Transcript Antimicrobial Stewardship Overview: An Urgent Patient

Antimicrobial Stewardship Overview:
An Urgent Patient Safety Imperative
Ed Septimus, MD, FACP, FIDSA, FSHEA
Medical Director Infection Prevention and
Epidemiology
Professor Internal Medicine Texas A&M
Professor, Distinguished Senior Fellow, School
of Public Health, George Mason University
[email protected]
Slide: 1
“Microbes are educated to resist penicillin
and a host of penicillin-fast organisms is bred
out…In such cases the thoughtless person
playing with penicillin is morally responsible
for the death of the man who finally succumbs
to infection with the penicillin-resistant
organism. I hope this evil can be averted.”
When and Who Said this?
Slide: 2
Slide: 3
Drug Resistant S. aureus in the Community
• Recently, the resistance pattern, formerly seen only in
the hospital, is also being replicated in the
community. This increase seems to parallel the
intensive and often indiscriminant use of antibiotics
outside the hospital ambience. Also, it can be
conjectured the hospital has served as a locus for the
“lateral” dissemination of resistant strains into the
community.
Ross, et al, JAMA, 1974
Slide: 4
Stop the killing of beneficial bacteria
Concerns about antibiotics focus on bacterial resistance — but
permanent changes to our protective flora could have more
serious consequences, says Martin Blaser.
Nature 2011;476:393
Collateral Damage
• Average child receives 1020 courses of antibiotics
before age 18
• Antibiotics affect our
resident microbiota and may
not fully recover after a
course of antibiotics
• Overuse of antibiotics may
be contributing to obesity,
DM, IBD, allergies, and
asthma
When mediating over a disease, I
never think of finding a remedy for
it, but instead a means of
preventing it
Louis Pasteur
Slide: 6
Case #1
32 year male presents to the ER with a 4-5 day of
sore throat, low grade fever, and myalgias followed
by a 1 day history of increasing shortness of breath
and cough. Patient has no underlying diseases.
In the ER, patient was in respiratory distress,
hypoxic, and febrile. CXR extensive left-sided
consolidation. The patient required intubation and
was admitted to the ICU with the diagnosis of CAP.
The patient was started on a macrolide and a thirdgeneration cephalosporin.
Does This Meet Core Measures?
Slide: 7
Slide: 8
CASE 2
This is a 46 year old female admitted with
hypotension, fever, and flank pain. She had no
underlying medical or urologic problems. Her urine
showed pyuria and bacteriuria, the peripheral WBC
was 16,000. She was admitted to the ICU and
empirically started on _______.
What would you start?
Slide: 9
?
2011+
Slide: 10
The Perfect Storm
Antimicrobial Resistance
Slide: 11
Slide: 12
Total # New Antibacterial Agents
Antibiotic Development
16
14
12
10
8
6
4
2
0
'83-'87
’83-’87
'88-'92 '93-'97 '98-'02 '03-'07 '08-'12
Slide: 13
Bad Bugs, No Drugs1
•
Declining research investments in
antimicrobial development2,3
•
The Antimicrobial Availability Task
Force of the IDSA identified problematic
pathogens including gram-negative
bacteria2
•
Problematic pathogens can “escape”
the activity of antibacterial drugs3
– “ESKAPE”(ESCAPE) pathogens include
• Escherichia coli
• Staphylococcus aureus
• Klebsiella pneumoniae(C.difficle)
• Acinetobacter baumannii
• Pseudomonas aeruginosa
• Enterobacter spp
1. Infectious Diseases Society of America. Bad Bugs, No Drugs: As Antibiotic Discovery
Stagnates, A Public Health Crisis Brews.
July, 2004. http://www.idsociety.org/WorkArea/showcontent.aspx?id=5554. Accessed January
15, 2009. 2. Talbot GH, et al.
Slide:
Clin Infect Dis. 2006;42:657-68. 3. Boucher HW, et al. Clin Infect Dis. 2009;48:1-12.
14
Clin Infect Dis 2011; 52:S397-S428
Slide: 15
Geographical Distribution
of KPC(CRE)-Producers
Widespread
Sporadic isolate(s)
November 2006
16
Centers for Disease Control andSlide:
Prevention.
Geographical distribution of
extreme-drug resistant Klebsiella
bacteria
KPCs received
17
August 2010
Slide: 17
New Delhi Metallo-β-lactamase (NDM)
Lancet Infect Dis 2010
Slide: 18
Latin America
(1997-1999)
(2007-2009)
P. aeruginosa / Imipenem-R
18→30%
P. aeruginosa / Piperacillin-tazobactam-R
25→45%
P. aeruginosa / Ciprofloxacin-R
35→41%
Acinetobacters / Amikacin-R
66→74%
Acinetobacters / Ceftazidime-R
67→85%
Acinetobacters / Imipenem-R
11→58%
Why We Need to Improve Antibiotic Use
• Antibiotics are misused across the continuum of care
• Use of antibiotics in animals
• Antibiotic misuse adversely impacts patients and society
• Antibiotics are the only drug where use in one patient can
impact the effectiveness in another.
• Improving antibiotic use improves patient outcomes and
saves money
• Improving antibiotic use is a public health imperativeWHO considers AR an emerging threat to global
stability
Slide: 20
Magnitude of Antimicrobial Use
• Antibiotics are the second most commonly used class
of drugs in the United States
• More than 8.5 billion dollars are spent on anti infectives annually
 200-300 million antimicrobials prescribed annually
 53% for outpatient use
• 30-50% of all hospitalized patients receive antibiotics
• Studies estimate up to 50% of antibiotic use is either
unnecessary or inappropriate across all type of health
care settings
Clin Infect Dis 2007; 44:159-177
Slide: 21
Unnecessary Use of Antimicrobials in
Hospitalized Patients
• Prospective observational study in ICU
• 576 (30%) of 1941 antimicrobial days of therapy
deemed unnecessary
Days of Therapy
Most Common Reasons for Unnecessary Days of Therapy
250
200
192
187
150
94
100
50
0
Duration of Therapy
Longer than Necessary
Noninfectious or
Nonbacterial Syndrome
Treatment of
Colonization or
Contamination
Hecker MT et al. Arch Intern Med.
2003;163:972-978. Slide: 22
International Study of the Prevalence and
Outcomes of Infection in ICUs
• 1-day, prospective, point prevalence study
• 14,414 patients in 1265 ICUs from 75 countries
• 51% were considered infected
• 71% were receiving antibiotics
• 62% of infections were due to gram-negative
organisms (compared to 39% of infections in 1995)
• 47% of infections were due to gram-positive organisms
and 19% were fungi
• ICU mortality of infected patients was more than twice
that of noninfected patients P<.001
JAMA 2009; 302:2323
Slide: 23
Antibiotic are misused
in a variety of ways
• Given when they are not needed
• Continued when they are no longer necessaryduration
• Given at the wrong dose-renal and weight-based
dosing
• Broad spectrum agents are used to treat very
susceptible bacteria
• The wrong antibiotic is given to treat an infection
Slide: 24
Goals of Antimicrobial Stewardship
Programs
Optimize
Patient
Safety
Reduce
Resistance
Decrease or
Control
Costs
Slide: 25
Antimicrobial Stewardship
Goals
• Improve patient outcomes
• Optimize selection, dose and duration of Rx
• Reduce adverse drug events including secondary
infection (e.g. C. difficile infection)
• Reduce morbidity and mortality
• Limit emergence of antimicrobial resistance
• Reduce length of stay
• Reduce health care expenditures
MacDougall CM and Polk RE. Clin Micro Rev 2005;18(4):638-56.
Ohl CA. J. Hosp Med. In press.
Slide: 26
Dellit TH, et. al. Clin Infect Dis. 2007;44:159-177
Costs of Antimicrobials
• Allergy
• Resistance
• Adverse
events
Clinical cure
vs
Therapeutic failure
Impact on
hospital/outpatient/society
Slide: 27
Antimicrobial Resistance
• Increases mortality and morbidity
• Antimicrobial resistance is accelerated by
excessive use of antibiotics
• Appropriate use of antibiotics reduces
antimicrobial resistance
• Inadequate infection control propagates
transmission of MDR strains
• Antibiotic-resistant infections have been
estimated to cost the US healthcare system
over $20 billion annually
Emerg Infect Dis 2001; 7:286
Arch Intern Med 2003; 163:972
Infect Control Hosp Epidemiol 2003; 24:642
Nat Rev Microb 2004;Slide:
2:251 28
Clin Infect Dis 2009; 49:1175-84
CLIN INFECT DIS 49(8):1175-1184.
Figure 1. Predicted mortality for patients with and without antimicrobial‐resistant infection (ARI). APACHE, Acute
Physiology and Chronic Health Evaluation.
Slide: 29
Hospital and Societal Costs of Antimicrobial-Resistant
Infections in a Chicago Teaching Hospital:
Implications for Antibiotic Stewardship
CLIN INFECT DIS 49(8):1175-1184.
.
Slide: 30
Projected cost savings if antimicrobial‐resistant infection (ARI) rates were reduced from 13.5% to 10%.
Can Antimicrobial Stewardship Limit
the Emergence of Resistance?
• Best evidence for:
– Decreased resistant Gram-negative
bacilli1,5
– Decreased CDI1-4
– Decreased VRE1
1. Carling P, et al. Infect Control Hosp Epidemiol. 2003;24(9):699706.
2. Climo MW, et al. Ann Intern Med. 1998;128(12, pt 1):989-995.
3. Pear SM, et al. Ann Intern Med. 1994;120(4):272-277.
4. McNulty C, et al. J Antimicrob Chemother. 1997;40(5):707-711.
5. de Man P, et al. Lancet. 2000;355(9208):973-978
Slide: 31
Antibiotic misuse adversely impacts
patients- C. difficile
• Antibiotic exposure is the single most important
risk factor for the development of Clostridium
difficile infection (CDI).
– Up to 85% of patients with CDI have antibiotic
exposure in the 28 days before infection1
• 20% of patients admitted to the ICU with CDI
were receiving antibiotics without evidence of
infection with an accompanying 28% in-hospital
mortality2
1 Infect Control Hosp Epidemiol 2007; 28:926–931.
Slide: 32
2 BMC Infect Dis 2007; 7:42
Principal Diagnosis
All Diagnoses
Mortality
90
25
80
20
70
60
15
50
40
10
30
20
Annual Mortality Rate
per Million Population
# of CDI Cases per 100,000 Discharges
CDI: Incidence and Mortality
are Increasing in US
5
10
0
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
1. Elixhauser A, et al. Healthcare Cost and Utilization Project: Statistical Brief #50. April 2008. Available at:
http://www.hcup-us.ahrq.gov/reports/statbriefs/sb50.pdf. Accessed March 10, 2010.
2. Redelings MD, et al. Emerg Infect Dis. 2007;13:1417-1419.
Slide: 33
C. Difficile PCR Ribotype 027:
assessing the risks of further worldwide spread
Lancet Infect Dis 2010; 10:395
Slide: 34
MMWR March 6, 2012
Slide: 35
MMWR March 6, 2012
Slide: 36
Challenges
•
•
•
•
Literature often not clear in Infectious Diseases
Everyone thinks they know how to use antibiotics
Providers perceive autonomy is lost
Medico legal implications of responsibility for
patients
• Difficulty proving impact of program(Ønational
measures)
• Financial pressures dictating decisions
–
–
–
–
Pharmaceutical manufacturers
Hospitals
Insurance companies
Patients
Slide: 37
Slide: 38
Efforts to Control Resistance
Develop New
Drugs and
Vaccines
Reduce
Resistance
Reservoirs
Improved
Diagnostics
Antimicrobial
Stewardship
Infection
Prevention
Research &
Public Policy
Education
Slide: 39
Front-end Approach
Physician writes order for “restricted drug”
Order arrives in pharmacy; pharmacist informs physician that drug is
“restricted”/“not part of the pathway”/“nonformulary”
Prescribing physician and the “GATE KEEPER” converse
Approval or alternative antibiotic selected
Slide: 40
Formulary Restriction/Preauthorization
Front-end Approach
• Disadvantages
• Advantages
– Personnel needs
– Direct control over
antimicrobial use
– Antagonistic relationship
(loss of autonomy)
– Effective control of
antimicrobial use during
outbreaks
– Therapy may be
delayed
– Decreased inappropriate
use of antimicrobials
(and thus costs)
– De-escalation not
addressed
– ID physicians often
exempt
– Effectiveness in
decreasing resistance is
less clear
Slide: 41
Prospective Audit and Feedback
Back-end Approach
Physician writes order
Antibiotic is Dispensed
1.) Antibiotic
Change/Continued based
on Practice Guidelines
At a later date, antibiotics are
reviewed
2.) Prescribing
physician contacted and
recommendation made
(Targeted list of antibiotics,
C/S mismatches, ICU patients,
duration)
Slide: 42
Prospective Audit and Feedback
• Disadvantages
• Advantages
– Prescriber autonomy
maintained
– Educational
opportunity provided
– Patient information
can be reviewed
before interaction
– Inappropriate
antimicrobial use
decreased
– De-escalation
– Compliance voluntary
– Identification of
patients may require
computer support
– Prescribers may be
reluctant to change
therapy if the patient
is doing well
– Some inappropriate
antimicrobial use
permitted (with
retrospective audit)
Slide: 43
Choice of Empiric Agent
MAXIMIZE
COVERAGE
MINIMIZE
SELECTION
against most likely
pathogens
for resistance
Slide: 44
Mortality associated with initial
inappropriate therapy in patients with
serious infections
Initial appropriate therapy
Rello et al
Initial inappropriate therapy
Infection-related mortality
Kollef et al
Crude mortality
Ibrahim et al
Infection-related mortality
Luna et al
Crude mortality
0
20
40
60
Mortality (%)
80
100
Rello et al. Am J Respir Crit Care Med 1997;156:196–200; Kollef et al. Chest 1998;113:412–420
Ibrahim et al. Chest 2000;118:146–155; Luna et al. Chest 1997;111:676–685
Slide: 45
Impact of Previous Therapy on Outcome
of Gram-Negative Severe Sepsis
Crit Care Med 2011; 39:1859
Slide: 46
Crit Care Med 2011; 39:1859
Slide: 47
Considerations in Empiric Choice
Host
Type of infection
Community-Acquired vs LTC
vs Nosocomial
Underlying comorbidities
Microbe
Local antibiogram
ICU vs Non-ICU
Drug
Prior antibiotic therapy
Selection based on potential for resistance
Need for multiple agents
Slide: 48
Range of Pathogens
Baseline
Infected Patient
Site (s) of Infection
Community vs. Hospital
BroadSpectrum
Empirical
therapy
Laboratory tests
Collection of infected materials
Gram Stain
Culture Results
Identification of organism
Sensitivity
Abx
Antimicrobial Spectrum of Activity
1 hours
24-48 hours
Discontinue
Agents
Streamline
Therapy
48-72 hours
72-96 hours
Precision and time
Slide: 49
Design of a `day 3 bundle` to improve the
reassessment of inpatient empirical
prescriptions
J Antimicrob Chemotherapy 2008; 61:1384
1.
2.
3.
4.
Process Measures
Review diagnosis
Antibiotic plan
Adaptation to microbiology
IV to PO switch
Slide: 50
Appropriate Use of Microbiology
Lab
If possible appropriate cultures
should be obtained before starting
antimicrobial therapy; prior
antimicrobial therapy may interfere
with bacterial growth.
51
Slide: 51
Rational Antibiotic Use in an ICU
• Rational use protocol
Antibiotic use controlled
by 4 ICU physicians
(members of ARC)
Year
Written algorithms for use
Total NI*
Patients
Systematic reassessment
at days 3, 7, 10
Twice-weekly meetings
Results
– Antibiotic use  36%
1994
1995†
1996
1997
1998
99
97
105
116
109
Total Days of
Antibiotic Use
3,658
3,314
2,974
2,496
2,311
Total Antibiotic
Costs (Euro)
64,500
52,200
50,100 40,950
42,00
44%
53%
% Antibiotic
Resistance
– Resistant nosocomial
infections  52% (P<10-5)
39%
31%
† Start
* NI
of program
= Nosocomial infection
– MRSA  at yr 3;
Enterobacteriaciae R at yr 4
– No change in PsA resistance or
ESBL producers
Geissler A et al. Inten Care Med. 2003;29:49-54.
21%
Stewardship Decreases Resistance
Ben Taub General Hospital, 1994
ID faculty held approval pager 24/7
All broad-spectrum antibiotic required approval
(ticar/clav, imipenem, aztreonam, ceftazidime,
ciprofloxacin, ofloxacin, amikacin, IV fluconazole)
Increased susceptibility of Gram negatives
P. aeruginosa susceptibilities, 1/93-12/93 vs. 7/94-6/95
Ticar/clav Imipenem Aztreonam Ceftazidime
Cipro
83  89
83  95
70  88
76  92
83  87
White et al. Clin Infect Dis. 1997;25:230
Slide: 53
Favorable Impact of a Multidisciplinary
Antibiotic Management Program
Infect Control Hosp Epidemiol 2003; 24:699-706
Slide: 54
ICHE 2003; 24:699
Slide: 55
Targeted antibiotic consumption and
nosocomial C. difficile disease
Tertiary care hospital; Quebec, 2003-2006
Valiquette, CID 2007:45 S112
Slide: 56
Clinical Outcomes Better With
Antimicrobial Management Program
Slide: 57
Optimize Duration of Antibiotic Therapy
• Avoid automatic 10-14-day course of therapy
• New evidence for duration of therapy
– Uncomplicated urinary tract infection: 3-5 days1
– Community-acquired pneumonia: 3-7 days2
– Ventilator-associated pneumonia: 8 days3
– CR-BSI Coagulase-negative staphylococci: 5-7 days4
– Acute Hem Osteomyelitis in children-21 days5
– Meningococcal meningitis-7 days6
– Uncomplicated secondary peritonitis with source control: 4-7
days7
– Uncomplicated SSTI8 5 days
1.
2.
3.
4.
5.
Clin Infect Dis 1999; 29:745-758
Clin Infect Dis 2007; 44:S27-72
JAMA 2003; 290:2588-2598
Clin Infect Dis 2009; 49:1-45
Pediatr Infect Dis 2010; 29:1123-1128
6.
7.
8.
N Engl J Med 1997; 336:708-716
Clin Infect Dis 2010: 50:133-164
Arch Intern Med 2004; 164:1669-1674
Cumulative Antibiotic Exposures Over Time and
the Risk of Clostridium difficile Infection(CDI)
Clin Infect Dis 2011;53:42
• Observed dose dependent increases in the risk of
CDI associated with increasing cumulative dose,
number of antibiotics, and days of antibiotic
exposure(duration).
• Compared to patients who received only 1 antibiotic,
the adjusted hazard ratios (HRs) for those who
received 2, 3 or 4, or 5 or more antibiotics were 2.5,
3.3, and 9.6, respectively(overlapping).
• The receipt of fluoroquinolones was associated with
an increased risk of CDI, while metronidazole was
associated with reduced risk.
Slide: 59
Value of Stewardship Programs
• Effective programs can be financially self
supporting and improve patient care
• Comprehensive programs have consistently
demonstrated a decrease in antimicrobial use
(22-36%), with annual savings of $200,000900,000 in both larger academic hospitals and
smaller community hospitals
• 51/66 (77%) studies of interventions to improve
antibiotic use in hospitals had positive results
Davey P et al. Cochrane Database of Syst Rev 2005
CID 2007;44:159-77.
Slide: 60
Some Stakeholders Do Not Align
•
Pharmacy director, physician, and hospital goals should align on patient
safety and efficacy of treatments
•
However, they approach that mutual goal from different points of view
Pharmacy
Director
Pharmacy
Costs
Overall
Costs
Hospital
C-Suite
Patient
safety
and
efficacy
Better outcomes
and reduced
adverse events
Physicians
A Collaborative Approach to Treatment Algorithms and
Align Stakeholders’ Goals
Slide: 61
Making the Business Case
• Two absolutes
– Improving quality almost always improves cost
– Reducing cost will almost never improve quality
• Failure to comprehend compromises both
business and clinical outcomes
Slide: 62
Craft Your Message
Physicians
• Discuss how these
activities can optimize
patient care and safety
Administration
• Individual patient
examples helpful
• Emphasize patient safety
• Emphasize common
goals and teamwork
• Discuss cost reduction
and reduced length of
stay
• Regulatory compliance
• Improve patient outcomes
Slide: 63
Evaluating Stewardship Programs: Financial
Outcomes
Durable Reduction in Antimicrobial Expenditures Associated With the
Antimicrobial Stewardship Program at Maine Medical Center
162,000
Average Monthly Expenditure ($)
157,000
Projected Expenditure
With 4.5% Inflation,
Assuming Use Had
Remained Stable
152,000
147,000
142,000
140,356
137,000
134,743
132,000
127,000
121,437
122,000
113,530
117,000
112,000
2001
2002
2003
2004
Fiscal Year
Adapted with permission from Fraser GL et al. In: Owens RC Jr et al,
eds. Antibiotic Optimization: Concepts and Strategies in Clinical
Practice. Marcel Dekker; 2005:261-326.
Slide: 64
Total Antibiotic Expenditures: MHH
1995-2003
4
$18.00
3.5
Dollars (millions)
$16.00
ASP Active
3
$14.00
2.5
$12.00
2
1.5
$10.00
1995
1996
1997
1998
Total Antiinfective Dollars
1999
2000
2001
2002
2003
Total Antiinfective Dollars/Pt Day
Slide: 65
Mohr JF, Maddock J, Ericsson CE, et al. 44th ICAAC. Abstract #987. November,
2004.
Antimicrobial Stewardship
The Cost of Discontinuing a Program
• Large tertiary care academic medical center: ASP Active
2002-2009
• FY01-08: ABX Utilization cost savings > $14 million
• FY09: Discontinued ASP = CONSEQUENCES
– >$1 million ABX costs FY09 compared with FY08
– 33-147% increased cost of broad spectrum agents
– Overall DDD increased 4.8% AND broad spectrum DDD
increased 26.8%
• Conclusions:
– ASP is a long term proposition
– The lack of ASP has significant costs
Standiford H, et al. Abstract presented at: Fifth Decennial International Conference
on Healthcare-Associated Infections; 2010; Atlanta, GA. Abstract 666.
Slide: 66
Elements for developing a
comprehensive antimicrobial
stewardship program
Multidisciplinary team
–
Physician champion
–
Clinical pharmacist (with ID training)
Both compensated for their time
–
Additional
– clinical microbiology
– Information systems specialist
– Infection prevention professional/ hospital
epidemiologist
Medical Staff function
Clin Infect Dis 2007;44:159-177
Slide: 67
Strategies for Medical Staff Ownership
Your Antibiotic Use!
Politics are Important!
Slide: 68
Physician Champion
• Basic knowledge of antibiotics*
• Must show interest in taking a leadership role in
the local community
• Respected by his or her peers
• Good interpersonal skills
• Good team player
• Basic understanding of human factors and
culture transformation
*Does not need to be an infectious disease specialist. Slide: 69
What can the individual physician do?
• Obtain appropriate cultures before starting
antibiotics
• Review antibiotic use in past 48-72 hours − Do
they need to be continued?
• Stop antibiotic in patients with alternative
noninfectious diagnosis
• Optimize dosing and duration of antibiotic
therapy
• Avoid unnecessary use, especially viral URIs
(75%)*
*Must implement across the continuum
of care community wide
Slide: 70
Key Elements for Successful ASP
• Establish compelling need and goals for ASP
• Senior leadership support
• Effective local physician champion
• Adequate resources (pharmacy, infection
preventionist [IP], microbiology, information
technology [IT])
• Primary objectives: optimize clinical outcomes
and reduce adverse events, not reduce costs
• Good teamwork
• Agreed upon process and outcome measures
Slide: 71
Criteria for Selecting Cases for ASP
Review
– High-cost agents (eg, linezolid, daptomycin, echinocandins)
– Broad-spectrum agents (eg, carbapenems,
piperacillin/tazobactam)
– High risk of adverse effects (eg, aminoglycosides)
– Intravenous to oral
– Syndromic approach (e.g., asymptomatic bacteriuria)
– High-use agents (facility dependent)
– Double coverage of organisms (eg, anaerobes)
– 3 or more anti-infectives for >3 days
– Susceptibility mismatch
Slide: 72
Potential Measurements
• Antimicrobial use
– Defined daily dose(DDD)
– Days of therapy(DOT)
• Antimicrobial costs
• Timely antibiotic administration and duration
• Cultures obtained before antibiotic(s) administered
• Adverse drug events including C. difficile rates
• Antimicrobial resistance patterns
• Not treating asymptomatic bacteriuria
• Physician’s acceptance of ASP recommendations
Slide: 73
Future Opportunities
• New diagnostics
– Rapid diagnostics, e.g. PCR, PNA FISH
– Procalcitonin
– β-D-glucan
– galactomannin
• Study what influences prescriber
behavior
Slide: 74
Antimicrobial Stewardship Team
Multidisciplinary Team Approach to Optimizing Clinical Outcomes*
Hospital
Epidemiologist
Hospital and Nurse
Administration
Infectious
Diseases
Director,
Quality
Infection
Prevention
AMP Directors
• Cl. Pharmacist
• Physician Champion
Medical
Information
Systems
Microbiology
Laboratory
Clinical
Pharmacy
Specialists
Chairman,
P&T
Committee
Partners in
Optimizing
Antimicrobial Use such as
ED, hospitalists, intensivists
and surgeons
Decentralized
Pharmacy
Specialist
*based on local resources
Modified: Dellit et al. ClD 2007;44:159-177.
Slide: 75
•
•CDC’s Get Smart
programs
Reduce the spread of
antimicrobial
resistance
Slide: 76
Case #1
32 year male presents to the ER with a 4-5 day of
sore throat, low grade fever, and myalgias followed
by a 1 day history of increasing shortness of breath
and cough. Patient has no underlying diseases.
In the ER, patient was in respiratory distress,
hypoxic, and febrile. CXR extensive left-sided
consolidation. The patient required intubation and
was admitted to the ICU with the diagnosis of CAP.
The patient was started on a macrolide and a thirdgeneration cephalosporin.
Does This Meet Core Measures?
Slide: 77
Empiric ICU Therapy
IDSA/ATS (Clin Infect Dis. Suppl 2, March, 2007)
• Beta-lactam (cefotaxime, ceftriaxone or ampicillinsulbactam) plus intravenous azithromycin or a
fluoroquinolone
• For penicillin allergic patients: aztreonam plus
levofloxacin 750 mg or moxifloxacin
Slide: 78
Slide: 79
CASE 2
She was admitted to the ICU and started on ceftriaxone.
By day 2, her urine and blood grew E. coli sensitive to all
tested antibiotics except ampicillin and TMP/SMX. She
stabilized and was transferred to the floor.
What is your recommendation?
By day 4 she is ready for discharge-what would send her
home and for how long?
Slide: 80
International Clinical Practice Guidelines for the
Treatment of Acute Uncomplicated Cystitis and Pyelonephritis:
A 2010 Update by the IDSA and the European Society for Microbiology
and Infectious Diseases
Clin Infect Dis 2011; 52:e103-120

Lower Urinary Tract Infections
• Nitrofurantoin (100 mg bid for 5 days)
• Trimethoprim-sulfamethoxazole (TMP-SMX) (160/800 mg [1 DS
tablet] bid for 3 days) if resistance <20%
• Fosfomycin (3 grams in a single dose)
• Fluoroquinolones(FQ) are efficacious in a 3-day course but
because of increased resistance and the ecological adverse effects,
FQ should be reserved for more important uses other than cystitis.

Pyelonephritis: in the past decade, several RCTs have demonstrated
that 7 days of treatment with ciprofloxacin was as successful as 14 days
with TMP/SMX. In addition two other RCTs demonstrated that 5 days of
high-dose levofloxacin (750 mg per day) was as effective as 10 days of
ciprofloxacin.
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VII’s Key Principles
• Effective empiric antimicrobial selection based on
local epidemiology and site of infection
• Optimize the antimicrobial dose and route of
administration
• Administer antimicrobial agent(s) for the shortest
duration possible
• Adjust or stop antimicrobial therapy as early as
possible to best target the pathogen(s) and
remove pressure on AR (de-escalation)
• Stop antimicrobial agent(s) if no infection identified
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Take Home Points
Optimize dose, duration, and indications
for antimicrobial
therapy
Take Home Points
Assure appropriate cultures are obtained
before starting antibiotics
Consider an antibiotic “time-out” 48-72
hours after starting antimicrobial therapy
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New Steps
Support a broad implementation of
comprehensive antimicrobial
stewardship program across all
healthcare settings
MMWR March 6, 2012
Infect Control Hosp
Epidemiol 2012; 33:322-327
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