Antibiotic Stewardship (Nadeau, 10/21/2020)

 Many thanks to our stellar SSRRH pharmacist team-- namely Sue Nadeau, Carolyn Dam, and Alicia Loh--for a very important Grand Rounds presentation this week on Antibiotic Stewardship. Antibiotic Stewardship is a topic that has gained importance and momentum over the last decade, and the SSRRH pharmacy team and antibiotic stewardship committee has REALLY pushed us to change practice in really good ways. Particular areas for clinicians to consider include 1) initial choice of empiric antibiotics, 2) narrowing antibiotics as soon as possible, and 3) transitioning to oral antibiotics in a timely manner. 

Thanks to the whole team for their diligent work (pushing doctors to change practice is no easy task) and special thanks to Sue for giving the Grand Rounds presentation.

Here are my take homes:

1) SSRRH publishes an annual antibiogram. The antibiogram is available on the Sutter intranet (under pharmacy resources) but also has been copied here for your viewing convenience. Using local data to guide our abx choice is key to choosing empiric antibiotics correctly.

2) SSRRH Antibiotics Stewardship Committee also publishes an annual empiric antibiotic guide. (This is also available on the Sutter intranet) and is similarly pasted here for your reference.

Key take homes from our antibiogram:

• CAP: Take note that the recommended empiric antibiotics for patients admitted with Community Acquired Pneumonia (even ICU level) are 2gm Ceftriaxone (plus either Doxy or Azithro). MRSA coverage is NOT needed unless clinically high suspicion, despite level of care.
• Also be aware that evolving data shows that patients with CAP and a negative MRSA nasal swab likely do NOT need to be treated empirically with vancomycin. So get the swab on admit!
• Pseudomonas: Also don't forget the increased dosing for pip/taz for pseudomonal coverage (4.5gm Q6h vs. 3.375 q6h). Locally, pseudomonas has decreasing susceptibility to pip/taz (down to 91%) and even worse for cefepime (87%).
• Cefepime use may not be recommended and is restricted to ID consult.
• Ciprofloxacin, on the other hand, has had increasing susceptibility locally (up to 91% from nader of 79%)and may be a better empiric choice to cover pseudomonas. 
• Staph Aureus: MRSA rates have been increasing from all our staph isolates (from 27% in 2017 to 41% in 2019)
• 
  Local Staph Aureus has very low susceptibility to clindamycin (MRSA 59% and MSSA 79%) and so clindamycin should not be used empirically for any suspected staph aureus.

De-escalation of antibiotics is a key tenet of antibiotic stewardship. Patients should be assessed daily for decision making for definitive therapy. Culture should be used when available (48-72 hours) to drive decisions, but when not available, patients should be de-escalated to one agent within 3-5 days maximum. Physicians are often hesitant to do so (especially if they presented quite "sick"), but we should push through our fear!

IV to Oral conversion is another central tenet of antibiotic stewardship. PO abx lead to reduce risk of IV catheter infections, reduced thrombophlebitis, less expense, less work and earlier hospital discharge. Generally pts should be converted to PO abx if they have negative blood cultures x 48 hours, have improving clinical status and have received an appropriate amount of parenteral abx prior to conversion

Decreasing our use of Vancomycin. Soon to be rolled out is a program to decrease our empiric use of vancomycin in the hospital. Things to consider include CAP (see above), inappropriate use of vancomycin for skin and soft tissue guidelines (review IDSA guidelines for SSTI here), treatment options for PCN allergic patients (including skin testing) and more. Look for that coming up!