Antimicrobial Stewardship Program

Mission

The mission of the antimicrobial stewardship program is to optimize clinical outcomes of antimicrobial use in adult s across the UCLA Health System. The ASP works to ensure the optimal selection, dose, and duration of antimicrobials that lead to the best clinical outcome for the treatment or prevention of infection while producing the fewest possible side effects and the lowest risk for subsequent resistance. 

Extended Infusion for Piperacillin/Tazobactam is here on March 17th!
03/12/14
As of March 17, 2014, UCLA Health is administering piperacillin/tazobactam (pip/tazo) as an extended infusion.  Currently pip/tazo is administered as a 30-minute infusion given every 6-8 hours.  With the new dosing scheme, pip/tazo will be administered as a single 30-minute bolus dose followed by a 4-hour extended infusion given every 8-12 hours. Extended infusion pip/tazo is better for our patients; studies show extended infusion pip/tazo improves patient outcomes, is associated with lower mortality rates, and shorter length of hospital stay. Extended-infusion (infused over 4 hours every 8-12 hours) will be the default method of Zosyn administration. Providers may choose to prescribe Zosyn using the traditional 30-minute infusions every 6-8 hours.  For specific questions, contact the ASP team at x77567.
What do I need to know?
FOR NURSES:

• There will be new drug name/lines for the 30-minute bolus dose and 4-hour infusion.  The Sigma pump library has been automatically updated
• Program the pump appropriately for the new infusion times: bolus (30 minute) vs. maintenance infusions (4-hours)
• Watch out for incompatible agents! See the chart
• ALWAYS assess for compatibility when infusing pip/tazo with another agent via Y-site
• Remember to administer concurrently scheduled parenteral medications
FOR PHYSICIANS:
• All adult doses will be 3.375 grams
• Dosing interval determined by patient age and renal function
• First dose will be a bolus administered over 30 minutes and followed by 4-hour extended infusions
• Conventional dosing is still available for specific areas
DOSING RECOMMENDATIONS:

Extended-infusion piperacillin/tazobactam (ZosynŽ) dosing recommendations

Patient population

Estimated CrCl (mL/min)a or mode of dialysis

Bolus dose

(infused over 30 minutes)

Maintenance dose

(infused over 4 hours)

Adults

CrCl ≥ 20 mL/min or

CRRT

3.375g IV x1 dose

3.375g IV q8h

CrCl < 20 mL/min or

Intermittent HD

3.375g IV q12h

Pediatrics

CrCl ≥ 20 mL/minb

100mg pip/kg/dose

x1 dose

50-100mg pip/kg/dose IV q6h

aCreatinine clearance (CrCl) estimated by Cockcroft and Gault
bOnly pediatric patients with estimated CrCl ≥ 20 mL/min qualify for extended-infusion dosing. Pediatrics with severe renal impairment or hemodialysis should be continued on traditional dosing (over 30-minutes) with doses adjusted for CrCl 

References:
Lodise, TP et al. Clin Infect Dis. 2007; 44(3):357-63 Yost, RJ et al. Pharmacotherapy. 2011; 31(8): 767-75
Kim, A. et al. Pharmacotherapy. 2007; 27(11):1490-97 Patel, N et al. Antimicrob Agents Chemother. 2010; 54(1):460-65
Heintz, BH. et al. Pharmacotherapy 2009; 29(5):562-577

FOR PHARMACISTS:
•All pip/tazo for adults will be ordered as a linked order panel; Loading dose over 30 minutes ‘followed by’ 4 hour infusion q8-12h
•All pediatric patients will also receive 4-hour infusions but interval will remain q6h, also available as an order panel. Pediatrics with renal insufficiency will continue to get dose-adjusted 30-minute infusions
•Panel selection will be based on estimated creatinine clearance/mode of dialysis. See pip/tazo med list in order entry for descriptors
•All doses administered will be 3.375 grams
•Staggering of loading dose and first extended-infusion dose is dependent on renal function and is built into the order panel. You should not have to manually time the first dose based on renal function. •Make sure the provider selects the correct panel based on CrCl/mode of dialysis

Hunting The Nightmare Bacteria
10/23/13
PBS aired a documentary on the rise of antibiotic-resistance bacteria and the search for new therapies.  Click here to go to the PBS site.

Polymyxins: Wisdom Doesn’t Always Come with Age
09/27/13
An increase in infections due to multi-drug resistant, gram-negative bacterial pathogens has led to a corresponding increase in use of polymyxin-class antibiotics. Although available clinically since the 1950s and 1960s, much remains unknown about polymyxin antibiotics including how best to dose them to maximize efficacy and minimize toxicity. This review provides insight regarding important questions that require answers: from product potency to use at the bedside.  Read the full article here.

"Nightmare Bacteria"
03/14/13
After the CDC's Vital Signs report, carbapenem-resistant Enterobacteriaceae (CRE) has been receiving attention from various news organizations and has been nicknamed the "nightmare bacteria" (here, here, and here).  Our program works with microbiology, infection prevention, pharmacy, quality management, infecious diseases, and many other departments and are committed to UCLA's vision of healing humankind, one patient at a time, by improving health, alleviating suffering and delivering acts of kindness.  


Flu Watch 2013
1/25/13
LA County Flu watch
Click here to view the UCLA Antimicrobial Guidebook section on Seasonal Influenza Diagnosis and Management  in ADULTS
Click here to view the UCLA Antimicrobial Guidebook section on Seasonal Influenza Diagnosis and Management  in PEDIATRICS
Click here to read the latest information on flu surveillance and related disease updates for Los Angeles County. 


The New England Journal of Medicine publishes a perspective on The Future of Antibiotics and Resistance

1/24/13
Today the NEJM published a perspective article, "The Furture of Antibiotics and Resistance", which briefly touches upon the many challenges of antimicrobial stewardship.  Drs. Brad Spellberg, John G. Bartlett and David N. Gilbert propose several avenues to combat antimicrobial resistance, including advancing infection prevention, policy changes to support new classes of antimicrobials, preserving existing antimicrobials through national reporting and benchmarking, exploring microbe-attacking treatments (such as infusion of monoclonal antibodies and white cells that kill microbes), and treatments that attack host targets rather than microbial targets (such as sequestration of host nutrient to prevent microbial access to nutrients). 
We enourage you to read the article, which can be found here


CDC Resleases Joint Statement on Antibiotic Resistance from 25 National Health Organizations

11/13/12
As part of Get Smart About Antibiotics week, the CDC, CDDEP & RWJF hosted a telebriefing titled "Uniting To Preserve Antibiotics Effectiveness and Combat Resistance".

On the call, Arjun Srinivasan, Centers for Disease Control and Prevention associate director for healthcare-associated infection prevention programs and Ramanan Laxminararayan, director of the Center for Disease Dynamics, Economics & Policy (CDDEP), unveiled the details of an unprecedented joint partnership with 25 National Health Organizations to fight against antibiotic resistance.  The full statement can be found here.

In addition, CDDEP's Extending the Cure project releaseed new research identifying patterns of antibiotic overuse in certain areas of the United States, a bar graph and a map.  Both are interactive and can be found here: www.cddep.org/map

Risk of Cardiovascular Death in Patients taking Azithromycin

Updated: 06/11/12
A new study in the New England Journal of Medicine by Wayne A. Ray et. al. has found patients taking azithromycin, as compared to those who took no antibiotics, ciprofloxacillin, amoxicillin or levofloxacillin, had an increased risk of cardiovascular death during five days of therapy.  The authors conducted a retrospective cohort study of mortality among patients who used azithromycin.  The cohort included patients enrolled in the Tennessee Medicaid program who had been prescribed azithromycin between 1992 and 2006 and met eligib ility criteria on the date the prescription was filled.  Criteria included: excluding persons at high risk for death from unrelated causes, persons 30-74 years of age, not life-threatening noncardsiovascular illness, not received a diagnosis of drug abuse or resided in a nursing home in the previous year, not been hospitalized in the previous 30 days, at least 365 days of Medicaid enrollment and regular use of medical care. The study found a 5-day course of azithromycin was associated with a small absolute increase in the risk of cardiovascular death.   The study analyzed two periods: a 5-day period and a 10-day period. When compared to a matched period of no antibiotic treatment, a 5-day course of azithromycin was associated with an increased risk of both cardiovascular death (hazard ratio = 2.88 (95% CI, 1.79 to 4.63; P<0.001)) and death from any cause (hazard ratio = 1.85; 95% CI, 1.25 to 2.75; P=0.002) during that interval.   Compared to amoxicillin therapy, a 5-day course of azithromycin was associated with significant increases in the risk of both cardiovascular death and death from any cause.  The same results were found with ciprofloxacin compared to azithromycin (though death from any cause was a nonsignificant increase).  The risk did not differ significantly from the risk with levofloxacin.

This study has important implications on the use of azithromycin, particularly for patients with increased cardiovascular risk and we encourage you to read the article.  

Bug Bits: Let's talk dirty 

Updated: March 7, 2012

The CDC has issued a report that highlights six steps to prevent spread of deadly C. difficile bacteria, which impacts patients in nursing homes and outpatient care, not just hospitals.  C. difficile is linked to about 14,000 U.S. deaths every year. Those most at risk are people who take antibiotics and also receive care in any medical setting. Almost half of infections occur in people younger than 65, but more than 90 percent of deaths occur in people 65 and older. Previously released estimates based on billing data show that the number of U.S. hospital stays related to C. difficile remains at historically high levels of about 337,000 annually, adding at least $1 billion in extra costs to the healthcare system. However, the Vital Signs report shows that these hospital estimates may only represent one part of C. difficile's overall impact. 

2. Test for C. difficile when patients have diarrhea while on antibiotics or within several months of taking them.

3. Isolate patients with C. difficile immediately.

4. Wear gloves and gowns when treating patients with C. difficile, even during short visits. Hand sanitizer does not kill C. difficile, and hand washing may not be sufficient.

5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with C. difficile has been treated there.

6. When a patient transfers, notify the new facility if the patient has a C. difficile infection. 
The full report can be found here.

SIX STEPS:
1. Prescribe and use antibiotics carefully. About 50% of all antibiotics given are not needed, unnecessarily raising the risk of C. difficile infections.

News for UCLA Physicians

New: Pediatric IV Antibiotic Dosing Card, added 10/09/14

Drug Shortages (click on the link)

We have a web-app!

Add the UCLA webapp to your mobile device for access to the guidebook at the bedside! Instructions found here

eConsult is here!

Click the "eConsult" link on the left to receive a consultation from a member of the Antimicribial Stewardship program on your patient.