stanfordasp.bsky.social
🏆 IDSA Center of Excellence in Antimicrobial Stewardship | CDPH AMS Honor Roll Gold | WHO Collaborating Centre
🩺 Stan Deresinski, Marisa Holubar, Alex Zimmet, Amy Chang, Emily Mui, Lina Meng, Will Alegria, David Ha
🔗 http://med.stanford.edu/bugsanddrugs
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🩺Always consider positive sputum cultures within the context of the patient's clinical symptoms!
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🔍 Pneumonia caused by Corynebacterium is very rare. However, some species have been associated with pneumonia, particularly in patients who are immunosuppressed or have abnormal pulmonary anatomy, such as those with cystic fibrosis (PMID: 30324081).
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🦠Corynebacterium is a genus of over 100 species, and most are part of the normal flora of human skin and mucous membranes, including the respiratory tract. They are traditionally considered contaminants or colonizers when isolated from upper respiratory specimens (PMID: 2116939).
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📚 References:
1. PMID: 38752732 Breakthrough Invasive Fungal Infections in Patients With High-Risk Hematological Disorders Receiving Voriconazole and Posaconazole Prophylaxis: A Systematic Review
2. www.jwatch.org/na57554/2024...
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🔍 For a review of posaconazole’s spectrum of activity, see the attached figure. PMID: 21803962
⚠️ If there is ever concern for breakthrough infection, it’s best to consult Infectious Diseases (ID).
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💡 A: Likely not. Posaconazole is effective against many molds, dimorphic fungi, and yeasts, including several species of Candida. Breakthrough candidal infections (e.g., Candida glabrata) can occur but are uncommon, with only ~2-5% of breakthrough invasive fungal infections reported.
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📚References:
1. Epstein DJ, Benamu E, Subramanian AK. Clin Infect Dis. 2018 Oct 30;67(10):1637-1639. doi: 10.1093/cid/ciy397. PMID: 29771330.
2. Nocardiosis in Immunocompromised Patients on Alternative Pneumocystis Prophylaxis - Vol 27, Number 10—Oct 2021 - Emerging Infectious Diseases
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3️⃣ Switching to 2nd-line prophylactic agents, e.g. atovaquone & dapsone are LESS EFFECTIVE than TMP/SMX at preventing PJP and opportunistic infections caused by Listeria monocytogenes, Toxoplasma gondii, and Nocardia spp. & can lead to breakthrough infections and significant morbidity and mortality.
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2️⃣ If TMP/SMX is discontinued, ongoing evaluation for resolution of cytopenias should prompt repeat trial of TMP/SMX.
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1️⃣ Evaluate if there is an alternative explanation for cytopenia. Cytopenias are multifactorial, relatively common in the early postoperative or post transplant period, and extremely rare at prophylactic TMP/SMX doses. It may be reasonable to continue TMP/SMX for ppx and monitor in many cases.
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References:
1. Pogue JM, Aitken SL. Open Forum Infect Dis. 2023;11(1):ofad645
2. Miano TA et al. Intensive Care Med. 2022;48(9):1144-1155
3. Qian ET. The ACORN Randomized Clinical Trial. JAMA. 2023;330(16):1557–1567
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✅ In conclusion, there is no clear evidence to avoid short durations (<72 hours) of vancomycin/pip-tazo combinations. Monitor renal function closely.
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💡 This finding supports the possibility of pip-tazo causing pseudotoxicity due to decreased tubular secretion of creatinine.
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📊 Interestingly, a 2022 prospective cohort study in critically ill patients showed that while the vancomycin/pip-tazo group had a higher rate of increased SCr compared to the vancomycin/cefepime group, there were no differences in cystatin C, a potentially unbiased marker of renal function. (3)
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🔍 The ACORN trial, a 2023 open-label RCT in critically ill patients, found no association between cefepime or pip-tazo and AKI, despite over 75% of patients receiving concomitant vancomycin, although most received therapy for <72 hours. (2)
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💡 A: There is no firm evidence suggesting that this combination should be avoided due to concerns about acute kidney injury (AKI). Retrospective analyses have inconsistently identified an increased AKI risk with this combination, particularly with durations of ≥72 hours. (1,2)
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See our FN guidelines, link below 👇
References:
1. NCCN Guidelines Prevention and Treatment of Cancer Related Infections v3.2024
2. ECIL-10 Guidelines
3. Elting et al J. Clin Oncol. 2000; PMID: 11054443
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🔍 Instead of switching antibiotics, continue diagnostic efforts to identify the infectious source or alternative explanations for the fever (e.g., fungal infection).
🤝 Consider ID consult if persistently febrile without a clear diagnosis or if concerns for non-bacterial/opportunistic infections.
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💡 A: In stable FN patients with persistent fever of unknown origin, current NCCN and ECIL guidelines do not recommend changing empiric coverage for Gram-negative bacteria.
⏳ Time to defervescence may last 2-7 days (median of 5 days) for patients on appropriate initial antibiotic therapy. (3)
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📚 References:
1. IDSA Guidelines on Intra-Abdominal Infections (IAI)
2. SIS Guidelines on IAI - 2024 Update
3. SHC IAI guidelines 👇
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🔍 If enterococcal coverage is desired (see risk factors), note that vancomycin does not add much if you are already using piperacillin/tazobactam, as it covers E. faecalis. Remember, E. faecium is usually vancomycin-resistant (VRE).
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⏳ IV vancomycin should be discontinued at 48 hours if MRSA is not recovered from cultures.
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💡 A: Empiric MRSA coverage for intra-abdominal infections is generally not recommended. (1,2)
📜 According to IDSA guidelines, empiric MRSA coverage may be considered in the following cases:
1️⃣ Hospital-acquired infection with known MRSA colonization
2️⃣ Invasive infection within the past year
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🚫 Treatment of ASB does not reduce the risk of death or sepsis but increases the risk of adverse effects, including C. difficile and the emergence of antimicrobial-resistant organisms.
📚 Reference:
2019 IDSA Guidelines on Asymptomatic Bacteriuria [PMID: 30895288]
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📊 Prevalence of asymptomatic bacteriuria (ASB) is high in this population:
🏠 Elderly individuals at home: 20%
🏥 Elderly individuals in long-term care facilities: 25-50%
🧑⚕️ Patients with Foley catheter > 30 days: ~100%
🧑⚕️ Patients with short-term Foley catheter: 3-5%/day catheter
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🔍 Patients should be assessed for other causes of cognitive impairment and carefully observed off antibiotics.
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📜 Guidelines do not recommend testing for or treating UTI in elderly patients with falls or new onset AMS in the absence of local genitourinary symptoms or systemic signs of infection (e.g., fever or hemodynamic instability).
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💡 A: Acute mental status change and functional decline are nonspecific findings and can be related to:
💧 Dehydration
🌬️ Hypoxia
⚖️ Electrolyte abnormalities
💊 Polypharmacy/new drug interactions
💤 Changes in sleep patterns
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References
1. IDSA 2017 Healthcare-Associated Ventriculitis and Meningitis Guidelines
2. Nigrovic LE et al Pediatrics. 2008 Oct;122(4):726-30. doi: 10.1542/peds.2007-3275. PMID: 18829794
3. Rogers T, Open Forum Infect Dis. 2019 Feb 6;6(3):ofz050. PMID: 30899767
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3️⃣ Consult Infectious Diseases (ID) for assistance with diagnostics and interpretation, especially in these scenarios:
-CSF cultures and fluid analysis are negative but suspicion remains high
-Persistent fevers without an alternative explanation
-Concern for fungal infection
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2️⃣ Be as accurate as possible in describing the CSF source when ordering cultures. Each source corresponds to a specific micro lab workup. For example, samples from patients with shunts or drains are incubated for 14 days (at SHC) to recover slow-growing C. acnes.
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1️⃣ Obtain CSF cultures BEFORE antimicrobials are initiated to minimize impact on yield. In bacterial meningitis, the sensitivity of the CSF culture decreases significantly:
📉 From 88% to 70% with any use of antimicrobial therapy
📉 To 59% if ABX are given > 24 hours prior to lumbar puncture (LP)
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⚠️ If there is concern for symptomatic Candida cystitis, pyelonephritis, or fungal ball, we recommend consulting ID.
Ref: IDSA 2016 Candidiasis Guidelines academic.oup.com/cid/article/...
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🔍 That said, Candida species are normal respiratory and skin flora. When isolated from non-sterile sites such as:
-Sputum or BAL
-Urine
-Indwelling drains
They are generally considered colonizers and do not require targeted antifungal therapy.
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💡 A: You should always assume that isolating Candida from blood warrants treatment and is NOT a contaminant.
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📚 References:
1. PMID: 16466123
2. PMID 16472283
3.PMID: 26011799
4.PMID: 12709719
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⚠️ If used in hospitalized patients with underlying heart conditions or multiple risk factors, use with caution and closely monitor QTc. The risk of QTc prolongation is LOWEST with CIPROFLOXACIN. See figure for comparison between FQs.
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📊 Data show that when administered in therapeutic doses for 7 days, ciprofloxacin and levofloxacin did not significantly prolong the QTc interval.[2]
🔍 Normal QTc ranges:
350-450 ms (female)
360-460 ms (male)
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💡 A: For most patients, this would not be an absolute contraindication. Assuming no concurrent risk factors (like electrolyte abnormalities, arrhythmias, or other QT-prolonging drugs), using either ciprofloxacin or levofloxacin presents a low risk of drug-induced torsades de pointes.
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📚 References:
Lodise 2013 PMID: 24041888
Ramsey 2013 PMID: 23548646
Woytowish 2013 PMID: 23424229
Bai 2022 PMC9856528
Elbarbry 2023 PMID: 37129603