prevention, diagnosis, & management of hospital-associated infections im r-1 orientation

Prevention, Diagnosis, & Prevention, Diagnosis, & Management of Management of

Hospital-Associated Hospital-Associated InfectionsInfections

IM R-1 OrientationIM R-1 Orientation

Paul Pottinger, MD, DTM&HPaul Pottinger, MD, DTM&H

June 27, 2013June 27, 2013

Hospital-Associated InfectionsHospital-Associated InfectionsOBJECTIVEOBJECTIVE• Increase your confidence in preventing, diagnosing, Increase your confidence in preventing, diagnosing, treating HAItreating HAI’’ss• Understand your role in Antimicrobial StewardshipUnderstand your role in Antimicrobial Stewardship

FORMATFORMAT• Case-based & interactiveCase-based & interactive

CONTENTCONTENT• Common infections you Common infections you willwill see PGY 1 see PGY 1

SLIDESSLIDES• Available on the webAvailable on the web

““Oh the Humanity!Oh the Humanity!””

MDR Infections:MDR Infections: More Toxic Drugs NecessaryMore Toxic Drugs Necessary Longer AdmissionsLonger Admissions More ComplicationsMore Complications Increased MorbidityIncreased Morbidity Increased MortalityIncreased Mortality

Magnitude of the ProblemMagnitude of the Problem

““Money… ItMoney… It’’s a Drags a Drag””

•Annual Cost of MDR Infections: Annual Cost of MDR Infections: $30B$30B

•Our Reality:Our Reality: Fee for Performance (carrot)Fee for Performance (carrot) Denial for Nosocomial Infections (stick)Denial for Nosocomial Infections (stick)

Magnitude of the ProblemMagnitude of the Problem

Ever heard this term?Ever heard this term?

Come from a center with a program?Come from a center with a program?

““Our Drugs vs. Their Genes”Our Drugs vs. Their Genes”

Antimicrobial StewardshipAntimicrobial Stewardship

Patient Care Patient Care ““The primary goal of antimicrobial stewardship is to optimize The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as pathogenic organisms (such as ClostridiumClostridium difficiledifficile), and the ), and the emergence of resistance.emergence of resistance.””

Financial Financial ““Effective antimicrobial stewardship programs can be Effective antimicrobial stewardship programs can be financially self-supporting and improve patient care. financially self-supporting and improve patient care. Comprehensive programs have consistently demonstrated a Comprehensive programs have consistently demonstrated a decrease in antimicrobial use (22%–36%), with annual savings decrease in antimicrobial use (22%–36%), with annual savings of $200,000–$900,000 in both larger academic hospitals and of $200,000–$900,000 in both larger academic hospitals and smaller community hospitals.smaller community hospitals.””

Dellit TH et al. Dellit TH et al. Clin Infect Dis.Clin Infect Dis. 2007;44:159-77. 2007;44:159-77.

Stewardship GoalsStewardship Goals

Jeannie Chan, PharmDJeannie Chan, PharmDHMCHMC

Rupali Jain, PharmDRupali Jain, PharmDUWMCUWMC

• Stewardship Teams Stewardship Teams at UWMC & HMC at UWMC & HMC

• OCCAM (in your pocket, OCCAM (in your pocket, on your phone, online)on your phone, online)

• Service PharmacistsService Pharmacists

• ID Consult ServiceID Consult Service

Stewardship ResourcesStewardship Resources

A 27 y/o man on the heme-onc service develops a fever to A 27 y/o man on the heme-onc service develops a fever to 40.240.2ooC 6 days following initiation of induction chemo Rx for C 6 days following initiation of induction chemo Rx for AML. A Hickman catheter is present in the R subclavian AML. A Hickman catheter is present in the R subclavian vein. No localizing sxvein. No localizing sx’’s on exam, Hickman entry site looks s on exam, Hickman entry site looks clean. Vitals fine. His WBC = 0.9, with an ANC = 100clean. Vitals fine. His WBC = 0.9, with an ANC = 100 ..

Possible sources of fever?Possible sources of fever?

Increased risk of infection? What type?Increased risk of infection? What type?

Diagnostic W/U?Diagnostic W/U?

Empiric antibiotics?Empiric antibiotics?

CaseCase

CaseCase

Possible sources of fever?Possible sources of fever?

Increased risk of infection? What type?Increased risk of infection? What type?

Diagnostic W/U?Diagnostic W/U?

Empiric antibiotics?Empiric antibiotics?

•Non-Infectious:Non-Infectious: Chemo, DVT / PE, CA Chemo, DVT / PE, CA•Infectious:Infectious: CABSI, typhlitis, HAP, UTI CABSI, typhlitis, HAP, UTI

•ANC < 500:ANC < 500: Gram-Negatives > Staph Gram-Negatives > Staph (fungal risk (fungal risk ↑ ↑ over time)over time)

•H&P!H&P!•CXR, U/A + micro, BCx x 2, sputum GS / CXR, U/A + micro, BCx x 2, sputum GS / C&S, C&S, ± ± Dopplers or CT-A, abd imagingDopplers or CT-A, abd imaging

•Cover PsA with Ceftaz; Cover MRSA in Cover PsA with Ceftaz; Cover MRSA in sepsis, suspect CABSI, or if febrile in 3 days.sepsis, suspect CABSI, or if febrile in 3 days.

CaseCase• BCX x 2 drawn via Hickman: Both grow BCX x 2 drawn via Hickman: Both grow

GPCs in clusters after 24 hours incubationGPCs in clusters after 24 hours incubation

Catheter-Associated Bloodstream InfectionCatheter-Associated Bloodstream Infection(CABSI)(CABSI)

Working DiagnosisWorking Diagnosis

CABSICABSIConfirm Diagnosis?Confirm Diagnosis?

• Look for alternative sourcesLook for alternative sources

• Send Send quantitative BCx quantitative BCx from line & peripheralfrom line & peripheral CFU 2-3 X > peripheralCFU 2-3 X > peripheral Line Cx + > 2 hours soonerLine Cx + > 2 hours sooner

Likely BugsLikely Bugs• Coagulase-negative staphCoagulase-negative staph• MSSA or MRSAMSSA or MRSA

Line likelyLine likelysourcesource

CABSICABSIEmpiric AbxEmpiric Abx• Add Vancomycin until ID / sensitivities are backAdd Vancomycin until ID / sensitivities are back• Maintain Ceftazidime for PsA coverage until ANC > 500Maintain Ceftazidime for PsA coverage until ANC > 500

Other ManagementOther Management• Central Lines: To Keep or Not to Keep?Central Lines: To Keep or Not to Keep?

CABSICABSILine ManagementLine Management• Pull line if:Pull line if:

– Patient is septic (once new access in)Patient is septic (once new access in)– Non-Tunneled Line (PICC)Non-Tunneled Line (PICC)– Line is not needed or not workingLine is not needed or not working– Pocket or track infection proximal to the cuffPocket or track infection proximal to the cuff– S.aureus, Pseudomonas, NTM, or fungusS.aureus, Pseudomonas, NTM, or fungus– Valvular heart diseaseValvular heart disease– Still febrile after 48 hours of salvage attempt….Still febrile after 48 hours of salvage attempt….

CABSICABSILine ManagementLine Management• Salvage Strategy: Abx LockSalvage Strategy: Abx Lock

Vanco + Heparin soak the lumenVanco + Heparin soak the lumen– Pros: Pros:

• 50% success rate50% success rate– ConsCons: :

• Lumen inaccessible during therapyLumen inaccessible during therapy• Risk of heparin bolusRisk of heparin bolus• WonWon’’t treat extra-lumenal infectiont treat extra-lumenal infection

EDTA + Abx or EtOH other EDTA + Abx or EtOH other options…. via ID Consultoptions…. via ID Consult

CABSICABSILine ManagementLine Management• Salvage Strategy: Guidewire ExchangeSalvage Strategy: Guidewire Exchange

““Save the Site, not the Line!Save the Site, not the Line!””– Pros: Pros:

• Avoid complications of temporary accessAvoid complications of temporary access– ConsCons: :

• May fail if extra-lumenal infectionMay fail if extra-lumenal infection

Consider exchange in HD Line Consider exchange in HD Line infections…. via ID infections…. via ID

ConsultConsult

CABSICABSILine ManagementLine Management• Salvage Strategy: Pull ItSalvage Strategy: Pull It

““Save the Patient, not the Site!Save the Patient, not the Site!””– Pros: Pros:

• Most likely to cure the infection whether bugs in lumen or on surfaceMost likely to cure the infection whether bugs in lumen or on surface– ConsCons: :

• Subjects pt to temporary accessSubjects pt to temporary access

CABSI: PreventionCABSI: Prevention““Central Line BundleCentral Line Bundle””• Hand Hygiene Hand Hygiene • Maximal Barrier Precautions Upon Insertion Maximal Barrier Precautions Upon Insertion • Chlorhexidine Skin Antisepsis Chlorhexidine Skin Antisepsis • Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Non-Tunneled Catheters Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Non-Tunneled Catheters • Daily Review of Line Necessity with Prompt Removal of Unnecessary LinesDaily Review of Line Necessity with Prompt Removal of Unnecessary Lines

• A 68 y/o woman with type-2 DM & HTN A 68 y/o woman with type-2 DM & HTN recently Rxrecently Rx’’d for CAP with cefotaximed for CAP with cefotaxime

• Now admitted for major CVA Now admitted for major CVA • Febrile → Ceftazidime startedFebrile → Ceftazidime started• BCx & foley cath urine grewBCx & foley cath urine grew K.pneumoniae K.pneumoniae • Two days later: Fever persists, and she Two days later: Fever persists, and she

becomes less responsive….becomes less responsive….

1)1) Switch to Levo or CiproSwitch to Levo or Cipro2)2) Switch to CeftriaxoneSwitch to Ceftriaxone3)3) Switch to CefepimeSwitch to Cefepime4)4) Switch to MeropenemSwitch to Meropenem5)5) EverythingEverything’’s groovy, make no changes groovy, make no change

1)1) Switch to Levo or CiproSwitch to Levo or Cipro2)2) Switch to CeftriaxoneSwitch to Ceftriaxone3)3) Switch to CefepimeSwitch to Cefepime4)4) Switch to MeropenemSwitch to Meropenem5)5) EverythingEverything’’s groovy, make no changes groovy, make no change

CaseCase

Catheter-Associated UTI: Catheter-Associated UTI: CAUTICAUTIPathogenesisPathogenesis

• Colonization: Endogenous flora ascends peri-catheter space or lumen Colonization: Endogenous flora ascends peri-catheter space or lumen

• Infection: Inflammatory response to adherent or invasive bugs Infection: Inflammatory response to adherent or invasive bugs (common)(common)

Confirm DiagnosisConfirm Diagnosis

• U/A and Quantitative UcxU/A and Quantitative Ucx

Treatment Options:Treatment Options: CAUTI CAUTIEmpiric coverage depends on gram stain:Empiric coverage depends on gram stain:GNRGNR’’s: Ceftazidime vs. Mero if MDRO hxs: Ceftazidime vs. Mero if MDRO hxGPCGPC’’s: add Vancomycin (cover Staph)s: add Vancomycin (cover Staph)

Total Length of Therapy:Total Length of Therapy:Usually 7 days; longer may be needed pyeloUsually 7 days; longer may be needed pyelo

Definitive Treatment:Definitive Treatment:Focus spectrum based on C&S results…Focus spectrum based on C&S results…

Emerging Resistance: Emerging Resistance: ESBLESBL

Extended Spectrum ß-LactamasesExtended Spectrum ß-Lactamases• Mutant TEM-1, SHV-1, CTX-M, or OXA Mutant TEM-1, SHV-1, CTX-M, or OXA

ß-lactamaseß-lactamase

• Enzymes hydrolyze oxyimino-ß-lactams Enzymes hydrolyze oxyimino-ß-lactams (includes 3(includes 3rdrd Gen Cephalosporins) Gen Cephalosporins)

• Usually in Usually in KlebsiellaKlebsiella spp. and spp. and E.coliE.coli

• Consider in all nosocomial infections with Consider in all nosocomial infections with these organisms these organisms Risk Factor = Previous ß-lactam useRisk Factor = Previous ß-lactam use Overall prevalence may > 10%Overall prevalence may > 10%

ESBLESBL• Worry if resistance Worry if resistance ““skips a generationskips a generation””

• Confirm with Confirm with 3-fold decrease in MIC with 3-fold decrease in MIC with ßß–lacatmase inhibitor–lacatmase inhibitor

• Rx of choice:Rx of choice: CarbapenemCarbapenem

• Variable success:Variable success: FQFQ AminoglycosideAminoglycoside TMP/SMX, Nitro, FosfoTMP/SMX, Nitro, Fosfo

CRECRE

““Doomsday” GNRsDoomsday” GNRs

David Ricci

Consider empiric contact Consider empiric contact precautions in pts recently precautions in pts recently

admitted overseasadmitted overseas

CAUTICAUTIOther ManagementOther Management• Change or remove the catheter if UTI detectedChange or remove the catheter if UTI detected• Colonization virtually universal… Colonization virtually universal… No need for routine No need for routine

surveillance cultures!surveillance cultures!• Appreciate difference between asymptomatic Appreciate difference between asymptomatic

bacteriuria and UTI!bacteriuria and UTI!

CAUTICAUTIPreventionPrevention• Use foley only when necessary!Use foley only when necessary!

• Aseptic insertion techniqueAseptic insertion technique

• Maintain securely, proper bag placementMaintain securely, proper bag placement

• Know who has a FoleyKnow who has a Foley

• Condom caths when feasibleCondom caths when feasible

• Pull them ASAP… can always put one back if pt failsPull them ASAP… can always put one back if pt fails

Case: VAPCase: VAPATS/IDSA GuidelinesATS/IDSA Guidelines

MDR Pathogen RisksMDR Pathogen Risks• Hospitalized Hospitalized ≥≥ 5 days 5 days• Abx in last 90 daysAbx in last 90 days• High ward MDR prevalenceHigh ward MDR prevalence• SNF residentSNF resident• Contact with MDR patientContact with MDR patient• Chronic DialysisChronic Dialysis• Chronic InfusionsChronic Infusions• ImmunosuppressedImmunosuppressed

• Anti-Pseudomonal cephalosporinAnti-Pseudomonal cephalosporin(Ceftaz, Cefepime) (Ceftaz, Cefepime) oror

• Anti-Pseudomonal carbapenemAnti-Pseudomonal carbapenem(Meropenem, Imipenem) (Meropenem, Imipenem) oror

• -lactam with lactamase inhibitor-lactam with lactamase inhibitor(Piperacillin/tazobactam)(Piperacillin/tazobactam)

++• Anti-Pseudomonal FQAnti-Pseudomonal FQ

(Cipro, Levo) (Cipro, Levo) oror• AminoglycosideAminoglycoside

(Gent, tobra)(Gent, tobra)+/-+/-

• Linezolid Linezolid or or VancomycinVancomycin

Case: VAPCase: VAP

MDR Pathogen RisksMDR Pathogen Risks• Hospitalized Hospitalized ≥≥ 5 days 5 days• Abx in last 90 daysAbx in last 90 days• High ward MDR prevalenceHigh ward MDR prevalence• SNF residentSNF resident• Contact with MDR patientContact with MDR patient• Chronic DialysisChronic Dialysis• Chronic InfusionsChronic Infusions• ImmunosuppressedImmunosuppressed

• Pseudomonas aeruginosaPseudomonas aeruginosa• BurkholderiaBurkholderia• StenotrophomonasStenotrophomonas• KlebsiellaKlebsiella• CitrobacterCitrobacter• AcinetobacterAcinetobacter• MRSAMRSA

ATS/IDSA GuidelinesATS/IDSA Guidelines

0

10

20

30

40

50

Hos

pita

l Mor

talit

y %

< 10 10 to 15 15 to 20 >20

Vancomycin Trough (mcg/ml)

Methods Methods - Retrospective analysis 1999-2005 - Retrospective analysis 1999-2005 - University Hospital (Washington U) - University Hospital (Washington U)

- N =102 Adults - N =102 Adults - Nosocomial MRSA pneumonia - Nosocomial MRSA pneumonia - MRSA established by BAL - MRSA established by BAL - Monotherapy with vancomycin - Monotherapy with vancomycin >> 72 72 hrs hrs

MeasurementsMeasurements - Vancomycin trough levels - Vancomycin trough levels - Clinical outcome - Clinical outcome

Study DesignStudy Design Patient OutcomesPatient Outcomes

From: Isakow W, et al. ICAAC 2006.From: Isakow W, et al. ICAAC 2006. DHS/DHS/PPPP

MRSA VAP: Vancomycin Levels?MRSA VAP: Vancomycin Levels?Case: VAPCase: VAP

MRSA: VanMRSA: Vancomycin MIC Creep?comycin MIC Creep?

Soriano Soriano CIDCID 2008 2008

• Not all VSSA created alike.Not all VSSA created alike.

• Published reports of rising vanco MICPublished reports of rising vanco MIC’’s s in last 5 years.in last 5 years.

• Presumed MOR: increased cell wall Presumed MOR: increased cell wall thickness.thickness.

• Retrospective case series: higher MICRetrospective case series: higher MIC’’s s associated with higher liklihood of associated with higher liklihood of clinical failure on vanco. clinical failure on vanco.

MRSA: MRSA: Vancomycin MIC Creep?Vancomycin MIC Creep?

• MIC ≤ 2 still considered susceptible MIC ≤ 2 still considered susceptible (VSSA)… Concern: clinical failures with (VSSA)… Concern: clinical failures with vanco.vanco.

• Recommend you routinely check vanco Recommend you routinely check vanco MIC, certainly if pt fails to clear MIC, certainly if pt fails to clear bacteremia or clinically improve after 7 bacteremia or clinically improve after 7 days of therapy.days of therapy.

• ““ConsiderConsider”” switch to alternative agent if switch to alternative agent if MIC = 2, MIC = 2, andand if pt is failing vanco. if pt is failing vanco.

MRSA: MRSA: Vancomycin MIC Creep?Vancomycin MIC Creep?

• ““ConsiderConsider”” switch to alternative agent if switch to alternative agent if MIC = 2, MIC = 2, andand if pt is failing vanco. if pt is failing vanco.

What, pray tell, shall I use instead of “Vitamin V?”

What, pray tell, shall I use instead of “Vitamin V?”

Study DesignStudy Design

Methods Methods - Retrospective analysis of 2 - Retrospective analysis of 2 prospective, randomized, case-control prospective, randomized, case-control studiesstudies - N =1019 Adults - N =1019 Adults - Nosocomial pneumonia - Nosocomial pneumonia - Suspected gram-positive pneumonia - Suspected gram-positive pneumonia - 339 with documented S. aureus - 339 with documented S. aureus - 160 with documented MRSA - 160 with documented MRSA

RegimensRegimens - Vancomycin + Aztreonam - Vancomycin + Aztreonam - Linezolid + Aztreonam - Linezolid + Aztreonam

Clinical CureClinical Cure

From: Wunderink RG, et al. Chest 2003;124:1789-97.From: Wunderink RG, et al. Chest 2003;124:1789-97. DHS/DHS/PPPP

P = 0.009P = 0.009P = 0.182P = 0.182

Vancomycin vs. LinezolidVancomycin vs. LinezolidRound One: VAPRound One: VAP

Wunderink et al. CHEST / 124 (5) 2003

Methods Methods - Blinded, Randomized prospective - Blinded, Randomized prospective non-inferiority trial of pneumonia non-inferiority trial of pneumonia - Nosocomial pneumonia - Nosocomial pneumonia - N =1225 Adults Randomized - N =1225 Adults Randomized - 339 with documented MRSA - 339 with documented MRSA - Well-matched… except 9% more - Well-matched… except 9% more ventilated pts in vanco armventilated pts in vanco arm

RegimensRegimens - Vancomycin 15mg/kg IV Q 12 H - Vancomycin 15mg/kg IV Q 12 H - Linezolid 600mg IV Q 12 H - Linezolid 600mg IV Q 12 H - Both arms treated 7-14 days - Both arms treated 7-14 days

Study DesignStudy Design OutcomesOutcomes

From: Chastre J et al, 2010 IDSA Conference and CID January 2012From: Chastre J et al, 2010 IDSA Conference and CID January 2012

““Not Not significantly significantly

different”different”

P = 0.042P = 0.042

CI = 0.5-21.6CI = 0.5-21.6

Vancomycin vs. LinezolidVancomycin vs. LinezolidRound Two: VAPRound Two: VAP

Newer, Fancier, Pricier ≠ Better!Newer, Fancier, Pricier ≠ Better!

LinezolidLinezolid VancomycinVancomycin

For empiric MRSA VAP For empiric MRSA VAP coverage…coverage…

Round Two: VAPRound Two: VAPVancomycin vs. LinezolidVancomycin vs. Linezolid• Jury Still Out.. At least for meJury Still Out.. At least for meTrend to survival benefit with Linezolid in Trend to survival benefit with Linezolid in

meta-analysismeta-analysisTrend to better “clinical response” in large Trend to better “clinical response” in large

prospective trial sponsored by industry… prospective trial sponsored by industry… no mortality differenceno mortality difference

Adverse events comparableAdverse events comparableMany intensivists now favor linezolid for Many intensivists now favor linezolid for

MRSA VAP… at UW we start with vancoMRSA VAP… at UW we start with vanco

17 19

2629

0

10

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40

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Perc

ent o

f Pat

ient

s

Excess Mortality Recurrent Infections

Day Rx 8

Day Rx 15

• Methods (N = 401) Methods (N = 401) - Microbiologically-Proven VAP* - Microbiologically-Proven VAP* - Received initial appropriate - Received initial appropriate therapytherapy - Randomized, double-blinded - Randomized, double-blinded - Performed 1999-2002 - Performed 1999-2002

• Regimens*Regimens* - 8 days of therapy - 8 days of therapy - 15 days of therapy - 15 days of therapy

• Methods (N = 401) Methods (N = 401) - Microbiologically-Proven VAP* - Microbiologically-Proven VAP* - Received initial appropriate - Received initial appropriate therapytherapy - Randomized, double-blinded - Randomized, double-blinded - Performed 1999-2002 - Performed 1999-2002

• Regimens*Regimens* - 8 days of therapy - 8 days of therapy - 15 days of therapy - 15 days of therapy

Study DesignStudy DesignStudy DesignStudy Design ResultsResultsResultsResults

From: Chastre J, et al. JAMA 2003;290:2588-98.From: Chastre J, et al. JAMA 2003;290:2588-98.

* All patients had quantitative cultures from * All patients had quantitative cultures from bronchoscopybronchoscopy

* All patients had quantitative cultures from * All patients had quantitative cultures from bronchoscopybronchoscopy

DHS/PPDHS/PP

Case: VAPCase: VAPHow Long to Treat? (Less is More)How Long to Treat? (Less is More)

Abx Stewardship: Abx Stewardship: CeftarolineCeftaroline

““Anti-MRSA CephalosporinAnti-MRSA Cephalosporin””• FDA-Approved forFDA-Approved for

Acute Skin & Soft Tissue Infxn due to Acute Skin & Soft Tissue Infxn due to susceptible MSSA & MRSA, GAS, susceptible MSSA & MRSA, GAS, GBS, E.coli, KlebsiellaGBS, E.coli, Klebsiella

CAP due to susceptible S.pneumo, CAP due to susceptible S.pneumo, MSSA, H.flu, Klebsiella, E.coliMSSA, H.flu, Klebsiella, E.coli

Abx Stewardship: Abx Stewardship: CeftarolineCeftaroline

““Anti-MRSA CephalosporinAnti-MRSA Cephalosporin””• Toxicities: Toxicities: “minimal,” but frequent + “minimal,” but frequent +

coombs DAT.coombs DAT.

• Dose: Dose: 600mg I VQ 12 H.600mg I VQ 12 H. No No levels! levels!

• Cost: Cost: ~ $82 / day (vs. ~$12 / day for ~ $82 / day (vs. ~$12 / day for vanco)vanco)

• Consider: Consider: Consider in proven MRSA Consider in proven MRSA failing vanco, failing vanco, ONLY with ID approvalONLY with ID approval..

Prevention: Prevention: VAPVAPWhat Works? What Works? ““VAP Bundle!VAP Bundle!””• Elevate head of bed to 30°Elevate head of bed to 30°

• Sterile technique with hand hygiene & ETT suctioning. Oral care.Sterile technique with hand hygiene & ETT suctioning. Oral care.

• Daily sedation holiday…Daily sedation holiday…

• Get the tube out ASAP!!Get the tube out ASAP!!

• SmallSmall added benefit: Silver-coated tubes or continuous suction added benefit: Silver-coated tubes or continuous suction

POP QUIZPOP QUIZ

Antimicrobial StewardshipAntimicrobial Stewardship

Ignac Philipp SemmelweisIgnac Philipp Semmelweis(1818-65)(1818-65)

1) 1) ““Clean Your *&^%@! HandsClean Your *&^%@! Hands””

•Hand Hygiene Remains Cornerstone of ICHand Hygiene Remains Cornerstone of IC

•Biggest Cost:Benefit Ratio AroundBiggest Cost:Benefit Ratio Around

•Patients Will Thank (or Chastise) You!Patients Will Thank (or Chastise) You!

•Obey Precaution PlacardsObey Precaution Placards

Prevent InfectionPrevent Infection

PP22I WANT YOU…I WANT YOU…

To bring MDR bugsTo bring MDR bugsunder control!under control!

16561656 20082008

VAPVAP

CABSICABSI

CAUTICAUTI

Time + Tube = TroubleTime + Tube = TroubleTime + Tube = TroubleTime + Tube = Trouble

2) 2) ““Dis-Invade ASAPDis-Invade ASAP””

Big 3 Associated with Indwelling TubesBig 3 Associated with Indwelling Tubes•VAPVAP

•CABSICABSI

•CAUTICAUTI

Prevent InfectionPrevent Infection

Daily or twice daily checklist:Daily or twice daily checklist:Is Tube Necessary?Is Tube Necessary?Is Site Care Appropriate?Is Site Care Appropriate?

3) 3) ““Less is MoreLess is More””

Coverage: Use only what you need.Coverage: Use only what you need.Trend: Reduce duration of abxTrend: Reduce duration of abxCaveat: Lack of RCTCaveat: Lack of RCT’’s in many s in many syndromes… some still need long syndromes… some still need long course (hardware-assoccourse (hardware-assoc’’d osteo, etc)d osteo, etc)Advice: Limit duration & spectrum in Advice: Limit duration & spectrum in consultation with ID serviceconsultation with ID service

Limit Drug ExposureLimit Drug Exposure

4) 4) ““De-Escalate ASAPDe-Escalate ASAP””

Example: VAPExample: VAPFact:Fact: VAP pts usually critically ill, little VAP pts usually critically ill, little physiological tolerance for errorphysiological tolerance for errorFact:Fact: Mortality worse if initial abx don Mortality worse if initial abx don’’t t cover pathogencover pathogenFact:Fact: ATS / IDSA Guidelines call for ATS / IDSA Guidelines call for broad, empiric coveragebroad, empiric coverage

Limit Drug ExposureLimit Drug Exposure

4) 4) ““De-Escalate ASAPDe-Escalate ASAP””

Example: VAPExample: VAPFact: Fact: VAP pts usually critically ill, little VAP pts usually critically ill, little physiological tolerance for errorphysiological tolerance for errorFact: Fact: Mortality worse if initial abx donMortality worse if initial abx don’’t t cover pathogencover pathogenFact:Fact: ATS / IDSA Guidelines call for ATS / IDSA Guidelines call for broad, empiric coveragebroad, empiric coverage

Limit Drug ExposureLimit Drug Exposure

FACT:FACT: TargetingTargeting the Pathogen Should: the Pathogen Should:Decrease Emergence of Drug ResistanceDecrease Emergence of Drug ResistanceDecrease CostsDecrease CostsDecrease ToxicityDecrease Toxicity

5) 5) ““Sometimes You Need a HummerSometimes You Need a Hummer””

Reality: Nosocomial MDR pathogens Reality: Nosocomial MDR pathogens are here.are here.Impact: Devastating for individuals, high Impact: Devastating for individuals, high outbreak potential.outbreak potential.Approach: Diagnose & treat Approach: Diagnose & treat aggressively... With help from ID.aggressively... With help from ID.

Treat MDROs AggressivelyTreat MDROs Aggressively

Abx Stewardship: Abx Stewardship: ConclusionConclusion

““Our vs. Their Genes” Our vs. Their Genes” • Be a Microbiota Champion!Be a Microbiota Champion!

• Few new abx coming…Few new abx coming…

• Abx resistance is our fault… Abx resistance is our fault…

• Fixing this is our responsibility…Fixing this is our responsibility…

• Together, we can do it!Together, we can do it!

• OCCAM your Friend!OCCAM your Friend!

abx@uw.eduabx@uw.edu

Brains Brains

abx@uw.eduabx@uw.eduabx@uw.eduabx@uw.edu

Feedback?Feedback?