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Hospitalist Lightning Round: ID

Maj Cina, MD, Matthew DeLaney, MD, FACEP, FAAEM, and Neda Frayha, MD
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Hospitalist Corner Lightning Round is back! This time Dr. Maj Cina drops knowledge on 4 common inpatient scenarios in the arena of infectious diseases.

Pearls:

  • If you are thinking of antibiotics for infectious diarrhea because you have a fever, bloody diarrhea, and more severe symptoms, think about just ciprofloxacin or azithromycin. Hold the metronidazole.
  • Probiotics are still not recommended by IDSA but recent evidence suggests efficacy. Don’t forget contraindications: immunocompromise, pregnancy, prosthetic heart valves.
  • For patients with nosocomial pneumonia with MRSA-negative respiratory tract cultures, you don’t need to continue covering for MRSA. 
  • For patients with gram-negative bacteremia resistant to ceftriaxone, go with a carbapenem (not beta-lactamase) and treat for only 7 days.

 

  • Infectious diarrhea:
    • Consider antibiotics for immunocompetent adults with the following:
      • Fever, diarrhea (may be bloody or mucoid) with abdominal cramps, nausea or vomiting consistent with shigella → ciprofloxacin, azithromycin
      • However, if you don’t have more severe symptoms, antibiotics are not necessary and most cases of diarrhea are not due to shigella
    • Metronidazole is commonly used with ciprofloxacin for bloody diarrhea, perhaps to treat both shigella and c. diff.  However, the latest recommendations do not include metronidazole and oral vancomycin is the recommended treatment if you think it is c. diff.
  • Probiotics:
    • IDSA (as of February 2018) says there is insufficient evidence to endorse probiotics but you may consider it for the hospitalized patient with infectious diarrhea for prevention of c. diff.
      • Journal of Gastroenterology in 2017 published a meta-analysis of 19 studies, 6000+ patients that showed probiotics reduced incidence of c. diff by 68% (RR 0.42), absolute difference 3.9% to 1.6%. Did not find significant adverse events but excluded people who should not get probiotics in the first place
      • These results are from the inpatient setting, not ICU or outpatient setting
      • Contraindications: immunocompromise, patients with prosthetic valves, pregnancy
      • Bottom line: consider lactobacillus 10-60 billion colony forming units within two days of antibiotic initiation 
  • MRSA for patients with hospital-acquired pneumonia:
    • If you are treating nosocomial pneumonia and start treating for MRSA coverage but your respiratory culture (sputa, trach aspirate, or bronchoalveolar lavage) comes up without MRSA, you can stop treating the MRSA
      • Chest 2019 publication showed peeling off MRSA coverage for this patient population resulted in a shorter length of stay, fewer ICU days, lower risk of acute kidney injury, and no increase in mortality
  • Gram-negative rod bacteremia:
    • If you have a patient with ceftriaxone-resistant gram-negative rod bacteremia, most recent evidence suggests the use of the carbapenem (meropenem) even if susceptible to a beta-lactamase (piperacillin-tazobactam)
      • JAMA 2018 randomized this patient population to either meropenem or piperacillin-tazobactam. The group that received meropenem had a much lower mortality rate (3.7% vs. 12.3%)
    • Seven (7) days with transition to oral antibiotic is adequate duration  if the patient is afebrile and hemodynamically stable within 48 hours, good source control
      • RCT in Clinical Infectious Diseases 2018
      • JAMA IM 2019 retrospective cohort supports this assertion

 

References:

  1. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. doi:10.1093/cid/cix669
  2. Shen NT, Maw A, Tmanova LL, et al. Timely Use of Probiotics in Hospitalized Adults Prevents Clostridium difficile Infection: A Systematic Review With Meta-Regression Analysis. Gastroenterology. 2017;152(8):1889-1900.e9. doi:10.1053/j.gastro.2017.02.003
  3. Cowley MC, Ritchie DJ, Hampton N, Kollef MH, Micek ST. Outcomes Associated With De-escalating Therapy for Methicillin-Resistant Staphylococcus aureus in Culture-Negative Nosocomial Pneumonia. Chest. 2019;155(1):53-59. doi:10.1016/j.chest.2018.10.014
  4. Harris PNA, Tambyah PA, Lye DC, et al. Effect of Piperacillin-Tazobactam vs Meropenem on 30-Day Mortality for Patients With E coli or Klebsiella pneumoniae Bloodstream Infection and Ceftriaxone Resistance: A Randomized Clinical Trial [published correction appears in JAMA. 2019 Jun 18;321(23):2370]. JAMA. 2018;320(10):984-994. doi:10.1001/jama.2018.12163
  5. Yahav D, Franceschini E, Koppel F, et al. Seven Versus 14 Days of Antibiotic Therapy for Uncomplicated Gram-negative Bacteremia: A Noninferiority Randomized Controlled Trial. Clin Infect Dis. 2019;69(7):1091-1098. doi:10.1093/cid/ciy1054
  6. Tamma PD, Conley AT, Cosgrove SE, et al. Association of 30-Day Mortality With Oral Step-Down vs Continued Intravenous Therapy in Patients Hospitalized With Enterobacteriaceae Bacteremia [published correction appears in JAMA Intern Med. 2019 Nov 1;179(11):1607]. JAMA Intern Med. 2019;179(3):316-323. doi:10.1001/jamainternmed.2018.6226

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