this power presentation (guidelines for antibiotic use in ICU)

1. GUIDELINES FOR ANTIBIOTIC
USE IN ICU
INTRODUCTION
Antibiotics are the most frequently prescribed drugs
among hospitalized patients especially in intensive
care. Programs designed
to encourage appropriate antibiotic prescriptions in
health institutions are an important element in
quality of care, infection control and cost
1containment.
Several authors have reported concern about the
continuous indiscriminate and excessive use of
antimicrobial agents that promote the emergence of
antibiotic-resistant organisms. Monitoring of
antimicrobial use and knowledge of prescription
habits are some of the strategies recommended

2. 10 important questions should be routinely addressed
Proper
Regime
Host
factor
Combination
illegibility
Effectivenes
assessment
urgency
Appropriate
dose
Modification
of initial
regime
Likely
organismculture
indication
Antibiotic
principles

3. General Considerations
Empirical antimicrobial choice should be guided by
Therapeutic Guidelines
In 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 within
1 hour from triage is a reasonable target (first 6 hours
after 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.

4. Where an amino glycoside is given for empirical
treatment, a maximum of 48 hours is
recommend (equating to 3 daily doses in
patients with e GFR > 60mL/min and 1-2 doses in
patients with degrees of renal failure),
If impending renal failure an issue avoid more
than 1 dose of gentamicin and consider an anti
pseudomonal beta-la c tam such as ticarcillin/
clavulanate or piperacillin/ tazobactam as an
alternative.

5. Identification of a potential source
for sepsis
Comprehensive physical assessment
Collect blood cultures, sputum, urine
consider non-infective causes of fever

6. 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 malignancy
o ischaemic gut or other ischaemic tissue
o pyrogens (e.g. from sterile hematoma in pleural,
retroperitoneal or pelvic spaces)
o factitious disease

7. Culture cutaneous wounds, lesions, invasive
devices ulcers, pressure areas
Consider bronchoalveolar lavage, sampling
cerebral spinal fluid, pleural fluid, abdominal
collections, stool culture, skin biopsy as clinically
appropriate
Obtain x-rays,CTScans, surgical consultation as
clinically appropriate

8. Detection of bloodstream
events
Site
technique
volume
number

9. methodSputum culture
TrachealAspirates standard technique highly sensitivelow spasticity
Protected Specimen Brush
Bronchoalveolar Lavage PAL broncoscopich
and non bronchoschopic

11. Which Diagnostic Method is
Best?
There is little agreement on which method should
be preferred for the diagnosis of. Pneumonia
mortality in ventilator-associated pneumonia is
Not influenced by the diagnostic methods.

12. FORANTI BIOTIC GUIDE LINES
CAP in ICU
The choice of empiric antibiotics for
patient with sever CAP admitted to ICU
should be dictated by the likelihood that
the colonized with Staphylococcus aurous
andpseudomonas
The characteristics of patients who are
likely and unlikely to colonized
pseudomonas is summarized in next slide

13. Colonization LikelyColonization Unlikely
Admitted more than 5days ago
Admitted from a nursing Health care
Other admissions in the past 3 months
copd or bronchectasis
frequent antimicrobial or glucosteriod useA
dialysis patient.,,
Admitted less than 5 days ago
Admitted from home,
No other admissions in past 3 months
completely healthy before
. The characteristics of patients who are likely and unlikely to
colonized pseudomonas are

14. NEW guidelines for patient without risk for
pseudomonas or MRSA
antibioticdrugregime
1to2g daily
1 -2 g every
eight
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 daily
or 400mg
daily
or a respiratory fluoroqunolone levofloxacin
moxifloxacin

15. Dosedrugregime
4.5 g every 6 h(piperacillin–tazobactam)
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
NEW guidelines for patient with risk for pseudomonas and other resist pathogen but not
MRSA

16. Empiric therapy for community-acquired methicillin-
resistant Staphylococcus aureus (CA-MRSA) should
be given to hospitalized patients with severe CAP, as
defined by any of the following:
admission to the ICU, necrotizing or cavitary infiltrates,
or empyema
We 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 , recent
antimicrobial 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 are known.
If MRSA is not isolated, coverage for this organism
should be discontinued.

17. 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
•

18. •
• 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 be
used 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 adjunctive
therapy
• A shorter duration of antibiotic therapy (7 to 8 days) is
recommended for patients with uncomplicated HAP,VAP
for provenVAP due to methicillin-resistant S. aureus..

20. 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

21. 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 dailyCeftriaxoneempirical
750 mg every d
400 mg daily
40omgevery 8hr
Levofloxacin, moxifloxacin,
or ciprofloxacin
or
3g /6hrAmpicillin /sulbactamor
1gm dailyErtapenemor

22. 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 PATHOGENS
Dosedrugregime
1–2 g every 8–12 h
2 g every 8 h
Antipseudomonal
cephalosporin
(cefepime, ceftazidime)
empirical
500 mg every 6 h or 1 g every
8 h1 g every 8 h
Antipseudomonal
carbepenem† (imipenem or
meropenem)
4.5 g every 6 h-Lactam/-lactamase inhibitor
(piperacillin–tazobactam)
750 mg every d
400 mg every 8 h
ntipseudomonal
fluoroquinolone†
(ciprofloxacin or levofloxacin
plus
7 mg/kg per d†
Tobramycin 7 mg/kg per d†
Amikacin 20 mg/kg per d†
Aminoglycoside
(amikacin, gentamicin, or
tobramycin)
or

23. doseDrugregime
4.5 g every 6 h(piperacillin–tazobactam)Pseudomonas
Vancomycin +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

24. 4.5 g every 6 h(piperacillin–tazobactam)If pseudomonas likely
vancomycin plus
combination 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 hOr ciprofloxacin
7 mg/kg per d†
Amikacin 20 mg/kg per d†
Or Aminoglycoside
(amikacin, gentamicin,)

25. Thank you
MAHMODALMAHJOBTMC MEDICAL INTESIVE
CARE UNIT 11 APRIL 2012

27. indication
urency
culure organism
regieme

28. Antibiotic
indication
Urgency
Speciment
for Culture
Likely
organism