Antibiotic Use for Sepsis in Critical Care: Steve McGloughlin Steve McGloughlin presents his thoughts on antibiotics and their use in sepsis and critical care. Steve discusses the ABC of sepsis… the trouble is after A for Antibiotics there is not a whole lot else! In sepsis and severe infection, the goal is to change the trajectory of the patient, away from death and to a more favourable outcome. The tools that are currently on offer in critical care are pretty simple. There are things to support the patient such as fluid and ventilators. In addition, we consider goal directed therapy. In terms of definitive therapy, the list is quite small. Perhaps only antibiotics and source control can be turned to. Antibiotics are a powerful tool. So much so that the number needed to treat is around four. They are also very commonly used. 70-80% of patients in the ICU will get antibiotics – far higher than nearly all other treatments. Steve has some basic advice for the use of antibiotics to enhance their effectiveness. Go early as possible when prescribing and administering. In saying that, he cautions to move beyond simple antibiotic prescribing regimes. Whilst we need early antibiotics, we need the right antibiotics. Why? Alexander Fleming warned against drug resistant bugs when developing penicillin. There has been reports of pandrug resistant organisms (bug against which no known drug is effective) in multiple countries and 214 000 neonatal sepsis deaths per year are attributed to resistant pathogens. Steve concludes with a discussion on what more we need when considering sepsis. We need more than antibiotics. As it stands one definition covers all categories of sepsis. The result is a homogenous treatment protocol. In reality, the source, the bug and the pathology all change the disease and all call for an individualised treatment regime. That is the future. For more like this, head to our podcast page. #CodaPodcast

1. A is for Antibiotics
After that we are STUCK
Steve McGloughlin
The Alfred

4. SEPSIS

5. Sepsis is

9. Severe Infection (sepsis)………

10. Age
GCS
Temp
HR
MAP
pH
P/F Ratio
Creatinine
51
13
39
125
55
7.14
180
140
ARISE
PROCESS
PROMISE
APACHE 25

11. Age
GCS
Temp
HR
MAP
pH
P/F Ratio
Creatinine
55
13
39
125
55
7.14
150
140
ARISE
PROCESS
PROMISE
APACHE 25
MORTALITY 45%

12. In Intensive Care………

13. Severe
Infection

14. ?
Severe
Infection
ED and ICU

15. Intensivists

16. Intensivists

17. Intensivists

18. Severe
Infection
?
Support
Fluids
Dialysis
Goal Directed Therapy?

19. Severe
Infection
?
Definitive
Antibiotics
Source Control

20. Severe
Infection
?
Support
Antibiotics
Source Control
We need something else!

21. Sepsis is

22. What do we have….

25. NNT

27. Why Not?

28. Sick Very Sick
Which Antibiotic?
I want you to be honest?

30. The thoughtless person playing with
penicillin treatment is morally
responsible for the death of the
person who succumbs to infection with
the penicillin resistant organism.

31. Pandrug resistant

32. 214000 neonatal
sepsis deaths
attributable to
resistant pathogens

33. Figure 1: Estimated pneumonia deaths avertable in under-5 populations with improved antibiotic access
Countries with less than 100 deaths averted are not labelled. Data on under-5 population with suspected pneumonia receiving antibiotics are from 1990 to 2013;
data from the most recent year reported is used, when available.
0 20 40 60 80
Trendline weighted by
the under-5 population
of each country
100
0
1
2
3
4
5
6
Pneumoniadeaths(duetoStreptococcuspneumoniaeandHaemophilus
influenzaetypeb)per1000childrenagedyoungerthan5years
Under-5 population with suspected pneumonia receiving antibiotics (%)
India
Nigeria
DR Congo
Pakistan
China
Ethiopia
Afghanistan
Sudan
Indonesia
Somalia
Mali
Niger
Uganda
Chad
Tanzania
Burkina Faso
Kenya
Yemen
Mozambique
Cameroon
Myanmar
Philippines
Côte d’Ivoire
Bangladesh
Guinea
Iraq
Madagascar
Nepal
Malawi
Ghana
Burundi
Benin
Sierra Leone
Uzbekistan
Zambia
Egypt
Haiti
Senegal
Iran
Central African Republic
Togo
Vietnam
Morocco
Brazil
Rwanda Zimbabwe
Mauritania
Cambodia
Tajikistan
Algeria
Congo (Brazzaville)
Guinea−Bissau
Bolivia
ColombiaTurkey
Thailand
North KoreaLaos
Argentina
KazakhstanPeru
Timor−Leste
Dominican Republic
Equatorial Guinea
Kyrgyzstan Syria
Gambia
Comoros Swaziland
Honduras
Paraguay
Ukraine
India (169760)
Nigeria (49407)
Nepal (2434)
Hypothetical under-5 pneumonia deaths
averted with universal antibiotic access
1 million Avoidable deaths in 2013 in
under 5’s from pneumonia
170 000 deaths
in India
avoidable with
Antibiotics

34. We need more
than
antibiotics?

37. A disease caused by an
uncontrolled division of abnormal
cells in a part of the body.
Life-threatening organ dysfunction
due to a dysregulated host
response to infection
Cancer is
Sepsis is

38. One
definition?

39. f not recognized early and treated promptly
Heart
Brain
Lung
Infection
Liver
Kidney
From a lo
general i
A local infect
comes the bo
Pathogenic g
produce leave
infection and
Stage1
The
source
changes
the risk
of death

40. MULTIDRUG-RESISTANT
PSEUDOMONAS AERUG
6,700 44MULTIDRUG-RESISTANT
PSEUDOMONAS
INFECTIONS
DEATH
THREAT LEVEL
SERIOUS
This bacteria is a serious concern and requires prompt
and sustained action to ensure the problem does not grow.
51,000
PSEUDOMONAS
INFECTIONS
PER YEAR
MET
STA
(MR
THREAT LEVEL
SERIOUS
This bacteria is a serious concern and requires prompt
and sustained action to ensure the problem does not grow.
Methicillin-resistant Staphylococcus aureus (MRSA) causes a range
of illnesses, from skin and wound infections to pneumonia and
bloodstream infections that can cause sepsis and death. Staph
bacteria, including MRSA, are one of the most common causes of
healthcare-associated infections.
The bugs are not the same…

41. Pathology is not the same

42. The Narrow Spectrum Era…….
1925
1950
1975
2000
2025
Golden Era
Nature products
Medicinal Chemistry Era
Synthetic tweaking
Resistance era
Target based, broad spectrum
Narrow-Spectrum era
Unconventional
Combination approaches
Diagnostic development
1925
1975
2000
2025
1950

43. The Narrow Spectrum Era…….
1925
1950
1975
2000
2025
Golden Era
Nature products
Medicinal Chemistry Era
Synthetic tweaking
Resistance era
Target based, broad spectrum
Narrow-Spectrum era
Unconventional
Combination approaches
Diagnostic development
1925
1975
2000
2025
1950

46. Sepsis is

47. If ICU and ED
want to own
sepsis…..

48. In memory of my sister Bec

49. Most people spend their time
and energy going around
problems rather than in
trying to solve them.
Henry Ford