Give Infections and Antibiotics Their Due Respect

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.

GRAPEVINE, TEX. – Respect. That is what it takes for the savvy hospitalist to pick a drug that’s safe for the patient and kills the bug.

Respect for both the pathogen and the drug that destroys it can make the difference between curing an infective illness and prescribing unnecessary treatment that can harm the patient.

Staphylococcus aureus, for example, can never be underestimated. "It never, ever ceases to amaze me in how virulent and aggressive it can be," Dr. Shanta Zimmer said at the annual meeting of the Society of Hospital Medicine.

On the other hand, she said, physicians must remember the serious comorbidities patients can experience with multiple drug therapy, or even with a single antibiotic.

"Respect the drugs. We often do things to our patients that are harmful, giving them unnecessary therapy. We can’t commit a patient to a line of therapy that may or may not be warranted because we can’t say for sure that there is an infection," or what the infective agent is. "So, take your time. Do a repeat culture. In infectious disease, we often have time to think and get more data before we make a decision."

Dr. Zimmer, an infectious disease expert at the University of Pittsburgh, presented the following cases to illustrate her approach:

• A woman who is between chemotherapy cycles for breast cancer presents with fever and reports chills when the port is flushed. Blood cultures from both port and periphery grow Candida albicans; the port also grows coagulase-negative staphylococcus.

Decisions about her treatment depend not only on the organism, but also on the environment. "If you have a patient in a hospital area where you see a lot of Candida, consider a kinase inhibitor as the first line of therapy. If you don’t see that much in your facility, it’s okay to start with fluconazole as the first line."

A big advantage of these drugs is their high oral bioavailability. "You can give them orally and not have to send the patient home with a PICC [peripherally inserted central catheter] line."

Treatment should continue for 14 days past the first negative blood culture, but don’t rush the timeline with Candida, she warned. "This is something that can grow very slowly, so you have to wait longer than 48 hours to really determine if the culture is negative. Often I wait 3 or 4 days to make sure that culture is clear."

When possible, remove any infected line, but especially one infected with Candida. "For Candida and [S. aureus], always remove the line. Never try to leave it in for one of those [infections]," Dr. Simmer said. For other organisms, removing the line is still preferable. "I realize this is sometimes a difficult decision, but it makes your treatment regimen so much easier."

• A 62-year-old man who had a recent mitral valve repair presents with a fever, some gaze abnormalities, and altered mental status. A transthoracic echocardiogram shows a 1.6-cm vegetation on the valve, and an MRI showed a new occipital stroke. The blood culture grew Streptococcus viridans.

Alpha-hemolytic streptococcus is one of the most common causes of endocarditis. The pathogens react differently to penicillin, depending on the species and virulence factors. Although the patient needs immediate empirical therapy with a broad-spectrum antibiotic, "the key here is to check the minimum inhibitory concentration [MIC] for penicillin before you change" to something more specific, she said. "If the MIC for penicillin is low, use penicillin for 4 weeks, or penicillin plus gentamycin for 2 weeks. If the MIC is intermediate, you really need to do 4 weeks of penicillin and add gentamycin for the first 2 weeks. If it’s high, then you need an enterococcal regimen."

• A 37-year-old man who had refractory acute myeloid leukemia and was awaiting a matched, unrelated-donor transplant presents with a large purplish lesion on his fingertip, which he said began to appear during a game of baseball with his son. As an outpatient, he takes levofloxacin, fluconazole and acyclovir. A culture grows Gram-negative Pseudomonas aeruginosa.

"When you suspect a Gram-negative bacteremia in an immunocompromised patient, you can’t wait for a susceptibility test to come back," Dr. Zimmer said. "Start with whatever Gram-negative coverage is working best at your hospital." Although the literature doesn’t completely support the use of multiple drugs, "I often use double coverage because resistance is high in many hospitals, and getting it right the first time is really important. My main reason for doing this is to make sure that one of the two agents is going to be effective against this organism."

• A 39-year-old construction worker comes in with multiple injuries after an off-roading vehicle accident. On hospital day 7, he develops severe facial swelling and periorbital pain; imaging shows a periorbital abscess with extension toward the brain.

"This man had an invasive fungal zygomycosis," Dr. Zimmer said. "This often involves the nose, sinuses, and eye and can extend directly into the brain. Mortality is extremely high, around 80%."

In a case like this, start empirical therapy with a broad antifungal immediately, but the real answer for this problem is surgical debridement. "If they can’t get to the operating room, they need to go into hospice." Patients usually need multiple debridements, because the fungus can grow back on a daily basis.

Posaconazole has become the drug of choice over the last few years, but may be impractical for those with zygomycosis. "It can only be taken orally, and these patients often have a hard time swallowing. I usually start fluconazole and a lipid formulation of amphotericin. It takes awhile for posaconazole to reach good blood levels, and it should be administered with a fatty meal."

• A 25-year-old female student presents with a low-grade fever and bilateral facial palsy. Imaging shows inflammation of facial nerves.

"Bilateral facial palsies are very rare," Dr. Zimmer said. "There can be noninfective causes, but the most common infectious cause is Lyme disease."

In considering the differential diagnosis, the patient history, outdoor activities, and geography are all important. "If you’re looking at a young, otherwise healthy person who spends some time in the woods," where Lyme is endemic, then Lyme is a good bet, she noted.

A lumbar puncture that shows lymphocytes, in conjunction with a Western blot that is positive for Lyme "puts you in good shape" with a diagnosis. "Lyme antibody is very sensitive but not very specific."

Treatment of central nervous system Lyme "is a little bit controversial," Dr. Zimmer said. Most U.S. physicians use intravenous ceftriaxone or penicillin for 14 days. A 14-day course of oral doxycycline is also effective, but not as common in this country. "All the studies have been done in Europe, so U.S. physicians are somewhat reluctant to use this, but no studies have shown any difference between IV antibiotics and oral doxycycline."

Dr. Zimmer reported having no financial disclosures.