pw few days of reduced appetite increased dyspnea Sats 88 RA afebrile RR 24 bibasal creps CXR bibasal collapseconsolidation Diagnosis Antibiotic choice CASE 2 50yo M with COPD but otherwise well ID: 1019739
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1. CASE 190yo M from NHfunctional status: bed bound / full assistp/w few days of reduced appetite, ?increased dyspneaSats 88% RA, afebrile, RR 24, bibasal crepsCXR: bibasal collapse/consolidation
2. Diagnosis?Antibiotic choice?
3. CASE 250yo M with COPD but otherwise wellP/w 1 weeks of dyspnea and coughO/E: low grade temp, Sats 94% on 1L O2 via NP, soft AE in chest
4. What’s the diagnosis?Scenario 1: CXR shows RUL consolidationDiagnosis? Antibiotic management?Scenario 2: CXR clearDiagnosis? Antibiotic management
5. Exacerbations of COPDDivide into:Non-infective or viral exacerbationsAcute exacerbation of chronic bronchitisCommunity acquired pneumonia i.e. consolidation on CXRClues to need for antibioticsPneumonia i.e. consolidation on CXRIncreased sputum volume and purulenceSignificantly raised CRPFeverSevere presentation
6. Choice of antibioticsAmoxycillin OR doxycycline for short course (5-7 days)Reserve broad-spectrum antibiotics for those who fail to respond to initial course or perhaps those with known resistant organismsWhich antibiotic for an infective exacerbation of COPD?
7. CASE 335yo F PMedHx: obese, asthma5 days ago had rhinnorhoea, malaise and feverInitially improved but then presented with 1 day of increased SOBO/E: Sats 93% on 4L O2, febrile, LLZ crepsCXR: LLZ consolidationDx? Mx?
8. Risk of death within 15 days of admission (OR 0.2; 95% CI 0.1-0.8)71% treated after 48 hours of symptom onsetReduced mortality (OR 0.13; 95% CI 0.04-0.40)Reduced LOSMedian LOS 4 days vs 6 days without oseltamivir RxProspective study of 754 hospitalised adultsEarlier discharge and improved mortality if treated within 4 days of Sx onsetNeuroaminidase inhibitors in observational studies
9. Staphylococcal pneumonia and gram negative pneumonia patients are usually very unwellPseudomonas is not generally a cause of CAPA marker of hospital contact and prior antibiotic exposureMild CAP: oral amoxycillin + doxycycline (5 days probably sufficient)Moderate CAP: iv benzylpenicillin + oral doxycycline (5-7 days total antis)Severe CAP:Iv ceftriaxone + oral/iv azithromycin (7-10 days total antis)General rules
10. CASE 455yo MPenicillin allergyPresents with 3/7 of cough, fever and pleuritic CP. Sats 95% RA, temp 37.8, RLL creps on auscultationRLL consolidation on CXRStarted on iv moxifloxacin + iv azithromycinManagement?
11. CASE 583yo M presents with 3/7 of dyspnea, cough and feverAssoc. myalgiaIn respiratory distress req. CPAP overnight in ED > transitioned to HiFlow NP. Sats 90% on FiO2 0.40Not an ICU candidateCRP ~150 / CXR pulmonary oedemaAfter frusemide overnight still had R basal creps on auscultation but Sats 94% on RAReceived iv ceftriaxone & iv azithromycin in ED > changed to oral azithromycinAre you happy with this management?
12. CASE 634yo F with RUQ pain / feverCTAP: R pyelonephritisHaemodynamically stableRx in ED: iv ceftriaxoneBC > E.coli (also urine) (S – cephazolin / augmentin / ciprofloxacin / Bactrim) (R – amoxicillin)Improved clinically by time of BC result on day 2Next management?
13. CASE 779yo M PMedHx: CKD 4 (baseline eGFR 22) / pAF – not anticoagulated / PPM / HT 3/7 gastro illnessD1: diarrhoea ~3-4D2: anorexia, diarrhoea ~2-3xD3: diarrhoea ~2x; took immodium, fevers and likely rigor, vomiting 2-3x (in short succession)Nil other localising symptomsO/E: Abdo lax; JVP low, BP 110/60, HR 84, febrileIx: Creat 310 (eGFR 13) / VBG lactate 1.2 / CRP <5 / WCC 7.0 / Hb 107 (normal MCV)Diagnosis? Management?
14. Nausea / Vomiting / Diarrhoea can all be false localising symptoms of sepsisOr symptoms of intra-abdominal surgical pathologyGastroenteritis is generally self-limiting Vomiting usually resolves quickly (i.e within first 24 hours) – if persistent think SURGICAL!Do not diagnose gastroenteritis in a patient who is vomiting in the absence of diarrhoeaBeware diagnosing gastroenteritis in the elderlyAbdominal pain is usually not severe / peritonitic / not persistentGeneral rules in gastroenteritis
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16. CASE 893yo F PMedHx: DLBCL with CMR to R-miniCHOP in 2016 / CKD 2-3 / recurrent fallsAt home with personal care a few times a weekPresented with vomiting; difficult historianO/E: haemodynamically stable / no localising symptoms+ve urine dipstick for leucs & nitritesDiagnosis?Management?
17. Leucocyte esterasecorrelates with pyuriaNitritescorrelates with the presence of Enterobacteriaceae and bacteruriaPositive dipstick in an asymptomatic patient has the same relevance as asymptomatic bacteruriaLittle et al (2009) of urinalysisSensitivity 75% / Specificity 67%Little et al (Br J Gen Pract, 2010)Nitrites OR leucs+blood: 81% PPVNitrites + either blood or leucs: 92% PPVAll 3 negative: NPV 76%Offensive urine smell was not predictive of a UTIIn a hospital setting – always confirm by looking at the MSU microscopy & cultureUrinalysis
18. Creat 89 / eGFR 48MSU: >100 leucs / 10-40 RBCs / 10-40 squamesCulture: E.coli (S-amp)Oral amoxicillin for 5 daysStill dizzy and unable to return home safely
19. Interpretation of a MSUWCC<10 x106/Lusually NOT consistent with UTI in immunocompetent hosts 10-100 x106/LEquivocal. Consider clinical history while interpretation>100 x106/Lusually consistent with UTIBacterial count<107 cfu/L insignificant bacteriuria107 -108 cfu/L Equivocal. Consider clinical history while interpretation>108 cfu/L “significant bacteriuria”
20. A lot of antibiotics get very high urinary concentrations so may overcome lab identified resistance, but only consider this for simple cystitis in a clinically well patientE.g. high dose amoxycillin for Enterococcal UTIs (irrespective of sensitivities, inc. VRE)Consider discussing with microbiology / ID if no oral options for a simple UTIFever and loin pain in pyelonephritis should resolve quickly (i.e. within 72 hours)If not consider renal tract imagingUTIs are generally monomicrobialIf polymicrobial think:IDC / colonizedContaminated specimenStents / urinary calculiColovesical fistulaeGeneral rules in UTIs
21. Diagnosis should be based on fever in a patient, without another clear focus, with a urine sample taken from a fresh IDC consistent with a UTIPyuria and bacteriuria are almost guaranteed in a patient with an IDC in-situ for any significant period of time If treating:Catheter must be changed – biofilm on IDC1 week of treatment usually sufficient Catheter-associated UTIs
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23. Infective exacerbations of bronchiectasisNo evidence to support :Routine anti-pseudomonal coverEmpiric atypical antibiotic coverageIntravenous vs oral antibioticsSteroids / Inhaled corticosteroids / beta 2 agonists in the absence of asthma
24. Often a poor sampleReflects oropharyngeal colonisation or salivaDelay in getting to lab for processingPeople feel obliged to treat the sputum culture result (and sensitivities)How to intepret a sputum sample:Look at the microscopy:predominance of an organism on gram stain (e.g. gram positive cocci)Low numbers or no squamesLook at the culture:Does the culture reflect the gram stain Look at your patient!!If they got better on ceftriaxone but the sputum grew Pseudomonas, the Pseudomonas is colonizing and not a reason to change antibioticsDon’t over-interpret a sputum test
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27. IDSA guidelines
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29. In general a gram positive infection:Group A StrepOther beta-haemolytic Strep (Groups B, C & G)Staph. aureusClinical presentation:Sx: pain, fever/chills (may precede the rash). Most commonly on the lower limbs. Pain in groin.Signs: erythema (shiny skin in dark skinned people), fever, tender, lymphangitis, vesicles/bullae if more severe or protractedSpecial situations:Cellulitis on the faceCellulitis following a biteCellulitis following trauma and water exposureCellulitis
30. Only swab if there is an open woundDo NOT draw a margin around the rash!Antibiotics for ~10-14 daysPerhaps iv only required if severe or systemically unwellGeneral measures:Elevate the limbRestIx and Rx underlying causes e.g. diabetes, tinea in toes, chronic ulcer, dry skin, peripheral oedema from CCF, peripheral vascular disease, etcManagement
31. Mild early cellulitisDi/flucloxacillin 500mg po QID for 7-10 daysCephalexin 500mg po QID for penicillin hypersensitive patients (not immediate hypersensitivity)Clindamycin 450mg po TDS for immediate penicillin hypersensitivitySevere cellulitisFlucloxacillin 2g iv QIDCephazolin 2g iv TDS for penicillin hypersensitive patients (not immediate hypersensitivity)Clindamycin / Lincomycin / Vancomycin ffor immediate penicillin hypersensitivity“Even with effective therapy, local signs (e.g. erythematous rash may worsen for 48 hours after initiation of therapy while systemic features improve”“IV therapy should be continued until systemic features have improved”“Total duration of up to 2 weeks”Therapeutic guidelines
32. Does MRSA matter?
33. IDSA Guidelines