Download Carpenter Service Overview

An Hitchiker’s Intern’s Guide
to the Galaxy Carpenter
Douglas Adams
Nate Summers
Objectives
 Approach to ID
 Overview of Commonly Encountered Infections
 Overview of Inpatient Care of the HIV Patient
 Overview of Antibiotics
Dr. Charles Carpenter
 After completing his residency at Johns Hopkins Hospital, he
began his career in international health in Kolkata, India,
during a Cholera epidemic and became the director of the
division of allergy and infectious diseases at Hopkins.
 He moved to Ohio in 1973, where he served as the
department of medicine chair until 1986, and was a leading
figure in the department of ID here, continuing his passion for
international health.
 He is currently the department of medicine chair at Brown.
Approach to Infectious Diseases
Host
Syndrome
Bugs
Drugs
Your patient, Doctor…
 47 year old WM presents with a bug bite
 HPI:
 Initially noticed this 5 days ago, but was much smaller
 Painful, on left antecubital fossa
 Subjective fevers and chills over the past 2-3 weeks
 Dyspnea over the past 1-2 weeks with cough
 Denies trauma, thinks he may have been bitten by a spider
More History
 PMH:
 DM type II, A1c=9.3%
 Allergies:
 PCN
 DLD
 FHx:
 PSH: None
 Home meds:
 Father with CLL
 Social:
 Metformin
 Injects heroin daily
 Glyburide
 Smokes 1ppd x20 years
 Rare EtOH
Physical Exam
 Host
 Diabetic, IVDU
 Syndrome
 Skin/soft tissue infection; probable infective endocarditis
 Bugs
 Staph. aureus, Strep pyogenes, Strep viridans, Enterococcus, Staph
Epidermidis, HACEK
 Drugs
 Vancomycin, nafcillin, cefazolin, daptomycin (inactivated by type II
pneumocytes!), ceftaroline for IE
 Doxycycline, TMP/SMX, clindamycin (increasing resistance), cephalexin,
dicloxacillin for SSTI
Keys to the Case (Cellulitis):
 Strep
 Staph
 More rapid onset
 Often purulent
 Rapid response to
beta-lactams
 May form abscesses
 No purulence
 Often multiple
More Keys to the Case (IE):
 Modified Duke Criteria
 Major
 Sustained bacteremia by an organism classic for IE (or 1 BCx or serology positive for
Coxiella)
 Endocardial involvement documented by either echocardiogram or new valvular
regurgitation
 Minor
 Predisposing condition (prior IE, RHD, IVDU, HD, PPM, biscuspid AV)
 Fever
 Vascular phenomena (septic/pulmonary emboli, mycotic aneurysms, ICH,
Janeway lesions)
 Immune phenomena (+RF, glomerulonephritis, Osler’s nodes, Roth spots)
 Positive BCx not meeting major criteria
 Definitive (2 major or 1 major + 3 minor or 5 minor)
 Possible (1 major + 1 minor or 3 minor)
Classic organisms: Strep viridans, Strep. bovis, HACEK, or Staph. aureus or Enterococcus w/out primary
focus
More Keys to the Case (Staph):
 Always take Staphylococcal bacteremia seriously
 Repeat blood cultures x2 before starting empiric treatment
 Staph aureus is sticky and loves to hide in places. Examine the Pt
for metastatic spread (spine, sternoclavicular joints, etc.)
 Image if concerning physical exam findings
 IDSA guidelines recommend at least 2 weeks of IV therapy for
Staph bacteremia
 2 weeks if: exclude IE, no implanted prostheses (including joints),
negative f/u BCx 2-4 days after initial Cx, defervescence w/in 72 hrs,
and no sites of metastatic infection
 Otherwise, treat for 4-6 weeks
Your patient, Doctor…
 74 year old AAF presents with a cough
 HPI:
 Cough x5 days with worsening dyspnea
 Yellow/green phlegm
 Subjective fevers/chills
More History
 PMH:
 Allergies: NKDA
 HTN
 FHx:
 PSH: None
 Home meds:
 Amlodipine
 Children are healthy
 Social:
 Denies tobacco/illicits
 Drinks a glass of wine
each evening
Physical Exam
 Host
 Elderly
 Syndrome
 Pneumonia
 Bugs
 Strep pneumoniae, non-typeable H. influenza, M. catarrhalis,
Chlamydia pneumoniae, Mycoplasma pneumoniae, Staph aureus,
Legionella pneumophilia
 Drugs
 3rd Gen Ceph/azithro, respiratory FLQ, doxycycline, amox/clav
Keys to the Case:
 CURB-65
 Confusion
 BUN>19
 RR>30
 BP<90/60
 Age>65
 Score >1 should generally
be treated inpatient
 HCAP:
 Hospitalization for 2+ days
w/ in past 90 days
 HD w/ in 30 days
 NH or LTAC w/ in 30 days
 IV therapy (chemo, Abx)
w/in 30 days
 Wound care w/ in 30 days
 Family member w/ MDR
pathogen
 Want to cover MRSA and
gram negatives
More Keys to the Case:
 Respiratory FLQ
 Why don’t we use
ciprofloxacin in CAP if we
use it as double coverage
for Pseudomonas
aeruginosa in HCAP?
 Post Influenza
 Strep. pneumoniae is still
#1
 Incidence of Staph.
aureus is increased
(especially community
acquired MRSA after the
H1N1 epidemic)
Your patient, Doctor…
 22 year old WF presents with HA
 HPI:
 Rhinorrhea, fatigue, malaise x2 days
 Severe HA starting this morning with subjective fevers
More History
 PMH:
 Allergies: NKDA
 None
 FHx:
 PSH: None
 Home meds:
 Oral contraceptives
 Dad with CAD
 Social:
 In college, binge drinks on
weekends
 Denies tobacco, illicits
Physical Exam
 Host
 Young
 Syndrome
 Meningitis
 Bugs
 Neisseria meningitidis, Strep. pneumoniae, nontypeable H. flu, Listeria
monocytogenes, enteroviruses, arboviruses, TB, Cryptococcus
neoformans
 Drugs
 Ceftriaxone, vancomycin, dexamethasone, +/- ampicillin, acyclovir
Keys to the Case:
 Why Vancomycin?
 Not for MRSA!
 Increasing resistance of
Strep. pneumo to
penicillins, and
penetrance to CSF is
tough, limiting the
AUC/MIC
 Dexamethasone?
 In cases of Strep. pneumo,
it reduces neurologic
deficits (especially
hearing loss) and may
decrease mortality
More Keys to the Case:
 Bacterial:
 Viral:
 TP: Elevated (100-1000)
 TP: Elevated (50-100)
 Glucose: Low (<45)
 Glucose: normal (2/3
serum)
 Cell count: Elevated,
PMN predominance
 Cell count: normal to
elevated w/ lymph
predominance
Fundamentals of HIV
 Key things to know about your patient:
 Most recent viral load and CD4 count
 HAART regimen, any prophylaxis
 CD4 nadir, history of OI
 In general, continue HAART and prophylaxis on admission
 If you have questions (more on that later), ask for help (senior resident,
attending, ID fellow)
Common Side Effects
Drug/Class
Common/Important Side Effects
Didanosine
Pancreatitis
Indinavir
Crystal nephropathy
Nevirapine
Liver failure
Abacavir
Hypersensitivity syndrome
NRTI’s
Lactic acidosis
NNRTI’s
Stevens-Johnson Syndrome
OI Prophylaxis
Pathogen
CD4 Count
Prophylaxis
TB
Any
Screen for and treat for latent TB if
positive
Coccidioidomycosis
<250
Screen in endemic areas;
fluconazole if positive
PCP
<200
TMP-SMX
Histoplasmosis
<150
Itraconazole in hyperendemic
areas (not USA)
Toxoplasma
<100
TMP-SMX
Cryptococcus
<100
None
MAC
<50
Azithromycin or Clarithromycin
Your patient, Doctor…
 39 year old WM presents with cough
 HPI:
 Nonproductive cough over the past 2 weeks
 Worsening dyspnea over the past 5 days
 Subjective fever, night sweats
More History
 PMH:
 Allergies: NKDA
 HIV, lost to follow up
 HTN
 PSH: None
 FHx: Unknown
 Social:
 Smokes 1ppd
 Home meds:
 Amlodipine
 Occasional EtOH
 Daily marijuana
Physical Exam
 Host
 HIV/AIDS
 Syndrome
 Pneumonia
 Bugs
 Strep pneumoniae, non-typeable H. influenza, M. catarrhalis,
Chlamydia pneumoniae, Mycoplasma pneumoniae, Staph aureus,
Legionella pneumophilia
 PCP, TB
 Drugs
 Ceftriaxone/azithro, TMP-SMX +/- prednisone
Keys to the Case:
 Prednisone?
 If PaO2<70 or A-a
gradient>35
 Don’t forget that
patients with HIV/AIDS
can have routine
bacterial infections as
well
Your patient, Doctor…
 One year later, our same 40 year old WM presents with AMS
 HPI:
 HA over the past week
 Increasing confusion past few days
More History
 PMH:
 Allergies: NKDA
 HIV, still lost to follow up
 HTN
 PSH: None
 FHx: Unknown
 Social:
 Smokes 1ppd
 Home meds:
 Amlodipine
 Occasional EtOH
 Daily marijuana
Physical Exam
 Host
 HIV/AIDS
 Syndrome
 Meningitis/CNS infection
 Bugs
 Neisseria meningitidis, Strep. pneumoniae, nontypeable H. flu, Listeria
monocytogenes, enteroviruses, arboviruses, TB, Cryptococcus neoformans,
Toxoplasma gondii (ring-enhancing lesions), CNS lymphoma (ringenhancing lesion, CSF EBV+)
 Drugs
 As for bacterial if CSF is suggestive, or Amphotericin B + flucytosine x2 weeks
then fluconazole PO for Cryptococcus; pyrimethamine + sulfadiazine if
Toxoplasma
Keys to the Case:
 Get a CT Head before
the LP in poorly
controlled HIV
patients
 At risk for space
occupying lesions,
including CNS lymphoma,
tuberculoma, CNS
abscess, and Toxoplasma
 Crypto
 May need to do serial LPs
if patient remains
symptomatic (HA, AMS)
due to high intracranial
pressure
 IRIS
 For intracranial processes,
generally delay starting
HAART for a few weeks to
avoid complications
(continue HAART if
already on)
Antibiotics
 Beta-lactams
 Inhibit cell wall synthesis by inhibiting penicillin binding proteins
 Generally bacerticidial
 Include penicillins, cephalosporins, carbapenems, and monobactams
Penicillins
 First Generation
 Excellent gram positive coverage; primarily used against Syphilis now
 Penicillin G (procaine; IV), Penicillin benzathine (IM), and Penicillin V (PO)
 Anti-Staphylococcal
 Gain coverage vs. penicillinase producing staphylococci but lose activity
against Enterocci, Listeria, and Neisseria
 Nafcillin, oxacillin, dicloxacillin, cloxacillin
 Second Generation
 Added coverage against gram negative bacilli and anaerobes
 When paired w/ beta lactamase inhibitors, broadens gram neg coverage
 Ampicillin (+ sulbactam), amoxicillin (+ clavulanate)
 Third/Fourth Generation
 Improved gram negative coverage, including Pseudomonas aeruginosa plus
anaerobes
 Ticarcillin, Carbenicillin, Piperacillin
Cephalosporins (5-10% crossreactivity)
 First Generation
 Excellent gram positive coverage, including MSSA but not Enteroccus, Listeria
 Some coverage vs. gram neg bacilli
 Cefazolin, cephalexin, cefadroxil
 Second Generation
 Added coverage against gram negative bacilli, slightly less gram positive
 Cefuroxime, cefoxitin, cefotetan, cefaclor, cefprozil
 Third Generation
 Highly active vs. enterics, loses some gram positive coverage
 Ceftriaxone, cefotaxime, cefixime, cefdinir
 Ceftazidime (3.5 generation; covers Pseudomonas aeruginosa)
 Fourth Generation: Similar to third gen plus Pseudomonas coverage
 Cefepime (of note: NO anaerobic coverage!)
 Fifth Generation: Similar to third gen plus MRSA and resistant Pneumo
 Ceftaroline
Carbapenems (2-5% crossreactivity)
 Very broad spectrum, including ESBL, anaerobes, and gram positives
(including Enterococcus and Listeria) but not VRE
 Doripenem, imipenem (+ cilastin to prevent proximal tubule necrosis), and
meropenem
 Beware CNS toxicity with imipenem
 Ertapenem does not cover Pseudomonas but is once daily dosing
 All cover Pseudomonas Except Ertapenem
 Generally reserve these medications for resistant pathogens as they are our
last ditch effort against growing gram negative resistance
 We all play a role in antimicrobial stewardship!
Monobactams (0% crossreactivity)
 Good gram negative coverage (including Pseudomonas) but NO
anaerobic coverage
 Aztreonam
MRSA Coverage
 Oral Agents
 CA: TMP/SMX, doxycycline, clindamycin (check D-test!)
 Linezolid
 Parenteral Agents
 Vancomycin (bacteriostatic; use if MIC<2 for invasive MRSA)
 Daptomycin (bactericidal; use if MIC<1 for invasive MRSA; watch CPK)
 Inactivated by type II pneumocytes, so not for pneumonia!
 Linezolid (bacteriostatic; good vs. invasive; beware pancytopenia & serotonin
syndrome; inhibits toxin production so good vs. toxic shock)
 Ceftaroline (bactericidal, not FDA approved for invasive but used regardless)
 Tigecycline (bacteriostatic; 4P’s=Proteus, Providencia, Pseudomonas, Pee)
 Televancin (bactericidal; used for SSTI; dalbavancin & oritavancin = depo forms)
 Synercid (Quinupristin-dalfopristin) (static alone, cidal together, requires central
line)
Questions?