2 clinical treatment of bacterial infections hando

8/12/2019 2 Clinical Treatment of Bacterial Infections Hando

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Clinical treatment of bacterial

infectionsDebra Wollner, PhD

Southwest College of NaturopathicMedicine

Tempe, AZ



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


2



Terminology

• Anorexia

• Nausea

•

Vomiting• Bloating

• Diarrhea


3



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?


4



When to use bacteriocidal drugs

• Immunosuppressed

• Life threatening dz

– Meningitis

– Endocarditis

– Osteomyelitis

– Pseudomonas in cystic fibrosis

Bacteriostatic won’t cut it in these cases


5



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)


6



ANTIBIOTIC TREATMENT

Specific bacterial infections

RTI, ABECB, CAP, UTI, skin, GI


7



RESPIRATORY TRACT INFECTIONS

PharyngitisSinusitis

Otitis

Bronchitis

Pneumonia


8



PHARYNGITIS


9



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


10



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


11



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 -


12



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


13



URI

Coughs and colds


16



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


17



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


18



ACUTE RHINOSINUSITIS


19



Acute rhinosinusitis

• Predictive characteristics

– Symptoms lasting > 7 days

– Maxillary facial or tooth pain or tenderness

– Purulent nasal discharge


20



Acute rhinosinusitis

• Cause

• S.pneumonia or H.influenza


21



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


22



Resistance

• Strep pneumo usu resistant to PCN due to

decreased uptake

• May use double the dose to overcome

resistance


23



BRONCHITIS


24



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


25



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


26



INFLUENZAVIRAL TREATMENTS


27



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


28



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


30



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)


31



Treatment guidelines ABECB

• CBC with differential

• If see shift to left

•

Leukocytosis• May see immature cells (blasts)


32



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


33



OTITIS MEDIA


34



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


35



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


36



PNEUMONIA


37



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


38



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


39



PRSP

• Penicillin resistant Strep Pneumoniae

• May still use penicillin and cephalosporin

• Generally recommended

– Amoxicillin, amoxicillin/clavulanat, crfuroxime

– Clarithro/azithromycin

– Doxycycline


40



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

Southwest College of NaturopathicMedicine 41



Telithromycin/Ketek

• Useful for ABECB, CAP, bacterial sinusistis

• Effective against multidrug resistance

Strep.pneumo

• Caution

– Associated with acute liver failure




Legionnaires

• Outbreaks

• Susceptible population

• Treatable with macrolides




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?

46



Response

• What is the microbe?

47



What is the microbe?

• If positive, then what?

48



Positive strep

• What if allergy is present?

49



Allergy to pen

• Comes back in a week, not feeling any better,now what?

50



Erythromycin resistant

51



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?

52



Diagnosis

• Organisms?

53



Organisms

• Treatment, particularly in pen allergy?

54



Treatment, particularly in pen allergy?

55



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?

56



Diagnosis and treatment?

• Patient returns in 1 week, now has a fever of

101, cough still remains.• Diagnosis and treatment?

57



Diagnosis and treatment?

• If bacterial – What are the most likely organisms?

58



What are the most likely organisms?

• Treatment?

59



Treatment

• What if patient is pregnant?

60



What if patient is pregnant?

61



UTI

Southwest College of Naturopathic

Medicine 62



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


Medicine 63



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%


Medicine 64



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


Medicine 65



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


Medicine 66



Treatment guidelines UTI

• Complicated cystitis

• Cotrimoxazole (TMP/SMX) >3day (longer

duration)

• Cephalexin >5-7 days

• Nitrofurantoin >5-7 days

• Quinolone > 3day


Medicine 67



Treatment guideline- UTI recurrences

• Low dose daily prophylaxis

• Post coital prophylaxis

• Patient self diagnosis and treatment

• Estrogen if postmenopausal

• Cranberries and probiotics


Medicine 69



CASE STUDY UTI


Medicine 70



UTI case study

• 22 year old woman presents with painful,urgent urination lasting 2 days.

• Your response?

71



Response

• What are the most likely microbes?

72



Now?

• Treatment?

73



Pen allergy

• Sulfa allergy?

74



To avoid development of quinolone



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

76



DIARRHEA


Medicine 77

ff



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


Medicine 78

f d h



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


Medicine 79

d h



Acute diarrhea

• Many causes• Take history

– # stools/day

– Consistency

– Volume

– Degree of interference

• Determine cause

– Associated with travel, food

– Associated symptoms

• Dystentery, dehydration


Medicine 80

ddi i l l



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


Medicine 81

Community acquired or traveler’s



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


Medicine 82

N i l di h



Nosocomial diarrhea

• Onset >3 days in hospital

• Test for C.difficile

– Discontinue antibiotics if Positive

– Consider metronidazole


Medicine 83

P i di h ( 7d)



Persistent diarrhea (>7d)

• Parasites possible

– Particularly if immunocompromised

– Giardia, cryptosporidium, Cyclospora, Isospora

belli

• If HIV positive

– microsporidium or MAC likely causes


Medicine 84

Q i l i t t C j j i



Quinolone resistant C.jejuni

• Campylobacter leading cause of bacterial GEin US

• 80% of chickens are contaminated

• Sarafloxacin and enrofloxacin used in chicken

farming


Medicine 85

T ll ’ di h



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


Medicine 86

S l ll Shi ll C l b t



Salmonella, Shigella, Campylobacter

• Erythromycin


Medicine 87

T t t id li di h



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


Medicine 88



H.PYLORI


Medicine 89



Di i f H l i



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)



Stool antigen test (HpSA)

• Can test pre treatment

• Can test post treatment as proof of cure

92

Non ulcer dyspepsia (NUD)



Non-ulcer dyspepsia (NUD)

• Treatment controversial

• Rule out other causes

• Treat if H.pylori positive

93

H pylori treatment



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)

94

Antacids and interactions



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

95



Skin and soft tissue

Bacterial

Fungal

Viral

Skin and soft tissue bacterial



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

97





• 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

98

Impetigo



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


Medicine 99





• 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

100





• Augmentin (amoxicillin + clavulanate)

• In penicillin allergy

– Use doxycycline or 2nd-3rd generation

cephalosporin – Don’t use macrolides, they won’t cover most

common causes

101

MRSA



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



Yersinia pestis – the plague

Yersinia pestis



Yersinia pestis

• Streptomycin• Gentamicin

• Tetracyclines

• Chloramphenicol• Doxycycline - standard

• Trimethoprin/sulfamethoxazole

• Associated treatments – Drain buboes



OPHTHALMIC INFECTIONS

Ophthalmic products



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

106

Ophthalmic



Ophthalmic

• Avoid ophthalmic corticosteroids – Cause herpes keratitis

• Antiviral

– Trifluridine

• Antifungal

– Natamycin

107

Neonatal conjunctivitis



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)

108

Overview of the lecture



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.

2 clinical treatment of bacterial infections hando

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