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Antibiotic Selection and Resistance: A Pharmacist’s perspective

Antibiotic Selection and Resistance: A Pharmacist’s perspective. Jennifer Ott, PharmD, BCPS Clinical Pharmacy Specialist, Infectious Diseases Eastern Maine Medical Center Bangor, ME jott@emh.org. The use of antibiotics is the single most important factor leading to antibiotic resistance

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Antibiotic Selection and Resistance: A Pharmacist’s perspective

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  1. Antibiotic Selection and Resistance: A Pharmacist’s perspective Jennifer Ott, PharmD, BCPS Clinical Pharmacy Specialist, Infectious Diseases Eastern Maine Medical Center Bangor, ME jott@emh.org

  2. The use of antibiotics is the single most important factor leading to antibiotic resistance • Up to 50% of all antibiotics prescribed are not needed or are not optimally effective as prescribed CDC. Threat Report 2013. http://www.cdc.gov/drugresistance/threat-report-2013/

  3. Increased Use of VancomycinAssociated with Resistance Kim NJ. JID 1999;179:163

  4. N. gonorrhoeae Resistance in the United States 1987-2011 The Gonococcal Isolate Surveillance Project

  5. Individuals prescribed an antibiotic in primary care for a respiratory or urinary infection develop resistance to that antibiotic • Greatest effect in the month immediately following treatment but may persist for up to 12 months Costelloe, C. et al. BMJ 2010: 340:c2096.

  6. Effect of Antibiotic Prescribing in Primary Care on Antimicrobial Resistance Costelloe C et al. BMJ. 2010;340:c2096.

  7. Nursing Home Patients Example 1 Centers for Medicare and Medicaid Services, Long Term Care Minimum Data Set, Resident profile table as of 05/02/2005. Baltimore. MD. 2 Loeb, M et.al. Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med 2001; 16: 376-383. 3 Centers for Disease Control and Prevention, National Center for Health statistics, 1999 National Nursing Home Survey. Nursing Home Residents, number, percent distribution, and rate per 10,000, by age at interview, according to sex, race, and region: United States, 1999.

  8. Acinetobacter Resistance to Imipenem http://www.cdc.gov/getsmart/campaign-materials/week/images/resistance.png

  9. Inappropriate Dosing May Lead to Resistance • Data pooled from 4 studies • Gram-negative pneumonia • Ciprofloxacin resistance associated with AUC/MIC <100 Thomas JK, et al. Antimicrob Agents Chemother. 1998;42:521-527.

  10. Dosing Matters – Penicillin Example • Penicillin half-life is only 30-45 minutes • Retrospective review of Streptococcal infective endocarditis • Penicillin given every 4 hours was associated with successful treatment vs every 6 hours (OR 2.79; 95%CI 1.43-5.62) Sandoe JAT, et al. J AntimicrobChemother. 2013; June 13 [Epub ahead of print]

  11. Pseudomonas aeruginosa MIC Distribution

  12. Dosing Optimization Example Shea KM, et al. Ann Pharmacother 2009;43:1747-1754

  13. Optimizing Dosing – Cefepime Example • Cefepime • Tertiary references suggest a dose of 1-2 g q8-12h • Susceptibility breakpoints are based on 1 g q8h (= 2g q12h) • Meaning: using 1 g q12h for pneumonia does not optimize the dosing of cefepime and risks undertreating the patient

  14. Current Antibiotic Resistance Threat in the United States CDC. Threat Report 2013. http://www.cdc.gov/drugresistance/threat-report-2013/

  15. BAD BUGS, NO DRUGS As Antibiotic Discovery Stagnates… A Public Health Crisis Brews Boucher HW, et al. Clin Infect Dis 2009;48:1-12.

  16. The AntibioticPipeline http://www.rff.org/RFF/Documents/ETC-06.pdf Accessed Jan 1, 2013

  17. Anti-infective Stewardship • Promotion of appropriate and responsible use of anti-infective agents • Optimize anti-infective therapy • Drug • Dose • Route • Duration • Patient tolerance and safety • Limit preventable adverse events • Drug-drug or drug-disease interactions

  18. Questions

  19. Are Antibiotics Really Benign? CDC. Threat Report 2013. http://www.cdc.gov/drugresistance/threat-report-2013/

  20. Infections with Resistant Organisms are on the Rise

  21. Objectives • Antibiotic overuse promotes resistance • Goal – use most narrow spectrum agent for appropriate duration • Increased resistant organisms are on the rise • Inappropriate antibiotic dosing may promote resistance • Antibiotic pipeline is diminishing • What to do • Promote appriopriate anti-infective use • Use most narrow spectrum anti-infective agent at optimal doses for the appropriate duration

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