Antibiotic selection, special problems and precautions

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Amy Seung, who will be talking with us about Antibiotic Selection, special problems, and precautions. Welcome Amy!

 Laurl at ONS 

I'd also like to let you know that Brenda Shelton, from yesterday's topic, is also here tonight - welcome Brenda!

 Amy Seung 

Welcome. What kind of setting are you in? What burning questions do you have?

 brenda 

What do you use first line for neutropenic fever?

 Amy Seung 

We follow an algorithm. For inpatient, first fever we start with Piperacillin/Tazo (Zosyn®)

 Amy Seung 

If patients have certain risks we also give Vancomycin.

 brenda 

Is it ever different between leukemia and solid tumors?

 Amy Seung 

We do different things for solid tumor and Heme malignancy patients.

 brenda 

So when is vanco(mycin) used?

 Amy Seung 

We may be able to triage low risk solid tumor pts to oral antibiotics...Cipro® and Augmentin®.

 Amy Seung 

For the Heme group, it's always high risk and they get IV Zosyn® +/- Vanco.

 Amy Seung 

Vanco is used if the pt is at risk for Gram Positive infections: (ie suspected lines, history of MRSA, severe mucositis, cellulitus to name the most common ones).

 Amy Seung 

We don't use Vanco in patients that just have a central line--it has to look suspicious.

 Amy Seung 

For example, erythema, warm, painful, etc

 Laurl at ONS 

Amy, what happens for a penicillin-allergic pt?

 Amy Seung 

It can be tricky.

 Amy Seung 

We need to give double gram negative coverage-meaning two agents...

 Amy Seung 

We do a quinolone such as Cipro® or Levofloxacin + an aminoglycoside (tobamycin or amikacin) or Aztreonam - 2 of these three.

 Amy Seung 

All of our pcn (penicillin) allergic patients get Vanco, since these agents have no good gram positive coverage.

 brenda 

I have heard discussion of "empiric" and "pre-emptive" regarding antifungal treatment. What is the difference between them?

 Amy Seung 

This is very controversial right now and many practices are doing different things.

 Amy Seung 

Empiric means broad spectrum-often this group just has had a fever and antifungals are what is started after the first fever- gram negative coverage.

 Amy Seung 

Preemptive therapy usually refers to obtaining at CT of the chest and if the chest looks probable for fungal, only starting therapy then. If it's negative then no antifungals are started.

 brenda 

So both practices may occur- physician preference, or are there standards to guide this decision?

 Amy Seung 

It is usually physician preference or institution specific. Some places will do empiric and some preemptive.

 Amy Seung 

What are y'all giving for antifungals as your first line?

 Amy Seung 

We have guidelines that dictate therapy, but we've had to change these many times in the past couple of years.

 rmiller 

I am listening to this chat to learn more, need to review this area. Currently working with breast cancer patients and am thinking about taking the AOCNS test. Using the NCCN guidelines to help me think this through logically

 Amy Seung 

Great. The first big thing is to assess risk for the patient - low vs high risk

 rmiller 

This is helpful. Will there be a PEP card on this ?

 brenda 

The NCCN guidelines are an excellent source for core best practices that will help immensely with the exam.

 rmiller 

Can we get a copy of yesterday's chat?

 oncnurse 

Yesterday's chat is now posted on the ONS website (but is down at this time for maintenance) but is at www.ons.org - CNE Central- Index- chats- Hot Topics- Dates and Speakers.

 brenda 

RE: PEP Card: I am unsure if it is in the works. They are always willing to accept suggestions and it seems there is plenty of literature that could be summarized. I will forward this thought to the EBP (evidence based practice) council I sit on.

 Amy Seung 

The NCCN guidelines have a lot of details as well that can help with individual decisions.

 rmiller 

Thanks for pointing me in the right direction to understand the care of the patients with infections.

 oncnurse 

So Amy, is there any kind of emerging resistance that you are seeing that is requiring separate antibiotics?

 Amy Seung 

Yes, there is some. The NCCN and IDS guidelines are starting to address this.

 Amy Seung 

We're seeing more VRE bacteremias. There is  some data for using Linezolid® or Daptomycin here although it's not known which one is best for neutropenic patients.

 Amy Seung 

We're also seeing ESBL organisms--extended spectrum beta lactamase.

 Amy Seung 

Standard penicillin type drugs including Zosyn® don't work.

 Amy Seung 

Often it's ESBL EColi or Klebsiella--Meropenem or imipenem is one of the few drugs for this.

 Amy Seung 

Are others seeing these organisms?

 brenda 

Resistant fungal infections seem really problematic in some patients. Have you used double/ triple antifungal coverage? If so, what are the indications?

 Amy Seung 

Again, controversial. We are using some double antifungal coverage.

 curryl81 

Are they finding that using multiple drugs for treatment being more effective or causing more resistance?

 Amy Seung 

Multiple drugs are being found more effective for bacterial infections--less so for fungal infections.

 Amy Seung 

Single use of drugs is increasing resistance with some antibiotics...such as the heavy use of Cipro® or levofloxacin in the outpatient setting.

 Amy Seung 

We may use double coverage for organisms that are highly resistant and few agents with sensitive profiles.

 Amy Seung 

It isn't across the board though--it's an individual patient decision.

 curryl81 

Is the rate of resistance relevant to oral or IV medications?

 Amy Seung 

Both

 Amy Seung 

We're seeing resistance to IV and PO antibiotics as we use solely one in a setting.

 Amy Seung 

We're having a hard time with resistance to Cipro® as a whole now since we use so much PO.

 Amy Seung 

We're also seeing sensitivity to Zosyn®  drop now, since we've been using it so heavily as monotherapy in the past several years.

 brenda 

I heard Cipro®  is not even that good for pneumonia and the practice of prophylaxis in breast cancer pts where the common infection was UTI. Started with Cipro®  but should not translate to the lung ca pt where pneumonia is more common- right?

 Amy Seung 

There are some definite nuances between patient populations.

 Amy Seung 

Cipro®  can work for pneumonias but it's less concentrated in the lungs than agents such as levo or moxifloxacin.

 brenda 

Have been thinking about your first fever notes---- how do you optimize time to patient with so many new guidelines for ID ( Infectious Disease) approval before starting some of these broad spectrum agents?

 Amy Seung 

ID approval...Do others of you require ID approval before starting new antibiotics at your practices?

 steph199 

Our Docs always consult ID.

 Amy Seung 

What about order sets or specific guidelines for neutropenic fever?

 curryl81 

No, someone is likely to prescribe a broad spectrum immediately.

 Amy Seung 

Interesting. We do have a restriction on some of the antibiotics, but we have order sets specifically for first fever --so we get these drugs quickly.

 curryl81 

Our hem/onc teams usually manage this without ID.

 steph199 

We have no order sets for neutropenia....

 curryl81 

The private docs are likely to consult ID.

 curryl81 

Usually see Zosyn® and Vanco, I think?

 Amy Seung 

Lots of different practices--as long as our patients get their correct antibiotics quickly.

 brenda 

What drugs require monitoring of levels? Are levels always drawn the same with all agents?

 Amy Seung 

We do levels on all patients receiving aminoglycosides.

 Amy Seung 

We draw a trough and then peak around the 3rd dose.

 Amy Seung 

The dose and frequency is adjusted from there.

 Amy Seung 

For Vanco we only need troughs in these patients.

 Amy Seung 

For Vanco there are new recommendations to shoot for a target of 20 in the neutropenic patient rather than just 10-15.

 brenda 

What do the rest of you do with antibiotic levels?

 steph199 

Pharmacy will guide the dose- if ordered by the Docs, and they monitor lab levels if the antibiotic effects kidney function, they will call us to call the MD.

 steph199 

Such as Levaquin®, they will automatically change the dose or frequency.

 curryl81 

That is usually what we do and pharmacy will dose it accordingly.

 Amy Seung 

That's what we do too. Pharmacists will dose adjust based on the levels or renal function.

 curryl81 

Our pharmacist will change dosing and frequency of Levaquin®,  related to kidney function.

 brenda 

I feel like my new nurses often forget to write all the info on the form and levels get cancelled. What is the important data to include on the lab slip when drawing levels?

 Amy Seung 

The time the last dose was given exactly - the up and down times. And the total dose given for the day.

 brenda 

Thanks.

 oncnurse 

Sometimes people go home on very complicated antibx regimens- how do we assure that they have all of the coverage, d/c information, insurance approval, etc. that they need? How do you coordinate this at your institution?

 Amy Seung 

We have the social work coordinate the efforts with input from nurses, pharmacists, and physicians.

 steph199 

SS works out the meds with the HHC agency, by fax the doctor's orders to them. We give pts the DC info written down.

 brenda 

Re antibiotics after discharge- we do try to use consistent home care companies. We also have an intensive ambulatory setting with shared inpt/ outpt nurses and docs to smooth the transition or give some of the antbx during the day.

 rmiller 

What new drugs are being given to patients for mold-active prophylaxis for patients at high risk for invasive fungal infections? Read a bit about this in the NCCN guidelines that these were available and had high safety profiles, just curious.

 Amy Seung 

We start teaching discharge education multiple days prior to discharge if they've been in the hospital for several days.

 Amy Seung 

Posaconazole is the new drug.

 Amy Seung 

However institutions are using fluconazole and voriconazole in these settings as well.

 steph199 

DC planning starts ASAP when it is known a pt will need antibiotics at home and other HHC services.

 Amy Seung 

All of these are oral. Micafungin is approved for this, but it is IV so we're not using.

 brenda 

Long-term pts needing antibiotics at home often know these drugs and administration procedures quite well- perhaps occasionally better than some of the general home care nurses.

 Amy Seung 

Posaconazole has good evidence for the high risk prophylactic setting, but has variable absorption.

 Amy Seung 

It only comes in a solution. Pts have to take with high fat foods.

 Amy Seung 

We end up trying Ensure or ice cream.

 Amy Seung 

Some patients can't do this well due to nausea or mucositis, so we have to pull these patients off of it.

 Amy Seung 

Any tricks you have for using posaconazole?

 oncnurse 

Just a couple of minutes before the end- any last minute burning questions?

 steph199 

Thanks for all the good info guys.

 Amy Seung 

Thanks. Enjoyed your comments and questions for us.

 oncnurse 

So glad you found helpful! Please come to Monday's chat on device-related infections/management with Mikaela Olsen

 Amy Seung 

Good night.