Infectious Disease Update 2017

Transcription

1 Infectious Disease Update 2017 Greg Moran, MD, FACEP, FIDSA Professor of Clinical Emergency Medicine Geffen School of Medicine at UCLA Dept. of Emergency Medicine and Division of Infectious Diseases Olive View-UCLA Medical Center

2 What's Pneu? Staph more common in CAP? 2005 IDSA/ATS guidelines included Hospital Acquired Pneumonia (HAP), Ventilator Associated Pneumonia (VAP), Health Care-associated Pneumonia (HCAP) 2016 guidelines only HAP and VAP

3 CAP Etiology: More Staph? 627 ED Patients Admitted with CAP, U.S. hospitals (EMERGEncy ID Net) Cultures done in 95% (92% blood, 50% resp) Pathogen isolated in 17% S. pneumo S. aureus H. influenzae MRSA 2.4% (range at sites 0-5%) - All were USA300 community strains - More ICU admits, intubation, death (14%) Moran GJ et al. Clin Infect Dis 2012;54(8): MRSA Pneumonia

4 CAP: Whom Do We Treat for MRSA? IDSA/ATS Guidelines: If CA-MRSA is a consideration, add vancomycin or linezolid My recommendation: Add vancomycin for: Severe pneumonia (ICU admit) IVDU (consider for post-influenza, hx MRSA) Consider Doxycycline for oral Rx Mandell LA, et al. Clin Infect Dis 2007;44 (supp 2) HCAP: Health Care Associated Pneumonia Criteria: Hospitalized within 90d, or nursing home Dialysis or hospital clinic IV antibiotics, chemo, wound care within 30d Higher mortality Different bacteriology: MRSA, Resistant gram-negatives Kollef MH, et al. Chest 2005;128: ATS/IDSA. Am J Respir Crit Care Med. 2005;171:

5 Hospital Mortality by Classification Mortality Rate (% Patients) CAP (n=2221) P< HCAP (n=988) P=NS P< HAP (n=835) VAP (n=499) BUT Publication bias in HCAP studies Many poor quality studies Poor association between HCAP and DRO in quality prospective studies Mortality not higher when adjusted for age and comorbidities Chalmers JD. Clin Infect Dis 2014;58:330.

6 Predicting Abx Resistance: DRIP Score Major (2 points): Minor (1 point): Abx in last 60d Hosp within 60d Resident in SNF Chronic pulm dz Tube Feeding Poor functional status Prior Resistant Bug Gastric acid suppression Wound Care Score > 4 is 76% sens and 91% spec for DRO - Mostly MRSA and Pseudomonas Compared w HCAP, 46% less broad abx Webb BJ. Antimicrob Agents Chemother 2016; 60:2652. Empiric Abx with DRO Risk Want to cover MRSA and Pseudomonas: - Vancomycin (or Linezolid) plus - Pip/Tazobactam or Cefepime or Ceftazidime or Levofloxacin or Ciprofloxacin or Imipenem or Meropenem Kalil AC. Clin Infect Dis (2016) 63 (5):

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8 Are we under attack by giant, radioactive, MRSAcarrying spiders from Mars???? Spider Bites and MRSA Vetter RS. West J Med. 2000;173:

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10 Should We Give Antibiotics After Abscess I & D? Many studies show no benefit of abx after I&D But, studies limited by: Done before emergence of MRSA Nonrandomized design, small numbers Vague outcome definitions Nonstandardized drainage Inappropriate antibiotic choice Moran GJ, Talan DA. NEJM Nov 16,2006;355:2155.

11 TMP/SMX v. Placebo for Abscess with I&D 1,265 pts. in 5 EDs: median abscess 2.5cm, median erythema 6.5cm, 45% MRSA T/S Placebo 14-21d 92.9% 85.7% Subseq. Surgery 3.4% 8.6% New skin infection 3.1% 10.3% Infxn in household 1.7% 4.1% Adverse events similar Talan DA et al. NEJM 2016;374:

12 Infection vs. No Infection 259 pts. Admitted from ED with cellulitis dx 30% determined to have other dx by derm in hospital or within 30 days - of these, 85% did not need hospitalization and 92% received unnecessary abx - most common venous stasis dermatitis Weng QY et al. JAMA Dermatol 2016 Nov 2. epub. PMID: Moran GJ, Talan DA. JAMA 2017;317(7):760.

13 Cellulitis?? Bedside Ultrasound of SSTI

14 Hospital or Home? 619 ED patients with skin infection 15% admitted Reasons given by ED doc: 85% need for IV abx (only reason 41%) 25% need for surgery 11% underlying disease Factors associated with admission: Fever, >10cm, Failed Tx, Comorbidity, Age Talan et al. West J Emerg Med 2015 Jan;16(1):89-97.

15 Hospital or Home? Skin infections median LOS 5d, cost > $8,000 Inpatient mortality for skin infections 0.5%* (compared to pneumonia 8-14%) No scoring system for skin infection admission WE ARE OVER-ADMITTING Not a risk of sudden death; po trial reasonable Long-acting IV antibiotics available * Khachatryan, et al. Acad Emerg Med. 2014;21(S1):S50. Moran GJ, Talan DA. JAMA 2017;317(7):760.

16 Etiology of Cellulitis Difficult to study if no pus. Results depend on methodology. Blood culture studies: 57-75% Strep and 14% Staph (but, blood cultures negative in > 90%) Punch biopsy, Aspiration studies: 9-28% Strep and 50-82% Staph Serology (ASO titer) studies: ~ 70% Strep Chambers HF. Clin Infect Dis : Should We Treat MRSA in Cellulitis? 500 outpts with cellulitis no abscess Cephalexin vs. Cephalexin+TMP-SMX x7d Cure rates: Cephalexin 85.5% Ceph + TS 83.5% Difference -2.0% (95% CI -9.7% - 5.7%) Moran GJ et al. JAMA 2017; 317(20):2088.

17 Cellulitis: Key Points Not all erythema is cellulitis Consider ultrasound to r/o abscess Trial of oral abx reasonable for most Cephalexin alone for cellulitis

18 STD Prevalences in US Thousands HSV Classic Appearance

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21 Trichomonas Wet mount only about 60% sensitive Newer Nucleic acid amplification tests (NAAT) % sens on vaginal swab or urine Treat with Metronidazole 2gm po once (topical metronidazole NOT effective) Gonorrhea in US: cdc.gov

22 Gonorrhea Rates 2015 cdc.gov Gonorrhea: Decreased Cephalosporin Susceptibility MMWR. 2012;61: 590.

23 GC - Treatment Options Fluoroquinolones no longer recommended Oral cephalosporins no longer recommended Recommended: Ceftriaxone 250 mg IM (Plus Azithro or Doxy) Cephalosporin allergy Azithromycin 2gm po PLUS gemifloxacin 320mg po (or Gent 240 IM) MMWR. 2015;64(RR-3). Chlamydia in US cdc.gov

24 U.S. Chlamydia Rates 2015 cdc.gov Zika now an STD! Mosquito-borne flavivirus Typically mild illness; ~80% asymptomatic Association w microcephaly Documented sexual transmission Virus in semen months after infection Use condom if partner pregnant/planning cdc.gov

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