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The ABC of ICU – The A is for antibiotics - Steve McGloughlin

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Sepsis is incredibly dangerous for our patients and very topical in ICU and Emergency. In intensive care and emergency medicine we rightly dissect and discuss extensively how best to resuscitate patients, Airway, Breathing, Circulation – the ABC! Our training focuses on the urgency and adequacy of resuscitation and the provision of excellent supportive care. However, for the critically ill, especially in sepsis, we have very few therapies available that actually change the natural history of illness and can cure our patients. Surely that is what being a doctor is all about – helping people and changing the course of their illness – giving the patient a chance to survive!

Over 75% of patients in ICU will receive antibiotics and the choice, timing and dose will directly influence your patients chance of surviving. Antibiotics are one of the few truly disease modifying therapies we have available and by far the one we utilize the most.

In addition, no other therapy is important to not only get right for the patient you are treating but, in the case of antibiotics, the therapy for one patient may influence other patients. Attention to correct antibiotic use might save the patient in front of you. However thoughtless antibiotic use might make it harder to save the next patient by increasing antibiotic resistance in your unit.

How and why must we get antibiotics right?

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The ABC of ICU – The A is for antibiotics - Steve McGloughlin

  1. 1. A is for Antibiotics After that we are STUCK Steve McGloughlin The Alfred
  2. 2. SEPSIS
  3. 3. Sepsis is
  4. 4. Severe Infection (sepsis)………
  5. 5. Age GCS Temp HR MAP pH P/F Ratio Creatinine 51 13 39 125 55 7.14 180 140 ARISE PROCESS PROMISE APACHE 25
  6. 6. Age GCS Temp HR MAP pH P/F Ratio Creatinine 55 13 39 125 55 7.14 150 140 ARISE PROCESS PROMISE APACHE 25 MORTALITY 45%
  7. 7. In Intensive Care………
  8. 8. Severe Infection
  9. 9. ? Severe Infection ED and ICU
  10. 10. Intensivists
  11. 11. Intensivists
  12. 12. Intensivists
  13. 13. Severe Infection ? Support Fluids Dialysis Goal Directed Therapy?
  14. 14. Severe Infection ? Definitive Antibiotics Source Control
  15. 15. Severe Infection ? Support Antibiotics Source Control We need something else!
  16. 16. Sepsis is
  17. 17. What do we have….
  18. 18. NNT
  19. 19. Why Not?
  20. 20. Sick Very Sick Which Antibiotic? I want you to be honest?
  21. 21. The thoughtless person playing with penicillin treatment is morally responsible for the death of the person who succumbs to infection with the penicillin resistant organism.
  22. 22. Pandrug resistant
  23. 23. 214000 neonatal sepsis deaths attributable to resistant pathogens
  24. 24. Figure 1: Estimated pneumonia deaths avertable in under-5 populations with improved antibiotic access Countries with less than 100 deaths averted are not labelled. Data on under-5 population with suspected pneumonia receiving antibiotics are from 1990 to 2013; data from the most recent year reported is used, when available. 0 20 40 60 80 Trendline weighted by the under-5 population of each country 100 0 1 2 3 4 5 6 Pneumoniadeaths(duetoStreptococcuspneumoniaeandHaemophilus influenzaetypeb)per1000childrenagedyoungerthan5years Under-5 population with suspected pneumonia receiving antibiotics (%) India Nigeria DR Congo Pakistan China Ethiopia Afghanistan Sudan Indonesia Somalia Mali Niger Uganda Chad Tanzania Burkina Faso Kenya Yemen Mozambique Cameroon Myanmar Philippines Côte d’Ivoire Bangladesh Guinea Iraq Madagascar Nepal Malawi Ghana Burundi Benin Sierra Leone Uzbekistan Zambia Egypt Haiti Senegal Iran Central African Republic Togo Vietnam Morocco Brazil Rwanda Zimbabwe Mauritania Cambodia Tajikistan Algeria Congo (Brazzaville) Guinea−Bissau Bolivia ColombiaTurkey Thailand North KoreaLaos Argentina KazakhstanPeru Timor−Leste Dominican Republic Equatorial Guinea Kyrgyzstan Syria Gambia Comoros Swaziland Honduras Paraguay Ukraine India (169760) Nigeria (49407) Nepal (2434) Hypothetical under-5 pneumonia deaths averted with universal antibiotic access 1 million Avoidable deaths in 2013 in under 5’s from pneumonia 170 000 deaths in India avoidable with Antibiotics
  25. 25. We need more than antibiotics?
  26. 26. A disease caused by an uncontrolled division of abnormal cells in a part of the body. Life-threatening organ dysfunction due to a dysregulated host response to infection Cancer is Sepsis is
  27. 27. One definition?
  28. 28. f not recognized early and treated promptly Heart Brain Lung Infection Liver Kidney From a lo general i A local infect comes the bo Pathogenic g produce leave infection and Stage1 The source changes the risk of death
  29. 29. MULTIDRUG-RESISTANT PSEUDOMONAS AERUG 6,700 44MULTIDRUG-RESISTANT PSEUDOMONAS INFECTIONS DEATH THREAT LEVEL SERIOUS This bacteria is a serious concern and requires prompt and sustained action to ensure the problem does not grow. 51,000 PSEUDOMONAS INFECTIONS PER YEAR MET STA (MR THREAT LEVEL SERIOUS This bacteria is a serious concern and requires prompt and sustained action to ensure the problem does not grow. Methicillin-resistant Staphylococcus aureus (MRSA) causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can cause sepsis and death. Staph bacteria, including MRSA, are one of the most common causes of healthcare-associated infections. The bugs are not the same…
  30. 30. Pathology is not the same
  31. 31. The Narrow Spectrum Era……. 1925 1950 1975 2000 2025 Golden Era Nature products Medicinal Chemistry Era Synthetic tweaking Resistance era Target based, broad spectrum Narrow-Spectrum era Unconventional Combination approaches Diagnostic development 1925 1975 2000 2025 1950
  32. 32. The Narrow Spectrum Era……. 1925 1950 1975 2000 2025 Golden Era Nature products Medicinal Chemistry Era Synthetic tweaking Resistance era Target based, broad spectrum Narrow-Spectrum era Unconventional Combination approaches Diagnostic development 1925 1975 2000 2025 1950
  33. 33. Sepsis is
  34. 34. If ICU and ED want to own sepsis…..
  35. 35. In memory of my sister Bec
  36. 36. Most people spend their time and energy going around problems rather than in trying to solve them. Henry Ford

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