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UTI & Pneumonia Translating Knowledge into Practice

UTI & Pneumonia Translating Knowledge into Practice. PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet. Attendance. Please email Brenda Flood ( brenda.flood@interiorhealth.ca ) if you attended this session

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UTI & Pneumonia Translating Knowledge into Practice

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

  2. Attendance • Please email Brenda Flood (brenda.flood@interiorhealth.ca) if you attended this session • Please email Brenda Flood (brenda.flood@interiorhealth.ca) if you view this presentation online at a later date

  3. 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

  4. Speaker Disclosure • The speakers have no actual or potential conflicts of interest to disclose

  5. 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?

  6. 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

  7. PIAS-KT Study Overview Intervention PRE phase POST phase Knowledge Knowledge Behavior Behavior Behavioral Change Strategies Jan 30 – Mar 14, 2014 DTP/DSEM DTP KPI/DSEM KPI Jul 1-Dec 31,2013 DTP/DSEM DTP KPI/DSEM KPI Jan 1-Jun 30, 2014 Quiz Jan 17-30, 2014 Quiz Mar 17-28, 2014 1. Audit & Feedback 2. Local opinion leaders 3. Educational meetings 4. Educational outreach 5. Printed education materials 6. Reminders

  8. 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

  9. Prevalence & Impact of UTIs Prevalence • Approximately 4,000,000 UTIs/year in Canada • Affects 20%of women between 15-29 yo • Number 1 healthcare-associated infection • 16thmost common non-surgical reason for IH admission Impact • 660 cases and 3200acute 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.

  10. 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 7000acute bed-days at IH each year • CAP is the leading infectious cause of death • Up to 15% of patients with CAP receive inadequatetherapy • Up to 75%of patients with HAP/VAP receive inadequate therapy Clin Infect Dis 2005;41:1709-16.; Postgrad Med 2010;122:130-141.

  11. 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.

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

  13. Clinical Pharmacists’ Role in Antimicrobial Stewardship ANTIMICROBIAL STEWARDSHIP PHARMACEUTICAL CARE

  14. Urinary Tract Infection Key Pharmacist Interventions • Initiate appropriate antibiotics for symptomatic UTI • Discontinue empiric antibiotics started for UTI that are not indicated • De-escalate antibiotics for UTI based on C&S data and clinical response • Perform IV to PO step-down of antibiotics for UTI • Promote appropriate duration of antibiotic therapy for UTI IH UTI Key Pharmacist Interventions, April 21, 2011

  15. Pneumonia Key Pharmacist Interventions • Initiate appropriate antibiotics for pneumonia • Discontinue empiric antibiotics started for pneumonia that are not indicated • De-escalate antibiotics for pneumonia based on C&S data and clinical response • Perform IV to PO step-down of antibiotics for pneumonia • Promote appropriate duration of antibiotic therapy for pneumonia IH Pneumonia Key Pharmacist Interventions, April 21, 2011

  16. 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

  17. 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

  18. 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)

  19. 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

  20. DTP Tracker Data - Pneumonia • In Pneumonia subgroup, AIMSfailed 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)

  21. Pharmaceutical Care of UTI and Pneumonia

  22. UTI Pharmaceutical CareOutline • When and When Not to treat with antibiotics? • Whatantibiotics to initiate and Why? • When, How, and Why to de-escalateantibiotics? • How long to treat with antibiotics?

  23. 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.

  24. UTI“Why should antibiotics be initiated?” •  duration of symptoms •  abscesses, metastatic infection, septic shock, AKI Clin Infect Dis 2005;40:643-54.

  25. 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

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

  27. UTI at Interior Health“What antibiotics should be initiated and why?” Organisms Associated with Urinary Tract Infections Infection 2007;35:150-3. (Calgary Data 2004-5)

  28. UTI at Interior Health“What antibiotics should be initiated and why?” PO options IV options *E. coli Susceptibilities at IH 2012

  29. UTI at Interior Health“What antibiotics should be initiated and why?” *Enterococcus Susceptibilities at IH 2012

  30. UTI at Interior Health“What antibiotics should be initiated and why?” • 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 Clin Infect Dis 2005;40:643-54.

  31. UTI at Interior Health“What antibiotics should be initiated and why?” • 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 Microbiol2005;16:349-60.

  32. Complicated Cystitis at IH“What antibiotics should be initiated?” “Oral antimicrobial therapy is appropriate for most episodes” Can J Infect Dis Med Microbiol 2005;16:349-60.

  33. Uncomplicated Cystitis at IH“What antibiotics should be initiated?” Recommendations for Empiric Therapy • Nitrofurantoin 100 mg PO BID x 5 days (CrCl ≥ 40 mL/min) • Trimethoprim/Sulfamethoxazolei DS PO BID x 3 days • Cefixime400 mg PO Daily x 3 days • Amoxicillin/Clavulanate875 mg PO BID x 3 days • Amoxicillin/Clavulanate500 mg PO TID x 3 days

  34. Complicated 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/Sulfamethoxazolei DS PO BID x 7-14 days 2nd Line (high prevalence resistance) • Ciprofloxacin 500 mg PO BID x 7-14 days

  35. Complicated Cystitis at IH“What antibiotics should be initiated?” Recommended Empiric IV Options • Ampicillin + Gentamicin • Ampicillin + Ceftriaxone • Piperacillin/Tazobactam +/- Gentamicin

  36. 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)

  37. Uncomplicated Pyelonephritis at IH“What antibiotics should be initiated and why?” Recommended Empiric IV Therapy for Acutely Ill Patients • Gentamicin 5-7 mg/kg/day IV OR • Ceftriaxone 1-2G IV daily

  38. Complicated Pyelonephritis at IH“What antibiotics should be initiated and why?” 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/Sulfamethoxazolei DS PO BID x 7-14 days 2nd Line (high prevalence resistance) • Ciprofloxacin 500 mg PO BID x 7-14 days

  39. 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

  40. Asymptomatic Bacteriuria in Pregnancy “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)

  41. 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.

  42. UTI Therapeutics“When and Howshould antibiotics be de-escalated?” • When to de-escalate • Once urine C&S known • No other suspected infections • No patient-limiting factors (e.g. allergy) Infection 2013;41:211-14.

  43. UTI Therapeutics“When and Howshould antibiotics be de-escalated?” • How to de-escalate • Broad spectrum to narrowest spectrum • Narrowest spectrum with  collateral damage risk Examples Infection 2013;41:211-14.

  44. 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 Infection 2013;41:211-14.

  45. 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)

  46. 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

  47. 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) Clin Infect Dis 2009;48:503-35.

  48. Pneumonia Pharmaceutical CareOutline • Whenand When Not to treat with antibiotics? • Whatantibiotics to initiate and Why? • When, How, and Why to de-escalateantibiotics? • How long to treat with antibiotics?

  49. IH Pneumonia DSEM

  50. Pneumonia When 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.

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