Retrospective Review of a CIWA-Ar Based Alcohol Withdrawal Protocol At St. Pauls Hospital

Pediatrics Rotation: Intra-abdominal Infections in ChildrenChristopher Yearwood2014-2015 Island Health Pharmacy Resident Presented on Tuesday December 16th, 2014ObjectivesReview the guidelines for intra-abdominal infections (IAIs) using a recent case examplePatient CaseIDN4D, a 23 mo (cGA 21 mo) femaleCCStoma site red & swollen despite recent abx txPt sleeps on stomach and not sleeping wellAllergiesNDKASocial HxLives with parents, mom & dadRecently moved from Calgary to VictoriaHPIDecember 6th, 2014@ER T 39.3C HR 160 reg RR 20 SpO2 100% RAPt had corrective surgery in October due to bladder malformationSeen by GP on previous day and started on abxFather noted no improvement after receiving x4 doses of abx oral intake, urine outputDiagnosed with suprapubic abdominal wall abscessMedical HistoryPMHxSurgical HxImmunizations up-to-date (incld. flu shot)Awaiting PICC placement (Dec 8th)Urogenital malformation causing urinary ascites in uteroVesicostomy to decompress her bladderCerebral artery occlusion causing right-sided weakness and seizuresReversal of vesicostomy and vaginal-bladder repair(Oct 31st/14)Developmental delayReview of SystemsFindings December 8th, 2014VitalsWt 10 kg BP 93/57 HR 85 RR norm T 36.5C SpO2 99% RACNSSlept well the night before; watching a show on her fathers lap; no obvious cognitive deficitsHEENTSwelling (puffiness) around the eyelidsCVUnremarkableRenal/GUUrea 1.2 SCr 24 Penrose drain (in site of previous vesicostomy) and Foley catheter draining to urine bagGINPO (awaiting PICC insertion)Review of SystemsFindings December 8th, 2014Skin/MSKUnremarkableEndocrineUnremarkableHematologyRBC 4.38 Hgb 126 HCT 0.37 MCV 84 RDW 13 PLT 293WBC 13.8 Neut 10.1 Fluids/LytesNa+ 136 K+ 5.0 Cl- 107 HCO3- 21 AG 3MicrobiologyMRSA ARO screen (-)-veWound Cx (final) Dec 9th: Pseudomonas + othersFluid Cx (final) Dec 9th: E. coli + Pseudomonas + othersBlood Cx (final) Dec 11th: No growth after 5 daysAll other systems unremarkableCultures & SensitivitiesSource: Culture Wound superficial abdominal swab (Dec 6th)Organisms: +3 Pseudomonas aeruginosa, +3 coliform, +1 Enterococcus spp NOT VRE, +1 Viridans group Streptococcus species, +3 Mixed anaerobes, NO MRSAFinal: Dec 9th Pseudomonas aeruginosaCeftazidimeSCiprofloxacinSGentamicinSImipenemSPiperacillin/TazobactamSTobramycinSCultures & SensitivitiesSource: Culture Fluid fluid from abdominal wall abscess (Dec 6th)Organisms: +3 Escherichia coli, +4 Pseudomonas aeruginosa, +2 Viridans group Streptococcus species, +4 Mixed anaerobic including Bacteroides fragilis groupFinal: Dec 9th Escherichia coliP. aeruginosaAmpicillinSCeftazidimeSCephalexinSCefazolinSCiprofloxacinSSGentamicinSSImipenemSPiperacillin/TazobactamSTobramycinSSTMX-SMXSGuidelines for 500Question: What are the Canadian Practice Guidelines for Intra-abdominal Infections?

Answer: Association of Medical Microbiology and Infectious Disease (AMMI) Canada Guidelines

Antibiotics for 500Question: Name one Gm(-), one Gm(+), and one anaerobic spp commonly found in IAIs.Answer:

Bonus for 500Question: Who coined the term antibiotic? Answer: The term was first used in 1942 by Selman Waksman and his collaborators in journals to describe a substance that was antagonistic to the growth of other microorganisms.

Patient Case for 500Question: Is this patient a candidate for a PICC? Home IV Program? Answer:PICC yes requires procedural or general anesthiaHome IV Program dependsDepends on the parentConcern with regards to CADD pump and tubing?Choking hazard in small childrenGuidelines for 1000Question: What is the definition of source control in the context of intra-abdominal infections?Answer: Source control is defined as any single procedure or series of procedures that eliminate infectious foci, control factors that promote ongoing infection, and correct or control anatomic derangements to restore normal physiologic function.

Antibiotics for 1000Question: Name these molecules.Answer:Tazobactam & Piperacillin

-lactam core-lactamase inhibitorExtended spectrum -lactamBonus for 1000Question: In what city were the first pharmacies thought to have been established?Answer: The first pharmacies were thought to have been established in Baghdad in 754.

Patient Case for 1000Question: Is ciprofloxacin a safe and effective PO step-down option for this patient?Answer:Both Pseudomonas & E. coli susceptible to ciprofloxacin (Historically E. coli 83% sensitive)No anaerobic coverage (?metronidazole GI SEs)Fluoroquinolones in children use should be limited?development of arthropathy with cartilage erosionBeagles? vs absence of arthropathy observed?Pediatrics. 2011 Oct 128(4):e1034-45.Ciprofloxacin has been approved by the FDA for use in children with complicated urinary tract infections and pyelonephritis due to Escherichia coli, as well as for postexposure prophylaxis against inhalational anthrax. The American Academy of Pediatrics recommends that the use of fluoroquinolones in children be limited to the treatment of infections for which no safe and effective alternative exists [69]. (See appropriate pediatric drug information topic reviews by searching on the drug name.)

31Case Follow-Up10 days of antibiotic therapy Piperacillin/tazobactam 750 mg IV Q6HPICC inserted on second attemptKetamine seizure thresholdWas not a candidate for Home IV ProgramEyelid resolved with IVFFollow-up utlrasoundClearD/C when antibiotics complete

Thanks!QuestionsDuration of therapy (4-7 vs 5-7 vs 10 days)AlternativesAMS concernsDosing in childrenWhat is good source control?Is piperacillin-tazobactam appropriate?

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