my approach to infectious disease cases · pdf fileobjectives • review common infecous...
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MYAPPROACHTOINFECTIOUSDISEASECASES
KarenBrust,MDJanuary,2013
DISCLOSURES
• NONE
OBJECTIVES
• ReviewcommoninfecKousdiseasecases• SuggestappropriateuseofanKbioKcsforspecificinfecKousprocess
• ReviewalternaKveanKbioKcchoicesinlightofpaKents’allergiesorotherfactors
CASE#1• 83y/oWMw/hxofhtn,dyslipidemia,BPH,andGERDadmiZedtothehospitalw/a7dayhxoffeversover101,poororalintake,persistentn/v.Discharged3daysagoa^era3daystayforsimilarsymptomsaswellasabdominalpainanddiarrhea.WorkupduringthathospitalizaKontoincludeNPswabforviralPCRandAbdominalCTwerenegaKve.Hewasd/c’doffabxandw/adxof“viralsyndrome”.
• 2daysa^eradmissionhebecomeslethargic,less&lessresponsiveandtachypneic.TransferredtoMICU
CASE#1• NKDA• CURRENTABX:Vancomycin,Ampicillin,Ce^riaxone,andAcyclovir
• PE:Tc98.2Tm101.5HR90‐110sBP150‐180s/60‐80sRR30O2100%onbipap
• Examunrevealingw/excepKonofunresponsiveness,tachycardiaandlackofrash
• PerKnentData:WBC22K,87%N,lactate2,AST245,ALT168,Creat1.21,URINE/BLOODCXnegaKve
• CSFanalysis:WBC259,55%N,36%L,8%M,elevatedprotein167.5(15‐60mg/dL),glucosenlat77,GSTneg,culturepending
CASE#1
• Thenextstepinmanagementis• A.ConKnuealltheanKbioKcsunKlculturescomeback(vanc,ampicillin,acyclovir,ce^riaxone)
• B.ConKnueonlyampicillin• C.ConKnueonlyacyclovir• D.ConKnueampicillinandacyclovir• E.DisconKnuealltheanKbioKcs
CASE#1
• Thenextstepinmanagementis• A.ConKnuealltheanKbioKcsunKlculturescomeback(vanc,ampicillin,acyclovir,ce^riaxone)
• B.ConKnueonlyampicillin• C.ConKnueonlyacyclovir• D.ConKnueampicillinandacyclovir• E.DisconKnuealltheanKbioKcs
MENINGITIS
• CLINICALSYMPTOMS– Headache– Fever– NecksKffness– Alteredmentalstatus
‐ ONLY44%willpresentw/allofthe1st3symptoms,but
‐ ALMOSTALLwillpresentw/2ofthese4symptoms
MENINGITIS
• DIAGNOSISrequiresaCSFpleocytosis&highproteinintherightclinicalseong
• DIFFERENTIALDIAGNOSISEXTENSIVE
MENINGITISANDENCEPHALITISABNORMALCSF…toomanycells&protein
• INFECTIOUSCAUSES:
– BACTERIAL• Mycoplasma,ureaplasma,legionella,chlamydia,Mycobacterial,Spirochetes(treponema,borrelia,leptospira),RickeZsia,Erlichia,Bartonella,nocardia,acKnomyces,brucella,listeria,CNSabscess,parameningealfociofinfecKon,parKallytreatedinfecKon
– FUNGAL• Blastomyces,histo,coccidioides,aspergillus,sprothrix,zygomycetes,
– PROTOZOAL/PARASITIC• Toxoplasmosis,taeniasolium,echinococcus,strongyloides,schistosoma,acnthamoeba,naeglaria,entamoebahistolyKca,trypanosoma,plasmodium
– VIRAL• Enteroviruses(60‐90%),ARBOviraldiseases(2ndmostcommon),HSV(10%),VZV,JapaneseB,measles,rabies
MENINGITISANDENCEPHALITISABNORMALCSF…toomanycells&protein
• POST‐INFECTOUSCAUSES– Guillain‐barresyndrome– BrainstemencephaliKs– Viralsyndrome(VZV,measles,influenza,parainfluenza,RSV,evenrhinovirus)
• NON‐INFECTIOUSCAUSES– DRUG‐INDUCED:sulfa,NSAIDs,IVIG– RHEUMATOLOGICDZ:SLE,sarcoid,Bechet’s,vasculiKdes– TUMORS/MASSES:anybraintumor,CNSlymphoma,AVMs– POISONS/TOXINS:lead,mercury,arsenic– DEMYELINATINGDZ:MS,adrenalleukodystrophy– TRAUMA/VASCULARINSULT:CVAorsubarachnoidhemorrhage
ENCEPHALITIS• DEFINITIONperIDSAguidelines:“presenceofaninflammatoryprocessinthebraininassociaKonwithclinicalevidenceofneurologicdysfuncKon”
• CLUESTODIFFERENTIATEFROMMENINGITIS– SameasmeningiKs:fever,h/a– Different:disorientaKon,behavioral/speechdisturbances,andotherneurologicsigns(CNpalsies,seizures,hemiparesis)
• Theterm“MENINGOENCEPHALITIS”existsforareason
MENINGITIS
• CSFFLUIDANALYSIS– 1ST:Istheretoomanycells?– 2nd:IsthissepKcorasepKcmeningiKs?– 3rd:WhatanKbioKcsshouldIstart?OURPATIENT:WBC259,55%N,36%L,8%M,elevatedprotein167.5(15‐60mg/dL),glucosenlat77,GSTneg,culturependingASEPTICMENINGITIS
MENINGITISTREATMENT
• SEPTIC(bacterial)– BroadspectrumempiricanKbioKcsunKlpathogencultured(Vancomycin,Ce^riaxone,+/‐Ampicillin)
• ASEPTIC(viralvsnon‐infecKous)– OnlyavailableanKviral=acyclovir/valacyclovir– D/ConcePCRtesKngforHSVandVZVnegaKve
OURPATIENT
• DiagnosedwithWestNileEncephaliKs
• MORECASES…
MENINGITIS• 58y/oWFw/MMP(cerebrovasculardemenKa,chronichepC,chronichepB,etc)admiZedw/“sepsis”andAMS
• CSF:CLARITY‐CLEAR• RBCCOUNT23• WBCCOUNT4• SEGNEUTROPHILS%31(H0‐7%)• LYMP%67(40‐80%)• MONO%2(L15‐45%)• GLUCOSE,CSF72(50‐80mg/dL)• PROTEIN,CSF19.1(15.0‐60.0mg/dL)• MENINGITISORNOMENINGITIS?
MENINGITIS• 30yoWFw/outsignificantPMHpresentstoEDw/infirst
24hofsevereh/a,necksKffness,n/v,photophobia.Recentlyrecuperatedfrominfluenzaabout2weeksprior
• CSF‐COLORLESS• RBCCOUNT3/mm3• WBCCOUNT261(H0‐5/mm3)• SEGNEUTROPHILS%8(H0‐7%)• LYMP%80(40‐80%)• MONO%11L(15‐45%)• EOS%1%• GLUCOSE,CSF46(L50‐80mg/dL)• PROTEIN,CSF133.4(H15.0‐60.0mg/dL)• MENINGITISORNOMENINGITIS?ASEPTICORSEPTIC?
MENINGITIS• 56y/oAAFs/psplenectomyadmiZedw/sepKcshock,AKI,
respiratoryfailurew/a3dayhistoryofrigorsandmentalstatuschanges
• Treatedforpneumococcalpneumoniaandbacteremiaw/Vanc/CTX;a^er9daysonthevenKlatorandoffsedaKonsheremainsunresponsive
• CSFCOLOR‐STRAWAB• RBCCOUNT4/mm3• WBCCOUNT47(H0‐5/mm3)• SEGNEUTROPHILS%6(0‐7%)• LYMP%70(40‐80%)• MONO%14L(15‐45%)• MENINGITISORNOMENINGITIS?ASEPTICORSEPTIC?
CASE#2HISTORYOFPRESENTILLNESS:• 51‐year‐oldwhitemalewithuncontrolleddiabetes(HgA1C15.5)and
tobaccoabuse;admiZedfortreatmentofdiabeKcfootinfecKon• 3wkhxofle^lateral“wart”that2weeksago“poppedanddrained”;
overlastweekhisarchturnedblackish‐purpleandthedrainagebecamefoul‐smelling;1dayPTAhehadsubjecKvefeverandrigors
ALLERGIES:PCN,whichcausesanaphylaxis.OccurredasachildandheremembersthehospitalizaKonINPATIENTANTIBIOTICS:Include1.IVvancomycin.2.IVCipro.3.IVflagyl
CASE#2PHYSICALEXAM:
‐Notableforabandagedfoot,‐2/6SEMbestatRUSB,‐splinterhemorrhagesofrighthandandrightconjuncKvalhemorrhage
DATA:Bloodcx2/2(+)forsteptococcusspecies,non‐viableforsuscepKbiliKesAnd,asusual…polymicrobialswabofdrainingwoundcollectedinER:
(1)sensiKvee. coli (2)sensiKvep. vulgaris (3)sensiKves. aureus (4)corynebacterium (5)anaerobes(prevotella)
CASE#2OPERATIVECULTURES
CASE#2
• ANTIBIOTICCHOICE?• A.AskmorequesKonsw/respecttohisallergyhistory,thentryPCN
• B.TrialdoseofCe^riaxoneasaninpaKentw/monitoringforsymptoms
• C.ConKnuetreatmentwithVancomycin,cipro,andFlagyl
• D.TrialdoseofErtapenemasaninpaKentw/monitoringforsymptoms
CASE#2
• ANTIBIOTICCHOICE?• A.AskmorequesKonsw/respecttohisallergyhistory,thentryPCN
• B.TrialdoseofCe^riaxoneasaninpaKentw/monitoringforsymptoms
• C.ConKnuetreatmentwithVancomycin,cipro,andFlagyl
• D.TrialdoseofErtapenemasaninpaKentw/monitoringforsymptoms
CASE#2
• Firstandforemost,aZemptacorrectassessment:immunosuppressedmalew/DMfootinfecKonandbacteremiawithdisseminaKonandAorKcValveInfecKveendocardiKs
• ChoiceofanKbioKcandlengthoftherapywillfallintoplace
DEFINITIONofBACTEREMIA
*Viableorganismsculturedfromblood
Red (+) BCx & Green (-) BCx Seifert, CID 2009; 28:S238-45
GENERALINFO
ALLBSIareclinicallyrelevant Common“contaminants” Bacillusspecies,notanthracis CoagulasenegaKvestaph Corynebacteriumspecies Propionibacterium
Whentobeconcernedabout“contaminants”? repeatedlyposiKvebloodcultures bloodculturesthatmatchothercultures
THEIDAPPROACH
BACTEREMIA
WHERE DID IT COME FROM?
WHERE DID IT GO?
HOW SHOULD I TREAT?
EMPHASIS ON HISTORY
EMPHASIS ON REVIEW OF SYSTEMS
PT FACTORS? CHOICE OF ABX?
DURATION?
WHEREdiditcomeFROM?
• Pathogenusuallyleadsyoutosource• UsualculpritsforS. aureus:
– Skin/so^KssueinfecKon/injury– IVcatheters– Intravasculardevices– So^‐KssueinfecKons– Pneumonia(espinfaceofmechvenKlaKon)– Recentprocedures
CANDIDA
ENTEROCOCCUSorSTREPBOVIS
STREPMILLERI
WHEREDIDITGO?DISSEMINATION
• Organism‐dependent– GPC/Candida>>>GNR– THEBIGTHREE:Candidemia,EnterococcalBacteremia,StaphylococcusBacteremia
• Host‐dependent– Immunosuppressedstatew/delayedclearance– ProstheKcmaterialinplace– AdvancedageandarthriKs
DISSEMINATION
FREQUENTSITESOFSPREAD?&DIAGNOSIS?
– Heartvalves‐TEE– Bone&joints–MRI(vsorthoevalfortap)– Intervertebraldiscs–MRI– Kidneys–CTscan– Spleen–CTscan
Who’satriskforcomplicatedbacteremia?
• Only4variablesweresignificanta^erstaKsKcalanalysis:– Community‐acquired– ProstheKcdevice– Advancedage– Ptonasurgservice– Skinfindings– Feverat72h– Persistentbacteremia
Fowler, Vance. Clinical identifiers of complicated staphylococcus aureus bacteremia. Arch Int Med 2003; 163: 2066-2072.
DISSEMINATION‐Candida
• HEART– InfecKveEndocardiKs– 4%riskofseeding
• EYES– EndophthalmiKs– 5%riskofseeding
• ImportanttoidenKfyinordertotreatappropriately
Horn, CID ’09; 48: 1695-703.
DISSEMINATION‐Enterococcus
• INCIDENCE– 2.3episodesofbacteremia/1000d/c’s
• MORTALITY– Crude30daymortality23%
• RISKofendocardiKs– HigherifBSIiscommunity‐acquired – HigherifprostheKcordamagedvalve– HigherinIVDU
Patterson, Makki, Caballero-Granado.
DISSEMINATION‐Staph
S.aureus,ingeneral=mcpathogenIE Right‐sidedIEinIVDUandle^fornon‐IVDU OverallesKmatedriskofinfecKveendocardiKs(IE)in
faceofs. aureusbacteremia(SAB)=25% TEEhasagreateradvantageoverTTEinidenKfying
cases CasesingeneralbutspecificadvantageintermsofcomplicatedIE(abscess,perforaKon)
ENDOCARDITIS–TEEvsTTE
• Sept1994–Jan1996,prospecKvestudy• 103paKents,followedfor12wkspost1stposiKvebloodcxwiths. aureus
• PtshadbothTTE&TEEdone• Resultscategorizedas(+)forIE,(‐),orindeterminant
Fowler, Vance. Role of echocardiography in evaluation of patients with staph aureus bacteremia: experience in 103 patients. JACC 1997; 30: 1072-8
DISSEMINATION‐Staph
• TEEDATA:
Fowler, JACC 1997; 30: 1072-8
Of all SAB, 25% picked up
Of the negative TTE, 20%
HOWSHOULDITREAT?MANAGEMENT
• Definethescenario– Immunosuppressedornot?– Organism?– Source?– DisseminaKon?
• 40y/opreviouslyhealthyfemalew/MSSAbacteremiasecondarytoPICClineinfecKonwithoutmetastaKcdz,vs
• 67y/oneutropenicfemales/pinducKonchemow/candidemiaandaorKcvalveendocardiKs
MANAGEMENT–byorganismCandida
• Startempirictherapywithanechinocandin(micafungin,caspofungin,anidulafungin)
• Narrowcoveragea^ersuscepKbiliKesreturn• IfcandidaspeciesisfluconazolesuscepKble,thenoralabxtherapyisanopKon
• EveryonegetsaTEE&aneyeexam
MANAGEMENT–byorganismEnterococcus
Startempirictherapywithvancomycin Narroworexpandcoveragea^ersuscepKbiliKesreturn IfvancsensiKve:guidancebysuscepKbilitypaZern IfVRE:daptomycinpreferredoverlinezolid
EveryonegetsaTEE Butcandebateifclearlynosocomial
MANAGEMENT–byorganismMSSAorMRSA
• Startempirictherapywithvancomycin• Narrowcoveragea^ersuscepKbiliKesreturn– IfMSSA:preferred=ce^riaxoneorcefazolinornafcillin
– IfMRSA,VancMICof>2:daptomycin• Specialcircumstances
– IfPCNallergic:vanc– IfwaxingandwaningGFR:dapto
SPECIFICTREATMENTOPTIONSFORMRSABACTEREMIA?
• Vancomycin15‐20mg/kgivq12h• Daptomycin6‐10mg/kgivq24h• Ce^aroline600mgivq12h‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐• Linezolid600mgivq12h• Bactrim10‐15mg/kg/daydividedq12h• Clindamycin600‐900mgivq6‐8h• QuinprisKn/DalfoprisKn7.5mg/kgivq12h
MANAGEMENT–BYDIAGNOSIS
**Source?DisseminaKon?Hostfactors? CentrallineassociatedbloodstreaminfecKon(CLABSI)
Secondarybacteremiaw/outmetdz(sourceclearlydefined)
Primarybacteremiaw/outmetastaKcdz(nosourceevident) Immunosuppressed Non‐immunosuppressed
InfecKveendocardiKsorequivalent
* In order of treatment difficulty
MANAGEMENT–CLABSI
Generalprinciples Makeanaccuratediagnosis
▪ growthof>15colony‐formingunits(cfu)froma5‐cmsegmentofthecatheterKpbysemiquanKtaKve(roll‐plate)culture
▪ BCxfromcathKpmatchesperipheralBCxandthecatheter‐obtainedbloodculture“goesposiKve”2hoursbeforethebloodcultureobtainedperipherally;
“DifferenKalKmetoposiKvity”
Removefocusifpossible StartVancomycinempirically
MANAGEMENT–CLABSI
• Mystandardapproach:– SuspectaCLABSI?(MatchingBCx(+)fromPICCandBCx(+)fromperiphery)
– PullPICC&cultureKp– Establishperipheraliv– Thenext3followingdays,obtainBCx– Startyour2weeksoftherapyfromthe1stsetofnegaKvecultures
MANAGEMENT–CLABSI
*CNS is only pathogen where “saving” the catheter is possible
*Staph & candida, it is never possible
IDSA guidelines, 2009
MANAGEMENTSecondarybacteremiaw/outmetdz
• Ingeneral,2‐4weeks• Easily“killed”bugs,shortercourse
– Streppneumoniaepneumoniaandbacteremia–2weeks
• Notsoeasily“killed”,longercourse– StaphBSI–usually4weeks(especiallyifpthighriskofmetastaKcdz…likeprostheKcvalve)
MANAGEMENT–Primarybacteremiaw/outmetastaKcdz
• Ingeneral,4weeks• Immunosuppressed:4wksminimum• Immunocompetent:youcandebate
MANAGEMENT‐InfecKveendocardiKsorequivalent
Ingeneral,6weeks(butdependentonbug) CardiothoracicsurgeryconsultaKon Whentoconsult?
Removematerialwhenpossible(Vascsx)
CASE#2–OURPATIENT• Moredata:TEEposiKveforAoVvegetaKon• RememberPCNallergy?HeadmiZedtotakingKeflexw/
outissue
• Correctassessment:immunosuppressedmalew/DMfootinfecKonandbacteremiawithAorKcValveInfecKveendocardiKs
• Plan?ErtapenemfortreatmentofpolymicrobialdiabeKcfootinfecKonfor2weeksthenfinishthefourweekcourseofAoIE2/2strepw/Ce^riaxone
INSUMMARY
AlwayspayaZenKontoculturedorganisms,even“contaminants”
Findthesource;whenfound,canthesourceberemoved?Don’tforgetyoursurgicalcolleagues
Erronthesideoflongertreatment Don’tunderesKmatethepowerofMRSA GetaTEEforMRSABSI…remember25%resultinIE
Whenindoubt,callanIDspecialist Useresources:www.idsociety.org
CASE#3
• 51y/oWMw/etohiccirrhosis,chronicvenousstasisisadmiZedtoMICUb/c“founddown”
• PE:95.65888/4792%RA,altered,bruiseandlacacrossbridgeofnose,mulKpleotherbruises,lacle^2ndtoe,2/6SEMbestatapex
• BCX2/2(+)forMRSA• HowquicklydidthesegoposiKve?11.8hours• HowquicklydidheclearhisBSI?w/in24hours• What’stheVancomycinMIC?One
CASE#4• 50y/oWMw/DMandtriple‐pathy,poorlycontrolledw/chroniculcerle^foot,lastdebrided5daysPTA;admiZedw/CPandfoundtohavenewonsetafibRVRandNSTEMI
• Le^legcelluliKcw/a1dayhxofpain,redness,swelling(samelegaschroniculcer)
• Bloodcx(+)groupBstrep(agalacKae)• ALLERGIES:sulfa=rash• CURRENTABX:Vanc/zosyn• Exam:VSS,o/wnothingoutoftheordinary
CASE#4
• Doesthepathogeninthebloodmakesensew/theclinicalscenario?
• AmIconcernedaboutdisseminaKonelsewhere?
• TreatmentchoicesandduraKon?
CASE#5
• 64y/omorbidlyobeseWM(BMI69)w/chronicvenousstasischangesofbilaterallowerextremiKespresentsw/a1dayhxofale^hot,swollen,tender,moreerythematousthanusualle^leg.Nof/c/n/v/d.Noinjuries,openwounds,recentmanipulaKons.
• PMH:CAD,OSA,DM(HgA1C7),etc.etc.• Exam:typicalskinchangesbilatbutclearlyinfectedLLEw/extensionalmosttogroin
• BCx1/2groupGstrep,PCN0.03
CASE#5• IsthisreallycelluliKs?
– Or,vasculopathylikelimbischemia?– Or,acutearthropathylikeCharcot,sepKcankle,goutyankle,etc?
– Or,localirritaKononly?• Whatpredisposedthisperson?• DoItreatw/anK‐staphylococcaloranK‐streptococcalanKbioKcs?
• OpKonsavailabeforPCNallergicpaKent?• IsthispreventablebybehavioralchangeorisprophylacKcanKbioKcneeded?
ACUTECHARCOTJOINT
ACUTEGOUTYATTACK
TAKEHOMEPOINTS
• INanycase,determinewhethertheclinicalscenariomakessense(ecoliUTIw/ecolibacteremiamakessense…proteussepsisw/negaKveurineculturedoesn’tmakesense)
• MAKEanefforttofindthesource(ifnot,paKentmayrepeatedlysuffer)
• TREATwiththemosteffecKveandnarrowestanKbioKcforthegerm
• ERRonthesideoflongerthanshortertherapy