Antibiotic Stewardship for Skin and Soft Tissue Infection and Respiratory Tract Infections

Transcription

1 Antibiotic Stewardship for Skin and Soft Tissue Infection and Respiratory Tract Infections Ghinwa Dumyati, MD Professor of Medicine Center for Community Health and Infectious Diseases Division University of Rochester Medical Center Feb 28, 2018

2 Outline Review common reasons for a red leg Discuss when skin lesions need to be cultured Differentiate between upper and lower respiratory tract infections Review treatment duration for cellulitis and pneumonia

3 Stewardship Opportunities in the Nursing Home Common Indications for Antibiotic Prescriptions among Nursing Home Patients 10% Urinary Tract Infection 14% 41% Respiratory (Upper and Lower) Tract Infection 35% Skin and Soft Tissue Infection (SSTI) Other Katz PR et al. Arch Intern Med 1990; 150:1465-8

4 Stewardship Opportunities in the Rochester Nursing Homes BONE/JOINT INFECTION 8% DENTAL/SURGICAL C. DIFF PROPHYLAXIS 5% 4% HEENT INFECTION 9% SSTI 28% PNEUMONIA 21% UTI 25% Proportion of residents treated by indication, example from one of the Rochester nursing homes

5 Skin and Soft Tissue Infections (SSTI): Many Diagnostic Challenges High prevalence of chronic skin changes Peripheral vascular disease Venous stasis disease Pressure ulcers Chronic wounds colonized with bacteria Difficulty in getting information due to cognitive impairment

6 Which one of these wounds should be cultured and Treated? DermNet New Zealand

7 SSTI Diagnostic and Treatment Criteria McGeer Criteria Pus at SSTI site OR Any four (4) of the following Increased warmth Increased redness Increased swelling Increased tenderness Serous drainage Constitutional findings (temp, WBC, etc) Loeb Minimum Criteria New of increased purulence at SSTI site OR Any two (2) of the following Increased warmth Increased redness Increased swelling Increased tenderness Fever (Temp > 100*F, or 2.4*F > baseline) Stone ND, et al. Infect Control Hosp Epidemiol. 2012;33(10): Loeb M, et al. Infect Control Hosp Epidemiol. 2001;22(2):120-4

8 A 60 year old male with history of CAD, CHF, chronic lower extremity edema and diabetes mellitus with ESRD in hemodialysis He had an abrupt onset of lower extremity pain associated with redness and swelling that evolved over a period of several hours

9 What is your diagnosis? What can mimic cellulitis?

10 Cellulitis Non Purulent Purulent Usually due to Streptococcus Group A, B, G Usually due to Staphylococcus aureus

11 Stasis Dermatitis Pictures Visual DX

12 Stasis Dermatitis Extremely common Can present with erythema, edema mimicking cellulitis Can present with bullae, drainage and crusting Severe presentations can mimic bacterial infection

13 Leg Cellulitis -vs- Stasis Dermatitis Cellulitis Often a history of preceding trauma, bite or injury preceding by days Lymphangitic streaking Unilateral Acute episode Fever or chills possible but not mandatory for diagnosis Usually no scale or skin breakdown Leukocytosis Stasis Dermatitis Varicose veins, lymphedema Skin redness often associated with scale Unilateral or Bilateral Usually chronic or recurring Afebrile Pruritic lesions, weeping lesions Relapsing and Remitting Course

14 Bilateral Cellulitis

15 Stasis Stasis Dermatitis

16 But really stasis, stasis, stasis Stasis Dermatitis

17 But Stasis really Dermatitis stasis, stasis, stasis

18 But really stasis, stasis, stasis Stasis Dermatitis: Scale Obvious or Subtle

19 Stasis Stasis dermatitis- Dermatitis: Can Can ulcerate ulcerate

20 Stasis Dermatitis

21 Lymphedema Lymphedema

22 Other Cellulitis Mimics Healthline.com Spider Bite Eczema or Contact Dermatitis Chemical Dermatitis at Peg Gout Deep Vein Thrombosis Fungal Dermatitis

23 Don t Miss

24 Necrotizing Fasciitis Group A strep common etiology Unexplained and rapidly progressing pain disproportional to the physical findings Erythema may be diffuse or localized or may be absent. Progress to bullae formation and necrosis Patients are sick: Fever, malaise, myalgia, diarrhea, and anorexia may also be present Hypotension may develop initially or over time Elevated WBC, bandemia, elevated creatinine

25 Opportunities of Antimicrobial Stewardship Don t culture uninfected ulcers or wounds Don t treat stasis dermatitis with antibiotics Treat cellulitis for 5 days Treat purulent cellulitis for 7 days

26 Respiratory Tract Infections

27 Respiratory Tract Infections Blue dots are syndromes caused by viruses Upper respiratory tract infections Green dots are syndromes caused primarily by bacteria 90% due to viruses Lower respiratory tract infections ~70% due to bacteria

28 Acute Bronchitis vs. Pneumonia Acute Bronchitis Pneumonia Definition Self-limited inflammation of bronchi, the large airways of the lung Inflammation or infection of the lung tissue Cause Viral (with rare exceptions)* ~75% bacteria, ~25% viral Symptoms Diagnostic Studies Cough for 5 days to 3 weeks Fever less common (unless influenza) 50% have sputum production Normal to slightly elevated WBC No specific chest x-ray findings Cough Fever is common Sputum production Chest wall pain Decline in oxygenation Elevated WBC Infiltrate, effusions **bacterial causes include Mycoplasma pneumoniae, Chlamydophila (Chlamydia) pneumoniae and Bordatella pertussis (causes whooping cough). Antibiotics are only appropriate for bronchitis caused by Bordatella pertussis, diagnosed using special tests on nasopharyngeal samples.

29 Evaluation of Pneumonia Signs and Symptoms Cough Sputum production RR 25 Decrease O2 saturation (<95%) New or changed lung exam Pleuritic chest pain Constitutional symptoms (fever, mental status changes, acute functional decline) Workup CBC Viral nasopharyngeal swab Legionella urine antigen and sputum culture if severe pneumonia* CXR (may be) *NYSDOH guidelines for legionella

30 Opportunities for Antibiotic Stewardship Re-assess the need for antibiotics after 2-3 days CXR: common interpretation Cannot rule out infiltrate Need to have positive signs and symptoms and exam findings consistent with pneumonia Treatment duration: 5-7 days for most residents (longer if slow to respond)

31 Updated McGeer Surveillance Criteria for Pneumonia Positive CXR >1 Respiratory criteria Cough, sputum, hypoxia, tachypnea, pleurisy, lung findings >1 Constitutional criteria Fever, neutrophilia/left shift, delirium, decline in function Stone D N. et al, Infect Control Hosp Epidemiol. 2012; 33(10):

32 Loeb Minimum Criteria for Initiating Antibiotics 1. Temp > F AND RR >25 or productive cough 2. Temp >100 0 or > 2.4 F over baseline AND new cough plus: P > 100 OR Delirium or rigors OR RR > COPD AND increased cough with purulent sputum 4. New productive cough AND RR > 25 or delirium Loeb M, Bentley DW, Bradley S, et al. Infect Control Hosp Epidemiol 2001;22:120e124

33 SBAR tools for SSTI and Lower RTI Nursing Home Antimicrobial Stewardship Guide Determine Whether To Treat

34 Rochester Nursing Home Collaborative Guidelines for Treatment of Common Infections

35 Acknowledgments Elizabeth Dodds Ashley, PharmD Alexandra Yamshchikov, MD Joseph Nicholas, MD Dallas Nelson, MD Annette Medina Walpole, MD Timothy Holahan, MD Scott Schabel, MD Thomas Pingree, MD Mary Aydelotte, MD Rena Pine, MD Kim Petrone, MD Brian Heppard, MD Diane Kane, MD Alexander Karlic, MD Robin Jump, MD

36 Questions?