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Prophylactic Use of Antibiotics in the Intensive Care Unit Yoğun Bakım JARSS 2019;27(2):87-93 Derleme / Review doi: 10.5222/jarss.2019.29491 Prophylactic Use of Antibiotics in the Intensive Hektor Sula ID Care Unit Rudin Domi ID Yoğun Bakım Ünitesinde Profilaktik Antibiyotik Kullanımı ABSTRACT Alındığı tarih: 01.03.2019 Kabul tarihi: 15.04.2019 Infections during the intensive care treatment present a great continuous challenge to the physi- Yayın tarihi: 30.04.2019 cians and to the patients. These infections can significantly increase the morbidity and mortality. One of the major issues to be addressed is the prophylactic use of antibiotics in intensive care units. The importance of infection prevention in critically ill patients is therefore based on its Atıf vermek için: Sula H. Domi R. Prophylactic Use potential to reduce both morbidity and mortality. The relationship between this reduction and the of Antibiotics in the Intensive Care Unit. JARSS prevention of the development of resistance remains unclear. The infections can also affect treat- 2019;27(2):87-93. ment costs, hospital stay, and patients’ prognosis. This review tends to summarize all the topics regarding the prophylactic use of antibiotics, prevention of infections in intensive care units, and minimizing the resistance. Rudin Domi Department of Anesthesiology and Keywords: Intensive care unit, infections, antibiotics prophylaxis Intensive Care Medicine, American Hospital, ÖZ Tirana, Albania ✉ [email protected] Yoğun bakım tedavisi sırasındaki enfeksiyonlar, hekimlere ve hastalara aşılması gereken bir sorun ORCİD: 0000-0003-4594-7815 teşkil edegelmiştir. Bu enfeksiyonlar morbidite ve mortalite oranlarını önemli ölçüde artırabilir. Ele alınacak ana konulardan biri, yoğun bakım ünitelerinde antibiyotiklerin profilaktik kullanımı- dır. Kritik hastalarda enfeksiyonun engellenmesinin önemi hem morbidite hem de mortaliteyi H. Sula 0000-0003-4594-7815 azaltma potansiyeline dayanmaktadır. Bu azalma ile direnç gelişiminin önlenmesi arasındaki Department of General Surgery, ilişki net değildir. Enfeksiyonlar ayrıca tedavi masraflarını, hastanede kalış süresini ve hastaların Service of Anesthesiology and prognozunu etkileyebilir. Bu derlemenin amacı, profilaktik antibiyotik kullanımı, yoğun bakım Intensive Care, “Mother Teresa” ünitelerinde enfeksiyonların önlenmesi ve antibiyotik direncini en aza indirgeme hususundaki University Hospital Center konuları özetlemektir. Anahtar kelimeler: Yoğun bakım ünitesi, enfeksiyon, antibiyotik profilaksisi INTRODUCTION Intensive care unit- acquired infections are frequ- ently seen complications in the practice of critical The development of infection during Intensive Care care, with their cumulative incidence varying consi- Unit (ICU) stay is associated with significant increa- derably among different patient populations. ses in morbidity and mortality. The administration of antibiotics in ICU is one of the major problems and The prevalence of antibiotic use among ICU patients subject of several controversies. Many efforts have is around 60%. It is reported that approximately 40% been undertaken for a suitable “antibiotic steward- of all ICU patients, receive empiric antibiotic therapy ship”, in order to optimize their utilization and mini- (5). Once initiated, empiric therapy is often continued mize their side effects (1,2). for over 7 days, despite persistent negative microbi- ology results (6). The appropriate use of antibiotics in ICU is important in ensuring an optimal clinical outcome, but in also ICUs hospitalize heterogeneous group of patients controlling the emergence of resistance among pat- under therapeutic treatment and prophylactic anti- hogenic microorganisms and in containing costs (3,4). biotherapy, in order to minimize the infection. © Telif hakkı Anestezi ve Reanimasyon Uzmanları Derneği. Logos Tıp Yayıncılık tarafından yayınlanmaktadır. Bu dergide yayınlanan bütün makaleler Creative Commons Atıf-GayriTicari 4.0 Uluslararası Lisansı ile lisanslanmıştır. © Copyright Anesthesiology and Reanimation Specialists’ Society. This journal published by Logos Medical Publishing. Licenced by Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) 87 JARSS 2019;27(2):87-93 The importance of prevention of infection in criti- dures. The early use of antibiotics may prevent the cally ill patients is therefore based on its potential to infection in these situations. reduce both morbidity and mortality. The relations- hip between such reduction in both morbidity and • Device-Related Risks: Patients who suffer an episo- mortality and the prevention of development of de of Ventilator Acquired Pneumonia (VAP) or noso- resistance remains unclear. comial bloodstream infection have been shown to need prolonged hospital stay associated with increa- A clear distinction should be made between surgical sed mortality rates as well (10-13). and non-surgical patients. Interestingly, the proporti- on of surgical patients on antibiotherapy (26%) did Endotracheal intubation and duration of mechanical not differ significantly from that of medical patients ventilation more than 48 hours are considered as (24%). Various publications have reported the most risk factors for infections. Patients who have altered frequent indications for antibiotherapy and the spe- protective airway reflexes prior to endotracheal intu- cific agents most frequently used (7,8). bation due to a decreased level of consciousness or other causes are at a particularly high risk of early It is known that approximately 500.000 surgical site onset VAP. Compared to a conscious patient with a infections (SSI) occur every year in the United States. natural airway and spontaneous breathing, the pre- Among patients who develop these infections, 60% sence of an endotracheal tube and mechanical ven- of them will remain longer in the ICU, and they are 5 tilation in patients under sedation and muscle rela- times more likely to be readmitted to the hospital xation carries a 6 to 21-fold increased risk for deve- and twice as likely to die compared to patients who lopment of nosocomial pneumonia (14). had not developed infections. Moreover, the costs of these infections are high, and they are associated Several mechanisms contribute to the increased risk with other adverse events (9). of respiratory tract infection. A decreased level of consciousness after head trauma, stroke or need for The antibiotic prophylaxis (ABP) in emergency sur- emergency endotracheal reintubation, are associa- gery seems to be difficult compared to elective pro- ted with aspiration of contaminated oral and/or cedures. Sometimes it is difficult to differentiate gastric contents due to the absence of upper airway between prophylaxis and early treatment. reflexes. Infections caused by microorganisms that colonize the digestive tract of the patient on admis- The risk of acquiring an infection depends on the sion to the ICU are called “primary endogenous degree of the severity of the illness and the use of diseases.” Pneumonias of primary endogenous deve- certain devices and procedures during ICU stay. lopment, for example, are caused by the flora pre- These factors can cause a cumulative incidence of sent in the oropharynx of patients at intubation. infections. These microorganisms have either been aspirated before admission by a comatose patient or are aspi- Clinical and Research Consequences rated through or inoculated on insertion of an endotracheal tube during the procedure of intubati- Through the factors predisposing for ICU infection, on. In the absence of systemic antibiotherapy, intu- the frequent device utilization in intensive care is bated stroke and head trauma patients have a 36% responsible for most nosocomial ICU-acquired infec- incidence of pneumonia developing soon after intu- tions. Endotracheal intubation, mechanical ventilati- bation (15). It is reported that at medical indications on, central venous catheter, and urinary catheteriza- for ICU stay (intubation for acute pulmonary edema, tion are the most important procedures responsible for resuscitation after cardiac arrest, coma due to for the infections of respiratory tract, bloodstream, drug overdose, and stroke), the incidence of early and urinary tract in ICU patients. The first week of onset pneumonia was 51.3% in patients not recei- ICU admission is characterized by impaired host ving antibiotic prophylaxis (ABP) (16). The infusion of defense (especially neutropenic patients), contribu- muscle relaxants and the absence of systemic antibi- ting to increased infection rates during these proce- otic therapy are considered as risk factors for VAP 88 H. Sula and R. Domi, Prophylactic Use of Antibiotics in the Intensive Care Unit during prolonged intubation and mechanical ventila- Control Consortium data gathered from 50 ICUs (31). tion (17). ABP reduces bacteremia, ventilator associa- ted pneumonia and mortality among patients in ICU UTIs can be classified as non-urologic (presented in (18-20). diabetes, trauma, renal failure) and urologic which include neurogenic bladder, urogenital surgery, kid- The use of ABP when aspiration is suspected or in ney transplantation, and urinary stones. Several trauma and comatose patients, is still a matter of conditions can predispose to UTI as diabetes, immu- debate, as several authors reported that restrictive nosuppressive diseases, different infectious sites politics may be more advantageous in reduction of (appendicitis, ileus, and diverticulitis), tissue hypo- antibiotic use to minimize development of resistance xia, and urogenital trauma. The main pathophysiolo-
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