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Antibiotics and ICU Infections

Antibiotics and ICU Infections. Jill Williams, ACNP-BC Vanderbilt University Medical Center Medical Intensive Care Unit. Objectives. Discuss strategies for antibiotic stewardship Review mechanisms of action (MOA) for antibiotics

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Antibiotics and ICU Infections

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  1. Antibiotics and ICU Infections Jill Williams, ACNP-BC Vanderbilt University Medical Center Medical Intensive Care Unit

  2. Objectives • Discuss strategies for antibiotic stewardship • Review mechanisms of action (MOA) for antibiotics • Discuss common ICU infections and antibiotic therapies including drug levels

  3. Antibiotic Stewardship • What is it? • Program to monitor use of antibiotics • Coordinated effort between pharmacist and medical team • Why do we need it? • To help achieve optimal clinical outcomes • Minimize development of resistant strains of bacteria • Decrease healthcare costs R/T toxicity and adverse events

  4. Antibiotic Stewardship – How? • Identify patient risk factors • Know the hospital or unit antibiogram • Review previous lab results and susceptibilities • Consult with your pharmacist • Monitor drug levels when appropriate • Collaborate with an infectious disease specialist

  5. Structure of Bacteria www.americanaquariumproducts.com

  6. Antibiotic Mechanism of Action

  7. Extended Spectrum Beta Lactamases • ESBLs • Increasing cause of nosocomial infections • Becoming prevalent in the community • Higher mortality rates, longer hospital stays • Action of ESBLs • Open beta lactam ring on the antibiotic • Opening of beta lactam ring = deactivation of antibiotic

  8. ESBL’s • Common Culprits • Klebsiellapneumoniae • Klebsiellaoxytoca • Escherichiacoli • Resistance • 3rd generation cephalosporins and monobactams • Lab Testing • Check sensitivities • Resistance to ceftazidime, ceftriaxone, or cefepime = high likelihood of ESBL

  9. ESBL Risk Factors • Hospital LOS* • ICU LOS* • Central venous catheters • Arterial catheters • Emergent abdominal surgery • Gut colonization • Presence jejunostomy or gastrostomy tube • Prior antibiotics • Residence in long-term care facility* • Severity of illness • Presence of urinary catheter • Hemodialysis* • Ventilatory assistance

  10. Treatment • Carbapenem family of antibiotics • Only proven therapeutic option for infections • Imipenem✴ • Meropenem✴ • Doripenem • Ertapenem • Duration of treatment • No longer than indicated with other antibiotics • Ex: 10-14 days depending on infection

  11. Carbapenems

  12. Methicillin Resistant Staph Aureus (MRSA) • Risk factors • Prior cephalosporin or quinolone use • HIV infection • Long-term indwelling dialysis catheters • Residence in long-term care facility

  13. MRSA Treatment • Bacteremia** • Vancomycin • 15 – 20 mg/kg based on actual body weight • Frequency of dose dependent on renal function OR • Daptomycin • 6mg/kg/dose IV daily • 8-10mg/kg/dose IV daily for complicated infections • Pneumonia • Vancomycin • 15 – 20 mg/kg based on actual body weight • Frequency of dose dependent on renal function OR • Linezolid • 600mg IV or PO BID • NO Daptomycin • Poor lung penetration

  14. Vancomycin • Treats multiple infections • Endocarditis, osteomyelitis, bacteremia, HCAP, meningitis • Optimal level 15 – 20 mg/L • Keep level > 10 mg/L to avoid potential antimicrobial resistance • Trough level = most effective measurement of levels • Draw 30 min prior to 5th dose

  15. Vancomycin Nephrotoxicity • Definition: • > 50% increase in Serum Creatinine over baseline on consecutive serum measurements (over 2 days) in the absence of alternative explanations • Increased risk toxicity: • Elderly, longer course of treatment, concomitant nephrotoxic medications, possibly increased serum trough levels • Reduce toxicity: • Monitor levels with fluctuating renal function

  16. Vancomycin Resistant Enterococci • Occurs in intestine and female urinary tract • Distinguish between active infection and colonization • E. Faecalis and E. faecium most common forms • More than 90% cases E. faecium • Limited studies for most effective drug • No official ID Guidelines • Treatment based on available data: • Linezolid 600mg PO/IV BID OR • Daptomycin 6mg/kg/dose daily**

  17. Fungal Infections

  18. Risk Factors Disseminated Disease • Duration of antibiotics • > 6 days • Number of antibiotics • ≥ 3 therapies • Renal failure • Central venous catheters • Steroid use • Gram negative sepsis • Cancer • Burns • Multiple trauma • Diabetes mellitus • Total parenteral nutrition • Neutropenic vs. Non-neutropenic

  19. Common Fungal Species • Candida • C. albicans • C. tropicalis • C. parapsilosis • C. glabrata • C. krusei • C. lusitaniae • Aspergillus

  20. Treatment Options • Azoles • Fluconazole, voriconazole, itraconazole, posaconazole • Echinocandins • Micafungin, caspofungin, anidulafungin • Polyenes • Amphotericin B + lipids

  21. Drug Dosing

  22. Drug Dosing

  23. Serum Drug Levels • Itraconazole • Check level after steady state achieved (suggested 2 weeks) • For invasive fungal infections: >3 mcg/mL by bioassay • Linear relationship between increased levels and toxicity • Voriconazole • Check 4 – 7 days into therapy (TROUGH level) • Invasive fungal infections: 1 mg/L → < 5.5 mg/L • Posaconazole • No official guidelines for therapeutic levels • Suggestion: Trough level • Prophylaxis: ≥ 0.5 mcg/mL • Severe infection: ≥ 0.7 mg/mL

  24. Echinocandins

  25. Clostridium Difficile Guidelines

  26. References • Society of Critical Care Medicine. (2009). ICU infection in an era of multi-resistance; selected proceedings from the 8th summer conference in intensive care medicine. Mount Prospect: Certified Fiber Sourcing. • Brandt, L. J., & Feuerstadt, P. (2011). Clostridium difficile: Epidemiology, transmission, and treatment. Infectious Disease Special Edition, 14, 75-83. • Martin, S. J., Micek, S. T., & Wood, G. C. (2012). Antimicrobial resistance is an adverse drug event. In J. Papadopoulos, B. Cooper, S. Kane-Gill, S. Corbett & J. Barletta (Eds.), Drug-Induced Complications in the critically ill patient: A guide for recognition and treatmentMount Prospect: Society of Critical Care Medicine.

  27. References • Rybak, M., Lomaestro, B., Rotschafer, J. C., Moellering Jr, R., Craig, W., Billeter, M., Dalovisio, J. & Levine, D. (2009). Therapeutic monitoring of vancomycin in adult patients: A consensus review of the american society of health system pharmacists, the infectious disease society of america, and the society of infectious disease pharmacists. American Journal Health System Pharmacists, 66, 82-98. Retrieved from http://www.ajhp.org • Liu, C., Bayer, A., Cosgrove, S., & Daum, R. (2011). Clinical practice guidelines but the infectious diseases society of america for the treatment of methicillin-resistant staphylococcus aureus infections in adults and children. Clinical Infectious Diseases, 52(3), e18-e55. Retrieved from http://cid.oxfordjournals.org

  28. References • Kelly, C. P., & LaMont, J. T. (2013, March). Clostridium difficile in adults:treatment. Retrieved from www.uptodate.com • Ashley, E. D., & Perfect, J. R. (2013, June). Pharmacology of azoles. Retrieved from www.uptodate.com • www.cdc.gov • http://www.idsociety.org • Kauffman, C. A., & (2013, July). Treatment of candidemia and invasive candidiasis in adults. Retrieved from www.uptodate.com • Chen, L. F., & Drew, R. H. (2013, April). Pharmacology of antimicrobial agents for treatment of methicillin-resistant staphylococcus aureus and vancomycin resistant enterococcus. Retrieved from www.uptodate.com

  29. References • Munoz-Price, L. S., & Jacoby, G. A. (2013, April). Extended-spectrum beta-lactamases. Retrieved from www.uptodate.com • Runyon, B. A., & (2013, July). Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis. Retrieved from www.uptodate.com • Sucher, A. J., Chahine, E. B., & Balcer, H. E. (2009). Echinocandins: The newest class of antifungals. The Annals of Pharmacotherapy, 43, 1647-57.

  30. The following slides exhibit various anatomical systems and common organisms responsible for infections.

  31. Streptococcus • S. Viridans • S. Mutans • Fusobacterium (Leimerre’s disease) • Staphylococcus • S. aureus • S. epidermidis

  32. Strep pneumoniae • Haemophilus influenzae • Bordetella • Staph. aureus • Legionella pneumophilia • Mycobacterium tuberculosis • Histoplasmosis • Enterobacteriaceae

  33. Infective Endocarditis • Streptococcus viridans (50% of all cases) • Staphylococcus aureus • Enterococcus • HACEK organisms* • Haemophilus • Actinobacillus • Cardiobacterium hominis • Eikenella corrodens • Kingella (Kingella kingae) *slow growing gram (-) organisms; Normal part of human flora

  34. Escherichia coli • Bacteroides

  35. Infectious pancreatitis • Hepatitis B • CMV • Varicella-zoster • HSV • Mycoplasma • Legionella • Salmonella

  36. Bacteroides • Enterococcus • Escherichia coli • Klebsiella pneumoniae • Staphylococcus aureus • Streptococcus

  37. Escherichia coli • Enterococcus • Bacteroides • Streptococcus • Lactobacillus

  38. Clostridium difficile • Escherichia coli • Bacteroides • Campylobacter • Salmonella • Shigella

  39. Escherichia coli • Proteus mirabilis • Klebsiella • Pseudomonas aeruginosa • Enterococcus

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