ANTIBIOTIC SELECTION AND

RESISTANCE: A
PHARMACISTS PERSPECTIVE
Jennifer Ott, PharmD, BCPS
Clinical Pharmacy Specialist, Infectious Diseases
Eastern Maine Medical Center
Bangor, ME
jott@emh.org
 The use of antibiotics is the single most
important factor leading to antibiotic
resistance
Up to 50% of all antibiotics prescribed are
not needed or are not optimally effective
as prescribed

CDC. Threat Report 2013.

 Increased Use of Vancomycin
Associated with Resistance

Kim NJ. JID 1999;179:163

 N. gonorrhoeae Resistance in
the United States 1987-2011

The Gonococcal Isolate Surveillance Project

 Individuals prescribed an antibiotic in
primary care for a respiratory or urinary
infection develop resistance to that
antibiotic
Greatest effect in the month immediately
following treatment but may persist for up
to 12 months

Costelloe, C. et al. BMJ 2010: 340:c2096.

 Effect of Antibiotic Prescribing in Primary Care
on Antimicrobial Resistance

Costelloe C et al. BMJ.

2010;340:c2096.
 Nursing Home Patients Example

1 Centers for Medicare and Medicaid Services, Long Term Care Minimum Data Set, Resident profile table as of 05/02/2005.
Baltimore. MD.
2 Loeb, M et.al. Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med 2001; 16: 376-383.
3 Centers for Disease Control and Prevention, National Center for Health statistics, 1999 National Nursing Home Survey.
Nursing Home Residents, number, percent distribution, and rate per 10,000, by age at interview, according to sex, race,
 Acinetobacter Resistance to
Imipenem

http://www.cdc.gov/getsmart/campaign-materials/week/images/resistance.png
 Inappropriate Dosing May Lead
to Resistance
Data pooled from 4 studies
Gram-negative pneumonia
Ciprofloxacin resistance associated with AUC/MIC
<100

Thomas JK, et al. Antimicrob Agents Chemother. 1998;42:521-527.

 Dosing Matters Penicillin
Example
Penicillin half-life is only 30-45 minutes
Retrospective review of Streptococcal
infective endocarditis
Penicillin given every 4 hours was associated
with successful treatment vs every 6 hours
(OR 2.79; 95%CI 1.43-5.62)

Sandoe JAT, et al. J Antimicrob Chemother. 2013; June 13 [Epub ahead of

print]
Pseudomonas aeruginosa MIC
Distribution
 Dosing Optimization
Example

Shea KM, et al. Ann Pharmacother 2009;43:1747-1754

 Optimizing Dosing
Cefepime Example
Cefepime
Tertiary references suggest a dose of 1-2 g q8-
12h
Susceptibility breakpoints are based on 1 g
q8h (= 2g q12h)
Meaning: using 1 g q12h for pneumonia does
not optimize the dosing of cefepime and risks
undertreating the patient
 Current Antibiotic Resistance
Threat in the United States

CDC. Threat Report 2013.

 BAD BUGS, NO DRUGS

As Antibiotic Discovery Stagnates

A Public Health Crisis Brews
Boucher HW, et al. Clin Infect Dis 2009;48:1-12.
 The
Antibiotic
Pipeline

http://www.rff.org/RFF/Documents/ETC-06.pdf Accessed Jan 1, 2013

 Anti-infective Stewardship
Promotion of appropriate and responsible
use of anti-infective agents
Optimize anti-infective therapy
Drug
Dose
Route
Duration
Patient tolerance and safety
Limit preventable adverse events
Drug-drug or drug-disease interactions
Questions
 Are Antibiotics Really
Benign?

CDC. Threat Report 2013.

Infections with Resistant
Organisms are on the Rise
 Objectives
Antibiotic overuse promotes resistance
Goal use most narrow spectrum agent for
appropriate duration
Increased resistant organisms are on the rise
Inappropriate antibiotic dosing may promote
resistance
Antibiotic pipeline is diminishing
What to do
Promote appriopriate anti-infective use
Use most narrow spectrum anti-infective agent at
optimal doses for the appropriate duration