Antimicrobial Stewardship in Oncology Care

Antimicrobial Stewardship in
Oncology Care
Aliyah Baluch, MD, MSc, FACP
Assistant Member, Division of Infectious Diseases
Moffitt Cancer Center
Rod Quilitz, PharmD, BCOP
Clinical Pharmacy Coordinator – Infectious Diseases &
Antimicrobial Stewardship
Nov. 5, 2016
10:15 am to 11:00 am

Disclosures
We have no disclosures to make
http://www.parentguide.ca/stages/toddler-and-preschooler/do-bugs-need-drugs/

Learning Objectives (1 of 2)
• Review risk factors for infections in the
oncology patient population
• Discuss the impact on infections by multi-drug
resistant (MDR) organisms on oncology
patient outcomes

• Review the concept of antimicrobial
stewardship (AS) and the most recent IDSA
guideline and the upcoming Joint Commission
standard pertaining to AS
• Describe the implementation of an AS
Program at a NCI-designated Comprehensive
Cancer Center

Which of the following bacterial infections
is most problematic in your institution?
• A. Enterococcus faecium
– VRE
• B. Staphylococcus aureus
– MRSA, VISA, hVISA
• C. Enterobacteriaceae such as E. coli,
Klebsiella, Enterobacter
– ESBL, AmpC, or Carbapenemase producing
• D. Acinetobacter
• E. Pseudomonas aeruginosa

What is the status of Antimicrobial
Stewardship at your institution?
• A. No formal ASP exists and no active plans to
start one exist
• B. ASP is currently in the planning stages
• C. ASP exists but has minimal involvement in
the oncology patient population at this time
• D. Formal ASP exists and is actively engaged
in the care of oncology patients receiving
antimicrobial therapy

What is the primary purpose of
Antimicrobial Stewardship?
• A. Institutional adherence to regulatory
standards, such as the Joint Commission
• B. Reduce drug costs
• C. Improve patient outcomes
• D. Managing critical antibiotic shortages

Which of the following are key
components to an ASP program?
• A. Pre-authorization of restricted antibiotics
• B. Prospective audit and feedback
• C. Antibiotic cycling
• D. All of the above
• E. A and B

Which of the following are mandated
in the proposed Joint Commission
Standard?
• A. Multi-disciplinary team
• B. Antibiotic data reporting and quality
improvement activities
• C. Institutional leadership support
• D. Staff and practitioner education
• E. Patient and caregiver education
• F. All of the above
• G. A and B

• Review risk factors for infections in the
oncology patient population
• Discuss the impact on infections by multi-drug
resistant organisms on oncology patient
outcomes

General Risk Factors
• Invasive IV access
– PICC
– Port
– Tunneled vs. non tunneled catheter
• Mucositis / enteritis
• Low IgG due to disease status
• Anatomic issues related to tumors
– Obstruction
– Erosion and rupture

Immunocompromised Hosts
Neutropenia 7d+
• Malignant Hematology
• Hematopoietic Cell
Transplant (HCT)
– Autologous HCT
– Allogeneic HCT
• CAR-T
Neutropenia <7d or low
IgG
• Oncology
• Common variable
immunodeficiency
disease

Allogeneic HSCT
‘Transplant’ Required
Family Member is
a potential match
Matched Related
Donor
Mismatched Related
Donor
Haploidentical
No Match in the family
National Registry or
International
Registries
Matched Unrelated
Donor
Mismatched
Unrelated
Donor
Cord Registry
Double
Cord

Net State of Immunosuppression
• Immunosuppression
in order to maintain
graft
•Steroids
•Calcineurin
Inhibitors
•mTOR inhibitors
•Nucleotide
synthesis
inhibitors
•Monoclonal
antibodies
• Infection risk
•Bacterial infection
•Fungal infection
•CMV
•EBV/PTLD
•HSV
•VZV
•mTB reactivation
•Cancer risk

Tomblyn et al, Guidelines for Preventing Infectious Complications among Hematopoietic Cell
Transplantation Recipients: A Global Perspective, Biol BMT, 2009

Neutrophil Recovery
• G-CSF mobilized PBSC
– 2 wks
• Marrow grafts
– 3 wks
• Umbilical cord blood
grafts
– 4 wks
– With Thiotepa  may be
even longer
• First recovered
– Monocyte, Neutrophil, and
NK-cells
• 2nd
– B and T-cells
• 3rd
– RBCs and platelets

Dictates Prophylaxis in alloHSCT:
cipro/ fluc vs micaf vs vori/ ACV
Phases of Infection in alloHCT

Phases of Infection in alloHCT

Colonization / Previous Infections
• Colonization with
– MRSA
– VRE
– Fluoroquinolone resistant Strep viridans (GVS)
– Fluoroquinolone resistant gram negative rods
– Fluoroquinolone screening for prostate patients

Colonization / Previous Infections
• Colonization with
– MRSA (PCR of nares)
– VRE (PCR of perianal area)
– Fluoroquinolone resistant Strep viridans (GVS)
• Historical positive blood cultures
– Fluoroquinolone resistant gram negative rods
• Historical positive blood cultures
– Fluoroquinolone screening for prostate patients
• Rectal swab pre prostate biopsy

Baker et al, The growing threat of MDR GNR in patients with heme malignancies, Leukemia and
Lymphoma, 2016

ESKAPE Organisms
• (E)nterococcus faecium
– Daptomycin/linezolid resistance
• (S)taphylococcus aureus
– Daptomycin/linezolid resistance
• (K)lebsiella pneumoniae
– ESBL producing , Carbapenem-resistant Enterobacteriacae
(CRE)
• (A)cinetobacter baumannii
• (P)seudomonas aeruginosa
• (E)nterobacter species
– AmpC de-repression, CRE
BSI with ESBL producing
organism was an independent
predictor of mortality, prolonged
length of stay, delay of
appropriate antimicrobials and
total hospital stay cost.
Boucher et al, Bad Bugs, No Drugs: No ESKAPE, CID, 2009

• Carbapenemase-producing gram-negative bacilli
– Polymyxins are polypeptide antibiotics that work by
affecting outer membranes of bacteria leading to
death
• MCR-1 gene
– Described initially in 2015, plasmid-mediated colistin
resistance
– Now has been found in human, animal and
environmental sources
– SENTRY project reviewed 21,006 samples of E. coli and
K. pneumoniae from 2014-2015 and there was only a
prevalence of 0.1%

Neutropenic (NP) Fever:
Initial Therapy
• High risk patient that is admitted
– Coverage needed for Pseudomonas
• Choice: (A-I)
– Anti-pseudomonal cephalosporin (i.e. cefepime)
– Piperacillin-tazobactam
– Anti-pseudomonal carbapenem (i.e. meropenem)
Freideld et al, Clinical Practice Guidelines for the Use of Antimicrobial Agents in Neutropenic
Patients … IDSA, CID, 2010

Initial Therapy
– Coverage needed for Pseudomonas
• Choice: (A-I)
– Anti-pseudomonal cephalosporin (i.e. cefepime)
– Piperacillin-tazobactam
– Anti-pseudomonal carbapenem (i.e. meropenem)
• If with hypotension, pneumonia or hx of multidrug
resistance
– Aminoglycoside, fluoroquinolone, IV vancomycin

Initial Therapy
– ***NOTE***
• IV vancomycin (or other gram positive coverage) is NO
LONGER recommended as part of standard initial
coverage for NP fever (A-I)
• Unless there is a cause for it
– For example: cellulitis or catheter-related infection

Initial Therapy
– Special caveats
• MRSA colonized/ hx of MRSA infection
– Consider early use of IV vancomycin, linezolid, daptomycin (B-
III)
• VRE colonized/ hx of VRE infection
– Consider early use of linezolid or daptomycin (B-III)

Initial Therapy
– Special caveats
• ESBL hx of infection
– Consider early use of a carbapenem (B-III)
• KPC hx of infection
– Consider early use of polymixin-colistin or tigecycline (C-III)

Initial Therapy
– Allergy to Penicillin
• Assess severity
– Age of symptoms
– Anaphylaxis vs. rash
• Most tolerate cephalosporins as long as without hx of
immediate-type hypersensitive reaction
• If true allergy utilize mono-bactam ring antibiotic
– Consider IV vancomycin and aztreonam
– Consider IV vancomycin and ceftazidime

Initial Therapy
• Inpatient treatment
– If the pt is on IV vancomycin, linezolid or
daptomycin
• Work-up is negative
– In 48 hrs  d/c gram positive coverage (A-II)
– If the pt is hemodynamically unstable after initial
antibiotics
• Consider adding coverage for resistant organisms,
anaerobes and/or fungi (A-III)

Special note:
Antifungal Prophylaxis
• Prophylaxis vs. Candida spp.
– Needed in pts at risk for invasive candidal
infections
• Salvage induction chemotherapy for acute leukemia
• Allogeneic hematopoietic stem cell transplants (HSCT)
– Options
• Fluconazole, triazoles, echinochandins

Antifungal Prophylaxis
• Prophylaxis vs. Aspergillus infection
– Patients that are neutropenic with prior history of
invasive aspergillosis (A-III)
– Patients with anticipated prolonged neutropenia
i.e. more than 2 wks (C-III)
– Patients with prolonged neutropenia immediately
prior to HSCT (C-III)

ASP vs. NP Fever
• Prospective trial
– N of 307 febrile neutropenia cases in 169 subjects
– Rate of adherence to ASP was only 53%
– ASP adherence still showed that it was
independently associated with lower mortality
• Hazard Ratio -0.36 (95% CI 0.14-0.92)
Rosa et al, Assoc between adherence to an ASP and mortality among hospitalized cancer
patients with febrile neutropenia, BMC Infectious Diseases, 2014

First a Few Words About
Laboratory Testing

Gold Standard: Culture
• Blood Culture
• Fungal Blood Culture
• Acid Fast Bacilli (AFB) Blood Culture
• Tissue Culture
– Bone Marrow Culture
– CSF Culture

Rapid Diagnostics: PCR Panels
• Blood Culture Identification (BCID) Panel
– 27 Targets
• Respiratory Panel
– 20 Targets
• Gastrointestinal Panel
– 21 Targets
• Increasing number of panels available
commercially

FilmArray Blood Culture Identification
(BCID) Panel

Evaluation of FilmArray BCID
• 206 blood culture bottles analyzed
– 153/167 (91.6%) identified monomicrobial growth
• 13/167 (7.8%) microorganisms not covered in panel
– 6/167 (3.6%) FilmArray detected an additional
microorganism compared to blood culture
– 3/206 (1.5%) FilmArray was invalid
• Results were reproducible
Altun et al, Clinical Evaluation of the FilmArray BCID in Identification of Bacteria and Yeasts
from Positive Blood Culture Bottles, JCM, 2013

Shortcomings of PCR Panels
• Lack of culture
– There is a lack of sensitivity data
• Thus an inability to assess for resistance
– Only gives information ‘Yes, I am here’

Rapid Diagnostics: Mass Spectrometry
• Matrix-assisted laser desorption/ ionization time of
flight mass spectrometry (MALDI-TOF-MS)
– Identification is based on protein fingerprints
• There is no culture so there is no added information available
about sensitivity to drugs
• Additional prep steps for yeasts compared to bacteria that are
time consuming
Alam et al, Comparative evaluation of 1,3 β-d-glucan, mannan and anti-mannan antibodies and
Candida species-specific snPCR in pts with candidemia, BMC ID, 2007

Rapid Diagnostics: Urine Antigens
• Legionella urine antigen
– Only measures serotype 1 of Legionella pneumophila
• Approximately 80% of Legionella cases
– Can be negated with 1 dose of appropriate therapy
• Streptococcus pneumoniae urine antigen
– S. pneumoniae is the etiology of ~40% of community acquired
pneumonia
• Histoplasmosis urine antigen
– Can follow quantitative urine antigen while on treatment
Johansson et al, Etiology of community-acquired pneumonia, CID, 2010

Tools for Work-up of Infection
Basnayake et al, Rapid diagnostic tests for defining the cause of community-acquired
pneumonia, Current Opinion, 2015

Impact on Oncology Patients
• Neutropenic fever rates after cytotoxic
chemotherapy
– Prostate cancer 0.9 – 1.1%
– Breast cancer 4 – 5%
– Colorectal 5 – 6%
– NHL 22 – 29%
– Acute leukemia 85 – 95%
• Invasive BSI in 20 – 25% of these patients
• If early effective and empiric antibacterial therapy
for neutropenic fever  mortality is decreased
from 21% to 2 – 10%
Bow, There should be no ESKAPE for febrile neutropenic cancer patients …, J Antimicrob
Chemother, 2013

Impact on Oncology Patients
• Heme malignancy
– ESBL GNR bacteremia increases overall mortality by
25%
• Neutropenic patients
– CRE bacterial colonization / infection is on the rise
• Hot spots: NY, NJ, Spain, Israel and India
– Greater than 100 million residents of the Indian subcontinent are
already colonized with carbapenem resistant gram-negative
bacilli
– CRE bacteremia related mortality is approximately
69% (95% CI 42 – 87%)
Bow, There should be no ESKAPE for febrile neutropenic cancer patients …, J Antimicrob
Chemother, 2013

If Carbapenem Use Decreases … What
is the Effect on Steno?
Utilizing MedMind Program at MCC

2007 IDSA Guidelines:
Antimicrobial Stewardship (AS)
• An Antimicrobial Stewardship Program is a
rational, systematic approach to the use of
antimicrobial agents in order to:
– Optimize clinical outcomes
– Minimize unintended consequences
• Toxicity
• Collateral damage, such as Clostridium difficile
• Emergence of resistance
• Intended to provide evidence-based guidelines to
develop hospital-based ASPs
CID 2007; 44:159-77

Core Elements for ASP
• Education
– Can icrease acceptance of ASP
– Only marginally effective w/o active intervention
• Guidelines and clinical pathways
– Multidisciplinary development
– Consider local microbiology and resistance
• Antimicrobial order forms
• Streamlining or de-escalation of therapy
• Dose optimization
• IV to PO conversion
• Antimicrobial cycling
• Combination therapy
CID 2007; 44:159-77

How Do We Do It?
• Tools for ASP
– Formulary restriction and preauthorization
– Prospective audit with intervention and feedback
– Education
– Guidelines / clinical pathway development
– Monitor and provide feedback regarding resistance
(eg, antibiogram)
– Document the impact on relevant outcomes
• Computer surveillance & decision-support
systems can facilitate good AS
CID 2007; 44:159-77

Recommended ASP Team Members
• Infectious Disease Physician
• Clinical Pharmacist with ID training
• Infection Control Professionals
• Hospital Epidemiologist
• Clinical Microbiologist
• Information System Specialist
• ASP Personnel should be actively involved
with Infection Control and P&T Committees
CID 2007; 44:159-77

2016 ASP Recommendations
• Reauthorization and/or prospective audit and
feedback
• Do not rely solely on passive didactic education
• Facility-specific clinical practice guidelines with
dissemination & implementation plan
• Reduce use of antibiotics with high risk of CDI
• Antibiotic time-outs or stop orders
• Computerized clinical decision support at time of
prescribing
CID 2016;62:e51-e77

• Antimicrobial cycling is not recommended
• Pharmacokinetic programs for
aminogyclosides & vancomycin
• Alternative dosing strategies for broad-
spectrum ß-lactams to decrease costs
• Appropriate oral antibiotics for initial therapy
and facilitate IV to PO transition
• Allergy assessments and penicillin skin testing
CID 2016;62:e51-e77

• Reduce therapy to shortest effective duration
• Develop stratified antibiograms
• Selective and cascade reporting of antibiotic
susceptibility test results
• Rapid viral testing for respiratory pathogens
• Rapid diagnostic testing on blood cultures
• Serial procalcitonin testing in ICU patients
with suspected infection
CID 2016;62:e51-e77

• Antifungal stewardship
– Heme/Onc patients: Nonculture-based fungal
markers (galactomanan, BDG, PCR)
• Days of therapy (DOT) > Defined daily dose (DDD)
• Measuring antibiotic cost based on use
• Facility-specific Neutropenic Fever guidelines
• Provide support to providers in decisions relating to
antibiotic treatment for terminally ill patients

2016
Issued on June 22, 216
Applies to Hospitals and Critical Access Hospitals
Effective January 1, 2017

Joint Commission AS Standard
• Standard MM.09.01
– The hospital has an antimicrobial stewardship
program based on current scientific literature.
• Elements of Performance
– Leaders establish AS as an organizational priority
– Educate staff & practitioners about antimicrobial
resistance & AS practices
• Upon hire or granting initial privileges
• Periodically thereafter
– Educate patients and caregivers about appropriate use
of antimicrobials, including antibiotics

JC Elements of Performance for ASP
(continued)
• Multidisciplinary ASP Team
– ID Physician
– Infection Preventionist(s)
– Pharmacist(s)
– Practitioner
• Core elements
– Leadership commitment
– Accountability – single physician leader
– Drug expertise – single pharmacist leader
– Action – implementation of recommended actions
– Tracking – monitoring antibiotic use & resistance
– Reporting – to doctors, nurses, relevant staff (i.e. P&T)
– Education

JC Elements of Performance for ASP
(continued)
• ASP uses organization approved protocols
– Policies and procedures
– Guidelines such as CAP, SSTI, UTIs, CDI, IV to PO
– Preauthorization requirements for restricted
antimicrobials
• Hospital collects, analyzes, and reports data
on its ASP
• Hospital takes action on improvement
opportunities identified by ASP

www.mapsoftheworld.com, www.worldatlas.com www.moffitt.org

Restricted Antimicrobials
• Level 1
– Require approval from Infectious Diseases or
Antimicrobial Stewardship Program
– Non formulary antimicrobials
• Level 2
– ID/ASP approval not required to start therapy for
specified clinical indications
– ID/ASP approval required for other indications

Level 1 Restriction
2012
• Amikacin
• Colistimethate
• Doripenem
• Flucytosine
• Fosfomycin
• Imipenem-cilasatin
• Minocycline IV
• Posaconazole*
• Tigecycline
• TMP-SMX IV
2016
• All of the stuff on the left +
• AmphoB Lipid Complex
• Ceftaroline
• Cefepime**
• Ceftazidime/avibactam
• Ceftolozane/tazobactam
• Cidofovir
• Ertapenem
• Foscarnet
• Ganciclovir
• Isavuconazonium IV
• Meropenem
• Piperacillin/tazobactam***
• Pyrimethamine
• Ribavarin for inhalation
• Trifluridine
• Valganciclovir
*except in prophylaxis for acute leukemics and HCT
**except for febrile neutropenia in BMT or penicillin allergy non-severe
***except for febrile neutropenia

Level 2 Restriction
2012
• Amphotericin B
deoxycholate or liposomal
• Aztreonam
• Ertapenem
• Meropenem
• Daptomycin
• Linezolid
• Micafungin*
• Voriconazole*
2016
• Amphotericin B
deoxycholate or liposomal
• Aztreonam
• Ceftazidime
• Daptomycin
• Isavuconazonium PO
• Linezolid
• Micafungin*
• Voriconazole*
*except in prophylaxis for acute leukemics and HCT

Goal 1: Reduce Carbapenem Utilization
Antimicrobial Stewardship Program implementation lead to ~50% reduction in
carbapenem DOT
Be aware of potential ASP induced fatigue
– Quarter 2 of 2016, SMART reported daily lists of patients on carbapenems
to ID & ASP team to focus attention on the increased usage

Goal 2: Reduce Broad Spectrum Gram-
Positive Antibiotic Use

Goal 3: Promote Cost Effective
Antimicrobial Therapy
• ASP initiated 11/1/12 in middle of FY2013
– FY2012 = first FY prior to program
– FY2014 = first FY after program initiation
• $1,713,930 cost avoidance FY’14 vs FY’12
• $397,214 cost avoidance FY’15 vs FY’14
– 14.5% reduction
• Annual Antimicrobial Purchases
$0
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
$6,000,000
$7,000,000
FY2008 FY2009 FY2010 FY2011 FY2012 FY2013 FY2014

Challenge: Antimicrobial Shortages
• December ‘14 Piperacillin-Tazobactam
– Changed to Level 1 Restricted Antibiotic
– Ended quarterly Neutropenic Fever cycling
• July ‘15 Cefepime
– Alternative dosing schema auto-sustitution approved
• 2g IV Q12H to 1g IV Q8H
• 2g IV Q8H to 1g IV Q6H except for neutropenic fever
• Provider education re: Risk Factors for Pseudomonas
• March ‘16 Cefuroxime IV
– Replaced peri-operative antibiotic orders with Cefazolin
– Level 1 Restricted Antibiotic
• September ‘16 Cefepime
– Cefepime to Level 1 Restricted Antibiotic except for NF & BMT or PCN allergy
– Piperacillin-tazobactam remains Level 1 except for NF
– De-escalation of therapy in culture negative NF at discretion of ID Attending

Antimicrobial Shortages & Utilization
September 2016 Update
Piperacillin-Tazobactam supply improving as Cefepime supply worsening
Cefepime and Piperacillin-Tazobactam utilization is therefore being reversed

Challenge: Antimicrobial Drug
Cost Escalations in 2015
• Ribavirin for Inhalation for RSV/HMPV
– Cost increased to ~$25,000 per day of therapy
– In 2012, ASP replaced this agent with oral ribavirin (<$10 per day)
– 100% nebulized ribavirin would have cost ~$2.5 million in 2015
• Pyrimethamine for Toxoplasmosis
– Cost increased from $1,763 to $75,000 for #100 tablets ($750/tab)
– ~$300,000 for initial 6 months of therapy
– Resulted in update in IDSA Toxoplasmosis guidelines
• Flucytosine for Cryptococcus meningitis
– Cost increased to $4,353 or $10,721 per 100 capsules
– Cost for 2 weeks in US: ~$14,000 to $28,000 vs UK: ~$308
• All these agents are now Level 1 Restricted Antimicrobials

Antimicrobial Stewardship Initiatives:
Antimicrobial Guide
• Antimicrobial Dosing Guide Approved by P&T and
Medical Executive Committees
– Allows pharmacists to correct antimicrobial dosing per policy
• Vancomcyin/Aminoglycoside Dosing and Monitoring
• Expanded Intravenous to Oral Medication Policy
• Automatic Formulary Substitution Policies
• Suggested Antibiotic Therapy by Infection Site for
Patients at Low Risk for Pseudomonas

Antimicrobial Stewardship Initiatives:
Antimicrobial Guide
• Antimicrobial Therapy: UTI, Pyelonephritis
• Clostridium difficile colitis treatment algorithm
• Peri-operative Antibiotic Dosing & Redosing Criteria
• Interventional Radiology Antibiotic Prophylaxis
• Culture targeted prophylaxis for transrectal ultrasound guided
prostate biopsy

Antimicrobial Adverse Drug Reactions
Following SMART Implementation

• ASP programs are now required by Joint
Commission as of Jan 1, 2017
– Many components intertwined in ASP including
education
• Improves utilization of antimicrobials without
an increase in mortality
– An extra tool to help navigate the waters with
ongoing antimicrobial shortages
Gratis of Ramon Sandin, MD

Acknowledgement: Thanks to SMART at
Circa 10/4/2016

SMART Team Members
• Infectious Diseases Attending Physicians
– John Greene, MD
– Ana Velez, MD
– Aliyah Baluch, MD, MSc
• Infectious Diseases Clinical Pharmacists
– Rod Quilitz, PharmD, BCOP
– Yanina Pasikhova, PharmD, BCPS-AQ ID, AAHIVP
– Wonhee So, PharmD, BCPS
• Microbiology
– Ramon Sandin, MD, MS, FCAP, ABP-MM
– Dawn Ruge, BS, MT (ASCP)
• Infection Prevention
– Stacy Martin, RN, BSN, CIC
– Kay Sams, RN, BSN, CIC
– Stephanie Carraway, Infection Prevention Specialist
– Patricia Tomasini, Infection Prevention Specialist
– Julie Gnage, Infection Prevention Specialist

Addendum 1:
Moffitt Cancer Center Antibiogram

52 52 54 50 49 50 44
52 52 53
50
47
0
10
20
30
40
50
60
70
80
90
100
2009 2010 2011 2012 2013 2014 2015
%Susceptible
Year
E.coli
Ampicillin
Cefazolin
Ceftriaxone
Ceftazidime
Cefepime
Ciprofloxacin
Levofloxacin
Trimeth/Sulfa
Pip/Tazo
Meropenem
Imipenem
Ciprofloxacin
0
10
20
30
40
50
60
70
80
90
100
2009 2010 2011 2012 2013 2014 2015
%Susceptible
Year
K. pneumoniae
Amp/Sulbactam
Cefazolin
Ceftriaxone
Ceftazidime
Cefepime
Ciprofloxacin
Levofloxacin
Trimeth/Sulfa
Pip/Tazo
Meropenem
Imipenem

92 91
97 97 95
86
95
82
89
77
82
86
0
10
20
30
40
50
60
70
80
90
100
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
%Susceptible
Year
S. maltophilia
Levofloxacin
Trimeth/Sulfa
Minocycline
Trimeth/Sulfa
90 90
84
89
93
86
91
95 93
90
87
94 94 95
88
80
87
91 92 94 96
0
10
20
30
40
50
60
70
80
90
100
2009 2010 2011 2012 2013 2014 2015
%Susceptible
Year
P. aeruginosa
Ceftazidime
Cefepime
Ciprofloxacin
Levofloxacin
Pip/Tazo
Meropenem
Imipenem
Tobramycin

81
72
79 80
70 69 71
100
97
90
95
90
98 98
0
10
20
30
40
50
60
70
80
90
100
2009 2010 2011 2012 2013 2014 2015
%Susceptible
Year
E. cloacae Ceftriaxone
Ceftazidime
Cefepime
Ciprofloxacin
Levofloxacin
Trimeth/Sulfa
Pip/Tazo
Meropenem
Imipenem
Tobramycin
Pip/Tazo
Meropenem
Synthesis graphics gratis of Yanina Pasikhova, PharmD

Questions
• Rod Quilitz, PharmD, BCOP
– Clinical Pharmacy Coordinator – Infectious
Diseases & Antimicrobial Stewardship
– Rod.Quilitz@moffitt.org
• Aliyah Baluch, MD, MSc, FACP
– Assistant Member, Division of Infectious Diseases
– Aliyah.Baluch@moffitt.org

Antimicrobial Stewardship in Oncology Care

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