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ANTIBIOTICS IN ICU

ANTIBIOTICS IN ICU. PRESENTER: HALIMATUL NADIA M HASHIM SUPERVISOR: DR NIK AZMAN NIK ADIB. CONTENTS. INTRODUCTION CLASSIFICATIONS OF ANTIBIOTICS PRINCIPLES OF EMPIRICAL ANTIMICROBIAL THERAPY PHYSIOLOGICAL CHANGES IN CRITICALLY ILL PATIENT COMMUNITY ACQUIRED PNEUMONIA

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ANTIBIOTICS IN ICU

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  1. ANTIBIOTICS IN ICU PRESENTER: HALIMATUL NADIA M HASHIM SUPERVISOR: DR NIK AZMAN NIK ADIB

  2. CONTENTS • INTRODUCTION • CLASSIFICATIONS OF ANTIBIOTICS • PRINCIPLES OF EMPIRICAL ANTIMICROBIAL THERAPY • PHYSIOLOGICAL CHANGES IN CRITICALLY ILL PATIENT • COMMUNITY ACQUIRED PNEUMONIA • ASPIRATION PNEUMONIAE • HEALTH- CARE ASSOCIATED PNEUMONIA

  3. INTRODUCTION • Antimicrobials are commonly administered in the intensive care unit (ICU). • This is in association with the high incidence of admissions with severe sepsis to ICUs and the increased risk of acquiring infections in ICU.

  4. EPIC II • Extended Prevalence of Infection in Intensive Care (EPIC II) study • international study on the prevalence and outcomes of infections in ICUs • 51% of patients were infected while 71% were receiving antibiotics on the day of the study. • In Malaysia, 18.7% of patients had severe sepsis on admission to ICU in 2011.

  5. In 2013 , 21.18% of patient admitted to icu HSNZ dx as sepsis including septic shock

  6. Classification of antibiotics

  7. PRINCIPLES OF EMPIRICALANTIMICROBIAL THERAPY • Empirical antimicrobial therapy should be guided by the knowledge of the most likely site of infection likely causative organisms, patient factors and properties of antimicrobials • All appropriate microbiological specimens including blood cultures should be obtained before commencing therapy whenever possible.

  8. Inappropriate antimicrobial therapy is associated with poor outcomes. • Increasing mortality and morbidity rates • emergence of resistant organisms, antimicrobial-related adverse events • increase in healthcare costs.

  9. The urgency to start antibiotics can be broadly classified as emergency or urgent:

  10. 1. Likely causative organism • Decide if community or healthcare-acquired infection • Identify the most likely source of infection -appropriate specimens for microscopy, culture and sensitivity testing. - Imaging modalities may be necessary to locate the source of infection. • Consider local epidemiological data • depends on local susceptibility patterns • resistance profiles in the community

  11. 2. Patient factors Severity of illness • Patients in severe sepsis or septic shock require emergent and broad spectrum antimicrobial therapy. Prior antimicrobial use or prolonged hospitalisation • Both are risk factors for the presence of resistant organisms. Immunosuppressive states • may require broad-spectrum therapy including antifungal.

  12. Presence of renal or hepatic dysfunction -Maintenance doses are adjusted in line with the severity of organ dysfunction. Others • Pregnancy, drug allergy

  13. 3. Antimicrobial profile •A) Route of administration - intravenous route should always be used in severe sepsis •B) Dose and interval • Pathophysiological changes in critically ill patients alter the pharmacokinetic (PK) and pharmacodynamic (PD) profile of the antimicrobials. • Antibiotics can be categorised into three different classes depending on the PK/PD indices associated with their optimal killing activity.

  14. C) Adequate tissue penetration - e.gaminoglycoside and glycopeptide : poor -quinolones and B-lactam : good • D) Post antibiotic effect (PAE) - defined as persistent suppression of bacterial growth even after the serum antibiotic concentration falls below the MIC of the target organism. - e.gAminoglycosides and fluoroquinolones

  15. Empirical therapy should be re-evaluated after 48-72 hours or when culture results become available. • Once a causative pathogen is identified, narrow the spectrum of antimicrobial therapy (de-escalation). • recommended duration : 5 to 7 days. • There is increased risk of resistance with prolonged use of antimicrobial • Consider switching to the oral route whenever possibles

  16. If there is no clinical response within 48-72 hours, consider: • The possibility of a secondary infection • The presence of resistant organisms • Abscesses that are not drained or infected foreign bodies that are not removed • Inadequate penetration of antimicrobial to the site of infection • Inadequate spectrum of antimicrobial coverage • Inadequate dose/interval • Non-infectious causes

  17. PHYSIOLOGICAL CHANGES IN THE CRITICALLY ILL PATIENT WITH SEPSIS • Sepsis has profound effects on all systems of the body esp CVS, renal and hepatic systems • Changes in PK and PD of antimicrobial

  18. Pharmacokinetic changes in critically ill patient • 1) changes in Vd • 2) changes in antibiotic half-life T1/2 • 3) hypoalbuminaemia • 4) development of end organ dysfunction • 5) tissue penetration

  19. COMMUNITY ACQUIRED PNEUMONIA (CAP) • a/w significant morbidity and mortality, particularly in the elderly. • 10% of patients who are admitted to the hospital with a diagnosis of CAP will require management in the ICU. • mortality for severe CAP : 20% - 50%.

  20. Aetiologic pathogens remain unidentified in up to 50% of cases. • Empirical therapy should be started after considering patients’ risk factors for certain organisms e.g. patients with chronic lung disease are at higher risk of Pseudomonas aeruginosa pneumonia

  21. RX: minimum of 5 days • longer duration of therapy may be needed if • initial therapy is not active against the identified pathogen • complicated by extrapulmonary infection, e.g meningitis or endocarditis • If no response, consider other possible diagnosis e.g. congestive heart failure

  22. ASPIRATION PNEUMONIA • Risk factors : conditions that suppress cough and mucociliary clearance. • In community-acquired oral anaerobes are the predominant organisms related to poor dentition or oral care and periodontal disease. • Hospitalised and institutionalised patients are more likely to have oropharyngealcolonisation with Gram-negative enteric bacilli and Staphylococcus aureus. • Antimicrobials are not indicated in aspiration without evidence of infection.

  23. HEALTH-CARE ASSOCIATED PNEUMONIA • Healthcare-associated pneumonia (HCAP) is defined as pneumonia in any patient who has been admitted to an acute care hospital for ≥ 2 days of the preceding 90 days; resided in a nursing home or long-term care facility; received recent intravenous antibiotic therapy, chemotherapy within the past 30 days; or attended a hospital or haemodialysis clinic.

  24. Hospital-acquired pneumonia (HAP) is defined as pneumonia that occurs 48 hours or more after hospitalisation • ventilator-associated pneumonia (VAP) is pneumonia that occurs after 48 hours following intubation.

  25. Risk factors for multidrug-resistant (MDR) infections are: • 1. Prolonged hospital stay (≥ 5 days) • 2. Previous hospitalisation of > 2 days within past 90 days • 3. Was on antibiotics within past 90 days, especially broad-spectrum antibiotics • 4. Antibiotic resistance in the healthcare setting • 5. Admission from long-term care institution • 6. Chronic renal dialysis within past 30 days • 7. Poor underlying condition • 8. Presence of chronic wounds • 9. Immunocompromised or neutropenic patient • 10. Presence of invasive catheters e.g. central venous catheters

  26. THANK YOU

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