• Describe the role of antibiotic use in the
development of resistance
• Review toxicity of commonly used antibiotics
• Understand the prevalence and clinical impact
of carbapenem resistant enterobacteriaceae
• State the prognosis antimicrobial resistant
Staph aureus infections
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
Dr. Steve Solomon - Metrics and Decision-Making for Antibiotic Stewardship in...John Blue
Metrics and Decision-Making for Antibiotic Stewardship in Human Medicine - Dr. Steve Solomon, Centers for Disease Control & Prevention, Currently serves as Director of the Office of Antimicrobial Resistance in the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, in the Office of Infectious Diseases at CDC., from the 2014 NIAA Symposium on Antibiotics Use and Resistance: Moving Forward Through Shared Stewardship, November 12-14, 2014, Atlanta, Georgia, USA.
More presentations at http://www.swinecast.com/2014-niaa-antibiotics-moving-forward-through-shared-stewardship
Advisor Live: Antimicrobial Stewardship - Why Now and How?Premier Inc.
This 90-minute webinar discusses strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance.
Join Premier’s free Advisor Live® webinar series for a special Get Smart About Antibiotics Week presentation on Thursday, November 19 from 12-1:30 p.m. EST. The panel for this 90-minute webinar will discuss strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance.
EXPERT PRESENTERS:
- Gina Pugliese, RN, MS, vice president, Premier Safety Institute®, moderator
- Arjun Srinivasan, MD, (CAPT, USPHS) medical director of the CDC’s Get Smart for Healthcare program, will highlight the national focus on antibiotic stewardship and reasons for the current urgency
- Michael Postelnick, RPh, BCPS AQ- Infectious Diseases, clinical manager and senior infectious diseases pharmacist for Northwestern Memorial Hospital, will share lessons learned from implementing their antibiotic stewardship program
- Craig Barrett, Pharm.D., BCPS, director safety solutions for Premier, Inc. will share strategies from Premier member hospitals striving for antimicrobial stewardship
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
Dr. Steve Solomon - Metrics and Decision-Making for Antibiotic Stewardship in...John Blue
Metrics and Decision-Making for Antibiotic Stewardship in Human Medicine - Dr. Steve Solomon, Centers for Disease Control & Prevention, Currently serves as Director of the Office of Antimicrobial Resistance in the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, in the Office of Infectious Diseases at CDC., from the 2014 NIAA Symposium on Antibiotics Use and Resistance: Moving Forward Through Shared Stewardship, November 12-14, 2014, Atlanta, Georgia, USA.
More presentations at http://www.swinecast.com/2014-niaa-antibiotics-moving-forward-through-shared-stewardship
Advisor Live: Antimicrobial Stewardship - Why Now and How?Premier Inc.
This 90-minute webinar discusses strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance.
Join Premier’s free Advisor Live® webinar series for a special Get Smart About Antibiotics Week presentation on Thursday, November 19 from 12-1:30 p.m. EST. The panel for this 90-minute webinar will discuss strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance.
EXPERT PRESENTERS:
- Gina Pugliese, RN, MS, vice president, Premier Safety Institute®, moderator
- Arjun Srinivasan, MD, (CAPT, USPHS) medical director of the CDC’s Get Smart for Healthcare program, will highlight the national focus on antibiotic stewardship and reasons for the current urgency
- Michael Postelnick, RPh, BCPS AQ- Infectious Diseases, clinical manager and senior infectious diseases pharmacist for Northwestern Memorial Hospital, will share lessons learned from implementing their antibiotic stewardship program
- Craig Barrett, Pharm.D., BCPS, director safety solutions for Premier, Inc. will share strategies from Premier member hospitals striving for antimicrobial stewardship
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Dr. Marion A. Kainer - Antimicrobial Stewardship - the State Health Departmen...John Blue
Antimicrobial Stewardship - the State Health Department Perspective - Dr. Marion A. Kainer, Director, Healthcare Associated Infections and Antimicrobial Resistance Program, Tennessee Department of Health, from the 2015 NIAA Antibiotic Symposium - Stewardship: From Metrics to Management, November 3-5, 2015, Atlanta, Georgia, USA.
More presentations at http://swinecast.com/2015-niaa-symposium-antibiotics-stewardship-from-metrics-to-management
Antibiotic Stewardship: A National and International ImperativePYA, P.C.
J. Michael Keegan, MD, an infectious disease specialist who leads the antibiotic stewardship team at PYA, discussed antibiotic stewardship at the South Dakota Pharmacists Association’s (SDPHA) Annual Convention in Deadwood, South Dakota.
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Dr. Marion A. Kainer - Antimicrobial Stewardship - the State Health Departmen...John Blue
Antimicrobial Stewardship - the State Health Department Perspective - Dr. Marion A. Kainer, Director, Healthcare Associated Infections and Antimicrobial Resistance Program, Tennessee Department of Health, from the 2015 NIAA Antibiotic Symposium - Stewardship: From Metrics to Management, November 3-5, 2015, Atlanta, Georgia, USA.
More presentations at http://swinecast.com/2015-niaa-symposium-antibiotics-stewardship-from-metrics-to-management
Antibiotic Stewardship: A National and International ImperativePYA, P.C.
J. Michael Keegan, MD, an infectious disease specialist who leads the antibiotic stewardship team at PYA, discussed antibiotic stewardship at the South Dakota Pharmacists Association’s (SDPHA) Annual Convention in Deadwood, South Dakota.
Antimicrobial Resistance: A One Health Challenge for Joint ActionSIANI
Presented by Juan Lubroth at the seminar "Antimicrobial resistance; linkages between humans, livestock and water in peri-urban areas" at the World Water Week, 29th August 2016.
Dr. Kurt Stevenson - Antimicrobial Resistance Surveillance and Management in ...John Blue
Antimicrobial Resistance Surveillance and Management in Hospital and Community Settings - Issues for Human Population Medicine - Dr. Kurt Stevenson, The Ohio State University Medical Center, from the 2012 NIAA One Health Approach to Antimicrobial Resistance and Use Symposium, October 26-27, 2012, Columbus, OH, USA.
More presentations at:
http://www.trufflemedia.com/agmedia/conference/2012-one-health-to-approach-antimicrobial-resistance-and-use
Dr. Lauri Hicks - Out-Patient Antibiotic Resistance (AMR) IssuesJohn Blue
Out-Patient Antibiotic Resistance (AMR) Issues - Dr. Lauri Hicks, Commander, U.S. Public Health Service, Medical Epidemiologist, Respiratory Diseases Branch; Medical Director, Get smart: Know When Antibiotic Work Program; Centers for Disease Control and Prevention (CDC), from the 2015 NIAA Antibiotic Symposium - Stewardship: From Metrics to Management, November 3-5, 2015, Atlanta, Georgia, USA.
More presentations at http://swinecast.com/2015-niaa-symposium-antibiotics-stewardship-from-metrics-to-management
Les différentes situations d’expertises
Expertise amiable
Expertise judiciaire
Le cadre médico-légal
Accident de circulation (AC)
Coups et blessure volontaire (CBV)
Responsabilité médicale
Accident du travail (AT)
Notion d’Incapacité
Réduction par les séquelles de la capacité physiologique
Évaluation barémique
AT : Art.38 alinéa 3 de la loi n°94/28 du 21/2/1994
AC : Art. 131 alinéa 2 de la loi n°2005-86 du 15/8/2005
Dr. Beth Bell - CDC’s Overall Effort on Antibiotics, FY 2015 Requested Fundin...John Blue
CDC’s Overall Effort on Antibiotics, FY 2015 Requested Funding and CARB Program - Dr. Beth Bell, Director of the National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), from the 2015 NIAA Antibiotic Symposium - Stewardship: From Metrics to Management, November 3-5, 2015, Atlanta, Georgia, USA.
More presentations at http://swinecast.com/2015-niaa-symposium-antibiotics-stewardship-from-metrics-to-management
Webinar: Defeating Superbugs: Hospitals on the Front Lines Modern Healthcare
About the Webinar: Defeating Superbugs: Hospitals on the Front Lines
http://www.modernhealthcare.com/article/20140917/INFO/309179926
Hospitals across the country are facing a grim reality in which some of the most deadly healthcare-associated infections they encounter are untreatable with first- or even second-line antibiotics. These “superbugs” affect at least 2 million Americans each year and lead to 23,000 deaths. And their threat is growing, public health officials warn. This editorial webinar and “Defeating Superbugs” white paper will explore the steps providers must take to ramp up surveillance efforts, promote appropriate antibiotic use and control outbreaks. Our panel of experts will share their organizations' experiences as well as proven strategies for success.
Registration for this webinar includes Modern Healthcare's “Defeating Superbugs” white paper, with proven tips and strategies for promoting appropriate antibiotic use, improving infection surveillance, identifying drug-resistant infections and dealing with outbreaks.
KEY TAKEAWAYS
- Best practices for effective antimicrobial stewardship
- Real-world examples of effective interventions, including universal rapid testing for drug-resistant MRSA
- Tips for engaging senior leadership
- Aggressive strategies for controlling outbreaks
PANELISTS
Lance Peterson
Director of the Clinical Microbiology and Infectious Disease Research Division
NorthShore University HealthSystem, Evanston, Ill.
Anurag Malani
Medical Director for the Infection Prevention and Antimicrobial Stewardship Programs
St. Joseph Mercy Hospital, Ann Arbor, Mich.
Robert Weinstein
Chief Medical Officer for Population Health
Chairman of the Department of Medicine, Cook County Health and Hospitals System; Professor, Rush University Medical Center, Chicago
MODERATOR
Maureen McKinney
Editorial Programs Manager
Modern Healthcare
This presentation focuses on appropriate selection of antibiotics in the ICU and discusses different strategies to optimize this selection with the aim to decrease resistance and improve appropriateness.
Optimizing antimicrobial therapy for hospitalized pneumonia: Focus on PK/PD p...WAidid
Professor Blasi slideset is about the optimization of antimicrobial therapy for pneumonia and it underlines how the appropriate early antibiotic therapy reduces mortality rates in patients with bloodstream infection.
Dr. Ceire Costelloe (Imperial College London) - Data-driven systems medicinemntbs1
The summary of Dr. Ceire Costelloe's presentation from the Jun 11-12th 2019 event Data-driven systems medicine at Cardiff University Brain Research Imaging Centre.
The newer antibiotics added to Our Arsenal against resistant bacteria. Know about the upcoming antibiotics and newer antibiotics in use.
Free text at
http://medchrome.com/basic-science/pharmacology/newer-antibiotics-review/
•Recognize patients at risk for diabetic foot infections
•Design a diagnostic work-up for diabetic foot osteomyelitis
•State the principles of management of diabetic foot infections
Care of the hospitalized geriatric patientBBrauer25
1. Use simple screening tools for cognitive impairment, delirium, and fall risk.
2. Recognize steps the individual clinician and system can take to reduce hazards of hospitalization.
3. Apply new updates to inappropriate therapy for the elderly
- Describe the basic characteristics of new oral anticoagulants (OACs)
- Recognize potential candidates for new anticoagulants for atrial fibrillation and treatment of venous thrombosis
•Assist patients with decision-making about duration of anticoagulation by providing information about:
– risk of recurrent venous thrombosis
– risk of complications of therapy (bleeding)
•Decide if hypercoagulabile testing will be useful for a patient
•Recognize patients at risk for diabetic foot infections
•Design a diagnostic work-up for diabetic foot osteomyelitis
•State the principles of management of diabetic foot infections
•Describe the role of antibiotic use in the development of resistance
•Review toxicity of commonly used antibiotics
•Understand the prevalence and clinical impact of carbapenem resistant enterobacteriaceae
•State the prognosis antimicrobial resistant Staph aureus infections
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
QA study - To improve the 6th monthly recall rate post-comprehensive dental treatment under general anaesthesia in paediatric dentistry department, Hospital Melaka
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
2. Objectives
• Describe the role of antibiotic use in the
development of resistance
• Review toxicity of commonly used antibiotics
• Understand the prevalence and clinical impact
of carbapenem resistant enterobacteriaceae
• State the prognosis antimicrobial resistant
Staph aureus infections
3. Which of the following are indications to
treat asymptomatic bacteriuria?
Choose all that apply
A. Pyuria
B. Pregnancy
C. Preparation for transurethral resection of the
prostate
D. Diabetes
5. Why has the antibiotic pipeline failed?
• All the easy ones have been discovered
• Antibiotics are not a good investment for drug
companies
• FDA regulatory system is outdated
6. Society expects antibiotics to be cheap
• Cost of Trastuzumab for breast cancer =
$54,000 per year
• Cost of Ipilimumab for melanoma = $240,000
for induction course
• Cost of ceftriaxone x 4 weeks for viridans
streptococcal endocarditis=$1600
7. Clinical Impact of Antimicrobial
Resistance
• Resistance is rising
• Resistance increases mortality
• Decreasing antimicrobial use reduces
resistance
8. Clinical Impact of Antimicrobial
Resistance
• Resistance is rising
• Resistance increases mortality
• Decreasing antimicrobial use reduces
resistance
11. Clinical Impact of Antimicrobial
Resistance
• Resistance is rising
• Resistance increases mortality
• Decreasing antimicrobial use reduces
resistance
12. Mortality of resistant (MRSA) vs.
susceptible (MSSA) S. aureus
• Mortality risk associated with MRSA
bacteremia, relative to MSSA bacteremia:
OR: 1.93; p < 0.001.1
• Mortality of MRSA infections was higher than
MSSA: relative risk [RR]: 1.7; 95% confidence
interval: 1.3–2.4).2
1. Clin. Infect. Dis.36(1),53–59 (2003).
2. Infect. Control Hosp. Epidemiol.28(3),273–279 (2007).
13. Mortality associated with carbapenem resistant
(CR) vs susceptible (CS) Klebsiella
pneumoniae (KP)
60
50
40
30
20
10
0
p<0.001
Overall Mortality Attributable
Mortality
Percent of subjects
CRKP
CSKP
OR 3.71 (1.97-7.01) OR 4.5 (2.16-9.35)
Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
p<0.001
14. Mortality Associated with CRE
• Crude mortality 48%-61%
• Infection-related mortality = 33%-40%
Patel G, ICHE 29:1099-1106, 2008; Snitkin ES, Science Translational Medicine 4:1-9, 2012
Munoz-Price LS ICHE 31:1074-7, 2010
15. Gram Negative Resistance Mechanisms
• Beta-lactamases-ESBL
• Multi-drug efflux pumps
• Porin changes-reduce permeability of outer
membrane (imipenem)
16. Gram Negative Resistance Mechanisms
• Carbapenemases
– KPC-Klebsiella pneumonia carbapenemase
– NDM-New Dehli Beta-lactamase
– VIM-Verona-integron-encoded
metallobetalactamase-found often in P.
aeruginosa, occasionally in Enterobacteriaceae
– IMP-imipenemase
17. What’s the big deal about KPC?
• It confers resistance to all beta-lactams, and is
frequently associated with resistance to other
drug classes
• Many isolates are sensitive only to
aminoglycosides, colistin, and tigecycline.
18. What’s the big deal about KPC?
• It is coded by blaKPC gene, which is plasmid
mediated and can be transferred from one
organism to another, facilitating rapid spread
of resistance
19. Clinical Impact of Antimicrobial
Resistance
• Resistance is rising
• Resistance increases mortality
• Decreasing antimicrobial use reduces
resistance
20. Annual prevalence of imipenem
resistance in P. aeruginosa vs.
carbapenem use rate
80
70
60
50
40
30
20
10
0
r = 0.41, p = .004
(Pearson correlation coefficient)
0 20 40 60 80 100
% Imipenem-resistant
P. aeruginosa
Carbapenem Use Rate
45 LTACHs, 2002-03 (59 LTACH years) Gould et al. ICHE 2006;27:923-5
21. P. aeruginosa susceptibilities before and after
implementation of antibiotic restrictions
(CID 1997;25:230)
100
80
60
40
20
0
Ticar/clav Imipenem Aztreonam Ceftaz Cipro
Percent susceptible
Before After
P<0.01 for all increases
22. Impact of Improving Antibiotic Use on
Rates of Resistant Enterobacteriaceae
Carling P et al. Infect Control Hosp Epidemiol. 2003;24(9):699-706.
23. Impact of fluoroquinolone restriction
on rates of C. difficle infection
2.5
2
1.5
1
0.5
0
2005 2006
Month and Year
HO-CDAD cases/1,000 pd
2007
Infect Control Hosp Epidemiol. 2009 Mar;30(3):264-72.
24. Targeted antibiotic consumption and
nosocomial C. difficile disease
Tertiary care hospital; Quebec, 2003-2006
Valiquette, et al. Clin Infect Dis 2007;45:S112.
25. What Can I Do?
• Ensure antimicrobial resistance is recognized
• Control nosocomial transmission of resistant
pathogens
• Reduce overall use of antimicrobial agents
26. What Can I Do?
• Ensure antimicrobial resistance is recognized
– Proper laboratory test protocols
– Identify patients at risk for colonization
• Control transmission of resistant pathogens
• Reduce overall use of antimicrobial agents
– Urinary tract
– Skin and soft tissue
– Respiratory tract
27. Resistance Definition
• Nonsusceptible to one of the 3 carbapenems-imipenem,
meropenem, or doripenem by
2012 CLSI breakpoints
AND
• Resistant to all of the third generation
cephalosporins tested-ceftriaxone,
cefotaxime, ceftazidime
*Morganella morganii, Proteus spp and Providencia spp. Are intrinsically
resistant to imipenem-look for resistance to another carbapenem
28. Resistance-A Simplified Approach
Old Breakpoints
CLSA M100 S19
Revised Breakpoints
January 2012
CLSI M-100 S22
Agent S I R S I R
Doripenem < 1 2 > 4
Ertapenem < 2 4 > 8 < 0.5 1 > 2
Imipenem < 4 8 > 16 < 1 2 > 4
Meropenem < 4 8 > 16 < 1 2 > 4
29. What Can I Do?
• Ensure antimicrobial resistance is recognized
– Proper laboratory test protocols
– Identify patients at risk for colonization
• Control transmission of resistant pathogens
• Reduce overall use of antimicrobial agents
– Urinary tract
– Skin and soft tissue
– Respiratory tract
30.
31. KPC Klebsiella pneumoniae
colonization
35
30
25
20
15
10
5
0
KPC Prevalence
ICUs LTACHs
KPC Prevalence
Lin M Y et al. Clin Infect Dis. 2013;57:1246-1252
32. What Can I Do?
• Ensure antimicrobial resistance is recognized
• Control transmission of resistant pathogens
• Reduce overall use of antimicrobial agents
33. CRE-Florida SICU Outbreak
• Daily CHG baths
• Cohorting during shifts-RTs, nurses, nurse aids
• Monitoring of environmental cleaning-black
light and culture
• Active surveillance cultures
Munoz-Price LS ICHE 31:1074-7, 2010
34. CDC Guidance-Core Measures
1. Hand Hygiene
2. Contact Precautions for all patients who are
colonized or infected with CRE
3. HCW Education
4. Minimize use of devices, e.g. CVCs,
endotracheal tubes, urinary catheters
35. CDC Guidance-Core Measures
5. Cohort patients and staff
6. Notification system for lab to promptly
inform Infection Control of all CRE
7. Antimicrobial stewardship
8. Screen contacts of patients colonized or
infected with CRE
36. Contact Precautions-Starting and
Stopping
• Micro lab should inform Infection Control of all
CRE
• Flag chart to identify patient for precautions on
re-admission
• Colonization may persist for 6 months or longer
• If screening for persistent colonization is used to
DC precautions, must screen > once
• CRE should not preclude transfer to another
facility
37. Contact Precautions for Long Term
Care
• Patients who are dependent on caregivers for
ADLs should be nursed in precautions
• For long term care residents who are able to
perform hand hygiene, are continent of stool,
are independent in ADLs and without draining
wounds contact precautions might be relaxed
38. Risk Factors for Mortality from CRE
• Age
• Mechanical ventilation
• Malignancy
• Heart disease
• ICU stay
39. But-removal of the primary focus of
infection (incision and drainage or
device removal) is independently
associated with survival
40. What Can I Do?
• Ensure antimicrobial resistance is recognized
• Control transmission of resistant pathogens
• Reduce overall use of antimicrobial agents
– Is an antibiotic truly needed?
– Discontinue or narrow therapy when data return
– Minimize duration of therapy
41. Antibiotic Assumptions
• Antibiotics are well tolerated insurance
against a bad outcome
• Treating longer is better
• My duty is to the patient in my care-if treating
him with an antibiotic increases societal risk,
that is secondary
42. Antibiotic Assumptions
• Antibiotics are well tolerated insurance
against a bad outcome
• Treating longer is better
• My duty is to the patient in my care-if treating
him with an antibiotic increases societal risk,
that is secondary
43. Case presentation
• 28 year-old male with no past medical history
admitted with fever and rash.
• On morning of admission: Red, bumpy, itchy
rash on right arm, pt thought possibly due to
bed bugs
• Rash progressed over course of the day to
involve chest, back, other arm, neck, face.
• Also c/o fever, malaise, sore throat, blurry
vision.
44. Case presentation
• Past medical history: kidney stone
• Past surgical history: none
• Medications: none on admission; recent Cipro
use for kidney stone
• Allergies: NKDA
• Family history: DM in mother and father
45. Clinical course
• Persistent high fever, tachycardia
• Rapidly progressive rash (vesicles large bullae) and
generalized facial edema
• Transferred to ICU on HD #3 due to concern for airway
compromise, intubated
• Derm evaluation:
– Clinical findings c/w toxic epidermal necrolysis
– SJS/TEN confirmed by shave biopsy
• Dx: SJS/TEN due to ciprofloxacin
46. Antibiotic Assumptions
• Antibiotics are well tolerated insurance
against a bad outcome
• Treating longer is better
• My duty is to the patient in my care-if treating
him with an antibiotic increases societal risk,
that is secondary
47. Stewardship optimizes patient safety:
decreased patient-level resistance
Cipro Standard
Antibiotic
duration
3 days 10 days
LOS ICU 9 days 15 days
Antibiotic
resistance/
superinfection
14% 38%
Study terminated early because attending
physicians began to treat standard care group
with 3 days of therapy
Singh N et al. Am J Respir Crit Care Med. 2000;162:505-11.
48. Pneumonia Scoring Systems
PSI Score-outpatients
http://pda.ahrq.gov/clinic/psi/psicalc.asp
CPIS Score-VAP
http://www.surgicalcriticalcare.net/Resources/CPIS.php
Curb 65 Score: One point per factor, score > 2 warrants hospitalization
Parameter Criteria
Confusion Disoriented to time/place/person or by other objective test
Uremia >20 mg/dL. Our normal range is 10-26 mg/dL so I think
above normal is an appropriate cutoff. Also, not everyone
includes this as it requires having completed labs.
Respiratory rate > 30 breaths/minute
Low Blood pressure < 90 mm Hg systolic or > 60 mm Hg diastolic
Age > 65 years
51. Antibiotic Assumptions
• Antibiotics are well tolerated insurance
against a bad outcome
• Treating longer is better
• My duty is to the patient in my care-if treating
him with an antibiotic increases societal risk,
that is secondary
– But…treating a patient with an antibiotic increases
that patient’s risk of resistance
52. Effect of antibiotic prescribing in primary care on
antimicrobial resistance in individual patients:
systematic review and meta-analysis
Costelloe C et al. BMJ.
2010;340:c2096.
53. What Can I Do?
• Ensure antimicrobial resistance is recognized
• Control transmission of resistant pathogens
• Reduce overall use of antimicrobial agents
– Urinary tract
– Respiratory tract
– Skin and soft tissue
54. Case 1
• 79 y/o man admitted for left foot gangrene
• Surgeons plan amputation
• PMHx chronic foley for urinary retention
• ROS negative
• Pre-op UA
– Dipstick + leukocyte esterase
– Microscopy > 50 WBC/hpf
55. How should the team respond to this
UA?
A. Order urine culture and treat empirically with
ciprofloxacin
B. Order urine culture and await results
C. Change the foley catheter
D. Watchful waiting
56. Case 2
• 81 y/o man admitted with fever, hypotension,
confusion
• PMHx DM, HTN, dementia, prostatism with a
chronic foley
• ROS unable to provide due to confusion
• Exam suprapubic tenderness, no flank
tenderness
58. What empiric therapy would you
select?
A. Vancomycin + pipracillin-tazobactam
B. Vancomycin + cefepime
C. Meropenem
D. Ciprofloxacin
59. Case 2
• Hospital course: treated with vancomycin +
pipracillin-tazobactam, defervesces, appears
pleasantly demented on day 2
• Blood and urine growing lactose fermenting
gram negative rods
60. How should therapy be altered?
A. Continue current management-he is
responding
B. Discontinue vancomycin-there is no evidence
of gram positive infection
C. Discontine vanc + pip-tazo and substitute
ceftriaxone
D. Discontinue vanc + pip-tazo and substitute
oral ciprofloxacin
61. Case 2
• C & S shows E. coli, resistant to cipro and
sensitive to the following agents. Which one
would you choose?
A. Ampicillin
B. Ampicillin-sulbactam
C. Cefazolin
D. TMP-SMX
62. Case 2
• What is the recommended duration of
therapy?
A. 3 days
B. 7 days
C. 10 days
D. 14 days
Editor's Notes
1. Thanks for coming 2. stewardship history=cost containment 3. shift focus to preserving the miracle of antibiotics 4. Reason for hope-decreased ag use, president’s exec order
More than 1oo antibiotics have been discovered since sulfonamides. Each new antibiotic must be better than the last, making it difficult to improve.
Antibiotics are used for short periods, making them much less lucrative than drugs taken by large numbers of people for many years
These factors interact-the regulatory burden increases the cost of drug development
Note that this increase occurred prior to the change in breakpoints
i.e. What are the outcomes associated with CRE?
Whenever a resistant pathogen is newly identified we hope that the fitness cost of expressing resistance mutation will make the organism less virulent. We are usually disappointed.
Beta-lactamases were first discovered in the 1950s, when our old friend Staph aureus learned to hydrolyze penicillin. ESBLs emerged ~20 years ago, and conferred resistance to all penicillins and 1st-3rd gen cephalosporins. Carbapenems were our last line of defense. In the 1990s a few CRE were described that had porin mutations combined with the AmpC betalactamase. That was bad, but did not become widespread.
KPC-found first in Klebs in North Carolina, but can be seen in other enterobacteriaceae, has spread rapidly and is now endemic in many New York hospitals. Others are mostly seen in patients who have received care outside the U.S.
Use of tigecycline for serious infections is hampered by inability to achieve high serum levels. In one study, mortality was higher in patients treated with tigecycline.
None of these are modifiable
So here is something positive we can do to improve survival. Physicians who grew up in the antibiotic era-virtually everyone practicing today-have forgotten the importance of a surgical approach to infection. We must remind them.