which antibiotics will work and which not in neonatal...

Which Antibiotics will work and which not in

neonatal sepsis in INDIA

Real case scenario

26 year old primiElective LSCS deli for non progressive labor

Male 34 kg Cried at birth

Respi Distress at birth

On ventilator at 6 hrs

Referred to local NICU for further support

Ive had the struggle of living with a resistance to

antibiotics for nearly eight years of my lifethere is a

clear need for new antibiotics

With every sting and every pain my heart sinks at the

thought of how many antibiotics I have

left to use this time

Indian J Med Res 2008 Jan127(1)85-8

Occurrence of ESBL amp Amp-C beta-lactamases amp susceptibility to newer antimicrobial agents in complicated UTITaneja N1 Rao P Arora J Dogra A

Neonatal Sepsis High Antibiotic Resistance of the Bacterial Pathogens in a Neonatal Intensive Care Unit of a Tertiary Care

HospitalNosocomial Infections in Neonatal Intensive Care Units Profile Risk Factor Assessment and Antibiogram

Saritha Kamath Shrikara Mallaya and Shalini Shenoy

Department of Microbiology Kasturba Medical College Mangalore Karnataka India

Indian J Pediatr 2011 Apr78(4)409-12 doi 101007s12098-010-0272-1 Epub 2010 Oct 17

Aetiology and antimicrobial resistance of neonatal sepsis at a tertiary care centre in eastern India a 3 year

study


Aetiology and antimicrobial resistance of neonatal sepsis at a tertiary care centre

in eastern India a 3 year studyViswanathan R1 Singh AK Mukherjee S Mukherjee R Das P Basu S

135 268 blood cultures

425 cities and 27 states

1820 collection centres

Acenatobacter most common org

HIGH degree of resistance to

Reserve antibiotics

Almost 50 CS positive died

25 of all death were bcs of sepsis

Mortality almost same between sensitive

and resistance pathogens

Nearly quarter of

Acinetobacter and three

quarter of Klebsiella

showed NDM-1 in pool of

carb Resistance strain

Early occurrence of Sepsis (most episodes occurred with

in 72 hrs )

Quarter of culture positive episodes occurred with in 24

hrs of birth

two third with in 72 hrs

CFR did not differ between Early or late onset

Antibiotic resistancemdashthe need for global solutions

Ramanan Laxminarayan PhD Adriano Duse MD Chand Wattal MD Anita K M Zaidi MD Heiman F L Wertheim MD Nithima

Sumpradit PhD Erika Vlieghe MD Prof Gabriel Levy Hara MD Ian M Gould MBChB Herman Goossens PhD Christina Greko PhD

Prof Anthony D So MD Maryam Bigdeli MPH Prof Goumlran Tomson MD Will Woodhouse Eva Ombaka PhD Prof Arturo Quizhpe

Peralta MD Farah Naz Qamar MBBS Fatima Mir PhD Sam Kariuki PhD Prof Zulfiqar A Bhutta PhD Prof Anthony Coates MD

Richard Bergstrom MSc Gerard D Wright PhD Eric D Brown PhD Prof Otto Cars MD

The Lancet Infectious Diseases

Volume 13 Issue 12 Pages 1057-1098 (December 2013) DOI 101016S1473-3099(13)70318-9

Copyright copy 2013 Elsevier Ltd Terms and Conditions

Volume 17 Number 10mdashOctober 2011

Worldwide geographic distribution ofKlebsiella pneumoniaecarbapenemase (KPC)


Geographic distribution of New Delhi metallo-β-lactamase-1 producers

Verona integronndashencoded metallo-β-lactamase (VIM)

and IMP enterobacterial producers

Verona integronndashencoded metallo-β-lactamase (VIM) and IMP

enterobacterial producers

oxacillinase-48 (OXA-48) type producers

Klebsiella pneumoniae carbapenemase-2 (KPC-2

New Delhi metallo-β-lactamase-1 (NDM-1)

oxacillinase-48 (OXA-48)ndashproducingK Pneumoniae


Worst for BRICK countries

ACCESSEXCESS

Prolonged course of antibiotics

Undisciplined use of broad spectrum antibiotics

Overdependence on CRP to startstop antibiotics

Absence of culture facilities

ESBL MRSAVRE

Carbepenem resistance

NDM -1

Poor public health infrastructure Rising income high burden of disease unregulated sale of antibiotics

50 samples from street taps mdash sources of drinking

washing and cooking water for entire neighborhoods mdash

and 171 samples of ―seepage (surface water and

street puddles) from around New Delhi NDM-1 in two

of the drinking-water samples (4 percent) and 51 of the

171 seepage samples (30 percent)

The Lancet Infectious Diseases 2013 13 1057-1098DOI (101016S1473-3099(13)70318-9)

Trends in retail sales of carbapenem antibiotics for Gram-negative bacteria

Antibiotic Therapy in Neonates No prophylactic antibiotics

Prophylactic antibiotics tried in

Prematurity

MSAF

All ventilated babies

Chest drains exchange etc

Prophylaxis ndash

Increases risk of infection with Multi drug resistant pathogen

Predispose to antibiotic resistance

Does not

prevent Sepsis

Antibiotic Therapy in Neonates Treat infection and not colonisation

Bacteria isolated from ET tube catheters long lines constitute

colonization

Do not use antibiotics for colonization

It is likely to increase antibiotic resistance and

It does not prevent systemic infection

Growth of bacterium from normally sterile body sites such as

blood CSF ascitic tap pleural tap etc suggests infection

Role of Infection Control

Strict hand washing- Before examining first baby a

thorough hand wash with detergent soap for at least 2 min

and in-between babies hand wash for 30 sec

Strict asepsis during any procedure

Periodic review of antibiotic policy in the light of culture

positive reports in the previous month

Rotation of antibiotics

Periodic fumigation

NICU policieshellip

Not to admit diarrhoea patients and patients

with open infected wounds in nicu

Isolation of culture positive septic babies

Restriction of visitors

Kangaroo mother care

Ten Point Action Plan on Antibiotic Use

Always take blood cultures prior to start of antibiotics

Use the narrowest spectrum antibiotics possible almost always a penicillin and

an aminoglycoside (eg Amikacin)

Do not start treatment as a general rule with a 3rd generation cephalosporin

(eg cefotaxime ceftazidime) or a carbapenem (eg imipenem

meropenem)


Develop local antibiotic policies to restrict the use of expensive

broad-spectrum antibiotics like imipenem for emergency

treatment

Trust the microbiology laboratory Rely on the blood culture results

Stop believing that a raised CRP means the baby is definitely septic

If blood cultures are negative at 2-3 days it is almost always safe to

stop antibiotics

Develop local antibiotic policies to restrict the use of expensive broad-spectrum

antibiotics like imipenem for emergency treatment



If blood cultures are negative at 2-3 days it is almost always safe to stop antibiotics

TRY YOUR LUCK

Conclusions

Canrsquot predict which antibiotics will work and which will not in current scenario of MDRS organism

Go by org pattern and CS sensitivity of your set up

Prevention of sepsis has to be a priority and on war foot basis

Ten rule of antibiotics usage is MUST to be observed

itrsquos a Question of our own image as a communitycountry

Lord Jim ONeill who led the Review on Antimicrobial

Resistance said a campaign was needed to stop

people treating antibiotics like sweets

Real case scenario

26 year old primiElective LSCS deli for non progressive labor

Male 34 kg Cried at birth

Respi Distress at birth

On ventilator at 6 hrs

Referred to local NICU for further support















study









Reserve antibiotics





Nearly quarter of






in 72 hrs )


hrs of birth


























ACCESSEXCESS





ESBL MRSAVRE


NDM -1












Prematurity

MSAF



Prophylaxis ndash



Does not

prevent Sepsis



colonization














Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions























study









Reserve antibiotics





Nearly quarter of






in 72 hrs )


hrs of birth


























ACCESSEXCESS





ESBL MRSAVRE


NDM -1












Prematurity

MSAF



Prophylaxis ndash



Does not

prevent Sepsis



colonization














Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions














Reserve antibiotics





Nearly quarter of






in 72 hrs )


hrs of birth


























ACCESSEXCESS





ESBL MRSAVRE


NDM -1












Prematurity

MSAF



Prophylaxis ndash



Does not

prevent Sepsis



colonization














Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions










in 72 hrs )


hrs of birth


























ACCESSEXCESS





ESBL MRSAVRE


NDM -1












Prematurity

MSAF



Prophylaxis ndash



Does not

prevent Sepsis



colonization














Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions
































ACCESSEXCESS





ESBL MRSAVRE


NDM -1












Prematurity

MSAF



Prophylaxis ndash



Does not

prevent Sepsis



colonization














Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions













ESBL MRSAVRE


NDM -1












Prematurity

MSAF



Prophylaxis ndash



Does not

prevent Sepsis



colonization














Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions




















Prematurity

MSAF



Prophylaxis ndash



Does not

prevent Sepsis



colonization














Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions











colonization














Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions

















Periodic fumigation

NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions









NICU policieshellip












meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions















meropenem)




treatment




stop antibiotics






TRY YOUR LUCK

Conclusions












treatment




stop antibiotics






TRY YOUR LUCK

Conclusions














TRY YOUR LUCK

Conclusions









Conclusions









which antibiotics will work and which not in neonatal...

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