Antibiotic update in icu
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Vancomycin is the drug of choice for MRSA infections. Clindamycin can be used in this case since the culture showed sensitivity to clindamycin. Clindamycin is an acceptable alternative to vancomycin for skin and soft tissue infections caused by MRSA.
Antibiotic update in icu
- 1. Sherif Anis, MD Assistant professor of Anesthesia & ICU Ain Shams University
- 2. Objectives Identify the appropriate 1st and 2nd line antibiotic for empiric treatment of common bacterial infections in the community and hospital settings Tailor the choice of antibiotic based on unique patient risk factors Reducing bacterial resistance Identify resources for information on safe, effective treatment
- 3. Conventional antibiotics Penicillins Cephalosporins Carbapenems Quinolones Aminoglycosides Macrolides Tetracyclines Nitrofurantoin, metronidazole, clindamycin, vancomycin, teicoplanin, cotrimoxazole, fusidic acid, etc Isoniazid, pyrazinamide, ethambutol, rifampin, cycloserine, etc
- 4. Penicillins Penicillin G Still useful for a number of diseases (e.g. meningitis, syphilis) Cloxacillin For MSSA infections Ampicillin, amoxicillin Active vs. Gram-positive (not MSSA), Gram-negative organisms Augmentin, Unasyn Broad spectrum, covers Gram-positive, Gram-negative and anaerobes Piperacillin, Tazocin, Timentin Are active vs. Pseudomonas
- 5. Cephalosporins Cefazolin, cephalexin Active vs. Gram-positive organisms including MSSA Cefuroxime, Cefaclor Covers some Gram-negative organisms Cefotaxime, Ceftriaxone Broad spectrum, enhanced activity towards Gram- negative organisms Ceftazidime, Cefepime, Sulperazon Additive Pseudomonas coverage
- 6. Carbapenems Imipenem Broad spectrum, covers Gram-positive, Gram-negative (including ESBL-producing strains), Pseudomonas and anaerobes Meropenem Less seizure-inducing potential, can be used to treat CNS infections Ertapenem Lacks activity vs. Acinetobacter and Pseudomonas Has limited activity against penicillin-resistant pneumococci
- 7. Quinolones Ciprofloxacin Active vs. MSSA, Gram-negative and Pseudomonas Levofloxacin Has activity vs. Streptococcus pneumoniae, but slightly less active towards Pseudomonas compared to ciprofloxacin Moxifloxacin Has activity vs. anaerobes but less active towards Pseudomonas
- 8. Aminoglycosides Active vs. some Gram-positive and Gram-negative organisms Gentamicin Active vs. Pseudomonas Tobramycin More active vs. Pseudomonas than gentamicin Shows less activity against certain other Gram-negative bacteria Amikacin More stable to enzymes, used in severe infections by gentamicin- resistant organisms Streptomycin Used for tuberculosis
- 9. Macrolides Erythromycin Active vs. Gram-positive organisms, atypicals GI side effects Clarithromycin Slightly greater activity than erythromycin Azithromycin Slightly less active than erythromycin vs. Gram-positive but enhanced activity vs. some Gram-negative organisms
- 10. Tetracyclines Drug of choice in infections caused by Chlamydia, Rickettsia, Brucella and Lyme disease Value has decreased due to increasing bacterial resistance Tetracycline Role in Helicobacter pylori eradication (less frequently used than other antibiotics) Doxycycline Once daily Minocycline Broader spectrum
- 11. Other antibiotics Clindamycin Vs. Gram-positive cocci and anaerobes Metronidazole Vs. anaerobes Preferred therapy in antibiotic associated diarrhoea (Clostridium difficile) than oral vancomycin, although unlicenced Vancomycin, teicoplanin For Gram-positive organisms (including MRSA)
- 12. Other antibiotics Cotrimoxazole Role in uncomplicated UTI, UTI prophylaxis, acute exacerbations of chronic bronchitis Pneumocystis carinii (now jiroveci) infections Nitrofurantoin For UTI, prophylaxis vs. UTI Fusidic acid, rifampin For penicillin-resistant staphylococci Not for monotherapy due to risk of emergence of resistance
- 13. Classes Bacteriostatic vs Bactericidal Narrow vs Broad spectrum
- 14. Classes Bacteriostatic Aminoglycosides (Streptomycin, Amikacin, Gentamicin, Tobramycin) Lincosamides (Clindamycin) Macrolides (Azithromycin) Tetracyclines (Doxycycline)
- 15. Bactericidal Aminoglycosides Glycopeptides (Vancomycin) Lipopeptides (Daptomycin) Nitrofurans Metronidazole Penicillins Cephalosporins Monobactams (Aztreonam) Carbapenems (Meropenem) Quinolones Sulfonamides
- 16. Broad Spectrum Amoxicillin/clavulanate (Augmentin) Ampicillin/sulbactam (Unasyn) Piperacillin/tazobactam (Tazocin) Ticarcillin/clavulanate (Timentin)
- 17. Newer Classes Cyclic lipopeptides (daptomycin) Bactericidal against Gram-positive, including MRSA Glycylcyclines (tigecycline) Bacteriostatic against Gram-pos, Gram-neg and MRSA Oxazolidinones (linezolid) Bacteriostatic and bactericidal against Gram-positive, including MRSA, VRE
- 18. Good news vs. bad news Good news A few novel antibiotics have shown promising results / are undergoing clinical studies Bad news As immunosuppressive diseases and use of immunosuppressive agents become more prevalent, opportunistic infections becomes more common, esp. by organisms rarely encountered previously Diseases: e.g. HIV, leukemia Drugs: e.g. in solid organ transplants, bone marrow transplants, rheumatoid disorders Development of bacterial resistance to antibiotics is much faster than research and development of new antibiotics
- 19. Principles on choosing an antibiotic for empiric therapy As best possible, attempt to localize the site of infection Do a good exam!!! Occam’s razor “Plurality must not be posited without necessity” Use only one diagnosis whenever possible
- 20. Gram-positive superbugs Resistant Gram-positive bacteria terminology PRSP Penicillin resistant Streptococcus pneumoniae MDRSP Multidrug resistant Streptococcus pneumoniae MRSA Methicillin resistant Staphylococcus aureus VRSA Vancomycin resistant Staphylococcus aureus VISA (GISA) Vancomycin (Glycopeptide) intermediate Staphylococcus aureus VRE (GRE) Vancomycin (Glycopeptide) resistant Enterococcus
- 21. Case 1 F/74, DM on oral hypoglycemic drugs Presented with fever and malaise, cough with sputum, tachypnea; chest X-ray revealed bilateral infiltrates Travel history, occupation, contact and clustering non- remarkable Received a course of amoxicillin for urinary tract infection 10 weeks ago Diagnosis: Community-acquired pneumonia Question What is the empirical treatment for CAP?
- 22. Chest X-ray
- 23. Chest X-ray
- 24. Community-acquired pneumonia (CAP) Microbiology “Typical” organisms Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis “Atypical” organisms Chlamydia pneumoniae Mycoplasma pneumoniae Legionella pneumophilia Empirical therapy Beta-lactams to cover typical organisms Doxycycline / macrolides to cover atypical organisms Respiratory fluoroquinolones (levo, moxi) for beta-lactam allergy
- 25. Community-acquired pneumonia (CAP) Empirical therapy CAP, out-patient Augmentin/Unasyn PO ± macrolide PO Amoxicillin PO + clarithromycin / azithromycin PO CAP, hospitalized in general ward Augmentin / Unasyn IV/PO ± macrolide Cefotaxime / ceftriaxone IV ± macrolide CAP, hospitalized in ICU for serious disease Add cover to Gram-negative enterics Tazocin / cefotaxime / ceftriaxone IV + macrolide Cefepime IV + macrolide
- 26. Community-acquired pneumonia (CAP) Empirical therapy Modifying factors Allergy to beta-lactams Fluoroquinolone (levofloxacin / moxifloxacin) Aspiration likely: anaerobes should be covered Augmentin / Unasyn / Tazocin already provide coverage Cephalosporins (except Sulperazon) is inactive Moxifloxacin Bronchiectasis: Pseudomonas cover essential Tazocin / Timentin / cefepime + macrolide Fluoroquinolone + aminoglycoside
- 27. Case 1 Patient was started on Augmentin + clarithromycin empirically 3 days later, fever persisted, chest X-ray showed progressive pneumonia Endotracheal aspirate (WBC +++, few epithelial cells) grew heavy Streptococcus pneumoniae, with penicillin MIC > 4mcg/ml Questions Risk factors for penicillin-resistant S. pneumoniae? Appropriate management in this case?
- 28. Penicillin resistant Streptococcus pneumoniae (PRSP) Risk factors Age > 65 years Beta-lactam therapy in past 3 months Alcoholism Multiple medical comorbidities (e.g. immunosuppressive illness or medications) Exposure to a child in a day care centre
- 29. Penicillin resistant Streptococcus pneumoniae (PRSP) If susceptible, penicillin group is the drug of choice for Streptococcus pneumoniae Check susceptibility and MIC if resistant to penicillin Penicillin susceptible (MIC 0.1 mcg/ml) Penicillin G, amoxicillin Penicillin resistant (0.1< MIC 1.0 mcg/ml) High dose penicillin G or ampicillin, cefotaxime / ceftriaxone
- 30. Penicillin resistant Streptococcus pneumoniae (PRSP) Penicillin resistant (MIC > 2.0 mcg/ml) Vancomycin rifampin High dose cefotaxime tried in meningitis Non-meningeal infection: cefotaxime / ceftriaxone, high dose ampicillin, carbapenems, or fluoroquinolone (levofloxacin, moxifloxacin) Multidrug resistant (MDRSP, resistant to any 2 of the following: penicillins, erythromycin, tetracycline, macrolides, cotrimoxazole) Vancomycin rifampin Clindamycin, levofloxacin, moxifloxacin could be tried
- 31. Penicillin resistant Streptococcus pneumoniae (PRSP) Any alternative for PRSP / MDRSP in respiratory tract infection? Newer agents Telithromycin (Ketek®) Linezolid (Zyvox®)
- 32. Telithromycin (Ketek®) A ketolide (structurally related to macrolides) Spectrum of activity Group A, B, C and G Streptococci, Streptococcus pneumoniae (including multidrug resistant strains), MSSA Listeria monocytogenes, Neisseria meningitidis, Moraxella catarrhalis, Haemophilus influenzae Legionella, Chlamydia, Mycoplasma No activity vs. MRSA, GRE, or any enteric gram-negative bacteria Indications Mild to moderate community acquired pneumonia
- 33. Linezolid (Zyvox®) An oxazolidinedione Spectrum of activity and indications Vancomycin-Resistant Enterococcus faecium infections, including cases with concurrent bacteremia Nosocomial pneumonia caused by MSSA or MRSA or Strep pneumoniae (including MDRSP) Complicated skin and skin structure infections, including diabetic foot infections, without concomitant osteomyelitis, caused by MSSA or MRSA, Strep pyogenes, or Strep agalactiae Uncomplicated skin and skin structure infections caused by MSSA or Strep pyogenes. Community-acquired pneumonia caused by Strep pneumoniae (including MDRSP), including cases with concurrent bacteremia, or MSSA
- 34. Case 2 M/56 Presented with skin redness, warmth, swelling, tenderness on his right lower limb, a pocket of fluid palpated Diagnosis: cellulitis with pus formation Question Empirical treatment?
- 35. Skin and soft tissue infection Cellulitis Microbiology Staphylococcus, Streptococci Streptococci more likely when cellulitis is well demarcated and there are no pockets of pus or evidence of vein thrombosis
- 36. Staphylococcus aureus If susceptible, penicillinase-resistant penicillins are the drugs of choice for methicillin-susceptible Staphylococcus aureus (MSSA) Drug of choice Cloxacillin, flucloxacillin Cefazolin, cephalexin (penicillin allergic but tolerate cephs) With beta-lactamase inhibitor As two-agent combination in Augmentin, Unasyn Erythromycin, clindamycin (if penicillin allergic) The above antibiotics also have good activity vs. Streptococci
- 37. Case 2 Skin tenderness and redness did not appear to improve despite Augmentin has been given Pus grew MRSA after 2 days R to methicillin, cephalothin, erythromycin S to clindamycin, vancomycin, gentamicin, cotrimoxazole Patient is clinically stable Questions What is the drug of choice in MRSA infection? Can clindamycin be used in this case?
- 38. Methicillin resistant Staphylococcus aureus (MRSA) Healthcare-associated Endemic in hospitals, old age homes Risk factors Hospitalization in previous 1 year Recent surgery Old age home residence Renal dialysis Exposure to invasive devices Employment in a healthcare institute Community-associated Do not have usual risk factors associated with HA- MRSA More common in the following in overseas countries Children with chronic skin condition Prisoners Military personnel Aboriginals Injection drug users The homeless Contact sports athletes
- 39. Methicillin resistant Staphylococcus aureus (MRSA) Healthcare-associated Multiresistant to Clindamycin Aminoglycosides Tetracyclines Fluoroquinolones Community-associated Often remains susceptible to Clindamycin Aminoglycosides Tetracyclines Fluoroquinolones More associated with skin/soft tissue infections and severe necrotizing pneumonia
- 40. Methicillin resistant Staphylococcus aureus (MRSA) Obtain culture for susceptibility testing right before empirical antibiotics! Treatment (as per Sanford Guide 37th ed) Community-associated Mild to moderate infections Abscess, afebrile, immunocompetent, outpatient Cotrimoxazole / doxycycline / minocycline rifampin Clindamycin (do not use if R to erythromycin due to inducible resistance) Abscess with fever, outpatient Cotrimoxazole-DS + rifampin or linezolid
- 41. Methicillin resistant Staphylococcus aureus (MRSA) Clinical guideline for management of suspected CA-MRSA infections (15 March 2007) Most CA-MRSA isolates in HKSAR are susceptible to: Cotrimoxazole Doxycycline, minocycline Clindamycin Moxifloxacin Out-patient oral therapy available for uncomplicated CA-MRSA skin and soft tissue infection
- 42. Methicillin resistant Staphylococcus aureus (MRSA) Antimicrobials for outpatient therapy of uncomplicated skin and soft tissue infections (Clinical guideline for management of suspected CA-MRSA infections,15 March 2007) Agent Potential advantage Precautions Usual adult dose (oral) Cotrimoxazole Oral Not for patient with sulfa allergy / G6PD 960mg bd Doxycycline High skin concentration Not for children <12 yo or pregnant women 200mg once, then 100mg bd Minocycline As above As above 100mg bd Clindamycin Inhibit toxin production Inducible resistance if erythromycin resistant 300-450mg tds Moxifloxacin Oral Resistance may develop during therapy 400mg qd
- 43. Methicillin resistant Staphylococcus aureus (MRSA) Appropriate treatment in uncomplicated skin and soft tissue infection Cotrimoxazole, doxycycline, minocycline or moxifloxacin Clindamycin is not reliable in this case Inducible clindamycin resistance due to erythromycin resistance
- 44. Case 2 What to do if the organism is resistant to agents listed above and vancomycin, and Infection is complicated (unstable patient, extensive involvement, severe sepsis, etc)?
- 45. VISA and VRSA VISA: vancomycin-intermediate Staph aureus VRSA: vancomycin-resistant Staph aureus Classified based on minimum inhibitory concentration (MIC) (CDC definition) VISA: vancomycin MIC is 4-8 µg/ml VRSA: vancomycin MIC is >16 µg/ml (HA Central Committee on Infectious Diseases) Susceptible: vancomycin MIC is ≤ 4µg/ml VISA: vancomycin MIC is 8-16 µg/ml VRSA: vancomycin MIC is >32 µg/ml
- 46. Another version of …?
- 47. Bad Cellulitis
- 48. MRSA
- 49. VISA and VRSA More likely to develop among patients with Underlying conditions (including renal failure) which predispose the patient to MRSA colonization; Indwelling medical devices; and/or MRSA infection requiring treatment with vancomycin for a prolonged period Usually isolated during vancomycin (or teicoplanin) therapy for MRSA infections which fail to respond
- 50. VISA and VRSA Linezolid (Zyvox®) (discussed in PRSP session) Quinupristin/dalfopristin (Synercid®) Dalbavancin (Zeven®) Still under investigation Daptomycin (Cubicin®) Tigecycline (Tygacil®)
- 51. Linezolid (Zyvox®) Demonstrate bacteriostatic action vs. VISA and VRSA Indications Complicated skin and skin structure infections, including diabetic foot infections, without concomitant osteomyelitis, caused by MSSA or MRSA, Strep pyogenes, or Strep agalactiae Uncomplicated skin and skin structure infections caused by MSSA or Strep pyogenes
- 52. Tigecycline (Tygacil®) A glycylcycline Derived from minocycline A very broad spectrum antibiotic Covers many resistant strains of Gram-positive, Gram- negative, and anaerobic organisms Note active vs. Pseudomonas Both in vitro and in vivo activities have been demonstrated against MSSA, MRSA, and VISA
- 53. Tigecycline (Tygacil®) Indications Complicated skin and skin structure infections by Escherichia coli Enterococcus faecalis (vancomycin-susceptible isolates only) Staphylococcus aureus (Methi-S or Methi-R) Streptococcus agalactiae Streptococcus anginosus grp. Streptococcus pyogenes Bacteroides fragilis Complicated intra- abdominal infections by Citrobacter freundii Enterobacter cloacae E. coli, K. oxytoca, K. pneumoniae Enterococcus faecalis (Vanco- S isolates only) Staphylococcus aureus (Methi-S or Methi-R) Streptococcus anginosus group Bacteriodes fragilis Clostridium perfringens Peptostreptococcus micros
- 54. Gram-negative superbugs Resistant Gram-negative bacteria terminology ESBL-producing Enterobacteriaceae Extended spectrum beta-lactamases producing Enterobacteriaceae, e.g. Escherichia coli, Klebsiella pneumoniae MRPA (MDR-PA) Multidrug resistant Pseudomonas aeruginosa MRAB (MDR-AB) Multidrug resistant Acinetobacter baumannii Pan-resistant Pseudomonas aeruginosa / Acinetobacter baumannii
- 55. Case 3 M/59 Presented with 2-day history of right upper quadrant pain, fever, jaundice Emesis x 2 past 24 hours, dark color urine Elevated LFT Radiologic finding: dilated common bile duct, no increase in gallbladder size Diagnosis: acute cholangitis Question What is the empirical therapy?
- 56. Acute cholangitis/cholecystitis Microbiology Gram negative enterics E. coli, Klebsiella spp., Proteus spp. Anerobes Bacteriodes fragilis, Clostridium spp. Enterococcus
- 57. Acute cholangitis/cholecystitis Adequate drainage is essential Empirical treatment complementary to drainage Augmentin/Unasyn ± aminoglycoside Timentin Cefuroxime + metronidazole Ciprofloxacin (if beta-lactam allergic)
- 58. Case 3 Biliary drainage performed with cefuroxime + metronidazole pre- and post-operation Became septic (with high fever, tachycardia, WBC > 12 x 109/L) 2 days post-op Blood culture grew E. coli (ESBL-producing), moderately sensitive to Augmentin, sensitive to Sulperazon and imipenem Question What is the appropriate treatment? Can Augmentin or Sulperazon be used?
- 59. Enterobacteriaceae Susceptible strains of E. coli and Klebsiella are sensitive to Augmentin/Unasyn Cefuroxime (if resistant to above) Other anti gram-negative penicillins/cephs also work Fluoroquinolones (if allergic to beta-lactams)
- 60. ESBL-producing Enterobacteriaceae Extended-spectrum beta-lactamases Any bacterial enzymes that are capable of inactivating third generation cephalosporins Generally regarded as resistant to penicillins and cephalosporins Drug of choice Urinary tract infection Cotrimoxazole, Augmentin, nitrofurantoin, levofloxacin / ciprofloxain Other serious infections Carbapenems: imipenem, meropenem, ertapenem (reliable activity vs. ESBL-producing Enterobacteriaceae) Fluoroquinolone + aminoglycoside
- 61. Case 3 Augmentin and Sulperazon are not appropriate Patient is clinically septic (likely due to the ESBL- producing strain of E. coli) The strain is only apparently susceptible to the above agents Appropriate agent Ertapenem (no activity vs. Pseudomonas) Imipenem (when activity vs. Pseudomonas required)
- 62. Pseudomonas aeruginosa Gram-negative bacilli Frequently present in small numbers in the normal intestinal flora and on the skin of humans and is the major pathogen Causes diseases in patients with abnormal host defenses, e.g. When mucous membranes and skin are disrupted When intravenous or urinary catheters are used When neutropenia is present (as in chemotherapy) Intrinsically resistant to many antibiotics
- 63. Pseudomonas aeruginosa Drug of choice Antipseudomonal penicillins/cephalosporins Piperacillin, piperacillin/tazobactam (Tazocin), ticarcillin/clavulanate (Timentin) Ceftazidime, cefoperazone, cefepime Carbapenems Imipenem, meropenem (NOT ertapenem) Aminoglycosides Gentamicin, tobramycin, amikacin Fluoroquinolones Ciprofloxacin, levofloxacin (less activity than cipro) Often a two-drug combination is employed except in uncomplicated UTI
- 64. Piperacillin vs. Tazocin Tazobactam in Tazocin® Tazobactam is a beta-lactamase inhibitor Renders the combination of Tazocin® more active against Gram positive: MSSA Gram negative: Haemophilus influenzae and others Anaerobe: Bacteroides fragilis
- 65. Piperacillin vs. Tazocin Tazobactam in Tazocin® For Pseudomonas aeruginosa susceptible to piperacillin, Tazocin 4.5g Q8H IV and Piperacillin 4g Q8H IV are equivalent At common usual dose (HA Corp drug price as of May 2007) Piperacillin 4g/vial: $56 Tazocin® 4.5g/vial: $108
- 66. Multidrug resistant Gram-negative organisms Any treatment options for ESBL-producing Enterobacteriaceae, or Pseudomonas aeruginosa, that are pan-resistant?
- 67. Colistin (Colomycin®) Indeed an old, toxic drug! a.k.a. Polymyxin E, colistimethate sodium Now being used with increasing frequency due to necessity (multidrug resistant Gram-negatives) Risk of neurotoxicity and nephrotoxicity Spectrum of activity (check susceptibility!) Pseudomonas aeruginosa, Acinetobacter spp. E. coli and Klebsiella (incl. ESBL-producing strains), Enterobacter spp. Citrobacter spp, Hemophilus spp. Indications Disease due to Gram-negative bacteria, acute or chronic due to sensitive strains of certain gram-negative bacilli
- 68. Acinetobacter baumannii Common cause of nosocomial infection especially in ICU setting Drug of choice Ampicillin/sulbactam or cefoperazone/sulbactam (sulbactam highly active vs. Acinetobacter) or fluoroquinolone (ciprofloxacin, levofloxacin) Gentamicin added to prevent resistance and for synergy Imipenem, meropenem can be used
- 69. Acinetobacter baumannii Acinetobacter strains are often resistant to antimicrobial agents Other agents with in vitro activity vs. Acinetobacter baumannii Minocycline / doxycycline Tigecycline Colistin
- 70. Sinusitis: X-rays Streptococcus Pneumonia Hemophillus Influenza Morexalla Catarrhalis
- 71. Sinusitis: Treatment Mild Acute Bacterial Sinusitis (ABS) Amoxicillin Amoxicillin/clavulanate Cefuroxime axetil Cefpodoxime Or antistrep. fluoroquinolones: Levofloxacin Moxifloxacin
- 72. Sinusitis: Treatment Drug option in the case of allergies to penicillin and cephalosporin with Mild ABS: Doxycycline Trimethoprim/sulfamethoxizole Azithromycin Clarithromycin
- 73. Sinusitis: Treatment Drug option in the case of allergies to penicillin and cephalosporin with Moderate to Severe ABS: Antipneumococcal fluoroquinolone: Levofloxacin Moxifloxacin
- 74. Intra-abdominal infections Common bacterial organisms GNRs E. coli, Klebsiella, Proteus Enterococcus and anaerobes also common
- 75. Intra-abdominal infections Empiric therapy should cover GNRs and anaerobes (Bacteroides fragilis) Ampicillin/sulbactam Ticarcillin/clavulanate Piperacillin/tazobactam Carbepenem: imipenem, meropenem
- 76. Intra-abdominal infections Cefoxitin no longer has reliable coverage against B. fragilis Cefotetan, another second generation cephalosporin, might be back on the market soon Pts allergic to penicillin could use: Fluoroquinolone + metronidazole For severely ill, cover Pseudomonas
- 78. Pregnancy Avoid tetracycline class Staining of teeth and bones in babies Avoid sulfa drugs in the third trimester May be associated with kernicterus Avoid aminoglycosides Kidney toxicities Fluoroquinolones – class C Concerns about cartilage development
- 79. Pregnancy Treat the Mother first and the baby will appreciate it Penicillins and cephalosporins are generally safe in pregnancy. Macrolides are generally safe They may increase nausea early on
- 80. Meningitis: Treatment Adults and children>2 months old: High dose ceftriaxone or cefotaxime + Vancomycin Ampicillin can be added if Listeria monocytogenes is a consideration
- 81. Meningitis: Use of steroids Give dexamethasone before or with the first dose of antibiotics. Corticosteroid treatment has been shown to decrease neurologic complications in children and is now recommended in adults. Continue steroids every 6 hours for four days.
- 82. Antibiotic Stewardship Program in Hospital Authority Multidisciplinary, programmatic, prospective, interventional approach to optimizing the use of antimicrobial agents The multidisciplinary team typically includes Clinical microbiologists Infectious diseases specialists Clinical pharmacists Infection control practitioners
- 83. Antibiotic Stewardship Program Involves Prescribing antimicrobial therapy only when it is beneficial to the patient Targeting therapy to the desired pathogens Using the appropriate drug, dose, and duration
- 84. Antibiotic Stewardship Program Should not be viewed simply as reduced use or a strategy for cost containment A strategy to enhance patient safety by Minimizing exposure to drugs Performing dose adjustments Reducing redundant therapy Targeting therapy to the likely pathogens
- 85. Big gun audit Big gun audit Targets 2 types of antibiotics Broad-spectrum antibiotics Tienam, Meropenem, Ceftazidime, Cefepime, Tazocin, Sulperazon All these agents have good Gram-negative as well as Pseudomonas coverage Anti Gram-positive antibiotics Vancomycin and teicoplanin Active vs. methicillin-resistant Staphylococcus aureus To be used as second-line agents
- 86. IV-PO switch IV-PO switch Criteria (as per IMPACT) 1. No indication for IV therapy 2. Patient is afebrile for ≥ 8 hours 3. WBC count is normalizing Falling towards or < 10 x 109/L 4. Signs and symptoms related to infection are improving 5. Patient is not neutropenic Neutrophil count > 2 x 109/L
- 87. IV-PO switch IV-PO switch Criteria (as per IMPACT) 6. Able to take drugs by mouth (non-NPO) 7. No continuous nasogastric suctioning 8. No severe nausea or vomiting, diarrhea, gastrointestinal obstruction, motility disorder 9. No malabsorption syndrome E.g. small bowel syndrome due to resection 10. No pancreatitis or active gastrointestinal bleeding or other conditions that contraindicated to the use of oral medications
- 88. IV-PO switch IV-PO switch Points to note Prescribe dose based on creatinine clearance when antimicrobials require renal dosage adjustment Augmentin®, Unasyn®, clarithromycin, ciprofloxacin, levofloxacin Drug interactions Oral ciprofloxacin and levofloxacin with antacid, sucralfate, didanosine, dairy products and enteral feeds
- 89. Reducing bacterial resistance IMPACT (Interhospital Multi-disciplinary Programme on Antimicrobial ChemoTherapy) Available for download at: HKU Centre of Infection http://www.hku.hk/hkucoi/impact.pdf DH Centre for Health Protection http://www.chp.gov.hk/files/pdf/reducing_bacterial_resistance_ with_impact.pdf HA intranet http://ha.home/ho/ps/impact.pdf Most updated: third version 2005 (version 3.0)
- 90. IMPACT guideline Contents of IMPACT guideline Local antibiotic resistance Guidelines for selected antimicrobial use, e.g. Vancomycin Ceftazidime Imipenem/meropenem/ertapenem Once daily aminoglycosides Selected antifungal agents
- 91. Useful guides to antimicrobial therapy Sanford Guide Covers a broad range of infectious diseases IMPACT With commonly prescribed empirical therapy and useful local resistance information Local antibiogram Bacterial resistance specific to an institution or a cluster of institutions
- 92. Conclusion New antibiotics intended to treat complicated diseases are under investigation Need to protect our antibiotic arsenal Justified use of antimicrobials not only treats infections, but also improves patient outcomes and reduces the risk of development of bacterial resistance Adherence to clinical guidelines, antimicrobial stewardship program and education helps to promote appropriate antimicrobial use
- 93. Conclusion Last but not least… Infection control is of utmost importance in reducing risk of infection, use of antibiotics and hence emergence of bacterial resistance Hand hygiene Appropriate isolation / contact restriction Prompt reporting of certain infectious diseases (e.g. MRSA infections) Many more!
- 94. Thank You