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Cases 2012

Cases 2012. Valerie Creswell, MD July 12, 2012. Case. A 75 yo wm with a history of severe COPD and frequent acute bronchitis presents with diarrhea. The next step A. Inquire about antibiotic use B. Send stool for Clostridium difficile toxin

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Cases 2012

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  1. Cases 2012 Valerie Creswell, MD July 12, 2012

  2. Case A 75 yo wm with a history of severe COPD and frequent acute bronchitis presents with diarrhea. The next step A. Inquire about antibiotic use B. Send stool for Clostridium difficile toxin C. Send stool for Clostridium difficile toxin times 3 D. Consider empiric metronidazole

  3. Treatment of C. dif If on antibiotics and if possible, stop the antibiotics-25% of patients will respond without further therapy. Treatment oral therapy with metronidazole 500m g q 8 hrs Meantime for diarrhea to stop;~2-4 days Treat for 10 days Treat ~ 7 days before declaring drug failure if patient is stable Avoid peristaltic agents Do not perform a test of cure-i.e. repeat stool for C. dif toxin Dale Gerding Loyola Univ. SHEA 2005

  4. Recurrences In pts with 1 recurrence-45% chance of additional recurrences Treatment 1. Vanco regimens 2. Biotherapeutics 3. passive treatment with immunoglobulins 4. toxin binding agents 5. fecal reconstitution

  5. Acid Suppression Studies indicate 900 low risk patients need to be treated to prevent one ulcer One-third of low risk patients receive acid suppression during hospitalization 50% of low risk patients are discharged with prescriptions for acid suppression 1. DeVault KR, Castell DO. Am J Gastroentrol 2005;100:190-200. 2. Heidelbaugh JJ, Inadomi JM. Am J Gastroenterol 2006;107:1-6. 3. Mostafa G, Sing RF, Matthews BD, Pratt BL, Norton HF, Heniford BT. Am Surg 2002;68:146-150. 4. Nardino RJ, Vender RJ, Herbert PN. Am J Gastroenterol 2000;95:3118-3122. 5. Naunton M, Peterson GM, Bleasel MD. J Clin Pharm Ther 2000;25:333-340. 6. Pham CoQD, Regal RE, Bostwick TR, Knauf KS. Ann Pharmacother 2006;40:1261-1266. 7. Pham CoQD, Sadowski-Hayes LM, Regal RE. P&T 2006;31:159-167. 8. Yang Y, Lewis JD, Epstein S, Metz DC. JAMA 2006;296:2947-2953.

  6. Complications of Acid Suppression Infection: C. difficile, MSSA, MRSA, VRE, community acquired pneumonia Drug-drug interactions Drug-nutrient interactions Increased costs 1. DeVault KR, Castell DO. Am J Gastroentrol 2005;100:190-200. 2. Heidelbaugh JJ, Inadomi JM. Am J Gastroenterol 2006;107:1-6. 3. Mostafa G, Sing RF, Matthews BD, Pratt BL, Norton HF, Heniford BT. Am Surg 2002;68:146-150. 4. Nardino RJ, Vender RJ, Herbert PN. Am J Gastroenterol 2000;95:3118-3122. 5. Naunton M, Peterson GM, Bleasel MD. J Clin Pharm Ther 2000;25:333-340. 6. Pham CoQD, Regal RE, Bostwick TR, Knauf KS. Ann Pharmacother 2006;40:1261-1266. 7. Pham CoQD, Sadowski-Hayes LM, Regal RE. P&T 2006;31:159-167. 8. Yang Y, Lewis JD, Epstein S, Metz DC. JAMA 2006;296:2947-2953.

  7. Vancomycin is the perfect antibiotic because resistance has never developed and it never will. Anonymous ID physician 1985

  8. I used to be Snow White but I drifted. Mae West

  9. 24 yo wm with LLE cellulitis who weighs 300 lbs with a Cr 0.5. Your initial vanco dose would be: Vanco 1 gm IV q 12 hrs Vanco 1.5 gm q 8 hrs Vanco load 3 gm IV then 1.5 q 8 hrs

  10. Active surveillance includes swabbing the nares for MRSA. If positive, you should Give Vanco IV q 12 hours for 1 week Place in droplet precautions If scheduled for surgery, give Cefazolin preop If scheduled for surgery, treat with mupirocin intranasally bid for 5 days and a chlorhexidine shower the night before

  11. Who to screen? ICU admissions Transfers from other hospitals or care facilities, prisons Surgical patients-esp. cardiovascular, prosthetic joint surgeries Dialysis patients Other high risk patients-antibiotic use in last 3 months, hospitalization in last 12 months, skin or soft tissue infection, HIV Not patients already identified with MRSA

  12. Decolonization Mupirocinintranasally bid for 5 days Chlorhexidine showers daily for 7 days then 3 times a week for several weeks If pt has a history of MRSA, then Vanco 1 gm IV given over an hour as preop antibiotic Must document a reason for using vancomycin for surgical prophylaxis

  13. Treatment of Choice for MSSA A. Vancomycin B. Clindamycin C. Azithromycin D. Nafcillin

  14. Staphylococcus aureus Treatment If susceptible, Nafcillin is indicated In pts with true penicillin allergy, Cefazolin is an acceptable alternative In vitro data suggest that vancomycin is a less effective antistaphyloccal drug than the beta-lactams Lowy NEJM Aug 20,1998 520-32

  15. Nafcillin dosing A. 2 gm IV q 6 hrs B. Continuous infusion 8 gm IV daily C. Bolus with 2 gm IV then 8 gm daily

  16. Nafcillin Time > MIC 2 gm q4h 8 gm CI

  17. 6 steps to Improve antibiotic therapy in the ICU 1. Fever should not mean automatic antibiotics 2. Cultures should be obtained before starting antibiotics 3. Single drug and the most narrow spectrum should be used when possible. 4. Reassess need for antibiotics daily 5. Antibiotic surveillance should be limited to 24 hours or less Maki Crit Care Med: Principles of Diagnosis and Management, 1995 pp 893-954

  18. Pt has temp to 100.5 UA shows 5-10 wbcs and it grows 10,000 cfu Candida glabrata A. Start Amphotericin B B. Start Micafungin C. Start fluconazoloe D. Remove the foley

  19. Asymptomatic Bacteruria During catheterization or within 48 hrs of cath removal if a pt has a positive culture with >100,000 cfu/ml of an organism with no symptoms or symptoms related to other infectious process Document in the chart

  20. 18 yo college student is admitted with confusion and fever. CSF gram stain shows gram negative diplococci A. Place pt in droplet precautions until he’s completed 7 days of treatment B. Use meningitis order set C. Inquire about his pneumococcal vaccination status D. Immediately take one dose of Cipro because you examined the pt

  21. A. Place pt in droplet precautions until he’s completed 7 days of treatment B. Use meningitis order set C. Inquire about his pneumococcal vaccination status D. Immediately take one dose of Cipro because you examined the pt

  22. Infection Control-Precautions Contact Resistant organisms-MRSA, Clostridium difficile(wash your hands with soap and water) Droplet SuspectedNeisseriameningitidis or Hemophilus influenza meningitis-for 24 hours from the first dose of appropriate antibiotics Influenza, pertussis etc. Airborne Suspected Tuberculosis-keep the door closed!

  23. Ciprofloxacin A. Can cause seizures B. Binds with Calcium, Magnesium, Iron and tube feeding C. Can select out for VRE D. Can select out carbepenam resistance in Pseudomonas aeruginosa

  24. A blood culture with this organism growing is generally a contaminant: A. Enterobacter cloacae B. Staphylococcus aureus C. Staphylococcus epidermidis D. Candida albicans

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