antimicrobial resistance in intensive care unit
TRANSCRIPT
Antimicrobial resistance in intensive care units
Mansoor Masjedi ; MD & FCCM
Assisstant professor of anesthesia & critical care consultant
Shiraz university of medical sciences , Iran
Oct . 2013
09:00 - 10:00 am
Critical Care Group
Panel Discussion: Infection in ICU
Coordinator: M.Masjedi
Panel members: HR.Jamaati, M.Mokhtari, A.Taher,
E.Ginzburg
Antimicrobial resistance in intensive care units
Introduction
Sites of Infection
Pathogens at Different Sites of Infection in Medical Surgical ICUs
Antimicrobials Resistant Infections in ICU
Implications of Increasing Antimicrobials Resistant Infections in ICU
Strategies for Preventing Antimicrobial Resistance
References
Antimicrobial resistance in intensive care units
Introduction:
Hospital-acquired and ICU - acquired infections : 1. Outstanding obstacles for health care systems through decades all around
the word
2. High cost to health system
3. Mortality and morbidity
ICU beds < 10% of hosp. beds but > 20% of all nosocomial infections are acquired in ICUs
Infections and sepsis are the leading cause of death in non-cardiac ICUs
Antimicrobial resistance in intensive care unitsEpidemiology
Incidence of sepsis in ICUs continues to rise
60 % of ICU patients considered infected
Infection :a strong independent predictor for mortality
More chronic comorbid illnesses & severe acute physiologic
derangements
High frequency of indwelling catheters
Necessitate frequent contact with healthcare personnel
Associated equipment → serve as reservoirs for pathogens →
horizontal patient-to-patient transmission
MDRs ( MRSA, VRE, ESBLs and carbapenem-resistant
Pseudomonas aeruginosa ) isolated with increasing frequency in ICUs
Antimicrobial resistance in intensive care unitsHigh incidence of infections in ICU
The most common and clinically important infections
in the ICU are those associated with the supportive
devices ventilator associated pneumonia - VAP
intravascular catheter-related bloodstream infection - CRBSI
catheter associated urinary tract infection - CAUTI
Antimicrobial resistance in intensive care unitsCommon infections in the ICU
Rapid Rise in the rate of resistance in ICUs
VRE : 24.7 → 33.3 %
MRSA : 53.5 → 56.2 %
P. aeruginosa resistant to imipenem or fluoroquinolones16.4→25.3% & 23.0 → 30.7 %
A. baumannii resistant to carbapenems : 11 → 30 %
ESBL producers :10.4 → 25 %
Enterobacteriaceae resistant to carbapenems (CREs) :0 → 8 %
Antimicrobial resistance in intensive care unitsPrevalence of drug resistant organisms
Older age
impaired immunity
Lack of functional independence and/or decreased cognition
Underlying comorbid conditions (eg, diabetes, renal failure, malignancies, immunosuppression) and higher severity of illness indices
Long hospital courses prior to ICU Frequent encounters with healthcare environments
(eg, hemodialysis units, ambulatory day-care clinics)
Frequent manipulations by and contact with healthcare personnel
Presence of indwelling devices such as CVCs, urinary cath. , ETT ,…
Recent surgery or other invasive procedures
Antimicrobial resistance in intensive care unitsRisk factors for resistant infections
Antimicrobial resistance in intensive care unitsRisk factors for resistant infections
Continued…
Presence of indwelling devices
such as CVCs, urinary cath. , ETT ,…
Recent surgery or other invasive procedures
Prior AB therapy
Frequent use of broad-spectrum ABs
↓nursing & support staff due to economic pressures
Delay in appropriate antimicrobial Rx ~ independent predictor of mortality
In septic shock, 1 hr delay ( in the first 6 hrs) ~ ↓7.6 % of survival
Antimicrobial resistance often “first line” → "second line" agents (inferior
bactericidal activity and unfavorable pharmacokinetic and/or pharmacodynamic
properties )
Virulence properties of the organism → poor outcomes ?
Antimicrobial resistance in intensive care units
Outcome of multidrug resistant infections
Antibiotic utilization controls
Antibiotic evaluation committees (often involving clinicians, pharmacists and
microbiologists) for :
Effective and safe use of antimicrobials
Evaluate and guide formulary decisions
Educational programs
Improve antimicrobial utilization
Protocols and guidelines for AB
Restrictions of broad-spectrum agents
Preferential use of narrow-spectrum antibiotics (such as first generation
cephalosporins and aminoglycosides)
Mandatory consultations with infectious man
Antimicrobial resistance in intensive care unitsPREVENTION OF INFECTIONS AND DRUG RESISTANCE
Antimicrobial resistance in intensive care units
PREVENTION OF INFECTIONS AND DRUG RESISTANCE…
Antibiotic class Cycling :
A class of antibiotics or a specific antibiotic drug is withdrawn from use for a defined period and reintroduced at a later point in time
Other methods include:
Mixing of antibiotic classes
Scheduled changes of antibiotic classes
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Infection control measures
1. Hand hygien2. Daily bathing with chlorhexidine3. Device specific strategies to decrease infection 4. Contact precautions for pts infected or colonized with resistant
organisms5. Environmental cleaning
Antimicrobial resistance in intensive care unitsPREVENTION OF INFECTIONS AND DRUG RESISTANCE
Hand hygiene No substitute for good hand hygiene
Contact precautions Gown and gloves before entering and removing after exiting may
decrease transmission of MDRs
Antimicrobial resistance in intensive care unitsPREVENTION OF INFECTIONS AND DRUG RESISTANCE
Decolonization/patient bathing Chlorhexidine bath : decreasing both HAI and MDRs in the ICU
Surveillance Surveillance for MDRs for early identification and control of epidemic
outbreaks & endemic increases of resistant bacteria
Antimicrobial resistance in intensive care unitsPREVENTION OF INFECTIONS AND DRUG RESISTANCE
Limiting hospitalization & invasive interventions ( daily clinician assessment is necessary for all indwelling devices)
Device-specific strategies specific strategies for placement and care of such devices
Environmental cleaning Innovative but as yet experimental techniques for environmental cleansing
include ultra-violet light sterilization lamps and
hydrogen-peroxide vapor decontamination devices
Antimicrobial resistance in intensive care unitsPREVENTION OF INFECTIONS AND DRUG RESISTANCE
Antimicrobial resistance in intensive care unitsPREVENTION OF INFECTIONS AND DRUG RESISTANCE
In addition the following should be considered to improve antibiotic efficacy, for limitation of toxicity, and to prevent the emergence of bacterial resistance:
Optimal dosing, Interval of drug administration, Duration of treatment
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