antimicrobial selection in the emergency department ... · the story of hcap . 2002-2005 •hcap...

Antimicrobial Selection in the Emergency Department:

Navigating Common Pitfalls and Applying Antimicrobial Stewardship

Kyle Dvoracek, Pharm.D., BCCCP

Objectives

• Navigate through common pitfalls in selecting antimicrobial therapy for: – Sepsis – Pneumonia – Skin and Soft Tissue Infections

• Apply methods for incorporating antimicrobial

stewardship in the emergency department

Sepsis

How to Please CMS

Sepsis Definitions

SIRS: 2 or More • HR >90 bpm • Temp >100.4°F or <96.8°F • RR >20 rpm or PaCO2<32 mmHg

• WBC >12,000 cells/mm3 or <4,000 cells/mm3 or Bands > 10%

Sepsis • SIRS + Suspected or confirmed infection

Specifications Manual for National Hospital Inpatient Quality Measures

Sepsis Definitions

Severe Sepsis • Sepsis plus end-organ dysfunction

• Lactate >2.0 mmol/L (REPEAT LACTATE 3 HR) • SCr >2.0 mmol/L • Bilirubin >2.0 g/dL • PLT <100,000 cells/mm3

Septic Shock: 30 mL/kg Fluids • Sepsis plus:

• SBP <90 mmHg or MAP <65 mmHg • Decrease SBP by >40 mmHg • Lactate >4.0 mmol/L (REPEAT LACTATE 3 HR)


Summary of CMS Measure

Severe Sepsis

Identified (Time 0)

3 Hour Bundle: • Draw initial lactate level • Draw blood cultures (before

antibiotics) • Administer “BROAD

SPECTRUM IV ANTIBIOTICS”

6 Hour Bundle: • Repeat lactate level if

initial is > 2.0mmol/L • Administer 30 ml/kg

crystalloid fluids for “SEPTIC SHOCK”

Septic Shock Criteria: •SBP < 90mmHg •MAP < 65mmHg •Decrease in SBP by > 40mmHg than last normal BP •Initial lactate level is ≥ 4.0mmol/L

Severe Sepsis Criteria: •SIRS criteria ≥ 2 •Source of infection •Evidence of organ dysfunction


What is NOT Broad Spectrum?

Gram Positive


Antimicrobial Selection in Severe Sepsis • Ceftriaxone + Azithromycin • Vancomycin + Cefepime OR Pip/Tazo Lung

• Cefepime + Metronidazole • Pip/Tazo Abdomen

• Ceftriaxone • Cefepime Urine

• Pip/Tazo + Vancomycin Skin/Soft Tissue

• Ceftriaxone 2g + Vancomycin • +/- Ampicillin, Acyclovir Meningitis

RED FONT = MULTIDRUG-RESISTANT RISK FACTORS

Special Situations

• Meropenem • +/- Vancomycin

Penicillin Allergy

• Vancomycin 125mg PO 4XD + Metronidazole 500mg IV q8h Clostridium

difficile

• Pip/Tazo +Vancomycin • Cefepime + Metronidazole +

Vancomycin

Not Sure on Source

Antibiotics for Pneumonia

Which patients REALLY require coverage for multi-drug resistant

organisms?

Classification of Pneumonia

CAP

• Viruses • Strep.

pneumo • Atypical

Bacteria

HCAP

HAP/VAP

• Drug-resistant pathogens

• Staph aureus (MRSA)

• Pseudomonas

?

Kalil AC et al. Clin Infect Dis. 2016 Sep 1;63(5):e61-111.

Original HCAP Risk Factors

HCAP Prior Hospitalization

Nursing Home

Hemodialysis Home Infusion Therapy

Home Wound Care

Family Member with

MDR

ATS/IDSA . Am J Respir Crit Care Med. 2005; 171: 388-416. Kalil AC et al. Clin Infect Dis. 2016 Sep 1;63(5):e61-111.

The Story of HCAP

2002-2005 • HCAP

Definition Determined

2005 • HCAP

Supported in HAP/VAP Guidelines

2006-2015 • HCAP

Definition Questioned

2016 • HCAP

removed from HAP/VAP Guidelines

Kalil AC et al. Clin Infect Dis. 2016 Sep 1;63(5):e61-111. Kollef MH et al. Chest. 2005 Dec;128(6):3854-62.

Yap V et al. Infect Dis Clin North Am. 2013 Mar;27(1):1-18.

ATS/IDSA . Am J Respir Crit Care Med. 2005; 171: 388-416. Chalmers JD et al. Clin Infect Dis. 2014 Feb;58(3):330-9. Gross AE et al. Antimicrob Agents Chemother. 2014 Sep:58(9):5262-8.

Limitations of Kollef

• Only culture-positive patients

• Only hospitalized patients • Limited number of:

– Hemodialysis

• Study did not include: – Nursing home patients – Home infusion patients – Home wound care patients – Family member with MDR

Kollef MH et al. Chest. 2005 Dec;128(6):3854-62.

• Compared to CAP, HCAP group had more: – Medical

Immunosuppression – Co-Morbidities – Mechanical Ventilation – Severity of Illness – Predicted Mortality upon

Admission

Newer Literature

• Yap and colleagues, 2013 – Hospitalization in past 90 days – Recent antibiotics in past 30 days – Severity of pneumonia – Immunosuppression – Poor functional status

Yap V et al. Infect Dis Clin North Am. 2013 Mar;27(1):1-18.

Newer Literature

• Gross and colleagues, 2014 – Admission from nursing home – Antibiotic use in past 90 days – Number of days hospitalized in prior 180 days – Prior Pseudomonas – Trend with prior MRSA

• Chalmers and colleagues, 2014 – HCAP is a poor predictor of MDR pathogens – Evidence is poor and subject to publication bias

Chalmers JD et al. Clin Infect Dis. 2014 Feb;58(3):330-9. Gross AE et al. Antimicrob Agents Chemother. 2014 Sep:58(9):5262-8.

Recommendations Antibiotics for MDR recommended in:

• Immunosuppressed • Antibiotics in prior 90 days • 12 month history of MDR

pathogen • Hospitalization within 90

days • Skilled nursing facility

Antibiotics for MDR considered in:

• Hemodialysis • Severely ill patients (i.e.

severe sepsis/septic shock/ARDS)

• Poor functional status • Severe co-morbidities • Home infusion therapy • Home wound care therapy

Watch for new CAP guidelines in 2017 for update on HCAP

Skin and Soft Tissue Infections

To Treat or Not to Treat

Impetigo/Ecthyma

• Mupirocin topically bid – Limited # of lesions

• Cephalexin 250mg 4xd

• TMP/SMX 1-2 DS bid

– If MRSA suspected

Abscesses, Carbuncles, Furuncles

• Incision and drainage

• Antibiotics if: – SIRS – Immunocompromised – Consider in:

• Extremes of age • Multiple abscesses • Lack of response to I&D

– TMP/SMX 1-2 DS bid – Clindamycin 300mg po 4xd – Doxycycline 100mg po bid

Stevens DL et al. Clin Infect Dis. 2014 Jul 15;59(2):e10-52.

Cellulitis/Erysipelas • Cover Streptococcus sp.

– Cephalexin 500mg 4xd – Clindamycin 300mg 4xd – Amoxicillin 500mg tid

• Cover MRSA if:

– Penetrating trauma – Purulent drainage – SIRS – IV drug use – TMP/SMX 1-2 DS bid with

cephalexin – Clindamycin 300mg 4xd – Vancomycin

Necrotizing Fasciitis • SSTI Emergency

• Treated aggressively with:

– Vancomycin + – Piperacillin/Tazobactam OR – Cefepime/Metronidazole OR – Meropenem

• Consider empiric

clindamycin 600-900mg q8h – For Streptococcal toxin and

cytokine suppression


Surgical Site Infections Fever < 4 days from operation

• Unlikely due to surgical site infection

• If systemic illness, gram stain for Strep or Clostridia – Open wound, debride – Penicillin G 2-4 million units IV

q4-6h AND – Clindamycin 600-900mg IV q8h

Fever >4 days after operation

• Antibiotics if: – Temp >38 °C – WBC >12,000 c/mm3 – Erythema >5cm from incision

• Perineum, GI tract or Axilla

– Ceftriaxone 1-2g IV q24h PLUS – Metronidazole 500mg IV q8h

• Trunk or Extremity

– Vancomycin OR – Cefazolin 1-2 g IV q8h


Diabetic Foot Infections • Is there clinical evidence of infection?

– If not, no antibiotics • Is there a risk for MRSA?

– MRSA infection/colonization in past year – Local prevalence of MRSA >30% – Severe infection (Admission, Septic)

• Is there a risk for Pseudomonas? – Soaking feet – Failed therapy not covering Pseudomonas – Severe infection (Severe Sepsis, Septic Shock)

• Has the patient received antibiotics in the past month? – If so, include agents active against gram-negatives – If not, just gram-positive coverage may be enough

Lipsky BA et al. Clin Infect Dis. 2012 Jun;54(12):e132-73.

How Severe is the Infection?

Mild

Cephalexin 500mg po 4xd

+/- TMP/SMX 1-2 DS po BID

Clindamycin 300-450mg po 4xd

Moderate

Ceftriaxone 2g IV Daily

+/- Vancomycin 15-20mg/kg

Ertapenem 1g IV Daily

Severe

Vancomycin 20-25mg/kg

Plus:

Pip/Tazo Cefepime/

Metronidazole Meropenem


Antimicrobial Stewardship in the ED

New Fluoroquinolone FDA Warning

• July 26th, 2016 • Not recommended for:

– Acute bacterial sinusitis – Acute exacerbation of chronic bronchitis – Uncomplicated urinary tract infections

• Reserved for patients who no alternatives exist – Allergies – Complicated infections (Resistant infections)

FDA.gov

Why So Serious?

2008: Tendinitis and

Tendon Rupture

2011: Worsening Myasthenia

Gravis Symptoms

2013: Irreversible Peripheral

Neuropathy

2016: Avoid Use in

Sinusitis, Bronchitis,

UTI

FDA.gov

Alternatives to Fluoroquinolones • Acute bacterial sinusitis

– Amoxicillin/Clavulanate – Doxycyline (Adults Only) – Clindamycin + Cefpodoxime

• Acute exacerbation of chronic bronchitis – Amoxicillin/Clavulanate – Azithromycin – Doxycycline

• Uncomplicated urinary tract infections – Nitrofurantoin (Cystitis Only) – Cephalexin OR Cefdinir – TMP/SMX

Get Smart About Healthcare. CDC.gov Chow AW et al. Clin Infect Dis. 2012 Apr;54(8):e72-112.

Warren JW et al. Clin Infect Dise. 1999 Oct;29(4):745-58

Ways to Improve Antimicrobial Stewardship in Your ED

1. Culture Follow-Up 2. Antibiotic Order Sets 3. Determine Local Antimicrobial Susceptibilities 4. Consider Cultures when Initiating Antimicrobial

Therapy 5. Avoid Antibiotics for Uncomplicated Abscesses 6. Withhold Antibiotics for Uncomplicated

Respiratory Tract Infections

Pulia MS et al. Common Sense: AAEM News. 2014

Review Questions

Which of the following patients require broad spectrum antibiotics according to the CMS Sepsis Criteria?

A. A patient with SIRS criteria B. A patient with Sepsis C. A patient with Severe Sepsis or Septic Shock D. Every patient who comes into the ED needs

antibiotics!!!

Review Questions

Which of the following patients require “broad spectrum antibiotics” according to the CMS Sepsis Criteria?

A. A patient with SIRS criteria B. A patient with Sepsis C. A patient with Severe Sepsis or Septic Shock D. Every patient who comes into the ED needs

antibiotics!!!

Review Questions

Which of the following antibiotic regimens IS appropriate for a severe septic patient according to the CMS core measure?

A. Vancomycin monotherapy for a cellulitis B. Ceftriaxone monotherapy for a urinary tract

infection C. Ciprofloxacin monotherapy for a urinary tract

infection D. Ceftriaxone plus azithromycin for a meningitis

Review Questions

Which of the following is/are indications in which the FDA issued a warning against the routine prescribing of fluoroquinolones?

A. Acute bacterial sinusitis B. Acute exacerbation of chronic bronchitis C. Uncomplicated urinary tract infections D. All of the above

THANK YOU!

QUESTIONS?

antimicrobial selection in the emergency department ... · the story of hcap . 2002-2005 •hcap...

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