Transcript Antibiotics, Cultures, and Neutropenic Fever

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.
ASYMPTOMATIC
BACTERIURIA
(Do not treat)
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
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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 poorlycontrolled
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, leftsided 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
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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/OxResistant
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
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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 (12/1,000X)
1+ GRAM POSITIVE COCCI,GROUPS (01/1,000X)
#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.
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TOBRAMYCIN <=1
AMIKACIN
<=2
CEFEPIME-4
2
PIP/TAZOBACTAM
CIPRO
<=0.25
IMIPENEM
<=1
S
S
S
S
S
S
IV:$ 2.
IV:$ 3.
IV:$ 12.
IV:$ 38.
IV:$ 18. ORAL:$ 0.18
IV:$ 60.
#2-Scrotal Abscess Gram Stain
• GRAM STAIN:
• NO WBC SEEN
• 1+ GRAM POSITIVE COCCI, PAIRS (01/1,000X)
#2 Culture/Sensis
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: HEAVY STAPHYLOCOCCUS AUREUS
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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
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ENTEROBACTER CLOACAE
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SXT (BACTRIM) >=320 R
GENTAMICIN
<=1 S
TOBRAMYCIN
<=1 S
AMIKACIN
<=2 S
CEFOXITIN
>=64 R
CEFAZOLIN-1
>=64 R
CEFTRIAXONE-3
8 S
CEFEPIME-4
<=1 S
PIP/TAZOBACTAM
S
CIPROFLOXACIN
>=4 R
ERTAPENEM
<=0.5 S
TIGECYCLINE
1 S
1 day IV:$ 21.
1 day IV:$ 8.
1 day IV:$ 2.
1 day IV:$ 3.
1 day IV:$ 29.
1 day IV:$ 6.
1 day IV:$ 4.
1 day IV:$ 12.
1 day IV:$ 38.
1 day IV:$ 18. ORAL:$ 0.18
I or R results are presumptive
I or R results are presumptive
#5-Complicated Pancreatitis
(Blood Culture)
• KLEBSIELLA
PNEUMONIAE
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AMPICILLIN >=32 R
BACTRIM
>=320 R
LEVOFLOX
>32 R
GENTAMICIN >=16 R
TOBRAMYCIN >=16 R
AMIKACIN
16 S
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CEFOXITIN
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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
>=64 R
#5 Comments from lab
• 06.21.11 - POSSIBLE ESBL AND KPC, CONFIRM. PENDING
• 06.22.11 - EXTENDED SPECTRUM B-LACTAMASE PRODUCER:
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MAY BE RESISTANT CLINICALLY TO ALL
CEPHALOSPORINS & AZTREONAM.
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HODGE TEST POSITIVE
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CARBAPENEMASE Producer-EFFICACY of ERTAPENEM
or IMIPENEM UNKNOWN
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INFECTIOUS DISEASE CONSULT SUGGESTED
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POLYMYXIN B PRESUMPTIVE:
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NON-STANDARDIZED SUSCEPTIBILITY, INTERPRET
WITH CAUTION