1. Things your mother never told you about infectious diseases Rob Kaplan, MD July 28 and 29, 2014

2. How to treat infections in one slide Is there an infection? Is therapy urgent? Pathogens? Likely sensis? Choose antibiotics for pathogens, site of infection, and patient. Drainage? Adjust approach based on data.

3. 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.

4. SIMPLE CYSTITIS 3 day therapy with trimethoprim-sulfa or ciprofloxacin (not single dose) Culture not mandatory!

5. 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, GPC. WBC 16, cre 1.0.

6. COMMUNITY-ACQUIRED PYELONEPHRITIS Admit, IV antibiotics. Here include vancomycin given GPC. GRAM STAIN HELPED! If just GNR not needed. Probably vancomycin and ceftriaxone. Switch to po when doing well, sensis known. Total duration at least 2 weeks

7. 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

8. 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

9. 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.

10. (Do not treat) ASYMPTOMATIC BACTERIURIA

11. 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…

12. 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

13. Soft Tissue Cases

14. NON-PURULENT CELLULITIS/ERYSIPELAS Very likely to be Strep. Good track record of studies supporting not covering MRSA Keflex, Augmentin (or even Penicillin, Amoxicillin) reasonable for outpatient use

15. Soft Tissue-2 A top high school basketball player scraped against his agent’s Bentley.

16. SUPPURATIVE SOFT TISSUE INFECTION Incise and drain first and foremost Special focus is MRSA For hospitalized patient vancomycin For outpatient TMP-sulfa or doxycycline/minocycline Yes there are other choices

17. Soft Tissue-3 After minor trauma to the foot a healthy 30 year old develops fever, shock, & severe LE pain.

18. NECROTIZING FASCIITIS Representative of complex soft tissue infections with many names When to think of this? Group A strep, or clostridial, or mixed aerobes and anaerobes… Initial rx: Vanco/Cefepime/Flagyl. May substitute clinda for flagyl for Eagle effect. SURGERY!!!

19. Soft Tissue-3 A poorly- controlled diabetic w/ neuropathy develops fever and foot drainage.

20. DIABETIC FOOT INFECTION Mixed aerobes and anaerobes. May include Pseudomonas. Often bone involved Often with poor perfusion Deep cultures to guide therapy. Vancomycin/Cefepime/Flagyl IF GANGRENE OR SEPSIS OR CHRONIC OSTEO-->SURGERY

21. Pulmonary Cases 60-year old previously healthy smoker with fever, cough with purulent sputum.

22. 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

23. Pulmonary-2 Alcoholic with 4 weeks of fever, weight loss, fetid sputum, left- sided chest pain.

24. LUNG ABSCESS Add Klebsiella and anaerobes to usual causes of CAP Ceftriaxone/Flagyl

25. Pulmonary-3 An SICU patient needs prolonged intubation after abd. surgery. Now fever, inc FiO2, purulent secretions.

26. 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

27. Neutropenic Fever-1 A 50-year old is getting cytotoxic chemotherapy for a solid tumor thru a Hickman catheter. ANC 200. T>100.5. No localizing findings.

28. BASIC FEVER, NEUTROPENIA Key organism is Pseudomonas aeruginosa Empiric therapy mandatory Single drug regimen with Cefepime as good as combos with aminoglycoside and penicillin Staph coverage not mandatory immediately, but… EXAMINE THE PATIENT!

29. Neutropenic Fever-2 A 25-year old with AML is getting induction chemo. ANC 10. T 102.5. SBP 80. Perineal skin lesions shown

30. ECTHYMA GANGRENOSUM Usually caused by Pseudomonas aeruginosa Gram stain and culture the lesion Empiric therapy now should definitely include an aminoglycoside!

31. Neutropenic Fever-3 Patient with persistent neutropenia, fever despite pip/amik/van/fluc & develops hemoptysis.

32. INVASIVE ASPERGILLOSIS Vs. Mucor, Fusarium, others Bad prognosis without neutrophil recovery Blood antigen testing may help but often need invasive diagnosis Voriconazole best for Aspergillus. For others…..

33. Cultures: Urine and Sputum Urine-- clean catch specimen. Get initial Gram stain. >10**5 not absolute. Sputum—Gram stain 25polys. Match up GS & culture. Get BC before rx for pneumonia if hospitalized.

34. Cultures: Miscellaneous (GET A GRAM STAIN TOO!!) Large specimen better than a swab, esp for anaerobes. Consider BC bottle. No sputum for anaerobe cult. Get specimen to lab quickly. Routine stool cultures cover E. coli, Salmonella, Shigella, Campy. Contact lab for special requests. Ag detection and PCR as alternatives to cultures.

35. Blood cultures “Sets,” not “bottles”. One set = 20-30 cc of blood from one stick divided into two bottles. Basic unit = 2 sets 5 minutes apart. (More for endocarditis) VA Lab disclaimer for <3cc/bottle Use appropriate antisepsis! Staph epi & diphtheroids usually contaminants unless… Do not order Gram stain of blood.

36. Interpreting sensis For staph: Resistant to Meth/Ox  Resistant to all other Beta Lactams* For GNR: normally more sensitive with increasing generation of cephs. If not, suspect ESBL!! Generally switch to least expensive/least toxic sensitive choice unless special situations…

37. #1- Diabetic Ulcer Gram Stain GRAM STAIN: NO WBC SEEN 4+ GRAM NEGATIVE RODS (>10/1,000X) 1+ GRAM POSITIVE RODS (0-1/1,000X) 2+ GRAM POSITIVE COCCI,PAIRS (1- 2/1,000X) 1+ GRAM POSITIVE COCCI,GROUPS (0- 1/1,000X)

38. #1-Culture 4 OR MORE ORGANISMS, PLEASE ADVISE. PLATES HELD 3 DAYS. HEAVY PSEUDOMONAS SPECIES HEAVY ALPHA HEMOLYTIC STREPTOCOCCUS FEW DIPTHEROIDS WORKED 2 PSEUDOMONAS COLONY TYPES

39. #1-Sensis PSEUDOMONAS AERUGINOSA GENTAMICIN <=1 S IV:$ 8. TOBRAMYCIN <=1 S IV:$ 2. AMIKACIN <=2 S IV:$ 3. CEFEPIME-4 2 S IV:$ 12. PIP/TAZOBACTAM S IV:$ 38. CIPRO <=0.25 S IV:$ 18. ORAL:$ 0.18 IMIPENEM <=1 S IV:$ 60.

40. #2-Scrotal Abscess Gram Stain GRAM STAIN: NO WBC SEEN 1+ GRAM POSITIVE COCCI, PAIRS (0- 1/1,000X)

41. #2 Culture/Sensis : HEAVY STAPHYLOCOCCUS AUREUS : TETRACYCLINE <=1 S 1 day IV:$ 14. ORAL:$ 0.10 ERYTHRO >=8 R BACTRIM <=10 S 1 day IV:$ 21. ORAL:$ 0.12 CLINDA <=0.25 S 1 day IV:$ 3. ORAL:$ 0.72 GENTAMICIN <=0.5 S 1 day IV:$ 8. VANCOMYCIN <=0.5 S 1 day IV:$ 10. OXACILLIN >=4 R 1 day IV:$ 79. ORAL:$ 0.48 CIPRO >=8 R 1 day IV:$ 18. ORAL:$ 0.18 RIFAMPIN <=0.5 S 1 day IV:$ 49. ORAL:$ 0.90 TIGECYCLINE <=0.12 S I or R results are presumptive LINEZOLID 2 S I or R results are presumptive DAPTOMYCIN 0.5 S

42. #4-Abdominal Abscess after perfed DU ENTEROBACTER CLOACAE SXT (BACTRIM) >=320 R 1 day IV:$ 21. GENTAMICIN <=1 S 1 day IV:$ 8. TOBRAMYCIN <=1 S 1 day IV:$ 2. AMIKACIN <=2 S 1 day IV:$ 3. CEFOXITIN >=64 R 1 day IV:$ 29. CEFAZOLIN-1 >=64 R 1 day IV:$ 6. CEFTRIAXONE-3 8 S 1 day IV:$ 4. CEFEPIME-4 <=1 S 1 day IV:$ 12. PIP/TAZOBACTAM S 1 day IV:$ 38. CIPROFLOXACIN >=4 R 1 day IV:$ 18. ORAL:$ 0.18 ERTAPENEM <=0.5 S I or R results are presumptive TIGECYCLINE 1 S I or R results are presumptive

43. #5-Complicated Pancreatitis (Blood Culture) KLEBSIELLA PNEUMONIAE AMPICILLIN >=32 R BACTRIM >=320 R LEVOFLOX >32 R GENTAMICIN >=16 R TOBRAMYCIN >=16 R AMIKACIN 16 S CEFOXITIN >=64 R CEFAZOLIN-1 >=64 R CEFTRIAXONE-3 >=64 R PIP/TAZOBACTAM R CIPROFLOXACIN >=4 R TIGECYCLINE 4 I TIMENTIN >256 R POLYMYXIN B 1.0 CHLORAMPHENICO>256 R

44. #5 Comments from lab 06.21.11 - POSSIBLE ESBL AND KPC, CONFIRM. PENDING 06.22.11 - EXTENDED SPECTRUM B-LACTAMASE PRODUCER: MAY BE RESISTANT CLINICALLY TO ALL CEPHALOSPORINS & AZTREONAM. HODGE TEST POSITIVE CARBAPENEMASE Producer-EFFICACY of ERTAPENEM or IMIPENEM UNKNOWN INFECTIOUS DISEASE CONSULT SUGGESTED POLYMYXIN B PRESUMPTIVE: NON-STANDARDIZED SUSCEPTIBILITY, INTERPRET WITH CAUTION