Antibiotic Stewardship C.G. Wlodaver, M.D. Agenda Basics

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Antibiotic Stewardship

• C.G. Wlodaver, M.D.

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Agenda

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

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Goal

• Condense clinical infectious disease ad absurdum
• Create mini-ID specialists, by recipe

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What is Antibiotic Stewardship?

• A program that encourages judicious (vs
  injudicious) use of antibiotics
• Antibiotics are relatively so effective,
  non-toxic and inexpensiveso easy to usethat
  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

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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

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What are its limitations?

• Its difficult/dangerous to practice clinical
  infectious diseases with limited information
• Select cases very carefully
• Primum non nocere

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Does it work?

• Data.

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Recommended by

• Collaborative
• Drs. Perl, Bratzler, CW
• IDSA
• Practiced regularly

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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

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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

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• 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..

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• Redundancy
• E.g. Unasyn or Zosyn Flagyl

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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

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Asymtomatic UTI

• Definition pyuria/bacteriuria, without Sx, e.g.
  temperature and WBC WNL
• Common
• Data

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Viral URI

• How do you know its viral and not bacterial?

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Exacerbation of COPD

• How do you know if its bacterial?
• ..
• Antibiotics not unreasonable.
• 5 days should suffice

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CHF misdiagnosed as pneumonia

• How do you distinguish one from the other?
• HP, temperature, WBC, CXR, BNP, cultures (sputum
  and blood), pneumococcal urine antigen
• If antibiotics started and continued, 5 days
  should suffice

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CoNS bacteremia

• How do you know if its 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

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Duration Criteria to d/c antibiotics

• Evidence-based
• Infectious endocarditis, osteomyelitis
• (Dont streamline!)

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• Uncomplicated UTI

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• Community-acquired pneumonia

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• Hospital-acquired pneumonia

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• Empiric discontinuation
• Once temperature and WBC have normalized

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Additional recommendations

• SCIP
• C.difficile
• Pneumonia
• MRSA furunculosis
• Therapeutic substitutions

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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

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Clostridium difficile

• Use guidelines..

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Community-acquired pneumonia

• Use guidelines

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MRSA furunculosis

• ID may suffice, without antibiotics

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Therapeutic Substitutions

• Quinolones
• Cephalosporins

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Physician/administration Acceptance

• Medical Executive Committee approval!
• Letter to physicians
• CW.

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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

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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 CS
• Changed dose
• IV-to-po switch
• Antibiotics discontinued altogether

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• C. difficile rate
• MRSA rate

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

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Reporting Measurements

• Hospital
• PT Committee
• Infection Control Committee
• Medical Executive Committee
• MRSA Collaborative
• Federal Agencies
• JCAHO
• CMS

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Cost Implications

• Its the right thing to do, regardless of cost
• Antibiotic costs
• Pharmacy
• Administration
• Personnel
• Pharmacist
• ID or other MD oversight
• Self-perpetuating

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BREAK
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Vignettes
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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, gt100K. Avelox
  continued x 1 wk. She becomes more confused,
  develops C.diff antibiotic-associated colitis and
  expires.

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• Comments
• On occasion, sepsis can present with normal or
  low temperature and WBC, and with confusion
  However, she wasnt 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

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Antibiotic StewardshipAsymptomatic UTI

• This patient appears to have an aymptomatic UTI
  which does not merit antibiotic Rx.
• Ref

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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
  CS, he was started on Rocephin and Zithromax for
  possible community-acquired pneumonia. The
  sputum had gt25 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.

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• 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 isnt 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.

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Antibiotic StewardshipViral URI

• This patient appears to have a viral URI which
  does not merit antibiotic Rx
• Ref, e.g. CDC