VA-GLA Infectious Diseases
We are pleased to announce that the BioFire Meningoencephalitis PCR panel for CSF is now available at GLA, orderable as “MENINGITIS/ENCEPHALITIS PCR PANEL.” It tests for 14 pathogens: https://www.biofiredx.com/products/the-filmarray-panels/filmarrayme/
There is a new randomized study researching the potential benefit of hydroxychloroquine versus vitamin C versus placebo as post-exposure prophylaxis for household contacts or health care workers with COVID-19 exposures. Potential enrollees can self-refer at the website below if they are within several days of an exposure (people must be enrolled within 96 hours of contact with a symptomatic person). The entire study is done with no in-person visits. Residents of LA County are eligible.
For more information, please email COVID19PEP@mednet.ucla.edu.
To refer a participant yourself, or to direct one of your patients to refer their close contacts, please go to https://depts.washington.edu/covid19pep/ and click “JOIN THE STUDY” or “PROVIDER REFERRAL”.
Our 2019 antibiogram, which compiles antimicrobial resistance data from GLA isolates from the calendar year 2019 is now available, posted here. Overall resistance patterns are largely stable compared to 2018. Notable findings include:
For Gram-negative rods in the hospital setting:
Amikacin resistance remains very low and so is still the most active agent vs. multi-drug resistant Gram-negative rod infections at GLA.
Carbapenem-resistant Enterobacteriaceae remain somewhat uncommon at GLA.
If specific coverage for Pseudomonas is warranted, there is not a benefit from using meropenem versus piperacillin-tazobactam (though meropenem and ertapenem do have better coverage against non-Pseudomonas Gram-negative nosocomial isolates.
Fluoroquinolone susceptibility versus most nosocomial Gram-negative organisms remains poor and ceftriaxone susceptibility among urine nosocomial Gram-negatives is also decreasing.
Pseudomonas is less frequently encountered in the urine as compared to other sites.
For Gram-negative rods in the outpatient setting:
Cefazolin susceptibility among common urinary Enterobacteriaceae is not readily captured in this antibiogram but susceptibility rates among other beta-lactams remains stable.
Fluoroquinolone and TMP-SMX susceptibilities remain similar (~75-80%).
Key trends among Gram-positive isolates:
MRSA remains quite common (~70% of nosocomial non-blood isolates, ~60% of nosocomial blood isolates, and ~40% of outpatient isolates).
Doxycycline susceptibility remains stable among non-blood S. aureus isolates (83% nosocomial, 90% outpatient).
Based on recent guidelines from the Infectious Diseases Society of America, the Antimicrobial Stewardship Program and Infectious Diseases Section at GLA have revised our local guidelines for management of pneumonia and updated our order sets (both for Inpatient Antibiotic Protocols and Outpatient Antibiotic Protocols).
The full guidelines are attached and also available at http://www.vaglaid.org/gla-guidelines.
Main takeaway points:
The Pneumonia Severity Index can be used in making a decision as to whether a patient with pneumonia is best served in an inpatient vs. outpatient setting: https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap (link provided in order sets)
Once a patient is admitted, the following criteria can be used to determine pneumonia severity (which has an impact on antimicrobial selection). Severe inpatient pneumonia can be defined by meeting either one major or three or more minor criteria:
Major criteria
Septic shock requiring vasopressors
Respiratory failure requiring mechanical ventilation
Minor criteria
Respiratory rate ≥ 30 breaths/min
PaO2/FiO2 ratio ≤ 250
Multilobar infiltrates
Confusion/disorientation
Azotemia (BUN > 20mg/dL)
Leukopenia (WBC < 4000 cells/µL)
Thrombocytopenia (platelets < 100,000/ µL)
Hypothermia (core temperature < 36°C)
Hypotension requiring aggressive fluid resuscitation
“Healthcare-associated pneumonia” (aka “HCAP”) is no longer a recognized distinct clinical entity. Risk factors for MRSA and resistant-Gram negative bacteria as pathogens in community-acquired pneumonia and ward-onset hospital acquired pneumonia should be assessed on an individual basis.
Risk factors for which MRSA coverage should be considered in CAP and ward-onset HAP:
Isolation of MRSA from respiratory culture/nares within the past year
Severe disease per criteria above
Risk factors for which broadened Gram-negative coverage should be considered in CAP and ward-onset HAP:
Isolation of ceftriaxone-resistant Gram-negative rods from respiratory cultures within the past year
Receipt of broad-spectrum Gram-negative therapy in the past 90 days
Residence in skilled nursing facility (relative indication)
Most community-acquired pneumonia can be treated with 5 total days of therapy, and most hospital-acquired pneumonia can be treated with 7 total days of therapy.