Rational Antibiotics: Practice & only practice
Mohit SahniConsultant Neonatologist, Neonatal Cardiologist
Director Division of Neonatology & Academics, Institute of Child Health
Nirmal Hospital Pvt. Ltd., Surat
Rational Antibiotics: Practice & only practice
Mohit SahniConsultant Neonatologist, Neonatal Cardiologist
Director Division of Neonatology & Academics, Institute of Child Health
Nirmal Hospital Pvt. Ltd., Surat
1960 1970 1980 1990 2018
Use of Technology &Confusion
What's make the man perfect?
Practice makes the man Perfect
Practice
Scenario…• Preterm 29+2 weeks
• Primi LSCS
• Leaking 14 hrs Fetal distress
• Male BW: 1.26 Kg
• 1 dose of steroids given
• Cried immediate
• No major resuscitation
• Shifted to NICU
Scenario…NICU course
• On admission started HFNC
• Feeds
• 1st line antibiotics: (Piperacillin +
Tazobactum)& Amikacin ? (evidence)
Evidence…
Risk Factor Based score
Risk Factor Score
IP vaginal Examination > 3 6
Clinical Chorioamnionitis 6
BW<1.5 Kg. 3
Male Gender 3
No intrapartum antibiotics 2
Gestation <30 wks. 2
Mainly for asymptomatic EOS
0-6 No antibiotics, Monitor carefully=/> 7 Prophylactic empirical antibiotic
The PGI NICU Handbook of Protocols, 4th Edition 2010
Scenario…NICU course• On admission started HFNC • Feeds• 1st line antibiotics: (Pipracillin + Tazobactum)& Amikacin• Tolerating feeds well • D4 started apneas• Feed intolerance • CBC: PLts from 2.4 lacs to 1.4 lacs, CRP 13
• On Admission Bld C/S was normal• Antibiotics 2nd line Piperacilin changed to Meropenem and
Amikacin continued
Scenario…• D6 Increase Apnea episodes
• CBC: PLts 24 K CRP: 46
• Blood C/S repeated: @
• Antibiotics 3rd line Meropenem Cont. and PolymixinB added instead of Amikacin
• On CPAP for 6 days
• D 9 Blood C/S: report
Burkholderia Cepacia
Sensitive to:• Ceftazidime-
(Intermediate)• Levoflox• Co trimoxazole• Tigycycline• Minocycline
How to treat Any Evidence ?
• NO protocol in hospital for starting antibiotics in newborns
• Different physician different approach
• Mismatch between blood reports and antibiotics usage
Guidelines Neonatal sepsis 2017
• Treatment should be initiated with broad-spectrum antibiotic cover appropriate for the prevalent organisms for each age group
• Early-onset sepsis: cited as example: benzylpenicillinplus gentamicin (from NICE guidelines) OR ampicillin plus gentamicin or cefotaxime Note: to cover group B streptococci (GBS) and gram-negative bacilli
• Only very limited reliable data on antimicrobial susceptibility are available from Asia, Latin America and Africa.
Antibiotic regimens for suspected early neonatal sepsis___ 2010• Authors' conclusions There is no evidence from randomised
trials to suggest that any antibiotic regimen may be better than any other in the treatment of presumed early neonatal sepsis. More studies are needed to resolve this issue.
Antibiotic regimens for suspected late onset sepsis in newborn infantsCochrane Systematic Review - Intervention Version published: 20 July 2005
• Authors' conclusions There is inadequate evidence from randomised trials in favour of any particular antibiotic regimen for the treatment of suspected late onset neonatal sepsi
• Evidence and Recommendations: – EOS or LOS as the bacterial and sensitivity profile in India seems to be
is similar in both situations.
– Policy for community acquired sepsis, Ampicillin + Gentamicin/Amikacin (empirical)
– If evidence of meningitis: Add Cefotaxime
– Nosocomial sepsis It is not possible to suggest a single antibiotic policy for use in all newborn units.
– Every newborn unit must have its own antibiotic policy based on the local sensitivity patterns and the profile of pathogens.
Evidence…
Nirmal hospital –(2013 – 2019)
10%
90%
positive
negative
Total Blood C/S send 530Positive 54
Organisms (Nirmal hospital) Jan- Oct 2013
39%
20%
15%
6%
6%
6%
4% 2 2% 2%
Kleib sp
CONS
Pseudomonas sp
Acinetobacter
enterococcus
E. coli
enterbacter
Staph aureus
Strept
Serratia
Organisms Nirmal Hosp. Jan – Nov. 2019
47%
29%
11%
8%5%
Culture Positive
Kliebsiella pneumonia
Burkholderia Cepacia
E.Coli
Staph.Hemolyticus
Acinatobacter Baumanni
Klebseilla sensitivity NH (Jan –Oct, 2013)
9
57
95
71
66
71
9
62
66
91
95
86
76
47
95 95
0
10
20
30
40
50
60
70
80
90
100
Series1
Klebseilla sensitivity NH (Jan – Nov 2019)
0% 20% 40% 60% 80% 100% 120%
Fosfomycin,Minocyclinie
Chloramphenicol
Poly B,Colistin
Tigicycline,Amikacin,Tobramycin,Gentamycin
Levoflox,Imipenem,Ciproflox
Nalidixic Acid
Meropenem,Doripenem
Cefuroxime,Ceftriaxone
Klebsiella Pneumoniae Sensitivity Pattern
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Levofloxacin,Doripenem
Chloramphenicol
Minocycline
Meropenem
Cotrimoxazole
Tigecycline
Burkholderia Cepacia Sensitivity Pattern NH Jan – Nov 2019
Pathogen specific antimicrobial resistance pattern (NORI hospital)
Organism Ampicillin Gentamicin Pipercillintazobactum
Meropenem
Klebsiella 70.6% 35.3% 41.2% 23.6%
Acinetobacter 100% 50% 50% 50%
E.Coli 100% 0 0 0
Pseudomonas 50% 50% 0 0
Burkholderia 100% 100% 100% 100%
Scenario…• After Blood C/S report
– Levofloxacin
– Ceftazidime (intermediate)
• After 2 days of change
• Low flow
• Tolerating feeds
• PLts 1.3 till day before yesterday from 23 thousand
Scratch your (A..) Brains
Antibiotics stewardship