Antibiotic Stewardship in Primary Care: Less is More

Marla Calvert, M.D.

No Disclosures

http://dianamackenzie.tumblr.com/post/86884680610/holy-crap-not-actually-mold-klari-reiss-daily

Antibiotic Stewardship

Why it mattersEnterobacteriaceaeStreptococcus pneumoniaeStaphylococcus aureusTake home points and resources

http://antibotics.ideo.com/

Antibiotic Resistance Threats in the United States, CDC, 2013

WHO Antimicrobial Resistance Global Report on Surveillance 2014

Resistance over time

Clatworthy, A., Pierson, E., & Hung, D. (n.d.). Targeting virulence: A new paradigm for antimicrobial therapy. Nature Chemical Biology., 3(9), 541-548.

National Ambulatory Medical Care Survey (NAMCS)National Hospital Ambulatory Medical Care Survey (NHAMCS)

184,032 ambulatory care visits

Antibiotics prescribed in 12.6% of visits

Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864-1873.

50% of prescriptions for acute respiratory conditions unnecessary

~30% of all prescriptions may have been inappropriate.”

Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016;315(17):1864-1873.

New Antibiotic Development

Fewer drug companies making antibiotics

Research funding cuts

Antibiotics are cheap and temporary

Slow adoption of new agents

Antibiotic resistance

Ventola CL. The Antibiotic Resistance Crisis: Part 1: Causes and Threats. Pharmacy and Therapeutics. 2015;40(4):277-283.

ANTIBIOTIC RESISTANCE IS A PROBLEM

Patient morbidity and mortality

Antimicrobial efficacy

Cost

https://www.youtube.com/watch?v=znnp-Ivj2ek

When they are necessary

The right antibiotics

In the right way

Antibiotic Stewardship:

Antibiotic Resistance Threats in the United States, 2013 (CDC report)

Antibiotic Resistance Threats in the United States, 2013. CDC

Hazard levels

Serious

Antibiotic Resistance Threats in the United States, CDC, 2013

Extended spectrum beta-lactamase:

Hydrolyze penicillins, cephalosporins, monobactams

Fluoroquinolone resistance

Carbapenem resistance risk

Rupp, M.E. & Fey, P.D. Extended Spectrum β-Lactamase (ESBL)-Producing Enterobacteriaceae: Considerations for Diagnosis, Prevention and Drug Treatment. Drugs (2003) 63: 353.

ESBL risk factors:Recent antibiotic useRecurrent UTI, catheterizationRecent hospitalizationAdvanced ageHemodialysisRecent international travel

http://love-life-science.blogspot.com/2014/09/bacterial-gifts.html?spref=pi

What can you do?

Foxman, B. (2010). The epidemiology of urinary tract infection. Nature Reviews.,7(12), 653-660.

2010 IDSA Guidelines for Uncomplicated UTI

100 mg BID for 5 days

160/800 mg BID for 3 days

*Resistance ≤ 20%

No use in the past 3 months

3 g once

Swedish 2015 Antibiogram:

Outpatient: 18% Bactrim resistance

Inpatient: 14% Bactrim resistance

Nitrofurantoin still best

Serious

Antibiotic Resistance Threats in the United States, CDC, 2013

Drug resistant S. pneumo

Current estimates: 5% penicillin resistance3% cephalosporin resistance30% macrolide resistance20% SMX-TMP resistance

Wiskirchen, D., Summa, M., & Perrin, A. (2016). Antibiotic stewardship: The FP's role. The Journal of Family Practice., 65(12), 876-885.

What can you do?

Reduce antibiotic use in URI

Rapid diagnostic assays

IDSA guidelines for ABRI

Vaccination

Delayed prescribing

Improve antibiotic use in URI PCN allergy testing

Reduce use with Rapid diagnostic assays:

Rapid strep test (sens 85.6%, spec 95.4%)

ProcalcitoninMeta analysis including 1,458 patients showed 51% reduction in antibiotic use without altering treatment outcomes

http://clinical-laboratory.blogspot.com/2015/04/

90%–98% of rhinosinusitis is viral

When to treat:Persistent symptoms for 10+ daysFever >39C, purulent discharge, facial pain for 3-4 days”Double sickening”

Augmentin is 1st line for adults.

http://www.wikihow.com/Clear-a-Sinus-Infection

Reduce use…

Reduce use with Delayed Prescribing

“Wait and see” approachWait to fill vs return to clinicBe specific about when to fill a prescriptionSinusitis, AOM, URI

Acute Otitis Media• At least half of patients with AOM will recover

without antibiotic therapy• NNT of approximately 4800 patients to prevent 1

case of mastoiditis

Lieberthal AS, Carroll AE, Chonmaitree T, et al. Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics, Feb 2014, 133 (2) 346-347

Delayed Prescribing for AOM:

• ~33% fewer prescriptions filled with delayed prescribing

• Patients >6 months with unilateral/mild symptoms: OBSERVE

• Otalgia >48H, T >39C, otorrhea, bilateral effusion: TREAT

• 90 mg/kg/day amoxicillin for 5-7 days

• Augmentin if amoxicillin prescribed in the past 30 days

Lieberthal AS, Carroll AE, Chonmaitree T, et al. Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013;131(3):e964–e999Pediatrics, Feb 2014, 133 (2) 346-347

• 3157 patients with URI symptoms• Delayed prescription reduced antibiotic use• No increase in complications• Patient satisfaction: immediate prescribing (92%), delayed

(87%), no prescribing (83%).

Spurling GKP, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotics for respiratory infections. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004417.

Reduce use with PCV13

PCV7 (2000) did not protect against serotype 19A PCV13 (2010) protects against serotype 19A80% effective in prevention of vaccine serotype invasive pneumococcal disease in children <2yo.

Lucero MG, Dulalia VE, Nillos LT, Williams G, Parreño RAN, Nohynek H, Riley ID, Makela H. Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and X-ray defined pneumonia in children less than two years of age. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD004977.

Improve use with Penicillin allergy testing

■ American Academy of Allergy, Asthma & Immunology

■ Released March 3, 2014

■ Don’t overuse non-beta lactam antibiotics in patients with a history of penicillin allergy, without an appropriate evaluation.

Swedish 2015 Antibiogram

Minimal resistance, very small sample sizes

http://www.cartoonistgroup.com/subject/The-Antibiotic+Resistant-Comics-and-Cartoons.php

Serious

Invasive MRSA infections

Overall cases declining

Recent rise in community-acquired infections

Antibiotic Resistance Threats in the United States, 2013. CDC

Community acquired MRSA

Skin & soft tissue infectionsResistance to beta-lactams, macrolides, aminoglycosides, fluoroquinolones, clindamycin

Wiskirchen, D., Summa, M., & Perrin, A. (2016). Antibiotic stewardship: The FP's role. The Journal of Family Practice., 65(12), 876-885.

MRSA: What can you do?■ Reserve antibiotics for extensive disease, systemic

symptoms, purulent cellulitis without drainable foci, septic phlebitis, failure to respond to incision and drainage alone.

Wiskirchen, D., Summa, M., & Perrin, A. (2016). Antibiotic stewardship: The FP's role. The Journal of Family Practice., 65(12), 876-885.

Wiskirchen, D., Summa, M., & Perrin, A. (2016). Antibiotic stewardship: The FP's role. The Journal of Family Practice., 65(12), 876-885.

In summary:■ Know local resistance patterns■ Use the right antibiotic for the shortest effective duration■ For uncomplicated cystitis: Nitrofurantoin, Bactrim if resistance doesn’t exceed

20%■ Minimize antibiotic use when viral URI is more likely (sinusitis, AOM, URI)■ Encourage vaccination with PCV13■ Consider delayed prescribing■ Reduce unnecessary antibiotic use in MRSA skin infections

SourcesAntibiotic Resistance Threats in the United States, 2013 (CDC report)

Antimicrobial Resistance Global Report on Surveillance 2014 (WHO report) http://www.who.int/drugresistance/documents/AMR_report_Web_slide_set.pdf?ua=1

Clatworthy, A., Pierson, E., & Hung, D. (n.d.). Targeting virulence: A new paradigm for antimicrobial therapy. Nature Chemical Biology., 3(9), 541-548.

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Michael CA, Dominey-Howes D, Labbate M. The Antimicrobial Resistance Crisis: Causes, Consequences, and Management. Frontiers in Public Health. 2014;2:145. doi:10.3389/fpubh.2014.00145.

American Academy of Pediatrics. Antimicrobial Resistance2. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book®: 2015 REPORT OF THE COMMITTEE ON INFECTIOUS DISEASES. American Academy of Pediatrics; 2015; 874

Ventola CL. The Antibiotic Resistance Crisis: Part 1: Causes and Threats. Pharmacy and Therapeutics. 2015;40(4):277-283.

Ventola CL. The Antibiotic Resistance Crisis: Part 2: Management Strategies and New Agents. Pharmacy and Therapeutics. 2015;40(5):344-352.

Rupp, M.E. & Fey, P.D. Extended Spectrum β-Lactamase (ESBL)-Producing Enterobacteriaceae: Considerations for Diagnosis, Prevention and Drug Treatment. Drugs (2003) 63: 353. doi:10.2165/00003495-200363040-00002

Sources, continuedTang H, Huang T, Jing J, Shen H, Cui W. Effect of procalcitonin-guided treatment in patients with infections: a systematic review and meta-analysis. Infection 2009; 37:497–507.

Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics. Adam L. Hersh, Mary Anne Jackson, Lauri A. Hicks, the COMMITTEE ON INFECTIOUS DISEASES. Pediatrics Dec 2013, 132 (6) 1146-1154; DOI: 10.1542/peds.2013-3260

Spurling GKP, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotics for respiratory infections. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004417. DOI: 10.1002/14651858.CD004417.pub4.

Lieberthal AS, Carroll AE, Chonmaitree T, et al. Clinical Practice Guideline: The Diagnosis and Management of Acute Otitis Media. Pediatrics. 2013;131(3):e964–e999Pediatrics, Feb 2014, 133 (2) 346-347

Lucero MG, Dulalia VE, Nillos LT, Wiliams G, Parreño RAN, Nohynek H, Riley ID, Makela H. Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and X-ray defined pneumonia in children less than two years of age. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD004977. DOI: 10.1002/14651858.CD004977.pub2.

Sabuncu E, David J, Bernède-Bauduin C, et al. Significant Reduction of Antibiotic Use in the Community after a Nationwide Campaign in France, 2002–2007. Klugman KP, ed. PLoS Medicine. 2009;6(6):e1000084. doi:10.1371/journal.pmed.1000084.

Foxman, B. (2010). The epidemiology of urinary tract infection. Nature Reviews.,7(12), 653-660.

Regamey N, Kaiser L, Roiha HL, Deffernez C, Kuehni CE, Latzin P. et al. Viral etiology of acute respiratory infections with cough in infancy — A community-based birth cohort study. Pediatr Infect Dis J. 2008;27(2):100–105.

Cohen JF, Bertille N, Cohen R, Chalumeau M. Rapid antigen detection test for group A streptococcus in children with pharyngitis. Cochrane Databaseof Systematic Reviews 2016, Issue 7. Art. No.: CD010502. DOI: 10.1002/14651858.CD010502.pub2.

Centers for Disease Control and Prevention (CDC). Guidance for Clinicians on the Use of Rapid Influenza Diagnostic Tests. CDC 2016 May 26

John G. Bartlett, David N. Gilbert, Brad Spellberg; Seven Ways to Preserve the Miracle of Antibiotics. Clin Infect Dis 2013; 56 (10): 1445-1450. doi: 10.1093/cid/cit070

Kalpana Gupta, Thomas M. Hooton, Kurt G. Naber, Björn Wullt, Richard Colgan, Loren G. Miller, Gregory J. Moran, Lindsay E. Nicolle, Raul Raz, Anthony J. Schaeffer, David E. Soper; International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. ClinInfect Dis 2011; 52 (5): e103-e120. doi: 10.1093/cid/ciq257

Wiskirchen, D., Summa, M., & Perrin, A. (2016). Antibiotic stewardship: The FP's role. The Journal of Family Practice., 65(12), 876-885.

https://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/adult-treatment-rec.pdf

https://www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/pediatric-treatment-rec.pdf