Infectious Diseases in Clinical Practice February 2011 Lisa G. Winston, MD

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1 Infectious Diseases in Clinical Practice February 2011 Lisa G. Winston, MD A 60 year old man was hospitalized 2 months ago for CABG. His course was uncomplicated, and he was discharged after 5 days. He was doing well at home and had returned to work and to his regular activities. Two days ago he developed a fever, productive cough, and pleuritic chest pain. Vital signs are normal except for T=38.7 (PSI= class II). His wound is healing well. CXR shows a right middle lobe infiltrate. The ED strongly advocates for admitting the patient, given his recent surgery. Which of the following regimens is guideline concordant: 1. Vancomycin + cefepime 2. Ceftriaxone + azithromycin 3. Meropenem + ciprofloxacin + linezolid 4. Vancomycin + piperacillin/tazobactam 5. Vancomycin + ceftriaxone + azithromycin 1

2 Clinical Infectious Diseases 2009;49: Online survey to 1313 physicians at 4 academic medical centers; 855 responded (65%) Hospital Medicine/Internal Medicine (60%); Emergency Medicine (25%); Critical Care (13%) CAP: selected guideline- concordant therapy 78% of the time HCAP: selected guideline- concordant therapy 9% of the time 71% aware of published guidelines; 79% agree with and practice according guidelines Clinical Infectious Diseases 2009;49:

3 Am J Resp Crit Care Med 2005;171: Am J Resp Crit Care Med 2005;171: Am J Resp Crit Care Med 2005;171:

4 Note: ciprofloxacin is not preferred Am J Resp Crit Care Med 2005;171: Am J Resp Crit Care Med 2005;171: Lancet Infectious Diseases, online Jan 20, 2011 Four U.S. academic medical schools Reviewed treatment and outcomes for adult patients in ICUs with pneumonia (specific criteria for dx) Adherence to treatment guidelines was associated with increased mortality (survival to 28d 65% vs. 79%) Primary difference was use of two Gram negative drugs 4

5 For most patients on the floor and those in step down or ICU for 5 days or fewer: Ceftriaxone or levofloxacin or moxifloxacin or ertapenem assess response For sick step down and ICU patients in the hospital for greater than 5 days: Vancomycin plus cefepime (unless previous antibiotics or known colonization with resistant Gram negatives) Try hard to get microbiology Stop antibiotics if cultures negative A 53 year- old man is admitted to the hospital for alcohol withdrawal. An indwelling urethral (foley) catheter is placed. On hospital day #3, he develops a new fever and appears more confused. Urinalysis shows 5 wbc/hpf. Urine culture has 10,000 cfu/ml enterococcus. How should he be treated with respect to a urinary tract infection? 1. Ceftriaxone for 7 days 2. Ciprofloxacin for 3 days 3. Ciprofloxacin for 10 days 4. Trimethoprim- sulfamethoxazole for 7 days 5. Piperacillin- tazobactam for 5 days 6. None of the above 5

6 Clinical Infectious Diseases 2010;50: CA- UTI defined as at least 1,000 cfu/ml in catheterized urine specimen plus compatible symptoms with no other identified source Symptoms include fever, rigors, altered mental status, malaise, flank pain, CVA tenderness, hematuria, pelvic pain Presence and degree of pyuria cannot be used to diagnose UTI Absence of pyuria in a symptomatic patient suggests an alternate source of symptoms Condom catheterization should be considered as an alternative to reduce catheter- associated bacteriuria (data not sufficient for recommendation re UTI) For catheters in place at least 2 weeks, decreased bacteriuria and faster resolution of symptoms when replaced at time of treating for UTI (one small study) Seven days of therapy for most patients (limited data) 6

7 Remember to remove urinary catheters and to place them judiciously Catheter-associated UTI is a CMS never event Which of the following is NOT a formally recommended strategy for preventing central- line associated bloodstream infection? 1. Cover patient with large, sterile drape during insertion 2. Use a chlorhexidine- based antiseptic in patients older than 2 months 3. Hand hygiene before catheter insertion 4. Choosing single- lumen versus multi- lumen catheters when appropriate for the patient 5. Use of a mask, cap, sterile gloves, and sterile gown by all inserters 6. Avoidance of femoral site in adults; preference for subclavian site, when feasible 7

8 Dezfulian et al, Crit Care Med 2003;31: (Meta- analysis for single- lumen versus multi- lumen central catheters) Marschall et al, Infect Control Hosp Epidemiol 2008;29:S22-30 (SHEA/IDSA Practice Recommendation) Pronovost et al, New Engl J Med 2006;355: (Collaborative cohort study in Michigan ICUs) Central line associated bloodstream infection is also a CMS never event A 45 year old woman has a peripherally inserted central catheter (PICC) in place for outpatient chemotherapy for breast cancer. She develops a fever but no other systemic symptoms or signs. The catheter site is non- tender with no erythema, swelling, or drainage. Which of the following statements regarding this case is true? 1. Inspection of the catheter is a sensitive method for detecting bloodstream infection 2. The general risk for central line associated bloodstream infection (CLABSI), including PICCs, is approximately 50 per 1000 catheter days 3. Coagulase negative staphylococci, S. aureus, and Candida are the organisms most commonly causing CLABSI 4. When performing differential time to positivity, a difference of one hour between the catheter blood culture and peripheral blood culture suggests CLABSI 8

9 Obtain blood cultures before antibiotics Avoid povidone iodine for skin antisepsis before blood cultures Growth of > 15 cfu of the same organism in blood culture from a 5- cm segment of catheter tip (roll plate method) strongly suggests CLABSI Don t treat catheter tip cultures alone Differential time to positivity is a reasonable strategy [but have a plan for positive blood cultures only from the catheter] Mermel et al, Clin Infect Dis 2009;49:1-49 A 68 year old woman with spinal stenosis underwent lumbar laminectomy at several levels with spinal fusion 5 days ago (bone graft and hardware placed). She was doing well post- operatively until today when she had a new fever. Otherwise, she appears well. The surgical site is red with a moderate amount of drainage (new). Which of the following would you do first? 9

10 1. Call the surgeon to discuss opening the incision site 2. Swab the erythematous skin and drainage to send for Gram stain and culture 3. Start broad spectrum antibiotics and an antifungal agent 4. Start penicillin and clindamycin in case of Group A streptococcal or clostridial infection A few points regarding surgical site infections Typically not apparent before 72 hours Most are superficial incisional S. aureus most common organism Coverage for Gram negatives depends on type of surgery (e.g. GI or GU) and depth of infection Treatment more complicated when infection is deep or hardware is present Consider I.D. consult, in addition to surgical management Clin Infect Dis. 2005;41: (Management of Adults with Skin and Soft-Tissue Infections) 10

11 A 75 year old woman presents in February 2011 with fever, chills, myalgia, sore throat, and cough. CXR has bilateral patchy opacities. Oxygen saturation is 88% on R.A., improving to 95% with 3L NC. A rapid influenza test is negative. Which of the following hospital isolation precautions are most appropriate? 1. Standard precautions, to include respiratory hygiene/cough etiquette and hand hygiene. 2. Droplet precautions with procedure mask and face shield for healthcare workers plus standard precautions. 3. Airborne precautions with N95 mask for healthcare workers, negative pressure room plus standard precautions. 4. Contact precautions with gown and gloves for healthcare workers plus standard precautions. 5. Bubble precautions patient placed in hermetically sealed bubble. CDC provided updated influenza prevention strategies for healthcare settings September Isolation precautions in general use appendix A to search by organism Examples: Localized zoster standard Disseminated zoster or chicken pox airborne and contact Meningococcus droplet until 24 hours after treatment 11

12 Antiviral treatment is recommended as soon as possible for patients with confirmed or suspected influenza who are sick enough to be hospitalized Sensitivity of rapid test may be less than 50% Antiviral treatment is recommended for outpatients with confirmed or suspected influenza at higher risk for complications; clinical judgment is an important component of treatment decisions MMWR, January 21, 2011/60(RR01):1-24 Groups at higher risk Age < 5 years (especially age < 2 years) Age > 65 years Chronic diseases: pulmonary, cardiovascular, renal, hepatic, neurologic, metabolic (including DM) Immunosuppressed, including HIV Pregnant or post partum (within 2 weeks) Children receiving long- term aspirin American Indians/Alaskan Natives Morbid obesity, BMI > 40 Residents of nursing homes and chronic care facilities MMWR, January 21, 2011/60(RR01):1-24 Use oseltamivir or zanamivir for treatment More experience with oseltamivir but rare isolates are resistant or develop resistance with therapy MMWR, January 21, 2011/60(RR01):

13 Avian influenza hits Miami What is the origin of the phrase: A picture is worth a thousand words? 1. A Chinese proverb 2. Fred R. Barnyard, an advertising guy in the 1920s 3. Millicent P. Thornton, an artist in the late 1800s 4. Oscar Wilde 5. Robert Koch 6. Teddy Roosevelt 7. Oscar the Grouch 13

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