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Lyme Disease

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Early Disease

• Localized EM • May disseminate to multiple lesions

• Fever

• Arthralgia

• Headache

• Lymphadenopathy

Complications

• Lyme carditis

• Neuroborreliosis (aseptic meningitis)

• Cranial Nerve Involvement (Bell’s Palsy)

Late Disease

• Chronic arthritis

• Chronic neuroborreliosis

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Reduce Risk• Deet or Icaridin

• Tuck in clothes• Light color, long sleeve/pant• Well travelled paths

Reduce Ticks• Clean lawn/leaf litter

• Play equipment in clean dry area away from woods

Remove Ticks• Check ASAP

• Take a bath within 2 hours• Heat dry clothes for 10 min• Clean tweezers as close to skin as

possible• Clean area

• Record date and location of bite

Diagnosis• 2 tiered

• ELISA-based screening (QE II)• Immunoblot (National Mirobiology Lab

Winnipeg) – If ELISA positive or indeterminate

Elisa

Immunoblot

Serologic Testing

• In season, diagnosis based on clinical judgement (poor sensitivity in first 4 weeks)

• Out of season, do test and repeat in 4-6 weeks if negative

• Pts with non-specific fever, no EM rash, and exposure (moderate or higher) should test, monitor and repeat in 4-6 weeks

• Pts with symptoms of early disseminated or late Lyme should have testing

• Neuroborreliosis should have LP plus serologic test plus ID consult

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Prophylaxis

• Only recommended if:• > 36 hour attachment of adult or nymphal backlegged tick

• Prophylaxis can start within 72 hours

• In area of moderate to high risk• Doxycycline is not CI

• Adult• Doxycycline 200 mg po

• Pediatrics• Doxycycline 4 mg/kg to max 200 mg po

• Round to nearest 25 mg (1/4 tab)

Treatment - Adult

EM, Bell’s palsy and early disseminated without CNS

• Doxycycline 100 mg bid x 14-21 days

• Amoxicillin 500 mg tid x 14-21 days

• Cefuroxime 500 mg bid x 14-21 days

CNS or Carditis

• Ceftriaxone 2 g IV daily x 14-28 days

• Pen G 4 million units IV q4h x 14-28 days

• Doxycycline 100-200 mg bid x 28 days (if other options not possible)

28 days for Late

Lyme without

CNS involvement

Treatment - Pediatrics

EM only

• Age > 8• Doxycycline 4.4 mg/kg/24 hours divided q12h x 10 days

• (max 200mg/24h)

• Round to nearest 25 mg (1/4 tablet)

• Use for 14 days for facial palsy

• Age < 8• Amoxicillin 50 mg/kg/24 hours divided q8h x 14 days

• Max 1.5 grams/24h

• Pen Allergy• Cefuroxime 30 mg/kg/24 hours divided q12h x 14 days

• Max 1 gram/24h

28 days for• Lyme Arthritis

• Incomplete response repeat the course

• Relapse

14-21 days for• Carditis

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Treatment - Pediatrics

Patients with worsening arthritis or meningitis

• Ceftriaxone 50-75 mg/kg/day IV once daily• 14-28 days for worsening arthritis

• 14-21 days for atrioventricular heart block or carditis who require IV therapy• Switch to PO when stable without symptoms

• 14 days for meningitis• May also use doxycycline for meningitis

Shingles (Herpes Zoster)

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Risk Factors

Strong• Age over 50

• HIV: 15 times higher

• Immunosuppression

Weak• Gender: Women over men

• White ethnicity: one study

suggests that black people less

likely than white to develop

Presentation• Burning pain

• Vesicular eruption

• 20% systemic symptoms

• Fever, headache,

malaise, fever

Complications• Post herpetic neuralgia

• Scarring/pigmentation

• Ocular

• Super infections

• Peripheral nerve palsies

• Sensory loss

• Disseminated herpes zoster

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Transmission• Non-immunized/infected

individuals

• Weeping skin lesions until

crusted over

• Less common through

airborne route

• Disseminated HZ

Treatment• Acyclovir 800 mg 5x/day

• Famciclovir 500 mg tid

• Valacyclovir 1000 mg tid

All for 7 days duration

Pain• Acetaminophen

• Ibuprofen

• Topical agents

• Lidocaine

• Capsaicin

• Calamine

• Opioids

• TCAs / Gabapentin /

Pregabalin

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Vaccinations• Live Attenuated Zoster

Vaccine

• Zostavax II

• Recombinant Zoster

Vaccine

• Shingrix

Live Attenuated Zoster Vaccine

Duration of Activity: Live Attenuated Vaccine

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Side Effects Live Attenuated Vaccine

Effect Live Zoster VaccineN = 3345%

PlaceboN = 3271%

Injection site pain 34.3 8.3

Injection site redness 35.6 6.9

Injection site swelling 26.1 4.5

Headache 1.4 0.8

Fatigue 1 0.4

Recombinant Zoster Vaccine

Adverse Effects Recombinant Zoster Vaccine

Grade 3 Reactions 50-59 years 60-69 year > 70 years

Site reaction 10.3 6.9 4

Myalgia 8.9 5.3 2.8

Fatigue 8.5 5 3.5

Headache 6 3.7 1.5

Shivering 6.8 4.5 2.2

Fever 0.4 0.5 0.1

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Storage Preparation and Administration

Zostavax® II (LZV) Shingrix® (RZV)

Date of authorization in Canada 2011 2017

Type of Vaccine Live attenuated Recombinant subunit (adjuvanted)

Schedule 1 dose 2 doses, 2-6 months apart

Route of administration Subcutaneous lntramuscular

Dose0.65 mL (entire contents of the reconstituted vial)

0.5 mL (entire contents of the reconstituted vial)

Contraindications

•Known hypersensitivity to any of the vaccine component•Immunosuppression or immunodeficiency•Pregnancy

Known hypersensitivity to any of the vaccine components.

Storage Requirements Refrigerator - stable Refrigerator – stable

Asymptomatic Bacteriuria/UTI.

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Urinary Tract Infections

Cystitis• Infection of the bladder or lower urinary tract

Pyelonephritis• Infection of the kidney or upper urinary tract

Cystitis can be further divided• Uncomplicated cystitis

• Complicated cystitis

• Asymptomatic Bacteriuria

Academic Detailing Service: Antibiotics - Why and Why Not 2018

Cystitis/Pyelonephritis

Greater than 30% women will have a UTI

50 times greater in women than men

Most common healthcare associated infection worldwide

Signs and Symptoms

• Cystitis• Acute or resent onset• Urinary frequency, pain/burning on urination, urgency, dysuria

• Pyelonephritis• Flank pain and fever

Etiology

Uncomplicated Cystitis• E. Coli 75-95%

• Remaining due to gram negative rods (Klebsiella, Proteus) and Enterococcus

Complicated Cystitis• E. Coli 50 – 90%

• More resistant species such as Proteus, Klebsiella, Enterococci, Pseudomonas

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Diagnosis

Urine culture (for complicated since less predictability of pathogen)

Uncomplicated, 2 symptoms and no vaginal discharge no culture required

Treatment

Uncomplicated Cystitis• Nitrofurantoin 100 mg bid x 5 days

• Trimethoprim/Sulfamethoxazole 160/800 mg bid for 3 days

• Fosfomycin 3 grams single dose

Complicated Cystitis• Nitrofurantoin 100 mg bid for 7 days

• Trimethoprim/Sulfamethoxazole 160/800 mg bid for 7 days

• Fosfomycin 3 grams every 3 days for 2-3 doses

• Oral beta lactam for 7 days

• Duration dependent on rate of recovery or factors associated with the complication

Treatment

Pyelonephritis• Perform Urine C & S and tailor antibiotics when returned

• Give one time dose of extended spectrum beta lactam or 24h aminoglycoside

• Fluoroquinolones for 5-7 days

• Trimethoprim/Sulfamethoxazole 160/800 mg bid for 7-14 days

• Oral or IV Beta-Lactam for 7-14 days

• Do not use Nitrofurantoin or Fosfomycin

• May not apply to patients with stones, abscess etc.

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Antibiogram – Central Zone

Asymptomatic Bacteriuria

“So I hear I have a UTI”

Definitions

“Asymptomatic bacteriuria” (ASB), or asymptomatic urinary infection, is an isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection.

CID March 2005 (40:5) 643–654

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Prevalence ASB

Diabetic• Women: 9-27%• Men: 0.7-11%

Pts > 70 years of age• Women: 10.8-16%• Men: 3.6-19%

LTC• Women: 25-50%• Men: 15-40%

Indwelling Catheter Use• Short tern: 9-23%• Long term: 100%

CID: 2005 ; 40 : 643 -654

Risk Factors for ASB

• Age related factors associated with ASB• Diabetes

• Pelvic prolapse/cystocele

• Enlarged prostate

• Vaginal Atrophy

• Immobility

• Incontinence

• Dehydration

Pyuria

• Pyuria is evidence of an increase of PMN leukocytes in urine• Pyuria is present:

• 32% young women• 30-70% pregnant women• 70% women with diabetes• 90% elderly institutionalized patients• 90% hemodialysis patients• 30-75% short term catheters• 50-100% long term catheters

• Pyuria present in inflammatory conditions• Renal tuberculosis• STIs• Interstitial nephritis

CID: 2005 ; 40 : 643 -654

Do not use urinalysis as diagnostic tool for UTI

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Treatment

• Antimicrobial therapy for ASB is only indicated for individuals for which harm may be caused:

• Pregnancy

• Urological procedures

• TURP

• High risk of mucosal bleeding is expected

• Why do we care?

• Love for a patient does not come in the form of an antibiotic…

• They can cause harm

Adverse Effects of Antibiotics

• Increases:

• Risk of Clostridium Difficile

• Risk of developing resistant bacteria

• Cost (drugs, test and treating adverse effects)

Not to forget

• Side effects of specific antibiotics

Medications associated with C. Diff

Increased incidence of Clostridium

difficile disease (OR 2.45, 95% CI 0.86-

6.96, p=0.132) with tx of ASB

Cochrane 2015

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If no symptoms are present, why are cultures ordered?

• 2002 urine cultures from 888 patients were obtained from inpatients at Toronto hospital

• Mean patient age = 68 +/- 9.4 years

• Medical records available for 335 patients

Why were cultures ordered?

• Altered mental status – 191/335 (57%)

• Fever – 122/335 (36%)

• Cloudy or malodorous urine –19/335 (6%)

Trends

• ASB with confusion were MORE LIKELY to be treated • 75% vs 43% OR 1.81 (CI 1.19 to 4.12: p=0.03)

• Outcomes

• 43 patients with ASB received 347 days of inappropriate antimicrobial therapy

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Clinical Question

• In delirious patients with ASB

• Does treatment with antibiotics vs no treatment lead to• Improvement in functional ability

• Increased risk of medication related adverse effects

Asymptomatic UTI Analysis

Delirious Sample343

No UTI treated 251

Asymptomatic UTI Treated93 (92)

Positive Urine Culture 68

Negative Urine Culture 24

Asymptomatic UTI treatment associated with worse functional (RR 1.30, 95% CI: 1.14-1.48) in comparison to rest

of delirious sample

Patient Progress

Days vs MDAS scores

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Point Prevalence Study: Bacteriuria/UTI/CAUTIObjectivesPrimary

• Determine rates of CA-UTI / 1000 catheter days in a general medicine hospital setting

Secondary• Measure catheter usage rates / 1000 patient days

• Reason for catheter use/length of catheter use• Observe all urine samples

• Reason for sample taken• Ordered by physician

• Record rates of UTI/ASBU• Symptoms• C & S

• Make and record recommendations when required• Acceptance rates

Point Prevalence Study: Bacteriuria/UTI/CAUTI

50%

37%

13%

VRH Bacteriuria DATA PAF

ASBU SUTI HA-CAUTI

4 4

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Recommendationsby AMS Pharmacistto D/C Antibiotics

Recommended Accepted

0 1 2 3 4

E. Coli

Klebsiellapneumonia

Enterococcus spec

Pseudomonas

Staph aureus

Isolated Bacteria

Isolated Bacteria

No growth = 25Total Samples with growth = 8

Total Samples Reviewed = 33

• One sample was combined Enterococcus/Klebsiella

• 3/25 pts with no growth were treated with an antibiotic (all stopped)• 2 by recommendation• 1 by physician

Point Prevalence Study: Bacteriuria/UTI/CAUTI

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25

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Urine Samples

Total Urine Samples Samples Ordered by Dr Samples with Urinary Sx

39% samples had one urinary symptom

28% not ordered by physician

61% no noted reason or symptoms not urinary

• 42% of samples had no reason noted to why sample taken

• 19% drawn for nonspecific reasons (decreased loc, dementia, delirium etc).• Of those 19%, none

were associated with bacterial growth

• All samples were ordered by physician

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Point Prevalence Study: Bacteriuria/UTI/CAUTI• Discussion

• More education needs to be done on when to draw urine samples• 76% yield no growth, more than ¼ ordered without physician aware, 61% ordered

without noted reason related to UTI

• Better documentation and monitoring needs to be in place for catheter use• More than half not clearly noted as to why inserted, or noted when to be reassessed

• Better sterile technique and insertion criteria required• Half of total bacteriuria noted in catheterized patients

• Continued education needed with regards to ASBU• 50% of bacteriuria was asymptomatic

What can we do?

Resources

• NS Antimicrobial Stewardship Webpage• https://library.nshealth.ca/AMS

• Spectrum App

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Questions?

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