Transcript Don`t do this… You will make people mad

Antibiotic Primer
Jen Nicol PGY-2
Dr. Sue Kuhn
Dr. McPherson
May 19, 2011
Objectives
• Review properties of commonly used
antibiotics in the ED
• Discuss Empiric Coverage of common
infectious diseases
• Brief review of resistant organisms
• Common ID mishaps in the ED
The Drugs
The Bugs
Community Acquired Pneumonia - Pediatrics
Outpatient
Most Common Pathogens
First Line Therapy
1-3 month
C. trachomatis, S.
pneumonia, parainfluenzae,
RSV, bordatella
Streptococcus pneumoniae
Erythromycin or
Azithromycin
Amoxicillin (80-90
mg/kg/day)
PCN allergy: azitho, clinda,
or erythromycin
Mycoplasma pneumoniae,
Chlamydia pneumonia, S.
pnemoniae
Azithromycin
Amoxicillin + Doxycycline (if
> 8 yrs old)
4mo – 5 yrs
>5 yrs
Alternative Therapy
Amoxicillin + Clarithromycin
Amoxicillin + erythromycin
Inpatient
Most Common Pathogens
1-3 month
C. trachomatis, S.
pneumonia, parainfluenzae,
RSV, bordatella
<5 yrs
Streptococcus pneumoniae
>5 yrs
Mycoplasma pneumoniae,
Chlamydia pneumonia, S.
pnemoniae*
Doxycycline if > 8 yrs old)
Non-ICU
Erythromycin or
azithromycin
Add cefuroxime or
cefotaxime if febrile
Ampicillin
OR
Cefotaxime
OR
cefuroxime
Ceftriaxone + Azithro
ICU
Cefuroxime
OR
Cefotaxime + cloxacillin
cefotaxime + azithromycin
+/-vancomycin
Ceftriaxone + Azithro +/Vanco (if evidence of lung
necrosis)
Paediatr Child Health. 2003:666-619
Alberta Clinical Practice Guideline 2008
Stanford guide 2009
Community Acquired Pneumonia - Adults
CID 2007:44(Suppl 2) S28-72
(Infectious Diseases Society of America/American Thoracic Society)
Can J Infect Dis 2000;11:237-48
(Canadian Infectious Disease Society/Canadian Thoracic Society)
Stanford Guide 2009
MDR Streptococcus
Pneumoniae
Age <2 or >65
Β-lactam therapy in last 3
months (most predictive)
Alcoholism, Immunosuppressive
Therapies or illness
Medical co-morbidities
Exposure to a child in daycare
Strep Pneumo Local susceptibilities
Penicillin 95% (83-91% 2009)
Ceftriaxone 95%
Erythromycin 78%
SXT 76%
Levofloxacin 86%
Tetracycline 87%
Community Acquired Pneumonia - Adults
CID 2007:44(Suppl 2) S28-72
(Infectious Diseases Society of America/American Thoracic Society)
Can J Infect Dis 2000;11:237-48
(Canadian Infectious Disease Society/Canadian Thoracic Society)
Stanford Guide 2009
Acute uncomplicated cystitis and Pyelonephritis
CID 2011;52:e103-120
(Infectious Diseases Society of America/European Society for
Microbiology and Infectious Diseases)
Stanford Guide 2009
E-Coli Local Susceptibility Patterns
– Amoxicillin 55%
– Cephalexin 73%
– Cefazolin 94%
– Ceftriaxone 97%
– TMP-SMX 79%
– Ciprofloxacin 94%
– Nitrofurantoin 98%
– Pip/tazo 98%
– Ceftriaxone 97%
– TMP-SMX 79%
– Ciprofloxacin 94%
– Gentamycin 95%
Acute Bacterial Meningitis
Clinical Microbiology Reviews;2010:467–492
(Infectious Diseases Society of America)
Paediatr Child Health;2008:309
(Canadian Paediatric Society)
Intra-abdominal Sepsis
Can J Infect Dis Med Microbiol. 2010;21:11-37
(Canadian Surgical Society/Association of Medical Microbiology and Infectious Disease Canada)
CID 2010;50:133-164
(Guidelines from The Surgical Infection Society and the Infectious Diseases Society of America)
Skin and Soft Tissue Infections
CID 2005;41:1373-1406 (Infectious Diseases Society of America)
CID 2011:52:18-55 (Infectious Diseases Society of America) – update on MRSA
Postpartum Endometritis
Antibiotics: Pregnancy & Breastfeeding
Pseudomonas aeruginosa
• Favors moist, warm environments
• Generally an infection of the hospitalized and
immunocomprimised
• Community infections:
– hot tub/whirlpools
– contact lens use
Risk Factors
• Chronic oral steroid administration
• Severe underlying bronchopulmonary disease
(ie COPD, asthma)
• Alcoholism
• Frequent antibiotic therapy
• Hospitalization
Treatment of p. aeruginosa infections
• Monotherapy vs. combination therapy
• Theory: to prevent resistance
– No definitive consensus
– Evidence to suggest non-inferiority
• Some antibiotics are not as effective as
monotherapy (gentamycin)
Treatment of p. aeruginosa infections
• Anti-pseudomonal β-lactam or carbapenem or
aztreonoman PLUS aminoglycoside
– β-lactam = Ceftazadime, cefepime, pipercillintazobactam
– Aminoglycoside = gentamycin, tobramycin,
amikacin
– Carbapenem = imipenem, meropenem,
• NOT ertapenem (not active against PA)
Local Susceptibilities
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Pipercillin/tazobactam 95%
Meropenem 94-99%
Ceftazadime 90-95%
Ciprofloxacin 91%
Gentamycin 89%
Tobramycin 96%
Calgary Lab Services Antibiogram 2010
MRSA: Methicillin Resistant
Staphylococcus Aureus
• First documented resistance in 1950’s,
increasing prevalence ever since.
• Netherlands 2% vs. Japan >70%
• Mutation of transpeptidase inhibiting binding
of penicillins
• 2 varieties…..
Community Acquired MRSA
Community Acquired MRSA
• “Little dog big bite”
• Cause serious soft tissue infections and
necrotizing pneumonia which can be rapidly
fatal.
• Much more susceptible to wide range of
antibiotic therapy
CA-MRSA RF’s
•native and aboriginal communities
•sports teams
•child care centers
•military personnel
•men who have sex with men
•prison inmates and guards
•Close contact with an MRSA carrier
•MANY HAVE NO RF’s AT ALL!!!
Hospital Acquired MRSA
Hospital Acquired MRSA
• “Big and ever present, need to trip over it to
get hurt, but hard to get rid of if he gets a hold
of you”
• More resistant and difficult to treat, but less
invasive.
HA-MRSA
•Recent hospitalization or surgery
•ICU stay
•Recent antibiotic use
•Living in a nursing home
•Carrying an indwelling catheter or device
Oral Outpatient Therapy
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Patient must be systemically well
Clindamycin
TMP-SMX
Doxycycline
• For improved coverage of β-hemolytic strep,
add beta-lactam (amoxicillin)
CID 2005;41:1373-1406 (Infectious Diseases Society of America)
CID 2011:52:18-55 (Infectious Diseases Society of America) – update on MRSA
Inpatient, sick patients
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IV Vancomycin
IV linezolid
Daptomycin
Rifampin (with vano/linez)
Tigecycline ?
• Double Coverage: MRSA prosthetic valve EI,
osteomyelitis, prosthetic joint infection, or septic
arthritis
CID 2005;41:1373-1406 (Infectious Diseases Society of America)
CID 2011:52:18-55 (Infectious Diseases Society of America) – update on MRSA
Local Susceptibility Patterns:
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Clindamycin 72%
TMP-SMX 98%
Doxycycline 98%
Vancomycin 100%
Linezolid N/A
Gentamycin 100%
• Penicillin 18%
Calgary Lab Services Antibiogram 2010
ESBL: Extended Spectrum β-Lactamase
producing Gram negative bacteria
• Resistant to all β-lactam antibiotics except
carbapenems and cephamycins
• Range of enterobactereae
– E-Coli, klebsiella most common
• Traditionally acquired in hospital setting;
recent increase in CA-ESBL
• Bacteremia, SSTI’s, UTI, pneumonia,
meningitis….
Risk Factors for CA-ESBL
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> 65
Female > male
Functional dependence
Admission from long term care
Recent hospitalization
Bladder catheter
Antibiotic use
Cefalosporin use
CID 2009;49: 682
Treatment
• Piptazo, cefepime, 3rd generation
cephalosporins, quinolones
• UTI: ? ciprofloxacin
• Carbapenems
– No randomized controlled studies
– Most prospective observational experience with
meropenem, best survival outcomes
Don’t do this… You will make people mad
• NOT taking ANY or enough cultures before
starting antibiotics
• Treating stable patients with empiric, broad
spectrum antibiotics before a clear source is
identified (it IS OK to wait!!!!)
• NOT using netcare to check for previous
treatment for resistant organisms in the past
Don’t do this… You will make people mad
• Fever in the returning traveler to HPTP (They
belong in medicine clinic!!)
• Sending joint prosthesis infections to HPTP
(DON’T bipass ortho – they will get angry!!)
• NOT draining fluctuant, juicy abscesses, or
arranging diagnostic or surgical interventions
before sending patient to HPTP
– (this is very difficult to do in high volume
outpatient clinic!!!)
The End
Questions???