Infectious Disease Update 2017
Infectious Disease Update 2017
Greg Moran, MD, FACEP, FIDSAProfessor of Clinical Emergency Medicine
Geffen School of Medicine at UCLA
Dept. of Emergency Medicine
and Division of Infectious Diseases
Olive View-UCLA Medical Center
What's Pneu?What's Pneu?
Staph more common in CAP?
2005 IDSA/ATS guidelines included Hospital Acquired Pneumonia (HAP),Ventilator Associated Pneumonia (VAP),Health Care-associated Pneumonia (HCAP)
2016 guidelines only HAP and VAP
CAP Etiology: More Staph?CAP Etiology: More Staph?627 ED Patients Admitted with CAP, 2006-7
12 U.S. hospitals (EMERGEncy ID Net)
Cultures done in 95% (92% blood, 50% resp)
Pathogen isolated in 17%S. pneumoS. aureusH. influenzae
MRSA 2.4% (range at sites 0-5%)- All were USA300 community strains- More ICU admits, intubation, death (14%)
Moran GJ et al. Clin Infect Dis 2012;54(8):1126–33
MRSA PneumoniaMRSA Pneumonia
CAP: Whom Do We Treat for MRSA?CAP: Whom Do We Treat for MRSA?
IDSA/ATS Guidelines:“If CA-MRSA is a consideration, add vancomycin or linezolid”
My recommendation:
Add vancomycin for:Severe pneumonia (ICU admit)IVDU(consider for post-influenza, hx MRSA)
Consider Doxycycline for oral Rx
Mandell LA, et al. Clin Infect Dis 2007;44 (supp 2)
HCAP: Health Care Associated Pneumonia
HCAP: Health Care Associated Pneumonia
Criteria:Hospitalized within 90d, or nursing home Dialysis or hospital clinicIV antibiotics, chemo, wound care within 30d
Higher mortality
Different bacteriology:MRSA, Resistant gram-negatives
Kollef MH, et al. Chest 2005;128:3854-62.
ATS/IDSA. Am J Respir Crit Care Med. 2005;171:388-416
Hospital Mortality by Classification
Hospital Mortality by Classification
10.0 19.8 18.8 29.30
5
10
15
20
25
30
35
CAP(n=2221)
HCAP(n=988)
HAP(n=835)
VAP(n=499)
Mo
rtality
Rate
(%
Pat
ien
ts)
P<0.0001
P=NS
P<0.0001
BUTBUT
Publication bias in HCAP studies
Many poor quality studies
Poor association between HCAP and DRO in quality prospective studies
Mortality not higher when adjusted for age and comorbidities
Chalmers JD. Clin Infect Dis 2014;58:330.
Predicting Abx Resistance:DRIP Score
Predicting Abx Resistance:DRIP Score
Major (2 points):
Abx in last 60d
Resident in SNF
Tube Feeding
Prior Resistant Bug
Score > 4 is 76% sens and 91% spec for DRO- Mostly MRSA and Pseudomonas
Compared w HCAP, 46% less broad abxWebb BJ. Antimicrob Agents Chemother 2016; 60:2652.
Minor (1 point):
Hosp within 60d
Chronic pulm dz
Poor functional status
Gastric acid suppression
Wound Care
Empiric Abx with DRO RiskEmpiric Abx with DRO RiskWant to cover MRSA and Pseudomonas:
- Vancomycin (or Linezolid)
plus
- Pip/Tazobactam or
Cefepime or Ceftazidime or
Levofloxacin or Ciprofloxacin or
Imipenem or Meropenem
Kalil AC. Clin Infect Dis (2016) 63 (5): 575-582.
Are we under attack by giant, radioactive, MRSA-carrying spiders from Mars????
Vetter RS. West J Med. 2000;173:357-358.
“Spider Bites” and MRSA“Spider Bites” and MRSA
Should We Give Antibiotics After Abscess I & D?
Should We Give Antibiotics After Abscess I & D?
Many studies show no benefit of abx after I&D
But, studies limited by:
Done before emergence of MRSA
Nonrandomized design, small numbers
Vague outcome definitions
Nonstandardized drainage
Inappropriate antibiotic choice
Moran GJ, Talan DA. NEJM Nov 16,2006;355:2155.
TMP/SMX v. Placebo for Abscess with I&D
TMP/SMX v. Placebo for Abscess with I&D
1,265 pts. in 5 EDs: median abscess 2.5cm, median erythema 6.5cm, 45% MRSA
T/S Placebo
Cure @ 14-21d 92.9% 85.7%
Subseq. Surgery 3.4% 8.6%
New skin infection 3.1% 10.3%
Infxn in household 1.7% 4.1%Adverse events similar
Talan DA et al. NEJM 2016;374:823-32.
Infection vs. No InfectionInfection vs. No Infection259 pts. Admitted from ED with cellulitis dx
30% determined to have other dx by derm in hospital or within 30 days- of these, 85% did not need hospitalization
and 92% received unnecessary abx- most common venous stasis dermatitis
Weng QY et al. JAMA Dermatol 2016 Nov 2. ePub. PMID: 27806170
Moran GJ, Talan DA. JAMA 2017;317(7):760.
Cellulitis ??Cellulitis ??
Bedside Ultrasound of SSTIBedside Ultrasound of SSTI
Hospital or Home?Hospital or Home?619 ED patients with skin infection
15% admitted
Reasons given by ED doc: 85% need for IV abx (only reason 41%)25% need for surgery11% underlying disease
Factors associated with admission:Fever, >10cm, Failed Tx, Comorbidity, Age
Talan et al. West J Emerg Med 2015 Jan;16(1):89-97.
Hospital or Home?Hospital or Home?
Skin infections median LOS 5d, cost > $8,000
Inpatient mortality for skin infections 0.5%*(compared to pneumonia 8-14%)
No scoring system for skin infection admission
WE ARE OVER-ADMITTING
Not a risk of sudden death; po trial reasonable
Long-acting IV antibiotics available
* Khachatryan, et al. Acad Emerg Med. 2014;21(S1):S50.
Moran GJ, Talan DA. JAMA 2017;317(7):760.
Etiology of CellulitisEtiology of CellulitisDifficult to study if no pus.
Results depend on methodology.
Blood culture studies:57-75% Strep and 14% Staph(but, blood cultures negative in > 90%)
Punch biopsy, Aspiration studies: 9-28% Strep and 50-82% Staph
Serology (ASO titer) studies: ~ 70% Strep
Chambers HF. Clin Infect Dis 2013 56:1763-4.
Should We Treat MRSA in Cellulitis?
Should We Treat MRSA in Cellulitis?
500 outpts with cellulitis – no abscess
Cephalexin vs. Cephalexin+TMP-SMX x7d
Cure rates:Cephalexin 85.5%Ceph + TS 83.5%
Difference -2.0% (95% CI -9.7% - 5.7%)
Moran GJ et al. JAMA 2017; 317(20):2088.
Cellulitis: Key PointsCellulitis: Key Points
• Not all erythema is cellulitis
• Consider ultrasound to r/o abscess
• Trial of oral abx reasonable for most
• Cephalexin alone for cellulitis
STD Prevalences in USSTD Prevalences in US
http://www.cdc.gov/std/stats/sti-estimates-fact-sheet-feb-2013.pdf
Tho
usan
ds
HSV – Classic AppearanceHSV – Classic Appearance
TrichomonasTrichomonas
Wet mount only about 60% sensitive
Newer Nucleic acid amplification tests (NAAT) 95-100% sens on vaginal swab or urine
Treat with Metronidazole 2gm po once
(topical metronidazole NOT effective)
Gonorrhea in US: 1941-2015
Gonorrhea in US: 1941-2015
cdc.gov
Gonorrhea Rates 2015Gonorrhea Rates 2015
cdc.gov
Gonorrhea: Decreased Cephalosporin Susceptibility
Gonorrhea: Decreased Cephalosporin Susceptibility
MMWR. 2012;61: 590.
GC - Treatment OptionsFluoroquinolones no longer recommendedOral cephalosporins no longer recommended
Recommended:Ceftriaxone 250 mg IM
(Plus Azithro or Doxy)
Cephalosporin allergy – Azithromycin 2gm poPLUS gemifloxacin 320mg po (or Gent 240 IM)
MMWR. 2015;64(RR-3).
Chlamydia in US 2000-2015Chlamydia in US 2000-2015
cdc.gov
U.S. Chlamydia Rates 2015U.S. Chlamydia Rates 2015
cdc.gov
Zika – now an STD!Zika – now an STD!
Mosquito-borne flavivirus
Typically mild illness; ~80% asymptomatic
Association w microcephaly
Documented sexual transmission
Virus in semen months after infection
Use condom if partner pregnant/planning
cdc.gov
