Category: Abx

EBM: Pneumonia

12/13/2017

Current Definitions

Pneumonia: A new lung infiltrate with symptoms concerning for an infectious etiology. Should be considered in all patients with a cough and fever, with a high index of suspicion in elderly who present with generalized weakness, confusion, or worsening medical conditions. Certain clinical features direct you towards the diagnosis of pneumonia, however no single finding is able to predict pneumonia.
CAP: Acute infection in patients not hospitalized of longterm care facility within the past 14 days
HAP: Acute infection 48 hours after hospitalization
VAP: Acute infection 48 hours after intubation
HCAP: No longer considered a diagnosis

Blood Cultures

Utilization of blood cultures can assist the treatment of many patients, however not every patient requires blood cultures. Whenever drawn, you should obtain two sets of cultures (or 3 for endocarditis). A recent article found a number needed to treat was 250 for a change in treatment, however other studies have found blood cultures more useful.

Major Criteria:

temperature > 39.5°C (103.0°F)
indwelling vascular catheter
clinical suspicion of endocarditis

Minor criteria

temperature 38.3–39.4°C (101– 102.9°F)
age > 65 years
chills
vomiting
hypotension (systolic blood pressure < 90 mm Hg)
neutrophil% > 80
white blood cell count > 18 k
bands > 5%
platelets < 150 k
creatinine > 2.0.

www.sciencedirect.com/science/article/pii/S0736467908004447?via%3DihubA blood culture is indicated by the rule if at least one major criterion or two minor criteria are present.

Admission Criteria: CURB 65 and PSI/PORT

Patients with CURB 65 scores 0-1 can potentially be discharged, however consider the patient's physical exam, oxygen saturation, and immunosupressed status, as the CURB 65 score does not take these into account. Those with a CURB 65 score greater than 3 should be considered for an ICU admission.

The PSI/PORT score can also be used but is more thorough, including nursing home status, liver and heart disease status, as well as ABG data. While the CURB 65 has better specificity for identifying severe disease, the PSI/PORT score is more sensitive at identifying low-risk patients for discharge.

Treatment

For CAP, guidelines recommend Azithromycin or Doxycycline as azythromycin has increasing rates of resistance. In outpatients with co-morbidities or risk for resistance, you should consider levofloxacin or moxifloxacin. Patients admitted for CAP should be treated with single agent fluoroquinolone or dual agent treatment with ceftriaxone and azithromycin. ICU admitted CAP patients require an anti-pneumococcal betalactam (Ceftriaxone) and either azithromycin or fluoroquinolone. Treatment duration is typically 5 days.

1 Comment

COPD Exacerbations & Antibiotics

8/17/2016

1 Comment

Adapted from Molly Graham's August 17th 2016 Grand Rounds presentation.

Treatment of acute COPD exacerbation

Acute exacerbations are characterized by sustained (48 hours or more) worsening of shortness of breath and coughing, with or without sputum. The most common cause is a viral or bacterial infection.

Therapy with short-acting beta2 agonists and anticholinergic bronchodilators
Oral corticosteroids (e.g., prednisone 25-50 mg/day) for less than two weeks in most moderate to severe COPD patients. A dose of 30–40 mg of prednisone equivalent per day has been used in practice.
Antibiotic use is based on risk factors; evidence shows that antibiotics improve outcomes in those with critically ill COPD exacerbations, however mild or moderate exacerbations are not improved by antibiotics.

Risk Factors

Age >65
FEV1 <50 % of predicted
> 4 exacerbations / year
Ischemic heart disease
Use of home oxygen
Chronic oral steroid use
Antibiotic use in the past 3 months.

Source: British Columbia COPD Guidelines

Common Co-morbidities in COPD

Procalcitonin Levels

Peptide inflammatory marker currently being evaluated for use as a POC marker for inflammatory and infectious disease.

Evaluation of COPD exacerbations with procalcitonin can decrease antibiotic use.

A PCT <0.1ng/mL indicates patient outcomes will not be improved with antibiotics.

Procalcitonin for COPD.pdf
File Size:	579 kb
File Type:	pdf

Download File

1 Comment

Meet the New Sepsis (same as the old sepsis)

7/20/2016

0 Comments

SIRS (>2) (old)

T <36 or >38
HR >90
RR >20
WBC <4000 or >12000

qSOFA (>2) (new)

RR > 22
AMS
SBP <100mmHG

0 Comments

From the TR: Pneumonia

7/13/2016

0 Comments

From the Teaching Resident: a quick review of how to treat any pneumonia patient

0 Comments

qSOFA & The New Sepsis Definitions

6/1/2016

0 Comments

qSOFA was introduced as part of the Sepsis-3 guidelines published in February 2016. SOFA is a well-known scoring system used in the ICU setting, and qSOFA is a simplified version that uses only 3 clinical criteria; altered mentation, tachypnea, and hypotension.

Why the change; the current SIRS Criteria is less sensitive and specific than the SOFA score. Utilizing 2 or more SIRS criteria was felt to be unhelpful by the 2016 task force,

Instead, qSOFA utilizes the most important criteria for those at risk for poor outcomes from sepsis.

Looking forward, remember that qSOFA is not a screening tool for sepsis, but a predictor of poor outcomes to help identify those patients who need additional providers and immediate interventions.

To learn more about the new JAMA Third International Consensus Definitions for Sepsis and Septic Shock, read the article, or listen to the FOAMcast on Sepsis Redefined.

0 Comments