Antibiotic Utilization in SNF/LTC Role of Consultant Pharmacist

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1 Antibiotic Utilization in SNF/LTC Role of Consultant Pharmacist Hennie Garza, M.S.Pharm, R.Ph., C.D.E. Director of Pharmacy Senior Care Centers Dallas, TX

2 Potential Roles for Consultant Pharmacists Provide/help analyze antibiotic utilization & cost data Identify practices that contribute to ABX overutilization & may increase risk for C.diff Continued use of Proton Pump Inhibitors Using Demeclocycline for hyponatremia Using Rifaximin for Hepatic Encephalopathy Underutilization of controller meds for COPD Atrophic Vaginitis -- UTI Monitor collateral damage from antibiotic overuse Drug interactions

3 ANTIBIOTIC UTILIZATION & COST

4 Antibiotics as a % of all medication costs Total Antibiotic Cost 5% Medications other than antibiotics 95%

5 Q4 Antibiotic Utilization Oral Antibiotics 8771 rx fills for 3455 patients $269,641 30% of rxs = Quinolones Only 5.8% of cost 60% of $$ was 3 drugs: Vancomycin oral Linezolid Rifaximin IV Antibiotics 1150 rx fills for 322 patients $276,046 67% of rx fills = 5 drugs & accounted for 59% of $$ Invanz Pip/Tazo Vancomycin Ceftriaxone Cefepime

6 PRACTICES THAT MAY LEAD TO OVERUTILIZATION OF ANTIBIOTICS & INCREASE RISK FOR C. DIFFICILE

7 USE OF PROTON PUMP INHIBITORS Safety Announcement [ ] The U.S. Food and Drug Administration (FDA) is informing the public that the use of stomach acid drugs known as proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile associated diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop diarrhea that does not improve.

8 PROTON PUMP INHIBITORS Standard of care for hospitals to decrease stress-induced ulcers Continued from acute care to post acute Widespread use in the community Utilization data may be under-reported due to OTC status Account for about 3% of RX LTC spend Literature linking PPIs to CAP and HAP

9 Hepatic Encephalopathy Newer treatment indication with Rifaximin (XIFAXAN) FDA indications for: Hepatic Encephalopathy, Irritable Bowel Syndrome, Traveler s Diarrhea Warning for C.diff

10 HYPONATREMIA Hyponatremia associated with use of Selective Serotonin Reuptake Inhibitors (SSRIs) and SSRI/SNRI (especially duolextine) Off-label use of demeclocyline (tetracyclinetype) 600mg-1200mg/day for Syndrome of Inappropriate Anti-diuretic Hormone (SIADH) results in hyponatremia

11 COPD EXACERBATIONS Standard is to treat exacerbations empirically with antibiotics when purulent sputum present and antibiotics should be given when all 3 sypmtoms (increased dyspnea, increased sputum volume and increased sputum purulence) are present Many patients do not have controller medications ordered as part of the regimen for PREVENTION of exacerbations Improved management may decrease exacerbations

12 RECURRENT UTI Sometimes see long-term prophylactic use of antibiotics for patients with recurrent UTI Very few female residents have any type of pelvic exam in LTC---always deferred on H&P Post-menopausal use of Estrogen use strongly discouraged (thanks to Women s Health Initiative) Atrophic Vaginitis Urinary symptoms include: Dysuria, Hematuria, Urinary frequency, Urinary tract infection, Stress incontinence

13 COLLATERAL DAMAGE Drug interactions with antibiotics Warfarin Sulfonamides, Quinolones, Metronidazole Vitamins, pro-biotics and timing of antibiotic doses Side Effects of antibiotics Linezolid, Serotonin Syndrome QT prolongation/cardiac effects of antibiotics Aside from nausea, vomiting & diarrhea Quinolones: confusion, delirium, risk of tendonitis & tendon rupture, changes to blood sugar, QT prolongation

14 New FDA Black Box Warning for Quinolones [ ] Today, the FDA is requiring labeling changes for antibacterial drugs called fluoroquinolones, including an updated boxed warning, stating that the serious side effects associated with fluoroquinolones generally outweigh the benefits for patients with sinusitis, bronchitis and uncomplicated urinary tract infections who have other treatment options. For patients with these conditions, fluoroquinolones should be reserved for those who do not have alternative treatment options

15 HENNIE S FINAL THOUGHTS It s not just about being good stewards of antibiotic use, it s really about prudent use of ALL medications ESPECIALLY in the elderly, population. Health Care Systems need to expand role of the Pharmacist as part of the health care team to improve overall medication utilization and transitions of care.