1、Outpatient antibiotic useCarlos A.DiazGranados,MD,MSDirector,Antimicrobial UtilizationGMH.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 normal vital signs
2、,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.Facial pain.Purulent d
3、ischarge.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 antibiotic of choice is Amoxicilli
4、n.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 Unclear RCT have used 5-10 days.Case 2 24 yo male,recently diagnosed with HIV,CD4 is 180 on Bactrim prophylaxis,star
5、ted 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 diagnosis?What is the first line antibiotic choice?.Acu
6、te bronchitisAntibiotics 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.Decrease breath sounds and rales RLL.O2sat 94%RA.Labs:PaO2 72.WBC=12.L
7、DH=180.What is the likely diagnosis?What would be your recommended therapy?.Community-acquired pneumonia.PCP vs.Bacterial.PCP vs.Bacterial.CAPCID 2007;44:Suppl 2.Site of care decisions.PSI Scoring.CURB 65 Score.Consider ruling out TB all patients that you treat for bacterial pneumonia with quinolone
8、 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 sputum which has become darker in color.PE shows tachypnea,normal temperature,mild tac
9、hycardia,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:Amoxicillin Doxycycline Bactrim Macrolides(azithromycin,clarithromycin)Levofloxacin.Case 5 36 y
10、o 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 activity.Physical exam shows Temp of 38.7,tachycardia,thick exudate in bilateral tonsils and cervical lymph
11、adenopathy.What is the diagnosis?What are the next steps?.Acute PharyngitisRemember that most are viral.Remember that Group A Streptococci(Strep.pyogenes)are the most common bacterial cause.Remember that GC can cause pharyngits in individuals that practice oral sex.Note:If you suspect GC from histor
12、y,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 and cultures are not available?-.CASE 6A 42 yo HIV+man presents with fever,chills,and 2 lesions over the back of his neck.
13、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.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 prop
14、hylaxis(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 bacteria.What is the diagnosis?What are the antibiotic options?.Urinary tract infection.1999 IDSA Guidelines Uncomplicated cystitis in WOMEN:TMP,Ba
15、ctrim 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 7-14 days Bactrim x 14 days if organism susceptible.Can start empirically with quinolone and change to Bactrim if isolate comes back susceptible.Case 8
16、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 subjective 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.W
17、hat is the diagnosis?What are the antibiotic options?.Pelvic inflammatory disease and STIsDiagnostic tests to consider:GC culture,GC/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 treatme
18、nt of acute bronchitis.Antibiotics may not be needed in the majority of patients with acute sinusitis.A short course of antibiotics is indicated in patients with acute exacerbations of chronic bronchitis(Doxycycline,Bactrim,or Amoxicillin).Many patients with HIV and pneumonia can be treated as outpa
19、tients,and many will NOT need RX for both PCP(Bactrim)and bacterial pneumonia(Levofloxacin+r/o TB,Amoxicillin+Azithromycin or Augmentin+Azitromycin).ConclusionsThe majority of patients with acute pharyngitis do not require antibiotics.Pursue an etiologic diagnosis rather than treating empirically as
20、 GA Strep.The most important therapy for MRSA soft tissue infections is appropriate incision and drainage.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
21、 patient groups for which antibiotics are recommended in asymptomatic bacteriuria.All UTI in males 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.
