Supplemental Content - Annals of Internal Medicine

Antimicrobial Self-Stewardship:
Putting the CDCs antibiotic
“timeouts” to work
Internal Medicine and Infectious Diseases
McGill University Health Centre
(Royal Victoria Hospital / Montreal General Hospital)
Assistant Professor of Medicine, McGill University
What is Stewardship?
• Optimizing:
– Selection of spectrum
– Dose
– Route
– Duration
• To MAXIMIZE clinical cure or prevention of
• While reducing:
1. Adverse drug events (including C. difficile)
2. Antimicrobial resistance within the hospital
3. Cost
• While reducing:
1. Adverse drug events (including C. difficile)
2. Antimicrobial resistance within the hospital
3. Cost
• While reducing:
1. Adverse drug events (including C. difficile)
2. Antimicrobial resistance within the hospital
3. Cost
• While reducing:
1. Adverse drug events (including C. difficile)
2. Antimicrobial resistance within the hospital
3. Cost
Methods of Stewardship
• Guidelines/Education
• Formulary restriction
– Often using special forms
• Antibiotic rotation
– i.e. change the common antibiotics used for
certain infections periodically
• Prospective audit and feedback
• Attempt to synthesize evidence-based
recommendations based on local
• Goal is to eliminate variability in practice for
the most common infections
• Recommendations based on epidemiology
and principles of stewardship
Local guidelines
• Consensus amongst ID faculty
• Based on professional society guidelines
• Adapted to base on local
epidemiology/resistance patterns
• Adjusted for new publications within the field
• Revised annually since 2011
Community Acquired Pneumonia
• What are the common pathogens?
• Which antibiotics predictably cover them in your
• Which antibiotics do we favor locally?
• Does the patient have an epidemiologic risk for
an infection not usually covered?
Community Acquired Pneumonia
• Notes:
• PO quinolones or azithromycin as soon as tolerates oral
• In the absence of bacteremic Staphylococcus aureus, empyema, abscess,
necrotizing lung infection or Legionella: CAP may safely be treated with FIVE
days total therapy – particularly with fluoroquinolones for which RCT data is
available and robust
– Clin Infect Dis. (2011) 52 (10): 1232-1240
• Who should receive antibiotics (if you accept that
they are associated with benefit)?
• What are the major pathogens?
• What is our local resistance?
• What is known about the patient’s own
COPD Exacerbations = 2 of 3 of sputum,
purulence, dyspnea; not pneumonia
• No risk factors for resistance:
• One of: FEV1<50; 4 exacerbations/yr., home
O2, steroids recently, abx in past 3 months
• Uncomplicated:
no venous catheter around site
no water borne injury or bite wound
not associated with purulence, gangrene, fasciitis or an infected
diabetic foot ulcer
**Up to 75% likely group A streptococcus and up to 95% will respond to
narrow spectrum beta-lactams**
Jeng et al., Medicine July 2010 - Volume 89 - Issue 4 - pp 217-226
Empiric MRSA Coverage
• Unless shock or purulence, empiric VANCOMYCIN not
required unless clearly not responding to beta-lactam
Frequent use of potentially unnecessary
diagnostic studies, broad-spectrum antibiotic
therapy, and prolonged treatment courses in
these patients suggest targets for antimicrobial
stewardship programs.
The diabetic foot
• Mild:
• Moderate:
The diabetic foot
• LIMB THREATENING – i.e. vascular surgery
probably should be the one admitting
C. Difficile – 1st episode or 1st relapse
• NB: 125mg VANCOMYCIN dose for moderate.
Never been shown more is better – certainly
costs more (especially when they go home!)
The elephant is in the room!
• In general requires:
– Positive urinalysis (unless neutropenic)
– Symptoms attributable to lower or upper urinary
Asymptomatic bacteriuria
• Very common
– especially in female patients from nursing homes,
incontinent patients
• Free guidelines available online from the IDSA
Asymptomatic bacteriuria
• Treatment in adults should be limited to:
– Pregnant women
– Upcoming invasive urologic procedure
• Procedure where there will be mucosal bleeding
• Doing a renal transplant
Asymptomatic bacteriuria
• Randomized trials have shown no harm in not
– See also: Gross PA, Patel B Reducing antibiotic overuse: a
call for a national performance measure for not treating
asymptomatic bacteriuria. Clin Infect Dis 2007;45:13351337.
Asymptomatic bacteriuria
• Other randomized trials have shown treating
causes more resistance and paradoxically
more UTIs
– Clin Infect Dis. (2012) 55 (6): 771-777.
Asymptomatic bacteriuria
• Many will use in kidney transplant 1st month
• Beyond 1 month some evidence of increased
rate of symptomatic UTIs requiring
Excluded 1st MONTH
Cohort study – but similar effects seen in three other
Scope of the problem
• We performed 38048 urine cultures in 2012!
• Each urine culture costs $7.40
• Total Cost (lab only) = $281 555
– Downstream costs exponentially more
– Antibiotics (potentially IV)
• C. difficile, resistance, $$$
– Length of Stay
Take home message
• Avoid treating asymptomatic bacteriuria
• Avoid culturing urine looking for ASB without
good reason
UTI – Hospitalized patients
Gentamicin with caution in:
Renal insufficiency or concomitant administration of other nephrotoxins
Cirrhosis (hepatorenal syndrome)
Existing sensorineural hearing loss or vestibular dysfunction
Level independent side effects
Existing sensory neuropathy for which loss of vestibular function would be severely disabling
Make sure levels are done after 48 hours of use and that you consult with your
pharmacist to ensure proper monitoring and targets
Culture data is going to be important to find alternative agent for longer use
Your mission…
• For each of your patients, at regular intervals
– Take a “time out” to reassess their antibiotics
Antibiotic Self-Stewardship
• Concept:
– Periodic twice weekly scheduled review of all
antibiotics by the practicing team
– On demand involvement of ID
Advantages of self-stewardship!
• Maintain full control over antibiotic
prescription without external influence
• Develop skills in antibiotic stewardship which
are expected to have long term educational
effects over a career
How do I perform self-stewardship?
• Then next several minutes dedicated to
teaching our housestaff how to use the
electronic audit tool properly.
• This tool is available for you to view in
appendix 2
If the patient does not have a suspected or
proven infection (i.e. you now know their
hypotension was caused by a GI bleed and not
sepsis) then it follows their empiric antibiotics
should be stopped
• Compare the antibiotics the patient is receiving
to those in the MUHC guidelines and the
guidelines I presented
• If they aren’t on guideline approved antibiotics,
why is that?
No guideline exists?
Culture data?
“Clinical judgment” to use alternative?
• In general it is best practice to follow your local
• Microbiology is essential to choosing the right
antibiotics for the infection in question
• Timely review of all recent results leads to the
most appropriate management
IV -> PO
• Many antibiotics are highly available PO (FQ,
metronidazole, TMP/SMX)
• Many infections do not require parenteral
antibiotics to achieve cure
• Change to PO, when appropriate, can reduce:
– Need for IV access and associated complications
– Length of stay
– Cost
• Review the duration received and compare to
what the guidelines, literature, clinical
experience or consultants suggest
• Record the number of days received and
compare against the number of planned days
• Stop today if it is time or set a stop date in the
future to avoid inadvertent renewal or
Targeted Drugs
• Review and optimize the use of targeted drugs
• In particular:
– Minimizing FQ use may help reduce C. difficile
– “PIP-TAZO” is the one of the most used antibiotics at
our centre
– Carbepenem use should be minimized as they are
expensive and our last-resort drugs (keep KPC out!)
– Vancomycin is also probably overused and potentially
nephrotoxic requiring laboratory monitoring in
patients without risk for MRSA or other organism
Audit Completed
• Thank you!
• Expected workload not greatly in excess of
existing procedures
– As little as 30 seconds per audit
Still don’t know what to do with the
• Ask your staff first
• Then if still in doubt:
– Consult the Infectious Diseases Service
– Page your self-stewardship advisor for advice (via
locating) if you aren’t sure if you need a full
consult or have any questions about the antibiotic
timeout process.

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