Infectious Diseases Emergencies

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Antibiotic Choices for Infections which Require Hospitalization Rodolfo E. Bégué, MD Chief, Infectious Diseases Pediatrics, LSUHSC [email protected]

Transcript of Infectious Diseases Emergencies

Page 1: Infectious Diseases Emergencies

Antibiotic Choices for Infections which Require Hospitalization

Rodolfo E. Bégué, MD

Chief, Infectious Diseases

Pediatrics, LSUHSC

[email protected]

Page 2: Infectious Diseases Emergencies

Infections which require hospitalization

Examples:r/o sepsismeningitis / encephalitisbrain abscess / orbital cellulitispneumonia / endocarditisacute abdomenurinary tract infection bone & jointskin & skin structures

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r/o sepsis

• Toxicity = clinical picture - lethargy - hypoperfusion - hypoventilation, hyperventilation or cyanosis.

• Hyperthermia or hypothermia• Tachycardia• Tachypnea• Leukocytosis or leukopenia

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Sepsis work-up

• Cell Blood Count (CBC).

• Urine analysis.

• Chest roentgenogram.

• Lumbar puncture.

• Cultures: blood, urine, stool, CSF

• Other: NPA

• (CRP, Procalcitonin)

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Etiologies of Sepsis

< 1 month of age

• Group B Streptococcus

• Escherichia coli

• (Listeria monocytogenes)

1-3 months of age

• Streptococcus pneumoniae (↓)

• Group B Streptococcus

• Neisseria meningitidis

• Salmonella spp

• (Haemophilus influenzae b)

• (Listeria monocytogenes)3-36 months of age

• Streptococcus pneumoniae (↓)

• Neisseria meningitidis

• (Haemophilus influenzae b)

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Antibiotics for a child with r/o Sepsis

Empiric Antibiotic Treatment:< 1 month:Ampicillin + Gentamicin

Ampicillin + Cefotaxime1-3 months: Ampicillin + Cefotaxime> 3 months: Cefotaxime

(Vancomycin?)

x 7-14 days

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Is it a contaminant?

• 1 vs >2 positive culture

• Pathogen vs no pathogen

• Symptoms vs no symptoms

• Plate vs broth (“thio”)

• Timing

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Central Line Infection

• Central & Peripheral Blood Culture

• Gram-positive, Gram-negative, Fungi

• If possible, change line(Staph, Enteroc, GN, Fungi, Mycobact)

• vs treat through line

• If line out: ~ 1 weekIf line in: ~ 2 weeks

• Antibiotic lock

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Bacterial Meningitis

• Diagnosis: LP, LP, LP

• Should I do an LP?

• Increased intracranial pressure

• Prior antibiotics

• “Bloody tap”

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Bacterial Meningitis: Treatment

• Empiric treatment with:cefotaxime plus vancomycin

• Modify according to susceptibilities:penicillincefotaximevancomycin plus cefotaxime

• Corticosteroids (?)

• Rifampin (?)

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Aseptic Meningitis

• Viral (enterovirus vs others)

• “Partially treated”

• Other causes only on special populations

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Encephalitis

• Not bacterial

• Viral HSV Enterovirus Arbovirus (WNV) EBV, CMV, etc

• ADEM

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HSV Encephalitis

Acyclovir:

60 mg/kg/d div q 8 hr

750 mg/m2/d div q 8 hr

x 21 days IV

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Brain abscess

Source:

• Proximity: middle ear, sinuses

• Meningitis

• Hematogenous

• Penetrating: wound, surgery

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Brain abscess

Triad:

• Headache

• Focal neurologic findings

• Fever

Treatment:

• Surgery

• Antibiotics: Cefotax + Vanco + (Metro)

• for 4-8 weeks (IV)

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Orbital Cellulitis

Triad:

• Proptosis

• Decreased eye movement

• Pain on eye movement

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Orbital Cellulitis

Treatment:

• Antibiotics:Cefotax + Vanco + (Metro) Cefotax + Clindax 10-14 d IV and 7-14 d PO

• Surgery (ORL, Ophthalmology)

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HSV Keratitis

Management:

• With an ophthalmologist

• antivirals:1-2% trifluridine1% iododeoxyuridine3% vidarabinex 14-21 days

• topical corticosteroids contraindicated

• No need for systemic acyclovir

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Pneumonia

• Viral:Influenza, RSV

• BacterialStreptococcus pneumoStaph aureusGroup A Streptococcus

• TB

• ChlamydiaMycoplasma

• Fungal

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Empiric Treatment for Pneumonia

• If sick enough to require admission (assuming viral panel negative), the regular r/o sepsis regimen is usually OK:• Ampi + genta / Ampi + cefotax / Cefotax• Usually add a macrolide (erythro or azithro)• Add Vancomycin if VERY sick or necrotizing• Others (TB, Gram-negative, PCP, fungal) only if a

good reason to suspect

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Endocarditis• Acute Staph (MRSA)

• Subacute viridans Strept

• Antibiotics: Vanco + gentamicin

• X 2 w, 4-6 w

• Surgery (?)

Pericarditis• “Purulent pericarditis”

• Strept PneumoStaph aureus (MRSA)

• Antibiotics: Ceftriaxone + Vancomycin

• X 4 weeks

• Surgery (?)

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Acute Abdomen

Treatment

• Surgery

• Antibiotics

Mild-moderate Severe

Ampi/sulb, Ticar/clav Piperac/Tazobactam

Imipenem, Meropenem, Ertapenem

Cefazolin or cefuroxime+ metronidazole

Cefotax, ceftriax, ceftaz, cefepime+ metronidazole

Gentamicin (Tobra) plus Clinda (Metronidazole) + ampicillin

Cipro, levoflox, gatiflox+ Metronidazole

Aztreonam + Metronidazole

For 5-7 days IDSA. CID 2010;50:133-64

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Urinary Tract Infection

• Always suspect in febrile children < 2 yrs of age

• Dx of UTI requires a UCx (bag-specimen not good)

• UA (WBC), dipstick OK as a guide, especially in combination

• Gram stain (“unspun” urine)

Etiology

• Escherichia coli

• Enterococcus

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Urinary Tract Infection

Follow-up

• US, VCUG

• DMSA scan

• Consider prophylaxis

Inpatient

• Cefotaxime or Ceftriaxone

• Ampicillin + gentamicin

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Septic arthritis

• Fever, joint pain/swelling, decreased ROM

• Diagnosis: clinical, XR (hip), US, arthrocentesis, CT (SI)

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Septic arthritis

Treatment:

• Aspirate vs Surgery: hips, shoulders

• Antibiotics:Oxacillin + cefotaximeCefuroxime

• x 3 weeks (IV/PO)

Etiologies:

• Staph aureus

• Streptococcus (GAS, Strept pneumo)

• Kingella kingae

• Neisseria (GC, N. meningitidis)

• (H. influenzae)

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Osteomyelitis

• Staph aureus

• (Others in especial populations)

• ClindamycinVancomycinLinezolid

• X 4 weeks (IV/PO)

• Surgery

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Puncture wounds (foot)

Etiology

• Staph aureus (~ 3 d)

• Pseudom spp (~ 7 d)

• Mycobacteria (~ 2-4 w)

Treatment

• Wound careTetanus vaccineAnti-Staph antibiotics

• If no responseSurgical exploration → cultureCeftazidime → ciprofloxacin (for 2 w)

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Skin and Soft Tissue

• Etiology:Group A Streptococcus Staphylococcus aureus (MRSA)Strep pneumo / Hib

• Treatment:Vancomycin or Clindamycinadd genta or rifampin?linezolid??

• Drain any abscess

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D test

• MRSA

• Erythro RClinda S

• D test negative: OK to use Clinda

• D test positive: do not use Clinda

Siberry et al. CID 2003;37:1257-1260