Massimo Antonelli, MD Dept. of Intensive Care & Anesthesiology Università Cattolica del Sacro Cuore...
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Massimo Antonelli, MD Dept. of Intensive Care & Anesthesiology Università Cattolica del Sacro Cuore Rome - Italy ntibiotics: The old and the new ntibiotics: The old and the new
Massimo Antonelli, MD Dept. of Intensive Care & Anesthesiology Università Cattolica del Sacro Cuore Rome - Italy Antibiotics: The old and the new
Massimo Antonelli, MD Dept. of Intensive Care &
Anesthesiology Universit Cattolica del Sacro Cuore Rome - Italy
Antibiotics: The old and the new
Slide 2
Major sites of infection in medical ICU n= 13,592 Richards MJ,
et al. Infect Control Hosp Epidemiol 2000; 21: 510-515
Slide 3
Facts Multi-resistant germs are common Antimicrobial resistance
increases over time Inadequate therapy is associated with Mortality
Can we adopt specific strategies to decrease resistance ?
Slide 4
Most Frequently Reported Pathogens from ICU Patients with
Nosocomial Pneumonia 1. Pseudomonas aeruginosa 2. Staphylococcus
aureus 3. Enterobacter spp. 4. Klebsiella pneumoniae 5.
Acinetobacter spp. Richards MJ et al. Crit Care Med 1999;
887-892.
Slide 5
S. aureus The Most Frequent Isolate in EPIC Study Vincent JL,
et al. JAMA 1995;274:639-644. Vincent JL. Int Care Med
2000;26:S3-S8.
Slide 6
MRSA Pneumonia: Infection-Related Mortality
Slide 7
Multiresistant bacteria are a problem in VAP 7.7S. pneumoniae %
of all isolatesOrganism 3.1MSSA 8.4H. influenzae 11.8A. baumannii
11.8MRSA 31.7P. aeruginosa Rello J. Am J Respir Crit Care Med 1999;
160:608-613. (n = 321 isolates from 290 episodes)
Slide 8
Acinetobacter baumannii Resistance in 118 ICUs of 5 European
Countries 16%5%9% Imipenem 81%75%78% Ciprofloxacin 51%10%36%
Amikacin 58%75%44% Pip/taz 76%81%70% Ceftazidime Spain
PortugalFranceAntibiotic Pip/taz=piperacillin/tazobactam Hanberger
H et al. JAMA 1999;281:67-71.
Slide 9
Variables indipendently associated with VAP caused by
Potentially Resistant bacteria *.0251.2-14.24.12Broad-spectrum
antibiotics (Y/N).00033.3-55.013.46Prior antibiotic use
(Y/N).0091.6-23.16.01Duration of MV before VAP episode 7 d (Y/N) p
Value95% CIOdds Ratio Variable Trouillet JL., et al. AM J RESPIR
CRIT CARE MED 1998; 157: 531-539 * Discriminant value (AUC) =
0.89
Slide 10
Facts Multi-resistant germs are common Antimicrobial resistance
increases over time Inadequate therapy is associated with Mortality
We may adopt specific strategies to decrease resistance: antibiotic
rotation ?
Facts Multi-resistant germs are common Antimicrobial resistance
increases over time Inadequate therapy is associated with Mortality
We may adopt specific strategies to decrease resistance: antibiotic
rotation ?
Slide 14
Mortality Associated With Initial Inadequate Therapy In
Critically Ill Patients With Serious Infections in the ICU
0%20%40%60%80%100 % Luna, 1997 Ibrahim, 2000 Kollef, 1998 Kollef,
1999 Rello, 1997 Alvarez-Lerma,1996 Initial appropriate therapy
Initial inadequate therapy *Mortality refers to crude or
infection-related mortality Alvarez-Lerma F et al. Intensive Care
Med 1996;22:387-394. Ibrahim EH et al. Chest 2000;118L146-155.
Kollef MH et al. Chest 1999; 115:462-474 Kollef MH et al. Chest
1998;113:412-420. Luna CM et al. Chest 1997;111:676-685. Rello J et
al. Am J Resp Crit Care Med 1997;156:196-200. Mortality*
Slide 15
Slide 16
Reducing Inadequate Therapy Antibiotic Management Through
Practice Guidelines 0 2 4 6 8 10 12 14 16 18 Duration of Antibiotic
Therapy Length of ICU Stay ICU Admission to Discharge Total Length
of Stay Number of Days Computer-Generated Regimen
Physician-Generated Regimen *P
Risk Factors for Resistance in VAP Use of antibiotics within 15
days 1 Duration of hospitalization 2 Duration of mechanical
ventilation > 7 days 1 1 Trouillet J-L et al. Am J Respir Crit
Care Med 1998;157:531-539. 2 Lautenbach E et al. Clin Infect Dis
2001;32:1162-1171.
Slide 18
Facts Multi-resistant germs are common Antimicrobial resistance
increases over time Inadequate therapy is associated with Mortality
We may adopt specific strategies to decrease resistance: antibiotic
rotation ?
Slide 19
Antimicrobial Resistance: Key Prevention Strategies Optimize
Use Prevent Transmission Prevent Infection Effective Diagnosis
& Treatment Pathogen Antimicrobial-Resistant Pathogen
Antimicrobi al Resistance Antimicrobial Use Infection Campaign to
Prevent Antimicrobial Resistance in Healthcare Settings Susceptible
Pathogen
Slide 20
Key Prevention Strategies Prevent infection Diagnose and treat
infection effectively Use antimicrobials wisely Prevent
transmission Campaign to Prevent Antimicrobial Resistance in
Healthcare Settings Clinicians hold the solution!
Slide 21
12 Steps to Prevent Antimicrobial Resistance: Hospitalized
Adults 1.Vaccinate 2.Get the catheters out 3.Target the pathogen
4.Access the experts 5.Practice antimicrobial control 6.Use local
data 7.Treat infection, not contamination 8.Treat infection, not
colonization 9.Know when to say no to vanco 10.Stop treatment when
infection is cured or unlikely 11.Isolate the pathogen 12. Break
the chain of contagion Diagnose and Treat Infection Effectively
Prevent Infection Use Antimicrobials Wisely Prevent Transmission 12
Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Slide 22
Use Antimicrobials Wisely Step 6: Use local data Fact: The
prevalence of resistance can vary by local, patient population,
hospital unit, and length of stay. Actions: know your local
antibiogram know your patient population Link to: NCCLS Proposed
Guidance for Antibiogram DevelopmentNCCLS Proposed Guidance for
Antibiogram Development 12 Steps to Prevent Antimicrobial
Resistance: Hospitalized Adults
Slide 23
Risk factors for Early Onset Pneumonia Incidence % 14,6 30 41,7
19 29,2 25 13,6 30,6 14,7 8,7 26,9 46,7 8,2 33,3 Age 65 Males
Females Multiple trauma Head trauma Pulmonary contusion No
pulmonary contusion AIS 1^ AIS 2 AIS 3 MV > 24 h MV