Sepsis, septic shock, sepsis induced hypotension, SIRS, common pathogens, trends of antimicrobial resistance. Emperical antibiotic therapy, Classification of surgical site infections with specifications regarding site specific pathogens and peri-operative prophylaxis

1. Treatment Guidelines for
Antimicrobial Use in Common
Syndromes
Based on ICMR Guidelines,
New Delhi, India(2017)
Dr SD Sanyal

2. Principles of Initial Empirical
Antimicrobial Therapy in Patients
with Severe Sepsis and Septic
Shock in The Intensive Care Units

3. Definitions
• SIRS:
- Two or more of the following variables:
i. Fever > 38°C (100.4°F) or hypothermia <
36°C (96.8°F)
ii. Tachypnea (>20 breaths/min) or PaCO2 < 32
mmHg
iii. HR >90 beats/min
iv. WBC > 12,000/<4000 cells/mm3, 10%
immature band forms

4. Definitions
• Sepsis : Systemic inflammatory response
syndrome that occurs due to a “known or
suspected” pathogen (bacteria, viruses, fungi
or parasites)

5. Definitions
• Severe sepsis:
- Sepsis plus evidence of organ dysfunction or tissue hypoperfusion
as follows:
i. Altered mental status.
ii. Hypoxemia, with PaO2/FIO2 <250
iii.Thrombocytopenia < 100,000/cmm
iv. Bilirubin >2mg/dl
v. INR >1.5 or aPTT> 60 seconds.
vi. Urinary output of 0.5 ml/kg for at least 2 hours or Serum
creatinine >2mg/dl despite fluid resuscitation.

6. Definitions
vii. Tissue hypoperfusion as suspected by mottled skin,
capillary refilling time ≥ 2 seconds or lactate >4 mmol/l
viii. Hypotension : Systolic blood pressure (SBP) ≤90
mmHg or mean arterial pressure ≤70 mm Hg
• Sepsis induced hypotension: SBP<90mmHg or
MAP<70mmHg or SBP fall > 40 mm Hg
• Septic shock:
- Sepsis induced hypotension that persists despite
adequate fluid resuscitation, requiring vasopressors to
maintain the blood pressure.

7. Common Pathogens
• Gram negative:
-Pseudomonas aeruginosa
-E. coli
-Klebsiella pneumoniae
-Acinetobacter spp

8. Common Pathogens
• Gram Positive:
- Methicillin resistant Staphylococcus aureus
(MRSA)
- Entercoccus faecium
- Vancomycin resistant enterocccci
• Fungi:
- Candida spp

9. Susceptible Individuals
• Antimicrobial therapy in preceding 90 days
• Current hospitalization of 5 days or more
• High frequency of community or hospital
antibiotic resistance
• Immunosuppressive disease or therapy

10. Susceptible Individuals
• Presence of multiple risk factors for Health Care
Associated Infections:
- Hospitalization for ≥2 days in preceeding 90
days
- Residence in nursing home or long term care
facility
-Home infusion therapy
-Chronic dialysis within 90 days
-Family member with MDR pathogen

11. Patterns of Antimicrobial
Resistance

12. S.aureus and Enterococci

13. Enterobacteriacae

14. P. aeruginosa & A.baumanii

15. Candida species

16. Principles of Emperical Therapy
• Form probable diagnosis
• Obtain cultures
• Source control
• Broad spectrum cover
• Antibiotics within the first hour
• Early Antifungal cover
• Antivirals

17. Choice of AMA
• The suspected site of infection
• The clinical syndrome
• The setting in which the infection developed
(i.e., home, nursing home, or hospital)
• Medical history
• Epidemiology, susceptibility patterns of bacteria
in the hospital and ICU, local microbial-
susceptibility patterns, resistance potential

18. Choice of AMA
• Prior antibiotic therapy(previous 3 months)
• Immunological competence of patient
• Severity of underlying illness
• Microbes that previously have been documented to
colonize or infect the patient
• Pharmacokinetics of the chosen antimicrobial agent
• Drug allergies / toxicities
• Cost

19. De-escalation
• As soon as the causative organism is identified
on culture
• Choose an agent which is CHEAP and COST
EFFECTIVE
• Daily reassessment to perform de-escalation
and prevent resistance, reduce costs and avoid
super-infections
• Use of LOW PROCALCITONIN levels

20. Recomendations
Clinical
condition
Common
pathogens
Emperical AMA Alternate AMA Comments
Urosepsis E. coli,
Pseudomonas
spp,
Enterococcus
spp.,
Klebsiella spp.,
Proteus spp.,
Anaerobes
Candidia spp
BL-BLI or
Meropenem or
Imipenem-
cilastatin.
Fluconazole if
Candida
Colistin with
Meropenam
In
pyelonephritis
with sepsis,
Echiocandins
may be
considered if
Candida
species
are likely to be
resistant to
Fluconazole

21. Recommendations
Clinical
condition
Common
pathogens
Emperical AMA Alternate AMA Comments
Intra-
abdominal
Sepsis
E. coli,
Pseudomonas
spp,
Enterococcus
spp.,
Klebsiella spp.,
Acinetobacter
spp,
Proteus spp.,
Candidia spp
BL-BLI or
Meropenem or
Imipenem-
cilastatin.
Colistin with
Meropenam
Source control
vital
Vancomycin or
Teicoplanin if
Enterococcus
spp isolated
Fluconazole or
Echinocandins
if Candida spp
isolated
Echinocandins
if prior h/o
Azole exposure
or Fluconazole
resistance is
suspected

22. Recommendations
Clinical
condition
Common
pathogens
Emperical AMA Alternate AMA Comments
Catheter
related
blood
stream
infections
Gram –
negative
pathogens
Ecoli Klebsiella
spp
Enterobacter
spp
P aeruginosa
Gram-positive
pathogens
CONS
S aureus,
MRSA
Fungi
Candida spp
Carbapenem,
or BL-BLI,
with or without
an
aminoglycoside
Vancomycin in
settings of high
MRSA
prevalence;
Echinocandin
or fluconazole
if fungal
infection
suspected
Add colistin for
Gram-negative
cover where
carbapenem
resistance rates
are high
Where MRSA
isolates have
vancomycin
MI 2 mg/mL,
daptomycin,
should be used

23. Cause Undetermined

24. Surgical Site Infections

25. Classification of Surgical Wounds
• Class I/Clean:
-Uninfected, operative wound with no inflammmation
and Resp/GI/Genital/Urinary tract is not entered
• Class II/Clean contaminated:
- Resp/GI/Genital/Urinary tract is entered under
controlled conditions without unusual contamination
• Class III/Contaminated:
- Open fresh accidental wounds. Operations with major
break in sterile technique with gross spillage from GIT
• Class IV/ Dirty-infected:
- Old traumatic wounds with retained devitalized tissue
and those that involve existing clinical infections and
perforated viscera

26. Superficial Incisional SSI
- Within 30 days of surgery and infection involves only
skin or SC tissue of the incision+ 1 of the following:
1. Purulent drainage, with or without laboratory
confirmation, from the superficial incision
2. Organisms isolated from an aseptically obtained
culture of fluid or tissue from the superficial incision
3. At least one of the following signs or symptoms of
infection:
- pain or tenderness
- localized swelling, redness, heat
- superficial incision is deliberately opened by surgeon,
unless incision is culture-negative
4. Diagnosis of superficial incisional SSI by the surgeon
or attending physician

27. Superficial Incisional SSI
• Following conditions not to be reported as SSI:
- Stitch abscess
- Infection of an episiotomy or newborn
circumcision site
- Infected burn wound
- Incisional SSI that extends into the fascial
and muscle layers (see deep incisional SSI)

28. Deep Incisional SSI
- Within 30 days without implant or within 1 year with implant
- Infection is likely due to surgery and involves fascial and muscle
layers) + 1 of the following:
1. Purulent drainage from the deep incision but not from the
organ/space component of the surgical site
2. Spontaneous dehiscence/deliberate opening by a surgeon when
the patient has at least 1 of the following :
- Fever (>38ºC)
- Localized pain or tenderness, unless site is culture-negative
- An abscess or infection of the deep incision is found on direct
examination, during reoperation, or by histopathologic or radiologic
examination.
- Diagnosis of a deep incisional SSI by a surgeon or attending
physician.

29. Deep Incisional SSI
• Notes:
i. Report infection that involves both
superficial and deep incision sites as deep
incisional SSI
ii. Report an organ/space SSI that drains
through the incision as a deep incisional SSI

30. Organ space SSI
• Within 30 days after the operation if no implant is left in place
or within 1 year if implant is in place
• Appears to be related to the operation and infection involves
any part of the anatomy (e.g., organs or spaces), other than
the incision, which was opened or manipulated during an
operation and + 1 of the following:
-Purulent drainage from a drain
- Organisms isolated from an aseptically obtained culture of fluid or tissue
in the organ/space.
- An abscess or other evidence of infection involving the organ/space that
is found on direct examination, during reoperation, or by histopathologic
or radiologic examination.
-Diagnosis of an organ/space SSI by a surgeon or attending physician.

31. Operations and Likely Surgical Site Infection
(SSI) Pathogens

32. Operations and Likely Surgical Site Infection
(SSI) Pathogens

33. Resistance patterns of S.aureus

34. Resistance patterns of Enterobacteriacae

35. Resistance patterns of Pseudomonas

36. Peri-operative Prophylaxis
• Choice of AMA:
- Dictated by the most common pathogen
encountered
- Skin pathogens are usual targets: 1st
Generation Cephalosporins
- H/o allergy to penicillins:
Vancomycin/Clindamycin
• Timing of administration:
- Before skin incision
- All agents 30-60 mins prior
- Vancomycin and Flouroquinolones 120mins
prior

37. Peri-operative Prophylaxis
• Route of administration:
- Intravenous
• Dosage:
- Same as therapy
• Duration:
- No longer than 24hrs
- Single dose as effective as multiple doses
- Multiple doses assoc with a higher risk of Resistance
& Colitis
• Re-dosing:
- If duration of surgery exceeds 2 x half lives
- Blood loss > 1500ml or Haemodilution> 15ml/kg

38. Pathogen specific AMA therapy

39. AMA Guidelines for SSI’s

40. AMA Guidelines for Skin & Soft tissue infections

41. AMA Guidelines for Skin & Soft tissue infections

42. Dosages of AMA’s active against MDR organisms

43. Thank You