1. Introduction to Antimicrobial Stewardship: Bugs and Drugs
Steve Grapentine PharmD, BCPS
Antimicrobial Stewardship Program
(612)

2. What percentage of antimicrobial use in the average healthcare setting is appropriate?
D) 90%

3. Objectives
Discuss the importance of antimicrobial resistance trends and strategies to combat them
Review best prescribing practices for common pediatric infections

4. Gateway Drugs

6. Susceptibility to P. aeruginosa (matte)

11. Susceptibility to P. aeruginosa (matte)

12. IV to PO Example Ciprofloxacin bioavailability = 80%
Ciprofloxacin 400 mg IV q8h = 1200 mg/day
Ciprofloxacin 750 mg PO q12h = 1500 mg/day
80% X 1500 mg = 1200 mg/day
IV & PO options result in the same peak:MIC & AUC:MIC ratios

13. IV to PO
Once adjusted gestational age (AGA) reaches 4 weeks bioavailability is much more consistent
Health systems still get paid for giving PO abx while inpatient

15. What is the best treatment option for a previously healthy 9 mo female for pneumococcal community acquired pneumonia in the inpatient setting? Hint: all routine vaccinations are up-to-date.
A) Ampicillin
B) Azithromycin (Zithromax®)
C) Ceftriaxone
D) Clindamycin
E) Levofloxacin

17. Why Does Vaccination Status Matter?
Serotype A MIC = 4
Serotype B MIC = 1
Serotype C MIC = 0.5
Serotype D MIC = 4
Prevnar® protects against more virulent and higher MIC pneumococcal strains
Simply look on MIIC and if not overdue for Prevnar and ActHib then amoxicillin is usually the best choice

18. Other Nuggets What about Augmentin?
Little benefit over amoxicillin for pneumonia
Comparable efficacy to cefprozil (Cefzil®) but with more diarrhea and more unnecessary anaerobic coverage
Better used for aspiration pneumonia
We use cefuroxime (2nd gen ceph) for patients with recent (<30 days) PCN exposure/non-anaphylactic allergy

19. How long should we treat this patient?
A) 5 days
B) 7 days
C) 10 days
D) 14 days

20. What is the most appropriate empiric treatment option for a previously healthy 21 mo female with a UTI in the ED setting?
A) Amoxicillin/Clavulanate (Augmentin®)
B) Cefdinir (Omnicef®)
C) Cephalexin (Keflex®)
D) Ciprofloxacin (Cipro®)
E) Nitrofurantoin (Macrobid®)

21. E. coli (1184 urine isolates)
% Susceptible
Augmentin®
79%
Cefdinir (Omnicef®)
99%*
Cephalexin (Keflex®)
91%
Ciprofloxacin (Cipro®)
94%
Nitrofurantoin (Macrobid®)
97%
2015 Antibiogram Data
*One cannot directly infer E. coli sensitivity to cefdinir from other 3rd generation cephalosporins

22. How long should we treat this patient?
A) 7 days
B) 8 days
C) 10 days
D) 14 days
E) 15 days

23. UTI Treatment Durations
7 days
8 days
10 days
14 days
15 days
AAP
Up-To-Date

24. Final Recommendation for UTI Treatment
Cephalexin (Keflex®) 25 mg/kg/dose (max 500 mg) PO TID X 7 days

25. A previously healthy 8 yo male patient comes into clinic with an abscess on his left buttocks. He is afebrile. What is the best treatment option?

26. Select the best answer below:
A) I&D alone
B) I&D + cephalexin (Keflex®)
C) I&D + Bactrim®
D) I&D + cephalexin (Keflex®) and Bactrim®

28. Abscess Pearls I&D alone is the preferred therapy in the
absence of systemic symptoms
If fever then Bactrim® OR clindamycin
Combination therapy is no better than monotherapy
Bactrim® may work for Group A Strep (GAS)?!

29. Which of the following is the least desirable treatment option (excluding patient preferences) for strep pharyngitis?
A) PCN IM
B) Amoxicillin 50 mg/kg/dose (max 1000 mg) PO qday
C) Cephalexin (Keflex®) 20 mg/kg/dose (max 500 mg) PO bid
D) Clindamycin 10 mg/kg/dose (max 300 mg) PO tid

31. Culturelle®
Suggested dosing
10 billion CFUs = 1 capsule po bid

32. Outpatient Recommendation Summary
Condition
DOC
Dose
Max mg/dose
Duration
CAP
Amoxicillin
45 mg/kg/dose BID
1000 mg
7 days
UTI
Keflex®
25 mg/kg/dose TID
500 mg
Abscess
I&D alone
N/A
Non-purulent cellulitis
15 mg/kg/dose TID
Pharyngitis
PCN IM or Amoxicillin
Varies
50 mg/kg/dose QDAY
10 days
Abx associated diarrhea
Culturelle
10 billion CFUs BID
Unknown
At least as long as the abx

33. Inpatient Recommendation Summary
Condition
DOC
Dose
Max mg/dose
Duration
CAP
Ampicillin
50 mg/kg/dose IV Q6H
2000 mg
10 days
UTI
Ceftriaxone
75 mg/kg/dose IV Q24H
7 days
Abscess
I&D +/- Bactrim® or Clindamycin
N/A
Non-purulent cellulitis
Cefazolin
25 mg/kg/dose IV Q8H
1000 mg
Abx associated diarrhea
Culturelle
10 billion CFUs BID
Unknown
At least as long as the abx

34. Questions?