Managing Drug-resistant Organisms In Acute Care

2y ago
20 Views
2 Downloads
442.56 KB
7 Pages
Last View : 2m ago
Last Download : 2m ago
Upload by : Arnav Humphrey
Transcription

Managingdrug-resistant organismsin acute care38 The Nurse Practitioner Vol. 41, No. 21Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.www.tnpj.com

2.0CONTACT HOURS2.0CONTACT HOURSAbstract: The purpose of this article is toprovide practitioners with therapeuticconsiderations for infections caused bydrug-resistant organisms in the acute caresetting. Proper identification of organisms andappropriate use of antibiotics are imperativestrategies to help reduce the development andspread of antimicrobial resistance.By Kimberly L. Nealy, PharmD, BCPS; Delilah J. McCarty, PharmD,BCACP, CPP, CDE; and J. Andrew Woods, PharmD, BCPSntimicrobial resistance is an ever-worsening issuethat creates challenges for NPs when caring forpatients with infections. A 2013 CDC report estimated that antimicrobial-resistant infection (ARI) incidences exceed 2 million cases in the United States annually.1ARI-associated patient mortality is still twice as high compared with other hospitalized patients even when the confounding variables of ICU stay, healthcare-associated infections (HAIs), and the acute physiology and chronic healthevaluation (APACHE) score are accounted for.2 Patientswith ARI also tend to have longer hospital stays in additionto higher healthcare-related costs.1-3Immunocompromised patients and those undergoingdialysis or surgery are at higher risk for infectious complications.1 Patients in these groups often require longer hospitalizations, multiple rounds of antibiotics, and have invasivemedical devices most commonly resulting in urinary tract,bloodstream, or lower respiratory tract infections.4 Antimicrobial resistance further adds to the infection managementcomplications among these patients. Several of the mostlife-threatening infectious pathogens have known resistanceagainst currently available antimicrobials.Photo by Science Source Awww.tnpj.comKeywords: antibiotics, antimicrobial-resistant infections,healthcare-associated infectionsTheTheNurseNursePractitionerPractitioner FebruaryJanuary 2016 39Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.

Managing drug-resistant organisms in acute careThe CDC has identified the following microbes as seriousthreats: methicillin-resistant Staphylococcus aureus (MRSA);vancomycin-resistant Enterococcus (VRE); extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae;multidrug-resistant (MDR) Pseudomonas aeruginosa; MDRAcinetobacter; drug-resistant Campylobacter; fluconazoleresistant Candida; drug-resistant nontyphoidal Salmonella;drug-resistant Salmonella typhi; drug-resistant Shigella; drugresistant Streptococcus pneumoniae; and drug-resistant tuberculosis.1 Additionally, the CDC lists carbapenem-resistantEnterobacteriaceae, Clostridium difficile, and drug-resistantNeisseria gonorrhoeae as urgent threats (see Preferred treatment options for managing drug-resistant organisms).1 Gram-positive infectionsMethicillin-resistant Staphylococcus aureus. Staphylococcus aureus is one of the most common pathogens associated with skin and soft tissue infection (SSTI), bloodstreaminfection ([BSI] or bacteremia), and healthcare-associatedpneumonia.5 MRSA accounts for more than half of allS. aureus isolates.6 MRSA strains, community-associated(CA-MRSA), and healthcare-associated (HA-MRSA) differin regards to their clinical and molecular epidemiology.CA-MRSA most commonly manifests as SSTIs in young,otherwise healthy individuals without recent healthcare exposure.7 Uncomplicated CA-MRSA SSTIs in immunocompetentpatients may be treated with abscess drainage alone.8 In contrast, patients with signs and symptoms of systemic infectionand those with comorbidities should be treated with antibiotics. The vast majority of CA-MRSA strains remain susceptibleto trimethoprim-sulfamethoxazole, tetracyclines, andclindamycin.9,10 By definition, HA-MRSA infections are contracted following hospitalization stay over 48 hours or presentwithin 12 months of hospital discharge as a direct result ofhospitalization (for example, MRSA SSTIs associated with asurgical incision).11In addition, several risks for HA-MRSA infection havebeen elucidated, including: prolonged hospitalization (especially hospitalizations that involve ICU); residence in along-term care facility; antibiotic use; hemodialysis; colonization with MRSA; and proximity to others with MRSAcolonization or infection.12 HA-MRSA is associated withsevere, invasive infections, including bacteremia, pneumonia, and complicated SSTIs (also known as acute bacterialskin and skin structure infections).11 Vancomycin remainsthe mainstay of therapy in treating invasive MRSA infections, although the minimum inhibitory concentration(MIC) creep phenomenon (a reported overall decrease inthe susceptibility of S. aureus isolates to vancomycin invarious geographic regions) has raised concern regardingits future efficacy.8,13Vancomycin alternatives should be considered for treating pathogens that are not susceptible to vancomycin (forexample, vancomycin intermediate Staphylococcus aureus[VISA]) as well as in the setting of vancomycin intoleranceor subclinical response to vancomycin. Linezolid is anacceptable alternative to vancomycin in treating MRSApneumonia and complicated SSTIs.14,15 Linezolid’s role intreating MRSA bacteremia is unclear. Daptomycin is a suitable substitute for vancomycin for treating MRSA bacteremia (including endocarditis and complicated SSTIs) butshould never be used for treating MRSA pneumonia.1618Additional alternatives to vancomycin include tigecycline,ceftaroline, telavancin, and quinupristin-dalfopristin.Vancomycin-resistant Enterococcus. Considered normal gastrointestinal tract flora, enterococci are rarelyvirulent; however, VRE are an increasingly common andconcerning cause of HAIs.5 Enterococcus faecalis and Enterococcus faecium are the most commonly isolated speciesof the genus with documented vancomycin-resistance ratesof greater than 9% and 80%, respectively.5 VRE infectionsare most often associated with patients in the ICU, especially those with intravascular devices and/or urinarydrainage catheters. In addition, immunosuppressed patients are particularly vulnerable to VRE infections. Otherrisk factors include prolonged hospitalization (greater than72 hours), residence in long-term-care facilities, and prolonged antibiotic exposure.19,20A clinician must first decide whether the isolate represents colonization or infection when addressing a VREpositive microbiological report. Source control (the removal/replacement of catheters and surgical management oflocalized infections) should always be the primary intervention in treating a VRE infection. The intrinsic resistanceto many antibiotics is the major challenge in pharmacotherapeutic management of a VRE infection. Despite highrates of resistance, increasing incidence, and high mortality, there remains a dearth of clinical efficacy data directingthe pharmacotherapeutic management of patients withVRE infections.Linezolid and quinupristin-dalfopristin are two antibiotics currently FDA approved for treatment of VRE infection.21,22 Quinupristin-dalfopristin is indicated for E. faeciumonly.23 Although there are insufficient data to support FDAapproval for VRE treatment, daptomycin is likely efficaciousagainst these pathogens.24-26 However, a recent meta-analysisof available retrospective and observational data indicatesthat, when compared with linezolid, daptomycin may beassociated with worse outcomes when treating patients withVRE bacteremia.27 Tigecycline and telavancin are otherantibiotics (with limited anecdotal evidence) that may beused to treat VRE.28,2940 The Nurse Practitioner Vol. 41, No. 2Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.www.tnpj.com

Managing drug-resistant organisms in acute carePreferred treatment options for managing drug-resistant organisms4,8,31BacteriaCommon reatment optionsSSTIsHealthcare-associated MRSAEnterococcus species(VRE)bacteremia, pneumonia, andcomplicated SSTIsbacteremia, UTIs, endocarditis,and ired pneumonia,bacteremia, UTIs, and ired pneumonia,bacteremia, UTIs, and woundinfection Trimethoprim-sulfamethoxazole Tetracyclines Clindamycin Linezolid*** Vancomycin*** Linezolid*** Daptomycin*,*** Tigecycline*** Telavancin*** Quinupristin-dalfopristin Clindamycin*** Linezolid*** Quinupristin-dalfopristin Daptomycin*** Tigecycline Telavancin*** Carbapenems: (imipenem***; meropenem;ertapenem; doripenem) Tigecycline** Colistin*** or polymyxin B Fosfomycin for UTIs Primary agent in combination regimens Tigecycline** Colistin*** or polymyxin B Adjunct for combination regimens Carbapenems: (imipenem***; meropenem;ertapenem; doripenem) Aminoglycoside*** RifampinMDRPseudomonas aeruginosahospital-acquired pneumonia,bacteremia, UTIs, and woundinfection Fosfomycin for UTIs beta-lactam-beta-lactamase inhibitorcombinations: (piperacillin-tazobactam***) Cephalosporins: (ceftazidime***; cefepime***) Carbapenems: (doripenem***; meropenem;imipenem***) Aztreonam*** Colistin*** Ciprofloxacin*** Adjunct for combination regimens Aminoglycosides*** RifampinMRSA: methicillin-resistant Staphylococcus aureus, VRE: vancomycin-resistant Enterococcus, MDR: multidrug-resistant, ESBL: extended-spectrum betalactamase, SSTI: skin and soft tissue infections, UTI: urinary tract infections*Daptomycin should not be used to treat pneumonia; **Tigecycline should not be used for bacteremia or UTIs; ***Medications are FDA approved for the listed indication Gram-negative infectionsGram-negative organisms pose a significant healthcare concern, as they are efficient at developing resistance, and theirassociated infections have a high morbidity and mortality.30They may acquire multiple mechanisms of resistance againstwww.tnpj.comone antimicrobial agent or employ a single mechanismagainst several different drugs.4Beta-lactamase production (an enzyme that alters thestructure of the antimicrobial molecule) is one of the mosttroublesome mechanisms of antibiotic resistance identifiedThe Nurse Practitioner February 2016 41Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.

Managing drug-resistant organisms in acute carerare occurrence but may include ataxia, paresthesias, visiondisturbances, and neuromuscular blockade.34 A lack of consistency with dosing units from one manufacturer to another is one factor that complicates colistin use (availableparenterally as colistimethate sodium). To avoid erroneousdosing, clinicians should refer to the package insert to implement the manufacturer recommended dose.Fosfomycin is available only in an oral formulation inthe United States, which may limit its use in severe infectionsin the acute care setting. Its current use is primarily limitedto urinary tract infections (UTIs); it could be a viable optionfor systemic infections if parenteral formulations were morewidely available.31ESBL-producing organisms. Carbapenems are considered first-line therapy for ESBL-producing organisms.31 Ina prospective observational study published in 2004, usinga carbapenem in patients with ESBL-producing Klebsiellapneumoniae bacteremia (specifically imipenem or meropenem) was associated with lower 14-day mortality than Antimicrobials reserved forother agents used as monotherapy, including ciprofloxacin,treating resistant Gram-negative infectionscephalosporins, beta-lactam-beta-lactamase inhibitor, orTigecycline is a parenteral minocycline derivative that isamikacin.36 Tigecycline use for ESBL infections is compliapproved for use in complicated SSTI and intra-abdominalinfections. The medication can be used against several ESBLcated by its inadequate concentrations in the urine andand carbapenemase-producing Enterobacteriaceae (includblood but can be considered in other types of infections.31ing Klebsiella species) and Acinetobacter; however, it is notOral fosfomycin or piperacillin-tazobactam (though theeffective against Pseudomonas or Proteus.4 Additionally, duelatter is not FDA-labeled for the indication) may be considered in UTIs.31 Additionally, piperacillintazobactam may be used for isolates withImplementing an antimicrobial stewardshipin vitro susceptibility in other types ofinfections with suspicion for low bacteprogram within healthcare systems improvesria inoculum.31 Cephalosporins, aminothe prescribing patterns of antibiotics.glycosides, trimethoprim-sulfamethoxazole, and fluoroquinolones are notrecommended even for isolates withapparent in vitro susceptibility due to a high rate of clinicalto low concentrations at the infection site, it should not befailure and cross resistance.31used for urinary tract or BSIs. Clinical experience with thisagent for resistant Gram-negative infections is limited.4 ItCarbapenemase-producing organisms. Treating organis often used in combination with other agents to treat reisms producing carbapenemases poses a significant challenge,sistant infections.30,32,33as resistance has been documented to all available antimicrobials.30,31 Combination therapy with two or more agents hasPolymyxins, including polymyxin B and colistin, wereused for Gram-negative infections in the 1940s but withshown superior survival over monotherapy in published redrawn from clinical use due to high rates of nephro- andports.30,32,37 Despite these organisms producing carbapenemas34,35neurotoxicity.es, regimens containing a carbapenem combined with one orThese agents have recently resurfaced asmore other agents (tigecycline, colistin, or an aminoglycoside)infections, with MDR Gram-negative organisms becomingare used.30,32 A few combinations, which have shown somemore prevalent. Evaluating recent use has revealed that theincidence of these toxicities is less than suspected despitesuccess in published literature, include: tigecycline and colistin,early reports of toxicity. Nephrotoxicity is associated witha carbapenem and colistin, tigecycline and gentamicin, and acumulative doses, combinations with other nephrotoxiccarbapenem with tigecycline and colistin or an aminoglycomedications (including nonsteroidal anti-inflammatoryside.30,32 Rifampin may have some synergistic activity in adrugs), and hypoalbuminemia; however, this effect seemscombination regimen against carbapenemase-producingto be reversible after discontinuation.34,35 Neurotoxicity is aorganisms for E. coli or Klebsiella pneumoniae infections.30,31among Gram-negative organisms. Several subtypes of betalactamases have been identified and classified, includingcarbapenemases (notably Klebsiella pneumoniae carbapenemases), extended-spectrum beta-lactamase, and metallobeta-lactamases.30 Carbapenemase enzymes decrease theefficacy of a wide spectrum of antimicrobials, includingcarbapenems, penicillins, cephalosporins, and potentiallyaztreonam.4 Aside from beta-lactamase production, Pseudomonas aeruginosa has been associated with several otherresistance mechanisms, including enzyme productionagainst aminoglycosides and the use of efflux pumps.31 Resistance genes are oftentimes encoded on transmissible plasmids, which facilitate resistance spread between organisms.Plasmids carrying beta-lactamase enzymes may also harborresistance genes against other antimicrobial agents, such asaminoglycosides, fluoroquinolones, and trimethoprimsulfamethoxazole, further limiting treatment options.3142 The Nurse Practitioner Vol. 41, No. 2Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.www.tnpj.com

Managing drug-resistant organisms in acute careMDR Pseudomonas aeruginosa. MDR Pseudomonasaeruginosa treatment is associated with controversy. Themerits and risks of monotherapy versus combination therapy have been highly evaluated in the literature with ongoingconflicting results.31 Agents with potential antipseudomonalactivity include: beta-lactam-beta-lactamase inhibitors(piperacillin-tazobactam), ceftazidime, cefepime, carbapenems (doripenem, meropenem, or imipenem-cilastatin),aztreonam, aminoglycosides, and ciprofloxacin.31 The use oftwo medications with differing mechanisms of action and/or resistance may improve therapeutic success, as resistanceto any of these agents may be present; however, additionalcosts are incurred with this strategy, and risk of adversereactions is increased.31 Colistin is typically reserved forhighly-resistant strains and last-line therapy. Additional management strategiesOther strategies to improve therapeutic outcomes have beenused aside from proper antimicrobial therapy. It is importantto be aware of appropriate dosing for treating MDR Gramnegative pathogens, as high doses are commonly used. Alternative dosing strategies to optimize pharmacokinetic andpharmacodynamic properties of antibiotics may be beneficial. The dosing of beta-lactam agents via extended or continuous infusion rather than intermittent dosing has beenimplemented to improve the duration of exposure to therapy. This works particularly well for medications, which havetime-dependent efficacy (for example, beta-lactam agents).Higher, less frequent dosing may be employed for agentsthat are primarily concentration-dependent (aminoglycosides).38 Additionally, alternative routes of administrationare being used (most commonly as adjunct therapy) todeliver medication more directly to the site of infection whilepotentially decreasing risk of systemic adverse reactions.Agents like tobramycin, colistin, and beta-lactams may beaerosolized for inhalation in pneumonia cases.31 Moving forwardAntibiotic resistance is an inevitable and natural consequenceof antibiotic use; however, there are ways to mitigate thepropagation of antibiotic resistance.1 Due to the high cost ofdrug development and the hurdles of implementing clinicaltrials, few antibiotics are currently in development.4 Therefore,antibiotic stewardship along with infection prevention protocols (including immunizations and appropriate hand hygiene) should be the focus and foundation of treatment.1Improper antibiotic prescribing is a significant contributor toantibiotic resistance. Implementing an antimicrobial stewardship program within healthcare systems improves the prescribing patterns of antibiotics by ensuring that selectedantibiotics are not only necessary for treatment but alsowww.tnpj.comappropriate for targeted microbes.1,39 The CDC offers guidance and toolkits to help NPs initiate infection control protocols and antimicrobial stewardship programs.39 Institutionsshould be familiar with local patterns of resistance and shouldutilize this information when choosing empiric regimens.Adherence to and regular enforcement of contact precautionsand hand hygiene standards is imperative.30,39REFERENCES1. Centers for Disease Control and Prevention. Antibiotic resistance threats inthe United States. 2013. ar-threats-2013-508.pdf.2. Roberts RR, Hota B, Ahmad I, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications forantibiotic stewardship. Clin Infect Dis. 2009;49(8):1175-1184.3. Neidell MJ, Cohen B, Furuya Y, et al. Costs of Healthcare- and CommunityAssociated Infections with Antimicrobial-Resistant Versus AntimicrobialSusceptible Organisms. Clin Infect Dis. 2012;55(6):807–815.4. Peleg AY, Hooper DC. Hospital-acquired infections due to gram-negativebacteria. N Engl J Med. 2010;362(19):1804-1813.5. Sievert DM, Ricks P, Edwards JR, et al. Antimicrobial-resistant pathogens associated with healthcare-associated infections: summary of data reported tothe National Healthcare Safety Network at the Centers for Disease Controland Prevention, 2009-2010. Infect Control Hosp Epidemiol. 2013;34(1):1-14.6. Richter SS, Diekema DJ, Heilmann KP, et al. Activities of vancomycin,ceftaroline, and mupirocin against Sta

40 The Nurse Practitioner † Vol. 41, No. 2 www.tnpj.com Managing drug-resistant organisms in acute care The CDC has identifi ed the following microbes as serious threats: methicillin-resistant Staphylococcus aureus (MRSA); vancomycin-resistant Enterococcus (VRE); extended-spec- trum beta-lactamase (ESBL)-producing Enterobacteriaceae; multidrug-resistant (MDR) Pseudomonas aeruginosa; MDR

Related Documents:

Acute Care Facility Multidrug-resistant Organisms Control Activity Assessment Tool This form can be used to assess the program in place in acute care hospitals to control transmission of multidrug-resistant organisms (MDROs). Element to be assessed Assessment Notes General Policies, Surveillance, and Reporting Hospital has a list of target MDROs.

Multidrug-resistant organisms (MDROs), in - cluding carbapenem-resistant Enterobacteriaceae (CRE), methicillin-resistant Staphylococcus aureus (MRSA), and organisms related to antimicrobial drug use and resistance, such as Clostridioides difficile, often are the causative agents in healthcare-associated infections (1,2). Studies show that these .

Multidrug-resistant organisms (MDROs), include: Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), . (for example from an acute care to a LTCF). If a facility can provide the level of medical care needed for a patient, the simple fact that .

member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

Diversity in Living Organisms Introduction to Diversity in Living Organisms We all know that there are abundant of living organisms present on the earth. Many organisms are not identical to each other. This variety of living beings present on the earth is called as a Biodiversity. Biologist have identified and classified

Feb 03, 2015 · organisms that obtain their energy from other organisms are called consumers. All animals are consumers, and they eat other organisms. Fungi and many protists and bacteria are also consumers. But, whereas animals eat other organisms, fungi, protists, and bacteria "consume" organisms through different methods.

Amoeba Paramecium Examples of organisms Examples of organisms Mould Fern Moss Mushroom Starfish Flatworm Examples of organisms Examples of organisms Yeast Hydra Bryophyllum Rose plant Multiple fission Examples Plasmodium Fragmentation Examples of organisms Spirogyra Planaria Regeneration

AngularJS is an extensible and exciting new JavaScript MVC framework developed by Google for building well-designed, structured and interactive single-page applications (SPA). It lays strong emphasis on Testing and Development best practices such as templating and declarative bi-directional data binding. This cheat sheet co-authored by Ravi Kiran and Suprotim Agarwal, aims at providing a quick .