Antimicrobial Resistance in Intensive Care Unit

Antimicrobial resistance in intensive care units

Mansoor Masjedi ; MD & FCCM

Assisstant professor of anesthesia & critical care consultant

Shiraz university of medical sciences , Iran

Oct . 2013

09:00 - 10:00 am

Critical Care Group

Panel Discussion: Infection in ICU

Coordinator: M.Masjedi

Panel members: HR.Jamaati, M.Mokhtari, A.Taher,

E.Ginzburg


Introduction

Sites of Infection

Pathogens at Different Sites of Infection in Medical Surgical ICUs

Antimicrobials Resistant Infections in ICU

Implications of Increasing Antimicrobials Resistant Infections in ICU

Strategies for Preventing Antimicrobial Resistance

References


Introduction:

Hospital-acquired and ICU - acquired infections : 1. Outstanding obstacles for health care systems through decades all around

the word

2. High cost to health system

3. Mortality and morbidity

ICU beds < 10% of hosp. beds but > 20% of all nosocomial infections are acquired in ICUs

Infections and sepsis are the leading cause of death in non-cardiac ICUs

Antimicrobial resistance in intensive care unitsEpidemiology

Incidence of sepsis in ICUs continues to rise

60 % of ICU patients considered infected

Infection :a strong independent predictor for mortality

More chronic comorbid illnesses & severe acute physiologic

derangements

High frequency of indwelling catheters

Necessitate frequent contact with healthcare personnel

Associated equipment → serve as reservoirs for pathogens →

horizontal patient-to-patient transmission

MDRs ( MRSA, VRE, ESBLs and carbapenem-resistant

Pseudomonas aeruginosa ) isolated with increasing frequency in ICUs

Antimicrobial resistance in intensive care unitsHigh incidence of infections in ICU

The most common and clinically important infections

in the ICU are those associated with the supportive

devices ventilator associated pneumonia - VAP

intravascular catheter-related bloodstream infection - CRBSI

catheter associated urinary tract infection - CAUTI

Antimicrobial resistance in intensive care unitsCommon infections in the ICU

Rapid Rise in the rate of resistance in ICUs

VRE : 24.7 → 33.3 %

MRSA : 53.5 → 56.2 %

P. aeruginosa resistant to imipenem or fluoroquinolones16.4→25.3% & 23.0 → 30.7 %

A. baumannii resistant to carbapenems : 11 → 30 %

ESBL producers :10.4 → 25 %

Enterobacteriaceae resistant to carbapenems (CREs) :0 → 8 %

Antimicrobial resistance in intensive care unitsPrevalence of drug resistant organisms

Older age

impaired immunity

Lack of functional independence and/or decreased cognition

Underlying comorbid conditions (eg, diabetes, renal failure, malignancies, immunosuppression) and higher severity of illness indices

Long hospital courses prior to ICU Frequent encounters with healthcare environments

(eg, hemodialysis units, ambulatory day-care clinics)

Frequent manipulations by and contact with healthcare personnel

Presence of indwelling devices such as CVCs, urinary cath. , ETT ,…

Recent surgery or other invasive procedures

Antimicrobial resistance in intensive care unitsRisk factors for resistant infections

Antimicrobial resistance in intensive care unitsRisk factors for resistant infections

Continued…

Presence of indwelling devices

such as CVCs, urinary cath. , ETT ,…

Recent surgery or other invasive procedures

Prior AB therapy

Frequent use of broad-spectrum ABs

↓nursing & support staff due to economic pressures

Delay in appropriate antimicrobial Rx ~ independent predictor of mortality

In septic shock, 1 hr delay ( in the first 6 hrs) ~ ↓7.6 % of survival

Antimicrobial resistance often “first line” → "second line" agents (inferior

bactericidal activity and unfavorable pharmacokinetic and/or pharmacodynamic

properties )

Virulence properties of the organism → poor outcomes ?


Outcome of multidrug resistant infections

Antibiotic utilization controls

Antibiotic evaluation committees (often involving clinicians, pharmacists and

microbiologists) for :

Effective and safe use of antimicrobials

Evaluate and guide formulary decisions

Educational programs

Improve antimicrobial utilization

Protocols and guidelines for AB

Restrictions of broad-spectrum agents

Preferential use of narrow-spectrum antibiotics (such as first generation

cephalosporins and aminoglycosides)

Mandatory consultations with infectious man

Antimicrobial resistance in intensive care unitsPREVENTION OF INFECTIONS AND DRUG RESISTANCE


PREVENTION OF INFECTIONS AND DRUG RESISTANCE…

Antibiotic class Cycling :

A class of antibiotics or a specific antibiotic drug is withdrawn from use for a defined period and reintroduced at a later point in time

Other methods include:

Mixing of antibiotic classes

Scheduled changes of antibiotic classes

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Do remember the Reasons for Infections are Many but solutions are few …

12/9/2015 Dr.T.V.Rao MD 16

Infection control measures

1. Hand hygien2. Daily bathing with chlorhexidine3. Device specific strategies to decrease infection 4. Contact precautions for pts infected or colonized with resistant

organisms5. Environmental cleaning


Hand hygiene No substitute for good hand hygiene

Contact precautions Gown and gloves before entering and removing after exiting may

decrease transmission of MDRs


Decolonization/patient bathing Chlorhexidine bath : decreasing both HAI and MDRs in the ICU

Surveillance Surveillance for MDRs for early identification and control of epidemic

outbreaks & endemic increases of resistant bacteria


Limiting hospitalization & invasive interventions ( daily clinician assessment is necessary for all indwelling devices)

Device-specific strategies specific strategies for placement and care of such devices

Environmental cleaning Innovative but as yet experimental techniques for environmental cleansing

include ultra-violet light sterilization lamps and

hydrogen-peroxide vapor decontamination devices



In addition the following should be considered to improve antibiotic efficacy, for limitation of toxicity, and to prevent the emergence of bacterial resistance:

Optimal dosing, Interval of drug administration, Duration of treatment

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Thank You

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Antimicrobial Resistance in Intensive Care Unit

Health & Medicine

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