GUIDELINES FOR ANTIBIOTIC USE IN ICU

INTRODUCTION Antibiotics are the most frequently prescribed drugsamong hospitalized patients especially in intensive

care. Programs designedto encourage appropriate antibiotic prescriptions in

health institutions are an important element inquality of care, infection control and cost

1containment.Several authors have reported concern about thecontinuous indiscriminate and excessive use of

antimicrobial agents that promote the emergence ofantibiotic-resistant organisms. Monitoring of

antimicrobial use and knowledge of prescriptionhabits are some of the strategies recommended

10 important questions should be routinely addressed

Proper Regime

Host factor

Combination

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Effectivenes

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urgency

Appropriate dose

Modification of initial

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Likely organismculture

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General Considerations Empirical antimicrobial choice should be

guided by Therapeutic GuidelinesIn ICU fluid resuscitation and source control

are as important as appropriate antimicrobial prescribing .

Time to antibiotic administration should be minimized in severe sepsis. It is suggested that within 1 hour from triage is a reasonable target (first 6 hours after the onset of hypotension was associated with >7% decrease in survival) .

Limit the duration of antibiotic therapy when clinically appropriate to minimize the opportunity for multi-drug resistant organisms infection .

Where an amino glycoside is given for empirical treatment, a maximum of 48 hours is recommend (equating to 3 daily doses in patients with e GFR > 60mL/min and 1-2 doses in patients with degrees of

renal failure) ,If impending renal failure an issue avoid

more than 1 dose of gentamicin and consider an anti pseudomonal beta-la c tam such as ticarcillin/ clavulanate or piperacillin/ tazobactam as an alternative .

Identification of a potential source for sepsis

Comprehensive physical assessment

Collect blood cultures, sputum, urine

consider non-infective causes of fever

o central cause (e g. Head injured or ICH patient)

o drugs/medications o pulmonary embolism

o autoimmune disease; e.g. temporal arteritis

o neuroleptic malignant syndrome o malignancy

o ischaemic gut or other ischaemic tissue o pyrogens (e.g. from sterile hematoma in

pleural, retroperitoneal or pelvic spaces) o factitious disease

Culture cutaneous wounds, lesions, invasive devices ulcers, pressure areas

Consider bronchoalveolar lavage, sampling cerebral spinal fluid, pleural fluid, abdominal collections, stool culture, skin biopsy as clinically appropriate

Obtain x-rays, CT Scans, surgical consultation as clinically appropriate

Detection of bloodstream events

Site technique volume number

method Sputum culture

Tracheal Aspirates standard technique highly

sensitive low spasticity Protected Specimen Brush Bronchoalveolar Lavage PAL broncoscopich and non bronchoschopic

Which Diagnostic Method is Best?

There is little agreement on which method should be preferred for the diagnosis of. Pneumonia mortality in ventilator-associated pneumonia is

Not influenced by the diagnostic methods.

FOR ANTI BIOTIC GUIDE LINES CAP in ICU

The choice of empiric antibiotics for patient with sever CAP admitted to ICU should be dictated by the likelihood that the colonized with Staphylococcus aurous and pseudomonas

The characteristics of patients who are likely and unlikely to colonized pseudomonas is summarized in next slide

Colonization Likely Colonization Unlikely

Admitted more than 5days ago

Admitted from a nursing Health care

Other admissions in the past 3 months

copd or bronchectasis frequent antimicrobial or glucosteriod use A

dialysis patient,,.

Admitted less than 5 days ago

Admitted from home ,

No other admissions in past 3 months

completely healthy before

. The characteristics of patients who are likely and unlikely to colonized pseudomonas are

NEW guidelines for patient without risk for pseudomonas or MRSA

antibiotic drug regime

1to2g daily 1 -2 g every eight hours 1.5-3g every six

hours

potent anti pneumococcal beta lactam (ceftriaxone or cefotaxime ) .or ampicillin-sulbactam plus

500mg daily

either advanced macrolide azithromycin

plus

750mg daily or 400mg

daily

or a respiratory fluoroqunolone levofloxacin moxifloxacin

Dose drug regime

4.5 g every 6 h (piperacillin–tazobactam)

500 mg every 6 h 1 g every

8 h

( imipenem or meropenem)

or

2 g every 8 hr2 g every 8 hr (cefepime, ceftazidime)

or

750 mg every d400 mg every 8 h

fluoroquinolone†((ciprofloxacin or

levofloxacin

plus

NEW guidelines for patient with risk for pseudomonas and other resist pathogen but not MRSA

Empiric therapy for community-acquired methicillin-resistant Staphylococcus aureus (CA-

MRSA) should be given to hospitalized patients with severe CAP, as defined by any of the following: admission to the ICU, necrotizing or cavitary infiltrates, or empyema We also suggest empiric therapy of MRSA in patients with severe CAP who have risk factors for (CA)-MRSA ( iv drug user living in crowded area prisoner , recent antimicrobial therapy or recent influenza-like illness). In such patients, we recommend treatment for MRSA with vancomycin (15 mg/kg IV every 12 hours, adjusted for renal) or linezolid (600 mg IV twice daily) until the results of culture and susceptibility testing are known. If MRSA is not isolated, coverage for this organism should be discontinued.

Guidelines for the Management of Adults withHospital-acquired, Ventilator-associated, and

Healthcare-associated Pneumoniakey recommendations and principles in this new,

evidence-based guideline are as follows: •A lower respiratory tract culture needs to be

collectedfrom all patients before antibiotic therapy, but

collectionof cultures should not delay the initiation of therapy

incritically ill patients..

bronchocopically or nonbronchoscopically, can be cultured

•Negative lower respiratory tract cultures can be used to

stop antibiotic therapy in a patient who has had cultures

obtained in the absence of an antibiotic change in the past

•

•

•An empiric therapy regimen should include agents that are

from a different antibiotic class than the patient has recently

received. •Combination therapy for a specific pathogen should beused judiciously in the therapy of HAP, and consideration

should be given to short-duration (5 days) amino glycoside

therapy, when used in combination with a -lactam to treatP. aeruginosa pneumonia.

•Linezolid is an alternative to vancomycin, and unconfirmed,

preliminary data suggest it may have an advantage •Aerosolized antibiotics may have value as

adjunctive therapy •A shorter duration of antibiotic therapy (7 to 8

days) isrecommended for patients with uncomplicated HAP,

VAP for proven VAP due to methicillin-resistant S. aureus..

RISK FACTORS FOR MULTIDRUG-RESISTANTPATHOGENS CAUSING HOSPITAL-ACQUIRED

PNEUMONIA,HEALTHCARE-ASSOCIATED PNEUMONIA, AND

VENTILATOR-ASSOCIATED PNEUMONIA •Antimicrobial therapy in preceding 90 d

•Current hospitalization of 5 d or more •High frequency of antibiotic resistance in the community or

in the specific hospital unit •Presence of risk factors for HCAP:

Hospitalization for 2 d or more in the preceding 90 dResidence in a nursing home or extended care facility

Home infusion therapy (including antibiotics)Chronic dialysis within 30 d

Home wound careFamily member with multidrug-resistant pathogen

•Immunosuppressive disease and/or therapy

INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR HOSPITAL-ACQUIRED PNEUMONIA ORVENTILATOR-ASSOCIATED PNEUMONIA IN PATIENTS WITH NO KNOWN RISK FACTORS FORMULTIDRUG-RESISTANT PATHOGENS, EARLY ONSET, AND ANY DISEASE SEVERITY

dose drug regime

2gm daily Ceftriaxone empirical

750 mg every d400 mg daily

40omgevery 8hr

Levofloxacin, moxifloxacin, or ciprofloxacin

or

3g /6hr Ampicillin /sulbactam or

1gm daily Ertapenem or

INITIAL INTRAVENOUS, ADULT DOSES OFANTIBIOTICS FOR EMPIRIC THERAPY OF HOSPITALACQUIRED

PNEUMONIA, INCLUDING VENTILATORASSOCIATEDPNEUMONIA, AND HEALTHCARE-ASSOCIATED

PNEUMONIA IN PATIENTS WITH LATE-ONSET DISEASE ORRISK FACTORS FOR MULTIDRUG-RESISTANT PATHOGENS

Dose drug regime

1–2 g every 8–12 h2 g every 8 h

Antipseudomonal cephalosporin

(cefepime, ceftazidime)

empirical

500 mg every 6 h or 1 g every 8 h1 g every 8 h

Antipseudomonal carbepenem† (imipenem or meropenem)

4.5 g every 6 h -Lactam/-lactamase inhibitor

(piperacillin–tazobactam)

750 mg every d400 mg every 8 h

ntipseudomonal fluoroquinolone†

(ciprofloxacin or levofloxacin

plus

7 mg/kg per d†Tobramycin 7 mg/kg

per d†Amikacin 20 mg/kg per

d†

Aminoglycoside(amikacin, gentamicin,

or tobramycin)

or

15 mg/kg every 12 h‡600 mg every 12 h

Linezolid or vancomycin‡

plus

dose Drug regime

4.5 g every 6 h (piperacillin–tazobactam)

Pseudomonas Vancomycin + unlikely

2 g every 8 hr2 g every 8 hr

500 mg every 6 h 1 g every

8 h

Or (cefepime, ceftazidime

or(imipenem or

meropenem)

Empirical anti biotic regime for sever sepsis and septic shock

4.5 g every 6 h (piperacillin–tazobactam)

If pseudomonas likely vancomycin plus combination of 2 of the follwing

2 g every 8 hr2 g every 8 hr

500 mg every 6 h 1 g

every 8 h

Or (cefepime, ceftazidime

or(imipenem or

meropenem)

400 mg every 8 h Or ciprofloxacin

7 mg/kg per d†Amikacin 20 mg/kg per

d†

Or Aminoglycoside(amikacin, gentamicin),

Thank you MAHMOD ALMAHJOB

TMC MEDICAL INTESIVE CARE UNIT 11 APRIL 2012

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