antibiotic use in icu

1. ANTIBIOTIC USAGE IN ICU

2. INTRODUCTION
The danger with germ-killing drugs is that they may kill the
patient as well as the germ.
J.B.S.Haldane

3. ANTIBIOTICS PRESCRIPTION PRINCIPLES
Send for the appropriate investigations-minimum
required for diagnosis, prognosis and follow up.
All antibiotic initiations would be done after sending
appropriate cultures.
Change in antibiotic would be done after sending
fresh cultures.
Follow the hospital antibiotic policy . If alternatives as
chosen, document the reason.
Check for factors which will affect drug choice and
dose (eg. Renal function ,interactions and allergy)
Check that appropriate dose is prescribed.

4. All IV antibiotics may only be given for 48-72 hours
without review and consideration of oral
antibiotics.Assessment by clinical judgement and lab
results.
Once culture reports are available-de escalate and if
not – document the reason
Empiric therapy- delay in initiating therapy to await
micro reports would be life threatening and mortality
rate will be increased. “Time is tissue”
 Antimicrobial therapy based on a clinically defined
infection is justified.
Rapid tests such as gram stain-can help determine
therapeutic choices when empiric therapy is required.

5. ANTIBIOTIC PRESCRIBING MODEL-AIMED
Micro
assessment
Evaluate/de-escalate
at 48 hours
Duration/review date
specified
Antimicrobial
selection/dose/allergy
Indication specified

6. STRATEGIES TO OPTIMIZE
THE USE OF ANTI-MICROBIALS
• Patient risk stratification
• De-escalation therapy
• Antibacterial cycling
• Pre-emptive therapy
• Use of PK/PD parameter for dose adjustment
• Implementation of antibiotic stewardship program

7. PATIENT RISK STRATIFICATION
Type 1 Type 2 Type 3 Type 4
No contact with health
care system
Contact with health
care system
without/minimal
invasive procedures
Hospitalization > 5
days and or
infections following
invasive procedures
Type 3 patient with
fever despite
antibiotic therapy
(>5 days) with no
obvious
source/appropriate
source control
No prior antibiotic
therapy in last 90 days
Antibiotic therapy in
last 90 days
Recent and multiple
antibiotic therapies
± severe
sepsis/septic shock
plus
Patient young with no
co-morbid conditions
Patient old(>65
years) with few co-
morbidities
Patient with multiple
co-morbidities
(Cystic
fibrosis,advanced
AIDS,neutropenia)
Has 1 or more than
1 of the following
factors for invasive
fungal
infecctions(TPN,HD
,Immunodeficiencie
s,major abdominal
surgery,multifocal
candidal
colonization,DM)

8. Type 1 Type 2 Type 3 Type 4
-Bacterial infections
with minimal risk of
MDR pathogens or
non fermentors
-Invasive fungal
infections unlikely
-Risk of bacterial
infections with
MDR pathogens
-Minimal risk of non
fermentors
-Minimal risk of
invasive fungal
infections
-High risk of
bacterial infections
with MDR
pathogens and non
fermentors.
-Risk of invasive
fungal infections in
special conditions
-Risk of bacterial
infections with
pan drug
resistant
organisms
-High risk of
invasive fungal
infections
Limited use of
broad spectrum
antibacterials
-ESBL-Non
pseudomonal
antibiotics like
group 1.
-BL+BLI’s for mild
ESBL infections
Vancomycin/Teicop
lanin for MRSA
-Broad spectrum
antibiotics
-Carbapenem or
anti psedomonal
BL+BLI’S Plus
FLQ/Ags/GPs
Novel combination
of antibacterials
suggested for pan
drug resistant
organisms usinf
alternate drug
delivery
systems/pk-pd
parameters
No role of anti-
fungals
No role of anti
fungals
Prophylaxis for
fungal infections in
select cases
Empiric treatment
of fungal infections
for both stable and

9. DE-ESCALATION THERAPY
• Initial administration of broad spectrum empirical
treatment- to cover the pathogens most frequently
related to the infection
• Rapid adjustment of antimicrobial treatment once the
causative pathogen has been identified
• Objective:
Lower morbidity and mortality
Limit the appearance of bacterial resistance

10.  De-escalation
 Discontinuation
 Stop when you are done!

11. ANTI-BACTERIALCYCLING
• The scheduled rotation of one class of antibacterials for few
weeks or months
-one or more different classes with comparable spectra of
activity
-Different mechanism of resistance
• Objective:
Reduce the appearance of resistance by replacing the
antibacterial before they occur and preserving its activity to be re-
introduced in the hospital in a later cycle

12. PRE-EMPTIVE THERAPY
• The administration of antimicrobials in certain patients
at very high risk of opportunistic
infections(CMV,Aspergillosis and invasive candidiasis)
before the onset of clinical signs of infection.
• Examples:
-Hematological malignancies
-Transplant recipients

13. PK AND PD PRINCIPLES
Time dependent(beta-lactams)-continuous
infusion.
Concentration dependent (aminoglycosides)-
once daily bolus dose.

14. ANTIBIOTIC STEWARDSHIP PROGRAM
• Constitute an antibiotic stewardship team along with
microbiologist, infection control nurse,ID consultant
and clinical pharmacist.
• Educating ICU staff-prime importance
• Proper utilization of antibiogram
• Utilize microbiological information report optimally
• Work in close collobration with microbiologists and
other physicians involved in antibiotic prescribing

15. COMMON INFECTIONS IN ICU
• VAP(Ventilator Associated Pneumonia)
• UROSEPSIS
• CRBSI(Catheter Related Blood Stream
Infection)

16. VENTILATOR ASSOCIATED PNEUMONIA
common pathogens:
Early Onset (<4 Days) Late Onset (>4 Days)
S.pneumoniae
H.influenzae
MSSA
E.coli
K.pneumoniae
MRSA
Acinetobacter
P.aeuroginosa
ESBL

17. VENTILATOR ASSOCIATED PNEUMONIA
Early onset VAP(<4 Days) Late onset VAP(>4 Days)
Second generation cephalosporins
or
Fluoroquinolones
or
Aminopenicillins+beta lactamase
inhibitors
or
Ertapenem
Cephalosporin
or
Beta -lactam/beta lactamase
inhibitors
or
Carbapenem
plus
Aminoglycosides
or
Anti pseudomonas fluroquinolones
plus
Coverage for MRSA

18. Commo
n
Pathoge
ns
Plan of
action
Type 1 Type 2 Type 3 Type 4
S.Aureus
(59%)
Presumpti
ve therapy
Ceftriaxo
ne or
Amoxicill
in-
clavulan
ate or
ciproflox
acin/
ofloxacin
Ertapenem
or
Piptaz±Am
ikacin
Imipenem/C
efoperazone-
sulbactam+A
mikacin±van
comycin
Hemodynamics-
stable and no prior
exposure to
azoles-
Fluconazole. If
prior exposure
AmpB. Unstable-
Amp
B/Echinocandins
Pseudo
monas(2
3%)
After
Culture
Report
E.Coli(17
%)
Continue
Treatment If
pathoge
n
sensitive
to drug
-ESBL+ve
Continue
monothera
py
-MRSA-
Vancomyci
Culture
negative and
patient
responds
-Sensitive
pseudomona
C.albicans and
stable-fluconazole
C.non albicans
and unstable-
continue Amp B/
Echinocardin
CRBSI

19. S.Paraty(
3%)
Step
down -
De-
escalate
If
nonESBL/
MSSA-
Monother
apy
If non
ESBL/MSS
A-
deescalate
and treat
as type 1
ESBL +ve –
deescalate –
Type 2
Non
ESBL/MSSA-
Type 1
Deescalate(starte
d on empirical
Amp.B) to Azoles
if culture shows
only C.albicans
and patient is
stable
Acineto
bacter(3
%)
Consider
Escalatio
n
Culture
negative
and no
clinical
response
in 48
hours
-IF ESBL
+ve treat
as type 2
Culture
negative
and no
clinical
response
in 48
hours
-culture
shows
pseudomo
nas/acinet
obacter-
Type 3
MDR
Pseudomon
as/klebsiella
-
colistin+beta
lactam-
carbapenem
MDR
Acinetobact
er-colistin
sulbactam±c
arbapenem
(EI)VRSA/VR
E-Linezolid
Culture shows
azole resistant
candida species
or patient
condition
deterioates-
escalate to
Amp.B(if started
on emp.Azole)

20. UROSEPSIS
Common
Pathogens
Plan of
action
Type 1 Type 2 Type 3 Type 4
E.Coli(49%)
Pseudomon
as(29%)
Enterococc
us(16%)
Preumpti
ve
Therapy
Ceftrixaone/
Ofloxacin or
Amikacin/
Ertapenem
Ertapenem/
Pip+Taz±A
mikacin
Imipenem/Pi
p+Taz/Cefop
erazone-
sulbactam+A
mikacin
Hemodynamic
s-stable and no
prior exposure
to azoles-
Fluconaazole.
If prior
exposure
AmpB.
Unstable-Amp
B/Echinocandi
ns
After
Culture
report
Continue
Tretment
If pathogen
sensitive to
drug or
culture
negative
and patient
-ESBL+ve
Continue
monothera
py
-MRSA-
Vancomyci
-Culture
negative and
patient
responds
-Sensitive
pseudomona
C.albicans and
stable-
fluconazole
C.non albicans
and unstable-
continue Amp

21. Step
down-de
escalate
If
nonESBL/
MSSA-
Monothera
py
If non
ESBL/MSS
A-
deescalate
and treat
as type 1
ESBL +ve –
deescalate
–Type 2
Non
ESBL/MSS
A-Type 1
Sensitive
enterococc
us-
ampilcillin+
gentamycin
or
vancomyci
n
Deescalate(
started on
empirical
Amp.B) to
Azoles if
culture
shows only
C.albicans
and patient
is stable
Consider
escalation
Culture
negative
and no
clinical
response
in 48 hours
-IF ESBL
+ve treat as
type 2
Culture
negative
and no
clinical
response
in 48 hours
Culture
shows
pseudomo
nas-treat
as type 3
MDR
Pseudomo
nas/klebsie
lla-
colistin+bet
alactam-
carbapene
m
MDR
Acinetobac
ter-
sulbactam±
Culture
shows
azole
resistant
candida
species or
patient
condition
deterioates
-escalate to
Amp.B(if
started on

22. PREVENTIVE MEASURES
VAP BUNDLE APPROACH
 Head of bed elevation (30 degree)
 Oral care with chlorhexidine
 Stress ulcer prophylaxis
 DVT prophylaxis
 Daily sedation assessment and SBT

23. STRATEGIESTO PREVENTCRBSI
• Maximal sterile barrier precautions
• Skin cleaning with 2%chlorhexidine
• USG guided insertion
• Examine the catheter site daily and assess the
need daily
• Remove when not required

24. STRATEGIESTO REDUCE UTI
• Insert only for appropriate indications
• Follow aspetic precautions
• Maintain closed drainage system
• No floor contact of urinary bag
• Change only if really indicated
• Remove when no longer needed

25. CONCLUSION
• The first rule of antibiotics-try not to use them
incorrectly
• The Second rule-try not to use too many of
them
• If antibiotics are needed pending culture
results, the combination of vancomycin and
imipenem will suffice in most situations.
• Remember that fever and leukocytosis are

26. RIGHT
ANTIBIOTIC
RIGHT
DOSE
RIGHT
TIME
RIGHT
DURATION