1. UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet

2. Attendance Please email Brenda Flood (brenda.flood@interiorhealth.ca) if you attended this sessionbrenda.flood@interiorhealth.ca Please email Brenda Flood (brenda.flood@interiorhealth.ca) if you view this presentation online at a later datebrenda.flood@interiorhealth.ca

3. THANK YOU! YOU SURPASSED OUR PROJECTED PARTICIPATION RATE FOR THE PRE-QUIZ! STAY TUNED FOR A POST-QUIZ THAT WILL BE SENT OUT IN MID-MARCH THANK YOU TO TASHA RAMSEY FOR HER EXPERT REVIEW OF THIS PRESENTATION

4. Speaker Disclosure The speakers have no actual or potential conflicts of interest to disclose

5. Outline PIAS-KT Study Overview Local Opinion Leaders Prevalence and Impact of UTIs & Pneumonia Antimicrobial Stewardship Key Pharmacist Interventions for UTIs & Pneumonia DTP Tracker Data for UTIs & Pneumonia UTIs & Pneumonia Therapeutics – When to treat with antibiotics and When Not to treat? – What antibiotics to initiate and Why? – When, How, and Why to de-escalate antibiotics? – How long to treat with antibiotics?

6. Objectives To review the pharmaceutical care of patients with UTIs & Pneumonia including: – Key pharmacist interventions – Indications for antibiotic therapy – Initial empiric antibiotic therapy recommendations – Antibiotic de-escalation strategies – IV to PO step-down considerations – Duration of antibiotic therapy

7. PIAS-KT Study Overview Intervention PRE phase KnowledgeBehavior POST phase KnowledgeBehavior Behavioral Change Strategies Jan 30 – Mar 14, 2014 1. Audit & Feedback 2. Local opinion leaders 3. Educational meetings 4. Educational outreach 5. Printed education materials 6. Reminders Quiz Jan 17-30, 2014 Quiz Mar 17-28, 2014 DTP/DSEM DTP KPI/DSEM KPI Jul 1-Dec 31,2013 DTP/DSEM DTP KPI/DSEM KPI Jan 1-Jun 30, 2014

8. Local Opinion Leaders KGH – Dawn Robb RIH – Kim Winters PRH/SOH – Orysya Fetterly VJH – Chelsea Argent SLH/OMH – Ian Petterson KBH/KLH – Michael Conci EKH/GDH – Darren Feere

9. Prevalence & Impact of UTIs Prevalence – Approximately 4,000,000 UTIs/year in Canada – Affects 20% of women between 15-29 yo – Number 1 healthcare-associated infection – 16 th most common non-surgical reason for IH admission Impact – 660 cases and 3200 acute bed-days at IH – Hospital-acquired UTIs associated with extra day of hospitalization – Up to 25% of patients with UTI receive inappropriate therapy – Up to 50% of patients with asymptomatic catheter-associated bacteriuria are treated with antibiotics (which is inappropriate) Mayo Clin Proc 2007;82:181-5.; Can J Infect Dis Med Microbiol 2005;16:166-70.

10. Prevalence & Impact of Pneumonia Prevalence – Approximately 170,000 cases of CAP each year in Canada – HAP/VAP is 2 nd most common nosocomial infection in Canada – 5th most common non-surgical reason for IH admission Impact – 1300 cases and 7000 acute bed-days at IH each year – CAP is the leading infectious cause of death – Up to 15% of patients with CAP receive inadequate therapy – Up to 75% of patients with HAP/VAP receive inadequate therapy Clin Infect Dis 2005;41:1709-16.; Postgrad Med 2010;122:130-141.

11. Antimicrobial Stewardship Definition An activity (or activities) that includes – Appropriate antibiotic selection – Appropriate antibiotic dosing – Appropriate antibiotic route selection – Appropriate antibiotic duration of therapy Clin Infect Dis 2007;44:159-77.

12. Antimicrobial Stewardship Goals Optimize clinical outcomes by ensuring effective antimicrobial therapy Minimize collateral damage from antimicrobials – Antimicrobial resistance – Antimicrobial toxicity – Costs of inappropriate antimicrobial use – Superinfections (e.g. Clostridium difficile) Clin Infect Dis 2007;44:159-77.

13. Clinical Pharmacists’ Role in Antimicrobial Stewardship PHARMACEUTICAL CARE ANTIMICROBIAL STEWARDSHIP

14. Urinary Tract Infection Key Pharmacist Interventions 1.Initiate appropriate antibiotics for symptomatic UTI 2.Discontinue empiric antibiotics started for UTI that are not indicated 3.De-escalate antibiotics for UTI based on C&S data and clinical response 4.Perform IV to PO step-down of antibiotics for UTI 5.Promote appropriate duration of antibiotic therapy for UTI IH UTI Key Pharmacist Interventions, April 21, 2011

15. Pneumonia Key Pharmacist Interventions 1.Initiate appropriate antibiotics for pneumonia 2.Discontinue empiric antibiotics started for pneumonia that are not indicated 3.De-escalate antibiotics for pneumonia based on C&S data and clinical response 4.Perform IV to PO step-down of antibiotics for pneumonia 5.Promote appropriate duration of antibiotic therapy for pneumonia IH Pneumonia Key Pharmacist Interventions, April 21, 2011

16. Project Alignment  CPhA “Blue Print” for Pharmacy Practice  CSHP “Vision 2015”  Canadian Clinical Pharmacy KPI Collaborative  Accreditation Canada  MOHS KRAs and CCM groups  IH SET goals, objectives  IH Pharmacy Clinical Priorities

17. DTP Tracker Data - UTI UTI ranks #6 in disease prevalence for all Rx interventions UTI ranks #3 in disease prevalence for 8 DSEM interventions UTI ranks #2 in disease prevalence for key pharmacist interventions

18. DTP Tracker Data - UTI AIMS study showed a statistically significant, clinically important increase after DSEMs – DSEM DTP/total DTP (27.9% to 31.9%, p<0.05) – KPI/total DTP (21.7% to 25.8%, p<0.05) In UTI subgroup, AIMS failed to show a statistically significant benefit – DSEM DTP/total DTP (3.91% to 3.93%, p=NS) – KPI/total DTP (3.82% to 4.61%, p=NS)

19. DTP Tracker Data - Pneumonia Pneumonia ranks #3 in disease prevalence for all Rx interventions Pneumonia ranks #2 in disease prevalence for 8 DSEM interventions Pneumonia ranks #3 in disease prevalence for key pharmacist interventions

20. DTP Tracker Data - Pneumonia In Pneumonia subgroup, AIMS failed to show a statistically significant benefit – DSEM DTP/total DTP (4.75% to 4.90%, p=NS) However, in Pneumonia subgroup, AIMS demonstrated a statistically significant REDUCTION – KPI/total DTP (5.07% to 3.94%, p=0.016)

21. Pharmaceutical Care of UTI and Pneumonia

22. UTI Pharmaceutical Care Outline When and When Not to treat with antibiotics? What antibiotics to initiate and Why? When, How, and Why to de-escalate antibiotics? How long to treat with antibiotics?

23. What Makes a UTI ‘Complicated’? Patients with structural or functional abnormalities of the genitourinary tract – Obstruction – Instrumentation (including catheters) – Impaired voiding – Metabolic abnormalities – Immunocompromised – Men Can J Infect Dis Med Microbiol 2005;16:349-60.

24. UTI “Why should antibiotics be initiated?”  duration of symptoms  abscesses, metastatic infection, septic shock, AKI Clin Infect Dis 2005;40:643-54.

25. UTI “When should antibiotics be initiated?” – Clinical manifestations of cystitis Dysuria, frequency, urgency, suprapubic pain, hematuria – Clinical manifestations of pyelonephritis Above symptoms together with fever (>38°C), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting – Asymptomatic bacteriuria in pregnancy

26. Cystitis at IH “When should antibiotics be initiated?” “If clinically feasible, initiation of antimicrobial therapy should be delayed until results of urine culture are available” Can J Infect Dis Med Microbiol 2005;16:349-60.

27. UTI at Interior Health “What antibiotics should be initiated and why?” Infection 2007;35:150-3. (Calgary Data 2004-5) Organisms Associated with Urinary Tract Infections

28. AntibioticSusceptibility (%)* Collateral Damage Risk Nitrofurantoin94-98Low Cefixime92-94Probable Amox/Clav84-90Probable TMP/SMX80-83Possible Ciprofloxacin78-85Probable Ceftriaxone94-97Probable Gentamicin94-96Possible Pip/Tazo94-97Probable Ampicillin61-68Probable UTI at Interior Health “What antibiotics should be initiated and why?” *E. coli Susceptibilities at IH 2012 PO options IV options

29. UTI at Interior Health “What antibiotics should be initiated and why?” *Enterococcus Susceptibilities at IH 2012

30. Risk Factors for Antibiotic Resistant UTIs – Abx exposure (especially to TMP/SMX or FQ) in past 3 months – Travel to endemic area – Previous multi-drug resistant UTI Clin Infect Dis 2005;40:643-54. UTI at Interior Health “What antibiotics should be initiated and why?”

31. Oral Antibiotic Selection – Oral antibiotics are first line for cystitis – Oral antibiotics are first line for uncomplicated pyelonephritis (not acutely ill) IV Antibiotic Selection – Unable to tolerate oral therapy (nausea/vomiting/ileus) – Impaired GI absorption – Hemodynamic instability (acutely ill) – Infecting organism resistant to available oral options Clin Infect Dis 2005;40:643-54., Can J Infect Dis Med Microbiol 2005;16:349-60. UTI at Interior Health “What antibiotics should be initiated and why?”

32. Complicated Cystitis at IH “What antibiotics should be initiated?” “Oral antimicrobial therapy is appropriate for most episodes” Can J Infect Dis Med Microbiol 2005;16:349-60.

33. Recommendations for Empiric Therapy 1.Nitrofurantoin 100 mg PO BID x 5 days (CrCl ≥ 40 mL/min) 2.Trimethoprim/Sulfamethoxazole i DS PO BID x 3 days Cefixime 400 mg PO Daily x 3 days Amoxicillin/Clavulanate 875 mg PO BID x 3 days Amoxicillin/Clavulanate 500 mg PO TID x 3 days Uncomplicated Cystitis at IH “What antibiotics should be initiated?”

34. Recommended Empiric Oral Options 1 st Line Cefixime 400 mg PO Daily x 7-14 days Amoxicillin/Clavulanate 875 mg PO BID x 7-14 days Amoxicillin/Clavulanate 500 mg PO TID x 7-14 days Trimethoprim/Sulfamethoxazole i DS PO BID x 7-14 days 2 nd Line (high prevalence resistance) Ciprofloxacin 500 mg PO BID x 7-14 days Complicated Cystitis at IH “What antibiotics should be initiated?”

35. Recommended Empiric IV Options Ampicillin + Gentamicin Ampicillin + Ceftriaxone Piperacillin/Tazobactam +/- Gentamicin Complicated Cystitis at IH “What antibiotics should be initiated?”

36. Uncomplicated Pyelonephritis at IH “What antibiotics should be initiated and why?” Recommend Empiric Oral Therapy Same as for uncomplicated cystitis EXCEPT: – No nitrofurantoin – Longer duration of therapy (7-14 days)

37. Gentamicin 5-7 mg/kg/day IV OR Ceftriaxone 1-2G IV daily Uncomplicated Pyelonephritis at IH “What antibiotics should be initiated and why?” Recommended Empiric IV Therapy for Acutely Ill Patients

38. Recommended Empiric Oral Options Same as for complicated cystitis 1 st Line Cefixime 400 mg PO Daily x 7-14 days Amoxicillin/Clavulanate 875 mg PO BID x 7-14 days Amoxicillin/Clavulanate 500 mg PO TID x 7-14 days Trimethoprim/Sulfamethoxazole i DS PO BID x 7-14 days 2 nd Line (high prevalence resistance) Ciprofloxacin 500 mg PO BID x 7-14 days Complicated Pyelonephritis at IH “What antibiotics should be initiated and why?”

39. Recommended Empiric IV Options Same as for complicated cystitis – Ampicillin + Gentamicin – Ampicillin + Ceftriaxone – Piperacillin/Tazobactam +/- Gentamicin Complicated Pyelonephritis at IH “What antibiotics should be initiated and why?”

40. Recommended Antibiotic Therapy Wait for results of screening urine C&S Select narrowest spectrum agent that is safe in pregnancy – Amoxicillin/Clavulanate – Amoxicillin – Cefixime – Cephalexin – Nitrofurantoin (avoid in 3 rd trimester) – TMP/SMX (avoid in 1 st and 3 rd trimesters) Asymptomatic Bacteriuria in Pregnancy “What antibiotics should be initiated and why?”

41. UTI Therapeutics “What is antibiotic de-escalation and why is it important?” Antibiotic De-escalation – Replace empiric broad-spectrum regimen with a more narrow spectrum regimen – Organism identified with susceptibilities – Intended to reduce collateral damage – De-escalation for UTIs is under-performed Infection 2013;41:211-14.

42. UTI Therapeutics “When and How should antibiotics be de-escalated?” When to de-escalate – Once urine C&S known – No other suspected infections – No patient-limiting factors (e.g. allergy) Infection 2013;41:211-14.

43. UTI Therapeutics “When and How should antibiotics be de-escalated?” How to de-escalate – Broad spectrum to narrowest spectrum – Narrowest spectrum with  collateral damage risk Infection 2013;41:211-14. EmpiricStep-Down CiprofloxacinAmoxicillin CefiximeCephalexin CeftriaxoneTMP/SMX Pip/TazoAmoxicillin/Clav CeftriaxoneCefixime Examples

44. UTI Therapeutics “How should antibiotics be de-escalated?” IV to PO Step-Down – Tolerates oral intake – No factors affecting absorption – Hemodynamically stable – If acutely ill pyelonephritis and considering PO β- lactam, patient should receive at least 1 dose of Ceftriaxone OR Aminoglycoside Infection 2013;41:211-14.

45. Interior Health IV to PO Step-Down Policy Pharmacists Have IV-PO Step-Down Authority – Applies to Ciprofloxacin/Moxifloxacin – Duration IV antibiotics: ≥ 48 hours – Tolerating other PO medications, fluids, or foods x 12 hours – No potential problems with absorption – Clinically stable (stable BP, resolving fever/afebrile, adequate urine output, absence of encephalopathy, WBC normal or normalizing) Exclusions Febrile neutropenia, gram negative bacteremia, CNS infections, septic shock, severe cellulitis InsideNet – Pharmacist managed IV to PO conversion program (2006)

46. UTI Therapeutics “How long to treat with antibiotics?” Uncomplicated cystitis – 3-7 days (5-7 days for nitrofurantoin) Complicated cystitis – 7-14 days Pyelonephritis – 7-14 days

47. Candida-Associated Cystitis Indications for treatment – Symptomatic cystitis – Asymptomatic, but high risk (neutropenia, planned urologic manipulation) Recommended treatment – Fluconazole 200-400 mg PO daily x 14 days – Amphotericin 0.3-0.6 mg/kg IV x 7 days (2 nd line) Clin Infect Dis 2009;48:503-35.

48. Pneumonia Pharmaceutical Care Outline When and When Not to treat with antibiotics? What antibiotics to initiate and Why? When, How, and Why to de-escalate antibiotics? How long to treat with antibiotics?

49. IH Pneumonia DSEM

50. Pneumonia When and Why Antibiotic Treatment? Physician/NP Diagnosis Varies depending on outpatient/inpatient Chest x-ray infiltrates PLUS Fever, purulent secretions, elevated WBC Other clinical manifestations: dyspnea, pleuritic chest pain Consequences of Pneumonia – Reduced survival – Increased risk of ICU admission – Prolonged length of hospitalization Clin Infect Dis 2007;44:sS.; Pneumonia DSEM 2008.

51. Community-Acquired Pneumonia Patients not hospitalized in previous 14 days Clin Infect Dis 2000;31:383-421.

52. Community-Acquired Pneumonia “What antibiotics should be initiated and why?” Microbiologic Etiology Clin Infect Dis 2000;31:347-82. Patient SettingOrganisms OutpatientsMycoplasma pneumoniae, Streptococcus pneumoniae, Haemophilus influenzae Inpatients (non-ICU) Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae, other gram (-) bacilli, Staphylococcus aureus Inpatients (ICU) Streptococcus pneumoniae, various gram (-) bacilli, Legionella pneumophilia, Staphylococcus aureus

53. Drug-Resistant Pneumococci MRSAPseudomonas aeruginosa Age > 65 yrs Abx exposure 90 d* Alcoholism Immunosuppression Comorbidities Exposed to child in daycare Dialysis Hospitalization ICU Admission Prior/Prolonged Abx Previous colonization Structural Lung Dz Corticosteroids (> 10 mg Prednisone/day) > 7 days Broad Abx in past month Malnutrition Community-Acquired Pneumonia Risk Factors for AROs *β-Lactam, Fluoroquinolone, Macrolide Can J Infect Dis Med Microbiol 2008;19:19-53., Clin Infect Dis 2007;44:(Suppl 2):S27-72.

54. Community-Acquired Pneumonia “What antibiotics should be initiated and why?” AntibioticSusceptibility (%)Cost/day S. pneumoH. fluAtypicals Ceftriaxone99-100 Ø$2.62 Amox/Clav99-10092-97Ø$0.72 Amoxicillin99-10073-80*Ø$0.18-0.36 Moxifloxacin99√√ $4.00 (PO) $17.50 (IV) Doxycycline81-8988-92√$0.18 Azithromycin74-89NR√ $1.28 (PO) $8.32 (IV) CefuroximeNR91-95Ø $1.84-3.68 (PO) $31.56 (IV) *Ampicillin Susceptibility Susceptibilities at IH 2012

55. Community-Acquired Pneumonia “What antibiotics should be initiated?” Recommendations for Empiric Therapy in Hospital General Ward 1.Moxifloxacin 400 mg PO/IV daily 2.Ceftriaxone 2 g IV daily + Azithromycin 500 mg IV daily ICU 1.Ceftriaxone 2 g IV daily + Azithromycin 500 mg IV daily 2.Ceftriaxone 2 g IV daily + Moxifloxacin 400 mg IV daily Clin Infect Dis 2007;44:(Suppl 2):S27-72.

56. Approach to De-Escalation Intensive Care Med 2014;40:92-5. Suspected CAP Empiric Antibiotics C&S Available? Significant Improvement after 48-96 hr? De-escalate Max 7 Days Review Abx Review Dose Re-culture Complication? Consider non-infection De-escalate using C&S Max 7 days NOYES NO YES

57. OrganismPreferredAlternatives S. pneumoniae; MIC < 2 mg/L Pen G, amoxicillinMacrolide, cephalosporins, clindamycin, doxycline, respiratory fluoroquinolone S. pneumonia; MIC ≥ 2 mg/L 3 rd generation cephalosporin, fluoroquinolone Vancomycin, linezolid, amoxicillin >3 g/day if MIC ≤ 4 mg/L H. influenzae (no beta- lactamase) AmoxicillinFluoroquinolone, doxycycline, azithromycin, clarithromycin H. Influenza (beta-lactamase) 2 nd or 3 rd generation cephalosporin, amoxicillin- clavulanate Fluoroquinolone, doxycycline, azithromycin, clarithromycin Enterobacteriacea e 3 rd generation cephalosporin, carbapenem Beta-lactam/beta-lactamase inhibitor, fluoroquinolone P. aeruginosaAntipseudomonal beta-lactam +/- cipro OR aminoglycoside Aminoglycoside PLUS cipro or levo MSSACloxacillinCefazolin, clindamycin Clin Infect Dis 2007;44:(Suppl 2):S27-72. Community-Acquired Pneumonia “Pathogen-Directed Therapy”

58. Community-Acquired Pneumonia “IV to PO Step-down Criteria” Normal functioning GI tract AND Able to ingest medications AND Improving clinically AND Clinical stability – T < 37.8 0 C – HR < 100 bpm – RR < 24 breaths/min – SBP > 90 mm Hg – Arterial O 2 sat > 90% – Normal mental status Clin Infect Dis 2007;44:(Suppl 2):S27-72.

59. Interior Health IV to PO Step-Down Policy Pharmacists Have IV-PO Step-Down Authority – Applies to Ciprofloxacin/Moxifloxacin – Duration IV antibiotics: ≥ 48 hours – Tolerating other PO medications, fluids, or foods x 12 hours – No potential problems with absorption – Clinically stable (stable BP, resolving fever/afebrile, adequate urine output, absence of encephalopathy, WBC normal or normalizing) Exclusions Febrile neutropenia, gram negative bacteremia, CNS infections, septic shock, severe cellulitis InsideNet – Pharmacist managed IV to PO conversion program (2006)

60. Minimum treatment duration 7 days AND Afebrile (T ≤ 37.8 x 48-72 h) AND ≤ 1 sign of CAP-related clinical instability T ≥ 37.8 HR ≥ 100 beats/min RR ≥ 24 breaths/min SBP ≤ 90 mmHg SaO2 ≤ 90% or PaO2 ≤ 60 mm Hg on room air Inability to maintain oral intake Abnormal mental status Azithromycin 500 mg IV daily x 3 days (with ceftriaxone) Community-Acquired Pneumonia “How long to treat?” Clin Infect Dis 2007;44:(Suppl 2):S27-72.

61. Hospital-Acquired/ Ventilator-Associated Pneumonia HAP – Pneumonia that occurs > 48 hours after admission VAP – Pneumonia arising > 48 hours after intubation Clin Infect Dis 2000;31:383-421.

62. HAP/VAP “What antibiotics should be initiated and why?” Microbiologic Etiology Patient SettingOrganisms Early HAP (≤ 4 days) S. pneumoniae, MSSA, H. influenzae, E. coli, Klebsiella spp., Enterobacter spp., Proteus spp., Serrratia spp Late HAP (> 4 days) All of the above PLUS: MRSA, P. aeruginosa VAP All of the above PLUS: Late (> 4 days on ventilator): MRSA, P. aeruginosa, Acinetobacter spp., Stenotrophomonas spp.

63. HAP/VAP “What antibiotics should be initiated and why?” Antibiotic Susceptibility (%) E. coli Klebsiella spp. Enterobacter P. aeruginosa Ceftriaxone94-9795-99NRR MoxifloxacinNR Piperacillin/ Tazobactam 94-9795-99NR91-95 Amoxicillin/ Clavulanate 84-9082-96RR Meropenem10099-10098-10096-98 Ciprofloxacin78-8592-9995-10080-89 Gentamicin94-9697-10099-10082-89 CeftazidimeNR 94-96 Susceptibilities at IH 2012

64. HAP/VAP “What antibiotics should be initiated and why?” MDR Bacteria Risk Factors

65. Infect Dis Clin N Am 2004;18:939-962. RSS 2012 HAP/VAP “What antibiotics should be initiated and why?”

66. Reasonable IH Strategy Early HAP/VAP, and no risks for MDR bugs Late HAP/VAP, or risks for MDR bugs Ceftriaxone Piperacillin-tazobactam Ciprofloxacin (?) Moxifloxacin Meropenem* +/- aminoglycoside (PA) +/- vancomycin (?) HAP/VAP “What antibiotics should be initiated and why?” RSS 2012

67. Am J Respir Crit Care Med 2005;171:388-416. RSS 2012 Approach to De-Escalation

68. Pneumonia Therapeutics “How long to treat with antibiotics?” Potential Benefits  Overall antibiotic use  Resistance rates  Super-infection  Drug costs  Adverse events Potential Risks  Treatment failures  Relapse rates  Re-infection rates  Complications J Clin Pharmacol Therap 2003;28:123-129. RSS 2012 Shorter Duration of Therapy

69. HAP/VAP “How long to treat?” Diagnosis*Duration HAP/VAP (not caused by MRSA/NLFGNR**) 7-8 days HAP/VAP (caused by MRSA/NLFGNR) 14-15 days Am J Respir Crit Care Med 2005;171:388-416. *Uncomplicated Pneumonia **Non-lactose fermenting Gram negative rods

70. Session Review PIAS-KT overview Local Opinion Leaders UTIs/Pneumonia are highly prevalent and impactful Pharmaceutical care of patients with infections naturally includes antimicrobial stewardship activities UTI/Pneumonia KPIs are antimicrobial stewardship activities When to initiate antibiotics for UTI/Pneumonia What antibiotic to initiate for UTI/Pneumonia When and how to de-escalate antibiotics for UTI/Pneumonia How long to treat with antibiotics for UTI/Pneumonia

71. Attendance Please email Brenda Flood (brenda.flood@interiorhealth.ca) if you attended this sessionbrenda.flood@interiorhealth.ca Please email Brenda Flood (brenda.flood@interiorhealth.ca) if you view this presentation online at a later datebrenda.flood@interiorhealth.ca

72. Questions?

73. TMP/SMX Resistance Clinical Cure Uncomplicated Cystitis Ann Intern Med 2001:135:41-50