Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
Anna Kaltsas MD MS
Assistant Attending Physician
Infectious Diseases Service
 Consults x7535
 Red team: bone marrow txp
 Green team: attending only
service
◦ Solid tumors, Ortho, GU,
Neurology
 B...
 Draw blood cultures first!!!
◦ Don’t forget UA, urine culture, CXR, C. difficile, LP if
indicated
◦ Work up for other so...
 Penicillin
◦ Most commonly reported
medication allergy – 10% of all
patients
◦ Anaphylaxis: 1-4 episodes/10,000
doses
◦ ...
 250,000 cases
annually/80,000 in ICU
 High hospital cost, patient
morbidity, 12-25% mortality
 Suspect if tunnel/exit ...
 Gram stain with GPC: Vancomycin
◦ Recent history of VRE: Linezolid
 Gram stain with GNR: Zosyn or Cefepime
◦ Narrow to ...
O’Grady NP et al. Guidelines for the
prevention of intravascular catheter-
related infections. CID 2011:52.
Mermel LA et a...
 Skin flora are common
contaminants
 Coagulase-negative staphylococci
(S. epidermidis)
 C. jeikeium, Bacillus, dipthero...
 UTI = most common nosocomial infection.
◦ 10-30% of catheterized patients develop bacteriuria.
 10-25% of those with ba...
 UAs are unreliable in patients with
foley catheters, PCNs, ileal conduits.
◦ Change foley and repeat UA/urine culture
 ...
 8-15 cases/1,000 persons per year
 Highest in winter months,
extremes of age
 S. pneumoniae most common
world-wide
 S...
 Does the patient need
respiratory isolation (viral,
TB)?
 Work up:
◦ Chest Xray/CT Chest (non
contrast)
◦ Sputum cultur...
 Inpatient, non ICU, CAP:
◦ Ceftriaxone 1gm IV daily x7d + Azithromycin 500
mg IV/po daily x5d
 Aspiration PNA:
◦ Unasyn...
 Infection extending beyond the
hollow viscus into previously
sterile peritoneal space.
◦ Cholecystitis, diverticulitis, ...
 Diagnosis: Physical exam, CT scan (po and IV contrast),
ultrasound (gall bladder).
◦ Signs of sepsis may be minimal in e...
 Unasyn, Zosyn, and Imipenem have anaerobic
coverage!
 Spontaneous Bacterial Peritonitis
◦ Ceftriaxone 2gm IV daily
 Bo...
 Gram positive anaerobic
bacillus; toxin producing.
 Most common cause of
antibiotic-associated diarrhea in
the hospital...
 Initial episode, mild/moderate:
WBC <15, Cr <1.5:
◦ Flagyl 500 mg po Q8h
 Initial episode, moderate or
severe, sepsis: ...
 Commonly seen at MSK
 Risk factors include
lymphadenectomies (axillary
LND – upper extremity
lymphedema; pelvic LND – l...
 Women with lymphedema have
10 times the risk of cellulitis
 (Brewer et al, Risk factor analysis for breast cellulitis c...
 “flesh eating disease;” can spread
through tissue at a rate of 3
cm/hour
 25% mortality
 Needs IMMEDIATE surgical
debr...
 Mortality 8-10% per episode
◦ Higher with liquid tumors, advanced age, multiple co-
morbidities
◦ Higher mortality: Gram...
Empiric antibiotic management for major infections
Empiric antibiotic management for major infections
Prochain SlideShare
Chargement dans…5
×

Empiric antibiotic management for major infections

Empiric antibiotic management for major infections

  • Identifiez-vous pour voir les commentaires

Empiric antibiotic management for major infections

  1. 1. Anna Kaltsas MD MS Assistant Attending Physician Infectious Diseases Service
  2. 2.  Consults x7535  Red team: bone marrow txp  Green team: attending only service ◦ Solid tumors, Ortho, GU, Neurology  Blue team: attendings + ID fellows ◦ Leukemia, lymphoma, ICU, Pediatrics  Pharmacists – Antibiotic Approval bpr 1100  Infection control – x7814  MSKCC guidelines on intranet (“Reference manuals and tutorials”)
  3. 3.  Draw blood cultures first!!! ◦ Don’t forget UA, urine culture, CXR, C. difficile, LP if indicated ◦ Work up for other source: ultrasound r/o DVT ◦ Not all fevers need empiric antibiotics!  Consider contact/respiratory isolation needs  Previous culture results  Allergies  What types of bacteria? ◦ Anatomic site  Oral/GI: mixed, anaerobes  Skin: GPC, ?viral  Lung: atypical, GPC;  HAP: GNR, anaerobes (aspiration)  Urine: GNR
  4. 4.  Penicillin ◦ Most commonly reported medication allergy – 10% of all patients ◦ Anaphylaxis: 1-4 episodes/10,000 doses ◦ 85-90% found not to be truly allergic (IgE mediated)  History of PCN “allergy”: only 0.17- 8.4% will react to cephalosporins  PCN allergy by skin test: 2% will react to cephalosporins  Imipenem: 0-11% cross reactive  Aztreonam, quinolones: 0 cross reactivity  Vancomycin/red man syndrome: ◦ histamine-mediated; rate dependent infusion reaction. ◦ Not a true allergy! Angioedema. http://www.wellsphere.com/chronic- pain-article/i-am-a-professional- patient-part-two/624311 Drug rash. http://www.riversideonline.com/source/ima ges/image_popup/r7_drugrash.jpg
  5. 5.  250,000 cases annually/80,000 in ICU  High hospital cost, patient morbidity, 12-25% mortality  Suspect if tunnel/exit site erythematous, has discharge, or pt has fever without a source.  CVC + PICC > tunneled catheters and implanted ports  Sources for infection: ◦ Skin flora (extraluminal) ◦ Contamination from hubs/access ports (intraluminal) ◦ Hematogenous/Infusion related http://www.executivehm.com/article/Improve- CRBSI-Prevention-Target-Intraluminal-Risks/ http://www.moffitt.org/moffittapps/ccj/v3n5/ dept6.html
  6. 6.  Gram stain with GPC: Vancomycin ◦ Recent history of VRE: Linezolid  Gram stain with GNR: Zosyn or Cefepime ◦ Narrow to cephalosporin or oral quinolone when sensitivities are back and repeat cultures are negative.  MSSA: oxacillin, nafcillin, cefazolin superior to Vancomycin.  Yeast/Candida: Micafungin ◦ Pull line ◦ Optho consult (rule out endophthalmitis), TEE  Repeat blood cultures daily until negative x72 hours. ◦ If repeated cultures positive after 72 hours of appropriate antibiotics, consider pulling line. ◦ If patient is sick/septic, consider pulling line.  Ok to replace central line/PICC when blood cultures clear x72 hours.
  7. 7. O’Grady NP et al. Guidelines for the prevention of intravascular catheter- related infections. CID 2011:52. Mermel LA et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter- related infections: 2009 update by the Infectious Diseases Society of America. CID 2009:49
  8. 8.  Skin flora are common contaminants  Coagulase-negative staphylococci (S. epidermidis)  C. jeikeium, Bacillus, diptheroids (gram positive bacilli)  Suspect contamination if single culture from one lumen positive. ◦ All peripheral cx and other lumens negative ◦ Pt/catheter looks well and has other source for fever. ◦ Blood cx were drawn before antibiotics.  S. aureus and Candida spp are almost never contaminants! Scanning EM; Bacteria underneath human toenail. http://resident-alien.blogspot.com/2007/07/humans- wear-diverse-wardrobe-of-skin.html
  9. 9.  UTI = most common nosocomial infection. ◦ 10-30% of catheterized patients develop bacteriuria.  10-25% of those with bacteriuria develop UTIs  Up to 80% of patients with cutaneous diversion of urine through conduits develop bacteriuria and chronic colonization. ◦ Stomal mucus, nephrostomy tubes, stents, catheters allow for biofilm formation and propagation of bacterial growth. ◦ UTI/pyelonephritis can occur from stasis of urine, reflux of urine, self catheterization techniques. ◦ PCN/stent obstruction or dislodgement:  Temporary blockage of the flow of (colonized urine) can result in ascending infection, fever, bacteremia.  Symptoms: fever >38oC, suprapubic/CVA tenderness, SIRS  Diagnosis: urine cx >105 cfu/mL OR urine cx >103 cfu/mL with pyuria on UA + above symptoms – on repeat specimen AFTER changing foley Warren J. Catheter-associated urinary tract infections. Infect Dis Clin; 1997. 11(3):609-22. Bruce AW et al. Bacterial adherence in the human ileal conduit: a morphological and bacteriological study. J Urol. 1984 Jul;132(1):184-8.
  10. 10.  UAs are unreliable in patients with foley catheters, PCNs, ileal conduits. ◦ Change foley and repeat UA/urine culture  Ceftazidime, Cefepime, Zosyn empirically ◦ Narrow once antibiotic sensitivities are known ◦ Target initial antibiotics to past urine culture results. ◦ High rate of GNR resistance to quinolones!  Enterococcus, CN staph, Candida are often contaminants (perineal flora, colonization of catheters).  Asymptomatic bacteriuria does not have to be treated except in pregnancy or before GU procedures.  In patients with GU hardware – persistent fever/UTI sx despite appropriate antibiotics is an indication to replace stent/PCN! http://www.theurologygroup.cc/images/Bladde Replacement-7.gif
  11. 11.  8-15 cases/1,000 persons per year  Highest in winter months, extremes of age  S. pneumoniae most common world-wide  Suspect if: cough (productive), fever, pleuritic chest pain, dyspnea  Following viral illness  High risk: >65, smokers, recent chemo, neutropenia, intubated, HIV/AIDS;  Post-obstructive PNA: lung mass/met obstructing bronchus  Aspiration pneumonia: ◦ head and neck surgery ◦ speech/swallowing difficulties ◦ mental status changes ◦ Tube feeds/aspiration event! Right middle lobe pneumonia. http://www.med- ed.virginia.edu/courses/rad/cxr/pathology3ch est.html
  12. 12.  Does the patient need respiratory isolation (viral, TB)?  Work up: ◦ Chest Xray/CT Chest (non contrast) ◦ Sputum cultures/deep tracheal cultures if intubated ◦ Blood cultures ◦ If CAP: Legionella urine antigen, S. pneumoniae urine antigen ◦ Viral nasal swab (automatic droplet precautions) ◦ To rule out TB: sputum for AFB x2, 24 hours apart Gram positive diplococci on sputum gram stain. http://drugster.info/img/ail/268_269_3.jpg
  13. 13.  Inpatient, non ICU, CAP: ◦ Ceftriaxone 1gm IV daily x7d + Azithromycin 500 mg IV/po daily x5d  Aspiration PNA: ◦ Unasyn or Ceftriaxone + Flagyl  ICU, Hospital-acquired PNA, nursing home resident: ◦ Zosyn 4.5 gm IV Q6h + Cefepime 2 gm IV Q12h +/- Azithromycin 500 mg IV daily +/- Vancomycin IV x5-7 days ◦ PCN allergy: Aztreonam + Flagyl; Imipenem
  14. 14.  Infection extending beyond the hollow viscus into previously sterile peritoneal space. ◦ Cholecystitis, diverticulitis, bowel anastomosis/surgery, typhlitis, bowel obstruction…  >1000 species of gut bacteria; more than 10 times the number of cells in the human body! ◦ Abscess formation ◦ Peritonitis  Second most common cause of infectious mortality in ICUs.  Appendicitis alone: 300,000 patients/year Solomkin et al. Diagnosis and Management of Complicated Intraabdominal Infections in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Disease Society of America. CID 2010:50 Free air. http://www.wjgnet.com/1007-9327/full/v14/i24/WJG- 14-3922-g001.htm
  15. 15.  Diagnosis: Physical exam, CT scan (po and IV contrast), ultrasound (gall bladder). ◦ Signs of sepsis may be minimal in elderly or those on high-dose steroids.  Draw blood cultures  Start appropriate antibiotics ◦ Cover GI flora: GNR, anaerobes, enterococcus, +/- Pseudomonas, +/- Candida ◦ Cover organisms previously isolated in abscess drainages ◦ Culturing fluid in JP drains is low yield  Surgical or IR consult ◦ Mainstay of treatment for intra-abdominal abscess is surgical drainage + antibiotics! ◦ Biliary stent change ◦ Treat for 10-14 days post drainage or until abscess resolved on follow up imaging.
  16. 16.  Unasyn, Zosyn, and Imipenem have anaerobic coverage!  Spontaneous Bacterial Peritonitis ◦ Ceftriaxone 2gm IV daily  Bowel Perforation, Intraperitoneal abscess ◦ Include Pseudomonas coverage! ◦ Zosyn or Cefepime/Flagyl OR Cipro/Flagyl +/- Vancomycin  Diverticulitis ◦ Unasyn Or Cipro/Flagyl  Neutropenic Enterocolitis (Typhlitis) ◦ Include Pseudomonas coverage! ◦ Zosyn + Amikacin  Gall bladder (biliary sepsis, cholangitis, cholecystitis) ◦ Unasyn OR Ceftriaxone/Flagyl OR Ciprofloxacin/Flagyl
  17. 17.  Gram positive anaerobic bacillus; toxin producing.  Most common cause of antibiotic-associated diarrhea in the hospital. ◦ Diarrhea; colitis; toxic megacolon; sepsis  20-30% recurrence rate; 1-2.5% overall mortality; 25% mortality in elderly or very infirm.  Cepheid GeneXpert PCR platform 96% sensitivity/specificity  Do not use as “test of cure” – false positives http://www.google.com/imgres?imgurl=http://www.health- writings.com/img/uf/pseudomembranous-colitis- symptoms/imgCdifficile4.jpg&imgrefurl
  18. 18.  Initial episode, mild/moderate: WBC <15, Cr <1.5: ◦ Flagyl 500 mg po Q8h  Initial episode, moderate or severe, sepsis: WBC >15, Cr >1.5 ◦ Vancomycin 125 mg po Q6h  Unable to take po, ileus, toxic megacolon:  Flagyl 500 mg IV Q8h + Vancomycin po/PR  Second episode:  Same as initial therapy x14 days  Third or more episodes: ◦ Consider ID consult; prolonged Vancomycin po taper Toxic megacolon. http://cueflash.com/decks/Pathology_Chapter_17_and_19_I mages*
  19. 19.  Commonly seen at MSK  Risk factors include lymphadenectomies (axillary LND – upper extremity lymphedema; pelvic LND – lower extremities), diabetes, PVD, DVTs, chemotherapy, radiation  Beware venous stasis dermatitis!  Abscesses require I&D  Culture anything that’s draining  Blood cultures low yield unless systemically ill  Antibiotics: Ancef 1gm IV q8h ◦ Vancomycin if PCN allergic or high suspicion for MRSA  po options: ◦ Skin flora: Keflex, Cefadroxil ◦ MRSA: Clindamycin, Doxycycline, Bactrim; Linezolid Cellulitis in setting of lymphedema. http://www.acols.com/lymphedematoday/ Left leg cellulitis http://odlarmed.com/wp- content/uploads/2009/01/cellulitis_left_leg.jpg
  20. 20.  Women with lymphedema have 10 times the risk of cellulitis  (Brewer et al, Risk factor analysis for breast cellulitis complicating breast conservation therapy; Clin Infect Dis. (2000) 31 (3): 654-659.)  Skin flora, ?gram negatives in seromas  Ancef -> po Cefadroxil  Vancomycin if PCN allergic  Consider adding quinolone for gram negative coverage if no improvement, evidence for infected seroma  Repeated infections or history of S. aureus: may need to remove expander/implant. Cellulitis with tissue expander. http://www.realself.com/question/tissue-expander- infection
  21. 21.  “flesh eating disease;” can spread through tissue at a rate of 3 cm/hour  25% mortality  Needs IMMEDIATE surgical debridement  Polymicrobial; Group A strep  Bacteria introduced by minor trauma ◦ Minor erythema, “pain out of proportion to exam” ◦ Deep tissue infection, sepsis, shock  Fournier’s gangrene: NF of pelvic area  ABX: Unasyn or Zosyn + Vancomycin +/- Clindamycin http://www.jyi.org/features/ft.php?id=463
  22. 22.  Mortality 8-10% per episode ◦ Higher with liquid tumors, advanced age, multiple co- morbidities ◦ Higher mortality: Gram negative bacteremia > gram positive bacteremia  “GI” or “oral” source – mucositis, translocation of bacteria across mucosa  Invasive fungal infections with prolonged neutropenia  Work up: Physical exam, CBC, chemistry, CXR or CT Chest, blood cultures x2, UA/urine culture  MSKCC guidelines: ◦ Zosyn or Cefepime; OR Aztreonam + Vancomycin ◦ After 72 hours: add Vancomycin ◦ After 5-7 days add antifungal (micafungin, voriconazole) ◦ Await count recovery!! Kuderer et al. Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. Cancer; 2006. 106(10):2258.

×