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    Robert Sinto, SP - PD-Single Vs Combination AB Sepsis

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    Olivia Dwimaswasti
    The document discusses the use of single versus combination antibiotics in sepsis treatment. It analyzes evidence from various studies on using empirical and definitive combination antibiotics in septic patients, particularly those with septic shock, specific infections, or drug-resistant pathogens.

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    Robert Sinto, SP - PD-Single Vs Combination AB Sepsis

    Uploaded by

    Olivia Dwimaswasti
    7 views37 pages
    The document discusses the use of single versus combination antibiotics in sepsis treatment. It analyzes evidence from various studies on using empirical and definitive combination antibiotics in septic patients, particularly those with septic shock, specific infections, or drug-resistant pathogens.

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    2. Robert Sinto,Sp.PD-Single vs Combination AB Sepsis

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    The document discusses the use of single versus combination antibiotics in sepsis treatment. It analyzes evidence from various studies on using empirical and definitive combination antibiotics in septic patients, particularly those with septic shock, specific infections, or drug-resistant pathogens.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    7 views37 pages

    Robert Sinto, SP - PD-Single Vs Combination AB Sepsis

    Uploaded by

    Olivia Dwimaswasti
    The document discusses the use of single versus combination antibiotics in sepsis treatment. It analyzes evidence from various studies on using empirical and definitive combination antibiotics in septic patients, particularly those with septic shock, specific infections, or drug-resistant pathogens.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 37

    Robert Sinto

    Birth place, date : Jakarta, 21 Juni


    E-mail : [email protected]
    Formal education
    2008 : Medical Doctor, Universitas Indonesia, Jakarta
    2014 : Internal Medicine Specialist, Universitas Indonesia, Jakarta
    2018 : Tropical and Infectious Diseases Consultant, Universitas Indonesia, Jakarta

    Informal education
    2014 : Sepsis, France
    2015 : Clinical training on Transplant-Oncology-Immunocompromised Host Infectious
    Diseases, Singapore General Hospital, Singapore
    2016 : Transplant Infectious Diseases Course, The Transplant Society, HongKong
    2017 : Antimicrobial Stewardship Training Course, Singapore
    2018 : Sepsis, Bangkok
    2019 : Medical Mycology Training Network, Asia Fungal Work Group, Malaysia

    Workplace & Position


    2016-now : Department of Internal Medicine, FM Universitas Indonesia-RS Cipto Mangunkusumo
    (Medical & academic staff, member of antimicrobial stewardship committee)
    2015-now : Indonesian College of Internal Medicine (Officer)
    2014-now : The Indonesian Society of Tropical Medicine and Infectious Diseases (Officer)
    Single versus Combination of
    Antibiotics in Sepsis

    Robert Sinto
    Division of Tropical and Infectious Diseases
    Department of Internal Medicine
    FM Universitas Indonesia - Cipto Mangunkusumo National Hospital
    2019
    • Measure lactate level
    • Obtain blood cultures prior to antibiotics
    • Administer broad - spectrum antibiotics
    • 30 mL/kg of intravenous crystalloid for hypotension or lactate
    >= 4 mmol/L
    • Vasopressors to achieve MAP >=65 mm Hg
    [email protected]

    DOI: 10.1097/CCM.0000000000003119.
    Effect of Antibiotics on Survival from Sepsis

    [email protected]
    Purpose on AB Use

    Prophylaxis Empirical Definitive

    [email protected]
    ▪ Empiric broad-spectrum therapy with one or
    more antimicrobials for patients presenting
    with sepsis or septic shock to cover all likely
    pathogens (including bacterial and potentially
    fungal or viral coverage).

    [email protected]

    Crit Care Med 2017;45:485-539.


    Single VS Combination of AB
    POTENTIAL ADVANTAGES POTENTIAL DISADVANTAGES
    • Broaden bacterial spectrum • Adverse effects.
    coverage. • Increased cost.
    • Prevention of emergence of • Possible antagonism between
    resistance during therapy. specific drug combinations.
    • Additive or synergistic effect • Propagation of antimicrobial
    of the antimicrobials. resistance.
    • C. difficile infection

    Antimicrob Agents Chemother 1984;25:534–6. Am J Med 1986;80:30–4.


    Rev Infect Dis 1982;4:294–301. Infect Control Hosp Epidemiol 1996;17:222–6.
    Int J Antimicrob Agents 1999;11:7–12. Chemioterapia 1985;4:110–2.
    [email protected] Am J Med 1986;80:126–37.
    Should We Use
    Empirical Combination of AB
    in All Septic Patients?
    [email protected]
    [email protected]

    Crit Care Med. 2010;38:1-14.


    [email protected] Crit Care Med. 2010;38:1-14.
    [email protected]

    Crit Care Med. 2010;38:1-14.


    Meta-regression Analysis of Combination AB

    Non-RCT
    N=44

    RCT
    N=12

    [email protected]

    Crit Care Med. 2010;38:1-14.


    Should We Use
    Empirical Combination of AB
    in All Septic Shock Patients?
    [email protected]
    [email protected]
    When Should We Use
    Empirical Combination of AB
    in non-Septic Shock Patients?
    [email protected] CID. 2004:39:1267-84.
    [email protected] CID. 2007:44:S27-72.
    MRSA CA-Pneumonia
    • Addition of empiric anti-MRSA is
    recommended for severe CAP:
    – Necrotizing or (multilobar) cavitary infiltrates
    – Empyema
    – Classical cases: previously young healthy adult, preceding ILI,
    hemoptysis, high fever, leukopenia, hypotension

    Liu C, et al. CID. 2011;52(3):e18–e55.


    Rubinstein W, et al. CID. 2008;46:S378-85.
    Nathwani D, et al. JAC. 2008;61:976-94.
    [email protected]
    CID. 2016:63:e61-111.
    [email protected]
    Empiric antibiotic therapy for suspected VAP:
    a systematic review and meta-analysis of
    randomized trials

    [email protected]

    Crit Care Med. 2008;36:108–17.


    Suggested antibiotic regimens
    for treating IAIs in the Asian region

    Community-acquired
    Mild to moderate

    Severe

    Health care-associated
    Mild to moderate

    Severe

    [email protected]

    Kurup A, et al. Annals of Medicine and Surgery. 2014;3:85-91.


    Suggested antibiotic regimens
    for treating IAIs in the Asian region

    [email protected]

    Kurup A, et al. Annals of Medicine and Surgery. 2014;3:85-91.


    Proposed antibiotic regimens for initial empirical treatment
    infective endocarditis in acute severely ill patients

    [email protected]

    European Heart Journal. 2015;36:3075-3123.


    Purpose on AB Use

    Prophylaxis Empirical Definitive


    When Should We Use Definitive
    Combination of AB in Septic Patients?
    Does combination antimicrobial therapy reduce
    mortality in Gram-negative bacteraemia?
    A meta-analysis

    [email protected]
    Does combination antimicrobial therapy reduce
    mortality in Gram-negative bacteraemia?
    A meta-analysis

    Analysis of studies done before 1990 Analysis of studies done in or after 1990

    Analysis of prospectives studies Analysis of retrospectives studies

    Analysis of studies comparing combination anti-infective


    therapy with monotherapy for reducing mortality of Pseudomonas spp bacteraemia
    [email protected]
    [email protected]
    [email protected]
    Combination Antimicrobials Therapy
    for Bacteremic Pneumococcal Infection

    ▪ Cover for atypical pathogens, unsuspected


    polymicrobial infections, antibiotic resistant infections.
    ▪ Synergistic effects.
    ▪ Anti-inflammatory immunomodulatory effects of the
    macrolides.
    [email protected]

    Feldman C, et al. Current Opinion in Infectious Diseases 2009;22:137–142.


    Combination Antimicrobials Therapy
    SSC 2012: Guideline recommendations

    ▪ Patients with difficult-to-treat, MDR pathogens


    (Acinetobacter or Pseudomonas bacteremia)
    ▪ Severe infections associated with respiratory
    failure and septic shock (Pseudomonas
    bacteremia)
    ▪ Septic shock from bacteremic Streptococcus
    pneumoniae
    [email protected]

    Crit Care Med 2013;41:580-637


    [email protected]

    CID. 2012:55:943-50.
    [email protected]

    CID. 2012:55:943-50.
    Conclusion:
    Combination of AB in Sepsis
    • Empirical: • Definitive:
    • Septic shock with: – MDR pathogens
    • Neutropenia
    • Unknown source – Pseudomonas
    • Meningitis bacteremia
    • CA-pneumonia – Pneumococcal
    • HA-pneumonia with bacteremia
    respiratory failure +/-
    shock
    • VAP
    • Certain cases of cIAI
    [email protected] • Endocarditis, ….

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