NON-ANTIBIOTIC STRATIGIES IN ICU Prof. M H Mumtaz.

NON-ANTIBIOTIC STRATIGIES IN ICU

Prof. M H Mumtaz

NON ANTIBIOTIC STRATEGIES IN ICU

“Preventing Ventilator Associated Pneumonia”

INFECTION CONTROL

Why at Risk?

Underlying Disease.

Drug Therapy.

Multiple Lines.

Organisms From Other Patients.

VENTILATED ASSOCIATED PNEUMONIA (VAP)

Nosocomial pneumonia (NP) that occurs

48 hrs of initiating CMV.

Early VAP Late VAP

<5 days >5 days

VAP

EFFECT ON STAY IN ICU.

Three fold Craig CP, Conelly S; AMJ

Infec Control 1984.

10-32 fold. Jimenez P. et al; Critical Care

Medicine 1989.

PREVENTIVE MEASURES

Cost.

Stay.

Morbidity.

Mortality.

PREVENTIVE MEASURES

1. Conventional infection control measures.

2. Strategies related to GIT.

3. Strategies related to patient placement.

4. Strategies related to artificial airway.

5. Strategies related to mechnical ventilator.

CONVENTIONAL MEASURES1. STEPS BEFORE ENTERING ICU

Jackets.

White Coats.

Ties & Dopata.

Change Clothes.

2. STEPS BEFORE APPROACHING PATIENT

Put on apron.

Wash hands & gloves.

Donot share equipment.

Donot use own stethoscope.

Wash hands on leaving.

PREVENTIVE MEASURES

Conventional Measures

2. Approaching the patient, 4 things to do.

1. Hand wash.

Dochbeling GN, Stanley Gb. Comparative efficacy

of alterantive hand washing agents in reducing

nosocomial infections in ICU”

N Engl J Med. 1992;327.

PREVENTIVE MEASURES

2. Protective gowns. Klein BS, Perlof WH, MAKI DG, “Reduction

of nosocomial infection during paediatric intensive care by protective isolation

N Engl Med 1989, 320”

3. Use of stethoscope.

4. Contamination – Resp Equipment.

5. Condensed water in circuit.

6. Manipulaiton – circuits.

7. Chlorhexidine oral rins.

BARRIER NURSING (REVERSE)

Immunocompromised.

Radiotherapy.

Immune disease.

BASIC PRINCIPALS

Don’t Enter Unnecessarily.

Wear Apron.

Wash Hands.

Wear Gloves.

Display on Door

BARRIER NURSING(Patients with Serious Infection)

Wear Apron & Leave In.

Wash Hands.

Wear Gloves.

Don’t Enter Unnecessarily.

Wear Mask.

1. STRATEGIES RELATED TO GIT

Stress Ulcer Prophylaxis.

Gastric Overdistension.

Nutritional Support.

STRESS ULCER PROPHYLAXIS

Why We Need? Ulcer Formation And Perforation.

Haemorrhage.

Drugs Available. Antacids.

H2 Receptor Blockers.

Proton Inhibitors.

Sucralfate.

Target PH<4.


Drawback.

Multiplication of bacteria

&

Colonisation in RT.

“Gastro Pulmonary Route”

Oesophageal wall

Nasogastric tube.

H2 RECEPTOR BLOCKERSCONFLICTING VIEWS

There is definite increased incidence of NP

“Apte NM & others”

Gastric colonization & pneumonia in

intubated critially ill patients receiving

stress ulcer prophylaxis, a randomised

controlled trial.

Crit. Care Med 192.80:59-593.


No increased risk of NP

Martin LF, booth FV Karlstadt RG.

Continuous intravenous cimetidine

decreases stress related GI hemorrhage

without promoting pneumonia.

Crit. Care Med 1993 21;19-30

Stress ulcer prophylaxis

Cook DJ, Guyatt GH & others.A comparision of sucral fate and ranitidine for prevention of upper GIT bleeding in patients requiring mechanical ventilation.

N Engl J Med 1998, 338;791-97.

“Failed ot identify increased risk of NP in either group”

STRATEGIES RELATED TO GIT

Gastric overdistention. Adequate nutrition

Prevent NP.

Nasogastric tube. Pathway for bacteria. reflow of bacteria.

Overdistention. Fascilitate reflux.

GASTRIC OVERDISTENTION

Fascilitate reflux. Food. Bacteria.

Can be reduced. of narcotics. of anticholinergics. Use prokinetic agents. Monitor residual volume. Nasojejunal feeding.

STRATEGIES RELATED TO GIT

Nutritional support. Malnutrition

host defence.

Nosocomial P

Entral feeding.

Colonisation.

NP if PH>4. Supine posutre

NP.

NUTRITIONAL SUPPORT

“Orojejunal feeding bypassing the

stomach, better method in ICU”

Montecalvo MA, Stegr KA.

Nutritional outcome and pneumonia in

critical care patients randomised trial

gastric versus jejunal tube feeding.

Lancet 1999, 35;1851-8,

NUTRITIONAL SUPPORT

Should immunonutrition become routine in

critically ill patients?

A systematic review of the evidence.

Heyland DK, Novak F, & others.

TAMA 2001. 286;944-53.

STRATEGIES RELATED TO PATIENT PLACEMENT

Semirecumbent Body Position.

Postural Changes by Rotating Beds.

SEMIRECUMBENT BODY POSITION

Torres A, Serra-Batlles J, & others.

Pulmonary aspiration of gastric contents in

patients receiving mechanical ventilation.

The effect of body position.

Ann Intern Med 1992, 116;540-3.


Orozco Levi M, Torres A, & others.

Semirecumbent position protects from

pulmonary aspiration but not completely

from gastro-oesophageal reflux on

mechanically ventilated patients.

AMJ Respir Crit Care Med 1995,

152;1387-90.


Drakulovic M, Torres A, & others.

Supine body position is a risk factor of NP

in mechanically ventilated patients, A

randomised clinical trial.

Lancet 1999, 354;1851-8.

RECOMMENDATIONS

“If no contraindication, head of

the bed should be elevated

30-45o for those receiving

mechanically ventilation and

having enteral tube in place”

POSTURAL CHANGES BY ROTATING BEDS

de Boisllane BP. Castron & others.

“Effect of air supported, continous,

postural oscillations on the risk of early

ICU pneumonia in non-traumatic critical

illness”

Chest 1993, 103:1543-7.


Nelson LD, Chol SC:

Kinetic therapy in Critically Ill Trauma

Patients.

Clin. Intensive Care 1992, 37:248-52.


Hospital Stay – No Reduction.

Expensive.

Mortality – No Reduction.

4. STRATEGIES RELATED TO ARTIFICIAL AIRWAY

A. Respiratory Airway Care.

1. Avoid Micro-aspiration. Adequate Tube Cuff Pressure. Suction Catheter System.

– Single Use System.

– Multiple Use System.

2. Avoid Nasal Intubation. Oro-tracheal Intubation. Tracheostomy.

STRATEGIES RELATED TO ARTIFICIAL AIRWAY

A. Respiratory Airway Care.

3. Avoid re-intubation.

VAP risk factor.

Cost effective.

STRATEGIES RELATED TO ARTIFICIAL AIRWAY

RE-INTUBATION

Torres A, Gatell Jon, & others.

Re-intubation increases the risk of nosocomial

pneumonia in patients needing ventilation.

AMJ Respi Crit Care Med 1995, 152:137-41.

4. STRATEGIES RELATED TO ARTIFICIAL AIRWAY

B. Design of ETT.

Why? Stagnant oropharyngeal secretion aspiration.

ETT with extra suction lumen. incidence of NP.

Cost effectiveness.

Sliver coated endotracheal tubes.

DESIGN OF ETT Shorr A, Omalley P:

Continuous subglottic suctioning for prevention of VAP, potential economic implications. Chest 2001, 119:228-35.

Valles J, Artigas & others: Continuous aspiration of subglottic secretions in preventing VAP. Ann Intern Med 1995, 122:179-86.

SILVER COATED ENDOTRACHEAL TUBES

Prevention of biofilm.

Tansen B, Kohnen W:

Prevention of biofilm formation by

polymer modification.

J Ind Microbiol 1995, 15:391-6.

5. STRATEGIES RELATED TO MECHANICAL VENTILATION

a) Maintenance of ventilator equipment.

Heat & moisture exchange. VAP.

No condensation.

Better than water heated homidifiers.

Use of sterile water. Rinsing nebulizer.


b) Adjustment of Sedation.

Excessive Sedation.

Sedation Interruption.


NIMV & Other Ventilation Strategies.

Nourdine K, Compes, Carten MJ & others.

Does non-invasive ventilation reduce ICU

nosocomial infection risk? A prospective

clinical survery.

Intensive care Medicine 1994, 25:567-73.


Girou E, Schortgen F & others.

Association of non-invasive ventilation with

nosocomial infections and survival in

critically ill patients.

JAMA 2000, 284:2361-7.

ANTIBIOTIC

POLICY

IN ICU

ABDOMINAL SEPSIS

Generalized Peritonitis. Localized

Abdominal Abscess. Cefuroxime 1.5g TDS + Metronidazole IV. Ciprofloxacin 400 mg BD

+ Metronidazole IV.

Duration of treatment five to seven days

ABDOMINAL SEPSIS

Severely ill with Prior Laparotomy

Tazocin 4.5g TDS + Gentamicin 7mg/kg as

a single daily dose IV.

Seek Microbiology advice

Duration of treatment five to seven days.

ABDOMINAL SEPSIS

Severe Pancreatitis: Prophylactic Regime

Cefuroxime 1.5g TDS + Metronidazole IV.

Seek Microbiology advice

Duration of prophylaxis 14 days.

Severe Pancreatitis suggested by

APACHE II score > 8 at 24 hrs.

WOUND INFECTION

Co-amoxiclav 1.2g TDS IV.

Clindamycin 600mg QDS

+

Ciprofloxacin 200mg BD IV.

Do not treat if wound is only colonized

RESPIRATORY TRACT INFECTION

Community Acquired.

Clarithromycin 500mg BD

+

Cefotaxime 2gm TDS IV.

Clithromycin 500mg BD

+

Ciprofloxacin 400mg BD IV.


Hospital (Ward) Acquired Pneumonia.

Ceftazidime 2g TDS IV + Gentamicin

7mg kg-1 day-1 as a single daily dose.

Ciprofloxacin 400mg BD IV +

Teicoplanin 400mg + Gentamicin 7mg

kg-1 day-1 as a single daily dose IV.


Ventilator Associated Pneumonia. Ceftazidime 2g TDS + Gentamicin 7mg

kg-1 day-1 as a single daily dose. Teicoplanin 400mg + Ciprofloxacin

400mg BD + Gentamicin 7mg kg-1 day-1 as a single daily dose.

If no response seek microbiology advice.


Aspiration with Evidence of Pneumonia, Lung Abscess.

If Aspiration has occurred in the community:-

Cefuroxime 1.5g TDS IV +

Metronidazole 500mg TDS IV. Clindamycin 600mg QDS IV.

SKIN & S/C INFECTION

Cellulitis & Superficial Infection

Benzyl Penicillin 1.2g IV – 6 doses/day

+

Flucloxacillin 1g QDS IV.

Clindamycin 600 mg qds IV.

SKIN & S/C INFECTION

Necrotizing Infection/Gangrene/Fascilities. Cefotaxzime 2g QDS

+Clindamycin 600mg QDS IV.

Ciprofloxacin 400mg BD +

Clindamycin 600 QDS IV.

NB. Treatment is primarily surgical.

PYELONEPHRITIS, UROSEPSIS

Ceftazidime 2g TDS +gentamicin 7mg kg-1 day-1 as a single daily dose.

Ciprofloxacillin 400mg BD + gentamicin 7mg kg-1 day-1 as a single daily dose.

Duration of treatment: Fourteen days.

May be switched to oral if appropriate

ENDOCARDITIS (empirical treatment prior to obtaining isolate)

Benzyl Penicillin 1.2 g IV – every 4hrs + Gentamicin 80mg BD IV.

Penicillin allergy or if: IV drug user-Hemodialysis Patient – Prosthetic Heart valve.

Vancomycin 1gm BD + Gentamicin (80-120 mg) IV TDS.

EYE INFECTIONS

Conjunctivitis

Chloremphenicol - topical

Gentamicin – topical

Keratitis/Orbital Cellulitis - seek

ophthalmologist /Microbiology advice.

MENINGITIS

Typical Meningococcal Rash present Benzyl Penicillin 2.4g *6/day IV. Chloremphenicol 25mg kg-1 QDS IV.

Without a Typical Rash Cefotaxime 2g QDS IV Chloremphenicol 25mg kg-1 QDS

+Vancomycin 1g BD IV

MENINGITIS

Samples to be sent for a meningitis

patient on admission Blood cultures EDTA blood – Meningococcal PCR Clotted blood - baseline blood for

meningococcal serology. Throat swab. Rash Scraping if present.

GASTROENTERITIS

Severe:

Ciprofloxacillin 400mg BD IV.

If acquired abroad:

Contact Microbiology with travel history.

CLOSTRIDIUM DIFFICILE

Metronidazole 400mg TDS by

mouth/NG tube.

If nil by mouth, give Metronidazole

500mg TDS IV + Vancomycin 1g BD IV.

ASPLENIC PATIENTS

All splenectomised patients should be

offered life long antibiotic prophylaxis:

Phenoxymethyl penicillin 500mg BD PO.

Erythromycin 500mg OD PO.

DEFENSE MECHANISM

Keep The Patient In.

Water Balance.

Electrolyte Balance.

Acid Base Balance.

Nutritional Balance.

CONCLUSION

“Appropriate use, simple, effective

methods without extra cost, should

be part of routine practice and can

tremendously lower the expensive

antibiotics and can reduce the

duration of stay”

NON-ANTIBIOTIC STRATIGIES IN ICU Prof. M H Mumtaz.

Documents

Transcript of NON-ANTIBIOTIC STRATIGIES IN ICU Prof. M H Mumtaz.