Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
September 18, 2013
Anna Kaltsas MD MS
Assistant Attending Physician
Infectious Diseases Service
 Consults x7535
 Green team: attending only
service
◦ Solid tumors, Ortho, GU,
Neurology
 Blue team: attendings + ID
fe...
 Draw blood cultures first!!!
◦ Don’t forget UA, urine culture, CXR, C. difficile, LP if
indicated
◦ Work up for other so...
 Penicillin
◦ Most commonly reported
medication allergy – 10% of all
patients
◦ Anaphylaxis: 1-4 episodes/10,000
doses
◦ ...
 250,000 cases
annually/80,000 in ICU
 High hospital cost, patient
morbidity, 12-25% mortality
 Suspect if tunnel/exit ...
 Gram stain with GPC: Vancomycin
◦ Recent history of VRE: Linezolid
 Gram stain with GNR: Zosyn or Cefepime
◦ Narrow to ...
O’Grady NP et al. Guidelines for the
prevention of intravascular catheter-
related infections. CID 2011:52.
Mermel LA et a...
 Skin flora are common
contaminants
 Coagulase-negative staphylococci
(S. epidermidis)
 C. jeikeium, Bacillus, dipthero...
 UTI = most common nosocomial infection.
◦ 10-30% of catheterized patients develop bacteriuria.
 10-25% of those with ba...
 UAs are unreliable in patients with
foley catheters, PCNs, ileal conduits.
◦ Change foley and repeat UA/urine culture
 ...
 8-15 cases/1,000 persons per year
 Highest in winter months,
extremes of age
 S. pneumoniae most common
world-wide
 S...
 Does the patient need
respiratory isolation (viral,
TB)?
 Work up:
◦ Chest Xray/CT Chest (non
contrast)
◦ Sputum cultur...
 Inpatient, non ICU, CAP:
◦ Ceftriaxone 1gm IV daily x7d + Azithromycin 500
mg IV/po daily x5d
 Aspiration PNA:
◦ Unasyn...
 Infection extending beyond the
hollow viscus into previously
sterile peritoneal space.
◦ Cholecystitis, diverticulitis, ...
 Diagnosis: Physical exam, CT scan (po and IV contrast),
ultrasound (gall bladder).
◦ Signs of sepsis may be minimal in e...
 Unasyn, Zosyn, and Imipenem have anaerobic
coverage!
 Spontaneous Bacterial Peritonitis
◦ Ceftriaxone 2gm IV daily
 Bo...
 Gram positive anaerobic
bacillus; toxin producing.
 Most common cause of
antibiotic-associated diarrhea in
the hospital...
 Initial episode, mild/moderate:
WBC <15, Cr <1.5:
◦ Flagyl 500 mg po Q8h
 Initial episode, moderate or
severe, sepsis: ...
 Commonly seen at MSK
 Risk factors include
lymphadenectomies (axillary
LND – upper extremity
lymphedema; pelvic LND – l...
 Women with lymphedema have
10 times the risk of cellulitis
 (Brewer et al, Risk factor analysis for breast cellulitis c...
 “flesh eating disease;” can spread
through tissue at a rate of 3
cm/hour
 25% mortality
 Needs IMMEDIATE surgical
debr...
 Mortality 8-10% per episode
◦ Higher with liquid tumors, advanced age, multiple co-
morbidities
◦ Higher mortality: Gram...
Empiric Antibiotic Management for Major Infections at MSKCC
Upcoming SlideShare
Loading in …5
×

Empiric Antibiotic Management for Major Infections at MSKCC

5,208 views

Published on

Published in: Health & Medicine
  • Be the first to comment

Empiric Antibiotic Management for Major Infections at MSKCC

  1. 1. September 18, 2013 Anna Kaltsas MD MS Assistant Attending Physician Infectious Diseases Service
  2. 2.  Consults x7535  Green team: attending only service ◦ Solid tumors, Ortho, GU, Neurology  Blue team: attendings + ID fellows ◦ Leukemia, lymphoma, ICU, Pediatrics  Pharmacists – Antibiotic Approval bpr 1100  Infection control – x7814  MSKCC guidelines on intranet (“Reference manuals and tutorials”)
  3. 3.  Draw blood cultures first!!! ◦ Don’t forget UA, urine culture, CXR, C. difficile, LP if indicated ◦ Work up for other source: ultrasound r/o DVT ◦ Not all fevers need empiric antibiotics!  Consider contact/respiratory isolation needs  Previous culture results  Allergies  What types of bacteria? ◦ Anatomic site  Oral/GI: mixed, anaerobes  Skin: GPC, ?viral  Lung: atypical, GPC;  HAP: GNR, anaerobes (aspiration)  Urine: GNR
  4. 4.  Penicillin ◦ Most commonly reported medication allergy – 10% of all patients ◦ Anaphylaxis: 1-4 episodes/10,000 doses ◦ 85-90% found not to be truly allergic (IgE mediated)  History of PCN “allergy”: only 0.17- 8.4% will react to cephalosporins  PCN allergy by skin test: 2% will react to cephalosporins  Imipenem: 0-11% cross reactive  Aztreonam, quinolones: 0 cross reactivity  Vancomycin/red man syndrome: ◦ histamine-mediated; rate dependent infusion reaction. ◦ Not a true allergy! Angioedema. http://www.wellsphere.com/chronic- pain-article/i-am-a-professional- patient-part-two/624311 Drug rash. http://www.riversideonline.com/source/ima ges/image_popup/r7_drugrash.jpg
  5. 5.  250,000 cases annually/80,000 in ICU  High hospital cost, patient morbidity, 12-25% mortality  Suspect if tunnel/exit site erythematous, has discharge, or pt has fever without a source.  CVC + PICC > tunneled catheters and implanted ports  Sources for infection: ◦ Skin flora (extraluminal) ◦ Contamination from hubs/access ports (intraluminal) ◦ Hematogenous/Infusion related http://www.executivehm.com/article/Improve- CRBSI-Prevention-Target-Intraluminal-Risks/ http://www.moffitt.org/moffittapps/ccj/v3n5/ dept6.html
  6. 6.  Gram stain with GPC: Vancomycin ◦ Recent history of VRE: Linezolid  Gram stain with GNR: Zosyn or Cefepime ◦ Narrow to cephalosporin or oral quinolone when sensitivities are back and repeat cultures are negative.  MSSA: oxacillin, nafcillin, cefazolin superior to Vancomycin.  Yeast/Candida: Micafungin ◦ Pull line ◦ Optho consult (rule out endophthalmitis), TEE  Repeat blood cultures daily until negative x72 hours. ◦ If repeated cultures positive after 72 hours of appropriate antibiotics, consider pulling line. ◦ If patient is sick/septic, consider pulling line.  Ok to replace central line/PICC when blood cultures clear x72 hours.
  7. 7. O’Grady NP et al. Guidelines for the prevention of intravascular catheter- related infections. CID 2011:52. Mermel LA et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter- related infections: 2009 update by the Infectious Diseases Society of America. CID 2009:49
  8. 8.  Skin flora are common contaminants  Coagulase-negative staphylococci (S. epidermidis)  C. jeikeium, Bacillus, diptheroids (gram positive bacilli)  Suspect contamination if single culture from one lumen positive. ◦ All peripheral cx and other lumens negative ◦ Pt/catheter looks well and has other source for fever. ◦ Blood cx were drawn before antibiotics.  S. aureus and Candida spp are almost never contaminants! Scanning EM; Bacteria underneath human toenail. http://resident-alien.blogspot.com/2007/07/humans- wear-diverse-wardrobe-of-skin.html
  9. 9.  UTI = most common nosocomial infection. ◦ 10-30% of catheterized patients develop bacteriuria.  10-25% of those with bacteriuria develop UTIs  Up to 80% of patients with cutaneous diversion of urine through conduits develop bacteriuria and chronic colonization. ◦ Stomal mucus, nephrostomy tubes, stents, catheters allow for biofilm formation and propagation of bacterial growth. ◦ UTI/pyelonephritis can occur from stasis of urine, reflux of urine, self catheterization techniques. ◦ PCN/stent obstruction or dislodgement:  Temporary blockage of the flow of (colonized urine) can result in ascending infection, fever, bacteremia.  Symptoms: fever >38oC, suprapubic/CVA tenderness, SIRS  Diagnosis: urine cx >105 cfu/mL OR urine cx >103 cfu/mL with pyuria on UA + above symptoms – on repeat specimen AFTER changing foley Warren J. Catheter-associated urinary tract infections. Infect Dis Clin; 1997. 11(3):609-22. Bruce AW et al. Bacterial adherence in the human ileal conduit: a morphological and bacteriological study. J Urol. 1984 Jul;132(1):184-8.
  10. 10.  UAs are unreliable in patients with foley catheters, PCNs, ileal conduits. ◦ Change foley and repeat UA/urine culture  Ceftazidime, Cefepime, Zosyn empirically ◦ Narrow once antibiotic sensitivities are known ◦ Target initial antibiotics to past urine culture results. ◦ High rate of GNR resistance to quinolones!  Enterococcus, CN staph, Candida are often contaminants (perineal flora, colonization of catheters).  Asymptomatic bacteriuria does not have to be treated except in pregnancy or before GU procedures.  In patients with GU hardware – persistent fever/UTI sx despite appropriate antibiotics is an indication to replace stent/PCN! http://www.theurologygroup.cc/images/Bladde Replacement-7.gif
  11. 11.  8-15 cases/1,000 persons per year  Highest in winter months, extremes of age  S. pneumoniae most common world-wide  Suspect if: cough (productive), fever, pleuritic chest pain, dyspnea  Following viral illness  High risk: >65, smokers, recent chemo, neutropenia, intubated, HIV/AIDS;  Post-obstructive PNA: lung mass/met obstructing bronchus  Aspiration pneumonia: ◦ head and neck surgery ◦ speech/swallowing difficulties ◦ mental status changes ◦ Tube feeds/aspiration event! Right middle lobe pneumonia. http://www.med- ed.virginia.edu/courses/rad/cxr/pathology3ch est.html
  12. 12.  Does the patient need respiratory isolation (viral, TB)?  Work up: ◦ Chest Xray/CT Chest (non contrast) ◦ Sputum cultures/deep tracheal cultures if intubated ◦ Blood cultures ◦ If CAP: Legionella urine antigen, S. pneumoniae urine antigen ◦ Viral nasal swab (automatic droplet precautions) ◦ To rule out TB: sputum for AFB x2, 24 hours apart Gram positive diplococci on sputum gram stain. http://drugster.info/img/ail/268_269_3.jpg
  13. 13.  Inpatient, non ICU, CAP: ◦ Ceftriaxone 1gm IV daily x7d + Azithromycin 500 mg IV/po daily x5d  Aspiration PNA: ◦ Unasyn or Ceftriaxone + Flagyl  ICU, Hospital-acquired PNA, nursing home resident: ◦ Zosyn 4.5 gm IV Q6h + Cefepime 2 gm IV Q12h +/- Azithromycin 500 mg IV daily +/- Vancomycin IV x5-7 days ◦ PCN allergy: Aztreonam + Flagyl; Imipenem
  14. 14.  Infection extending beyond the hollow viscus into previously sterile peritoneal space. ◦ Cholecystitis, diverticulitis, bowel anastomosis/surgery, typhlitis, bowel obstruction…  >1000 species of gut bacteria; more than 10 times the number of cells in the human body! ◦ Abscess formation ◦ Peritonitis  Second most common cause of infectious mortality in ICUs.  Appendicitis alone: 300,000 patients/year Solomkin et al. Diagnosis and Management of Complicated Intraabdominal Infections in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Disease Society of America. CID 2010:50 Free air. http://www.wjgnet.com/1007-9327/full/v14/i24/WJG- 14-3922-g001.htm
  15. 15.  Diagnosis: Physical exam, CT scan (po and IV contrast), ultrasound (gall bladder). ◦ Signs of sepsis may be minimal in elderly or those on high-dose steroids.  Draw blood cultures  Start appropriate antibiotics ◦ Cover GI flora: GNR, anaerobes, enterococcus, +/- Pseudomonas, +/- Candida ◦ Cover organisms previously isolated in abscess drainages ◦ Culturing fluid in JP drains is low yield  Surgical or IR consult ◦ Mainstay of treatment for intra-abdominal abscess is surgical drainage + antibiotics! ◦ Biliary stent change ◦ Treat for 10-14 days post drainage or until abscess resolved on follow up imaging.
  16. 16.  Unasyn, Zosyn, and Imipenem have anaerobic coverage!  Spontaneous Bacterial Peritonitis ◦ Ceftriaxone 2gm IV daily  Bowel Perforation, Intraperitoneal abscess ◦ Include Pseudomonas coverage! ◦ Zosyn or Cefepime/Flagyl OR Cipro/Flagyl +/- Vancomycin  Diverticulitis ◦ Unasyn Or Cipro/Flagyl  Neutropenic Enterocolitis (Typhlitis) ◦ Include Pseudomonas coverage! ◦ Zosyn + Amikacin  Gall bladder (biliary sepsis, cholangitis, cholecystitis) ◦ Unasyn OR Ceftriaxone/Flagyl OR Ciprofloxacin/Flagyl
  17. 17.  Gram positive anaerobic bacillus; toxin producing.  Most common cause of antibiotic-associated diarrhea in the hospital. ◦ Diarrhea; colitis; toxic megacolon; sepsis  20-30% recurrence rate; 1-2.5% overall mortality; 25% mortality in elderly or very infirm.  Cepheid GeneXpert PCR platform 96% sensitivity/specificity  Do not use as “test of cure” – false positives http://www.google.com/imgres?imgurl=http://www.health- writings.com/img/uf/pseudomembranous-colitis- symptoms/imgCdifficile4.jpg&imgrefurl
  18. 18.  Initial episode, mild/moderate: WBC <15, Cr <1.5: ◦ Flagyl 500 mg po Q8h  Initial episode, moderate or severe, sepsis: WBC >15, Cr >1.5 ◦ Vancomycin 125 mg po Q6h  Unable to take po, ileus, toxic megacolon:  Flagyl 500 mg IV Q8h + Vancomycin po/PR  Second episode:  Same as initial therapy x14 days  Third or more episodes: ◦ Consider ID consult; prolonged Vancomycin po taper Toxic megacolon. http://cueflash.com/decks/Pathology_Chapter_17_and_19_I mages*
  19. 19.  Commonly seen at MSK  Risk factors include lymphadenectomies (axillary LND – upper extremity lymphedema; pelvic LND – lower extremities), diabetes, PVD, DVTs, chemotherapy, radiation  Beware venous stasis dermatitis!  Abscesses require I&D  Culture anything that’s draining  Blood cultures low yield unless systemically ill  Antibiotics: Ancef 1gm IV q8h ◦ Vancomycin if PCN allergic or high suspicion for MRSA  po options: ◦ Skin flora: Keflex, Cefadroxil ◦ MRSA: Clindamycin, Doxycycline, Bactrim; Linezolid Cellulitis in setting of lymphedema. http://www.acols.com/lymphedematoday/ Left leg cellulitis http://odlarmed.com/wp- content/uploads/2009/01/cellulitis_left_leg.jpg
  20. 20.  Women with lymphedema have 10 times the risk of cellulitis  (Brewer et al, Risk factor analysis for breast cellulitis complicating breast conservation therapy; Clin Infect Dis. (2000) 31 (3): 654-659.)  Skin flora, ?gram negatives in seromas  Ancef -> po Cefadroxil  Vancomycin if PCN allergic  Consider adding quinolone for gram negative coverage if no improvement, evidence for infected seroma  Repeated infections or history of S. aureus: may need to remove expander/implant. Cellulitis with tissue expander. http://www.realself.com/question/tissue-expander- infection
  21. 21.  “flesh eating disease;” can spread through tissue at a rate of 3 cm/hour  25% mortality  Needs IMMEDIATE surgical debridement  Polymicrobial; Group A strep  Bacteria introduced by minor trauma ◦ Minor erythema, “pain out of proportion to exam” ◦ Deep tissue infection, sepsis, shock  Fournier’s gangrene: NF of pelvic area  ABX: Unasyn or Zosyn + Vancomycin +/- Clindamycin http://www.jyi.org/features/ft.php?id=463
  22. 22.  Mortality 8-10% per episode ◦ Higher with liquid tumors, advanced age, multiple co- morbidities ◦ Higher mortality: Gram negative bacteremia > gram positive bacteremia  “GI” or “oral” source – mucositis, translocation of bacteria across mucosa  Invasive fungal infections with prolonged neutropenia  Work up: Physical exam, CBC, chemistry, CXR or CT Chest, blood cultures x2, UA/urine culture  MSKCC guidelines: ◦ Zosyn or Cefepime; OR Aztreonam + Vancomycin ◦ After 72 hours: add Vancomycin ◦ After 5-7 days add Ambisome ◦ Await count recovery!! Kuderer et al. Mortality, morbidity, and cost associated with febrile neutropenia in adult cancer patients. Cancer; 2006. 106(10):2258.

×