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Antibiotic Prescription in ICU: Indian Critical Care Medicine Society Releases Guidelines

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New Delhi: Indiscriminate use and ease of availability of antibiotics is a growing menace in the country with medical practitioners themselves not being aware, how much antibiotics to prescribe to patients, in particular critically ill patients.

To address this issue, a panel of experts from across the country have released the first ever India-centric guidelines for antibiotic use in intensive care unit (ICU). The guidelines are published in the Indian Journal of Critical Care Medicine. The guideline has been made in lieu of increasing mortality rate due to severe sepsis, acute infective diarrhea, septic shock, multi-drug resistance, and soft tissue infection in ICUs.

The 160-page document prepared by the 40-doctor committee comprising members of Indian Critical Care Medicine Society (ICCMS), provides scenario-wise instructions on drug to use.

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The guideline covers common issues encountered in ICU including community-acquired pneumonia, ventilator-associated pneumonia, catheter-related bloodstream infections, urinary and urogenital infections, abdominal infections, biliary sepsis, and skin and soft-tissue infections.

Key Recommendations

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Community-Acquired Pneumonia in the Intensive Care Unit

  • All patients admitted with CAP in ICU should be evaluated for risk factors for infection with MDR organisms.
  • Antibiotic therapy should be individualized to cover the commonly implicated organisms according to risk factors, including Pseudomonas, ESBL producing Enterobacteriaceae or MRSA.
  • Appropriate antimicrobial therapy should be initiated as early as possible in patients of CAP requiring ICU admission, preferably within the first hour after obtaining necessary microbiologic samples.
  • Empirical therapy covering common etiologic organisms should be initiated for severe CAP requiring ICU admission.
  • Investigations including the culture of respiratory secretions (sputum, endotracheal aspirate), blood cultures, urinary antigen testing for Pneumococcus and Legionella may be performed to narrow down therapy. Bronchoscopic BAL or protected specimen brush samples or polymerase chain reaction (PCR) for viral etiology may be performed for microbiologic diagnosis on a case by case basis.
  • Patients with CAP requiring ICU admission should initially receive a combination of empirical antimicrobial agents covering common causative organisms.
  • For patients with CAP requiring ICU admission, a non-pseudomonal beta-lactam (cefotaxime, ceftriaxone, or amoxicillin-clavulanic acid) plus a macrolide (azithromycin or clarithromycin) should be preferred if there are no risk factors for Pseudomonas aeruginosa infection.
  • For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam may be used.
  • If macrolides cannot be used, a fluoroquinolone may be used if there is no clinical suspicion of tuberculosis, after sending sputum or endotracheal aspirate for AFB and Genexpert.
  • All patients admitted with CAP in ICU should be evaluated for the presence of risk factors associated with MRSA.
  • Empirical antibiotics with anaerobic coverage should be considered in the treatment of CAP in ICU in the presence of clinical risk factors for aspiration or presence of lung abscess, empyema or necrotizing pneumonia.
  • Patients with CAP at risk of anaerobic infection should be initiated on antibiotics with anaerobic activity such as amoxicillin-clavulanate, clindamycin or moxifloxacin.
  • Piperacillin-tazobactam or carbapenems can be used for empirical therapy in CAP due to anaerobes if otherwise indicated.
  • Duration of treatment should be individualized according to the response and severity of the disease.
  • Patients with CAP requiring ICU admission should receive antibiotics for 7 to 10 days.
  • Patients with CAP due to Pseudomonas or aspiration pneumonia should be treated for 14 days.
  • Procalcitonin levels can be used along with clinical judgment for de-escalation of antibiotics in CAP in ICU in patients treated beyond 5 to 7 days.

Ventilator Associated Pneumonia 

  • Among patients with VAP who are not at high risk of MDR pathogens and are in ICUs with a low prevalence of MRSA (<15%) and resistant gram-negative organisms (<10%), single antibiotic active against both MSSA and Pseudomonas is preferred over combination antibiotic.
  • Among patients with VAP who are at high risk of MDR pathogens or are in ICU with a high prevalence of MRSA (> 15%) and resistant gram-negative organisms (> 10%), an agent active against MRSA and at least two agents active against gram-negative organisms including P. aeruginosa is recommended.
  • Among patients with VAP who are not at high risk of MDR pathogens and are in ICU with a high prevalence of resistant gram-negative organisms (>15%) but low prevalence of MRSA (<10%), two agents active against gram-negative organism including P. aeruginosa is recommended.
  • Colistin is not recommended for routine use as an empirical agent in VAP. However, it may be used upfront in the ICUs if there is a high prevalence of carbapenem-resistant Enterobacteriaceae.
  • In our country or areas with high endemicity of tuberculosis, use of linezolid may be restricted unless no suitable alternative is available.
  •  Fluoroquinolones and aminoglyosides should be cautiously used as monotherapy in VAP in our country as well as in other areas with high endemicity of tuberculosis.
  • In ICUs where the distribution of pathogen and antibiotic resistance pattern is known, empiric treatment should be designed accordingly, based upon patient risk factors for MDR pathogens.
  • Serum procalcitonin may be used to guide the de-escalation of antibiotics in VAP when the anticipated duration of therapy is >7 to 8 days.

Catheter-Related Bloodstream Infections

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  • Empirical antibiotic regimen for CRBSI should include coverage for both gram-positive and gram-negative organisms.
  • Vancomycin or teicoplanin is the recommended first-line drug for the empiric treatment of CRBSI for MRSA and MR-CONS while linezolid and daptomycin are good alternative agents.
  • An echinocandin or fluconazole should be used as empirical antifungal agents for the treatment of suspected central line-associated candidemia.
  • For suspected fungal CRBSI, antifungal therapy for at least 14 days is recommended (UPP).

Urinary and Urogenital Infections in ICU

  • The initial choice of antibiotics should cover for ESBL producing gram-negative organisms and includes aminoglycosides, beta-lactam along with a beta-lactamase inhibitor or carbapenems.
  • In the initial empirical regimen for UTI, antibiotics against gram-positive organisms are not recommended.
  • In appropriate clinical settings, antifungals should be considered in the empirical regimen.

Abdominal Infections in ICU

  • Routine use of prophylactic antibiotics to prevent pancreatic infection following acute pancreatitis of any severity is not recommended.
  • Duration of antibiotic therapy should be guided by clinical, radiological and laboratory parameters (UPP).
  • Patients not responding to antibiotics should undergo necrosectomy and drainage.

Biliary Sepsis

  • Either beta-lactam/beta-lactamase inhibitor (such as cefoperazone-sulbactam or piperacillin/tazobactam) or carbapenems (imipenem/meropenem) is reccommended as monotherapy in patients with moderate to severe cholangitis.
  • Biliary drainage should be considered in all patients with cholangitis in addition to empirical antibiotic therapy.

Skin and Soft-Tissue Infections

  • For moderate non-purulent SSTI, we recommend intravenous penicillin or clindamycin as the first choice of antibiotics.
  • Severe non-purulent SSTI should be treated with a combination of piperacillin-tazobactam along with coverage for MRSA.
  • Empiric therapy should attempt to provide antimicrobial activity against the most likely pathogens based upon clinical features along with local patterns of infection and resistance (UPP).
  • Duration of therapy is 7 to 10 days, though longer courses may be appropriate in patients with slow response.

The Indian Critical Care Medicine Society will now present the guidelines to the health ministry, Indian Council of Medical Research and circulate them among all medical associations and government hospitals.

For further reference follow the link:

Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit.Indian Journal of Critical Care Medicine 2019;23(Suppl 1):S1 S63.

Source: With inputs from Indian Journal of Critical Care Medicine

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