3/15/18 Disclosures § I have no disclosures. Top Curbside Consult Questions in ID 39 th Annual Advances in Infectious Diseases March 2018 Jennifer Babik, MD, PhD Associate Clinical Professor Division of Infectious Diseases, UCSF Learning Objectives Roadmap At the end of this talk, you will be able to: § A Brief Word on Curbsides vs. Formal Consults § Describe the situations in which formal in-person § Case-Based Approach to the Top Curbside Consult consultation is preferred over curbside consultation Questions in ID § Outline an approach to common ID questions that arise in the inpatient and outpatient setting 1
3/15/18 Curbsides vs Formal Consults Are Curbsides Okay? § Need to balance patient safety, provider workload, Curbsides education • Information inaccurate Study of 47 curbsides vs. or incomplete in 51% formal consults § Curbside volume in ID • Medicine consult § In the literature: 20-120 curbsides/month • Curbside à formal § UCSF Medical Center: 60 curbsides/mo (15 hours/mo) Formal Consults consult by a colleague • Changed Rx in 60% • Curbsided providers § Impossible in most practices to convert all curbsides (36% “major changes”) could not look in chart into formal consults • If info was inaccurate/incomplete then it changed Rx in 92% (45% “major Grace et al, Clin Infect Dis 2010, 51:651. Wachter, B. "The Dangers of Curbside Consults... and Why We changes”) Need Them." Wachter's World . 29 Apr. 2013. Burden et al, J Hosp Med 2013, 8:31. Is This An Appropriate Curbside? Is This An Appropriate Curbside? What is the dose of ertapenem when the CrCl is <30? 1. Yes 2. No 2
3/15/18 Is This An Appropriate Curbside? Is This An Appropriate Curbside? 1. Yes 2. No Is This An Appropriate Curbside? Is This An Appropriate Curbside? Theoretically, if a patient has mild cystitis due to VRE 1. Yes that is sensitive to doxycycline, can I use that drug to treat a VRE UTI? 2. No 3
3/15/18 What is an Appropriate Curbside? The Special Case of S. aureus Bacteremia § The Goldilocks of Curbside Consultation § Benefit of ID consultation versus no consultation § Not too simple: the answer can be easily looked up § ñ adherence to quality indicators for SAB: § Not too complicated: the answer requires nuanced clinical § Getting an echo, repeat blood cultures § Improved antibiotic choice and duration judgment or interpretation of a lot of data § ñ removal of prosthetic devices/source control § Just right: Hypothetical, factual question § ñ detection of metastatic foci of infection § We also tell our ID Fellows that it § ê mortality (by 20-50%) should probably be a consult if: § You need to look up the answer § It’s early in the year § The team calls you back several times Saunderson et al, Clin Micro Infect 2015, 21:779. Forsblom et al, Clin Infect Dis 2013, 56:527. Bai et al, Clin Infect Dis 2015; 60:1451. Paulsen et al, OFID 2016. Vogel et al, J Infection 2016; 72:19. Curbsides for S. aureus Bacteremia? Curbside #1 § Curbside consult is associated with: 55 y/o woman in the ICU after a complicated spinal surgery. She § Less identification of deep infectious foci remains intubated, spikes a fever § Less likely to receive the proper duration of therapy on POD#3 and is pan-cultured. § ñ 90d mortality by > 2-fold compared to formal consult § She has thick secretions and a new CXR infiltrate. § Formal consult for SAB is preferred if available § Sputum is growing MRSA. § UA (catheter): 11-20 WBC, Ucx positive for VRE. Forsblom et al, Clin Infect Dis 2013, 56:527. 4
3/15/18 Do You Need to Treat the VRE? Asymptomatic Bacteriuria 1. Yes ASB = (+) urine culture AND no signs/symptoms of UTI 2. No 3. Not sure Asymptomatic Bacteriuria is COMMON! Hazards of ASB Treatment § Side effects of antibiotics § Seen in up to: § 25% of elderly, diabetic, or HD patients § 50% of patients in long term care facilities § ñ risk of Cdiff § 25% of patients with short-term catheters, ~100% with long-term catheters § ñ risk of resistance § Of positive urine cultures obtained on the wards § May increase risk of recurrent UTI by getting rid of after hospital admission à ~90% are ASB “good” interfering bacteria Nicolle et al, Clin Infect Dis 2005, 40:643. Leis et al, Clin Infect Dis 2014, 58:980 Cai et al, Clin Infect Dis 2012;55(6):771. Cai et al, Clin Infect Dis 2015;61(11):1655.. 5
3/15/18 Exceptions: Who With ASB Should Be Treated? What About Patients Undergoing Arthroplasty? § Pregnant women § ASB is not associated with: § ê risk pyelo, premature delivery § Risk of joint infection from the organism in the urine § Risk of post-operative UTI § GU procedures w/mucosal bleeding § ê post-procedure bacteremia/sepsis § Pre-op screening and treatment of ASB is not recommended § Immunosuppressed patients? § Renal transplant in the first 3 months? § Neutropenia? Sousa et al, Clin Infect Dis 2014;59:41. Duncan, Clin Infect Dis 2014;59:48. Lamb et al, Clin Infect Dis 2017, Nicolle et al, Clin Infect Dis 2005, 40:643. 64:806. The Heart of the Problem How To Distinguish ASB vs. UTI? § It’s Hard to Ignore a Positive Culture Does the UA help? Does the organism help? • Only if negative • No, the same organisms § Proof of concept study: Pyuria is very common in cause ASB and UTI (even • ASB, but the absence of WBC Pseudomonas and ESBL) § At Mount Sinai, 90% of inpatient urine cultures were ASB, suggests an alternative dx and 50% were treated with ABx Always order a UA when • § They stopped reporting (+) urine cultures in the EMR ordering a urine culture § Results: § The % of ASB that was treated dropped by 80% § No untreated UTIs and no sepsis Use clinical context: does the patient have signs/symptoms of UTI? Nicolle et al, Clin Infect Dis 2005, 40:643. Tambyah et al, Arch Intern Med 2000, 160:678. Lin et al, Arch Int Med 2012, 172:33. Leis et al, Clin Infect Dis 2014, 58:980. 6
3/15/18 What if I Can’t Assess Symptoms? How to Interpret Urine Studies in a Patient With a Foley or AMS Alternate Diagnosis Likely? How to define UTI in patients with a catheter or AMS? (Signs/ sx of other illness present) No Yes Send U/A, Do not order urine cx U/A, urine cx Surrogate signs/symptoms that are No other source of infection AND consistent w/ UTI (i.e., diagnosis of exclusion) U/A, urine cx U/A (-), urine U/A (+), urine U/A (+), • Fever, rigors, AMS, malaise (-) cx (+) cx (+) urine cx (-) • Flank pain, CVAT, pelvic pain • Acute hematuria Do not treat for UTI Treat for UTI Asymptomatic Do not treat (If no alternate dx bacteriuria • Spinal cord injury: ñ spasticity, identified) autonomic dysreflexia, unease Slide courtesy of Catherine Liu. Nicolle et al, Clin Infect Dis 2005, 40:643. ASB vs. UTI: Take-Home Points Curbside #2 § ASB is common, especially in catheterized patients A 75 y/o F with neurogenic bladder and history of prior UTI is admitted with confusion, fever, and a 2d history § Pyuria ≠ UTI, but its absence points to a different source of suprapubic pain and dysuria. § ASB does not require therapy except for: UA shows >50 WBC/hpf and urine culture grows E. coli . § Pregnancy Blood cultures are negative. She improves on empiric § Urologic procedures ertapenem and is ready for discharge. Susceptibilities § Neutropenia, renal transplant <3 mo? come back and the E. coli is an ESBL producer. § To diagnose a UTI in a patient with a catheter or who cannot report symptoms, the patient must have: Do I need to send her home on ertapenem or are there § Signs and symptoms compatible with UTI any oral options? § No other source for infection (i.e., diagnosis of exclusion) 7
3/15/18 Which Oral ABx Has the Best Efficacy in ESBL UTI? Oral Options for ESBL E. coli in the Urine 1. Fosfomycin Antibiotic % Sensitive in vitro Ciprofloxacin 4-36 2. Nitrofurantoin TMP-SMX 22-43 Amoxicillin/Clavulanate 11-70 Nitrofurantoin 58-94 3. Minocycline Fosfomycin 91-100 4. Cephalexin Caveat: susceptibilities for ESBL Klebsiella are lower for both fosfomycin (~54-80%) and nitrofurantoin (14%) Prakash et al, AAC 2009, 53:1278. Liu et al, J Micro Immunol Infect 2011, 44:364. Kumar et al, Infect Dis Res Treat 2014, 7:1. Meier et al, Infect 2011, 39:333. Kresken et al, IJAA 2014, 44:295. Fournier et al, Med Mal Infect 2013, 43:62. Rodriguez-Bano, Arch Intern Med 2008, 168:1897. Linsenmeyer, AAC 2016, 60:1134. Data for Oral ABx in E.coli ESBL Cystitis (Outpatient) What if the Patient has Pyelonephritis? § Small study in community-acquired pyelonephritis showing non-carbapenem = carbapenem Nitrofurantoin Fosfomycin Amoxicillin/clav • 14d à 69% cure • 1-3 doses à 94% cure • 5-7d à 93% cure • No pyelo/bacteremia • No pyelo/bacteremia § But, non-carbapenem group: • Avoid if CrCl<60 • MIC not routinely done • Dose at 3gm PO qod x 3 § Mostly aminoglycoside or pip/tazo (or improvement) § Had much lower rates of bacteremia § Bottom line: could consider orals in very select circumstances without bacteremia, but no data Falagas et al, Lancet ID 2010, 10:43. Rodriguez-Bano, Arch Intern Med 2008, 168:1897. Pullukcu et al, Int J Antimicrob Agents 2007, 29:62. Reffert and Smith, Pharmacotherapy 2014, 34:845. Park et al, J Antimicrob Chemother 2014, 69:2848. 8
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