Philippe Montravers, MD, Ph.D. Anaesthesia and Surgical ICU CHU Bichat Claude Bernard ...

51 Pages·2017·1.5 MB·English

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Philippe Montravers, M.D., Ph.D.
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Anaesthesia and Surgical ICU
C CHU Bichat Claude Bernard
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Assistance Publique-Hôpitaux de Paris
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University Paris VII Denis Diderot Sorbonne Cite
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Paris, France
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cIAI, complicated intra- abdominal infection; ICU, intensive care unit.
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Speaker for Astellas, Astra Zeneca, Basilea, Cubist,
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Gilead, MSD, The Medicines Company and Pfizoer

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Advisory board membership for Astellas, Astra Zeneca,
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Cubist, MSD, Parexel, Tetraphase, The Medicines
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Company and Pfizer
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We suggest:
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• ASPs develop facility-specific clinical practice guidelines coupled with a

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dissemination and implementation strategy
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• ASPs implement interventIions to improve antibioutic use and clinical
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outcomes that target patients with specific infectious diseases syndromes
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• We recommend that hospitals implement PK monitoring
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• Antibiotic stewardship interventionsb designed to reduce the use of
antibiotics
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• The use of strategies (eg, stop orders) to encourage prescribers to perform

routine review of an tibiotic regimens to improve antibiotic prescribing

• ASPs implement guidelines and strategies to reduce antibiotic therapy to

the shortest effective duration

Barlam TF et al. Clinical Infectious Diseases® 2016;62(10):e51–e77
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Empirical antibiotic therapy
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Monitoring of anti-infective agents
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De-escalation and definitive therapy
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Use of biomarkers
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Duration of anti-infective therapy

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Empirical antibiotic therapy
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Monitoring of anti-infective agents
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De-escalation anM d definitive therapy
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Use of biomarkers
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Duration of anti-infective therapy
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Primary peritonitis i
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Diffuse bacterial infection (usually single organism) without loss of integrity of the
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gastrointestinal tract, typically seen in cirrhoetic patients with ascites or patients with
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an indwelling peritoneal dialysis catheter

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Secondary peritonitis
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 Acute peritoneal inflammatIion resulting from loss of integruity of the gastrointestinal
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tract. Depending on the underlying pathology, it can be infectious or sterile
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Community-acquired IAIs
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Healthcare-associated IAIs
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Hospital-acquired IAIs
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Nosocomial
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Postoperative
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Tertiary peritonitis

Recurrent infection of the peritoneal cavity that occurs >48 hours after apparently
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successful and adequate surgical source control of secondary peritonitis

IAI, intra-abdominal infection.
WeigeltJ. ClevClinJ Med2007;74 (Suppl4):S29–37.
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Key micro-organisms of the bowel flora
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Cocci
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Bacterial anaerobic flora (Streptococci spp, Peptostreptococci spp…)
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Bacilli
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(Bacteroides spp, Clostridium spp, Fusobacterium spp, …)
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Streptococci
Bacterial aerobic flora t
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(E. faecalis, E. faecium, …)
Gram-positive M
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Staphylococci
(S.a aureus)
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Enterobacteriaceae
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(E coli, Klebsiellaspp, Enterobacter spp, Proteus spp, Serratia spp…)
Gram-negative bacilli
 Non-fermenting Gram-negative bacilli
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Yeasts

Fungal flora
(C. albicans, C. glabrata,…)

Other fungi

Adapted from: SolomkinJ, et al. ClinInfect Dis 2010;50:133–64; 2. SartelliM, et al. World J EmergSurg2013;8:3; 3. Montravers P, et al.
AnaesthCritCare Pain Med2015;34:117–30; 4. EckmannC. Chirurg2016;87:26–33; 5. SartelliM, et al. World J EmergSurg2016;11:33.
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A retrospective analysis on the Surviving Sepsis Ciampaign database to evaluate
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the relationship between timing of antibiotic administration
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and mortality
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165 ICUs in Europe, the United State s, and South America
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A total of 28,150 patients with severe sepsis and septic shock, were evaluated
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00- à1 1 H Hr 11- à2 2 H Hr 22 à- 33 HHr 33 à- 44 H Hr 44 à- 55 HHr 55- à6 6 HHr >> 66 HHr

Délai de l’antibiothérapie (heures)

Antibiotic timing (Hr)

Ferrer R, et al. CritCare Med 2014;42:1749–55.
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Delayed in first antibiotic administration associated with increased
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in-hospital mortality L
Linear increase in the risk of mortality for each hour delay r
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Adjusted hospital mortality odds ratio and probability of mortality for time to antibiotics based on a
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generalised estimating equation population averaged logistic regression model
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Odds ratio D deéacthèsrate
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DAénlatii bdieo ttricai tteimmienngt ((hHeur)r e s )

Ferrer R, et al. CritCare Med 2014;42:1749–55.
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Retrospective study
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Three countries
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5,715 patients with septic shock
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Pulmonary infection 1381 <.0001
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IAI 1041 <.0001
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0 20 40 60 80 1 10 100
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Inappropriate AB %
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Bowel perforation/peritonitis Postoperative bowel Intra-abdominal abscess
perforation/anastomotic dehiscence

Kumar A, et al. Chest 2009;136:1237–48.