Mazen Kherallah, MD, FCCP

Case Scenario

• 17 year old male with PMH cyctinosis complicated with chronic renal failure requiring kidney transplantation X2 that failed and placed on chronic dialysis, patient acquired HBV

• Admitted on January 17, 2010 with:– Fulminant hepatitis secondary to HBV– Acute liver failure– Coagulopathy– Hepatic encephalopathy

Management

• ICU monitoring

• Dialysis continued

• Vitamin K

• Lactulose

• Not candidate for liver transplantation

January 21, 2010

• Respiratory distress

• Fever

• Developed bilateral pulmonary infiltrates

• Intubated

• FiO2 50%, pO2: 65 mm Hg

• Yellowish endotracheal aspirate

• WBC: 12.400

Which of the following organisms is unlikely in this situation?

A. Pseudomonas aerugniosa

B. Escherichia coli

C. Staphylococcus aureus

D. Klebsiella pneumoniae

E. Haemophillus influenza

Tracheal Aspirate Gram Stain

Common HAP Pathogens in ICU Patients

Others

n=4365

Data from the National Nosocomial Infections Surveillance (NNIS) system (1986–2003) for HAP. Gaynes et al. CID 2005;41:848– 54.

What empiric antibiotics would you choose at this time?

A. Ceftriaxone + metronidazole

B. Ceftazidime + vancomycin

C. Pipercillin/tazobactam + vancomycin

D. Meropenem + vancomycin

E. Ciprofloxacin + amikacin + vancomycin

Hospital Acquired Aspiration PneumoniaAntibiotic Selection

β -lactam/β-lactamase inhibitor (PIP/TAZ) ± AG or Ciprofloxacin ± Glycopeptide Carbapenem (Imipenem, Doripenem or Meriopenem) ± AG or Ciprofloxacin ± Glycopeptide Cefepime ± AG or Ciprofloxacin ± Glycopeptide Ceftazidime ± AG or Ciprofloxacin ± Glycopeptide

Broncho-alveolar Lavage

ATS combination treatment guidelines for healthcare-acquired pneumonia (HCAP)

ATS/IDS. Am J Respir Crit Care Med 2005;171:388-416

β -lactam/β-lactamaseinhibitor (PIP/TAZ)

OR

Antipseudomonal carbapenem(imipenem or meropenem)

OR

Antipseudomonal cephalosporin (cefipime or ceftazidime)

AntipseudomonalFluoroquinolone(ciprofloxacin or

levofloxacin)

Aminoglycoside(amikacin, gentamicin

or tobramycin)

Vancomycin

+ OR +

Linezolid

Antibiotic Course

Pip/Taz

Vancomycin

January 31, 2010

• Developed acute abdominal pain

• Distended abdomen with tenderness and decreased bowel sounds

Perforated Viscus

• Managed conservatively secondary to high risk surgery

Which of the following organisms is least likely in this situation?

A. Bacteroides fragilis

B. Pseudomonas aerugniosa

C. Escherichia coli

D. Klebsiella pneumoniae

E. Enterococcus

Microbiology of Peritonitis

Enterococci

Pseudomonas

S. epidermidis

Candida

B. fragilis group

E. coli

Clostridium spp.

Klebsiella spp.

Streptococcus spp.

Enterococcus spp.

Pseudomonas spp.

E. coli

Klebsiella spp.

Streptococcus spp.

Enterococcus spp.

Other gram-negative bacilli

Tertiary (Polymicrobial)

Secondary (Polymicrobial)

Primary (Monomicrobial)

Barie PS. J Chemother. 1999;11:464-477.LaRoche M, Harding G. Eur J Clin Microbiol Infect Dis. 1998;17:542-550.

S. anginosus

64

©Copyright 2005 gbf.de / All rights reserved

B. fragilisE. coli

S. epidermidis

©Copyright 2005 cmsp.com / All rights reserved©Copyright 2005 cmsp.com / All rights reserved

What empiric antibiotics would you choose at this time?

A. Ceftriaxone + metronidazole

B. Pipercillin/tazobactam

C. Imipenem

D. Tigecycline

E. Ciprofloxicin + metronidazole

Secondary Peritonitis(Antibiotic Selection)

Enterobacteriacea

Amoxicillin / clavulanate

Piperacillin / tazobactam

Carbapenems

3rd gen cephalosporins

4rd gen cephalosporins

Aztreonam

Fluoroquinolones

± aminoglycoside

Tigecycline

B. Fragilis Group

Metronidazole

Clindamycin

Amoxicillin / clavulanate

Piperacillin / tazobactam

Cefoxitin

Carbapenems

Moxifloxacin

Tigecycline

Enterococcus

Ampicillin

Vancomycin

Ticoplanin

Telavancin

±Aminoglycosides

Daptomycin

Linezolid

Qunupristin/Dalfopistin

Tigecycline

Risk factors for ESBL, AmpC or MDR?

Abdominal Drainage Feb 1, 2010

Antibiotic Course

Pip/Taz

Vancomycin

Meroppenem

Vancomycin

Fluconazole

Feb 6, 2010

• No improvement with concervative approach

• CT scan abdomen

CT Scan Report

• Significant wall thickening involving the large and small bowel loops with patent abdominal vessels, probably representing nonocclusive bowel ischemia with differential diagnosis inflammatory bowel disease.

• Interval progression of ascites with interval regression of pneumoperitoneum.

• Interval progression of bilateral pleural effusion with passive basal atelectatic changes. The rest of the examination is unchanged compared with the recent previous study done on 1 February 2010.

ICU Course

• Laporatomy revealed peritonitis

• No clear perforation site

• Washing and drains placed

• Improved over the next days

• Discharged to floor

February 19, 20010

• Fever: T: 101.3• Hypotension: SBP 70• Tachypnea: RR 32• Tachycardia: 130/min• WBC: 28.4

• pO2: 56 on FiO2 60%

• Thrombocytopenia: 87,000• Anuric• Lactic acid: 4.2

SepsisSIRS Severe Sepsis Septic ShockInfection

Chest 1992;101:1644

Sepsis Continuum

A clinical response arising from a nonspecific insult, with 2 of the following: T >38oC or

<36oC HR >90

beats/min RR >20/min WBC

>12,000/mm3 or <4,000/mm3 or >10% bands

Microorganism invading

sterile tissue

SIRS with a presumed

or confirmed infectious process

Sepsis with organ failure

Vascular collapseRenalHemostasisLungLA

Refractoryhypotension

Burns

Trauma

Sepsis Syndromes1992: SCCM/ACCP

Parasite

Virus

Fungus

BacteriaBSI

SevereSepsis

ShockSevereSIRS

Infection SIRSSepsis

What is the likely source of sepsis?

A. Line infection?

B. Nosocomial pneumonia?

C. Further cIAI with or without abscesses?

D. Urinary catheter-related infection?

E. C-diff colitis

F. Any of the above

Urinalysis

Severe Sepsis Management

Source Control

Appropriate and Adequate Empiric

Antibiotics

Early Goal Directed Therapy

Which of the following organisms is least likely in this situation?

A. Bacteroides fragilis

B. Pseudomonas aerugniosa

C. Proteus mirabilis

D. Candida albicans

E. Enterococcus

CR-UTI(Antibiotic Selection)

Pseudomonas

Piperacillin / tazobactam

Carbapenems

Ceftazidime

Cefepime

Ceftobiprole

Aztreonam

Ciprofloxacin

± aminoglycoside

Candida

Ampho B

Azoles

Enterococcus

Ampicillin

Vancomycin

Ticoplanin

Telavancin

±Aminoglycosides

Daptomycin

Linezolid

Qunupristin/Dalfopistin

Tigecycline

Risk factors for ESBL, AmpC or MDR?

What empiric antibiotics would you choose at this time?

A. Ceftazidime

B. Pipercillin/tazobactam

C. Imipenem

D. Tigecycline

E. Ciprofloxicin

Blood Culture

Urine Culture

Antibiotic Course

Pip/Taz

Vancomycin

Meroppenem

Vancomycin

Fluconazole

Pip/Taz

Vancomycin

February 25, 2010

• Wound dehiscence

• Surgically reduced

• Complicated with intra-abdominal bleed which was surgically and medically controlled

19/2/2010

March 1, 2010

• Distended abdomen

• Decreased bowel sounds

• Fever

• WBC 2.5

• Abdominal fluids: >1200 WBC, 85%PMN’s

Which of the following organisms is least likely in this situation?

A. Bacteroides fragilis

B. Pseudomonas aerugniosa

C. Proteus mirabilis

D. Candida albicans

E. Enterococcus

Which of the following resistant mechanism is likely in this situation?

A. ESBL

B. AmpC

C. KPC

D. Capabemases

E. Any of the above

What empiric antibiotics would you choose at this time?

A. Tigecycline + anidulafungin

B. Colistin + anidulafungin

C. Meropinem + anidulafungin

D. Colistin+ Ceftazidime + anidulafungin

E. Piperacillin/tazobactam + anidulafungin

Tertiary Peritonitis(Antibiotic Selection)

MDR Pseudomonas

Meropenem

Doripenem

Imipenm

Colistin

Cefepime

Ceftobiprole

Aztreonam

Ciprofloxacin

± aminoglycoside

Candida

Ampho B

Anidulafungin

Caspofungin

Micafungin

Fluconazole

Voriconazole

Enterococcus

Ampicillin

Vancomycin

Ticoplanin

Telavancin

±Aminoglycosides

Daptomycin

Linezolid

Qunupristin/Dalfopistin

Tigecycline

Risk factors for ESBL, AmpC or MDR?

March 1, 2010

Antibiotic Course

Pip/Taz

Vancomycin

Meroppenem

Vancomycin

Fluconazole

Pip/Taz

Vancomycin

Meropenem

Colistin

Caspofungin

Vancomycin

March 13, 2010

• Tertiary peritonitis

• Not responding

• Bacteremia

Peritoneal FluidMarch 13, 2010

March 13, 2010

Antibiotic Course

Pip/Taz

Vancomycin

Meroppenem

Vancomycin

Fluconazole

Pip/Taz

Vancomycin

Meropenem

Colistin

Caspofungin

Amikacin

Tigecycline

Findings

Quite large amounts of pleural effusion seen on the right side with adjacent atelectasis and spread opacifications seen in the visualized lower part of the lung. The amount of pleural effusion on the right side is essentially unchanged compared to previous examination dated February 6, 2010. On the left side, the pleural effusion seen previously has resolved and there is now atelectasis seen in the lower part of the left lung.

No free air intraabdominally. Nasogastric tube with its tip in the duodenum. Double abdominal drains, one on each side. There are dilated bowel loops, both small and large bowel, but there is gas seen all the way to the rectum. There is some free fluid intraabdominally with variable attenuation. No certain collection though. The variability of the free fluid density is of uncertain cause, contrast leak? though no free air. Blood/clotted blood? Kidney transplants seen to the left and right in the pelvis. Splenomegaly. Previous examination revealed extensive wall thickening of both small and large bowel. Today, there is remaining wall thickness of small bowel loops.

March 21, 2010

• Right pleural effusion

Persistent BacteremiaMarch 23-April 23

Blood Body Fluid

MDR Pseudomonas

What persistent pseudomonas bacteremia indicate?

A. Persistent intra-abdominal infection

B. Persistent pneumonia

C. Catheter related blood stream infection

D. Enterovesicular fistula

E. Endocarditis

April 17, 2010

• Fever

• Increasing FiO2

What Organisms?

Stenotrophomonas maltophilia Flavobacterium

Pseudomonas aeruginosa

April 17, 2010

What antibiotics would you add?

A. Bactrim

B. Doxyclycline

C. Tigecycline

D. Imipenem

E. Chramphenicole