Battling Against Resistant Pseudomonas Infections in the ICU - Episode 10

Core Challenges in <i>Pseudomonas</i> Treatment Protocol

Marin Hristos Kollef, MD; Andrew Shorr, MD; Peter L. Salgo, M; and Jason Pogue, PharmD, BCPS-AQID, identify the core challenges present in the treatment protocol of Pseudomonas infections, such as nuances with the Centers for Medicare and Medicaid Services or end-of-life care.

Marin Hristos Kollef, MD: There are 2 points I’d like to make. One is that oftentimes, hospitals like to take the easy route. Instead of really getting in the trenches and saying, “Yes, this is an infected patient” or “This is not; we should stop antibiotics,” they may say, “OK, we’re going to restrict certain drugs and we’re not going to restrict others.” That’s the backbone of how things are done. That means that a drug like fluoroquinolone or piperacillin/tazobactam keeps getting used empirically when it probably isn’t necessary.

The other point I’ll make is that there are simply patients who come into the intensive care unit where we can’t help them. They’re going to die regardless. I think that becomes another area where stewardship may be helpful. Why use our best antibiotics in a situation where we know there’s really no hope for that person?

Andrew Shorr, MD: To echo that, one of the fascinating drivers of antibiotic abuse in United States hospitals right now are the sepsis quality markers from the Centers for Medicare and Medicaid Services. You can think CMS stands for that, but I think CMS stands for “Can’t Manage…” and you can figure it out.

Peter L. Salgo, MD: Stuff.

Andrew Shorr, MD: Exactly. They are saying, “Look, we want to see how quickly you’re getting antibiotics onboard, we want to look at your mortality rates for sepsis, and it’s an effort at coding and blah, blah, blah,” but what that means is any time someone is flagged “positive” for sepsis in your EMR [electronic medical record], all of a sudden these resources get mobilized and the first thing they do is give the patient antimicrobials when it was probably just heart failure; or, they were hypo-bulimic and they had a lactate from that; or, they were under dialyzed. The reflex is, because all of these syndromes look similar, “Since I’m getting dinged if I miss sepsis, we’re going to overtreat sepsis.”

Jason Pogue, PharmD, BCPS-AQID: They also choose which agents you get to use and they might be counterintuitive.

Andrew Shorr, MD: Absolutely. This is destroying the value and the logic based on evidence, because we have evidence in the infectious disease literature that clearly supports the tail-end stewardship approach. Don’t restrict it to the front end. But clearly, the benefit comes from restricting at the tail end, where you enforce shorter courses of therapy; restricting it at the front end just causes harm. We have that literature. Compare it with the literature that Marin has developed over a career really demonstrating that for severe infection in the case of septic shock, the number needed to treat to save 1 life with appropriate antibiotic therapy is 5. And we’re arguing about this. It’s absurd that policymakers up here are trying to make benchmarks in dashboards that are actually causing active harm to our patients. On this, I think pharmacy infectious disease and critical care would all concur.

Peter L. Salgo, MD: Even I, down in the trenches every day fighting with infectious disease, agree. How is that? What occurred to me as I was hearing all of you talking—we have to move on, but I do want to at least talk about this—is that we see critically ill patients. As they reach end-of-life decisions, we have less trouble it seems to me in cutting back on pressors, or stopping them, because everybody says pressors can be harmful. We have a lot more trouble stopping antibiotics, even if they’re not working.

Andrew Shorr, MD: I agree with you. People say, “Well, it’s just an antibiotic.”

Peter L. Salgo, MD: It’s just an antibiotic.

Andrew Shorr, MD: And Brad Spellberg, the gentle soul that he is, had a great editorial in The Journal of the American Medical Association about a year-and-a-half ago. He says that antibiotics are a life-sustaining therapy. If you wouldn’t offer vasopressors, why are you offering an antibiotic? Often, an antibiotic is actually worse than offering pressors because the antibiotic may prolong suffering, and at the same time create resistance that’s going to hurt someone else. And so, I totally embrace that. There are patients who come into my ICU where we are limiting therapy, with or without the family’s approval. That will include not only artificial nutrition but also antimicrobial therapy because it’s prolonging suffering. I think you’re seeing, at least in intensive care units, that attitude changing a lot. I think in oncology services is where I don’t see that happening at all yet.