Download Antibiotic Selection and Resistance: A Pharmacist`s perspective

Jennifer Ott, PharmD, BCPS
Clinical Pharmacy Specialist, Infectious Diseases
Eastern Maine Medical Center
Bangor, ME
[email protected]


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/
85
200
80
150
75
100
70
50
65
0
60
1990
1991
1992
Patients with VRE
Kim NJ. JID 1999;179:163
1993
1994
DDD vancomycin
1995
Defined daily doses of
vancomycin/1000 patient days
Number of patients with VRE
250
The Gonococcal Isolate Surveillance Project

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.
Costelloe C et al. BMJ.
2010;340:c2096.
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.
http://www.cdc.gov/getsmart/campaign-materials/week/images/resistance.png

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.


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 Antimicrob Chemother. 2013; June 13 [Epub ahead of print]
Shea KM, et al. Ann Pharmacother 2009;43:1747-1754

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

CDC. Threat Report 2013. http://www.cdc.gov/drugresistance/threat-report-2013/
Boucher HW, et al. Clin Infect Dis 2009;48:1-12.
http://www.rff.org/RFF/Documents/ETC-06.pdf Accessed Jan 1, 2013

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
CDC. Threat Report 2013. http://www.cdc.gov/drugresistance/threat-report-2013/

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