门诊病人抗生素的使用（英文ppt）outpatientantibiotic

Outpatient antibiotic use Carlos A. DiazGranados, MD, MS Director, Antimicrobial Utilization GMH Case 1 48 yo male, HIV on ARV, VL 75 k, CD4=120, comes to the clinic complaining of nasal congestion with yellow-thick discharge, cough, postnasal drip and headache for 4 days. Physical exam reveals normal vital signs, tenderness to pressure in maxillary sinus and yellow postnasal drip. WBC 4k, Crypto AG negative. What is the diagnosis? What is antimicrobial should be given? Acute sinusitis ACP Guidelines High-risk (50%) of bacterial sinusitis if 2 or more of the following present: Symptoms 7 days. Facial pain. Purulent discharge. If low risk, do not prescribe antibiotics. If high-risk and mild symptoms, defer antibiotic therapy. If no improvement after 7-10 days of symptomatic therapy, consider antibiotic therapy. If high-risk and severe symptoms, consider immediate antibiotic therapy. The antibiotic of choice is Amoxicillin. Assess the probability of bacterial sinusitis and treat if high and symptoms severe. Otherwise, defer antibiotic Rx. Red flagsconsider early/immediate antibiotics Sinusitis AB duration Unclear RCT have used 5-10 days. Case 2 24 yo male, recently diagnosed with HIV, CD4 is 180 on Bactrim prophylaxis, started ARV 2 months prior. Comes to the clinic with 3 days of mild shortness of breath, productive cough of yellow/green sputum. PE afebrile, lungs with few bilateral wheezes. O2 sat 99% RA before and after activity. LDH normal, CXRay negative. What is the diagnosis? What is the first line antibiotic choice? Acute bronchitis Antibiotics NOT recommended Case 3 35 yo male, h/o HIV, CD4 150, VL undetectable, comes with a 5 days history of SOB, productive cough, and low-grade fever. Adherence 100%. Meds: Atripla, Bactrim. PE: T=100, RR=22, HR=98, BP=110/70. Decrease breath sounds and rales RLL. O2sat 94% RA. Labs: PaO2 72. WBC=12. LDH=180. What is the likely diagnosis? What would be your recommended therapy? Community-acquired pneumonia PCP vs. Bacterial PCP vs. Bacterial CAP CID 2007;44:Suppl 2. Site of care decisions PSI Scoring CURB 65 Score Consider ruling out TB all patients that you treat for bacterial pneumonia with quinolone monotherapy Case 4 52 yo male with HIV, CD4 350, VL undetectable, chronic tobacco use, history of chronic bronchitis/COPD, comes to the clinic with 5 days of worsening shortness of breath, increase in the amount of the sputum which has become darker in color. PE shows tachypnea, normal temperature, mild tachycardia, hypoventilated lungs bilaterally. CXRay shows lung hyperinflation, no infiltrates. What is the diagnosis? What are the antibiotic options? Acute exacerbations of chronic bronchitis Antibiotic options: Amoxicillin Doxycycline Bactrim Macrolides (azithromycin, clarithromycin) Levofloxacin Case 5 36 yo male, HIV, CD4 300, on ARVs, VL undetectable. Comes to the clinic with 2 day history of fever, sore throat and odynophagia. Similar clinical picture in house-hold family member. Denies recent sexual activity. Physical exam shows Temp of 38.7, tachycardia, thick exudate in bilateral tonsils and cervical lymphadenopathy. What is the diagnosis? What are the next steps? Acute Pharyngitis Remember that most are viral. Remember that Group A Streptococci (Strep. pyogenes) are the most common bacterial cause. Remember that GC can cause pharyngits in individuals that practice oral sex. Note: If you suspect GC from history, obtain swab for GC culture (ideally from urinary tract, rectum and tonsils) and consider NAAT. Rx is different, and it also has epidemiologic implications. What to do if rapid strep and cultures are not available? - CASE 6 A 42 yo HIV + man presents with fever, chills, and 2 lesions over the back of his neck. Gram stain of pus from 1 of the lesions is shown below. What is the likely pathogen and what are reasonable options to for empiric therapy? Skin and soft-tissue infections http:/health.state.ga.us/pdfs/epi/notifiable/CA-MRSA%20rev.pdf Case 7 32 year-old female, HIV/AIDS, CD4 80, off ARV, off Bactrim prophylaxis (not compliant), drops-in with right flank pain, dysuria and fever x 3 days. PE: Mild tachycardia, T=38.3, no SOB. UA: 3+LE, positive nitrate and positive bacteria. What is the diagnosis? What are the antibiotic options? Urinary tract infection 1999 IDSA Guidelines Uncomplicated cystitis in WOMEN: TMP, Bactrim or Quinolone x 3 days (prefer quinolone if rate of resistance to Bactrim is more than 20%, which is the case at GMH). Pyelonephritis: Quinolone x 7-14 days Bactrim x 14 days if organism susceptible. Can start empirically with quinolone and change to Bactrim if isolate comes back susceptible. Case 8 25 year old female, HIV, CD4 150, recently started on ARVs. Comes to clinic with 5 day history of pelvic pain, vaginal secretion and mild subjective fevers. Physical exam T=37.8, HR 98. Tender lower abdomen to deep palpation. Vaginal exam: yellow cervical secretion, pain to cervical movement at bimanual exam. What is the diagnosis? What are the antibiotic options? Pelvic inflammatory disease and STIs Diagnostic tests to consider: GC culture, GC/Chlamydia cervical/urine sample, direct gram stain if available, direct wet prep., KOH test?. RPR, HepB, HIV testing. Conclusions Antibiotics are NOT indicated in the treatment of acute bronchitis. Antibiotics may not be needed in the majority of patients with acute sinusitis. A short course of antibiotics is indicated in patients with acute exacerbations of chronic bronchitis (Doxycycline, Bactrim, or Amoxicillin). Many patients with HIV and pneumonia can be treated as outpatients, and many will NOT need RX for both PCP (Bactrim) and bacterial pneumonia (Levofloxacin + r/o TB, Amoxicillin + Azithromycin or Augmentin + Azitromycin). Conclusions The majority of patients with acute pharyngitis do not require antibiotics. Pursue an etiologic diagnosis rather than treating empirically as GA Strep. The most important therapy for MRSA soft tissue infections is appropriate incision and drainage. A short course of antibiotics (Clinda+Bactrim, Dox