Transcript Antibiotic Use in Clinical Practice

Diagnosis and Treatment of
Common Infectious Diseases
Angela Heithaus, MD, PS
Internal Medicine
Seattle Healing Arts Center
Gioconda
 20 YO non-pregnant UW female student
sexually active 3 x week with 1 partner
over past 6 months (he is
asymptomatic), no prior medical history
including STD
 C/O: pain on urination x 3 days with
increased frequency and urgency, some
suprapubic pain, no: blood, back pain,
vaginal d/c, fever
Epidemiology
 First 10 years of life:
 Girls 3%
Boys 1.1%
 Teen girls 0.5 episodes/year
 Adult women 50-60% at least 1
episode/life time
 Young, sexually active women 0.5
episodes/ person year
 Post-menopausal women 0.07% episodes
per person per year
UTI
 UNCOMPLICATED
 Healthy, young, nonpregnant female
 COMPLICATED
 Everything else: men,
recurrent UTI, pyelo,
in-dwelling catheters,
pregnant, diabetic
 Increased risk of
failing therapy
Microbiology
 80-85% Escherichia coli
 Staphylococcus saprophyticus, Proteus
mirabilis, enterococci
 Chlamydia-(acute urethral syndrome)
 Negative standard culture
Diagnosis in Uncomplicated UTI
 PEx
 Nl temp
 No costovertebral angle tenderness
 Clinical Criteria
 Dipstick: leukocyte esterase (pyuria) and nitrite
(Enterobacteriaceae)
75-96% sensitivity; 94-98% specificity for
detecting >10 leukocytes per HPF
 Evaluation of mid stream urine (unspun) for pyuria
is most valuable laboratory diagnostic test
(abnl: 10 or more leukocytes per microL)
Selected Oral AB Regimens for
Use in Uncomplicated UTI
Drug
Dose, Intervals
Duration
Ciprofloxacin
100-250 mg q12 hrs 3 days
(500 mg q24)
Levofloxacin
250 mg q24 hrs
3 days
Trimethoprim160/800 mg q12 hrs 3 days
sulfamethoxazole
Trimethoprim
100 mg q12 hrs
3 days
Amoxicillin/
Clavulanate
500 mg q 12 hrs
7 days
Giovanni Battista Morgagni
 22 YO M C/O (not: homeless, recently
incarcerated, IDU, in military, on athletic
team or have family member with
infection):
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Local pain, swelling, redness
? Drainage
? Hit something a while ago
Denies: fever, chills
Skin and Soft Tissue Infections
 Cellulitis
 Most common skin infection leading to
hospitalization
 Superficial, spreading infection involving
subcutaneous tissue
 Other Common Skin Infections
 Impetigo, Folliculitis, Furuncles, and
Carbuncles
 Abscess
Impetigo, Folliculitis, Furuncle,
Carbuncle
 Impetigo: superficial vesiculopustular skin
infection occurring prominently on
exposed areas of the face and extremities
 FFC: arise from hair follicle
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Staph Aureus
Rarely require hospitalization
Respond to local measures
Recurrence may be prevented by decreasing
staph aureus skin carriage
Abscess
 Localized accumulation of
polymorphonuclear leukocytes with tissue
necrosis involving the dermis and
subcutaneous tissue
 Large numbers of microorganisms are
typically present in the purulent material
 Infection begins from tracking in from the
skin surface
Microbiology
 Most common microorgansim: Staph
Aureus
 Increased incidence of communityassociated infections due to: methicillinresistant S. Aureus (CA-MRSA)
 Urban ER: 61/119 MRSA isolated
 An average of more than 3 organisms;
anaerobic in 1/3 of cases (1/2 IDU)
Management
 Incision, Drainage and culture
 Fluctuant or has ‘pointed’
 Culture ?MRSA
 Bacteremia and Antibiotic Prophylaxis
 AHA guidelines for those high risk for EC and who
have hardware (oxacillin, cefazolin, vanco)
 Oral Antibiotic Therapy
 Not ready for I&D, cellulitis, fever, high-risk features
 Community Associated MRSA
 Awareness of the local antimicrobial susceptibility
patterns of community S. aureus isolates
Oral Antibiotic Therapy
Drug
Dosage, interval
Dicloxacillin
Cephalexin
Clindamycin
Azithromycin
500 mg qid
250 mg qid
150-450 mg qid
500 mg x 1, 250 mg qd
Oral, peri-rectal, vulvovaginal abscesses
Amoxicillin-clavulanate
Clindamycin
PLUS Ciprofloxacin
875/125 mg BID
150 mg QID
500 mg BID
Galileo Galilei
 40 YO otherwise healthy, non-smoker C M
presents C/O:
 dry cough x 2 weeks
 clear sputum production and fatigue
 Denies: pharyngitis, fever, chills
 Vitals: Nl temp, RR, P
Acute Bronchitis
 Over 90% are viral
 Approximately 60% of patients seeking
medical care are given antibiotics
 One of the most common causes of
antibiotic abuse
 ACP and CDC state Pertussis is only form
that should be treated
Usual Suspects
Coronavirus (types 1-3)
Rhinovirus
Influenza A and B
Parainfluenza
Respiratory syncytial virus
Human metapneumovirus
Influenza
 Cough, purulent sputum, fever, and
constitutional complaints during the
influenza season
 Amantadine, rimantadine, or
neuraminidase inhibitors
 Must be given within 48 hours of symptom
onset for demonstrable benefit
Other Suspects
 Mycoplasma pneumoniae
 Chlamydophila (formerly Chlamydia)
pneumoniae
 Bordetella pertussis (severe paroxysmal
cough)
To Shoot or Not to Shoot
Pneumonitis vs Acute Bronchitis
Abnl vital signs:
temp > 38 C (100.4 F)
Pulse > 100/min
RR >24
Crackles on exam
Chronic Cough
Think…
 Postnasal drip syndrome
 Asthma
 Gastroesophageal reflux
Beatrice
 28 YO otherwise healthy female who C/O:
 nasal congestion, purulent nasal
discharge, maxillary tooth discomfort,
hyposmia, and facial pain or pressure that
is worse when bending forward,
headache, fever (nonacute), halitosis,
fatigue, cough, ear pain, and ear fullness
Acute Sinusitis
 Almost all cases viral in etiology
 Rhinovirus, parainfluenza, and influenza virus
 Usually resolves in 7-10 days
 2% complicated by acute bacterial sinusitis
 Streptococcus pneumoniae and Haemophilus
influenzae
 Self-limited, 75% resolve without tx in 1 month
 Morbidity can include intracranial and orbital
complications and of possibly developing chronic
sinus disease
How many get it?
 Average adult has from 2-3 colds and influenza-like
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illnesses per year
Average child six to 10
Represents approximately one billion acute respiratory
illnesses annually
Approximately 0.5 to 2 percent of colds and influenzalike illnesses are complicated by acute bacterial sinusitis
in adults
Annual incidence of acute community-acquired bacterial
sinusitis is approximately 20 million cases
Comparison of Contemporary Guidelines for the Diagnosis
of Acute Community Acquired Bacterial Sinusitis
 CDC
 Sinus & Allergy Health
 Maxillary pain or
Partnership
 Persistant sxs after 10
days or worsening after
5-7 days
tenderness in face or
teeth + rhinorrhea, no
improvement x 7 days
 Severe sxs
 Plain films not needed
 Nasal drainage,
congestion, d/c; facial
pressure/pain;
hyposmia/anosmia; fever;
cough; ear sxs
 Plain films, CT, MRI not
needed
Treatment of Viral Rhinosinusitis
in Adults
 At first sign of a cold
 Sustained release 1st generation antihistamine
(chlorpheniramine, brompheniramine,
clemastine), PLUS NSAID (ibuprofen,
naproxen)
 Continue taking both q 12 hrs until sxs clear
 Add oral decongestant (pseudoephedrine)
and/or a cough suppressant
(dextromethrophan)
 If sxs persist and are no better or worse
after 7-10 days, consider antibiotic therapy
Comparison Guidelines for the Treatment of ACA
Bacterial Sinusitis
 CDC
 Sinus & Allergy Health
Partnership
 Only those meeting clinical dx
criteria
 Narrow spectrum agents
 Amoxicillin 1.5-3.5 g/d
 Doxycycline 100mg BID
 TMP-SMX 1DS BID
 Mild disease, - AB 4-6 wks
 Amoxicillin
 Amoxicillin-Clavulanate
 Cefpodoxime
 Cefuroxime axetil
 Mild disease +AB or moderate
disease – AB in 4-6 wks
 Any of above or
 Levofloxacin or gatifloxicin
 Moderate +AB in 4-6 wks
 Amoxicillin-Clavulanate or
 Levofloxacin or gatifloxicin or
 Combo tx with amoxicillin or
clindamycin PLUS cefpodoxime or
cefixime
Intranasal Steroids
 Use is not recommended
 OK in treating chronic sinus disease
 Steroid therapy increases viral
concentrations in nasal secretions in
cases of viral rhinosinusitis