1 / 40

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

paloma
Télécharger la présentation

Antibiotics and ICU Infections

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 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

More Related