3 Antibiotics III- Antimicrobial Stewardship and PCN allergy

define antimicrobial resistance

inactivity of an antibiotic against a microbe to which it previously had activity

antimicrobial resistance is ________

a consequence of normal antimicrobial use -- appropriate or inappropriate

What is the MOA of antimicrobial resistance?

Antibiotic is taken but does not kill off all pathogenic bacteria present (stopped early, intrinsic resistance, etc.) and the resistant bacteria can continue to multiply

How does antibiotic resistance arise in hospitals?

-transfer of patient who has a resistant pathogen from one facility to another

-transfer of resistance genes b/w organisms

-patient to patient transmission

-in vivo selection w/in a patient d/t antibiotic use

-transfer from healthcare worker to patient

what methods of antibiotic resistance can we, as clinicians, impact?

-in vivo selection by antibiotic use

-patient to patient transfer of organisms

-healthcare-worker-to-patient transfer

Good hand hygiene and appropriate ABX use can reduce transmission

negative effects of antimicrobial resistance

-increased morbidity and mortality

-prolonged hospitalization

-increased costs (patient costs, economic costs) in the billions of dollars

-highest cost is $35 billion in loss of productivity

what are the classifications the CDC places on organisms based on their threat level?

-urgent

-serious

-concerning

antimicrobial resistance has been deemed a _________

global health crisis

what governmental plans have been enacted to deal with antimicrobial resistance?

-CDC threat report

-white house national action plan

-Joint commission stewardship recommendations

some consequences of ABX use (basically, general AEs that can be seen)

-allergic rxn

-heart rhythm disturbances (FQs)

-myelosuppression

-peripheral neuropathy

-ABX-associated diarrhea / C.diff

Antibiotics are the #_____ cause of allergic rxn in adults and children

#1

what is antimicrobial stewardship

ongoing effort by a health care institution to optimize ABX use among hospitalized patients to improve outcomes, ensure cost-effective therapy, and reduce AEs of ABX use

goals of antimicrobial stewardship

-optimize outcomes w/ individualized ABX therapy

-minimize unintended consequences (toxicity, selection of pathogenic organisms, and emergence of resistance)

Key Members of an antimicrobial stewardship program (LEARNING OBJECTIVE)

-ID physician

-clinical ID pharmacist

-hospital epidemiologist

-infection control / prevention

-microbiologist

-IT specialist

role of the ID physician in ASP (LO)

leader or co-leader who is responsible for overall outcomes

role of pharmacist in ASP (LO)

co-leader who assists w/ most of the day-to-day activities and reporting outcomes

Note the physician is a "figure head" who is there for support, while the pharmacist is usually responsible for most of the day-to-day work that goes into ID ASP

role of an epidemiologist in ASP (LO)

-identification of MDR organisms w/in the population served

-conduct surveillance and monitoring reports of MDR trends

role of infection control/prevention in ASP (LO)

-oversight in the use of standard precautions

-transmission-based precautions to prevent cross-transmission

-hand hygiene compliance

-implement strategies aimed at preventing infection

role of microbiologist in ASP (LO)

-promote diagnostic stewardship

-selective and/or cascade reporting of ABX on culture results

-assist w/ getting new technology to improve use of ABX

-develop antibiograms

role of IT specialist in ASP (LO)

-integrate interventions into order sets

-help track outcomes

CDC core elements (LO)

-pharmacy expertise

-hospital leadership commitment (human, financial, and IT resources)

-accountability (leaders or co-leaders responsible for program and outcomes)

-action (interventions, such as proseptive audit and feedback or preauthorization to improve ABX use)

-reporting (regularly report ABX use and resistance to prescribers, RPh, nurses, hospital leadership)

-tracking (monitor ABX prescribing, impact if interventions, and other outcomes)

-education (to everyone involved, including patient, about AEs, resistance, and optimal prescribing)

P.H.A.A.R.T.E

what are the specific actions that institutions and their ASP teams engage in to enhance an ASP program? (LO)

-prior authorization

-prospective audit and feedback

-facility specific treatment recommendations

what is a prior authorization (in relation to ASP) (LO)

requirement for providers to get approval for certain ABX before they are prescribed

Pros of prior authorizations in ASP (LO)

-reduce inappropriate ABX use

-optimize empiric choices

-prompt review of clinical data / prior cultures at initiation of therapy

-decrease costs

-rapid response to ABX shortages

-direct control over ABX use

cons to prior authorizations in ASP (LO)

-impacts use of restricted agents only

-impacts empiric >> definitive tx

-loss of prescriber autonomy

-delayed therapy

-effectiveness depends on skill of approver

-real time resource intensive

-potential for manipulation of system

-may simply shift to other ABX agents and select for different ABX-resistance patterns

what is prospective audit and feedback as it relates to ASP (LO)

engagement of prescriber after an ABX is prescribed

pros of prospective audit and feedback (LO)

-increased visibility of ASP and builds collegial relationships

-more clinical data available, enhancing uptake by prescribers

-↑ flexibility in timing of recommendations

-prescriber autonomy maintained

-address de-escalation of ABX and duration of therapy

cons to prospective audit and feedback (LO)

-compliance voluntary

-labor intensive

-success depends on delivery method of feedback to prescribers

-prescribers may be reluctant to change therapy if pt is doing well

-identification of interventions may require IT support and/or purchase of computerized surveillance systems

-may take longer to achieve reductions in targeted ABX use

in simple terms, what is prospective audit and feedback? (LO)

"the majority of what ASP pharmacists do"

-reviewing pt charts

-looking at info

-talking to provider after ABX are started, and providing feedback and recommendations to improve outcomes

what are facility specific treatment recommendations (LO)

development of clinical practice guidelines, algorithms, and order sets based on local epidemiology

Pros of facility specific tx recommendations (LO)

-standardized practices based on local data

-ABX selection and duration are optimized

-increases likelihood of appropriate empiric therapy

cons to facility specific tx recommendations (LO)

-most useful if the ASP has a reliable way to identify patients w/ specific syndromes

-need to be evaluated and updated w/ local resistance data regularly

-need interventions to maintain guideline adherence over time

What is the most commonly reported drug allergy? What % of patients report this allergy, and what % truly have an allergy?

Penicillin:

-1-15% of patients report allergy

-0.004-0.015% truly have anaphylactic rxn

How are penicillin allergies usually reported?

By patients who report an "allergy" but really had an AE. Most patients w/ a reported PCN allergy can actually tolerate PCN

why is it problematic for patients to be labeled w/ a PCN allergy if they don't actually have one?

-receive less effective ABX tx w/ agents that have higher incidence of AEs (vanco, FQs, clindamycin)

-higher risk of resistant infections like MRSA, VRE, and C. diff

-longer length of stay

why is it difficult to de-label patients w/ a PCN allergy or give them another beta lactam for tx

-potential for cross-reactivity b/w beta lactams can make providers wary to challenge w/ a different beta lactam

-misinformation (next card)

what misinformation may contribute to providers being wary to prescribe a different beta lactam if a patient has a PCN allergy?

early cephalosporins were sometimes contaminated w/ PCN and thus were reported w/ higher rate of cross-reactivity

rate of cross reactivity b/w PCNs and cephalosporins

-1st gen cephs = 1% cross reactivity

-2nd-5th gen = negligible (ie/ as generation increases, cross reactivity decreases)

Note that 1st gen cephs are the gen w/ the highest rate of cross reactivity, and this is due to similarity b/w side chains

rate of cross reactivity b/w PCN and carbapenems

<1%

strategies for de-labeling patients w/ a PCN allergy

-allergy reconciliation

-PCN skin testing

-education (patient, family, provider)

-graded challenges

-review of prior exposure

-allergy pathways

-EMR/order set modification

Bolded ones are those associated w/ LOs

what is the cornerstone of allergy delabeling?

allergy reconciliation

How to perform allergy reconciliation

Ask:

-what allergies do you have?

-what was the rxn? severity? duration? onset? tx?

-when did the rxn occur?

-what other similar agents have been tried since?

Relative efficacy of allergy reconciliation

Pretty darn effective. Sometimes, you may be able to de-label a patient's PCN allergy w/ this strategy alone

of patients who report a PCN allergy, ____ - ____% have a negative penicillin skin test (PST)

80-90% of patients w/ a reported PCN allergy have a negative skin test

what is the utility of a Penicillin skin test? What are the most common results?

provides likelihood of IgE-mediated hypersensitivity (anaphylaxis) rxn to PCN

-most commonly, those w/ "Penicillin allergy" have a negative skin test

Steps of a penicillin skin test

1) Skin prick test w/ PCN determinant (PenG), w/ histamine as positive control and saline as negative control

2) If all of the above are negative, perform an intradermal test of the same agents

3) If intradermal is negative, can proceed to oral challenge

why is it important to discuss allergies with patients?

-Most patients have not discussed their allergies w/ a healthcare provider

-most patients don't understand the negative consequences of carrying an "allergy" when they don't actually have an allergy

who should be targeted w/ allergy education?

-Ideally everyone, but if not possible, speak w/ high risk patients. Target high risk groups (pts who receive lots of broad spec ABX or have had multiple infections w/ susceptible organisms)

-providers

what happens after de-labeling a patient (w/ PCN allergy)?

up to 1/3 get re-labeled

Who is responsible for overall outcomes for an ASP program?

ID physician

Explain the roles of each of these professionals in an ASP program:

a) microbiologist

b) epidemiologist

c) infection preventionist

d) ID physician

a) microbiologists involved in identification and diagnostic stewardship; assembling antibiograms

b) epidemiologists track organisms over time

c) infection preventionist is involved w/ compliance

d) ID physician is the figure-head who is responsible for overall outcomes

which of these is a core element of CDC antimicrobial stewardship? SAA:

a) education

b) decreased MRSA rates

c) hospital leadership commitment

d) microbiologist involvement

A and C

what is meant by the CDC's core element of "hospital leadership commitment"?

You need buy-in from upper-level administration for success / funding of the program (human, IT, financial resources)

Tigecycline is restricted at your current institution to ID physicians or approval by an ASP pharmacist. This is an example of what type of intervention?

Prior authorization

A guideline is developed for your institution for all patients who present w/ CAP as part of an ASP prevention. Of the ASP interventions discussed, which represents a benefit of this type of ASP intervention?

standardizes prescriber practices at the local level

After reviewing patient chart, ASP pharmacist discusses the case w/ the patient's provider to make an ABX recommendation resulting in cheaper, narrower, PO ABX usage. What type of ASP intervention does this represent?

Based on more clinical data, improving strength of the recommendation

This is "prospective audit and feedback"

who is education on drug allergies important for and why?

-patients (target high risk groups)

-providers

-prevention of re-labeling (which occurs frequently)

Increasing clarity of antibacterial stewardship programs (ASP) and developing relationships with colleagues is a positive effect of which ASP intervention:

prospective audit and feedback

If you decided, Dr. P, MD and Dr. M, R.Ph were going to be the leader and co-leader of an antibiotic Stewardship Program.

Which CDC Core Element does this fall under?

Accountability

Describe the cross reactivity of penicillins and cephalosporins

cross reactivity b/w penicillins and 1st gen cephs is <1% and decreases as the generations increase

If you interviewing a patient who reports that they were hospitalized and intubated due to a penicillin allergy, which strategy for allergy delabeling would you be using?

allergy reconciliation

This CDC Core Element involves interventions such as prospective audit, feedback or preauthorization that improves antibiotic use.

actions

This CDC Core Element involves overseeing the influence of interventions, antibiotic prescribing and outcomes like C. difficile infections.

tracking

This member of the ASP is responsible for identifying the multi-drug resistant organisms (MDROs) within the population, conducting surveillance and monitoring/report MDRO trends over time

epidemiologist

Patients with Penicillin allergies are more likely to receive ________than patients without a penicillin allergy:

1) longer length of stay

2) MDR organisms (MRSA, pseudomonas, C.diff)

3) broad spec abx

T/F A prior authorization is usually associated with increased antibiotic cost

Falso