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stewardship Flashcards

(47 cards)

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1
Q

What is antimicrobial stewardship?

A

promoting the selection of optimal drug regimen to improve and measure the appropriate use of antibiotics
- dosing, duration, route of administration

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2
Q

Goals of antimicrobial stewardship

A
  1. optimize outcomes of abx use
  2. minimize toxicity/ADR
  3. reduce costs for infx
  4. limit the selection for resistant strains
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3
Q

Abx overuse and misuse

A
  1. unnecessary use
  2. wrong dose
  3. wrong drug
  4. excessive duration of therapy
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4
Q

abx threat: urgent

A

Gram neg:
CRA
CRE (klebsiella, enterobacter)

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5
Q

abx threat: serious

A

ESBL producing enteroacteriales (K,E)
VRE
MDR Pseudomonas aeruginosa
MRSA

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6
Q

Low threshold for abx prescribing

A
  1. perceived as non-toxic
  2. lack appropriate de-escalation
  3. suboptimal regimens
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7
Q

Consequences of inappropriate abx therapy: patient

A
  1. inadequate tx
  2. ADR
  3. Allergic rxn
  4. Superinfections/abx resistance/selection of problematic pathogens
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8
Q

Consequences of inappropriate abx therapy: society

A
  1. collateral damage (abx resistance)
  2. increased healthcare costs
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9
Q

Benefits of antimicrobial stewardship

A
  1. improved pt outcomes
  2. decreased ADR (C.diff diarrhea)
  3. ABX maintain susceptibility
  4. resource optimization
  5. reduced healthcare cost
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10
Q

Broad spectrum agents: gram-positive

A
  1. Vanco
  2. Linezolid
  3. Dapto
  4. Ceftaroline
  5. Clindamycin
  6. Bactrim
  7. Doxycycline
    etc
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11
Q

Broad spectrum agents: gram-negative

A
  1. piperacillin/tazobactam
  2. Cefepime
  3. Ceftazidime +/- Avibactam
  4. Ceftolozane/tazobactam
  5. Cefiderocol
  6. Carbapenems
  7. Aminoglycosides
  8. Fluoroquinolones
  9. Aztreonam
  10. Polymyxins
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12
Q

7 core elements of hospital ASP

A
  1. Hospital leadership commitment
  2. accountability
  3. pharmacy expertise
  4. action
  5. tracking
  6. reporting
  7. education
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13
Q

Regulation of ASP

A
  1. Joint Commission
  2. CMS (government)
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14
Q

Pharmacy-based stewardship interventions

A
  1. document indications
  2. IV to PO switch
  3. Dose adjust/optimization
  4. Use the most narrow spectrum drug to properly treat infection
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15
Q

Treating infection

A
  1. Empiric tx
  2. Definitive tx - after C/S, use narrow spectrum drug
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16
Q

Empiric tx

A

Target most likely pathogen using antibiogram
consider: recent abx use, pt specific factors, local resistance patterns for institution

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17
Q

Definitive tx

A

C/S results available, de-escalate to narrow spectrum drug based on ability of drug to reach site of action

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18
Q

Drugs of choice for: MSSA

A

Penicillins (NOD)
- Nafcillin, Oxacillin, Dicloxacillin
1st gen Cephalosporins (faz, pha)
- Cefazolin, Cephalexin

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19
Q

Drugs of choice for: MRSA

Study These Flashcards
A

Hospital-acquired: IV
- Vanco
- Linezolid
- Dapto
- Ceftaroline (5th gen)
Community-acquired: any of above and PO
- clindamycin
- Bactrim
- Doxycycline

20
Q

Drugs of choice for: Streptococci

Study These Flashcards
A

Penicillins
Cephalosporins
Vancomycin
Respiratory Fluoroquinolones
- moxifloxacin, levofloxacin

21
Q

Drugs of choice for: Enterococci

Study These Flashcards
A

Ampicillin
Vancomycin
Linezolid
Daptomycin

22
Q

LAME organisms

Study These Flashcards
A

L = listeria
A = acinetobacter
M= MRSA (ceftaroline covers)
E= enterococcus
NOT covered by cephalosporins

23
Q

Drugs of choice for: Pseudomonas

Study These Flashcards
A

Beta lactams
- pip/tazo
- Ceftozolane/tazo
- ceftazidime/avibactam
- ceftazidime
- cefiderocol
- carbapenems (not ertapenem)
Non-beta lactams
- Fluoroquinolones (not moxifloxacin)
- Aminoglycosides (amikacin>tobramycin>gentamicin)

24
Q

Acinetobacter

Study These Flashcards
A

Requires susceptibility tests
Carbapenems (not ertapenem)
- Meropenem
- Imipenem/cilastatin
Ampicillin/sulbactam
Cefiderocol

25
Ertapenem lacks coverage of APE organisms
Acinetobacter Pseudomonas Enterococcus
26
Penicillin-ase
Amox/clav Amp/sulbactam Pip/tazo
27
ESBL-ase
Carbapenems pip/tazo
28
CRE-ase
Ceftazidime/avibactam Meropenem/vaborbactam Imipenem/Cilastatin/relebactam Cefiderocol
29
Cephalo-ase
Carbapenem Non-BL agents
30
Oral Anaerobes
peptostreptococcus, prevotella
31
Oral Anaerobe tx
Clindamycin penicillin --- Moxifloxacin Amp/sulbact Amox/clav pip/tazo carbapenems
32
Intestinal anaerboes
Bacteroids (b.fragilis), clostridium
33
Intestinal anaerobe tx
Metronidazole -- Moxifloxacin Amp/sulbact Amox/clav pip/tazo carbapenems penicillin
34
Clostridium difficile treatment
Fixaxomicin PO Vancomycin PO Metronidazole IV for fullminant
35
3rd gen cephalosporin cautioned use with
HECK YES organisms due to inducible ampC
36
HECK YES organisms
Hafnia alvei *Enterobacter cloacae *Citrobacter freundii *Klebsiella aerogenes YerSinia enterocolitica *most problematic organisms that induce ampC (8-40% initially S --> R in a few days)
37
Drugs to treat HECK YES
1. Cefipime 2. Piperacillin/Tazobactam (maybe) 3. carbapenems avoid ceftriazone unless uncomplicated cystitis
38
Methods for stewardship
1. time sensitive automatic stop order 2. PCN allergy assessment 3. Detection/prevention DDI 4. Formulary restiction/preauthorization
39
Less common AmpC inducers
Halfnia alvei Citrobacter **youngae** Yersinia enterocolitica
40
risk <5% AmpC inducers
Serratia marcenscens Morganella mrganii providencia
41
Formulary restriction/Preauthorization
Helps decrease abx use, resistance (gram negative primarily), and cost Examples of formulary restriction Daptomycin Micafungin Linezolid Coritavancin Tigecycline Amphotercin B Meropenem Ertapenem Ceftaroline
42
PCN allergy assessment
Differentiate between severe vs non-severe reactions - 10-30% patients report PCN allergy but only 10% documented are true IgE T1HS rxns Check how long ago the reaction was - IgE antibodies decrease over time want to keep PCN a viable option because first line, less costly, better ADR profile
43
Management of PCN allergy
Review prior abx use, check for hx of tolerance Assess R1 side chain Skin test to confirm allergy update allergy profile
44
Low cross-reactivity between PCN and beta lactams
0.17-8.4% Cephalosporins (1st>3rd) 0.3-4.3% Carbapenems None: Aztreonam
45
Caution use of aztreonam with which 2 cephalosporins due to same R1 side chain
caution if allergy to Cefazidime Cefiderocol
46
Alternative agents for severe PCN allergy
Vancomycin Fluoroquinolones Clindamycin Aztreonam
47
Why do we want to avoid using alt agents
increased costs increased risk for MDR organisms Increased risk for ADR

Immunology (6 decks)

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