Introduction to Antimicrobial Stewardship: Bugs and Drugs Steve Grapentine PharmD, BCPS Antimicrobial Stewardship Program grap0013@umn.edu (612)813-8360

What percentage of antimicrobial use in the average healthcare setting is appropriate? D) 90%

Objectives Discuss the importance of antimicrobial resistance trends and strategies to combat them Review best prescribing practices for common pediatric infections

Gateway Drugs

Susceptibility to P. aeruginosa (matte)

Susceptibility to P. aeruginosa (matte)

IV to PO Example Ciprofloxacin bioavailability = 80% Ciprofloxacin 400 mg IV q8h = 1200 mg/day Ciprofloxacin 750 mg PO q12h = 1500 mg/day 80% X 1500 mg = 1200 mg/day IV & PO options result in the same peak:MIC & AUC:MIC ratios

IV to PO Once adjusted gestational age (AGA) reaches 4 weeks bioavailability is much more consistent Health systems still get paid for giving PO abx while inpatient

What is the best treatment option for a previously healthy 9 mo female for pneumococcal community acquired pneumonia in the inpatient setting? Hint: all routine vaccinations are up-to-date. A) Ampicillin B) Azithromycin (Zithromax®) C) Ceftriaxone D) Clindamycin E) Levofloxacin

Why Does Vaccination Status Matter? Serotype A MIC = 4 Serotype B MIC = 1 Serotype C MIC = 0.5 Serotype D MIC = 4 Prevnar® protects against more virulent and higher MIC pneumococcal strains Simply look on MIIC and if not overdue for Prevnar and ActHib then amoxicillin is usually the best choice

Other Nuggets What about Augmentin? Little benefit over amoxicillin for pneumonia Comparable efficacy to cefprozil (Cefzil®) but with more diarrhea and more unnecessary anaerobic coverage Better used for aspiration pneumonia We use cefuroxime (2nd gen ceph) for patients with recent (<30 days) PCN exposure/non-anaphylactic allergy

How long should we treat this patient? A) 5 days B) 7 days C) 10 days D) 14 days

What is the most appropriate empiric treatment option for a previously healthy 21 mo female with a UTI in the ED setting? A) Amoxicillin/Clavulanate (Augmentin®) B) Cefdinir (Omnicef®) C) Cephalexin (Keflex®) D) Ciprofloxacin (Cipro®) E) Nitrofurantoin (Macrobid®)

E. coli (1184 urine isolates) % Susceptible Augmentin® 79% Cefdinir (Omnicef®) 99%* Cephalexin (Keflex®) 91% Ciprofloxacin (Cipro®) 94% Nitrofurantoin (Macrobid®) 97% 2015 Antibiogram Data *One cannot directly infer E. coli sensitivity to cefdinir from other 3rd generation cephalosporins

How long should we treat this patient? A) 7 days B) 8 days C) 10 days D) 14 days E) 15 days

UTI Treatment Durations 7 days 8 days 10 days 14 days 15 days AAP Up-To-Date

Final Recommendation for UTI Treatment Cephalexin (Keflex®) 25 mg/kg/dose (max 500 mg) PO TID X 7 days

A previously healthy 8 yo male patient comes into clinic with an abscess on his left buttocks. He is afebrile. What is the best treatment option?

Select the best answer below: A) I&D alone B) I&D + cephalexin (Keflex®) C) I&D + Bactrim® D) I&D + cephalexin (Keflex®) and Bactrim®

Abscess Pearls I&D alone is the preferred therapy in the absence of systemic symptoms If fever then Bactrim® OR clindamycin Combination therapy is no better than monotherapy Bactrim® may work for Group A Strep (GAS)?!

Which of the following is the least desirable treatment option (excluding patient preferences) for strep pharyngitis? A) PCN IM B) Amoxicillin 50 mg/kg/dose (max 1000 mg) PO qday C) Cephalexin (Keflex®) 20 mg/kg/dose (max 500 mg) PO bid D) Clindamycin 10 mg/kg/dose (max 300 mg) PO tid

Culturelle® Suggested dosing 10 billion CFUs = 1 capsule po bid

Outpatient Recommendation Summary Condition DOC Dose Max mg/dose Duration CAP Amoxicillin 45 mg/kg/dose BID 1000 mg 7 days UTI Keflex® 25 mg/kg/dose TID 500 mg Abscess I&D alone N/A Non-purulent cellulitis 15 mg/kg/dose TID Pharyngitis PCN IM or Amoxicillin Varies 50 mg/kg/dose QDAY 10 days Abx associated diarrhea Culturelle 10 billion CFUs BID Unknown At least as long as the abx

Inpatient Recommendation Summary Condition DOC Dose Max mg/dose Duration CAP Ampicillin 50 mg/kg/dose IV Q6H 2000 mg 10 days UTI Ceftriaxone 75 mg/kg/dose IV Q24H 7 days Abscess I&D +/- Bactrim® or Clindamycin N/A Non-purulent cellulitis Cefazolin 25 mg/kg/dose IV Q8H 1000 mg Abx associated diarrhea Culturelle 10 billion CFUs BID Unknown At least as long as the abx

Questions?