Post on 15-Jan-2017
CRRT NATIONAL GUIDELINE IN ICU
Mansoor Masjedi MD , FCCMShiraz University of Medical sciences
3rd international congress of critical care medicineTeh., Iran ; 20-22th Jan. 2016
Guideline – driven decision making in management of IFI in ICUOutline:
• Introduction• Necessity of guideline approach • Prophylactic, Preemptive or Empiric Use of Anti-fungals• Suggested treatment algorithms• Disease specific treatment• Summary
Guideline – driven decision making in management of IFI in ICUIntroduction:
IFI in the ICU → ↑ morbidity & mortality
Invasive candidiasis (IC) in ICU ˃10-fold medical or surgical wards
Delays in Rx → negative pt outcomes
Difficult to diagnose and treat
Imposes a substantial financial burden because of:longer requirements for ICU care expensive antifungal pharmacotherapygreater overall use of hospital resources
Guideline – driven decision making in management of IFI in ICUIntroduction:
Available antifungal pharmacotherapies are: complex costly drug-drug interactions Toxicity
New drugs →new therapies in ICU
Advances in diagnostics & susceptibility testing → ↑Identification of pts who require antifungal Rx Aid in drug selection
Guideline – driven decision making in management of IFI in ICUIntroduction:
Optimal management of IFI• pt risk factor identification
• diagnostic testing • early effective pharmacotherapy
Many protocols and algorithms for prevention and treatment of these infections
Invasive Mycosis
Candidiasis Aspergillosis
Decreasing immunity
SOT or BMTMICU or SICU
Loss of Barrier / immunity
Loss of barrier plus cellular immunity
Oncology
OUR MIXED CLOSED INTENSIVIST DRIVEN ICUCENTRAL ICU – NEMAZEE HOSPITAL – SHIRAZ - I.R.IRAN
Guideline – driven decision making in management of IFI in ICU
Algorhitm Developement
Can we wait for the blood culture results in candidemia?
• Retrospective cohort analysis 1/2001-12/2004: N=157 patients with candidemia
• Delay in empiric Rx of candidemia till after blood cultures turn positive resulted in higher mortality
• Start of anti-fungal Rx >12 hrs of drawing a blood culture that turns positive had AOR= 2.09 for mortality, p=0.018
Morrel M et al. 2005. Antimicrob Agents Chemother. 49(9):3640-5
Major Risk Factors
• Prior antibiotic use • CVL• TPN• Major Sx. within a week• Steroids• Dialysis • Immunosuppression • ICU length of stay - infections rising rapidly after 7-10 d
Dimopoulos G, et al. Candidemia in immunocompromised and immunocompetent critically ill
patients: a prospective comparative study. Eur J Clin Microbiol Infect Dis. 2007
Guideline – driven decision making in management of IFI in ICUAlgorhitm Development – Diagnostic approach:
Guideline – driven decision making in management of IFI in ICUAlgorhitm Development – Medical treatment :
Guideline – driven decision making in management of IFI in ICUProphylactic, Preemptive, and Empiric Strategies :
• IFI :• Negative outcomes • Difficult definitive diagnosis early intervention either to prevent infection or to preempt severe fungal infection
is desirable.
• Candida ; most common fungal pathogens in ICU→ most strategies→on Candida spp.
Guideline – driven decision making in management of IFI in ICUProphylactic, Preemptive, and Empiric Strategies :
Prophylactic, Preemptive or Empiric Use of Anti-fungals
• PROS– High Mortality
– Difficulty in Diagnosis
– Undetected Infection
– Reduced systemic mycoses and improved mortality with prophylaxis
• CONS– Toxicity
– Expense
– Diagnosis not certain• Too much treatment
without infection• Too little treatment with
infection
World J Crit Care Med. 2014 Nov 4; 3(4): 102–112. • Invasive candidiasis in critical care setting,
updated recommendations from “Invasive Fungal Infections-Clinical Forum”, Iran
• Ashraf Elhoufi, Arezoo Ahmadi, Amir Mohammad Hashem Asnaashari, Mohammad Ali Davarpanah, Behrooz Farzanegan Bidgoli, Omid Moradi Moghaddam, Mohammad Torabi-Nami, Saeed Abbasi, Malak El-Sobky, Ali Ghaziani, Mohammad Hossein Jarrahzadeh, Reza Shahrami, Farzad Shirazian, Farhad Soltani, Homeira Yazdinejad, and Farid Zand
Guideline – driven decision making in management of IFI in ICUSummary:
• local epidemiology of Candida spp. → appropriate empiric and preemptive Rx
• local epidemiology at institution and also at unit
• Optimal management of IFI involves:• Pt. risk factor identification• Diagnostic testing • Early effective pharmacotherapy
Guideline – driven decision making in management of IFI in ICUSummary:
• Appropriate empiric regimen depends on: • Local patterns of infection and • Severity of illness
Delays in antifungal therapy → ↑mortality
To avoid delays and guide appropriate therapy,many institutions approach the management of
fungal bloodstream infection in the ICU with an algorithm
Suggested treatment algorithm for the ICU patient with invasive candidiasis(NAS: non- albicans species, CVC: central venous catheter, AmB: amphotericin B,
LipAmB: liposomal amphotericin B)
Any ?