Thank You for Joining! Session 4 Antibiotic Selection, De-Escalation, and Duration Webinar Will Begin Shortly. Call-In Number: (888) 895-6448 Access Code: 5196001
Antibiotic Selection, De- Escalation, and Duration Shira Doron, MD Kirthana Beaulac, PharmD
3 Polling Question 1 With respect to antimicrobial stewardship, I feel that my facility: A. Has a program in place B. Has a feasible plan to implement a program C. Has little if any program or plan
4 Case A 68 year old long term care resident develops respiratory symptoms, and chest x-ray is consistent with pneumonia, so he is started on the broad-spectrum antibiotic piperacillintazobactam to cover resistant organisms 2 days later the sputum culture grows Strep pneumoniae The patient responds quickly, so no one narrows the antibiotic, and the patient completes a 10-day course One month later the patient develops urosepsis with Pseudomonas aeruginosa highly resistant to all antibiotics tested including piperacillin-tazobactam
5 What could have been done differently? Use of a narrower agent rather than a broadspectrum antibiotic Shorter, appropriate course of treatment Adjust antibiotics based on culture results
Objectives Identify appropriate resources for optimal antibiotic selection Understand the importance of the antibiotic time out to determine opportunities for antibiotic discontinuation and de-escalation Recognize the impact of de-escalation on clinical outcomes Appreciate the appropriate antibiotic treatment durations for specific clinical conditions
7 Get SMART with antibiotics Starting off choosing the appropriate empiric regimen Maintenance of therapy: Targeting, deescalating, and discontinuing therapy Are you treating infection or colonization? Route: IV or PO Time: Stop antibiotics as early as possible
Get SMART Starting off choosing the most appropriate empiric regimen 8 Antibiotics Disease State Pathogens
Does this patient need antibiotics right now? Can the patient s symptoms be attributed to a non-bacterial condition Dyspnea/ SOB: COPD exacerbation, fluid overload Rhinorrhea: viral upper respiratory tract infection, sinusitis Altered mental status: dehydration, pain, meds Watchful waiting
When Do You Need Big Guns? Using the broadest spectrum antibiotics every time empirically will inevitably lead to resistance Think about patient risk factors to assess who is at risk for multi-drug resistant organisms (MDRO)
Risk Factors MRSA Recent hospitalization Residence in a long term care facility Recent surgery Hemodialysis HIV IV drug use Prior antibiotics Resistant Gram Negatives (Pseudomonas, ESBL, Acinetobacter) Older age Poor functional status Long hospital stay (especially ICU) Frequent healthcare exposure (dialysis, other treatment centers) Recent surgery Indwelling devices Prior antibiotics
Antibiotic Choices MRSA Vancomycin Daptomycin Linezolid Ceftaroline Tetracyclines Clindamycin Bactrim Resistant Gram Negatives (Pseudomonas, ESBL, Acinetobacter) Penicillin: piperacillin/ tazobactam Cephalosporin: cefepime, ceftazidime, ceftazidime/ avibactam, ceftolozane/ tazobactam Carbapenem: ertapenem, doripenem, meropenem, imipenem Monobactam: aztreonam Fluoroquinolones: ciprofloxacin, levofloxacin, moxifloxacin Aminoglycosides: gentamicin, tobramycin, amikacin
Identifying Resources Evidence Based Guidelines www.idsociety.org
Endocarditis/ bacteremia 14 Meningitis C. Difficile UTI Asymptomatic Bacteriuria Intra-abdominal Infection Pneumonia: HAP/VAP CAP Osteomyelitis Prosthetic Joint Infection Skin and Soft Tissue Infection
Get SMART Ms. M Maintenance Ms. M is a 45 year old woman with breast cancer who has been in the hospital for 1 week for complications of chemotherapy Yesterday, hospital day 6, she developed low-grade fevers and her urinalysis was positive, so she was started on cefepime Today, her blood pressure is low and the lab reports urine is growing Acinetobacter spp. It will be another 24 hours before they have susceptibility testing results
Local Resistance
Local Resistance
Local Resistance
Local Resistance
Empiric Antimicrobial Prescribing Initial administration of a broad-spectrum antibiotic regimen that attempts to improve outcomes and minimize resistance. Defined or Targeted Modification of antimicrobial therapy once the cause of infection is identified. Therapy may also be discontinued if the diagnosis of infection becomes unlikely. 1 Focus on de-escalation of antibiotic therapy with the goal of minimizing resistance and toxicity, and improving cost-effectiveness. 1. Kollef MH. Drugs. 2003;63:2157 2168. 2. Kollef MH. Crit Care Med. 2001;29:1473 1475. 3. Evans RS et al. N Engl J Med. 1998;338:232 238.
Get SMART Maintenance of therapy Empiric regimen is often NOT the regimen that needs to be continued for the full treatment course GET CULTURES and use the data to target therapy using the most narrow spectrum agent possible. Take an Antibiotic Time Out reassess after 48-72 hours
Antibiotic Time-Out Hard Stop vs. Soft Stop Electronic vs. Manual Passive Alert vs. Actionable Item Resources for next steps CHECK YOUR CULTURES
Definition of De-escalation Narrowing the spectrum of the antibiotic relative to clinically pathogenic organisms Reducing the ecologic consequences of an antimicrobial on the microbiota Choosing an antibiotic with a milder safety and toxicity profile
Impact of De-escalation on C. diff Aldyab MA, Kearney MP, Scott MG, et al. J Antimicrob Chemother. 2012; 67(12):2988-96.
Adjusted odds ratios of risk factors for Clostridium difficile. 25
Adjusted odds ratios of risk factors for Clostridium difficile. 26 Tartof et al. ICHE 2015; 36(12), 1409.
Caution about Antibiotic Shunting Cephalosporin restriction due to resistant K. pneumoniae 80% reduction in hospital-wide cephalosporin use Imipenem use increased 141% Burke JP. JAMA. 1998; 280:1270 1. Friedrich LV, et al. Clin Infect Dis. 1999; 28:1017 24.
Polling Question 2 I feel that the selection of antibiotics for residents with suspected infection in my facility is: A. Generally too broad B. Generally too narrow C. Appropriate D. I don t know
Get SMART Are you treating infection or colonization? Colonization = bacteria are present at the site sampled, but are not causing disease Contamination = bacteria are present in the laboratory sample, but not at the site NEITHER requires antibiotics! Avoid drawing blood cultures through a central line or taking urine cultures from a catheter WBCs in the urine UTI; NO WBCs in the urine = NO UTI Candida is a frequent colonizer
Treatment of candiduria Sobel JD, Kauffman CA, McKinsley D, et al. CID 2000; 30: 19-24
Nicolle LE, Bradley S, Colgan R, et al. CID 2005; 40: 643-54. 31 31
Nicolle LE, Bradley S, Colgan R, et al. CID 2005; 40: 643-54. 32 32
Nicolle LE, Bradley S, Colgan R, et al. CID 2005; 40: 643-54. 33 33
Get SMART Route: IV or PO 34 Many drugs are highly available in the PO form The oral route is less expensive and allows for earlier removal of lines and decreased length of stay Patients on oral antimicrobials with clearly documented reasons for continued hospital stay are not at risk for claims rejection by payors
Parenteral To Oral Conversion Several antibiotics have good oral bioavailability Fluoroquinolones Linezolid Metronidazole Clindamycin SMX/TMP Fluconazole Associated with Decreased: Length of stay Cost of care Risk for line-related infections Additional Benefits Fluid / sodium restriction Enterohepatic cycling Patient Satisfaction Jones M, et al. Infect Control Hosp Epidemiol. 2012; 33(4): 362-367.
Get SMART Route: IV or PO Many drugs are highly available in the PO form The oral route is less expensive and allows for earlier removal of lines and decreased length of stay Patients on oral antimicrobials with clearly documented reasons for continued hospital stay are not at risk for claims rejection by payors e know everything about antibiotics except how much to give. Maxwell Finland (one of the forefathers of antibiotic therapy)
Get SMART SomeTimes less is more The single most important modifiable risk factor for the development of Clostridium difficile infection is exposure to antimicrobial agents Cohen SH, Gerding DN, Johnson S, et al. Inf Cont Hosp Epi 2010: 31(5): 431-455. Muto CA, Blank MK, Marsh JW, et al. CID 2007: 45; 1266-73.
Duration Spellberberg, B. JAMA Internal Medicine. 2016; 176(9):1254-1255.
Early Discontinuation for Pneumonia Raman KR, Nailor MD, Nicolau DP, et al. Crit Care Med. 2013; 41(7):1656-1663.
7 Days for UTI Sandberg T, Skoog G, Hermansson AB, et al. Lancet. 2012; 380: 484-490.
Polling Question 3 Excluding cases of bacteremia, endocarditis and osteomyelitis, how often do you see antibiotic courses that exceed two weeks being prescribed for residents? A. Frequently B. Occasionally C. Rarely D. Never
42 Get SMART with antibiotics Starting off choosing the appropriate empiric regimen Maintenance of therapy: Targeting, deescalating, and discontinuing therapy Are you treating infection or colonization? Route: IV or PO Time: Stop antibiotics as early as possible
43 Polling Question 4 I feel that the strategies discussed in today s webinar are largely: A. Feasible in my facility B. Not feasible in my facility C. Already being used in my facility
Contact your Nursing Home CDI/ NHSN Initiative State Contacts Connecticut Cynthia Hayle chayle@qualidigm.org Maine Danielle Watford dwatford@healthcentricadvisors.org Massachusetts Sarah Dereniuk sdereniuk@healthcentricadvisors.org New Hampshire Pamela Heckman pamela.heckman@area-n.hcqis.org Rhode Island Janet Robinson jrobinson@healthcentricadvisors.org Vermont Gail Harbour gharbour@qualidigm.org This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINC22017030944 44
The NE QIN-QIO Outpatient Antibiotic Stewardship Collaborative No-cost opportunity for antibiotic stewardship support in physician offices and other outpatient settings Continues through at least July 2019 but limited time to sign up Includes: Resources and tools for patients and providers Webinars and direct assistance as desired Opportunities to connect with peers and highlight best practices 45
Connecticut Carol Dietz Interested in the NE QIN-QIO Antibiotic Stewardship Collaborative? Contact us... 860-632-3737 cdietz@qualidigm.org New Hampshire Margaret Crowley 603-573-0333 margaret.crowley@area-n.hcqis.org Massachusetts Alyssa DaCunha 877-904-0057 ext.3241 adacunha@healthcentricadvisors.org Rhode Island Maureen Marsella 401-528-3223 mmarsella@healthcentricadvisors.org Maine Amanda Gagnon 207-406-3977 agagnon@healthcentricadvisors.org Vermont Regina-Anne Cooper 802-522-9413 rcooper@qualidigm.org Questions regarding CE status may be submitted to Ileizy Victor at Ivictor@healthcentricadvisors.org This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSMAC22017051026. 46
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