1 / 37

Antibiotics in Acute Respiratory Failure

Antibiotics in Acute Respiratory Failure. Robin J Green PhD Division of Paediatric Pulmonology University of Pretoria. Definitions. ALI- acute onset of impaired gas exchange PaO 2 /FIO 2 <300 ARDS- PaO 2 /FIO 2 <200 Oxygenation index=( MAP x FI02/Pao2)x100. Acute Lung Injury. CAP

aman
Download Presentation

Antibiotics in Acute Respiratory Failure

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Antibiotics in Acute Respiratory Failure Robin J Green PhD Division of Paediatric Pulmonology University of Pretoria

  2. Definitions • ALI- acute onset of impaired gas exchange PaO2/FIO2 <300 • ARDS- PaO2/FIO2 <200 • Oxygenation index=( MAP x FI02/Pao2)x100

  3. Acute Lung Injury • CAP • HIV-associated pneumonia • HAP/VAP • Viral lung disease

  4. Definition CAP • Acute infection (less than 14 days) acquired in the community, of the lower respiratory tract, leading to cough or difficulty breathing, tachypnoea or chest-wall indrawing • Accounts for 30-40% of all hospital admissions • Case fatality rate 15-28% Zar HJ, et al SAMJ 2005

  5. Causes CAP • Bacterial: - Strep Pneumoniae - Haemophilus influenzae - Staph aureus - Moraxella catarrhalis • Atypical bacteria - Mycoplasma pneumoniae - Chlamydaphila pneumoniae/trachomatis • Viral - RSV - Human metapneumovirus - Parainfluenza - Adenovirus - Influenza - Rhinovirus - Measles virus

  6. Causes of CAP • In addition in HIV-infected children • Gram-negative bacteria • Staph aureus (including CA-MRSA) • TB • Fungi

  7. Organisms cultured - Ward

  8. Treatment CAP • Antibiotis for all – Amoxicillin (90mg/kg/day tds 5 days) – (IV Ampicillin) • < 2 months add aminoglycoside/cephalosporin • > 5 years add macrolide • HIV - infection add aminoglycoside • HIV - exposed < 6 months add cotrimoxazole • AIDS add cotrimoxazole Zar HJ, et al SAMJ 2005

  9. HIV-infected children • No evidence that PK/PD principles are different to healthy children • All specimens showed resistance to co-trimoxazole. • SavitreeChaloryooInternational Journal of PediatricOtorhinolaryngology 1998; 44:103-107 • Brink A. Personnel communication

  10. PCP Pneumonia • Diagnosis: - Immune compromised - Respiratory distress and few crepitations - Interstitial pattern on CXR - LDH > 500 - PCR

  11. 3. Fluids in ARDS/ALI NHLBI and ARDS net - FACTT trial • Conservative fluid management strategy favoured • Increase in ventilator free days and reduction in ICU stay, lower OI, plateau pressure, PEEP, higher PaO2/FIO2 • No increase rates of shock or renal failure • Need to closely monitor electrolytes Calfee CS, Matthay MA. Chest 2007;131:913-19

  12. Managing Severe PCP Pneumonia • Lung protective strategies (low tidal volume, high PEEP) • Fluid restriction • TMX/SMX • Oral steroids • Treating CMV pneumonitis – Ganciclovir • Early introduction HAART

  13. Survival analysis, adjusted age and hospitalHazard ratio 0.54, 95% CI(0.29-1.02), p value 0.06 Hazard ratio 0.54 95% CI(0.29-1.02) p value 0.06 Terblanche A, et al. SAMJ 2008

  14. CMV Pneumonitis • Diagnosis: - CMV viral load > 10 000 copies/ml - Blood • CMV PCR – NBBAL • Treatment: • Ganciclovir (10mg/kg/dose BD) • Duration – 3 weeks after starting HAART

  15. HAP Definition • HAP – Pneumonia developing more than 48 hours after admission to hospital • VAP – Nosocomial infection occuring in patients receiving mechanical ventilation that is not present at the time of intubation and develops more than 48 hours after initiation of ventilation

  16. Epidemiology • Pneumonia = 2nd most common nosocomial infection • Accounts for 18 – 26% of nosocomial infections • Children aged 2 – 12 months most affected • 95% of nosocomial pneumonia occurs in ventilated children

  17. Risk Factors • Immunodeficiency • Immunosuppression • Neuromuscular blockage • Septicaemia • TPN • Steroids • H2-blockers • Mechanical ventilation • Re-intubation • Transport while intubated

  18. Microbiology • Early-onset VAP: - Strep pneumoniae - Haemophilus influenzae - Moraxella catarrhalis • Late-onset VAP (Resistant species): - Staph aureus - Pseudomonas aeruginosa - Lactose fermenting gram-negatives

  19. Organisms cultured - PICU

  20. Criteria for VAP for Infants Younger than 12 Months of AgeClinical Criteria / Radiographic Criteria Worsening gas exchange with at least 3 of the clinical criteria: • Temperature instability without other recognized cause • White blood cells <4,000/mm3 or > 15,000/mm3 and band forms > 10% • New onset purulent sputum or change in the character of sputum or increased respiratory secretions • Apnea, tachypnea, increased work of breathing, or grunting • Wheezing, rales, or rhonchi • Cough • Heart rate <100 beats/min or >170 beats/min plus radiographic criteria • At least 2 serial chest x-rays with new or progressive and persistent infiltrate, consolidate, cavitation or pneumatocele that develops >48 hours after initiation of mechanical ventilation Wright ML, et al. Semin Pedaitr Infect Dis 2006;17:58-64

  21. Prevention Strategies • Head of bed elevation • Daily sedation holidays • Stress ulcer prophylaxis • DVT prophylaxis • Pneumococcal vaccination • Change in ventilator circuits only when dirty • Avoidance of re-intubation • Orotracheal intubation • Oropharyngeal toilet

  22. Management • Antibiotic selection policies • De-escillation • Antibiotic rotation • Regular microbiology for a • Antibiotic STEWARDSHIP

  23. Dosage • Correct antibiotic dosages and duration • Correct antibiotic administration - Concentration dependent antibiotics (Aminoglycosides, quinolones) = single daily concentration - Time dependent antibiotics (B-lactams, vancomycin, pip-taz, carbapenems, linezolid) = continuous infusion over 24 hours or multiple dosings (3-4 hours for carbapenems)

  24. Duration • No culture = 3 – 5 days • Positive culture = 5-7 days. • Seldom need 10 days • Exceptions – Staph 2-3 weeks - PCP 3 weeks - Fungal 2-3 weeks

  25. De-escillation • If broad spectrum antibiotics or combinations used downgrade with positive culture and sensitivity • Vancomycin can be used alone • Single antibiotics = combinations

  26. Decontaminate • Hand washing – the most effective startegy to prevent resistance • All personnel and parents must hand wash • Anti-inflammatory strategies of Macrolides

  27. Dont • Use third generation cephalosporins routinely (except meningitis) • Use inappropriate antibiotics • Use a long course • Use too low a dose • Routinely combine antibiotics • Routinely use probiotics

  28. Antibiotics for ESBL • Carbapenem • - Meropenem • - Imipenem • - Ertapenem (Invanz) • Cefepime (Maxipime) • Piperacillin/tazobactam (Tazocin) • Never – Ciprofloxacin/3rd Generation Cephalosporins

  29. Risk factors for and outcomes of bloodstream infection caused by ESBL-producing Escherichia coli and Klebsiella species in childrenPaediatrics 2005;115: 942-949

  30. Antibiotics for MRSA • Vancomycin (highly protein bound – better for septicaemia) • Linezolid (Zyvoxid) – better lung penetration • Teicoplanin

  31. Bronchiolitis

  32. Viral Identification 2007

  33. Bronchiolitis in HIV positive children • 12% of bronchiolitics at PAH are HIV positive • Mean age 8 months old (vs 3 months in non HIV-infected children) • No increase in numbers co-infected in more mild disease

  34. Pearson correlation r = 0.138

  35. Pearson correlation r = 0.373

  36. Summary • CAP = Ampicillin +/- • HAP = Meropenem +/- • PCP = Bactrim + oral steroids + Ganciclovir • Bronchiolitis = nothing ? • Using this policy and noting that all HIV-infected children are offered ventilation if required – Mortality in PICU at PAH = 18.7%

  37. Aknowledgement • Dr RefiloeMasekela • Dr OmolemoKitchin • Dr TeshniMoodley • Dr Sam Risenga • Prof Max Klein

More Related