The Increasing Threat of Antibiotic Resistance Shira Doron, MD Assistant Professor of Medicine Division of Geographic Medicine and Infectious Diseases Tufts Medical Center Boston, MA Consultant to Massachusetts Partnership Collaborative: Improving Antibiotic Stewardship for UTI 1
The Increasing Threat of Antibiotic Resistance. Shira Doron, MD Assistant Professor of Medicine Division of Geographic Medicine and Infectious Diseases Tufts Medical Center Boston, MA Consultant to Massachusetts Partnership Collaborative: Improving Antibiotic Stewardship for UTI. - PowerPoint PPT Presentation
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The Increasing Threat of Antibiotic Resistance
Shira Doron, MDAssistant Professor of Medicine
Division of Geographic Medicine and Infectious DiseasesTufts Medical Center
Boston, MA
Consultant to Massachusetts Partnership Collaborative: Improving Antibiotic Stewardship for UTI
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Objectives
The attendee will:• Understand the nature of the antibiotic
resistance crisis• Understand the link between antibiotic use and
the development of resistant infections, including C diff.
• Understand the importance of differentiating between colonization and infection in ensuring prudent use of antibiotics.
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Antibiotics in Long Term Care:why do we care?
• Antibiotics are among the most commonly prescribed classes of medications in long-term care facilities
• Up to 70% of residents in long-term care facilities per year receive an antibiotic
• It is estimated that between $38 million and $137 million are spent each year on antibiotics for long-term care residents
• As much as half of antibiotic use in long term care may be inappropriate or unnecessary
Appropriate initial antibiotic while improving patient
outcomes and healthcare
Antimicrobial Therapy
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Unnecessary Antibiotics, adverse patient
outcomes and increased cost
What is Antimicrobial Stewardship?
• Antimicrobial stewardship involves the optimal selection, dose and duration of an antibiotic resulting in the cure or prevention of infection with minimal unintended consequences to the patient including emergence of resistance, adverse drug events, and cost
Dellit TH, et al. CID 2007;44:159-77, Hand K, et al. Hospital Pharmacist 2004;11:459-64Paskovaty A, et al IJAA 2005;25:1-10Simonsen GS, et al Bull WHO 2004;82:928-34
Ultimate goal is improved patient care and healthcare outcomes
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• 12 studies in North America:– 1.8-13.5 infections per 1000 resident-care
days– Rate of death from infection 0.04-0.71 per
1000 resident-care days15
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The burden of infection in long-term care
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Why focus on long term care?• Many long-term care residents are colonized
with bacteria that live in and on the patient without causing harm
• Protocols are not readily available or consistently used to distinguish between colonization and true infection
• So, patients are regularly treated for infection when they have none– 30-50% of elderly long-term care residents have a
positive urine culture in the absence of infection
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Why focus on long term care?• When patients are transferred from acute
to long-term care, potential for miscommunication can lead to inappropriate antibiotic use
• Elderly or debilitated long-term care residents are at particularly high risk for complications due to the adverse effects of antibiotics, including Clostridium difficile infection
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Antibiotic misuse adversely impacts
patients
Getting an antibiotic increases a patient’s chance of becoming colonized or infected with a resistant organism.
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Association of vancomycin use with resistance
0
50
100
150
200
250
1990 1991 1992 1993 1994 1995
Num
ber o
f pat
ient
s w
ith V
RE
60
65
70
75
80
85
Def
ined
dai
ly d
oses
of
vanc
omyc
in/1
000
patie
nt d
ays
Patients with VRE DDD vancomycin
(JID 1999;179:163)
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Annual prevalence of imipenem resistance in P.
aeruginosa vs. carbapenem use rate
01020304050607080
0 20 40 60 80 100Carbapenem Use Rate
% Im
ipen
em-re
sist
ant
P. a
erug
inos
a
45 LTACHs, 2002-03 (59 LTACH years) Gould et al. ICHE 2006;27:923-5
r = 0.41, p = .004 (Pearson correlation coefficient)
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Case• An 82-year-old long-term care resident
has a fever and a productive cough• He has no urinary or other symptoms, and
a chronic venous stasis ulcer on the lower extremity is unchanged
• A “pan-culture” is initiated in which urine is sent for UA and culture, sputum and blood are sent for culture, and the ulcer on the leg is swabbed
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• A CXR is done and is negative• The urinalysis has 3 white blood cells• Urine culture is positive for >100,000 CFU