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Inhaled Colistin Use in Adults With Hospital-Acquired and Ventilator-Associated Pneumonia

Inhaled Colistin Use in Adults With Hospital-Acquired and Ventilator-Associated Pneumonia. Samantha L Gauthier, Pharm.D . PGY-1 Pharmacy Resident Unity Health – White County Medical Center. Disclosure. I have nothing to disclose

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Inhaled Colistin Use in Adults With Hospital-Acquired and Ventilator-Associated Pneumonia

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  1. Inhaled Colistin Use in Adults With Hospital-Acquired and Ventilator-Associated Pneumonia Samantha L Gauthier, Pharm.D. PGY-1 Pharmacy Resident Unity Health – White County Medical Center

  2. Disclosure • I have nothing to disclose • Neither I, nor my spouse, have at present and/or have had within the past 12 months a relevant financial relationship with a commercial interest

  3. Pharmacist Objectives • Differentiate between available formulations • Compare doses of inhaled colistimethate, considering formulations and patient prognosis/severity • Identify patients that qualify to receive inhaled colistimethateper the 2016 IDSA and ATS HAP/VAP guidelines • Summarize appropriate use of inhaled colistimethateper the 2016 IDSA and ATS HAP/VAP guidelines

  4. Technician Objectives • Identify which patients should receive inhaled colistimethate per the 2016 IDSA and ATS HAP/VAP guidelines. • Compare the different formulations of colistimethate. • Discuss the dosing techniques for colistimethate based on the patient’s severity.

  5. Abbreviations • HAP: hospital-acquired pneumonia • VAP: ventilator-associated pneumonia • CMS: colistimethate sodium • CBA: colistin base activity • GNB: gram-negative bacilli • AG: aminoglycosides • MDR: multi-drug resistant

  6. Outline • Background • Dosing/Administration • Patient Qualifications • Recommendations per IDSA/ATS • Summary

  7. Background • Class: polymyxin • MOA: disruption of outer cell membrane • Bactericidal • Spectrum of Activity: • Narrow • P. aeruginosa • A. baumannii • Resistance: uncommon • Formulations: • Colistin sulfate • Colistimethate sodium (CMS) • ColistinBase Activity (CBA) • 1mg CBA = 2.67mg CMS • ColistimethateSodium (CMS) • 1mg CMS = 12500 units CMS • Half-life: • CMS: 124 minutes • CBA: 251

  8. Dosing/Administration • HAP/VAP due to MDR GNB • Nebulized: 150mg CMS every 8 hours delivered over 60 minutes for 14 days* • Bronchodilator within 15 minutes prior to administration

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  10. Patient Qualifications • VAP due to GNB susceptible to AG or polymyxins • Not responding to IV antibiotics alone • HAP/VAP due to Acinetobacter sensitive only to polymyxins • HAP/VAP due to carbapenem-resistant pathogens

  11. IDSA/ATS HAP/VAP Guidelines Recommendations • VAP due to GNB susceptible to AG or polymyxins • IV + Inhaled • Compared: tobramycin, gentamicin, colistin • Organisms: • MDR Klebsiella pneumoniae • Pseudomonas aeruginosa • Acinetobacter baumannii • Improved clinical cure rate • No additional harmful effects • Reduced duration of mechanical ventilation

  12. IDSA/ATS HAP/VAP Guidelines Recommendations (continued) • HAP/VAP due to Acinetobacter sensitive only to polymyxins • IV Polymyxin+ Inhaled (adjunctive) • Higher clinical response • No increase in harm

  13. IDSA/ATS HAP/VAP Guidelines Recommendations (continued) • HAP/VAP due to carbapenem-resistant pathogens • IV Polymyxin+ Inhaled (adjunctive) • Potential pharmacokinetic advantage • Improved clinical outcomes • Improved mortality • No increase in harm • Routine antimicrobial susceptibility testing

  14. Summary • IV + Inhaled colistin • VAP due to GNB susceptible to AG or polymyxins • Not responding to IV antibiotics alone • HAP/VAP due to Acinetobacter sensitive only to polymyxins • HAP/VAP due to carbapenem-resistant pathogens • No differences in clinical response rates, mortality, or nephrotoxicity. • Exception: improved mortality in carbapenem-resistant pathogens • Reasonable component of empiric regimens in intensive care units with high rates of resistance to agents from other classes. • Over use of polymyxinsmay jeopardize its current role as the antibiotic of last resort for resistant gram-negative pathogens.

  15. References [1] Management of Patients with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Disease Society of American and the American Thoracic Society [2] Colistin: An overview, UpToDate. MacLaren, Spelman. March 14, 2017 [3] Colistimethate, Lexi-Drugs

  16. Questions?

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