Point of care testing for influenza Dr Jen Kok Centre for ...
Transcript of Point of care testing for influenza Dr Jen Kok Centre for ...
ANTIBIOTIC ESSENTIALS Intern Orientation 21ST Jan 2019 MATTHEW O’SULLIVAN | INDY SANDARADURA| JON IREDELL ANGELA NETLUCH
icpmr Centre for Infectious Diseases and Microbiology
∼
THE PIPELINE IS RUNNING DRY • Antimicrobial use inevitably leads to antimicrobial resistance
• Ongoing drug development is required to combat resistance development to older agents
• Disappointing sales of recently launched antibiotics
3
∼
INAPPROPRIATE ANTIMICROBIAL USE Numerous studies have found
a large percentage of antimicrobials prescribed are inappropriate – No bacterial infection
– Ineffective antibiotic
– Inappropriate antibiotic Antimicrob Agents Chemo 51:864
J Hosp Inf 71:108
5
Euro Surveill. 2007;12(41):pii=3284.
icpmr Centre for Infectious Diseases and Microbiology
∼
ANTIMICROBIAL STEWARDSHIP (AMS)
• Systematic approach to optimising use of antimicrobials
• Aim: – Reduce inappropriate antimicrobial use – Improve patient outcomes – Reduce adverse effects/toxicity – Reduce development of antimicrobial resistance – Reduce costs
Clin Micro Rev 18:638
6 icpmr Centre for Infectious Diseases and Microbiology
∼
The AMS Team • AMS Ward Rounds
– Mondays, Wednesdays & Fridays @ 10:30am
Doctors • Matthew O’Sullivan, Matthew Watts, Indy
Sandaradura, Trish Ferguson + 7 other ID Drs AMS Pharmacist • Angela Netluch Infection Prevention & Control Team • Wednesday Rounds
What we do? • Education • Interpreting microbiology results • Therapeutic Drug Monitoring (TDM) • Advice
– De-escalation – Dose optimisation – IV to Oral Switch – Appropriate duration – Other investigations – Cessation – Directed therapy/Broadening cover – Formal ID consult
• Conflict Resolution
Don’t be shy!
Always happy to answer
ID/Micro/AMS questions on the
round!
There are no dumb questions
9
RED ANTIBIOTICS Infectious Diseases/Microbiology input is advocated for these agents PRIOR to use because they may either: - Be very broad spectrum agents which should
only be used when difficult-to-treat multi-resistant organisms are suspected/present; and/or
- Lead to increased rates of antimicrobial resistance if overused; and/or
- Require therapeutic drug monitoring to ensure efficacy and avoid toxicity; and/or
- Be expensive; and/or - Possibly have life threatening drug
interactions/adverse effects.
RESTRICTED ANTIMICROBIALS
icpmr Centre for Infectious Diseases and Microbiology
∼
10
GREEN ANTIBIOTICS Infectious Diseases/Microbiology input is not essential for these agents because they may either: - Be narrow spectrum agents which are
suitable for directed therapy and are less likely to promote antimicrobial resistance
- Do not require therapeutic drug monitoring
- Less likely to have life threatening drug interactions/adverse effects.
icpmr Centre for Infectious Diseases and Microbiology
∼
UNRESTRICTED ANTIMICROBIALS
ANTIMICROBIAL ADVICE AND APPROVALS
11 icpmr Centre for Infectious Diseases and Microbiology, Westmead Hospital
∼
• Electronic decision support and approval system – MANDATORY to obtain approvals for restricted
antimicrobials
• Training for interns – 24/01 and 25/01
Medical Officer Responsibilities
12 icpmr Centre for Infectious Diseases and Microbiology, Westmead Hospital
∼
• To log use of restricted antimicrobials on Guidance MS as soon as you wish to prescribe the antimicrobial
• To select an appropriate indication – NOT TO FALSIFY MEDICAL RECORDS
• To write APPROVAL NUMBER on the medication chart • To discontinue antimicrobials when appropriate
Charting Antimicrobials • Drug in generics – important for allergies • Indication • Date therapy was started or Day 1, 2, 3 • Review date – mandatory for eMeds (2019) • Guidance approval number • TDM – indicate when to take level
Spectrum What is the spectrum? • Gram Positive • Gram Negative • Anaerobes • Atypicals
Acknowledge Dr Craig Boutlis - http://www.boutlis.com/files/AntibioticPrescribing.pdf
Narrow vs Broad Spectrum What’s the difference? Which one is better?
Surgical Prophylaxis
• Read the Surgical Antibiotic Prophylaxis Guidelines available on the ABCs of Antibiotics Intranet Page
• Postoperative surgical prophylaxis SHOULD NOT extend beyond 24 hrs
– >24hrs = no further benefit & ↑ adverse effects
• The recommended surgical prophylaxis dose of cephazolin is 2g
• Timing
Simple principles
Special Attention to those doing - Ortho, Vascular, Cardiothoracic, Colorectal, Neurosurgery, Plastics, Urology or Upper GI terms
CASE STUDY 1 • 50 yo woman presents with lower abdominal and left
loin pain, dysuria, frequency and lethargy • NKDA • PR 98, BP 90/55, Temp 38.9ºC • Urine dipstick: WBC 3+, protein 2+, nitrites 2+ • WCC 19, CRP 230, Cr 60 • MSU and blood cultures collected
17
Ampicillin 2g IV 6th hourly and gentamicin 5mg/kg What is your empiric antibiotic therapy?
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 1
What is your treatment plan?
18
Change to oral amoxycillin 500mg tds once improving and temp <38ºC for 24 hours
› Blood culture negative
› Urinary tract ultrasound normal
icpmr Centre for Infectious Diseases and Microbiology
∼
• It’s 2am • Called by a nurse on one of the wards • “Mrs Smith has a temperature of 39 degrees.
Can you please come assess her?”
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
You go to the ward and assess Mrs Smith: • What do you want to know?
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
• 61 year old lady • NKDA • Had an open cholecystectomy 8 days ago • Was in HDU for 3 days post-op due to blood loss • Complaining of feeling short of breath, cough
with some sputum production Other medical problems: • Type II Diabetes Mellitus • Hypertension
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
O/E • Alert and oriented • Heart rate = 98 • Blood pressure = 150/90 • Respiratory Rate = 25 • Temp = 39
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
• Respiratory examination: Coarse crackles in right base
• Cardiovascular examination: Normal • Abdominal examination: Wound looks ok,
drain in situ
• Peripheral cannula in situ, inserted yesterday, site looks clean
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
• Take Blood cultures!!
• Other blood tests as necessary
• Sputum microscopy and culture
• Chest Xray
What next? icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
How will you choose which antibiotic to give?
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
How will you choose which antibiotic to give? Call your registrar/senior and/or
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
How will you choose which antibiotic to give? Call your registrar/senior and/or Call Infectious Diseases if it is tricky! (e.g. resistance, allergies etc.) and/or Use the available online resources to guide your choice
Which are found…
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2
Let’s change the story a little… •You’ve seen Mrs Smith in the Emergency Department.
•No recent surgery, but presents from home with precisely the same symptoms and signs.
•What’s the difference?
icpmr Centre for Infectious Diseases and Microbiology
∼
CASE STUDY 2 part 2
Community Acquired Pneumonia
1. Common organisms 2. Severity scores 3. Investigations 4. Treatment
icpmr Centre for Infectious Diseases and Microbiology
∼
COMMUNITY ACQUIRED PNEUMONIA GUIDELINES
38 icpmr Centre for Infectious Diseases and Microbiology
∼ Green = Typical Blue = Atypical
COMMUNITY ACQUIRED PNEUMONIA GUIDELINES
• Pneumonia severity scores – Several scores available – Predict likelihood of death – Can be used as an aid to determine severity and help
decide: • Outpatient vs inpatient therapy
• Oral vs IV therapy
• Broad spectrum vs targeted therapy
39 icpmr Centre for Infectious Diseases and Microbiology
∼
COMMUNITY ACQUIRED PNEUMONIA GUIDELINES
43 icpmr Centre for Infectious Diseases and Microbiology
∼ Red = Needs Guidance Approval
COMMUNITY ACQUIRED PNEUMONIA GUIDELINES
44 icpmr Centre for Infectious Diseases and Microbiology
∼
Red = Needs Guidance approval
COMMUNITY ACQUIRED PNEUMONIA GUIDELINES
45 icpmr Centre for Infectious Diseases and Microbiology
∼ Red = Needs Guidance approval
COMMUNITY ACQUIRED PNEUMONIA GUIDELINES
46 icpmr Centre for Infectious Diseases and Microbiology
∼
Red= Needs Guidance approval
Adverse reactions to antibiotics are common
Adverse reactions may involve any organ: • cutaneous • haematological (eg cytopenias) • renal (eg interstitial nephritis) • hepatic (eg hepatitis) • gastrointestinal (eg pseudomembraneous colitis) • neurological (eg encephalopathy) • cardiac (eg prolonged QT interval)
icpmr Centre for Infectious Diseases and Microbiology
∼
ANTIBIOTICS AND ALLERGIES
CUTANEOUS REACTIONS • around 2% of hospitalised patients develop a cutaneous drug reaction and
antibiotics account for ~55% of cases
• 5% of the population have an antibiotic allergy but 15% of patients report one, and it may be difficult to clarify which patients have a true allergy
• an immediate (IgE mediated) reaction to penicillin can be predicted by a positive skin test
• a negative skin test does not exclude the development of a delayed maculopapular rash
icpmr Centre for Infectious Diseases and Microbiology
∼
ANTIBIOTICS AND ALLERGIES
In the UK (1992-1997): • 12 deaths due to antibiotic anaphylaxis
• 6 of these followed cephalosporin administration
• …and 3 of these had a history of anaphylaxis to penicillins
Patients with a history of anaphylaxis to a penicillin should NOT be given a cephalosporin .
Risk of cross reactivity with carbapenems is 0.01%
icpmr Centre for Infectious Diseases and Microbiology
∼
ANTIBIOTICS AND ALLERGIES
• Patients who develop a maculopapular rash to a penicillin should NOT receive any penicillin
• Cross-reactivity between penicillin and cephalosporins is OVERESTIMATED
• Only 1% of those with a delayed penicillin allergy will also develop a rash with a 1st generation cephalosporin
• Therefore may be given a cephalosporin with care Campagna et al, J Emerg Med. 2012;42(5):612-20.
icpmr Centre for Infectious Diseases and Microbiology
∼
ANTIBIOTICS AND ALLERGIES
Natural penicillins Penicillin G (benzylpenicillin) Penicillin G procaine Penicillin G benzathine Phenoxymethyl penicillin (V) Penicillinase resistant Flucloxacillin Dicloxacillin Aminopenicillins Ampicillin Amoxicillin
Beta lactamase inhibitor combinations
Amoxicillin-clavulanate (Augmentin®)
Ticarcillin-clavulanate (Timentin®) Piperacillin-tazobactam (Tazocin®)
icpmr Centre for Infectious Diseases and Microbiology
∼
First-generation Oral Cephalexin IV Cefazolin Cephalothin Second-generation Cefuroxime Cefoxitin Cefaclor
Third-generation (Cefotaxime) Ceftriaxone Third-generation Ceftazidime Fourth-generation Cefepime Fifth-generation Ceftaroline
icpmr Centre for Infectious Diseases and Microbiology
∼
• An injecting drug user presents with fever and the CXR pictured • Blood cultures are positive with Gram positive cocci
icpmr Centre for Infectious Diseases and Microbiology
∼
Case 3
• Sepsis (and likely endocarditis) due to Staphyloccus aureus is
suspected
• The medical registrar recommends you commence flucloxacillin
Thoughts about dose and spectrum?
icpmr Centre for Infectious Diseases and Microbiology
∼
Case 3
Which of the following reason(s) would be a contraindication to commencing flucloxacillin?
1. the patient developed a maculopapular rash while on piperacillin-tazobactam during a previous admission
2. the patient developed a urticaria and wheeze after he was given cephalexin by a GP
3. the patient has chronic active hepatitis due to HCV
icpmr Centre for Infectious Diseases and Microbiology
∼
Case 3
Which of the following reason(s) would be a contraindication to commencing flucloxacillin?
1. the patient developed a maculopapular rash while on piperacillin-tazobactam during a previous admission
2. the patient developed a urticaria and wheeze after he was given cephalexin by a GP
3. the patient has chronic active hepatitis due to HCV
icpmr Centre for Infectious Diseases and Microbiology
∼
Case 3
• A 34 yo male presents to the emergency department with 24 hours of fevers and chills
• BP 95/60, PR 110, Temp 38.4°C • No clear source of infection on examination • Urine dipstick is clear • He has a history of face swelling minutes after being given
amoxycillin • You take bloods (including blood cultures) • Blood pressure remains low despite fluid boluses • What antibiotics would you commence?
icpmr Centre for Infectious Diseases and Microbiology
∼
Charting Exercise
• Using the medication chart provided, please chart vancomycin and gentamicin for this patient. He weighs 80kg, 185cm tall. Assume normal renal function.
Name: John Smith, MRN 1234567, DOB 12/1/1981 • Should we use ideal or actual body weight to calculate the
doses?
Charting Exercise
icpmr Centre for Infectious Diseases and Microbiology
∼
• Chart gentamicin in the ‘once-only’ or ‘variable-dose’ section of the medication chart
• Chart vancomycin loading dose in the ‘once-only’ and maintenance dosing in the regular section of the medication chart (not variable dose section)
– Need two charts if use variable = unsafe
• Round doses to the nearest half-vial. Vials are: – 80mg for gentamicin – 500mg and 1g for vancomycin
• Don’t forget: – Patient identifiers – Allergies – Indication – Approval number – Trough level on day 3 of vancomycin dosing – Write a time of administration not STAT
icpmr Centre for Infectious Diseases and Microbiology
∼
Key Points from Charting Exercise
Vancomycin and Gentamicin dosing and monitoring
icpmr Centre for Infectious Diseases and Microbiology
∼
INDICATIONS FOR VANCOMYCIN Infections caused by Gram positive organisms:
• suspected or confirmed MRSA infection
• Enterococcal infection (not VRE)
• surgical prophylaxis in known colonizer
• severe C. difficile infection (oral)
• penicillin hypersensitivity icpmr
Centre for Infectious Diseases and Microbiology
∼
• Dosing is based on – WEIGHT (actual body weight) – RENAL FUNCTION – SEVERITY OF INFECTION
• loading dose of 25-30 mg/kg (only for patients with severe sepsis)
• Round dose to the nearest 250 mg • Adjust dose based on trough levels
icpmr Centre for Infectious Diseases and Microbiology
∼
VANCOMYCIN DOSING
Loading with vancomycin
Without loading dose With loading dose
Target concentration
12 hours to reach target steady state
Target concentration
Reach target steady state after
the 1st dose
VANCOMYCIN GUIDELINES
• Full details in the WSLHD vancomycin guidelines:
icpmr Centre for Infectious Diseases and Microbiology, Westmead Hospital
∼
Maintenance intermittent dose: Creatinine Clearance (mL/min) Initial maintenance IV dose
≥ 90 15 to 20 mg/kg/dose 12-hourly 60 to 90 15 mg/kg/dose 12-hourly 20 to 60 15 mg/kg/dose 24-hourly
< 20 15 mg/kg/dose 48-hourly On renal replacement therapy Refer to guideline
Dosing in obesity • Definition: body mass index (BMI) ≥30 kg/m2 or an
actual body weight ≥100 kg AND an actual body weight (ABW) of ≥140% of the ideal body weight (IBW)
• Using actual body weight for obese patients for standard doses (ie 15-20 mg/kg dose) supra-therapeutic conc – So 10mg/kg/dose is recommended
• Still use ACTUAL BODY WEIGHT
Creatinine Clearance Loading doses Maintenance IV dose Timing of trough
> 60 mL/min 20 mg/kg/dose 10 mg/kg/dose 12-hourly Before the 4th dose
20 to 60 mL/min No loading dose 10 mg/kg/dose 24-hourly Before the 3rd dose
< 20 mL/min No loading dose 10 mg/kg/dose 48 to 96 hourly 48 hours after the last dose
TDM for intermittent Vancomycin
Target trough concentration Uncomplicated infections 10 to 20 mg/L Complicated infections: (e.g. bacteraemia, septic shock, endocarditis, osteomyelitis, meningitis, necrotising fasciitis, and pneumonia)
15 to 20 mg/L (up to 25 mg/L in meningitis)
TDM for intermittent Vancomycin • When is a trough?
– Within 60 mins before the next dose is due – VERY IMPORTANT!
• Has the level been taken too early?
– Steady state
• Do not withhold subsequent doses whilst waiting for trough level (unless CrCl < 20 mL/min)
Vancomycin dose adjustment
For example: • 50 kg patient is on vancomycin 750 mg 12-hourly • Measured trough level was 7.5 mg/L (Target trough 15
mg/L) • 15 mg/L ÷ 7.5 mg/L = 2 previous dose (750 mg 12-hourly) x 2 = 1.5 g 12-hourly Practice tips • <10 mg/L consider changing patient to continuous
infusion
• >25 mg/L check timing of collection, withhold icpmr Centre for Infectious Diseases and Microbiology
If your level is twice what it should be … halve the dose
• Similar efficacy and tolerance for continuous infusion vs. intermittent infusion
• Required for patients on PACC (Hospital In The Home *HITH*)
• Dose similar to that of intermittent infusion
• Target level higher (20-25 mg/L) since it is not a trough level
icpmr Centre for Infectious Diseases and Microbiology
∼ Wysocki Antimicrob Agents Chemother 2001
Vancomycin Infusions
INDICATIONS FOR GENTAMICIN
Infections caused by Gram negative organisms • intra-abdominal sepsis • febrile neutropenia • synergy in enterococcal endocarditis • limit use to no more than 48 hrs when given as
empirical therapy
icpmr Centre for Infectious Diseases and Microbiology
∼
GENTAMICIN DOSING • Initial dose of 4 – 7 mg/kg daily (up to 640 mg)
– Higher doses appropriate for sepsis
• Doses based on Ideal Body Weight – Exceptions exist to this including obesity
• Seek advice from Infectious Diseases or Pharmacy
• Round dose to the nearest multiple of 40mg – They come as 80mg vials *easier for
administration*
icpmr Centre for Infectious Diseases and Microbiology
∼
• No need for monitoring if only used for < 72 hrs • For once daily dosing estimate AUC and subsequent dose using
computer program – Requires 2 plasma levels (1 hour and 6 – 14 hrs after start of dose
administration) • Angela Netluch(AMS Pharmacist; pager 8926) • Trough concentrations are not useful for once daily dosing
icpmr Centre for Infectious Diseases and Microbiology
∼
GENTAMICIN MONITORING
• 47 year old AML patient presents with fevers, chills and rigors after receiving chemotherapy 10 days ago
• NKDA • not known to be colonized with any multi-
resistant organisms – Screening was recent and no recent hospitalisations
• Hickman’s line in situ, otherwise examination normal
• neutrophil count 0.2 x 109/L
icpmr Centre for Infectious Diseases and Microbiology, Westmead Hospital
∼
Case 4
after collecting BC, what antibiotics would you prescribe assuming normal renal function?
a. piperacillin-tazobactam b. gentamicin c. piperacillin-tazobactam + gentamicin d. piperacillin-tazobactam + gentamicin + vancomycin e. meropenem f. amikacin
icpmr Centre for Infectious Diseases and Microbiology, Westmead Hospital
∼
Case 4
after collecting BC, what antibiotics would you prescribe assuming normal renal function?
a. piperacillin-tazobactam b. gentamicin c. piperacillin-tazobactam + gentamicin d. piperacillin-tazobactam + gentamicin + vancomycin e. meropenem f. Amikacin
NOTE: There is a piperacillin-tazobactam shortage – cefepime is an alternative agent
icpmr Centre for Infectious Diseases and Microbiology, Westmead Hospital
∼
Case 4
JMO Oncall contains tips for
antimicrobial prescribing
• Should be used in conjunction with locally endorsed policies and guidelines
• We welcome feedback on this resource as we continue to develop it