Inpatient antibiotic resistance: Everyone’s problem
Whether you’re seeing patients in the hospital or after discharge, awareness of their inpatient antibiotic exposure and support of antibiotic stewardship practices are key to combating antibiotic resistance.
PRACTICE RECOMMENDATIONS
› Consider alternatives to vancomycin for health care-associated methicillin-resistant Staphylococcus aureus isolates with a vancomycin minimum inhibitory concentration >2 mcg/mL or in the setting of poor clinical response. A
› Identify colonization vs infection with vancomycin-resistant enterococci (VRE) in the gastrointestinal tract following antibiotic exposure to minimize inappropriate antibiotic prescribing for VRE. C
› Use carbapenems as first-line treatment for severe infections caused by Enterobacteriaceae-producing extended-spectrum beta-lactamases. C
› Treat invasive carbapenem-resistant Enterobacteriaceae infections with combination therapy; site of infection, susceptibility patterns, and patient-specific factors should guide antibiotic selection. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Key players in acute care antibiotic stewardship programs (ASPs) often include physicians, pharmacists, infectious disease specialists, epidemiologists, microbiologists, nurses, and experts in quality improvement and information technology.
The core elements. The CDC has defined the core elements of successful inpatient ASPs.46 These include:
- commitment from hospital leadership
- a physician leader who is responsible for overall program outcomes
- a pharmacist leader who co-leads the program and is accountable for enterprise-wide improvements in antibiotic use
- implementation of at least one systemic intervention (broad, pharmacy-driven, or infection/syndrome-specific)
- monitoring of prescribing and resistance patterns
- reporting antibiotic use and resistance patterns to all involved in the medication use process
- Education directed at the health care team about optimal antibiotic use.
Above all, success with antibiotic stewardship is dependent on identified leadership and an enterprise-wide multidisciplinary approach.
The FP’s role in hospital ASPs can take a number of forms. FPs who practice inpatient medicine should work with all members of their department and be supportive of efforts to improve antibiotic use. Prescribers should help develop and implement hospital-specific treatment recommendations, as well as be responsive to measurements and audits aimed at determining the quantity and quality of antibiotic use. Hospital-specific updates on antibiotic prescribing and antibiotic resistance should be shared widely through formal and informal settings. FPs should know if patients with resistant organisms are hospitalized at institutions where they practice, and should remain abreast of infection rates and resistance patterns.
,When admitting a patient, the FP should ask if the patient has received medical care elsewhere, including in another country. When caring for patients known to be currently or previously colonized or infected with resistant organisms, the FP should follow the appropriate precautions and insist that all members of the health care team follow suit.
CASE
A diagnosis of carbapenem-resistant E.coli sepsis is eventually made. Additional susceptibility test results reported later the same day revealed sensitivity to tigecycline and colistin, with intermediate sensitivity to doripenem. An infectious disease expert recommended contact precautions and combination treatment with tigecycline and doripenem for at least 7 days. The addition of a polymyxin was also considered; however, the patient’s renal function was not favorable enough to support a course of that agent. Longer duration of therapy may be required if adequate source control is not achieved.
After a complicated ICU stay, including the need for surgical wound drainage, the patient responded satisfactorily and was transferred to a medical step-down unit for continued recovery and eventual discharge.
CORRESPONDENCE
Dora E. Wiskirchen, PharmD, BCPS, Department of Pharmacy, St. Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT 06105; Email: Dora.Wiskirchen@stfranciscare.org.
