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Antibiotics In Acute Respiratory Failure

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  • 1. Antibiotics in Acute Respiratory Failure dr shabeel pn www.hi-dentfinishingschool.blogspot.com
  • 2. Definitions
    • ALI- acute onset of impaired gas exchange PaO 2 /FIO 2 <300
    • ARDS- PaO 2 /FIO 2 <200
    • Oxygenation index=( MAP x FI02/Pao2)x100
  • 3. Acute Lung Injury
    • CAP
    • HIV-associated pneumonia
    • HAP/VAP
    • Viral lung disease
  • 4. Definition CAP
    • Acute infection (less than 14 days) acquired in the community, of the lower respiratory tract, leading to cough or difficulty breathing, tachypnoea or chest-wall indrawing
    • Accounts for 30-40% of all hospital admissions
    • Case fatality rate 15-28%
    Zar HJ, et al SAMJ 2005
  • 5. Causes CAP
    • Bacterial:
    • - Strep Pneumoniae
    • - Haemophilus influenzae
    • - Staph aureus
    • - Moraxella catarrhalis
    • Atypical bacteria
    • - Mycoplasma pneumoniae
    • - Chlamydaphila pneumoniae/trachomatis
    • Viral
    • - RSV
    • - Human metapneumovirus
    • - Parainfluenza
    • - Adenovirus
    • - Influenza
    • - Rhinovirus
    • - Measles virus
  • 6. Causes of CAP
    • In addition in HIV-infected children
    • Gram-negative bacteria
    • Staph aureus (including CA-MRSA)
    • TB
    • Fungi
  • 7. Organisms cultured - Ward
  • 8. Treatment CAP
    • Antibiotis for all – Amoxicillin (90mg/kg/day tds 5 days) – (IV Ampicillin)
    • < 2 months add aminoglycoside/cephalosporin
    • > 5 years add macrolide
    • HIV - infection add aminoglycoside
    • HIV - exposed < 6 months add cotrimoxazole
    • AIDS add cotrimoxazole
    Zar HJ, et al SAMJ 2005
  • 9. HIV-infected children
    • No evidence that PK/PD principles are different to healthy children
    • All specimens showed resistance to co-trimoxazole.
    • Savitree Chaloryoo International Journal of Pediatric Otorhinolaryngology 1998; 44: 103-107
    • Brink A. Personnel communication
  • 10. PCP Pneumonia
    • Diagnosis:
    • - Immune compromised
    • - Respiratory distress and few crepitations
    • - Interstitial pattern on CXR
    • - LDH > 500
    • - PCR
  • 11. 3. Fluids in ARDS/ALI
    • NHLBI and ARDS net - FACTT trial
    • Conservative fluid management strategy favoured
    • Increase in ventilator free days and reduction in ICU stay, lower OI, plateau pressure, PEEP, higher PaO 2 /FIO 2
    • No increase rates of shock or renal failure
    • Need to closely monitor electrolytes
    • Calfee CS, Matthay MA. Chest 2007;131:913-19
  • 12. Managing Severe PCP Pneumonia
    • Lung protective strategies (low tidal volume, high PEEP)
    • Fluid restriction
    • TMX/SMX
    • Oral steroids
    • Treating CMV pneumonitis – Ganciclovir
    • Early introduction HAART
  • 13. Survival analysis, adjusted age and hospital Hazard ratio 0.54, 95% CI(0.29-1.02), p value 0.06 Hazard ratio 0.54 95% CI(0.29-1.02) p value 0.06
  • 14. CMV Pneumonitis
    • Diagnosis:
    • - CMV viral load > 10 000 copies/ml - Blood
    • CMV PCR – NBBAL
    • Treatment:
    • Ganciclovir (10mg/kg/dose BD)
    • Duration – 3 weeks after starting HAART
  • 15. HAP Definition
    • HAP – Pneumonia developing more than 48 hours after admission to hospital
    • VAP – Nosocomial infection occuring in patients receiving mechanical ventilation that is not present at the time of intubation and develops more than 48 hours after initiation of ventilation
  • 16. Epidemiology
    • Pneumonia = 2 nd most common nosocomial infection
    • Accounts for 18 – 26% of nosocomial infections
    • Children aged 2 – 12 months most affected
    • 95% of nosocomial pneumonia occurs in ventilated children
  • 17. Risk Factors
    • Immunodeficiency
    • Immunosuppression
    • Neuromuscular blockage
    • Septicaemia
    • TPN
    • Steroids
    • H2-blockers
    • Mechanical ventilation
    • Re-intubation
    • Transport while intubated
  • 18. Microbiology
    • Early-onset VAP:
    • - Strep pneumoniae
    • - Haemophilus influenzae
    • - Moraxella catarrhalis
    • Late-onset VAP (Resistant species) :
    • - Staph aureus
    • - Pseudomonas aeruginosa
    • - Lactose fermenting gram-negatives
  • 19. Organisms cultured - PICU
  • 20. Criteria for VAP for Infants Younger than 12 Months of Age Clinical Criteria / Radiographic Criteria
    • Worsening gas exchange with at least 3 of the clinical criteria :
    • Temperature instability without other recognized cause
    • White blood cells <4,000/mm 3 or > 15,000/mm 3 and band forms > 10%
    • New onset purulent sputum or change in the character of sputum or increased respiratory secretions
    • Apnea, tachypnea, increased work of breathing, or grunting
    • Wheezing, rales, or rhonchi
    • Cough
    • Heart rate <100 beats/min or >170 beats/min
    • plus radiographic criteria
    • At least 2 serial chest x-rays with new or progressive and persistent infiltrate, consolidate, cavitation or pneumatocele that develops >48 hours after initiation of mechanical ventilation
  • 21. Prevention Strategies
    • Head of bed elevation
    • Daily sedation holidays
    • Stress ulcer prophylaxis
    • DVT prophylaxis
    • Pneumococcal vaccination
    • Change in ventilator circuits only when dirty
    • Avoidance of re-intubation
    • Orotracheal intubation
    • Oropharyngeal toilet
  • 22. Management
    • Antibiotic selection policies
    • De-escillation
    • Antibiotic rotation
    • Regular microbiology for a
    • Antibiotic STEWARDSHIP
  • 23. Dosage
    • Correct antibiotic dosages and duration
    • Correct antibiotic administration
    • - Concentration dependent antibiotics (Aminoglycosides, quinolones) = single daily concentration
    • - Time dependent antibiotics (B-lactams, vancomycin, pip-taz, carbapenems, linezolid) = continuous infusion over 24 hours or multiple dosings (3-4 hours for carbapenems)
  • 24. Duration
    • No culture = 3 – 5 days
    • Positive culture = 5-7 days.
    • Seldom need 10 days
    • Exceptions
    • – Staph 2-3 weeks
    • - PCP 3 weeks
    • - Fungal 2-3 weeks
  • 25. De-escillation
    • If broad spectrum antibiotics or combinations used downgrade with positive culture and sensitivity
    • Vancomycin can be used alone
    • Single antibiotics = combinations
  • 26. Decontaminate
    • Hand washing – the most effective startegy to prevent resistance
    • All personnel and parents must hand wash
    • Anti-inflammatory strategies of Macrolides
  • 27. Dont
    • Use third generation cephalosporins routinely (except meningitis)
    • Use inappropriate antibiotics
    • Use a long course
    • Use too low a dose
    • Routinely combine antibiotics
    • Routinely use probiotics
  • 28. Antibiotics for ESBL
    • Carbapenem
    • - Meropenem
    • - Imipenem
    • - Ertapenem (Invanz)
    • Cefepime (Maxipime)
    • Piperacillin/tazobactam (Tazocin)
    • Never – Ciprofloxacin/3 rd Generation Cephalosporins
  • 29. Risk factors for and outcomes of bloodstream infection caused by ESBL-producing Escherichia coli and Klebsiella species in children Paediatrics 2005;115: 942-949
  • 30. Antibiotics for MRSA
    • Vancomycin (highly protein bound – better for septicaemia)
    • Linezolid (Zyvoxid) – better lung penetration
    • Teicoplanin
  • 31. Bronchiolitis
  • 32. Viral Identification 2007
  • 33. Bronchiolitis in HIV positive children
    • 12% of bronchiolitics at PAH are HIV positive
    • Mean age 8 months old (vs 3 months in non HIV-infected children)
    • No increase in numbers co-infected in more mild disease
  • 34. Pearson correlation r = 0.138
  • 35. Pearson correlation r = 0.373
  • 36. Summary
    • CAP = Ampicillin +/-
    • HAP = Meropenem +/-
    • PCP = Bactrim + oral steroids + Ganciclovir
    • Bronchiolitis = nothing ?
    • Using this policy and noting that all HIV-infected children are offered ventilation if required – Mortality in PICU at PAH = 18.7%