Eleana M Zamora MD Department of Internal Medicine Division of PulmonaryCritical CareSleep Objectives Understand the difference between nosocomial and communityacquired Know where to find ID: 588803
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Slide1
The ABC’s of Infections
Eleana M. Zamora, MDDepartment of Internal MedicineDivision of Pulmonary/Critical Care/SleepSlide2
Objectives
Understand the difference between nosocomial and community-acquiredKnow where to find
antibiogram
data
Have a basic understanding of how to approach common infections in the inpatient and outpatient settingSlide3
Overview
Community vs. nosocomialUpper/Lower respiratory infectionsC.difficile
-associated diarrhea
Intra-abdominal infections
Skin-soft tissue infections
Bacteremia
Osteomyelitis
, septic jointsSlide4
Gram positivesSlide5
Gram negativesSlide6
Urine AntibiogramSlide7
Objectives: Crash Course
Commonly encountered infections in inpatient and outpatient settingsWhat bugs?What drugs?Common clinical syndromesSlide8
Community vs. Nosocomial
Why important?AtypicalsMDRO
MRSA
Pseudomonas
Broadened definition of “
nosocomial
”
SNF, OPAT, jail, community-living, homeless, etc.Slide9
Common Outpatient Infections
Upper respiratory
Lower respiratory
Sinusitis
Pharyngitis
UTI
SSTSlide10
Upper Respiratory Infection
Def’n:Acute infxn which is typically viral
Sinus,
pharngeal
, or lower airway symptoms may be present, but
are not prominent
Abx
are rarely indicated
Although most “colds” have sinus symptoms, less than 2% have complication of acute bacterial sinusitis
Presence of green mucus does not necessarily indicate bacterial infectionSlide11
Acute Pharyngitis
GAS causes 10% of adult pharyngitis90% are NOT GAS!
DDx
: EBV, CMV (less likely), gonococcus, HSV, HIV, Syphilis
ABX are rarely indicated for routine
pharyngitis
Use the
Centor
diagnostic criteria to decide who to test
Treat only positive GAS rapid screens or patients who have all 4 criteria Slide12
Centor Criteria
History of feverTonsillar
exudates
No cough
Tender anterior cervical LAD
≥2 of the above = treatSlide13
Treatment of GAS Pharyngitis
Treatment of choice: Penicillin V 500mg BID or 250mg QID x 10 daysAlternativesBenzathine
PCN 1.2 MU IM x 1 dose (for noncompliant patients)
2
nd
gen cephalosporin: cefuroxime or
cefprozil
500 mg
qday
, etc.
etc
Azithro
500mg x1, then 250mg
po
day x 4d
If macrolide failure or
pcn
-allergy: FQ
Bactrim does not cover GASSlide14
Acute Sinusitis
Most cases of sinusitis are viralBacterial
rhinosinusitis
Sx
lasting
≥7 d
who have maxillary pain
or tenderness
in the face or teeth (
esp. unilateral
)
and purulent
nasal
secretions
Severe
dz
: dramatic
symptoms of severe unilateral
maxillary pain
, swelling, and fever.Slide15
Sinusitis Guidelines: IDSA 2012Slide16
IDSA: Treatment
First line = B-lactam (amox/clav)
Preferred over respiratory FQ
Doxycycline is equivalent to
amox
/
clav
Not recommended to cover for MRSA
Not recommended for use:
Macrolides, Bactrim
Duration of
tx
: 5-7 days
Recommended over 10-14 daysSlide17
Acute Sinusitis
EtiologyCommunity-acquired from obstruction of ostia, allergens, post-viral
infxn
:
S.pneumo
31%
H.influenzae
21%
M.catarrhalis
10%
S.aureus
4%
Diabetic,
neutropenic
, IV iron therapy:
mucor
/
rhizopus
,
aspergillusSlide18
Etiology of Acute Sinusitis
Nosocomial , NGT, or nasal intubation:Gram neg (pseudomonas,
acinetobacter
) 47%
Staph
aureus
/gram pos 35%
Yeast 18%
Polymicrobial
80%Slide19
Chronic Sinusitis
Pathogenesis is multifactorialSmokingNasal polyps
Periodontitis
Antibiotics are
rarely
effective
Refer to ENT
STOP SMOKING!
Atypical pathogens
Prevotella
, anaerobes,
fusobacterium
, Pseudomonas, fungi/moldsSlide20
URISlide21
Non-Specific URI
Resistant Strep pneumoniaeoutpatient
abx
Treating a viral URI with
abx
directly increases the risk of resistant bug transmission
Upper URI account for over 75% of outpatient RX each yearSlide22
For URI Syndromes:
Very strongly consider NO abx:
Adult uncomplicated acute bronchitis
Not acute exacerbations of chronic bronchitis)
Acute sinusitis
Pharyngitis
Nonspecific URI
ABX
should
be used for:
Documented GAS
pharyngitis
Severe sinusitis with fever,
ptosis
, etc.
Pneumonia (LRI)Slide23
WHATUP!
Lower RespiratorySlide24
Lower Respiratory Infections
Tracheitis – biggest airwaysBronchitis –large airwaysBronchiolitis – smallest airways, wheezing
Pneumonia – air space infection
Basic concepts are the same for allSlide25
Stepwise Approach
Decide viral, bacterial, atypical, other?Not always so easy…sometimes more than oneRule of thumb:
cover the top 3
Risk factors
Smoking, travel,
immunosuppression
, diabetesSlide26
Pseudomonas?
Community-acquired vs. nosocomial +/- aspirationHospitalized vs. non-hospitalized
Remember new broader risk categories for MDRO
Pseudomonas and
Acinetobacter
longer duration of
txSlide27
Powers of Pseudomonas
PredictionSlide28
Common CAP Etiologies
IDSA CAP Guidelines 2007Slide29
Outpatient CAP TxSlide30
To Hospitalize or not?
Pneumonia severity index (PSI)CURB-65Your gut feeling counts
CURB-65
Confusion, Uremia, RR, low BP, age>65
Score > 2
admitSlide31
Severe CAP
IDSA Guidelines 2007Slide32
Inpatient, non-ICU CAP Tx
UNMH FormularyCeftriaxone
+
azithromycin
/doxy
If
β
-
lactam
allergy:
moxifloxacin
Moxi
not for UTI or PseudomonasSlide33
Inpatient CAP, ICU
UNMH Formulary
Ceftriaxone
+
azithromycin
Not doxy
If
β
-
lactam
allergy:
moxifloxacinSlide34
Pseudomonal Risk Factors
UNM: Know the
antibiogram
!
Available to you without ID consult:
Zosyn
(87%S),
Cefepime
(82%),
Cipro
(72%), Gent/
Tobra
(85%)
ID Consult only:
Meropenem
(95%),
amikacin
(89%),
doripenem
,
colistinSlide35
Infectious DiarrheaSlide36
Clostridium difficile
SHEA/IDSA Guidelines 2010Who to test?What to do?
How to treat?
When to take out of isolation?Slide37
The New CDAD
4 x’s increase in cases over 13 year period Increase in disease severityMajor risk factors for NAP1 strain
Age > 65
Recent use of FQsSlide38
Severity assessment score
≥2 points classified as severe
1 point given for each of the following:
Age > 60
Temp >38.3
WBC > 15K
Albumin < 2.5mg/
dL
2 points for endoscopic evidence of
CDAD
(Alternate: AKI)
(Alternate: sepsis, ICU)Slide39
Case Definition
Presence of diarrhea (>3 unformed stools in 24 hours)Stool test positive for
Cdiff
or its toxins
Colonoscopic
evidence of
CdifficileSlide40
Who to test?
Anyone with diarrhea?Do not test asymptomatic patientsOnly patients with diarrhea, not formed
Unless toxic
megacolon
/
ileus
High risk:
SNF, jail, group home
Recent (<90d)
abx
Recent (<30d) hospitalization
Known
contact (2-3 days
avg
)
Severe, ICU
intraabdominal
source suspectedSlide41
What test?
Previously used test for toxinUNMH uses PCR confirmationA single test per episode of diarrheal illness is recommended
No more than one test every 7 days
Do not need multiple tests to “rule-out
”
Do not need test of cureSlide42
Understanding the test
Stool tested for Antigen (Ag) and toxin (T)Ag (+) T (+) positive
C.diff
(red)
Ag (+) T (-) reflex to PCR (red)
Ag (-) T (+) reflex to PCR (red)
Ag (-) T (-) negative
C.diffSlide43
What to do?
If you think it, patient must be in isolationNEVER EVER order the test without putting patient in isolation at same time
Never treat empirically without putting in isolation at same time
If patient is ill, empiric
tx
is okSlide44
How to treat?
Consider calling general surgery for severe disease!Slide45
Intra-AbdominalSlide46
Complicated Intra-abdominal
InfectionsExamples:Perf
diverticulum
Complicated GB infection
Abscess
Peritonitis
Location matters
Flora of upper small bowel vs. from beyond small bowel vs. from beyond ileum vs. rectumSlide47
It’s All About Location!
Upper GI, duodenum, biliary system, proximal small bowelPeritonitis common
Gram
pos, gram
neg
aerobic and facultative organisms
Enterococcus
is not a real concern
Distal small bowel
Less GPC, more GNR (aerobes, facultative)
Often evolve into abscesses (not peritonitis)Slide48
Location, location, location
ColonFacultative (E.coli) and obligate anaerobes (
B.frag
), Streptococci (
S.bovis
)
Abscesses
Abscesses, in general, should be drained
ABX have hard time getting into abscess
Exception?
ALWAYS send aspirate for anaerobic/aerobic cultureSlide49
So, Why So Complicated?
Location Some drugs are inactive in abscessesSome drugs are pH dependentBugs
Some bugs are resistant
B.frag
vs.
clinda
/
fq
/
cefotetan
/
cefoxitin
Community-Acquired vs. Nosocomial?
Pseudomonas is less common in abscessesSlide50
Who to Treat?
Bowel trauma that get surgically repaired within 12 hours, upper GI perf in the absence of antacids, or acute appendicitis
Abx
used for <24h
Acute uncomplicated
cholecystitis
= NO
Ascending
cholangitis
= YES
Acute pancreatitis = NO
Necrotizing pancreatitis = YESSlide51
What to give?
Note: Empiric coverage of Candida is NOT recommended.
If
candida
is found, strongly consider if it needs therapySlide52
Questions?Slide53
References
Gonzales
et.al.
“Principles
of Appropriate Antibiotic Use
for
Treatment of
Nonspecific Upper
Respiratory Tract Infections in Adults:
Background”
Ann Intern Med. 2001;134:490-494
.
Cooper
et.al.
“
Principles of Appropriate Antibiotic Use for Acute
Pharyngitis
in
Adults:
Background”
Ann Intern Med. 2001;134:509-517
.
Hickner
et.al. “
Principles of Appropriate Antibiotic Use for Acute
Rhinosinusitis
in
Adults:
Background
”
Ann Intern Med. 2001;134:498-505
.
IDSA Guidelines or Acute
Bacerial
Rhinosinusitis
in Children and Adults 2012
Gonzales R,
et.al.
“Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults: Background, Specific Aims, and Methods”
Ann
Int
Med 2001; 134:479-486
Mandell
, LA,
et.al.
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CID 2007;44:S27-72
Joint statement of ATS/IDSA 2004
“Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Healthcare-associated Pneumonia”
Am J
Respir
Crit
Care Med 171:388-416Slide54
Cohen SH, et.al.
“Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Heathcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)”
ICHE 2010;31(5): 000-000
Solomkin
JS,
et.al.
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CID 2010;50:133-64
Stevens DL,
et.al.
“Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections”
CID 2005;41:1373-1406
Lipsky
, BA,
et.al.
“Diagnosis and Treatment of Diabetic Foot Infections”
CID 2004;39:885-910
Nicolle, LE,
et.al.
“Infectious Disease Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic
Bacteriuria
in Adults”
CID 2005;40-643-54
Hooton TM
, et.al. “
Diagnosis, prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Disease Society of America.” CID 2010;50:625-663.