Head to Toe: Common infections in Hospital settings. Katya Calvo MD Medical Director of Antimicrobial Stewardship Division of Infectious Diseases

Transcription

1 Head to Toe: Common infections in Hospital settings Katya Calvo MD Medical Director of Antimicrobial Stewardship Division of Infectious Diseases

2 Objectives To identify at least one common infection in each organ system To identify likely pathogen related to infection To be able to chose antibiotic regimen based on suspected site of infection

3 "The man who asks a question is a fool for a minute, the man who does not ask is a fool for life." - Confucius

4 Important Points No consensus on definition of fever Sometimes defined as > 38.0 ⁰C (100.4 ⁰F) Arbo. Am J Med 1993; 95: Bone. Chest 1992; 101: Single elevation of > 38.3 ⁰C (101.0 ⁰F) Hughes. Clin Infect Dis 2002; 34: Neutropenic pts: >38.0 ⁰C for more than an hour Hughes. Clin Infect Dis 2002; 34: A substantial proportion of infected patients are not febrile Up to 50% of patients with fever do not have an infection (in hospitalized patients) Arbo. Am J Med 1993; 95:

5 Head-to-Toe Meningitis Sinusitis Endocarditis Pneumonia Diarrhea Lines Urinary Cellulitis

6 Case 1 24 year old female college students wakes up not feeling well, tells her roomate she will skip classes that morning. Roomate does not see her at lunch and when returns to her room at 3 pm, she is not arousable. In the ED she is noted to have a fever of ⁰F, stiff neck and petechial lesions on her lower extremities.

7 What are common pathogens in Acute Meningitis? Streptococcus pneumoniae Neisseria meningiditis Haemophilus influenzae

8 Mandell: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

9 Questions for you What antibiotics will you start empirically? Would initial antibiotics change if patient were a 65 year old alcoholic? When do we worry about chronic meningitis? Should you add Acyclovir?

10 Antibiotic Summary Empiric regimen Ceftriaxone 2 gm IV q 12 + Vancomycin (loading dose) For possible PCN resistant Streptococcus For immunocompromized Add Ampicillin 2gm IV q 4 hours If encephalitis is in your differential Acyclovir 10 mg/kg IV q 8

11 Case 2 65 year old male with HTN and DM II, presents to your clinic with 5 weeks of weight loss, night sweats, low grade fevers and on exam you note a new murmur, and note conjunctival hemorrhages and splinter hemorrhages of the toes (because you actually took his socks off!) A thorough history reveals a dental extraction 6 weeks prior

12 Common pathogen in community acquired endocarditis (native valve) Staphylococcus aureus Streptococcus Strep. viridans Strep. bovis Enterococcus HAECK Gram negative organisms De sa DD. Mayo Clin Proc. 2010;85:422-6 McDonald. Infec Dis Clin North Am. 2009;23: Murdoch. Arch Intern Med. 2009;169: Baddour. Circulation. 2005;111:e394-e434

13 Common pathogen in community acquired endocarditis (prosthetic valve) Early (< 2mo) Coag negative Staph Staph aureus Gram negative bacilli Intermediate (> 2 mo, < 1 yr) Coag neg Staph Staph Aureus Fungi Enterococcus Late (>12 mo) Streptococcus Staph aureus

14 Common pathogen in IVDA Staphylococcus aureus Streptococcus Enterococcus Gram negative bacilli Fungi Candida

15 Questions for you What antibiotic would you start empirically What must you do prior to starting antibiotics TTE or TEE?

16 Antibiotic Summary Empiric regimen Ampicillin --- Unasyn 3 gm IV q 6 + Nafcillin --- Vancomycin + Gentamicin 1 gm/kg q 8 (synergy dose)

17 Case 3 53 year old female with Hypothyroidism presents with 1 week of cough, yellow sputum production and a 2 day history of right flank pain. She has felt increasingly SOB. In the office, you check an SpO2 and it is 87% on RA

18 Terminology Community Acquired Pneumonia (CAP) Health-care Associated Pneumonia (HCAP) Any patient who was hospitalized in an acute-care hospital for 2 or more days within 90 days of presentation Residents of nursing homes, long-term care facility Received home infusion therapy (30 d) Chronic dialysis (30 d) Home wound care (30 d) Family member with multidrug-resistant pathogen Hospital Acquired Pneumonia (HAP) Ventilator Associated Pneumoina (VAP)

19 Pathogens in CAP File. Lancet 2003;362;

20 Questions for you What empiric antibiotics would you start? What tests to order for diagnosis? When do you add anaerobic coverage? When would you cover for Pseudomonas?

21 Risk factors for Pseudomonas Structural lung disease + steroid use, prior antibiotic therapy. Mandell. CID 2007;44:s27-72

22 Antibiotic Summary Empiric regimen Ceftriaxone 1-2 gm IV q day + Azithromycin 500 mg po q day OR Doxycycline 100 mg po BID If Aspiration is a concern Add Clindamycin 600 mg IV q 8 Use Unasyn 3 gm IV q 6 instead of Ceftriaxone If Pseudomonas is a concern No need to double cover Zosyn q IV 8 (extended infusion) DO NOT USE CIPROFLOXACIN

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24 HCAP/HAP/VAP HCAP Cover Pseudomonas and MRSA No need to double cover Pseudomonas HAP/VAP Cover Pseudomonas and MRSA NEED to double cover at least for 1 st dose after diagnosis CMS rules

25 Case 4 23 year old female G1P1 with a 2 month old comes to your office with diarrhea. She states that she is having 5-10 watery BM, and sometimes she does not get to the bathroom in time. No fever, no abdominal pain, just cramping.

26 Clostridium difficile infection New testing at UNM 2 step process Loose stool tested for GDH antigen and Toxin by EIA If indicated, PCR test done

27 Antibiotic Summary Initial therapy Mild/Moderate Metronidazole 500 mg po TID x days Severe (WBC 15 or SCr 1.5 x baseline) Vancomycin 125 mg po QID x days Severe, complicated (hypotension, shock, ileus, megacolon) Vancomycin 500 mg po QID + Metronidazole 500 mg IV q 8 1 st recurrence Same as initial 2 nd recurrence Vancomycin in tapered and/or pulse regimen Do not use Metronidazole Cohen. Infect Control Hosp Epidemiol 2010;31:431-55

28 Case 5 A 45 year old female comes to your office with 3 days of frequency, urgency and dysuria. On exam she is afebrile with no CVA tenderness

29 Terminology Asymptomatic Bacteriuria Acute Uncomplicated Cystitis/Pyelonephritis No pregnancy, DM, Functional or anatomical abnormalities, immunosuppression Pyelonephritis requiring hospitalization Complicated UTI Males Catheter-Associated UTI (CA-UTI)

30 SHOULD BE SCREENED Pregnant women at least once early in pregnancy Men before a transurethral resection of the prostate Other urologic procedures for which mucosal bleeding is anticipated NO SCREENING Premenopausal, nonpregnant women Diabetic women Older persons living in the community Elderly, institutionalized patients Persons with spinal cord injury Catheterized patients while the catheter remains in situ Nicole et al. CID 2005;40:

31 Pathogens in Acute Uncomplicated UTI or Pyelonephritis Uropathogens E. coli Proteus Klebsiella Enterobacter Pseudomonas Staphylococcus aureus is not normal!

32 Treatment Acute Uncomplicated Cystitis Nitrofurantoin monohydrate/macrocrystals 100 mg po BID for 5 days TMP-SMX 1 DS tablet BID for 3 days Fosfomycin trometamol 3gm in a single dose Gupta.CID 2011;52:e

33 TRICORE NON-HOSPITAL UTI ANTIBIOGRAM

34 Bactrim not to be used as first line when prevalence of resistance is more than 20% Ciprofloxacin not to be used as first line when prevalence of resistance more than 10%

35 Acute Uncomplicated Pyelonephritis 1 st Line: 7 days of therapy Ciprofloxacin 500 mg 1 PO BID Cipro ER 1000 mg 1 PO daily Alternative: 14 days of therapy Amoxicillin/clavulanate (Augmentin) 875/125 mg PO BID Cephalexin 500 mg PO QID TMP/SMX DS 1 PO BID Talan DA, et al. JAMA. 2000;283(12): Gupta, CID 2011;52:e

36 Pyelonephritis requiring Hospitalization 14 days Start with IV and then change to PO after pt is afebrile for hrs 1st line: Ceftriaxone 1 g IV q24h Ciprofloxacin 400 mg IV q12h Ampicillin 2 g IV q6h + gentamicin 3 mg/kg IV q24h Talan DA, et al. JAMA. 2000;283(12): Gupta, CID 2011;52:e

37 CAUTI -Treatment Duration 7 days for patients who have prompt resolution of symptoms 5 day therapy with Levofloxacin may be considered in patients with CA-UTI who are not severly ill Peterson et al. Urology 2008;71: day therapy may be considered in women < 65yrs, without upper tract symptoms whose catheter has been removed Harding et al. Ann Intern Med 1991;114: days for patient with delayed response Hooton et al. CID 2010;50:

38 Case 6 A 47 year old male, no PMH, is seen in your office due to a left lower extremity abscess (1x1 cm) self draining with surrounding erythema, approximately a 4 cm circumference. The area is tender and warm. Patient is afebrile, looks stable. He denies any trauma to area and there have been no animal contact.

39 Pathogens in Skin and Soft Tissue infections Erysipelas: fiery red, tender, painful plaque with well-demarcated edges. Commonly caused by streptococcal species, usually S. pyogenes Cellulitis associated with furuncles, carbuncles, or abscesses is usually caused by S. aureus Cellulitis that is diffuse or unassociated with a defined portal is most commonly caused by streptococcal species.

40 Questions for you What can you do in the office that may help management? What antibiotic are you going to prescribe? What is considered a treatment failure? Do we always worry about MRSA?

41 Antibiotic Summary Erysipelas Dicloxacillin 250 mg po QID Amoxicillin 500 mg mg po TID Cellulitis with Abscess Doxycycline 100 mg IV/PO BID SMX/TMP 2 DS tabs PO BID-TID Vancomycin (inpatient) Cellulitis without Abscess Cephalexin 500 mg PO QID Cefazolin 1 g IV q8h (inpatient) Nafcillin 12 g IV CI (inpatient) Stevens. CID 2005;41:

42 Questions for me?