Outpatient ID

1. Outpatient ID Ariel Pablos-Méndez, MD, MPH Division of General Internal Medicine Columbia University Medical Center New York, NY 2018

2. Topics covered separately • TB • HIV • Flu/URI • STDs, Vaginitis • GI Review- including H pylori

3. Topics covered today • Outpatient epidemiology and ID stewardship • UTI / pyelonephritis • Cellulitis • Lower respiratory tract infection (bronchitis/pneumonia)

4. CDC’s page on IDs

5. 20 Leading Reasons for OutPt Visits Source: CDC’s National Hospital Ambulatory Care Survey, 2011

6. Source: JAMA 2017. doi:10.1001/jama.2017.8531

7. Antibiotic stewardship • In 2014, 266.1 million courses of antibiotics are dispensed to outpatients in U.S. community pharmacies (nearly 1 per person). • An estimated 80-90% of the volume of human antibiotic use occurs in the outpatient setting (accounts for >60% of the $). • At least 30% of outpatient antibiotics are unnecessary, and an additional 20% are inappropriate (selection, dosing and duration) • Much of this in children or for common cold & acute bronchitis • Local prescribing practices contribute to local resistance patterns. Source: CDC’s “Outpatient Antibiotic Prescriptions—United States, 2014,” https://www.cdc.gov/getsmart/community/pdfs/annual-reportsummary_2014.pdf.

8. Antibiotic prescribing in the outpatient setting varies by state, 2014 Source: CDC’s “Outpatient Antibiotic Prescriptions—United States, 2014,” https://www.cdc.gov/getsmart/community/pdfs/annual-reportsummary_2014.pdf.

9. Factors that influence prescribing antibiotics • Patient satisfaction and pressure. • Time Constraints (“decision fatigue”) • Diagnostic uncertainty • Externalized responsibility (“blame others”) Improving prescribing behavior • Educational initiatives & Communications training  • Audit and feedback strategies  • Clinical decision support systems  • Delayed prescriptions (“watchful waiting” and prn Rx) Source: Pew Charitable Trusts, 2017.  http://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2017/06/what-drives-inappropriate-antibiotic-use-in-outpatient-care

10. Urinary Tract Infection A 36 year old woman comes to WIC with a 1 day history of dysuria and urinary urgency and frequency. The patient has a sulfa allergy. On physical examination, temperature is normal, blood pressure is 110/60, pulse in 60/min, and resp rate is 14/min. There is mild suprapubic tenderness. The remainder of the examination is normal. Urine dipstick analysis shows 3+ leukocyte esterase. A pregnancy test is negative. Treatment with which of the following antibiotics is most appropriate? • Amoxicillin • Fosfomycin • Levofloxacin • Cephalexin • TMP/SMX

11. Urinary Tract Infection • Upper urinary tract Infections: • Pyelonephritis • Lower urinary tract infections • Cystitis(“traditional” UTI) • Urethritis(often sexually-transmitted) • Prostatitis Source: Ritter M, Course Hero 2007

12. Symptoms of Urinary Tract Infection • Dysuria • Increased frequency • Hematuria • Fever (or confusion in elderly) • Nausea/Vomiting (pyelonephritis) • Flank pain (pyelonephritis) Source: Ritter M, Course Hero 2007

13. Findings on Exam in UTI • Physical Exam: • CVA tenderness (pyelonephritis) • Urethral discharge (urethritis) • Tender prostate on DRE (prostatitis) • Urinalysis: + Leukocyte esterase (pyuria also seen w vaginitis) + Nitrites (more likely gram-negative rods) + WBCs [>10 WBCs/uL, correlates to >100k CFUs] + RBCs Source: Ritter M, Course Hero 2007

14. Culture in UTI • Positive Urine Culture = >105 CFU/mL • Most common pathogens: • Escherichia coli • Staphylococcus saprophyticus • Proteus mirabilis, Klebsiella, Enterococcus • For urethritis: - Chlamydia trachomatis - Neisseria Gonorrhea Source: Ritter M, Course Hero 2007

15. CUMC Guidelines Cystitis

16. Special cases of Complicated cystitis • Indwelling Foley catheter [frequently colonized] • Try to get rid of foley if possible! • Only treat patient when symptomatic (fever, dysuria, flank pain) • Should change foley before obtaining culture, if possible • Candiduria • Frequently occurs in patients with indwelling foley. • If it grows in urine, try to get rid of foley! • Treat only if symptomatic. • If need to treat, give fluconazole Source: Ritter M, Course Hero 2007

17. Urethritis • Chlamydia trachomatis • Frequently asymptomatic in females, or dysuria, discharge or PID • Send UA, Urine culture (if pyuria seen, but no bacteria, suspect Chlamydia) • Pelvic exam – send discharge from cervical or urethral os for chlamydia PCR • Chlamydia screening is now recommended for all females ≤ 25 years • Treatment: • Azithromycin – 1 g po x 1 • Doxycycline – 100 mg po BID x 7 days • Neisseria gonorrhoeae • May present with dysuria, discharge, PID • Send UA, urine culture • Pelvic exam – send discharge samples for gram stain, culture, PCR • Treatment: • Ceftriaxone – 125 mg IM x 1 • Cipro – 500 mg po x 1 • Levofloxacin – 250 mg po x 1 • Spectinomycin – 2 g IM x 1 You should always also treat for chlamydia when treating for gonorrhea! Source: Ritter M, Course Hero 2007

18. Prostatitis • Symptoms: • Pain in the perineum, lower abdomen, testicles, penis, and with ejaculation, bladder irritation, bladder outlet obstruction, and sometimes blood in the semen • Diagnosis: • Typical clinical history (fevers, chills, dysuria, malaise, myalgias, pelvic/perineal pain, cloudy urine) • The finding of an edematous and tender prostate on physical examination • Will have an increased PSA • Urinalysis, urine culture • Treatment: • Trimethoprim/sulfamethoxazole, fluroquinolone or other broad spectrum antibiotic • 4-6 weeks of treatment Source: Ritter M, Course Hero 2007

19. Bacterial Skin Infections American Academy of Dermatology

20. Case One: History Common Case • HPI: Mr. López is a 55-year-old man who presents with 5 days of worsening right lower extremity pain and a red rash. He reports recent fevers and chills since he returned from a camping trip last week. • PMH: arthritis; Meds: NSAIDs; NKDA • Social history: lives in the city with his wife • Health behaviors: no alcohol, tobacco or drugs • ROS: able to bear weight, no itching. American Academy of Dermatology

21. Case One: Exam • Vital signs: T 100.4, HR 90, BP 120/70, RR 14, O2 sat 97% on RA • Skin: erythematous plaque with ill-defined borders over the right medial malleolus. Lesion is tender to palpation. • Tender, slightly enlarged right inguinal lymph nodes (not shown) • Laboratory data: WBC 12,000 (75% neutrophils, 10% bands), Plts 335 American Academy of Dermatology

22. Case One, Question 1 What is the next best step in management? • Apply topical antibiotics • Apply topical steroids, and encourage leg elevation • Begin antibiotics immediately Gm(+) • Order an imaging study • Obtain aspirate for c/s What is the most likely diagnosis? • Bacterial folliculitis • Cellulitis • Necrotizing fasciitis • Stasis dermatitis • Tinea corporis American Academy of Dermatology

23. Diagnosis: Cellulitis Cellulitis • Cellulitis is a very a common infection, occurring in up to 3% of people per year • Results from an infection of the dermis that often begins with a portal of entry that is usually a wound or fungal infection (e.g., tinea pedis) • Presents as a spreading erythematous, non-fluctuant tender plaque • More commonly found on the lower leg • Streaks of lymphangitis may spread to LN American Academy of Dermatology

24. Masqueraders of cellulitis • Erythema migrans • Herpes zoster • Septic arthritis • Septic bursitis • Osteomyelitis • Mycotic aneurysm (IDUs) • Contact dermatitis • Acute gout • Vasculitis (non blanching) • Insect bite • Deep venous thrombosis • Panniculitis • Erythema ab igne (RT) • Stasis dermatitis • Lymphedema • Botryomycosis • Myiasis

25. THE COMMON pyogenic SKIN INFECTIONS are:(Gram +ve) Primary, Secondary And systemic • Streptococci Staphylococci • 1. Impetigo & Ecthyma 1. Impetigo(10% of cases • 2. Erysiplase 2. Bullous Impetigo • 3. Cellulites 3. superficial & deep Follicullitis • 4. Lymphangitis 4. Sweat gland abscess Primary

26. A type of cellulitis called Erysipelas American Academy of Dermatology

27. Skin Abscess • Erythematous, warm, fluctuant nodule with several small pustules throughout the surface • Very tender to palpation American Academy of Dermatology

28. What is this? • Peri-oral papules and plaques with overlying honey-colored crust • Minimal surrounding erythema

30. Examples of Folliculitis American Academy of Dermatology

31. Furunculosis • A furuncle (boil) is an acute, round, tender, circumscribed, perifollicular abscess that generally ends in central suppuration American Academy of Dermatology

32. Carbunculosis • A carbuncle is a coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles American Academy of Dermatology

33. Ecthyma • Ecthyma is an ulcerative form of impetigo in which the lesions extend through the epidermis and deep into the dermis. • They consist of “punched out” ulcers covered with yellow crust surrounded by raised margins. American Academy of Dermatology

34. Diabetic Foot Infections Photo courtesy of T. File MD

35. Clostridial cellulitis American Academy of Dermatology Photo courtesy of T. File MD

36. CA-MRSA Infections are Mainly Skin Infections (90%) Most Invasive MRSA Infections Are Healthcare-Associated (85%) Fridkin et al NEJM 2005;352:1436-44 Klevens et al JAMA 2007;298:1763-71

37. MRSA: key points - MRSA is primarily healthcare-associated - Community-acquired MRSA think skin infections - Drainage: “not just a good idea, it’s the law”. - If you can culture it, you should. - Fever + skin infection = blood culture - Pos. blood cultures for S. aureus = admission - In 2009, Empiric Rx for skin should cover MRSA - For non-cultured skin, consider Septra + B-lactam http://www.cdc.gov/mrsa

38. CUMC Guidelines

39. LRTIs

40. Acute Bronchitis • Self-limited LRTI w/o pneumonia or COPD • 10% of ambulatory care visits, specially in fall & winter • Presents with 1-3 weeks of cough (+/- wheezing) • 90% due to viruses (Influenza, Parainfluenza , Rhinoviruses, Coronavirus, RSV) –sometimes following a URI • Bacterial (<10%): Only B. pertussis warrants antibiotics • r/o: asthma, ACE inhibitors, postnasal drip, etc.

41. Acute Bronchitis 2 • Test for flu in season or high-risk individuals • We do not routinely use procalcitonin or CxR • r/o asthma, ACE inhibitors, postnasal drip, etc. • Reassurance the disease is self limited (though bronchial hyper-reactivity may last a couple of weeks) • Avoid antibiotics (little benefit) and codeine (addiction) • Symptomatic relief with hot tea and prn albuterol and dextromethorphan

42. COPD Exacerbation • Antibiotics in patients with a moderate to severe exacerbation: 2 of 3 symptoms (increased dyspnea, sputum volume or purulence) or requiring hospitalization. • Target likely bacterial pathogens (Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pneumoniae) and take into account local patterns of antibiotic resistance • The majority are treated as outpatients with an advanced macrolide with anti­Haemophilus activity, doxycycline, trimethoprim­sulfamethoxazole, or a cephalosporin GOLD by WHO/NIH

43. Community Acquired Pneumonia • USA: > 4 million cases of CAP each year • < 10% of patients with CAP need hospitalization • No causative agent is identified in 30% to 50% • S. pneumoniae most commonly identified organism • Aspiration and viruses each cause 5-10% of cases • In nursing home residents, 30-day mortality ranges from 10 to 30 percent

44. Diagnosis of Pneumonia Signs and symptoms • Fever or hypothermia, cough with or without sputum, dyspnea, pleuritic CP, sweats or chills • ‘Atypical’ pneumonia associated with headaches, diarrhea, nonexudative pharyngitis, bullous myringitis, slow onset, myalgias (and CxR may look worse!) • Gral exam: fever, tachypnea, tachycardia, agitation/confusion. • Lung exam: increased tactile fremitus, dullness to percussion, decreased breath sounds, presence of rales or crackles Metlay JP. JAMA 1997

45. Procalcitonin (PCT>>>CPR) • In 1993, Assicot et al reported in The Lancet that PCT was a marker of systemic infections in neonates and pediatric patients.  • In 2004, PCT guidance substantially reduced antibiotic use in adult patients presenting to the ED with lower respiratory tract infections  • In 2016, the Stop Antibiotics on guidance of PCT Study (SAPS) found a reduction of duration of treatment and a decrease in mortality in critically ill adult patients with presumed bacterial infection. • In two large Swiss studies, with the PCT-guided algorithm, antibiotic exposure was 50—75% lower than in the control group.  • Sensitivity (90%), and equally high PV(-) with serum levels <0.25 ug/L • Specificity (80%), with a PV(+) >90% in patients with levels >0.50 ug/L • (better than PCR in head to head comparisons) Source: Lancet Aug 26, 2017

46. Pneumonia Severity Index • Age > 65 years • Confusion • RR > 30 x’ • SBP < 90 mmHg • BUN >30 mg/dL 0 - 1: ambulatory treatment 2 - 3: hospitalization 4 - 5: admission to ICU * Other RFs (PORT): hypothermia, acidosis; CHF, ESRD, cancer

47. CUMC Guidelines

48. Aspiration Pneumonia • Aspiration is normal but cleared (microbiota below pharynx) • Most CAPs come from aspiration (or inhalation) • But real aspiration defenses are not there, and periodontal commensals like anaerobes (and strep) more likely • RFs: hospitalized, neuro patients, MS alteration, esophageal disease or N/V, tubes, alcoholics • Clinical presentation is variable (more indolent than classic CAP); abscesses more common. • Rx: Amoxicillin-sulbactam for aspiration pneumonia (or amoxi+metronidazol) x 7 days (longer for abscess) • Chemical pneumonitis ("flash burn") can produce acute cyanosis and infiltrates of lower lobes & clears in 2-3 days (but could cause ARDS) • Rx: immediate tracheal suction and respiratory support

49. Thanks!