How To Treat Infections Without Using Antibiotics dr shabeel pn
Disclosures <ul><li>No drug company interactions </li></ul><ul><li>Slides are my own  </li></ul><ul><li>Reflect my perspec...
My Objectives <ul><li>Review rationale for less Abx use </li></ul><ul><li>Introduction to Abx stewardship </li></ul><ul><l...
Your Objectives <ul><li>Reflect on the myths </li></ul><ul><ul><li>Abx are risk free  </li></ul></ul><ul><ul><li>Abx effic...
Bottom of the R&D Barrel <ul><li>No novel Abx classes </li></ul><ul><ul><li>Cross resistance </li></ul></ul><ul><li>Big ph...
Nosocomial Menace <ul><li>“ ESKAPE” (IDSA) </li></ul><ul><ul><li>VRE </li></ul></ul><ul><ul><li>MRSA </li></ul></ul><ul><u...
Community Menace <ul><li>CA-MRSA </li></ul><ul><li>Penicillin/MDR  S. pneumoniae </li></ul><ul><li>EBSL  E. coli  (CTX typ...
Darwin and the Microbes <ul><li>Evolutionary forces favour microbes </li></ul><ul><ul><li>Generation time permits rapid ad...
Playing for Stalemate
Ecological Burden of Resistance <ul><li>Genes are the “currency” </li></ul><ul><ul><li>Inter- & intra species trade </li><...
More use of fewer effective Abx Self amplifying cycle “ Treatment Stenosis” New Infection Abx Therapy Clinical Cure Abx St...
Basic Tenants of Stewardship <ul><li>Patient safety initiative </li></ul><ul><ul><li>Too much Abx use with no clear benefi...
Antibiotic Balance - Patient <ul><li>Proper empiric Abx </li></ul><ul><ul><li>Common bacteria for syndrome </li></ul></ul>...
Antibiotic “Co-lateral Damage” <ul><li>The 7 C’s </li></ul><ul><ul><li>Colonization with AROs </li></ul></ul><ul><ul><li>C...
Antibiotic Balance - Population <ul><li>Increasing Abx needs </li></ul><ul><ul><li>Advances in transplant/oncology </li></...
Antibiotic “Co-lateral Damage”
Antibiotic Stewardship <ul><li>Hospitals based </li></ul><ul><ul><li>Multidisciplinary team </li></ul></ul><ul><ul><li>Con...
Summary 1 <ul><li>Antibiotic resistant organism on the rise are unchecked </li></ul><ul><li>New Abx not the answer (per se...
Strategies for Outpatients <ul><li>Avoid prescribing </li></ul><ul><li>Fix the underlying problem </li></ul><ul><li>Do not...
Infectious Syndromes to Target <ul><li>Acute pharyngitis </li></ul><ul><li>Acute otitis media </li></ul><ul><li>Acute sinu...
AVOID ANTIBIOTIC PRESCRIBING
Avoid Prescribing When Safe <ul><li>Abx have no/little effect on natural history </li></ul><ul><ul><li>Mild illness </li><...
Sinusitis <ul><li>United Kingdom </li></ul><ul><ul><li>90% get Abx </li></ul></ul><ul><ul><li>£10 million pounds/year </li...
Sinusitis – Primary Care RCT <ul><li>Amox 500 mg 3  x 7 days </li></ul><ul><li>Block randomized (ITT) </li></ul><ul><li>He...
Sinusitis – Meta-analysis <ul><li>15 pts treated before 1 addition pt benefits </li></ul><ul><li>Common clinical features ...
Asymptomatic Bacteriuria <ul><li>Lack cystitis/pyelonephritis S&S </li></ul><ul><ul><li>Pyuria is not a “symptom” </li></u...
Asymptomatic Bacteriuria <ul><li>No treatment benefit </li></ul><ul><ul><li>Premenopausal non pregnant women </li></ul></u...
Otitis Media <ul><li>15 million Rx per year in USA </li></ul><ul><li>Spontaneous resolution common </li></ul><ul><li>Compl...
Otitis Media <ul><li>RCT – Standard vs. Wait & See  </li></ul><ul><ul><li>Well 6-12 mos old seen in ER </li></ul></ul><ul>...
Otitis Media <ul><li>Meta analysis favour Abx </li></ul><ul><ul><li>Clinical cure (RR = 1.13) </li></ul></ul><ul><ul><li>S...
FIX THE UNDERLYING PROBLEM
Infection as a “Symptom” <ul><li>Predisposition from other disease </li></ul><ul><ul><li>Unknown or known </li></ul></ul><...
Case Example - Cellulitis <ul><li>38 yr M outdoor construction worker </li></ul><ul><ul><li>Healthy </li></ul></ul><ul><li...
Case Example - Cellulitis Courtesy of Center for Disease Control and Prevention Image Library
Case Controlled Studies Bjornsdottir  et al.  Clin Infect Dis 2005; 41:1416-22 Dupuy  et al.  BMJ 1999; 318:1591-4 <ul><li...
Prophylaxis Pitfalls <ul><li>Recurrent UTI risk </li></ul><ul><ul><li>Severe vesicoureteral reflux </li></ul></ul><ul><ul>...
DO NOT OVER VALUE NON STERILE SITE CULTURES
Non Sterile Site Cultures <ul><li>Clinical impression your guide </li></ul><ul><ul><li>When to test and its interpretation...
Colonization Contamination Disease Invasion Non Sterile Site Sample Sterile Site Sample Skin Flora – Low Virulence (e.g. C...
A Typical Case <ul><li>Longstanding DM2 </li></ul><ul><li>Acute foot ulcer –  S. aureus </li></ul><ul><ul><li>Better with ...
DM Foot Discordance <ul><li>Abx not recommended for non infected/non healing ulcers </li></ul><ul><li>Chronic osteomyeliti...
MAKE THE DIAGNOSIS
Death to Empiric Therapy <ul><li>Clinical exam has limitations </li></ul><ul><ul><li>Bacterial vs. viral </li></ul></ul><u...
Community Acquired Pneumonia <ul><li>No symptom can rule in/rule out </li></ul><ul><li>Signs with modest likelihood ratios...
Acute Bronchitis <ul><li>9 th  most common outpatient issue </li></ul><ul><ul><li>5% of adults annually </li></ul></ul><ul...
TAPER TO (OR USE) NARROW SPECTRUM THERAPY
Less is More <ul><li>Broad spectrum therapy </li></ul><ul><ul><li>Risk and/or uncertainty </li></ul></ul><ul><ul><li>Cultu...
Community Acquired Pneumonia <ul><li>Outpatient  </li></ul><ul><ul><li>PSI I to III </li></ul></ul><ul><ul><li>Benign dise...
COPD Exacerbations <ul><li>50/50 viral & bacterial </li></ul><ul><li>Problems studying Abx benefit </li></ul><ul><ul><li>S...
SHORTER DURATIONS
Longer Is Not Better <ul><li>Length of therapy generally too long </li></ul><ul><ul><li>Poorly studied </li></ul></ul><ul>...
Shorter Duration - Cellulitis <ul><li>Double blinded RCT </li></ul><ul><ul><li>All patients - 5 days of levofloxacin </li>...
Shorter Duration - Cystitis <ul><li>Well studied in women </li></ul><ul><li>3 = 5-10 days for symptomatic improvement </li...
Shorter Duration - CAP <ul><li>Recommended 7-14 days ?evidence </li></ul><ul><li>RCTs with various Abxs </li></ul><ul><li>...
Summary 2 <ul><li>Multiple “mild” conditions over treated </li></ul><ul><li>Practical tips </li></ul><ul><ul><li>Treat bac...
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abscess advanced trauma life support anterio advanced trauma life support antibiotics apically repositioned flap dental diseases dr dr shabeel drshabeel’s face eye trauma lidocaine anodontia management medical medi

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  • hi, i am mr gabriel, living in abuja, nigeria. i am a mentality repositioning therapist. that is helping people with the wrong way of thinking responsible for their present travails to think well and right to achieve their god given goal and purpose in life. i need assistance in terms of knowledge and facilities. thank you and god bless
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abscess advanced trauma life support anterio advanced trauma life support antibiotics apically repositioned flap dental diseases dr dr shabeel drshabeel’s face eye trauma lidocaine anodontia management medical medi

  1. 1. How To Treat Infections Without Using Antibiotics dr shabeel pn
  2. 2. Disclosures <ul><li>No drug company interactions </li></ul><ul><li>Slides are my own </li></ul><ul><li>Reflect my perspective on “best/useful” evidence </li></ul><ul><li>I am an antibiotic minimalist </li></ul><ul><li>Don’t fully understand the ins & outs of family practice </li></ul>
  3. 3. My Objectives <ul><li>Review rationale for less Abx use </li></ul><ul><li>Introduction to Abx stewardship </li></ul><ul><li>Exemplify areas in outpatient ID where </li></ul><ul><ul><li>Less antibiotics can be used </li></ul></ul><ul><ul><li>No antibiotics are required </li></ul></ul><ul><ul><li>Provide some 1 st principles </li></ul></ul><ul><li>Not to steal too much from Dr. Low’s talk </li></ul>
  4. 4. Your Objectives <ul><li>Reflect on the myths </li></ul><ul><ul><li>Abx are risk free </li></ul></ul><ul><ul><li>Abx efficacy is untouchable </li></ul></ul><ul><ul><li>Practices patterns in ID stable </li></ul></ul><ul><li>Examine your Abx prescribing as it relates to the evidence </li></ul><ul><li>Find ways to reduce unnecessary Abx use (“practical stewardship”) </li></ul>
  5. 5. Bottom of the R&D Barrel <ul><li>No novel Abx classes </li></ul><ul><ul><li>Cross resistance </li></ul></ul><ul><li>Big pharma disinterested </li></ul><ul><li>Nothing anticipated for 10 years </li></ul><ul><li>Abx efficacy under siege </li></ul><ul><ul><li>Multi-drug R gram negative era emerges </li></ul></ul>
  6. 6. Nosocomial Menace <ul><li>“ ESKAPE” (IDSA) </li></ul><ul><ul><li>VRE </li></ul></ul><ul><ul><li>MRSA </li></ul></ul><ul><ul><li>ESBL producing E. coli & Klebsiella </li></ul></ul><ul><ul><li>Carbapenemase producing Klebsiella </li></ul></ul><ul><ul><li>Acinetobacter baumannii </li></ul></ul><ul><ul><li>Pseudomonas aeruginosa </li></ul></ul><ul><ul><li>Enterobacter sp. </li></ul></ul>
  7. 7. Community Menace <ul><li>CA-MRSA </li></ul><ul><li>Penicillin/MDR S. pneumoniae </li></ul><ul><li>EBSL E. coli (CTX type) </li></ul><ul><li>C. difficile </li></ul><ul><li>Spread of classic hospital acquired antibiotic resistant bacteria </li></ul><ul><ul><li>Quicker discharges </li></ul></ul><ul><ul><li>More “advanced” community care </li></ul></ul><ul><ul><li>IV antibiotic therapy </li></ul></ul>
  8. 8. Darwin and the Microbes <ul><li>Evolutionary forces favour microbes </li></ul><ul><ul><li>Generation time permits rapid adaptation </li></ul></ul><ul><ul><li>Abx pressure = ongoing mutant selection </li></ul></ul><ul><li>Precedent for quick adaptation </li></ul><ul><ul><li>E. coli R to penicillin </li></ul></ul><ul><ul><li>S. aureus R to penicillin/methicillin </li></ul></ul><ul><li>Resistance costs organism </li></ul><ul><ul><li>Cellular energy to run machinery </li></ul></ul><ul><ul><li>Decreased fitness to replicate </li></ul></ul>
  9. 9. Playing for Stalemate
  10. 10. Ecological Burden of Resistance <ul><li>Genes are the “currency” </li></ul><ul><ul><li>Inter- & intra species trade </li></ul></ul><ul><ul><li>Survival advantage </li></ul></ul><ul><li>The “markets” </li></ul><ul><ul><li>Individual - colon </li></ul></ul><ul><ul><li>Community – water, soil, biofilms </li></ul></ul><ul><ul><li>Hospitals – synergistic mix of both </li></ul></ul><ul><li>Less Abx use  less evolution </li></ul><ul><ul><li>Favour wild-type strains </li></ul></ul><ul><ul><li>Decrease resistance gene acquisition </li></ul></ul>
  11. 11. More use of fewer effective Abx Self amplifying cycle “ Treatment Stenosis” New Infection Abx Therapy Clinical Cure Abx Stopped
  12. 12. Basic Tenants of Stewardship <ul><li>Patient safety initiative </li></ul><ul><ul><li>Too much Abx use with no clear benefit </li></ul></ul><ul><ul><li>Too much harm with no clear reason </li></ul></ul><ul><ul><li>Abx benefit plateaus at some point </li></ul></ul><ul><ul><ul><li>Risks exceed benefit </li></ul></ul></ul><ul><li>Prevent/control antibiotic resistance </li></ul><ul><ul><li>Patient or population focus </li></ul></ul><ul><li>Moving target for application </li></ul><ul><ul><li>Severity of illness </li></ul></ul><ul><ul><li>Clinical uncertainty </li></ul></ul>
  13. 13. Antibiotic Balance - Patient <ul><li>Proper empiric Abx </li></ul><ul><ul><li>Common bacteria for syndrome </li></ul></ul><ul><ul><li>Patient co-morbidities </li></ul></ul><ul><ul><li>Previous culture results </li></ul></ul><ul><ul><li>Unique exposures </li></ul></ul><ul><ul><ul><li>Occupation/hobbies </li></ul></ul></ul><ul><ul><ul><li>Animal </li></ul></ul></ul><ul><ul><ul><li>Travel </li></ul></ul></ul><ul><ul><ul><li>Previous Abx </li></ul></ul></ul><ul><li>Avoid Abx harm </li></ul><ul><ul><li>Protect health flora </li></ul></ul><ul><ul><li>Eliminate unnecessary combinations </li></ul></ul><ul><ul><li>Evidence based durations </li></ul></ul><ul><ul><li>Narrow spectrum </li></ul></ul><ul><ul><li>Avoid/reduce IV catheter days </li></ul></ul>
  14. 14. Antibiotic “Co-lateral Damage” <ul><li>The 7 C’s </li></ul><ul><ul><li>Colonization with AROs </li></ul></ul><ul><ul><li>C. difficile </li></ul></ul><ul><ul><li>Candidemia </li></ul></ul><ul><ul><li>Continuing need for IVs </li></ul></ul><ul><ul><li>Cytochrome 450 drug-drug interactions </li></ul></ul><ul><ul><li>Catastrophic adverse reactions </li></ul></ul><ul><ul><li>Cost </li></ul></ul>
  15. 15. Antibiotic Balance - Population <ul><li>Increasing Abx needs </li></ul><ul><ul><li>Advances in transplant/oncology </li></ul></ul><ul><ul><li>More chronic illness </li></ul></ul><ul><ul><li>Longevity </li></ul></ul><ul><li>Quality assurance around use has not advanced </li></ul><ul><ul><li>When/if to treat </li></ul></ul><ul><ul><li>Helpful diagnostics </li></ul></ul><ul><ul><li>Overtreatment is ubiquitous </li></ul></ul>
  16. 16. Antibiotic “Co-lateral Damage”
  17. 17. Antibiotic Stewardship <ul><li>Hospitals based </li></ul><ul><ul><li>Multidisciplinary team </li></ul></ul><ul><ul><li>Controlled prescribing </li></ul></ul><ul><ul><li>Quality assurance cycle </li></ul></ul><ul><li>Non acute care </li></ul><ul><ul><li>Hard to replicate </li></ul></ul><ul><ul><li>Education (non bias) </li></ul></ul><ul><ul><li>Taper therapy </li></ul></ul>
  18. 18. Summary 1 <ul><li>Antibiotic resistant organism on the rise are unchecked </li></ul><ul><li>New Abx not the answer (per se) </li></ul><ul><li>Abx use fuels selection pressure </li></ul><ul><li>Stewardship a logical start </li></ul><ul><ul><li>Patient safety </li></ul></ul><ul><ul><li>Protect Abx efficacy (population level) </li></ul></ul><ul><li>Community stewardship model needs different emphasis </li></ul>
  19. 19. Strategies for Outpatients <ul><li>Avoid prescribing </li></ul><ul><li>Fix the underlying problem </li></ul><ul><li>Do not over value non sterile site cultures </li></ul><ul><li>Make the diagnosis </li></ul><ul><li>Taper to or use narrow spectrum Abx </li></ul><ul><li>Shorter duration </li></ul><ul><li>Non bias education/CME </li></ul>
  20. 20. Infectious Syndromes to Target <ul><li>Acute pharyngitis </li></ul><ul><li>Acute otitis media </li></ul><ul><li>Acute sinusitis </li></ul><ul><li>Acute bronchitis </li></ul><ul><li>AECOPD (mild) </li></ul><ul><li>Cellulitis </li></ul><ul><li>Outpatient pneumonia </li></ul><ul><li>Asymptomatic bacteriuria </li></ul><ul><li>UTIs (cystitis) </li></ul>Viral or self limited bacteria Excessive Abx use
  21. 21. AVOID ANTIBIOTIC PRESCRIBING
  22. 22. Avoid Prescribing When Safe <ul><li>Abx have no/little effect on natural history </li></ul><ul><ul><li>Mild illness </li></ul></ul><ul><ul><li>Minimal risk of complications if untreated </li></ul></ul><ul><ul><li>Common etiological agents are viral </li></ul></ul><ul><li>“ False disease” from micro tests </li></ul><ul><ul><li>Colonization </li></ul></ul>
  23. 23. Sinusitis <ul><li>United Kingdom </li></ul><ul><ul><li>90% get Abx </li></ul></ul><ul><ul><li>£10 million pounds/year </li></ul></ul><ul><li>USA </li></ul><ul><ul><li>85-98% get Abx </li></ul></ul><ul><ul><li>$2.4 billion/year </li></ul></ul><ul><li>Placebo effect 60-85% </li></ul><ul><ul><li>Benefit for Abx from non 1˚ care settings </li></ul></ul>
  24. 24. Sinusitis – Primary Care RCT <ul><li>Amox 500 mg 3 x 7 days </li></ul><ul><li>Block randomized (ITT) </li></ul><ul><li>Healthy >15 yr </li></ul><ul><li>Median 7 days symptoms </li></ul><ul><li>No difference at day ≥ 10 </li></ul><ul><ul><li>Symptom duration </li></ul></ul><ul><ul><li>Symptom severity </li></ul></ul><ul><li>No severe complications at 6 wks </li></ul><ul><li>No interactions </li></ul><ul><ul><li>Factorial trial with nasal steroids </li></ul></ul>
  25. 25. Sinusitis – Meta-analysis <ul><li>15 pts treated before 1 addition pt benefits </li></ul><ul><li>Common clinical features can not </li></ul><ul><ul><li>Differentiate viral from bacterial </li></ul></ul><ul><ul><li>Determine “Abx beneficial” subgroup(s) </li></ul></ul><ul><li>65% pts cured at 2 wks on placebo </li></ul><ul><ul><li>1/1381 placebo pt serious complication </li></ul></ul><ul><li>Antibiotics not useful despite </li></ul><ul><ul><li>Symptoms >7-10 days </li></ul></ul><ul><ul><li>Severe symptoms in absence of complications </li></ul></ul><ul><li>Symptomatic relief and time for healthy adults </li></ul>
  26. 26. Asymptomatic Bacteriuria <ul><li>Lack cystitis/pyelonephritis S&S </li></ul><ul><ul><li>Pyuria is not a “symptom” </li></ul></ul><ul><ul><li>Cloudy or smelly urine not diagnostic </li></ul></ul><ul><li>>10 5 cfu/mL single species </li></ul><ul><ul><li>Female – 2 consecutive samples </li></ul></ul><ul><ul><li>Male – 1 sample </li></ul></ul><ul><li>>10 2 cfu/mL single species </li></ul><ul><ul><li>Single catheterized sample </li></ul></ul><ul><li>Exclude </li></ul><ul><ul><li>Pregnant women </li></ul></ul><ul><ul><li>Pre TURP/other urological procedures </li></ul></ul>
  27. 27. Asymptomatic Bacteriuria <ul><li>No treatment benefit </li></ul><ul><ul><li>Premenopausal non pregnant women </li></ul></ul><ul><ul><li>Diabetic women </li></ul></ul><ul><ul><li>Male/female elderly </li></ul></ul><ul><ul><ul><li>Community or LTCF </li></ul></ul></ul><ul><ul><li>Spinal cord injuries </li></ul></ul><ul><ul><li>Short/long term Foley </li></ul></ul><ul><li>May benefit - bacteriuria >48 hr post short term Foley removal </li></ul><ul><li>No long term risk of not treating </li></ul><ul><ul><li>Short term sterilization </li></ul></ul><ul><ul><li>Drug side effects </li></ul></ul><ul><ul><li>Resistance with subsequent infections </li></ul></ul>
  28. 28. Otitis Media <ul><li>15 million Rx per year in USA </li></ul><ul><li>Spontaneous resolution common </li></ul><ul><li>Complication rate similar treated & untreated </li></ul><ul><li>UK guidelines for Tx </li></ul><ul><ul><li>Age <2 yr with bilateral acute otitis media </li></ul></ul><ul><ul><li>Otorrhea on presentation </li></ul></ul><ul><ul><li>No/delay Tx for all else </li></ul></ul>
  29. 29. Otitis Media <ul><li>RCT – Standard vs. Wait & See </li></ul><ul><ul><li>Well 6-12 mos old seen in ER </li></ul></ul><ul><ul><li>Co intervention with analgesia </li></ul></ul><ul><li>Wait & see (statistical significance): </li></ul><ul><ul><li>49% less Abx use </li></ul></ul><ul><ul><li>Fever & otalagia triggers to fill Rx </li></ul></ul><ul><ul><li>0.5 day more fever/otalagia (relevant?) </li></ul></ul><ul><ul><li>15% less diarrhea </li></ul></ul>
  30. 30. Otitis Media <ul><li>Meta analysis favour Abx </li></ul><ul><ul><li>Clinical cure (RR = 1.13) </li></ul></ul><ul><ul><li>Symptoms at day 2 to 4 of Tx (RR = 0.68) </li></ul></ul><ul><ul><li>More diarrhea (RR = 1.5) </li></ul></ul><ul><ul><li>No difference in severe complications </li></ul></ul><ul><li>Margin of benefit very narrow </li></ul><ul><ul><li>Parental relief & less absenteeism </li></ul></ul><ul><ul><li>Side effects & resistant bacteria </li></ul></ul><ul><li>RCT F/U Amox vs. placebo </li></ul><ul><ul><li>20% more recurrences in Abx group </li></ul></ul>
  31. 31. FIX THE UNDERLYING PROBLEM
  32. 32. Infection as a “Symptom” <ul><li>Predisposition from other disease </li></ul><ul><ul><li>Unknown or known </li></ul></ul><ul><ul><li>1 condition repeatedly </li></ul></ul><ul><ul><li>Multiple infectious syndromes </li></ul></ul><ul><li>Fix underlying cause </li></ul><ul><ul><li>Global health improvement </li></ul></ul><ul><ul><li>Reduced infections & repeat visits </li></ul></ul><ul><ul><li>Reduced Abx need (therefore risks) </li></ul></ul><ul><ul><li>Prevent resistant flora development </li></ul></ul><ul><ul><li>Avoid lure of chronic prophylaxis </li></ul></ul>
  33. 33. Case Example - Cellulitis <ul><li>38 yr M outdoor construction worker </li></ul><ul><ul><li>Healthy </li></ul></ul><ul><li>Classic GAS </li></ul><ul><ul><li>Lymphadenitis/fever  cellulitis </li></ul></ul><ul><li>3 standard 14 day 1 st gen cephalosporin courses </li></ul><ul><ul><li>Fully resolution each time </li></ul></ul><ul><li>Relapses within 30 day each time </li></ul><ul><li>Inpatient admission 2 to 3 day/episode </li></ul><ul><li>Cause? </li></ul>
  34. 34. Case Example - Cellulitis Courtesy of Center for Disease Control and Prevention Image Library
  35. 35. Case Controlled Studies Bjornsdottir et al. Clin Infect Dis 2005; 41:1416-22 Dupuy et al. BMJ 1999; 318:1591-4 <ul><li>Risk factors at least partially reversible </li></ul><ul><li>Not prospectively tested </li></ul><ul><li>More frequent cellulitis likely will benefit more </li></ul><ul><li>Prevent multiple Tx courses or prophylaxis </li></ul><ul><li>Big 2 </li></ul><ul><ul><li>Tinea pedis </li></ul></ul><ul><ul><li>Chronic venous insufficiency </li></ul></ul>
  36. 36. Prophylaxis Pitfalls <ul><li>Recurrent UTI risk </li></ul><ul><ul><li>Severe vesicoureteral reflux </li></ul></ul><ul><ul><li>Abx prophylaxis no effect </li></ul></ul><ul><ul><li>Controversial – no Abx prophylaxis for at least mild disease </li></ul></ul><ul><li>Abx resistant infections </li></ul><ul><ul><li>Prophylaxis exposure </li></ul></ul><ul><li>Fix the problem </li></ul><ul><li>Repeated Abx creates new problems </li></ul>
  37. 37. DO NOT OVER VALUE NON STERILE SITE CULTURES
  38. 38. Non Sterile Site Cultures <ul><li>Clinical impression your guide </li></ul><ul><ul><li>When to test and its interpretation </li></ul></ul><ul><ul><li>Not vice versa </li></ul></ul><ul><li>Avoid unnecessary testing </li></ul><ul><ul><li>During or post Abx with clinical improvement </li></ul></ul><ul><ul><li>Asymptomatic state </li></ul></ul><ul><ul><li>Low probably of helping (e.g. cellulitis) </li></ul></ul><ul><li>Leads to “bug – drug – kill” mentality </li></ul><ul><ul><li>Colonization not a disease </li></ul></ul><ul><ul><li>Can not sterilize these sites </li></ul></ul><ul><li>Polymicrobial results ≠ multiple pathogens </li></ul>
  39. 39. Colonization Contamination Disease Invasion Non Sterile Site Sample Sterile Site Sample Skin Flora – Low Virulence (e.g. CoNS, Corynebacterium sp ., Viridans Group Strep) Skin Flora – Moderate Virulence (e.g. Staphylococcus aureus , E. coli , Pseudomonas ) Professional Pathogen - High Virulence (e.g. M.tuberculosis , Brucella , Franciella ) More Less Clinical Correlation to Culture Results
  40. 40. A Typical Case <ul><li>Longstanding DM2 </li></ul><ul><li>Acute foot ulcer – S. aureus </li></ul><ul><ul><li>Better with cefazolin </li></ul></ul><ul><li>Non infected non healing ulcer </li></ul><ul><ul><li>Re swabbed – cefazolin R E.coli </li></ul></ul><ul><ul><ul><li>Ciprofloxacin added </li></ul></ul></ul><ul><ul><li>Re swabbed – cipro R P. aeruginosa </li></ul></ul><ul><ul><ul><li>Piperacillin-tazobactam subbed in </li></ul></ul></ul><ul><ul><li>Re swabbed – multiple R GNBs, E. faecium </li></ul></ul><ul><li>“ Survivor phenomena” of non sterile sites </li></ul>
  41. 41. DM Foot Discordance <ul><li>Abx not recommended for non infected/non healing ulcers </li></ul><ul><li>Chronic osteomyelitis </li></ul><ul><ul><li>Bone biopsy gold standard </li></ul></ul><ul><ul><li>Non bone specimen poor correlation </li></ul></ul><ul><ul><ul><li>52% false negative </li></ul></ul></ul><ul><ul><ul><li>36% false positive </li></ul></ul></ul><ul><ul><ul><li>28% concordance with bone biopsy </li></ul></ul></ul>
  42. 42. MAKE THE DIAGNOSIS
  43. 43. Death to Empiric Therapy <ul><li>Clinical exam has limitations </li></ul><ul><ul><li>Bacterial vs. viral </li></ul></ul><ul><ul><li>Infectious vs. non infectious </li></ul></ul><ul><li>Diagnostic test can confirm/refute clinical impression </li></ul><ul><ul><li>Abx needed? </li></ul></ul><ul><ul><li>Understand why if empiric Tx fails </li></ul></ul><ul><ul><li>Risk benefit alignment </li></ul></ul><ul><li>Avoid repeated rounds of Abx </li></ul><ul><li>Not always convenient for Family MDs </li></ul>
  44. 44. Community Acquired Pneumonia <ul><li>No symptom can rule in/rule out </li></ul><ul><li>Signs with modest likelihood ratios </li></ul><ul><ul><li>Temp >37.8˚C LHR+ 2.4-4.4 </li></ul></ul><ul><ul><li>Dullness to percussion LHR+ 2.2-4.3 </li></ul></ul><ul><ul><li>Decreased breath sound LHR+ 2.2-2.5 </li></ul></ul><ul><ul><li>Crackles LHR+ 2.6-2.7 </li></ul></ul><ul><ul><li>Bronchial breath sounds LHR+ 3.5 </li></ul></ul><ul><ul><li>Egophony LHR+ 5.3-8.6 </li></ul></ul><ul><li>No sign can rule out </li></ul><ul><ul><li>Lack of any vital abnormalities reduces probability LHR- 0.16 </li></ul></ul><ul><li>CXR infiltrate recommended for diagnosis </li></ul>
  45. 45. Acute Bronchitis <ul><li>9 th most common outpatient issue </li></ul><ul><ul><li>5% of adults annually </li></ul></ul><ul><li>Viral etiology predominates </li></ul><ul><li>Antibiotics not recommended </li></ul><ul><ul><li>Reduce cough by 0.6 of a day </li></ul></ul><ul><ul><li>Trend towards Abx adverse events </li></ul></ul><ul><ul><li>B. pertussis an exception </li></ul></ul><ul><ul><ul><li>Reduce transmission </li></ul></ul></ul><ul><ul><ul><li>Decrease cough duration (given) in 1 st week </li></ul></ul></ul>
  46. 46. TAPER TO (OR USE) NARROW SPECTRUM THERAPY
  47. 47. Less is More <ul><li>Broad spectrum therapy </li></ul><ul><ul><li>Risk and/or uncertainty </li></ul></ul><ul><ul><li>Culture & wait </li></ul></ul><ul><li>Narrow spectrum therapy generally equivalent </li></ul><ul><ul><ul><li>With results (based on CLSI) </li></ul></ul></ul><ul><ul><ul><li>Safer for patient </li></ul></ul></ul><ul><li>Best hints for empiric therapy </li></ul><ul><ul><li>Know the common pathogens by syndrome </li></ul></ul><ul><ul><li>Previous culture results </li></ul></ul><ul><ul><li>Previous Abx use </li></ul></ul>
  48. 48. Community Acquired Pneumonia <ul><li>Outpatient </li></ul><ul><ul><li>PSI I to III </li></ul></ul><ul><ul><li>Benign disease </li></ul></ul><ul><li>Broader therapy (quinolones) no effect </li></ul><ul><ul><li>Mortality </li></ul></ul><ul><ul><li>Treatment success </li></ul></ul><ul><ul><li>Microbiological eradication for S. pneumoniae </li></ul></ul><ul><li>Equivalent to  -lactams or macrolides </li></ul><ul><li>Why the over coverage? </li></ul>
  49. 49. COPD Exacerbations <ul><li>50/50 viral & bacterial </li></ul><ul><li>Problems studying Abx benefit </li></ul><ul><ul><li>Study design flaws </li></ul></ul><ul><ul><li>Bacterial colonization in stable disease </li></ul></ul><ul><ul><li>Small benefit overall </li></ul></ul><ul><li>Atypical bacteria no clear role </li></ul><ul><li>P. aeruginosa advanced disease </li></ul><ul><li>Avoid overly broad coverage </li></ul><ul><ul><li>Mild exacerbations </li></ul></ul><ul><ul><li>Uncomplicated COPD </li></ul></ul>
  50. 50. SHORTER DURATIONS
  51. 51. Longer Is Not Better <ul><li>Length of therapy generally too long </li></ul><ul><ul><li>Poorly studied </li></ul></ul><ul><ul><li>Shorter therapy equivalent when studied </li></ul></ul><ul><ul><ul><li>Especially for outpatients </li></ul></ul></ul><ul><ul><ul><li>Risk of progressing to severe disease less </li></ul></ul></ul><ul><ul><ul><li>VAP – CAP example </li></ul></ul></ul><ul><li>Longer therapy </li></ul><ul><ul><li>Does not prevent resistance </li></ul></ul><ul><ul><li>Harms healthy flora </li></ul></ul><ul><ul><li>Raises risk of adverse events </li></ul></ul>
  52. 52. Shorter Duration - Cellulitis <ul><li>Double blinded RCT </li></ul><ul><ul><li>All patients - 5 days of levofloxacin </li></ul></ul><ul><ul><li>Randomized - 5 days placebo or levofloxacin </li></ul></ul><ul><li>No difference </li></ul><ul><ul><li>Day 14 for clinical endpoints </li></ul></ul><ul><ul><li>Day 28 for recurrence </li></ul></ul><ul><li>Levofloxacin likely overkill </li></ul><ul><ul><li>S. aureus,  -hemolytic Streptococcus </li></ul></ul><ul><ul><li>Cephalexin could of been used but no evidence exists </li></ul></ul><ul><ul><ul><li>Rapid improvement duration should be <10 days </li></ul></ul></ul>
  53. 53. Shorter Duration - Cystitis <ul><li>Well studied in women </li></ul><ul><li>3 = 5-10 days for symptomatic improvement </li></ul><ul><ul><li>Most relevant outcome </li></ul></ul><ul><li>5-10 > 3 days for microbiological eradication </li></ul><ul><li>Balance </li></ul><ul><ul><li>5-10 day group </li></ul></ul><ul><ul><ul><li>More side effects </li></ul></ul></ul><ul><ul><ul><li>More drug resistance (possible) </li></ul></ul></ul><ul><ul><li>Risk of recurrence with 3 day group </li></ul></ul><ul><ul><ul><li>Pyelonephritis extremely rare </li></ul></ul></ul>
  54. 54. Shorter Duration - CAP <ul><li>Recommended 7-14 days ?evidence </li></ul><ul><li>RCTs with various Abxs </li></ul><ul><li>Peds (2-5 yr) non severe </li></ul><ul><ul><li>3 = 5 days of therapy </li></ul></ul><ul><ul><ul><li>Clinical cure </li></ul></ul></ul><ul><ul><ul><li>Tx failure or relapse </li></ul></ul></ul><ul><li>Adults (admitted) mild-mod severe </li></ul><ul><ul><li>3 = 8 days Amoxicillin </li></ul></ul><ul><ul><ul><li>Treatment success, symptoms, radiographic, adverse effects </li></ul></ul></ul><ul><ul><li>Improved at day 3 needed </li></ul></ul><ul><li>Adults outpatient </li></ul><ul><ul><li>3 = 5 days respiratory quinolone </li></ul></ul><ul><ul><li>Clinical, microbiological, radiographic </li></ul></ul>
  55. 55. Summary 2 <ul><li>Multiple “mild” conditions over treated </li></ul><ul><li>Practical tips </li></ul><ul><ul><li>Treat bacterial infections </li></ul></ul><ul><ul><ul><li>Not colonization or viruses </li></ul></ul></ul><ul><ul><li>Understand value of culture results </li></ul></ul><ul><ul><li>Use less Abx when possible </li></ul></ul><ul><ul><li>Establish Dx & fix reversible risk factors </li></ul></ul><ul><li>Ongoing ID education provides the evidence </li></ul>

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