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It’s Time to Be Antibiotics Aware:
Antimicrobial Stewardship in the
ClinicMegan Bernabe, PharmD, MPH, BCIDP
Antimicrobial Stewardship/Infectious Diseases Pharmacist
Mercy Medical Center
Disclosure
Megan Bernabe does not have any relevant financial interest with any entity producing, marketing, re‐selling, or distributing health care goods or services consumed by or used on patients.
Objectives
• Learn what antimicrobial stewardship (AMS) is and why it is needed• Discuss outpatient AMS targets, both nationally and specifically within Mercy Medical Center/MercyCare
• Identify how you can be an every day antimicrobial steward
Why is AMS needed?
http://www.michiganpharmacists.org/Portals/0/104%20‐%20VandeHorst,%20Tiberg,%20Torney.pdf?ver=2017‐02‐16‐111802‐297
HERE
Antibiotics are different from other drugs
Critically important and life‐saving drugs, but their use is not benign
Efficacy decreases over time
(even when used correctly)
They are a shared resource
Use in one person can harm a different
person
Srinivasan A. Cleveland Clin J Med. 2017.Freedberg DE, Salmasian H, Cohen B, et al. JAMA Intern Med. 2016.
Antibiotic use is high• Compare to Scandinavian countries where antibiotic use is 20% less than the lowest prescribing US state
Outpatient: 5 out of every 6 people get an antibiotic course of annually
• Nonteaching hospitals tend to use more antibiotics than teaching hospitals
Inpatient: 55% of patients receive at least 1 dose of an antibiotic
• Main reasons: excessive duration and treatment of colonizing organisms/noninfectious syndromes
Studies consistently show 20% to 40% of antibiotics are unnecessary or inappropriate
Srinivasan A. Cleveland Clin J Med. 2017.Baggs J, Fridkin SK, Pollack LA, et al. JAMA Int Med. 2016.Hecker MT, Aron DC, Patel NP, et al. Arch Intern Med. 2003.
Antibiotic use is high
↑ antibiotic use = ↑antibiotic resistance
Dellit TH, et al. Clin Infect Dis. 2007.Teshome BF, et al. Pharmacother. 2019.
Antibiotic use is causally
associated with the emergence of antibiotic resistance
Changes in antibiotic use = changes in
resistance prevalence
Infections caused by resistant strains
more likely in patients who have received prior antibiotics
Hospital areas with ↑ rates of an bio c resistance have ↑rates of antibiotic
use
↑ duration of antibiotics = ↑ risk of colonization or infection with
resistant organisms
Antibiotic resistance: how it happens
https://www.cdc.gov/antibiotic‐use/week/pdfs/How_Antibiotic_Resistance_Happens_508.pdf
https://www.cdc.gov/drugresistance/pdf/2‐2013‐508.pdf
Antibiotic resistance: potential impact
https://amr‐review.org
It is predicted that there will be more deaths globally due to antimicrobial resistance (AMR) in 2050 than cancer if we do not change how we are using antibiotics
Lack of new antibiotics
• 2010: Infectious Diseases Society of America (IDSA) launched 10 x ’20 Initiative• Goal of 10 new antibiotics by 2020
• 2012: Congress passed GAIN Act (Generating Antibiotic Incentives Now) for Qualified Infectious Disease Products• Expedited review/approval• Extra 5 years of market exclusivity
• Since 2013, 12 new antibiotics have been approved• No new classes, only modifications of existing classes
• Major pharmaceutical companies are still exiting antibacterial and antiviral research• Not profitable enough
Antibiotics have negative consequences: adverse effects
Tamma PD, et al. JAMA Intern Med. 2017.Edmond M. http://haicontroversies.blogspot.com/2017/06/antibiotics‐theres‐no‐free‐lunch.html#!/2017/06/antibiotics‐theres‐no‐free‐lunch.html
1 in 5 inpatients treated with antibiotics is harmedRetrospective cohort study of 5,579 adult internal medicine inpatients at Johns Hopkins Hospital• 27% received
antibiotics• 20% developed at
least 1 adverse antibiotic event
• 19% of antibiotic regimens not indicated
324 adverse eventsGI 41%
MDRO infection 26%
Renal 14%
Heme 9%
Hepatobiliary 4%
Neuro 4%
97% of adverse events had additional clinical ramifications:• Additional laboratory tests, electrocardiograms, or imaging studies (61%)• Prolonged hospital stay (24%)• Additional clinical or emergency department visits (9%)• Additional hospitalizations (3%)
Antibiotics have negative consequences: ED visits for adverse effects
Adults (≥ 20 years): 2011‐2015• ~145,000 visits per year
• About 14% of all ED visits for adverse effects from a medication
• Young adults accounted for 33% of the visits (20‐34 years)
• Most common adverse effect was allergic reaction• Followed by adverse effects due to supratherapeutic or excessive dosing
• Similar to findings in 2008
Children (≤ 19 years): 2011‐2015• ~70,000 visits per year
• About 45% of all ED visits for adverse effects from a medication
• Children ≤ 2 years accounted for 41% of the visits
• Most common adverse effect was allergic reaction• Followed by general adverse effects specific to the antibiotic
Gellar AI, et al. J Gen Intern Med. 2018.Shehab N, et al. Clin Infect Dis. 2008.
Lovegrove MC, et all. J Pediatric Infect Dis Soc. 2018.
Antibiotics have negative consequences: disturbance of the gut microbiome
https://www.cdc.gov/drugresistance/pdf/ARSI‐Microbiome‐Infographic‐2017.pdf
Antibiotics have negative consequences: increased risk of C. difficile• Risk of C. difficile infection after antibiotic use
• 7 to 10 times higher than baseline for 1 month after antibiotic use• 3 times higher than baseline in the following 2 months
• Most recent CDC data show that nearly 500,000 infections occurred in 2011• 29,000 deaths within 30 days of initial diagnosis• > 80% of deaths in patients ≥ 65 years
• High rate of recurrence• 30% of patients within 30 days
Hensgens MP, Goorhuis A, Dekkers OM, et al. J Antimicrob Chemother. 2012.Srinivasan A. Cleveland Clin J Med. 2017.Lessa FC, Mu Y, Bamberg WM, et al. NEJM. 2015.
What can we do?
Use the antibiotics we do have more wisely…
Antibiotic use: most impactful modifiable AMR driver
Human and animal antibiotic misuse and overuse
Holmes AH, Moore LSP, Sundsfjord A, et al. Lancet. 2016.
Response and action: national and global• 2004: IDSA releases “Bad Bugs, No Drugs” policy report• 2007: IDSA/SHEA guidelines on developing an institutional AMS program• 2010: IDSA 10 x ‘20 initiative• 2012: GAIN Act• 2013: CDC’s AMR Threat Report (Urgent, Serious, and Concerning threats)
• Urgent: C. diff, carbapenem resistant Enterobacteriaceae, drug resistant Neisseria gonorrhoeae• 2014: President’s Council of Advisors on Science and Technology (PCAST) AMR report• 2015: National Action Plan for Combating Antibiotic Resistant Bacteria (CARB)• 2015: World Health Organization Global Action Plan on AMR• 2017: Joint Commission antimicrobial stewardship program (ASP) standards for acute care and critical access hospitals and nursing care centers
• 2020: Joint Commission ASP standards for ambulatory care settings• What is most likely coming: CMS Conditions of Participation for ASP (already in place for long‐term care facilities)
What is AMS?
• Coordinated interventions and processes designed to optimize antibiotic use• Increase appropriate use and decrease inappropriate use• Includes interventions to guide providers
• When antibiotics are needed• Which antibiotic(s) to use• Optimal dose, route, and duration of therapy
• Who is involved? Everyone!• Anyone who prescribes, dispenses, administers, monitors, or receives antibiotics• Teamwork makes the dream work
• An ASP typically involves a core team and committee
MMC’s Antimicrobial Stewardship Program Goals• Optimize antimicrobial use across MMC in order to
• Slow and prevent the emergence of resistance• Improve patient outcomes through evidence‐based used of antimicrobials• Reduce the incidence of antimicrobial‐related adverse effects and unintended consequences (such as C. difficile infection)
• Promote culture change around the use of antimicrobials• Antimicrobial stewardship is everyone’s responsibility• Antimicrobials are not harmless• Antimicrobials are a shared resource
Core Elements of Outpatient AMSCommitment: demonstrate
dedication to and accountability for
optimizing antibiotic prescribing and patient
safety
Action for policy and practice: implement at least
one policy or practice, assess whether it is
working, and modify as needed
Tracking and reporting:monitor antibiotic
prescribing practices and offer regular feedback to
clinicians, or have clinicians assess their own prescribing
Education and expertise:provide educational
resources to clinicians and patients on antibiotic prescribing, and ensure
access to needed expertise
CDC. The Core Elements of Outpatient Antibiotic Stewardship. 2016.
Commitment• Write and display public commitments in support of AMS
CDC. The Core Elements of Outpatient Antibiotic Stewardship. 2016.Meeker D, et al. JAMA Int Med. 2014.
Intervention: ‐Poster with a public commitment to use antibiotic judiciously with clinician picture and signature‐Displayed in exam rooms at point of clinician‐patient encounter
Outcome:Antibiotic prescribing rates for acute respiratory infections (ARI) that are typically viral
Results:‐954 adults with ARI‐Poster group had a 19.7% ↓ in antibiotic prescribing (p=0.02)
Conclusions: public commitments in a poster are a low‐cost intervention that can reduce unnecessary prescribing
Randomized controlled trial15 primary care providers5 primary care clinics in the US
CDC has a draft commitment poster that clinicians can sign and hang
Actions
• Implement policies and interventions to promote appropriate antibiotic prescribing practices• Use evidence‐based diagnostic criteria and treatment recommendations• Use delayed prescribing practices or watchful waiting, when appropriate
• Where to start and how to incorporate these? data evaluation• CDC 2018 Update: Antibiotic Use in the United States, Progress and Opportunities
• Local/internal data
CDC. The Core Elements of Outpatient Antibiotic Stewardship. 2016.
Data: acute respiratory infections
• Nationally, antibiotics are often being prescribed for respiratory illnesses where not indicated
Included diagnoses: viral URIs, bronchitis and/or bronchiolitis, asthma and/or allergy, influenza, nonsuppurative otitis media, and viral pneumonia
Palms DL, et al. JAMA Int Med. 2018.CDC 2018 Update: Antibiotic Use in the United States, Progress and Opportunities
Data: acute respiratory infections
• Nationally, sinusitis is the most common indication for an antibiotic prescription in the outpatient setting
• Most antibiotic durations for sinusitis were longer than recommended• 5‐7 days recommended for uncomplicated sinusitis• 70% of antibiotic courses were 10 or more days
• Azithromycin accounted for > 20% of antibiotics prescribed for sinusitis• Azithromycin is not a first line recommended therapy due to resistance
Fleming‐Dutra KE, et al. JAMA. 2016.King LM, et al. JAMA Int Med. 2018.CDC 2018 Update: Antibiotic Use in the United States, Progress and Opportunities.
Data: acute respiratory infections, bronchitis
Guideline recommendations for acute uncomplicated bronchitis
• New National Quality Forum (NQF) measure for Urgent Care: appropriate treatment for children with URI• Percentage of children (3 months‐18 years) with a diagnosis of URI who were NOT prescribed an antibiotic
• On or within 3 days after an outpatient or ED encounter• August 2019: only 30% were NOT prescribed an antibiotic
Causes Antibiotic prescribing strategy
• > 90%: viruses• Nonviral: Mycoplasma pneumoniae, Chlamydophila
pneumoniae, Bordetella pertussis
• In the absence of pneumonia, antibiotics are not indicated (exception: pertussis)
• Routine testing for nonviral causes is not recommended
Harris AM, et al. Ann Intern Med. 2016.
Data: acute respiratory infections, sinusitis
Guideline recommendations for acute rhinosinusitis
• NQF measure for Urgent Care: antibiotic prescribed for acute sinusitis• Percentage of adults with a diagnosis of acute sinusitis who were prescribed an antibiotic within 7 days after onset of symptoms
• July 2019: 27% received an antibiotic within 7 days of symptom onset
Harris AM, et al. Ann Intern Med. 2016.
Causes Antibiotic prescribing strategy
Recommended antibiotic (no penicillin allergy)
Recommended antibiotic (penicillin allergy)
• Most cases caused by viruses, allergies, or irritants
• < 2%: S. pneumoniae, H. influenzae, S. pyogenes, M. catarrhalis, and anaerobic bacteria
Antibiotics may be prescribed if symptoms ≥ 7‐10 days, severe symptoms last for ≥ 3 days, or onset of worsening symptoms ≥ 3 days after initial improvement
Amoxicillin/clavulanate 875/125 mg PO BID x 5‐7 days (OR 2000 mg PO BID x 5‐7 days for severe infection)
• Doxycycline 100 mg PO BID x 5‐7 days
• Still in guidelines: levofloxacin 500 mg PO daily OR moxifloxacin 400 mg PO daily x 5‐7 days
Actions: acute respiratory infections
Mangione‐Smith R, et al. Ann Fam Med. 2015.
• Cross‐sectional study assessing communication techniques associated with prescribing antibiotics for ARIs and parent visit satisfaction
• 28 pediatric providers and 1284 parents in the US
• Combined explanations of 1) why antibiotics are not needed + 2) recommendations for treating symptoms lower risk of antibiotic prescribing and higher parental visit satisfaction
Dennis E, et al.Wellness Bags initiative for bronchitis
Mayo Regional Hospital, Maine
• Wellness Bags: tissue, cough drops, hand sanitizer and patient education materials about why antibiotics are not recommended for bronchitis
• Clinicians at the ED and five primary care practices were given a set number of bags + posters to hang in offices and waiting rooms
• 3 month comparison between 2016 and 2017• Primary care clinics: 84% received antibiotics vs 8% post‐intervention
• ED: 67% received antibiotics vs 54% post‐intervention
http://www.choosingwisely.org/resources/updates‐from‐the‐field/bagging‐antibiotics‐in‐maine/
Actions: acute respiratory infections (coming)
• Resource being developed for Mercy providers: symptomatic treatment handout
• Working on pediatric version as well
• Will make available in multiple ways to fit different workflows
Data: fluoroquinolones (FQs)
• Updated FDA labeling in 2016: do not use FQs for acute bacterial sinusitis, acute exacerbation of chronic bronchitis, or uncomplicated UTI• Potentially irreversible tendinitis/tendon rupture and peripheral neuropathy
• CNS effects• Glucose regulation disturbance• Rupture of aortic aneurysm
• Nationally, ~25% of FQs are prescribed unnecessarily• 2014: ~5% for colds/bronchitis and ~20% for UTIs and sinusitis
• 2011‐2014: FQs account for 22% of all antibiotics prescribed for adults ≥ 65 years
• Mercy baseline FQ data‐indications (2017)• 34% UTI• 19% bronchitis/URI• 13% sinusitis• 13% skin/soft tissue infection
• Determined overall expected FQ prescribing rate of ~9% (note overall goal not zero!)
CDC 2018 Update: Antibiotic Use in the United States, Progress and Opportunities.Kabbani S, et al. Clin Infect Dis. 2018.CDC. Outpatient antibiotic prescriptions– United States, 2014.Kabbani S, et al. J Am Geriatr Soc. 2018.
Actions: fluoroquinolones (FQs)
• Success at MMC + FDA warnings led to ASP goal to decrease outpatient FQ prescribing
Baseline data and
determination of expected
FQ prescribing rate
Education to providers and individual baseline FQ prescribing
rates
Tracking of rates every 6 months and dissemination to providers
1 on 1 discussions
with providers one year into
project
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HO‐CDI per 100
00 patient days
Days of the
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per 100
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ys present
Hospital‐onset C. diff infection (HO‐CDI) and use of levofloxacin at MMC
Levofloxacin HO‐CDI/10000 pt days
Actions: fluoroquinolones (FQs)
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2017 (baseline) 2018 H1/2019
FQ prescribing among MercyCareproviders
(Internal Medicine, Family Medicine, Pediatrics, Urgent Care)
Number of providers with FQ prescribing rate > 9%
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H1/2017 H1/2018 H1/2019
Community‐associated C. diff infections among Mercy patients
Number of community‐associated C. diff infections
Data: penicillin allergy
• Most commonly reported drug allergy but highly overreported• Penicillin allergy label leads to other risks
• ↑ risk of MRSA and C. diff infection than patients without penicillin allergy• ↑ risk of surgical site infec on
• De‐labeling of penicillin allergy is an important AMS practiceCDC. Is it really penicillin allergy? 2016. https://www.cdc.gov/antibiotic‐use/community/pdfs/penicillin‐factsheet.pdf.Rubin R. JAMA. 2018.
Action: penicillin allergy• Evaluate clinical history of penicillin allergy to determine if testing is indicated• Two penicillin allergy testing options: skin test or oral test dose procedure
• Only rule out type I IgE‐mediated allergy• Current outpatient testing option at Mercy: skin test
Type Descriptor Clinical features Typical onset
I Anaphylactic (IgE‐mediated)
Anaphylaxis, urticaria, angioedema, wheezing/ dyspnea, bronchospasm, hypotension, laryngeal edema
Minutes to hours
II Cytotoxic Hemolytic anemia, thrombocytopenia, neutropenia Days to weeks
III Immune complex Serum sickness, drug fever Days to weeks
IV Cell‐mediated Maculopapular rash, severe exfoliative dermatoses (e.g. Stevens‐Johnson syndrome, toxic epidermal necrolysis), drug rash with eosinophilia and systemic symptoms, interstitial nephritis, drug‐induced hepatitis
Days to weeks
Shenoy ES, et al. JAMA. 2019.
Based on allergy history/chart review, classify past penicillin reaction and follow
recommended process
Not allergic: reaction was an adverse effect (N/V/D, yeast vaginitis,
etc.) OR family members with allergy
Penicillin skin testing not indicated. Beta‐lactam can be used.
Correct/clarify the allergy documentation.
Serious delayed reaction (type II‐IV)
Penicillin skin testing contraindicated. Beta‐lactam should not be
used.
Type I (IgE‐mediated) NOT within past 5 years ORunknown reaction/ insufficient detail but without mucosal involvement, skin
desquamation, or organ involvement
Penicillin skin testing indicated
Type I (IgE‐mediated) reaction within past 5
years
Penicillin skin testing contraindicated per
MMC policy. Cephalosporins should not be used unless known tolerance.
Mild reaction without features of an IgE‐mediated reaction
(rash with or without itching) OR known
tolerance of cephalosporins
Cephalosporins can be used without further testing OR penicillin skin testing can be done for allergy de‐
labeling
Shenoy ES, et al. JAMA. 2019.Blumenthal KG, et al. Ann Allergy Asthma Immunol. 2015.
Action: penicillin allergy
• Penicillin skin testing is completed by trained staff only (Healing Center nurses)
• If negative penicillin skin test• Can use penicillin or related antibiotics, including cephalosporins
• If patient has reported cephalosporin allergy, recommend avoiding cephalosporins (but can still use penicillin/amoxicillin)• Can refer to allergist for cephalosporin allergy testing if available
Shenoy ES, et al. JAMA. 2019.
• Outpatient ordering: Ambulatory Referral to Healing Center (REF110)
• Inpatient ordering: Inpatient consult to Pharmacy for penicillin allergy testing• Also have a process set up to proactively identify patients who would benefit from penicillin allergy testing (pharmacist‐driven)
Data: asymptomatic bacteriuria (ASB)• Asymptomatic bacteriuria is common
• Isolation of significant colony counts of bacteria in the urine without symptoms of a UTI
• Pyuria in the setting of ASB is common• Not an indication for antibiotics
• Be cautious in assuming that mental status changes means UTI• Can lead to the real cause being missed• Altered mental status and ASB are both independently common in elderly
• Randomized, controlled trials show no benefit to treating ASB in most patients• Treatment of ASB indicated for pregnant women and patients undergoing invasive urologic procedures
• Treatment when not indicated has been found to be associated with adverse events, resistance, and increased risk of subsequent UTIs
Nicolle LE, Bradley S, Colgan R, et al. IDSA guidelines for ASB. Clin Infect Dis. 2005 and 2019.Cai T, Mazzoli S, Mondaini N, et al. Clin Infect Dis. 2012.Cai T, Nesi G, Maazoli S, et al. Clin Infect Dis. 2015. https://www.ammi.ca/Content/AntibioticAwareness/AC‐Brief%20poster_Eng_8.5x11_colour.pdf
Data: ASB
Population Prevalence of ASB
Prevalence of pyuria in persons with ASB
Healthy premenopausal women < 5% 32%
Women 65‐90 years old 6‐16% ‐‐
Women > 90 years old 22‐43% ‐‐
Diabetic women 9‐27% 70%
People receiving hemodialysis 28% 90%
Female long‐term care residents 25‐50% 90%
Male long‐term care residents 15‐35% 90%
Presence of indwelling urinary catheter 100% 50‐100%
Nicolle LE, Bradley S, Colgan R, et al. IDSA guidelines for ASB. Clin Infect Dis. 2005 and 2019.
Data: ASB in the nursing home
• Suspected UTIs account for 30‐60% of antibiotic prescriptions in nursing homes• Up to 40‐50% of these treating ASB rather than UTI• Risk of C. diff was found to be 8.5 times higher in the following 3 months for residents treated for ASB
• AHRQ developed the UTI SBAR to guide communication between nursing home staff and prescribing clinicians about the potential need for antibiotics• A study in 12 nursing homes in Texas found that using the UTI SBAR reduced antibiotic treatment of ASB by about 33%
Rotjanapan P, et al. Arch Intern Med. 2011.CDC Core Elements of Antibiotic Stewardship in Nursing Homes. 2015.AHRQ Suspected UTI SBAR Toolkit. 2016.
Actions: ASB in the nursing home
• July 2019: incorporated the UTI SBAR into Epic SmartText for Hallmarnursing staff
• If there is a suspected UTI, the note will be utilized in a telephone encounter• If UTI criteria is met, will route to the provider
• If UTI criteria is not met, will not route to the provider
• Patient/family education in newsletter• Nursing education at staff meeting and through Net Learning
• Provider education through letter0
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% of antibiotic prescriptions linked to UTI diagnosis
Percentage of antibiotic prescriptions for UTI at Hallmar
Baseline (July‐Dec 2018) Jul‐19
Data: C. diff infection
• Highly sensitive C. diff nucleic acid amplification tests (NAAT; or C. difficile toxin by PCR) can detect colonization of C. diff
• A multistep algorithm is recommended for C. diff testing of stool specimens
• Testing should be in patients with unexplained and new‐onset diarrhea with ≥ 3 unformed stools in 24 hrs
McDonald LC, et al. Clin Infect Dis. 2017.https://www.knowyourpoo.com/images/Cepheid‐Clinician‐Education‐Poster.pdf
Data: C. diff infection‐ new testing as of 9/10/18GDH Result Toxin A/B Result NAAT (PCR)
ResultComment/ Interpretation (displayed in Epic with results)
Positive Positive N/A Positive for the presence of toxigenic C. difficile. Active C. difficile disease is likely. Isolation and contact precautions are likely needed.
Negative Negative N/A Negative for the presence of C. difficile and C. difficile toxin. No evidence of C. difficile infection. Consider alternative diagnoses.
Negative Positive N/A This specimen has produced discordant results. Please recollect a new sample for repeat testing, if clinically indicated.
Positive Negative Negative Negative for the presence of toxigenic C. difficile. Results suggest the presence of a non‐toxigenic C. difficile strain that does not cause C. difficile colitis. Treatment and isolation are not indicated.
Positive Negative Positive Positive for the presence of toxigenic C. difficile, but negative for the presence of C. difficile toxin. May be consistent with asymptomatic C. difficile colonization or active C. difficiledisease. Treat only if clinical suspicion is high.
Data: C. diff infectionTime period # of potential
CDI episodes% non‐adherent to treatment recommendations or potentially unnecessary treatment
2019 (Jan, April, May)
47 38 10 patients with likely colonization (+ virus or bacterial pathogen
on stool panel, C. diff toxin A/B was negative but GDH and PCR positive)o Of these, 6 patients treated with metronidazole and 1
patient given azithromycin with the C. diff treatment 7 patients treated with metronidazole (no longer 1st line, except
for pediatrics) 1 patient with wrong taper regimen
https://mobilesyrup.com/2017/11/03/even‐unicode‐consortium‐struggling‐poop‐emoji/
Action: C. diff infection decision support (coming)
BPA for colonization• GDH +, toxin A/B ‐, PCR + AND• Stool pathogen panel positive for a viral or non‐C. diff bacterial pathogen
• BPA will fire upon ordering of PO vancomycin or metronidazole recommending no C. diff treatment
BPA for metronidazole• GDH +, toxin A/B + (active C. diff)AND• Patient is ≥ 18 yrs• BPA will fire upon ordering of PO metronidazole recommending PO vancomycin
• Metronidazole is no longer first line for any severity of C. diff in adults
Resources
• Antibiogram and antibiotic quick reference available in Epic• Updated yearly• No longer printing copies for distribution
• One page guidelines that include outpatient/PO antibiotic treatment recommendations
One last non‐antibiotic thing (by request)
• Pre‐Operative Medications to Take and Hold Policy update in April 2019: • ACE inhibitors and ARBs should be held 24 hours prior to surgery and may be held up to 48 hours per surgeon instruction
• Due to risk of hypotension• Perioperative management of ACEIs/ARBs is controversial
• ACC/AHA guidelines (2014) for noncardiac surgery state “continuation perioperatively is reasonable”
• ACCF/AHA guidelines (2011) for CABG surgery state ACEIs/ARBs given before CABG should be “reinstituted postoperatively once the patient is stable unless contraindicated”
• Multiple observational studies and some small randomized studies show increased risk of intraoperative and/or postoperative hypotension for noncardiac and CABG surgery• Outcomes variable on cardiovascular or renal injury outcomes
• Noncardiac: most studies show no difference between groups who held or continued• Cardiac: some nonrandomized suggest possible myocardial protective effect of continuation but conflicting
results on kidney injuryRoshanov PS, et al. Anesthesiology. 2017.Fleisher LA, et al. Circulation. 2014.Hillis LD, et al. Circulation. 2011.Muluk V, et al. UpToDate: perioperative medication management. 2019.
Takeaways• Everyone needs to contribute to antimicrobial stewardship the future of antibiotics depends on it• Evidence‐based use of antibiotics means better patient outcomes and less risk for unintended consequences• Has to be a multidisciplinary and team process• Utilize the CDC Core Elements
• Write and display public commitments in support of AMS in your clinics (it’s easy!)• Decrease unnecessary antibiotics for ARI by explaining why antibiotics are not needed and offering patients specific symptomatic treatment recommendations
• Continue to use FQs judiciously due to associated toxicities• Evaluate penicillin allergy, ensure accurate documentation in the chart, and consider referral to the Healing Center for penicillin skin testing if indicated
• Symptom free pee, let it be! ASB (with pyuria) is common in nursing home patients and treatment is not beneficial
• Treatment of C. diff colonization has not been shown to be beneficial utilize comments for interpretation of C. diff testing and decision support once available
https://www.idri.org/antibiotic‐resistance‐are‐you‐contributing‐to‐the‐problem/
Thank you!Questions?mbernabe@mercycare.org319‐221‐8850
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