Transcript Antibiotics in acute respiratory failure SATS mod 2008

Antibiotics in Acute
Respiratory Failure
Robin J Green PhD
Division of Paediatric Pulmonology
University of Pretoria
Definitions
ALI- acute onset of impaired gas exchange
PaO2/FIO2 <300
ARDS- PaO2/FIO2 <200
Oxygenation index=( MAP x FI02/Pao2)x100
Acute Lung Injury
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CAP
HIV-associated pneumonia
HAP/VAP
Viral lung disease
Definition CAP
 Acute infection (less than 14 days) acquired
in the community, of the lower respiratory
tract, leading to cough or difficulty breathing,
tachypnoea or chest-wall indrawing
 Accounts for 30-40% of all hospital
admissions
 Case fatality rate 15-28%
Zar HJ, et al SAMJ 2005
Causes CAP
 Bacterial:
- Strep Pneumoniae
- Haemophilus influenzae
- Staph aureus
- Moraxella catarrhalis
 Atypical bacteria
- Mycoplasma pneumoniae
- Chlamydaphila pneumoniae/trachomatis
 Viral
- RSV
- Human metapneumovirus
- Parainfluenza
- Adenovirus
- Influenza
- Rhinovirus
- Measles virus
Causes of CAP
 In addition in HIV-infected children
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Gram-negative bacteria
Staph aureus (including CA-MRSA)
TB
Fungi
Organisms cultured - Ward
Meningitis
1 2
Pneumonia 0
0
3
4
3
5
10
Pneumococcus
E. Coli
Staph aureus
Alpha Haem. Strep
None
27
20
30
ESBL Klebs
MRSA
CNS
Salmonella t.
N. Meningitis
40
50
Treatment CAP
 Antibiotis for all – Amoxicillin (90mg/kg/day tds 5
days) – (IV Ampicillin)
 < 2 months add aminoglycoside/cephalosporin
 > 5 years add macrolide
 HIV - infection add aminoglycoside
 HIV - exposed < 6 months add cotrimoxazole
 AIDS add cotrimoxazole
Zar HJ, et al SAMJ 2005
HIV-infected children
 No evidence that PK/PD principles are different to
healthy children
 All specimens showed resistance to cotrimoxazole.
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Savitree Chaloryoo International Journal of Pediatric
Otorhinolaryngology 1998; 44:103-107
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Brink A. Personnel communication
PCP Pneumonia
 Diagnosis:
- Immune compromised
- Respiratory distress and few crepitations
- Interstitial pattern on CXR
- LDH > 500
- PCR
3. Fluids in ARDS/ALI
NHLBI and ARDS net - FACTT trial
Conservative fluid management strategy favoured
Increase in ventilator free days and reduction in
ICU stay, lower OI, plateau pressure, PEEP,
higher PaO2/FIO2
No increase rates of shock or renal failure
Need to closely monitor electrolytes
Calfee CS, Matthay MA. Chest 2007;131:913-19
Managing Severe PCP
Pneumonia
 Lung protective strategies (low tidal volume,
high PEEP)
 Fluid restriction
 TMX/SMX
 Oral steroids
 Treating CMV pneumonitis – Ganciclovir
 Early introduction HAART
Survival analysis, adjusted age and hospital
Hazard ratio 0.54, 95% CI(0.29-1.02), p value 0.06
1
Cox proportional hazards regression
.4
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Survival
.8
Hazard ratio 0.54
95% CI(0.29-1.02)
p value 0.06
0
20
40
analysis time
Placebo
60
Prednisone
Terblanche A, et al. SAMJ 2008
80
CMV Pneumonitis
 Diagnosis:
- CMV viral load > 10 000 copies/ml - Blood
- CMV PCR – NBBAL
 Treatment:
- Ganciclovir (10mg/kg/dose BD)
- Duration – 3 weeks after starting HAART
HAP
Definition
1. HAP – Pneumonia developing more than
48 hours after admission to hospital
2. VAP – Nosocomial infection occuring in
patients receiving mechanical ventilation
that is not present at the time of intubation
and develops more than 48 hours after
initiation of ventilation
Epidemiology
 Pneumonia = 2nd most common nosocomial
infection
 Accounts for 18 – 26% of nosocomial
infections
 Children aged 2 – 12 months most affected
 95% of nosocomial pneumonia occurs in
ventilated children
Risk Factors
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Immunodeficiency
Immunosuppression
Neuromuscular blockage
Septicaemia
TPN
Steroids
H2-blockers
Mechanical ventilation
Re-intubation
Transport while intubated
Microbiology
 Early-onset VAP:
- Strep pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
 Late-onset VAP (Resistant species):
- Staph aureus
- Pseudomonas aeruginosa
- Lactose fermenting gram-negatives
Organisms cultured - PICU
Meningitis 0
Pneumonia 0
0
3
11
5
Pneumococcus
MRSA
Gram positive cocci
Non haem strep
None
10
15
ESBL Klebs
CNS
Sternotrophomonas
Bacillus sp
N. Meningitis
20
Criteria for VAP for Infants Younger than
12 Months of Age
Clinical Criteria / Radiographic Criteria
Worsening gas exchange with at least 3 of the clinical criteria:
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Temperature instability without other recognized cause
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White blood cells <4,000/mm3 or > 15,000/mm3 and band forms > 10%
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New onset purulent sputum or change in the character of sputum or increased respiratory
secretions
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Apnea, tachypnea, increased work of breathing, or grunting
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Wheezing, rales, or rhonchi
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Cough
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Heart rate <100 beats/min or >170 beats/min
plus radiographic criteria
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At least 2 serial chest x-rays with new or progressive and persistent infiltrate, consolidate,
cavitation or pneumatocele that develops >48 hours after initiation of mechanical ventilation
Wright ML, et al. Semin Pedaitr Infect Dis 2006;17:58-64
Prevention Strategies
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Head of bed elevation
Daily sedation holidays
Stress ulcer prophylaxis
DVT prophylaxis
Pneumococcal vaccination
Change in ventilator circuits only when dirty
Avoidance of re-intubation
Orotracheal intubation
Oropharyngeal toilet
Management
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Antibiotic selection policies
De-escillation
Antibiotic rotation
Regular microbiology for a
Antibiotic STEWARDSHIP
Dosage
 Correct antibiotic dosages and duration
 Correct antibiotic administration
- Concentration dependent antibiotics
(Aminoglycosides, quinolones) = single daily
concentration
- Time dependent antibiotics (B-lactams,
vancomycin, pip-taz, carbapenems, linezolid)
= continuous infusion over 24 hours or
multiple dosings (3-4 hours for carbapenems)
Duration
 No culture = 3 – 5 days
 Positive culture = 5-7 days.
 Seldom need 10 days
 Exceptions
– Staph 2-3 weeks
- PCP 3 weeks
- Fungal 2-3 weeks
De-escillation
 If broad spectrum antibiotics or
combinations used downgrade with positive
culture and sensitivity
 Vancomycin can be used alone
 Single antibiotics = combinations
Decontaminate
 Hand washing – the most effective startegy
to prevent resistance
 All personnel and parents must hand wash
 Anti-inflammatory strategies of Macrolides
Dont
 Use third generation cephalosporins
routinely (except meningitis)
 Use inappropriate antibiotics
 Use a long course
 Use too low a dose
 Routinely combine antibiotics
 Routinely use probiotics
Antibiotics for ESBL
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Carbapenem
- Meropenem
- Imipenem
- Ertapenem (Invanz)
Cefepime (Maxipime)
Piperacillin/tazobactam (Tazocin)
Never – Ciprofloxacin/3rd Generation
Cephalosporins
Risk factors for and outcomes of bloodstream infection
caused by ESBL-producing Escherichia coli and
Klebsiella species in children
Paediatrics 2005;115: 942-949
Antibiotics for MRSA
 Vancomycin (highly protein bound – better
for septicaemia)
 Linezolid (Zyvoxid) – better lung
penetration
 Teicoplanin
Bronchiolitis
Viral Identification 2007
14
12
10
RSV
Para'flu
'Flu
Adeno
8
6
4
2
0
Jan
March
May
July
Bronchiolitis in HIV positive
children
 12% of bronchiolitics at PAH are HIV
positive
 Mean age 8 months old (vs 3 months in non
HIV-infected children)
 No increase in numbers co-infected in more
mild disease
CRP vs WCC
30
WCC
25
20
15
10
5
0
0
50
100
150
CRP
200
Pearson correlation
r = 0.138
250
CRP vs % Neut
90
80
70
60
50
40
30
20
10
0
Pearson correlation r = 0.373
0
10
20
30
40
50
60
70
80
90
Summary
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CAP = Ampicillin +/HAP = Meropenem +/PCP = Bactrim + oral steroids + Ganciclovir
Bronchiolitis = nothing ?
 Using this policy and noting that all HIVinfected children are offered ventilation if
required – Mortality in PICU at PAH = 18.7%
Aknowledgement
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Dr Refiloe Masekela
Dr Omolemo Kitchin
Dr Teshni Moodley
Dr Sam Risenga
Prof Max Klein