uti & pneumonia translating knowledge into practice pias-kt study sukhjinder sidhu sean gorman...
TRANSCRIPT
![Page 1: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/1.jpg)
UTI & PneumoniaTranslating Knowledge into Practice
PIAS-KT StudySukhjinder Sidhu
Sean GormanRichard SlavikTasha RamseySarah Murray
Nicole Bruchet
![Page 2: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/2.jpg)
Attendance
• Please email Brenda Flood ([email protected]) if you attended this session
• Please email Brenda Flood ([email protected]) if you view this presentation online at a later date
![Page 3: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/3.jpg)
THANK YOU!
• YOU SURPASSED OUR PROJECTED PARTICIPATION RATE FOR THE PRE-QUIZ!
• STAY TUNED FOR A POST-QUIZ THAT WILL BE SENT OUT IN MID-MARCH
• THANK YOU TO TASHA RAMSEY FOR HER EXPERT REVIEW OF THIS PRESENTATION
![Page 4: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/4.jpg)
Speaker Disclosure
• The speakers have no actual or potential conflicts of interest to disclose
![Page 5: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/5.jpg)
Outline• PIAS-KT Study Overview• Local Opinion Leaders• Prevalence and Impact of UTIs & Pneumonia• Antimicrobial Stewardship• Key Pharmacist Interventions for UTIs & Pneumonia• DTP Tracker Data for UTIs & Pneumonia• UTIs & Pneumonia Therapeutics
– When to treat with antibiotics and When Not to treat?– What antibiotics to initiate and Why?– When, How, and Why to de-escalate antibiotics?– How long to treat with antibiotics?
![Page 6: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/6.jpg)
Objectives
• To review the pharmaceutical care of patients with UTIs & Pneumonia including:– Key pharmacist interventions– Indications for antibiotic therapy– Initial empiric antibiotic therapy recommendations– Antibiotic de-escalation strategies– IV to PO step-down considerations– Duration of antibiotic therapy
![Page 7: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/7.jpg)
PIAS-KT Study OverviewInterventionPRE phase
Knowledge Behavior
POST phase
Knowledge Behavior
Behavioral Change
StrategiesJan 30 – Mar 14,
2014
1. Audit & Feedback2. Local opinion leaders3. Educational meetings4. Educational outreach5. Printed education materials6. Reminders
QuizJan 17-30, 2014
QuizMar 17-28, 2014
DTP/DSEM DTPKPI/DSEM KPI
Jul 1-Dec 31,2013
DTP/DSEM DTPKPI/DSEM KPI
Jan 1-Jun 30, 2014
![Page 8: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/8.jpg)
Local Opinion Leaders
• KGH – Dawn Robb• RIH – Kim Winters• PRH/SOH – Orysya Fetterly• VJH – Chelsea Argent• SLH/OMH – Ian Petterson• KBH/KLH – Michael Conci• EKH/GDH – Darren Feere
![Page 9: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/9.jpg)
Prevalence & Impact of UTIsPrevalence
– Approximately 4,000,000 UTIs/year in Canada – Affects 20% of women between 15-29 yo– Number 1 healthcare-associated infection– 16th most common non-surgical reason for IH admission
Impact– 660 cases and 3200 acute bed-days at IH– Hospital-acquired UTIs associated with extra day of hospitalization– Up to 25% of patients with UTI receive inappropriate therapy– Up to 50% of patients with asymptomatic catheter-associated
bacteriuria are treated with antibiotics (which is inappropriate)
Mayo Clin Proc 2007;82:181-5.; Can J Infect Dis Med Microbiol 2005;16:166-70.Mayo Clin Proc 2007;82:181-5.; Can J Infect Dis Med Microbiol 2005;16:166-70.
![Page 10: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/10.jpg)
Prevalence & Impact of Pneumonia
Prevalence– Approximately 170,000 cases of CAP each year in Canada – HAP/VAP is 2nd most common nosocomial infection in Canada– 5th most common non-surgical reason for IH admission
Impact– 1300 cases and 7000 acute bed-days at IH each year– CAP is the leading infectious cause of death– Up to 15% of patients with CAP receive inadequate therapy– Up to 75% of patients with HAP/VAP receive inadequate therapy
Clin Infect Dis 2005;41:1709-16.; Postgrad Med 2010;122:130-141.Clin Infect Dis 2005;41:1709-16.; Postgrad Med 2010;122:130-141.
![Page 11: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/11.jpg)
Antimicrobial Stewardship Definition
• An activity (or activities) that includes– Appropriate antibiotic selection– Appropriate antibiotic dosing– Appropriate antibiotic route selection– Appropriate antibiotic duration of therapy
Clin Infect Dis 2007;44:159-77.Clin Infect Dis 2007;44:159-77.
![Page 12: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/12.jpg)
Antimicrobial Stewardship Goals
• Optimize clinical outcomes by ensuring effective antimicrobial therapy
• Minimize collateral damage from antimicrobials– Antimicrobial resistance– Antimicrobial toxicity– Costs of inappropriate antimicrobial use– Superinfections (e.g. Clostridium difficile)
Clin Infect Dis 2007;44:159-77.Clin Infect Dis 2007;44:159-77.
![Page 13: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/13.jpg)
Clinical Pharmacists’ Role in Antimicrobial Stewardship
PHARMACEUTICAL CARE
ANTIMICROBIALSTEWARDSHIP
![Page 14: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/14.jpg)
Urinary Tract Infection Key Pharmacist Interventions
1. Initiate appropriate antibiotics for symptomatic UTI
2. Discontinue empiric antibiotics started for UTI that are not indicated
3. De-escalate antibiotics for UTI based on C&S data and clinical response
4. Perform IV to PO step-down of antibiotics for UTI
5. Promote appropriate duration of antibiotic therapy for UTI
IH UTI Key Pharmacist Interventions, April 21, 2011IH UTI Key Pharmacist Interventions, April 21, 2011
![Page 15: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/15.jpg)
Pneumonia Key Pharmacist Interventions
1. Initiate appropriate antibiotics for pneumonia
2. Discontinue empiric antibiotics started for pneumonia that are not indicated
3. De-escalate antibiotics for pneumonia based on C&S data and clinical response
4. Perform IV to PO step-down of antibiotics for pneumonia
5. Promote appropriate duration of antibiotic therapy for pneumonia
IH Pneumonia Key Pharmacist Interventions, April 21, 2011IH Pneumonia Key Pharmacist Interventions, April 21, 2011
![Page 16: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/16.jpg)
Project Alignment
CPhA “Blue Print” for Pharmacy Practice CSHP “Vision 2015” Canadian Clinical Pharmacy KPI Collaborative Accreditation Canada MOHS KRAs and CCM groups IH SET goals, objectives IH Pharmacy Clinical Priorities
![Page 17: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/17.jpg)
DTP Tracker Data - UTI
• UTI ranks #6 in disease prevalence for all Rx interventions
• UTI ranks #3 in disease prevalence for 8 DSEM interventions
• UTI ranks #2 in disease prevalence for key pharmacist interventions
![Page 18: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/18.jpg)
DTP Tracker Data - UTI
• AIMS study showed a statistically significant, clinically important increase after DSEMs– DSEM DTP/total DTP (27.9% to 31.9%, p<0.05)– KPI/total DTP (21.7% to 25.8%, p<0.05)
• In UTI subgroup, AIMS failed to show a statistically significant benefit– DSEM DTP/total DTP (3.91% to 3.93%, p=NS)– KPI/total DTP (3.82% to 4.61%, p=NS)
![Page 19: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/19.jpg)
DTP Tracker Data - Pneumonia
• Pneumonia ranks #3 in disease prevalence for all Rx interventions
• Pneumonia ranks #2 in disease prevalence for 8 DSEM interventions
• Pneumonia ranks #3 in disease prevalence for key pharmacist interventions
![Page 20: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/20.jpg)
DTP Tracker Data - Pneumonia
• In Pneumonia subgroup, AIMS failed to show a statistically significant benefit– DSEM DTP/total DTP (4.75% to 4.90%, p=NS)
• However, in Pneumonia subgroup, AIMS demonstrated a statistically significant REDUCTION– KPI/total DTP (5.07% to 3.94%, p=0.016)
![Page 21: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/21.jpg)
Pharmaceutical Care of UTI and Pneumonia
![Page 22: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/22.jpg)
UTI Pharmaceutical CareOutline
• When and When Not to treat with antibiotics?
• What antibiotics to initiate and Why?
• When, How, and Why to de-escalate antibiotics?
• How long to treat with antibiotics?
![Page 23: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/23.jpg)
What Makes a UTI ‘Complicated’?
• Patients with structural or functional abnormalities of the genitourinary tract– Obstruction– Instrumentation (including catheters)– Impaired voiding– Metabolic abnormalities– Immunocompromised– Men
Can J Infect Dis Med Microbiol 2005;16:349-60.Can J Infect Dis Med Microbiol 2005;16:349-60.
![Page 24: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/24.jpg)
UTI“Why should antibiotics be initiated?”
• duration of symptoms
• abscesses, metastatic infection, septic shock, AKI
Clin Infect Dis 2005;40:643-54.Clin Infect Dis 2005;40:643-54.
![Page 25: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/25.jpg)
UTI“When should antibiotics be initiated?”
– Clinical manifestations of cystitis• Dysuria, frequency, urgency, suprapubic pain, hematuria
– Clinical manifestations of pyelonephritis• Above symptoms together with fever (>38°C), chills, flank
pain, costovertebral angle tenderness, and nausea/vomiting
– Asymptomatic bacteriuria in pregnancy
![Page 26: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/26.jpg)
Cystitis at IH“When should antibiotics be initiated?”
“If clinically feasible, initiation of antimicrobial therapy should be delayed until results of urine
culture are available”
Can J Infect Dis Med Microbiol 2005;16:349-60.Can J Infect Dis Med Microbiol 2005;16:349-60.
![Page 27: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/27.jpg)
UTI at Interior Health“What antibiotics should be initiated and why?”
Infection 2007;35:150-3. (Calgary Data 2004-5)Infection 2007;35:150-3. (Calgary Data 2004-5)
Organisms Associated with Urinary Tract Infections
![Page 28: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/28.jpg)
UTI at Interior Health“What antibiotics should be initiated and why?”
*E. coli Susceptibilities at IH 2012*E. coli Susceptibilities at IH 2012
PO options
IV options
![Page 29: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/29.jpg)
UTI at Interior Health“What antibiotics should be initiated and why?”
*Enterococcus Susceptibilities at IH 2012*Enterococcus Susceptibilities at IH 2012
![Page 30: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/30.jpg)
• Risk Factors for Antibiotic Resistant UTIs– Abx exposure (especially to TMP/SMX or FQ) in past 3 months
– Travel to endemic area
– Previous multi-drug resistant UTI
Clin Infect Dis 2005;40:643-54.Clin Infect Dis 2005;40:643-54.
UTI at Interior Health“What antibiotics should be initiated and why?”
![Page 31: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/31.jpg)
• Oral Antibiotic Selection– Oral antibiotics are first line for cystitis– Oral antibiotics are first line for uncomplicated
pyelonephritis (not acutely ill)
• IV Antibiotic Selection– Unable to tolerate oral therapy (nausea/vomiting/ileus)– Impaired GI absorption – Hemodynamic instability (acutely ill)– Infecting organism resistant to available oral options
Clin Infect Dis 2005;40:643-54., Can J Infect Dis Med Microbiol 2005;16:349-60.Clin Infect Dis 2005;40:643-54., Can J Infect Dis Med Microbiol 2005;16:349-60.
UTI at Interior Health“What antibiotics should be initiated and why?”
![Page 32: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/32.jpg)
Complicated Cystitis at IH“What antibiotics should be initiated?”
“Oral antimicrobial therapy is appropriate for most episodes”
Can J Infect Dis Med Microbiol 2005;16:349-60.Can J Infect Dis Med Microbiol 2005;16:349-60.
![Page 33: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/33.jpg)
Recommendations for Empiric Therapy
1. Nitrofurantoin 100 mg PO BID x 5 days (CrCl ≥ 40 mL/min)
2. Trimethoprim/Sulfamethoxazole i DS PO BID x 3 days
• Cefixime 400 mg PO Daily x 3 days
• Amoxicillin/Clavulanate 875 mg PO BID x 3 days
• Amoxicillin/Clavulanate 500 mg PO TID x 3 days
Uncomplicated Cystitis at IH“What antibiotics should be initiated?”
![Page 34: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/34.jpg)
Recommended Empiric Oral Options
1st Line•Cefixime 400 mg PO Daily x 7-14 days•Amoxicillin/Clavulanate 875 mg PO BID x 7-14 days•Amoxicillin/Clavulanate 500 mg PO TID x 7-14 days•Trimethoprim/Sulfamethoxazole i DS PO BID x 7-14 days
2nd Line (high prevalence resistance)•Ciprofloxacin 500 mg PO BID x 7-14 days
Complicated Cystitis at IH“What antibiotics should be initiated?”
![Page 35: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/35.jpg)
Recommended Empiric IV Options
• Ampicillin + Gentamicin
• Ampicillin + Ceftriaxone
• Piperacillin/Tazobactam +/- Gentamicin
Complicated Cystitis at IH“What antibiotics should be initiated?”
![Page 36: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/36.jpg)
Uncomplicated Pyelonephritis at IH“What antibiotics should be initiated and why?”
Recommend Empiric Oral Therapy
• Same as for uncomplicated cystitis EXCEPT:– No nitrofurantoin
– Longer duration of therapy (7-14 days)
![Page 37: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/37.jpg)
• Gentamicin 5-7 mg/kg/day IV OR
• Ceftriaxone 1-2G IV daily
Uncomplicated Pyelonephritis at IH“What antibiotics should be initiated and why?”
Recommended Empiric IV Therapy for Acutely Ill Patients
![Page 38: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/38.jpg)
Recommended Empiric Oral Options
• Same as for complicated cystitis
1st Line• Cefixime 400 mg PO Daily x 7-14 days• Amoxicillin/Clavulanate 875 mg PO BID x 7-14 days• Amoxicillin/Clavulanate 500 mg PO TID x 7-14 days• Trimethoprim/Sulfamethoxazole i DS PO BID x 7-14 days
2nd Line (high prevalence resistance)• Ciprofloxacin 500 mg PO BID x 7-14 days
Complicated Pyelonephritis at IH“What antibiotics should be initiated and why?”
![Page 39: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/39.jpg)
Recommended Empiric IV Options
• Same as for complicated cystitis– Ampicillin + Gentamicin
– Ampicillin + Ceftriaxone
– Piperacillin/Tazobactam +/- Gentamicin
Complicated Pyelonephritis at IH“What antibiotics should be initiated and why?”
![Page 40: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/40.jpg)
Recommended Antibiotic Therapy
• Wait for results of screening urine C&S• Select narrowest spectrum agent that is safe in pregnancy
– Amoxicillin/Clavulanate– Amoxicillin– Cefixime– Cephalexin– Nitrofurantoin (avoid in 3rd trimester)– TMP/SMX (avoid in 1st and 3rd trimesters)
Asymptomatic Bacteriuria in Pregnancy“What antibiotics should be initiated and why?”
![Page 41: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/41.jpg)
UTI Therapeutics“What is antibiotic de-escalation and
why is it important?”
• Antibiotic De-escalation– Replace empiric broad-spectrum regimen with a
more narrow spectrum regimen– Organism identified with susceptibilities– Intended to reduce collateral damage – De-escalation for UTIs is under-performed
Infection 2013;41:211-14.Infection 2013;41:211-14.
![Page 42: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/42.jpg)
UTI Therapeutics“When and How should antibiotics be
de-escalated?”
• When to de-escalate– Once urine C&S known– No other suspected infections– No patient-limiting factors (e.g. allergy)
Infection 2013;41:211-14.Infection 2013;41:211-14.
![Page 43: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/43.jpg)
UTI Therapeutics“When and How should antibiotics be
de-escalated?”• How to de-escalate
– Broad spectrum to narrowest spectrum– Narrowest spectrum with collateral damage risk
Infection 2013;41:211-14.Infection 2013;41:211-14.
Empiric Step-Down
Ciprofloxacin Amoxicillin
Cefixime Cephalexin
Ceftriaxone TMP/SMX
Pip/Tazo Amoxicillin/Clav
Ceftriaxone Cefixime
Examples
![Page 44: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/44.jpg)
UTI Therapeutics“How should antibiotics be de-escalated?”
• IV to PO Step-Down– Tolerates oral intake– No factors affecting absorption– Hemodynamically stable– If acutely ill pyelonephritis and considering PO β-
lactam, patient should receive at least 1 dose of Ceftriaxone OR Aminoglycoside
Infection 2013;41:211-14.Infection 2013;41:211-14.
![Page 45: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/45.jpg)
Interior Health IV to PO Step-Down Policy
• Pharmacists Have IV-PO Step-Down Authority– Applies to Ciprofloxacin/Moxifloxacin– Duration IV antibiotics: ≥ 48 hours – Tolerating other PO medications, fluids, or foods x 12 hours – No potential problems with absorption – Clinically stable (stable BP, resolving fever/afebrile, adequate urine
output, absence of encephalopathy, WBC normal or normalizing)
• Exclusions• Febrile neutropenia, gram negative bacteremia, CNS infections, septic
shock, severe cellulitis
InsideNet – Pharmacist managed IV to PO conversion program (2006)InsideNet – Pharmacist managed IV to PO conversion program (2006)
![Page 46: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/46.jpg)
UTI Therapeutics“How long to treat with antibiotics?”
• Uncomplicated cystitis– 3-7 days (5-7 days for nitrofurantoin)
• Complicated cystitis– 7-14 days
• Pyelonephritis– 7-14 days
![Page 47: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/47.jpg)
Candida-Associated Cystitis
• Indications for treatment– Symptomatic cystitis– Asymptomatic, but high risk (neutropenia,
planned urologic manipulation)
• Recommended treatment – Fluconazole 200-400 mg PO daily x 14 days– Amphotericin 0.3-0.6 mg/kg IV x 7 days (2nd line)
Clin Infect Dis 2009;48:503-35.Clin Infect Dis 2009;48:503-35.
![Page 48: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/48.jpg)
Pneumonia Pharmaceutical CareOutline
• When and When Not to treat with antibiotics?
• What antibiotics to initiate and Why?
• When, How, and Why to de-escalate antibiotics?
• How long to treat with antibiotics?
![Page 49: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/49.jpg)
IH Pneumonia DSEM
![Page 50: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/50.jpg)
PneumoniaWhen and Why Antibiotic Treatment?
• Physician/NP Diagnosis• Varies depending on outpatient/inpatient• Chest x-ray infiltrates PLUS• Fever, purulent secretions, elevated WBC• Other clinical manifestations: dyspnea, pleuritic chest pain
• Consequences of Pneumonia– Reduced survival– Increased risk of ICU admission– Prolonged length of hospitalization
Clin Infect Dis 2007;44:sS.; Pneumonia DSEM 2008.Clin Infect Dis 2007;44:sS.; Pneumonia DSEM 2008.
![Page 51: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/51.jpg)
Community-Acquired Pneumonia
• Patients not hospitalized in previous 14 days
Clin Infect Dis 2000;31:383-421.Clin Infect Dis 2000;31:383-421.
![Page 52: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/52.jpg)
Community-Acquired Pneumonia“What antibiotics should be initiated and why?”
Microbiologic Etiology
Clin Infect Dis 2000;31:347-82. Clin Infect Dis 2000;31:347-82.
![Page 53: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/53.jpg)
Community-Acquired PneumoniaRisk Factors for AROs
*β-Lactam, Fluoroquinolone, Macrolide
Can J Infect Dis Med Microbiol 2008;19:19-53., Clin Infect Dis 2007;44:(Suppl 2):S27-72.
![Page 54: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/54.jpg)
Community-Acquired Pneumonia“What antibiotics should be initiated and why?”
*Ampicillin SusceptibilitySusceptibilities at IH 2012Susceptibilities at IH 2012
![Page 55: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/55.jpg)
Community-Acquired Pneumonia“What antibiotics should be initiated?”
Recommendations for Empiric Therapy in Hospital
•General Ward1. Moxifloxacin 400 mg PO/IV daily2. Ceftriaxone 2 g IV daily + Azithromycin 500 mg IV daily
•ICU1. Ceftriaxone 2 g IV daily + Azithromycin 500 mg IV daily2. Ceftriaxone 2 g IV daily + Moxifloxacin 400 mg IV daily
Clin Infect Dis 2007;44:(Suppl 2):S27-72.Clin Infect Dis 2007;44:(Suppl 2):S27-72.
![Page 56: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/56.jpg)
Approach to De-Escalation
Intensive Care Med 2014;40:92-5.Intensive Care Med 2014;40:92-5.
Suspected CAPEmpiric Antibiotics
C&S Available?
Significant Improvement after
48-96 hr?
Significant Improvement after
48-96 hr?
• De-escalate• Max 7 Days
• Review Abx• Review Dose• Re-culture• Complication?• Consider non-infection
• De-escalate using C&S
• Max 7 days
NO YES
YES NO NO YES
![Page 57: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/57.jpg)
Organism Preferred Alternatives
S. pneumoniae; MIC < 2 mg/L
Pen G, amoxicillin Macrolide, cephalosporins, clindamycin, doxycline, respiratory fluoroquinolone
S. pneumonia; MIC ≥ 2 mg/L
3rd generation cephalosporin, fluoroquinolone
Vancomycin, linezolid, amoxicillin >3 g/day if MIC ≤ 4 mg/L
H. influenzae (no beta-lactamase)
Amoxicillin Fluoroquinolone, doxycycline, azithromycin, clarithromycin
H. Influenza (beta-lactamase)
2nd or 3rd generation cephalosporin, amoxicillin-clavulanate
Fluoroquinolone, doxycycline, azithromycin, clarithromycin
Enterobacteriaceae 3rd generation cephalosporin, carbapenem
Beta-lactam/beta-lactamase inhibitor, fluoroquinolone
P. aeruginosa Antipseudomonal beta-lactam +/- cipro OR aminoglycoside
Aminoglycoside PLUS cipro or levo
MSSA Cloxacillin Cefazolin, clindamycinClin Infect Dis 2007;44:(Suppl 2):S27-72.Clin Infect Dis 2007;44:(Suppl 2):S27-72.
Community-Acquired Pneumonia“Pathogen-Directed Therapy”
![Page 58: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/58.jpg)
Community-Acquired Pneumonia“IV to PO Step-down Criteria”
• Normal functioning GI tract AND
• Able to ingest medications AND
• Improving clinically AND
• Clinical stability– T < 37.8 0C– HR < 100 bpm– RR < 24 breaths/min– SBP > 90 mm Hg– Arterial O2 sat > 90%– Normal mental status
Clin Infect Dis 2007;44:(Suppl 2):S27-72.Clin Infect Dis 2007;44:(Suppl 2):S27-72.
![Page 59: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/59.jpg)
Interior Health IV to PO Step-Down Policy
• Pharmacists Have IV-PO Step-Down Authority– Applies to Ciprofloxacin/Moxifloxacin– Duration IV antibiotics: ≥ 48 hours – Tolerating other PO medications, fluids, or foods x 12 hours – No potential problems with absorption – Clinically stable (stable BP, resolving fever/afebrile, adequate urine
output, absence of encephalopathy, WBC normal or normalizing)
• Exclusions• Febrile neutropenia, gram negative bacteremia, CNS infections, septic
shock, severe cellulitis
InsideNet – Pharmacist managed IV to PO conversion program (2006)InsideNet – Pharmacist managed IV to PO conversion program (2006)
![Page 60: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/60.jpg)
• Minimum treatment duration 7 days AND• Afebrile (T ≤ 37.8 x 48-72 h) AND• ≤ 1 sign of CAP-related clinical instability
• T ≥ 37.8• HR ≥ 100 beats/min• RR ≥ 24 breaths/min• SBP ≤ 90 mmHg• SaO2 ≤ 90% or PaO2 ≤ 60 mm Hg on room air• Inability to maintain oral intake• Abnormal mental status
• Azithromycin 500 mg IV daily x 3 days (with ceftriaxone)
Community-Acquired Pneumonia “How long to treat?”
Clin Infect Dis 2007;44:(Suppl 2):S27-72.
![Page 61: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/61.jpg)
Hospital-Acquired/Ventilator-Associated Pneumonia
• HAP – Pneumonia that occurs > 48 hours after admission
• VAP– Pneumonia arising > 48 hours after intubation
Clin Infect Dis 2000;31:383-421.Clin Infect Dis 2000;31:383-421.
![Page 62: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/62.jpg)
HAP/VAP“What antibiotics should be initiated and why?”
Microbiologic Etiology
![Page 63: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/63.jpg)
HAP/VAP“What antibiotics should be initiated and why?”
Susceptibilities at IH 2012Susceptibilities at IH 2012
![Page 64: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/64.jpg)
HAP/VAP“What antibiotics should be initiated and why?”
MDR Bacteria Risk Factors
![Page 65: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/65.jpg)
Infect Dis Clin N Am 2004;18:939-962. RSS 2012RSS 2012
HAP/VAP“What antibiotics should be initiated and why?”
![Page 66: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/66.jpg)
Reasonable IH StrategyReasonable IH StrategyEarly HAP/VAP, and
no risks for MDR bugs
Late HAP/VAP, orrisks for MDR bugs
Ceftriaxone Piperacillin-tazobactam
Piperacillin-tazobactam Ciprofloxacin (?)
Moxifloxacin Meropenem*
+/- aminoglycoside (PA)
+/- vancomycin (?)
HAP/VAP“What antibiotics should be initiated and why?”
RSS 2012RSS 2012
![Page 67: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/67.jpg)
Am J Respir Crit Care Med 2005;171:388-416. RSS 2012RSS 2012
Approach to De-Escalation
![Page 68: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/68.jpg)
Pneumonia Therapeutics“How long to treat with antibiotics?”
Potential Benefits• Overall antibiotic use• Resistance rates• Super-infection• Drug costs• Adverse events
Potential Risks• Treatment failures• Relapse rates• Re-infection rates• Complications
J Clin Pharmacol Therap 2003;28:123-129.RSS 2012RSS 2012
Shorter Duration of Therapy
![Page 69: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/69.jpg)
HAP/VAP“How long to treat?”
Am J Respir Crit Care Med 2005;171:388-416.
*Uncomplicated Pneumonia**Non-lactose fermenting Gram negative rods
![Page 70: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/70.jpg)
Session Review
• PIAS-KT overview• Local Opinion Leaders• UTIs/Pneumonia are highly prevalent and impactful• Pharmaceutical care of patients with infections naturally
includes antimicrobial stewardship activities• UTI/Pneumonia KPIs are antimicrobial stewardship activities• When to initiate antibiotics for UTI/Pneumonia• What antibiotic to initiate for UTI/Pneumonia• When and how to de-escalate antibiotics for UTI/Pneumonia• How long to treat with antibiotics for UTI/Pneumonia
![Page 71: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/71.jpg)
Attendance
• Please email Brenda Flood ([email protected]) if you attended this session
• Please email Brenda Flood ([email protected]) if you view this presentation online at a later date
![Page 72: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/72.jpg)
Questions?
![Page 73: UTI & Pneumonia Translating Knowledge into Practice PIAS-KT Study Sukhjinder Sidhu Sean Gorman Richard Slavik Tasha Ramsey Sarah Murray Nicole Bruchet](https://reader035.vdocuments.us/reader035/viewer/2022070308/551bb933550346b4588b4578/html5/thumbnails/73.jpg)
TMP/SMX ResistanceClinical Cure Uncomplicated Cystitis
Ann Intern Med 2001:135:41-50