Antibiotic Stewardship in the

Long Term Acute Care Hospital

Brandon Walser, MD

Medical Director of Antibiotic Stewardship and Infection Control

Cornerstone Hospital, Little Rock, AR

Disclosures

• None

Objectives

• Identify the length of antibiotic therapy for common infections seen in the LTAC

• Hospital Acquired Pneumonia

• Central Line Bloodstream infections

• UTI

• Cdiff

• Wound infections

• Recognize the role for newer antibiotics in LTAC infections

Hospital Acquired Pneumonia

Hospital Acquired Pneumonia

• 2016 IDSA/ATS guidelines

• Cover empirically, target if able

• 7 days duration, though use your clinical judgement

• Procalcitonin

Central Line Associated Bacteremia

Central Line Associated Bacteremia

• If persistent infection >72 hours post line removal or if complication (e.gosteomyelitis, endocarditis, septic phlebitis): consider 4-6 weeks

• Coag negative staph: 7 days post line removal or 10-14 day with line salvage

• Gram negative: 10-14 days post line removal vs 14 days line salvage

• Candida: d/c line and 14 days from –ve blood culture• TTE and Dilated eye exam

Staph aureus

• 1. obtain TTE/TEE, if negative go to #2

• 2. Is there intravascular hardware (PM, ICD, prosthetic valve)?

• If no then consider 14 days for line infection if cultures clear rapidly post line removal.

• Always err on side of caution and longer abx, 4-6 weeks

Urinary Tract Infection

Urinary Tract Infection

• Minimize foley use as able

• Symptoms + pyuria (> 10 WBC/hpf) + Urine culture

• Urine Culture

• Straight Cath

• Indwelling catheter biofilm likely: replace if feasible then sample

Urinary Tract Infection

• GNR (Enterobacteriaceae, Pseudomonas)>>> S. aureus, Enterococcus

• Candida does not typically cause UTI

• Abx choice, Know your local sensitivities• Cefepime

• Ceftazidime

• Imipenem (or meropenem)

• Ceftazidime/avibactam

• Ceftolozane/tazobactam

• If gram stain shows GPC, consider adding vancomycin

Urinary Tract Infection

• Narrow once culture and sensitivities are back

• Duration

• European guidelines 3-5 days after fever resolution and elimination of complicating factor (stone vs catheter)

• Shorter courses of 7 days if patient improves rapidly

• Longer courses of 10-14 days if severely ill or delayed response.

C diff Diarrhea

C diff Diarrhea

• IDSA Guidelines 2017

• Initial episode

• Vancomycin 125mg PO four times daily

• Fidaxomicin 200mg PO twice daily

• Duration 10 days

• Fulminant (hypotension, shock, ileus, toxic megacolon)

• Vancomycin 500mg PO four times daily

• Ileus: Metronidazole 500mg IV q 8 hrs and Rectal vancomycin

C diff Diarrhea

• First recurrent CDI• Vancomycin 125mg po four times daily x 10-14 days then taper 125 mg po bid

x 7 days then daily x 7 days then pulse every 2-3 days x 2-6 weeks

• Fidaxomicin 200mg po bid x 10 days

• Second or more Recurrence• Vancomycin pulse taper

• Vancomycin 125 mg po four times daily x 10 days then rifaximin 400mg po TID x 20 days

• Fidaxomicin 200mg op bid x 10 days

• FMT

C. diff Diarrhea

• Surgery sometimes needed in severe disease

• Ileus, wbc >20k, septic shock, renal failure

• Fecal Microbial Transplant

• Multiple relapses

• Outcome: Cure rate 84%

Wound infections

Figure 1. Algorithmic approach to antibiotic therapy for wounds.

Journal of Antimicrobial Chemotherapy, Volume 71, Issue 11, November 2016, Pages 3026–3035, https://doi.org/10.1093/jac/dkw287

The content of this slide may be subject to copyright: please see the slide notes for details.

Erythema

Swelling

Pain

Purulent secretions

Odor

Confusion

Fever/chills

leukocytosis

Wound infection: Duration of antibiotics

• Soft tissue 5 to 14 days

• Muscle 2 to 3 weeks

• Osteomyelitis 6 weeks

• Debridement is your friend

Clinical Infectious Diseases, Volume 59, Issue 2, 15 July 2014, Pages e10–e52,

New Antibiotics on the Block

BRANDONWALSER@IDRGAR.COM