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Fevers and Antibiotics Intern Survival Series

Fevers and Antibiotics Intern Survival Series. Elizabeth Cerceo, MD Assistant Professor of Medicine Robert Wood Johnson. Overview. Cases Need to Know Miscellaneous Antibiotic pearls Calling Consults Antibiotic Approval System. Case 1.

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Fevers and Antibiotics Intern Survival Series

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  1. Fevers and AntibioticsIntern Survival Series Elizabeth Cerceo, MD Assistant Professor of Medicine Robert Wood Johnson

  2. Overview • Cases • Need to Know • Miscellaneous • Antibiotic pearls • Calling Consults • Antibiotic Approval System

  3. Case 1 • 48 yo male with PMH – HTN a/w fevers, chills, sweats, n/v x1. 102.5, 121, 130/71, 18, 97%. Bibasilar crackles, 2/6 HSM at LSB, decreases with Valsalva. 134 97 45 11.2 170 3.5 17 1.6 13.6 268 38 Bcx – ¼ GPC 85-S, 12-L

  4. Case 2 • 48 yo male alloBMT for AML-M2. Day10 post-transplant. Neutropenia x 7 days. Chills, 101.5. • What would you give first? • Cefepime • Then ¼ GPC in blood. Right Hickman is C/D/I. 9.6 0.1 103 28.1

  5. Neutropenic fever • Cefepime (Maxipime™) –Gram positive & Gram neg coverage • including Pseudomonas • Indicated as MONOTHERAPY for NEUTROPENIC FEVER • High dose • Imipenem (Primaxin™) - 2nd line as monotherapy for neutropenic fever

  6. Case 3 • 67 yo male with PMH – CHF, DM a/w SOB, left-sided chest pain. JVP ~ 8cm, crackles L>R base, +2 LE edema. Trp 1.3, CK 809. EKG – new ST depressions V3-6. Admitted for NSTEMI; started on heparin gtt, morphine 2 iv q4h, oxygen, ASA 325. Taken for cath -> stent to Rcx. • Day 2 – devl fever 101.2. • Fever ≠ Antibiotic

  7. Case 4 • 74 yo female with no significant PMH a/w 3 days SOB, cough productive of greenish sputum. 101.8, 110, 103/64, 22, 92% on 2L NC. CXR with RLL infiltrate. Bcx sent. 12.7 138 102 25 204 16.2 403 4.1 22 1.2 35.9

  8. Community acquired pneumonia • Ceftriaxone (Rocephin™) +azithromycin • not renally cleared • Levofloxacin (Levaquin™) - monotherapy • ICU admission – different antibiotic choice

  9. Severe/ICU CAP • Ceftriaxone + azithromycin • Ceftriaxone + levofloxacin • Aztreonam + levofloxacin (For beta-lactam allergy only) • Not levofloxacin alone

  10. Case 5 • 74 yo female nursing home resident PMH – DM, HTN, gout, s/p CVA with left-sided hemiparesisa/w 3 days SOB, cough productive of greenish sputum. 101.8, 110, 103/64, 22, 92% on 2L NC. CXR with RLL infiltrate. Bcx sent. 12.7 138 102 25 16.2 403 204 4.1 22 1.2 35.9

  11. HCAP/HAP • Consider Pseudomonas • Cefepime + gentamicin + azithromycin • Cefepime + aztreonam + levofloxacin • Cefepime + levofloxacin • Consider MRSA • Vancomycin or linezolid

  12. Case 6 • 53 yo male in ICU x 10 days with acute gallstone pancreatitis. Intubated x 10 days. 101.2, 108, 93/58, 14 on AC TV 450, PEEP +10. Anasarca, GCS 11T, Foley, R SC TLC, OGT, ETT, rhonchi diffusely, tachy, abd distended, ↓ BS. CXR c/w ARDS. Bcx 4/4 GPC.

  13. Catheter-Related BSI • Repeat blood cultures! • Most commonly gram positive organisms • IV vancomycin • Pull catheter and culture tip

  14. Case 7 • 29 yo female with PMH – IVDA a/w 3 days for LUE edema, erythema from forearm extending up 8 cm proximally. Some fluctuance appreciated. Temp 102.6 • Bactrim • Often not adequate for cellulitis alone (Poor streptococcal coverage) • Decrease dose for renal impairment

  15. Case 8 • 26 yo male student with no PMH admitted with headache, somnolence, fever 100.9 x 3 days.

  16. Meningitis • Adults <50 years old • High dose IV vancomycin and ceftriaxone • Adults >50 years old • Add high dose IV ampicillin to above • Always check blood cultures when suspecting meningitis • If you think lumbar puncture, likely it needs to be done!

  17. Overview • Cases • Need to Know • Miscellaneous • Antibiotic pearls • Calling Consults • Antibiotic Approval System

  18. Fever basics • Pain is a helpful sign • Vital signs • Abnormal physical findings • Icteric sclera • Basic Labs & Chest X-Ray

  19. Need to know stuff • Cultures before antimicrobials • Blood, urine, sputum, peritoneal fluid, stool, throat, purulent discharge, etc… • Imaging – leg swelling, hypoxia, confusion, vomiting • With cultures sent from sites of concern…empiric antibiotics prudent for severely ill patients

  20. Miscellaneous stuff • What is Extended Spectrum B-Lactamase? • Antibiotic Allergy • Intranet Portal • Lexicomp - pharmacy resource • Application & Resource Website Links

  21. ESBL • ESBL organisms – BAD! • resistant to ALLpenicillins, cephalosporins, & aztreonam • Alternatives • Carbapenem • Aminoglycoside • Quinolone

  22. Antibiotic Allergies • Most Important – IgE Mediated: • urticaria, laryngeal edema, bronchospasm, or anaphylaxis • Always ask the patient what the ‘allergic’ reaction is • Nausea, headache, fatigue, etc… – not true allergic reaction

  23. Intranet portal • Departments -> Pharmacy • Dosing Tools & • Creatinine Clearance Calculator • Laboratory -> Microbiology -> • Antibiogram • Annually • Cooper Hospital Only • Bacteria and Antimicrobial sensitivities

  24. Overview • Cases • Need to Know • Miscellaneous • Antibiotic pearls • Calling Consults • Tips for Interns • Antibiotic Approval System

  25. Calling consults • Know your patients • Have a thoughtful question • Call consults early • Any consult completed should be read by the primary team or signed out to the after hours team • Decreases delays in patient care - expedites discharge! • All consultants’ progress notes should be read by the primary team

  26. Calling consults • Page the Consult team • Briefly discuss with the Fellow • Patient Name • Room Number…

  27. Calling consults • Reason for Consult • Pertinent history, hospital course, current situation • Be succinct…everyone’s • What has already been done to address this question? • Was the Patient evaluated? • Was laboratory/culture data obtained?

  28. Calling consults • Daily Progress Notes – Don’t write: • “Fever – ID following.” • Instead, write your thoughts! • “Fever – blood cultures negative so far, check CT of Abd/Pelvis…drug fever?” • "Invest a few moments in thinking. It will pay good interest.” • Unknown

  29. Overview • Cases • Need to Know • Miscellaneous • Antibiotic pearls • Calling Consults • Antibiotic Approval System

  30. Antibiotic approvals - #1473 • Patient Name • Room Number • Antibiotic • Dose • Duration or Indication • Empiric • Staph Aureus septic arthritis…3 weeks

  31. Antibiotic Approvals • Is the antibiotic appropriate? • Ceftriaxone for enterococcalbacteremia…not a good choice • Impacts on overuse of Antibiotics in Hospital • Costs & microbial resistance • Educational component

  32. Antibiotic approvals • An Antibiotic Approval ≠Consult • Allows for dispensing of the antibiotic • Some antibiotics require no approval, some after 3 days of use, & some before dispensing any doses

  33. “Reading furnishes the mind only with materials of knowledge; it is thinking that makes what we read ours.” • John Locke

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