Module 6: Stewardship in fever/sepsis, neutropenia ......Sepsis Neutropenia and fever Osteoarticular...
Transcript of Module 6: Stewardship in fever/sepsis, neutropenia ......Sepsis Neutropenia and fever Osteoarticular...
Objectives Discuss initial management of various complex infectious-
disease scenarios Fever Sepsis Neutropenia and fever Osteoarticular infection Endocarditis
Disclaimer! These patients are complex and generally managed with formal
infectious disease consultation where available The primary role of a stewardship program is typically to ensure an
appropriate empiric regimen and to identify whether further infectious disease consultation might be appropriate
Guidelines Sepsis1
Neutropenia and fever2,13
Fever in the ICU3
Bone/joint infections4,5
Endocarditis6
Intravascular catheter infections7
Cardiac device infections12,14
Empiric sepsis therapy Immediate work-up for source as directed by symptoms
Blood cultures x2 Chest x-ray Urine
If source determined, use appropriate regimen for source and level of illness
If source NOT determined, must consider and treat for occult bacteremiaand/or intra-abdominal source Vancomycin PLUS piperacillin/tazobactam, OR Vancomycin PLUS cefepime PLUS metronidazole Strongly consider need for CT imaging of the abdomen
Some programs use PCT levels to guide initiation and duration of therapy.
If patient improves and no source is found, antibiotics can often be stopped. PCT levels can assist with ensuring it is safe to discontinue in this setting (if f/u level <0.5 or >80% drop from baseline).15,16
Fever and neutropenia Drug induced ANC <500 or <1000 with expected fall <500 AND
temperature >101F or >100.4 for >1 hour
Obtain blood cultures x2
Other workup as directed by symptoms
Cefepime 2g iv q8h ALONE if hemodynamically stable and no source
If source known (lung, skin and soft tissue, abdomen) then use the regimen for NOSOCOMIAL infection E.g. HCAP regimen, or anti-pseudomonal intra-abdominal regimen
If no source and hemodynamically unstable, add vancomycinand consider addition of second gram negative drug (e.g. tobramycin)
Fever and neutropenia If fever persists >4-7 days add antifungal (e.g. micafungin) and
consider imaging workup
Antibiotics are generally continued until the ANC is >500 cells/uL
The following patients should receive ID consultation Neutropenia and septic shock Neutropenia and bacteremia or fungemia Neutropenia and intra-abdominal infection Neutropenia and lung nodules Prolonged neutropenic fever >4-7 days
Determining final regimen construction and duration is challenging and best done with ID assistance
New fever in the hospital Common scenario with multiple possible causes
Nosocomial infection (e.g. IV catheter, CAUTI, HAP) Drug fever DVT Atelectasis Central fever after neurological injury Sinusitis Gout/pseudogout
Work-up PRIOR to antibiotics EXAM!!!! Blood cx x2 CXR or urine as directed by clinical history and exam
New fever in the hospital Most new fevers in the hospital DO NOT require new
antibiotics or a change in prior antibiotic
Workup as directed and await results
If hemodynamically UNSTABLE, then MUST give empiric SEPSIS regimen once evaluation done based on likely source
If a line infection is strongly suspected and patient is unstable, consider removing the line; however, in general, fever in a patient with a central line does not require empiric line removal/line change
Line infections 3 types: Intraluminal, hematogenous, or tunnel/exit site
Controversy regarding culturing IDSA- Culture from each line and peripheral NHSN- Culture from 2 peripheral sites only
Standard cultures are fine Do not need quantitative/isolator cultures or fungal cultures except
in very rare circumstances
If a pathogen grows in the blood, and there is no other obvious source, then it is a line infection
Coag negative staph from a single site is likely a contaminant If it repeatedly grows, then consider real
Line infections If line infected, remove line
Especially if: Staphylococcus aureus Candida species Gram negatives
Duration of therapy from date of line removal: Coagulase negative Staphylococcus: 5 – 7 days Enterococcus and gram negative rods: 7 – 14 days Staphylococcus aureus AT LEAST 14 days (consult ID) Candida species: AT LEAST 14 days from first negative
culture (consult ID)
Line infections If line MUST be salvaged: 2 weeks from negative culture WITH antimicrobial lock
therapy (usually vancomycin) Attempt only with poorly-pathogenic organisms (e.g.
coagulase negative Staphylococcus) Tunneled lines with soft tissue infection of the tunnel tract
CANNOT be salvaged and MUST be removed
Bone/joint infections Hematogenous Most common in children Staphylococcus aureus, Beta-hemolytic strep Gonococcal
Contiguous or innoculation (e.g. wound or trauma) Polymicrobial
Prosthetic joint
Bone/joint infection Hematogenous Vancomycin +/- ceftriaxone AFTER blood and joint cultures
Contiguous Get cultures Probably vancomycin plus something else- highly
individualized
Prosthetic joint Get joint and blood cultures first Vancomycin Add gram negative coverage if hemodynamically unstable or
GNR seen in gram stain
Bone/joint duration of therapy Hematogenous
At least 3 weeks if isolated to joint, guided by clinical, lab, and imaging resolution
6 weeks if concomitant bone infection Parenteral therapy for gram positives Can consider oral quinolones for susceptible GNR Consider ID consult
Prosthetic joint 6 weeks if removed and antimicrobial impregnated spacer placed 3 – 6 months for Staphylococcus species in combination with
rifampin if Debride And Implant Retention (DAIR) is being attempted
Consult ID
Bone/joint in children Virtually always hematogenous
Excellent data that children can be treated with oral therapy once CRP falls and clinically improving8-11
3 weeks for joint, 6 weeks for bone guided by CRP and imaging
Shorter courses probably reasonable9
Outpatient IV therapy and PICC lines are rarely needed for bone/joint infections in children9-11
Vertebral osteomyelitis Native- NO hardware or preceding procedures Monomicrobial, hematogenous S aureus, beta-hemolytic strep, brucella, TB If no sepsis or neurologic impairment, HOLD ANTIBIOTICS
until AFTER tissue obtained for cultures AND pathology IR guided aspiration usually attempted first Send for bacterial, AFB, and fungal cultures
If non-diagnostic, generally repeat by operative technique If no sepsis or neurologic impairment, withhold empiric
antimicrobial therapy until a microbiologic diagnosis is established
If blood grows S aureus, can assume this is etiology and do NOT have to biopsy
Vertebral osteomyelitis Treatment varies by organism
6 weeks of IV therapy vs. highly bioavailable oral therapy
Trend inflammatory markers
Avoid re-imaging unless clinically failing as MRI improvement greatly-lags clinical resolution
These are difficult to treat infections: ID consultation early in the course of workup and management is advised
Orthopedic hardware infections Mono-microbial vs. poly-microbial
Early vs late onset
Unremoved hardware remains a nidus of infection Washout with or without removal, followed by prolonged
systemic therapy If hardware not removed, oral convalescent or suppressive
therapy for a prolonged period may be needed Rifampin generally added for Staphylococcal infections when
hardware remains in place
These are complex infections without easily generalized recommendations: Recommend ID consultation
Endocarditis Modified Duke criteria: 2 major, 1 major and 3 minor, or 5
minor
Major: Multiple positive blood cultures for typical organism Valvular vegetation or new valve regurgitation
Minor: Predisposing valve condition or IVDU Fever >38C Emboli (vascular phenomena) Immune phenomena (glomerulonephritis, osler nodes, + RF) Positive blood culture not meeting major criteria
Endocarditis Get blood cultures first! Preferably 3 sets.
TTE ok for initial imaging but does not rule-out disease; if moderate-high suspicion and TTE negative, do TEE
Vancomycin PLUS ceftriaxone Covers Staphylococcus, Streptococcus, Enterococcus, and HACEK
organisms
Treatment varies by organism, type of valve (prosthetic vs. native)
Gentamicin no longer used for native valve Staphylococcus
Decisions regarding surgical indications are complex
Strongly consider ID consultation
Cardiac device infections Staphylococcus species most common
Categories Superficial/incisional Pocket site Wires/bacteremia
Blood cultures in all cases If bacteremic get TEE
LIMITED superficial skin or incisional infection may be treated with 7-10d of PO anti-staphylococcal antibiotic
In MOST cases the pocket will need to be debrided and the ENTIRE device removed
Consult ID
References1. http://www.survivingsepsis.org/Guideli
nes/Pages/default.aspx
2. Journal of Clinical Oncology 36, no. 14 (May 2018) 1443-1453.
3. Crit Care Med 2008; 36:1330–1349
4. Clinical Infectious Diseases 2013;56(1):e1–25
5. Clinical Infectious Diseases® 2015;61(6):e26–46
6. Circulation. 2015;132:00-00
7. Clinical Infectious Diseases 2009; 49:1–45
8. Journal of Pediatric Orthopedics 1982; 2:255-62
9. Clinical Infectious Diseases 2009; 48:1201–10
10. Pediatrics 2009;123;636-642
11. Pediatrics. 2012 Oct;130(4):e821-8
12. Circulation 2010;121;458-477
13. Clinical Infectious Diseases 2011;52(4):e56–e93
14. Heart Rhythm 2017;14:e503–e551
15. Am J Respir Crit Care Med Vol 177. pp 498–505, 2008
16. Lancet. 2010;375:463-74.