Antimicrobial And Opioid Stewardship - NAPLEX

1. What is the preferred targeted therapy for MSSA bacteremia: vancomycin or a beta-lactam?

   A beta-lactam (nafcillin/oxacillin or cefazolin). Beta-lactams provide superior efficacy against MSSA compared to alternatives like vancomycin.

2. What is the definition of MME (morphine milligram equivalents)?

   Standardized opioid dose expressed as mg morphine per day. MME standardizes comparison of opioid potencies to assess daily exposure and risk.

3. What is the primary goal of antimicrobial stewardship in patient care?

   Optimize outcomes while minimizing resistance, toxicity, and cost. Antimicrobial stewardship balances effective treatment with reducing risks to improve patient care and public health.

4. Identify the correct stewardship action: patient on broad-spectrum antibiotics with negative cultures and clinical improvement at $72$ hours.

   De-escalate or discontinue antibiotics if no bacterial source. Negative cultures and improvement suggest non-bacterial etiology, warranting stewardship-driven de-escalation.

5. Which combination should generally be avoided due to additive respiratory depression: opioids with benzodiazepines or opioids with acetaminophen?

   Opioids with benzodiazepines. Concurrent use heightens respiratory depression risk, a critical concern in opioid stewardship.

6. What is the recommended stewardship action when a viral syndrome is diagnosed and bacterial infection is unlikely?

   Avoid or discontinue antibiotics. Antibiotics are ineffective against viruses and contribute to resistance and adverse effects when misused.

7. What is antibiotic "time-out," and when is it typically performed?

   Reassess indication, drug, dose, duration at $48$–$72$ hours. Antibiotic time-out ensures ongoing appropriateness of therapy by systematic review after initial empiric treatment.

8. Which agent is preferred for MRSA infection when systemic therapy is needed: vancomycin or cefazolin?

   Vancomycin. Vancomycin effectively covers MRSA, unlike beta-lactams such as cefazolin which lack activity against it.

9. Which is the preferred first-line therapy for chronic noncancer pain: nonopioids or long-term opioids?

   Nonopioids and nonpharmacologic therapies. Guidelines prioritize safer alternatives to mitigate long-term opioid risks in chronic pain management.

10. What is the key opioid stewardship intervention to reduce overdose risk when appropriate?

    Co-prescribe naloxone for patients at increased risk. Naloxone provides a reversal agent for potential opioid overdose in high-risk scenarios.

11. Identify the best stewardship action: urine culture positive but patient has no urinary symptoms and is not pregnant.

    Do not treat; asymptomatic bacteriuria. Absence of symptoms indicates colonization, not infection, avoiding unnecessary antibiotics per guidelines.

12. What is the definition of antibiotic de-escalation?

    Narrow or stop therapy based on cultures and clinical response. De-escalation refines antibiotic therapy to the most appropriate regimen once diagnostic information is available.

13. Which stewardship strategy reviews therapy after start and provides recommendations: preauthorization or audit/feedback?

    Prospective audit and feedback. Prospective audit and feedback allows post-initiation review to optimize ongoing antibiotic therapy.

14. Identify the stewardship concept: switching from IV to oral when stable and absorbing medications.

    IV-to-PO conversion. IV-to-PO conversion reduces hospital stay, costs, and complications while maintaining efficacy in suitable patients.

15. What is the primary goal of opioid stewardship in patient care?

    Optimize pain control while minimizing misuse, overdose, and harm. Opioid stewardship focuses on effective pain management while addressing risks associated with opioid use.

16. What is the key stewardship rationale for obtaining cultures before starting antibiotics?

    Enables targeted therapy and de-escalation. Cultures identify specific pathogens, allowing for precise antibiotic selection and reduced broad-spectrum use.

17. What is the key stewardship principle regarding treatment of asymptomatic bacteriuria in most patients?

    Do not treat (exceptions: pregnancy, urologic procedures). Treating asymptomatic bacteriuria promotes resistance and adverse effects without clinical benefit in most cases.

18. What is the stewardship concern with unnecessary anaerobic coverage (for example, metronidazole) when not indicated?

    Increases adverse effects and C. difficile risk without benefit. Unnecessary anaerobic coverage exposes patients to avoidable risks without improving outcomes.

19. Which condition requires antibiotics even if urinary symptoms are absent: asymptomatic bacteriuria in pregnancy or nonpregnancy?

    Pregnancy. Asymptomatic bacteriuria in pregnancy risks pyelonephritis and adverse fetal outcomes, necessitating treatment.

20. What is the definition of opioid tolerance used in many guidelines?

    At least $60$ mg oral morphine equivalents daily for $7$ days. This threshold indicates physiological adaptation, guiding dosing adjustments in opioid management.

21. Which opioid stewardship action is most appropriate: patient on opioids and benzodiazepines with OSA reports sedation.

    Avoid combination; reduce/stop one agent and consider naloxone. Combination increases sedation and respiratory risks, especially with OSA, requiring intervention to mitigate harm.

22. What is the most appropriate action when initiating opioids in an opioid-naive patient: start high and taper or start low and titrate?

    Start low and titrate based on response and adverse effects. Low starting doses minimize risks like respiratory depression in patients without opioid tolerance.

23. Which stewardship strategy requires justification to use certain antibiotics: prospective audit/feedback or preauthorization?

    Preauthorization. Preauthorization restricts broad-spectrum antibiotics to justified cases, promoting judicious use from the outset.

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