Transcript ‘Resistant infections’ 22.03.13 Dr Julian Sutton Consultant in Infectious Diseases & Medical Microbiology Case 1 • • • • • • 21F N fit & well Admitted via ED to ICU Hypoxia CRP 470,

‘Resistant infections’
22.03.13
Dr Julian Sutton
Consultant in Infectious Diseases &
Medical Microbiology
Case 1
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21F N fit & well
Admitted via ED to ICU
Hypoxia
CRP 470, neutrophilia (17)
normotensive#
CXR R-sided consolidation
• Empiric Rx for CAP – iv benpen &
clarythromycin & oseltamivir
Initial CXR
Admission blood cultures positive
• ‘GPC ? Staph’ in both bottles
• CA-BSI
PVL- MRSA bacteraemia and cavitating pneumonia
Rx changed to include clindamycin, rifampicin and Linezolid
2-3 week admission – complicated by rash and deraanged LFTs
Good respiratory recovery
S. aureus bacteraemia at UHS, 2006-2012
COMMUNITY
Resistant
Sensitive
Total Community
Acquired Isolates
% of Community
Isolates
Resistant to
Rifampicin
Resistant
Sensitive
Total Hospital
Acquired Isolates
% of Hospital
Acquired Isolates
Resistant to
Rifampicin
2006
0
18
18
0%
2
51
53
4%
2007
0
10
10
0%
0
30
30
0%
2008
0
3
3
0%
0
13
13
0%
2009
0
4
4
0%
0
4
4
0%
2010
0
4
4
0%
0
7
7
0%
2011
0
6
6
0%
1
2
3
33%
2012
0
4
4
0%
0
1
1
0%
Year
MRSA
HOSPITAL
Mean Resistance
MSSA
0%
2006
0
40
40
0%
0
68
68
0%
2007
1
47
48
2%
0
53
53
0%
2008
0
44
44
0%
0
40
40
0%
2009
0
37
37
0%
0
22
22
0%
2010
1
50
51
2%
0
25
25
0%
2011
0
56
56
0%
0
23
23
0%
2012
1
55
56
2%
0
31
31
0%
Mean Resistance
Combined MRSA & MSSA
Mean Resistance
5%
1%
0%
2006
0
58
58
0%
2
119
121
2%
2007
1
57
58
2%
0
83
83
0%
2008
0
47
47
0%
0
53
53
0%
2009
0
41
41
0%
0
26
26
0%
2010
1
54
55
2%
0
32
32
0%
2011
0
62
62
0%
1
25
26
4%
2012
1
59
60
2%
0
32
32
0%
1%
1%
2012 - 92 S. aureus bacteraemias -64% were community-acquired)
86 MSSA, 6 MRSA (6.5%)
Bilateral breast abscess surgically drained,
4 weeks post partum (30.04.12)
‘bilateral basal atelectasis’
Extensive bilateral basal and posterior
consolidation with air bronchogram and shallow reactive
pleural effusions
MSSA-PVL positive bilateral pneumonia and
bilateral breast abscesses
Antibacterial gents for select resisttant
gram positive organisms
• Glycopeptides - Vancomycin and Teicoplanin
• Linezolid
• Daptomycin
• Rifampicin
• Clindamycin
Streptococcus pneumoniae
Burden of pneumococcal disease
at UHS over 9 years
MDR-TB and XDR-TB
• MDR-TB is defined as resistance to isoniazid and rifampicin, with
or without resistance to other first-line drugs (FLD).
• XDR-TB is defined as resistance to at least isoniazid and
rifampicin, and to any fluoroquinolone, and to any of the three
second-line injectables (amikacin, capreomycin, and kanamycin).
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Within a year of the first reports of XDR-TB, isolated cases were reported in
Europe that had resistance to all first-line anti-TB drugs (FLD) and secondline anti-TB drugs (SLD) that were tested.[3,4,5] In 2009, a cohort of 15
patients in Iran was reported which were resistant to all anti-TB drugs
tested.[6] The terms “extremely drug resistant” (“XXDR-TB”) and “totally
drug-resistant TB” (“TDR-TB”) were given by the respective authors
reporting on this group of patients. Recently, a further 4 patients from India
with “totally drug resistant” tuberculosis (“TDR-TB”) were described [7], with
subsequent media reports of a further 8 cases.[8]
The Global threat of
Multidrug resistant TB
October 2012
Health Protection Agency,
UK data on MDR TB
October 2012
Clinical case
• 26 year old, female
• Born Bangladesh, married, moved to UK 2004
• PMH
• Pulmonary TB Rx in Bangladesh 2004
• Rx with 3 drugs
• Total duration Rx said to be 6 months, including
‘injections’ for 1st 3 months
• Miscarriages 2005 + April 2006
• LMP 8 weeks ago
Clinical case
• 5/12 hx
– Cough
• Saw GP
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CXR R apical consolidation with cavity formation
Referred to local Respiratory clinic
Sputum AAFB positive
Commenced on conventional quadruple antituberculous Rx rifinah, pyrazinamide, ethambutol
19.09.06
Initial susceptibilities available 05.10.06
Clinical case - Investigations
Hb 12.5 Plts 508 WBC 7.8 neuts 4.5 lymphs 2.5
Clotting N; fibrinogen 4.12; ESR 64
Na 138 K 4.2 U 2.4 Creat 60
Alb 37 TP 72 globulins 35
AST 44, otherwise normal LFTs, incl ALT
CRP 3
Urine pregnancy test positive; lab -hcg 16,000
Clinical case - Investigations
• CXR 18.08.06
– RUL opacification with thick wall cavity and
septation within the upper lobe
– L lung clear
Mycobacterium tuberculosis Susceptibilities
• Resistant
– Rifampicin, Isoniazid, Ethambutol,
Streptomycin
• Sensitive
– Pryrazinamide, Ciprofloxacin
Initial Management…
• Isolate in negative pressure sideroom
• Stop all TB Rx
• Await further sensitivities
• Involve Obstetric team and Cardiothoracic team
BTS guidelines MDR TB
• Rx with 5 or more drugs to which organism is, is is likely
to be, susceptible, until sputum cultures negative
• Continue with at least 3 drugs to which organism is
susceptible, for minimum of 9 further months, perhaps
up to or beyond 24 months
• Negative pressure isolation until deemed non-infectious
• All treatment (inpatient and outpatient) should be fully
supervised
Agents available to use in this case...
• Pyrazinamide
• Moxifloxacin
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Cycloserine
Capreomycin
Ethionamide
PAS
Amikacin
• Clarithromycin
Widespread pneumonia. Decreased air entry at the bases. Cough and
fever. Rule out TB Pneumonia.
There is miliary shadowing seen bilaterally throughout both lungs.
There is a moderately large rightsided pleural effusion. .
Appearances are consistent with miliary tuberculosis.