Mohit Sahni - Neocon2019 · Mohit Sahni Consultant Neonatologist, Neonatal Cardiologist Director Division of Neonatology & Academics, Institute of Child Health Nirmal Hospital Pvt.

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