CHALLENGING CASES &DIFFICULT DECISION MAKING ISSUES IN MICUby dr,mahmoud almahjob TMC TRIPOLI LIBYA

38years old female G5P4 transferred from remote local hospital in southern region post 2days of admission with h/o acute dyspnea & headache ,high reading of BP

and fits ,emergency c/s done there . Her clinical back ground significant for chron,s disease

also she suffered from sever hyper emesis gravid arum during current pregnancy

on arrival she was under weight of average , incubated and mechanically ventilated where the anesthesia team failed to extubate her post c/s cz her oxygen demand was high fo2/po2 was 250, so2 92% zero spontaneous breaths eye opened fixed dilated pupils

Corneal reflex absent BP 100/60 pulse 100 T37.8asculatory findings reveal to coarse crackles Rt side

mainly, pan diastolic murmur

neurological assessment revealed depressed peripheral reflexes

wbcs 13 mainly neutrophils urea 10 creat 0.2 urine analysis revealed acetone ++ no pus cells other biochemical investigation ok

ct chest revealed ground appearance with bilateral infiltration more at RT side .

DIFFICULT DECISIONS

-Do we consider this patient brain death ?

-Should we start antibiotic for her?

Brain death

Don’t make threshold too low (local guide lines important)

Fixed dilated pupils and absence of spontaneous breathing ≠BDYou should exculde mimic conditions(E2H2MD)

Electrolytes disturbance Encephalopathy(thiamine defiecency,hepaticencphalopathy)

Hypotension HypothermiaMetabolic derangement mgnesium

Drugs(adequate reverse doses )

MRI

Should we start AB?Don’t be hurry it might be false impression for

VAP

CPIS SCOREIC IT IS YOUR GUIDE FOR START&STOP ANTIBIOTICS FEVER ALONE MEANS NOTHING PURLENT SECRETION IN FEBRILE PATIENT MEANS NO THING

LEUKOCYTOSIS WITH FEVER ALSO MEAN NO THING IT SHOULD BE PACKGE

 Even In the setting of ARDS, Bell et al. reported a false-negative rate of 46% for the clinical diagnosis of VAP 

CPIS of >6 had a sensitivity of 93% and a specificity of 100% Pugin J, Auckenthaler R, Mili N,

Janssens JP, Lew PD, Suter PM

2nd case 34 ys old female 7th day post admission to MICU as a case of

mysthenic crisis her clinical background was significant for hypothyroidism on levothyroxine 100 microgramronic chronic use of steroid& immuran h/o ICU admission 3months back for

more than a week for same reason . her MICU admission was significant for reintubation duo to ETT

blockage with thick secretion ,also she become febrile one day before 39c . Recently, her MV sitting changed to ward increase FO2 because she became desaturated

O/E generally ill SOFA score 4 distressed conscious communicating with staff by writing on blank paper febrile 39 bp 100/60 with out ionotrope support edematous

her investigation showed that her WBCS count was high 14,000 mainly neutrophil urea 70 creat 0.3 Na 135 k 3.0 mg 1.2 s.albumin 1.5

LFT ok, TFT subnormal for all values CXR bilateral infiltration

Is she case of VAP

How we suspect vap an inflammatory response

indicators(fever wbcs counts) in >48hrs intubated patient with evedinces of

purlent secresion , new ascultatory findings , new/or progressive radiological chest infiltrations

Misleading findings

heamoptysis localized or generalized

new onset ronchi apparently normal x ray

IS IT CASE OF MDRWHICH AB SHOULD WE

STARTHOW MANY THEY ARE

HOW LONGSHOULDWEKEEPTHEM

WHAT ABOUT IF THERE IS NO IMPROVEMENT

???

Difficulty of dicesion

Unnecessaryantibiotics and adverse patient outcomes and

increased cost

Appropriate initial antibiotic while improving patient outcomes and heathcare

A Balancing Act

Choice of antibiotic

microorganism

host

antibiotics

1.MICRORGANISMS Usual sensitivity pattern

STREPTO COCCusSTAPHILOCOCCIMS

NONESBL GNB ..…ATYPICALBACTERIA

MULTI DRUG RESISTANCE BUGSEnterococcusS. aureusKlebsiella spp.AcinetobacterP. aeruginosaEnterobacter spp.

HOW WE CAN SUSPECT THE BUGS

RISK STRATIFICATION POLICY•overgeneralization to consider all HCAP ,VAP patients at increased risk for

MDR

•Recent hospitalization of at least 48 hours during the preceding 90 days – 4 points Residence in a nursing home – 3 points

•Chronic hemodialysis – 2 points •Critical illness – 1 point

•median score 4 significant for MDR

How the figure looks

like in our unit

Bacterial Pathogens that Isolated from 224 sputum samples (86% infected) in MICU,

2014

Candida sputum postive = psedomonas

ICU PATIENT ≠ WORD PATEINTHyperdynemic /hypoprfusion status

multiorgan failure antibiotic toxicity

hypoalbumenic plasma v/d

serious drug drug interactions warfarin –clarithromycin ampicillin septrin

serious disease drug interactions quinolones- arrhythmiasmyasthenia - amino glycosides& macrolides

Accurate weight adjustment (actual ,dry , leaner .TBW& adjusted BW) BWtGENTAMICIN..TBW

IN OBESE PATEINTS USE ADJUSTED BW 0.4(TBW-LBW)IN DIALYSIS PATEINTS USE DRY WIGHT

2 .HOST

MIC IS SOME THING YOU HAVE TO Clarify FROM C/S REPORT

high MIC for CABIMENEM vs CARBIMEM resistance even break point not exceeded

Pseudomonas isolated vs appropriate dosage should used\ 

carbapenemase-producing strains vs amino glycosides and fluoroquinolones β-lactams is time-dependent killing activity, (drug conc. exceeds the MIC value)

aminoglycoside dose depended killing activity

Resistance can be emerge during antibiotic therapy don’t prescribe amino glycosides > 5 days and don't give them alone

CONSOLIDATIN DOSE

EXSTENDED INFUSION

3 .ANTIBIOTIC .pharmacology

.Antibiogram

PK/PD IMPORTANCE

1 )Concentration dependent killing activity and moderate to prolonged persistent effects (Cmax/MIC, AUC/MIC)

AminoglycosidesFluoroquinolones

MetronidazoleColistin

RifampicinClindamycin

2 )Time dependent killing activity and minimal persistent effects (T>MIC)

Beta lactamsLinezolid

3 )Time dependent killing activity and moderate to prolonged persistent effects (AUC/MIC)

TetracyclinesVancomycin

Antimicobial characteristics related to pK/pD behaviour involving new forms of administration

GENTAMICIN CONSILDATION DOSE 7mg/kg over 2hrs once 24-48hrs

PD of gentamicin post antibiotic effect 3hrs

concentration dependent killing Effect /Nephroprotection?

(uptake by proximal tubules more with low intermittent doses)more bacterio cidal effect cz high conc).

don’t use in prolonged immunotherapy cc<40 with lasix CNS infection

GENTAMICIN LOADING DOSE REGIRME

LOADING DOSE SITE OF INFECTION TARGET PEAK CONCENTRATION

0.6 TO 1.2 mg/kg INFECTIVE ENDOCARDITIS SYNERGYSTC FOR BETALACTAMS

4 MICRO/ML

3 mg/kg SEVER GRAM NEGATIVE PNEUMONIA OR LIFETHREATNING INFECTION IN CRITICLLY ILL PATIENTS

9 micro/ml

LOCAL ANTIBIOGRAM

Antibiotic susceptibility of 37 Acinetobacter baumannii isolated from Sputum samples,

MICU-2014

Levofl

oxaci

n

Nitrofua

rntoin

Tobra

mycin

Ceftazi

dim

Ciprofl

oxaci

n

Pipera

cillin

Gentam

icinSe

ptrin

Ampi/

Sulba

ctam

Ceftria

xone

Cefazol

in

Cefoxit

in

Ampic

illin

Cefepim

e0%10%20%30%40%50%60%70%80%90%100%

Sensitive Intermediate Resistant

Antibiotic susceptibility of 11 Acinetobacter baumannii that isolated from 19 ETT

samples, MICU-2014

Ampicillin

Cefoxit

in

Cefazo

lin

Ceftria

xone

Ampi/Sulba..

.

Septri

n

Genta

micin

Piperac

illin

Ciproflox

acin

Ceftaz

idim

Tobr

amyc

in

Nitrof

uarn...

Levo

floxac

in

Merop

enem

0102030405060708090100

Sensitive Intermediate Resistant

Antibiotic susceptibility of 39 Klebsiella pneumoniae (ESBL) isolated from sputum

samples, MICU-2014

Levofl

oxaci

n

Nitrofua

rntoin

Tobra

mycin

Ceftazi

dim

Ciprofl

oxaci

n

Pipera

cillin

Gentam

icinSe

ptrin

Ampi/

Sulba

...

Ceftria

xone

Cefazol

in

Cefoxit

in

Ampic

illin

Cefepim

e

Amika

cin

Merope

nem

Imipe

nem

Augm

antin

Ertap

enem

0102030405060708090100

Sensitive Intermediate

Antibiotic susceptibility of 25 Pseudomonas aeruginosa (ESBL) isolated from Sputum

samples, MICU-2014

0%10%20%30%40%50%60%70%80%90%100%

Sensitive Intermediate Resistant

Antibiotic susceptibility of 7 Staph aureus (MRSA) that isolated from sputum samples,

MICU-2014

Vanco

mycin

Pencil

lin

Muppirocin

Teico

planin

Tetra

cycli

ne

Fusid

ic ac

id

Tigyc

yclin

e

Moxiflox

acin

Clindam

ycin

linez

olid

Oxacil

lin

Eryth

romyc

in

Fosfo

mycin

Rifampin

Levo

floxac

in

Nitrofu

rantio

n

Tobra

mycin

Genta

micin

Septri

n0102030405060708090100

Sensitive IntermediateResistant

LOOKS LIKE BAD NEWS BUT ALWAYS THERE IS SOMTHIG GOOD

We have carbemenem

resistant acitenobacter

We have other ESCAPE

carbimenem sensitive

So let we start with the sensitive and wait the resistance

PROTOCOL for deep discussion

Suspected HAP/VAP

CPIS score>6MDR risk4

SOFA/ABACHEIIIMIPENEM

/-+AMIKACI

NCPISREVIEW 2-3 DAY

ADD VANCOMYCINfor

MRSA

ADD COLICITIN

For acitenobacter

OR BOTH

IMPROVMENT

Descalate by c/s for 8 days

Difficult decision/both for

more hop full patients

miniBAL/direct BAL

Consider AB rotation

(meronam/cipro)

MRSA/RISK FACT.

THERAPEUTIC FALIURE

NO IMPROVEMENT

C/S +VE

C/S -VE

OTHER DIGNOSIS/OTHER

ATYPICAL ORGANISM

ORGANISM AB

HOST

Therapeutic failure, definition and causes

summary

Proper LRTS (QUNTITIVE PAL mini PAL

MDRM risk stratification Local resistance AntibiogramOnset of VAP development 5d cutoff pointCPIS score monitoring post 84 to 72 hrs

&C/S profile report

Strategies to optimize the use of antimicrobials in the ICU

1 )De-escalation therapy

2 )Antibacterial cycling

3 )Pre-emptive therapy

4 )Use of pharmacokinetic/pharmacodynamic parameters for dose adjustment

The scheduled rotation of one class of antibacterial

One or more different classes with comparable spectra of activity

Different mechanisms of resistance

Some weeks and a few months

ObjectiveReduce the appearance of resistances by replacing

the antibacterial before they occur and preserving its activity to be re-introduced in the hospital in a

later cycle

Antibacterial cycling

THANK YOU TMCU MICU

21thSept 2015mahmoud

almahjoob

Other diagnoses includeNONINFECTIOUS)

atelectasis ,congestive heart failure ,

venous thromboembolic disease ,pancreatitis ,

chemical pneumonitis from aspiration ,proliferative phase of acute respiratory distress

syndrome, drug fever, or pulmonary hemorrhage

(infectious) but not VAP .empyema, lung abscess,

 Clostridium difficile colitis, urinary tract infection, and sinusitis