Antibiotic Stewardship

1. Antibiotic Stewardship C.G. Wlodaver, M.D.

2. Agenda Basics Specifics Physician/administration acceptance Physician response Measurement/reporting Cost implications Clinical vignettes and user friendly recommendations

3. Goal Condense clinical infectious disease ad absurdum Create mini-ID specialists, by recipe

4. What is Antibiotic Stewardship? A program that encourages judicious (vs injudicious) use of antibiotics Antibiotics are relatively so effective, non-toxic and inexpensive�so easy to use�that they are prone to abuse When the diagnosis is uncertain, antibiotics are often prescribed� Stewardship strives to fine tune antibiotic Rx in regards to Efficacy Toxicity Resistance-induction C. difficile-induction Cost Discontinuation

5. How does it relate to MRSA? Resistance-induction: MRSA and other MDRSs Darwinism Flemming Weinstein, L Native American wisdom Efficacy Some prescribers are still in the MSSA era

6. What are its limitations? It�s difficult/dangerous� to practice clinical infectious diseases with limited information Select cases very carefully Primum non nocere

7. Does it work? Data�����.

8. Recommended by Collaborative Drs. Perl, Bratzler, CW IDSA Practiced regularly

9. How does it work? A pharmacist, par excellence, or someone else� reviews patients on antibiotics and makes recommendations, prn; overseen by ID-trained physician, when available. Training� Physician contacted Telephone call� Notation in chart� Rx change written Pharmacist, verbal order Physician

10. Common InterventionsSome are so evident that they should be automatic Allergy Efficacy Empiric, vs MRSA Based on culture and sensitivity Dosing Cefazolin, q8h Ceftriaxone, q24h Levels Vancomycin� Aminoglycosides� Vaccines: influenza, pneumococcal, Hep B� Vaccines: influenza, pneumococcal, Hep B�

11. IV-to-po switch Criteria Afebrile WBC normalized Oral bio-availability, e.g. quinolones���. Intact GI tract Patient can often go home on po without further in-hospital observation��..

12. Redundancy E.g. Unasyn or Zosyn + Flagyl�

13. When to discontinue antibiotics altogether! Asymtomatic UTI Viral URI Exacerbation of COPD??? CHF misdiagnosed as pneumonia CoNS bacteremia, when contamination more likely than true infection Duration: criteria to d/c

14. Asymtomatic UTI Definition: pyuria/bacteriuria, without Sx, e.g. temperature and WBC WNL Common Data����

15. Viral URI How do you know it�s viral and not bacterial?

16. Exacerbation of COPD How do you know if it�s bacterial? ��.. Antibiotics not unreasonable. 5 days should suffice�

17. CHF misdiagnosed as pneumonia How do you distinguish one from the other? H&P, temperature, WBC, CXR, BNP, cultures (sputum and blood), pneumococcal urine antigen�� If antibiotics started and continued, 5 days should suffice

18. CoNS bacteremia How do you know if it�s real or contamination? Real Hospitalized, IV (phlebitis), fever, leukocytosis, multiple positive cultures Contamination Present on admission/no IV, no fever, no leukocytosis, few positive cultures/denominator

19. Duration: Criteria to d/c antibiotics Evidence-based Infectious endocarditis, osteomyelitis� (Don�t streamline!)

20. Uncomplicated UTI

21. Community-acquired pneumonia

22. Hospital-acquired pneumonia

23. Empiric discontinuation Once temperature and WBC have normalized

24. Additional recommendations SCIP C.difficile Pneumonia MRSA furunculosis Therapeutic substitutions

25. SCIP Antibiotic prophylaxis Which agent? Function of most common pathogen(s) Staph. aureus First generation cephalosporin If PCN-allergic� If high prevalence of MRSA� Anaerobes Cefoxitin When to start? 1 hour pre-op�����. When to stop? 1 dose only Within 24 hours

26. Clostridium difficile Use guidelines�..

27. Community-acquired pneumonia Use guidelines

28. MRSA furunculosis I&D may suffice, without antibiotics�

29. Therapeutic Substitutions Quinolones Cephalosporins

30. Physician/administration Acceptance Medical Executive Committee approval! Letter to physicians CW������.

31. Physician Response Bell-shaped curve�� Dr. S Dr. D Antibiotics viewed as �drugs of fear� Fear of omission Law suits� Fear of commission Law suits�

32. Measure Interventions # patients reviewed # physicians contacted (interventions recommended/ # patients reviewed: % # interventions accomplished/ # recommended: % Change to avoid allergic reaction Drug-drug interactions addressed Change to different antibiotic based on C&S Changed dose IV-to-po switch Antibiotics discontinued altogether

33. C. difficile rate MRSA rate

34. Bad outcomes, viz. patient suffered because of an antibiotic-deficiency

35. Reporting Measurements Hospital P&T Committee Infection Control Committee Medical Executive Committee MRSA Collaborative Federal Agencies JCAHO CMS

36. Cost Implications It�s the right thing to do, regardless of cost Antibiotic costs Pharmacy Administration Personnel Pharmacist ID or other MD oversight Self-perpetuating

37. BREAK

38. Vignettes

39. Asymtomatic UTI An 83 yo woman suffers from dementia and resides in a nursing home. The NH staff is concerned about her increased confusion and decides to send her to the local ER. VS: BP 140/90, P 90, RR 16, T 98.6. PE WNL except for mild confusion. No Foley. WBC 10.1. U/A 5-10 WBC/hpf. Dx: �UTI.� Rx Avelox. The following day her urine culture returns with E.coli, >100K. Avelox continued x 1 wk. She becomes more confused, develops C.diff antibiotic-associated colitis and expires.

40. Comments: On occasion, �sepsis� can present with normal or low temperature and WBC, and with confusion� However, she wasn�t septic based on the normal BP and P� An asymptomatic UTI does not need Rx Avelox is not indicated for UTI. Quinolones can cause CNS problems� All antibiotics can cause C.diff AAC The elderly and NH residents are predisposed

41. Antibiotic Stewardship:Asymptomatic UTI This patient appears to have an aymptomatic UTI which does not merit antibiotic Rx. Ref:

42. Viral URI A 72 yo diabetic man developed nasal congestion and cough productive of purulent sputum. He went to his local ER where the evaluation was noteworthy for a temperature of 99.6, normal respirations, mild tenderness to palpation and percussion over his sinuses, clear lungs, a WBC of 7.8 with 6% eosinophils and CXR showing �chronic scarring.� His blood sugar was 311. He was admitted. After a sputum was obtained for C&S, he was started on Rocephin and Zithromax for �possible community-acquired pneumonia.� The sputum had >25 epithelial cells and was rejected. The symptoms persisted for another 3 days. Levaquin was added. He developed C.diff antibiotic-associated colitis which has relapsed x5.

43. Comments: Great respect and extra attention must be given to immunocompromised hosts, e.g. diabetics. Yet even immunocompromised hosts can catch otherwise benign, self-limiting viral URIs for which antibiotics are not indicated. 99.6 isn�t fever. A reasonable clinical approach would be to d/c antibiotics and follow clinically, re-thinking their indication if the patient develops symptoms of a bacterial superinfection, e.g. fever.

44. Antibiotic Stewardship:Viral URI This patient appears to have a viral URI which does not merit antibiotic Rx Ref, e.g. CDC���