BUGS AND DRUGS: UPDATE ON

ANTIMICROBIAL THERAPY

KCNPNM 2014 Conference

Objectives Compare and contrast the antimicrobial drug

classes Understand the types of antimicrobial drug

resistance that can occur Create treatment plans for which

antimicrobial therapy can be managed successfully

Related prudent use of antimicrobial therapy to quality metrics

Introduction The modern age of antibiotic therapeutics

was launched in the 1930s with sulfonamides and the 1940s with penicillin

Since then, many antibiotic drugs have been developed, most aimed at the treatment of bacterial infections

These drugs have played an important role in the dramatic decrease in morbidity and mortality due to infectious diseases

While the absolute number of antibiotic drugs is large, there are few unique antibiotic targets

Nine Factors to Consider When Selecting an Antibiotic1. Spectrum of coverage2. Patterns of resistance3. Evidence or track record for the specified

infection4. Achievable serum, tissue, or body fluid

concentration (e.g. cerebrospinal fluid, urine)

5. Allergy6. Toxicity7. Formulation (IV vs. PO); if PO assess

bioavailability8. Adherence/convenience (e.g. 2x/day vs.

6x/day)9. Cost

Principles of Antibiotic TherapyDirected Therapy (15%) Infection well defined Narrow spectrum One, seldom two

drugs Evidence usually

stronger Less adverse

reactions Less expensive

Empiric Therapy (85%) Infection not well defined

(“best guess”) Broad spectrum Multiple drugs Evidence usually only 2

randomized controlled trials

More adverse reactions More expensive

Why So Much Empiric Therapy?

Need for prompt therapy with certain infections Life or limb threatening infection Mortality increases with delay in these cases

Cultures difficult to do to provide microbiologic definition (i.e. pneumonia, sinusitis, cellulitis)

Negative cultures Provider Beliefs

Fear of error or missing something Not believing culture data available “Patient is really sick, they should have ‘more’ antibiotics” Myth of “double coverage” for gram-negatives e.g.

pseudomonas “They got better on drug X, Y, and Z so I will just continue

those”

To Increase Directed Therapy for Inpatients:

Define the infection 3 ways Anatomically, microbiologically, pathophysiologically

Obtain cultures before starting antibiotics Use imaging, rapid diagnostics and special

procedures early in the course of infection Have the courage to make a diagnosis Do not rely solely on “response to therapy” to

guide therapeutic decisions; follow recommended guidelines

If empiric therapy is started, reassess at 48-72 hoursMove to directed therapy (de-escalation or

streamlining)

To Increase use of Directed Therapy for Outpatients:

Define the infection 3 ways Anatomically, microbiologically, pathophysiologically

Obtain cultures before starting antibioticsOften difficult in outpatients (acute otitis media,

sinusitis, community-acquired pneumonia) Narrow therapy often with good supporting

evidenceAmoxicillin/clavulanate for AOM, sinusitis and CAPPenicillin for Group A Streptococcal pharyngitisClindamycin or trimethoprim/sulfamethoxazole for

simple cellulitisTrimethoprim/sulfamethoxazole or ciprofloxicin for

cystitis

IS AN INFECTION PRESENT?

Signs and Symptoms Increase in WBCs and a “left shift” Fever Pain and Inflammation Hemodynamic changes Neurologic changes Gram stain

Overview Colonization

Where bacteria are supposed to resideBacteria are present but no signs and symptoms of

infection Infection

Where bacteria invadeBacteria are present and have often migrated to

different organs to cause systemic infectionMost likely to occur

○ The intrinsic virulence of the particular organism○ The immune status of the host○ The quantity or load of the initial innoculant

Treat Bacterial Infection, not Colonization

Many patients become colonized with potentially pathogenic bacteria but are not infectedAsymptomatic bacteriuria or foley catheter

colonizationTracheostomy colonization in chronic respiratory

failureChronic wounds and decubitiLower extremity stasis ulcersChronic bronchitis

Can be difficult to differentiatePresence of WBCs not always indicative of infectionFever may be due to another reason, not the positive

culture

Treat Bacterial Infection, not ColonizationExample: Asymptomatic Bacteriuria

≥105 colony forming units is often used as a diagnostic criteria for a positive urine culture

It does NOT prove infection; it is just a number to state that the culture is unlikely due to contamination

Pyuria also is not predictive on its own

It is the presence of symptoms AND pyuria AND bacteriuria that denotes infection

CAP: often a difficult diagnosis X-rays can be difficult to

interpret. Infiltrates may be due to non-infectious causes.

Examples:AtelectasisMalignancyHemorrhagePulmonary edema

Do Not Treat Sterile Inflammation or Abnormal Imaging Without InfectionExample: Community-Acquired Pneumonia (CAP)

Acute bronchitis Common colds Sinusitis with symptoms

less than 7 days Sinusitis not localized to

the maxillary sinuses Pharyngitis not due to

Group A Streptococcus spp.

Gonzales R, et al. Annals of Intern Med 2001;134:479Gonzales R, et al. Annals of Intern Med 2001;134:400Gonzales R, et al. Annals of Intern Med 2001;134:521

Do not Treat Viral Infections with Antibiotics

Culture and Sensitivity Final identification of pathogen and

effectiveness of antibiotics May not give appropriate information

Patient previously taking antibioticsCulture not obtained properlyContaminationNot time sensitive

Key Terms

MIC = Minimal inhibitory concentration. Lowest concentration of antimicrobial that inhibits growth of bacteria. Commonly used in clinical lab MBC = Minimal bactericidal concentration. Concentration of an antimicrobial that kills bacteria. Used clinically only in special circumstances Breakpoint = The MIC that is used to designate between susceptible and resistant. Arbitrarily set by the laboratory

Breakpoint Susceptibility Susceptible – pathogens with the lowest

MICs and are most likely to be eradicated with antibiotic therapy

Intermediate - ?? – Treatment may be successful if the antibiotic is used in higher doses or if the antibiotic has good penetration into the infection site

Resistant – significantly higher MICs that will cause a less than optimal clinical outcome even if higher doses of the antibiotic are used

Concept of Breakpoint to Determine Susceptibility

Antibiotic MIC Breakpoint SusceptibilityAmpicillin >16 8 ResistantGentamicin 2 4 SusceptibleCephalothin >16 N/A ResistantCefepime 8 32 SusceptibleCefotaxime 16 16/32 IntermediateCeftazidime 2 32 SusceptibleAztreonam 4 16 SusceptibleCiprofloxacin 2 2 ResistantAmp/Sulbactam >16 8 ResistantMeropenem 4 4/8 IntermediatePip/tazo 8 32-64/128 Susceptible

EXAMPLE: Susceptibility testing for a single isolate of Pseudomonas aeruginosa

-Breakpoint for intermediate resistance for meropenem is 4 and for piperacillin/tazobactam (pip/tazo) 32-Pip/tazo is the better choice between the two -Ciprofloxacin is a poor choice even though the MIC is lowest of the three

Resistance

Introduction Since the first use of antibiotics in the 1930s

and 1940s, bacteria quickly adapted and developed mechanisms to escape their effects

Over the following decades, new antibiotics were developed to overcome resistance

Since the 1990s, new antibiotic development has fallen sharply while bacterial resistance continues to increase

Antibiotic resistance is responsible for countless human deaths and billions of dollars in healthcare expenses

70% of bacteria that cause healthcare-acquired infections are resistant to common antibiotics

Agriculture

Inpatient

Outpatient

Antibiotic Use Leads to Antibiotic Resistance

Clearing Up Misconceptions Misconception: Antibiotics are no longer

effective because people who have taken the medication have developed a tolerance to the drug

Truth: People do NOT develop a tolerance to drugs; the reason drugs no longer work is because the bacteria is no longer killed by the drug because they have become resistant to the effects

Factors that Promote Resistance Exposure to antibiotics

Prolonged courses Use of incorrect antibiotic Sub-therapeutic doses Treatment of viral infections

Introduction of resistant organisms from outside the population Transfers from outside facilities

○ Long-term care facilities are primary reservoirs of antimicrobial resistance

Food sources (BSE, VRE, Hepatitis A, GI bugs) Mobile society (SARS)

Tissue culture passage effect Spread from patient to patient (hand hygiene) Animal to human spread - agriculture

Reasons for Antibiotic Overuse : Conclusions from Eight Focus GroupsPatient Concerns Want clear

explanation Green nasal

discharge Need to return to

work

Physician Concerns Patient expects

antibiotic Diagnostic

uncertainty Time pressure

Barden L.S. Clin Pediatr 1998;37:665

Antibiotic Prescription

“As long as we expose bacteria to antibiotics, they will evolve resistance to them. The more exposure…the more rapidly resistance will occur”

(National Institute of Allergy and Infectious Diseases, 2014)

Antibiotic Use Leads to Antibiotic Resistance

Resistant bacteria or their genetic determinates are selected when colonizing or infecting bacteria are exposed to antibiotics

Resistant bacteria can then be transmitted between patients

Highest risk patients:ImmunocompromisedHospitalizedInvasive devices

(central venous catheters)

Antibiotic Mechanism of Action

Daptomycin

DaptomycinDaptomycinDaptomycinDaptomycinLinezolid

Daptomycin

Linezolid

Mechanisms Of Antibiotic Resistance Can be related back to how the

antibiotic works Bacteria are capable of

becoming resistant through several mechanisms

One or many mechanisms may exist in an organism

Multidrug-resistant bacteria often have multiple mechanisms

Genes encoding resistance may exist on plasmid or chromosome Alteration in

Target Molecule

Decreased Permeability

Mechanisms of ResistanceAntibiotic Degrading Enzymes

Sulfonation, phosphorylation, or esterifictation Especially a problem for aminoglycosides

β-lactamasesSimple, extended spectrum β-lactamases (ESBL),

cephalosporinases, carbapenemasesConfer resistance to some, many, or all beta-

lactam antibioticsMay be encoded on chromosome or plasmidMore potent in gram-negative bacteriaExamples: S. aureus, H. influenzae, N.

gonorrhoeae, E. coli, Klebsiella sp., Enterobacter sp., Serratia sp., other enteric bacteria, anaerobes

Extended Spectrum -lactamases

-lactamases capable of hydrolysing extended spectrum cephalosporins, penicillins, and aztreonam

Most often associated with E. coli and Klebsiella pneumoniae but spreading to other bacteria

Usually plasmid mediated Aminoglycoside, ciprofloxacin and

trimethoprim-sulfamethoxazole resistance often encoded on same plasmid

Has become a significant resistance determinate in acute and long-term care facility enteric pathogens

Class A Carbapenemases Most common in Klebsiella pneumoniae (KPC) Also seen in E. coli, Enterobacter, Citrobacter,

Salmonella, Serratia, Pseudomonas and Proteus spp.

Very often with multiple other drug resistance mechanisms, resistance profile similar to ESBL but also carbapenem resistant

Became problem in New York City first in 2002-2003 and is being increasingly recognized in Mid-Atlantic US.

Spreading across species to other gram-negatives and enterobacteriaceae

Emerging in long-term care facilities

Multidrug Resistant Gram-Negative Organisms Development of resistance to multiple antimicrobial

classes severely limits treatment options and the incidence of resistance is rising

Proportion of isolates resistant to three antibiotic classes ranged from 10 to 60% for different gram-negative bacteria, while some are resistant to four antibiotic classes

Resistant to 3 antibiotic classes

Resistant to 4 antibiotic classes

Pseudomonas aeruginosa 10% 2%

Acinetobacter baumannii 60% 34%

Klebsiella pneumoniae 15% 7%

Multidrug Resistant Gram-Negative Organisms Widespread use of cephalosporins and beta-lactam

combination antibiotics has led to extended-spectrum beta-lactamases (ESBLs), which are resistant to both classes Carbapenems have been the only effective agents for ESBLs

Emergence of carbapenemases, such as Klebsiella pneumoniae carbapenemase (KPCs) are threatening carbapenems as the antibiotics of last resort Significant issue for many military personnel due to the high

amount of Acinetobacter in the desert NO NEW ANTIBIOTICS ON THE HORIZON!!!

Mechanisms of ResistanceDecreased Permeability

Pseudomonas spp. Affects many antibiotics including

carbapenems

Efflux Pumps Pseudomonas spp. (multiple antibiotics) Tetracyclines Macrolides

Mechanisms of ResistanceTarget Alteration

DNA gyrase • Fluoroquinolones• Many gram-negatives, S. pneumoniae

Penicillin-binding protein• Methicillin-resistant S. aureus (MRSA)• Penicillin-resistant S. pneumoniae

Gram positive cell wall• Vancomycin• Enterococcus spp.

Mechanisms of ResistanceTarget Alteration (cont’d)

Ribosome • Tetracyclines• Macrolides

○ S. pneumoniae, Staphylococcus sp., N. gonorrhoeae, enteric gram-negative rods

Treatment Options for Common Infections

HA-MRSA Patients have multiple risk factors Usually involves various types of infection

BacteremiaIntravenous linesPneumoniaSkin and soft tissue infections

Transmission is person to person Growth rate is slow Resistant to multiple antibiotics Need to make sure that patient has an infection

Antibiotic Therapy for HA-MRSA Usually resistant to multiple antibiotics

Resistant to penicillins and cephalosporinsMay be resistant to clindamycin and trimethoprim-

sulfamethoxazole Drugs of choice include vancomycin, linezolid

(Zyvox), daptomycin (Cubicin), or quinupristin-dalfopristin (Synercid)

CA-MRSA Risk factors not clearly identified other than more

likely in a younger patientDes seem to be a correlation between sharing of close

quarters Transmission is person to person Growth rate is fast The prevalence factor is PVL (panton-valentine

leukocidin) and two major clones have been identified - makes this strain more virulent

Resistant to beta-lactams, but sensitive to other agents

Antibiotic Therapy for CA-MRSA When the infection is skin/ soft tissue, incision

and drainage of area may be needed Usually resistant to the beta-lactams (penicillin

and cephalosporins) Usually sensitive to clindamycin, trimethoprim-

sulfamethoxazole, minocycline, doxycycline May be beneficial to add Rifampin for

synergistic effect Also sensitive to vancomycin, daptomycin, and

linezolid, although these agents are not first-line

Acute Pharyngitis One of the four most common

episodic clinic visit May be viral or bacterial

40% of children with pharyngitis have Group A Streptococcal pharyngitis○ Most commonly affected ages of 5 to

12 years○ Not usually seen in children under

age 3Only 5-15% of adult cases of acute

pharyngitis are caused by group A beta-hemolytic streptococcal (GABHS)

Acute Pharyngitis Treatment

No antibiotics when viral!Treatment with antibiotics usually last for 7 to 10 days

○ Penicillin○ Amoxicillin or amoxicillin/ clavulanate○ Second or third generation oral cephalosporin○ Macrolide

Penicillin is recommended for initial treatment of GABHS○ No resistance seen in the United States yet

Fluoroquinolones are NOT appropriate

Rhinosinusitis Most cases are viral

Less than 10% are bacterialResolves in about 7 days

Bacterial - often atypicalsDouble-sickening – symptoms last longer than 7 daysNasal congestionCough - often worse at night due to drainageFacial pain - above or below the eyes that worsens when

patient leans forwardToothache - if maxillary sinuses are involvedHeadachePurulent drainage, although nasal discharge alone is not a

good predictor of a bacterial infection○ Clear to yellow to green

High fever – 102 or higher

Pharmacologic Treatments

Regardless of whether the etiology is infectious, allergic, or irritant, treatment should focus on relieving obstruction and establishing drainage

Analgesics Decongestants Antihistamines Corticosteroids Mucolytics Antibiotics

Antibiotics Rhinosinusitis is the fifth most common

diagnosis for which an antibiotic is prescribed First need to be sure that the infection is

bacterial – most are viral and not bacterial Want to use antibiotics with good coverage of

atypicals and gram-positive organisms, as well as good penetration into the sinus cavity

Usually need to treat for 10 to 14 days If chronic sinusitis, may need to consider 3 to 4

weeks of antibiotics, especially if surgery may be required

Antibiotics For milder infections

Penicillins, such as amoxicillin/clavulanateDoxycycline

May not be as effective due to increasing resistance among pneumococciSecond or third generation cephalosporinsMacrolides

For more serious infectionsAmoxicillin/ clavulanate (high dose)Quinolone with antipneumococcal activity, such as

levofloxacin PQRS Measure

Treatment Options for OM

Studies have shown that the symptoms of OM spontaneously resolved in 80% of children at 2 to 7 days. (Otalgia – endpoint)More likely to be bacterial if child has siblings or attends

day care Ibuprofen or acetaminophen are the best options for

pain control Analgesic ear drops can also provide symptomatic

relief Some controversy over the use of decongestants,

although fluid accumulating behind the ear drum is often a contributing factor

Treatment Options for OM

Antibiotics Amoxicillin or Amoxicillin/ clavulanateSecond or third generation cephalosporinMacrolide

PQRS Measure

Pneumonia Common lower respiratory tract infection that

causes inflammation of the lung parencyma Pneumonia – sixth leading cause of death The defense mechanisms of the lung usually help

to prevent passage of foreign materialsDisease states, such as COPDAgeSmoking

Immunization!Pneumococcal vaccination will help to decrease incidence

and severity of susceptible strains of pneumonia

CAP vs HCAP HCAP - Healthcare-associated pneumonia

Acquired in an environment, such as a hospital, residing in a nursing home, receiving home health care, or dialysis

Usually caused by very different organisms○ MRSA○ Gram-negative organisms

CAP - Community-acquired pneumoniaStreptococcus pneumoniaeMore than 15% of S. pneumoniae are highly resistant to

penicillin and increasingly resistant to macrolides and cephalosporins

Hospital Core Measure

Macrolide-Resistant S. pneumoniaePrevalence is Increasing in US – 2000 to 2005

Jenkins S. et al Emerg Infect Dis. 2009;5:1260Hicks L et. Al. Emerg Infect Dis. 2010;16:896

Empiric Treatment - Outpatients Macrolide (azithromycin, clarithromycin) Doxycyline If S. pneumoniae is thought to be the causative

organism, then a penicillin or cephalosporin would be the drug of choice provided there is no resistance

Also starting to see resistance to macrolidesIf resistance is an issue, may need to use a

quinolone

Empiric Treatment - Inpatients

Necessary to cover both typical and atypical pathogens Ampicillin/Sulbactam plus a Macrolide Newer Fluoroquinolone – high dose, short course Third-generation Cephalosporin plus a Macrolide s

With structural lung disease a regimen with activity against Pseudomonas should be considered, such as a Third or Fourth generation Cephalosporin plus a Fluoroquinolone

If aspiration pneumonia is suspected, Metronidazole or Clindamycin can be added

In treating pneumococcal pneumonia that is highly resistant, an IV fluoroquinolone, vancomycin, or linezolid may need to be added to the regimen.

Early gram-stain may be helpful for choosing antibiotics Core Measure

Treatment Options for Bronchitis No antibiotics! Increase hydration Expectorants/ Antitussives Antipyretics Albuterol ? If antibiotics are considered

Macrolides or doxycycline for atypical coverageSecond generation cephalosporinsAmoxicillin/clavulanate (high dose)Quinolones when compromised lung function

C. Diff Treatment Decreasing the use of antibiotics that most often

lead to C diff infections by 30% could lead to 26% fewer infectionsQuinolonesBeta-lactamsExtended spectrum cephalosporin

In 23% of patients, C difficile-associated disease will resolve within 2 to 3 days of antibiotic discontinuation

Avoid anti-motility agents Hospital HAC Measure

C. Diff Treatment Infection can be treated with either metronidazole

or oral vancomycin for 10 to 14 daysLikely to take 2 to 4 days before the diarrhea stopsVancomycin should only be used if treatment failure to

metronidazole, patient is pregnant, or known resistant strain

Oral agents preferred but may use IV metronidazole if patient cannot tolerate oral therapy

New Strain of C diff Increased rates of C diff-associated disease with more

severe symptoms and an increase in mortality has been seen

Meta-analysis showed a 23% annual increase in hospitalizations from C diff-associated disease from 2000 through 2005 along with a 35% increase in deaths

A new strain of C diff has been found that appears to be more virulent, produces greater quantities of toxin A and B, and is resistant to current therapies

Cause may be changes in antimicrobial usage Treatment – metronidazole or vancomycin Fidoxamicin Fecal transplant

Gaining more acceptance No standard administration approach

Most often enema/ colonoscopy although can be administered through NG tube

Stool slurry that needs to be used immediately from donor

Success is measured through resolution of symptoms and absence of relapse within 8 weeks

Fecal Transplant

UTI Organisms E. coli causes 80% of all community-acquired UTIs and

about half of UTIs in the hospitalE. coli has become increasingly resistant to TMP-SMX to where

it is no longer a first line agent for complicated UTI or pyelonephritis

Beta-lactams are associated with about a 40% resistance rate for E. coli

Other pathogens include gram-negative rods, such as Proteus, Klebsiella, and EnterobacterAlthough the quinolones are used for complicated UTIs, more

resistance is being seen with Enterococci Nitrofurantoin has low resistance, but has little use

beyond the urinary tract because of poor tissue perfusion

Summary of Asymptomatic Bacteriuria Treatment

Treat symptomatic patients with pyuria and bacteriuria Don’t treat asymptomatic patients with pyuria and/or

bacteriuria Define the symptomatic infection anatomically Dysuria and frequency without fever equals cystitis Dysuria and frequency with fever, flank pain, and/or

nausea and vomiting equals pyelonephritis Remember prostatitis in the male with cystitis

symptoms Remove catheters!!!

SCIP Measure PQRS Measure Hospital HAC Measure

Treatment Options for UTIs

Antibiotic DurationUncomplicated UTI TMP-SMX or

Nitrofurantoin3 days

Uncomplicated UTI in Older Women TMP-SMX 7 days

Uncomplicated UTI with Suspected Resistant Organisms

Quinolone (ciprofloxacin)

3 – 7days

UTI in Pregnancy Amoxicillin/ clavulanate orSecond Generation Cephalosporin or Nitrofurantoin

7 – 10 days

Complicated UTI (Outpatient) Quinolone 10-14 days

Complicated UTI (Inpatient) Third Generation Cephalosporin orCarbapenem

10- 14 days

Treatment Options for UTIs

Antibiotic DurationPyelonephritis Quinolone plus

Aminoglycoside orThird Generation Cephalosporin or Antipseudomonal Penicillin

7 – 14 days, up to 21 days

Hospital-Acquired UTI Quinolone orThird Generation Cephalosporin orCarbapenem orAntipseudomonal Penicillin

10-14 days

Pearls for Antibiotics

Key Points for Antibiotics Carbapenems

Not all agents are the same○ Ertapenem – not as broad spectrum○ Doripenem – concern about use in pneumonia

Use carefully due to the development of carbapenases Clindamycin

Good choice for CA-MRSAPsedomembraneous colitis

Daptomycin Should not be used for pneumoniaWatch for myositis

Key Points for Antibiotics Fluoroquinolones

Same effect either PO or IVStarting to see more issues with resistanceWatch for tendon issues Not indicated for children under the age of 16

LinezolidSame effect either PO or IVShould be reserved for when resistance to vancomycin is

presentThrombocytopenia – more common after 10 days of

therapyPotential serotonin syndrome?

Key Points for Antibiotics Metronidazole

Same effect either PO or IVPotential for several adverse reactions’

○ GI Watch for disulfiram-like reaction with alcohol

PenicillinsUse may be limited because of resistanceAddition of other agents to help combat resistance

RifampinShould not be used as monotherapy because quick

development of resistanceUsed in combination with other antibiotics in the treatment of

CA-MRSA for synergistic effectChange in secretions to red-orange

Key Points for Antibiotics Sulfa

Several potential drug-drug interactionsLots of potential adverse reactionsWatch for hypersensitivity reactions

TetracyclinesDrug-drug and drug-food interactionsContraindicated in pregnancy and in children under age 16

VancomycinIV for MRSA onlyPO for C diff onlyWatch renal function and monitor trough levels

Antimicrobial Stewardship

What Is Antimicrobial Stewardship? Antimicrobial stewardship is a

mutlidisciplinary approach for rational antibiotic therapyMust be based on evidence-based guidelinesMust be based on dataMust apply to all practitioners

Core Actions to Prevent Antibiotic Resistance1. Preventing infections2. Prevent the spread of resistance3. Tracking and surveillance4. Improve antibiotic prescribing through

stewardship5. Development of new antibiotics and new

diagnostic tests for resistance bacteria

Principles of Antibiotic Stewardship• Re-evaluate, de-escalate or stop therapy at 48-72

hours based on diagnosis and microbiologic results• Re-evaluate, de-escalate or stop therapy with

transitions of care (e.g. ICU to step-down or ward)• Do not give antibiotic with overlapping activity• Do not “double-cover” gram-negative rods (i.e.

Pseudomonas sp.) with 2 drugs with overlapping activity

• Make sure that all prescriptions/orders for antibiotics have the appropriate dose, duration, and indication

Limit duration of surgical prophylaxis to <24 hours perioperatively

Use rapid diagnostics if available (e.g. respiratory viral PCR)

Prevent infectionUse good hand hygiene and infection control

practicesRemove catheters

Consult infectious disease

Principles of Antibiotic Stewardship

Conclusion Antibiotics clearly save lives Poor prescribing of antibiotics are putting patients at

unnecessary risk Adverse reactionsDevelopment of resistant organisms

Every time an antibiotic is prescribedIf at all possible, order recommended cultures before antibiotics

are givenMake sure an indication, dose, and expected duration are part of

the prescription orderReassess within 48 hours and adjust antibiotic or discontinue if

warranted Pay for performance indicators

Questions?

Thank You!

Melinda Joycembjoyce@chc.net