ANALYSIS OF APPROPRIATENESS OF RESERVE/RESTRICTED ANTIMICROBIALS USAGE IN THE ADULT ICU PATIENTS OF DIFFERENT DEPARTMENTS OF THE HOSPITAL AS A PART OF ANTIMICROBIAL STEWARDSHIP PROGRAM- A PROSPECTIVE OBSERVATIONAL STUDY.

Abstract

In the past few years there has been a steep rise in the antimicrobial resistance (especially to carbapenems) globally which has resulted in antimicrobial therapy failure leading to increase in patient morbidity and mortality rates. The limited effective available reserve/restricted antimicrobials surveillance has become important to ensure their judicious use and prevent their resistance development. Therefore, the hospital has Antimicrobial Stewardship Program which monitors the appropriateness of usage of the last resort Reserve/Restricted antimicrobials being prescribed to the patients. Method: Prospective data of 320 ICU admitted adult patients who were prescribed Reserve/Restricted antimicrobials was collected in Restricted Antimicrobial Usage Form during 6 months period from different medical and surgical specialties to monitor the appropriateness of the restricted antimicrobials prescribed empirically in accordance to Indian Council of Medical Research (ICMR) treatment guidelines for antimicrobial use in common syndromes 2022. Result: In our study maximum number of patients admitted in ICU were male (63%) and mostly belonged to 51-60 year followed by 61-70 year of age group. Out of 320 admitted patients, Type 4 category (very high risk) were 47 %, Type 3 (high risk) were 44%, Type 2 (moderate risk) were only 9 % and Type 1 (low risk) were none. Patients were prescribed restricted antimicrobials empirically (71%) and definitively (29%).  Patients were found to have infection in lungs (34%) followed by intra-abdominal (25%) and renal (25%) then central nervous system (14%), musculoskeletal system (9%), blood (8%) and skin (7%). The top five intermingled clinical reasons for giving empirical restricted antimicrobials were high Total Leucocyte Count (68%), ventilator support (41%), comorbidities (diabetes, hypertension, asthma, cancer, kidney failure, liver failure) (35%),  sepsis/septic shock (26%) and invasive lines (17%).To treat gram negative infections intravenous administered restricted antimicrobials Polymyxin B was given to 129 patients (40 %), Tigecycline to 45 patients (14%), Ceftazidime Avibactam + Aztreonam to 39 patients (12%), , Colistin to 35 patients (11%), Ceftazidime Avibactam to 20 patients (6%), Minocycline to 10 patients (3%), and Fosfomycin to none and to treat gram positive infections Linezolid was given to 64 patients (20%) followed by Vancomycin to 38 patients (12%) and then Daptomycin to 3 patients (1%). Conclusion: We found that Type 4 and Type 3 patients altogether constituted 91% but 71% patients received restricted antimicrobials empirically and in appropriate doses as prescribed by the ICMR 2022 guidelines to cover the Extensive drug resistance (XDR) as well as Difficult to treat (DTR) A. baumannii and K. pneumoniae and Multi drug resistance (MDR) E. Coli, P. Aeruginosa, Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistant enterococci (VRE) organisms prevalent in the hospital ICUs. The complex critical patients with very high-risk/high risk were managed well within timelines with limited rapid microbial diagnostic methods with varied Pharmacokinetic / Pharmacodynamic index parameters of available limited effective restricted antimicrobials influenced by patients’ dynamic pathophysiology changes and expected adverse drug reactions based on patient clinical diagnosis. Highest level of wisdom was implied while choosing the antimicrobial to be given empirically against resistant bugs in correct loading and maintenance doses delivered via prolonged /continuous infusions if required for dose optimization in order to reduce the patient morbidity and mortality. Newer rapid microbial diagnostic tests and newer effective and safe antimicrobials are need of the hour to shoot down the resistant hospital bugs and improve the health and survival of the critically ill patients.