Module 6: Stewardship in fever/sepsis, - PowerPoint Presentation

Slide1

Module 6: Stewardship in fever/sepsis, neutropenia, osteoarticular infection, and endocarditis

Benjamin Westley MD FAAP FACP

4120 Laurel St Suite 204

Anchorage, AK 99508Slide2

ObjectivesDiscuss initial management of various complex infectious-disease scenariosFever

Sepsis

Neutropenia

and fever

Osteoarticular

infection

Endocarditis

Disclaimer!

These patients are complex and generally managed with formal infectious disease consultation where available

The primary role of a stewardship program is typically to ensure an appropriate empiric regimen and to identify whether further infectious disease consultation might be appropriateSlide3

GuidelinesSepsis1Neutropenia and fever

2

Fever in the ICU

3

Bone/joint infections

4,5

Endocarditis

6

Intravascular catheter infections

7

Cardiac device infections

12Slide4

Empiric sepsis therapyImmediate work-up for source as directed by symptomsBlood cultures x2

Chest x-ray

Urine

If source determined, use appropriate regimen for source and level of illness

If source NOT determined, must consider and treat for occult

bacteremia

and/or intra-abdominal source

Vancomycin

PLUS

piperacillin/tazobactam

, OR

Vancomycin

PLUS

cefepime

PLUS

metronidazole

Strongly consider need for CT imaging of the abdomen

Some programs use PCT levels to guide initiation and duration of therapySlide5

Fever and neutropeniaObtain blood cultures x2Other workup as directed by symptoms

Cefepime

2g iv q8h ALONE if

hemodynamically

stable and no source

If source known (lung, skin and soft tissue, abdomen) then use the regimen for NOSOCOMIAL infection

E.g. HCAP regimen, or anti-

pseudomonal

intra-abdominal regimen

If no source and

hemodynamically

unstable, add

vancomycin

and consider addition of second gram negative drug (e.g.

tobramycin

)Slide6

Fever and neutropeniaIf fever persists >4-7 days add antifungal (e.g. micafungin

)

Antibiotics are generally continued until the ANC is >500 cells/

uL

The following patients should receive ID consultation

Neutropenia

and septic shock

Neutropenia

and

bacteremia

or

fungemia

Neutropenia

and intra-abdominal infection

Neutropenia

and lung nodules

Prolonged

neutropenic

fever >4-7 days

Determining final regimen construction and duration is challenging and best done with ID assistanceSlide7

New fever in the hospitalCommon scenario with multiple possible causesNosocomial infection (e.g. IV catheter, CAUTI, HAP)

Drug fever

DVT

Atelectasis

Central fever after neurological injury

Sinusitis

Gout/

pseudogout

Work-up PRIOR to antibiotics

EXAM!!!!

Blood

cx

x2

CXR or urine as directed by clinical history and examSlide8

New fever in the hospitalMost new fevers in the hospital DO NOT require new antibiotics or a change in prior antibioticWorkup as directed and await resultsIf

hemodynamically

UNSTABLE, then MUST give empiric SEPSIS regimen once evaluation done based on likely source

If a line infection is strongly suspected and patient is unstable, consider removing the line; however, in general, fever in a patient with a central line does not require empiric line removal/line changeSlide9

Line infections3 types: Intraluminal,

hematogenous

, or tunnel/exit site

Controversy regarding culturing

IDSA- Culture from each line and peripheral

NHSN- Culture from 2 peripheral sites only

Standard cultures are fine

Do not need isolator cultures or fungal cultures

If a pathogen grows in the blood, and there is no other obvious source, then it is a line infection

Coag

negative staph from a single site is likely a contaminant

If it repeatedly grows, then consider realSlide10

Line infectionsIf line infected, remove lineEspecially if:Staphylococcus

aureus

Candida

species

Gram negatives

Duration of therapy from date of line removal:

Coagulase

negative

Staphylococcus

: 5 – 7 days

Enterococcus

and gram negative rods: 7 – 14 days

Staphylococcus

aureus

AT LEAST 14 days (consult ID)

Candida

species: AT LEAST 14 days from first negative culture (consult ID)Slide11

Line infectionsIf line MUST be salvaged:2 weeks from negative culture WITH antimicrobial lock therapy (usually vancomycin

)

Attempt only with poorly-pathogenic organisms (e.g.

coagulase

negative

Staphylococcus

)

Tunneled lines with soft tissue infection of the tunnel tract CANNOT be salvaged and MUST be removedSlide12

Bone/joint infectionsHematogenousMost common in childrenStaphylococcus

aureus

, Beta-hemolytic strep

Gonococcal

Contiguous or

innoculation

(e.g. wound or trauma)

Polymicrobial

Prosthetic jointSlide13

Bone/joint infectionHematogenousVancomycin +/-

ceftriaxone

AFTER blood and joint cultures

Contiguous

Get cultures

Probably

vancomycin

plus something else- highly individualized

Prosthetic joint

Get joint and blood cultures first

Vancomycin

Add gram negative coverage if

hemodynamically

unstable or GNR seen in gram stainSlide14

Bone/joint duration of therapyHematogenous

At least 3 weeks if isolated to joint, guided by clinical, lab, and imaging resolution

6 weeks if concomitant bone infection

Parenteral

therapy for gram positives

Can consider oral

quinolones

for susceptible GNR

Consider ID consult

Prosthetic joint

6 weeks if removed and antimicrobial impregnated spacer placed

3 – 6 months for

Staphylococcus

species in combination with

rifampin

if

Debride

And Implant Retention (DAIR) is being attempted

Consult IDSlide15

Bone/joint in childrenVirtually always hematogenousExcellent data that children can be treated with oral therapy once CRP falls and clinically improving

8-11

3 weeks for joint, 6 weeks for bone guided by CRP and imaging

Shorter courses probably reasonable

9

Outpatient IV therapy and PICC lines are rarely needed for bone/joint infections in children

9-11Slide16

Vertebral osteomyelitisNative- NO hardware or preceding proceduresMonomicrobial

,

hematogenous

S

aureus

, beta-hemolytic strep,

brucella

, TB

If no sepsis or neurologic impairment, HOLD ANTIBIOTICS until AFTER tissue obtained for cultures AND pathology

IR guided aspiration usually attempted first

Send for bacterial, AFB, and fungal cultures

If non-diagnostic, generally repeat by operative technique

If no sepsis or neurologic impairment, withhold empiric antimicrobial therapy until a microbiologic diagnosis is established

If blood grows

S

aureus

, can assume this is etiology and do NOT have to biopsySlide17

Vertebral osteomyelitisTreatment varies by organism6 weeks of IV therapy vs. highly bioavailable

oral therapy

Trend inflammatory markers

Avoid re-imaging unless clinically failing as MRI improvement greatly-lags clinical resolution

These are difficult to treat infections: ID consultation early in the course of workup and management is advisedSlide18

Orthopedic hardware infectionsMono-microbial vs. poly-microbialEarly vs

late onset

Unremoved

hardware remains a

nidus

of infection

Washout with or without removal, followed by prolonged systemic therapy

If hardware not removed, oral convalescent or suppressive therapy for a prolonged period may be needed

Rifampin

generally added for

Staphylococcal

infections when hardware remains in place

These are complex infections without easily generalized recommendations: Recommend ID consultationSlide19

EndocarditisDuke criteria: 2 major, 1 major and 3 minor, or 5 minorMajor:Multiple positive blood cultures for typical organism

Valvular

vegetation or new valve regurgitation

Minor:

Predisposing valve condition or IVDU

Fever >38C

Emboli

Immune phenomena (

glomerulonephritis

,

osler

nodes, + RF)

Positive blood culture not meeting major criteria

Abnormal echocardiography without vegetationSlide20

EndocarditisGet blood cultures first! Preferably 3 sets.TTE ok for initial imaging; if high suspicion and negative, do TEE

Vancomycin

PLUS

ceftriaxone

Covers

Staphylococcus

,

Streptococcus

,

Enterococcus

, and HACEK organisms

Treatment varies by organism, type of valve (prosthetic vs. native)

Gentamicin

no longer used for native valve

Staphylococcus

Decisions regarding surgical indications are complex

Strongly consider ID consultationSlide21

Cardiac device infectionsStaphylococcus species most commonCategories

Superficial/

incisional

Pocket site

Wires/

bacteremia

Blood cultures in all cases

If

bacteremic

get TEE

LIMITED superficial skin or

incisional

infection may be treated with 7-10d of PO anti-staphylococcal antibiotic

In MOST cases the pocket will need to be

debrided

and the ENTIRE device removed

Consult IDSlide22

Referenceshttp://www.survivingsepsis.org/Guidelines/Pages/default.aspx

Clinical Infectious Diseases 2011;52(4):e56–e93

Crit

Care Med 2008; 36:1330–1349

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–25

Clinical Infectious Diseases® 2015;61(6):e26

–46

Circulation. 2015;132:00-00

Clinical Infectious Diseases 2009; 49:1–45

Journal of Pediatric Orthopedics 1982; 2:255-62

Clinical Infectious Diseases 2009; 48:1201–10

Pediatrics 2009;123;636-642

Pediatrics. 2012 Oct;130(4):e821-8

Circulation 2010;121;458-477