ICN Victoria: Padiglione on "Antimicrobial Stewardship in ICU"
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ICN Victoria presents Alex Padiglione from Alfred Health and Monash Health talking on antibiotic stewardship in the ICU.
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ICN Victoria: Padiglione on "Antimicrobial Stewardship in ICU"
- 1. Antimicrobial stewardship Alex Padiglione Alfred Health, Monash Health Melbourne
- 2. Disclosures Symposium at University Malaya, KL travel only funded by MSD Alfred ICU symposium receives Pharma support No advisory boards or personal remuneration
- 3. STEWARDSHIP
- 5. STEWARDSHIP = STEWARD you onto Space SHIP Insert Electrodes – Inflict PAIN If just THINK of using antibiotics
- 6. Houston , we have a problem…
- 7. More antibiotics = more resistance O.R. VRE Prior - Imi/Meropenem 2.8 Timentin 3.6 Padiglione AAC 2003 Imipenem resistant Gram negs Imipenem 1-3 days 5.9 >3 days 7.8 Penicillin – protective! 0.3 Armand-Lefevre AAC 2013
- 8. Increased Resistance… Increases complexity, morbidity & (us.) mortality Usually adds to, not substitutes for, burden of disease ie More MRSA = More Staph infections Get rid of MRSA = Fewer Staph infections
- 9. Did you kill someone today? USA: Nosocomial infection 8th commonest killer Thailand: Antibiotic resistance = 0.6% GDP Collateral damage - not obvious to treating doctor
- 10. … teamwork- shared values! ICU & ID: Less resistance Less complications Lower Mortality Enjoy work
- 11. Outcome measures Less resistance Less complications Lower Mortality Enjoy work Process measures, not outcomes! Save money Pleasant side effect! Use less Echinocandins/Lipo Ampho B Linezolid/Tigecycline/Dapto mycin
- 12. Good antibiotic use Quality intervention Process measures, not outcomes! Save money Pleasant side effect! Use less Echinocandins/Lipo Ampho B Linezolid/Tigecycline/Dapto mycin
- 17. ID consult in sepsis? Significantly lower Mortality Schmitt CID 2014 (May);58(1):22–8 Fowler VG CID 1998;27:478–86. Doern J Clin Microbiol 1994; 32:1757–62 Elhanan G J Infect 1997; 35:283–8 Byl Clin Infect Dis 1999; 29:60–6 Nathwani QJM 1996; 89:789–97
- 19. How you do something more important than what you do …as long as you get a few basics right
- 20. The basics… Better diagnostics/Biomarkers as available Optimize antibiotic use 1. Guidelines based on local ecology A-I 2. Pk/Pd adequate timing/dosing/duration A-II 3. Streamlining based on microbiology or clinical improvement A-II 4. Shorter courses virtually always effective in well-controlled trials A-I Regular review/ timely action Rapid source control Audit what you do A-I Adapted from CID 2007 44:159-77
- 21. Better Diagnosis Better specimens Before starting antibiotics BC – yield 2-3 x lower after antibiotics BAL – yield halves 12 hrs after antibiotics % hrs
- 22. But we don’t do it! BCs in Sepsis Sets 50% after antibiotics 21% investigated properly >2 sets, 8-12ml blood/bottle Local audit, Alfred hospital %
- 23. Taking BCs before antibiotics saves lives Li et al Chin Med J 2013; 126: 1819-1825 Similar findings in: Cardoso et al. Critical Care 2010
- 24. Molecular methods – now! PCR Maldi -TOF PCR – ESI-TOF Soon - most pathogens in 1-2 hrs Implementation is key Stewardship more important than ever!
- 25. Non automated or Automated - Improvements shown with both! Ibrahim, 2001, Singh, 2000, Evans, 1994; Evans, 1994; Evans, 1998 Implementation! “used to control costs rather than improve outcomes” Sintchenko, 2001 “Local is best” Onion, 1998 Clear, short, relevant!
- 26. Shorter duration/Streamlining Surgical peritonitis – after source control 4 days as good as 8 ! Sawyer et al NEJM 2015; 372: 1996-2005 De-escalation may lower mortality in sepsis! Garnacho-Montero ICM 2014; 40:32-40
- 27. Better diagnostics/Biomarkers as available Explicit antibiotic policy 1. Guidelines– based on local ecology 2. Adequate timing/dosing/duration 3. Rapid Streamlining - based on microbiology or clinical improvement 4. Shorter courses: virtually always effective in well-controlled trials Regular review/ timely action Rapid source control Audit what you do
- 28. Sepsis mortality thanks to David Pilcher
- 29. Antibiotic audit Meropenem Only Haem, Lung Tx, ID Often not required Alfred Local data 2012
- 30. Resistance - Gram positives Days Organism Penicillin Amoxycillin Fluclox Piperacillin Cephazolin Vancomycin Linezolid Daptomycin Teicoplanin 1 MSSA R R S S S S S S S 2 MSSA R R S S S S S S S 2 MRSA R R R R R S S S S 2 Strep pyogenes S S S S S S S S S 3 E faecalis S S S S R S S S S 3 MSSA S S S S S S S S S 4 MSSA R R S S S S S S S 5 MRSA R R R R R S S S S 6 MSSA R R S S S S S S S 6 MSSA R R S S S S S S S 7 MRSA R R R R R S S S S 8 Strep pneumoniae S S S S S S S S S 8 VRE R R R R R R S S S 8 MSSA R R S S S S S S S 9 E faecalis S S S S R S S S S 24 MRSA R R R R R S S S S 63 E faecalis R S S S R S S S S Return of MRSA- 4 cases! 3 another hospital: Frankston, Mildura, Vietnam 1 Hematology
- 31. Gram neg Day Organism Amoxy Piptaz Cephazolin Ceftriaxone Cefepime Meropenem Ciprofloxacin Gentamicin Tobramycin Amikacin 1 E coli S S S S S S S S S S 1 E coli R R R R U S S S S S 1 Plesiomonas R S* R S* S* S* S* S S S 1 E coli R S S S S S S S S S 1 E coli R S S S S S S S S S 1 Pseudomonas R S R R S S I S S S 2 E coli R R R R U S S S S S 3 E coli R R R R R S R R R S 3 Pseudomonas R S R R S S S S S S 6 Escherichia coli S S S S S S S S S S 6 Pseudomonas R S R R S S S S S S 8 E coli S S S S S S S S S S 10 Pseudomonas R S R R S S S S S S 13 E coli R R R R R S S R R S 16 Pseudomonas R R R R S S I S S S
- 32. Candida Days Organism Flu Vori Ampho Caspo 4 albicans S S S S 6 albicans S S S S 7 glabrata S S S S 11 albicans S S R S 12 albicans S S S S
- 33. Finally, if ID want to influence ICU… “Patient characteristics, antibiotic therapies do not influence ….. In contrast, the ward & its characteristics play a major role” Pulcini et al JAC 2005 Culture is everything
- 34. Good communication / respect Multidisciplinary, interested, Led by ICU Portfolio responsibility: Intensivist (senior), ID, Pharmacy ID ICU Useful Engage Available Demand quality Don’t interrupt Don’t mention costs Educate
- 35. “If this is work, then this is the closest work ever gets to fun”
Editor's Notes
- Emergence of imipenem-resistant gram-negative bacilli in intestinal flora of intensive care patients. Armand-Lefèvre L1, Angebault C, Barbier F, Hamelet E, Defrance G, Ruppé E, Bronchard R, Lepeule R, Lucet JC, El Mniai A, Wolff M, Montravers P, Plésiat P, Andremont A. Author information Abstract Intestinal flora contains a reservoir of Gram-negative bacilli (GNB) resistant to cephalosporins, which are potentially pathogenic for intensive care unit (ICU) patients; this has led to increasing use of carbapenems. The emergence of carbapenem resistance is a major concern for ICUs. Therefore, in this study, we aimed to assess the intestinal carriage of imipenem-resistant GNB (IR-GNB) in intensive care patients. For 6 months, 523 consecutive ICU patients were screened for rectal IR-GNB colonization upon admission and weekly thereafter. The phenotypes and genotypes of all isolates were determined, and a case control study was performed to identify risk factors for colonization. The IR-GNB colonization rate increased regularly from 5.6% after 1 week to 58.6% after 6 weeks in the ICU. In all, 56 IR-GNB strains were collected from 50 patients: 36 Pseudomonas aeruginosa strains, 12 Stenotrophomonas maltophilia strains, 6 Enterobacteriaceae strains, and 2 Acinetobacter baumannii strains. In P. aeruginosa, imipenem resistance was due to chromosomally encoded resistance (32 strains) or carbapenemase production (4 strains). In the Enterobacteriaceae strains, resistance was due to AmpC cephalosporinase and/or extended-spectrum β-lactamase production with porin loss. Genomic comparison showed that the strains were highly diverse, with 8 exceptions (4 VIM-2 carbapenemase-producing P. aeruginosa strains, 2 Klebsiella pneumoniae strains, and 2 S. maltophilia strains). The main risk factor for IR-GNB colonization was prior imipenem exposure. The odds ratio for colonization was already as high as 5.9 (95% confidence interval [95% CI], 1.5 to 25.7) after 1 to 3 days of exposure and increased to 7.8 (95% CI, 2.4 to 29.8) thereafter. In conclusion, even brief exposure to imipenem is a major risk factor for IR-GNB carriage.
- Standard of care – defined as normalisation of WCC (<11,000); afebrile for 24 hrs; gut working (tolerating feeds at least 50% of desired volume) In study by Garnacho-Montero the mortality predictors in sepsis were: Septic shock SOFA score Inadequate Px Failure to de-escalate (still protective if apply propensity score or in subgroup who got appropriate treatment) Garnacho-Montero ICM 2014; 40:32-40