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Healthcare-Associated Infections
Peter Linden, MD
Discussion Dr Kollef: Are you seeing more Klebsiella pneumoniae carbapenemase (KPC) producing Klebsiella? At St. Louis it just seems like we are seeing more, even in the community. More than 30% to 40% of the Klebsiella isolates now are KPC-positive. You mentioned Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA), but maybe KPC Klebsiella is another that in the next 5 years could be a problem.
Dr Linden: This also gets back to the issue of knowing your local organisms and your local pathogens and incorporating that information into your decisions.
Dr Kollef: I do not think that there is a high level of awareness among clinicians in general about recognizing healthcare-associated risk factors, especially among the emergency department physicians and hospitalists, or even the surgeons, who are seeing these patients come in from the community. |
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Antimicrobial Stewardship Programs
Rob Owens, PharmD
Discussion
Dr Kollef: My take on stewardship is that the focus is really on the back end of trying to minimize resistance. The hospital’s goal is to keep costs down. One of the things that has not been emphasized is that if you look upfront, if the patient is treated with the wrong drug, they are more likely to die, but they are also probably going to have higher costs, because the main driver of cost is the length of hospital stay. You mentioned that if they are not dosed appropriately they may have a longer time until they respond, which might mean a longer time in the hospital. |
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Risk Factors for Infection: Community-Acquired Resistant Pathogens
George H. Karam, MD
Discussion
Dr Linden: For Clostridium difficile, are there pending studies of alternatives to vancomycin and metronidazole that might be important?
Dr Bartlett: I think it is going to be hard to beat vancomycin in patients who are seriously ill. There has never been a resistant strain and when given orally it goes right to the colon. You will be able to beat it in terms of relapse, but not for response to an acute infection. Tolevamer looks good for preventing relapse but does not look good for the acute disease. OPT-80 recently tied vancomycin for acute infection and was superior in the rate of relapses.
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Healthcare-Associated Infections: CAP/VAP/MRSA
Marin Kollef, MD
Discussion
Dr Napolitano: One of the features of broad empiric antimicrobial coverage and then deescalation when we get the cultures back is that we are using more antibiotics for a longer duration with the antibiotics we previously reserved for very ill patients. Is there any negative effect of that?
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Surgical Aspects of MRSA
Lena Napolitano, MD, FACS, FCCP, FCCM
Discussion
Dr Kollef: I think I have heard people say that for some of these so-called spider bites, if you drain them you may not even need antibiotics. This is probably not correct.
Dr Napolitano: Pediatric studies have reported that if the abscess is less than 5 cm in diameter, you could get away without using antibiotics.1 Not 100% of the time, but a good percentage of the time. The question is how to determine which ones need the antibiotics. A recent randomized trial of cephalexin versus placebo in patients with uncomplicated skin abscesses (mostly due to methicillin-resistant Staphylococcus aureus [MRSA]) documented a 90.5% cure rate in the placebo arm.2 These data provide evidence that antibiotics may not be necessary after surgical drainage of uncomplicated abscesses. But when lesions are large, are surrounded by cellulitis, or do not have drainable foci, or when patients manifest systemic signs of infection, antimicrobial therapy is warranted.3
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