New Drugs for Bad Bugs- Statewide AntibiogramAntibiogram Summary •Enterococcus faecium resistant...

Felicia Matthews, Pharm.D., BCPS

Senior Consultant, Pharmacy Specialty

BE MedMined Services

New Drugs for Bad Bugs-Statewide Antibiogram

© 2018 BD. BD, the BD Logo and MedMined are trademarks of Becton, Dickinson and Company.

Disclosures

• Employee of BD Corporation

– MedMined ™ Services


Agenda

• Antimicrobial Resistance

• New Drugs to Combat Emerging Resistance

• Updates to Regulation for Antimicrobial Stewardship

• Statewide Antibiogram

• Antibiotics


Antimicrobial Resistance


Antibiotic –resistant infections add considerable

and avoidable cost to the U.S. health care

system:

Up to:direct cost

lost productivity


• Clostridium Difficle (C. Diff)

• Carbapenem-Resistant Enterobacteriaceae (CRE)Urgent Threat

• Multidrug-Resistant Acinetobacter

• Extended Spectrum Enterobacteriaceae

• Vancomycin Resistant Enterococcus

• Multidrug-Resistant Pseudomonas Aeruginosa

• Methicillin-Resistant Staphylococcus Aureus(MRSA)

Serious Threat




Treatment

TestingPrevention & Control

New Treatment Options: Gram Positive Agents

Drug Indication Coverage Approval Date Comments/Opinions

Dalbavancin(Dalvance®)

ABSSSI MRSA 2014 • Bactericidal• 1-2 dose regimen

Oritavancin(Orbactiv®)

ABSSSI MRSA, VRE 2014 • Bactericidal• One time dosing• Contraindicated

with heparin

Tedizolid (Sivextro®) ABSSSI MRSA, VRE 2014 • Bactericidal• Prodrug• IV/PO dosing

Delafloxacin(Baxdela™)

ABSSSI MRSA 2017 • Bactericidal• Polymicrobial

ABSSSI


Pipeline for Gram Positive Agents


New Treatment Options: Gram Negative Agents


Pipeline for Gram Negative Agents


Regulatory

• Joint Commission ASP Standard MM.09.01.01– Effective since January 2017.

– Organization must have a policy that address each core element in the ASP.

– Currently there is not any specific data that should be collected, analyzed or reported.

– Your organization must show improvement opportunities based on the collected and data analyzed.


Regulatory

• Joint Commission ASP Standard MM.09.01.01– Providing written material such as the organizations

antibiogram will meet the education requirement.

– Organizations may receive a requirement for improvement if there is not a physician on the team.

– They will not be reviewing staff records on education received regarding antimicrobial stewardship.


Regulatory

• CMS Conditions of Participation for Long Term Care Facilities (LTC)

• CMS Medicare Beneficiary Quality Improvement Project (MBQIP)

• CMS Conditions of Participation for Critical Access Hospitals (CAHs)


AHQI Antibiogram


What is included?

Duplicate isolates removed

Significantly different susceptibility results are considered unique or non-duplicate

Includes data from 1/2017 to 12/2017

One isolate per organism per 365 day period

Isolates from 56 hospitals in Alabama


Community versus Hospital

• That which is collected from an outpatient or an inpatient within the first 3 days of an admission who has had no admissions within the past 14 days

Community isolate

• That which is collected from a inpatient on or after day 3 of an admission or within 14 days of discharge

Hospital isolate


0

200

400

600

800

1000

1200

1400

1600

1800

2000

2010 2011 2012 2013 2014 2015 2016 2017

E Faecium

E Faecalis

19001767 1799

15351500

1327

11491122

Hospital Enterococcus Isolates (Non-Urine)

33% (31%) of Enterococcusisolates are the more resistant faecium strain


E. faecium resistant to vancomycin is unchanged from last year 80% (80%)

E. faecium resistance to linezolid is unchanged from last year 6% (6%). Still below 2007 levels

* 95% of E. faecalis remain susceptible to vancomycin

Vancomycin Resistant E Faecium(Hospital Non-Urine)


80%

6%

0

10

20

30

40

50

60

70

80

90

Vancomycin

Linezolid

MRSA has been flat since about 2012 and is at 58% in 2017.

The percent remains high relative to other regions in the US

Hospital MRSA (Non-Urine)


58%

40

45

50

55

60

65

70

75

80

MRSA All HAIs | 2011-2014

http://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html


MRSA Hospital versus Community (Non-Urine)

Lines appear to be separating since 2013 as hospital is about 5% more resistance

Community will include patients from nursing homes and long-term care hospitals and may not reflect “Community” in the traditional sense.


58%

53%

40

45

50

55

60

65

70

Hospital

Community

Klebsiella pneumonia Isolates Resistant to Meropenem (KPC)

Previous presentations have reported K. pneumonia strains tested against imipenem. A greater number of hospitals have been testing meropenem instead of imipenem. We will report meropenem moving forward.

2017 testing against meropenemincreased to 7015 (6310) but total resistant isolates remained flat. There was an increase in community resistant strains but a decrease in hospital resistant strains.


75

4457

97

6248

0

20

40

60

80

100

120

140

160

180

200

2015 (n=6267) 2016 (n=6310) 2017 (n=7015)

Comm Hosp

172 total

106 total105 total

Hospital Non-Urine A. baumannii Isolates Susceptible to Meropenem

17% drop in susceptibility reported in 2017. A. baumannii has always been difficult to treat so infection prevention is critical.

Multi-drug Resistant A. baumannii is associated with high mortality and is difficult to treat.

Combination therapy of carbapenem with ampicillin/sulbactam, colistinor tigecycline still may be necessary


78

92

104

64%

70%

53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2015 2016 2017

0

20

40

60

80

100

120

Total Isolates % Susceptible

Carbapenms R or I Acinetobacter NATIONAL HAIs | 2011-2014

http://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html


Hospital P. aeruginosaNon-Urine

B-Lactams

Pipercillin/Tazobactam and Cefepime continue to be stable

Drop in Aztreonam 60% (66%) marks the first decline the last 5 years


82%

60%

85%

50

60

70

80

90

100Cefepime

Aztreonam

Pip/Tazo


AminoglycosidesAmikacin and Tobramycin steady at over 90%

Gentamicin continues to improve over the last 5 years


90%

91%

81%

50

55

60

65

70

75

80

85

90

95

100

Amikacin

Tobramycin

Gentamicin


Carbapenems

P. aeruginosa susceptibility to imipenem and meropenemimprove respectively at 71% (68%) and 76% (73%).

There is still concern here as this one of our last lines of defense against resistant gram negative bacteria.


71%

76%

50

60

70

80

90

100

Imipenem

Meropenem


Quinolones

Poor activity against Pseudomonas but there is a trend towards improvement over the past 4 years and since 2006.


70%

50

60

70

80

90

100

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Levofloxacin

Antibiogram Summary

• Enterococcus faecium resistant to vancomycin or linezolid, hospital non-urine, remains stable (80%, 6%)

• MRSA, hospital non-urine, is flat. Geographically, still high. Appears that MRSA, community non-urine, is declining slightly faster.

• CRKP, hospital and community, was flat in 2017, however the make-up changed with more of the resistant strains coming from the community setting.

• A. baumannii , hospital non-urine, big drop in susceptibility (53% vs 70%). Preventing the infection is critical.

• P. aeruginosa, hospital non-urine, resistance to carbapenems flat although still a concern.


Antibiotic National Comparison

Antibiotics



Carbapenems



Piperacillin / Tazobactam



Quinolones



3rd/4th Generation Cephalosporins



Vancomycin, Linezolid, Daptomycin, Tigercycline



Proton Pump Inhibitors


Felicia Matthews, Pharm.D., BCPS

Senior Consultant, Pharmacy Specialty

BE MedMined Services

New Drugs for Bad Bugs-Statewide Antibiogram


New Drugs for Bad Bugs- Statewide AntibiogramAntibiogram Summary •Enterococcus faecium resistant...

Documents

Transcript of New Drugs for Bad Bugs- Statewide AntibiogramAntibiogram Summary •Enterococcus faecium resistant...