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ANTIBIOTIC USAGE IN ICU
Dr. Swarnalingam Thangavelu. M.D
Associate Professor
Department of Anaesthesiology
Tagore Medical College & Hospital
INTRODUCTION
The danger with germ-killing drugs is that they may kill the
patient as well as the germ.
J.B.S.Haldane
ANTIBIOTICS PRESCRIPTION PRINCIPLES
Send for the appropriate investigations-minimum
required for diagnosis, prognosis and follow up.
All antibiotic initiations would be done after sending
appropriate cultures.
Change in antibiotic would be done after sending
fresh cultures.
Follow the hospital antibiotic policy . If alternatives as
chosen, document the reason.
Check for factors which will affect drug choice and
dose (eg. Renal function ,interactions and allergy)
Check that appropriate dose is prescribed.
All IV antibiotics may only be given for 48-72 hours
without review and consideration of oral antibiotics
following assessment by clinical judgement and lab
results.
Once culture reports are available-de escalate and if
not – document the reason
Empiric therapy- delay in initiating therapy to await
micro reports would be life threatening and mortality
rate will be increased. “Time is tissue”
 Antimicrobial therapy based on a clinically defined
infection is justified.
Rapid tests such as gram stain-can help determine
therapeutic choices when empiric therapy is required.
ANTIBIOTIC PRESCRIBING MODEL-AIMED
Micro
assessment
Evaluate/de-escalate at
48 hours
Duration/review date
specified
Antimicrobial
selection/dose/allergy
Indication specified
STRATEGIES TO OPTIMIZE
THE USE OF ANTI-MICROBIALS
• Patient risk stratification
• De-escalation therapy
• Antibacterial cycling
• Pre-emptive therapy
• Use of PK/PD parameter for dose adjustment
• Implementation of antibiotic stewardship program
PATIENT RISK STRATIFICATION
Type 1 Type 2 Type 3 Type 4
No contact with health
care system
Contact with health
care system
without/minimal
invasive procedures
Hospitalization > 5
days and or
infections following
invasive procedures
Type 3 patient with
fever despite
antibiotic therapy
(>5 days) with no
obvious
source/appropriate
source control
No prior antibiotic
therapy in last 90 days
Antibiotic therapy in
last 90 days
Recent and multiple
antibiotic therapies
± severe
sepsis/septic shock
plus
Patient young with no
co-morbid conditions
Patient old(>65
years) with few co-
morbidities
Patient with multiple
co-morbidities
(Cystic
fibrosis,advanced
AIDS,neutropenia)
Has 1 or more than
1 of the following
factors for invasive
fungal
infecctions(TPN,HD
,Immunodeficiencie
s,major abdominal
surgery,multifocal
candidal
colonization,DM)
Type 1 Type 2 Type 3 Type 4
-Bacterial infections
with minimal risk of
MDR pathogens or
non fermentors
-Invasive fungal
infections unlikely
-Risk of bacterial
infections with
MDR pathogens
-Minimal risk of non
fermentors
-Minimal risk of
invasive fungal
infections
-High risk of
bacterial infections
with MDR
pathogens and non
fermentors.
-Risk of invasive
fungal infections in
special conditions
-Risk of bacterial
infections with
pan drug
resistant
organisms
-High risk of
invasive fungal
infections
Limited use of
broad spectrum
antibacterials
-ESBL-Non
pseudomonal
antibiotics like
group 1.
-BL+BLI’s for mild
ESBL infections
Vancomycin/Teicop
lanin for MRSA
-Broad spectrum
antibiotics
-Carbapenem or
anti psedomonal
BL+BLI’S Plus
FLQ/Ags/GPs
Novel combination
of antibacterials
suggested for pan
drug resistant
organisms usinf
alternate drug
delivery
systems/pk-pd
parameters
No role of anti-
fungals
No role of anti
fungals
Prophylaxis for
fungal infections in
select cases
Empiric treatment
of fungal infections
for both stable and
DE-ESCALATION THERAPY
• Initial administration of broad spectrum empirical
treatment- to cover the pathogens most frequently
related to the infection
• Rapid adjustment of antimicrobial treatment once the
causative pathogen has been identified
• Objective:
Lower morbidity and mortality
Limit the appearance of bacterial resistance
 De-escalation
 Discontinuation
 Stop when you are done!
ANTI-BACTERIALCYCLING
• The scheduled rotation of one class of antibacterials for few
weeks or months
-one or more different classes with comparable spectra of
activity
-Different mechanism of resistance
• Objective:
Reduce the appearance of resistance by replacing the
antibacterial before they occur and preserving its activity to be re-
introduced in the hospital in a later cycle
PRE-EMPTIVE THERAPY
• The administration of antimicrobials in certain patients
at very high risk of opportunistic
infections(CMV,Aspergillosis and invasive candidiasis)
before the onset of clinical signs of infection.
• Examples:
-Hematological malignancies
-Transplant recipients
PK AND PD PRINCIPLES
Time dependent(beta-lactams)-continuous
infusion.
Concentration dependent (aminoglycosides)-
once daily bolus dose.
ANTIBIOTIC STEWARDSHIP PROGRAM
• Constitute an antibiotic stewardship team along with
microbiologist, infection control nurse,ID consultant
and clinical pharmacist.
• Educating ICU staff-prime importance
• Proper utilization of antibiogram
• Utilize microbiological information report optimally
• Work in close collobration with microbiologists and
other physicians involved in antibiotic prescribing
COMMON INFECTIONS IN ICU
• VAP(Ventilator Associated Pneumonia)
• UROSEPSIS
• CRBSI(Catheter Related Blood Stream
Infection)
VENTILATOR ASSOCIATED PNEUMONIA
common pathogens:
Early Onset (<4 Days) Late Onset (>4 Days)
S.pneumoniae
H.influenzae
MSSA
E.coli
K.pneumoniae
MRSA
Acinetobacter
P.aeuroginosa
ESBL
VENTILATOR ASSOCIATED PNEUMONIA
Early onset VAP(<4 Days) Late onset VAP(>4 Days)
Second generation cephalosporins
or
Fluoroquinolones
or
Aminopenicillins+beta lactamase
inhibitors
or
Ertapenem
Cephalosporin
or
Beta -lactam/beta lactamase
inhibitors
or
Carbapenem
plus
Aminoglycosides
or
Anti pseudomonas fluroquinolones
plus
Coverage for MRSA
Commo
n
Pathoge
ns
Plan of
action
Type 1 Type 2 Type 3 Type 4
S.Aureus
(59%)
Presumpti
ve therapy
Ceftriaxo
ne or
Amoxicill
in-
clavulan
ate or
ciproflox
acin/
ofloxacin
Ertapenem
or
Piptaz±Am
ikacin
Imipenem/C
efoperazone-
sulbactam+A
mikacin±van
comycin
Hemodynamics-
stable and no prior
exposure to
azoles-
Fluconazole. If
prior exposure
AmpB. Unstable-
Amp
B/Echinocandins
Pseudo
monas(2
3%)
After
Culture
Report
E.Coli(17
%)
Continue
Treatment If
pathoge
n
sensitive
to drug
-ESBL+ve
Continue
monothera
py
-MRSA-
Vancomyci
Culture
negative and
patient
responds
-Sensitive
pseudomona
C.albicans and
stable-fluconazole
C.non albicans
and unstable-
continue Amp B/
Echinocardin
CRBSI
S.Paraty(
3%)
Step
down -
De-
escalate
If
nonESBL/
MSSA-
Monother
apy
If non
ESBL/MSS
A-
deescalate
and treat
as type 1
ESBL +ve –
deescalate –
Type 2
Non
ESBL/MSSA-
Type 1
Deescalate(starte
d on empirical
Amp.B) to Azoles
if culture shows
only C.albicans
and patient is
stable
Acineto
bacter(3
%)
Consider
Escalatio
n
Culture
negative
and no
clinical
response
in 48
hours
-IF ESBL
+ve treat
as type 2
Culture
negative
and no
clinical
response
in 48
hours
-culture
shows
pseudomo
nas/acinet
obacter-
Type 3
MDR
Pseudomon
as/klebsiella
-
colistin+beta
lactam-
carbapenem
MDR
Acinetobact
er-colistin
sulbactam±c
arbapenem
(EI)VRSA/VR
E-Linezolid
Culture shows
azole resistant
candida species
or patient
condition
deterioates-
escalate to
Amp.B(if started
on emp.Azole)
UROSEPSIS
Common
Pathogens
Plan of
action
Type 1 Type 2 Type 3 Type 4
E.Coli(49%)
Pseudomon
as(29%)
Enterococc
us(16%)
Preumpti
ve
Therapy
Ceftrixaone/
Ofloxacin or
Amikacin/
Ertapenem
Ertapenem/
Pip+Taz±A
mikacin
Imipenem/Pi
p+Taz/Cefop
erazone-
sulbactam+A
mikacin
Hemodynamic
s-stable and no
prior exposure
to azoles-
Fluconaazole.
If prior
exposure
AmpB.
Unstable-Amp
B/Echinocandi
ns
After
Culture
report
Continue
Tretment
If pathogen
sensitive to
drug or
culture
negative
and patient
-ESBL+ve
Continue
monothera
py
-MRSA-
Vancomyci
-Culture
negative and
patient
responds
-Sensitive
pseudomona
C.albicans and
stable-
fluconazole
C.non albicans
and unstable-
continue Amp
Step
down-de
escalate
If
nonESBL/
MSSA-
Monothera
py
If non
ESBL/MSS
A-
deescalate
and treat
as type 1
ESBL +ve –
deescalate
–Type 2
Non
ESBL/MSS
A-Type 1
Sensitive
enterococc
us-
ampilcillin+
gentamycin
or
vancomyci
n
Deescalate(
started on
empirical
Amp.B) to
Azoles if
culture
shows only
C.albicans
and patient
is stable
Consider
escalation
Culture
negative
and no
clinical
response
in 48 hours
-IF ESBL
+ve treat as
type 2
Culture
negative
and no
clinical
response
in 48 hours
Culture
shows
pseudomo
nas-treat
as type 3
MDR
Pseudomo
nas/klebsie
lla-
colistin+bet
alactam-
carbapene
m
MDR
Acinetobac
ter-
sulbactam±
Culture
shows
azole
resistant
candida
species or
patient
condition
deterioates
-escalate to
Amp.B(if
started on
PREVENTIVE MEASURES
VAP BUNDLE APPROACH
 Head of bed elevation (30 degree)
 Oral care with chlorhexidine
 Stress ulcer prophylaxis
 DVT prophylaxis
 Daily sedation assessment and SBT
STRATEGIESTO PREVENTCRBSI
• Maximal sterile barrier precautions
• Skin cleaning with 2%chlorhexidine
• USG guided insertion
• Examine the catheter site daily and assess the
need daily
• Remove when not required
STRATEGIESTO REDUCE UTI
• Insert only for appropriate indications
• Follow aspetic precautions
• Maintain closed drainage system
• No floor contact of urinary bag
• Change only if really indicated
• Remove when no longer needed
CONCLUSION
• The first rule of antibiotics-try not to use them
incorrectly
• The Second rule-try not to use too many of
them
• If antibiotics are needed pending culture
results, the combination of vancomycin and
imipenem will suffice in most situations.
• Remember that fever and leukocytosis are
RIGHT
ANTIBIOTIC
RIGHT
DOSE
RIGHT
TIME
RIGHT
DURATION
Antibiotic usage in icu

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Antibiotic usage in icu

  • 1. ANTIBIOTIC USAGE IN ICU Dr. Swarnalingam Thangavelu. M.D Associate Professor Department of Anaesthesiology Tagore Medical College & Hospital
  • 2. INTRODUCTION The danger with germ-killing drugs is that they may kill the patient as well as the germ. J.B.S.Haldane
  • 3. ANTIBIOTICS PRESCRIPTION PRINCIPLES Send for the appropriate investigations-minimum required for diagnosis, prognosis and follow up. All antibiotic initiations would be done after sending appropriate cultures. Change in antibiotic would be done after sending fresh cultures. Follow the hospital antibiotic policy . If alternatives as chosen, document the reason. Check for factors which will affect drug choice and dose (eg. Renal function ,interactions and allergy) Check that appropriate dose is prescribed.
  • 4. All IV antibiotics may only be given for 48-72 hours without review and consideration of oral antibiotics following assessment by clinical judgement and lab results. Once culture reports are available-de escalate and if not – document the reason Empiric therapy- delay in initiating therapy to await micro reports would be life threatening and mortality rate will be increased. “Time is tissue”  Antimicrobial therapy based on a clinically defined infection is justified. Rapid tests such as gram stain-can help determine therapeutic choices when empiric therapy is required.
  • 5. ANTIBIOTIC PRESCRIBING MODEL-AIMED Micro assessment Evaluate/de-escalate at 48 hours Duration/review date specified Antimicrobial selection/dose/allergy Indication specified
  • 6. STRATEGIES TO OPTIMIZE THE USE OF ANTI-MICROBIALS • Patient risk stratification • De-escalation therapy • Antibacterial cycling • Pre-emptive therapy • Use of PK/PD parameter for dose adjustment • Implementation of antibiotic stewardship program
  • 7. PATIENT RISK STRATIFICATION Type 1 Type 2 Type 3 Type 4 No contact with health care system Contact with health care system without/minimal invasive procedures Hospitalization > 5 days and or infections following invasive procedures Type 3 patient with fever despite antibiotic therapy (>5 days) with no obvious source/appropriate source control No prior antibiotic therapy in last 90 days Antibiotic therapy in last 90 days Recent and multiple antibiotic therapies ± severe sepsis/septic shock plus Patient young with no co-morbid conditions Patient old(>65 years) with few co- morbidities Patient with multiple co-morbidities (Cystic fibrosis,advanced AIDS,neutropenia) Has 1 or more than 1 of the following factors for invasive fungal infecctions(TPN,HD ,Immunodeficiencie s,major abdominal surgery,multifocal candidal colonization,DM)
  • 8. Type 1 Type 2 Type 3 Type 4 -Bacterial infections with minimal risk of MDR pathogens or non fermentors -Invasive fungal infections unlikely -Risk of bacterial infections with MDR pathogens -Minimal risk of non fermentors -Minimal risk of invasive fungal infections -High risk of bacterial infections with MDR pathogens and non fermentors. -Risk of invasive fungal infections in special conditions -Risk of bacterial infections with pan drug resistant organisms -High risk of invasive fungal infections Limited use of broad spectrum antibacterials -ESBL-Non pseudomonal antibiotics like group 1. -BL+BLI’s for mild ESBL infections Vancomycin/Teicop lanin for MRSA -Broad spectrum antibiotics -Carbapenem or anti psedomonal BL+BLI’S Plus FLQ/Ags/GPs Novel combination of antibacterials suggested for pan drug resistant organisms usinf alternate drug delivery systems/pk-pd parameters No role of anti- fungals No role of anti fungals Prophylaxis for fungal infections in select cases Empiric treatment of fungal infections for both stable and
  • 9. DE-ESCALATION THERAPY • Initial administration of broad spectrum empirical treatment- to cover the pathogens most frequently related to the infection • Rapid adjustment of antimicrobial treatment once the causative pathogen has been identified • Objective: Lower morbidity and mortality Limit the appearance of bacterial resistance
  • 10.  De-escalation  Discontinuation  Stop when you are done!
  • 11. ANTI-BACTERIALCYCLING • The scheduled rotation of one class of antibacterials for few weeks or months -one or more different classes with comparable spectra of activity -Different mechanism of resistance • Objective: Reduce the appearance of resistance by replacing the antibacterial before they occur and preserving its activity to be re- introduced in the hospital in a later cycle
  • 12. PRE-EMPTIVE THERAPY • The administration of antimicrobials in certain patients at very high risk of opportunistic infections(CMV,Aspergillosis and invasive candidiasis) before the onset of clinical signs of infection. • Examples: -Hematological malignancies -Transplant recipients
  • 13. PK AND PD PRINCIPLES Time dependent(beta-lactams)-continuous infusion. Concentration dependent (aminoglycosides)- once daily bolus dose.
  • 14. ANTIBIOTIC STEWARDSHIP PROGRAM • Constitute an antibiotic stewardship team along with microbiologist, infection control nurse,ID consultant and clinical pharmacist. • Educating ICU staff-prime importance • Proper utilization of antibiogram • Utilize microbiological information report optimally • Work in close collobration with microbiologists and other physicians involved in antibiotic prescribing
  • 15. COMMON INFECTIONS IN ICU • VAP(Ventilator Associated Pneumonia) • UROSEPSIS • CRBSI(Catheter Related Blood Stream Infection)
  • 16. VENTILATOR ASSOCIATED PNEUMONIA common pathogens: Early Onset (<4 Days) Late Onset (>4 Days) S.pneumoniae H.influenzae MSSA E.coli K.pneumoniae MRSA Acinetobacter P.aeuroginosa ESBL
  • 17. VENTILATOR ASSOCIATED PNEUMONIA Early onset VAP(<4 Days) Late onset VAP(>4 Days) Second generation cephalosporins or Fluoroquinolones or Aminopenicillins+beta lactamase inhibitors or Ertapenem Cephalosporin or Beta -lactam/beta lactamase inhibitors or Carbapenem plus Aminoglycosides or Anti pseudomonas fluroquinolones plus Coverage for MRSA
  • 18. Commo n Pathoge ns Plan of action Type 1 Type 2 Type 3 Type 4 S.Aureus (59%) Presumpti ve therapy Ceftriaxo ne or Amoxicill in- clavulan ate or ciproflox acin/ ofloxacin Ertapenem or Piptaz±Am ikacin Imipenem/C efoperazone- sulbactam+A mikacin±van comycin Hemodynamics- stable and no prior exposure to azoles- Fluconazole. If prior exposure AmpB. Unstable- Amp B/Echinocandins Pseudo monas(2 3%) After Culture Report E.Coli(17 %) Continue Treatment If pathoge n sensitive to drug -ESBL+ve Continue monothera py -MRSA- Vancomyci Culture negative and patient responds -Sensitive pseudomona C.albicans and stable-fluconazole C.non albicans and unstable- continue Amp B/ Echinocardin CRBSI
  • 19. S.Paraty( 3%) Step down - De- escalate If nonESBL/ MSSA- Monother apy If non ESBL/MSS A- deescalate and treat as type 1 ESBL +ve – deescalate – Type 2 Non ESBL/MSSA- Type 1 Deescalate(starte d on empirical Amp.B) to Azoles if culture shows only C.albicans and patient is stable Acineto bacter(3 %) Consider Escalatio n Culture negative and no clinical response in 48 hours -IF ESBL +ve treat as type 2 Culture negative and no clinical response in 48 hours -culture shows pseudomo nas/acinet obacter- Type 3 MDR Pseudomon as/klebsiella - colistin+beta lactam- carbapenem MDR Acinetobact er-colistin sulbactam±c arbapenem (EI)VRSA/VR E-Linezolid Culture shows azole resistant candida species or patient condition deterioates- escalate to Amp.B(if started on emp.Azole)
  • 20. UROSEPSIS Common Pathogens Plan of action Type 1 Type 2 Type 3 Type 4 E.Coli(49%) Pseudomon as(29%) Enterococc us(16%) Preumpti ve Therapy Ceftrixaone/ Ofloxacin or Amikacin/ Ertapenem Ertapenem/ Pip+Taz±A mikacin Imipenem/Pi p+Taz/Cefop erazone- sulbactam+A mikacin Hemodynamic s-stable and no prior exposure to azoles- Fluconaazole. If prior exposure AmpB. Unstable-Amp B/Echinocandi ns After Culture report Continue Tretment If pathogen sensitive to drug or culture negative and patient -ESBL+ve Continue monothera py -MRSA- Vancomyci -Culture negative and patient responds -Sensitive pseudomona C.albicans and stable- fluconazole C.non albicans and unstable- continue Amp
  • 21. Step down-de escalate If nonESBL/ MSSA- Monothera py If non ESBL/MSS A- deescalate and treat as type 1 ESBL +ve – deescalate –Type 2 Non ESBL/MSS A-Type 1 Sensitive enterococc us- ampilcillin+ gentamycin or vancomyci n Deescalate( started on empirical Amp.B) to Azoles if culture shows only C.albicans and patient is stable Consider escalation Culture negative and no clinical response in 48 hours -IF ESBL +ve treat as type 2 Culture negative and no clinical response in 48 hours Culture shows pseudomo nas-treat as type 3 MDR Pseudomo nas/klebsie lla- colistin+bet alactam- carbapene m MDR Acinetobac ter- sulbactam± Culture shows azole resistant candida species or patient condition deterioates -escalate to Amp.B(if started on
  • 22. PREVENTIVE MEASURES VAP BUNDLE APPROACH  Head of bed elevation (30 degree)  Oral care with chlorhexidine  Stress ulcer prophylaxis  DVT prophylaxis  Daily sedation assessment and SBT
  • 23. STRATEGIESTO PREVENTCRBSI • Maximal sterile barrier precautions • Skin cleaning with 2%chlorhexidine • USG guided insertion • Examine the catheter site daily and assess the need daily • Remove when not required
  • 24. STRATEGIESTO REDUCE UTI • Insert only for appropriate indications • Follow aspetic precautions • Maintain closed drainage system • No floor contact of urinary bag • Change only if really indicated • Remove when no longer needed
  • 25. CONCLUSION • The first rule of antibiotics-try not to use them incorrectly • The Second rule-try not to use too many of them • If antibiotics are needed pending culture results, the combination of vancomycin and imipenem will suffice in most situations. • Remember that fever and leukocytosis are