Bugs and Drugs Elaine Dowell SM MLS (ASCP), Stacey Hamilton MT SM (ASCP), Samuel Dominguez MD PhD, Sarah Parker MD, and Ann-Christine Nyquist MD MSPH New this year in Bugs and Drugs In response to a request from our Pediatric Residents, we have made significant changes to the Bugs and Drugs Handbook for 2017. Residents rotating here at CHCO were surveyed this year and a working group comprised of Residents (Robin Ortenberg and Bradley Anderson), Microbiology, Infectious Disease and Antimicrobial Stewardship was formed to improve utility of the current edition of Bugs and Drugs. The most notable change in the handbook is our colorful antimicrobial tables, which have been coded to indicate which drug/bug combinations are most desirable from a treatment perspective. This change was made to assure that the handbook provides maximum value to clinicians selecting antimicrobials for our patients. Color coding of the tables is used to designate appropriate empiric treatments selections for each bug-drug combination similar to the “Sanford Guide for Antimicrobial Therapy”. Blue shaded boxes indicate first-line therapy, with susceptibility between 75-100%. This medication has good penetration, limited side-effects and overall strong susceptibilities. Green shaded box indicates second-line choice with susceptibility between 75-100%, but not first choice due to overly broad-spectrum, toxicities, or both. May be appropriate as initial therapy before specific bacteria has been identified. Yellow shaded box indicates susceptibility between 50-74%. Not initial treatment of choice, but can be used if other medications are not available, patient has significant allergies, or susceptibility known. Pink shaded box indicates susceptibility for these medications is less than 50%. Consult ID prior to using these medications and/or use only if known susceptible. Colorless box with a dash is a drug-bug combination that is not tested per policy. Pink box with an R indicates this organism is known to have intrinsic resistance to this antibiotic. Green box with an S indicates that this organism is known to be susceptible to this antibiotic. Please also note that comments in the footnotes of the tables have been updated with important interpretive information. Clarifying Carbapenem Resistant Enterobacteriaceae (CRE) Carbapenem resistance among enterobacteriaceae is a focus of concern nationally and in January of 2015, CDC changed their definition of this group of gram negative bacteria to include ALL isolates of enterobacteriaceae (enteric gram negative bacteria) that have either intermediate or resistant MICs to one of the carbapenems (imipenem, meropenem, ertapenem or doripenem). Resistance mechanisms that cause this resistance fall into two categories and although detection of a CRE in the Microbiology lab is dependent upon phenotypic characteristics, molecular techniques are required for definitive classification into one of these two groups. 1. Non-CP CRE – resistance is conferred by production of an extended-spectrum Beta-lactamase (ESBL) and/or an AmpC Beta-lactamase in conjunction with membrane impermeability or active drug efflux pump. 2. CP-CRE or more simply CPE - resistance is conferred by production of a carbapenemase – also called carbapenemase producing enterobacteriaceae (CP-CRE or more simply CPE). VOLUME XXXII NUMBER 6 September 2017 CONTAGIOUS COMMENTS Department of Epidemiology
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Bugs and Drugs Elaine Dowell SM MLS (ASCP), Stacey Hamilton MT SM (ASCP), Samuel Dominguez MD PhD,
Sarah Parker MD, and Ann-Christine Nyquist MD MSPH
New this year in Bugs and Drugs In response to a request from our Pediatric Residents, we have made significant changes to the Bugs and Drugs Handbook for 2017. Residents rotating here at CHCO were surveyed this year and a working group comprised of Residents (Robin Ortenberg and Bradley Anderson), Microbiology, Infectious Disease and Antimicrobial Stewardship was formed to improve utility of the current edition of Bugs and Drugs. The most notable change in the handbook is our colorful antimicrobial tables, which have been coded to indicate which drug/bug combinations are most desirable from a treatment perspective. This change was made to assure that the handbook provides maximum value to clinicians selecting antimicrobials for our patients. Color coding of the tables is used to designate appropriate empiric treatments selections for each bug-drug combination similar to the “Sanford Guide for Antimicrobial Therapy”.
Blue shaded boxes indicate first-line therapy, with susceptibility between 75-100%. This medication has good
penetration, limited side-effects and overall strong susceptibilities.
Green shaded box indicates second-line choice with susceptibility between 75-100%, but not first choice due to overly
broad-spectrum, toxicities, or both. May be appropriate as initial therapy before specific bacteria has been identified.
Yellow shaded box indicates susceptibility between 50-74%. Not initial treatment of choice, but can be used if other
medications are not available, patient has significant allergies, or susceptibility known.
Pink shaded box indicates susceptibility for these medications is less than 50%. Consult ID prior to using these
medications and/or use only if known susceptible.
Colorless box with a dash is a drug-bug combination that is not tested per policy.
Pink box with an R indicates this organism is known to have intrinsic resistance to this antibiotic.
Green box with an S indicates that this organism is known to be susceptible to this antibiotic.
Please also note that comments in the footnotes of the tables have been updated with important interpretive information. Clarifying Carbapenem Resistant Enterobacteriaceae (CRE) Carbapenem resistance among enterobacteriaceae is a focus of concern nationally and in January of 2015, CDC changed their definition of this group of gram negative bacteria to include ALL isolates of enterobacteriaceae (enteric gram negative bacteria) that have either intermediate or resistant MICs to one of the carbapenems (imipenem, meropenem, ertapenem or doripenem). Resistance mechanisms that cause this resistance fall into two categories and although detection of a CRE in the Microbiology lab is dependent upon phenotypic characteristics, molecular techniques are required for definitive classification into one of these two groups.
1. Non-CP CRE – resistance is conferred by production of an extended-spectrum Beta-lactamase (ESBL) and/or
an AmpC Beta-lactamase in conjunction with membrane impermeability or active drug efflux pump.
2. CP-CRE or more simply CPE - resistance is conferred by production of a carbapenemase – also called
carbapenemase producing enterobacteriaceae (CP-CRE or more simply CPE).
VOLUME XXXII NUMBER 6 September 2017
CONTAGIOUS COMMENTS Department of Epidemiology
VOLUME XXXII NUMBER 6 September 2017 Page 2
Non-CP CRE includes mechanisms of resistance that may be intrinsic, acquired or transferred between organisms on a plasmid. These organisms as a group are less frequently associated with outbreaks, potentially less contagious and less concerning from an epidemiological standpoint. Many become resistant due to treatment with carbapenems and they do not generally display resistance in ALL other classes of antimicrobials. The CP-CRE or CPE group of organisms produces a carbapenemase enzyme that confers resistance to the carbapenems with some enzymes also conferring resistance to other Beta-lactams. Metallo-beta-lactamases, such as KPC and NDM are included in this group and are associated with outbreaks of difficult to treat organisms. Travel to endemic areas is a risk factor. The Colorado Department of Public Health and Environment (CDPHE) has begun to collect data and in some cases, isolates, to study the emerging resistance patterns of both groups of organisms. At CHCO, all enteric Gram negative rods that are tested for susceptibilities are screened for carbapenem resistance. Ertapenem, imipenem, and meropenem with MICs in the intermediate or resistant range are submitted to CDPHE for screening and confirmed for the production of carbapenemases by molecular methods as needed. At CHCO, non-CP CRE isolates are detected intermittently; we have not had any CP-CRE yet detected. For a nice review of this topic, please see Goodman et al, “Infection control implications of heterogenous resistance mechanisms in carbapenem resistant Enterobacteriaceae (CRE),” Expert Review of Anti-infective Therapy, 2015. MRSA Update Both inpatient and outpatient MRSA rates have remained relatively stable for the past 5 years. CHCO data is submitted through the CDC’s Emerging Infectious Pathogens Program (EIP) and through CDC’s National Healthcare Safety Network (NHSN). When we isolate MRSA from a patient for the first time, two methods are used to confirm the isolate as MRSA. A full antimicrobial susceptibility panel is performed and reported for all first-time MRSA isolates. Methods available at CHCO for MRSA testing and confirmation include PBP2 antigen testing, cefoxitin screen, Microscan MIC and chromagar.
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