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Bloodstream infections: oportunities for outcome
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improvement.
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Clinical evaluation and management.
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Pilar Retamar Gentil
Department of Infectious Diseases and Clinical Microbiology
Hospital Universitario Virgen Macarena, Seville
A patient in Emergency….
• 78th years-old man.
• Coming from a LTCF. Cirrhotic (alcoholic).
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• He was in the hospital 3 weeks ago because of a pneumonia treated
with levofloxacin. Discharged with a urine catheter not removed
because an acute urinary retention.
Physical exam:
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• 100/78 Fc 102. Tº 38,2.
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• Thorax exam and X-ray normal.
• Abdomen: lightly painful.
• Coloured urine.
• Urine and blood culture taken.
14 hrs later….Micro lab:
Gram-negative bacilli in
the blood sample
A question to begin:
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Which of those is the main outcome
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predictor in bacteremia?
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1. The age of the patient
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2. The microorganism
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3. The source
of the BSI
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4. The severity
of presentation
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A question to begin:
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Which of those is the main outcome
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predictor in bacteremia?
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1. The age of the patient
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2. The microorganism
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3. The source
of the BSI
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4. The severity
of presentation
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Clinical evaluation
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Retamar AAC 2012
Clinical evaluation
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THE HOST
Age
Underlying conditions
(Inmunodeficency)
Risk factors for MDR
Retamar AAC 2012
Clinical evaluation
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THE SOURCE
Unknown source
Source control
Retamar AAC 2012
Clinical evaluation
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THE MICROORGANISM
Regarding:
- source
- acquisition
- local resistances
(Individual risk factors)
Specific management
Retamar AAC 2012
Clinical evaluation
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SEVERITY OF ILLNESS
Diagnosis
Support treatment
Retamar AAC 2012
Clinical evaluation
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TREATMENT
Drug of choice
(Timeframe)
Retamar AAC 2012
Clinical evaluation and management
GRAM
HOST
Patient
evaluation
“in situ”
(acquisition/
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local resistances)
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SOURCE
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EPIDEMIOLOGY
SEVERITY OF ILLNES
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MICROORGANISM
Empiric AB THERAPY
SOURCE CONTROL
SEPSIS SUPPORT TREATMENT
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1. Evaluating the HOST: inmunocompromise
• Age
• Neutropenia
• Cirrhosis
• Haemodyalisis
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• Solid cancer
D or
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• Diabetes
mellitus
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• COPD
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• Chronic heart
failure
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• HIV (<200 CD4)
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Yoshikawa J Am Geriatr Soc 1996
Increased suceptibility
Atypical presentation
Severity
INCREASE
your GRADE
of
SUSPICION!
1.
Evaluating the HOST:
individual risk factors for MDR BSI
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Which of those is not a risk factor
of
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developing a ESBL-Enterobacteriaceae
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BSI?
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1. Previous treatment
with levofloxacin
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2. Recent history
catheterization
D of urinary
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3. A health-care
related
acquisition
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4. A respiratory
source
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1.
Evaluating the HOST:
individual risk factors for MDR BSI
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Which of those is not a risk factor
of
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developing a ESBL-Enterobacteriaceae
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BSI?
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1. Previous treatment
with levofloxacin
O
2. Recent history
catheterization
D of urinary
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3. A health-care
related
acquisition
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4. A respiratory
source
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A patient in Emergency….
• 78th years-old man.
• Coming from a LTCF. Cirrhotic (alcoholic).
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• He was in the hospital 3 weeks ago because of a pneumonia treated
with levofloxacin. Discharged with a urine catheter not removed
because an acute urinary retention.
Physical exam:
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• 100/78 Fc 102. Tº 38,2.
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• Thorax exam and X-ray normal.
• Abdomen: lightly painful.
• Coloured urine.
• Urine and blood culture taken.
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Predictive models for infection due to
ESBL-producers on admission
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Italian model
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Duke model
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Recent history of urinary catheterization
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Charlson score ≥4
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2
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Italian Model
Duke model
Sensitivity
≥95%
≥94%
Specificity
≤47%
≤65%
Sensitivity
≤50%
≤ 58%
Specificity
≥96%
≥95%
Recent beta-lactams of fluoroquinolones
Previous hospitalization
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Transfer from another healthcare facility
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Age ≥70 years
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Immunosupression
Tumbarello AAC 2011
Johnson ICHE 2013
Score 3
Score 8
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Evaluating the HOST:
individual risk factors for MDR BSI
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MRSA: HA/HCR (haemodyalisis/LTCF), previous
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colonisation/infection, local endemia, SouthAmerica/USA
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ESBL: recent beta-lactams of fluoroquinolones,
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HA/HCR (haemodyalisis/LTCF), urinary catheterization,
Charlson score ≥4, age ≥70 years
CR, XR_GNF: recent carbapenems, ICU, endemic areas
AzoleR: previous colonisation, previous azole treatment
2. Evaluating the SOURCE
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Clinical symptoms: WATCH! HEAR! TOUCH!
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Xray, CT, MNR…
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Staphylococci: Device-related infections
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Streptococci: LTRI, skin
Enterococci: Abdominal / Uro tracts
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Gram-negative bacilli: Digestive tract, urinary tract
Polymicrobial: Abdominal / Gine tracts
More specific…
Salmonella: Vascular/aneurysmal infection
S. bovis isolated: GI malignancy?
2. Evaluating the SOURCE
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With what frecuency a patient would present
bacteremia of unknown source?
1.
5-10%
2.
15-30%
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3. 30-40%
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4. >40%
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2. Evaluating the SOURCE
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With what frecuency a patient would present
bacteremia of unknown source?
1.
5-10%
2.
15-30%
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3. 30-40%
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4. >40%
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2. Evaluating the SOURCE
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The unknown SOURCE
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Rguez-Baño CMI 2010
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Devices: catheter related, prostesis.
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Atypical symptoms in inmunocompromised patients: frequent sources.
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Low symptomatic sources: Endocarditis/Osteomyelitis/IAI abcesses.
3. Evaluating the MICROORGANISM:
acquisition
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Which of these is not a criteria for a
health-care associated bacteremia?
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2. Receiving chemotherapy in the outpatient clinic
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O the hospital 3 days before
3. A discharge from
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4. Being haemodialysed
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1.
Coming from a LTCF
3. Evaluating the MICROORGANISM:
acquisition
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Which of these is not a criteria for a
health-care associated bacteremia?
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2. Receiving chemotherapy in the outpatient clinic
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3. A discharge O
from the hospital 3 days before
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4. Being haemodialysed
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1.
Coming from a LTCF
3. Evaluating the MICROORGANISM:
acquisition
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Rguez-Baño Expert Review 2010
3. Evaluating the MICROORGANISM:
acquisition
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•iv therapy or specialist nursing care at home
•haemodialysis in the 30 d before
•hospitalization >2 d in a hospital in 1 yr before
•resident in a LTCF
Fowler A Int Med 2002
Rguez-Baño Expert Review 2010
3. Evaluating the MICROORGANISM:
acquisition
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Rguez-Baño Expert Review 2010
3. Evaluating the MICROORGANISM:
local resistance patterns
Pseudomonas Aeruginosa R a carbapenemas
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http://ecdc.europa.eu/en/activities/surveillance/EARS-Net
3. Evaluating the MICROORGANISM:
local resistance patterns
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ABSw team. HUV Macarena Seville
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4. Evaluating the SEVERITY OF ILLNESS:
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Which of this is a criteria of severe
sepsis?
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2. Cirrhosis MELD>10
n
Omg/dL
3. Glycemia>120
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4. CR-P >10 UI/L or
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1.
Pulse rate>90 bpm
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4. Evaluating the SEVERITY OF ILLNESS:
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Which of this is a criteria of severe
sepsis?
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2. Cirrhosis MELD>10
n
Omg/dL
3. Glycemia>120
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4. CR-P >10 UI/L or
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Pulse rate>90 bpm
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4. Evaluating the SEVERITY OF ILLNESS:
Review the chart data for the previous 48 h
Active evaluation of the patient in situ
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Asymptomatic?
Transient BSI
Intermittent BSI
Source controlled (CVC)
Contamination?
Lever BMJ 2007
Dellinger Crit Care Med 2013
BSI MANAGEMENT
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Broad spectrum AB/combination → De-escalation→ Duration
HOST
MICRO
SOURCE
SEVERITY
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Time
Survive → symptoms control → avoid resistances and toxicity
Adapted from JR Paño
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Day 0: TREATMENT: Support treatment
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Dellinger Crit Care Med 2013
Day 0:TREATMENT: Ab_Gram Staim
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Stretococci: ceftriaxone, ampiciline (if enterecocci)
MSSA: cloxacillin or cefazolin (if haemodyalisis) plus
Risk MRSA: dapto, vanco, linezolid
CN: vanco
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Amoxi-CA, 1er or 2ond Cephalosp, Fluorquin
If Pseudomonas risk: pip/taz, meropenem, amikacin
If ESBL risk: carbapenem
If GI tract: add metronidazol
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Echinocandin
Azole
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Day 0:TREATMENT: Broad spectrum a
Ab?
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ECOLOGIC IMPACT?
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Coffee
for everybody?
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What about…
COSTS?
Day 0:TREATMENT: Broad spectrum Ab?
ry
Importance of
coverage
Low risk
Severe presentation/condition
Source, virulent pathogen
Risk or resistance
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High risk ID
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Importance of
ecology and cost
Broad spectrum  de-escalate
Day 0:TREATMENT: Broad spectrum Ab?
ry
Importance of
coverage
Low risk
Low severity
Low risk for resistance
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O
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High risk ID
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Importance of
ecology and cost
Narrow spectrum  revise
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Day 0: TREATMENT: Source controla
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Marshall Crit Care Clin 2009
Day 3: Reevaluate
1. Consider definitive therapy…..
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http://www.hospital-macarena.com/antibioterapia
2. Consider switching to oral therapy
3. Plan/give advice about total duration
http://www.hospital-macarena.com/antibioterapia
MANAGEMENT regarding the organism
S. aureus bacteremia
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Which of these is not considerea quality
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markers in S. aureus BSI management?
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1. Follow-up blood culture e
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2. Echocardiography li
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Otherapy with levofloxacin at 3º day of
3. Switching to oral
therapy ID
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4. Vancomycin
dosing
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MANAGEMENT regarding the organism
S. aureus bacteremia
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Which of these is not considerea quality
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markers in S. aureus BSI management?
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1. Follow-up blood culture e
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2. Echocardiography li
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O therapy with levofloxacin at 3º
3. Switching to oral
D or
day of therapy
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4. Vancomycin
dosing
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MANAGEMENT regarding the organism
S. aureus bacteremia
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Ecocardiography always if:
Primary or commnunity-acquired bacteremia
Presence of intracardiac medical devices
Persistent bacteremia (> 72 h)
Short-course of antimicrobial therapy (all cases?)
Twaites LID 2011
López-Cortés CID 2013
MANAGEMENT regarding the organism
Candidemia
IDSA guidelines 2009_ Pappas CID 2009
Candidemia in Nonneutropenic Patients
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• Echinocandin for patients with moderately severe to severe illness (A-III).
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•Fluconazole for patients who are less critically ill (A-III).
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•Transition from an echinocandin to fluconazole is recommended for patients who
have isolates that are likely to be susceptible to fluconazole (e.g.,Candida albicans)
and who are clinically stable (A-II).
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ESCMID guidelines_CMI 2012
Duration of treatment:
14 days after
clearance of Candida from the blood
IDSA (AIII) and ESCMID (BII):
Removal of central lines:
IDSA (AII) and ESCMID (AII): strongly
recommended.
If not possible (ESCMID, AII): lock therapy with amphothericin
B in addition to systemic therapy.
MANAGEMENT regarding the organism
MDR gram negatives: PK/PD strategies
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Different dosing regimens of meropenem
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Population pharmacokinetic analysis
Montecarlo simulation
MIC ≤4
T>MIC=100%
MIC≤8
T>MIC>80%
Daikos el al. CMI 2011
Conclusions:
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Bacteremia outcome depends on the underlying conditions of the host, the
etiology, the source, the severity of presentation and the treatment
adequacy.
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A careful and skilled clinical evaluation (IN SITU!!!) should be performed
in all BSI episodes.
•
An early support treatment, a source control and the most appropriate
antibiotic should be initiate considering the previous evaluation (host risk
factors, epidemiology, source and severity).
•
When available… call the Infectious Diseases colleague.
•
If possible….stablish a Bacteremia Program in your hospital.
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Thanks for your attention!
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Welcome to ESGBIS Business meeting
Mon 13.15 Room 125
[email protected]