SSI: Abx Treatment & Management

7/25/2019 SSI: Abx Treatment & Management

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ANTIBIOTICS TREATMENT

AND MANAGEMENT

SITI NUR BAITI BINTI SHAIK

KHAMARUDIN


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OUTLINE

Monomicrobial vs Polymicrobial

Selecting and initiating antibiotic regimen

Factors inl!encing antibiotic c"oice Antimicrobial combination

Host actors

D!ration #ral vs Intraveno!s t"era$y

Mis!se


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Manner o t"era$y is em$loyed de$ends on%"et"er inection is monomicrobialor

polymicrobial&


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Monomicrobial infections

Nosocomial %"ic" occ!rred in postoperative

$atients' e&g& UTI' $ne!monia' cat"eter(

related inection' bacteremia

)!lt!re and sensitivity tests

Polymicrobial infections

c!lt!re res!lts less "el$!l


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POLYMICROBIAL

Antibiotic regimen should not be modified in t"e

basis o culture&

*&g&' $atient %"o !ndergoes a$$endectomy or

gangreno!s $erorated a$$endicitis+bo%el resection

or intestinal $eroration s"o!ld receive antibiotic or

,(- days occasionally longer&

I "e regains bo%el !nction d!ring t"is time'

convert rom I. to oral %"ic" is saer' earlier

disc"arge&


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SELECTING AND INITIATING

ANTIBIOTIC REGIMEN

(A)Obtaining an Accurate Diagnosis

/ Determining site of infection' deine t"e

host0imm!nocom$romised' diabetic'advanced age1 2 establis" a microbiological

diagnosis.

/ Diagnostic s$ecimens are properly obtained

and promptly submitted&

/ Detailed e3$os!re history&


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Sometimes diagnosis can be concl!ded

rom clinical $resentation' cultural test-independent& Cellulitis

Ass!med ca!sed by stre$tococci or sta$"ylococci

Antibacterial treatment %it"o!t $ositive c!lt!res&

Community acuired pneumonia Treated em$irically %it" macrolides 2 F4

5it"o!t s$eciic diagnostic test

Finally non-infectiousconditions to be

r!led o!t or !nclear diagnosis&


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(!) "iming of #nitiation

)ritically ill Stable

/ *m$iric t"era$y

s"o!ld be initiatedimmediately ater or

conc!rrently %it"

collection o

s$ecimen&

/ *&g&6 se$tic s"oc7'

ebrile ne!tro$enic'

bacterial meningitis&

/ Ab3 t"era$y s"o!ld

be %it""eld !ntila$$ro$riate

s$ecimens collected

and s!bmitted&

/ *&g&6 S!bac!te

bacterial

endocarditis'

vertebral

osteomyelitis+dis7itis


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(C) $mpiric vs Definitive "herapy

Microbiological res!lts are not available89 to :8 "o!rso %e c"oose em$iric initial t"era$y g!ided by

clinical $resentation&

!road spectrum antimicrobial agents'sometimes combination&

)over multiple possible pathogens;

comm!nity 2 "os$ital ac

Neisseria meningitidis ,rdgen

ce$"alos$orin = vancomycin


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%ospital-acuired infection

Related to invasive devices and procedures Intravasc!lar cat"eter(associated bacteremia'

ventilator(associated $ne!monia and

cat"eter(associated UTI&

Dr!g(resistant gram($ositive 0MRSA1 and

gram(negative bacteria 0Pseudomonas

aeruginosa1


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FACTORS INFLUENCING

ANTIBIOTIC CHOICE

&) 'ite of infection organisms liely to

coloni*e

/ I. cat"eter(associated bacteremia' sta$"ylococc!s

on s7in+) Prior no,ledge of bacteria no,n to

coloni*e

/ Screening nasal s%ab beore admit to I)U' MRSA

coloni>ation&

) ocal bacteria resistance pattern

/ Antibiograms


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ANTIMICROBIAL

COMBINATIONS5"en to !se?

&. Agents e/hibit synergistic activity against

microorganisms

Penicillin and gentamicin to treat endocarditisca!sedby Enterococcuss$$&

Penicillin =gentamycin

+. Critically ill patients

Healt"(care associated ca!sed by resistant to m!lti$leab3&

To ens!re at least @ agent %ill be activated against

organisms&


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/ *3am$le' $atient hospitali*ed for ,ees

develo$s septic shoc' blood c!lt!res ;

gram negative bacilli

#nitial therapy %it" 8 agents against $artic!lar

P aeruginosa' a common nosocomial and

m!lti$le(dr!g resistant&

Anti$se!domonal (lactam = F4 or

aminoglycoside


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. "o e/tend antimicrobial spectrum for

polymicrobial infections.

/ )ombination %ill e3tend t"e s$ectr!m beyondt"at ac"ieved by single agent&

0. Prevent emergence of resistance.

/ T"e res!lt o selective pressure romantimicrobial t"era$y&

/ )ombination %ill $rovide better c"ance at

least one dr!g %ill be eective&

/ *&g&6 standard t3 in TB and HI. %"ere

d!ration o t3 is $rolonged and resistance

emerged' limited t"era$e!tic&


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HOST FACTORS

1enal hepatic function )oncerned %it" dose reduction to $revent

acc!m!lation and to3icity

Age2conditons Pediatrics6 dose g!ided by %eig"t

3eriatrics6 de$ends on age and %eig"t' not

creatinine clearance solely or 7idney !nction Obese6 de$ends on at $ercentage


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3enetic variation S!sce$tibility to drug AD1

l!cose(C($"os$"ate de"ydrogenase 0CPD1 deiciency Avoid certain antimicrobials li7e da$sone' $rima

nitro!rantoin&

Res!lt in "emolysis&

%istory of allergy or intolerance Tr!e allergic sym$toms 0!rticaria' bronc"os$asm or ot"er

similar maniestation2 dyspepsia4 nausea1&

Ro!tinely obtained in eval!ation and management

%istory of recent antimicrobial use

Past , mont"s Microorganisms in c!rrent e$isode emerge !nder $revio!s

$ress!re

Mig"t be resistant to t"e dr!g


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DURATION

I cultures are negative' em$irical

antibiotic t"era$y s"o!ld be sto$$ed ; 9to :8 "o!rs& Unnecessity ris7 o MDR inections


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I infection is evident' treatment is contin!ed as indicated&

- days or less

)linical res$onse should not be a sole determinant

Host res$onse mig"t not be as ra$id as t"e bacterial

7illing res$onse

- I $atient still "as SIRS at $redetermined end $oint'

more !se!l to stop therapy reevaluate or6

- Persistence

- Ne% inection

- MDR $at"ogens

-

Noninectio!s ca!ses


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MONOMICROBIAL

Standard g!ideline6

,(- days or 5"#

:(@E days or pneumonia

:(@9 days or bacteremia

/ onger course do not res!lt in im$roved care

and associated %it" increase ris7 o

s!$erinection by resistant microorganism&


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POLYMICROBIAL

St!dies oc!sed on $atients %it" peritonitis&

Satisactory o!tcomes6

@8 to 89 "o!rs or penetrating gestrointestinal trauma

%it" absence o e3tensive contamination

, to - days or perforated2gangrenous appendicitis

- to : days or peritoneal soilage d!e to $erorated visc!s

%it" moderate contamination&

: to @9 days or ad6unct therapy o e3tensive $eritoneal

soilage 0ec!lent $eritonitis1 or t"at o in

imm!nos!$$ressed "ost&


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ater phases o $ost(o$erative antibiotic

treatment o serious intra-abdominal

infection

Signs s"o% inection eradicated6Absence o elevated 7!C count

ac7 o band forms o PMNs on $eri$"eral

smear

ac7 o fever0G,o)1


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ORAL VS INTRAVEOUS

THERAPY Patients "os$itali>ed %it" inections al%ays

treated %it" intraveno!s ab3 Prompted by severity o inection

Patients %it" mild to moderate infection'admit or other reasons 0de"ydration' $ain

control1 2 normal I !nction 5ell(absorbed oral ab3

#nitially parenteral can saely s%itc"ed to oral 5"en clinically stable


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S"o!ld select dr!gs %it" e3cellent

absor$tion or invasive infections Pyelone$"ritis or abscess

In serious infection i&e& inective

endocarditis and )NS inection Re

Oral therapy is less reliable


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MISUSE

'cenarios8

Prolonged em$iric t"era$y %it"o!t clear

evidence of infection'

9ailure to narro, antimicrobial t"era$y

%"en ca!sative organism is identiied&

/ Data available ; narro%est or contin!ation

Prolonged prophylactic t"era$y&

$/cessive use o certain antimicrobial

agents&


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Actions by a res$onsible $ractitioner6

imits prophyla/is to t"e $eriod d!ring

o$erative $roced!re

Does not convert prophyla/is into em$irical

e3ce$t !nder %ell(deined conditions

'ets duration o antibiotic rom beginning&

Curtails%"en t"ere are non(s!$$orting clinicaland microbiological evidence o inection&


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REFERENCE

Mayo )linic article "tt$6++%%%&ncbi&nlm&ni"&gov+$mc+articles+PM),E,@998 +

Sc"%art>s Princi$les o S!rgery' Tent" *dition

Sabiston Te3tboo7 o S!rgery' @t"*dition
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/

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SSI: Abx Treatment & Management