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Infectious Diseases II Gabrielle Gibson, Pharm.D., FCCM, BCCCP, BCPS Barnes-Jewish Hospital St. Louis, Missouri…

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Infectious Diseases II Infectious Diseases II Gabrielle Gibson, Pharm.D., FCCM, BCCCP, BCPS Barnes-Jewish Hospital St. Louis, Missouri…

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Learning Objectives 3 min

Infectious Diseases II Learning Objectives 1. Compose a plan to incorporate quality metrics (e.g., prevention of catheter-associated urinary tract infec- tions and catheter-related bloodstream infec…

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Infectious Diseases II 2. Which statement best describes antimicrobial stew- ardship in the ICU? A. Formal antimicrobial stewardship team membership should be reserved for clinical pharmacists…

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Infectious Diseases II antiretroviral therapy because of nonadherence. The patient requires intubation and is receiving 40% fraction of inspired oxygen (Fio2). His relevant labo- ratory values are a…

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Exam Content Outline 1 min

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

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Infectious Diseases II I.  QUALITY IMPROVEMENTS A. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) provides general best-practice guidelines. ACS NSQIP al…

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Infectious Diseases II (e) Perineum: Aerobic gram-negative and mixed anaerobic organisms (f) Respiratory: Aerobic gram-positive and gram-negative organisms 4. Risk factors for SSIs: a. Patient-re…

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Infectious Diseases II (b) Retrospective cohort studies have found that patients with a reported penicillin or cephalosporin allergy had a higher odds of developing an SSI than those without a repo…

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Data Tables 2 min

Infectious Diseases II Table 1. Prophylactic Antibiotic Regimens for Surgery Type of Surgery Recommended Prophylaxis Alternative Prophylaxis in Patients with β-Lactam Allergies Coronary artery bypass…

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Infectious Diseases II E. Prevention of Catheter-Associated Urinary Tract Infections (CAUTIs) 1. Definition a. CDC definition: See Figure 1. b. IDSA definition i. Asymptomatic bacteriuria: Refers…

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Infectious Diseases II iii. CAUTI: In patients with indwelling urethral, indwelling subrapubic, or intermittent catheterization, CAUTI is defined by the presence of symptoms or signs compatible with…

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Infectious Diseases II (d) Practice hand hygiene before insertion of the catheter, as well as before and after any manipulation of the catheter site or apparatus. (e) Proper care and maintenance of…

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Infectious Diseases II b. IDSA definition: Defines catheter-related bloodstream infection minimally as bacteremia or fungemia in a patient who has an intravascular device and: i. More than 1 posit…

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Infectious Diseases II (c) Daily chlorhexidine baths for patients to reduce colonization (d) Use of a systemic process or checklist at the time of insertion to ensure adherence to the proper insert…

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Infectious Diseases II B. Epidemiology 1. Bacterial meningitis has community-acquired or health care–associated epidemiology; health care– associated meningitis is usually associated with neurotraum…

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Infectious Diseases II c. Gram stain and culture: Bacteriologic examination of CSF can provide rapid and reliable identification of the causative pathogen(s). Although CSF cell count and analysis is…

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Infectious Diseases II surrounding intraventricular antibiotics administration and the lack of head-to-head comparisons with intravenous antimicrobials, the administration of systemic antimicrobials…

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Infectious Diseases II Table 4. Selected Antibiotic CSF Penetration and Dosages for Meningitis Agent CSF Penetration, % of Serum Concentration Dosage for Meningitis Amikacin Low Conventional: 10–15…

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Infectious Diseases II III.  ANTIBIOTIC STEWARDSHIP A. Goals: To optimize clinical outcomes while minimizing unintended consequences of antimicrobial use, which include the emergence of antimicrobia…

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Infectious Diseases II 1. Critical care pharmacists could either have an active role as a member of a multidisciplinary antibiotic stewardship team or serve in many of the different roles and activi…

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Infectious Diseases II 2. Several studies have shown significant cost savings associated with ASPs. However, most of these studies focused only on antimicrobial costs, with little focus devoted to i…

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Infectious Diseases II 2. Most of these techniques, when combined with antibiotic stewardship efforts, lead to significant reductions in health care costs and improvements in clinical outcomes in re…

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Infectious Diseases II ii. In a prospective randomized controlled study in which patients were randomized to early notification of PNA FISH results for CoNS or S. aureus within 3 hours or usual care…

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Infectious Diseases II ii. Sensitivity and specificity (a) For species identification: Greater than 90% (b) For resistance genes: 100% (currently only available for mecA - methicillin resistance; v…

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Data Tables 2 min

Infectious Diseases II Table 5. Examples of Rapid Diagnostic Tests of Positive Blood Cultures and Their Characteristics Assay Technology Manufacturer/ Trade Name Organisms/Antimicrobial Resistance…

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Data Tables 2 min

Infectious Diseases II Assay Technology Manufacturer/ Trade Name Organisms/Antimicrobial Resistance Targets Detection Time After Positive Growth on Blood Culture Chromogenic media • CHROMagar…

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Data Tables 3 min

Infectious Diseases II Resistance Genes Species Recommended Therapy Alternative Therapy OXA β-lactamasea P. aeruginosa and Enterobacterales Colistin/polymyxin B Carbapenemb Ceftazidime-avibactamc Cef…

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Infectious Diseases II D. Early Identification of Fungal Organisms 1. Up to 50% of patients with histopathologically proven invasive candidiasis have negative blood cultures. 2. Cultures for Asperg…

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Infectious Diseases II c. Both tests are more specific than the β-d-glucan test, but they are not as sensitive. d. A meta-analysis that included studies in non-neutropenic critically ill patients fo…

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Infectious Diseases II 6. According to current evidence, PCT should not routinely be measured in patients without signs and symptoms of infection. The decision to initiate patients on antibiotics wi…

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Infectious Diseases II F. MeMed BV 1. A host response diagnostic that differentiates bacterial from viral infection at the point of need by computationally integrating the levels of three host immu…

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Infectious Diseases II Patient Case 4. A 64-year-old woman is admitted to the medical ICU with possible community-acquired pneumonia. The patient is initiated on ceftriaxone and azithromycin. Chest…

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Infectious Diseases II 4. Automated systems (e.g., Vitek, Microscan, Sensititre, Phoenix, Accelerate Pheno test) a. Uses computerized algorithms for interpreting MIC values b. Can usually perform A…

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Infectious Diseases II ii. Maintains sensitivity with cephamycins (e.g., cefotetan, cefoxitin) and cloxacillin iii. Confirmatory test with E-test containing cephamycin alone or a combination of ceph…

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Infectious Diseases II 2. PK/PD: Derived from human or animal data and modeled to determine the likelihood that standard prescribed doses will meet specified PD criteria for suppressing bacterial gr…

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Infectious Diseases II d. Understanding of the tested antimicrobial’s PD parameters, which conveys the highest likelihood for eradication of the microorganism e. Selecting the most appropriate anti…

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Infectious Diseases II 4. The antibiotic pipeline has slowed down considerably, with consistent decreases in FDA approvals of antimicrobial agents during the past 3 decades. The combination of preva…

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Infectious Diseases II B. Mechanisms of Resistance (bacteria often possess several mechanisms) 1. Decreased permeability (i.e., porin loss, thickened cell wall) 2. Increased efflux (i.e., macrolide…

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Infectious Diseases II f. Cefepime-enmetazobactam i. FDA approved in 2024 for treatment of complicated UTIs including pyelonephritis caused by ESBL-producing gram-negative organisms, including orga…

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Infectious Diseases II Patient Case 5. A 74-year-old man is admitted to the surgical ICU after elective hip replacement surgery. The patient, who has a history of chronic pulmonary obstructive disea…

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Infectious Diseases II studies, patients with secondary bacteremia treated with tigecycline were compared with patients treated with other antibiotics. Overall, no significant differences in outcome…

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Infectious Diseases II (4) Around 2000, with the emergence of CRE, colistin use was reconsidered, given the lack of treatment options. (5) Dosing challenges (A) Different products provide differen…

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Infectious Diseases II (9) Empiric colistin therapy: In an analysis of the association between covering empiric antibiotics and mortality for infections caused by carbapenem-resistant gram- negative…

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Infectious Diseases II (c) FDA approved for the treatment of complicated intra-abdominal infection and complex UTIs. However, most clinicians will reserve its coverage for difficult-to-treat pathoge…

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Infectious Diseases II (e) A recent multicenter, randomized, double-blind, comparator controlled trial compared the efficacy and safety of imipenem/relebactam and colistin combined with imipenem/ ci…

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Infectious Diseases II ix. Sulbactam/durlobactam (a) Only agent developed for the treatment of carbapenem-resistant Acinetobacter baumanii (CRAB) (b) Sulbactam has intrinsic activity to Acinetobac…

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Infectious Diseases II i. Ceftolozane is a novel fifth-generation cephalosporin. ii. Spectrum of activity: Gram-negative organisms, including P. aeruginosa. Activity includes coverage against ESBL…

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Infectious Diseases II (e) The 2011 IDSA guidelines for the treatment of MRSA state that the treatment of isolates with a vancomycin MIC of 2 mcg/mL or less should be determined by the patient’s re…

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Infectious Diseases II (2) Tedizolid once daily for 7 days was compared with linezolid twice daily for 10 days for the treatment of gram-positive hospital-acquired or ventilator-associated bacterial…

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Infectious Diseases II Patient Case 6. A 72-year-old woman with a history of end-stage renal disease is admitted to the medical ICU with signs and symptoms of sepsis. Blood cultures are obtained in…

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Infectious Diseases II 4. Consider dual gram-negative therapy (fluoroquinolone or aminoglycosides) in patients with shock or if antimicrobial resistance is suspected. 5. Consider adding vancomycin…

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Infectious Diseases II c. Severe infections sometimes warrant a reduction in maintenance immunosuppression. Consult with the transplant team regarding plans for maintenance immunosuppression. d. Be…

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Infectious Diseases II VIII.  HUMAN IMMUNODEFICIENCY VIRUS/ACQUIRED IMMUNE DEFICIENCY SYNDROME IN CRITICALLY ILL PATIENTS A. Diagnosis 1. Isolated CD4+ lymphopenia has occurred in critically ill pa…

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Infectious Diseases II b. In general, if one of the antiretroviral therapies has to be discontinued, all of the therapies should be discontinued to decrease the promotion of resistance caused by the…

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Infectious Diseases II D. Management and Prophylaxis of HIV-Associated Infections: See Table 10. Table 10. AIDS-Defining Conditions Bacterial infections, multiple/recurrent (children < 13 yr) Candi…

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Infectious Diseases II Table 11. AIDS-Associated OIs and Their Respective Prophylactic and Treatment Options OI/CD4+ Threshold for Prophylaxis Prophylaxis Option Treatment Option P. jiroveci: < 200 c…

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Infectious Diseases II OI/CD4+ Threshold for Prophylaxis Prophylaxis Option Treatment Option Mycobacterium tuberculosis: Primary prophylaxis not indicated Latent infection treatment Preferred: Iso…

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Infectious Diseases II Table 12. Common Interactions Between Antiretrovirals and Commonly Used Medications in Critically Ill Patients Agent Antiretroviral Interactions Stress ulcer prophylaxis (proto…

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Infectious Diseases II Agent Antiretroviral Interactions Sildenafil Protease inhibitors; delavirdine Increase in sildenafil concentration Anticoagulants: Warfarin Apixaban Rivaroxaban Delavirdine, ef…

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Infectious Diseases II (2) Ibuprofen 600 mg orally (3) Acetaminophen 650 mg orally with diphenhydramine 50 mg orally (4) Meperidine 25–50 mg intravenously if patient previously experienced rigors (…

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Infectious Diseases II 4. Voriconazole a. Spectrum of activity i. Candida spp. – Has coverage similar to fluconazole with the addition of activity against C. krusei ii. Aspergillus, Fusarium, Sce…

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Infectious Diseases II c. Adverse reactions i. Increase in liver function tests ii. Nausea/vomiting iii. Drug interaction: CYP3A4 inhibitor iv. QTc prolongation 6. Isavuconazole a. Spectrum of…

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Infectious Diseases II 5. Empiric treatment of critically ill patients: A recent large, multicenter study evaluated the use of empiric micafungin in immunocompromised critically ill patients with se…

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Infectious Diseases II B. Social determinants of health are a key focus of Healthy People 2030: “Create social, physical, and economic environments that promote attaining the full potential for heal…

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Infectious Diseases II REFERENCES Quality Improvements Allegranzi B, Bischoff P, de Jonge S, et al. New WHO recommendations on preoperative measures for surgi- cal site infection prevention: an evide…

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Infectious Diseases II Bacterial Meningitis de Gans J, van de Beek D; European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis.…

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Infectious Diseases II Forrest GN, Mehta S, Weekes E, Lincalis DP, Johnson JK, Venezia RA. Impact of rapid in situ hybridization testing on coagulase-negative staphylococci positive blood cultures.…

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Infectious Diseases II trial. Am J Respir Crit Care Med. 2014;190(10):1102- 1110. https://doi.org/10.1164/rccm.201408-1483oc Timbrook TT, Morton JB, McConeghy KW, Caffrey AR, Mylonakis E, LaPlante KL…

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Infectious Diseases II a randomized clinical trial. JAMA. 2022;328(13):1304- 1314. https://doi.org/10.1001/jama.2022.17034 Lee NY, Lee CC, Huang WH, Tsui KC, Hsueh PR, Ko WC. Cefepime therapy for mon…

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Infectious Diseases II importance of combination therapy. Clin Infect Dis. 2012;55(7):943-950. https://doi.org/10.1093/cid/cis588 van Duin D, Bonomo RA. Ceftazidime/avibactam and ceftolozane/tazobac…

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Infectious Diseases II Antifungal Therapy Limper AH, Knox KS, Sarosi GA, et al. An official American Thoracic Society statement: treatment of fungal infections in adult pulmonary and critical care…

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Answers & Explanations 4 min

Infectious Diseases II ANSWERS AND EXPLANATIONS TO PATIENT CASES 1. Answer: D The CDC definitions for CAUTIs, which are used by the CMS reporting system, were recently updated. Because this patient…

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Infectious Diseases II considered in the medical treatment of prosthetic valve endocarditis (Answer B is incorrect). Because the patient is responding to current vancomycin therapy, an escalation t…

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Self-Assessment 4 min

Infectious Diseases II ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS 1. Answer: C The prophylactic regimen for a patient without a β-lactam allergy who is undergoing cardiac surgery should…

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Infectious Diseases II and Acinetobacter baumannii is less likely. Hence, the most likely resistance mechanism in this patient is either selection of derepressed mutants or acquisition of a pathoge…

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