guidelinesforantibioticuseinicu-120414150702-phpapp02

8/13/2019 guidelinesforantibioticuseinicu-120414150702-phpapp02

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GUIDELINES FOR ANTIBIOTIC

USE IN ICU

INTRODUCTIONAntibiotics are the most frequently prescribed drugsamong hospitalized patients especially in intensive

care. Programs designed

to encourage appropriate antibiotic prescriptions inhealth institutions are an important element inquality of care, infection control and cost

1containment.Several authors have reported concern about the

continuous indiscriminate and excessive use ofantimicrobial agents that promote the emergence of

antibiotic-resistant organisms. Monitoring ofantimicrobial use and knowledge of prescription

habits are some of the strategies recommended


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10 important questions should be routinely addressed

Proper

Regime

Host

factor

Combination

illegibilityEffectivenes

assessment

urgency

Appropriate

dose

Modificationof initial

regime

Likelyorganismculture

indicationAntibiotic

principles


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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 within1 hour from triage is a reasonable target (first 6 hoursafter 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.


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Where an amino glycoside is given for empirical

treatment, a maximum of 48 hours isrecommend (equating to 3 daily doses inpatients with e GFR > 60mL/min and 1-2 doses inpatients with degrees of renal failure),

If impending renal failure an issue avoid morethan 1 dose of gentamicin and consider an antipseudomonal beta-la c tam such as ticarcillin/

clavulanate or piperacillin/ tazobactam as analternative.


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Identification of a potential source

for sepsis

Comprehensive physical assessment

Collect blood cultures, sputum, urine

consider non-infective causes of fever


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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 malignancyo ischaemic gut or other ischaemic tissue

o pyrogens (e.g. from sterile hematoma in pleural,retroperitoneal or pelvic spaces)

o factitious disease


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Culture cutaneous wounds, lesions, invasivedevices ulcers, pressure areas

Consider bronchoalveolar lavage, samplingcerebral spinal fluid, pleural fluid, abdominalcollections, stool culture, skin biopsy as clinicallyappropriate

Obtain x-rays, CT Scans, surgical consultation asclinically appropriate


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Detectionof bloodstream events

Sitetechnique

volumenumber


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methodSputum culture

Tracheal Aspirates standard technique highly sensitive lowspasticityProtected Specimen Brush

Bronchoalveolar Lavage PAL broncoscopich

and non bronchoschopic


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Which Diagnostic Method is

Best? There is little agreement on which method shouldbe preferred for the diagnosis of. Pneumonia

mortality in ventilator-associated pneumonia isNot influenced by the diagnostic methods.


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FORANTI BIOTIC GUIDE LINES

CAP in ICUThe choice of empiric antibiotics for

patient with sever CAP admitted to ICU

should be dictated by the likelihood thatthe colonized with Staphylococcus aurous

andpseudomonas

The characteristics of patients who arelikely and unlikely to colonized

pseudomonas is summarized in next slide


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Colonization LikelyColonization Unlikely

Admitted more than 5days ago

Admitted from a nursing Health care

Other admissions in the past 3 months

copd or bronchectasisfrequent antimicrobial or glucosteriod useA

dialysis patient.,,

Admitted less than 5 days ago

Admitted from home,

No other admissions in past 3 monthscompletely healthy before

. The characteristics of patients who are likely and unlikely to

colonized pseudomonas are


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risk forwithoutNEW guidelines for patient

pseudomonas or MRSA

antibioticdrugregime

1to2g daily1 -2 g everyeight hours

1.5-3g every

six hours

potent anti pneumococcal beta lactam(ceftriaxone or cefotaxime )

.or

ampicillin-sulbactam plus

500mg dailyeither advanced macrolide azithromycinplus

750mg dailyor 400mg

daily

or a respiratory fluoroqunolone levofloxacin

moxifloxacin

k f d d h h bhd l f


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Dosedrugregime

4.5 g every 6 h(piperacillintazobactam)

500 mg every 6 h

1 g every 8 h(imipenem or meropenem)or

2 g every 8 hr

2 g every 8 hr

(cefepime, ceftazidime)or

750 mg every d

400 mg every 8 h

fluoroquinolone((ciprofloxacin or levofloxacin

plus

risk for pseudomonas and other resist pathogen but notwithNEW guidelines for patient

MRSA

E i i h f i i d hi illi


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Empiric therapyfor community-acquired methicillin-

resistant Staphylococcus aureus (CA-MRSA) shouldbe given to hospitalized patients with severe CAP, asdefined by any of the following:admission to the ICU, necrotizing or cavitary infiltrates,

or empyemaWe 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 , recentantimicrobial 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 areknown. If MRSA is not isolated, coverage for this

organism should be discontinued.

id li f h f d l i h


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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


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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 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 adjunctivetherapy

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..


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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


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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

dosedrugregime

2gm dailyCeftriaxone

empirical

750 mg every d400 mg daily

40omgevery 8hr

Levofloxacin, moxifloxacin,or ciprofloxacin

or

3g /6hrAmpicillin /sulbactam

or

1gm dailyErtapenem

or

INITIAL INTRAVENOUS ADULT DOSES OF


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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 PATHOGENSDosedrugregime

12 g every 812 h

2 g every 8 h

Antipseudomonalcephalosporin

(cefepime, ceftazidime)

empirical

500 mg every 6 h or 1 g every

8 h1 g every 8 h

Antipseudomonalcarbepenem (imipenem or

meropenem)

4.5 g every 6 h-Lactam/-lactamase inhibitor

(piperacillintazobactam)

750 mg every d

400 mg every 8 h

ntipseudomonalfluoroquinolone

(ciprofloxacin or levofloxacin

plus

7 mg/kg per dTobramycin 7 mg/kg per d

Amikacin 20 mg/kg per d

Aminoglycoside(amikacin, gentamicin, or

tobramycin)

or

Empirical anti biotic regime for sever sepsis and septic shock


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doseDrugregime

4.5 g every 6 h(piperacillintazobactam)PseudomonasVancomycin +unlikely

2 g every 8 hr

2 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


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4.5 g every 6 h(piperacillintazobactam)If pseudomonas likelyvancomycin pluscombination of 2 of the

follwing

2 g every 8 hr

2 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,)


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indication

urencyculure organism

regieme


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Antibioticindication

Urgency

Specimentfor Culture

Likelyorganism


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