Surgical Prophylaxis in the ICU

Hello everyone. Welcome to our new episode in the IVPN critical care list serve. Today we are happy to have Dr. Hibba Othman Shacker. Dr. Hibba graduated from the Faculty of Pharmacy at Alexandria University. She had formed a degree and she had an American board in critical care clinical pharmacy. She got hospital management diploma from Ainsham's University and the clinical research scholarship from Harvard University. She was the general supervisor of the clinical pharmacy units in Alexandria, Maine University Hospital from January 2017, Tidal January 2023. Now she is senior of the clinical pharmacy in critical care units in Alexandria, Maine University Hospital. She has many international publications in clinical pharmacy and different medical fields. Welcome Dr. Hibba. Welcome Dr. Hibba. Thank you for this kind indication. I'm happy to be with you today. Thank you so much to the visitors hours to have you today and to have you experience with us. Today, in short, a lot of Dr. Hibba is going to talk about the prophylactic use of antibiotics in ICU and its specific indications. So without further ado, I will start the podcast explaining how prophylactic antibiotics are used in the ICU and when it is appropriate and when it is not. So Dr. Hibba, I will start asking you. So what is the difference between prophylactic antibiotics and empirical use of antibiotics and definitive use of antibiotics? Okay. Prophylactic antibiotic is indicated to prevent infection. In patients have no current infection but they are at high risk as neutropinic patients, patients will go for surgery or patients with open wounds. Imperic antibiotic means there is an infection but the clinicians does not define the causative microorganism. So he tries to target the most suspected one, till torture results become available. Definitive therapy, where there is an infection and the organism is known by culture results and based on the culture sensitivity, the physician selects the most suitable antibiotics. The most suitable means the most suitable to this patient in particular, according to his age, comorbidities, kidney, liver function, allergy and so on. Brilliant. Then what are the risks of international use of prophylactic antibiotics in the ICU? In appropriate use, we'll lead to antibiotic resistance which is a currently challenge in many ICU use as we know. Also it increases the cost of care during hospital's day and increases the incidence of adverse events and drug interactions. So what's the, I think there's a critical role for the antimaheorbal stewardship interventions here so we can reduce the antimaheorbal stewardship in that concern, right? Yes, antibiotic stewardship in prophylaxis, focus on optimizing the selection, time, those duration of antibiotic to prevent infection and also to minimize adverse event and resistance. So I select selection of the appropriate antibiotic based on the procedure itself, the expected pathogen, the local resistance pattern or the antimigram. So it is really important. That's a lot of great. So in which ICU patients is prophylactic antibiotics use recommended and in whose it's not recommended? Okay. For example of prophylactic misuse, there is a misconcept that each patient admitted to ICU will catch infection for every intervention done in ICU needs adding antibiotics. But incubation IV or central line insertion or dream placement are not indication for prophylactic antibiotic. Even brain or head injury or closed fracture do not need antibiotic unless there is a penetration or an open wound. A prophylactic antibiotic is recommended in high risk group as both with pre or post surgical prophylaxes for neutropaneal patients, for HIV patients with low CD4 count for liver serotic patients with special criteria for some patients admitted with animal bites or with open wounds or open fractures. These patients will are at high risk of the infection. Great. So in those patients who are just having their neutropenia and who are the surgical patients, especially for the neutropenia first, for how long they are going to have the antibiotics use. Like I know this is a broad question but in general there's a certain duration that they have to get that prophylaxes or no. Yes. I mean by neutropenic patients and neutropenic patients without fever as the prior neutropenia is considered and existing infection and needs sympathetic and then definitive antibiotic. But here we are talking about neutropenic patients without fever those need prophylactic antibiotic. Only for the high risk group who is acute neutrophil count is less than 100 cells and the decline in neutrophils is expected to last for seven days or more. For which for this patient we can give quinoleons and flucon as well as antifungal and acyclover as antiviral till the neutrophil count exceeds 500 cells. And this situation we can stop, we can consider that acute neutrophil count is will be normal with what is going to the normal level and then we can amazing. So this brings us to the next question which you already touched and a bit to given that answer. So what examples of antibiotics used for the prophylaxes for neutropenic patient and for other population as well? Yes. For neutropenic patients, it's a hematology and oncology guidelines recommended quinoleons, acyclover, acyclover, acyclover, antiviral for these neutropenic patients. Generally for pre-opus operative prophylaxes, usually the syphazoline is the most commonly used antibiotic. In some cases in some GIT surgeries we may need to add, we may need an aerobic coverage so between the dissolved may be added. And broad spectrum antibiotics is usually unnecessary, unless in some few critical surgeries as the pancreatic surgery or some neurosurgery. And very few examples of critical surgery, surgeries where broad spectrum antibiotics is the business surgery. That looks great. And like for after doing the surgery, is there a recommendation to continue antibiotics? It's just for certain circumstances we do that. Yes, yes. It's not really a post-seurgical prophylaxes. It is recommended in some types of surgeries not all and usually one dose or just for 24 hour administration is enough. Except in some rare cases in some neurosurgery, may extend to 48 hours, not more. A prolonged duration is unnecessary. Amazing. So in what basis we choose the appropriate antibiotic agent? In what considerations we look at the patient so we may change our routine prophylactic antibiotic. Okay, usually we refer to the recent guidelines, like for surgical patients, it's our share guidelines. As we said for hematology or oncology patients, it's and the hematology organizations and American oncology society. And HIV for each IV patient, CDC guidelines plus the hospital antimicram for hospital acquired infection prophylaxes and the national surveillance if available for community. acquired infection for relaxes plus patient characteristics also should be considered as we said allergy age comorbidities concurrent drug administration kidney or liver functions all these factors should be put into consideration. So does also the colonization of the patient is gonna affect our choice right? The colonization may be put into consideration in in high risk group if there is a previous if there is a previous infection we may be we may put consideration we may put colonization into consideration but it is not for prophylactic if we have a sign of infection we may put colonization or previous cultural results into consideration to choose antibiotic but colonization alone unless there is no signs of infection does not need the antibiotics. So what examples of prophylactic misuse in the ICU setting? Yes as we said there is a misconception that each patient admitted to ICU will catch infection or every intervention we need antibiotic that as in a mechanical ventilation or IV insertion or this patient has central line or has a drain they are also again they are not in the not indication for prophylactic and there is a misconcept that this intervention may need prophylactic but this intervention do not need also I would like to focus on basal skull fracture many new surgeons prefer to add anti-brow spectrum antibiotic in basal skull fracture even with CSF leak unless this is not recommended by its or by other trauma or surgery guidelines unless there is a penetrating brain injury or open wound and this also need just 424 or or maximum 72 hours basal skull fracture and even with CSF leak do not need it does not need a prophylactic antibiotic. Thank you for all this informative answers so what does you take home masses or recommendations for people who are practicing in the ICU regarding that topic? Okay healthcare team members can prevent unnecessary antibiotic use by following guidelines by assess if the patient really meets the criteria of prophylaxis and prophylactic antibiotic in ICU should be limited to specific evidence-based situation and antibiotic decision should balance benefits against the risks. Thank you so much Dr. Hiba for that informative session and for all the information and the comprehensive answers and regarding that topic it was our pleasure having you. Chalala will be like continuing this podcast episodes in the future and thank you so much for giving us this lecture Dr. Hiba. And Chalala thank you Dr. Yed and thank you for IVP and team. I hope I can clearly outline when prophylactic antibiotic should and should not be used. Thank you thank you. Hiba. [BLANK_AUDIO]