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Prevention, Diagnosis, & Management of Hospital-Associated Infections IM R-1 Orientation

Prevention, Diagnosis, & Management of Hospital-Associated Infections IM R-1 Orientation. Paul Pottinger, MD, DTM&H June 27, 2013. Hospital-Associated Infections. OBJECTIVE Increase your confidence in preventing, diagnosing, treating HAI ’ s

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Prevention, Diagnosis, & Management of Hospital-Associated Infections IM R-1 Orientation

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  1. Prevention, Diagnosis, & Management of Hospital-Associated InfectionsIM R-1 Orientation Paul Pottinger, MD, DTM&H June 27, 2013

  2. Hospital-Associated Infections • OBJECTIVE • Increase your confidence in preventing, diagnosing, treating HAI’s • Understand your role in Antimicrobial Stewardship • FORMAT • Case-based & interactive • CONTENT • Common infections you will see PGY 1 • SLIDES • Available on the web

  3. Magnitude of the Problem • “Oh the Humanity!” • MDR Infections: • More Toxic Drugs Necessary • Longer Admissions • More Complications • Increased Morbidity • Increased Mortality

  4. Magnitude of the Problem • “Money… It’s a Drag” • Annual Cost of MDR Infections: $30B • Our Reality: • Fee for Performance (carrot) • Denial for Nosocomial Infections (stick)

  5. Antimicrobial Stewardship Ever heard this term? Come from a center with a program? “Our Drugs vs. Their Genes”

  6. Stewardship Goals Patient Care “The primary goal of antimicrobial stewardship is to optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms (such as Clostridiumdifficile), and the emergence of resistance.” Financial “Effective antimicrobial stewardship programs can be financially self-supporting and improve patient care. Comprehensive programs have consistently demonstrated a decrease in antimicrobial use (22%–36%), with annual savings of $200,000–$900,000 in both larger academic hospitals and smaller community hospitals.” Dellit TH et al. Clin Infect Dis. 2007;44:159-77.

  7. Patients

  8. Rupali Jain, PharmD UWMC Jeannie Chan, PharmD HMC

  9. Stewardship Resources • Stewardship Teams at UWMC & HMC • OCCAM (in your pocket, on your phone, online) • Service Pharmacists • ID Consult Service

  10. Case A 27 y/o man on the heme-onc service develops a fever to 40.2oC 6 days following initiation of induction chemo Rx for AML. A Hickman catheter is present in the R subclavian vein. No localizing sx’s on exam, Hickman entry site looks clean. Vitals fine. His WBC = 0.9, with an ANC = 100. Possible sources of fever? Increased risk of infection? What type? Diagnostic W/U? Empiric antibiotics?

  11. Case • Non-Infectious: Chemo, DVT / PE, CA • Infectious: CABSI, typhlitis, HAP, UTI • ANC < 500: Gram-Negatives > Staph • (fungal risk ↑ over time) • H&P! • CXR, U/A + micro, BCx x 2, sputum GS / C&S, ± Dopplers or CT-A, abd imaging Possible sources of fever? Increased risk of infection? What type? Diagnostic W/U? Empiric antibiotics? • Cover PsA with Ceftaz; Cover MRSA in sepsis, suspect CABSI, or if febrile in 3 days.

  12. Case • BCX x 2 drawn via Hickman: Both grow GPCs in clusters after 24 hours incubation Working Diagnosis Catheter-Associated Bloodstream Infection (CABSI)

  13. CABSI Confirm Diagnosis? • Look for alternative sources • Send quantitative BCx from line & peripheral CFU 2-3 X > peripheral Line Cx + > 2 hours sooner Likely Bugs • Coagulase-negative staph • MSSA or MRSA Line likely source

  14. CABSI Empiric Abx • Add Vancomycin until ID / sensitivities are back • Maintain Ceftazidime for PsA coverage until ANC > 500 Other Management • Central Lines: To Keep or Not to Keep?

  15. CABSI Line Management • Pull line if: • Patient is septic (once new access in) • Non-Tunneled Line (PICC) • Line is not needed or not working • Pocket or track infection proximal to the cuff • S.aureus, Pseudomonas, NTM, or fungus • Valvular heart disease • Still febrile after 48 hours of salvage attempt….

  16. CABSI Line Management • Salvage Strategy: Abx Lock Vanco + Heparin soak the lumen • Pros: • 50% success rate • Cons: • Lumen inaccessible during therapy • Risk of heparin bolus • Won’t treat extra-lumenal infection EDTA + Abx or EtOH other options…. via ID Consult

  17. CABSI Line Management • Salvage Strategy: Guidewire Exchange “Save the Site, not the Line!” • Pros: • Avoid complications of temporary access • Cons: • May fail if extra-lumenal infection Consider exchange in HD Line infections…. via ID Consult

  18. CABSI Line Management • Salvage Strategy: Pull It “Save the Patient, not the Site!” • Pros: • Most likely to cure the infection whether bugs in lumen or on surface • Cons: • Subjects pt to temporary access

  19. CABSI: Prevention “Central Line Bundle” • Hand Hygiene • Maximal Barrier Precautions Upon Insertion • Chlorhexidine Skin Antisepsis • Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Non-Tunneled Catheters • Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

  20. Case • A 68 y/o woman with type-2 DM & HTN recently Rx’d for CAP with cefotaxime • Now admitted for major CVA • Febrile → Ceftazidime started • BCx & foley cath urine grew K.pneumoniae • Two days later: Fever persists, and she becomes less responsive…. Switch to Levo or Cipro Switch to Ceftriaxone Switch to Cefepime Switch to Meropenem Everything’s groovy, make no change Switch to Levo or Cipro Switch to Ceftriaxone Switch to Cefepime Switch to Meropenem Everything’s groovy, make no change

  21. Catheter-Associated UTI: CAUTI Pathogenesis • Colonization: Endogenous flora ascends peri-catheter space or lumen • Infection: Inflammatory response to adherent or invasive bugs (common) Confirm Diagnosis • U/A and Quantitative Ucx

  22. Treatment Options: CAUTI Empiric coverage depends on gram stain: GNR’s: Ceftazidime vs. Mero if MDRO hx GPC’s: add Vancomycin (cover Staph) Total Length of Therapy: Usually 7 days; longer may be needed pyelo Definitive Treatment: Focus spectrum based on C&S results…

  23. Emerging Resistance: ESBL • Extended Spectrum ß-Lactamases • Mutant TEM-1, SHV-1, CTX-M, or OXA ß-lactamase • Enzymes hydrolyze oxyimino-ß-lactams (includes 3rd Gen Cephalosporins) • Usually in Klebsiella spp. and E.coli • Consider in all nosocomial infections with these organisms • Risk Factor = Previous ß-lactam use • Overall prevalence may > 10%

  24. ESBL • Worry if resistance “skips a generation” • Confirm with  3-fold decrease in MIC with ß–lacatmase inhibitor • Rx of choice: • Carbapenem • Variable success: • FQ • Aminoglycoside • TMP/SMX, Nitro, Fosfo

  25. CRE “Doomsday” GNRs Consider empiric contact precautions in pts recently admitted overseas David Ricci

  26. CAUTI Other Management • Change or remove the catheter if UTI detected • Colonization virtually universal… No need for routine surveillance cultures! • Appreciate difference between asymptomatic bacteriuria and UTI!

  27. CAUTI Prevention • Use foley only when necessary! • Aseptic insertion technique • Maintain securely, proper bag placement • Know who has a Foley • Condom caths when feasible • Pull them ASAP… can always put one back if pt fails

  28. ATS/IDSA Guidelines Case: VAP • MDR Pathogen Risks • Hospitalized ≥ 5 days • Abx in last 90 days • High ward MDR prevalence • SNF resident • Contact with MDR patient • Chronic Dialysis • Chronic Infusions • Immunosuppressed

  29. ATS/IDSA Guidelines Case: VAP • Anti-Pseudomonal cephalosporin • (Ceftaz, Cefepime) or • Anti-Pseudomonal carbapenem • (Meropenem, Imipenem) or • -lactam with lactamase inhibitor • (Piperacillin/tazobactam) • + • Anti-Pseudomonal FQ • (Cipro, Levo) or • Aminoglycoside • (Gent, tobra) • +/- • Linezolid or Vancomycin • MDR Pathogen Risks • Hospitalized ≥ 5 days • Abx in last 90 days • High ward MDR prevalence • SNF resident • Contact with MDR patient • Chronic Dialysis • Chronic Infusions • Immunosuppressed • Pseudomonas aeruginosa • Burkholderia • Stenotrophomonas • Klebsiella • Citrobacter • Acinetobacter • MRSA

  30. Case: VAP MRSA VAP: Vancomycin Levels? Patient Outcomes Study Design • Methods - Retrospective analysis 1999-2005 - University Hospital (Washington U) - N =102 Adults - Nosocomial MRSA pneumonia - MRSA established by BAL - Monotherapy with vancomycin > 72 hrs • Measurements - Vancomycin trough levels - Clinical outcome From: Isakow W, et al. ICAAC 2006. DHS/PP

  31. MRSA: Vancomycin MIC Creep? • Not all VSSA created alike. • Published reports of rising vanco MIC’s in last 5 years. • Presumed MOR: increased cell wall thickness. • Retrospective case series: higher MIC’s associated with higher liklihood of clinical failure on vanco. Soriano CID 2008

  32. MRSA: Vancomycin MIC Creep? • MIC ≤ 2 still considered susceptible (VSSA)… Concern: clinical failures with vanco. • Recommend you routinely check vanco MIC, certainly if pt fails to clear bacteremia or clinically improve after 7 days of therapy. • “Consider” switch to alternative agent if MIC = 2, and if pt is failing vanco.

  33. MRSA: Vancomycin MIC Creep? What, pray tell, shall I use instead of “Vitamin V?” • “Consider” switch to alternative agent if MIC = 2, and if pt is failing vanco.

  34. Round One: VAP Vancomycin vs. Linezolid Clinical Cure Study Design • Methods - Retrospective analysis of 2 prospective, randomized, case-control studies - N =1019 Adults - Nosocomial pneumonia - Suspected gram-positive pneumonia - 339 with documented S. aureus - 160 with documented MRSA • Regimens - Vancomycin + Aztreonam - Linezolid + Aztreonam P = 0.182 P = 0.009 From: Wunderink RG, et al. Chest 2003;124:1789-97. DHS/PP Wunderink et al. CHEST / 124 (5) 2003

  35. Round Two: VAP Vancomycin vs. Linezolid Outcomes Study Design • Methods - Blinded, Randomized prospective non-inferiority trial of pneumonia - Nosocomial pneumonia - N =1225 Adults Randomized - 339 with documented MRSA - Well-matched… except 9% more ventilated pts in vanco arm • Regimens - Vancomycin 15mg/kg IV Q 12 H - Linezolid 600mg IV Q 12 H - Both arms treated 7-14 days P = 0.042 CI = 0.5-21.6 “Not significantly different” From: Chastre J et al, 2010 IDSA Conference and CID January 2012

  36. For empiric MRSA VAP coverage… Linezolid Vancomycin Newer, Fancier, Pricier ≠ Better!

  37. Round Two: VAP Vancomycin vs. Linezolid • Jury Still Out.. At least for me • Trend to survival benefit with Linezolid in meta-analysis • Trend to better “clinical response” in large prospective trial sponsored by industry… no mortality difference • Adverse events comparable • Many intensivists now favor linezolid for MRSA VAP… at UW we start with vanco

  38. Case: VAP How Long to Treat? (Less is More) Study Design Results • Methods (N = 401) - Microbiologically-Proven VAP* - Received initial appropriate therapy - Randomized, double-blinded - Performed 1999-2002 • Regimens* - 8 days of therapy - 15 days of therapy * All patients had quantitative cultures from bronchoscopy From: Chastre J, et al. JAMA 2003;290:2588-98. DHS/PP

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