Antimicrobial Stewardship Guidance Federal Bureau of Prisons Clinical Practice Guidelines March 2013 Clinical guidelines are made available to the public for informational purposes only. The Federal Bureau of Prisons (BOP) does not warrant these guidelines for any other purpose, and assumes no responsibility for any injury or damage resulting from the reliance thereof. Proper medical practice necessitates that all cases are evaluated on an individual basis and that treatment decisions are patient-specific. Consult the BOP Clinical Practice Guidelines Web page to determine the date of the most recent update to this document: http://www.bop.gov/news/medresources.jsp Federal Bureau of Prisons Antimicrobial Stewardship Guidance Clinical Practice Guidelines March 2013 Table of Contents 1. Purpose ............................................................................................................................................. 3 2. Introduction ...................................................................................................................................... 3 3. Antimicrobial Stewardship in the BOP............................................................................................ 4 4. General Guidance for Diagnosis and Identifying Infection ............................................................. 5 Diagnosis of Specific Infections ........................................................................................................ 6 Upper Respiratory Infections (not otherwise specified) ............................................................................... 6 Rhinosinusitis ............................................................................................................................................. 6 Pharyngitis ................................................................................................................................................. 6 Bronchitis .................................................................................................................................................. 6 Osteomyelitis .............................................................................................................................................. 7 Clostridium Difficile Infection (CDI) .......................................................................................................... 7 5. Culture and Sensitivity ..................................................................................................................... 8 Urinalysis .......................................................................................................................................... 8 Urine Culture .................................................................................................................................... 8 Respiratory Cultures.......................................................................................................................... 9 6. Therapy Selection ............................................................................................................................. 9 Specific Diagnoses .......................................................................................................................... 10 Upper Respiratory Infections (URIs) – Not Otherwise Specified ................................................................ 10 Rhinosinusitis ........................................................................................................................................... 10 Acute Pharyngitis ..................................................................................................................................... 11 Bronchitis ................................................................................................................................................ 11 Pneumonia ............................................................................................................................................... 11 Deep Tissue Infections .............................................................................................................................. 12 Immunocompromised ............................................................................................................................... 12 Osteomyelitis ............................................................................................................................................ 12 Cellulitis .................................................................................................................................................. 13 Acne ......................................................................................................................................................... 14 Clostridium Difficile Infection (CDI) ........................................................................................................ 14 Dental Prophylaxis ................................................................................................................................... 14 7. Intravenous to Oral Conversion Guidelines .................................................................................. 16 Three Types of IV to PO Therapy Conversions ............................................................................... 16 General IV to PO Conversion Considerations .................................................................................. 17 Major Criteria to Consider When Selecting Patients for IV to PO Conversion .................................. 18 Considerations for Converting Specific Medications from IV to PO ................................................ 19 IV to PO Conversion Myths ............................................................................................................ 20 8. Multi-Drug Resistant Organisms – Specific Diagnoses ................................................................. 20 9. Communication Strategies ............................................................................................................. 21 10. Competencies and Training .......................................................................................................... 22 National Guidelines ............................................................................................................................. 24 References ............................................................................................................................................ 26 i Federal Bureau of Prisons Antimicrobial Stewardship Guidance Clinical Practice Guidelines March 2013 Appendix 1: Treatment of Pharyngitis .............................................................................................. 29 Appendix 2: Treatment of Community Acquired Pneumonia .......................................................... 30 Appendix 3: Treatment of Hospital, Ventilator, and Healthcare Acquired Pneumonia .................. 31 Appendix 4: Antibiotics Used in the Treatment of Pneumonia ......................................................... 32 Appendix 5: Treatment of Osteomyelitis ........................................................................................... 33 Appendix 6: Treatment of Cellulitis .................................................................................................. 34 Appendix 7: Vancomycin Monitoring ................................................................................................ 35 Tables: Table 1. Common Methods to Confirm the Presence of Infection and Identify the Cause ................ 5 Table 2. Common Diagnoses NOT Recommended for Treatment with Antibiotics ......................... 10 Table 3. Dental Prophylaxis for Bacterial Endocarditis Prevention (Adult Patients Only) ............. 15 Table 4. Examples of Medications That Can Be Converted with the Sequential or Switch Methods ................................................................................................................ 16 Table 5. Step-Down Therapy Conversion Medication Pairs ............................................................. 17 Table 6. Considerations Concerning the GI Tract and Conversion from IV to PO Therapy .......... 18 Table 7. Signs That Clinical Status is Improving .............................................................................. 18 ii Federal Bureau of Prisons Antimicrobial Stewardship Guidance Clinical Practice Guidelines March 2013 1. Purpose The purpose of this document is to provide guidance on the appropriate use of antimicrobials, to provide recommendations and standards for the medical management of inmates receiving antimicrobial therapy, and to outline the Federal Bureau of Prisons (BOP) Antimicrobial Stewardship Program. This document should be utilized in tandem with the BOP Technical Guidance for the Use of Injectable Medications, as applicable. 2. Introduction Antimicrobial resistance is a growing problem in the healthcare and community settings— leading to increased morbidity, mortality, and healthcare costs. The Centers for Disease Control and Prevention (CDC) states that antibiotic resistance is one of the world’s most pressing public health problems. Inappropriate antimicrobial prescribing practices are largely responsible for the growth of resistant microbes. Studies have shown antibiotic use is unnecessary or inappropriate in as many as 50% of the cases in the United States. According to one study, antibiotics were prescribed