antibiotic therapy in the intensive care unit [autosaved]
TRANSCRIPT
![Page 1: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/1.jpg)
ANTIBIOTIC THERAPY IN THE INTENSIVE CARE
UNITDr amrita
Moderator : dr amit rastogi
![Page 2: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/2.jpg)
THE ACTION OF ANTIMICROBIAL DRUGS
Figure 20.2
![Page 3: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/3.jpg)
PROTEIN SYNTHESIS INHIBITORS
Figure 20.4
![Page 4: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/4.jpg)
BETA LACTAMS
• Narrow spectrum
• Narrow spectrum pEnicillinase susceptible. Penicillin
• Very-narrow-spectrum penicillinase-resistant drugs
• Methicillin
• Nafacillin
• Oxacillin
![Page 5: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/5.jpg)
• Wide spectrum
• Wider-spectrum penicillinase-susceptible drugs
• Ampicillin and amoxicillin.
• Piperacillin and ticarcillin.
• Wide spectrum pEnicillinase resistant drugs
• Carbapenem
• Imipinem
• Meropenem
• Doripinem
• Ertapenem
![Page 6: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/6.jpg)
THE CEPHALOSPORIN FAMILY
![Page 7: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/7.jpg)
OTHER CELL WALL INHIBITORS
• Monobactams
• Aztreonams
• Vancomycin
• Telavancin
• Dalacin
• teichoplanin
![Page 8: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/8.jpg)
AMINOGLYCOSIDES
• Gentamycin
• Tobramcin
• Amikacin
• Toxicity profile
• Ototoxicity
• Nephrotoxicity
• Blocking neuromuscular transmission
• hypersensitivity
![Page 9: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/9.jpg)
PROTEIN SYNTHESIS INHIBITORS
• Linezolid
• Quinupristin/Dalfopristin
• Daptomycin
• Tigecycline
![Page 10: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/10.jpg)
ANTIMICROBIALS WITH ACTIVITY AGAINST ANAEROBES
• Metronidazole
• clindamycin
![Page 11: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/11.jpg)
PHARMACOKINETICS AND PHARMACODYNAMICS OF ANTIBIOTICS
![Page 12: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/12.jpg)
SPECIAL CONSIDERATIONS IN THE CRITICALLY ILL PATIENT
• Volume of distribution
• Metabolism
• Clearance : ranal hyper and hypo filtration
• hypoalbunaemia
![Page 13: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/13.jpg)
HOW TO START
• Loading dose = target plasma conc * volume of distribution
• High loading doses for hydrophilic drugs like beta lactams , vancomycin , and
aminoglycosides
• Lipophilic drugs like macrolides,linezolid,tetracyclins do not require a high loading
dose
• Renal and hepatic function do not affect loading dose
![Page 14: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/14.jpg)
PHARMACOKINETIC AND PHARMACODYNAMICS PROPERTIES OF ANTIBIOTICS
• Minimum inhibitory concentration : The MIC is the lowest concentration of an
antibiotic that completely inhibits the growth of a microorganism in vitro. While the
MIC is a good indicator of the potency of an antibiotic, it indicates nothing about the
time course of antimicrobial activity
• Parameters quantifying serum level :
• Peak serum level : Cmax
• Trough level : Cmin
• Area Under the serum concentration time Curve (AUC) : indicates the amount of drug
![Page 15: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/15.jpg)
![Page 16: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/16.jpg)
PARAMETERS INDICATING ANTIBIOTIC ACTIVITY
• he Peak/MIC ratio, Cpmax divided by the MIC.
• the T>MIC, percentage of a dosage interval in which the serum level exceeds the
MIC.
• and the 24h-AUC/MIC ratio. determined by dividing the 24-hour-AUC by the MIC
![Page 17: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/17.jpg)
Pattern of Activity Antibiotics Goal of Therapy PK/PD Parameter
Type I
Concentration-dependent killing and
Prolonged persistent effects
Aminoglycosides
Daptomycin
Fluoroquinolones
Ketolides
Maximize concentrations24h-AUC/MIC
Peak/MIC
Type II
Time-dependent killing and
Minimal persistent effects
Carbapenems
Cephalosporins
Erythromycin
Linezolid
Penicillins
Maximize duration of exposure T>MIC
Type III
Time-dependent killing and
Moderate to prolonged persistent effects.
Azithromycin
Clindamycin
Oxazolidinones
Tetracyclines
Vancomycin
Maximize amount of drug 24h-AUC/MIC
![Page 18: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/18.jpg)
DOSING OF A CONCENTRATION DEPENDANT ANTIBIOTIC
![Page 19: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/19.jpg)
DOSING OF A TIME DEPENDANT ANTIBIOTIC
• Multiple small dosing to obtain the
maximum t > MIC
• Role of prolonged infusions
![Page 20: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/20.jpg)
ANTIBIOTIC RESISTANCE
• Common mechanisms
• Impermeability of the drug:
• alteration in target molecules
• enzymatic drug modifications
• Efflux
• both chromosomal mutations or genetic transfer ( plasmids ) can be responsible for
the resistance acquisition,
![Page 21: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/21.jpg)
FACTORS RESPONSIBLE FOR ANTIBIOTIC RESISTANCE
• Lack of education
• Hospital acquired infections
• Use of antibiotics in agriculture or aquaculture
• Environmental factors
• Use in household products
![Page 22: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/22.jpg)
SOME COMMON RESISTANT STRAINS : GRAM POSITIVE
• Methicillin resistant Staplylococcus aureus (MRSA)
• Vancomycin intermediate staph. Aureus ( VISA )
• Enterococcus- HLAR
• Multi drug resistant strep pneumoniae
![Page 23: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/23.jpg)
SOME COMMON RESISTANT STRAINS : GRAM NEGATIVE
• Extended-Spectrum b-Lactamase –Producing Enterobacteriaceae
• Antibiotic options carbapenems,
• tigecycline
• Carbapenemase producing enterobacteriaciae
• The delhi metalloprotease
• No susceptibility to any beta lactam or other higher antibiotics
• Susceptible to tigecycline and colistin
![Page 24: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/24.jpg)
• Multi drug resistant pseudomonas MDR P aeruginosa are strains that are
resistant to 2 or more classes of antibiotics
• Antipseudomonal Penicillins with or with out beta lactamases
• Piperacillin tazobactum
• Ticarcillin
• Aztreonam
• Caeftazidime in combination with aminoglycosides
• Carbapenems : imipinem > doripinem > meropenem.etrapenem has no role against
pseudomonas.
• colistin
![Page 25: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/25.jpg)
ANTIBIOTIC THERAPY IN THE ICU
![Page 26: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/26.jpg)
ANTIBIOTIC STEWARDSHIP
• The Centers for Disease Control and Prevention (CDC) estimates more than two
million people are infected with antibiotic-resistant organisms, resulting in
approximately 23,000 deaths annually.
• Has recommended the setting up of special bodies in all acute care hospitals for the
optimization of antibiotic use-called antibiotic stewardship programmes.
![Page 27: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/27.jpg)
SPECIFIC INTERVENTIONS TO IMPROVE ANTIBIOTIC USE
• formal procedure for all clinicians to review the appropriateness of all antibiotics 48
hours after the initial orders (e.g. antibiotic time out)
• specified antibiotic agents need to be approved by a physician or pharmacist prior to
dispensing
• physician or pharmacist to review courses of therapy for specified antibiotic agents
(i.e., prospective audit with feedback)
• Automatic changes from intravenous to oral antibiotic therapy in appropriate
situations
• Dose adjustments in cases of organ dysfunction
![Page 28: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/28.jpg)
• Dose optimization (pharmacokinetics/pharmacodynamics) to optimize the treatment
of organisms with reduced susceptibility
• Automatic alerts in situations where therapy might be unnecessarily duplicative
• Time-sensitive automatic stop orders for specified antibiotic prescriptions
• track rates of C. difficile infection
• Monitor total amounts of antibiotics used
![Page 29: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/29.jpg)
ANTIBIOTIC STRATEGIES TO COMBAT RESISTANCE
Blast them
![Page 30: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/30.jpg)
Fool them
![Page 31: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/31.jpg)
Stop irritating them.
![Page 32: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/32.jpg)
ANTIBIOTIC STRATEGY FOR SKIN AND SOFT TISSUE INFECTION
![Page 33: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/33.jpg)
![Page 34: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/34.jpg)
ANTIBIOTIC STRATEGY FOR COMMUNITY ACQUIRED PNEUMONIA
• A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam)
azithromycin (level II evidence) or a respiratory fluoroquinolone
• If Pseudomonas is a consideration
• An antipneumococcal, antipseudomonal b-lactam (piperacillintazobactam,
cefepime, imipenem, or meropenem) plus
• either ciprofloxacin or levofloxacin (750 mg)
+
![Page 35: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/35.jpg)
• Or
• The above b-lactam plus an aminoglycoside and azithromycin
• or
• The above b-lactam plus an aminoglycoside and an antipneumococcal
fluoroquinolone (for penicillin-allergic patients,
substitute aztreonam for above b-lactam)
![Page 36: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/36.jpg)
![Page 37: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/37.jpg)
![Page 38: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/38.jpg)
![Page 39: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/39.jpg)
ANTIBIOTIC INFECTION FOR INTRA ABDOMINAL INFECTIONS
![Page 40: Antibiotic therapy in the intensive care unit [autosaved]](https://reader033.vdocument.in/reader033/viewer/2022052413/559b26bb1a28ab65488b47ea/html5/thumbnails/40.jpg)