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Ghiddemanagementalinfecțiilorasociateîngrijirilordesănătate–un
punctdevedere
Prof.AdrianStreinu-CercelMD,PhD,HC2017
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We live in a BACTERIAL World !! 3 miliarde de ani de dezvoltare a bacteriilor înainte de apari!ie a
animalelor "i plantelor pe P mânt
!! Microbii reprezint 60% din biomasa p mântului
!! Se estimeaz c < 0.5 % din cele 2-3 miiarde de specii bacteriene au fost identificate
!! Numai o mic parte a acestor microbi ar fi patogeni pentru om A.S. Fauci CID, 2001
!! Compozi!ia celular a corpului uman: !! 1013 eukaryotic cells !! 1014 microbiene cells !! Represents endogen flora !! 500 commensal bacterial species colonies GI tract
• AnHmicrobialmanagementteam:mulHdisciplinary,compensated(AII-AIII)• CoreacHviHesoftheteam:
– Audit&feedback(AI)– FormularyrestricHon/preauthorizaHon(AII)
• OpHonalacHviHes:– Guidelines/pathways(AI)– IV/POconversion(AI)– De-escalaHontherapy(AII)– DoseopHmizaHon(AII)– EducaHon(AIII)– Orderforms(BII)– Cycling(CII)– CombinaHontherapy(CII)
• Processmeasures• OutcomemeasurestodeterminetheimpactofanHmicrobialstewardshipon
anHmicrobialuseandresistancepaYerns(B-III)• HealthcareinformaHontechnologyintheformof
– Electronicmedicalrecords(A-III)– Computerphysicianorderentry(B-II)– Clinicaldecisionsupport(B-II)
RatedkeystrategiesofanHmicrobialstewadship–Dellit2007
ENTEROBACTERII ȘI CARBAPENEMAZE
q PrevalențabacteriilorgramnegaHveanHbioHcrezistenteesteîncreștereînmultețărieuropene
q MDR=mulHdrugresistance–defineștetulpinirezistentela3saumaimulteclasereprezentaHvedeagențianHmicrobieni
q XDR=extensivedrugresistance–rezistențalatoateclasele,maipuținunasaudouaclase
q PDR=pandrugresistance–rezistențalatoateclaseledeanHbioHcedisponibile
M Souli et al, Eurosurveillance, 2008
Redefinirea ESKAPE…ca ESCAPE
Peterson LR. Clin Infect Dis. 2009;49:992
Aceasta redefinire include noi patogeni
E Enterococcus faecium
S Staphylococcus aureus
C Clostridium difficile
A Acinetobacter baumannii
P Pseudomonas aeruginosa
E Enterobacteriaceae
Cresterea virulentei C. difficile
Enterobacteriaceae includ K. pneumoniae, Enterobacter spp., si alte specii rezistente ca Escherichia coli si Proteus spp.
E Enterobacteriaceae
Cal toriile au un rol major în r spândirea germenilor multirezisten!i
16
ScorulCarmeliBacteriișiFungi
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INFEC!II COMUNITARE INFEC!II NOSOCOMIALE
INFEC!II COMUNITARE INFEC!II ASOCIATE ASISTEN!EI MEDICALE
INFEC!II NOSOCOMIALE
Germeni cu sensibilitate la AB posisbil p"strat"
G-neg/poz posibil MDR ± ESBL
MRSA G-neg MDR: + non-fermentativi: -!piocianic -!acinetobacter
Evaluareariscului-CarmeliA.Contactulcusectorulsanitar:
1) Fărăcontact2) Contactfărăproceduriinvazive3) Contacterepetatecuproceduriinvazive
B.TratamentAB:1) FărăAB2) CuABînantecedente
C.CaracterisNcilepacientului:1) Tânăr–fărăcomorbidităţi2) Vârstniccucomorbidităţi3) Pacientimunodeprimat:
Ø AIDSØ BPOCØ CancerØ BMT
1
2
3
2
1
1
2
3
Scor: 1,2 sau 3
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VWX42#
Infec ii asociate îngrijirilor de s n tate
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7(CQ9%.%#&C-%,R"'9%#&%,-(+#2LM#
42#@#%,C(.%#
Carmeli 1
Carmeli 2
Carmeli 3
Infecţii comunitare
Ampicilină Amoxi/clav
FQ – Levo/Moxi po CGII/III
Macrolide
Ertapenem Aminoglicozide
±FQ – Levo/Moxi po/i.v. CGIII/IV
C-antiPs. βlactami+I.β lactamaze
(Amoxi/clav SR, ES) Linezolid/Vancomicină
Macrolide
Imipenem/Meropenem Aminoglicozide FQ GIV – Moxi iv
CGIII antiPS CGIV:
• Cefepim, • Cefpirom
Linezolid / Vancomicină Macrolide
Infecţii asociate
îngrijirilor medicale
Infecţii nosocomiale
Sari direct aici!
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AB#A'(')-%("$N)"9%#&')"%,-+9+"D#EF! MO,*(#P#I*(*##)[email protected](Q"0"-*R"#HF! !O($-,")#P#)+##)[email protected](Q"0"-*R"#KF! S.+,C)C.&(C."$D##
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1
2
3
2
1
1
2
3
Score : 1, 2 or 3
Carmeli-like 1
Carmeli-like 2
Carmeli-like 3
IFI comunitare
Caspo (AI) Anidula (AI)
Mica (AI) Voriconazol Posaconazol
AMB
Neutropenic: Caspofungin Voriconazol
IFI asociate
îngrijirilor de s"n"tate
IFI Nosocomiale
Non-neutropenic: Caspofungin
Anidulafungin Micafungin Voriconazol Posaconazol
Terapia Infectiilor fungice invazive
Fluconazol Itraconazol
Fluconazol Itraconazol Fluconazol
Posaconazol
AB + AF cu spectru ultralarg 72h
Pacientul TI
Non-neutropenic F0 + factt de risc
Neutropenic F0
PMN<1000/mm3
PCT
<1 >1
1,3-!-D-glucans Neg
1,3-!-D-glucans Poz
AB + AF AB
<1
1,3-!-D-glucans
>1
1,3-!-D-glucans
Sepsis Sever Soc
septic
PCT
septic
Dezescaladare Completa*
±Sepsis
AB + AF cu
Suspected IFI - Carmeli-like Score
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Sugestii în vederea ini#ierii TAF în TI – de la practica curent" la ghiduri 2013
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a?()$#$0S(%010-(1#)*#()(%2&9&1(%
b0)>b&7+108&)#.% Neutropenic
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** Vezi criteriile de diferentiere
CriteriiledediferenHere
• SinguracuindicaHeinaspergiloza
• SinguracuindicaHeinterapiadeprimaintenHe
• Spectrulcelmailarginvitro
Cancidas Micafungin Anidulafungin
• Anomalii suplimentare hematologice (anemie, neutropenie, leucopenie)
• Avertizare FDA/EMEA cu privire la riscul de HCC
• Singura cu indicatie la copilul < 1 an
• Cele mai putine interactiuni medicamentoase
• Indicata in Insuficienta hepatica severa P-Ch >9
ScoruldeagresivitatebacterianăşicorespondenţacuscorulCarmeli
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