New Drugs for Bad Bugs- Statewide Antibiogram Felicia Matthews, Pharm.D., BCPS Senior Consultant, Pharmacy Specialty BE MedMined Services
Disclosures Employee of BD Corporation MedMined Services
Agenda Antimicrobial Resistance New Drugs to Combat Emerging Resistance Updates to Regulation for Antimicrobial Stewardship Statewide Antibiogram Antibiotics
Antimicrobial Resistance Antibiotic resistant infections add considerable and avoidable cost to the U.S. health care system: Up to: direct cost lost productivity
Antimicrobial Resistance 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company
Antimicrobial Resistance Urgent Threat Clostridium Difficle (C. Diff) Carbapenem-Resistant Enterobacteriaceae (CRE) Serious Threat Multidrug-Resistant Acinetobacter Extended Spectrum Enterobacteriaceae Vancomycin Resistant Enterococcus Multidrug-Resistant Pseudomonas Aeruginosa Methicillin-Resistant Staphylococcus Aureus (MRSA)
Antimicrobial Resistance
Antimicrobial Resistance Prevention & Control Testing Treatment
Antimicrobial Resistance
Antimicrobial Resistance
New Treatment Options: Gram Positive Agents Drug Indication Coverage Approval Date Comments/Opinions Dalbavancin (Dalvance ) Oritavancin (Orbactiv ) ABSSSI MRSA 2014 Bactericidal 1-2 dose regimen ABSSSI MRSA, VRE 2014 Bactericidal One time dosing Contraindicated with heparin Tedizolid (Sivextro ) ABSSSI MRSA, VRE 2014 Bactericidal Prodrug IV/PO dosing Delafloxacin (Baxdela ) ABSSSI MRSA 2017 Bactericidal Polymicrobial ABSSSI
Pipeline for Gram Positive Agents
Pipeline for Gram Positive Agents
New Treatment Options: Gram Negative Agents
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Regulatory Joint Commission ASP Standard MM.09.01.01 Effective since January 2017. Organization must have a policy that address each core element in the ASP. Currently there is not any specific data that should be collected, analyzed or reported. Your organization must show improvement opportunities based on the collected and data analyzed.
Regulatory Joint Commission ASP Standard MM.09.01.01 Providing written material such as the organizations antibiogram will meet the education requirement. Organizations may receive a requirement for improvement if there is not a physician on the team. They will not be reviewing staff records on education received regarding antimicrobial stewardship.
Regulatory CMS Conditions of Participation for Long Term Care Facilities (LTC) CMS Medicare Beneficiary Quality Improvement Project (MBQIP) CMS Conditions of Participation for Critical Access Hospitals (CAHs)
AHQI Antibiogram
What is included? Isolates from 56 hospitals in Alabama Includes data from 1/2017 to 12/2017 One isolate per organism per 365 day period Duplicate isolates removed Significantly different susceptibility results are considered unique or nonduplicate
Community versus Hospital Community isolate That which is collected from an outpatient or an inpatient within the first 3 days of an admission who has had no admissions within the past 14 days Hospital isolate That which is collected from a inpatient on or after day 3 of an admission or within 14 days of discharge
Hospital Enterococcus Isolates (Non-Urine) 2000 1900 1767 1799 1800 1600 1400 1200 1000 1535 1500 33% (31%) of Enterococcus 1327 1149 isolates are the more resistant faecium strain 1122 E Faecium E Faecalis 800 600 400 200 0 2010 2011 2012 2013 2014 2015 2016 2017
Vancomycin Resistant E Faecium (Hospital Non-Urine) 90 80 70 80% E. faecium resistant to vancomycin is unchanged from last year 80% (80%) 60 50 40 30 Vancomycin Linezolid E. faecium resistance to linezolid is unchanged from last year 6% (6%). Still below 2007 levels 20 10 0 6% * 95% of E. faecalis remain susceptible to vancomycin
Hospital MRSA (Non-Urine) 80 75 70 65 60 55 58% MRSA has been flat since about 2012 and is at 58% in 2017. The percent remains high relative to other regions in the US 50 45 40
MRSA All HAIs 2011-2014 http://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html
MRSA Hospital versus Community (Non-Urine) 70 65 60 58% Lines appear to be separating since 2013 as hospital is about 5% more resistance 55 50 45 53% Hospital Community Community will include patients from nursing homes and long-term care hospitals and may not reflect Community in the traditional sense. 40
Klebsiella pneumonia Isolates Resistant to Meropenem (KPC) 200 180 160 140 120 100 80 60 40 20 0 172 total 106 total 105 total 97 62 48 75 57 44 2015 (n=6267) 2016 (n=6310) 2017 (n=7015) Comm Hosp Previous presentations have reported K. pneumonia strains tested against imipenem. A greater number of hospitals have been testing meropenem instead of imipenem. We will report meropenem moving forward. 2017 testing against meropenem increased to 7015 (6310) but total resistant isolates remained flat. There was an increase in community resistant strains but a decrease in hospital resistant strains.
Hospital Non-Urine A. baumannii Isolates Susceptible to Meropenem 100% 90% 80% 70% 60% 50% 40% 78 64% 92 70% 104 53% 120 100 80 60 17% drop in susceptibility reported in 2017. A. baumannii has always been difficult to treat so infection prevention is critical. Multi-drug Resistant A. baumannii is associated with high mortality and is difficult to treat. 30% 20% 10% 0% 2015 2016 2017 40 20 0 Combination therapy of carbapenem with ampicillin/sulbactam, colistin or tigecycline still may be necessary Total Isolates % Susceptible
Carbapenms R or I Acinetobacter NATIONAL HAIs 2011-2014 http://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html
Hospital P. aeruginosa Non-Urine 100 90 80 70 Cefepime Aztreonam Pip/Tazo 85% 82% B-Lactams Pipercillin/Tazobactam and Cefepime continue to be stable Drop in Aztreonam 60% (66%) marks the first decline the last 5 years 60 60% 50
Hospital P. aeruginosa Non-Urine 100 95 90 85 80 75 91% 90% 81% Aminoglycosides Amikacin and Tobramycin steady at over 90% Gentamicin continues to improve over the last 5 years 70 65 60 55 Amikacin Tobramycin Gentamicin 50
100 Hospital P. aeruginosa Non-Urine Carbapenems 90 80 70 60 50 Imipenem Meropenem 76% 71% P. aeruginosa susceptibility to imipenem and meropenem improve respectively at 71% (68%) and 76% (73%). There is still concern here as this one of our last lines of defense against resistant gram negative bacteria.
Hospital P. aeruginosa Non-Urine 100 90 80 Levofloxacin Quinolones Poor activity against Pseudomonas but there is a trend towards improvement over the past 4 years and since 2006. 70 70% 60 50 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Antibiogram Summary Enterococcus faecium resistant to vancomycin or linezolid, hospital non-urine, remains stable (80%, 6%) MRSA, hospital non-urine, is flat. Geographically, still high. Appears that MRSA, community non-urine, is declining slightly faster. CRKP, hospital and community, was flat in 2017, however the make-up changed with more of the resistant strains coming from the community setting. A. baumannii, hospital non-urine, big drop in susceptibility (53% vs 70%). Preventing the infection is critical. P. aeruginosa, hospital non-urine, resistance to carbapenems flat although still a concern.
Antibiotic National Comparison Antibiotics 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company
Antibiotic National Comparison Carbapenems 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company
Antibiotic National Comparison Piperacillin / Tazobactam 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company
Antibiotic National Comparison Quinolones 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company
Antibiotic National Comparison 3 rd /4 th Generation Cephalosporins 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company
Antibiotic National Comparison Vancomycin, Linezolid, Daptomycin, Tigercycline 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company
Antibiotic National Comparison Proton Pump Inhibitors 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company
New Drugs for Bad Bugs- Statewide Antibiogram Felicia Matthews, Pharm.D., BCPS Senior Consultant, Pharmacy Specialty BE MedMined Services