Tag Archives: Infectious Disease

Clinical Pearls: PD-related peritonitis

One of the most common complications of peritoneal dialysis is peritonitis. Things to remember:

  • Diagnosis: Peritoneal fluid with >100 nucleated cells (usually >50% PMNs)
  • Pathophysiology: Skin-related (usually gram positive) vs. Secondary (enteric, usually gram-negative and polymicrobial)
  • Empiric treatment: Should cover gram positive and negative organisms. A frequently used combination is a first-generation cephalosporin (i.e. cefazolin) plus an anti-pseudomonal cephalosporin (i.e. cefepime). If the patient or population has a high frequency of methicillin-resistant organisms, vancomycin is a reasonable choice for gram-positive coverage.
  • Drug delivery: Intra-peritoneal (IP) preferred to intravenous (IV) route due to increased local concentration with IP. Vancomycin, aminoglycosides and cephalosporins can be mixed with dialysate solution and achieve therapeutic blood levels (must monitor closely)
  • Indications for catheter removal:

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Information based on ISPD 2005 guidelines for PD-related peritonitis

New & Improved! CDC STD Guidelines 2015

The CDC released their Mortality & Morbidity Weekly Report on June 5, 2015 which is comprised of the latest STD prevention, diagnosis, and treatment guidelines.These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection.

Continue reading New & Improved! CDC STD Guidelines 2015

Empiric Antibiotics: Vancomycin-Resistant Enterococcus

Basics

  • GI or GU infections in patients with prior abx
  • Bacteremia, endocarditis in those with extensive HC exposure
  • E. faecalis: Often remains sensitive to ampicillin, beta-lactams
  • E. faecium: Often multi-drug resistant

Cystitis Rx

  • Consider Nitrofurantoin or Fosfomycin

Invasive infections Rx

  • Amp-sens VRE faecalis: Amp, Amp/Sulb, Pip/Tazo, Imi/Meropenem active
  • Linezolid, High dose Daptomycin (8-12 mg/kg daily), Tigecycline à Consult ID for assistance

Empiric Antibiotics: MRSA (HINT: not just Vanc!)

Basics

  • Uncomplicated Bacteremia
    • Must meet all of following: No IE (by TEE); No prostheses; Negative f/u blood cultures at 2-4 days; Defervescence within 72 h of effective therapy; No metastatic infection
    • Vancomycin or Daptomycin for minimum 2 weeks
  • Complicated Bacteremia or Endocarditis
    • 4-6 weeks at minimum
    • No benefit to adding gentamicin or rifampin for native valve IE
  • Treatment Failure
    • Generally defined as persistent bacteremia around day 7 of therapy (median time to clearance of MRSA bacteremia is 7-9 days)
    • May also define failure as patient getting worse on current tx
    • Remember SOURCE CONTROL!!!

Antibiotic Choices

  • MRSA Abx
  • PO options acceptable for SSTI or completion of osteo Rx; IV preferred for invasive disease
  • Vancomycin is the empiric drug of choice in most serious infections (duh!)
    • Vanc MIC ≥ 2 associated with higher rates of Rx failure so consider alternative agents
  • If vancomycin intolerance or failure:
    • PNA: Linezolid, Ceftaroline
    • Bacteremia/Endocarditis: Daptomycin, Ceftaroline
    • CNS: Linezolid
    • Osteo: Dapto, Ceftaroline

Empiric Antibiotics: Septic Shock

Principles

  • Goal is “the administration of effective IV abx within 1st hour of recognition of septic shock or severe sepsis.” — (grade 1B and 1C, respectively)
  • Initial empiric Rx should include “one or more drugs active against all likely pathogens with adequate penetration into tissues presumed to be source of sepsis.” — (grade 1B)
  • Abx should be “reassessed daily for potential de-escalation.” — (grade 1B)
  • Combination therapy, when used empirically for severe sepsis, should not be continued more than 3-5 days” but de-escalate to single-agent therapy as soon as susceptibilities are known.” — (grade 2B)
  • Source control in first 12 hours if feasible. — (grade 1C)

Empiric Therapy

  • Empiric Rx depends on host factors, recent abx exposure, allergies, clinical syndrome and likely site of infection, local antibiogram and pt’s prior infections or colonization
  • Combination therapy recommended in neutropenics with severe sepsis, those with prior MDR pathogens, and respiratory failure or septic shock patients. — (grade 2B)
  • Practically, this usually means vancomycin + anti-Pseudomonal beta-lactam + either aminoglycoside or anti-Pseudomonal FQ

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Continue reading Empiric Antibiotics: Septic Shock

MERS Virus in South Korea Causing Concern

Recently, South Korean authorities have increased the number of people quarantined and have temporarily closed many schools due to fears of the Middle Eastern Respiratory Syndrome (MERS) spreading. As of June 4, 35 South Koreans had tested positive for the virus including 2 deaths. Click on the link below to read about this from The New York Times.

Middle Eastern Respiratory Syndrome – Coronavirus

  • Coronavirus first isolated in 2012
  • Camels and bats established as a reservoir
  • Range of disease includes “common cold” type symptoms/signs to severe pulmonary illness
  • Majority of cases identified in regions near Arabian Peninsula: Saudi Arabia, United Arab Emirates, Qatar, Oman, Jordan, Kuwait
  • Human-human spread likely requiring close-contact
  • Symptoms: fever, cough, and dypsnea most common; also includes nausea, vomiting, and diarrhea
  • Mortality: 50-65%
  • Molecular diagnostics are the method of choice: PCR assays of respiratory, stool, blood specimens
  • Treatment:
    • Cases should be reported immediately to the local and state health department
    • No antiviral therapy identified
    • Supportive care including mechanical ventilation

(Hopkins ABX Guide)

Fears of MERS Virus Prompt Broadening of Cautions in South Korea

Dr. Jade Le talks about West Nile Virus on KERA!

Today on KERA – Dallas affiliate of NPR – Dr. Jade Le from the division of infectious diseases at UT Southwestern talked about West Nile virus and cases already being reported. She provides a quick overview of the infection including individuals who may be at higher risk. Listen to the interview by clicking on the link below!

West Nile Virus Came to Texas Early this Year

Answer to CC #18

Case challenge #18 presented a 68 year old Asian female with HIV admitted for fever and SOB. Three days prior to admission, she developed watery diarrhea, approximately 5-6 BM a day. The work-up revealed 40% Eos and stool O&P with larval forms.

CC18 

  • The correct answer is: Strongyloides Stercoralis!

    • General Information
      • Strongyloidiasis is a chronic parasitic infection of humans caused by Strongyloides stercoralis.
      • Transmission occurs mainly in tropical and subtropical regions but also in countries with temperate climates.
      • An estimated 30–100 million people are infected worldwide
      • Infection is acquired through direct contact with contaminated soil during agricultural, domestic and recreational activities.
      • Like other soil-transmitted helminthiases, the risk of infection is associated with hygiene, making children especially vulnerable.
    • Clinical Manifestations
      • Strongyloidiasis is frequently underdiagnosed because many cases are asymptomatic
      • Strongyloidiasis may cause intermittent symptoms that mostly affect the intestine (abdominal pain and intermittent or persistent diarrhea), the lungs (cough, wheezing, chronic bronchitis) or skin (pruritus, urticaria).
      • Infection may be severe and even life-threatening in cases of immunodeficiency.
      • Without appropriate therapy, the infection does not resolve and may persist for life.
    • Diagnosis
      • Most diagnostic methods lack sensitivity.
      • Locating juvenile larvae, either rhabditiform or filariform, in recent stool samples will confirm the presence of this parasite.
        • Ascaris, Necator, and Schistosoma will have eggs in the fecal smear, not larvae
        • Trichinella will have larvae in the muscle 
      • Other techniques used include direct fecal smears, serodiagnosis through ELISA, and duodenal fumigation.
    • Management
      • Ivermectin is the drug of choice, but is not available in all endemic countries.
      • Albendazole is also an option, but is considered less effective.

What species of Strongyloides-small

For more information, as Nico Barros or Fernando Woll, our resident Strongy scientists!

HIV Treatment at Diagnosis According to U.S. Officials!

Yesterday the U.S. National Institutes of Health announced the early termination of a trial (START-Strategic Timing of AntiRetroviral Treatment) looking at early treatment of HIV at diagnosis due to clear benefits seen in the study. They recommended patients who learn they are HIV positive should immediately be put on antiretroviral therapy as their study shows a significant survival benefit. The START trial showed that the risk of death or serious illness in patients randomized to early treatment was reduced by 53%. The findings are expected to impact global guidlines regarding HIV treatment. Current W.H.O guidelines recommend treating at CD4 of 500, but acknowledged that treatment at CD4 count of 350 was more practical in many poor countries. They are expected to release updated guidelines very soon. Of note, the CDC recommends immediate treatment at diagnosis of HIV but estimated that 37% of Americans with HIV actually have prescriptions for antiretroviral therapy. Check out the link below from the NIH that summarizes their announcement!

NIH-Starting antiretroviral treatment early improves outcomes for HIV-infected individuals

(photo from Susan Sterner/Associated Press)