icmr guidelines on antimicrobial use in sepsis and ssi's in india
TRANSCRIPT
Treatment Guidelines for Antimicrobial Use in Common
Syndromes
Based on ICMR Guidelines, New Delhi, India(2017)
Dr SD Sanyal
Principles of Initial Empirical Antimicrobial Therapy in Patients
with Severe Sepsis and Septic Shock in The Intensive Care Units
Definitions
• SIRS:- Two or more of the following variables:
i. Fever > 38°C (100.4°F) or hypothermia < 36°C (96.8°F) ii. Tachypnea (>20 breaths/min) or PaCO2 < 32 mmHg iii. HR >90 beats/min iv. WBC > 12,000/<4000 cells/mm3, 10% immature band forms
Definitions
• Sepsis : Systemic inflammatory response syndrome that occurs due to a “known or suspected” pathogen (bacteria, viruses, fungi or parasites)
Definitions• Severe sepsis:
- Sepsis plus evidence of organ dysfunction or tissue hypoperfusion as follows:
i. Altered mental status.
ii. Hypoxemia, with PaO2/FIO2 <250
iii.Thrombocytopenia < 100,000/cmm
iv. Bilirubin >2mg/dl
v. INR >1.5 or aPTT> 60 seconds.
vi. Urinary output of 0.5 ml/kg for at least 2 hours or Serum creatinine >2mg/dl despite fluid resuscitation.
Definitionsvii. Tissue hypoperfusion as suspected by mottled skin, capillary refilling time ≥ 2 seconds or lactate >4 mmol/l
viii. Hypotension : Systolic blood pressure (SBP) ≤90 mmHg or mean arterial pressure ≤70 mm Hg
• Sepsis induced hypotension: SBP<90mmHg or MAP<70mmHg or SBP fall > 40 mm Hg
• Septic shock:
- Sepsis induced hypotension that persists despite adequate fluid resuscitation, requiring vasopressors to maintain the blood pressure.
Common Pathogens
• Gram negative:-Pseudomonas aeruginosa -E. coli -Klebsiella pneumoniae -Acinetobacter spp
Common Pathogens
• Gram Positive: - Methicillin resistant Staphylococcus aureus (MRSA) - Entercoccus faecium - Vancomycin resistant enterocccci
• Fungi:- Candida spp
Susceptible Individuals
• Antimicrobial therapy in preceding 90 days • Current hospitalization of 5 days or more • High frequency of community or hospital
antibiotic resistance • Immunosuppressive disease or therapy
Susceptible Individuals
• Presence of multiple risk factors for Health Care Associated Infections:- Hospitalization for ≥2 days in preceeding 90 days- Residence in nursing home or long term care facility -Home infusion therapy-Chronic dialysis within 90 days -Family member with MDR pathogen
Principles of Emperical Therapy
• Form probable diagnosis• Obtain cultures• Source control• Broad spectrum cover• Antibiotics within the first hour• Early Antifungal cover• Antivirals
Choice of AMA• The suspected site of infection
• The clinical syndrome
• The setting in which the infection developed (i.e., home, nursing home, or hospital)
• Medical history
• Epidemiology, susceptibility patterns of bacteria in the hospital and ICU, local microbial-susceptibility patterns, resistance potential
Choice of AMA• Prior antibiotic therapy(previous 3 months)
• Immunological competence of patient
• Severity of underlying illness
• Microbes that previously have been documented to colonize or infect the patient
• Pharmacokinetics of the chosen antimicrobial agent
• Drug allergies / toxicities
• Cost
De-escalation
• As soon as the causative organism is identified on culture
• Choose an agent which is CHEAP and COST EFFECTIVE
• Daily reassessment to perform de-escalation and prevent resistance, reduce costs and avoid super-infections
• Use of LOW PROCALCITONIN levels
RecomendationsClinical condition
Common pathogens
Emperical AMA
Alternate AMA Comments
Urosepsis E. coli, Pseudomonas spp, Enterococcus spp.,Klebsiella spp., Proteus spp., AnaerobesCandidia spp
BL-BLI or
Meropenem or Imipenem-cilastatin.
Fluconazole if Candida
Colistin with Meropenam
In pyelonephritiswith sepsis,Echiocandinsmay beconsidered ifCandida speciesare likely to be resistant to Fluconazole
RecommendationsClinical condition
Common pathogens
Emperical AMA
Alternate AMA Comments
Intra-abdominal Sepsis
E. coli, Pseudomonas spp, Enterococcus spp.,Klebsiella spp., Acinetobacter spp,Proteus spp.,Candidia spp
BL-BLI or
Meropenem or Imipenem-cilastatin.
Colistin with Meropenam
Source controlvitalVancomycin orTeicoplanin ifEnterococcusspp isolated
Fluconazole orEchinocandins if Candida spp isolatedEchinocandins if prior h/o Azole exposure or Fluconazole resistance is suspected
RecommendationsClinical condition
Common pathogens
Emperical AMA
Alternate AMA Comments
Catheter related blood stream infections
Gram –negative pathogens Ecoli Klebsiella spp Enterobacter spp P aeruginosa Gram-positive pathogens CONS S aureus, MRSA
Fungi Candida spp
Carbapenem, or BL-BLI, with or without an aminoglycoside Vancomycin in settings of high MRSA prevalence; Echinocandin or fluconazole if fungal infection suspected
Add colistin for Gram-negative cover where carbapenem resistance rates are high
Where MRSA isolates have vancomycin MI 2 mg/mL, daptomycin, should be used
Classification of Surgical Wounds• Class I/Clean:
-Uninfected, operative wound with no inflammmation and Resp/GI/Genital/Urinary tract is not entered
• Class II/Clean contaminated:- Resp/GI/Genital/Urinary tract is entered under controlled conditions without unusual contamination
• Class III/Contaminated:- Open fresh accidental wounds. Operations with major break in sterile technique with gross spillage from GIT
• Class IV/ Dirty-infected:- Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infections and perforated viscera
Superficial Incisional SSI - Within 30 days of surgery and infection involves only skin or SC tissue of the incision+ 1 of the following: 1. Purulent drainage, with or without laboratory confirmation, from the superficial incision 2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision 3. At least one of the following signs or symptoms of infection:- pain or tenderness- localized swelling, redness, heat - superficial incision is deliberately opened by surgeon, unless incision is culture-negative4. Diagnosis of superficial incisional SSI by the surgeon or attending physician
Superficial Incisional SSI
• Following conditions not to be reported as SSI:- Stitch abscess- Infection of an episiotomy or newborn circumcision site - Infected burn wound- Incisional SSI that extends into the fascial and muscle layers (see deep incisional SSI)
Deep Incisional SSI - Within 30 days without implant or within 1 year with implant
- Infection is likely due to surgery and involves fascial and muscle layers) + 1 of the following:
1. Purulent drainage from the deep incision but not from the organ/space component of the surgical site
2. Spontaneous dehiscence/deliberate opening by a surgeon when the patient has at least 1 of the following : - Fever (>38ºC)- Localized pain or tenderness, unless site is culture-negative- An abscess or infection of the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination.- Diagnosis of a deep incisional SSI by a surgeon or attending physician.
Deep Incisional SSI
• Notes: i. Report infection that involves both superficial and deep incision sites as deep incisional SSI ii. Report an organ/space SSI that drains through the incision as a deep incisional SSI
Organ space SSI• Within 30 days after the operation if no implant is left in place or within
1 year if implant is in place
• Appears to be related to the operation and infection involves any part of the anatomy (e.g., organs or spaces), other than the incision, which was opened or manipulated during an operation and + 1 of the following:
-Purulent drainage from a drain- Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space. - An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination.
-Diagnosis of an organ/space SSI by a surgeon or attending physician.
Peri-operative Prophylaxis• Choice of AMA:
- Dictated by the most common pathogen encountered- Skin pathogens are usual targets: 1st Generation Cephalosporins- H/o allergy to penicillins: Vancomycin/Clindamycin
• Timing of administration:- Before skin incision- All agents 30-60 mins prior- Vancomycin and Flouroquinolones 120mins prior
Peri-operative Prophylaxis• Route of administration:
- Intravenous• Dosage:
- Same as therapy• Duration:
- No longer than 24hrs- Single dose as effective as multiple doses- Multiple doses assoc with a higher risk of Resistance & Colitis
• Re-dosing:- If duration of surgery exceeds 2 x half lives- Blood loss > 1500ml or Haemodilution> 15ml/kg