1、Outpatient antibiotic use,Carlos A. DiazGranados, MD, MSDirector, Antimicrobial Utilization GMH,Case 1,48 yo male, HIV on ARV, VL 75 k, CD4=120, comes to the clinic complaining of nasal congestion with yellow-thick discharge, cough, postnasal drip and headache for 4 days. Physical exam reveals norma
2、l vital signs, tenderness to pressure in maxillary sinus and yellow postnasal drip. WBC 4k, Crypto AG negative. What is the diagnosis?What is antimicrobial should be given?,Acute sinusitis,ACP Guidelines,High-risk (50%) of bacterial sinusitis if 2 or more of the following present: Symptoms 7 days. F
3、acial pain. Purulent discharge. If low risk, do not prescribe antibiotics. If high-risk and mild symptoms, defer antibiotic therapy. If no improvement after 7-10 days of symptomatic therapy, consider antibiotic therapy. If high-risk and severe symptoms, consider immediate antibiotic therapy. The ant
4、ibiotic of choice is Amoxicillin.,Assess the probability of bacterial sinusitis and treat if high and symptoms severe. Otherwise, defer antibiotic Rx.,Red flagsconsider early/immediate antibiotics,Sinusitis AB duration,UnclearRCT have used 5-10 days.,Case 2,24 yo male, recently diagnosed with HIV, C
5、D4 is 180 on Bactrim prophylaxis, started ARV 2 months prior. Comes to the clinic with 3 days of mild shortness of breath, productive cough of yellow/green sputum. PE afebrile, lungs with few bilateral wheezes. O2 sat 99% RA before and after activity. LDH normal, CXRay negative. What is the diagnosi
6、s? What is the first line antibiotic choice?,Acute bronchitis,Antibiotics NOT recommended,Case 3,35 yo male, h/o HIV, CD4 150, VL undetectable, comes with a 5 days history of SOB, productive cough, and low-grade fever. Adherence 100%. Meds: Atripla, Bactrim. PE: T=100, RR=22, HR=98, BP=110/70. Decre
7、ase breath sounds and rales RLL. O2sat 94% RA. Labs: PaO2 72. WBC=12. LDH=180. What is the likely diagnosis? What would be your recommended therapy?,Community-acquired pneumonia,PCP vs. Bacterial,PCP vs. Bacterial,CAP,CID 2007;44:Suppl 2.,Site of care decisions,PSI Scoring,CURB 65 Score,Consider rul
8、ing out TB all patients that you treat for bacterial pneumonia with quinolone monotherapy,Case 4,52 yo male with HIV, CD4 350, VL undetectable, chronic tobacco use, history of chronic bronchitis/COPD, comes to the clinic with 5 days of worsening shortness of breath, increase in the amount of the spu
9、tum which has become darker in color. PE shows tachypnea, normal temperature, mild tachycardia, hypoventilated lungs bilaterally. CXRay shows lung hyperinflation, no infiltrates. What is the diagnosis? What are the antibiotic options?,Acute exacerbations of chronic bronchitis,Antibiotic options: Amo
10、xicillin Doxycycline Bactrim Macrolides (azithromycin, clarithromycin) Levofloxacin,Case 5,36 yo male, HIV, CD4 300, on ARVs, VL undetectable. Comes to the clinic with 2 day history of fever, sore throat and odynophagia. Similar clinical picture in house-hold family member. Denies recent sexual acti
11、vity. Physical exam shows Temp of 38.7, tachycardia, thick exudate in bilateral tonsils and cervical lymphadenopathy. What is the diagnosis? What are the next steps?,Acute Pharyngitis,Remember that most are viral.Remember that Group A Streptococci (Strep. pyogenes) are the most common bacterial caus
12、e. Remember that GC can cause pharyngits in individuals that practice oral sex.,Note: If you suspect GC from history, obtain swab for GC culture (ideally from urinary tract, rectum and tonsils) and consider NAAT. Rx is different, and it also has epidemiologic implications.,What to do if rapid strep
13、and cultures are not available? -,CASE 6 A 42 yo HIV + man presents with fever, chills, and 2 lesions over the back of his neck. Gram stain of pus from 1 of the lesions is shown below. What is the likely pathogen and what are reasonable options to for empiric therapy?,Skin and soft-tissue infections
14、,http:/health.state.ga.us/pdfs/epi/notifiable/CA-MRSA%20rev.pdf,Case 7,32 year-old female, HIV/AIDS, CD4 80, off ARV, off Bactrim prophylaxis (not compliant), drops-in with right flank pain, dysuria and fever x 3 days. PE: Mild tachycardia, T=38.3, no SOB. UA: 3+LE, positive nitrate and positive bac
15、teria. What is the diagnosis? What are the antibiotic options?,Urinary tract infection,1999 IDSA Guidelines,Uncomplicated cystitis in WOMEN: TMP, Bactrim or Quinolone x 3 days (prefer quinolone if rate of resistance to Bactrim is more than 20%, which is the case at GMH).Pyelonephritis: Quinolone x 7
16、-14 days Bactrim x 14 days if organism susceptible. Can start empirically with quinolone and change to Bactrim if isolate comes back susceptible.,Case 8,25 year old female, HIV, CD4 150, recently started on ARVs. Comes to clinic with 5 day history of pelvic pain, vaginal secretion and mild subjectiv
17、e fevers. Physical exam T=37.8, HR 98. Tender lower abdomen to deep palpation. Vaginal exam: yellow cervical secretion, pain to cervical movement at bimanual exam. What is the diagnosis? What are the antibiotic options?,Pelvic inflammatory disease and STIs,Diagnostic tests to consider: GC culture, G
18、C/Chlamydia cervical/urine sample, direct gram stain if available, direct wet prep., KOH test?.RPR, HepB, HIV testing.,Conclusions,Antibiotics are NOT indicated in the treatment of acute bronchitis.Antibiotics may not be needed in the majority of patients with acute sinusitis.A short course of antib
19、iotics is indicated in patients with acute exacerbations of chronic bronchitis (Doxycycline, Bactrim, or Amoxicillin). Many patients with HIV and pneumonia can be treated as outpatients, and many will NOT need RX for both PCP (Bactrim) and bacterial pneumonia (Levofloxacin + r/o TB, Amoxicillin + Az
20、ithromycin or Augmentin + Azitromycin).,Conclusions,The majority of patients with acute pharyngitis do not require antibiotics. Pursue an etiologic diagnosis rather than treating empirically as GA Strep. The most important therapy for MRSA soft tissue infections is appropriate incision and drainage.
21、 A short course of antibiotics (Clinda+Bactrim, Doxycycline+Bactrim) may be added if significant cellulitis, induration or some systemic toxicity. HIV patients are not considered by IDSA as one of the patient groups for which antibiotics are recommended in asymptomatic bacteriuria. All UTI in males
22、are complicated (required at least 7-10 days of therapy, but may require longer therapy). Treat Chlamydia when treating GC.,Conclusions,The duration of therapy is short for most of outpatient AB therapies: Sinusitis: 5-10 days. AE COPD: 5 days. CAP: 5 days. SSTI: 5-7 days. Uncomplicated cystitis in women: 3 days. Pyelonephritis: 7-14 days. Group A Streptococcal pharyngitis (1 dose IM PCN vs 10 days PO PCN). PID: 14 days.,
