2 Clinical Treatment of Bacterial Infections Hando

Clinical treatment of bacterial
infections
Debra Wollner, PhD
Southwest College of Naturopathic
Medicine
Tempe, AZ
Lecture objectives
At the end of this lecture, students will be able to
Identify when the use of antibiotics may be indicated
Identify the correct antibiotic to use for a given
infection/infectious organism
Recognize when the incorrect antibiotic has been
prescribed
Due to contraindications/precautions
Due to mis-application of medication
Identify common and serious side effects associated
with given antibiotics
Medicine
2
Terminology
Anorexia
Nausea
Vomiting
Bloating
Diarrhea
Medicine
3
Principles of treatment
Is an antibiotic indicated
What organisms are most likely
Have a list of local infectious organisms and their susceptibilities
How to choose the most appropriate antibiotic
Is a combination appropriate
Tuberculosis, H.Pylori and HIV always use combo
Important host factors
Allergy, side effects, organ system disease
Best route of administration
Oral easiest, topical possible, im?
Appropriate dose
Duration of therapy
Resistance? Side effects?
Medicine
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When to use bacteriocidal drugs
Immunosuppressed
Life threatening dz
Meningitis
Endocarditis
Osteomyelitis
Pseudomonas in cystic fibrosis
Bacteriostatic wont cut it in these cases

Medicine
5
How long should an infection be
treated?
A guess
3 days enough for most infections in healthy
individual
10 day or more necessary for the chronically ill and
immunosuppressed
10 days necessary for strep throat
Currently
Diabetic infections generally require longer term (2-3
weeks)

Medicine
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ANTIBIOTIC TREATMENT
Specific bacterial infections
RTI, ABECB, CAP, UTI, skin, GI
Medicine
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RESPIRATORY TRACT INFECTIONS
Pharyngitis
Sinusitis
Otitis
Bronchitis
Pneumonia
Medicine
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PHARYNGITIS
Medicine
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RTIs - Pharyngitis
5-15% adult sore throats group A b hemolytic
strep
15-30% children sore throats group A b hemolytic
strep
All other most likely caused by a virus or other
untreatable microbe
Treatment recommended to prevent life
threatening complications
Rheumatic fever
Symptomatic relief felt rapidly only if treated
within 48 hours of onset of symptoms
Medicine
10
RTIs - When to treat pharyngitis
Four predictors of A b
hemolytic strep
Pharyngeal/tonsillar exudate
Tender anterior cervical
lymphadenopathy
Fever or history of fever
Absence of cough
Clinical treatment
guidelines
Patients with 3-4 criteria
40-60% positive predictive
value
Absence of 3-4 criteri
80% negative predictive value
Medicine
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Guidelines for treatment
Patient positive for 2-4 criteria
Perform RAT
If positive, begin treatment
Patient positive for 3-4
No RAT needed
Treatment recommended

Must confirm RAT, either + or -
Medicine
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Treatment for pharyngitis (+)
Penicillin (oral)
Pen V250 mg bid in children
Pen V 500 mg bid or 250 mg quid in adults
OR Pen G benzathine im 1.2 million U once
Amoxicillin liquid for children unable to swallow oral
pills
Cephalosporins also effective
10 days

5 days azithromycin sometimes useful
Medicine
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Resistance
Strains resistant to macrolides, not generally
penicillin
If trying erythromycin, be careful of resistant
strains erythro usually doesnt work
Some resistance to quinolones
May require amoxicillin/clavulanic acid for
recurrences, resistant strains
Medicine
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Basic treatment guidelines pharyngitis
Group A strep +
Treat with penicillin for 10 days
If allergic to pen
Try macrolide
If macrolide resistance
Use clindamycin (careful blackbox for causing
pseudomembranous colitis c. difficile
overgrowth)
Medicine
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URI
Coughs and colds
Medicine
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Upper Respiratory Infection
Strep pneumonia
URI
Otitis
Sinusitis
Pneumonia
Group A
Strep throat
Cellulitis
Group B
Neonatal sepsis
Chronic adult skin infection
UTI
Diabetic foot
Medicine
17
URI infections
Usually
H.influenza, S.pneumoni, M.catarrhalis,
C.pneumococcus
Choice of medication
First doxycycline (could destroy child liver)
Second cefpodoxixime or cefdinir
Third amoxicillin/clavulanic acid
Last choice quinolones $500! Harms joints
Medicine
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ACUTE RHINOSINUSITIS
Medicine
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Acute rhinosinusitis
Predictive characteristics
Symptoms lasting > 7 days
Maxillary facial or tooth pain or tenderness
Purulent nasal discharge
Medicine
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Acute rhinosinusitis
Cause
S.pneumonia or H.influenza
Medicine
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Treatment
Doxycycline
1/day for 7-10 days
Not in pregnancy
Not in children
Amoxicillin
Up to 50% resistant strains
Use amoxiciliin plus clavulanic acid
Or cephuroxime or cefposoxime
Cotrimoxazole (TMP+SMZ)
Many strains are resistant
Medicine
22
Resistance
Strep pneumo usu resistant to PCN due to
decreased uptake
May use double the dose to overcome
resistance
Medicine
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BRONCHITIS
Medicine
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Acute bronchitis
Most cases are viral
No antibiotic indicated

Bacterial bronchitis
Mycoplasma or Chlamydia pneumonia
In an outbreak, could be Bordatella pertussis
Erythromycin
2005 last outbreak in AZ
Outbreaks (2010) in northern CA, TX
No evidence for S. pneumo, H. influenza or M.catarrhalis
Doxycycline not generally useful
Medicine
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When to treat acute bronchitis
Bordetella pertussis
Atypical presentation in immunized population
Outbreaks every 2-5 years, summer/fall
Persistent chronic cough without whoop or post-tussive
vomiting
Lasts several weeks
Starts as a cold, progresses to severe cough, then convalescent
phase
5-7 day incubation period
Treatment recommended to reduce contagion
Erythromycin
Rarely seen in the absence of an outbreak
Medicine
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INFLUENZA
VIRAL TREATMENTS
Medicine
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Anti-viral treatment of influenza
Will decrease the course of the infection by 1 day
Must begin treatment within 48 hours of onset
Amantadine, rimantadine
Influenza A only
Zanamivir, oseltamavir
Influenza A and B
Prophylaxis recommended for high risk patients
during outbreak, and during the 14 day post
immunization period
Medicine
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Treatment guidelines- acute bronchitis
Adults with cough < 3 weeks
Presume viral bronchitis
Purulent sputum does not suggest bacterial
Must rule out pneumonia

Vitamin C as effective as Z-pack
Lancet 2002; 359:1648.
Use >3 gm/day vit.C and 2-3 mg Zn acetate

Medicine
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Treatment guidelines non specific URI
Usually viral
May have sinus, pharyngeal and lower airways
symptoms
May see green nasal discharge, tonsillar exudate
and green phlegm
No antibiotic treatment indicated
Medicine
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Treatment guidelines ABECB
Acute bacterial exacerbation of chronic
bronchitis
Cough producing sputum
Mucous hypersecretion and hypertrophy of submucosal
glands
Decreased mucociliary clearance, loss of ciliated cells and
increased secretions
Functional airway inflammation and narrowing

Not reactive airway disease (asthma)
Not chronic bronchitis (usually associated with smoking)
Medicine
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Treatment guidelines ABECB
CBC with differential
If see shift to left
Leukocytosis
May see immature cells (blasts)

Medicine
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Treatment of ABECB
Probably H.flu, S.pneumo, M.cat or
C.pneumoniae
Doxycycline first choice
Or cefpodoxime, cefdinir
Amoxacillin +clavulanic acid
TMP/SMZ
Last choice quinolones
Medicine
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OTITIS MEDIA
Medicine
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Acute otitis media
Spontaneous resolution likely within 3-5 days
Treatment with antibiotic NOT recommended
even if you see a bulging, pusy eardrum

If Strep pneumo, then amoxicillin is likely to be
effective
But could become mastoiditis
Medicine
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Acute otitis media
If amoxicillin does not clear the infection
Consider S.pneumo, H.flu, M.cat
Amoxicllin/clavulanate
Cefuroxime
Cefrtriaxone
Doxycycline (adults)
For pen allergy
Clindamycin + cotrimoxazole
However
10% S.pneumo resistant to clindamycin
40% resistant to TMP/SMZ
Medicine
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PNEUMONIA
Medicine
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CAP community acquired pneumonia
Likely S.pneumoniae, H.influenzae, M.catarrhalis,
Mycplasma pneumoniae
Sudden onset, severe pain
Chlamydia pneumoniae
Legionella sp (in outbreaks)
Staph aureus
In diabetes, or in nursing homes
Enterobacteriaceae
In nursing homes
Pseudomonas
Bronchiectasis, chronic steroid use
Oral anearobes
Aspiration prone patients

Medicine
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Treatment of CAP
Doxycycline
Macrolide/azalide
Some S.pneumo and H.flu is resistant
Cefuroxime
Some resistance among atypical bacterial causes
Cefpodoxime
Some resistance among atypicals
Amoxicillin/clavulanate
Some resisitance among atypicals
Amoxicillin alone
30% H.flu, most M.cat resistant
3
rd
/4
th
generation quinolones
Resistance developing
Medicine
39
PRSP
Penicillin resistant Strep Pneumoniae
May still use penicillin and cephalosporin
Generally recommended
Amoxicillin, amoxicillin/clavulanat, crfuroxime
Clarithro/azithromycin
Doxycycline
Medicine
40
Macrolide resistant Strep pneumoniae
High level of resistance
Possible mechanisms of resistance
Efflux
Blocked binding to ribosome
20-30% Strep pneumo resistant
>95% H.influenzae resistant
Medicine
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Telithromycin/Ketek
Useful for ABECB, CAP, bacterial sinusistis
Effective against multidrug resistance
Strep.pneumo

Caution
Associated with acute liver failure
Medicine
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Legionnaires
Outbreaks
Susceptible population
Treatable with macrolides
Medicine
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Summary of treatment of RTI
Otitis media
No antibiotic
Pharyngitis
No antibiotic unless Strep +
Bronchitis
No antibiotic unless CBC diff shows left shift
Sinusitis
No antibiotic unless >10 days or severe acute
Common cold
No antibiotic
Medicine
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URI CASES
Medicine
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Case study strep throat
15 year old patient presents with severe sore
throat, inability to speak above a whisper,
duration >1 week. Throat shows pus filled
blisters.

Response?
46
Response

What is the microbe?

47
What is the microbe?

If positive, then what?

48
Positive strep

What if allergy is present?
49
Allergy to pen

Comes back in a week, not feeling any better,
now what?
50
Erythromycin resistant

51
Case study rhinosinusitis
37 year old female presents 1 month post
acute viral cold. Cold symptoms gone,
however facial pain on pressing cheeks, and
tooth pain when eating. Night-time and
morning cough, productive.

Diagnosis?
52
Diagnosis

Organisms?
53
Organisms

Treatment, particularly in pen allergy?
54
Treatment, particularly in pen allergy?

55
Case study acute bronchitis
FA, 35 year old female, persistent cough
following an acute respiratory viral infection
that began 7 days ago. Nasal stuffiness and
sore throat resolved 3-4 days ago, cough
persisted, sputum thick and mucoid, burning
substernal pain.
Afebrile, course rales
Diagnosis and treatment?
56

Patient returns in 1 week, now has a fever of
101, cough still remains.

57

If bacterial
What are the most likely organisms?
58
What are the most likely organisms?

Treatment?
59
Treatment

What if patient is pregnant?
60
What if patient is pregnant?

61
UTI
Medicine
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Common causes of UTI
E.coli
70-95%
Staph.saprophyticus
5-20%
Other Enterobacteriaceae, proteus
5-15%
Enterococcus sp
Low, but increasing
Found in bactrim and quinolone users
Medicine
63
UTI susceptibilities
Depends on local factors
Nitrofurantoin >99%
Dependable
Newer Fluoroquinolones >99%
2
nd
-3
rd
generation cephs >95%
Trimethoprim plus sulfamethoxazole 3 days 80-90%
1
st
generation cephalosporins 60-70%
Amp or Amox <50-60%

Medicine
64
Nitrofurantoin
Black box warning
ACUTE, SUBACUTE, OR CHRONIC PULMONARY
REACTIONS HAVE BEEN OBSERVED IN
PATIENTS TREATED WITH NITROFURANTOIN.
IF THESE REACTIONS OCCUR, MACRODANTIN
SHOULD BE DISCONTINUED AND
APPROPRIATE MEASURES TAKEN. REPORTS
HAVE CITED PULMONARY REACTIONS AS A
CONTRIBUTING CAUSE OF DEATH.
Usually only seen on long term use
More of a concern with elderly
Medicine
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Treatment guidelines UTI
Uncomplicated cystitis
Cotrimoxazole (TMP/SMZ) for 3 days
If sulfa allergy, use trimethoprim alone
Nitrofurantoin 3-5 days or longer
Quinolone for 3 days
Amox

50% of the time doesnt work

Medicine
66
Treatment guidelines UTI
Complicated cystitis
Cotrimoxazole (TMP/SMX) >3day (longer
duration)
Cephalexin >5-7 days
Nitrofurantoin >5-7 days
Quinolone > 3day

Medicine
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Pyelonephritis
Cotrimoxazole (TMP/SMZ) 14 days
Cephalexin 14 days
Quinolone 7-14 days
Daily IM gentamicin

IN RENAL IMPAIRMENT
Cephalosporin

Medicine
68
Treatment guideline- UTI recurrences
Low dose daily prophylaxis
Post coital prophylaxis
Patient self diagnosis and treatment
Estrogen if postmenopausal
Cranberries and probiotics
Medicine
69
CASE STUDY UTI
Medicine
70
UTI case study
22 year old woman presents with painful,
urgent urination lasting 2 days.

Your response?
71
Response

What are the most likely microbes?
72
Now?

Treatment?
73
Pen allergy

Sulfa allergy?
74
Sulfa allergy

75
To avoid development of quinolone
resistant microbes
Dont use quinolones
Other older medications work also

May use quinolones when nothing else works
Cystic fibrosis pseudomonas
Chronic UTI
76
DIARRHEA
Medicine
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Differential diagnosis- diarrhea
Acute
Infections (bacterial, parasitic, viral)
Food poisoning
Medications
Chronic (osmotic)
Secretory
Congenital
Bacterial toxins
Ileal bile acid
Malabsorption
IBD-UC, Crohns, diverticulitis
Chronic inflammatory
Many
Medicine
78
Major causes of acute diarrhea
Bacterial
Bacilius cereus
Campylobacter
Clostridium difficile
Clostridium perfringens
Escherichia coli
Enterotoxigenic
Enteroinvasive
Enterohemorrhagic
0157:H7
Listeria monocytogenes
Salmonella
Shigella
Staphylococcus aureus
Vibrio
Yersinia enterocolitis
Parasites and protozoa
Crytposproidium
Cyclospora
Entamaeba histolytica
Viruses
Adenovirus
Norwalk virus
Rotavirus
Medicine
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Acute diarrhea
Many causes
Take history
# stools/day
Consistency
Volume
Degree of interference
Determine cause
Associated with travel, food
Associated symptoms
Dystentery, dehydration
Medicine
80
Additional clues
Bloody stools
Salmonella, shigella, campylobacter, e.coli 0157, clostridium difficile, entamoeba histolytica
Rectal pain
Campylobacter, salmonella, shigella, neisseria gonorrheae, herpes, chlamydia, E. histolytica
Severe or persistent abdominal pain
Campylobacter, yersinia, clostridium perfringens, aeromonas
Recent antibiotic therapy or chemotherapy
C. difficile, salmonella
Travel (Mexico, Africa, Middle or Far East)
Enterotoxigenic Ecoli, others
Family or friends affected
Food borne pathogens, staphylococcus
Homosexual male
Herpes, Chlamydia, Treponema pallidum, E.histolytica, Shigell, Giardia, N.gonorrheae,
Cryptosporidium
Hospital acquired
C. difficile
Daycare centers, mental institutions
Giardia, C.difficile, Salmonella, Shigella, rotavirus
Medicine
81
Community acquired or travelers
diarrhea
Accompanied by fever or bloody stool
Culture for Salmonella, Shigella,
Campylobacter, E.coli 0157, C.difficile
Shigella-quinolone
Resistant Campylobacter- macrolide
Avoid anti-motility agents and anti-microbials if
STEC suspected
Medicine
82
Nosocomial diarrhea
Onset >3 days in hospital
Test for C.difficile
Discontinue antibiotics if Positive
Consider metronidazole
Medicine
83
Persistent diarrhea (>7d)
Parasites possible
Particularly if immunocompromised
Giardia, cryptosporidium, Cyclospora, Isospora
belli
If HIV positive
microsporidium or MAC likely causes
Medicine
84
Quinolone resistant C.jejuni
Campylobacter leading cause of bacterial GE
in US
80% of chickens are contaminated
Sarafloxacin and enrofloxacin used in chicken
farming
Medicine
85
Travellers diarrhea
Mild
1-2 stools/24 hours
No therapy
Mild to moderate
>2 stools/24 hours
If no distressing symptoms
Loperimide or bismuth
If distressing symptoms
Loperimide + fluoroquinolone 500 mg quinolone po bid up
to 3 days
Reassess
Severe
Fever, bloody stool >6/24 hours
400 mg norfloxacin bid 3-5 days
Medicine
86
Salmonella, Shigella, Campylobacter
Erythromycin
Medicine
87
Treatment guidelines- diarrhea
Rarely use antibiotic in acute
Dont use antibiotic if virus or E.coli 0157
Quinolones dont cover most common cause,
C.jejuni
Travelers diarrhea may require quinolone
short course
C.diff requires metronidazole
Medicine
88
H.PYLORI
Medicine
89
H. pylori
About 50% or world population infected
About 1/3 of US population infected
Only about 10% develop disease
Eradication in PUD decreases recurrences and
complications
90
Diagnosis of H.pylori
Endoscopy (invasive)
Histology
Culture
CLO-test
Non-invasive
Serum serology (IgG)
Saliva or urine test
Breath test for urea
Stool antigen HpSA
91
Stool antigen test (HpSA)
Can test pre treatment
Can test post treatment as proof of cure
92
Non-ulcer dyspepsia (NUD)
Treatment controversial
Rule out other causes
Treat if H.pylori positive
93
H.pylori treatment
Usually recommended together
Bismuth subsalicylate 525 mg QID x 1week
(protects stomach lining)
Metronidazole 250 mg QID x 1 week
Tetracycline 500 mg QID x 1 week
Omeprazole 20mg BID x 1 week (Proton
pump inhibitor - lowers stomach acidity)
94
Antacids and interactions
Acid stomach required for absorption of many
drugs
Digoxin, phenytoin, isoniazid, ketoconazole
Take the antacid 2 hours before or 2 hours
after other drugs
Cipro best taken 2 hours before antacids
Tetracyclines at least 2-3 hours before antacids
95
Skin and soft tissue
Bacterial
Fungal
Viral

Skin and soft tissue, bacterial
Abscess must be drained
Antibiotic treatment may be needed, if
cellulitis or deep tissue involved
Skin infections almost always Staph.aureus
97
Routine erysipelas and cellulitis
b hemolytic Strep., sometimes Staph. Aureus, less
commonly Gram Negative bacteria
PCN, erythro, cephalexin, clindamycin
Impetigo from sandbox
b Strep
Treat with dicloxacillin (extended spectrum penicillin)
instead of topically
Bollous
Staph
Treat with dicloxacillin

98
Impetigo
Retapamulin/Altabax
Topical treatment approved for impetigo
Derived from Clitopilus passeckerionus
Inhibits 50S bacterial ribosomal subunit
Not approved for mucosal surfaces
Do not use on large surface area
Some irritation at application site
Preg B
Medicine
99
Folliculitis, furunculitis, carbunculitis
Staph.aureus +/- b hemolytic Strep
May need antibiotic if cellulitis or deep tissue involved
Human/animal bite
Treat skin flora and whats in the mouth
Amox alone, augmentin (amox+clavulanate) standard for
bites, PCN + dicloxacillin, cephalexin, clindamycin,
doxycycline
Macrolides wont cover
100
Augmentin (amoxicillin + clavulanate)
In penicillin allergy
Use doxycycline or 2
nd
-3
rd
generation
cephalosporin
Dont use macrolides, they wont cover most
common causes
101
MRSA
Local wound cleansing and debridement must be
accompanied by antibiotic therapy.
At least 10 days of
Trimethoprim/sulfamethoxazole
Minocycline or doxycycline
Rifampin plus tmp/smz or minocycline or doxycycline
Vancomycin
Linezolide standard today
Watch for myelosuppression
Yersinia pestis the plague

Yersinia pestis
Streptomycin
Gentamicin
Tetracyclines
Chloramphenicol
Doxycycline - standard
Trimethoprin/sulfamethoxazole
Associated treatments
Drain buboes

OPHTHALMIC INFECTIONS
Ophthalmic products
Bacitracin GPC (S.aureus, S.pneumo.)
conjunctivitis
Sulfonamides- GPC, hemoph
Conjunctivitis, allergenic
Macrolides (erythro)- GPC
Tetracyclines GPC, hemoph, irritating
Aminoglycosides- GNB, sensitizing
Quinolones- GPC + GNB, broad, expensive
Trimethoprim/polymyxin B +bacitracin/polymixin B
Cost effective, fewer toxicities of some others
106
Ophthalmic
Avoid ophthalmic corticosteroids
Cause herpes keratitis
Antiviral
Trifluridine
Antifungal
Natamycin

107
Neonatal conjunctivitis
May be passed through vaginal birth
Mother may not know of infection
Possibly gonorrhea or chlamydia
Many states routinely require treatment of
newborns with eye drops
Erythromycin
Silver nitrate (rarely used)

108
Overview of the lecture
Common bacterial infections
Know when antibiotics are appropriate
Know which antibiotic is most likely to be
effective
Recognize problems of antibiotic use in
patients.
109

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