Antibiotic Selection and Resistance: A Pharmacist’s perspective
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ANTIBIOTIC SELECTION AND RESISTANCE: A
PHARMACIST’S PERSPECTIVEJennifer Ott, PharmD, BCPS
Clinical Pharmacy Specialist, Infectious DiseasesEastern Maine Medical Center
Bangor, [email protected]
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The use of antibiotics is the single most important factor leading to antibiotic resistance
Up to 50% of all antibiotics prescribed are not needed or are not optimally effective as prescribed
CDC. Threat Report 2013. http://www.cdc.gov/drugresistance/threat-report-2013/
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Increased Use of Vancomycin Associated with Resistance
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Kim NJ. JID 1999;179:163
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N. gonorrhoeae Resistance in the United States 1987-2011
The Gonococcal Isolate Surveillance Project
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Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop resistance to that antibiotic Greatest effect in the month immediately
following treatment but may persist for up to 12 months
Costelloe, C. et al. BMJ 2010: 340:c2096.
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Effect of Antibiotic Prescribing in Primary Care on Antimicrobial Resistance
Costelloe C et al. BMJ. 2010;340:c2096.
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Nursing Home Patients Example
1 Centers for Medicare and Medicaid Services, Long Term Care Minimum Data Set, Resident profile table as of 05/02/2005. Baltimore. MD. 2 Loeb, M et.al. Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med 2001; 16: 376-383. 3 Centers for Disease Control and Prevention, National Center for Health statistics, 1999 National Nursing Home Survey. Nursing Home Residents, number, percent distribution, and rate per 10,000, by age at interview, according to sex, race, and region: United States, 1999.
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Acinetobacter Resistance to Imipenem
http://www.cdc.gov/getsmart/campaign-materials/week/images/resistance.png
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Inappropriate Dosing May Lead to Resistance
Data pooled from 4 studies Gram-negative pneumonia Ciprofloxacin resistance associated with AUC/MIC
<100
Thomas JK, et al. Antimicrob Agents Chemother. 1998;42:521-527.
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Dosing Matters – Penicillin Example
Penicillin half-life is only 30-45 minutes Retrospective review of Streptococcal
infective endocarditis Penicillin given every 4 hours was associated
with successful treatment vs every 6 hours (OR 2.79; 95%CI 1.43-5.62)
Sandoe JAT, et al. J Antimicrob Chemother. 2013; June 13 [Epub ahead of print]
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Pseudomonas aeruginosa MIC Distribution
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Dosing Optimization Example
Shea KM, et al. Ann Pharmacother 2009;43:1747-1754
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Optimizing Dosing – Cefepime Example
Cefepime Tertiary references suggest a dose of 1-2 g q8-
12h Susceptibility breakpoints are based on 1 g
q8h (= 2g q12h) Meaning: using 1 g q12h for pneumonia does
not optimize the dosing of cefepime and risks undertreating the patient
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Current Antibiotic Resistance Threat in the United States
CDC. Threat Report 2013. http://www.cdc.gov/drugresistance/threat-report-2013/
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BAD BUGS, NO DRUGS
As Antibiotic Discovery Stagnates…A Public Health Crisis Brews
Boucher HW, et al. Clin Infect Dis 2009;48:1-12.
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The AntibioticPipeline
http://www.rff.org/RFF/Documents/ETC-06.pdf Accessed Jan 1, 2013
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Anti-infective Stewardship Promotion of appropriate and responsible
use of anti-infective agents Optimize anti-infective therapy
Drug Dose Route Duration
Patient tolerance and safety Limit preventable adverse events Drug-drug or drug-disease interactions
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Questions
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Are Antibiotics Really Benign?
CDC. Threat Report 2013. http://www.cdc.gov/drugresistance/threat-report-2013/
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Infections with Resistant Organisms are on the Rise
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Objectives Antibiotic overuse promotes resistance
Goal – use most narrow spectrum agent for appropriate duration
Increased resistant organisms are on the rise Inappropriate antibiotic dosing may promote
resistance Antibiotic pipeline is diminishing What to do
Promote appriopriate anti-infective use Use most narrow spectrum anti-infective agent at
optimal doses for the appropriate duration