Ways YOU can act against Antibiotic Resistance

The new antibiotic mantra:

Shorter is better!Multiple randomized trials have compared

patient outcomes with longer vs shorter duration of therapy; For pneumonia, pyelonephritis, uncomplicated gram negative bacteremias,

cellulitis, ~7 days is enough!

Highlighted references (complete list online at www.bradspellberg.com/shorter-is-better)

Community Acquired Pneumonia: Effectiveness of discontinuing antibiotic treatment after three days versus eight days in mild to moderate-severe community acquired pneumonia: randomised, double blind study. Bmj 2006; 332(7554): 1355.Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Random-ized Clinical Trial. JAMA internal medicine 2016; 176(9): 1257-65.

Nosocomial/Ventilator Associated Pneumonia: Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. JAMA: the journal of the American Medical Association 2003; 290(19): 2588-98.Early-onset ventilator-associated pneumonia in adults randomized clinical trial: comparison of 8 versus 15 days of antibiotic treatment. PLoS One 2012; 7(8): e41290. Complicated UTI/PyelonephritisOne or three weeks’ treatment of acute pyelonephritis? A double-blind comparison, using a fixed combination of piv ampicillin plus pivmecillinam. Acta Med Scand 1988; 223(5): 469-77.Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet 2012; 380(9840): 484-90.

GNB BacteremiaSeven versus fourteen Days of Antibiotic Therapy for uncomplicated Gram-negative Bactere-mia: a Non-inferiority Randomized Controlled Trial. Clin Infect Dis 2018 69:1091-8.

CellulitisComparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med 2004; 164(15): 1669-74.Antibiotic treatment for 6 days versus 12 days in patients with severe cellulitis: a multicentre randomised, double-blind, placebo-controlled, non-inferiority trial. Clin Microbiol Infect 2019; ePub

Neutropenic FeverOptimisation of empirical antimicrobial therapy in patients with haematological malignancies and febrile neutropenia (How Long study): an open-label, randomised, controlled phase 4 trial. Lancet Haematol 2017; 4(12): e573-e83.

Symptom Free Pee - Let It Be!Asymptomatic bacteriuria (ASB - bacteria in the urine

without any symptoms) should be distinguished clinically from a UTI;

Unnecessary antibiotic treatment of ASB in older adults is common, and now antimicrobial resistance in

urinary organisms is a HUGE problem!

Some common misconceptions:My patient has (+) Leuk Esterase/ WBC’s in her urine – they have a UTI!Bacteriuria and even WBC’s in urine is often seen in elderly and institutionalized patients (25–50% of women and 15–49% of men). Bacteriuria and pyuria in the elderly is, to a large degree, an expected finding. In the absence of urinary symptoms, this does not need treatment. Do not treat a lab result, treat the patient!

My patient is altered. She cannot tell me his/her symptoms, I should treat for a UTI.WBC’s in urine/bacteriruria is especially common in this population. Elderly patients with mental status changes, with bacteriuria and pyuria, but without clinical instability or other signs or symptoms of UTI, should be observed for resolution of confusion for 24–48 h without antibiotics, as confusion is often from other causes.

My delirious patient got better with antibiotics. She had a UTI for sure!Just because “B” followed “A”, does not mean “A” caused “B”

Resources to help youProcalcitoninPCT is highly specific biomarker for bacterial infection. It can be used to differentiate bacterial from viral causes of infection or non-infectious states. (results should be used as a guide and should not supercede clinical judgement)

Antibiotics are generally not recommended if PCT result is lower than established thresholds but for very ill patients, initial value can be negative and antibiotics should NOT be withheld while awaiting results.

See website below for more details

MRSA Nares PCRHas a negative predictive value of >99% for MRSA pneumonia; NO MRSA in nares = NO MRSA pneumonia; (You can stop that Vanco if you are treating pneumonia)

Montefiore/Einstein Stewardship TeamGuidelines for C. diff, PCT, infectious diarrhea, antibiograms, empiric prescribing cards and much more are available at:

http://www.einstein.yu.edu/departments/medicine/divisions/infectious-diseases/antimicrobial-stewardship/