Ghid de management al infecțiilor asociate îngrijirilor de sănătate un punct de vedere. Prof. Adrian Streinu-Cercel MD, PhD, HC 2017

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1 Ghid de management al infecțiilor asociate îngrijirilor de sănătate un punct de vedere Prof. Adrian Streinu-Cercel MD, PhD, HC 2017

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5 % din cele 2-3 miiarde de specii bacteriene au fost identificate!

10 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:!! eukaryotic cells!! microbiene cells!! Represents endogen flora!! 500 commensal bacterial species colonies GI tract

13 Rated key strategies of anhmicrobial stewadship Dellit 2007 AnHmicrobial management team: mulhdisciplinary, compensated (AII-AIII) Core achvihes of the team: Audit & feedback (AI) Formulary restrichon/preauthorizahon (AII) OpHonal achvihes: Guidelines/pathways (AI) IV/PO conversion (AI) De-escalaHon therapy (AII) Dose ophmizahon (AII) EducaHon (AIII) Order forms (BII) Cycling (CII) CombinaHon therapy (CII) Process measures Outcome measures to determine the impact of anhmicrobial stewardship on anhmicrobial use and resistance payerns (B-III) Health care informahon technology in the form of Electronic medical records (A-III) Computer physician order entry (B-II) Clinical decision support (B-II)

14 ENTEROBACTERII ȘI CARBAPENEMAZE q Prevalența bacteriilor gram negahve anhbiohc rezistente este în creștere în multe țări europene q MDR = mulhdrug resistance definește tulpini rezistente la 3 sau mai multe clase reprezentahve de agenți anhmicrobieni q XDR = extensive drug resistance rezistența la toate clasele, mai puțin una sau doua clase q PDR = pandrug resistance rezistența la toate clasele de anhbiohce disponibile M Souli et al, Eurosurveillance, 2008

15 Redefinirea ESKAPE ca ESCAPE E Enterococcus faecium S Staphylococcus aureus C Clostridium difficile Aceasta redefinire include noi patogeni Cresterea virulentei C. difficile A Acinetobacter baumannii P Pseudomonas aeruginosa E Enterobacteriaceae Enterobacteriaceae includ K. pneumoniae, Enterobacter spp., si alte specii rezistente ca Escherichia coli si Proteus spp. Peterson LR. Clin Infect Dis. 2009;49:992

16 Cal toriile au un rol major în r spândirea germenilor multirezisten!i 16

18 Scorul Carmeli Bacterii și Fungi

19 ?,(2#\.(1&(%#)-&.`##,01% INFEC!II COMUNITARE INFEC!II NOSOCOMIALE INFEC!II COMUNITARE Germeni cu sensibilitate la AB posisbil p"strat" INFEC!II ASOCIATE ASISTEN!EI MEDICALE G-neg/poz posibil MDR ± ESBL INFEC!II NOSOCOMIALE MRSA G-neg MDR: + non-fermentativi: -!piocianic -!acinetobacter

20 Evaluarea riscului - Carmeli A. Contactul cu sectorul sanitar: 1) Fără contact 2) Contact fără proceduri invazive 3) Contacte repetate cu proceduri invazive B. Tratament AB: 1) Fără AB 2) Cu AB în antecedente C. CaracterisNcile pacientului: 1) Tânăr fără comorbidităţi 2) Vârstnic cu comorbidităţi 3) Pacient imunodeprimat: Ø AIDS Ø BPOC Ø Cancer Ø BMT Scor: 1,2 sau 3

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21 :1#).#8(,##%*&1'&)#%#'8,#.(`#% S,I%)R""#)C.+,"-'(%# Infec ii asociate îngrijirilor de s n tate S,I%)R""#,C$C)C."'9%#!!##7,%+.C)C)+9#!!!"#$%&'(%)*(!!!!+,-*.(//*!0*12*-*/$3!!!##7,%+.C)C)+9#=#9'#7#!!!"#$%&#!Y#$%)(%-C(!!!!+#!4*12*-*/$3!=#9'#7#!!##<=T2#)C.+,"-'(#!!##Z%(.%,"#0%#$&"-'9#!!##<=T2#0%#$&"-'9#!!##5#!6%('7,%$*(!!!!2)",%-CQ')-%(#$&&B#!!##7"C)"',")#!!##Z%(.%,"#<4=## 7(CQ9%.%#&C-%,R"'9%# &%,-(+#2LM# 7(CQ9%.%#&C-%,R"'9%# &%,-(+#2LM# 7(CQ9%.%# &C-%,R"'9%# &%,-(+#2LM# VWX42# 42# 42#@#%,C(.%#

22 Carmeli 1 Carmeli 2 Sari direct aici! Carmeli 3 Infecţii comunitare Ampicilină Amoxi/clav FQ Levo/Moxi po CGII/III Macrolide Infecţii asociate îngrijirilor medicale Ertapenem Aminoglicozide ±FQ Levo/Moxi po/i.v. CGIII/IV C-antiPs. βlactami+i.β lactamaze (Amoxi/clav SR, ES) Linezolid/Vancomicină Macrolide Infecţii nosocomiale Imipenem/Meropenem Aminoglicozide FQ GIV Moxi iv CGIII antips CGIV: Cefepim, Cefpirom Linezolid / Vancomicină Macrolide

23 2B#AC,-',)-#)+#$%)-C(+9#$',"-'(D# EF! G*(*#)C,-')-# HF! AC,-')-#I*(*#&(C)%0+("#",8'J"8%# KF! AC,-')-%#I(%)8%,-%#)+#&(C)%0+("#",8'J"8%# LB#M%('&"%#)+#2L#\"#2GD# EF! G*(*#2L#\"X$'+#2G# HF! A+#2L#\"X$'+#2G#(%)%,-%#)+#'JC9"# AB#A'(')-%("$N)"9%#&')"%,-+9+"D# EF! KF! S.+,C)C.&(C."$D## "! 2S4T# "! L7UA# "! A',)%(# "! L<M# Score : 1, 2 or 3

comunitare IFI asociate îngrijirilor de s"n"tate

Neutropenic: Caspofungin Voriconazol Posaconazol

24 Terapia Infectiilor fungice invazive Carmeli-like 1 Carmeli-like 2 Carmeli-like 3 IFI comunitare IFI asociate îngrijirilor de s"n"tate IFI Nosocomiale Fluconazol Itraconazol Caspo (AI) Anidula (AI) Mica (AI) Voriconazol Posaconazol AMB Fluconazol Itraconazol Neutropenic: Caspofungin Voriconazol Posaconazol Non-neutropenic: Caspofungin Anidulafungin Micafungin Voriconazol Posaconazol

25 ±Sepsis Pacientul TI Sepsis Sever Soc septic Non-neutropenic F 0 + factt de risc Neutropenic F 0 PMN<1000/mm 3 PCT <1 >1 AB + AF cu spectru ultralarg 72h Dezescaladare Completa * 1,3-!-D-glucans Neg 1,3-!-D-glucans Poz AB AB + AF

26 Sugestii în vederea ini#ierii TAF în TI de la practica curent" la ghiduri 2013 Suspected IFI - Carmeli-like Score G')]B#0%#("$)#&-B# 2$&B#T&&# G')-B#0%#("$)#&-B% A',0"0'#$&&B#!U=#^2SF#X#AT7#^ASSSF# A'(.%9"P9"[%#E#X#H# G*(*#'JC9"#',-%("C(# G*(*#0'-%#9C)'9%# %&"0%."C9C_")%#0%## AB#,C,@'9Q")',$# A'(.%9"#P9"[%#H#$'+#K#?e&+,%(%#9'#'JC9# 4'-%#9C)'9%#%&"0%."C9C_"%## 0%#=#9'#G9+)C,'JC9#'#AB#'9Q")',$X#,C,@'9Q")',$# A'(.%9"@9"[%#E# G*(*#)C,-')-#)+# $%)-C(+9#$',"-'(# GaW#bcc._XJ"# A'(.%9"@9"[%#H## S,I%)R""#'$C)"'-%# :,_("d"("9c(#0%# $*,*-'-%#!AT7##!2V4#!<SA2#!U=#!7UT`# b0)>b&7+108&)#.% AT7#X#2V4#X#<SA2#X#!U=``## Neutropenic AT7#^2SF#!U=#^LSF# 2GLaA#^LSF# <SA2^LSSF# a?()$#$0s(%010-(1#)*#()(%2&9&1(% ** Vezi criteriile de diferentiere

27 Criteriile de diferenhere Cancidas Micafungin Anidulafungin Singura cu indicahe in aspergiloza Singura cu indicahe in terapia de prima intenhe Spectrul cel mai larg in vitro 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

28 Scorul de agresivitate bacteriană şi corespondenţa cu scorul Carmeli

29 T)C(#0%#'_(%$"8"-'-%#'#$-'/9C)C)+9+"# 20%(%,R'# T)C(#0%#'_(%$"8"-'-%# K# H# E# c# c% icg# kcg# fk5ejg# <=T2# <=T2 <TT2 <=T2 <TT2 <TT2# hfg# bfg# ih5jhgg# L"C/9.#

30 AC(%9'R"%D#T)C(+9#0%#'_(%$"8"-'-%#'# T)C(#0%#'_(%$"8"-'-%# K# H# E# c# <=T2# <=T2 <TT2 <=T2 <TT2 <TT2# MX!Xa# MX!Xa Ue' MX!Xa Ue' Ue'# K# H# E# T)C(+9#A'(.%9"# dj%d&#.08,()#)b%vjv().0'#.#)5b%eje#)&s0,#$b%t_(j%t_(.#,#)5%

31 <','_%.%,-+9#)'-%-%(+9+"#8%,C$# )%,-('9# T)C(#0%#'_(%$"8"-'-%# K# H# E# c# <=T2# <=T2 <TT2 <=T2 <TT2 <TT2# l,9c)+"(%'#a!a# l,9c)+"(%'#a!a# <%,R",%(%'#A!A## :,#I+,)R"%#0%# (%J+9-'-+9#79%eS4# <%,R",%(%'#A!A## :,#I+,)R"%#0%# (%J+9-'-+9#79%eS4# <','_%.%,-+9#A!A#

32 Cam așa ceva...

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