S43 - Antibiotic Stewardship

Question 1

The United States is the fifth most intensive user of antibiotics in the world, only surpassed by

Answer 1

France, Greece, Italy, and Belgium.

Question 2

_____ of hospitalized patients receive antibiotics

Answer 2

25-40%

Question 3

Antibiotics are the most common cause of emergency department visits for adverse drug events in

Answer 3

children under 18 years of age.

Question 4

Section 505E(g) of the FD&C Act provides for the designation by FDA of certain antimicrobial products as

Answer 4

Qualified Infectious Diseases Product Designation (QIDP)

an antibacterial or antifungal drug for human use intended to treat serious or life-threatening infections

Question 5

To establish and maintain a list of “qualifying pathogens,” and make public the methodology for developing the list. A qualifying pathogen is defined as a pathogen identified and listed by the Secretary . . . that has the potential to pose a serious threat to public health, such as ─

Answer 5

(A) resistant gram positive pathogens, including methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus;
(B) multi-drug resistant gram negative bacteria, including Acinetobacter, Klebsiella, Pseudomonas, and E. coli species;
C) multi-drug resistant Tuberculosis; and
(D) Clostridium difficile

Question 6

to encourage the development of new antibiotics, as each year at least two million people develop serious infections caused by antibiotic-resistant bacteria.

Answer 6

Generating Antibiotic Incentives Now (GAIN)Actwas passed as part of the Food and Drug Administration Safety and InnovationAct(FDASIA)

Question 7

Newly Approved Antibiotics 2018 and 2019

Answer 7

Cefiderocol (2019) ***NEW***
Lefamulin (2019)
Imipenem/cilastatin/relebactam (2019)
Omadacycline (2018)
Eravacycline (2018) 
Plazomicin (2018)

Question 8

How are Antibiotics Misused?

Answer 8

Given when NOT indicated or for a non-infectious disease state
Wrong antibiotic selected
Wrong dose or route
Wrong duration of therapy
Inappropriate use of broad-spectrum antibiotics
Treatment of colonization/contamination
Redundancy in therapy/duplication

Question 9

Consequences of Antibiotic Misuse

Answer 9

Adverse drug events
Increased prevalence of Multi-Drug Resistant Organisms (MDROs)
Increase in infection/ colonization with MDROs
Fewer susceptible antibiotics available

Question 10

Most Common Adverse Drug Events (ADEs) Associated with Antibiotics

Answer 10

Allergic reactions/anaphylaxis
Hearing loss(ototoxicity)
Renal failure (nephrotoxicity)
Liver toxicity (hepatotoxicity)
Bone marrow suppression (myelosuppression)
QT prolongation and risk of sudden cardiac death

Question 11

SPACE

Answer 11

(Serratia spp., Pseudomonas aeruginosa, Acinetobacter spp., Citrobacter spp., Enterobacter spp.)

Question 12

SPICE

Answer 12

(Similar to SPACE, but “I” stands for Indole positive Proteae, such as Proteus vulgaris, Morganella morganii, and Providencia spp.)

Question 13

ESKAPE

Answer 13

(Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp.)

Question 14

ESCAPE

Answer 14

(Similar to ESKAPE, but “C” stands for Clostridiodes difficile and the second “E” stands for Enterobacteriaceae

Question 15

CDC’s Antibiotic Resistance Threats Report 2019

Urgent

Answer 15

Carbapenem-resistant Acinetobacter NEW
Candida auris (C. auris) NEW
Clostridium difficile (now Clostridiodes difficile)
Carbapenem-resistant Enterobacteriaceae (CRE)
Drug-resistant Neisseria gonorrhoeae

Question 16

CDC’s Antibiotic Resistance Threats 2019

Concerning Threats

Answer 16

Erythromycin-resistant Group A Streptococcus spp.
Clindamycin-resistant Group B Streptococcus spp.

**Vancomycin-resistant Staphylococcus aureus (VRSA)
removed from the list in 2019

Question 17

CDC’s Antibiotic Resistance Threats 2019

Watch List NEW

Answer 17

Azole-resistant Aspergillus fumigatus (A. fumigatus)
Drug-resistant Mycoplasma genitalium (M. genitalium)
Drug-resistant Bordetella pertussis (B. pertussis)

Question 18

Infection controlis the discipline concerned with preventing________or healthcare-associated infection, a practical (rather than academic) sub-discipline of____________.

Answer 18

nosocomial

epidemiology

Question 19

Components of Infection Control include:
Hand hygiene
Sterilization
Cleaning
Disinfection
Personal protective equipment
Antimicrobial surfaces
 as well as :

Answer 19

Vaccination of health care workers
Post-exposure prophylaxis
Surveillance of infections
Isolation and quarantine
Outbreak investigation
Training in infection control and health care epidemiology

Question 20

What is Antimicrobial Stewardship?

Answer 20

A systematic and multidisciplinary approach to the appropriate use of antimicrobial agents to achieve optimal patient outcomes

Coordinated interventions

Improve the appropriate use of antibiotics

Measure the appropriate use of antibiotics

Promote the selection of the optimal antibiotic regimen

• Right antibiotic
• Right dose
• Right route of administration
• Right frequency of administration
• Right duration of therapy
• Right indication

Question 21

ASP Core Team Players: A Multidisciplinary Approach:

Two primary players:

Answer 21

Infectious Diseases Physician Champion (Director)

Infectious Diseases trained/Antimicrobial Stewardship clinical pharmacist (Co-Director)

Question 22

Responsibilities of the Antimicrobial Stewardship Program (ASP)

Answer 22

Monitoring of antimicrobial use

• Dangerous or toxic anti-infective broad-spectrum anti-infective where emerging resistance may be a problem for the facility
• High-cost items that may have more cost-effective alternatives

Question 23

The ASP may use a variety of mechanisms to improve the use of antimicrobials within the hospital. These may include, but are not limited to the following:

Answer 23

Primary:

• Prospective audit with the intervention and feedback
• Formulary restriction and preauthorization requirement for specific agents

Secondary

• Education
• Guidelines and/or clinical pathways
• Antimicrobial cycling and scheduled antimicrobial switch
• Antimicrobial order forms
• Combination therapy: prevention of resistance versus redundant antimicrobial coverage
• Streamlining and/or de-escalation of therapy
• Dose optimization (e.g., renal dosing, pharmacokinetic dosing)
• Parenteral to oral conversion of antimicrobials

Question 24

Barriers to Implementation of an ASP

Answer 24

Personnel shortages (ID physician, ID pharmacists)

Financial considerations (compensation for time)

Higher-priority clinical initiatives

Opposition from prescribers/other specialties (loss of autonomy in clinical decision making)

Resistance from administration

Restriction policies that may be difficult to adopt

Continued need to assess the success of a program in order to sustain efforts

Question 25

National Action Plan for Combating Antibiotic-Resistant Bacteria issued by the White House in March 2015. This plan:

Answer 25

calls for establishment of ASPs in all acute care hospitals by 2020 and for the Centers for Medicare and Medicaid Services to issue a Condition of Participation that participating hospitals develop programs based on recommendations from the Centers for Disease Control and Prevention’s (CDC) Core Elements of Hospital Antibiotic Stewardship Programs.

Question 26

2016 Antimicrobial Stewardship Guidelines | Updated Definition:

Answer 26

“Coordinated interventions designed to improve and measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug regimen including dosing, duration of therapy, and route of administration” **Removed Cost effectiveness and AE**

Question 27

**2016 Antimicrobial Stewardship Guidelines | We recommend preauthorization and/or prospective audit and feedback over

Answer 27

no such intervention (strong recommendation, moderate-quality evidence).

Question 28

2016 Antimicrobial Stewardship Guidelines | General Interventions

Answer 28

We suggest against relying solely on didactic educational materials for stewardship (weak recommendation, low-quality evidence). New We suggest ASPs develop facility-specific clinical practice guidelines coupled with a dissemination and implementation strategy (weak recommendation, low-quality evidence). New We suggest ASPs implement interventions to improve antibiotic use and clinical outcomes that target patients with specific infectious disease syndromes (weak recommendation, low-quality evidence). New

Question 29

**2016 Antimicrobial Stewardship Guidelines We recommend antibiotic stewardship interventions designed to reduce the use of antibiotics associated with a high risk CDI compared

Answer 29

with no such intervention (strong recommendation, moderate-quality evidence). New

Question 30

2016 Antimicrobial Stewardship Guidelines

Answer 30

We suggest the use of strategies (e.g., antibiotic time-outs, stop orders) to encourage prescribers to perform routine review of antibiotic regimens to improve antibiotic prescribing (weak recommendation, low-quality evidence). New We suggest incorporation of computerized clinical decision support at the time of prescribing into ASPs (weak recommendation, moderate-quality evidence). New We suggest against the use of antibiotic cycling as a stewardship strategy (weak recommendation, low-quality evidence). Continuation

Question 31

**2016 Antimicrobial Stewardship Guidelines | We recommend that hospitals implement PK monitoring and adjustment programs for

Answer 31

aminoglycosides (strong recommendation, moderate-quality evidence). Expansion

Question 32

**2016 Antimicrobial Stewardship Guidelines | We recommend that ASPs implement guidelines and strategies to reduce antibiotic therapy to the

Answer 32

shortest effective duration (strong recommendation, moderate-quality evidence). New

Question 33

**2016 Antimicrobial Stewardship Guidelines | We suggest the use of rapid viral testing for respiratory pathogens to reduce

Answer 33

the use of inappropriate antibiotics (weak recommendation, low-quality evidence). New

Question 34

**2016 Antimicrobial Stewardship Guidelines | In adults in the ICUs with suspected infection, we suggest

Answer 34

the use of serial PCT measurements as an ASP intervention to decrease antibiotic use (weak recommendation, moderate-quality evidence). New

Question 35

CDC’s 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Answer 35

``` Vaccinate Get the catheters out Target the pathogen Access the experts Practice antimicrobial control Use local data Treat infection, not contamination Treat infection, not colonization Know when to say “no” to vanco Stop treatment when infection is cured or unlikely Isolate the pathogen Break the chain of contagion ```

Question 36

What can you do to be better Antibiotic Stewards?

Answer 36

Take a 48-hour to 72-hour time-out! Think about situations where you can avoid antibiotics Adjust your antibiotics appropriately Laboratory monitoring Educate patients about antibiotics Pick the RIGHT antibiotic for the patient