Critical Care Refresher Course: Infection and Inflammation

Antibiotic PK/PD (Rello)

Knowledge of PK/PD on ICU improves safety and efficiency

  • Penicillins & Cephalosporins – T>MIC is most important PK/PD parameter (maintain about >50%)
  • Aminoglycosides & quinalones – Most imporatnt parameter is Peak/MIC > 8-10 and a 24hr AUC/MIC >100-125

When antibiotics ‘fail’; what is the solution?

  • Ensure sensitivity correct (liaise with microbiologist)
  • Improving the probability of positive outcomes i.e. improve efficacy and limit resistance
    • Alter duration of infusions
    • Combination (Synergies)
    • Increase peak concentration

References

Use of meropenem by continuous infusion to treat a patient with a Bla(kpc-2)-positive Klebsiella pneumoniae blood stream infection. – https://www.ncbi.nlm.nih.gov/pubmed/21859337

Efficacy of high-dose nebulized colistin in ventilator-associated pneumonia caused by multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii. – http://www.ncbi.nlm.nih.gov/pubmed/23132092

Update on Sepsis (Marshall)

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) – http://jama.jamanetwork.com/article.aspx?articleid=2492881

Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. – https://www.ncbi.nlm.nih.gov/pubmed/26414292

Recognise!

Resuscitation – Keep it simple and assess the response to therapy

  • oxygen – target SpO2 92-95%
  • intravenous fluids – target: Systolic BP>100, HR<100, UO>30ml/hs, CVP>8
    • ITS THE RESPONSE THAT IS CRUCIAL
  • vasoactive drugs

Diagnose infection

  • site – history, examination, imaging
  • pathogen – blood cultures and targeted cultures

Treat infection

  • early antibiotics

?immunomodulatory therapy

  • cytokine inhibition
  • endotoxin neutralisation

Supportive care on ICU

  • support organ dysfunction
  • minimise harm
  • de-escalate wherever possible
  • anticipate complication

Fungal Infection (Gruber)

International Study of the Prevalence and Outcomes of Infection in Intensive Care Units http://jama.jamanetwork.com/article.aspx?articleid=184963

Aspergilus

Candida

Decreasing incidence of albicans with increasing glabrata

Recent alert on Candida auris – http://www.cdc.gov/fungal/diseases/candidiasis/candida-auris-alert.html

Diagnosis of invasive candidiasis in the ICU – https://annalsofintensivecare.springeropen.com/articles/10.1186/2110-5820-1-37

Candida score – https://annalsofintensivecare.springeropen.com/articles/10.1186/2110-5820-1-50