33/34 - Antimicrobial Resistance Flashcards
Antimicrobial Stewardship
PRIMARY GOAL
IMPROVE PATIENT OUTCOMES
Systematic process to optimize ABx use to improve patient outcomes
while:
Minimizing unintended consequences
Optimizing:
Utilized only when indicated
Ideal Agent
Dose/ Route/Duration
SAFETY
ABx Stewardship
CORE STRATEGIES
- *Formulary Management**
- *Restrictions + Preauthorization**
Prospective AUDIT
with intervention + feedback
ABx Stewardship
Supplemental Strategies
IV to PO Switch
for HIGHLY BIOAVAILABLE AGENTS - Fluoroquinolones
Indications and durations
Education
Dosing protocols
Including optimization of PK/PD through alternative dosing schemes
Guideline development
Use of CPOE/CDS
Formulary Management
Abx Stewardship
RESTRICTIONS
- *Pre-Authorization Chalenges:**
- *Staff/coverage**
- *Documentation / Challenging Physicians autonomy**
- *DELAYS IN THERAPY**
Antimicrobial TIME-OUT
@48-96 hours to RE-ASSESS NEED for continued therapy
Transition from:
Empiric –> DEFINITIVE THERAPY
- *NNIS report from 2004**
- *showed notable increases in resistance:**
Kleb. Pneumonia
resistance to 3rd Gen Cephs
Ceftazadime / Ceftriaxone / Cefotaxime
MRSA
Pseudomonas AUREGINOSA
increase in quinolone + 3rd gen cephs
- *Bad Bugs, No Drugs**
- *Campaign**
Developed by IDSA in 2004
to increase awareness of RESISTANCE RATES
INCENTIVES FOR R&D
within pharmaceutical industry for ABx development
Followed up by:
2011 ESKAPE PATHOGENS
2011 ESKAPE PATHOGENS
Cause significant # of Healthcare infxns:
HAP/VAP - IntraAbdominal - UTI - CRSBI
Update to IDSA’s “Bad bugs, No Drugs” campaign
Considered to cause significant burden of healthcare infections which can “escape” effects of current abx agents.
+ Enterococus faceum +
+ S. aureus +
Below are gram NEGATIVE:
- K*lebsiella pneumonia
- *Acinetobacter** species
- *P.** aeruginosa
- *Enterobacteriacea** (gut ones)
3 Mecanisms of Gram NEGATIVE Resistance
INTRINSIC
INTRINSIC
Characteristic of the organism
EFFLUX pumps
Enzymes = AmpC
Low permeability membrane
3 Mecanisms of Gram NEGATIVE Resistance
ACQUIRED
ACQUIRED
Incorporation of “extra” genetic material
Plasmids** / **Transposons** / **Integrons
- *BETA-LACTAMASES**
- *Enzymes**
3 Mecanisms of Gram NEGATIVE Resistance
ADAPTIVE
ADAPTIVE
Baceria develops ability to RESIST by:
modifying DNA/genetic material
Typically due to:
REPEAT ABx exposure
Subtherapeutic Conc.** + **OVERUSE
Beta-Lactamase Mutations
Arose from mutations from WHAT?
TEM
+
SHV
B-lactamases
had activity against:
ampicillin / cephalothin / 3rd gen Cephs.
CeftriaXone - CeftaZadime - CefotaXime
- *ESBLs**
- *Extended Spectrum B-Lactamases**
Resistant to WHAT + What ORGANISMS?
Resistance is:
ACQUIRED - Plasmid Mediated
CEPHalosporims 1st-3rd gen + Penicillins
also typically resistant to:
Quinolones
Typically seen in:
Enterobecteriacea
esp Kleb + E. Coli
- *ESBLs**
- *Extended Spectrum B-Lactamases**
TREATMENT OF CHOICE
CEPHalosporims 1st-3rd gen + Penicillins
also typically resistant to:
Quinolones
Typically seen in:
Enterobecteriacea
esp Kleb + E. Coli
- *CARBAPENEM**
- *Mero**penem / Imipenem / Ertapenem
Cefepime
4th gen ceph - may have some activity
Fofsomycin / Tigecycline
AmpC - B-Lactamases
Aka - cephalosporinases
Resistant to WHAT + What ORGANISMS?
Resistance is: INDUCED
might NOT show resistance NOW –> will be INDUCED after ABX given
- *CEPHalosporims** 1st-3rd gen + Penicillins
- similar to ESBLs*
Seen in:
SPACE organisms
