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2016 • BOOK 1
INFECTION
CRITICAL CARE
Series Editors
Bradley A. Boucher, Pharm.D., FCCP, BCPS Curtis
E. Haas, Pharm.D., FCCP, BCPS
IMPORTANT INFORMATION ON THE RELEASE OF
CCSAP 2016 BOOK 1 INFECTION CRITICAL CARE
TESTING
BCCCP test deadline: 11:59 p.m. (Central) on May 16, 2016.
ACPE test deadline: 11:59 p.m. (Central) on January 14, 2019.
Online Errata: Follow this link to check for any changes or updates to this Critical Care Self-Assessment Program release.
Be sure to check the online errata before submitting a posttest.
You may complete one or all modules for credit. Tests may not be submitted more than one time. For information on
passing lev- els, assignment of credits, and credit reporting, see Continuing Pharmacy Education and Recertification
Instructions page for each module.
Important Notice on BCCCP Recertification: Submitting a required posttest for BCCCP recertification attests that you
have com- pleted the test as an individual effort and not in collaboration with any other individual or group. Failure to
complete this test as an individual effort may jeopardize your ability to use CCSAP for BCCCP recertification.
BOOK FORMAT AND CONTENT
E-Media Format: All purchasers of this CCSAP book also have access to the e-media version. Follow these instructions to
load the text and self-assessment questions in this book onto your e-reader, tablet, or Android phone.
Electronic annotation: The online format of this book can be saved to the desktop or printed. The latest version of Adobe
Reader (available free) offers functionality such as highlighting or adding “sticky notes” to the text.
Hyperlinks: This book contains both internal and external hypertext links. Clicking on the intra-document links in the
Table of Contents will take you to the page containing the selected content. Clicking on external hyperlinks will take you
away from the ACCP Web site to the outside resource, guidelines, tools, or other information you have selected.
NOTE: To facilitate further learning and research, this publication incorporates live hyperlinks to Web sites administered by
,other organizations. The URLs provided are those of third parties not affiliated in any way with ACCP. ACCP assumes no
liability for material downloaded from or accessed on these Web sites. It is the responsibility of the reader to examine the
copyright and licensing restrictions of linked pages and to secure all necessary permissions.
Abbreviations, Laboratory Values: This table, which is also reached by links at the beginning of each chapter, lists
selected abbreviations and reference ranges for common laboratory tests that can be used as a resource in completing
the self-assess- ment questions.
NOTE: The editors and publisher of CCSAP recognize that the development of this volume of material offers many
opportunities for error. Despite our best efforts, some errors may persist into publication. Drug dosage schedules are, we
believe, accurate and in accordance with current standards. Readers are advised, however, to check package inserts for
the recommended dosages and contraindications. This is especially important for new, infrequently used, and highly
toxic drugs.
Director of Professional Development: Nancy M. Perrin, M.A., CAE
Associate Director of Professional Development: Wafa Y. Dahdal, Pharm.D., BCPS
Recertification Project Manager: Edward Alderman, B.S., B.A.
Medical Editor: Kimma Sheldon, Ph.D., M.A.
Information Technology Project Manager: Brent Paloutzian, A.A.S.
For ordering information or questions, write or call:
Ambulatory Care Self-Assessment
Program American College of Clinical
Pharmacy 13000 W. 87th St. Parkway
Lenexa, KS 66215-4530
Telephone: (913) 492-3311
Fax: (913) 492-4922
E-mail:
Library of Congress Control Number: 2015957574
ISBN-13: 978-1-939862-23-5 (CCSAP 2016 BOOK 1, Infection Critical Care)
Copyright © 2016 by the American College of Clinical Pharmacy. All rights reserved. This book is protected by copyright.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic or mechanical, including photocopy, without prior written permission of the American College of Clinical
Pharmacy.
To cite CCSAP properly:
Authors. Chapter name. In: Boucher BA, Haas CE, eds. Critical Care Self-Assessment Program, 2016 Book 1. Infection Critical Care.
Lenexa, KS: American College of Clinical Pharmacy, 2016:page range.
CCSAP™ is a registered trademark of the American College of Clinical Pharmacy.
, TABLE OF CONTENTS
Infection Critical Care I Infection Critical Care II
Fungal Infections in the ICU Sepsis
By Christine M. Groth, Pharm.D., BCPS; and Elizabeth S. Dodds- By Jeffrey P. Gonzales, Pharm.D., BCPS, BCCCP, FCCM; and Rachel W.
Ashley, Pharm.D., MHS, BCPS, AQ-ID Flurie, Pharm.D., BCPS
Introduction....................................................................................................... 1 Introduction.................................................................................................... 75
Epidemiology.....................................................................................................2 Initial Assessment....................................................................................... 78
Advances in Diagnosis of Fungal Infections....................................... 3 Antimicrobial Pharmacokinetic and Pharmacodynamic
Evidence-Based Approach to Invasive Candidiasis Treatment 8 Changes in Sepsis........................................................................................80
Treatment Strategies for Patients with Empiric Antimicrobial Therapy........................................................... 84
Invasive Fungal Disease............................................................................ 10 Duration of Antimicrobial Therapy and De-Escalation
Antifungal Pharmacotherapy.................................................................... 13 of Antimicrobials......................................................................................... 88
Concentration Monitoring........................................................................ 16 Sepsis Bundles.............................................................................................. 89
Antifungal Stewardship............................................................................. 18 Conclusion....................................................................................................... 89
Conclusion........................................................................................................ 19 References...................................................................................................... 89
References........................................................................................................ 19
Antimicrobial Stewardship in the ICU
Antimicrobial Management of HAP/VAP
By Anthony J. Guarascio, Pharm.D., BCPS
By Martin J. Ohlinger, Pharm.D., FCCM Introduction.................................................................................................... 99
Introduction..................................................................................................... 25 Core Antimicrobial Stewardship Processes
Guidelines........................................................................................................ 26 in the ICU...................................................................................................... 100
Prevention........................................................................................................ 26 Antimicrobial Treatment Principles................................................. 103
Principles of Antimicrobial Management of HAP and VAP...... 28 Microbiological Tools for Antimicrobial Stewardship..............108
Empiric Antimicrobial Therapy.............................................................29 Surveillance of Antimicrobial Use and Drug Resistance......... 110
Definitive Antimicrobial Therapy......................................................... 34 Antimicrobial Stewardship Outcomes............................................. 111
Conclusion........................................................................................................ 38 Conclusion...................................................................................................... 112
References........................................................................................................ 39 References..................................................................................................... 113
Other Common Infections in the ICU Antibiotic Resistance in the ICU
By Christopher M. Bland, Pharm.D., BCPS, FIDSA; and Trisha N. By Paul Juang, Pharm.D., BCPS, BCCCP
Branan, Pharm.D., BCCCP Introduction................................................................................................... 121
Introduction..................................................................................................... 47 Transmission of Resistant Isolates................................................... 122
Challenges of Treating Infections in the ICU.................................. 47 Prevention Strategies.............................................................................. 123
Catheter-Associated Bloodstream Infection..................................... 48 Mechanism of Resistance....................................................................... 124
Urinary Tract Infections............................................................................ 51 Gram-Positive Organisms........................................................................125
Intra-Abdominal Infections...................................................................... 53 Gram-Negative Organisms......................................................................127
Skin and Soft Tissue Infections.............................................................. 57 Dosing Considerations............................................................................. 130
Community-Acquired Pneumonia.......................................................... 58 New Agents.................................................................................................. 131
CNS Infections................................................................................................ 59 Conclusion...................................................................................................... 131
Conclusion........................................................................................................ 62 References..................................................................................................... 131
References........................................................................................................ 62
2016 • BOOK 1
INFECTION
CRITICAL CARE
Series Editors
Bradley A. Boucher, Pharm.D., FCCP, BCPS Curtis
E. Haas, Pharm.D., FCCP, BCPS
IMPORTANT INFORMATION ON THE RELEASE OF
CCSAP 2016 BOOK 1 INFECTION CRITICAL CARE
TESTING
BCCCP test deadline: 11:59 p.m. (Central) on May 16, 2016.
ACPE test deadline: 11:59 p.m. (Central) on January 14, 2019.
Online Errata: Follow this link to check for any changes or updates to this Critical Care Self-Assessment Program release.
Be sure to check the online errata before submitting a posttest.
You may complete one or all modules for credit. Tests may not be submitted more than one time. For information on
passing lev- els, assignment of credits, and credit reporting, see Continuing Pharmacy Education and Recertification
Instructions page for each module.
Important Notice on BCCCP Recertification: Submitting a required posttest for BCCCP recertification attests that you
have com- pleted the test as an individual effort and not in collaboration with any other individual or group. Failure to
complete this test as an individual effort may jeopardize your ability to use CCSAP for BCCCP recertification.
BOOK FORMAT AND CONTENT
E-Media Format: All purchasers of this CCSAP book also have access to the e-media version. Follow these instructions to
load the text and self-assessment questions in this book onto your e-reader, tablet, or Android phone.
Electronic annotation: The online format of this book can be saved to the desktop or printed. The latest version of Adobe
Reader (available free) offers functionality such as highlighting or adding “sticky notes” to the text.
Hyperlinks: This book contains both internal and external hypertext links. Clicking on the intra-document links in the
Table of Contents will take you to the page containing the selected content. Clicking on external hyperlinks will take you
away from the ACCP Web site to the outside resource, guidelines, tools, or other information you have selected.
NOTE: To facilitate further learning and research, this publication incorporates live hyperlinks to Web sites administered by
,other organizations. The URLs provided are those of third parties not affiliated in any way with ACCP. ACCP assumes no
liability for material downloaded from or accessed on these Web sites. It is the responsibility of the reader to examine the
copyright and licensing restrictions of linked pages and to secure all necessary permissions.
Abbreviations, Laboratory Values: This table, which is also reached by links at the beginning of each chapter, lists
selected abbreviations and reference ranges for common laboratory tests that can be used as a resource in completing
the self-assess- ment questions.
NOTE: The editors and publisher of CCSAP recognize that the development of this volume of material offers many
opportunities for error. Despite our best efforts, some errors may persist into publication. Drug dosage schedules are, we
believe, accurate and in accordance with current standards. Readers are advised, however, to check package inserts for
the recommended dosages and contraindications. This is especially important for new, infrequently used, and highly
toxic drugs.
Director of Professional Development: Nancy M. Perrin, M.A., CAE
Associate Director of Professional Development: Wafa Y. Dahdal, Pharm.D., BCPS
Recertification Project Manager: Edward Alderman, B.S., B.A.
Medical Editor: Kimma Sheldon, Ph.D., M.A.
Information Technology Project Manager: Brent Paloutzian, A.A.S.
For ordering information or questions, write or call:
Ambulatory Care Self-Assessment
Program American College of Clinical
Pharmacy 13000 W. 87th St. Parkway
Lenexa, KS 66215-4530
Telephone: (913) 492-3311
Fax: (913) 492-4922
E-mail:
Library of Congress Control Number: 2015957574
ISBN-13: 978-1-939862-23-5 (CCSAP 2016 BOOK 1, Infection Critical Care)
Copyright © 2016 by the American College of Clinical Pharmacy. All rights reserved. This book is protected by copyright.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic or mechanical, including photocopy, without prior written permission of the American College of Clinical
Pharmacy.
To cite CCSAP properly:
Authors. Chapter name. In: Boucher BA, Haas CE, eds. Critical Care Self-Assessment Program, 2016 Book 1. Infection Critical Care.
Lenexa, KS: American College of Clinical Pharmacy, 2016:page range.
CCSAP™ is a registered trademark of the American College of Clinical Pharmacy.
, TABLE OF CONTENTS
Infection Critical Care I Infection Critical Care II
Fungal Infections in the ICU Sepsis
By Christine M. Groth, Pharm.D., BCPS; and Elizabeth S. Dodds- By Jeffrey P. Gonzales, Pharm.D., BCPS, BCCCP, FCCM; and Rachel W.
Ashley, Pharm.D., MHS, BCPS, AQ-ID Flurie, Pharm.D., BCPS
Introduction....................................................................................................... 1 Introduction.................................................................................................... 75
Epidemiology.....................................................................................................2 Initial Assessment....................................................................................... 78
Advances in Diagnosis of Fungal Infections....................................... 3 Antimicrobial Pharmacokinetic and Pharmacodynamic
Evidence-Based Approach to Invasive Candidiasis Treatment 8 Changes in Sepsis........................................................................................80
Treatment Strategies for Patients with Empiric Antimicrobial Therapy........................................................... 84
Invasive Fungal Disease............................................................................ 10 Duration of Antimicrobial Therapy and De-Escalation
Antifungal Pharmacotherapy.................................................................... 13 of Antimicrobials......................................................................................... 88
Concentration Monitoring........................................................................ 16 Sepsis Bundles.............................................................................................. 89
Antifungal Stewardship............................................................................. 18 Conclusion....................................................................................................... 89
Conclusion........................................................................................................ 19 References...................................................................................................... 89
References........................................................................................................ 19
Antimicrobial Stewardship in the ICU
Antimicrobial Management of HAP/VAP
By Anthony J. Guarascio, Pharm.D., BCPS
By Martin J. Ohlinger, Pharm.D., FCCM Introduction.................................................................................................... 99
Introduction..................................................................................................... 25 Core Antimicrobial Stewardship Processes
Guidelines........................................................................................................ 26 in the ICU...................................................................................................... 100
Prevention........................................................................................................ 26 Antimicrobial Treatment Principles................................................. 103
Principles of Antimicrobial Management of HAP and VAP...... 28 Microbiological Tools for Antimicrobial Stewardship..............108
Empiric Antimicrobial Therapy.............................................................29 Surveillance of Antimicrobial Use and Drug Resistance......... 110
Definitive Antimicrobial Therapy......................................................... 34 Antimicrobial Stewardship Outcomes............................................. 111
Conclusion........................................................................................................ 38 Conclusion...................................................................................................... 112
References........................................................................................................ 39 References..................................................................................................... 113
Other Common Infections in the ICU Antibiotic Resistance in the ICU
By Christopher M. Bland, Pharm.D., BCPS, FIDSA; and Trisha N. By Paul Juang, Pharm.D., BCPS, BCCCP
Branan, Pharm.D., BCCCP Introduction................................................................................................... 121
Introduction..................................................................................................... 47 Transmission of Resistant Isolates................................................... 122
Challenges of Treating Infections in the ICU.................................. 47 Prevention Strategies.............................................................................. 123
Catheter-Associated Bloodstream Infection..................................... 48 Mechanism of Resistance....................................................................... 124
Urinary Tract Infections............................................................................ 51 Gram-Positive Organisms........................................................................125
Intra-Abdominal Infections...................................................................... 53 Gram-Negative Organisms......................................................................127
Skin and Soft Tissue Infections.............................................................. 57 Dosing Considerations............................................................................. 130
Community-Acquired Pneumonia.......................................................... 58 New Agents.................................................................................................. 131
CNS Infections................................................................................................ 59 Conclusion...................................................................................................... 131
Conclusion........................................................................................................ 62 References..................................................................................................... 131
References........................................................................................................ 62
