Embed Size (px)
Citation preview
8/11/17
1
Antimicrobials: An UpdateKatrina Viviano, DVM, PhD, DACVIM, DACVPVETgirl WebinarAugust 17, 2017
GarretPachtinger,VMD,DACVECC
COO,VETgirl
Introduction
JustineA.Lee,DVM,DACVECC,DABTCEO,VETgirl
Introduction VETgirl…on the run!� Thetech-savvywaytogetRACE-approved,onlineveterinaryCE!
� Asubscription-basedpodcastandwebinarserviceofferingveterinaryRACE-approvedCE
50-60podcasts/yearplus30+hoursofwebinars!�$199/year�40+hoursofRACE-CE
Upto5members:$599/year
Upto10members:$999/year
>10members:Pingus
8/11/17
2
VETgirl online veterinary CE video archives
Download our VETgirlpodcasts
Find VETgirl on social media!n Typeinquestionsn Emailedtoyou48hoursafterthewebinarn Activeparticipation=noquizn Watchingvideolater,mustcompletequiz
n ELITEmembersonlyn Email/contactwithANYquestions
n [email protected] [email protected]
How to get your VETgirl CE certificate!
Katrina Viviano, DVM, PhD, DACVIM, DACVCP
Introduction Lecture Outline
�Current challenges�Antibiotic use in CA�Antibiotic stewardship�Evidence-based prescribing
�Antimicrobial update
8/11/17
3
Current Challenges
MDR Bacterial Isolates
�MRSP�ESBL E. coli�VRE�Pseudomonas aeruginosa
HUMAN and VETERINARY MEDICINE
Differences: Antibiotic Use
Human Veterinary
80%
Harrison and Lederberg, 1998
Differences: Antibiotic Used
Human SA Veterinary
other
pen/ceph.
FQ
amox/clav/1st gen.ceph.
other
FQ
75%59%
8%
10%
Guardabassi and Prescott, 2015
MRSP� Dogs
� Link between antimicrobial therapy within 30 days and MSRP infections
� S. psuedintermedius� In vitro susceptibility may not be reflective of
susceptibility if organisms present at biofilm
Weese et al, 2012Ferran et al, 2016
UWVC – ESBL Isolates
Year TotalESBLs
E. coli E. cloacae P. mirabilis P. aeruginosa
2014 15 15/393
2015 13 10/401 2/81 1/92
2016 12 9/386 1/15 1/93 1/117
8/11/17
4
UWVC – ESBL Isolates
Year Urine ESBLs E. coli
2014 11 (15) 11/192
2015 9 (10) 9/192
2016 6 (9) 6/234
11 yr old, FS, Am. Shorthair� Dx – pyelonephritis (hx CKD, IRIS stage III)
� Tx – Clavamox 1/2017
� UWVC 1/2017� BUN 221, creatinine 9, PO4 24.6� Urine > 100,000 CFU/mL Proteus mirabilis� Rx – marbofloxacin� Culture neg. on ABX (~10 days) – creatinine 2.5
11 yr old, FS, Am. Shorthair� Urine > 100,000 CFU/mL MRSP
� Following a 4 wk course of marbofloxacin� Rx chloramphenicol� Clinically ill with increasing creatinine 3.9� Urine culture neg. on ABX (~ 3 wks)
� Urine > 100,000 CFU/mL Enterococcus faecium� Susceptible – gentamicin, nitrofurantoin, tetracycline� Clinically doing well with stable creatinine 2.6
� Urine > 100,000 CFU/mL Enterococcus faecium� Vancomycin resistant; susceptible – nitrofurantoin� Feels well with stable creatinine 2.3
Antibiotic use in CA
Gaps Antimicrobial Rx – Vet Med
�Over-prescribing�Documentation /Justification �Inappropriate Selection�Education
Antimicrobial Rx
Fowler et al, 2016
8/11/17
5
UWVC – Antimicrobial Use2009-2011
O CR C/S AS D
Antimicrobial Stewardship
Antimicrobial Stewardship�Reduce inappropriate use
�Develop guidelines for prescribers�Max health benefits�Maintain clinical efficacy�Min. resistance�Adverse effects
ASP – Veterinary Medicine
�2013 AVMA committee�Dev. resources/programs ASP
�Not widely adapted/used
SA VMTH (Guelph)
� Antibiotic use/impact antimicrobial guidelines
� Dogs/cats Rx antibiotics – 1995-2004� Introduction ABX guidelines 2001� Post-guidelines – overall decrease antibiotic use
� Decrease – pen./ceph. and FQ� Decrease in carapenems
Weese, 2006
DVMs Attitudes - ASP
�NCSU VMTH and AVMA members
AVMA, 2015
NCSU AVMAConcern ABX resistance 59% 45%Guidance- Choosing ABX- Duration tx
77%83%
Lack awareness guidelines 88%
8/11/17
6
Antibiotic Stewardship
Resources
Education
Documentation
RATIONAL USE Evidence-Based Rxs
Evidence-Based Rx
�Evidence bacterial infection�Site of Infection�Understanding Drugs�C/S testing�Patient specific factors
Consensus Guidelines
�General – antibiotic use dog/cats
�UTI (2011)�Superficial pyoderma (2014)�Respiratory tract (2017)�MRSP (2017)
Duration Therapy
Urinary Tract InfectionsWestropp et al, 2012 Clare et al, 2014
UncomplicatedDogs
UTI n=68; FS 57/MN 11
Bacterial cystitis n=38, FS
Random/blinded Multicenter (5) Placebo-controlled
ABX enro x 3 d vsamox/clav x 14 d
TMS x 3 d vsceph x 10 d
Cure rates 7 days post ABX 3 days; 4 and > 30 days post ABX
E AC TMS CMicrobiologic 77% 81% 4d post 59% 36%
> 30d post 44% 20%Clinical 89% vs. 88% 3d 89% 94%
4d post 85% 72%> 30d post 50% 65%
8/11/17
7
Bacterial Pneumonia
Dogs- bacterial pneumonia
Tx ABX discretion clinician
Tx ABX CRP normalized + 7 days
N=19
N=9
Monitor – CRP, CXR, clinical signs
N=8
Viitanen et al, 2017
Died (1)Euthanized (1)
Bacterial Pneumonia
Dogs- bacterial pneumonia
Tx ABX discretion clinician
Tx ABX CRP normalized + 7 days
N=19
N=9
Monitor – CRP, CXR, clinical signs
N=8
Median Tx 35 days 21 days
Died (1)Euthanized (1)
Viitanen et al, 2017
Antimicrobial Update
Pradofloxacin
�MOA – inhibits topoisomerase II/IV�PK/PD – low MIC (FQ)
�Cats�Approval wounds/abscesses
Pradofloxacin
�Cats: Bacteriuria LUTS
Lister et al, 2007
0
5
10
15
20
25
30
Pradofloxacin (n= 27) Amox/clav (n = 28) Doxycyline (n = 23)
Post Tx NG Post Tx Bacteriuria
Pradofloxacin
Cats URI� All cats resolved
clinical signs� Mycoplasma PCR
neg. both gps� Chlamydia - prado
PCR positive (4)
Hartmann et al, 2008
pradodoxy
8/11/17
8
PradofloxacinRhinitis – HS cats � Amox 10/15 vs prado (low) 11/15 vs prado (high) 11/12
Spindel et al, 2008
Pradofloxacin�Cats – exp. infected M. haemofelis
Dowers et al, 2009
PradofloxacinCefovecin�3rd generation cephalosporin
�Poor – P. aeruginosa, �None – Enterococcus spp.
�Half-live 7 days� Tx conc. urine and skin – 14 days
�Approved tx�Pyoderma, wounds, abscesses�Urinary tract
Cefovecin
�Murphy et al, 2012� Reported uses in cats� Sig. use in tx lower UTI and URI� URI – Mycoplasma, Bordetella, Chlamydia
�Burke et al, 2016� UK cats – describe clinical use of cefovecin� Skin (48%); Urinary (14%); Respiratory (10%)
Cefovecin� URI shelter cats – doxy. amox/clav. had
higher efficacy to cefovecin
Litster et al, 2012
doxy
A/C
cefovecin
8/11/17
9
Cefovecin� Healthy dogs (n=14)– impact fecal flora� Single 8 mg/kg SQ (n=7) vs no tx (n=17)
Cefovecin-resistant E. coliE. coli
Lawrence et al, 2013
Cefovecin
Lawrence et al, 2013
Minocycline
�Similar spectrum activity doxycycline
�MRSP� Inducible resistance assay/PCR
�Tet(M) – R all tetracyclines�Tet (K) – no minocycline R
�Tetracycline R ≠ minocycline R
Weese et al, 2013
Minocycline �Side Effects
� Esophageal strictures?
� Bioavailability� Dogs – concurrent
sucralfate� Sig. reduction in
PO bioavailability
KuKanich et al, 2014
Chloramphenicol
�Use based on C/S testing – MDR isolates� MRSP, prostatitis, recurrent UTI
�CYP 450 enzyme inhibition (CYP2B11)� Healthy greyhounds � Significant increase methadone PO
�AUC: 90-fold�Cmax: 8-fold
� Others - propofol
KuKanich and KuKanich, 2015KuKanich et al, 2011
Nitrofurantoin
�Lower urinary antiseptic
�PK�Half-life 20 minutes�Peak urine conc. 20 min.�50% excreted unchanged in urine
�Poor tissue conc.
8/11/17
10
Fosfomycin
�Broad spectrum antibacterial activity
�Low MW, water soluble, low protein binding� Good penetration tissues/fluids
� In vitro susceptibility E. coli� Urinary isolates - dogs and cats� MIC90 2 µg/mL; MIC50 1 µg/mL
Hubuka and Boothe, 2011
Fosfomycin�Nephrotoxicity
�Young cats�Increased BUN/creatinine
�Young and adult cats�Renal bx – tubular necrosis�Glomerular and basement membrane normal�Neither group – systemically ill
�Dogs - no biochem or morphological changes
Fukata et al. 2008
Bacteria/Antibiotic Resistance
Increasing rate of resistance to conventional
antibiotics
Development of novel-acting
antibiotics
Bacteria
Drug Discovery
Antibiotic Stewardship
Resources
Education
Documentation
RATIONAL USE
Questions?
VETgirl
8/11/17
11
This material is copyrighted by VETgirl, LLC. None of the materials provided may be used, reproduced or transmitted, in whole or in part, in any form or by any means, electronic or otherwise, including photocopying, recording or the use of any information storage and retrieval system, without the consent of VETgirl, LLC. Unless expressly stated otherwise, the findings, interpretations and conclusions expressed do not necessarily represent the views of VETgirl, LLC. Medical information here should be references by the practitioner prior to use. Under no circumstances shall VETgirl, LLC. be liable for
any loss, damage, liability or expense incurred or suffered that is claimed to have resulted from the use of the information provided including, without limitation, any fault, error, omission, interruption or delay with respect thereto. If you have any questions regarding the information provided, please contact [email protected]
