Discuss strategies to limit antimicrobial resistance (AMR) in the ICU.
Factors driving antimicrobial resistance (AMR) include inappropriate use of antibiotics, inadequate monitoring and surveillance, poor infection control practices and failing antibiotic pipeline.
Strategies to limit AMR include:
1. Antimicrobial Stewardship
Appropriate antimicrobial prescribing (right indication, right drug(s), right dose, right dosing regime, right duration)
Liaison with microbiology / infectious diseases team
Knowledge of local antibiograms
Streamlining to narrow spectrum drugs / oral agents when appropriate Education of staff
Cycling of antibiotics (uncertain benefit)
Antimicrobial prescribing committee
2. Infection control
Isolation / cohorting of patients
Surveillance / screening / monitoring
Appropriate staff:patient ratios
Limit indwelling devices / appropriate asepsis for insertion etc
Care bundles to reduce VAP, reduce time on ventilator, early enteral feeding etc
Adequate source control e.g. surgical drainage of abscesses Future directions include:
More rapid and accurate diagnosis of sepsis
Advances in genomics
Use of bacteriophages
Use of antibiotics in agriculture and animal husbandry
New drug development
Synergistic combinations of antibiotics and drugs with no antimicrobial effect (eg minocycline and loperamide enhances action against staph aureus)
Prevention of resistance development
- Use of some antibiotics should be restricted/reserved
- Use in agriculture and animal husbandry needs to be limited
- Broad spectrum antibiotics must be deployed intelligently
- Rapid diagnostic methods to guide rapid de-escalation
- Antibiotics must be reviewed daily, and narrowed or discontinued when appropriate
- Infectious diseases physicians should have greater input into prescribing practices
- Perioperative prophylaxis needs to be rationalised
- Antibiotic cycling may be helpful in preventing the emergeance of resistant strains
- Combination therapy may be relevant to some species (eg. rifampicin plus fusidic acid, rather than either one as a sole agent).
- Selective digestive tract decontamination could potentially be useful
- Scrupulous attention to source control (i.e. do not use antibotics as a substitute for source control)
Prevention of MRO transmission:
- Routine barrier and infection control process needs complicance monitoring and regular review.
- Surveillance for MROs must be proactive.
- Patient isolation should be practiced
- Decolonisation may be used in certain circumstances
Prevention of clinically relevant MRO infections in colonised patients
- Careful monitoring of indwelling devices
Management of MRO infections
- Multi-drug cocktails might be helpful
- Use of a higher concentration of a drug may defeat resistance
- MIC monitoring may guide dosing
- New drugs may need to be developed
- Novel drug combinations which exploit a synergy between antibiotics and non-antibiotic drugs - the college mention minocycline with loperamide but there are numerous others (Worthington, 2013)
- Non-drug (eg. bacteriophage, immunoglobulin, hyperbaric oxygen) therapy may become necessary
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