Antimicrobial Usage 2023.pdf. .0

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1. Antimicrobial Usage
Adel Mohamad Alansary, MD

2. Objectives
•Why give antimicrobials in ICU?
•How to choose the proper antimicrobial?
–Classification.
–Gram staining.
–Parameters.
•Duration of therapy.
•Combating resistance factors.
•Why YOU?

3. THE START

4. Do I need to give an
antimicrobial?

5. Noninfectious causes of fever
•Neoplasms
•Rheumatologic activity
•Deep vein thrombophlebitis
•Drug reaction
•Vasculitis
•Lung Collapse
•Serious infection can be present without the patient
displaying a fever—especially if certain
comorbidities are present, such as diabetes or
immunosuppression.

6. Indications for Antimicrobials
•Prophylactic.
•Empiric.
•Therapeutic.

7. Surgical Prophylaxis
•Prevent postoperative infection of the surgical
site.
•Prevent postoperative infectious morbidity and
mortality.
•Reduce the duration and cost of health care
•Produce no adverse effects.
•Have no adverse consequences for the microbial
flora of the patient or the hospital.

8. Surgical Prophylaxis
•Timing.
•Dose and redose.
•Choice:
–Penetration of site.
–Hospital microbiology.
–Patient factors.

9. Surgical Prophylaxis
(The American Journal of Surgery (2013)
206, 451-456)

10. Factors affecting the incidence of
wound infection
•Extremes of age.
•Under nutrition.
•Obesity.
•Diabetes.
•Hypoxemia.
•Remote infection.
•Corticosteroid or immunosuppressive therapy.
•Recent operation.

11. Factors affecting the incidence of
wound infection
•Surgeon’s experience.
•Length of the procedure.
•Hospital and operating-room environments.

12. Factors affecting the incidence of
wound infection
•Instrument sterilization.
•Air filters.
•Hospital flora.

13. Timing
•By consensus, the ideal time of administration is within
30 minutes to one hour before the incision.
•The exceptions are:
–Cesarean section, in which the antimicrobial should be
administered after cross-clamping of the umbilical cord and
–Colonic procedures, in which oral antimicrobials should be
administered starting 19 hours before the scheduled time of
surgery.

14. Duration
•For most procedures, the duration of
antimicrobial prophylaxis should be 24 hours or
less, with the exception of cardiothoracic
procedures (48 to 72 hours’ duration).

15. Cardiothoracic Surgery

16. Mediastinitis
•The frequency of this infection with or without
associated sternal dehiscence is 0.7% to 1.5%;
however, the associated mortality rate is 13% to
33%.

17. Risk Factors
•Chronic obstructive pulmonary disease.
•Prolonged stay in the intensive care unit.
•Respiratory failure.
•Connective tissue disease.
•Male sex.
•Advanced age.
•Lengthy surgery.
•Diabetes mellitus.

18. Organism and Antimicrobial
•Endocardium: Staphylococcus aureus.
•Sternal wound and SVG wound: G-ve bacilli.
•Cephalosporins, as single agents, are at least as effective
as combination regimens of antistaphylococcal
penicillins and aminoglycosides and are much easier to
administer.
•Cefazolin has been the traditional cephalosporin of
choice.

19. Recommendations
•Cefazolin 1 g intravenously at induction of anesthesia and every 8
hours for up to 72 hours.
•Cefuroxime 1.5 g intravenously at induction of anesthesia and
every 12 hours or
•cefamandole 1 g at induction of anesthesia and every six hours
are suitable alternatives.
•Vancomycin 1 g (as the hydrochloride) intravenously over one
hour, with or without gentamicin 2 mg/kg intravenously, should
be reserved as an alternative for allergic patients or high risk
groups.

20. EMPIRIC THERAPY

21. THE ORGANISM

22. Interpretation of Gram Stain Results
•Gram-Positive Cocci (GPC)
–Pairs, chains, clusters:Staphylococcus sp.
–Pairs, chains:
Streptococcus sp.
Enterococcus sp.
–Pairs, lancet-shaped:
Streptococcus pneumoniae

23. Gram Negative Cocci (GNC)
•Diplococci
–Pairs:
Neisseria meningitidis
Neisseria gonorrhoeae
Moraxella catarrhalis
•Other:
Acinetobacter sp

24. Gram-Positive Bacilli (GPB)
•Diphtheroids:
–Small, pleomorphic:
Corynebacterium
Propionibacterium
•Large, with spores:
–Clostridium sp
–Bacillus sp
Branching, beaded, rods:
•Nocardia sp
•Actinomyces sp
Other:
•Listeria sp
(blood/cerebrospinal
fluid)
•Lactobacillus sp
(vaginal/blood)

25. Gram Negative Bacilli (GNB)
•Enterobacteriaceae:
–Escherichia coli
–Serratia sp
–Klebsiella sp
–Enterobacter sp
–Citrobacter sp
•Nonfermentative:
–Pseudomonas aeruginosa
–Stenotrophomonas maltophilia
–Haemophilus influenzae
–Bacteroides fragilis group
–Fusiform (long, pointed):
Fusobacterium sp
Capnocytophaga sp

26. ESKAPEE
•Enterococci
•Staph
•Klebsiella
•Acintobacter
•Pseudomonas
•Enterbacter
•E. Coli

27. RESISTANCE PROBLEM

28. ESBLs and CRE
•Bacteria that produce Beta Lactamase that
hydrolyses Pencillins, Cephalosporins, and
Aztreonam.
•Carbanemases are similar enzymes that
specifically hdrolyses Carbapenems.

29. ESBLs
Jordan
ESBL Klebsiella spp.
ESBL E. coli
MRSA
30-80%
25-44%
56%
Lebanon
ESBL E. coli
ESBL Klebsiella spp.
MRSA
13-81%
11-24%
12%
Saudi Arabia
MRSA
ESBL
E. coli
Klebsiella spp.
12-49%
16%
16%
48%
Iran
MRSA
Vancomycin-Resistant
Enterococci
54%
6-14%
Egypt
ESBL E. coli
Enterobacteriaceae
MRSA
61%
38.5%
52%
Shehabi et al 2000; Rahban et al 2001; Hamze et al 2003; Bouchillon et al 2004; Matar et al 2005;
Baddour et al 2006; Daoud et al 2006; El Kizzi et al 2006; Mohamed Al Agamy et al 2006;
Assadian et al 2007; Borg et al 2007; Askarian et al 2008

31. Selection for resistant strains

32. Definitions
•MDR: The isolate is non-susceptible to
at least 1 agent in ≥3 antimicrobial
categories
•XDR: The isolate is non-susceptible to
at least 1 agent in all but 2 or fewer
antimicrobial categories.
•PDR: Non-susceptibility to all agents in
all antimicrobial categories.

33. Mortality associated with carbapenem resistant
(CR) vs susceptible (CS) Klebsiella pneumoniae
(KP)0
10
20
30
40
50
60
Overall MortalityAttributable
Mortality
Percent of subjects
CRKP
CSKP
Patel G et al. Infect Control Hosp Epidemiol 2008;29:1099-1106
OR 3.71 (1.97-7.01)OR 4.5 (2.16-9.35)
p<0.001
p<0.001

34. Consequences of antimicrobial resistance:
mortality
•Mortality in patients with
bacteraemia due to
carbapenemase-producing
Klebsiella pneumoniae (KPC
or VIM)
Tigecycline is the property of Pfizer.
KPC, Klebsiella pneumoniae carbapenemase; MβL, metallo-β-lactamase;
VIM, Verona Integron-encoded-β- lactamase.
Daikos GL, et al. Bloodstream infections caused by carbapenemase-producing Klebsiella pneumoniae: a clinical perspective. Expert
Rev Anti Infect Ther 2012;10(12):1393–404.

35. Global Prevalence of ESBL-producing E. coli
(2011-2014)
CDDEP report, 2015

36. Blood Culture Bullets for Adults
•Blood cultures are most likely to be positive when an ample
volume of blood is collected and if the patient is not already
on antimicrobials.
•Two sets of cultures (total volume each set 20 mL) should be
drawn 1 hour apart, preferably from a peripheral site rather
than through a central vascular catheter.
•Ten mL each is inoculated into aerobic and anerobic bottles.
Cultures are held at least 4 days before reported as negative.

37. THE DRUG

39. Cidal Versus Static

40. Spectrum
•Cefazolin:
–G positive cocci only.
–G positive cocci excluding MRSA
–G positive and some G negatives
–G positives and anaerobes

41. Cefazolin
•Antimicrobial Spectrum:
•Gram-positive bacteria: methicillin-susceptible
Staphylococcus aureus (MSSA), coagulase –
negative Staphylococci, penicillin-susceptible
Streptococcus pneumoniae, Streptococci spp.
•Gram-negative bacteria: Moraxella catarrhalis,
Escherichia coli, Klebsiella pneumoniae, Proteus
mirabilis

42. Levofloxacin
•Atypical bacteria only.
•MSSA, MRSA, Pseudomonas and
Enterobacteriaceae.
•Enterobacteriaceae and atypical bacteria.
•Anaerobes and atypical bacteria.

43. Levofloxacin
•Gram positive bacteria: methicillin-
susceptibleStaphylococcus aureus(MSSA),
methicillin-resistantStaphylococcus
aureus(MRSA),Streptococcus pneumoniae,
Listeria monocytogenes
•Gram negative bacteria:Enterobacteriaceae,
H. influenzae, other Haemophilus spp., N.
gonorrhoeae, N. meningitides, M. catarrhalis, P.
aeruginosa, Stenotrophomonas maltophilia, S.
maltophilia
•Atypicals:Legionella pneumophilia

44. Clarithromycin
•Staphylococcus aureus,Bacillus
cereus,Bordetella pertussis,Chlamydia
trachomatis,Corynebacterium
diphtheriae,Gardnerella vaginalis,H.
influenzae,Legionella
pneumophila,Moraxella
catarrhalis,Mycobacterium
spp.,Mycoplasma pneumoniae,Pasteurella
multocida,S. pneumoniae,S. pyogenes.

45. Penetration
•Vancomycin Vs Linezolid.
•UTI:
–Quinolones
–Nitrofurantoin
•Skin and soft tissue:
–Penicillins

46. Toxicity

48. Hospitalized patients With Risk
Factors
Tienam is the Most Adequate Antibiotic
De-Escalation Therapy
Choose Adequate broad-spectrum, empiric treatment
regimen based on clinical symptoms and unit-specific
antibiogram data and guidelines.
Obtain and analyze microbiological data
Modify regimen accordingly
Reassess patient
Adapted from Kollef MH,12 Kollef MH,13 Kollef MH et al,8 Niederman MS.14
Clinical Infectious Diseases 2006; 42:S72–81

49. Hospitalized patients With Risk
Factors
Tienam is the Most Adequate Antibiotic
Patients Who May Benefit from Empirical
Broad-Spectrum Antimicrobial Therapy
•HAP
•VAP
•Bacteremia
•Severe sepsis (including bacterial and fungal pathogens)
•Cardiothoracic Surgery ( valves, patients with risk factors,
Co morbidities)
•Severe community-acquired pneumonia
•Burns
Critically ill non-neutropenic patients with serious infections, for
example, patients with:

50. Adequate
Therapy
Concept
Better Patient Outcomes
Spectrum
Timing
Dosage
Tolerability
Prior Antimicrobials
Resistance
Main Factors Defining Adequate Therapy
1. Kollef MH. Clin Infect Dis 2000;31(Suppl 4):S131-S138.
2. Kollef MH et al. Chest 1999;115:462-474.

51. Why You?

52. THANK YOU