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
SPACE BUGS
What are they?
KNOW THIS
AmpC - B-lactamase producers
INDUCIBLE, will see suceptibility first –> INDUCED RESISTANCE
Serratia marcescens
Pseudomonasaureginosa
Acinetobacter baumannii
Citrobacter feundii
Enterobacter cloacae
AmpC TREATMENT
INDUCIBLE, need to closely monitor those with:
Serratia marcescens
Pseudomonas aureginosa
Acinetobacter baumannii
Citrobacter feundii
Enterobacter cloacae
AmpC Treatment
CARBAPENEMS
Meropenem / Imipenem / Ertapenem
- *Cefipime**
- above same as ESBL treatment*
Quinolones** + **Bactrim
Carbapenamase Producers
Resistant to WHAT + What ORGANISMS?
Similar to ESBL+ AmpC but now resistant to:
CARBAPENEMS
Typically also show resistance to:
Quinolones** + **AminoGlycosides
Typically Seen in:
CRE = Carbapenamase Resistant Enterobacter
Klebsiella**+**E.Coli**+**Enterobacter
Also:
P. Aeurginosa + A. Baumanni
can pick up MANY resistant genes
Carbapenamase Producers
TREATMENT OPTIONS?
CRE = Carbapenamase Resistant Enterobacter
Klebsiella**+**E.Coli**+**Enterobacter
Also:
P. Aeurginosa + A. Baumanni
B-Lactam + Inhibitor Combos
CEFTAZIDIME** + **AVIBACTAM
Avycaz
MEROPENEM** + **VABORBACTAM
Vabomere
Tigecycline ?
Multidrug-Resitant Isolates
Which ORGANISMS often PICK UP many INDUCIBLE RESITANT GENES?
Pseudomonas. Aeruginosa + Acinetobacter. Baumanni
both are SPACE bugs - AmpC B-lacamase producers
Typically only
Susceptible < 2 classes of ABx
Have Numerous mechanisms for drug resistance:
Inducible ceph / B-lactamase / enzymes
Porins
Efflux Pumps
Colistin** / **Polymyxin B
Option for Resistant Gram-Pathogens?
- *Old drug**
- no GRAM POS activity*
issue is:
NEPHROTOXICITY
can use inhalation
TIGECYCLINE
Drug Option / Issues?
KNOW THIS
does NOT cover
_PSEUDOMONAS
_meaning that you can NOT use it for:
HAP
“Minocycline on Steroids”
Covers:
MRSA / MDR Acinetobacter / ESBLs
good for POLYMICROBIAL infxns
Barf-a-cycline
Drug of Choice for Resistant Phenotype?
AmpC B-Lactamase
SPACE ORGAMISMS
Enterobacter / Citrobacter Freundii / Serratia
Resistant to:
ALL B-Lactamases except cefepime + carbapenems
CEFEPIME
preferred
CARBAPENEMS
FQ** + **SMX/TMP
Drug of Choice for Resistant Phenotype?
ESBL
Extended spectrum B-lactamase
CTX-M / SHV/TEM
Enterobacteriacae = E. Coli + Kleb
CARBAPENEMS
pip/tazo too but not used
Drug of Choice for Resistant Phenotype?
CARBAPENAMASES
KPC / NDM / OXA
enterobactericiae
CEFTAZ** + **AVI
MERO** + **VABO
Polymixins / Aminoglycosides
