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Infections in general Practice

Infections in general Practice. Philip G. Murphy Consultant in Medical Microbiology The Adelaide and Meath Hospitals incorporating the National Children’s Hospital, Tallaght. System approach. URT LRT 70% of antibiotics SST GUT- STD CNS meningitis emergency GIT diarrhoea

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Infections in general Practice

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  1. Infections in general Practice Philip G. Murphy Consultant in Medical Microbiology The Adelaide and Meath Hospitals incorporating the National Children’s Hospital, Tallaght.

  2. System approach • URT • LRT 70% of antibiotics • SST • GUT- STD • CNS meningitis emergency • GIT diarrhoea • Common viral: HS, VZ • Others: tropical parasites, Toxoplasmosis etc • Post-op hospital & minor ops. in GP

  3. Factors influencing prescribing Choice Organism susceptibility Concurrent therapy Drug rep pressure Patient pressure Policies Prophylaxis Drug familiarity: Dosage / cost Toxicity / kinetics Bioavailability Best guess susceptibility Patient immune state Nature of infection Patient physiology Allergy history Breast feeding Pregnancy Age Compliance

  4. Antimicrobial therapy • Usually - empirical • Why? - to avoid delay in initiating therapy for serious infection - eg. community acquired pneumonia • - difficulty in establishing the identity of the pathogen eg. acute/chronic otitis, sinusitis, bronchitis • - unavoidable delay in laboratory • processing of clinical samples.

  5. Choice of empirical therapy • Empirical therapeutic choice requires • knowledge of : • - likely causative pathogen • - local, national and world-wide antimicrobial susceptibility patterns

  6. Upper Respiratory Tract

  7. Lower Respiratory Tract

  8. Microbial aetiology • Haemophilus influenzae • Streptococcus pneumoniae • Moraxella catarrhalis • Mycoplasma pneumoniae • Chlamydia pneumoniae • Chlamydia psittaci • Legionella pneumoniae • Coxiella burnetti Conventional Atypical

  9. Haemophilus influenzaeResistance Tallaght 1999

  10. Susceptibility of Haemophilusinfluenzae isolates to doxycycline • Combined 1992/93 data • (% susceptibility) • EU isolates 99.5 • Belfast isolates 100 • USA isolates 100 • Breakpoint MIC <2 mg/L

  11. Streptococcus pneumoniae Resistance mechanisms • PBP alteration in numbers and size • Genetic mosaicism and transformation • Acquired resistance from oral viridans Streptococci. • No beta lactamase • No plasmid mediation

  12. Penicillin Breakpoints sensitive < 0.01 mg/l commonly 0.03 - 0.1 mg/l formerly 0.006 - 0.008 mg/l low level resistance 0.1 - 1.0 mg/l (intermediate) high level resistance >1.0 mg/l

  13. NI PHL (PRP) 1988 - 1995 YearResistanceSensitive 1988 4 (0.8) 484 1989 0 410 1990 4 (1) 400 1991 0 395 1992 0 377 1993 3 (0.9) 345 1994 12 (3.1) 372 1995 46 (10.6) 388 Goldsmith et al BMJ 1996

  14. Streptococcus pneumoniaeTallaght resistance 98-99

  15. InvasiveStreptococcus pneumoniaeErythromycin resistance Irl & Eu 2004 Ireland

  16. InvasiveStreptococcus pneumoniaepenicillin resistance IRL & EU 2004 Ireland

  17. Pneumococci Vs time since last antibiotic(n =919 children)

  18. Antibiotic strategyLRTI • Chronic chest • Mild: tetracycline • Moderate: amoxicillin +/- quinolone • Severe: ceph, or aug +/- quinolone • Pneumonia • mild: amoxicillin • moderate: cephalosporin + macrolide • Severe: macrolide + quinolone

  19. Enteric infection • H. pylori • Campylobacter jejuni/coli • Salmonellae • Shigellae • Hepatitis • Parasitic • Rotavirus

  20. Campylobacter therapy • Fluid and electrolyte replacement • Avoid anti-motility agents • Antimicrobials if indicated : early treatment if Dx known • - ie. if fever present, bloody diarrhoea, > 8 stools / day, • worsening S&S, ? s&s > 1 week • Erythromycin 250 mg po qid 5-7 days • (carriage eliminated in 72 h) • If septicaemic add an aminoglycoside • Others : Fluoroquinolones, tetracyclines, FFP &Ig’s • not Beta lactams (except Co-amoxiclav)

  21. Viral infection • Herpes simplex: cold sores, genital • Varicella zoster: chickenpox, shingles • Parvovirus • EBV: Infectious mononucleosis • CMV • Hepatitis • HIV

  22. CellulitisSkin & soft tissue infection 90 % Streptococcal (BHStrep) 10 % Staphylococcal (S. aureus) Rx penicillin +/- flucloxacillin Titrate dose Vs symptoms

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