Things your mother never told you about antibiotics, UTI s, and Pneumonia Rob Kaplan, MD July 12 and 14, 2017
Objectives After this talk participants will: Be able to articulate some of the principles and pitfalls of antibiotic use Have a working approach to management of UTI s and pneumonia Probably choose to subspecialize in infectious diseases
Common misconceptions/distortions about antibiotics
1. Let s just throw in some antibiotics-it can t hurt
1. The Problem Microbiome change->c. diff and other superinfections, resistance in patient and community Allergic and nonallergic drug toxicities Cost (materials,labor, indirect costs) Diagnostic pitfalls (impaired cultures, early closure, etc.)
2. Always cover Pseudomonas
2. The Problem Pseudomonas actually has a limited place. Mainly neutropenic patients, plantar infections in diabetics, hospital-acquired infections, severe chronic lung disease such as CF A lot of use of antipseudomonal drugs increasing antipseudomonal resistance
3. With the high prevalence of MRSA, Vancomycin should be used for all severe Staph infections
3. Why not? Vancomycin has a valuable role, but Not reliably bactericidal; better outcomes for MSSA infections with anti-staph beta lactams Some MRSA are VISA and better treated with daptomycin or other agents Need trough level monitoring both for efficacy and safety
4. I don t feel comfortable changing from the empiric regimen because the patient is doing well
4. Let me help you with this What does empiric therapy mean? What is the other kind of therapy? Why do we change regimens when a patient is dong poorly? Why do we change regimens when a patient is doing well? (DISCUSS WITH YOUR NEIGHBOR)
5. I know the organisms are sensitive to the antibiotics but the patient s not getting better
5. Why? Is it the antibiotics? Or the patient? Or the anatomy? Or the organisms? (TALK AMONGST YOURSELVES)
UTI Cases A 21-year-old sexually active woman has one day of dysuria but no fever. Exam is normal; urinalysis shows many wbc and bacteria.
SIMPLE CYSTITIS 3 day therapy with trimethoprim-sulfa or 5 days with nitrofurantoin** Culture not mandatory! Quinolones no longer first line because of collateral damage **
UTI-2 A 65-year-old man with BPH has 2 days of fever, rigors, vomiting, and severe left flank pain. T 102.8, marked left CVAT, moderately enlarged, nontender prostate. Urine-many WBC, WBC 16, cre 1.0.
GRAM STAIN???? What if I told you urine Gram stain was loaded with Gram positive cocci? Or with thin Gram negative rods without bipolar staining?
Men are complicated. (At least their urinary tracts are )
COMMUNITY-ACQUIRED PYELONEPHRITIS Admit, IV antibiotics. Must cover enteric GNR s, especially E. coli. Ceftriaxone fine. Don t count on quinolones! But if Gram stain has a twist.add Vanco or change to antipseudomonal agent Switch to po when doing well, sensis known. Total duration at least 2 weeks (in men)**
UTI-3 A 50 year old quadriplegic, long term resident of VA SCI service, develops fever, altered mentation, and hypotension. Exam shows no skin lesions or inflammation; CXR clear. Foley urine many wbc, mixed bacteria, ph8
HEALTH-CARE ASSOCIATED UROSEPSIS Supportive care with lots of fluid +/- pressors. Consider ICU. Empiric antibiotics to cover resistant GNR +MRSA. At VA Pseudomonas resistant to zosyn. Change based on results. Rec: Vancomycin, Cefepime, consider Amikacin
Did anyone notice anything interesting about the urinalysis?
ph 8 Urea splitter (e.g. Proteus) triple phosph crystals-> struvite staghorn calculi Mechanical approach to stones, not just antibiotics
UTI-4 Down the hall from case 3, another longterm resident of SCI gets a routine urinalysis from his Foley which shows 800 WBC and mixed bacteria. Afebrile, VSS, no new symptoms. No skin lesions; normal mental status. WBC 6, crea 0.5.
ASYMPTOMATIC BACTERIURIA (Do not treat)
UTI-5 A 79-year old paraplegic man with chronic neurogenic bladder has T 102.1, WBC 12, U/A 2600 WBC and many bacteria. Started on ceftriaxone. Urine grows Klebsiella pneumoniae resistant only to ampicillin. Fever continues
NOT UTI-5** Exam reveals RUQ tenderness above level of SCI Abd CT reveals edematous GB wall Metronidazole added for anaerobic coverage Cholecystectomy performed: Acute cholecystitis
Pulmonary Cases 60-year old previously healthy smoker with fever, cough with purulent sputum.
COMMUNITY-ACQUIRED PNEUMONIA Pneumococcus, Haemophilus, Moraxella, maybe Legionella. Consider anaerobes, special exposure/risk history TRY TO GET SPUTUM GRAM STAIN AND CULTURE Ceftriaxone/Azithromycin or respiratory quinolone
Alcoholic with 4 weeks of fever, weight loss, fetid sputum, leftsided chest pain. Pulmonary-2
LUNG ABSCESS Add Klebsiella and anaerobes to usual causes of CAP Ceftriaxone/Flagyl
Pulmonary-3 An SICU patient needs prolonged intubation after abd. surgery. Now fever, inc FiO2, purulent secretions.
VENTILATOR-ASSOCIATED PNEUMONIA Possibility of resistant hospital flora Get deep specimen Gram stain and culture Vancomycin, Cefepime (or Carbapenem if previously on beta lactam), probably Amikacin Consider hospital-acquired Legionella. At VA should probably include Azithromycin.**
A previously healthy 70-year old has 2 weeks of fever, dry cough, increasing dyspnea. RA ABG 7.50/28/60 Pulmonary-4
Pneumonia in the compromised host HIV Antibody positive, CD4 56, VL 100K BAL: Stains positive for Pneumocystis In every patient we need to think about exposures and risks. Check HIV in everybody especially with confusing illness. Be ready for more than one infection at the same time
Pulmonary-5 (A surprise.) A 72-year old man with CLL on chemotherapy was admitted for 24 hours of fever, cough, dyspnea, and altered mentation. WBC 95 (mainly lymphs), Cre 2.2, ABG 6.99/65/61. CXR bilateral infiltrates. The patient died within 6 hours despite intubation, vancomycin, zosyn, pressors, steroids
Chest X-Ray
Blood Cultures The next day blood cultures grew facultative Gram negative coccobacilli with bipolar staining..
Pasteurella multocida Identified as..
Social History The patient s daughter told me that this crusty veteran was a great lover of cats, playing with every cat in the neighborhood and famous for kissing them!