2 clinical treatment of bacterial infections hando
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Clinical treatment of bacterial
infectionsDebra Wollner, PhD
Southwest College of NaturopathicMedicine
Tempe, AZ
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Lecture objectives
• At the end of this lecture, students will be able to
– Identify when the use of antibiotics may be indicated
– Identify the correct antibiotic to use for a given
infection/infectious organism – Recognize when the incorrect antibiotic has been
prescribed
• Due to contraindications/precautions
• Due to mis-application of medication
– Identify common and serious side effects associatedwith given antibiotics
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Terminology
• Anorexia
• Nausea
•
Vomiting• Bloating
• Diarrhea
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Principles of treatment
• Is an antibiotic indicated• What organisms are most likely
• Have a list of local infectious organisms and their susceptibilities
• How to choose the most appropriate antibiotic• Is a combination appropriate
• Tuberculosis, H.Pylori and HIV always use combo
• Important host factors• Allergy, side effects, organ system disease
• Best route of administration• Oral easiest, topical possible, im?
• Appropriate dose• Duration of therapy• Resistance? Side effects?
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When to use bacteriocidal drugs
• Immunosuppressed
• Life threatening dz
– Meningitis
– Endocarditis
– Osteomyelitis
– Pseudomonas in cystic fibrosis
Bacteriostatic won’t cut it in these cases
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How long should an infection be
treated?
• A guess
• 3 days enough for most infections in healthy
individual
• 10 day or more necessary for the chronically ill andimmunosuppressed
• 10 days necessary for strep throat
–
Currently• Diabetic infections generally require longer term (2-3
weeks)
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ANTIBIOTIC TREATMENT
Specific bacterial infections
RTI, ABECB, CAP, UTI, skin, GI
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RESPIRATORY TRACT INFECTIONS
PharyngitisSinusitis
Otitis
Bronchitis
Pneumonia
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PHARYNGITIS
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RTI’s - Pharyngitis
• 5-15% adult sore throats group A b hemolyticstrep
• 15-30% children sore throats group A b hemolyticstrep
• All other most likely caused by a virus or otheruntreatable microbe
• Treatment recommended to prevent lifethreatening complications – Rheumatic fever
• Symptomatic relief felt rapidly only if treatedwithin 48 hours of onset of symptoms
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RTI’s - When to treat pharyngitis
• Four predictors of A b hemolytic strep – Pharyngeal/tonsillar exudate
– Tender anterior cervicallymphadenopathy
– Fever or history of fever – Absence of cough
• Clinical treatmentguidelines – Patients with 3-4 criteria
•
40-60% positive predictivevalue
– Absence of 3-4 criteri• 80% negative predictive value
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Guidelines for treatment
• Patient positive for 2-4 criteria
– Perform RAT
– If positive, begin treatment
• Patient positive for 3-4
– No RAT needed
– Treatment recommended
• Must confirm RAT, either + or -
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Treatment for pharyngitis (+)
• Penicillin (oral) – Pen V250 mg bid in children
– Pen V 500 mg bid or 250 mg quid in adults
– OR Pen G benzathine im 1.2 million U once
– Amoxicillin liquid for children unable to swallow oralpills
– Cephalosporins also effective
• 10 days
• 5 days azithromycin sometimes useful
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URI
Coughs and colds
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Upper Respiratory Infection
• Strep pneumonia – URI
• Otitis
• Sinusitis
• Pneumonia
• Group A – Strep throat
– Cellulitis
• Group B –
Neonatal sepsis – Chronic adult skin infection
– UTI
– Diabetic foot
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URI infections
• Usually
– H.influenza, S.pneumoni, M.catarrhalis,
C.pneumococcus
• Choice of medication
– First doxycycline (could destroy child liver)
– Second cefpodoxixime or cefdinir
– Third amoxicillin/clavulanic acid
– Last choice quinolones $500! Harms joints
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ACUTE RHINOSINUSITIS
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Acute rhinosinusitis
• Predictive characteristics
– Symptoms lasting > 7 days
– Maxillary facial or tooth pain or tenderness
– Purulent nasal discharge
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Acute rhinosinusitis
• Cause
• S.pneumonia or H.influenza
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Treatment
• Doxycycline – 1/day for 7-10 days
– Not in pregnancy
– Not in children
• Amoxicillin – Up to 50% resistant strains
– Use amoxiciliin plus clavulanic acid
– Or cephuroxime or cefposoxime
• Cotrimoxazole (TMP+SMZ) – Many strains are resistant
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Resistance
• Strep pneumo usu resistant to PCN due to
decreased uptake
• May use double the dose to overcome
resistance
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BRONCHITIS
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Acute bronchitis
• Most cases are viral
• No antibiotic indicated
•
Bacterial bronchitis – Mycoplasma or Chlamydia pneumonia
– In an outbreak, could be Bordatella pertussis
• Erythromycin
• 2005 last outbreak in AZ
• Outbreaks (2010) in northern CA, TX
– No evidence for S. pneumo, H. influenza or M.catarrhalis
• Doxycycline not generally useful
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When to treat acute bronchitis
• Bordetella pertussis
• Atypical presentation in immunized population
• Outbreaks every 2-5 years, summer/fall
• Persistent chronic cough without whoop or post-tussive
vomiting – Lasts several weeks
– Starts as a cold, progresses to severe cough, then convalescentphase
– 5-7 day incubation period
• Treatment recommended to reduce contagion – Erythromycin
• Rarely seen in the absence of an outbreak
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INFLUENZAVIRAL TREATMENTS
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Anti-viral treatment of influenza
• Will decrease the course of the infection by 1 day
• Must begin treatment within 48 hours of onset
• Amantadine, rimantadine
– Influenza A only
• Zanamivir, oseltamavir
– Influenza A and B
•
Prophylaxis recommended for high risk patientsduring outbreak, and during the 14 day postimmunization period
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Treatment guidelines non specific URI
• Usually viral
– May have sinus, pharyngeal and lower airways
symptoms
– May see green nasal discharge, tonsillar exudateand green phlegm
• No antibiotic treatment indicated
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Treatment guidelines ABECB
• Acute bacterial exacerbation of chronicbronchitis
• Cough producing sputum
•
Mucous hypersecretion and hypertrophy of submucosalglands
• Decreased mucociliary clearance, loss of ciliated cells andincreased secretions
• Functional airway inflammation and narrowing
• Not reactive airway disease (asthma)
• Not chronic bronchitis (usually associated with smoking)
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Treatment guidelines ABECB
• CBC with differential
• If see shift to left
•
Leukocytosis• May see immature cells (blasts)
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Treatment of ABECB
• Probably H.flu, S.pneumo, M.cat or
C.pneumoniae
• Doxycycline first choice
• Or cefpodoxime, cefdinir
• Amoxacillin +clavulanic acid
•
TMP/SMZ• Last choice quinolones
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OTITIS MEDIA
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Acute otitis media
• Spontaneous resolution likely within 3-5 days
• Treatment with antibiotic NOT recommended
– even if you see a bulging, pusy eardrum
• If Strep pneumo, then amoxicillin is likely to be
effective
• But could become mastoiditis
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Acute otitis media
• If amoxicillin does not clear the infection• Consider S.pneumo, H.flu, M.cat
• Amoxicllin/clavulanate
• Cefuroxime
• Cefrtriaxone
• Doxycycline (adults)
• For pen allergy – Clindamycin + cotrimoxazole
• However• 10% S.pneumo resistant to clindamycin
• 40% resistant to TMP/SMZ
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PNEUMONIA
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CAP community acquired pneumonia
• Likely S.pneumoniae, H.influenzae, M.catarrhalis,
• Mycplasma pneumoniae
– Sudden onset, severe pain
• Chlamydia pneumoniae
• Legionella sp (in outbreaks)
• Staph aureus
– In diabetes, or in nursing homes
• Enterobacteriaceae
– In nursing homes
• Pseudomonas
– Bronchiectasis, chronic steroid use
• Oral anearobes – Aspiration prone patients
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Treatment of CAP
• Doxycycline
• Macrolide/azalide – Some S.pneumo and H.flu is resistant
• Cefuroxime – Some resistance among atypical bacterial causes
• Cefpodoxime – Some resistance among atypicals
• Amoxicillin/clavulanate – Some resisitance among atypicals
• Amoxicillin alone – 30% H.flu, most M.cat resistant
• 3rd/4th generation quinolones – Resistance developing
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PRSP
• Penicillin resistant Strep Pneumoniae
• May still use penicillin and cephalosporin
• Generally recommended
– Amoxicillin, amoxicillin/clavulanat, crfuroxime
– Clarithro/azithromycin
– Doxycycline
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Macrolide resistant Strep pneumoniae
• High level of resistance
• Possible mechanisms of resistance
– Efflux
– Blocked binding to ribosome
• 20-30% Strep pneumo resistant
• >95% H.influenzae resistant
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Telithromycin/Ketek
• Useful for ABECB, CAP, bacterial sinusistis
• Effective against multidrug resistance
Strep.pneumo
• Caution
– Associated with acute liver failure
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Legionnaires
• Outbreaks
• Susceptible population
• Treatable with macrolides
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Case study strep throat
• 15 year old patient presents with severe sore
throat, inability to speak above a whisper,
duration >1 week. Throat shows pus filled
blisters.
• Response?
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Response
• What is the microbe?
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What is the microbe?
• If positive, then what?
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Positive strep
• What if allergy is present?
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Allergy to pen
• Comes back in a week, not feeling any better,now what?
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Erythromycin resistant
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Case study rhinosinusitis
• 37 year old female presents 1 month post
acute viral cold. Cold symptoms gone,
however facial pain on pressing cheeks, and
tooth pain when eating. Night-time andmorning cough, productive.
• Diagnosis?
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Diagnosis
• Organisms?
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Organisms
• Treatment, particularly in pen allergy?
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Treatment, particularly in pen allergy?
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Case study acute bronchitis
• FA, 35 year old female, persistent coughfollowing an acute respiratory viral infectionthat began 7 days ago. Nasal stuffiness and
sore throat resolved 3-4 days ago, coughpersisted, sputum thick and mucoid, burningsubsternal pain.
• Afebrile, course rales
• Diagnosis and treatment?
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Diagnosis and treatment?
• Patient returns in 1 week, now has a fever of
101, cough still remains.• Diagnosis and treatment?
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Diagnosis and treatment?
• If bacterial – What are the most likely organisms?
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What are the most likely organisms?
• Treatment?
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Treatment
• What if patient is pregnant?
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What if patient is pregnant?
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UTI
Southwest College of Naturopathic
Medicine 62
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Common causes of UTI
• E.coli – 70-95%
• Staph.saprophyticus
– 5-20%
• Other Enterobacteriaceae, proteus
– 5-15%
• Enterococcus sp
–
Low, but increasing – Found in bactrim and quinolone users
Southwest College of Naturopathic
Medicine 63
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UTI susceptibilities
• Depends on local factors
• Nitrofurantoin >99%
– Dependable
• Newer Fluoroquinolones >99%• 2nd-3rd generation cephs >95%
• Trimethoprim plus sulfamethoxazole 3 days 80-90%
•
1st
generation cephalosporins 60-70%• Amp or Amox <50-60%
Southwest College of Naturopathic
Medicine 64
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Nitrofurantoin
• Black box warning – ACUTE, SUBACUTE, OR CHRONIC PULMONARY
REACTIONS HAVE BEEN OBSERVED INPATIENTS TREATED WITH NITROFURANTOIN.
IF THESE REACTIONS OCCUR, MACRODANTINSHOULD BE DISCONTINUED ANDAPPROPRIATE MEASURES TAKEN. REPORTSHAVE CITED PULMONARY REACTIONS AS ACONTRIBUTING CAUSE OF DEATH.
• Usually only seen on long term use• More of a concern with elderly
Southwest College of Naturopathic
Medicine 65
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Treatment guidelines UTI
• Uncomplicated cystitis
• Cotrimoxazole (TMP/SMZ) for 3 days
– If sulfa allergy, use trimethoprim alone
• Nitrofurantoin 3-5 days or longer
• Quinolone for 3 days
•
Amox – 50% of the time doesn’t work
Southwest College of Naturopathic
Medicine 66
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Treatment guidelines UTI
• Complicated cystitis
• Cotrimoxazole (TMP/SMX) >3day (longer
duration)
• Cephalexin >5-7 days
• Nitrofurantoin >5-7 days
• Quinolone > 3day
Southwest College of Naturopathic
Medicine 67
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Treatment guideline- UTI recurrences
• Low dose daily prophylaxis
• Post coital prophylaxis
• Patient self diagnosis and treatment
• Estrogen if postmenopausal
• Cranberries and probiotics
Southwest College of Naturopathic
Medicine 69
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CASE STUDY UTI
Southwest College of Naturopathic
Medicine 70
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UTI case study
• 22 year old woman presents with painful,urgent urination lasting 2 days.
• Your response?
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Response
• What are the most likely microbes?
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Now?
• Treatment?
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Pen allergy
• Sulfa allergy?
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To avoid development of quinolone
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To avoid development of quinolone
resistant microbes
• Don’t use quinolones
• Other older medications work also
• May use quinolones when nothing else works
– Cystic fibrosis pseudomonas
– Chronic UTI
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DIARRHEA
Southwest College of Naturopathic
Medicine 77
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Differential diagnosis- diarrhea
• Acute – Infections (bacterial, parasitic, viral) – Food poisoning – Medications
• Chronic (osmotic) – Secretory
• Congenital• Bacterial toxins• Ileal bile acid• Malabsorption•
IBD-UC, Crohn’s, diverticulitis• Chronic inflammatory
– Many
Southwest College of Naturopathic
Medicine 78
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Major causes of acute diarrhea
•Bacterial – Bacilius cereus – Campylobacter
– Clostridium difficile – Clostridium perfringens – Escherichia coli
•
Enterotoxigenic• Enteroinvasive• Enterohemorrhagic• 0157:H7
– Listeria monocytogenes – Salmonella
– Shigella – Staphylococcus aureus – Vibrio – Yersinia enterocolitis
• Parasites and protozoa – Crytposproidium
– Cyclospora
– Entamaeba histolytica
• Viruses – Adenovirus
– Norwalk virus
– Rotavirus
Southwest College of Naturopathic
Medicine 79
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Acute diarrhea
• Many causes• Take history
– # stools/day
– Consistency
– Volume
– Degree of interference
• Determine cause
– Associated with travel, food
– Associated symptoms
• Dystentery, dehydration
Southwest College of Naturopathic
Medicine 80
ddi i l l
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Additional clues
•
Bloody stools – Salmonella, shigella, campylobacter, e.coli 0157, clostridium difficile, entamoeba histolytica
• Rectal pain – Campylobacter, salmonella, shigella, neisseria gonorrheae, herpes, chlamydia, E. histolytica
• Severe or persistent abdominal pain – Campylobacter, yersinia, clostridium perfringens, aeromonas
• Recent antibiotic therapy or chemotherapy – C. difficile, salmonella
• Travel (Mexico, Africa, Middle or Far East) – Enterotoxigenic Ecoli , others
• Family or friends affected – Food borne pathogens, staphylococcus
• Homosexual male – Herpes, Chlamydia, Treponema pallidum, E.histolytica, Shigell, Giardia, N.gonorrheae,
Cryptosporidium
•Hospital acquired – C. difficile
• Daycare centers, mental institutions – Giardia, C.difficile, Salmonella, Shigella, rotavirus
Southwest College of Naturopathic
Medicine 81
Community acquired or traveler’s
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Community acquired or traveler s
diarrhea
• Accompanied by fever or bloody stool
• Culture for Salmonella, Shigella,
Campylobacter, E.coli 0157, C.difficile
– Shigella-quinolone
– Resistant Campylobacter - macrolide
– Avoid anti-motility agents and anti-microbials if
STEC suspected
Southwest College of Naturopathic
Medicine 82
N i l di h
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Nosocomial diarrhea
• Onset >3 days in hospital
• Test for C.difficile
– Discontinue antibiotics if Positive
– Consider metronidazole
Southwest College of Naturopathic
Medicine 83
P i di h ( 7d)
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Persistent diarrhea (>7d)
• Parasites possible
– Particularly if immunocompromised
– Giardia, cryptosporidium, Cyclospora, Isospora
belli
• If HIV positive
– microsporidium or MAC likely causes
Southwest College of Naturopathic
Medicine 84
Q i l i t t C j j i
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Quinolone resistant C.jejuni
• Campylobacter leading cause of bacterial GEin US
• 80% of chickens are contaminated
• Sarafloxacin and enrofloxacin used in chicken
farming
Southwest College of Naturopathic
Medicine 85
T ll ’ di h
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Traveller’s diarrhea
• Mild – 1-2 stools/24 hours – No therapy
• Mild to moderate – >2 stools/24 hours –
If no distressing symptoms• Loperimide or bismuth
– If distressing symptoms• Loperimide + fluoroquinolone 500 mg quinolone po bid up
to 3 days• Reassess
• Severe – Fever, bloody stool >6/24 hours – 400 mg norfloxacin bid 3-5 days
Southwest College of Naturopathic
Medicine 86
S l ll Shi ll C l b t
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Salmonella, Shigella, Campylobacter
• Erythromycin
Southwest College of Naturopathic
Medicine 87
T t t id li di h
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Treatment guidelines- diarrhea
• Rarely use antibiotic in acute
• Don’t use antibiotic if virus or E.coli 0157
• Quinolones don’t cover most common cause,
C.jejuni
• Traveler’s diarrhea may require quinolone
short course
• C.diff requires metronidazole
Southwest College of Naturopathic
Medicine 88
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H.PYLORI
Southwest College of Naturopathic
Medicine 89
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Di i f H l i
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Diagnosis of H.pylori
• Endoscopy (invasive) – Histology
– Culture
– CLO-test
• Non-invasive
– Serum serology (IgG)
– Saliva or urine test
– Breath test for urea
– Stool antigen HpSA
91
Stool antigen test (HpSA)
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Stool antigen test (HpSA)
• Can test pre treatment
• Can test post treatment as proof of cure
92
Non ulcer dyspepsia (NUD)
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Non-ulcer dyspepsia (NUD)
• Treatment controversial
• Rule out other causes
• Treat if H.pylori positive
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H pylori treatment
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H.pylori treatment
• Usually recommended together
• Bismuth subsalicylate 525 mg QID x 1week
(protects stomach lining)
• Metronidazole 250 mg QID x 1 week
• Tetracycline 500 mg QID x 1 week
• Omeprazole 20mg BID x 1 week (Proton
pump inhibitor - lowers stomach acidity)
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Antacids and interactions
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Antacids and interactions
• Acid stomach required for absorption of manydrugs
– Digoxin, phenytoin, isoniazid, ketoconazole
•
Take the antacid 2 hours before or 2 hoursafter other drugs
• Cipro best taken 2 hours before antacids
•
Tetracyclines at least 2-3 hours before antacids
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Skin and soft tissue
Bacterial
Fungal
Viral
Skin and soft tissue bacterial
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Skin and soft tissue, bacterial
• Abscess must be drained
• Antibiotic treatment may be needed, if
cellulitis or deep tissue involved
• Skin infections almost always Staph.aureus
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Skin and soft tissue bacterial
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Skin and soft tissue, bacterial
• Routine erysipelas and cellulitis – b hemolytic Strep., sometimes Staph. Aureus, less
commonly Gram Negative bacteria
– PCN, erythro, cephalexin, clindamycin
• Impetigo – from sandbox – b Strep
– Treat with dicloxacillin (extended spectrum penicillin)instead of topically
• Bollous – Staph
– Treat with dicloxacillin
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Impetigo
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Impetigo
• Retapamulin/Altabax• Topical treatment approved for impetigo
• Derived from Clitopilus passeckerionus
• Inhibits 50S bacterial ribosomal subunit• Not approved for mucosal surfaces
• Do not use on large surface area
• Some irritation at application site• Preg B
Southwest College of Naturopathic
Medicine 99
Skin and soft tissue bacterial
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Skin and soft tissue, bacterial
• Folliculitis, furunculitis, carbunculitis – Staph.aureus +/- b hemolytic Strep
– May need antibiotic if cellulitis or deep tissue involved
•
Human/animal bite• Treat skin flora and what’s in the mouth
– Amox alone, augmentin (amox+clavulanate) standard for
bites, PCN + dicloxacillin, cephalexin, clindamycin,
doxycycline – Macrolides won’t cover
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Skin and soft tissue bacterial
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Skin and soft tissue, bacterial
• Augmentin (amoxicillin + clavulanate)
• In penicillin allergy
– Use doxycycline or 2nd-3rd generation
cephalosporin – Don’t use macrolides, they won’t cover most
common causes
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MRSA
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MRSA
• Local wound cleansing and debridement must beaccompanied by antibiotic therapy.
• At least 10 days of
–
Trimethoprim/sulfamethoxazole – Minocycline or doxycycline
– Rifampin plus tmp/smz or minocycline or doxycycline
– Vancomycin
– Linezolide – standard today• Watch for myelosuppression
Yersinia pestis – the plague
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Yersinia pestis – the plague
Yersinia pestis
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Yersinia pestis
• Streptomycin• Gentamicin
• Tetracyclines
• Chloramphenicol• Doxycycline - standard
• Trimethoprin/sulfamethoxazole
• Associated treatments – Drain buboes
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OPHTHALMIC INFECTIONS
Ophthalmic products
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Ophthalmic products
• Bacitracin –GPC (S.aureus, S.pneumo.) – conjunctivitis
• Sulfonamides- GPC, hemoph
– Conjunctivitis, allergenic
• Macrolides (erythro)- GPC
• Tetracyclines – GPC, hemoph, irritating
• Aminoglycosides- GNB, sensitizing
•Quinolones- GPC + GNB, broad, expensive
• Trimethoprim/polymyxin B +bacitracin/polymixin B
– Cost effective, fewer toxicities of some others
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Ophthalmic
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Ophthalmic
• Avoid ophthalmic corticosteroids – Cause herpes keratitis
• Antiviral
– Trifluridine
• Antifungal
– Natamycin
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Neonatal conjunctivitis
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Neonatal conjunctivitis
• May be passed through vaginal birth
• Mother may not know of infection
• Possibly gonorrhea or chlamydia
• Many states routinely require treatment of
newborns with eye drops
– Erythromycin
– Silver nitrate (rarely used)
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Overview of the lecture
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Overview of the lecture
• Common bacterial infections
• Know when antibiotics are appropriate
• Know which antibiotic is most likely to be
effective
• Recognize problems of antibiotic use in
patients.