How did I decide on the topics?

Disclosures None

How did I decide on the topics? Important papers within 1 year vs topics of importance or innovation/aha moments Sepsis Atrial Fibrillation Pneumonia Procalcitonin

Objectives By the end of this lecture you should consider: What are the best screening criteria for sepsis (in my work area)? What should I consider regarding anticoagulation in the care of the patient with atrial fibrillation? What is new in the care of the pneumonia patient? Is procalcitonin helpful in making decisions on antibiotic choices?

What is the best screening for sepsis?

Case 1 67 yo man with hx ESRD and CAD presented 50 days prior to today with unremitting intestinal ischemia causing ileus, requiring TPN. He also was diagnosed with GNR bacteremia 4 days prior. He is on Cipro. This am, patient starts complaining of chest and abdominal pain. His rn reports his heart rate has increased to 124.

Case 1 His other vital signs are: T 37 RR 18 BP 120/57 100% on 2 liters What could be going on with this patient?

Case 1 Which criteria has the highest sensitivity for sepsis? SIRS qsofa NEWS MEWS

Am J Respir Crit Care Med Vol 195, Iss 7, pp 906 911, Apr 1, 2017

University of Chicago, Chicago, Ill All admitted patients who met the criteria for suspicion of infection from 11/08-1/16 (30,677) Observational study Compared for predicting death and composite outcome of death and ICU transfer

Scoring system Sens for death+icu Spec for death+icu Main criticism >/= 2 SIRS 91 13 Id s too many patients >/= 2 qsofa 54 67 Id s pt s too late >/=8 NEWS 67 66 Complicated >/=5 MEWS 59 70 Complicated

..less than one in five patients who later go on to die or be transferred to the ICU will have met >2 qsofa criteria by the time of infection suspicion Furthermore, most patients who experienced the composite outcome met >2 SIRS criteria more than 17 hours before the composite outcome compared with only 5 hours for >2 qsofa, with almost one-half of patients still not meeting >2 qsofa criteria at the time of the outcome. They advocated for not using qsofa

Case 1 Which criteria has the highest sensitivity for sepsis? SIRS qsofa NEWS MEWS

Case 1 Which criteria should we use to screen for sepsis in this patient? SIRS qsofa NEWS MEWS

Which criteria do we use at UNM? SIRS

Our Sepsis leader

Surviving Sepsis Assuming that the reduction in mortality seen to date can be sustained and 10,000 hospitals comply with the Campaign recommendations, we could save 400,000 lives if we treat only half of the eligible patients with the Surviving Sepsis Campaign Bundles.

Case 1 Which of these is not an initial sepsis bundle element? 30ml/kg crystalloid fluid bolus. Draw blood cultures and cultures of other areas of suspected infection. Draw a lactate or lactic acid level. Administer a broad spectrum antibiotic Draw a follow up lactate after fluid

Caveats / Limitations of ProCESS, ARISE & Promise The overall management of sepsis has changed In all three studies patients had early antibiotics, 30ml/kg of intravenous fluid prior to randomization. We need therefore to be very careful about over interpreting the results in areas where this paradgim is not valid.

The River s work was useful. As it provided us a construct on how to understand resuscitation: Start early- (give antibiotics) Correct hypovolaemia Restore perfusion pressure And in some cases a little more may be required..! These concepts are as important today as they ever were.

Sepsis bundle C C A L 30ml/kg crystalloid fluid bolus for suspected hypovolemia and/or tissue hypo-perfusion (especially for lactate>4 SBP<90 or MAP<65). Draw blood cultures and cultures of other areas of suspected infection. (Do not delay antibiotics greater than 30 minutes, if unable to draw cultures). Administer a broad spectrum antibiotic. Draw a lactate or lactic acid level.

Case 1 Which of these is not an intial sepsis bundle element? 30ml/kg crystalloid fluid bolus. Draw blood cultures and cultures of other areas of suspected infection. Draw a lactate or lactic acid level. Administer a broad spectrum antibiotic Draw a follow up lactate after fluid

Case wrapup Patient developed fever however remained hemodynamically stable He was cultured and his antibiotics were broadened to Vancomycin/Zosyn. He did not received fluids due to his ESRD. He had a cardiac arrest 1-2 hours later and died in the ICU 1 day later

Bottom line Which sepsis screening criteria you use depends on your setting. However qsofa may be too insensitive Don t forget about the initial sepsis bundle: fluids, cultures, antibiotics and lactate

What is new in anticoagulation in the care of the patient with afib?

Case 2 67 yo man with hx htn and ICH admitted for syncopal episode and found to be in asymptomatic atrial fibrillation.

Case 2. Which of these would not help us make a decision on whether to anticoagulate this man? ECHO of the heart Current blood pressure of 120/80 with medication Hx of aortic stenosis Hx of liver cirrhosis

JAMA. 2015;313(19):1950-1962

Net clinical benefit CVA risk Bleeding risk CHADS2VASC HASBLED Multiplied By 1.5

Case wrap up CHADS 2 VASC HTN-1 CVA-2 Age-1 HAS BLED CVA-1 Bleeding-1 Elderly-1 4% 3.75% X 1.5=5.6

Case wrapup Pt was seen by anticoag service Discussion held with pt neurologist Pt had MRI brain multiple prior intracranial hemorrhages, as could be seen with either amyloid angiopathy or severe chronic hypertension. With discussion of all patient started on apixiban

Bottom line Use CHADS2VASC and HASBLED when making decisions on anticoagulation

mitral stenosis or artificial heart valves Arch CV Dis 10/2015)

Case 2. If this patient had a CHADS2 VASC score of 1 what would not be appropriate in terms of anticoagulation for afib? None ASA Warfarin DOAC

Part time hospitalist Full time viking

Ann Intern Med. 2007;146:857-867.

29 RCT that tested >12 weeks use of antithrombotic agents in nonvalvular afib Outcomes: All CVA Ischemic ICH Mortality Major bleeding outside head

Adjusted dose warfarin vs placebo or control 2900 patients Primary prevention CVA NNT 37 Secondary prevention CVA NNT 12

Adjusted dose warfarin vs placebo or control

Asa compared with placebo or no treatment 4876 patients Primary prevention CVA NNT 125 Secondary prevention CVA NNT 40

Asa compared with placebo or no treatment

Case 2. If this patient had a CHADS2 VASC score of 1 what would not be appropriate in terms of anticoagulation for afib? None ASA Warfarin DOAC

Guidelines? European Society of Cards still endorse but oac preferred ACC/AHA still endorse ASA level of evid C

Bottom line There does not appear to be antithrombotic benefit of ASA in Atrial fibrillation

What is new in the care of the pneumonia patient?

Case 3 57 yo male with 5 day hospitalization for congestive heart failure within the last month presents with cough productive of green sputum. His T is 39, his HR is 110 and his RR is 26. His CXR shows a dense infiltrate.

Case 3. What antibiotics might you put this patient on? Oral amoxicillin/clavulinic acid ceftriaxone iv and azithromycin po vancomycin and piperacillin/tazobactam iv fluconazole iv

Clinical Infectious Diseases 2014;58(3):330 9

Metaanalysis Outcomes: Frequency Resistant Organisms Mortality 24 studies, 22456 patients --15 retrospective --12 Asian studies -- high risk of bias --mod-poor quality studies --heterogeneity

Table 3. Discrimination of the Healthcare-Associated Pneumonia Concept for Identifying Potentially Resistant Microorganisms Across All Included Studies

Conclusions Our meta-analysis raises serious questions about the validity of the HCAP concept by demonstrating that it is poorly predictive of resistant pathogens No difference in mortality

Case 3. What antibiotics might you put this patient on? Oral amoxicillin/clavulinic acid ceftriaxone iv and azithromycin po vancomycin and piperacillin/tazobactam iv fluconazole iv

Case 4 A 27 yo male with a history of persistent vegetative state due traumatic brain injury with trach, PEG lives in a NH. He presents to ED with increased work of breathing and purulent sputum per the trach. On PE his T is 38.2 and his HR is 130. He has green mucus coming from his trach and coarse breath sounds bilaterally. CXR shows dense pneumonia. You do not know his hx of MDRO.

Case 4. What antibiotics might you put this patient on? Oral amoxicillin/clavulinic acid ceftriaxone iv and azithromycin through the PEG vancomycin and piperacillin/tazobactam fluconazole iv

Bottom line HCAP, in it s current definition, does not select for patients with resistant organiisms. That does not mean that some of those populations which we considered in the HCAP category do not have resistant organisms

Is procalcitonin helpful in making decisions on antibiotic choices?

Case 5 45 yo male smoker presents to ed with malaise, sob and vomiting/diarrhea. He is found to have diffusely coarse breath sounds on exam. His CXR shows atelectasis vs. infiltrate on the right. He is started on treatment for CAP/aspiration pneumonia. Eventually his diarrheal stool comes back positive for Cdiff and his nasal swab is positive for rhinovirus. His procalcitonin is 2.3.

Case 5 Antibiotic stewardship calls and asks that you stop the antibiotics as his procalcitonin of 2.3 is likely due to the Cdiff infection. His respiratory status is not improving after 2-3 days of hospitalization. He requires 4-5 liters of O2 Do you stop the antibiotics?

www.thelancet.com/infection Vol 16 July 2016

Prospective, multicenter, randomized, controlled open-label intervention Netherlands Sept 2009-July 2013 1575 adult ICU patients --80% sepsis or severe sepsis --20% septic shock --65% pulmonary infection, 14% intraabdominal Intervention: Daily measurement of procalcitonin in intervention group. Advice given to discontinue antibiotics if: --Procalcitonin decreased by 80% or to less than.5ug.l Note: Clinicians did not have to follow advice

Case 5 wrapup We continued the respiratory antibiotics for 5 days However once we started treating him for a COPD exacerbation his respiratory status improved substantially. We treated his Cdiff for 10 days after stopping the respiratory antibiotics

Bottom line Procalcitonin can help to make decisions about stopping antibiotics but does not supplant clinical reasoning.

Thank you. Questions?