A few ID pearlsA few ID pearls

A 37-year-old man presents for the evaluation of A 37-year-old man presents for the evaluation of localized swelling and tenderness of the left leg localized swelling and tenderness of the left leg just below the knee. He suspects this lesion just below the knee. He suspects this lesion developed after a spider bite, although he did developed after a spider bite, although he did not see a spider. Examination of the leg reveals not see a spider. Examination of the leg reveals an area of erythema and warmth measuring an area of erythema and warmth measuring approximately 5 by 7 cm. At the center of the approximately 5 by 7 cm. At the center of the lesion is a fluctuant area measuring lesion is a fluctuant area measuring approximately 2 by 2 cm, overlaid by a small approximately 2 by 2 cm, overlaid by a small area of necrotic skin. The man's temperature is area of necrotic skin. The man's temperature is 38.3°C. The pulse rate is 115 beats per minute. 38.3°C. The pulse rate is 115 beats per minute. The blood pressure is 116/78 mm Hg. How The blood pressure is 116/78 mm Hg. How should this patient be evaluated and treated?should this patient be evaluated and treated?

Risk Factors for MRSARisk Factors for MRSA

Recent ABX use.Recent ABX use.Recent hospitalizationRecent hospitalizationHDHD IVDUIVDUDMDMPrevious MRSA infection/colonizationPrevious MRSA infection/colonization

Initial treatmentInitial treatment

Best initial treatmentBest initial treatment I&D of “small” abscessesI&D of “small” abscesses Small = less than 5cm in lengthSmall = less than 5cm in length Randomized trial of 166 patients with uncomplicated Randomized trial of 166 patients with uncomplicated

skin abscesses at risk for community-associated skin abscesses at risk for community-associated MRSA (CA-MRSA) who were managed with MRSA (CA-MRSA) who were managed with cephalexin or placebo following incision and drainage cephalexin or placebo following incision and drainage of skin and soft tissue abscesses.of skin and soft tissue abscesses.

The cure rates were similar in the two groups (84 and The cure rates were similar in the two groups (84 and 90 percent, respectively).90 percent, respectively).

MRSA Skin and Soft Tissue MRSA Skin and Soft Tissue InfectionsInfections

Patients with larger areas of infection Patients with larger areas of infection and/or systemic signs of infection should and/or systemic signs of infection should be managed with antimicrobial therapy.be managed with antimicrobial therapy.

Empiric therapyEmpiric therapyBeta-lactam antibiotics are no longer reliable Beta-lactam antibiotics are no longer reliable

empiric therapy for skin and soft tissue empiric therapy for skin and soft tissue infections.infections.

Local incidence rate = 56%Local incidence rate = 56%

Options for therapyOptions for therapy

ClindamycinClindamycinUse caution if local resistance rate is 10-15%Use caution if local resistance rate is 10-15%

TMP/SMXTMP/SMXUse based on observational study onlyUse based on observational study only

Tetracyclines (Doxy or Mino)Tetracyclines (Doxy or Mino)Also from observational/retrospective dataAlso from observational/retrospective data

LinezolidLinezolidRifampinRifampin

MRSA Skin and Soft Tissue MRSA Skin and Soft Tissue InfectionsInfections

Bottom lineBottom line I&D is essential for abscessesI&D is essential for abscessesPay attention to local resistance patternsPay attention to local resistance patternsBeta-lactams are no longer viable first choices Beta-lactams are no longer viable first choices

for empiric treatment of at-risk patientsfor empiric treatment of at-risk patientsTMP/SMX is good parenteral option but TMP/SMX is good parenteral option but

evidence is observational.evidence is observational.Linezolid second choice for those that cannot Linezolid second choice for those that cannot

tolerate first choice meds.tolerate first choice meds.

A 37 year old man comes to the clinic with A 37 year old man comes to the clinic with a 7-day history of coarse productive a 7-day history of coarse productive cough, fatigue/malaise, sore throat, nasal cough, fatigue/malaise, sore throat, nasal congestion and runny nose, and mild congestion and runny nose, and mild shortness of breath. His medical history is shortness of breath. His medical history is unremarkable. His vital signs include a unremarkable. His vital signs include a temp of 99.1, RR of 18 and BP of 125/78. temp of 99.1, RR of 18 and BP of 125/78. Examination reveals slightly erythematous Examination reveals slightly erythematous oropharynx and very faint wheezes on oropharynx and very faint wheezes on chest exam but is otherwise chest exam but is otherwise unremarkable. What is the most likely unremarkable. What is the most likely diagnosis and treatment?diagnosis and treatment?

A 37 year old man comes to the clinic with a 7-A 37 year old man comes to the clinic with a 7-day history of coarse productive cough, day history of coarse productive cough, fatigue/malaise, sore throat, nasal congestion fatigue/malaise, sore throat, nasal congestion and runny nose, and mild shortness of breath. and runny nose, and mild shortness of breath. His medical history includes poorly controlled His medical history includes poorly controlled diabetes, HTN, CAD and childhood asthma. His diabetes, HTN, CAD and childhood asthma. His vital signs include a temp of 99.1, RR of 18 and vital signs include a temp of 99.1, RR of 18 and BP of 125/78. Examination reveals slightly BP of 125/78. Examination reveals slightly erythematous oropharynx and very faint erythematous oropharynx and very faint wheezes on chest exam. There are multiple wheezes on chest exam. There are multiple small pustular skin lesions over his trunk and small pustular skin lesions over his trunk and legs which he says were diagnosed as “staph” legs which he says were diagnosed as “staph” by a previous physician. What is the most likely by a previous physician. What is the most likely diagnosis and treatment?diagnosis and treatment?

A 37 year old man comes to the clinic with a 7-A 37 year old man comes to the clinic with a 7-day history of coarse productive cough, day history of coarse productive cough, fatigue/malaise, sore throat, nasal congestion fatigue/malaise, sore throat, nasal congestion and runny nose, and mild shortness of breath. and runny nose, and mild shortness of breath. His medical history includes HIV/AIDS, chronic His medical history includes HIV/AIDS, chronic diarrhea, and medical noncompliance. His vital diarrhea, and medical noncompliance. His vital signs include a temp of 99.1, RR of 18 and BP of signs include a temp of 99.1, RR of 18 and BP of 125/78. Examination reveals slightly 125/78. Examination reveals slightly erythematous oropharynx and very faint erythematous oropharynx and very faint wheezes on chest exam but is otherwise wheezes on chest exam but is otherwise unremarkable. What is the most likely diagnosis unremarkable. What is the most likely diagnosis and treatment?and treatment?

EpidemiologyEpidemiology

Usual causes of AB:Usual causes of AB: Influenza A/BInfluenza A/BParainfluenzaParainfluenzaCoronavirusCoronavirusRhinovirusRhinovirusRSVRSV

StatsStats

How many patients diagnosed with acute How many patients diagnosed with acute bronchitis are given antibiotics?bronchitis are given antibiotics?

60-70%60-70%

S pneumo, H flu, S aureus, M catS pneumo, H flu, S aureus, M cat

““There is no convincing evidence to There is no convincing evidence to support the concept of "acute bacterial support the concept of "acute bacterial bronchitis" caused by these pathogens in bronchitis" caused by these pathogens in adults, with the exception of patients with adults, with the exception of patients with airway violations such as tracheostomy or airway violations such as tracheostomy or endotracheal intubation, or those with endotracheal intubation, or those with exacerbations of chronic bronchitis.”exacerbations of chronic bronchitis.”

Acute BronchitisAcute Bronchitis

““Routine antibiotic treatment of Routine antibiotic treatment of uncomplicated acute bronchitis is not uncomplicated acute bronchitis is not recommended. If pertussis infection is recommended. If pertussis infection is suspected (an unusual circumstance), a suspected (an unusual circumstance), a diagnostic test should be performed and diagnostic test should be performed and antimicrobial therapy initiated.”antimicrobial therapy initiated.”

Acute Bronchitis DiagnosisAcute Bronchitis Diagnosis

Productive cough as the essential Productive cough as the essential symptomsymptom

Concurrent URI symptomsConcurrent URI symptomsRhinitis, sore throat, hoarsenessRhinitis, sore throat, hoarseness

Fever is unusual sign and may suggest Fever is unusual sign and may suggest pneumonia or influenzapneumonia or influenza

AB vs pneumoniaAB vs pneumonia

When to order a CXR?When to order a CXR?Abnormal VS (HR>100, RR>24, Temp>38C)Abnormal VS (HR>100, RR>24, Temp>38C)Rales or signs of consolidation on examRales or signs of consolidation on examAdvanced age (>75 years)Advanced age (>75 years)

Duration of coughDuration of cough

What if cough is present for 2 weeks?What if cough is present for 2 weeks? Selected studies have recovered pertussis in up Selected studies have recovered pertussis in up

to 10% to 20% of patients with cough lasting to 10% to 20% of patients with cough lasting longer than 2 to 3 weeks.longer than 2 to 3 weeks.

Clinicians should limit suspicion and treatment of Clinicians should limit suspicion and treatment of adult pertussis to adults with a high probability of adult pertussis to adults with a high probability of exposure to pertussis—for example, during exposure to pertussis—for example, during documented outbreaks. documented outbreaks.

Pertussis may be suspected regardless of Pertussis may be suspected regardless of immunization history.immunization history.

Treatment of ABTreatment of AB

NSAIDs, Tylenol, nasal decongestantsNSAIDs, Tylenol, nasal decongestantsStrong patient-physician relationship and Strong patient-physician relationship and

good communicationgood communicationReassuranceReassurance

Evidence against ABX for ABEvidence against ABX for AB

A meta-analysis of 9 studies:A meta-analysis of 9 studies: 5 of 9 showed no benefit of either doxycycline or 5 of 9 showed no benefit of either doxycycline or

erythromycinerythromycin 2 showed slight clinical differences in patients treated 2 showed slight clinical differences in patients treated

with erythromycin or TMP/SMXwith erythromycin or TMP/SMX 2 showed superiority of albuterol to erythromycin2 showed superiority of albuterol to erythromycin

A second meta-analysis showed a 0.6 day A second meta-analysis showed a 0.6 day reduction in cough duration.reduction in cough duration.

Another study showed Azithromycin and Vitamin Another study showed Azithromycin and Vitamin C were equivalent.C were equivalent.

Patient informationPatient information

Because the prevailing thought among Because the prevailing thought among many patients is that “antibiotics will treat many patients is that “antibiotics will treat my cough”, patient information/hand-outs my cough”, patient information/hand-outs are available to provide further are available to provide further reassurance that they are being treated reassurance that they are being treated appropriately and in line with current appropriately and in line with current recommendations.recommendations.

A 57 year old man with cirrhosis is ready A 57 year old man with cirrhosis is ready to go home after an ICU admission and to go home after an ICU admission and treatment of acute variceal hemorrhage. treatment of acute variceal hemorrhage. He has never had a GIB before. Besides He has never had a GIB before. Besides the usual medications aimed at preventing the usual medications aimed at preventing recurrent GI bleeding, should he take any recurrent GI bleeding, should he take any other preventative medications?other preventative medications?

Prophylaxis for SBPProphylaxis for SBP

Risk factors have been identifiedRisk factors have been identifiedAF protein concentration < 1AF protein concentration < 1Variceal hemorrhageVariceal hemorrhagePrior episode of SBPPrior episode of SBP

Most flora originate in the gutMost flora originate in the gutTheory: Intestinal decontamination can Theory: Intestinal decontamination can

reduce SBP incidence in at risk patients.reduce SBP incidence in at risk patients.

Does prophylaxis work?Does prophylaxis work?

Meta-analysis of 13 RCTs (hospitalized patients Meta-analysis of 13 RCTs (hospitalized patients with cirrhosis with risk factors for infection)with cirrhosis with risk factors for infection) Significant mortality benefitSignificant mortality benefit

RR 0.70, CI 0.56-0.89RR 0.70, CI 0.56-0.89 Significant reduction in SBP developmentSignificant reduction in SBP development

RR 0.39, CI 0.32-0.48RR 0.39, CI 0.32-0.48

Antibiotic prophylaxis in cirrhotic patients with Antibiotic prophylaxis in cirrhotic patients with gastrointestinal bleeding was studied via gastrointestinal bleeding was studied via systematic review.systematic review. Significantly reduced SBP development, bacteremia Significantly reduced SBP development, bacteremia

and death.and death.

RegimensRegimens

Single weekly Cipro vs placeboSingle weekly Cipro vs placebo3.6 versus 22 percent3.6 versus 22 percent

Bactrim DS 1 tab daily 5 days/weekBactrim DS 1 tab daily 5 days/week3 versus 27 percent3 versus 27 percent

Continuous oral Cipro (reduced mortality Continuous oral Cipro (reduced mortality and incidence of SBP at 12 months)and incidence of SBP at 12 months)

Continous TMP/SMX 1 tab dailyContinous TMP/SMX 1 tab daily Inpatient-only use of norfloxacin with Inpatient-only use of norfloxacin with

discontinuation at time of discharge.discontinuation at time of discharge.

RecommendationsRecommendations

Those with gastrointestinal bleedingThose with gastrointestinal bleeding Cefotaxime IV until taking PO then switch to Cefotaxime IV until taking PO then switch to

Norfloxacin PO x 7 days total.Norfloxacin PO x 7 days total.

Continuous quinolone or TMP/SMX in those who Continuous quinolone or TMP/SMX in those who have had one or more episodes of SBPhave had one or more episodes of SBP Switch antibiotics if develops SBP on this regimenSwitch antibiotics if develops SBP on this regimen

Short-term norfloxacin or TMP/SMX (in-patient Short-term norfloxacin or TMP/SMX (in-patient only) in those with cirrhosis and AF protein only) in those with cirrhosis and AF protein <1g/dl hospitalized for another reason.<1g/dl hospitalized for another reason.