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Strategies for Optimizing Anti-Infective Therapy in the Home Infusion Setting

Supported by an unrestricted educationalgrant from Cubist Pharmaceuticals

Thursday, April 77:00‐8:45 a.m.Hilton Orlando—Florida Ballroom 4

NHIA Annual Conference & Exposition

A Symposium Held in Conjunction with the 2011 NHIA Annual Conference & Exposition

Strategies for Optimizing Anti‐Infective Therapy in the Home Infusion Setting

2011 NHIA Annual Conference & Exposition 1

Thursday, April 7, 7:00 to 8:45 a.m.06‐S. Strategies for Optimizing Anti‐infective Therapy in the Home Infusion Setting Supported by an educational grant from Cubist PharmaceuticalsHilton Orlando – Florida Ballroom 4Pharmacist, Pharmacy Technician and Nurse Continuing Education Contact Hours: 1.5ACPE Pharmacist and Pharmacy Technician Program #: 207‐999‐11‐232‐L01‐P&TKnowledge‐Based Learning Activity

Education Overview:Antimicrobial drug resistance and emerging “super bugs” remain a global crisis as we face a future with few new drugs in the antimicrobialpipeline. Clinicians are increasingly being called upon to identify and implement strategies that will prolong the efficacy of our current ar‐senal. Education is an essential component in ensuring that clinicians have the knowledge base needed to fully comprehend the alarmingtrends in microbial resistance, and to understand the steps that must be taken today in order to sustain our current level of control overthese microorganisms. With clinicians at the patient’s bedside playing a pivotal role in antimicrobial treatment success or failure, educationalprogramming that addresses these concepts and provides guidance for future clinical best practice is foundational to their success.

With antimicrobial stewardship and optimization as the cornerstones, this program will educate clinicians regarding their crucial role in ap‐propriate selection and delivery of available treatment regimens that are based on the individual patient’s medical condition, self‐care abil‐ities, and level of caregiver support. Novel delivery approaches will be examined, including prolonged and continuous antimicrobialadministration, in concert with strategies to improve patient compliance through education and clinical monitoring. Clinicians will leavethis program armed with the critical knowledge they need to be effective antimicrobial stewards in the home infusion setting.

Faculty: David J. Feola, Pharm.D., Ph.D., BCPS, Assistant Professor, Pharmacy Practice and Science, University of Kentucky College of Pharmacy,Lexington, KY

Dr. Feola is an Assistant Professor at the University of Kentucky College of Pharmacy in the Department of Pharmacy Practice and Science,and holds a Joint Appointment in the Division of Infectious Diseases, Department of Internal Medicine at the UK College of Medicine. Hereceived a Doctor of Pharmacy degree in 1997, a Doctor of Philosophy degree in Clinical and Experimental Therapeutics in 2005, and com‐pleted residency training in both Pharmacy Practice and Infectious Diseases Therapeutics. His research program focuses on mechanisticand translational investigations to define the role of alternative macrophage activation in the pathophysiology of pulmonary fibrosis. Thisis accomplished through the use of a mouse model of Pseudomonas aeruginosa infection and through clinical studies in patients with cysticfibrosis. The goal of this research is to identify potential therapeutic targets to slow the progression of chronic inflammation and tissue re‐modeling as the immune system interfaces with bacterial pathogens in the lungs. He also coordinates the infectious diseases module inthe Advanced Therapeutics course for the Doctor of Pharmacy Program, and provides clinical service to the Infectious Diseases inpatientconsult team at the UK Chandler Medical Center.

Pharmacist and Nurse Education Objectives:1. Describe factors influencing trends in resistance of organisms.2. Discuss the current status of antimicrobial resistance rates and patterns among common pathogens.3. Examine novel antimicrobial delivery approaches.4. List strategies to achieve optimum outcomes when administering antimicrobial agents in the alternate‐site setting.

Pharmacy Technician Education Objectives:1. Describe factors influencing trends in resistance of organisms.2. Discuss the current status of antimicrobial resistance rates and patterns among common pathogens.3. Examine novel antimicrobial delivery approaches.4. List strategies to achieve optimum outcomes when administering antimicrobial agents in the alternate‐site setting.


2011 NHIA Annual Conference & Exposition2

Learning Assessment Questions:

1. You are treating a patient with outpatient parenteral antimicrobial therapy (OPAT) for a severe skin infection with community‐acquiredMRSA. It is important to understand that compared to hospital‐acquired MRSA strains, in general community‐acquired MRSA strainshave:a. More virulence, more resistance b. More virulence, less resistance c. Less virulence, more resistanced. Less virulence, less resistance

2. In the monitoring of home antimicrobial therapy, beta‐lactamase production by the infecting organism can lead to:a. Treatment failureb. Change in antimicrobial agentc. Need for combination therapyd. All of the above

3. You sit on your organization’s OPAT team, charged with making policy decisions based on formulary inclusion and use of antimicrobials.Which of the following drug classes has the highest rate of collateral damage associated with its use?a. 3rd generation cephalosporinsb. 1st generation cephalosporinsc. Aminopenicillinsd. Fluoroquinolonese. Tetracyclines

4. Which of the following statements is true regarding antimicrobial stewardship?a. Always make sure that you cover all infectious possibilities with empiric therapyb. Err on the side of caution with empiric treatment of infectious diseases because as long as we redirect therapy when we get culture

results, outcomes aren’t affected by inadequate initial therapyc. We must balance adequate empiric therapy with judicious antimicrobial used. All of the above are true

5. Which of the following statements concerning antimicrobial use and resistance is false?a. Resistance is higher in healthcare‐associated infections compared to infections from the communityb. Receipt of previous antimicrobial therapy is a risk factor for resistancec. Care settings with highest antimicrobial use are associated with highest resistance ratesd. Increased duration of therapy decreases the likelihood of colonization with resistant organismse. All of the above are true

Answers can be found on the last page of this booklet.



Strategies for Optimizing Anti-Infective

Therapy in the Home Infusion Setting David J. Feola, Pharm.D., Ph.D.

Assistant Professor University of Kentucky College of Pharmacy

Top 5 Things to Know for CE: Make sure your BADGE IS SCANNED each time you enter a session, to record

your attendance. Carry the Evaluation Packet you received on registration with you to EVERY

session. If you’re not applying for CE, we still want to hear from you! Your opinions about our conference are very valuable.

Pharmacists, Pharmacy Technicians and Nurses need to track their hours on the Statement of Continuing Education Certificate form as they go.

FOR CE: At your last session, total the hours and sign both pages of your Statement of Continuing Education Certificate form.

Keep the PINK copies for your records. Place the YELLOW and WHITE copies in your Evaluation packet. Make sure an evaluation form from each session you attended is

completed and in your Evaluation packet (forgot to pick up an evaluation form at a session? (Extras are available in an accordion file near the registration desk.)

Put your name and unique member ID number (six digit number on the bottom of your badge) on the outside of the packet, seal it, and drop it in the drop boxes in the NHIA registration area at the convention center.

Disclosures

David Feola declares no conflicts of interest or financial interest in any service or product mentioned in this program.

Clinical trials and off-label uses will not be discussed during this presentation.



Modern Healthcare, August 7, 2006, page 36 – Protesting infections from MRSA

Hospital Acquired Infections

Mortality Length of Stay Average Charge Readmission Rate

Without infection 1.8% 4.9 days $37,635 16.3%

With HAI 9.4% 21.6 days $306,943 40.7%

Pennsylvania 2009 Heath Care Cost Containment Counsel

“Patients/consumers can use this report as an aid in making decisions about where to seek treatment…”

PA Health Care Cost Containment Council, February 2011 www.phc4.org/reports/hai/09/docs/hai2009report.pdf

Educational Objectives

1. Describe factors influencing trends in resistance of microorganisms.

2. Discuss the current status of antimicrobial resistance rates and patterns among common pathogens.

3. Examine novel antimicrobial delivery approaches.

4. List strategies to achieve optimum outcomes when administering antimicrobial agents in the alternate-site setting.

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Presentation Overview

Why antimicrobial management is essential

What is antimicrobial stewardship IDSA Guidelines: Definition Application to OPAT

How to implement/role of practitioners Recommendations Novel delivery approaches Strategies in the alternate-site setting

Why Stewardship is Needed

Antimicrobial resistance results in Increased morbidity/mortality Increased healthcare costs

Practices in antimicrobial use often inadequate, not routinely implemented

Up to 50% antimicrobial prescribing inappropriate Causal relationship between antimicrobial use and emergence of resistance

A Disturbing Trend

1930 1940 1950 1960 1970 1980 1990 2000 2010

Sulfa, BL, AG, Chloramphenicol

TCN, MAC, Vanc, RIF, FQ, TMP

No new classes. Modification of existing agents.

LZD, DAP, TIG

CPT; DAL; New Entities

Limited

PCN-resistant S. aureus

MRSA

VRE

VISA in 7 states

VRSA

LZD-R S. aureus

MDR Pseudomonas and Acinetobacter, metallo-beta-lactamases, carbapenemases

Over half of companies END antimicrobial research and development



The Critical Balance

Importance of appropriate empiric therapy

Effect of broad-spectrum therapy on resistance

Mortality increases when initial therapy is inappropriate

Resistance increases when broad-spectrum

agents are needed; Resistance has a

negative impact on outcomes

“Collateral damage”

Appropriate Initial Therapy

*Difference in mortality not significant. LOS significantly increased



Antimicrobial Use and Resistance

Changes in use parallel changes in resistance Resistance higher in healthcare-associated infections Patients with resistant infections more likely to have received prior antimicrobials Hospital areas of highest resistance associated with highest antimicrobial use Increased duration of therapy increase likeliness of colonization with resistant organisms

Shales DM et al. CID 1997;25:584-99.

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Resistance and OPAT

Most common resistant organisms in OPAT Methicillin-resistant Staph aureus (MRSA) Vancomycin-resistant Enterococci (VRE) Multidrug-resistant Gram-negatives

P. aeruginosa K. pneumoniae E. coli

Penicillin-resistant Streptococcus pneumoniae

CDC. Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings. www.cdc.gov/ncidod/dhqp/ar_multidrugFAQ.html

MRSA and Outcomes

MRSA vs. MSSA bacteremia Clinical Failure: 59.6% vs. 33% (P<0.001) Length of Stay (infection-related): 20.1 vs. 13.7 days (P<0.001)

Mortality (infection-related): 30.6% vs. 15.3% (P=0.001)

Lodise T and McKinnon P. Diag Microbiol Inf Dis 2005;52.


and outcomes


VRE and Outcomes

VRE bacteremia Decreased survival: 24% vs. 59% Length of Stay: 34.8 vs. 16.7 days

Attributable cost: $27,190

VRE bloodstream meta-analysis Mortality increase: 30%

Stoser V et al. Arch Int Med 1998;158:522-7

DiazGranados CA et al. CID 2005;41:327-33.

Salgado CD et al. Inf Contr Hosp Epid 2003;24:690-8.


and outcomes




ESBL Production and Outcomes

Non-urinary tract isolates of Klebsiella, E. coli Length of stay

21 days vs. 11 days (P=0.006)

Clinical success 48% vs. 86% (P=0.027)

Lee, et al. Inf Cont Hosp Epi 2006;27:1226-32


and outcomes


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Collateral Damage

Fluoroquinolones—selection of resistant isolates when appropriate pharmacodynamic parameters are not met (AUC/MIC)

Pseudomonas aeruginosa Methicillin-susceptible Staph aureus Streptococcus pneumoniae

Garcia-Rey C et al. Clin Microbial Infect 2006;12:55-66 Jacobi GA. Clin Infec Dis 2005;41:S120-6 Cook PP et al. J Hosp Infect 2006:54:341-58.

Collateral Damage

3rd generation cephalosporins Cause/associated with several different problems (oximinocephalosporins)

Extended-spectrum beta-lactamases Selection of stably derepressed isolates Gram-negatives Selection of vancomycin-resistant enterococcus Contribution to MRSA emergence Increased cases of Clostridium difficile associated diarrhea/colitis

Dancer SJ. J Antimcirobial Chemother 2001; 48: 463-478

Pseudomonas aeruginosa Correlation Between Imipenem Use and Resistance

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Mechanism Classes

Mechanism Affected Agents

Drug modification/degradation -lactams, FQ, AGL, TCN, macrolides, linezolid, clindamycin

Decreased bacterial permeability

Sulfa, AGL, TCN, daptomycin, carbapenems

Alteration of target site -lactams, FQ, TCN, vancomycin, linezolid, clindamycin, macrolides

Efflux pumps FQ, AGL, TCN, macrolides, carbapenems

-Lactamases

More than 340 different types have been described More than 120 ESBLs New ESBLs identified monthly

Classified by: Plasmid vs. chromosomally mediated

Genes located on plasmids can spread

Constitutive vs. inducible production Expression relates to -lactam exposure

TEM and SHV -Lactamases

Extended spectrum beta-lactamases (ESBL) Mutants of classical enzymes Hydrolyze most extended-spectrum cephalosporins and aztreonam Carbapenems are spared Inhibited by clavulanic acid

Organisms that produce ESBLs Klebsiella, E. coli, other Enterobacteriaceae and non-fermenting Gram-negative bacteria

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Molecular Basis of ESBLs

Treatment of ESBL Producers

Carbapenems: current drugs of choice

Cefepime: more stability but reports of treatment failures

Little reported experience with trimethoprim/ sulfamethoxazole, aminoglycosides and fluoroquinolones

Tigecycline may be an option

Inducible Beta-lactamases

Produced by the SPACE Bacteria Serratia marcescens Pseudomonas aeruginosa Acinetobacter species Citrobacter species

Enterobacter species

-lactamase under the control of the ampC gene (turn on) and repressor gene (turn off)

Mutation is loss of the repressor gene – terminology is the isolate becomes “stably de-repressed” Drugs of choice: carbapenems, cefepime

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Stable Derepression

Selection of stable derepressed mutants: susceptible when tested, then resistance 3 days later

Resistant Strain Rare

Selection During Therapy

Resistant Strain Dominant

Carbapenems: Emerging Resistance

Meropenem and P. aeruginosa Up-regulation of efflux pumps Loss of the OprD protein (porin channel)

Both mutations needed for resistance development MIC 0.12–0.5 g/ml (before mutation) MIC 2-4 g/ml (with one mutation) MIC >8 g/ml (with both mutations)

Emergence of carbapenemases

Livermore D. JAC 2001; 47: 247-250

Perilous Cycle: KPC Example

Resistant Pathogen

Antimicrobial Resistance

Antimicrobial Use

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Oximinocephalosporins ESBL production

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MRSA – loss of the target site – PBP2 which is replaced by PBP2a

mecA gene, associated with other resistance genes in the Staphylococcal chromosome cassette (SCCmec) PBP2a confers resistance to all beta-lactams

Streptococcus pneumoniae PCN resistance when mutations in 4 PBPs If PCN resistant, increased macrolide resistance, FQ resistance still low

CA-MRSA Prescribing Trends

KY Medicaid Database

Beavers C. et al. Unpublished

MRSA Treatment Options

FDA-approved Vancomycin, linezolid, daptomycin, tigecycline, telavancin

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CA-MRSA vs. HA-MRSA

Characteristic CA-MRSA HA-MRSA Susceptibility

Chloramphenicol Usually susceptible Frequently resistant

Clindamycin Usually susceptible Frequently resistant

Erythromycin Usually resistant Usually resistant

TMP/SMZ Usually susceptible Usually susceptible

SCC mec type IV II

Lineage USA 300 USA 100, USA 200

Toxins More Fewer

PVL Common Rare

Weber JT. CID 2005;41 Suppl 4:S269-72

CA-MRSA Importance of I&D

166 patients randomized to receive cephalexin or placebo after incision and drainage

87.8% of positive cultures were MRSA

Outcome Number of Isolates

All isolates MRSA PVL-positive

Cephalexin (82)

Cure 69 40 38

Failure 13 2 2

Placebo (84)

Cure 76 39 37

Failure 8 4 3

Rajendran et al. Antimicr Agents Chemother 2007;51:4044-8.

Vancomycin

Glycopeptide antimicrobial that inhibits transpeptidation reaction

D-ala–D–ala

Mechanisms of resistance: change in bacterial target D-ala–D–lac (VanA, B, D) D-ala–D–ser (VanC, E, L) Enterococcus sp.

E. faecium incidence of resistance higher that E. faecalis VanA gene is on a plasmid

Am J Health Syst Pharm 2000;57:S4-9 Clin Pharmacokinet 2004;43:925-942 Clin Infect Dis 2006; 2006; 42:S35–9



Vancomycin Resistance

MRSA increasing MICs to vancomycin (1-2 mcg/ml) Still susceptible, but increase in treatment failures VISA mechanism: increased cell wall structural material

VRSA mechanism: MRSA acquires the VanA gene Rare in the US

Am J Health Syst Pharm 2000;57:S4-9 Clin Pharmacokinet 2004;43:925-942 Clin Infect Dis 2006; 2006; 42:S35–9

Vancomycin MIC and Outcomes

Clinical success rates decrease with increasing MICs, even in the susceptible range

Percent Success

Vanco MIC ( g/ml) Bacteremia Various Indications

0.5 56 54

1.0 28

1.0-2.0 10

2.0 8

Moise-Broder PA. Clin Infect Dis. 2004;38:1700-05. Sakoulas G et al. J Clin Microbiol. 2004; 42:2398-402.

MRSA Treatment Options

Vancomycin still the standard

What are the local MICs for MRSA (i.e., 0.5 vs. 2 μg/ml)

Need for higher doses

Alternatives to Vancomycin

Hospitalized SSSI – Daptomycin, linezolid, tigecycline

Hospital-acquired pneumonia – Linezolid, tigecycline, telavancin

Bacteremia – Daptomycin monotherapy

Endocarditis – Daptomycin monotherapy



Resistance and OPAT

Risk factors for infection with resistant organisms Severity of illness Previous exposure to antimicrobial agents Underlying disease conditions

Chronic renal disease, DM, PVD, skin lesions

Invasive procedures Dialysis, invasive devices, urinary catheterization

Repeated contact with healthcare system Previous colonization with drug-resistant organisms Advanced age


Economic Impact of Resistance

S. aureus bacteremia Methicillin resistance: 100% greater cost of therapy

Klebsiella and E. coli infections ESBL production: 66% greater cost of therapy

Pseudomonas aeruginosa infections Imipenem resistance: 68% greater cost of therapy

Lodise T and McKinnon P. Diag Microbiol Inf Dis 2005;52.

Lee, et al. Inf Cont Hosp Epi 2006;27:1226-32.

Lautenbach, et al. Inf Cont Hosp Epi 2006;27:893-90.

Antimicrobial Stewardship

Infection control plus antimicrobial management Appropriate antimicrobial selection, dosing, route, and duration System selection of antimicrobials that cause the least collateral damage

MRSA ESBLs Clostridium difficille Stable derepression Metallo-beta-lactamases and other carbapenemases VRE



Guideline Resources

IDSA and SHEA Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship Dellit TH et al. CID 2007;44:159-77

IDSA Practice Guidelines for Outpatient Parenteral Antimicrobial Therapy

Tice AD et al. CID 2004;38:1651-72

ASM and SHEA Antimicrobial Resistance Prevention Initiative Moellering RC et al. Am J of Inf Contr 2007;35:S1-23

Role of Infection Control

Infection control trumps everything else Hand hygiene – must have hand washing police Barrier precautions

Devotion to all aspects of strict infection control Nursing staff Medical staff Medical staff leadership

Infection Control – is it cost effective?

Infection Cost Savings VAP $25,072 Bacteremia $23,242 Surgical Site infection $10,443 Urinary Tract Infection $ 758

Anderson, et al. Infect Control Hosp Epidem 2007;28:767-73



Resistance and OPAT

Home precautions Wash hands with soap and water after physical contact with infected person, and before leaving the home Wash towels after each use Wear disposable gloves for contact of body fluids, and wash hands after glove removal Change linens on a routine basis Clean patient environment regularly Notify all who provide care that the patient is colonized/infected with a multidrug-resistant pathogen


Hand Hygiene

Bacterial contamination of mobile phones 110 nurses carrying mobile phones

79.1% of phones had viable bacteria

68.6% had S. aureus

Flora on mobile phones at a teaching hospital S. aureus 33%

P. aeruginosa 2%

Acinetobacter spp. 9.1%

Behavioral changes necessary

Single-most effective measure to prevent spread of resistant organisms

Multifaceted educational programs, persistence

vs.

Mathai E et al. Infection 2010;38(5):349-56. Morioka I et al. 2011;66(1):115-21 Sadat-Ali M et al. AJIC 2010;38:404-5

Goals of Stewardship

Primary goal Optimize clinical outcome/minimize unintended consequences of antimicrobial use Unintended consequences:

Toxicity Selection of pathogenic organisms Emergence of resistant pathogens

Secondary goal Reduce healthcare costs without adversely impacting quality of care

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Active Core Strategies

Prospective audit with intervention and feedback to reduce inappropriate antimicrobial use

Formulary restriction and pre-authorization leading to reductions in antimicrobial use and cost

NOTE – neither of these strategies are mutually exclusive

Assessments

Antimicrobial consumption Defined daily dose Cost Days of treatment

Antimicrobial adverse events Resistance patterns/development Clinical outcomes measurements

Patel D et al. Exp Rev Anti Infect Ther 2008; 6:209-22

Elements for Consideration

Parenteral to oral conversion OPAT allows for IV treatment to continue, while minimizing cost

Streamlining/de-escalating therapy Often requires changes in home care/monitoring

Dose optimization Based on PK/PD parameters

Educational programs Prescribers, clinicians, patients, caregivers

Guidelines/clinical pathways development Incorporate local antimicrobial resistance data

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Formulary Restriction: Example

After initiation of formulary restriction

Third-generation cephalosporins use decreased

Cefepime use remained stable

Rates of ceftazidime-resistant Klebsiella pneumoniae decreased

Martin CA et al. Am J Health Syst Pharm. 2005;62:732-738.

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Concentration-dependent killing Higher the concentration, the greater the rate & extent of bactericidal activity

Cpk/MIC ratio or AUC/MIC correlate with activity

Aminoglycosides, fluoroquinolones, metronidazole

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Time-dependent killing Saturation of the killing rate occurs at low multiples of the MIC Killing dependent upon time above the MIC

Beta-lactams, vancomycin, clindamycin, macrolides

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Continuous Infusion

Vancomycin Continuous infusion unlikely to substantially improve patient outcomes

Beta-lactams Meta-analysis of 9 RCT

Clinical failure rate lower, statistically significant in studies of patients receiving same total daily dose

No differences in mortality

Rybak MJ et al. Am J Health-Syst Pharm 2009;66:82-98.

Kasiakou SK et al. Lancet Inf Dis 2005;5(9):581-9.

Continuous Infusion

Piperacillin/tazobactam Harford Hospital utilizing CI since 1999

Results dependent upon MIC

Use for P. aeruginosa

Kim A et al. Pharmacotherapy 2007;27(11):1490-7.

Grant EM et al. Pharmacotherapy 2002;22:471-83.

Success Rates P Value

Clinical Microbiologic

Continuous 94% 89% 0.081

Intermittent 82% 73% 0.092

PK/PD Challenges in OPAT

Must balance optimum dosing and convenience Continuous infusion of beta-lactams increasingly studied Intricate communication required for therapeutic drug monitoring and dosage adjustment in home Adequate dosing must minimize collateral damage Treatment duration with antimicrobials an issue on the horizon

Tice AD et al. CID 2004;38:1651-72.



Treatment Duration

Adequate duration essential However, increases in duration equate with increases in resistance development

Experts call for study of treatment duration to attempt to minimize Will require individualized patient case decisions and coordination

OPAT uniquely positioned to impact this issue

Rice LB. CID 2008;46:491-6.

Treatment Duration

Prolonged antibiotics courses have long been considered the solution to, instead of the cause of, resistance

CDC “Get Smart” Website “Complete the prescribed course of treatment, even if you are feeling better.”

Example: CAP Guidelines 2000: “We are not aware of any controlled trials that have specifically addressed the question of how long pneumonia should be treated”

2007: “Patients with CAP should be treated for a minimum of 5 days, should be afebrile for 48-72h, and should have no more than 1 sign of CAP-associated clinical instability before discontinuation of therapy.”

Rice LB. CID 2008;46:491-6.

www.cdc.gov/getsmart (accessed Mar 29, 2011)

Mandel LA et al. CID 2007;44(Suppl 2):S27-72.

Research Priorities

Antimicrobial duration of therapy

Validation of mathematical models of resistance

Long-term impact of formulary restrictions

Focusing interventions on “collateral damage issues”

Development of more rapid susceptibility tests

Bad bugs/no drugs – stimulate research

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Critical Success Factors

Collegial and educational relationship

Review of antimicrobial orders by a consistent accountable team

Support of hospital/medical leadership

FTE’s dedicated to stewardship

Development of criteria and guidelines for anti-infective use

Formulary restriction

Education of prescribers to insure compliance

Summary and Conclusions

Antimicrobial Stewardship programs show great promise and offer new opportunities for patient care and cost impact

Recommendation by both IDSA/ASHP and the CDC offer firm foundations to obtain support and funding for antimicrobial stewardship programs

Huge opportunity for advancement of clinical pharmacy practice, role of OPAT



Answers:BDACD

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