Antibiotics

What are some of the major changes in the 2016 Infectious Diseases Society of America and the American Thoracic Society guidelines on pneumonia in hospitalized patients?

FA Manian MD, MPH, , , , , , , , , , Leave a comment

The most noticeable change is the elimination of the concept of health-care associated pneumonia (HCAP) altogether1. This action is in part related to the fact that many patients with HCAP were not at high risk for multi-drug resistant organisms (MDROs) , and that individual patient risk factors, not mere exposure to healthcare facilities, were better determinant of  the need for broader spectrum antimicrobials.

Other noteworthy points in the guidelines include:

  • Although hospital-associated pneumonia (HAP) is still defined as a pneumonia not incubating at the time of admission and occurring 48 hrs or more following hospitalization, it now only refers to non-VAP cases; VAP cases are considered a separate category.
  • Emphasis is placed on each hospital generating antibiograms to guide providers with respect to the optimal choice of antibiotics.
  • Despite lack of supportive evidence, the guidelines recommend obtaining respiratory samples for culture in patients with HAP.
  • Prior intravenous antibiotic use within 90 days is cited as the only consistent risk factor for MDROs, including methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas sp.

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Reference

  1. Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016 ;63:e61-e111.  Advance Access published July 14, 2016. https://www.ncbi.nlm.nih.gov/pubmed/27418577
What are some of the major changes in the 2016 Infectious Diseases Society of America and the American Thoracic Society guidelines on pneumonia in hospitalized patients?

Is oral vancomycin prophylaxis (OVP) effective in preventing recurrent Clostridium difficile infection (CDI) in patients requiring systemic antimicrobial therapy (SAT)?

FA Manian MD, MPH, , , , , Leave a comment

Although OVP is often administered to patients with history of CDI who require SAT, evidence to support this practice has been lacking until recently.

In a 2016 retrospective study of 203 patients with prior history of CDI, those who received OVP (125 mg or 250 mg 2x/daily) during the course of their SAT and for up to 1 week thereafter were significantly less likely to have a recurrence than the non-OVP group (4.2% vs 26.6%, respectively, O.R. 0.12 [C.I. 0.04-0.4]) (1). In this study, the mean interval between prior CDI and initiation of prophylaxis was 6.1 months (1-21 months), and the mean duration of prophylaxis following discontinuation of SAT was 1 day (0-6 days). Similar results have been reported by others (2,3).

Despite their retrospective nature, these studies lend support to the use of OVP in reducing the risk of recurrent CDI in patients who require SAT. It is unclear how long OVP should be continued after SAT is completed, if at all, but common practice is 1-2 weeks.

A randomized-controlled study comparing OVP 125 mg daily for the duration of SAT plus 5 days vs placebo appears to be on the way (4)!

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References

  1. Van Hise NW, Bryant AM, Hennessey EK, Crannage AJ, Khoury JA, Manian FA. Efficacy of oral vancomycin in preventing recurrent Clostridium difficile infection in patients treated with systemic antimicrobial agents. Clin Infect Dis 2016; Advance Access published June 17, 2016. Doi.10.1093/cid/ciw401.
  2. Carignan A, Sebastien Poulin, Martin P, et al. Efficacy of secondary prophylaxis with vancomycin for preventing recurrent Clostridium difficile infections. Am J Gastroenterol 2016;111: 1834-40. https://www.ncbi.nlm.nih.gov/pubmed/27619835
  3. Granetsky A, Han JH, Hughes ME, et al. Oral vancomycin is highly effective in preventing Clostridium difficile infection in allogeneic hematopoietic stem cell transplant recipients. Blood 2016;128:2225; http://www.bloodjournal.org/content/128/22/2225?sso-checked=true
  4. https://clinicaltrials.gov/ct2/show/NCT03462459

Disclosure: The author of this post was also a co-investigator of one of the studies cited (ref. 1).

 

 

 

Is oral vancomycin prophylaxis (OVP) effective in preventing recurrent Clostridium difficile infection (CDI) in patients requiring systemic antimicrobial therapy (SAT)?

In hospitalized patients with community-acquired pneumonia (CAP), has empiric treatment with beta-lactam plus macrolide or a quinolone been shown to be superior to beta-lactam monotherapy ?

FA Manian MD, MPH, , , , , , , Leave a comment

Actually no!

In fact, a 2015 study of CAP from Netherlands, published in New England Journal of Medicine, demonstrated that empiric treatment with beta-lactam monotherapy was not inferior to strategies using a beta-lactam-macrolide combination or fluoroquinolone monotherapy with regard to 90-day mortality, or length of hospital stay (1). To help exclude Legionella pneumonia (often accounting for <5% of CAP[2]), urine Legionella antigen was routinely performed in this study.

So once Legionella has been reasonably excluded, unless suspicion for other atypical causes of CAP (i.e. Mycoplasma pneumoniae or Chlamydophila pneumoniae) remains high, empiric monotherapy with a beta-lactam (e.g. ceftriaxone) may be just as effective in many cases of CAP.

References

1. Postma DF1, van Werkhoven CH, van Elden LJ, et al. CAP-START Study Group Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med. 2015;372:1312-23.  https://www.ncbi.nlm.nih.gov/pubmed/25830421  

2. von Baum H, Ewig S, Marre R, et al. Competence Network for Community Acquired Pneumonia Study Group. Community-acquired Legionella pneumonia: new insights from the German competence network for community acquired pneumonia. Clin Infect Dis 2008;46:1356. https://www.ncbi.nlm.nih.gov/pubmed/18419436

Contributed by Jessica A. Hennessey, MD, PhD, Mass General Hospital, Boston, MA

In hospitalized patients with community-acquired pneumonia (CAP), has empiric treatment with beta-lactam plus macrolide or a quinolone been shown to be superior to beta-lactam monotherapy ?

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?

FA Manian MD, MPH, , , , , , , , , , , , , , , , , , Leave a comment

Although historically sterile pyuria (SP) has been associated with genitourinary (GU) tuberculosis, there are many more common causes to consider in the hospitalized patient (1-3).    

Recent antibiotic exposure (within past 2 weeks) in the setting of UTI is one of the most frequent causes.  Prostatitis is also an often overlooked cause.  Sexually transmitted diseases such as gonorrhea and Chlamydia trachomatis should also be considered in at risk patients. Hospitalized patients with systemic infections outside of the GU tract (e.g. pneumonia, appendicitis, diverticulitis) may also have SP (1-3). High prevalence of SP (>70%) has been reported among patients with appendicitis or diverticulitis (2). 

Non-infectious causes include current or recent catheterization of bladder, urinary stones, stents, GU malignancy, papillary necrosis,  Kawasaki’s disease, autoimmune diseases (eg, SLE) and analgesic nephropathy. 

I would start with repeating the u/a as 50% of sterile pyuria may be transient (3). If repeat u/a still shows pyuria, a prostate exam in our elderly male is indicated to exclude prostatitis. 

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References:

  1. Wise GJ, Schlegel PN. Sterile pyuria. N Engl J Med 372;11:1048-54. https://www.nejm.org/doi/pdf/10.1056/NEJMra1410052
  2.  Goonewardene S, Persad R. Sterile pyuria: a forgotten entity. Ther Adv urol 2015; 7:295-298.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549703/ 
  3. Hooker JB, Mold JW, Kumar S. Sterile pyuria in patients admitted to the hospital with infections outside of the urinary tract. J Am Board Fam Med 2014;2&:97-103. https://www.jabfm.org/content/27/1/97.long#T1 

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My 70 year old male patient with recent hip fracture has developed fevers with sterile pyuria. How do I interpret the sterile pyuria in this patient?

Can oral candidiasis be symptomatic without actual pseudomembranes or “thrush”?

FA Manian MD, MPH, , , , , , , , , , , Leave a comment

Yes!  Although we often associate oral candidiasis with thrush or pseudomembranous white plaques, another common form of oral candidiasis seen in hospitalized patients is “acute atrophic candidiasis” (AAC), also referred to as “antibiotic sore mouth” because of its association with use of broad spectrum antibiotics (1,2). 

Despite the absence of thrush, patients with AAC often have erythematous patches on the palate, buccal mucosa and dorsum of the tongue. Common symptoms include burning sensation in the mouth (especially with carbonated drinks in my experience), dry mouth and taste buds “being off” (2).  

Aside from antibiotics, other predisposing factors for AAC include corticosteroids, HIV disease, uncontrolled diabetes mellitus, iron deficiency anemia, and vitamin B12 deficiency.

So next time you see a hospitalized patient with new onset sore, burning mouth that wasn’t present on admission, think of antibiotic sore mouth!

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References

1. Stoopler ET, Sollecito TP. Oral mucosal diseases. Med Clin N Am 2014;98:1323-1352. https://www.ncbi.nlm.nih.gov/pubmed/25443679

2. Millsop JW, Fazel N. Oral candidiasis. Clin Derm 2016;34:487-94. https://www.ncbi.nlm.nih.gov/pubmed/27343964

Can oral candidiasis be symptomatic without actual pseudomembranes or “thrush”?