THE JUDICIOUS USE OF ANTIBIOTICS

1
THE JUDICIOUS USE OF ANTIBIOTICS

• New medicines, and new methods of cure, always
  work miracles for a while - William Heberden,
  1802

2
INCREASING RESISTANCE IN THE US
Thornsberry C. Infect Med. 199393
(suppl)15-24. Barry AL. AAC. 1994382419-25.
Washington JA. DMID. 199625183-190. Thornsberry
C. DMID 199729249-57 Doern GV. AAC.
1996401208-13. Thornsberry C. JAC
199944749-59.
3
INFECTIOUS DISEASES

• Syndrome
• Host
• Likely pathogens
• Antibiotic options

4
SYNDROME

• First distinguish infectious from non-infectious
• Allergy
• Malignancy
• Autoimmune
• Drugs

5
SYNDROMEANATOMY/ORGAN SYSTEM

• Site of infection influences
• Likely pathogens
• ABX activity - penetration, pH, foreign body
• Need for cidal vs static therapy

6
SYNDROMEANATOMY/ORGAN SYSTEM

• General - FUO, adenopathy
• Skin/soft tissue - cellulitis, wound infection,
  necrotizing fasciitis
• CNS - meningitis, encephalitis, brain abscess
• HEENT - sinusitis, otitis, pharyngitis, abscess
• Respiratory - bronchitis, pneumonia
• CV - endocarditis, phlebitis, bacteremia,
  catheter-related

7
SYNDROMEANATOMY/ORGAN SYSTEM

• Abdominal - peritonitis, abscess,
  cholecystitis/cholangitis, appendicitis
• Urinary tract - cystitis, pyelonephritis,
  perinephric abscess
• Genital tract - urethritis, cervicitis, PID,
  prostatitis
• Musculoskeletal - pyomyositis, osteomyelitis,
  septic arthritis

8
HOST

• Demographics - age, habits
• Exposure - sick contacts, residence/travel,
  hospitalization/institutionalization
• Co-morbidities - immunosuppression, organ
  dysfunction, surgery, foreign bodies
• Prior antibiotic use

9
LIKELY PATHOGENS

• Based on syndrome and host

10
ISOLATION/IDENTIFICATION

• Real vs contaminant
• Possible presence of others

11
SUSCEPTIBILITY

• Testing may not take into account
• Inoculum effect
• ABX concentrations at site of infection
• Subpopulations
• Repressed but inducible genes

12
ANTIBIOTIC USAGE PRINCIPLES

• Use narrow spectrum when possible
• Use older agent when feasible
• Use combination therapy only when indicated

13
ANTIBIOTIC OPTIONS

• Staphylococcus aureus
• MSSA - antistaphylococcal PCN, 1st or 3rd
  generation ceph, clindamycin, macrolide,
  carbapenem
• MRSA - vancomycin, linezolid, daptomycin

14
ANTIBIOTIC OPTIONS

• Streptococcus pyogenes
• PCN, 1st or 3rd generation ceph, clindamycin,
  macrolide
• Streptococcus pneumoniae
• PSSP - PCN, 1st or 3rd generation ceph,
  clindamycin, macrolide, doxy
• PRSP - newer quinolone, 3rd generation ceph,
  vancomycin

15
ANTIBIOTIC OPTIONS

• Enterococci
• PCN-susceptible - PCN/amp AGC
• PCN-resistant - vancomycin or daptomycin AGC
• VRE - linezolid, quinopristin/dalfopristin,
  teicoplanin, daptomycin
• AGC-resistant - high-dose continuous infusion
  PCN/amp

16
ANTIBIOTIC OPTIONS

• Gram-negative rods
• Older quinolones, TMP/SMX, 2nd and 3rd generation
  ceph, beta-lactam/beta-lactamase inhibitor
  combinations, carbapenem
• SPACEY - inducible extended spectrum
  beta-lactamase production

17
ANTIBIOTIC OPTIONS

• Anaerobes
• Metronidazole, clindamycin, beta-lactam/beta-lacta
  mase inhibitor combinations, carbapenem

18
ABECB

• Annual treatment costs in U.S. - inpatient 1.6
  billion, outpatient 40 million (Niederman et
  al, 1999)
• Almost 7 million prescriptions written annually
  for ABX related to bronchitis 11 of total ABX
  prescriptions (Gonzalez et al, 1997)

19
ABECBCommon Pathogens
Fredrick, AM, et al. Clin Ther 2001 23
1683-1706.
20
ABECBTREATMENT STRATEGIES

• Simple
• Increased dyspnea, sputum, sputum purulence
• 1st line Amox, Doxy, TMP-SMX
• Alternatives Amox-Clav, FQ, macrolide, 2nd
  generation Ceph
• Complicated
• Above Sx plus 1 of frequent exacerbations,
  co-morbidity, age 65, chronic bronchitis 10 yr
• 1st line FQ
• Alternative Amox-Clav, 2nd-3rd generation Ceph,
  newer macrolide consider hospitalization and iv
  Rx
• Chronic
• Above plus continuous year-round production of
  purulent sputum
• 1st line Cipro Amox-Clav
• Alternative consider hospitalization and iv Rx

21
OTITIS MEDIACOMMON PATHOGENS
22
ACUTE OTITIS MEDIADIAGNOSIS

• Acute onset
• Signs of middle ear effusion
• Signs and symptoms of middle-ear inflammation

AAP. Pediatrics 20041131451-54.
23
ACUTE OTITIS MEDIAMANAGEMENT

• Pain management
• Observation if
• 2 y old
• Non-severe illness
• Ready means of communication
• Able to re-evaluate within 48-72 h if not
  improved
• Ability to obtain medications in timely manner
• Antibacterial therapy
• Amoxicillin 80-90 mg/kg/d
• Alternatives include cephalosporins or newer
  macrolides
• Amoxicillin-clavulanate 90 mg/kg/d for treatment
  failures

AAP. Pediatrics 20041131451-54.
24
SINUSITISCOMMON PATHOGENS
Pfaller et al. AJM 2001 111 4S.
25
SINUSITISDIAGNOSIS

• Most important criterion is persistence of nasal
  purulence for 14 days, associated with daytime
  cough
• Sinus pressure and tenderness are nonspecific
  markers

26
SINUSITISTREATMENT

• Systematic review of 32 trials involving 7000
  patients acute maxillary sinusitis
• Penicillin and amoxicillin better than placebo
• No significant difference in cure rate between
  classes of antibiotics for the following
  comparisons
• Newer non-penicillin antibiotics versus
  penicillins
• Newer non-penicillin antibiotics versus
  amoxicillin-clavulanate

Tang. Ann EM 2003.
27
PNEUMONIACOMMON PATHOGENS

• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
• Legionella pneumophila
• Mycoplasma pneumoniae
• Chlamydia pneumoniae

28
PNEUMONIALIKELY PATHOGENS

• Alcoholism - S. pneumoniae, anaerobes
• COPD and/or smoking - S. pneumoniae, H.
  influenzae, M. catarrhalis, Legionella species
• Poor dental hygiene - anaerobes
• Elderly - S. pneumoniae, Legionella spp.
• HIV infection (early stage) - S. pneumoniae, H.
  influenzae, M. tuberculosis, S. aureus, P.
  aeruginosa
• HIV infection (late stage) - above plus P.
  jerovici (carinii), Cryptococcus, Histoplasma
  spp.
• Corticosteroid therapy - S. pneumoniae, L.
  pneumophila ,P. aeruginosa

29
PNEUMONIALIKELY PATHOGENS

• Suspected large-volume aspiration - anaerobes
  (chemical pneumonitis, obstruction)
• Structural disease of lung (bronchiectasis,
  cystic fibrosis, etc.) - P. aeruginosa,
  Burkholderia cepacia, S. aureus
• Injection drug use - S. aureus, anaerobes, M.
  tuberculosis, S. pneumoniae
• Airway obstruction - anaerobes, S. pneumoniae H.
  influenzae, S. aureus
• Recent hospitalization - S. aureus, P.
  aeruginosa, enteric Gram-negative bacilli

30
PNEUMONIALIKELY PATHOGENS

• Nursing home residency - S. pneumoniae,
  gram-negative bacilli, H. influenzae, S. aureus,
  anaerobes, C. pneumoniae
• Influenza active in community - influenza, S.
  pneumoniae, S. aureus, S. pyogenes, H. influenzae
• Epidemic legionnaires' disease - Legionella spp.
• Exposure to bats or soil enriched with bird
  droppings - H. capsulatum, C. neoformans
• Exposure to birds - Chlamydia psittaci
• Exposure to rabbits - Francisella tularensis
• Travel to southwestern US - Coccidioides spp.
• Exposure to farm animals or parturient cats -
  Coxiella burnetii (Q fever)

31
PNEUMONIAMANAGEMENT
32
UTIDIAGNOSIS

• Leukocyte esterase test 80-90 sensitive,
  nitrite test 50 sensitive compared with
  quantitative culture with greater than or equal
  to 105 cfu
• False-negative nitrite test results may occur
  with
• low levels of bacteriuria
• patients taking diuretics
• patients on a low-nitrate diet
• infections with bacteria that do not reduce
  nitrates
• Combining both tests improves sensitivity
  85-90
• Specificity 95 for both

33
UTICOMMON PATHOGENS
34
UTITREATMENT

• Acute uncomplicated cystitis
• 3-day treatment with TMP/SMX, FQ
• Recurrent cystitis
• Treat relapse with 7-day course of FQ, otherwise
  treat as acute uncomplicated
• Acute pyelonephritis
• 2-week course

35
ANTIBIOTIC OVERUSE

• Of 6.5 million ABX prescriptions written in 1992
  for children younger than 18 (Nyquist AC et al.
  JAMA 1998279875-877.)
• 12 for colds
• 9 for URI or nasopharyngitis
• 9 for bronchitis
• In Kentucky study (Mainous AG et al. J Fam Pract
  199642357-61)
• 60 of patients with common cold received ABXs
• Estimated 37.5 million spent for ABX
  prescriptions in U.S. annually for common cold

36
(No Transcript)
37
(No Transcript)
38
PATIENT

• 43 year old male presents with cough x 3 days

39
PATIENT
40
PATIENT
41
ANTIBIOTIC FAILURE

• Persistent or new fever or other signs of
  infection
• Persistent laboratory abnormalities
• Development of sepsis or other organ involvement
• Persistent isolation of organism from culture

42
ANTIBIOTIC FAILURE

• Antibiotic-related
• Compliance
• Wrong agent
• Wrong dose
• Drug interactions
• Poor tissue penetration

43
ANTIBIOTIC FAILURE

• Host-related
• Immunologic defect
• Anatomic defect
• Foreign body

44
ANTIBIOTIC FAILURE

• Organism-related
• Emergence of resistance
• Pre-existing co-infection
• Superinfection

45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
CONTROLLING OUTPATIENT RESISTANCE

• Explain that unnecessary antibiotics may be
  harmful
• Share the facts
• Build cooperation and trust
• Encourage active management of the illness
• Be confident with recommendations to use
  alternative treatments
• Start the educational process in the waiting room
  (www.cdc.gov/ncidod/dbmd/antibioticresistance)
• Involve office personnel in the process

51
VIRAL PRESCRIPTION PAD
http//www.cdc.gov/drugresistance/technical/preven
tion_tools.htm
52
CONTROLLING INPATIENT RESISTANCE

• Alcohol hand rubs
• Isolation procedures
• Prescription restrictions
• Computer-assisted prescribing
• Cycling antibiotics?

53
ANTIBIOTIC RESISTANCE