Drugs for Bugs What’s new in 2012?

1. Drugs for Bugs What’s new in 2012? Valerie Creswell MD FACP July 10, 2012

2. Or the wonderful bugs you can meet when illness knocks you off your feet!

3. How do antibiotics work? • Inhibition or disruption of cell wall growth • Beta-lactams, vancomycin, bacitracin • Inhibition of protein synthesis • 50S ribosomal unit • macrolide, clindamycin, chloramphenicol • 30S ribosomal unit • aminoglycosides and tetracycline • Interference with DNA or RNA synthesis • Quinolones, Trimethoprim/sulfa

5. Empiric Antibiotics • 77 yo WF presents with fevers, chills, myalgias and a productive cough • PE T 101 P100 R16 BP110/60 • You order a CBC with man dif, BMP, BC x2, CXR and UA. The cost is: • A. $500 • B. $1000 • C. $2000+

6. RADIOLOGY COSTS 2011 Chest X-ray, Port. $480 Chest X-ray, PA/lat $523 KUB $480

7. RADIOLOGY COSTS 2011 • Renal sonogram $970 • Gallbladder sono $1258

8. RADIOLOGY COSTS 2011 CT Scan With and Without Brain $3590 Chest $4696 Abd/pelvis $7065

9. Radiology Costs 2011 • MRI with/without contrast • Brain $4326 • Chest $4377 (without)

10. Inpatient LAB COSTS 2011 • Urine culture $97 • Sputum c & s $310 • Blood c & s $409 for one set • Clostridium difficile toxin $159

11. Inpatient LAB COSTS 2011 • Serum creatinine $161 • Basic metabolic profile $320 • Comprehensive metabolic profile $376 • CBC man diff– $236 auto diff-- $174 • CBC $144 • Urinalysis w/ microscopic $105 • Drug levels --vancomycin $320 --gentamicin $288

12. Vanco levels-My pet peeves • Don’t order “Vanco with am lab” unless a random level will be helpful • Don’t order when Vanco will be discontinued within 3 days if cultures are negative • Do order a TROUGH before the fourth dose if: • Staph aureus in the blood or CSF (level 15-20) • Changes in renal function • High doses required ( young patients with good kidneys)

13. Empiric Antibiotics for our 77 yo man • Antibiotic choice • A. None • B. Ceftriaxone 1 gm IV q24hr and azithromycin 500 mg load, then 250 mg daily for total of 5 days (i.e. Use the community acquired pneumonia order set form 243 at Wesley) • C. Meropenem 500 mg IV q 6hrs • D. Vancomycin 1 gm IV q 12hrs

14. CAP Grade Card • Blood cultures before antibiotics (ICU) • Appropriate antibiotics and within 4 (6)hours of admission-ICU admissions-IV levofloxacin • Pneumococcal vaccination (year round)(needed every 5 years) and Influenza vaccination (during flu season)(needed yearly)

15. VCH Pneumonia Order Set

16. VCH Pneumonia Order Set

17. VCH Pneumonia Order Set

18. Via Christi Antibiogram/Empiric Guide

20. VCH Empiric Antibiotic Guide

21. Pregnant Women, Newborns, and Influenza Vaccination • Pregnant women are at increased risk of complications of influenza • women who are or will be pregnant during influenza season should receive influenza vaccine (TIV only) • Infants younger than 6 months of age are at very high risk of complications and hospitalization from influenza • no vaccine is available for infants younger than 6 months MMWR 2010;59(RR-8)

22. PPSV is recommended for: • People who are 65 years of age and older • People 2 years of age and older who have a chronic illness such as: • Cardiovascular or lung disease • Sickle cell disease • Diabetes • Alcoholism • Chronic liver disease • Cerebrospinal fluid (CSF) leak • A cochlear implant

23. PPSV is recommended for: • 2 years of age and older with a weakened immune system • Due to illnesses such as: • HIV infection • AIDS • Chronic renal failure • Nephrotic syndrome • Organ or bone marrow transplantation • Hodgkin's disease • Leukemia,lymphoma,multiple myeloma • Generalized malignancy

24. PPSV is recommended for: • Those receiving immunosuppressive therapy (e.g., steroids) • Those who have had their spleen removed or whose spleen is dysfunctional due to an illness such as sickle cell disease. • Residents of nursing homes or long-term care facilities • People 19 through 64 years of age who smoke cigarettes or have asthma.

25. One of the most importantreasons adults identify for not receiving a vaccine is the lack ofa provider recommendation for the vaccine.

26. Saving 100,000 Lives Campaign • Hospital associated pneumonia • Central line infections • Hospital associated UTIs • Surgical site Infections

27. HAC vs. HAI HAC (Healthcare Associated Condition)= based on physician documentation obtained thru administrative data HAI (Healthcare Associated Infection) = based on standardized surveillance definition from the CDC/HNSN reviewed and reported by infection prevention

28. The Center for Medicare and Medicaid Services (CMS) 2007 • Serious Preventable Events (SPAE) • Effective October 2008, CMS no longer reimburses for these identified events including • CA-UTI fractures/other • Decubitus Ulcers surgery foreign obj • IV catheter infections • Mediastinitis post CABG • Air embolism • Blood incompatibilites

29. CAUTI • Surveillance Definition: CDC/NHSN only considers symptomatic CAUTI; catheter must be in place within 48 hours prior to specimen collection or when catheters removed within previous 48 hours and meet the stated criteria in following slides. Asymptomatic bacteriuria no longer qualifies as a surveillance case definition. • Asymptomatic bacteriuria does NOT require treatment regardless of colony count or presence of pyuria except pregnant women or patients undergoing an invasive urological procedure. Do NOT order routine urinalysis or culture unless the patient has signs and symptoms of a urinary tract infection. Cloudy or foul smelling urine is not an indication for a urine culture.

30. CAUTI Criteria #1a • Patient has an indwelling catheter in place at the time of specimen collection and at least 1 of the following sign and symptoms without another cause: • Fever (>38o C) • Suprapubic tenderness or costovertebral pain or tenderness and • A positive urine culture of ≥105 CFU/ml with no more than 2 species

31. CAUTI Criteria #2a • Patient had a in dwelling urinary catheter in place removed within 48 hours prior to specimen collection and at least 1 of the following without another cause: • fever (>38oC) • urgency, frequency, dysuria • Suprapubic tenderness or costovertebral pain or tenderness and • A positive urine culture of ≥105 CFU/ml with no more than 2 species

32. Indications for an Indwelling Urinary Catheter • Urinary tract obstruction • Prostatic hyperplasia • Acute or chronic urinary retention • Hypotonic bladder • Neurogenic bladder • Critically ill patients • Management of refractory incontinence • Pre and post-pelvic surgery • Accurate ins and outs • Active labor • Clot retention • Chemotherapy

33. Reasons We Hear • The patient is on lasix • I haven’t gotten around to it yet • I forgot it was still in • The patient is getting bumex…..

34. Key points • Avoid catheterization if at all possible • Reevaluate the need for a foley daily and remove ASAP (RN driven protocol) • Do not order “cath prn” • Do not routinely change catheter • Yeast in the urine is best treated by simply removing the catheter • Don’t irrigate the foley unless the foley is clogged with blood clots

35. Central Line Associated Bloodstream infections (CLABSI) • Bloodstream infections (BSIs) are a major cause of healthcare-associated morbidity and mortality • Up to 35% attributable mortality • BSI leads to excess hospital length of stay of 24 days • Central Line (CL) use a major risk factor for BSI • More than 250,000 central line-associated BSIs (CLABSIs) in US yearly • Rates of CLABSI appear to vary by type of catheter Pittet et al. JAMA 1994; 271 1598-1601. Klevens et al. Public Health Reports 2007;122:160-6.

36. Background: PathogenesisCLABSI Healthcare Personnel Hand Contamination More Common Mechanisms 1. Pathogen migration along external surface - more common early (< 7days) 2. Hub contamination with intraluminal colonization -more common >10 days Less Common Mechanisms 1. Hematogenous seeding from another source 2. Contaminated infusates Hub Contamination Contamination of insertion site Contaminated Infusate Extraluminal Contamination Hematogenous spread HICPAC. Guideline for Prevention of Intravascular Device-Related Infections. 1996

37. Background: EpidemiologyModifiable Risk Factors

38. Background: Prevention Strategies Interventions • Michigan Keystone Project • Decrease in CLABSI in 103 ICUs in Michigan (66% reduction) • Basic interventions: • Hand hygiene • Full barrier precautions during CL insertion • Skin cleansing with chlorhexidine • Avoiding femoral site • Removing unnecessary catheters • Use of insertion checklist • Promotion of safety culture Pronovost et al. NEJM 2006;355:2725-32.

39. CLABSI: Specimen Collection • For patients with suspected CLABSI : • Collect blood cultures prior to initiating antimicrobial therapy. • Two peripheral venous blood cultures (separate sticks) are preferred over paired blood samples drawn from the catheter and a peripheral vein. • Collecting both sets of blood cultures from multiple lumens of the catheter may be necessary in patients with immunosuppression, leukopenia and thrombocytopenia and for patients with poor peripheral vascular access. • Do not routinely culture catheter tips on removal unless there are clinical signs and symptoms for infection.

40. NHSN CLABSI Surveillance Definitions Surveillance Definition: Central line in place at the time of or within 48 hours before onset of event.  • Criteria 1: Patient has a recognized pathogen cultured from one or more blood cultures (at least one bottle), and organism cultured is not related to another site of infection. Recognized pathogen excludes organisms considered common skin contaminants

41. Guidance on Interpretation of Culture Results • Results: The same organism grow from at least 1 percutaneous blood culture and a quantity of >15 colonies from the catheter tip. Interpretation: This probably is a catheter-associated infection. • Results: Paired blood cultures, either from two peripheral separate sticks or one drawn from a catheter hub and the other from a peripheral vein, growing the same organism in a patient with clinical signs and symptoms and no other recognized source. Interpretation: This is a catheter-associated infection.

42. Central Venous Catheter Blood Stream -Infections (CVC-BSI) • Definition • Pt with a CVC up to 48 hours after removal with a positive blood culture not related to another source • Use “insertion bundle” • Remove ASAP

43. Surgical Site Infections (SSI) and MRSA • SSIs prolong hospitalizations and increase morbidity and mortality • Staphylococcus aureus is the most common cause of SSI and healthcare-associated pneumonia and a leading cause of nosocomial bacteremia in the US

44. Infection Control • Hand Hygiene • Foam in Foam out every time you enter a pts room • PPE-Personal Protective Equiptment • Use when performing a task when body fluid exposure could occur • i.e. removing lines or tubes

45. Infection Control-Precautions • Contact • Resistant organisms-MRSA, Clostridium difficile(wash your hands with soap and water) • Droplet • SuspectedNeisseriameningitidis or Hemophilus influenza meningitis-for 24 hours from the first dose of appropriate antibiotics • Influenza, pertussis etc. • Airborne • Suspected Tuberculosis-keep the door closed!

46. Antimicrobial Therapy Selection • Broad - Spectrum Therapy • empiric -- infecting organism(s) unknown • Narrow - Spectrum Therapy • culture and sensitivity data known

47. Selection of Antibiotic Therapy • Active agents have comparable efficacy • Compliance is necessary for cure • The least toxic and least expensive effective drug should be used • Resistance can be the result of antibiotic pressure Mayo Clinic Proc 1998;73:1114-1122

48. Penicillins Vancomycin Gentamicin synergy Daptomycin Linezolid Selected Bacteria and Targeted Antimicrobial Therapy Enterococci

49. MRSA Empiric Therapy Outpatient Inpatient Vancomycin Linezolid Daptomycin Clindamycin • MRSA only • Clindamycin • TMP/SMX • Minocycline or doxycyline • Linezolid • MRSA + β-hemolytic Strep • Clindamycin • TMP/SMX + β-lactam • Mino/Doxy + β-lactam IDSA MRSA Guidelines CID 2011; 52: 1-38

50. Metronidazole Clindamycin B-lactam plus B-lactamase inhibitor (Piperacillin/Tazobactam, Ampicillin/sulbactam, Amoxicillin/clavulanate) Cefotetan Carbapenems Selected Bacteria and Targeted Antimicrobial Therapy Anaerobes