UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet.

UTI & PneumoniaTranslating Knowledge into Practice

PIAS-KT StudySukhjinder Sidhu

Sean GormanRichard SlavikTasha RamseySarah Murray

Nicole Bruchet

Attendance

• Please email Brenda Flood ([email protected]) if you attended this session

• Please email Brenda Flood ([email protected]) if you view this presentation online at a later date

mailto:[email protected]


THANK YOU!

• YOU SURPASSED OUR PROJECTED PARTICIPATION RATE FOR THE PRE-QUIZ!

• STAY TUNED FOR A POST-QUIZ THAT WILL BE SENT OUT IN MID-MARCH

• THANK YOU TO TASHA RAMSEY FOR HER EXPERT REVIEW OF THIS PRESENTATION

Speaker Disclosure

• The speakers have no actual or potential conflicts of interest to disclose

Outline• PIAS-KT Study Overview• Local Opinion Leaders• Prevalence and Impact of UTIs & Pneumonia• Antimicrobial Stewardship• Key Pharmacist Interventions for UTIs & Pneumonia• DTP Tracker Data for UTIs & Pneumonia• UTIs & Pneumonia Therapeutics

– When to treat with antibiotics and When Not to treat?– What antibiotics to initiate and Why?– When, How, and Why to de-escalate antibiotics?– How long to treat with antibiotics?

Objectives

• To review the pharmaceutical care of patients with UTIs & Pneumonia including:– Key pharmacist interventions– Indications for antibiotic therapy– Initial empiric antibiotic therapy recommendations– Antibiotic de-escalation strategies– IV to PO step-down considerations– Duration of antibiotic therapy

PIAS-KT Study OverviewInterventionPRE phase

Knowledge Behavior

POST phase

Knowledge Behavior

Behavioral Change

StrategiesJan 30 – Mar 14,

2014

1. Audit & Feedback2. Local opinion leaders3. Educational meetings4. Educational outreach5. Printed education materials6. Reminders

QuizJan 17-30, 2014

QuizMar 17-28, 2014

DTP/DSEM DTPKPI/DSEM KPI

Jul 1-Dec 31,2013

DTP/DSEM DTPKPI/DSEM KPI

Jan 1-Jun 30, 2014

Local Opinion Leaders

• KGH – Dawn Robb• RIH – Kim Winters• PRH/SOH – Orysya Fetterly• VJH – Chelsea Argent• SLH/OMH – Ian Petterson• KBH/KLH – Michael Conci• EKH/GDH – Darren Feere

Prevalence & Impact of UTIsPrevalence

– Approximately 4,000,000 UTIs/year in Canada – Affects 20% of women between 15-29 yo– Number 1 healthcare-associated infection– 16th most common non-surgical reason for IH admission

Impact– 660 cases and 3200 acute bed-days at IH– Hospital-acquired UTIs associated with extra day of hospitalization– Up to 25% of patients with UTI receive inappropriate therapy– Up to 50% of patients with asymptomatic catheter-associated

bacteriuria are treated with antibiotics (which is inappropriate)

Mayo Clin Proc 2007;82:181-5.; Can J Infect Dis Med Microbiol 2005;16:166-70.Mayo Clin Proc 2007;82:181-5.; Can J Infect Dis Med Microbiol 2005;16:166-70.

Prevalence & Impact of Pneumonia

Prevalence– Approximately 170,000 cases of CAP each year in Canada – HAP/VAP is 2nd most common nosocomial infection in Canada– 5th most common non-surgical reason for IH admission

Impact– 1300 cases and 7000 acute bed-days at IH each year– CAP is the leading infectious cause of death– Up to 15% of patients with CAP receive inadequate therapy– Up to 75% of patients with HAP/VAP receive inadequate therapy

Clin Infect Dis 2005;41:1709-16.; Postgrad Med 2010;122:130-141.Clin Infect Dis 2005;41:1709-16.; Postgrad Med 2010;122:130-141.

Antimicrobial Stewardship Definition

• An activity (or activities) that includes– Appropriate antibiotic selection– Appropriate antibiotic dosing– Appropriate antibiotic route selection– Appropriate antibiotic duration of therapy

Clin Infect Dis 2007;44:159-77.Clin Infect Dis 2007;44:159-77.

Antimicrobial Stewardship Goals

• Optimize clinical outcomes by ensuring effective antimicrobial therapy

• Minimize collateral damage from antimicrobials– Antimicrobial resistance– Antimicrobial toxicity– Costs of inappropriate antimicrobial use– Superinfections (e.g. Clostridium difficile)


Clinical Pharmacists’ Role in Antimicrobial Stewardship

PHARMACEUTICAL CARE

ANTIMICROBIALSTEWARDSHIP

Urinary Tract Infection Key Pharmacist Interventions

1. Initiate appropriate antibiotics for symptomatic UTI

2. Discontinue empiric antibiotics started for UTI that are not indicated

3. De-escalate antibiotics for UTI based on C&S data and clinical response

4. Perform IV to PO step-down of antibiotics for UTI

5. Promote appropriate duration of antibiotic therapy for UTI

IH UTI Key Pharmacist Interventions, April 21, 2011IH UTI Key Pharmacist Interventions, April 21, 2011

Pneumonia Key Pharmacist Interventions

1. Initiate appropriate antibiotics for pneumonia

2. Discontinue empiric antibiotics started for pneumonia that are not indicated

3. De-escalate antibiotics for pneumonia based on C&S data and clinical response

4. Perform IV to PO step-down of antibiotics for pneumonia

5. Promote appropriate duration of antibiotic therapy for pneumonia

IH Pneumonia Key Pharmacist Interventions, April 21, 2011IH Pneumonia Key Pharmacist Interventions, April 21, 2011

Project Alignment

CPhA “Blue Print” for Pharmacy Practice CSHP “Vision 2015” Canadian Clinical Pharmacy KPI Collaborative Accreditation Canada MOHS KRAs and CCM groups IH SET goals, objectives IH Pharmacy Clinical Priorities

DTP Tracker Data - UTI

• UTI ranks #6 in disease prevalence for all Rx interventions

• UTI ranks #3 in disease prevalence for 8 DSEM interventions

• UTI ranks #2 in disease prevalence for key pharmacist interventions

DTP Tracker Data - UTI

• AIMS study showed a statistically significant, clinically important increase after DSEMs– DSEM DTP/total DTP (27.9% to 31.9%, p<0.05)– KPI/total DTP (21.7% to 25.8%, p<0.05)

• In UTI subgroup, AIMS failed to show a statistically significant benefit– DSEM DTP/total DTP (3.91% to 3.93%, p=NS)– KPI/total DTP (3.82% to 4.61%, p=NS)

DTP Tracker Data - Pneumonia

• Pneumonia ranks #3 in disease prevalence for all Rx interventions

• Pneumonia ranks #2 in disease prevalence for 8 DSEM interventions

• Pneumonia ranks #3 in disease prevalence for key pharmacist interventions

DTP Tracker Data - Pneumonia

• In Pneumonia subgroup, AIMS failed to show a statistically significant benefit– DSEM DTP/total DTP (4.75% to 4.90%, p=NS)

• However, in Pneumonia subgroup, AIMS demonstrated a statistically significant REDUCTION– KPI/total DTP (5.07% to 3.94%, p=0.016)

Pharmaceutical Care of UTI and Pneumonia

UTI Pharmaceutical CareOutline

• When and When Not to treat with antibiotics?

• What antibiotics to initiate and Why?

• When, How, and Why to de-escalate antibiotics?

• How long to treat with antibiotics?

What Makes a UTI ‘Complicated’?

• Patients with structural or functional abnormalities of the genitourinary tract– Obstruction– Instrumentation (including catheters)– Impaired voiding– Metabolic abnormalities– Immunocompromised– Men

Can J Infect Dis Med Microbiol 2005;16:349-60.Can J Infect Dis Med Microbiol 2005;16:349-60.

UTI“Why should antibiotics be initiated?”

• duration of symptoms

• abscesses, metastatic infection, septic shock, AKI


UTI“When should antibiotics be initiated?”

– Clinical manifestations of cystitis• Dysuria, frequency, urgency, suprapubic pain, hematuria

– Clinical manifestations of pyelonephritis• Above symptoms together with fever (>38°C), chills, flank

pain, costovertebral angle tenderness, and nausea/vomiting

– Asymptomatic bacteriuria in pregnancy

Cystitis at IH“When should antibiotics be initiated?”

“If clinically feasible, initiation of antimicrobial therapy should be delayed until results of urine

culture are available”


UTI at Interior Health“What antibiotics should be initiated and why?”

Infection 2007;35:150-3. (Calgary Data 2004-5)Infection 2007;35:150-3. (Calgary Data 2004-5)

Organisms Associated with Urinary Tract Infections


*E. coli Susceptibilities at IH 2012*E. coli Susceptibilities at IH 2012

PO options

IV options


*Enterococcus Susceptibilities at IH 2012*Enterococcus Susceptibilities at IH 2012

• Risk Factors for Antibiotic Resistant UTIs– Abx exposure (especially to TMP/SMX or FQ) in past 3 months

– Travel to endemic area

– Previous multi-drug resistant UTI



• Oral Antibiotic Selection– Oral antibiotics are first line for cystitis– Oral antibiotics are first line for uncomplicated

pyelonephritis (not acutely ill)

• IV Antibiotic Selection– Unable to tolerate oral therapy (nausea/vomiting/ileus)– Impaired GI absorption – Hemodynamic instability (acutely ill)– Infecting organism resistant to available oral options

Clin Infect Dis 2005;40:643-54., Can J Infect Dis Med Microbiol 2005;16:349-60.Clin Infect Dis 2005;40:643-54., Can J Infect Dis Med Microbiol 2005;16:349-60.


Complicated Cystitis at IH“What antibiotics should be initiated?”

“Oral antimicrobial therapy is appropriate for most episodes”


Recommendations for Empiric Therapy

1. Nitrofurantoin 100 mg PO BID x 5 days (CrCl ≥ 40 mL/min)

2. Trimethoprim/Sulfamethoxazole i DS PO BID x 3 days

• Cefixime 400 mg PO Daily x 3 days

• Amoxicillin/Clavulanate 875 mg PO BID x 3 days

• Amoxicillin/Clavulanate 500 mg PO TID x 3 days

Uncomplicated Cystitis at IH“What antibiotics should be initiated?”

Recommended Empiric Oral Options

1st Line•Cefixime 400 mg PO Daily x 7-14 days•Amoxicillin/Clavulanate 875 mg PO BID x 7-14 days•Amoxicillin/Clavulanate 500 mg PO TID x 7-14 days•Trimethoprim/Sulfamethoxazole i DS PO BID x 7-14 days

2nd Line (high prevalence resistance)•Ciprofloxacin 500 mg PO BID x 7-14 days


Recommended Empiric IV Options

• Ampicillin + Gentamicin

• Ampicillin + Ceftriaxone

• Piperacillin/Tazobactam +/- Gentamicin


Uncomplicated Pyelonephritis at IH“What antibiotics should be initiated and why?”

Recommend Empiric Oral Therapy

• Same as for uncomplicated cystitis EXCEPT:– No nitrofurantoin

– Longer duration of therapy (7-14 days)

• Gentamicin 5-7 mg/kg/day IV OR

• Ceftriaxone 1-2G IV daily

Uncomplicated Pyelonephritis at IH“What antibiotics should be initiated and why?”

Recommended Empiric IV Therapy for Acutely Ill Patients

Recommended Empiric Oral Options

• Same as for complicated cystitis

1st Line• Cefixime 400 mg PO Daily x 7-14 days• Amoxicillin/Clavulanate 875 mg PO BID x 7-14 days• Amoxicillin/Clavulanate 500 mg PO TID x 7-14 days• Trimethoprim/Sulfamethoxazole i DS PO BID x 7-14 days

2nd Line (high prevalence resistance)• Ciprofloxacin 500 mg PO BID x 7-14 days

Complicated Pyelonephritis at IH“What antibiotics should be initiated and why?”

Recommended Empiric IV Options

• Same as for complicated cystitis– Ampicillin + Gentamicin

– Ampicillin + Ceftriaxone

– Piperacillin/Tazobactam +/- Gentamicin

Complicated Pyelonephritis at IH“What antibiotics should be initiated and why?”

Recommended Antibiotic Therapy

• Wait for results of screening urine C&S• Select narrowest spectrum agent that is safe in pregnancy

– Amoxicillin/Clavulanate– Amoxicillin– Cefixime– Cephalexin– Nitrofurantoin (avoid in 3rd trimester)– TMP/SMX (avoid in 1st and 3rd trimesters)

Asymptomatic Bacteriuria in Pregnancy“What antibiotics should be initiated and why?”

UTI Therapeutics“What is antibiotic de-escalation and

why is it important?”

• Antibiotic De-escalation– Replace empiric broad-spectrum regimen with a

more narrow spectrum regimen– Organism identified with susceptibilities– Intended to reduce collateral damage – De-escalation for UTIs is under-performed

Infection 2013;41:211-14.Infection 2013;41:211-14.

UTI Therapeutics“When and How should antibiotics be

de-escalated?”

• When to de-escalate– Once urine C&S known– No other suspected infections– No patient-limiting factors (e.g. allergy)


UTI Therapeutics“When and How should antibiotics be

de-escalated?”• How to de-escalate

– Broad spectrum to narrowest spectrum– Narrowest spectrum with collateral damage risk


Empiric Step-Down

Ciprofloxacin Amoxicillin

Cefixime Cephalexin

Ceftriaxone TMP/SMX

Pip/Tazo Amoxicillin/Clav

Ceftriaxone Cefixime

Examples

UTI Therapeutics“How should antibiotics be de-escalated?”

• IV to PO Step-Down– Tolerates oral intake– No factors affecting absorption– Hemodynamically stable– If acutely ill pyelonephritis and considering PO β-

lactam, patient should receive at least 1 dose of Ceftriaxone OR Aminoglycoside


Interior Health IV to PO Step-Down Policy

• Pharmacists Have IV-PO Step-Down Authority– Applies to Ciprofloxacin/Moxifloxacin– Duration IV antibiotics: ≥ 48 hours – Tolerating other PO medications, fluids, or foods x 12 hours – No potential problems with absorption – Clinically stable (stable BP, resolving fever/afebrile, adequate urine

output, absence of encephalopathy, WBC normal or normalizing)

• Exclusions• Febrile neutropenia, gram negative bacteremia, CNS infections, septic

shock, severe cellulitis

InsideNet – Pharmacist managed IV to PO conversion program (2006)InsideNet – Pharmacist managed IV to PO conversion program (2006)

UTI Therapeutics“How long to treat with antibiotics?”

• Uncomplicated cystitis– 3-7 days (5-7 days for nitrofurantoin)

• Complicated cystitis– 7-14 days

• Pyelonephritis– 7-14 days

Candida-Associated Cystitis

• Indications for treatment– Symptomatic cystitis– Asymptomatic, but high risk (neutropenia,

planned urologic manipulation)

• Recommended treatment – Fluconazole 200-400 mg PO daily x 14 days– Amphotericin 0.3-0.6 mg/kg IV x 7 days (2nd line)


Pneumonia Pharmaceutical CareOutline

• When and When Not to treat with antibiotics?

• What antibiotics to initiate and Why?

• When, How, and Why to de-escalate antibiotics?

• How long to treat with antibiotics?

IH Pneumonia DSEM

PneumoniaWhen and Why Antibiotic Treatment?

• Physician/NP Diagnosis• Varies depending on outpatient/inpatient• Chest x-ray infiltrates PLUS• Fever, purulent secretions, elevated WBC• Other clinical manifestations: dyspnea, pleuritic chest pain

• Consequences of Pneumonia– Reduced survival– Increased risk of ICU admission– Prolonged length of hospitalization

Clin Infect Dis 2007;44:sS.; Pneumonia DSEM 2008.Clin Infect Dis 2007;44:sS.; Pneumonia DSEM 2008.

Community-Acquired Pneumonia

• Patients not hospitalized in previous 14 days


Community-Acquired Pneumonia“What antibiotics should be initiated and why?”

Microbiologic Etiology

Clin Infect Dis 2000;31:347-82. Clin Infect Dis 2000;31:347-82.

Community-Acquired PneumoniaRisk Factors for AROs

*β-Lactam, Fluoroquinolone, Macrolide

Can J Infect Dis Med Microbiol 2008;19:19-53., Clin Infect Dis 2007;44:(Suppl 2):S27-72.

Community-Acquired Pneumonia“What antibiotics should be initiated and why?”

*Ampicillin SusceptibilitySusceptibilities at IH 2012Susceptibilities at IH 2012

Community-Acquired Pneumonia“What antibiotics should be initiated?”

Recommendations for Empiric Therapy in Hospital

•General Ward1. Moxifloxacin 400 mg PO/IV daily2. Ceftriaxone 2 g IV daily + Azithromycin 500 mg IV daily

•ICU1. Ceftriaxone 2 g IV daily + Azithromycin 500 mg IV daily2. Ceftriaxone 2 g IV daily + Moxifloxacin 400 mg IV daily

Clin Infect Dis 2007;44:(Suppl 2):S27-72.Clin Infect Dis 2007;44:(Suppl 2):S27-72.

Approach to De-Escalation

Intensive Care Med 2014;40:92-5.Intensive Care Med 2014;40:92-5.

Suspected CAPEmpiric Antibiotics

C&S Available?

Significant Improvement after

48-96 hr?

Significant Improvement after

48-96 hr?

• De-escalate• Max 7 Days

• Review Abx• Review Dose• Re-culture• Complication?• Consider non-infection

• De-escalate using C&S

• Max 7 days

NO YES

YES NO NO YES

Organism Preferred Alternatives

S. pneumoniae; MIC < 2 mg/L

Pen G, amoxicillin Macrolide, cephalosporins, clindamycin, doxycline, respiratory fluoroquinolone

S. pneumonia; MIC ≥ 2 mg/L

3rd generation cephalosporin, fluoroquinolone

Vancomycin, linezolid, amoxicillin >3 g/day if MIC ≤ 4 mg/L

H. influenzae (no beta-lactamase)

Amoxicillin Fluoroquinolone, doxycycline, azithromycin, clarithromycin

H. Influenza (beta-lactamase)

2nd or 3rd generation cephalosporin, amoxicillin-clavulanate

Fluoroquinolone, doxycycline, azithromycin, clarithromycin

Enterobacteriaceae 3rd generation cephalosporin, carbapenem

Beta-lactam/beta-lactamase inhibitor, fluoroquinolone

P. aeruginosa Antipseudomonal beta-lactam +/- cipro OR aminoglycoside

Aminoglycoside PLUS cipro or levo

MSSA Cloxacillin Cefazolin, clindamycinClin Infect Dis 2007;44:(Suppl 2):S27-72.Clin Infect Dis 2007;44:(Suppl 2):S27-72.

Community-Acquired Pneumonia“Pathogen-Directed Therapy”

Community-Acquired Pneumonia“IV to PO Step-down Criteria”

• Normal functioning GI tract AND

• Able to ingest medications AND

• Improving clinically AND

• Clinical stability– T < 37.8 0C– HR < 100 bpm– RR < 24 breaths/min– SBP > 90 mm Hg– Arterial O2 sat > 90%– Normal mental status

Clin Infect Dis 2007;44:(Suppl 2):S27-72.Clin Infect Dis 2007;44:(Suppl 2):S27-72.

Interior Health IV to PO Step-Down Policy

• Pharmacists Have IV-PO Step-Down Authority– Applies to Ciprofloxacin/Moxifloxacin– Duration IV antibiotics: ≥ 48 hours – Tolerating other PO medications, fluids, or foods x 12 hours – No potential problems with absorption – Clinically stable (stable BP, resolving fever/afebrile, adequate urine

output, absence of encephalopathy, WBC normal or normalizing)

• Exclusions• Febrile neutropenia, gram negative bacteremia, CNS infections, septic

shock, severe cellulitis

InsideNet – Pharmacist managed IV to PO conversion program (2006)InsideNet – Pharmacist managed IV to PO conversion program (2006)

• Minimum treatment duration 7 days AND• Afebrile (T ≤ 37.8 x 48-72 h) AND• ≤ 1 sign of CAP-related clinical instability

• T ≥ 37.8• HR ≥ 100 beats/min• RR ≥ 24 breaths/min• SBP ≤ 90 mmHg• SaO2 ≤ 90% or PaO2 ≤ 60 mm Hg on room air• Inability to maintain oral intake• Abnormal mental status

• Azithromycin 500 mg IV daily x 3 days (with ceftriaxone)

Community-Acquired Pneumonia “How long to treat?”

Clin Infect Dis 2007;44:(Suppl 2):S27-72.

Hospital-Acquired/Ventilator-Associated Pneumonia

• HAP – Pneumonia that occurs > 48 hours after admission

• VAP– Pneumonia arising > 48 hours after intubation


HAP/VAP“What antibiotics should be initiated and why?”

Microbiologic Etiology


Susceptibilities at IH 2012Susceptibilities at IH 2012


MDR Bacteria Risk Factors

Infect Dis Clin N Am 2004;18:939-962. RSS 2012RSS 2012


Reasonable IH StrategyReasonable IH StrategyEarly HAP/VAP, and

no risks for MDR bugs

Late HAP/VAP, orrisks for MDR bugs

Ceftriaxone Piperacillin-tazobactam

Piperacillin-tazobactam Ciprofloxacin (?)

Moxifloxacin Meropenem*

+/- aminoglycoside (PA)

+/- vancomycin (?)


RSS 2012RSS 2012

Am J Respir Crit Care Med 2005;171:388-416. RSS 2012RSS 2012

Approach to De-Escalation

Pneumonia Therapeutics“How long to treat with antibiotics?”

Potential Benefits• Overall antibiotic use• Resistance rates• Super-infection• Drug costs• Adverse events

Potential Risks• Treatment failures• Relapse rates• Re-infection rates• Complications

J Clin Pharmacol Therap 2003;28:123-129.RSS 2012RSS 2012

Shorter Duration of Therapy

HAP/VAP“How long to treat?”

Am J Respir Crit Care Med 2005;171:388-416.

*Uncomplicated Pneumonia**Non-lactose fermenting Gram negative rods

Session Review

• PIAS-KT overview• Local Opinion Leaders• UTIs/Pneumonia are highly prevalent and impactful• Pharmaceutical care of patients with infections naturally

includes antimicrobial stewardship activities• UTI/Pneumonia KPIs are antimicrobial stewardship activities• When to initiate antibiotics for UTI/Pneumonia• What antibiotic to initiate for UTI/Pneumonia• When and how to de-escalate antibiotics for UTI/Pneumonia• How long to treat with antibiotics for UTI/Pneumonia

Attendance

• Please email Brenda Flood ([email protected]) if you attended this session

• Please email Brenda Flood ([email protected]) if you view this presentation online at a later date



Questions?

TMP/SMX ResistanceClinical Cure Uncomplicated Cystitis

Ann Intern Med 2001:135:41-50

UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet.

Documents

uti pneumonia

appropriate antibiotics

presentation slide

empiric antibiotics

inappropriate therapy

symptomatic uti

po stepdown of antibiotics

rx interventions uti