3. “Antimicrobial resistance, as I say
again and again, is a slow-motion
tsunami. It is a global crisis that
must be managed with the utmost
urgency.”
Dr. Margaret Chan
New York
April 18, 2016
2
4. Core competencies for
antimicrobial prescribing
C1: Understands the patient and the patient’s clinical needs
C2: Understands treatment options and how they support the
patient’s clinical needs
C3: Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
C4: Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
C5: Monitors and reviews the patient’s response to treatment
3
Core Competencies
5. Objectives
• Understand how the emergence of antimicrobial resistance in
a particular hospital jeopardizes patients with nosocomial
infections, like ventilator-associated pneumonia
• Illustrate the importance of obtaining appropriate specimens
for culture and using these results to optimize the use of
antibiotics.
• Emphasize the appropriate duration of therapy for ventilator
associated pneumonia
4
6. Ventilator-associated pneumonia (VAP)
5
• Among the most
common hospital-
acquired conditions
• Associated with longer
hospitalizations and
intense resource
utilization
7. Epidemiology of VAP
6
• Distinct from
community-acquired
pneumonia
• Hospitalized patients
often colonized with
nosocomial pathogens
8. A hospital’s microbial ecology
7
Several factors contribute
including:
• Patient population
• Intensity of antibiotic
use
• Infection control
precautions
10. 65 year-old female ICU patient with:
congestive heart failure
developed respiratory failure
requiring mechanical ventilation
developed renal insufficiency
9
11. 65 year-old female ICU patient who:
On hospital day #4, developed fever
increased suctioning requirements
increased oxygenation requiremnts
diffuse rhonchi
chest x-ray with new right lower lobe
infiltrate
10
14. What is the likely source & pathogens?
Severity Source
Drug
resistance
Patient
factors
Cultures
• Clinical picture consistent with VAP
13
15. What is the likely source & pathogens?
Severity Source
Drug
resistance
Patient
factors
Cultures
• Clinical picture consistent with VAP
• Most common organisms: S. aureus &
• gram-negative organisms
14
17. Severity Source
Drug
resistance
Patient
factors
Cultures
How likely is resistance?
16
Risk factors for infection due to MDROs:
• Intravenous antibiotics within 90 days
• Septic shock at time of VAP diagnosis
• Acute respiratory distress syndrome
• Renal replacement therapy prior to
VAP
2016 American guidelines
18. Severity Source
Drug
resistance
Patient
factors
Cultures
How likely is resistance?
17
Consider empiric therapy directed at
methicillin resistant Staphylococcus
aureus (MRSA) if:
• Patient received intravenous antibiotics
within 90 days
• Prevalence of MRSA in your hospital
>10 – 20%
2016 American guidelines
19. Severity Source
Drug
resistance
Patient
factors
Cultures
How likely is resistance?
18
Consider empiric therapy directed at MDR
gram-negative pathogens if:
• Prevalence of resistance among gram-
negative pathogens in your hospital
>10 % or unknowns
2016 American guidelines
24. Return to case
Subsequent evaluation
Initial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
23
Core Competencies 1, 2, 4 & 5
25. 48 hours after initiation of antibiotics…
less suctioning requirements
decreased ventilator support
requirements
afebrile for last 24 hours
blood cultures without growth
24
26. 48 hours after initiation of antibiotics…
25
• Endotracheal aspirate culture:
Pseudomonas aeruginosa
– Susceptible to cefepime,
piperacillin-tazobactam,
aminoglycosides
– Resistant to
fluoroquinolones
29. Does the microbiologic data make sense?
28
• Some cultures obtained
through endotracheal
tubes represent
colonization instead of
infection.
WHO/A. Kristensen
30. Verify the spectrum of therapy
Review
micro-
biologic
data
Assess
spectrum
Check for
adverse
effects
Evaluate
route &
duration of
therapy
MRSA not isolated in culture
29
31. Verify the spectrum of therapy
Review
micro-
biologic
data
Assess
spectrum
Check for
adverse
effects
Evaluate
route &
duration of
therapy
De-escalation:
Anti-bacterials to target
Pseudomonas isolated in culture
30
33. How long and by which route?
Review
micro-
biologic
data
Assess
spectrum
Check for
adverse
effects
Evaluate
route &
duration of
therapy
7 days for most
patients with VAP
32
34. How long and by which route?
Review
micro-
biologic
data
Assess
spectrum
Check for
adverse
effects
Evaluate
route &
duration of
therapy
Durations tailored to
individual patients
Consider use of
procalcitonin if
available
33
35. Prevention of VAP
34
Interventions include:
• Minimizing sedation
• Assessing for extubation
readiness
• Minimizing pooling of
secretions
• Elevating head of bed
