antibiotic stewardship Flashcards
Urgent threats
C. diff
carbapenem resistant Enterobacteriaceae (CRE)
Serious threats
MCR acinetobacter
MDR pseudomonas aeruginosa
ESBLs in enterobacteriaceae
reason to be concerned?
antibiotics are the only drug where use in one patient can impact the effectiveness in another
antimicrobial stewardship has been identified as the key component to improving antibiotic use
core elements of hospital ASPs
leadership support
accountability
drug expertise
acttions to support optimal antibiotic use: policies, broad interventions, pharmacy driven interventions, diagnosis and infection specific interventions
tracking: monitoring of antibiotic prescribing, use and resistance
reporting information
education
goals of AS
combat emergence of resistance
control costs
improve clinical outcomes
core members of the ASP
directed or co-directed by: ID physician, clinical pharmacist with ID training
other: microbiologist, IT specialist, infection control and hospital epidemiologist, members of the medical staff interested/engaged in antimicrobial stewardship
antibiotic selection - the “five rights”
right patient right drug right dose (strength and interval) right route right time (duration)
colonization
bacteria or fungi are present at the site sampled, but are not causing infection - no ABs required!
contamination:
bacteria or fungi are present in the lab sample but not at the site being culture - no ABs required!
right drug
disease state (type of infection) probably pathogens/organisms (risk stratification) drug activity against pathogens penetration at site of infection effective conc AEs down stream resistance/collateral damage
antibiogram
a summary of the cumulative susceptibilities of bacteria against specified antimicrobials in a defined period of time
Cmax:MIC
aminoglycosides
fluoroquinolones
daptomycin
metronidazole
AUC:MIC
vancomycin
T>MIC
B-lactams
criteria for IV to PO
diagnosis compatible with oral therapy adequate GI absorption improvement in local s/sxs of infection afebrile (under 100 F) for at least 8 hours improving leukocytosis
de-escalation
preferred order of treatment recommendations:
penicillins to cephalosporins to carbapenems
preferred order for de-escalating:
carbapenems to cephalosporins to penicillins
mechanisms of drug resistance
altered target binding site (HIGH level resistance - MSSA to MRSA)
up-regulation of efflux pumps (LOW level resistance - increased MICs, can overcome)
Increased production of enzymes
Altered out membrane protein “porin channel”
most bacteria have 1 or 2 - P. aeruginosa and Acinetobacter use ALL FOUR
