Cases 2012Cases 2012

Valerie Creswell, MDValerie Creswell, MDJuly 12, 2012July 12, 2012

Case• A 75 yo wm with a history of severe COPD and

frequent acute bronchitis presents with diarrhea. The next step

• A. Inquire about antibiotic use• B. Send stool for Clostridium difficile toxin• C. Send stool for Clostridium difficile toxin times 3• D. Consider empiric metronidazole

Treatment of C. dif• If on antibiotics and if possible, stop the antibiotics-25%

of patients will respond without further therapy.• Treatment oral therapy with metronidazole 500m g q 8

hrs• Meantime for diarrhea to stop;~2-4 days• Treat for 10 days• Treat ~ 7 days before declaring drug failure if patient is

stable• Avoid peristaltic agents• Do not perform a test of cure-i.e. repeat stool for C. dif

toxin» Dale Gerding Loyola Univ. SHEA 2005

Recurrences• In pts with 1 recurrence-45% chance of additional

recurrences• Treatment

– 1. Vanco regimens– 2. Biotherapeutics– 3. passive treatment with immunoglobulins– 4. toxin binding agents– 5. fecal reconstitution

Acid Suppression

• Studies indicate 900 low risk patients need to be treated to prevent one ulcer

• One-third of low risk patients receive acid suppression during hospitalization

• 50% of low risk patients are discharged with prescriptions for acid suppression

1. DeVault KR, Castell DO. Am J Gastroentrol 2005;100:190-200. 2. Heidelbaugh JJ, Inadomi JM. Am J Gastroenterol 2006;107:1-6. 3. Mostafa G, Sing RF, Matthews BD, Pratt BL, Norton HF, Heniford BT. Am Surg 2002;68:146-150. 4. Nardino RJ, Vender RJ, Herbert PN. Am J Gastroenterol 2000;95:3118-3122. 5. Naunton M, Peterson GM, Bleasel MD. J Clin Pharm Ther 2000;25:333-340. 6. Pham CoQD, Regal RE, Bostwick TR, Knauf KS. Ann Pharmacother 2006;40:1261-1266. 7. Pham CoQD, Sadowski-Hayes LM, Regal RE. P&T 2006;31:159-167. 8. Yang Y, Lewis JD, Epstein S, Metz DC. JAMA 2006;296:2947-2953.

Complications of Acid Suppression

• Infection: C. difficile, MSSA, MRSA, VRE, community acquired pneumonia

• Drug-drug interactions• Drug-nutrient interactions• Increased costs

1. DeVault KR, Castell DO. Am J Gastroentrol 2005;100:190-200. 2. Heidelbaugh JJ, Inadomi JM. Am J Gastroenterol 2006;107:1-6. 3. Mostafa G, Sing RF, Matthews BD, Pratt BL, Norton HF, Heniford BT. Am Surg 2002;68:146-150. 4. Nardino RJ, Vender RJ, Herbert PN. Am J Gastroenterol 2000;95:3118-3122. 5. Naunton M, Peterson GM, Bleasel MD. J Clin Pharm Ther 2000;25:333-340. 6. Pham CoQD, Regal RE, Bostwick TR, Knauf KS. Ann Pharmacother 2006;40:1261-1266. 7. Pham CoQD, Sadowski-Hayes LM, Regal RE. P&T 2006;31:159-167. 8. Yang Y, Lewis JD, Epstein S, Metz DC. JAMA 2006;296:2947-2953.

• Vancomycin is the perfect antibiotic because resistance has never developed and it never will.– Anonymous ID physician 1985

• I used to be Snow White but I drifted.

Mae West

24 yo wm with LLE cellulitis 24 yo wm with LLE cellulitis who weighs 300 lbs with a who weighs 300 lbs with a Cr 0.5. Your initial vanco Cr 0.5. Your initial vanco dose would be:dose would be:A.A.Vanco 1 gm IV q 12 hrsVanco 1 gm IV q 12 hrsB.B.Vanco 1.5 gm q 8 hrsVanco 1.5 gm q 8 hrsC.C.Vanco load 3 gm IV then Vanco load 3 gm IV then 1.5 q 8 hrs1.5 q 8 hrs

Active surveillance Active surveillance includes swabbing the includes swabbing the nares for MRSA. If nares for MRSA. If positive, you shouldpositive, you shouldA.A. Give Vanco IV q 12 hours Give Vanco IV q 12 hours

for 1 weekfor 1 weekB.B. Place in droplet precautionsPlace in droplet precautionsC.C. If scheduled for surgery, If scheduled for surgery,

give Cefazolin preopgive Cefazolin preopD.D. If scheduled for surgery, If scheduled for surgery,

treat with mupirocin treat with mupirocin intranasally bid for 5 days intranasally bid for 5 days and a chlorhexidine shower and a chlorhexidine shower the night beforethe night before

Who to screen?

• ICU admissionsICU admissions• Transfers from other hospitals or care facilities, Transfers from other hospitals or care facilities,

prisonsprisons• Surgical patients-esp. cardiovascular, prosthetic Surgical patients-esp. cardiovascular, prosthetic

joint surgeriesjoint surgeries• Dialysis patientsDialysis patients• Other high risk patients-antibiotic use in last 3 Other high risk patients-antibiotic use in last 3

months, hospitalization in last 12 months, skin or months, hospitalization in last 12 months, skin or soft tissue infection, HIVsoft tissue infection, HIV

• Not patients already identified with MRSANot patients already identified with MRSA

Decolonization

• Mupirocinintranasally bid for 5 daysMupirocinintranasally bid for 5 days• Chlorhexidine showers daily for 7 days Chlorhexidine showers daily for 7 days

then 3 times a week for several weeksthen 3 times a week for several weeks• If pt has a history of MRSA, then Vanco If pt has a history of MRSA, then Vanco

1 gm IV given over an hour as preop 1 gm IV given over an hour as preop antibioticantibiotic

• Must document a reason for using Must document a reason for using vancomycin for surgical prophylaxisvancomycin for surgical prophylaxis

Treatment of Choice for MSSATreatment of Choice for MSSA

A. VancomycinA. VancomycinB. ClindamycinB. ClindamycinC. AzithromycinC. AzithromycinD. NafcillinD. Nafcillin

Staphylococcus aureus

• TreatmentTreatment• If susceptible, Nafcillin is indicated If susceptible, Nafcillin is indicated • In pts with true penicillin allergy, In pts with true penicillin allergy,

Cefazolin is an acceptable alternative Cefazolin is an acceptable alternative • In vitro data suggest that vancomycin is In vitro data suggest that vancomycin is

a less effective antistaphyloccal drug a less effective antistaphyloccal drug than the beta-lactamsthan the beta-lactams

Lowy NEJM Aug 20,1998 520-32

Nafcillin dosingNafcillin dosing

A. 2 gm IV q 6 hrsA. 2 gm IV q 6 hrsB. Continuous infusion 8 gm IV dailyB. Continuous infusion 8 gm IV dailyC. Bolus with 2 gm IV then 8 gm dailyC. Bolus with 2 gm IV then 8 gm daily

Nafcillin Time > MIC

0

10

20

30

40

50

60

0 2 4 6 8 10 12 14 16 18 20 22 24

2 gm q4h

8 gm CI

6 steps to Improve antibiotic therapy in the ICU

1. Fever should not mean automatic antibiotics1. Fever should not mean automatic antibiotics2. Cultures should be obtained before starting antibiotics2. Cultures should be obtained before starting antibiotics3. Single drug and the most narrow spectrum should be 3. Single drug and the most narrow spectrum should be

used when possible.used when possible.4. Reassess need for antibiotics daily4. Reassess need for antibiotics daily5. Antibiotic 5. Antibiotic surveillancesurveillance should be limited to should be limited to

24 hours or less24 hours or less

Maki Crit Care Med: Principles of Diagnosis and Management, Maki Crit Care Med: Principles of Diagnosis and Management, 1995 pp 893-9541995 pp 893-954

Pt has temp to 100.5 Pt has temp to 100.5 UA shows 5-10 wbcs and it grows UA shows 5-10 wbcs and it grows

10,000 cfu Candida glabrata10,000 cfu Candida glabrataA. Start Amphotericin BA. Start Amphotericin BB. Start MicafunginB. Start MicafunginC. Start fluconazoloeC. Start fluconazoloeD. Remove the foleyD. Remove the foley

Asymptomatic Bacteruria

• During catheterization or within 48 hrs During catheterization or within 48 hrs of cath removal if a pt has a positive of cath removal if a pt has a positive culture with >100,000 cfu/ml of an culture with >100,000 cfu/ml of an organism with no symptoms or organism with no symptoms or symptoms related to other infectious symptoms related to other infectious process process

• Document in the chartDocument in the chart

18 yo college student is admitted 18 yo college student is admitted with confusion and fever. with confusion and fever.

CSF gram stain shows gram negative CSF gram stain shows gram negative diplococcidiplococci

A. Place pt in droplet precautions until A. Place pt in droplet precautions until he’s completed 7 days of treatmenthe’s completed 7 days of treatment

B. Use meningitis order setB. Use meningitis order setC. Inquire about his pneumococcal C. Inquire about his pneumococcal

vaccination statusvaccination statusD. Immediately take one dose of Cipro D. Immediately take one dose of Cipro

because you examined the ptbecause you examined the pt

A. Place pt in droplet A. Place pt in droplet precautions until he’s completed precautions until he’s completed 7 days of treatment7 days of treatmentB. Use meningitis order setB. Use meningitis order setC. Inquire about his C. Inquire about his pneumococcal vaccination pneumococcal vaccination statusstatusD. Immediately take one dose D. Immediately take one dose of Cipro because you examined of Cipro because you examined the ptthe pt

Infection Control-Precautions• Contact

– Resistant organisms-MRSA, Clostridium difficile(wash your hands with soap and water)

• Droplet– SuspectedNeisseriameningitidis or

Hemophilus influenza meningitis-for 24 hours from the first dose of appropriate antibiotics

– Influenza, pertussis etc.• Airborne

– Suspected Tuberculosis-keep the door closed!

CiprofloxacinCiprofloxacin

A. Can cause seizuresA. Can cause seizuresB. Binds with Calcium, Magnesium, Iron and B. Binds with Calcium, Magnesium, Iron and

tube feedingtube feedingC. Can select out for VREC. Can select out for VRED. Can select out carbepenam resistance in D. Can select out carbepenam resistance in

Pseudomonas aeruginosaPseudomonas aeruginosa

A blood culture with this organism A blood culture with this organism growing is generally a contaminant:growing is generally a contaminant:

A. Enterobacter cloacaeA. Enterobacter cloacaeB. Staphylococcus aureusB. Staphylococcus aureusC. Staphylococcus epidermidisC. Staphylococcus epidermidisD. Candida albicansD. Candida albicans