Battling Against Resistant Pseudomonas Infections in the ICU - Episode 9

Exploring Appropriate Treatment Protocols for <i>Pseudomonas</i> Infections

Peter L. Salgo, MD; Marin Hristos Kollef, MD; Jason Pogue, PharmD, BCPS-AQID; Andrew Shorr, MD; and Yoav Golan, MD, share insight on appropriate treatment protocols regarding Pseudomonas infections, specifically those concerning the value of treating a patient versus the safety of other patients.

Peter L. Salgo, MD: Let’s talk about treatment protocols and the diagnostic protocols we’ve got. Who are you most concerned about—let’s limit this to the ICU to start with—developing a multidrug-resistant infection, of all comers, in the ICU?

Marin Hristos Kollef, MD: I think we’ve already alluded to that. These are individuals who have host factors. They’re oftentimes immune suppressed. They may have other host factors as well in terms of age and trauma, etc. They also have the issue of the bug. At least in an institution like ours, we have a very good informatic system. We have a 13-hospital system. We can actually track patients who have higher colonization or infection with particular organisms, so we know when they come back. And that becomes important from the standpoint of picking an empiric antibiotic regimen. We know if someone has been colonized with an XDR [extensively drug-resistant] Pseudomonas, which does happen in our intensive care unit. The other thing is that the drugs are available. So, I think it’s a combination of all those things. But I would say that by far the 2 most important factors are prior antibiotic exposure and host factors, a combination of those 2.

Peter L. Salgo, MD: If you had somebody in the ICU who you knew had multidrug-resistant Pseudomonas and you send them to the floor and they came back, it’s the old joke: “Doc, what have I got?” If you had it before, you’ve got it again, but de novo. If somebody shows up in your ICU, I have a sense that you didn’t perform across the board culturing of all these folks.

Marin Hristos Kollef, MD: Well, no. What I think I said earlier is that I’m not in favor of just getting random cultures.

Peter L. Salgo, MD: Fair enough.

Marin Hristos Kollef, MD: There has to be an indication for getting the culture. As an example, we had a recent individual—not to get into a lot of details—with a gunshot wound, long-term acute care, and G2 tracheostomy. This individual has multiple decubiti. We know, because he’s been in our intensive care unit before, that he has ESBL [extended-spectrum beta-lactamases] in his bladder and he’s colonized with essentially an extremely drug-resistant Pseudomonas in his airway. And so, when he came back to us, we knew what we were likely dealing with and we could then go to one of the new drugs in that setting for empiric therapy. So, I think knowing the host, knowing the pathogens, and knowing the profile of the case becomes very important.

Jason Pogue, PharmD, BCPS-AQID: I just want to build on that a little bit. I want to echo what you said because I think it’s so important. There are ways to track these people when they come back. Marin has a really nice publication, and they have their own EMR [electronic medical record] in Barnes-Jewish Hospital and they used it to be able to do that. But other infection control folks are normally doing this, and there’s no reason that antimicrobial stewardship programs can’t tap into that to identify these patients when they come back, investigate those patients, and get them on appropriate therapy faster.

Peter L. Salgo, MD: Do you see an inherent contradiction between a physician’s responsibility to his or her patient and his or her responsibility to the entire hospital environment?

Andrew Shorr, MD: Why narrow it to the hospital environment?

Peter L. Salgo, MD: To the world. Let’s do that.

Andrew Shorr, MD: I think it’s important to realize that antimicrobials are the only class of drugs where my practice style can hurt someone else’s patient. If I misuse a statin, I may cause some myositis in the patient in front of me, but it’s not going to hurt the patient next to them. If I misuse antimicrobials, either over or under, I can leave a little bomb for the next patient down the hall to walk on. That’s why I think our whole approach in how we prescribe antibiotics and how we develop antibiotics is farcical, because you never say to your police station or your fire station, “Well, we’re only going to pay when we use you.” We say that it’s our community obligation to have a police station and a fire station that we can call on at times of emergency, and it’s a community obligation. We don’t think that way about antibiotics, at the policy level nor at the institution level.

Yoav Golan, MD: I think you’ve touched a very important point. As an infectious disease representative on this panel, I can tell you that very often, we are considered to be the antibiotic police. I think you are right. I think that clinicians who are primarily responsible for a patient would sometimes like to use whatever they can for the patient because 1, they don’t know the environment; and 2, they sometimes don’t face the consequences of that as someone who’s running the entire system. I can tell as an infectious disease clinician who stops antibiotics and who starts antibiotics, I have to write a very short note when I give someone an antibiotic. I have to write a very short note to explain why I don’t want an antibiotic because the tendency is just to treat and treat and treat. So, I would say to physicians, first of all, understand your infectious disease clinicians. They’re trying to help you treat your future patients and not just your current patients. But it’s really important that you understand that the antibiotics are working.

Peter L. Salgo, MD: Let me give you a quote. One is from the doctor who says, “I don’t care about the next patient. My patient’s sitting right here and he’s dying, give me the gosh darn drugs.” And you would say?

Yoav Golan, MD: I would say yes. I would say yes if your patient is dying, if you don’t know what’s killing the patient and if you come with an aggressive approach. We already talked about the commonality of risk factors. We talked about your balance cultures and we talked about how important it is to know about the bacteria your patient is carrying or has been infected with in the past, for the future. We had a patient who came with 2 different consecutive bacteremias with Pseudomonas that was only susceptible to 1 antibiotic, piperacillin/tazobactam. She came septic into the ICU. We thought she had pneumonia. It was very early in the treatment. We gave her piperacillin/tazobactam in combination with ciprofloxacin and vancomycin.

She ended up having bacteremia with ESBL-producing E.coli [Escherichia coli]. So, I would agree with that. The problem is that this approach of being very aggressive and upfront is being used very often when it’s not necessary. And for how many patients who use antibiotics, are more dying? For how many patients are more safe? There are a few who are dying, but more patients are stable. You have to have this balance.

Jason Pogue, PharmD, BCPS-AQID: Yes, I would just add to that. We all want the same thing. We all want that patient to get better. We just need to have a rational discussion about what that patient needs based off of how sick they are and what their history is. Even for that given patient, I know that if I add vancomycin to his piperacillin/tazobactam and he doesn’t need it, that increases the chance that he’ll have an adverse drug reaction that can lead to all kinds of problems in that situation.

Peter L. Salgo, MD: That’s critical. It’s not just the next patient down the line, but it’s this patient sitting right here. If you do it wrong, this patient is going to get a resistant infection.