11/12/17

1

AntimicrobialTherapyinSepsis

SiuYanAmyYeung,PharmD,BCPSCriticalCareClinicalSpecialist

UniversityofMarylandMedicalCenter

LearningObjectives

• Explaintheoptimaltimeforantimicrobialtherapyinapatientwithsepsis

• Developanempiricantimicrobialregimenforapatientwithsepsisbasedonpatientspecificfactors

• Modifyantimicrobialregimenanddurationbasedonpatientclinicalcourseanddata

AntimicrobialTherapyinSepsis• RecommendthatadministrationofIVantimicrobialsbeinitiated

assoonaspossibleafterrecognitionandwithin1hourforbothsepsisandsepticshock(Strongrecommendation,moderatequalityofevidence)

• Recommendempiricbroad-spectrumtherapywithoneormoreantimicrobialstocoveralllikelypathogens(Strongrecommendation,moderatequalityofevidence)

• Suggestempiriccombinationtherapy(usingatleasttwoantibioticsofdifferentantimicrobialclasses)aimedatthemostlikelybacterialpathogen(s)fortheinitialmanagementofsepticshock(Weakrecommendation;lowqualityofevidence)

Rhodesetal.Crit CareMed.2017;45:486–552

TimingofAntimicrobialsinSepsisPredictedHospitalM

ortality

Ferreretal.Crit CareMed2014;42:1749–1755

InappropriateAntimicrobials

KumarA,etal.Chest 2009;136:1237-1248.

AntimicrobialSelection

• Whatisthesourceofinfection?• Prevalenceofpathogensinhospitalorcommunity

• Resistancepatterninhospitalorcommunity• Ispatientimmunocompromised?• Ispatientatriskofinfectionwithmulti-drugresistant(MDR)organisms?

• Ispatientatriskforcandidainfection?• Drugallergies?

11/12/17

2

CDCVitalSignsReport.Aug2016.AccessedJune9th 2017

Nose, nasopharynx & sinuses:S. epidermidis, S. aureus, streptococci,

Haemophilus spp., Neisseria spp.

Mouth & Throat:Streptococci, diphtheroids, anaerobes,

S. epidermidis, spirochetes

Intra abdominal:Enterobacteriaceae

(E. coli, Klebsiella), Enterococci, Bacteroides sp., Streptococcus,

Candida sp.

Urinary TractE.coli, Proteus

Skin flora:S. epidermidis, S. aureus,

Diphtheroids (Corynebacterium)

Pneumonia:Community acquired –

S. pneumoniae, H. influenzae, Atypical (M. pneumoniae, C.

pneumoniae, Legionella)Nosocomial - Pseudomonas,

Klebsiella, S. aureus, Acinetobacter

CNS:S. pneumoniae, N. meningitides, ListeriaDevice related: S. aureus, Pseudomonas

AntimicrobialSelection

• Ispatientatriskofinfectionwithmulti-drugresistant(MDR)organisms?• Prolongedhospital(5ormoredays)orlongtermcarefacilitystay

• Priorantimicrobialusewithin90days• PriorinfectionorcolonizationwithMDRorganism

Rhodesetal.Crit CareMed.2017;45:486–552

11/12/17

3

AntifungalSelection

• Ispatientatriskforcandidainfection?• Immunocompromisedstate• Prolongedinvasivevasculardevice• Totalparenteralnutrition• Prolongedadministrationofbroadspectrumantibiotics

• Recentmajorsurgery(especiallyabdominalsurgery)

• MultisitecolonizationRhodesetal.Crit CareMed.2017;45:486–552

AntibioticCombinationTherapy• Increasespectrumofcoverageincreaseprobabilityofappropriateinitialtherapy

• Synergisticeffectincreasepathogenclearance

• Reduceriskforemergenceofresistance

Vazquez-Grandeetal.Semin Respir Crit CareMed.2015;36:154–166

AntimicrobialStewardship• Recommendthatempiricantimicrobialtherapybenarrowedoncepathogenidentificationandsensitivitiesareestablishedand/oradequateclinicalimprovementisnoted(BestPracticeStatement)

• Suggestthatanantimicrobialtreatmentdurationof7-10daysisadequateformostseriousinfectionsassociatedwithsepsisandsepticshock(Weakrecommendation;lowqualityofevidence)

• Recommenddailyassessmentforde-escalationofantimicrobialtherapyinpatientswithsepsisandsepticshock(BestPracticeStatement)

Rhodesetal.Crit CareMed.2017;45:486–552

TakeHomePoints• Initiationofappropriatebroadspectrumantimicrobialsiscrucialinpatientswithsepsis

• Antimicrobialsshouldbegivenwithin1hourafterrecognitionofsepsis

• Broadspectrumantimicrobialsshouldcoverallpotentialpathogens

• Considercombinationantimicrobialsinpatientswithsepticshock

• Antimicrobialsshouldbede-escalatedoncepathogenisidentified,orifpatienthasadequateclinicalresponse

11/12/17

4

InterprofessionalEducationModuletoLearn,Teach,andOptimizetheTreatmentofSepsis

• JeffreyP.Gonzales,PharmD• Nirav G.Shah,MD• ReneeDixon,MD• JoanM.Davenport,RN,PhD• Mojdeh Heavner,PharmD• SamuelA.Tisherman,MD• TraceyWilson,DNP• SiuYanAmyYeung,PharmD• Nimeet Kapoor,RN• PeterP.Olivieri,MD