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Infectious Diseases I Jacob Schwarz, Pharm.D., MBA, FAzPA, BCIDP, BCCCP, BCPS Mayo Clinic Phoenix, AZ…

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Infectious Diseases I Infectious Diseases I Jacob Schwarz, Pharm.D., MBA, FAzPA, BCIDP, BCCCP, BCPS Mayo Clinic Phoenix, AZ…

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Learning Objectives 3 min

Infectious Diseases I Learning Objectives 1. Develop risk factor–based empiric antibiotic regi- mens for patients with suspected ventilator-associated pneumonia. 2. Develop empiric and definitive a…

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Infectious Diseases I 2. Based on the 2016 IDSA guidelines, which empiric antibiotic regimen is best for the likely causative pathogen(s) of K.P.’s suspected VAP? A. Azithromycin plus moxifloxacin…

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Infectious Diseases I 8. J.E. is a 67-year-old woman admitted to the MICU for severe metabolic acidosis secondary to uninten- tional metformin overdosage. Her ICU stay has been complicated by a fem…

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Exam Content Outline 1 min

Infectious Diseases I BPS Critical Care Pharmacy Examination Content Outline This chapter covers the following sections of the Critical Care Pharmacy Examination Content Outline: 1. Domain 1: Critica…

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Infectious Diseases I I.  VENTILATOR-ASSOCIATED PNEUMONIA A. Epidemiology 1. About 90% of hospital-acquired pneumonia episodes in critically ill patients occur during MV. MV is an independent risk…

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Infectious Diseases I i. Preferentially use multimodal strategies and medications other than benzodiazepines to manage agitation. ii. Use a protocol to minimize sedation. iii. Implement a ventilat…

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Infectious Diseases I a. If an invasive strategy with quantitative cultures is used, it is suggested that antibiotics be withheld rather than continued if quantitative culture results are below the…

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Data Tables 2 min

Infectious Diseases I Table 1. VAP Classifications and Recommended Empiric Antibiotic Therapy Based on 2016 IDSA VAP Guidelines Likely Pathogens Recommended Empiric Antibiotic(s)a Patients without MDR…

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Infectious Diseases I 4. Definitive antibiotic therapy should be focused on the causative pathogen(s) identified on lower respiratory tract culture. a. Pathogen-specific definitive antibiotic choic…

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Data Tables 3 min

Infectious Diseases I (c) The rate of MDR pathogens during a recurrent VAP episode was higher in patients in the 15-day group. ii. Two meta-analyses that included the results of the PneumA trial su…

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Infectious Diseases I Characteristic 2005 Guidelines 2016 Guidelines Classification Early onset or late onset No longer differentiate VAP episodes based on time from hospital admission Emphasis on l…

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Infectious Diseases I Patient Cases 1. C.T. is a 48-year-old man sustaining a 40% total body surface area burn to his left side with likely inhala- tional injury requiring mechanical ventilation. C.T…

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Infectious Diseases I B. Diagnosis 1. Clinical signs and symptoms of infection have poor sensitivity and specificity. Fever is the most sensitive clinical finding, whereas inflammation or purulence…

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Infectious Diseases I b. Complicated CLABSI i. Endocarditis; immunosuppression (S. aureus only); diabetes (S. aureus only); chronic intravascular hardware; osteomyelitis; positive blood cultures gr…

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Infectious Diseases I Patient Cases (continued) Questions 5 and 6 pertain to the following case. F.P. is a 29-year-old man admitted to the MICU from another hospital with severe, alcohol-induced, ster…

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Infectious Diseases I C. Treatment 1. A urinary culture should be obtained before initiation of antimicrobial therapy. 2. If an indwelling catheter has been in place for longer than 2 weeks, the ca…

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Infectious Diseases I IV.  COMPLICATED INTRA-ABDOMINAL INFECTION A. Epidemiology 1. Complicated intra-abdominal infection spans prehospital and in-hospital dispositions and a variety of pathogenic…

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Infectious Diseases I a. Esophageal, gastric, and duodenal secretions are usually sterile or with limited inocula of gram- positive bacteria and Candida spp. b. Proximal small bowel is densely popul…

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Infectious Diseases I c. Community-acquired, mild to moderate severity, low risk for treatment failure i. Routine culture is not recommended. ii. Empiric antibiotic therapy should include agents ac…

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Infectious Diseases I iii. Anti-enterococcal therapy should be considered in patients with recent exposure to broad- spectrum antimicrobial therapy, septic shock, postoperative infections, and those…

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Infectious Diseases I Patient Cases 9. D.L. is a 69-year-old woman admitted from home to the SICU with severe acute abdominal pain in the left lower quadrant. An abdominal CT reveals free air in the…

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Infectious Diseases I 2. About 20% –30% of acute pancreatitis episodes are severe, have evidence of pancreatic necrosis, and are associated with local and systemic complications (e.g., multiple orga…

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Infectious Diseases I 5. Additional late complications of peripancreatic necrosis include secondary pancreatic infection of previously acute necrotic collections during the first 4 weeks after prese…

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Infectious Diseases I v. If infection is confirmed, antibiotic therapy should be de-escalated toward the identified pathogen(s) according to antibiotic susceptibility. vi. Definitive antibiotic the…

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Infectious Diseases I 2. C. difficile is transmitted person to person through the fecal-oral route. The capability to become dormant in spores increases the potential for environmental spread. 3. C…

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Infectious Diseases I C. Risk Factors 1. Antibiotic therapy is the most important risk factor. a. All antibiotic classes have been associated with CDI. b. Highest-risk (listed by decreasing risk)…

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Infectious Diseases I c. Enzyme immunoassay (EIA) tests for C. difficile toxins A and B are rapid and widely available; however, poor sensitivity may limit their utility. Obtaining serial samples ha…

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Infectious Diseases I iii. Metronidazole is primarily only recommended in addition to oral vancomycin for the treatment of severe-complicated/fulminant CDI. The IDSA guidelines indicate that metroni…

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Data Tables 2 min

Infectious Diseases I Table 3. Treatment Options for Clostridioides difficile Infection Clinical Definition ACG 2013 IDSA/SHEA 2018 IDSA/SHEA 2021 Focused Update ACG 2021 Initial episode, nonsev…

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Data Tables 2 min

Infectious Diseases I Clinical Definition ACG 2013 IDSA/SHEA 2018 IDSA/SHEA 2021 Focused Update ACG 2021 First recurrence Same regimen as used for initial episode, unless severe; if severe,…

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Infectious Diseases I Clinical Definition ACG 2013 IDSA/SHEA 2018 IDSA/SHEA 2021 Focused Update ACG 2021 Second recurrence Vancomycin PO, then 28-day dosage taper Vancomycin in tapered and…

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Infectious Diseases I Patient Cases 14. K.L. is a 57-year-old man admitted to the MICU with diffuse abdominal pain, temperature 101.9°F (38.8°C), WBC 27 x 103 cells/mm3, heart rate 125 beats/minute,…

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Infectious Diseases I VII.  WOUND INFECTION A. The epidemiology, definitions, etiology, and prevention for postoperative wound infections are discussed in the Infectious Diseases II chapter. B. Dia…

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Infectious Diseases I b. Antibiotic therapy is empiric or definitive. i. Empiric antibiotic therapy should be initiated as early as possible. ii. Polymicrobial infection should be suspected, with e…

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Infectious Diseases I VIII.  INFLUENZA A. Epidemiology 1. Influenza is a seasonal viral illness affecting all ages and associated with significant morbidity and mortality. Seasonal patterns in the…

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Infectious Diseases I 3. Institutions should begin implementing influenza screening and infection control measures when influenza viruses are confirmed to be in the local community. 4. The CDC reco…

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Infectious Diseases I c. Neuraminidase inhibitors continue to be the mainstay of antiviral therapy for recent influenza A and B strains. These agents inhibit viral neuraminidase, decreasing the rele…

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Data Tables 2 min

Infectious Diseases I ii. High levels of resistance to the adamantanes (amantadine and rimantadine) have persisted among circulating influenza A viruses. The adamantanes are not effective against in…

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Data Tables 2 min

Infectious Diseases I Agent Influenza Activity Bioavailability Half-life (hr) Treatment Dosage Adverse Effects Comments Zanamivir Neuraminidase inhibitor; A and B Inhaled: Up to 17% 2.5–5 10 m…

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Infectious Diseases I Patient Cases 19. T.Y., a 32-year-old woman who has had flulike symptoms for the past 72 hours, presents to the ED from home with severe fatigue, shortness of breath, and rigor…

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Infectious Diseases I 6. Risk factors for COVID-19–related hospitalization span several comorbidities, including hypertension, diabetes, cardiovascular disease, COPD, obesity, and chronic kidney dis…

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Infectious Diseases I 4. The incubation period for SARS-CoV-2 is estimated to be up to 14 days from exposure. Information on onset and duration of viral shedding and infectious potential is still em…

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Infectious Diseases I ii. Fluid resuscitation: Conservative management strategy using balanced crystalloid solutions iii. Vasopressors: Norepinephrine as first line; vasopressin or epinephrine as se…

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Infectious Diseases I (1) The COVACTA trial (N Engl J Med 2021;384:1503-16) was a randomized, placebo- controlled trial in 438 hospitalized adults with severe COVID-19 pneumonia. (A) Patients were…

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Infectious Diseases I (A) At enrollment, 32% of patients had severe disease, with 10.7% of patients requiring MV or ECMO. Patients receiving corticosteroids for COVID-19 were excluded. (B) Overall…

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Infectious Diseases I (3) Anti–IL-6 monoclonal antibody siltuximab (4) Bruton tyrosine kinase inhibitors (e.g., acalabrutinib, ibrutinib, zanubrutinib) e. Antiviral therapy i. Remdesivir (a) Nucl…

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Data Tables 2 min

Infectious Diseases I ii. Hydroxychloroquine or chloroquine (a) Antimalarial agents that, in vitro, increase the endosomal pH, inhibiting fusion of SARS- CoV-2 to the host cell membranes (b) Not re…

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Data Tables 3 min

Infectious Diseases I Disease Severity Remdesivir Dexamethasonea Baricitinib Tocilizumabb Anticoagulation High-flow oxygen device or noninvasive ventilation requirement Recommended in combinati…

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Infectious Diseases I REFERENCES Ventilator-Associated Pneumonia Bouglé A, Tuffet S, Federici L, et al. Comparison of 8 versus 15 days of antibiotic therapy for Pseudomonas aeruginosa ventilator-ass…

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Infectious Diseases I infections in the ICU. N Engl J Med. 2006;355(26):2725- 2732. https://doi.org/10.1056/nejmoa061115 Catheter-Associated Urinary Tract Infections Centers for Disease Control and Pr…

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Infectious Diseases I Dellinger EP, Tellado JM, Soto NE, et al. Early antibiotic treatment for severe acute necrotizing pancreatitis: a ran- domized, double-blind, placebo-controlled study. Ann Surg…

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Infectious Diseases I Wound Infection Anaya DA, Dellinger EP. Necrotizing soft-tissue infec- tion: diagnosis and management. Clin Infect Dis. 2007;44(5):705-710. https://doi.org/10.1086/511638 Calder…

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Infectious Diseases I Kalil AC, Patterson TF, Mehta AK, et al. Baricitinib plus remdesivir for hospitalized adults with Covid-19. N Engl J Med. 2021;384(9):795-807. https://doi.org/10.1056/ nejmoa20…

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Answers & Explanations 4 min

Infectious Diseases I ANSWERS AND EXPLANATIONS TO PATIENT CASES 1. Answer: A The patient has suspicion for MDR VAP, as evidenced by the presence of clinical signs of infection, the patient’s increa…

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Infectious Diseases I antibiotic therapy should be considered if there is strong clinical suspicion for infection (Answer C is correct). Waiting for final culture results before initiating antimi- c…

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Infectious Diseases I gram-negative bacilli and yeast (Answer A is incorrect). Empiric antimicrobial therapy is indicated for suspected infected pancreatitis. Extended-spectrum carbapenems, which a…

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Infectious Diseases I 19. Answer: D This patient likely has severe influenza amid a local seasonal outbreak. Local infection patterns suggest a prevalence of influenza A and B strains. Empiric inf…

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Self-Assessment 4 min

Infectious Diseases I ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: D The patient described has early onset VAP without apparent updated risk factors for MDROs (Answers A, B, and…

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Infectious Diseases I and guideline recommendations do not support prophy- lactic antibiotic therapy for preventing infection of the necrotic tissue (Answer D is incorrect). The mainstay of therapy…

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