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Transcript of Antibiotics Over-prescribing and New Antibiotics •acute pharyngitis, rhinosinusitis, acute...

  • Antibiotics Over-prescribing and New Antibiotics

    Sept 18, 2018

    Paul Bonnar, FRCPC

    paule.bonnar@nshealth.ca

    http://www.cdha.nshealth.ca/nsha-antimicrobial-stewardship

  • No disclosures

    • Off-label antibiotic recommendations will be declared

    • Receiving evaluations is critical to the accreditation process.

    Please provide feedback

  • Learning objectives

    • To understand the state of antibiotic resistance and

    antibiotic use patterns

    • To be aware of new antibiotics in the pipeline

    • To understand treatment of common community-acquired

    syndromes

    • To become stewards of antimicrobials

  • MCQ

    • Most antimicrobials are used in:

    a) Hospital

    b) Community

    c) Long-term Care

  • MCQ 2

    • What % of antibiotics are used unnecessarily?

    a) 10%

    b) 30%

    c) 60%

    d) 90%

  • pewtrusts.org

    Each year in Canada, >18,000 hospitalized patients acquire

    infections that are resistant to antimicrobials

  • WHO: Antimicrobial Stewardship for Hospitals Training Workshop

    Antimicrobial resistance is an

    urgent global public health threat

  • Carbapenemase-producing Enterobacteriaceae

    Canadian Antimicrobial Resistance

    Surveillance System Report 2016

  • WHO priority list

    Lancet Infect Dis. 2017 Dec 21

  • N Engl J Med 2005;352:380-91

  • Vancomycin-resistant Enterococcus infections

    Canadian Antimicrobial Resistance

    Surveillance System Report 2016

  • BSAC 2018

    Resistant microorganisms are expensive

  • http://sitn.hms.harvard.edu

  • Used for short

    duration

    Priced low

    Held in reserve

    LESS REWARD

    LONGER

    DEVELOPMENT

  • Ceftazidime / Avibactam

    IDSA

  • Indication FDA

    Approval date

    Dalbavancin Lipoglycopeptide

    (1953) Dalvance IV SSTIs May 2014

    Tedizolid

    phosphate

    Oxazolidinone

    (1955) Sivextro PO/IV SSTIs June 2014

    Oritavancin

    diphosphate

    Lipoglycopeptide

    (1953) Orbactiv IV SSTIs Aug 2014

    Delafloxacin

    meglumine Baxdela IV/PO SSTIs June 2017

    Ceftolozane and

    tazobactam

    Ceph (1928)

    + BLI Zerbaxa IV

    cIAI (+metronidazole)

    cUTI Dec 2014

    Ceftazidime and

    avibactam

    Ceph (1928)

    + BLI Avycaz IV

    cIAI (+metronidazole)

    cUTI

    HAP/VAP

    Feb 2015

    Meropenem and

    vaborbactam Vabomere IV cUTI Aug 2017

    Isavuconazonium

    sulfate Cresemba IV/PO

    Invasive aspergillosis

    Invasive mucormycosis March 2015

    Secnidazole Solosec PO Bacterial vaginosis Sept 2017

    GAINS FDA report

  • Jan 2010-2015

    Ceftaroline Cephalosporin

    (1928) IV SSTI, CAP

    Fidaxomicin Macrolide

    (1948) PO C. diff

    Bedaquiline Diarylquinoline (1997) PO MDR-TB

    Ann Intern Med. 2016 Sep 6;165(5):363-72.

    2009

    Telavancin Lipoglycopeptide IV SSTI, CAP

  • pewtrusts.org

  • • Surveillance

    • Infection prevention and

    control

    • Antimicrobial Stewardship

    • Research and innovation

  • ANTIBIOTIC USE PATTERNS

  • Medically important

    antimicrobials in Canada

    • 2014

    Food-

    producing

    animals

    82%

    Human

    medicine

    18%

    Canadian Integrated Program for Antimicrobial

    Resistance.

    Annual Report 2014.

  • MCQ

    • Most antibiotics are used in the community to treat:

    a) Urinary tract infections

    b) Skin infections

    c) Respiratory infections

    d) Gastrointestinal infections

  • • 23 million Rx dispensed

    • 93% dispensed from community pharmacies

    • $786M

    • 65% Canadians received abx

    • Most often for respiratory tract infections

    Antibiotic use in the community

    2014

    Canadian Antimicrobial Resistance

    Surveillance System Report 2016

  • Canadian Antimicrobial Resistance

    Surveillance System Report 2016

  • 26% amoxicillin

    9% azithromycin

    8% ciprofloxacin

    Patterns in antimicrobial use by age group, as dispensed by

    Canadian Pharmacies, 2010-2014

    Canadian Antimicrobial Resistance

    Surveillance System Report 2016

    65% Canadians filled Rx

  • Ciprofloxacin was the most commonly recommended antimicrobial

    agent used to treat 46% of lower UTIs in women

    Management of UTIs

    Canadian Antimicrobial Resistance

    Surveillance System Report 2016

  • Canadian Antimicrobial Resistance

    Surveillance System Report 2016

  • Ambulatory care

    antibiotic use in US

    Overall

    • 506 antibiotic prescriptions/1000 pop/year

    • >30% are unnecessary

    • 50% if include selection, dosing, duration

    • Top 3: sinusitis, otitis media, pharyngitis

    Acute respiratory conditions

    • 221 antibiotic prescriptions/1000 pop annually

    • 50% unnecessary

    Fleming-Dutra. JAMA. 2016;315(17):1864-1873

    CDC

  • A Point Prevalence Survey of Antimicrobial Use at

    Hospitals in Nova Scotia Emily Black, Heather Neville, Mia Losier, Megan Harrison, Kim Abbass, Kathy Slayter, Lynn Johnston, and

    Ingrid Sketris

    11.1%

    10.9%

    8.9%

    8.0%

    7.4%

    5.5%

    4.4%

    3.6%

    3.3%

    3.0%

    2.6%

    2.1%

    2.0%

    2.0%

    Metronidazole

    Cefazolin

    Ceftriaxone

    Piptazo

    Ciprofloxacin

    Vanco

    Cephalexin

    SMX/TMP

    Fluconazole

    Levofloxacin

    Imipenem

    Moxifloxacin

    Amoxclav

    Ampicillin

    30% NS inpatients

    on antimicrobials

    47% ICU

    ~2/3 IV

    Black E, Neville H, Losier M, Harrison M, Abbass K, Slayter K, Johnston

    K, Sketris I. CPJ. 2017;150(4):S35. (abstract)

  • OPTIMIZE ANTIBIOTIC USE

  • MCQ

    • How common are antibiotic side-effects?

    a) 5%

    b) 20%

    c) 40%

    d) 60%

  • Misuse of antibiotics

    • An antibiotic is not used when it could improve healthUnderuse

    • An antibiotic is not indicated e.g. non bacterial infections

    Unnecessary use

    • Incorrect timing, choice, dose, route, or duration

    Inappropriate use

  • Dose /

    frequency Choice

    Duration /

    timing Route

    Optimal

    use

  • WHO: Antimicrobial Stewardship for Hospitals Training Workshop

    Empiric vs targeted therapy

    • Empiric therapy

    – Treating an infection without knowing

    the causative pathogen

    – Relying on experience and precedent

    • Prophylaxis

    – Prevention of disease

    Both rely on

    - Knowledge of

    location of disease

    in the body

    - Local epidemiology

    • Targeted therapy • Antibiotic regimen determined by identity and antibiotic sensitivities

    • More refined and specific compared to empiric therapy

    WHO: Antimicrobial Stewardship for Hospitals Training Workshop

    Classes of infective agents • Commensal

    – an organism in a co-operative relationship in which the person

    derives some benefit while remaining unaffected by its presence

    – do not cause disease when in their usual location

    • Staphylococcus epidermidis on skin, Escherichia coli in

    gastrointestinal tract

    • Pathogen

    – an organism that causes disease

    – some organisms are always regarded as pathogenic

    • Mycobacterium tuberculosis, Salmonella typhi, influenza virus

    - some sites are normally sterile

    • e.g. blood, cerebrospinal fluid (CSF), bladder

    • any organisms in these sites are usually thought of as pathogenic

  • What is Antimicrobial Stewardship?

    Coordinated interventions designed to improve and measure the

    appropriate use of antimicrobials

    Barlam. Clin Infect Dis. 2016;62(10):e51–e77

    Tamma CID 2017;64(5):537–43

    Right drug

    Right dose

    Right duration

    Right route

  • SUMMARY OF ACTIVITIES

    Prospective

    audit and

    feedback

    IV to PO policy

    Obtaining

    antimicrobial

    use data

    Presentations /

    education

    Handbook &

    guidelines

    Research /

    QI projects

    Point Prevalence

    Surveys

    Redundant

    therapy policy

    Public

    engagement:

    Antibiotic

    Awareness Week

    Website

    Cascading

    sensitivities Antibiograms

    Beta-lactam

    allergy

    algorithm

    Formulary

    review

    Outpatient

    Academic

    Detailing

  • • D