MY APPROACH TO INFECTIOUS DISEASE CASES · PDF fileOBJECTIVES • Review common infecous disease cases • Suggest appropriate use of anbiocs for speciﬁc infecous

MYAPPROACHTOINFECTIOUSDISEASECASES

KarenBrust,MDJanuary,2013

DISCLOSURES

•  NONE

OBJECTIVES

•  ReviewcommoninfecKousdiseasecases•  SuggestappropriateuseofanKbioKcsforspecificinfecKousprocess

•  ReviewalternaKveanKbioKcchoicesinlightofpaKents’allergiesorotherfactors

CASE#1•  83y/oWMw/hxofhtn,dyslipidemia,BPH,andGERDadmiZedtothehospitalw/a7dayhxoffeversover101,poororalintake,persistentn/v.Discharged3daysagoaêra3daystayforsimilarsymptomsaswellasabdominalpainanddiarrhea.WorkupduringthathospitalizaKontoincludeNPswabforviralPCRandAbdominalCTwerenegaKve.Hewasd/c’doffabxandw/adxof“viralsyndrome”.

•  2daysaêradmissionhebecomeslethargic,less&lessresponsiveandtachypneic.TransferredtoMICU

CASE#1•  NKDA•  CURRENTABX:Vancomycin,Ampicillin,Ce^riaxone,andAcyclovir

•  PE:Tc98.2Tm101.5HR90‐110sBP150‐180s/60‐80sRR30O2100%onbipap

•  Examunrevealingw/excepKonofunresponsiveness,tachycardiaandlackofrash

•  PerKnentData:WBC22K,87%N,lactate2,AST245,ALT168,Creat1.21,URINE/BLOODCXnegaKve

•  CSFanalysis:WBC259,55%N,36%L,8%M,elevatedprotein167.5(15‐60mg/dL),glucosenlat77,GSTneg,culturepending

CASE#1

•  Thenextstepinmanagementis•  A.ConKnuealltheanKbioKcsunKlculturescomeback(vanc,ampicillin,acyclovir,ce^riaxone)

•  B.ConKnueonlyampicillin•  C.ConKnueonlyacyclovir•  D.ConKnueampicillinandacyclovir•  E.DisconKnuealltheanKbioKcs

CASE#1

•  Thenextstepinmanagementis•  A.ConKnuealltheanKbioKcsunKlculturescomeback(vanc,ampicillin,acyclovir,ce^riaxone)

•  B.ConKnueonlyampicillin•  C.ConKnueonlyacyclovir•  D.ConKnueampicillinandacyclovir•  E.DisconKnuealltheanKbioKcs

MENINGITIS

•  CLINICALSYMPTOMS– Headache– Fever– NecksKffness– Alteredmentalstatus

‐  ONLY44%willpresentw/allofthe1st3symptoms,but

‐  ALMOSTALLwillpresentw/2ofthese4symptoms

MENINGITIS

•  DIAGNOSISrequiresaCSFpleocytosis&highproteinintherightclinicalseong

•  DIFFERENTIALDIAGNOSISEXTENSIVE

MENINGITISANDENCEPHALITISABNORMALCSF…toomanycells&protein

•  INFECTIOUSCAUSES:

–  BACTERIAL•  Mycoplasma,ureaplasma,legionella,chlamydia,Mycobacterial,Spirochetes(treponema,borrelia,leptospira),RickeZsia,Erlichia,Bartonella,nocardia,acKnomyces,brucella,listeria,CNSabscess,parameningealfociofinfecKon,parKallytreatedinfecKon

–  FUNGAL•  Blastomyces,histo,coccidioides,aspergillus,sprothrix,zygomycetes,

–  PROTOZOAL/PARASITIC•  Toxoplasmosis,taeniasolium,echinococcus,strongyloides,schistosoma,acnthamoeba,naeglaria,entamoebahistolyKca,trypanosoma,plasmodium

–  VIRAL•  Enteroviruses(60‐90%),ARBOviraldiseases(2ndmostcommon),HSV(10%),VZV,JapaneseB,measles,rabies

MENINGITISANDENCEPHALITISABNORMALCSF…toomanycells&protein

•  POST‐INFECTOUSCAUSES–  Guillain‐barresyndrome–  BrainstemencephaliKs–  Viralsyndrome(VZV,measles,influenza,parainfluenza,RSV,evenrhinovirus)

•  NON‐INFECTIOUSCAUSES–  DRUG‐INDUCED:sulfa,NSAIDs,IVIG–  RHEUMATOLOGICDZ:SLE,sarcoid,Bechet’s,vasculiKdes–  TUMORS/MASSES:anybraintumor,CNSlymphoma,AVMs–  POISONS/TOXINS:lead,mercury,arsenic–  DEMYELINATINGDZ:MS,adrenalleukodystrophy–  TRAUMA/VASCULARINSULT:CVAorsubarachnoidhemorrhage

ENCEPHALITIS•  DEFINITIONperIDSAguidelines:“presenceofaninflammatoryprocessinthebraininassociaKonwithclinicalevidenceofneurologicdysfuncKon”

•  CLUESTODIFFERENTIATEFROMMENINGITIS–  SameasmeningiKs:fever,h/a–  Different:disorientaKon,behavioral/speechdisturbances,andotherneurologicsigns(CNpalsies,seizures,hemiparesis)

•  Theterm“MENINGOENCEPHALITIS”existsforareason

MENINGITIS

•  CSFFLUIDANALYSIS–  1ST:Istheretoomanycells?–  2nd:IsthissepKcorasepKcmeningiKs?–  3rd:WhatanKbioKcsshouldIstart?OURPATIENT:WBC259,55%N,36%L,8%M,elevatedprotein167.5(15‐60mg/dL),glucosenlat77,GSTneg,culturependingASEPTICMENINGITIS

MENINGITISTREATMENT

•  SEPTIC(bacterial)– BroadspectrumempiricanKbioKcsunKlpathogencultured(Vancomycin,Ce^riaxone,+/‐Ampicillin)

•  ASEPTIC(viralvsnon‐infecKous)– OnlyavailableanKviral=acyclovir/valacyclovir– D/ConcePCRtesKngforHSVandVZVnegaKve

OURPATIENT

•  DiagnosedwithWestNileEncephaliKs

•  MORECASES…

MENINGITIS•  58y/oWFw/MMP(cerebrovasculardemenKa,chronichepC,chronichepB,etc)admiZedw/“sepsis”andAMS

•  CSF:CLARITY‐CLEAR•  RBCCOUNT23•  WBCCOUNT4•  SEGNEUTROPHILS%31(H0‐7%)•  LYMP%67(40‐80%)•  MONO%2(L15‐45%)•  GLUCOSE,CSF72(50‐80mg/dL)•  PROTEIN,CSF19.1(15.0‐60.0mg/dL)•  MENINGITISORNOMENINGITIS?

MENINGITIS•  30yoWFw/outsignificantPMHpresentstoEDw/infirst

24hofsevereh/a,necksKffness,n/v,photophobia.Recentlyrecuperatedfrominfluenzaabout2weeksprior

•  CSF‐COLORLESS•  RBCCOUNT3/mm3•  WBCCOUNT261(H0‐5/mm3)•  SEGNEUTROPHILS%8(H0‐7%)•  LYMP%80(40‐80%)•  MONO%11L(15‐45%)•  EOS%1%•  GLUCOSE,CSF46(L50‐80mg/dL)•  PROTEIN,CSF133.4(H15.0‐60.0mg/dL)•  MENINGITISORNOMENINGITIS?ASEPTICORSEPTIC?

MENINGITIS•  56y/oAAFs/psplenectomyadmiZedw/sepKcshock,AKI,

respiratoryfailurew/a3dayhistoryofrigorsandmentalstatuschanges

•  Treatedforpneumococcalpneumoniaandbacteremiaw/Vanc/CTX;aêr9daysonthevenKlatorandoffsedaKonsheremainsunresponsive

•  CSFCOLOR‐STRAWAB•  RBCCOUNT4/mm3•  WBCCOUNT47(H0‐5/mm3)•  SEGNEUTROPHILS%6(0‐7%)•  LYMP%70(40‐80%)•  MONO%14L(15‐45%)•  MENINGITISORNOMENINGITIS?ASEPTICORSEPTIC?

CASE#2HISTORYOFPRESENTILLNESS:•  51‐year‐oldwhitemalewithuncontrolleddiabetes(HgA1C15.5)and

tobaccoabuse;admiZedfortreatmentofdiabeKcfootinfecKon•  3wkhxofle^lateral“wart”that2weeksago“poppedanddrained”;

overlastweekhisarchturnedblackish‐purpleandthedrainagebecamefoul‐smelling;1dayPTAhehadsubjecKvefeverandrigors

ALLERGIES:PCN,whichcausesanaphylaxis.OccurredasachildandheremembersthehospitalizaKonINPATIENTANTIBIOTICS:Include1.IVvancomycin.2.IVCipro.3.IVflagyl

CASE#2PHYSICALEXAM:

‐Notableforabandagedfoot,‐2/6SEMbestatRUSB,‐splinterhemorrhagesofrighthandandrightconjuncKvalhemorrhage

DATA:Bloodcx2/2(+)forsteptococcusspecies,non‐viableforsuscepKbiliKesAnd,asusual…polymicrobialswabofdrainingwoundcollectedinER:

(1)sensiKvee. coli (2)sensiKvep. vulgaris (3)sensiKves. aureus (4)corynebacterium (5)anaerobes(prevotella)

CASE#2OPERATIVECULTURES

CASE#2

•  ANTIBIOTICCHOICE?•  A.AskmorequesKonsw/respecttohisallergyhistory,thentryPCN

•  B.TrialdoseofCe^riaxoneasaninpaKentw/monitoringforsymptoms

•  C.ConKnuetreatmentwithVancomycin,cipro,andFlagyl

•  D.TrialdoseofErtapenemasaninpaKentw/monitoringforsymptoms

CASE#2

•  ANTIBIOTICCHOICE?•  A.AskmorequesKonsw/respecttohisallergyhistory,thentryPCN

•  B.TrialdoseofCe^riaxoneasaninpaKentw/monitoringforsymptoms

•  C.ConKnuetreatmentwithVancomycin,cipro,andFlagyl

•  D.TrialdoseofErtapenemasaninpaKentw/monitoringforsymptoms

CASE#2

•  Firstandforemost,aZemptacorrectassessment:immunosuppressedmalew/DMfootinfecKonandbacteremiawithdisseminaKonandAorKcValveInfecKveendocardiKs

•  ChoiceofanKbioKcandlengthoftherapywillfallintoplace

DEFINITIONofBACTEREMIA

*Viableorganismsculturedfromblood

Red (+) BCx & Green (-) BCx Seifert, CID 2009; 28:S238-45

GENERALINFO

 ALLBSIareclinicallyrelevant Common“contaminants”  Bacillusspecies,notanthracis  CoagulasenegaKvestaph  Corynebacteriumspecies  Propionibacterium

 Whentobeconcernedabout“contaminants”?  repeatedlyposiKvebloodcultures  bloodculturesthatmatchothercultures

THEIDAPPROACH

BACTEREMIA

WHERE DID IT COME FROM?

WHERE DID IT GO?

HOW SHOULD I TREAT?

EMPHASIS ON HISTORY

EMPHASIS ON REVIEW OF SYSTEMS

PT FACTORS? CHOICE OF ABX?

DURATION?

WHEREdiditcomeFROM?

•  Pathogenusuallyleadsyoutosource•  UsualculpritsforS. aureus:

– Skin/so^KssueinfecKon/injury–  IVcatheters–  Intravasculardevices– So^‐KssueinfecKons– Pneumonia(espinfaceofmechvenKlaKon)– Recentprocedures

CANDIDA

ENTEROCOCCUSorSTREPBOVIS

STREPMILLERI

WHEREDIDITGO?DISSEMINATION

•  Organism‐dependent– GPC/Candida>>>GNR– THEBIGTHREE:Candidemia,EnterococcalBacteremia,StaphylococcusBacteremia

•  Host‐dependent–  Immunosuppressedstatew/delayedclearance– ProstheKcmaterialinplace– AdvancedageandarthriKs

DISSEMINATION

 FREQUENTSITESOFSPREAD?&DIAGNOSIS?

– Heartvalves‐TEE– Bone&joints–MRI(vsorthoevalfortap)–  Intervertebraldiscs–MRI– Kidneys–CTscan– Spleen–CTscan

Who’satriskforcomplicatedbacteremia?

•  Only4variablesweresignificantaêrstaKsKcalanalysis:– Community‐acquired– ProstheKcdevice– Advancedage– Ptonasurgservice– Skinfindings– Feverat72h– Persistentbacteremia

Fowler, Vance. Clinical identifiers of complicated staphylococcus aureus bacteremia. Arch Int Med 2003; 163: 2066-2072.

DISSEMINATION‐Candida

•  HEART–  InfecKveEndocardiKs– 4%riskofseeding

•  EYES– EndophthalmiKs– 5%riskofseeding

•  ImportanttoidenKfyinordertotreatappropriately

Horn, CID ’09; 48: 1695-703.

DISSEMINATION‐Enterococcus

•  INCIDENCE– 2.3episodesofbacteremia/1000d/c’s

•  MORTALITY– Crude30daymortality23%

•  RISKofendocardiKs– HigherifBSIiscommunity‐acquired – HigherifprostheKcordamagedvalve– HigherinIVDU

Patterson, Makki, Caballero-Granado.

DISSEMINATION‐Staph

 S.aureus,ingeneral=mcpathogenIE Right‐sidedIEinIVDUandle^fornon‐IVDU OverallesKmatedriskofinfecKveendocardiKs(IE)in

faceofs. aureusbacteremia(SAB)=25% TEEhasagreateradvantageoverTTEinidenKfying

cases  CasesingeneralbutspecificadvantageintermsofcomplicatedIE(abscess,perforaKon)

ENDOCARDITIS–TEEvsTTE

•  Sept1994–Jan1996,prospecKvestudy•  103paKents,followedfor12wkspost1stposiKvebloodcxwiths. aureus

•  PtshadbothTTE&TEEdone•  Resultscategorizedas(+)forIE,(‐),orindeterminant

Fowler, Vance. Role of echocardiography in evaluation of patients with staph aureus bacteremia: experience in 103 patients. JACC 1997; 30: 1072-8

DISSEMINATION‐Staph

•  TEEDATA:

Fowler, JACC 1997; 30: 1072-8

Of all SAB, 25% picked up

Of the negative TTE, 20%

HOWSHOULDITREAT?MANAGEMENT

•  Definethescenario–  Immunosuppressedornot?–  Organism?–  Source?–  DisseminaKon?

•  40y/opreviouslyhealthyfemalew/MSSAbacteremiasecondarytoPICClineinfecKonwithoutmetastaKcdz,vs

•  67y/oneutropenicfemales/pinducKonchemow/candidemiaandaorKcvalveendocardiKs

MANAGEMENT–byorganismCandida

•  Startempirictherapywithanechinocandin(micafungin,caspofungin,anidulafungin)

•  NarrowcoverageaêrsuscepKbiliKesreturn•  IfcandidaspeciesisfluconazolesuscepKble,thenoralabxtherapyisanopKon

•  EveryonegetsaTEE&aneyeexam

MANAGEMENT–byorganismEnterococcus

 Startempirictherapywithvancomycin NarroworexpandcoverageaêrsuscepKbiliKesreturn  IfvancsensiKve:guidancebysuscepKbilitypaZern  IfVRE:daptomycinpreferredoverlinezolid

  EveryonegetsaTEE  Butcandebateifclearlynosocomial

MANAGEMENT–byorganismMSSAorMRSA

•  Startempirictherapywithvancomycin•  NarrowcoverageaêrsuscepKbiliKesreturn–  IfMSSA:preferred=ce^riaxoneorcefazolinornafcillin

–  IfMRSA,VancMICof>2:daptomycin•  Specialcircumstances

–  IfPCNallergic:vanc–  IfwaxingandwaningGFR:dapto

SPECIFICTREATMENTOPTIONSFORMRSABACTEREMIA?

•  Vancomycin15‐20mg/kgivq12h•  Daptomycin6‐10mg/kgivq24h•  Ceâroline600mgivq12h‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐•  Linezolid600mgivq12h•  Bactrim10‐15mg/kg/daydividedq12h•  Clindamycin600‐900mgivq6‐8h•  QuinprisKn/DalfoprisKn7.5mg/kgivq12h

MANAGEMENT–BYDIAGNOSIS

**Source?DisseminaKon?Hostfactors? CentrallineassociatedbloodstreaminfecKon(CLABSI)

  Secondarybacteremiaw/outmetdz(sourceclearlydefined)

 Primarybacteremiaw/outmetastaKcdz(nosourceevident)  Immunosuppressed  Non‐immunosuppressed

  InfecKveendocardiKsorequivalent

* In order of treatment difficulty

MANAGEMENT–CLABSI

 Generalprinciples Makeanaccuratediagnosis

▪  growthof>15colony‐formingunits(cfu)froma5‐cmsegmentofthecatheterKpbysemiquanKtaKve(roll‐plate)culture

▪  BCxfromcathKpmatchesperipheralBCxandthecatheter‐obtainedbloodculture“goesposiKve”2hoursbeforethebloodcultureobtainedperipherally;

“DifferenKalKmetoposiKvity”

  Removefocusifpossible  StartVancomycinempirically

MANAGEMENT–CLABSI

•  Mystandardapproach:– SuspectaCLABSI?(MatchingBCx(+)fromPICCandBCx(+)fromperiphery)

– PullPICC&cultureKp– Establishperipheraliv– Thenext3followingdays,obtainBCx– Startyour2weeksoftherapyfromthe1stsetofnegaKvecultures

MANAGEMENT–CLABSI

*CNS is only pathogen where “saving” the catheter is possible

*Staph & candida, it is never possible

IDSA guidelines, 2009

MANAGEMENTSecondarybacteremiaw/outmetdz

•  Ingeneral,2‐4weeks•  Easily“killed”bugs,shortercourse

– Streppneumoniaepneumoniaandbacteremia–2weeks

•  Notsoeasily“killed”,longercourse– StaphBSI–usually4weeks(especiallyifpthighriskofmetastaKcdz…likeprostheKcvalve)

MANAGEMENT–Primarybacteremiaw/outmetastaKcdz

•  Ingeneral,4weeks•  Immunosuppressed:4wksminimum•  Immunocompetent:youcandebate

MANAGEMENT‐InfecKveendocardiKsorequivalent

  Ingeneral,6weeks(butdependentonbug) CardiothoracicsurgeryconsultaKon Whentoconsult?

 Removematerialwhenpossible(Vascsx)

CASE#2–OURPATIENT•  Moredata:TEEposiKveforAoVvegetaKon•  RememberPCNallergy?HeadmiZedtotakingKeflexw/

outissue

•  Correctassessment:immunosuppressedmalew/DMfootinfecKonandbacteremiawithAorKcValveInfecKveendocardiKs

•  Plan?ErtapenemfortreatmentofpolymicrobialdiabeKcfootinfecKonfor2weeksthenfinishthefourweekcourseofAoIE2/2strepw/Ce^riaxone

INSUMMARY

 AlwayspayaZenKontoculturedorganisms,even“contaminants”

  Findthesource;whenfound,canthesourceberemoved?Don’tforgetyoursurgicalcolleagues

  Erronthesideoflongertreatment Don’tunderesKmatethepowerofMRSA GetaTEEforMRSABSI…remember25%resultinIE

 Whenindoubt,callanIDspecialist Useresources:www.idsociety.org

CASE#3

•  51y/oWMw/etohiccirrhosis,chronicvenousstasisisadmiZedtoMICUb/c“founddown”

•  PE:95.65888/4792%RA,altered,bruiseandlacacrossbridgeofnose,mulKpleotherbruises,lacle^2ndtoe,2/6SEMbestatapex

•  BCX2/2(+)forMRSA•  HowquicklydidthesegoposiKve?11.8hours•  HowquicklydidheclearhisBSI?w/in24hours•  What’stheVancomycinMIC?One

CASE#4•  50y/oWMw/DMandtriple‐pathy,poorlycontrolledw/chroniculcerle^foot,lastdebrided5daysPTA;admiZedw/CPandfoundtohavenewonsetafibRVRandNSTEMI

•  Le^legcelluliKcw/a1dayhxofpain,redness,swelling(samelegaschroniculcer)

•  Bloodcx(+)groupBstrep(agalacKae)•  ALLERGIES:sulfa=rash•  CURRENTABX:Vanc/zosyn•  Exam:VSS,o/wnothingoutoftheordinary

CASE#4

•  Doesthepathogeninthebloodmakesensew/theclinicalscenario?

•  AmIconcernedaboutdisseminaKonelsewhere?

•  TreatmentchoicesandduraKon?

CASE#5

•  64y/omorbidlyobeseWM(BMI69)w/chronicvenousstasischangesofbilaterallowerextremiKespresentsw/a1dayhxofale^hot,swollen,tender,moreerythematousthanusualle^leg.Nof/c/n/v/d.Noinjuries,openwounds,recentmanipulaKons.

•  PMH:CAD,OSA,DM(HgA1C7),etc.etc.•  Exam:typicalskinchangesbilatbutclearlyinfectedLLEw/extensionalmosttogroin

•  BCx1/2groupGstrep,PCN0.03

CASE#5•  IsthisreallycelluliKs?

– Or,vasculopathylikelimbischemia?– Or,acutearthropathylikeCharcot,sepKcankle,goutyankle,etc?

– Or,localirritaKononly?•  Whatpredisposedthisperson?•  DoItreatw/anK‐staphylococcaloranK‐streptococcalanKbioKcs?

•  OpKonsavailabeforPCNallergicpaKent?•  IsthispreventablebybehavioralchangeorisprophylacKcanKbioKcneeded?

ACUTECHARCOTJOINT

ACUTEGOUTYATTACK

TAKEHOMEPOINTS

•  INanycase,determinewhethertheclinicalscenariomakessense(ecoliUTIw/ecolibacteremiamakessense…proteussepsisw/negaKveurineculturedoesn’tmakesense)

•  MAKEanefforttofindthesource(ifnot,paKentmayrepeatedlysuffer)

•  TREATwiththemosteffecKveandnarrowestanKbioKcforthegerm

•  ERRonthesideoflongerthanshortertherapy

Documents

MY APPROACH TO INFECTIOUS DISEASE CASES · PDF fileOBJECTIVES • Review common infecous disease cases • Suggest appropriate use of anbiocs for speciﬁc infecous