SFGH Clinical Pearls on Antibiotic Treatment
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SFGH Clinical Pearls on Antibiotic Treatment
- 1. Antibiotics at SFGH Clinical Pearls & Treatment Recommendations dr shabeel pn www.hi-dentfinishingschool.blogspot.com
- 30. Gram-Negative Bacilli Resistance Associated With Fluoroquinolone Use Adapted from Neuhauser MM et al. JAMA. 2003;289:885–888; copyright (2003), with permission from American Medical Association, all rights reserved. 0 5 10 15 20 25 30 35 1994 1995 1996 1997 1998 1999 2000 0 50,000 100,000 150,000 200,000 250,000 Strains resistant to ciprofloxacin, % Fluoroquinolone use, kg P aeruginosa All gram-negative bacilli Fluoroquinolone use
- 31. 2006 SFGH Inpatient Susceptibilities (Gram-negative pathogens) N/A 89 86 96 95 Pip/Tazo 79 69 55 33 N/A Acinetobacter baumanii N/A 84 80 N/A N/A Pseudomonas aeruginosa 80 94 92 74 N/A Enterobacter cloacae 85 97 97 92 92 Klebsiella pneumoniae 64 80 94 92 84 Escherichia coli SMX/TMP Cipro/Levo Cefepime Ceftriax Kefzol Organism
- 35. HAP or VAP Suspected (All Disease Severity) Late Onset or Risk Factors for Multi-drug Resistant (MDR) Pathogens No Yes Limited Spectrum Antibiotic Therapy Empiric Antibiotic Therapy for HAP Broad Spectrum Antibiotic Therapy For MDR Pathogens
- 42. MRSA in San Francisco Hospitals
- 49. Relationship of MIC to Vancomycin Treatment Failures in MRSA Infections MIC, minimal inhibitory concentration. Moise-Broder PA et al. Clin Infect Dis. 2004;38;1700-1705 . 22% 27% 51% Failure Rate (%) 31% MIC ( μ g/mL)
- 51. Purulent skin and soft tissue infection caused by MRSA Tice, Honolulu
Editor's Notes
- The potential for drug interactions must always be considered Most of the newer agents have low affinity for the hepatic cytochrome P450 system or are excreted renally There are reports that polyvalent cations can reduce the oral bioavailability of quinolones anywhere from 10-50%, especially when given concomitantly This is a problem especially in patients on multiple medications such as the elderly or ICU patients QT prolongation? Check patient profiles!
- Antibacterial resistance in several important groups of microbial pathogens appears to be correlated with the use of fluoroquinolones. This is true for several clinically important gram-negative bacilli. Therefore, infection with a gram-negative bacillus in patients who have received fluoroquinolone treatment in the past is more likely to be with a resistant organism, including resistant P aeruginosa . 1 Further support for this pattern comes from a recent hospital program that restricted quinolone use, particularly levofloxacin. 2 After a lag of 5 months, the monthly percentage of levofloxacin-resistant P aeruginosa decreased significantly by 0.77% ( P <0.005), declining from 43.8% in January 2001 to 37.7% by March 2004. A drop in gentamicin-and cefepime-resistance was also associated with decreased quinolone use. 2 Prior quinolone use also increases the likelihood of infection with ESBL-producing strains. Case-control studies have identified ESBL-producing K pneumoniae and E coli in nursing home patients who were previously treated with quinolones. 3 In addition, nosocomial Acinetobacter infections in the ICU have been associated with prior quinolone use. 4 References: 1. Paterson DL. “Collateral damage” from cephalosporin or quinolone antibiotic therapy. Clin Infect Dis. 2004;38(suppl 4):S341–S345. 2. Paterson DL; Lopez-Lozano J, Potoski B, Capitano B, Monnet DL. Effects of reduction of quinolone use on antibiotic susceptibility in Pseudomonas aeruginosa. Interscience Conference on Antimicrobial Agents and Chemotherapy; October 30, 2004;Washington DC. Abstract 401968. 3. Wiener J, Quinn J, Bradford P, et al. Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes. JAMA. 1999;281:517–523. 4. Villers D, Espaze E, Coste-Burel M, et al. Nosocomial Acinetobacter baumannii infections: microbiological and clinical epidemiology. Ann Intern Med. 1998;129:182–189.
- Data from a study by Neuhauser et al, illustrated in this slide, show that the increasing resistance rates for P aeruginosa and other key gram-negative bacilli from 1994 to 2000 correlated with fluoroquinolone use. The percentage of susceptible P aeruginosa strains declined dramatically, from 89% in 1990 through 19 93 to 68% in 2000. This decline in activity was associated with a significant increase in total fluoroquinolone use over that same time period. 1 Reference: 1. Neuhauser MM, Weinstein RA, Rydman R, Danziger LH, Karam G, Quinn JP. Antibiotic resistance among gram- negative bacilli in US intensive care units: implications for fluoroquinolone use. JAMA . 2003;289:885 – 888.