioic. A Superbug is an organism ha shows significan anibioic resisance, usually o wo or more classes of anibioics. 18
Resisan Organisms arbapenem-resisan Enerobaceriaceae (RE) can cause deadly infecions are have become resisan o all or nearly all anibioics ha are currenly available. RE can easily spread beween hospials and long-erm care faciliies when appropriae acions are no aken losridium difficile ( diff) is commonly found in hospials and longerm care faciliies and can be spread from conaminaed surfaces or healhcare provider s hands Alhough careful aenion o cleaning and isolaion precauions is necessary, he mos common reason for diff infecions is he overuse of anibioics Srains of boh Pseudomonas and Acineobacer ha are resisan o mos anibioics have been found in mos hospials and long-erm care faciliies Inappropriae Animicrobial Use Diagnosic Uncerainy and Fear Knowledge Gaps Indiscriminae Lab Tesing Inadequae Documenaion and Transiions of are 19 20 Poor Anibioic Prescribing Poor anibioic prescribing pus paiens a risk Abou half of paiens receive an anibioic for a leas one day during he course of an average hospial say The mos common ypes of infecions for which hospial clinicians wroe anibioic prescripions were lung infecions (26%), urinary rac infecions (14%), and suspeced infecions by MRSA (17%) Abou 1 ou of 3 imes, prescribing pracices o rea urinary rac infecions do no have proper esing or evaluaion and he anibioics are given for oo long Over half of anibioic prescribing in oupaien seings is unnecessary and mos of he inappropriae use is for acue respiraory infecions, such as pharyngiis, sinusiis or bronchiis D Vial Signs Includes several imporan opics including healhcare-associaed infecions Issues include graphic fac shee and websie, a media release, and social media ools an sign up o receive he issues a no cos www.cdc.gov 21 www.cdc.gov/vialsigns 22 Vial Signs: Healhcare-Associaed Infecions Six separae aricles relaed o anibioic usage 1. Sop Spread of Anibioic Resisance 2. Making Healhcare Safer Anibioic Rx in Hospials: Proceed wih auion 3. Making Healhcare Safer Anibioic Rx in Hospials: Proceed wih auion 4. Making Healhcare Safer Sop Infecions from Lehal RE Germs Now 5. Making Healhcare Safer Sopping. difficile Infecions 6. Making Healhcare Safer Reducing Bloodsream Infecions OBJETIVE #2 Describe incenives for implemening prescribing pracices ha reduce raes of anibioic resisance.. www.cdc.gov/vialsigns 23 24
Anibioic Prescribing Impac In addiion o he concern for he healh of he public, various qualiy merics ha affec reimbursemen for he healh-sysem involve infecions and anibioic usage Safey Domain of Value-Based Purchasing (VBP): Healhcare- Associaed Infecions as well as Hospial-Acquired ondiions (HAs) LABSI: enral line-associaed blood sream infecions among adul, pediaric, and neonaal IU paiens AUTI: aheer-associaed urinary rac infecions among adul and pediaric IU paiens SSI: Surgical sie infecions specific o abdominal hyserecomy and colon surgeries losridium difficile infecions MRSA baceremias VBP for FY 2017 linical are 30% linical Process 5% Influenza Immunizaion (IMM-2) Early Elecive Delivery (P-01) Oucomes 25% 30 Day Moraliy AMI 30 Day Moraliy HF 30 Day Moraliy PN Paien and aregiver Experience 25% HAHPS including are oordinaion Quesions 25% Safey 20% 20% LABSI AUTI SSI AHRQ PSI-90 MRSA Baceremia. Diff Efficiency and os Reducion -25% Medicare Spending per Beneficiary 25% 30% 25 www.qualiyne.org 26 VBP for FY 2018 linical are 25% Oucomes 30 Day Moraliy AMI 30 Day Moraliy HF 30 Day Moraliy PN Paien and aregiver Experience 25% HAHPS including are oordinaion Quesions 25% 25% Safey 25% Early elecive delivery (P-01) LABSI AUTI SSI AHRQ PSI-90 MRSA Baceremia. Diff Efficiency and os Reducion -25% Medicare Spending per Beneficiary 25% 25% Healhcare-Associaed Infecions as Par of he Safey Domain Some of hese measures are also included as par of hospialacquired condiions (HAs) Scoring is based agains naional benchmarks Sandardized Infecion Rae (SIR) Numeraor: Number of observed infecions Denominaor: Number of prediced infecions Equals a sandardized infecion raio (SIR) enral-line associaed bloodsream infecions (LABSI) and caheer-associaed urinary rac infecions (AUTIs) Surgical sie infecions Pos-op infecions wihin 30 o 90 days of he surgery Dependen on he ype of surgery www.qualiyne.org 27 28 Safey Infecion Raes Infecion enral-line associaed bloodsream infecions (LABSIs) - IU Naional Rae 0.462 aheer-associaed urinary rac infecions (AUTIs) - IU 0.996 Surgical sie infecions from colon surgery (SSI: olon) 1.010 Surgical sie infecions from hyserecomy (SSI: Hyserecomy) MRSA bloodsream infecions (laboraory idenified) losridium difficile infecions (laboraory idenified) 0.882 0.883 0.921 Hospial-Acquired ondiion (HA) Reducion Program HA Reducion program reduces oal Medicare paymens by 1% for wors performing quarile of hospials Began in FY 2015 All or none reducion Two domains Agency for Healhcare Research and Qualiy (ARHQ) measures eners for Disease onrol (D) and Prevenion Naional Healhcare Safey Nework (NHSN) measures I is possible o have muliple penalies for he same measure as some of hese infecions are also par of VBP Safey domain The rae is he Sandardized Infecion Rae, which compares he expeced o he acual Daa submied o NHSN beween April 1 2014 March 30, 2015 30
Overlapping HA and VBP Measures Hospial-Acquired ondiion (HAs) No Eligible for Higher Paymen VBP HA Reducion Program aheer-associaed UTI X FY 2016 FY 2016 Surgical sie infecions X FY 2016 FY 2016 Vascular caheer-associaed infecions X PSI-90/ LABSI PSI-90/ LABSI Foreign objec reained afer surgery X Air embolism X Blood incompaibiliy X Pressure ulcer sages III or IV X PSI-90 FY 2015 PSI-90 FY 2015 Falls and rauma X PSI-90 FY 2015 PSI-90 FY 2015 DVT/PE afer hip/knee replacemen X PSI-90 FY 2015 PSI-90 FY 2015 Manifesaions of poor glycemic X conrol Iarogenic pneumohorax X PSI-90 FY 2015 PSI-90 FY 2015 Mehicillin-resisan Saph aureus (MRSA) FY 2017 FY 2017 losridium difficile FY 2017 FY 2017 Readmission Penalies All cause 30 day readmissions for paiens wih hear failure (HF), pneumonia (PN), acue myocardial infarcion (AMI), chronic obsrucive pulmonary disease (OPD), and elecive oal hip and oal knee replacemens (THA/TKA) oronary arery bypass graf (ABG) will be added for FY 2017 A possible reason for readmission can ofen be relaed back o an infecion The maximum penaly can be as high as 3.0% of base operaing DRG paymens for our Medicare paiens The penaly is assessed on all Medicare admissions FY 2014: Hospials were penalized $227 million FY 2015: Hospials are projeced o be penalized $428 million 21% of all hospials penalized he maximum 3% were in Kenucky Kenucky is in he op five saes for he mos anibioics prescribed 32 Addiional Focus ore Acions o omba Resisance In addiion o he qualiy measures required by MS, infecion daa is publically repored hrough oher survey ools, such as he Leapfrog Hospial Safey Score and HealhGrades an impac paien percepion of he faciliy Individual provider informaion will be publically repored hrough PQRS measures on Physician ompare 33 www.cdc.gov 34 ore Acions o omba Resisance ore Acions o omba Resisance www.cdc.gov 35 www.cdc.gov 36
ore Acions o omba Resisance Naional Acion Plan for ombaing Anibioic Resisan Baceria In March, 2015, he Whie House issued he firs-ever plan aimed a slowing anibioic resisance over he nex five years hrough major invesmens and policy changes a a range of federal healh agencies Goals: Slow he emergence of resisan baceria and preven he spread of resisan infecions Srenghen naional One-Healh surveillance effors o comba resisance Advance developmen and use of rapid and innovaive diagnosic ess for idenificaion and characerizaion of resisan baceria Accelerae basic and applied research and developmen for new anibioics, oher herapeuics, and vaccines Improve inernaional collaboraion and capaciies for anibioic-resisance prevenion, surveillance, conrol, and anibioic research and developmen www.cdc.gov 37 hps://www.whiehouse.gov/sies/defaul/files/docs/naional_acion _plan_for_combaing_aniboic-resisan_baceria.pdf 38 Naional Acion Plan The Join ommission (TJ) The hough is ha by 2020, implemenaion of he Naional Acion Plan will lead o major reducions in he incidence of urgen and serious hreas, including: arbapenem-resisan Enerobaceriaceae (RE) 60% reducion of RE infecions acquired during hospializaions compared o 2011 esimaes Mehicillin-resisan Saphylococcus aureus (MRSA) 50% overall reducion in MRS bloodsream infecions as compared o 2011 losridium difficile ( diff) 50% reducion compared o 2011 esimaes efriaxone-resisan Neisseria gonorrhoeae Mainain he prevalence of his resisan organism below 2% compared o 2013 esimaes Proposed Medicaion Managemen Sandards for ambulaory ceners, criical access hospials, hospial, nursing care ceners (long-erm care), and behavioral healh faciliies ommens were aken hrough he end of 2015 Alhough housed wihin he Medicaion Managemen sandards, here are ies back o he Leadership and he Infecion Prevenion chapers hps://www.whiehouse.gov/sies/defaul/files/docs/naional_acion _plan_for_combaing_aniboic-resisan_baceria.pdf 39 www.joincommission.org 40 The Join ommission (TJ) MM.09.01.01: The organizaion has an animicrobial sewardship program based on evidence-based naional guidelines EP.1 Leaders esablish animicrobial sewardship as an organizaional prioriy EP.2 Educae saff and licensed independen praciioners involved in animicrobial ordering, dispensing, adminisraion, and monioring abou animicrobial resisance and animicrobial sewardship pracices. Educaion occurs upon hire and annually hereafer. EP.3 Educae paiens and heir families as needed, regarding he appropriae use of animicrobial medicaions, including anibioics. The Join ommission (TJ) EP. 4 The organizaion has an animicrobial sewardship mulidisciplinary eam ha includes he following members, when available in he seing: Pharmacis(s) Infecion disease physician Infecion prevenionis(s) www.joincommission.org 41 www.joincommission.org 42
The Join ommission (TJ) EP.5 The hospial s animicrobial sewardship program includes he following core elemens: Leadership commimen Accounabiliy Drug experise Acion Tracking Reporing Educaion The Join ommission (TJ) EP. 6 The hospial s animicrobial sewardship program uses organizaion-approved mulidisciplinary proocols EP. 7 The hospial collecs and analyzes daa on is animicrobial sewardship program, including animicrobial prescribing and resisance paerns EP.8 The hospial akes acion on improvemen opporuniies idenified in is animicrobial sewardship program www.joincommission.org 43 www.joincommission.org 44 MS Hospial Infecion Workshee hps://www.cms.gov/medicare/provider- Enrollmen-and- erificaion/surveyerificaiongeninfo/ Downloads/Survey-and-er-Leer-15-12-Aachmen-1.pdf Wha is Animicrobial Sewardship? Animicrobial sewardship (AS) is a mulidisciplinary approach for raional anibioic herapy Mus be based on evidence-based guidelines Mus be based on daa Mus apply o all praciioners oordinaed inervenions designed o improve and measure he appropriae use of animicrobial agens by promoing he selecion of he opimal animicrobial drug regimen including dosing, duraion of herapy, and roue of adminisraion. No he complee workshee Policy saemen on Animicrobial Sewardship by he Sociey for healhcare Epidemiology of American (SHEA) and he Infecious Diseases Sociey of America (IDSA). 2012 46 Wha is Animicrobial Sewardship? There are five main principles of AS 1. Prevening infecions 2. Preven he spread of resisance 3. Tracking and surveillance 4. Improve anibioic prescribing hrough sewardship 5. Developmen of new anibioics and new diagnosic ess for resisance baceria www.cdc.gov 47
ore Elemens of AS Leadership Dedicae necessary human, financial, and informaion echnology (IT) resource Accounabiliy A single leader needs o be appoined o be responsible for program oucomes. This is ofen a physician, alhough ha is no a requiremen. Drug Experise A single pharmacis leader needs o be appoined o suppor improved prescribing Acive Oversigh oninually review inervenion acions ore Elemens of AS Tracking Monior prescribing and anibioic resisance paerns Reporing Regularly repor o saff prescribing and resisance paerns along wih seps for improvemen Ongoing Educaion Educaion abou anibioic resisance and improving prescribing pracices 49 50 omprehensive Mulidisciplinary Approach Monioring of Processes and Oucomes Measuremen Acive Sraegies Effecive Animicrobial Sewardship Microbiology and Lab Supplemenal Sraegies Informaion Technology Mos ommon Animicrobial Sewardship Inervenions Process o review new anibioic before adding o he formulary reaion of anibioic reamen guidelines Proocol for dose adjusmen based on organ dysfuncion Regular pharmacy and/or infecion prevenion review of drug/bug mismaches Proocol for swiching form IV o oral drug herapy Resricion or prior auhorizaion of cerain anibioics Prospecive audi and feedback Provider educaion, boh by groups or deparmens and o individuals 51 52 Oher Inervenions Selecive reporing of suscepibiliy profiles for posiive culures Sophisicaed informaion echnology sysems for improving anibioic prescripions hrough clinical decision suppor sysems Poin-of-care diagnosic esing for a faser resul of nonbacerial eiologies Paien educaion Barriers o Animicrobial Sewardship Lack of saff resources o idenify or implemen sewardship inervenions Pharmacis resources Physician resources Adminisraive suppor Resisance from fron-line physicians Difficuly in obaining daa o deermine opporuniies or impac Real-ime daa No good mechanisms for feedback and communicaion 53 54
A Lile Abou Me PYG2 rained in infecious diseases & animicrobial sewardship Experience in academia & hospial pharmacy urrenly wih Miami VA Healhcare Sysem DR. GAUTHIER PRATIING ID PHARMAIST Enhusiasic abou pharmacy educaion and social media 55 56 Find me on social media: @IDsewardship My moivaion 57 58 OBJETIVE #3 How o figh animicrobial resisance Explain sraegies ha can be used by pharmaciss in healh sysems and oher seings o suppor appropriae anibioic use and reduce he developmen of anibioic resisance 1. Preven infecions and preven he spread of resisance 2. Track resisan baceria 3. Improve he use of oday s anibioics 4. Promoe he developmen of new anibioics and develop new diagnosic ess for resisan baceria D, Anibioic resisance hreas in he US, 2013 59 60
How o figh animicrobial resisance How o figh animicrobial resisance 1. Preven infecions and preven he spread of resisance 2. Track resisan baceria 3. Improve he use of oday s anibioics 4. Promoe he developmen of new anibioics and develop new diagnosic ess for resisan baceria 1. Preven infecions and preven he spread of resisance 2. Track resisan baceria 3. Improve he use of oday s anibioics 4. Promoe he developmen of new anibioics and develop new diagnosic ess for resisan baceria D, Anibioic resisance hreas in he US, 2013 D, Anibioic resisance hreas in he US, 2013 61 62 How o figh animicrobial resisance Pracice locaion & paien mix 1. Preven infecions and preven he spread of resisance Animicrobial sewardship is no one-size-fis all 2. Track resisan baceria 3. Improve he use of oday s anibioics 4. Promoe he developmen of new anibioics and develop Inpaien Transiions of care Long-erm care Oupaien new diagnosic ess for resisan baceria D, Anibioic resisance hreas in he US, 2013 63 64 Pracice locaion & paien mix Pracice locaion & paien mix Animicrobial sewardship is no one-size-fis all Animicrobial sewardship is no one-size-fis all Inpaien Transiions of care Long-erm care Oupaien Inpaien Transiions of care Long-erm care Oupaien ommon comorbidiies Local resisance paerns ommon comorbidiies Local resisance paerns Acuiy Acuiy ommon comorbidiies Rural Urban Local providers Local culure & cusoms 65 66
Animicrobial sewardship sraegies Acive/ore Sraegies 1. Prospecive audi wih inervenion and feedback 2. Formulary resricion wih preauhorizaion Supplemenal Sraegies 1. Educaion 2. Guidelines and clinical pahways 3. Animicrobial cycling 4. Animicrobial order forms 5. ombinaion herapy 6. Sreamlining and de-escalaion of herapy 7. Dose opimizaion 8. Pareneral o oral conversion Animicrobial sewardship sraegies Acive/ore Sraegies 1. Prospecive audi wih inervenion and feedback 2. Formulary resricion wih preauhorizaion Supplemenal Sraegies 1. Educaion 2. Guidelines and clinical pahways 3. Animicrobial cycling 4. Animicrobial order forms 5. ombinaion herapy 6. Sreamlining and de-escalaion of herapy 7. Dose opimizaion 8. Pareneral o oral conversion Delli e al. lin Infec Dis. 2007; 44:159-177 Delli e al. lin Infec Dis. 2007; 44:159-177 67 68 Educaion raising awareness Anibioics are socieal drugs Educaion raising awareness ollaeral damage Ecologic adverse effecs of anibioic herapy ephalosporin use linked o VRE, ESBLs,. difficile Quinolones use linked o MRSA, Gram negaive resisance Message: 3 rd -generaion cephalosporins and fluoroquinolones are poor workhorse anibioics D, Anibioic resisance hreas in he US, 2013 Paerson DL, lin Infec Dis. 2004; 38(S4): S341-5. 69 70 Educaion raising awareness Educaion disribuing resources Anibioics can be oxic D, Anibioic resisance hreas in he US, 2013 www.cdc.gov/gesmar/communiy 71 72
Educaion sharing your knowledge IV o PO If he gu works, use i! A pharmacis is 1 of 2 core ASP members Pharmacis involvemen is essenial Dose selecion Monioring for oxiciy Managing drug-drug ineracions os-effecive herapy selecion Paien counseling Poenial benefis of IV o PO include Increase paien comfor Reduce lengh of say / discharge faciliaion Removal of IV caheers and risks hey bring Reduced healhcare (and drug) coss D, Anibioic resisance hreas in he US, 2013 73 74 IV o PO If he gu works, use i! Poenial benefis of IV o PO include Increase paien comfor Reduce lengh of say / discharge faciliaion Removal of IV caheers and risks hey bring Reduced healhcare (and drug) coss ommon IV o PO Targes Azihromycin iprofloxacin Moxifloxacin Doxycycline Fluconazole Levofloxacin Linezolid Meronidazole Dose opimizaion Paien characerisics ausaive organism Sie of infecion Pk/Pd characerisics 75 76 Dose opimizaion prolonged infusions Dose opimizaion prolonged infusions Maximize on ime-dependen anibacerial aciviy > 50-70% of dosing inerval for Gram negaives >40-50% of dosing inerval for Gram posiives β-lacams Penicillins ephalosporins arbapenems 77 78
Dose opimizaion prolonged infusions Dose opimizaion ime above he T > T > 79 80 Dose opimizaion infusion sraegies Sraegy Admin. Time Examples IV push 3 o 5 minues efriaxone Dose opimizaion infusion sraegies Sraegy Admin. Time Examples IV push 3 o 5 minues efriaxone Inermien 30 minues Ampicillin Inermien 30 minues Ampicillin Exended infusion 3 o 4 hours Piperacillin-azobacam Exended infusion 3 o 4 hours Piperacillin-azobacam oninuous infusion 20 o 24 hours Penicillin G, oxacillin oninuous infusion 20 o 24 hours Penicillin G, oxacillin 81 82 Dose opimizaion infusion sraegies Sraegy Admin. Time Examples IV push 3 o 5 minues efriaxone Dose opimizaion infusion sraegies Sraegy Admin. Time Examples IV push 3 o 5 minues efriaxone Inermien 30 minues Ampicillin Inermien 30 minues Ampicillin Exended infusion 3 o 4 hours Piperacillin-azobacam Exended infusion 3 o 4 hours Piperacillin-azobacam oninuous infusion 20 o 24 hours Penicillin G, oxacillin oninuous infusion 20 o 24 hours Penicillin G, oxacillin 83 84
Dose opimizaion infusion opions Dose opimizaion infusion opions 85 86 Dose opimizaion infusion opions Dose opimizaion inermien Inermien 87 88 Dose opimizaion exended Dose opimizaion coninuous Exended oninuous 89 90
Dose opimizaion prolonged infusions Time < T > Inermien Exended oninuous oninuous Exended Inermien 91 92 Time < Time < oninuous Exended Inermien oninuous 93 94 Loading dose may be helpful Loading dose may be helpful Firs dose as inermien infusion Firs dose as inermien infusion Sar coninuous infusion direly aferwards 95 96
Loading dose may be helpful Exended infusions: piperacillin-azobacam (example) Firs dose as inermien infusion Sar coninuous infusion direly aferwards Re-dose o keep level above Dose Frequency Infusion ime % Targe Aainmen Daily os 3.375 gm Q6H 30 min 84 $$$$ 3.375 gm Q6H 90 min 89 $$$$ 3.375 gm Q6H 4 hr 96 $$$$ 3.375 gm Q8H 30 min 77 $$$ 3.375 gm Q8H 90 min 83 $$$ 3.375 gm Q8H 4 hr 91 $$$ 10.125 gm Q24H 24 hr 95 $$$ 13.5 gm Q24H 24 hr 99 $$$$ 97 98 Exended infusions: piperacillin-azobacam (example) Exended infusions: piperacillin-azobacam (example) Dose Frequency Infusion ime % Targe Aainmen Daily os 3.375 gm Q6H 30 min 84 $$$$ 3.375 gm Q6H 90 min 89 $$$$ 3.375 gm Q6H 4 hr 96 $$$$ 3.375 gm Q8H 30 min 77 $$$ 3.375 gm Q8H 90 min 83 $$$ 3.375 gm Q8H 4 hr 91 $$$ 10.125 gm Q24H 24 hr 95 $$$ 13.5 gm Q24H 24 hr 99 $$$$ Dose Frequency Infusion ime % Targe Aainmen Daily os 3.375 gm Q6H 30 min 84 $$$$ 3.375 gm Q6H 90 min 89 $$$$ 3.375 gm Q6H 4 hr 96 $$$$ 3.375 gm Q8H 30 min 77 $$$ 3.375 gm Q8H 90 min 83 $$$ 3.375 gm Q8H 4 hr 91 $$$ 10.125 gm Q24H 24 hr 95 $$$ 13.5 gm Q24H 24 hr 99 $$$$ 99 100 Exended infusions: piperacillin-azobacam (example) Dose opimizaion Remember s maer Dose Frequency Infusion ime % Targe Aainmen Daily os 3.375 gm Q6H 30 min 84 $$$$ 3.375 gm Q6H 90 min 89 $$$$ 3.375 gm Q6H 4 hr 96 $$$$ 3.375 gm Q8H 30 min 77 $$$ 3.375 gm Q8H 90 min 83 $$$ 3.375 gm Q8H 4 hr 92 $$$ 10.125 gm Q24H 24 hr 95 $$$ 13.5 gm Q24H 24 hr 99 $$$$ #2 #1 101 102
Dose opimizaion Remember s maer Noes on prolonged-infusion anibioics #2 T > for #2 Benefi is mos likely for criically ill paiens suffering from infecion due o an organism wih a high an assis ransiion paiens ou of he hospial #1 T > for #1 Paien saisfacion an imporan consideraion 103 104 OBJETIVE #4 3 quesions o ask during each assessmen Given a clinical scenario, idenify sraegies which may be employed o achieve he primary goals of animicrobial sewardship 1. Does he paien have an infecion? 2. Wha is he paien mos likely infeced wih? Organism, sie of infecion 3. Wha is he preferred reamen? P-specific consideraions 105 106 linical Scenario BB is a 45 y/o F who presens o AB Hospial wih of pain and swelling of he lef lower exremiy. PMH of hyperension Physical examinaion reveals celluliis wih abscess Vial signs show: Temp HR BP RR 98.9 F 79 bpm 160/90mmHg 16 bpm linical Scenario Blood culures are drawn Incision and drainage of he abscess is planned and specimen will be sen for culure Anibioics are sared Labs: WB SR BUN PLT 12 cells/mm 3 0.7 mg/dl 12 256 W: 85 kg H: 64 in ALL: NKDA 107 108
linical Scenario Orders are wrien for Vancomycin 1gm IV Q12H Piperacillin-azobacam 3.375gm IV Q6H Meronidazole 500mg IV Q8H Fluconazole 400mg IV Q24H linical Scenario poenial inervenions Appropriae dosing & monioring Orders are wrien for Vancomycin 1gm IV Q12H Piperacillin-azobacam 3.375gm IV Q6H Exended-infusion Meronidazole 500mg IV Q8H Fluconazole 400mg IV Q24H Dual anaerobic herapy likely unnecessary Animicrobial w/o indicaion if indicaion idenified, IV o PO? 109 110 linical Scenario Following discussion w/ pharmacis, paien is given: Vancomycin 1250 mg IV Q12H Adjused for weigh and kidney funcion Vancomycin rough level ordered prior o 4 h dose Piperacillin-azobacam 3.375 gm IV Q8H over 3 hour infusion Exended-infusion dosing Fluconazole 100mg oral x1 Paien found o have vaginal yeas infecion, which had been inadverenly lef ou of he progress noe linical Scenario day 2 Day 2 anibioics coninued as ordered, blood culures negaive hus far, fluid from I&D shows Gram posiive cocci in clusers, p afebrile, WB 12 8.6, no signs of clinical worsening of celluliis urren anibioics: Vancomycin 1.25gm IV Q12H Piperacillin-azobacam 3.375gm IV Q8H, 3-hour infusion 111 112 3 quesions o ask during each assessmen 3 quesions o ask during each assessmen 1. Does he paien have an infecion? 2. Wha is he paien mos likely infeced wih? Organism, sie of infecion 3. Wha is he preferred reamen? P-specific consideraions 1. Does he paien have an infecion? YES 2. Wha is he paien mos likely infeced wih? Organism, sie of infecion MSSA or MRSA (GPs in clusers) 3. Wha is he preferred reamen? P-specific consideraions Broad Gram-posiive coverage 113 114
3 quesions o ask during each assessmen 1. Does he paien have an infecion? YES 2. Wha is he paien mos likely infeced wih? Organism, sie of infecion MSSA or MRSA (GPs in clusers) linical scenario day 3 Day 3, paien coninues o improve and physician wans o discharge paien. ulures from I&D are showing Saphylococcus aureus 3. Wha is he preferred reamen? P-specific consideraions Broad Gram-posiive coverage Vancomycin 1.25gm IV Q12H Piperacillin-azobacam 3.375gm IV Q8H, 3-hour infusion Disconinue? 115 116 linical scenario day 3 Day 3, paien coninues o improve and physician wans o discharge paien. ulures from I&D are showing Saphylococcus aureus Resisan: cefazolin, oxacillin, nafcillin, piperacillin-azobacam Sensiive: SMX-TMP, clindamycin, vancomycin, linezolid, doxycycline linical scenario day 3 Day 3, paien coninues o improve and physician wans o discharge paien. ulures from I&D are showing Saphylococcus aureus Resisan: cefazolin, oxacillin, nafcillin, piperacillin-azobacam Sensiive: SMX-TMP, clindamycin, vancomycin, linezolid, doxycycline MRSA 117 118 linical Scenario: weighing oupaien opions linical Scenario: weighing oupaien opions Drug Oral Opion Frequency Major/ommon Toxiciies SMX-TMP Yes Q8-12H Phoosensiiviy, hyperkalemia, GI, hemaologic effecs, rash ollaeral Damage os + $ Drug Oral Opion Frequency Major/ommon Toxiciies SMX-TMP Yes Q8-12H Phoosensiiviy, hyperkalemia, GI, hemaologic effecs, rash ollaeral Damage os + $ Doxycycline Yes Q12H Phoosensiiviy, esophagiis, GI + $ Doxycycline Yes Q12H Phoosensiiviy, esophagiis, GI + $ lindamycin Yes Q6-12H GI ++ $ Linezolid Yes Q12H Few w/ shor-erm herapy + $$$ Vancomycin No Q12H Nephrooxiciy + $$$$$ lindamycin Yes Q6-12H GI ++ $ Linezolid Yes Q12H Few w/ shor-erm herapy + $$$ Vancomycin No Q12H Nephrooxiciy + $$$$$ 119 120
Paien counseling When o ake vs. when no o ake anibioics Anibioics can be oxic, you should wach ou for Wha o do if you do no improve Prevenaive measures and sympomaic relief linical Scenario sraegies covered Acive/ore Sraegies 1. Prospecive audi wih inervenion and feedback 2. Formulary resricion wih preauhorizaion Supplemenal Sraegies 1. Educaion 2. Guidelines and clinical pahways 3. Animicrobial cycling 4. Animicrobial order forms 5. ombinaion herapy 6. Sreamlining and de-escalaion of herapy 7. Dose opimizaion 8. Pareneral o oral conversion 121 122 Key Poin Key Poin Animicrobial sewardship is a eam game wih he paien a he cener pharmaciss play an inegral role and i is your eamwork ha makes our dream work Animicrobial sewardship is a eam game wih he paien a he cener pharmaciss play an inegral role and i is your eamwork ha makes our dream work 123 124 Key Poin Animicrobial sewardship is a eam game wih he paien a he cener pharmaciss play an inegral role and i is your eamwork ha makes our dream work 1. The eners for Disease onrol (D) has idenified all of he following resisan organisms as urgen hreas excep A. losridium difficile B. arbapenem-resisan Enerobaceriaceae (RE). Neisseria gonorrhoeae D. Mehicillin-Resisan Saphylococcus aureus 125 126
2. Which of he following is rue regarding he goals of he Naional Acion Plan for ombaing Anibioic Resisan Baceria? A. Eradicae he emergence of resisan baceria B. urail he developmen of rapid diagnosic ess for idenificaion of resisan baceria. By 2020, decrease losridium difficile infecions by 50% as compared o 2011 esimaes D. Require all providers o obain a leas 2 hours of coninuing educaion on pruden animicrobial prescribing each year 3. Why are animicrobial drugs considered o be socieal in naure? A. They are used by mos people in sociey B. Use in one person can impac heir uiliy in ohers. They are expensive D. They can be oxic 127 128 4. Which of he following wo drug classes are highly associaed wih collaeral damage? A. Penicillins and eracyclines B. Fluoroquinolones and cephalosporins. Lincosamides and oxazolidinones D. Glycopepides and carbapenems 5. Uilizaion of an exended-infusion o enhance anibacerial killing is an example of which animicrobial sewardship aciviy? A. Dose opimizaion B. Educaion. Prospecive audi wih inervenion and feedback D. Formulary resricion 129 130