The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious...
-
Upload
nyla-weller -
Category
Documents
-
view
230 -
download
8
Transcript of The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious...
![Page 1: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/1.jpg)
The Use and Misuse of Antimicrobials in NICU
Ban AL-Sayyed, MD, FAAP, FIDSAPediatric Infectious Diseases Consultant
KFSH& RC
![Page 2: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/2.jpg)
A 20 day old male, X- 27 wk, 900 gm. Developed fever of 38.7 C0 and apnea. He’s been intubated since admission. An axillary central line was inserted 10 days ago. He received several PRBC transfusions and two courses of IV antibiotics. Blood cultures were sent and they are pending.
Is he septic?
What is your differential?
What is your empirical antibiotic coverage?
![Page 3: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/3.jpg)
Sepsis in Neonates
• Early onset sepsis (EOS)
Less than 48 to 72 hours
Incidence of EOS in VLBW is 2%
• Late onset sepsis; (LOS)
Incidence is higher in premature infants
15% for 1001-1250 g
20-25% for infants <1500 g
28% for infants 751- 1000 g
43% for infants <750 g
![Page 4: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/4.jpg)
Incidence of Early- and Late-onset Sepsis during 1978-2006
Neonatology 2009; 97: 22-28
GBS Screening
![Page 5: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/5.jpg)
Distribution of Gram-positive and Gram-negative Microorganisms causing Early-Onset
Sepsis during 1978-2006
Neonatology 2009; 97: 22-28
![Page 6: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/6.jpg)
Early Onset Sepsis Annual Cumulative Incidence (NICU 1997 and 2007)
Antibiotics
GBS
![Page 7: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/7.jpg)
![Page 8: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/8.jpg)
What is a Nosocomial Infection?
• CDC:
Any infection occurring after admission to hospital , not transplacental
• Risk factors:
- Gestational age and birth weight
- Maternal infection
- Intrinsic Immunologic Factors:
Poor chemotaxis, low levels immunoglobulins, low CH50
Decreased number of CD3, CD4, CD8, and NK cells
- Poor skin integrity
- Immature gastrointestinal development
- Extrinsic Factors: Instrumentation, Procedures
![Page 9: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/9.jpg)
PEDIATRICS Vol. 103 No. 4 April 1999
![Page 10: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/10.jpg)
Late Onset Sepsis Annual Cumulative Incidence (NICU 1997 and 2007)
![Page 11: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/11.jpg)
Neonatology 2009; 97: 22-28
![Page 12: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/12.jpg)
Coag neg Staph
Neonatology 2009; 97: 22-28
![Page 13: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/13.jpg)
Journal of Perinatology (2004) 24, 382–388
Pathogen Distribution
![Page 14: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/14.jpg)
Pathogen Distribution in Abha
EMHJ • Vol. 16 No. 1 • 2010
![Page 15: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/15.jpg)
Summary
• Pathogen distribution:
Gram positive organisms 50-60%
Gram negative organisms 20%
Fungal pathogens increasing- ~ 10%• Clinical signs and symptoms:
Non specific
Temperature instability (51%), jaundice (35%), respiratory distress (33%), feeding problems (28%), lethargy (25%), pallor and/or cyanosis (24%), apneic attacks and/or bradycardias (22%), and distended abdomen (17%)
![Page 16: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/16.jpg)
Back to the Case The culture from CVC came back
as: Gram negative bacilli. You called the Lab, and the technician said,” it ferments lactose.”
How will you change your coverage?
Would you do a combination therapy? Why?
![Page 17: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/17.jpg)
Antibiotic Use in NICU
![Page 18: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/18.jpg)
Variation in Antibiotic Use in NICU
J Antimicrob Chemother doi:10. 1093/jac/dkq107
![Page 19: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/19.jpg)
CDC 12-Step Guidelines
• http://www.kliinikum.ee/infektsioonikontrolliteenistus/doc/oppematerjalid/children.pdf
• Multicenter retrospective observational study of antibiotic use targeted 4 tertiary NICUs to assess adherence
• Antibiotic regimens, clinical and microbiological data, indications for initiation and continuation of antibiotics (after 72 h of use) were recorded
PID Journal • Volume 28, Number 12, December 2009
![Page 20: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/20.jpg)
![Page 21: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/21.jpg)
Definition of Inappropriate Use
PID Journal • Volume 28, Number 12, December 2009
![Page 22: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/22.jpg)
![Page 23: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/23.jpg)
Summary
• 200 neonates received 323 antibiotic courses totaling 3344 antibiotic-days
• 28% of courses and 24% of days were judged to be nonadherent to a CDC 12-Step Campaign
• Inappropriate use was more common with continuation of antibiotics (39%) than with initiation (4%) of therapy
• Vancomycin was the most commonly used drug of which 284 (32%) days were considered inappropriate
• Carbapenems were used less frequently (n = 310 antibiotic-days), and 132 (43%) of these days were inappropriate
![Page 24: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/24.jpg)
Summary 2• Nonadherence to CDC 12 step was because of :
- Failure to narrow the spectrum
- Prolonged antibiotic prophylaxis after surgeries and certain procedures
- Treatment of colonization rather than real infection
- No targeting of the pathogen
![Page 25: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/25.jpg)
Back to Case
The patient’s antibiotics were changed from ceftazidime and vancomycin to meropenem + gentamcin + vancomycin pending sensitivity of the CVC blood culture isolate. The identification revealed Klebsiella oxytoca. The tracheal aspirate grew Stenotrophomonas maltophilia and the patient had a positive nasal PCR for MRSA.
Do you agree?
How can you modify the antibiotics?
![Page 26: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/26.jpg)
Emerging Infections
![Page 27: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/27.jpg)
![Page 28: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/28.jpg)
Courtesy of CDC
![Page 29: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/29.jpg)
Courtesy of CDC
![Page 30: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/30.jpg)
Courtesy of CDC
![Page 31: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/31.jpg)
J Antimicro Chemother. 2000 Jul; 58 (1): 205-10
![Page 32: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/32.jpg)
Facts about ESBL Gram-negative species
• These organisms are resistant to all ß-Lactam antibiotics except cephamycins (cefoxitin, cefotetan) and carbapenems
• They are frequently resistant to many other classes of antibiotics, including aminoglycosides and fluoroquinolones
• High rates of third-generation cephalosporin use have been implicated as a major cause of this problem. (Ceftazidime)
• Carbapenems are the most active and reliable treatment options for infections caused by ESBL isolates
• Overuse of carbapenems may lead to resistance of other gram-negative organisms; Pseudomonas
![Page 33: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/33.jpg)
Antibiotic Stewardship
![Page 34: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/34.jpg)
IDSA Guidelines
• Prospective audit with intervention and feedback• Education• Guidelines and clinical pathways• Antimicrobial cycling• Antimicrobial order forms• Combination therapy• Streamlining or de-escalation of therapy• Dose optimizationThe application in pediatrics is not commonly used
![Page 35: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/35.jpg)
Antibiotic RestrictionSeoul National Children’s University
• Hospital High rates of ESBL K pneumoniae (64%) in late 1990’s
• 2002-2003 campaign to decrease use of extended-spectrum cephalosporins
• Encouraged use of piperacillin/tazobactam
• Reductions in overall rates, did not elaborate on other interventions
![Page 36: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/36.jpg)
![Page 37: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/37.jpg)
Restriction of Cephalosporins and ESBL in a NICU
indianpediatrics.net/sep2010/785.pdf
![Page 38: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/38.jpg)
Antibiotic Cycling
A recent systematic review found only four studies worthy of inclusion and concluded that antibiotic cycling could not, at present, be promoted as a methodology to control
resistance
![Page 39: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/39.jpg)
Journal of Neonatology Vol. 21, No. 1, Jan. - Mar. 2007
![Page 40: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/40.jpg)
Antibiotic cycling: more than it might seem?
• Good for Gram-negative resistance control
• Where antibiotic cycling is introduced and no specific susceptibility problem exists, it can still reduce background levels of resistance for Gram-negative pathogens, not for Gram-positive organisms
• Helps in reduction of ICU ventilator-associated pneumonia, less convincingly for other types of sepsis.
![Page 41: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/41.jpg)
continue
• Where antibiotic cycling is introduced, there is an improvement in effective antibiotic prescribing in ICU
• There is a reduction in ICU mortality rates
Journal of Antimicrobial Chemotherapy (2005) 55, 1–5
![Page 42: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/42.jpg)
Journal of Neonatology Vol. 21, No. 1, Jan. - Mar. 2007
![Page 43: The Use and Misuse of Antimicrobials in NICU Ban AL-Sayyed, MD, FAAP, FIDSA Pediatric Infectious Diseases Consultant KFSH& RC.](https://reader035.fdocuments.net/reader035/viewer/2022062307/551b7f77550346a10a8b50bd/html5/thumbnails/43.jpg)
“The ideal way to get rid of any infectious disease would be to shoot instantly every person who comes down with it."
H. L. Mencken