1 / 43

The Use and Misuse of Antimicrobials in NICU

The Use and Misuse of Antimicrobials in NICU. Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.

liluye
Download Presentation

The Use and Misuse of Antimicrobials in NICU

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. The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC

  2. A 20 day old male, X- 27 wk, 900 gm. Developed fever of 38.7 C0 and apnea. He’s been intubated since admission. An axillary central line was inserted 10 days ago. He received several PRBC transfusions and two courses of IV antibiotics. Blood cultures were sent and they are pending. Is he septic? What is your differential? What is your empirical antibiotic coverage?

  3. Sepsis in Neonates • Early onset sepsis (EOS) Less than 48 to 72 hours Incidence of EOS in VLBW is 2% • Late onset sepsis; (LOS) Incidence is higher in premature infants 15% for 1001-1250 g 20-25% for infants <1500 g 28% for infants 751- 1000 g 43% for infants <750 g

  4. Incidence of Early- and Late-onset Sepsis during 1978-2006 GBS Screening Neonatology 2009; 97: 22-28

  5. Distribution of Gram-positive and Gram-negative Microorganisms causing Early-Onset Sepsis during 1978-2006 Neonatology 2009; 97: 22-28

  6. Early Onset Sepsis Annual Cumulative Incidence (NICU 1997 and 2007) Antibiotics GBS

  7. What is a Nosocomial Infection? • CDC: Any infection occurring after admission to hospital , not transplacental • Risk factors: • - Gestational age and birth weight • - Maternal infection • - Intrinsic Immunologic Factors: • Poor chemotaxis, low levels immunoglobulins, low CH50 • Decreased number of CD3, CD4, CD8, and NK cells - Poor skin integrity - Immature gastrointestinal development - Extrinsic Factors: Instrumentation, Procedures

  8. PEDIATRICS Vol. 103 No. 4 April 1999

  9. Late Onset Sepsis Annual Cumulative Incidence (NICU 1997 and 2007)

  10. Neonatology 2009; 97: 22-28

  11. Coag neg Staph Neonatology 2009; 97: 22-28

  12. Pathogen Distribution Journal of Perinatology (2004) 24, 382–388

  13. Pathogen Distribution in Abha EMHJ • Vol. 16 No. 1 • 2010

  14. Summary • Pathogen distribution: Gram positive organisms 50-60% Gram negative organisms20% Fungal pathogens increasing- ~ 10% • Clinical signs and symptoms: Non specific Temperature instability (51%), jaundice (35%), respiratory distress (33%), feeding problems (28%), lethargy (25%), pallor and/or cyanosis (24%), apneic attacks and/or bradycardias (22%), and distended abdomen (17%)

  15. Back to the Case The culture from CVC came back as: Gram negative bacilli. You called the Lab, and the technician said,” it ferments lactose.” How will you change your coverage? Would you do a combination therapy? Why?

  16. Antibiotic Use in NICU

  17. Variation in Antibiotic Use in NICU J Antimicrob Chemother doi:10. 1093/jac/dkq107

  18. CDC 12-Step Guidelines • http://www.kliinikum.ee/infektsioonikontrolliteenistus/doc/oppematerjalid/children.pdf • Multicenter retrospective observational study of antibiotic use targeted 4 tertiary NICUs to assess adherence • Antibiotic regimens, clinical and microbiological data, indications for initiation and continuation of antibiotics (after 72 h of use) were recorded PID Journal • Volume 28, Number 12, December 2009

  19. Definition of Inappropriate Use PID Journal • Volume 28, Number 12, December 2009

  20. Summary • 200 neonates received 323 antibiotic courses totaling 3344 antibiotic-days • 28% of courses and 24% of days were judged to be nonadherent to a CDC 12-Step Campaign • Inappropriate use was more common with continuation of antibiotics (39%) than with initiation (4%) of therapy • Vancomycin was the most commonly used drug of which 284 (32%) days were considered inappropriate • Carbapenems were used less frequently (n = 310 antibiotic-days), and 132 (43%) of these days were inappropriate

  21. Summary 2 • Nonadherence to CDC 12 step was because of : -Failure to narrow the spectrum - Prolonged antibiotic prophylaxis after surgeries and certain procedures - Treatment of colonization rather than real infection - No targeting of the pathogen

  22. Back to Case The patient’s antibiotics were changed from ceftazidime and vancomycin to meropenem + gentamcin + vancomycin pending sensitivity of the CVC blood culture isolate. The identification revealed Klebsiellaoxytoca. The tracheal aspirate grew Stenotrophomonasmaltophilia and the patient had a positive nasal PCR for MRSA. Do you agree? How can you modify the antibiotics?

  23. Emerging Infections

  24. Courtesy of CDC

  25. Courtesy of CDC

  26. Courtesy of CDC

  27. J Antimicro Chemother. 2000 Jul; 58 (1): 205-10

  28. Facts about ESBL Gram-negative species • These organisms are resistant to all ß-Lactam antibiotics except cephamycins (cefoxitin, cefotetan) and carbapenems • They are frequently resistant to many other classes of antibiotics, including aminoglycosides and fluoroquinolones • High rates of third-generation cephalosporin use have been implicated as a major cause of this problem. (Ceftazidime) • Carbapenems are the most active and reliable treatment options for infections caused by ESBL isolates • Overuse of carbapenems may lead to resistance of other gram-negative organisms; Pseudomonas

  29. Antibiotic Stewardship

  30. IDSA Guidelines • Prospective audit with intervention and feedback • Education • Guidelines and clinical pathways • Antimicrobial cycling • Antimicrobial order forms • Combination therapy • Streamlining or de-escalation of therapy • Dose optimization The application in pediatrics is not commonly used

  31. Antibiotic RestrictionSeoul National Children’s University • Hospital High rates of ESBL K pneumoniae (64%) in late 1990’s • 2002-2003 campaign to decrease use of extended-spectrum cephalosporins • Encouraged use of piperacillin/tazobactam • Reductions in overall rates, did not elaborate on other interventions

  32. Restriction of Cephalosporins and ESBL in a NICU indianpediatrics.net/sep2010/785.pdf

  33. Antibiotic Cycling A recent systematic review found only four studies worthy of inclusion and concluded that antibiotic cycling could not, at present, be promoted as a methodology to control resistance

  34. Journal of Neonatology Vol. 21, No. 1, Jan. - Mar. 2007

  35. Antibiotic cycling: more than it might seem? • Good for Gram-negative resistance control • Where antibiotic cycling is introduced and no specific susceptibility problem exists, it can still reduce background levels of resistance for Gram-negative pathogens, not for Gram-positive organisms • Helps in reduction of ICU ventilator-associated pneumonia, less convincingly for other types of sepsis.

  36. continue • Where antibiotic cycling is introduced, there is an improvement in effective antibiotic prescribing in ICU • There is a reduction in ICU mortality rates Journal of Antimicrobial Chemotherapy (2005) 55, 1–5

  37. Journal of Neonatology Vol. 21, No. 1, Jan. - Mar. 2007

  38. “The ideal way to get rid of any infectious disease would be to shoot instantly every person who comes down with it." H. L. Mencken

More Related