Carpenter Service Overview
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Transcript Carpenter Service Overview
An Hitchiker’s Intern’s Guide
to the Galaxy Carpenter
Douglas Adams
Nate Summers
Objectives
Approach to ID
Overview of Commonly Encountered Infections
Overview of Inpatient Care of the HIV Patient
Overview of Antibiotics
Dr. Charles Carpenter
After completing his residency at Johns Hopkins Hospital, he
began his career in international health in Kolkata, India,
during a Cholera epidemic and became the director of the
division of allergy and infectious diseases at Hopkins.
He moved to Ohio in 1973, where he served as the
department of medicine chair until 1986, and was a leading
figure in the department of ID here, continuing his passion for
international health.
He is currently the department of medicine chair at Brown.
Approach to Infectious Diseases
Host
Syndrome
Bugs
Drugs
Your patient, Doctor…
47 year old WM presents with a bug bite
HPI:
Initially noticed this 5 days ago, but was much smaller
Painful, on left antecubital fossa
Subjective fevers and chills over the past 2-3 weeks
Dyspnea over the past 1-2 weeks with cough
Denies trauma, thinks he may have been bitten by a spider
More History
PMH:
DM type II, A1c=9.3%
Allergies:
PCN
DLD
FHx:
PSH: None
Home meds:
Father with CLL
Social:
Metformin
Injects heroin daily
Glyburide
Smokes 1ppd x20 years
Rare EtOH
Physical Exam
Host
Diabetic, IVDU
Syndrome
Skin/soft tissue infection; probable infective endocarditis
Bugs
Staph. aureus, Strep pyogenes, Strep viridans, Enterococcus, Staph
Epidermidis, HACEK
Drugs
Vancomycin, nafcillin, cefazolin, daptomycin (inactivated by type II
pneumocytes!), ceftaroline for IE
Doxycycline, TMP/SMX, clindamycin (increasing resistance), cephalexin,
dicloxacillin for SSTI
Keys to the Case (Cellulitis):
Strep
Staph
More rapid onset
Often purulent
Rapid response to
beta-lactams
May form abscesses
No purulence
Often multiple
More Keys to the Case (IE):
Modified Duke Criteria
Major
Sustained bacteremia by an organism classic for IE (or 1 BCx or serology positive for
Coxiella)
Endocardial involvement documented by either echocardiogram or new valvular
regurgitation
Minor
Predisposing condition (prior IE, RHD, IVDU, HD, PPM, biscuspid AV)
Fever
Vascular phenomena (septic/pulmonary emboli, mycotic aneurysms, ICH,
Janeway lesions)
Immune phenomena (+RF, glomerulonephritis, Osler’s nodes, Roth spots)
Positive BCx not meeting major criteria
Definitive (2 major or 1 major + 3 minor or 5 minor)
Possible (1 major + 1 minor or 3 minor)
Classic organisms: Strep viridans, Strep. bovis, HACEK, or Staph. aureus or Enterococcus w/out primary
focus
More Keys to the Case (Staph):
Always take Staphylococcal bacteremia seriously
Repeat blood cultures x2 before starting empiric treatment
Staph aureus is sticky and loves to hide in places. Examine the Pt
for metastatic spread (spine, sternoclavicular joints, etc.)
Image if concerning physical exam findings
IDSA guidelines recommend at least 2 weeks of IV therapy for
Staph bacteremia
2 weeks if: exclude IE, no implanted prostheses (including joints),
negative f/u BCx 2-4 days after initial Cx, defervescence w/in 72 hrs,
and no sites of metastatic infection
Otherwise, treat for 4-6 weeks
Your patient, Doctor…
74 year old AAF presents with a cough
HPI:
Cough x5 days with worsening dyspnea
Yellow/green phlegm
Subjective fevers/chills
More History
PMH:
Allergies: NKDA
HTN
FHx:
PSH: None
Home meds:
Amlodipine
Children are healthy
Social:
Denies tobacco/illicits
Drinks a glass of wine
each evening
Physical Exam
Host
Elderly
Syndrome
Pneumonia
Bugs
Strep pneumoniae, non-typeable H. influenza, M. catarrhalis,
Chlamydia pneumoniae, Mycoplasma pneumoniae, Staph aureus,
Legionella pneumophilia
Drugs
3rd Gen Ceph/azithro, respiratory FLQ, doxycycline, amox/clav
Keys to the Case:
CURB-65
Confusion
BUN>19
RR>30
BP<90/60
Age>65
Score >1 should generally
be treated inpatient
HCAP:
Hospitalization for 2+ days
w/ in past 90 days
HD w/ in 30 days
NH or LTAC w/ in 30 days
IV therapy (chemo, Abx)
w/in 30 days
Wound care w/ in 30 days
Family member w/ MDR
pathogen
Want to cover MRSA and
gram negatives
More Keys to the Case:
Respiratory FLQ
Why don’t we use
ciprofloxacin in CAP if we
use it as double coverage
for Pseudomonas
aeruginosa in HCAP?
Post Influenza
Strep. pneumoniae is still
#1
Incidence of Staph.
aureus is increased
(especially community
acquired MRSA after the
H1N1 epidemic)
Your patient, Doctor…
22 year old WF presents with HA
HPI:
Rhinorrhea, fatigue, malaise x2 days
Severe HA starting this morning with subjective fevers
More History
PMH:
Allergies: NKDA
None
FHx:
PSH: None
Home meds:
Oral contraceptives
Dad with CAD
Social:
In college, binge drinks on
weekends
Denies tobacco, illicits
Physical Exam
Host
Young
Syndrome
Meningitis
Bugs
Neisseria meningitidis, Strep. pneumoniae, nontypeable H. flu, Listeria
monocytogenes, enteroviruses, arboviruses, TB, Cryptococcus
neoformans
Drugs
Ceftriaxone, vancomycin, dexamethasone, +/- ampicillin, acyclovir
Keys to the Case:
Why Vancomycin?
Not for MRSA!
Increasing resistance of
Strep. pneumo to
penicillins, and
penetrance to CSF is
tough, limiting the
AUC/MIC
Dexamethasone?
In cases of Strep. pneumo,
it reduces neurologic
deficits (especially
hearing loss) and may
decrease mortality
More Keys to the Case:
Bacterial:
Viral:
TP: Elevated (100-1000)
TP: Elevated (50-100)
Glucose: Low (<45)
Glucose: normal (2/3
serum)
Cell count: Elevated,
PMN predominance
Cell count: normal to
elevated w/ lymph
predominance
Fundamentals of HIV
Key things to know about your patient:
Most recent viral load and CD4 count
HAART regimen, any prophylaxis
CD4 nadir, history of OI
In general, continue HAART and prophylaxis on admission
If you have questions (more on that later), ask for help (senior resident,
attending, ID fellow)
Common Side Effects
Drug/Class
Common/Important Side Effects
Didanosine
Pancreatitis
Indinavir
Crystal nephropathy
Nevirapine
Liver failure
Abacavir
Hypersensitivity syndrome
NRTI’s
Lactic acidosis
NNRTI’s
Stevens-Johnson Syndrome
OI Prophylaxis
Pathogen
CD4 Count
Prophylaxis
TB
Any
Screen for and treat for latent TB if
positive
Coccidioidomycosis
<250
Screen in endemic areas;
fluconazole if positive
PCP
<200
TMP-SMX
Histoplasmosis
<150
Itraconazole in hyperendemic
areas (not USA)
Toxoplasma
<100
TMP-SMX
Cryptococcus
<100
None
MAC
<50
Azithromycin or Clarithromycin
Your patient, Doctor…
39 year old WM presents with cough
HPI:
Nonproductive cough over the past 2 weeks
Worsening dyspnea over the past 5 days
Subjective fever, night sweats
More History
PMH:
Allergies: NKDA
HIV, lost to follow up
HTN
PSH: None
FHx: Unknown
Social:
Smokes 1ppd
Home meds:
Amlodipine
Occasional EtOH
Daily marijuana
Physical Exam
Host
HIV/AIDS
Syndrome
Pneumonia
Bugs
Strep pneumoniae, non-typeable H. influenza, M. catarrhalis,
Chlamydia pneumoniae, Mycoplasma pneumoniae, Staph aureus,
Legionella pneumophilia
PCP, TB
Drugs
Ceftriaxone/azithro, TMP-SMX +/- prednisone
Keys to the Case:
Prednisone?
If PaO2<70 or A-a
gradient>35
Don’t forget that
patients with HIV/AIDS
can have routine
bacterial infections as
well
Your patient, Doctor…
One year later, our same 40 year old WM presents with AMS
HPI:
HA over the past week
Increasing confusion past few days
More History
PMH:
Allergies: NKDA
HIV, still lost to follow up
HTN
PSH: None
FHx: Unknown
Social:
Smokes 1ppd
Home meds:
Amlodipine
Occasional EtOH
Daily marijuana
Physical Exam
Host
HIV/AIDS
Syndrome
Meningitis/CNS infection
Bugs
Neisseria meningitidis, Strep. pneumoniae, nontypeable H. flu, Listeria
monocytogenes, enteroviruses, arboviruses, TB, Cryptococcus neoformans,
Toxoplasma gondii (ring-enhancing lesions), CNS lymphoma (ringenhancing lesion, CSF EBV+)
Drugs
As for bacterial if CSF is suggestive, or Amphotericin B + flucytosine x2 weeks
then fluconazole PO for Cryptococcus; pyrimethamine + sulfadiazine if
Toxoplasma
Keys to the Case:
Get a CT Head before
the LP in poorly
controlled HIV
patients
At risk for space
occupying lesions,
including CNS lymphoma,
tuberculoma, CNS
abscess, and Toxoplasma
Crypto
May need to do serial LPs
if patient remains
symptomatic (HA, AMS)
due to high intracranial
pressure
IRIS
For intracranial processes,
generally delay starting
HAART for a few weeks to
avoid complications
(continue HAART if
already on)
Antibiotics
Beta-lactams
Inhibit cell wall synthesis by inhibiting penicillin binding proteins
Generally bacerticidial
Include penicillins, cephalosporins, carbapenems, and monobactams
Penicillins
First Generation
Excellent gram positive coverage; primarily used against Syphilis now
Penicillin G (procaine; IV), Penicillin benzathine (IM), and Penicillin V (PO)
Anti-Staphylococcal
Gain coverage vs. penicillinase producing staphylococci but lose activity
against Enterocci, Listeria, and Neisseria
Nafcillin, oxacillin, dicloxacillin, cloxacillin
Second Generation
Added coverage against gram negative bacilli and anaerobes
When paired w/ beta lactamase inhibitors, broadens gram neg coverage
Ampicillin (+ sulbactam), amoxicillin (+ clavulanate)
Third/Fourth Generation
Improved gram negative coverage, including Pseudomonas aeruginosa plus
anaerobes
Ticarcillin, Carbenicillin, Piperacillin
Cephalosporins (5-10% crossreactivity)
First Generation
Excellent gram positive coverage, including MSSA but not Enteroccus, Listeria
Some coverage vs. gram neg bacilli
Cefazolin, cephalexin, cefadroxil
Second Generation
Added coverage against gram negative bacilli, slightly less gram positive
Cefuroxime, cefoxitin, cefotetan, cefaclor, cefprozil
Third Generation
Highly active vs. enterics, loses some gram positive coverage
Ceftriaxone, cefotaxime, cefixime, cefdinir
Ceftazidime (3.5 generation; covers Pseudomonas aeruginosa)
Fourth Generation: Similar to third gen plus Pseudomonas coverage
Cefepime (of note: NO anaerobic coverage!)
Fifth Generation: Similar to third gen plus MRSA and resistant Pneumo
Ceftaroline
Carbapenems (2-5% crossreactivity)
Very broad spectrum, including ESBL, anaerobes, and gram positives
(including Enterococcus and Listeria) but not VRE
Doripenem, imipenem (+ cilastin to prevent proximal tubule necrosis), and
meropenem
Beware CNS toxicity with imipenem
Ertapenem does not cover Pseudomonas but is once daily dosing
All cover Pseudomonas Except Ertapenem
Generally reserve these medications for resistant pathogens as they are our
last ditch effort against growing gram negative resistance
We all play a role in antimicrobial stewardship!
Monobactams (0% crossreactivity)
Good gram negative coverage (including Pseudomonas) but NO
anaerobic coverage
Aztreonam
MRSA Coverage
Oral Agents
CA: TMP/SMX, doxycycline, clindamycin (check D-test!)
Linezolid
Parenteral Agents
Vancomycin (bacteriostatic; use if MIC<2 for invasive MRSA)
Daptomycin (bactericidal; use if MIC<1 for invasive MRSA; watch CPK)
Inactivated by type II pneumocytes, so not for pneumonia!
Linezolid (bacteriostatic; good vs. invasive; beware pancytopenia & serotonin
syndrome; inhibits toxin production so good vs. toxic shock)
Ceftaroline (bactericidal, not FDA approved for invasive but used regardless)
Tigecycline (bacteriostatic; 4P’s=Proteus, Providencia, Pseudomonas, Pee)
Televancin (bactericidal; used for SSTI; dalbavancin & oritavancin = depo forms)
Synercid (Quinupristin-dalfopristin) (static alone, cidal together, requires central
line)
Questions?