More Insights from the 2015 Intensive Care and Critical Care Infection Symposium

Stefan Hajkowicz (@stefanhajkowicz), chief futurologist from the Australian Scientific organisation CSIRO, noted 7 “Megatrends” that will shape our coming world. Of particular relevance to ICU were “Planetary pushback”, the most obvious example being the development of antimicrobial resistance; “Porous boundaries” which seems to portend a more wholistic approach to problem solving, and the need to breakdown traditional “silo mentality” that is all too pervasive in hospitals; and “Doing more with less” suggesting we will have to become cleverer as resource limitations will increasingly affect our work. A podcast of a similar talk is available on Radio national (http://www.abc.net.au/radionational/programs/bigideas/megatrends-for-the-future/6520968)

Marin Kollef, from Washington University in St Louis, Missouri, spoke on the future of intensive care. Notable were the high rate of hospitals deaths now occurring in ICU, which is likely to rise in the future as the percentage of hospital beds that are in ICU increases to 20-30% of all beds. However Marin pointed out that bigger is not always better, and that increases in the number of people treated in ICU is not always associated with better outcomes- we will need to better define who really benefits from ICU care in the future. Echoing Stefan’s creed of “Doing more with less” Marin highlighted the increased use of nurse practitioners/physician extenders in ICU. Increased use of Protocols (including nurse led protocols) and use of telemedicine are also emerging as growth areas. Technology will obvisously be important in diagnostics, but also potentially in coping with the massive increase in information, as concepts like “cognitive computing” (such as IBM’s WATSON) come to be applied to clinical questions.

Marin also spoke about the emergence of drug resistance in Gram negatives, and emphasized the need for prevention and effective stewardship, but also pointing out how hard this could be to acheive in real life. It was nice t hear some good news finally emerging around new agents in the pipeline, including a push for targeted therapies for specific bacteria, such as Eravacycline for Acinetobacter baumannii and other resistant enterobacteriaceae. Also noteworthy was a comment that adding gentamicin can drammatically increase sensitivity to fosfomycin, though more clinical data is required.

Lindsay Grayson, head of Infectious diseases at the Austin Hospital in Melbourne, was more downbeat about resistance in gram positives, noting the recent emergence of VanA VRE in a number of hospitals in Melbourne, with significant spillover from haematology and renal wards into ICU. He expressed a view that hVISA may be underdiagnosed, and possibly searched for in all serious MRSA infections. And will the future be Linezezolid DEPENDENT Staph epidermidis? An infection prevention highlight was a new mantra of “One bum per toilet” in hospitals!

Finally Jason Roberts (@jasonroberts_pk) from the Royal Brisbane hospital emphasized the difficulty of getting dosing right in the ICU setting, with altered fluid balance, hyperdynamic circulation, BMI, organ dysfunction (esp renal or hepatic) and artificial organ support all altering the PK/PD of antimicrobials. An important but overlooked problem in surgical patients was the loss of antibiotics through high volume drains – beware the patient with drain output over 500ml per day, they may well be losing a lot of their antibiotic as well. He firmly believes that therapeutic drug monitoring is the only way to accurately dose some of these patients, though clinical data to support its use is still a work in progress.