Transcript NON-ANTIBIOTIC STRATIGIES IN ICU

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
<5 days
Late VAP
>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 MEASURES
1. 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.


3.
4.
5.
6.
7.
Klein BS, Perlof WH, MAKI DG, “Reduction
of nosocomial infection during paediatric
intensive care by protective isolation
N Engl Med 1989, 320”
Use of stethoscope.
Contamination – Resp Equipment.
Condensed water in circuit.
Manipulaiton – circuits.
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.
STRESS ULCER PROPHYLAXIS
Drawback.
Multiplication of bacteria
&
Colonisation in RT.
“Gastro Pulmonary Route”
Oesophageal wall
Nasogastric tube.
H2 RECEPTOR BLOCKERS
CONFLICTING 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.
STRESS ULCER PROPHYLAXIS
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.
SEMIRECUMBENT BODY
POSITION
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.
SEMIRECUMBENT BODY
POSITION
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.
POSTURAL CHANGES BY
ROTATING BEDS
Nelson LD, Chol SC:
Kinetic therapy in Critically Ill Trauma
Patients.
Clin. Intensive Care 1992, 37:248-52.
POSTURAL CHANGES BY
ROTATING BEDS
 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.
5. STRATEGIES RELATED TO
MECHANICAL VENTILATION
b) Adjustment of Sedation.
 Excessive Sedation.
 Sedation Interruption.
5. STRATEGIES RELATED TO
MECHANICAL VENTILATION
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.
5. STRATEGIES RELATED TO
MECHANICAL VENTILATION
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.
RESPIRATORY TRACT
INFECTION
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.
RESPIRATORY TRACT
INFECTION
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.
RESPIRATORY TRACT
INFECTION
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 userHemodialysis 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”