Antimicrobial stewardship Flashcards
(32 cards)
Antimicrobial stewardship refers to
(AVMA)
the actions veterinarians take individually and as a profession to preserve the effectiveness and availability of antimicrobial drugs through conscientious oversight and responsible medical decision-making while safeguarding animal, public, and environmental health
core principles of antimicrobial stewardship
- maintain animal health and welfare using preventative and management strategies to prevent common diseases
- using an evidence-based approach in making decisions to use antimicrobial drugs
- using antimicrobials judiciously, sparingly, and with continual evaluation of the outcomes of therapy, respecting the client’s available resources
according to antimicrobial stewardship principles, when should we use antibiotics for dermatology cases?
only when topical therapy is expected to fail
- Many cases can resolve with topical treatment alone
Highest Priority Critical Important (HPCIA) or Critically Important Antimicrobial (CIA) refer to what type of drugs?
an antimicrobial class authorized for use in both humans and animals
what are the tier 1 antimicrobials?
- first generation cephalosporins (cephalexin),
- clindamycin,
- Amoxicillin-clavulanic acid
what are the tier 2 antimicrobials?
(never use without a culture)
- Doxycycline,
- Minocycline,
- Fluoroquinolones (marbofloxacin, enrofloxacin),
- Chloramphenicol,
- Rifampin,
- Amikacin
what are tier 3 antibiotics?
should be avoided since they are used in human medicine for patients with limited options
Avoid in veterinary medicine with few exceptions
Linezolid, Vancomycin
- never a need in veterinary dermatology
- 3rd gen cephalosprins will likely be upgraded to this tier
can resistance to antibiotics spread from non-humans to humans?
There are human infections where evidence exists for the transmission of
resistant bacteria or resistance genes from non-human sources
3 Ds of antimicrobial stewardship
De-escalate: reduce or minimize
systemic antibiotic usage
Decontaminate: clean-up site
Design – consider dose and duration to maximize delivery to the target site and killing of the organism (not just inhibiting)
what does it mean to de-escalate antimicrobial use?
– reduce or minimize systemic antibiotic usage.
Likely the most effective means to reducing resistance
Question or confirm the need for systemic treatment
Antimicrobials can be used if indicated – shorten duration
what does decontamination mean for antimicrobial stewardship
– clean up the site. Topical therapy is the cornerstone of effective and judicious use of antimicrobials
Reduce size of infection (fewer colonies, less drug needed) > Topical therapy
Reduce biofilms (MICs may be 500X higher), remove barriers to blood supply > Topical therapy
Reduce pre-disposing host factors (ex. inflammatory responses)
Reduce potential spread in clinic and home
what does ‘design’ mean as an antimicrobial stewardship principle?
– consider dose and duration to maximize delivery to the target site and killing of the organism (not just inhibiting)
Avoid prescribing antibiotics prior to receiving culture results
Choose a lower tier drug where possible
Use the upper end of a dosing range (increased GI risk)
Dead bugs don’t mutate (want to kill rather than inhibit)
Dosing well above the MIC, trying to achieve MPC (mutant prevention concentration)
Choose drugs with better penetration for deeper infections (Clindamycin, Fluoroquinolones)
antibiotic treatment duration - what is it based, and will it change?
New guidelines may recommend a shorter duration (14 days) and emphasize reassessment.
According to ISCAID,
“Previous durations of treatment have no scientific basis and likely reflected convenience rather than thought. They are decades old and implemented before the insidious nature of resistance was understood.”
should we use topical antibiotics if we are already using systemic?
antimicrobial shampoos or sprays should be used in all cases whenever possible, whether or not systemic drugs are used
go- to products for pyoderma
chlorhexidine containing products
contact time for shampoos in pyoderma cases
5-10 minutes contact time (BTC – by the clock!)
shampoo and spray for pyoderma
- frequency and duration
- additional benefit of shampoos
- bathe the dog twice a week and use a topical chlorhexidine spray on non-shampoo days for the first two weeks,
> slowly decreasing the shampoo frequency.
> In this way I have a chlorhexidine containing product on the patients daily for the first two weeks.
<><> - Shampoos offer the additional benefit of rehydrating the skin and washing off allergens in the allergic patient.
- As with systemic treatments, topical treatments should continue until lesions are gone for at least 2 weeks; however, I find spray and shampoos to be a good control program for patients with recurrent pyoderma
what is phovia?
- adjunct to antimicrobial therapy for pyoderma
- It uses fluorescent light energy and is promoted as a treatment to shorten antibiotic treatment courses and help wound
what is the mutant prevention concentration?
(MPC) represents a threshold above which the selective proliferation of resistant mutants is expected to occur only rarely
Therapy for the patient infected with Methicillin Resistant Staphylococcus Pseudintermedius
- treat based on what?
- which antibiotics should be our last resort and why
- should be treated as per culture test results
- Aminoglycosides and fluoroquinolones should be reserved for serious infections or when there are no other options
- MRSA seems to rapidly develop resistance to fluoroquinolones, as it is a one-step process, and this may be true for MRSP too.
Therapy for the patient infected with Methicillin Resistant Staphylococcus Pseudintermedius
- good choice for antimicrobial, adverse effect with this drug
Trimethoprim sulfa (TMS)
- the period of time needed to resolve pyoderma with TMS increases the likelihood of inducing hypothyroidism with this sulfa drug
> breed sensitivities (eg. doberman)
- Patients on long term TMS should have their tear production checked regularly as KCS is another important potential side effect
many MR cases are still sensitive to what drugs?
TMS and chloramphenicol
MRSP infections are resistant to what drugs?
Resistant to all β-lactam antibiotics and are often resistant to many other antimicrobials
MRSP infection - can we use clindamycin or erythromycin to treat? considerations for these drugs?
clindamycin can be a good choice
- look at culture and sensitivity
- MRSP cases that are sensitive to Clindamycin are best assessed for sensitivity to erythromycin
> avoid if not reported or resistant to erythromycin
> resistance may be induced > use D-test with adjacent erythromycin and clindamycin discs to predict inducible resistance
> In the absence of this test, one might consider alternate treatments when clindamycin is susceptible, but erythromycin is resistant
