Upload
shawn
View
30
Download
0
Tags:
Embed Size (px)
DESCRIPTION
UTI & Pneumonia Translating Knowledge into Practice. PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet. Attendance. Please email Brenda Flood ( [email protected] ) if you attended this session - PowerPoint PPT Presentation
Citation preview
UTI & PneumoniaTranslating Knowledge into Practice
PIAS-KT StudySukhjinder Sidhu
Sean GormanRichard SlavikTasha RamseySarah Murray
Nicole Bruchet
Attendance
• Please email Brenda Flood ([email protected]) if you attended this session
• Please email Brenda Flood ([email protected]) if you view this presentation online at a later date
THANK YOU!
• YOU SURPASSED OUR PROJECTED PARTICIPATION RATE FOR THE PRE-QUIZ!
• STAY TUNED FOR A POST-QUIZ THAT WILL BE SENT OUT IN MID-MARCH
• THANK YOU TO TASHA RAMSEY FOR HER EXPERT REVIEW OF THIS PRESENTATION
Speaker Disclosure
• The speakers have no actual or potential conflicts of interest to disclose
Outline• PIAS-KT Study Overview• Local Opinion Leaders• Prevalence and Impact of UTIs & Pneumonia• Antimicrobial Stewardship• Key Pharmacist Interventions for UTIs & Pneumonia• DTP Tracker Data for UTIs & Pneumonia• UTIs & Pneumonia Therapeutics
– When to treat with antibiotics and When Not to treat?– What antibiotics to initiate and Why?– When, How, and Why to de-escalate antibiotics?– How long to treat with antibiotics?
Objectives
• To review the pharmaceutical care of patients with UTIs & Pneumonia including:– Key pharmacist interventions– Indications for antibiotic therapy– Initial empiric antibiotic therapy recommendations– Antibiotic de-escalation strategies– IV to PO step-down considerations– Duration of antibiotic therapy
PIAS-KT Study OverviewInterventionPRE phase
Knowledge Behavior
POST phase
Knowledge Behavior
Behavioral Change
StrategiesJan 30 – Mar 14,
2014
1. Audit & Feedback2. Local opinion leaders3. Educational meetings4. Educational outreach5. Printed education materials6. Reminders
QuizJan 17-30, 2014
QuizMar 17-28, 2014
DTP/DSEM DTPKPI/DSEM KPI
Jul 1-Dec 31,2013
DTP/DSEM DTPKPI/DSEM KPI
Jan 1-Jun 30, 2014
Local Opinion Leaders
• KGH – Dawn Robb• RIH – Kim Winters• PRH/SOH – Orysya Fetterly• VJH – Chelsea Argent• SLH/OMH – Ian Petterson• KBH/KLH – Michael Conci• EKH/GDH – Darren Feere
Prevalence & Impact of UTIsPrevalence
– Approximately 4,000,000 UTIs/year in Canada – Affects 20% of women between 15-29 yo– Number 1 healthcare-associated infection– 16th most common non-surgical reason for IH admission
Impact– 660 cases and 3200 acute bed-days at IH– Hospital-acquired UTIs associated with extra day of hospitalization– Up to 25% of patients with UTI receive inappropriate therapy– Up to 50% of patients with asymptomatic catheter-associated
bacteriuria are treated with antibiotics (which is inappropriate)
Mayo Clin Proc 2007;82:181-5.; Can J Infect Dis Med Microbiol 2005;16:166-70.
Prevalence & Impact of Pneumonia
Prevalence– Approximately 170,000 cases of CAP each year in Canada – HAP/VAP is 2nd most common nosocomial infection in Canada– 5th most common non-surgical reason for IH admission
Impact– 1300 cases and 7000 acute bed-days at IH each year– CAP is the leading infectious cause of death– Up to 15% of patients with CAP receive inadequate therapy– Up to 75% of patients with HAP/VAP receive inadequate therapy
Clin Infect Dis 2005;41:1709-16.; Postgrad Med 2010;122:130-141.
Antimicrobial Stewardship Definition
• An activity (or activities) that includes– Appropriate antibiotic selection– Appropriate antibiotic dosing– Appropriate antibiotic route selection– Appropriate antibiotic duration of therapy
Clin Infect Dis 2007;44:159-77.
Antimicrobial Stewardship Goals
• Optimize clinical outcomes by ensuring effective antimicrobial therapy
• Minimize collateral damage from antimicrobials– Antimicrobial resistance– Antimicrobial toxicity– Costs of inappropriate antimicrobial use– Superinfections (e.g. Clostridium difficile)
Clin Infect Dis 2007;44:159-77.
Clinical Pharmacists’ Role in Antimicrobial Stewardship
PHARMACEUTICAL CARE
ANTIMICROBIALSTEWARDSHIP
Urinary Tract Infection Key Pharmacist Interventions
1. Initiate appropriate antibiotics for symptomatic UTI
2. Discontinue empiric antibiotics started for UTI that are not indicated
3. De-escalate antibiotics for UTI based on C&S data and clinical response
4. Perform IV to PO step-down of antibiotics for UTI
5. Promote appropriate duration of antibiotic therapy for UTI
IH UTI Key Pharmacist Interventions, April 21, 2011
Pneumonia Key Pharmacist Interventions
1. Initiate appropriate antibiotics for pneumonia
2. Discontinue empiric antibiotics started for pneumonia that are not indicated
3. De-escalate antibiotics for pneumonia based on C&S data and clinical response
4. Perform IV to PO step-down of antibiotics for pneumonia
5. Promote appropriate duration of antibiotic therapy for pneumonia
IH Pneumonia Key Pharmacist Interventions, April 21, 2011
Project Alignment
CPhA “Blue Print” for Pharmacy Practice CSHP “Vision 2015” Canadian Clinical Pharmacy KPI Collaborative Accreditation Canada MOHS KRAs and CCM groups IH SET goals, objectives IH Pharmacy Clinical Priorities
DTP Tracker Data - UTI
• UTI ranks #6 in disease prevalence for all Rx interventions
• UTI ranks #3 in disease prevalence for 8 DSEM interventions
• UTI ranks #2 in disease prevalence for key pharmacist interventions
DTP Tracker Data - UTI
• AIMS study showed a statistically significant, clinically important increase after DSEMs– DSEM DTP/total DTP (27.9% to 31.9%, p<0.05)– KPI/total DTP (21.7% to 25.8%, p<0.05)
• In UTI subgroup, AIMS failed to show a statistically significant benefit– DSEM DTP/total DTP (3.91% to 3.93%, p=NS)– KPI/total DTP (3.82% to 4.61%, p=NS)
DTP Tracker Data - Pneumonia
• Pneumonia ranks #3 in disease prevalence for all Rx interventions
• Pneumonia ranks #2 in disease prevalence for 8 DSEM interventions
• Pneumonia ranks #3 in disease prevalence for key pharmacist interventions
DTP Tracker Data - Pneumonia
• In Pneumonia subgroup, AIMS failed to show a statistically significant benefit– DSEM DTP/total DTP (4.75% to 4.90%, p=NS)
• However, in Pneumonia subgroup, AIMS demonstrated a statistically significant REDUCTION– KPI/total DTP (5.07% to 3.94%, p=0.016)
Pharmaceutical Care of UTI and Pneumonia
UTI Pharmaceutical CareOutline
• When and When Not to treat with antibiotics?
• What antibiotics to initiate and Why?
• When, How, and Why to de-escalate antibiotics?
• How long to treat with antibiotics?
What Makes a UTI ‘Complicated’?
• Patients with structural or functional abnormalities of the genitourinary tract– Obstruction– Instrumentation (including catheters)– Impaired voiding– Metabolic abnormalities– Immunocompromised– Men
Can J Infect Dis Med Microbiol 2005;16:349-60.
UTI“Why should antibiotics be initiated?”
• duration of symptoms
• abscesses, metastatic infection, septic shock, AKI
Clin Infect Dis 2005;40:643-54.
UTI“When should antibiotics be initiated?”
– Clinical manifestations of cystitis• Dysuria, frequency, urgency, suprapubic pain, hematuria
– Clinical manifestations of pyelonephritis• Above symptoms together with fever (>38°C), chills, flank
pain, costovertebral angle tenderness, and nausea/vomiting
– Asymptomatic bacteriuria in pregnancy
Cystitis at IH“When should antibiotics be initiated?”
“If clinically feasible, initiation of antimicrobial therapy should be delayed until results of urine
culture are available”
Can J Infect Dis Med Microbiol 2005;16:349-60.
UTI at Interior Health“What antibiotics should be initiated and why?”
Infection 2007;35:150-3. (Calgary Data 2004-5)
Organisms Associated with Urinary Tract Infections
UTI at Interior Health“What antibiotics should be initiated and why?”
*E. coli Susceptibilities at IH 2012
PO options
IV options
UTI at Interior Health“What antibiotics should be initiated and why?”
*Enterococcus Susceptibilities at IH 2012
• Risk Factors for Antibiotic Resistant UTIs– Abx exposure (especially to TMP/SMX or FQ) in past 3 months
– Travel to endemic area
– Previous multi-drug resistant UTI
Clin Infect Dis 2005;40:643-54.
UTI at Interior Health“What antibiotics should be initiated and why?”
• Oral Antibiotic Selection– Oral antibiotics are first line for cystitis– Oral antibiotics are first line for uncomplicated
pyelonephritis (not acutely ill)
• IV Antibiotic Selection– Unable to tolerate oral therapy (nausea/vomiting/ileus)– Impaired GI absorption – Hemodynamic instability (acutely ill)– Infecting organism resistant to available oral options
Clin Infect Dis 2005;40:643-54., Can J Infect Dis Med Microbiol 2005;16:349-60.
UTI at Interior Health“What antibiotics should be initiated and why?”
Complicated Cystitis at IH“What antibiotics should be initiated?”
“Oral antimicrobial therapy is appropriate for most episodes”
Can J Infect Dis Med Microbiol 2005;16:349-60.
Recommendations for Empiric Therapy
1. Nitrofurantoin 100 mg PO BID x 5 days (CrCl ≥ 40 mL/min)
2. Trimethoprim/Sulfamethoxazole i DS PO BID x 3 days
• Cefixime 400 mg PO Daily x 3 days
• Amoxicillin/Clavulanate 875 mg PO BID x 3 days
• Amoxicillin/Clavulanate 500 mg PO TID x 3 days
Uncomplicated Cystitis at IH“What antibiotics should be initiated?”
Recommended Empiric Oral Options
1st Line•Cefixime 400 mg PO Daily x 7-14 days•Amoxicillin/Clavulanate 875 mg PO BID x 7-14 days•Amoxicillin/Clavulanate 500 mg PO TID x 7-14 days•Trimethoprim/Sulfamethoxazole i DS PO BID x 7-14 days
2nd Line (high prevalence resistance)•Ciprofloxacin 500 mg PO BID x 7-14 days
Complicated Cystitis at IH“What antibiotics should be initiated?”
Recommended Empiric IV Options
• Ampicillin + Gentamicin
• Ampicillin + Ceftriaxone
• Piperacillin/Tazobactam +/- Gentamicin
Complicated Cystitis at IH“What antibiotics should be initiated?”
Uncomplicated Pyelonephritis at IH“What antibiotics should be initiated and why?”
Recommend Empiric Oral Therapy
• Same as for uncomplicated cystitis EXCEPT:– No nitrofurantoin
– Longer duration of therapy (7-14 days)
• Gentamicin 5-7 mg/kg/day IV OR
• Ceftriaxone 1-2G IV daily
Uncomplicated Pyelonephritis at IH“What antibiotics should be initiated and why?”
Recommended Empiric IV Therapy for Acutely Ill Patients
Recommended Empiric Oral Options
• Same as for complicated cystitis
1st Line• Cefixime 400 mg PO Daily x 7-14 days• Amoxicillin/Clavulanate 875 mg PO BID x 7-14 days• Amoxicillin/Clavulanate 500 mg PO TID x 7-14 days• Trimethoprim/Sulfamethoxazole i DS PO BID x 7-14 days
2nd Line (high prevalence resistance)• Ciprofloxacin 500 mg PO BID x 7-14 days
Complicated Pyelonephritis at IH“What antibiotics should be initiated and why?”
Recommended Empiric IV Options
• Same as for complicated cystitis– Ampicillin + Gentamicin
– Ampicillin + Ceftriaxone
– Piperacillin/Tazobactam +/- Gentamicin
Complicated Pyelonephritis at IH“What antibiotics should be initiated and why?”
Recommended Antibiotic Therapy
• Wait for results of screening urine C&S• Select narrowest spectrum agent that is safe in pregnancy
– Amoxicillin/Clavulanate– Amoxicillin– Cefixime– Cephalexin– Nitrofurantoin (avoid in 3rd trimester)– TMP/SMX (avoid in 1st and 3rd trimesters)
Asymptomatic Bacteriuria in Pregnancy“What antibiotics should be initiated and why?”
UTI Therapeutics“What is antibiotic de-escalation and
why is it important?”
• Antibiotic De-escalation– Replace empiric broad-spectrum regimen with a
more narrow spectrum regimen– Organism identified with susceptibilities– Intended to reduce collateral damage – De-escalation for UTIs is under-performed
Infection 2013;41:211-14.
UTI Therapeutics“When and How should antibiotics be
de-escalated?”
• When to de-escalate– Once urine C&S known– No other suspected infections– No patient-limiting factors (e.g. allergy)
Infection 2013;41:211-14.
UTI Therapeutics“When and How should antibiotics be
de-escalated?”• How to de-escalate
– Broad spectrum to narrowest spectrum– Narrowest spectrum with collateral damage risk
Infection 2013;41:211-14.
Empiric Step-Down
Ciprofloxacin Amoxicillin
Cefixime Cephalexin
Ceftriaxone TMP/SMX
Pip/Tazo Amoxicillin/Clav
Ceftriaxone Cefixime
Examples
UTI Therapeutics“How should antibiotics be de-escalated?”
• IV to PO Step-Down– Tolerates oral intake– No factors affecting absorption– Hemodynamically stable– If acutely ill pyelonephritis and considering PO β-
lactam, patient should receive at least 1 dose of Ceftriaxone OR Aminoglycoside
Infection 2013;41:211-14.
Interior Health IV to PO Step-Down Policy
• Pharmacists Have IV-PO Step-Down Authority– Applies to Ciprofloxacin/Moxifloxacin– Duration IV antibiotics: ≥ 48 hours – Tolerating other PO medications, fluids, or foods x 12 hours – No potential problems with absorption – Clinically stable (stable BP, resolving fever/afebrile, adequate urine
output, absence of encephalopathy, WBC normal or normalizing)
• Exclusions• Febrile neutropenia, gram negative bacteremia, CNS infections, septic
shock, severe cellulitis
InsideNet – Pharmacist managed IV to PO conversion program (2006)
UTI Therapeutics“How long to treat with antibiotics?”
• Uncomplicated cystitis– 3-7 days (5-7 days for nitrofurantoin)
• Complicated cystitis– 7-14 days
• Pyelonephritis– 7-14 days
Candida-Associated Cystitis
• Indications for treatment– Symptomatic cystitis– Asymptomatic, but high risk (neutropenia,
planned urologic manipulation)
• Recommended treatment – Fluconazole 200-400 mg PO daily x 14 days– Amphotericin 0.3-0.6 mg/kg IV x 7 days (2nd line)
Clin Infect Dis 2009;48:503-35.
Pneumonia Pharmaceutical CareOutline
• When and When Not to treat with antibiotics?
• What antibiotics to initiate and Why?
• When, How, and Why to de-escalate antibiotics?
• How long to treat with antibiotics?
IH Pneumonia DSEM
PneumoniaWhen and Why Antibiotic Treatment?
• Physician/NP Diagnosis• Varies depending on outpatient/inpatient• Chest x-ray infiltrates PLUS• Fever, purulent secretions, elevated WBC• Other clinical manifestations: dyspnea, pleuritic chest pain
• Consequences of Pneumonia– Reduced survival– Increased risk of ICU admission– Prolonged length of hospitalization
Clin Infect Dis 2007;44:sS.; Pneumonia DSEM 2008.
Community-Acquired Pneumonia
• Patients not hospitalized in previous 14 days
Clin Infect Dis 2000;31:383-421.
Community-Acquired Pneumonia“What antibiotics should be initiated and why?”
Microbiologic Etiology
Clin Infect Dis 2000;31:347-82.
Community-Acquired PneumoniaRisk Factors for AROs
*β-Lactam, Fluoroquinolone, Macrolide
Can J Infect Dis Med Microbiol 2008;19:19-53., Clin Infect Dis 2007;44:(Suppl 2):S27-72.
Community-Acquired Pneumonia“What antibiotics should be initiated and why?”
*Ampicillin SusceptibilitySusceptibilities at IH 2012
Community-Acquired Pneumonia“What antibiotics should be initiated?”
Recommendations for Empiric Therapy in Hospital
•General Ward1. Moxifloxacin 400 mg PO/IV daily2. Ceftriaxone 2 g IV daily + Azithromycin 500 mg IV daily
•ICU1. Ceftriaxone 2 g IV daily + Azithromycin 500 mg IV daily2. Ceftriaxone 2 g IV daily + Moxifloxacin 400 mg IV daily
Clin Infect Dis 2007;44:(Suppl 2):S27-72.
Approach to De-Escalation
Intensive Care Med 2014;40:92-5.
Suspected CAPEmpiric Antibiotics
C&S Available?
Significant Improvement after
48-96 hr?
Significant Improvement after
48-96 hr?
• De-escalate• Max 7 Days
• Review Abx• Review Dose• Re-culture• Complication?• Consider non-infection
• De-escalate using C&S
• Max 7 days
NO YES
YES NO NO YES
Organism Preferred AlternativesS. pneumoniae; MIC < 2 mg/L
Pen G, amoxicillin Macrolide, cephalosporins, clindamycin, doxycline, respiratory fluoroquinolone
S. pneumonia; MIC ≥ 2 mg/L
3rd generation cephalosporin, fluoroquinolone
Vancomycin, linezolid, amoxicillin >3 g/day if MIC ≤ 4 mg/L
H. influenzae (no beta-lactamase)
Amoxicillin Fluoroquinolone, doxycycline, azithromycin, clarithromycin
H. Influenza (beta-lactamase)
2nd or 3rd generation cephalosporin, amoxicillin-clavulanate
Fluoroquinolone, doxycycline, azithromycin, clarithromycin
Enterobacteriaceae 3rd generation cephalosporin, carbapenem
Beta-lactam/beta-lactamase inhibitor, fluoroquinolone
P. aeruginosa Antipseudomonal beta-lactam +/- cipro OR aminoglycoside
Aminoglycoside PLUS cipro or levo
MSSA Cloxacillin Cefazolin, clindamycinClin Infect Dis 2007;44:(Suppl 2):S27-72.
Community-Acquired Pneumonia“Pathogen-Directed Therapy”
Community-Acquired Pneumonia“IV to PO Step-down Criteria”
• Normal functioning GI tract AND
• Able to ingest medications AND
• Improving clinically AND
• Clinical stability– T < 37.8 0C– HR < 100 bpm– RR < 24 breaths/min– SBP > 90 mm Hg– Arterial O2 sat > 90%– Normal mental status
Clin Infect Dis 2007;44:(Suppl 2):S27-72.
Interior Health IV to PO Step-Down Policy
• Pharmacists Have IV-PO Step-Down Authority– Applies to Ciprofloxacin/Moxifloxacin– Duration IV antibiotics: ≥ 48 hours – Tolerating other PO medications, fluids, or foods x 12 hours – No potential problems with absorption – Clinically stable (stable BP, resolving fever/afebrile, adequate urine
output, absence of encephalopathy, WBC normal or normalizing)
• Exclusions• Febrile neutropenia, gram negative bacteremia, CNS infections, septic
shock, severe cellulitis
InsideNet – Pharmacist managed IV to PO conversion program (2006)
• Minimum treatment duration 7 days AND• Afebrile (T ≤ 37.8 x 48-72 h) AND• ≤ 1 sign of CAP-related clinical instability
• T ≥ 37.8• HR ≥ 100 beats/min• RR ≥ 24 breaths/min• SBP ≤ 90 mmHg• SaO2 ≤ 90% or PaO2 ≤ 60 mm Hg on room air• Inability to maintain oral intake• Abnormal mental status
• Azithromycin 500 mg IV daily x 3 days (with ceftriaxone)
Community-Acquired Pneumonia “How long to treat?”
Clin Infect Dis 2007;44:(Suppl 2):S27-72.
Hospital-Acquired/Ventilator-Associated Pneumonia
• HAP – Pneumonia that occurs > 48 hours after admission
• VAP– Pneumonia arising > 48 hours after intubation
Clin Infect Dis 2000;31:383-421.
HAP/VAP“What antibiotics should be initiated and why?”
Microbiologic Etiology
HAP/VAP“What antibiotics should be initiated and why?”
Susceptibilities at IH 2012
HAP/VAP“What antibiotics should be initiated and why?”
MDR Bacteria Risk Factors
Infect Dis Clin N Am 2004;18:939-962. RSS 2012
HAP/VAP“What antibiotics should be initiated and why?”
Reasonable IH StrategyEarly HAP/VAP, and
no risks for MDR bugsLate HAP/VAP, or
risks for MDR bugsCeftriaxone Piperacillin-tazobactam
Piperacillin-tazobactam Ciprofloxacin (?)Moxifloxacin Meropenem*
+/- aminoglycoside (PA)
+/- vancomycin (?)
HAP/VAP“What antibiotics should be initiated and why?”
RSS 2012
Am J Respir Crit Care Med 2005;171:388-416. RSS 2012
Approach to De-Escalation
Pneumonia Therapeutics“How long to treat with antibiotics?”
Potential Benefits• Overall antibiotic use• Resistance rates• Super-infection• Drug costs• Adverse events
Potential Risks• Treatment failures• Relapse rates• Re-infection rates• Complications
J Clin Pharmacol Therap 2003;28:123-129.RSS 2012
Shorter Duration of Therapy
HAP/VAP“How long to treat?”
Am J Respir Crit Care Med 2005;171:388-416.
*Uncomplicated Pneumonia**Non-lactose fermenting Gram negative rods
Session Review• PIAS-KT overview• Local Opinion Leaders• UTIs/Pneumonia are highly prevalent and impactful• Pharmaceutical care of patients with infections naturally
includes antimicrobial stewardship activities• UTI/Pneumonia KPIs are antimicrobial stewardship activities• When to initiate antibiotics for UTI/Pneumonia• What antibiotic to initiate for UTI/Pneumonia• When and how to de-escalate antibiotics for UTI/Pneumonia• How long to treat with antibiotics for UTI/Pneumonia
Attendance
• Please email Brenda Flood ([email protected]) if you attended this session
• Please email Brenda Flood ([email protected]) if you view this presentation online at a later date
Questions?
TMP/SMX ResistanceClinical Cure Uncomplicated Cystitis
Ann Intern Med 2001:135:41-50