Antibiotics 101 Bingo: Learn and Win with Antibiotic Knowledge!

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

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

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

4. Basic Antibiotic Coverage

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

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

7. HCAP Cont’d • Pathogens: • Pseudomonas • MRSA • Klebsiella, enterobacter, acinetobacter, serratia, E.Coli • Anaerobes (aspiration) • Empiric treatment: • Vitamin P and V • Piperacillin/tazo OR cefepime OR meropenem + vancomycin • 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 • Most common pathogens: • H.flu • Moraxella • Strep pneumo • Viruses: parainfluenza, flu, rhinovirus, RSV • Antibiotics: • Azithromycin (Z-pack) • Doxycycline 100mg BID x 10d • Amoxicillin 500-875mg TID x 10d • Other therapies: • Prednisone • Duonebs http://meded.ucsd.edu/clinicalimg/thorax_tripod.htm

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

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

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

12. Cellulitis- Diabetics • Common pathogens: • Staph and strep • Enterobacter • Enterococcus • Pseudomonas • Anaerobes • Empiric treatment: • Augmentin 875mg BID • Clindamycin 300mg TID • Amp/sulbactam 3g IV Q6hrs • +/- vancomycin • 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 • Pathogens: • Pathogens: E.Coli, E.Coli, E.Coli, Staph saprophyticus, Proteus • Uncomplicated: • Women, no systemic symptoms (afebrile, no leukocytosis, etc) • Complicated: • Men, indwelling foley, systemic symptoms • Pyelonephritis: • Flank pain, fever, leukocytosis, +/- WBC casts

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

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

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

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

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