3/19/2019 Disclosures I have no disclosures. Curbside Consults in - PDF document

3/19/2019 Disclosures  I have no disclosures. Curbside Consults in Infectious Diseases 40 th Annual Advances in Infectious Diseases March 2019 Jennifer Babik, MD, PhD Associate Clinical Professor Division of Infectious Diseases University of California, San Francisco Learning Objectives Roadmap  A Brief Word on Curbsides vs. Formal Consults At the end of this talk, you will be able to:  Describe the situations in which formal in‐person  Case‐Based Approach to the Top Curbside Consult consultation is preferred over curbside consultation Questions in ID 1. Asymptomatic bacteriuria  Outline an approach to common ID questions that arise 2. Oral antibiotics for ESBL cystitis in the inpatient setting 3. Line management in CLABSI 4. Oral therapy for pyelonephritis 5. Antibiotics for nonpurulent cellulitis 1

3/19/2019 Roadmap Curbsides vs Formal Consults  A Brief Word on Curbsides vs. Formal Consults Curbsides Curbsides • Information inaccurate • Information inaccurate Study of 47 curbsides vs. Study of 47 curbsides vs.  Case‐Based Approach to the Top Curbside Consult or incomplete in 51% or incomplete in 51% formal consults formal consults Questions in ID • Medicine consult • Medicine consult 1. Asymptomatic bacteriuria • Curbside  formal • Curbside  formal 2. Oral antibiotics for ESBL cystitis Formal Consults Formal Consults consult by a colleague consult by a colleague 3. Line management in CLABSI • Changed Rx in 60% • Changed Rx in 60% • Curbsided providers • Curbsided providers (36% “major changes”) (36% “major changes”) 4. Oral therapy for pyelonephritis could not look in chart could not look in chart • If info was • If info was 5. Antibiotics for nonpurulent cellulitis inaccurate/incomplete inaccurate/incomplete then it changed Rx in then it changed Rx in 92% (45% “major 92% (45% “major Burden et al, J Hosp Med 2013, 8:31. changes”) changes”) Are Curbsides Okay? Is This An Appropriate Curbside?  Need to balance patient safety, provider workload, What is the dose of ertapenem when the CrCl is <30? education  Curbside volume in ID  In the literature: 20‐120 curbsides/month  UCSF Medical Center: 60 curbsides/mo (15 hours/mo)  Impossible in most practices to convert all curbsides into formal consults Grace et al, Clin Infect Dis 2010, 51:651. Wachter, B. "The Dangers of Curbside Consults... and Why We Need Them."Wachter's World. 29 Apr. 2013. 2

3/19/2019 Is This An Appropriate Curbside? Is This An Appropriate Curbside? 1. Yes 2. No Is This An Appropriate Curbside? Is This An Appropriate Curbside? 1. Yes 2. No 3

3/19/2019 Is This An Appropriate Curbside? Is This An Appropriate Curbside? 1. Yes Theoretically, if a patient has mild cystitis due to VRE that is sensitive to doxycycline, can I use that drug to treat a VRE UTI? Does doxycycline penetrate into the urine? 2. No Is This An Appropriate Curbside? What is an Appropriate Curbside?  The Goldilocks of Curbside Consultation 1. Yes  Not too simple: the answer can be easily looked up  Not too complicated: the answer requires nuanced clinical 2. No judgment, interpretation of a lot of data, or a deep dive into the literature  Just right: Hypothetical, factual question  We also tell our ID Fellows that it should probably be a consult if:  You need to look up the answer  It’s early in the year  The team calls you back several times 4

3/19/2019 The Special Case of S. aureus Bacteremia Curbsides for S. aureus Bacteremia?  Curbside consult is associated with:  Benefit of ID consultation versus no consultation  Less identification of deep infectious foci   adherence to quality indicators for SAB:  Less likely to receive the proper duration of therapy  Getting an echo, repeat blood cultures  Improved antibiotic choice and duration   90d mortality by > 2‐fold compared to formal consult   removal of prosthetic devices/source control   detection of metastatic foci of infection  Formal consult for SAB is preferred if available   mortality (by 20‐50%) Saunderson et al, Clin Micro Infect 2015, 21:779. Forsblom et al, Clin Infect Dis 2013, 56:527. Bai et al, Clin Infect Dis 2015; 60:1451. Paulsen et al, OFID 2016. Vogel et al, J Infection 2016; 72:19. Forsblom et al, Clin Infect Dis 2013, 56:527. Roadmap Curbside #1  A Brief Word on Curbsides vs. Formal Consults 55 year old woman in the ICU after a complicated spinal surgery. She remains intubated,  Case‐Based Approach to the Top Curbside Consult spikes a fever on POD#3 and is Questions in ID pan‐cultured.  She has thick secretions and a 1. Asymptomatic bacteriuria new CXR infiltrate. 2. Oral antibiotics for ESBL cystitis  Sputum is growing MRSA. 3. Line management in CLABSI  UA (catheter): 11‐20 WBC, Ucx 4. Oral therapy for pyelonephritis positive for VRE. 5. Antibiotics for nonpurulent cellulitis 5

3/19/2019 Do You Need to Treat the VRE? Asymptomatic Bacteriuria 1. Yes ASB = (+) urine culture AND no signs/symptoms of UTI 2. No 3. Not sure Asymptomatic Bacteriuria is COMMON! Hazards of ASB Treatment  Side effects of antibiotics  Seen in up to:  25% of elderly, diabetic, or HD patients  50% of patients in long term care facilities   risk of Cdiff  25% of patients with short‐term catheters, ~100% with long‐term catheters   risk of resistance  Of positive urine cultures obtained on the wards  May increase risk of recurrent UTI by getting rid of after hospital admission  ~90% are ASB “good” interfering bacteria Nicolle et al, Clin Infect Dis 2005, 40:643. Leis et al, Clin Infect Dis 2014, 58:980 Cai et al, Clin Infect Dis 2012;55(6):771. Cai et al, Clin Infect Dis 2015;61(11):1655.. 6

3/19/2019 Exceptions: Who With ASB Should Be Treated? What About Patients Undergoing Arthroplasty?  Pregnant women  ASB is not associated with:   risk pyelo, premature delivery  Risk of joint infection from the organism in the urine  Risk of post‐operative UTI  GU procedures w/mucosal bleeding   post‐procedure bacteremia/sepsis  Pre‐op screening and treatment of ASB is not recommended  Immunosuppressed patients?  Renal transplant in the first 3 months?  Neutropenia? Nicolle et al, Clin Infect Dis 2005, 40:643. Sousa et al, Clin Infect Dis 2014;59:41. Duncan, Clin Infect Dis 2014;59:48. Lamb et al, Clin Infect Dis 2017, 64:806. The Heart of the Problem How To Distinguish ASB vs. UTI?  It’s Hard to Ignore a Positive Culture Does the organism help? Does the UA help? • • Only if negative No, the same organisms  Proof of concept study: • Pyuria is very common in cause ASB and UTI (even  At Mount Sinai, 90% of inpatient urine cultures were ASB, ASB, but the absence of WBC Pseudomonas and ESBL) suggests an alternative dx and 50% were treated with ABx • Always order a UA when  They stopped reporting (+) urine cultures in the EMR ordering a urine culture  Results:  The % of ASB that was treated dropped by 80%  No untreated UTIs and no sepsis Use clinical context: does the patient have signs/symptoms of UTI? Nicolle et al, Clin Infect Dis 2005, 40:643. Tambyah et al, Arch Intern Med 2000, 160:678. Lin et al, Arch Int Med 2012, 172:33. Leis et al, Clin Infect Dis 2014, 58:980. 7

3/19/2019 What if I Can’t Assess Symptoms? How to Interpret Urine Studies in a Patient With a Foley or AMS Alternate Diagnosis Likely? How to define UTI in patients with a catheter or AMS? (Signs/ sx of other illness present) Yes No Do not order Send U/A, U/A, urine cx urine cx No other source of infection Surrogate signs/symptoms that are AND consistent w/ UTI (i.e., diagnosis of exclusion) U/A, urine cx U/A (‐), urine U/A (+), urine U/A (+), • Fever, rigors, AMS, malaise (‐) urine cx (‐) cx (+) cx (+) • Flank pain, CVAT, pelvic pain • Acute hematuria Do not treat for UTI Asymptomatic Treat for UTI Do not treat (If no alternate dx bacteriuria • Spinal cord injury:  spasticity, identified) autonomic dysreflexia, unease Nicolle et al, Clin Infect Dis 2005, 40:643. Slide courtesy of Catherine Liu. ASB vs. UTI: Take‐Home Points Curbside #2  ASB is common, especially in catheterized patients A 75 year old woman with neurogenic bladder is admitted with confusion, fever, and 2 days of suprapubic pain and dysuria.  Pyuria ≠ UTI, but its absence points to a different source UA shows >50 WBC/hpf and urine culture grows E. coli . Blood  ASB does not require therapy except for: cultures are negative.  Pregnancy  Urologic procedures She improves on empiric ertapenem and is ready for discharge.  Neutropenia, renal transplant <3 mo? Susceptibilities come back and the E. coli is an ESBL producer.  To diagnose a UTI in a patient with a catheter or who Do I need to send her home on ertapenem or are there any cannot report symptoms, the patient must have:  Signs and symptoms compatible with UTI oral options?  No other source for infection (i.e., diagnosis of exclusion) 8