9/12/2011. Conflicts of Interest. Endocarditis. Last Chance Pharmacotherapy Review Webinar Infectious Diseases September 7, Causative organisms

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1 Conflicts of Interest I have no conflicts to disclose. Last Chance Pharmacotherapy Review Webinar Infectious Diseases September 7, 2011 Endocarditis Endocarditis Causative organisms Other C. albicans Coag-neg Staph Enterococci S. aureus Streptococci Viridans Streptococci penicillin G (± gentamicin) ceftriaxone (± gentamicin) vancomycin * treatment is for 2-4 weeks (gentamicin allows for shorter course of therapy) * treatment is for 6 weeks with prosthetic valve Enterococci penicillin G or ampicillin plus streptomycin or gentamicin vancomycin plus streptomycin or gentamicin * treatment is for 4-6 weeks * treatment is for 6 weeks in prosthetic valves * streptomycin or gentamicin must be given due to inherent resistance Endocarditis Surgical Prophylaxis Methicillin sensitive S. aureus oxacillin or nafcillin (± gentamicin) cefazolin (± gentamicin) vancomycin * treatment is for 6 weeks (gentamicin for 3-5 days decreases bacterial load) * treatment is for 6 weeks plus gentamicin for 2 weeks in prosthetic valves also add rifampin Methicillin resistant S. aureus vancomycin daptomycin * treatment is for 6 weeks * treatment is for 6 weeks plus gentamicin for 2 weeks in prosthetic valves also add rifampin Gastric/duodenal Indicated for morbid obesity, esophageal obstruction, gastric acidity, or GI motility cefazolin 1 2 g preinduction Biliary Acute cholecystitis, obstructive jaundice, CD stones, age > 70 cefazolin [or cefoxitin] 1 2 g preinduction Appendectomy cefoxitin 1 2 g [or cefazolin plus metronidazole or ampicillin/sulbactam] preinduction Colorectal Cefoxitin or cefotetan 1 2 g [or cefazolin plus metronidazole or ampicillin/sulbactam or ertapenem] preinduction OR gentamicin/ tobramycin 1.5 mg/kg and clindamycin 600 mg/metronidazole g preinduction ± neomycin 1 g and erythromycin 1 g at 19, 18, and 9 hours before surgery or neomycin 2 g and metronidazole 2 g at 13 and 9 hours before surgery 1

2 Surgical Prophylaxis Pneumonia Vaginal/abdominal hysterectomy cefazolin or cefoxitin or cefotetan 1 2 g [or ampicillin/sulbactam] preinduction Cesarean section cefazolin 1-2 g after the cord is clamped Oth Orthopedic (surgery involves prosthetic materials) cefazolin 1-2 g preinduction [or cefuroxime or vancomycin] Head and Neck (incision thru oral or pharyngeal mucosa) cefazolin 1 2 g or ampicillin / sulbactam g or gentamicin 1.5 mg/kg and clindamycin mg preinduction Cardiac surgery cefazolin or cefuroxime 1 2 g preinduction (+ intraoperative doses); if MRSA is probable or patient has been hospitalized, then vancomycin Pulmonary resection (i.e., lobectomy and pneumonectomy) cefazolin or cefuroxime 1 2 g preinduction [or vancomycin] Vascular surgery cefazolin 1 g preinduction and every 8 hours for 3 doses; if MRSA is probable, then use vancomycin. Definitions CAP - no hospital or LTC facility for past 14 days HAP - 48 hours or more after admission VAP - more than hours after endotracheal intubation HCAP hospitalized in past 90 days; resides in NH or LTC; IV antibiotic therapy, chemotherapy, or wound care in past 30 days; attends hospital or HD clinic CURB-65 RR >= 30 DBP <=60 or SBP < 90 BUN > 19 Confusion Age >= 65 CURB-65 score 0 or 1 = home treatment 2 = consider hospital = 3 hospital Pneumonia - Community CAP Outpatient Therapy CAP Inpatient Therapy Healthy / No abx in 3 mos Moderate Fluoroquinolone Macrolide Macrolide plus 3rd Doxycycline generation cephalosporin Comorbidities / Abx in 3 mos or ampicillin or ertapenem Fluoroquinolone Macrolide (or doxycycline) Severe Ampicillin/sulbactam plus with high-dose amoxicillin (1g a respiratory FQ or TID) or azithromycin amoxicillin/clavulanate (2g 3rd gen cephalosporin BID) or cephalosporin (ceftriaxone, cefuroxime, plus a respiratory FQ or azithromycin cefpodoxime) May need broader antibacterial activity Pneumonia - Nosocomial Nosocomial Therapy Early onset and no MDR 3rd-generation ceph Fluoroquinolone Ampicillin-sulbactam Ertapenem Late onset or MDR Ceftazidime or cefepime or imipenem or meropenem or doripenem or piperacillintazobactam plus aminoglycoside or fluoroquinolone Vancomycin or linezolid if MRSA is suspected Risk factors for MDR organisms Antibiotic therapy < 90 days Hospitalization ti 5d days High local resistance Risk factors for HCAP Immunosuppressive disease and/or therapy Case Vignette 1 - ID Question 1-A TP is a 56-year-old male who presents with increasing malaise and fevers that have occurred over the past few weeks. His weakness is now affecting his activities of daily living. He is occasionally short of breath. PMH: COPD, hypertension, BPH, mitral valve prolapse with regurgitation and generalized anxiety disorder. He is a past 2 pack per day smoker, but quit 5 years ago. Medications on admission include: sertraline 100mg po daily, tamsulosin 0.4mg po daily, tiotropium i inhalation daily, and lisinopril 40mg po daily. TP develops a rash when receiving penicillins. On physical exam TP has an extensive systolic ejection murmur. He is afebrile. Labs: Na 143, K 4.2, Cl 102, HCO3 22, BUN 28, Scr 1.43 and glucose 134, Hgb 10.2, Hct 30.8, WBC 12.2 and platelets 220. Three of 3 blood cultures: gram positive cocci in chains. Echo: large vegetation on his mitral valve and an ejection fraction of 56%. His cultures ultimately grow Streptococci mitis (one of the viridans group of Streptococci) that is highly sensitive to penicillin. What is the best therapy for TP? 1. Penicillin G 2 million units every 4 hours for 4 weeks plus gentamicin 1 mg/kg IV q12h for the first 5 days. 2. Cefazolin 1g IV q8h plus gentamicin 1mg/kg IV q12h for 6 weeks. 3. Ceftriaxone 2g IV daily plus gentamicin 1mg/kg IV q12h for 2 weeks. 4. Vancomycin 15mg/kg IV q24h for 2 weeks. 2

3 Reevaluate Case 1-A - ID Question RE1-A DL is a 38 year old male with a history of IV drug use who presents with fever and chills. Blood cultures are drawn and all are positive for Gram positive cocci in chains, ultimately identified ed as Enterococcus faecalis. He is started on ampicillin and gentamicin. In this situation the best reason for using gentamicin is that it: 1. allows for a shortened length of therapy. 2. has a necessary synergistic effect since no single antibiotic is bactericidal against Enterococcus. 3. has activity against Gram negative organisms, which frequently co-infect valves in patients with Enterococcal endocarditis. 4. lessens the bacterial load and quickens the time to defervescence. Case Vignette 1 - ID Question 1-B TP completes his therapy but 6 weeks later he continues to have problems with shortness of breath and further development of heart failure. It is decided ded that he will need a mitral valve replacement. Surgery is scheduled. For TP, undergoing open heart surgery, which is the best recommendation for his perioperative antibiotics? 1. Vancomycin 1g IV within one hour of surgery andupto24hoursafter after. 2. Cefazolin 1g IV within one hour of surgery and every 8 hours for 72 hours after surgery. 3. Cefazolin 1g IV within one hour of surgery and up to 24 hours after. 4. Ceftriaxone 1g IV within one hour of surgery, and 1g IV after surgery. Reevaluate Case 1-B - ID Question RE1-B You are developing a table of appropriate antibiotic choices for surgical prophylaxis at your local hospital. For which one of the following procedures would cefazolin alone not be the best antibiotic to use? 1. Vaginal hysterectomy 2. Total hip replacement in a patient who develops a rash with ampicillin 3. Biliary surgery in a patient with common duct stones 4. Colorectal surgery in a patient who develops diarrhea with penicillin 3

4 Case Vignette 1 - ID Question 1-C Following surgery TP recovers in the intensive care unit and is mechanically ventilated. On the third day of hospitalization/intensive care unit stay, TP develops e a fever e and localized infiltrates on chest x-ray. He is also producing copious, thick sputum. Vital signs: temperature: F, HR 78, RR vented, BP 134/86. Labs: Na 136, K 4.8, Cl 98, HCO3 23, BUN 24, Scr 0.92 and glucose 110, Hgb 9.6, Hct 28.5, WBC 18.6 and platelets 335. What is the best empiric treatment for TP? 1. Ceftriaxone 1g IV daily plus azithromycin 500mg IV daily. 2. Ceftriaxone 1g IV daily plus levofloxacin 750mg IV daily plus linezolid 600mg IV q12h. 3. Cefepime 1g IV q12h plus tobramycin 7 mg/kg IV q24h plus linezolid 600mg IV q12h. 4. Piperacillin/tazobactam 4.5g IV q6h plus tigecycline 50mg IV q12h plus vancomycin 15 mg/kg IV q12h Reevaluate Case 1-C - ID Question RE1-C JW is a 66-year-old female who presents to the emergency department with extreme shortness of breath, cough with productive sputum and confusion. PMH: diabetes, hypertension and osteoporosis. She does not smoke. Medications on admission include: metformin 1000mg po BID, glyburide 5mg po daily, lisinopril 40 mg po daily, hydrochlorothiazide 12.5 mg po daily and alendronate 70mg weekly. JW lives at home with her husband and has had no antibiotics for at least 3 years. JW is allergic to morphine and sulfa antibiotics. On physical exam: temperature of 102.4F, HR 95 bpm, RR of 31 bpm and BP of 86/62. Labs: Na 147, K 3.7, Cl 101, HCO3 19, BUN 36, Scr 1.22 and glucose 144, Hgb 11.2, Hct, 34.8, WBC 18.4 and platelets 333. What is the best treatment for JW? 1. Send her home with a prescription for doxycycline 100mg po twice daily for 10 days. 2. Admit her to the hospital, to a general medicine floor, and start on ceftriaxone 1g IV daily plus clarithromycin 500mg po twice daily for at least 5 days. 3. Admit her to the hospital, to an intermediate care unit and start on levofloxacin 750mg IV daily for at least 10 days. 4. Admit her to the hospital to an intensive care unit and start on ceftriaxone 1g IV daily plus azithromycin 500mg IV daily for at least 5 days. Case Vignette 1 - ID Question 1-D TPs sputum eventually grows Klebsiella pneumoniae. Sensitivities are typical for K. pneumoniae and it is not a multi drug resistant organism. oga TPs therapy is best refined to: 1. Linezolid 600mg IV q12h with treatment for a total of 8 days. 2. Cefepime 1g IV q12h with treatment for a total of 8 days. 3. Tigecycline 50mg IV q12h with treatment for a total of 14 days. 4. Piperacillin/tazobactam 4.5g IV q6h with treatment for a total of 14 days. 4

5 Question RE1-D Of the following scenarios, which patient demonstrates the best case for starting vancomycin or linezolid empirically? 1. A patient with CAP who has comorbidities (CHF and diabetes) but no recent antibiotic use. 2. A patient who develops pneumonia on day 6 of his stay in an ICU, but has not had antibiotics in more than 5 years. 3. A patient hospitalized for trauma who develops a pneumonia on day 3 of hospitalization in the ICU. 4. A patient with a CURB-65 score of 2, who is hospitalized for pneumonia, lives at home and had a week s worth of oral antibiotics 6 weeks ago. Urinary Tract Infections Community Factors - complicated UTIs: Male sex K. pneumoniae P. mirabilis S. saprophyticus Enterococcus Hospital-acquired Pregnancy Anatomical abnormality E. coli Childhood UTI Nosocomial Recent antimicrobial use Fungi Diabetes Enterococcus Indwelling urinary catheter P. mirabilis Recent UT instrumentation S. aureus Immunosuppression E. coli K. pneumoniae P. aeruginosa Other Gram-negative Urinary Tract Infections Tuberculosis Uncomplicated cystitis TMP/SMZ (3 days) Nitrofurantoin (5 days) Fosfomycin (1 dose) Alternatives: Fluoroquinolone l (3 days) Beta lactams (3-7 days) Pregnancy (7 days) Amoxicillin Nitrofurantoin Cephalexin TMP/SMZ Uncomplicated pyelonephritis* Fluoroquinolone (5-7 days) TMP/SMZ (14 days) Beta lactam (10-14 days) Complicated UTIs (5-14 days) Fluoroquinolone Aminoglycoside Extended spectrum beta lactam HIV-negative patients: INH + RIF + PZA + EMB for 2 months (daily, 5x/week, TIW or BIW) then INH + RIF for 4 more months (daily, 5x/week, TIW, or BIW) INH + RIF + EMB for 2 months (daily or 5x/week) then INH + RIF for 7 more months (daily, 5x/week or BIW) HIV-positive patients: INH + RIF + PZA + EMB for 2 months (daily, 5x/week or TIW) then INH + RIF for 4 more months (daily, 5x/week or TIW) INH + RIF + EMB for 2 months (daily or 5x/week) then INH + RIF for 7 more months (daily or 5x/week) * If uropathogen resistance > 10% use initial dose of long acting beta lactam or once daily aminoglycoside Case Vignette 2 - ID Question 2-A HT is a 25-year-old female who presents to the clinic with a 3 day history of burning on urination and pain in her lower back. She has not taken her temperature at home but has felt warm over the past 24 hours. PMH: partial complex seizures. Recently she has also had cough with minimal sputum production, that won t go away. She smokes ½ pack of cigarettes daily and immigrated to the US from Laos 11 years ago. HT has NKDA and is taking Ortho Novum 7/7/7 daily and valproic acid 250mg po TID. On physical exam HT continues to complain of back pain. Her temperature is 100.5F. Labs: Na 138, K 4.1, Cl 97, HCO3 25, BUN 18, Scr 1.07 and glucose 99, Hgb 12.2, Hct, 36.2, WBC 14.2 and platelets 195. Her valproic acid concentration is 82 mg/l. A urinalysis is completed which shows turbidity, neg. glucose; ph 5.4; protein 0 mg/dl; WBCs; + nitrites; 8-10 red blood cells (RBCs); many bacteria and +casts. Urine cultures are obtained but no results are back. The best treatment for HT s infection is: 1. Trimethoprim/sulfamethoxazole DS po q12h for 14 days of therapy 2. Levofloxacin 500mg gpo daily for 3 days of therapy 3. Azithromycin 500mg po x1, then 250mg po daily for 5 total days of therapy 4. Nitrofurantoin 100mg po BID for 5 days of therapy 5

6 Reevaluate Case 2-A - ID Question RE2-A RM is a 56-year-old female who presents to the clinic with a 5 day history of burning on urination and urgency. She is afebrile. PMH: diabetes and severe rheumatoid arthritis. RM has NKDA and is taking metformin 500mg po BID, insulin glargine 20 units SC at bedtime, methotrexate 15mg po weekly and prednisone 10mg po daily. RM has no specific complaints. Her temperature is 98.5F. Urinalysis: turbidity, pos. glucose; ph 5.8; protein 0 mg/dl; WBCs; + nitrites; 0 red blood cells (RBCs); many bacteria and no casts. Urine cultures are obtained but no results are back. The best treatment for RM s infection is: 1. Trimethoprim/sulfamethoxazole DS po q12h for 14 days of therapy 2. Levofloxacin 750mg po daily for 5 days of therapy 3. Gentamicin 5 mg/kg IV daily for 3 days of therapy 4. Cefazolin 1g IV q8h for 7 days Case Vignette 2 - ID Question 2-B During the clinic visit HT is scheduled for a follow up to assess her chronic cough. A sputum culture is sent and a chest x-ray is taken. ae On ces chest x-ray, HT has infiltrates in her right upper lobe and her sputum smear is positive for acid-fast bacilli. If HT s cough is treated with appropriate antibiotics, based on the sputum results, what would most likely happen to HT if no changes occurred in her current drug therapy: 1. An increase in weight gain and breast tenderness. 2. An increase in somnolence. 3. An increase in seizure frequency. 4. An increase in acne. Reevaluate Case 2-B - ID Question RE2-B ML is a 38 year old male with a history of recent exposure to two patients with tuberculosis. He develops a cough with a low grade fever, frequent night sweats s and a 10 pound weight loss. In the emergency department a sputum sample is taken and ML is admitted. The sputum is positive for acid fast bacilli. What is the best empiric regimen for ML? 1. Rifampin plus isoniazid for 6 months. 2. Rifampin plus isoniazid plus ethambutol for 2 months, followed by rifampin plus isoniazid for 4 months. 3. Rifampin plus isoniazid plus ethambutol plus pyrazinamide for 2 months followed by rifampin plus isoniazid for 4 months. 4. Rifampin plus isoniazid plus ethambutol plus pyrazinamide for 6 months. 6

7 Cellulitis Immunizations - Adult Acute cellulitis (S. pyogenes, S. aureus) 5 10 days Anti-staphylococcal PCN Penicillin G (if strep) Clindamycin -lactamase inhibitor combinations 1 st generation cephalosporin Vancomycin or linezolid Erysipelas (S. pyogenes) 7 10 days Penicillin G Clindamycin Necrotizing fasciitis (Streptococcal, Mixed - includes anaerobes) Surgical debridement -lactamase inhibitor combinations plus clindamycin plus ciprofloxacin i Carbapenems Cefotaxime plus clindamycin or metronidazole Streptococcal necrotizing fasciitis: high-dose IV penicillin plus clindamycin Immunizations - Adult Case Vignette 3 - ID SD is a 69-year-old male who presents to the ED with a 2 day history of redness and swelling of his right thigh. A week ago he sustained a significant abrasion to the thigh from an accident involving a power sander. Although the abrasion was initially healing, over the past few days the area around the injury has become red and warm to the touch, and the redness appears to be spreading. PMH: bipolar disorder, atrial fibrillation, hypertension, and osteoarthritis. SD is taking lamotrigine 100mg po daily, bupropion SR 150mg po BID, warfarin 3mg po daily, diltiazem CD 240mg po daily, and acetaminophen 500mg po prn. SD has NKDA. On physical exam SD has an area of redness about 4.5cm in diameter, around a recent abrasion. The area is warm to the touch but is not raised. The right thigh circumference is greater than the left thigh. His temperature is 102.4F. Labs: Na 148, K 4.6, Cl 100, HCO3 23, BUN 12, Scr 0.89 and glucose 88, Hgb 13.4, Hct 40.2, WBC 12.2 and platelets 344. SD is admitted to the hospital for treatment. Question 3-A The best treatment for SD s infection is: 1. Trimethoprim/sulfamethoxazole 5 mg/kg of TMP IV q12h followed by i DS BID for 7 days total 2. Clindamycin 900mg IV q8h followed by 300mg po QID for 10 days total 3. Piperacillin/tazobactam 3.375g IV q8h for 5 days total 4. Linezolid 600mg po q12h for 14 days Reevaluate Case 3-A - ID PL is a 44-year-old male with diabetes who presents to the emergency department with a 4 day history of scrotal redness and swelling. The area adjacent to the scrotum is also red and warm to the touch. He is diagnosed with Fournier s gangrene, a type of necrotizing fasciitis. PL is taken to surgery for debridement and started on antibiotics. 7

8 Question RE3-A Case Vignette 3 - ID The best empiric therapy for PL is: 1. Nafcillin 2g IV q4h 2. Vancomycin 15mg/kg IV q12h plus clindamycin 900mg IV q8h 3. Doripenem 500mg IV q8h 4. Penicillin G 2 million units q6h plus metronidazole 500mg IV q8h SD is questioned about his vaccine use. He has received the flu vaccine off and on over the past 10 years, but has received no other vaccinations. a Question 3-B Reevaluate Case 3-B - ID Which of the following is the best combination of vaccinations for SD? 1. Influenza, pneumococcal polysaccharide, Tdap booster, zoster 2. Influenza, meningococcal, Td booster, hepatitis B 3. Influenza, pneumococcal polysaccharide, measles-mumps-rubella booster, zoster 4. Influenza, hepatitis A, hepatitis B, Tdap booster Five patients come to your clinic: LP a 4-year-old female with sickle cell disease SS a 36-year-old male with hypertension, hyperlipidemia p and hypothyroidism y TM a 62-year-old female with osteoarthritis, seasonal allergies and GERD WA a 48-year-old male with diabetes mellitus, peripheral neuropathy and sinusitis RG a 27-year-old female with migraines and depression, who smokes ½ pack per day Question RE3-B Extra Question Case 1 - ID Vaccinating which of the following groups would best protect all the patients that should receive the pneumococcal polysaccharide vaccine? 1. LP, SS and TM 2. LP and WA 3. LP, WA, and RG 4. SS, TM and RG LA is a 28-year-old female who has had three urinary tract infections in the past 7 months. She presents to the clinic once again with dysuria, urgency and frequency. The UTIs do not appear to be associated with sexual activity. 8

9 Extra Question 1 - ID Extra Question Case 2 - ID Following appropriate treatment for this UTI, what is the best therapy to offer LA? 1. Nothing. She should call her physician when she experiences symptoms again. 2. A prescription for trimethoprim/sulfamethoxazole, which she should initiate on her own at the first sign of another UTI. 3. A prescription for trimethoprim/sulfamethoxazole single strength to take once daily to prevent another UTI. 4. A prescription for trimethoprim/sulfamethoxazole single strength to take after sexual intercourse. CF is a 59-year-old male with type 2 diabetes mellitus. His diabetes is poorly controlled and he now has peripheral neuropathy and stage 3 chronic c kidney disease (CrCl C 35 ml/min). He comes to the emergency department with a red, swollen, left foot. The redness has increased over the past few days. A small ulcer has begun to form on the bottom of his left foot. He has had no antibiotics for many years. Extra Question 2 - ID Extra Question Case 3 - ID What is the best treatment for CF? 1. Levofloxacin 750mg IV every 48 hours and clindamycin 900mg IV q8h 2. Ampicillin/sulbactam 3g IV q8h. 3. Azithromycin 500mg IV daily 4. Cefazolin 1g IV q8h MW is a 45-year-old male who was admitted to the ICU following a motorcycle versus deer accident. He only has a history of hypertension for which he takes lisinopril. On day 3 of hospitalization he spikes a temperature and his WBC count increases to He has some new markings on his chest X-ray as well. Extra Question 3 - ID Extra Question Case 4 - ID What is the best empiric treatment for MW? 1. Doripenem 500mg IV q8h plus vancomycin 15 mg/kg IV q12h for 14 days 2. Cefepime 1g IV q12h plus tobramycin 7 mg/kg IV daily plus linezolid 600mg IV q12h for 14 days 3. Piperacillin/tazobactam 4.5g IV q6h for 8 days 4. Ceftriaxone 1g IV daily for 7-8 days. NL is scheduled to have a dental procedure (root canal) performed next week. She has a history of congenital heart disease. She is allergic aegcope to penicillin (as) (rash). 9

10 Extra Question 4 - ID Extra Question Case 5 - ID What is the best recommendation for endocarditis prophylaxis in NL? 1. No prophylaxis is required 2. Clarithromycin 500mg, one hour before procedure 3. Amoxicillin 2g, one hour before procedure 4. Clindamycin 600mg, one hour before and six hours after procedure RB is a 69-year-old male who presents to the emergency department with a 4 day history of fever, chills, frequency, urgency and perineal pain. A urinalysis s is completed ed and found to have many bacteria. A rectal exam is completed and RB is found to have a swollen, tender prostate. He is diagnosed with acute bacterial prostatitis. Extra Question 5 - ID Your recommendation for the best therapy, including duration, for RB is: 1. Trimethoprim/sulfamethoxazole DS po BID for 7 days. 2. Amoxicillin/clavulanate 875 po BID for 14 days 3. Cefpodoxime 200mg po BID for 21 days 4. Ciprofloxacin 500mg po BID for 28 days 10