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The ABC’s of Infections The ABC’s of Infections

The ABC’s of Infections - PowerPoint Presentation

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The ABC’s of Infections - PPT Presentation

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

guidelines acute infections test acute guidelines test infections respiratory sinusitis adults abx pseudomonas upper infection society community treatment idsa

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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.

“Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults”

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.

“Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America.”

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.