ANTIBIOTIC DE-ESCALATION

Madison Heath, PharmD

 • Understand the antibiotic coverage needed
for common disease states
OBJE CTIVES • Identify opportunities for de-escalation in
specific patient populations
• Understand how the new BPA process
works and be able to list the elements
embedded in it
DISEASE STATES

UTI, SSTI, Intra-abdominal and PNA

 URINARY TRACT
INFECTION
Acute Uncomplicated Cystitis, Complicated Cystitis and
Catheter-associated
 URINARY TRACT INFECTION

• Acute Uncomplicated Cystitis: Acute UTI confined to the bladder, no systemic symptoms
• Complicated Cystitis/Pyelonephritis: Extending beyond the bladder
• Temperature >99.9ᵒF
• Signs/Symptoms of systemic illness
• Flank Pain
• Catheter-associated UTI: Infection occurring in a patient who is currently catheterized or had been
catheterized in the past 48 hours
 URINARY TRACT INFECTION
- COMMON C AUSATIVE ORGANISMS -

Escherichia coli Proteus mirabilis

Staphylococcus
Klebsiella
saprophyticus
pneumoniae
*mainly outpatient
 UTI - ACUTE UNCOMPLICATED CYSTITIS
- EMPIRIC THERAPY -

Nitrofurantoin 100mg PO BID x 5 days

TMP/SMX 1 DS tab PO BID x 3 days

Fosfomycin 3g x 1 dose

Alternatives:
• Ciprofloxacin, x 3 days
• beta-lactams x 3-7 days
MRSA: No
Pseudomonas: No
 UTI - PYELONEPHRITIS
- EMPIRIC THERAPY -

Ciprofloxacin 500mg PO BID x7 days

Levofloxacin 750mg PO daily x5 days

Alternative:
• Ceftriaxone

MRSA: No
Pseudomonas: No
 CYSTITIS/PYELONEPHRITIS
- DE-ESC ALATION AND PEARLS -

De-escalation Opportunities:

• Urine Culture Sensitivity Based

• Pseudomonas Coverage Needed? No
• MRSA Coverage Needed? No

Asymptomatic Bacteriuria

• Treated only in Pregnant patients or patients undergoing

urologic procedures
 C AUTI
- COMMON C AUSATIVE ORGANISMS -

Escherichia Enterococcus
Candida spp.
coli spp.

Pseudomonas
Klebsiella spp.
aeruginosa
 C AUTI
- EMPIRIC THERAPY -

Levofloxacin

Alternatives:
• Cefepime
• Zosyn
• Gentamicin
• Tobramycin

MRSA: No
Pseudomonas:Yes
 C AUTI
- DE-ESC ALATION AND PEARLS -

De-escalation Opportunities:

• Urine Culture Sensitivity Based

• Pseudomonas Coverage Needed? Yes
• MRSA Coverage Needed? No

Pearl

• Urine sample should be taken from a newly inserted catheter

SKIN AND SOFT TISSUE
 SKIN AND SOFT TISSUE INFECTIONS

NONPURULENT PURULENT
• Mild: Typical cellulitis with no focus of purulence • Mild: Purulent infection
• Moderate: Typical cellulitis with signs of systemic • Moderate: Purulent infection with signs of
infection systemic infection
• Severe: • Severe:
• Failed PO antibiotics • Failed I&D AND PO antibiotics
• OR systemic signs of infection • OR systemic signs of infection
• OR immunocompromised
Systemic Signs of Infection
• OR have clinical signs of deeper infection
• Temperature >38ᵒC
• Bullae, Skin Sloughing, Hypotension, • HR >90 beats per min
Evidence of Organ Dysfunction • RR >24 breaths per min
• WBC >12k or <400
• Immunocompromised
 SSTI
- COMMON C AUSATIVE ORGANISMS -

Beta-hemolytic Group A
streptococci Streptococcus

Streptococcus Staphylococcus
pyogenes aureus
 SSTI
- EMPIRIC THERAPY -

MRSA: Dependent
Pseudomonas: Dependent
 SSTI
- DE-ESC ALATION AND PEARLS -

De-escalation Opportunities:

• Culture Sensitivity Based

• Pseudomonas Coverage Needed? Dependent
• MRSA Coverage Needed? Dependent
INTRA-ABDOMINAL
 INTRA-ABDOMINAL
- COMMON C AUSATIVE ORGANISMS -

Escherichia Pseudomonas
Klebsiella spp.
coli aeruginosa

Bacteroides Clostridium Streptococcus

fragilis spp. spp.
 INTRA-ABDOMINAL
- EMPIRIC THERAPY, EXTRA-BILIARY -

MRSA: No
Pseudomonas: Dependent
 INTRA-ABDOMINAL
- EMPIRIC THERAPY, BILIARY -

MRSA: No
Pseudomonas: Dependent
 INTRA-ABDOMINAL
- DE-ESC ALATION AND PEARLS -

De-escalation Opportunities:

• Culture Sensitivity Based

• Pseudomonas Coverage Needed? Dependent
• MRSA Coverage Needed? No

Outpatient completion of therapy

• Augmentin
• Cefuroxime + Metronidazole
• Ciprofloxacin + Metronidazole
• Acceptable in patients able to tolerate PO and when susceptibilities do not
display resistance
 PNEUMONIA

Community-Acquired, Hospital-Acquired and

Ventilator-Associated
 C AP
- COMMON C AUSATIVE ORGANISMS -

Streptococcus Haemophilus Mycoplasma

pneumoniae influenzae pneumoniae*

Staphylococcus Legionella Chlamydia

aureus spp.* pneumoniae*

Moraxella
catarrhalis
*denotes atypical pathogens
 C AP CLASSIFIC ATION

Severe CAP: Either one major criterion or ≥ 3 minor criteria

MAJOR CRITERIA MINOR CRITERIA

• Septic shock with need for vasopressors • Respiratory rate ≥ 30 breaths/min

• PaO2/FiO2 Ratio ≤ 250
• Respiratory failure requiring mechanical
ventilation • Multilobar infiltrates
• Confusion/disorientation
• Uremia – BUN ≥ 20mg/dL
• Leukopenia – WBC < 4k
• Thrombocytopenia – Platelets <100k
Previous respiratory isolation of pathogen: Add coverage
Severe CAP with: Add coverage • Hypothermia – Core temperature < 36°C
• Recent Hospitalization in past 90 days • Hypotension requiring aggressive fluid
• IV Antibiotics in the past 90 days resuscitation
• Localized Risk
 C AP
- EMPIRIC THERAPY -

Ceftriaxone + Azithromycin
• Alt: Ampicillin/Sulbactam, Doxycycline

MRSA Coverage: Vancomycin added to standard regimen

• Alt: Linezolid

Pseudomonas Coverage: Piperacillin/Tazobactam in place of Ceftriaxone

• Alt: Cefepime

Previous respiratory isolation of pathogen: Add coverage

Severe CAP with: Add coverage
• Recent Hospitalization in past 90 days
• IV Antibiotics in the past 90 days MRSA: Dependent
• Localized Risk Pseudomonas: Dependent
 C AP
- DE-ESC ALATION AND PEARLS -

De-escalation Opportunities,
should be considered at 48 hours:
• MRSA PCR, negative – Discontinue coverage, if added
• Cultures negative for MRSA and/or Pseudomonas – De-escalation guided by
clinical response
• Patient is clinically improving
• De-escalate to standard CAP regimen

Oral Options

• Augmentin, Cefuroxime
• Azithromycin, Doxycycline
• Levofloxacin
 HAP/VAP
- COMMON C AUSATIVE ORGANISMS -

Pseudomonas Klebsiella
Escherichia coli
aeruginosa pneumoniae

Staphylococcus
Enterobacter spp. Acinetobacter spp.
aureus
 VAP
- EMPIRIC THERAPY -

MRSA:Yes
Pseudomonas:Yes
 HAP
- EMPIRIC THERAPY -

MRSA: Dependent
Pseudomonas:Yes
 HAP/VAP
- DE-ESC ALATION AND PEARLS -

De-escalation Opportunities,
should be considered at 48 hours:
• MRSA PCR, negative – Discontinue MRSA coverage
• Cultures negative for MRSA and/or Pseudomonas – De-
escalation guided by clinical response
• Patient is clinically improving

Aspiration Risk

• Ampicillin/Sulbactam
 SEPSIS

• Once source is identified, dose of broad-spectrum can be tailored to

indication
• Sepsis 2/2 UTI: Zosyn can be adjusted to UTI dosing based off renal function
CRH EMPIRIC RECOMMENDATIONS
 Infection Recommended Inpatient Therapy
Pneumonia:
• CAP First-Line Ceftriaxone (OR Ampicillin/Sulbactam) + Azithromycin
Alternative Ceftriaxone (OR Ampicillin/Sulbactam) + Doxycycline
• HAP/VAP First-Line Cefepime +/- Tobramycin + Vancomycin
Urinary:
• UTI, community First-Line Ampicillin + gentamicin
onset Alternative(s) Gentamicin
Cefuroxime
• UTI, severe/sepsis First-Line Piperacillin/Tazobactam
Alternative Cefepime
SSTI First-Line Cefazolin + Vancomycin +/- Clindamycin
Alternative Ampicillin/Sulbactam + Vancomycin +/- Clindamycin
Intra-abdominal, First-Line Cefuroxime + Metronidazole
community onset Alternative Ampicillin/Sulbactam + Gentamicin
 Infection Recommended Outpatient Therapy
Pneumonia:
• CAP and AECOPD, First-Line Amoxicillin
no comorbidities Alternative Doxycycline

• CAP and AECOPD, First-Line Amoxicillin/Clavulanate + Azithromycin (Doxycycline)

with comorbidities Alternative Cefuroxime + Azithromycin (Doxycycline)
Urinary:
• UTI First-Line Nitrofurantoin
Alternative(s) Amoxicillin/Clavulanate
Cefuroxime
SSTI:
• Purulent First-Line SMX/TMP OR Doxycycline
Alternative Clindamycin (Lower activity against MRSA)

• Non-purulent First-Line Penicillin VK

Alternative(s) Cephalexin
Amoxicillin/Clavulanate
DURATION
Common Infection Types Recommended Duration of Therapy
Pneumonia:
• HAP/VAP 7 days
• CAP 5 days
AECOPD 5 days
Urinary:
• Cystitis 3-5 days
• Pyelonephritis 7-14 days
• CAUTI 7-14 days
Intra-abdominal 5 days – after adequate source control
CDI 10-14 days
SSTI:
• Cellulitis 5 days
• Diabetic Foot Infection 7-21 days
Osteomyelitis 2-4 weeks – dependent on source control method
DE-ESCALATION BPA
- WHY -
 SAAR: BROAD SPE CTRU M
ABX, I CU

• SAAR: Standardized Antimicrobial Administration Ratio

• Measure of Antibiotic Use vs Predictive Use
• Goal: ≤1
• Broad Spectrum Antibacterial Agents: Meropenem,
Zosyn, Cefepime
SAAR: BROAD SPE CTRU M
ABX, M ED/SURG UN ITS
SAAR: BROAD SPE CTRU M
ABX, STE P DOWN (4T)
 Review Patient
• Indication, Drug, Dose, Duration

Formulate
BPA P ROCESS Recommendation

Page Provider

Give Recommendation
 FEEDBACK

If you could please fill out this survey for formal feedback, I
would greatly appreciate it!

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 REFERENCES
Cystitis and Pyelo:
Gupta K, Hooton TM, Naber KG et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and
pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious
Diseases. Clin Infect Dis. 2011; 52(5):e103-e120. doi: 10.1093/cid/ciq257
Intra-abdominal:
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by
the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50(2):133-164. doi: 10.1086/649554
CAP:
Metlay JP, Waterer GW, Long AC et al. Diagnosis and treatment of adults with community-acquired pneumonia: an official clinical practice
guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200(7):e45-e67. doi:
10.1164/rccm.201908-1581ST
VAP/HAP:
Kalil AC, Metersky ML, Klompas M et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice
guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63(5):e61-111. doi:
SSTI:
Stevens DL, Bisno AL, Chambers HF et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by
the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2):e10-52. doi: 10.1093/cid/ciu296