Things your mother never told you about infectious diseases Rob Kaplan, MD July 28 and 29, 2014.
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Transcript of Things your mother never told you about infectious diseases Rob Kaplan, MD July 28 and 29, 2014.
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Things your mother never told you about infectious diseases
Rob Kaplan, MD
July 28 and 29, 2014
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How to treat infections in one slide
• Is there an infection? Is therapy urgent?
• Pathogens? Likely sensis?• Choose antibiotics for pathogens,
site of infection, and patient.• Drainage?• Adjust approach based on data.
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UTI Cases
• A 21-year-old sexually active woman has one day of dysuria but no fever. Exam is normal; urinalysis shows many wbc and bacteria.
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SIMPLE CYSTITIS
• 3 day therapy with trimethoprim-sulfa or ciprofloxacin (not single dose)
• Culture not mandatory!
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UTI-2
• A 65-year-old man with BPH has 2 days of fever, rigors, vomiting, and severe left flank pain. T 102.8, marked left CVAT, moderately enlarged, nontender prostate. Urine-many WBC, GPC. WBC 16, cre 1.0.
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COMMUNITY-ACQUIRED PYELONEPHRITIS
• Admit, IV antibiotics. Here include vancomycin given GPC. GRAM STAIN HELPED! If just GNR not needed. Probably vancomycin and ceftriaxone.
• Switch to po when doing well, sensis known.
• Total duration at least 2 weeks
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UTI-3• A 50 year old quadriplegic, long
term resident of VA SCI service, develops fever, altered mentation, and hypotension. Exam shows no skin lesions or inflammation; CXR clear. Foley urine many wbc, mixed bacteria, pH8
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HEALTH-CARE ASSOCIATED UROSEPSIS
• Supportive care with lots of fluid +/-pressors. Consider ICU.
• Empiric antibiotics to cover resistant GNR +MRSA. At VA Pseudomonas resistant to zosyn. Change based on results.
• Rec: Vancomycin, Cefepime, consider Amikacin
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UTI-4
• Down the hall from case 3, another longterm resident of SCI gets a routine urinalysis from his Foley which shows 800 WBC and mixed bacteria. Afebrile, VSS, no new symptoms. No skin lesions; normal mental status. WBC 6, crea 0.5.
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(Do not treat)
ASYMPTOMATIC BACTERIURIA
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UTI-5
• A 79-year old paraplegic man with chronic neurogenic bladder has T 102.1, WBC 12, U/A 2600 WBC and many bacteria.
• Started on ceftriaxone. Urine grows Klebsiella pneumoniae resistant only to ampicillin.
• Fever continues…
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NOT UTI-5
• Exam reveals RUQ tenderness above level of SCI
• Abd CT reveals edematous GB wall
• Metronidazole added for anaerobic coverage
• Cholecystectomy performed: Acute cholecystitis
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Soft Tissue Cases
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NON-PURULENT CELLULITIS/ERYSIPELAS
• Very likely to be Strep.
• Good track record of studies supporting not covering MRSA
• Keflex, Augmentin (or even Penicillin, Amoxicillin) reasonable for outpatient use
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Soft Tissue-2
• A top high school basketball player scraped against his agent’s Bentley .
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SUPPURATIVE SOFT TISSUE INFECTION
• Incise and drain first and foremost
• Special focus is MRSA
• For hospitalized patient vancomycin
• For outpatient TMP-sulfa or doxycycline/minocycline
• Yes there are other choices
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Soft Tissue-3• After minor
trauma to the foot a healthy 30 year old develops fever, shock, & severe LE pain.
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NECROTIZING FASCIITIS
• Representative of complex soft tissue infections with many names
• When to think of this?• Group A strep, or clostridial, or mixed
aerobes and anaerobes…• Initial rx: Vanco/Cefepime/Flagyl. May
substitute clinda for flagyl for Eagle effect.• SURGERY!!!
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Soft Tissue-3
• A poorly-controlled diabetic w/ neuropathy develops fever and foot drainage.
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DIABETIC FOOT INFECTION
• Mixed aerobes and anaerobes. May include Pseudomonas.
• Often bone involved• Often with poor perfusion• Deep cultures to guide therapy.
Vancomycin/Cefepime/Flagyl• IF GANGRENE OR SEPSIS OR
CHRONIC OSTEO-->SURGERY
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Pulmonary Cases
60-year old previously healthy smoker with fever, cough with purulent sputum.
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COMMUNITY-ACQUIRED PNEUMONIA
• Pneumococcus, Haemophilus, Moraxella, maybe Legionella. Consider anaerobes, special exposure/risk history
• TRY TO GET SPUTUM GRAM STAIN AND CULTURE
• Ceftriaxone/Azithromycin or respiratory quinolone
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Pulmonary-2
• Alcoholic with 4 weeks of fever, weight loss, fetid sputum, left-sided chest pain.
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LUNG ABSCESS
• Add Klebsiella and anaerobes to usual causes of CAP
• Ceftriaxone/Flagyl
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Pulmonary-3
• An SICU patient needs prolonged intubation after abd. surgery. Now fever, inc FiO2, purulent secretions.
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VENTILATOR-ASSOCIATED PNEUMONIA
• Possibility of resistant hospital flora
• Get deep specimen Gram stain and culture
• Vancomycin, Cefepime (or Carbapenem if previously on beta lactam), probably Amikacin
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Neutropenic Fever-1
• A 50-year old is getting cytotoxic chemotherapy for a solid tumor thru a Hickman catheter. ANC 200. T>100.5. No localizing findings.
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BASIC FEVER, NEUTROPENIA
• Key organism is Pseudomonas aeruginosa• Empiric therapy mandatory• Single drug regimen with Cefepime as good as
combos with aminoglycoside and penicillin• Staph coverage not mandatory immediately, but…• EXAMINE THE PATIENT!
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Neutropenic Fever-2
• A 25-year old with AML is getting induction chemo. ANC 10. T 102.5. SBP 80. Perineal skin lesions shown
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ECTHYMA GANGRENOSUM
• Usually caused by Pseudomonas aeruginosa
• Gram stain and culture the lesion
• Empiric therapy now should definitely include an aminoglycoside!
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Neutropenic Fever-3
• Patient with persistent neutropenia, fever despite pip/amik/van/fluc & develops hemoptysis.
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INVASIVE ASPERGILLOSIS
• Vs. Mucor, Fusarium, others
• Bad prognosis without neutrophil recovery
• Blood antigen testing may help but often need invasive diagnosis
• Voriconazole best for Aspergillus. For others…..
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Cultures: Urine and Sputum• Urine-- clean catch specimen. Get
initial Gram stain. >10**5 not absolute.
• Sputum—Gram stain <10epi >25polys. Match up GS & culture. Get BC before rx for pneumonia if hospitalized.
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Cultures: Miscellaneous (GET A GRAM STAIN TOO!!)
• Large specimen better than a swab, esp for anaerobes. Consider BC bottle. No sputum for anaerobe cult.
• Get specimen to lab quickly. • Routine stool cultures cover E. coli,
Salmonella, Shigella, Campy. • Contact lab for special requests. Ag
detection and PCR as alternatives to cultures.
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Blood cultures• “Sets,” not “bottles”. One set = 20-30 cc of
blood from one stick divided into two bottles. Basic unit = 2 sets 5 minutes apart. (More for endocarditis)
• VA Lab disclaimer for <3cc/bottle• Use appropriate antisepsis! • Staph epi & diphtheroids usually contaminants
unless…• Do not order Gram stain of blood.
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Interpreting sensis• For staph: Resistant to Meth/OxResistant
to all other Beta Lactams*
• For GNR: normally more sensitive with increasing generation of cephs. If not, suspect ESBL!!
• Generally switch to least expensive/least toxic sensitive choice unless special situations…
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#1- Diabetic Ulcer Gram Stain•
• GRAM STAIN:• NO WBC SEEN • 4+ GRAM NEGATIVE RODS (>10/1,000X) • 1+ GRAM POSITIVE RODS (0-1/1,000X) • 2+ GRAM POSITIVE COCCI,PAIRS (1-2/1,000X) • 1+ GRAM POSITIVE COCCI,GROUPS (0-
1/1,000X)
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#1-Culture
• 4 OR MORE ORGANISMS, PLEASE ADVISE. PLATES HELD 3 DAYS.
• HEAVY PSEUDOMONAS SPECIES
• HEAVY ALPHA HEMOLYTIC STREPTOCOCCUS
• FEW DIPTHEROIDS
• WORKED 2 PSEUDOMONAS COLONY TYPES
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#1-Sensis
• PSEUDOMONAS AERUGINOSA• GENTAMICIN <=1 S IV:$ 8.
• TOBRAMYCIN <=1 S IV:$ 2.
• AMIKACIN <=2 S IV:$ 3.
• CEFEPIME-4 2 S IV:$ 12.
• PIP/TAZOBACTAM S IV:$ 38.
• CIPRO <=0.25 S IV:$ 18. ORAL:$ 0.18
• IMIPENEM <=1 S IV:$ 60.
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#2-Scrotal Abscess Gram Stain
• GRAM STAIN:
• NO WBC SEEN
• 1+ GRAM POSITIVE COCCI, PAIRS (0-1/1,000X)
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#2 Culture/Sensis
• : HEAVY STAPHYLOCOCCUS AUREUS :• TETRACYCLINE <=1 S 1 day IV:$ 14. ORAL:$ 0.10 • ERYTHRO >=8 R • BACTRIM <=10 S 1 day IV:$ 21. ORAL:$ 0.12• CLINDA <=0.25 S 1 day IV:$ 3. ORAL:$ 0.72 • GENTAMICIN <=0.5 S 1 day IV:$ 8.• VANCOMYCIN <=0.5 S 1 day IV:$ 10.• OXACILLIN >=4 R 1 day IV:$ 79. ORAL:$ 0.48 • CIPRO >=8 R 1 day IV:$ 18. ORAL:$ 0.18• RIFAMPIN <=0.5 S 1 day IV:$ 49. ORAL:$ 0.90• TIGECYCLINE <=0.12 S I or R results are presumptive• LINEZOLID 2 S I or R results are presumptive• DAPTOMYCIN 0.5 S
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#4-Abdominal Abscess after perfed DU
• ENTEROBACTER CLOACAE
• SXT (BACTRIM) >=320 R 1 day IV:$ 21.
• GENTAMICIN <=1 S 1 day IV:$ 8.
• TOBRAMYCIN <=1 S 1 day IV:$ 2.
• AMIKACIN <=2 S 1 day IV:$ 3.
• CEFOXITIN >=64 R 1 day IV:$ 29.
• CEFAZOLIN-1 >=64 R 1 day IV:$ 6.
• CEFTRIAXONE-3 8 S 1 day IV:$ 4.
• CEFEPIME-4 <=1 S 1 day IV:$ 12.
• PIP/TAZOBACTAM S 1 day IV:$ 38.
• CIPROFLOXACIN >=4 R 1 day IV:$ 18. ORAL:$ 0.18
• ERTAPENEM <=0.5 S I or R results are presumptive
• TIGECYCLINE 1 S I or R results are presumptive
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#5-Complicated Pancreatitis (Blood Culture)
• KLEBSIELLA PNEUMONIAE
• AMPICILLIN >=32 R
• BACTRIM >=320 R
• LEVOFLOX >32 R
• GENTAMICIN >=16 R
• TOBRAMYCIN >=16 R
• AMIKACIN 16 S
• CEFOXITIN >=64 R
• CEFAZOLIN-1 >=64 R• CEFTRIAXONE-3 >=64 R• PIP/TAZOBACTAM R• CIPROFLOXACIN >=4 R• TIGECYCLINE 4 I
• TIMENTIN >256 R
• POLYMYXIN B 1.0 • CHLORAMPHENICO>256 R
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#5 Comments from lab
• 06.21.11 - POSSIBLE ESBL AND KPC, CONFIRM. PENDING
• 06.22.11 - EXTENDED SPECTRUM B-LACTAMASE PRODUCER:
• MAY BE RESISTANT CLINICALLY TO ALL CEPHALOSPORINS & AZTREONAM.
• HODGE TEST POSITIVE
• CARBAPENEMASE Producer-EFFICACY of ERTAPENEM or IMIPENEM UNKNOWN
• INFECTIOUS DISEASE CONSULT SUGGESTED
• POLYMYXIN B PRESUMPTIVE:
• NON-STANDARDIZED SUSCEPTIBILITY, INTERPRET WITH CAUTION