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Evaluation Of Acinetobacter Infection, Eastern States Presentation

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Presentation of original reseach completed during PGY1 residency at VCU Health System

Presentation of original reseach completed during PGY1 residency at VCU Health System


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  • Talk about genus and species, acinetobacter calcoaceticus and baumannii
  • β -lactamase & ESBL production β -lactams, cephalosporins, carbapenems Alteration in porin structure carbapenems Overexpression of efflux pumps β -lactams, quinolones, tetracyclines, chloramphenicol, tigecycline, aminoglycosides, trimethoprim
  • Rationale: Infections with Acinetobacter have become problematic at MCVH MDR Acinetobacter infections have resulted in: Prolonged exposure to ineffective antibiotics Increased length of treatment and hospital stay Increased occurrence of adverse reactions, including renal failure
  • Antimicrobial Drug Therapy: Antimicrobial Therapy Drug Dose Duration Dosage formulation Alteration due to C&S results Monotherapy vs. Combination Therapy Presence of Adverse Effects SCr ( ≥2x baseline) and/or BUN ( ≥2x baseline) within 1 week of initiation of therapy
  • Transcript

    • 1. Evaluation of Acinetobacter Infection Sarah Nelson, Pharm.D. Pharmacy Practice Resident
    • 2. Acinetobacter
      • Non-fermenting, non-motile, aerobic gram negative coccobacilli
      • Isolated from soil, water, animals, and humans
      • Colonizes on inanimate objects with high stability
          • Ventilators, mattresses, pillows, bed rails, urine collection jugs, IV equipment, nebulizers, etc.
      Giamarellou, H. et al. Acinetobacter baumannii: a universal threat to public health? International Journal of Antimicrobial Agents.2008;32:106-119
    • 3. Clinical Manifestations
      • Pulmonary
      • Bacteremia
      • Skin & skin structure infections
      • Urinary tract infections
      • Post surgical meningitis
      Giamarellou, H. et al. Acinetobacter baumannii: a universal threat to public health? International Journal of Antimicrobial Agents.2008;32:106-119
    • 4. Mechanisms of Resistance Munoz-Price, L. et al. Acinetobacter Infection. N Engl J Med. 2008;358(12):1271-81
    • 5. Current Treatment Options
        • Sulbactam based β -lactams
        • Carbapenems
        • Tigecycline
        • Colistin
    • 6. Background
      • 29 critically ill patients with pneumonia or bacteremia causes by MDR Acinetobacter baumanii
        • Treatment: IV Colistin (2 million IU three times daily) PLUS IV rifampicin (10mg/kg every 12 hours)
        • Mean duration of treatment: 17.6 days (+/- 10.4)
        • Clinical & microbiological response: 76% (22 pts)
        • Infection-related mortality: 21% (6 pts)
        • Nephrotoxicity: 10% (3 pts)
      Colistin and rifampicin in the treatment of multidrug-resistant Acinetobacter baumannii infections. J Antimicrob Chemother. 2008;61(2):417-420
    • 7. Background Kwon, KT et al. Impact of imipenem resistance on mortality in patients with Acinetobacter bacteremia. J antimicrob Chemother . 2007;59:525-530
      • Higher 30 day mortality with:
        • MDR strain of Acinetobacter caused infection (57.5% vs. 27.5%)
        • Inappropriate empiric treatment was utilized (60% vs. 20%)
    • 8. Objectives
      • Characterize the extent of Acinetobacter infection at VCUHS
      • Identify common treatment regimens currently utilized at VCUHS
      • Delineate adverse effects associated with the most utilized treatment regimens
      • Provide education regarding selection of treatment regimen if deemed necessary
    • 9. Methods
      • Retrospective
        • July 1, 2007- July 31, 2008
      • Quality Improvement Project
      • IRB Approval, expedited
    • 10. Patients
      • Inclusion Criteria
        • Adults ( ≥18 years of age)
        • ≥ 1 positive culture of Acinetobacter calcoaceticus-baumannii complex
        • Received antimicrobial treatment for ≥ 2 days
      • Exculsion Criteria
        • Infection with other species of Acinetobacter
          • A. lwoffii
          • Undifferentiated specimens
    • 11. Data Collection
      • Demographics
      • Specimen information
          • Source, sensitivities
      • Antimicrobial Therapy
          • Empiric & final drug therapy
      • Adverse Reactions
          • Serum Creatinine & BUN
    • 12. Data Collection
      • Efficacy Outcomes
        • Favorable vs. unfavorable response
          • Favorable:
            • Signs & symptoms resolved within 48 hours of end of therapy
            • Negative repeat culture
          • Unfavorable:
            • Signs & symptoms persisted >48 hours after therapy ended
            • Required additional antibiotic therapy
            • Positive repeat culture
    • 13. Statistical Analyses
      • Descriptive statistics were used to describe variables
      • Chi-squared test was used to identify significant outcomes
      • Logistic regression was used to determine independent risk factors for favorable outcomes
    • 14. Study Subjects
      • 207 patients with ≥ 1 positive culture for Acinetobacter calcoaceticus-baumannii complex
        • 83 patients excluded
          • Other species
          • <18 years old
          • Outpatients
          • 23 hour observation
        • 12 charts not available
      • 112 patients included in study
    • 15. Demographics 22 (20%) >1 source of Acinetobacter 2.6 2.5 2.5 Days to positive culture 32 27.5 28.5 LOS (days) 57.1 51.4 52.6 Age (years) 20 (59%) 38 (50%) 59 (53%) Male Unfavorable Outcome (n= 34) Favorable Outcome (n=76) Overall (n=112)
    • 16. Source of Infection
    • 17. Locality of Infection
    • 18. Rates of Resistance 0% --- Colistin 31% --- Tigecycline 70% 48% Piperacillin/Tazobactam 64% 50% TMP/SMX 56% 31% Imipenem 68% 58% Gentamicin 76% 65% Ciprofloxacin 74% 60% Cefepime 72% --- Amikacin Study Group 2007 Antibiogram Antimicrobial
    • 19. Empiric Therapy
      • Appropriate empiric therapy is associated with a favorable outcome (p<0.0001)
      • 29 patients (26%) were treated with appropriate empiric therapy
        • 28 (97%) had a favorable outcome
      • Inappropriate empiric therapy accounts for 33 of the 34 unfavorable outcomes (97%)
      • 17% of patients were not started on empiric antimicrobial therapy
    • 20. Tailored Antimicrobial Therapy
      • Appropriate tailored therapy is associated with a favorable outcome (p<0.0001)
      • 79 (72%) patients were treated with appropriate antimicrobial therapy
        • 65 (82%) patients had a favorable outcome
      • Average duration of tailored antimicrobial therapy was 12.4 days
      • Most common final antimicrobial therapy included imipenem (18), colistin (17), tigecycline (12), & piperacillin/tazobactam (10)
        • 14 patients were treated with combination therapy
    • 21. Colistin
      • 17 patients were treated with colistin
        • Never used as empiric therapy
        • Used as monotherapy in 9 (53%) patients
        • Most commonly used with tigecycline for combination therapy
      • Intravenous route most common; inhalation also utilized for respiratory infections
      • 3 (18%) patients experienced an increase in serum creatinine & 4 (25%) patients experienced an increase in BUN
    • 22. Limitations
      • Retrospective analysis
        • Documentation of assessment and plan
      • Evaluation of only Acinetobacter calcoaceticus-baumannii complex
      • Withdrawl of care promoted an unfavorable endpoint
    • 23. Conclusion
      • Selection of correct empiric antimicrobial therapy is necessary for a favorable outcome
      • No independent risk factors exist that demonstrate a favorable outcome
      • Nosocomial strains of Acinetobacter calcoaceticus-baumannii complex exhibit increased resistance to common antimicrobials
      • Colistin is an effective and safe antimicrobial with 100% susceptibility to the MDR Acinetobacter baumanii-calcoaceticus complex