rdu opd lampoon 10 aug 2018...06/08/2018 5 คณะแพทยศาสตร ศ ร ราชพยาบาล มหาว ทยาล ยมห ดล Common Causes of Food

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คณะแพทยศาสตรศิ์รริาชพยาบาล มหาวทิยาลยัมหดิล

รศ.ดร.พญ.ภญิโญ รตันาอมัพวลัยสาขาวิชาโรคติดเช้ือและอายุรศาสตรเขตรอน

คณะแพทยศาสตรศิริราชพยาบาล มหาวิทยาลัยมหิดล

Rational Antimicrobial Use in OPD Settings

คณะแพทยศาสตรศิ์ริราชพยาบาล มหาวิทยาลยัมหดิล

Outline of Presentation

Antimicrobial resistance and Thailand situation

Rational Antimicrobial Use in OPD Settings

Common cold

A di h Acute diarrhea

Fresh wound

UTIs


คณะแพทยศาสตรศิ์ริราชพยาบาล มหาวิทยาลยัมหดิล คณะแพทยศาสตรศิ์ริราชพยาบาล มหาวิทยาลยัมหดิล

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World Burden of Bacterial Resistance

More than 140,000 episodes of infection caused by resistant bacteria per yearp y

More than 30,000/year patients die More than 2 billion loss in productivity /year

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Antimicrobial resistance

Prevent transmission

Susceptible host

Infection control

Key Prevention Strategies

Infection

Early Dx & RxAntimicrobial therapy

Rational Use


Upper Respiratory Tract Infections

Causes: 80% virus 20% bacteria

Adults with URIs at Siriraj hospital: GAS infectionGAS infection

7.9% in patients with tonsillitis/pharyngitis

3.1% in patients with non-specific URI/common cold

J Med Assoc Thai. 2006 Aug;89(8):1178-86.


Meta-analysis of antibiotics for common cold and acute purulent rhinitis

Cochrane Database Syst Rev. 2013 Jun 4;6


Differential Diagnosis of upper respiratory tract conditions

SymptomsCommon

coldStreptococcal

pharyngitis

Acute bacterial sinusitis

Allergic rhinitis

Duration ͠ 7 d 7 d > 10 d variable

Sore throat - sometimes

Nasal discharge -

Discharge color White - Yellow/Green Clear

Sneezing - -

Cough - sometimes sometimes

Facial pressure sometimes - -

Fever sometimes -

Common cold: mild injected pharynx, no exudate

Exudative tonsillitis:Injected pharynx with yellowish exudate

Diphtheria:Dirty greyish patch

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CENTOR criteria

GAS AOM, Sinusitis


Acute Bronchitis

Mostly viral Clues: dry cough with chest rhonchi Treatment: Supportive Rx

Antibiotics in high risk (elderly, COPD, low IR) Amoxycillin 500 mg tid or 1000 mg bid

Roxithromycin 150 mg PO bid

Amoxyclav 625 mg tid or 1000 mg bid

Levofloxcin 500 mg od

Duration = 5 days


Acute Diarrhea

Acute diarrhea: ≥ 3 loose or watery stools per day

≥ 1 mucous bloody stools

Causes: Food poisoning (toxin) – watery diarrhea N/V Food poisoning (toxin) – watery diarrhea, N/V

Viral infection – loose stool, low-grade fever. Feel ill

Bacterial infection – high fever, bloody stools

Most are self-limited!!


Food poisoning

Bacterial Preformed-Toxin Food Poisoning

Causes: Bacillus cereus

Staphylococcus aureus

Clostridium perfringens Clostridium perfringens

Clinical features: Short incubation period

Vomiting is the predominant presentation

Often no fever, mild diarrhea with abdominal cramp

Recovery occurring in 1-2 days

Romney MH. Clin microbiol Rev 2015: 28; 1‐31

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Common Causes of Food poisoning

Causes IC(hr)

Food Toxin Clinical Syndrome

S. aureus 2-7 Improperly cooked or stored food

Heat-stable preformed-toxin

Vomiting

C.perfringens 8-14 Contaminated meat vegetables

Enterotoxin(Heat labile

Watery diarrhea S vomitingmeat, vegetables,

or poultry(Heat-labile toxin, heat-stable spore)

vomiting“Pig-bel” beta toxin– intestinal wall necrosis

B. cereus ½-6 Contaminated fried rice,vegetable sprouts

Emetic toxin(cereulide)

Similar to S. aureus enterotoxin(nausea/vomiting)

8-16 Pore-forming enterotoxin

Similar to C. perfringens(diarrhea)

Romney MH. Clin microbiol Rev 2015: 28; 1‐31


Acute Infectious DiarrheaParameter Secretory

gastroenteritisInflammatory

gastroenteritisInvasive

gastroenteritis

Location Proximal small bowel Colon Distal small bowel

Type of illness Watery diarrhea Dysentery Enteric fever

Stoolexamination

No fecal PMN Fecal PMN Fecal PMN

Mechanism Enterotoxin or bacterial adherence/invasion cause a shift in water and electrolyte excretion/adsorption

Bacterial invasion or cytotoxins cause mucosal damage that leads to inflammation

Bacterial penetrate the mucosa and invade the reticuloendothelialsystem

Classic pathogens

Vibrio cholerae, ETEC, Clostridium perfringens, Bacillus cereus, Staphylococcus aureus

Shigella, STEC, Salmonella (not Salmonella Typhi/Paratyphi), Vibrio parahaemolyticus, Clostridium difficile, Campylobacter

SalmonellaTyphi/Paratyphi, Yersiniaenterocolitica

Principles and syndromes of enteric infection, 7th Ed Mandell 2010: 1335–1351


Investigations for Acute Diarrhea

No need of investigations in most cases

Stool exam: if severe or persist ≥ 2 days

Stool culture: Inflammatory or Cholera-like diarrheay Diarrhea ≥ 1 week Traveler or immunocompromised host

Stool parasite: Diarrhea ≥ 2 weeks Outbreak setting Traveler or immunocompromised host

Mayo Clinic Infectious Diseases Board Review 2011


Management

Adequate hydration and symptomatic treatment

Empirical antibiotic treatment in1. Febrile dysentery or elderly Norflox 400 mg bid x 3 d

2. Suspected V.cholera Norflox 400 mg bid x 3 d2. Suspected V.cholera Norflox 400 mg bid x 3 d

3. Severe traveler’s diarrhea Azithro 1000 mg stat

4. Antibiotic-associated diarrhea Metronidazole/vanco

5. Non-typhoidal salmonellosis with

Severe or bacteremia

High risk patients

Mayo Clinic Infectious Diseases Board Review 2011


Fresh Wound

Bleeding-heart bird

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WHO wound management guideline

Never close infected wound

Delayed primary closure for 48 hours in contaminated wounds and clean wounds > 6 hours old

A ibi i h l i i l d d i Antibiotic prophylaxis is only recommended in high-risk and contaminated wound

Topical antibiotics and washing wounds with antibiotic solutions are not recommended!!

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Upper UTI VS.

Lower UTI

Urinary Tract Infections

CA-UTIVS.

Nosocomial UTI

Complicated VS.

UncomplicatedUTI


Diagnosis Clinical signs and symptoms

Pyuria: Centrifuged ≥ 10 WBC/HPF, Uncentrifuged ≥ 5 WBC/HPF Might be absent in neutropenic hostsg p

Significant bacteriuria:

Conditions MUC

Acute uncomplicated cystitis ≥105 CFU/ml

Acute uncomplicated pyelonephritis ≥104 CFU/ml

UTIs in Male ≥104 CFU/ml

Complicated UTIs ≥103 CFU/ml

Rubin RH, et al. CID 1992. 15; S216‐27


Common UTIs

1. Asymptomatic bacteriuria (ASUB)

2. Uncomplicated UTI in female

• Cystitis

• Acute pyelonephritis


Asymptomatic Bacteriuria Diagnosis:

Single cath (both sex): MUC > 102

Asymptomatic patient: MUC > 105 ( 1 time for male, 2 times for female)

Treatment is recommended in

Pregnancy

Plan to undergo TURP/Urosx with mucosal bleeding

Asymptomatic female with cath-bacteriuria that persists 48 h after indwelling catheter removal

IDSA Guidelines for Asymptomatic Bacteriuria • CID 2005:40

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Acute Cystitis 1st time – MUC and imaging not necessary

Treatment options:

Nitrofurantoin (Dual) 100 mg bid x 7 d

Fosfomycin 3 g single dose

Co-trimoxazole 800/160 mg bid x 3 d

IDSA guideline for acute uncomplicated cystitis and pyelonephritis in women: CID 2011

X CCr < 50X PregnancyX Early upper UTI

X Early upper UTI X High resistant ratei.e. > 20%


Acute Cystitis Alternative treatment options:

Fluoroquinolones

Ofloxacin 200 mg bid x 3 dCiprofloxacin 250 mg bid x 3 d

β lactams

Amoxicillin/clavulanateCefdinir


p gLevofloxacin 250-500 mg od x 3 d

X Pregnancy & childrenX Avoid if FQ resistance > 10%Reserved for future use


Recommended antimicrobials for acute pyelonephritis in Female

IV: Ciprofloxacin 400 mg IV q 12 h Ceftriaxone 1-2 g IV od Once daily aminoglycoside Ertapenem 1 g IV od if ESBL is suspectedp g p

PO: Ciprofloxacin 500 mg bid (if susceptible) Levofloxacin 750 mg od (if susceptible) Cotrimoxazole DS 1 tab bid (IV to PO) Oral 3rd Ceph (IV to PO)** Avoid empirical FQ Rx if FQ resistance >10%**



Risk factors for ESBL+ Pathogens

Risk factors OR 95% CI Ref.Prior hospitalization 4.52 1.6-13.1 (1)ICU admission 35.7 6.0-214.1 (1)Previous antibiotic exposure

1.10 1.03-1.18 (2)

Ceftazidime use 13.40 1.21-148.85 (3) Fluoroquinolone use 7.1 2.3-22.4 (4) NG tube insertion 3.1 1.5-6.3 (4) Tracheostomy 5.13 1.24-21.1 (3)

(1) Antimicrob Agents Chemother 2002;46:1481-91(2) CID2001;32:1162-71

(3) J Hosp Infect 2003;53: 39-45(4) SIRIRAJ data


Meta-analysis of short (≤7d) vs. long (>7d) duration of antibiotic in ac. pyelonephritis

Clinical failure at the end of follow up; RR = 0.79 [0.56 – 1.12]

J Antimicrob Chemother. 2013 Oct;68(10):2183-91


CPG for the Treatment of Acute Uncomplicated Cystitis & Pyelonephritis in Women 2010

• Recommended duration of antibiotic for acute uncomplicated pyelonephritis• FQs for 7 days• Cotrimoxazole 14 days• Beta-lactam 10-14 daysBeta-lactam 10-14 days

Clinical Infectious Diseases 2011;52(5):561–564

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Indications for Radiologic Studies

1. Acute pyelonephritis, who did not respond to appropriate ATB within the first 72 hrs.

2. Poor controlled DM

3. Immunocompromised hosts

4 P KT4. Post-KT

5. Recurrent UTIs


IV to PO conversions• Types of IV to PO conversions:

1. Sequential therapy: same drug2. Switch therapy: different drug, same spectrum3. Step-down therapy: different drug, narrower

spectrumspectrum

• Can’t be used in some conditions:• CNS infections• Infective endocarditis

• Bacteremia is not a contraindication

Kris M kuper. Health-system pharmacies fourth edition (chapter 39)


IV to PO conversions (cont.)• Selection of patients:1. Intact and functioning GI tract2. Improving clinical status3. Effective antibiotic with good bioavailability is

availableavailable4. Still need antibiotic therapy!!

*** IV to PO conversions may lead to unnecessary (prolonged) antibiotic use ***

Kris M kuper. Health-system pharmacies fourth edition (chapter 39)


Antibiotics commonly used for sequential therapy

Antibiotics IV dose PO doseCiprofloxacin 400 mg q 12 h 500 mg q 12 h

Levofloxacin 500-750 mg q 24 h 500-750 mg q 24 h

Moxifloxacin 400 mg q 24 h 400 mg q 24 hg q g qCotrimoxazole 800/80 q 12 h 800/80 q 12 hMetronidazole 500 mg q 8 h 400 mg q 8 h

Linezolid 600 mg q 12 h 600 mg q 12 h

Azithromycin 500 mg q 24 h 500 mg q 24 h

Cefuroxime 750-1500 mg q 8 h 250-500 mg q 12 h

Clindamycin 300-600 mg q 8 h 300-450 mg q 6 h


Antibiotics commonly used for switch therapy

IV antibiotics PO antibioticsAmpicillin 1-2 g q 4-6 h Amoxycillin 500 mg tid or 1000 mg bid pc

Cefazolin 1-2 g q 8 h Cephalexin 250-1000 mg qid pc

Ceftriaxone 1-2 g q 24 hCefotaxime 1-2 g q 8 h

Cefdinir 100 mg tid or 200 mg bid pcCefixime 400 mg od pcCefditoren 100 mg tid or 200 mg bid pcCeftibuten 400 mg od pc

Cloxacillin 2 g q 4 h Dicloxacillin 250-500 mg qid ac

17 May 2019 (Friday) Workshop on Antimicrobial Stewardship Program

18‐20 May 2019 (Sat‐Mon)f f

SAVE THE DATE

Siriraj Infectious Disease Conference 2019

@ Siriraj Hospital, Bangkok

Organized by Division of Infectious Diseases and Tropical Medicine, Faculty of Medicine Siriraj Hospital

Contact: [email protected] page: Siriraj Infectious Disease Conference

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rdu opd lampoon 10 aug 2018...06/08/2018 5 คณะแพทยศาสตร ศ ร ราชพยาบาล มหาว ทยาล ยมห ดล Common Causes of Food