Shira Doron MD Assistant Professor of Medicine Division of Geographic Medicine and Infectious Diseases Tufts Medical Center Boston MA Consultant to Massachusetts Partnership Collaborative Improving Antibiotic Stewardship for UTI ID: 935651
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The Increasing Threat of Antibiotic Resistance
Shira Doron, MDAssistant Professor of MedicineDivision of Geographic Medicine and Infectious DiseasesTufts Medical CenterBoston, MAConsultant to Massachusetts Partnership Collaborative: Improving Antibiotic Stewardship for UTI
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Slide2ObjectivesThe attendee
will:Understand the nature of the antibiotic resistance crisisUnderstand the link between antibiotic use and the development of resistant infections, including C diff.Understand the importance of differentiating between colonization and infection in ensuring prudent use of antibiotics.2
Slide3Antibiotics in Long Term Care:why do we care?
Antibiotics are among the most commonly prescribed classes of medications in long-term care facilitiesUp to 70% of residents in long-term care facilities per year receive an antibioticIt is estimated that between $38 million and $137 million are spent each year on antibiotics for long-term care residentsAs much as half of antibiotic use in long term care may be inappropriate or unnecessary3
Slide4The importance of prudent use of antibiotics
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Slide5Bad Bugs No Drugs
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Slide6The drug development pipeline for antibacterials
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Slide7A Balancing Act
Appropriate initial antibiotic while improving patient outcomes and healthcare Antimicrobial Therapy
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Unnecessary Antibiotics, adverse patient outcomes and increased cost
Slide8What is Antimicrobial Stewardship?
Antimicrobial stewardship involves the optimal selection, dose and duration of an antibiotic resulting in the cure or prevention of infection with minimal unintended consequences to the patient including emergence of resistance, adverse drug events, and cost
Dellit TH, et al. CID 2007;44:159-77, Hand K, et al. Hospital Pharmacist 2004;11:459-64
Paskovaty A, et al IJAA 2005;25:1-10
Simonsen GS, et al Bull WHO 2004;82:928-34
Ultimate goal is improved patient care and healthcare outcomes
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Slide1512 studies in North America:
1.8-13.5 infections per 1000 resident-care daysRate of death from infection 0.04-0.71 per 1000 resident-care days15
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The burden of infection in long-term care
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Slide18Why focus on long term care?Many long-term care residents are colonized with bacteria that live in and on the patient without causing harm
Protocols are not readily available or consistently used to distinguish between colonization and true infectionSo, patients are regularly treated for infection when they have none30-50% of elderly long-term care residents have a positive urine culture in the absence of infection18
Slide19Why focus on long term care?
When patients are transferred from acute to long-term care, potential for miscommunication can lead to inappropriate antibiotic useElderly or debilitated long-term care residents are at particularly high risk for complications due to the adverse effects of antibiotics, including Clostridium difficile infection19
Slide20Antibiotic misuse adversely impacts patients
Getting an antibiotic increases a patient’s chance of becoming colonized or infected with a resistant organism.
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Slide21Association of vancomycin use with resistance
(JID 1999;179:163)
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Slide22Annual prevalence of imipenem resistance in P. aeruginosa vs. carbapenem use rate
45 LTACHs, 2002-03 (59 LTACH years)
Gould et al. ICHE 2006;27:923-5
r = 0.41, p = .004
(Pearson correlation coefficient)
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Slide23Case
An 82-year-old long-term care resident has a fever and a productive coughHe has no urinary or other symptoms, and a chronic venous stasis ulcer on the lower extremity is unchangedA “pan-culture” is initiated in which urine is sent for UA and culture, sputum and blood are sent for culture, and the ulcer on the leg is swabbed23
Slide24A CXR is done and is negativeThe urinalysis has 3 white blood cells
Urine culture is positive for >100,000 CFU of E coliSputum gram stain has no PMNs, no organismsSputum grows 1+ Candida albicansWound culture grows VRE24
Slide25The patient is started on cipro for the E coli in the urine, linezolid for the VRE in the wound, and fluconazole for the Candida in the sputum
Two weeks later the patient has diarrhea and C. diff toxin assay is positive25
Slide26The only infection this patient ever had was a viral URI
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Slide27Colonized or Infected:
What is the Difference?People who carry bacteria or fungi without evidence of infection are colonizedIf an infection develops, it is usually from bacteria or fungi that colonize patientsBacteria or fungi that colonize patients can be transmitted from one patient to another by the hands of healthcare workersThere is no need to treat for colonization
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Slide28The Iceberg Effect
Infected
Colonized
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Slide29What could have been done differently?Understanding the difference between colonization and infection
No (or few) WBCs in a UA = no UTIIn the absence of dyspnea, hypoxia and CXR changes, pneumonia is unlikelyCandida is an exceedingly rare cause of pneumoniaWounds will grow organisms when cultured- infection can only be determined clinically29
Slide3010 clinical situations in long term care in which antibiotics are often prescribed but rarely necessary
Khandelwal et al. Annals of Long Term Care 2012: 20 (4)30
Slide31Urinary tract conditions
1. Positive urine culture in an asymptomatic patient2. Urinalysis or culture for cloudy or malodorous urine3. Non-specific symptoms or signs not referable to the urinary tract31
Slide32Respiratory tract conditions
4. Upper respiratory tract conditions5. Bronchitis absent of COPD6. Suspected or proven influenza without a secondary infection7. Respiratory symptoms in a terminal patient with dementia32
Slide33Skin wounds
8. Skin wounds without cellulitis, sepsis or osteomyelitis9. Small localized abscess without significant cellulitis10. Decubitus ulcer in a terminal patient33
Slide34UTIs in Long Term Care Residents
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Slide35Microbiology in Nursing HomesNew Haven, CT 5 Nursing Homes May 2005-2007
551 patients, presumed UTIDas R et al. ICHE 2009;30(11):1116-1119.35
Slide36Antimicrobial Susceptibilities from Nursing Home Residents in New Haven, CT
Das R et al. ICHE 2009;30(11):1116-1119.36
Slide37Antibiogram
Helps to determine best choices for empiric therapy37
Slide38Antimicrobial Prescribing
Empiric Initial administration of an antibiotic regimen Goal: improve outcome while minimizing potential to promote resistanceDefined or Targeted Modification of antimicrobial therapy once the cause of infection is identified
Goal: select the narrowest spectrum agent possibleTherapy may also be discontinued if the diagnosis of infection becomes unlikely
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Slide39Targeting, de-escalating and discontinuing antibiotics
The empiric regimen is very often NOT the regimen that should be continued for the full treatment courseGET CULTURES and use the data to target therapy using the most narrow spectrum agent possibleTake an “Antibiotic Time Out” – reassess after 48-72 hours
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Slide40Culture Data
Collect date: 04/15/12 08:35 Result Date: 04/17/12 09:33 SPECIMEN DESCRIPTION : URINE CLEAN CATCH/MIDSTREAMCULTURE : >100,000 COL/ML ESCHERICHIA COLIORGANISM >100,000 COL/ML ESCHERICHIA COLI
AMPICILLIN RESISTANT
AMPICILLIN/SULBACTAM INTERMEDIATEAMOXICILLIN/CLAVULAN SUSCEPTIBLE
CEFAZOLIN SUSCEPTIBLECEFEPIME SUSCEPTIBLECEFTRIAXONE SUSCEPTIBLE
CIPROFLOXACIN SUSCEPTIBLEERTAPENEM SUSCEPTIBLEGENTAMICIN SUSCEPTIBLE
LEVOFLOXACIN SUSCEPTIBLEMEROPENEM SUSCEPTIBLENITROFURANTOIN SUSCEPTIBLE
PIPERACILLIN/TAZOBAC SUSCEPTIBLETRIMETH/SULFAMETHOX SUSCEPTIBLETETRACYCLINE SUSCEPTIBLE
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Slide41Choosing the perfect antibiotic…Empiric:
Needs to get to the site of infectionPatient’s microbiology and antibiotic historyMinimize adverse effectsOther medical problems (renal insufficiency, C.diff, etc)Avoid drug interactionsAllergyThreshold for failureAntibiogram41
Slide42Choosing the perfect antibiotic…Targeted
Treat specific organismNarrowest spectrum possibleComplianceCostOral option?42
Slide43Take Home PointsAntibiotics are a shared resource… and becoming a scare resource
Appropriate antibiotic use is a patient safety priority Know the difference between colonization and infectionTo combat resistance: Think globally, act locally43