Approach to selecting the appropriate antibiotic
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Approach to Selecting the Appropriate Antibiotic. Teresa Lianne Beck, MD Assistant Professor Family Medicine Residency Program Adapted from Eddie Needham, MD with permission. Objectives.

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Approach to selecting the appropriate antibiotic

Approach to Selecting the Appropriate Antibiotic

Teresa Lianne Beck, MD

Assistant Professor

Family Medicine Residency Program

Adapted from Eddie Needham, MD with permission

Emory University Physician Assistant Program


Objectives

Objectives

  • Identify the appropriate 1st and 2nd line antibiotic for empiric treatment of common bacterial infections in the community and hospital settings

  • Tailor the choice of antibiotic based on unique patient risk factors

  • Identify EBM electronic resources for information on safe, effective treatment

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Basic assumptions

Basic Assumptions

  • Everyone knows who Jay Sanford was…as in Sanford’s Guide to treating infections

  • Everyone has an ID reference they carry with them

    • Epocrates ID, Griffith’s 5 minute consult…

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Basic assumptions1

Basic Assumptions

  • Everyone will attempt to use when possible:

    • The least costly effective drug

      • Use Epocrates or a similar tool to check costs

    • A once or twice daily drug

    • The most safe drug with the least side effects and interactions

      • Use Epocrates drug interaction tool

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Basic assumptions2

Basic Assumptions

  • Drug dosages are readily available

    • Sanford, Epocrates, Griffith’s 5MCC, etc…

  • Drug dosages change based on renal function and recent literature

  • New drugs are produced often

  • As such, I will not mention specific dosages unless appropriate for the discussion

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Principles on choosing an antibiotic for empiric therapy

Principles on choosing an antibiotic for empiric therapy

  • As best possible, attempt to localize the site of infection

    • Do a good exam!!!

  • Occam’s razor

    • “Plurality must not be posited without necessity”

    • Use only one diagnosis whenever possible

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Classes

Classes

  • Bacteriostatic vs Bactericidal

  • Narrow vs Broad spectrum

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Classes1

Classes

  • Bacteriostatic

    • Aminoglycosides (Streptomycin, Amikacin,

      Gentamicin, Tobramycin)

    • Lincosamides (Clindamycin)

    • Macrolides (Azithromycin)

    • Tetracyclines (Doxycycline)

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Bactericidal

Bactericidal

  • Penicillins

  • Cephalosporins

  • Monobactams (Aztreonam)

  • Carbapenems (Meropenem)

  • Quinolones

  • Sulfonamides

  • Aminoglycosides

  • Glycopeptides (Vancomycin)

  • Lipopeptides (Daptomycin)

  • Nitrofurans

  • Metronidazole

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Broad spectrum

Broad Spectrum

  • Amoxicillin/clavulanate (Augmentin)

  • Ampicillin/sulbactam (Unasyn)

  • Piperacillin/tazobactam (Zosyn)

  • Ticarcillin/clavulanate (Timentin)

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Newer classes

Newer Classes

  • Cyclic lipopeptides (daptomycin)

    • Bactericidal against Gram-positive, including MRSA

  • Glycylcyclines (tigecycline)

    • Bacteriostatic against Gram-pos, Gram-neg and MRSA

  • Oxazolidinones (linezolid)

    • Bacteriostatic and bactericidal against Gram-positive, including MRSA, VRE

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Case 1

Case 1

  • 35 year old female presents to your clinic with c/o:

    • Dry cough x 7 days

    • Intermittent fevers, measured to 100.8

    • Few URI sx

  • PMHx: Healthy, ran Peachtree 2 months ago, no meds

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Case 11

Case 1

  • PSHx – C-section for second child

  • Social – nonsmoker, 1-2 glasses wine per month, married 10 yrs – faithful, works as an accountant

  • FamHx – HTN, T2DM

  • Travel – none recent outside Georgia

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Case 12

Case 1

What could this be? DDx?

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Case 13

Case 1

  • Exam

    • VS – temp 100.3, P 92, RR 18, Pulse Ox 96% on room air, BP 123/75

    • HEENT – normal

    • Neck – normal w/o palpable LAD or TMG

    • Lungs – scattered inspiratory crackles in midlung fields, R>L, clear at bases, no EA changes (egophony)

    • CV – normal

    • Legs – no edema

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Case 1 chest x ray

Case 1: Chest X-ray

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Approach to selecting the appropriate antibiotic

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Case 1 diagnosis

Case 1 – Diagnosis?

  • Community –acquired Pneumonia (CAP)

  • Can use the Pneumonia severity index calculator to help determine inpatient vs outpatient treatment

    • See List at end of presentation

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Approach to selecting the appropriate antibiotic

CAP

  • Common Outpatient Bacterial Etiologies

    • Streptococcus pneumonia

    • Mycoplasma pneumonia

    • Chlamydophila pneumonia

      • New and improved name

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The pneumococcus

The pneumococcus

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Cap outpatient treatment

CAP – Outpatient Treatment

  • Antibiotics

    • Oral macrolide

      • Erythromycin

      • Azithromycin

      • Clarithromycin

    • Doxycycline

      • Be careful with potentially pregnant moms or fair-skinned patients who work in the sun.

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Cap outpatient treatment1

CAP – Outpatient Treatment

  • In patients who are older, have comorbid illnesses, or in communities with high pneumococcal resistance to penicillin, consider antipneumococcal fluoroquinolones:

    • Levofloxacin

    • Moxifloxacin

  • In patients previously treated with antibiotics within the previous 90 days, consider a fluoroquinolone.

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Streptococcal resistance

Streptococcal resistance

  • Nationally, <1% of isolates are resistant to fluoroquinolones.

  • This number can be higher is some urban centers, especially ICU settings.

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Cap inpatient treatment

CAP – Inpatient Treatment

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Cap inpatient setting

CAP – Inpatient Setting

  • Common Inpatient Bacterial Etiologies

    • Streptococcus pneumonia

    • Hemophilis influenza

    • Klebsiella pneumonia

    • Staphlococcus aureus

    • Other gram-negative bacilli (GNRs)

    • Anaerobic mouth organisms

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Cap inpatient treatment1

CAP – Inpatient Treatment

  • Beta-lactam + macrolide

    • Ceftriaxone or cefotaxime

      +

    • Erythromycin, azithromycin, or clarithromycin

      or

  • Fluoroquinolone with antistreptococcal activity

    • Levofloxacin or moxifloxacin

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Cap aspiration risk

CAP – aspiration risk

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Cap aspiration risk1

CAP – aspiration risk

  • Consider adding one of the following:

    • Metronidazole

    • Clindamycin

  • Reasonable alternatives include:

    • Moxifloxacin

    • Ampicillin-sulbactam

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Cap icu setting

CAP – ICU setting

  • Consult Infectious Diseases

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Tuberculosis

Tuberculosis

  • Don’t forget about TB, especially in the HIV and immigrant populations.

  • This is a whole talk in itself.

  • Guidelines for treatment in the back.

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Case 2

Case 2

  • 23 year old female presents with symptoms of dysuria and frequency.

  • Recently married – returned from honeymoon two weeks ago.

  • Previously healthy with no significant FamHx.

  • Uses no medications and has NKDA.

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Case 21

Case 2

Diagnosis?

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Case 22

Case 2

  • The urinalysis confirms a UTI.

  • What else do you want to know?

  • No fevers

  • No CVAT – to r/o pyelonephritis.

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Approach to selecting the appropriate antibiotic

UTI

  • Common bacteria (is there more than one?):

    • E. coli

    • Second most common bacteria is…

    • Staphylococcus saprophyticus

    • Others are:

    • Proteus spp.

    • GNRs

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Uti treatment

UTI - Treatment

  • Trimethoprim/sulfamethoxizole x 3 days

  • With high resistance or in women with risk factors, consider:

  • Fluoroquinolone x 3 days:

    • Ciprofloxacin

    • Norfloxacin

    • Ofloxacin, or

  • Nitrofurantoin x 7 days

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Pyelonephritis

Pyelonephritis

  • Initial drug selections:

    • Fluoroquinolones

      • Ciprofloxacin

      • Levofloxacin

    • Beta-lactam

      • Ceftriaxone

      • Cefotaxime

    • Ampicillin-sulbactam

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Case 3

Case 3

  • 57 yo male went fishing five days ago and slipped on a rock, cutting his leg. Leg is now red and moderately painful. Slight subjective fevers at home, per his wife.

  • PMHx – COPD, high cholesterol

  • Social – stopped tobacco two years ago, works in retail business – men’s clothing

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Case 31

Case 3

  • Exam

    • Temp 101.2 otherwise stable

    • Exam unremarkable except for:

    • Lungs – few inspiratory rales, at his baseline per your previous exams

    • Right leg …

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Case 3 leg exam

Case 3 – Leg Exam

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Case 3 admit or not admit

Case 3 – Admit or not Admit?

Audience poll now ensues 

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Cellulitis reasons to admit

Cellulitis – reasons to admit

  • Failed outpatient therapy

  • Toxic appearing

    • High fevers

    • Low BP

    • This was a common cause of “blood poisoning”

  • Potential abscess formation in “difficult” location

  • Poor social situation/follow up lacking

  • Consideration of bad bacteria, eg. Pseudomonas

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Cellulitis

Cellulitis

  • Common bacterial organisms

    • Streptococcus spp.

      • S. pyogenes (group A) or S. agalactiae (group B)

    • Staphylococcus aureus

  • Complicated skin infections

    • Think polymicrobial, in addition to above:

    • GNRs – E. coli, P. aeruginosa

    • Clostridium spp.

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Cellulitis uncomplicated

Cellulitis - uncomplicated

  • Outpatient Treatment: non-MRSA

    • Antistaphylococcal penicillins:

    • Dicloxacillin

    • First-generation cephalosporin

      • Cephalexin

  • Inpatient Treatment: non-MRSA

    • Nafcillin

    • Cefazolin

  • Clindamycin is a good alternate with penicillin allergy

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Bad cellulitis a k a

Bad cellulitis, A.K.A…?

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Another version of

Another version of …?

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Necrotizing cellulitis or fasciitis

Necrotizing cellulitis or fasciitis

  • Increasing causes include:

    • Group A streptococcus

    • Methicillin resistant Staph. aureus

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Cellulitis complicated non mrsa

Cellulitis – complicated, non-MRSA

  • Drug choices include:

    • Piperacillin/tazobactam

    • Ticarcillin/clavulanate

    • Imipenem

    • Meropenem

  • Consider surgical debridement

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Approach to selecting the appropriate antibiotic

MRSA

  • Most predominant cause of suppurative skin infections in many parts of the USA

  • Consider if:

    • Patient recently treated with antibiotics

    • Patient known to be colonized

    • Patient recently hospitalized

    • Geographic area of high prevalence

  • In areas of high rates of Community-acquired MRSA (CA-MRSA), risk factors do not need to be present

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Approach to selecting the appropriate antibiotic

MRSA

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Mrsa treatment

MRSA - Treatment

  • Outpatient

    • Trimethoprim/sulfamethoxizole

    • Clindamycin

    • Doxycycline

    • Not fluoroquinolines – increasing resistance

  • Local debridement

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Mrsa treatment1

MRSA - Treatment

  • Inpatient

    • Vancomycin

    • Anything else would usually necessitate a consultation with infectious diseases

  • Local debridement

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Case 4

Case 4

  • A 43 year old male presents with 10 days of purulent rhinorrhea, subjective fevers, and facial headaches.

  • PMHx – HTN, high cholesterol

  • Meds – lisinopril/HCTZ, pravastatin

  • FamHx – noncontributory

  • Allergies - penicillin

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Case 41

Case 4

  • Exam

    • VSS

    • HEENT – TTP over right maxillary sinus

    • Exam otherwise unremarkable

  • Diagnosis?

  • Sinusitis

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Sinusitis x rays

Sinusitis: x-rays

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Sinusitis

Sinusitis

  • Common bacterial etiologies:

    • Streptococcus pneumonia

    • Hemophilus influenza

    • Moraxella catarrhalis

  • The same three are implicated in Acute Otitis Media

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Sinusitis treatment

Sinusitis - Treatment

  • Mild Acute Bacterial Sinusitis (ABS)

    • Amoxicillin

    • Amoxicillin/clavulanate

    • Cefuroxime axetil

    • Cefpodoxime

    • Or antistrep. fluoroquinolones:

      • Levofloxacin

      • Moxifloxacin

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Sinusitis treatment1

Sinusitis - Treatment

  • Macrolides are not recommended because of increasing pneumococcal resistance.

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Sinusitis treatment2

Sinusitis - Treatment

  • Drug option in the case of allergies to penicillin and cephalosporin with Mild ABS:

    • Doxycycline

    • Trimethoprim/sulfamethoxizole

    • Azithromycin

    • Clarithromycin

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Sinusitis treatment3

Sinusitis - Treatment

  • Drug option in the case of allergies to penicillin and cephalosporin with Moderate to Severe ABS:

    • Antipneumococcal fluoroquinolone:

      • Levofloxacin

      • Moxifloxacin

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Consider adding a decongestant in addition to antibiotic

Consider adding a decongestant in addition to antibiotic

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Case 5

Case 5

  • 42 yo Latino male with 5 days of progressive diffuse headache, mildly stiff neck, low grade fevers.

  • Lives with several families in a large household

  • PMHx – none known

  • PSHx - none

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Case 51

Case 5

  • Immunizations – unknown

  • Meds – OTC acetaminophen, o/w none

  • Social – ½ ppd Marlboros, 1-2 six packs on the weekends, no drugs of abuse

  • Works as a laborer/builds homes

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Case 52

Case 5

  • Exam

    • VS: T 100.9, Pulse 96, RR 16, BP 138/82

    • Gen: mildly ill appearing

    • Mental status: normal

    • HEENT: mild photophobia, no facial TTP

    • Neck: mild pain with flexion

    • Skin: no rash

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Case 53

Case 5

DDx?

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Case 54

Case 5

  • Normal Head CT and elevated WBC lead ER physician to perform Lumbar Puncture, which confirms meningitis.

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Classic exam findings

Classic Exam Findings

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Meningitis

Meningitis

  • Community-acquired etiologies:

    • S. pneumonia

    • Neisseria meningitidis

    • Hemophilus influenza type b

      • Rare with advent of vaccine

    • GNRs

    • Group B strep

    • Listeria monocytogenes

80% cases

Neonates and

Pregnant women

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Meningitis treatment

Meningitis - Treatment

  • Adults and children>2 months old:

  • High dose ceftriaxone or cefotaxime

    +

  • Vancomycin

  • Ampicillin can be added if Listeria monocytogenes is a consideration

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Meningitis use of steroids

Meningitis – Use of Steroids

  • Give dexamethasone before or with the first dose of antibiotics.

  • Corticosteroid treatment has been shown to decrease neurologic complications in children and is now recommended in adults.

  • Continue steroids every 6 hours for four days.

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Case 6

Case 6

  • 62 year old male with Type 2 DM presents with 2 month h/o ulcer on the bottom of his foot.

  • Last A1C = 9.1

  • Last monofilament test ¼ bilateral

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Diabetic foot ulcer

Diabetic foot ulcer

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X ray changes

X-ray changes

Periosteal reaction

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Approach to selecting the appropriate antibiotic

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Diabetic foot ulcer a k a osteomyelitis

Diabetic Foot UlcerA.K.A. Osteomyelitis

  • Treatment

    • Determine vascular status

    • Can the antibiotics reach the tissue or does arterial insufficiency limit medical Rx?

    • Aggressively seek limb preservation

      • Can do stenting of peripheral vessels for limb salvage

    • Get the bug juice to the bugs!

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Osteomyelitis

Osteomyelitis

  • Common bacterial etiologies

    • Polymicrobial in diabetic foot ulcers

    • S. aureus most common bacteria

    • S. pyogenes and S. agalactiae

    • Salmonella spp. in pts with sickle cell

    • GNRs, especially in pts with open fx or orthopedic procedures

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Osteomyelitis1

Osteomyelitis

  • Get bone for culture to determine bacterial organism

  • Empiric Rx

    • Antistaph. Penicillin, e.g. oxacillin, or

    • 1st generation cephalosporin like cefazolin

    • Consider adding vancomycin to cover MRSA until cx results are available

    • If GC is possible, add ceftriaxone

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Diabetic foot ulcer1

Diabetic Foot Ulcer

  • Initial Treatment

    • Ampicillin/sulbactam

    • Ticarcillin/clavulanate

    • Piperacillin/tazobactam

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Case 7

Case 7

  • 63 year old male presents with 3 days of slightly increasing lower left-sided abdominal pain.

  • Mild fevers by history

  • No rectal blood or melena

  • Occasional constipation

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Case 71

Case 7

  • PMHx: HTN, high cholesterol, prostate cancer in remission

  • PSHx: right knee replacement 10 yrs prior, s/p cholecystectomy, s/p TURP and radium seed implants

  • FamHx: noncontributory

  • Social: Civil engineer, married 35 yrs, no tobacco, social EtOH

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Case 7 exam

Case 7 - Exam

  • VS: T 100.1, P 78, RR 16, BP 145/89

  • Lungs/CV – normal

  • Abdomen – left lower quadrant TTP w/o rebound, mild voluntary guarding, negative obturator and psoas signs

  • Back – no CVAT

  • Rectal – guaiac negative, no hard stool

  • Prostate – normal size, no TTP, not boggy

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Case 72

Case 7

  • WBC elevated at 15.3, PMNs 83%, bands 8%

  • UA – normal

  • DDx?

  • In the ER, he would have already rec’d a CT of the abdomen…

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Diverticulitis

Diverticulitis

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Intra abdominal infections

Intra-abdominal infections

  • Common bacterial organisms

    • GNRs

      • E. coli, Klebsiella, Proteus

    • Enterococcus and anaerobes also common

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Intra abdominal infections1

Intra-abdominal infections

  • Empiric therapy should cover GNRs and anaerobes (Bacteroides fragilis)

    • Ampicillin/sulbactam

    • Ticarcillin/clavulanate

    • Piperacillin/tazobactam

    • Carbepenem: imipenem, meropenem

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Intra abdominal infections2

Intra-abdominal infections

  • Cefoxitin no longer has reliable coverage against B. fragilis

  • Cefotetan, another second generation cephalosporin, might be back on the market soon

  • Pts allergic to penicillin could use:

    • Fluoroquinolone + metronidazole

  • For severely ill, cover Pseudomonas

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Approach to selecting the appropriate antibiotic

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Pregnancy

Pregnancy

  • Avoid tetracycline class

    • Staining of teeth and bones in babies

  • Avoid sulfa drugs in the third trimester

    • May be associated with kernicterus

  • Avoid aminoglycosides

    • Kidney toxicities

  • Fluoroquinolones – class C

    • Concerns about cartilage development

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Pregnancy1

Pregnancy

  • Treat the Mother first and the baby will appreciate it 

  • Penicillins and cephalosporins are generally safe in pregnancy.

  • Macrolides are generally safe

    • They may increase nausea early on

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Approach to selecting the appropriate antibiotic

HIV

  • First and foremost, determine the most recent CD4 count, viral load, and any HAART.

  • If the CD4 count is in the acceptable range (>200 or more), treat the patient’s infection similar to any other immunocompetent patient.

  • If the CD4 count is low, then treat with a broad differential.

    • PCP, MAI, TB, Fungal infections, Badness

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Hiv previous guidelines

HIV (Previous Guidelines)

  • When to start HAART meds:

    Sx CD4 Viral load Comments

    (+)Sx Any Any Rx

    Asx <200 Any Rx

    Asx 200-350 Any Consider Rx,

    discuss with pt

    Asx >350 <100,000 Defer Rx

    Asx >350 >100,000 Some would treat, some wouldn't

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Approach to selecting the appropriate antibiotic

New 2010 IAS/USA and USDHHS Recommendations

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Electronic resources

Electronic Resources

  • Pneumonia Severity Index Calculator

  • Tuberculosis treatment guidelines

  • Johns Hopkins antibiotic guide

  • Immunizations

  • Diagnosaurus

  • Epocrates

  • Emory Physician Assistant Program PDA links

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Key references

Key References

  • Treatment Guidelines from The Medical Letter, May 2007, pp 33-50

  • Pneumonia

    LA Mandell et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2: S27.

  • Cellulitis

    DL Stevens et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections.Clin Infect Dis 2005; 41:1373.

    GJ Moran et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 2006; 355:666.

    LG Miller et al. Clinical and epidemiologic characteristics cannot distinguish community-associated methicillin-resistant Staphylococcus aureus infection from

    methicillin-susceptible S. aureus infection: a prospective investigation. Clin Infect Dis 2007; 44:471.

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Key references1

Key References

  • Meningitis

  • MT Fitch and D van de Beek. Emergency diagnosis and treatment of adult meningitis. Lancet Infect Dis 2007; 7:191.

  • D van de Beek et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351:1849.

  • AR Tunkel et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis 2004; 39:1267.

  • D van de Beek and J de Gans. Adjunctive corticosteroids in adults with bacterial meningitis. Drugs 2006; 66:415.

  • D van de Beek et al. Corticosteroids for acute bacterial meningitis (Review). Cochrane Database Syst Rev 2007; 1:CD004405.

  • J de Gans et al. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002; 347:1549.

  • D van de Beek et al. Community-acquired bacterial meningitis in adults. N Engl J Med 2006; 354:44.

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