June 1 2017 Courtney Holzheimer DNP FNPBC Sara Lee MD Courtney Holzheimer DNP FNPBC Nurse Practitioner Case Western Reserve University Sara Lee MD Adolescent Medicine Rainbow Babies and Childrens ID: 908101
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Slide1
Antibiotic Resistance and Overuse: Strategies for College Health
June 1, 2017
Courtney
Holzheimer
, DNP, FNP-BC
Sara Lee, MD
Slide2Courtney Holzheimer, DNP, FNP-BCNurse Practitioner, Case Western Reserve University
Sara Lee, MD
Adolescent Medicine, Rainbow Babies and Children’s HospitalAssistant Professor of Pediatrics, CWRU SOMWho are you?
Slide3We have NO actual or potential conflict of interest in relation to this educational activity or presentation.
Slide4Learning ObjectivesExplain the development of antibiotic resistance.
Describe the current state of antibiotic prescribing.
List the appropriate use of antibiotics in typical college health clinical scenarios.
Slide5Antibiotics are awesome!Average life expectancy extended by 20 yearsCommunicable to non-communicable disease management
Major advances in cancer treatment, organ transplants, surgery
Slide6Antibiotic Stewardship Is EssentialImprove antibiotic prescribing by clinicians and use by patientsPrescribe and use only when needed
Right drug, right dose, right duration
Goal: maximize benefit of antibiotic treatment while minimizing harm to individuals and communities
Slide7Consequences of Antibiotic OverusePatient beliefAdverse ReactionsFinancial Burden
Antibiotic
Resistance
Slide8Antibiotic ResistanceMicrobes become resistant to an antibiotic that was once useful in treating an infection caused by that microbe.
2 million antibiotic illnesses in the US per year
23,000 deaths per year$30 billion per year
Slide9Antibiotic Resistance#1 cause: Using Antibiotics
Agriculture/food production
Antibiotic overuse in health careAntimicrobial treatment places selective pressure on target organisms favors emergence of drug resistant strains
Bacteria have shown the ability to become resistant to EVERY antibiotic that has been developed
Slide10Slide11Emerging Threats
cdc.gov
Slide12History of Antibiotic Resistance
Slide13History of Antibiotic Resistance1928 Penicillin discovered1940- Penicillin R- staphylococcus resistance discovered 1943- Penicillin in widespread use
Prior to 1980, most strep pneumococcus susceptible to penicillin. By 2000, there was a 60X increase in high level resistance
No ‘new’ antibiotic discovered since 1987 https://www.cdc.gov/drugresistance/about.html
Slide14Defining the ProblemPopulation levelCommunities with more antibiotic prescriptions have higher rates of resistance
Individual level
Longer duration and multiple courses increased resistance
Slide15Antibiotic Prescriptions in the Outpatient Setting80% of all antibiotics prescribed in the outpatient setting
41% for URI
12% UTIAcute rhinosinusitis (ARS): 20 million cases per year in US11% of all primary care antibiotic prescriptions2% would benefit from an antibiotic
Up to 80% seen are given an antibiotic
source: Centers for Disease Control and Prevention; National Center for Emerging and Zoonotic Infectious Diseases (NCEZID); Division of Healthcare Quality Promotion (DHQP)
Slide16College Health15.2% of all visits are for ARS management
6.1% for Bronchitis
9.8% for Pharyngitis10% for Cystitis ACHA Spring 2016 Reference Group Executive Summary
Slide17College Health-Specific IssuesStudents travel!Bringing medications from home
Multiple points of care
Stress and academic concerns
Slide18Why Do We Overprescribe?Knowledge gapStudent expectations
Clinical time management
Slide19Student satisfactionHaltiwanger et al., 2001
Relationship between patient satisfaction with visit, belief in antibiotics, and getting a prescription for antibiotics
93% positive satisfaction scoreAntibiotics givenClear diagnosisClear explanation of treatment recommendations
Slide20Does the student expect antibiotics?Zoorob et al., 2001
Examined college health student beliefs in the effectiveness of antibiotics to treat URI illnesses
Clinical vignettesOnly 41% thought an antibiotic would be effective
Slide21Clinical SCENARIOS
Slide22Scenario 1A 19 year old student presents with pain in his forehead and maxillary sinuses. He has had upper respiratory symptoms for the past 10 days. While initially after 5 days he was improving, for the past several days he has felt worse. His current temperature is 102F. On exam, he has severe pain over his right maxillary sinus.
Slide23What is your primary clinical diagnosis? A. Acute bacterial
sinusitis
B. Acute viral sinusitisC. Other
Slide24Which of the following interventions (if any) would be in your treatment plan for this patient? A. Antibiotic
B. Nasal
steroid sprayC. OTC meds (antihistamine, decongestant, cough suppressant, etc.)D. Referral to specialistE. Transfer to emergency department
Slide25If you chose to prescribe an antibiotic for this patient, which one of the following would you most likely prescribe?A. Amoxicillin
B.
Amoxicillin/clavulanateC. AzithromycinD. Trimethoprim-sulfamethoxazole E. Levofloxacin
F. Other
Slide26Scenario 2 A 20 year old female student presents with cough, congestion and sore throat. Her symptoms have been persistent over the past 8 days. She is in for evaluation today because over the counter medications are not helping and her symptoms have been ‘going on a long time”. On exam, her temperature is 97.3F and she has mildly enlarged, reddened nasal
turbinates
and some palpable anterior cervical lymph nodes.
Slide27What is your primary clinical diagnosis? A. Acute bacterial
sinusitis
B. Acute viral sinusitisC. Other
Slide28Which of the following interventions (if any) would be in your treatment plan for this patient? A. Antibiotic
B. Nasal
steroid sprayC. OTC meds (antihistamine, decongestant, cough suppressant, etc.)D. Referral to specialistE. Transfer to emergency department
Slide29If you chose to prescribe an antibiotic for this patient, which one of the following would you most likely prescribe?A. Amoxicillin
B.
Amoxicillin/clavulanateC. AzithromycinD. Trimethoprim-sulfamethoxazole E. Levofloxacin
F. Other
Slide30Our StudyDescriptive, exploratory study designQuestion: Can college health providers identify and manage acute sinusitis?
Right diagnosis
Appropriate use of antibioticsRight antibiotic
Slide31ResultsABRS vs AVRSAntibiotics for bacterial
presentation
Antibiotics for viral presentationCorrect antibiotic
Slide32ResultsScenario 1Scenario 2
Slide33Management of Acute Sinusitis Bacterial PresentationPersistent illnessSevere symptoms for at least 3-5 days
“Double sickening”
Right Antibiotic
Slide34Antibiotics for Acute SinusitisGuidelines for Management of Acute RhinosinusitisIDSA Guidelines, 2011 (Chow et al., 2011)
Am Academy of Otolaryngology, 2015 (Rosenfeld et al., 2015
)Ahuvuo-Saloranta et al. (2014)Cochrane Study of RCTs since 1970
Adults with
ARS
Results: Little difference in improvement rates (87%, 81%)
No difference by day 16
Slide35Antibiotic Choice
Chow, A. W.,
Benninger, M. S., Brook, I., Brozek, J. L., Goldstein, E. J. C., Hicks, L. A., ... File, T. M. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases, 54(8). DOI: 10.1093/cid/cir1043
Slide36Scenario 3A 22 yo male, nonsmoker, presents with a 10 day history of URI symptoms, most notably mild shortness of breath with exertion and a frequent deep, productive cough for much of the illness. Student is afebrile,
rr
=16, pulse=80. On exam, occasional coughing. Lung exam clear with the exception of scattered rhonchi.
Slide37What is your primary clinical diagnosis? A. Acute bacterial
sinusitis
B. Pneumonia C. Bronchitis
Slide38Which of the following interventions (if any) would be in your treatment plan for this patient? A. Antibiotic
B. Nasal
steroid sprayC. OTC meds (antihistamine, decongestant, cough suppressant, etc.)D. Referral to specialistE. Transfer to emergency department
Slide39If you chose to prescribe an antibiotic for this patient, which one of the following would you most likely prescribe?A. Amoxicillin
B.
Amoxicillin/clavulanateC. AzithromycinD. Trimethoprim-sulfamethoxazole E. Levofloxacin
F. Other
Slide40BronchitisWenzel and Fowler, NEJM, 2006, Acute Bronchitis DOI: 10.1056/NEJMcp061493Generally cough lasts at least 7-10 days
Up to 50% still coughing after 3 weeks
Up to 25% still coughing after 4 weeksRCT : 112 given azithromycin, 108 given vitamin C – no difference in outcome after 7 days
Slide41Scenario 4 20 year old female presents with dysuria x 2 days. No fever, no back pain, no nausea. NKDA. No recent antibiotic use. One previous UTI treated with “an antibiotic.”
Slide42If you chose to prescribe an antibiotic for this patient, which one of the following would you most likely prescribe?A. Amoxicillin
B.
Amoxicillin/clavulanateC. CiprofloxacinD. Nitrofurantoin mono/macE. Trimethoprim-sulfamethoxazole F. Other
Slide43International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious
Diseases.AUGupta
K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, Raz R, Schaeffer AJ, Soper DE, Infectious Diseases Society of America, European Society for Microbiology and Infectious Diseases SOClin
Infect Dis. 2011;52(5):e103.
Slide44https://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/adult-treatment-rec.html
Resources
Slide45What can we do? 4 Core Actions
Slide46Question and Answer Period
Slide47Additional Questions?courtney.holzheimer@case.edu
sara.lee@uhhospitals.org
Slide48ReferencesArnold, S. R., & Straus, S. AE. (2005). Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database of Systematic Reviews 2005, 4. Art NO; CD003539.
Doi
: 10.1002/14651858.cd.003539.pub2Chow, A. W., Benninger, M. S., Brook, I., Brozek, J. L., Goldstein, E. J., Hicks, L. A., File, T. M. (2011). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Retrieved from Infectious Disease Society of America website http://www.idsociety.org/uploaded files/IDSA/Guidelines-patient_care/
PDF_Library
Haltiwanger
, K. A., Hayden, G. F., Weber, T., Evans, B. A., &
Possner
, A.B. (2001). Antibiotic-seeking behavior in college students: what do they really expect? Journal of American College Health, 50, 9-13.