Antimicrobial Therapy: An Empiric Approach | The EM Boot Camp Course

good morning everybody you already talk about some pharmacology eight hours of farm i mean how exciting is that right so uh i'm from nashville i'm a professor at vanderbilt university i teach there with our acute care and emergency nurse practitioner program practice as an emergency and flight nurse practitioner there at vanderbilt and also with team health been one of the core em faculty for the boot camp since we started this and it's just grown tremendously so we're gonna do is talk about some common medications that we may be prescribing there in emergency care settings but also some of those medications that we may encounter that our patients are taking most of us are probably not prescribing a lot of the immunosuppressants that are out there like a lot of our biologic agents but we'll talk about some of the key caveats and things are really important for us to know as the clinician we're caring for those patients so first off this morning we'll talk about antimicrobial therapy and kind of do a quick review of an empiric approach to a lot of things out there that we encounter and that we deal with in these scenarios especially now as we're entering cold and flu season what are the current cdc guidelines and when should we use antivirals and when should we just recommend conservative therapy so talk about some of these mechanisms of action these common medications and then lastly how do we really focus on empiric therapy to make sure we're using the appropriate agents and one of the key caveats with that is to always consider that we talk about a lot of regional resistance issues and problems and then what may work for me in tennessee it may not work for you if you're in the west coast or up north and definitely it's important to be aware of what is out there for you as a resource in your area if your hospital uses an io antibiogram or you have access to one that's a phenomenal resource as well so there's a quick review of microbiology because everybody loved that course right or that courses in microbiology but think about the difference in those bacteria that we deal with and the cell wall is one of the things that really differentiate them from other organisms and outside of mycoplasma they have that cell wall which differentiates from us and a lot of other animal species and one of the nice things there is a lot of our antibiotics address that cell wall which really helps limit the interactions for us since we do not have that so it gives it that great protection but then our antibiotics can go in there and attack that cell wall and either impair its ability to be repaired or to be developed and that hopefully allows us to destroy that bacterium so the gram stain really helps us to differentiate quickly whether we're talking a gram negative or gram positive so our gram negatives don't take on the gram stain they do take on that saffron stain they have this kind of more complex three layer wall that has some different stuff in there compared to our gram positives and those three layers are important but it does tend to different from our gram positives which only has those two layers and this gram positive layer has this glycopeptide wall and the plasma membrane as well and both these are going to release those toxins and those toxins when we're talking about the endo or the exotoxins is what usually triggers the activation of our sepsis response in the body that cause the initial response of the vasodilation and then the release of all our inflammatory mediators we look at this that gram negative has a lot thinner wall but it's more complex overall where our gram positive has that very thick wall but it doesn't have as many layers and so that's why some antibiotics work better at one than the other depending upon the organism depending on how complex that cell wall is we talk about our antibiotics we just talk about them in two classes are these agents gonna be bacterial static are they just going to slow down and inhibit growth are they going to be bactericidal they're actually going to be really effective at going there and destroying the bacterium and the big thing here is what's the patient's host immune system if your patient's immune compromised they're critically ill they don't have an intact immune system then it's very important we consider a bacterial societal agent but if that patient's immune competent we're talking about some community acquired infection they're probably managed on an outpatient basis then a bacterial static agent may be all they need we just want to make sure we're picking the right agent for treating the patient because this is your patient who is immune suppressed there are immunosuppressants they're currently being treated for chemotherapy and that patient probably needs to be getting a cyto agent at least to make sure their immune system doesn't have to work as hard and then we other talk about the antibiotics based on these five mechanisms of action how they work and one of our big ones i've already alluded to is our cell wall inhibitors that's your betalactams your penicillins your cephalosporins your carbopenums and are one monobactum they're really going to go in there and attack and destroy that cell wall and allow the body to take care of the rest we also have other agents that are very effective in that category this gets in our glycopeptide agents like vancomycin which is not a balactam but affects that cell wall also and there are cell membrane inhibitors there's only a few in this class so it's one we don't use a whole lot this is like polymixin we talk about a lot of our topical things or some of our odoc or optimalic drops but amphitarism b actually falls in this category as well and the other big group that we usually use that's bacterial cytologic acid synthesis inhibitors and this includes our quinolones and a lot of stuff out there and we'll come back to the quinolones a little bit and a lot of their bad press but as we've used them longer and longer we've learned some of the bad things that happen with using these quinolones but also things like rifampin and a lot of our antivirals fall in this category and they go on there and affect the ability for it to reproduce or for it to produce this nucleic acid and then we have our ribosome synthesis inhibitors our macrolides our tetracyclines and these tend to be more bacterial static so they do rely upon that host immune system to be more effective now some of these agents may have qualities of both so at lower concentrations they're bacterial static but at full concentration their bactericidal and we'll sometimes do that with like the fluoroquinolones at full dose those fluoroquinolones are bacterocidal but as the half-life starts to get implemented and we start getting a drop in the concentration it still has some post-antibiotic effects so it may still have some static properties for several days even after the course of therapy has been completed and then lastly we have our cell membrane modifiers or sometimes referred to as our folic acid synthesis inhibitors or a metabolite inhibitors our big one here are things like our sulfonamides these are going to go in there and affect the folic acid cycle unlike us bacteria cannot use exogenous folic acid they have to produce their own so these agents go in there and inhibit that process and without folic acid they're not going to be able to procreate they're not going to carry on and eventually they will die so we use some of these agents also and that's why we may sometimes use agents from different classes because they have different mechanisms of action and definitely thinking about this patient is it a intact immune system or is it an immune system that's been altered we may need to use that cyto versus that static agent i just want to kind of give you an idea and update on some of the different types of agents that are out there and some of the examples if you don't use goodrx it's a really good tool to use especially if you have patients who don't have access to prescription coverage and really can help us find that drug for that patient and here's a reasonable source to go get it but if you use the app just download it put in the medication it'll tell you what around you has it and what their cost is and that really can be a big factor for a lot of patients if they don't have prescription coverage or even they have limited resources that hey at this pharmacy it's only 40 bucks at this pharmacy it's 120 bucks so just kind of refresh your mind on some of these agents like are penicillins lots of those out there and some may be in combination some maybe by themselves so like augment with clavulanic acid or augmentin what does that clavulanic acid doe and the big thing think about here is we have so much resistance now we have a lot of bacteria that produce those beta lactamases they're going in damage that beta-lactamarine which is really important for the function of the antibiotic so if we're seeing those combination drugs such as here clavulanate or clavulanic acid is the beta-lactamase inhibitor so it's going to allow that antibiotic to be effective is going to inhibit the enzyme our bacteria are now producing trying to fight off our antibiotics we're smart they're smart as well so we have to keep getting smarter our carbopenums like miriam and dorabax are sulfusporins those tend to all be considered to be cross-reactive and cross-effective so if you have a patient who's highly allergic to a penicillin that may be the case for a cephalosporin or a carpet if it's a mild reaction then probably they're not going to have that cross reactivity but estimate about five percent of people that are truly allergic to one of these drugs may have that risk of cross reactivity to one of the other family members so it's always important to ask what's your allergy to penicillin oh a little rash probably not a big deal when we get to our higher generation cephalosporins like ceftraxone or to our carbopenums but there's always a concern so definitely keep that in mind the the only one we have azotram is similarly but doesn't have that risk so if someone truly is allergic to penicillin or cephalosporin or carpentum then a monobactin doesn't have that risk and that may be a good alternative in those scenarios fluoroquinolones definitely good agents for a lot of our complicated infections pulmonary infections sometimes our gi gu infections so there's several of those out there we often talk about those that are just purely respiratory quinolones and that's your agents except for cipro cipro tends to be referred to as below the diaphragm or below the belt it only really covers most of our gi gu bugs but unfortunately due to a lot of use in the last 10 15 years the resistance is pretty high in a lot of areas but if we're trying to treat one of those respiratory infections or sepsis it definitely needs to be a respiratory quinolone so levaquin or mox those also tend to have really good anti-pseudomonal properties so definitely your nursing home patient or your hospitalized patient and we're about pseudomonas those tend to be really good agents but now they have several box warnings out about their use and their risk for complications the macrolides lots of those out there azithro's been used a lot unfortunately its resistance rate has increased as well so we talk about these adverse drug reactions there's a lot of intolerances out there and that's your patient who gets the gi distress they may have some nausea they may even have some diarrhea with it and that's just an intolerance it's not a true allergic reaction and unfortunately we know that when we use antimicrobial agents they're also going to alter the normal floor of the gut and we see a lot of problems with that as well and we may talk about in some cases recommending prebiotics or even probiotics which may help decrease that risk but definitely that allergic response to something we have to ask about what was the allergy i don't know my mother just told me years ago i had a reaction to penicillin well that may or may not be a true reaction depends on the scenario but something we need to ask about decide is the risk there or not typically if they're truly allergic to first generation about five percent as i mentioned risk for a cross reaction but if they just have a little mild reaction and now we're using a third or fourth generation cephalosporin the risk is pretty low but definitely think about using your clinical decision making and that the side with your clinical gestalt is it the risk or not as i alluded to the super infections definitely one of the things we have to think about as we use these antibiotics they're very effective in treating what we're trying to treat but we're also alter the normal flora we know that just one round of antibiotics is enough to alter our gi flora but also normal floor on our skin and patients that are higher risk they're already immune suppressed maybe at risk for developing c diff infections or fungal infections like canada unfortunately c diff has become a big problem in a lot of our areas and actually now it's now considered to be a community acquired infection in some areas we see so many people that have c diff not doing good hand washing they leave the bacterium somewhere somebody else picks it up and now they get a c diff infection as well so that's definitely part of our decision making should be part of the risk especially we're talking with patients about why we're not going to prescribe antimicrobial agents we're trying to save them from some kind of bad infection like c diff and a lot of these agents also have that risk for renal insult some of these are going to be actively have active metabolites which may affect renal function somebody's going to go very little hepatic transformation and so they're going to float the kidneys unaffected and so we have to consider that as well we'll talk about some of those higher risk medications as we move throughout so as i alluded to at the very beginning resistance is definitely a big concern and as we've become smarter we've evolved with our knowledge so are our bacteria and they have developed the ability to produce those enzymes i mentioned earlier the beta lactamases and now we're also seeing carcinomas and cephalosporinases and those enzymes are actually to go in there and attack the bacteria is to defend themselves so now we've got a lot of these combination drugs trying to prevent that and now we're getting where we have antibiotics that are no longer effective and they used to work really well we've got some infections we no longer have really good agents to treat them like now we talk about gonorrhea we're getting the cases of saftraxon resistant gonorrhea so now the recommendations we hit them with two antibiotics always because of that if we can't cure conoreo what's next so those are things we've got to think about and definitely having stewardship is really important for these patients some of them can alter their cell wall we'll see that with mrsa and several other bacteria and they're actually able to go in there and replace something or remove a pore or hide it so those antibiotics we use have got to get inside the cell wall to be effective but what about that entry point if it's removed where it's hidden and now we can't get our antibiotic in and we've actually found that antibiotics become less effective when they're used longer of course but bacteria also have the ability to share genetic information there's been several shows they've looked at they'll place under the electron microscope a e coli bacterium that is not resistant to anything and one that is resistant and you actually can watch this fimbriae come out and the one that's resistant shares its genetic information with the other one and over time that other bacterium now becomes resistant they share information just like we do and that's why stewardship is so important sun develops these efflux pumps we said a lot with their fluoroquinolones and the bacterium actually developed the ability to pump out the antibiotic that detected the cytoplasm and detected inside and actually can push it out so now the antibiotic can't reach minimal effective concentration inside the bacteria and be effective so there's just some of the things we run into with resistance it's pretty impressive they're smart we have to be smarter but there's lots of other things that play a role with resistance as well there's lots of discussions about agriculture and the role of antibiotics in use in livestock and other animal products and how that may infect but also when antibiotics end up in the sewer system and end up in the water supply so there's lots of concerns out there and definitely it falls to us as clinicians to really be good stewards and educate people about why this viral infection doesn't require antibiotics and we know over time that we've got now is not going to be effective and there's less new antibiotics produced every year we haven't had any major breakthroughs in a while some great new class so trying to focus on these and how we try to do that and the importance of just education and shared decision making so we talk about patient management the goal is to start out in peric so based upon the site or we suspect as a site of infection we hope think it's urinary we think it's pulmonary we think it's a skin infection but then hopefully get our gram stain soon and identify hey is this gram negative or is this gram positive so at least it helps us differentiate what the organism is what we might be trying to treat and then try to get down to definitive therapy as soon as possible and for most of us that may take 48 hours to get those cultures back but those can definitely help our inpatient colleagues or sometimes even us in the ed narrow that spectrum as soon as possible so if i'm admitting that patient with a community acquired pneumonia and we've already got them on a zithro and ceftrax zone and figure out hey it's not an atypical we can take they zithral away and that's really our goal was trying to limit that be appropriate but also recognize when i no longer need certain agents and get those out as i alluded to early definitely got to consider your resistance regional resistance because that definitely can play a role in what may work for me but may not work for you some people work at a facility that produces their own antibiogram we usually get ours every six months and they revise it if your hospital doesn't publish its own antibiogram they're usually regional ones published by the cdc that kind of give you an idea of what's out there and what this antibiogram does is look at what isolates we've seen in the last six months the last year and tell us hey here's what we're seeing a lot of and allows us to get an idea of what really works against this specific species at some facilities your hospital may have three or four antibiograms one for inpatient units and one for icus and then some even do some for fungal infections as well but literally help us differentiate to go here's what's really working currently to treat these types of pathogens and this may alter what's on your formulary so every six months we change what our first line agents are for community acquired pneumonia or what we're using for fungal infections so what happens every six months every year it's published and gives us an idea of what's there this is one from a couple of years ago from an institution to mine and you get an idea that hey if we're talking about acenobacter well there's not many good options out there there's no green category and this just tells us this percentage of susceptibility if i'm dealing with acetobacter i've got a couple options and the cases probably my best but it's not that effective if it's going to treat roughly 84 percent that still leaves that other percent of patients that it may not work on but hey if i'm looking at treating uh enterobacter then i've got some really good effective things and the case is 100 effective in those cases that have been tested so that's definitely a really good agent this kind of helps guide my clinical decision maker may help guide the overall formulary recommendations for the whole hospital of when we sometimes change things and some hospitals now are doing rotational therapy so for this six months we're using this agent and this agent to treat community acquired pneumonia the next six months we're going to change drugs and try to limit exposure and so that we keep changing the antibiotics up that hopefully prevents some of the resistance that may develop in our region so those are some things we're doing in some areas trying to combat this but if you have an antibiogram definitely look at it or ask do we have one how can this guide what i'm doing in my practice so definitely things we want to consider when we're talking about prescribing antimicrobials definitely how is it going to be given can this patient effectively swallow these medications or they're going to need to have required either infusions every day or some type of parental administration always looking at their hepatic their cardiac and their renal function those are really important if this drug is say a pro drug and it requires hepatic biotransformation and they have impaired liver function this may not be a good agent if we're looking for a drug that's going to be really effective in treating the urinary tract how was this drug excreted is it going to build up and lead to toxicity or is it going to be very effective if this patient's got heart failure they're volume overloaded that's going to change the volume of distribution for this medication and may affect how effective it is at treating whatever we're trying to treat always ask about other medications the patient's on including those over-the-counters including those herbals because definitely a lot of those can definitely impact biotransformation that if it can impact the therapeutic effect of some of these agents we talked about earlier what is their immune status if this patient is immunocompromised or has that risk make sure we're using a cyto agent if they're hiv and we don't know their cd4 count we don't know what their viral load is i'm going to go on the side of this patient's immune suppress let's go with a cyto agent versus a static agent just to make sure we're going to treat that patient as effectively as possible some things we typically want to try to avoid in pregnancy and definitely getting a history getting that hcg will be important but typically these are the agents we really try to avoid if this patient is pregnant so like the aminoglycosides those can definitely have some significant renal impacts but also can affect fetal development the tetracyclines can definitely affect bone and teeth development tetracycline loves calcium we try to avoid that if at all in pediatrics but also in ob patients the fluoroquinolones lots of issues here lately especially with soft tissue development cartilage tendon but definitely those can affect fetal development as well we try to use our sulfonamides or antivirals and antifungals very carefully if we need to use those then it's a risk and benefit model we've got to treat mom to take care of the baby but definitely look at those options consult with our ob providers if you need to and they may have some great expertise in those areas also things we try to avoid renal disease we definitely have to think about adjusting their dose vancomycin is a big one most of us in the ed will start off with a gram but ideally it should be weight based and then after that it's gonna be based on renal function what is their gfr what do we need to do with this with those peaks and troughs because definitely they have impaired renal function and they're not clearing this drug out fast enough we don't want to cause toxicity but definitely the quinolones are another one the aminoglycosides those are huge renal hitters we try to limit genomics and amikacin for probably three to five days max if at all possible with those hydration is really important so we make sure we maintain renal perfusion most of us were starting them out and they're getting admitted but those are things we definitely think about this patient was recently admitted and now they're back and they have an acute kidney injury we've got to choose another antibiotic something to keep in mind so now let's talk about our empirics for the rest of the section so we talk about some of our h e e and t stuff so conjunctivitis typically is viral in most scenarios so treatment really is going to be focused on just supportive care but we usually go ahead and treat most of us that are bacterial because we don't have cultural and sensitivity results and the risk of resistance from topical agents is very low so if i think it's bacterial definitely go ahead and treat it if i'm not sure probably go ahead and treat it if it looks like a true allergic or viral conjunctivitis then probably supportive care only but just keep in mind that the risk of resistance from topical agents is pretty low and so most people and most will recommend go ahead and treat them but definitely your big bugs are listed for you here staff h flu streptococcus sometimes we'll see these association with other things like sinusitis or otitis infections as well several good options out there like polymix and b or trimethoprium the quinolones are really important especially for word about pseudomonas so if your patient's a contact lens wear they have some type of contact exposure they have a corneal abrasion or they have that ulceration then the fluoroquinolones are definitely important there and the risk of systemic problems the topicals is also pretty low so i'd be more likely to use that with this patient versus using a quinoa to treat some simple infection we're talking about systemic things but with conjunctivitis it simply goes back to good hand care good eye care they need to throw away their eye makeup throw away their contacts and not resume those until they have been symptom-free for probably three days after the infection is gone if they go back to using them too quickly or use the same ones they're going to get the infection right back and just like everything else hand washing is one of the best ways it saves lives we can all probably be better at it so otitis media and i'll go this little bit more detail tomorrow in my talk on ear stuff but there's some really good guidelines out there about especially pediatrics and when we should watch and wait versus we should treat those most patients is usually viral also probably most people have recently had an upper respiratory infection and now that's got new station tubes and got into the middle ear if this is bacterial your big culprits i've got listed for you h-flu big one strap pneumoniae m catarrhalis the typical bugs we see with a lot of our ent infections if it's bacterial or we're highly concerned about bacterial infection i'm not still in with our drug of choice for years but it's been used a lot so the resistance is pretty high and so we see most recommendations now so we should probably do higher dose amoxicillin especially in kids we're talking 80 90 milligrams per kilogram that's a lot and probably gonna have some gi distress with it between the antibiotic itself and also altering normal flora that's common if the patient's been recently treated for an ear infection especially talk about our kids if they've been treated in the last six months some will say up to a year probably to go and consider they probably have resistance and go ahead and add something's going to cover those beta-lactamases so using your augments augmenting or maybe going to something else like a cephalosporin if it's a kid especially they have bilateral and they have high fevers that's usually bacterial low-grade fever one ear most people recommend watching weight it's viral supportive therapy so fever control pain control unfortunately we lost oralgun that antipyring benzocaine was a great tool for treating that ear pain no longer available so we use other things like lidocaine or just acetaminophen ibuprofen but definitely we have other options out there macrolides are also good but increased resistance in some areas because they've been used a lot and typically once we reach about 25 or 30 percent resistance in a region that antibiotic is no longer effective so otis externa a little different see this a lot more in the summer months spring people using large bodies of water for recreational the biggest culprit here usually is also pseudomonas our big risk factors those of us that love our cotton tip swabs in the morning after a shower guilty this morning but a lot of our earbud users now hearing aid users all that movement tends to remove the cerumen cerumen is protective as much as we don't want to think about how good earwax is but they go in there and they abrade the wall they go swimming they get exposed the microbes in the water pseudomonas is a big one and they get that localized external infection pain swelling lots of debris in the canal that we'll see these are usually going to require only topical treatments so something that usually has some kind of anti-sudamel coverage probably also with a corticosteroid so neomycin polymix and hydrocortisone very effective fairly inexpensive one thing we have to consider though is that the neomycin sometimes can cause some contact dermatitis so probably twenty percent of patients that use neomycin may develop a localized irritation so that patient may come back and their ears worse it's more red it's more erythemic and swollen that may not necessarily be a worsening infection it may just be the contact dermatitis from the neomyosin so just keep that in mind that neomycin symptoms cause that there are other things out there some are quinn loans as you see listed there but the cost can be pretty costly in some areas depending on what your patients resources are definitely they've got a lot of edema a lot of swelling that an earwick usually becomes very helpful if you're not used to using those get that wick in there to pull the medication down through the whole canal and usually allows it to resolve a lot faster earwick stays in place until it falls out in the shower or the bath and they're usually much better this usually doesn't need systemic treatment usually topicals only a good focus on education always think about if you're worried about a tm rupture it needs to be a suspension whether it's a traumatic perforation or it could be from otitis and we're using external drops always a suspension the ph is more stable and tends not to cause as much harm to those internal structures our dental abscesses i love our dental patients that come in with their toothaches and occasionally they have something going on this is usually polymicrobial and one of the nice things about a lot of these dental problems is penicillin steel is pretty effective against most of them so usually we can use our pin vk if they have a large abscess formation that makes me very concerned they probably have an anaerobic infection went to throw in some that's going to treat those anaerobes those pus formers clindamius is a really good agent for treating anaerobic infections so is metronidazole one thing we're worried about now with clindamycin is it's one of our big culprits now for causing c difficile infections clintomics is a really good agent for these we use it a lot now for mrsa but it's definitely one of our big culprits then causing some c diff infections so definitely something we need to think about with our patient education give them a little bit of informed consent for these patients pharyngitis about 30 of pharyngitis that are bacterial usually group a strep and penicillin is still really effective against it as well but this sometimes can be other culprits and it may just be viral in some patients but definitely they're strep positive then probably penicillin is going to be effective a lot of debate that we should be treating these patients how word are we now with scarlettina or some type of significant strep infection probably less of a concern nowadays than it was 50 years ago so that some patients may do better with just observation but probably most people still go ahead and treat them whether it's the shot of bicillin or this couple day course of oral agents if it's the paratoms or abscess i've got that huge abscess on one side usually unilaterally i've got that uvular shift makes me concerned several thoughts out there should we drain this or should we not there's some really good techniques now we use an ultrasound and going there with a guarded needle and draining out some of that pus this usually is polymicrobial also clendon myosin is a good option here maybe some of our systemic agents going to give us some good broad spectrum coverage for these patients there's been a couple studies that looked at just doing iv antibiotics only and no ind and some of them actually showed pretty good resolution without doing any draining so you may hear that talked about with some of our ent colleagues hey let's just try conservative therapy before we go stick a needle in it so several options out there for that as well so community acquired pneumonia regional resistance definitely can play a role here definitely want to look at is is this truly community acquired or they had any recent high-risk things they've been admitted to the hospital have they have been institutionalized that may change this as well we typically consider the nursing home patient to be their own community so typically for most of those patients it is truly a community acquired infection it's just a different group of bugs we don't necessarily consider them to be hospital acquired so our big culprits here are your typical things but sometimes also your atypicals most would say that macrolide is a good choice azithromycin but it's definitely got some increased resistance in some areas so probably now a lot would say hey let's go with doxycycline it's going to be a 10-day course or seven-day course versus that nice little azithromycin rapid start pack that we're used to but definitely has a lower risk of resistance in most areas doxy can sometimes cause some gi distress it does cause some photosensitivity in some patients so definitely make sure we're educating them if they're planning a trip to the beach and doxycycline may not be a good option they're definitely going to need to use good spf to help prevent some of that photosensitivity if we're worried about our atypicals that's when your things like the macrolides come in really good coverage that patient has that typical walking pneumonia they've got the cough they've got the malaise but nothing else that may be your typical atypical presentation and their macrolides usually have really good coverage for those if they have comorbidities they've got copd their immune compromise or something else this is what we might consider the fluoroquinolones or might consider something else with a little better beta-lactamase coverage but definitely if it's your typical patient got a pneumonia looks like a pneumonia but there's no high complications there's no comorbidities a fluoroquinolone should not be our first line agent it should be reserved for those people that have comorbidities or other problems that may complicate this for most people probably azithro or macrolides going to be just as effective as you go into a quinolone as long as they're immune competent how many familiar with the curb 65 score use it a lot in my practice as well but can help guide you there's several other clinical decision tools out there there's one called smart cop that really can help guide what does this patient need does this patient need to be admitted to the hospital or this can patient be managed outpatient so definitely if you don't use those clinical decision tools that may be good options to help you guide your care well the first thing i'm talking to a hospital is sort of admit this patient i'm going to ask what's his curb score hey he's higher risk he's hypoxic this guy needs to come in but you definitely can use that score to help guide your clinical decision making decide hey is this patient safe for outpatient therapy or does this patient only need to be admitted because they're high risk if we're dealing with the patient who now needs to be admitted to the hospital they've got that community acquired pneumonia but they need to come in that patient probably treated at least with two agents a macrolide like a zithro to cover my atypicals and then probably a higher generation cephalosporin left septrexon so most of us that patient comes in community acquired until i know the culprit we're going to give them those two agents my most important thing here besides the antibiotics is going to be getting that sputum culture and that's when probably the worst things we're bad about getting collected from our patients especially our nursing staff are getting respiratory to help us is that sputum culture is really important most people that do not go the icu don't need blood cultures medicare has not changed their guidelines yet but looking at the evidence those blood cultures usually are just a waste they're either cross-contaminated or they're negative the sputum culture is what's really important to help us differentiate and narrow that spectrum down as soon as possible but this definitely the patient i consider a quinolone as so using our leatherqueen or amoxifloxacin if they need to go the icu they're hypoxic they have other complications this patient needs a little bit more broad spectrum coverage and this is a patient i definitely might consider a respiratory quinolone but i'm going to weigh the risk and benefits of that but definitely these are the patients that i have to worry about pseudomonas and look at those risk factors who's at risk for pseudomonas those who are bed bound those who've been admitted to a nursing home recently or had prolonged exposure to other things those that have some comorbidities their immune compromise they were intubated and ventilated weeks ago those are people that are higher risk for pseudomonas and your quinolones have really good suitable coverage now this is some of the other agents here that have some decent pseudomonal coverage we've got a whole class of antisedimental penicillins that tend to work very well for those patients as well and now our hospital acquired patients this patient was recently admitted to the hospital some will say 30 60 days some will stay up in 90 days we should consider to be hospital acquired so we got to think about our typical infections because that patient usually could have picked up a pneumonia while they were out in the community or it could be hospital stuff so now i've definitely got to worry about things like pseudomonas and mrsa so most time we're going to put them on a third or fourth generation cephalosporin someone's going to get pseudomonas like our respiratory quinolones or carbopenum and go ahead and throw in the vancomycin to get their mrsa coverage until i get some cultures back the goal here again is to narrow that spectrum as soon as possible if i don't need three agents let's take them away because some of these are going to be big renal hitters and now we're just exposing that patient and changing their normal flora so we can we narrow that down there'll be something that's going to be helpful is to look back what have they been on recently if they were admitted here a month ago what do they get them what do their cultures show was it mrsa or was it pseudomonas or something else and that may help guide some of my empiric therapy as well they originally had this type of infection maybe they need to go ahead and think about treating that again you know that may not be your typical pathogen we're worried about mycoplasma as i mentioned earlier the one antibody that doesn't have a cell wall most this is going to be referred quickly out to public health or epidemiology id to treat those patients just kind of give you a refresher on the current recommendations is that patients that have active tb are going to be treated with ripe therapy they're going to on rifampin inh pga and ethambutol current recommendations we should be doing dot therapy direct observational therapy that patient comes in every day to the health department and somebody watches them swallow their appeals typically they're going to be on agents for probably three to six months most current recommendations are they're gonna start on all four agents for three months at the end of three months if they're clinically better they're gonna drop to the agents and do at least two more agents for another three months for a total of six months of therapy if you are non-compliant the infectious disease group public health has the ability to quarantine you to your home and institutionalize you that's a public health hazard in some areas if you receive government assistance that check stops showing up if you're non-compliant that could be a big motivator in some areas but multi-drug resistance tb is a huge problem and definitely something we want to make sure that's being addressed properly because the big problem is most people are going to start feeling better in a couple of weeks a month or two they're feeling better and they don't want to take their peels and then we get multi-drug resistance here's the current cdc recommendation for treating latent tv i just want to give you that information people that are considered high risk looking at what their lab tests are and how we should treat those so i just want to give you that reference because we'll occasionally get those people that come in with latent tb that's going to be different than your active activity being probably one or two agents but definitely follow up and working with id or health department is gonna be really important for these patients to make sure they're gonna get followed through so what about your asymptomatic bacteria patient comes in we're screening we're looking for whatever we find bacteria in their urine but they really have no symptomology they're not complaining of anything the current isda recommendations are we should not treat them unless they're pregnant or they're getting ready to undergo some type of urological instrumentation they're getting ready to go have some type of procedure done a cystoscopy or they're pregnant those are the ones we should treat otherwise watch and wait we shouldn't be putting people on antibiotics just because we find bacteria have them follow up in a week for repeat ua so e coli is our biggest culprit for most of our urinary tract infections it's usually enteric it's usually translocated from the g out of the gu tract in most patients we know that females are higher risk than males good options out here nitrofront is still really effective for treating e coli or sulfonamides tmp smx also very effective ceflexa may be a good option fluoroquinolone should not be a first line agent for a non-systemic problem if it's just a simple urinary tract infection it should not be a four clenolone but in most people nitroferon or tmp-smx is going to be good if it's a pregnant patient cephaluxin usually is our first line agent if we've had to admit them or worry about things like pyelonephritis now we've got a good thing about more systemic coverage and that might be the patient anything about using quinolone but usually it's e coli but in some of our other patients it may be things like pseudomonas or protease especially they have an indwelling urinary catheter so considering what agent's going to cover those what's our big differentiating factor what's going to help us figure out is this a urinary tract infection or just acid the patient who has pile nephritis what's going to be our big clinical findings these are the fever and the cva tenderness that's our two big textbook things if they truly have a high fever 100 203 and they have cba tenderness that's pyelonephritis if they can tolerate po we get their pain under control they can probably go home unless they're pregnant if they have pregnancy and pilo that's almost always an admission that needs systemic antibiotics cetraxone is a good agent has really good coverage for the urinary tract and close follow-up to make sure because these can cause some problems but if they've got the fever they've got the apollo with the cva internist can they go home or not depends on their differentials so i've talked about this several times so the quinn alones lots of black box warnings lots of issues come out lots of publications from the fda about using those disabling potentially permanent side effects with soft tissue tendon ligaments some neuropsychiatric problems just recently some aortic vascular problems acute dissections quinolones should not be our first line agents for simple infections skin infections urinary tract infections non-complicated lung infections and they're like this reserved for use in patients who have no other treatment options most things we have other options unless they're truly allergic to things and that does sometimes narrow things down but definitely if you're using quinolones a lot you're not familiar with these warnings please look at them there's a lot of stuff out there and almost every month something new comes out oh we found this with the fluoroquinolones but definitely if it's a simple infection this should not be our first line agent unless nothing else is an option kind of give you an idea of the timeline got these in 1962 now almost 60 years later we're learning lots of stuff about them the first box warning came out 28 2008 it gets worse and it gets worse and it gets worse so share decision-making inform your patient these risks you know this drug could give you an aortic dissection definitely this patient's had a recent tenant injury or ligament or tendon repair that's not the patient i want to prescribe a quinn alone unless i have to topical agents different systemic antibiotics those are the ones that have the biggest risk so our cotties definitely we may play a role in these thinking about when we place urinary catheters when we shouldn't there's some really good evidence about certain patients that would benefit from a urinary catheter not all do but definitely this could be things like pseudomonas or klebsiella quinolones play a role here but shouldn't be my first line so pipertazobactum is a good agent cefepime carbopenums are going to have also good coverage for most these patients a lot of these patients are just colonized so is it truly an infection or are they actually just colonized because they've had this catheter now for years are they symptomatic or not there's no symptomology probably we shouldn't treat them they're colonized we're not going to get it cured but definitely just keep that in mind that your typical uti treatments are going to be different than your patient who has a catheter associated urinary tract infection and then are sexually transmitted infections in the u.s chlamydias are most common followed by gonorrhea current recommendations are for presumptively treating we should always treat for chlamydia and gonorrhea together if you have the ability to get your results back within an hour or two then that definitely may be an option to weight and not presumably treat everybody if we're treating for gonorrhea currently cetraxone is our most effective agent if we're treating for just gonorrhea itself the recommender recommendations are to treat with ceftraxone and azithromycin due to the risk of resistance if we're treating presumptively we were always giving them the ceftriaxone and the azithro because they're treating for both chlamydia and gonorrhea but if you had the results back and it's just gonorrhea they still recommend giving them both if we're treating for just chlamydia that's going to be azithromycin now if you trust them to take pills for seven days you can send them home with dossier but i'm a little jaded if i can't trust them to use condoms and safer sex practices i'm not sure they're going to take pills for seven days and most the guidelines say dot direct observational therapy they come in they get their ceftrax on injection they get their dose of azithro and we're done trichomonas metronidazole is still our first line agent for these and very effective and they also still recommend the dot give them that two grams of azithro there in the ed definitely making sure we educate them about the concerns with with giving metronidazole they should not consume any ethanol for at least the next week or two most recommendations are they shouldn't take alcohol a couple days before and up to a week after their last dose we usually don't have the luxury of hey come back in three days and we'll give your azithro i mean your metronidazole but definitely keep that in mind and educate the patient they tend to cause that disulfiram-like reaction and they thought that they ever had nausea and vomiting bad weight to its metronidazole induced and some people even the slight taste of a little bit of whiny communion was enough to put them into that nausea and vomiting if you've never encountered the luxury of treating a patient for chlamydia gonorrhea and trichomonas all those pills at one time tend not to set well in the stomach so definitely consider an anti-medic maybe space them out give them something to eat between them but i've seen multiple people that come in from the health department because they got all of it they started puking it's a lot of azithro a lot of metronidazole in the stomach so definitely consider then an anti-medic or something to eat that tends to help so pid outpatient yeah may be a good option especially they're not severely symptomatic they're not having a ton of circumstance tenderness they're able to take in po then outpatient therapy may be appropriate but definitely they have significant complications or they're having a high fever where they have to worry about developing an abscess that maybe the patient needs to come in for systemic antibiotics parentally pid can have some significant complications not treated if it can lead to abscess formation definitely can increase the risk of having ectopic pregnancies sometimes they can develop a significant hepatic complication with this as well so definitely it's important to recognize it and treat it and this patient definitely needs to follow up quickly as well probably in a week to make sure they've got resolution syphilis still a common sti we're running to and in some areas there's been a significant rise in cases of syphilis luckily penicillin is still very effective at treating any type of syphilis we run into so primary syphilis that's your canker secondary syphilis that's the rash that usually develops after the canker is resolved sometimes we'll see latent syphilis so that's your patient who has a positive test but has no history of a canker or the rash so if it's early latent versus late latent depends upon what we think the exposure was penicillin's still effective as you see can be a large dose and then if it's neurosyphilis we're going to be treating them with penicillin and usually adding in something like probinocid probinas is just going to increase the reabsorption of penicillin the renal tubules so it has a longer half-life and usually we're definitely involving id with these patients but definitely if we're treating any of these levels it's going to be penicillin if they truly have late layton or neurosyphilis they often recommend that we try to desensitize these patients against penicillin and use it but cestrac so may be effective in some other agents and those patients who cannot get penicillin but not every patient's going to come in with the rash not every patient's going to come in with the canker so definitely our labs may help us with that so some of our non-sexually transmitted infections so bacterial vaginosis isn't an sti but it does increase the risk of getting sexually transmitted infections in females it's just an alteration the normal flora of the vaginal area so we're going to treat with metronidazole this is going to require a seven day course not that direct observational therapy dose that's not going to be effective if she's pregnant then definitely bv needs to be treated because this definitely can cause complication with a developing fetus and definitely if she's nearing term that definitely can lead to problems during delivery as well volvo candidiasis just an overgrowth of canada it's one of those super infections we sometimes deal with for most patients topicals that over-the-counter are going to be effective if they're not a one-time dose of an azole-like ketoconazole is usually very effective in treating that some patients are higher risk than others especially if they're on current antimicrobial therapy there is some evidence that using probiotics may reduce the risk of developing a vaginal canada infection when taking antibiotics so gi coverage talking about prophylaxis for most things cyphotin or cefetan is going to be a good agent it's going to cover a lot of our gi normal flora so that patient who's going we think they've got an api that may be a good option we definitely can use other agents like the carbopenems are going to have good coverage some of our pipo tazobactum has good coverage zosin unison those tend to cover very well if it's complicated that they're already showing systemic problems we're worried about peritonitis we probably should go ahead and add in metronidazole to cover those anaerobes we see a lot of anaerobic growth in the gi and the gu tract because it's without oxygen and so definitely metronidazole is a very good option there several recommendations here for diverticulitis there's even been discussion about maybe we shouldn't even treat it with antibiotics just do supportive therapy but most of general consensus still go ahead and treat them with something to cover either anaerobes in our normal flora so whether it's a quinolone plus metronidazole or pipotazo or taxilla and clavulanate penzone formula depends on what you've got what's effective for the patient cdf i've alluded to several times definitely a growing problem with super infections now it's also community acquired in some areas we're having patients come in with c diff infections who have not been owning any antibiotics and they've required a community acquired the current recommendations are is vancomycin po you used to be start with metronidazole and then go to vanco but now isda recommends we go to vancopo if vancopo is not an option or available then we can try metronidazole vancomycin po is not cheap and there's actually a couple studies i've looked at using systemic iv vanco by mouth is just as effective and a lot less expensive vancomycin is not absorbed in the gi tract it's only going to have its effect there in the gi tract so definitely if you have it available either oral vanco or calvin drink vanco it's gonna be just as effective but metronidazole is another option if we can't do the vancomycin po lots of discussion out there about treating repeated c diff infections that definitely doing fecal microbiota transplants is definitely going to be an option in some of those areas and in some patients that's definitely what they're going to need not usually our first line in the ed with those patients we need to consider getting gi involved or they've had repeated cdi infections and getting them treated to the light line of treatment involving id as i mentioned several times there's some really growing evidence that doing prebiotics may be effective in preventing c diff infections but also other super infections associated with using antibiotics if the patient's not immune compromised then recommend they take some prebiotics is probably appropriate look at the literature decide what you want there's actually even probiotics now that we may consider as well as the prebiotics and using those in those patients some growing literature that may be helpful every time about traveler's diarrhea probably tmp smx is going to be a good option if we're talking about some type of infectious diarrhea that person who comes in with bloody stools fever then that's definitely have to worry about some of those enteric infections that may have picked up somewhere else then a zithro plus saftraxone or a quinolone is a good option those are definitely the patients we probably do not want to recommend anti-diarrheals with they need to be evaluated and treated most will say that hey we shouldn't recommend antodia rules at all because it just delays the inevitable as bad as diarrhea is it's the body's way of getting out whatever it is but definitely they're having bloody diarrhoea we should not recommend antidiarrheals they need an evaluation because this probably is a true bacterial infection bismuth which is in pepto couple other over-the-counter gi preps they have some really good antimicrobial coverage and may help with some of those patients as well if you're traveling outside the country pepto is a good thing to take with you just to prove last year as we have a new agent now rift from myasin for treating travelers diarrhea does have a higher cost but it's shown to be very effective in treating if somebody has that traveler's diarrhea very similar other drug that's going to be similar to it it's off label but as you can see with good rx a little over two thousand dollars this is when your id people or if you have a travel clinic comes in really good hand to call those up and ask them so our skin and soft tissue infections what used to be our typical bugs staph aura strep pyogenes not always our typical bugs anymore typically if it's an abscess that's almost always staph if it doesn't have an abscess it's just the redness just the erythema as they start having red streaks that's more likely to be strep but those are usually our two biggest ones recommendations here if they have cellulitis typical things like penicillin or maybe some type of penicillinase resistant penicillin but we usually deal with nowadays is mostly that cutaneous abscess for years we were taught just ind is all they need unless there's a significant amount of cellulitis but looking a lot of the newer evidence that probably they have a cutaneous abscess there is improved resolution and reduced recurrence if we do the ind and a short course of antibiotic therapy for most people nowadays our culprit is mrsa they've got community acquired mri not all those spider bites that we see at least i see a lot of the spider bites mrsa spider gets a lot of bad rap i don't know about y'all but he does but definitely look at this one study that found that we had improved resolution with a number needed treat of only seven that's pretty good so definitely if you're usually just doing an ind maybe considering a short course five to seven days may be beneficial in those patients but definitely if they have an abscess and they have a complicated cellulitis with it we definitely should consider antimicrobial therapy along with the ind tnp smx still has really good coverage in most areas for mrsa clinda is a good option they can't take a safanamide but clinda now is one of our big cults in causing c diff infections in some patients in some areas tetracycline is still effective it has really good sensibility and if we need to we can go with systemic vanco for those systemic problems but typically one of the other oral agents will be first line for most of us i found tetra actually pretty well in most patients and tolerated pretty well besides some of the gi distress it causes so how long should we could put them on antibiotic therapy what's the recommendations so this was last year they looked at 23 randomized control trials what's the effect what's the big recommendation and they found that shorter durations were as effective as long duration therapy in most patients so for some stuff five days may be all they need versus a seven or ten day course probably the shorter course we probably have better compliance so at five days they're feeling better and there's no more to take they're probably going to be finishing that course versus saving those last couple days just in case they need them later it's amazing how many people do that they want to save those last three or four days just in case i need them later and that's where we see a lot of resistance problems for uncomplicated cystitis one day of phosma myosin or three days of tnp smx is just as effective as a longer course of therapy for your female patient with an uncomplicated cystitis they only need three days five days if you're doing nitro feron not 10 days not 14 days and for skin and soft tissue infections that probably seven days if they've got an abscess if it's just cellulitis no complications probably five days so definitely we've rethought this whole duration of therapy and knowing that probably shorter courses are just effective in most patients may improve compliance and decrease our risk of resistance in some areas cns infections meningitis our best agent here is going to be ceftraxone ceftrax ceftraxone has really good penetration of the cns even if the blood-brain barrier is not inflamed ceftraxon can still penetrate and enter the cns most antibiotics cannot get in the cns unless the blood-brain barrier is damaged seftraxon doesn't have to worry about that if we're worried about pneumococcal we probably need to add in some vanco otherwise for h flu or typical meningitis problems probably ceftraxone is enough if it's our neonate our corpus is going to change we should be still using amp and gent for post exposure prophylaxis you're exposed family members are exposed dorm mates exposed we start chemical prophylaxis within 24 hours of the exposure usually it's very effective at reducing the risk of that person developing meningitis so a dose of cipro a dose of rifampin or they just want to or you just want to give it to them an injection of ceftriaxone is also effective but for most people that single dose of cipro or rifampin's all they're going to need to prevent contracting that bacterial infection current guidelines for sepsis vary kind of regionally but typically this patient probably should be on at least vancomycin a beta-lactam and something's going to cover pseudomonas if not already addressed so carbopenum or fluoroquinolone for most areas it's going to be those three agents initially and then we're going to tailor that as we move across but definitely something that may vary definitely look at georgia hospital if you have a pharmacy and therapeutics committee your id recommends it may vary and definitely ideally in most people vancomycin should be weight based not just the standard one gram for our initial dose and then obviously inpatient wise they're going to adjust that based on renal function but if you have a very large patient one gram may not cover them effectively so definitely think about weight based for that initial dose in those patients so influenza definitely in that time of the season in some areas now it's not considered to be seasonal with influenza it's considered to be year-round it never stops anymore it used to peak it would fall off but now we see cases even in the summer months in some areas our neuraminase inhibitors are our first line recommendations if we're doing acute treatment or prophylaxis it may be something like relenza or tamiflu prophylaxis and i've listed here who they recommend we treat only for those that are high risk and on the next slide we'll look at who high risk is but your typical person who has influenza or has been exposed to influenza probably does not need to be an antiviral it's supportive therapy and let's save the antivirals for those who need them us healthcare providers our high risk patients especially those who are immune compromised or those who are pregnant we do have a couple of newer agents out now for acute treatment zoflooza and we have rapidvap which could be given iv that may be indicated for people who have acute influenza that are hospitalized especially they also have a pneumonia they have other type of disease process those patients probably need to be treated so this is who isda and also supported by cdc says probably should be treated or if they're exposed should have prophylaxis you're extremes of age you're very young your older patients over 65. those under the age of 19 are on long-term aspirin therapy this is not really well understood but thought to sometimes deal with the anti-inflammatory properties of aspirin but definitely those patients are higher risk those of native american descent including our alaskans or inuits they're higher risk thought to be genetic influence there patients who are pregnant and up to two weeks postpartum those with significant comorbidities which includes obesity those are high-risk patients especially they have diabetes they have copd they have some type of lung disease long-term care residents and those that we admit with some type of pulmonary tract or pulmonary tree infection those are the ones we really should be treating most of our patients it's supportive care if you look at a lot of the literature what does giving them tamiflu do it reduces their course by about 23 hours for most people one day is not going to make a huge difference we probably should save those antivirals for those who need them and they're not without risk they're going to have some gi distress there are some neuropsychiatric problems that sometimes develop in people who take some of the neuraminase inhibitors but definitely as we're getting in that time think about who needs antiviral treatment who doesn't it's not every patient so herpes zoster patient comes in they've got the outbreak sometimes this takes a couple of days for the shingles to actually show up classic presentation is pain in an area and then a couple of days later they'll start out with the vesicles and the outbreak shows up but definitely within 72 hours the onset antivirals are very effective at slowing down the process they definitely help with the pain to some extent they usually help prevent further expansion especially this is on the face or into the eyes those patients need close follow-up and close observation for most patients with shingles they're not contagious unless it's disseminated or if they have significant immunocompromised states that may increase the risk of being transmittable usually it's only the fluid from the vesicles we have to worry about but if they're immunocompromised they have disseminated shingles that should be treated always no matter the duration post exposure prophylaxis a couple things we run into if you're exposed to pertussis or your patient family member is azithromycin is really effective again within 24 hours diphtheria azithro also works we could use penicillin tick-borne illnesses it's usually going to be doxy unless they're highly allergic then we're going to moxicillin most recommendations say we shouldn't treat prophylactically for tick-borne illness unless they're in a high-risk area they live up in connecticut and they get a tick bite that's the person i might consider treating for lyme disease prophylactically because we know that lyme disease can have some complications significantly over a course of time but most recommendations say let's watch and wait but if they come in with the rash they come in with the fever the myalgias and i'm worried about tick-borne illness that's the person i'm going to start in doxie get my labs and follow through if we can't use doxy than amazicillin but doxie is our first line even in pregnancy doxy is the first line looking at tetracyclines tetracycline is the biggest concern doxy is not and especially rocky mountain spotted fever doxy is more effective at treating yet than amoxicillin endocarditis and threats hopefully we never have to deal with it but cipro or doxy are good agents we have stockpiles of cipro across the country for a lot of our biological events so if there is one we can break out those stockpiles and rapidly treat as many people as possible mammal bites first line usually is going to be augmenting it's going to cover the typical pathogens we see there think about your mammal bites whose highest risk it's the human bites 90 plus percent of those patients are going to get infected especially if it's the fight bite they punch somebody in the face they get those breaks in the skin from the teeth that's going to be a higher risk cats dogs in that order dogs are the least risky but usually cause a lot more tissue trauma hepatitis a last year we had a significant outbreak of hep across the country the nice thing about hep a is we do have immune globus available we also have the two-step vaccine available so definitely someone's exposed or start developing symptomatology we can treat them hep b if they haven't been vaccinated we do the hep b immune globulin and administer the vaccine rabies are highest risk animals for rabies non-domesticated animals foxes raccoons skunks bats any contact with a bat they recommend prophylaxis you wake up and find a bat in your house they recommend prophylaxis bats have such small teeth that they may not be able to locate the bite mark you get bit by a domesticated cat or dog the risk of rabies is very low in this country not other countries but if it's a high risk bite we're going to recommend the rabies immune globulin which is weight based and then the vaccine here the four doses of the vaccine if we're doing the rabies immune globulin the recommendations are to try to administer half of the rig in and around the bite if possible now this was on a finger that's going to be kind of hard to do but if they're on a limb we're going to inject as much of that rig as possible in and around the bite prophylaxis is very effective within the first six days of the bite after the bite if it's been seven to ten days and they develop symptomology it's usually fatal there's only six documented cases of people that have survived rabies it is fatal but in the u.s it's very rare compared to other countries tetanus if someone has a tetanus prone wound and they've not been vaccinated properly they've not had at least three shots in a series they should get the tetanus immune globulin plus we start the vaccine if they've been vaccinated like most people and it's been more than five years they've probably seen a booster for most people unless it's 7-10 years they're good if it's a highly contaminated wound especially that involves dirt or manure those are high risk wounds so we see most of our tetanus grows in the dirt and the manure if we're actually treating tetany then it's going to be benzos for the muscle spasms and penicillin is usually our first line antibiotic things that we don't see a whole lot but definitely we're seeing more and more with the lack of vaccinations in some patient populations or under vaccination we also know that not every patient who gets vaccinated will develop immunity unfortunately so hiv post exposure prophylaxis current really good guidelines about who we should treat and what the risk is if it's blood to blood contact like hollow bore needle to blood that's a high risk exposure splash to intact skin or even at the face that's lower risk we need to look at the risk and there's really good algorithms that help us decide who's high risk and not but within 72 hours we can start uh prophylaxis use it for four weeks and then we follow up tests at four to six weeks then usually at six months and 12 months there also is prep if you're not familiar with the term prep that we do have patients who are higher risk maybe on prep which was truvada and now there's another version as well that has less side effects but if you encounter patients who are just taking to novavir and nothing else with this combination they're probably on prep and that's people that have lifestyles that are higher risk for hiv iv drug users those who have sex with men or those who have partners who are hiv positive so you will see people that are on prep for pro for prophylaxis and then lastly our ectoparasites those things that we love so much they come in with that itching and that scratching and as soon as you see it on the board you start itching and scratching too like no but pediculosis there's several good options out there for treating pediculosis in most patients the over-the-counter options are just as effective as the prescription options but definitely things to look at the ability to for this to be affected varies upon whether it's an oversight or not some of these don't kill the eggs they require two treatments some kill the eggs they destroy one treatment it's important for the patient to read the labels and know hey is this a apply for five minutes or supply for an hour and then bathe if we're talking about scabies permethrin cream is when we use mostly but we definitely have lindane as well scabies is that classic burrowing between the web spaces we do have some oral agents out there like ivermectin that can be used especially if nothing else is working but for most people topicals work very well just remember we also have to treat part of their living environment their bedding their clothing we're talking about kids their stuffed animals need to be treated otherwise they're going to get the infection right back but definitely in winter months this is common in our children because of heavy coats and they're all put together somewhere during the day and it transmits over this is just a table that i found very helpful this is a published in journal feed some of my colleagues at vanderbilt do this as a weekly and also a daily update but found this kind of just a good way to quickly look back at drugs and see what covers what so i gave you that as well as the link to that website any questions about antimicrobial therapy how that wasn't too mundane but thinking about what works for what areas yes the alternative treatment for penicillin for for diarrhea for treating diarrhea like travelers diet gonorrhea sorry so if they're penicillin allergic the current recommendation is trying the azithro plus genomicin genemyosins was our backup for now treating gonorrhea yes so time frame the goal is to initiate antivirus within 48 hours that after 48 hours there's probably not as much benefit but if they're emitted or they're high risk we should go ahead and administer antivirals no matter the direct the exposure but ideally within 48 hours so the question was for pyelonephritis for ceftrix and usually it's the one gram and they're usually probably getting that for at least three to five days plus something else usually either tmp smx or quinolone or one of the other agents that'll cover those bacteria usually it's a gram a day for the first three to five days but also if they're getting better and they're only in hospital for 23 48 hours they may only need that one or two doses but they're probably going to go home with oral agents probably at least 10 days depending on the bacteria

Channel: The Center for Medical Education

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Keywords: emergency medicine

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Length: 74min 5sec (4445 seconds)

Published: Thu Mar 18 2021