Download How to prescribe antibiotics: maybe it`s not as simple as you think…

Microbiology Nuts & Bolts
Session 4
Dr David Garner
Consultant Microbiologist
Frimley Park Hospital NHS Foundation Trust
www.microbiologynutsandbolts.co.uk
Aims & Objectives
• To know how to diagnose and manage lifethreatening infections
• To know how to diagnose and manage common
infections
• To understand how to interpret basic
microbiology results
• To have a working knowledge of how antibiotics
work
• To understand the basics of infection control
www.microbiologynutsandbolts.co.uk
Gladys
• 71 years old
• Presents with painful
swollen left leg
• On examination
– Temperature 38.5 oC
– Erythema overlying left
lower leg
– Unable to weight bear
• How should Gladys be
managed?
www.microbiologynutsandbolts.co.uk
Differential Diagnosis
• Immediately life-threatening
• Common
• Uncommon
• Examination and investigations explore the
differential diagnosis
• What would be your differential diagnosis for
Gladys?
www.microbiologynutsandbolts.co.uk
Differential Diagnosis
• Immediately life-threatening
– Sepsis
• Common
– Osteomyelitis, cellulitis, varicose eczema…
• Uncommon
– Inflammatory?
• How would you investigate this differential
diagnosis?
www.microbiologynutsandbolts.co.uk
• Full history and examination
• Bloods
– FBC, CRP, U&Es
– Clotting
• Blood culture
• Wound swabs
www.microbiologynutsandbolts.co.uk
• Bloods
–
–
–
–
WBC 25 x 109/L
CRP 457
U&Es – Urea 9, Creat 113
INR 1.5
• How are you going to manage
Gladys now?
www.microbiologynutsandbolts.co.uk
How to interpret a wound swab
result?
• Appearance
– Not available
• Microscopy
– Not available
• Culture
– Is the organism consistent with the clinical picture?
www.microbiologynutsandbolts.co.uk
Culture: how are wound
swabs processed?
• Cannot do a Gram-stain
• Pus is always better!
• Mixture of selective and non-selective
agar plates
• Culture 24-48 hours
• Sensitivities 24-48 hours
• Swab total time 48-96 hours
• A swab cannot diagnose an infection,
that is a clinical judgement, it tells
you what might be causing the
infection
www.microbiologynutsandbolts.co.uk
Culture: classification of
bacteria
Gram’s Stain
Positive
Cocci
No Stain
Uptake
Negative
Bacilli
Cocci
Bacilli
Acid Fast
Bacilli
Non-culturable
Skin infections are usually from direct inoculationwww.microbiologynutsandbolts.co.uk
or haematogenous spread
Classification of Grampositive cocci
www.microbiologynutsandbolts.co.uk
Group
Names
Flora
Clinical
A
S. pyogenes
Mucus
membranes?
Tonsillitis, cellulitis, septic arthritis,
necrotising fasciitis…
B
S. agalactiae
Bowel, genital
tract (females)
Neonatal sepsis, septic arthritis,
infective endocarditis, association
with malignancy?
C
S.
S.
S.
S.
Mucus
membranes,
animals?
Tonsillitis, cellulitis, septic arthritis
D
Enterococcus faecalis
Enterococcus faecium
Bowel
Infective endocarditis, IV catheter
associated bacteraemia
F
“Milleri group”
S. intermedius
S. anginosus
S. constellatus
Bowel
Empyema (pleural and biliary),
bowel inflammation and
perforation…
G
S. dysgalactiae
Mucus
membranes,
bowel?
Tonsillitis, cellulitis, septic arthritis,
association with malignancy?
dysgalactiae
equi
equisimilis
zooepidemicus
B-haemolytic Streptococci
www.microbiologynutsandbolts.co.uk
Community Normal Flora
www.microbiologynutsandbolts.co.uk
Factors Affecting Normal
Flora
• Exposure to antibiotics provides a selective
pressure
– e.g. previous b-lactams may select out MRSA
• Increased antimicrobial resistant organisms in
the environment
– e.g. Meticillin Resistant Staphylococcus aureus (MRSA)
• Easily transmissible organisms
– e.g. Skin flora such as Coagulase-negative
Staphylococci
• Immunosuppressants
– e.g. Steroids, chemotherapy, prosthetic joints etc
www.microbiologynutsandbolts.co.uk
Back to Gladys…
• Bloods
–
–
–
–
WBC 25 x 109/L
CRP 457
U&Es – Urea 9, Creat 113
INR 1.5
• Erythema spreads within the 30 minutes after
she was examined
• What is the probable diagnosis?
• How would you manage Gladys now?
www.microbiologynutsandbolts.co.uk
Types & Causes of Bacterial
Skin Infections
• Ulcers
– Staphylococcus aureus, b-haemolytic Streptococcii
• Become colonised with bacteria, especially
Enterobacteriaceae that DO NOT need treating in most
patients
• Take samples from “healthy” base after debriding
slough
• Only treat if increasing pain, erythema or purulent
discharge
• Cellulitis
– Staphylococcus aureus, b-haemolytic Streptococcii
• Necrotising Fasciitis
– Beta-haemolytic Streptococcii, Clostridium perfringens,
Synergistic gangrene
www.microbiologynutsandbolts.co.uk
Types & Causes of Bacterial
Skin Infections
• Ulcers
– Staphylococcus aureus, b-haemolytic Streptococcii
• Become colonised with bacteria, especially
Enterobacteriaceae that DO NOT need treating in most
patients
• Take samples from “healthy” base after debriding
slough
• Only treat if increasing pain, erythema or purulent
discharge
• Cellulitis
– Staphylococcus aureus, b-haemolytic Streptococcii
• Necrotising Fasciitis
– Beta-haemolytic Streptococcii, Clostridium perfringens,
Synergistic gangrene
www.microbiologynutsandbolts.co.uk
Necrotising Fasciitis
Treatment
1.
Surgical
•
2.
Remove all dead or
diseased tissue
Antibiotics
•
3.
Combination of blactam plus
Clindamycin
Adjuncts
•
Immunoglobulin
www.microbiologynutsandbolts.co.uk
How do you choose an
antibiotic?
• What are the common bacteria causing the
infection?
• Is the antibiotic active against the common
bacteria?
• Do I need a bactericidal antibiotic rather than
bacteriostatic?
• Does the antibiotic get into the site of infection
in adequate amounts?
• How much antibiotic do I need to give?
• What route do I need to use to give the
antibiotic?
www.microbiologynutsandbolts.co.uk
In reality…
…you look at empirical guidelines
www.microbiologynutsandbolts.co.uk
How antibiotics work
www.microbiologynutsandbolts.co.uk
www.microbiologynutsandbolts.co.uk
Antibiotic resistance
www.microbiologynutsandbolts.co.uk
www.microbiologynutsandbolts.co.uk
Other considerations
• Are there any contraindications and cautions?
– e.g. Clostridium difficile and clindamycin
• Is your patient allergic to any antibiotics?
– e.g. b-lactam allergy
• What are the potential side effects of the
antibiotic?
– e.g. Vancomycin and red man syndrome if infusion
too fast
• What monitoring of your patient do you have
to do?
– e.g. Teicoplanin levels and full blood count
www.microbiologynutsandbolts.co.uk
Next Day
• Still cardiovascularly unstable
• Bloods
–
–
–
–
WBC 27 x 109/L
CRP 411
U&Es – Urea 18, Creat 178
INR 1.6
• Blood Culture
– Gram-positive coccus in chains
• What would you do for Gladys now?
www.microbiologynutsandbolts.co.uk
Gladys
• After multiple extensive surgical debridements
and IV Benzylpenicillin and Clindamycin Gladys
starts to make a slow recovery
• 2 weeks into admission PICC line becomes
erythematous
– IV Flucloxacillin 2g QDS started
• 2 days later erythema is still spreading
• Why might Gladys not be responding to
antibiotics?
www.microbiologynutsandbolts.co.uk
Reasons for failing antibiotics
treatment
• Does the antibiotic cover the normal causes of
this type of infection?
• Is the patient compliant?
• Is the patient receiving the antibiotics?
• If on oral antibiotics is the patient able to absorb
oral antibiotics?
• Is the antibiotic appropriate for the patients
weight?
• Does the patient have prosthetic material that
needs removing to allow recovery e.g. IV
access, urinary catheters etc?
• Does the patient have a resistant bacteria
causing the infection e.g. MRSA?
www.microbiologynutsandbolts.co.uk
Intravenous catheter
infections
• IV lines breach the body’s main
barrier to infection, the skin
• The most common causes of
infection are skin bacteria e.g.
Staphylococci
– Gram-negative bacteria are
unusual and normally occur in
immunosuppressed patients or
those on antibiotics that cause
changes in skin flora
• The main treatment of an IV line
infection is to remove the line
– Essential with Staphylococcus
aureus, Pseudomonas sp. and
Klebsiella sp.
www.microbiologynutsandbolts.co.uk
Gladys
• Line site swab grew Staphylococcus aureus
resistant to Flucloxacillin, i.e. MRSA
• PICC line removed
• Antibiotics switched to IV Teicoplanin 6mg/kg as
body weight over 70kg
• Erythema settled in 7 days and antibiotics
stopped
• Gladys eventually recovered
www.microbiologynutsandbolts.co.uk
Conclusions
• Most skin infections are caused by Grampositive cocci e.g. Staphylococci and
Streptococci
• Necrotising fasciitis is an emergency for which
the main treatment is surgery
• Antibiotics are chosen to treat the likely bacteria
• All of the microbiology report is important and
helps with interpretation of the result
• MRSA is commonly selected by the use of blactam and quinolone antibiotics and is not
treatable by either class
www.microbiologynutsandbolts.co.uk
Any Questions?
www.microbiologynutsandbolts.co.uk