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Management of Common Management of Common Inpatient Infections:Inpatient Infections:

MRSA, C diff, VRE, and more…MRSA, C diff, VRE, and more…

Bradley A. Sharpe, M.D.Associate Professor Medicine

Department of MedicineUCSF

[email protected]

Common Inpatient Infections

RoadmapRoadmap

• Background

• MRSA

• Clostridium difficile

• VRE

• More…


Specific Goals:Specific Goals:

• Appreciate the morbidity and mortality associated with hospital-acquired infections (HAIs).

• Describe optimal therapy for MRSA infections.

• List key principles in the management of Clostridium difficile infection.

• Understand evidence for preventing HAIs.

CaveatsCaveats

• Will discuss hospital-acquired infections + community-acquired

• Cannot cover all in-depth

• Often complex patients (ID consult?)

• Highlight key principles, what you need to know


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RoadmapRoadmap

• Background

• MRSA


• VRE

• More…


Inpatient InfectionsInpatient Infections

• Estimated 1.7 million HAIs per year (2002)

-- Up to 10% of all hospitalized patients

• Responsible for 99,000 deaths/year

• Cost of $4.5 - $11 billion/year

Klevens RM, et al. Pub Health Reports. 2007;122:160. Common Inpatient Infections


Inpatient InfectionsInpatient Infections

http://www.bactiguard.com/problem/healthcare_infections.php Common Inpatient Infections

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RoadmapRoadmap

• Background

• MRSA


• VRE

• More…


MRSA EpidemiologyMRSA Epidemiology

• Facultative gram-positive

• Colonizer in humans (mainly nares)-- 20% persistent, 30% intermittent

• Transmitted in the hospital (your hands)

Ammerlaan HS, et al. CID. 2009;49:922. Solberg, CO. Scand J Infect Dis. 2000;32:587.


History of History of Staphylococcus Staphylococcus aureusaureus: : HAHA--MRSA, CAMRSA, CA--MRSA, VISA, VRSAMRSA, VISA, VRSA

‘59

Introduction of

methicillin

1st MRSA isolate

identified

‘98

Report of

MRSA infxn in

children w/o “classic” risk

factors

’99

MMWR

report of 4

deaths due to MRSA in

previously

healthy

children

‘06

CA-MRSA

predominant

cause of SSTI

‘97

VISAJapan

‘96

VISAU.S.

‘02

VRSAU.S.

‘10

11th case VRSA

Outbreaks of CA-

MRSA reported in

multiple diverse populations

MRSA Isolated from Adult & Pediatric In-Patients

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

2001 2002 2003 2004 2005 2006 2007 2008 2009

Year

New

Pat

ien

ts/1

000

Pat

ien

t Day

s

COMM/1000PT DAYS

HOSPONSET/1000PT DAYS

TOTAL/1000PT DAYS

Linear

Comm = specimen collected < 3 days after admissionHosp Onset = specimen collected > 3 days after admission

Moffitt-Long/ Mt.Zion

4

MRSA InfectionsMRSA Infections

• Skin and soft-tissue infections (SSTIs)

• Pneumonia (CAP, HCAP, HAP, VAP)

• Bacteremia/endocarditis

• Bone and joint infections

• Other (epidural abscess, etc.)


1. A 34 man with no PMH presents with 3 days of forearm redness & pain; started after moving furniture. He is afebrile and looks well.

Physical ExamPhysical Exam1. A 34 man with no PMH presents with 3 days of forearm redness & pain; started after moving furniture. He is afebrile, looks well. Which

antibiotic would you choose?

Trim

ethoprim

/s...

Clin

damycin

PO

Cephale

xin P

O A

moxi

cilli

n PO

... V

ancom

ycin

PO

Ste

roid

s. I

t...

47%

4%

0%0%2%

47%

a. Trimethoprim/sulfamethoxazole PO

b. Clindamycin PO

c. Cephalexin PO

d. Amoxicillin PO + TMP/SMX PO

e. Vancomycin PO

f. Steroids. I treat all rashes with steroids.

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Skin & SoftSkin & Soft--tissue Infectionstissue Infections

• Most common Staphyloccocus Aureus and streptococcal species (GAS)

• Depends on purulent vs. non-purulent infection


Purulent SSTIsPurulent SSTIs

• Furuncle

• Carbuncle

• Abscess

• Cellulitis with purulence



Microbiology of Purulent SSTIMicrobiology of Purulent SSTI

59.0%17.0%

2.6%

4.5%8.1%

9.0%

MRSA MSSA

B-hemolytic strep non-B hemolytic strep

other unknown

Moran NEJM 2006

6

CACA--MRSA SusceptibilitiesMRSA Susceptibilities

Antimicrobials % susceptible

TMP/SMX 100%

Rifampin 100%

Clindamycin 95%

Tetracycline 92%

Fluoroquinolones 60%

Erythromycin 6%

Moran GJ. NEJM. 2006

Purulent SSTIs Purulent SSTIs -- TreatmentTreatment

Outpatient (PO)

• Clindamycin

• Trimethoprim-sulfamethoxazole

• Tetracycline (doxycycline)

Inpatient (IV)

• Vancomycin


CAP: A Practical Approach

NonNon--Purulent SSTIsPurulent SSTIs

• Erisypelas

-- Raised above skin

-- Clear borders

• Cellulitis

-- Poorly defined borders


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NonNon--Purulent SSTIsPurulent SSTIs

• Probably β-hemolytic streptoccal (group A strep) in most cases

-- Likely > 70%

• Unclear how often CA-MRSA in non-purulent SSTIs

-- “Role of CA-MRSA is unknown”

Liu C, et al. CID. 2011;52:285.Jeng A, et al. Medicine. 2010;89:217. Common Inpatient Infections

Treat MRSA in nonTreat MRSA in non--purulent SSTIpurulent SSTI

• Risk factors:

-- Hemodialysis, IVDU, SNF, recent abx

• Known prior MRSA

• (Possibly) MRSA rates > 30%

• Systemic illness

-- Fever, appearing ill, etc.

Stevens DL, et al. CID. 2005;41:1373. Common Inpatient Infections

NonNon--Purulent SSTIs Purulent SSTIs -- TreatmentTreatment

NO MRSA Risk*

Outpatient (PO)

• Dicloxacillin

• Cephalexin

Inpatient (IV)

• Cephazolin (?)

MRSA Risk

Outpatient (PO)

• Clindamycin

• Amoxicillin/TMP-SMX

• Linezolid

Inpatient (IV)

• Vancomycin

* If worse after 2nd day of treatment, consider change

Skin & softSkin & soft--tissue, MRSAtissue, MRSA

• Likely cause of purulent SSTIs.

• May or may not be involved with non-purulent SSTIs.

• If the patient is sick, treat for MRSA.

• Duration: 5-10 days.

Liu C, et al. CID. 2011;52:285.

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1. A 34 man with no PMH presents with 3 days of forearm redness & pain; started after moving furniture. He is afebrile, looks well. Which



b. Clindamycin PO

c. Cephalexin PO


e. Vancomycin PO


NonNon--Purulent SSTIs Purulent SSTIs -- TreatmentTreatment

NO MRSA Risk*

Outpatient (PO)

• Dicloxacillin

• Cephalexin

Inpatient (IV)

• Cephazolin (?)

MRSA Risk

Outpatient (PO)

• Clindamycin

• Amoxicillin/TMP-SMX

• Linezolid

Inpatient (IV)

• Vancomycin

* If worse after 2nd day of treatment, consider change

1. A 34 man with no PMH presents with 3 days of forearm redness & pain; started after moving furniture. He is afebrile, looks well. Which



b. Clindamycin PO

c. Cephalexin PO


e. Vancomycin PO


MRSA Infections






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MRSA PneumoniaMRSA Pneumonia

• Empiric Rx for MRSA for severe CAP (ICU admission, etc.) pending sputum and blood cx (AIII).

� Discontinue Rx if cultures do not grow MRSA

• Vancomycin or linezolid (AII).

� Superiority of either antibiotic unclear

� Daptomycin is inactivated by surfactant

Francis JL CID 2005; Gonzalez BE Clin Infect Dis 2005; Hageman JC EID 2006; MMWR 2007; Mandell L CID 2007; Finelli L Pediatrics 2008; Rubinstein E CID 2001; Wunderink RG Clin Therap 2003; Wunderink RG Chest 2003 Jung Crit Care Med 2010

MRSA Infections






2. All patients with Staphylococcus aureusbacteremia should undergo

echocardiography.

Tru

e

False

It d

epends. N

o way. D

o you...

51%

0%

43%

6%

a. True

b. False

c. It depends.

d. No way. Do you think the cardiologists need to make more money?

2. All patients with Staphylococcus aureusbacteremia should undergo

echocardiography.

a. True

b. False

c. It depends.

d. No way. Do you think the cardiologists need to make more money?

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MRSA Bacteremia and Endocarditis

• All patients need echocardiography

� TEE preferred; can start with TTE

• For uncomplicated bacteremia, treat with 2 weeks of IV antibiotics

� No endocarditis, repeat cx negative, better in 3 days, no implanted prostheses

• For complicated bacteremia, treat with 4-6 weeks of IV antibiotics

Liu C, et al. CID. 2011;52:285.. Common Inpatient Infections

MRSA Bacteremia and Endocarditis

• Vancomycin or daptomycin (AII)

• Addition of gentamicin (AII) or rifampin (AI) to vancomycin is not recommended for bacteremia or native-valve endocarditis

� No clear evidence of benefit for either drug1

� Increased risk of nephrotoxicity2 with gentamicin

� Increased risk of drug interactions and development of rifampin resistance3

1Levine D Annals of Intern Med 1991; Riedel DJ AAC 2008; 2Rybak MJ AAC 1990; Goetz, MJ JAC 1993; Rybak MJ AAC 1999; Cosgrove SE CID 2009 3Riedel DJ AAC 2008

ID Consult & Staph ID Consult & Staph bacteremiabacteremia????

• Complex disease, high mortality

• Infectious diseases consultation associated with improved outcomes

-- Improved adherence to standards of care

-- Decreased mortality by 40-60%

Lahey T, et al. Medicine. 2009;88:263. Rieg S, et al. J Infect. 2009;59:232. Jenkins TC, et al. CID. 2008;46:1000. Honda H, et al. Am J Med. 2010;123:631. Common Inpatient Infections

Infection ControlInfection Control


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MRSA Control: What’s the Data?

• MRSA screening (active surveillance testing)-- Observational study over 3 consecutive time periods ↓ MRSA infections1

-- Cluster randomized trial of surgical patients – no benefit2

• Contact isolation-- Systematic review -- ↓ MRSA but many confounding interventions3

-- Prospective study – no change MRSA transmission4

-- Potential adverse consequences: pressure ulcers, falls, depression5

1Robicsek Ann Intern Med 2008; 2Harbarth JAMA 2008; 3Cooper BMJ

2004; 4Cepeda Lancet 2005; 5Stelfox JAMA 2003;

MRSA Control: What’s the Data?

• Hand hygiene-- Alcohol hand rub ↓ HA-MRSA (20%) and VRE

(40%), not C. diff4

-- ↑ Hand hygiene compliance by 20% -- ↓ MRSA transmission by 50%5

-- MRSA outbreaks: hand hygiene combined with other interventions works6,7

4Gordin ICHE 2005; 5Pittet Lancet 2000; 6Webster J Paediatr Child Health 1994; 7Zafar Am J Inf Control 1995.

Hand hygiene compliance and HA-MRSA rates

at Massachusetts General HospitalHH and MRSA Rates

91%

94%1.95

1.79

1.33

0.990.88

1.08

0.82

0.66

0.960.74

1.03

1.091.25

0.52

0.69

0.650.61

1.52

1.00

1.33

0.81

1.121.08

1.211.181.22

1.51

1.33

0.60

0.45

0%

20%

40%

60%

80%

100%

120%

Qua

rter

3

Qua

rter

4

Qua

rter

1

Qua

rter

2

Qua

rter

3

Qua

rter

4

Qua

rter

1

Qua

rter

2

Qua

rter

3

Qua

rter

4

Qua

rter

1

Qua

rter

2

Qua

rter

3

Qua

rter

4

Qua

rter

1

Qua

rter

2

Qua

rter

3

Qua

rter

4

Qua

rter

1

Qua

rter

2

Qua

rter

3

Qua

rter

4

Qua

rter

1

Qua

rter

2

Qua

rter

3

Qua

rter

4

Qua

rter

1

Qua

rter

2

Qua

rter

3

Qua

rter

4

2002 2003 2004 2005 2006 2007 2008 2009

0.00

0.50

1.00

1.50

2.00

2.50

Before contact rates After contact rates MRSA Rate

RoadmapRoadmap

• Background

• MRSA


• VRE

• More…


12

C. Diff MicrobiologyC. Diff Microbiology

• First isolated in 1935 (stool of a healthy infant)

• Named for difficulty in culture and isolation

• Association with disease recognized in 1978

• Now leading cause of hospital-acquired diarrhea

Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247.

C. Diff EpidemiologyC. Diff Epidemiology

• Since 2001, ↑ incidence AND ↑ severity & mortality (Especially ≥ 65 year olds)

• Multiple outbreaks in US between 2001-2006

• Due to a virulent BI/NAP1/027 strain:

-- ↑↑↑↑ toxin A and B production

-- Production of a binary toxin

-- Deletion of tcdC gene (negative regulator of toxin prod)

Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247. Common Inpatient Infections

3. There are 80 people at the conference. What percentage of all of you are colonized with C diff (assume none have been hospitalized recently)?

90%

50%

10% 2% 0% I

can’t

believ.

..18%

25%

6%6%

25%

20%

a. 90%

b. 50%

c. 10%

d. 2%

e. 0%

f. I can’t believe I just licked my fingers…

3. There are 80 people at the conference. What percentage of all of you are colonized with C diff (assume none have been hospitalized recently)?

a. 90%

b. 50%

c. 10%

d. 2%

e. 0%

f. I can’t believe I just licked my fingers…

13

C. Diff PathogenesisC. Diff Pathogenesis

• Only 2-3% of healthy adults are colonized with C diff.

• Up to 40% of hospitalized patients are colonized (not all pathogenic)

• Transmitted by all of you…


C. diff Risk FactorsC. diff Risk Factors

1) Antibiotic exposure (last 2-3 months)

Highest Risk Lower Risk

Clindamycin

Cephalosporins

Penicillins

Fluoroquinolones

Aminoglycosides

Vancomycin

Metronidazole

Tetracyclines


C. diff Risk FactorsC. diff Risk Factors

1) Antibiotic exposure (last 2-3 months)

2) Hospitalization

3) Advanced age (≥ 65 yrs. old)

4) Proton Pump Inhibitors


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C. Diff DiagnosisC. Diff Diagnosis

“If the stool is not loose, the test is no use.”



• Perform testing only on diarrheal (unformed) stool (B-II)

-- Only ~1% have ileus from severe colitis

-- Usually ≥ 3 times/day

• Do not test asymptomatic patients; no role for “test of cure.” (B-III)



• Many different tests available

• Most are ELISA for toxin or for cell membrane proteins

• Find out your local testing – most have very high sensitivity


C. Diff TreatmentC. Diff Treatment

• Stop inciting antibiotic if possible! (A-II)

• Treat empirically if suspect severe or complicated C. difficile (C-III)

• Consider colectomy for severely ill patients (B-II) – consult surgery early!


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4. A 65 yo man hospitalized 5 days prior for CAP now has fever, abdominal pain, and diarrhea (yes, loose). He appears ill and has a wbc of 22,000 and new acute renal failure (creatinine 2.2 mg/dL). A C diff test comes back positive. What is the optimal initial treatment?

Common Inpatient Infections Clin

damycin

PO

Vanco

myc

in P

O M

etronid

azole

...

Vanco

myc

in IV

Sto

ol tra

nspla

...

0%

31%

4%

12%

53%a. Clindamycin PO

b. Vancomycin PO

c. Metronidazole PO

d. Vancomycin IV

e. Stool transplant.

4. A 65 yo man hospitalized 5 days prior for CAP now has fever, abdominal pain, and diarrhea (yes, loose). He appears ill and has a wbc of 22,000 and new acute renal failure (creatinine 2.2 mg/dL). A C diff test comes back positive. What is the optimal initial treatment?

a. Clindamycin PO

b. Vancomycin PO

c. Metronidazole PO

d. Vancomycin IV

e. Stool transplant.


C. Diff TreatmentC. Diff Treatment

• Initial antibiotic depends on severity of disease.

• “Severe” disease best defined as:

▪ WBC > 15,000 cells/microL OR

▪ Creatinine > 1.5x pre-morbid level


Oral Oral VancomycinVancomycin vs. Oral vs. Oral MetronidazoleMetronidazole??

98%90%

97%

76%

0%

20%

40%

60%

80%

100%

Cure Rates

Mild Infection Severe Infection

Vancomycin Metronidazole

Zar, et al. CID. 2007

p= 0.36 p= 0.02

N=150


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C. difficile Treatment: Initial Episode

Mild/

moderate

disease

WBC ≤ 15K, Cr < 1.5x

premorbid level

Metronidazole 500 mg PO

q8h x 10-14 daysA-I

Severe

Disease

WBC>15K, Cr > 1.5x

premorbid level

Vancomycin 125 mg PO q 6h

x 10-14 daysB-I

Severe

Disease,

Complicated

Hypotension or shock,

ileus, megacolon

Vancomycin 500 mg PO q6h

AND

Metronidazole 500 mg IV

q8h*If ileus, consider PR vanco

C-III

Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431.

C. Diff PreventionC. Diff Prevention

• Wash your hands!

• Must use soap and water to kill spores (EtOH rub won’t do it).

• Gown and gloves with suspected or documented C diff.

Cohen SH, et al. Inf Cont Hosp Epid. 2010;31:431. Heinlen L, et al. Am J Med Sci. 2010;340:247.


RoadmapRoadmap

• Background

• MRSA


• VRE

• More…


17

EnterococcusEnterococcus MicrobiologyMicrobiology

• Enterococci are gram positive cocci, identified in 1980s

• Two main enterococcal species

▪ E. faecalis: 85-90% of isolates

▪ E. faecium: 5-10% of isolates

• Normal colonizer of human GI tract


EnterococcusEnterococcus EpidemiologyEpidemiology

• Enterococcus causes infections in the hospital

▪ Second or third most common nosocomial infxn

• Generally fecal-oral transmission � colonization � infection

▪ Can survive in the hospital

• Risk factors for enterococcal infection:

▪ Long hospital or ICU admission

▪ Bone marrow or other transplant

▪ Urinary or vascular catheter

Noskin GA, et al. Inf Cont Hosp Epid. 1995;16:577.

What about VRE?What about VRE?

• Main risk factor is antibiotics (vanco, others)

• Rates of VRE have increased substantially

Noskin GA, et al. Inf Cont Hosp Epid. 1995;16:577. Common Inpatient Infections


Hidron HI, et al. Inf Cont Hosp Epid. 2008;29:996.

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• Main risk factor is antibiotics (vanco, others)

• Rates of VRE have increased substantially

• VRE associated with worse outcomes compared to vancomycin sensitive enterococcus

▪ Mortality odds ratio = 2.5 (95% CI, 1.9-3.4)

Diazgranados CA, et al. CID. 2005;41:327.

Common VRE InfectionsCommon VRE Infections

• Urinary tract infection

• Bacteremia

• Intra-abdominal/pelvic infections


5. That same 65 yo man with C diff required ICU admission and remains intubated with respiratory

failure. He has had an indwelling foley for 4 weeks. A U/A and culture are randomly sent (no fever or other signs or symptoms of infection). The U/A has 11-20 wbc/hpf and the culture grows < 100,000 CFUs of

enterococcus. What should you do?

Sta

rt v

ancom

yc...

Sta

rt li

nezoli.

.. S

tart

am

oxici

l...

Repla

ce th

e fo...

Noth

ing.

Tal

k to th

e fa...

3%

14% 14%17%

49%

3%

a. Start vancomycin IV

b. Start linezolid PFT

c. Start amoxicillin IV.

d. Replace the foley catheter.

e. Nothing.

f. Talk to the family about goals of care.

4. That same 65 yo man with C diff required ICU admission and remains intubated with respiratory

failure. He has had an indwelling foley for 4 weeks. A U/A and culture are randomly sent (no fever or other signs or symptoms of infection). The U/A has 11-20 wbc/hpf and the culture grows < 100,000 CFUs of

enterococcus. What should you do?

a. Start vancomycin IV

b. Start linezolid PFT

c. Start amoxicillin IV.

d. Replace the foley catheter.

e. Nothing.

f. Talk to the family about goals of care.

19

VRE Urinary Tract InfectionVRE Urinary Tract Infection

• Urinary tract colonization w/ VRE common in ICU/hospital setting▪ Can stay colonized for > 1 year

• Need to differentiate between:

▪ Colonization

▪ Asymptomatic bacteriuria

▪ True infection

Byers KE, et al. Inf Cont Hosp Epid. 2002;23:207. Common Inpatient Infections

VRE Urinary Tract ColonizationVRE Urinary Tract Colonization

• Most VRE in the urine is colonization▪ In 100 pts, only 13% had true infection

▪ Others colonized or asymp. bacteriuria

▪ True infection more common in patients with cancer

Wong AH, et al. Am J Infect Cont. 2000;28:277. Common Inpatient Infections

VRE Urinary Tract InfectionVRE Urinary Tract Infection

True infection should include:

1) Symptoms (fever, confusion, malaise, flank pain, etc.)

2) Pyuria and/or leukocyte est/nitrate

3) ≥ 103 cfu/ml of enterococcus

Hooten TM, et al. CID. 2010;50:625. Common Inpatient Infections

VRE UTI TreatmentVRE UTI Treatment

• If true infection+ high-risk for VRE + ill, treat empirically for VRE▪ Linezolid pending cultures

• Replace the foley catheter▪ May help rid colonization

Heintz BH, et al. Pharmacotherapy. 2010;30:1136. Common Inpatient Infections

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• Bacteremia



VRE VRE BacteremiaBacteremia

• Usually in patients with multiple morbidities

• From catheters, UTIs, GI tract

• Rarely associated with endocarditis

• Rarely associated with sepsis or severe illness▪ Consider gram-negative polymicrobial infxn

Wisplinghoff H, et al. CID. 2004;39:309. Common Inpatient Infections

VRE VRE BacteremiaBacteremia

• Treat empirically for VRE in high-risk patients

• Await sensitivities

• Duration of treatment unclear▪ Likely 1-2 weeks for bacteremia

▪ Probably 4-6 weeks for endocarditis




• Bacteremia



21

VRE Abdominal/Pelvic InfectionVRE Abdominal/Pelvic Infection

• Usually mixed aerobic/anaerobic infection

• Not the most virulent (vs. GNRs)

• If grow it in culture, should treat it

• Duration of treatment unclear – parellel tx of other organisms

VRE PreventionVRE Prevention

• Wash your hands!

• Data on contact isolation is mixed – follow your local policy


RoadmapRoadmap

• Background

• MRSA


• VRE

• More…


GramGram--negative HAIsnegative HAIs

• MDR Pseudomonas aeruginosa

• MDR Acinetobacter baumanii

• ESBL producing E. coli and Klebsiella

• Carbapenem-resistant Enterobacteriaceae(CRE)

22

5. I always gel in and gel out (or wash) each time I see patients in the inpatient setting.

Tru

e

False

45%

55%

1. True

2. False


RoadmapRoadmap

• Background

• MRSA


• VRE

• More…

Common Inpatient Infections Common Inpatient Infections

Specific Goals:Specific Goals:

• Appreciate the morbidity and mortality associated with hospital-acquired infections (HAIs).

• Describe optimal therapy for MRSA infections.

• List key principles in the management of Clostridium difficile infection.

• Understand evidence for preventing HAIs.

23


MRSA TakeMRSA Take--home Pointshome Points

• Treat for MRSA with purulent SSTIs; consider in non-purulent SSTIs if risk factors or systemically ill

• Add vanco for patients with CAP admitted to the ICU

• Consider ID consultation in patients with S. aureus bacteremia


C Diff. TakeC Diff. Take--home Pointshome Points

• “If the stool is not loose, the test is no use!”

• Treat severe disease (wbc > 15,000, Cr > 1.5x) with oral vancomycin


VRE TakeVRE Take--home Pointshome Points

• VRE infections are generally in sick hospitalized patients.

• Most patients with VRE in the urine are colonized or have asymp. bacteriuria

• For true infection, need symptoms + pyuria + positive culture.

Management of Common Management of Common Inpatient Infections:Inpatient Infections:

MRSA, C diff, VRE, and more…MRSA, C diff, VRE, and more…

Bradley A. Sharpe, M.D.Associate Professor Medicine

Department of MedicineUCSF

[email protected]

Download - Management of Common Roadmap Inpatient Infections · Common Inpatient Infections Purulent SSTIs •Furuncle ... •Infectious diseases consultation ... •Hand hygiene

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