Common Hospital Infections

If you want three opinions then ask two infectious disease doctors- KBA

Fever
Its 1am and the nurse on Lakeside 65 just called you because Mrs. Price has a T of 101.5 . . . What do you do?

More cowbell!

What is the definition of a fever?

Textbook
Elevation in the bodys thermoregulatory set point

In the different IDSA guidelines dealing with fever

T >101 at any timepoint T >100.4 for greater than one hour

Use your judgement

Fever
1) Assess the patient
As always this is #1 when you are called about a patient
What are they in for? Have they been febrile? What do they look like?

Are there any symptoms consistent with infection or non-infectious causes of fever (which are?)

Non-infectious causes of fever

Venous thromboembolism Medications Transfusion reaction Neuroleptic malignant syndrome Connective tissue disease Malignancy Just drank hot coffee

Fever
2) Orders Blood cultures Urinalysis, urine culture Chest x-ray

Sepsis
Documented or suspected infection
plus

Systemic Inflammatory Response Syndrome (2 of the following 4)

Pyrexia or hypothermia- T >38C or <36C Tachycardia- HR >90 Respiratory- RR >20 or PaCO2 <32mmHg WBC- Total >12,000, <4000 or Bands >10%

Keep in mind that many clinical scenarios can produce 2 of 4 SIRS criteria

Hypotension
Systolic BP <90mmHg
or

Systolic BP reduced >40mmHg from baseline

Types of sepsis
Severe sepsis- sepsis associated with organ dysfunction, hypoperfusion, or hypotension

Septic shock- Sepsis with hypotension, despite adequate fluid resuscitation, along with the presence of perfusion abnormalities- lactic acidosis, oliguria, mental status change

Treatment
Antibiotics
Targeted at known organism or empiric treatment

Early goal directed therapy

Sepsis- Early goal directed therapy

Sepsis considerations
Corticosteroids
given only to adult septic shock patients after it has been confirmed that their blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy

Activated Protein C (Xigris)

APACHE II >25 Talk with your fellow

Your clinic patient is . . .

44 yo female h/o HTN who complains of 2 days of dysuria and subjective fever On exam T is 99.7, HR 68, BP 120/64 Abdominal exam with suprapubic tenderness

UTI risk
Females
Atrophic vaginal mucosa with altered flora Use of diaphragms and spermaticides Foley catheter

Males
Stricture or obstruction of the urethra (e.g. BPH) Foley catheter

Etiology of UTI
Uncomplicated
E. coli- 85% of females with uncomplicated infection Staph. Saprophyticus

Recurrent
Enterococci (faecium and faecalis) Klebsiella Proteus

UTI pathogenesis
Introduction of bacteria into the urinary bladder Incomplete emptying of the bladder (as little as 10mL of residual) Fast reproduction time of many of the bacteria that cause UTI (e.g. E. coli which reproduces in 20 minutes)

Urinalysis
Leukocyte esterase- test for esterase which is released from leukocytes Nitrite- produced when bacteria convert nitrates to nitrites WBC- pyuria is defined as . . .
>5WBC per HPF in women >2WBC per HPF in men

Bacteruria- different for clinical scenario

The presence of bacteria in male urine should always be considered abnormal Females- >10^5 per HPF (100,000)

Complicated UTI
Abnormal anatomy- residual urine, neurogenic bladder, BPH Foreign bodies- Catheters, Calculi, Tumors Vesicoureteral reflux Diabetes

Uncomplicated UTI treatment

Oral
Bactrim Nitrofurantoin Augmentin Cephalosporin Fluoroquinolone

IV
Cephalosporin- ceftriaxone Fluoroquinolone

 54 yo male h/o HTN, DM who presents with raised erythematous lesion on right leg and subjective fevers. T 99.7 HR 86 RR 16 BP 140/90

Soft tissue infections

Cellulitis
Erythematous lesions with less clear line of demarcation compared to erysipelas Involves deeper dermis and subcutaneous fat

Erysipelas
raised above the level of surrounding skin, and there is a clear line of demarcation between involved and uninvolved tissue Involves upper dermis and superficial lymphatics

Treatment of routine cellulitis

MRSA coverage? Beta-lactam
Often in hospital would use Unasyn Consider Pseudomonas coverage for diabetics (Piperacillin-tazobactam)

PCN allergic
Consider fluoroquinolone

When is cellulitis not cellulitis?

Myositis Osteomyelitis

When is cellulitis not cellulitis?

Toxic appearance to patient Pain out of proportion to exam Quickly spreading infection Presence of crepitation Bullae formation

Risk of necrotizing fasciitis- score >6 is suggestive and score >8 is highly predictive
Serum C-reactive protein 150 mg/L (4 points) White blood cell count 15,000 to 25,000/microL (1 point) or >25,000/microL (2 points) Hemoglobin 11.0 to 13.5 g/dL (1 point) or 11 g/dL (2 points) Serum sodium less than 135 meq/L (2 points) Serum creatinine greater than 1.6 mg/dL (141 mmol/L) (2 points) Serum glucose greater than 180 mg/dL (10 mmol/L) (1 point) A total score 6 should raise the suspicion for necrotizing fasciitis while a score 8 was highly predictive (>75 percent). Among the patients with necrotizing fasciitis, 75 to 80 percent had a score 8, while only 7 to 10 percent had a score less than 6. Thus, the score is only useful when severe soft tissue infection is strongly suspected.

Treatment of necrotizing fasciitis

Stat surgical consult for debridement Clindamycin or metronidazole
plus

Beta-lactam/beta-lactamase inhibitor or 3rd gen cephalosporin or carbapenem or fluoroquinolone or aminoglycoside

The DACR paged you and the report is . . .

73 yo male h/o CHF, CKD, CAD who presents with fever, productive cough x 2 days. On exam, the patient is febrile to 101. You note that the patient has mildly labored breathing with RR of 28, HR 106. Has crackles at the right lower lung field. Labs- WBC 13.5 Hct 34 Plt 175 Na 134 BUN 35 What do you think? What studies would you like?

Initial investigation
CXR Sputum culture Blood culture Consider ABG if respiratory distress or hypoxia

None of the above should delay antibiotic treatment and guidelines dictate that antibiotics should be given within four hours of initial encounter

Clinical manifestationsSigns and Symptoms

Cough- 90% Dyspnea- 66% Sputum production60% Pleuritic chest pain50% Subjective fever Nonspecific symptoms

Temp>37C- 78% Crackles- 78% Confusion- 30% Consolidation- 29%

Epidemiology
Risk factors for CAP
Older age COPD Renal Insufficiency Congestive Heart Disease CAD Diabetes Malignancy Chronic Neurologic Disease Chronic Liver Disease

Pneumonia- Etiology
The clinical features of community-acquired pneumonia cannot be reliably used to establish the etiologic diagnosis of pneumonia with adequate sensitivity and specificity- IDSA guidelines on Community Acquired Pneumonia

CAP- Etiology
The bugs . . .
Strep. Pneumoniae Mycoplasma pneumoniae Haemophilus influenza Chlamydia pneumoniae Respiratory viruses

Risk stratification The PORT score

Usually prior to you seeing the patient May or may not be documented

Pneumonia Severity IndexPORT Score

Applying the PORT score

Fine, M. J. et al. N Engl J Med 1997;336:243-250

PORT in our patient

Age 73

CHF
CKD BUN

10
10 20

Total= 113

PORT score

PORT Categories and mortality

Class I- age <50, no comorbidities
0.1% mortality

Class II- <70

0.6% mortality

Class III- 71-90

0.9 % mortality

Class IV- 91-130

9.3% mortality

Class V- >130
27% mortality

CAP- Initial empiric treatment

Respiratory fluoroquinolone (e.g. moxifloxacin) Or . . . Macrolide (e.g. azithromycin) + betalactam (usually ceftriaxone)

CAP- special considerations Legionella

Legionella risk (relative risk in parentheses)
Glucocorticoids or Cushings disease (2-5) Cytotoxic chemo (5) Cigarette smoking (2-5) Diabetes (2) Male gender (>2) Age >50 (>2) AIDS (40) Renal failure requiring dialysis (20) Lung or hematologic cancer (7-20)

Diagnostics- urine legionella antigen Treatment- Erythromycin or tetracycline (usually doxycycline)

CAP- special considerations Aspiration pneumonia

Risk
Think of patients with loss of consciousness (seizures, alcoholics), patients with neurological impairment

The bugs
Gram-negative enteric pathogens Mouth anaerobes

Treatment for the hospitalized patient

Piperacillin/tazobactam 3.375g q6H Imipenem 500mg q6H Clindamycin 900mg IV q8H plus ciprofloxacin 400mg q12H or Aztrenoam 1-2g q8H

The DACR paged you and the report is . . .

83 yo male with h/o CKD, COPD, Alzheimers who presents from nursing home with mental status change. T 102 HR 135 BP 86/40 RR 40 On exam you find that patient has lower lobe rhonchi. How is this different from your other patient with pneumonia?

Defining Healthcare Associated Pneumonia

Pneumonia in someone who. . .
Has developed pneumonia after being in hospital 2 days Was hospitalized for 2 days in the last 90 days Resident of nursing home or long term care facility (e.g. SNF) Recently received IV antibiotics, chemotherapy or wound care in past 30 days Attended a hospital or hemodialysis clinic

Etiology of HCAP
Think of MDR pathogens

Risks for MDR

 Common bugs
Strep pneumo and H. flu- usually cause early rather than late infections Staph- worry about MRSA Gram negative bacilli
Pseudonas aeruginosa E. coli Klebsiella Acinetobacter- if you suspect this then consider ID consult and utilize full barrier and respiratory precautions

Treating HCAP
Empiric antibiotics should be different classes than recently prescribed antibiotics

Recommendation for empiric therapy

Empiric treatment of HAP- early onset and no known risk factors for MDR

Empiric treatment of HAP

Recommendation for empiric therapy

Therapy can decreased to 7 days unless the infection is proven to be Acinetobacter or Pseudomonas

The DACR paged you and the report is . . .

60 yo male with pancreatic cancer who received gemcitabine 8 days ago presents with fever. On exam, T is 101.8, HR is 94, RR is 18, BP is 128/64. Exam is largely unremarkable. On labs his WBC is 0.8 with % neutrophils of 50% What do you think?

Neutropenic fever
Fever (single oral temperature >101 or >100.4 for greater than one hour) in patient with ANC < 500 or in patient who has ANC <1000 with suspected nadir of <500

Epidemiology of Neutropenic fever

of patients who have ANC <500 and fever have established or occult infection 1/5 of patients who have ANC <100 have bacteremia

Problem with neutropenia

They may not act infected
Patient with cellulitis may not have erythema and induration Patient with pneumonia may be without a radiographic infiltrate Patient with meningitis may not have pleocytosis in CSF Patient with UTI may not have pyuria on urinalysis

Initial workup
Blood cultures Urine cultures Sputum cultures CXR

Etiology
Gram positive cocci account for 60-70% of proven bacterial infection in these patients

Low risk vs. high risk

Empiric therapy for high risk patients

Antivirals
Should be used if signs and symptoms of HSV or VZV are present to heal portal of entry for bacteria

Duration of therapy

Fever resolved in first 3-5 days

Persistent fever in first 3-5 days

Colony-stimulating factors
Not routinely recommended for therapy Consider in patients who are severely ill or who have documented bacterial infection, persistent neutropenia and are not responding to antimicrobial therapy

Uh-oh
Your patient that you are treating for HAP begins to have profuse, watery diarrhea!

C. Diff Infection
Clostridium difficile is the most common infectious cause of healthcare associated diarrhea in the United States
3.4 to 8.4 cases per 1000 admissions

Suspect C. diff
What do you order?
C. diff toxin assay from 3 separate stools Fecal leukocytes

Spectrum of disease
Asymptomatic carrier state
3% of healthy adults 16-35% of hospitalized patients

Antibiotic associated diarrhea

Accounts for 10-25% of cases

Colitis without pseudomembrane formation

60-75% of antibiotic associated colitis

Pseudomembranous colitis
90-100% of antibiotic associated pseudomembanous colitis

Fulminant colitis- 1-3% of patients

May lead to ileus, toxic megacolon, perforation and death

Pathogenesis- 3 hit theory

From Cohen and Powderly

Figure 44.1 The pathogenesis model for hospital-acquired Clostridium difficile -associated diarrhea (CDAD).]

Risk factors associated with Clostridium difficile

Risk factor Specific antibiotics -Clindamycin -3rd generation cephalosporins -Fluoroquinolones Increasing age Use of proton pump inhibitor Gastrointestinal surgery Length of stay >7 days Feeding via NG tube Admission to intensive care unit Comments Cefazolin OR=3.5 Levofloxacin OR=2.1 OR=2.8 for age >71 OR=2.1 OR=7.9 OR=2.3 OR=2.8

Treatment of clostridium difficile

Stop offending antibiotic
Leads to resolution in 15-23% of patients

Antibiotics - similar efficacy with resolution in approximately 93% of patients

Oral metronidazole 500mg TID Oral vancomycin 125mg QID as second line treatment

Avoid anti-motility agents

Leads to ileus and toxic megacolon formation

Supportive measures

THE END