Rational use of antibiotics ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLOGY ( JANUARY 2020 -DECEMBER 2022 SESSION) NIMHANS BANGALORE

RATIONAL USE OF ANTIBIOTICS
Presenter- Dr. Avinash kumar
Senior Resident, D.M.Neurology (session
January 2020 to December 2022 session),
NIMHANS Bangalore

1.Introduction
2.Antibiotic classification
3.Mechanism of resistance
4.Steps of rational antibiotic use
5.Guidelines for antibiotic use
6.Antibiotic use in ICU
7.Nimhans antibiotics policy 2019
8.Nimhans ward and ICU Antibiogram
9.Antibiotics stewardship
10.Summary

INTRODUCTION
• Antimicrobial resistance (AMR) is a global threat today and has
overshadowed the potential gain in reducing deaths due to infections.
• It is estimated that by the year 2050,Asia will have 4.7 million deaths that
could be directly attributed to AMR.
• Antimicrobial resistance is rampant in India with up to 12-59 % of E. coli
being extended beta lactamase (ESBL) producers and up to 30% being
carbapenemase producers (CP).
ICMR:Treatment Guidelines for Antimicrobial Use in Common
Syndromes 2019

• India is the largest consumer of antibiotics in the world i.e., 13 billion
standard units in 2010 and from 2000 to 2010 the per capita consumption
increased by 66%.
• In May 2015, the World Health Assembly adopted a resolution to endorse
a global action plan on antimicrobial resistance.
ICMR:Treatment Guidelines for Antimicrobial Use in
Common Syndromes 2019

• Azithromycin is the most frequently prescribed antibiotic in outpatient
settings and is often inappropriately prescribed for conditions for which it is
not a recommended first-line treatment or antibiotics are not indicated.
• In 2013, the US Food and Drug Administration (FDA) warned that
azithromycin can lead to potentially fatal heart rhythm irregularities.
• Fluoroquinolones are also commonly used in outpatient settings, often
inappropriately.
Hicks LA et al 2011 Sanchez GV, Shapiro et al U.S.F.D.A.2013 Kabbani S et al 2018

• In 2016, FDA updated its warning on fluoroquinolones due to disabling and
permanent side effects, including tendonitis, tendon rupture, worsening of
myasthenia gravis, peripheral neuropathy, and central nervous system
effects.
• FDA recommended that fluoroquinolones be avoided in acute sinusitis,
acute bronchitis, and uncomplicated urinary tract infections.
U.S.F.D.A. 2013

• Klebsiella pneumoniae has emerged over the last few years as a highly
resistant pathogen with up to 50% resistance to carbapenems and rapidly
increasing resistance to Polymyxin.
• In addition, methicillin resistance in Staphylococcus aureus is seen in up to
30% of S. aureus isolates nationally
• It is well documented that antibiotic abuse is one of the major drivers of
antibiotic resistance and thus optimising usage of antibiotics is the
need of the hour.
ICMR:Treatment Guidelines for Antimicrobial Use in Common
Syndromes 2019

• Current evidence is limited, but indicates that early-life antibiotic use may
be associated with increased risk of chronic diseases, such as juvenile
idiopathic arthritis,celiac disease, inflammatory bowel disease,diabetes, and
food allergies,likely mediated through disruption in the microbiome.
Horton DB et al 2015 Marild K et al 2013 Hviid A et al 2011
Boursi B et al 2015 Love BL et al 2016 Vangay P et al 2015

Super bug from India
• The bug is actually a single-celled bacteria belonging to
the Eschericia coli (E. coli) family. The species carries an enzyme
called New Delhi metallo-beta—lactamase (NDM-1), which allows it
to neutralise all known antibiotics and survive in their presence.
• The enzyme was first isolated from a patient who had come to India
for elective surgery. When he left, he took the “super bug” with him.
•
• No one knows how prevalent the organism is in India, as we do not
have a centralised surveillance and reporting system that tracks
hospital acquired infections and bacterial antibiotic resistance
patterns.
The Telegraph 4
September 2020

Bengal Bay clone
• This killer Indian superbug resistant to antibiotics infects 5,000
Australians and threatens hospitals
• Dangerous strain of MRSA kills 1 in 4 infected people and has
spread from India
• Scientists say the bacteria has mutated and already infected
5,000 Australians
• Known as the Bengal Bay clone-The killer bug, which is
becoming increasingly drug-resistant and has a 25 per cent
mortality rate, has already caused around 5,000 blood infections
in Australia.
• A strain of MRSA known as the Bengal Bay clone has mutated
and spread across the world and is now resistant to antibiotics.
• So strong is the pathogen, scientists said it can cause severe
illness in normally 'young, healthy individuals’.
Mail online News 4 September
2020

Bactericidal Bacteriostatic
• Vancomycin
• Fluoroquinolone
• Penicillin
• Aminoglycosides
• Cephalosporin
• Carbapenem
• Metronidazole
• Erythromycin (and
other macrolides)
• Clindamycin
• Sulphamethoxazole
• Trimethoprim
• Tetracycycline
• Chloramphenicol

MECHANISM OF RESISTANCE
Various mechanisms of antibiotic resistance, including drug efflux with the help of efflux pump, enzymatic modifications of the antibiotic,
enzymatic breakdown of the antibiotics, and modification in the target sites. Wei Wang et al 2018

• Plasmid transmission is the most important phenomenon which may
transfer genes of antibiotic resistance to the host cell.
• At the community level, faeco–oral route is the most important route of
transmission especially for resistant pathogens of the
family Enterobacteriaceae, usually due to sanitation failure.
Wellington EM et al 2013 Chamchod F et al 2012

• Community-acquired (CA)-MRSA is also a good example to understand
the transmission dynamics of resistance at the human–human level, which
is usually transmitted due to prolonged hospital stay or unhygienic hospital
settings.
Chamchod F et al 2012

STEPS OF RATIONAL
ANTIBIOTIC USE

Steps of rational antibiotic use
• Step 1: Making a clinical diagnosis - A clinical diagnosis most often helps us
to predict causative pathogens fitting in to a clinical syndrome which
would tailor the correct antibiotic rather than blindly relying on fever,
pro-calcitonin levels, WBC counts, cultures or radiology to make a
diagnosis of infection.
ICMR 2019

Step 2: Limiting empiric antibiotic therapy to genuine seriously ill
patients
• Generally,empiric antibiotic therapy is ONLY recommended for a select group
of patients as described below after taking appropriate cultures
- Febrile neutropenia
- Severe sepsis and septic shock
- Community acquired pneumonia
- Ventilator associated pneumonia
- Necrotizing fasciitis
ICMR 2019
1

Step 3: Know your bugs
Approach includes-
• Identify the clinical syndrome
• Elucidate possible sources of infection
• Predict possible microbial pathogens
• Predict the local resistance pattern based on institutional antibiogram
ICMR 2019

4.Choose the appropriate antibiotic
Based on the spectrum of the antibiotic, taking into account possible resistant
patterns
• Use the correct dose, route and duration
• Ensure chosen antibiotic has adequate tissue penetration at the site of
infection
• Optimize PK-PD parameters according to co-morbidities
ICMR 2019

5.De-escalation
• Antimicrobial de-escalation (ADE) is defined as the discontinuation
of one or more components of combination empirical therapy,
and/or the change from a broad-spectrum to a narrower spectrum
antimicrobial.
• It is most commonly recommended in the intensive care unit (ICU)
patient who is treated with broad-spectrum antibiotics as a strategy
to reduce antimicrobial pressure of empirical broad-spectrum
therapy and prevent antimicrobial resistance, yet this has not been
convincingly demonstrated in a clinical setting.
• Jan J. De Waele et al 202018

• Modify empiric broad spectrum antibiotics depending on culture and
antimicrobial susceptibility reports and patient status
• Stop polymyxins and glycopeptides, if no carbapenem resistant organisms
(CRO) or methicillin resistant Staphylococcus aureus (MRSA) identified on
cultures
• Avoid double or redundant gram negative or anaerobic coverage
• Discontinue antibiotics if a non-infectious mimic identified
ICMR 2019

• De-escalate combination therapy to a single agent
• Change a broad spectrum antibiotic to a narrow spectrum one
• Change IV to oral antibiotics
• De-escalation is safe in all patients including febrile neutropenia and
septic shock and reduces mortality and length of hospital stay
ICMR 2019

• For short courses of antimicrobial therapy (5 days or less),
continuing the empirical treatment, if appropriate, can avoid
sequential use of different antimicrobials and thus multiple impacts
on the microbiome.
• For longer courses of antimicrobial therapy (7 days or more), ADE
should probably be a recommended strategy, particularly if high-
quality and clinically relevant samples are available.
• For intermediate-duration antimicrobial therapy (5–7 days),
decisions should be tailored according to institutional ASP
recommendations.
• Jan J. De Waele et al 202018

Step 6: Stop antibiotics in the following clinical situations
I. Respiratory tract syndromes
• - Viral pharyngitis
• - Viral rhinosinusitis
• - Viral bronchitis
• - Non-infectious cardio-pulmonary syndromes misdiagnosed as
pneumonia
II. Skin and Soft Tissue Infections
• Subcutaneous abscesses
• Lower extremity stasis dermatitis
III. Asymptomatic bacteriuria and pyuria including in catheterized patients
IV. Microbial colonization and culture contamination
V. Low grade fever
ICMR 2019

Step 7: Reduce the duration of therapy
Duration of therapy should be optimized to minimum possible to reduce
selection pressure:
• Community acquired pneumonia: 5 days
• Hospital acquired pneumonia: 8 days
• Skin and Soft tissue infections: 5 days
• Urinary tract infections
cystitis: 3-5 days
ICMR 2019

Step 7: Reduce the duration of therapy
• Pyelonephritis: 5-14 days
• Catheter associated: 7 days
• Staphylococcal aureus bacteraemia –
low risk of complications = 2 weeks
high risk of complications = 4-6 weeks
• Intra-abdominal infection: 4-7 days
• Surgical antibiotic prophylaxis: 1 dose
ICMR 2019

Step 8: Optimize PK-PD parameters
• Overall, exposure of the infective agent to the unbound antibiotic drug
fraction at the relevant effect site seems to be the most important factor.
• Optimizing PK-PD parameters include loading doses when needed,
therapeutic drug monitoring for toxicity and efficacy and optimization of
drug infusion or administration.
ICMR 2019

For e.g.,
• Loading dose of Colistin 9 million units stat and then followed by 3 million units
Q8H or 4.5 million units Q12H [to target Colistin Average Steady State Plasma
Concentration (Css,avg = 2-2.5 mg/L)
• Inj vancomycin 1g IV Q12H and dose to be adjusted to maintain a trough level
between 15-20 µg/ml [however there are increasing recent data that suggests that
AUC/MIC may be a better indicator of clinical efficacy than a trough level]
• - Extended infusion of lactams
ICMR 2019

Shira Doron et al 2011

Acute Bacterial Meningitis (ABM)
• Unlike the western world, Group B Streptococcus and Listeria are not reported as
common causes of neonatal meningitis in India.
• A significant proportion of late onset neonatal meningitis can also be due to
nosocomial pathogens including MRSA and Candida
• H.Influenzae and meningococcus are uniformly susceptible to the 3rd generation
cephalopsorins. There is a rising incidence of resistance in S. pneumoniae to
penicillins and 3rd generation cephalosporins
Treatment Guidelines for
Antimicrobial Use in Common
Syndromes ICMR 2019

Etiology and empiric therapy of community
acquired acute bacterial meningitis
Age Likely
Treatment Guidelines for Antimicrobial Use in
Common Syndromes ICMR 2019

Community acquired acute bacterial meningitis
• A practical issue is that the turn around time for confirmation of etiology
of meningitis is at least 48 hours unless molecular tests are used.
• Also in most suspected meningitis, the first dose of antibiotic is given soon
after drawing blood cultures/ doing the lumbar puncture even before the
basic CSF reports come in.
Treatment Guidelines for Antimicrobial Use in Common Syndromes ICMR 2019

• If an organism is identified, therapy can be modified accordingly.
• If the organism is cephalosporin susceptible, vancomycin can be stopped.
• Consider adding rifampicin ,if cephalosporin MIC ≥4 µg/mL, if the child’s
condition worsening after 48 hours of vancomycin + ceftriaxone, if
dexamethasone has been given or if repeat LP shows the presence of
bacteria.

• In patients improving clinically, there is no need to repeat CSF analysis to
demonstrate improvement or prior to stopping therapy.
.Repeat CSF should be done in cases of clinical non -response at 48 hours,
patients with penicillin /cephalosporin resistant strains ,who have received
adjunctive dexamethasone, and in neonates to document sterilization of CSF.
• Causes of clinical non response in a case of bacterial meningitis include
complications such as subdural empyema, cerebral abscess, ventriculitis etc or
drug resistance

• The duration of therapy for uncomplicated meningitis is generally 10-14
days.
• If a pathogen is identified then duration is pathogen dependent:
-7 days for meningococcus and H. influenzae,
-10-14 days for pneumococcus,
-2-3 weeks for group B Streptococcus,
- 3-6 weeks for Listeria, and
- 3 weeks for gram negative meningitis
Treatment Guidelines for Antimicrobial Use in Common Syndromes 2019

Health care associated meningitis/ ventriculitis
• Health care associated meningitis/ ventriculitis,seen in patients
undergoing neurosurgeries, head trauma, external ventricular drainage,
lumbar punctures etc.
• The etiology depends on local epidemiology but commonly includes multi
drug /extremely drug resistant gram negative pathogens including
Acinetobacter,Pseudomonas, Klebsiella and Staphylococcus aureus/
epidermidis.

• Diagnosis is a challenge since sensorial obtundation (a cardinal symptom
of meningitis) may be due to the underlying disease/ surgery.
• The CSF may be abnormal due to pre existing bleed/ surgery induced
chemical meningitis. The patients are frequently on antibiotics and hence
microbial isolation rates are low.

• CSF should be sampled and sent for cell count, protein, sugar and aerobic cultures.
• Elevated CSF lactate (> 4 mmol/l) and procalcitonin help in differentiating between
infective and chemical meningitis.
• The results of cultures especially those obtained through EVD(external ventricular
drain) should be carefully interpreted since they may grow
colonizers/contaminants.

• Empirical therapy depends on local flora but usually includes high dose
meropenem with vancomycin.
• Therapy should be modified based on culture reports.
• Surgical drainage of pus and removal of hardware may be needed.
• For carbapenem resistant pathogens, intraventricular / intrathecal therapy
with colistin/ polymyxin B/ aminoglycosides is indicated.

• The drugs are best administered through an Ommaya reservoir but may
sometimes have to be given through EVD/ lumbar punctures.
• The duration of therapy varies depending on the causative organism but is
generally 2-3 weeks

Treatment Guidelines for Antimicrobial Use in
Common Syndromes ICMR 2019

Etiology and empiric therapy for brain abscess
Treatment Guidelines for Antimicrobial Use in Common
Syndromes 2019

GUIDELINES
FOR ANTIBIOTIC USE
IN ICU
Community-acquired Pneumonia in the Intensive Care Unit
•CAP can simply be defined as pneumonia which is not acquired in hospital or long-
term care facility.
NICE 2014

Risk Factors for Multidrug-Resistant (MDR) Pathogens for CAP
in ICU
age > 65 years,
antimicrobial therapy in the preceding 3 months,
high frequency of antibiotic resistance in the community,
hospitalization for ≥ 48 hours in the preceding 3 months,
home infusion therapy including antibiotics,
home wound care,
chronic dialysis within 1 month,
family member with MDR pathogen
and ongoing immunosuppressive treatment.
GC Khilnani et al,
Indian J Crit Care Med. 2019 Jan; 23(Suppl 1): S1–S6311
•
• 1
Antibiotic use in ICU

Community acquired pneumonia
.Appropriate antimicrobial therapy should be initiated in patients of CAP requiring ICU
admission, within the first hour, after obtaining necessary microbiologic samples .
.Empirical therapy covering common etiologic organisms should be initiated for severe CAP
requiring ICU admission .
• GC Khilnani et al, Indian J Crit Care Med. 2019 Jan; 23(Suppl 1): S1–S63
•

• Investigations including the culture of respiratory secretions (sputum,
endotracheal aspirate), blood cultures, urinary antigen testing for
Pneumococcus and Legionella may be performed to narrow down therapy.
. Bronchoscopic BAL or protected specimen brush samples or polymerase
chain reaction (PCR) for viral etiology may be performed for microbiologic
diagnosis on a case by case basis.
GC Khilnani et al, Indian J Crit Care Med. 2019 Jan; 23(Suppl 1): S1–S63

• For patients with CAP requiring ICU admission, a non-pseudomonal beta-
lactam (cefotaxime, ceftriaxone, or amoxicillin-clavulanic acid) plus a
macrolide (azithromycin or clarithromycin) should be preferred if there are
no risk factors for Pseudomonas aeruginosa infection .
GC Khilnani et al, Indian J Crit Care Med. 2019 Jan; 23(Suppl 1):
S1–S63

• For penicillin-allergic patients, a respiratory fluoroquinolone (levofloxacin,
moxifloxacin or ciprofloxacin) and aztreonam may be used .
• If macrolides cannot be used, a fluoroquinolone may be used if there is no clinical
suspicion of tuberculosis, after sending sputum or endotracheal aspirate for AFB
and Genexpert .

3
Indian J Crit Care Med. 2019 Jan; 23(Suppl 1): S1–S63
C.A.P.
For patients with severe CAP requiring ICU admission, risk factors for infection
with Pseudomonas aeruginosa include-
• Chronic pulmonary disease (chronic obstructive pulmonary disease, asthma,
bronchiectasis),
• Frequent systemic corticosteroid use,
• Prior antibiotic therapy,
• old age,
• Immunocompromised states,
• Enteral tube feeding,
• Cerebrovascular or cardiovascular disease.

• If P. aeruginosa is an etiological consideration, antipneumococcal,
antipseudomonal antibiotic (like ceftazidime, cefoperazone, piperacillin-
tazobactam, cefoperazone–sulbactam, imipenem, meropenem or cefepime)
should be used.
• Combination therapy should be considered with the addition of
aminoglycosides or antipseudomonal fluoroquinolones (e.g., ciprofloxacin)
GC Khilnani et al, Indian J Crit Care Med. 2019 Jan; 23(Suppl
1): S1–S63

.Risk factors for MRSA in CAP in ICU include-
1.close contact with MRSA carrier or patient,
2.Prisoners,
3.influenza
4.Professional athletes,
5.Army recruits,
6.Men having sex with men (MSM),
7.Intravenous (IV) drug abusers,
8.and those with recent antibiotic use.
.MRSA pneumonia should be suspected after influenza or in previously healthy
young patients, if there is cavitation or necrotizing pneumonia, along with the
rapid increase of pleural effusion, massive hemoptysis, neutropenia or
erythematous rashes.
GC Khilnani et al, Indian J Crit Care Med.
2019 Jan; 23(Suppl 1): S1–S63

• All patients admitted with CAP in ICU should be evaluated for the presence of risk factors
associated with MRSA .
• If MRSA is a consideration, empiric vancomycin or teicoplanin should be added to the
regimen.
• Linezolid should be used for vancomycin intolerant patients, vancomycin-resistant
Staphylococcus aureus (VRSA), or patients with renal failure .

.Anaerobic organisms were reported to cause the majority of pulmonary infections
associated with lung abscesses, aspiration pneumonia and empyema .
.Risk factors for aspiration pneumonia in patients admitted with CAP in ICU include
dysphagia, altered sensorium, coma, witnessed aspiration, putrid discharge, the
presence of lung abscess, empyema or necrotizing pneumonia.

.Empirical antibiotics with anaerobic coverage should be considered for treatment of
CAP in ICU in the presence of clinical risk factors for aspiration or presence of lung
abscess, empyema or necrotizing pneumonia.
• Patients with CAP at risk of anaerobic infection should be initiated on antibiotics
with anaerobic activity such as amoxicillin-clavulanate, clindamycin or moxifloxacin
.
GC Khilnani et al, Indian J Crit Care Med. 2019 Jan; 23(Suppl
1): S1–S63

• Piperacillin-tazobactam or carbapenems can be used for empirical therapy in CAP
due to anaerobes if otherwise indicated .
. Duration of treatment should be individualized according to the response and
severity of the disease
GC Khilnani et al, Indian J Crit Care Med. 2019 Jan; 23(Suppl 1): S1–
S63

Optimal Duration of Antibiotics for C.A.P. in I.C.U.
.Patients with C.A.P. requiring I.C.U. admission should receive antibiotics for 7–10 days .
.Patients with C.A.P. due to Pseudomonas or aspiration pneumonia should be treated for 14 days .
.Necrotizing pneumonia due to GNB(gram negative bacilli), MRSA(Methicillin resistant Staphylococcus
aureus) or anaerobes also require treatment for 14–21 days

• Duration of treatment should be individualized according to causative
organism, response, the severity of disease and complications .
.Procalcitonin levels can be used along with clinical judgment for de-
escalation of antibiotics in C.A.P. in I.C.U. in patients treated beyond 5–7
days .

Ventilator associated pneumonia
• VAP is a type of hospital-acquired pneumonia that occurs more than 48
hours after endotracheal intubation.
• This can be further classified into early onset (within the first 96 hours of
MV) and late onset (more than 96 hours after the initiation of MV), which
is more commonly attributable to multidrug–resistant pathogens.
• VAP is common in critical care patients and is responsible for around half
of all antibiotics given to patients in ICUs
Felicity miller 2018 ,World federation of society of anaesthesiologist

Risk Factors for Ventilator-associated Pneumonia
• Increasing age (>55 years)
• Chronic lung disease
• Aspiration/ microaspiration
• Previous antibiotic therapy, especially broad-spectrum antibiotics
• Reintubation after unsuccessful extubation, or prolonged intubation
• Acute respiratory distress syndrome
• Frequent ventilator circuit changes
• Prolonged paralysis

• The key to the development of VAP is the presence of an ETT or
tracheostomy, which interfere specifically the functional mechanisms
involved in clearing secretions (cough and mucociliary action).
• Early-onset VAP, occurring within the first four days of MV, is usually
caused by antibiotic-sensitive community-acquired
bacteria such as Haemophilus and Streptococcus.
VAP developing more than 5 days after initiation of MV is usually caused by
multidrug–resistant bacteria such as Pseudomonas aeruginosa.

Felicity miller 2018 ,World federation of
society of anaesthesiologist

Felicity miller 2018 World federation of
society of anaesthesiologist

CPIS( Clinical Pulmonary Infection Score)of 6 or higher out of a maximum
score of 12 indicates -likely diagnosis of VAP
Felicity miller 2018 World federation of society of
anaesthesiologist

low risk for mortality is defined as a ≤15% chance of dying, a mortality
rate that has been associated with better outcomes using monotherapy
than combination therapy when treating serious infection
European respiratory society 2018

• In our country or areas with high endemicity of tuberculosis, use of linezolid may
be restricted unless no suitable alternative is available
• Fluoroquinolones and aminoglycoside should be cautiously used as monotherapy
in VAP in our country as well as in other areas with high endemicity of tuberculosis
.

• In ICUs where gram-negative isolate resistance rate is low(<10% gram-negative isolate
resistant to the agent being considered for monotherapy) and patients have no risk
factors for antimicrobial resistance, one anti-pseudomonal antibiotic may be given
. In ICUs where gram-negative isolate resistance rate is high (>10% gram-negative isolate
resistant to the agent being considered for monotherapy or not known), two
antipseudomonal antibiotics from a different class to be given .

What should be the Duration of Antibiotic Treatment for HAP/VAP?
.Short course (7–8 days) of antibiotic therapy - in the case of VAP with good clinical
response to therapy .
.Longer duration (14 days) of antibiotic therapy -in case of VAP caused by NF-
GNBs(non-fermenting gram-negative bacilli) or is associated with severe
immunodeficiency, structural lung disease (COPD, bronchiectasis, and interstitial lung
disease), empyema, lung abscess, necrotizing pneumonia, and inappropriate initial
antimicrobial therapy
.The incidence of anaerobic bacteria as the causative agent of VAP is 2–7%.
.Risk factors for VAP due to anaerobes are altered consciousness, aspiration
pneumonitis.

an • NIMHANS
ANTIBIOTIC
POLICY
2019
NATIONAL INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES
BENGALURU (INDIA)
Compiled by
Hospital Infection Surveillance System (HISS)
Department of Neuromicrobiology
NIMHANS

NIMHANS ANTIBIOTIC POLICY 2019
1.1 Urinary Tract Infections
Empirical – Amikacin 1g OD IM/IV / Gentamicin 7mg/kg/day
Alternative - Piperacillin-Tazobactam 4.5g IV 6 hourly / Cefoperazone-
Sulbactam 3g IV 12 hourly / Ertapenem 1g IV OD
1.Empirical Treatment Protocol

VENTILATOR ASSOCIATED PNEUMONIA
Pseudomonas aeruginosa
Or
Klebsiella pneumoniae(ESBL)
Or
Acinetobacter species
Beta Lactam + beta lactamase inhibitor
(Piperacillin – Tazobactam)
Plus
Aminoglycoside (Amikacin,
Gentamicin, /Tobramycin)
OR
Antipseudomonal fluoroquinolone
(Cipro/ Levofloxacin)for Ps aeruginosa
Methicillin – Resistant
Staphylococcus Aureus (MRSA)
Vancomycin or Linezolid

. VENTILATOR ASSOCIATED PNEUMONIA
.Second line Therapy
Meropenem – 60 mg/kg/day I/V every 8 hourly +
Vancomycin - 40 mg/kg/day I/V every 6 - 8 hourly
.Third line Therapy
Colistin IV., 2.5 – 5 mg/kg/day I/V every 6 – 12 hourly (1mg= 30000 IU)+
Vancomycin - 40 mg/kg/day I/V every 6 - 8 hourly

1.3 CNS Infections
Acute bacterial Meningitis
• Ceftriaxone 2 g IV 12hourly/ Cefotaxime 2 g IV 4-6hourly 10-14
days treatment
• Meningitis-Post- neurosurgery or Penetrating head trauma
• Amikacin 2gm IV 8 hourly +Vancomycin+Metronidazole
15mg/kg IV 8 hourly for 14 days.
Brain abscess, Subdural empyema
• Ceftriaxone 2 gm IV 12hourly /Cefotaxime 2 gm IV 4-6 hourly
+Metronidazole 1 gm IV 12 hourly

2. Surgical Antimicrobial Prophylaxis
• To be administered within 1 hr before the surgical incision.
• Single dose is recommended. Consider for second intra-
operative dose in prolong surgery (if it exceeds more than 2
half lives of the given antibiotic/4hrs) based on the choice of
antibiotic used for prophylaxis.
• Prophylaxis should not be given beyond surgery duration

Neurosurgery Inj.Cefazolin 2gm IV stat or Inj.Cefuroxime 1.5gm IV stat
Trauma Inj.Cefuroxime 1.5gm IV stat and q12h (for 24hours) Or
Inj.Ceftriaxone2gm IV OD
Signature ICO (HISS) Signature HOD
(Dr. Veena Kumari H.B) (Dr. Nagarathna)
Professor Professor & HOD
Dept.of Neuromicrobiology Dept.of Neuromicrobiology

Ward and ICU antibiogram
NIMHANS 2019

Isolates from CSF sample from All
ICUs+ Wards:
Organism Number Antibiotics % sensitivity
NFGNB 7 Colistin 100
Piper+ tazo 40
Cefo+ Sul 40
Imipenem 45
Amikacin 50
Cipro 47
Oflox 29
Klebsiella 19 Colistin 100
Piper+ tazo 100
Cefo+ Sul 75
Imipenem 80
Amikacin 40
Cipro 42
Oflox 20

15%
41%
22%
22%
Distribution of organism
NFGNB
Klebsiella
E.coli
Pseudomonas

0
10
20
30
40
50
60
70
80
90
100
NFGNB Klebseilla E.coli pseudomonas
Colistin
Piper+ tazo
Cefo+ Sul
Imipenem
Amikacin
Cipro
Oflox

ANTIMICROBIAL STEWARDSHIP
• Antimicrobial stewardship is a coordinated program that promotes the
appropriate use of antimicrobials (including antibiotics), improves patient
outcomes, reduces microbial resistance, and decreases the spread of
infections caused by multidrug-resistant organisms.
• 5D’s are essential for optimal antimicrobial therapy which includes
diagnosis/indication, right drug, right dose, right duration of therapy and de-
escalation to pathogen-targeted therapy.
Association for Professionals in Infection Control and Epidemiology, Inc
ICMR AMSP Guideline

• Today, AMS is one of three “pillars” of an integrated approach to
health systems strengthening.
• The other two are infection prevention and control (IPC) and
medicine and patient safety.
• When applied in conjunction with antimicrobial use surveillance, and
the WHO essential medicines list (EML) AWaRe classification (ACCESS,
WATCH, RESERVE), AMS helps to control AMR by optimizing the use
of
WHO 2019

Purpose of antimicrobial stewardship programme
• Primary goal-
To optimise safe and appropriate use of antibiotics to improve clinical
outcomes and minimize adverse effects of antibiotics.
• Secondary goal-
1.To reduce health care cost without adversely impacting quality of patient
care
2. To reduce antibiotics induced collateral damage
AMSP Guidelines ICMR 2018

Stewardship approaches and stategies Description Advantages
/

Stewardship approaches and strategies Description Advantages

Formulary Restriction. -
• Example-most hospitals carry only one echinocandin antifungal.
• Making only certain drugs available is a way to steer clinicians toward the use of
those drugs

Important criteria for switching (from i.v. to oral therapy) comprises-
1.Good oral absorption
2.Temperature less than 380C for 24 to 48 hours.
3.NO signs of sepsis
4.appropriate oral antibiotic is available
5.increase tissue penetration of antibiotic.

AMSP Guidelines 15_11_2018.

Few suggested antibiotic conversion regimen

Summary
• Antibiotic resistance is global problem and multifactorial.
• Much of increase in MDR bacteria can be attributed to the
overuse of broad-spectrum anti-microbials.
• Efforts to develop antimicrobial over past two decades have
lagged behind the rapid evolution of resistance developing in
both gram positive and gram negative pathogens.
• AMS (Antimicrobial stewardship) has direct impact on optimal
clinical outcomes with fewer adverse effects,cost-effective
and helps to prevent the emergence of resistance.

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Rational use of antibiotics ppt -Dr AVINASH KUMAR SENIOR RESIDENT DM NEUROLOGY ( JANUARY 2020 -DECEMBER 2022 SESSION) NIMHANS BANGALORE

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