Contents
Bad news
As immunosuppressive diseases and use of
immunosuppressive agents become more prevalent,
opportunistic infections becomes more common, esp. by
organisms rarely encountered previously
Diseases: e.g. HIV, leukemia
Drugs: e.g. in solid organ transplants, bone marrow transplants,
rheumatoid disorders
Development of bacterial resistance to antibiotics is much
faster than research and development of new antibiotics
Emerging and reemerging infectious diseases
Antibiotic resistance
Novel agents and their clinical uses
Part 1
Gram-positive superbugs
Gram-positive superbugs
Resistant Gram-positive bacteria terminology
PRSP Penicillin resistant Streptococcus pneumoniae
Question
What is the empirical treatment for CAP?
Community-acquired pneumonia
(CAP)
Microbiology
“Typical” organisms
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
“Atypical” organisms
Chlamydia pneumoniae
Mycoplasma pneumoniae
Legionella pneumophilia
Empirical therapy
Beta-lactams to cover typical organisms
Doxycycline / macrolides to cover atypical organisms
Respiratory fluoroquinolones (levo, moxi) for beta-lactam
allergy
Community-acquired pneumonia
(CAP)
Empirical therapy (as per IMPACT)
CAP, out-patient
Augmentin/Unasyn PO ± macrolide PO
Amoxicillin PO + clarithromycin / azithromycin PO
CAP, hospitalized in general ward
Augmentin / Unasyn IV/PO ± macrolide
Cefotaxime / ceftriaxone IV ± macrolide
CAP, hospitalized in ICU for serious disease
Add cover to Gram-negative enterics
Tazocin / cefotaxime / ceftriaxone IV + macrolide
Cefepime IV + macrolide
Community-acquired pneumonia
(CAP)
Empirical therapy
Modifying factors
Allergy to beta-lactams
Fluoroquinolone (levofloxacin / moxifloxacin)
Aspiration likely: anaerobes should be covered
Augmentin / Unasyn / Tazocin already provide coverage
Cephalosporins (except Sulperazon) is inactive
Moxifloxacin
Bronchiectasis: Pseudomonas cover essential
Tazocin / Timentin / cefepime + macrolide
Fluoroquinolone + aminoglycoside
Case 1
Patient was started on Augmentin +
clarithromycin empirically
3 days later, fever persisted, chest X-ray
showed progressive pneumonia
Endotracheal aspirate (WBC +++, few
epithelial cells) grew heavy Streptococcus
pneumoniae, with penicillin MIC > 4mcg/ml
Questions
Risk factors for penicillin-resistant S. pneumoniae?
Appropriate management in this case?
Penicillin resistant Streptococcus pneumoniae
(PRSP)
Risk factors
Age > 65 years
Beta-lactam therapy in past 3 months
Alcoholism
Newer agents
Telithromycin (Ketek®)
Linezolid (Zyvox®)
Telithromycin (Ketek®)
A ketolide (structurally related to macrolides)
Spectrum of activity
Group A, B, C and G Streptococci, Streptococcus
pneumoniae (including multidrug resistant strains),
MSSA
Listeria monocytogenes, Neisseria meningitidis,
Moraxella catarrhalis, Haemophilus influenzae
Legionella, Chlamydia, Mycoplasma
No activity vs. MRSA, GRE, or any enteric gram-
negative bacteria
Indications
Mild to moderate community acquired pneumonia
Linezolid (Zyvox®)
An oxazolidinedione
Spectrum of activity and indications
Vancomycin-Resistant Enterococcus faecium infections,
including cases with concurrent bacteremia
Nosocomial pneumonia caused by MSSA or MRSA or Strep
pneumoniae (including MDRSP)
Complicated skin and skin structure infections, including
diabetic foot infections, without concomitant osteomyelitis,
caused by MSSA or MRSA, Strep pyogenes, or Strep
agalactiae
Uncomplicated skin and skin structure infections caused by
MSSA or Strep pyogenes.
Community-acquired pneumonia caused by Strep
pneumoniae (including MDRSP), including cases with
concurrent bacteremia, or MSSA
Case 2
M/56
Presented with skin redness, warmth,
swelling, tenderness on his right lower
limb, a pocket of fluid palpated
Diagnosis: cellulitis with pus formation
Question
Empirical treatment?
Skin and soft tissue infection
Cellulitis
Microbiology
Staphylococcus, Streptococci
Streptococci more likely when cellulitis is
well demarcated and there are no pockets
of pus or evidence of vein thrombosis
Staphylococcus aureus
If susceptible, penicillinase-resistant penicillins are the
drugs of choice for methicillin-susceptible
Staphylococcus aureus (MSSA)
Drug of choice
Cloxacillin, flucloxacillin
Cefazolin, cephalexin (penicillin allergic but tolerate cephs)
With beta-lactamase inhibitor
As two-agent combination in Augmentin, Unasyn
Erythromycin, clindamycin (if penicillin allergic)
The above antibiotics also have good activity vs.
Streptococci
Case 2
Skin tenderness and redness did not appear to
improve despite Augmentin has been given
Pus grew MRSA after 2 days
R to methicillin, cephalothin, erythromycin
S to clindamycin, vancomycin, gentamicin,
cotrimoxazole
Patient is clinically stable
Questions
What is the drug of choice in MRSA infection?
Can clindamycin be used in this case?
Methicillin resistant Staphylococcus aureus
(MRSA)
Healthcare-associated Community-associated
Endemic in hospitals, old Do not have usual risk
age homes factors associated with
Risk factors HA-MRSA
Hospitalization in More common in the
previous 1 year following in overseas
Recent surgery countries
Old age home residence Children with chronic
Renal dialysis skin condition
Exposure to invasive
Prisoners
devices Military personnel
Employment in a Aboriginals
healthcare institute Injection drug users
The homeless
Contact sports athletes
Methicillin resistant Staphylococcus aureus
(MRSA)
Healthcare-associated Community-associated
Multiresistant to Often remains
Clindamycin susceptible to
Aminoglycosides Clindamycin
Tetracyclines Aminoglycosides
Fluoroquinolones Tetracyclines
Fluoroquinolones
More associated with
skin/soft tissue
infections and severe
necrotizing pneumonia
Methicillin resistant Staphylococcus aureus
(MRSA)
What to do if
the organism is resistant to agents listed
above and vancomycin, and
Infection is complicated (unstable patient,
extensive involvement, severe sepsis, etc)?
VISA and VRSA
VISA: vancomycin-intermediate Staph aureus
VRSA: vancomycin-resistant Staph aureus
Classified based on minimum inhibitory
concentration (MIC)
(CDC definition)
VISA: vancomycin MIC is 4-8 µg/ml
VRSA: vancomycin MIC is >16 µg/ml
(HA Central Committee on Infectious Diseases)
Susceptible: vancomycin MIC is ≤ 4µg/ml
VISA: vancomycin MIC is 8-16 µg/ml
VRSA: vancomycin MIC is >32 µg/ml
VISA and VRSA
More likely to develop among patients with
Underlying conditions (including renal failure) which
predispose the patient to MRSA colonization;
Indwelling medical devices; and/or
MRSA infection requiring treatment with
vancomycin for a prolonged period
Usually isolated during vancomycin (or
teicoplanin) therapy for MRSA infections which
fail to respond
VISA and VRSA
Linezolid (Zyvox®)
(discussed in PRSP session)
Quinupristin/dalfopristin (Synercid®)
Dalbavancin (Zeven®)
Still under investigation
Daptomycin (Cubicin®)
Tigecycline (Tygacil®)
Linezolid (Zyvox®)
Part 2
Gram-negative superbugs
Gram-negative superbugs
Resistant Gram-negative bacteria terminology
ESBL-producing Extended spectrum beta-lactamases
Enterobacteriaceae producing Enterobacteriaceae, e.g.
Escherichia coli, Klebsiella pneumoniae
Question
What is the empirical therapy?
Acute cholangitis/cholecystitis
Microbiology
Gram negative enterics
E. coli, Klebsiella spp., Proteus spp.
Anerobes
Bacteriodes fragilis, Clostridium spp.
Enterococcus
Acute cholangitis/cholecystitis
Cefuroxime + metronidazole
Question
What is the appropriate treatment?
Can Augmentin or Sulperazon be used?
Enterobacteriaceae
Question
Appropriate known pathogen therapy?
Pseudomonas aeruginosa
Gram-negative bacilli
Frequently present in small numbers in the
normal intestinal flora and on the skin of
humans and is the major pathogen
Causes diseases in patients with abnormal
host defenses, e.g.
When mucous membranes and skin are disrupted
When intravenous or urinary catheters are used
When neutropenia is present (as in chemotherapy)
Intrinsically resistant to many antibiotics
Pseudomonas aeruginosa
Drug of choice
Antipseudomonal penicillins/cephalosporins
Piperacillin, piperacillin/tazobactam (Tazocin),
ticarcillin/clavulanate (Timentin)
Ceftazidime, cefoperazone, cefepime
Carbapenems
Imipenem, meropenem (NOT ertapenem)
Aminoglycosides
Gentamicin, tobramycin, amikacin
Fluoroquinolones
Ciprofloxacin, levofloxacin (less activity than cipro)
Often a two-drug combination is employed except in
uncomplicated UTI
Case 4
Tazocin (Piperacillin/tazobactam) plus
gentamicin were prescribed
Microbiologist suggested using piperacillin
plus gentamicin is sufficient for this patient
Question
What is the difference in activities (and hence uses)
between Tazocin and piperacillin?
Piperacillin vs. Tazocin
Tazobactam in Tazocin®
Tazobactam is a beta-lactamase inhibitor
Renders the combination of Tazocin® more
active against
Gram positive: MSSA
Gram negative: Haemophilus influenzae and
others
Anaerobe: Bacteroides fragilis
Piperacillin vs. Tazocin
Tazobactam in Tazocin®
For Pseudomonas aeruginosa susceptible
to piperacillin, Tazocin 4.5g Q8H IV and
Piperacillin 4g Q8H IV are equivalent
At common usual dose (HA Corp drug price
as of May 2007)
Piperacillin 4g/vial: $56
Tazocin® 4.5g/vial: $108
Multidrug resistant
Gram-negative organisms
Any treatment options for
ESBL-producing Enterobacteriaceae, or
Pseudomonas aeruginosa,
Question
Appropriate known pathogen therapy?
Acinetobacter baumannii
Common cause of nosocomial infection
especially in ICU setting
Drug of choice
Ampicillin/sulbactam or cefoperazone/sulbactam
(sulbactam highly active vs. Acinetobacter) or
fluoroquinolone (ciprofloxacin, levofloxacin)
Gentamicin added to prevent resistance and for
synergy
Imipenem, meropenem can be used
Case 5
Question
Any treatment options for pan-resistant
strains?
Acinetobacter baumannii
Colistin
Case 6
M/40 y/o, good past health
Referred by GP
Presented with fever, chills and night sweats; cough
initially nonproductive but became productive over
past 2 months
Did not recognize weight loss
A sputum smear revealed acid-fast bacilli, further
culture and sensitivity results pending
Diagnosis: Pulmonary TB
Question
What is the drug(s) of choice in tuberculosis?
Mycobacterium tuberculosis
Acid-fast bacilli, replicates very slowly (once
every 24 hours vs. 20-40 mins in other
organisms)
Contagious and spreads through the air
Disease of poverty; affecting mostly young
adults in their most productive years
Leading killer among HIV-infected people with
weakened immune systems
8.8 million new TB cases in 2005, and 1.6
million people died from TB worldwide
A curable disease with appropriate treatment
Mycobacterium tuberculosis
Requires combination therapy
The usual course of drug treatment for
pulmonary TB lasts 6 months:
4 drugs in the first 2 months: isoniazid, rifampin,
pyrazinamide, ethambutol/streptomycin
2 drugs in the subsequent 4 months: isoniazid,
rifampin
Can be given daily or three times a week
Given under DOT (directly observed treatment) by
healthcare staff
Case 6
Patient was started on isoniazid, rifampin,
pyrazinamide and ethambutol
Culture of sputum grew Mycobacterium
tuberculosis
Resistant to isoniazid and rifampin
Question
Is this a case of multidrug resistant TB?
What agents are available?
Multidrug Resistant TB
MDR-TB (Multidrug Resistant TB )
Resistant to isoniazid and rifampin
Isoniazid and rifampin are “backbone” in first-
line TB treatment
Isoniazid exhibits very low MIC vs. the organism
Rifampin allows short-course treatment (6-9
months)
Treatment generally extends to at least 18 months without
rifampin
Resistance to rifampin is frequently associated with
resistance to isoniazid
Multidrug Resistant TB
Multidrug Resistant TB
Management
Microbiologist consultation!
Check susceptibility to other agents!
Multidrug Resistant TB
Tuberculosis
Modify treatment plan according to
Weight
Hepatic function
Hepatotoxic: isoniazid, rifampin
Renal function
Nephrotoxic: aminoglycosides
Dose adjustment: fluoroquinolones (except moxifloxacin)
Pregnancy: Isoniazid, rifampin, ethambutol theoretically relatively
safe, insufficient safety data for pyrazinamide
Penetration (e.g. in TB meningitis)
Drug interactions (e.g. with anti-HIV drugs)
Duration
May require longer treatment in specific drug combinations,
extensive diseases / extrapulmonary diseases
Case 6
Patient was alarmed that the organism was
resistant to isoniazid and rifampin (i.e. MDR-
TB)
He heard of the term XDR-TB from newspaper
some months ago and was very worried
Question
Difference(s) between MDR-TB and XDR-TB?
Extensive Drug Resistant TB
MDR-TB (Multidrug Resistant TB)
Resistant to isoniazid and rifampin
XDR-TB (Extensive Drug Resistant TB)
In addition to resistance vs. isoniazid and rifampin,
Resistant to any fluoroquinolones, and
At least one of three injectable second-line drugs
(capreomycin, kanamycin and amikacin)
Revised definition agreed by the WHO Global Task Force
on XDR-TB in October 2006
Extensive Drug Resistant TB
Situation worldwide
XDR-TB found in
USA: 4% of MDR-TB
Latvia: 19% of MDR-TB
http://www.chp.gov.hk/files/pdf/reducing_bacterial_resista
nce_with_impact.pdf
HA intranet
http://ha.home/ho/ps/impact.pdf
Most updated: third version 2005 (version 3.0)
IMPACT guideline
Imipenem/meropenem/ertapenem
Involves
Prescribing antimicrobial therapy only when
it is beneficial to the patient
Targeting therapy to the desired pathogens
Cost containment
ASP in Hospital Authority
Multidisciplinary, programmatic, prospective,
interventional approach to optimizing the use
of antimicrobial agents
The multidisciplinary team typically includes
Clinical microbiologists
Infectious diseases specialists
Clinical pharmacists
Infection control practitioners
ASP in Hospital Authority
Overall strategies
Build an antibiotic usage database in terms of usage
density i.e. DDD/1000 patient-days (recommend
consistent DDD definition throughout all HA units to
maximize data utility)
Develop a HA-wide an antibiotic resistance database of
selected organisms
Formation of multidisciplinary Antimicrobial Stewardship
Teams (AST) in each hospital/cluster
Audit use of antimicrobials based on established
guidelines, e.g. IMPACT guideline
Education and consensus-building
Outcome measurement and user feedback
ASP in Hospital Authority
Examples
Penicillins
Cefuroxime
Macrolides
Quinolones
Fluconazole
IV-PO switch
IV-PO switch
IV antimicrobials are indicated in
Meningitis
Intracranial abscess
Infective endocarditis
Mediastinitis
Severe infections during chemotherapy-related
neutropenia
Inadequately drained abscess and empyema
Severe soft tissue infections
S. aureus or P. aeruginosa bacteremia
IV-PO switch
IV-PO switch
Criteria (as per IMPACT)
1. No indication for IV therapy
2. Patient is afebrile for ≥ 8 hours
IV-PO switch
Points to note
Prescribe dose based on creatinine clearance
when antimicrobials require renal dosage
adjustment
Augmentin®, Unasyn®, clarithromycin, ciprofloxacin,
levofloxacin
Drug interactions
Oral ciprofloxacin and levofloxacin with antacid,
sucralfate, didanosine, dairy products and enteral
feeds
Useful guides to antimicrobial
therapy
Sanford Guide
Covers a broad range of infectious diseases
IMPACT
With commonly prescribed empirical
therapy and useful local resistance
information
Local antibiogram
Bacterial resistance specific to an institution
or a cluster of institutions
Conclusion
New antibiotics intended to treat complicated
diseases are under investigation
Need to protect our antibiotic arsenal
Justified use of antimicrobials not only treats
infections, but also improves patient outcomes
and reduces the risk of development of
bacterial resistance
Adherence to clinical guidelines, antimicrobial
stewardship program and education helps to
promote appropriate antimicrobial use
Conclusion
Last but not least…
Infection control is of utmost importance in
reducing risk of infection, use of antibiotics
and hence emergence of bacterial
resistance
Hand hygiene
Appropriate isolation / contact restriction