antibiotic stewardship

Question 1

Urgent threats

Answer 1

C. diff

carbapenem resistant Enterobacteriaceae (CRE)

Question 2

Serious threats

Answer 2

MCR acinetobacter
MDR pseudomonas aeruginosa
ESBLs in enterobacteriaceae

Question 3

reason to be concerned?

Answer 3

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

Question 4

core elements of hospital ASPs

Answer 4

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

Question 5

goals of AS

Answer 5

combat emergence of resistance
control costs
improve clinical outcomes

Question 6

core members of the ASP

Answer 6

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

Question 7

antibiotic selection - the “five rights”

Answer 7

right patient
right drug
right dose (strength and interval)
right route
right time (duration)

Question 8

colonization

Answer 8

bacteria or fungi are present at the site sampled, but are not causing infection - no ABs required!

Question 9

contamination:

Answer 9

bacteria or fungi are present in the lab sample but not at the site being culture - no ABs required!

Question 10

right drug

Answer 10

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

Question 11

antibiogram

Answer 11

a summary of the cumulative susceptibilities of bacteria against specified antimicrobials in a defined period of time

Question 12

Cmax:MIC

Answer 12

aminoglycosides
fluoroquinolones
daptomycin
metronidazole

Question 13

AUC:MIC

Answer 13

vancomycin

Question 14

T>MIC

Answer 14

B-lactams

Question 15

criteria for IV to PO

Answer 15

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

Question 16

de-escalation

Answer 16

preferred order of treatment recommendations:
penicillins to cephalosporins to carbapenems
preferred order for de-escalating:
carbapenems to cephalosporins to penicillins

Question 17

mechanisms of drug resistance

Answer 17

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