antibiotic choice in icu 20.10.04 final

ANTIBIOTIC CHOICE IN ICUANTIBIOTIC CHOICE IN ICU

Ram ChitlangiaPreceptors-

Dr. Rajiva GuptaDr. Sanjeev Sinha

Introduction Epidemiological dataDifferent ICU profilesMicrobiological dataPrinciples of antibiotic useChoice of antibioticsAntimicrobial resistance & its preventionConclusions

Introduction Introduction

Infections are important cause of morbidity & mortality in critically ill patients

Type of infection varies according to type of ICU

Different organisms in different ICU’sGeographical variationIncreasing resistance to antimicrobials

Infections in Critically Ill PatientsInfections in Critically Ill Patients

Bloodstream infectionsPneumoniasGastrointestinal infectionsCNS infectionsUrinary Tract infectionsSkin & Soft Tissue infection

[Crit Care Med, 2004,32, 1510-1526]

The European Prevalence of The European Prevalence of Infection in Intensive Care (EPIC) Infection in Intensive Care (EPIC) StudyStudy1- day point prevalence studyICU’s in 17 countries in western Europe,

excluding CCU, PICU & special care infant units

All patients occupying (>10 yrs age) an ICU bed over 24 h period

Total 1417 ICU’s10038 patient case reports [JAMA 1995,274(8),639-44]

Results of EPIC StudyResults of EPIC Study

Total infected = 4501 pts.(44.8 %)

ICU acquired infection = 2064 pts.(20.6 %)


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Pneumonia LRTI UTI BSI

Results of EPIC StudyResults of EPIC Study34.4

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Results of EPIC StudyResults of EPIC StudyRisk factors for ICU acquired infections-

– Increasing length of ICU stay (>48 hrs)– Mechanical ventilation– Diagnosis of trauma– Central venous catheterization– Pulmonary artery catheterization– Urinary tract catheterization– Stress ulcer prophylaxis

[JAMA 1995,274(8),639-44]


Risk of ICU deaths-– ICU acquired pneumonia (OR = 1.91)– Clinical sepsis (OR = 3.50)– Bloodstream infection (OR = 1.73)

[JAMA 1995,274(8),639-44]

National Nosocomial Infection National Nosocomial Infection Surveillance System (NNIS) Study Surveillance System (NNIS) Study 19991999

1992-1997

181,993 patients in medical ICU in the US

Most frequent nosocomial infection- UTI (31 %)

[Crit Care Med 1999, 27(5), 853-54]

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UTI Pneumonia BSI

Results of NNIS StudyResults of NNIS Study

Medical ICUMedical ICU

Pneumonia

Septicemia

COAD with Ac. exacerbation

CNS Infections

Surgical ICUSurgical ICU

Post operative patients

Septicemia

Intraabdominal infections

Trauma

Pediatric ICUPediatric ICU

Post operative patients Septicemia Respiratory tract

infections Neurological illnesses Others e.g.renal,

gastrointestinal etc

Ventilator Associated Pneumonia Ventilator Associated Pneumonia (VAP) Pathogens(VAP) Pathogens

1. Staph. aureus

2. Pseudomonas aeruginosa

3. Enterobacter spp.

Am J Infect Control 1999, 27, 520-32

MICU % SICU % PICU % CCU % CTVS % NSICU %

TOTAL %

Enterobacter 8.6 12.8 9.8 9.8 13.1 10.5 11.2E.Coli 3.5 4.9 3.6 4.2 4.8 4.6 4.3K.Pneumoniae 7.7 7.2 5.4 8.4 5.9 7.5 7.2H influenzae 1.5 4.4 9.3 3.1 5.8 7.4 4.3P aeruginosa 21.2 17.2 22.4 14.9 13.1 12.1 17.0S aureus 21.4 17.0 16.4 20.2 11.3 21.6 18.1Enterococcus 1.7 1.8 0.9 1.8 2.3 1.3 1.7C albicans 5.0 3.9 2.0 6.3 6.3 4.3 4.7Others 29.4 30.9 30.2 31.3 37.4 30.7 31.5Total 100 100 100 100 100 100 100

CDC NNIS Report , Am J Infect Control

Ventilator Associated Pneumonia Ventilator Associated Pneumonia (VAP) Pathogens(VAP) Pathogens

VAP Rates in ICU , NNIS ReportVAP Rates in ICU , NNIS Report

Type of ICU No. of units Ventilator days

Pooled mean* median

MICU 82 111,764 5.0 3.6

SICU 86 107,162 9.9 8.3

PICU 45 49,239 2.9 2.2

CCU 49 30,586 4.2 3.1

CTVS ICU 43 36,871 7.9 5.1

NSICU 25 19,149 12.9 9.6

[Am J Infect Control 2003, 31, 481-98]*Per thousand ventilator days

Urinary Tract Infection (UTI) PathogensUrinary Tract Infection (UTI) Pathogens

1. E. coli

2. Candida albicans

3. Enterococcus

[Am J Infect Control 1999, 27, 520-32]

NNIS Report 1992-99, UTI PathogensNNIS Report 1992-99, UTI Pathogens

MICU %

SICU % PICU % CCU % CTVS %

NSICU %

TOTAL %

Enterobacter 4.1 6.2 9.5 3.9 5.9 5.1 5.1E.Coli 13.7 14.6 19.2 26.0 12.5 28.3 17.5K.Pneumoniae 6.3 6.1 6.8 7.8 6.1 7.9 6.2P.Aeruginosa 9.7 13.1 14.3 6.5 12.6 10.9 11.0S aureus 1.8 1.3 1.3 2.3 0.6 1.9 1.6Staph.coagulase -ve 2.3 1.9 4.3 3.2 1.6 3.8 2.7Enterococcus 14.2 14.5 9.6 14.3 8.5 11.9 13.8C albicans 20.8 16.3 14.0 10.2 21.0 8.1 15.8Others 27.1 26.0 21.0 25.8 31.2 22.1 26.3Total 100 100 100 100 100 100 100

UTI Rates in ICU, NNIS Report UTI Rates in ICU, NNIS Report

Type of ICU No. of units Urinary catheter days

Pooled mean* Median

MICU 142 1,399,462 6.2 5.5

SICU 161 1,640,514 5.1 4.4

PICU 75 301,096 4.7 4.3

CCU 114 567,232 5.4 7.3

CTVS ICU 71 655,566 3.1 2.5

NSICU 52 329,201 7.7 6.7

[Am J Infect Control 2003, 31, 481-98]*Per thousand urinary catheter days

Blood Stream Infection (BSI)- Blood Stream Infection (BSI)- PathogensPathogens

1. Coagulase negative staphylococci

2. Enterococcus

3. Staphylococcus aureus

[Am J Infect Control 1999, 27, 520-32]

NNIS Report 1992-99, BSI pathogensNNIS Report 1992-99, BSI pathogens

MICU %

SICU % PICU % CCU % CTVS %

NSICU %

TOTAL %

Enterobacter 3.1 5.8 6.8 2.9 6.2 4.1 4.9E.Coli 2.1 2.2 3.0 2.8 2.0 2.6 2.3K.Pneumoniae 3.9 4.0 4.3 2.2 2.2 3.1 3.4P.Aeruginosa 3.6 4.1 4.9 2.1 2.6 3.7 3.8S aureus 14.0 10.4 9.7 23.2 9.0 13.1 12.6Staph.coagulase -ve 35.7 36.1 37.7 37.0 42.7 44.6 37.3Enterococcus 16.5 15.3 10.7 10.2 14.3 11.3 13.5C albicans 6.3 4.5 5.1 2.6 4.4 3.0 5.0Others 14.8 17.6 17.8 17 16.6 14.5 17.2Total 100 100 100 100 100 100 100

BSI Rates in ICU, NNIS ReportBSI Rates in ICU, NNIS Report

Type of ICU No. of units Central line days

Pooled mean* Median

MICU 143 975,318 5.7 5.0

SICU 160 1,267,959 5.2 4.7

PICU 79 428,104 7.3 5.9

CCU 114 363,976 4.2 4.2

CTVS ICU 71 598,118 2.9 2.2

NSICU 52 180,581 4.8 4.1

[Am J Infect Control 2003, 31, 481-98]*Per thousand central line days

AIIMS Data – ICU Infection 2003-04AIIMS Data – ICU Infection 2003-04

ICU Bacteremia (%)

RTI (%) UTI (%) SSI (%)

MICU 2 18 0 0.6

SICU 9 5 0.8 23

Special(AB8) 24 23 3 4

Gastro 8 5 0.4 1

Paed.med 13 14 0.4 4

Paed.surg 11 19 6 34

Neonatal 4 1 0 4

(Source: Deptt. of Microbiology,AIIMS)

AIIMS Data – Common PathogensAIIMS Data – Common Pathogens

Gram negative-– Acinetobacter spp.– Pseudomonas spp.– Klebsiella pneumoniae– E.coli– Enterobacter spp.

Gram positive –– Staphylococcus aureus – Coagulase negative

staphylococci (CoNS)– Enterococcus spp.– Streptococcus


AIIMS Data - PrevalenceAIIMS Data - Prevalence

Gram negative bacteria (GNB) contribute about 60 % of total bacteriologically proven infection

Gram positive bacteria (GPC) constitute the rest of 40 %

Recent trend is increase in GPC infection especially in ICU’s & patients on intravascular devices


AIIMS Data – C 2 ICU AIIMS Data – C 2 ICU Total no. of patients = 80Nosocomial infections = 25 episodes

– VAP = 23 episodes– BSI = 1 episode– UTI = 1 episode

Organisms (VAP)–– Acinetobacter spp. = 60.8 %– Pseudomonas aeruginosa = 17.3 %– Klebsiella = 13.04 %

Principles of Antibiotic UsePrinciples of Antibiotic Use

Goal – To choose a drug selectively active against the most likely infecting organism & least potential to cause toxicity

Empirical / Definitive / Prophylactic

Principles of Antibiotic UsePrinciples of Antibiotic Use

Whether or not antibiotic indicated ?

Microbial sensitivity to agent

Pharmacokinetic factors

Host factors

Introduction Epidemiological dataDifferent ICU profilesMicrobiological dataPrinciples of antibiotic useChoice of antibiotics in ICUAntimicrobial resistance & its preventionConclusions

Choice of Antibiotic in ICUChoice of Antibiotic in ICU

Community acquired pneumoniaVentilator associated pneumoniaIntravascular catheter related infectionUrinary tract infectionIntra abdominal infectionCentral nervous system infection

Community Acquired Pneumonia (CAP) Community Acquired Pneumonia (CAP) in ICUin ICU

A common and serious illnessSixth leading cause of death in USThe number one cause of death from

infectious diseasesSevere community acquired pneumonia

requires ICU admission

[Am J Respir Crit Care Med 2001, 163,1730-54]

Severe CAP - EtiologySevere CAP - EtiologyOrganisms-

– S.pneumoniae– Atypical pathogens (Chlamydia pneumoniae,

M.pneumoniae, Legionella)– Enteric gram negatives– H.influenzae– Staph.aureus } specific risk– Pseudomonas aeruginosa } factors– Respiratory tract viruses

Severe CAP - EtiologySevere CAP - Etiology50-60 % of patients with severe CAP have

unknowm etiologyDrug resistant S. pneumoniae (DRSP)-

– Intermediate = penicillin MIC 0.12-0.20 μg/mL – High = penicillin MIC ≥ 2 μg/ mL– Clinical relevance – controversial

CDC study- Breakpoint for clinically relevant resistance to penicillin is MIC ≥ 4 μg/mL

[Am J Public Health 2000; 90,223-29]

Treatment Treatment Organism specific therapy is ideal Limited diagnostic methods Patients with severe CAP-

– With no risk factors for pseudomonas– With risk factors for pseudomonas

Risk factors- – Structural lung disease (Bronchiectasis)– Corticosteroid therapy (>10 mg prednisolone per day)– Broad spectrum antibiotic therapy for > 7 days in the past

month– Malnutrition

TreatmentTreatmentPatients with no risk factors for pseudomonas-

– Intravenous β- lactam (cefotaxime, ceftriaxone) plus either– Intravenous macrolide (azithromycin) or

Intravenous fluoroquinolone


TreatmentTreatmentPatients with risk factors for pseudomonas-

– Selected I.V. antipseudomonal β- lactam (cefepime, imipenem, meropenem, piperacillin/tazobactam)

plus I.V.antipseudomonal quinolone (ciprofloxacin)

OR– Selected I.V. antipseudomonal β- lactam plus I.V. Aminoglycoside Plus either I.V. macrolide (Azithromycin)

or I.V. nonpseudomonal fluoroquinolone [Am J Respir Crit Care Med 2001, 163,1730-54]

TreatmentTreatmentIf patient is allergic to β- lactam, it should be

replaced with Aztreonam and combined with aminoglycoside & antipseudomonal FQ

The β- lactam used should be active against DRSP

Agents active against pseudomonas are not recommended as primary therapy when this organism is not suspected

Duration Of TreatmentDuration Of TreatmentFactors-

– Coexisting illness and/or bacteremia– Severity of illness at onset of antibiotic therapy– Subsequent hospital course

In general-– S.pneumoniae – 7-10 d– Myco.pneumoniae – 10-14 d– Chlamydia pneumoniae – 10-14 d– Legionella – 10-14 d


Switch to Oral TherapySwitch to Oral TherapyCriteria –

– Improvement in cough & dyspnea– Afebrile (<100 °F ) on two occasions 8 h apart– White cell count decreasing– Functioning G.I. tract with adequate oral intake

Narrowest spectrum agent according to etiologic organism with an appropriate pharmacokinetic profile should be chosen

Compliance is very important

Ventilator Associated Pneumonia In ICUVentilator Associated Pneumonia In ICU

VAP in ICUVAP in ICU

A pneumonia is considered to be ventilator associated when it occurs after intubation & is judged not to have incubated before an artificial airway is put in place

Incidence = 9-68 %Mortality = 33-71 % (Am Rev Respir Dis 1990,142,523-528)


Mechanical ventilation (MV) was associated with 86 % of episodes of hospital acquired pneumonia in the NNIS study

(Crit Care Med 1999,27(5) 887-92)

The risk of VAP increases linearly by approximately 1 % per day in the intubated patient for the first 30 days

(Am Rev Respir Dis.1989, 139(4) 877-884)


VAP is associated with significant increase in morbidity, mortality, length of ICU stay and costs.

Jiminez et.al- – The mean duration of MV increased from 10 to

32 days when VAP developed in intubated patient.

[Crit Care Med 1989,17(9) 882-885]


Rello et.al- retrospective study Patients with VAP had-

- Longer duration of MV (14.3±15.5 d versus 4.7±7 d)- ICU stay (11.7±7 d versus 5.6±6.1 d)- Hospital stay (25.5±22.8 d versus 14±14.6 d) [Chest 2002 122(6)2115-2121]

Risk factors for development of VAPRisk factors for development of VAP

Shock Multiorgan failure Worsening respiratory failure Ultimately or rapidly fatal underlying illness Age > 60 years Supine position Inappropriate or prior antibiotic treatment [Chest Surg Clin N Am 2002, 379-395]

Microbiology of VAPMicrobiology of VAP

Gram negative bacilli (GNB) and staphylococcus aureus are the most common causes of VAP

Among GNB, Pseudomonas aeruginosa and Acinetobacter baumani are most frequent isolates.

The role of anaerobes has not been thoroughly investigated

[CDC NNIS System; Am J Infect Control 1999,27, 520-532]

Treatment of VAPTreatment of VAP

Empiric or Directed TreatmentMonotherapy or Combination therapyAntibiotic RegimenModification of Initial Empiric TreatmentDuration of Treatment [Drugs & Aging 2001,18(3),189-200]

VAP-Empiric or Directed TreatmentVAP-Empiric or Directed TreatmentEmpiric treatment is reasonableNo role of prophylactic antibioticsNon availability of accurate, cost effective and

rapid diagnostic proceduresChoice of therapy should be based on

– Knowledge of most frequent pathogen and their pattern of susceptibility

– Specific risk factors esp. prior antibiotic use– Time since admission to hospital– Duration of MV before development of VAP

VAP-Monotherapy or Combination VAP-Monotherapy or Combination TherapyTherapy

55 % of VAP are polymicrobial in natureCombination therapy is preferableReduces appearance of resistanceSynergistic effects of antibioticsDecreases risk of inadequate treatment before

microbiological data are available

(AJRCCM 1998,157,531-9)

VAP-Monotherapy or Combination VAP-Monotherapy or Combination TherapyTherapy

Disadvantages – higher risk of toxicity esp. in regimens with aminoglycosides, higher costs

Knowledge of prior antibiotic treatment is very important as the organism may be resistant to those drugs

VAP-Antibiotic RegimenVAP-Antibiotic Regimen

Patients with VAP can be divided into two groups-– Early onset & without risk factors– Any onset & with risk factors

The definition of early onset varies from 4 to 7 days according to various guidelines.

VAP-Antibiotic RegimenVAP-Antibiotic RegimenEarly onset VAP & without risk factors-

First choice- Second or third generation nonpseudomonal

cephalosporins or combined β -lactam/ β -lactamase inhibitor

If patient is allergic to these- Fluoroquinolones or clindamycin + aztreonam

VAP-Antibiotic RegimenVAP-Antibiotic Regimen Any onset VAP & with risk factors-

First choice- – Aminoglycosides or ciprofloxacin plus one of the following:– Antipseudomonal penicillin– β-lactam/β-lactamase inhibitor– Ceftazidime or Cefoperazone– Imipenem– Azteonam ± Vancomycin (AJRCCM 153,1995,1711-25)

VAP-Antibiotic RegimenVAP-Antibiotic Regimen

Patients at risk of aspiration pneumonia should receive antibiotics with anaerobic activity

A glycopeptide may be added if the prevalence of MRSA is high & especially if β-lactams have been given previously

VAP-Modification of Initial VAP-Modification of Initial RegimenRegimen

Adjust therapy after availability of microbiological data.

Aim – narrower spectrum antibioticsTherapeutic de-escalation advisableModify if appearance of resistant organismsPoor clinical response

VAP-Modification of Initial VAP-Modification of Initial RegimenRegimen

New antibiotic must be from different class of drugs

New respiratory samples should be sent before any change in antibiotic therapy

VAP-Duration of TreatmentVAP-Duration of Treatment There must be clinical improvement & afebrile period of at

least 48 hrs. before stopping antibiotics

P.aeruginosa or A.baumani infections should be treated for minimum of 14-21 days

Patients with multilobar involvement, malnutrition, severe debilitation, cavitation, or a necrotizing GNB pneumonia also require 14-21 days treatment

(AJRCCM 1995,153,1711-25)

Prevention of VAP – Physical StrategiesPrevention of VAP – Physical Strategies Oral endotracheal tube Recommended Ventilator circuit change Recommended Heat & moisture exchanger Recommended Weekly change of humidifier Recommended Closed suction system Recommended Change in suction system Recommended Drainage of subglottic secretions Consider Systematic search for sinusitis No recommendation Chest physiotherapy No recommendation Early tracheostomy No recommendation

(Ann Intern Med 2004;141:305-313)

Prevention of VAP – Positional StrategiesPrevention of VAP – Positional Strategies

Semi-recumbent positioning Recommended

Kinetic beds Consider

Prone positioning No recommendation

(Ann Intern Med 2004;141:305-313)

Prevention of VAP – Pharmacologic Prevention of VAP – Pharmacologic StrategiesStrategies

Sucralfate Not recommended Intratracheal antibiotics Not recommended Topical antibiotics Not

recommended Intravenous(I.V.) antibiotics No

recommendation I.V. and topical antibiotics No

recommendation(Ann Intern Med 2004;141:305-313)

Intravascular Catheter Related Intravascular Catheter Related Infections In ICUInfections In ICU

IVC Related Infections in ICUIVC Related Infections in ICU

Major cause of morbidity & mortality in critically ill patients

Organisms- – Coagulase negative staphylococci– Staph. Aureus– Aerobic gram negative bacilli– Candida albicans

(IDSA Guidelines; Clin Infect Dis 2001;32,1249-72)

Source of IVC Related InfectionsSource of IVC Related Infections

IVC Related Infections in ICUIVC Related Infections in ICU

Byers et al – Meta analysis– 2573 catheter related infections– Case fatality rate was 14 %– 19 % of these deaths were attributed to catheter

related infectionMortality rate attributed to S. aureus was

significantly higher than others

Diagnosis Diagnosis

Clinical diagnosis – unreliable Semiquantitative (roll plate) or Quantitative (vortex or

sonication methods) catheter culture techniques are most reliable diagnostic methods

A yield of ≥ 15 cfu by semiquantitative or ≥ 100 cfu by quantitative culture from a catheter , with accompanying signs of local or systemic infection is indicative of catheter related infection


Treatment Treatment

Vancomycin – where methicillin resistant staphylococci (MRSA) is common

Nafcillin or Oxacillin – where MRSA or MRSE are rare

Linezolid – if pt. is allergic to vancomycin3rd or 4th Gen. cephalosporin added – in

immunocompromised or severely ill pts.Amphotericin – if possibility of fungemia

[Clin Chest Med 24(2003) 645-669]

When to Remove IVC ?When to Remove IVC ?

If pt. have signs of infection or inflammation overlying the catheter exit site

Clinical evidence of sepsisBlood culture results are positiveInfection due to staph. aureusPatients with fungemia

[Clin Chest Med 24(2003) 645-669]

Duration of TreatmentDuration of Treatment

Uncomplicated infections – 10-14 d

BSI due to CoNS – 5-7 d (if IVC removed) 10-14 d (if IVC not removed)

BSI due to Candida – 14 d after last positive culture

[Clin Chest Med 24(2003) 645-669]

Antibiotic Lock TherapyAntibiotic Lock TherapyInability of antibiotics to kill microorganism

growing in biofilmAntibiotic concentrations must be 10-100 times

greater to kill sessile (biofilm) than to kill planktonic (in solution) bacteria

Filling the catheter lumen with pharmacologic concentrations of antibiotics & leaving them there for hours or days.


Prevention of IVC Related InfectionPrevention of IVC Related Infection

Sterile barrier precautions e.g. gloves, gowns,masks, large drapes

Chlorhexidine for skin antisepsis prior to catheter placement

Removal of “idle” catheters Antimicrobial or Antiseptics impregnated

catheters

Prevention of IVC Related InfectionPrevention of IVC Related Infection

Avoidance of femoral site for catheter insertion

Rotation of peripheral catheters to a new site at specified intervals

Applying disposable transducers for pressure monitoring

Complicated Intra-abdominal infectionsComplicated Intra-abdominal infections

Infections that extend beyond the hollow viscus of origin into the peritoneal space & associated either with abscess formation or peritonitis

Can be –– Community acquired– Hospital acquired

(Clin Infect Dis 2003;37, 997-1005)

Pathogens Pathogens

Hospital acquired:– P.aeruginosa– Enterobacter spp.– Proteus spp.– MRSA– Enterococci– Candida spp.

Community acquired:– Gram neagtive aerobes &

facultative organisms e.g. E.coli

– Anaerobes e.g. B.fragilis– Streptococci– Enterococci

Antimicrobial therapyAntimicrobial therapy

Antibiotics should be started once intra abdominal infection is suspected

Goals – – Elimination of infecting microorganism– To decrease the likelihood of recurrence– To shorten the time to resolution of signs

&symptoms of infection

Treatment-Community Acquired InfectionTreatment-Community Acquired Infection

MILD-MODERATE– Single agent –

• Ampicillin/sulbactam• Ticarcillin/clavulanic acid• Ertapenem

– Combination –• Cefazolin/ cefuroxime plus

Metronidazole• Cipro /levo/ gati/

moxifloxacin with Metronidazole

SEVERE INFECTIONS-– Single agent-

• Piperacillin/tazobactam• Imipenem/ cilastatin• Meropenem

– Combination –• 3rd / 4th gen. cephalosporin

plus Metronidazole• Ciprofloxacin plus

Metronidazole• Aztreonam plus

Metronidazole (Clin Infect Dis 2003;37, 997-1005)

Treatment- Hospital Acquired InfectionTreatment- Hospital Acquired Infection

Complex multidrug regimens (e.g. an aminoglycoside/ quinolone/ carbapenem & vancomycin) is recommended

Treat according to local nosocomial resistance patterns

Modify treatment according to results of microbiological data

Urinary Tract Infection (UTI) in ICUUrinary Tract Infection (UTI) in ICU

Urinary Tract Infection (UTI) in ICUUrinary Tract Infection (UTI) in ICUMost common nosocomial infection

Significant morbidity & mortality if complicated by bacteremia or urosepsis

Increased length of hospital stay

Increased cost[NNIS Study, Crit Care Med 1999,27(3),853-54]

Nosocomial UTINosocomial UTI Risk Factors-

– Presence of indwelling urinary catheter- M. Imp.– Female gender– Extended ICU stay

Complications – Urosepsis– Age >60 years– Extended hospital stay– Extended duration of urinary catheterization

(Infection 1999; 27(1); 16-22)

Nosocomial UTI -EtiologyNosocomial UTI -Etiology

E.coliCandida albicansP aeruginosaEnterococcus spp.Klebsiella pneumoniae

(Clin Chest Med 2003; 24,645-69)

Nosocomial UTI- TreatmentNosocomial UTI- Treatment

Piperacillin/tazobactam or ticarcillin/clavulanateImipenem / MeropenemCiprofloxacin / Levofloxacin / GatifloxacinAmpicillin with GentamicinCeftazidime with VancomycinAntifungal therapy if strong clinical suspicion of

disseminated candidiasis & pt. is unstable

(Clin Chest Med 2003; 24,645-69)

CNS Infections in ICU CNS Infections in ICU Pyogenic Meningitis Pyogenic Meningitis

Organisms

Hospital acquired:– Staphylococci– Gram negatives

including P.aeruginosa

Community acquired:– S. pneumoniae– N. meningitidis– Gr. B streptococci– L. monocytogenes

HPIM 16th Ed.

Treatment of Pyogenic Meningitis Treatment of Pyogenic Meningitis

Community acquired –– Cefotaxime / Ceftriaxone + Vancomycin

Hospital acquired –– Ampicillin + Ceftazidime + Vancomycin

Antimicrobial Resistance & its PreventionAntimicrobial Resistance & its Prevention

Rapid emergence & spread of antibiotic resistant bacteria Important variable related to patient outcomes Risk factors –

– Use of antimicrobial agents– Prolonged hospital stay– Presence of invasive devices

– Inadequate infection control practice

[Ann Intern Med 2001, 134, 298-314]

AIIMS Data – Resistance PatternAIIMS Data – Resistance Pattern

Staph. aureus ─ 40 % MRSA ─ 99 % β- lactamaseCoNS ─ 80 % MRSACiprofloxacin – overall 45 % sensitive but

25 % in MRSAAll are sensitive to vancomycin, teicoplanin

& linezolid



Enterococcus spp.-– HLAR – 50-55 %– VRE - <1 %

Gram negative bacteria –– Ciprofloxacin – 70-80 %– Amikacin - 40-50 %– Piperacillin - 30-40 %– 3rd & 4th Gen. cephalosporins – 60-70 %



β – lactamase in GNB –– ESBL - 75-80 %– β-lactam/ β-lactamase inhibitor combination

(pip/tazo, cefotaxime/sulb, ticar/clav) – resistance in 10 % of ESBL

– Carbapenems – resistance in 10 % of ESBL


Strategies for PreventionStrategies for Prevention

Antimicrobial strategies

Non antimicrobial strategies

[Ann Intern Med 2001, 134, 298-314]

Antimicrobial strategy for preventionAntimicrobial strategy for prevention

Limit unnecessary antimicrobial administration-– Develop hospital based guidelines for antibiotic use– Hospital formulary restriction– Use of narrow spectrum or older antibiotics– Quantitative cultures & assessment for nosocomial

pneumonia– Education & professional detailing on antibiotic use

for physicians

[Ann Intern Med 2001, 134, 298-314]

Antimicrobial strategy for preventionAntimicrobial strategy for prevention

Optimize antimicrobial effectiveness –– Avoid inadequate treatment– Combination antimicrobial treatment– Antibiotic cycling & scheduled antibiotic changes– Area specific empirical antimicrobial therapy– Limit short course antibiotic prophylaxis to

clinically validated indications– Avoid routine antimicrobial decontamination of

aerodigestive tract in ICU

Nonantimicrobial strategy for preventionNonantimicrobial strategy for prevention

Primary prevention –– Reducing length of hospital stay– Minimization of CVC use– Vaccines

Prevention of horizontal transmission –– Hand washing– Decreasing workload in ICU– Gloves & Gowns [Ann Intern Med 2001, 134, 298-314]

Conclusions Conclusions

Antibiotics – Most commonly used as well as misused

Empirical therapy usually necessary in ICU’sChoice should be based on local microbial patternEmerging problem of antimicrobial resistanceAim – Restrict the use of antibioticsProphylactic antibiotics should be avoided