guideline – driven decision making in management of ifi in icu
TRANSCRIPT
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الرحیم الرحمن الله بسم
يعلمون ال ذين وال يعلمون ذين ال يستوي هلاأللباب أولوا ر يتذك ما إن
- ازآیه بخشی الزمر ٩سوره
Are those who know and those who do not know alike? Only the men of understanding are mindful
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GUIDELINE – DRIVEN DECISION MAKING IN MANAGEMENT OF
IFI IN ICU
Mansoor Masjedi ; MD FCCMAss. Prof. of anesthesia & critical care consultant
SUMS , Azar - 1394
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Guideline – driven decision making in management of IFI in ICUOutline:
• Introduction• Necessity of guideline approach • Prophylactic, Preemptive or Empiric Use of Anti-fungals• Suggested treatment algorithms• Disease specific treatment• Summary
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Guideline – driven decision making in management of IFI in ICUIntroduction:
IFI in the ICU → ↑ morbidity & mortality
Invasive candidiasis (IC) in ICU ˃10-fold medical or surgical wards
Delays in Rx → negative pt outcomes
Difficult to diagnose and treat
Imposes a substantial financial burden because of:longer requirements for ICU care expensive antifungal pharmacotherapygreater overall use of hospital resources
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Guideline – driven decision making in management of IFI in ICUIntroduction:
Available antifungal pharmacotherapies are: complex costly drug-drug interactions Toxicity
New drugs →new therapies in ICU
Advances in diagnostics & susceptibility testing → ↑Identification of pts who require antifungal Rx Aid in drug selection
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Guideline – driven decision making in management of IFI in ICUIntroduction:
Optimal management of IFI• pt risk factor identification
• diagnostic testing • early effective pharmacotherapy
Many protocols and algorithms for prevention and treatment of these infections
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Invasive Mycosis
Candidiasis Aspergillosis
Decreasing immunity
SOT or BMTMICU or SICU
Loss of Barrier / immunity
Loss of barrier plus cellular immunity
Oncology
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OUR MIXED CLOSED INTENSIVIST DRIVEN ICUCENTRAL ICU – NEMAZEE HOSPITAL – SHIRAZ - I.R.IRAN
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Guideline – driven decision making in management of IFI in ICU
Algorhitm Developement
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Can we wait for the blood culture results in candidemia?
• Retrospective cohort analysis 1/2001-12/2004: N=157 patients with candidemia
• Delay in empiric Rx of candidemia till after blood cultures turn positive resulted in higher mortality
• Start of anti-fungal Rx >12 hrs of drawing a blood culture that turns positive had AOR= 2.09 for mortality, p=0.018
Morrel M et al. 2005. Antimicrob Agents Chemother. 49(9):3640-5
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Major Risk Factors
• Prior antibiotic use • CVL• TPN• Major Sx. within a week• Steroids• Dialysis • Immunosuppression • ICU length of stay - infections rising rapidly after 7-10 d
Dimopoulos G, et al. Candidemia in immunocompromised and immunocompetent critically ill
patients: a prospective comparative study. Eur J Clin Microbiol Infect Dis. 2007
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Guideline – driven decision making in management of IFI in ICUAlgorhitm Development – Diagnostic approach:
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Guideline – driven decision making in management of IFI in ICUAlgorhitm Development – Medical treatment :
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Guideline – driven decision making in management of IFI in ICUProphylactic, Preemptive, and Empiric Strategies :
• IFI :• Negative outcomes • Difficult definitive diagnosis early intervention either to prevent infection or to preempt severe fungal infection
is desirable.
• Candida ; most common fungal pathogens in ICU→ most strategies→on Candida spp.
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Guideline – driven decision making in management of IFI in ICUProphylactic, Preemptive, and Empiric Strategies :
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Prophylactic, Preemptive or Empiric Use of Anti-fungals
• PROS– High Mortality
– Difficulty in Diagnosis
– Undetected Infection
– Reduced systemic mycoses and improved mortality with prophylaxis
• CONS– Toxicity
– Expense
– Diagnosis not certain• Too much treatment
without infection• Too little treatment with
infection
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World J Crit Care Med. 2014 Nov 4; 3(4): 102–112. • Invasive candidiasis in critical care setting,
updated recommendations from “Invasive Fungal Infections-Clinical Forum”, Iran
• Ashraf Elhoufi, Arezoo Ahmadi, Amir Mohammad Hashem Asnaashari, Mohammad Ali Davarpanah, Behrooz Farzanegan Bidgoli, Omid Moradi Moghaddam, Mohammad Torabi-Nami, Saeed Abbasi, Malak El-Sobky, Ali Ghaziani, Mohammad Hossein Jarrahzadeh, Reza Shahrami, Farzad Shirazian, Farhad Soltani, Homeira Yazdinejad, and Farid Zand
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Guideline – driven decision making in management of IFI in ICUSummary:
• local epidemiology of Candida spp. → appropriate empiric and preemptive Rx
• local epidemiology at institution and also at unit
• Optimal management of IFI involves:• Pt. risk factor identification• Diagnostic testing • Early effective pharmacotherapy
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Guideline – driven decision making in management of IFI in ICUSummary:
• Appropriate empiric regimen depends on: • Local patterns of infection and • Severity of illness
Delays in antifungal therapy → ↑mortality
To avoid delays and guide appropriate therapy,many institutions approach the management of
fungal bloodstream infection in the ICU with an algorithm
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Suggested treatment algorithm for the ICU patient with invasive candidiasis(NAS: non- albicans species, CVC: central venous catheter, AmB: amphotericin B,
LipAmB: liposomal amphotericin B)
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Any ?