Antimicrobial stewardship and

infection control in the ICU

HAI short course

CIDM-PH/ SEIB

jon.iredell@sydney.edu.au

antibiotic effects

• antibiotics drive resistance that can persist

• some are worse than others

• stewardship is complex and ill-informed

increased resistance

Costelloe C et al. BMJ.

2010;340:c2096.

antibiotic effects

• antibiotics drive resistance that can persist

• some are worse than others

• stewardship is complex and ill-informed

streptococci and friends (incl. lactococci and staph)E. coli and friends

funny things we don’t think about much like propionibacteria

infecting populations

n

infecting populations

t

quinolones?

3GC?

(eg.

(MRSA

•niche competition

•displacement

•niche competition

•not consistent with

evidence for

ecological integrity

(MRSA

(P. aeruginosa

(outside clones•large potential reservoir; not enabled

•not consistent with

•evidence for old genes

•evidence in gene capture system

•large potential reservoir; enabled

•is consistent with

•evidence for old genes

•evidence in gene capture systems

antibiotic effects

• antibiotics drive resistance that can persist

• some are worse than others

• stewardship is complex and ill-informed

complexities of stewardship

• variable perturbations in robust dynamic systems

• niche specificity exists at multiple levels

• anthropocentric view of ‘medically important bacteria’ vs • anthropocentric view of ‘medically important bacteria’ vs

responsible husbandry of a complex ecosystem

• adaptive strategies vary with bug and drug

(genome) size does matter

• GPC – think opportunism, environmental control/ fomites; surveillance is simple

• Enterobacteriaceae – think selection pressure, resistance potential

eg MRSA (S. aureus) – tough, predictable, common but not universal, mostly a solo operator (clonal outbreaks)

eg E.coli, Klebsiella – universal but adaptable, not so tough but a real team player (clonal R outbreaks unusual)pressure, resistance potential

• “non-fermenters” (Acb, PA etc) – think environmental control, real-time adaptive responses, selection pressure

eg Pseudomonas, Acinetobacter – tough, adaptable, versatile – as a solo or team operator (clonal and polyclonal R outbreaks)

HICSIG

Hospital Infection Control

Special Interest Group

of the

Australian Society

for Infectious Diseases

Clinical outcomes better with antimicrobial management program

Perc

en

t

RR 2.8 (2.1-3.8) RR 1.7 (1.3-2.1) RR 0.2 (0.1-0.4)

Perc

en

t

AMP = Antibiotic Management Program

UP = Usual PracticeFishman N. Am J Med. 2006;119:S53.

Improving antibiotic use saves money

• “Comprehensive programs have consistently demonstrated a decrease in antimicrobial use with annual savings of $200,000 -$900,000”$900,000”

• IDSA/SHEA Guidelines for Antimicrobial Stewardship Programs

• http://www.journals.uchicago.edu/doi/pdf/10.1086/510393

Stewardship optimizes patient safety: decreased patient-level resistance

Cipro Standard

Antibiotic duration

3 days 10 days

LOS ICU 9 days 15 days

Antibiotic resistance/ superinfection

14% 38%

Study terminated early because attending

physicians began to treat standard care group

with 3 days of therapy

Singh N et al. Am J Respir Crit Care Med. 2000;162:505-11.

antibiotics in ICU

• most (90% ID / 74% ICU) agree1: – ab R is a clinical problem that needs action

– local susceptibility data are essential• only 68% ID / 39% ICU used local databases

• current advice not very useful / accessible– 64% ICU consult ID;

• 25% find that advice to be generally unhelpful1

• 13% Rx informed by MC/S (unpub.)

• better data with prescriber guidelines– improves antibiotic prescribing

– reduces ICU length of stay2,3

1. Sintchenko et al. IJAA 2001, 2. Sintchenko et al. JAMIA 04 3. Sintchenko et al. JAMIA 05

Liaison rounds

•Face-to-face(best) or teleconferenced; twice weekly or more in large units. Ensure ALL

intensive care units receive ID and Clinical Microbiologist input.

•At each round: bed by bed.

•Examine clinical situation, what the function of treatment is (prophylaxis, empiric or

directed treatment). Review previous decisions and patient outcome as required.

•Recommend necessary changes - switches to directed treatment, cessation of •Recommend necessary changes - switches to directed treatment, cessation of

prophylaxis, cessation/end dates for empiric or directed treatment. Where possible

tie treatment plans back to existing guidelines.

•what the microbiology and other tests show.

•Recommend additional investigations in potentially undiagnosed infection

•Be mindful of necessary infection control procedures (hand hygiene) during the round

- ensure compliance by visiting liaison staff - provide an example!

•Document the round decisions - [ eg entry/ sticker in medical record]

culture clashes

• the individual good vs the common good

• power and control/ personality effects

• sovereign immunity vs accountability

Reducing 3GC use usually involves a switch to aminoglycosides.

Advantages:

•aminoglycosides generally broader Gram negative spectrum

•aminoglycosides are rapidly bactericidal

•benefit of dual therapy in septic shock (b-lactam + aminoglycosides)•benefit of dual therapy in septic shock (b-lactam + aminoglycosides)

•nephrotoxicity of aminoglycosides correlates with duration of use and is very

low following 1-3 daily doses

•ECF-distributed and low GI penetration/ ecological impact

Craig and Andes

Semin Resp Infect 1997; 12 (4): 271-

Kumar et al

Crit Care Med. 2010 Sep;38(9):1773-85

3GC3GC

3GC

SMH Sydney 2012 …clinicians clean up after massive 3GC exposure in ICU

main messages

• some drugs are just bad news

• protocols can protect

• prevention is a moment in time

• keep it simple