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Inappropriate Prescribing Of Antimicrobials
 

Inappropriate Prescribing Of Antimicrobials

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    Inappropriate Prescribing Of Antimicrobials Inappropriate Prescribing Of Antimicrobials Presentation Transcript

    • Inappropriate combinations of antimicrobial agents
      Munzur Morshed, Pharm D. candidate 2011
      Arnold & Marie Schwartz College of Pharmacy and Health Sciences
      North Shore- Long Island Jewish Health System
      Infectious Diseases-Advanced Pharmacy Practice
    • Bacterial Targets for Antimicrobials
    • Resistant Nosocomial Pathogens.
      • Staphylococcus Aureus
      • Streptococcus Pneumonia.
      • Enterococcus Species
      • Pseudomonas aeruginosa
      • Enterobacter Species
      • Acinobacter Species
      • Klebsiella Pneumonia
      - Extended Spectrum Beta-Lactamase producing.
      - Carbapenem resistant (KPC)
      John Papadopoulos- Pharmacodynamic Principles of Antimicrobial Pharmacotherapy.
    • New Antimicrobials in the pipeline
      ??????
      John Papadopoulos- Pharmacodynamic Principles of Antimicrobial Pharmacotherapy.
    • Risk factor of developing bacterial resistance
      • Inappropriate prescribing-overprescribing, under prescribing and wrong dose
      • Prior use of the same antimicrobial
      • Prolonged administrations of antimicrobial
      • Hospital Stay-Length of stay and prior hospitalization
      • Use of invasive devices
      • Lack of patient compliance
      • Sub-Optimal antibiotic concentration in the critically-ill patients
      • Inadequate infection control practice
    • Inappropriate Antimicrobial Combinations
    • Spectrum of Activity
    • Spectrum of Activity cont…
    • Beta-Lactams plus Beta-Lactams
      • Subclasses of Beta-Lactam Antibiotics
      • Penicillins- Ampicillin, Piperacillin, Nafcillin
      • Cephalosporins- Ceftazidime, Cefazolin, Cefoxitin
      • Carbapenems- Imipenem/Cilastatin (Primaxin), Meropenem
      • β-lactamase inhibitors- Tazobactam, Sulbactam/ Unasyn, Zosyn
      • MOA- Inhibits or disrupts the synthesis of the peptidoglycan layer hence inhibition of cell-wall growth
    • Beta-Lactams plus Beta-Lactamscont…
      •  Zosyn plus Unasyn
      • Avoid use b/c of therapeutic Duplication
      • Same MOA and same class and same spectrum of activity
      • Clinical Trials-Zosyn more efficacious than Unasyn if empiric treatment is desired- Pseudomonal Coverage
      • Zosyn plus Primaxin/Meropenem or Unasyn plus Primaxin/ Meropenem
      • Combination of a Beta-Lactam and Carbapenem
      • Same class but different Sub-Class
      • Avoid use
      • Major Drug Interactions- Antagonistic Effect
      • Carbapenems inhibits the destruction of Beta-Lactamases
      • Carbapenems induces the production of Beta-Lactamases
      • Zosyn/Unasyn induces the destruction of the Beta-Lactamase producing organism
      • Clinical Trial- Zosyn is as effective as Primaxin and it constitutes a good choice as an initial empiric monotherapy.
    • Beta-Lactams plus Beta-Lactamscont…
      • Ceftazidime plus Zosyn or Cefoxitin plus Zosyn
      • Combination of a cephalosporin and a Beta-Lactam
      • Same class but different Sub-Class
      • Ceftazadime- Third Generation; Cefoxitin- Second Generation
      • Ceftazadime SOA- serious gram (+) infections, DRSP, pseudomonas, nosocomial pneumonia.
      • Cefoxitin SOA- Anaerobes-Bacteroides Fragilis; gram (-) such as Proteus, Klebsiella, E-Coli
      • Avoid use
      • Both combo represents therapy duplication; similar spectrum of activity
      • Clinical Trial
      • Each antimicrobial in both combo’s are equally efficacious
      • Same spectrum of activity
      • Eradication rate of each antimicrobial in both combo for the corresponding pathogens are similar
      .
    • Beta-Lactams plus Beta-Lactamscont…
      • Ceftazadime plus Primaxin/Meropenem or Cefoxitin plus Primaxin/Meropenem
      • Combination of a cephalosporin and a carbapenem
      • Same class but different Sub-Class
      • Avoid use
      • Major Drug Interactions- Antagonistic effect
      • Carbapenems inhibits the destruction of Beta-Lactamases
      • Carbapenems induces the production of Beta-Lactamases
      • Ceftazadime/ Cefoxitin induces the destruction of the Beta-Lactamase producing organisms
      • Clinical Trials
      • Primaxin- enhanced efficacy in tx. of both gram (+) and gram (-) infections
      • Ceftazadime has greater pseudomonal coverage- advantage
    • Beta-Lactams plus Beta-Lactamscont…
      • Naficillin plus Cefazolin
      • Same class, but different sub-class
      • Naficillin- a penicillinase resistant penicillin
      • SOA- mostly gram (+)- staph, strep
      • Common therapy for skin and soft tissue infection, Endocarditis, Bacteremia
      • Cefazolin- 1 st generation cephalosporin.
      • Mainly gram (+) coverage- Staph, strep, NO enterococci
      • Partial Gram (-) coverage- E.Coli, Proteus, Klebsiella
      • Commonly used as surgical prophylaxis
      • Avoid use
      • Represents Therapy Duplication
      • Same MOA at the bacterial site
    • Fluoroquinolone plus Macrolides
      Fluoroquinolones
      Avelox-Moxifloxacin
      MOA- Inhibts DNA gyrase , which maintains the superhelical structure of DNA and necessary for DNA replication, transcription, and DNA repair; hence inhibition of the synthesis of DNA
      BBW- Tendon Rupture
      Macrolides
      Erythromycin-Erythrocin
      Azithromycin-Zithromax, Zmax
      MOA- Inhibits the ribosomal protein synthesis by inhibiting the 50s ribosomal subunits, resulting in blockage of transpeptidation
      QT prolongation
    • Fluoroquinolone plus Macrolides cont…
      Avelox plus Erythromycin or Avelox plus Azithromycin
      Combination of a fluoroquinolone and a macrolide
      Avelox SOA- Pseudomonas, Strep. , Staph. Enterobacter
      Erythro./Azithro. SOA- Strep. , Moraxella Catarrahalis, Chlamydia pneumonia.
      Avoid use
      Major Drug Interactions- additive effect
      Causes QT interval prolongation-Life threatening ventricular arrhythmias
    • Lincosamide plus Beta-Lactam
      • Clindamycin plus Unasyn, or Clindamycin PO plus Augmentin or Clindamycin plus Zosyn, or Clindamycin plus Primaxin/Meropenem
      • Combination of 1st and 2nd line agents
      • Clindamycin- has excellent bone penetration ability-osteomyelitis, dental surgery
      • MOA- binds to 50S ribosomal subunit of the bacteria and therefore interfering with protein synthesis
      • SOA- mostly gram (+)-Excellent MSSA, strep, bacteroides
      • BBW- colitis and excessive GI upset and diarrhea (C. Difficile associated)
      • Augmentin- beta –lactam/ beta-lactamse inhibitor combinations
      • Mainly gram (+) coverage- MSSA, Bacteroides, strep.
      • No pseudomonas coverage
      • Avoid use
      • The Beta-lactam’s are cross-sensitive with penicillin
      • Clindamycin is a substitute for patients who is unable to take the Beta-lactam’s
      • Usage of both can lead to developing significant resistance
    • Lincosamide plus Nitroimidazole
      • Clindamycin plus Metronidazole
      • Metronidazole- Drug of choice for Mixed infections, Trichomonas, and alternative for C-Difficile
      • SOA- Bacteroides, streptococci, C-Difficile, Gardnerella Vaginalis
      • Avoid alcohol- Good for alcoholics( Disulfiram reaction- nausea, vomiting, tachycardia)
      • Clindamycin- has excellent bone penetration ability-osteomyelitis, dental surgery
      • MOA- binds to 50S ribosomal subunit of the bacteria and therefore interfering with protein synthesis
      • SOA- mostly gram (+)-Excellent MSSA, strep, bacteroides
      • BBW- colitis and excessive GI upset and diarrhea (C. Difficile associated)
      • Avoid use
      • Therapeutic Duplication
      • Metronidazole- alternative for clindamycin induced C-Diffcile associated diarrhea
      • Usage of both can lead to developing significant resistance
    • Glycopeptides plus Oxazolidinone
      Vancomycin plus Linezolid
      Vancomycin-Bactericidal agent; works by inhibiting the cell wall synthesis, resulting in cell death
      SOA- Gram (+), Penicillin resistant Pneumococci, Gram positive anaerobes,no gram (-) coverage
      DOC for MRSA, PCN allergy gram (+) infection, C-Difficile Colitis alternative to Metronidazole
      Linezolid- inhibits protein synthesis by binding to the 23s ribosomal subunit; Preventing them from multiplying
      1:1 IV to Po conversion (advantage)
      SOA- VRE, Gram (+) aerobes, anaerobes, MRSA, Penicillin resistant pneumococci
      Avoid use
      Therapy duplication; Equally efficacious
      Clinical Trials- Linezolid effective alternative to vancomycin for the tx. of cSSTI caused by MRSA .
      Vancomycin DOC of hospital acquired C-Dif
    • Thank You!
    • References
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      • Arnold SR, Straus SE. "Interventions to improve antibiotic prescribing practices in ambulatory care". Cochrane Database Syst Rev,2005 (4)-Accessed on may 25,2010.
      • Tausk F, Evans ME, Patterson LS, et al. Imipenem-induced resistance to antipseudomonal beta-lactams in Pseudomonas aeruginosa. Antimicrob Agents Chemother1985; 28(1):41—45. Accessed on May 25, 2010. Accessed on may 25,2010
      • Boghossian J, Caputo W,, Dana A, Gray S, Harkless L, Pollak R,, Wu D. An open-label, randomized study comparing efficacy and safety of intravenous piperacillin/tazobactam and ampicillin/sulbactam for infected diabetic foot ulcers. Surgical Infections. 2005: 6(1): 27-40. Accessed on may 25,2010
      • Arranz R, de La Cámara R, Figuera A,, Font P, Leyra F, Pajuelo F,  Rivero N. Comparative study of piperacillin/tazobactam versus imipenem/cilastatin in febrile neutropenia (1994-1996). Med Clin (Barc). 2001 May 5;116(16):610-1. Accessed on may 25,2010
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      • Brun-Buisson C,Brière S, Petit C. Sollet JP, Schweich H Treatment of ventilator-associated pneumonia with piperacillin-tazobactam/amikacin versus ceftazidime/amikacin: a multicenter, randomized controlled trial. VAP Study Group. Clin Infect Dis. 1998 Feb;26(2):346-54. Accessed on may 25,2010
      • Andrien F,  Anniko M,  Baudrihaye M, Bow E, Burman LA,  Louie T, Norrby SR, Vandercam B. Imipenem/cilastatin versus amikacin plus piperacillin in the treatment of infections in neutropenic patients: a prospective, randomized multi-clinic study. Perit Dial Int. 2004 Sep-Oct;24(5):440-6. Accessed on may 25,2010
      • ,Chow KM., Leung CB, , Lui SF, Li PK. , Szeto CC, Wang AY, Cefazolin plus ceftazidime versus imipenem/cilastatin monotherapy for treatment of CAPD peritonitis--a randomized controlled trial. Perit Dial Int. 2004 Sep-Oct;24(5):440-6. Accessed on may 25,2010
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