New C. difficile guidelines and order sets!

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The Infectious Diseases Society of America guidelines on the management of Clostridium difficile-associated disease have been recently updated.  The most notable change in recommendations from prior guidelines is that oral metronidazole is no longer a first-line option in the management of mild-to-moderate disease. 

Our local guidelines (available under the Guidelines/GLA Guidelines link above) have been updated accordingly.  Both the standard 10-14d course of oral vancomycin for initial disease and oral vancomycin tapers for recurrent disease no longer require approval from the Infectious Diseases service.  We have also created order sets for management of C. difficile in the "Outpatient Antibiotic Protocols" and "Inpatient Antibiotic Protocols" order sets that are available within most CPRS order sets.  The ID service highly encourages use of the antibiotic protocol order sets, as they are routinely updated to be consistent with local and national guidelines for management of common infectious conditions.

GLA will also be soon be participating in a VA Cooperative Studies Program study in which patients with first recurrence of C. difficile disease will be randomized to receive a standard vs. tapering vancomycin course vs. fidaxomicin.  More details to follow.

New GLA antibiogram!

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Our 2017 antibiogram, which compiles antimicrobial resistance data from GLA isolates from the calendar year 2017 is now available here.  Overall resistance patterns are largely stable to slightly improved compared to 2016.  Notable findings include:

For Gram-negative rods in the hospital setting:

  • Amikacin remains the most active agent vs. multi-drug resistant Gram-negative rod infections at GLA.
  • Carbapenem-resistant Enterobacteriaceae remain somewhat uncommon at GLA.
  • There is not much overall difference between piperacillin-tazobactam, cefepime, and meropenem for most Enterobacteriaceae and Pseudomonas (but all are better than fluoroquinolones)
  • Pseudomonas is less frequently encountered in the urine as compared to other sites.

For Gram-negative rods in the outpatient setting:

  • Cepahlexin remains our first-line option for outpatient UTI treatment (the 92% susceptiblity rate of outpatient urinary E. coli to cefazolin may actually underestimate urinary cephalexin susceptibility as urinary breakpoints are higher than serum).
  • Fluoroquinolones and TMP-SMX susceptibility rates for urinary isolates are similar (~75-80%).

For Gram-positive rods:

  • MRSA remains common (~60% of nosocomial isolates and ~40% of outpatient isolates).
  • Doxycycline resistance is increasing among non-blood nosocomial S. aureus isolates (30%).

CDC Antibiotic Awareness Week: November 13-17, 2017

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CDC Get Smart About Antibiotics Week: November 14-19

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With the many threats that face our ability to manage infectious syndromes in the current age, from Clostridium difficile infection to infections caused by organisms resistant to most or all categories of antibiotics, now is the time to get involved in antimicrobial stewardship.

Click here for important information on antimicrobial stewardship, ranging from why stewardship is important, what causes antibiotic resistance, what should be considered during an antibiotic timeout, how to choose the shortest duration of antibiotic therapy necessary, and how to talk to your outpatients with upper respiratory infection on when antibiotics are not needed.

You can start practicing good antibiotic stewardship NOW! What can you do?

·         Observe antibiotic best practices

o   Get culture results

o   Choose antibiotics based on severity and location of infection

o   Use the most narrow antibiotic possible

o   Take an antibiotic timeout to reassess your antibiotic use at 48-72 hours

o   Use the shortest duration of treatment possible based on the indication

·         AVOID antibiotics for inappropriate indications

o   Upper respiratory tract infections

o   Asymptomatic bacteriuria

·         Take the time to educate your patients on when antibiotics ARE and ARE NOT needed

o   Recommend symptomatic relief andback-up plans

o   Reassure your patients