Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
9/9/2019
1
Lyme Disease
1
2
3
9/9/2019
2
Early Disease
• Localized EM • May disseminate to multiple lesions
• Fever
• Arthralgia
• Headache
• Lymphadenopathy
Complications
• Lyme carditis
• Neuroborreliosis (aseptic meningitis)
• Cranial Nerve Involvement (Bell’s Palsy)
Late Disease
• Chronic arthritis
• Chronic neuroborreliosis
4
5
6
9/9/2019
3
Reduce Risk• Deet or Icaridin
• Tuck in clothes• Light color, long sleeve/pant• Well travelled paths
Reduce Ticks• Clean lawn/leaf litter
• Play equipment in clean dry area away from woods
Remove Ticks• Check ASAP
• Take a bath within 2 hours• Heat dry clothes for 10 min• Clean tweezers as close to skin as
possible• Clean area
• Record date and location of bite
Diagnosis• 2 tiered
• ELISA-based screening (QE II)• Immunoblot (National Mirobiology Lab
Winnipeg) – If ELISA positive or indeterminate
Elisa
Immunoblot
Serologic Testing
• In season, diagnosis based on clinical judgement (poor sensitivity in first 4 weeks)
• Out of season, do test and repeat in 4-6 weeks if negative
• Pts with non-specific fever, no EM rash, and exposure (moderate or higher) should test, monitor and repeat in 4-6 weeks
• Pts with symptoms of early disseminated or late Lyme should have testing
• Neuroborreliosis should have LP plus serologic test plus ID consult
7
8
9
9/9/2019
4
Prophylaxis
• Only recommended if:• > 36 hour attachment of adult or nymphal backlegged tick
• Prophylaxis can start within 72 hours
• In area of moderate to high risk• Doxycycline is not CI
• Adult• Doxycycline 200 mg po
• Pediatrics• Doxycycline 4 mg/kg to max 200 mg po
• Round to nearest 25 mg (1/4 tab)
Treatment - Adult
EM, Bell’s palsy and early disseminated without CNS
• Doxycycline 100 mg bid x 14-21 days
• Amoxicillin 500 mg tid x 14-21 days
• Cefuroxime 500 mg bid x 14-21 days
CNS or Carditis
• Ceftriaxone 2 g IV daily x 14-28 days
• Pen G 4 million units IV q4h x 14-28 days
• Doxycycline 100-200 mg bid x 28 days (if other options not possible)
28 days for Late
Lyme without
CNS involvement
Treatment - Pediatrics
EM only
• Age > 8• Doxycycline 4.4 mg/kg/24 hours divided q12h x 10 days
• (max 200mg/24h)
• Round to nearest 25 mg (1/4 tablet)
• Use for 14 days for facial palsy
• Age < 8• Amoxicillin 50 mg/kg/24 hours divided q8h x 14 days
• Max 1.5 grams/24h
• Pen Allergy• Cefuroxime 30 mg/kg/24 hours divided q12h x 14 days
• Max 1 gram/24h
28 days for• Lyme Arthritis
• Incomplete response repeat the course
• Relapse
14-21 days for• Carditis
10
11
12
9/9/2019
5
Treatment - Pediatrics
Patients with worsening arthritis or meningitis
• Ceftriaxone 50-75 mg/kg/day IV once daily• 14-28 days for worsening arthritis
• 14-21 days for atrioventricular heart block or carditis who require IV therapy• Switch to PO when stable without symptoms
• 14 days for meningitis• May also use doxycycline for meningitis
Shingles (Herpes Zoster)
13
14
15
9/9/2019
6
Risk Factors
Strong• Age over 50
• HIV: 15 times higher
• Immunosuppression
Weak• Gender: Women over men
• White ethnicity: one study
suggests that black people less
likely than white to develop
Presentation• Burning pain
• Vesicular eruption
• 20% systemic symptoms
• Fever, headache,
malaise, fever
Complications• Post herpetic neuralgia
• Scarring/pigmentation
• Ocular
• Super infections
• Peripheral nerve palsies
• Sensory loss
• Disseminated herpes zoster
16
17
18
9/9/2019
7
Transmission• Non-immunized/infected
individuals
• Weeping skin lesions until
crusted over
• Less common through
airborne route
• Disseminated HZ
Treatment• Acyclovir 800 mg 5x/day
• Famciclovir 500 mg tid
• Valacyclovir 1000 mg tid
All for 7 days duration
Pain• Acetaminophen
• Ibuprofen
• Topical agents
• Lidocaine
• Capsaicin
• Calamine
• Opioids
• TCAs / Gabapentin /
Pregabalin
19
20
21
9/9/2019
8
Vaccinations• Live Attenuated Zoster
Vaccine
• Zostavax II
• Recombinant Zoster
Vaccine
• Shingrix
Live Attenuated Zoster Vaccine
Duration of Activity: Live Attenuated Vaccine
22
23
24
9/9/2019
9
Side Effects Live Attenuated Vaccine
Effect Live Zoster VaccineN = 3345%
PlaceboN = 3271%
Injection site pain 34.3 8.3
Injection site redness 35.6 6.9
Injection site swelling 26.1 4.5
Headache 1.4 0.8
Fatigue 1 0.4
Recombinant Zoster Vaccine
Adverse Effects Recombinant Zoster Vaccine
Grade 3 Reactions 50-59 years 60-69 year > 70 years
Site reaction 10.3 6.9 4
Myalgia 8.9 5.3 2.8
Fatigue 8.5 5 3.5
Headache 6 3.7 1.5
Shivering 6.8 4.5 2.2
Fever 0.4 0.5 0.1
25
26
27
9/9/2019
10
Storage Preparation and Administration
Zostavax® II (LZV) Shingrix® (RZV)
Date of authorization in Canada 2011 2017
Type of Vaccine Live attenuated Recombinant subunit (adjuvanted)
Schedule 1 dose 2 doses, 2-6 months apart
Route of administration Subcutaneous lntramuscular
Dose0.65 mL (entire contents of the reconstituted vial)
0.5 mL (entire contents of the reconstituted vial)
Contraindications
•Known hypersensitivity to any of the vaccine component•Immunosuppression or immunodeficiency•Pregnancy
Known hypersensitivity to any of the vaccine components.
Storage Requirements Refrigerator - stable Refrigerator – stable
Asymptomatic Bacteriuria/UTI.
28
29
30
9/9/2019
11
Urinary Tract Infections
Cystitis• Infection of the bladder or lower urinary tract
Pyelonephritis• Infection of the kidney or upper urinary tract
Cystitis can be further divided• Uncomplicated cystitis
• Complicated cystitis
• Asymptomatic Bacteriuria
Academic Detailing Service: Antibiotics - Why and Why Not 2018
Cystitis/Pyelonephritis
Greater than 30% women will have a UTI
50 times greater in women than men
Most common healthcare associated infection worldwide
Signs and Symptoms
• Cystitis• Acute or resent onset• Urinary frequency, pain/burning on urination, urgency, dysuria
• Pyelonephritis• Flank pain and fever
Etiology
Uncomplicated Cystitis• E. Coli 75-95%
• Remaining due to gram negative rods (Klebsiella, Proteus) and Enterococcus
Complicated Cystitis• E. Coli 50 – 90%
• More resistant species such as Proteus, Klebsiella, Enterococci, Pseudomonas
31
32
33
9/9/2019
12
Diagnosis
Urine culture (for complicated since less predictability of pathogen)
Uncomplicated, 2 symptoms and no vaginal discharge no culture required
Treatment
Uncomplicated Cystitis• Nitrofurantoin 100 mg bid x 5 days
• Trimethoprim/Sulfamethoxazole 160/800 mg bid for 3 days
• Fosfomycin 3 grams single dose
Complicated Cystitis• Nitrofurantoin 100 mg bid for 7 days
• Trimethoprim/Sulfamethoxazole 160/800 mg bid for 7 days
• Fosfomycin 3 grams every 3 days for 2-3 doses
• Oral beta lactam for 7 days
• Duration dependent on rate of recovery or factors associated with the complication
Treatment
Pyelonephritis• Perform Urine C & S and tailor antibiotics when returned
• Give one time dose of extended spectrum beta lactam or 24h aminoglycoside
• Fluoroquinolones for 5-7 days
• Trimethoprim/Sulfamethoxazole 160/800 mg bid for 7-14 days
• Oral or IV Beta-Lactam for 7-14 days
• Do not use Nitrofurantoin or Fosfomycin
• May not apply to patients with stones, abscess etc.
34
35
36
9/9/2019
13
Antibiogram – Central Zone
Asymptomatic Bacteriuria
“So I hear I have a UTI”
Definitions
“Asymptomatic bacteriuria” (ASB), or asymptomatic urinary infection, is an isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection.
CID March 2005 (40:5) 643–654
37
38
39
9/9/2019
14
Prevalence ASB
Diabetic• Women: 9-27%• Men: 0.7-11%
Pts > 70 years of age• Women: 10.8-16%• Men: 3.6-19%
LTC• Women: 25-50%• Men: 15-40%
Indwelling Catheter Use• Short tern: 9-23%• Long term: 100%
CID: 2005 ; 40 : 643 -654
Risk Factors for ASB
• Age related factors associated with ASB• Diabetes
• Pelvic prolapse/cystocele
• Enlarged prostate
• Vaginal Atrophy
• Immobility
• Incontinence
• Dehydration
Pyuria
• Pyuria is evidence of an increase of PMN leukocytes in urine• Pyuria is present:
• 32% young women• 30-70% pregnant women• 70% women with diabetes• 90% elderly institutionalized patients• 90% hemodialysis patients• 30-75% short term catheters• 50-100% long term catheters
• Pyuria present in inflammatory conditions• Renal tuberculosis• STIs• Interstitial nephritis
CID: 2005 ; 40 : 643 -654
Do not use urinalysis as diagnostic tool for UTI
40
41
42
9/9/2019
15
Treatment
• Antimicrobial therapy for ASB is only indicated for individuals for which harm may be caused:
• Pregnancy
• Urological procedures
• TURP
• High risk of mucosal bleeding is expected
• Why do we care?
• Love for a patient does not come in the form of an antibiotic…
• They can cause harm
Adverse Effects of Antibiotics
• Increases:
• Risk of Clostridium Difficile
• Risk of developing resistant bacteria
• Cost (drugs, test and treating adverse effects)
Not to forget
• Side effects of specific antibiotics
Medications associated with C. Diff
Increased incidence of Clostridium
difficile disease (OR 2.45, 95% CI 0.86-
6.96, p=0.132) with tx of ASB
Cochrane 2015
43
44
45
9/9/2019
16
If no symptoms are present, why are cultures ordered?
• 2002 urine cultures from 888 patients were obtained from inpatients at Toronto hospital
• Mean patient age = 68 +/- 9.4 years
• Medical records available for 335 patients
Why were cultures ordered?
• Altered mental status – 191/335 (57%)
• Fever – 122/335 (36%)
• Cloudy or malodorous urine –19/335 (6%)
Trends
• ASB with confusion were MORE LIKELY to be treated • 75% vs 43% OR 1.81 (CI 1.19 to 4.12: p=0.03)
• Outcomes
• 43 patients with ASB received 347 days of inappropriate antimicrobial therapy
46
47
48
9/9/2019
17
Clinical Question
• In delirious patients with ASB
• Does treatment with antibiotics vs no treatment lead to• Improvement in functional ability
• Increased risk of medication related adverse effects
Asymptomatic UTI Analysis
Delirious Sample343
No UTI treated 251
Asymptomatic UTI Treated93 (92)
Positive Urine Culture 68
Negative Urine Culture 24
Asymptomatic UTI treatment associated with worse functional (RR 1.30, 95% CI: 1.14-1.48) in comparison to rest
of delirious sample
Patient Progress
Days vs MDAS scores
49
50
51
9/9/2019
18
Point Prevalence Study: Bacteriuria/UTI/CAUTIObjectivesPrimary
• Determine rates of CA-UTI / 1000 catheter days in a general medicine hospital setting
Secondary• Measure catheter usage rates / 1000 patient days
• Reason for catheter use/length of catheter use• Observe all urine samples
• Reason for sample taken• Ordered by physician
• Record rates of UTI/ASBU• Symptoms• C & S
• Make and record recommendations when required• Acceptance rates
Point Prevalence Study: Bacteriuria/UTI/CAUTI
50%
37%
13%
VRH Bacteriuria DATA PAF
ASBU SUTI HA-CAUTI
4 4
0
1
2
3
4
5
Recommendationsby AMS Pharmacistto D/C Antibiotics
Recommended Accepted
0 1 2 3 4
E. Coli
Klebsiellapneumonia
Enterococcus spec
Pseudomonas
Staph aureus
Isolated Bacteria
Isolated Bacteria
No growth = 25Total Samples with growth = 8
Total Samples Reviewed = 33
• One sample was combined Enterococcus/Klebsiella
• 3/25 pts with no growth were treated with an antibiotic (all stopped)• 2 by recommendation• 1 by physician
Point Prevalence Study: Bacteriuria/UTI/CAUTI
0
5
10
15
20
25
30
35
Urine Samples
Total Urine Samples Samples Ordered by Dr Samples with Urinary Sx
39% samples had one urinary symptom
28% not ordered by physician
61% no noted reason or symptoms not urinary
• 42% of samples had no reason noted to why sample taken
• 19% drawn for nonspecific reasons (decreased loc, dementia, delirium etc).• Of those 19%, none
were associated with bacterial growth
• All samples were ordered by physician
52
53
54
9/9/2019
19
Point Prevalence Study: Bacteriuria/UTI/CAUTI• Discussion
• More education needs to be done on when to draw urine samples• 76% yield no growth, more than ¼ ordered without physician aware, 61% ordered
without noted reason related to UTI
• Better documentation and monitoring needs to be in place for catheter use• More than half not clearly noted as to why inserted, or noted when to be reassessed
• Better sterile technique and insertion criteria required• Half of total bacteriuria noted in catheterized patients
• Continued education needed with regards to ASBU• 50% of bacteriuria was asymptomatic
What can we do?
Resources
• NS Antimicrobial Stewardship Webpage• https://library.nshealth.ca/AMS
• Spectrum App
55
56
57
9/9/2019
20
Questions?
58