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Antimicrobial Selection in the Emergency Department:
Navigating Common Pitfalls and Applying Antimicrobial Stewardship
Kyle Dvoracek, Pharm.D., BCCCP
Objectives
• Navigate through common pitfalls in selecting antimicrobial therapy for: – Sepsis – Pneumonia – Skin and Soft Tissue Infections
• Apply methods for incorporating antimicrobial
stewardship in the emergency department
Sepsis
How to Please CMS
Sepsis Definitions
SIRS: 2 or More • HR >90 bpm • Temp >100.4°F or <96.8°F • RR >20 rpm or PaCO2<32 mmHg
• WBC >12,000 cells/mm3 or <4,000 cells/mm3 or Bands > 10%
Sepsis • SIRS + Suspected or confirmed infection
Specifications Manual for National Hospital Inpatient Quality Measures
Sepsis Definitions
Severe Sepsis • Sepsis plus end-organ dysfunction
• Lactate >2.0 mmol/L (REPEAT LACTATE 3 HR) • SCr >2.0 mmol/L • Bilirubin >2.0 g/dL • PLT <100,000 cells/mm3
Septic Shock: 30 mL/kg Fluids • Sepsis plus:
• SBP <90 mmHg or MAP <65 mmHg • Decrease SBP by >40 mmHg • Lactate >4.0 mmol/L (REPEAT LACTATE 3 HR)
Specifications Manual for National Hospital Inpatient Quality Measures
Summary of CMS Measure
Severe Sepsis
Identified (Time 0)
3 Hour Bundle: • Draw initial lactate level • Draw blood cultures (before
antibiotics) • Administer “BROAD
SPECTRUM IV ANTIBIOTICS”
6 Hour Bundle: • Repeat lactate level if
initial is > 2.0mmol/L • Administer 30 ml/kg
crystalloid fluids for “SEPTIC SHOCK”
Septic Shock Criteria: •SBP < 90mmHg •MAP < 65mmHg •Decrease in SBP by > 40mmHg than last normal BP •Initial lactate level is ≥ 4.0mmol/L
Severe Sepsis Criteria: •SIRS criteria ≥ 2 •Source of infection •Evidence of organ dysfunction
Specifications Manual for National Hospital Inpatient Quality Measures
What is NOT Broad Spectrum?
Gram Positive
Specifications Manual for National Hospital Inpatient Quality Measures
Antimicrobial Selection in Severe Sepsis • Ceftriaxone + Azithromycin • Vancomycin + Cefepime OR Pip/Tazo Lung
• Cefepime + Metronidazole • Pip/Tazo Abdomen
• Ceftriaxone • Cefepime Urine
• Pip/Tazo + Vancomycin Skin/Soft Tissue
• Ceftriaxone 2g + Vancomycin • +/- Ampicillin, Acyclovir Meningitis
RED FONT = MULTIDRUG-RESISTANT RISK FACTORS
Special Situations
• Meropenem • +/- Vancomycin
Penicillin Allergy
• Vancomycin 125mg PO 4XD + Metronidazole 500mg IV q8h Clostridium
difficile
• Pip/Tazo +Vancomycin • Cefepime + Metronidazole +
Vancomycin
Not Sure on Source
Antibiotics for Pneumonia
Which patients REALLY require coverage for multi-drug resistant
organisms?
Classification of Pneumonia
CAP
• Viruses • Strep.
pneumo • Atypical
Bacteria
HCAP
HAP/VAP
• Drug-resistant pathogens
• Staph aureus (MRSA)
• Pseudomonas
?
Kalil AC et al. Clin Infect Dis. 2016 Sep 1;63(5):e61-111.
Original HCAP Risk Factors
HCAP Prior Hospitalization
Nursing Home
Hemodialysis Home Infusion Therapy
Home Wound Care
Family Member with
MDR
ATS/IDSA . Am J Respir Crit Care Med. 2005; 171: 388-416. Kalil AC et al. Clin Infect Dis. 2016 Sep 1;63(5):e61-111.
The Story of HCAP
2002-2005 • HCAP
Definition Determined
2005 • HCAP
Supported in HAP/VAP Guidelines
2006-2015 • HCAP
Definition Questioned
2016 • HCAP
removed from HAP/VAP Guidelines
Kalil AC et al. Clin Infect Dis. 2016 Sep 1;63(5):e61-111. Kollef MH et al. Chest. 2005 Dec;128(6):3854-62.
Yap V et al. Infect Dis Clin North Am. 2013 Mar;27(1):1-18.
ATS/IDSA . Am J Respir Crit Care Med. 2005; 171: 388-416. Chalmers JD et al. Clin Infect Dis. 2014 Feb;58(3):330-9. Gross AE et al. Antimicrob Agents Chemother. 2014 Sep:58(9):5262-8.
Limitations of Kollef
• Only culture-positive patients
• Only hospitalized patients • Limited number of:
– Hemodialysis
• Study did not include: – Nursing home patients – Home infusion patients – Home wound care patients – Family member with MDR
Kollef MH et al. Chest. 2005 Dec;128(6):3854-62.
• Compared to CAP, HCAP group had more: – Medical
Immunosuppression – Co-Morbidities – Mechanical Ventilation – Severity of Illness – Predicted Mortality upon
Admission
Newer Literature
• Yap and colleagues, 2013 – Hospitalization in past 90 days – Recent antibiotics in past 30 days – Severity of pneumonia – Immunosuppression – Poor functional status
Yap V et al. Infect Dis Clin North Am. 2013 Mar;27(1):1-18.
Newer Literature
• Gross and colleagues, 2014 – Admission from nursing home – Antibiotic use in past 90 days – Number of days hospitalized in prior 180 days – Prior Pseudomonas – Trend with prior MRSA
• Chalmers and colleagues, 2014 – HCAP is a poor predictor of MDR pathogens – Evidence is poor and subject to publication bias
Chalmers JD et al. Clin Infect Dis. 2014 Feb;58(3):330-9. Gross AE et al. Antimicrob Agents Chemother. 2014 Sep:58(9):5262-8.
Recommendations Antibiotics for MDR recommended in:
• Immunosuppressed • Antibiotics in prior 90 days • 12 month history of MDR
pathogen • Hospitalization within 90
days • Skilled nursing facility
Antibiotics for MDR considered in:
• Hemodialysis • Severely ill patients (i.e.
severe sepsis/septic shock/ARDS)
• Poor functional status • Severe co-morbidities • Home infusion therapy • Home wound care therapy
Watch for new CAP guidelines in 2017 for update on HCAP
Skin and Soft Tissue Infections
To Treat or Not to Treat
Impetigo/Ecthyma
• Mupirocin topically bid – Limited # of lesions
• Cephalexin 250mg 4xd
• TMP/SMX 1-2 DS bid
– If MRSA suspected
Abscesses, Carbuncles, Furuncles
• Incision and drainage
• Antibiotics if: – SIRS – Immunocompromised – Consider in:
• Extremes of age • Multiple abscesses • Lack of response to I&D
– TMP/SMX 1-2 DS bid – Clindamycin 300mg po 4xd – Doxycycline 100mg po bid
Stevens DL et al. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.
Cellulitis/Erysipelas • Cover Streptococcus sp.
– Cephalexin 500mg 4xd – Clindamycin 300mg 4xd – Amoxicillin 500mg tid
• Cover MRSA if:
– Penetrating trauma – Purulent drainage – SIRS – IV drug use – TMP/SMX 1-2 DS bid with
cephalexin – Clindamycin 300mg 4xd – Vancomycin
Necrotizing Fasciitis • SSTI Emergency
• Treated aggressively with:
– Vancomycin + – Piperacillin/Tazobactam OR – Cefepime/Metronidazole OR – Meropenem
• Consider empiric
clindamycin 600-900mg q8h – For Streptococcal toxin and
cytokine suppression
Stevens DL et al. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.
Surgical Site Infections Fever < 4 days from operation
• Unlikely due to surgical site infection
• If systemic illness, gram stain for Strep or Clostridia – Open wound, debride – Penicillin G 2-4 million units IV
q4-6h AND – Clindamycin 600-900mg IV q8h
Fever >4 days after operation
• Antibiotics if: – Temp >38 °C – WBC >12,000 c/mm3 – Erythema >5cm from incision
• Perineum, GI tract or Axilla
– Ceftriaxone 1-2g IV q24h PLUS – Metronidazole 500mg IV q8h
• Trunk or Extremity
– Vancomycin OR – Cefazolin 1-2 g IV q8h
Stevens DL et al. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.
Diabetic Foot Infections • Is there clinical evidence of infection?
– If not, no antibiotics • Is there a risk for MRSA?
– MRSA infection/colonization in past year – Local prevalence of MRSA >30% – Severe infection (Admission, Septic)
• Is there a risk for Pseudomonas? – Soaking feet – Failed therapy not covering Pseudomonas – Severe infection (Severe Sepsis, Septic Shock)
• Has the patient received antibiotics in the past month? – If so, include agents active against gram-negatives – If not, just gram-positive coverage may be enough
Lipsky BA et al. Clin Infect Dis. 2012 Jun;54(12):e132-73.
How Severe is the Infection?
Mild
Cephalexin 500mg po 4xd
+/- TMP/SMX 1-2 DS po BID
Clindamycin 300-450mg po 4xd
Moderate
Ceftriaxone 2g IV Daily
+/- Vancomycin 15-20mg/kg
Ertapenem 1g IV Daily
Severe
Vancomycin 20-25mg/kg
Plus:
Pip/Tazo Cefepime/
Metronidazole Meropenem
Stevens DL et al. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.
Antimicrobial Stewardship in the ED
New Fluoroquinolone FDA Warning
• July 26th, 2016 • Not recommended for:
– Acute bacterial sinusitis – Acute exacerbation of chronic bronchitis – Uncomplicated urinary tract infections
• Reserved for patients who no alternatives exist – Allergies – Complicated infections (Resistant infections)
FDA.gov
Why So Serious?
2008: Tendinitis and
Tendon Rupture
2011: Worsening Myasthenia
Gravis Symptoms
2013: Irreversible Peripheral
Neuropathy
2016: Avoid Use in
Sinusitis, Bronchitis,
UTI
FDA.gov
Alternatives to Fluoroquinolones • Acute bacterial sinusitis
– Amoxicillin/Clavulanate – Doxycyline (Adults Only) – Clindamycin + Cefpodoxime
• Acute exacerbation of chronic bronchitis – Amoxicillin/Clavulanate – Azithromycin – Doxycycline
• Uncomplicated urinary tract infections – Nitrofurantoin (Cystitis Only) – Cephalexin OR Cefdinir – TMP/SMX
Get Smart About Healthcare. CDC.gov Chow AW et al. Clin Infect Dis. 2012 Apr;54(8):e72-112.
Warren JW et al. Clin Infect Dise. 1999 Oct;29(4):745-58
Ways to Improve Antimicrobial Stewardship in Your ED
1. Culture Follow-Up 2. Antibiotic Order Sets 3. Determine Local Antimicrobial Susceptibilities 4. Consider Cultures when Initiating Antimicrobial
Therapy 5. Avoid Antibiotics for Uncomplicated Abscesses 6. Withhold Antibiotics for Uncomplicated
Respiratory Tract Infections
Pulia MS et al. Common Sense: AAEM News. 2014
Review Questions
Which of the following patients require broad spectrum antibiotics according to the CMS Sepsis Criteria?
A. A patient with SIRS criteria B. A patient with Sepsis C. A patient with Severe Sepsis or Septic Shock D. Every patient who comes into the ED needs
antibiotics!!!
Review Questions
Which of the following patients require “broad spectrum antibiotics” according to the CMS Sepsis Criteria?
A. A patient with SIRS criteria B. A patient with Sepsis C. A patient with Severe Sepsis or Septic Shock D. Every patient who comes into the ED needs
antibiotics!!!
Review Questions
Which of the following antibiotic regimens IS appropriate for a severe septic patient according to the CMS core measure?
A. Vancomycin monotherapy for a cellulitis B. Ceftriaxone monotherapy for a urinary tract
infection C. Ciprofloxacin monotherapy for a urinary tract
infection D. Ceftriaxone plus azithromycin for a meningitis
Review Questions
Which of the following antibiotic regimens IS appropriate for a severe septic patient according to the CMS core measure?
A. Vancomycin monotherapy for a cellulitis B. Ceftriaxone monotherapy for a urinary tract
infection C. Ciprofloxacin monotherapy for a urinary tract
infection D. Ceftriaxone plus azithromycin for a meningitis
Review Questions
Which of the following is/are indications in which the FDA issued a warning against the routine prescribing of fluoroquinolones?
A. Acute bacterial sinusitis B. Acute exacerbation of chronic bronchitis C. Uncomplicated urinary tract infections D. All of the above
Review Questions
Which of the following is/are indications in which the FDA issued a warning against the routine prescribing of fluoroquinolones?
A. Acute bacterial sinusitis B. Acute exacerbation of chronic bronchitis C. Uncomplicated urinary tract infections D. All of the above
THANK YOU!
QUESTIONS?