CAP/HAP
A standard test when evaluating a moderate to severely patient with suspected pneumonia.
What is a CXR?
Prevalence of Cipro resistant E. coli among inpatient isolates at CHA in 2018.
What is 20%?
It was worse in 2017 (32%).
Conditions where treatment of asymptomatic bacteriuria is indicated.
What is pregnancy and patients scheduled for GU surgery associated with mucosal bleeding.
Recommended empiric therapy for community-acquired diverticulitis or appendicitis at CHA?
What is ceftriaxone and metronidazole?
A 32 yo previously healthy male presents to the ED with fever, altered mental status, and meningismus. An LP reveal 800 WBCS (97% PMNs), glucose 30, and a protein 500. The Gram stain is pending. What is the best empiric therapy?
What is:
Ceftriaxone 2 g IV q 12 hrs PLUS
Vancomycin per pharmacist protocol
PLUS Dexamethasone 10 mg IV q 6h (give before antibiotics)
WITH or WITHOUT
Ampicillin 2 g IV q 4 hrs (>50 years or immunocompromised)
In the Epic study (NEJM 2015), diagnostic results for both bacteria and viruses were available for 2259 adults (97%) with radiographic evidence of pneumonia. A viral or bacterial pathogen was detected in a minority. (20-30%, 31-40%, 41-50%, 51-60%)
What is 38%?
Answer is 31-40%. No pathogen was detected in 62%.
In an afebrile patient without an indwelling catheter, what symptoms should be present before ordering urine testing?
What are two of the following ssymptoms:
Gross hematuria
Incontinence (new or increased)
Urgency
Suprapubic pain
CVA tenderness
Frequency
The negative predictive value of pyuria for a UTI (75-80%, 81-85%, 86-90%, 91-96%).
What is 91-96% (96%)?
Major pathogens for diverticulitis and appendicitis.
What are enteric Gram negatives (Enterobacteriaceae*) and anarerobes**?
*E. coli, K. pneumoniae, Proteus spp, Enterobacter
Treatment for enterococcus is not typically needed, unless critically ill
**Anaerobes (B. fragilis, Prevotella, Peptostreptococcus).
A 34 yo toxic appearing female presents to the ED with fever, headache, nausea, vomiting, diarrhea, and a maculopapular rash. She is confused. A friend reports she recently returned from Oklahoma for a college roommate's bachelorette party. She is tachypneic, tachycardic, and her BP is 89/56. Among her empiric antibiotic therapy pending an LP, a specific antibiotic must be administered soon.
What is doxycycline 100 mg IV bid?
Describe the components of CURB-65.
What is:
Confusion
Uremia (> 20 mg/dl)
Respiratory rate (> 30)
Low Blood pressure (< 90/60)
Age 65 yr or greater
The absence of pyuria is a strong indicator that a UTI does not exist; it is very helpful in excluding a UTI and is the basis for the UA with reflex to culture. What criteria is used at CHA to reflex to a urine culture?
What is greater than 10 WBCs?
The positive predictive value of pyuria for a UTI (< 15%, 15-30%, 31-46%, 47-60%, > 60%).
What is 31-46%?
Hence, careful assessment of symptoms is imperative, as indiscriminate orders for a UA with reflex can be associated with a high false positive result.
Pathogens for cholecystitis.
What are enteric Gram negatives?
Treatment for enterococcus is not typically needed, unless critically ill.
Anaerobes (B. fragilis, Prevotella, Peptostreptococcus) are rare in community-acquired, uncomplicated cases.
Hence, piperacillin-tazobactam 3.375 gm IV q6h (normal renal function) should generally be reserved for critically ill patients, those with a healthcare-associated infection, or recent biliary tract manipulation or stent placement.
A 45 yo male with a prior splenectomy presents to the ED in August with fever, headache, and myalgias. He returned from Martha's Vineyard a week ago. His T is 102, P 110, BP 105/65. WBC 6, H/H 11/32, PLT 130, Tbili 2.2, direct 1.1, AST 92, ALT 99. The lab tech calls you because there are intraerythrocytic parasities on his peripheral smear. This patient requires treatment.
What is atovaquone and azithromycin?
or
Clindamycin and quinine if severely ill.
Best empiric therapy for CAP when a patient is admitted to the medical unit at CHA?
What is ceftriaxone and azithromycin?
The best empiric therapy for a patient with urosepsis and a Epic banner flag denoting ESBL.
What is a carbapenem (ertapenem, meropenem)?
The best standalone symptom supporting a UTI.
What is dysuria?
The STOP trial demonstrated that patients with complicated IAI and source control benefit from short course antibiotic therapy (3, 4, 5, or 7 days)
What is 4 days?
61 yo ♀ with DM presented with a 10 hr hx of R foot pain (no trauma)
VSS
WBC 23.2
CRP 149
BS 379
Within 1 hr, gas-filled hemorrhagic blisters developed on the dorsum of his right foot. MRI imaging revealed necrotizing fasciitis. He requires prompt surgical intervention and broad-spectrum antibiotics.
What is meropenem or piperaciliin-tazobactam plus vancomycin plus clindamycin.
What is the empiric treatment regimen for a CHA patient being admitted to the ICU with HAP?
What is cefepime and vancomycin?
Hospital-acquired pneumonia: pneumonia not incubating at the time of admission and occurring >48 hours after admission. Consider MRSA coverage if ICU (high risk for mortality) or IV antibiotics within previous 90 days. Limit duration to 7 days in most cases.
Treatment of CAP, HAP, VAP and nursing-home pneumonia differ. Refer to AST Team Recommendations by Disease State on Staffnet.
At CHA, what is the best empiric therapy for community-acquired pyelonephritis?
What is
Gentamicin 5 mg/kg IV q 24 hrs
WITH or WITHOUT
Ampicillin 2 g IV q 6 hrs?
What is nitrofurantoin 100 mg po bid for 5 days?
Recently, there has been a trend for treating selected, uncomplicated patients with appendicitis with medical therapy alone (true or false).
What is true?
When evaluating a septic patient, empiric therapy should be based on the most likely source for infection. to accomplish this quickly, describe the approach.
What is notable on the patient's history, exam and preliminary laboratory and imaging results?
See slide at the end of the presentation for items to consider.