1. Antibiotics 101 A review of common infections and their treatment For others, like me, who have a mental block against all things related to antibiotics

2. Antibiotic BINGO!! 0 Rules: 0 I will read a question for each “bingo ball,” if you have the corresponding phrase on your sheet, answer the question in the box 0 Complete a row, column or diagonal 0 All answers must be correct to win the game 0 Winner will receive a prize! Woohoo!!

3. Brief Micro Refresher 0 Gram positive cocci: 0 Catalase positive: 0 Coag positive: staph aureus 0 Coag negative: staph epi 0 Catalase negative: 0 Enterococcus 0 Streptococcus 0 Atypicals: 0 C.pneumo: intracellular gram neg 0 Mycoplasma: no cell wall 0 Legionella: intracellular gram neg 0 Gram negatives: 0 Lactase positive: 0 E.coli 0 Klebsiella 0 Enterobacter 0 Others: 0 Proteus 0 Acinetobacter 0 Morganella 0 Serratia 0 Pseudomonas aeruginosa 0 Moraxella 0 H. flu

4. Basic Antibiotic Coverage StrepStaphMRSAEnteroGram -PseudoAnaerobes (except bacteroides) Atypicals Penicillin+------- Ampicillin++*-++/--+- Amox/clav++-++-+- Vancomycin++++/---+- 1 st ceph++------ 2 nd ceph++--+--- 3 rd ceph++--+-*+- 4 th ceph++--+++- Mero/imi++-+/-+++- Pip/tazo++-+*+++- Quinilones+*+-+/-++ + Azithromycin+/-+-- -++ Doxycyline+/- +/- *-+/--++ TMP-SMX+/-++-+---

5. Community Acquired Pneumonia 0 Common pathogens: 0 S.pneumo, H.flu, moraxella, chlamydia, legionella, mycoplasma, viruses 0 Empiric treatment: 0 Outpatient: 0 Azithromycin 500mg x 1d then 250mg x 4d 0 Doxycycline 100mg BID x 7-10d 0 Moxifloxacin 400mg (or levo) x 7d for pts with co-morbidities 0 Inpatient: 0 Ceftriaxone 1g IV Q24hrs + azithromycin 500mg IV Q24hrs 0 Moxifloxacin 400mg or levofloxacin 750mg IV Q24hrs 0 Duration: 7-10d http://www.acutemed.co.uk/diseases/Pneumonia

6. Healthcare Associated Pneumonia 0 Criteria: 0 Hospitalization for two or more days within the past 90 days 0 Current hospitalization > 48hrs (*HAP) 0 Residence in skilled nursing facility or long term care facility within the last 30 days 0 Receiving outpatient IV therapy within the past 30 days 0 Attending a dialysis center in the last 30 days 0 Home wound care 0 Family member with known MDRP

7. HCAP Cont’d 0 Pathogens: 0 Pseudomonas 0 MRSA 0 Klebsiella, enterobacter, acinetobacter, serratia, E.Coli 0 Anaerobes (aspiration) 0 Empiric treatment: 0 Vitamin P and V 0 Piperacillin/tazo OR cefepime OR meropenem + vancomycin 0 Can also consider addition of gentamicin Pic 1: http://www.qvision.es/blogs/almudena-valero/2013/04/21/trasplante-de-membrana-amniotica-en-queratitis-aguda-por-pseudomona/ Pic 2: http://www.gasdetection.com/Interscan_News/health_news_digest181.html

8. COPD Exacerbation 0 Most common pathogens: 0 H.flu 0 Moraxella 0 Strep pneumo 0 Viruses: parainfluenza, flu, rhinovirus, RSV 0 Antibiotics: 0 Azithromycin (Z-pack) 0 Doxycycline 100mg BID x 10d 0 Amoxicillin 500-875mg TID x 10d 0 Other therapies: 0 Prednisone 0 Duonebs http://meded.ucsd.edu/clinicalimg/thorax_tripod.htm

9. Sinusitis 0 Common Pathogens: 0 Viruses: rhinovirus 0 S.pneumo 0 H.flu 0 Classification: 0 Acute: < 4wks 0 Subacute: 4-12 wks 0 Chronic: > 12wks http://www.cnn.com/2012/02/14/health/antibiotics-not-helpful-sinus-infections/

10. Sinusitis: Empiric Tx 0 When? 0 Persistent symptoms (>10d) or worsening symptoms at day 7 0 What? 0 Augmentin 875/125mg BID 0 Amoxicillin 500mg TID 0 Duration: 10-14d http://4.bp.blogspot.com/_3xJEG7fcX7w/SMS5ECJRwtI/AAAAAAAA CBA/v126PDIjCZA/s1600/Neti+Pot+2.JPG

11. Cellulitis 0 Common pathogens: 0 Strepococcus 0 Staphylcoccus 0 Empiric treatment: 0 Outpatient: 0 Cephalexin 500mg QID or amoxicillin 500mg TID +/- doxycycline or TMP-SMX 0 Duration: 7-10d 0 Inpatient: 0 Vancomycin 0 Duration: 7-10d 0 Other therapies: elevation of affected area, +/- steroids http://en.wikipedia.org/wiki/File:Cellulitis_Left_Leg.JPG

12. Cellulitis- Diabetics 0 Common pathogens: 0 Staph and strep 0 Enterobacter 0 Enterococcus 0 Pseudomonas 0 Anaerobes 0 Empiric treatment: 0 Augmentin 875mg BID 0 Clindamycin 300mg TID 0 Amp/sulbactam 3g IV Q6hrs 0 +/- vancomycin 0 Duration: 5-14d (resolution of symptoms) *Important note: bactrim and doxycycline have less strep activity so are not preferred agents http://healthyliving.blog.ocregister.com/files/2008/10/cellulitis.jpg

13. Urinary Tract Infection 0 Pathogens: 0 Pathogens: E.Coli, E.Coli, E.Coli, Staph saprophyticus, Proteus 0 Uncomplicated: 0 Women, no systemic symptoms (afebrile, no leukocytosis, etc) 0 Complicated: 0 Men, indwelling foley, systemic symptoms 0 Pyelonephritis: 0 Flank pain, fever, leukocytosis, +/- WBC casts

14. http://hsl.uw.edu/files/antibiograms/uw-medicine-2012-antibiogram

15. UTIs Empiric Treatment 0 Uncomplicated: 0 Check antiobiograms for resistance patterns 0 In Seattle: TMP-SMX = ciprofloxacin BUT nitrofurantoin is better than all! 0 Duration: 3-5d (5d for nitrofurantoin) 0 Complicated: 0 Cipro or TMP-SMX if mild to moderate illness 0 Pip/tazo, cefepime, ceftazidime, carbapenem for severe illness 0 Duration: 7-14 days in general (3-5 days after defervescence) 0 Pyelonephritis: 0 Ceftriaxone, ceftazidime, pip/tazo 0 Duration: 48hrs IV or until afebrile, then complete total 14d course

16. Osteomyelitis 0 Acute vs chronic: 0 Acute: first presentation, symptoms < 2 weeks, absence of necrotic bone 0 Chronic: necrotic bone, > 3 weeks of symptoms 0 Pathogens: 0 S. Aureus, coag negative staph, strep, enterococcus, pseudomonas, anaerobes 0 Diagnosis: 0 Blood culture, bone biopsy culture; wound culture is generally not helpful

17. Osteomyelitis 0 Chronic treatment: based on culture results 0 Empiric treatment for acute: need to cover anaerobes, MRSA, pseudomonas 0 Ampicillin/sulbactam OR pip/tazo OR carbopenem OR ceftriaxone 0 AND Vancomycin 0 Duration: 0 Acute: 4-6 weeks abx (usually minimum 2 weeks IV) 0 Chronic: 2-6 weeks IV abx then usually addition 6 weeks with oral therapy (until ESR and CPR normalize)

18. References 0 Sanford Guide to Antimicrobial Therapy: Sanford Guide Web Edition 2 0 Johns Hopkins Antibiotics Guide, Unbound Medicine iPhone App 0 Cleveland Clinic Guidelines for Antimicrobial Usage 2011-2012