GUIDELINES FOR ANTIBIOTIC USE IN ICU

INTRODUCTION Antibiotics are the most frequently prescribed drugs among hospitalized patients especially in intensive care. Programs designed to encourage appropriate antibiotic prescriptions in health institutions are an important element in quality of care, infection control and cost 1containment. Several authors have reported concern about the continuous indiscriminate and excessive use of antimicrobial agents that promote the emergence of antibiotic-resistant organisms. Monitoring of antimicrobial use and knowledge of prescription

habits are some of the strategies recommended

10 important questions should be routinely addressed

urgency

culture

Likely organism

indication
Antibiotic principles
Appropriate dose Modification of initial regime

Proper Regime

Host factor
Effectivenes assessment
Combination illegibility

General Considerations
Empirical antimicrobial choice should be guided by Therapeutic Guidelines In 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

Sputum culture method

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.

ANTI BIOTIC GUIDE LINES FOR 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 pseudomonas and The characteristics of patients who are likely and unlikely to colonized pseudomonas is summarized in next slide

The characteristics of patients who are likely and unlikely to colonized pseudomonas are
Colonization Unlikely Colonization Likely

Admitted less than 5 days ago Admitted from home, No other admissions in past 3 months completely healthy before

Admitted more than 5days ago Admitted from a nursing Health care Other admissions in the past 3 months copd or bronchectasis A frequent antimicrobial or glucosteriod use dialysis patient.,,

NEW guidelines for patient without risk for pseudomonas or MRSA

regime drug antibiotic

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

1to2g daily 1 -2 g every eight hours

1.5-3g every six hours

plus either advanced macrolide azithromycin

500mg daily

or a respiratory fluoroqunolone levofloxacin moxifloxacin

750mg daily or 400mg daily

NEW guidelines for patient with risk for pseudomonas and other resist pathogen but not MRSA regime drug (piperacillintazobactam) Dose 4.5 g every 6 h

or

(imipenem or meropenem)

500 mg every 6 h 1 g every 8 h

or (cefepime, ceftazidime)

2 g every 8 hr 2 g every 8 hr

plus

fluoroquinolone (ciprofloxacin or levofloxacin(

750 mg every d 400 mg every 8 h

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 with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia key recommendations and principles in this new, evidence-based guideline are as follows: A lower respiratory tract culture needs to be collected from all patients before antibiotic therapy, but collection of cultures should not delay the initiation of therapy in critically 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 be used 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 treat P. 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) is recommended for patients with uncomplicated HAP, VAP
for proven VAP due to methicillin-resistant S. aureus..

RISK FACTORS FOR MULTIDRUG-RESISTANT PATHOGENS 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 d Residence in a nursing home or extended care facility Home infusion therapy (including antibiotics) Chronic dialysis within 30 d Home wound care Family member with multidrug-resistant pathogen Immunosuppressive disease and/or therapy

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

regime

drug

dose

empirical

Ceftriaxone

2gm daily

or Levofloxacin, moxifloxacin, or ciprofloxacin

750 mg every d 400 mg daily 40omgevery 8hr 3g /6hr

or Ampicillin /sulbactam

or Ertapenem

1gm daily

INITIAL INTRAVENOUS, ADULT DOSES OF ANTIBIOTICS FOR EMPIRIC THERAPY OF HOSPITALACQUIRED PNEUMONIA, INCLUDING VENTILATORASSOCIATED PNEUMONIA, AND HEALTHCARE-ASSOCIATED PNEUMONIA IN PATIENTS WITH LATE-ONSET DISEASE OR RISK FACTORS FOR MULTIDRUG-RESISTANT PATHOGENS

regime empirical Antipseudomonal cephalosporin (cefepime, ceftazidime)

drug

Dose 12 g every 812 h 2 g every 8 h 500 mg every 6 h or 1 g every 8 h1 g every 8 h 4.5 g every 6 h

Antipseudomonal carbepenem (imipenem or meropenem) -Lactam/-lactamase inhibitor (piperacillintazobactam)

plus ntipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin

or Aminoglycoside (amikacin, gentamicin, or tobramycin)

750 mg every d 400 mg every 8 h

7 mg/kg per d Tobramycin 7 mg/kg per d Amikacin 20 mg/kg per d

Empirical anti biotic regime for sever sepsis and septic shock

regime
Pseudomonas unlikely Vancomycin +

Drug
(piperacillintazobactam)

dose
4.5 g every 6 h

Or (cefepime, ceftazidime

2 g every 8 hr 2 g every 8 hr 500 mg every 6 h 1 g every 8 h

or (imipenem or meropenem)

If pseudomonas likely vancomycin plus combination of 2 of the follwing

(piperacillintazobactam)

4.5 g every 6 h

Or (cefepime, ceftazidime

2 g every 8 hr 2 g every 8 hr 500 mg every 6 h 1 g every 8 h

or (imipenem or meropenem)

Or ciprofloxacin

400 mg every 8 h

Or Aminoglycoside (amikacin, gentamicin,)

7 mg/kg per d Amikacin 20 mg/kg per d

Thank you MAHMOD ALMAHJOB TMC MEDICAL INTESIVE CARE UNIT 11 APRIL 2012

indication

urency culure

organism

regieme

Antibiotic indication

Likely organism

Urgency

Speciment for Culture