Podcast #159 - EM ID: Antibiotic Stewardship in Unique Cases with Dr. Gompf

Both Patrick Bafuma and Dr. Sandra Gompf who specializes in infectious disease (Gompf's ID Pearls) are back this time to discuss some unique cases regarding antibiotic stewardship in the emergency department.

Pyelonephritis - Why IV ceftriaxone and then oral levofloxacin?

• More for patients initially too nauseated for oral antibiotics initially.
• Options in this include 24 hour coverage with an IV fluoroquinolone (like once daily levofloxacin), ceftriaxone, or once-daily-dose aminoglycoside. 
• These guidelines are from 2011 and fluoroquinolones were initially preferred given their high oral bioavailability, bacteriocidal properties, and faster cure than beta-lactams.
• Many are moving away from fluoroquinolones first line due to increasing resistance and downstream complications such as hypoglycemia, tendon rupture, & recent FDA warnings about AAA & dissection (FDA reports and four studies found risk is doubled). 

​
Two Broad Categories of Cellulitis:

• Cellulitis associated with chronic lymphedema 
  • Lower extremity venous stasis, post vein harvesting.
  • Overwhelmingly streptococcal including Group A.
  • Needs penicillin G +/- clindamycin or other toxin-inhibiting agent.
  • Do NOT use doxycycline alone or a fluoroquinolone due to poor strep A coverage.
  • Vancomycin is NOT as effective .
    
  • Treat any tinea pedis in these patients as it is often the entry point.
    
• Cellulitis associated with boils, punctures, insect bites, IVDU, surgery
  
  • These include pustules, phlegmons, and abscesses.
    
  • Overwhelmingly Staph. aureus especially community acquired MRSA.
    
  • Vancomycin or daptomycin good if poor kidney function.
  • Doxycycline or trimethoprim-sulfamethoxazole (TMP-SMX) orally if the abscess is fully drained and relatively mild cellulitis

What about Dalbavancin?

• May not be a good idea as clinical trials tended to have a ~80% response rate.
• Best if you know exactly what you are treating and it is under control.

Vancomycin for Pneumonia:

• Most community acquired pneumonia (CAP) and hospital acquired pneumonia (HAP) is NOT Staph. aureus (about 5%)
• Staph. aureus causes a severe, progressive, often necrotizing pneumonia, septic shock, etc. and you should also consider Group A strep in those patients.  
  
• Vancomycin is not the best option in many cases due to poor penetration into alveolar fluids and due to nephrotoxicity.
  
• Better choices for severe CAP where you’d suspect MRSA/pneumococcus:
  
  • Linezolid (most data; bacteriostatic; inhibits toxin--don’t combine with vanc/clinda!)
    
  • Ceftaroline (cidal; clears bacteremia well)
    
  • Either can be used with azithromycin, levofloxacin for atypicals/GNRs

Adjunctive Treatment for Cellulitis and Abscess:

• Steroids or NSAIDs can help decrease length of stay, erythema, and pain.
• They are recommended by the IDSA
• NSAIDs preferred over steroids as the benefit is not worth the risk of event short course corticosteroids in certain cases (such as with potential diabetes complications or avascular necrosis of the hip).

​Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook.  Remember to look us up on Libsyn and on iTunes.  If you have any questions you can also comment below, email at thetotalem@gmail.com, or send a message from the page.  We hope to talk to everyone again soon.  Until then, continue to provide total care everywhere.

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