Final

Year CUCMS Teaching Module

Dr Nor Shuhaila Shahril
BACTERIA!!
 Gram staining method

If stained dark blue or violet = gram positive

Due to high amount of peptidoglycan in cell wall

If cannot retained crystal violet but takes up

counterstain (safranine or fuchsine), and
appear pink or red = gram negative

 coccus (sing.), cocci
(pl.): are spherical
(coccus = a berry),
bacillus (sing.), bacilli
(pl.): are rod-shaped
(bacill(um) = a little
stick) Streptococcus in chains (strepto =
spirillum (sing.), bent, twisted, pliable)
Staphylococcus in clusters
spirilla (pl.): are spiral (staphylo = a bunch of grapes
(spiro = spiral, coil). Diplococcus in sets of two (diplo =
double)
 Gram-positive bacteria, stained purple, of both the bacillus (rod-shaped) and coccus
(spherical) forms. A few Gram-negative bacteria are also present, stained pink. Numbered
ticks are eleven (11) microns apart.
 Cocci (sphere-shaped bacteria)
Streptococcus spp.
Staphylococcus spp.

Bacilli (rod-shaped bacteria)

Subdivided based on their ability to form spores:-
Non-spore formers are Corynebacterium and Listeria (a
coccobacillus)
Spore-formers: Bacillus and Clostridium (anaerobes)
 E.coli

Coxiella burnetti (coccobacilli)

Coccobacillus intermediate
between cocci and bacilli shape
 Enzymes produced by some bacteria
Responsible for their resistance to beta
lactam antibiotics like penicillins and
carbapenems.
These antibiotics have a common element in
their molecular structure: a four-atom ring
known as a beta-lactam.
The lactamase enzyme breaks that ring
open, deactivating the molecule's
antibacterial properties.
 Beta-lactam antibiotics are typically used to
treat a broad spectrum of Gram-negative
bacteria.
Beta-lactamases produced by Gram-negative
organisms are usually secreted.
Enterobacteriaceae, Pseudomonas aeruginosa,
Haemophilus inuenzae, and Neisseria
gonorrhoeae
 Cephalosporins (except for 1st generation) are
relatively resistant to beta-lactamase.
cephalosporins with an oxyimino side chain, such
as cefotaxime, ceftazidime, ceftriaxone, or
cefepime.
Consequently, when these antibiotics were
rst introduced, they were eective against a
broad group of otherwise resistant bacteria.
 Enzyme not only chops apart penicillins, but also
cephalosporin antibiotics.
Many dierent species of bacteria can produce the
ESBL enzyme, including both gram positive and gram
negative bacteria.
The most common ESBL bacteria are E. coli and
Klebsiella species.
Surgical site infections and blood infections, and are
commonly responsible for urinary tract infections (UTIs).


 Clavulanic acid + amoxicillin = Augmentin
Sulbactam+ ampicillin= Unasyn
Tazobactam+ piperacillin= Tazosin
GOOD NEWS!
Beta-lactamase inhibitors inhibit the beta lactamase thereby not
allowing the molecule to hydrolyze the antibiotic. Most ESBLS
remain susceptible to Beta-lactamase inhibitors

BAD NEWS!
Some ESBL producing bacteria produce large amounts of beta-
lactamase thereby overwhelming the beta-lactamase inhibitors.
 Antibiotics may need dosage adjustment in
patients with renal impairment.
Calculate creatinine clearance

Some antiBx do not need adjustement for
patients with renal insuciency
e.g. amphotericin B, azithromycin, ceftriaxone,
clindamycin, doxycycline, pyrimethamine,
rifampicin.
 A group of antibiotics derived from Penicillium fungi

1. Natural penicillins:
Pen G and V indicated against streptococci, anaerobes (above
the diaphragm), syphilis, Listeria monocytogenes (high dose), dog
and cat bites (Pasteurella multocida ).
Does not cover S. aureus.

2. Penicillinase-Resistant Penicillins (PRSP):
Methicillin / cloxacillin indicated against penicillinase producing
S.aureus (MSSA not MRSA) for endocarditis, osteomyelitis.

3. Aminopenicillins:
Ampicillin / Amoxicillin: G(+) coverage similar to above, covers
many G(-) in GI tract (Salmonella, Shigella, E. coli, Proteus), N.
meningitidis, 70% of H. inuenza, Listeria, Nocardia.
 Amoxicillin + clavulanate = Augmentin.
Covers most G(+) except MRSA, and many G(-).
Anaerobe coverage ((B. fragilis, C. dicile )

Ampicillin + sulbactam = Unasyn.
Coverage to G(+) similar to above and G(-) all
except Serratia, Enterobacter, Pseudomonas,
Legionella.
Anaerobe coverage (B. fragilis, C. dicile )
Indication: GYN, GI and skin.
4. Anti-pseudomonal penicillins:
CarboxyPCN e.g. ticarcillin
UreidoPCN e.g. piperacillin

Cover most streptococci, and most G(-) with variable coverage for
Klebsiella, M. catarrhalis, Serratia, Legionella.
NO coverage for Staphylococcus (except for Piperacillin
+Tazobactam).
Good anaerobic coverage (B. fragilis, C. dicile ).
Main indication is Pseudomonas aeuroginosa.
For serious Pseudomonas infections an aminoglycoside should be
added for synergism.
 A class of -lactam antibiotics originally
derived from the fungus Acremonium, which
was previously known as "Cephalosporium.
First-generation cephalosporins are active
predominantly against Gram-positive
bacteria
Successive generations have increased
activity against Gram-negative bacteria
(albeit often with reduced activity against
Gram-positive organisms).
 Infrequent ADRs (0.11% of patients) include:
nausea, vomiting, rash, headache, dizziness,
oral and vaginal candidiasis,
pseudomembranous colitis, eosinophilia,
and/or fever.
The cross reactivity with penicillin (5-10%) is a
concern especially if pt had anaphylaxis -
cephalosporins should be completely
avoided.
 Cephalexin , Cefazolin.

Covers all streptococci, S. aureus (not

MRSA) and S. epidermis.

Also cover G (-) bacteria: N. gonorrhea, M.

catarrhalis, H. inuenza , E. coli, Klebsiella.

Main indications are surgical prophylaxis and

Strep. / Staph. (not MRSA)
 Subdivided into:-
"good for H. inuenza" cefuroxime and
"good for anaerobes" cefoxitin, cefotetan.

Similar G(+) coverage as 1ST generation and

better G(-) coverage including N. meningitis (not
the drug of choice for meningitis), Salmonella /
Shigella / Proteus and +/- Yersenia.
Main indications are GI (colorectal surgery and
appendicectomy), and Ob-Gyn procedures.
 Ceftriaxone (Rocephin) & ceftazidime
(Fortum) two most commonly used.

Others: cefotaxime (Claforan),

cefoperazone (Cefobid)

G(+) coverage is similar to 1ST and 2ND

generation.

 Bacterial meningitis
Has activity against H. inuenza (resistant to PCN), N.
gonorrhea and N. meningitidis
Good CSF penetration.
Dose 2g bd
Pneumonia
CAP (1-2g od, together with macrolide)
Mild-to-mod health-care associated pneumonia
Typhoid fever (3g od)
Gonorrhoea (125mg IM stat)
 Anaerobic coverage varies from one drug to
the other.

G(-) are generally covered well except for

atypicals (e.g. Legionella).

Cephalosporins DO NOT cover Listeria or

Enterococcus.
 Ceftazidime: indicated against
Pseudomonas.

Older 3RD generation include cefotaxime

(Claforan), similar to ceftriaxone, and
cefoperazone (Cefobid), similar to
ceftazidime.
 Cefepime (Maxipine)

Similar to 3rd generation but with better G(-)

coverage (P. aeruginosa, Enterobacter,
Serratia, C. freundii) and better G(+)
coverage (S. aureus ).
 Erythromycin
Clarithromycin
Azithromycin

Clarithromycin and azithromycin have similar

antimicrobial proles, providing enhanced
activity against H. inuenza as compared with
erythromycin and retaining good ecacy
against G+ organisms.
 Cover Streptococcus, Staphylococcus (not
MRSA), +/- N. gonorrhea, H. inuenza, M.
catarrhalis, Legionella, M. pneumonia and
Chlamydia.
 Cross-resistance is seen among all
macrolides, particularly in Gram positive
bacteria.
Because azithromycin has the best activity
against Chlamydia trachomatis
1 gm PO single dose for the treatment of non-
gonococcal urethritis and cervicitis.
 An alternative to penicillin in allergic patients

Non-gonococcal urethritis / cervicitis

Upper respiratory tract infections

Pneumonia (atypical) secondary to Legionella

or Mycoplasma.
 Gastrointestinal complaints, particularly
nausea, abdominal pain and diarrhea
Headache
Abnormal LFT's
Reversible hearing loss.
Azithromycin and clarithromycin lowest S/
E.
Clarithromycin - taste disturbance, Archilles
tendon rupture

 More signicant with clarithromycin and
erythromycin, as they both increase serum
concentrations of drugs metabolized by the
P-450 system in the liver.
May increase the levels of warfarin, digoxin,
carbamezapine
May cause arrhythmias when used with some
anti-histamines.
 Most common is imipenam + cilastatin (Imipenem)
given with cilastatin to inhibit renal breakdown.

Wide spectrum antibiotic

Covers most G (+) except MRSA and most G (-) except

Legionella and some strains of Pseudomonas
(maltophilia, cepacia ).

Also covers all anaerobes and has activity against

Listeria and Nocardia.

 Seizures are reported particularly in patients
with history of seizures or renal failure.

Main indication is multidrug resistant

bacteria and should NOT be a rst choice.
 Good activity against G(-) such as Proteus mirabilis and E. coli.
Good for GI pathogens such as Vibrio cholera, Campylobacter
jejuni, Yersinia, Salmonella and Shigella (drug of choice for
traveler's diarrhoea)
Most active uoroquinolone against the Pseudomonas
species.
Good against bacteria that depend on the production of beta
lactamase for survival, thus it covers H. inuenza and S.
aureus
But surprisingly weak against streptococci (including S.
pyogenes and S. pneumonia)
 NO activity against anaerobic bacteria,
including B. fragilis. (not a good choice for
PID - weak against chlamydia and
enterococci.
NOT used in children impair proper growth
of cartilage.
 Levooxacin
Better activity against Gram (+) cocci and perhaps
less toxicity.
Main advantage: daily dose (250-500mg po qd)

Moxioxacin (Avelox)
Main indication: community acquired pneumonia
Used as monotherapy

 Gentamycin, netilmicin and amikacin are
the most common.

BEWARE! All aminoglycosides have the

potential to cause nephrotoxicity and
ototoxicity.

 They cover many G(-) including Pseudomonas
aeruginosa (but not cepacia or maltophilia) and
they do not cover Neisseria (gonorrhea or
meningitidis).

DO NOT cover anaerobes, Legionella or

atypicals.

G(+) coverage is poor, but they will cover S.

aureus (MSSA only) and Listeria monocytogenes.

 As volume of distribution increases (CHF,
ascites, third spacing) the dosage of the drug
must be increased.
NO CSF penetration.
TDM: Peaks and troughs should be
measured, although other dosing alternatives
are now being used, such as once-daily 7 mg/
kg/day of gentamycin.
Divided dosing in endocarditis.

 Gram negative sepsis, endocarditis (in
combination with penicillin), and for
synergism against P. aeruginosa infections.
 Indicated mainly for anaerobic coverage

Good activity against C. dicile (given PO),

Trichomonas, Giardia and B. fragilis.
 E.g Tetracycline, doxycycline, minocycline
Indication:
Infection due to Rickettsiae, Chlamydia, Nocardia, Lyme's
disease (early)
Patients allergic to PCN that requires treatment for
syphilis
Minocycline is more eective against staph and used
for the treatment of acne.
Drugs should be taken on empty stomach since milk,
Fe, Ca and antacids interfere with absorption.
Photosensitivity reported.
Not given to pregnant women or children < 10 years
old.
 Wide spectrum including activity against
streptococci and H. inuenza.
Indicated PO for uncomplicated UTI, COPD/
bronchitis, otitis media and PCP prophylaxis.
Indicated IV for active PCP with pO2 < 70 mmHg
or if unable to tolerate PO.
TMP/SMX (TMP 20mg/kg/day divided into 4 doses).
In HIV (+) pt allergic eects are as high as 50%.
Avoid in G6PD deciency.
 Excellent against anaerobes, including such
below the diaphragm pathogens as B. fragilis.
Covers streptococci and S. aureus (not
MRSA).
Well absorbed orally
Most frequent cause of C. dicile
pseudomembranous colitis.
 Glycopeptide antibiotics

Covers all G(+) including MRSA, C. dicile, Diphtheria,
Enterococcus.
Indications: alternative to PCN / Cephalosporin in the allergic
patient, C. dicile (oral preparation) and MRSA.
Red-man syndrome is seen following rapid administration and is
believed to be histamine mediated.
Vancomycin has good CSF penetration and is used as a secondary
drug in meningitis to cover resistant Streptococcus.
Because of emerging patterns in drug resistance, Vancomycin
should be reserved for specic situations and not be used as a rst
line agent.
 30 yr old Malay man
Gardener
Left lower limb swelling and
redness X 5/7
Fever+
Diagnosis?
What is the oending
organism?
What antibiotics do you want to
initiate?
 Uncomplicated /Immunocompetent
Staphylococcus aureus
Streptococcus pyogenes (Group A)
Streptococcus agalactiae (Group B)

Complicated (burns, diabetes, infected

pressure ulcers, traumatic/ surgical wounds)
Gram negative bacilli (Escherichia coli,
Pseudomonas aeruginosa)
 Group A streptococci or Clostridium species,
with or without other anaerobes, can cause
fulminant soft tissue infection and necrosis,
especially in diabetic patients.
 Anti-staphylococcal penicillin
Cloxacillin/ ucoxacillin
Amoxicillin plus clavulanic acid (Augmentin)
1st gen. Cephalosporin (Cephalexin)

If allergic to penicillin
Fluroquinolones with good activity against gram
positive organism (levooxacin, moxioxacin,
gatioxacin)
Clindamycin
 Reasonable empiric monotherapy
Piperacillin/tazobactam (Tazocin)
Carbapenem (imipenem/ meropenem)

Methicillin-resistant Staphylococcus aureus

(MRSA)
Vancomycin
Alternatives: Linezolid
 21 yr old female
Monoarthritis of the left knee
Sexually active
 Possible diagnosis?
Septic arthritis
Reactive arthritis

What investigation would you do to conrm

your suspicion?
Joint aspiration and send synovial uid for FEME/
C&S
 Gonococcal septic arthritis
Neisseria gonorrhoeae

Non-gonoccal septic arthritis

S. aureus (60-70%)
Strep species (15-20%)
Gram negative bacilli (haemophilus) 5-25%
Anaerobes (bacteroides/ Prophionibacterium acnes)
1-5%
Brucella/ mycoplasma (rare)
 Gonococcal Non-gonococcal
Host Young, healthy adults Small children, elderly,
immunocompromised
Pattern Migratory, Monoarthritis
polyarthralgias/ arthritis
Tenosynovitis Common Rare
Dermatitis Common Rare
Positive joint cultures < 25% > 95%
Positive blood cultures Rare 40-50%

Outcome Good in > 95% Poor in 30-50%

 Ceftriaxone
Covers for S. aureus, Strep and N.gonorrhoeae.
 50 yr old Malay man
Diabetes Type 2
Swelling of right big toe X
3/52
Associated with redness,
yellowish pus discharge+ x 1/52
Fever X 1/52

What investigations would

you do?
 WCC 15 X 109/L
RBS 20 mmol/l
Blood C&S: gram positive
cocci
X-ray as shown:

What is the diagnosis?

What antibiotic of choice
would you commence?
 Hallmark characteristics:-
Bone destruction
Periosteal new bone formation

Location:
Lower extremities (most common)
Over pressure areas in diabetics
Spine
Lumbar > thoracic > cervical
Radial styloid
Sacroiliac joint
 S.aureus (most common)
Streptococcus pyogenes
Pseudomonas, Klebsiella (drug addicts)
Salmonella spp (in sickle cell disease patients)
Gram negative bacilli (E.coli, Pseudomonas)
post-orthopaedic procedures
REMEMBER!
Infections of the feet in diabetic patients often
involve both bone and soft tissue and are usually
POLYMICROBIAL both aerobic and anaerobic
bacteria.
 Gram positive cocci
Group A Strep (may cause acute
sepsis)
Enterococcus (may be most
common)
S. aureus

Enterobactericaeae
 Streptococcus spp
IV Penicillin
IV Ceftriaxone

Gram negative
IV Ceftriaxone
IV Ceftazidime
IV Ciprooxacin

IV Vancomycin/ Linezolid if MRSA
 22 yr old male student
Fever and headache of 2/7
Vomiting 10X today

What other information do you require?

 Nature of headache
Headache worse with coughing, sneezing,
bending over, defaecation raised ICP
Photophobia
ENT symptoms ENT region entry point to
meninges
Reason for immunocompromised state
TB, cryptococcal
Travel history
Contact history
 Orientated to time/ place/ person
Photophobic++
Kernigs positive
Tone generally increased bilaterally
Power 5/5 both UL and LL
Plantars downgoing
Unable to perform fundoscopy severe
photophobia.
No rash
 What is the most likely diagnosis?

List the investigations that you would do in

this case with justication.
 FBC Hb 14, WCC 23, Plt 290
BU 9.0, Na 135, K 3.4, Cl 91, Creat 120
INR 1.05 , PTT 33s (n < 33)
RBS 6.8
Blood C&S prior to empirical antiBx Rx

CT brain - normal

 What do you want to send for:
CSF biochemistry protein, glucose
CSF FEME/ Gram stain
CSF Indian ink
CSF culture and sensitivity
CSF AFB smear
CSF AFB stain
CSF virology
CSF cryptococcal antigen
 LP results are as follows:-
Opening pressure 20 cmH2O
Appearance cloudy
CSF protein 1.0 g/L
CSF glucose 1.5 mmol/l
CSF FEME: numerous polymorphonuclear
neutrophils, RBC 0.2 X 106/L

COMMENT!

Value Normal Range
Appearance Clear & colourless
0 - 5 x 106 /L
White Cells
(all lymphocytes with no neutrophils)
Red Cells 0 - 10 x 106 /L
0.2 - 0.4 g/L
Protein
(or less than 1% of the serum protein concentration)
3.3 - 4.4 mmol/L
Glucose (or 60% of a simultaneously derived plasma glucose
concentration)
pH 7.31
Pressure 7 18 cmH2O
Condition Appearance White Cells Red Cells Protein Glucose
Bacterial Cloudy & Raised
N H or VH VL
Meningitis Turbid neutrophils
Raised
Viral Meningitis N N N or H N or L
lymphocytes
Tuberculous N or slightly Raised
N H or VH VL
Meningitis cloudy lymphocytes
Usually
Subarachnoid
blood N VH N or H N or L
Haemorrhage
stained
H (only
Guillan-Barr
N N N after 1 N or L
Syndrome
week)
Multiple Raised
N N H N
Sclerosis lymphocytes
N= normal, L= low, H = high, VH = very high, VL = very low
 Streptococcus pneumoniae (pneumococcus)
Neisseria meningitidis
H. inuenza type b
usually children, but now decreased incidence due to
immunization
Enteric gram negative bacteria
neonates, elderly, recent neurosurgery, immunosuppressed
Group B strep
neonates
Listeria monocytogenes
pregnant women, newborns, elderly, immunosuppressed
 Pending culture results
High-dose IV Ceftriaxone or Cefotaxime

If suspect Cephalosporin-resistant pneumococci, add

vancomycin (usually very high doses needed to
reach CSF [may need up to 4g/day) needs very
careful monitoring!)
STOP if organism known susceptible to cephalosporin/
penicillin
 Nosocomial meningitis
Make sure cover for Pseudomonas
IV Vancomycin and a cephalosporin with good
activity against Pseudomonas e.g. IV Ceftazidime
If conrmed Pseudomonas, add an
aminoglycoside e.g. gentamicin or amikacin.

Listeria meningitis
IV Ampicillin +/- gentamicin
IV Bactrim if allergic to penicillin
 45 year old lady
c/o fever and dysuria X 3/7
Chills and rigors
Nausea+, poor appetite
Vomiting 2-3X per day
What is the diagnosis?
Lethargic+
BP 110/70 PR 96/min
PA: soft, tender Rt loin with positive renal
punch, no ballotable kidneys.
UTI Pathogens Antibiotics
Uncomplicated: Enterobacteriacae Augmentin
Cystitis/ urethritis (E.coli, Serratia, Fluroquinolones (ciprooxacin,
Klebsiella, Enterobacter, levooxacin)
Citrobacter) Bactrim
Staph saprophyticus
Enterococci
Recurrent cystitis (> As above As above with prophylaxis
3 episodes per year) Bactrim

Complicated UTI: As above Beta-lactam plus

Indwelling cathter, Possible pseudomonas aminoglycoside
obstruction, Fluroquinolones
pyelonephritis Piperacillin-tazobactam
Imipenem
 65 year old lady, non-smoker
Diabetic Type 2 for 2 years
Fever and cough X 4/7
Productive cough of yellowish sputum
No haemoptysis
Right-sided pleuritic chest pain
Poor appetite
No history of recent travel
No contact with persons with respiratory
illness.
 Pink on air, spO2 93%, alert
Dyspnoeic RR 32/min
Febrile T 38C
BP 100/70 mmHg
PR 115/ min reg
Lungs: dull percussion note with coarse
crepitations at right lower zone, bronchial
breath sounds.
Diagnosis?
Investigation?
 FBC Hb 14 Hct 50% Plt 239 TWC 20
BU 16 Na 134 K 4.2 Creat 140
RBS 15
UFEME gluc 1+, ketones nil, prot 1+
ABG pH 7.49 pO2 76 pCO2 29 HCO3 19

What other Investigations would you like to

do?
 Rt lower lobe pneumonia
(urea > 7 mmol/l)
 Streptococcus pneumoniae
Adults with risk factors for drug-resistant Strep pneumoniae (DRSP):
older than 65, having exposure to children in day care, having
alcoholism or other severe underlying disease, or recent treatment
with antibiotics
Hemophilus inuenzae
commonly causes CAP in people who have suered recent lung
damage from viral pneumonia.
Enteric Gram negative bacteria
Escherichia coli and Klebsiella pneumoniae (bacteria in human
intestines)
Risk factors for infection including residence in a nursing home,
serious cardiac and pulmonary disease, and recent antibiotic use.
Pseudomonas aeruginosa
An uncommon cause of CAP
Risk factors: malnourished, bronchiectasis, on corticosteroids , or have
recently had strong antibiotics for a week or more.
 Mycoplasma pneumoniae

Chlamydophila pneumoniae

Legionella pneumophilia (less common)

Atypical organisms are more dicult to grow.

 Healthy outpatients without risk factors
No risk factors for DRSP, enteric Gram negative
bacteria, Pseudomonas
Usually caused by viruses, atypical bacteria,
penicillin sensitive Streptococcus pneumoniae, and
Hemophilus inuenzae.
Recommended management is with a macrolide
antibiotic such as azithromycin/ clarithromycin/
erythromycin for 7 10 days.
IDSA 2007
 Outpatients with underlying illness and/or
risk factors but do not require hospitalization
underlying cardiac (e.g. CCF) or pulmonary
disease (COPD) or is at risk for DRSP and/or
enteric Gram negative bacteria.
Treatment:
Fluroquinolone active against Streptococcus
pneumoniae such as levooxacin or moxioxacin, or
A beta-lactam antibiotics (e.g. cefuroxime,
augmentin) plus a macrolide (azithromycin,
clarithromycin) for 7 10 days.
 Hospitalized individuals NOT at risk for
Pseudomonas
Beta lactam antibiotics (cefotaxime, ceftriaxone,
ampicillin/sulbactam, ertapenem for selected
patients), plus IV macrolide antibiotic
(azithromycin) for 7 - 10 days (alternative to
azithromycin is doxycycline)
Or
IV uroquinolones active against Streptococcus
pneumoniae such as levooxacin or moxioxacin
(if penicillin-allergy)
 Hospitalized, ICU treatment NOT at risk for
Pseudomonas
Beta lactam antibiotics (cefotaxime, ceftriaxone,
ampicillin/sulbactam, ertapenem for selected
patients), plus
IV macrolide antibiotic (azithromycin) or
uroquinolones (levooxacin)

 Individuals requiring intensive care at risk for
Pseudomonas
2 regimes:
IV anti-pseudomonal beta-lactam (cepime, imipenem,
meropenem, piperacillin/ tazobactam) plus IV anti-
pseudomonal uoroquinolone (levooxacin)
Or
IV anti-pseudomonal beta-lactam (cefepime, imipenem,
meropenem, or piperacillin/ tazobactam)
plus
IV aminoglycoside (gentamicin) and
IV macrolide (azithromycin) or IV anti-pneumococcal
uroquinolone.
 72 year old man
Recent admission to a private hospital for
upper GIT bleed due to duodenal ulcer.
Discharged 5/7 ago.
c/o cough and dyspnoea for 2/7
OE: temp 37.5C, BP 110/78 PR 100/min
Lungs: creps left lower zone with reduced air
entry
What is the diagnosis?
 Early onset
Occurring < 5 days after hospital admission
Commonly associated with antibiotic-sensitive bacteria :
H.inuenzae, oxacillin-sensitive S. aureus, and S. pneumoniae
No risk factors for infection due to potentially antibiotic-resistant
bacteria : antibiotic treatment or prior health care facility exposure

Late onset
Occurring 5 days after hospital admission
Usually antibiotic-resistant bacteria: MRSA, P. aeruginosa,
Acinetobacter spp., and Enterobacter spp.

ATS. Am J Respir Crit Care Med. 171;388, 2005

Ibrahim EH, et al. Chest. 117:1434, 2000 ;
Trouillet JL, et al. Am J Respir Crit Care Med. 157;531, 1998
 Antimicrobial therapy in preceding 90 days
Current hospitalization of 5 days
High frequency of antibiotic resistance in the
community or in the specic hospital unit
Presence of risk factors for HCAP :
hospitalization for 2 days in the preceding 90 days
residence in a nursing home
home infusion therapy
chronic dialysis within 30 days
home wound care
family member with MDR pathogens
Immunosuppressive disease and/or therapy
 57 year old man
Fever X 1/12
Lethargy+
O/E: febrile 38C
Lungs: clear
PA soft, hepatosplenomegaly
Petechiae rashes on lower limbs

Hb 5.6 Plt 27 TWC 2.0

ANC 0.4
 Fever in the presence of neutropenia

Neutropenia:
ANC of <500 cells/mm3 or
ANC that is expected to decrease to < 500 cells/mm3
during the next 48 h.

Profound is sometimes used to describe

neutropenia in which the ANC is < 100 cells/mm3
a manual reading of the blood smear is required to
conrm this degree of neutropenia.
 Infections (more commonly viral infections, but also bacterial or parasitic infections).
E.g HIV, TB, malaria, EBV

Medications that may damage the bone marrow or neutrophils, including cancer and
chemotherapy

Vitamin deciencies (megaloblastic anaemia B12 and folate)

Diseases of the bone marrow such as leukaemias, myelodysplastic syndrome, aplastic
anaemia, myelobrosis,

Radiation therapy

Congenital (inborn) disorders of bone marrow function or of neutrophil production

Autoimmune destruction of neutrophils (either as a primary condition or associated with
another disease such as Feltys syndrome) or from drugs stimulating the immune system to
attack the cells

Hypersplenism, which refers to the increased sequestration and/or destruction of blood

cells by the spleen
 RP
LFT
FBP
2 sets of blood culture
Culture from any suspected sites of infection
CXR
 Monotherapy with:
an anti-pseudomonal beta-lactam agent, such as
cefepime, or
carbapenem (meropenem or imipenem-
cilastatin), or
piperacillin-tazobactam

IDSA 2011
 Other antimicrobials (aminoglycosides, uoroquinolones,
and/or vancomycin) may be added to the initial regimen
for management of complications (eg, hypotension and
pneumonia) or if antimicrobial resistance is suspected or
proven.
Vancomycin (or other agents active against aerobic gram-
positive cocci) is not recommended as a standard part of
the initial antibiotic regimen for fever and neutropenia
To be considered for specic clinical indications including
suspected catheter-related infection, skin or soft-tissue
infection, pneumonia, or hemodynamic instability.
If MRSA: Consider early addition of vancomycin, linezolid,
VRE: Consider early addition of linezolid
 Empirical antifungal therapy and
investigation for invasive fungal infections
should be considered for patients with
persistent or recurrent fever after 47 days of
antibiotics and whose overall duration of
neutropenia is expected to be > 7 days
 Hand hygiene is the most eective means of
preventing transmission of infection in the
hospital.
Standard barrier precautions should be followed
for all patients, and infection-specic isolation
should be used for patients with certain signs or
symptoms.
Plants and dried or fresh owers should not be
allowed in the rooms of hospitalized neutropenic
patients.
Avoid attending to patient if health care
workers are ill.