When To Use Antibiotic in PICU and Antibiotic Stewardship

Dr. Ira Shah explains to us the rational use of Antibiotics in PICU and Antibiotic Stewardship.
Is the choice of antibiotics correct?
What should be given in this child?
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Also, check out the lecture on Cough Syrups by Dr. Ira Shah
• Cough Syrups | Dr. Ira...
For the seven major classes of known antibiotics, resistance has developed within 1-4 years from the clinical introduction of the drug.
Timeline of antibiotic resistance and antibiotic deployment.
This is the kind of organism that we say Antibiotic resistance- Bad Bugs in ICU
SUMMARY:
• Multi-drug resistant pathogens are becoming more common everywhere
• New antibiotics with novel mechanisms of action are not being produced
• Rational use of antibiotics is required
This is for the major problem in USA-Bad Bugs, No Drugs:
In July 2004, IDSA sent a white paper to Capitol Hill stressing the rapidly growing public health crisis in the emergence of bacteria that were resistant to many, if not all, antibiotics that typically had activity against them.
What is SB 739?
• By 1/1/2008, California department of public health(CDPH) required that all general acute care hospitals
-evaluate their antibiotic use
-create an oversight committee to monitor responsibilities for this issue
• CDPH responsible for implementing a program for the statewide surveillance and prevention of HAI in acute care
Antibiotic stewardship
• What is it?
- Program to monitor the use of antibiotics
- Coordinated effort between pharmacist, microbiologist, infectious disease specialist and medical team
• Minimizing consequence of antibiotic use
-Toxicity
-Selection of resistance
-selection of virulent organisms
-Clostridium dificile
• Combine with comprehensive infection control to limit emergence and transmission of resistance
• Reduce healthcare costs without adversely impacting care
Guidelines to develop an institutional Antimicrobial Stewardship Program (ASP)
• Antimicrobial stewardship committee
• Computer surveillance and decision support
• Proactive microbiology lab
• Monitoring of process and outcomes measures
Antibiotic stewardship-How?
• Identify patient risk Factors: patient age, previous hospitalizations, previous antibiotics, where they live; Co-morbid conditions
- cancer, organ transplantation, HIV, ESRD
- risk of developing an MNR organism increases as ICU LOS increases
• know the hospital antibiogram
• Review previous lab results and susceptibilities
• Consult with your pharmacist
• Monitor drug levels when appropriate
• Collaborate with an infectious disease specialist
Treatment guidelines for Antimicrobials in ICU
• Must be timely: do not start too late
• Appropriate:
• Administered at adequate dose and intervals consistent with pK/pD parameters
• Escalate or de-escalate based on microbiological data
• Prompt discontinuation when practical
What is the importance of acquired resistance-plasmid mediated
• Resistance genes encoding inactivating enzymes for beta-lactam agents(including extended-spectrum beta-lactamases),macrolides, aminoglycosides, and chloramphenicol;
• Efflux genes for macrolides and tetracyclines;
• Altered targets for sulfonamides
Tests to determine drug resistance
• MIC
• Disk diffusion method
• Molecular tests
Risk factors to develop antibiotic resistance
• Use of broad-spectrum antibiotics: antibiotic exposure can increases the bioburden of MDR bacteria in a patient through suppression of normal flora, allowing multiplication of the MDR bacteria. This increased bioburden makes the patient more likely to contaminate the environment, staff, and other patients
• Biofilm formation
Rational use of antibiotics in PICU
• Is it a bacterial infection?
- Fever
- Temperature instability
- CRP/procalcitonin
• Community or hospital-acquired infection(HAI)?
• Site of infection?
• What are likely pathogens?
• Antimicrobial susceptibility
Common infections in the pediatric intensive care unit (PICU)
• Ventilator-associated pneumonia
• CVC related sepsis
• MRSA is uncommon in PICU
Ventilator-Associated Pneumonia (VAP) Bundle
• Elevation of the head of the bed 30-45
• Use 15-30 for neonates and small infants,
• Daily sedation vacations
• Daily assessment of readiness to extubate
• Peptic ulcer disease (PUD) prophylaxis
Extended-spectrum beta-lactamase(ESBL) Risk Factors
• Long hospital stay
• Presence of catheters: urinary, CVCs, arterial
• Abdominal surgery
• Gut colonization
• Jejunostomy or gastrostomy tube
• Prior antibiotics
• Mechanical ventilation

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