Things your mother never told you about infectious diseases

Rob Kaplan, MD

July 28 and 29, 2014

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.

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.

SIMPLE CYSTITIS

• 3 day therapy with trimethoprim-sulfa or ciprofloxacin (not single dose)

• Culture not mandatory!

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.

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

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

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

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.

(Do not treat)

ASYMPTOMATIC BACTERIURIA

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…

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

Soft Tissue Cases

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

Soft Tissue-2

• A top high school basketball player scraped against his agent’s Bentley .

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

Soft Tissue-3• After minor

trauma to the foot a healthy 30 year old develops fever, shock, & severe LE pain.

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!!!

Soft Tissue-3

• A poorly-controlled diabetic w/ neuropathy develops fever and foot drainage.

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

Pulmonary Cases

60-year old previously healthy smoker with fever, cough with purulent sputum.

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

Pulmonary-2

• Alcoholic with 4 weeks of fever, weight loss, fetid sputum, left-sided chest pain.

LUNG ABSCESS

• Add Klebsiella and anaerobes to usual causes of CAP

• Ceftriaxone/Flagyl

Pulmonary-3

• An SICU patient needs prolonged intubation after abd. surgery. Now fever, inc FiO2, purulent secretions.

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

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.

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!

Neutropenic Fever-2

• A 25-year old with AML is getting induction chemo. ANC 10. T 102.5. SBP 80. Perineal skin lesions shown

ECTHYMA GANGRENOSUM

• Usually caused by Pseudomonas aeruginosa

• Gram stain and culture the lesion

• Empiric therapy now should definitely include an aminoglycoside!

Neutropenic Fever-3

• Patient with persistent neutropenia, fever despite pip/amik/van/fluc & develops hemoptysis.

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…..

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.

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.

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.

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…

#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)

#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

#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.

#2-Scrotal Abscess Gram Stain

• GRAM STAIN:

• NO WBC SEEN

• 1+ GRAM POSITIVE COCCI, PAIRS (0-1/1,000X)

#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

#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

#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

#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