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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? ~-~~-~~~-~~-~ For more info visit our WEBSITE Pediatric Oncall: https://www.pediatriconcall.com/ SUBSCRIBE to Pediatric Oncall for more such videos:    / pediatriconcall   FOLLOW us on social media pages for updates and regular case discussions: Facebook: www.facebook.com/PediatricOncall/ Instagram:   / pediatriconcall   Twitter:   / pediatriconcall   ~-~~-~~~-~~-~ Also, check out the lecture on Cough Syrups by Dr. Ira Shah    • Cough Syrups | Dr. Ira Shah   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