Guidelines for antibiotic use in icu


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Guidelines for antibiotic use in icu

  1. 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. 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. 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. 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. 5. Identification of a potential source for sepsis Comprehensive physical assessment Collect blood cultures, sputum, urine consider non-infective causes of fever
  6. 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. 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. 8. Detection of bloodstream events Site technique volume number
  9. 9. methodSputum culture TrachealAspirates standard technique highly sensitivelow spasticity Protected Specimen Brush Bronchoalveolar Lavage PAL broncoscopich and non bronchoschopic
  10. 10. 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.
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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.
  16. 16. 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 •
  17. 17. • • 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..
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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,)
  24. 24. indication urency culure organism regieme
  25. 25. Antibiotic indication Urgency Speciment for Culture Likely organism