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