1 / 30

Infectious disease Family Practice topics

Infectious disease Family Practice topics. Bugs and drugs FP style. Case 1. 34 yo sexually active female presents with acute onset of dysuria, frequency and urgency without fevers, chills or flank pain. No new partners, no vaginal discharge. UTI. What is the likely bug?

fadey
Download Presentation

Infectious disease Family Practice topics

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Infectious disease Family Practice topics Bugs and drugs FP style

  2. Case 1 • 34 yo sexually active female presents with acute onset of dysuria, frequency and urgency without fevers, chills or flank pain. No new partners, no vaginal discharge.

  3. UTI • What is the likely bug? • Do you need cultures? • What is significant bacteriuria? • Drug of choice? • Duration of therapy?

  4. Etiology • Ecoli 80-90% • Staph Saprophyticus 5-10% • Klebsiella, Proteus, Enterococcus

  5. Significant? • 10^2 CFU • 10^3 CFU • 10^5 CFU

  6. Drug of choice? • Ampicillin/Amoxicillin • Amoxicillin-clavulanate • Keflex • TMP-SMX • Cipro • Nitrofurantoin

  7. Lets talk susceptibilityre: Resistance • The Surveillance Network (TSN) is a group of 250 micro labs in the US • 2003 data include 350,000-416,000 isolates (urinary) • TMP-SMX 17.5 % resistance • Ampicillin 38% resistance • Nitrofurantoin 0.8% resistance • Ciprofloxacin 2.3% resistance

  8. How about Saint Joes • Susceptibilty E.coli isolates (all comers) • T/S 19% resistance • Ampicillin 35% resistance • Ampicillin-clavulanate 30% resistance • Levofloxacin 9% resistance

  9. Some tips • If resistant to TMP-SMX then likely some resistance to Cipro (data suggests about 9.5%) • also some resistance likely with nitrofurantoin (2%) • Clin Infect Dis 2003;36:183

  10. Other issues • Keflex- may miss proteus, dose 500 QID X 7 • Nitrofurantoin- great for ecoli, not great for other GNR’s, misses proteus and pseudomonas, short 1/2 life so use for 7 days • Cipro- use three days not one (500mg BID) • Nitrofurantoin 100mg BID X 7 (cheap) • TMP-SMX DS BID X 3

  11. What about enterococcus • Ampicillin/Amoxicillin • Nitrofurantoin • Doxycycline • Fluoroquinolones • Vancomycin • At Joes 41% resistance to Levofloxacin! And 11% resistance to Ampicillin

  12. Therapy for pyelonephritis • Best to use Cipro 500 mg po BID X 7 days or TMP-SMX DS BID X 14 days, cipro is drug of choice b/c of resistance discussed and more cost effective • Could use a single IV dose of cipro or ceftriaxone

  13. Blood cultures in Pyelonephritis • One old study 1997 showed that blood cultures are not needed for uncomplicated pyelo • blood cultures overall were positive in 18% and only one was positive for a different organism • Take home..blood cultures do not influence therapy choice

  14. Next... • 56 yo hispanic male with diabetes presents with an ulcer on the MP, plantar surface. There is obvious cellulitis and the ulcer is necrotic at the base. No purulent drainage, no fever, no systemic signs of infection.

  15. Is it infected? • Pus • sinus track • cellulitis with fever or leukocytosis

  16. Questions • What’s the bug? • Do I need cultures? • What therapy do you chose? • What is the best way to rule in/out osteomyelitis?

  17. Usual suspects • Staph Aureus • Streptococcus • Enterococcus • proteus • pseudomonas • anaerobes * usually polymicrobial

  18. Wound cultures • Essentially worthless at identifying pathogens

  19. Outcomes of uncomplicated Diabetic foot Infections • Clindamycin (300 qid) • Cephalexin 500 mg qid • Ampicillin-clavulanate • ?levofloxicin

  20. Clinical diagnosis of osteo • Ulcers larger than 2X2 sensitivity 56% specificity 92% • Ulcers deeper than 3 mm • Exposed bone or probe to bone • ESR > 70 28% sensitive and 100% specific

  21. Diagnostic testing for Osteomyelitis in Diabetes • Probe to bone PPV 89% • Radiograph 74-87% • bone scan 43-87% • MRI 50-93% • Indium-111 WBC Scan 75-85% • in doubt= bone biopsy

  22. Treatment • One week Ofloxacin (400 q12), then 2 weeks oral (if osteo requires resection) OR • Two weeks imipenem-cilastatin (500mg q6) or ampicillin-sulbactam (3g q6) OR • Eight weeks oral Cipro (750 BID) , not monotherapy in staph aureus

  23. Next... • 18 yo female, college student with headache, vomiting and fever for 1 day • temp 104 pulse 125 BP 100/50 95% sat • A&O X4, no focal neurologic signs

  24. Differential • Bacterial meningitis • Viral meningitis • HSV / WNV meningitis • brain abscess/empyema • parameningeal infection (TB) • sepsis, TTP, HUS, vasculitis

  25. Clinical signs • Fever, HA, stiff neck, altered consciousness • rapid clinical course if not treated • remember the presentation may be atypical in neonates, kids, elderly

  26. Bugs Post- HIB vaccine • S. pneumoniae 47% • N.meningitidis 25% • GBS 12% • L. monocytogenes 8% • H. influenza 7%

  27. Meningitis management • ?Fulminant presentation • start antibiotics empirically after BC X1 • LP if no contraindication do not wait to give ABXs do get a CT/MRI to rule out mass lesion if seizure, focal neuro defect or papilledema

  28. Effect of delay of treatment • Canadian research 2003, sept ICAAC • retrospective study of 123 adults • 13% mortality rate • Mortality predicted by severity of impairment of mental status and >6 hour delay in antibiotics

  29. Empiric therapy by age • Neonate Ampicillin +cefotaxime • Infant 1-3 mo Ampicillin + cefotaxime • 3mo-18y 3rd gen cephalosporin add vanco if gram + 18 and up 3rd gen cephalosporin add vanco if gram + add Ampicillin for >50 or immunocompromised

  30. Dexamethasone for meningitis in adults • Indicated for documented or suspected pneumococcal meningitis • Give just before or with antibiotic • Still some controversy ?does it delay antibiotics?, does it have an adverse effect? NEJM 2002, 347:1549

More Related